Prevalence and reasons for introducing infants early to solid foods: variations by milk feeding type

Relationship between Infant Feeding and the Microbiome: Implications for Allergies and Food Intolerances

Childhood is a critical period for immune system development, which is greatly influenced by the gut microbiome. Likewise, a number of factors affect the gut microbiome composition and diversity, including breastfeeding, formula feeding, and solid foods introduction. In this regard, several studies have previously demonstrated that breastfeeding promotes a favorable microbiome. In contrast, formula feeding and the early incorporation of certain solid foods may adversely affect microbiome development. Additionally, there is increasing evidence that disruptions in the early microbiome can lead to allergic conditions and food intolerances. Thus, developing strategies to promote optimal infant nutrition requires an understanding of the relationship between infant nutrition and long-term health. The present review aims to examine the relationship between infant feeding practices and the microbiome, as well as its implications on allergies and food intolerances in infants. Moreover, this study synthesizes existing evidence on how different eating habits influence the microbiome. It highlights their implications for the prevention of allergies and food intolerances. In conclusion, introducing allergenic solid foods before six months, alongside breastfeeding, may significantly reduce allergies and food intolerances risks, being also associated with variations in gut microbiome and related complications.

Environmental Scan of Online Government Complementary Feeding Resources in the United States

BACKGROUND

Parents commonly seek online sources of information on the important complementary feeding period, but the accuracy of these sources varies. The 21st Century Integrated Digital Experience Act (IDEA) states federal government resources should be accurate and user-friendly; however, the quantity, quality, and accuracy of federal resources on complementary feeding is unknown.

METHODS

An environmental scan of online federal, parent-facing resources about complementary feeding was conducted. The authors reviewed federal resources for concordance of information with the Dietary Guidelines for Americans (DGA). Quality was evaluated using the Patient Education Materials Assessment Tool.

RESULTS

A total of 112 resources across 2 federal government departments. Overall quality was high as was concordance with recommendations from the DGA for age of complementary food introduction, foods to introduce, and foods to avoid. Allergenic food introduction and textured food progression recommendations were less consistent. Recommendations for improvements to federal resources are made.

CLINICAL IMPLICATIONS

This environmental scan only included federal resources for CF. Parents may be accessing other, non-federal resources online. However, given the enactment of IDEA, it is expected that these federal resources will be up-to-date and user-friendly, which was not always the case. Nurses should review the DGA guidelines for complementary feeding and provide evidence-based anticipatory guidance to families, focusing especially on allergenic food introduction and textured food progression. Future complementary feeding interventions may benefit from directing families to online exemplars from federal sources.

The role of breastfeeding and formula feeding regarding depressive symptoms and an impaired mother child bonding

Associations between depressive symptoms and breastfeeding are well documented. However, evidence is lacking for subdivisions of feeding styles, namely exclusive breastfeeding, exclusive formula feeding and a mixed feeding style (breastfeeding and formula feeding). In addition, studies examining associations between mother-child-bonding and breastfeeding have yielded mixed results. The aim of this study is to provide a more profound understanding of the different feeding styles and their associations with maternal mental health and mother-child-bonding. Data from 307 women were collected longitudinally in person (prenatally) and by telephone (3 months postnatally) using validated self-report measures, and analyzed using correlational analyses, unpaired group comparisons and regression analyses. Our results from a multinomial regression analysis revealed that impaired mother-child-bonding was positively associated with mixed feeding style (p = .003) and depressive symptoms prenatal were positively associated with exclusive formula feeding (p = .013). Further studies could investigate whether information about the underlying reasons we found for mixed feeding, such as insufficient weight gain of the child or the feeling that the child is unsatiated, could help prevent impaired mother-child-bonding. Overall, the results of this study have promising new implications for research and practice, regarding at-risk populations and implications for preventive measures regarding postpartum depression and an impaired mother-child-bonding.

A Scoping Review of the Complementary Feeding Practices and Early Eating Experiences of Children With Down Syndrome

OBJECTIVE

Children with Down syndrome may experience more challenges in their early feeding and may be introduced to complementary foods comparatively later than typically developing (TD) children. This scoping review aimed to identify and synthesize the existing literature that describes feeding problems and early eating experiences relating to the period of complementary feeding for children with Down syndrome.

METHODS

Scopus, PubMed, Medline, Web of Science, and PsycInfo were searched. Journal articles published between January 1991 and June 2022 that reported on the complementary feeding period with children with Down syndrome were included.

RESULTS

Eighteen journal articles met the inclusion criteria. Children with Down syndrome were introduced to complementary foods later than TD children and progressed to more challenging food textures at a slower rate. Gross and fine motor skill delays and sensory difficulties contributed to secondary feeding problems such as difficulties chewing, biting, and reduced awareness of food on lips and tongue. Parents of children with Down syndrome reported exercising more caution and employing more controlling feeding practices compared to TD and had higher levels of concern regarding their child's weight.

CONCLUSIONS

Guidelines and early feeding support specific to children with Down syndrome should be available before the first complementary foods are introduced and throughout this period. Feeding support should aim to address parental concerns and provide assistance when feeding problems occur, to minimize delays and encourage the optimum development of eating abilities. Future research should address the development of feeding problems during this period and explore possible interventions.

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis

CONTEXT

The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood.

OBJECTIVE

This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants.

DATA SOURCES

Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews.

DATA EXTRACTION

Two investigators independently extracted data from the included studies on a standardized data-extraction form.

DATA ANALYSIS

Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score.

CONCLUSION

Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42020218517.

Parental Decision-Making Around Introducing Complementary Foods: An Integrative Review

A primary role in infant parenting is feeding, and this role undergoes a significant transition when introducing complementary foods (CF), with important long-term health implications. Understanding the influences on parental decision-making around timing the introduction to CF can help health care providers provide parents with effective support for feeding; however, the factors that influence parental decision-making have not been recently reviewed in the United States. To determine influences and information sources, this integrative review examined the literature from 2012 to 2022. Results indicated that parents are confused and distrustful of inconsistent and changing guidelines around CF introduction. Instead, developmental readiness signs may be a more appropriate way for practitioners and researchers to support parents in appropriate CF introduction. Future work is needed to evaluate interpersonal and societal influences on parental decision-making, as well as to develop culturally sensitive practices to support healthful parental decisions.

Early introduction of complementary foods/drinks and milk feeding type in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Infants younger than 4 months are not ready for complementary foods/drinks (any solid or liquid other than breast milk or infant formula). Almost half of US infants participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which provides nutrition education and support to low-income families. We describe the prevalence of early introduction (<4 months) of complementary foods/drinks and examine the association of milk feeding type (fully breastfed, partially breastfed or fully formula fed) with early introduction of complementary foods/drinks. We used data from 3310 families in the longitudinal WIC Infant and Toddler Feeding Practices Study-2. We described the prevalence of early introduction of complementary foods/drinks and modeled the association of milk feeding type at Month 1 with early introduction of complementary foods/drinks using multi-variable logistic regression. Thirty-eight percent of infants were introduced early to complementary foods/drinks (<4 months). In adjusted models, infants who were fully formula fed or partially breastfed at Month 1 were 75% and 57%, respectively, more likely to be introduced early to complementary foods/drinks compared with fully breastfed infants. Almost two in five infants were given complementary foods/drinks early. Formula feeding at Month 1 was associated with higher odds of early introduction of complementary foods/drinks. There are opportunities to support families participating in WIC to prevent early introduction of complementary foods/drinks and promote child health.

Nutritional Considerations for the First Year of Life

Feeding during the first year of life is a dynamic process with unique questions, concerns, and milestones emerging at every step. This article will review a small selection of specific questions and concerns related to feeding in the first 12 months of infancy. The aim of this article is to inform and support pediatric providers and parents during this crucial developmental period. [Pediatr Ann. 2023;52(9):e316-e321.].

Complementary Feeding and Child Appetitive Traits in a Sample of Hispanic Mother-Child Dyads

BACKGROUND

Complementary feeding practices may contribute to toddler eating practices that affect weight outcomes. Studies are needed to understand the relationship between complementary feeding practices and toddler dietary self-regulation.

OBJECTIVE

This study tests the hypothesis that earlier complementary food introduction predicts toddler food responsiveness and emotional overeating (ie, tendency to overeat in response to food cues and emotions, respectively), and considers whether introduction of certain foods better predict toddler dietary self-regulation.

DESIGN

This study is a secondary analysis of data from a parent longitudinal birth cohort study on early growth/development among Hispanic mother-infant dyads.

PARTICIPANTS/SETTING

The analytic sample included 174 mother-child dyads recruited from maternity clinics affiliated with the University of Southern California in Los Angeles County. Recruitment and data collection were ongoing from July 2016 to April 2020. At 1-, 6-, 12-, and 24-months postpartum, mothers reported exclusive breastfeeding duration and age of complementary food introduction via questionnaire.

MAIN OUTCOME MEASURES

Child food responsiveness and emotional overeating scores calculated from the Child Eating Behavior Questionnaire at 12 and 24 months of age.

