Family-based obesity prevention for infants: Design of the "Mothers & Others" randomized trial

Barriers and facilitators to healthy eating during post-partum among non-Hispanic Black mothers

Maternal diet is a key predictor of child diet, yet an in-depth inquiry into the barriers and facilitators for the adoption of healthy eating behaviours during the post-partum period is lacking, specifically for non-Hispanic Black mothers. This study used qualitative research methods to investigate healthy eating practices among a sample of non-Hispanic Black mothers participating in a family-based obesity prevention intervention. In-depth interviews were conducted with 22 mothers who participated in the Mothers and Others: Family-based Obesity Prevention for Infants and Toddlers intervention trial. Interviews were audio-recorded and transcribed verbatim. A deductive and inductive process was used to develop a consensus codebook; once the data were coded, matrices were developed to explore the data and identify similarities and differences between respondents. Relevant themes were identified, and salient quotes were used to illustrate each theme. Mothers believed that time and taste were significant barriers to eating healthy. Social influence and social support had both positive and negative influences on mothers' ability to adopt healthy eating behaviours. Despite their children often being a facilitator to healthy eating, many mothers struggled with finding the time, energy and desire to focus on themselves when it came to healthy eating. Many mothers were intent on preparing healthy meals and snacks for their children but did not prepare them for themselves. Future interventions should focus on the importance of role-modelling healthy eating behaviours for their children and include behaviour change strategies that incorporate skill-building activities emphasizing time-saving methods for planning and preparing healthy meals and snacks for the whole family to eat.

Sleep SAAF Responsive Parenting Intervention for Black Mothers Impacts Response to Infant Crying: A Randomized Clinical Trial

OBJECTIVE

Many parents use food to soothe their infant, regardless of infant hunger, which can increase risk for rapid weight gain. Interventions promoting alternative soothing strategies may help parents respond more appropriately to crying. This secondary analysis aimed to examine effects of the Sleep SAAF (Strong African American Families) responsive parenting (RP) intervention on maternal responses to infant crying and to explore moderating effects of infant negativity.

METHODS

Primiparous Black mothers (n = 212) were randomized to an RP or safety control intervention, delivered during home visits at 3 and 8 weeks postpartum. Parents were empowered to first use non-food soothing strategies (eg, white noise, swaddling) when responding to crying. Mothers completed the Babies Need Soothing questionnaire at 8 and 16 weeks, and the Infant Behavior Questionnaire at 16 weeks. Data were analyzed using linear or logistic regression.

RESULTS

RP mothers were significantly more likely than controls to use shushing/white noise to soothe their infant at 8 (OR = 4.9, 95% CI: 2.2-10.6) and 16 weeks (OR = 4.8, 95% CI: 2.2-10.5), to go for a walk in stroller/ride in car at 8 weeks (OR = 2.3, 95% CI: 1.2-4.6), and to swing/rock/bounce their infant at 16 weeks (OR = 5.5, 95% CI: 1.2-25.7). RP mothers also reported significantly more frequent use of deep breathing, exercising, and bathing/showering than controls when frustrated with crying. Infant negativity moderated some intervention effects such that the RP intervention was more effective at increasing use of some soothing practices among mothers with less negative infants.

CONCLUSIONS

An RP intervention positively impacted first-time Black mothers' responses to infant crying.

Healthy home food environments of pregnant Black women are shaped by food outlet access and participation in nutrition assistance programs

OBJECTIVES

Improving access to healthy food in Black communities is imperative to combat intergenerational health disparities. Pregnant Black women represent an especially vulnerable population to multiple (and overlapping) sources of socioeconomic and political disenfranchisement and thus for whom maternal nutrition is crucial. This study aimed to (1) define household food environment types, (2) determine whether the distribution of community food outlets is associated with these household food environment types, and (3) determine whether the community-household food environment relationship differs by maternal education or participation in nutrition assistance programs.

