Association Between Bottle Size and Formula Intake in 2-Month-Old Infants

National survey of infant feeding bottles in Germany: Their characteristics and marketing claims

Bottles and teats are ubiquitously used for feeding infants and young children. Yet there are limited empirical studies on the scope of infant feeding bottles, their attributes, or their marketing claims. We report the first comprehensive survey on infant feeding bottles and teats in Germany. We aimed to explore the extent of bottles and teats available in Germany, describe their physical attributes and analyze their marketing claims. A cross-sectional survey of German bottle and teat manufacturer websites was conducted between June and November 2022. Product attributes are presented with descriptive statistics and photographs. Marketing claims are summarized in a descriptive content analysis. We identified 41 brands encompassing 447 unique products (226 bottles, 221 teats). The majority of bottles were plastic (147, 65%) or glass (64, 28%), and the majority of teats were silicone (188, 85%). Most brands (38, 93%) promoted products using one or more inappropriate marketing claims, including equivalency to breastfeeding (29, 73%), idealization through technical or medical descriptions (23, 58%), claims on disease prevention (31, 78%), references to naturalness (29, 73%), infant autonomy (10, 25%), and endorsements from parents (10, 25%) or health professionals (11, 28%). The majority of bottles and teats available in Germany appear to be marketed inappropriately and hold the potential to undermine public health recommendations on infant and young child feeding. Therefore, we recommend Germany strengthens legislation on the marketing of bottles and teats in accordance with the International Code of Marketing of Breastmilk Substitutes.

The Cerebellar Response to Visual Portion Size Cues Is Associated with the Portion Size Effect in Children

The neural mechanisms underlying susceptibility to eating more in response to large portions (i.e., the portion size effect) remain unclear. Thus, the present study examined how neural responses to portion size relate to changes in weight and energy consumed as portions increase. Associations were examined across brain regions traditionally implicated in appetite control (i.e., an appetitive network) as well as the cerebellum, which has recently been implicated in appetite-related processes. Children without obesity (i.e., BMI-for-age-and-sex percentile < 90; N = 63; 55% female) viewed images of larger and smaller portions of food during fMRI and, in separate sessions, ate four meals that varied in portion size. Individual-level linear and quadratic associations between intake (kcal, grams) and portion size (i.e., portion size slopes) were estimated. The response to portion size in cerebellar lobules IV-VI was associated with the quadratic portion size slope estimated from gram intake; a greater response to images depicting smaller compared to larger portions was associated with steeper increases in intake with increasing portion sizes. Within the appetitive network, neural responses were not associated with portion size slopes. A decreased cerebellar response to larger amounts of food may increase children's susceptibility to overeating when excessively large portions are served.

A Pilot Feasibility Randomized Controlled Trial of Effects of Opaque Bottles on Maternal Sensitivity, Infant Intake, and Infant Weight Status

BACKGROUND

Conventional clear infant feeding bottles provide visual cues about the amount of milk consumed, which may decrease caregivers' sensitivity to infant cues, increase infant intake, and lead to greater infant weight gain.

OBJECTIVE

This study examined feasibility, adherence, acceptability, and preliminary effectiveness of an intervention in which families received clear vs opaque bottles.

DESIGN

A pilot feasibility randomized controlled trial was conducted.

PARTICIPANTS/SETTING

Participants included mothers (N = 76) with young infants (2.9 ± 1.4 months old). Data collection occurred between December 2018 and July 2022 and within San Luis Obispo and Santa Barbara Counties, California. All assessments occurred within participants' homes.

INTERVENTION

Participants were randomized to use clear (Clear group, n = 38) or opaque (Opaque group, n = 38) bottles for 12 weeks.

MAIN OUTCOME MEASURES

We assessed feasibility of recruitment and retention, participant perceptions of study bottles, participant adherence to the intervention, maternal sensitivity to cues, infant intake (mL and mL/kg), and infant weight-for-length z-scores (WLZ).

STATISTICAL ANALYSES PERFORMED

Data were analyzed using linear regression, χ2 analysis, and repeated-measures analysis of variance (ANOVA).