STATISTICAL ANALYSES PERFORMED

Separate linear mixed models with repeated measures were used to examine associations between age of complementary food introduction as a predictor of child food responsiveness or emotional overeating, controlling for infant sex, birth body mass index z score, duration of exclusive breastfeeding, and mother's body mass index.

RESULTS

In separate models, delaying complementary food introduction by 1 month was associated with a 6% reduction in food responsiveness (P = 0.007) and a 5% reduction in emotional overeating scores (P = 0.013). Fifty-eight unique combinations of complementary foods introduced first were found, precluding analyses to examine whether specific combinations were related to eating behavior outcomes due to sample size limitations.

CONCLUSIONS

Earlier complementary feeding was associated with higher food responsiveness and emotional overeating scores among Hispanic children. Future studies in larger samples are needed to characterize patterns of complementary food introduction and their influence on child self-regulation.

Timing of Introduction of Complementary Foods - United States, 2016-2018

The American Academy of Pediatrics (AAP) recommends introducing complementary foods (i.e., any solid or liquid other than breast milk or infant formula) to infants at approximately age 6 months (1). Although a consensus on ideal timing is lacking, most experts agree that introduction of complementary foods before age 4 months is too early because of infant gastrointestinal and motor immaturity (1,2). In addition, early introduction prevents exclusively breastfed infants from reaching the recommended 6 months of exclusive breastfeeding (1) and might be associated with increased risk for overweight and obesity (3). Nationally representative data on complementary feeding are limited; state-level estimates have been previously unavailable. CDC analyzed 2016-2018 data from the National Survey of Children's Health (NSCH) (N = 23,743) to describe timing of complementary feeding introduction and prevalence of early introduction of complementary foods before age 4 months (early introduction) among children aged 1-5 years. Prevalence of early introduction was 15.6% nationally and varied geographically and across sociodemographic and infant feeding characteristics. These estimates suggest that approximately one in six infants are introduced to complementary foods before they are developmentally ready. Efforts by health care providers and others who might influence infant feeding practices could help decrease the number of infants who are introduced to complementary foods too early.

Associations of maternal food addiction, dietary restraint, and pre-pregnancy BMI with infant eating behaviors and risk for overweight

Maternal food addiction, dietary restraint, and pre-pregnancy body mass index (BMI) are associated with high-risk eating behaviors and weight characteristics in children and adolescents. However, little is known about how these maternal factors are associated with individual differences in eating behaviors and risk for overweight in infancy. In a sample of 204 infant-mother dyads, maternal food addiction, dietary restraint and pre-pregnancy BMI were assessed using maternal self-report measures. Infant eating behaviors (as measured by maternal report), objectively measured hedonic response to sucrose, and anthropometry were measured at 4 months of age. Separate linear regression analyses were used to test for associations between maternal risk factors and infant eating behaviors and risk for overweight. Maternal food addiction was associated with increased risk for infant overweight based on World Health Organization criteria. Maternal dietary restraint was negatively associated with maternal report of infant appetite, but positively associated with objectively measured infant hedonic response to sucrose. Maternal pre-pregnancy BMI was positively associated with maternal report of infant appetite. Maternal food addiction, dietary restraint, and pre-pregnancy BMI are each associated with distinct eating behaviors and risk for overweight in early infancy. Additional research is needed to identify the mechanistic pathways driving these distinct associations between maternal factors and infant eating behaviors and risk for overweight. Further, it will be important to investigate whether these infant characteristics predict the development of future high-risk eating behaviors or excessive weight gain later in life.

Infant and young child feeding practices and the factors that influence them: a qualitative study

BACKGROUND

Early child feeding is important for healthy growth and forming positive eating behaviors.

METHODS

This qualitative study sought to describe early childhood feeding behaviors, challenges, and opportunities through four focus group discussions with a diverse group of mothers of at least one child under two years or pregnant with their first child.

RESULTS

Although providing healthy foods was a priority, feeding behaviors reflected the mothers' partial understanding of infant and child nutrition. Mothers sought guidance on early child feeding from several sources, including in-person and virtual relationships but made decisions based largely on their own instincts. Participants consulted clinicians the least often, and mothers often felt frustrated by strict guidelines and negative messaging. Mothers were most receptive to suggestions when they felt supported and valued in the decision-making process.

CONCLUSIONS

In order to help mothers provide the best nutrition for their young children, clinicians should use positive tones, provide flexibility when possible, and work to create open lines of communication with parents.

Associations between early introduction to complementary foods, subsequent cereal-added bottle feeding and daily macronutrient intake among infants

Introducing complementary foods early during infancy has been associated with an increased risk of overweight later in life, but the pathway is an understudied topic. Hence the study was conducted with low-income and primarily minority mother-infant dyads to: 1) understand how the introduction of complementary foods prior to 4 months was associated with socio-demographic characteristics and food security status; 2) determine the association between early introduction to complementary foods and breastfeeding and adding cereal into the bottle in later infancy (i.e., at 6 and 9 months), and; 3) examine how adding infant cereal into the bottle was related to daily calorie and macronutrient intake in infancy. We conducted interviews with mothers (n = 201) at 4 months of age and 24-h feeding recalls at age 6 and 9 months. Results indicated that 29% of the infants were fed complementary foods before 4 months of age. Introducing complementary foods early was negatively associated with breastfeeding and positively associated with adding cereal into the bottle at 6-months. This practice was more common among those who experienced marginal to very low levels of food security. Comparing by race/ethnicity, Latinx mothers were significantly less likely to introduce solids early. After controlling for sex, infants fed cereal in the bottle were consuming significantly more calories compared to their counterparts. Specifically, adding cereal into the bottle resulted in approximately 10% additional daily calorie intake among infants. Understanding how these feeding practices affect appetite development and weight status during infancy is warranted.

MDITRE: Scalable and Interpretable Machine Learning for Predicting Host Status from Temporal Microbiome Dynamics

Longitudinal microbiome data sets are being generated with increasing regularity, and there is broad recognition that these studies are critical for unlocking the mechanisms through which the microbiome impacts human health and disease. However, there is a dearth of computational tools for analyzing microbiome time-series data. To address this gap, we developed an open-source software package, Microbiome Differentiable Interpretable Temporal Rule Engine (MDITRE), which implements a new highly efficient method leveraging deep-learning technologies to derive human-interpretable rules that predict host status from longitudinal microbiome data. Using semi-synthetic and a large compendium of publicly available 16S rRNA amplicon and metagenomics sequencing data sets, we demonstrate that in almost all cases, MDITRE performs on par with or better than popular uninterpretable machine learning methods, and orders-of-magnitude faster than the prior interpretable technique. MDITRE also provides a graphical user interface, which we show through case studies can be used to derive biologically meaningful interpretations linking patterns of microbiome changes over time with host phenotypes. IMPORTANCE The human microbiome, or collection of microbes living on and within us, changes over time. Linking these changes to the status of the human host is crucial to understanding how the microbiome influences a variety of human diseases. Due to the large scale and complexity of microbiome data, computational methods are essential. Existing computational methods for linking changes in the microbiome to the status of the human host are either unable to scale to large and complex microbiome data sets or cannot produce human-interpretable outputs. We present a new computational method and software package that overcomes the limitations of previous methods, allowing researchers to analyze larger and more complex data sets while producing easily interpretable outputs. Our method has the potential to enable new insights into how changes in the microbiome over time maintain health or lead to disease in humans and facilitate the development of diagnostic tests based on the microbiome.

Qualitative exploration of perceived barriers of exclusive breastfeeding among pregnant teenagers in the Greater Accra Region of Ghana

BACKGROUND

The World Health Organization endorses exclusive breastfeeding for the first six months of every child's life since exclusive breastfeeding has the potential of saving thousands of infants' lives. The global exclusive breastfeeding rate among mothers is sub-optimal. This predisposes infants born to teenage mothers to all types of ailments. Therefore, this study explored the factors that inhibit the practice of exclusive breastfeeding as perceived by pregnant teenagers in the Greater Accra Region of Ghana which is an urban area.

METHODS

The study used techniques in qualitative descriptive exploration to collect data from 30 pregnant teenagers through focus group discussions. Six focus group discussions were conducted and each group was made up of five participants. Informed consent was obtained from participants who were 18 years and above as well as parents of participants below 18 years while informed assent was obtained from participants below 18 years after purposive sampling. Interviews were audiotaped, transcribed and data were analysed through content analysis.

RESULTS

Two major themes and eight sub themes emerged from the data after analysis. Personal related barriers (negative emotional feelings, irrational thinking, perceived health risks to the baby and perceived self-inefficacy) and social related barriers (provider-client interaction, disapproval of exclusive breastfeeding by close relatives, unfriendly workplace policies and social myths) were the perceived factors that discouraged exclusive breastfeeding among teenage mothers.

