Addressing child and adolescent obesity management in Ireland: identifying facilitators and barriers in clinical practice.

Background: Ireland's Model of Care for the Management of Overweight and Obesity outlines a plan for treating adolescent and child obesity (CO). However, engagement with key stakeholders is required to support its implementation and improve health services. Aim: This study aims to map the perceived barriers and facilitators related to CO management across healthcare settings, professional disciplines, and regions in the Republic of Ireland (ROI). Materials and methods: An online cross-sectional survey of registered healthcare professionals (HPs), designed to adhere to the Consolidated Framework for Implementation Research (CFIR), was co-developed by a project team consisting of researchers, healthcare professionals, and patient advocates. The survey was pilot tested with project stakeholders and distributed online to professional groups and via a social media campaign, between September 2021 and May 2022, using "SurveyMonkey." Data were summarised using descriptive statistics and thematic analyses. Themes were mapped to the CFIR framework to identify the type of implementation gaps that exist for treating obesity within the current health and social care system. Results: A total of 184 HPs completed the survey including nurses (18%), physicians (14%), health and social care professionals (60%), and other HPs (8%). The majority were female (91%), among which 54% reported conducting growth monitoring with a third (32.6%) giving a diagnosis of paediatric/adolescent obesity as part of their clinical practice. Nearly half (49%) of the HPs reported having the resources needed for clinical assessment. However, 31.5% of the HPs reported having enough "time," and almost 10% of the HPs reported having no/limited access to suitable anthropometric measurement tools. Most HPs did not conduct obesity-related clinical assessments beyond growth assessment, and 61% reported having no paediatric obesity training. CFIR mapping identified several facilitators and barriers including time for clinical encounters, suitable materials and equipment, adequate training, perceived professional competency and self-efficacy, human equality and child-centredness, relative priorities, local attitudes, referral protocols, and long waiting times. Conclusions: The findings provide actionable information to guide the implementation of the Model of Care for the Management of Overweight and Obesity in Ireland. Survey findings will now inform a qualitative study to explore implementation barriers and facilitators and prioritise actions to improve child and adolescent obesity management.

Obesity in Adults: A 2022 Adapted Clinical Practice Guideline for Ireland.

BACKGROUND: This Clinical Practice Guideline (CPG) for the management of obesity in adults in Ireland, adapted from the Canadian CPG, defines obesity as a complex chronic disease characterised by excess or dysfunctional adiposity that impairs health. The guideline reflects substantial advances in the understanding of the determinants, pathophysiology, assessment, and treatment of obesity. SUMMARY: It shifts the focus of obesity management toward improving patient-centred health outcomes, functional outcomes, and social and economic participation, rather than weight loss alone. It gives recommendations for care that are underpinned by evidence-based principles of chronic disease management; validate patients' lived experiences; move beyond simplistic approaches of "eat less, move more" and address the root drivers of obesity. KEY MESSAGES: People living with obesity face substantial bias and stigma, which contribute to increased morbidity and mortality independent of body weight. Education is needed for all healthcare professionals in Ireland to address the gap in skills, increase knowledge of evidence-based practice, and eliminate bias and stigma in healthcare settings. We call for people living with obesity in Ireland to have access to evidence-informed care, including medical, medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy, and bariatric surgery. This can be best achieved by resourcing and fully implementing the Model of Care for the Management of Adult Overweight and Obesity. To address health inequalities, we also call for the inclusion of obesity in the Structured Chronic Disease Management Programme and for pharmacotherapy reimbursement, to ensure equal access to treatment based on health-need rather than ability to pay.

Guidelines for treating child and adolescent obesity: A systematic review.