METHODS

Cross-sectional data for pregnant Black women in North Carolina (n = 429) come from the Mothers & Others study, an obesity-prevention randomized control trial, with linked spatial data on all community food outlets (n = 6312) in the study area in 2015. Factor analysis was used to define household food environment types. These factor scores were regressed on access metrics to community food outlets. Adjusted linear regressions tested interaction by maternal education and nutrition assistance programs.

RESULTS

Four household food environment types were defined: Factor 1 (fresh fruits and vegetables (F/V), low snack), Factor 2 (canned F/V, sweet drinks), Factor 3 (dried/frozen F/V, candy), and Factor 4 (low F/V, soda). Having more convenience stores within 0.25 miles was associated with higher Factor 4 scores. No food outlets were associated with higher Factor 1 scores overall. However, SNAP or WIC participating households saw higher Factor 1 scores with increased access to supermarkets, convenience stores, and dollar stores.

CONCLUSIONS

Nutrition assistance programs play an important role as buffers against unhealthy community food environments which influence household food environments and maternal nutrition.

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.

A systematic literature review of breastfeeding interventions among Black populations using the RE-AIM framework

BACKGROUND

Lactation support resources are less likely to be located in close proximity to where Black families live and there is a systemic racist health care belief that Black women prefer bottle feeding (with infant formula) over breastfeeding. Together, these lead to lower reported breastfeeding rates of Black babies compared to other racial / ethnic groups. It is imperative to have a deeper understanding of the cultural aspects as well as the underlying limitations that prevent Black women / persons from being supported to breastfeed. There is a need to know how effective breastfeeding interventions are in reaching the intended population; how well they work in promoting breastfeeding initiation and continuation; and how successful they are when implemented at the setting and staff level. The purpose of this investigation was to establish the level of internal and external validity that was reported by breastfeeding intervention studies among Black communities.

METHODS

Studies on breastfeeding interventions on Black people that were published between the years 1990 and 2019 were carefully examined through PubMed, EBSCOhost, Web of Science, and OneSearch. A total of 31 studies fulfilled the requirements to be included for this evaluation. In order to extract the information from the articles, the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework extraction tool was utilized.

RESULTS

On average, the proportion of studies that reported across reach, effectiveness, adoption, implementation, and maintenance indicators was 54, 35, 19, 48, and 9%, respectively. Across core RE-AIM indicators only sample size (100%) and breastfeeding outcomes (90%) were reported consistently. External validity indicators related to representativeness of participants (16%) and sites (3%) were rarely reported. Similarly, adherence to intervention protocol, and indicator of internal validity, was reported in a small proportion of articles (19%).

CONCLUSION

This body of literature under-reported on aspects associated to both internal and external validity across all RE-AIM domains. The reporting of the individual level of representativeness; the setting level of representativeness; the intervention's adherence to the protocol; the expenses; and the factors of sustainability would benefit from improvement in future research.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Barriers to Providing Lactation Services and Support to Families in Appalachia: A Mixed-Methods Study With Lactation Professionals and Supporters

Objectives. To understand the barriers and facilitators that lactation professionals and supporters (LPSs) in the Appalachian region of the United States experience when providing services and support to families. Methods. We used a mixed-methods explanatory sequential design with a survey of LPSs in Appalachia (March‒July 2019), followed by semistructured interviews with LPSs (January‒April 2020). We summarized survey responses descriptively and analyzed interview transcripts thematically. Results. The survey was completed by 89 LPSs in Appalachia. We conducted semistructured interviews with 20 LPSs. Survey participants most commonly identified challenges with other health care providers, hospital practices, and non‒medically indicated supplementation as barriers. Interview participants described challenges with clients' families not supporting breastfeeding, difficulty reaching clients, limited numbers of LPSs, and lack of racial/ethnic diversity among LPSs. LPSs identified the need for training in lactation and substance use, mental health, and birth trauma, and supporting lesbian, gay, bisexual, transgender, queer or questioning, plus (LGBTQ+) families. LPSs described social media and telehealth as both facilitators and barriers. Social support from other LPSs was a facilitator. Conclusions. LPSs in Appalachia face various challenges. Addressing these challenges has the potential to improve the lactation support and services families in Appalachia receive. (Am J Public Health. 2022;112(S8):S797-S806. https://doi.org/10.2105/AJPH.2022.307025).

