Complementary feeding challenges: Insights from Swiss parents ’ perspectives

Parents play a crucial role in deciding what foods to introduce to their infants during the transition from milk to solids. This study examined the challenges they face, including adherence to official complementary feeding recommendations and the struggles and concerns across different stages of feeding. Specifically, this study focused on the initial stage (transition from breastmilk/formula to mashed foods), middle stage (consumption of mashed foods and some fingerfoods, transitioning towards family foods) and late stage (complete transition to family diet). Findings from 22 semi-structured interviews with Swiss parents reveal that, despite being well-informed, practical obstacles such as returning to work, limited time for preparing homemade foods, managing multiple children, and food preferences often hinder adherence. Safety concerns like allergies and choking were prominent early on but decreased as infants grew older and parents gained confidence. In the middle phase, concerns shifted towards pesticides, indicating a growing awareness of food quality. Maintaining a healthy diet was a constant concern, with early reassurance from breastfeeding or formula feeding giving way to worries about balanced nutrition as solids became more prominent. Time constraints were particularly significant in the first two stages, due to the effort of preparing small amounts of mash and later cooking separate meals. Tailored support and clear communication can help parents navigate these challenges and promote healthier feeding practices.


Introduction
Parents hold a unique and critical role in deciding what foods to feed their infants during the transition from milk to solids.They are not only responsible for their child's nutritional intake but also for shaping early eating habits and preferences.The current study focused on the challenges parents face in a developed country like Switzerland, including adherence to official complementary feeding recommendations and the struggles and concerns they encounter throughout the process.By examining these aspects, the study aimed to provide insights into the complexities of parental decision-making, the factors influencing adherence to or disregard for feeding guidelines, and the specific difficulties parents face, in developed countries like Switzerland.These countries have been less researched in the past and can offer a unique perspective on challenges encountered in a well-ressourced setting (e.g., information and healthcare).

Importance of the complementary feeding stage
The period of complementary feeding-also known as weaning-is defined as the introduction of solid foods alongside breast milk or infant formula (World Health Organization, 2023).This period not only represents a significant milestone in an infant's neural and physical development (Koletzko et al., 2017), but it also brings major changes in eating behavior as infants move from an exclusive liquid diet to the family's diet (D'Auria et al., 2018;Fewtrell et al., 2017).This transitional phase usually begins between the fourth and sixth months of age and is the point at which breast milk or infant formula alone is no longer sufficient to provide the infant with the energy and nutrients needed for optimal growth (World Health Organization, 2023).
Besides meeting nutritional requirements, the introduction of solid foods represents a critical period for exposing infants to new flavors and textures.Particular attention should be paid to the foods that are chosen for infants during this developmental stage because they have a significant impact on shaping infants' long-term preferences and habits for healthy eating (Harris & Mason, 2017;Koletzko et al., 2014Koletzko et al., , 2017;;Schwartz et al., 2011).Extant evidence has indicated that parental feeding practices and the timing of introducing solid foods can affect infants' future acceptance of food and food intake (e.g., Burnett et al., 2022;Hendricks et al., 2006;Klerks et al., 2021;Lange et al., 2013;Nicklaus, 2011;Schwartz et al., 2011;Synnott et al., 2007).For example, the innate tendencies for sweet and salty foods can be modified through complementary feeding practices such as a step-by-step introduction to vegetables (Hetherington et al., 2015;Nekitsing & Hetherington, 2022).
As evidenced in recent literature reviews, scholars have increasingly focused on complementary feeding practices, including parental approaches and feeding styles (Shloim et al., 2015), the decision-making processes and motives behind parents' infant food choices (Spyreli et al., 2021;Thompson et al., 2023), and a wide array of elements associated with appropriate complementary feeding.These include parental knowledge, perceptions, skills, and attitudes, as well as socio-environmental aspects such as income, educational level, residence, employment status, ethnicity, and informational sources (Dickin et al., 2021;Herman et al., 2023).

Official complementary feeding guidelines
Eventhough, recommendations and guidelines regarding complementary feeding are very similar worldwide, there are some countryspecific differences (Nantel & Gingras, 2023).These recommendations are generally based on a large body of scientific evidence (Fewtrell et al., 2017).Therefore, adhering to them ensures that infants receive the optimal nutrients needed for growth and development (Fegan et al., 2016).In Switzerland, the national guidelines suggest exclusive breastfeeding until 4-6 months, with solid foods introduced between the 17th and 26th week.Initially, a few spoonfuls of vegetable mash daily are recommended to help infants adjust while continuing breast-or formula feeding.From 6 to 8 months, parents can offer mash twice a day, adding ingredients like cereals, meat, fish, and fruit.Between 7 and 9 months, three mashed meals a day are recommended, including small quantities of eggs and milk products, with continued breast-or formula feeding in the morning or at night.By 9-11 months, infants should have 3 to 4 solid meals daily, incorporating more textures (e.g., finger foods) and some family foods.Raw animal products, processed meats, salty or sweet foods, and items that pose a choking hazard (e.g., grapes, nuts) are not recommended at this stage.From 10 to 12 months, infants can fully transition to family meals, including processed milk products like cheese.It is recommended to have three main meals and two to three small snacks each day, along with sufficient water or unsweetened beverages.The Swiss national guidelines indicate that at this stage, breastmilk or formula is no longer necessary, but can still be continued if it is considered beneficial for the mother and/or infant (Federal Food Safety and Veterinary Office, 2020).
Although the Swiss national recommendations generally align with the WHO complementary feeding guidelines, there are some differences regarding the timing of solid food introduction and continued breastfeeding.The WHO advises exclusive breastfeeding until 6 months of age, with complementary feeding starting not earlier than the 26th week of life (180 days).Additionally, the WHO recommends continued breastfeeding up to 2 years of age (World Health Organization, 2023).The European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) also suggests exclusive breastfeeding for at least 4 months, aiming for predominantly breastfeeding for around 6 months.Both ESPGHAN and the WHO advise against introducing solid foods before 4 months of age (Fewtrell et al., 2017;World Health Organization, 2023).
Despite the critical importance of parents adhering to official complementary feeding guidelines, there is limited research on whether parents are aware of and follow these guidelines.Furthermore, the majority of existing research has primarily used quantitative methods (Briefel et al., 2004;Brown et al., 2023;Carletti et al., 2017;Dratva, Gross, Späth, & Zemp Stutz, 2020;Spyreli et al., 2021) and/or has been conducted in developing countries (Aber et al., 2018;Khaliq et al., 2023;Sarrassat et al., 2019;Ukoji & Fayehun, 2023;Victor et al., 2014), or among socioeconomically disadvantaged parents (Begley et al., 2019;Heinig et al., 2006), where access to information and resources is often limited.In contrary, in developed countries like Switzerland concerns during the complementary feeding phase have shifted from undernutrition to overnutrition and early childhood obesity (Webb et al., 2018;World Health Organization, 2024), despite having abundant information on appropriate feeding practices and a robust healthcare system (Roy & Girvan, 2023).