CONCLUSION

Health professionals should be trained to provide culturally sensitive care to teenage mothers in order to promote exclusive breastfeeding. The media, religious leaders and politicians should help debunk misconceptions about breastfeeding expressed by participants in the study.

Infant appetite traits, feeding practices and child obesity in low-income Hispanic families

BACKGROUND

Appetite traits and feeding practices are important determinants of child weight and obesity.

OBJECTIVES

This study examined whether: (1) infant appetite traits were associated with feeding practices and (2) feeding practices mediated the link between appetite traits and weight-for-age z-scores at age 3 years.

METHODS

We conducted a secondary data analysis from the 'Starting Early Program' of low-income, Hispanic mother-child pairs. Appetite traits were assessed using the Baby Eating Behaviour Questionnaire. Infant feeding practices were collected using 24-h dietary recalls and surveys: (1) breastfeeding exclusivity, intensity and duration; (2) early introduction to complementary foods/liquids and (3) any 100% fruit juice consumption at age 10 months. Regression and mediation analyses were used to explore associations between appetite, feeding and weight.

RESULTS

Higher infant Slowness in Eating scores were associated with greater breastfeeding exclusivity, intensity and duration, compared to lower Slowness in Eating. Infants with higher Slowness in Eating and Satiety Responsiveness had lower odds of early introduction to complementary foods/liquids. Infants with higher Enjoyment of Food had greater odds of 100% juice consumption. Breastfeeding duration mediated the relationship between higher infant Slowness in Eating and lower weight-for-age z-scores.

CONCLUSIONS

Appetite traits represent potential targets for early life infant feeding interventions.

Breastfeeding and complementary feeding in fragile settings: the case of Syrian refugees and their host communities in North Lebanon

BACKGROUND

Adequate breastfeeding and complementary feeding practices are paramount in fragile situations where access to food and healthcare is limited. The objectives of this study are to examine breastfeeding and complementary feeding practices among Syrian refugees and their Lebanese host communities and to investigate the correlates of exclusive breastfeeding (EBF) at four and 6 months in these communities.

METHODS

Using two-stage stratified sampling, a cross-sectional survey was conducted in Akkar, a region with a high density of Syrian refugees in Lebanon, between April and November 2019. In one-to-one interviews, mothers of children (6-24 months) completed a questionnaire including specific questions about breastfeeding and complementary feeding practices, a 24-h recall, and socio-demographic characteristics for 189 Syrian refugees and 182 Lebanese host community households. Descriptive statistics, simple and multiple logistic regression were used in data analysis.

RESULTS

Among breastfeeding practices, ever-breastfeeding was most prevalent (90%), followed by early initiation of breastfeeding (64.8%), EBF at four (49.6%), and six (36%) months. One in four children was introduced to solids before 6 months of age, and less than a third was given iron-fortified baby cereals as the first complementary foods. Only 24.4% and 9.2% of children met the minimum dietary diversity and minimum acceptable diet requirements, respectively. Compared to children of the Lebanese host communities, those of Syrian refugees had higher rates of EBF at four and 6 months as well as continued breastfeeding at 1 year, whereas only 17.9% of Syrian refugees' children met minimum dietary diversity compared to 30.9% of Lebanese host community children (p <  0.05). Among refugees, education and spouse's employment status were associated with higher odds of EBF at 4 months. As for Lebanese households, female children were less likely to be exclusively breastfed at 4 months and 6 months, while a natural delivery increased the odds of EBF at 6 months.

CONCLUSION

Breastfeeding and complementary feeding practices are suboptimal among children of Syrian refugees and their Lebanese host communities in North Lebanon. There is a need for intervention strategies to tackle gaps in services and assistance delivery programs to enhance infant and young child feeding practices among both communities.

Feeding Patterns, Mother-Child Dietary Diversity and Prevalence of Malnutrition Among Under-Five Children in Lebanon: A Cross-Sectional Study Based on Retrospective Recall

Background

Despite demonstrated benefits, most countries fall short of meeting international targets for breastfeeding patterns, optimal complementary feeding, mother-children's quality diet, and malnutrition among under-five children.

Rationale

Since mothers usually play the most vital role in the healthcare of their children, research is needed to illuminate maternal factors that might promote a child's health and nutritional status.

Aim

The purpose of this study is to retrospectively (1) examine the under-five children's (0–59 months) feeding habits including exclusive breastfeeding, exclusive bottle feeding, continued breastfeeding, and complementary feedings, (2) investigate the mother-child's dietary diversity, and (3) identify any factors that cause less optimal nutrition due to a lack of food diversity in children aged 6 to 59 months. Moreover, (4) the prevalence of wasting, stunting, underweight, and overweight in the under-five offspring living in households located in the main two provinces in Lebanon (Beirut and Mount Lebanon) was determined.

Methods

The data for this analysis were collected from a representative sample of 384 households [384 mothers (21–49 years old) and children (0–59 months)] between February 2019 and June 2019. A questionnaire was used to inquire mothers of children ages 0–23 months about exclusive breastfeeding (EBF), continuous breastfeeding (CBF), exclusive bottle feeding (EBOT), mixed feeding (MF), and complementary feeding patterns. Moreover, additional questions regarding dietary diversity were asked to mothers of children aged 6 to 59 months. This score was calculated based on the 24 h recall of the mother and her child's consumption of 7 food groups, during the 24 h prior to the survey. Moreover, stunting, wasting, overweight, and underweight were calculated using the z-score for height-for-age (HAZ), weight-for-height (WHZ), and weight-for-age (WAZ), respectively. Binary logistic regression was used to explore the dietary diversity among children (ages 6–59 months) adjusting for covariates at maternal and household levels.

Results

Around 44% of children (0–59 months) had normal body weight. In addition, 9.3% were underweight (WAZ < -2SD to −3SD), 6.5% were at risk of being overweight, 24.45% were overweight, 9.3% were stunted (HAZ < -2SD to −3SD), and 6.25% (WHZ < -2SD to −3SD) were wasted. In total, among under-five children, the prevalence of EBF at 40 d and 6 months was 27 and 30%, respectively. The prevalence of CBF was 23%. Around 60% of mothers breastfed their offspring between 0 and 6 months and half of them introduced infant formula at earlier stages between 0–6 months. Furthermore, 78.4% of mothers introduced food to their children between 4 and 6 months (of which 40% before 6 months) and 62.5% of them introduced sugary drinks before 6 months. As for dietary diversity (DD), one out of two mothers and one out of three children (ages 6–59 months) had a low DD score (DDS) (46 and 32%, respectively). The children's and mother's DD were strongly found to be correlated (p-value = 0.034). Regression analysis showed that children's DD increased around 2 times [AOR = 1.7; 95% CI (1.042–2.914)] in context of high maternal DDS, and about 12 times [AOR = 11.7; 95% CI (1.2–111)] when a member of the highest-income households.

Conclusions

Our findings demonstrated low rates of EBF and CBF, high prevalence of EBOT, and early introduction of complementary foods among children ages 0–59 months. Furthermore, for children ages 6–59 months, there was poor mother-child dietary diversity and a high prevalence of overweight and stunted children in the main two Lebanese provinces. This suggests the alarming need for continuous nutrition intervention to improve infant feeding patterns and dietary diversity to reduce the malnutrition rates.

Choking, allergic reactions, and pickiness: A qualitative study of maternal perceived threats and risk avoidance strategies during complementary feeding

An infant's early eating experiences influence later growth and health. However, motivators for mothers' complementary feeding decisions for their infants, such as the process of introducing solid foods, remains unclear. This qualitative study identified maternal perceived threats surrounding complementary feeding and strategies mothers use to mitigate perceived threats of adverse feeding-related health outcomes for their infants. Twenty-seven mothers participated in private, semi-structured interviews. Inductive and deductive qualitative content analysis revealed three primary themes of maternal perceived threats: a) choking, b) allergic reaction, and c) pickiness. Within each primary theme were sub-themes that further delineated the perceived threats and outlined specific and focused complementary feeding practices (CFPs) mothers used for each type of perceived threat. Findings suggest mothers have difficulty with estimating the likelihood and severity of risks and rely on elevated threat perception to guide their feeding decisions. CFPs used to prevent perceived threats were disproportionate to risks, and, at times, actually introduced additional, alternative risks.

Associations of infant appetitive traits during milk feeding stage with age at introduction to solids and sweet food/beverage intake

BACKGROUND

Suboptimal feeding behaviors during infancy, such as introducing solids prior to 4 months and providing foods containing added sugars, are associated with increased risk of later obesity. Although focus group studies suggest that infant appetitive traits during milk feeding stage may influence complementary feeding practices, quantitative evidence on this relationship is lacking.

