A comparison of executive function in very preterm and term infants at 8 months corrected age

Executive function (EF) emerges in infancy and continues to develop throughout childhood. Executive dysfunction is believed to contribute to learning and attention problems in children at school age. Children born very preterm are more prone to these problems than their full-term peers.

Breastfeeding self-efficacy of women using second-line strategies for healthy term infants in the first week postpartum : an Australian observational study

Background Breastfeeding self-efficacy (BFSE) supports breastfeeding initiation and duration. Challenges to breastfeeding may undermine BFSE, but second-line strategies including nipple shields, syringe, cup, supply line and bottle feeding may support breastfeeding until challenges are resolved. The primary aim of this study was to examine BFSE in a sample of women using second-line strategies for feeding healthy term infants in the first week postpartum. Methods A retrospective self-report study was conducted using the Breastfeeding Self-Efficacy Scale - Short Form (BSES-SF), demographic and infant feeding questionnaires. Breastfeeding women who gave birth to a singleton healthy term infant at one private metropolitan birthing facility in Australia from November 2008 to February 2009 returned anonymous questionnaires by mail. Results A total of 128 (73 multiparous, 55 primiparous) women participated in the study. The mean BSES-SF score was 51.18 (Standard deviation, SD: 12.48). The median BSES-SF score was 53. Of women using a second-line strategy, 16 exceeded the median, and 42 were below. Analyses using Kruskal-Wallis tests confirmed this difference was statistically significant (H = 21.569, p = 0.001). The rate of second-line strategy use was 48%. The four most commonly used second-line strategies were: bottles with regular teats (77%); syringe feeding (44%); bottles with wide teats (34%); and nipple shields (27%). Seven key challenges were identified that contributed to the decision to use second-line strategies, including: nipple pain (40%); unsettled infant (40%); insufficient milk supply (37%); fatigue (37%); night nursery care (25%); infant weight loss > 10% (24%); and maternal birth associated pain (20%). Skin-to-skin contact at birth was commonly reported (93%). At seven days postpartum 124 women (97%) were continuing to breastfeed. Conclusions The high rate of use of second-line strategies identified in this study and high rate of breastfeeding at day seven despite lower BFSE indicate that such practices should not be overlooked by health professionals. The design of this study does not enable determination of cause-effect relationships to identify factors which contribute to use of second-line strategies. Nevertheless, the significantly lower BSES-SF score of women using a second-line strategy highlights this group of women have particular needs that require attention.

Association between feeding style and weight gain in infants aged 2–7 months

Introduction: Feeding on demand supports an infant’s innate capacity to respond to hunger and satiety cues and may promote later self-regulation of intake. Our aim was to examine whether feeding style (on demand vs to schedule) is associated with weight gain in early life. Methods: Participants were first-time mothers of healthy term infants enrolled NOURISH, an RCT evaluating an intervention to promote positive early feeding practices. Baseline assessment occurred when infants were aged 2-7 months. Infants able to be categorised clearly as feeding on demand or to schedule (mothers self report) were included in the logistic regression analysis. The model was adjusted for gender, breastfeeding and maternal age, education, BMI. Weight gain was defined as a positive difference in baseline minus birthweight z-scores (WHO standards) which indicated tracking above weight percentile. Results: Data from 356 infants with a mean age of 4.4 (SD 1.0) months were available. Of these, 197 (55%) were fed on demand, 42 (12%) were fed on schedule. There was no statistical association between feeding style and weight gain [OR=0.72 (95%CI 0.35-1.46), P=0.36]. Formula fed infants were three times more likely to be fed on schedule and formula feeding was independently associated with increased weight gain [OR=2.02 (95%CI 1.11-3.66), P=0.021]. Conclusion: In this preliminary analysis the association between feeding style and weight gain did not reach statistical significance, however , the effect size may be clinically relevant and future analysis will include the full study sample (N=698).