Effects of the Sleep SAAF responsive parenting intervention on rapid infant weight gain: A randomized clinical trial of African American families

Responsive parenting (RP) interventions reduce rapid infant weight gain but their effect for underserved populations is largely unknown. The Sleep SAAF (Strong African American Families) study is a two-arm randomized clinical trial for primiparous African American mother-infant dyads that compares an RP intervention to a child safety control over the first 16 weeks postpartum. Here we report on intervention effects on rapid infant weight gain and study implementation. Families were recruited from a mother/baby nursery shortly after delivery. Community Research Associates (CRAs) conducted intervention home visits at 3 and 8 weeks postpartum, and data collection home visits at 1, 8, and 16 weeks postpartum. To examine rapid infant weight gain, conditional weight gain (CWG) from 3 to 16 weeks, the primary outcome, and upward crossing of 2 major weight-for-age percentile lines were calculated. Among the 212 mother-infant dyads randomized, 194 completed the trial (92% retention). Randomized mothers averaged 22.7 years, 10% were married, and 49% participated in the Supplemental Nutrition Assistance Program (SNAP). Adjusting for covariates, mean CWG was lower among RP infants (0.04, 95% CI [-0.33, 0.40]) than among control infants (0.28, 95% CI [-0.08, 0.64]), reflecting non-significantly slower weight gain (p = 0.15, effect size d = 0.24). RP infants were nearly half as likely to experience upward crossing of 2 major weight-for-age percentile lines (14.1%) compared to control infants (24.2%), p = 0.09, odds ratio = 0.52 (95% CI [0.24, 1.12]). Implementation data revealed that participating families were engaged in the intervention visits and intervention facilitators demonstrated high fidelity to intervention materials. Findings show that RP interventions can be successfully implemented among African American families while suggesting the need for modifications to yield stronger effects on infant weight outcomes.

Family‐based interventions for preventing overweight or obesity among preschoolers from racial/ethnic minority groups: A scoping review

Objective

This scoping review aimed to synthesize the published literature on family‐based childhood obesity prevention interventions from 2015 to 2021 that focused on children 2–5 years of age from racial and/or ethnic minority households.

Methods

A PICOS (population, intervention, comparison, outcome, and setting) framework was used to guide the development of the research question, search strategy, and inclusion/exclusion criteria. To be included, the study must have been a randomized controlled trial or quasi‐experimental trial that enrolled participants 2–5 years of age and their caregivers who identified as being from a racial and/or ethnic minority group in the United States. The study must have also examined a family‐based intervention that incorporated components to prevent childhood obesity (i.e., fruits and vegetable intake, parental responsive feeding, physical activity), be conducted in a remote (i.e., online, text, mail), home, community, primary care setting, or early childhood education institution setting, and report on body mass index (BMI, kg/m²), BMI z‐score, anthropometric measures (weight, waist circumference, fat mass, etc.), changes in health behaviors, or increase in nutritional knowledge.

Results

Fourteen individual studies were identified. Most interventions used multiple components for promoting nutritional knowledge and behavioral changes among families. Eight interventions included culturally tailored components targeting four aspects: (1) language barriers, (2) food choices, (3) relationships between family members, and (4) rapport building.

Conclusions

There is limited research in this field focusing on children from racial and/or ethnic minority groups. Future efforts should invest in developing culturally appropriate interventions for these groups.

Directionality of the associations between bedsharing, maternal depressive symptoms, and infant sleep during the first 15 months of life

OBJECTIVES

To identify predictors of infant sleep arrangement and examine the directionality of the relationships between maternal depressive symptoms, infant sleep problems, and bedsharing.

DESIGN

Secondary analysis of longitudinal data from the Mothers and Others: Family-Based Obesity Prevention for Infants and Toddlers randomized trial.

SETTING

Central North Carolina, USA.