METHODS

This study included women who were followed from first trimester to 1-year postpartum. At 6-months postpartum, mothers (n = 217) completed the Baby Eating Behavior Questionnaire which assesses infant appetitive traits during exclusive milk-feeding (food responsiveness, satiety responsiveness, slowness in eating, enjoyment of food and general appetite). Mothers reported infant dietary intake via a food frequency questionnaire (FFQ) administered at 6, 9 and 12 months, from which age at introduction to solids and sweet foods/beverages, and 6- and 12-month sweet food/beverage intake frequency, were calculated. Linear regression analyses examined the relationship of appetitive traits with age at introduction to solids and sweet foods/beverages, and frequency of sweet food/beverage intake, whereas logistic regression examined associations of appetitive traits with odds of introduction to solids prior to 4 months.

RESULTS

Greater infant enjoyment of food was associated (B±SE = 0.45 ± 0.18, p = 0.01) with higher age at introduction to solids. Slowness in eating was inversely associated with 12-month sweet food/beverage intake frequency (B±SE = -0.25 ± 0.10, p = 0.01). Other associations of appetitive traits with age at introduction to solids and sweet food/beverage exposure were not statistically significant.

CONCLUSIONS

Findings imply that lower infant enjoyment of food and greater speed of eating during the period of exclusive milk-feeding could be associated with suboptimal complementary feeding practices. Understanding how parents respond to infant appetitive traits may be important considerations in efforts to promote appropriate complementary feeding practices during infancy.

Longitudinal association of actigraphy-assessed sleep with physical growth in the first 6 months of life

STUDY OBJECTIVES

Suboptimal sleep is associated with obesity and its sequelae in children and adults. However, few studies have examined the association between sleep and physical growth in infants who experience rapid changes in sleep/wake patterns. We examined the longitudinal association of changes in objectively assessed sleep/wake patterns with changes in growth between ages 1 and 6 months.

METHODS

We studied 298 full-term infants in the longitudinal Rise & SHINE cohort study. Changes from 1 and 6 months in nighttime sleep duration, wake after sleep onset (WASO), and number of waking bouts ≥5 min were assessed using ankle actigraphy. Overweight was defined as age- and sex-specific weight for length ≥95th percentile. Generalized estimating equation analyses adjusted for infants' and mothers' characteristics.

RESULTS

The mean (SD) birth weight was 3.4 (0.4) kg; 48.7% were boys. In multivariable adjusted models, each 1-h increase in nighttime sleep duration between months 1 and 6 was associated with a 26% decrease in the odds of overweight from 1 to 6 months (odds ratio [OR] = 0.74; 95% confidence interval [CI, 0.56, 0.98]). Each 1-unit decrease in number of waking bouts was associated with a 16% decrease in the odds of overweight (OR = 0.84; 95% CI [0.72, 0.98]). Changes in WASO were not associated with the odds of overweight.

CONCLUSIONS

Greater increases in nighttime sleep duration and more consolidation of nighttime sleep were associated with lower odds of overweight from 1 to 6 months. Adverse sleep patterns as early as infancy may contribute to excess adiposity.

Protocol of the Snuggle Bug/Acurrucadito Study: a longitudinal study investigating the influences of sleep-wake patterns and gut microbiome development in infancy on rapid weight gain, an early risk factor for obesity

BACKGROUND

Overweight, obesity, and associated comorbidities are a pressing global issue among children of all ages, particularly among low-income populations. Rapid weight gain (RWG) in the first 6 months of infancy contributes to childhood obesity. Suboptimal sleep-wake patterns and gut microbiota (GM) have also been associated with childhood obesity, but little is known about their influences on early infant RWG. Sleep may alter the GM and infant metabolism, and ultimately impact obesity; however, data on the interaction between sleep-wake patterns and GM development on infant growth are scarce. In this study, we aim to investigate associations of infant sleep-wake patterns and GM development with RWG at 6 months and weight gain at 12 months. We also aim to evaluate whether temporal interactions exist between infant sleep-wake patterns and GM, and if these relations influence RWG.

METHODS

The Snuggle Bug/ Acurrucadito study is an observational, longitudinal study investigating whether 24-h, actigraphy-assessed, sleep-wake patterns and GM development are associated with RWG among infants in their first year. Based on the Ecological Model of Growth, we propose a novel conceptual framework to incorporate sleep-wake patterns and the GM as metabolic contributors for RWG in the context of maternal-infant interactions, and familial and socio-physical environments. In total, 192 mother-infant pairs will be recruited, and sleep-wake patterns and GM development assessed at 3 and 8 weeks, and 3, 6, 9, and 12 months postpartum. Covariates including maternal and child characteristics, family and environmental factors, feeding practices and dietary intake of infants and mothers, and stool-derived metabolome and exfoliome data will be assessed. The study will apply machine learning techniques combined with logistic time-varying effect models to capture infant growth and aid in elucidating the dynamic associations between study variables and RWG.

DISCUSSION

Repeated, valid, and objective assessment at clinically and developmentally meaningful intervals will provide robust measures of longitudinal sleep, GM, and growth. Project findings will provide evidence for future interventions to prevent RWG in infancy and subsequent obesity. The work also may spur the development of evidence-based guidelines to address modifiable factors that influence sleep-wake and GM development and prevent childhood obesity.

A prenatal group based phone counseling intervention to improve breastfeeding rates and complementary feeding: a randomized, controlled pilot and feasibility trial

Background

Despite numerous benefits for both mom and baby, few infants are exclusively breastfed for the recommended first six months. Additionally, infants are given solids too early. Prenatal education increases rates of breastfeeding initiation and we hypothesize it can also improve exclusive breastfeeding rates and prevent the early introduction of solids. We conducted a randomized controlled pilot and feasibility trial to understand the feasibility and maternal acceptance of a prenatal behavioral lifestyle intervention (PBLI) delivered via group based phone counseling (GBPC) and its effectiveness on rates of exclusive breastfeeding up to six months postpartum. Secondary aims included rates of any breastfeeding up to six months, rates of early introduction of solids, and infant feeding progression.

Methods

Forty-one pregnant women were recruited from a Kansas City Metropolitan Obstetrics and Gynecology office and randomly assigned to a usual care group or a PBLI. Women in the PBLI participated in six GBPC sessions where they learned about breastfeeding and introducing solids. Feeding questionnaires to assess breastfeeding and introduction of solids were sent at two weeks, two months, four months, and six months postpartum. Structured interviews were also conducted after the intervention and at six months postpartum to assess maternal acceptance and intervention feasibility.

Results

Participants overwhelmingly found the intervention acceptable and beneficial.

Rates of exclusive breastfeeding and any breastfeeding did not differ between groups at any time point. No between group differences were found for early introduction of solids or infant feeding progression.

Conclusions

Mothers discontinue breastfeeding earlier than recommended despite high rates of initiation. A PBLI delivered via GBP is feasible, acceptable to participants, and showed positive impacts such as maternal empowerment for both breastfeeding and introducing solids. Future interventions should incorporate both prenatal and postpartum components.

Trial registration

Study protocols were approved by the University of Kansas Medical Center’s Human Subjects Committee (STUDY00140506) and registered at ClinicalTrials.gov on 02/22/2018 (NCT03442517, retrospectively registered). All participants gave written informed consent prior to data collection.

Timing of Introduction of Complementary Foods and Beverages to Infants of Low-Income Women

Background: Although rates of complementary food and beverage (CFB) consumption among infants under 4 to 6 months of age have been declining, they remain well above the American Academy of Pediatrics (AAPs) recommendations. It is unclear if women with low income in the United States are more likely than other women to introduce CFBs early. We examined timing of introduction of CFBs to infants of mothers with low income to further illuminate infant feeding practices in this potentially vulnerable population. Materials and Methods: We analyzed infant feeding data collected prospectively from 443 mother-infant dyads. Data were obtained by interview at 1, 3, and 6 months postpartum. We used Kaplan-Meier curves to show time to introduction of CFBs overall and by type of CFB, and log-rank tests to compare timing by demographic and clinical characteristics. Results: Participants were mostly non-Hispanic black or white, with a high school education or less. By month 3, 48% of infants were fed at least one CFB, increasing to over 83% by month 5. Women who did not work outside the home introduced CFBs significantly earlier than those who worked, as did women who smoked compared with those who did not. Timing did not differ by other participant characteristics. Conclusions: Introduction of CFBs before 4-6 months was common. Clinical guidance and intervention programs should support mothers toward the goal of improving infant diets in this at-risk population.

Prevalence and Predictor of Exclusive Breastfeeding among Mothers of 0 to 6 months Infants from Pastoralists and Hunters' Community in Tanzania; A Community Based Cross-Sectional Study

BACKGROUND

Initiating breastfeeding during the first hour after birth and continuing breastfeeding exclusively for 6 months prevents childhood infections such as diarrhoea. Exclusive breastfeeding (EBF) for the first 6 months of life of the baby is recognised globally as the best and the most effective intervention to ensure the survival of babies. The aim of this study was to determine the prevalence of EBF and its predictors among mothers of 0 to 6 months infants from pastoralists and hunters' community in Manyara region-Tanzania.

