Responsive Feeding, Infant Growth, and Postpartum Depressive Symptoms During 3 Months Postpartum

Effects of responsive breastfeeding intervention on breastfeeding and infant growth in China: A randomised controlled trial

Responsive feeding serves as an important protective factor for infant growth and overall health development. This study based on self-determination theory (SDT) aimed to assess the effects of a responsive breastfeeding (RBF) intervention programme on maternal breastfeeding and infant growth and development. A total of 110 mother-infant pairs were recruited and randomly divided into an intervention group (n = 55) and a control group (n = 55). The primary outcomes were breastfeeding motivation score, breastfeeding self-efficacy (BSE) and exclusive breastfeeding rate; the secondary outcomes were infant physical development at 6 weeks and 3 months. A repeated measures ANOVA indicated that the intervention group had significantly higher Enjoyment scores compared to the control group at three time points: at discharge (MD: 5.28; 95% CI: 3.68 to 6.89; p < 0.001), 6 weeks post-partum (MD: 5.06; 95% CI: 3.80 to 6.31; p < 0.001) and 3 months post-partum (MD: 5.24; 95% CI: 4.12 to 6.35; p < 0.001). Similarly, the intervention group reported significantly higher connection and mother's self-perception scores at discharge (MD: 4.31; 95% CI: 3.07 to 5.56; p < 0.001), 6 weeks post-partum (MD: 4.69; 95% CI: 3.71 to 5.68; p < 0.001) and 3 months post-partum (MD: 4.93; 95% CI: 4.14 to 5.72; p < 0.001), compared to the control group. In contrast, the pressure from significant others scores were higher in the control group relative to the intervention group at discharge (MD: -2.09; 95% CI: -2.88 to -1.31; p < 0.001), 6 weeks post-partum (MD: -4.35; 95% CI: -5.20 to -3.49; p < 0.001) and 3 months (MD: -4.89; 95% CI: -5.70 to -4.08; p < 0.001). Finally, the intervention group also reported higher Instrumental Needs scores at all three time points: at discharge (MD: 1.96; 95% CI: 1.35 to 2.58; p < 0.001), 6 weeks post-partum (MD: 3.58; 95% CI: 3.05 to 4.11; p < 0.001) and 3 months post-partum (MD: 1.18; 95% CI: 0.68 to 1.69; p < 0.001). BSE scores were significantly higher in the intervention group compared to the control group at discharge (MD: 14.29; 95% CI: 10.38 to 18.21; p < 0.001), 6 weeks post-partum (MD: 14.04; 95% CI: 11.05 to 17.02; p < 0.001) and 3 months post-partum (MD: 6.80; 95% CI: 4.66 to 8.94; p < 0.001). The rates of exclusive breastfeeding were higher in the intervention group than in the control group at each stage of the intervention (p < 0.01). At 6 weeks post-partum, the intervention group's infants showed slower weight (t = -0.90, p = 0.371) and length (t = -0.69, p = 0.495) growth compared to the control group, though not significantly. By 3 months post-partum, there was a significant difference in both weight (t = -3.46, p = 0.001) and length (t = -2.95, p = 0.004) between the groups. The findings in this study suggest that the RBF intervention programme based on SDT may be effective in improving mothers' motivation to breastfeed, building breastfeeding self-confidence and increasing the rate of exclusive breastfeeding. The effects of the intervention on infant physical development will need to be verified with longer follow-up in future research.

Mental Health and Feeding Styles in Parents of Formula-Fed Infants

Background: Nonresponsive feeding styles can contribute to rapid weight gain in infancy and subsequent obesity in childhood. There is a need to investigate factors such as parental mental health symptoms (stress, depression, and anxiety) that may contribute to nonresponsive feeding styles. The purpose of this study was to investigate the relationship between parental mental health symptoms and feeding styles in parents of healthy, term formula-fed infants during the first year of life. Methods: A cross-sectional, descriptive correlational design was employed using online surveys. We recruited participants through Facebook groups and pediatricians' offices. Instruments included a demographic questionnaire, the Perceived Stress Scale-10, Patient Health Questionnaire-Depression Module-9, 7-item Generalized Anxiety Disorder Assessment, and Infant Feeding Style Questionnaire. Results: Participants were 306 parents of formula-fed infants. Greater depressive symptoms was the strongest predictor of the pressuring style (β = 0.54), while greater symptoms of stress (β = -0.13) and anxiety (β = -0.28) were associated with lower pressuring scores. Greater depressive symptoms was the strongest predictor of the laissez-faire style (β = 0.48), while greater symptoms of stress (β = -0.17) and anxiety (β = -0.23) were associated with lower laissez-faire scores. Engaging in ≤50% of the infant's feeds was the strongest control variable predictor for the pressuring and laissez-faire styles. None of the mental health variables were significantly related to the restrictive style. Conclusions: We recommend increased screening for depressive symptoms in parents of infants and responsive feeding support, especially for those experiencing depressive symptoms.

