Good nutrition and healthy eating habits early in life can set the foundation for life-long dietary patterns and behaviors.¹ Developing healthy habits at an early age may help prevent childhood obesity.² Obesity is a chronic disease affecting approximately 13.9% of 2 to 5 year old children in the US.³ Development of childhood obesity can lead to a wide range of adverse short- and long-term health conditions.^4,5 Effective strategies to prevent childhood obesity include targeting both nutrition-related factors in the child’s dietary intake, as well as healthy feeding and lifestyle behaviors practiced by both the caregiver and the child.^6,7 These prevention strategies can start before a child reaches the age of 2 years, and pediatricians can play a key role. They can help parents understand the impact of nutrition on their children’s health and how to make the best feeding choices possible for their families.⁸ Limited information is available in the literature regarding physician practices related to promotion of healthy eating behaviors and obesity prevention for very young children.^9,10 This study seeks to address that gap in the literature by exploring pediatrician self-reported practices related to nutrition and growth for children under 2 years of age.

The American Academy of Pediatrics (AAP) endorses several recommendations related to growth, feeding, and nutrition for infants and young children. First, in line with the Centers for Disease Control and Prevention’s endorsement, the AAP recommends the use of the World Health Organization (WHO) growth charts for monitoring age- and sex-specific weight-for-length measures in children under 2 years of age.^11,12 These international growth standards released by the WHO in 2006 describe optimal growth patterns for children ages 0 to 59 months.¹³

Second, the AAP recommends that infants are exclusively breastfed (ie, fed only breast milk without any other liquids or foods) for about the first 6 months of life. After this period, continued breastfeeding is recommended for at least 1 year as complementary foods are introduced.¹⁴ These recommendations state that the infant should be developmentally ready to eat solid foods, but do not specify which particular foods should be introduced first.^15,16 Finally, the AAP guides pediatricians on a variety of healthy behavior topics related to nutrition and physical activity to discuss with parents at well-child visits for children under 2 years of age.^16,17 These include topics such as understanding hunger and fullness cues, offering a variety of tastes and textures as solid foods are introduced, and limiting juice and other sugar-sweetened beverages.

In addition to the recommendations provided by the AAP, the Institute of Medicine’s Early Childhood Obesity Prevention Policies include several similar recommendations, such as: monitoring growth for all children aged 0 to 5 years, supporting breastfeeding and promoting consumption of a variety of nutritious foods, creating a healthy eating environment and practicing responsive feeding techniques, and encouraging health professionals to provide guidance to parents on healthy eating behaviors for young children.¹⁸

Pediatricians are an essential source of information for parents and caregivers of young children; however, research in this area has been limited. Data from national samples of pediatricians from 1995 to 2014 found that more pediatricians reported recommending exclusive breastfeeding over time (65% in 1994 to 76% in 2014), but fewer agreed that mothers could be successful at breastfeeding (70% in 1994 to 57% in 2014).⁹ Apart from breastfeeding, very little is known about pediatricians’ implementation of recommendations related to nutrition for infants and young children. This study sought to address this gap using data from the AAP Periodic Survey, a national survey of pediatricians who are members of AAP, which focused on topics related to obesity prevention and treatment in 2017. This study aimed to examine current pediatrician practices related to growth and nutrition for children aged under 2 years of age in the US. These results were also explored by pediatrician and practice characteristics to look for potential variation in practices by subgroups. Understanding this information might help to inform strategies aimed at improving provider practices around nutrition and growth for young children.

This study sought to examine US pediatric practices related to nutrition and health behavior counseling for children under 2 years of age, using a national survey of pediatricians. These findings indicated that pediatrician practices are generally in line with AAP recommendations and guidance related to nutrition for children aged under 2 years of age, with some exceptions.

In our study, 8 in 10 pediatricians reported using the recommended WHO growth charts for children under 2 years of age at every well-child visit. Other research using AAP Periodic Survey data found the use of growth charts for children under 2 years of age has steadily increased over time, with 65.5% of pediatricians in 2006 reporting use of any growth chart (including, but not limited to WHO charts) to 87.5% of pediatricians in 2017.²⁰ This prevalence of growth chart use for children under 2 years of age in 2017 was lower than the percentage of pediatricians reporting use of body mass index–for-age growth charts for children over age 2.²⁰ In 2006, 35% of pediatricians reported they plot body mass index on age and sex-appropriate growth charts at every well-child visit for children over age 2, increasing to 95% in 2017.²⁰ The literature suggests that there has been a significant increase in use of electronic health records (EHR) in the pediatric practice setting.²¹ The percentage of pediatricians who report using EHR increased from 58% in 2,009% to 94% in 2016.²¹ EHR can play an important role in screening for healthy childhood weight by automatically displaying height and weight information in the age-appropriate growth chart at all well-child visits.^22,23