Complementary feeding concerns and struggles
Generally, parents have described the introduction of solid foods as a very challenging time (Matvienko-Sikar et al., 2018).For instance, Norlyk et al. (2019, p. 7) concluded their qualitative study stating that: "Parents were alert and felt anxious when introducing their infants to new foods".Alongside the existence of various and different guidelines for complementary feeding, parents also need to navigate numerous other factors that influence infants' feeding choices (Maslin & Venter, 2017;Matvienko-Sikar et al., 2018;Williams et al., 1999).In an effort to provide their infants with a balanced and nutritious diet, parents must juggle their personal beliefs (e.g., personal views of complementary feeding) and cultural values (e.g., tradition) with the realities of everyday life (e.g., time constraints, practicality, availability and affordability) (Boak et al., 2016;Isaacs et al., 2022;Williams et al., 1999).This complex trade-off goes beyond just nutritional and safety concerns (Graf et al., 2022;Norlyk et al., 2019, it also involves broader circumstances such as dietary and lifestyle choices.For example, parents who adhere to a particular diet, such as veganism, may face additional hurdles in ensuring that their infants receive adequate nutrition while adhering to their dietary principles (Jones & Burton, 2023).Similarly returning to work presents its own challenges, which can affect the time and resources available to prepare meals and select appropriate foods for infants (Matvienko-Sikar et al., 2018;Neve et al., 2024).
Interestingly, preliminary qualitative evidence from Nielsen et al. (2013) in Denmark revealed that mothers' concerns evolved throughout the phases of complementary feeding.In the initial stage (children aged 7 months), providing healthy foods was a top priority and safety concerns such as allergic reactions and choking accidents were particularly relevant.In the later phases (children aged 13 months), the focus shifted to the healthy integration of the child into family meals, with an emphasis on preventing fussy eating.The authors acknowledged that future research was needed to include a more detailed separation of phases.

Objectives of the current study
The current study addresses the following research questions: (1) To what extent do parents follow the Swiss national complementary feeding recommendations?(2) What are the reasons behind parents decisions to follow or disregard these recommendations?(3) What struggles and concerns do parents face during the complementary feeding process?and ( 4) To what extent are these struggles and concerns dependent on the complementary feeding stage (initial, middle and later stages)?
Our research intends to contribute to the existing literature in two ways.First, our focus on a developed country like Switzerland, where access to information and resources is abundant, can point to unique challenges parents face even in well-resourced settings.Unlike most of prior research, this context combined with our qualitative approach, offers an opportunity to investigate whether parents are willing to follow official guidelines.If they choose not to follow them, understanding the reasons behind their decisions is crucial.Gaining deeper insights into why parents follow or deviate from guidelines, along with identifying the reasons for non-compliance, can help in crafting successful early-life interventions focused on complementary feeding.Second, by examining the evolving nature of parental struggles and concerns across three distinct stages of complementary feeding (initial, middle, and later stages), we provide a comprehensive view of how challenges and priorities shift over time.This approach not only addresses a notable gap in the literature, but is likely to offer richer insights into their decision-making processes.Such information can be used to develop targeted interventions and communication strategies that are adapted to the specific needs and concerns of parents at various stages of their infants' development.

Study participants
The current study took place in the German-speaking part of Switzerland between June and July 2023 and was approved by the ETH Zurich Ethics Commission (EK 2023-N-92).The participants were recruited through snowball sampling among WhatsApp baby groups (e. g., groups for second-hand infant clothes, information events, playgroups).The access to the initial WhatsApp group was gained through an acquaintance of the primary investigator (PI) (AH), who happened to have a 16-month-old toddler at the time of the study.A message was sent to the initial WhatsApp group, informing potential participants that the interviews were part of the PI's PhD thesis and would cover topics such as the timing of introducing solid foods, the initial types of foods introduced, and the consumption of commercial infant foods, including commercial infant snacks.Group members were encouraged to share the message with other potential target group parents.Interested participants could contact the PI directly via WhatsApp message, email, or phone call.Parents were eligible if they were the primary caregiver of an infant between 6 and 18 months, had main responsibility for the infant's feeding, and had started with complementary feeding before the beginning of the study.Furthermore, the study criteria required that the infants of the interviewed parents had a normal birth weight (2500-4000 g) and were free from severe allergies or chronic medical conditions that could affect food intake.At the beginning of each interview, the participants were screened to confirm that they met the inclusion criteria.Our final study sample consisted of 22 caregivers.The recruitment of further participants was stopped once similar answers began to appear without any new responses emerging.The research team therefore came to the conclusion that "data saturation" had been reached, i.e. that further interviews no longer yielded any new insights (Guest et al., 2006).According to Hennink and Kaiser (2022) a homogenous study population, as is the case in our study design, can achieve data saturation with a relatively small numbers of interviews (e. g., 9-17 interviews).
All participants were fluent in German (n = 21) or English (n = 1).As shown in Table 1, our sample consisted of 82% women.The participants' ages ranged from 26 to 43 years, with an average age of 32 years.Here, 64% (n = 14) were first-time parents and 50% (n = 11) had a migration background (at least one of the parents was not originally from Switzerland).The interviewees had different educational backgrounds (vocational training, university of applied sciences or university degree) as well as different number of children in the household (1-4 children).The average age of the infants was M = 12 months, with an age range between 6 and 18 months.The higher proportion of women in our sample is representative of those typically being the primary caregivers at home (Federal Office of Statistics, 2019).The age range of infants included in our study aligns with the period of introduction of complementary and family foods (World Health Organisation, 2019).All participants who contacted the PI expressing their interest in participating in the study were found eligible during the initial screening process and none dropped out of the study at a later stage.