METHODS

This was a community-based analytical cross-sectional study that involved 342 mothers of 0 to 6 months infants who were randomly selected through 4 stage multistage sampling technique. Data was collected using an interviewer-administered questionnaire. Collected data was analysed using Statistical Package for Social Sciences (SPSS) version 20. Binary Logistic Regression analysis was used to establish factors associated with EBF practices.

RESULTS

The prevalence of EBF among postnatal women from hunters and pastoralists societies was 47.1% at 95% CI=41.7%-52.5%. After adjusted for confounders, the predictors of EBF practice were age of infants (0-1 months, AOR = 2.838 at 95% CI = 1.326-6.075, p=.007), age of mothers (26-35 years, AOR=1.851 at 95% CI= 1.059-3.234, p=.031), Level of education of infants' mothers (primary education, AOR= 2.374 at 95% CI= 1.321-4.265, p=.004) and knowledge on exclusive breast feeding, AOR=2.51 at 95% CI= 1.435-4.393, p=.001.

CONCLUSION

Majority of mothers from pastoralists' and hunters' societies were not practising EBF. Predictors of EBF practice were; the age of infants, maternal age, level of education of the mother and knowledge on exclusive breastfeeding. Poor EBF practice was mainly contributed to low level of knowledge about the EBF. The low level of knowledge could have been contributed by poor access to maternal services. Nature of living (lack of permanent settlement) of the study population could have contributed to low access to maternal services. An innovative interventional study is highly recommended to come up with strategies that will improve knowledge on EBF and practice of EBF.

First Bites-Why, When, and What Solid Foods to Feed Infants

Humans are the only mammals who feed our young special complementary foods before weaning and we are the only primates that wean our young before they can forage independently. There appears to be a sensitive period in the first several months of life when infants readily accept a wide variety of tastes and this period overlaps with a critical window for oral tolerance. As a result, infants should be exposed to a wide variety of flavors while mother is pregnant, while mother is nursing and beginning at an early age. There also appears to be a sensitive period between 4 and 9 months when infants are most receptive to different food textures. There remains debate about when it is best to begin introducing solid foods into an infant's diet however, the available evidence suggests that provided the water and food supply are free of contamination, and the infant is provided adequate nutrition, there are no clear contraindications to feeding infants complementary foods at any age. There is emerging evidence that introduction of solid foods into an infant's diet by 4 months may increase their willingness to eat a variety of fruits and vegetables later in life, decrease their risk of having feeding problems later in life, and decrease their risk of developing food allergies, and the early introduction of solid foods into an infant's diet does not appear to increase their risk of obesity later in childhood.

Factors Affecting Complementary Feeding of Infants. A Pilot Study Conducted after the Introduction of New Infant Feeding Guidelines in Poland

Adequate nutrition in the first year of life is the key prerequisite for a child’s healthy growth and development. The success of complementary feeding is influenced by various factors, including the family’s socioeconomic status, maternal age, place of residence and educational level, older children and duration of breastfeeding. Modified infant feeding guidelines were introduced in Poland in 2016. The aim of this study was to identify the factors that exert the greatest influence on infant feeding practices in the Polish population. A thorough understanding of maternal factors that are responsible for undesirable feeding practices is required to improve the mothers’ knowledge and to promote healthy feeding practices. This study was carried out in March–June 2018 and between November 2018 and March 2019 in the Region of Lublin in southeastern Poland. The mothers of children aged 9–14 months, who had introduced complementary foods, were invited to the study. A total of 441 mothers agreed to participate, and 289 of them fully and correctly completed the questionnaires. Logistic regression models were developed to assess the association between maternal factors, such as age, educational level and the nutrition knowledge score, and introduction of solid foods. The infant’s sex and birth weight and the mother’s place of residence had no significant influence on the duration of breastfeeding. The mother’s age and educational level, the number of children in the family and maternal nutrition knowledge scores contributed to significant differences in breastfeeding duration. Older mothers (30–34 years vs. 25–29 years, p = 0.001), better educated mothers (university vs. secondary school education p = 0.002) and mothers with one or two children exclusively breastfed their children for longer (17 weeks vs. 11 weeks, p = 0.002) than younger mothers with secondary school education and more than three children. Exclusive formula feeding was significantly correlated with untimely introduction of solid foods compared to exclusive breastfeeding (13 weeks vs. 19.7 weeks, p = 0.001). Mothers with nutrition knowledge scores in the upper tertile were more likely to adapt food consistency to the skills manifested by the child (88%) (OR = 1.88; Cl: 1.53–2.26, p < 0.05) and were less likely to delay the introduction of new foods that required chewing and biting (84%) (OR = 0.22; Cl: 0.09–0.34, p < 0.05) than mothers with nutrition knowledge scores in the bottom tertile. Maternal age, educational level and nutrition knowledge significantly increased the age at which infants were introduced to solid foods and the correct identification of the signs indicative of the child’s readiness to explore new tastes and foods with a new consistency. The above factors contributed to delayed, but not untimely, introduction of complementary foods (6 months of age or later), including gluten.

Protocol for iGrow (Infant Growth and Development Study): biopsychosocial predictors of childhood obesity risk at 2 years

Background

Childhood obesity remains a significant public health problem. To date, most research on the causes and correlates of obesity has focused on a small number of direct predictors of obesity rather than testing complex models that address the multifactorial nature of the origins of obesity in early development. We describe the rationale and methods of iGrow (Infant Growth and Development Study) which will test multiple pathways by which (a) prenatal maternal psychobiological risk predicts infant weight gain over the first 6 months of life, and (b) this early weight gain confers risk for obesity at age 2. Infant hormonal and psychobiological risk are proposed mediators from prenatal risk to early weight gain, though these are moderated by early maternal sensitivity and obesogenic feeding practices. In addition, higher maternal sensitivity and lower obesogenic feeding practices are proposed predictors of adaptive child self-regulation in the second year of life, and all three are proposed to buffer/reduce the association between high early infant weight gain and obesity risk at age 2.

Methods

iGrow is a prospective, longitudinal community-based study of 300 diverse mothers and infants to be followed across 5 data waves from pregnancy until children are age 2. Key measures include (a) maternal reports of demographics, stress, well-being, feeding practices and child characteristics and health; (b) direct observation of maternal and infant behavior during feeding, play, and distress-eliciting tasks during which infant heart rate is recorded to derive measures of vagal withdrawal; (c) anthropometric measures of mothers and infants; and (d) assays of maternal prenatal blood and infant saliva and urine. A host of demographic and other potential confounds will be considered as potential covariates in structural equation models that include tests of mediation and moderation. Efforts to mitigate the deleterious effects of COVID-19 on study success are detailed.

Discussion

This study has the potential to inform (1) basic science about early life processes casually related to childhood obesity and (2) development of targeted intervention and prevention approaches that consider mother, infant, and family risks and resources.

Evaluating the pathways linking complementary feeding practices to obesity in early life

The complementary feeding period, when solids and liquids other than breast milk and formula are added to the infant diet, is an important development window shaping infant growth and weight gain, metabolic development, and lifelong eating practices. Yet, relatively little is known about how the timing and types of foods offered to infants at this stage may shape their growth and subsequent risk of developing obesity. This narrative review describes the existing literature on complementary feeding practices, discusses potential biological and behavioral pathways linking complementary feeding practices to the development of obesity, and offers potential avenues for intervention. While further research is needed to more fully understand optimal complementary feeding practices, existing evidence supports the importance of healthful early feeding practices in the physiological and behavioral regulation of growth and metabolism and the need for early intervention to prevent the development of obesity.

Timing of Introduction of Complementary Foods - United States, 2016-2018

The American Academy of Pediatrics (AAP) recommends introducing complementary foods (i.e., any solid or liquid other than breast milk or infant formula) to infants at approximately age 6 months (1). Although a consensus on ideal timing is lacking, most experts agree that introduction of complementary foods before age 4 months is too early because of infant gastrointestinal and motor immaturity (1,2). In addition, early introduction prevents exclusively breastfed infants from reaching the recommended 6 months of exclusive breastfeeding (1) and might be associated with increased risk for overweight and obesity (3). Nationally representative data on complementary feeding are limited; state-level estimates have been previously unavailable. CDC analyzed 2016-2018 data from the National Survey of Children's Health (NSCH) (N = 23,927) to describe timing of complementary feeding introduction and prevalence of early introduction of complementary foods before age 4 months (early introduction) among children aged 1-5 years. Prevalence of early introduction was 31.9% nationally and varied geographically and across sociodemographic and infant feeding characteristics. These estimates suggest that many infants are introduced to complementary foods before they are developmentally ready. Efforts by health care providers and others who might influence infant feeding practices could help decrease the number of infants who are introduced to complementary foods too early.

Infant Feeding Practices and Subsequent Dietary Patterns of School-Aged Children in a US Birth Cohort

BACKGROUND

Infant feeding practices are thought to shape food acceptance and preferences. However, few studies have evaluated whether these affect child diet later in life.

OBJECTIVE

The study objective was to examine the association between infant feeding practices and dietary patterns (DPs) in school-aged children.

