“Breast Is Best,But…” According to Childcare Administrators,Not Best for the Childcare Environment

Abstract

Background:

Nearly 74% of U.S. mothers work full-time and employment is a cited reason for stopping breastfeeding. In the effort to increase breastfeeding duration, childcare providers could facilitate continuation of human milk feeding when mothers return to work. Yet, mothers report receiving little support when transitioning infants into childcare.

Objective:

Explore the themes of comfort with human milk and formula feeding among childcare administrators near Tampa, Florida.

Material and Methods:

Twenty-eight childcare administrators participated in semistructured interviews regarding policies and perceptions about infant feeding practices at their center. Using Applied Thematic Analysis, interview themes were identified.

Results:

Most administrators agreed “breastfeeding is best.” However, they expressed discomfort with mothers breastfeeding at the center and perceived risk with handling and feeding human milk. These perceptions are illustrated through the theme “Formula feeding is normative” and four emergent subthemes: “Human milk is potentially harmful,” “People are uncomfortable with breastfeeding in public,” “I'm not the expert,” and “‘Breastfeeding is best’, in theory.”

Conclusion:

While breastfeeding may be best for health, from the childcare administrators' perspectives, it may not be best for the childcare environment. A cultural shift may be needed to change norms and perceptions in the childcare environment to support mothers in their effort to provide human milk. Perhaps it is time for a new message, such as “We can help you.”

Introduction

Due to numerous benefits of human milk production, lactation, and consumption to both maternal and child health, the World Health Organization,¹ American Academy of Pediatrics,² and other health organizations³ recommend exclusive breastfeeding for 6 months with continued breastfeeding with the introduction of complementary foods for the first 1 to 2 years of life. Most infants in the United States, however, are not meeting these breastfeeding goals. While ∼83% of U.S. infants initiate breastfeeding, only 25% are exclusively breastfed for 6 months⁴ and 36% are breastfeed for at least 1 year.⁴ One frequently cited reason for the drop in U.S. breastfeeding rates is maternal employment.^5–8 Fifty-eight percent of U.S. mothers with infants are in the labor force,⁹ and nearly three-quarters of employed U.S. mothers with infants work full-time.⁹

Given 47% of U.S. infants regularly receive some form of nonparental care,¹⁰ childcare providers have the potential to either exacerbate the negative effects of employment on human milk feeding or facilitate continued human milk feeding after mothers return to work. Some childcare providers lack knowledge about breastfeeding,¹¹ which could make it difficult to support breastfeeding mothers. Yet, childcare provider support for breastfeeding is positively associated with breastfeeding duration at 6 months.¹² A recent article by Lundquist et al.¹³ found that breastfeeding mothers experienced many stressors and little support when transitioning their infants into childcare. The authors suggest researchers should (1) investigate childcare workers' perceptions of “feeding human milk to infants in explore childcare, and supporting breastfeeding mothers,” and (2) “explore childcare settings as a source of support for breastfeeding mothers.”¹³ This data analysis is a response to their call.¹³

Recognizing the potential role that childcare providers could play in supporting breastfeeding exclusivity and duration, in 2011, the U.S. Surgeon General recommended the training of childcare providers in the use of human milk and the adoption of national standards for breastfeeding support within childcare centers.¹⁴ In the years since, at least 11 states have adopted breastfeeding-friendly childcare designation programs.¹⁵ The Florida Breastfeeding-Friendly Childcare Initiative (BFCCI), which was created in 2012, has to-date identified 462 breastfeeding-friendly childcare centers¹⁶—approximately 6% of the centers in the state. Our prior work on Florida's BFCCI was designed to gauge childcare administrators' knowledge of, and interest in, becoming one of Florida's BFCCI-designated centers using an implementation framework.¹⁷ However, our results revealed that many childcare administrators are uncomfortable with breastfeeding and regard formula feeding as normative. The purpose of this article is to explore the themes of comfort with human milk and formula feeding among childcare administrators.