Interview flow
A qualitative approach using semi-structured interviews was used to gather insights into parents' choices of complementary foods.This method was selected because of its ability to deeply explore participants' experiences and perspectives, offering a richer understanding of the research topic (Adams, 2015).Previous qualitative research examining on parents' experiences with complementary feeding was used to develop the interview flow (Maslin et al., 2015;Norlyk et al., 2019).Specifically, Maslin et al. (2015) investigated mothers' perceptions of weaning and commercial infant food, providing a foundation for structuring the interview.This influenced aspects such as the introduction (e. g., confidentiality), warm-up questions, and the number of predefined questions per theme.Additionally, the study inspired several questions about weaning, including those exploring attitudes and associated struggles and concerns.The study by Norlyk et al. (2019), which examined first-time parents' experiences during the transition from milk to solids, offered valuable insights for identifying topics that influence parents' decision-making processes during this period, which helped in formulating some of our questions.
We developed an interview flow, with fixed questions.We revised and adapted the interview flow multiple times to ensure the clarity of the questions, reducing the likelihood of participants interpreting the questions differently.At the end of this process, the interview guide contained various open-ended questions aimed at exploring initial feeding practices, indicators for solid food introduction, and challenges and concerns associated with the complementary feeding phase.The orders in which the predefined questions were asked, and the nature of the subsequent follow-up questions depended on the participants' responses, hence differing between the interviews.The interview guide was tested in a pilot interview with an acquaintance of the PI, as she herself was in the phase of introducing solid foods to her toddler.The pilot study revealed that all but one question were clear, and the interview duration was deemed acceptable.Based on the pilot feedback, minor adjustments were made, including refining the question about safe foods.

Interview process
All interviews were conducted by the PI, who was a female PhD candidate in Food Science at ETH Zurich at the time of the study.The PI also held a Master of Science in Health Science and Technology from ETH Zurich and had previous experience in qualitative interview procedures.
The interviews took place at the participants' homes at convenient times, with the participants' infants present.At the start of each interview, the PI introduced herself, explained the study's purpose to establish rapport, and reviewed the study procedure.Participants were informed about their rights, such as the option to withdraw from the study at any time, to skip any uncomfortable questions, and assurances of anonymity.They were then asked to sign an informed consent form, which included details about the interview topics, procedure, audio recording practices, and compensation.All interviews were audio recorded with a digital voice recorder and conducted in Swiss German, German, or English, lasting between 45 and 60 min.
After initial questions about sociodemographic factors (e.g., age, education level, workload, number of children, diet), participants answered specific questions about complementary foods (as shown in Table 2).To initiate the conversation and gain preliminary insights into typical feeding routines, participants were asked to describe what their infants had eaten over the past 24h.Subsequent questions focused on complementary feeding choices, such as: "How often do you breastfeed your child?" "When did you start introducing complementary foods?" "What kind of foods did you start with?" "Why did you choose those foods as introductory foods?" "Why do you think those foods are safe for your infant?"Participants also discussed the signals they used to guide their decisions on complementary food choices and the sources of their recommendations and guidelines.For each participant, we aimed to understand the extent to which they followed the Swiss guidelines and the reasons behind their adherence or non-adherence, using individual prompts based on the conversation.
Next, parents were asked about the challenges and concerns they faced during the complementary feeding period.Although questions about commercial infant snacks were included, these topics are not analyzed in this paper and will be discussed in another study.Upon completing the interview, participants received a financial compensation of 50 CHF in cash (approximately $54).