DESIGN

A secondary analysis of data from a diverse prospective birth cohort with 10 years of follow-up (WHEALS [Wayne County Health Environment Allergy and Asthma Longitudinal Study]) was conducted.

PARTICIPANTS/SETTING

Children from the WHEALS (Detroit, MI, born 2003 through 2007) who completed a food screener at age 10 years were included (471 of 1,258 original participants).

MAIN OUTCOME MEASURES

The main outcome was DPs at age 10 years, identified using the Block Kids Food Screener.

STATISTICAL ANALYSIS PERFORMED

Latent class analysis was applied for DP identification. Breastfeeding and age at solid food introduction were associated with DPs using a 3-step approach for latent class modeling based on multinomial logistic regression models.

RESULTS

The following childhood DPs were identified: processed/energy-dense food (35%), variety plus high intake (41%), and healthy (24%). After weighting for loss to follow-up and covariate adjustment, compared with formula-fed children at 1 month, breastfed children had 0.41 times lower odds of the processed/energy-dense food DP vs the healthy DP (95% CI 0.14 to 1.25) and 0.53 times lower odds of the variety plus high intake DP (95% CI 0.17 to 1.61), neither of which were statistically significant. Results were similar, but more imprecise, for breastfeeding at 6 months. In addition, the association between age at solid food introduction and DP was nonsignificant, with each 1-month increase in age at solid food introduction associated with 0.81 times lower odds of the processed/energy-dense food DP relative to the healthy DP (95% CI 0.64 to 1.02).

CONCLUSIONS

A significant association between early life feeding practices and dietary patterns at school age was not detected. Large studies with follow-up beyond early childhood that can also adjust for the multitude of potential confounders associated with breastfeeding are needed.

Infant feeding practices and sleep at 1 year of age in the nationwide ELFE cohort

Sleep problems reported by parents affect 20% to 30% of infants. Few studies focused on the longitudinal association between infant feeding practices and sleep, especially in France. Analyses were based on 8,696 infants from the French national birth cohort ELFE. Collection of feeding practices from birth to 10 months allowed for the identification of trajectories of use of baby cereals and thickened formula by group‐based trajectory modelling and calculation of duration of any breastfeeding (BF) and age at complementary feeding introduction (CFI) excluding baby cereals. Total sleep duration (TSD), night waking (NW) and sleep onset difficulties (SOD) were reported at age 1. Associations between feeding and sleep were tested by multinomial logistic regressions. BF duration ≥6 months was associated with parent‐reported frequent NW, SOD and TSD ≤ 12 h/24 h at age 1. For TSD and SOD, this association was no longer significant after accounting for parental sleep‐related practices. Early use of baby cereals (≤5 months) was associated with poor sleep. Early CFI (<4 months) was associated with shorter TSD and SOD but not NW. Early use of thickened formula (only <6 months) was related to poor sleep at age 1 (NW and SOD), whereas late (around 6 months) use of thickened formula was associated with better sleep. BF duration ≥6 months was related to poor sleep at age 1 but not after adjustment on 1‐year parental sleep‐related practices except for NW. The use of baby cereals or early CFI was not related to better sleep at age 1.

Does domestic violence during pregnancy influence the beginning of complementary feeding?

BACKGROUND

This study investigate the influence of domestic violence against pregnant women on early complementary feeding and associated factors.

METHODS

A longitudinal observational study was conducted with a convenience sample recruited from three public hospitals in Porto Alegre, Rio Grande do Sul, Brazil. Data on maternal age, education, marital status, breastfeeding, introduction of complementary feeding and domestic violence during pregnancy were investigated at four follow-ups points. Data on domestic violence was collected through a self-report questionnaire based on the Abuse Assessment Screen. The early introduction of complementary feeding, characterized as occurring before or at 3 months of life, was verified through a questionnaire prepared by the research group. Data analysis involved Student's t-test, the chi-square test and Cox regression and was carried out in Statistical Package for the Social Sciences program. The significance level was set at 5%.

RESULTS

A total of 232 mother-infant pairs participated in the analyses, and 15.1% of the mothers reported suffering some form of violence. Domestic violence was directly associated with maternal education, marital status, and health status during pregnancy. Domestic violence was not associated with maternal age or breastfeeding at 3 months after delivery. In the univariate analysis, domestic violence during pregnancy was associated with early complementary feeding (RR = 1.74; CI: 1.01-2.98). This effect disappeared after the model was adjusted in multivariate analysis.

CONCLUSIONS

There was no relationship between domestic violence during pregnancy and early complementary feeding.

WHO infant and young child feeding indicators in relation to anthropometric measurements

Objective:

This study aimed to report the WHO infant and young child feeding (IYCF) indicators from Kuwait and to investigate the associations between these indicators and anthropometric measurements.

Design:

The Kuwait Nutritional Surveillance System uses observational cross-sectional approach to collects data by face-to-face interviews with mothers or child guardians using a structured questionnaire that was developed based on the WHO IYCF indicators. The weight and height of infants and young children were measured using digital scales in a standardised manner.

Setting:

Vaccination centres in all governorates (provinces) of Kuwait.

Participants:

Infants and young Kuwaiti children aged 0–23 months (N 5839).

Results:

The prevalence of exclusive breastfeeding and age-appropriate breastfeeding were 8·0 and 7·4 %, respectively. The prevalence of stunting and wasting was 7·5 and 2·4 %, respectively, while the prevalence of overweight and obesity was 6·5 and 1·6 %, respectively. In the multivariable analysis, exclusive breastfeeding and age-appropriate breastfeeding were more common in children with stunted growth (AOR 1·71 (95 % CI 1·08, 2·70; P = 0·021) and 1·44 (95 % CI 1·01, 2·06; P = 0·046), respectively). The introduction of solid/semisolid or soft foods was inversely associated with stunting (AOR 0·52; 95 % CI 0·30, 0·90; P = 0·021). Only age-appropriate breastfeeding was inversely associated with overweight (AOR 0·62; 95 % CI 0·39, 0·98; P = 0·043).

Conclusion:

Our findings showed that indicators of breastfeeding are low in Kuwait. Our findings suggest that the associations between different WHO IYCF indicators and stunting as well as overweight is complex, which highlights the need for a better understanding of WHO IYCF indicators in both low- and high-income countries.

Determinants for early introduction of complementary foods in Australian infants: findings from the HSHK birth cohort study

OBJECTIVE

The purpose of this study was to examine the timing of introduction of complementary (solid) foods among infants in South Western Sydney, Australia, and describe the maternal and infant characteristics associated with very early introduction of solids.

METHODS

Mother-infant dyads (n = 1035) were recruited into the "Healthy Smiles Healthy Kids" study by Child and Family Health Nurses at the first post-natal home visit. Data collected via telephone interviews at 8, 17, 34 and 52 weeks postpartum included timing of introduction of solids and a variety of maternal and infant characteristics (n = 934). Multiple logistic regression was used to identify factors independently associated with the risk of introducing solids very early, which for the purpose of this study was defined as being before 17 weeks.

RESULTS

The median age of introduction of solids was 22 weeks. In total, 13.6% (n = 127) of infants had received solids before 17 weeks and 76.9% (n = 719) before 26 weeks of age. The practice of introducing solids early decreased with older age of the mother. Compared to women < 25 years of age, those who were 35 years or older were 72% less likely to introduce solids very early (OR = 0.28, CI95 0.14-0.58). Single mothers had more than twice the odds of introducing solids before the age of 17 weeks compared to married women (OR = 2.35, CI95 1.33-4.16). Women who had returned to work between 6 to 12 months postpartum were 46% less likely to introduce solids very early compared with those who were not working at the child's first birthday (OR = 0.54, CI95 0.30-0.97). Women born in Vietnam and Indian sub-continent had lower odds of introducing solids very early compared to Australian born women (OR = 0.42, CI95 0.21-0.84 and OR = 0.30, CI95 0.12-0.79, respectively). Infants who were exclusively formula-fed at 4 weeks postpartum had more than twice the odds of receiving solids very early (OR = 2.34, CI95 1.49-3.66).

CONCLUSIONS

Women who are younger, single mothers, those not working by the time of child's first birthday, those born in Australia, and those who exclusively formula-feed their babies at 4 weeks postpartum should be targeted for health promotion programs that aim to delay the introduction of solids in infants to the recommended time.

A collaborative approach to developing sustainable behaviour change interventions for childhood obesity prevention: Development of the Choosing Healthy Eating for Infant Health (CHErIsH) intervention and implementation strategy

OBJECTIVES AND DESIGN

There is growing recognition of the need for effective behaviour change interventions to prevent chronic diseases that are feasible and sustainable and can be implemented within routine health care systems. Focusing on implementation from the outset of intervention development, and incorporating multiple stakeholder perspectives to achieve this, is therefore essential. This study explores the development of the Choosing Healthy Eating for Infant Health (CHErIsH) childhood obesity prevention intervention and implementation strategy to improve infant feeding behaviours.

