Good oral health was defined by the absence of disease: aesthetically pleasing teeth were white, straight, evenly spaced, without pain, holes, decay or discoloration; pink gums and attractive smiles (13, 41, 44–50). However, parents’ views on the health of primary and permanent teeth differed. Parents valued primary teeth if they believed it would impact the health of permanent teeth (47, 48, 51–53). Conversely, only permanent teeth were valued when these were viewed as having more long-term importance than primary teeth (49, 54–56).

Healthy or desirable body weight was determined by size or shape, appetite and physical activity. Many parents considered largeness or heaviness to demonstrate adequate nutrition and growth, energy reserves, physical strength, and contentment (35, 37, 39, 57–65). Parents considered good appetite and dietary intake, lack of fussiness around food, and physical activity or play without signs of overexertion or developmental delay, as signs of children having healthy weight, receiving adequate nutrition, and being sufficiently active (33, 35, 38, 39, 42, 43, 57–60, 62, 65–72). Largeness or heaviness, which demonstrated growth and nutrition, were distinct from overweight or obesity as disease conditions. This was conceptualised as “solid”, “thick”, or “fresh”, “baby fat”, “plumpness”, “chubbiness”, “muscled” or “chunkiness”, and could be informed by cultural beliefs and norms (32, 35, 38, 42, 43, 60, 62–66, 73, 74). Few studies found positive beliefs towards smaller body weight, and could be mitigated by health provider advice (67, 75) or beliefs about breastfeeding benefits (76).

Few parents viewed the use of growth charts as a clinical method of identifying healthy body weight positively (36, 40, 70, 77). However, parents also viewed high growth chart trajectories or percentiles positively when this was reported or viewed as healthy, “normal”, or showing increasing body weight (65, 78, 79).

Parents valued their ability to meet their children's wants and needs (43), and provide a safe family and household environment (33, 80, 81). These beliefs informed perspectives regarding feeding, activity and play, and screen time.

Parents identified poor oral health through symptomatic disease and unattractive teeth. Few parents used medical terms, such as “tooth decay” or “cavities”—instead, this was reported as visible decay, including holes, “rot” and “black spots”; fractured or cracked teeth; tooth discoloration; tooth loss and extraction; pain, distress, poor behaviour and mood; bad breath; inability to eat and sleep; visible fillings; and swollen gums (36, 41, 44, 45, 48–51, 55, 100, 110–114).

Parents believed that smallness or thinness in children indicated undernutrition; poor growth and development; or illnesses, like anaemia and tapeworms. These beliefs could be informed by health provider assessment when children did not follow a standardised growth trajectory (32, 78) or in populations with poverty or socioeconomic disadvantage (33, 77, 96). Thinness was also associated with parental neglect or inability to meet nutritional needs (40, 66, 77, 96).

Parents considered infants or children to be at an unhealthy weight when their appearance or behaviour appeared unattractive; when they appeared “larger” than their peers; or when they required larger clothing sizes (35, 40, 59, 60, 62, 65, 66, 84, 89, 115, 116). While parents may acknowledge that their child had a clinical diagnosis of overweight or obesity, few parents felt this meant their child's weight was unhealthy unless physical and emotional consequences were experienced, which is discussed separately in theme 2.4.

Notably, there were opposing views on the suitability of standardised growth charts to identify healthy weight and growth. Few parents felt that growth charts were suitable for identifying overweight or obesity (35, 60, 67, 84, 115). Parents demonstrated uncertainty towards the purpose of growth charts (63, 70, 79). When growth charts identified a clinical diagnosis of overweight/obesity that was incongruent with parental expectations, parents viewed growth charts negatively or being incompatible with a child's unique growth trajectory (32, 35, 42, 79, 89).

Parents generally were able to identify certain causal and protective factors in ECC, overweight, obesity or weight gain. These findings are focused on the parental perspective, instead of biomedical models of pathophysiology.

