Do maternal grandmothers influence breastfeeding duration and infant nutrition? Evidence from Merida, Mexico

OBJECTIVES

Breast-feeding is sensitive to somatic, hormonal, behavioral and psychological components of maternal capital. However, through grandmothering, older women may also influence breast-feeding by transferring informational resources to their daughters. We hypothesized that mothers with prolonged instrumental support from their own mother are more likely to have received advice and to have favorable attitudes/practices regarding breastfeeding, compared to those lacking such support, with implications for the grandchild's somatic capital.

METHODS

We recruited 90 mother-infant dyads (52 with grandmaternal support, 38 without) in Merida, Yucatan, Mexico. All children were first-borns, aged ~2 years. Anthropometry and body composition were assessed. Data on grandmother's breastfeeding advice and maternal breastfeeding duration were obtained by questionnaire. Maternal attitudes to breast-feeding were assessed using the Iowa Infant Feeding Attitude Scale.

RESULTS

Women with instrumental support were more likely to have received grandmaternal advice during pregnancy/infancy on exclusive breast-feeding duration (60% vs. 37%, p = 0.033) and the type of first complementary food (81% vs. 47%, p = 0.001). However, women with support had a less favorable attitude to breastfeeding than those without and breastfed their children for less time (median 5 vs. 10.5 months, p = 0.01). No group differences were found in children's length, weight, skinfolds or lean mass z-score.

DISCUSSION

Although grandmothers providing instrumental support provided advice regarding breastfeeding, their attitudes may reflect issues beyond nutritional health. Advice of maternal grandmothers did not promote extended breastfeeding, however the differences in breastfeeding attitudes were not associated with the children's nutritional status. Grandmothers should be included in public health interventions promoting breastfeeding.

Metabolomic Insights into the Effects of Breast Milk Versus Formula Milk Feeding in Infants

PURPOSE OF REVIEW

This review summarizes the latest scientific evidence for the presence of metabolomic differences between infants fed breast milk (I-BM) and infants fed formula milk (I-FM).

RECENT FINDINGS

Across the studies included in this review, a total of 261 metabolites were analyzed, of which 151 metabolites were reported as significantly associated with infant feeding modality (BM versus FM). However, taken as a whole, the relevant literature was notable both for methodological limitations, such as small sample sizes, and heterogeneity between the studies. This may be why many associations between infant metabolite profile and feeding modality have not replicated across studies. To our knowledge, this is the first review to integrate the available literature on metabolomic differences between I-BM versus I-FM. This narrative review synthesized the data across studies and identified those metabolites which show the most robust associations with infant feeding modality. Methodological limitations of the current studies are identified, followed by recommendations for how to address these in future studies.

Analysis of 'sensitive' periods of fetal and child growth

BACKGROUND

Birth weight and weight gain in infancy and early childhood are commonly studied as risk factors for later cardiometabolic diseases. In this study, we explore methods for quantifying weight gain during different age periods and for comparing the magnitude of the associations with later blood pressure.

METHODS

Based on data from a birth cohort study nested within a large cluster-randomized trial with repeated measures of weight from birth to 16 years of age, we compared the results of four analytic approaches to assess sensitive periods of growth in relation to blood pressure at age 16 years.

RESULTS

Approaches based on z-scores of weight or weight gain velocity (both standardized for age and sex) or on regression-based conditional weight standardized residuals yielded more coherent results than an approach based on absolute weight gain velocity. Weight gain standardized by sex and age was positively associated with blood pressure at 16 years at all postnatal age periods, but the magnitude of association was larger during adolescence (11.5-16 years) than during earlier intervals (0-3 months, 3-12 months, 1-6.5 years or 6.5-11.5 years).

CONCLUSIONS

Standardization of weight and weight gain by age and sex, or regression-based standardized residuals based on conditional weight, reflects relative gain and thus accounts for the rapid weight gains normally observed in early infancy and puberty. Adolescence appears to be a more sensitive period for relative weight gain effects on later blood pressure than earlier periods, even those of similar duration.

Associations of fat mass and fat-free mass accretion in infancy with body composition and cardiometabolic risk markers at 5 years: The Ethiopian iABC birth cohort study

BACKGROUND

Accelerated growth in early childhood is an established risk factor for later obesity and cardiometabolic disease, but the relative importance of fat mass (FM) and fat-free mass (FFM) accretion is not well understood. We aimed to study how FM and FFM at birth and their accretion during infancy were associated with body composition and cardiometabolic risk markers at 5 years.

METHODS AND FINDINGS

Healthy children born at term were enrolled in the Infant Anthropometry and Body Composition (iABC) birth cohort between December 2008 and October 2012 at Jimma University Specialized Hospital in the city of Jimma, Ethiopia. FM and FFM were assessed using air displacement plethysmography a median of 6 times between birth and 6 months of age. In 507 children, we estimated individual FM and FFM at birth and their accretion over 0-3 and 3-6 months of age using linear-spline mixed-effects modelling. We analysed associations of FM and FFM at birth and their accretion in infancy with height, waist circumference, FM, FFM, and cardiometabolic risk markers at 5 years using multiple linear regression analysis. A total of 340 children were studied at the 5-year follow-up (mean age: 60.0 months; girls: 50.3%; mean wealth index: 45.5 out of 100; breastfeeding status at 4.5 to 6 months post-partum: 12.5% exclusive, 21.4% almost exclusive, 60.6% predominant, 5.5% partial/none). Higher FM accretion in infancy was associated with higher FM and waist circumference at 5 years. For instance, 100-g/month higher FM accretion in the periods 0-3 and 3-6 months was associated with 339 g (95% CI: 243-435 g, p < 0.001) and 367 g (95% CI: 250-484 g, p < 0.001) greater FM at 5 years, respectively. Higher FM at birth and FM accretion from 0 to 3 months were associated with higher FFM and cholesterol concentrations at 5 years. Associations for cholesterol were strongest for low-density lipoprotein (LDL)-cholesterol, and remained significant after adjusting for current FM. A 100-g higher FM at birth and 100-g/month higher FM accretion from 0 to 3 months were associated with 0.16 mmol/l (95% CI: 0.05-0.26 mmol/l, p = 0.005) and 0.06 mmol/l (95% CI: 0.01-0.12 mmol/l, p = 0.016) higher LDL-cholesterol at 5 years, respectively. Higher FFM at birth and FFM accretion in infancy were associated with higher FM, FFM, waist circumference, and height at 5 years. For instance, 100-g/month higher FFM accretion in the periods 0-3 and 3-6 months was associated with 1,002 g (95% CI: 815-1,189 g, p < 0.001) and 624 g (95% CI: 419-829 g, p < 0.001) greater FFM at 5 years, respectively. We found no associations of FM and FFM growth with any of the other studied cardiometabolic markers including glucose, HbA1c, insulin, C-peptide, HOMA-IR, triglycerides, and blood pressure. Non-attendance at the 5-year follow-up visit was the main limitation of this study, which may have introduced selection bias and limited the power of the regression analyses.

CONCLUSIONS

FM accretion in early life was positively associated with markers of adiposity and lipid metabolism, but not with blood pressure and cardiometabolic markers related to glucose homeostasis. FFM accretion was primarily related to linear growth and FFM at 5 years.

Exclusive breastfeeding practices in an urban settlement of Vellore, southern India: findings from the MAL-ED birth cohort

Background

Exclusive breastfeeding is recommended in the first six months of life. Observing breastfeeding practices and further the introduction of complementary food using a birth cohort can provide a better understanding with reference to the child's growth and nutrition. We aim to describe the exclusive breastfeeding practices in the Indian MAL-ED birth cohort.

Methods

The Indian MAL-ED (Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health) birth cohort comprises of eight contiguous urban slums in Vellore. Of the 251 children enrolled in the cohort at birth, a 24 month follow-up was completed for 228 children and data collection was from March 2010 through February 2012. Trained field research assistants collected data on exclusive breastfeeding and complementary feeding practices from birth using a structured questionnaire through a biweekly surveillance. Survival and Cox proportional hazard regression analyses were used to estimate the duration of exclusive breastfeeding and factors influencing the same.

Results

Breastfeeding was initiated within the first hour of birth in 148 (59%) infants. Colostrum was given in 225 (89.6%) infants whilst 32 (12.7%) infants received prelacteal feeds. Exclusive breastfeeding up to four months was observed in 55 (22.1%, 95% Confidence Interval [CI] 17.1%, 27.5%) infants with only three (1.1%, 95% CI 0.2%, 3.5%) of the cohort mothers continuing to exclusively breastfeed up to six months. Cox proportional hazard regression analysis revealed no gender differences to being exclusive breastfed (Adjusted Hazard Ratio [AHR] 0.97; 95% CI 0.74, 1.27). Children from families of low socioeconomic status had a lower risk of early cessation of exclusive breastfeeding compared to children from middle or higher socioeconomic status (AHR 0.52; 95% CI 0.38, 0.71).

Conclusions

Early initiation of exclusive breastfeeding is important and improving rates suggest continuation of efforts in this direction energetically. Continuation of exclusive breastfeeding practice is significantly low in these urban slums with introduction of animal milk and complementary foods even before six months of age. This highlights the urgent need to evaluate pragmatic interventions to raise awareness on the importance of exclusive breastfeeding and its practice.