The NOURISH randomised control trial : positive feeding practices and food preferences in early childhood - a primary prevention program for childhood obesity

Background Primary prevention of childhood overweight is an international priority. In Australia 20-25% of 2-8 year olds are already overweight. These children are at substantially increased the risk of becoming overweight adults, with attendant increased risk of morbidity and mortality. Early feeding practices determine infant exposure to food (type, amount, frequency) and include responses (eg coercion) to infant feeding behaviour (eg. food refusal). There is correlational evidence linking parenting style and early feeding practices to child eating behaviour and weight status. A focus on early feeding is consistent with the national focus on early childhood as the foundation for life-long health and well being. The NOURISH trial aims to implement and evaluate a community-based intervention to promote early feeding practices that will foster healthy food preferences and intake and preserve the innate capacity to self-regulate food intake in young children. Methods/Design This randomised controlled trial (RCT) aims to recruit 820 first-time mothers and their healthy term infants. A consecutive sample of eligible mothers will be approached postnatally at major maternity hospitals in Brisbane and Adelaide. Initial consent will be for re-contact for full enrolment when the infants are 4-7 months old. Individual mother- infant dyads will be randomised to usual care or the intervention. The intervention will provide anticipatory guidance via two modules of six fortnightly parent education and peer support group sessions, each followed by six months of regular maintenance contact. The modules will commence when the infants are aged 4-7 and 13-16 months to coincide with establishment of solid feeding, and autonomy and independence, respectively. Outcome measures will be assessed at baseline, with follow up at nine and 18 months. These will include infant intake (type and amount of foods), food preferences, feeding behaviour and growth and self-reported maternal feeding practices and parenting practices and efficacy. Covariates will include sociodemographics, infant feeding mode and temperament, maternal weight status and weight concern and child care exposure. Discussion Despite the strong rationale to focus on parents’ early feeding practices as a key determinant of child food preferences, intake and self-regulatory capacity, prospective longitudinal and intervention studies are rare. This trial will be amongst to provide Level II evidence regarding the impact of an intervention (commencing prior to age 12 months) on children’s eating patterns and behaviours. Trial Registration: ACTRN12608000056392

Parenting behaviours and maternal infant-feeding practices in first-time Australian mothers

Introduction: There is emerging evidence that parenting style and early feeding practices are associated with child intake, eating behaviours and weight status. The aim of this cross sectional study was to examine the relationships between general maternal parenting behaviour and feeding practices and beliefs. Methods: Participants were 421 first-time mothers of 9-22 week old healthy term infants (49% male, mean±sd age 19±4 weeks) enrolled in the NOURISH trial. At baseline mothers self-reported their parenting behaviours (self-efficacy, warmth, irritability) and infant-feeding beliefs using questions from the Longitudinal Study of Australian Children and the Infant Feeding Questionnaire (Baughcum, 2001), respectively. Multivariable regression analyses were used with feeding practices (four factors) as the dependent variables, Independent variables were maternal BMI, weight concern, age, education level perception of infant weight status, feeding mode (breast vs formula) and infant gender, age and weight gain z-score. Results: Parenting behaviours partly were associated with feeding beliefs (adjusted R2 =0.21-0.30). Higher maternal parenting self-efficacy was inversely associated with concerns that the baby would become underweight (p=0.006); become overweight (p<0.001); and lack of awareness of infant hunger/satiety cues (p<0.001). Higher maternal irritability was positively associated with lack of awareness of cues (p<0.05). Maternal warmth was not associated with any feeding beliefs. Infant weight- gain (from birth) z-score and age, maternal BMI and education level and mothers’ perception of infant weight status and feeding mode were covariates. Conclusions: These findings suggest strategies to improve early feeding practices need to be address broader parenting approaches, particularly self-efficacy and irritability.

The association between maternal infant feeding practices and child weight at 11-17 months in first-time Australian mothers

Introduction: Emerging evidence reveals that early feeding practices are associated with child food intake, eating behaviour and weight status. This cross-sectional analysis examined the association between maternal infant feeding practices/beliefs and child weight in Australian infants aged 11-17 months. Methods: Participants were 293 first-time mothers of healthy term infants (144 boys, mean age 14±1 months) enrolled in the NOURISH RCT. Mothers self-reported infant feeding practices and beliefs using the Infant Feeding Questionnaire (Baughcum, 2001). Anthropometric data were also measured at baseline (infants aged 4 months). Multiple regression analysis was used, adjusting for infant age, gender, birth weight, infant feeding mode (breast vs. formula), maternal perceptions of infant weight status, pre-pregnancy weight, weight concern, age and education. Results: The average child weight-for-age z-score (WAZ) was 0.62±0.83 (range:-1.56 to 2.94) and the mean change in WAZ (WAZ change) from 4 to 14 months was 0.62±0.69 (range:-1.50 to 2.76). Feeding practices/beliefs partly explained child WAZ (R2=0.28) and WAZ change (R2=0.13) in the adjusted models. While child weight status at 14 months was inversely associated with responsive feeding (e.g. baby feeds whenever she wants, feeding to stop baby being unsettled) (β=-0.104, p=0.06) and maternal concern about the child becoming underweight (β=-0.224, p<0.001), it was positively associated with mother’s concern about child overweight (β=0.197, p<0.05). Birth weight, infant’s age, maternal weight concern and perceiving her child as overweight were significant covariates. WAZ change was only significantly associated with responsive feeding (β=-0.147, p<0.05). Conclusion: Responsive feeding may be an important strategy to promote healthy child weight.