RESULTS

Of 842 potential participants, 295 (35%) could not be reached after initial contact, 166 (20%) declined to participate, and 305 (36%) were ineligible. Of those who declined, 16 (10%) declined because they did not want to use study bottles. No differences were observed for loss to follow-up for Clear (8 of 38; 21%) vs Opaque (5 of 38; 13%) groups (P = 0.36) or for reported use of assigned bottles for Clear (89.8% ± 24.5% of daily feedings) vs Opaque (90.1% ± 22.1%) groups (P = 0.96). No group differences were observed for sensitivity to cues (P = 0.52) or intake (mL, P = 0.53 or mL/kg, P = 0.56) at follow-up. Opaque group infants had lower WLZ at follow-up compared with Clear group infants (mean difference, 0.47; 95% confidence interval, 0.08, 0.86; ηp2 = 0.17), adjusting for baseline WLZ.

CONCLUSIONS

Relative to providing clear bottles, providing families with opaque bottles appeared feasible and acceptable, with good adherence. Although preliminary, study findings suggest the potential of opaque bottles to support healthier weight outcomes for bottle-fed infants.

Infant Bottle-Feeding: A Prospective Study of Infant Physiology and Parental Report Metrics

The aim of this study was to examine associations between parent reports of bottle-feeding behaviors and infant non-nutritive suck (NNS) on a pacifier as well as oral feeding skills during bottle-feeding. A prospective study was conducted. Full-term infants with no prior diagnosed feeding disorders were recruited at 3-months. Parents reported their infant's bottle-feeding behaviors using the Neonatal Eating Assessment Tool-Bottle-Feeding (NeoEAT-Bottle-Feeding), consisting of five domains: Infant Regulation, Energy and Physiologic Stability, Gastrointestinal Tract Function, Sensory Responsiveness, and Compelling Symptoms of Problematic Feeding. Infant NNS was measured using a custom pacifier, pressure transducer device, which yields the following NNS variables: duration (sec), frequency (Hz), amplitude (cmH20), cycles per burst, cycle amount, and burst amount. The Oral Feeding Skills (OFS) scale was used to measure the initial volume, transfer volume, proficiency, and rate of milk transfer during bottle feeding. Fifty-two infants (58% male) with reported prior bottle experience completed this study. NeoEAT-Bottle-Feeding Total score was significantly positively associated with NNS burst duration and NNS cycles per burst. The NeoEAT-Bottle-Feeding Energy and Physiologic Stability domain was significantly positively correlated with NNS cycles per burst. NeoEAT-Bottle-Feeding Gastrointestinal Tract Function domain score was significantly positively correlated with NNS duration, amplitude, and cycles per burst. There were no significant associations between NeoEAT-Bottle-Feeding domains and the OFS scale. The findings demonstrate that parent reports of problematic feeding at 3 months of age are associated with aspects of infant NNS physiology and not with oral feeding metrics during bottle-feeding. Parent reports of bottle-feeding behaviors, particularly pertaining to gastrointestinal issues, were associated with aspects of infant NNS. These data together will allow for a more nuanced understanding of infant feeding and will be beneficial in determining if infants have a feeding delay.

Exploring the Feasibility and Acceptability of Providing Caregivers Who Formula-feed with Smaller Infant Bottles in a Primary Care Clinic

OBJECTIVES

Larger bottle size is associated with faster weight gain in infants, but little is known about acceptability and feasibility of providing bottles in primary care clinics.

METHODS

We randomized parent-infant dyads (N = 40) to receive a set of 4-ounce bottles or to continue using their own bottles. Demographic and anthropometric information were collected at enrollment and one follow-up visit 1-5 months later. The primary aim was to assess feasibility and acceptability of the intervention strategy. We compared components of bottle feeding, including usual bottle sizes used, number and volume of feeds with Wilcoxon rank-sum tests, and changes in weight-for-age and weight-for-length z-scores during the study period with t-tests, using p < 0.05 as an indicator of statistical significance.

RESULTS

Of participants randomized to receive bottles, 90% were using the 4oz bottles at follow up. The intervention group reported a significantly lower median bottle size (4oz) than the control group (8oz) at follow up, and parents reported acceptability and continued use of the bottles.

CONCLUSIONS FOR PRACTICE

An intervention to provide smaller bottles was feasible, mostly acceptable, resulted in lower median bottle size. Further research is needed to determine whether it represents a novel way to prevent rapid infant weight gain.

