Effects of promoting longer-term and exclusive breastfeeding on childhood eating attitudes: a cluster-randomized trial

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.

Breastfeeding duration in infancy and dietary intake in childhood and adolescence

Although several studies have focused on associations between breastfeeding and child obesity, few have focused on associations with dietary intake. We examined associations between breastfeeding duration in infancy and dietary intake in childhood and explored whether associations are still observed in adolescence. The QUALITY (QUebec Adipose and Lifestyle InvesTigation in Youth) cohort includes 630 children aged 8-10 years at baseline (T1) who have at least one parent with obesity. A follow-up assessment was done 7 years later (T2) when participants were aged 15-17 years (n=377). Non-exclusive breastfeeding duration was evaluated at T1 using a parent questionnaire (never, < 3 months, 3-6 months, > 6 months). Dietary intake was assessed at T1 and T2 using three 24-h diet recalls, namely daily servings of vegetables (≥ 2 vs < 2), fruits (≥ 2 vs < 2), vegetables and fruits combined (≥ 5 vs < 5), sugar-sweetened beverages (SSB) (none vs any), and an overall diet quality index (DQI-I) (good vs poor). Multiple logistic regressions, adjusted for age, sex and total kilocalorie intake of the child, for age and body mass index of the mother, and for parental education and income were used. Compared to children breastfed > 6 months (reference group), those never breastfed or breastfed for 3-6 months were 42% (OR = 0.58, 95% CI: 0.34-0.96) and 38% (OR = 0.62, 95% CI: 0.39-1.00) less likely to consume ≥ 2 servings of vegetables per day at 8-10 years, respectively, while no association was found for those breastfed < 3 months. Compared to children breastfed > 6 months, those never breastfed were 1.8 times more likely to drink any SSB (OR = 1.82, 95% CI: 1.03-3.22). No associations were found for other diet indicators, and associations observed in childhood were no longer found by adolescence. In this cohort, breastfeeding was associated with greater vegetable intake and the avoidance of SSB in childhood, but not in adolescence, nor were associations found for fruit intake or overall diet quality.

Breastfeeding reduces ultra-processed foods and sweetened beverages consumption among children under two years old

BACKGROUND

Breastfeeding and adequate complementary feeding are associated with healthy eating habits, prevention of nutritional deficiencies, obesity and non-communicable diseases. Our aim was to identify feeding practices and to evaluate the association between breastmilk intake and complementary feeding, focusing on ultra-processed foods (UPF) and sweetened beverages, among children under 2 years old.

METHODS

We conducted a cross-sectional study including 847 children from 20 Primary Health Units. We evaluated children's food consumption using a food intake markers questionnaire. We conducted a logistic regression to evaluate the effect of breastmilk intake on feeding practices.

RESULTS

The breastmilk intake was associated with lower odds of consuming non-recommended foods, such as cookies or crackers (OR: 0.29; IC 95%: 0.20-0.41) for children under 6 months, yogurt (OR: 0.33; CI 95%: 0.12-0.88) for children between 6 and 12 months and soft drinks (OR: 0.36; CI 95%: 0.17-0.75) for children between 12 and 24 months. Moreover, the breastmilk intake was associated with lower odds of consuming UPF (OR: 0.26; CI 95%: 0.09-0.74) and sweetened beverages (OR: 0.13; CI 95%: 0.05-0.33) for children under 6 months. For children between 12 and 24 months, breastmilk intake was associated with lower odds of consuming sweetened beverages (OR: 0.40; CI 95%: 0.24-0.65).

CONCLUSION

Breastmilk intake was associated with a reduced consumption of UPF and sweetened beverages. Investment in actions to scale up breastfeeding can generate benefits, besides those of breastmilk itself, translating into better feeding habits and preventing health problems in childhood.

Assessment of eating attitudes and dieting behaviors in healthy children: Confirmatory factor analysis of the Children's Eating Attitudes Test

OBJECTIVE

The Children's Eating Attitudes Test (ChEAT) is a self-report questionnaire that is conventionally summarized with a single score to identify "problematic" eating attitudes, masking informative variability in different eating attitude domains. This study evaluated the empirical support for single- versus multifactor models of the ChEAT. For validation, we compared how well the single- versus multifactor-based scores predicted body mass index (BMI).

