Exclusively breastfed overweight infants are at the same risk of childhood overweight as formula fed overweight infants

Systematic review and meta-analysis of breastfeeding and later overweight or obesity expands on previous study for World Health Organization

AIM

To update a systematic review and meta-analysis of the association of breastfeeding with overweight or obesity that had been commissioned by the World Health Organization. We also assessed the likelihood of residual confounding.

METHODS

Two independent reviewers searched MEDLINE, LILACS and Web of Science for manuscripts published between August 2014 and May 2021. Studies that only evaluated infants were excluded. Random-effects models were used to pool the estimates.

RESULTS

The review comprised 159 studies with 169 estimates on the association of breastfeeding with overweight or obesity, and most of the studies were carried out among individuals aged 1-9 years (n = 130). Breastfeeding protected against overweight or obesity (pooled odds ratio:0.73, 95% confidence interval:0.71; 0.76). And, even among the 19 studies that were less susceptible to publication bias, residual confounding and misclassification, a benefit was observed (pooled odds ratio:0.85, 95% confidence interval:0.77; 0.93). Among those studies that were clearly susceptible to positive confounding by socioeconomic status, a benefit of breastfeeding was observed even after adjusting for socioeconomic status (pooled odds ratio:0.76, 95% confidence interval: 0.69; 0.83).

CONCLUSION

Breastfeeding reduced the odds of overweight or obesity, and this association was unlikely to be due to publication bias and residual confounding.

Overweight in childhood of exclusively breastfed infants with a high weight at 5 months

High infant weight increases the risk of childhood overweight, while breastfeeding may reduce the risk. However, some infants have a very high weight gain even though they are exclusively breastfed. We examined the risk of a high body mass index (BMI) and overweight in childhood for infants ≥2.5 SD above the median weight-for-age (WAZ) at age 5 months according to duration of exclusive breastfeeding (≤2, >2 to <4 or ≥4 months). The study is based on 13,401 7-year-old and 9,819 11-year-old children enrolled into the Danish National Birth Cohort (born 1997-2003). Linear and logistic regression analyses were used to examine the associations while adjusting for presumed confounders including birth weight. The results showed that infants ≥2.5 SD at 5 months, breastfed exclusively ≤2, >2 to <4 or ≥4 months had adjusted odds ratios (ORs) for overweight at age 7 at 3.67 (95% confidence interval [CI] [2.10, 6.43]), 3.42 (95% CI [2.32, 5.04]) and 3.19 (95% CI [1.90, 5.36]) respectively, when compared with infants <2.5 SD WAZ exclusively breastfed ≥4 months. The corresponding results for BMI z-scores were 0.82 (95% CI [0.60, 1.04]), 0.63 (95% CI [0.48, 0.78]) and 0.57 (95% CI [0.38, 0.77]). For the ≥2.5 SD infants, the differences in risk of overweight and BMI according to duration of exclusive breastfeeding were neither significantly different among the 7-year nor among the 11-year-old children. A high infant weight increases the odds of overweight and is associated with a higher BMI in childhood. Whereas the odds and BMI z-scores tended to be lower for those exclusively breastfed longer, the differences were not statistically significant.

Breastmilk Lipids and Oligosaccharides Influence Branched Short-Chain Fatty Acid Concentrations in Infants with Excessive Weight Gain

SCOPE

The aim is to identify breastmilk components associated with fecal concentration of SCFAs and to investigate whether they differ between infants with high weight gain (HW) and normal weight gain (NW).

