Awareness and support of responsive bottle-feeding among WIC counselors and caregivers: A formative qualitative study

Abstract

Objective:

To understand Special Supplemental Nutrition Program for Women, Infants and Children (WIC) counselors’ experiences discussing responsive bottle-feeding during counseling and WIC participants’ knowledge, understanding, and use of responsive bottle-feeding.

Methods:

Qualitative descriptive; semi-structured interviews with 23 participants (8 WIC counselors and 15 WIC participants) were conducted online via Zoom. WIC counselors and mothers of WIC-enrolled bottle-fed infants were recruited through a network of WIC clinics in North Carolina. Interviews were recorded, transcribed, and collaboratively analyzed using content analysis.

Results:

WIC participants received responsive infant feeding support from WIC counselors but often in the context of breastfeeding. WIC counselors provided valuable support for families, but were challenged by limited training on responsive bottle-feeding, balancing promoting breastfeeding with supporting mothers’ feeding decisions, and time constraints.

Conclusions and Implications:

Findings provide preliminary support for the need to develop and pilot an intervention focused on promoting responsive feeding for parents of bottle-fed infants. (Abstract Word Count: 150)

INTRODUCTION

The first year of life is a critical period for growth and development, and excessive weight gain during this time can increase the risk of obesity in childhood and beyond.^1,2 Early onset of obesity significantly increases the likelihood of having overweight or obesity in adulthood ³ as well as a higher risk for chronic diseases, certain types of cancer, and poor quality of life.^4–6 Given the significant impact of obesity on health and well-being, primary prevention during infancy is crucial.

An important obesity prevention strategy that is recommended by the American Academy of Pediatrics⁷ and World Health Organization (WHO)⁸ is responsive feeding. Responsive feeding describes caregivers being attuned and attentive to their infant’s feeding cues;⁹ this feeding style is hypothesized to facilitate infant appetite self-regulation¹⁰ and has been linked to healthy weight trajectories during infancy and into childhood and adulthood.¹¹

Responsive feeding is recommended regardless of whether caregivers are breastfeeding or bottle-feeding (with breast milk or infant formula), but previous research suggests mothers of infants fed directly from the breast report greater responsiveness to their infants’ feeding cues compared to bottle-feeding mothers.^12,13 In addition, bottle-feeding permits caregivers to exert more control over the feed, which can facilitate a pressuring feeding style.¹⁴ Thus, bottle-feeding may predispose infants to impaired self-regulation contributing to overfeeding and increased risk for rapid infant weight gain.¹⁵ Indeed, infants fed from bottles, whether with breast milk or formula, exhibit greater rates of weight gain and are at increased risk for obesity during later childhood and adulthood compared to infants fed directly from the breast.^15–17

In the United States, most infants are fed from a bottle during the first 6 months of life; about 75% of infants are formula-fed,¹⁸ and at least 85% of breastfed infants are fed pumped breast milk.¹⁹ Thus, efforts to promote responsive bottle-feeding hold the potential to benefit a large number of families. One promising strategy is paced bottle-feeding, a practice consistent with responsive feeding wherein the caregiver positions the bottle in a way that moderates milk flow and permits the infant to lead the feeding. Use of paced bottle-feeding has been associated with a lower likelihood of infant bottle-emptying, a dimension of the pressuring feeding style.²⁰ Research is needed to identify additional promising strategies, with a specific need for interventions targeting families at high risk for bottle-feeding, overfeeding, and obesity.

Infants enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are more likely to be fed formula compared to infants not enrolled in WIC,²¹ with about 87% receiving some formula.²² The WIC program is a U.S. federal nutrition assistance program for pregnant, postpartum, and breastfeeding women, infants, and children up to age 5 living in low-income households.²³ In addition to providing formula, WIC provides nutritious foods to supplement diets, nutrition education, breastfeeding promotion and support, and referrals to health care. The WIC program has important public health implications as over 80% of eligible U.S. infants participate and on average 1.5 million infants are enrolled each month.²⁴ However, mothers participating in WIC reported feeding less responsively compared to mothers not enrolled in WIC.²⁵ Thus, there is a need to ensure responsive feeding education is conveyed to all families, particularly those enrolled in WIC, to promote healthy bottle-feeding and support healthy weight gain trajectories.