Data analysis
The coding and analysis of the results were guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).After the interviews were completed, the audio files were transcribed verbatim by two scholars independently, one of whom was the PI.The transcripts were then cross-validated to ensure accurate word-for-word transcription.Transcripts were returned to each respondent for correction and clarification when necessary.Because most of the interviews (n = 21) were conducted in Swiss German or German, the transcripts had to be translated into English.To do so, the translation software DeepL Pro was used.The translation was checked for accuracy by two researchers of the study team before analysis.After transcription and translation, each interview was uploaded into the qualitative research software NVivo 12 for the thematic analysis.
The qualitative analysis of the interview responses was conducted by the PI (AH) (coder 1), in collaboration with second author, (SR) (coder 2), a marketing professor, and under the supervision of the fourth author (MS), a psychology professor experienced in qualitative research methods.Transcripts were analyzed using an iterative, inductivedeductive qualitative content analysis, which is consistent with the methods used in previous studies on similar research topics (Franck et al., 2024;Graf et al., 2022;Jones et al., 2023).The content analysis approach allowed the research team to measure the frequency of different themes and subthemes in the data (Vaismoradi, Turunen, & Bondas, 2013a, 2013b).Following the approach used by Graf et al. (2022), the study questions guided the two coders in developing an initial hierarchical coding system to categorize participants' responses using color codes in NVivo software.Previous qualitative research on similar topics suggests becoming familiar with the transcripts before data analysis (Franck et al., 2024;Jones et al., 2023).Therefore, the two coders read the transcripts multiple times, allowing them to become more familiar with the data and making it easier to identify recurring subthemes related to the main themes outlined in the initial coding system.As new themes and subthemes emerged in participants' responses, additional codes were added.
The coding process was conducted independently by the two coders for the first three transcripts.After initially coding these transcripts, the coders met to assess the suitability of the coding system and address any discrepancies.Based on participants' responses, two main themes were identified: (1) Awareness and engagement with official recommendations and (2) Struggles and concerns (see Table 3).Subthemes within these main topics were coded and summarized to determine their frequency.Furthermore, the two main topics were subdivided by complementary feeding stages to identify more specific subthemes relevant to each phase.The three complementary feeding phases were defined based on the different complementary feeding phases outlined in the Swiss national recommendations (Hayer, 2018).Fig. 1 shows a visualization of how participants were categorized into the three complementary feeding phases.
Quotes were selected that best supported the topic at hand.For each quote, the participant number and the infant's age are provided in brackets at the end of the quote.For the rest of the transcripts the updated coding system was used, with regular meetings between the two coders whenever a new sub-theme or inconsistencies emerged.To increase the validity of the findings, several rounds of review with the two coders and the professor regarding the coding system were conducted at various stages of the qualitative analysis (Patton, 1999).Upon completion of the individual transcript analyses by both coders, the research team deliberated on the shared discoveries and identified the primary findings from the interviews.The entire research team conducted several review rounds to discuss and refine major themes and subthemes.

Results
All parents encountered challenges during complementary feeding.The parents interviewed were in one of three phases: (1) the early phase, when the infant was transitioning from breastmilk/formula to mashed foods; (2) the middle phase, when the infant was starting to lose interest in mash and some family foods were being introduced; and (3) the late phase, when the infant was transitioning to the regular family diet.Our results revealed two main themes where parents faced the most challenges: adherence to official national recommendations and their struggles and concerns during complementary feeding.The following paragraphs will present these two themes along with their related subthemes.

Awareness and engagement with official recommendations
This theme examines parents' awareness and adherence to official national recommendations, including their attitudes towards these guidelines.All parents were informed about exclusive breastfeeding, the timing of solid food introduction, and appropriate first foods according to the Swiss national recommendations through pediatricians, midwives, and/or mother councling services.Most parents (n=19) were knowledgeable about the recommended age for starting complementary feeding and knew about appropriate first foods and feeding approaches.They were also aware of when to introduce various food groups and which foods were not recommended before 12 months of age (e.g., cheese or salt).However, our results showed that some parents (n=5) had negative attitudes towards certain recommendations.Additionally, despite most parents (n=14) knowing and agreeing with the guidelines, many found it challenging to follow them due to several factors described below.Note.The flowchart was developed based on the Swiss national recommendations for complementary feeding (Hayer, 2018).
3.1.1.Negative attitudes towards recommendations 3.1.1.1.Time point of solid food introduction.The most disagreed-upon recommendation among parents was the timing of solid food introduction.Several parents (n=7) felt that 4 months was too early.One mother shared her experience: "I started after 4 months because the pediatrician told me to, but in retrospect, it was way too early.I would not do it again" (P#18-10 months).Specifically, some parents who began introducing solid foods at 4 months (n=5) found that their infants initially resisted, requiring several attempts.One mother explained: "I started complementary feeding when he was 4 months old, as recommended, but he kept throwing up the food.I was desperate and tried everything possible, but the only thing he needed was more time.I waited for two weeks and tried again, and suddenly, he ate" (P#6-8 months).
3.1.1.2.First solid foods.Besides the timing, some parents (n=3) disagreed with the recommended first foods.One mother mentioned: "The pediatrician advised me to start with mashed foods, but I preferred babyled weaning, which enabled my child to eat 'everything'" (P#13-8 months).Another mother followed her intuition instead of the recommendations: "I started with children's biscuits.I just listened to my gut feelings and did not introduce the foods recommended by the midwife" (P#17-14 months).Similarly, the sequence of introducing certain food types was questioned by one mother: "I think salmon is a superfood.It has so many healthy fats, why shouldn't I give her smoked salmon now?Yes, of course, there is salt on it, but there is a lot of good stuff in it too, like the proteins she needs" (P#2-8 months).

General skeptisism about recommendations.
Five parents expressed general skepticism regarding the official recommendations.
One mother explained: "The recommendations change so fast.I can't imagine that complementary feeding has been reinvented since I was little; my mother also gave me everything to eat" (P#2-8 months).A mother with a Brazilian background highlighted the different recommendations between countries, which made her question which guidelines to follow: "In Brazil, it is recommended to exclusively breastfeed until six months.I have friends there who continued to breastfeed at least once a day until their child was three years old.
[ …] I don't understand why the recommendations differ between countries [Brazil and Switzerland]" (P#1-18 months).Finally, another mother expressed skepticism due to a lack of understanding about some recommendations: "I don't understand why at 12 months you can suddenly start giving your infant everything.It makes no sense to me.Sometimes it would help to know why recommendations are what they are" (P#22-6 months).