PARTICIPANTS

Four-hundred and twenty-eight predominantly low-income, non-Hispanic Black mother-infant pairs.

MEASUREMENTS

Data were collected at 28 weeks pregnancy and 1, 3, 6, 9, 12, and 15 months postpartum. Maternal depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale and infant sleep variables were measured using the Brief Infant Sleep Questionnaire.

RESULTS

The prevalence of reported bedsharing increased from 16.7% at 1 month to 35.6% at 15 months postpartum. Bedsharing was associated with shortened breastfeeding duration and maternal perception of an infant sleep problem. Concurrently, maternal perception of an infant sleep problem, but not presence of maternal depressive symptoms, was associated with an increased likelihood of bedsharing. Longitudinally, neither maternal perception of an infant sleep problem nor presence of maternal depressive symptoms predicted bedsharing. Bedsharing predicted an increased likelihood of maternal perception of an infant sleep problem and presence of maternal depressive symptoms.

CONCLUSION

Prevalence of bedsharing increased over time and was predictive of maternal depressive symptoms. Providers should discuss the conflicting infant sleep recommendations with their patients and provide safe-sleep guidelines for mothers who intend to bedshare.

Grandparent Coresidence and Risk of Early Child Overweight and Obesity in Low-Income, Hispanic Families in New York City

OBJECTIVE

Children in low-income Hispanic families are at high risk of obesity and are more likely to live with grandparents than their non-Hispanic white counterparts. We aimed to determine if grandparent coresidence (prenatal through age 2 years) was associated with: 1) obesogenic feeding practices; and 2) child weight outcomes from birth to three years.

METHODS

We analyzed data from 267 low-income, Hispanic mother-infant pairs in the control group of an obesity prevention trial in New York City. Linear and logistic regression tested differences in obesogenic feeding practices and weight outcomes at 2 and 3 years, dependent upon grandparent coresidence. Multilevel modeling tested associations between grandparent coresidence and WFAz over time.

RESULTS

Persistent grandparent coresidence (vs none) was associated with putting cereal in the bottle (adjusted odds ratio [aOR] 3.46; 95% confidence interval [CI] 1.43, 8.40). Persistent grandparent coresidence (vs none) was associated with higher mean WFAz (2 years: B 0.83; 95% CI 0.41, 1.25; 3 years: B 0.79; 95% CI 0.32, 1.25) and higher odds of child overweight/obesity risk (2 years: aOR 4.38; 95% CI 1.64, 11.69; 3 years: aOR 3.15; 95% CI 1.19, 8.36). In multilevel models, more occasions of grandparent coresidence were associated with higher WFAz.

CONCLUSIONS

Grandparent coresidence may be associated with higher risk of child overweight/obesity in low-income, Hispanic families. Further research is needed to elucidate mechanisms of these associations and to inform obesity prevention strategies in the context of multigenerational families.

Feeding style profiles are associated with maternal and infant characteristics and infant feeding practices and weight outcomes in African American mothers and infants

Much literature links individual feeding styles to infant feeding practices and growth; however, parents' feeding styles are not discrete and may vary by context. We use latent profile analysis (LPA) as a person-centered approach to categorize infant feeding style patterns, test factors predicting profile membership, and examine if profiles are associated with infant feeding and weight. Additionally, we test the impact of a responsive feeding intervention on profile membership and stability. Data come from 270 African-American women and infants participating in the Mothers and Others Study, an early life obesity prevention intervention. LPA was used to categorize mothers across five constructs (laissez-faire, pressuring, restrictive, responsive and indulgent) measured at 28-weeks gestation and 3- and 15-months postpartum. Adjusted multinomial regression and regression models test the characteristics associated with profile membership and the associations between profile membership and breastfeeding and infant weight-for-age z-score (WAZ). We identified two groups (Positive and Less Responsive) prenatally, an additional group (High Controlling) at 3 months and a fourth group (High Indulgent) at 15 months. Several characteristics differed between the groups, including maternal age, income and depressive symptoms, infant sex and temperament, and treatment group. Mothers in the Positive group were more likely to breastfeed at 3 months. Infants with mothers in the High Controlling group had higher WAZ at 15 months. The intervention was associated with more Positive feeding practices at 15 months and a greater likelihood of remaining in the Positive group across the study. LPA identified profiles that are associated with maternal and infant characteristics and treatment group and with better feeding practices and growth outcomes, providing preliminary evidence that early intervention promoting more responsive feeding profiles may improve infant outcomes.