The purpose of this study was to gain a better understanding of WIC counselors’ experiences discussing responsive bottle-feeding practices during counseling interactions with WIC participants, and WIC participants’ knowledge, understanding, and use of responsive bottle-feeding practices. Findings will be used to inform the development of a text-messaging intervention to support parents of bottle-fed infants.

METHODS

This study was part of a pilot randomized controlled trial with an exploratory sequential design. Here, we report on the formative work that includes qualitative findings from our interviews with WIC counselors and participants, which we conducted to inform intervention development using a qualitative descriptive design.²⁶

Sample and Setting

We obtained a convenience sample comprised of 8 WIC counselors and 15 mothers of bottle-fed infants who participated in WIC in North Carolina. Our sample of WIC counselors included 6 Registered Dietitians (2 of which were Internationally Board Certified Lactation Consultants) and 2 nutritionists (1 of which was a WIC-designated breastfeeding expert) who worked within the same network of WIC clinics and were of various racial and ethnic groups (details omitted to protect identification). For mothers of bottle-fed infants, we recruited from 5 different WIC clinics, allowing us to enroll WIC participants from various geographic areas in North Carolina.

Recruitment

The research team attended WIC staff meetings to introduce and describe the study. Recruitment for WIC counselors occurred from July to August 2022. Eligible WIC counselors included those who were actively counseling WIC participants. Recruitment for WIC participants occurred from October 2022 to March 2023. Participants enrolled in WIC were recruited primarily by WIC counselors during their scheduled appointments; WIC counselors introduced the study and recorded the contact information of interested WIC participants in a secure Box folder. We followed up with those who were interested to assess eligibility. Various social media outlets were also used to help recruit WIC participants (i.e., Facebook, NextDoor). Eligible WIC participants included those who were aged ≥18 years, could read and write in English or Spanish, and had a child that used a bottle for at least some of their feeds, was ≤ 15 months old, and was receiving WIC benefits.

Data Collection

We used semi-structured interview guides for data collection (see Supplementary Tables 1 and 2). The interview guides were developed by the principal investigator (M.C.K.) with input from stakeholders including WIC staff and content experts in qualitative research and responsive infant feeding. The interview guides consisted of open-ended questions focused on barriers and facilitators to providing counseling (counselors), along with knowledge and use (participants) of responsive feeding. They also included questions on demographic characteristics for descriptive purposes (see Supplementary Tables 1 and 2). All study materials were translated into Spanish and quality-checked by two bilingual researchers from the study team. Semi-structured interviews were conducted via Zoom (Zoom Video Communications, 2022) by two bilingual clinical research coordinators with extensive training and expertise in qualitative interviewing. Interviews were digitally recorded with a duration between 12 and 66 minutes. Upon completion of the interview, all participants were compensated with a $40 Walmart gift card. All study procedures underwent expedited IRB review and were approved by the ethical review board at Duke University; verbal consent was required prior to participation.

Data Analysis

The interviews were audio-recorded then professionally transcribed and translated verbatim. One research team member (M.C.K.) checked the transcripts against the audio recordings for accuracy. We used NVivo 12 (Version 12.7.0, Lumivero, 2021) to analyze the data using content analysis.²⁷ Two investigators (T.N.R. & M.C.K.) developed a codebook based on a priori codes from the interview guides and jointly coded two transcripts, using inductive coding to refine the codebook by including content that emerged. Subsequently, four team members participated in the analysis process (T.N.R., B.B., A.S., & M.C.K.). First, each transcript was read to get a sense of the whole; then, at least two team members independently coded each transcript. We met to discuss coding discrepancies and achieve a consensus of a minimum of 0.70 Kappa coefficient, indicative of moderate to strong interrater reliability, for each code across transcripts.²⁸ Codes were examined within and across transcripts to determine categories and themes. Given this was a descriptive study with the purpose of informing an intervention, the interview questions were relatively direct, and the data were categorized in a way that fulfilled the purpose by providing information on the current practices related to responsive bottle-feeding in the WIC setting and opportunities for improvement that could be targeted through an intervention. To increase rigor and reproducibility, we maintained a detailed audit trail and engaged in writing memos after coding sessions to practice reflexivity and reflect on patterns in the data. We took a collaborative analysis approach, engaging in researcher triangulation,²⁹ and we practiced multivocality, ensuring that various participants’ voices were reflected.²⁹