Methods

Participants and procedure

A convenience sample of 28 childcare center administrators in the Tampa Bay area of Florida was recruited to participate in a semistructured interview in 2015. Study methods were approved by the University of South Florida Institutional Review Board. Childcare centers in the region (n = 190) were identified from a list of providers obtained through the Florida Department of Health, mailed study information, and called for recruitment. Eligible centers had currently enrolled infants; eligible administrators were at least 18 years old. Thirty-one administrators agreed to participate during the recruitment call, but 28 consented and completed the in-person interview. Each participant received a $50 gift card after interview completion.

Data collection

Semistructured interviews with administrators included open-ended questions, allowing for probing and follow-up questions to elicit detailed information about infant feeding practices at the center and administrators' personal feelings and perceptions. Interviews were audio recorded, transcribed verbatim, and checked for accuracy. The Consolidated Framework for Implementation Research¹⁸ (CFIR) was a guiding framework for the interviews. Findings related to CFIR constructs are published elsewhere.¹⁷ For the purpose of this article, key interview questions regarded the center's policies for preparation of human milk and formula, where mothers could feed infants in the center, if mothers could breastfeed without a cover in the center, administrator's perceptions of human milk feeding, and if there were written breastfeeding policies at the center (Table 1).

Table 1.

Interview Questions

What can you tell me about policies and procedures for infant feeding in your organization?

How do they differ for formula versus breastfeeding?

In your day-to-day experience, what are the real differences in feeding formula versus breastfeeding?

Tell me about your policies for storing and handling infant bottles.

Tell me about your policies for storing and handling breast milk.

Suppose a new infant, Devin, 6 months old, has just started coming to your center. Mom works next door, so she stops by at lunchtime and tells you she is here to breastfeed Devin. What happens next?

What are her options for where to feed?

Suppose mom wants to feed him in the infant room, without a nursing cover. How do the staff react?

Are there written policies about what to do if a mother wants to breastfeed in your center?

What happens if, after feeding him at lunch, she wants to set up a schedule for coming in for his next feeding?

In general, how do the infant teachers react when a mom wants to breastfeed at your center?

What are some of the resources that are available to parents about infant feeding at your center?

Imagine a mother came into your center/facility and said that she had difficulty breastfeeding. What information or resources would you have available to give them?

What information would you like to have available?

How would you react or feel if someone asked you for this type of information?

Overall, how would you rate your infant staff in terms of comfort in feeding breast milk?

Overall, how would you rate your infant staff in terms of comfort with the idea of breastfeeding, in general?

Overall, how would you rate your infant staff in terms of comfort with moms breastfeeding in the infant classroom?

Data analysis

Interview transcripts were analyzed using Dedoose.¹⁹ All authors reviewed transcripts, becoming immersed in the data. Using Applied Thematic Analysis,²⁰ codes were created based on themes and subthemes identified from phrases that summarized major points in administrators' interviews regarding their thoughts, perceptions, and opinions of feeding human milk in a childcare setting. After one overarching theme and five subthemes were identified based on pervasiveness and importance across participants, a codebook was developed to promote uniformity of classification. Three authors (E.S., T.L., and R.-R.R.) coded the transcripts. A Kappa value of 0.8 was reached between the three coders for each code. Kappa was calculated using the Training Center application within Dedoose.²¹ To help readers evaluate the extent to which conclusions from this analysis are transferrable to other childcare settings, themes are discussed using thick description in administrators' own words.²²

Results

Participant characteristics

Of the 28 participants (Table 2), all were female and had at least 6 years (range: 6–45 years) of childcare experience and 1 year (range: 1–42 years) as an administrator. Most participants were non-Hispanic white (60.7%) with a mean age of 50 years (SD = 9.8, range: 27–69 years old). The childcare centers represented the economic diversity of the Tampa Bay area with median household incomes for their census tracts ranging from $20,035 to $70,515 and 63% of the childcare centers participated in the United States Department of Agriculture (USDA) Child and Adult Care Food Program. The USDA Food Program provides reimbursement to nonprofit centers, as well as private centers with at least 25% enrollment of low-income children.²³ At the time of the study, none of the childcare centers was considered breastfeeding friendly by the state of Florida BFCCI.

Table 2.

