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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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6

Considerations for Scaling Infant and Young Child Feeding Interventions

In this chapter the committee describes conclusions from both the scoping review identified literature as well as existing information on considerations needed for scaling infant and young child feeding interventions. The chapter begins with a discussion of the importance of identifying the systems each setting fits within and concludes with a discussion of considerations for scaling infant and young child feeding interventions that were informed by the identified studies within the scoping review.

SHIFTING PERSPECTIVE FROM SETTINGS TO SYSTEMS

As indicated in Chapter 4, the number of studies identified in the scoping review varied across settings, with 16 studies in health care settings (27 publications), 12 studies in home-visiting programs (18 publications), 5 studies in early care and education (ECE) (5 publications), two studies in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) settings (4 publications), 1 study in university cooperative extension (CE) programs (1 publication), and 23 studies (28 publications) that did not occur in any of the pre-specified settings. To ensure effective implementation and scaling, it is important to know, in addition to the setting, the system of systems that would be responsible for overseeing the implementation, scale-up, monitoring, evaluation, and maintenance of the programs or interventions. This approach is needed because a sector may be engaged in coordinating the delivery of a program across multiple settings, including those outside of the sector. For

Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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example, the health care system may coordinate infant and young child feeding programs delivered at home or at ECE centers, and the food assistance sector may coordinate delivery of programs such as WIC in partnership with the health care system. Many programs also involve social networking and information technology (IT) communications systems.

As discussed earlier, the committee identified and classified informative studies (n=3) and informative intervention elements (n=6) by setting and system (see Table 6-1). Which systems would be likely to oversee the coordination of program implementation and sustainability on a large scale was inferred from the program or discrete intervention implementation characteristics, primarily considering the U.S. context. One of the informative studies fell within the health system, and the other two were within the home-visiting system (see Table 6-1). Among the six discrete interventions that provided informative elements, one within food assistance, health, and social media/IT, and three in health and education. As these different systems are operated by different agencies, multisectoral coordination is needed for the successful implementation of informative programs and elements across settings.

TABLE 6-1 Noteworthy Features of Informative Studies and Intervention Elements by Systems and Settings

Program/Intervention [Location] System(s) Setting(s) Comment
Informative Studies
INfant Feeding, Activity, and Nutrition Trial (INFANT) [Victoria, Australia] Health
National (funding) and state (funding and operational) levels
Scaling up funded by National Medical Research Council with in-kind support from the Victorian Department of Health
Diverse health care provider practices Delivered as part of routine practice by dietitians, maternal and child health nurses, health promotion officers, midwives, other parenting support or allied health workers

A new scale-up iteration of the program relies on an interactive app and is currently being tested for effectiveness
Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) [PA, USA] Home Visit
Academic study funded by the National Institutes of Health (NIH)
Home Research nurses delivered the intervention at home visits
Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Program/Intervention [Location] System(s) Setting(s) Comment
Family Spirit Nurture [Navajo Nation, USA] Home Visit
Academic study funded by Healthy Eating Research, Navajo Area Indian Health Service, Osprey Foundation, the McCune Charitable Foundation, and The Robert Wood Johnson Foundation
Home Delivered by Navajo paraprofessional family health coaches
Informative Intervention Elements
Grow2Gether [PA, USA] Health and Social Media/IT
Academic study funded by the Children’s Hospital of Philadelphia Healthy Weight Program
Could be delivered by multiple sectors providing infant feeding services
Private Facebook peer group Videos based on American Academy of Pediatrics (AAP) Bright Futures guidelines Interactive Facebook groups of pregnant people assembled by the research team and facilitated by a psychologist postpartum and throughout early infancy
Early Food for Future Health [Norway] Health and Social Media/IT
Study funded by the University of Agder, with financial support from the Eckbo Foundation, Norway
Website Website videos developed by research team
Participants recruited from child health centers and Facebook
Short messaging service (SMS) WIC [Puerto Rico and HI, USA] Food Assistance, Health, and Social Media/IT
Study supported by the National Institute of Minority Health and Health Disparities
Interactive text messages Participants recruited at WIC clinics
SMS reinforced WIC education messages
Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Program/Intervention [Location] System(s) Setting(s) Comment
Early Childhood Obesity Prevention Program (ECHO) [CT, USA] Health and Education
Academic study in partnership with a children’s medical center and existing home visiting program funded by the Hartford Foundation for Public Giving Research study funded by NIH
Home Staff from existing home visiting program trained on delivery of enhanced home visiting sessions
Repetition Counts [UK] Health and Education
Academic study Funded by the European Community’s Seventh Framework Programme
Early Care and Education (ECE) ECE staff conducted the repeated exposures in ECE settings
EniM [Spain] Health and Education
Academic study with support from primary health care clinic
Early Care and Education Unclear who delivered educational sessions to parents of infants and young toddlers at the ECE centers, but intervention may be delivered by nurses at primary health care centers

SOURCES: Cameron et al. (2014); Campbell et al. (2008, 2013); Caton et al. (2013); Cloutier et al. (2018); Fiks et al. (2017); Gibby et al. (2019); Harris et al. (2020); Helle et al. (2019a,b); Hohman et al. (2017, 2020); Ingalls et al. (2019); Macchi et al. (2022); Palacios et al. (2018); Paul et al. (2014); Rosenstock et al. (2021); Roset-Salla et al. (2016); Savage et al. (2016, 2018); Spence et al. (2013, 2014); Zheng et al. (2022).