Evaluation of an intervention to promote protective infant feeding practices to prevent childhood obesity : outcomes of the NOURISH RCT at 14 months of age and 6 months post the first of two intervention modules

OBJECTIVE: To evaluate a universal obesity prevention intervention, which commenced at infant age 4-6 months, using outcome data assessed 6-months after completion of the first of two intervention modules and 9 months from baseline. DESIGN: Randomised controlled trial of a community-based early feeding intervention. SUBJECTS AND METHODS: 698 first-time mothers (mean age 30±5 years) with healthy term infants (51% male) aged 4.3±1.0 months at baseline. Mothers and infants were randomly allocated to self-directed access to usual care or to attend two group education modules, each delivered over three months, that provided anticipatory guidance on early feeding practices. Outcome data reported here were assessed at infant age 13.7±1.3 months. Anthropometrics were expressed as z-scores (WHO reference). Rapid weight gain was defined as change in weight-for-age z-score (WAZ) > +0.67. Maternal feeding practices were assessed via self-administered questionnaire. RESULTS: There were no differences according to group allocation on key maternal and infant characteristics. At follow up (n=598 [86%]) the intervention group infants had lower BMIZ (0.42±0.85 vs 0.23±0.93, p=0.009) and infants in the control group were more likely to show rapid weight gain from baseline to follow up (OR=1.5 CI95%1.1-2.1, p=0.014). Mothers in the control group were more likely to report using non- responsive feeding practices that fail to respond to infant satiety cues such as encouraging eating by using food as a reward (15% vs 4%, p=0.001) or using games ( 67% vs 29%, p<0.001). CONCLUSIONS: These results provide early evidence that anticipatory guidance targeting the ‘when, what and how’ of solid feeding can be effective in changing maternal feeding practices and, at least in the short term, reducing anthropometric indicators of childhood obesity risk. Analyses of outcomes at later ages are required to determine if these promising effects can be sustained.

Recruiting and engaging new mothers in nutrition research studies : lessons from the Australian NOURISH randomised controlled trial

Background: Despite important implications for the budgets, statistical power and generalisability of research findings, detailed reports of recruitment and retention in randomised controlled trials (RCTs) are rare. The NOURISH RCT evaluated a community-based intervention for first-time mothers that promoted protective infant feeding practices as a primary prevention strategy for childhood obesity. The aim of this paper is to provide a detailed description and evaluation of the recruitment and retention strategies used. Methods: A two stage recruitment process designed to provide a consecutive sampling framework was used. First time mothers delivering healthy term infants were initially approached in postnatal wards of the major maternity services in two Australian cities for consent to later contact (Stage 1). When infants were about four months old mothers were re-contacted by mail for enrolment (Stage 2), baseline measurements (Time 1) and subsequent random allocation to the intervention or control condition. Outcomes were assessed at infant ages 14 months (Time 2) and 24 months (Time 3). Results: At Stage 1, 86% of eligible mothers were approached and of these women, 76% consented to later contact. At Stage 2, 3% had become ineligible and 76% could be recontacted. Of the latter, 44% consented to full enrolment and were allocated. This represented 21% of mothers screened as eligible at Stage 1. Retention at Time 3 was 78%. Mothers who did not consent or discontinued the study were younger and less likely to have a university education. Conclusions: The consent and retention rates of our sample of first time mothers are comparable with or better than other similar studies. The recruitment strategy used allowed for detailed information from non-consenters to be collected; thus selection bias could be estimated. Recommendations for future studies include being able to contact participants via mobile phone (particular text messaging), offering home visits to reduce participant burden and considering the use of financial incentives to support participant retention.

