Environmental Scan of Online Government Complementary Feeding Resources in the United States

Abstract

Background:

Parents commonly seek out online sources of information on the important complementary feeding period, but the accuracy of these sources varies. The 21^st Century Integrated Digital Experience Act (IDEA) states federal government resources should be accurate and user-friendly; however, the quantity, quality, and accuracy of federal resources on complementary feeding is unknown.

Methods:

This study involved an environmental scan of online federal, parent-facing resources about complementary feeding. The authors reviewed federal resources for concordance of information with the Dietary Guidelines for Americans (DGA). Quality was evaluated using the Patient Education Materials Assessment Tool.

Results:

A total of 112 resources across 2 federal government departments.. Overall quality was high as was concordance with recommendations from the DGA for age of complementary food introduction, foods to introduce, and foods to avoid. Allergenic food introduction and textured food progression recommendations were less consistent. Recommendations for improvements to federal resources are made.

Discussion:

This environmental scan only included federal resources for CF. Parents may be accessing other, non-federal resources online. However, given the enactment of IDEA, it is expected that these federal resources will be up-to-date and user friendly, which was not always the case. Nurses should review the DGA guidelines for complementary feeding and provide evidence-based anticipatory guidance to families, focusing especially on allergenic food introduction and textured food progression. Future complementary feeding interventions may benefit from directing families to online exemplars from federal sources.

Introduction

The complementary feeding (CF) period, from around 6 through 11 months of age, marks the transition from exclusive breastmilk or formula feeding to a solid food diet. Specific CF practices are associated with long-term health and developmental outcomes. Introduction to CF before 4 months and consuming sugar-sweetened beverages and sweets during infancy are linked to increased risk of childhood obesity (Auerbach et al., 2017; Gingras et al., 2019; Moore et al., 2019). Early introduction of potentially allergenic foods helps to prevent later food allergy (Du Toit et al., 2015; Peters et al., 2019). Parents are often aware of the impact of specific CF practices on their infant’s health, and they largely prioritize health promotion during CF (Graf et al., 2023). However, they often report confusion about how to approach CF (Samady et al., 2023).

The Dietary Guidelines for Americans (DGA) is produced by the United States Department of Agriculture (USDA) and United States Department of Health and Human Services (DHHS) to provide evidence-based diet and nutrition recommendations for health care providers (USDA & DHHS, 2020). The DGA, first published in 1980, is developed by a committee of scientific experts and is updated every 5 years, with the current edition effective from 2020 to 2025 (USDA & DHHS, 2020). This edition was the first to include CF-specific recommendations. The DGA serves as a crucial resource in shaping education materials, including federal online resources about CF. Educational materials in print or online formats play a critical role in shaping patient understanding of health concepts (Krasnoryadtseva et al., 2020). Effectiveness of these materials to facilitate comprehension and retention hinges on factors such as accuracy, readability such as clear language and concise information, and ease of use in appropriate formatting and user-friendly interfaces (Beaunoyer et al., 2017; Mackert et al., 2016). Most parents (89% as reported in Garcia et al., 2019) turn to online resources as their primary source of information for CF (Garcia et al., 2019; Graf, 2023; Kubb & Foran, 2020). However, accuracy of online information varies (Azak et al., 2023; Cheng et al., 2020; Taki et al., 2015). These inconsistencies can leave parents confused about how to approach CF (Clayton et al., 2013; Samady et al., 2023; Thompson et al., 2023).

The 21st Century Integrated Digital Experience Act (IDEA, 2018) mandates modernizing government websites for user-friendly content discovery. With an average of 2 billion monthly visits to federal websites in the United States (IDEA, 2018), and considering parents’ heavy reliance on the internet for CF information (Garcia et al., 2019), it is highly likely that parents are accessing federal webpages to inform their CF choices. The accuracy and quality of federal resources providing information on CF has not been reviewed.

With the enactment of IDEA in 2018, it is expected that parent-facing, federal online nutrition education resources about CF are consistent with the updated, evidence-based recommendations published by the DGA (USDA & DHHS, 2020). However, it is unclear what federal resources are available and how well they fit the updated DGA guidelines. The purpose of this research was to evaluate parent-facing federal CF resources and their concordance with the DGA recommendations for CF.