Childcare Center & Administrator (Participant) Characteristics

Participant	Race/ethnicity	Experience working in childcare (years)	Experience working as childcare administrator (years)	Center participates in Food Program^a	2015 Weekly price for full-time care of a 6-month old^b	Median household income for center's census tract (2012–2016)^c
Cary	White	Missing^d	14	No	$155	$40,382
Ruth	White	21	11	Yes	$165	$50,344
Elle	White	30	20+	No	$260	$67,039
Rachel	White	14	10	Yes	$160	$22,500
Maya	White	34	26	Yes	$205	$41,333
Angela	African American	24	15	Yes	$145	$23,342
Helen	African American	24	14.5	Yes	$160	$22,599
Lisa	White	12	6	Yes	$160	$22,045
Ellie	White	45	15	No	$225	$61,452
Jasmine	African American	10	10	Yes	$150	$40,536
Kary	African American	23	7	No	$120	$40,239
Patricia	White	44	42	No	$205	$42,466
Julie	White	26	14	Yes	$195	$22,600
Emma	African American	6	5.5	Yes	$195	$46,350
Madison	White	30+	25+	Yes	Missing^d	$60,104
Isabella	African American	23	18	Yes	$185	$20,035
Hina	African American	15	15	Yes	$150	$27,477
Sophie	White Hispanic	9	9	No	$245	$68,125
Jessica	African American	25	10	Yes	$165	$21,620
Lillian	White	25	20	Yes	$210	$46,545
Faith	White	25	22	No	$200	$70,515
Hope	White	12	10	Yes	$180	$40,239
Carol	White	20	15	Missing^d	$220	$44,956
Amber	White	40	20	No	$242	$26,591
Lindsey	Hispanic or Latino	15	12	Yes	$231	$42,644
Lily	White	15	1	No	$295	$50,221
Selena	White	17	9	No	$265	$59,744
Libby	Caribbean American	25+	8–10	Yes	$200	$61,452

The USDA Food Program provides reimbursement for meals and snacks provided to nonprofit childcare centers, and private childcare centers who have allotted at least 25% of their enrollment to serving low-income children.²³

The 2015 average market rate for infant childcare centers in Hillsborough County was $174 per week, and in Pinellas County, $224 per week.³⁸

The median household income for 2012–2016 was $51,681 for Hillsborough County and $47,090 for Pinellas County.³⁹

Missing = data not available.

Themes

In describing their childcare center's infant feeding policies and practices, administrators shared their thoughts, perceptions, and opinions of human milk feeding in a childcare setting. In our sample, one administrator/childcare center stood out from all the others as welcoming of breastfeeding. The overarching emergent theme from the remaining 27 interviews was “Formula feeding is normative.” Within this theme, four emergent subthemes were identified: “Human milk is potentially harmful,” “People are uncomfortable with breastfeeding in public,” “I'm not the expert,” and “‘Breastfeeding is best’, in theory” (Table 3).

Table 3.

Additional Quotes

Theme	Quotes
“Formula feeding is normative”	[Responses to question: “Tell me about your policies for storing and handling infant bottles.”] “Well, the parents are required to bring in formula for their—their infants and food, if they're on food. Um, we do supply a backup of what—whatever type of formula the parent is on because we're on the food program, but we do encourage the parents to supply their formula and everything like that. The teachers and the parents get together and discuss the feeding schedule. The parents have to write out the feeding schedule when they first come to us, um, as far as how their schedule is at home. Sometime it work for us. Sometime it don't. So it depends on the parent, as far as how many bottles they give their infant on a daily basis.”—Helen “The parents are supposed to bring in the bottles premade, if it is not a formula that we, uh, provide. Which, there's only one formula that we provide, which is [formula band name]. Uh, we also have a soy-based one that we provide. But no one is on that. So if they are not using the [formula brand name], then they are—the parents are to provide the bottles. So they have to be already premade and brought in. Ones that are—uh, that we do provide, the bottles are brought in empty. We add the appropriate amount of water and formula and whatnot. We rinse the bottles out and send'em back home. We don't wash them here.”—Cary [Administrators had to be probed to answer the question about the storage and handling of bottles for human milk. The following quote is a response to this probe.] “Um, we don't have any breast fed babies here.”—Ruth

Theme

Quotes

“Formula feeding is normative”

