A systematic review of lay views about infant size and growth

What is normal, healthy growth? Global health, human biology, and parental perspectives

OBJECTIVES

The widespread variation seen in human growth globally stands at odds with the global health perspective that young child growth should not vary across populations if nutritional, environmental and care needs are met. This paper: (1) evaluates the idea that a single standard of "healthy" growth characterizes children under age 5, (2) discusses how variation from this standard is viewed in global health, in human biology and by parents, and (3) explores how views of "normal" growth shape biomedical and parental responses.

METHODS

This paper reviews the anthropological, public health and clinical literature on the nature of child growth and the applicability of World Health Organization Multicenter Growth Reference Study growth standards across contexts.

RESULTS

The considerable variability in child growth across contexts makes it unlikely that any one framework, with issues of sample selection and representativeness, can serve as the model of healthy growth. Global health, human biology and parents differ in the emphasis they place on heredity versus environmental context in understanding this variability, but human biologists and parents tend to view a wider range of growth as "normal." Since both biomedicine and parents base their care decisions on their perceptions of normal, healthy growth, the comparative framework used has important implications for medical treatment and feeding practices.

CONCLUSIONS

A more nuanced approach that incorporates the biology of growth and its association with health outcomes across contexts is critical to identify patterns of healthy growth and to avoid over-reliance on a single standard that may pathologize variability.

A mixed-methods systematic review of patients' experience of being invited to participate in surgical randomised controlled trials

RATIONALE

Randomised controlled trials (RCTs) of surgical interventions are increasing. Such trials encounter challenges that are not present in RCTs of non-surgical interventions because of the nature of the intervention. Several studies have explored patients' experiences of surgical trials to improve recruitment or identify barriers and facilitators to research in this setting. Synthesizing these studies may reveal further insights or confirm whether saturation of relevant themes has been achieved.

OBJECTIVE

This review aimed to understand the experiences of adults who are invited to participate in surgical RCTs.

METHOD

MEDLINE, Web of Science, and CINAHL were searched to identify articles meeting the inclusion criteria. Assessment of quality was conducted with studies given an overall quality rating of good, fair, or poor. A segregated approach was used to synthesize the data. This method included a thematic synthesis of the qualitative data and a narrative review of the quantitative data. The findings of both syntheses were then integrated.

RESULTS

Thirty-four articles reporting 28 trials were included. This review found that the decision to participate in a surgical trial is influenced by multiple factors including patients' individual circumstances and attitudes, and the characteristics of the trial itself. The study identified three themes which encompass both qualitative and quantitative findings. These themes reveal it was important for patients to i) make sense of the trial and trial processes, ii) weigh up the risks and benefits of their different treatment options and participation, and iii) trust the trial and staff.

CONCLUSIONS

A patient-centred approach to trial recruitment may help staff build trusting relationships with patients and address their individual concerns about the trial and the risks and benefits of participation.

Perceptions of Child Body Size and Health Care Seeking for Undernourished Children in Southern Malawi

Child undernutrition affects millions of children globally, but little is known about the ability of adults to detect different types of child undernutrition in low-income countries. We used focused ethnographic methods to understand how Malawian parents and grandparents describe the characteristics they use to identify good and poor child growth, their actual or preferred patterns of health seeking for undernourished children, and the perceived importance of child undernutrition symptoms in relation to other childhood illnesses. Malawians value adiposity rather than stature in assessing child growth. Symptoms of malnutrition, including wasting and edema, were considered the least severe childhood illness symptoms. Parents delayed health care seeking when a child was ill. When they sought care, it was for symptoms such as diarrhea or fever, and they did not recognize malnutrition as the underlying cause. These findings can be used to tailor strategies for preventing and treating growth faltering in Malawian children.

Uncertainty: A little bit not sure. Parental concern about child growth or development

Delays in child growth or development are significant problems for children, their families and population health. Eliciting parental concerns as early as possible to promote child growth and development requires close collaborative working with parents. There is evidence that parents delay expressing concern and that health-care professionals are not always effective at eliciting and attending to parental concerns. The aim of this study was to understand the experiences of parents of preschool children who had expressed a child growth or development concern. An Interpretative Phenomenological Analysis (IPA) study design was used with a purposive sample of parents of 15 preschool children in Ireland. Data were collected by semi-structured interviews and analysed using IPA. One key superordinate theme - Uncertainty - 'a little bit not sure' captured how parents made sense of their concerns about their child's growth and development. In addition to watching, comparing and wondering, parents assessed whether their child could 'do other things' or if something in particular could have caused the growth or development problem. Parents, particularly mothers, grapple with uncertainty associated with unfamiliar cues in the complex and multifaceted nature of child growth and development in their efforts to make sense of what is happening with their child.