METHODS AND RESULTS

Breastmilk and fecal samples are collected from mother-infant dyads with HW (n = 11) and NW (n = 15) at 5 and 9 months of age. Breastmilk is profiled on ultra-performance LC-quadrupole TOF-MS platform. Fecal SCFAs are quantified using an isotope-labeled chemical derivatization method. Human milk oligosaccharides (HMOs) are quantified using HPLC after fluorescent derivatization. Lower levels of α-linolenic acid, oleic acid, 3-oxohexadecanoic acid, LPE (P-16:0), LPC (16:0), LPC (18:0), PC (36:2) in breastmilk from mothers from the HW-group at 5 months of age is found. Fecal SCFA concentrations are increased during the transition period from breastfeeding to complementary feeding. Fecal butyrate concentration is higher in the NW-group at 9 months of age. Fecal branched SCFAs are positively associated with breastmilk phospholipid levels, free-fatty acid levels, HMO-diversity, sialylated-HMOs, 6'-sialyllactose, and disialyl-lacto-N-hexaose.

CONCLUSION

Fecal branched SCFA concentrations seem to be affected by breastmilk lipid and HMO composition. These differences in breastmilk metabolites may partially explain the excessive weight gain in early life.

Human Milk Oligosaccharide Composition Is Associated With Excessive Weight Gain During Exclusive Breastfeeding-An Explorative Study

Background: Some infants experience excessive weight gain during exclusive breastfeeding. The cause is unknown, but variation in human milk composition might play a role. Several human milk koligosaccharides (HMOs) have been associated with growth velocity in breastfed infants, and it has been suggested that the mechanism could be through an effect on infant gut microbiota composition. Objective: The purpose of this exploratory study was to evaluate if HMO composition was different in milk fed to infants with excessive weight gain compared to infants with normal weight gain. Furthermore, we aimed to examine if HMO composition was associated with growth velocity and change in body composition and if there were maternal determinants of HMO composition. Materials and Methods: We recruited 13 high weight-gain (HW) and 17 normal weight-gain (NW) breastfed infants, collected human milk and anthropometry data at 5 and 9 months, and analyzed HMO composition by high performance liquid chromatography. Results: In the HW group eight out of 11 infants received milk from secretor mothers and in the NW group 15 out of 17. Comparing milk from Secretor mothers only, four HMO's were significantly different between the HW and NW group at 5 months and two remained significant at 9 months. Total HMO concentrations as well as total HMO-bound fucose at 5 months were positively associated with both fat mass index (FMI) and weight velocity from 0 to 5 months (all p < 0.025). 2'-fucosyllactose (2'-FL) was positively associated with weight velocity from 0 to 5 months and FMI at 5 months. In contrast, lacto-N-neotetraose was lower in the HW group (p = 0.012) and negatively associated with height-for-age Z-scores (p = 0.008), weight velocity from 0 to 5 months (p = 0.009) and FMI (p = 0.033). Maternal BMI at 5 months was negatively associated with 6'-sialyllactose and sialyl-lacto-N-tetraose (LSTb) and positively with 2'-FL, total HMO and total HMO-bound fucose (all p ≤ 0.03). Conclusion: In a small cohort, we found significantly different HMO concentrations in milk to exclusively breastfed infants with excessive weight gain, suggesting that some HMOs, including 2'-FL, which is the most abundant HMO and currently added to some infant formula, could be part of the cause for the excessive weight gain.

Food Consumption, Nutrient Intake and Status during the First 1000 days of Life in the Netherlands: a Systematic Review

Adequate nutrition is essential for growth and development in early life. Nutritional data serves as a basis for national nutritional guidelines and policies. Currently, there is no insight into the availability of such data during the first 1000 days of life. Therefore, a systematic review was performed, following the PRISMA reporting guideline, to identify studies on food consumption, nutrient intake or status in the Netherlands. Potential gaps were identified, and the quality of the studies is discussed. The databases Embase and Medline were used, as well as databases from national institutes. Articles published in 2008-2018 were screened by two independent reviewers. In total 601 articles were identified, of which 173 were included. For pregnant women, 32 studies were available with nutritional data, for young children 40 studies were identified. No studies were available for breastfeeding women. A large variety of foods and nutrients were assessed, however certain nutrients were lacking (e.g., vitamin K). Overall, the studies had methodological limitations, making the data unsuitable to assess nutrient inadequacies. There is a need for recent, high quality nutritional research to strengthen the understanding of the nutritional needs and deficiencies during early life, and is fundamental for national guidelines and policies.