Comparison of the Effect of Direct Breastfeeding, Expressed Human Milk, and Infant Formula Feeding on Infant Weight Trajectories: A Systematic Review

Background: Formula and breastfeeding are known factors associated with infant weight trajectories. Evidence exploring the effect of expressed human milk feeding on infant weight in the community setting has not been well synthesized. Objectives: This systematic review examined (1) weight changes among infants fed expressed human milk and (2) differences in weight change between infants fed expressed human milk and infants fed at the breast or infant formula via bottle. Methods: A comprehensive search of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of each study was appraised using the Joanna Briggs Critical Appraisal Tools. Results: A total of six studies met the eligibility criteria and included a total of 5,152 infants. The within-subject analysis identified only 31 infants strictly or predominantly fed expressed human milk. The between-subject analysis comparing expressed human milk feeding to the available comparison groups (formula-fed or direct at the breastfed) revealed that higher weight gains were observed in the weight trajectories among infants in the bottle or formula-fed conditions in four of the six included studies. Conclusions: Findings from the few studies included in this review found a difference in the infant weight gain patterns among expressed human milk-fed infants when compared with their respective feeding groups (directly breastfed or formula-fed). Further research is needed to corroborate these findings and elucidate the clinical significance of the differences in weight gain patterns observed across infant feeding groups.

Why do mothers mix milk feed their infants? Results from a systematic review

CONTEXT

Combining or supplementing breastfeeding with formula feeding, also called mixed milk feeding (MMF), is a common infant feeding practice. However, there is no well-established MMF evidence-base for informing and guiding parents. A better understanding of the reasons why mothers practice MMF may facilitate identification of efficient strategies for supporting exclusive breastfeeding, and/or opportunities to prolong breastfeeding, at least partially.

OBJECTIVE

An updated systematic literature review was undertaken with the primary aim of gaining a deeper understanding of the reasons why mothers choose MMF.

DATA SOURCES

Six databases were searched for relevant articles published in English from January 2012 to January 2022.

DATA EXTRACTION

Two reviewers independently performed the screenings and data extraction, and any differences were resolved by a third reviewer. Data from 138 articles were included, 90 of which contained data on MMF reasons/drivers, and 60 contained data on infant age and/or maternal demographic factors associated with MMF.

DATA ANALYSIS

A total of 13 different unique MMF drivers/reasons were identified and categorized according to whether the drivers/reasons related to perceived choice, necessity, or pressure. Risk of bias was evaluated using the Quality Assessment Tool of Diverse Studies and the JBI Systematic Reviews tool. Several different terms were used to describe and classify MMF across the studies. The most commonly reported reasons for MMF were related to a perception of necessity (39% of drivers, eg, concerns about infant's hunger/perceived breast milk insufficiency or breastfeeding difficulties), followed by drivers associated with perceived choice (34%; eg, having more flexibility) and perceived pressure (25%; eg, returning to work or healthcare professionals' advice). This was particularly true for infants aged 3 months or younger.

CONCLUSION

The key global drivers for MMF and their distribution across infant age and regions were identified and described, providing opportunities for the provision of optimal breastfeeding support. A unified definition of MMF is needed in order to enable more comparable and standardized research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022304253.

Complementary feeding approach and maternal responsiveness in 8- and 12-month-old Italian infants: A longitudinal study

In Western countries, infants are usually introduced to solids through spoon-fed puréed foods (parent-led weaning, PLW). However, an alternative approach known as "baby-led weaning" (BLW), in which infants usually participate in family meals and eat independently, is becoming increasingly popular. We investigated the relationship between the type of complementary feeding approach and maternal responsiveness to infant feeding cues in a longitudinal sample of 178 infants observed at 8 and 12 months. Mothers reported the complementary feeding method used and, from video-recorded meals, we coded the proportion of time infants self-fed and rated maternal responsiveness by means of the Responsiveness to Child Feeding Cues Scale (Hodges et al., 2013). Responsiveness to infant receptiveness and fullness cues were significantly correlated at 8 months, but not at 12 months, when unresponsiveness decreased for receptiveness but remained stable for fullness cues. Thus, as infants got older, mothers were increasingly tuned in to their receptiveness cues. However, we did not observe the same pattern for fullness cues, perhaps because mothers were concerned that their infants did not eat enough. Moreover, at both time points, mothers were more responsive to infants' receptiveness than fullness cues, possibly due to an evolutionary drive to protect infants from starvation. Finally, responsiveness to fullness, but not responsiveness to receptiveness, was positively related to the proportion of infant self-feeding, but there were no significant differences in responsiveness depending on the self-reported complementary feeding approach. Thus, a weaning style that emphasizes independent feeding, regardless of whether this is labeled as BLW, may promote more infant-centered maternal responses at the end of the meal, with potential implications for promoting infant self-regulation not only at mealtimes, but also in other domains.