Obesity is a chronic disease that compromises the physical and mental health of an increasing proportion of children globally. In high-income countries, prevalence of paediatric obesity is increasing faster in those from marginalised populations such as low-income households, suggesting the disease as one that is largely systemic. Appropriate treatment should be prioritised in these settings to prevent the development of complications and co-morbidities and manage those that already exist. An array of clinical practice guidelines are available for managing overweight and obesity in children and adolescents, but no systematic review has yet compared their quality or synthesised their recommendations. We aimed to narratively review clinical practice guidelines published in English for treating child and adolescent obesity, to identify the highest quality guidelines, and assess similarities, conflicts, and gaps in recommendations. We systematically searched academic databases and grey literature for guidelines published. We used the AGREE II tool to assess the quality, and identified nine high quality guidelines for inclusion in a narrative review of recommendations. Guidelines predominantly recommended the delivery of multi-component behaviour-change interventions aimed at improving nutrition and physical activity. Treatment outcomes were generally focussed on weight, with less emphasis on managing complications or improving quality-of-life. There was no evidence-based consensus on the best mode of delivery, setting, or treatment format. The guidelines rarely included recommendations for addressing the practical or social barriers to behaviour change, such as cooking skills or supervised physical activity. There is insufficient evidence to evaluate pharmaceutical and surgical interventions in children, and these were generally not recommended. It should be noted that this review addressed documents published in English only, and therefore the included guidelines were applicable predominantly to high-resource settings.

Usability and Engagement Testing of mHealth Apps in Paediatric Obesity: A Narrative Review of Current Literature.

Mobile health (mHealth) platforms have become increasingly popular for delivering health interventions in recent years and particularly in light of the COVID-19 pandemic. Childhood obesity treatment is an area where mHealth interventions may be useful due to the multidisciplinary nature of interventions and the need for long-term care. Many mHealth apps targeting youth exist but the evidence base underpinning the methods for assessing technical usability, user engagement and user satisfaction of such apps with target end-users or among clinical populations is unclear, including for those aimed at paediatric overweight and obesity management. This review aims to examine the current literature and provide an overview of the scientific methods employed to test usability and engagement with mHealth apps in children and adolescents with obesity. A narrative literature review was undertaken following a systematic search. Four academic databases were searched. Inclusion criteria were studies describing the usability of mHealth interventions for childhood obesity treatment. Following the application of inclusion and exclusion criteria, fifty-nine articles were included for full-text review, and seven studies met the criteria for usability and engagement in a clinical paediatric population with obesity. Six apps were tested for usability and one for engagement in childhood obesity treatment. Sample sizes ranged from 6-1120 participants. The included studies reported several heterogenous measurement instruments, data collection approaches, and outcomes. Recommendations for future research include the standardization and validation of instruments to measure usability and engagement within mHealth studies in this population.

Factors Associated With Intimate Partner Violence Perpetration and Victimization in Asylum Seeking and Refugee Populations: A Systematic Review.

Intimate partner violence (IPV) is a common and serious health and justice problem. Asylum seekers and refugees are generally vulnerable to violence and may be particularly vulnerable to IPV. The aim of this study is to identify factors associated with IPV perpetration and victimization in asylum seeking and refugee populations through a systematic review of the literature. PubMed, Web of Science, Scopus, Embase, Global Health, PsycINFO, Westlaw, and Social Science Research Network databases were searched. Quantitative studies were included according to a population, exposure, outcome framework. Studies were critically appraised with the Joanna Briggs Institute's System for the Unified Management, Assessment and Review of Information tool and quality assessed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach. Meta-analysis was not possible due to heterogeneity. A complex multitude of factors associated with IPV perpetration and victimization in asylum seeking and refugee populations was found. Narrative synthesis of 23 studies showed an inverse association between both perpetrator and victim education level and IPV. Relationship factors, legal status, and age were also important factors associated with IPV. The majority of studies had a cross-sectional design. Heterogeneity in definitions of IPV, sample, methods, statistical procedures, and outcomes was reported. Low education level is a consistent modifiable factor associated with IPV in asylum seeking and refugee populations. This work points to a testable intervention that stakeholders could trial to address the unjust and unhealthy problem of IPV. More and better quality research using standardized definitions, longitudinal design, and sensitive tools is needed in this area.

Protective Factors for LGBTI+ Youth Wellbeing: A Scoping Review Underpinned by Recognition Theory.