Excessive Weight Gain Followed by Catch-Down in Exclusively Breastfed Infants: An Exploratory Study

Some infants experience excessive weight gain (EWG) during exclusive breastfeeding, but causes and consequences are unknown. The objective was to identify factors associated with early EWG. Infants with EWG (HW-group) were examined at 5, 9 and 18 mo and compared to a breastfed group with normal weight gain (NW-group). Anthropometry, body composition, milk and blood samples, and milk intake were measured. Mean body-mass-index-for-age z-scores (BAZ) increased 1.93 from birth to 5 mo in the HW-group (n = 13) while the NW-group (n = 17) was unchanged (-0.01). The HW-group had 70% more fat mass at 5 mo, and then showed marked catch-down in BAZ from 5 to 18 mo (-0.84). Milk intake at 5⁻6 mo did not differ between the groups. In the HW-group milk-leptin was lower at 5 mo and serum-leptin was considerably higher at 5 and 9 mo compared to the NW-group. Serum-leptin at 5 mo was positively associated with weight-for-age z-score (WAZ) and fat mass and negatively with WAZ change from 5 to 9 mo. In conclusion, breastfed infants with EWG had catch-down growth when other foods were introduced. Low milk-leptin in the HW-group may have stimulated appetite and milk intake when weight gain was high. High serum-leptin in the HW-group suggests early leptin resistance, which could impact cerebral regulation of energy intake. Larger studies are needed to confirm these results.

Effects of infant formula composition on long-term metabolic health

Early nutrition may have long-lasting metabolic impacts in adulthood. Even though breast milk is the gold standard, most infants are at least partly formula-fed. Despite obvious improvements, infant formulas remain perfectible to reduce the gap between breastfed and formula-fed infants. Improvements such as reducing the protein content, modulating the lipid matrix and adding prebiotics, probiotics and synbiotics, are discussed regarding metabolic health. Numerous questions remain to be answered on how impacting the infant formula composition may modulate the host metabolism and exert long-term benefits. Interactions between early nutrition (composition of human milk and infant formula) and the gut microbiota profile, as well as mechanisms connecting gut microbiota to metabolic health, are highlighted. Gut microbiota stands as a key actor in the nutritional programming but additional well-designed longitudinal human studies are needed.

Infant Feeding Beliefs, Attitudes, Knowledge and Practices of Chinese Immigrant Mothers: An Integrative Review of the Literature

Chinese are a fast-growing immigrant population group in several parts of the world (e.g., Australia, Canada, Europe, Southeast Asia, United States). Research evidence suggests that compared to non-Hispanic whites, individuals of Asian-origin including Chinese are at higher risk of developing cardiovascular disease and type 2 diabetes at a lower body mass index (BMI). These risks may be possibly due to genetic differences in body composition and metabolic responses. Despite the increasing numbers of Chinese children growing up in immigrant families and the increasing prevalence of obesity among Chinese, little research has been focused on children of Chinese immigrant families. This integrative review synthesizes the evidence on infant feeding beliefs, attitudes, knowledge and practices of Chinese immigrant mothers; highlights limitations of available research; and offers suggestions for future research. Using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, we searched four electronic academic/research databases (CINAHL, Medline, PsycINFO, and PubMed) to identify peer-reviewed, full-text papers published in English between January 2000 and September 2017. Only studies with mothers 18+ years old of normally developing infants were included. Of the 797 citations identified, 15 full-text papers were retrieved and 11 studies (8 cross-sectional studies, 3 qualitative studies) met the inclusion criteria and were included in this review. Reviewed studies revealed high initiation rates of breastfeeding, but sharp declines in breastfeeding rates by six months of age. In addition, reviewed studies revealed that the concomitantly use of breast milk and formula, and the early introduction of solid foods were common. Finally, reviewed studies identified several familial and socio-cultural influences on infant feeding beliefs and practices that may increase risk of overweight and obesity during infancy and early childhood among Chinese children of immigrant families. Nonetheless, as only 11 studies were identified and because the majority of studies (n = 8) were conducted in Australia, additional research including longitudinal studies, and studies conducted in countries with large Chinese immigrant population are needed to further identify and understand influences on Chinese immigrant mothers' beliefs, attitudes, and practices related to infant feeding that may increase risk of child overweight and obesity. This information is needed to develop interventions tailored to the beliefs and needs of this fast-growing immigrant group and aimed at promoting healthy infant feeding practices to prevent childhood overweight and obesity.