The population-based prevalence of hypertension and correlates of blood pressure among Australian children

OBJECTIVE

Hypertension is increasingly recognized as a disease spanning the entire life course. Continued efforts to refine the diagnosis and management of hypertension in children are highlighted by the recent American Academy of Pediatrics (AAP) guidelines, which include lower threshold values than the previous reference standard (Fourth Report). We aimed to determine the population-based prevalence of children exceeding thresholds for hypertension using these two guidelines. We also sought to identify the correlates of blood pressure (BP) among Australian children.

METHODS

Cross-sectional data from the Growing Up in Australia: Longitudinal Survey of Australian Children were analyzed. Blood pressure was measured in 7139 Australian children aged 10-12 years and sampled using population-based methodology. The association between BP and explanatory variables linked to BP in other populations was examined using multiple linear regression with fractional polynomial terms for continuous, non-linear relationships.

RESULTS

The threshold for hypertension was exceeded in 3.1% and 5.4%, and prehypertension in 3.0% and 3.7% of children, using the Fourth Report and AAP guidelines respectively. Children at the threshold for obesity had a 9.1 mmHg higher adjusted BP than those on the 50th centile for body mass index (BMI) (95% CI 8.4 to 9.9). BMI had a non-linear relationship with BP, and the magnitude of association between BMI and BP increased with BMI. Socioeconomic status, hypertension during pregnancy, birth weight, and sports participation were also independently associated with BP.

CONCLUSIONS

Using the AAP guidelines is likely to substantially increase the population prevalence of hypertension. The association between BMI and BP was strongest and non-linear for obese children, who should be the focus of interventional trials.

Association Between Breastfeeding and Childhood Cardiovascular Disease Risk Factors

Introduction The immediate benefits of breastfeeding are well-established but the long-term health benefits are less well-known. West Virginia (WV) has a higher prevalence of cardiovascular disease (CVD) and lower breastfeeding rates compared to national averages. There is a paucity of research examining the relationship between breastfeeding and subsequent childhood CVD risk factors, an issue of particular relevance in WV. Methods This study used longitudinally linked data from three cross-sectional datasets in WV (N = 11,980). The information on breastfeeding was obtained retrospectively via parental recall when the child was in the fifth grade. The outcome variables included blood pressure measures [systolic blood pressure (SBP), diastolic blood pressure (DBP)] and lipid profile [total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), non-HDL, and triglycerides (TG)]. Multiple regression analyses were performed, adjusting for childhood body mass index (BMI) and additional covariates. Results Only 43% of mothers self-reported ever breastfeeding. The unadjusted analysis showed that children who were ever vs. never breastfed had significantly lower SBP (b = - 1.39 mmHg; 95% CI - 1.97, - 0.81), DBP (b = - 0.79 mmHg; 95% CI - 1.26, - 0.33), log-TG (b = - 0.08; 95% CI - 0.1, - 0.05), and higher HDL (b = 0.95 mg/dL; 95% CI 0.33, 1.56). After adjustment for the child's BMI, socio-demographic and lifestyle factors, log-TG remained significantly associated with breastfeeding (b = - 0.04; 95% CI - 0.06, - 0.01; p = 0.01). Conclusion The observed protective effect of any breastfeeding on childhood TG level was small but significant. This finding provides some support for a protective effect of breastfeeding on later CVD risk.

Infant milk-feeding practices and cardiovascular disease outcomes in offspring: a systematic review

BACKGROUND

During the Pregnancy and Birth to 24 Months Project, the US Departments of Agriculture and Health and Human Services initiated a review of evidence on diet and health in these populations.

OBJECTIVES

The aim of these systematic reviews was to examine the relation of 1) never versus ever feeding human milk, 2) shorter versus longer durations of any human milk feeding, 3) shorter versus longer durations of exclusive human milk feeding, and 4) lower versus higher intensities of human milk fed to mixed-fed infants with intermediate and endpoint cardiovascular disease (CVD) outcomes in offspring.

METHODS

The Nutrition Evidence Systematic Review team conducted systematic reviews with external experts. We searched CINAHL, Cochrane, Embase, and PubMed for articles published January 1980-March 2016, dual-screened the results using predetermined criteria, extracted data from and assessed the risk of bias for each included study, qualitatively synthesized the evidence, developed conclusion statements, and graded the strength of the evidence.

RESULTS

The 4 systematic reviews included 13, 24, 6, and 0 articles, respectively. The evidence was insufficient to draw conclusions about endpoint CVD outcomes across all 4 systematic reviews. Limited evidence suggests that never versus ever being fed human milk is associated with higher blood pressure within a normal range at 6-7 y of age. Moderate evidence suggests there is no association between the duration of any human milk feeding and childhood blood pressure. Limited evidence suggests there is no association between the duration of exclusive human milk feeding and blood pressure or metabolic syndrome in childhood. Additional evidence about intermediate outcomes for the 4 systematic reviews was scant or inconclusive.

CONCLUSIONS

There is insufficient evidence to draw conclusions about the relationships between infant milk-feeding practices and endpoint CVD outcomes; however, some evidence suggests that feeding less or no human milk is not associated with childhood hypertension.

Nutritional status and related factors of schoolchildren in Çorum, Turkey

OBJECTIVE

We aimed to determine nutritional status and related factors among schoolchildren in Çorum, Central Anatolia, Turkey.

DESIGN

Schoolchildren's height and weight were measured to calculate BMI and BMI Z-scores. Height, weight and BMI Z-scores were analysed and nutritional status classified according to the WHO.

SETTING

Central Anatolia, Turkey.ParticipantsSchoolchildren aged 5-17 years (n 1684) participated in study.

RESULTS

Of children, 4·2% were stunted, 6·9% thin, 13·8% overweight and 6·6% were obese. Proportions of stunting, thinness and overweight/obesity were significantly higher in children aged &gt;10 years (78·6, 75·0 and 64·9%, respectively) than in those aged ≤10 years (21·4, 25·0 and 35·1%, respectively; all P &lt;0·001). Median (range) birth weight and breast-feeding duration in children with stunting (2750 (1400-3600)g; 10 (0-36) months) were significantly lower and shorter, respectively, than those of normal height (3200 (750-5500)g; 15 (0-72) months) and tall children (3500 (2500-4900)g; 18 (0-36) months; P &lt;0·001, &lt;0·001, 0·011 and 0·016, respectively). The same relationship was observed in thin children (3000 (1000-4500)g; 12 (0-36) months) compared with normal-weight (3200 (750-5500)g; 15 (0-72) months) and overweight/obese children (3300 (1200-5500)g; 16 (0-48) months; P=0·026, &lt;0·001, 0·045 and 0·011, respectively).

CONCLUSIONS

Overweight and obesity are health problems that must be addressed in schoolchildren. Adolescents also have a risk of double malnutrition. Promoting normal birth weight and encouraging long duration of breast-feeding are important to support normal growth in children.

Infant breastfeeding and childhood general, visceral, liver, and pericardial fat measures assessed by magnetic resonance imaging

Background

Although a longer duration of breastfeeding has been associated with a lower risk of childhood obesity, the impact on specific organ fat depots is largely unknown.

Objective

We examined the associations of any breastfeeding, duration and exclusiveness of breastfeeding, and of age at introduction of solid foods with measures of general, visceral, and organ adiposity at 10 y.

Design

In a population-based prospective cohort study in 4444 children, we obtained information on infant feeding by questionnaires. At the mean age of 9.8 y, we estimated body mass index from height and weight; fat mass index and fat-free mass index by dual-energy X-ray absorptiometry; and visceral fat index, pericardial fat index, and liver fat fraction by MRI. MRI scans were performed in a subgroup of 2646 children.

Results

After adjustment for age and sex, we observed associations of infant feeding with all general, visceral, and organ fat outcomes, except for pericardial fat index, at the age of 10 y. After further adjustment for family-based sociodemographic, maternal lifestyle-related, and childhood factors, only the associations of shorter breastfeeding duration and nonexclusive breastfeeding with a lower fat-free mass index remained significant (P < 0.05). The associations of infant feeding with visceral fat index and liver fat fraction were attenuated to nonsignificant. Maternal education was found to be the strongest confounder.

Conclusion

Our results suggest that the assoiations of any breastfeeding, duration and exclusiveness of breastfeeding, and age at the introduction of solid foods with general, visceral, and organ fat measures at the age of 10 y are largely explained by family-based sociodemographic factors.

Socioeconomic differences in childhood BMI trajectories in Belarus

Objective

To examine associations of parental socioeconomic position with early-life offspring body mass index (BMI) trajectories in a middle-income country.

Subjects

Overall, 12,385 Belarusian children born 1996–97 and enrolled in a randomised breastfeeding promotion trial at birth, with 3–14 measurements of BMI from birth to 7 years.

Methods

Cohort analysis in which exposures were parental education (common secondary or less; advanced secondary or partial university; completed university) and occupation (manual; non-manual) at birth, and the outcome was BMI z-score trajectories estimated using multilevel linear spline models, controlling for trial arm, location, parental BMI, maternal smoking status and number of older siblings.