RESULTS

WIC Counselors

The 8 WIC counselors in our sample worked across 5 different sites within the same network of WIC clinics, and the average time worked in WIC was about 6 years (range 1 to 15 years). We categorized experiences discussing responsive feeding practices into two broad themes: 1) current strategies for supporting responsive feeding; and 2) challenges experienced related to supporting responsive bottle-feeding.

Current strategies for supporting responsive feeding.

This theme encompassed how WIC counselors supported parents and how WIC counselors themselves were supported in learning about responsive feeding and included three subthemes: teaching feeding cues; general bottle-feeding support; and staff training.

Teaching feeding cues

Most WIC counselors mentioned discussing responsive feeding in the form of teaching feeding cues. Some took a proactive approach by discussing cues at the first appointment, while others took a reactive approach and discussed cues if the infant was exhibiting challenges with feeding (e.g., spitting up). One counselor stated:

“I mean sometimes it may come up more kind of in a reactive approach to where, um, you know, maybe there’s an issue of like a lot of spitting up or something like that. Um, but then other times I think especially with new moms, I, I think that’s something that proactively trying to bring up.” (WC4)

Some WIC counselors also felt that providing cue-based feeding support was often more difficult with bottle-feeding compared to breastfeeding. For example, one counselor stated:

“I mean with breastfeeding a lot of the time, I feel like moms are usually more in tune with the hunger and satiety cues with breastfeeding especially if the baby is going to the breast. I feel like it’s more so bottle feeding where a lot of times, maybe being overfed.” (WC1)

Finally, WIC counselors mentioned they educate parents on initiating infant feeds according to hunger cues while maintaining awareness of the feeding schedule, which could be perceived as contradictory advice for parents. One counselor stated:

“Um, and so that’s a lot of education around what are the signs that we’re getting from the baby that lead, that show hunger. Um, and so to me, it means we’re to be looking prioritizing hunger cues. Um, and I will say that’s very challenging in the first couple – I would say the first month, because we’re telling moms yes, feed your baby 8–12 times in 24 hours, but also don’t watch the clock. So I think that comes across very like, kind of contradictory to people.” (WC2)

General bottle-feeding support

When asked about support they provide specifically around bottle-feeding, many WIC counselors mentioned topics such as how to mitigate spitting up and how to slow down feedings; half mentioned paced bottle feeding to help with these problems, including looking for feeding cues and letting the infant control the feeding. Many offered support around the frequency and amount of feeding. Some counselors offered guidance on formula mixing and breast milk storage (e.g., amount of time breast milk can be left out, freezer storage, and warming milk), and choosing a nipple type similar to the breast.

When asked what questions specific to bottle feeding are received from WIC participants, WIC counselors stated questions most often come from mothers who formula-feed, such as which formula is best for intolerances or spitting up, how much formula should they be feeding, and formula safety, such as proper mixing. Support was also provided for which bottle and nipple type to use. There was no mention of WIC participants asking questions about how to bottle feed (using responsive feeding techniques or paced bottle feeding).

Staff training

We asked WIC counselors about the trainings they received to support responsive feeding, bottle feeding, and formula feeding. Many WIC counselors noted they received minimal or infrequent training specific to responsive feeding. The WIC counselors also expressed that formula-feeding training was focused on understanding the nutritional content of various formula types and not necessarily on how to bottle-feed. Many WIC counselors indicated that there was a dearth of bottle-feeding training for WIC counselors compared to breastfeeding education. One counselor stated:

“Um-hmm, that one again is more obviously more focused on breastfeeding. Um-hmm, let’s see, for formula you know it’s been a little bit -- It’s been more sparse understandably.” (WC5)

Many WIC counselors mentioned they received sparse information on bottle-feeding integrated into other trainings, including paced bottle-feeding.

