Dr Blandine De Lauzon-Guillain

Prof Gerry Jager

Prof Noël Peretti

Dr Thierry Cardoso

Andrea Jalpa

Courtney

Résumé

Les mille premiers jours, de la grossesse à 2 ans, sont cruciaux, entre autres aspects, pour le développement d'habitudes alimentaires et de préférences alimentaires saines chez les enfants.

Les pratiques alimentaires des parents influencent de manière significative les consommations et les choix alimentaires des nourrissons au cours de cette période. Par conséquent, les parents doivent être correctement informés et guidés tout au long du processus de diversification alimentaire. De nouvelles directives couvrant ce thème ont été publiées en France en juin 2019.

Compte tenu des interactions fréquentes que les professionnels de santé, tels que les pédiatres, ont avec les parents lors de la diversification alimentaire, leur rôle peut être considéré comme fondamental pour la transmission d'informations correctes aux parents à ce sujet. Cette thèse vise à contribuer à l'élaboration d'une brochure papier pour diffuser ces recommandations de santé publique auprès du grand public. Elle consiste en quatre études visant d'une part à éclairer une nouvelle stratégie de communication en santé publique tenant compte des besoins des parents et des professionnels de santé en matière de communication sur l'alimentation des enfants ; et d'autre part à évaluer si le matériel développé (brochure papier) a un effet à court terme sur les connaissances parentales ; et enfin, s'il est évalué positivement par les professionnels de santé. Les résultats, rapportés dans quatre articles, ont mis en évidence que les professionnels de santé sont la source d'information la plus utilisée et la plus influente pour les parents. Certaines différences existaient concernant les besoins de communication des parents et les perceptions des pédiatres concernant ces besoins. En particulier, les parents demandent souvent des conseils à leur entourage et ils recherchent de conseils pratiques, divergeant en cela de l'opinion des pédiatres. La brochure papier a contribué à accroître les connaissances sur l'alimentation des enfants indépendamment des caractéristiques sociodémographiques parentales. Les professionnels ont évalué la brochure comme un bon outil pour soutenir leur discours lors des consultations. Ces résultats contribuent à la preuve pour les acteurs de santé publique lors de la mise à jour et de la diffusion des recommandations d'alimentation des enfants, dans le but ultime de construire une stratégie prenant en compte les besoins de tous les utilisateurs pour faciliter la circulation d'informations officielles et mises à jour.

Mots-clés : santé publique, directives relatives à l'alimentation, recommandations, diversification alimentaire, sevrage, parents, soignants, enfants, petite enfance, comportements alimentaires, pratiques d'alimentation, promotion de la santé, communication sur la santé, éducation à la santé, connaissances nutritionnelles, littératie en santé, pédiatres, professionnels de santé, approche qualitative, questionnaire, perceptions, pratiques, besoins parentaux.

List of figures

List of tables

Preface

This doctoral thesis is part of a larger project funded by the European Commission under the program Innovative Training Networks (ITN) Marie Sklodowska-Curie, grant agreement No 764985. As stated in the website of the project (https://edulia.eu/): "Edulia responds to the urgent need of the European society to find new ways to tackle the escalating issue of obesity, through promoting healthier eating from childhood, within the context of choice. Based on the relations between sensory perception, pleasure, food choice and food behavior, the project looks for new approaches to drive children to like and actively choose healthy foods, developing healthier dietary habits". The overall aim of the research program is to better understand how multiple factors act as barriers for children's healthy eating and how to tackle them, bringing together leading scientists in the Food Choice arena. all the hired ESRs must demonstrate that they have not had any work or study activities in the host country during the 12 months prior to their recruitment. This aspect helps to encourage mobility between European countries and to recruit students of a different nationality to that of the host country. Moreover, ESRs, as stated in their contracts, had to spend part of their doctorate study period in institutes other than their hosting one; those periods are called secondments.

Edulia is made of eight work packages with specific objectives and deliverables. My doctoral thesis belongs to work package 5, aiming at studying the development of healthy eating habits in toddlers and young children. In this context my project aimed to inform the communication strategy (supporting the development of dissemination material in the design phase) for the new recommendations on child feeding (0-3 years), released in France by public health authorities during summer 2019. This project was conducted in collaboration with a non-academic partner which is a public health agency in charge of nutrition recommendations in France: Santé publique France (SpF). Initially the purpose was to evaluate if the newly developed material had an impact on parental feeding practices and on children eating behaviors via the mean of an intervention involving young parents, but the upcoming health emergency linked to the spreading of the Covid-19 made it relevant to adopt some changes in the objectives of the project and related adaptations. Finally, as it will be described more in detail further on in this thesis, the two main aims became (1) supporting the development of communication material by exploring perceptions and needs of parents and pediatricians and (2) evaluating the developed material quantitatively with parents (short-term impact on parental knowledge regarding child feeding) and qualitatively with healthcare professionals (e.g. acceptability of the new recommendations).

CHAPTER 1 -General introduction and theoretical framework

The focus of this doctoral thesis is the period expanding from 4-6 months to 3 years of the child (milk feeding will be only briefly discussed in the introduction, but specific development related to it was not the main focus of any of the studies). Therefore, alongside this document the term "child feeding" will be used to refer particularly to the period that goes from complementary feeding (CoF) until when the child can eat like the rest of the family (approximately from the 6 months to the 36 months of the child). In this general introduction the early development of eating habits in children will be presented, giving a special focus on which are the main modifiable factors that could have an influence in the establishment of obesity and healthy behaviors during childhood. Moreover, the evolution of child feeding guidelines will be described with particular attention to the French situation. Finally, a general overview of public health communication will be given on the basis of literature, especially in regards to promoting healthy eating from early childhood.

Considering the role played by parents in influencing children's food intakes and preferences, and the role of healthcare professionals in advising parents regarding feeding practices, this thesis will be mostly dedicated to the study of the practices and needs of parents and those professional figures when coming to communication matters around child feeding.

The final objective is to inform a public health communication strategy able to account for those needs when developing tools to disseminate public health guidelines about child feeding to the general public.

1.1) The development and evolution of eating behaviors during childhood

1.1.1) Childhood obesity: a global public health burden

Obesity is a highly discussed issue worldwide, threatening the health of children especially in Western societies, but also in developing countries, where the double burden of malnutrition is a major public health issue (1)(2)(3). According to the World Health Organization (WHO) it was estimated that in 2020 the threshold of 38.9 millions of children under 5 years of age with moderate or severe overweight was reached (4). There has been no progress to dam the rates of overweight and obesity in children under 5 years of age in nearly 20 years despite achieving the deployment of obesity prevention programs. The fact that the current trends continue increasing, in defiance of interventions accounting for global health efforts, is even more worrying. Being affected by overweight or obesity during early childhood is a consolidated risk factor for the maintenance of those chronic conditions also in adult age (5). Childhood obesity is also associated with increased risk of other conditions such as type 2 diabetes, certain forms of cancer and increased incidence of cardiovascular diseases (6)(7)(8). Moreover, the general quality of life could be affected with serious short-and long-term adverse effects on physical and psychological performances, it can decrease life expectancy, as well as create high financial burdens due to loss of productivity (9); not accounting for the ensuing costs for country-related health care and social support systems (8,10). One of the United Nations' objectives on the 2030 Agenda for Sustainable Development (target 3.4) is reducing premature mortality from noncommunicable diseases (11). Currently WHO is aligning its work to reach this goal; one of its current work plans is to develop a science-informed, people-centered guideline for the management of children with obesity and those considered at high risk (presenting excessive adiposity). The core of the strategy is to use a primary prevention health care approach (12).

In France, like in other European countries, the trend is not less alarming. In 2013, overweight was affecting 12% of children under the age of 6 (13); moreover, in 2017, 18% of adolescents were overweight, and 5% were living with obesity. Those percentages are confirmed by a cross-sectional population-based survey (Esteban-2015), which found 17% of children between 6 and 17 years were affected by overweight and 4% by obesity (14). Between 2009 and 2017, the prevalence of obesity increased from 3.8% to 5.2% (15). In 2019, the French Ministry of Health launched its fourth national health nutrition program, valid for five years (Programme national nutrition santé PNNS -4; 2019-2023). One of the objectives of this program is to decrease the prevalence of overweight and obesity (in adults and children). To achieve this goal five axes have been drafted and are driving public health nutrition and feeding related programs and interventions in France (16). The five axes of PNNS-4 are:

1) improve the food and physical environment to make it more favorable to health;

2) encourage healthy behaviors (including healthy eating behaviors);

3) better care for overweight, undernourished or chronically ill people; 4) boost a territorial dynamic, by facilitating and promoting local initiatives (including local food production and consumption); 5) develop research, expertise and surveillance in support of nutritional policy.

It is in coordination and support of this program that public health stakeholders in France in the last couple of years reviewed and updated the former feeding guidelines for all the populations (children, adults, elderly). A more detailed description of the updating process of the French child feeding guidelines will be given in section 4 of this introductive chapter.

1.1.2) The first 1000 days: a critical window of opportunity for obesity prevention

Understanding the determinants of unhealthy weight gain in infancy is crucial in order to prevent diet-related diseases later in life (17,18). The first 1000 days are an important period in the life of an individual, they are defined as the time spanning roughly from conception to the second birthday of a child. This period of time is a unique opportunity for the establishment of optimum health, growth, and neurodevelopment across the lifespan (19,20). As confirmed by the "Barker hypothesis", the fetal environment and early infant health permanently program the body metabolism and growth, determining the increased disease risk in adulthood (21,22).

Moreover, during the first 2 years of life of a child, food preferences, dietary patterns, as well as the risk of obesity, develop rapidly (23,24), therefore any intervention aiming at reducing childhood obesity should be focused on this early-life period (25,26). A special attention should be paid toward the risk factors that could influence the different nutritional phases that the child encounter starting from the prenatal period. A research done by Mameli and colleagues focused on the different phases of nutritional exposure of children during the first 1000 days and related risk factors for obesity development (27): it identified three main critical steps of dietary development as summarized in Table 1.

Table 1. Main risk factors in the first 1000 days for the development of childhood obesity. Table adapted from Mameli et al, 2016 (27).

Nutritional phase Risk factor

Prenatal (0-280 days)

Higher maternal pre-pregnancy BMI Excess maternal Gestational Weight Gain Maternal Diabetes Mellitus (gestational or Type 1) Genetic predisposition Nutritional environment (maternal diet)

Milk Feeding (280 days -6 months of age)

Formula feeding:

• Accelerated growth curve If during the prenatal phase the risk factors are mainly dependent on the mother and the progress of the gestation period (28), it is after birth that the child's diet starts to play a key role.

The postnatal early feeding environment is determined by the choice/possibility of the mother to breastfeed or formula feed the infant. There is growing evidence of the protective effect of breast milk over the development of chronic diseases such as obesity or diabetes (29)(30)(31)(32). It has been shown that formula milk, compared to breast milk, was richer in proteins and energy and lower in fat (33), which led to an evolution of the regulation regarding protein content, to reduce it 1 . The high protein content in formula milk may have contributed to an accelerated growth curve, with health-related consequences later in life (34,35). The transition from milk-based feeding to CoF is considered as another challenging period in terms of obesity prevention. The early introduction of solids is an especially highly debated topic (due also to the link with the latest discoveries regarding the development of allergies) (36)(37)(38), with the right timing for the introduction of the first foods that regularly varied during the last decades and according to different feeding guidelines, creating confusion for parents and healthcare professionals.

Details regarding the optimal timing of introduction of solids will be given in part 1.4.

1.1.3) The first 1000 days: a sensitive period for the development of children's eating behaviors

The first 1000 days of life are also a period of feeding transitions for the child, passing from umbilical feeding to milk feeding to the start of solid foods to finally eat as the rest of the family probably around the first birthday (39). Often defined as a critical window for obesity prevention, this period is also very important for learning about food and eating and increasing the possibilities to develop healthy eating behaviors. In fact, it is at this moment of life that the child learns what, when and how much to eat; this learning happens through direct experience,

or by observing others' eating behaviors (most often the parents) (40,41). It is at this stage that children can, for example, learn to self-regulate their food intake, giving an imprint for the development of future eating patterns and health status as adults (42).

In this perspective it is fundamental to introduce the concept of responsive feeding.

Responsive feeding derives from responsive parenting, indicating a prompt and appropriate parental response to a child's need, expressed via specific signals (e.g. facial expressions) (43).

Responsive feeding is defined as a two-way relationship between the parent and the child accounting for the feeding context (44); it is an attentive way of nurturing the child, watching for child's hunger and satiety cues and responding to them accordingly (45). Previous studies demonstrated that responsive feeding is associated with more desirable eating behaviors in children (less food fussiness and more food enjoyment) (46), increasing the likelihood for the establishment of healthier dietary habits lasting in adulthood.

Within the first 1000 days the phase when solid foods start to be introduced in the child's diet can be considered as the most sensitive period for infants to accept new foods. For instance, it is in this period that children learn to like different flavors (47), meaning that it can be easier for example to introduce fruits and vegetables (48) before the second birthday of the child, before the emergence of food neophobia (fear for novel foods), which begins around 20 months (49). An infant exposed to the flavor of a vegetable at the beginning of CoF will be more willing to accept it in his/her diet; moreover, in this time frame, offering the child a variety of foods fosters the acceptance of different flavors (50). Moreover, when starting to introduce complementary foods, repeated exposures to different varieties of vegetables encourage the consumption and appreciation of those same vegetables in young children, reducing food neophobia and increasing food acceptance in the long run (50). Other aspects of CoF will be addressed more in detail in the following section.

1.1.4) The foundations of eating behaviors: breastfeeding & complementary feeding

Breastfeeding

Two are the possibilities offered to a newborn in terms of feeding: breastmilk or formula (or a mix of them). Breastfeeding, when possible, is the recommended best choice; in fact, even if the topic appears controversial (probably due to the methodological limitations related to the difficult randomization of early feeding mode), numerous studies confirmed the protective effect of breastfeeding in preventing obesity (30-32, 51, 52). Moreover, breastfeeding plays an important role in promoting infants' acceptance and preference for healthy foods: data shows healthier and more varied dietary patterns in breastfed vs. formula-fed children (53,54). This difference could be partly explained by different opportunities of flavor learning, with breastfed infants having more possibilities to taste the flavors transmitted from the mother diet via the breastmilk than formula fed infants who are exposed to a constant, blank food with a poorer flavor profile (55). While all infants have the same possibilities when they are in utero, only breastfed infants can keep learning thanks to the repeated exposure of different flavors linked to the mother's diet during breastfeeding (55).

Despite the superiority of breastmilk in terms of nutritional composition is demonstrated (34), the fact that breastfeeding could protect against the risk of later obesity is still a controversial subject, beside the existence of systematic reviews and meta-analysis in favor of this theory (56)(57)(58)(59). In fact, some of these reviews were unable to establish causation due to confounding factors regarding the strong sociodemographic differences between breastfed and formula-fed infants. However, a work by Singhal and Lanigan summarized three main explanations supporting the protective role of breastfeeding against obesity (60). The behavioral explanation supports the fact that families of breastfed infants have healthier attitudes and dietary habits that is why they are less at risk for obesity. Moreover, breastfed babies, by controlling their milk intake, may develop better capacities of energy intake selfregulation compared to formula-fed babies (61). The nutritional explanation is related to the nutrient concentration of breast-versus formula-milk. For example, there was a time when formula-milk was richer in protein compared to breastmilk [START_REF] Heinig | Energy and protein intakes of breast-fed and formula-fed infants during the first year of life and their association with growth velocity: the DARLING Study[END_REF] and differences in early protein intake could program later adiposity [START_REF] Scaglioni | Early macronutrient intake and overweight at five years of age[END_REF]. Finally, the growth acceleration hypothesis suggests that breastfed infants have a slower growth pattern in the first weeks of life, compared to formula fed infants. Accelerated postnatal growth was associated, among others, to later insulin resistance and higher risk of developing cardiovascular diseases (especially in preterm infants), not to count for the increased obesity risk [START_REF] Singhal | Early origins of cardiovascular disease: is there a unifying hypothesis?[END_REF][START_REF] Singhal | Low nutrient intake and early growth for later insulin resistance in adolescents born preterm[END_REF].

Complementary feeding

As stated above, within the first 1000 days of life, CoF is the most sensitive period for a child to learn to like a wide variety of foods, especially fruits and vegetables. Food preferences are also established during this phase (23). Beside its definition as "the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk", CoF is also more generally defined as the transition from breastfeeding to family foods; a period that typically covers the 6-24 months of age of the child [START_REF]F. Strengthening action to improve feeding of infants and young children 6-23 months of age in nutrition and child health programmes : report of proceedings[END_REF]. When talking about CoF there are some questions that give rise to doubts in all parents (and professionals who have the duty to advise parents) and to which precise answers must be given, preferably through the support of renewed recommendations, updated in accordance with the latest scientific evidence. The next paragraphs will address those questions in relation to the literature. The directions taken by the French public health authorities (regarding those topics) for the renewed child feeding guidelines will be summarized in part 4 of this introduction chapter.

1) Why CoF is so important?

CoF is an important period not only for the development of healthy eating behaviors in children, but also because it has an influence on later health [START_REF] Fewtrell | Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology[END_REF]. Appropriate and timely CoF has a positive effect on child's optimal growth, body composition and neurodevelopment [START_REF] Przyrembel | Timing of Introduction of Complementary Food: Short-and Long-Term Health Consequences[END_REF].

In this period dietary exposure determines the development of taste preferences and is linked to later dietary patterns [START_REF] Schwartz | The role of taste in food acceptance at the beginning of complementary feeding[END_REF]. Moreover, inappropriate CoF can sway the nutritional status: infants can experience nutrient deficiencies or excesses; one more reason why attention should be paid to the type and quantities of the first foods that are given to the child. For example, a high consumption of energy-dense or protein-rich complementary foods can be related to a higher obesity risk in the short and long term [START_REF] Monteiro | Rapid growth in infancy and childhood and obesity in later life--a systematic review[END_REF][START_REF] Ong | Rapid infancy weight gain and subsequent obesity: systematic reviews and hopeful suggestions[END_REF][START_REF] Hörnell | Protein intake from 0 to 18 years of age and its relation to health: a systematic literature review for the 5th Nordic Nutrition Recommendations[END_REF]. Starting CoF too early or too late can also be linked to the risk of developing infections and allergies or other diseases (e.g. cardiovascular diseases, diabetes) [START_REF] Li | Breastfeeding and risk of infections at 6 years[END_REF][START_REF] Ierodiakonou | Timing of Allergenic Food Introduction to the Infant Diet and Risk of Allergic or Autoimmune Disease: A Systematic Review and Meta-analysis[END_REF][START_REF] Pieścik-Lech | Systematic Review: Early Infant Feeding and the Risk of Type 1 Diabetes[END_REF].

2) When to start CoF?

There is a physiological moment when the child is ready to start with solid foods. This moment comprises the fact that milk alone cannot suffice to meet the infant's nutritional need; the child's digestive tract and motors skills are sufficiently developed (oral motor skills allow the swallowing of foods other than milk [START_REF] Nicklaus | 8 -Modifying the texture of foods for infants and young children. Modifying Food Texture. Sensory analysis, consumer requirements and preferences[END_REF]), and there is a low risk for allergies development [START_REF] Agostoni | Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition[END_REF]. Different recommendations exist that are debating the proper date of starting CoF. The WHO suggests to exclusively breastfeed until 6 months of the child and to start with solid foods at about the age of 6 months, continuing alongside with the breastfeeding thereafter [START_REF]F. Strengthening action to improve feeding of infants and young children 6-23 months of age in nutrition and child health programmes : report of proceedings[END_REF]. A reason why WHO suggests not to start before the 6 months of the child is because exclusive breastfeeding could prevent the risk of microbial contamination from water used to prepare formula milk or other foods (especially in developing countries), however exclusive breastfeeding could also lead to iron deficiency [START_REF] Chantry | Full breastfeeding duration and risk for iron deficiency in U.S. infants[END_REF]. Formula milk is considered as complementary food by the WHO, so the recommendation does not apply to formula-fed infants. In 2017 the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition agreed that complementary foods should not be introduced before 17 weeks, but their introduction should not be delayed beyond 26 weeks [START_REF] Fewtrell | Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology[END_REF]. Recently, in 2019, the European Food Safety Authority (EFSA) agreed that there is not substantial evidence that starting CoF before the 6 months of the child is either harmful or beneficial for health (38). Therefore, there is no single precise age at which complementary foods should be introduced to all infants living in Europe, but it rather depends on individual characteristics and development of the child (38).

EFSA concluded that the earliest developmental skills relevant to consume pureed foods can be observed between 3 and 4 months of age (but this does not necessarily mean that solid foods need to be introduced immediately), whereas the majority of children is commonly ready for consuming finger foods at about 5 to 7 months (38). In France, in 2011-12 62% of parents started CoF between 4 and 6 months, but 26% of them started before the 4 months of the child and 12% after 6 months [START_REF] Bournez | Factors associated with the introduction of complementary feeding in the French ELFE cohort study[END_REF].

3) What to start CoF with?

Infants should be offered foods with respect to their nutrient's requirements and with a variety of flavors and age-appropriate textures, as it was shown that this fosters food acceptability and boosts later (healthier) eating habits [START_REF] Hetherington | Feeding infants and young children. From guidelines to practice[END_REF][START_REF] Schwartz | Comment faire aimer les légumes aux bébés ?[END_REF]. A review conducted by Boeing et al. in 2012 has explored the importance of a diet rich in fruits and vegetables in preventing chronic diseases in the general population [START_REF] Boeing | Critical review: vegetables and fruit in the prevention of chronic diseases[END_REF]. As the development of eating habits early in life has an impact on food preferences and eating patterns in adulthood (42), it is important to promote the consumption of fruits and vegetables as early as possible to make the child accept them more easily in his/her diet. However, despite the existence of national recommendations, throughout Europe fruits and vegetables' consumption in young children stays below the suggested intakes in many countries [START_REF] Nicklaus | Complementary Feeding Strategies to Facilitate Acceptance of Fruits and Vegetables: A Narrative Review of the Literature[END_REF][START_REF] Huybrechts | Food intakes by preschool children in Flanders compared with dietary guidelines[END_REF][START_REF] Leclercq | The Italian National Food Consumption Survey INRAN-SCAI 2005-06: main results in terms of food consumption[END_REF]. Vegetables can be perceived by infants and children as bitter or sour, tastes that are not naturally liked [START_REF] Bell | Short-term vegetable intake by young children classified by 6-npropylthoiuracil bitter-taste phenotype[END_REF][START_REF] Capaldi | Decreasing dislike for sour and bitter in children and adults[END_REF]; even if between 5 and 7 months children have less negative reactions also to the most bitter or sour taste [START_REF] Schwartz | The role of taste in food acceptance at the beginning of complementary feeding[END_REF][START_REF] Barends | Effects of starting weaning exclusively with vegetables on vegetable intake at the age of 12 and 23 months[END_REF][START_REF] Barends | Effects of repeated exposure to either vegetables or fruits on infant's vegetable and fruit acceptance at the beginning of weaning[END_REF].

Hence, starting CoF with vegetables could be a good strategy to attain the objective of vegetables' acceptance (48,[START_REF] Schwartz | The role of taste in food acceptance at the beginning of complementary feeding[END_REF]. However, it should be kept in mind that all food groups can be introduced simultaneously (different food groups per day) at the start of the CoF, as the introduction to a diversity of food groups has been shown to increase tolerance to allergens [START_REF] Toit | Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy[END_REF][START_REF] Muraro | EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy[END_REF]. Introducing a variety of foods within a given group is important to promote acceptance of foods from this group and beyond [START_REF] Nicklaus | Development of food variety in children[END_REF][START_REF] Nicklaus | Children's acceptance of new foods at weaning. Role of practices of weaning and of food sensory properties[END_REF].

Food and beverages containing high sugar levels should be avoided in children's diet as they can have a negative effect on dental health [START_REF] Ruottinen | Sucrose Intake since Infancy and Dental Health in 10-Year-Old Children[END_REF], and in the long run increase the risk of developing obesity [START_REF] Keller | Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews[END_REF]. Regarding liquids, water, and in alternative only non-sweetened beverages, are the only recommended drinks for children [START_REF] Dereń | Consumption of Sugar-Sweetened Beverages in Paediatric Age: A Position Paper of the European Academy of Paediatrics and the European Childhood Obesity Group[END_REF]. In other respects, the consumption of salt-rich foods is not adapted in the younger years as it could contribute to the onset of hypertension and later development of cardiovascular disease in adults [START_REF] Strazzullo | Does salt intake in the first two years of life affect the development of cardiovascular disorders in adulthood?[END_REF]. Contrarily, the lipidic component is really important in the child's diet as it provides fatty acids that are essentials for normal growth [START_REF] Uauy | Fat intake during childhood: metabolic responses and effects on growth[END_REF]. Young children require about 35% of energy from fat [START_REF] Uauy | Lipid Requirements of Infants: Implications for Nutrient Composition of Fortified Complementary Foods[END_REF], but recently in France nutritional intakes of children between 8 and 12 months were found to be characterized by a contribution of lipids in the total energy intake that was below the reference interval (100). In children below 3 years, dietary quality and variety is also influenced by the availability of food in the house, thus parents' food choices are important in promoting healthy food preferences (101).

4) How to start CoF?

Parental behaviors and practices in the context of feeding influence food preferences and food intakes in infants (102). Parents are encouraged to feed their children in a responsive way, meaning that they have to be able to respond properly to the child's cues of hunger and satiety favoring the autonomy of the child to eat according to his/her needs, encouraging self-regulation (45). In fact, when parent-child interaction patterns are dominated by parental intrusiveness and lack of reciprocity the child has higher likelihood of presenting early feeding difficulties, overeating and lower, or higher, growth rates (103, 104). Further details about the influence of parental practices on children behaviors and responsive feeding are given in section 2. From a practical point of view, regarding the CoF process, it must be noted that repeated exposures to an initially rejected food can foster its acceptance. It was demonstrated that at least 8 repeated exposures were needed to accept an initially rejected vegetable as much as an initially accepted ones (105). A comparative study carried out in France and Germany reveals that in France 30% of mothers do not re-offer a food after one refusal and 40% after two refusals (105). Also, the exposure to a wide variety of foods at the beginning of CoF was found to increase the acceptance of those foods (106-108).

Baby-led weaning

Baby-led weaning is an alternative approach to spoon-feeding for introducing solids in the infants' diet at the beginning of the CoF period. This relatively new approach consists of letting the baby to feed him/herself pieces of foods using the hands or handling a spoon, allowing the regulation of his/her own food intake toward the development of motor skills and more autonomy (109). Baby-led weaning critical points include concerns regarding choking, growth impairment and iron deficiency (110, 111); however, recent randomized controlled trials did not find significant differences between adapted baby-led weaning and usual table-spoon feeding on those points (112,113). Despite the growing evidence outlining the positive health related outcomes of baby-led weaning (e.g. lower body mass index), the limited number of longitudinal studies and randomized controlled trials proving those positive effects leaves open the debate whether this approach is truly more effective in establishing healthier eating behaviors than the widely practiced spoon feeding (114,115). However, parents are becoming aware of this feeding method and are willing to try it (116). A study done in New Zeeland found that only 21% of parents following baby-led weaning were advised by health professionals on this topic (117). Having official guidelines addressing this topic is important also for healthcare professionals to understand if and under which circumstances they should discuss and provide information to parents about this practice.

1.2) Multiple influences on children's eating behaviors during the 0-3 years period

1.2.1) Framework of the multifaceted environment influencing eating behaviors

The development of healthy eating habits in children depends on both the provision of healthy foods and responsive parenting behaviors (44), but many other factors play a role in influencing children's eating behaviors. Each person is the product of the combination of his/her genetical predisposition with the environment (118); like other behaviors, eating habits and food preferences are a consequence of the specific influences that surround each individual starting from infancy, lasting alongside the life course (119).

In this thesis the Socio-Ecological Model (SEM), often used to build public health communication and health promotion interventions, has been chosen as a framework to characterize the different environmental influences on children's eating behaviors (120). The SEM was first introduced as a conceptual model for understanding human development by Urie Bronfenbrenner in the1970s and later formalized as a theory in the 1980s (ecological systems theory) (121,122). According to the Bronfenbrenner's theory the developmental process of a child is defined by his/her individual characteristics, accompanied by the relationships that are established with those who populate his/her own environment (parents, other family members and friends, teachers at school etc.) (123). As shown in Figure 1, this environment can be divided in multiple levels ranging from the interpersonal level, comprising the home environment, or the closer community to the policy/enabling environment, encompassing policymakers and political stakeholders. Those levels correspond to the five nested systems of Bronfenbrenner: the micro-, meso-, exo-, macro-and chronosystem (124).

At the individual/child level an addition has been made to the original model: food (Figure 1). In fact, when talking about the development of eating behaviors, beside the influences strictly linked to the environment, the dietary exposures to foods also play a role in determining future eating habits (125). Food can be considered as part of the environment, but it has a very specific role to play in the case of eating behavior, in terms of "proximal exposure". Foodrelated characteristics like energy density, palatability, flavor, color or texture could define whether this food is accepted or not (126), not to mention other "qualities" that may affect health (e.g. presence of additives, pesticide residues…). In the upcoming sections a special focus will be given to the individual (child characteristics)

and interpersonal (parental feeding practices) levels. Moreover, at interpersonal level, attention will be given also to healthcare and childcare professionals (section 3), figures that are in constant relation with parents during the early years of the child. As far as Figure 1 is concerned, it should especially be noted that each level exerts an influence on all the lower levels. This means, for example, that changes at the political level have the potential to drive the development of the individual's behavior in many aspects of his/her life, including eating (for example via regulations to adapt the composition of specific products or introduction/renewal of feeding guidelines 2 ). This reinforces the idea that this model is not static but subject to regular changes at each environmental level.

1.2.2) Child-related temperamental characteristics

Some individual characteristics may influence children's relationship with food. Some of them are congenital and cannot be changed: genetic code, sex, birth weight. Some can be influenced by external factors: early flavor experience, health status and temperament. Previous researches already demonstrated that factors associated with the individual personality traits of the child (such as his/her temperament) could have an influence on eating behaviors and the weight status (127, 128). In children some temperamental traits like low negative affectivity and poor general self-regulation can be related to an increased adiposity and body mass index later in life (129). The temperamental dimension is also related to the so-called qualitative and quantitative dimensions of eating (e.g., related to what and how much is eaten, respectively).

The quantitative dimension refers for example to the amount of food eaten by the child. The food intake is subject to self-regulation (defined as part of child's temperament), a trait that has been studied in connection with eating behaviors. Higher self-regulation ability in young children has been associated to a lower BMI and lower risk of developing obesity (130).

Children can exert proper self-regulation by showing high inhibitory control in eating contexts.

Inhibitory control is defined as the capacity to restrain a dominant behavior in order to engage in another behavior that is required for an activity (131). Showing high inhibitory control could mean having the capacity to refrain from eating in absence of hunger. In previous researches it was shown that children with overweight, compared to average weight children, have lower inhibitory control (132-134), but this topic is still under debate. The capacity to regulate the energy intake is also a quantitative dimension; in particular, other studies showed that eating in the absence of hunger and low capacities of caloric compensation have been associated with overweight and higher BMI in children (135-137). Caloric compensation reflects a subject's sensitivity to internal satiation cues, it is defined as the adjustment of energy intake in response to a food preload of various energy content or energy density (138, 139). Poor caloric compensation could also be responsible for overeating and lead to weight gain, especially when the child grows up and becomes less attentive to internal satiety cues and he/she is more influenced by external factors (140, 141).

The qualitative dimension of eating behaviors generally refers to the variety of food that a child could or would like to eat. For example, some children can be picky or fussy eaters, meaning that they consume an inadequate variety of foods because they tend to reject many foods, whether they are familiar or unfamiliar to them; this could reflect in an increased risk of underweight (142-144). Food neophobia, enjoyment of food and emotional eating are other traits related to the qualitative dimension. Those eating related behaviors can be both a cause and a consequence of parental feeding styles resulting in sub-optimal feeding practices (145).

For instance, neophobic (or picky) behaviors are a concern for parents, who fear that their children's apparently low intake might not meet the needs for optimal growth and development (146). Those child's behaviors are often associated with parental feeding styles and feeding practices (147). More details regarding parental practices and their influence on children's eating behaviors are given in the next section.

1.2.3) The influence of parents on children's eating behaviors

According to the SEM model parents are part of the interpersonal level of influence: children, especially infants and toddlers, depend on their parents or caregivers regarding their food intake. Parents, with their parenting style and feeding practices exert the strongest influence on children's eating behaviors; they define the home food environment that contributes to shape food preferences as well as eating patterns of their offspring (101, 148), not forgetting that dietary habits formed at younger age last over the life course, impacting future health (42). Parents are responsible for the child's food environment, they teach to the child how, what, when, and how much to eat (148); they transmit also cultural and familial beliefs and practices related to food experiences (149). The influence that parents have depends on their own intrinsic characteristics: gender, BMI, Socio-Economic Status (SES), their own food preferences and dietary intakes, physical activity and lifestyle, but also on their own parenting style, related feeding practices and their interactions with the child in the feeding context (125, 150).

Parenting styles and feeding styles

Individual characteristics (education, SES, childhood history, etc.) define how parents behave in their parenting role. Parenting style is defined as the emotional climate in which parenting practices happen (151). The characterization of different parenting styles lays in the combination of two dimensions: responsiveness (degree of parental warmth) and demandingness (degree of parental control) that parents exert on children (152). The combination of those two dimensions defines feeding styles as specific subtype of parenting styles, with the addition of some characteristic feeding behaviours (153, 154). In the feeding context responsiveness corresponds to how responsively the parents encourage the child eating, and demandingness is defined as how much the parents force/encourage eating (155).

According to the different combinations of degree of responsiveness and demandingness four feeding styles can be derived: authoritarian (highly demanding, non-responsive), authoritative (highly demanding, responsive), permissive/indulgent (not demanding, responsive), and neglectful/uninvolved (not demanding, non-responsive) (150). Previous researches agree to conclude that the authoritative feeding style is associated with the best health outcomes for the child, while the permissive/indulgent feeding style is linked with higher child BMI (147, 156).

Authoritative feeding styles, unlike authoritarian styles, include parental high expectations of the child's diet and eating behaviour in combination with parental modelling, communication, negotiation and a warm emotional feeding interaction (157).

Parental feeding practices are associated with children's eating behaviors

Parental feeding style define the willingness of parents to adapt or not certain feeding practices with their children. Feeding practices are defined as those feeding behaviors or techniques that parents use to facilitate, limit or control what, how much, when, where and how the child eats (157). Parental feeding practices have been considered to have a significant effect on infants' food choices and consumption. Infants' food preferences and intake patterns are influenced by many different practices of the parents such as: modelling, pressure to eat, restriction of (certain) foods, and food as a reward (158). As it was underlined in the work of Haines and colleagues, performing positive feeding practices is not the only solution in order to promote the adoption of healthy eating practices among children in the modern Western world (158). They identified three key themes that encourage the establishment of healthy eating habits: eating together (socialization through family meals), a healthy home food environment (e.g. food availability/accessibility at home), and pleasure of eating (e.g. repeated exposures to healthy food to enhance perceived pleasure and reinforce cognitive properties of healthful foods (126)). The common point of the abovementioned solutions to nurture children's healthy eating lies in the type of relationship and interactions that can be established between the parent and the child during the feeding situation.

Parent-child interaction: responsive feeding

In the previous sections of this introduction we already described how a child, in the earlier years of his/her life is dependent on the parents in terms of eating, and that parents influence children's eating behaviors. However, talking about "dependency" might not be correct. In fact, latest research strongly suggests that the existing feeding interaction between parent and children is rather bidirectional (162, 163). Especially during the CoF period the parents and the child should share responsibilities around feeding: the parents should decide what, where and when to eat; the child should decide how much to eat and if eating or not (164). Responsive feeding reflects reciprocity between child and caregiver in the context of feeding (165, 166).

There are 4 responsive processes: (1) the caregiver creates a context that promote interaction;

(2) the child responds and signals to the caregiver; (3) the caregiver responds promptly in appropriate way to child cues; (4) the child experiences predictable responses (44). Feeding the child responsively, being attentive to hunger and satiety cues and respond accordingly has been associated with favorable eating behaviors and healthier outcomes for the child (44). Contrarily, nonresponsive feeding is positively linked to increased weight status in children (167), and it may result in: forcing/pressuring or restricting food intake (when the caregiver takes excessive control of the feeding situation), indulgent feeding (when the child is controlling the feeding situation), or uninvolved feeding (when the caregiver is completely uninvolved during meals) (166). Responsive feeding can be considered as a preventive action against childhood obesity and malnutrition and should be promoted in feeding guidelines (44,168).

1.3) The role of healthcare and childcare professionals

If we place the child as the center of the model in Figure 1 we can understand the influence that parents exert on the development of his/her eating behaviors (section 2). However, it is also true that, if we imagine to place the parent as individual at the center of that model, we can visualize how he/she will also receive many influences that will reflect on different parenting behaviors, which can apply when feeding the child. Healthcare professionals can be placed in the interpersonal level (of both parents and children); beside their primary role in treating infections, they can also be a support for parents with advice and guidance toward the relay of updated and evidence-based information. To understand which are the healthcare and childcare professionals' figures that were interrogated for the purpose of this thesis, this section will serve to define their duties within the French healthcare system and will make it clear under which circumstances they have the possibility to interact with parents.

New parents interact with many health and childcare professionals' figures in the prenatal (e.g. obstetrician, gynecologist, nurse, midwife) and postnatal periods (e.g. pediatrician, general practitioner, childcare assistant, nursery caregiver). Discussion regarding preventive issues (like healthy feeding practices) could happen in many occasions. However, some studies revealed that time constraints are a major problem for some professionals (especially medical doctors), letting them discuss only the strictly urgent questions (relating for example to vaccinations or diseases if parents see them when the child is not feeling well, which is often the case), leaving very little time to discuss primary prevention issues (169, 170). Hence, time constraints are often a limiting factor to fully discuss feeding topics.

However, in France several medical appointments are compulsory for children between 0 and 16 years of age and free of charge for parents. In particular, parents can bring their child to see a pediatrician or a general practitioner 15 times from 0 to 3 years of the child, and, during the first year, one visits per a month is scheduled, as presented in (

Primary care for children: how does it work in France?

Regarding healthcare providers parents encounter three main figures for medical check-ups: pediatricians, general practitioners or doctors working in maternal and child protection (PMI) centers (174). Not differently from other countries the pediatricians and the general practitioners are medical professional figures specialized in the first case in children's diseases and monitoring development from birth to 18 years of age, in the second case the specialization covers general medicine and they deal with a variety of medical problems in patients of all ages (including children). The third professional figure works in a PMI center, which is a free public service for children under 6 years of age, pregnant women, teenagers and young adults.

Consultations are generally of longer duration than in private practice, parents first meet a pediatric nurse and then they meet a medical practitioner (pediatrician or general practitioner).

PMIs are multidisciplinary centers: they gather medical practitioners, nurses, psychologists, social workers, childcare workers, etc.

Regarding childcare services, in France two main facilities exist: collective day-care and individual day-care facilities. The professionals working in individual day-care facilities are nursery assistants; they take daily care of children aged 2 months to 6 years at their home or in a structure gathering several (max 4) nursery assistants. Concerning collective day-care there are three types of facilities: nurseries (steady care for children aged 2 months to 3 years), kindergartens (steady care for children aged 18 months to 6 years) and drop-in daycare centers (occasional care for children aged 2 months to 3 years). Several professional figures are working in collective day-care facilities, taking care of young children; their duties are summarized in Table 3 (175). Table 3. Professional figures working (in France) in collective day-care facilities and their related duties.

Nursery caregiver

The nursery caregiver organizes daily activities, nap times, gives meals, changes diapers, etc.

Childcare assistant

The childcare assistant takes care of healthy or disabled children (activities, hygiene, feeding), informs and counsels parents, and his/her objective is to lead children to autonomy.

Childcare worker

The childcare worker is in charge of favoring children's development by the mean of play and early learning activities.

Nursery director

The director has several years of experience as childcare worker or as pediatric nurse. He/she is in charge of administrative, logistic and financial management, and he/she is involved in carrying out pedagogical programs.

Pediatric nurse

The pediatric nurse is a nurse specialized in childcare. He/she can work in nurseries, in PMI centers, at the hospital, etc. Nurse's duties depend on the workplace: prevention, monitoring, informing parents, hygiene care, medical care, feeding children, entertainment and activities, supervising pedagogical programs, etc.

Doctor working in nursery (médecin de crèche)

The doctor working in nursery/kindergarten is a pediatrician or a general practitioner. He/she works one or several half days a month in the collective day-care facility to ensure that hygiene and safety conditions are observed and that the environment is favorable for child well-being and early learning. He/she carries out medical examinations upon arrival for babies under 4 months of age and for children with health issues (chronic illness, disability, etc.)

1.4) Child feeding and evolving guidelines and recommendations: what is new? What changed?

It must be noted that in this thesis the terms "guidelines" and "recommendations" will recur often. A difference should be made in order to avoid confusion.

1.4.1) How was child feeding addressed in national and international

guidelines?

To answer the major questions concerning CoF, addressed those themes (41). The main results of this review, with particular focus on the French guidelines, are briefly described below (41).

According to this review (41), the start of CoF was encouraged either at 6 months, or after 6 months (WHO, European network for public health nutrition, UK), or between 4 and 6 months (France, United States). In the most comprehensive recommendations, behaviors indicating that infants are ready for the introduction of solids were illustrated. Regarding the "what" two parameters were considered: nutrients intake and sensory exposure (texture and taste of sugar and salty foods). As shown in Figure 2, for this dimension the UK guidelines were the most complete, properly covering all the aspects, whereas the French ones were completely lacking a part regarding the introduction of different textures and not providing many details on how to limit sugary and salty snack intake. The US guidelines were very poorly covering these topics, except for exposure to textures, on which some details were given. It should be reported that the US updated the nutritional guidelines in 2019-2020, it would have been interesting to assess the extent to which the limitations identified by Schwartz's work persisted in the new recommendations, but it was beyond the scope of this thesis. Finally, regarding the "how" to perform CoF, the following aspects were considered: repeated exposure, self-regulation, parent-child interactions, dietary variety and self-feeding.

Compared to the other guidelines, the French ones performed quite poorly in almost all of the aspects of the CoF process. In particular repeated exposure and self-feeding were not discussed at all and, in the case of food refusal, the use of the bottle to feed formula was encouraged. Moreover, self-regulation was not well covered; it was only mentioned alongside with the proposition of fixed food quantities.

From this review it could be concluded that the recommendations available in France since 2005 did not integrate the latest scientific knowledge related to the development of eating behavior (see section 1.1.4). In particular, explanations on the importance of repeated exposure, dietary variety and introduction of different textures, or the way to encourage the child's appetite "self-regulation" were missing. Providing information can be effective in promoting those behaviors, as it was demonstrated in a French study evaluating the acceptance of textured foods in children between 8 and 15 months (the study demonstrated that the provision of information was effective in promoting the introduction of small and soft food pieces) (189).

From this analysis there was clear evidence of the need for an update of the French child feeding guidelines and recommendations (41).

1.4.2) The evolution of nutritional guidelines in France

In France, the nutritional and physical activity guidelines have been issued since 2001, as part of the national health nutrition program (PNNS), for five population's categories: adults, pregnant women, adults aged over 55, children and adolescents. The general objective of the PNNS has been to improve the health status of the entire population by acting on one of its major determinants: nutrition (including physical activity). References for the paragraphs that follows are from the ANSES and HCSP reports (178, 179).

Since 2001, the PNNS nutritional guidelines have been disseminated to the French population in form of recommendations (nested in health messages) by various means of communication: nutrition guides, the "mangerbouger.fr" website and campaigns on traditional media and social media. Professionals in the health sector, the social sector, national education etc. integrated and relayed these messages. Since 2007, they have also been relayed by the agrifood sector. In fact, the Health Code for publicity obliges advertisers of manufactured food products to affix health messages with the content of some of the recommendations derived from the latest guidelines on their advertisements. However, scientific knowledge evolved since 2001 and consequently, from 2012 in France studies on child feeding have been carried out aimed at revising these guidelines for the population, taking into account this new knowledge.

After the formulation of the new adults' recommendations (the previous ones were from 2004), ended up in 2019 with the launch of the related online and media campaign, an update of guidelines for feeding children aged 0 to 3 years have been completed. A report containing guidelines in line with the latest scientific evidence was published by ANSES (the French national agency for Food, Environmental and Occupational Health Safety -Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement et du travail) in June 2019 (178).

The process was supervised by the Ministry of Health and, in October 2020, the High Council of Public Health also released a report reflecting these updated guidelines (179). In this context, the general health directorate (Direction générale de la santé) commissioned to the French public health agency (SpF) the development of messages intended for the general public, able to disseminate the revised guidelines. The content for a paper brochure intended for parents was finally developed in 2019-2020 thanks to the support of a group of experts gathered by SpF.

The intent of this working group, called "comité d'appui thematique"or CAT (as described with more details in chapter 2), was to decide on the content of the communication material that could make the recommendations relating to feeding children aged 0 to 3 years as accessible as possible to the final users of this communication strategy: the parents. The process of designing the brochure went from October 2019 to July 2021 and the campaign to launch the final product to the general public started in September the same year.

1.4.3) Toward the new French recommendations on child feeding

According to the latest scientific evidence some changes have been made to the child feeding guidelines and have been reported in the renewed recommendations addressed to the lay public.

The decisions that have been made by public health authorities (178, 179) regarding the topic of CoF are labelled according the classification of when, what, how of CoF. The reports from ANSES and HCSP also address other topics besides feeding (sleep, physical activity, screen time); those topics are also important for the development of healthy behaviors in children, but they will not be discussed for the purpose of this thesis. Below are reported the main child feeding recommendations addressed in the brochure. The final, fully-formatted, brochure containing the new recommendations is reported in the Appendix at the end of this document.

When to start CoF?

In order to reduce the risk of obesity, infections, celiac disease and food allergies, it is best for children born at term to start CoF after 4 months of age. After 6 months of age, breast milk and formula do no longer cover the nutritional needs of the child. Thus, it is preferable to start CoF between 4 and 6 months (not before 4 months, not after 6 months). Continuation of milk feeding alone after 6 months is not recommended.

How to start CoF?

Readiness to start textures: It is important for parents to know the signs that the child is ready (e.g. has developed chew skills, shows interest for foods…) to eat foods with different textures.

From his/her 8 months the child can start to eat small, soft pieces of food and increasingly harder pieces from 10 months of age. During this training phase it may be useful to let the child touch the food before bringing it to his mouth. However, attention should be paid to hard and/or round foods (peanut, grape, hazelnut, cherry tomato, etc.) in children under 3 years old (risk of chocking). Division of responsibility and responsive feeding: parents are responsible for providing the child with varied and healthy foods, regular meals, in a harmonious atmosphere, and the child is responsible for the amounts of food he/she consumes according to his/her needs. Rather than controlling their child's diet, parents have more of a supervising and supporting role. However, it also means that parents can trust their child's appetite.