METHODS

Five qualitative and quantitative evidence syntheses, two primary qualitative studies, and formal/informal consultations were conducted with practice, policy, research, and parent stakeholders. The Behaviour Change Wheel was used to guide the integration of findings.

RESULTS

The CHErIsH intervention targets parent-level behaviour change and comprises (1) brief verbal messages and (2) trustworthy resources, to be delivered by health care professionals (HCPs) during routine infant vaccination visits. The implementation strategy targets HCP-level behaviour change and comprises (1) a local opinion leader, (2) incentivized training, (3) HCP resources and educational materials, (4) electronic delivery prompts, (5) awareness-raising across all primary care HCPs, and (6) local technical support.

CONCLUSIONS

This study provides a rigorous example of the development of an evidence-based intervention aimed at improving parental infant feeding behaviours, alongside an evidence-based behaviour change strategy to facilitate implementation and sustainability in primary care. This approach demonstrates how to systematically incorporate multiple stakeholder perspectives with existing literature and move from multiple evidence sources to clearly specified intervention components for both the intervention and implementation strategy. Statement of Contribution What is already known? Incorporating insights from practice, policy, and public/patient stakeholders plays a key role in developing behaviour change interventions that are feasible and sustainable and can be implemented within routine health care systems. However, there are limited examples that provide in-depth guidance of how to do this using a systematic approach. What this study adds? This study describes an innovative use of the Behaviour Change Wheel to integrate multiple sources of evidence collected from practice, policy, research, and parent stakeholders to concurrently develop an evidence-based intervention to improve parental infant feeding behaviours and an implementation strategy to facilitate sustainable delivery by health care professionals in routine primary care.

Factors Influencing the Age of Complementary Feeding-A Cross-Sectional Study from Two European Countries

The timing of introducing complementary feeding affects nutritional status and children's health. The aim of this study was to determine sociodemographic and birth-related factors associated with the age of introducing complementary foods. This cross-sectional study investigated parents (n = 5815) of children aged 12-36 months from Poland (n = 4065) and Austria (n = 1750) using a single online questionnaire. During the study, detailed data about sociodemographic characteristics, variables related to pregnancy, and early feeding practices were collected. Univariate and multivariate logistic regression models were used to investigate factors associated with the introduction of complementary feeding before 4 completed months, between 4 and 6 months, and after 6 completed months separately for both countries. Complementary foods were introduced before 4 months in 3.0% of infants (2.4% in Poland and 4.3% in Austria), between 4 and 6 months in 65.0% (60.5% in Poland and 75.3% in Austria), and after 6 completed months in 32.1% of infants (37.1% in Poland and 20.4% in Austria). The factors related to earlier introduction of complementary feeding were lower maternal age (in Austria 25-29 years: aOR 2.21 (95% CI 1.06-4.65)) and education level (in Poland and Austria primary and vocational: aOR 14.49 (95% CI 3.73-56.35), aOR 2.13 (95% CI 1.10-4.11), respectively), preterm birth (in Poland and Austria: aOR 10.21 (95% CI 5.73-18.20); aOR 4.45 (95% CI 2.42-8.18), respectively), never breastfeeding (Poland: aOR 2.73 (95% CI 1.29 - 5.76)) and receiving an infant formula after hospital discharge (in both countries: aOR 3.73 (95% CI 2.06-6.75); aOR 3.65 (95% CI 1.87-7.12), respectively). These factors should be taken into account by health professionals in identifying mothers who are least likely to follow nutritional recommendations.

Current practice in the introduction of solid foods for preterm infants

OBJECTIVE

The present study compared the age of first solid foods in a cohort of preterm infants with term infants and identified factors influencing timing of solid food introduction.

DESIGN

Structured interviews on infant feeding practices, growth and medical status at term equivalence and at 3, 6, 9 and 12 months corrected postnatal age. The age of solid food introduction was compared between term and preterm infants, and the influence of maternal, infant and milk feeding factors was assessed.

SETTING

This prospective longitudinal study recruited primary carers of preterm and term infants from a regional metropolitan referral hospital in eastern Australia.

PARTICIPANTS

One hundred and fifty infants (preterm, n 85; term, n 65).

RESULTS

When corrected for prematurity, preterm infants received solid foods before the recommended age for the introduction of solid foods for term infants. Median introduction of solid foods for preterm infants was 14 weeks corrected age (range 12-17 weeks). This was significantly less than 19 weeks (range 17-21 weeks) for term infants (P < 0·001). Lower maternal education and male gender were associated with earlier introduction of solid foods among preterm infants.

CONCLUSIONS

Preterm infants are introduced to solid foods earlier than recommended for term infants, taking account of their corrected age. Further research is needed to assess any risk or benefit associated with this pattern and thus to develop clear evidence-based feeding guidelines for preterm infants.

Choosing Healthy Eating for Infant Health (CHErIsH) study: protocol for a feasibility study

INTRODUCTION

Childhood obesity is a public health challenge. There is evidence for associations between parents' feeding behaviours and childhood obesity risk. Primary care provides a unique opportunity for delivery of infant feeding interventions for childhood obesity prevention. Implementation strategies are needed to support infant feeding intervention delivery. The Choosing Healthy Eating for Infant Health (CHErIsH) intervention is a complex infant feeding intervention delivered at infant vaccination visits, alongside a healthcare professional (HCP)-level implementation strategy to support delivery.

METHODS AND ANALYSIS

This protocol provides a description of a non-randomised feasibility study of an infant feeding intervention and implementation strategy, with an embedded process evaluation and economic evaluation. Intervention participants will be parents of infants aged ≤6 weeks at recruitment, attending a participating HCP in a primary care practice. The intervention will be delivered at the infant's 2, 4, 6, 12 and 13 month vaccination visits and involves brief verbal infant feeding messages and additional resources, including a leaflet, magnet, infant bib and sign-posting to an information website. The implementation strategy encompasses a local opinion leader, HCP training delivered prior to intervention delivery, electronic delivery prompts and additional resources, including a training manual, poster and support from the research team. An embedded mixed-methods process evaluation will examine the acceptability and feasibility of the intervention, the implementation strategy and study processes including data collection. Qualitative interviews will explore parent and HCP experiences and perspectives of delivery and receipt of the intervention and implementation strategy. Self-report surveys will examine fidelity of delivery and receipt, and acceptability, suitability and comprehensiveness of the intervention, implementation strategy and study processes. Data from electronic delivery prompts will also be collected to examine implementation of the intervention. A cost-outcome description will be conducted to measure costs of the intervention and the implementation strategy.

ETHICS AND DISSEMINATION

This study received approval from the Clinical Research Ethics Committee of the Cork Teaching Hospitals. Study findings will be disseminated via peer-reviewed publications and conference presentations.

Assessing the Lifetime Cost-Effectiveness of Low-Protein Infant Formula as Early Obesity Prevention Strategy: The CHOP Randomized Trial

Background: Although there is a growing number of early childhood obesity prevention programs, only a few of them are effective in the long run. Even fewer reports exist on lifetime cost-effectiveness of early prevention strategies. This paper aimed to assess the lifetime cost-effectiveness of infant feeding modification aiming at reducing risk of later obesity. Methods: The simulation model consists of two parts: (a) Model I used data from the European Childhood Obesity Project (CHOP) trial (up to 6 years) and the German Interview and Examination Survey for Children (KiGGS) (6–17 years) to evaluate BMI trajectories of infants receiving either lower protein (LP) or higher protein (HP) content formula; and (b) Model II estimated lifetime cost-effectiveness based on Model I BMI trajectories. Compared to HP formula, LP formula feeding would incur lower costs that are attributable to childhood obesity across all decades of life. Results: Our analysis showed that LP formula would be cost-effective in terms of a positive net monetary benefit (discounted 3%) as an obesity prevention strategy. For the 19% of infants fed with formula in Germany, the LP strategy would result in cost savings of € 2.5 billion. Conclusions: Our study is one of the first efforts to provide much-needed cost-effectiveness evidence of infant feeding modification, thereby potentially motivating interventionists to reassess their resource allocation.

[Complementary feedings and socioeconomic factors]

INTRODUCTION

In order to limit the risk of food allergies, it is recommended to begin complementary feedings for infants between the ages of 4 and 6 months old. The objective of this study is to describe how complementary feedings are carried out until the age of 1 year old and to analyze criteria, especially socio-economic, that influence compliance with recommendations.

METHODS

This observational and descriptive quantitative study lasted from November 21st, 2016 to February 21st, 2017 and took place in 10 doctor's offices around the city of Saint-Etienne. Anonymous surveys were distributed to the mothers of children aged between 12 and 47 months old inclusive, born at term, and with a weight above 2.5 kg.

RESULTS

More than 2/3rds of the 163 children included started complementary feedings between 4 and 6 months old. Gluten (P = 0.02) and meat (P = 0.016) were introduced later and infant formulas (P = 0.005) were stopped sooner when the mother's education level was low. The average number of fruit and vegetables was smaller when the mother had a low socio-economic level or if she was multiparous. At the age of one, fewer than 20% of the children had consumed fat content rich in omega-3. At the same age, 70% had consumed egg and 12.3% nuts, which are some of the major allergens.

