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Abstract

Infant feeding is a central component of daily care in early care and education (ECE) settings, particularly in infant classrooms where routines revolve around feeding, sleeping, comfort, and early developmental milestones. Feeding practices in these environments shape children’s nutritional and developmental outcomes, but they also reflect the broader organizational conditions under which participants work. While evidence-based feeding guidelines emphasize responsive, individualized, and developmentally appropriate practices, the extent to which these practices are consistently implemented in everyday ECE settings depends heavily on staffing levels, workload demands, and available institutional supports.

A strong body of research documents the structural challenges facing the ECE workforce, including chronic understaffing, low wages, high emotional labor, and limited opportunities for personal wellness. Studies such as Tovar et al. (2017) and Carmona et al. (2025) highlight the prevalence of high stress and poor health behaviors among participants, while work by Demirci et al. (2025) and Risica et al. (2022) identifies concerns surrounding infant feeding and breastfeeding practices in ECE contexts. Together, these findings underscore the need for supportive environments that promote both professional development and educator wellness. However, little research examines the lived experiences of individuals who carry out infant feeding routines daily or explore how workplace wellness influences their ability to implement recommended practices. Even fewer studies capture both teacher and director perspectives, which together illuminate tensions between organizational possibilities (e.g., staffing, scheduling, administrative support) and the on-the-ground realities of caring for multiple infants with diverse feeding needs. This gap is particularly notable in New Hampshire, where persistent workforce shortages, low compensation, and varying organizational capacities shape the support available to ECE staff.

Critically, the consistent implementation of evidence-based feeding practices depends not only on educator knowledge but on educator capacity, which is shaped by workload, staffing structures, institutional policies, and personal wellness. Infant teachers routinely juggle individualized feeding schedules, allergies and dietary restrictions, breast-milk storage and handling procedures, and developmental variability across children. Directors, meanwhile, navigate budget limitations, enrollment demands, regulatory compliance, and the ongoing challenge of supporting staff well-being in understaffed environments. Rather than evaluating adherence to best practices alone, it is essential to examine the conditions under which those practices are enacted and sustained.

The purpose of this study, conducted as part of a Summer Undergraduate Research Fellowship (SURF) at the �鶹app, was to examine how early care directors and infant teachers describe their attitudes, beliefs, and daily practices related to infant feeding, and how workplace wellness and organizational conditions shape these experiences. Specifically, I sought to understand the structural and interpersonal factors that influence feeding practices within infant classrooms, and to identify how participants believe they can be better supported in implementing evidence-based care.

The two questions guiding my research were (1) what are ECE educators’ attitudes, beliefs and practices related to breastfeeding support and infant feeding, and (2) what are ECE educators’ perspectives on their own health and wellness within the ECE workplace setting? By examining both reported feeding practices and participants’ lived experiences, this study contributes to broader conversations about ECE workforce well-being and infant nutrition by illustrating the interconnectedness of educator wellness and infant feeding, and by highlighting how strengthening one domain may meaningfully support the other.

Study Design 

Figure 1. Participant Flow and Data Sources for Qualitative and Quantitative Analyses. The qualitative component included early care and education (ECE) directors and infant teachers who completed consent, a demographic survey, focus groups, and the Go NAPSACC Breastfeeding and Infant Feeding (BFIF) Self-Assessment (n = 9). Quantitative BFIF analyses include responses from both the present qualitative sample (n = 9) and additional participants from the Farm to Early Childhood and Parent Engagement in New Hampshire study, Objective 1 (n = 25), collected prior to November 2025. Demographic characteristics reported in this study reflect the 34 participants who completed the BFIF self-assessment and were included in quantitative analyses (N = 34).

To provide a comprehensive perspective, I employed a mixed-methods design to examine infant feeding practices within ECE settings, and to contextualize these practices within participants’ lived experiences of workload, wellness, and organizational support. (Figure 1) Semi-structured focus groups centered the voices of both infant teachers and directors, capturing qualitative accounts of feeding routines, breastfeeding support, professional needs, and wellness experiences. To situate these narratives within a broader policy and practice framework, participants also completed the Go NAPSACC “Breastfeeding & Infant Feeding” (BFIF) Self-Assessment (Ward et al., 2014), a standardized tool measuring center-level alignment with evidence-based feeding practices, including responsive feeding techniques (feeding in a way that responds to child cues of hunger and fullness), milk-handling procedures, breastfeeding support, and professional development. The BFIF assessment provided descriptive quantitative context to complement participants’ lived accounts of caregiving and workplace strain.