Outcomes of an early feeding practices intervention to prevent childhood obesity

Objective Use a randomised controlled trial (RCT) to evaluate outcomes of a universal intervention to promote protective feeding practices, which commenced in infancy and aimed to prevent childhood obesity Subjects and Methods The NOURISH RCT enrolled 698 first-time mothers (mean age 30.1 years, SD=5.3) with healthy term infants (51% female) aged 4.3 (SD=1.0) months at baseline. Mothers were randomly allocated to self-directed access to usual care or to attend two 6-session interactive group education modules that provided anticipatory guidance on early feeding practices. Outcomes were assessed six months after completion of the second information module, 20 months from baseline and when the children were two years old. Maternal feeding practices were self-reported using validated questionnaires and study-developed items. Study-measured child height and weight were used to calculate BMI Z-score. Results Retention at follow-up was 78%. Mothers in the intervention group reported using responsive feeding more frequently on 6/9 subscales and 8/8 items (Ps ≤.03) and overall less ‘controlling feeding practices’ (P<.001). They also more frequently used feeding practices (3/4 items; Ps <.01) likely to enhance food acceptance. No statistically significant differences were noted in anthropometric outcomes (BMI Z-score: P=.11), nor in prevalence of overweight/obesity (control 17.9% vs. intervention 13.8%, P=.23). Conclusions Evaluation of NOURISH at child age two years found that anticipatory guidance on complementary feeding, tailored to developmental stage, increased use by first-time mothers of 'protective' feeding practices that potentially support the development of healthy eating and growth patterns in young children.

Child eating behaviour outcomes of an early feeding intervention to reduce risk indicators for child obesity : the NOURISH RCT

Objective Describe parent-reported child eating behaviour and maternal parenting impact outcomes of an infant feeding intervention to reduce child obesity risk. Design and Methods An assessor masked Randomised Controlled Trial (RCT) with concealed allocation of individual mother-infant dyads. The NOURISH RCT enrolled 698 first-time mothers (mean age 30.1 years, SD=5.3) with healthy term infants (51% female) aged 4.3 months (SD=1.0) at baseline. Outcomes were assessed six months post-intervention when the children were 2-years old. Mothers reported on child eating behaviours using the Child Eating Behaviour Questionnaire (CEBQ), food preferences and dietary intake using a 24-hour telephone recall. Parenting was assessed using five scales validated for use in Australia. Results Intervention effects were evident on the CEBQ overall (MANOVA P=.002) and 4/8 subscales: child satiety responsiveness (P=.03), fussiness (P=.01), emotional overeating (P<.01), and food responsiveness (P=.06). Intervention children ‘liked’ more fruits (P<.01) and fewer non-core foods and beverages (Ps=.06, .03). The intervention mothers reported greater ‘autonomy encouragement’ (P=.002) Conclusions Anticipatory guidance on protective feeding practices appears to have modest positive impacts on child eating behaviours that are postulated to reduce future obesity risk.

The timing of solid introduction in an ‘obesogenic’ environment : a narrative review of the evidence and methodological issues.

Objective To evaluate the evidence for association between obesity risk outcomes >12 months of age and timing of solid introduction in healthy term infants in developed countries, the large majority of whom are not exclusively breastfed to 6 months of age. Methods Studies included were published 1990-March 2013. Results Twenty-six papers with weight status or obesity prevalence outcomes were identified. Studies were predominantly cohort design, most with important methodological limitations. Ten studies reported a positive association. Of these only two were large good quality studies and both examined the outcome of early (<4 months) solid introduction. None of the four good quality studies that directly evaluated current guidelines provided evidence of any clinically relevant protective effect of solid introduction from 4-5 versus ≥ 6 months of age. Conclusion Overall the introduction of solids prior to 4 months may result in increased risk of childhood obesity but there is little evidence of adverse weight status outcomes associated with introducing solids at 4-6 rather than at 6 months. Implications More and better quality evidence is required to inform guidelines on the ‘when, what and how’ of complementary feeding.

An early feeding practices intervention for obesity prevention

Objective - Report long term outcomes of the NOURISH randomized controlled trial (RCT) that evaluated a universal intervention commencing in infancy to provide anticipatory guidance to first-time mothers on ‘protective’ complementary feeding practices which were hypothesized to reduce childhood obesity risk. Subjects and Methods - The NOURISH RCT enrolled 698 mothers (mean age 30.1 years, SD=5.3) with healthy term infants (51% female). Mothers were randomly allocated to usual care or to attend two 6-session, 12-week group education modules. Outcomes were assessed five times: baseline (infants 4.3 months); 6 months after module 1 (infants 14 months); 6 months after module 2 (infants 2 years) and at 3.5 and 5 years of age. Maternal feeding practices were self-reported using validated questionnaires. BMI Z-score was calculated from measured child height and weight. Linear Mixed Models evaluated intervention (group) effect across time. Results - Retention at 5 years of age was 61%. Across ages 2-5 years, intervention mothers reported less frequent use of non-responsive feeding practices on 6/9 scales. At 5 years they also reported more appropriate responses to food refusal on 7/12 items (Ps ≤.05). No statistically significant group effect was noted for anthropometric outcomes (BMI Z-score: P=.06), or the prevalence of overweight/obesity (control 13.3% vs. intervention 11.4%, P=.66). Conclusions - Anticipatory guidance on complementary feeding resulted in first-time mothers reporting increased use of protective feeding practices. These intervention effects were sustained up to five years of age and were paralleled by a non-significant trend for lower child BMI Z-scores at all post-intervention assessment points.