Parental perception of premature infant growth and feeding behaviors: use of gestation-adjusted age and assessing for developmental readiness during solid food introduction

BACKGROUND

The extent to which pediatricians inform parents about gestation-adjusted age growth plotting is unclear. Uninformed parents may have decreased satisfaction of infant growth. Subsequent early introduction of solid foods may lead to avoidant feeding behaviors and poor parental perception of infant feeding patterns.

METHODS

Questionnaires regarding infant growth and feeding behaviors were given to parents (n = 76) of premature infants. The Wilcoxon rank-sum and χ(2)/Fisher's exact tests were used.

RESULTS

Uninformed parents were less satisfied with their infant's growth (P < .002). Uninformed parents had more developmentally unready infants at the time of solid food introduction compared with informed parents (P = .03). Significant differences were found in avoidant feeding behaviors and parental perception of infant feeding patterns between developmentally ready and unready infants.

CONCLUSION

Pediatricians should adjust for gestational age when plotting growth and assess for developmental readiness for premature infants when recommending solid foods.

A pragmatic evaluation of a family-based intervention for childhood overweight and obesity

Background

Childhood overweight is unequally distributed by ethnicity and socioeconomic circumstances. Weight management interventions are moderately effective under research conditions. We evaluated the Mind, Exercise, Nutrition, Do it! (MEND) 7–13 programme, a multicomponent family-based intervention for children aged 7–13 years who are overweight or obese. The programme was tested in a randomised controlled trial (RCT) and then delivered at scale under service conditions.

Objectives

The aims of this study were to describe the characteristics of children who take part in MEND, when implemented at scale and under service conditions; assess how the outcomes associated with participation in MEND vary with the characteristics of children (sex, socioeconomic circumstances and ethnicity), MEND centres (type of facility, funding source and programme group size) and areas where children live (in relation to area-level deprivation and the obesogenic environment); examine the cost of providing MEND, per participant, to the NHS and personal social services, including how this varies and how variation in cost is related to variation in outcome; evaluate the salience and acceptability of MEND to those who commission it, those who participate in full, those who participate but drop out and those who might benefit but do not take up the intervention; and investigate what types of costs, if any, are borne by families (and by which members) when participating in MEND, and in sustaining a healthy lifestyle afterwards.

Data and methods

We compared the sociodemographic characteristics of all children referred to MEND (‘referrals’,n = 18,289), those who started the programme (‘starters’,n = 13,998) and those who completed it (‘completers’,n = 8311) with comparable overweight children in England. Associations between participant, programme and neighbourhood characteristics and change in body mass index (BMI) and other outcomes associated with participation in MEND 7–13 were estimated using multilevel models. Economic costs were estimated using published evaluations in combination with service data. We used qualitative methods to explore salience and acceptability to commissioners (n = 27 interviews) and families (n = 23 family interviews and eight individual interviews), and costs to families.

Findings

Less than 0.5% of children eligible for MEND were referred to, participated in or completed the programme. Compared with the MEND-eligible population, proportionally more MEND 7–13 starters and completers were girls, Asian or from families with a lone parent, and lived in social or private rented rather than owner-occupied accommodation, in families where the primary earner was unemployed, and in urban and deprived areas. Compared with the MEND-eligible population, proportionally less MEND 7–13 starters and completers were white or from ‘other’ ethnic groups. Having started the programme, boys and participants who were psychologically distressed, lived in socioeconomically deprived circumstances, or attended large groups or groups whose managers had delivered several programmes were less likely to complete the programme.

Multilevel multivariable models showed that, on average, BMI reduced by 0.76 kg/m2over the period of the programme (10-week follow-up). BMI reduced on average in all groups, but the reduction was greater for boys, as well as children who were of higher baseline BMI, younger, white or living in less socioeconomically deprived circumstances, and for those who attended more sessions and participated in smaller programmes. BMI reductions under service and RCT conditions were of a similar order of magnitude. Reported participant self-esteem, psychological distress, physical activity and diet improved overall and were also moderated by participant-, family-, neighbourhood- and programme-level covariates.