Considerable research has been undertaken regarding the mental health inequalities experienced by lesbian, gay, bisexual, transgender and intersex (LGBTI+) youth as a consequence of societal and individual prejudice, stigma and discrimination. Far less research has focussed on protective factors that promote wellbeing for this population. A scoping review was conducted using a six-stage methodological framework, and is reported in accordance with the PRISMA-ScR statement. This explored the extent, range and nature of the peer-reviewed, published, academic literature on what is known about the protective factors that promote LGBTI+ youth wellbeing. Six databases were systematically searched applying Population-Concept-Context key inclusion criteria, complemented by contact with authors to identify additional sources, reference checks and hand searches. Ninety-six individual research records were identified and analysed, drawing from Honneth's Recognition Theory. Interpersonal relations with parents (n = 40), peers (n = 32) and providers (n = 22) were associated with indicators of enhanced wellbeing, as were LGBTI+ community relations (n = 32). Importantly, online (n = 10), faith (n = 10) and cultural (n = 5) communities were potentially protective. Content and thematic analysis highlighted the importance of Gay-Straight Alliances (GSAs) (n = 23) offering powerful protective opportunities through intersecting interpersonal, community and legal forms of recognition. GSAs enhance allyship by peers and providers (n = 21), facilitate access to LGBTI+ community networks (n = 11) and co-exist alongside inclusive policies (n = 12), curricular (n = 5) and extracurricular activities (n = 1). This scoping review underscores the need to move beyond the predominant focus on risk factors for LGBTI+ youth, which subsequently inform protectionist approaches. It concludes with an appeal to develop mechanisms to apply recognitive justice to policy, practice and, importantly, future research directions. This emphasises the salience of enhanced understandings of inclusion, which is rights-based, universally available and of potential benefit to all.

Pediatric Weight Management Through mHealth Compared to Face-to-Face Care: Cost Analysis of a Randomized Control Trial.

BACKGROUND: Mobile health (mHealth) may improve pediatric weight management capacity and the geographical reach of services, and overcome barriers to attending physical appointments using ubiquitous devices such as smartphones and tablets. This field remains an emerging research area with some evidence of its effectiveness; however, there is a scarcity of literature describing economic evaluations of mHealth interventions. OBJECTIVE: We aimed to assess the economic viability of using an mHealth approach as an alternative to standard multidisciplinary care by evaluating the direct costs incurred within treatment arms during a noninferiority randomized controlled trial (RCT). METHODS: A digitally delivered (via a smartphone app) maintenance phase of a pediatric weight management program was developed iteratively with patients and families using evidence-based approaches. We undertook a microcosting exercise and budget impact analysis to assess the costs of delivery from the perspective of the publicly funded health care system. Resource use was analyzed alongside the RCT, and we estimated the costs associated with the staff time and resources for service delivery per participant. RESULTS: In total, 109 adolescents participated in the trial, and 84 participants completed the trial (25 withdrew from the trial). We estimated the mean direct cost per adolescent attending usual care at €142 (SD 23.7), whereas the cost per adolescent in the mHealth group was €722 (SD 221.1), with variations depending on the number of weeks of treatment completion. The conversion rate for the reference year 2013 was $1=€0.7525. The costs incurred for those who withdrew from the study ranged from €35 to €681, depending on the point of dropout and study arm. The main driver of the costs in the mHealth arm was the need for health professional monitoring and support for patients on a weekly basis. The budget impact for offering the mHealth intervention to all newly referred patients in a 1-year period was estimated at €59,046 using the assessed approach. CONCLUSIONS: This mHealth approach was substantially more expensive than usual care, although modifications to the intervention may offer opportunities to reduce the mHealth costs. The need for monitoring and support from health care professionals (HCPs) was not eliminated using this delivery model. Further research is needed to explore the cost-effectiveness and economic impact on families and from a wider societal perspective. TRIAL REGISTRATION: ClinicalTrials.gov NCT01804855; https://clinicaltrials.gov/ct2/show/NCT01804855.

Recruiting 'hard to reach' parents for health promotion research: experiences from a qualitative study.

OBJECTIVE: Marginalised populations are less likely to take part in health research, and are sometimes considered 'easy to ignore'. We aimed to describe our approach and results of recruiting parents who experience disadvantage, for focus groups exploring infant feeding on the island of Ireland. Upon receiving ethical approval, we implemented recruitment strategies that included building rapport with community organisations through existing networks, targeting specific organisations with information about our aims, and utilising social media groups for parents. RESULTS: We approached 74 organisations of which 17 helped with recruitment. We recruited 86 parents/carers (one male) for 19 focus groups (15 urban/4 rural). Seventy two percent met at the eligibility criteria. Most participants were recruited through organisations (91%), and the remainder on social media (9%). Recruitment barriers included multiple steps, research fatigue, or uncertainty around expectations. Factors such as building rapport, simplifying the recruitment process and being flexible with procedures were facilitators. Despite comprehensive, multi-pronged approaches, the most marginalised parents may not have been reached. Further alternative recruitment strategies are required for recruiting fathers, rural populations, or those without the capacity or opportunity to engage with local services.