We collected data for the qualitative component between June and August 2024 following approval from the �鶹app Institutional Review Board (IRB). Participants included licensed ECE directors (n = 4) and infant teachers (n = 5) working in childcare centers across New Hampshire. Recruitment involved email outreach, phone calls, and in-person visits, facilitated in part by my prior professional experience in a local childcare center. Although the initial recruitment goal was twenty participants, statewide workforce shortages, summer staffing constraints, and ECE workforce burnout limited participation. Ultimately, nine participants completed the full qualitative study protocol. (Figure 2) 

Four semi-structured focus groups were conducted virtually via Microsoft Teams, with directors and infant teachers interviewed separately to promote role-specific discussion. Sessions lasted approximately sixty to seventy-five minutes and followed a structured moderator guide developed by the research team. Topics included feeding routines, breastfeeding support, educator wellness, professional development, and organizational policies. I moderated two focus groups, and my faculty adviser, Dr. Noereem Z. Mena, moderated the other two groups. A graduate research assistant attended each session to take notes. I transcribed audio and video recordings, reviewed them for accuracy, and de-identified the transcripts before analysis. Recordings were destroyed after transcript verification.

Following the focus group, qualitative participants completed the Go NAPSACC BFIF Self-Assessment (Ward et al., 2014), which evaluates center-level practices related to breastfeeding environment, professional development, feeding policies, and responsive feeding practices. (Figure 3) To strengthen quantitative analyses and enhance contextual interpretation, we included additional BFIF responses from participants in the Farm to Early Childhood and Parent Engagement in New Hampshire study (Objective 1), collected before November 2025. Only participants who completed the BFIF self-assessment were included in quantitative analyses (N = 34; n = 9 from the present study; n = 25 from the Farm to ECE study). Demographic characteristics reported in this manuscript reflect these thirty-four participants.

BFIF data were analyzed descriptively to summarize adherence to evidence-based feeding practices. I integrated qualitative and quantitative findings during analysis to examine how center-level policies and reported practices aligned with participants’ personal experiences.

Quantitative Findings: Alignment with Breastfeeding and Infant Feeding Best Practices

Descriptive results from the Go NAPSACC Breastfeeding and Infant Feeding (BFIF) Self-Assessment (N = 34) indicated strong alignment with responsive feeding and breastfeeding best practices across participating centers. (Figure 4) Nearly all BFIF respondents reported consistent access to refrigerator/freezer space for breast-milk storage (94%) and availability of a designated breastfeeding space (94%).

Responsive feeding practices were widely endorsed. Seventy-six percent of respondents reported always using responsive feeding techniques, 79% reported always providing praise and hands-on support during meals, and 59% indicated that feedings are ended based solely on infant cues. Half of respondents (50%) described feeding schedules as fully flexible, and 68% reported providing families with both written and verbal daily communication regarding infant intake.

Greater variability emerged in professional development and policy infrastructure. While 56% of respondents reported receiving infant feeding training annually, 36% reported receiving such training less than annually or never. Similarly, although 62% indicated that their written policies included two or more infant feeding topics, 15% reported having no written policy in place.

Overall, quantitative findings suggest that participating centers report strong adherence to core responsive feeding and breastfeeding support practices, with more variability in formalized training and policy supports. Complete item-level results are presented in Supplementary Table S1.

Qualitative Findings: Feeding Within Personal and Structural Contexts

Data were analyzed using thematic analysis to identify and interpret recurring patterns across participants’ narratives. We managed and coded transcripts in NVivo to support systematic organization and comparison of textual data. I developed an initial codebook using deductive categories informed by prior literature (educator attitudes, barriers, wellness, and supports). Following preliminary coding, the research team refined the framework to better capture patterns emerging from the data. Through iterative revision, analysis resulted in four primary thematic categories, each comprising three to four subthemes. My mentor and I  independently coded the transcripts  and resolved discrepancies through discussion.