Results

Infants born to university-educated mothers were heavier at birth than those born to secondary school-educated mothers [by 0.13 BMI z-score units (95% confidence interval, CI: 0.07, 0.19) for girls and 0.11 (95% CI: 0.05, 0.17) for boys; equivalent for an infant of average birth length to 43 and 38 g, respectively]. Between the ages of 3–7 years children of the most educated mothers had larger BMI increases than children of the least educated mothers. At age 7 years, after controlling for trial arm and location,  children of university-educated mothers had higher BMIs than those born to secondary school-educated mothers by 0.11 z-score (95% CI: 0.03, 0.19) among girls and 0.18 (95% CI: 0.1, 0.27) among boys, equivalent to differences in BMI for a child of average height of 0.19 and 0.26 kg/m², respectively. After further controlling for parental BMI, these differences attenuated to 0.08 z-score (95% CI: 0, 0.16) and 0.16 z-score (95% CI: 0.07, 0.24), respectively, but changed very little after additional adjustment for number of older siblings and mother’s smoking status. Associations were similar when based on paternal educational attainment and highest household occupation.

Conclusions

In Belarus, consistent with some middle-income countries, higher socioeconomic position was associated with greater BMI trajectories from age 3 onwards.

Methodological challenges in studying the causal determinants of child growth

Background

Previous studies of early life influences on later growth in childhood have varied in their analytical approaches, particularly with respect to 'adjustment' for differences in size at the beginning of the growth period examined.

Methods

We compared three commonly used statistical models to assess the effect of maternal body mass index (BMI) on growth between 6.5 and 11.5 years in a large cohort of Belarusian children, as follows: (Model 1) analysis of the difference in anthropometric measurements between the two ages; (Model 2) analysis of the measurement at 11.5 years after adjustment for the same measurement at 6.5 years; and (Model 3) analysis of the difference in measurements after adjustment for the measurement at 6.5 years (mathematically identical to Model 2).

Results

Among PROBIT children of obese mothers (BMI ≥ 30 kg/m 2 ) vs those of mothers with normal BMI (18.5 to < 25 kg/m 2 ), Model 1 yielded larger increases in most weight and adiposity outcomes than did Model 2. We show that these larger effects arise because Model 2 parameterizes the effect of maternal BMI twice in same model: once for its effect on size at 6.5 years, and a second time for its effect on growth over the 5-year period between 6.5 and 11.5 years. Similar results were obtained in analogous analyses from cohorts in Boston, MA, and Singapore.

Conclusion

Analysing the effect of exposure on change in outcome between two ages (Model 1) is clearly preferable to 'adjustment' for the outcome at the earlier age whenever the exposure under study affects the outcome at the earlier age.

Projecting the impact of hypothetical early life interventions on adiposity in children living in low-income households

It is difficult to evaluate the effectiveness of interventions aimed at reducing early childhood obesity using randomized trials. Objective To illustrate how observational data can be analysed using causal inference methods to estimate the potential impact of behavioural 'interventions' on early childhood adiposity. Methods We used longitudinal data from 1054 children 1-5 years old enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children and followed (WIC) from 2008 to 2010 for a mean duration of 23 months. The data came from a random sample of WIC families living in Los Angeles County in 2008. We used the parametric g-formula to estimate the impact of various hypothetical behavioural interventions. Results Adjusted mean weight-for-height Z score at the end of follow-up was 0.73 (95% CI 0.65, 0.81) under no intervention and 0.63 (95% CI 0.38, 0.87) for all interventions given jointly. Exclusive breastfeeding for 6 months or longer was the most effective intervention [population mean difference = -0.11 (95% CI -0.22, 0.01)]. Other interventions had little or no effect. Conclusions Compared with interventions promoting healthy eating and physical activity behaviours, breastfeeding was more effective in reducing obesity risk in children aged 1-5 years. When carefully applied, causal inference methods may offer viable alternatives to randomized trials in etiologic and evaluation research.

Modifiable risk factors in the first 1000 days for subsequent risk of childhood overweight in an Asian cohort: significance of parental overweight status

BACKGROUND/OBJECTIVE

Many studies have identified early-life risk factors for subsequent childhood overweight/obesity, but few have evaluated how they combine to influence risk of childhood overweight/obesity. We examined associations, individually and in combination, of potentially modifiable risk factors in the first 1000 days after conception with childhood adiposity and risk of overweight/obesity in an Asian cohort.

METHODS

Six risk factors were examined: maternal pre-pregnancy overweight/obesity (body mass index (BMI) ⩾25 kg m^-2), paternal overweight/obesity at 24 months post delivery, maternal excessive gestational weight gain, raised maternal fasting glucose during pregnancy (⩾5.1 mmol l^-1), breastfeeding duration <4 months and early introduction of solid foods (<4 months). Associations between number of risk factors and adiposity measures (BMI, waist-to-height ratio (WHtR), sum of skinfolds (SSFs), fat mass index (FMI) and overweight/obesity) at 48 months were assessed using multivariable regression models.

RESULTS

Of 858 children followed up at 48 months, 172 (19%) had none, 274 (32%) had 1, 244 (29%) had 2, 126 (15%) had 3 and 42 (5%) had ⩾4 risk factors. Adjusting for confounders, significant graded positive associations were observed between number of risk factors and adiposity outcomes at 48 months. Compared with children with no risk factors, those with four or more risk factors had s.d. unit increases of 0.78 (95% confidence interval 0.41-1.15) for BMI, 0.79 (0.41-1.16) for WHtR, 0.46 (0.06-0.83) for SSF and 0.67 (0.07-1.27) for FMI. The adjusted relative risk of overweight/obesity in children with four or more risk factors was 11.1(2.5-49.1) compared with children with no risk factors. Children exposed to maternal pre-pregnancy (11.8(9.8-13.8)%) or paternal overweight status (10.6(9.6-11.6)%) had the largest individual predicted probability of child overweight/obesity.

CONCLUSIONS

Early-life risk factors added cumulatively to increase childhood adiposity and risk of overweight/obesity. Early-life and preconception intervention programmes may be more effective in preventing overweight/obesity if they concurrently address these multiple modifiable risk factors.

Age at adiposity rebound and body mass index trajectory from early childhood to adolescence; differences by breastfeeding and maternal immigration background

OBJECTIVE

This paper aims to assess association between breastfeeding and maternal immigration background and body mass index development trajectories from age 2 to 16 years.

METHODS

A cohort of children born in Stockholm during 1994 to 1996 was followed from age 2 to 16 years with repeated measurement of height and weight at eight time points (n = 2278). Children were categorized into groups by breastfeeding status during the first 6 months of life and maternal immigration background. Body mass index (BMI) trajectories and age at adiposity rebound were estimated using mixed-effects linear models.

RESULTS

Body mass index trajectories were different by breastfeeding and maternal immigration status (P-value < 0.0001). Compared with exclusively breastfed counterparts, never/short breastfed children of Swedish mothers had a higher BMI trajectory, whereas never/short breastfed children of immigrant mothers followed a lower BMI trajectory. Ages at adiposity rebound were earlier for higher BMI trajectories regardless of maternal immigration background.

CONCLUSION

Differences in BMI trajectories between offspring of immigrant and of Swedish mothers suggest a lack of beneficial association between breastfeeding and long-term BMI development among children of immigrant mothers. Given the relation between long-term BMI development and risk of overweight/obesity, these differences challenge the notion that exclusive breastfeeding is always beneficial for children's BMI development and subsequent risk of overweight/obesity.

Programming maternal and child overweight and obesity in the context of undernutrition: current evidence and key considerations for low- and middle-income countries

The goals of the present targeted review on maternal and child overweight and obesity were to: (i) understand the current situation in low- and middle-income countries (LMIC) with regard to recent trends and context-specific risk factors; and (ii) building off this, identify entry points for leveraging existing undernutrition programmes to address overweight and obesity in LMIC. Trends reveal that overweight and obesity are a growing problem among women and children in LMIC; as in Ghana, Kenya, Niger, Sierra Leone, Tanzania and Zimbabwe, where the prevalence among urban women is approaching 50 %. Four promising entry points were identified: (i) the integration of overweight and obesity into national nutrition plans; (ii) food systems (integration of food and beverage marketing regulations into existing polices on the marketing of breast-milk substitutes and adoption of policies to promote healthy diets); (iii) education systems (integration of nutrition into school curricula with provision of high-quality foods through school feeding programmes); and (iv) health systems (counselling and social and behaviour change communication to improve maternal diet, appropriate gestational weight gain, and optimal infant and young child feeding practices). We conclude by presenting a step-by-step guide for programme officers and policy makers in LMIC with actionable objectives to address overweight and obesity.

Maternal excess gestational weight gain and infant waist circumference: a 2-y observational study

BACKGROUND

The purpose of this study was to examine the effects of gestational weight gain (GWG) and infant feeding practices on infant growth parameters in infants from 6 to 24 mo of age.