“But it’s like – it’s sometimes, like, part of another training, we might get like a little bit of information within another training, you know, paced bottle feeding or, giving them a chance to feel those hunger [inaudible] and stuff like that. So yeah, I mean, I guess we have, I can’t in my mind right now, put my finger on one thing.” (WC1)

The WIC counselors also described a greater need for training on bottle and nipple types and specialized formulas, as these were questions they were often asked by parents.

Challenges related to supporting responsive bottle-feeding.

This theme included three subthemes: balancing breastfeeding support; dispelling misinformation; and navigating structural constraints.

Balancing breastfeeding support

While we were interested in bottle-feeding support and asked directed questions related to bottle-feeding, WIC counselors repeatedly discussed the support they provide around breastfeeding. Nearly all counselors specifically mentioned providing information and education about the benefits of breastfeeding and working to demystify preconceived notions about breastfeeding. A challenge some WIC counselors faced included the need to balance providing support for bottle feeding, especially during pregnancy, with the encouragement of breastfeeding resulting from their training as WIC counselors. They noted difficulties in providing education on the importance of breastfeeding while not seeming coercive or unsupportive of mothers discussing the introduction of formula into their infant’s feeding plan. One counselor stated:

“…trying to walk that line and be, you know, open and compassionate and here for questions, but also firmly supportive of breastfeeding”..” (WC2)

Dispelling misinformation

The WIC counselors contended with the navigation of misinformation participants receive that influences their feeding decisions (e.g., to not breastfeed), which may come from family members, social media, employers, doctors, and hospitals who suggest or even provide formula and large bottles. One counselor stated:

“The bottles in the hospital, they’re the two-ounce bottles, and a newborn, one-day-old baby’s belly only holds about 5 to 10 ml. And so they’re given these bottles that are 60 ml plus. And often they’re overfed.” (WC5)

Many WIC counselors noted parents’ preconceived notions can make infant bottle-feeding counseling challenging. These included associating spit up and gas with milk intolerance or previous negative experiences with an infant formula, leading to a reluctance of its use with their current child. For example, one counselor stated:

“The biggest thing is just when there’s the, the notion that the formula is, is always the problem or, or like the specific type of formula that WIC has is the problem. And it’s hard to kind of navigate around that…it’s where we could focus more on positioning and again, recognizing the feeding cues…it’s easy to get really fixated on what’s in the bottle…” (WC4)

Navigating strutural constraints

Half of the WIC counselors discussed the challenges of providing support over the phone, specifically related to troubleshooting problems with latching and demonstrating proper ways to hold an infant when breast- or bottle-feeding. One counselor noted “feeling somewhat handicapped trying to explain things over the phone” (WC5). Lastly, some WIC counselors mentioned simply running out of time. With the extensive foundational and logistical topics required to be discussed at each WIC visit, WIC counselors were challenged to find time for education or anticipatory guidance, especially if the WIC participant had an issue they wanted to address. The WIC counselors noted a lack of time to teach things like paced bottle feeding.

“I feel like sometimes we have limited time with (sic) each patient, and probably having more time with each patient would help (sic) us a little bit more with teaching the patients...” (WC6)

WIC Participants

Responses from WIC participant interviews were categorized into two broad themes: 1) responsive feeding awareness; and 2) responsive feeding support within WIC and beyond.

Responsive feeding awareness.

While many participants did not recognize the terms “responsive feeding,” “feeding on demand,” or “baby-led feeding,” most had an awareness of the concept, primarily related to cue-based feeding.

Recognizing hunger cues

When mothers were asked how they knew when their infant was hungry, 7 mentioned using time or a schedule. Despite this, many mothers mentioned noticing hunger cues such as the infant being fussy, turning their head and looking for the breast or bottle, or sucking on their hands or bringing their hands to their mouth as signs of hunger. In addition, many mothers mentioned crying as a way to know when their infant was hungry.

