Table 3.

Quotes illustrative of themes.

Theme 1. Pediatricians are uncertain about the concept, definition, and implications of excessive or rapid infant weight gain

“So, to be honest, I don’t think I have seen a large number of infants who are gaining too much weight, and I don’t know if that’s related to the practice and patient population that I see. I definitely see older kids, toddlers, who are gaining too much weight, but not really, truly in the infant period.” – participant 2007 “Typically (I do) not (get concerned). I think I would if I saw an infant crossing curves rapidly and again, being asymmetric in their growth or if they were just. . . If they were symmetrically large, I would at least step back and think about some syndromes and to go back and re-evaluate the feeding history. It would be rare for me to be really concerned about just about a baby growing rapidly.” – participant 2012 “So, I think that counseling families (of infants with excessive or rapid weight gain) is an area where I struggle as a pediatrician. I think a lot of people struggle as an outpatient practice in this domain, not just for infants, but for many patient populations. I think the biggest thing for infants is again showing that the rapid weight velocity could be linked to problems later on, which again, I don’t think the evidence is really clear yet, and so, it’s sort of hard to counsel in that area for parents.” – participant 2018 “Generally, (for infants with) too much weight, I don’t really. . . I feel like babies can be chunky and chubby [chuckle] and that’s okay. And I don’t necessarily do a whole lot of work up for that. I’d be happy to learn if I should.” – participant 2009 “For breastfed babies as long as mom is happy if baby’s gaining too much weight, I don’t do really anything about that. For formula-fed babies if they are gaining too much weight, and I’ve seen a couple who are consistently gaining in the 50 or 60 gram per day weight gain, I talk to mom about other ways of soothing the baby, and about trying pacifiers, and rocking, and playing, and other things other than feeding.”- participant 2011 “If see a baby who’s shooting off the top of the (growth) curve and the mother says, “ he breastfeeds every few hours during the day, he eats once overnight and he’s not spitting up.” Then I just say like, “Well this is who he is then.” I just do their typical well visits. I don’t think I’ve ever brought a baby in for a weight check for gaining too much weight.”- participant 2014

Theme 2 – Pediatricians have greater comfort with the evaluation of inadequate weight gain versus rapid infant weight gain

“I think, personally, I’m probably not as good at counseling and advising in excessive weight gain scenarios as opposed to the underweight scenarios.” – participant 2012 “The biggest thing (about evaluating an infant who may not be gaining weight appropriately) is more history. So, trying to understand, is this an organic thing with the baby, is it an inorganic thing, is it imbalance of, are they not getting enough in, are they losing calories, ‘cause there’s too much coming out? Do they have increased metabolic needs? I sort of divide it into different categories in my mind to better understand, like, which one do I think this baby is fitting in, and then ask more questions to better understand within that category what’s going on. So, if I’m concerned that they’re not getting enough in or don’t have enough caloric intake, is it because the family doesn’t have enough access to get enough formula for them? Are they mixing the formula incorrectly? Is it a really chaotic household, and it’s just kinda getting lost, like what the baby is actually eating and when they’re actually eating? Or I might worry that the baby is showing signs that they’re sweating when they’re feeding, having a fast heart rate, really incredibly fussy, and I’m worried that there might be some increased metabolic needs or demands. Do they have an underlying chronic illness that’s playing into this? Have they had lots and lots of back-to-back illnesses, even just viral illnesses, that’s playing into it? And then there’s the other side of, like, is it too much loss for the baby? So, either they’re burning more calories ‘cause of this increased metabolic demand, or what are their voids and stools like? Are they having increased insensible losses that are making it hard for them to gain weight?. . . When it comes to (counseling families) of infants who are gaining too much, I really struggle.” – participant 2015 “Usually, I monitor infants gaining too much weight much less closely than I do babies who are gaining too little weight. So if they come in at their two-month visit, and they were at the 15th percentile and now they’re at the 50th, I do nothing.” - participant 2001 “Generally, too much weight, I don’t really. . . I feel like babies can be chunky and chubby [chuckle] and that’s okay. And I don’t necessarily do a whole lot of work up for that. . .I think I’ve only referred folks (to our dietician) with inadequate weight gain problems more so than too much weight. I think the hard part is I don’t know about all of the evidence that would help me say, if an infant is obese and what problems they might have later on. I have very clear images and pictures in my mind as well as clear evidence of what the problems of undernutrition are.” – participant 2005 “I think you have to be really careful about how you word and phrase (concern about too much weight gain) to the family because I never wanna create a complex early on around eating and food. . . Because these situations are so few and far between. I think, personally, I’m probably not as good at counseling and advising in the excess weight scenarios as opposed to the underweight scenarios.” – participant 2006

Theme 3 – Pediatricians perceive overfeeding as the primary cause of excessive or rapid infant weight gain

“I think one of the biggest causes is pacification with the bottle. This is especially true for formula-fed infants. I really have only seen this excessive weight gain in formula-fed infants, not in breastfed infants, where they just rapidly gain weight. And it’s because they’re being offered too much in a bottle and they’re just being given the bottle and not really monitored for when they might be done. And I think that there’s an idea that like, “Oh, they took a few ounces when they were so little, and now they’re older, so they definitely need much more,” and I see infants sometimes being offered what I would consider excess amount in the bottle.” – participant 2018 “So, I think excessive formula-feeding, I think sometimes colicky babies get fed more, because they cry more, inappropriate foods being given. So, whether that be juice that’s unnecessary, or solids that are higher caloric intake, snacks, that kind of stuff. And then, genetic factors.” - participant 2015 “I think excess weight gain is caused by the practice of force-feeding, meaning really working with them to finish an entire bottle when they may be full. Utilizing food as a calming mechanism for the crying baby, they can be overfed in that way. The Italian grandmother syndrome of, “Food is love.” – participant 2010 “So I do think that maybe some babies that’s just who they are and they’re eating appropriately and they’re just big, so there could be like a genetic or an innate component to it. And then I do, I have seen kids who are being overfed, fed for comfort or having, parents will put cereal into the milk or the formula to thicken it because they think it helps the baby sleep better or it helps with the reflux and that can increase the calories in the milk. So those are. . . The times when I have identified things it’s things like that.” – participant 2002