FACTORS FOR SUCCESSFUL SCALING OF INFANT AND YOUNG CHILD FEEDING INTERVENTIONS

The committee identified several interventions in what and how to feed infants and young children that reported improvements in self-reported outcomes, but their scalability and generalizability to diverse populations is unknown and their results will require replication with objective measures to avoid social desirability bias in outcome assessment. When designing an intervention with the promise to be viable and effective for wide dissemination, considering factors important for scaling will facilitate broader implementation in large or diverse populations. Programs that were designed

Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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as research studies and tested in homogenous, nonrepresentative, highly educated, or otherwise privileged populations or restricted to those who were highly motivated to participate in research may not be applicable to broader populations. The committee identified factors to consider when developing programs, monitoring progress, making adaptions and obtaining funding that are important for scaling infant and young child feeding interventions (see Box 6-1).

Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

To support effective implementation, it is important to give consideration to the skills that staff members will need to implement the intervention and to reconcile these with the organization’s ability to identify, maintain, and compensate those with the needed expertise. An intervention that requires extensive time and knowledge or that can only be done by highly specialized, skilled staff may not be realistic for broader use.

Limiting the burden on caregivers and children will increase the likelihood that an intervention is tolerable, or even welcomed, by recipients. An intervention that is engaging and motivating will have higher retention than one that is demanding or uninteresting to participants, and its effects are more likely to be sustained. Using culturally and linguistically appropriate program components and content that is sensitive to diverse views on child feeding and care will also increase acceptance among the target population. A program that is not respectful of tradition or that comes across as an imposition from outsiders would not be well received. Any program may have features that need to be adapted to different populations to be effective.

An intervention that considers a household’s diet will support full integration into the day-to-day life of program participants since the infant or young child will, over time, start consuming the family diet.

Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Thus, child dietary changes that occur as the result of the intervention (e.g., consumption of more fruits and vegetables) need to become the household norm in order to be sustained, rather than just a temporary accommodation for the infant or young child.

Limiting implementation costs will allow a program to be broadly implementable and sustainable over time. A program that is costly on a per-participant basis may be feasible for a small, select group or for a limited period of time, but to have a meaningful public health impact, the program should be suitable for widespread application over an indefinite period of time. While studies reviewed by the committee generally did not address the costs required to implement the intervention, the committee noted that programs with modest implementation costs are generally more feasible for widespread implementation.

Continuous monitoring, evaluation, and refinement of any large-scale program will help to ensure adequate coverage and quality of delivery of services. No matter how carefully a program is developed, unexpected challenges may call for changes based on practical experience or to recognize changes in the food system. Those changes may involve making the intervention as cost-effective as possible, enabling the intervention to be implemented by the most readily available and employable staff, and imposing the minimum necessary burden with maximum appeal to the target audience. Ongoing monitoring and evaluation will require systems for data collection from staff, intervention participants, and others engaged in the settings in which the program is being implemented and an ongoing experimental or quality improvement approach to identify, test, refine, adapt, and adopt changes.

NEXT STEPS FOR SCALING COMPLEMENTARY FEEDING INTERVENTIONS

These scalability lessons learned through the committee’s analysis are highly consistent with the findings of implementation science (Weiner, 2023) and with equity principles (Kumanyika, 2019, 2022), and they indicate the need for further implementation science research to improve the implementation, impact, and sustainability of large-scale infant and young toddler comprehensive feeding programs. Such a research agenda could also further address equity considerations and the sustainability of programs following successful scale-up.

The committee notes that only two of the studies reviewed (INFANT and Family Spirit Nurture) had evidence of moving beyond one efficacy study, likely due to the many barriers that exist to moving interventions from research study to scaled interventions. In addition to the studies described in this report, the committee identified 16 ongoing interven-

Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

tions for which results had not been published as of June 2023 (Alayli et al., 2020; Bryant et al., 2021; Dennis et al., 2021; Díaz-Rodríguez et al., 2020; Economos et al., 2023; Ferris et al., 2022; Hughes et al., 2016; Ingalls et al., 2019; Karssen et al., 2021, 2022; Laws et al., 2021; O’Reilly et al., 2021; Øverby et al., 2022; Pate et al., 2020; Reifsnider et al., 2013; Urkia-Susin et al., 2021). Many of these ongoing studies align with the life-stage approach; are guided by evidence-based frameworks, theories, and models; and will evaluate aspects of scalability as well as include implementation and process evaluation aspects. As made clear by the 83 publications identified in the scoping review and these ongoing studies that will result in additional publications in the coming years, infant and young child complementary feeding is an active area of research, and the evidence will continue to evolve.

SUMMARY

This chapter discussed the identification of the specific systems that can coordinate complementary feeding interventions within the settings that the committee reviewed in this report. The committee also identified factors and next steps for scaling complementary feeding interventions based on its scoping review, and it identified examples. While the evidence is evolving, the current literature suggests the need for multisystem approaches, improving the implementation, impact, equity, and sustainability of large-scale infant and young toddler comprehensive feeding programs to improve feeding behaviors.

The next chapter describes opportunities and challenges for both building effective, scalable complementary feeding programs that consider the existing infrastructure and for future data collection and research.

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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Page 146
Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Page 147
Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Page 148
Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Page 150
Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"6 Considerations for Scaling Infant and Young Child Feeding Interventions." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Complementary feeding refers to the introduction of foods other than human milk or formula to an infants diet. In response to a request from the Centers for Disease Control and Prevention, the National Academies Health and Medicine Division convened the Committee on Complementary Feeding Interventions for Infants and Young Children under Age 2 to conduct a consensus study scoping review of peer-reviewed literature and other publicly available information on interventions addressing complementary feeding of infants and young children. The interventions studied took place in the U.S. and other high-income country health care systems; early care and education settings; university cooperative extension programs; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); home visiting programs; and other settings. This consensus study report summarizes evidence and provides information on interventions that could be scaled up or implemented at a community or state level.

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