Repeated exposure: Proposing several times an initially rejected food can increase the likelihood of this food to be accepted. It is recommended to propose the same food 8 to 10 times before consider it as rejected by the child.

What to start CoF with?

Dietary variety and taste acceptance: At the start of CoF, it is recommended to expose the child to a variety of foods (and not to limit to a single food introduced one at a time), so as to promote acceptance of new tastes. The period between 5 and 18 months seems to be a favorable window for the child to discover as many foods and new tastes as possible, in particular vegetables which are often the least accepted foods when the child is older. Optimal CoF practices (as well as breastfeeding) can promote vegetables' acceptance and contribute to the prevention of food neophobia. Once CoF has started, it is recommended that major food allergens such as dairy products, egg, cereals and peanuts are introduced without any delay.

Textures: It is important to support the child towards a diet with varied textures by adapting the size and hardness of the pieces to the child's abilities. The window for the introduction of textured foods, other than purees, is between 8 and 10 months (and in all cases before 12 months) to best support the child toward normal chewing.

Recommended and non-recommended foods: The nutritional needs of children under 3 years of age are characterized by a higher requirement for lipids than that of adults. Fat should be provided by solid foods (in addition to breast/formula milk), especially homemade preparations in which fat should be incorporated. It is also recommended to incorporate fat into baby commercial food when they do not contain added fat. A number of foods are not suitable for the diet of children under 3, in particular, it is important to avoid the consumption of added salt and sugar. The only recommended drink is water.

The recommendations above have been formulated in specific health messages within the brochure. These messages have been designed by SpF with the help of literacy experts to be as simple as possible, with the intent to be understood by all.

1.5) Public health communication: promoting healthy eating from childhood

The following sections will give an overview of what communication is, which are the barriers to effective communications, the need of communication to be inclusive of the different needs of the population and which are some of the challenges for behavior change. However, it must be noted that one of the objectives of this thesis was to inform the communication strategy via the mean of different studies with parents and professionals. Building the communication strategy itself was a task implemented by the French public health agency in charge of it: SpF.

1.5.1) Design and deliver a message: the communication process

One of the best-known formal models of communication is the one developed by the engineers Shannon and Weaver in 1949 and defined as the "transmission model of communication". In this model communication is seen as a linear process of transmitting information from a sender to a receiver. There are five elements in their model: an information source, a transmitter, a channel, a receiver that decodes (interprets) the message, and an ultimate destination. Noise in the system was added as an obstacle interfering with the message traveling along the channel, and being correctly interpreted by the receiver (190). We can translate this considering the existing information about child feeding as the messages and parents as the receiver; in this case applying the messages could be seen as adopting/changing current behaviors regarding appropriate feeding practices. Given the multiplicity of messages coming from a multitude of different sources (internet, own personal network, media), it is important to make clear to parents where the reliable and official information is available and effective solutions should be found to put all parents in the position to understand the information correctly.

Different models were inspired by and followed the one of Shannon and Weaver; it is important to notice that in those later models the concept of the information environment was expanded; in fact, more variables were considered as interacting in the process, potentially disturbing the linearity of the former model (191). The communication process, as described by Barnlund in the 70s, is seen as a transactional model, where communication is dynamic; it is a circular and reciprocal system in which participants interact and influence each other, giving a meaning to messages that can be influenced also by external factors (e.g. personal networks). This process includes a sender who forwards a message to a receiver using a channel; the receiver normally, after having understood the message, responds with a feedback, which can be, for example, a change regarding a health behavior (in our scenario) (192). There are two main communication methods: mass communication, meaning sending the same message to a large segment of the population and face-to-face communication, where there is a direct interaction between sender and receiver. Mass communication can be generic (large, undifferentiated audiences receive identical messages), targeted (population subgroups who share characteristics receive identical messages) and tailored (individuals with very personal characteristics, like personality factors, attitudes, knowledge receive messages matched to their needs and preferences) (193). Face-to-face communication is defined also as interpersonal communication: it happens between two people; the message depends on the person and the context (interpersonal communication is well explained by the Barnlund model, in which the two communicators act both as sender and receiver, continuously exchanging cues during the communication process).

There are many barriers that can disturb effective communication, the existing literature spreads across a wide range of disciplines, taking into account a variety of different contexts (194)(195)(196)(197); the most relevant barriers are briefly explained here below. Communication barriers can be physical (e.g. difficulties of the receiver in hearing/seeing the message), environmental (e.g. noise, invisibilitythe message does not reach the receiver) or they can be dependent on the status of the information source (trustable or not). Moreover, the receiver could be not intellectually-ready to receive the message. This does not only mean that the educational background of the receiver could affect how the message is understood, but it could also include perceptual (belief that the other person will not understand us), semantic and language barriers (the language and vocabulary that is used in communication should be mutually understandable between communicators). Furthermore, emotional barriers define the readiness and willingness of the receiver to receive the message (level of emotional involvement of the receiver). Finally, cultural barriers depend on the customs, beliefs of the sender and receiver and can also affect the communication process. Intellectual, emotional and cultural barriers raise the consideration for the ethical aspects connected to communication, especially health communication. Indeed, those barriers could contribute to accentuate health inequalities, which would be contradictory to the intentions.

1.5.2) Does communication influence everyone in the same way? The principle of proportionate universalism

Public health communication activities and messages could have unintended adverse effects, as it is well explained in the research done by Guttman and Salmon in 2004 (198). For example, health messages could contribute to stigmatize and label part of the population, by presenting a negative image of those people living with a particular disease/health-related behavior, that the health message is trying to warn about. Moreover, while higher SES groups often have more expanded knowledge on health issues, and are more willing to adopt recommended practices, low SES groups might have high motivation for improving their health, but they may lack of basic health knowledge on some topics. Such knowledge can sometimes be given for granted in the available communication material or when planning primary prevention interventions. This is why health communication interventions can indirectly contribute to expand knowledge gaps and consequently social gaps. Another harmful adverse effect of public health communication is that messages can exaggerate the importance of health as a value. Many people are in constant worry about their health as they perceive it as a virtue and, when they are ill, there is the risk that they could feel unworthy and socially excluded (199).

Health communication should be inclusive and representative of vulnerable and underserved groups to reduce health disparities. The current challenge is to consider the specific needs of the different sub-classes of the population when programming legitimate interventions (e.g. intervention promoted by public health authorities). In fact, nowadays plenty of information is available everywhere, there are no boundaries between evidence-based information, that has been validated by legitimate authorities, and non-validated information (200), this could, for instance, pave the way to "fake news". The so called "unofficial" information is becoming increasingly accessible to the general population, partly due to the use of internet and other technological means of communication, making it difficult to distinguish between the different types of information that are accessible and whether those can be trustable or not.

Reaching health equity by keeping high effectiveness of campaigns or prevention interventions is an important dilemma in public health (201,202); this implies providing services based on scientific knowledge to all who could benefit, trying to minimize disparities (203). The concept of equity must not be confused with the one of equality (204). For example, an approach that can be defined as "equal" corresponds to provide everybody with the same health messages given with the same tools. This approach might give the same means (e.g. the same information) to the whole population, but it could end up in knowledge gaps and increased health disparities. In fact, as mentioned above, this approach might not account for the specificities of some population sub-groups (e.g. different levels of education, different cultural backgrounds). Another example of an unequal approach is when healthcare providers offer different care's options based on race or ethnicity (205). Contrarily, an approach aimed at ensuring equity could entail a distribution of health care (or health information in our case) by accounting for specific characteristics of sub-groups of the population in such a way to get as closer as possible to an equal distribution of healthcare (or health information) and reaching social justice (204). The above explained issue mostly refers to access to healthcare, but it might also be extended to preventive actions or communication campaigns. In fact, despite the effort made by public health stakeholders, prevention strategies often produce results that are socially differentiated, worsening health inequalities instead of reducing them (198). Low SES families, compared to high SES families, could benefit less from communication campaigns for instance (206).

Health behaviors among low-income groups have become a major issue when promoting health equity. In this context, the principle of proportionate universalism emerged in the last years as a conceptual possible solution to tackle health inequalities toward health equity (207,208). This approach, applied to public health, implies carrying out actions that should be universal, but with an intensity and a scale that is proportional to the level of disadvantage of the different sub-groups of the population (207). This means that, as reported by Marmot and Bell, there is the need of combining targeted and universal interventions (generally this applies to policy development, but it can apply also to communication programs, prevention strategies) in order to make progress (209). Despite the recognized utility that proportionate universalism could have in reducing health inequalities (210), up to date there are not specific guidelines allowing to systematically apply this approach in public health prevention interventions (207).

To the best of our knowledge there is not comprehensive evidence regarding the application of the principles of proportionate universalism in health communication, however those principles have been lately adopted to community-based interventions like the program MALIN.

In France, the program MALIN has the objective to promote healthy feeding practices in young children coming from financially disadvantaged families (211). It aims to build knowledge, skills and cultural adapted individual support for parents regarding optimal feeding practices, as well as to bring financial support to families. This program started in 2012 with an experimental phase in fourteen pilot-sites, and it was finally launched at national level in 2021.

Before the national implementation of the MALIN program, the ECAIL study (a randomized controlled trial) was launched with the aim of providing essential elements to improve the effectiveness of public health actions targeting populations in precarious situations. Currently, the ECAIL study is still on going. The lessons learned from the ECAIL study so far made it possible to adapt the variation of health messages to families in precarious situations, placing this intervention within the framework of the proportionate universalism of public health actions (212).

1.5.3) Health promotion and changes in health behaviors: from health communication campaigns to community-based interventions

Promoting healthy eating habits and latest scientific discoveries through attractive communication strategies/campaigns is one way to change dietary behaviors of a large amount of people, but often it is not sufficient in order to make changes that can last over time. Stating behavioral changes as the goal of a specific campaign is important, as it will drive the formulation of appropriate health messages targeting specific behaviors (213). However, some intermediate outcomes exist that can be helpful in attaining behavior change goals; those are knowledge, beliefs, and interpersonal communication, and not much is known about changes in those outcomes following the impact of campaigns and public health prevention interventions (214). Normally campaigns do not focus on intermediate goals (like increasing knowledge), as their scope is changing individual motivations (and ultimately behaviors) rather than raising awareness about a problem. In fact, it was demonstrated that it is very unlikely that the rising of awareness about a problem will immediately bring someone to take action and change behavior regarding that issue (215). This is the so-called "communication effects gap" (216).

Nevertheless, it might be hypothesized that an increase in knowledge (as intermediate outcome) could act as a proxy in changing behavior, and further investigation is needed regarding this point.

Communication alone cannot achieve changes in people's behavior also because it cannot contribute to the modification of all the environmental factors that define how people act facing a specific situation. The environment can also play a role in facilitating the establishment of new or modified behaviors. According to the Ottawa charter, the principle of health promotion goes through the empowerment of government bodies, communities and individuals at different degrees of responsibility (217). Even if it goes beyond the scope of this thesis, it is important to keep in mind that only the creation of a supportive environment can improve the level of education of the population and slowly make changes in the behavior of the individual. For instance, modifying the environment could enable people to make healthy food choices in a non-conscious way (e.g. all the regulations aimed at improving food quality, or soda tax regulation

1.6) Research objectives of the thesis

In this context, the general objective of this thesis was: "To contribute to the development and the evaluation of communication material, dedicated to parents, aimed at disseminating public health guidelines regarding the adoption of healthy eating behaviors in children aged 0-3 years."

The main research question that this project attempted to answer was: "How can we transfer the research knowledge (evidence-based knowledge), at a large scale, to parents and health care professionals to leverage healthier feeding practices, and in turn healthier children's eating behaviors?".

Following what emerged from the literature some points were considered as potential gaps in line with the general aim of the thesis and worthy of investigation. In particular:

• Parents are the first influencers of their children's eating behaviors, especially in the 0 to 3 years period; properly informing them via the mean of communication material containing updated recommendations is necessary in order to facilitate the application of feeding practices that can turn into healthier dietary habits for children. However, we do not know how French parents seek information regarding child feeding, which information they look for and to which extent they trust the advice they find or receive.

• HCPs interact with parents at the onset of CoF transition (one of the key periods in early feeding for the development of eating behaviors), but we do not know how they advise parents and if they are confident about giving information on child feeding.

In fact, the latest recommendations are outdated and professionals might not be willing to point out communication material dated over 15 years ago. It is important to understand whether HCPs have the proper means to communicate with parents regarding those topics and to evaluate any further need in order to facilitate their counselling role.

Therefore, considering the recent release of the updated child feeding guidelines in France, parents and HCPs appear as potential targets for public health communication interventions aimed at increasing the compliance of parents with the latest child feeding recommendations.

Moreover, studying a national representative sample of parents could facilitate the generalization of the results to the French population of young parents, allowing the exploration of the needs of parents with different socio-demographics characteristics. This thesis was organized in two parts. The first part (studies 1 and 2) comprises the evaluation of the needs and practices of parents and HCPs (pediatricians in this case) regarding information seeking on child feeding. This part informs and precedes the development of the communication material (a paper brochure made by SpF with the help of a working group of experts) whereby the recommendations will be spread to the lay public. The second part of the thesis (studies 3 and 4) comprises an evaluation of the developed material with parents on the one hand, and HCPs and CCPs on the other hand. More details regarding the four studies and the outline of the thesis project are given in the next chapter (chapter 2).

The following specific objectives were defined: 1) To explore the perceptions and practices of pediatricians and parents of children aged 0 to 3 years regarding child feeding information and subsequently inform the communication strategy accounting for their needs: Studies 1&2. 3) To evaluate the short-term impact of the communication material on parental knowledge regarding child feeding: Study 3.

4)

To evaluate the level of understanding of HCPs and CCPs regarding the information (new recommendations) contained in the brochure for parents and to explore their barriers and needs in communicating with parents about child feeding: Study 4.

Taken in a transversal way the studies that are part of this thesis are trying to answer the following research questions:

• How to inform the communication strategy accounting for the needs of parents and HCPs in relation to child feeding information?

• How to design and deliver a public health communication strategy able to leverage parents feeding practices in a way that the majority of parents will understand correctly the messages?

• Which are the effects of the child feeding messages on parents' knowledge?

• Are professionals ready to deliver the child feeding messages to parents?

2.1) Outline of the thesis project

This project aimed to develop effective communication tools to disseminate public health guidelines relating to the adoption of healthy eating habits in children aged 0 to 3 years. The thesis project consisted of four studies, the general objective of which was to inform the new public health communication strategy of the new child feeding recommendations, taking into account the information needs of parents and pediatricians (and more generally healthcare and childcare professionals) on children's feeding practices. Moreover, we aimed to assess whether the material developed had a short-term impact on parental knowledge and finally if it was positively evaluated by professionals. Below an overview of the four studies conducted during this thesis is given, including the main research questions and methodological aspects for each study. knowledge (accuracy and certainty) about feeding children 0-3 years old? Method: quantitative study, online survey. In this study parents had to complete the same knowledge questionnaire twice, before (T0) and after (T1) reading the draft of the brochure they were provided via post and email. Study 4: Questions: which are French HCPs' and CCPs' practices and perceptions in terms of communication with parents about child feeding? Which is the level of understanding of the information contained in the official brochure and the level of acceptance of the new recommendations? Method: qualitative study, semi-structured interviews.

Figure 3 shows an outline of my thesis project. The three different colors in Figure 3 highlight the actors in charge for a given task; for each task the year when it took place is reported. The pink color corresponds to the four studies that I performed, the blue color corresponds to actions from public health actors involved in the project and the yellow color corresponds to actions run by SpF with the support of the thematic support committee (CATmore details in the 2.2 section). In the specific case of the evaluation of the understanding of the messages my contribution came from the results of studies 3 and 4, but in parallel SpF run some focus groups with parents of children aged 0-3 years coming from different SES. This

2.2) Development of the communication strategy at the French Public

Health Agency

From June 2019 to February 2020 I spent nine months in the offices of SpF in Saint Maurice (FR), in accordance with the requirements of the European Commission which is funding my thesis (ITN Marie Sklodowska-Curie program). During this time, I worked at the Nutrition and Physical Activity Unit in order to contribute to the reformulation of the recommendations for the dissemination material based on the new ANSES and HCSP reports. An effort was made trying to develop educational tips for parents regarding optimal child feeding practices considering the latest guidelines (178, 179), and scientific evidence on child feeding, as developed above.

SpF relied on a thematic support committee (CAT) to reformulate the new recommendations and educational advice for parents of children under the age of 3. I participated in this thematic committee since November 2019 until June 2021 with the frequency of about one meeting per month (the frequency of these meetings has been lately modulated and adapted to the Covid-19 situation). The objective of the CAT was to formulate new recommendations that were acceptable, easily understandable and applicable by parents on their daily child feeding routine.

The respect of these characteristics has been constantly evaluated with various studies carried out by SpF (focus groups with parents) or by myself in the context of my thesis (see section 2.1). Moreover, it was meant to accompany those recommendations with more practical guidance, considering the needs of the population of parents of young children demanding: "easy to perform" advice (as it emerged from the results of study 2, chapter 3 of the thesis).

Based on the work of the CAT, the new recommendations were reformulated and the information channels for disseminating them had been discussed. Finally, the objectives of the public health communication strategy for the dissemination of the recommendations had been agreed by SpF 3 . The brochure summarizing this work, titled "Pas à pas, votre enfant mange comme un grand. Le petit guide de la diversification alimentaire", had been finalized in summer 2021 by SpF. The campaign for the launch of this brochure started in September 2021 and the document is now available for download in the website of SpF (MangerBouger: link). The communication strategy also includes four short YouTube videos that show the different steps of CoF (videos) and six thematic tutorials addressing frequent issues that parents could encounter when starting to feed their child with food other than milk (tutorials).

Thematic support committee (CAT): composition and activities

The CAT counted 16 participants (6 internal and 10 external to SpF) with different expertise in child feeding. The group was leaded by two members of the Nutrition and Physical Activity Unit of SpF with long experience in managing processes of development of feeding recommendations. Other two members of the group belonged to the same unit; they were experts in nutrition and public health communication. The last two members of the CAT working at SpF were a pediatrician and a nutritional epidemiologist. Between the external 3 Objectives of the public health communication strategy -from internal document "Fiche campagne Diversification alimentaire, Septembre 2021" (SpF):

1. To disseminate the new recommendations in terms of child feeding and CoF (for children from 4 months to 3 years old) to the general public and to professionals. 2. To allow parents of children aged 4 months to 3 years to properly understand the new child feeding recommendations by offering practical tools and accessible content (brochure + poster, educational tutorials, articles on mangerbouger.fr, recipes). Thanks to the work of SpF and the CAT three different versions of the brochure were developed before the final one, which was nationally disseminated. In the course of this process, my studies have brought evidence that, first made it possible to assess the needs of professionals and parents in terms of communication about child feeding (including the period of CoF), and subsequently allowed the evaluation of the content of the intermediate versions of the brochure with parents of children aged 0 to 3 years and HCPs and CCPs. Moreover, SpF conducted focus groups with parents coming from different SES groups, all of the studies enabled a comprehensive pre-evaluation of the material. Figure 4 shows a timeline of the development process of the brochure and the different evaluation phases.

The studies that compose the core of this thesis will be presented in the next chapters (3 and 4) in the form of four articles published, in review or in preparation for peer review international journals. During the first few months of life, an infant faces a phase of rapid growth, which is largely determined by early childhood and complementary feeding (CoF) practices. CoF is defined as the period when solid foods start to be introduced in an infant's diet [1]. Inappropriate CoF can have serious implications for the healthy growth of the child and for the development of healthy eating habits [2]. Proper infant feeding gives the right footprint to a healthy process of development for the child, reducing the risks for non-communicable chronic diseases later in life [3,4]. During this period, parents are the key players in shaping the eating behaviors of their children [5], but they also have to deal with a phase of learning and upheaval at the emotional and physical level. In fact, the transition to parenthood can affect what new parents perceive as healthy eating behavior, accentuating their stress around their feeding practices [6]. High levels of parenting stress have been associated with more authoritarian parenting styles, which in the feeding context emerges in a decreased ability to interpret the child's satiety cues, the use of more controlling child-feeding practices (e.g., pressure to eat) and offering less healthy foods to the child [7,8]. Overeating and emotional eating in children have indeed been proven to result from higher levels of parenting stress, whereas mindful parenting and mindful feeding were positively associated with healthier eating habits [9,10]. The strong concern of not knowing how to behave, and the high level of stress due to new parenting situations, can lead parents to beg for any kind of advice regarding how to care for and feed their children, thereby lowering the degree of rigor demanded of the information [11]. New parents look for information on infant feeding via many different sources-from the Internet, media, books and magazines to family, friends and healthcare professionals, among whom are pediatricians [12,13]. The feeling of reluctance that hovers around the introduction of the first solid foods and food pieces is high in some parents [14]. The confusion is raised by the fact that guidelines on infant feeding may change and evolve, in relation to the increasing evidence that centralizes the role of the first 1000 days of life of a child as a cornerstone for the early prevention of obesity [15,16].

During the last few years, in Europe and all over the world, countries have released different guidelines to properly inform parents and healthcare professionals on infant feeding practices likely to optimize short and long-term health. However, in many cases, the feeding behavior of parents is not fully in compliance with official feeding recommendations [17][18][19].

Among the many factors accounting for this gap there is, for example, the fact that national guidelines can be incomplete or not updated-some emerging evidence-based topics might be poorly covered (e.g., the introduction of different textures and how to cope with food refusal) [20]. Moreover, mothers often perceive guidelines as something divergent from what they consider the "reality" of the CoF process, and therefore they allow themselves a certain degree of flexibility in following what is recommended [21]. Considering the fact that early eating habits typically have long-lasting impacts throughout childhood and may ultimately turn into adult eating patterns [22], supporting parents and guiding them early to boost children's healthy development is paramount.

To avoid the risk of leaving parents with inconsistent information, healthcare professionals have a responsibility to provide them with the best practice advice and guidance, based on the latest scientific evidence. In France, when the child is aged between 0 and 16, parents are encouraged to take him/her to several free and mandatory consultations with healthcare professionals, and the majority of these visits take place in the first three years of life [23]. Among all the healthcare professionals, pediatricians have one of the most important roles; they interact with parents during the CoF transition, and therefore they are in a convenient position to provide advice to support parental decisions when it comes to feeding matters.

Pediatricians are trusted by parents in France, as shown by the Nutri-Bébé 2013 study: 58% of mothers of children aged between 15 days and 35 months appealed to medical advice for feeding their children [24]. In France, the official updated recommendations for feeding children aged 0 to 3 years old have recently been published [25,26] to replace the previous recommendations dated back to 2004. Simultaneously investigating the perceptions and needs of parents and pediatricians regarding CoF information could help to build an evidence-based strategy for developing a targeted health communication program.

To allow public health stakeholders to develop a communication strategy to effectively spread the latest official recommendations on infant and young children feeding, this study aims to provide an overview of the current situation, in France, in terms of perceptions towards CoF and the CoF information needs of parents and pediatricians. Therefore, we first describe parents' and pediatricians' perceptions and needs regarding the available information on CoF, and subsequently investigate parental information-seeking strategies and behaviors (sources used to gather CoF information, content searched for, etc.) seen from both parents' and pediatricians' perspectives.

Materials and Methods

Web Surveys and Participant Sampling

Two online surveys were prepared and administrated for each target group separately. The parent survey targeted a French representative sample of 1000 parents of children <4 years old and was prepared with the help of a private research and consulting firm (BVA). It was open for completion from the 10 to the 29 of January 2020. The sample size of 1000 was defined a priori, and it was considered representative for our purposes according to previous studies conducted by BVA on similar subpopulations. The sample of parents aimed to represent the French population of young parents. The quota method was applied to ensure the representativeness of the sample, and the general population census was used for data calibration [27]. The following variables were controlled for with quotas: age of the parent; profession of the household reference person (i.e., the parent with the highest salary); region; living area; first-time or multiparous parent. Multiparous parents (included in the study because at least one of their children was <4 years old) were asked to refer to their youngest children when answering to the questionnaire. A total of 1001 parents responded to the survey and their answers were considered for analysis. The questionnaire was divided into five sections: characteristics of the youngest child, the parents and the household; parents' perceptions on CoF; parents' perceptions on available CoF information; sources of information used by parents (with self-perceived influence on their feeding practices) and type of CoF information sought by parents.

The second survey was intended for members of the French Association of Ambulatory Pediatrics (AFPA, n = 1402). The AFPA is a nationwide recognized association that brings together many pediatricians (mostly in private practice) from all over France (https://afpa.org/;

accessed date: 04/05/2021). The pediatricians' questionnaire was prepared with Sphinx and remained open for completion from the 10 of October to the 7 of November 2019. Considering the total size of the population being studied (n = 1402), and according to a power calculation with a confidence interval of 95% and a margin of error of 5%, the required number of respondents to reach was equal to 302 [28]. Answers were obtained from 318 healthcare professionals, the 301 answers from pediatricians were considered for the analysis (the few general practitioners who answered were excluded in favor of a more homogeneous sample).

The questionnaire consisted of four parts: demographical data, attitudes and perceptions regarding CoF and CoF information, current practices regarding communication with parents about CoF and new plans/suggestions for implementing CoF communication with parents. For both questionnaires, all the answers were mandatory and the inclusion of participants ended when the sample sizes had been reached.

The original versions of the questionnaires (in French), with translations to English, are presented as Supplementary Materials S1 and S2, for parents and pediatricians, respectively.

The questions and the lists of answers (multiple choice) were developed based on previous studies [12,29], while considering the advice of public health experts and BVA for the parents' survey. The pediatricians' questionnaire was piloted with a small network of healthcare professionals (from the Perinatal Network of Burgundy, n = 200; n = 33 of participants answered the pilot survey). The parents' questionnaire was pretested by BVA with their panelists. Both questionnaires included closed-ended multiple choice questions, with one or check-all-that-apply answer options; Likert scale and demographic questions; and one optional open question for the pediatricians' questionnaire asking for additional suggestions to implement the content or format of the material to facilitate communication on CoF with parents. The Likert scale used was differently in the two surveys. A 5-point scale (strongly agree; agree; neither disagree nor agree; disagree; strongly disagree) was used to ask pediatricians if they agreed with statements regarding their attitudes and perceptions on CoF in general, and with the available CoF information they give to parents. After consultation with BVA, it was decided to remove the "neutral" option from the parents' survey; this decision was made in order to gather specific and stronger opinions from parents, but ran the risk of forcing respondents with no opinion to make decisions. Therefore, a 4-point scale (strongly agree; tend to agree; tend to disagree; strongly disagree) was used to ask parents if they agreed with some statements regarding perceptions around CoF and available CoF information.

Statements requiring an answer on a Likert scale were considered as discrete variables and were grouped in "agree" and "disagree" (and "neutral" for the 5-point Likert scale of the pediatricians' survey)

for the description of the results.

The parents' and pediatricians' surveys addressed many identical issues, with questions formulated almost in the same way, but there were also some differences. In the parents' questionnaire, parents were asked to report how much their sources used to gather CoF information influenced them (continuous scale from 1 to 10, with 1 meaning the source was not at all influential and 10 meaning it was strongly influential) in making decisions on how to feed their youngest children. For the majority of the questions in the parents' questionnaire, we referred to "feeding children aged 0-3 (other than milk feeding), including complementary feeding" and specified the definition of CoF in order to avoid misunderstandings. In the pediatricians' questionnaire, specific questions addressed, for example, how they obtained information on CoF in the last two years and who they thought formulated official infant and young children feeding recommendations in France.

Ethical Consideration

The studies were conducted according to the guidelines laid down in the Declaration of Helsinki. This kind of research in France does not require mandatory approval from an ethics committee. For the parents' study, a panel of eligible respondents was surveyed and ethical measures were undertaken according to BVA's procedures. Written informed consent was obtained from all subjects and the panel of participants involved in the study was declared to the appropriate committee (CNIL-Commission nationale de l'informatique et des libertés) for data protection. The processing of the personal data of BVA panel members was carried out in accordance with the European regulation "General Data Protection Regulation (GDPR)." All participants were assigned unique identifiers by BVA. The unique identifier allowed registering in the panel and it is essential for BVA to manage the contacts with panelists. Researchers did not have access to identifying panelist data. Small incentives were given to parents for participation. For the pediatricians' study, researchers never had access to any personal data of the respondents, who accepted to participate voluntarily and anonymously.

Data Analysis

For all statistical analyses, R version 3.6.1 was used [30]. Frequencies, percentages and means ± SDs were used to describe the results. The quota sampling method ensured the representativeness of the parents' sample for the general population. For the parents' sample, a

Friedman test was carried out to see if the sources of information had different perceived levels of influence. Chi-square tests were calculated to check whether the pediatricians who answered the survey were a representative sample of the AFPA pediatricians regarding age and gender.

An independent sample t-test was used to compare means, and the test for homogeneity was used to draw a conclusion about whether the distribution of responses was the same in the two populations. The level of significance was set at p < 0.05.

Results

The main findings reported in this paper provide an overview of perceptions and needs regarding information on CoF, accounting for the points of view of French parents and pediatricians. For example, regarding perceptions: Is CoF important for the healthy development of the child? Are parents satisfied with the available information? Do pediatricians think they have the means to start discussing CoF with parents during consultations. Regarding needs: When is the information needed? what type of content do parents look for? What do pediatricians think is important to tell to parents? Which sources are used and influential to give information on CoF?

Study Populations

The study populations are described in Table 1. Answers were obtained from a total of 1001 parents, representative of the French parents' population with at least one child <4 years, according to the quota sampling method. Information was available regarding age and gender of the pediatrician members of AFPA. The sample of pediatricians (n = 301) was representative for age, with 47% of members being less than 50 years old, 27% 51 to 60 years old and 26% over 60 years old. Regarding the gender, there was an overrepresentation of female pediatricians in our sample (80%) compared to the general AFPA population (75%).

Perceptions of Parents and Pediatricians toward CoF and Feeding Children aged 0-3

All parents were aware of the importance of CoF for their children's current and future health and growth (99%); 77% even thought it was very important. In addition, all parents (99%) knew that this period is important for developing health-favoring eating habits in children, and 79% thought it is very important. Overall, the period of CoF was positively experienced by parents. Thus, 91% considered that it went well. Nevertheless, for 35% of parents, CoF was or had been a cause of concern.

The importance of CoF for the development of young children was well recognized by all pediatricians (99%), as was the need to advise parents on the subject in order to help them adopt healthy feeding practices for their children (93%; 7% were neutral); 68% thought this was very important. Ninety-nine percent of pediatricians were confident in their role of advising parents about CoF, and 82% of them thought they had enough knowledge about CoF and infant feeding.

All pediatricians believed that advising parents on CoF was one of their responsibilities; 93% of them always gave advice on this subject during medical consultations, compared to 7% who gave advice only when they recognized it was necessary.

1 A level corresponds to the diploma obtained after completion of upper secondary school (equivalent to 12 years of formal education in France). 2 I.e., the parent with the highest income. The socio-professional category was high (liberal profession, entrepreneur, executive or higher intellectual profession), intermediate or low (laborers and clerks) or no occupation/retired (including also students). 3 Parents were classified as having a good financial situation when they perceived they were comfortable or okay with it. The other parents were classified as being in a difficult financial situation when they had a perceived uncomfortable situation imposing to pay attention to their budget, or making it difficult to reach the end of the month or forcing them to take out debts (Supplemental Material 1, question 28, modalities 3, 4, 5).

When Did Parents Look for Information on CoF and When Did Pediatricians Provide

Advice?

On average, parents began to learn about CoF when children were five months of age (4.7 ± 3.7). When the child was less than six months old, during medical follow-up consultations with the child, 52% of pediatricians spontaneously broached the subject of CoF and 54% of parents asked questions or sought advice. Seventy-nine percent of interviewed parents reported they already looked for information on CoF for at least one of their children, and 73% for their last child.

Eighty two percent of pediatricians said they started giving CoF advice to parents when children were around four months of age (3.8 ± 0.8), tackling the issue of the different stages of CoF when children were 4 or 5 months of age (4.3 ± 0.7).

Parents' Perceptions about CoF Information and Pediatricians' Perception about Parental Information Needs

Eighty seven percent of parents felt they were well informed about CoF, and 87% of them were satisfied with the available information. The proportion of parents who considered themselves to be very well informed was rather small (37%); the same went for those who felt very satisfied with the information (29%) or considered the search for information to be very easy (28%). The information on the subject of CoF appeared clear to 90% of parents; that relevant to their questions was present for 87%; and it easy to put into practice for 86% of parents. However, a third of parents (34%) considered that the advice available was not always consistent and could even be contradictory. According to 32% of parents, the available advice on infant feeding could make them experience a feeling of guilt of not behaving as recommended.

Forty-one percent of pediatricians thought that parents did not want more information on

CoF than what they were able to provide during consultations, whereas 31% of pediatricians thought parents wanted more information (28% were neutral regarding this topic). Although only 16% of pediatricians said they were not satisfied with the available CoF material, 55% of them said they prepared the documents on CoF to give to parents themselves. Thirty-five percent of pediatricians thought that the different economic and cultural situations of families were not sufficiently taken into account in the information and communication materials available to parents (35% were neutral; 30% thought differences were considered).

Type of Content Parents Are Looking for Versus What Pediatricians Thought is Important for Parents to Know

Figure 1 shows that parents found particularly useful information on very concrete topics, such as examples of recipes or menus (61%), quantities and sizes of food and milk portions (45%), how to present food in case of refusal (35%), ages of introduction for different food groups (32%) and strategies to feed the child to promote the development of healthy eating habits (30%).

Concerning the information to be transmitted to parents about CoF, pediatricians thought that the most important topics were: the age of start to CoF (age and modalities of introduction of first foods other than milk-91%), the ages at which the different food groups must be introduced (88%), how to feed a child to promote the development of healthy eating habits (86%) and presentation strategies in case of food refusal (80%). Only 28% of pediatricians thought it was important to provide more information on recipes and menus, a topic widely sought for by parents (Figure 1). For each question/topic, the percentages were significantly different for parents and pediatricians (p < 0.001).

Sources Used by Parents to Learn About CoF (with Their Degrees of Influence), and Sources Pediatricians Thought were Relevant for Parents

Figure 2 shows the use of the different sources of information in relation to their influences on parents in terms of decision making when feeding their children. Healthcare professionals were a source of information for 81% of parents, and their degree of influence was the highest (7.6 ± 1.7/10). Among healthcare professionals, the pediatricians and general practitioners were positioned as the main vectors of information (49% and 46%). The Internet in the broad sense (including websites, blogs, social networks and applications) turned out to be the second most used source of information; 73% of parents resorted to these online means. However, in spite of the widespread use, the mean level of influence for the Internet was the lowest (5.7 ± 2.1/10).

The parental network was globally identified as a source of information by 62% of parents, with a mean influence of 6.9 ± 1.8/10. Paper documents were a source of information for 44% of parents, and of relatively low influence (6.3 ± 1.8/10). Early childhood professionals were among the sources of information that parents used the least (31%), but they had a strong influence on parents (7.4 ± 1.8/10). Only 26% of parents referred to the media (television, radio)

and the mean influence of this source of information was 6.0 ± 2.0/10. There was a statistically significant difference in self-perceived influence depending on the information source used (Friedman test: χ2(5) = 1191, p < 0.001). For pediatricians, the most effective tools to grab the attention of parents were websites (for 73% of respondents), paper brochures (59%) and smartphone or tablet applications (57%).

Only 13% of pediatricians thought that parents relied on their personal networks to gather advice, and therefore they underestimated the usage of this source. According to 98% of pediatricians, the bodies responsible for formulating official recommendations concerning CoF in France were the pediatrician professional organizations; only 56% of them recognized Public Health France, the French public health agency, as an official source in charge to inform the general public about feeding recommendations.

Appropriate Communication Formats According to Parents

As shown in Table 2, for 79% of parents, the most appropriate communication format was digital (applications or websites), but 58% of parents liked the paper format. Smartphone applications (43%), multi-page booklets (41%) and websites (38%) were the most suitable formats for providing information on CoF. A one-page brochure seemed less appropriate (23%).

Discussion

Two surveys were conducted in France at the end of 2019/beginning of 2020. The aim was to explore the needs and perceptions of parents and pediatricians in regard to information on CoF, in order to inform the deployment of a public health strategy to disseminate the new CoF recommendations issued in 2019. The results showed that there was full awareness of the fact that the CoF period has a strong impact on the healthy development and growth of children, and on the evolution of their eating habits, from both parents' and pediatricians' points of view.

Nevertheless, for some parents, CoF was perceived as a cause of concern. There was clear evidence that providing CoF information to parents is essential in order to help them understand how to adopt healthy eating practices for their children, and pediatricians were well-recognized by parents as information providers. We observed that information was requested by parents and advice was given by pediatricians before the implementation of CoF at slightly different times. Notwithstanding, according to parents, only half of the pediatricians spontaneously broached the subject of CoF during medical appointments, and this is in contrast with the majority of pediatricians saying that they always gave advice on this subject during consultations. Despite the preponderant feeling of parents that they were well informed and satisfied with the information they are able to find, over one third of them perceived the available advice as contradictory and inconsistent.

The parental perception of receiving conflicting information highlights the confusion that parents can experience when they are put in the position of deciding which advice to follow regarding their child feeding. Mothers can be pushed to the point of not relying to any feeding guidance, but just on their own instinct and on the fact that "all babies are different," and they may consequently adapt their feeding practices to what they think is the best for their babies [31]. Moreover, our analysis showed that, according to more than one third of the interviewed pediatricians, the information and communication material available for parents may be culturally inappropriate, with approaches that may not account for different socio-economical situations of families. The unsuitability of existing CoF communication means for the needs of disadvantaged populations frequently emerged in literature. Parents complain, for example, that healthcare professionals do not know their culture and traditions, and therefore they trust family members better [32]. Additionally, mothers who, for some reason (e.g., medical concerns: crying, spitting up and waking), are unable to follow the infant feeding recommendations are not inclined to seek advice from healthcare professionals even in case of difficulty, as they do not feel understood by them [33].

Even though these previous studies suggested a conflicting and unstable level of trust in healthcare professionals' guidance, our results showed that pediatricians and general practitioners are the most used source of information for parents and the advice coming from them is the most influential in terms of feeding practices. Findings from other studies suggested that healthcare professionals' advice was valued more if perceived as coming from personal experience or scientifically verified, up-to-date sources [34,35]. Consistently with earlier findings, parents in this survey also gave high value to the advice from family and friends, and one reason can be that they did not perceive the health professionals' advice as practical or relevant to the needs of their children [36,37]. The social pressure from peers (family members, friends or other parents of young children in the own network), but also the existence of social norms and their influences on infants and feeding decisions are topics widely discussed in literature and might undermine adherence to recommendations [38]. Our results bring new insights about the fact that pediatricians in this study largely underestimated parents' reliance on their personal network. This is unfortunate since, if they do not realize who parents are listening to, they cannot attempt to counterbalance the influence of these sources. Healthcare professionals should seek every opportunity to promote infant feeding recommendations during medical appointments. In doing this, it is important to try to positively involve parents, reassure them in their new roles and build confidence in a way to override social expectations or strict cultural advice.

Another aspect that might be considered is whether the advice coming from physicians is in line with infant feeding guidelines. Surprisingly 55% of pediatricians produced their own CoF materials, which can leave room to personal interpretation of public health messages. A study conducted in the South of France showed that pediatricians' advice on CoF was only partially in line with current recommendations [39]. Moreover, frequently updated recommendations were well followed by pediatricians, but those that had not been recently updated were less well followed [39]. Contrariwise, the findings from Chouraqui and colleagues showed that French pediatricians and general practitioners give CoF advice mostly in line with the official guidelines. Despite the congruence of given advice with recommendations, parents still experience confusion due to the fact that their perceptions rarely align with what is said by doctors; that is one reason why they are still far to reaching the point where their feeding behaviors perfectly match guidelines [40].

Our results revealed that only a small percentage of pediatricians were not satisfied with the available material on CoF, but over half of them declared that they prepared themselves the documents with CoF information to give to parents. Moreover, the vast majority of the pediatricians of our study could not correctly identify the body in charge of the release of official feeding guidelines, and over half of them did not know who handled the production of the related official material. The fact of preparing their own materials to distribute to their patients can be seen as a sign of mistrust in institutions or a lack of awareness of the roles of various public health stakeholders. Knowing who is developing the material could increase pediatricians' level of trust and encourage them to use official material instead of creating and distributing their own. It is important to create a nationally unified strategy to communicate in two directions: directly with the general population, via accessible information disseminated by appropriate means, but also with healthcare providers, such as pediatricians who are in direct contact with the parents and work on the front line to spread health-related information.

During the last few years, research has incrementally focused on the different aspects of parenting, including feeding [41][42][43]. It is well acknowledged that becoming a parent, especially for the first time, is a life changing experience that brings together joy and challenges, along with the stress of not fitting into this new role [44,45]. The reality of the early parenting journey is complex, and it is difficult to generalize as there is not a unique way to face it [46].

The fact of dealing for the first time with a new situation, for example, CoF, brings parents to search for advice. Parents might feel overwhelmed with all the information they can easily access via many sources and with the influences and pressure coming from their social environments, and this can be one other factor that contributes to increasing their level of confusion [31,47]. The parents in our study acknowledged mainly referring to healthcare professionals for trustworthy advice. The Internet was also a recurrent source of information, even if its influence was low. Being able to find easily trustworthy health related advice can help parents to make use of the powerful tools of information and communication to better cope with the challenges they face every day. In this light, exploiting the resources made available by new technologies is essential, as we saw in our study how much parents made use of the Internet and applications, for example.

Public health stakeholders in charge should prepare the communication strategy for the new recommendations in accordance with the different needs of parents and pediatricians in terms of CoF information. Pediatricians, but also other healthcare professional figures that have the opportunity to be in contact with new parents during the early-child feeding period, should be considered as central for the dissemination of the new recommendations, and training courses in this regard could be organized at the national level. Since pediatricians are the first relay of advice for parents, it is important that they can align with parents' demands of information. Parents look for practical information, such as menus and recipes to propose to the children when introducing new foods into their diets, whereas pediatricians think the most important information to give to parents is the ages of introduction for the different foods and food groups. A double-pronged strategy could be used, allowing, for example, material with detailed information for pediatricians and material with more practical tips for parents.

Translations in other languages, or offering some specific examples of menus and recipes adapted to different "cuisines" could also account for cultural differences. Moreover, to reach optimal diffusion of official information, it is paramount that pediatricians recognize the bodies in charge of formulating and spreading official recommendations. Pediatricians' professional organizations could be relevant in this direction in order to focus the attention and augment the level of trust of the professionals towards the right stakeholders in charge to provide evidencebased information to the different members of the public. Official public health agencies and institutional logos could be associated with the information given by pediatricians' professional organizations in a way to improve visual familiarization when talking about official recommendations via different channels.

Some strengths and limitations must be considered alongside our study. First of all, both surveys allowed us to collect quantitative data, but we could not explore further motivations behind the answers of the participants. Moreover, we aimed at collecting similar information within two different populations (parents and pediatricians), but we had to adapt some questions, which therefore might make slightly difficult the direct comparison of some topics.

One strength of this study lies in the utilization of large samples; the parents' sample in particular is nationally representative of the French population of young parents, and it accounts for the point of view of primiparous and multiparous parents, something not common in the literature. Since, to the best of our knowledge, there were no existing studies focusing exclusively on CoF information needs in France, this double survey provides important data by seeking the views of both parents and pediatricians, thereby providing opportunities to build on these findings from the perspective of designing a national communication strategy in an appropriate, timely manner.

When implementing public health recommendations regarding infant feeding, attention should be paid to relays of information, such as pediatricians, who are conscious of their role in this regard, and whom parents trust. In this process, the present data suggest that it is important to ensure that parents have access to clear and non-contradictory messages, in line with updated recommendations.

Conclusions

Our results highlighted some common points and divergences in perceptions and needs of French parents and pediatricians regarding CoF information. In particular, parents have the perception that they are provided with inconsistent and contradictory CoF information; they need clear guidance from the sources they use and that influence them the most (e.g., healthcare professionals). Moreover, advice should be provided to parents in a non-pressuring but engaging manner, in order to avoid the establishment of feelings of inadequacy or guilt.

Relevant and easy to understand messages, given with consistency, might make CoF information less confusing for parents, thereby providing more realistic and acceptable advice, which might increase compliance with the official recommendations.

Pediatricians acknowledge the need for CoF informational material able to provide support accounting for family and cultural differences. Pediatricians should be aware of the influence of parents' personal networks and the need for more practical tips. It is essential that pediatricians understand the parental information demands in order to deliver timely and appropriate CoF messages based on updated recommendations.

Effort is demanded from the public health sector in order to build a strategy to spread the new infant and child feeding recommendations via the means of informational material adapted to meet parents' and pediatricians' needs. In particular, pediatricians' needs and perceptions must be considered, given the importance that parents confer to them. Moreover, given the coexistence of different sources of information that can influence parents, it is also important that the advice given by pediatricians is consistent with the official recommendations and that pediatricians recognize the official bodies in charge of the communication material. This strategy should focus on the provision of CoF information via simplified and coherent messages in order to facilitate the communication between parents and pediatricians and reduce parental confusion around feeding recommendations. Salarié du secteur public 4.

A votre compte 5.

A la recherche d'un premier emploi 6.

A la recherche d'un emploi (vous avez déjà travaillé) 7.

A la retraite 8.

Au foyer 9.

Elève ou étudiant 10.

Dans une autre situation 1.

Private sector employee 2.

Employee of a public or national company 3.

Public sector employee 4.

On your own account 5.

Looking for a first job 6.

Looking for a job (you have already worked) Artisan petit commerçant 3.

Chef d'entreprise de plus de 10 salariés 4.

Profession libérale (SAUF paramédical) 5.

Professeur / profession scientifique 6.

Cadre et autre profession intellectuelle supérieure 7.

Contremaître, agent de maîtrise, profession paramédicale, technicien 8. Instituteur 9.

Employé 10.

Personnel de service 11.

Ouvrier / Ouvrier agricole 12.

Retraité 13.

Élève / étudiant 14.

Autre inactif 1.

Farmer-operator 2.

Artisan small trader 3.

Company manager with more than 10 employees 4.

Liberal profession (EXCEPT paramedical) 5.

Professor / scientific profession 6.

Executive and other higher intellectual profession 7.

Foreman, supervisor, paramedical profession, technician 8. Teacher 9. Employee 10.

Service staff 11.

Worker / Agricultural worker 12.

Retired 13.

Pupil / student 14.

Other inactive

Z4. Êtes-vous la personne de référence du ménage ?

La personne de référence est la personne en activité au sein de votre foyer qui apporte le plus de revenus Z4. Are you the household reference person?

The reference person is the person working in your household who brings the highest income

1. Oui 2. Non 1. Yes 2. No

Z8. En ce moment, quelle est l'activité principale de la personne de référence du ménage ?

La personne de référence est la personne en activité au sein de votre foyer qui apporte le plus de revenus

Z8. Currently, what is the main activity of the household reference person?

The reference person is the person working in your household who brings the highest income

1.
Salarié du secteur privé 2.

Salarié d'une entreprise publique ou nationale 3.

Salarié du secteur public 4.

A son compte 5.

A la recherche d'un premier emploi 6.