METHODS

Forty mother-infant pairs were recruited after delivery and followed up to 24 mo postpartum. GWG was calculated as prepregnancy weight subtracted from weight at delivery. Infant weight velocity was calculated as the change in weight between consecutive visits divided by the intervening time. Infant feeding practices were measured by interview and infant growth and waist circumference by standard anthropometry.

RESULTS

Infants born to mothers with excess GWG were heavier at birth (3,521 ± 91 vs. 3,196 ± 97 g, P = 0.02) and had an average 2.16 ± 1.1 cm (P = 0.03) larger waist circumference throughout the 24 mo compared with infants born to mothers with appropriate GWG. Waist circumference increased by 0.12 and 2.0 cm for every 1 unit increase in GWG and infant birth weight.

CONCLUSION

Infants born to women who exceeded the Institute of Medicine (IOM)-recommended guidelines for GWG were heavier at birth and had a significantly higher waist circumference up to 2 y of age. Strategies to control maternal excess GWG and thus the outcome on infant birth weight and waist circumference should be pursued.

Influence of early-life and parental factors on childhood overweight and obesity

PURPOSE

We recently reported that a high BMI and high waist circumference prevalence is present in Sicilian children and that the male gender is associated with a significant risk of obesity. Early-life and parent-related risk factors were investigated 1521 Sicilian children (752 females and 769 males, aged 9.0-14.0 years) to identify biological and environmental factors that can contribute to obesity onset.

METHODS

Anthropometric measurements of children, their urban vs rural area provenience, birth weight and neonatal feeding were collected. In addition, the BMI and educational level of their parents and the perception of their child weight status were investigated.

RESULTS

In the study cohort, the prevalence of overweight and obesity was 27.2 and 14.1 %, respectively, significantly (p < 0.05) higher in males than in females. Breastfeeding emerged as a protective factor (OR 0.64; p < 0.0005), while risk factors for developing childhood obesity were a birth weight ≥4.0 kg (OR 1.83; p < 0.05), an overweight or obese mother (OR 2.33; p < 0.0001) or father (OR 1.68; p < 0.0001) and a mother with a low/medium education level (OR 1.72; p < 0.005).

CONCLUSION

Understanding risk factors for pediatric obesity is a prerequisite to identify children at highly risk of being obese and to predispose early intervention strategies.

Predictors of blood pressure at 7-13 years: The "new millennium baby" study

BACKGROUND AND AIMS

The purpose of this study is to evaluate the association between blood pressure (BP) at 7-13 years of age and body mass index (BMI), early feeding, lifestyle indicators, and parental characteristics.

METHODS AND RESULTS

Retrospective plus cross-sectional cohort study was started in 1294 children born in 2000-2004, right from their birth in primary care settings. Early feeding was estimated by measuring breast-feeding (BF) duration, complementary feeding (CF) introduction time, and lifestyle indicators such as daily screen time and weekly extracurricular sports activity time. Parental education, smoking, and obesity-related diseases were also considered. Multivariable linear regression and mediation analysis were used. CF introduction at 5-6 months of age was a negative predictor of systolic and diastolic BP (mean systolic BP-standard deviation score (SDS) -0.38 [95% CI: -0.47, -0.29] (p < 0.001); mean diastolic BP-SDS -0.32 [95% CI: -0.40, -0.24]) (p < 0.001); BMI was a positive predictor of systolic and diastolic BP (p < 0.001); and parental hypertension was a positive predictor of diastolic BP (p < 0.05). Predictors of mean BMI-SDS at 7-13 years of age were birth weight, screen time, and parental obesity and smoking (p < 0.001). BF had no effect on BP or BMI. Mediation analysis showed virtually no indication of the effect of CF on BP mediated by BMI.

CONCLUSIONS

CF introduction between 5 and 6 months of age could be associated with low BP at 7-13 years. The effect of CF on BP seems to be independent of BMI. Low screen time is associated with low BMI. CF time may play a role in the occurrence of surrogates of noncommunicable disorders in future.

Effects of an exclusive breastfeeding intervention for six months on growth patterns of 4-5 year old children in Uganda: the cluster-randomised PROMISE EBF trial

Background

Breastfeeding promotion is regarded as one of the most effective interventions to improve child health, and could reduce under-5-mortality by 8 % globally. Few studies have assessed the health outcomes beyond infancy of interventions promoting exclusive breastfeeding.

Methods

This study assessed growth in under-five children who participated in a cluster-randomised trial in Eastern Uganda (ClinicalTrials.gov.no.NCT00397150). In the intervention arm, peer counsellors promoted exclusive breastfeeding during the first 6 months of infancy. There were no interventions after 6 months of age. Mother-infant pairs were interviewed at visits scheduled at 3, 6, 12 and 24 weeks after birth and follow-up visits at 2 and 5 years, with 765 included in the analyses.

Results

The mean length/height-for-age and weight-for-age-z-score (HAZ, WAZ) decreased with increasing age in both the intervention and control arms. At the three weeks visit, HAZ in the intervention was −0.45 (−0.68;−0.21) and −0.32 (−0.56;−0.07) in the control arm. At the 2 year follow-up, the mean HAZ in the intervention was −1.85 (95 % CI −1.97;−1.73) compared to −1.61 (−1.87;−1.34) in the control. Similarly, at the 5 year follow-up, the mean HAZ in the intervention was −1.78 (−2.08;−1.47) compared to −1.53 (−1.79;−1.28) in the control arm. At the 2 year follow-up visit, 139 (45 %) were stunted (HAZ<−2) in the intervention compared to 109 (37 %) in the control arm, odds ratio (OR) 1.7 (1.1;2.4). Underweight (WAZ<−2) was also more common in the intervention arm than in the control at the five years follow-up (OR 1.7 (1.0;2.8)), with a mean WAZ of −1.28 (−1.47;−1.08) and −1.06 (−1.19;−0.92) in the intervention and control arm, respectively.

Conclusion

While stunting was widespread at 2 and 5 years of age in both arms, it was more common in the intervention arm. It is questionable whether community-based support from lay people with short training and focussing only on exclusive breastfeeding, is an appropriate strategy to improve child health and development.

Trial registration

ClinicalTrials.gov.no.NCT00397150. Registered 7th of November 2006.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3234-3) contains supplementary material, which is available to authorized users.

BReastfeeding Attitude and Volume Optimization (BRAVO) trial: study protocol for a randomized controlled trial

BACKGROUND

A growing body of evidence shows the short-term benefits of breastfeeding, which include protection against infections, allergies, and lung diseases. However, evidence on the long-term benefits of breastfeeding is scarce and often conflicting. The BReastfeeding Attitude and Volume Optimization (BRAVO) trial is designed to study the effect of breastfeeding on early signs of later chronic diseases, particularly cardiovascular, respiratory, and metabolic risks later in life. In addition, the effectiveness of breastfeeding empowerment in promoting breastfeeding will also be evaluated.

METHODS/DESIGN

This study is an ongoing randomized trial in Jakarta, Indonesia, that began in July 2012. Pregnant women are being screened for their breastfeeding plan in the third trimester, and those with low intention to breastfeed are randomly allocated to either receiving an add-on breastfeeding-optimization program or usual care. Primary outcomes include breastfeeding rate, lung function, and blood pressure during the first year of life and vascular/cardiac characteristics, which will be measured at the age of 4 to 5 years. Child growth and infection/illness episodes are measured, whereas cognitive testing is planned for the children at 5 years of age.

DISCUSSION

To date, 784 women (80 %) have been randomized of the 1,000 planned, with satisfactory completeness of the 1-year follow up (90.1 %). Included mothers are of lower socioeconomic status and more often have blue-collar jobs, similar to what was observed in the pilot study.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01566812 . Registered on 27 March 2012.

Risk Factors for Childhood Obesity in the First 1,000 Days: A Systematic Review

CONTEXT

Mounting evidence suggests that the origins of childhood obesity and related disparities can be found as early as the "first 1,000 days"-the period from conception to age 2 years. The main goal of this study is to systematically review existing evidence for modifiable childhood obesity risk factors present from conception to age 2 years.

EVIDENCE ACQUISITION

PubMed, Embase, and Web of Science were searched for studies published between January 1, 1980, and December 12, 2014, of childhood obesity risk factors present during the first 1,000 days. Prospective, original human subject, English-language research with exposure occurrence during the first 1,000 days and with the outcome of childhood overweight or obesity (BMI ≥85th percentile for age and sex) collected between age 6 months and 18 years were analyzed between December 13, 2014, and March 15, 2015.

EVIDENCE SYNTHESIS

Of 5,952 identified citations, 282 studies met inclusion criteria. Several risk factors during the first 1,000 days were consistently associated with later childhood obesity. These included higher maternal pre-pregnancy BMI, prenatal tobacco exposure, maternal excess gestational weight gain, high infant birth weight, and accelerated infant weight gain. Fewer studies also supported gestational diabetes, child care attendance, low strength of maternal-infant relationship, low SES, curtailed infant sleep, inappropriate bottle use, introduction of solid food intake before age 4 months, and infant antibiotic exposure as risk factors for childhood obesity.

CONCLUSIONS

Modifiable risk factors in the first 1,000 days can inform future research and policy priorities and intervention efforts to prevent childhood obesity.