Obesity in Children

Child obesity is widely prevalent, and general pediatricians play an important role in identifying and caring for patients with obesity. Appropriate evaluation and treatment require an understanding of the complex etiology of child obesity, its intergenerational transmission, and its epidemiologic trends, including racial/ethnic and socioeconomic disparities. The American Academy of Pediatrics has published screening, evaluation, and treatment guidelines based on the best available evidence. However, gaps in evidence remain, and implementation of evidence-based recommendations can be challenging. It is important to review optimal care in both the primary care and multidisciplinary weight management settings. This allows for timely evaluation and appropriate referrals, with the pediatrician playing a key role in advocating for patients at higher risk. There is also a role for larger-scale prevention and policy measures that would not only aid pediatricians in managing obesity but greatly benefit child health on a population scale.

Childhood obesity and adverse cardiometabolic risk in large for gestational age infants and potential early preventive strategies: a narrative review

Accumulating evidence indicates that obesity and cardiometabolic risks become established early in life due to developmental programming and infants born as large for gestational age (LGA) are particularly at risk. This review summarizes the recent literature connecting LGA infants and early childhood obesity and cardiometabolic risk and explores potential preventive interventions in early infancy. With the rising obesity rates in women of childbearing age, the LGA birth rate is about 10%. Recent literature continues to support the higher rates of obesity in LGA infants. However, there is a knowledge gap for their lifetime risk for adverse cardiometabolic outcomes. Potential factors that may modify the risk in early infancy include catch-down early postnatal growth, reduction in body fat growth trajectory, longer breastfeeding duration, and presence of a healthy gut microbiome. The early postnatal period may be a critical window of opportunity for active interventions to mitigate or prevent obesity and potential adverse metabolic consequences in later life. A variety of promising candidate biomarkers for the early identification of metabolic alterations in LGA infants is also discussed. IMPACT: LGA infants are the greatest risk category for future obesity, especially if they experience rapid postnatal growth during infancy. Potential risk modifying secondary prevention strategies in early infancy in LGA infants include catch-down early postnatal growth, reduction in body fat growth trajectory, longer breastfeeding duration, and presence of a healthy gut microbiome. LGA infants may be potential low-hanging fruit targets for early preventive interventions in the fight against childhood obesity.

Artificial Neural Network for Identification of Infant Feeding Tracking Using the Smart Bottle System

In this work, we present the results of a comparison of simple artificial neural network (FFNN) designs intended to identify infant bottle-feeding events and appropriate feeding volume recording intervals using accelerometer data recorded from a custom designed "Smart Bottle" system. To properly identify and distinguish these events with an accuracy of 99.8%, while accommodating the constraints of the deployment environment, two concurrent FFNNs were implemented.

Large-for-gestational-age phenotypes and obesity risk in adulthood: a study of 195,936 women

While there is evidence that being born large-for-gestational-age (LGA) is associated with an increased risk of obesity later in life, the data are conflicting. Thus, we aimed to examine the associations between proportionality at birth and later obesity risk in adulthood. This was a retrospective study using data recorded in the Swedish Birth Register. Anthropometry in adulthood was assessed in 195,936 pregnant women at 10-12 weeks of gestation. All women were born at term (37-41 weeks of gestation). LGA was defined as birth weight and/or length ≥2.0 SDS. Women were separated into four groups: appropriate-for-gestational-age according to both weight and length (AGA - reference group; n = 183,662), LGA by weight only (n = 4,026), LGA by length only (n = 5,465), and LGA by both weight and length (n = 2,783). Women born LGA based on length, weight, or both had BMI 0.12, 1.16, and 1.08 kg/m² greater than women born AGA, respectively. The adjusted relative risk (aRR) of obesity was 1.50 times higher for those born LGA by weight and 1.51 times for LGA by both weight and height. Length at birth was not associated with obesity risk. Similarly, women born LGA by ponderal index had BMI 1.0 kg/m² greater and an aRR of obesity 1.39 times higher than those born AGA. Swedish women born LGA by weight or ponderal index had an increased risk of obesity in adulthood, irrespective of their birth length. Thus, increased risk of adult obesity seems to be identifiable from birth weight and ignoring proportionality.