The four overarching themes were

1. educator attitudes and beliefs toward infant feeding,
2. challenges and barriers shaping daily experience,
3. educator wellness and meaning-making, and
4. support and resources (present and desired).

Across themes, participants’ accounts revealed that feeding practices were shaped not only by knowledge of best practices but also by emotional labor, structural constraints, and the availability of institutional support. Although presented separately, themes were highly interconnected in participants’ narratives.

Attitudes and Beliefs Toward Infant Feeding

Across focus groups, participants consistently expressed strong commitment to responsive, child-centered feeding. Teachers described making moment-to-moment decisions based on infants’ hunger cues, comfort, and daily variability, emphasizing flexibility rather than rigid schedules. Directors more often framed feeding practices in logistical or policy-oriented terms. However, both groups emphasized balancing children’s needs with licensing regulations, center policies, and parent expectations.

Support for breastfeeding in ECE settings was widely endorsed. Participants described accommodating breastfeeding families through flexible visitation policies, careful handling and storage of breast milk, and open communication. Teachers highlighted their day-to-day role in supporting families, while directors focused on establishing broader supportive systems. Those with greater professional experience or personal exposure to breastfeeding often engaged more confidently in conversations with families. Although logistical challenges were occasionally noted, attitudes toward breastfeeding support were overwhelmingly positive.

Attitudes toward solid foods and baby-led weaning (BLW) revealed greater variation and tension. Some expressed enthusiasm and curiosity about BLW, while others voiced concern regarding choking risks, supervision demands, and licensing restrictions. Directors frequently referenced state guidelines as limiting implementation, noting that policies had not kept pace with evolving feeding recommendations. Teachers similarly expressed interest in updated resources but emphasized that policy-level shifts would be necessary before classroom practices could change more fully.

Feeding decisions were often framed in ethical and relational terms. Some described feeling responsible both to honor parent preferences and to advocate for responsive, child-centered care. When parent expectations conflicted with participants’ perceptions of infant cues, participants emphasized communication, negotiation, and trust-building. Generational and training-era differences emerged most clearly around solid food practices, with feeding philosophies often shaped by the guidance available at the time of professional training.

Challenges and Barriers Shaping Daily Experience

Despite strong commitment to best practices, participants described persistent emotional, logistical, and systemic challenges shaping their daily feeding work. Emotional stress and burnout were discussed, particularly during periods of illness, staffing shortages, or caregiving demands outside of work. Teachers described guilt associated with taking sick leave, while directors noted blurred boundaries between administrative duties and classroom coverage.

Feeding-specific challenges often intersected with staffing and ratio constraints. Participants described managing multiple individualized feeding schedules, supporting infants struggling with bottle feeding, and responding when several infants were hungry simultaneously. Licensing requirements, such as holding infants during bottle feeding, were described as increasing strain when staffing levels were insufficient, often requiring staff to be pulled from other classrooms and disrupting overall center functioning.

Systemic constraints were viewed as persistent and largely outside participants’ control. Directors emphasized that state regulations governed ratios, break requirements, and staffing coverage, often limiting flexibility. Many expressed a desire to offer higher wages, improved scheduling, or additional wellness supports but described insufficient financial and staffing capacity to implement such changes. Several directors acknowledged their own experiences of overload and burnout while balancing administrative and classroom responsibilities.

Importantly, participants did not frame these constraints as justification for abandoning best practices. Rather, they described implementing responsive feeding within environments characterized by ongoing structural strain.

Wellness and Meaning-Making

Participants frequently described a normalized state of daily strain, often referencing long hours, physical fatigue, and stacked caregiving responsibilities as expected aspects of the profession. A strong sense of responsibility to children and families consistently motivated participants to persist despite exhaustion.

Participants described a range of coping strategies, including peer support, brief moments of reprieve during breaks, mindfulness practices, and external supports such as family, exercise, faith, or mental health services when accessible. Directors noted informal strategies to manage overwhelm, such as stepping outside briefly during the day.

Wellness was consistently linked to caregiving quality. Participants described how stress and emotional strain could directly affect interactions with children and emphasized the importance of workplace cultures that prioritize staff care alongside family support. Despite high levels of strain, participants described deep emotional fulfillment derived from relationships with children, families, and colleagues. Many articulated a strong sense of purpose rooted in supporting child development and community-building through their career. 