METHOD

Using data from 13,674 participants of the 11.5 year-follow-up of the Promotion of Breastfeeding Intervention Trial (PROBIT) in the Republic of Belarus, we conducted confirmatory factor analysis to evaluate the performance of 3- and 5-factor models, which were based on past studies, to a single-factor model representing the conventional summary of the ChEAT. We used cross-validated linear regression models and the reduction in mean squared error (MSE) to compare the prediction of BMI at 11.5 and 16 years by the conventional and confirmed factor-based ChEAT scores.

RESULTS

The 5-factor model, based on 14 of the original 26 ChEAT items, had good fit to the data whereas the 3- and single-factor models did not. The MSE for concurrent (11.5 years) BMI regressed on the 5-factor ChEAT summary was 35% lower than that of the single-score models, which reduced the MSE from the null model by only 1%-5%. The MSE for BMI at 16 years was 20% lower.

DISCUSSION

We found that a parsimonious 5-factor model of the ChEAT explained the data collected from healthy Belarusian children better than the conventional summary score and thus provides a more discriminating measure of eating attitudes.

Breastfeeding to 12 mo and beyond: nutrition outcomes at 3 to 5 y of age

Background

Little is known about nutrition outcomes in preschoolers associated with breastfeeding duration beyond 12 mo of age.

Objective

The aim was to examine the association between total breastfeeding duration and nutrition outcomes at 3 to 5 y of age.

Design

A cross-sectional study in healthy children, ages 3-5 y, recruited from 9 primary care practices in Toronto was conducted through the TARGet Kids! (The Applied Research Group for Kids) research network. Parents completed standardized surveys, including the Nutrition Screening for Every Preschooler (NutriSTEP) used to assess nutrition risk.

Results

A total of 2987 children were included. Ninety-two percent of children were breastfed, and the mean ± SD breastfeeding duration was 11.4 ± 8.4 mo. The prevalence of nutrition risk (score >20) was 17.0%. We examined breastfeeding duration as a continuous variable. With the use of restricted cubic spline modeling, we confirmed a nonlinear relation between breastfeeding duration and NutriSTEP score, dietary intake and eating behavior subscores, and sugar-sweetened beverage and sweet-savory snack consumption. Segmented linear regression was used to examine this nonlinear relation in a piecewise approach. We found a decreasing trend in NutriSTEP score for children who were breastfed for 0-6 mo (β = -0.14; 95% CI: -0.29, 0.004), a significant decrease in NutriSTEP score for children breastfed for 6-12 mo (β = -0.20; 95% CI: -0.33, -0.07), and no significant change after 12 mo (β = 0.09; 95% CI: -0.07, 0.24) and beyond. The mean ± SD NutriSTEP scores were 17.1 ± 7.4 for no breastfeeding, 15.9 ± 6.5 for breastfeeding >0-6 mo, 13.9 ± 6.2 for >6-12 mo, 13.7 ± 6.3 for >12-18 mo, 14.6 ± 6.7 for >18-24 mo, and 14.3 ± 6.8 for >24-36 mo.

Conclusions

Breastfeeding for ≤12 mo was associated with decreased nutrition risk and healthier eating behaviors and dietary intake at 3-5 y of age. We found insufficient evidence of additional benefit for breastfeeding beyond 12 mo of age. The TARGet Kids! practice-based research network is registered at www.clinicaltrials.gov as NCT01869530.