A narrative review of the associations between six bioactive components in breast milk and infant adiposity

OBJECTIVE

This narrative review examines six important non-nutritive substances in breast milk, many of which were thought to have little to no biological significance. The overall objective is to provide background on key bioactive factors in breast milk believed to have an effect on infant outcomes (growth and body composition).

METHODS

The evidence for the effects of the following six bioactive compounds in breast milk on infant growth outcomes are reviewed: insulin, leptin, adiponectin, ghrelin, interleukin-6, and tumor necrosis factor-α.

RESULTS

The existing literature on the effects of breast milk insulin, ghrelin, interleukin-6, and tumor necrosis factor-α and their associations with infant growth and adiposity is sparse. Of the bioactive compounds reviewed, leptin and adiponectin are the most researched. Data reveal that breast milk adiponectin has negative associations with growth in infancy.

CONCLUSIONS

There is a need for innovative, well-designed studies to improve causal inference and advance our understanding in the effects of breast milk and its components on offspring growth and body composition. The recommendations provided, along with careful consideration of both known and unknown factors that affect breast milk composition, will help improve, standardize, and ultimately advance this emergent field.

Interventions for Childhood Obesity in the First 1,000 Days A Systematic Review

CONTEXT

The "first 1,000 days"-conception through age 24 months-are critical for the development and prevention of childhood obesity. This study systematically reviews existing and ongoing interventions during this period, identifies gaps in current research, and discusses conceptual frameworks and opportunities for future interventions.

EVIDENCE ACQUISITION

PubMed, Embase, Web of Science, and ClinicalTrials.gov were searched to identify completed and ongoing interventions implemented during pregnancy through age 24 months that aimed to prevent overweight/obesity between ages 6 months and 18 years. English-language, controlled interventions published between January 1, 1980 and December 12, 2014, were analyzed between December 13, 2014 and March 15, 2015.

EVIDENCE SYNTHESIS

Of 34 completed studies from 26 unique identified interventions, nine were effective. Effective interventions focused on individual- or family-level behavior changes through home visits, individual counseling or group sessions in clinical settings, a combination of home and group visits in a community setting, and using hydrolyzed protein formula. Protein-enriched formula increased childhood obesity risk. Forty-seven ongoing interventions were identified. Across completed and ongoing interventions, the majority target individual- or family-level changes, many are conducted in clinical settings, and few target early-life systems and policies that may impact childhood obesity.

CONCLUSIONS

Obesity interventions may have the greatest preventive effect if begun early in life. Yet, few effective interventions in the first 1,000 days exist, and many target individual-level behaviors of parents and infants. Interventions that operate at systems levels and are grounded in salient conceptual frameworks hold promise for improving future models of early-life obesity prevention.

Development and evaluation of an intervention for the prevention of childhood obesity in a multiethnic population: the Born in Bradford applied research programme

Background

There is an absence of evidence about interventions to prevent or treat obesity in early childhood and in South Asian populations, in whom risk is higher.

Objectives

To study patterns and the aetiology of childhood obesity in a multiethnic population and develop a prevention intervention.

Design

A cohort of pregnant women and their infants was recruited. Measures to compare growth and identify targets for obesity prevention, sensitive to ethnic differences, were collected. A feasibility randomised controlled trial (RCT) was undertaken.

Setting

Bradford, UK.

Participants

A total of 1735 mothers, 933 of whom were of South Asian origin.

Intervention

A feasibility trial of a group-based intervention aimed at overweight women, delivered ante- and postnatally, targeting key modifiable lifestyle behaviours to reduce infant obesity.

Main outcome measures

The feasibility and acceptability of the pilot intervention.

Data sources

Routine NHS data and additional bespoke research data.

Review methods

A systematic review of diet and physical activity interventions to prevent or treat obesity in South Asian children and adults.

Results

Routine measures of growth were accurate. The prevalence of risk factors differed between mothers of white British ethnicity and mothers of Pakistani ethnicity and weight and length growth trajectories differed between Pakistani infants and white British infants. Prediction equations for risk of childhood obesity were developed. An evidence-based intervention was evaluated in a pilot RCT and was found to be feasible and acceptable.

Limitations

This was a single-centre observational study and a pilot evaluation.

Conclusions

The programme has been successful in recruiting a unique multiethnic childhood obesity cohort, which has provided new evidence about modifiable risk factors and biethnic growth trajectories. A novel group-based behavioural change intervention has been developed and successfully piloted. A multisite cluster RCT is required to evaluate effectiveness.

Trial registration

Current Controlled Trials ISRCTN56735429.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Evaluating the efficacy of breastfeeding guidelines on long-term outcomes for allergic disease

BACKGROUND

WHO guidelines advocate breastfeeding for 6 months, and EAACI guideline recommends exclusive breastfeeding for 4-6 months. However, evidence for breastfeeding to prevent asthma and allergic disease is conflicting. We examined whether following recommended breastfeeding guidelines alters the long-term risks of asthma, eczema, rhinitis or atopy.

METHODS

The effect of nonexclusive (0, >0-6, >6 months) and exclusive breastfeeding (0, >0-4, >4 months) on repeated measures of asthma (10, 18 years), eczema, rhinitis, and atopy (1-or-2, 4, 10, 18 years) risks was estimated in the IoW cohort (n = 1456) using log-linear models with generalized estimating equations. The Food Allergy and Intolerance Research (FAIR) cohort (n = 988), also from the IoW, was examined to replicate results.

RESULTS

Breastfeeding (any or exclusive) had no effect on asthma and allergic disease in the IoW cohort. In the FAIR cohort, any breastfeeding for >0-6 months protected against asthma at 10 years (RR = 0.50, 95% CI = 0.32-0.79, P = 0.003), but not other outcomes, whilst exclusive breastfeeding for >4 months protected against repeated rhinitis (RR = 0.36, 95% CI = 0.18-0.71, P = 0.003). Longer breastfeeding was protective against late-onset wheeze in the IoW cohort.

CONCLUSION

The protective effects of nonexclusive and exclusive breastfeeding against long-term allergic outcomes were inconsistent between these colocated cohorts, agreeing with previous observations of heterogeneous effects. Although breastfeeding should be recommended for other health benefits, following breastfeeding guidelines did not appear to afford a consistent protection against long-term asthma, eczema, rhinitis or atopy. Further research is needed into the long-term effects of breastfeeding on allergic disease.

Infant emotional distress, maternal restriction at a home meal, and child BMI gain through age 6years in the Colorado Adoption Project

Infant temperament and parental feeding practices may be risk factors for childhood obesity, however most studies have relied upon parent-report assessments. We tested whether infant emotional distress and maternal restrictive feeding at 12-months of age, assessed observationally at a home feeding interaction, predicted child BMI through age 6years. We conducted a prospective observational study of 86 children (34 girls and 52 boys, from 55 adoptive and 31 non-adoptive families) enrolled in the Colorado Adoption Project. Mother-infant feeding interactions were video-recorded during a home snack or meal at year 1, and child anthropometrics (length or height, and weight) were assessed at years 1 through 6. The main outcome measures were child weight-for-length at year 1 and body mass index (BMI: kg/m(2)) at years 2-6. Results of generalized linear models indicated that greater infant emotional distress at 12-months predicted greater increases in child weight status through age 6years, B=0.62 and odds ratio (OR)=1.87. In separate analyses, restrictive feeding interacted with child sex in predicting weight status trajectories (p=.012). Male infants whose mothers displayed any compared to no restriction at year 1 showed a downward BMI trajectory from 2 to 6years; for female infants, exposure to any compared to no restriction prompts predicted increasing BMI from 4 to 6years. In sum, early obesity prevention strategies should pay greater attention to infant temperament, especially distress and negative affect, and how parents respond to such cues. Additionally, 'responsive feeding' strategies that provide an alternative to restriction warrant greater research during infancy.

Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review

The Baby-friendly Hospital Initiative (BFHI) is a key component of the World Health Organization/United Nations Children's Fund Global Strategy for Infant and Young Child Feeding. The primary aim of this narrative systematic review was to examine the impact of BFHI implementation on breastfeeding and child health outcomes worldwide and in the United States. Experimental, quasi-experimental and observational studies were considered eligible for this review if they assessed breastfeeding outcomes and/or infant health outcomes for healthy, term infants born in a hospital or birthing center with full or partial implementation of BFHI steps. Of the 58 reports included in the systematic review, nine of them were published based on three randomized controlled trials, 19 followed quasi-experimental designs, 11 were prospective and 19 were cross-sectional or retrospective. Studies were conducted in 19 different countries located in South America, North America, Western Europe, Eastern Europe, South Asia, Eurasia and Sub-Saharan Africa. Adherence to the BFHI Ten Steps has a positive impact on short-term, medium-term and long-term breastfeeding (BF) outcomes. There is a dose-response relationship between the number of BFHI steps women are exposed to and the likelihood of improved BF outcomes (early BF initiation, exclusive breastfeeding (EBF) at hospital discharge, any BF and EBF duration). Community support (step 10) appears to be essential for sustaining breastfeeding impacts of BFHI in the longer term.