Evaluation of a Mobile-based Maternal Feeding Education Program for Overweight Prevention in Infants

PURPOSE

The purpose of this study was to evaluate a mobile-based maternal feeding education program for overweight prevention in infants based on breastfeeding attitude, breastfeeding self-efficacy, breastfeeding duration, recognition of hunger and satiety cues of infants, and knowledge regarding providing solids foods.

METHODS

A nonequivalent control group pretest-posttest design was used for the study. Participants included 15 primiparas in the experimental group and 14 primiparas in the control group in all the follow-up tests. Using self-reported questionnaires in electronic format, data were collected four times (before the intervention, 1 month after childbirth, 3 months after childbirth, and 6 months after childbirth). Using SPSS 24 version, independent t-test and repeated-measures analysis of variance were used to test the effects of the mobile-based maternal feeding education program.

RESULTS

The experimental group showed significantly more positive breastfeeding attitude (F = 5.28, p = .008), higher breastfeeding self-efficacy (F = 3.50, p = .041), and increased breastfeeding duration (t = -2.09, p = .046) than the control group. In addition, the experimental group showed significantly improved knowledge regarding providing solid foods to the infants (F = 4.86, p = .009) in comparison with the control group. However, for education on recognizing hunger and satiety cues of infants, the mobile-based maternal feeding education program was not effective (F = 0.23, p = .878).

CONCLUSION

According to the results of this study, the mobile-based maternal feeding education program has the potential to contribute to overweight prevention in infants.

Engaging fathers in the first 1000 days to improve perinatal outcomes and prevent obesity: Rationale and design of the First Heroes randomized trial

BACKGROUND

Early pregnancy through the first year of life represents an important period for family health promotion and obesity prevention. Overall, preventive interventions in pregnancy and infancy have insufficiently engaged fathers. We describe the rationale and design of First Heroes, an intervention to improve perinatal and obesity-related outcomes among mother-father-infant triads beginning in pregnancy.

METHODS/DESIGN

First Heroes is a hybrid type 1 effectiveness-implementation randomized trial of mother-father-infant triads recruited in the second trimester of pregnancy from a large Obstetric practice in eastern Massachusetts and continuing through 12 months of infant age. Triads are randomized to the intervention arm or to an enhanced safety education control group. Triads randomized to the intervention arm receive three virtual visits with a health educator, in the 3rd trimester of pregnancy, at 3-4 weeks, and 3-4 months postpartum, and receive continuous multimedia education through text messaging, print material, and videos. The educational curriculum addresses parent health behaviors, family relationships, social determinants of health, and infant feeding, sleep, and development. The primary outcome is prevalence of rapid infant weight gain from birth to 6 months of age. Secondary outcomes include parent anthropometrics, parent obesogenic behaviors, family functioning, and infant behaviors.

DISCUSSION

First Heroes will evaluate the extent to which intentional mother-father dyad engagement, coaching on adoption of early life health behaviors, and addressing social determinants of health, influence obesogenic behaviors and outcomes in the first year of life. Findings from this work will inform future obesity prevention efforts, especially those focused on whole family inclusion.

Process evaluations of early childhood obesity prevention interventions delivered via telephone or text messages: a systematic review

BACKGROUND

Increasingly, public health interventions are delivered via telephone and/or text messages. Recent systematic reviews of early childhood obesity prevention interventions have not adequately reported on the way interventions are delivered and the experiences/perceptions of stakeholders. We aimed to summarise the literature in early childhood obesity prevention interventions delivered via telephone or text messages for evidence of application of process evaluation primarily to evaluate stakeholders' acceptability of interventions.