Infant feeding and growth trajectory patterns in childhood and body composition in young adulthood

Background: Growth patterns of breastfed and formula-fed infants may differ, with formula-fed infants growing more rapidly than breastfed infants into childhood and adulthood.Objective: Our objectives were to identify growth patterns and investigate early nutritional programming potential on growth patterns at 6 y and on body composition at 20 y.Design: The West Australian Pregnancy Cohort (Raine) Study and 3 European cohort studies (European Childhood Obesity Trial, Norwegian Human Milk Study, and Prevention of Coeliac Disease) that collaborate in the European Union-funded Early Nutrition project combined, harmonized, and pooled data on full breastfeeding, anthropometry, and body composition. Latent growth mixture modeling was applied to identify growth patterns among the 6708 individual growth trajectories. The association of full breastfeeding for <3 mo compared with ≥3 mo with the identified trajectory classes was assessed by logistic regression. Differences in body composition at 20 y among the identified trajectory classes were tested by analysis of variance.Results: Three body mass index (BMI; in kg/m²) trajectory patterns were identified and labeled as follows-class 1: persistent, accelerating, rapid growth (5%); class 2: early, nonpersistent, rapid growth (40%); and class 3: normative growth (55%). A shorter duration of full breastfeeding for <3 mo was associated with being in rapid-growth class 1 (OR: 2.66; 95% CI: 1.48, 4.79) and class 2 (OR: 1.96; 95% CI: 1.51, 2.55) rather than the normative-growth class 3 after adjustment for covariates. Both rapid-growth classes showed significant associations with body composition at 20 y (P < 0.0001).Conclusions: Full breastfeeding for <3 mo compared with ≥3 mo may be associated with rapid growth in early childhood and body composition in young adulthood. Rapid-growth patterns in early childhood could be a mediating link between infant feeding and long-term obesity risk.

Effects of Promoting Long-term, Exclusive Breastfeeding on Adolescent Adiposity, Blood Pressure, and Growth Trajectories: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Evidence that breastfeeding reduces child obesity risk and lowers blood pressure (BP) is based on potentially confounded observational studies.

OBJECTIVE

To investigate the effects of a breastfeeding promotion intervention on adiposity and BP at age 16 years and on longitudinal growth trajectories from birth.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized Promotion of Breastfeeding Intervention Trial. Belarusian maternity hospitals and affiliated polyclinics (the clusters) were allocated into intervention (n = 16) or control arms (n = 15) in 1996 and 1997. The trial participants were 17 046 breastfeeding mother-infant pairs; of these, 13 557 children (79.5%) were followed up at 16 years of age between September 2012 and July 2015.

INTERVENTIONS

Breastfeeding promotion, modeled on the Baby-Friendly Hospital Initiative.

MAIN OUTCOMES AND MEASURES

Body mass index (BMI, calculated as weight in kilograms divided by height in meters squared); fat and fat-free mass indices and percentage of body fat from bioimpedance; waist circumference; overweight and obesity; height; BP; and longitudinal growth trajectories. The primary analysis was modified intention-to-treat (without imputation for losses to follow-up) accounting for within-clinic clustering.