[Responses to question: “Tell me about your policies for storing and handling infant bottles.”]
“Well, the parents are required to bring in formula for their—their infants and food, if they're on food. Um, we do supply a backup of what—whatever type of formula the parent is on because we're on the food program, but we do encourage the parents to supply their formula and everything like that. The teachers and the parents get together and discuss the feeding schedule. The parents have to write out the feeding schedule when they first come to us, um, as far as how their schedule is at home. Sometime it work for us. Sometime it don't. So it depends on the parent, as far as how many bottles they give their infant on a daily basis.”—Helen
“The parents are supposed to bring in the bottles premade, if it is not a formula that we, uh, provide. Which, there's only one formula that we provide, which is [formula band name]. Uh, we also have a soy-based one that we provide. But no one is on that. So if they are not using the [formula brand name], then they are—the parents are to provide the bottles. So they have to be already premade and brought in. Ones that are—uh, that we do provide, the bottles are brought in empty. We add the appropriate amount of water and formula and whatnot. We rinse the bottles out and send'em back home. We don't wash them here.”—Cary
[Administrators had to be probed to answer the question about the storage and handling of bottles for human milk. The following quote is a response to this probe.]
“Um, we don't have any breast fed babies here.”—Ruth

Subthemes	Quotes
“Human milk is potentially harmful”	“I mean, I don't think that they really look at it any differently. Um, they know my urgency on breast milk, and I make it like it's—I make them think like I feel it's the worst thing in the world, in that it can hurt them, because in all reality, it can. Um, and so, I tell them my high importance of if you touch it, you need to have on gloves. So I think just because I am that way, handling it, I always know when I walk in there, they're gonna have on gloves. I know if that breast milk goes into that classroom, they're gonna have “breast milk” labeled on those bottles, and that they're going to absolutely only be warming it in those bottles. But I don't think, um, that they would look at it any different or—than a formula bottle.”—Isabella “Breastmilk, we have a different color label that's—the teachers know that it's a body fluid. Then, so anyway, the teachers to feed any baby, for health and sanitation they have to wear gloves. We're more careful when we are handling breastmilk.”—Lindsey “I can tell you that breast milk has to be kept in Ziploc baggies, teachers wear their gloves, um, they make sure to read the name on the bottle before they actually give it to them, out loud, so that another teacher can look at it. Um, formula does not have to be kept in a Ziploc baggie. Um, and the teachers, although they wash their hands, they do not have to wear a glove for [formula feeding].”—Selena
“People are uncomfortable with breastfeeding in public”	[How would your staff react if the mom wanted to breastfeed without a cover?] “I think she [the baby room staffer] would freak out. Um, we would try to encourage [the mom] to cover up, but, you know, I—we've never been dealt that, so it's—it's hard to know how she would react…I think she would probably be, like, you know, please cover up, you know, ‘cause other parents could walk in, or whatever.”—Ruth [If a mother wants to feed without a cover?] “Turn your chair, take the baby outside, whatever […] Other than, please don't get up half naked and dance around our room.”—Elle “She could take the child to the car if she wants, you know, her own area, or we have a resource room [… Q: OK. And um, suppose that she wants to feed him in the infant room without a nursing cover, how do the staff react?] We don't allow that. Um, so the staff would call me, just because if we're giving a tour, and it makes anyone else uncomfortable, we're trying to protect everybody's feelings. [Q: OK, so that's—so the only options are the resource room in the building?] Mm-hmm. Inside the building, yes. I guess they could use a restroom as well, but I wouldn't recommend it, because it's not very sanitary.”—Selena
“I am not the expert”	[The quotes below are answers to the questions: Imagine a mother came into your center/facility and said that she had difficulty breastfeeding. What information or resources would you have available to give them?] “I don't have any. I don't have any resources available. I did have one, uh, parent that had said that, that she was having a hard time breastfeeding. And, um, I simply told her maybe she should tell—talk to the doctor, to see if there's any way of implementing, uh, formula for the baby and that we provide [formula brand name] and, uh, she could get with the doctor to see if that would be something that we can help her with.”—Carol “What I'll tell them is maybe they can go over to the Health Department and talk to someone at WIC and see what information they can give them as far as milk. And most likely, they'll say follow up with your doctor to see what's the best milk to start giving your baby.”—Helen “That's not for us to determine. I keep going back to the doctor and the La Leche Club, because they're the experts at it. I'm not.”—Ellie
“‘Breastfeeding is best,’ in theory”	“I think that they should breastfeed th—(laughs) I mean, I feel like breast milk is better for them, at least, the first few months, but –”—Ruth “Breastfeeding is more nutritious than regular milk, powdered milk, and more nutrients in that milk.”—Helen “I know that there's been a lot of studies out there that it's better for them, that they're smarter, that—you know, wives' tales and all of these things.”—Isabella