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

To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.To examine the effectiveness of different care providers and (where information was available) training.To explore the interaction between background breastfeeding rates and effectiveness of support.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) 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.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 100 trials involving more than 83,246 mother-infant pairs of which 73 studies contribute data (58 individually-randomised trials and 15 cluster-randomised trials). We considered that the overall risk of bias of trials included in the review was mixed. Of the 31 new studies included in this update, 21 provided data for one or more of the primary outcomes. The total number of mother-infant pairs in the 73 studies that contributed data to this review is 74,656 (this total was 56,451 in the previous version of this review). The 73 studies were conducted in 29 countries. Results of the analyses continue to confirm that all forms of extra support analyzed together showed a decrease in cessation of 'any breastfeeding', which includes partial and exclusive breastfeeding (average risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.95; moderate-quality evidence, 51 studies) and for stopping breastfeeding before four to six weeks (average RR 0.87, 95% CI 0.80 to 0.95; moderate-quality evidence, 33 studies). All forms of extra support together also showed a decrease in cessation of exclusive breastfeeding at six months (average RR 0.88, 95% CI 0.85 to 0.92; moderate-quality evidence, 46 studies) and at four to six weeks (average RR 0.79, 95% CI 0.71 to 0.89; moderate quality, 32 studies). We downgraded evidence to moderate-quality due to very high heterogeneity.We investigated substantial heterogeneity for all four outcomes with subgroup analyses for the following covariates: who delivered care, type of support, timing of support, background breastfeeding rate and number of postnatal contacts. Covariates were not able to explain heterogeneity in general. Though the interaction tests were significant for some analyses, we advise caution in the interpretation of results for subgroups due to the heterogeneity. Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Several factors may have also improved results for women practising exclusive breastfeeding, such as interventions delivered with a face-to-face component, high background initiation rates of breastfeeding, lay support, and a specific schedule of four to eight contacts. However, because within-group heterogeneity remained high for all of these analyses, we advise caution when making specific conclusions based on subgroup results. We noted no evidence for subgroup differences for the any breastfeeding outcomes.

AUTHORS' CONCLUSIONS

When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased. Characteristics of effective support include: that it is offered as standard by trained personnel during antenatal or postnatal care, that it includes ongoing scheduled visits so that women can predict when support will be available, and that it is tailored to the setting and the needs of the population group. Support is likely to be more effective in settings with high initiation rates. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed with women practising exclusive breastfeeding.

Prospective associations between problematic eating attitudes in midchildhood and the future onset of adolescent obesity and high blood pressure

BACKGROUND

Clinically diagnosed eating disorders may have adverse cardiometabolic consequences, including overweight or obesity and high blood pressure. However, the link between problematic eating attitudes in early adolescence, which can lead to disordered eating behaviors, and future cardiometabolic health is, to our knowledge, unknown.

OBJECTIVE

We assessed whether variations in midchildhood eating attitudes influence the future development of overweight or obesity and high blood pressure.

DESIGN

Of 17,046 children who participated in the Promotion of Breastfeeding Intervention Trial (PROBIT), we included 13,557 participants (79.5% response rate) who completed the Children's Eating Attitudes Test (ChEAT) at age 11.5 y and in whom we measured adiposity and blood pressure at ages 6.5, 11.5, and 16 y. We assessed whether ChEAT scores ≥85th percentile (indicative of problematic eating attitudes) compared with scores <85th percentile at age 11.5 y were associated with new-onset overweight, obesity, high systolic blood pressure, or high diastolic blood pressure between midchildhood and early adolescence.

RESULTS

After controlling for baseline sociodemographic confounders, we observed positive associations of problematic eating attitudes at age 11.5 y with new-onset obesity (OR: 2.18; 95% CI: 1.58, 3.02), new-onset high systolic blood pressure (OR: 1.34; 95% CI: 1.05, 1.70), and new-onset high diastolic blood pressure (OR: 1.25; 95% CI: 0.99, 1.58) at age 16 y. After further controlling for body mass index at age 6.5 y, problematic eating attitudes remained positively associated with new-onset obesity (OR: 1.80; 95% CI: 1.28, 2.53); however, associations with new-onset high blood pressure were attenuated (OR: 1.14; 95% CI: 0.89, 1.45 and OR: 1.09; 95% CI: 0.86, 1.39 for new-onset systolic and diastolic blood pressure, respectively).

CONCLUSIONS

Problematic eating attitudes in midchildhood seem to be related to the development of obesity in adolescence, a relatively novel observation with potentially important public health implications for obesity control. PROBIT was registered at clinicaltrials.gov as NCT01561612 and isrctn.com as ISRCTN37687716.