Methods

We conducted an environmental scan between October 2022 and April 2023 of online, publicly available, CF resources from federal sources. An environmental scan is a method for reviewing the current state of services and evaluating potential patient needs or gaps in available resources (Choo, 2001; Scobba, 2010). The environmental scan was completed by two researchers with expertise in the CF period, one speech language pathologist who specializes in pediatric feeding and one family nurse practitioner with a background in pediatric primary care. Complementary feeding resources were defined as written materials that provided information about CF to parents. Resources were eligible for inclusion if they: (1) addressed the CF period, up to 12 months of age; (2) were located on a US federal website that ended in “.gov”; (3) were publicly available; (4) were available in English; and (5) were intended for parents. Any resources that required login credentials or with broken links were excluded. The search also examined eligible resources from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program webpages for all 50 US states. We identified eligible resources for state WIC programs through two methods: (1) accessed the webpage for each state WIC program and navigated the website to locate nutrition education resources, and (2) Google searched, “(State) WIC nutrition education.” For other federal resources, we reviewed the “usa.gov” list of US government departments and agencies. Relevant sources such as webpages for specific agencies were reviewed for any resources, for example written materials, that met eligibility criteria. Table 1 (supplemental digital content at http://links.lww.com/MCN/A97) includes the identified resources and corresponding URLs. Based on the DGA recommendations, we developed a data extraction form that included information about the resources and a set of CF best practices. Both authors coded six WIC webpages independently and then met to reach consensus on definitions for CF practices. Nine additional WIC webpages were double coded, and an overall percentage agreement was calculated for dichotomous variables at 77.12%. We divided the remaining sources and reviewed and extracted the data from each, independently. The authors met regularly throughout the data extraction process to come to consensus on any questions that arose. Quality of the resources was assessed using a modified version of the Patient Education Materials Assessment Tool (Shoemaker et al., 2014). The tool has two sections: Understandability and Actionability. Most items are scored as either Agree (1) or Disagree (0); some items have a NA option. A total percentage score is calculated for each section. Higher scores indicate more Understandability or Actionability. We modified the tool for this review to include items that were most important for the target population of parents, most relevant to the purpose of the resources, and least redundant. We selected 5 of the 19 Understandability items and 3 of the 7 Actionability items. As many agencies had multiple resources, a single resource from each agency was chosen for reliability assessment. Initially, both authors rated the quality of six state WIC program resources individually and then met to resolve differences. The percent agreement for quality rating was 81.2%, indicating excellent interrater reliability. One author assessed (MG) the quality of the remainder of the resources. Descriptive statistics, including frequency counts, percentages, means, and standard deviations, were calculated for quantitative fields. Open-ended responses were analyzed using qualitative content analysis. For the content analysis, responses were inductively coded to determine key responses or themes. Then, the authors determined the frequency of those responses.

Results

Resources that met inclusion criteria (n = 112) were identified from two parent federal departments: the USDA and the DHHS (Table 2). We identified two agencies within the DHHS (Centers for Disease Control and Prevention [CDC] and Medline Plus) and two agencies within the USDA (MyPlate and individual state-run WIC agencies). Henceforth, the term federal agency refers to an organization within a federal department (USDA or DHHS) that produces health consumer information for an audience across the United States such as CDC, Medline Plus, and MyPlate. The term state WIC programs refers to the state-run WIC programs under the federal WIC agency.

Table 2.

Webpage Information and Quality

	Federal Sources				Overall
	Department of Health and Human Services		United States Department of Agriculture
	CDC	Medline Plus	MyPlate	State WIC Programs	All Federal Resources Combined
Number of Resources per Agency	15	2	1	33
Publication Year	2021–2023	2021	2022	2008 – 2023
Understandability Mean (SD)	100.0 (0)	60.0 (54.77)	100.0 (0)	75.3 (22.3)	87.06 (18.52)
Actionability Mean (SD)	66.67 (57.74)	33.33 (57.74)	66.67 (57.74)	64.20 (26.0)	66.17 (26.17)

Concordance with DGA Recommendations

DGA Recommendation #1: Timing of Complementary Food Introduction

In line with DGA recommendations, all of the federal agencies (CDC, MyPlate, and Medline Plus) and a majority of the state WIC programs recommended introduction of CF around 6 months old (75%), with 27% of sources noting risks of early introduction. State WIC programs that did not recommend 6 months for introduction, either did not specify an age for introduction, or recommended introducing between 4 and 6 months. One state WIC programs recommended introducing CF at 4 months old for formula-fed infants and 6 months old for breastfed infants (Table 3).