Barriers and Facilitators for Implementing Paediatric Telemedicine: Rapid Review of User Perspectives.

Background: COVID-19 has brought to the fore an urgent need for secure information and communication technology (ICT) supported healthcare delivery, as the pertinence of infection control and social distancing continues. Telemedicine for paediatric care warrants special consideration around logistics, consent and assent, child welfare and communication that may differ to adult services. There is no systematic evidence synthesis available that outlines the implementation issues for incorporating telemedicine to paediatric services generally, or how users perceive these issues. Methods: We conducted a rapid mixed-methods evidence synthesis to identify barriers, facilitators, and documented stakeholder experiences of implementing paediatric telemedicine, to inform the pandemic response. A systematic search was undertaken by a research librarian in MEDLINE for relevant studies. All identified records were blind double-screened by two reviewers. Implementation-related data were extracted, and studies quality appraised using the Mixed-Methods Appraisal Tool. Qualitative findings were analysed thematically and then mapped to the Consolidated Framework for Implementation Research. Quantitative findings about barriers and facilitators for implementation were narratively synthesised. Results: We identified 27 eligible studies (19 quantitative; 5 mixed-methods, 3 qualitative). Important challenges highlighted from the perspective of the healthcare providers included issues with ICT proficiency, lack of confidence in the quality/reliability of the technology, connectivity issues, concerns around legal issues, increased administrative burden and/or fear of inability to conduct thorough examinations with reliance on subjective descriptions. Facilitators included clear dissemination of the aims of ICT services, involvement of staff throughout planning and implementation, sufficient training, and cultivation of telemedicine champions. Families often expressed preference for in-person visits but those who had tried tele-consultations, lived far from clinics, or perceived increased convenience with technology considered telemedicine more favourably. Concerns from parents included the responsibility of describing their child's condition in the absence of an in-person examination. Discussion: Healthcare providers and families who have experienced tele-consultations generally report high satisfaction and usability for such services. The use of ICT to facilitate paediatric healthcare consultations is feasible for certain clinical encounters and can work well with appropriate planning and quality facilities in place.

Mobile Health Apps in Pediatric Obesity Treatment: Process Outcomes From a Feasibility Study of a Multicomponent Intervention.

BACKGROUND: Multicomponent family interventions underline current best practice in childhood obesity treatment. Mobile health (mHealth) adjuncts that address eating and physical activity behaviors have shown promise in clinical studies. OBJECTIVE: This study aimed to describe process methods for applying an mHealth intervention to reduce the rate of eating and monitor physical activity among children with obesity. METHODS: The study protocol was designed to incorporate 2 mHealth apps as an adjunct to usual care treatment for obesity. Children and adolescents (aged 9-16 years) with obesity (BMI ≥98th centile) were recruited in person from a weight management service at a tertiary health care center in the Republic of Ireland. Eligible participants and their parents received information leaflets, and informed consent and assent were signed. Participants completed 2 weeks of baseline testing, including behavioral and quality of life questionnaires, anthropometry, rate of eating by Mandolean, and physical activity level using a smart watch and the myBigO smartphone app. Thereafter, participants were randomized to the (1) intervention (usual clinical care+Mandolean training to reduce the rate of eating) or (2) control (usual clinical care) groups. Gender and age group (9.0-12.9 years and 13.0-16.9 years) stratifications were applied. At the end of a 4-week treatment period, participants repeated the 2-week testing period. Process evaluation measures included recruitment, study retention, fidelity parameters, acceptability, and user satisfaction. RESULTS: A total of 20 participants were enrolled in the study. A web-based randomization system assigned 8 participants to the intervention group and 12 participants to the control group. Attrition rates were higher among the participants in the intervention group (5/8, 63%) than those in the control group (3/12, 25%). Intervention participants undertook a median of 1.0 training meal using Mandolean (25th centile 0, 75th centile 9.3), which represented 19.2% of planned intervention exposure. Only 50% (9/18) of participants with smart watches logged physical activity data. Significant differences in psychosocial profile were observed at baseline between the groups. The Child Behavior Checklist (CBCL) mean total score was 71.7 (SD 3.1) in the intervention group vs 57.6 (SD 6.6) in the control group, t-test P<.001, and also different among those who completed the planned protocol compared with those who withdrew early (CBCL mean total score 59.0, SD 9.3, vs 67.9, SD 5.6, respectively; t-test P=.04). CONCLUSIONS: A high early attrition rate was a key barrier to full study implementation. Perceived task burden in combination with behavioral issues may have contributed to attrition. Low exposure to the experimental intervention was explained by poor acceptability of Mandolean as a home-based tool for treatment. Self-monitoring using myBigO and the smartwatch was acceptable among this cohort. Further technical and usability studies are needed to improve adherence in our patient group in the tertiary setting.