For ECC, causal factors included insufficient tooth brushing, dietary sugar intake (particularly sweets, fruit juice and milk), and bottle feeding (13, 36, 44–53, 55, 76, 82, 85, 91, 95, 97, 99, 101, 103, 105, 107, 108, 110, 113, 117–119). Protective factors included regular tooth brushing or gum cleaning, limiting dietary sugar intake, limiting bottle use, and routine dental check-ups (41, 44, 46, 47, 49, 50, 52, 53, 98, 100, 103, 104, 107). Few parents identified night-time breastfeeding, cariogenic bacteria transmission, or carbohydrous foods, as causes of ECC (50, 53, 91, 95, 101, 105, 110); or the role of fluoride in ECC prevention (46, 47, 100, 104, 120).

For weight gain, causal factors included dietary intake of high fat and/or high sugar foods, overeating, early introduction of solid foods for infants, prolonged bottle or formula feeding, and physical inactivity or sedentary behaviour (35, 37, 60, 62, 65–67, 75, 77, 78, 82, 85, 86, 89, 90). Protective factors included breastfeeding, healthy eating, decreased intake of energy-dense unhealthy foods, physical activity, and infants reaching developmental milestones, such as walking (32, 42, 58, 60, 82, 89).

Dental attendance was not consistently seen as a protective factor against ECC. Many parents considered accessing dental care only for symptom treatment (36, 45, 48, 49, 53, 54, 81, 94, 97, 98, 102, 104, 114, 120–122). Parents who valued preventative dental care may only do so after negative experiences of ECC from their families and communities (52, 54, 56, 94, 97, 111).

Genetic susceptibility to ECC or higher body weight was frequently discussed as being intrinsic. Therefore, ECC, overweight, or obesity was inevitable or untreatable, even with preventative behaviours, such as regular dental attendance or lifestyle behaviours (33, 35, 38, 39, 42, 43, 46–51, 57, 60, 61, 65, 66, 68, 69, 71, 77, 86–89, 94, 95, 98, 99, 105, 112, 115, 118, 123).

Some beliefs reflect unclear understanding of biological causes of ECC or overweight and obesity. This included ECC being caused by poor tooth formation from undernutrition, e.g., insufficient milk or calcium during pregnancy or infancy (46, 55, 95, 103, 112, 118), or use of antibiotics (49, 110); and overweight and obesity being caused by metabolism, poor sleep, stress from bullying, and hormones in animal production (35, 60, 65–67, 77). Parents also believed mouth washing was sufficient for oral hygiene, especially when feeding to sleep made tooth-brushing difficult (36, 76, 91). For parents who misunderstood the causes of ECC, cariogenic risk factors could be maintained—for example, parents who believed that chewing or sucking of bottle teats caused ECC (46, 95, 117, 118) replaced bottles with cups during feeding to sleep.

The cariogenicity and obesogenicity of foods and drinks could be poorly understood, as demonstrated through beliefs on: the healthiness of fruit juice, fruit drink and soft drinks; dilution of sugary drinks with water being protective against ECC; or use of unrefined sugars, such as jaggery or honey (49, 52, 54, 60, 61, 85, 91, 92, 94, 95, 112, 117, 120). Some parents were unaware that certain foods or drinks—such as candy, chocolate, cookies, potato chips, or ice cream—were cariogenic or obesogenic (49, 72, 81, 91, 95) or felt that certain foods, while cariogenic, remained nourishing (36, 54, 81, 94).

For parents, unhealthy teeth and weight was defined by consequential impacts. Understanding the life course trajectory of overweight, obesity and ECC could inform how parents responded to these conditions. However, there were notable differences in perceptions on ECC, compared to overweight and obesity. Fewer parents proactively discussed prevention, while those who did could be informed by experiences in their family and community, such as their childhood or the care of other children (38, 39, 41, 45, 75, 82, 84, 85, 94–96, 101, 107).