A la recherche d'un emploi (a déjà travaillé) 7.

A la retraite 8.

Au foyer

9.

Élève ou étudiant 10.

Dans une autre situation 1.

Private sector employee 2.

Employee of a public or national company 3.

Public sector employee 4.

Self-employed 5.

Looking for a first job 6.

Looking for a job (has already worked) 7.

Retired 8.

At home 9.

Student 10.

In another situation

Z8b. Quelle est la profession, la catégorie socio-professionnelle de la personne de référence du ménage ? Z8b. What is the profession, the socio-professional category of the household reference person?

Z8b. Avant d'être au chômage, quelle était la dernière profession, la dernière catégorie socioprofessionnelle de la personne de référence du ménage ? La personne de référence est la personne en activité au sein de votre foyer qui apporte le plus de revenus Z8b. Before being unemployed, what was the last occupation, the last socio-professional category of the household reference person?

The reference person is the person working in your household who brings the highest income

1.
Agriculteur exploitant 2.

Artisan petit commerçant 3.

Chef d'entreprise de plus de 10 salariés 4.

Profession libérale (SAUF paramédical) 5.

Professeur / profession scientifique 6.

Cadre et autre profession intellectuelle supérieure 7.

Contremaître, agent de maîtrise, profession paramédicale, technicien 8. Instituteur 9.

Employé 10.

Personnel de service 11.

Ouvrier / Ouvrier agricole 12.

Retraité 13.

Élève / étudiant 14.

Autre inactif 1.

Farmer-operator 2.

Artisan small trader 3.

Company manager with more than 10 employees 4.

Liberal profession (EXCEPT paramedical) 5.

Professor / scientific profession 6.

Executive and other higher intellectual profession 7.

Foreman Since the birth of your youngest child, during usual medical appointments with health care professionals (pediatrician, doctor, nurse, etc.), did they spontaneously give you advice on feeding your child (foods other than milk) including complementary feeding? Complementary feeding is the period during which foods other than milk are gradually introduced into a child's diet 1. Régulièrement, tout au long du suivi de mon enfant 2. Plusieurs fois pendant la période de diversification alimentaire 3. Uniquement au début de la diversification alimentaire 4. Jamais 1. Regularly, throughout the follow-up of my child 2. Several times during the period of complementary feeding 3. Only at the start of complementary feeding 4. Never Q7. Depuis la naissance de votre plus jeune enfant, lors de rendez-vous médicaux habituels avec des professionnels de santé (pédiatre, médecin, infirmier…), leur avez-vous vous-même posé des questions ou demandé des conseils sur l'alimentation de votre enfant (aliments autre que le lait) dont la diversification alimentaire ? La diversification alimentaire est la période pendant laquelle des aliments autres que le lait sont progressivement introduits dans l'alimentation d'un enfant Q7.

Since the birth of your youngest child, during usual medical appointments with health care professionals (pediatrician, doctor, nurse, etc.), did you yourself ask them questions or for advice on feeding your child (foods other than milk) including complementary feeding? Complementary feeding is the period during which foods other than milk are gradually introduced into a child's diet 1. Régulièrement, tout au long du suivi de mon enfant 2. Plusieurs fois pendant la période de diversification alimentaire 3. Uniquement au début de la diversification alimentaire 4. Jamais 1. Regularly, throughout the follow-up of my child 2. Several times during the period of complementary feeding 3. Only at the start of complementary feeding 4. Never

Q8. Votre plus jeune enfant a-t-il ou a-t-il eu un problème de santé pouvant affecter fortement

son alimentation, comme par exemple : reflux gastro oesophagien pris en charge médicalement, allergie aux protéines de lait de vache, intubation nasogastrique, anomalies congénitales du tube digestif ? Q8.

Does or did your youngest child have a health problem that could strongly affect his diet, such as: medically managed gastroesophageal reflux disease, cow's milk protein allergy, nasogastric intubation, congenital abnormalities of digestive the tract? Pour commencer, cliquez s'il vous plait sur le bouton "Suivant".

Veuillez cocher pour indiquer votre réponse.

As part of a research program led by INRA, this questionnaire aims to describe the way in which healthcare professionals approach complementary feeding with parents. This survey should only take you 15 minutes to complete. Your answers will be anonymous and your participation is completely free.

In advance, we thank you for your help.

To get started, please click on the "Next" button.

Please tick to indicate your answer. Objective: As part of an update of feeding benchmarks targeting children aged 0-3 years, this study aimed to explore parental perceptions, information-seeking practices and needs concerning infant and young child feeding (IYCF) to design an efficient communication strategy. Design: Participants were recruited using the quota sampling to complete an online survey. Effects of parity, child age, prematurity, parental education and financial situation on parents' responses were evaluated separately. Setting: France. Participants: A nationally representative sample of 1001 parents of children <4 years. Results: Parents whose child had any medical condition affecting feeding (children with medical condition (CMC), 17 %) were considered separately from healthy children's parents. All the healthy children's parents recognized the importance of IYCF for children's health and growth; however, one-third considered the available advice contradictory and not guilt-free. The most used information sources were healthcare professionals (HCP, 81 %), internet (72 %) and parental networks (63 %). The most influential sources (mean influence ± SD) included HCP (7•7 ± 1•7/10), childcare professionals (7•3 ± 1•8/10) and parental networks (6•9 ± 1•8/10). Parents searched for practical tips for implementing IYCF starting when their child was 5 months old. Differences regarding the type of source used by parents with higher v. lower educations were small. Search strategies differed according to parity or child age but not to prematurity. The CMC parents reported slightly different practices and needs. Conclusions: Parents receive information from multiple sources, which can lead to confusion when deciding which advice to follow. A public health communication strategy adapted to the current parental needs should target these various sources.

Introduction

During the first 1000 days of the life of a child, individual dietary patterns develop rapidly, and they can impact risk factors for later-life obesity and health in general. This period constitutes a perfect window of opportunity to implement health-related programs that promote healthy eating and growth in young children (1-3) . Children's eating behaviors (e.g., food preferences and appetite control abilities) are also established at this stage, particularly during complementary feeding (CoF) (4-6) . CoF is the period in the life of a child when foods other than milk start to be introduced into the diet (7) ; this is a dietary transition that typically covers the first years of life. During this phase, parental influence on feeding practices is essential in shaping infant eating behaviors (8) .

Previous studies have explored parental behaviors and feelings regarding infant and young child feeding (IYCF), and they demonstrated that most parents are aware of the importance of their role in shaping the early foundations of their children's diet (9, 10) . However, for parents, especially mothers, the pressure of "doing well" and the feeling of being responsible for the health of their child can easily turn into a source of stress, which may lead them to feel strained in their parental role (11-13) . Parents look for information and experience-related feedback regarding the IYCF process. However, they often feel impotent and frustrated when receiving official recommendations, because they find them too demanding (14) .

The social ecological model (SEM) has been used frequently to develop frameworks for prevention; it explains the theory about how the behavior of an individual is influenced by multiple factors (15) . This approach applies to parental feeding behavior, which is influenced by many interacting components, both intrinsic (gender, age) and environmental (family, community, and society) (15, 16) . Increasing the IYCF literacy of parents and empowering them can foster a change toward healthier feeding practices. However, as shown in social and behavioral change communication (SBCC) theory, interactive approaches and mixed communication strategies are required to reach these goals (17) . Parents can rely on different sources to gather information and advice on IYCF, including previous experience and professional (pediatricians, nurses, midwives and general practitioners) and nonprofessional (family, friends, online forums and blogs) sources (18, 19) , and not forgetting the influence of social media, which has recently been successfully tested as an effective means to spread IYCFrelated information (20) .

The source of information used by mothers changes as their child grows (21) . A French national survey conducted in 2013 suggested that primiparous mothers with infants <12 months old are more likely to seek advice from HCPs than multiparous mothers (19) . It is therefore topical to explore which information sources parents currently use and the influence these sources have on parental IYCF decisions. Education is also linked to the forms of advice sought by parents. According to a study set in five European countries (England, Finland, Germany, Hungary, and Spain), mothers who have received education beyond the age 16 years reportedly rely more on written sources, HCPs and family/friends (22) . A qualitative and quantitative study conducted in a socially deprived area in Scotland reported that the primary sources of CoF information are family/friends (91%), the internet (89%) and health visitors (77%) (23) . Although many public health authorities issue IYCF recommendations, related adherence is often low (24, 25) . More insights are needed regarding parents' perception of IYCF information (accessibility and understanding) to facilitate compliance with official recommendations.

Parents of premature children might rely even more on medical advice than on other sources, but this reliance has not been extensively documented. Notably, parents of premature children look for information more actively than do other parents (26) . However, no official documents specifically address premature child feeding. For the parents of premature children, the absence of specific guidance about child feeding could contribute to feeling uncertain and lacking confidence about feeding practices, thereby accentuating parental frustration. The same might also apply to parents of children with medical conditions that could impact their diet (e.g., cow's milk protein allergy or nasogastric intubation), but it has not been extensively studied.

Considering their specific or similar information-seeking practices compared to those of parents of healthy children may allow for the optimization of resources in regard to producing public health information material.

The literature related to information source use by parents to obtain IYCF information is not extensive. There has been a limited exploration of how much those sources are considered influential in determining parental decisions in IYCF, especially from a quantitative point of view with a nationally representative sample and regarding the changing landscape of information and communications technology in public health and prevention. In France, the former official IYCF recommendations are not recent (the related communication material was released in 2004), but new IYCF recommendations for children aged 0 to 3 years old have recently been published (27) . In this context, to prepare a public health communication strategy to spread those recommendations to the lay public, it is particularly necessary to focus on the information-seeking practices of parents with different profiles.

Therefore, the aim of the present study is first to describe the perceptions of French parents of children <4 years old about IYCF (e.g., is it important for the health and growth of the child?

Has it been a source of concern? Is it easy to find information on IYCF?), how informed they feel and whether these perceptions differ according to selected sociodemographic characteristics (parental education, perceived financial situation, parity, child age and prematurity). The second aim is to explore parental practices related to searches for guidance about IYCF (e.g., when do they look for information, what type of content do they look for, which sources of information do they use and how much are they influenced by those sources) and whether these practices differ according to the abovementioned sociodemographic characteristics. The final objective is to explore the same topics among parents of children with a medical condition that could have an impact on their diet in comparison with parents of healthy children.

Methods

Study design, setting and sampling procedure

The present descriptive study was conducted in France in the form of an online survey that was open for completion from the 10 th to the 29 th of January 2020. The recruitment procedure was managed by a private research and consulting firm, by applying the quota sampling method. This method is a nonprobabilistic sampling approach that employs purposeful selection criteria to include the participants. It allows researchers to study a characteristic of a particular subgroup of the population (in our case, parents of children aged below 4 years) by giving an accurate representation of the population of interest. The quota method was applied to the following variables: age of the parent, profession of the household reference person (defined as the person earning the most in the household), region, living area (rural, urban), and first-time or multiparous parent. The sample was drawn from within the panel of eligible respondents to the research and consulting firm, and it was made to ensure national representativeness by calibrating the participant data according to the general population census (28) . We targeted a representative sample of 1000 French parents of children <4 years old. Those 1000 parents were the first respondents presenting the required characteristics to answer the questionnaire. The sample size of 1000 was defined a priori, and it was considered sufficient to represent our population of interest according to previous surveys conducted by the private research and consulting firm with the same sampling method on similar subgroups of the population.

Questionnaire

A full description of the information collected using the questionnaire is listed in Supplement Material 1, and the original version of the questionnaire (in French) is presented as Supplement Material 2. The questions and the list of multiple-choice answers were developed based on previous studies (12, 19) . The questionnaire was divided into five sections: characteristics of the youngest child, the parents and the household; parents' perceptions of IYCF; parents' perceptions of IYCF information; the sources of information used by parents with relative influence of the chosen sources on their IYCF practices; and the type of information (content) sought by parents. All the parents were asked to refer to their youngest child when answering the questionnaire. Multiparous parents were asked to answer referring their youngest child, except one question asked only to multiparous parents ("CoF is easier for my last child than for the first one(s)"). The survey included closed-ended multiple choice questions, with one or check-all-that-apply answer options, as well as questions for which the respondents rated their answer on a scale. A continuous scale was used to evaluate how much the parents were influenced by a chosen source of information in making IYCF-related decisions (from 1 to 10, with 1 meaning the source did not influence their decisions at all and 10 meaning it influenced their decisions very strongly). A 4-point Likert scale (strongly agree, tend to agree, tend to disagree, and strongly disagree) was used to ask the parents their degree of agreement about some statements regarding perceptions and feelings around IYCF. The questionnaire was reviewed by public health experts and by the private research and consulting firm in charge of the recruitment process.

Statistical analysis

For all the statistical analyses, R version 3.6.1 was used (29) . Following descriptive data analysis, parents whose the youngest child has or had a medical condition that could have a serious impact on his/her diet (CMC) were treated as a separate subsample from parents with healthy children. Based on the assumption of potentially different information-seeking behavior, analyses were then run separately for the two subsamples of parents. Both subsamples were representative of the study population. Two-way Chi-square tests of independence (χ2) were calculated to evaluate whether having medical conditions that could affect the diet was associated with any sociodemographic characteristic.

Frequencies, percentages and means ± SDs are used to describe the results. Statements requiring an answer on a 4-point Likert scale were considered discrete and were dichotomized as "agree" or "disagree" for the analysis. Where appropriate, the χ2 was used to determine whether the relationship between two variables was statistically significant. In the case of a quasi-continuous variable (i.e., the degree of influence of used sources of information, scale from 1 to 10), one-way ANOVA or independent two-sample t-tests were used to compare the means of the different groups. Two-way Chi-square tests of independence (χ2) were calculated to compare the results of parents of healthy children vs. CMC (for this subsample, detailed results are presented in Supplement Material 3). Assumptions of normality for each test were checked and met. Significance was set at P < 0.05.

Results

Participants

The two subsamples of the study population are described in Table 1. Answers were obtained from a total of 1001 parents who were representative of French parents with at least one child <4 years old. Among them, 175 reported having CMC (medical conditions: gastroesophageal reflux disease, cow's milk protein allergy, nasogastric intubation, or congenital abnormalities of the digestive tract) and were excluded from the primary analysis. The subsample of the remaining 826 parents is also representative of the French population, because no differences were observed from the original study population regarding the quota variables (Table 1). In other respects, some significant differences were found between the two subsamples, with a higher percentage of premature children (17% vs. 10%, respectively; p=0.01) and more fathers than mothers answering the survey (26% vs. 18%, respectively; p=0.02) in the CMC subsample.

Parent perceptions of IYCF (including CoF) and how informed they feel

Among parents of healthy children (n=826), 98% were aware of the importance of IYCF for the current and future health and growth of their child (Table 2). In addition, 99% of parents were aware that this period is important for acquiring healthy eating habits. Overall, the CoF period was experienced fairly well by parents, 92% considering that it went well. However, for 30% of the parents, CoF turned out to be a source of concern. Being a multiparous parent did not necessarily facilitate CoF with the younger child, with only 53% considering that CoF was easier for the younger child than for the older ones. Eighty-eight percent of the parents considered themselves well-informed, and 86% were satisfied with the available information.

Eighty-eight percent of them also considered finding IYCF information to be easy to understand and reported that the available information answered their questions. Thirty-two percent of the parents indicated that the available information could be contradictory, and 30% reported that the information gave the perception that they were not implementing IYCF correctly. This table shows frequencies and percentages of parents, with the correspondent characteristics, that answered positively (strongly agree and tend to agree) to the statements in the left column. The second column shows the total of parents that answered positively (strongly agree and tend to agree) on the statements in the left column. † n = 7 parents did not give information on their financial situation and were excluded from the analysis. * based on χ2 tests, comparing perceptions and feelings on IYCF with selected characteristics of parents (n=826). Significant p-values are in boldface.

A higher proportion of parents of 3-year-olds found that CoF went well (98%) compared to parents of younger children (1-to 2-year-old children, 90%; p=0.01). Parents of younger children (<12 months) were less satisfied with the available information on IYCF (82% vs. 93% for parents of 3-year-old children; p=0.02) and felt less well informed about it (81% vs. 92% for parents of 3-year-old children; p=0.004). A smaller proportion of parents of younger children (<12 months) stated that the available information on IYCF gave them the perception that they were not implementing IYCF correctly (23% vs. 33% for parents of 3-year-old children; p=0.03) (Table 2). Primiparous parents reported that the progression of CoF was more a cause of concern than it was for multiparous parents (40% vs 25%; p<0.001); they also felt less informed (83% vs. 91%; p=0.002) and less satisfied with the available information (82% vs. 90%; p=0.001). Primiparous parents found that the information was contradictory more frequently than multiparous parents (36% vs 29%; p=0.04).

Parental practices related to searches on guidance about IYCF (including CoF)

When parents look for information on IYCF (including CoF) and related content, what do they look for? Seventy-nine percent of parents looked for information on IYCF for at least one of their children; 72% did so for their youngest child. The mean age of the child when the parents began to look for information specifically on CoF was 4.6±3.6 months (median=4 months; IQR 3-6 months). Seventy-two percent of the parents reported that they were advised by health care professionals (HCPs) during regular follow-up consultations. The subject of IYCF, including CoF, was either spontaneously broached by HCPs or as a result of specific questions from parents; in total, 80% of the parents received advice during consultations. Regarding the search content, the parents' searches were focused primarily on examples of recipes/menus (63%), portion sizes for complementary foods and milk (55%), age and modalities of the introduction of foods (54%) and feeding strategies to address children's specific behaviors (53%), for example, how to offer food in case of food refusal or how to address "small" or "big" appetites (Table 3). 27) 103 ( 24) 33 ( 23) 174 ( 25) 89 ( 28) 118 ( 23) 47 ( 21) 59 ( 27) 56 ( 26) 45 ( 27) 23 ( 28) 184 (25) p-value* 0.28 0.62 0.15 0.37 0.47 The second column shows the total of parents who selected the item in the first column. The "Subtotals" shows the number of parents who selected at least one of the item related to that topic. † n = 7 parents did not give information on their financial situation and were excluded from the analysis. * based on χ2 tests, comparing the content that parents look for with selected characteristics of them. Significant p-values are in boldface.

A higher proportion of parents with self-perceived difficult financial situations looked more frequently for examples of menus/recipes (68% vs. 58%; p=0.004) and less frequently for information about age and modalities for the introduction of foods (50% vs. 58%; p=0.02) or how to feed a child to promote the development of healthy eating habits (28% vs. 36%; p=0.01).

Parents with more years of formal education in comparison with parents with fewer years of formal education were more frequently interested in feeding strategies (55% vs. 42%; p=0.005) and in the definition of portion sizes for complementary foods (58% vs. 40%; p<0.001). They were also more frequently interested in how to feed a child to promote the development of healthy eating habits (33% vs. 24%; p=0.05). The topics related to the age and modalities of the introduction of foods were more relevant for primiparous than multiparous parents (58% vs. 51%; p=0.03) and for parents of children <1-year-old (67% vs. 44% for 2-year-olds; p<0.001).

Parents with children >1 year were more interested in feeding strategies (57% vs. 43% for <12 months; p=0.01). Premature birth was not associated with specific information searches.

Sources of information used by parents and their degree of influence

As shown in Table 4, HCPs were the primary source of information for 81% of parents, and their level of influence was strong (7.7±1.7/10). Among HCPs, pediatricians and general practitioners were the primary vectors of information (each used by 47% of parents). The internet (including websites, blogs, social networks, applications for smartphones) was the second source of information, being consulted by 72% of the parents; however, its influence was low (5.6±2.1). Parental networks were a source of information for 63% of the parents, and their influence was quite high (6.9±1.8). Paper-based tools (e.g., books, newspapers) were a source of information for 44% of the parents, and their influence was slightly lower (6.2±1.8).

Although childcare professionals had a strong influence (7.3±1.8), nearly as strong as that of HCPs, they were among the sources that parents used the least (30%). Only 24% of the parents used media (radio, television), and they were weakly influenced by these sources (5.8±2).

Although some differences were significant with regard to the levels of influence of the sources according to parental characteristics, their amplitude was rather small (<1 point of difference, Table 4). Parents of children <1-year-old used the internet more frequently (78% vs. 62% for parents of 3-year-olds; p=0.002). Parental networks were more frequently used by parents with fewer years of formal education (70% vs. 61%; p=0.04), and those parents also more frequently used media as a source of information compared to parents with more years of formal education (33% vs. 22%; p=0.007). Primiparous vs. multiparous parents more frequently used their parental network (75% vs. 55%; p<0.001) and the internet (81% vs. 66%; p<0.001) (Table 4).

IYCF perceptions and information-seeking practices of parents of CMC vs. parents of healthy children

Parents of CMC (n=175) perceived that CoF did not go as well as it did for parents of healthy children (86% vs. 92%; p=0.01) and was more frequently a source of concern (56% vs. 31%; p<0.001). They also reported they were less informed about IYCF (81% vs. 88%; p=0.02), the available information was more contradictory (51% vs. 32%; p<0.001), and it gave more of a perception that they were not implementing IYCF correctly (45% vs. 30%; p<0.001)

(Supplement Table 1, Supplement Material 3).
The mean age of the child when CMC parents began to look for information on IYCF was 4.9±4.1 months (median= 4 months; IQR 3-6 months). Eighty percent of CMC parents reported that they received advice from HCPs during follow-up consultations, i.e., more frequently than parents of healthy children. Parents of CMC generally looked for the same content as parents of healthy children, except for examples of recipes/menus, for which they searched less frequently (53% vs. 63%; p=0.01, Supplement Table 2, Supplement Material 3).

Parents of CMC more frequently used the internet (80% vs. 72%; p=0.03) and media sources (37% vs. 24%; p<0.001) to inform themselves about IYCF compared to parents of healthy children. CMC parents were slightly more influenced by media and childcare professionals (Supplement Tables 3 and4, Supplement Material 3). The columns about the use of the sources show frequencies and percentages of parents who selected that source. The columns about the influence show the mean (± SD) of the sources (parents rated sources on a scale from 1 to 10 and this variable was considered as continuous). † N (%) ‡ Mean +/-SD * based on T-tests to compare means of two subgroups, ANOVA to compare the means of more than two subgroups, if ANOVA was significant then specific comparisons were performed with post-hoc tests. Significant p-values are in boldface. § n = 7 parents did not give information on their financial situation and were excluded from the analysis.

Discussion

The aim of this study was to explore the information-seeking practices, needs and determinants of French parents with regard to IYCF (including CoF) using a nationally representative sample. The parents were aware of the importance of IYCF for the health and growth of their children. First-time parents were generally more insecure when facing CoF; they found more contradictions when looking for guidance, and they were less satisfied with the information. As previously shown in other studies, parents accessed information about IYCF from a wide variety of sources (30, 31) , confirming the complexity of the information environment (15) . The most used and trustworthy source was HCPs, followed by the internet, which was the least influential source. Those sources had a very different reported influence on parental feeding behavior, and the relative influence could differ according to the studied characteristics of the parent (financial situation, education, and parity) or the child (age, prematurity). Lastly, the parents often looked for practical tips regarding IYCF, such as examples of recipes and menus.

The latest advances in new communication and information technologies have revolutionized the way health information is gathered and disseminated (32) . Currently, a massive quantity of information is reachable via different sources, including the internet, where social media use has expanded among mothers looking for advice on childhood health (33) .

However, the quantity and accessibility of this information are not necessarily related to the level of understanding of the messages (34, 35) . Our results show that the parents of 2020 felt well-informed and satisfied with the available IYCF information; they also found this information easy to understand and put into practice. This finding was especially true for multiparous parents and those with older children. Those parents could also feel more confident because of their previous experience, as reported in different studies (36, 37) . Nevertheless, for one-third of the parents in our study, the available information could appear contradictory and give the perception they were not implementing IYCF correctly. This observation highlights the room for improvement regarding the formulation of public health messages regarding IYCF.

Our results suggest that parents recognize HCPs as their most influential source of advice and the option to which they refer most often to obtain information on IYCF. This perspective was especially true for parents of younger children, those with a better financial situation or with a higher education level. The vast use of this professional source could be related to the fact that in France, several free and mandatory consultations with HCPs take place when the child is between 0 and 16 years old, with the majority of the visits occurring within the first 3 years of life (38) . French HCPs are in a dominant position to disseminate IYCF information.

Previous studies investigating the role played by different sources in influencing mothers' feeding decisions across countries have shown that cultural-and country-related factors impact how mothers use information (22, 39) . For example, Gage et al. found that lower proportions of mothers in England and Finland are influenced by doctors in making infant feeding decisions compared to mothers in Germany, Hungary and Spain, reflecting the different roles played by HCPs depending on the public health policies of each country (22) . Our study shows that parents of CMC resort as frequently as parents of healthy children to HCPs. The use of the internet to establish contact with others in similar situations to exchange opinions has been reported in the literature and it could apply to our study (40) . This observation suggests a specific role for forums in a public health communication strategy for parents with special needs. A deeper investigation of IYCF information in terms of the searching practices of CMC parents and accounting for specific feeding-related illnesses, might be of help in defining to what extent a generic communication strategy can be suited to their needs.

The internet is a widely used source of information according to our results; however, its degree of influence is the lowest of all the examined sources. The internet was used more by and had more influences on parents of younger children, and it was used more by primiparous than multiparous parents. First-time mothers are the most active in looking up information on the internet, according to a Swedish literature review (40) . The reasons why new parents (or parents) seek information on the internet could vary. Performing research on the internet is easy and allows parents to gather answers to their questions quickly regardless of where they are or the time at which the information is needed (41, 42) . Using the internet, it is easier to find the most updated information, and parents can find both expert advice and peer support (via blogs, forums) (40) . Looking for information on the internet could also help parents integrate or complete the information given to them by HCPs during a quick consultation (43) ; moreover, searches can be performed anonymously with regard to some topics that can be embarrassing to discuss with the doctor (40) .

The internet has the potential of being a largely accessible source of information, but being able to perform meaningful searches has been shown to require the development of specific competencies in terms of eHealth literacy (44) . One of the reasons is that the credibility and truthfulness of the given information require constant verification. Furthermore, recent studies have explored the problem of the digital divide, showing that socioeconomic disparities are present in the access to and use of health information, especially with regard to internet use (45) .

However, the present study does not reveal differences in the use or influence of the internet according to financial situation or education level. In France, Banti et al. found that the information on websites dedicated to CoF could be contradictory and not always consistent with that of the French Society of Pediatrics, showing the need for a recognized official website (46) . According to our results, the financial situation of the parents was not a determinant of the source used to gather information on IYCF. Nevertheless, there were some differences in regards to searched topics based on financial situation and level of education. Parents with more vulnerable financial situations looked more frequently for information on menus/recipes and less often for information on promoting the development of healthy eating habits or the appropriate age for the introduction of foods. They were less influenced by HCPs. Parents with more years of formal education better recognized the importance of IYCF for the health of their child; they looked more often for information regarding feeding strategies and portion sizes. This approach highlights the need for public health communication content that is easily accessible and understandable for parents with lower socioeconomic positions to avoid reinforcing social disparities in health.

Our study confirms that first-time parents and parents with fewer years of formal education often use their personal network as a source of information (11, 47) . Surprisingly, parents with more years of formal education are more influenced by this informal source than parents with fewer years of formal education despite a lower level of use. This observation is in contrast with a study conducted in the UK on mothers with more years of formal education showing that advice on CoF was commonly received from friends and family but was often perceived as negative and outdated (48) . The high influence of personal network advice could be related to the fact that parents become overwhelmed and are left confused about the large amount of conflicting information; thus, they end up adopting valued familial or culturally established practices or choosing the advice that best suits them (49) . Recognizing the primary influencers of parents and better understanding familial transmission regarding IYCF information is of interest but beyond the scope of the current study.

Paper-based support sources were used by 44% of the parents in our study, and not surprisingly, parents with more years of formal education reported that they were more influenced by this source (35) , whereas parents with fewer years of formal education reported using media more. For parents of 2020 in France, paper documents still have a role to play in a digital world. The parents in this study gave credit for the information obtained from childcare professionals, especially when the child was born preterm, but they made little use of this source.

Our study confirms that parents, especially those in difficult financial situations and with lower levels of education, need practical advice regarding IYCF (23) . Practical needs are identified not only as ideas for menus/recipes but also as feeding strategies (e.g., addressing "little" or "big" appetites). This last topic is researched more by parents with more years of formal education and parents of older children (12 to 35 months old), which could be related to the fact that as the child grows, neophobia develops, and parents begin to face food refusal (50) .

Those parents may also have a higher level of concern regarding their children's future weight status and may want to control their child's appetite (51) .

No differences were reported in terms of content research for parents of premature vs. fullterm children. This finding is surprising since parents of preterm-born children could base their feeding decisions on corrected age, not chronological age. For that reason, it might be natural to think that questions about the age of introduction of the first foods or different food groups may easily arise in parents, but this is not what our findings show. Developmental considerations may lead to think that preterm-born children could be ready to eat solids later than their norm-term peers, even if there is a lack of evidence regarding the optimal age or the best first foods to introduce into their diet (52) . However, a recently published systematic review showed that premature infants are generally introduced to solids earlier than norm-term infants, often because breastfeeding or milk feeding can be challenging with them (53) . Whether premature babies are actually ready at the same postnatal age as norm-term babies remains a topic that requires further clarification to promote the relevant public health messages. Undifferentiated access to many sources and the individual ability to comprehend information can impact the completion of parents' information needs. In the literature, the notion of parental health literacy is widely explored, showing that the individual capacity to obtain, process, and understand basic health information might influence the informationseeking strategies of parents and subsequently their health knowledge and behaviors (54, 55) . This phenomenon can accentuate health inequalities, which are also related to socioeconomic disparities; lower parental health literacy is associated with specific obesogenic infant care behaviors (56, 57) . However, providing information with the only aim of increasing knowledge has been shown to be insufficient to spur the adoption of health-related behavioral changes (58) .

Because the successful implementation of public health practices depends largely on behavior changes, interactive communication approaches and the simultaneous use of different theories and strategies for behavior change are necessary to encourage people to follow recommendations. The theoretical framework designed by Michie and colleagues (Behaviour Change Wheel) shows that effective interventions should cover multiple intervention functions and policies and should address several drivers within capability, motivation or opportunity (59) .

Providing information is related to capability building and is one of the most frequently used behavioral change techniques for infant feeding interventions (60, 61) , but it is just the start of a process of facilitating the adoption of healthy feeding behavior. Further research may complement the present findings to address other components of behavioral change.

Concern should be raised for public health communicators regarding the need to find the best solution to having the entire population on the same level when looking for health information, especially on the internet, thus ensuring that parents with a lower health literacy level can easily retrieve information. Attention should be paid to indexing official websites in search engines so that evidence-based information can reach everyone equally. Another takeaway from our study is that public health stakeholders could consider making better use of childcare professionals as a means of transmitting information based on the influence that these figures have on parents and the regular contacts they have during the very first months of the child's life. The provision of evidence-based information, as translated into easy messages that could be understood by the largest part of the population of interest and spread via easily accessible sources, should serve as the foundation for a more structured education strategy that is ultimately aimed at the adoption of healthy feeding-related behaviors starting from infancy.

Our findings add to the knowledge about the multiple sources of IYCF information available to parents and their influence. However, the study strengths and limitations must be considered.

The limitations of the study lie in its nature, because it did not make a deeper exploration of possible motivations or the understanding of the health messages. Additionally, the use of closed-ended questions facilitates data analysis but limits the possibility of exploring contradictions. Complementing the study with a qualitative section could have allowed us to deepen some aspects of this work. The primary strength of the study lies in its use of a large, nationally representative French sample. This makes the generalization of the results to the French population of young parents possible, even if using the quota sampling method and voluntary online surveys has sometimes been noted as a source of potential bias due to the limited inclusion of populations in precarious situations. The methodology deployed here can also be used in other countries, provided that some cultural adaptations are made to the questionnaire. Moreover, we explored information-seeking strategies during the IYCF period and through the completion of the third year, which is not frequent in the literature. In fact, to the best of our knowledge, this topic is more often investigated during the antenatal, pregnancy or milk-feeding periods than during IYCF and CoF.

Conclusions

Parents receive IYCF information from multiple sources, which can lead to confusion when deciding which advice to follow. We highlighted differences in search strategies according to parity or child age, but surprisingly, few differences among parents of premature vs. full-term children were found. This study contributes to the evidence available for public health stakeholders when updating and providing resources for parents regarding IYCF.

Dissemination via HCPs and childcare professionals is preferable due to their influence on parental behavior. Attention should be paid to the clarity of the explanation on the content, making sure to adopt a tone that is less injunctive and that the content will be adapted to parents with different socioeconomic statuses to avoid accentuating health literacy inequalities. In developing communication strategies for IYCF guidelines, both paper-based and digital tools should be considered, including the creation of a recognized official website that is wellindexed in search engines or a digital tool such as an application for smartphones. These tools should help confront topics related to practical needs. Our findings will ultimately help to build a new French public health communication strategy regarding IYCF (0-3 years old) by taking advantage of the IYCF sources that most influence parents Bibliography Supplement Material 1. Studied characteristics, questions and their modalities. health-promoting nutritional practices in the first 1000 days of life can positively impact future health (4). For example, the introduction of vegetables can be boosted during the early years of a child through the application of specific feeding practices, fostering their acceptance later on (5).

Characteristics

Furthermore, food preferences established early in life track into adulthood and are the basis for pursuing the maintenance of a healthy diet (6). Parental feeding practices influence the development of children's eating habits and preferences (7,8). Those practices have an impact on shaping the child's risk of developing diet-related, noncommunicable chronic diseases, such as obesity.

International and national feeding guidelines aim to facilitate the familiarization of parents with evidence-based best practices and guide them in the feeding process; however, two main problems might arise. First, from a public health perspective, it is difficult to always maintain the recommendations in line with the latest scientific evidence. Some countries may have incomplete feeding recommendations due to a lack of regular updating (9). Consequently, public health stakeholders may face challenges in terms of institutional time required for national nutrition and health policies renovation. For instance, in France, the communication material used to spread the official child feeding recommendations is not recent (2004), despite new guidelines covering feeding children 0-3 years of age having recently been published, but not yet adapted toward lay public dissemination (10). Second, having updated guidelines does not automatically leads to knowledge increase and changes in behavior. Care should be given in bridging the existing gap between the evolution of scientific knowledge and the ability to transfer this evidence-based knowledge in a timely manner into public health policies and actions (e.g., communication campaigns, interventions on the environment). Ultimately, this should be beneficial for promoting healthy behaviors changes within the population.

Feeding practices of French parents do not always meet official recommendations. A crosssectional study conducted in 2013 with a sample of 1,184 children under the age of three years increased focus on the low prevalence and duration of breastfeeding (11). Regarding the introduction of solid foods, the same study showed that 54% of infants were introduced to solid foods between four and six months of age, but younger mothers still struggled with achieving the initiation of complementary feeding within the recommended time frame (11). Low breastfeeding duration was observed in another French cohort and was shown to be linked to a variety of factors. Those factors included the fact that mothers had been breastfed themselves, and a high rate of maternal professional activities (12)(13)(14). Data from the French study Epifane (a nationwide birth cohort) confirmed that socioeconomic characteristics can affect the concordance of complementary feeding behavior with national recommendations. In fact, parents in more disadvantaged situations were more likely to follow less strictly the guidelines (15). Similar results emerged from studies conducted in other European countries, with the introduction of solid foods occurring earlier than recommended by national guidelines (16). Parental cultural and sociodemographic characteristics (e.g., lower socioeconomic status and education level), or other markers of unhealthy lifestyle (e.g., maternal smoking), often predicted the early start of complementary feeding (16)(17)(18).

A recent integrative review showed that European parents' knowledge about child feeding, particularly complementary feeding (e.g., when to first start the introduction of solid foods), is far from optimal (19). In contrast, an online survey conducted in the UK quantitatively evaluated parents' understanding of feeding guidelines, reporting high knowledge of the recommendations (20). Providing information is one means to increase knowledge, but increasing knowledge is not sufficient to predict a change toward healthier behaviors (21). Nevertheless, knowledge remains one of the main components of the theoretical domains framework to achieve behavior change when implementing health interventions, especially from a public health perspective (22). Therefore, understanding information and comprehending recommendations remain important steps in the early-stage process of eliciting lifestyle changes through behavior modifications. One major challenge, however, is to define the best strategy to educate parents toward feeding practices that encourage the adoption of healthy eating behaviors in children. Many different theories have been applied to explain parent feeding practices, including ecological systems theory (23) and social cognitive theory (24). Nevertheless, little is known about the knowledge that might drive parents to adopt a certain practice. Metacognition theories explore how the "feeling of knowing" can mediate controlled vs. automatic processes, implying that a difference might exist in applying knowledge that we might be more or less conscious to have acquired (25). A study performed by Bruttomesso et al. found that, in order to better characterize knowledge when answering a knowledge questionnaire, subjects can be asked to indicate their degree of certainty for each answer (26). A similar approach has been used by Norman and Furnes to measure confidence rate when answering questions (27). To the best of our knowledge, no similar research has been done in the context of understanding parental perception of child feeding guidelines, highlighting a gap in the literature. It is hypothesized that being certain of one's own (correct) knowledge can make one more inclined to apply it (26). In this context, when evaluating knowledge, it seems important to understand both the correctness (accuracy) and degree of certainty.

In France, public health stakeholders have been preparing a new communication strategy regarding infant and young child feeding before its field implementation. A first step was the renewing the official child feeding guidelines (10,28). Then two quantitative studies were performed to understand French parents' and pediatricians expectations on communicating about child feeding information (29,30). Among the support measures employable for public health dissemination purposes, paper documents have been shown to continue to play a role: 44% of parents expressed using them when seeking child feeding information (30). For 59% of pediatricians, paper brochures appeared to be the most effective tool for grabbing parents' attention when advising them about feeding during consultations (29). Santé publique France (the public health agency of the French Ministry of Health) then developed a paper brochure containing the latest child feeding recommendations, as an attempt to spread new child feeding recommendations efficiently to parents. Parents qualitatively tested this brochure (focus groups and individual interviews). In this context, it was judged essential to characterize whether this brochure could make it possible to increase parental knowledge accuracy and degree of certainty. In addition to evaluating the global effect of reading the brochure, this approach should also make it possible to identify which, if any, of the specific topics the parents were more uncertain about. The public health perspective is focused on intervening to modify and formulate clearer messages before the dissemination of the brochure to the general public. Within this framework, considering the existing gap in child feeding knowledge evaluation, the present study aimed to evaluate: (1) how much French parents know about child feeding (accuracy and certainty of knowledge); (2) whether the brochure containing new official child feeding recommendations could contribute to increasing parental knowledge (accuracy and certainty) about child feeding; and (3) whether knowledge evolution related to reading the brochure would depend on parental sociodemographic characteristics. A secondary objective was to explore parental attitudes toward the content of the brochure.

in France) on the following variables: age of the parent; profession of the household reference person (i.e., the parent with the highest salary); living area (urban vs. rural); and primiparous or multiparous parent. The general population census was used to identify the quotas within our study population and for data calibration (31). To collect the data, two online questionnaires were prepared by the researchers and were administered online to the participants via the web system of the recruitment agency (Made in Surveys) at two different time points. The first online questionnaire (T0) comprised an initial part to collect demographic data and a second part made up of 30 items in the form of declarative sentences to evaluate the child feeding knowledge of parents (see detailed content below and Table 1 for the items). The second questionnaire (T1) was made up of the same 30 items plus some questions to gather other information regarding the attitudes of parents toward the brochure (i.e., usefulness of the content and parental self-efficacy regarding following the recommendations of the brochure). The questionnaire was checked for accuracy and appropriateness by two experts working at Santé publique France in October 2020, to ensure that all the topics of the brochure were covered by the questionnaire. At the same time, it was also certified that all the novel aspects of the recommendations were covered by the items; to check for this, the items were classified as new, old or reformulated notions (in comparison to the previous guidelines) and checked by two of the authors. The questionnaires were pretested by the recruitment agency with 41 participants. After the pre-test the questionnaire was sent to all the other participants. Quality of the answers was ensured by the fact that all of the questions required a mandatory answer, therefore there was no risk for uncompleted questionnaires.

The T0 questionnaire was sent to the participants on November 13th, 2020. The exact date of completion was registered for each participant. Immediately after completion the participants received an email with a PDF version of the brochure, and the paper version of the brochure was also sent to each participant by regular mail. The last answers to T0 were obtained on November 24th, 2020, and by November 25th, all the paper brochures were sent to the participants. The T1 questionnaire was then sent by December 8th, 2020 to all the participants who answered at T0; in this way, it was estimated that all the parents had at least two weeks to read the brochure before completing the second questionnaire. The last answers to T1 were obtained on January 4th, 2021. Growing-up milk is suitable for babies aged 6 to 12 months. X 3 almond milk Almond milk is suitable for the baby's needs, as long as it is fortified with calcium.

X 4 milk alternance

From one year, it is possible to give alternately "growing-up milk" and whole UHT cow's milk.

X 5 all foods 4-6 m

All foods can be given between the 4 and 6 months of the child (vegetables, meat, fish, fruits, eggs, pulses (lentils, beans, chickpeas), starches including whole starches (pasta, rice, semolina, bread), dairy products, unsalted nuts (almonds, hazelnuts, walnuts)) in the order you want but adapting the texture to the child's age.

Measures

Demographics

Parents were asked to report how many children they had and specify the sex and the date of birth of each child to ensure a precise calculation of each child's age. Parents were also asked to report their own sex, age, living area, employment status, number of persons in the household, number of years living in France, whether French was their mother tongue, level of education and perception of their financial status. In addition, to describe the feeding history of their youngest child, parents were asked to report whether the youngest child was born preterm, had medical problems that could have impacted his or her diet (medical conditions: gastroesophageal reflux disease, cow's milk protein allergy, nasogastric intubation or congenital abnormalities of the digestive tract), was breastfed (if yes, for how long), and had started complementary feeding (if yes, what was the frequency of given commercial and homemade baby foods).

in the study (by ticking a box on the first page of the questionnaire), and were compensated for their participation according to the criteria of the recruiting agency. The compensation was set at 3.80 euros for all finalized respondents (who went to the end of the process, with T1 completed at 100%).

This amount was credited to the participant's account on the website of the recruiting agency. This study was approved by the institutional review board (IRB00003888, IORG0003254, FWA00005831) of the French Institute of Medical Research and Health, and a study registration was performed by the relevant data protection service.

Statistical analysis

For all statistical analyses, R version 3.6.1 was used (34). Frequencies, percentages and medians with interquartile ranges (IQRs) were used to describe the results. The statements regarding parental

attitudes requiring an answer on a 4-point Likert scale were considered discrete and were dichotomized as "agree" (grouping the two positive answers) or "disagree" (grouping the two negative answers) for the analysis. An answer was considered correct when parents gave the right true/false value and mastered when parents gave the correct answer with a higher degree of certainty.

A global score of knowledge was calculated by summing the number of correct answers of all the questions (range, 0 to 30). The same global score was also calculated for mastered answers. The difference in the number of correct answers between T0 and T1 (T1 -T0) was considered to define the evolution of knowledge accuracy; knowledge certainty evolution was defined by the difference in the number of mastered answers between T0 and T1 (T1 -T0). Paired t-tests were performed to determine whether the mean difference in correct and mastered answers between T0 and T1 was significant. McNemar's tests were calculated to check whether the proportion of correct answers (and mastered answers) differed significantly for each individual item between T0 and T1. The effect of selected sociodemographic characteristics (parent age, parity and education level) on knowledge (accuracy and certainty) at T0 and evolution between T0 and T1 was tested with a linear model. One model per variable was run to verify the effect of each characteristic on the number of correct and mastered answers at T0 and on the difference in correct and mastered answers between T0 and T1.

For each question, the proportion of correct answers was compared to 0.5, the chance level, through tests based on the normal approximation of the binomial distribution. Two kinds of tests were performed. First, a unilateral test was performed at T0 to detect recommendations opposite to the common belief. The alternative was a probability lower than 0.5, and rejection of the null hypothesis was an indication of disagreement with the general conviction. Second, another unilateral test was performed at T1 to detect questions that clearly ought to be reworked. The alternative was a probability higher than 0.5, and no rejection of the null hypothesis was an indication of response at chance level. When appropriate, the χ2 test was used to determine whether the relationship between parental attitudes toward the content of the brochure and sociodemographic characteristics was statistically significant. Significance was set at p < 0.05.

Results

Characteristics of the study sample

The characteristics of the study sample are described in Table 2. A total of 501 parents responded at T0, but only 452 parents also responded at T1 and were considered for the analysis (Figure 1). 1 A level corresponds to the diploma obtained after completion of upper secondary school (equivalent to 12 years of formal education in France). 2 High (liberal profession, entrepreneur, executive or higher intellectual profession), intermediate or low (laborers and clerks) or no occupation/retired (including also students). 3 Parents were classified as having a good financial situation when they perceived they were comfortable or okay with it. The other parents were classified as being in a difficult financial situation when they had a perceived uncomfortable situation imposing to pay attention to their budget, or making it difficult to reach the end of the month or forcing them to take out debts.

Evolution of knowledge accuracy and degree of certainty between T0 and T1

In our sample of parents, knowledge accuracy and knowledge certainty significantly improved after reading the brochure. In fact, the number of correct answers increased from 22 (IQR=4) at T0 to 25 (IQR=5) at T1, and the number of mastered answers increased from 11 (IQR=9) to 17 (IQR=10) (Figure 2). Paired t-tests showed that both differences were significant (correct answers: t(451)=17.15, p<0.001; mastered answers: t(451)=18.81, p<0.001). At T1, the variability in the number of mastered answers (ranging from 0 to 30) was higher than the variability in the number of correct answers (13 to 30). Figure 3 shows the distribution of answer evolution between T0 and T1. For 75% of parents, the number of correct answers increased, and for more than 75% of parents, the number of mastered answers increased. No significant effect of the parents' sociodemographic characteristics (age, education level and parity status) was found on the evolution of knowledge between T0 and T1. At T0, an effect of education on the proportion of mastered answers was observed. Parents with a higher education level had a significantly higher mean of mastered answers at T0 than did parents who had fewer years of formal education (mean difference = 1.4; t-value = 2.14; p=0.03). The effects of other sociodemographic characteristics on knowledge accuracy or degree of certainty at T0 were not significant (all p values > 0.05).

Knowledge accuracy and certainty at T0 and T1 for each question

Figure 4 shows the evolution of knowledge between T0 and T1 for each of the 30 questions. The proportion shown for each question is equal to the proportion of participants answering correctly (or correctly with the higher degree of certainty) to this specific question. Questions are ranked according to the number of correct responses at T0, from bottom to top. At T0, the proportion of correct answers ranged from 20% to 100%, with a proportion higher than 50% for most questions (90% of them) and was significantly lower than the level of chance (less than 0.5) for q5, q24, q25 and q26. The proportion of correct answers increased significantly between T0 and T1, except for q6, q8, q10, q13, q17, q23 and q30. For questions q10, q13, and q30, the proportion of correct answers was already close to 100% and thus could not increase. At T1, the probability of a correct answer was not significantly higher than 0.5 for q5, q17 or q26. The lowest proportion of correct

Parental perception of the content of the brochure

The parents were on average very satisfied with the content of the brochure. The majority (98%) agreed that the content of the brochure was useful, easy to understand and answered their questions.