Table 3.

Concordance of Federal Agency Resources with DGA Guidelines and Percentage of State WIC Programs Providing DGA-Concordant Resources for When and How to Introduce Complementary Foods

DGA Recommendations for Complementary Feeding	Federal Sources
	Department of Health and Human Services		United States Department of Agriculture
	CDC	Medline Plus	MyPlate	State WIC Programs (N=33)
Age for Introducing	DGA-Concordant Recommendations Yes=✓ No = x	DGA-Concordant Recommendations Yes=✓ No = x	DGA-Concordant Recommendations Yes=✓ No = x	Overall N (%) of State WIC Programs with DGA-Concordant Recommendations
Introduce around 6 months old	✓	✓	✓	25 (75.8)
Readiness Signs for Introducing
Head/neck control	✓	✓	✓	23 (69.7)
Sitting up with support	✓	✓	✓	27 (81.8)
Bringing objects to the mouth	✓	x	✓	9 (27.3)
Grasping	✓	x	✓	7 (21.2)
Swallowing	✓	x	✓	16 (48.5)
Foods to Introduce
Foods Rich in iron	✓	✓	✓	19 (57.6)
Foods Rich in zinc	✓		✓	6 (18.2)
Vegetables	✓	✓	x	25 (75.8)
Fruits	✓	✓	x	23 (69.7)
Grains		✓	x	19 (57.6)
Proteins	✓	✓	x	16 (48.5)
Dairy	✓	✓	x	4 (12.1)
Provide repeated exposures to new foods	✓	x	✓	22 (66.7)
Foods to Avoid
Added sugar	✓	✓	✓	18 (54.4)
Higher sodium	✓	✓	✓	18 (54.5)
Honey	✓	✓	✓	25 (75.8)

DGA Recommendation #2: Readiness Signs for Complementary Foods

All sources included CF readiness signs. The most commonly included DGA-concordant signs were head or neck control and sitting up. Commonly stated cues that were not endorsed by the DGA included other oral motor signs of readiness such as can take food off of a spoon, ability to demonstrate hunger or fullness cues such as opening mouth for an approaching spoon, turning head away when full, and interest in food such as reaches for parent’s food (Table 3).

DGA Recommendation #3: Nutritional Content: Foods to Introduce

All of the sources mentioned foods to introduce, although the specific items varied by source. Most sources recommended introducing iron-rich foods (federal agencies = 100%; state WIC programs = 57%), whereas few recommended zinc-rich foods (federal agencies = 67%; state WIC programs = 18%). As per DGA recommendations, a majority of sources recommended introducing foods from a variety of food groups (Table 3) and repeated exposure to new foods to encourage acceptance (federal agencies = 67%; state WIC programs = 67%). Some (12%) state WIC programs recommended introducing baby food, although this was not specifically endorsed by the DGA. Three (9%) state WIC programs recommend introduction of juice, although the DGA states that no juice should be given to infants during the CF period (Table 3).

DGA Recommendation #4: Nutritional Content: Foods to Limit or Avoid

All of the reviewed sources included specific foods to avoid. Specifically, all federal agencies aligned with the DGA by recommending avoidance of honey, juice, and cow’s milk or plant-based milk before 12 months old. A majority of state WIC programs also mentioned avoiding honey (76%) and juice (53%). Fewer mentioned avoiding cow’s milk (48%) and plant-based milk (12%). Most sources recommended avoiding added sugar (federal agencies = 100%; state WIC programs = 54%) and higher sodium (federal agencies = 100%; state WIC programs = 54%). Other foods to avoid that were not included in the DGA but were referenced by the reviewed resources included desserts and sweets; foods with added oil, butter, or fat; processed meat; spices/seasonings; fried foods; and artificial sweeteners (Table 3).