CONCLUSION

These outcomes show the need for general practitioners to inform parents, especially those with a low socio-economic level, about early food introduction, including allergens.

Associations between timing and quality of solid food introduction with infant weight-for-length z-scores at 12 months: Findings from the Nurture cohort

This study assesses associations of the timing and quality of solid foods introduced during infancy with weight-for-length (WFL) z-scores at 12 months within the Nurture cohort. Women from North Carolina self-reported sociodemographics, the timing and type of solid food introduction, and reasons for introducing solids; infant anthropometrics were measured every 3 months through 1 year (n = 666). Frequency (0-5x/day) infants consumed fruits and vegetables was used to compute a mean (4-12 months) healthy food score (HFS), and sweets, french fries, snacks, and ice cream was used to compute a mean unhealthy food score (UnHFS). Multivariable-adjusted generalized linear models were used to examine the relationship of early solid food introduction, HFS quartiles (Q), UnHFS quartiles, and interactions between these variables with WFL z-scores at 12 months (n = 449). Exploratory analyses evaluated WFL z-scores among 4 groups of infants with high/low HFS and high/low UnHFS. On average, mothers were 28 years with a pre-pregnancy BMI of 30.5 kg/m²; 65% were Non-Hispanic Black, and 59% had incomes <$20,000. Mean HFS and UnHFS were 2.4 (range 0-7.4 of 10) and 1.8 (range 0-9.9 of 20), respectively. Nearly 1/3 of mothers introduced solids early, but early introduction and the HFS were not associated with WFL z-scores. Infants in Q3 and Q4 of the UnHFS had higher WFL z-scores (0.75-0.79 ± 0.09) compared to infants in Q1 (0.42 ± 0.0.9), p < 0.05. Frequent unhealthy food intake was associated with higher WFL z-scores at 12-months, underscoring the importance of reducing unhealthy food intake in the first year.

Factors associated with early introduction of complementary feeding and consumption of non-recommended foods among Dutch infants: the BeeBOFT study

BACKGROUND

Timing and types of complementary feeding in infancy affect nutritional status and health later in life. The present study aimed to investigate the factors associated with early introduction of complementary feeding (i.e., before age 4 months), and factors associated with infants consumption of non-recommended foods, including sweet beverages and snack foods.

METHODS

This study used cross-sectional data from the BeeBOFT study (n = 2157). Data on complementary feeding practices and potential determinants were obtained by questionnaire at infant's age of 6 months. Logistic regression models were used to investigate factors associated with early introduction of complementary feeding and infants' consumption of non-recommended foods.

RESULTS

21.4% of infants had received complementary feeding before 4 months of age. At the age of 6 months, 20.2% of all infants were consuming sweet beverages daily and 16.5% were consuming snack foods daily. Younger maternal age, lower maternal educational level, absence or shorter duration of breastfeeding, parental conviction that "my child always wants to eat when he/she sees someone eating" and not attending day-care were independently associated with both early introduction of complementary feeding and the consumption of non-recommended foods. Higher maternal pre-pregnancy BMI and infant postnatal weight gain were associated only with early introduction of complementary feeding.

CONCLUSIONS

We identified several demographical, biological, behavioral, psychosocial, and social factors associated with inappropriate complementary feeding practices. These findings are relevant for designing intervention programs aimed at educating parents.

TRIAL REGISTRATION

The trail is registered at Netherlands Trial Register, trail registration number: NTR1831 . Retrospectively registered on May 29, 2009.

Marshallese Beliefs, Perceptions, and Practices Related to Child Feeding Among Marshallese in the United States: Implications for Childhood Obesity

Introduction:

Obesity affects more than 40 million children globally. Efforts to promote proper nutrition in an attempt to reduce childhood obesity should consider maternal beliefs and cultural customs around food. Little is known regarding child feeding, including weaning practices and foods consumed in the first years of life among Marshallese children, a sub-group of Pacific Islanders, residing in the United States.

Methods:

This study aims to explore the influences on introduction of complementary foods among Marshallese mothers and caregivers residing in the United States, to serve as the basis for promotion of improved nutrition. Focus groups and demographic surveys were conducted with Marshallese mothers and caregivers (N = 27) to explore child-feeding beliefs, perceptions, and practices.

Results:

All mothers reported breastfeeding their infants, and 80% reported using some type of milk supplementation. There was a difference in mother and caregiver responses regarding which first foods to introduce and average age of introduction.

Discussion:

Analysis revealed three themes identified as being influential for child-feeding practices: Marshallese breastfeeding customs, introduction of solid foods, and Marshallese family feeding customs.

Standard and Specialized Infant Formulas in Europe: Making, Marketing, and Health Outcomes

Infant formulas are the only suitable substitute for human milk. The most common infant formulas are standard formulas based on cow's milk. In addition, there are formulas for infants showing signs and symptoms of intolerance and for clinical conditions such as allergy, prematurity, and gastrointestinal diseases. A comprehensive review of the literature was made to review the composition of standard and specialized infant formulas and analyze indications for use, real or presumed nutrition differences and properties, and impact on infant growth. A brief consideration on costs is outlined for each formula. Over the past few years, industrial production and advertising of infant formulas have increased. Human milk still remains the most complete source of nutrition for infants and should be continued according to the current recommendations. Few differences exist between infant formulas, both for the nutrition action and the macronutrient/micronutrient composition. Specialized infant formulas have limited indications for use and high costs. The role of the pediatrician is crucial in the management of infant nutrition, promotion of breastfeeding, and prescribing of specialized formulas only in specific clinical conditions.

Age at Introduction of Solid Food and Obesity Throughout the Life Course

OBJECTIVE

This study aimed to examine the association between age at solid food (SF) introduction and obesity throughout the life course.

METHODS

Among 31,816 mother- nurse daughter dyads in the Nurses' Mothers' Cohort Study and the Nurses' Health Study II, information was collected on age at SF introduction, body somatotype at ages 5 and 10, and Body Mass Index at age 18 and in adulthood. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for obesity throughout life were estimated using logistic regression models with adjustment for parental and nurse daughter covariates.

RESULTS

Nurse daughters introduced to SF at ≥ 9 months versus 6 to 9 months had marginally higher age-adjusted (OR: 1.21; 95% CI: 1.01, 1.47) and covariate-adjusted (OR: 1.22; 95% CI: 1.01, 1.47) odds of obesity at age 5. Age at SF introduction was not related to obesity at ages 10 and 18 or in adulthood.

CONCLUSIONS

Late age at SF introduction was marginally associated with obesity at age 5, but this association did not persist throughout the life course.

Association of Early Introduction of Solids With Infant Sleep: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

The World Health Organization recommends exclusive breastfeeding for 6 months. However, 75% of British mothers introduce solids before 5 months and 26% report infant waking at night as influencing this decision.

OBJECTIVE

To determine whether early introduction of solids influences infant sleep.

DESIGN, SETTING, AND PARTICIPANTS

The Enquiring About Tolerance study was a population-based randomized clinical trial conducted from January 15, 2008, to August 31, 2015, that included 1303 exclusively breastfed 3-month-old infants from England and Wales. Clinical visits took place at St Thomas' Hospital, London, England, and the trial studied the early introduction of solids into the infant diet from age 3 months.

INTERVENTIONS

The early introduction group (EIG) continued to breastfeed while nonallergenic and then 6 allergenic foods were introduced. The standard introduction group (SIG) followed British infant feeding guidelines (ie, exclusive breastfeeding to around age 6 months and to avoid any food consumption during this period).

MAIN OUTCOMES AND MEASURES

Secondary analysis of an a priori secondary outcome of the effect of early food introduction on infant sleep using the standardized Brief Infant Sleep Questionnaire.

RESULTS

Of the 1303 infants who were enrolled in the Enquiring About Tolerance study, 1225 participants (94%) completed the final 3-year questionnaire (618 SIG [95%] and 607 EIG [93%]). Randomization was effective and there were no significant baseline differences between the 2 groups. Following the early introduction of solids, infants in the EIG slept significantly longer and woke significantly less frequently than infants in the SIG. Differences between the 2 groups peaked at age 6 months. At this point, in the intention-to-treat analysis infants in the EIG slept for 16.6 (95% CI, 7.8-25.4) minutes longer per night and their night waking frequency had decreased from 2.01 to 1.74 wakings per night. Most clinically important, very serious sleep problems, which were significantly associated with maternal quality of life, were reported significantly more frequently in the SIG than in the EIG (odds ratio, 1.8; 95% CI, 1.22-2.61).

CONCLUSIONS AND RELEVANCE

In a randomized clinical trial, the early introduction of solids into the infant's diet was associated with longer sleep duration, less frequent waking at night, and a reduction in reported very serious sleep problems.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN14254740.