Mobile Health for Pediatric Weight Management: Systematic Scoping Review.

BACKGROUND: The prevalence and consequences of obesity among children and adolescents remain a leading global public health concern, and evidence-based, multidisciplinary lifestyle interventions are the cornerstone of treatment. Mobile electronic devices are widely used across socioeconomic categories and may provide a means of extending the reach and efficiency of health care interventions. OBJECTIVE: We aimed to synthesize the evidence regarding mobile health (mHealth) for the treatment of childhood overweight and obesity to map the breadth and nature of the literature in this field and describe the characteristics of published studies. METHODS: We conducted a systematic scoping review in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews, by searching nine academic databases in addition to gray literature for studies describing acceptability, usability, feasibility, effectiveness, adherence, or cost-effectiveness of interventions assessing mHealth for childhood obesity treatment. We also hand searched the reference lists of relevant articles. Studies aimed at the prevention of overweight or obesity were excluded, as were studies in which mHealth was not the primary mode of treatment delivery for at least one study arm or was not independently assessed. A random portion of all abstracts and full texts was double screened by a second reviewer to ensure consistency. Data were charted according to study characteristics, including design, participants, intervention content, behavior change theory (BCT) underpinning the study, mode of delivery, and outcomes measured. RESULTS: We identified 42 eligible studies assessing acceptability (n=7), usability (n=2), feasibility or pilot studies (n=15), treatment effect (n=17), and fidelity (n=1). Change in BMI z-scores or percentiles was most commonly measured, among a variety of dietary, physical activity, psychological, and usability or acceptability measures. SMS, mobile apps, and wearable devices made up the majority of mobile interventions, and 69% (29/42) of the studies specified a BCT used. CONCLUSIONS: Pediatric weight management using mHealth is an emerging field, with most work to date aimed at developing and piloting such interventions. Few large trials are published, and these are heterogeneous in nature and rarely reported according to the Consolidated Standards of Reporting Trials for eHealth guidelines. There is an evidence gap in the cost-effectiveness analyses of such studies.

What is known about the protective factors that promote LGBTI+ youth wellbeing? A scoping review protocol.

Background: There is much concern at the substantial vulnerabilities experienced by lesbian, gay, bisexual, transgender and intersex (LGBTI+) youth as a consequence of discrimination, stigmatisation and marginalisation. Recent research highlights the importance of understanding factors that can promote wellbeing for this population. This paper presents a protocol for a scoping review which aims to systematically map and synthesise the extent and nature of the peer-reviewed, published academic literature on the protective factors that promote wellbeing for sexual and gender minority young people. Methods: In accordance with the methodological framework for scoping reviews, the following six stages will be undertaken: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting results and (6) consultation. The PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation will be used throughout the review process. Key inclusion criteria will use the Population, Concept, Context approach, with two reviewers independently conducting the screening and extraction stages across five databases. Identified protective factors will be collated, summarised and categorised iteratively by one reviewer in consultation with the review team. Stakeholder consultation is a key strength of the scoping review process and will be complemented by the public patient involvement of LGBTI+ young people with expertise by experience. Conclusions: The scoping review has the potential to inform policy, practice and future research through enhanced understandings of the complex interplay of factors that promote wellbeing for sexual and gender minority youth. This first stage of the research process will inform the development of a larger research project. The findings will be disseminated through a peer reviewed publication, a conference presentation and by sharing the findings with key stakeholders, including LGBTI+ young people.

Assessing the Potential for Integrating Routine Data Collection on Complementary Feeding to Child Health Visits: A Mixed-Methods Study.