Reasons for not being able to follow recommendations
Interestingly, several parents (n=14) expressed a strong motivation to comply with official recommendations.However, they encountered various barriers that made it unrealistic for them to follow these recommendations in their daily lives.
3.1.2.1.Maternity leave.Some mothers (n=6) struggled with the challenge of continuing breastfeeding after returning to work.One mother explained: "I started complementary feeding as recommended at 4 months because I wanted to go back to work after 6 months [ …] How should I exclusively breastfeed until 6 months if paid maternity leave is only 4 months?That is just not possible if you need the money" (P#5-11 months).Another mother recalled her anxiety: "I became really anxious when I realized that my maternity leave was ending in two weeks [after 6 months] and he was still eating nothing.[ …] Six months is really not a long time, let alone four months-they are still so little" (P#6-8 months).Another mother shared similar feelings: "I remember when she was 7.5 months, I started to get nervous because I wanted to go back to work after 9 months and she was still eating so little solids.I felt I had to force her to eat.[ …] With a second child, I would definitely plan more time at home, but I know many families who do not have that financial freedom" (P#1-18 months).
The pressure from maternity leave often prompted mothers to start solid foods as soon as possible (n=4).One mother elaborated: "It is important to me that he becomes less dependent on me in the next 2 months as my maternity leave is ending.That is why we quickly started with mash, so by then he will hopefully eat enough to feel full" (P#22-6 months).
3.1.2.2.Time for cooking homemade complementary foods.Several parents (n=9) found it challenging to find the time to cook homemade complementary foods as recommended, particularly when combined with a full-time job.One mother shared her experience: "I am aware of the recommendation to feed your infant homemade complementary foods.When I was on maternity leave, I cooked everything myself.However, now I work 70% and simply do not have the time to cook every meal at home" (P#5-11 months).Another mother expressed her doubts about how full-time working mothers manage to cook homemade infant foods: "I cook everything myself as recommended, and also because I enjoy cooking.However, I do not know how mothers who work full-time can do it.[ …] I am a full-time mom, and even for me, finding time to prepare homemade infant food is sometimes challenging" (P#4-12 months).

Multiple children households.
Parents with multiple children at home (n=5) often followed a more pragmatic approach rather than strictly adhering to the recommendations, due to the dynamics of their household.One mother described her experience with introducing complementary foods to her fourth child: "I probably started too early with complementary foods because, at 6 months, she was already eating everything from the family table.But she was our fourth child; she just wanted to eat what her brothers ate" (P#8-16 months).A father explained their more relaxed approach with their second child: "With him [the second son], we were not as strict with salt as with our first son.With our first son, we were very careful and did not even cook pasta in salt water.But with him, we really no longer paid attention to these things" (P#3-13 months).
Additionally, second-time parents, in particular, relied on their familiarity with the recommendations from their first child and felt less need to search for information again.One mother noted: "With our first son, we went to maternity counseling.Now, with him [the second son], we don't, but we certainly took a lot of recommendations from our first son, although we are no longer as strict with many things" (P#12-11 months).Similarly, another mother of two said: "I did a lot of reading with my first daughter, but not with the second one.Now I do things more intuitively" (P#19-18 months).
3.1.2.4.Parental and/or infants food preferences.Some parents (n=7) expressed difficulties following complementary feeding recommendations due to their own or their infants' food preferences.One mother explained why she had not introduced fish to her 11-month-old: "I haven't introduced fish yet because we [my husband and I] don't like it much.[ …] I wouldn't cook fish just for her.That would be too expensive" (P#5-11 months).Similarly, a vegetarian mother shared her perspective: "I don't eat meat, so I won't cook it just for her.[ …] I'm still breastfeeding her, so I believe breast milk is a safer iron source than meat.
[ …] I'm sure she will eat meat soon enough" (P#13-8 months).Another mother expressed her frustration with cooking for her picky infant: "I received many recipes for homemade mash from the midwife, and it makes sense-if we [my husband and I] don't eat convenience food, why should he?[ …] I've tried several times, but he just doesn't like vegetable mash.Who has the time and money to waste when he only eats two spoonfuls and the rest ends up on the floor or in the trash?" (P#18-10 months).
3.1.2.5.External influences.Lastly, several parents (n=6) mentioned difficulties in influencing the behaviors of other caretakers, such as grandparents and daycare providers.One mother shared: "My mother gives her baby biscuits between meals.I wouldn't give her foods with so much sugar, but what can I do?She will continue to do it anyway" (P#5-11 months).Similarly, a father working full-time expressed their lack of control over what their child eats at daycare: "We both work fulltime, so we try to at least have dinner together with one healthy homecooked meal.[ …] We don't really know what she gets at daycare.We know on paper, but we don't actually know" (P#20-7 months).

Struggles and concerns with complementary feeding
The main struggles and concerns faced by the parents interviewed during complementary feeding are detailed in the following paragraphs, organized according to the different phases of complementary feeding.The most important results are summarized in Fig. 2.