Moreover, 98% of parents found that all the themes that they considered interesting were covered by the content of the brochure. Thirty-two percent of parents revealed that in the weeks prior to completing the questionnaire at T1 they looked for information on child feeding by means other than the brochure. Among those parents using other sources, the most popular ways to search information were via the internet (in particular websites on childcare, 37%), health care professionals (especially pediatricians, 28%) and parents' personal networks (grandparents, 19%, and friends, 16%). Regarding the three self-efficacy statements, a majority of parents (98%) declared they would try to follow the advice and recommendations contained in the brochure, but for 29% of them it would be difficult without the support of their partner and family. For 10% of parents, it would be difficult to follow the recommendations if their friends were not following the same ones.

Whether parents would follow the recommendations did not differ according to parents' sociodemographic characteristics (age, parity, education level).

Discussion

The main objective of this study was to evaluate the short-term effect of reading a brochure containing child feeding recommendations on the accuracy and the degree of certainty of French parents' knowledge. The results showed that knowledge accuracy, but especially knowledge certainty increased after parents read the brochure, even if for some questions parents answered below the level of chance. However, the brochure had a stronger effect in increasing knowledge certainty than accuracy. At completion of the first questionnaire, the parents with higher education levels were more certain of their correct knowledge compared to parents who had fewer years of formal education. Nevertheless, there was a generalized improvement in knowledge accuracy and certainty for all parents. Moreover, for most of the questions, the proportion of correct answers significantly increased, as did the proportion of mastered answers for all questions. A secondary aim of the study was to evaluate parental attitudes toward the brochure. There was clear evidence that almost all parents were satisfied with the content of the brochure. Nevertheless, one-third of them sought child feeding information between T0 and T1 via means other than the brochure: internet, health care professionals and parental network above all. The majority of parents were positive about following the recommendations of the brochure, but for one-third, it would be difficult to do so without the support of their partner and family. For some parents, following the advice of the brochure would be easier if their friends would also be willing to do so.

Our findings indicated that French parents already have a good level of knowledge regarding child feeding regardless of their age and parity; they scored high (median 22/30) even before having read the updated recommendations provided in the brochure. This may be seen as a result of the public health policy, first developed in 2001 regarding the National Program on Nutrition and Health (3). However, at T1, parents did not answer better than chance to q5 (all foods 4-6 m), q17 (family food) or q26 (allergens), meaning that sentences regarding those topics in the brochure might need reformulation or that parents might need more time or other consistent advice to gain more confidence with these recommendations. Parents with lower education levels, despite similar knowledge accuracy to parents with higher education levels, were less certain of their knowledge before reading the brochure. This interesting result could suggest that lack of confidence may interfere with parents' attitudes and actual knowledge and undermine the ability of parents with lower education to apply their knowledge regarding child feeding (35), thereby often displaying feeding practices less compliant with recommendations (15)(16)(17)(18). In fact, higher education is often associated with better knowledge performance (36,37). Knowledge accuracy significantly increased between T0 and T1 for all questions, except for q6 (new textures 6-8 m), q8 (food refusal), q17

(family food) and q23 (salt). For q26 (age of introduction of allergens), there was a significant increase, but the proportion of correct answers was still low after reading the brochure. For those questions, a reformulation of the related recommendations in the brochure might be advised to improve comprehension. Interestingly, the evolution in knowledge certainty was equivalent regardless of education level, which reveals that the design of the brochure was appropriate to reach its goal to inform all parents, regardless of their age, parity or education level, about best practices in child feeding.

This work introduces a novel approach to evaluate the effect of reading a brochure containing child feeding recommendations on the degree of knowledge certainty in parents. A questionnaire was completed by parents before and after reading the brochure, and for each answer they were asked to provide an estimate of the degree of certainty. Combining accuracy and certainty allowed us to define mastered answers and correct answers that were given with the highest degree of certainty. From the results, we highlighted an increase in both accuracy and certainty, but the increment of certainty was higher. Self-efficacy is defined as the belief in one's own capacity to perform a task or behavior (38), and it can transfer to different domains, including parents' ability to feed their child. According to Bandura's theory applied to the parenting domain, parents need to judge themselves efficacious in their parenting role to be successful and skillful in performing tasks related to that role (for example, feeding) (39). Also demonstrated in a study examining parental knowledge on child development is that the relationship between parental self-efficacy and proficiency in a given behavior is moderated by knowledge. In fact, when knowledge is high, selfefficacy and parenting competences (such as feeding) are positively associated (40). Parental selfefficacy and knowledge can both play a role in predicting parental behavior related to feeding, but this has not been extensively studied. Conrad et al. explored how accounting for both parental selfefficacy and knowledge could predict maternal behavioral competence (41). This study showed that, when there was high confidence, mothers who had more knowledge (vs. less) had more positive interactions with their children (41). Being certain in one's own knowledge might also strengthen parenting self-efficacy and contribute to the prediction of specific behaviors, but this aspect was not investigated in the present study, and further research is required to explore this point.

Evidence suggests that even if parents might have some basic nutritional knowledge and are aware of guidelines, they may still struggle to implement proper feeding practices due to factors, such as inconsistent and conflicting advice (42,43). In fact, conflicting advice can create doubts as to whether your knowledge is the most up to-date or correct. A qualitative study conducted in Australia highlighted the perception of mothers that "everyone gives you advice" (43). Mothers can be influenced by their personal network in making decisions related to the introduction of solids, but they also do their own research, which may accentuate the perception of being surrounded by conflicting information (43). Parents' knowledge in relation to feeding is a fundamental basis on how to empower them to provide their children healthy foods and diets and favor healthy eating behavior. Strictly related to knowledge, there is the concept of health literacy, which is considered a health determinant and defined as "the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions" (44). While high health literacy levels might favor the adoption of healthier lifestyles (45), there is rising interest in a newer and more feeding-related concept, known as food literacy.

Food literacy is defined as a set of food-related knowledge and skills that enables people to improve their own health by making informed choices about food and nutrition (46). This might be extended to parents making feeding choices for their children.

From a purely public health institutional perspective, the fact that the brochure was very welcomed by parents is an important achievement. The development of this kind of material requires a huge amount of time and the involvement of many different stakeholders (Minister of Health, research and public health institutions). In such processes, it is paramount to ensure proper vulgarization of messages that otherwise would not be fully understood from those that are the first recipients, in this case the parents. Despite the high satisfaction with the content of the brochure, 32% of parents declared they looked for information via other means. There might be different reasons for which parents still did so, but this was not explored in this study. First, since some topics were new, some recommendations may have surprised parents who needed to search for confirming information. Second, it is normal that some people need to double check information: a given piece of advice found on the internet may be more likely to be followed if it is also confirmed by a doctor.

Third, not all the information needed by all parents can be present on a paper brochure, which has the purpose of giving information in a direct and synthetic way. For example, parents of premature children or children presenting with certain medical conditions might not find what they are looking for regarding their children's needs (30). Finally, some parents might still find it time-consuming to go and check one specific piece of information on the brochure, passing by all ages before finding what they needed. Parents might find it easier just to ask one specific question to a doctor or on an internet search engine, as examples. According to our present results, the most popular ways to search for information were via the internet (in particular websites on childcare), health care professionals (especially pediatricians) and parents' personal networks. This is in accordance with other studies (11,30,47) placing those three sources as the most used by parents when seeking child feeding information. It is important to simplify access to consistent information for parents from different and officially recognized sources.

Even if the majority of parents declared they would try to follow the advice and recommendations contained in the brochure, one-third of them thought it would be difficult to do so without the support of their partner and family. This aspect might limit the transition from knowledge to behavior.

Parents' confidence in their role can also be defined as infant care self-efficacy, and it can impact the belief that parents can provide adequate and good care for their babies. Self-efficacy is also defined as one's judgment of how effectively one can deal with a designated situation. Self-efficacy influences people's thinking, feelings, motivations and actions (48). One of the sources to evaluate self-efficacy is verbal persuasion from others that for infant care translates into reinforcement from others (e.g., family, friends) (49). In fact, maintaining self-efficacy beliefs can be easier for those in whose capacities their significant others (e.g., family, friends) believe, thereby strengthening their belief to be doing well in the parent role (48). From our results, it can be deduced that parents may have low self-efficacy in relation to the verbal persuasion aspect. If encouragement from family and partner is lacking, this might exacerbate doubts that can lead to suboptimal care for the baby (49).

More specific investigation is needed, using appropriate validated questionnaires to explore all four sources of information involved in the construction of parental self-efficacy [positive enactive mastery experiences, vicarious experiences, verbal persuasion and appropriate physiological and affective state (48)] regarding following recommendations.

This study is part of the brochure deployment process in order to validate the ability of the brochure to convey child feeding recommendation messages (before the national dissemination of the brochure). However, strengths and limitations must be considered alongside these results. First, the choice between different degrees of certainty that participants had to perform might have been impacted by the participants' individual capacity to estimate their own knowledge. In fact, estimating one's own knowledge is a task that people are not used to performing, and this kind of task often requires some training, which was not performed for our study. Additionally, one may raise the fact that knowledge is not always transformed into practice. Increasing knowledge may contribute to change behavior but further long-term studies are necessary to evaluate effective practices of parents. Even if, according to the knowledge-attitudes-behavior model, knowledge can impact attitudes and reflect on behavior, Eccles et al. tested multiple theoretical models trying to explain clinical behaviors, and, from their results, it appeared that knowledge was not predictive of behavior (21). However, in France, recent studies have shown that guidelines for feeding practices are generally followed in practice. In fact, a quantitative study including a sample of 600 parents showed that the majority adhered to recommendations on the introduction of solid foods (50), but other topics, such as milk feeding, were still not well integrated into parents' practices. Further studies will investigate the effect of the information contained in the brochure and whether the newly introduced recommendations will be integrated into parental feeding practices. The primary strength of our study lies in the novelty of its approach in the field of public health guideline evaluation. To the best of our knowledge, this is the first time that material intended for the general public has been evaluated for both knowledge accuracy and certainty before national dissemination. This study was included in a timely manner in the evaluation process of the brochure. The results allowed public health stakeholders to consider final adjustments about how information was given and organized in the brochure to be disseminated.

Conclusions

Our results showed that, after reading a brochure containing the newly updated guidelines regarding child feeding, parents' knowledge increased. The knowledge increased both, in terms of accuracy and degree of certainty despite a good level of knowledge at baseline, even for younger or less educated parents. The participants were generally satisfied with the content of the brochure, even if some of them expressed that they might experience some insecurity in following the Supplemental material. The version of the brochure (in French) used for this study. Quand l'alimentation au sein est bien installée, on peut aussi alterner avec des biberons de préparation pour nourrisson (communément appelé « lait infantile ») en cas de besoin.

Introduction ou 4 e de couverture -

Quand on n'allaite pas ou plus

Donnez alors du « lait infantile » en poudre, 1 er puis 2 e âge, aux doses conseillées par le médecin traitant ou de PMI.

A partir de 1 an, donnez de préférence un « lait de croissance », qui est enrichi en fer (les formules en poudre sont moins chères). Vous pouvez aussi alterner avec du lait de vache entier UHT (ex : un biberon sur 2). Si vous donnez seulement du lait de vache entier UHT, il y a un risque que votre enfant manque de fer ; pour compenser il faudra alors lui donner des aliments riches en fer (légumes secs, viande) avec des aliments riches en vitamine C (agrumes) qui améliorent l'absorption du fer.

Les laits et produits laitiers ½ écrémés ou écrémés et 0 % MG ne sont pas adaptés aux nourrissons ; les laits et tous les produits à base de lait cru non plus.

Utilisez des « laits de croissance » et des produits laitiers nature, non aromatisés.

Le lait, et d'autres produits laitiers

Donner du yaourt et du fromage blanc non sucrés, un peu de fromage râpé de temps en temps à faire fondre dans les purées, c'est possible dès le début de la diversification, en plus de la tétée au sein ou du biberon. Il n'est pas nécessaire de donner des produits laitiers « spécial bébé » qui sont plus chers.

Les faux « laits »

Les « laits d'amande » et autres boissons végétales, même enrichis en calcium, ne sont pas du lait et ne répondent pas aux besoins nutritionnels d'un jeune enfant. Le « lait » de soja et les autres produits à base de soja sont déconseillés avant 3 ans.

La bonne position

Pour éviter une fausse route (le fait d'« avaler de travers »), présentez la cuillère par en dessous, c'est-à-dire en la portant du menton de l'enfant vers sa bouche.

L'alimentation végétalienne ou vegan (sans aliments d'origine animale) est dangereuse pour les jeunes enfants, car elle peut entraîner des carences importantes en fer, protéines, calcium, vitamines...

Clé 3 -Etre attentif pour répondre au mieux aux besoins de son enfant

Accompagner l'évolution de votre enfant Chaque nouveauté est une étape ! Un aliment inconnu, des morceaux à mâcher, une cuillère à attraper… autant de situations qui vont entraîner des réactions de votre enfant. Pour bien s'adapter à ses besoins, le mieux est de l'observer. A-t-il l'air surpris ? Content ? Votre rôle de parent est de le laisser expérimenter des aliments, à son rythme, en lui montrant qu'il peut avoir confiance.

L'encourager et être patient

Si votre enfant est surpris par l'odeur, la couleur, le goût ou la texture d'un aliment, il faut le rassurer en lui parlant de cet aliment. Une petite grimace ne doit pas vous empêcher de refaire un essai. Ne le forcez pas, mais proposez-lui quelques jours plus tard ce qu'il a refusé : petit à petit, il se familiarisera avec la nouveauté, la goûtera... et finira sans doute par l'apprécier. Moins vous vous braquerez, plus il y a de chances que votre enfant goûte avec plaisir l'aliment quelque temps plus tard.

Attention cependant à distinguer le refus d'un aliment nouveau avec un véritable dégoût : comme vous, votre enfant peut ne pas aimer certains produits. Il ne faut jamais le forcer à manger.

Pour les fruits

Cuire un fruit de saison épluché à la casserole avec 2 cuillères d'eau puis mixer, sans ajouter de sucre ; Puis, progressivement, proposez des fruits tendres crus ou cuits écrasés à la fourchette, toujours sans sucrer. 1. Tous les aliments hachés ou écrasés grossièrement à la fourchette (purée granuleuse) 2. Purées dans lesquelles on ajoute des pâtes alphabet, de la semoule, du riz bien cuit, de petits morceaux de volaille, de viande tendre ou de poisson très cuits, de l'oeuf dur haché 3. Aliments en morceaux très mous qui s'écrasent entre la langue et le palais ou entre les doigts (ex. banane)

Bannir les écrans pendant le repas

Ordre des différentes textures à proposer progressivement de 6/8 mois jusqu'à 3 ans

Le saviez-vous ? Même sans dents, un enfant peut mastiquer des morceaux mous, fondants.

Pour vérifier la texture d'un aliment, vous pouvez tester vous-même la texture et voir s'il s'écrase contre le palais avec la langue ou entre les doigts

Ne donnez pas d'aliments petits, durs et ronds (type cacahuète) à un enfant de moins de 5 ans, il risquerait de s'étouffer.

Coupez toujours les aliments mous et ronds ou ovales en deux avant de les donner.

Clé 5 -Faire confiance à l'appétit de son enfant 4. Aliments en morceaux à croquer, à mâcher avec les dents (aliments cuits, fruits crus, crudités en petits morceaux…)

Astuce : Proposer un quignon de pain de temps en temps au repas permet de stimuler la mastication et de fortifier la mâchoire. Au début il est préférable de remplacer le morceau de pain lorsqu'il est trop imbibé de salive car un morceau risque de se détacher.

La seule boisson indispensable : l'eau L'eau du robinet convient aux bébés et aux jeunes enfants (sauf exception signalée par la mairie). Si vous utilisez de l'eau en bouteille, vérifiez sur l'étiquette qu'elle convient aux nourrissons. Proposez de l'eau nature, à la tasse ou au verre.

Les jus de fruits quels qu'ils soient sont trop sucrés ; ils ne sont pas recommandés. Ne pas non plus donner de sodas (même light).

Bien veiller à l'hygiène -Nettoyage et entretien régulier des surfaces de travail, des matériels et des ustensiles.

-Nettoyage du frigo à chaque fois que des aliments ont souillé des surfaces.

-Maintien de la température à 4°C maximum dans la zone la plus froide du réfrigérateur (avec un thermomètre de frigo) Pour plus de précisions sur l'hygiène alimentaire et en cuisine, rendez-vous sur le site agirpourbébé.fr

Clé 7 -A partir de 1 an, une alimentation équilibrée à la table familiale

Prendre ou reprendre de meilleures habitudes pour toute la famille Peu à peu, votre enfant va manger presque la même chose que toute la famille, en quantités adaptées à son âge. D'où l'importance que votre alimentation soit variée et équilibrée. Vous l'avez expérimenté, la grossesse et l'arrivée d'un enfant sont souvent l'occasion d'adopter ou de reprendre des habitudes plus saines… à garder au long cours.

Retrouvez les recommandations pour l'alimentation des enfants et des adultes,

des recettes et des idées de menus sur mangerbouger.fr. Toujours beaucoup de lait Jusqu'à 3 ans, continuer à donner à votre enfant beaucoup de lait ; l'allaitement maternel est toujours possible; sinon donnez environ ½ litre par jour de « lait de croissance » de préférence, ou de « lait de croissance » alterné avec du lait de vache entier UHT ; à défaut donnez du lait de vache entier UHT seul (voir Clé 1).

repas par jour + 1 goûter (et 1 seul)

Dorénavant et pendant toute l'enfance, donnez 3 repas par jour et un goûter. Au goûter, proposez une tranche de pain et un fruit ou une compote ou un produit laitier ; évitez les viennoiseries ou autres aliments sucrés et gras.

-Ne redonnez pas un goûter si l'enfant en a déjà eu un à la crèche ou chez la nounou ! -Aux repas, servir de petites quantités et ne pas resservir sauf si votre enfant le demande.

-En dehors des repas, ne laissez pas de nourriture visible et encore moins à portée de main.

-Ne laissez pas votre jeune enfant se servir seul dans le placard ou le réfrigérateur.

Les biscuits pour bébé et autres aliments sucrés proposés dans le commerce pour les moins de 3 ans sont trop gras et sucrés.

Clé 8 -A partir d'environ 2 ans : le refus de certains aliments

Il ne veut pas ou plus de certains aliments, surtout les légumes… Jusqu'à environ 2 ans, la plupart des enfants acceptent de nouveaux aliments même s'il faut parfois plusieurs essais pour qu'ils s'y habituent. Ensuite, et parfois pendant plusieurs années, beaucoup d'enfants deviennent plus « difficiles ». 2 ans, c'est aussi l'âge où la plupart commencent à affirmer leur autonomie, à dire non à tout ; un enfant peut même rejeter des aliments qu'il appréciait avant, en particulier les légumes.

Être patient…

Pas de panique, cette opposition est normale. Le mieux est de s'armer de patience : ça va passer ! Inutile de forcer votre enfant à manger ou à finir son assiette. Le repas doit rester un moment de plaisir, pas de combat. Votre enfant aura l'occasion de goûter à nouveau l'aliment la prochaine fois qu'il sera au menu familial, peut-être sous une autre forme.

… mais poser des limites

C'est vous qui décidez de la composition du repas, pas votre enfant. S'il refuse de goûter un plat, évitez de compenser en donnant plus de dessert ou un gros goûter. Parlez-en aussi avec les personnes qui le gardent.

Comme vous, un enfant a ses préférences

La variété de l'alimentation favorise une bonne santé ; mais si vous voyez que votre enfant aime beaucoup quelque chose, rien n'empêche de le mettre au menu plusieurs fois dans la semaine.

Eviter le « chantage affectif »

Bannir les formules comme « Encore une petite cuillère pour me faire plaisir » ou « Si tu finis ton assiette, tu auras un bon dessert ». Un enfant ne doit pas manger pour faire plaisir à ses parents ou pour avoir une récompense, mais parce qu'il a faim.

Manger plus de légumes en famille

Manger est un plaisir contagieux ! Les enfants reproduisent les comportements qu'ils observent. En mettant plus de légumes au menu de toute la famille, frères et soeurs compris, on montre (et on dit) à notre enfant qu'on aime ça. Une façon de motiver toute la famille ! Jouer sur la diversité -Un même légume n'a pas le même goût ni le même aspect en salade, en tarte ou dans un pot-aufeu. -Mettez de la couleur en ajoutant des légumes (courgettes, brocolis, tomates, etc.) ou un peu de sauce tomate dans les pâtes… Attention, le ketchup n'est pas un légume, mais une sauce qui contient du sucre ! Découvrir ensemble les fruits et légumes -Aller au marché ou dans une grande surface avec son enfant peut aussi être l'occasion de lui faire découvrir les différentes formes et couleurs des fruits et légumes. On nomme les produits, on lui fait toucher le velouté des pêches… -Si on n'a pas de jardin, faire pousser du basilic ou des tomates en pot sur le balcon permet à un enfant de se familiariser avec des odeurs et des formes

Clé 9 -Bouger, jouer et dormir

Votre enfant évolue sans cesse…

Au fil des mois, un enfant progresse de façon impressionnante : il sait maintenir sa tête et son dos droit, se tenir debout avec un appui, se déplacer à quatre pattes, avant de marcher puis de courir… Il aime bouger et en a besoin, alors laissez-le faire ou sollicitez-le, notamment par des jeux, plusieurs fois par jour.

Dès le plus jeune âge, bouger

A partir du moment où l'enfant peut tenir sa tête, il est conseillé de le mettre au moins 30 minutes à plat ventre plusieurs fois par jour pendant qu'il est éveillé.

A partir de 6 mois -Allongez votre enfant sur le dos sur un revêtement matelassé (tapis, moquette, etc.). Posez à côté de lui, dans son champ de vision, un objet très coloré, brillant, ou qui fait de la musique. Attiré par cet objet, votre enfant va se retourner et ramper pour l'attraper. -Tenez votre enfant debout et laissez-le prendre appui fermement sur ses jambes.

-À la maison, laissez-le se mouvoir et découvrir les objets autour de lui en étant présent et attentif, en l'encourageant et en vérifiant bien tout pour sécuriser son environnement : prises, portes, petits objets, produits dangereux…

À partir de 12 mois

Créez un parcours avec des cerceaux, des petites marches, etc. Aidez-le à suivre les différentes étapes.

A partir de 2 ans -Votre enfant découvre son corps et commence à jouer avec les autres. L'emmener régulièrement au parc ou dans un square qui offre des structures adaptées à son âge lui permettra de rencontrer d'autres enfants pour jouer. -Jouez au ballon en famille : asseyez-vous en rond et faites rouler le ballon vers les autres joueurs, sur le sol.

-Faites découvrir à votre enfant les joies du tricycle, de la trottinette ou encore des patins à roulettes pour qu'il découvre de nouvelles sensations, améliore son endurance, son équilibre et son orientation dans l'espace.

-Emmenez-le à la piscine pour qu'il se familiarise avec l'eau à son rythme. Background: Parents are crucial in establishing their children's eating habits, and healthcare (HCPs) and childcare professionals (CCPs) can provide meaningful and trusted guidance on feeding, especially in the 0-3-year-old period. With the upcoming release of the official brochure containing the new child feeding recommendations in France, this study aims to: 1) assess professionals' practices and perceptions regarding their communication with parents on child feeding and 2) evaluate their impressions of the new brochure. Methods: A 15-page brochure containing updated child feeding recommendations for children 0-3 years old was developed by the French public health agency. Online semi-structured interviews were conducted with professionals (n=21), including 13 pediatricians and general practitioners, nine childcare assistants or professionals two weeks after they were provided with this brochure to read. The interview guide was developed and piloted with other professionals (n=3) prior to these interviews. Interview data were transcribed verbatim and analyzed thematically using an inductive approach. Results: While HCPs and CCPs mostly communicate orally with parents, both acknowledged that the brochure might be a helpful supplement, especially for CCPs to legitimize their advice to parents. For HCPs, giving the brochure to parents may help provide systematic advice and save time during consultations. Professionals serving parents of lower socioeconomic status would prefer a supplement with less text and more illustrations. In general, the messages were perceived to be easily understandable but providing detachable cards to distribute according to the child's age would facilitate information dissemination and might be more useful to parents. Professionals reported that lack of training, the circulation of contradictory information, and language barriers were common challenges. Professionals suggested that short texts with more references and visual aids could improve the brochure. Conclusions: French professionals welcome the new official brochure as a means to spread updated child feeding recommendations, but it could be modified to be better adapted to their needs of communication with parents and to facilitate the relay of information. Providing updated and consistent information to parents should be considered a priority for public health stakeholders toward increased adherence to new recommendations.

Background

The first thousand days of life from conception constitute a crucial period in child development; in fact, this stage is characterized by rapid growth in terms of physical evolution and behavior establishment (1). Interventions targeting early childhood provide a unique window of opportunity to establish optimal infant nutrition and healthy eating behaviors (2,3). Moreover, promoting healthy lifestyles from infancy is paramount for the prevention of chronic conditions such as childhood obesity, of which the increasing prevalence in developed and developing countries is growing into a significant global health concern (4). Childhood obesity, in addition to being a strong risk factor for adult overweight or obesity (5), is associated with an increased risk of comorbidities throughout life, including the development of diabetes, certain forms of cancer, premature all-cause and cause-specific mortality, and cardiovascular diseases (6)(7)(8).

Diet and physical activity are factors directly associated with the development of overweight and obesity (9,10). These factors are linked to behaviors that are sensitive to the effects of the different environmental stimuli that influence child development during early life, as shown by Bronfenbrenner's ecological systems theory (11). Among the external components that could affect children, parents play a decisive role in shaping the eating behaviors of their offspring, among other behaviors (12). For example, parents could modify children's food regulation capacities (13)(14)(15). Lack of responsiveness in parent-child interaction during meal times could impair the ability of the child to adjust his or her energy intake, often resulting in accelerated weight gain (16)(17)(18). Parental feeding practices related to introducing vegetable are also likely to influence how much children like these foods (19). Addressing lifestyle behaviors and feeding practices with parents early in children's lives could help in the prevention of chronic diseases such as obesity and its health-related consequences (20,21). Public policies, for child feeding in this case, should account for the latest scientific contributions when addressing public health initiatives aimed at shifting the management of health education of the population toward evidence-based best practices (22,23).

Parents might worry about not knowing how to behave to establish healthy diet habits for their children, which can drive them to search for any kind of advice about feeding. The need for guidance might alter parents' ability to look for factual information (24). Parents seek information about child feeding from many different sources, including the internet, media, books and magazines, family, friends, and health and childcare professionals (25,26). The nature of the information conveyed by these different sources can vary widely, and the content brochure produced by the French public health agency, together with their level of understanding and acceptance of the new recommendations.

Methods

Spreading child feeding recommendations via the mean of a brochure targeting parents

In France, there was a recent update of official guidelines for feeding children aged zero to three years, which were published by the French national agency for Food, Environmental and Occupational Health Safety (ANSES) in 2019 (29). The process was supervised by the Ministry of Health, and in October 2020, the High Council of Public Health released a report reflecting these benchmarks (30). The main changes in the new recommendations (tested with this study) compared to the previous recommendations (37) are summarized in Table 1. Subsequently, in 2019-2020, the content for a paper brochure intended for parents was developed by the French public health agency (Santé publique France). Santé publique France organized a group of experts with the intent of designing material to make recommendations relating to feeding children aged zero to three years as accessible as possible to parents, who are the ultimate users of this communication strategy. The process of reformulating the recommendations and designing the brochure spanned November 2019 to July 2021, with the document becoming available to the general public in September 2021 (the version used in this study was one of the latest drafts).

The draft version of the brochure, comprising the core text without pictures or illustrations, was provided to the professionals interviewed in this study. The document contained 15 pages plus a table summarizing the recommendations based on the age of the child and for the quantities of each food group. The brochure consisted of eight chapters. The first three chapters addressed generic topics pertaining to the development of eating behaviors of children and good practices for parents (including responsive feeding, discovering textures, screen exposure); the remaining five chapters covered the development of feeding practices based on the age of the child.

Participant recruitment

In a previous quantitative study exploring the sources of parental information on child feeding in France, it was highlighted that HCPs and CCPs are the most influential sources of advice on child feeding for parents (31). Following what emerged in that study, we aimed to recruit a sample composed of two-thirds of HCPs, including pediatricians, general practitioners (GPs), and physicians working in maternal and child protection (PMI centers: protection maternelle infantile), and one-third of CCPs, including professionals working in childcare centers, childcare assistants, and nurses working in PMI centers. Professionals were eligible for the study if they were older than 18 years of age, practicing in France, and regularly interacting with young children (and consequentially their parents) as part of their professional practice.

Retired professionals were excluded. To recruit participants, a purposive sampling method was initially used to ensure sample variety diversification: gender and age, profession and duration of professional experience, whether the participant has children, working in rural, urban, or semi-urban areas, and poverty rate of the working area. The objective was not to reach any quotas but rather to obtain a sample that was as balanced and diverse as possible. This initial method of recruitment was based on random calls or emails to HCPs and CCPs in departments that were pre-selected according to poverty and urbanization rates, (42,43) to include participants who dealt with parents of different socioeconomic status. As per the protocol, if enough participants could not be recruited in due time, then we planned to use the snowball sampling method. Participants were also recruited by means of Facebook groups. Considering other qualitative studies interviewing healthcare professionals (44)(45)(46), 21 participants was considered sufficient to ensure a diverse sample to explore the objectives of this study. However, a possible data saturation effect was evaluated, i.e., the recruitment of participants would stop if new interviews did not provide any additional information. Recruitment and data collection took place simultaneously. The recruitment outcome was determined if further recruitment was needed to ensure representatives from different professional categories.

Data collection

Data collection took place in April and May 2021. An online demographic questionnaire was developed, and an informed consent form was also included. The link to complete the questionnaire and the informed consent were sent to those professionals whom, after first being contacted by the researchers (CRN or SDR) with a brief explanation of the study, volunteered to participate. No other links were established between researchers and participants before the study commenced. The eligibility questionnaire was sent to 118 professionals, of which 40 completed the questionnaire (25 HCPs, 15 CCPs), although one HCP was unreachable after having completed the eligibility questionnaire, and thus was not included in the study. After an eligibility check, the participants who corresponded to the required profiles were selected and included in the study (n=21), and none of the included participants refused to participate in the study. Once the inclusion phase was completed, individual, semi-structured interviews were then scheduled for a date and time that suited the participants. The brochure was sent to participating professionals by email at least two weeks before the interview to allow adequate time to read it.

Interview guide and interview procedure

The interview guide was first developed based on data found in the literature (47) and then was tailored to the objectives of the study. This guide was checked by a reference group of public health stakeholders: three members of Santé publique France with backgrounds in nutrition and policy communication convened to advise the research team for the purposes of this study. This group worked on revising the brochure before national dissemination in September 2021. They reviewed and refined the study protocol and the interview guide. The interview guide was pilot tested with three preliminary interviews involving one HCP and two CCPs. A preliminary analysis of these interviews allowed modifications and refinements of the script and provided an estimate of the duration of interviews. This final version of the script ensured that the flow of the interviews could develop according to the research objectives.

However, there was a margin of flexibility to enable participants to express their ideas and deepen their responses. The interview guide comprised three main topic sections: (1) perceptions and practices related to the communication needs of professionals about child feeding; (2) changes in communication with parents due to the COVID-19 health crisis; and (3) comprehension of a brochure intended for parents and acceptance of the new recommendations.

For each section, there were several core questions and probes. The interview guide used for this study is presented in original language (French) in the Supplementary Material.

Semi-structured interviews took place in April and May 2021 in the professionals' native language (French). Interviews lasted an average of 54 ± 9 minutes. They were performed by the second author (CRN), a 25-year-old female, for the purpose of her thesis for her Master in Physiological and Psychological Food Choice Determinants. The interviewer had experience in health services research and engaging with HCPs as a result of her prior studies in medicine.

The interviews were conducted either using a videoconference system (Skype for Business) or via telephone (two interviews). During the interviews, the participants were at their home of a research technician with experience in transcribing interviews. All verbatim data were double checked for accuracy by the interviewer and the first author (CRN and SDR). The software NVivo was used to analyze the interviews in their original language to avoid loss of meaning. A thematic analysis was conducted in accordance with the six steps proposed by Braun and Clarke ( 48): (1) data familiarization, (2) initial coding generation using a data-led approach, (3) searching for themes based on initial coding, (4) review of the themes, (5) themes final definition and labeling, and (6) report writing. The familiarization step was performed throughout the data collection phase by the first two authors (SDR, CRN), who both listened to recorded interviews and read the transcripts. The first author discussed with the interviewer on a regular basis during the interview phase to brainstorm about the themes based on emerging patterns (main ideas) in the data. The first three steps were performed manually and independently by SDR and CRN. Initially, eight interviews were selected for independent initial coding. Coding was performed with a data-led approach, with particular attention to include the topics addressed in the interview guide. At the completion of this coding phase, the emerging themes and subthemes were discussed with the other authors until a consensus was reached and a final coding scheme was created. The coding scheme was used to complete the coding of all the other interviews, which were coded independently by SDR and CRN. The final coding scheme was also used to readjust the initial coding of the first eight interviews. SDR and CRN subsequently compared the coding of all the interviews and evaluated whether there were doubts or difficulties regarding the placement of quotes. Then, a discussion took place until an agreement was reached, and all the codes were homogenized. At the end of this process, SDR and CRN once again reviewed the themes and subthemes and defined those that were relevant for answering the research questions of the current study. A final decision was made after discussion with SN. Data were analyzed in two parts: 1) discourse dealing with HCP and CCP practices and needs in terms of communication with parents about child feeding and 2) discourse dealing with their perception and impressions of the brochure and its evaluation.

Results

Table 2 summarizes the characteristics of the 21 participants. Interviews were undertaken with a total of 13 HCPs (nine women) and eight CCPs (seven women) from a range of disciplines: five pediatricians, five GPs, and three PMI physicians (working in maternal and child protection centers) for a sub-total of 13 HCPs, and two childcare assistants, three professionals working in childcare centers, one childminder, and two PMI nurses, for a subtitle of eight CCPs. Eleven of the 21 professionals were aged 25-34 years (8/13 HCPs, 3/8 HCPs mentioned that exchanges about child feeding become less frequent and less systematic after one year. The media used by HCPs to support oral communication are the child health record booklet, paper documents adapted to the child's age range, and websites that parents can visit (see Table 4). Professionals working with the most disadvantaged families (especially in PMIs) explained using Google during consultations to show pictures on the computer screen and to translate their speech.

"We adapt to families, for example when we recommend whole milk, we put pictures on the computer, we say "the red cap", or "the pink cap" for follow-on milk; finally, we manage to find solutions." (P20, CCP, PMI nurse)

Regarding CCPs, very practical information on child feeding is exchanged with parents (what the child eats at home and at the childcare center), especially orally during the morning (when parents drop off their child) and evening "transmission" times (when parents pick up their child) but also with the support of paper documents. It was also reported that parents' meetings are occasionally organized in some childcare centers.

Communication barriers between professionals and parents

Language was mentioned by professionals as a barrier to communication with parents, especially in PMIs, where professionals meet the most disadvantaged families (often with a foreign origin).

"One of the difficulties we have at the PMI is that we have a lot of very precarious families [...] therefore they face many difficulties other than the problems linked to their daily diet." (P12, HCP, PMI physician).

The lack of time and training (inconsistent training done on a voluntary basis) were also mentioned as barriers. It was also stated that the perpetual change in the child feeding recommendations confuses parents and impairs communication, since it induces the circulation of conflicting information, even among professionals. Socioeconomic insecurity was reported to impact communication on child feeding.

"It's supposed to be our role, but we don't necessarily have the training, support or the time." (P7, HCP, General practitioner)

Needs of professionals to improve communication with parents

Professionals mentioned that they needed "official documents" and nutrition training to improve their communication with parents to standardize the knowledge related to infant and young child feeding.

"There are a lot of different speeches that are not necessarily very serious and not very embarrassing, but I think that by standardizing the speeches, we would have more credit and it would be easier for parents." (P8, HCP, General practitioner) Professionals working in PMIs emphasized their need for more adapted media (in particular, a short document with many illustrations and few texts and/or in various languages).

"In fact, we would need either adapted documents in several languages, or much simpler things. We really need things that are quick and simple to show to parents. And that's kind of what we're missing." (P20, CCP, PMI nurse)

Needs of parents

Professionals reported that parents are asking for information on feeding, especially CoF.

They noted that some parents need very specific guidance from HCPs, while other parents prefer flexibility in the information they receive. Parents ask for details on the recommended quantities of food and milk as well as practical advice (e.g., how to introduce an allergen).

2) Perceptions of the brochure

New recommendations

Professionals were aware that it is now recommended to start CoF between four to six months of age to prevent allergies. However, when a mother was breastfeeding, professionals were more likely to recommend starting CoF at six months of age in accordance with the World Health Organization (WHO) recommendations (encouraging exclusive breastfeeding until six months of age).

"Sometimes breastfeeding mothers want to continue exclusive breastfeeding up to six months. In general, I am not really against it because the WHO recommends that. So, I don't have too many reasons to go against it especially if it's desired on their part." (P2, HCP, Pediatrician)

Recommending introducing all types of food between four to six months of age was still not grounded in practice among the interviewed professionals. Professionals were used to advising introducing proteins from six months of age, as suggested in the previous recommendations. Some doubts about the early introduction of allergens and proteins were expressed.

"Being able to introduce all the foods is the biggest novelty. We can introduce everything, taste more or less anything, in particular and at the same time, without respecting ..

. waiting the six months." (P8, HCP, General practitioner) "What's the point of wanting to absolutely start protein right away between four and six months? […]. The info on the introduction of peanuts, which I used to do previously, but is it really scientifically validated? Because they don't all have the same indications about it between allergology organizations." (P5, HCP, Pediatrician)

According to the new brochure, pulses and whole grain starches can be introduced to children from four months of age. This recommendation sounded relatively new to professionals, but it appeared to be well accepted despite some doubts about their digestibility were raised. Some CCPs noticed that feeding practices in childcare centers do not meet this recommendation.

"I discovered that at four months you could give that: lentils and mashed beans. I did not know. It was complicated for me because the fiber and the lentil, bean or chickpea skins have to be very well mixed. But I find it good, it's interesting." (P21, CCP, PMI nurse)

Most of the professionals knew that it was possible to alternate follow-on milk and full-fat cow milk after the child turned one years old. They found that this was a good option to propose to disadvantaged families. However, there was a tendency to emphasize follow-on formula to avoid iron deficiency. The purpose of this recommendation seemed to be less understood by CCPs.

"And I had to do it before because I know that you can give whole cow's milk instead of follow-on milk. [...] On the other hand, it is true that where I insisted, it was that it should not be exclusively cow's milk. They need a lot of iron and that is not covered by cow's milk." (P9, HCP, General practitioner)

"I think there is a vagueness and we are not sure if we are completely marketing or if this follow-on milk really brings more to the children. And again, from one pediatrician to another, we can see that there are two schools, there are really those who switch to UHT milk without worry and others who are reluctant." (P14, CCP, professional working in a childcare center).

Professionals were familiar with non-recommended foods (e.g., plant-based alternatives to formula, sugar sweetened beverages and foods). Some of them asked for more explanation, especially regarding the new recommendation about avoiding chocolate until three years old.

Professionals mentioned that they particularly enjoyed one section of the brochure on babyled weaning as they face an increasing number of questions about this topic and need more evidence-based information.

"As I read I also thought about the baby-led weaning, I wondered if it would be covered when I saw that there was a little passage on it. It's true that sometimes it's not very common, but it so happens that there are parents who say they want to do the baby-led weaning when in fact, frankly, I have no knowledge of it. I do not know what to advise them, as it is really outside the framework of the recommendations that I've read." (P2, HCP, Pediatrician) "Then we have more and more questions about the baby-led weaning. This is something I had never heard of ... I have the feeling that a year ago we didn't talk about it, and in the last year we have talked about it a lot. There is a little insert on it, that's good." (P17, CCP, Childcare assistant)

General impressions of the brochure

Positive impressions of the brochure outweighed negative impressions (see Table 5). In fact, all 21 professionals expressed at least one positive impression, and overall, they seemed enthusiastic about the brochure (some of them wanted to use it forthwith). illustrations. Participants suggested translating the brochure in different languages or to make one document with visual explanations and many pictures adapted to PMI populations.

Participants also proposed making different detachable sheets adapted for each age range of the child to easily distill the information to parents. Including the brochure in the child health record booklet and adding more explanations and/or scientific references (e.g., why starting CoF between four to six months of age help prevent the development of allergies; why is it recommended to avoid salt until three years of age; scientific references to justify the introduction of gluten and nuts, etc.) were also popular suggestions.

"In fact, we should be able to cut down the number of items to give just the one that corresponds to the needs of the families in the moment. After that there is a need to put images so that we can adapt it to our families." (P20, CCP, PMI nurse)

Perceptions of the use that parents can have of the brochure

Professionals believe that the brochure is a comprehensive and useful written tool for parents and can serve as a reference for discussing child feeding with doctors. They believe that the brochure will be more useful for parents who are already invested in the topic of child feeding and that its usefulness will be more limited for parents of the most disadvantaged backgrounds.

The brochure could encourage parents to change certain habits (e.g., to cook more homemade dishes).

Discussion

In this qualitative study, we interviewed French healthcare and childcare professionals who serve young children and their parents with the aim to explore their practices and needs when communicating with parents about child feeding from zero to three years of age. We also aimed to explore professionals' impressions regarding a brochure containing the newly updated child feeding recommendations and focused on understanding acceptance of the new nutritional recommendations. We decided to focus specifically on HCPs and CCPs in recognition of their central role in guiding and influencing parents in the early life of children (31).

The results of this study suggest that overall, the brochure meets professionals' needs. The paper format was well appreciated by professionals. This is in line with the results of a recent double survey regarding the perceived needs of French parents and pediatricians concerning information on CoF, in which 59% of pediatricians and 42% of parents considered paper brochures to be an appropriate tool to spread information regarding CoF (27). Professionals indeed reported they would use the brochure as a medium to communicate with parents, except in serving PMI populations where a simpler and more colorful document was requested (it worth noting that the draft version of the brochure that was being tested at the time did not present any graphical adaptation yet). There are some differences in terms of communication practices between CCPs and HCPs, especially concerning the content of exchanges with parents. While CCPs tend to discuss more practical topics such as daily issues related to the diet of the child, HCPs tended to discuss more feeding-related topics. On average, pediatricians and GPs perceived the brochure as more useful in their practice than CCPs. Those dissimilarities in practices between CCPs and HCPs and their perceptions of the utility of the brochure could reflect the different roles of employment between these two professional categories. Specifically, while HCPs reported they could use the brochure in a systematic way with parents during consultations, CCPs would rather use it as an instrument to inform themselves, legitimize their knowledge on the subject, or to assuage the doubts of curious parents.

Nevertheless, both types of professionals agreed that this brochure would enable them to update their knowledge about nutrition for children from zero to three years of age.

In PMI centers, the story is completely different from that in pediatricians' offices. In fact, the professionals dealing with more disadvantaged families expressed strain in having to use the brochure with their patients. Parents visiting PMI professionals are often immigrants or those of foreign origin who do not fluently speak or understand French; in those cases, an adapted tool with more pictures and images is required to facilitate communication. The lack of tools that account for the needs of those parents was previously noted in another study in which 35% of pediatricians thought that communication materials available to parents do not sufficiently consider the different economic and cultural situations of families (27). It was already demonstrated that public health campaigns focused on diet and nutrition struggle to reach those of modest means (49,50). This aligns with data showing that chronic conditions such as obesity and diabetes are more prevalent within the lowest socioeconomic classes of society (51,52). The challenges of involving a disadvantaged population in public health campaigns could exacerbate social health inequalities (53). To tackle this issue, the campaign regarding the new recommendations, which launched in September 2021, also included other mediums of communication, such as videos. These tools can overcome language barriers and may increase parents' capabilities to turn recommendations into practice by providing concrete advice and examples for feeding children. Disseminating health messages through HCPs and CCPs was also a means to efficiently reach all parents (including those who are disadvantaged), since a previous study has shown that HCPs and CCPs are the most influential sources of information to parents regardless of their financial status (31). In addition, in the near future, other tools are planned to be designed to specifically address the needs of disadvantaged populations as identified by professionals. Moreover, in France, the program MALIN (www.programme-malin.com) is now disseminated through the family allowance with the objective of promoting healthier food practices for children under the age of three who come from families in precarious situations (54). Disadvantaged families who meet the eligibility criteria (e.g., income) could be provided vouchers to buy baby food or groceries and given advice, to empower them to make better nutrition-related choices for themselves and for their children.

This study did not reveal important differences between the new recommendations and the advising practices of professionals (especially HCPs) but still pointed out particular advice given by professionals that could be updated and improved in light of the new recommendations, in particular with regard to the introduction of allergens and of all types of food between four to six months of age. Our results are in line with those of a study conducted in France in 2016, in which the interviewed GPs and pediatricians reported giving advice on child feeding in line with recommendations (55). For instance, in this study, professionals acknowledged that the right age for introducing complementary food was between four and six months of age and gave the appropriate advice to parents in 85.2% of cases. However, in the same study, the given advice was not in line with recommendations as was highlighted regarding the introduction of allergens and some foods. For example, 44.5% of professionals were advising parents to introduce gluten to their child after six months of age (55).

Additionally, in the case of parental allergy history, there was a tendency to tell parents to postpone the introduction of some specific foods. Some of the professionals interviewed in our study also experienced doubts regarding the introduction of allergens. An uncertain opinion from a professional could create confusion regarding the time of introduction of complementary foods and could introduce non-compliance in parents due to reasons such as lack of confidence in the doctor and preference to follow advice from family or friends (56,57). The uncertainty experienced by some professionals facing the newest recommendations underscores the time required for scientific, evidenced-based, knowledge to reach all the intended recipients. A consensus among professionals on child feeding recommendations could improve parental confidence to follow the given advice, but this remains a difficult objective to achieve. The French Public Health Agency has been moving in this direction with a communication campaign targeted toward professionals with the goal of sensitizing them to the new recommendations prior to the launch of the campaign targeted toward parents (August 2021).

The brochure produced by Public Health France is an official document that formalizes and standardizes the latest recommendations for feeding children from zero to three years of age. It is interesting to note that the brochure itself did not fulfill the HCPs' need for explaining some recommendations, since they expressed the need to verify some of the information themselves.

As was the case in this study, GPs and pediatricians surveyed by Chouraqui et al. reported their need to obtain more information about certain infant feeding practices, more generally on specific pathology-related recommendations (such as the prevention of allergies, the age of gluten introduction, and the treatment of food allergies) as well as weaning and the introduction of foods according to the child's age (55). Interestingly, in our study, GPs and pediatricians also reported their need to obtain more information regarding the quantities of milk according to the child's age to answer parents' questions, which suggested that this recommendation about milk quantities still creates confusion. Professionals also needed more explanations regarding why some foods are not recommended to young children (e.g., certain types of fish, chocolate).