Bottle-feeding an infant feeding modality: An integrative literature review

Bottle‐feeding is an infant feeding modality that has been in existence since ancient times, and currently, a significant number of infants are being fed via a bottle with either breastmilk or formula. Although research on bottle‐feeding has continued, it exists in fragmented, often small studies that focus on singular aspects of feeding an infant using a bottle, with limited information on the bottle‐feeding act. Systems theory was the approach used to define the act of bottle‐feeding and identify the parts within this act. Health databases were searched using MeSH terms. A summary of the studies are included. The findings of this review revealed that healthy term bottle‐feeding infants use similar tongue and jaw movements, can create suction and sequentially use teat compression to obtain milk, with minimal differences in oxygen saturation and SSB patterns, when compared with breastfeeding infants. Bottle and teat characteristics were revealed to affect infant feeding and milk intake. An infant's milk intake during feeding was shown to have a strong association with the interaction between the infant and parent/caregiver. With the issue of who controls the feed, mother or infant, likely to affect an infant's ability to self‐regulate their milk intake. Redefining bottle‐feeding as a holistic system identifies the interrelationship of the various parts which will improve the understanding of the reciprocal nature of infant feeding. To optimize bottle‐feeding outcomes, further research is required on parents' and health professionals' knowledge and understanding of the parts within the act of bottle‐feeding.

Effects of opaque, weighted bottles on maternal sensitivity and infant intake

Caregivers' abilities to assess how much is in the bottle may lead to encouragement of infant bottle emptying and overfeeding. The present study assessed whether use of opaque, weighted bottles (as compared with conventional, clear bottles) improves feeding outcomes. Mothers with infants <32 weeks of age (n = 76) were assessed on two separate days. Mothers fed their infants from an opaque, weighted bottle on 1 day and a clear bottle on the other; conditions were counterbalanced. Blinded raters certified in the Nursing Child Assessment Feeding Scale scored all videos to determine maternal sensitivity. Infant intake was assessed by weighing the bottle before and after each feeding, and feeding outcomes included infant intake (mL), intake per kilogram body weight (mL/kg), meal duration (min), and feed rate (mL/min). Mothers exhibited significantly greater sensitivity (p = 0.041), fed their infants fewer millilitres per kilogram body weight (p = 0.049), and fed their infants at a significantly slower rate (p = 0.009) when using opaque compared with clear bottles. Infant clarity of cues was a significant moderator of effects of bottle type on intake per kilogram body weight (p = 0.028): Infants who exhibited greater clarity of cues were fed less during the opaque versus clear conditions whereas infants who exhibited poorer clarity of cues were fed similar amounts during both conditions. Effects of bottle type were not moderated by bottle contents (expressed breast milk vs. formula). In sum, promotion of opaque, weighted bottles for infant feeding may be a pragmatic approach to improve the quality and outcome of bottle-feeding interactions.

Amount, Preparation and Type of Formula Consumed and Its Association with Weight Gain in Infants Participating in the WIC Program in Hawaii and Puerto Rico

The aim of this study was to assess the association between amount (below or above recommendations), preparation (liquid vs. powder), and type (regular vs. hydrolysate) of infant formula consumed and weight in infants participating in the Women, Infant and Children (WIC) Program in Hawaii (HI) and Puerto Rico (PR). This was a secondary analysis of 162 caregivers with healthy term 0–2-month-old infants. Socio-demographics, infant food frequency questionnaires, and weight and length were assessed at baseline and after four months. Infant feeding practices were associated with weight-for-length z-scores using multivariable logistic regression. In total, 37.7% were exclusively breastfed and 27.2% were exclusively formula-fed. Among formula users, regular (63.6%) and powder (87.0%) formula were the most common; 43.2% consumed formula above recommendations. Most infants had rapid weight gain (61.1%). Infants fed regular formula had higher odds of overweight after four months (adjusted OR = 8.77, 95% CI: 1.81–42.6) and higher odds of rapid weight gain (adjusted OR = 3.10, 95% CI: 1.12, 8.61). Those exclusively formula fed had higher odds of slow weight gain (adjusted OR = 4.07, 95% CI: 1.17–14.2). Formula preparation and amount of formula were not associated with weight. These results could inform the WIC program’s nutrition education messages on infant feeding. Studies with longer follow-up are needed to confirm these results.