RESULTS

We examined 13 557 children at a median age of 16.2 years (48.5% were girls). The intervention substantially increased breastfeeding duration and exclusivity compared with the control arm (exclusively breastfed: 45% vs 6% at 3 months, respectively). Mean differences at 16 years between intervention and control groups were 0.21 (95% CI, 0.06-0.36) for BMI; 0.21 kg/m2 (95% CI, -0.03 to 0.44) for fat mass index; 0.00 kg/m2 (95% CI, -0.21 to 0.22) for fat-free mass index; 0.71% (95% CI, -0.32 to 1.74) for percentage body fat; -0.73 cm (-2.48 to 1.02) for waist circumference; 0.05 cm (95% CI, -0.85 to 0.94) for height; -0.54 mm Hg (95% CI, -2.40 to 1.31) for systolic BP; and 0.71 mm Hg (95% CI, -0.68 to 2.10) for diastolic BP. The odds ratio for overweight/obesity (BMI ≥85th percentile vs <85th percentile) was 1.14 (95% CI, 1.02-1.28) and the odds ratio for obesity (BMI ≥95th percentile vs <95th percentile) was 1.09 (95% CI, 0.92-1.29). The intervention resulted in a more rapid rate of gain in postinfancy height (1 to 2.8 years), weight (2.8 to 14.5 years), and BMI (2.8 to 8.5 years) compared with the control arm. The intervention had little effect on BMI z score changes after 8.5 years.

CONCLUSIONS AND RELEVANCE

A randomized intervention that increased the duration and exclusivity of breastfeeding was not associated with lowered adolescent obesity risk or BP. On the contrary, the prevalence of overweight/obesity was higher in the intervention arm. All mothers initiated breastfeeding, so findings may not apply to comparisons of the effects of breastfeeding vs formula feeding.

TRIAL REGISTRATION

isrctn.org: ISRCTN37687716; and clinicaltrials.gov: NCT01561612.

A scoping review of epidemiologic risk factors for pediatric obesity: Implications for future childhood obesity and dental caries prevention research

RESEARCH QUESTIONS

What are the non-modifiable (socioeconomic, genetic) and modifiable factors (physical activity, dietary behaviors) related to childhood (under age 12) obesity? How can this knowledge be applied to oral health professionals' efforts to prevent or manage dental caries in children?

OBJECTIVES

Studies have identified risk factors for childhood obesity. The purpose of this scoping review was to develop a conceptual model to identify non-modifiable and modifiable risk factors for childhood obesity and to illustrate how these findings are relevant in developing interventions aimed at preventing obesity and dental caries in children.

METHODS

The authors searched PubMed and Embase and limited the study to English-language publications. A total of 2,572 studies were identified. After de-duplication, 2,479 studies remained and were downloaded into a citation-management tool. Two authors screened the titles and abstracts for relevance. Two hundred and sixty studies remained and were retrieved for a full-text review, and 80 studies were excluded, resulting in 180 studies included in the scoping review. An inductive content analytic methods was used to organize all statistically significant obesity risk factors into seven domains, which were classified as non-modifiable or modifiable; then a conceptual model of common risk factors associated with childhood obesity and dental caries was developed.

RESULTS

Non-modifiable obesity risk factors include biological and developmental (e.g., genes, developmental conditions, puberty), sociodemographic and household (e.g., race/ethnicity, socioeconomic status, parent education, unemployment), cultural (e.g., degree of acculturation), and community (e.g., neighborhood composition). Modifiable risk factors included behavioral (e.g., diet, physical activity, weight), psychosocial (e.g., maternal stress, family functioning, parenting practices, child temperament), and medical (e.g., parent smoking, maternal health, child health).

CONCLUSIONS

Identifying common risk factors has important implications for future oral health research aimed at preventing childhood obesity and dental caries. Epidemiologic knowledge gleaned from the literature can be used to develop rigorous interventions and programs aimed at preventing these highly prevalent diseases and improving health outcomes for children.