There is no routine data collection in the UK on infant dietary diversity during the transition to solid foods, and health visitors (HVs) (nurses or midwives with specialist training in children and family health) have the potential to play a key role in nutrition surveillance. We aimed to assess items for inclusion in routine data collection, their suitability for collecting informative data, and acceptability among HVs. A mixed-methods study was undertaken using: (i) an online survey testing potential questionnaire items among parents/caregivers, (ii) questionnaire redevelopment in collaboration with community staff, and (iii) a survey pilot by HVs followed by qualitative data collection. Preliminary online questionnaires (n = 122) were collected to identify useful items on dietary diversity. Items on repeated exposure to foods, aversive feeding behaviors, flavor categories, and sugar intake were selected to correspond to nutrition recommendations, and be compatible with electronic records via tablet. HVs surveyed 187 parents of infants aged 12 months. Semi-structured interviews indicated that HVs found the questionnaire comparable with standard nutrition conversations, which prompted helpful discussions, but questions on eating behavior did not prompt such useful discussions and, in some cases, caused confusion about what was 'normal.' Lack of time among HVs, internet connectivity issues, and fear of losing rapport with parents were barriers to completing electronic questionnaires, with 91% submitted by paper. Routine nutrition data collection via child health records seems feasible and could inform quality improvement projects.

"The One Time You Have Control over What They Eat": A Qualitative Exploration of Mothers' Practices to Establish Healthy Eating Behaviours during Weaning.

BACKGROUND: Weaning marks the transition from a milk-only diet to the consumption of solid foods. It is a time period where nutrition holds an undeniable importance and taste experiences have a long-lasting effect on food preferences. The factors and conditions that form parental feeding practices are yet to be fully understood; doing so can help target problematic behaviours and develop interventions aiming to modify them. OBJECTIVE: This study used a qualitative methodology to gain a better understanding of parental experiences of weaning a child. Particular emphasis was placed on exploring the factors and conditions that favour the establishment of a healthy relationship with food in infancy and those that impede it. METHODS: Thirty-seven mothers of healthy infants 3⁻14 months with no previous history of allergies or food-related disorders were recruited. Eight semi-structured focus group discussions were conducted, transcribed and analysed thematically. RESULTS: Discussions revealed a number of opportunities to establish healthy eating habits during weaning, as well as relevant challenges. Important opportunities included: acting as a role model for healthy foods; giving multiple opportunities to try a food; food variety "so you don't have a fussy eater"; and without food variety "things aren't going to work properly". Additionally, some of the challenges identified were: misconceptions about the definition of food variety; and distractions occurring during feeding. CONCLUSIONS: Mothers were mindful of the need to provide their children with appropriate nutritional stimuli during weaning. They were aware of their role in influencing their infants' likes and used strategies such as modelling and repeated food exposure. The importance of a diverse diet in infancy was acknowledged, although knowledge gaps exist in relation to its definition. Distractions were tactfully employed by mothers to assist feeding. Findings of this study have applications in developing interventions for nutritional education in the complementary feeding period.

Solid advice: Complementary feeding experiences among disadvantaged parents in two countries.

The initiation of complementary feeding (CF; introducing infants to food/drink other than milk) is recommended close to 6 months and not before 4 months of age. Low socio-economic status (SES) is a determinant of nonadherence to CF recommendations, but there is an evidence gap around reasons for nonadherence among these parents. This study investigated knowledge, attitudes, and practices of disadvantaged families (in terms of SES and social support) and use of guidance for CF, in the Republic of Ireland and Northern Ireland. Parents of infants aged 3-14 months were recruited via community groups. Semistructured focus groups aided by vignettes were used. Data were analysed using an inductive thematic approach. Nineteen focus groups took place with parents (n = 83). A range of factors influence parents when introducing solids. Sources of guidance extend to family, friends, the internet, and commercial resources. Parents experience uncertainty and anxiety during this time, driven by lack of knowledge and conflicting advice. Five major themes were identified: (a) more guidance that is accessible, timely, and respectfully needed; (b) the challenge of choosing safe, nutritious food; (c) "everybody has an opinion"; (d) feelings of inadequacy, embarrassment, and guilt; and (e) decisions are ultimately based on individual circumstances. CF advice should be culturally appropriate, practical, and empowering, emphasising the rationale behind updates to recommendations and consequences of nonadherence. Future training of health professionals for delivery of CF advice and guidance should consider these findings. Compliance with CF recommendations is influenced by health professionals, the wider family, and the commercial baby-food sector.