DGA Recommendation #5: Allergenic Food Introduction

Most resources covered allergenic food introduction (federal agencies = 100%; state WIC programs = 85%); however, specific recommendations varied widely. Peanuts were the most discussed allergenic food item, with fewer sources mentioning other potential allergens including eggs, fish, shellfish, tree nuts, wheat, cow’s milk, soy, and sesame. All of the federal agencies recommended introducing at least one potentially allergenic food along with other CFs; however, only 12 (36%) of the state WIC programs included this DGA-concordant recommendation. Thirteen (39%) of the state WIC programs made no recommendation for age of introduction of allergenic foods. In contrast to DGA recommendations, one of the federal agencies and one of the state WIC programs recommended delaying allergenic foods until after the first birthday. The DGA recommends introducing peanuts at 4 to 6 months old to infants at increased risk of a food allergy, for example those with eczema or egg allergy. Yet, none of the federal agencies and only one state WIC program had this recommendation. As per DGA, two of the federal agencies (67%) and eight of the state WIC programs (24%) recommended speaking to a health care provider before introducing allergenic foods to infants with increased risk of experiencing a food allergy. Many (24%) of the state WIC programs mentioned family history of a food allergy as a high-risk indicator, although this is not specified by the DGA (Table 3).

DGA Recommendation #6: Responsive Feeding

Most sources recommended using a responsive feeding method (federal agencies = 67%; state WIC programs = 88%). Some commonly reported feeding methods not included in the DGA were offering allowing infant self-feeding, family meals without distractions, feeding the infant with a spoon, and allowing messy eating (Table 4).

Table 4.

Concordance of Federal Agency Resources with DGA Guidelines and Percentage of State WIC Programs Providing DGA-Concordant Resources for Allergenic Food Introduction and Developmental Feeding

DGA Recommendations for Complementary Feeding	Federal Sources
	Department of Health and Human Services		United States Department of Agriculture
	CDC	Medline Plus	MyPlate	State WIC Programs (N=33)
Allergenic Food Introduction	DGA-Concordant Recommendations Yes=✓ No = x	DGA-Concordant Recommendations Yes=✓ No = x	DGA-Concordant Recommendations Yes=✓ No = x	Overall N (%) of State WIC Programs with DGA-Concordant Recommendations N (%)
Introduce along with other CFs	✓	✓	✓	12 (36.4)
Introduce peanuts at 4–6 months if high risk	x	x	x	1 (3.0%)
Signs of increased risk of food allergy mentioned	✓	✓	x	6 (18.2)
Speak to a healthcare provider before introducing	✓	✓	x	8 (24.2)
Feeding Method
Utilize a responsive feeding method	✓	x	✓	29 (87.9)
Choking Prevention
Vary the thickness and texture of foods as infant oral skills develop	✓	x	✓	17 (51.5)
Offer appropriate size, consistency and shape food	✓	✓	✓	27 (81.8)
Make sure the infant is sitting up in a high-chair/safe place when feeding	✓	x	✓	10 (30.3)
Ensure adult supervision during mealtimes	✓	x	✓	13 (39.4)
Avoid adding infant cereal or other solid foods to the bottle	✓	✓	✓	16 (48.5)

DGA Recommendation #7: Choking Prevention and Textured Food Progression

The most commonly mentioned DGA-concordant choking prevention strategy was to offer foods in the appropriate size, consistency, and shape for easy swallowing (federal agencies = 100%; state WIC programs = 82%). Listed choking hazards to avoid included hot dogs, raisins, and uncooked apples. Although most federal agencies also recommended positioning the infant in a highchair or other safe place for feedings with adult supervision (67%), fewer state WIC programs included these recommendations (30%). About half of state WIC programs (52%) and two-thirds of federal agencies recommended varying food texture as infant oral skills develop. Many of the state WIC programs (79%) offered specific ages for introducing textures, although age ranges were not provided by the federal agencies. Generally, resources recommended starting with pureed and mashed foods from about 6 to 8 months, introducing soft chopped and ground food from 8 to 10 months, and adding bite-sized pieces or finger foods from about 9 to 12 months (Table 4).