French pediatricians surveyed by Banti et al. in 2015 to understand whether their practices followed official recommendations stated that frequent changes could be perceived as errors in the original or latest recommendations (58). This might reduce the level of trust in updated official documents, and consequently, the given advice may no longer align with the latest evidence. Clear explanations are requested to detail why recommendations had changed in comparison to the previous ones. In this case, scientific references are requested, especially by HCPs.

Our results showed that professionals believed that they have a role to play in the dissemination of the brochure. Indeed, the discourse of HCPs suggested that the brochure could help overcome some of their communication barriers. In fact, providing the brochure to parents would allow HCPs to save time during consultation (parents would have all the necessary information in the document so HCPs focus on talking about the most important topics and save time to answer questions) and to overcome the lack of practical advice (since the brochure contained practical advice such as recipes, which were appreciated by HCPs). In addition, using the brochure as a support to communicate with parents would help HCPs and CCPs provide more complete and systematic information about child feeding and bring more legitimacy to their communication with parents. In serving PMI populations, the main barrier to communication with parents was language. However, a written support with images and few words could facilitate communication with foreign or immigrant families. The development of other means of dissemination of information might be needed to foresee an inclusive strategy at every population level. The perspective of creating digital solutions has been discussed previously in the literature, but doubts still exist on how to deal with social disparities in terms of digital health (59).

Strengths and limitations must be analyzed when considering the results of our study. For the design of the study, we aimed to include unequal numbers in different professional categories. This decision was based on another recent study, as explained above, but this consideration should be taken when interpreting and generalizing the findings of our study. A potential bias could emerge when interpreting findings by giving undue prominence to views of certain professions (mostly GPs and pediatricians). Notwithstanding, during the analysis and presentation of the results, efforts were made to ensure that points at which views and perceptions differed across professional groups was explicitly stated. Additionally, as often happens with qualitative studies, social desirability bias could be a limitation; in fact, professionals might have had the instinct to say something just because it was perceived to be the "correct" answer according to their perception of their role. In addition, an effort was made to include a high number of doctors (GPs, pediatricians, PMI physicians) across a spread of different departments in France. In fact, this population is often difficult to involve in research studies due to work schedules that often cannot accommodate activities other than outpatient practice. Moreover, while we included a wide variety of professionals, other categories of HCPs and CCPs, such as midwives, could have been involved. Our inclusion method occurred mostly via social media, which yielded heterogeneity in terms of the age of the participants, which was not representative of the national population.

Conclusions

Early life is an important period for the development of healthy behaviors in children, especially regarding eating. Involving health professionals in a structured strategy of disseminating child feeding recommendations can be important given the high frequency of routine contact that they have with parents in their child's early years. This qualitative analysis conducted with health and childcare professionals allowed us to explore their practices and needs in terms of communication with parents on child feeding. Professionals reported that while communication with parents primarily occurs orally, they also often refer to other supports (e.g., pamphlets, online sources). Lack of time and language were major barriers, especially in PMI centers that are serving disadvantaged populations. Moreover, this study investigated whether professionals found the brochure developed by Santé publique France suitable to meet their needs, whether they could easily integrate the new recommendations when advising parents, and whether they considered that additional adaptations are needed. Our Auriez-vous des contacts de personnes qui pourraient être intéressées par l'étude?

Reminder of context and objectives

According to the literature, the first 1000 days of life are a window of opportunity for the prevention of adverse health-related outcomes later in life. During this period, parental feeding practices influence later children eating behaviors, defining, among others, food preferences and dietary intakes. In this timeframe, interventions promoting healthy outcomes have been proven effective in the prevention of childhood overweight and obesity. Previous studies aiming at improving child feeding practices included the collaboration of different HCPs to support parents during early feeding stages. In fact, those professional figures have the possibility to exert an influence on parents as parents trust professionals' advice. Public health communication strategies (especially if setting behavior change objectives) have the potential to provide updated information and increasing the awareness of a targeted population regarding a specific health issue, toward an improvement of specific health behaviors related to that issue (e.g. changing parental feeding practices).

The research work carried out during this thesis first explored parents' and pediatricians' needs and practices in regards to child feeding communication, and then evaluated the communication material developed by the French public health agency (SpF), in line with the updated child feeding guidelines. In particular, we could coordinate our work in relation to the development of the communication strategy which was conducted by SpF. The two first studies of this thesis were run in parallel of the work of the CAT (the working group of experts in charge of elaborating the content of the communication material and giving advice about the best ways to spread child feeding related information). Studies 1 and 2 informed the communication strategy by giving insights on which type of information was needed and which were the most adapted tools to spread this information (according to parents and pediatricians).

Once SpF developed a complete draft of a paper brochure containing the child feeding recommendations, study 3 was run to evaluate if this tool was effective for increasing the knowledge of parents of young children. With study 4, we qualitatively evaluated whether an updated version of the same brochure was well accepted by HCPs and CCPs. Studies 3 and 4 allowed us to identify which were the most difficult recommendations to understand for parents and pediatricians, enabling SpF deciding whether it was necessary to reformulate health messages to make that information clearer.

The aim of this chapter is to discuss these results bearing in mind public health implications.

First, the results of the articles presented in the previous chapters will be summarised. Then, some methodological considerations will be addressed, the results of this work will be discussed in view of existing literature, and strengths and limitations of this approach will be highlighted.

Finally, public health perspectives for future research or possible applications of the same methodology will be suggested.

5.1) Summary of the main findings

The general aim of this doctoral project was informing the new public health communication strategy for disseminating the new child feeding recommendations. In order to do that, the information needs of parents and pediatricians were explored before the development of adapted policy media (paper brochure), Chapter 3. The draft of the brochure was then evaluated with parents and HCPs/CCPs (Chapter 4), before the launch of the national communication campaign. This thesis is made of four studies, which resulted in four scientific articles which findings are briefly described below.

In chapter 3 (article 1), we explored the needs and perceptions of parents and pediatricians about information on CoF. The results showed that both parents and pediatricians were aware that the early feeding period strongly influences healthy growth and eating behaviors of children. Parents could perceive the CoF transition as a source of concern and they needed advice on how adopting appropriate feeding practices; they recognized the importance of pediatricians as information providers. However, discrepancies were found on the frequency at which dietary advice is spontaneously provided during consultations. Parents were in general satisfied with the available information they could find via different sources, even if the advice was sometimes perceived as contradictory and inconsistent. This could drive parents to trust information coming from their personal network, especially regarding practical advice for implementing CoF; these two points appeared underestimated by pediatricians. The Internet was a well-recognized source of information according to both parents and pediatricians.

In chapter 3 (article 2), we took a closer look at parents' information-seeking practices in relation to specific characteristics of parents and children (parental education, perceived financial situation, parity, child age and prematurity). Generally speaking the most used and trustworthy advice source was HCPs, followed by the internet, which was the least influential source. The influence that those sources have on parental feeding behavior could differ according to the characteristics of the parent or the child. We highlighted differences in search strategies according to parity, parental level of education or child age, for example primiparous parents and parents of younger children made more use of the internet as source of information, parents with higher level of education were more influenced by HCPs and paper supports, and were using less the traditional media. Surprisingly, few differences were found among parents of premature vs. full-term children. Parents of children who presented medical conditions affecting their diet had slightly different practices and needs.

In chapter 4 (article 3), we studied the short-term effect of reading the draft of the brochure (developed by SpF with the support of the CAT) containing child feeding recommendations on the accuracy and the degree of certainty of French parents' knowledge. The results revealed a significant increase of both parental knowledge accuracy and certainty after reading the brochure, with higher increase on knowledge certainty than accuracy. Parents with higher vs. lower level of education were more certain of their correct knowledge before reading the brochure, but this difference was not evident once they have read it. With this study we also aimed to evaluate parental attitudes toward the brochure. It was highlighted that parents were satisfied with the content of the brochure; they expressed the intention of following the recommendations. However, part of the respondents expressed the need of the support of their partner and family to do so.

In chapter 4 (article 4), we qualitatively explored HCPs and CCPs practices and needs when communicating with parents about child feeding and in particular CoF. We also studied professionals' impressions regarding the SpF brochure, with a focus on understanding their acceptance of the new nutritional recommendations. The results of the semi-structured interviews showed that the brochure was appreciated by professionals, they found useful to have a paper support summarizing the recommendations; it will go together and legitimate the oral advice, as especially reported by CCPs. However, professionals working in PMI expressed the need of having less text and material translated in different languages. On a general basis, the messages were considered easily understandable and the recommendations were mainly already known and accepted, however, HCPs would appreciate more explanation regarding some specific topics (e.g. allergens).

5.2) Methodological considerations

For the purpose of this thesis we adopted a novel methodology for supporting the development of communication material containing the updated child feeding recommendations. In fact, we used a mix methods approach that allowed us to support the finalization of a paper brochure by considering which are the needs of the target population (parents of 0-3 years old children), and of those that play an important role in the relay of information to the parents (HCPs and CCPs). We made a pre-evaluation of which were the needs and practices of parents and pediatricians in terms of information seeking. Then, following the development of a draft material (paper brochure), we tested if reading this brochure could increase parents' child feeding knowledge and whether HCPs and CCPs considered the brochure appropriate to communicate with parents about the new child feeding recommendations. Finally, this enabled the edition of further modifications to the draft of the brochure by SpF in order to include what emerged from these evaluations.

In this thesis project three quantitative studies and one qualitative study were conducted. For the quantitative study with pediatricians (study 1), the questionnaire was pilot-tested with a small network of healthcare professionals (from the Perinatal Network of Burgundy, n = 200; n = 33 of participants answered the pilot survey). To amplify the possibility to collect enough answers at national level a sample of AFPA pediatricians was then included for the study. The AFPA is a pediatric association accounting for members from all over France, allowing us to have a vast sample of pediatricians from various French departments. This association was chosen because we had connections with a member, and this facilitated the spreading of our survey among the AFPA network, increasing the chance of including the requested number of participants in due time. For the two quantitative studies with parents of children from 0 to 3 years, the aim was to include a representative sample. In order to do that we recurred to recruitment agencies that could send our surveys to their panel of participants, accounting for the quotas that we set (for details on the quotas see chapter 3, article 2 and chapter 4, article 3). The fact of using representative samples was important for being able to produce material that could be adapted to the largest portion of parents of children between 0 and 3 years living in France. Finally, for the qualitative study we aimed at including a heterogeneous sample of HCPs and CCPs; with a mix of profession, age, sex and living area. Despite the effort we put in the recruitment phase, the professionals were difficult to reach, and we could not manage to have a large representation of older professionals, especially males. However, we could interview enough professionals to reach our sample size in due time and provide meaningful feedback to make the last changes to the brochure before the launch of the national communication campaign.

It is interesting to note that this methodology brings something new to the process of the development of new recommendations; in fact, the method usually used by SpF foresees only qualitative evaluations (focus groups), but not a quantitative approach. The quantitative studies are normally performed by SpF after the launch of the campaign to assess its impact, but the evaluation of knowledge change has never been performed before what was done in study 3.

5.3) Discussion of the main findings

In chapters 3 and 4 the results of the four studies composing this thesis are discussed in form of articles. The articles are grouped in a way to explain first the process of research made before the development of the communication strategy and related material (articles 1 and 2), and then the evaluation of the draft brochure produced by SpF with the support of the CAT (articles 3 and 4). The sections below will link the results of the four articles and discuss them in a transversal and more holistic way, in order to answer the same research questions (and implicitly address the same research objectives) described in the introductive chapter. It must be specified that in the next sections when talking about "child feeding messages" we mean the health messages containing child feeding recommendations. Those messages are supposed to be associated with a specific behavior in order to reach ultimately health-related outcomes.

5.3.1) How to inform the communication strategy accounting for the needs of parents and HCPs in relation to child feeding information?

Principles from social marketing One of the problems in developing a public health communication campaign at national level is to respond to the needs of the totality (or at least the majority) of the target population of that campaign (in our case parents of children between 0 and 3 years old). In this direction some principles of social marketing are useful to understand the approach that most often is taken when programming public health communication strategies focusing on behavioral change (221). Although a discussion about social marketing itself is not intended for the purpose of this thesis, it must be acknowledged that this discipline had an important influence on public health and health communication in the last decades (222). Therefore, principles of social marketing are also applied by SpF in their campaigns and some principles will be explained in the following paragraphs, they will serve as a lens to analyze the work done by SpF.

First, public health's as well as communication's objectives need to be pre-fixed. In particular, for this campaign, the public health challenge was to decrease the incidence of pathologies, which derive from suboptimal eating habits. The pre-defined communication objectives were4 :

1. to disseminate the new recommendations on feeding children from 4 months to 3 years old (the 0 to 4 months period is not deeply addressed, as specific recommendations for milk feeding had been discussed elsewhere) to the general public and professionals (HCPs); 2. to enable parents of children aged 4 months to 3 years to appropriate the new child feeding recommendations by offering practical tools and accessible content (brochure + poster, educational tutorials, articles on mangerbouger.fr, recipes). Moreover, once the objectives are determined, to respond better to the needs of the target population, an audience analysis is usually performed to identify segments for specific approaches. An audience analysis includes, for instance, demographics and social structure analysis; this data is critical for the formulation of effective strategies. For example, it is useful in order to design targeted and more effective messages and better strategies to deliver those messages, leading to better reception by the public (223). Another aspect brought from social marketing is the systematic use of qualitative methods, in particular focus groups (223). SpF made use of this approach to pretest messages during the developing phase of the communication material. Finally, the strategic use of mass media to spread messages is also a well-known and used strategy that permits to reach a vast number of people, often targeting specific media depending on the segment of the population (223).

What did my studies bring to an already existing methodology derived from social marketing? The added value could reside in the use of quantitative studies to evaluate the needs of parents and pediatricians regarding communication and information seeking around child feeding; as well as to check the effectiveness of this communication. The use of national representative samples is an important point when informing the communication strategy, it allowed to retrieve the child feeding information needs of parents and pediatricians accounting for specific characteristics of those populations (as ensured by the quota method that was used to include the participants).

Child feeding is an important topic, but public health policies must align to this priority

From chapter 3 (article 1) we understood that CoF and early child feeding are key periods for the child's development according to both parents and pediatricians, however, in chapter 4 (article 4) HCPs revealed that often, during consultations, they do not have the time to tackle those prevention-related topics. This was confirmed by other studies examining doctor-patient communication, finding lack of time as a barrier in communication (169,170). A few public health-related problems can emerge from this finding. We could question which the real problem is (lack of communication tools vs. lack of time to address this topic) and why there is no time to cover those topics. A systematic review by Wilson and Childs showed that doctors who have high-volume of medical appointments, but shorter consultation times do less prevention and health-promotion activity (224). Moreover, following what emerged from the health system crises of the last few years in France, especially regarding public hospitals (e.g. lack of funding enabling to provide quality treatment, staff shortages) (225), we can assume for example that there are not enough professionals to account for the needs of the whole population and it is not possible to prolong each consultation's time. In fact, this would mean receiving less patients per day and consequently decreasing daily wages, which is certainly not acceptable for most professionals; or contrarily accepting underpaid and unrecognized shifts (e.g. working in the weekends). Those problems are not directly linked to issues in communication but could have an influence on it. For example, knowing that HCPs do not have time to talk about primary prevention matters (such as healthy child feeding), gives an indication on the type of communication strategy that should be built, by making sure it is time-efficient. In our qualitative study, professionals were satisfied by the use they could have of the brochure because they expressed it could have help them saving time during consultations. Maybe the health system could incentive professionals to devote time to prevention issues during consultation. This would mean reconnecting healthcare to a broader perspective, in fact, the SEM in the introduction of this thesis explained how making changes to the external levels of the model could influence all the internal levels (123). In this sense, taking a stance on the side of health policies would be necessary (in particular to redefine the content of consultations that could be reimbursed, or involving other professionnals in the dissemination of materials such as the brochure or prevention-related topics). However such a process could be particularly long and could also be a barrier toward rapid changes in people's behaviors, seen all the actors that must be involved and put in agreement to take decisions at policy level. This was clearly beyond the reach of this thesis, but other research works demonstrated the importance for the political actors to intervene through early childhood programs to cut future costs for reducing health and social inequalities once they are already in place (226,227).

What kind of information do parents need?

From chapter 3 (article 1) it emerged that parents look for practical tips when searching for child feeding information. In particular, they think it is important to find examples of menus and recipes, quantities and sizes of food and milk portions, and tips on how to present food in case of food refusal. Pediatricians, on their side, think that parents must primarily be informed about the age of start of CoF, and the age of introduction of the different food groups. This incongruence might highlight the fact that pediatricians, and more generally HCPs, do not feel at the right place to give such kind of (practical) advice and specific material is needed to satisfy the parents' request for practical tips. Complementarily, from the analysis of interviews with professionals (chapter 4, article 4) it emerged as a matter of fact that CCP's, especially those working in collective facilities, are mostly giving to parents very practical information on child feeding (what the child eats at home/at the childcare center). They provide such information especially orally, but also with the support of paper documents, therefore they would feel in a more appropriate position to spread those kinds of information (even if, according to the results presented in article 2, despite being influential for parents, CCPs were not one of the most used source of information). A mix method study by Garcia and colleagues found, in 2019, the same needs of practical advice among English parents. They found both, quantitative and qualitative evidence of this parental need. Practical advice, such as how to cook, was received by 48% of parents only (multiple sources are considered), whereas recommendation on weaning age, for instance, was received by 95% of parents (228). Another study in the UK found that parents were in need for practical tips like including vegetables in the diet of the child (229).

From the interviews with parents in the Garcia's study it emerged that online videos were a good way of getting more practical advice, even better if those videos were legitimate by a trusted source (e.g. spread via official governmental websites) (228). Those needs of parents were included in the communication campaign officially launched by SpF in September 2021.

In fact, four videos and six tutorials are available for parents, this material is particularly focused on understanding the child eating behavior and how adapt the feeding practices based on the child's cues. Moreover, some recipes (20 recipes, 5 per season) are available on the dedicated website. Those recipes consider the needs of disadvantages families, they are suitable for the whole family and their realization allows to prepare the meal for all at once5 . The visuals instructions will allow to clearly seeing for each recipe the food textures that are adapted to each stage of CoF, as this topic was indeed under covered by the previous recommendations and put forward in the new recommendations.

Which are the best tools to spread child feeding information to parents?

Regarding sources to spread information to parents, from chapter 3 we highlighted that HCPs should be privileged; they are the most used and trusted source according to the parents surveyed for our study. Pediatricians confirmed that they feel at their place advising parents on child feeding and CoF (article 1). The influence of HCPs was perceived stronger by parents of children below one year of age, those with a better financial situation and higher education.

With our study we could not explore why low SES parents trusted less HCPs, but, in a qualitative study performed by Heinig and colleagues it was highlighted that low-income mothers tend to avoid guidance from medical providers if they perceived the given advice was not working for their family (230). A recent systematic review analyzed factors that parents consider in relation to CoF. From this research it was confirmed that HCPs are the source of advice most frequently used by parents (231); however the advice was trusted more if the advising professionals had children themselves (232,233). HCPs are one of the preferred information sources, and SpF included them in the communication strategy; in fact, they were a target for the campaign for the new recommendations, they are able to order some material to keep in their office (to give to parents), and they have a dedicated page on the SpF website where they can find all the content (changes in the recommendations, etc.).

From chapter 3 it was also highlighted that Internet, the personal network of parents and paper documents are also widely used sources of information. Internet was more used by primiparous parents of children below 12 months (article 2). Professionals themselves suggest to parents to go to look for information on specific websites, as we saw from the results reported in chapter 4 (article 4). According to a survey conducted in Belgium, 90.5% of women admitted they look for information on the Internet after childbirth regardless of socioeconomic status.

Even if they seemed not to consider the information found on the Internet as a good quality (as shown in study 2), they still look there for advice as they expressed the need to find information themselves and make their own opinion (234). Another study from the same authors found that women think that HCPs should suggest reliable Internet websites for new mothers (235).

Parents do not only look for information on the Internet, they also look for social support (236).

Parents from our studies also look for social support (articles 2 and 3) by asking advice to their closest network (family, friends, etc.), especially primiparous parents with lower education. This evidence is supported by other studies examining how parents get information during the early years of the child and how family, friends and peers can positively or negatively influence their CoF decisions (237-240). According to the results of article 1 pediatricians were not aware of the vast use that parents made of their network, but professionals interviewed for our qualitative study were more aware of it (showing the added value of interviews). Whereas information to be spread via the Internet (e.g. website mangerbouger.fr) was part of the communication strategy implemented by SpF, there is still some research to do in order to understand how to actively involve the parents' personal network. In fact, the personal network is part of the closest environment of parents and the influence that it can exert on them should not be underestimated. First, it would be interesting to know to which extent each figure (grandparents, friends, extended family) influence parents (may be different according to SES and/or personal history) and subsequently to evaluate if a specific strategy (or different strategies) targeting them is needed.

Finally, the dissemination of child feeding information via the mean of a brochure is central for the communication strategy implemented by SpF. Forty-four percent of the parents answering to our survey favored paper tools as source of information (chapter 3, article 2), the influence of this support was higher in parents with higher level of education. The literature aligned to our findings: books were the most used information source among older first-time parents and parents with older children (236). Pediatricians (59%) also considered paper documents has an appropriate tool to communicate with parents about child feeding (chapter 3, article 1), and when interviewing HCPs and CCPs to evaluate their impressions of the brochure, the positive feedback outreached the negative one (chapter 4, article 4). Therefore, a paper brochure was considered an appropriate tool to spread child feeding recommendations to parents, via also the mean of HCPs and CCPs because it could easily be given during consultations and could "save time" for professionals, as discussed above.

Public health outlook and future research

When planning public health communication interventions aimed at influencing children's eating behaviors it is paramount to consider not only the influence that parents can have on children behaviors, but also what can influence parents. When looking for advice on child feeding parents turn to different kind of professionals and also to their closest network including family and friends. From a public health perspective HCPs should be facilitated in their work, besides the systematic provision of the brochure, providing solutions that may include more time to devote to primary prevention (including more advice on nutrition) could be beneficial.

Prevention-dedicated consultations (single or group e.g. mandatory and free trainings for parents with HCPs specialized in child feeding) could be scheduled at key ages for the child feeding process (e.g. transition to CoF, change of textures or even prenatally for the initiation of breastfeeding). However, those kinds of strategies require the support of political actors and a deployment of financial resources, therefore an exploration would be needed in order to understand whether these measures should concern all or just parents of children with specific needs (e.g. premature). Further research is needed in order to explore quantitatively and qualitatively which are the role that parents' personal network foresee for their advising role and to which extent the support of the family would make it easier to follow the recommendations.

5.3.2) How to design and deliver a public health communication strategy able

to leverage parents feeding practices in a way that the majority of parents will understand correctly the messages?

Today we live in the globalization era; an era of movement and exchange that encompasses all the possible domains, including the moving of individuals between countries. The gathering of people with different ethnicities (with different languages, religions, traditions, and behavioral norms), or the adherence to different social norms, can have implications for several segments of the receiving society, including health (241). People generally engage in practices that are consistent with their own customs, including adherence to patterns of behavior that may be suboptimal from a health-related perspective, such as dietary habits, or involvement in preventative health care. The delivery of health services must grapple with the complex relationship between people (with different cultures, languages, etc.), health related behaviors, and health services access and utilization (242).

From the results presented in chapter 3 (article 1), it emerged that, for 35% of pediatricians, the different economic and cultural situations of families were not sufficiently considered in the information and existing communication material on child feeding available to parents. This finding was reinforced by what was highlighted in chapter 4 (article 4), this time specifically in relation to the tested brochure. In fact, the analysis of the semi-structured interviews revealed that professionals perceived the SpF brochure as not adapted to all the families whom they were meeting. Particularly, according to the HCPs and CCPs participating in study 4, low SES families, or families of migrants or refugees could have experienced problems in understanding the recommendations of the brochure. The main obstacles that were underlined were the difference in culture and language, suggesting the fact that a tool made just of images with really simple text would be of better usefulness for such populations 6 . The fact that problems of communication between parents/patients and their children's healthcare providers could influence health outcomes, and increase health disparities, have been already addressed in literature (243, 244). This is especially true for low income parents and foreign-born parents, for linguistic minorities, or those with limited proficiency of the language of the country in which they sought for care (245-247). One paper exploring conditions for better communication between HCPs and parents raised evidence to the fact that communication's expectations are different in the presence of language barriers. In fact, whereas HCPs preferred to recur to an interpreter when communicating with parents, parents wanted to be able to speak for themselves or have a friend as interpreter, showing the need of "translating the cultural aspects" rather than barely words (248). The implementation of cultural-adapted communication strategies (besides policies) might be needed to reduce communication barriers for low income families seeking for healthcare for their children (especially for those not speaking the language of the country), translation in other languages should be foreseen. Those strategies could contribute to reducing health disparities toward more favourable health outcomes. This is not a minor problem in France, where about 20% of any new parents were born abroad, with feeding practices sometimes differing from those of France-born parents [START_REF] Bournez | Factors associated with the introduction of complementary feeding in the French ELFE cohort study[END_REF]249,250).

In chapter 3 (article 1) we observed that the 34% of the parents who were surveyed considered that the available information on child feeding was not always consistent and could contradict itself (especially for primiparous parents, as shown in article 2). For 32% of parents, the received advice could make them experiencing a feeling of guilt of not behaving as recommended. These results raise the problem of stigmatization and social inequalities when implementing nutritional recommendations, as people could have a different perception of the health messages (251). As shown in a study by Regnier, people tend to react differently to nutritional recommendations, and the extent of this phenomenon can depend on their SES category. Modest/intermediate categories have shown a critical reaction: they knew the recommendations, but they perceived them as an external imposition. In low SES categories, following the recommendations was not a priority, they prioritized the fact of having stocks of food (252). A qualitative study run in the Netherlands showed that low SES participants seemed motivated to change their lifestyle when they experienced health issues, but they were less willing to change their lifestyle for preventive purposes (253). This aligns with data showing that chronic conditions such as obesity and diabetes (at the center of many prevention campaigns) are more prevalent within the low SES (254, 255). As targeting only disadvantaged populations could worsen stigmatization, Regnier concluded that it may be good to target modest categories (not only the most precarious, nor only obese populations), to articulate a discourse with a general aim and the specificities of the social categories at stake, with campaigns that account for their taste/hedonic preferences and lifestyles (251, 252).

In order to deal with this potential problem, when drafting the child feeding messages to be included in the brochure, SpF proceeded to some qualitative evaluations of the messages with parents from different SES, and especially middle and low SES, coming from different parts of France. The results from those focus groups allowed to understand specific needs and specificities of groups of parents, and to modify the child feeding messages, adapting them to the level of understanding of the interviewed parents (who are supposed to be representative of different SES categories of the target population). Moreover, the newly developed child feeding messages have a new approach to the recommendations; they take more into account the behavioral component of feeding than in previous versions, giving more importance on "how" to feed a child than "what" to feed. As shown from the Figure 5 (from a SpF internal document), messages are focused on how to behave to feed responsively during the period of CoF, emphasizing the importance of the parent's role in listening to and observing their child's cues during a feeding, and adapting to them. SpF conducted some post-test to evaluate the impact of the first months of the campaign. It emerged that the campaign was well recognized and understood, showing a good performance of the dissemination strategy especially for the less advantaged populations (SpF internal report).

Public health outlook and future research

The coexistence of different cultures in the same country should rise the attention on the development of public health prevention strategies that are inclusive of minorities and communities of different ethnicities (different cultures, languages, etc.). More research is needed (especially in the European landscape) in order to understand which communication 7 from internal document "Fiche campagne Diversification alimentaire, Septembre 2021" (SpF). type can better address the needs of diverse people in a globalized society, avoiding any kind of stigmatization. This research can include a qualitative approach intended at exploring needs of the different minorities (low SES French, but also migrants and refugees). Focusing attention on translating communication material in other languages (e.g. English, Arabic) or helping professionals with translation services in hospitals or private practice may be an effective strategy for reducing communication problems in healthcare settings (including communication with parents regarding child feeding).

5.3.3) Which are the effects of the child feeding messages on parents' knowledge?

Parental decisions regarding child feeding can develop under social constraints and they are influenced by multiple factors including their own knowledge about infant development, nutrition, and infant feeding recommendations (256, 257). Parental self-efficacy (parents' belief in their ability to successfully perform their parenting role) also applies to infant feeding practices and, therefore, it affects how parents behave in the feeding context ( 258). An integrative review by Bahorski and colleagues found several studies reporting higher likelihood of following feeding practices in line with recommendations in mothers with a higher sense of self-efficacy (259). Parental knowledge (in domains related to child development, caregiving and childrearing skills) was found to be a moderator in the relation between parental selfefficacy and parenting competence (how the parent act / parental practices); in fact, parental self-efficacy and parenting competence were positively associated when parental knowledge was high (260, 261). According to the results from chapter 3 (article 1), 87% of parents felt they were well informed about CoF, and were satisfied with the available information. The information they were able to find regarding the subject of CoF appeared clear to 90% of parents; relevant to answer their questions for 87%; and easy to put into practice for 86% of them. Those results could raise the idea that French parents already have a high level of selfefficacy concerning child feeding. However, a specific methodology should be used to measure self-efficacy, and the questions in our survey rather aimed at gathering a general perception from parents about the existing information on child feeding and CoF, than actually measuring self-efficacy.

Parental knowledge is linked to increased self-efficacy which relates to parenting practices promoting more positive child outcomes. Being certain of one's own knowledge could also be linked to self-efficacy, but, to the best of our knowledge, no studies explored that aspect. As suggested by McKee et al., this evidence points out that parental knowledge is a meaningful target for public health interventions (262), and knowing how to successfully increase parental knowledge on specific matters could be beneficial when planning prevention interventions, for instance on feeding and nutrition. However, literature in this area explored mostly the effect of parental knowledge about child development on children's behaviors (260, 262), with no specific focus on feeding. Contrarily, in many nutrition studies, the effect of the intervention on the evolution of feeding behaviors is studied, but whether there was a previous increase in knowledge or awareness of the topic is not discussed. To the best of our knowledge, there is not comprehensive evidence on the effect of parental child feeding knowledge about children's eating behavior, and no studies were found taking into consideration both accuracy and certainty of knowledge. In chapter 4 (article 3) we analyzed the short-term change in parental child feeding knowledge accuracy (how much parents know) and certainty (how certain parents are about what they know) after reading the SpF brochure. In this regard, this study is very original. We highlighted that an increase in both knowledge accuracy and certainty was shown regarding most of the 30 questions (covering the new child feeding recommendations), and for the questions scoring the lowest proportions, adaptation in the child feeding messages to be included in the brochure have been made by SpF after the conduct of this study. Whether an increase in knowledge as a result of reading the brochure was linked to an increase in selfefficacy and a change in children's eating behavior was not explored with this study (only three questions were related to self-efficacy at the end of the second questionnaire T1 and an evaluation of them would not give a reliable measure of self-efficacy). However, a supplemental analysis regarding those answers revealed that the parents most convinced of their ability to follow the recommendations and those who believed they could follow these recommendations even if their friends do not follow them, were also those who benefited the most from reading the brochure (greatest increase in the number correct and mastered answers) (unpublished results). Further research on this aspect could be of interest in order to build evidence for the construction of specific education interventions aimed at increasing parental knowledge on child feeding, as well as self-efficacy, toward improved parental feeding practices, and ultimately children's eating behaviors.

Public health outlook and future research

From a public health perspective, focusing on prevention interventions addressing the increase of parental knowledge in order to increase parental self-efficacy, as a first step toward healthier feeding practices, could be seen as a cost-effective strategy to improve healthier outcomes for children (even if cost-effectiveness was not specifically calculated in the present work). Knowledge development should be considered as an important basis for behaviour change.

Future research is needed in order to explore whether increase in child feeding knowledge could eventually predict healthier parental feeding practices which could improve children's eating behaviors. In terms of evaluation of the brochure developed by SpF, it would be interesting to re-evaluate the knowledge of parents in few years from now, in order to explore whether the recommendations that were less understood at the time of study 3 (end of 2020) would have evolved after diffusion of the recommendations among parents and professionals. It might be interesting to evaluate which is the effect of the circulation of the messages via different types of media and communication channels (263).

5.3.4) Are professionals ready to deliver the child feeding messages to parents?

From chapter 3 (article 1) it was highlighted that 93% of pediatricians always advise parents on child feeding during consultations. Ninety nine percent of them were confident in their role of counselling parents on those matters, and 82% of them thought they had enough knowledge about CoF and infant feeding. From an answer to a question of the same survey (that is not presented in the results of article 1), we saw that 96% of pediatricians said they received nutrition training within the last 2 years before the survey, mainly via continuous medical training. This rate seems quite high, but we cannot exclude a social desirability bias for this answer. However, from the survey we could not identify if pediatricians were satisfied with the quality of the training they had received/were receiving. This matter was better addressed in the qualitative study. From the analysis of the interviews (chapter 4, article 4) it emerged that HCPs perceived they did not receive enough training in nutrition during medical school, the training they had was considered inconsistent and it happened mostly on a voluntary basis. This is confirmed in literature; in fact physicians often do not feel competent in giving advice not related to care that they relate to a well-defined pathology, for example, on obesity care or prevention (264), and the risk exists that obesity is not diagnosed and consequently not treated in clinical practice (265). For professionals in study 4, the lack of proper training about nutrition and feeding was considered as a potential barrier in properly communicating with parents, and having more organized nutrition training to standardize the knowledge related to infant and young child feeding was considered an important need, raising also the question about who should deliver those trainings. Previous researches support our results, reporting lack of training/education as one of the biggest barriers for the implementation of preventing counseling on feeding and nutrition, or when addressing weight management, in primary care (266, 267). Recent studies explored the effect of an alternative way of learning about nutrition for preventive medicine residents or medical students. They followed culinary and nutrition education courses or workshops aiming to teach practical skills and knowledge; the results were positive, showing improvements in nutrition knowledge, confidence in counseling, and personal culinary skills that could be lately transferred onto patients (268-270). This method could be a promising approach also for specific trainings on child feeding. It might allow pediatricians and other professionals in charge to advice parents on child feeding to increase, for example, their willingness and ability to promote adherence to guidelines. CCPs did not discuss much regarding potential trainings in nutrition during the interviews, but they agreed that having a "universal" support could help them to stay up to date with the recommendations.

The results from chapter 4 (article 3) help to identify for which questions the knowledge of parents was weaker, the two questions in which parents had the lowest proportions of correct and mastered answers were q5 and q26 (early introduction of allergens and introducing all foods between the 4 th and 6 th months of the child). Even if, as reported at the beginning of this section, pediatricians were confident in their child feeding knowledge (article 1), from chapter 4 (article 4) we could understand if there were specific topics in the brochure they felt less sure about.

We could indeed notice that those two topics for which parents were the least knowledgeable about, were also the new recommendations for which professionals expressed more uncertainties (chapter 4, article 4). They were more willing to advise introducing proteins from 6 months of age, as suggested in the previous recommendations and they expressed doubts regarding the early introduction of allergens (e.g. eggs). These points were taken in consideration for the strategy of SpF. On one hand, SpF had the possibility to consider the modification of the child feeding messages to make those points as much clear as possible. On the other hand, SpF reinforced those messages during the dissemination campaign that happened for professionals (September 2021) right before the campaign to parents (October 2021).

Public health outlook and future research

From a public health/educational perspective, more training on nutrition is needed, specifically for HCPs (CCPs are not really concerned), in order to allow them to keep on track with latest evidence-based knowledge. This is especially true for practitioners in charge for advising parents on child feeding. The trainings should include approaches other than the traditional scholar ones (e.g. culinary workshops), with the intention to improve self-efficacy and motivation to talk about important prevention matters. Future research should focus on evaluating, few years from now, whether and to which extent the new recommendations have been integrated in the advice given by professionals and whether parents follow the professionals' advice and modify their feeding practices in accordance with the new recommendations.

5.4)

To what extent will the new child feeding recommendations allow parents to adopt the recommended feeding practices?

As mentioned in section 1.1 of the introduction, in France the PNNS (launched for the first time in 2001) exists with the general objective of improving the health status of the entire population by acting on one of its major determinants: nutrition (including physical activity).

Since 2001 this program has been evaluated and improved, and in 2019 its fourth version has been launched. In fact, from the evaluation of the PNNS-3 8 , it emerged that, despite the contribution of the program to increase the awareness of the fundamental role of nutrition in the prevention of chronic pathologies, there were some limitations and the deployed actions had marginal health impact on the population, because of limited behavior change. The PNNS-4 was build-up in order to give priority to public health promotion actions, with focus on few clear messages and on few target populations (children and young people, precarious populations, isolated elderly people). This new program acknowledges that an important thread for the coming years is the reduction of social inequalities in health, considering the contributions of the social sciences and the latest discoveries in terms of nutrition and feeding, when planning actions.

The new child feeding guidelines have indeed been designed to be evidence-based; taking into account the most recent results in terms of parental feeding practices and children's eating behaviors. The child feeding messages were developed in order to disseminate the new recommendations to the population of parents of young children, and the messages were designed to teach to parents more "how to feed" than "what to feed". If parents adopt the parental feeding practices as described in the new recommendations, this could, theoretically, contribute to improve children's eating habits and therefore reduce the risk of developing obesity. Following the results of study 3 of this thesis, it was shown that the communication material containing the new recommendations can contribute to increase parental knowledge on child feeding related topics, and this might relate to an increase in self-efficacy. However, it is important to understand if parents will be able to integrate the recommendations in their feeding practices and will behave accordingly. Moreover, we cannot be sure whether children will display healthier eating behaviors if their parents act in accordance to the recommendations. We know from observational studies (271), that there is bidirectionality between parental feeding practices and children's eating behaviors, and certain feeding practices should be related to some children's reactions, but more non-observational research (e.g., interventional studies) is needed to give insights to those points.

Upon the completion of this thesis project, an intervention (randomized controlled trial NUTRIENT) will be implemented to investigate those points. It will establish research-based knowledge regarding the effectiveness of the newly developed communication material (the brochure) and the extent to which parents understand and apply the recommendations within their feeding practices. For the purpose of the intervention a web-based app had also been developed and will be used as additional information dissemination tool by the parents in the intervention group. Taken as a whole, this project (my thesis and the intervention that will follow) will assess the effects of the use of new communication media (developed based on the latest child feeding guidelines) to spread child feeding recommendations, on the feeding practices of parents, and on the eating behavior and body mass index of children up to the age of 3 years.

5.5) Strengths and limitations of the thesis project

This doctoral project is part of the process of development of the communication material aimed to convey child feeding recommendation messages to a target population of parents of children from 0 to 3 years old. Four studies have been conducted: two studies before the development of the material, to understand the communication needs of parents and pediatricians; two studies to evaluate subsequent versions of the brochure, supporting SpF during the definition of the most adapted child feeding messages. Methodological considerations need to be taken into account when interpreting the results of the different studies, as discussed in every individual paper. However, some strengths and limitations must be considered alongside the project as a whole.

The main strength of the thesis is the appropriate timing of the different studies. In fact, the project was built and adapted to the timing of release of the French guidelines for feeding children aged 0-3, and the subsequent work-plan of SpF: all the studies could provide results in the right timing to integrate the required modifications in the material. The three quantitative studies had a large and nationally representative sample of participants, and this contributes to reinforce the value of the results. In particular, for the two studies with parents, the quota-sampling method was employed, in order to align the characteristics of our sample with the characteristics of the national population under study. When recruiting the samples of parents, the collaboration with recruitment agencies was of great help in ensuring the required number of parents with defined characteristics at the metropolitan France level. Recruitment efforts must be recognized also for the qualitative study. In fact, we could enrol a high number of doctors, despite HCPs are a population remarkably very difficult to involve in research (especially when there is the need to schedule time for an interview), given the limited time they have to devote to activities other than medical practice. This was especially true in the context of the COVID-19 pandemic that was prevailing when the study took place. Finally, it must be highlighted that this project brought some novelty to the methodology usually employed by SpF. It used a mixed-method approach including not only studies with parents (whose also the change in child feeding knowledge was evaluated for the first time), but also with HCPs and CCPs, with a pre-evaluation of needs, and the evaluation of the developed material addressing those needs before national dissemination. We believe that this helped SpF to adjust both the content of the brochure and the dissemination strategy.

It must be reminded that this doctoral project took place during the COVID-19 pandemic and associated lockdowns and efforts were made to conduct (and adapt) the foreseen research despite the pandemic, in fact, extensions of the project could not be foreseen as stated in the grant agreement of the ITN program. Regarding limitations, beyond methodological weaknesses of each individual study, it must be said that a qualitative evaluation with parents (besides the focus groups already conducted by SpF) could have underlined important aspects especially for those populations with special needs (e.g. low SES or parents of children with a medical condition affecting their diet). These parents may have more easily revealed their points of view with individual interviews rather than with the quantitative surveys.

General conclusion and perspectives

This doctoral thesis aimed initially to give an insight into which were the needs and practices of parents of young children, and pediatricians, with respect to child feeding communication, and then, to evaluate the brochure that was developed by SpF (with the support of the CAT) in line with the updated child feeding guidelines. The results of four studies, presented in four articles, provided interesting evidence into the similarities and divergences between parental and professional's visions of which are the best ways to communicate around child feeding and CoF recommendations. Some needs of parents emerged as linked to specific parental or child's characteristics, paving the way for understanding how to deal with differences in a target population when having to plan a public health intervention (like programming a public health communication strategy to disseminate the new recommendations). Child feeding messages were modified and adapted based on the understanding that parents and professionals had of the new recommendations. The brochure developed by SpF took into considerations the results of our studies and is now available to the French population, since September 2021. The communication strategy of SpF includes different ways of disseminating the updated child feeding recommendations (videos, tutorials and specific websites). This strategy takes into account the needs of vulnerable populations via the formulation of child feeding messages considered as easy as possible to understand (child feeding messages have been formulated with the help of experts in the field of health literacy to ensure messages to be accessible and understandable).

Taking a systemic look at the results we can conclude that the development of healthy eating behaviours in young children is influenced by different actors at different levels. The main level explored in this thesis is the interpersonal one, referring in particular to the influence of parents and HCPs on the development of children's eating habits. In fact, children's behaviours are primarily defined by parents' practices that are influenced by the guidance of HCPs, who act within the health system of a specific country. The health system is defined by specific policies and decisions that are undertaken at the political level; those decisions define, for instance, which directions health prevention and health promotion bodies could take in the planning of public health actions and strategies (including communication strategies targeting the general public). The results of the studies performed during this thesis supported and informed the development of a communication strategy to be implemented in France. This strategy considered the communication needs of parents and HCPs and the developed material has the purpose to efficiently reach the majority of the target population. Communication between the different actors at the different levels is essential for the transfer of evidence-based knowledge to guide best practice. Public health interventions should be planned to guarantee an efficient flow of information adapted to each level, toward an increase in knowledge as first step for the adoption of behaviours in line with public health recommendations (in our case specifically on child feeding).

In Figure 6 a general overview including conclusions and perspectives derived from the results of this thesis is given. This overview includes some points already mentioned in section 5.3, but it gives a triple vision, foreseeing aspects to consider and future research at policy, organizational and interpersonal level, keeping the SEM model as a reference. An aspect that appears in Figure 6 but was not specifically addressed in the discussion is the key role that social networks (e.g., Instagram, Tweeter) could have in the dissemination of information. People from all SES use social networks, and such networks can be seen as an important instrument influencing feeding practices. In fact, with social networks people are able to exchange with their peers (another possibility of being influenced by its own personal network). SpF is currently evaluating the impact of their campaign on social networks, and what will emerge could be useful to plan further strategies of dissemination of the recommendations.

Le projet de ma thèse a été mené en collaboration avec un partenaire non académique : Santé publique France (SpF). Ce projet avait deux objectifs principaux, (1) soutenir le développement du matériel de communication en explorant les perceptions et les besoins des parents et des pédiatres, et (2) évaluer le matériel développé quantitativement avec les parents (impact à court terme sur les connaissances parentales concernant l'alimentation des enfants) et qualitativement avec les professionnels de santé (par exemple tester l'acceptabilité des nouvelles recommandations).

Introduction générale

L'obésité est un problème alarmant dans le monde entier, menaçant la santé des enfants notamment dans les sociétés occidentales, mais aussi dans les pays en développement, où le double fardeau de la malnutrition est un problème majeur de santé publique (1). Il est essentiel de comprendre les déterminants d'une prise de poids inadaptée pendant la petite enfance afin de prévenir les maladies liées à l'alimentation plus tard dans la vie (17,18). Les 1000 premiers jours de la conception au deuxième anniversaire d'un enfant sont une période importante dans la vie d'un individu. Cette période de temps est une opportunité unique pour une croissance et un développement neurologique optimaux tout au long de la vie (19,20).

Faisant partie des 1000 premiers jours, le passage de l'allaitement à l'alimentation diversifiée est d'une importance cruciale pour le développement de comportements alimentaires sains chez les nourrissons. Au cours de la diversification alimentaire (DA) un nourrisson rencontre, pour la première fois, différents goûts, différentes textures et ses préférences alimentaires se développent, ainsi que ses habitudes en matière de quantités consommées. En effet, c'est à ce moment que l'enfant apprend quoi, quand et combien manger ; cet apprentissage se fait par expérience directe, ou en observant les comportements alimentaires des autres (le plus souvent les parents) (40,41). Selon la théorie de Bronfenbrenner (développé dans le modèle socioécologique), le processus de développement d'un enfant est défini par ses caractéristiques individuelles, accompagnées des relations qui s'établissent avec ceux qui peuplent son propre environnement (famille et amis, enseignants à l'école, etc.) (118, 119, 123).

Les pratiques alimentaires des parents sont considérées comme ayant un impact significatif sur les choix alimentaires et les consommations des nourrissons. Les parents, avec leur style parental et leurs pratiques de nourrissage, exercent la plus forte influence sur les comportements alimentaires des enfants ; ils définissent, entre autres, l'environnement alimentaire à la maison, ce qui contribue à façonner les préférences alimentaires ainsi que les habitudes alimentaires de leur progéniture (54,157). Il est donc important que les parents soient correctement informés et guidés tout au long du processus de DA.

Cependant, les recommandations disponibles en

Objectifs de recherche de la thèse

Dans ce contexte, l'objectif général de cette thèse était de : « Contribuer à l'élaboration et à l'évaluation de supports de communication, dédiés aux parents, visant à diffuser les directives de santé publique concernant l'adoption d'habitudes alimentaires saines chez les enfants de 0 à 3 ans. » La principale question de recherche à laquelle ce projet a tenté de répondre était : « Comment pouvons-nous transférer les connaissances de la recherche (connaissances fondées sur des données probantes), à grande échelle, aux parents et aux professionnels de la santé pour tirer parti de pratiques d'alimentation plus saines et, par conséquent, conduire au développement de comportements alimentaires plus sains chez les enfants ? ». Suite à ce qui est ressorti de la littérature, certains points ont été considérés comme des lacunes potentielles en ligne avec l'objectif général de la thèse et dignes d'investigation. En particulier :

• Les parents sont les premiers influenceurs des comportements alimentaires de leurs enfants, notamment dans la période de 0 à 3 ans ; les informer correctement via des supports de communication contenant des recommandations actualisées est nécessaire afin de faciliter l'application de pratiques alimentaires pouvant se transformer en habitudes alimentaires plus saines pour les enfants. Cependant, nous ne savons pas comment les parents français recherchent des informations concernant l'alimentation des enfants, quelles informations ils recherchent et dans quelle mesure ils font confiance aux conseils qu'ils trouvent ou reçoivent.