Effect of Exclusive Breastfeeding Among Overweight and Obese Mothers on Infant Weight-for-Length Percentile at 1 Year

BACKGROUND

Breastfeeding is associated with decreased risk of childhood obesity. However, there is a strong correlation between maternal weight status and childhood obesity, and it is unclear whether or not breastfeeding among overweight mothers could mitigate this risk. Our goal was to examine whether or not exclusive breastfeeding (compared to formula feeding) among overweight and obese mothers is associated with lower weight-for-length (W/L) percentile at 1 year.

MATERIALS AND METHODS

Data from the Infant Feeding Practices II study were used. Infants who were preterm or underweight at 1 year, and mothers who were underweight before pregnancy, were excluded from analysis. There was a significant interaction between exclusive breastfeeding for 4 months and maternal prepregnancy weight status (normal weight, overweight, obese) on infant W/L percentile at 1 year. Stratified linear mixed-effects growth modeling controlling for covariates was created to test the relationship between exclusive breastfeeding and infant W/L percentile within each maternal weight category.

RESULTS

A total of 915 subjects met inclusion criteria. Normal weight and obese mothers who exclusively breastfed for 4 months had infants with a smaller rate of increase in W/L percentile during the first year compared with those who used formula. Infants of overweight and obese mothers who exclusively breastfed for 4 months had lower W/L percentile at 1 year than those who used formula.

CONCLUSIONS

Exclusive breastfeeding for 4 months among normal weight and obese mothers resulted in less increase in W/L percentiles in the first year. Obese mothers often have a difficult time initiating and maintaining breastfeeding. Concerted efforts are needed to support this population with breastfeeding.

Approaches for drawing causal inferences from epidemiological birth cohorts: a review

Large-scale population-based birth cohorts, which recruit women during pregnancy or at birth and follow up their offspring through infancy and into childhood and adolescence, provide the opportunity to monitor and model early life exposures in relation to developmental characteristics and later life outcomes. However, due to confounding and other limitations, identification of causal risk factors has proved challenging and published findings are often not reproducible. A suite of methods has been developed in recent years to minimise problems afflicting observational epidemiology, to strengthen causal inference and to provide greater insights into modifiable intra-uterine and early life risk factors. The aim of this review is to describe these causal inference methods and to suggest how they may be applied in the context of birth cohorts and extended along with the development of birth cohort consortia and expansion of "omic" technologies.

The association of early childhood cognitive development and behavioural difficulties with pre-adolescent problematic eating attitudes

OBJECTIVES

Few studies have prospectively investigated associations of child cognitive ability and behavioural difficulties with later eating attitudes. We investigated associations of intelligence quotient (IQ), academic performance and behavioural difficulties at 6.5 years with eating attitudes five years later.

METHODS

We conducted an observational cohort study nested within the Promotion of Breastfeeding Intervention Trial, Belarus. Of 17,046 infants enrolled at birth, 13,751 (80.7%) completed the Children's Eating Attitude Test (ChEAT) at 11.5 years, most with information on IQ (n = 12,667), academic performance (n = 9,954) and behavioural difficulties (n = 11,098) at 6.5 years. The main outcome was a ChEAT score ≥ 85th percentile, indicative of problematic eating attitudes.

RESULTS

Boys with higher IQ at 6.5 years reported fewer problematic eating attitudes, as assessed by ChEAT scores ≥ 85th percentile, at 11.5 years (OR per SD increase in full-scale IQ = 0.87; 0.79, 0.94). No such association was observed in girls (1.01; 0.93, 1.10) (p for sex-interaction = 0.016). In both boys and girls, teacher-assessed academic performance in non-verbal subjects was inversely associated with high ChEAT scores five years later (OR per unit increase in mathematics ability = 0.88; 0.82, 0.94; and OR per unit increase in ability for other non-verbal subjects = 0.86; 0.79, 0.94). Behavioural difficulties were positively associated with high ChEAT scores five years later (OR per SD increase in teacher-assessed rating = 1.13; 1.07, 1.19).

CONCLUSION

Lower IQ, worse non-verbal academic performance and behavioural problems at early school age are positively associated with risk of problematic eating attitudes in early adolescence.