Support and Resources: Present and Desired

Supportive leadership emerged as a key protective factor. Teachers emphasized the value of directors who were present, flexible, and willing to step into classrooms. Directors described efforts to support staff through scheduling flexibility, time off, and recognition, while acknowledging systemic constraints that limited these efforts.

Infant feeding resources varied across centers. Participants described using parent education materials during enrollment or developmental transitions to support communication and align expectations. Referrals to healthcare providers were used when feeding concerns exceeded classroom scope and were framed as a collaborative process. One director described using Go NAPSACC as a professional resource for evidence-based guidance. More broadly, participants expressed a desire for accessible, practical tools to support both feeding practices and staff wellness. Desired supports included expanded professional development in infant nutrition and more accessible mental health resources.

Participants also described unmet needs related to compensation, healthcare access, staffing stability, and mental health support. Barriers to therapy, medication, and telehealth services included lack of employer-sponsored insurance, high out-of-pocket costs, and limited time. Increased access to mental health care was viewed as making self-care more feasible within demanding work schedules.

Discussion

Quantitative findings indicated strong reported adherence to responsive feeding and breastfeeding support practices across participating centers. At the same time, qualitative findings revealed that these practices are enacted within environments characterized by persistent emotional labor, staffing instability, licensing constraints, and normalized daily strain. Considered together, these findings suggest that alignment with best practices may be sustained not in the absence of constraint, but within it.

The quantitative data reflect the presence of policy infrastructure and reported practice alignment, including access to breastfeeding supports, responsive feeding techniques, and communication with families. Qualitative narratives, however, provide critical context regarding the effort required to maintain those practices. Participants described juggling individualized feeding schedules, navigating regulatory requirements, and managing emotional and physical fatigue while striving to uphold responsive, child-centered care. Rather than contradicting the quantitative findings, these accounts add depth by illustrating the relational and structural work underpinning reported adherence. Best-practice implementation appears to depend not only on knowledge or written policy but on educator capacity within constrained systems.

Importantly, participants acknowledge ways in which their own wellness can be linked to caregiving quality. Stress and burnout from participants were described as having an impact on the classroom dynamic at times, and participants discussed the various ways in which they support themselves and one another to avoid these situations. Participants also articulated strong professional pride and meaning derived from their relationships with children and families. These findings position educator wellness as a part of the infrastructure supporting high-quality feeding practices. Efforts to strengthen infant feeding in ECE settings may therefore require attention to not only training and policy alignment but also to staffing stability, compensation, and accessible wellness supports.

Conclusion

This project was a valuable opportunity to explore infant feeding practices in early care and education settings in a way that captured both reported practices and the everyday realities surrounding them. While participants reported strong alignment with responsive feeding and breastfeeding-supportive efforts, participants’ narratives showed that feeding practices are shaped by personal stress, competing workplace demands, and the realities of everyday caregiving. 

Working on this study deepened my understanding of how qualitative and quantitative findings can complement each other by providing important context and nuanced understanding. It also reinforced the importance of looking beyond best-practice recommendations alone, and paying closer attention to the conditions in which teachers and directors in the ECE setting are expected to carry out these practices. Overall, this project highlighted for me that supporting high-quality infant feeding practices in ECE settings also requires supporting the well-being and capacity of the teachers and directors providing care. We hope this work can contribute to ongoing efforts to support the wellness of ECE teachers and directors, and the implementation of infant feeding practices that align with best practices, by emphasizing the interconnectedness of both aspects.

I would like to sincerely thank Dr. Noereem Z. Mena for her guidance and support throughout this project. I am also very grateful to Susanna Henry and Selina Agandaa for their mentorship, to Yobanna Taylor and Dr. Kendra Lewis for their support and contributions, as well as the Mena Lab for their encouragement. I would also like to thank the Hamel Center for generously supporting this project through the Summer Undergraduate Research Fellowship (SURF), and the ECE directors and teachers who shared their time and experiences in this study.