Almost half of pediatricians reported recommending the introduction of baby cereals, fruits and vegetables, or meats to children at 4 to 5 months of age, earlier than the current AAP recommendation of solid food introduction around 6 months. This finding is similar to the percentage of US mothers who reported introducing their infants to complementary foods before 6 months of age (54.6%) in the National Health and Nutrition Examination Surveys from 2009 to 2014, although it is not clear how heavily pediatrician recommendations contribute to those decisions.²⁴ Although meat is mentioned in AAP guidance as good food to introduce soon after solids are started because of its iron content,¹⁵ most pediatricians in this study still recommended its introduction later than cereals or fruits and vegetables. This result is in line with findings from the US-based Feeding Infants and Toddlers Study, which found that parents of infants aged 4 to 6 months reported 65.8% consumed grain products, 39.9% vegetables, 41.9% fruit, and 14.2% meat or other proteins.²⁵

Nine in 10 pediatricians reported discussing key healthy eating behaviors with parents at most or all well-child visits, but fewer, about one-third, reported discussing topics related to responsive feeding behaviors and interactions between parents and their children. It is encouraging that most pediatricians reported discussing the importance of physical activity and several healthy eating behaviors with parents of young children, especially topics related to foods to encourage or avoid. This finding is similar to data from other studies focused on older children showing topics like physical activity, screen time, fruit and vegetable consumption, and limiting sugar-sweetened beverages are commonly discussed by pediatricians.^10,26 However, in this study, less than half of pediatricians reported regularly discussing topics related to the food environment, such as eating meals as a family and limiting meals eaten in front of the television, and few reported discussion of understanding and responding to hunger and satiety cues and avoiding using food as a reward or punishment. This is also similar to findings for children over 2 years of age in the 2017 AAP Periodic Survey, where pediatricians reported frequently discussing topics such as consumption of fruits and vegetables and being physically active, while topics related to food environment and responsive feeding, such as eating meals as a family and role modeling good nutrition by parents, were less commonly discussed.²⁰

Discussion of many healthy behavior topics varied by pediatrician practice type. Respondents in academic or hospital settings, which included residents, were less likely to report counseling on most of the healthy eating behaviors in the survey, compared with pediatricians in other practice types. These variations may reflect differences in time allotted for well-child visits, in the health status of patients across settings, or in resources available to provide information and counseling related to obesity prevention. For example, patients in academic or hospital settings may have other more critical health concerns needing attention at well-child visits, limiting the time available for healthy behavior discussions than those being seen in other practice settings. Pediatricians may also tailor their discussions with parents around feeding to their perceived likelihood of developing obesity based on family risk or other factors. Although there is a lack of evidence in this area for very young children, research using Medical Expenditure Panel Surveys from 2002 to 2011 found that among children 6 to 17 years old, counseling rates on both diet and physical activity increased for children with overweight and obesity.²⁷

For several of the healthy behaviors, differences in the likelihood of regularly discussing these topics were also noted by pediatrician sex, age, and residency status. Some of these findings were expected, while others were unexpected. For example, the finding that female pediatricians were slightly more likely than males to report counseling on limiting juice, avoiding sugary beverages, and eating a variety of fruits and vegetables align with other research on female pediatricians’ counseling practices.²⁸ However, the finding that men were more likely to counsel on avoiding restrictive and permissive food practices and not providing food as a reward was unexpected. Variation in practice noted by pediatrician age and residency status may be related to changes over time in training program content as well as differences in knowledge or uptake of the most current evidence-based recommendations. Other personal factors that may affect practices around early child nutrition include perceived importance of nutrition for young children, as well as individual or cultural beliefs related to feeding practices, among others. Pediatricians may also have varied access to user-friendly resources to provide parents with nutrition-related topics for young children.

With 10 well-child visits recommended in the first 2 years of life, pediatrician visits are a frequent touchpoint for parents, offering key opportunities for guidance and information on feeding and nutrition.¹⁷ Further research is needed to understand the reasons for variations in the provision of this information as well as the most effective ways to convey the recommended guidance to families.

Most US primary care pediatricians are following AAP recommendations and guidance related to optimal nutrition and growth for children aged under 2 years of age;however some topic areas and subgroups of pediatricians have lower implementation of recommended practices. Continued efforts to support pediatricians’ work related to early nutrition, feeding, and growth could help improve implementation of recommended practices.