Recognizing fullness cues

When asked how they knew when their infant was full, mothers identified a wide array of cues that they interpreted to mean their infant was satiated. The most common satiation cue was that the infant stopped sucking or detached from the nipple. Other cues included spitting the nipple out, playing with the nipple, turning their head away or pushing back, or shutting their mouth. Some mothers mentioned their infant spitting up or spilling milk out of their mouth as a sign their infant was full. Five mothers mentioned knowing their infant was full when they fell asleep: “He continues to sleep calmly, he is happy, he doesn’t bother me, he doesn’t cry or anything” (mother of 2 month old, formula feeding). Notably, some participants perceived that breastfed infants were to be fed according to hunger and fullness cues, while formula-fed infants should be fed on a schedule. For example, one participant stated, “By demand yes, I have heard of that term, for example, you have to breastfeed him on demand, but the milk, I mean, formulated milk must be provided by the hour instead of demand” (mother of 5 month old, combination feeding).

Responsive feeding support within WIC and beyond.

Participants also discussed their experiences receiving responsive feeding support within and outside of WIC. We categorized the responses into three subthemes: sources of support; content of support; and desired support.

Sources of Support

All participants reported receiving infant feeding support from WIC, particularly around breastfeeding. When asked how they learned to bottle-feed, most participants described drawing on past experiences. One participant stated: “At home, I had brothers, and I think I had been training since I was a little girl” (mother of 2 month old, formula feeding). Many also reported receiving support for infant feeding from hospital staff, such as nurses and lactation consultants. Five mothers reported learning to bottle-feed from family members, such as sisters and the infant’s maternal and paternal grandmothers. One participant stated:

“Well, it was my mom, thankfully shés still alive, and she taught me everything. I’m the middle sister out of five sisters, and out of all my sisters I’m the one with the youngest child, so my sisters have also helped me read the signals that my baby makes: whenever he wants to eat, and all that.” (mother of 7 month old, combination feeding)

Some participants mentioned receiving books or printed materials on infant feeding from WIC and other healthcare professionals. Others searched the internet for information. Two participants noted receiving infant feeding information in prenatal classes. One participant noted that she learned to bottle-feed “just by nature” (mother of 15 month old, fed breast milk).

Content of Support

Participants reported receiving counseling from WIC staff on infant feeding cues related to breastfeeding and bottle-feeding. Many reported receiving information on how much and how often to feed their infants.

“Um, they have given me information about like, um, uh, age and what the amount she should be taking too. And what at every hour, before it was two ounce every two hour to give me that information. And they are also tell me like to watch for signs that when she’s full, she would just refuse the bottle.” (mother of 2 month old, fed primarily breast milk)

Mothers also reported receiving information on positioning the infant during bottle-feeding, including using paced bottle feeding.

“Um, and then they also, they also talked about, um, how to feed the baby, how to position him, how the bottle should be positioned as well. Um, to take it out once in a while so he learns to, um, have like a good suck and not just get the milk easily so he can work on his own as well. ... Um, well, I was giving him the bottle like I wasn’t letting him paced feed. I was just giving it to him so he would finish. And, um, they told me that, they asked me if he would give, he would finish the bottle soon, and then I would answer, yes. And they said that, um, I should start the pace feeding because then he would, it would be, um, he would probably get frustrated while breastfeeding because he wasn’t gonna get it as fast as he would as a bottle.” (mother of 2 month old, feeding primarily breast milk)

Another participant stated, “Well, I was explained on how the position of giving the bottle should be so that he does not get used to the bottle, but continue with the breast milk” (mother of 5 month old, combination feeding). Mothers also reported receiving support around bottle and nipple types including bottles to reduce colic and nipples that best mimic breast anatomy; few mentioned receiving support around different types of formula. Lastly, a few participants mentioned receiving reassurance regarding their infant feeding decision from healthcare professionals, as noted by this quote:

“Um, but yeah, I, it helped me to add, to accept the decision of going to bottle feeding because I didn’t want to. … Yeah. So but they help me to understand why we need to do this and yeah, which is for the well-being for the baby, we as parents.” (mother of 2 month old, feeding primarily breast milk)

However, many discussed a focus on breastfeeding education compared to bottle-feeding. For example, one participant stated:

“My WIC person, she’s an incredible, the person that I did speak to from WIC at, [WIC clinic], she’s super great. She’s been, truthfully, she’s been much more than I needed, much more than I needed her to be, like, she always gave me extra information, she was always there on the tap of a button for me to contact her and tell her [WIC counselor] this is my situation, I really need some help and she was always willing to help me. But we leaned more towards nursing than bottle, Like more to the breastfeeding, not to the bottle.” (mother of 3 month old, feeding breast milk)