Discussion

This environmental scan of public, parent-facing federal sources on CF evaluated a number of resources. Agreement across resources and agreement with the DGA varied depending on the topic, with strong agreement for age of introduction and moderate agreement for readiness signs, foods to introduce, and foods to avoid. Concordance with the DGA and across sources was less consistent for allergenic food introduction and textured food progression. Parents may face confusion when referencing federal materials for guidance on some areas of CF introduction. This wide range in publication dates may explain the variability in sources’ concordance with the DGA, which was published in 2020 (USDA & DHHS, 2020). Federal agencies tended to be more recently updated than state WIC programs. This discrepancy might reflect differences in staffing and resources allocated for the development of nutritional education materials. The development of a federal CF template, using a Human Factors approach (Holden et al., 2013), could streamline guidance, improve quality and reliability of the materials, and allow for customization by state and local agencies to facilitate uptake of recommended CF practices. CF practices can have a significant impact on a child’s growth and development (Gingras et al., 2019; Hurley et al., 2011; Le, 2016). A majority of sources, in line with DGA recommendations (USDA & DHHS, 2020), mentioned foods to introduce to achieve micro- and macro-nutrient requirements. Most focused on iron-rich foods, which is encouraging, given the increasing prevalence of iron-deficiency anemia in the United States (Le, 2016). Most sources also recommended using a responsive feeding method in concordance with the DGA (USDA & DHHS, 2020). All of the federal agencies and a majority of state WIC programs recommended appropriate timing of CF introduction around 6 months old, rather than the previously recommended 4 months (American Academy of Pediatrics [AAP] Committee on Nutrition, 2008; Thompson et al., 2023). Historically, introduction to CF prior to 4 months has been relatively common in the United States and linked to rapid weight gain and increased risk for obesity (Barrera et al., 2018). Prevalence of recommendations for responsive feeding and appropriate timing for CF introduction are promising signs that may indicate increasing national attention to early childhood feeding practices and efforts to attenuate early risk factors for childhood obesity (Hurley et al., 2011; Thompson et al., 2023).

Inconsistencies and Deficiencies Among Sources

Some resources recommended avoiding juice in the CF period, whereas others recommended offering it. This may have been due to different publication dates, as AAP only began to explicitly recommend avoiding juice during the CF period in 2017 (Heyman et al., 2017). However, these types of inconsistencies can cause confusion for parents (Clayton et al., 2013; Thompson et al., 2023). To maintain consistency and accuracy, federal nutrition resources should be updated every 5 years to reflect the frequency of DGA updates (USDA & DHHS, 2020). Few sources encouraged zinc-rich foods, as recommended by the DGA (USDA & DHHS, 2020). This may be due to lack of awareness of zinc deficiency, despite its increasing prevalence in high-income countries and adverse impacts on child growth and health (Fischer Walker et al., 2009; Vreugdenhil et al., 2021). Federal resources should explicitly recommend zinc-rich foods to encourage optimal nutrition and development. A significant weakness in the federal nutrition education resources was related to allergenic food introduction. Despite most resources discussing allergenic food introduction, many did not align with the DGA recommendations for timing of introduction, especially for infants at increased risk of food allergies (USDA & DHHS, 2020). This inconsistency may be attributed to changes in AAP policies in 2017 (Togias et al., 2017), which previously recommended delaying the introduction of allergenic foods (AAP, 2000). Regarding resources from state WIC programs, the absence of allergenic food introduction recommendations might stem from WIC’s lack of financial assistance for highly allergenic foods in the CF period (USDA, 2022). Recognizing the established link between delayed allergenic food introduction and increased food allergy risk (Du Toit et al., 2015; Peters et al., 2019), federal online CF resources should be updated to align with the DGA’s allergenic food recommendations (USDA & DHHS, 2020). The majority of resources also lacked guidance on textured food progression, which is crucial for the development of oral motor skills needed to safely consume table foods (Delaney & Arvedson, 2008; Simione et al., 2018). Delayed introduction to lumpy textures (later than 9–10 months) can result in an increased risk for picky or selective eating (Coulthard et al., 2009). Even the DGA lacks specific guidance on textured food progression, offering only broad recommendations to gradually vary the thickness and texture of foods (USDA & DHHS, 2020). Some resources such as Maryland and Kentucky state WIC programs offered more explicit guidance, including visuals illustrating advancing food textures and sample menus for different food textures. These resources provide potential models for improvement across resources.