• Les professionnels de santé interagissent avec les parents au début de la diversification alimentaire, mais nous ne savons pas comment ils conseillent les parents et s'ils sont confiants pour donner des informations sur l'alimentation des enfants. En fait, les dernières recommandations sont obsolètes et les professionnels pourraient ne pas être disposés à donner des conseils en s'appuyant sur du matériel de communication datant de plus de 15 ans. Il est important de comprendre si les professionnels de santé disposent des moyens appropriés pour communiquer avec les parents sur ces sujets et d'évaluer tout autre besoin afin de faciliter leur rôle de conseil.

Cette thèse a été organisée en deux parties. La première partie (études 1 et 2) comprend l'évaluation des besoins et des pratiques des parents et des professionnels de santé (dans ce cas, des pédiatres) en matière de recherche d'informations sur l'alimentation de l'enfant. Cette partie informe et précède l'élaboration du support de communication (brochure papier réalisée par SpF avec l'aide d'un groupe de travail d'experts) par lequel les recommandations seront diffusées auprès du grand public. La deuxième partie de la thèse (études 3 et 4) comprend une évaluation du matériel développé par SpF avec les parents et les professionnels de santé et de la petite enfance.

Les objectifs spécifiques suivants ont été définis : 1) Explorer les perceptions et les pratiques des pédiatres et des parents d'enfants âgés de 0 à 3 ans concernant l'information sur l'alimentation des enfants et éclairer la stratégie de communication tenant compte de leurs besoins : Études 1&2.

2) Contribuer à l'élaboration de supports de communication, dédiés aux parents, visant à diffuser les directives de santé publique (alignées avec l'ANSES et le HCSP) concernant l'adoption d'habitudes alimentaires saines chez les enfants de 0 à 3 ans. Détachement chez SpF (et travail avec le groupe de d'experts).

3) Évaluer l'impact à court terme du matériel de communication sur les connaissances parentales concernant l'alimentation des enfants : Étude 3. Nous avons ciblé un échantillon national représentatif de 1000 parents français d'enfants de moins de 4 ans. Les participants ont été recrutés à l'aide de la méthode d'échantillonnage par quotas. Les effets de la parité, de l'âge de l'enfant, de la prématurité, de l'éducation parentale et de la situation financière sur les réponses des parents ont été évalués séparément.

Les parents dont l'enfant avait un problème médical affectant l'alimentation (17 %) ont été considérés séparément des parents d'enfants en bonne santé. Tous les parents d'enfants en bonne santé ont reconnu l'importance de l'alimentation des jeunes enfants pour leur santé et leur croissance. Quatre-vingt-huit pour cent des parents se considéraient comme bien informés sur l'alimentation des enfants et 86 % étaient satisfaits des informations disponibles. Quatre-vingthuit pour cent des parents considéraient également qu'il était facile de trouver des informations sur l'alimentation des enfants et ont déclaré que les informations disponibles répondaient à leurs questions. Cependant, un tiers de parents considérait que les conseils disponibles étaient contradictoires et culpabilisants. Généralement, pour les parents primipares, il était plus difficile de trouver des informations et de les comprendre, sans avoir un sentiment d'inquiétude.

Les sources d'information les plus utilisées étaient les professionnels de santé (81 %), internet (72 %) et les réseaux parentaux (63 %). Les sources les plus influentes (influence moyenne ± déviation standard) comprenaient les professionnels de santé (7,7 ± 1,7/10), les professionnels de la petite enfance (7,3 ± 1,8/10) et l'entourage parental (6,9 ± 1,8/ dix). Nos Les parents reçoivent des informations sur l'alimentation des enfants de plusieurs sources, ce qui peut prêter à confusion au moment de décider les conseils à suivre. Nous avons mis en évidence des différences dans les stratégies de recherche en fonction de la parité ou de l'âge de l'enfant, mais étonnamment, peu de différences entre les parents d'enfants prématurés et nés à terme ont été trouvées. Cette étude contribue aux preuves disponibles pour les acteurs de santé publique lors de la mise à jour de ressources concernant l'alimentation des enfants. Les parents jouent un rôle crucial dans l'établissement des habitudes alimentaires de leurs enfants, et les professionnels de la santé et de la petite d'enfants peuvent fournir des conseils utiles et fiables sur l'alimentation, en particulier pendant la période de 0 à 3 ans. Avec la sortie prochaine de la brochure officielle contenant les nouvelles recommandations d'alimentation des En moyenne, les pédiatres et les médecins généralistes ont perçu la brochure comme plus utile dans leur pratique que les professionnels de la petite enfance. Ces différences de pratiques entre les professionnels de santé et de la petite enfance et leurs perceptions de l'utilité de la brochure pourraient refléter l'usage différent que ces deux catégories professionnelles peuvent en faire. Concrètement, alors que les professionnels de santé ont indiqué qu'ils pouvaient utiliser la brochure de manière systématique avec les parents lors des consultations, les professionnels de la petite enfance l'utiliseraient plutôt comme un instrument pour s'informer, légitimer leurs connaissances sur le sujet ou apaiser les doutes des parents curieux. Néanmoins, les deux types de professionnels ont convenu que cette brochure leur permettrait d'actualiser leurs connaissances sur la nutrition des enfants de 0 à 3 ans. Pour les professionnels de santé, la remise de la brochure aux parents peut permettre de donner des conseils systématiques et de gagner du temps lors des consultations. Les professionnels au service des parents de statut socio-économique inférieur préféreraient un supplément avec moins de texte et plus Les professionnels français accueillent la nouvelle brochure officielle comme un bon moyen de diffuser les recommandations actualisées sur l'alimentation des enfants, mais elle pourrait être modifiée pour être mieux adaptée à leurs besoins de communication avec les parents et pour faciliter le relais de l'information.

Discussion des résultats

Comment éclairer la stratégie de communication tenant compte des besoins des parents et des professionnels de la santé en matière d'information sur l'alimentation des enfants ?

Du chapitre 3 (article 1), il est ressorti que les parents recherchent des conseils pratiques lorsqu'ils recherchent des informations sur l'alimentation des enfants. Du chapitre 3 (article 2), il a également été montré qu'une proportion plus élevée de parents en situation financière difficile étaient ceux qui recherchaient plus fréquemment des exemples de menus/recettes. Les pédiatres, de leur côté, pensent que les parents doivent avant tout être informés de l'âge de début de la DA, et de l'âge d'introduction des différents groupes d'aliments. Cette différence de perception pourrait augmenter le fait que les pédiatres, et plus généralement les professionnels de santé pensent qu'il n'est pas de leur ressort de donner ce genre de conseils (pratiques) et qu'un matériel spécifique est nécessaire pour satisfaire la demande des parents de conseils pratiques.

En revanche, de l'analyse des entretiens avec les professionnels (chapitre 4, article 4), il ressort que les professionnels de la petite enfance, notamment ceux travaillant dans les structures collectives, donnent pour la plupart des informations très pratiques sur l'alimentation des enfants, notamment par voie orale, mais également à l'aide de documents papier, ils se sentiraient donc dans une position plus appropriée pour diffuser ce genre d'informations.

Concernant les sources pour diffuser l'information aux parents, dès le chapitre 3, nous avons souligné que les professionnels de santé devraient être privilégiés ; ils sont la source la plus utilisée et la plus fiable selon les parents interrogés dans notre étude. Les pédiatres ont confirmé qu'ils se sentaient à leur place pour conseiller les parents sur l'alimentation des enfants (article 1). L'influence des professionnels de santé était plus forte pour les parents d'enfants de moins

Quels sont les effets des messages d'alimentation de l'enfant sur les connaissances des parents ?

Les connaissances parentales (dans les domaines liés au développement de l'enfant, à la prise en charge et à l'éducation des enfants) se sont révélées dans des études antérieures être un modérateur de la relation entre l'auto-efficacité parentale et la compétence parentale (comment le parent agit / pratiques parentales) ; en fait, l'auto-efficacité parentale et la compétence parentale étaient positivement associées lorsque les connaissances parentales étaient élevées. D'après les résultats du chapitre 3 (article 1), 87 % des parents ont estimé qu'ils étaient bien informés sur la DA et étaient satisfaits des informations disponibles. Les informations qu'ils ont pu trouver au sujet de la DA sont apparues claires à 90 % des parents ; pertinent pour répondre à leurs questions pour 87 % ; et facile à mettre en pratique pour 86 % d'entre eux. Ces résultats pourraient soulever l'idée que les parents français ont déjà un niveau élevé de connaissances et d'auto-efficacité concernant l'alimentation des enfants.

La littérature suggère que les connaissances parentales sont liées à une auto-efficacité accrue.

L'augmentation de l'auto-efficacité est liée aux pratiques parentales favorisant des résultats plus positifs pour les enfants. Être certain de ses propres connaissances pourrait également être lié à l'auto-efficacité, mais, à notre connaissance, aucune étude n'a exploré cela. À notre connaissance, il n'existe pas de preuves complètes de l'effet des connaissances des parents sur l'alimentation des enfants sur le comportement alimentaire de leurs enfants, et aucune étude n'a été trouvée prenant en considération à la fois l'exactitude et la certitude des connaissances. Dans le chapitre 4 (article 3), nous avons analysé le changement à court terme de l'exactitude des connaissances des parents sur l'alimentation de l'enfant (combien les parents savent) et de la certitude (comment certains parents savent ce qu'ils savent) après avoir lu la brochure de SpF.

Une augmentation à la fois de l'exactitude et de la certitude des connaissances a été démontrée concernant les 30 questions couvrant les nouvelles recommandations sur l'alimentation des enfants qui ont été adressées aux parents, et pour les questions obtenant les proportions les plus faibles, l'adaptation des messages sur l'alimentation des enfants à mettre dans la brochure a été réalisée par SpF.

Cette étude n'a pas examiné si une augmentation des connaissances résultant de la lecture de la brochure était liée à une augmentation de l'auto-efficacité et à un changement dans le comportement de nourrissage des parents et dans le comportement alimentaire des enfants.

Conclusions et perspectives

Cette thèse de doctorat visait dans un premier temps à donner un aperçu de quels étaient les besoins et pratiques des parents de jeunes enfants, et des pédiatres, en matière de communication sur l'alimentation de l'enfant, puis, à évaluer la brochure qui a été élaborée par SpF, conformément aux directives actualisées sur l'alimentation des enfants. Les résultats de quatre études, présentés dans quatre articles, ont fourni des preuves intéressantes des similitudes et des divergences entre les visions parentales et professionnelles, dont les meilleurs moyens de communiquer autour de l'alimentation des enfants et des recommandations. Les messages sur l'alimentation des enfants ont été modifiés et adaptés en fonction de la compréhension que les parents et les professionnels avaient des nouvelles recommandations. La brochure élaborée par SpF a pris en considération les résultats de nos études et est désormais accessible à la population française, depuis septembre 2021. La stratégie de communication de SpF comprend également d'autres moyens de diffusion des nouvelles recommandations sur l'alimentation des enfants (vidéos, tutoriels et sites internet spécifiques), cette stratégie prend en compte les besoins des populations vulnérables via la formulation de messages considérés comme les plus faciles à comprendre.

En examinant les résultats de manière systémique, nous pouvons conclure que le développement de comportements alimentaires sains chez les jeunes enfants est influencé par différents acteurs à différents niveaux. Les comportements des enfants sont principalement définis par les pratiques de nourrissage des parents, qui sont influencées par les conseils des professionnels de santé, qui agissent au sein du système de santé d'un pays spécifique. Le système de santé est défini par des politiques et des décisions qui sont prises au niveau politique ; ces décisions définissent, par exemple, les orientations que la prévention et la promotion de la santé pourraient prendre dans la planification des actions et des stratégies de santé publique. La communication entre les différents acteurs aux différents niveaux est essentielle pour le transfert de connaissances fondées sur des preuves afin de guider les meilleures pratiques. Les interventions de santé publique doivent être planifiées pour garantir une circulation efficace de l'information adaptée à chaque niveau, vers une augmentation des connaissances comme première étape pour l'adoption de comportements conformes aux recommandations de santé publique, dans notre cas spécifiquement sur l'alimentation des enfants.

Figure 1 .

 1 Figure 1. Adaptation of the Socio-Ecological Model from Bronfenbrenner.

Figure 2 .

 2 Figure 2. Comparative analysis by Schwartz et al. of selected complementary feeding guidelines regarding the "WHAT themes".

Figure 3 .

 3 Figure 3. Outline of the thesis project and the strategy established by Santé publique France in parallel.

Figure 4 .

 4 Figure 4. Timeline of the development of the brochure.

Figure 5 .

 5 Figure 5. Strategy to approach the recommendations in the campaign of Santé publique France.

Figure 6 .

 6 Figure 6. Overview of perspectives and considerations for future research according to some levels of the SEM model.

  Edulia is a multi-disciplinary and inter-sectorial European Training and Research Network with a global reach. The network of Edulia foresees the training of eleven early stage researchers (ESRs) in high-level skills across complementary fields through studying children's food choices. Seven beneficiaries are part of the project: four universities (University of Firenze, Wageningen University, MAPP-Aarhus University, Universidad de la República) and three research institutes (Nofima; INRAE Bourgogne-Franche-Comté; Institut Paul Bocuse Research Centre). The beneficiaries liaise with local non-academic partners from different sectors: industry (Tine, Arla, Elior, Samontana), applied research (Food & Biobased Research-WUR-FBR), marketing (Kidvertising), and the public sector (Santé public France, Norwegian Institute of Public Health, Netherlands Nutrition Centre Foundation-NC, National Food Institute of Uruguay-INDA). As part of the transnational mobility requirements of ITN projects,

  As specified above, ITN projects require the ESRs to go on secondments. My first secondment took place in May 2019 at Wageningen University. I was hosted by the group of Sensory Science in the division of Human Nutrition, department of Agrotechnology and Food Sciences. When in Wageningen I took two courses in interdisciplinary skills, I went to visit the Dutch Nutrition Centre in Den Haag, where I had the possibility to interview three professionals about nutrition guidelines and communication techniques. The other secondment took place from June 2019 to March 2020 at SpF, where I was hosted by the Nutrition and Physical activity unit under the supervision of Pauline Ducrot. When there I was part of a working group of experts in charge of formulating educational advice (based on the official French guidelines) in regards to infant and young child feeding practices. The working group met regularly with the aim of supporting SpF in formulating new recommendations intended for parents of children aged 0 to 3 years that are acceptable and easily understood, targeting all the population.

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 1 Règlement délégué (UE) 2016/127 de la Commission du 25 septembre 2015 complétant le règlement (UE) n° 609/2013 du Parlement européen et du Conseil en ce qui concerne les exigences spécifiques en matière de composition et d'information applicables aux préparations pour nourrissons et aux préparations de suite et les exigences portant sur les informations relatives à l'alimentation des nourrissons et des enfants en bas âge (Texte présentant de l'intérêt pour l'EEE) ; -Règlement délégué (UE) 2016/128 de la Commission du 25 septembre 2015 complétant le règlement (UE) n° 609/2013 du Parlement européen et du Conseil en ce qui concerne les exigences spécifiques en matière de composition et d'information applicables aux denrées alimentaires destinées à des fins médicales spéciales (Texte présentant de l'intérêt pour l'EEE).

Figure 1 .

 1 Figure 1. Adaptation of the Socio-Ecological Model from Bronfenbrenner.

  Parental feeding practices have been categorized in three groups by Vaughn and colleagues: coercive control, structure, and autonomy support practices (159). Each one of this group of practices relate to specific eating behaviors and health outcomes in children. Coercive control refers to more parent-centered feeding practices such as pressure to eat and food as rewards, resulting in increased food rejections, neophobic behaviors and lower self-regulation in children. Parents performing structure practices exert non-coercive control; they influence children behaviors via modelling and providing rules related to the feeding environment (e.g.where, when and what to eat). Modelling (categorized in structure practices) was associated with decrease in children's dietary intakes (160), whereas rules about eating (what, where, when) were increasing the possibility for the child to become a "picky" or "fussy" eater or perform "emotional eating" behaviors (161). Autonomy support practices are more open to child's exploration of the food environment, for example by involving the child in cooking activities. Structure and autonomy practices are usually more positively associated with better health outcomes and optimal children eating behaviors (159).

Figure 2 .

 2 Figure 2. Comparative analysis by Schwartz et al. of selected complementary feeding guidelines regarding the "WHAT themes" (188).

2 )

 2 To contribute to the development of communication material, dedicated to parents aimed at disseminating Public Health Guidelines (aligned with ANSES and HCSP) regarding the adoption of healthy eating behaviors in children 0-3 years old. Secondment at SpF.

Study 1 :Study 2 :Study 3 :

 123 Question: which are the practices and needs of French parents of children aged 0 to 3 years (nationally representative sample) regarding seeking the information available on child feeding and CoF? Method: quantitative study, online survey. Question: which are the attitudes, practices and needs of the pediatricians members of the French Association for Ambulatory Pediatrics (AFPA -one of the most present pediatric associations in France on a national level) regarding counselling parents on child feeding and CoF? Method: quantitative study, online survey. Question: which is the short-term effect of reading the brochure containing the new child feeding recommendations on French parents' (nationally representative sample)

  process made it possible to have a complete evaluation of the understanding of the messages by parents and HCPs/CCPs. Once the evaluation was completed and further modifications were made on the communication material, the communication campaign was launched by SpF in September 2021.

Figure 3 .

 3 Figure 3. Outline of the thesis project and the strategy established by SpF in parallel.

Figure 4 .

 4 Figure 4. Timeline of the development of the brochure.

Figure 1 .

 1 Figure 1. Levels of importance of various topics related to CoF according to French parents (n = 1001) and pediatricians (n = 301). Ranked by decreasing importance for pediatricians.

Figure 2 .

 2 Figure 2.Parental perception of the influence of each information source on their feeding practices, and degree of usage for each source. Left axis: percent of use among all respondents (n = 1001); right axis: self-perceived influence (Mean +/-SD; scale from 1 to 10) of the information source among those who reported to use that corresponding source.

  'hui, vous sentez-vous bien informé sur ce qu'un enfant de 0 à 3 ans peut manger en dehors du lait ? Q9. Today, do you feel well informed about what a child aged between 0 and 3 years old can eat apart from milk? 1. Oui, tout à fait Sentiment d'information vis-à-vis de l'alimentation des enfants de 0 à 3 ans Perceptions on information about the feeding children 0 to 3 years old 2. Oui, plutôt 3. Non, plutôt pas 4. Non, pas du tout 1. Yes, absolutely 2. Yes, rather 3. No, rather not 4. No, not at all Q10. Selon vous, l'alimentation de 0 à 3 ans (autre que le lait) est-elle importante pour la santé actuelle et future des enfants et leur croissance ? Q10. In your opinion, is the topic of feeding children aged from 0 to 3 years old (foods other than milk) important for the present and future health of children and their growth?

1

  communication tools on complementary feeding to be provided to parents? Question facultative : Avez-vous d'autres suggestions (en termes de contenu et de format) concernant les outils de communication sur la diversification alimentaire à fournir aux parents ? Optional question: Do you have any other suggestion (in terms of content and format) concerning the communication tools on complementary feeding to be provided to parents? …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …… Merci d'avoir pris le temps de remplir ce questionnaire ! Thank you for taking the time to complete this questionnaire! 3.2) How parents seek information about child feeding and what determines those seeking behaviors. Article 2 Information seeking of French parents regarding infant and young child feeding: practices, needs and determinants Sofia De Rosso 1 , Sophie Nicklaus 1 , Pauline Ducrot 2 and Camille Schwartz 1 Centre des Sciences du Goût et de l'Alimentation, AgroSup Dijon, CNRS, INRAE, Université Bourgogne Franche-Comté, F-21000 Dijon, France 2 Santé publique France, French national public health agency. F-94415 Saint-Maurice, France * Correspondence: Camille.schwartz@inrae.fr; Tel.: +33 3 80 69 35 18 Submitted 27 January 2021: Final revision received 29 June 2021: Accepted 26 July 2021 Public Health Nutrition 2021, 1-14. https://doi.org/10.1017/S1368980021003086 Abstract:

Figure 1 .

 1 Figure 1. Flowchart of the participants.

Figure 2 .

 2 Figure 2. Distributions of correct and mastered answers at T0 and T1 with median, lower and upper quartiles, out of a maximum of 30 answers in a sample of French parents (n=452) after reading a brochure regarding child feeding recommendations.

Figure 3 .

 3 Figure 3. Individual differences in frequencies of correct and mastered answers between T0 and T1.

4. 2 ) 4 Counseling 1 1

 241 How did healthcare and childcare professionals perceive the new brochure containing child feeding recommendations? Article parents about child feeding: a qualitative evaluation of French healthcare and childcare professionals' experiences and their perception of a brochure containing new recommendations Sofia De Rosso 1 , Camille Riera-Navarro 1 , Pauline Ducrot 2 , Camille Schwartz 1 , Sophie Nicklaus Centre des Sciences du Goût et de l'Alimentation, AgroSup Dijon, INRAE, Université Bourgogne Franche-Comté, Dijon, France. 2 Santé publique France, French national public health agency. Saint-Maurice, France Submitted the 28 th December 2021 at BMC Public Health Abstract:

Figure 5 .

 5 Figure 5. Strategy to approach the recommendations in the campaign of SpF 7 .

Figure 6 .

 6 Figure 6. Overview of perspectives and considerations for future research according to some levels of the SEM model.

  France depuis 2005 n'intégraient pas les dernières connaissances scientifiques relatives à l'évolution des comportements alimentaires. Notamment, les explications sur l'importance des expositions répétées, la variété alimentaire et l'introduction de textures différentes, ou la manière d'encourager l' « autorégulation » de l'appétit de l'enfant manquaient. La nécessité d'une mise à jour des directives et recommandations françaises sur l'alimentation infantile était évidente (41). En 2019 de nouvelles directives couvrant ces thèmes ont été publiées par l'ANSES et le HCSP (178, 179). Toutefois, le niveau de compréhension parentale des directives est souvent incertain, ce qui pourrait être dû à une méthode de communication inappropriée. Les nouveaux parents interagissent avec de nombreux professionnels de santé et de la petite enfance en période prénatale et postnatale. Il existe de nombreuses occasions où la discussion concernant les questions de prévention (comme les pratiques d'alimentation saines) pourrait être abordée. Des recherches antérieures ont démontré comment les interventions éducatives ciblant les parents pourraient améliorer la santé des enfants et les pratiques de DA ; nombreuses de ces interventions éducatives incluent des formations dispensées par des professionnels de la santé ou de la petite enfance (172, 173). Voyant l'opportunité qu'ils ont d'influencer les parents durant les premières années de l'enfant, les professionnels de santé devraient avoir un rôle clé dans la diffusion des nouvelles recommandations et des supports de communication associés, donc la prise en compte de leurs besoins en termes d'accompagnement aux parents est d'une importance cruciale.

4 ) 1 2

 412 Évaluer le niveau de compréhension des professionnels de santé et de la petite enfance concernant les informations (nouvelles recommandations) contenues dans la brochure pour les parents, et explorer leurs obstacles et besoins dans la communication avec les parents sur l'alimentation des enfants : Étude 4.Les quatre études ont permis la rédaction de quatre articles scientifiques dont les principaux méthodes et résultats seront résumés dans les sections suivantes de ce résumé.RésultatsArticle Les perceptions et les besoins des parents et des pédiatres français concernant l'information sur la diversification alimentaire Auteurs : Sofia De Rosso, Camille Schwartz, Pauline Ducrot and Sophie Nicklaus Article publié dans Nutrients : https://doi.org/10.3390/nu13072142 Résumé : Une diversification alimentaire (DA) appropriée est la clé de la prévention de l'obésité infantile et de la promotion de la santé à long terme. Les parents doivent être correctement informés tout au long du processus de DA. Les pédiatres ont l'occasion d'interagir avec les parents pendant la transition de la DA et d'influencer les décisions parentales en matière d'alimentation. Ils peuvent transmettre des messages de santé publique sur la nutrition aux parents. Avec la sortie des nouvelles recommandations sur l'alimentation des enfants en France en 2019, et dans la perspective de leur conversion en supports de communication officiels de santé publique, l'objectif de cette étude était d'explorer les perceptions et les besoins des parents et des pédiatres en matière d'information sur la DA. Deux enquêtes en ligne ont été préparées ; leur remplissage était anonyme et sur la base du volontariat. Les pédiatres membres de l'AFPA, l'Association française de pédiatrie ambulatoire, (n = 1402), ont été interrogés en octobre 2019 sur leurs attitudes et pratiques en matière de conseil aux parents sur la DA. Des réponses ont été obtenues pour 301 pédiatres. Par ailleurs, un échantillon national représentatif de 1001 parents, avec au moins un enfant de moins de 4 ans, a été interrogé en janvier 2020 pour connaître leurs attentes et leurs sources concernant les informations sur la DA, et plus largement l'alimentation de l'enfant de 0 à 3 ans. L'analyse des résultats a montré que l'importance de la DA pour la santé et la croissance de l'enfant est bien reconnue par tous (99% de parents et de pédiatres). Les pédiatres considèrent que conseiller les parents sur la DA est une de leurs responsabilités, 93% d'entre eux donnent toujours des conseils à ce sujet lors des consultations médicales. Les parents reconnaissent les pédiatres comme étant leur source de conseils la plus influente et aussi celle à laquelle ils font le plus confiance (parmi 81 % des parents qui se tournent vers des professionnels de santé, 46% se tournent vers des pédiatres). Cependant, seule une faible proportion de pédiatres (13%) a conscience que les parents font presque autant confiance à leur entourage lorsqu'ils recherchent des informations sur la DA. L'entourage a été globalement identifié comme source d'information par 62% des parents. Les parents commencent à se renseigner sur l'alimentation autre que le lait aux 5 mois de l'enfant. La plupart des recherches se font quand l'enfant est âgé de 6 mois à 1 an. Les pédiatres déclarent donner des informations sur la DA de manière systématique lorsque les enfants ont entre 4 et 5 mois. Les parents accordent du crédit aux informations émanant des professionnels de la petite enfance mais ont finalement peu recours à eux. Internet est une source d'information très utilisée et plébiscitée par les pédiatres comme support adéquat pour communiquer auprès des parents. Toutefois, la confiance qu'ont les parents dans les informations présentes sur Internet (incluant les sites internet, blogs, réseaux sociaux, applications) est mitigée et leur degré d'influence est moindre que celui des professionnels de santé. Les applications pour smartphones ou tablettes sont également évaluées comme un outil de communication approprié par les pédiatres, mais aucune application officielle n'existe à ce jour en France. Les supports ou document papier sont une source d'information pour presque la moitié de parents interrogés. Un tiers des parents considèrent que les conseils disponibles peuvent se contredire, ne sont pas toujours cohérents et peuvent aller jusqu'à culpabiliser les parents. Contrairement à ce que les pédiatres pensent, les parents recherchent des conseils très pratiques pour mettre en oeuvre la DA, tels que des exemples de recettes ou de menus. Cette étude donne des directions pour le secteur de la communication en santé publique afin de construire une stratégie de diffusion des nouvelles recommandations sur l'alimentation du nourrisson et de l'enfant via un matériel d'information adapté aux besoins des parents et des pédiatres. En particulier, les besoins et les perceptions des pédiatres doivent être considérés, compte tenu de l'importance que les parents leur accordent. Article Recherche d'information des parents français sur l'alimentation du nourrisson et du jeune enfant : pratiques, besoins et déterminants Auteurs : Sofia De Rosso, Sophie Nicklaus, Pauline Ducrot and Camille Schwartz Article publié dans Public Health Nutrition : https://doi.org/10.1017/S1368980021003086 Résumé : Dans le cadre d'une mise à jour des directives d'alimentation ciblant les enfants de 0 à 3 ans, cette étude visait à explorer les perceptions des parents français d'enfants de moins de 4 ans sur l'alimentation des enfants, leur sentiment d'information et si ces perceptions diffèrent selon des caractéristiques socio-démographiques sélectionnées (éducation des parents, situation financière perçue, parité, âge de l'enfant et prématurité). Le deuxième objectif était d'explorer les pratiques parentales liées aux recherches d'information sur l'alimentation des enfants et si ces pratiques diffèrent selon les caractéristiques socio-démographiques susmentionnées. L'objectif final était d'explorer les mêmes sujets chez les parents d'enfants ayant une condition médicale pouvant avoir un impact sur leur alimentation par rapport aux parents d'enfants en bonne santé. La présente étude descriptive a été menée en France sous la forme d'une enquête en ligne.

  résultats suggèrent que les parents reconnaissent les professionnels de santé comme leur source de conseils la plus influente et l'option à laquelle ils se réfèrent le plus souvent pour obtenir des informations sur l'alimentation des enfants. Cette perspective était particulièrement vraie pour les parents d'enfants plus jeunes (7,5 ± 1,5 vs. 7,5 ± 1,6), ceux ayant une meilleure situation financière (7,5 ± 1,5 vs. 7,7 ± 1,7) ou ayant un niveau d'éducation plus élevé (7,1 ± 2,0 vs. 7,8 ± 1,5). Internet était davantage utilisé et avait plus d'influence sur les parents de plus jeunes enfants, et il était davantage utilisé par les parents primipares que par les parents multipares. Notre étude confirme que les parents primipares et les parents ayant moins d'années d'éducation formelle utilisent plus souvent leur entourage comme source d'information. Les parents ont recherché des conseils pratiques pour mettre en place la DA dès l'âge de 5 mois. Selon nos résultats, la situation financière des parents n'était pas un déterminant de la source utilisée pour recueillir des informations sur l'alimentation des enfants. Néanmoins, il y avait quelques différences en ce qui concerne les sujets recherchés en fonction de la situation financière et du niveau d'éducation. Les parents ayant une situation financière plus vulnérable ont recherché plus fréquemment des informations sur les menus/recettes et moins souvent des informations sur la promotion du développement d'habitudes alimentaires saines ou l'âge approprié pour l'introduction des aliments. Ils étaient moins influencés par les professionnels de santé. Les parents ayant plus d'années d'éducation formelle reconnaissaient mieux l'importance de la DA pour la santé de leur enfant ; ils cherchaient plus souvent des informations concernant les stratégies d'alimentation et la taille des portions. Les stratégies de recherche différaient selon la parité ou l'âge de l'enfant mais pas selon la prématurité. Les parents dont l'enfant avait un problème médical affectant l'alimentation ont signalé des pratiques et des besoins légèrement différents. Par exemple, les parents d'enfants souffrant de troubles médicaux étaient plus préoccupés par le déroulement de la DA et utilisaient plus fréquemment internet (80 % contre 72 %) et les médias (37 % contre 24 %).

Article 3 Accroître 4

 34 les connaissances des parents sur l'alimentation des enfants : évaluation de l'effet des supports de communication des politiques de santé publique en France Auteurs : Sofia De Rosso, Pauline Ducrot, Claire Chabanet, Sophie Nicklaus and Camille Schwartz Article soumis à Frontiers in Public Health Résumé : Les comportements alimentaires inadaptés sont des facteurs de risque de maladies non transmissibles. Les comportements alimentaires se développent pendant l'enfance, et les parents influencent largement ce processus par leurs pratiques alimentaires. Les pratiques d'alimentation parentale conformes aux recommandations sont plus susceptibles de se transformer un meilleur état de santé de l'enfant. Du point de vue de la santé publique, il convient d'abord de déterminer si fournir aux parents des recommandations sur l'alimentation des enfants est une approche utile pour accroître les connaissances parentales. Récemment, les autorités sanitaires françaises ont élaboré une brochure reprenant les recommandations actualisées en matière d'alimentation des enfants. La présente étude vise à évaluer les effets à court terme de la lecture de cette brochure sur les connaissances parentales sur l'alimentation des enfants, en distinguant l'exactitude et la certitude des connaissances. Une brochure contenant des recommandations actualisées sur l'alimentation des enfants de 0 à 3 ans a été élaborée par SpF. Un échantillon de parents représentatif de la population française en termes de nombre d'enfants, d'âge, de milieu socioprofessionnel et de quartier d'habitation (n=400) a été ciblé pour remplir un questionnaire en ligne (T0) comprenant 30 déclarations concernant l'alimentation des enfants. Pour chaque énoncé, les parents ont indiqué si c'était vrai ou faux et dans quelle mesure ils étaient certains de leur réponse (échelle en 4 points). Après avoir reçu et lu la brochure, les mêmes parents ont rempli le même questionnaire trois semaines plus tard (T1). L'exactitude (nombre de réponses correctes) et la certitude des connaissances (nombre de réponses maîtrisées : réponses correctes données avec le degré de certitude maximal) ont été comparées à T1 vs. T0 à l'aide de tests-t appariés. L'évolution des connaissances en fonction de l'âge, de la parité et du niveau d'éducation des parents a été testée avec des modèles linéaires. Au total, 452 parents ont répondu à T0 et T1 et ont été pris en compte pour l'analyse. Entre T0 et T1, le nombre de réponses correctes (médiane 22 à 25, t (451) =17.2, p=<0,001) et de réponses maîtrisées (médiane 11 à 17, t (451) =18.8, p=<0,001) a significativement augmenté. La médiane de la différence entre T1 et T0 était plus grande pour les réponses maîtrisées que pour les réponses correctes. Aucun effet significatif des caractéristiques sociodémographiques des parents (âge, niveau d'éducation et statut de parité) n'a été trouvé sur l'évolution des connaissances entre T0 et T1. A T0, un effet de l'éducation sur la proportion de réponses maîtrisées a été observé. Les parents ayant un niveau d'éducation plus élevé avaient une moyenne significativement plus élevée de réponses maîtrisées à T0 que les parents ayant moins d'années d'éducation formelle (différence moyenne = 1,4 ; valeur t = 2,14 ; p = 0,03). Les effets d'autres caractéristiques sociodémographiques sur l'exactitude des connaissances ou le degré de certitude à T0 n'étaient pas significatifs (toutes les valeurs p > 0,05). L'exactitude des connaissances a augmenté significativement entre T0 et T1 pour toutes les questions, à l'exception des questions q6 (nouvelles textures 6-8 m), q8 (refus alimentaire), q17 (passage à la table familiale) et q23 (sel). Pour q26 (âge d'introduction des allergènes), il y a eu une augmentation significative, mais la proportion de bonnes réponses était encore faible après lecture de la brochure. Les parents étaient en moyenne très satisfaits du contenu de la brochure. Trente-deux pour cent des parents ont révélé qu'au cours des semaines précédant le remplissage du questionnaire à T1, ils avaient recherché des informations sur l'alimentation des enfants par d'autres moyens que la brochure. Parmi les parents utilisant d'autres sources, les moyens les plus populaires pour rechercher des informations étaient via Internet (en particulier les sites Web sur la garde d'enfants, 37 %), les professionnels de la santé (en particulier les pédiatres, 28 %) et l'entourage (grands-parents, 19 %, et amis, 16 %). Concernant l'auto-efficacité, une majorité de parents (98%) ont déclaré qu'ils essaieraient de suivre les conseils et recommandations contenus dans la brochure, mais pour 29% d'entre eux ce serait difficile sans le soutien de leur partenaire et de leur famille. Pour 10 % des parents, il serait difficile de suivre les recommandations si leurs amis ne suivaient pas les mêmes recommandations. Le fait que les parents suivraient les recommandations ne différait pas selon les caractéristiques sociodémographiques des parents (âge, parité, niveau d'éducation). Une brochure contenant des recommandations sur l'alimentation des enfants semble donc avoir le potentiel d'augmenter l'exactitude et, à un degré encore plus grand, la certitude des connaissances parentales, même pour les parents plus jeunes, primipares ou moins instruits. Pour les questions avec des proportions plus faibles de réponses correctes à T1, une reformulation des messages portant ces recommandations dans la brochure peut être conseillée pour améliorer leur compréhension par les parents. Article Conseiller les parents sur l'alimentation des enfants : évaluation qualitative des expériences des professionnels de santé et de la petite enfance français et leur perception d'une brochure contenant de nouvelles recommandations Auteurs : Sofia De Rosso, Camille-Riera Navarro, Pauline Ducrot, Camille Schwartz and Sophie Nicklaus Article soumis à BMC Public Health

  d'illustrations. En général, les messages étaient perçus comme étant facilement compréhensibles, mais fournir des cartes détachables à distribuer selon l'âge de l'enfant faciliterait la diffusion de l'information et pourrait être plus utile aux parents. Les professionnels de la petite enfance (en particulier en PMI) ont signalé que le manque de formation, la circulation d'informations contradictoires et les barrières linguistiques étaient des défis courants. Les professionnels ont suggéré que des textes courts avec plus de références et d'aides visuelles pourraient améliorer la brochure. Cette étude n'a pas révélé de différences importantes entre les nouvelles recommandations et les pratiques de conseil des professionnels (notamment des professionnels de santé) mais a tout de même souligné des conseils donnés par les professionnels qui pourraient être actualisés et améliorés à la lumière des nouvelles recommandations, notamment en ce qui concerne l'introduction des allergènes et de tous les types d'aliments entre quatre et six mois. Cependant, la brochure elle-même n'a pas répondu au besoin des professionnels d'expliquer certaines recommandations, car ils ont exprimé le besoin de vérifier certaines des informations euxmêmes. Les médecins généralistes et les pédiatres ont également signalé leur besoin d'obtenir plus d'informations pour répondre aux questions des parents sur les quantités de lait selon l'âge de l'enfant et sur les raisons pour lesquelles certains aliments ne sont pas recommandés aux jeunes enfants (par exemple, certains types de poisson, chocolat).

  d'un an, ceux ayant une meilleure situation financière et un niveau d'études supérieur. Cependant, les professionnels de santé ont révélé que souvent, lors des consultations, ils n'avaient pas le temps d'aborder ces sujets liés à la prévention. Ceci est confirmé par d'autres études examinant la communication médecin-patient, révélant le manque de temps comme un obstacle à la communication. Dans le chapitre 3, il a également été souligné qu'internet ; le réseau personnel des parents et les documents papier sont également des sources d'information largement utilisées.Les parents de nos études recherchaient également un soutien social (articles 2 et 3) en demandant conseil à leur réseau le plus proche (famille, amis, etc.), notamment les parents primipares ou moins instruits. Cette preuve est étayée par d'autres études examinant comment les parents obtiennent des informations pendant les premières années de l'enfant et comment la famille, les amis et les pairs peuvent influencer positivement ou négativement leurs décisions. D'après les résultats de l'article 1, les pédiatres n'étaient pas conscients de la grande utilisation que les parents faisaient de leur réseau personnel, mais les professionnels interrogés pour notre étude qualitative en étaient plus conscients.Lors de la planification d'interventions de communication en santé publique visant à influencer les comportements alimentaires des enfants, il est primordial de considérer non seulement l'influence que les parents peuvent avoir sur les comportements des enfants, mais aussi ce qui peut influencer les parents. Lorsqu'ils recherchent des conseils sur l'alimentation des enfants, les parents se tournent vers différents types de professionnels ainsi que vers leur réseau le plus proche, notamment la famille et les amis. Du point de vue de la santé publique, les professionnels de santé devraient être aidés dans la réalisation pratique leur travail, en leur fournissant des solutions qui peuvent inclure plus de temps à consacrer à la prévention primaire (y compris plus de conseils sur la nutrition). Des consultations dédiées à la prévention (individuelles ou en groupe, par exemple des formations obligatoires et gratuites pour les parents avec des professionnels de santé spécialisés dans l'alimentation des enfants) pourraient être programmées, mais ce type de stratégies nécessite le soutien des acteurs politiques, notamment financier.Des recherches supplémentaires sont nécessaires afin d'explorer quantitativement et qualitativement quel est le rôle que joue le réseau personnel des parents français dans leurs prises de décisions relatives à l'alimentation de leur enfant et dans quelle mesure le soutien de la famille faciliterait le suivi des recommandations.Comment concevoir et mettre en oeuvre une stratégie de communication en santé publique capable de tirer parti des pratiques d'alimentation des parents de manière à ce que la majorité des parents comprenne correctement les messages?Des résultats discutés au chapitre 3 (article 1), il est ressorti que, pour 35 % des pédiatres, les différentes situations économiques et culturelles des familles n'étaient pas suffisamment prises en compte dans les supports d'information et de communication existants et à disposition des parents sur l'alimentation des enfants. Ce constat a été renforcé par ce qui a été souligné au chapitre 4 (article 4), cette fois spécifiquement en relation avec la brochure testée. En effet, de l'analyse des entretiens semi-directifs, il ressort que les professionnels perçoivent la brochure SpF comme inadaptée à toutes les familles qu'ils rencontrent. En particulier, selon les professionnels interrogés, les familles de faible statut socio-économique, ou les familles de migrants ou de réfugiés pourraient avoir des difficultés à comprendre les recommandations de la brochure. Les principaux obstacles qui ont été soulignés étaient la différence de culture et de langue, suggérant le fait qu'un outil composé uniquement d'images avec un texte plus simple serait d'une plus grande utilité pour ces cibles spécifiques. Le fait que les problèmes de communication entre les parents/patients et les prestataires de soins de leurs enfants puissent influencer les résultats de santé et augmenter les disparités a déjà été abordé dans la littérature.Cela est particulièrement vrai pour les parents à faibles revenus et les parents nés à l'étranger, pour les minorités linguistiques ou pour ceux qui ont une maîtrise limitée de la langue du pays dans lequel ils ont demandé une prise en charge.Au chapitre 3 (article 1) nous avons vu que les 34 % des parents interrogés considéraient que les informations disponibles sur l'alimentation des enfants n'étaient pas toujours cohérentes et pouvaient se contredire (notamment pour les parents primipares, comme le montre l'article 2). Pour 32 % des parents, les conseils qu'ils trouvent pourraient leur faire ressentir un sentiment de culpabilité de ne pas se comporter comme recommandé. Ces résultats devraient soulever le problème de la stigmatisation et des inégalités sociales lors de la mise en oeuvre des recommandations nutritionnelles, car les personnes pourraient percevoir différemment les messages de santé.La coexistence de différentes cultures dans un même pays devrait attirer l'attention sur le développement de stratégies de prévention en santé publique capables d'inclure les minorités et les communautés de différentes ethnies. Des recherches supplémentaires sont nécessaires pour comprendre quel type de communication peut mieux répondre aux besoins d'une société mondialisée, en évitant toute forme de stigmatisation. Cette recherche peut inclure une approche qualitative destinée à explorer les besoins des différentes minorités. Concentrer l'attention sur la traduction du matériel de communication dans d'autres langues ou aider les professionnels avec des services de traduction dans les hôpitaux ou les cabinets privés peut être une stratégie pour réduire les problèmes de communication dans les établissements de santé, dans le cas particulier de la communication avec les parents concernant l'alimentation des enfants.

  Cependant, d'autres recherches sur cet aspect pourraient être intéressantes afin de consolider des preuves pour la construction d'interventions éducatives spécifiques visant à accroître les connaissances des parents sur l'alimentation des enfants, à améliorer les pratiques d'alimentation des parents et, finalement, les comportements alimentaires des enfants. Les professionnels sont-ils prêts à transmettre les messages sur l'alimentation des enfants (les recommandations) aux parents ? Du chapitre 3 (article 1), il a été souligné que 93% des pédiatres conseillent toujours les parents sur l'alimentation des enfants lors des consultations. 99% d'entre eux étaient confiants dans leur rôle de conseil aux parents sur ces questions, et 82% d'entre eux pensaient avoir suffisamment de connaissances sur la DA et l'alimentation du nourrisson. De l'analyse des entretiens (chapitre 4, article 4), il est ressorti que les professionnels de santé considéraient qu'ils n'avaient pas reçu suffisamment de formation en nutrition pendant leurs études de médecine, que la formation qu'ils avaient reçue était considérée comme dépassée et qu'elle se faisait sur une base volontaire. Ceci est confirmé dans la littérature ; en fait, souvent les médecins ne se sentent pas compétents pour donner des conseils, par exemple, sur la prise en charge de l'obésité et le risque existe que l'obésité ne soit pas diagnostiquée et par conséquent non traitée en pratique clinique. Des études récentes ont exploré l'effet d'une façon alternative d'apprendre la nutrition pour les résidents en médecine préventive ou les étudiants en médecine. Ils ont suivi des cours ou des ateliers d'éducation culinaire et nutritionnelle visant à enseigner des compétences et des connaissances pratiques ; les résultats ont été positifs, montrant des améliorations dans les connaissances nutritionnelles, la confiance dans le conseil et les compétences culinaires personnelles qui pourraient être récemment transmises aux patients. Cette méthode pourrait être une approche prometteuse également pour des formations spécifiques sur l'alimentation des enfants. Cela pourrait permettre aux pédiatres et autres professionnels chargés de conseiller les parents sur l'alimentation des enfants d'augmenter, par exemple, leur motivation à promouvoir le respect des directives de santé publique en matière d'alimentation.

Table 1 .

 1 Main risk factors in the first 1000 days for the development of childhood obesity.

Table 2 .

 2 List of the 20 mandatory medical check-ups from 0 to 16 years of age to check child growth, development and vaccination in France.

Table 3 .

 3 Professional figures working (in France) in collective day-care facilities and their related duties.

Table 4 .

 4 Summary of the activities of the CAT of Santé publique France according to the different meetings.

Table 2

 2

) (171). Previous research demonstrated how education interventions targeting parents could enhance children's health and improve CoF practices; many of these education interventions include trainings given by healthcare or childcare professionals (172, 173). Considering the opportunity that they have to influence parents during the earliest years of the child, healthcare professionals should have a key role in the dissemination of the new recommendations regarding child feeding and related communication material, therefore considering their needs in terms of the most adapted communication supports and required content is paramount.

Table 2 .

 2 List of the 20 mandatory medical check-ups from 0 to 16 years of age to check child growth, development and vaccination.

15 medical check-ups between 0-3 years of age 5 medical check-ups after 3 years of age

	1) Within 8 days after birth	16) At 4 years
	2) During the 2 nd week of life	17) At 5 years
	3) Before 1 month of age	18) Between 8 and 9 years
	4) At 1 month	19) Between 11 and 13 years
	5) At 2 months	20) Between 15 and 16 years
	6) At 3 months
	7) At 4 months
	8) At 5 months
	9) At 8 months
	10) At 11 months
	11) At 12 months
	12) Between 16 and 18 months
	13) Between 23 and 24 months
	14) At 2 years
	15) At 3 years

  The United Nations' Food and Agriculture Organization (FAO) has a specific definition of the "Food Based Dietary Guidelines (FBDG)". The FBDG are short scientific-based, practical and accessible messages that may help consumers to make healthy dietary choices and to adopt healthy lifestyles, while keeping them well-nourished. The FBDG are adapted to specific nutritional, geographical, economic and cultural conditions (177).For the purpose of this thesis an operational distinction has been made between guidelines and recommendations. Guidelines are identified as the content of the National Agency for Food,

According to the WHO (176): "A guideline is any document containing recommendations about health interventions, whether these are clinical, public health or policy recommendations. A recommendation provides information about what policy-makers, health-care providers or patients should do. It implies a choice between different interventions that have an impact on health and that have implications for the use of resources. Guidelines are recommendations intended to assist providers and recipients of health care and other stakeholders to make informed decisions".