Desired Support

When mothers were asked about any additional support they would have liked to receive, specifically related to bottle-feeding, participants mentioned wanting guidance on the right bottle and nipple type, particularly for those who were breast- and bottle-feeding. Three participants mentioned wanting more support for breastfeeding, including initiating breastfeeding, proper latch, and how to increase milk supply. Two participants mentioned that receiving breast pump supplies, such as breast milk storage bags, would have been helpful. Some participants noted they would have liked to learn about bottle-feeding; they were not planning to bottle-feed, but found themselves doing so without the proper knowledge or support.

“I was interested in breastfeeding exclusively, but I would have liked to be told that it was still okay if I wasn’t able to breastfeed, and to have been given the option to receive information regarding what happens with the bottle. Information about both things; and so when the time comes, I would have the information.” (mother of 2 month old, formula feeding)

DISCUSSION

Through qualitative interviews with a sample of WIC counselors and participants in the North Carolina WIC program, we sought to understand the role WIC counselors play in supporting responsive bottle-feeding and the knowledge and use of responsive feeding among mothers of bottle-fed infants participating in WIC. Similar to other studies,^30,31 WIC participants in our study viewed WIC counselors as a source of support, and continuation of this support is imperative for parents to feel prepared to feed their infants appropriately. However, WIC counselors discussed several challenges with providing responsive feeding support including their limited time and competing demands during WIC appointments. With approximately 56,500 infants enrolled in WIC in North Carolina,²⁴ many WIC counselors have a high caseload leading to longer wait times and shorter appointments. Routine WIC visits include collecting anthropometric and hematologic data and addressing any parent concerns, which may present challenges in their ability to discuss topics such as responsive feeding and proper bottle-feeding techniques.³² Additionally, WIC counselors struggled with balancing providing support for bottle-feeding with their training to encourage breastfeeding. Counselors found it challenging to navigate providing education on the importance of breastfeeding while not coming across as coercive or overly persuasive when a caregiver expresses an interest in introducing infant formula. We acknowledge there are broader structural factors at play, such as adherence to the WHO Code of Marketing Breast Milk Substitutes,³³ that may limit what WIC counselors can discuss with participants.

The WIC participants in the present study had an awareness of responsive feeding, specifically cue-based feeding; this is consistent with our findings from WIC counselors who described educating parents on infant feeding cues. However, many WIC participants described using a feeding schedule for their infants. Feeding strictly based on a schedule is a nonresponsive feeding practice and has previously been associated with rapid weight gain in infancy.³⁴ Additionally, while WIC participants discussed having an awareness of feeding cues, many seemed to have a clearer understanding of hunger cues compared to fullness cues. The most common fullness cues mentioned by mothers in our study included detaching from the nipple, falling asleep, and spitting up; these are mid and late cues, which manifest as the infant’s feelings of satiation strengthen.³⁵ Early fullness cues, such as gaze aversion, slowing or pausing feeding, and decreasing muscle tone or activity level, indicate the infant’s initial signs of satiation.³⁵ Educating parents on early fullness cues is necessary to promote early recognition of infant fullness and facilitation of infant appetite self-regulation. Additionally, many participants perceived that responsive feeding applied to breastfeeding but not bottle-feeding. For example, participants felt breastfed infants should be fed “on demand,” while bottle-fed infants should be fed on a schedule. Responsive feeding applies to breast and bottle-fed infants as a way to allow the infant to control the pace of their feeds and promote appetite self-regulation.³⁵ There is a need to correct this misconception by promoting responsive feeding support to all caregivers, including those who directly breastfeed and bottle-feed.