The consequences of ECC related to the permanence of primary and permanent teeth. Parents reacted to poor health in primary teeth when it impacted nutrition, speaking, child mood and behaviour, or when it was believed to impact the health of permanent teeth (36, 47, 48, 51–53, 94, 99, 100, 114). While asymptomatic ECC, such as white spots, did not prompt health seeking by some parents, parents also reported being dismissed and unsupported by health professionals when seeking advice on asymptomatic ECC (36, 46, 48, 111, 112, 114). Parents' views on primary teeth was related to its impermanence, and varied from apathy to concern (13, 36, 44, 47–50, 53, 56, 94, 98, 102, 113, 121). For some parents, the health of primary teeth appeared unrelated to the health of permanent teeth, and primary teeth were “practice” for oral hygiene behaviours for permanent teeth (13, 48, 49, 53, 111). Subsequently, dental care reflected a focus on acute symptom treatment, such distress and poor behaviour from dental pain, with minimal focus on ECC prevention (94, 112, 114, 124). Longer-term dental care behaviours varied after experiences of ECC: for some, the resolution of symptoms after removal of decayed teeth led to dental care behaviours not being maintained, while others were motivated to maintain dental care behaviours (49, 94, 95, 99, 101, 106, 110, 111).

Consistent with this, overweight and obesity—either as a present diagnosis or a future risk—was not seen as significant if children appeared asymptomatic (40, 43, 67, 84, 89, 125). Overweight or obesity was detrimental when it was consequential, such as parental back pain when carrying a heavy infant; physical incapacity, including delays in reaching developmental milestones, shortness of breath, and tiredness during play; and teasing or bullying that impacted children's mental health and self-esteem (32–35, 37–39, 42, 43, 60, 61, 64–67, 77, 82–84, 87–89, 96, 116).

Understanding the life course trajectory of overweight or obesity meant that some parents anticipated the risk of future weight-related health problems and the normalization of obesogenic lifestyle behaviours into adulthood (32, 33, 37, 39, 43, 60, 64–66, 75, 77, 82, 84, 85, 87–89). However, despite significant health consequences, overweight or obesity were unimportant at present, and would only be a problem beyond infancy or school age (58, 65, 68, 69, 78, 87). Subsequently, parents believed that obesogenic behaviours could be addressed later, or that body weight would self-resolve when child height or physical activity intrinsically increased (58, 64–66, 69, 83, 84, 87, 89, 116).

Parents utilised professional and non-professional sources for information about children's health, such as medical, nursing, dentistry, allied health professionals and government programs, and family, friends, peers and advertising, respectively. Teachers, early childhood educators and social workers were also important non-health professional sources of information (45, 46, 49, 55, 76, 88, 97, 101, 103, 104, 108, 117, 126). Attitudes towards these sources were dependent on being aligned with parents’ expectations. Parents' satisfaction with professional sources was impacted by expectations of care, agreement with information received, comprehensiveness of education, quality of services, and the parent-provider relationship, particularly a clinician's competence when working with children (13, 32, 35, 38, 49, 53, 58, 60, 63, 75–78, 81, 82, 84, 87, 89, 90, 92, 94, 97–99, 103, 107, 111, 113, 114, 120, 122, 123, 126). The use of non-professional sources of information varied: many parents trusted the advice and experiences of other parents and family members (13, 35–37, 46, 48, 58, 76, 83, 87, 92, 93, 96), while few parents felt this information did not align with professional advice (74, 87, 99, 114). Notably, information from health professionals could impact how parents perceived the severity or significance of ECC, overweight or obesity (32, 46, 48, 58, 65, 84, 86, 89, 112) – and parents were confused when received conflicting information from trusted sources or were advised by health professionals that further health care seeking was not needed (35, 53, 54, 76, 84, 89, 99, 111, 114, 121, 125).

Parents reported difficulty accessing health providers being a barrier to accessing information or care to support their child's health. This included actual or perceived cost of services; time barriers; inability to receive specialist referrals; attendance to service locations, related to transport challenges and isolation of rural, regional and remote areas; language barriers; and refusal of dental services for children reportedly too young for care (13, 43–46, 50, 52–54, 56, 81, 82, 94, 98–100, 111–114, 117, 120).

Parents identified information and resource needs based on gaps in care, which may indicate that routine well-child services were not meeting parent needs, or that parents were not accessing health services. These topics included breastfeeding and introduction of solid foods, healthy eating, physical activity, sleep, understanding growth charts, oral health and care, and general parenting, such as responding to infant cues, and child development. Information also needed to be specific, factual and practical (32–34, 47, 50, 53, 58, 62–64, 70, 74, 76, 78, 80–84, 87, 88, 90, 96, 102, 103, 108, 111–113, 115–117, 120, 125, 126).