Safety issues
When choosing complementary foods, safety was a top priority, mentioned 55 times by participants.During the early complementary feeding phase (n=5), concerns mainly involved issues like detection of allergies (n=5), choking (n=5), and bloating (n=3).A mother who was starting to introduce solid foods said: "The pediatrician told me I should repeat the same mash for several days to see if he is allergic to anything.I am allergic to apples myself, so I am anxious to see if he has any allergies" (P#22-6 months).Concerns about choking and bloating during this early phase influenced parental food choices.A father explained how the choking risk influenced which foods he lets his infant play with during mealtime: "We let her play with corn puffs during mealtimes because we do not have to worry about her choking.[ …] I would not let her play with a piece of apple, maybe with a piece of soft banana" (P#20-7 months).A mother explained how she selects foods for dinner: "I avoid introducing new foods in the evening before bedtime.Instead, I give her plain oats because she tolerates them well.I do not want her to experience bloating or an upset stomach that would prevent her from sleeping" (P#2-8 months).
When infants are transitioning from mash to family foods (n=10), concerns about choking are still relevant (n=6), as some infants are not able to bite well.A father said: "I am still very careful about what foods I give to him because I am still afraid that he will choke on something, as he cannot bite very well yet" (P#3-13 months).Additionally, new concerns arise, such as the fear of pesticides (n=5).A mother explained: "I only give him organic raw vegetables.I think our bodies can handle some pesticides, even though it's not healthy, but I want to protect his little body as long as I can.However, I will definitely not be as strict when he's older, as it is a financial burden" (P#18-10 months).Another mother shared her thoughts: "What scares me a little is the whole pesticide thing.It all sounds super healthy with fruit and vegetables and so on, but how heavily contaminated are they?Maybe in the end, pasta is healthier than a fully sprayed broccoli?I do not know.But organic products are also extremely expensive for the 99% of vegetables he does not want to eat anyway" (P#15-14 months).
As the infants get older and are nearly fully transitioned to the family Fig. 2. Summary of parental struggles and concerns devided by subtheme and complementary feeding phase.
Note: Early complementary feeding phase: Infant transitioning from breastmilk/formula to mashed foods; middle complementary feeding phase: infant eating mashed foods, some finger and family foods are introduced; late complementary feeding phase: infants fully transitioning to family diet.
diet (n=8), parents appeared more relaxed about their infant food choices.By this point, all parents trusted their infants to handle chunks of food without choking, and concerns about pesticides seemed to diminish.A mother shared her opinion about pesticides: "I no longer make sure that her food is always organic.I used to do that when she was younger, but now I just don't anymore because of the financial aspect.But I do make sure that it looks fresh" (P#1-18 months).Another mother explained why she is no longer afraid of her son choking: "I used to be scared [about choking], but he is getting older now.It used to be a lot more challenging when he started eating solids, but now he handles solid foods very well.If he chokes, he goes straight for water" (P#9-16 months).However, certain family foods like honey (n=8), spicy foods (n=8), extremely sweet foods (n=8), fatty foods (n=8), meat (n=8), raw meat/fish (n=5), and leftovers (n=2) remained off-limits for older infants because these foods were considered unsafe for them.

Striving for a healthy and balanced diet (mentioned 42 times)
Parents in the early complementary feeding phase shared that they did not worry much about vitamins or a balanced diet, as their infants were still breastfeeding.For example, one mother elaborated: "Generally, she eats really well, but if she has a day where she does not want to eat, I do not worry much, as she is still breastfeeding and gets all the energy and vitamins she needs for the day" (P#2-8 months).Three parents in this phase mentioned that they provided their infants with snacks between breastfeeding or during family meals to ensure the infants felt full.A mother elaborated: "Right now, he only eats a few spoonfuls of fruit mash and a lot of these corn puffs alongside breastmilk.At least with the corn puffs, he has something in his tummy (P#22-6months)." As infants transition from mash to family foods, parents became increasingly concerned about providing a healthy and balanced diet.They faced a dilemma between offering healthy foods like vegetables and providing foods their infants enjoy.One mother said: "On one hand, he has to eat vegetables to get enough vitamins, but he does not like vegetables or fruits.At the same time, I want my children to enjoy their food, so what should I do?" (P#16-12 months).Another mother noted that: "My husband and I prioritize a healthy diet.I want to provide my children with a balanced diet, but I often find myself exhausted from cooking for hours only for them to dislike the food.I am tempted every day to just make pasta with yogurt" (P#4-12 months).
When parents attempt to fully incorporate their infants into the family diet, the challenges of providing a healthy and balanced diet become even more intense.Initially, parents are willing to cook separately for their infants, but later they aim for full integration into the family diet.A mother said: "I am just tired of cooking extra meals.[ …] I do not cook extra meals for her anymore.Sometimes I fear that she does not get all the vitamins she needs, but the mother counseling told me that she could eat just bread for two weeks and still be fine" (P#1-18 months).Additionally, some parents (n=3) found that as their infants got older, they had less control over what they could feed them.For instance, one mother said: "She has a strong attitude.She already shakes her head very firmly when she does not want to eat something.[ …] With vegetables, she shakes her head very firmly; you cannot just put them in her mouth anymore.This was definitely easier when she was little" (P#10-17 months).Another mother shared: "The transition to the family diet was harder on me.I felt it was easier to provide her with fruit and vegetables when she was eating mash.Now, ensuring she gets enough vitamins is much harder as she prefers carbs" (P#1-18 months).In addition, parents also felt a loss of control over providing a healthy diet due to daytime childcare arrangements: "Vegetables are very difficult at the moment.When they are at my parents', they do not want to fight with them, so they just offer them what they like, mostly pasta" (P#11-15 months).Furthermore, parents found it more difficult to keep their infants away from unhealthy foods: "Now she is too old and realizes when we eat ice cream for dessert, so we have to give her some too" (P#19-18 months).Another mother said: "I also like to have a bit of chocolate in between.I do not eat it in front of him, but he is like a dog.As soon as he hears it, he comes running, and I have to give him some too" (P#9-16 months).

Time demands and patience (mentioned 31 times)
Time and patience emerged as main struggles for parents during the first two phases of complementary feeding.During the early complementary feeding phase parents struggled with the feeling that the time spent cooking mash was not well-spent, as their infants were still eating very little.One mother said: "He eats so little mash, if we are lucky three spoonfuls, and for that you free your afternoon to cook.I feel like it is not worth the time."Some parents found that their child did not want to be put down during cooking.A mother elaborated: "The amount they eat at the beginning is a teaspoon, and for that, you stand in the kitchen for hours and sit the children down.At best, they can keep themselves busy, and at worst, you are stressed while cooking because your child is screaming non-stop" (P#6-8 months).Similarly, another mother mentioned needing lots of patience to think about what foods to offer her infant: "To be honest, I see the period of complementary feeding as very exhausting.I am not patient enough to teach him how to eat.I am already looking forward to the time when I do not have to think about what he can or cannot eat" (P#22-6 months).
As infants transitioned from mash to some family foods, parents found it very time-consuming and requiring a lot of patience to prepare separate meals for the infant while also cooking for the family.One mother elaborated: "I want to cook everything myself, but sometimes it is so difficult to find something that satisfies everyone's needs" (P#4-12 months).A father described: "It just takes a long time to think about what you want to cook.You still have to cook some things separate for him because the texture is not appropriate.And then to have everything ready at the same time is very challenging" (P#3-13 months).
In the late complementary feeding phase, parents tend to be more relaxed about meal preparation.Still, some parents express concern about their infants becoming picky eaters and worry about not having the patience to manage this.One mother shared: "It used to be more challenging, but now I more or less know her preferences and can plan the meals accordingly.[ …] I just cook one meal.I don't want my kids to be those who only eat pasta without sauce, so they at least have to try new things.But I also try not to cook things I know she wouldn't like" (P#19-18 months).