Excessive gestational weight gain and emotional eating are positively associated with postpartum depressive symptoms among taiwanese women

BACKGROUND

Excessive gestational weight gain and emotional eating may be associated with postpartum depression symptoms. This study was designed to identify how gestational weight gain and eating behaviors are related to postpartum depression (PPD) symptoms among women in Taiwan.

METHODS

A cross-sectional study was conducted from March 2022 to October 2022 with 318 postpartum women recruited in Taipei, Taiwan. Gestational weight gain (GWG) for the total pregnancy period was recorded as inadequate, adequate, or excessive, based on the 2009 Institute of Medicine recommendations (IOM), accounting for pre-pregnancy body mass index category. Eating behavior at one month postpartum was measured on a 16-item 5-point Likert scale with three subscales: uncontrolled, restrained, and emotional. Maternal depressive symptoms were measured using the Edinburgh Postnatal Depression Scale with a cutoff score of 13.

RESULTS

The prevalence of postpartum depression symptoms (Edinburgh Postnatal Depression Scale ≥ 13) was 23.9% at one month postpartum. Logistic regression analysis revealed that excessive gestational weight gain and emotional eating were positively associated with postpartum depression symptoms at that time.

CONCLUSION

Evidence presented here suggests that emotional eating and excessive GWG are associated with PPD symptoms in a Taiwanese population. In addition, it should be a public health priority to ensure a particular focus on mental health during the postpartum period. Healthcare providers should discourage pregnant women from unhealthy eating habits by targeting appropriate GWG and focusing on demand eating to reduce PPD in the postpartum period.

A Responsive Feeding Questionnaire Based on Self-Determination Theory for Caregivers of Chinese Toddlers

OBJECTIVE

To develop and test the psychometric properties of a responsive feeding questionnaire (RFQ) on the basis of Self-Determination Theory for caregivers of toddlers aged 12-24 months in China.

DESIGN

Item generation, preliminary evaluation items, refinement questionnaire, and psychometric properties testing.

SETTING

Toddlers' caregivers from Shandong Province, China, were surveyed online between June 2021 and February 2022 (n = 616).

MAIN OUTCOME MEASURE

Content, face, and construct validity and reliability of the RFQ.

ANALYSIS

Content validity was performed on the basis of expert panel feedback and cognitive interviews among caregivers. Construct validity was evaluated using principal component analysis with varimax rotation. Test-retest reliability was conducted with a sample of 105 caregivers.

RESULTS

Over 3 phases of testing, a new instrument was developed to measure responsive feeding in toddler caregivers. The instrument was reliable, with an internal consistency of 0.87 and an intraclass correlation of 0.92. The principal component analysis identified a 3-factor solution (autonomy support, positive involvement, appropriate response) aligning with a theoretical framework from Self-Determination Theory. The final version of the instrument included 23 items.

CONCLUSIONS AND IMPLICATIONS

The 23-item RFQ has been validated in a Chinese population. Future research needs to validate this instrument in other countries and with children of different ages.

The trajectories of physical growth in 4 months postnatal corrected age among preterm infants discharged from neonatal intensive care units and associated factors: A prospective study

Objectives

Growth retardation is a risk for premature infants. In addition to demographic and perinatal factors, preterm infants' physical growth may be affected by neonatal intensive care unit (NICU) stress, maternal postpartum depression, and mother-infant interaction. This study aimed to investigate the trajectories of physical growth in 4 months corrected age among preterm infants discharged from the NICU and the impactors on these trajectories.

Methods

A prospective study was conducted among 318 preterm infants from September 2019 to April 2021 in Shanghai, China. Latent growth modeling was applied to identify the weight, length, and head circumference growth trajectories in 4 months corrected age and explore the effects of demographic and medical characteristics, infant stress during NICU stay, maternal postpartum depression, and mother-infant interaction on each trajectory.