METHODS

A systematic search of major electronic databases was carried out using the Population, Intervention, Comparison, Outcomes framework. Studies were included if interventions were delivered via telephone/text messages; aimed at changing caregivers' behaviours to prevent early childhood obesity; with one or more outcomes related to early obesity risk factors such as breastfeeding, solid feeding, tummy time, sleep and settling, physical activity and screen time; published from inception to May 2020. All eligible studies were independently assessed by two reviewers using the Cochrane Collaboration tool for assessing risk of bias. Qualitative studies were assessed using the Consolidated Criteria for Reporting Qualitative Research and Standards for Reporting Qualitative Research tools.

RESULTS

Twenty-four studies were eligible, and the overall risk of bias was low. Eight studies (33%) had evidence of process evaluation that examined participants' perceptions of interventions. Participants appreciated the convenience of receiving interventions via telephone or text messages. 63% of all studies in this review showed improvement in one or more behaviours related to childhood obesity prevention. Participants were likely to modify behaviours if they received information from a credible source such as from health professionals.

CONCLUSION

There is limited reporting of stakeholders' experiences in early obesity prevention studies delivered by telephone or text messages. Only one-third of studies examined participants' acceptability and the potential for delivery of childhood obesity prevention interventions conveniently using this mode of delivery. Interventions delivered remotely via telephone or text messages have the potential to reach equal or a greater number of participants than those delivered via face-to-face methods. Future research should build in process evaluation alongside effectiveness measurements to provide important insight into intervention reach, acceptability and to inform scale up.

TRIAL REGISTRATION

PROSPERO registration: CRD42019108658.

Home-based intervention for non-Hispanic black families finds no significant difference in infant size or growth: results from the Mothers & Others randomized controlled trial

Background

Non-Hispanic black (NHB) infants are twice as likely as non-Hispanic white infants to experience rapid weight gain in the first 6 months, yet few trials have targeted this population. The current study tests the efficacy of “Mothers & Others,” a home-based intervention for NHB women and their study partners versus an attention-control, on infant size and growth between birth and 15 months.

Methods

Mothers & Others was a two-group randomized controlled trial conducted between November 2013 and December 2017 with enrollment at 28-weeks pregnancy and follow-up at 3-, 6-, 9-, 12-, and 15-months postpartum. Eligible women self-identified as NHB, English-speaking, and 18–39 years. The obesity prevention group (OPG) received anticipatory guidance (AG) on responsive feeding and care practices and identified a study partner, who was encouraged to attend home visits. The injury prevention group (IPG) received AG on child safety and IPG partners only completed study assessments. The primary delivery channel for both groups was six home visits by a peer educator (PE). The planned primary outcome was mean weight-for-length z-score. Given significant differences between groups in length-for-age z-scores, infant weight-for-age z-score (WAZ) was used in the current study. A linear mixed model, using an Intent-To-Treat (ITT) data set, tested differences in WAZ trajectories between the two treatment groups. A non-ITT mixed model tested for differences by dose received.

Results

Approximately 1575 women were screened for eligibility and 430 were enrolled. Women were 25.7 ± 5.3 years, mostly single (72.3%), and receiving Medicaid (74.4%). OPG infants demonstrated lower WAZ than IPG infants at all time points, but differences were not statistically significant (WAZ_diff = − 0.07, 95% CI − 0.40 to 0.25, p = 0.659). In non-ITT models, infants in the upper end of the WAZ distribution at birth demonstrated incremental reductions in WAZ for each home visit completed, but the overall test of the interaction was not significant (F_2,170 = 1.41, p = 0.25).

Conclusions

Despite rich preliminary data and a strong conceptual model, Mothers & Others did not produce significant differences in infant growth. Results suggest a positive impact of peer support in both groups.

Trial registration

ClinicalTrials.gov, NCT01938118, 09/10/2013.

Education of family members to support weaning to solids and nutrition in later infancy in term-born infants

BACKGROUND

Education of family members about infant weaning practices could affect nutrition, growth, and development of children in different settings across the world.