Obesity Prevention and Treatment in Primary Care

Despite extensive public health and clinical interventions, obesity rates remain high, and evidence-based preventive strategies are elusive. Many consensus guidelines suggest that providers should screen all children after age 2 years for obesity by measuring height and weight, calculating body mass index (BMI), and sensitively communicating weight status in the context of health to the family at each visit. However, preventive counseling should begin in infancy and focus on healthy feeding, activity, and family lifestyle behaviors. For children with overweight or obesity, the American Academy of Pediatrics outlines 4 stages of treatment: 1) Primary care providers should offer "prevention plus," the use of motivational interviewing to achieve healthy lifestyle modifications in family behaviors or environments; 2) children requiring the next level of obesity treatment, structured weight management, need additional support beyond the primary care provider (such as a dietitian, physical therapist, or mental health counselor) and more structured goal setting with the team, including providers adept at weight management counseling; 3) children with severe obesity and motivated families may benefit from referral to a comprehensive multidisciplinary intervention, such as an obesity treatment clinic; and 4) tertiary care interventions are provided in a multidisciplinary pediatric obesity treatment clinic with standard clinical protocols for evaluation of interventions, including medications and surgery. Although it is certainly a challenge for providers to fit in all the desired prevention and treatment counseling during preventive health visits, by beginning to provide anticipatory guidance at birth, providers can respond to parents' questions, add to parents' knowledge base, and partner with parents and children and adolescents to help them grow up healthy. This is especially important in an increasingly toxic food environment with numerous incentives and messages to eat unhealthfully, barriers to appropriate physical activity, and concomitant stigma about obesity. Focusing on key nutrition and physical activity habits and establishing these healthy behaviors at an early age will allow children to develop a healthy growth trajectory. However, much more work is needed to determine the best evidence-based practices for providers to counsel families on improving target behaviors, environmental modifications, and parenting skills and to decrease abundant disparities in obesity prevalence and treatment.

INSIGHT responsive parenting intervention and infant feeding practices: randomized clinical trial

Background

What, when, how, how much, and how often infants are fed have been associated with childhood obesity risk. The objective of this secondary analysis was to examine the effect of a responsive parenting (RP) intervention designed for obesity prevention on parents’ infant feeding practices in the first year after birth.

Methods

Primiparous mother-newborn dyads were randomized to the Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) Study RP intervention or child safety control. Research nurses delivered intervention content at home at infant age 3–4, 16, 28, and 40 weeks, and at a research center at 1 year. RP feeding guidance advised feeding that was contingent (i.e., feed in response to hunger and satiety signs, alternatives to using food to soothe), and developmentally appropriate (i.e., delaying introduction of solids, age-appropriate portion sizes). Infant feeding practices (i.e., bottle use, introduction of solids, food to soothe) were assessed by phone interviews and online surveys and dietary intake was assessed using a food frequency questionnaire.

Results

RP mothers were more likely to use of structure-based feeding practices including limit-setting (p < 0.05) and consistent feeding routines (p < 0.01) at age 1 year. RP group mothers were less likely to use non-responsive feeding practices such as pressuring their infant to finish the bottle/food (p < 0.001), and using food to soothe (p < 0.01), propping the bottle (p < 0.05) assessed between 4 and 8 months, and putting baby to bed with a bottle at age 1 year (p < 0.05). Few differences were seen between groups in what specific foods or food groups infants were fed.

Conclusions

Anticipatory guidance on RP in feeding can prevent the use of food to soothe and promote use of more sensitive, structure-based feeding which could reduce obesity risk by affecting how and when infants are fed during the first year.

Trial registration

The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) Study. www.clinicaltrials.gov . NCT01167270. Registered 21 July 2010.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0700-6) contains supplementary material, which is available to authorized users.

Preserving Cardiovascular Health in Young Children: Beginning Healthier by Starting Earlier

PURPOSE OF REVIEW

The goals of this paper are to review current literature regarding maternal-fetal-pediatric diet and nutritional factors related to preserving cardiovascular health in the very young child and the emerging data implicating nutritional influences on neurodevelopmental factors. Questions related to maternal diet and influences of human milk on child's growth, neurodevelopment, and risk of developing obesity were addressed.