Formula feeding is normative

Childcare administrators' responses regarding how their center stored and handled bottles revealed their perception that formula feeding was the normative practice. Nearly all the administrators only mentioned their policies for formula bottles and had to be asked follow-up questions about how they handled bottles containing human milk. Furthermore, over half of the time, childcare administrators interchanged “milk” for “formula” when discussing infant feeding—“it's regular milk or there's breast milk.” Most noted that they did not have formalized policies for human milk feeding at the center because they did not “have any breastfed babies here.” The perception that formula feeding was the normative way to feed babies was further revealed when administrators mentioned the following: (1) precautions taken when feeding human milk; (2) wanting mothers to use a cover when breastfeeding at the center; and (3) their discomfort providing breastfeeding support or advice to breastfeeding mothers.

Human milk is potentially harmful

A few center administrators believed exposure to human milk could be harmful to others, citing that human milk is a bodily fluid. These administrators seemed unaware that human milk is not one of the bodily fluids to which universal precautions apply.²⁴ Concerns about potential dangers posed by exposure to human milk led to different procedures for handling human milk versus formula. Staff in centers with these safety concerns would wear gloves while handling human milk, but not while handling formula. Two administrators took pains to ensure their staff viewed human milk as potentially harmful. For example, Isabella stated,

They know my urgency on breast milk, and I make it like it's—I make them think like I feel it's the worst thing in the world, in that it can hurt them, because in all reality, it can. And so, I tell them my high importance of if you touch it, you need to have on gloves.

While only a small number of centers took such precautions as those mentioned by Isabella, all centers took steps to ensure the separation of human milk and formula. Most notably, all centers specially labeled bottles of human milk and used separate crockpots to warm formula bottles and human milk bottles.

People are uncomfortable with breastfeeding in public

Childcare administrators overwhelmingly characterized their centers and staff as comfortable with feeding human milk and breastfeeding. Even those who considered human milk “dangerous” reported that they and their staff were comfortable with “the general idea of breastfeeding,” although they also tended to note they were only comfortable with a mother breastfeeding at the center “if she is covered.” When asked what they would do if a mother wanted to breastfeed at the center without a cover, one administrator reported “even [the center] supply[ies] her with a blanket.” If a mother wanted to feed without a cover at Libby's center, problems would occur:

Um, well, because it's, um, because it's a daycare center and we have, um, other parents coming through, uh, even children, you know, we ask them to cover, because we actually don't want children to go home and say, “Mom! We saw Miss [name's]”—you know, so, we would ask her, can you please cover because it's a daycare.

Administrators also noted that, while breastfeeding, mothers must be in the infant room and not in other areas of the center. As Maya said, “some parents will think—you know, will totally be appalled.”

I'm not the expert

Nearly all administrators expressed feeling more knowledgeable about feeding infant formula, compared to human milk. Administrators reported easily and freely giving advice to parents with formula-fed babies, such as whether to mix cereal with formula. When asked what they would do if a mother approached them with a breastfeeding question or problem, they all said they would refer that mother to her physician or pediatrician. None of the administrators indicated having breastfeeding or human milk-related materials to provide. Also, none mentioned that they would refer a mother to a lactation consultant. This hesitancy among administrators to address the non-normative feeding method they experience in their childcare center (human milk and breastfeeding) relays the message that they are only comfortable with formula, almost to say: “I am an expert in formula, but I'm not an expert in breastfeeding.” For example, Carol stated,

I did have one, uh, parent that had said that she was having a hard time breastfeeding. And, um, I simply told her maybe she should tell – talk to the doctor, to see if there's any way of implementing, uh, formula for the baby – and that we provide [brand name of formula] and, uh, she could get with the doctor to see if that would be something that we can help her with.