OBJECTIVES

To compare effects of family nutrition educational interventions for infant weaning with conventional management on growth and neurodevelopment in childhood.

SEARCH METHODS

We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5), MEDLINE via PubMed (1966 to 26 June 2018), Embase (1980 to 26 June 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 26 June 2018). We searched clinical trials databases, conference proceedings, and references of retrieved articles. We ran an updated search from 1 January 2018 to 12 December 2019 in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost.

SELECTION CRITERIA

We included randomised controlled trials that examined effects of nutrition education for weaning practices delivered to families of infants born at term compared to conventional management (standard care in the population) up to one year of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified eligible trial reports from the literature search and performed data extraction and quality assessments for each included trial. We synthesised effect estimates using risk ratios (RRs), risk differences (RDs), and mean differences (MDs), with 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 21 trials, recruiting 14,241 infants. Five of the trials were conducted in high-income countries and the remaining 16 were conducted in middle- and low-income countries. Meta-analysis showed that nutrition education targeted at improving weaning-related feeding practices probably increases both weight-for-age z scores (WAZ) (MD 0.15 standard deviations, 95% CI 0.07 to 0.22; 6 studies; 2551 infants; I² = 32%; moderate-certainty evidence) and height-for-age z scores (0.12 standard deviations, 95% CI 0.05 to 0.19; 7 studies; 3620 infants; I² = 49%; moderate-certainty evidence) by 12 months of age. Meta-analysis of outcomes at 18 months of age was heterogeneous and inconsistent in the magnitude of effects of nutrition education on WAZ and weight-for-height z score across studies. One trial that assessed effects of nutrition education on growth at six years reported an uncertain effect on change in height and body mass index z score. Two studies investigated effects of nutrition education on neurodevelopment at 12 to 24 months of age with conflicting results. No trials assessed effects of nutrition education on long-term neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

Nutrition education for families of infants may reduce the risk of undernutrition in term-born infants (evidence of low to moderate certainty due to limitations in study design and substantial heterogeneity of included studies). Modest effects on growth during infancy may not be of clinical significance. However, it is unclear whether these small improvements in growth parameters in the first two years of life affect long-term childhood growth and development. Further studies are needed to resolve this question.

Sleep during Infancy and Associations with Childhood Body Composition: A Systematic Review and Narrative Synthesis

Introduction: Prevention of childhood overweight should start as early as possible preferably in "the first 1000 days of life." Sleep is one of the modifiable health behaviors during this age period, besides dietary intake and physical activity. The aim of this systematic review is to summarize the existing literature regarding the association between sleep during infancy (age ≤24 months) and body composition measures during childhood (age ≤12 years). Methods: We registered the protocol of this systematic review (PROSPERO registration no. CRD42018087088) and conducted the review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. We searched for articles published until July 31, 2019 reporting on longitudinal associations with a minimal follow-up of 6 months. Methodological Quality was assessed and a narrative synthesis was performed. Results: We included 19 studies. Sleep was reported as sleep duration (n = 18) or sleep problems (n = 2). Sleep was assessed at least once before the age of 12 months in 14 out of the 19 studies. Methodological quality was rated as strong for five studies, moderate for five studies, and weak for nine studies. Conclusion: This narrative synthesis found inconsistent evidence that longer infant sleep duration during the first 2 years of life is associated with a healthier body composition during childhood.

Parent preferences for text messages containing infant feeding advice

BACKGROUND

Text-messaging is beneficial in health promotion. Research on impact of message framing (gain- versus loss-framed) has had variable results, depending on type of behavior targeted. There is no research on framing of text-messaging to promote healthful infant feeding practices.