Discussion
Our study provides insights into the extent to which parents follow official complementary feeding guidelines, the reasons behind their adherence or disregard, the struggles and concerns they face, and how these challenges vary across the initial, middle, and later stages of complementary feeding.Several implications can be derived from our findings based on 22 in-depth interviews with Swiss parents.

Difficulties in adhering to official guidelines
Previous research in developing countries shows that parents are not very much aware of official complementary feeding guidelines (Aber et al., 2018;Khaliq et al., 2023;Sarrassat et al., 2019;Ukoji & Fayehun, 2023;Victor et al., 2014).For example, Sarrassat et al. (2019, p. 13), who conducted a survey in Burkina Faso (Africa) concluded that: "We also found poor levels of knowledge regarding timely introduction of complementary foods."Obviously, adherence to official guidelines in these countries is also limited (Issa et al., 2022).On the contrary, the evidence in developed countries, where access to information is significantly greater, shows that parents are generally well aware of official guidelines (Brown et al., 2023;Spyreli et al., 2021), while there seems to be moderate compliance with such recommendations (Brown et al., 2023;Carletti et al., 2017;Dratva et al., 2020).For example, findings from a birth cohort of 400 Italian infants revealed that seventy-five percent of mothers followed three or more of the five WHO recommendations on adequate complementary feeding, but only 5% adhered to all five (Carletti et al., 2017).
Importantly, the quantitative approach in this area of research falls short in understanding why parents do not follow recommendations.While quantitative research can indicate whether parents follow guidelines, qualitative research can explain the reasons behind their choices.Our study contributes to the literature by using a qualitative methodology, which is particularly valuable in exploring the underlying motives and reasons behind parents' choices, providing rich, detailed insights that quantitative studies might miss (Choy, 2014).Specifically, our findings highlight parents' awareness and engagement with official recommendations, their attitudes, and the challenges they face.Most parents were knowledgeable about the recommended age for starting complementary feeding and the appropriate first foods according to the Swiss guidelines.However, some parents had negative attitudes towards certain recommendations, particularly the timing of solid food introduction, with several feeling that 4 months was too early.
Despite a considerable motivation to comply, many parents found it challenging due to various factors, including the pressure of returning to work after maternity leave, lack of time for preparing homemade complementary foods, the dynamics of households with multiple children, and their own or their infants' food preferences.Additionally, external influences from other caretakers, such as grandparents and daycare providers, made adherence difficult.This comprehensive examination reveals that while parents are generally aware of and agree with official guidelines, practical barriers often prevent them from following these recommendations consistently.Although there is limited research directly assessing the barriers to adhering to complementary feeding guidelines, our findings align with a qualitative evidence synthesis on parental experiences during complementary feeding (Matvienko-Sikar et al., 2018).This synthesis found that while most parents seemed aware of infant feeding guidelines, many did not follow them.Reasons cited included parents finding the guidelines either too structured or lacking structure.Furthermore, many parents were confused about the multiple sources of information reducing their adherence.Additionally, the study highlighted time constraints, often due to having multiple children at home, as a barrier to healthy feeding practices (Matvienko-Sikar et al., 2018).Moreover, another study described how infants' preferences and aversions to certain foods significantly influenced parental food choices during complementary feeding (Spyreli et al., 2021).
To address these barriers, extending maternity leave could help easing the transition to solid foods.Providing practical support, such as affordable, pre-prepared complementary foods and efficient meal preparation resources, can assist time-pressed parents.Tailoring feeding advice to individual circumstances and fostering open communication with all caregivers, including grandparents and daycare providers, can ensure consistency.