“Breastfeeding is best,” in theory

Nearly all administrators specified that breastfeeding was best for babies, although that was not a question asked in the interview. They noted breastfed babies were “healthier,” had a “better immune system,” were “smarter,” and that breast milk was “more nutritious than regular milk” and was “better on the stomach” (see Table 3 for more quotes). While expounding the benefits of breast milk, the administrators also noted that handling breast milk could be dangerous, and that mothers could breastfeed in the center, but only if there were restrictions on where and how. For example, Elle notes that breastfeeding makes the transition to childcare easier for babies because they have antibodies from their mothers, but she suggests women who want to breastfeed at the center turn the rocking chair toward the wall in the infant room and that these women should not “get up half naked and dance around our room.” Similarly, Jasmine stated that breast milk does not contain chemicals like formula and that breast milk is “better, healthier for the babies' growth and development,” but is only okay with breastfeeding as “long as she ain't goin’ around, walkin’ around all over the school with her breasts out.”

Overall, administrators revealed that, while breastfeeding may be best for babies, their centers regarded formula feeding as normative, as evidenced by their discomfort with breastfeeding at the centers, discomfort handling human milk, inability to address breastfeeding mother's questions, and perceptions that breastfeeding women would outlandishly flaunt their breasts. Further evidence that administrators typically perceived formula to be the normative food for babies comes from their discussion of participation in the USDA Food Program, which provides centers remuneration for feeding meals (breast milk or other foods) to children in their care.²⁵ Over half of the centers participated in the USDA Food Program. Interestingly, administrators noted they followed the program's guidelines for feeding infants formula, but did not mention the program's guidelines for feeding human milk, which include provisions for flexible feeding schedules and quantities for children receiving human milk.²⁶

Discussion

In interviews regarding infant feeding policies and practices at daycare centers, all but one of the childcare administrators revealed that formula feeding is normative, and for a few, human milk is perceived as a dangerous substance requiring extra precaution in its handling. While they acknowledged breastfeeding is the optimal food for infants, they were uncomfortable with children feeding at the breast within the center and did not know how to help or where to refer breastfeeding women who need support. Their contradictory statements highlight the perceived cultural norm of formula feeding. This cultural norm is unlikely to be overcome in these childcare settings if the centers have no enrolled infants receiving human milk. This creates a tautology whereby administrators are uncomfortable because they do not have exposure to breastfeeding, but the fact that they are uncomfortable with breastfeeding may minimize their exposure because breastfeeding mothers may be uneasy taking their infants to a center where people are uncomfortable with breastfeeding or may choose to stop breastfeeding to fit the norm.

Recognizing the importance of childcare centers in helping families meet their breastfeeding goals is a worldwide issue.²⁷ While breastfeeding coalitions across the United States may have developed guidance to help their local childcare programs support breastfeeding (e.g., North Carolina²⁸ and Florida¹⁶), we could not find standard industry-wide training manuals or required modules for childcare providers that provide information on human milk feeding in a childcare setting. This suggests the larger childcare industry reinforces the cultural norm that most infants are fed formula. This norm is compounded by the larger public health and biomedical discourse around “breast is best.” For the past 40 years, among public health officials, breastfeeding researchers, and skilled lactation providers, there has been an emphasis on the benefits of breastfeeding.^29–31 However, this messaging has been insufficient for achieving our nation's goals³² for exclusive breastfeeding rates through the first 6 months of life. As mentioned, daycare administrators overwhelmingly accept that breastfeeding is best for babies, even repeating some of the most mentioned benefits. Yet administrators are not comfortable with breastfeeding and are not supportive of its practice. Thus, while we cannot specifically point to childcare as the reason women stop breastfeeding, the fact that childcare administrators are less comfortable with breastfeeding than formula feeding likely contributes to women weaning. Research is needed to explore this hypothesis.

The results of our study support the findings of Lundquist et al.¹³ that childcare administrators—and likely childcare staff, as well—need education and training about breastfeeding to better support mothers. Such trainings may include education about differences in handling, storing, and feeding human milk versus formula, and, for centers participating in the USDA Food Program, information about its different regulations surrounding human milk and formula.²⁶ In addition, efforts to inoculate childcare providers against discomfort with the breast and the visual images of breastfeeding could be effective in normalizing breastfeeding for them. Videos explaining some of the basics of breastfeeding and showing women in the act of breastfeeding may be effective and help to debunk the myth that breastfeeding women are “running around with their clothes off” in public. Also, it is worth noting the majority of Americans (68%) support the right of women (and children) to breastfeed in public³³; sharing this information may help assuage fears of administrators and childcare workers.