Environmental and Occupational Health Safety (ANSES -Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement et du travail) and High Council of Public Health (HCSP -Haut Conseil de la santé publique) reports (178, 179), whereas recommendations relate to the advice that is directly addressed to the population, giving an indication on how to apply official public health guidelines. Therefore, when talking about recommendations in this document it is meant the reformulations of the guidelines, that are the messages contained in the communication material developed by the official French public health agency (SpF).

  ). Examples of interventions that are able to change the environment, and are effective in pursuing long lasting behavior changes, are community-based interventions.

	Community-based interventions are widely used in health promotion, they employ various
	interventions at different levels (individual, families, public policy) and have the potential to
	change the social environment toward behavioral changes (218). For example, in France, the
	program EPODE was implemented with the final aim of preventing childhood obesity, and it
	serves now as a model for other countries (219). This program is seen as an innovative
	methodology that enables the entire community (teachers, school catering, health professionals,
	parents, media, urban environment…) to create a healthy environment able to facilitate social
	change and best practice in relation to nutrition and physical activity. This multidisciplinary
	approach aims at changing the environment, behaviors and social norms with the involvement
	of all sectors (public, private) (220). However, differently from what can be done with health
	communication campaigns, community-based interventions are not implemented at national
	level, but in specific areas or they are addressed to specific sub-groups of the population
	(communities).

Table 4 .

 4 Summary of the activities of the CAT according to the different meetings.

	participants there were: one pediatrician, one general practitioner, two physicians working in
	maternal and child protection centers (PMI centers: protection maternelle infantile), one
	nursery director, two pediatric nurses (one working in PMI center), one pediatric nutritionist,
	one researcher expert in children's eating behavior (working at INRAE), and myself (PhD
	student in Public Health with background in nutritional epidemiology and previous working
	experience in public health communication).
	The CAT could meet eight times, four meetings could be held in person in the offices of
	SpF, whereas the other four meetings were held by phone (or videoconference), seeing the
	restrictions imposed by the sanitary emergency linked to the spread of the Sars-Cov-2 virus.
	Table 4 summarizes the agenda of the CAT for each of the meeting and the activities performed
	in line with the points on the agenda.
	Date

of the meeting Agenda Activities of the group

	CAT 1	Introduction of all the participants and	Discussion on the presentation of previous SpF
	04/11/2019	presentations by SpF and myself	activities on adults' recommendations, the Edulia
		(thesis project)	project, my thesis and results of study 1 (with
			pediatricians)
	CAT 2	Critical review of communication	A grid allowing to identify the positive and
	09/12/2019	material on CoF from France and other	negative points was completed by the members of
		countries (paper supports, video,	the CAT for each of the supports proposed by SpF
		websites)
	CAT 3	Reflection on the type of support and	Work in sub-groups for the choice of themes and
	14/01/2020	channels to spread recommendations	type of support and propositions
	CAT 4	Choice of themes and type of support	Prioritization of the themes to be treated
	07/02/2020	(multipage paper brochure as first	according to the critical review of the selected
		support to be developed)	recommendations and video supports carried out
			by the CAT → reach of a consensus
	CAT 5	Presentation of the first draft of the	Discussion on some points regarding the content
	23/06/2020	multipage paper brochure prepared by	and the way advice is formulated or illustrated by
		SpF	examples in the brochure
	CAT 6	Discussion of new recommendations	Agreement on how the recommendations would
	16/09/2020	of the HCSP report, SpF presents the	be addressed and reported in the brochure
		pretests guide for the focus groups
	CAT 7	Discussion portion size/age, table of	Finalization of the content of the brochure and
	12/10/2020	introduction of foods, menus	agreement on the discussed points
	CAT 8	Presentation of the results of the	Discussion on the presented results, brainstorming
	01/06/2021	pretests by SpF (focus groups) and	of tools more adapted to HCPs and CCPs and how
		study 3 (knowledge parents) by	to improve the communication strategy
		myself, presentation of the whole
		communication strategy for the child
		feeding recommendations

Table 1 .

 1 Characteristics of French parents and pediatricians who responded to the survey.

	Parents (N = 1001)		Pediatricians (N = 301)
	Characteristics	N (%)	Characteristics	N (%)
					≤30 years old	12 (4)
	Age	Less than 35 years old 604 (60)	Age	31-40 years old 41-50 years old	(26) (15)
					51-60 years old	(25)
		35 years old and more 397 (40)		≥61 years old	(30)
		<12 months	277 (28)		0-10 years	(26)
	Age of the youngest	12-23 months	260 (26)	Years of working	11-20 years	(19)
	child	24-35 months	260 (26)	experience	21-30 years	(25)
		≥36 months	204 (20)		More than 30 years (30)
	Gender	Men Women	198 (20) 803 (80)	Gender	Men Women	(20) 241 (80)
	Parity	Primiparous Multiparous	388 (39) 613 (61)	Having children	Yes No	260 (86) (14)
	Education level 1	<A level ≥A level	179 (18) 822 (82)	Working area	Rural Urban	(10) 272 (90)
	Socio-professional	High	456 (46)
	category of the household reference parent 2	Low No occupation/retired 44 (4) 501 (50)	/	/	/
	Self-perception of	Good	457 (46)
	household financial	Difficult	535 (53)	/	/	/
	situation 3	No answer	9

Table 2 .

 2 The appropriate means to receive CoF information according to parents (N = 1001).

	Parents (N = 1001)

Z1. Êtes-vous : Z1. Are you :

	1. Un homme
	2. Une femme
	1. A man
	2. A woman
	Z2. Quel est votre âge ?
	Z2. How old are you?
	/__/__/ ans
	/__/__/ years old

Supplement Material 1. Parents' original questionnaire with English translation in blue. Z9. Combien d'enfants avez-vous ? Z9. How many children do you have? Si vous n'en avez pas, indiquer 0 If you do not have any child write 0 /__/__/ enfant(s) /__/__/ children Z10. Précisément quel est le mois et l'année de naissance ainsi que le sexe de chacun de vos enfants ? Z10. Precisely which is the month and year of birth as well as the sex of each of your children? a) 1er enfant : Mois : /__/__/ Année /__/__/__/__/ sexe : 1. Homme 2. Femme b) 2ème enfant : Mois : /__/__/ Année /__/__/__/__/ sexe : 1. Homme 2. Femme c) 3ème enfant : Mois : /__/__/ Année /__/__/__/__/ sexe : 1. Homme 2. Femme d) … a) 1st child: Month: / __ / __ / Year / __ / __ / __ / __ / sex: 1. Male 2. Female b) 2nd child: Month: / __ / __ / Year / __ / __ / __ / __ / sex: 1. Male 2. Female c) 3rd child: Month: / __ / __ / Year / __ / __ / __ / __ / sex: 1. Male 2. Female d)… Z0a. Merci d'indiquer le code postal de votre commune Z0a. Please indicate the zip code of your municipality /__/__/__/__/__/ Enquête

sur les parents de jeunes enfants et la diversification alimentaire Questionnaire Survey on parents of young children and complementary feeding Questionnaire Renseignements signalétiques/quotas Identifying information/quotas Z0b. Dans quelle commune habitez-vous ? Z0b. In which municipality do you live? Z3. En ce moment, quelle est votre activité principale ? Z3. Cuurently what is your main activity?

	1.	Salarié du secteur privé
	2.	Salarié d'une entreprise publique ou nationale
	3.

Quelle est votre profession, votre catégorie socio-professionnelle ? Z3b. What is your profession, your socio-professional category? Z3b. Avant d'être au chômage, quelle était votre dernière profession, votre dernière catégorie socio-professionnelle ? Z3b. Before being unemployed, what was your last occupation, your last socio-professional

	7.	Retired
	8.	stay at home mother/father
	9.	Student
	10.	In another situation
	Z3a. Actuellement, travaillez-vous à…
	Z3a. Currently, do you work…
		1. Temps complet
		2. Temps partiel
		1. Full-time
		2. Part-time
	Z3b. category?
	1.	Agriculteur exploitant
	2.

De combien de personnes se compose votre foyer, vous y compris ? Z6. How many people live in your household, including yourself?

	9.	Employee
	10.	Service staff
	11.	Worker / Agricultural worker
	12.	Retired
	13.	Pupil / student
	14.	Other inactive
	Z6. 1.	1 personne
	2.	2 personnes
	3.	3 personnes
	4.	4 personnes
	5.	5 personnes
	6.	6 personnes
	7.	7 personnes
	8.	8 personnes
	9.	9 personnes ou plus
	1.	1 person
	2.	2 people
	3.	3 people
	4.	4 people
	5.	5 people
	6.	6 people
	7.	7 people
	8.	8 people
	9.	9 people or more
		, supervisor, paramedical profession, technician
	8.	Teacher

Cette enquête concerne principalement VOTRE ENFANT LE PLUS JEUNE. Merci de bien lire attentivement toutes les questions et d'en tenir compte lorsque vous répondez. This survey is primarily about YOUR YOUNGEST CHILD. Please carefully read all questions and take them into account when answering. Q1. Votre plus jeune enfant est né… Q1. Your youngest child was born ...

	1. À terme (accouchement à 37 semaines ou plus)
	2. Prématuré (accouchement à 36 semaines ou moins)
	1. At term (delivery at 37 weeks or more)
	2. Premature (delivery at 36 weeks or less)
	Q2.

Votre plus jeune enfant a-t-il été allaité au sein (tire-lait inclus) ? Q2

. Was your youngest child breastfed (including fed from pumped breastmilk)? 1. Oui 2. Non

Vécu et comportements avec l'enfant le plus jeune Feeding behavior related to the youngest child

	1. Yes
	2. No
	Q3.

Combien de temps a-t-il été allaité au sein (tire-lait inclus) ? Q3. How long has he been breastfed (including fed from pumped breastmilk )?

	1. /__/ jours
	2. /__/ semaines
	3. /__/ mois
	4. Je ne sais pas
	1. /__/ days
	2. /__/ weeks
	3. /__/ months
	4. I do not know
	Q4. Est-

ce que votre plus jeune enfant a commencé à manger des aliments autres que le lait ? Q4. Has your youngest child started to eat foods other than milk?

	1. Oui
	2. Non
	1. Yes
	2. No
	Q5.

Actuellement, à quelle fréquence donnez-vous à votre plus jeune enfant… Q5

	1. Systématiquement
	2. Souvent
	3. De temps en temps
	4. Jamais
	a) commercial baby food?
	b) any homemade dishes or small pots that you have cooked?
	1. Systematically
	2. Often
	3. From time to time
	4. Never
	Q6.

. Currently, how often do you give to your youngest child ... a) des plats ou petits pots pour bébé achetés dans le commerce ? b) des plats ou des petits pots maison que vous avez cuisinés ?

Depuis la naissance de votre plus jeune enfant, lors de rendez-vous médicaux habituels avec des professionnels de santé (pédiatre, médecin, infirmier…), vous ont-ils donné spontanément des conseils sur l'alimentation de votre enfant (aliments autre que le lait) dont la diversification alimentaire

?

La diversification alimentaire est la période pendant laquelle des aliments autres que le lait sont progressivement introduits dans l'alimentation d'un enfant Q6.

elle importante pour que les enfants aient ensuite de bonnes habitudes alimentaires ? Q11. In your opinion, is the topic of feeding children aged from 0 to 3 years old (foods other than milk), important for children to develop healthy eating habits afterwards

	1. Très importante
	2. Plutôt importante
	3. Plutôt pas importante
	4. Pas du tout importante
	1. Very important
	2. Rather important
	3. Rather not important
	4. Not at all important
	?
	1. Très importante
	2. Plutôt importante
	3. Plutôt pas importante
	4. Pas du tout importante
	1. Very important
	2. Rather important
	3. Rather not important
	4. Not at all important
	Q12. Globalement,

Q11. Selon vous, l'alimentation de 0 à 3 ans (autre que le lait) est-

êtes-vous satisfait des informations sur l'alimentation de 0 à 3 ans (autre que le lait) dont la diversification alimentaire, que vous avez à votre disposition ?

  La diversification alimentaire est la période pendant laquelle des aliments autres que le lait sont progressivement introduits dans l'alimentation d'un enfant Q12.

Overall, are you satisfied with the information on feeding children aged from 0 to 3 years old (foods other than milk), including complementary feeding, that you have at your disposal?

	3. Rather not satisfied
	4. Not at all satisfied
	Q13.
	Complementary feeding is the period during which foods other than milk are gradually introduced into
	a child's diet
	1. Très satisfait
	2. Plutôt satisfait
	3. Plutôt pas satisfait
	4. Pas du tout satisfait
	1. Very satisfied
	2. Somewhat satisfied

Et globalement concernant l'alimentation de 0 à 3 ans (autre que le lait) dont la diversification alimentaire, diriez-vous que les informations et conseils que vous avez à votre disposition sur ce sujet…

  La diversification alimentaire est la période pendant laquelle des aliments autres que le lait sont progressivement introduits dans l'alimentation d'un enfant Q13.

And generally concerning the topic of feeding children aged from 0 to 3 years old (foods other than milk), would you say that the information and advice you have at your disposal on this subject ...

	Complementary feeding is the period during which foods other than milk are gradually introduced into
	a child's diet
	a) Répondent à vos questions
	b) Sont clairs, faciles à comprendre
	c) Sont faciles à mettre en pratique pour votre enfant
	d) Se contredisent, ne sont pas cohérents entre eux
	e) Sont culpabilisants pour les parents
	1. Oui, tout à fait
	2. Oui, plutôt
	3. Non, plutôt pas
	4. Non, pas du tout
	a) Answer to your questions
	b) Are clear, easy to understand
	c) Are easy to put into practice for your child
	d) Contradict each other, are not consistent with each other
	e) Are guilty-laden for parents
	1. Yes, absolutely
	2. Yes, rather
	3. No, rather not
	4. No, not at all

Q14. Êtes-vous d'accord ou non avec les affirmations suivantes concernant la diversification alimentaire ?

  La diversification alimentaire est la période pendant laquelle des aliments autres que le lait sont progressivement introduits dans l'alimentation d'un enfant Q14.

Do you agree or disagree with the following statements about complementary feeding?

  Complementary feeding for my youngest child is or was a source of concern (only for multiparous) c) Complementary feeding for my youngest child is going well or has gone well d) Complementary feeding is easier for my last child than for my first child 1.

	b) Strongly agree
	2. Tend to agree
	3. Tend to disagree
	4. Strongly disagree
	Q15. Au
	Complementary feeding is the period during which foods other than milk are gradually introduced into
	a child's diet
	a) Il est facile de trouver des informations concernant la diversification alimentaire
	b) La diversification alimentaire de mon plus jeune enfant est ou a été source d'inquiétude
	c) La diversification alimentaire pour mon plus jeune enfant se passe bien ou s'est bien passée
	d) La diversification alimentaire est plus facile pour mon dernier enfant que pour le premier
	1. Tout à fait d'accord
	2. Plutôt d'accord
	3. Plutôt pas d'accord
	4. Pas du tout d'accord
	a) It is easy to find information about complementary feeding

cours des 12 derniers mois, par quels moyens avez-vous eu des informations sur l'alimentation de votre plus jeune enfant (alimentation autre que le lait) ? Plusieurs réponses possibles Q15. During the past 12 months, how did you learn about the topic of feeding children aged from 0 to 3 years old (foods other than milk)?

	Professionnel de la petite enfance
	23. Personnel de PMI ou d'établissement d'accueil de jeunes enfants (crèche, accueil collectif…)
	24. Assistante maternelle
	25. Autre moyen, précisez : ____________________
	Media
	1. Television
	2. Radio Sources d'informations et recherche Paper support or document Sources of information 3. Written press, newspapers, magazines
	4. Books
	Internet, social networks or smartphone applications
	5. Parents' blog or forum
	6. Smartphone application
	Several answers are possible Média 1. Télévision 2. Radio Support ou document papier 3. Presse écrite, journaux, magazines 4. Livres Internet, réseaux sociaux ou applications smartphone 5. Blog ou forum de parents 6. Application pour smartphone 7. Parental network
	7. Site internet d'industriel ou fabricant d'aliments pour bébé (bledina, nestlé, babybio, hipp, 14. My friends
	goodgout…) 15. My parents
	8. Site internet spécialisé dans la petite enfance (parents.fr, magicmaman.com…) 16. My grandparents
	9. Site internet dédié à la santé (doctissimo.fr, santémagazine.fr, topsanté.com, 17. Another family member
	passeportsanté.net…) Health professional
	10. Site internet d'une autorité de santé (ameli.fr, mangerbouger.fr, santépubliquefrance.fr, 18. General practitioner
	santé.gouv.fr, santé.fr…) 19. Pediatrician
	11. Site internet d'une mutuelle ou d'une assurance (lamutuellegenerale.fr, mutualite.fr, 20. Nurse, childcare worker
	axaprevention.fr, harmonie-mutuelle.fr, interiale.fr…) 21. Dietitian
	12. Réseaux sociaux (facebook, instagram, twitter, youtube, whatsapp…) 22. Midwife
	13. Autre site internet Early childhood professional
	Entourage 23. Staff of PMI or establishment for the reception of young children (crèche, collective reception,
	14. Mes amis etc.)
	15. Mes parents 24. Maternal assistant
	16. Mes grands-parents
	17. Un autre membre de la famille 25. Other means, specify: ____________________
	Professionnel de santé
	18. Médecin généraliste Q16. Sur quel(s) réseau(x)
	19. Pédiatre
	20. Infirmier(ère), puériculteur(trice)
	21. Diététicien(ne)
	22. Sage-femme

Industrial or baby food manufacturer's website (bledina, nestlé, babybio, hipp, goodgout, etc.) 8. Website specializing in early childhood (parents.fr, magicmaman.com…) 9. Internet site dedicated to health (doctissimo.fr, santémagazine.fr, topsanté.com, passportsanté.net, etc.) 10. Website of a health authority (ameli.fr, mangerbouger.fr, santépubliquefrance.fr, santé.gouv.fr, santé.fr, etc.) 11. Website of a mutual or insurance company (lamutuellegenerale.fr, mutualite.fr, axaprevention.fr, harmonie-mutuelle.fr, interiale.fr ...) 12. Social networks (facebook, instagram, twitter, youtube, whatsapp…) 13. Other website

social(ux) vous êtes-vous informé concernant l'alimentation de votre plus jeune enfant (aliments autres que le lait) ? Plusieurs réponses possibles Q16. On which social network(s) did you learn about the topic of feeding children aged from 0 to 3 years old (foods other than milk) for your youngest child?

	It is possible to give more than one answer
	1. Facebook
	2. Instagram
	3. Twitter
	4. Youtube
	5. Whatsapp
	6. Autre
	Q17. Vous arrive-t-

il de partager sur les réseaux sociaux, sur des blogs ou des forums, des informations sur l'alimentation de l'enfant de 0 à 3 ans que vous trouviez utiles ? Q17. Do you ever share on social media, blogs or forums information that you find useful about feeding children aged from 0 to 3 years old (foods other than milk)?

	1. Très souvent
	2. Souvent
	3. De temps en temps
	4. Jamais
	1. Very often
	2. Often
	3. From time to time
	4. Never
	Q18.

Pour chacune de vos sources d'information, indiquez sur une échelle de 1 à 10 dans quelle mesure elles ont influencé vos décisions sur la façon de nourrir votre plus jeune enfant au cours des 12 derniers mois.

	1 signifie qu'elle n'a pas du tout influencé vos décisions et 10 signifie qu'elle a très fortement influencé
	vos décisions. Les notes intermédiaires permettent de nuancer votre jugement.
	Q18.

For each of the source of information you have used, rate on a scale of 1 to 10 how much it influenced your decisions about how to feed your youngest child during the past 12 months. 1

  means it did not influence your decisions at all and 10 means it very strongly influenced your decisions. The intermediate points of the scale allow you to qualify your judgment.

	1	2	3	4	5	6	7	8	9	10
	It did not influence my									It has influenced my
	decisions at all									decisions very strongly
	1	2	3	4	5	6	7	8	9	10
	Q19. Vous
	a) La télévision ou la radio
	b) Les supports ou documents papier comme la presse écrite, les journaux, les magazines ou les
	livres
	c) Internet, réseaux sociaux ou applications smartphone
	d) L'entourage
	e) Les professionnels de santé
	f) Les professionnels de la petite enfance
	a) Television or radio
	b) Media or paper documents such as the written press, newspapers, magazines or books
	c) Internet, social networks or smartphone applications
	d) Parental network
	e) Health care professionals
	f) Early childhood professionals
	N'a pas du tout influencé									A très fortement influencé
	mes décisions									mes décisions

est-il arrivé de chercher des informations concernant l'alimentation des enfants de 0 à 3 ans (autre que le lait) pour votre enfant ? Q19. Have you ever looked for information about the topic of feeding children aged from 0 to 3 years old (foods other than milk) for your child?

	1. Oui
	2. Non
	1. Yes
	2. No
	Q20.

Quel âge avait votre plus jeune enfant lorsque vous avez commencé à chercher des informations sur l'alimentation autre que le lait ?

	S'il avait moins d'1 mois, indiquer 0
	Q20.

How old was your youngest child when you first started looking for information about food other than milk?

	If he was less than 1 month old, enter 0
	/__/__/ mois
	/__/__/ months
	Q21.

Pour avoir une information fiable sur l'alimentation des enfants de 0 à 3 ans (autre que le lait), faites-vous personnellement confiance ou non… Q21. To have reliable information on the topic of feeding children aged from 0 to 3 years old (foods other than milk), do you personally trust or not ...

	a) Aux médias comme la télévision, la radio ou la presse écrite
	b) Aux livres dédiés à la petite enfance
	c) À Internet
	d) Aux réseaux sociaux, blogs ou forums de parents
	e) Aux autorités de santé ou pouvoirs publics
	f) Aux industriels ou fabricants de produits alimentaires pour jeunes enfants
	g) Aux professionnels de santé (médecin, pédiatre, infirmière, sage-femme…)
	h) Aux professionnels de la petite enfance (personnel de PMI ou d'établissement d'accueil des jeunes
	enfants, assistante maternelle…)
	1. Tout à fait confiance
	2. Plutôt confiance
	3. Plutôt pas confiance
	4. Pas du tout confiance
	a) Media such as television, radio or the written press
	b) Books dedicated to early childhood / parenting
	c) Internet

Confiance dans les sources d'informations Trust in sources of information

	d) Social networks, blogs or parent forums
	e) Public health authorities
	f) Manufacturers of food products for young children
	g) Health care professionals (doctor, pediatrician, nurse, midwife, etc.)
	h) Early childhood professionals (staff from PMI or childcare facilities, childminders, etc.)
	1. Complete trust
	2. Somewhat trust
	3. Tend not to trust
	4. Not trust at all
	Q22. Quels types d'

informations sur l'alimentation des enfants de 0 à 3 ans (autre que le lait) et la diversification alimentaire vous seraient particulièrement utiles pour votre enfant le plus jeune ? 5 réponses maximum Q22. Which kinds of information about the topic of feeding children aged from 0 to 3 years old (foods other than milk) and complementary feeding would be particularly useful for your youngest child

? 5 answers maximum 1. Âge d'introduction des premiers aliments autres que le lait 2. Âge d'introduction des différents groupes d'aliments 3. Âge et modalités d'introduction des premiers morceaux d'aliments 4. Comment donner ou présenter les aliments en cas de refus 5. Quantités et tailles des portions à proposer à l'enfant 6. Stratégies alimentaires en cas de « petit appétit » de l'enfant 7. Stratégies alimentaires en cas de « gros appétit » de l'enfant 8. Comment interpréter les signaux de l'enfant lorsqu'il mange ou refuse de manger 9. Comment nourrir un enfant pour favoriser le développement d'habitudes alimentaires saines 10. Exemples de recettes 11. Exemples de menus 12. Adaptation de la quantité de lait à l'introduction des autres aliments 13. Autres informations, précisez :_________ Q23.

Pour vous, quels types de supports sont les plus adaptés pour avoir des informations sur l'alimentation des enfants de 0 à 3 ans (autre que le lait) dont la diversification alimentaire ? 3 réponses maximum Q23. For you, which types of media are the most suitable for obtaining information on the topic of feeding children aged from 0 to 3 years old (foods other than milk), including complementary

	feeding?
	3 answers maximum
	1. Une brochure papier d'1 page
	2. Un livret papier de plusieurs pages
	3. Un site internet
	4. Une application pour smartphone
	5. Un espace interactif sur internet avec la possibilité de poser des questions (chat, blog, forum,
	post de témoignage…)
	6. Autre, précisez :_________
	1. A 1-page paper brochure
	2. A paper booklet of several pages
	3. A website
	4. A smartphone application
	5. An interactive space on the internet with the possibility of asking questions (chat, blog, forum,
	testimonial post, etc.)
	6. Other, specify: _________
	Q24.

Êtes-vous né en France ? Q24. Were you born in France?

	1. Oui
	2. Non
	1. Yes
	2. No
	Q25.

Depuis combien de temps habitez-vous en France ?

	Si vous habitez en France depuis moins d'un an, indiquez 0
	Q25. How long have you lived in France?
	If you have lived in France for less than a year, enter 0
	/__/__/ ans
	/__/__/ years
	Q26. Le français est-il votre langue maternelle ?
	Q26. Is French your mother tongue?
	1. Oui
	2. Non
	1. Yes
	2. No
	Q27.

Quel est le diplôme le plus élevé que vous ayez obtenu ? Autres renseignements signalétiques Other socio demographic information Supplemental Material 2.

  Pediatricians' original questionnaire with English translation in blue.Dans le cadre d'un programme de recherche mené par l'INRA, ce questionnaire a pour objectif de décrire la manière dont les professionnels de santé abordent la diversification alimentaire avec les parents. Ce sondage ne devrait vous prendre que 15 minutes. Vos réponses seront anonymes et votre participation est entièrement libre. D'avance, nous vous remercions de votre aide.

	Professionnels de santé
	« La diversification alimentaire »
	Healthcare professionals
	"Complementary feeding"

Vos pratiques actuelles en matière de communication avec les parents 3. Your current communication practices with parents

  Indiquez dans quelle mesure vous êtes d'accord avec les affirmations suivantesIndicate the extent to which you agree with the following statements 3.8 Je suis satisfait des documents sur la diversification alimentaire dont je dispose. Concernant les informations à transmettre aux parents à propos de la diversification alimentaire, merci de cocher si les sujets sont très importants ou moins importants selon vous.

	2.6 Je pense que les parents veulent plus d'informations	Other (please specify) Totally agree Tout à fait d'accord (professional journals, professional Research institutes / Universities 9 months 12 months Associations Pas du tout d'accord
	………………………………… Agree D'accord websites, newsletters, etc.) 2.11 Hiérarchiser les freins pour donner des conseils aux parents sur la diversification alimentaire sur la diversification alimentaire que ce que je suis 16 months 20 months Je crée mes propres documents I think that the documents that I give to parents Totally agree
	1.2 Depuis combien d'années exercez-vous cette profession en mesure de leur fournir. listés ci-dessous du plus contraignant au moins contraignant Neither disagree nor agree 0-10 ans Ni en désaccord, ni d'accord Public health brochures (Public 24 months 30 months Autre (veuillez préciser) make it possible to take into account the cultural Agree
	? and / or financial differences specific to each -le manque de temps	11-20 ans Disagree Pas d'accord Health France, ARS, IREPS, etc.) 36 months ………………………………….. Neither disagree nor agree
	I think parents want more information on -mes compétences en conseil 3.4 Avec qui discutez-vous de la diversification family.		21-30 ans Strongly disagree Pas du tout d'accord Brochures from manufacturers of Mère Père Public health France Disagree
	Since how many years have you practiced this 2.2 La diversification alimentaire est une étape complementary feeding than what I can provide -le manque d'intérêt de certains parents alimentaire le plus souvent ?		>30 ans Tout à fait d'accord Totally agree baby milk or food Autres membres de la famille PNNS Strongly disagree
	profession? importante pour le développement équilibré des them with. -le manque de matériel de communication approprié D'accord 0-10 years Agree Events organized by manufacturers (plusieurs réponses possibles) (veuillez préciser) ARS
	nourrissons. 4. Nouveaux plans et suggestions	11-20 years Ni en désaccord, ni d'accord Neither disagree nor agree of milk or baby food ………………………………….. IREPS
	21-30 years Pas d'accord Disagree Nutrition blogs, other nutrition Prioritize the obstacles to give advice to parents on complementary feeding listed below Who do you the most often discuss Mother Father CAF 4. New plans and suggestions
	Complementary feeding is an important step for the from the most restrictive to the least restrictive complementary feeding with?		>30 years Pas du tout d'accord Strongly disagree network sites Other family members (please Pediatric societies (French Society of
	1.3 Quel âge avez-vous ? How old are you? balanced development of infants. 2.7 Je pense avoir suffisamment de connaissances sur la nutrition infantile et la diversification alimentaire. I think I have enough knowledge about infant -lack of time (multiple answers allowed) Pediatrics, Association of Outpatient ≤ 30 ans 31-40 ans 41-50 ans 51-60 ans Totally agree Agree Neither disagree nor agree Disagree Tout à fait d'accord D'accord Ni en désaccord, ni d'accord Pas d'accord General media (radio, television, newspapers, magazines) Discussions with colleagues Other (please specify) 4.1 Hiérarchiser les caractéristiques suivantes de la Le matériel que je donne devrait être : specify) -my consulting skills ………………………………… .. plus importante à la moins importante pour des Clair Pediatrics, French Society of Nutrition, -the lack of interest of some parents -lack of appropriate communication material 3.5 De quelle manière abordez-vous la diversification alimentaire ? Academy of Medicine, other) documents à destination des parents afin Synthétique En discutant En remettant des documents Milk and baby food manufacturers d'attirer leur attention sur la diversification Détaillé
	1. Données démographiques 1.4 Êtes-vous... ? Are you…? 1.5 Où travaillez-vous ? 2.3 La diversification alimentaire est une étape importante pour l'acquisition de bonnes habitudes alimentaires chez les nourrissons. Complementary feeding is an important step in the acquisition of healthy eating habits in infants. nutrition and complementary feeding. 2.8 Au cours des dernières années, avez-vous acquis de nouvelles connaissances sur la diversification alimentaire ? Over the past years, did you acquire new knowledge 2.10 Parmi les propositions suivantes, quelles sont selon vous les organismes chargés de formuler les recommandations officielles concernant la diversification alimentaire ? Among the following propositions, which organizations do you think are responsible for formulating official recommendations concerning complementary feeding? (plusieurs réponses possibles) alimentaire. 3. 3.1 Sur l'ensemble de vos consultations/RDV avec des parents de jeunes enfants (0-3 ans), à quelle fréquence conseillez-vous les parents sur la diversification alimentaire ? Over all of your consultations / appointments with parents of young children (0-3 years old), how often do you advise parents on How do you approach the topic of complementary feeding? (multiple answers allowed) (e.g. breast pump) ≥ 61 ans ≤ 30 years old 31-40 years old 41-50 years old 51-60 years old ≥ 61 years old un homme une femme man woman zone urbaine Strongly disagree Tout à fait d'accord D'accord Ni en désaccord, ni d'accord Pas d'accord Pas du tout d'accord Totally agree Agree Neither disagree nor agree Disagree Strongly disagree Pas du tout d'accord Totally agree Agree Neither disagree nor agree Disagree Strongly disagree Oui Non Yes No ………………………………… .. Santé publique France Sociétés savantes (Société française de Pédiatrie, Association de Pédiatrie Ambulatoire, Société Française de Nutrition, Académie de Médecine, autre) ARS (Agence régionale de santé) / IREPS (Instance régionale d'Education et de Promotion de la Santé) En conseillant des sites internet Manufacturers of childcare equipment Axé sur les aspects pratiques Jamais Uniquement si j'identifie que cela est En m'appuyant sur le carnet de santé Autre (veuillez préciser) By discussing By handing over documents By advising websites Facile à consulter Prioritize the following characteristics from the Illustré General Council most important to the least important for The material I donate should be: Associations documents intended for parents in order to draw Clear I create my own documents Other (please specify) their attention to complementary feeding. Synthetic nécessaire By relying on the health notebook ………………………………… .. Detailed Toujours Other (please specify) Focused on practical aspects Never Only if I identify that it is necessary 3.6 À quelle fréquence donnez-vous des documents concernant la diversification alimentaire aux Easy to consult Jamais Rarement Tout à fait d'accord Illustrated Always parents ? Parfois D'accord 4.2
	1. Demographic data 2.4 Conseiller les parents sur la diversification regarding complementary feeding? complementary feeding?		zone rurale Tout à fait d'accord ANSES (Agence nationale de Souvent Ni en désaccord ni d'accord
	1.1 Quelle est votre profession ? What is your profession ? Where do you work? alimentaire est efficace pour leur faire adopter des 2.9 Au cours des deux dernières années, comment avez-3.2 Quel âge ont habituellement les nourrissons How often do you give documents about I am satisfied with the documents on pratiques alimentaires saines pour leur enfant. vous acquis de nouvelles connaissances sur la lorsque vous commencez à parler de la complementary feeding to parents? complementary feeding that I have. 1.6 Quel est votre code postal ? diversification alimentaire ? diversification alimentaire ? Counseling parents on complementary feeding is (plusieurs réponses possibles) What is your postal code? 1.7 Avez-vous vous même des enfants ? Do you have children? 1.8 En quelles années sont nés vos premiers et derniers effective in making them adopt healthy eating practices for their child. How old are infants usually when you start Over the past two years, how did you acquire new talking about complementary feeding? knowledge about complementary feeding? 3.7 Qui vous fournit les documents de (multiple answers allowed) communication sur la diversification alimentaire 3.9 Je pense que les documents que je remets aux à remettre aux parents ? parents suscitent leur intérêt pour la enfants ? 2.5 Je me sens à l'aise pour conseiller les parents sur la (plusieurs réponses possibles) diversification alimentaire. diversification alimentaire. In which years were your first and last children born? Who provides you with the communication I think that the documents that I give to parents 2. Attitudes et perceptions I feel comfortable advising parents on 3.3 Quel âge ont habituellement les nourrissons documents on complementary feeding to give to Française de Pédiatrie, Association de Urban area D'accord Formation professionnelle sécurité sanitaire de l'alimentation, de Avant la naissance Toujours Pas d'accord Médecin généraliste Rural area Ni en désaccord, ni d'accord continue: réunions, congrès et/ou l'environnement et du travail) Peu après la naissance Never Pas du tout d'accord Pédiatre …….. Pas d'accord medias (journaux professionnels, sites Fabricants de laits et d'aliments 1 mois 2 mois Rarely Totally agree Infirmier/ère puériculteur/trice Pas du tout d'accord internet professionnels, newsletters, pour bébés 3 mois 4 mois Sometimes Agree Personnel de PMI ou d'établissement d'accueil des jeunes enfants : auxiliaire de puériculture, aide soignant, éducateur de jeunes enfants, autre Oui Non Yes No Totally agree Agree Neither disagree nor agree Disagree etc.) Médias généralistes (radio, 5 mois 6 mois Often Neither disagree nor agree Brochures de santé publique (Santé télévision, journaux, magazines) 9 mois 12 mois Disagree Always Publique France, ARS, IREPS…) Instituts de recherche / Universités Before birth Strongly disagree Santé publique France Brochures des fabricants de laits ou Public health France Soon after birth Tout à fait d'accord PNNS 1 er enfant ____ Strongly disagree aliments pour bébés Learned societies (French Society 1 month 2 months ARS D'accord Diététicien/ne Dernier enfant ____ Tout à fait d'accord Événements organisés par des of Pediatrics, Association of 3 months 4 months IREPS Ni en désaccord, ni d'accord Sage-femme/Maïeuticien Autre (veuillez préciser) First child ____ D'accord fabricants de laits ou aliments pour Ambulatory Pediatrics, French 5 months 6 months CAF Pas d'accord Last child ____ Ni en désaccord, ni d'accord bébés Society of Nutrition, Academy of 9 months 12 months Sociétés de pédiatrie (Société Pas du tout d'accord …………………………………. Pas d'accord Blogs sur la nutrition, autres sites Medicine, other) 1 mois 2 mois arouse their interest in complementary feeding. Totally agree General practitioner 2. Attitudes and perceptions complementary feeding. Pas du tout d'accord des réseaux de nutrition ARS (Regional Health Agency) / lorsque vous parlez des étapes de la 3 mois 4 mois parents? Pédiatrie Ambulatoire, Société Française Agree Pediatrician Pediatric nurse PMI or young childcare establishment staff: childcare assistant, caregiver, educator of young children, other Dietitian Midwife / Maieutician Totally agree Médias généralistes (radio, IREPS (Regional Authority for diversification alimentaire (introduction des 5 mois 6 mois (more than one answer allowed) de Nutrition, Académie de Médecine, Neither disagree nor agree Indiquez dans quelle mesure vous êtes d'accord avec les affirmations suivantes Agree télévision, journaux, magazines) Education and Health Promotion) groupes d'aliments,…) ? 9 mois 12 mois autre) Disagree Indicate the extent to which you agree with the following statements 2.1 Conseiller les parents sur la diversification alimentaire est l'une de mes responsabilités. Advising parents on complementary feeding is one of my responsibilities. Neither disagree nor agree Discussions avec des collègues ANSES (National Agency for 16 mois 20 mois Fabricants de laits et d'aliments pour Strongly disagree Tout à fait d'accord Disagree Autre (veuillez préciser) Food, Environmental and How old are infants usually when you talk about 24 mois 30 mois bébés 3.10 Je pense que les documents que je remets aux Tout à fait d'accord D'accord Strongly disagree ………………………………….. Occupational Health Safety) the stages of complementary feeding 36 mois Fabricants de matériel de puériculture parents permettent de tenir compte des D'accord Ni en désaccord, ni d'accord Continuing professional training : Milk and baby food manufacturers (introduction of food groups, etc.)? 1 month 2 months (ex : tire-lait) différences culturelles et/ou financières propres à Ni en désaccord, ni d'accord Pas d'accord newspapers, magazines) 5 months 6 months Pas du tout d'accord meetings, congresses and / or media General media (radio, television, 3 months 4 months Conseil général chaque famille. Pas d'accord

Regarding the information to be transmitted to parents about complementary feeding, please check if the subjects are very important or less important in your opinion. Sujets

concernant la diversification alimentaire Topics concerning complementary feeding Sujets très importants Very important topic Sujets moins importants Less important topics

  Concernant les informations à transmettre aux parents à propos de la diversification alimentaire, merci de cocher si vous voulez plus d'information ou si vous avez déjà suffisamment d'information en ce qui concerne les sujets suivants.Regarding the information to be transmitted to parents about complementary feeding, please check if you want more information or if you already have enough information regarding the following topics.

	Stratégies alimentaires en cas de « petit mangeur » Stratégies alimentaires en cas de « gros mangeur
	How to deal with "little" appetite »
	Stratégies alimentaires en cas de « gros mangeur » How to deal with "big" appetite
	How to deal with "big" appetite Observations du comportement des nourrissons
	Observations du comportement des nourrissons How to interpret the child's behavior
	How to interpret the child's behavior Comment nourrir un enfant pour favoriser le
	Comment nourrir un enfant pour favoriser le développement de saines habitudes alimentaires
	développement de saines habitudes alimentaires How to feed a child to promote the development
	How to feed a child to promote the development of of healthy eating habits
	healthy eating habits Exemples de menus ou de recettes
	Exemples de menus ou de recettes Examples of menus and recipes
	Examples of menus and recipes 4.4 En dehors des discussions que vous pouvez	Brochures
	mener en face à face, quels sont les outils de communication que vous considérez comme étant les plus accessibles et plus susceptibles d'attirer l'attention des parents aujourd'hui ? (plusieurs réponses possibles) Aside from face-to-face discussions, which 4.3 Sujets concernant la diversification alimentaire communication tools do you consider the most	Télévision Radio Sites internet YouTube Réseaux sociaux (Facebook, Instagram, Twitter, Pinterest) Applications pour smartphone Sujets pour Sujets pour Blogs
	Topics concerning complementary feeding accessible and most likely to grab the attention	lesquels j'ai Forums de discussion lesquels j'ai
	of parents today?	besoin de plus Chats (Des chats individuels offrent la déjà
	(more than one answer allowed)	d'information possibilité d'échanger en temps réel et en suffisamment
		Topics for which privé avec un intervenant) d'information
		I need more Coups de téléphone à des amis ou Topics for
		information parents / grands-parents which I already
		Brochures	have enough
		Television	information
	Age de début de la diversification alimentaire	Radio
	Age of start of complementary feeding	Websites
	Age d'introduction des différents groupes	YouTube
	d'aliments	Social networks (Facebook, Instagram,
	Age and modalities of introduction of different Age de début de la diversification alimentaire food groups Age of start of complementary feeding Age d'introduction des aliments texturés et Age d'introduction des différents groupes Twitter, Pinterest) Smartphone applications Blogs progression souhaitée Discussion forums d'aliments Age and modalities of introduction of first food Chats (Individual chats offer the Age and modalities of introduction of different pieces and different textures possibility of discussing in real time and food groups Stratégies de présentation en cas de refus in private with a speaker) Age d'introduction des aliments texturés et alimentaire Phone calls to friends or relatives / progression souhaitée How to present food in case of refusal grandparents Age and modalities of introduction of first food Quantités et tailles des portions 4.5 Avez-vous d'autres suggestions (en termes de …………………………………….. pieces and different textures Portions sizes of food and milk contenu et de format) concernant les outils de ..…………………………............... Stratégies de présentation en cas de refus Do you have any other suggestion (in terms of Quantités et tailles des portions How to deal with "little" appetite How to present food in case of refusal » à fournir aux parents ? alimentaire Stratégies alimentaires en cas de « petit mangeur communication sur la diversification alimentaire ..…………………………………….
	Portions sizes of food and milk content and format) concerning the

Table 1 . Characteristics of the study sample (n=1001) and the two subsamples; of parents of healthy children (n=826) and parents of children with a medical condition that could affect their diet (n=175). †

 1 HC, parents of healthy children. CMC, parents of children with medical condition that could affect the diet. † For results regarding parents of CMC refer also to Supplement Material 3. * based on χ2 tests, comparing parents of HC and parents of CMC. Significant p-values are in boldface. ‡ i.e., the parent with the highest income.

	N (%)

Table 2 . Perceptions (frequencies and percentages of parents who answered positively for each item) of IYCF (including CoF), and of IYCF information of parents of healthy children (n=826); comparisons according to selected socio-demographic characteristics.

 2

	Characteristics N (%)

Table 3 . Type of content that parents of healthy children (n=826) look for: comparison according to selected socio-demographic characteristics (frequencies and percentages of parents who selected each item).

 3

	Characteristics N (%)

How to interpret the child's hunger and satiety cues' 207

(25)

103 (

Table 4 . Utilization (frequencies and percentages) and influence (means ± SD) of the different sources of information on IYCF of parents of healthy children (n=826); comparisons according to selected socio-demographic characteristics. Sources of information on IYCF

 4 IYCF, infant and young child feeding. HCPs, health care professionals.

			HCPs	Internet	Parents' network		Paper	Childcare professionals		Media
		Use †	Influence ‡	Use †	Influence ‡	Use †	Influence ‡	Use †	Influence ‡	Use †	Influence ‡	Use † Influence ‡
	Parents n=826	669 (81)	7.7 ± 1.7	594 (72)	5.6 ± 2.1	517 (63)	6.9 ± 1.8	360 (44)	6.2 ± 1.8	251 (30)	7.3 ± 1.8	197 (24) 5.8 ± 2.0
	Child characteristics
	Age of the youngest child
	<12 months	186 (83)	7.9 ± 1.5	175 (78)	6.0 ± 2.0	128 (57)	7.0 ± 1.7	103 (46)	6.1 ± 1.8	60 (27)	7.2 ± 2.0	(24) 5.8 ± 1.9
	12-23 months	181 (83)	7.8 ± 1.6	164 (76)	5.7 ± 2.0	139 (64)	6.7 ± 1.8	89 (41)	6.1 ± 1.7	64 (30)	7.6 ± 1.4	(18) 5.7 ± 2.3
	24-35 months	171 (78)	7.4 ± 1.9	154 (70)	5.2 ± 2.2	143 (65)	6.8 ± 1.9	99 (45)	6.2 ± 1.8	77 (35)	7.2 ± 1.8	(26) 5.6 ± 1.9
	≥36 months	131 (80)	7.5 ± 1.6	101 (62)	5.7 ± 2.0	107 (65)	7.0 ± 1.5	69 (42)	6.4 ± 1.8	50 (31)	7.5 ± 2.0	(29) 6.2 ± 2.0
	p-value*	0.41	0.04	0.002	0.01	0.22	0.23	0.72	0.57	0.29	0.47	0.09	0.61
	Born preterm
	Yes	63 (78)	7.6 ± 1.8	55 (68)	5.7 ± 2.2	56 (69)	7.1 ± 1.7	34 (42)	6.4 ± 1.6	27 (33)	8.1 ± 1.4	(22) 6.1 ± 2.2
	No	606 (81)	7.7 ± 1.6	539 (72)	5.6 ± 2.0	461 (62)	6.8 ± 1.8	326 (44)	6.2 ± 1.8	224 (30)	7.3 ± 1.9	179 (24) 5.8 ± 1.9
	p-value*	0.53	0.87	0.47	0.94	0.25	0.36	0.76	0.56	0.54	0.03	0.72	0.52
	Parental characteristics
	Self-perceived financial
	situation (n=819) §
	Good	311 (81)	7.9 ± 1.5	283 (74)	5.7 ± 2.0	239 (62)	6.9 ± 1.7	174 (45)	6.3 ± 1.7	119 (31)	7.6 ± 1.8	(24) 6.0 ± 1.7
	Difficult	353 (81)	7.7 ± 1.7	306 (70)	5.6 ± 2.1	273 (63)	6.9 ± 1.8	181 (41)	6.2 ± 1.8	130 (30)	7.4 ± 1.8	103 (24) 5.8 ± 2.0
	p-value*	0.93	0.05	0.24	0.86	0.95	0.67	0.26	0.43	0.70	0.20	0.83	0.60
	Education
	<A level	119 (84)	7.1 ± 2.0	100 (71)	5.4 ± 2.4	99 (70)	6.5 ± 2.2	64 (45)	5.8 ± 1.9	51 (36)	7.2 ± 1.7	(33) 6.0 ± 2.4
	≥A level	550 (80)	7.8 ± 1.5	494 (72)	5.7 ± 2.0	418 (61)	7.0 ± 1.6	296 (43)	6.3 ± 1.7	200 (29)	7.4 ± 1.8	151 (22) 5.8 ± 1.8
	p-value*	0.25	0.001	0.77	0.16	0.04	0.01	0.63	0.03	0.10	0.52	0.007	0.50
	Parity status
	Primiparous	268 (84)	7.8 ± 1.6	259 (81)	5.8 ± 2.0	239 (75)	6.9 ± 1.7	152 (48)	6.3 ± 1.8	107 (33)	7.6 ± 1.8	(23) 6.0 ± 1.8
	Multiparous	401 (79)	7.6 ± 1.7	335 (66)	5.5 ± 2.1	278 (55)	6.8 ± 1.8	208 (41)	6.1 ± 1.8	144 (29)	7.2 ± 1.8	123 (24) 5.8 ± 2.1
	p-value*	0.11	0.08	< 0.001	0.09	< 0.001	0.60	0.07	0.29	0.13	0.06	0.70	0.51
	SD, standard deviation.