Struggles and concerns across different stages of complementary feeding
Our interviews reveal that parents' struggles and concerns-ranging from safety issues and efforts to provide a healthy, balanced diet to managing time demands and patience-vary significantly across different phases of complementary feeding.
Regarding safety issues, parents in the early phase were primarily worried about allergies and choking, while in the middle phase, concerns shifted towards pesticides.All concerns about food safety (e.g., allergies, choking, pesticides) became less prominent during the late phase of complementary feeding when infants started to be fully incorporated into the family diet.Notably, the level of concern about choking decreased in the late complementary feeding phase as parents gained more confidence in their infants' ability to handle chunks of food.Previous research by Graf et al. (2022), who interviewed mothers with infants between 6 and 19 months, identified allergic reactions and choking as parents' threats during complementary feeding, but did not specify if concerns evolve over time.The fear of choking has been described as a well-known obstacle to introducing new textures in complementary feeding (Norlyk et al., 2019), despite the benefits of varied textures for jaw development and future eating habits (Boulanger & Vernet, 2018).Emphasizing these aspects can encourage parents to follow the guidelines as their infants progress through complementary feeding.
Ensuring a healthy diet for their infants was a major concern in our study, which is consistent to prior research (Devia et al., 2021;Graf et al., 2023;Román & Sánchez-Siles, 2018;Vidal et al., 2022;Walls et al., 2023).Our findings, along with those of Nielsen et al. (2013), contribute to the understanding of how health concerns evolve during complementary feeding.Nielsen et al. (2013) found that in the early phase (infants aged 7 months), ensuring the child had healthy food was a given, with their diet distinct from the family's.In the later phase (infants aged 13 months), health concerns shifted to a longer-term perspective, focusing on integrating the child into the family's diet while maintaining their well-being.However, Nielsen et al. (2013) did not specify the extent to which the mothers were breastfeeding or giving formula milk.In comparison to Nielsen et al.'s (2013) study, the current study offers a more comprehensive analysis by comparing three distinct phases: early, middle, and later stages of complementary feeding, as outlined by the Swiss national guidelines.By examining these three phases, our study provides a more nuanced understanding of the evolving concerns and practices of mothers during complementary feeding.
Our interviews revealed that in the early complementary feeding phase, parents generally felt secure about their infants' health because many were still breastfeeding or receiving formula daily.This reassured parents that their infants were getting adequate energy and nutrients, reducing worries about food selection.As infants transition to the family diet, parents face intensified challenges in maintaining a healthy and balanced diet, often struggling with reduced control over food choices and the influence of external caregivers, while also dealing with their children's growing preferences and resistance to certain foods.Notably, some parents admitted to supplementing mash with less healthy options like puffs in the early stage.This aligns with prior research showing a tendency among parents to provide infants with processed snacks instead of healthy finger foods like raw vegetables or fruits (Childs & Sibson, 2023;Isaacs et al., 2022).Given the crucial role of early nutrition in shaping infants' taste development and its long-term impact on eating habits (Koletzko et al., 2014(Koletzko et al., , 2017;;Schwartz et al., 2011), healthcare professionals should stress the importance of avoiding salty and sweet foods, including highly processed snacks, at the onset of complementary feeding.Early exposure to these foods can foster unhealthy dietary preferences later (World Health Organization, 2017, 2019).
Finally, some studies have highlighted that lack of time is one of the main challenges faced by parents of young children during the complementary feeding stage (Heller et al., 2021;Nielsen et al., 2014;Weber et al., 2023).However, these studies do not delve into how this challenge and concern vary throughout the different stages of complementary feeding.Time and patience emerged as significant struggles for parents during the early and middle phases of complementary feeding.In the early phase, parents felt that the time spent preparing mash was not worthwhile since their infants ate very little.They also faced challenges with infants who did not want to be put down during cooking, making meal preparation stressful.As infants transitioned from mash to some family foods, the demands on parents' time and patience increased, as they had to prepare separate meals for the infant while also cooking for the family.In the late complementary feeding phase, parents became more relaxed about meal preparation.

Limitations
The present study has some limitations that merit consideration.First, our study sample consisted of 22 participants in Switzerland.Although we ceased conducting interviews upon reaching data saturation (deteremined by the study team), it is important to acknowledge that data saturation is quite a problematic concept in qualitative research and highly subjective (Braun & Clarke, 2021).Our current sample was highly homogeneous, with all infants having at least one Swiss parent and all participants living in the same region (Kanton of Zurich, Switzerland), which limits the generalizability of our findings.Future research should focus on including more diverse populations.Specifically, we recommend incorporating racial and ethnic diversity, along with parents from various socioeconomic backgrounds, to explore how cultural norms and individual circumstances affect the challenges parents face during complementary feeding.In addition, all participants who reached out to the PI were self-selected, suggesting a likely interested in the topic of this study.Consequently, participants responses might be different from those who are less interested in the topic.However, this self-selection also ensured that participants were engaged and knowledgeable, providing valuable insights into the area of research.Finally, the current study faces limitations because of its reliance on self-reported data, which are vulnerable to recall and social desirability biases, potentially leading participants to present their behaviors more favorably.

Conclusion
Our study offers insights into parents' adherence to complementary feeding guidelines, their reasons for compliance or non-compliance, and the evolving struggles and concerns they face across different feeding stages.While parents were generally well-informed about guidelines, practical barriers such as the pressure of returning to work, limited time for homemade foods, managing multiple children, and food preferences often hindered adherence.Concerns about safety, like allergies and choking, were prominent early on but decreased as infants grew older and parents gained confidence in their ability to handle varied foods.In the middle phase, concerns shifted towards pesticides, reflecting a growing awareness of food quality.Ensuring a healthy diet remained a major concern throughout.Initially, parents felt secure about their infants' health due to continued breastfeeding or formula feeding, but as infants grew older and ate more solids, parents worried about providing a balanced nutrition.Time constraints were particularly relevant in the first two stages, initially due to the effort of preparing small quantities of mash and later due to the demands of cooking separate meals for the family and the infant.Tailored support and clear communication can help parents navigate these challenges and promote healthier feeding practices.

Ethical statement
Ethical approval for the involvement of human subjects in this study was granted by the ethic commission of the ETH Zürich.Reference number EK 2023-N-92.Before starting each interview, the participants were asked to sign an informed consent form, where they were told about the interview topics, the study procedure, audio recording practices and compensation.All interviews were performed, and audio recorded by two researchers from ETH Zurich including the corresponding author.The participants were assured that the recordings would be kept confidential and were told that they had the option not to answer any question if they felt uncomfortable doing so.

Declaration of competing interest
Co-author Luisma Sanchez-Siles works for the Institute for Research Nutrition, Hero Group.

Fig. 1 .
Fig. 1.Flow chart for participant categorization into the three complementary feeding phases.Note.The flowchart was developed based on the Swiss national recommendations for complementary feeding(Hayer, 2018).

Table 1
Description of interviewed parents.

Table 2
Interview procedure: Sections and questions asked during the semi-structured interview.
•How often do you breastfeed your child with breast milk or formula?If none: With how many months did you stop breastfeeding?•When did you start the introduction of solid foods?(Prompts: Why did you start introducing solid foods?What helped you make the decision to introduce solid foods?Did you follow the Swiss guidelines in this regard?,Why do you follow the guidelines,

Table 3
Hierarchical coding structure of themes and subthemes retrieved from participants interviews.