METHODS

The purpose of this cross-sectional survey was to examine whether parents of infants aged three months or younger viewed gain- or loss-framed text messages as more helpful and which style was viewed as more likely to affect feeding practices. A secondary purpose was to determine what time of day and frequency of messaging was preferred. Parents were recruited from an urban pediatric medical clinic. PsychData was used to administer the survey. Parents rated message pairs targeting constructs of the Health Belief Model using a five-point Likert scale. Paired t- tests compared overall ratings for helpfulness and likelihood of messages affecting feeding practices between gain- and loss-framed messages. Descriptive and frequency analyses were applied to demographics and questions regarding preferred timing for receiving messages.

RESULTS

A total of 34 parents (3 fathers and 31 mothers, mean age 26±5.5 years) completed the survey, with 41% enrolled in WIC and 29% in SNAP. There was no overall difference in helpfulness or likelihood of messages affecting feeding practices between gain- and loss-framed messages. Message style did not affect likelihood of adopting a feeding practice. However, gain framed messages relating to benefits and self-efficacy for breastfeeding were viewed more positively (mean =2.32; P=0.034; mean =1.79; P=0.041, respectively). The greatest proportion of parents (38%) preferred receiving messages once per week, and 50% preferred morning messages.

CONCLUSIONS

Framing of text messages appeared to have little effect on parents' acceptance of messages related to infant feeding practices. Parents were receptive to receiving messages from their infant's healthcare provider once per week, in the morning.

Validation of the Infant Feeding Beliefs Questionnaire (IFBQ) among pregnant African- American women and their study partners

Maternal feeding beliefs and practices have been associated with weight gain in infants and young children. Less work examines feeding beliefs prenatally or the feeding beliefs of other non-maternal caregivers (NMCs) who play important roles in infant feeding. This study validates a scale, the Infant Feeding Beliefs Questionnaire (IFBQ), to assess feeding beliefs during pregnancy among African-American women and other caregivers and tests whether the resulting belief constructs (laissez-faire, restrictive, responsive, pressuring and indulgent) are associated with maternal and NMC characteristics. Data come from 429 pregnant women and 374 NMCs including fathers, grandmothers and other family and friends enrolled in the baseline 28-week gestation visit of the Mothers and Others Study, a family-based, randomized control trial to support healthy infant feeding and prevent obesity. Confirmatory factor analysis (CFA) was used to test the fit of four a priori feeding constructs. Models were modified iteratively in mothers and then separately tested in the NMCs sample. Construct scores were created by averaging the remaining items and scale reliability was assessed. External validity was tested using bivariate and multivariable regression models. We validated five feeding belief constructs, measured through 8 sub-constructs. Reliability coefficients ranged from 0.58 for laissez faire to 0.76 for pressuring. Goodness of fit indices for CFA models indicated good fit with CFIs from 0.97 to 0.99 and RMSEA from 0.00 to 0.06. Construct scores differed significantly by depressive symptoms, obesity, education, income, and previous children in mothers and NMCs. The IFBQ may be used among mothers and NMCs to assess feeding beliefs beginning in the prenatal period, providing a tool to assess the longitudinal development of feeding beliefs and to highlight avenues for intervention on feeding practices during a critical period for behavior change.

Self-efficacy, infant feeding practices, and infant weight gain: An integrative review

It has been suggested that self-efficacy specific to parenting or feeding may influence the decisions parents make regarding infant feeding; however, a review of this topic has not been conducted. The purpose of this integrative review is to synthesize the literature regarding the potential role of self-efficacy in infant feeding practices or infant weight gain. A total of 40 articles were used to guide this review, which were classified into three categories examining an association with self-efficacy (1) breastfeeding; (2) infant feeding practices such as parental feeding style and dietary quality; and (3) infant weight gain. Evidence regarding breastfeeding self-efficacy (BFSE) and breastfeeding is extensive; mothers with a higher sense of BFSE more often initiate breastfeeding and breastfeed for longer durations. The evidence regarding self-efficacy and the association with infant feeding practices other than breastfeeding is sparse. However, several studies report that mothers who have a higher sense of self-efficacy are more likely to follow infant feeding practices which align with recommendations. The authors have speculated an association between self-efficacy and infant weight gain; yet, to date, no study has found a significant association. More research is needed on the topic, particularly in diverse populations and with fathers and mothers.