Supplementary Materials

Supplementary Table S1. Focus Group Participant Characteristics (n = 9) 

Supplementary Table S2. Focus Group Program Characteristics (n = 9) 

Supplementary Table S3. Full Go NAPSACC Breastfeeding and Infant Feeding (BFIF) Self-Assessment Item-Level Responses (N = 34) 

References

Carmona, B. A., Deng, L., Gilbert, C., Freimuth, E., Xie, R., & Bellows, L. L. (2025). Prioritizing early childhood educators’ health: Insights for worksite health promotion efforts. Childhood Obesity, 21(3), 242–254. 

Clark, A., Anderson, J., Adams, E., & Baker, S. (2008). Assessing the knowledge, attitudes, behaviors and training needs related to infant feeding, specifically breastfeeding, of child care providers. Matern Child Health J. 2008 Jan;12(1):128-35.

Demirci, J. R., Dieterich, R., Glasser, M., Harpel, C., & Shope, T. (2025). “There’s a little bit of tension there”: Perspectives of mothers and early childhood educators on breastfeeding in child care centers. Public Health Nutrition, 28(1), e38. 

Dunn, R. L., Phillips, S. M., Arnold, L., Messer, J., Nelson, B., & Kalich, K. A. (2021). Early care and education professionals’ breastfeeding knowledge and practices before and after an e-learning program. Journal of Health Science Education, 5(4), 218. 

Glauber, R., & Carson, J. A. (2024). New Hampshire’s well educated, underpaid child care workforce. Carsey School of Public Policy. 

Lee, D. L., Gurzo, K., Nhan, L., et al. (2020). Nutrition provided to infants in licensed childcare centers and homes: A descriptive study. Maternal and Child Health Journal, 24, 932–942. 

Lundquist, A., McBride, B. A., Donovan, S. M., et al. (2019). An exploratory look at the role of childcare providers as a support and resource for breastfeeding mothers. Breastfeeding Medicine, 14, 313–319.

Kovar, M. G., Serdula, M. K., Marks, J. S., & Fraser, D. W. (1984). Review of the epidemiologic evidence for an association between infant feeding and infant health. Pediatrics, 74(4), 615–638. 

Risica, P. M., Karpowicz, J. M., von Ash, T., Gans, K. M., Cooksey-Stowers, K., & Tovar, A. (2022). Feeding and activity environments for infants and toddlers in childcare centers and family childcare homes in southeastern New England. International Journal of Environmental Research and Public Health, 19(15), 9702. 

Schachtner-Appel, A., Moses, L., Jackey, B., et al. (2024). Evaluation of an online training course for childcare providers participating in the CACFP infant feeding program. Maternal and Child Health Journal, 28, 391–399. 

Schafer, E. J., Livingston, T. A., Roig-Romero, R. M., Wachira, M., Louis-Jacques, A. F., & Marhefka, S. L. (2021). “Breast is best, but…” according to childcare administrators, not best for the childcare environment. Breastfeeding Medicine, 16(1), 21–28. 

Tovar, A., Vaughn, A. E., Grummon, A., Burney, R., Erinosho, T., Østbye, T., & Ward, D. S. (2017). Family child care home providers as role models for children: Cause for concern? Preventive Medicine Reports, 5, 308–311. 

Ward, D., Morris, E., McWilliams, C., Vaughn, A., Erinosho, T., Mazzuca, S., Hanson, P., Ammerman, A., Neelon, S., Sommers, J., & Ball, S. (2014). Go NAPSACC: Nutrition and physical activity self-assessment for child care (2nd ed.). Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill.

Author and Mentor Bios

Neha Sharma is from Merrimack, New Hampshire, and will graduate from the �鶹app in 2026 with a major in neuroscience and behavior and a minor in Spanish. She is a research assistant at the Exploration, Learning and Mind (ELM) lab at UNH, works as an assistant teacher in an early care and education center, and serves as Youth Council Coordinator for KIOCH Partners of America (KPALS), a nonprofit organization that supports the development of a children’s hospital network in Nepal. After graduation, she plans to pursue graduate training and a career in psychology.

Dr. Noereem Z. Mena, RDN LD is a bilingual (English/Spanish) registered dietitian nutritionist and assistant professor of nutrition in the Department of Agriculture, Nutrition, and Food Systems at the �鶹app. Dr. Mena’s research efforts are focused on promoting healthy eating behaviors in early childhood.

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