Best (but oft-forgotten) practices: sensitivity analyses in randomized controlled trials

A randomized controlled clinical trial is the best way to minimize bias in ascertaining treatment effects, but the credibility of the results of a trial depends on the validity of the methods used to analyze the data, and the conditions under which such methods produce valid answers. A sensitivity analysis is a method to determine the robustness of trial findings by examining the extent to which results are affected by changes in methods, models, values of unmeasured variables, or assumptions. The goal of a sensitivity analysis is to identify results that are most dependent on questionable or unsupported assumptions. In this article, we briefly review the current use of sensitivity analyses in a random sample of published nutrition literature and provide a guide on the use of sensitivity analyses in randomized trials as to when to consider them, what to consider when planning them, and different methods of implementing them. We propose an 8-step strategy for improving the approach to conducting and reporting sensitivity analyses in nutrition-based trials.

Breastfeeding is associated with waist-to-height ratio in young adults

Background

The current study investigated the association between breastfeeding and adult weight distribution using an emerging indicator of weight distribution, the waist-to-height ratio (WHtR).

Methods

The study sample consisted of two subsamples of individuals that were part of the National Longitudinal Study of Adolescent Health. One sample (n = 1 179) consisted of individuals from the sibling pair data. A second sample (n = 4 648) consisted of individuals that were not part of the paired data. Regression models were constructed to establish if there was a relationship between breastfeeding and two measures of weight distribution: WHtR and body mass index (BMI). Controls for parental socioeconomic status, maternal smoking, race, sex, age, birth weight, maternal BMI, genetic ancestry, and a genetic risk score (GRS) for obesity were included. In addition, a behavioral risk score (BRS) was constructed to control for other residual confounding factors.

Results

A significant, inverse relationship between breastfeeding and adult WHtR persisted in models constructed from the sibling pair sample (P = 0.002) and unrelated sample (P <0.0001). This association remained significant with the inclusion of ancestry principal components, GRS, and a measure of maternal obesity.

Conclusions

The moderate association between breastfeeding and weight distribution persists into adulthood while controlling for potential confounders. This paper also provides evidence that the WHtR may be a superior outcome measure to BMI in studies investigating breastfeeding and obesity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2611-7) contains supplementary material, which is available to authorized users.

Effect of breastfeeding promotion interventions on child growth: a systematic review and meta-analysis

AIM

To update a previous systematic review and meta-analyses about the effect of breastfeeding promotion interventions on child growth.

METHODS

Studies evaluating the effect of any type of breastfeeding promotion intervention on child weight, length (or height) and weight/height (or BMI) were screened. Papers published between 2006 and 2014 were checked using the following databases: PubMed/MEDLINE, Embase, Cochrane Database of Systematic Reviews, Lilacs and SciELO.

RESULTS

Sixteen studies were added to 19 other studies identified in the previous review, resulting in 35 studies. Meta-analyses of studies reporting on mean weight, length, weight/length or BMI showed that the interventions had no impact on weight or length/height z scores [pooled effect: 0.03 (95% confidence interval: -0.06;0.12) and 0.03 (95% confidence interval: -0.02;0.08), respectively] and had a modest, but significant, reduction in body mass index/weight-for-height z scores [z score mean difference: -0.06 (95% confidence interval: -0.12;0.00)], which was limited to studies from low- and high-incomes settings. For all three outcomes, there was important heterogeneity among studies, which should be taken into account when interpreting the results.

CONCLUSION

Breastfeeding promotion interventions were not associated with significant changes in weight or length, but led to a modest, albeit significant, reduction in body mass index/weight-for-height z scores.

The evaluation of risk factors for recurrent hospitalizations resulting from wheezing attacks in preschool children

BACKGROUND

We aimed to evaluate the risk factors in preschool children admitted to inpatient services with a diagnosis of recurrent attacks of wheezing.

METHOD

The medical files of 44 preschool children with 2 or more recurrent hospitalizations resulting from wheezing between November 2011 and January 2012 were retrospectively investigated.

RESULTS

There were 28 males (64 %) and 16 females. The median age was 14 months (2.0-50). The median numbers of previous wheezing attacks and hospitalizations were 4 (2-10) and 2 (2-8), respectively. Fourteen patients (32 %) had been treated for gastroesophageal reflux (GER). The previous and recent hospital evaluations were investigated. Bronchopulmonary dysplasia and anemia were significantly more common in patients with 3 or more hospitalizations for wheezing than in those with 2 hospitalizations (p = 0.010 and p < 0.001, respectively). A review of the cases with 3 or more hospitalizations revealed that a history of GER and anemia were significant risk factors.

CONCLUSION

Anemia and GER are risk factors for recurrent hospitalizations resulting from wheezing and should be treated. If the history and physical examination suggest asthma, inhaler therapy treatment should be administered, with other investigations planned for patients who do not respond to treatment as expected.

Epidemiology of elevated blood pressure and associated risk factors in Chinese children: the SNEC study

Despite the association of childhood blood pressure (BP) with hypertension later in the life course, there remains dearth of information regarding the prevalence and emergence of hypertension in children, especially in China. To investigate the current status of BP, prevalence of elevated BP and related factors in Chinese children, a cross-sectional survey in a representative sample of 9354 Chinese children 5-17 years old was conducted in seven cities in Northeastern China during 2011 and 2012. BP measurements were taken by mercury sphygmomanometer. Elevated BP in children was defined as an average diastolic BP or systolic BP that is in the 95th percentile or higher for their gender, age and height. Overall, total prevalence of elevated BP was 13.8%, and no significant difference between males and females was identified. Multivariate analyses revealed that children having a higher area of residence had a lower of elevated BP. Increased odds for elevated BP were found for individuals who were lean (odds ratio (OR)=2.12; 95% confidence interval (CI): 1.67-2.69), overweight (OR=2.05; 95% CI: 1.74-2.42), obese (OR=3.15; 95% CI: 2.70-3.68), were born with low birth weight (OR=1.26; 95%CI: 1.01-1.63), premature birth (OR=1.46; 95%CI: 1.13-1.88), and were with home coal use (OR=1.24; 95%CI: 1.02-1.52). In conclusion, elevated BP was found to be prevalent in children in urban areas of Northeast China. These results underscore the importance of implementing a package of measures aimed at reducing malleable risk for this cardiovascular condition in school-aged children in Northeast China.

Association between breastfeeding and body mass index at age 6-7 years in an international survey

BACKGROUND

Breastfeeding is believed to reduce children's risk for obesity but data are conflicting. It is also uncertain if breastfeeding has different effects on obesity in high- and low-income countries.

OBJECTIVES

This study aimed to investigate the association between having been breastfed and body mass index (BMI) in 6- to 7-year-old children in a large international survey.

METHODS

Parents/guardians reported whether their child had been breastfed and their current height and weight. Some centres measured height and weight directly. Analyses adjusted for whether height and weight were reported or measured, child's age, sex, country gross national income and centre.

RESULTS

Data were available for 76,635 participants from 31 centres in 18 countries. Reported breastfeeding rates varied from 27 to 98%. After adjusting for potential confounders, the estimated BMI difference was 0.04 kg m(-2) lower among those who had been breastfed (P = 0.07). The risk for being overweight or obese was slightly lower among breastfed children (odds ratio = 0.95, P = 0.012). There was no evidence that the association between breastfeeding and BMI was different in lower income countries compared with higher income countries.

CONCLUSIONS

The findings suggest that breastfeeding has little impact on children's BMI. Increasing breastfeeding is unlikely to reduce the global epidemic of childhood obesity.

The Effect of a Pro-Breastfeeding and Healthy Complementary Feeding Intervention Targeting Adolescent Mothers and Grandmothers on Growth and Prevalence of Overweight of Preschool Children

Introduction

The pattern and duration of breastfeeding (BF) and the age at onset of complementary feeding, as well as its quality, have been associated with the prevalence of overweight in childhood.

Objective

To assess the effect of a pro-BF and healthy complementary feeding intervention, targeted to adolescent mothers and maternal grandmothers, on growth and prevalence of overweight and obesity in children at preschool age. This intervention had a positive impact on duration of BF and timing of onset of complementary feeding.

Methods

This randomized clinical trial involved 323 adolescent mothers, their infants, and the infants’ maternal grandmothers, when they cohabited. Mothers and grandmothers in the intervention group received counseling sessions on BF and healthy complementary feeding at the maternity ward and at home (7, 15, 30, 60, and 120 days after delivery). When children were aged 4 to 7 years, they underwent anthropometric assessment and collection of data on dietary habits. Multivariable Poisson regression with robust estimation was used for analysis.

Results

BMI-for-age and height-for-age were similar in the intervention and control groups, as was the prevalence of overweight (39% vs. 31% respectively; p=0.318). There were no significant between-group differences in dietary habits.

Conclusion

Although the intervention prolonged the duration of exclusive BF and delayed the onset of complementary feeding, it had no impact on growth or prevalence of overweight at age 4 to 7 years.