Our results indicated that anticipatory guidance on how to bottle-feed was rarely offered to parents, suggesting bottle-feeding may be viewed as easier or more straightforward than breastfeeding. Additionally, WIC participants in a previous study reported feeling judged by WIC staff for formula-feeding and felt less supported by WIC staff compared to mothers of breastfed infants.³⁶ It was clear that breastfeeding support is a priority in WIC,³⁷ and is warranted given 80% of WIC participants in our sample were feeding their infants at least some breast milk. However, it is important for bottle-feeding caregivers to also benefit from anticipatory guidance, particularly related to responsive bottle-feeding, as most families use a bottle to feed their infants.^19,22

Despite our best efforts to create a comprehensive study, there are some study limitations to note. While we are confident we reached data saturation with 15 WIC participant interviews based on Saunders et al.’s (2018) model of a priori thematic saturation, we may not have reached saturation with the WIC counselor interviews.³⁸ However, the sample size was limited by the number of WIC counselors employed and their interest and availability. There are a total of 12 WIC counselors within the organization, so it is possible that we would have uncovered additional themes if we were able to interview the remaining 4. Additionally, in our sample, 73% of WIC participants identified as Hispanic, while few WIC counselors identified as Hispanic. This incongruity in ethnicity may have played a role in the provision of infant feeding counseling, considering that infant feeding practices are highly cultural.^39,40 Our study also has several strengths. First, we captured the perspectives of both WIC counselors and participants from the same program. This allowed us to attain both viewpoints of how responsive feeding support was delivered and received. Second, our study was strengthened by the community-based nature of the design, including the team’s ongoing reciprocal partnership with the WIC clinics, and the prioritization of centering the interview questions around the needs of those whom our subsequent intervention is intended to serve. Lastly, our team included two bilingual researchers, permitting us to include participants who spoke English and Spanish, which was important because the WIC clinics from which our sample was derived serve a large number of people who primarily speak Spanish.

Table.

Demographic Characteristics of WIC^a Participants Completing In-depth Qualitative Interviews (n=15).

Characteristic	n (%)
Infant age (months)
0–6	12 (80%)
7–12	2 (13%)
13–15	1 (7%)
Infant sex
Male	10 (67%)
Female	5 (33%)
Age of bottle introduction (weeks)
0–3	13 (87%)
5–10	2 (13%)
Milk type
Breast milk	7 (47%)
Formula	3 (20%)
Breast milk and formula	5 (33%)
Maternal age (years)
18–25	3 (20%)
26–30	5 (33%)
31–35	4 (27%)
36–40	2 (13%)
41+	1 (7%)
Number of children
1	4 (27%)
2	5 (33%)
3	5 (33%)
8	1 (7%)
Other feeders b
Father	11 (73%)
Grandmother	4 (27%)
Sibling	1 (7%)
Aunt	1 (7%)
None	2 (13%)
Race and ethnicity
Hispanic	11 (73%)
Black non-Hispanic	2 (13%)
White non-Hispanic	2 (13%)

The sample included mothers of bottle-fed infants participating in WIC in North Carolina. Interviews were conducted online via Zoom (Zoom Video Communications, 2022) and were focused on knowledge and use of responsive feeding.

^aWIC = Special Supplemental Nutrition Program for Women, Infants, and Children

^bThe total n for “other feeders” is more than the sample size (n=15) because participants were able to indicate as many other people that fed their infant as was applicable.

IMPLICATIONS FOR RESEARCH AND PRACTICE.

Findings from the present study suggest most WIC participants received responsive infant feeding support from WIC counselors, but it was often in the context of breastfeeding. Participants in this study indicated equitable responsive infant feeding support was not present for parents who bottle-fed compared to those who fed directly from the breast. It is clear WIC counselors in our sample provided a variety of necessary and valuable support for families, but were challenged by limited responsive bottle-feeding training, balancing promoting breastfeeding and supporting mothers’ decisions, and time constraints. Findings from our study suggest supplemental education to augment the existing breastfeeding support that is provided is needed for parents who bottle-feed, whether with breast milk or formula. Additionally, our study highlights the need for responsive bottle-feeding training for WIC staff to promote confidence with educating parents on responsive bottle-feeding during WIC appointments. Notably, there is a need for our study to be replicated with a larger, more diverse WIC counselor and participant sample. Future exploration of the training and counseling experiences of WIC counselors regarding responsive bottle-feeding from other states and organizations would be beneficial, and there is a need to expand the sample population to parents not enrolled in WIC. Our findings provide preliminary support for the need to develop and pilot an intervention focused on promoting responsive feeding for parents of bottle-fed infants.