Perceptions of IYCF (including CoF) (the following

	5) IYCF is important for the	Strongly agree; Tend to agree (=Agree); Tend to
		present and future health of my	disagree; Strongly disagree (=disagree)
		child and for his/her growth	Modalities
	Youngest child's characteristics 6) IYCF is important for the	Strongly agree; Tend to agree (=Agree); Tend to
	Sex	establishment of good eating	Female; male disagree; Strongly disagree (=disagree)
	Age	habits	<12 months; 12-23 months; 24-35 months; ≥36
	months Perceptions of IYCF information (including CoF) (the following statements were
	Born pre term presented and answers were recorded on a 4-point Likert scale grouped in agree and Yes (birth at 36 weeks or less); no (birth at 37
	disagree for the analysis)	weeks or more)
	Have or had a medical condition 7) I feel well informed about	Yes (for example gastroesophageal reflux treated Strongly agree; Tend to agree (=Agree); Tend to
	affecting the diet IYCF	by medication, allergy to cow's milk protein, disagree; Strongly disagree (=disagree)
	8) I am satisfied with the available	nasogastric intubation or digestive tract Strongly agree; Tend to agree (=Agree); Tend to
		information on IYCF	congenital defects); no disagree; Strongly disagree (=disagree)
	Eating food other than milk (including CoF)	Yes (CoF started); no (CoF had not started yet)
	Parental demographic and socioeconomic characteristics 9) The available information on Strongly agree; Tend to agree (=Agree); Tend to
	Sex	IYCF (including CoF) answers	Female; male disagree; Strongly disagree (=disagree)
	Age	to my questions	<35 years old; ≥35 years old
	Education level 10) The available information on	<A level (did not attend university); ≥A level Strongly agree; Tend to agree (=Agree); Tend to
		IYCF (including CoF) is clear,	(attended university). disagree; Strongly disagree (=disagree)
	Socio-professional category of the easy to understand	High (Self-employed business owners, Executive,
	interviewed parent 11) The available information on	Intermediate); Low (Manual worker, Office Strongly agree; Tend to agree (=Agree); Tend to
		IYCF (including CoF) is easy	employee); no occupation/retired. disagree; Strongly disagree (=disagree)
	Parity	to put into practice	Primiparous (1 child 0-3 years old) ; Multiparous
	12) The available information on	(>1 child, the youngest child is 0-3 years old) Strongly agree; Tend to agree (=Agree); Tend to
	Mother tongue IYCF (including CoF) is	French; other disagree; Strongly disagree (=disagree)
	Household characteristics contradictory
	Self-perception of financial situation 13) The available information on	Good (I am comfortable, I am OK?); difficult (ok Strongly agree; Tend to agree (=Agree); Tend to
		IYCF (including CoF) is giving	but I need to be careful, difficult to get the end of disagree; Strongly disagree (=disagree)
		me the perception of not	the month, I cannot make it without debts); no
		implementing correctly IYCF	answer
	Living area	Rural (<20000 inhabitants); urban (>20000
			inhabitants)
	Socio-professional category of the	High (Self-employed business owners, Executive,
	household reference parent †	Intermediate); low (Manual worker, Office
			employee); no occupation/retired.
			statements were presented and
	answers were recorded on a 4-point Likert scale grouped in agree and disagree for the
	analysis)
	(the definition of CoF was given to parents when they had to answer a question related to
	that)
	1) CoF for my youngest child is	Strongly agree; Tend to agree (=Agree); Tend to
		going or went well	disagree; Strongly disagree (=disagree)
	2) It is easy to find information on	Strongly agree; Tend to agree (=Agree); Tend to
		IYCF (including CoF)	disagree; Strongly disagree (=disagree)
	3) CoF is easier for my last child	Strongly agree; Tend to agree (=Agree); Tend to
		than for the first one(s) (only	disagree; Strongly disagree (=disagree)
		multiparous)
	4) CoF for my last child is or it	Strongly agree; Tend to agree (=Agree); Tend to
		has been source of concern	disagree; Strongly disagree (=disagree)

Information sources used by parents (multiple choice answer: if parents choose the main source on the left column they had the possibility to select between the options on the right column) and

how strongly the sources influenced parents in making decisions in feeding their youngest child

	CHAPTER 4 -
	Health care professionals	Pediatricians; General practitioners; Midwives;
		Pediatric nurses; Dieticians
	Internet, social networks or	Website specialized in early childhood; Blogs or
	applications for smartphones	forums for parents; Website specialized in health ;
		Websites of baby food manufacturer/industries;
		Health authority website; Social networks;
		Applications for smartphones; Health insurance
		websites
	Parents' network	Own parents; Friends; Own grandparents;
		Other family's members
	Paper tools	Books; Printed media, newspapers, magazines
	Early childhood professionals	Social service for mothers ("Personnel de PMI");
		Licensed childminder
	Media	Television, radio

(linear scale from 1 to 10: 1 means the source did not influence decisions at all and 10 means it influenced decisions very strongly).

Evaluating public health communication material with parents and healthcare professionals This chapter will be presented in the form of two articles: article 3 is under revision in Frontiers in Public Health and article 4 is under revision in BMC Public Health. Increasing parental knowledge about child feeding: evaluation of the effect of public health policy communication media in France 1 Introduction

	Childhood obesity is a major public health concern worldwide, threatening the health of children,
	especially in Western societies. In France, in 2013, 12% of children under the age of six were
	overweight (1); moreover, in 2017, 18% of adolescents were overweight, and 5% were affected by
	obesity. More of concern, between 2009 and 2017, the prevalence of childhood obesity rose (2),
	despite the deployment of public health campaigns starting in 2001 to target nutrition and physical
	activity (3). The benefits of establishing healthy eating behaviors from early childhood are countless
	in terms of noncommunicable disease prevention. In fact, previous studies have demonstrated that

Table 1 .

 1 Items exploring parental knowledge about child feeding.

	Q	Q code	Item*	True False
	1 only milk <4m Until the age of 4 months, a baby should be given only milk, nothing else.	X
	2 growup milk
		6-12 m

Table 2 .

 2 Characteristics of the sample of French parents who responded to the survey at T0 and T1 (n=452).

	Characteristics

De la naissance à 3 ans, du lait, du lait, du lait ! Clé 2 -Entre 4 et 6 mois, commencez à donner de tout Clé 3 -Être attentif pour répondre au mieux aux besoins de son enfant Clé 4 -A partir de 6/8 mois, des nouvelles textures à goûter, des nouveaux objets à manipuler Clé 5 -Faire confiance à l'appétit de son enfant Clé 6 -Privilégier le fait maison Clé 7-A partir de 1 an, une alimentation équilibrée à la table familiale Clé 8 -A partir de 2 ans, le refus de certains aliments Clé 9 -Bouger, jouer et dormir Clé 10 -En résumé : les groupes d'aliments à donner, des exemples de quanti- tés, les aliments « interdits » Clé 1 -De la naissance à 3 ans, du lait, du lait, du lait !

  Nourrir son enfant, c'est bien sûr le faire manger, mais aussi guetter ses réactions, s'adapter, communiquer avec lui, l'accompagner vers l'autonomie... Les repas sont des moments forts dans la relation parents/enfant. Ce livret vous accompagne dans la diversification alimentaire de votre enfant, dès qu'il commence à prendre autre chose que du lait jusqu'à ce qu'il mange -presque -comme les grands.Jusqu'à l'anniversaire de ses 4 mois, un enfant ne doit prendre que du lait, sans rien d'autre. Entre 4 et 6 mois, en plus du lait, il va goûter d'autres aliments. Après 6 mois, son alimentation sera variée, mais toujours avec beaucoup de lait.

	Clé 1 -Allaiter,

le moyen le plus naturel de débuter une alimentation santé L

  'allaitement est une décision personnelle. Pour une mère, être soutenue par son entourage proche et avoir les conseils de professionnels formés facilite un bon démarrage. Il est recommandé d'allaiter jusqu'aux 6 mois de l'enfant mais même moins longtemps, c'est bénéfique à sa santé. Et si on veut prolonger, on peut donner le sein aussi longtemps qu'on le souhaite. Le tire-lait peut aider à continuer à allaiter à la reprise du travail.

Clé 2 -Entre 4 et 6 mois, commencez à donner de tout Légumes, fruits, volaille, poisson, viande, oeufs, légumes secs (lentilles, haricots, pois chiches…), féculents (pâtes, riz, semoule, pain), produits laitiers, fruits à coque non salés, matières grasses...

  Un bébé peut commencer à découvrir toutes les familles d'aliments entre 4 et 6 mois. On sait aujourd'hui que c'est la meilleure période pour que son organisme accepte les aliments en cause dans les allergies. Vous pouvez cependant demander l'avis de votre médecin traitant ou de PMI s'il y a des allergies dans la famille.Les fruits à coque non salés (amandes, noix, noisettes) sont riches en oméga 3. Achetés en poudre, une cuillère à café peut être mélangée de temps en temps dans une purée.

	Le saviez-vous ?
	N'hésitez pas à proposer des légumes secs (lentilles, pois chiches, haricots secs) en purée lisse.
	Le bon moment ? C'

est le vôtre et celui de votre bébé

  Commencez quand vous le souhaitez, mais en tout cas pas après 6 mois : dès l'anniversaire des 4 mois ou un peu plus tard, en particulier si votre enfant est prématuré. Si c'est le cas de votre enfant, demandez un avis médical. Vous pouvez commencer au repas qui convient le mieux à votre organisation familiale. Si votre enfant est gardé à l'extérieur, cela peut tout à fait être le soir.Pour les légumes, les légumes secs, les pommes de terre : cuire à l'eau ou à la vapeur, sans sel. Pour la volaille, la viande ou le poisson : bien cuire à coeur, sans sel.Mixer les aliments ou les écraser très finement à la fourchette. Ajouter un peu d'eau fraîche et de la matière grasse (huile ou beurre). Mélanger pour obtenir une consistance bien lisse. Ne pas saler.Astuce : congeler une partie de la purée dans un bac à glaçons recouvert de film alimentaire, pour utiliser au fur et à mesure des repas. Placez-le dans une poche plastique datée et identifiée. Au début, votre bébé ne prend que quelques cuillérées car son estomac est petit, suivies de la tétée à volonté ou du biberon dans les quantités indiquées par votre médecin. Peu à peu, il va manger plus : fiez-vous à son appétit, observez ses réactions, ne le forcez jamais. Il n'y a pas de quantité à atteindre, chaque enfant est différent. S'il refuse un nouvel aliment, n'insistez pas mais réessayez quelques jours plus tard. Il faut souvent présenter plusieurs fois le même aliment (parfois jusqu'à 10 fois !) pour qu'un enfant l'accepte et commence à y prendre plaisir. Tenez compte de son humeur… et de la vôtre ! Si votre enfant a du mal les premiers jours à accepter autre chose que son lait, ce n'est pas grave, tant qu'il boit du lait ! Mais rappelez-vous qu'après 6 mois, le lait seul ne suffit plus à couvrir ses besoins.

	Pour se repérer et à titre indicatif
	Consultez le tableau d'introduction par groupes d'aliments page 00.

A la cuillère, les purées et les compotes bien lisses

On commence en général à donner à manger à la cuillère. Proposez tous les aliments en purée ou en compote lisses pour que le bébé puisse les avaler sans risque. Les soupes moulinées peuvent aussi être proposées à la tasse. Si votre enfant veut découvrir les aliments avec les doigts, laissez-le faire, même si c'est un peu salis-sant… Il les aimera d'autant plus !

Faire découvrir un goût à la fois

Au début, il vaut mieux donner chaque nouvel aliment séparément. Par exemple, quelques cuillères à café de purée d'un légume, de purée de volaille, de compote… Votre enfant acceptera encore mieux les nouveaux aliments si vous variez les légumes, les fruits, etc. au fil de la semaine, pour lui faire découvrir différents goûts et couleurs.

Une fois que chaque aliment a été accepté seul, vous pouvez proposer les aliments mélangés (purée de légumes et pomme de terre, purée de légumes et volaille, etc.) Donner des matières grasses Mélangez 1 cuillère à café de matière grasse dans l'équivalent d'un petit pot au repas dès le début de la diversification.

Petit encadré : Préparer une purée lisse Sinon, on peut conserver la purée au maximum 24 h au réfrigérateur dans une boîte hermétique en verre. Si on utilise un petit pot du commerce, on vérifie sur l'étiquette la durée de consommation après ouverture.

Les quantités : proposer sans forcer

partir de 6/8 mois, des nouvelles textures à goûter, des nouveaux objets à manipuler Faire découvrir de nouvelles textures…

  Pour que le repas soit un moment d'échange, on éteint télé, tablette et on laisse son téléphone à distance. A l'heure du repas comme à beaucoup d'autres moments, votre enfant a besoin de toute votre attention. En étant pleinement présent, vous captez tous les signaux qu'il envoie et vous pouvez y répondre au mieux. A partir de 6/8 mois (et pas après 10 mois), selon l'âge auquel vous avez commencé à diversifier, c'est important de proposer progressivement de nouvelles textures à votre enfant. Il va ainsi pouvoir développer ses capacités à bien mâcher. Introduisez une seule nouvelle texture lors d'un repas. Si vous donnez des petits pots, variez les marques et les recettes, la consistance et la taille des morceaux varient d'un produit à l'autre.

	Clé 4 -A

… et expérimenter de nouveaux « ustensiles »

Votre enfant va tester la cuillère, la tasse… plus tard ce sera la fourchette... Laissez-le aussi prendre en main des morceaux tendres afin qu'il se familiarise avec : il va les malaxer, les suçoter, les mâchouiller puis les avaler.

Vous pouvez aussi lui donner de l'eau au verre, en l'aidant pour boire.

Il est important que votre enfant soit bien assis et sous votre regard pendant toute la durée du repas Tous à table ! Même s'il ne mange pas comme le reste de la famille, vous pouvez dès cet âge installer votre bébé à table avec vous pour partager ce temps convivial. Quelques signes qu'un enfant est prêt pour de nouvelles textures • Il avale les purées lisses et épaisses sans problème • Il maintient sa tête et son dos droits dans sa chaise • Il fait des mouvements de mâchonnement quand il porte quelque chose à sa bouche • Il est capable de tenir un aliment et de le porter à sa bouche (il cherche à se nourrir seul) • Il essaye de prendre des aliments dans votre assiette A la crèche ou chez la nounou N'hésitez pas à parler des habitudes alimentaires que vous souhaitez donner à votre enfant avec les personnes qui le gardent. C'est important qu'on respecte vos choix.

Vous savez quoi lui donner et quand, mais votre enfant sait combien

  Dès sa naissance, un bébé prend naturellement les quantités de lait dont son corps a besoin. Et cela continue après quand vous lui proposez d'autres aliments. Au début, il goûtera quelques cuillérées à café, puis progressivement, son appétit et ses capacités de digestion augmentent. Augmentez les quantités que vous lui proposez, en vous aidant des moyennes proposées dans les menus p. 00 et en respectant son appétit. Il est possible qu'au moment où il commence à manger tout seul, votre enfant mange moins. N'insistez pas : il sait quand il n'a plus faim. Evitez de lui donner à manger en dehors des repas « pour compenser » ; en ne mangeant qu'aux repas,

Quoi et quand

Avec le temps, un enfant mange plus aux repas mais fait moins de repas par jour. Avec la diversification, un enfant, petit à petit ou du jour au lendemain, se met spontanément à manger cinq puis quatre fois par jour. A partir d'environ 8 mois, il va prendre un petit déjeuner, un déjeuner, un goûter et un dîner.

Pour des conseils indicatifs, allez à la Clé 10.

A partir de 1 an, en plus du lait, un enfant mangera chaque jour des aliments de chaque grand groupe d'aliments : légumes, fruits, viande ou poisson (ou légumes secs deux fois par semaine), féculents, produits laitiers. Par exemple, volaille, poisson ou viande et légumes avec un peu de matière grasse à midi et produit laitier et féculents et fruits au goûter. Ou, aussi bien, volaille ou poisson, légumes et féculents avec un peu de matière grasse à midi et produit laitier et fruit au goûter. il lui sera plus facile d'être lui-même à l'écoute de son appétit.

fr et agirpourbébé.fr. Pas d'écrans pour les jeunes enfants...

  Avant 5 ans, il est recommandé qu'un enfant « bouge » au moins 3 heures par jour, par des activités variées et ludiques, et aussi souvent que possible en plein air : marcher, courir, sauter, lancer une balle, voire nager…Pour toutes les recommandations concernant l'activité physique des jeunes enfants, consultez les sites mangerbouger.Evitez de mettre votre enfant devant un écran (télévision, tablette, smartphone) avant l'âge de 3 ans, ni dans une pièce où la télévision est allumée, même s'il ne la regarde pas. C'est une période très importante

d'apprentissage, notamment du langage, et les mauvais effets des écrans sur le langage, le sommeil, la corpulence ne se voient pas immédiatement mais apparaîtront plus tardivement. Jouer « en vrai » avec son enfant est la meilleure façon de favoriser son développement.

Table 4 .

 4 Websites cited by HCPs (from top to bottom, the most to the least cited).

	Websites
	Mpedia.fr
	Pediadoc.fr
	MangerBouger.fr
	Pédiatre-online.fr
	Ameli.fr
	Pap-pédiatrie.fr
	Alimentationdutoutpetit.fr

Conclusion de l'entretien + remerciements et indemnisation + explication de la suite

  Pour les professionnels de la santé -Est-ce que vous pensez que ce typede brochure est utile pour vous pendant des consultations avec les parents ? Pourquoi ? -Pour finir, il y a des conseils qui sont difficiles à expliquer dans une brochure et que nous pensions essayer de faire passer aux parents par les professionnels de la santé, par exemple la manière d'introduire certains allergènes comme les fruits à coque ou alors par exemple le chocolat à éviter. -Si vous n'avez plus d'éléments à ajouter, je vous remercie vivement pour votre temps et pour avoir répondu à mes questions. -Pour vous indemniser pour le temps que vous avez consacré à notre étude, j'aimerais vous offrir des bons d'achat Amazon d'un montant total de 40€. -Avez-vous encore des questions par rapport à l'étude en général ?

		Compréhension et mémorisation
		-Quels sont les éléments de cette brochure qui vous ont particulièrement marqué ? Pourquoi ?
		-Y a-t-il des choses qui vous ont étonné / surpris dans cette brochure ? Lesquels ? Pourquoi ?
		-Avez-vous remarqué des nouveautés dans les recommandations ? Lesquels ?
		Que pensez-vous de cette/ces informations ?
		RELANCER :
		o Est-ce que vous seriez d'accord pour relayer ce type de conseils aux parents -Parmi les nouveautés / nouvelles recommandations, il y a par exemple la notion de : Ne pas démarrer o Est-ce que vous trouvez que c'est votre rôle ? Qui d'autre pourrait la relayer ? Comment la diversification alimentaire après 6 mois (sauf cas particuliers bien sûr…). pourrait-on faire autrement ? Que pensez-vous de cette information ? Pensez-vous que l'explication pour comprendre cette notion est claire ? Pensez-vous que cela puisse être clair pour les parents ou vaut-il mieux donner encore plus o De quoi auriez-vous besoin pour que ce soit facile pour vous de donner ces informations ?
		d'informations à ce sujet ? (Voir si prévention des allergies a été retenue)
	-Une autre notion nouvelle est celle d'introduire tous les groupes alimentaires entre 4 et 6 mois. Que Pour tous :
		pensez-vous de cette information ? Avez-vous besoins d'informations pour comprendre pourquoi ? -S'ils disent qu'ils ont créé leur propre matériel à donner aux parents, demandez-leur s'ils remplaceraient
		-Vous avez surement vu qu'on parle aussi d'introduire les aliments comme les légumes secs, les pommes ce matériel par la brochure.
		de terres, les céréales complètes. (Peu consommés et plus difficiles à digérer) Que pensez-vous de cette -La brochure va-t-elle leur faire changer certaines pratiques/conseils qu'ils donnent aux parents ?
		information ? Avez-vous besoins d'informations pour comprendre pourquoi ?
		-Un autre point sur lequel je souhaitais échanger avec vous, c'est le fait qu'on propose l'alternance lait
	de croissance/lait de vache entier UHT. Que pensez-vous de cette information ? Avez-vous besoins 1. Remarques/ pensées supplémentaires du participant
		d'informations pour comprendre pourquoi ? -Y-a-t-il des éléments dont je n'ai pas parlé que vous souhaiteriez ajouter ?
	2.	-Et en ce qui concerne les aliments déconseillés, qu'avez-vous pensé des informations que nous donnons
		? Notamment pour les produits sucrés, et les boissons sucrées dont les jus de fruits? Pour les produits
		ultra-transformés ? Les produits à base de soja et les boissons végétales ? Certains poissons ? Avez-vous
		besoins d'informations pour comprendre pourquoi ?
		-Sinon dans cette brochure, y a-t-il des choses que vous avez eu du mal à comprendre ou qui ne semblent
		pas claires ? Lesquelles ?
		Agrément et adhésion
		-Qu'est-ce qui vous a plu dans cette brochure ? et qu'est-ce qui vous a moins plus ou pas plus ?
		Pourquoi?
		RELANCER PLUS SPECIFIQUEMENT :
		-Que pensez-vous du vocabulaire utilisé ? RELANCER : Les messages sont-ils clairs et faciles à
		comprendre pour les parents ?
		-Que pensez-vous du ton utilisé dans la brochure ?
		-Que pensez-vous des informations données ? RELANCER : Est-ce qu'il manque des choses
		importantes/ que vous jugez importantes à communiquer aux parents ?
		-Que pensez-vous de l'ordre dans lequel sont présentées les différents sujets ?
		-Que feriez-vous pour améliorer cette brochure ?
		Utilité de la brochure pour les parents et pour les professionnels
		-Ces messages sont-ils utiles ? Pourquoi ?
		-Avez-vous le sentiment que les parents peuvent apprendre des choses ? Lesquelles ?
		-Qu'est-ce que pensez-vous que cette brochure donne envie de faire aux parents ? Vont-ils changer des
		choses concernant la nutrition de leurs enfants au quotidien ? (RELANCER EVENTUELLEMENT :
		MODIFIER L'ALIMENTATION AU QUOTIDIEN, EN DISCUTER AVEC SON CONJOINT(E), UN
		PROFESSIONNEL DE SANTE, DES AMI.E.S, DES PROCHES …)
		Pour les professionnels de la petite enfance :
		-Enfin, pensez-vous qu'il soit utile pour vous d'avoir cette brochure à donner aux parents ? Pourquoi ?

Regulations on baby foods: "Commission Delegated Regulation (EU) 2016/127 and 128 of 25 September 2015 supplementing Regulation (EU) No 609/2013 of the European Parliament and of the Council as regards the specific compositional and information requirements for infant formula and follow-on formula, as regards requirements on information relating to infant and young child feeding and as regards the specific compositional and information requirements for food for special medical purposes."

Chardon OG, Nathalie; de Saint Pol, Thibaut. La santé des élèves de grande section de maternelle en 2013: des inégalités sociales dès le plus jeune âge. DREES Études et Résultats. 2015.

-Pas de café, de thé, de sodas caféinés ni de boissons dites « énergisantes » car contiennent de la caféine pas de produits et boissons contenant des édulcorants ou faux sucres (les produits « light ») -pas de viandes crues ou peu cuites pas de lait cru ou de fromages au lait cru, à l'exception des fromages à pâte pressée cuite comme le gruyère ou le comté pas d'oeufs crus ni produits à base d'oeufs crus ou peu cuits (tels que les mousses au choco-lat et mayonnaises faites maison) ; -pas de coquillages ni poissons crus.Aliments déconseillés-Chocolat et produits chocolatés (contiennent trop de nickel pour eux) -limiter les produits à base de sojaSupplémentations alimentairesEn dehors d'une prescription de votre médecin (en vitamine D, K par exemple), ne donnez pas de vous-même de supplémentation en vitamines ou minéraux à votre enfant.

Internal document SpF: « Fiche campagne Diversification alimentaire Septembre 2021 », Direction de la prévention et de la promotion de la santé (unité : Alimentation et activité physique)

Internal document SpF: « Fiche campagne Diversification alimentaire Septembre 2021 », Direction de la prévention et de la promotion de la santé (unité : Alimentation et activité physique)

It must be kept in mind that the brochure tested was a draft that did not contain graphical adaptations, but only plain text.

« Évaluation du programme national nutrition santé 2011-2015 et du plan obésité 2010-2013 », C.de Batz -F.Faucon -D.Voynet (IGAS) -https://www.igas.gouv.fr/spip.php?article622

enfants en France, cette étude vise à : 1) évaluer les pratiques et perceptions des professionnels concernant leur communication avec les parents sur l'alimentation des jeunes enfants et 2) évaluer leurs impressions sur la nouvelle brochure.Une brochure de 15 pages contenant les recommandations actualisées sur l'alimentation des enfants de 0 à 3 ans a été élaborée par SpF. Des entretiens semi-directifs en ligne ont été menés auprès de professionnels (n=21), dont 13 pédiatres, médecins généralistes ou médecins de PMI ; et neuf professionnels de la petite enfance, deux semaines après avoir reçu cette brochure à lire.Le guide d'entretien a été développé et testé avec d'autres professionnels (n=3) lors d'entretiens pilotes. Les données des entretiens ont été transcrites mot à mot et analysées thématiquement en utilisant une approche inductive.Deux thèmes principaux et neuf sous-thèmes ont été développés à travers l'analyse thématique. Les thèmes principaux étaient : 1) les pratiques et besoins des professionnels en termes de communication avec les parents sur l'alimentation des enfants, et 2) les perceptions de la brochure. Les professionnels ont mentionné qu'ils fournissaient principalement des informations sur l'alimentation des enfants par voie orale aux parents, mais ils ont reconnu que la brochure pourrait être un complément utile, en particulier pour les professionnels de la petite enfance, pour légitimer leurs conseils aux parents.

Acknowledgments

First of all, I would like to thank Sophie Nicklaus and Camille Schwartz: my thesis supervisors. Thanks for giving me the chance to take part to this project and for guiding me and supporting me along the way. I am honored to have had you as supervisors and to have had the opportunity to learn from your experience as a researcher. Thank you for your patience, your availability and the trust you have placed in me.

I also thank all the members of team 8 for their constructive feedback on my work during our team meetings, for all the "pauses café" and shared moments. In particular, I would like to thank Claire Chabanet for her precious statistical advice and Camille Riera-Navarro for the help in the realization of the qualitative study as part of her stage. Thanks to Valérie Feyen et Emilie Szleper for their help in the administrative/organizational part of some of the studies.

One thing that certainly left its mark during these three years of thesis was the 9-month stay I spent in Paris, in the offices of SpF. A special thanks goes to Pauline Ducrot, supervisor of my work at SpF. Thank you for taking part in this project and for sharing your expertise in Acknowledgments: The authors thank the parents, the pediatrician members of AFPA and the professionals from the Perinatal Network of Burgundy for their time and willingness to participate in the studies. We also acknowledge Claire Chabanet for statistical advice; Solange Brugnaux and Bérengère Gall from BVA Group regarding the questionnaire design; Fabienne Kochert (president of AFPA) and Marie-Laure Frelut (pediatrician member of AFPA) for their advice and help in spreading the survey to the pediatricians' network; Ombeline Desplanches (Perinatal Network of Burgundy).

Acknowledgements

The authors thank the professionals for their time and willingness to participate in the study. We also acknowledge Corinne Delamaire, Laurence Noirot and Anne-Juliette Serry (Santé publique France) for their advice when designing the interview guide and Courtney Dow (INSERM) for the translation of the verbatim.

Funding

The study was conducted as part of the project "Edulia-Bringing down barriers to children's healthy eating", which has received funding from the European Union's Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement No 764985. This work was also supported by grants from the Conseil Régional Bourgogne, Franche-Comte (PARI grant) and the FEDER (European Funding for Regional Economic Development).

Data Availability Statement:

The data presented in this study are available on request from the corresponding author.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ANSES

CHAPTER 2 -Methodological aspects

Supplementary Materials: The following are available online at www.mdpi.com/xxx/s1, Supplement Material S1: Parents' original questionnaire with English translation, Supplemental Material S2. Pediatricians' original questionnaire with English translation.

Author Contributions: S.D.R. drafted the first versions of both questionnaires. S.N. and C.S. critically edited the pediatricians' questionnaire. S.N., P.D. and C.S. critically edited the parents' questionnaire. S.D.R. finalized both questionnaires. S.D.R. analyzed the data and wrote the first draft of the manuscript. All authors critically reviewed and commented on subsequent drafts of the manuscript and have approved the final version.

Funding:

The study was conducted as part of the project "Edulia-Bringing down barriers to children's healthy eating," which has received funding from the European Union's Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement, number 764985. This work was supported also by grants from the Conseil Régional Bourgogne, Franche-Comte (PARI grant) and the FEDER (European Funding for Regional Economic Development).

Institutional Review Board Statement:

This study was conducted according to the guidelines laid down in the Declaration of Helsinki. This kind of research in France does not require mandatory approval from an ethics committee. The panel of participants involved in the study has been declared to the appropriate committee (CNIL-Commission nationale de l'informatique et des libertés) for the data protection.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Conflicts of Interest:

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Information seeking of French parents regarding infant and young child feeding: practices, needs and determinants

Type of information sought by parents (multiple choice answer: if parents choose the main topic on the left column they had the possibility to select between the options on the right column) Menus, recipes Example of menus Example of recipes Age and modalities of introduction of Different food groups First food pieces First foods other than milk Feeding strategies How to present food in case of food refusal How to deal with little appetite of the child How to deal with big appetite of the child Portions sizes

Portions sizes of food Adapt milk quantities when introducing other foods How to feed a child to promote the development of healthy eating habits How to interpret the child hunger's and satiation's cues IYCF, infant and young child feeding. CoF, complementary feeding. HCPs, health care professionals.

† i.e., the parent with the highest income.

Supplement Material 2. Original questionnaire.

The questionnaire used is the same as article 1. Please see Supplemental material 1 of Article 1.

Supplement Material 3. Infant and young child feeding (IYCF) perceptions and information seeking practices of French parents of children with medical condition that could affect his/her diet vs. parents of healthy children: tables with results.

Abstract:

Background: Unhealthy eating behaviors are risk factors for noncommunicable diseases. Parents largely influence the development of eating behaviors during childhood through their feeding practices. Parental feeding practices in line with recommendations are more likely to turn into healthier outcomes in children. From a public health perspective, it should be first ascertained whether providing parents with recommendations about child feeding is a useful approach for increase parental knowledge. Recently, the French health authorities developed a brochure covering updated child feeding recommendations. The present study aims to evaluate the short-term effects of reading this brochure on parental knowledge about child feeding, distinguishing knowledge accuracy and certainty. Methods: A brochure containing updated child feeding recommendations for 0-3 years old was developed by the French public health agency. A representative sample of French parents (n=400) was targeted to complete an online questionnaire (T0) comprising 30 statements regarding child feeding. For each statement, parents indicated whether it was true/false and how certain they were of their answer (4-point scale). After receiving and reading the brochure, the same parents completed the same questionnaire three weeks later (T1). Accuracy (number of correct answers) and certainty (number of mastered answers: correct answers given with the maximal degree of certainty) were compared at T1 vs. T0 using paired t-tests. Knowledge evolution based on parental age, parity and education level was tested with linear models. Results: A total of 452 parents responded at T0 and T1 and were considered for analysis. Between T0 and T1, the number of correct answers (median 22 to 25, t(451)=17.2, p=<0.001) and mastered answers (median 11 to 17, t(451)=18.8, p=<0.001) significantly increased. The median of the difference between T1 and T0 was larger for mastered than for correct answers. The observed evolution in knowledge was independent of parental age, parity or education level. Conclusions: A brochure containing child feeding recommendations has the potential to increase the accuracy and, to an even greater degree, the certainty of parental knowledge. This increase was observed even for younger or less educated parents. Keywords: public health nutrition, child feeding, knowledge assessment, feeding guidelines, nutrition education.

Materials and methods

The updating of child feeding recommendations and the development of a brochure targeted to parents

In France, official recommendations for feeding children ages 0-3 years have been updated and published recently by ANSES (the French national agency for Food, Environmental and Occupational Health Safety) under the supervision of the Ministry of Health (10). In October 2020, the High Council of Public Health released a report reflecting these benchmarks (28). As of followup in 2019-2020, the content for a paper brochure intended for the final users of this communication strategy, the parents, had been developed by the French public health agency, Santé publique France.

The intent was to make the recommendations relating to feeding children ages 0 to 3 years as accessible as possible to parents. In the present study, the document that was sent to the parents was a draft version of the final brochure, and it comprised just the core text, without subsequent graphical adaptations. The brochure contained 11 pages plus a table that summarized the recommendations for introduction of each food group based on the age of the child. The brochure was divided into ten chapters. Five chapters addressed the topic of feeding based on the age of the child (milk feeding, complementary feeding until three years of age when the child eats like the whole family); three chapters covered specific topics in line with parental feeding practices (e.g., responsive feeding); one chapter addressed physical activity and sleeping; and one chapter summarized foods not suitable for children. The version of the brochure (in French) used for this study is presented as Supplemental Material.

Participants, questionnaire and study procedure

The recruitment was done via an agency (Panelabs -MIS Group) composed of a panel of participants from all around France. We could not run a power calculation to set the population size in the absence of a previous study on this topic, but a targeted sample size of 400 was defined a priori, as it was considered large enough for our purposes based on previous studies conducted by Panelabs on similar subpopulations. The recruiting agency aimed to initially include a sample of 500 parents to account for potential drops out (see Figure 1 for the flowchart of participants). The targeted population comprised French parents of children between 0 and 3 years of age. Specific prerequisites to participate were: (1) having a child <4 years old and ( 2) not residing in one of the following French departments: 21, 52, 70, 71 or 39 (to avoid biases due to the implementation of another study in these areas). The representativeness of the sample was ensured by the quota sampling method, which was applied to the study population (parents of 0-3 years old children living

Parents' knowledge (accuracy and degree of certainty)

The questionnaire items exploring parental knowledge were in line with the content of the brochure, covering the ten chapters. The 30 items were developed to ensure that all of the chapters of the brochure were covered, and special attention was given to those recommendations that differed from previous guidelines. In fact, 17 of the 30 items covered aspects that were not addressed in the previous recommendations (32) and were thus considered new. Following results from a previous survey, it was ensured that all the content that parents were looking for was also covered (30). The content can be categorized into one of the following six areas: (1) breastfeeding/milk feeding (four questions); (2) age and modalities of introduction of food groups and different textures (three questions); (3) feeding strategies (four questions); (4) child behavior and parental feeding practices (six questions); (5) recommended foods (nine questions); and (6) children's cues (four questions). The questionnaire (list of items) is shown in Table 1. For each item, participants were asked to indicate whether it was true or false and to score their degree of certainty on a four-point scale (absolutely not sure, rather not sure, rather sure, very sure).

Parental attitudes toward the content of the brochure

In the second part of the T1 questionnaire, parents were asked their opinion regarding the content of the brochure. They were asked to indicate whether they found the content to be useful, easy to

understand, to answer their questions and whether the topics that they considered interesting were well covered in the brochure using a 4-point Likert scale, which ranged from strongly agree to strongly disagree. Parents were also asked whether, in the prior two weeks, they had sought information regarding child feeding anywhere other than in the brochure and, in the case of an affirmative answer, in which media they did so. Finally, parents were asked to answer using the same 4-point Likert scale whether they agreed on three self-efficacy statements regarding following the recommendations contained in the brochure. In particular, they were asked to indicate whether:

(1) they were willing to follow those recommendations; (2) it would be difficult to follow the recommendations without the support of their partner and family; and (3) it would be difficult to follow the recommendations if their friends were not following the same recommendations. These three self-efficacy statements were formulated in accordance with a validated questionnaire to assess maternal attitudes toward infant feeding (33).

Ethical consideration

The study was conducted according to the guidelines laid down in the Declaration of Helsinki.

Participants voluntarily agreed to participate in the study, gave their informed consent to take part answers at T1 was detected for q26 (allergens). The proportion of mastered answers significantly increased between T0 and T1 for all the questions. recommendations without the support of their close family. Some parents felt the need to gather information from sources other than the brochure. From the perspective of programming a national plan for the dissemination of new child feeding recommendations it can be useful to provide parents with the same official information via differing sources (internet, health care professionals). This will contribute to avoiding rising doubts about how to perform optimal feeding practices and will make parents even more certain about their knowledge.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Author Contributions

SDR was a major contributor in writing the manuscript, the study design and conception of the questionnaires. SN, PD and CS contributed and validated the methodology and critically edited the questionnaires. SDR finalized the questionnaires. SDR and CC analyzed the data. All authors critically reviewed and commented on subsequent drafts of the manuscript and approved the final version.

Funding

The study was conducted as part of the project "Edulia-Bringing down barriers to children's healthy eating", which has received funding from the European Union's Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement No 764985. This work was also supported by grants from the Conseil Régional Bourgogne, Franche-Comte (PARI grant) and the FEDER (European Funding for Regional Economic Development).

Acknowledgments

The authors thank the parents for their time and willingness to participate in the study. We also acknowledge Corinne Delamaire and Laurence Noirot (Santé publique France) for their advice when designing the questionnaire.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Le sommeil

De la naissance à 1 an, il est recommandé qu'un enfant dorme entre 12 et 16 heures par 24 h ; puis, jusqu'à l'âge de 5 ans, entre 11 et 14 h par 24 h. Il est important de respecter une régularité dans les rythmes de sommeil (heures de coucher, de sieste…).

- of information can even be contradictory (27), resulting in the spread of disinformation and misinformation. Considering that early eating habits generally have a lasting impact throughout childhood and continue into adulthood (28), it is essential to support parents with the appropriate tools and guide them to promote the healthy development of children. In France, official recommendations for feeding children aged zero to three were updated and published in 2019 (29,30). A paper brochure intended for parents and professionals was produced by the French public health agency to make the recommendations relating to infant and young child feeding as accessible as possible to parents. From a public health perspective, a precise and systematic evaluation of communication tools produced by policy-makers and public health stakeholders at the design stage is useful to account for the needs of public health intervention recipients. In the present case, these recipients are parents and professionals, who are judged by parents as a natural intermediary for the circulation of such information (31).

In France, when the child is between zero and sixteen years old, parents are encouraged to take her or him to 20 free and compulsory consultations with health care professionals (HCPs), and the majority of visits (13 visits) take place within the first three years of life (32). Therefore, health and childcare professionals (CCPs) play an important role in France for the support of harmonious child development: they interact with parents during the different phases of child feeding, and they are well placed to positively influence parenting decisions. The majority of parents in France trust pediatricians; as the 2013 Nutri-Bébé study showed, 58% of mothers of children between 15 days and 35 months seek advice to feed their child (33). Moreover, a recent study explored French parents' information-seeking behaviors on infant and young child feeding. In terms of influence on parental feeding practices, HCPs are the most used and trusted source of advice (primary source of information for 81% of parents with a level of influence of 7.7 ± 1.7/10), followed by CCPs (influence 7.3 ± 1.8, but less used, 30%) (31). For these reasons, it is relevant to address HCPs' and CCPs' perceptions of public health material to support parental feeding decisions.

Interventions given via HCPs have an impact on obesity prevention, as shown by quantitative and qualitative studies (34)(35)(36). However, little research has been conducted on understanding professionals' practices and needs and integrating those needs to design effective prevention material for feeding children aged zero to three years. This material could be used to efficiently disseminate relevant messages and up-to-date information about child feeding to parents. Thus, the main objectives of this study were: (1) to investigate, via semi-structured interviews, the practices and needs of HCPs and CCPs when giving guidance to parents on child feeding (zero to three years old) and ( 2) to explore the first impressions of professionals on the

Study design

HCPs and CCPs experiences with communication with parents about child feeding were undertaken using a qualitative inductive approach (38). Face-to-face, semi-structured interviews were considered the best methodology to address the aim of the study, as they could allow us to address specific questions in line with the research aims, but they could still give the freedom to the participant to freely talk about his or her experiences (39). Given the context of the COVID-19 pandemic, interviews were scheduled online and conducted via videoconference when possible. In this way, it was easier to access participants in distant and different geographical locations, which allowed us to interview professionals from all over France (40). Moreover, the advantage of seeing the person and capturing the body language of participants was maintained and could allow researchers to make considerations on that, if needed. Written notes were taken after each interview to determine whether the interviewer deemed it necessary to highlight the attitudes or reactions of participants. The consequences of the restrictions imposed by COVID-19 health management on professionals' practices and their interactions with parents (doing medical appointments via video or phone calls) were also assessed in this study but will not be discussed in the present article. The consolidated criteria for reporting qualitative research (COREQ) checklist was applied to the description of methods and results (41).

(n=18) or workplace (n=3), and only the participant and the interviewer were present during the recording phase. At the beginning of each interview, CRN introduced herself (name and workplace) and gave a short introduction to the study and the data protection policy. The participants did not know anything else about the interviewer. Professionals had to verbally confirm that they agreed to be audio recorded. After being asked all the questions regarding the interview topics, professionals were invited to share any additional information that they considered important. When the participants had not read the brochure prior to the interview (n=2), the interviewer gave them time to read it, either by postponing the interview or by calling for a break during the session, according to participant's preference. When there was nothing to add, participants were thanked for their time, and the following steps of the study were elucidated. The interviewer took some notes after each interview and had regular discussions with SDR, the PhD student (31-year-old female) with a background in public health and nutrition who oversaw this study and who contributed to the conception of the brochure and could participate in the previous phases of the brochure evaluation (e.g., focus groups with parents, evaluation of effect of the brochure on parental knowledge). All interviews were audio recorded and transcribed verbatim. After all the interviews concluded, the participants were sent a brief summary of the whole analysis (not a transcript) and were asked to refer to the researchers if they had anything to add or disprove. Participants did not provide additional feedback on the report to the researchers.

Ethical consideration

All the participants received a written description of the project and were informed of their right to withdraw at any time without prejudice. Professionals agreed to participate in the study by giving their informed consent and selecting the appropriate case in the online form. To ensure confidentiality of the information collected and anonymity, the participants were assigned a code that only the interviewer could match to their names. These codes were erased once the interviews were completed, and only sociodemographic characteristics were retained.

Each participant received a voucher worth 40 Euros as a token of appreciation. Ethical approval (n°21-788) for this study was obtained from the Institutional Review Board (IRB00003888, IORG0003254, FWA00005831) of the French Institute of Medical Research and Health. This study was registered by the data protection service involved.

Data analysis

The responses of the professionals were audio-recorded and transcribed verbatim by a professional transcription service (11/21 interviews) or by the interviewer (CRN) with the help CCPs), eight were aged 35-49 years and two were aged 50-64 years. Fourteen professionals out of 21 (including 11/13 HCPs and 3/8 CCPs) had from zero to ten years of professional experience. Four professionals had 11-20 years of experience (1/13 HCP, 3/8 CCPs), two professionals had between 21 and 30 years of experience (one HCP, one CCP), and one CCP had over 30 years of experience. Fifteen professionals had children (8/13 HCPs and 7/8 CCP).

Nine out of the 21 professionals were working in areas with low poverty rates (< 13.3%), four in areas with high poverty rates (>17.2%) and eight in areas with middle poverty rates (between 13.3% and 17.2%). Fourteen out of the 21 professionals were working in rural areas (urbanization rate over 80%) and seven in semi urban areas (urbanization rate between 40% and 80%). 1 HCPs = Healthcare professionals.

2 CCPs = Childcare professionals. * Poverty rate: the monetary poverty rate corresponds to the proportion of individuals (or households) in a given department in a situation of monetary poverty. An individual (or a household) is considered poor when he lives in a household with a standard of living below the poverty line. In France and in Europe, the threshold is most often set at 60% of the median standard of living.

Two main themes and nine subthemes were developed through the thematic analysis. The main themes were: 1) practices and needs in terms of communication with parents on child feeding, and 2) perceptions of the brochure. Regarding practices and needs, four subthemes were identified: communication practices, communication barriers between professionals and parents, needs of professionals and needs of parents to improve communication. Regarding perceptions of the brochure, subthemes included new recommendations, general impressions, suggestions to improve the brochure, perceptions of the utility of the brochure in HCP and CCP practices, and of the use that parents can make of it. Detected differences between HCPs' and CCPs' discourse were reported in the results. The themes and subthemes are illustrated in Table 3 and described in detail below.

Communication practices

Professionals mentioned that they mostly provided information on child feeding orally to parents. HCPs also suggest websites to parents where they could search for information and the list of the most cited websites is reported in Table 4. HCPs explained that they systematically spoke with parents about child feeding at regular consultations within the first year of life, especially on complementary feeding (CoF) when the child is from four or five months of age.

They mentioned that they do not have a rigid approach on how and when parents should start CoF. However, almost all HCPs reported that they liked to provide parents with a framework (starting with fruits and vegetables and introducing proteins after six months of age).

"So, I recommend starting at five months but only with vegetables, and then introducing fruits. After six months, introduce animal proteins such as meat, fish and eggs." (P2, HCP, General practitioner) In PMIs, the brochure could be used only with a few parents because it is too long and complex for serving the most disadvantaged populations. CCPs generally stated that they would give the brochure to parents who have specific questions about infant and young child feeding. Suggestions to improve the brochure Most of the participants recommended making the brochure more entertaining (more pictures and less text) as they were provided with a preliminary version of the brochure with no results showed that professionals generally welcomed the brochure, but this medium was still considered as a tool that was not well-suited for disadvantaged populations, for whom a different support that includes more visual representations should be developed. A strategy that entails the use of the same document by both parents and professionals has the advantage of harmonizing the information circulating between them. Professionals would feel more legitimate in advising parents with the help of a document enclosing recommendations supported by all the newest scientific evidence. Moreover, providing relevant and consistent information to parents could help reduce the flow of conflicting information and misinformation and ultimately increase parental support for adopting new recommendations in their child feeding practices. To reduce health inequalities, further actions are needed from the public health sector to more specifically address the disadvantaged population. In the long run, this may contribute to reducing social disparities in nutrition and health.

Declarations

Ethics approval and consent to participate See the paragraph regarding "Ethical considerations".

Consent for publication

The manuscript does not contain any individual person's data, therefore this section is "Not applicable".

Competing interests

The authors declare that they have no competing interests. Authors' contributions SDR was a major contributor in writing the manuscript, the study design and conception of the interview guide. SN, CRN, PD and CS contributed and validated the methodology and critically edited the interview guide. SDR and CRN finalized the interview guide. SDR and CRN analyzed the data, with constant feedback from the SN. All authors critically reviewed and commented on subsequent drafts of the manuscript and approved the final version.