Parents offered suggestions on community- or school-based programs that could be available, such as parent groups, playgroups, education programs with peer learning, dental outreach, and activity programs (33, 48, 50, 53, 58, 80, 88, 96, 109, 125). To be accessible, these programs needed to be free, provide childcare, and involve children in age-appropriate education (34, 125). Resources also needed to be proactive instead of reactive, such as the establishment of food assistance programs or food co-ops with healthy food, and the provision of dental care supplies, like toothbrushes and toothpaste, through community services (34, 45, 50, 87, 100, 108).

Parents wanted improved access to dental care for children, such as affordable, subsidised or free dental care; alignment of dental services with medical services; or access to paediatric dentists (45, 53, 54, 98, 99, 106, 108, 113). While free or subsidized dental care could be available in countries with public healthcare, this was not broadly known, or was perceived as poorer quality compared to private health services (44, 51, 53, 54).

Resources were needed to meet diverse language needs, such as low literacy resources, access to interpreters, and increased language diversity (38, 44, 48, 53, 63, 87, 90, 102, 113). Resources in different formats or modes were required, varying from print resources; digital resources, such as electronic newsletters, internet and social media websites; and in-person resources, such as parenting classes, and community health workers to link parents to services (44, 48, 63, 87, 90, 120, 125).

Parents identified practices to raise a healthy child in theme 1.2. However, internal and external factors limit their efficacy in doing this.

While parents considered tooth brushing as important, they experienced barriers, including self-efficacy, lack of time, and responding to a resistant child (13, 36, 48–50, 53, 80, 81, 94, 95, 97, 99–105, 110, 122). Some parents reported teeth cleaning that was not best-practice, such as unsupervised tooth brushing before 7 years of age, mouth rinsing or cleaning with cloth instead of tooth brushing, delayed tooth brushing initiation, or suboptimal tooth brushing time (44, 49, 53, 97, 101, 103, 110, 119, 120, 122).

Parents recognised the difficulty in supporting children's healthy eating in obesogenic and cariogenic environments. Parents felt their attempts to encourage healthy eating were undermined by other carers and children's peers (13, 37, 42, 44, 49, 50, 53, 56, 60, 61, 64, 66, 67, 78, 81–84, 93, 99, 104, 111, 115, 127). Similar to tooth brushing, parents experienced barriers to providing healthy foods, including self-efficacy, children's food preferences, financial and time costs of providing healthy food, and the convenience and inexpensive nature of unhealthy foods (13, 34, 35, 50, 60–62, 66, 74, 77, 81, 82, 84, 85, 88, 96, 99, 100, 116, 117, 125, 126).

Parents' use of food, or response to signs of hunger, indicated these were barriers to healthy eating. Parents reported the use of persuasive feeding to pressure children into eating healthy foods, reduce disruptive behaviour, or to reward good behaviour (13, 37, 38, 42, 49, 57, 64, 75, 77, 81, 83, 85, 87, 126). Parents felt unable to deny food requests, challenge food refusal, or address resistance from children, even during food introduction for infants (35, 36, 38, 44, 49, 61, 64, 71, 75, 83, 85, 91–94, 97, 98, 115, 123). This awareness of foods being unhealthy while also feeling children could not be refused is distinct from theme 1.2.2, where food should not be denied and should be provided to encourage diverse food experiences.

Ensuring infants and children were fed, particularly “fussy” or “picky” eaters, could lead to prolonged bottle feeding (36, 42, 49, 90). Likewise, parents' concerns that children's refusal to use drinking cups or eat healthy foods would cause undernutrition led to encouragement or maintenance of cariogenic or obesogenic feeding behaviours (35, 49, 61, 76, 81, 90, 93, 95, 97, 99). Parents did not feel confident to deny food for children who reported being hungry (32, 35, 42, 60, 61, 97, 109, 115), which was similar to parents feeling that feeding to soothe was the only behaviour that could settle crying, tantrums or fussiness (13, 57, 64, 80, 123).