The ontogeny of serum immunoreactive pancreatic lipase and cationic trypsinogen in the premature human infant

We evaluated the development of the exocrine pancreas in 16 healthy preterm infants (29.3 ± 1.6 weeks). The infants were fed breast milk with formula supplements (n=8) or formula alone (n=8). Growth was monitored weekly for 12 weeks then at 3, 6, 9, 12 months. At the same intervals sera were determined for pancreatic lipase and cationic trypsinogen. In addition, cord blood samples were analysed from another 33 preterm (27.6 ± 5.2 weeks) and 75 healthy full-term infants. Serum pancreatic lipase in the cord blood of term (3.7 ± 0.4 μg/l) and preterm infants (1.8 ± 0.2 μg/l) was significantly below values reported for older children (10.5 ± 0.9 μg/l; p < 0.001). In the preterm infant, serum lipase was also significantly lower than values obtained at term (p < 0.001). At birth, serum trypsinogen for preterm (16.8 ± 1.3 μg/l) and term infants (23.3 ± 1.9 μg/l) were below those for older children (31.4 ± 3.7 μg/l; p < 0.05). Over the first 3 weeks of life, serum lipase and trypsinogen increased significantly. From 3 weeks to 12 months of age, serum trypsinogen values remained unchanged, but serum lipase increased dramatically after 10 weeks of age. Thus, at 6 and 12 months of age, the preterm infants had significantly higher serum lipase values than infants of the same age born at term. These two pancreatic enzymes appear to show independent age-related maturation in infants born before term. The rate of maturation of lipase appears to be accelerated by exposure to the extrauterine environment.

Women's views of ultrasonography: A comparison of women's experiences of antenatal ultrasound screening with cerebral ultrasound of their newborn infant

Ultrasound screening is now a routine procedure which forms part of antenatal care provision. Within this routine context ultrasound technology has been found to be generally acceptable and indeed is positively demanded by many women. This paper raises the question whether the routine presentation of ultrasound implicitly conveys the message that is use in antenatal care is both valuable and safe. It examines women's views of ultrasound technology beyond a routine context. In a study designed to examine women's reactions to cerebral ultrasound on their normal term infants mothers were asked their views and knowledge of ultrasound and a comparison with their antenatal experience of ultrasound was elicited. A generalized concern about ultrasound techniques was found to underlie many of the women's comments. This raised questions concerning the current practice in the presentation of ultrasound to women attending for antenatal care.

Child dietary and eating behaviour outcomes up to 3.5 years after an early feeding intervention: the NOURISH RCT

- Objective To evaluate dietary intake impact outcomes up to 3.5 years after the NOURISH early feeding intervention (concealed allocation, assessor masked RCT). - Methods 698 first-time mothers with healthy term infants were allocated to receive anticipatory guidance on protective feeding practices or usual care. Outcomes were assessed at 2, 3.7 and 5 years (3.5 years post-intervention). Dietary intake was assessed by 24-hour recall and Child Dietary Questionnaire. Mothers completed a food preference questionnaire and Children’s Eating Behaviour Questionnaire. Linear mixed models assessed group, time and time x group effects. - Results There were no group or time x group effects for fruit, vegetables, discretionary food and non-milk sweetened beverages intake. Intervention children showed a higher preference for fruits (74.6% vs 69.0% liked, P<.001), higher Child Dietary Questionnaire score for fruit and vegetables (15.3 vs 14.5, target>18, P=0.03), lower food responsiveness (2.3 vs 2.4, of maximum 5, P=.04) and higher satiety responsiveness (3.1 vs 3.0, of maximum 5, P=.04). - Conclusions Compared to usual care, an early feeding intervention providing anticipatory guidance regarding positive feeding practices led to small improvements in child dietary score, food preferences and eating behaviours up to 5 years of age, but not in dietary intake measured by 24-hour recall.