Furthermore, we follow Lundquist et al. in their suggestion that more research needs to be done investigating and evaluating how childcare centers can help mothers meet their infant feeding goals. The findings of our study indicate that childcare administrators are uncomfortable answering mother's questions about breastfeeding and lack the resources and education to provide support. However, administrators readily provide suggestions to mothers whose children are receiving formula. While at least 11 states have “breastfeeding-friendly childcare” programs,¹⁵ all have different qualifications for certification. Research is needed on what is meant by “breastfeeding-friendly childcare” and whether it is effective in helping mothers meet their breastfeeding goals. In addition, future research should consider what role parents would like childcare providers to play in breastfeeding support and promotion. Furthermore, research should guide and test programs to support childcare administrators and staff in effectively providing breastfeeding information, resources, and support.

Limitations

The findings of this research reflect the questions that were asked in the interview. We did not pursue the nuances of other questions regarding childcare feeding practices to the extent that we did surrounding policies related to women breastfeeding at the center. Hypothetical questions regarding what the center would do in certain situations were only asked about breastfeeding at the center, so we cannot speculate as to how administrators would have responded if we asked hypothetical questions such as how administrators would respond if a mother asked for their advice for her formula-fed child or if she wanted to feed this child at the center. In addition, the findings of this study may not be transferrable to other contexts across the United States, due, in part, to the geographic setting, breastfeeding knowledge, and cultural norms and values of childcare administrators in the Tampa Bay area. Furthermore, the sample of childcare administrators in this study was a convenience sample and may not be representative of the larger Tampa Bay childcare administrator population. This qualitative work was ideal for illustrating some of the perceptions and sentiments of childcare administrators in this area. Future work will determine the extent to which these perceptions and sentiments are representative of this and other populations.

Conclusion

The results of our study leave us considering the limitations of the “breast is best” discourse. As mentioned, childcare administrators were in overwhelming agreement with this sentiment. However, for these administrators, it did not change their perceptions about breastfeeding in public or the potential dangers of handling human milk. Human milk may be best for health, but from childcare administrators' perspectives, it may not be best for the childcare environment. While administrators acknowledge the benefits of breastfeeding, for them “breast is best” has a big asterisk next to it, namely that it is best if they do not have to see the act of breastfeeding, if they are able to feed infants without extra precautions, and if it does not mean the baby will have to be fed more often. Understanding—or acknowledging—that “breast is best” may be necessary, but is insufficient for reaching our nation's breastfeeding goals. No doubt breastfeeding initiation rates in the United States have continued to rise over the time period of the campaign, but duration rates remain far from optimal.⁴ Research has shown the limitations of education alone in changing health-related behavior.³⁴ Indeed, while giving birth in a Baby Friendly Hospital Initiative (BFHI)³⁵-certified hospital increases breastfeeding initiation, it may not translate into increased long-term continuation without community breastfeeding support.^36,37 After hospital discharge, many families may be clear about “breast is best,” but likely will need support to reach the 6-month exclusive breastfeeding milestone. The moment is ripe for our communities, including childcare providers, to embrace a new message: “We can help you.”

Footnotes

Acknowledgments

The authors would like to thank the childcare centers and staff members in the Tampa Bay area for their time and participation in the study. Special acknowledgments go to Krista Schoen at the FDOH, the Tampa Bay Breastfeeding Taskforce, the Florida Breastfeeding Coalition, and Jessica Gordon for providing informational support. They also thank DeAnne Turner, Vinita Sharma, Rachel Logan, Preeti Vadlamani, Emily Rizzo, Adebukola Sangobowale, Carly Truett, Cheralynn Corsack, Tiffany Graske, Tabassum Tasnim, Laketa Entzminger, and Hanh Van Tran for their contribution in data collection and validation.

Disclosure Statement

No competing financial interests exist.

Funding Information

Funding was provided by the University of South Florida College of Public Health Individual Investigator Award.

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