RECENT FINDINGS

The majority of US women in their reproductive years have overweight or obese status thereby increasing the risk of developing obesity in their children. Efforts to restrict gestational weight gain, perpetuate breast-feeding, and introduce heart-healthy complementary feeding after 6 months of age are now more commonly recommended and offer practical translational approaches to prevent pediatric obesity and encourage neurodevelopment intended to support cognitive and executive function. There is growing literature on the role of maternal-fetal-pediatric nutrition on cardiometabolic and neurodevelopmental health in children. Potential influences of maternal diet quality and obesity on not only birth outcomes but subsequent risk factor development in the child are increasingly apparent. Further investigation of these factors has become a major research focus in developing future diet recommendations to better inform underlying potential mechanisms and identify opportunities for primary prevention starting in utero.

Early feeding of larger volumes of formula milk is associated with greater body weight or overweight in later infancy

Background

The relation between infant feeding and growth has been extensively evaluated, but studies examining the volume of formula milk consumption on infant growth are limited. This study aimed to examine the effects of early feeding of larger volumes of formula on growth and risk of overweight in later infancy.

Methods

In total, 1093 infants were studied prospectively. Milk records collected at 3 mo of age were used to define the following 3 feeding groups: breast milk feeding (BM, no formula), lower-volume formula milk feeding (LFM, <840 ml formula/d), and higher-volume formula milk feeding (HFM, ≥840 ml formula/d). Body weight and length were measured at 3 time points of 3, 6 and 12 mo of age.

Results

The results showed that the difference in weight and length between the HFM and BM infants was significant at 3 mo of age (P < 0.05) and continued until 12 mo of age (P < 0.001). The adjusted mean changes in weight-for-length z-scores (WLZ) and BMI-for-age z-scores (BAZ) from 3 to 6 mo of age were significantly higher in HFM and LFM group than in BM group. Two-way interactions between feeding practice and age intervals were significant for WLZ changes (P = 0.002) and BAZ changes (P = 0.017). Compared with BM-fed infants, infants fed with HFM had 1.60-fold (95% CI 1.05–2.44) higher odds of greater body weight (1SD < WLZ ≤2 SD) at the age of 6 mo and 1.55-fold (95% CI 1.01–2.37) higher odds of greater body weight and 2.13-fold (95% CI 1.03–4.38) higher odds of overweight (WLZ > 2 SD) at the age of 12 mo.

Conclusion

Feeding higher volumes of formula in early infancy is associated with greater body weight and overweight in later infancy.

Bottle Size and Weight Gain in Formula-Fed Infants

BACKGROUND

Formula-fed infants may be at greater risk for overfeeding and rapid weight gain. Different size bottles are used for feeding infants, although little is known about whether bottle size is related to weight gain in bottle-fed infants.

METHODS

Data from the Greenlight Intervention Study, a cluster randomized trial to prevent childhood obesity at 4 pediatric resident clinics, were used to analyze the exposure to regular (<6 oz) or large (≥6 oz) bottle size at the 2-month visit on changes in weight, weight-for-age z score (WAZ), and weight-for-length z score (WLZ) at the 6-month visit. Using multivariable regression, we adjusted for potential confounders (birth weight, gender, age, weight measures at 2 months, parent race/ethnicity, education, household income and size, time between 2- and 6-month visits, and first child status).

RESULTS

Forty-five percent (n = 386; 41% black, 35% Hispanic, 23% white, 2% other) of infants at the 2-month visit were exclusively formula-fed, and 44% used large (≥6 oz) bottles. Infants whose parents fed with large bottles had 0.21 kg (95% confidence interval [CI]: 0.05 to 0.37) more weight change, 0.24 U (95% CI: 0.07 to 0.41) more change in WAZ, and 0.31 U (95% CI: 0.08 to 0.54) more change in WLZ during this period than infants fed with regular bottles.

CONCLUSIONS

Using a large bottle in early infancy independently contributed to greater weight gain and change in WLZ at the 6-month visit. Although growth in infancy is complex, bottle size may be a modifiable risk factor for rapid infant weight gain and later obesity among exclusively formula-fed infants.