Trial Registration

ClinicalTrials.gov NCT00910377

The Early Childhood Obesity Prevention Program (ECHO): an ecologically-based intervention delivered by home visitors for newborns and their mothers

BACKGROUND

Obesity is a major problem in the United States, particularly among socio-economically disadvantaged Latino and Black children. Effective interventions that can be disseminated to large numbers of at-risk children and their families are needed. The goals of the Early Childhood Obesity Prevention Program (ECHO) are to examine the 12-month efficacy of a primary obesity prevention program targeting the first year of life that is delivered by home visitors and that engages mothers as agents of change to modify their own behavior and their infant's behavior through education and skill-building around nutrition, physical activity, and wellness, and then "echoes" her training with linkages to neighborhood programs and resources.

METHODS/DESIGN

Six family centers located in low-income neighborhoods in Hartford, CT were randomized into control and intervention neighborhoods. Fifty-seven mothers were recruited either prenatally or shortly after delivery into the Nurturing Families Network home visitation program; 27 lived in a control neighborhood and received the standard home visitation program and 30 lived in an intervention neighborhood and received both the standard home visitation program and the ECHO intervention. The intervention increases maternal skills in goal-setting, stimulus control and problem-solving, engages family members to support changes, links mothers to neighborhood resources and is embedded in the standard home visitation program. ECHO targets include breastfeeding, solids, juice and sugar-sweetened beverages, routines for sleep and responding to infant cues, television/screen time, and maternal diet and physical activity. We hypothesize that infants in ECHO will have been breastfed longer and exclusively, will have delayed introduction of solids and juice, have longer sleep duration, decreased television/screen time and a lower weight for length z-score at 12 months, and their mothers will have greater fruit and vegetable consumption and higher levels of physical activity.

DISCUSSION

ECHO will provide important information about whether an enhanced behavior change curriculum integrated into an existing home visitation program, focused on the mother as the agent of change and linked to neighborhood resources is effective in changing energy balance behaviors in the infant and in the mother. If effective, the intervention could be widely disseminated to prevent obesity in young children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02052518 January 30, 2014.

The timing of solid introduction in an 'obesogenic' environment: a narrative review of the evidence and methodological issues

OBJECTIVE

To evaluate the evidence for association between obesity risk outcomes >12 months of age and timing of solid introduction in healthy term infants in developed countries, the large majority of whom are not exclusively breastfed to six months of age.

METHODS

Studies included were published 1990 to March 2013.

RESULTS

Twenty-six papers with weight status or obesity prevalence outcomes were identified. Studies were predominantly cohort design, most with important methodological limitations. Ten studies reported a positive association. Of these, only two were large, good-quality studies and both examined the outcome of early (<4 months) introduction of solids. None of the four good-quality studies that directly evaluated current guidelines provided evidence of any clinically relevant protective effect of solid introduction from 4-5 versus ≥6 months of age.

CONCLUSION

The introduction of solids prior to 4 months of age may result in increased risk of childhood obesity but there is little evidence of adverse weight status outcomes associated with introducing solids at 4-6 rather than at six months.

IMPLICATIONS

More and better quality evidence is required to inform guidelines on the 'when, what and how' of complementary feeding.

Does Breastfeeding Protect Against Childhood Obesity? Moving Beyond Observational Evidence

Human milk is the optimal feeding choice for infants, as it dynamically provides the nutrients, immunity support, and other bioactive factors needed for infants at specific stages during development. Observational studies and several meta-analyses have suggested that breastfeeding is protective against development of obesity in childhood and beyond. However, these findings are not without significant controversy. This review includes an overview of observational findings to date, then focuses on three specific pathways that connect human milk and infant physiology: maternal obesity, microbiome development in the infant, and the development of taste preference and diet quality. Each of these pathways involves complex interactions between mother and infant, includes both biologic and non-biologic factors, and may have both direct and indirect effects on obesity risk in the offspring. This type of integrated approach to examining breastfeeding and childhood obesity is necessary to advance research in this area beyond observational findings.

Childhood obesity: Current and novel approaches

The prevalence of childhood obesity has increased over the last fifty years by approximately 5% per decade, and approximately a quarter of all children are now either overweight or obese. These children have a significantly increased risk of many future health problems including adult obesity, type 2 diabetes and heart disease. Despite this relentless increase, common-sense approaches aimed at prevention and treatment have failed to solve the problem. Current approaches at prevention have faced major challenges with some progress in implementing smaller scale programs and social marketing, but little action on broad public policy approaches which often appears unpalatable to society or individual governments. Meanwhile, treatment approaches have mainly focused on lifestyle change, and novel approaches are urgently needed. Prevention needs to shift to improving maternal health prior to conception, with more research focussed on the impact of early years in programming offspring to future overweight/obesity. Likewise, treatment paradigms need to move from simply thinking that obesity can be solved by readdressing diet and activity levels. Novel approaches are needed which take into consideration the complex physiology which regulates early childhood growth and the development of obesity in susceptible individuals.

Growth trajectories in early childhood, their relationship with antenatal and postnatal factors, and development of obesity by age 9 years: results from an Australian birth cohort study

BACKGROUND

In an era where around one in four children in the United Kingdom, the United States, and Australia are overweight or obese, the development of obesity in early life needs to be better understood. We aimed to identify groups of children with distinct trajectories of growth in infancy and early childhood, to examine any association between these trajectories and body size at age 9, and to assess the relative influence of antenatal and postnatal exposures on growth trajectories.

DESIGN

Prospective Australian birth cohort study.

SUBJECTS AND METHODS

In total, 557 children with serial height and weight measurements from birth to 9 years were included in the study. Latent class growth models were used to derive distinct groups of growth trajectories from birth to age 3½ years. Multivariable logistic regression models were used to explore antenatal and postnatal predictors of growth trajectory groups, and multivariable linear and logistic regression models were used to examine the relationships between growth trajectory groups and body size at age 9 years.

RESULTS

We identified four discrete growth trajectories from birth to age 3½ years, characterised as low, intermediate, high, or accelerating growth. Relative to the intermediate growth group, the low group had reduced z-body mass index (BMI) (-0.75 s.d.; 95% confidence interval (CI) -1.02, -0.47), and the high and accelerating groups were associated with increased body size at age 9 years (high: z-BMI 0.70 s.d.; 95% CI 0.49, 0.62; accelerating: z-BMI 1.64 s.d.; 95% CI 1.16, 2.11). Of the antenatal and postnatal exposures considered, the most important differentiating factor was maternal obesity in early pregnancy, associated with a near quadrupling of risk of membership of the accelerating growth trajectory group compared with the intermediate growth group (odds ratio (OR) 3.72; 95% CI 1.15, 12.05).

CONCLUSIONS

Efforts to prevent childhood obesity may need to be embedded within population-wide strategies that also pay attention to healthy weight for women in their reproductive years.

Systematic review to identify and appraise outcome measures used to evaluate childhood obesity treatment interventions (CoOR): evidence of purpose, application, validity, reliability and sensitivity

BACKGROUND

Lack of uniformity in outcome measures used in evaluations of childhood obesity treatment interventions can impede the ability to assess effectiveness and limits comparisons across trials.

OBJECTIVE

To identify and appraise outcome measures to produce a framework of recommended measures for use in evaluations of childhood obesity treatment interventions.

DATA SOURCES

Eleven electronic databases were searched between August and December 2011, including MEDLINE; MEDLINE In-Process and Other Non-Indexed Citations; EMBASE; PsycINFO; Health Management Information Consortium (HMIC); Allied and Complementary Medicine Database (AMED); Global Health, Maternity and Infant Care (all Ovid); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); Science Citation Index (SCI) [Web of Science (WoS)]; and The Cochrane Library (Wiley) - from the date of inception, with no language restrictions. This was supported by review of relevant grey literature and trial databases.

REVIEW METHODS

Two searches were conducted to identify (1) outcome measures and corresponding citations used in published childhood obesity treatment evaluations and (2) manuscripts describing the development and/or evaluation of the outcome measures used in the childhood intervention obesity evaluations. Search 1 search strategy (review of trials) was modelled on elements of a review by Luttikhuis et al. (Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev 2009;1:CD001872). Search 2 strategy (methodology papers) was built on Terwee et al.'s search filter (Terwee CB, Jansma EP, Riphagen II, de Vet HCW. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res 2009;18:1115-23). Eligible papers were appraised for quality initially by the internal project team. This was followed by an external appraisal by expert collaborators in order to agree which outcome measures should be recommended for the Childhood obesity Outcomes Review (CoOR) outcome measures framework.

RESULTS

Three hundred and seventy-nine manuscripts describing 180 outcome measures met eligibility criteria. Appraisal of these resulted in the recommendation of 36 measures for the CoOR outcome measures framework. Recommended primary outcome measures were body mass index (BMI) and dual-energy X-ray absorptiometry (DXA). Experts did not advocate any self-reported measures where objective measurement was possible (e.g. physical activity). Physiological outcomes hold potential to be primary outcomes, as they are indicators of cardiovascular health, but without evidence of what constitutes a minimally importance difference they have remained as secondary outcomes (although the corresponding lack of evidence for BMI and DXA is acknowledged). No preference-based quality-of-life measures were identified that would enable economic evaluation via calculation of quality-adjusted life-years. Few measures reported evaluating responsiveness.