Results

Unconditional latent growth models showed curve trajectories with increasingly slower growth in weight, length, and head circumference until 4 months of corrected age. Conditional latent growth models showed that a longer length of stay in the NICU and more skin punctures were negatively associated with weight at 40 weeks corrected gestational age (β = -0.43 and -0.19, respectively, P < 0.05). The maternal postpartum depression between 40 weeks corrected gestational age and 1 month corrected postnatal age was associated with a lower growth rate of length (β = -0.17, P = 0.040), while between 2 and 3 months corrected postnatal age, there were lower growth rates of weight and head circumference (β = -0.15 and -0.19, respectively, P < 0.05). The mother-infant interaction scores between 40 weeks corrected gestational age and 1 month corrected postnatal age negatively predicted the growth rate of weight (β = -0.19, P = 0.020).

Conclusion

The physical growth trajectories of preterm infants discharged from the NICU were influenced by infant stress during the NICU stay, maternal postpartum depression and mother-infant interaction.

Integrative Review of Mental Health and Feeding Styles in Parents of Bottle-Fed Infants

OBJECTIVE

To review the literature regarding the relationship between symptoms of anxiety and depression and feeding styles in parents of bottle-fed infants.

DATA SOURCES

We conducted literature searches in PubMed, CINAHL, Scopus, and PsycINFO.

STUDY SELECTION

We used Covidence systematic review management software during the selection process to allow for full blinding of decisions by team members. Articles were eligible for inclusion if they were reports of primary research, written in English, and focused on the relationship between symptoms of anxiety or depression and feeding styles in parents of term, bottle-fed infants younger than 12 months of age. We placed no restriction on date of publication because of the sparse amount of published literature on this topic. We identified a total of 1,882 articles. After removing duplicates, we screened 988 articles and retained six articles that met criteria for our review.

DATA EXTRACTION

We used Whittemore and Knafl's integrative review methodology to guide data extraction and reporting. We extracted relevant data from all primary data sources and compiled the data into a matrix. We used the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies to assess the quality of the studies.

DATA SYNTHESIS

Using an a priori coding scheme, we summarized the data using categorization of established parental feeding styles in infancy applicable to bottle-feeding. We synthesized the data into two broad categories: responsive and nonresponsive feeding styles.

CONCLUSION

Although research on the topic is limited, our findings suggest that symptoms of postpartum depression may be associated with nonresponsive feeding styles in parents of bottle-fed infants. We suggest several areas for future research and recommend increased emotional and feeding support in practice for parents of bottle-feeding infants.

Timing of Breastfeeding Initiation Mediates the Association between Delivery Mode, Source of Breastfeeding Education, and Postpartum Depression Symptoms

Background: Emergency cesarean section (EMCS) and breastfeeding difficulties increase the risk of postpartum depressive (PPD) symptoms. Early initiation of breastfeeding (EIBF) may not only alleviate PPD symptoms but also facilitate subsequent breastfeeding success. EMCS is a risk factor for not practicing EIBF. Therefore, it is important to understand the relationship between EMCS, EIBF, and PPD symptoms. Methods: We conducted a prospective cohort study in three areas of China. At baseline, a total of 965 mothers completed electronic questionnaires within 72 h postpartum. Women were screened for PPD symptoms using the Edinburgh Postpartum Depression Scale (EPDS). Multivariate logistic regression was used to identify the determinants of PPD symptoms. Mediation analysis was used to determine if EIBF mediated the relationship between delivery mode or breastfeeding education source and PPD symptoms. Results: The prevalence of EIBF was 40.6%; 14% of 965 mothers experienced EMCS, and 20.4% had PPD symptoms. The risk factors for developing PPD symptoms were excessive gestational weight gain (adjusted odds ratio [aOR] = 1.55, confidence interval [95% CI]: 1.03−2.33, p = 0.037) and EMCS (aOR = 2.05, 95% CI: 1.30−3.25, p = 0.002). The protective factors for developing PPD symptoms were monthly household income over CNY 10000 (aOR = 0.68, 95% CI: 0.47−0.97, p = 0.034), EIBF (aOR = 0.49, 95% CI: 0.34−0.72, p < 0.001), and prenatal breastfeeding education from nurses (aOR = 0.46, 95% CI: 0.29−0.73, p = 0.001). EIBF indirectly affected PPD symptoms in patients who had undergone EMCS (percentage mediated [PM] = 16.69, 95% CI: 7.85−25.25, p < 0.001). The source of breastfeeding education through EIBF also affected PPD symptoms (PM = 17.29, 95% CI: 3.80−30.78, p = 0.012). Conclusion: The association between EMCS on PPD symptoms was mediated by EIBF. By providing breastfeeding education, nurses could also help alleviate PPD symptoms.