Limitations

There are several limitations to this environmental scan. Many of the resources were outdated, with some versions dated as early as 2008. Inconsistencies across resources were noted. Because this scan focused exclusively on federal resources, we may have overlooked other important private CF resources. Accessibility of resources and prevalence of use by parents remains unknown. Some state WIC programs lacked any publicly available nutrition resources, raising concerns about access. Although WIC clinics may be providing in-house handouts to clients, parents most often seek out resources about CF online (Garcia et al., 2019; Graf, 2023).

Next Steps

The work offers multiple opportunities for future research. The first step is to evaluate which resources parents and clinicians access online. Researchers should evaluate all CF resources and compare accuracy and quality between federal and private sources. Future research may also benefit from incorporating a human factors framework to design and evaluate a federal CF template (Holden et al., 2013), whereas CF interventions may benefit from directing families to online exemplars from federal sources. Future research should investigate prevalence of responsive feeding methods and early CF introduction to determine if the updated guidance is having the intended effect of improving CF practices in the United States. Regardless of the information included in these resources, knowledge is only one of the many factors influencing behavior (Bronfenbrenner, 1979). Attitudes and beliefs, community, and societal structures should also be included in future research about decision-making for CF.

Conclusion

The CF period is critical for long-term health and nutrition and parents commonly seek CF information online. Nurses are pivotal in nutritional education within primary care and WIC settings and should be communicating the most up-to-date CF guidance to families. Nurses would benefit from a thorough review of DGA recommendations for CF, especially for allergenic food introduction practices and textured food progression. Nurses should be aware of outdated guidance that remains prevalent online, such as delaying allergenic food introduction or introducing CF at 4 months of age. Because parents seek out information online when needed, it would be helpful for nurses to provide anticipatory guidance for CF early in infancy, prior to parents seeking information. Familiarity with online federal resources for CF would enable nurses to direct families to the most reliable online materials. Nurses can contribute to the development of a centralized federal resource that can support the creation of parent-friendly online tools to promote evidence-based CF strategies to enhance infant health and nutrition.

Supplementary Material

Supplementary Material

Supplementary Table. URL Used to Access Complementary Feeding Resources by Federal Agency

CALLOUTS AND KEY WORDS.

• Parents often access complementary feeding information online.

• The 21^st Century Integrated Digital Experience Act (IDEA) (2018) mandates the modernization, standardization, and centralization of federal government websites to ensure that content is easily discoverable, comprehensible, and user-centered.

• Parents likely access online federal government websites, which are expected to be up to date and aligned with current best practices; however, the accuracy and quality of these resources is unknown.

• The reviewed federal resources generally aligned with the evidence-based Dietary Guidelines for Americans recommendations for age of introduction, foods to introduce, and foods to avoid.

• Recommendations for allergenic food introduction and textured food progression were less aligned with current best practices.

CLINICAL IMPLICATIONS.

• The complementary feeding period is a rapid, transitional time that can have long-term health and developmental impacts.

• Parents seek complementary feeding online but are often confused by conflicting and inaccurate information.

• Anticipatory guidance for complementary feeding should start early in infancy, prior to parents seeking the information online.

• Nurses should review the Dietary Guidelines for Americans 2020–2025 recommendations for complementary feeding and provide complementary feeding anticipatory guidance to families, especially for allergenic food introduction and textured food progression.

• To counter inaccurate information, nurses should be aware of outdated guidance for complementary feeding, such as introducing solid foods at 4 months old, introducing juice in infancy, and delaying allergenic food introduction.

• Nurses should familiarize themselves with online federal resources so that they can direct families to the most evidence-based, up-to-date resources.