LIMITATIONS

Proposed recommended measures are fit for use as outcome measures within studies that evaluate childhood obesity treatment evaluations specifically. These may or may not be suitable for other study designs, and some excluded measures may be more suitable in other study designs.

CONCLUSIONS

The CoOR outcome measures framework provides clear guidance of recommended primary and secondary outcome measures. This will enhance comparability between treatment evaluations and ensure that appropriate measures are being used. Where possible, future work should focus on modification and evaluation of existing measures rather than development of tools de nova. In addition, it is recommended that a similar outcome measures framework is produced to support evaluation of adult obesity programmes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Does breastfeeding help to reduce the risk of childhood overweight and obesity? A propensity score analysis of data from the KiGGS study

BACKGROUND

Current studies suggest that the beneficial effect of breastfeeding on overweight and obesity may have been largely overestimated. We examined the relationship between >4 months of full breastfeeding and overweight/obesity in children living in Germany.

METHODS

We analyzed retrospectively collected data on breastfeeding from children aged 3-17 years who participated in the German Health Interview and Examination Survey for Children and Adolescents (KiGGS baseline study) between 2003 and 2006 (n = 13163). To minimize confounding, we applied propensity score matching and multivariate logistic regression analyses to estimate the effect of breastfeeding on childhood overweight and obesity.

RESULTS

Adjusted analyses of the matched dataset (n = 8034) indicated that children who were breastfed for >4 months had a significant reduction in the odds of overweight (OR 0.81 [95% CI 0.71–0.92]) and obesity (OR 0.75 [95% CI 0.61–0.92]) compared to children who were not breastfed or who were breastfed for a shorter duration [corrected].Further analyses stratified by age group showed that the association was strongest in children aged 7-10 years (OR 0.67 [95% CI 0.53-0.84] for overweight and OR 0.56 [95% CI 0.39-0.81] for obesity), while no significant effect could be seen in other age groups.

DISCUSSION

Our findings support the hypothesis that breastfeeding does have a beneficial effect on childhood overweight and obesity, although the effect seems to be strongest in children of primary school age.

The relationship between early life modifiable risk factors for childhood obesity, ethnicity and body mass index at age 3 years: findings from the Born in Bradford birth cohort study

Background

Many modifiable risk factors in early infancy have been shown to be associated with childhood overweight and obesity. These risk factors have not been studied within children of South Asian origin in the UK. The aims of this paper are to describe differences in the prevalence of modifiable risk factors for childhood obesity between children of White British and Pakistani origin and investigate the association between these risk factors and childhood BMI measured at age 3 years. We used data from a sub-study of the Born in Bradford birth cohort with detailed follow-up visits throughout early childhood. 987 participants with a BMI measurement at age 3 were included; 39% were White British, 48% were of Pakistani origin and 13% were of other ethnicities. Linear and Poisson regression models were used to assess the association between risk factors and two outcomes at age 3; BMI z-scores and child overweight.

Results

Compared to Pakistani mothers, White British mothers were more likely to smoke during pregnancy, have higher BMI, breastfeed for a shorter duration and wean earlier, while Pakistani mothers had higher rates of gestational diabetes and were less active. There was no strong evidence that the relationship between risk factors and BMI z-score differed by ethnicity. There were associations between BMI z-score and maternal smoking (mean difference in BMI z-score 0.33 (95% CI 0.13, 0.53)), maternal obesity (0.37 (0.19, 0.55)), indulgent feeding style (0.15 (−0.06, 0.36)), lower parental warmth scores (0.21 (0.05, 0.36)) and higher parental hostility scores (0.17 (0.01, 0.33)). Consistent associations between these risk factors and child overweight were found. Mean BMI and the relative risk of being overweight were lower in children of mothers with lower parental self-efficacy scores and who watched more hours of TV. Other risk factors (gestational diabetes, child diet, child sleep, child TV viewing and maternal physical activity) were not associated with BMI.

Conclusions

Whilst the prevalence of risk factors that have been associated with childhood greater BMI differ between White British and Pakistani the magnitude of their associations with BMI are similar in the two groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s40608-015-0037-5) contains supplementary material, which is available to authorized users.

Anti-obesogenic effects of calcium prevent changes in the GLP-1 profile in adult rats primed by early weaning

SCOPE

Gut peptides regulate appetite and adipogenesis. Early weaning (EW) leads to later development of obesity that can be prevented by calcium supplementation. We evaluated gut peptides that may have a role in the establishment of this dysfunction.

METHODS AND RESULTS

At birth, lactating Wistar rats were separated in: EW, lactating rats involved with a bandage interrupting the lactation during the last 4 days of standard lactation, and C (control) dams whose pups had free access to milk during throughout lactation. At 120 days old, half of EW group received calcium supplementation (EWCa); EW and C received standard diet. At 21 days old, EW presented higher glucagon-like peptide 1 (GLP-1) in plasma and glucagon-like peptide 1 receptor (GLP1-R) in adipose tissue and hypothalamus, but lower GLP-1 and GLP1-R in the gut. At 180 days old, GLP-1 response to food intake was blunted in EW and restored by calcium. GLP-1 in the gut was lower in EW and its receptor was lower in adipose tissue, and GLP1-R was higher in the gut of calcium EW group.

CONCLUSION

Thus, EW had short- and long-term effects upon GLP-1 profile, which may have contributed to obesity development, hyperphagia, and insulin resistance due to its adipogenic and appetite control roles. Calcium supplementation was able to prevent most of the changes in GLP-1 caused by EW.

Weighing the Evidence of Common Beliefs in Obesity Research

Obesity is a topic on which many views are strongly held in the absence of scientific evidence to support those views, and some views are strongly held despite evidence to contradict those views. We refer to the former as "presumptions" and the latter as "myths." Here, we present nine myths and 10 presumptions surrounding the effects of rapid weight loss; setting realistic goals in weight loss therapy; stage of change or readiness to lose weight; physical education classes; breastfeeding; daily self-weighing; genetic contribution to obesity; the "Freshman 15"; food deserts; regularly eating (versus skipping) breakfast; eating close to bedtime; eating more fruits and vegetables; weight cycling (i.e., yo-yo dieting); snacking; built environment; reducing screen time in childhood obesity; portion size; participation in family mealtime; and drinking water as a means of weight loss. For each of these, we describe the belief and present evidence that the belief is widely held or stated, reasons to support the conjecture that the belief might be true, evidence to directly support or refute the belief, and findings from randomized controlled trials, if available. We conclude with a discussion of the implications of these determinations, conjecture on why so many myths and presumptions exist, and suggestions for limiting the spread of these and other unsubstantiated beliefs about the obesity domain.

Satiety responsiveness and the relationship between breastfeeding and weight status of toddlers of overweight and obese women

Numerous studies indicate an association between breastfeeding and decreased toddler adiposity. The mechanism behind this association is still unknown. One possibility is that children who are breastfed may have increased responsiveness to internal satiety cues. This study assessed the effect of satiety responsiveness on the association between breastfeeding and weight status among toddlers. We conducted a secondary analysis of data from 428 toddlers aged 2 years. Mothers' body mass index (BMI) and children's BMI z score were calculated from measured height and weight. Mothers completed a detailed breastfeeding survey and the satiety responsiveness subscale of the Child Eating Behaviour Questionnaire. Multiple linear regression and logistic regression were used to determine if satiety responsiveness mediated the effect of breastfeeding on BMI z score or overweight/obesity (BMI ≥ 85th percentile). Establishment of breastfeeding was associated with decreased BMI z score (0.40 vs. 0.60; p = 0.04), and increased breastfeeding intensity was associated with lower odds of overweight/obesity (OR 0.97, p = 0.04). Satiety responsiveness was not associated with either breastfeeding measures, suggesting it does not play a meditational role in the relationship between breastfeeding and toddler weight status. Furthermore, a relationship between satiety responsiveness and obesity does not exist after controlling for well-known confounders. This study did not find a mediation effect of satiety responsiveness on the association between breastfeeding and weight status in toddlers. More research is needed to characterize satiety responsiveness and its influence on the relationship between breastfeeding and childhood obesity.

Optimal treatment of replicate measurements in anthropometric studies

BACKGROUND

Anthropometric studies often include replicates of each measurement to decrease error. The optimal method to combine these measurements is uncertain.

AIM

To identify the optimal method to combine replicate measures for analysis.

METHODS

The authors carried out 10 000 Monte Carlo simulations to explore the effect of six approaches to combine replicate measurements in a hypothetical two-group intervention study (n = 100 per arm) in which the outcome, infant length at age 1 year, was measured two or three times. One group had a true value with a normal distribution N (mean = 76, SD = 2.4 cm). Statistical power was estimated to detect a 1 cm difference between the groups, based on a t-test.

RESULTS

Under a realistic scenario with a measurement error distribution N (0, 0.8), highest power was reached by use of the mean and the median of pairwise averages. However, when a portion of the data (≥2%) were contaminated by greater error (e.g. due to data entry), the median of three measurements outperformed all other methods while the mean had the lowest performance.

CONCLUSION

Obtaining three rather than two measures and using the median of the three replicates is a safe and robust approach to combine participants' raw data values for use in subsequent analyses.