Non-Responsive Feeding Practices, Unhealthy Eating Behaviors, and Risk of Child Overweight and Obesity in Southeast Asia: A Systematic Review

Childhood obesity is increasing dramatically in many Southeast Asian countries, and becoming a significant public health concern. This review summarizes the evidence on associations between parental feeding practices, child eating behaviors, and the risk of overweight and obesity in Southeast Asian children 2–12 years old. We systematically searched five electronic academic/research (PubMed, PsycINFO, ProQuest Nursing, Medline, and CINAHL) databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for peer-reviewed studies published in English between January 2000 and December 2016. Fourteen observational studies met the inclusion criteria and were reviewed. Reviewed studies were examined separately for preschool- and school-aged children and revealed that non-responsive parental feeding practices and unhealthy child eating behaviors were associated with a risk of child overweight and obesity in several Southeast Asian countries. Nonetheless, due to the small number of identified studies (n = 14) and because only about half of the Southeast Asian countries (Thailand, Vietnam, Singapore, the Philippines, and Malaysia) were represented (5/11) in the examined studies, additional research is needed to further understand the factors associated with childhood obesity among children in Southeast Asia to develop interventions that are tailored to the specific needs of Southeast Asian countries and designed to address practices and behaviors that may promote childhood obesity.

Effect of the INSIGHT Responsive Parenting Intervention on Rapid Infant Weight Gain and Overweight Status at Age 1 Year: A Randomized Clinical Trial

IMPORTANCE

Rapid infant weight gain is associated with later obesity, but interventions to prevent rapid infant growth and reduce risk for overweight status in infancy are lacking.

OBJECTIVE

To examine the effect of a responsive parenting (RP) intervention on infant weight gain between birth and 28 weeks and overweight status at age 1 year.

DESIGN, SETTING, AND PARTICIPANTS

The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) study is an ongoing randomized clinical trial comparing an RP intervention designed to prevent childhood obesity with a safety control. The study includes primiparous mother-newborn dyads (n = 291) and was conducted at the Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, in addition to home visits. Enrollment was initiated in January 2012, and evaluable population analyses for this study were conducted between April 2015 and November 2015.

INTERVENTIONS

At 2 weeks post partum, initial intervention materials appropriate to the assigned treatment group were mailed to the participant's home. Research nurses conducted home visits at 3 weeks, 16 weeks, 28 weeks, and 40 weeks, and a research center visit occurred at 1 year. The Intervention Nurses Start Infants Growing on Healthy Trajectories curriculum included messages about infant feeding, sleep hygiene, active social play, emotion regulation, and growth record education. The control group received a developmentally appropriate home safety intervention also delivered by nurse home visitors.

MAIN OUTCOMES AND MEASURES

Conditional weight gain from birth to 28 weeks was calculated. General linear models examined intervention effect on conditional weight gain. The intervention's effect on infant weight-for-length percentiles was tested using analysis of variance. Logistic regression compared the odds of overweight status (weight for length ≥95th percentile) at 1 year as a function of conditional weight gain.

RESULTS

Of the mothers included in the study, 246 were white (88%), 260 were non-Hispanic (93%), 210 were married (75%), and 201 were working full time (72%) at time of enrollment. The mean conditional weight gain score was lower among infants in the RP group compared with the control group (-0.18; 95% CI, -0.36 to -0.001), reflecting that the RP infants gained weight more slowly than control group infants (0.18; 95% CI, 0.02-0.34); this effect did not differ by feeding mode (predominantly fed breast milk or not). Infants in the RP group also had lower mean weight-for-length percentiles at 1 year than infants in the control group (57.5%; 95% CI, 52.56%-62.37% vs 64.4%; 95% CI, 59.94%-69.26%; P = .04) and were less likely to be overweight at age 1 year (5.5% vs 12.7%; P = .05).

CONCLUSIONS AND RELEVANCE

An RP intervention is associated with reduced rapid weight gain during the first 6 months after birth and overweight status at age 1 year.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01167270.