Based on previous studies the cost per programme was around £4000. The mean cost per starter is £463 and the mean cost per completer is £773. The estimated costs varied according to costs associated with local programmes and MEND Central (the organisation which sells MEND interventions to commissioners and delivery partners), and the number of participants per programme.

Commissioners liked the fact that the programme was evidence-informed, involved families and was ‘implementation-ready’. However, recruitment and retention of families influenced their view on the extent to which the programme offered value for money. They wanted longer-term outcome data and had concerns in relation to skills for delivery to diverse populations with complex health and social needs.

At least one individual in every family felt that participation in MEND had been beneficial, but few had managed long-term change. Most families had self-referred via the mother on the basis of weight concerns and/or bullying and anxiety about the transition to secondary school. Exercising with others of a similar build, tips for parents and cooking lessons for children were all valued. Less positively, timings could be difficult for parents and children, who reported competing after-school activities, and feeling tired and hungry. Getting to venues was sometimes difficult. Although families described liking the facilitators who delivered the programme, concerns were expressed about their skills levels. Engagement with the behaviours MEND recommends was challenging, as were the family dynamics relating to support for participants. The costs families mostly associated with the programme were for higher quality food or ‘treats’, time and transport costs, and the emotional cost of making and maintaining changes to lifestyle behaviours generally unsupported by the wider environment.

Considerations

Further research should focus on the sustainability, costs (including emotional costs to families) and cost-effectiveness of behaviour change. However, weight management schemes are only one way that overweight and obese children can be encouraged to adopt healthier lifestyles. We situate this work within a social model of health with reference to inequalities, obesogenic environments, a lifecourse approach and frameworks of translational research.

Funding

The National Institute for Health Research Public Health Research programme.

Excess nutrient supply in early life and its later metabolic consequences

Suboptimal nutrition in early life, both in utero and during infancy, is linked to increased risk of adult obesity and its associated adverse metabolic health problems. Excess nutrient supply during early life can lead to metabolic programming in the offspring. Such overnutrition can occur in the offspring of obese mothers, the offspring of mothers who gain excess weight during gestation, infants of diabetic mothers and infants who undergo rapid growth, particularly weight gain, during early infancy. Postnatal overnutrition is particularly detrimental for infants who are born small for gestational age, who are overfed to attain 'catch-up growth'. Potential mechanisms underlying metabolic programming that results from excess nutrition during early life include resetting of hypothalamic energy sensing and appetite regulation, altered adipose tissue insulin sensitivity and impaired brown adipose tissue function. More detailed understanding of the mechanisms involved in metabolic programming could enable the development of therapeutic strategies for ameliorating its ill effects. Research in this field could potentially identify optimal and appropriate preventative interventions for a burgeoning population at risk of increased mortality and morbidity from obesity and its concomitant metabolic conditions.

"Whatever average is:" understanding African-American mothers' perceptions of infant weight, growth, and health

Biomedical researchers have raised concerns that mothers' inability to recognize infant and toddler overweight poses a barrier to stemming increasing rates of overweight and obesity, particularly among low-income or minority mothers. Little anthropological research has examined the sociocultural, economic or structural factors shaping maternal perceptions of infant and toddler size or addressed biomedical depictions of maternal misperception as a "socio-cultural problem." We use qualitative and quantitative data from 237 low-income, African-American mothers to explore how they define 'normal' infant growth and infant overweight. Our quantitative results document that mothers' perceptions of infant size change with infant age, are sensitive to the size of other infants in the community, and are associated with concerns over health and appetite. Qualitative analysis documents that mothers are concerned with their children's weight status and assess size in relation to their infants' cues, local and societal norms of appropriate size, interactions with biomedicine, and concerns about infant health and sufficiency. These findings suggest that mothers use multiple models to interpret and respond to child weight. An anthropological focus on the complex social and structural factors shaping what is considered 'normal' and 'abnormal' infant weight is critical for shaping appropriate and successful interventions.

'It's on your conscience all the time': a systematic review of qualitative studies examining views on obesity among young people aged 12-18 years in the UK

OBJECTIVE

To explore the perspectives of young people in the UK on obesity, body size, shape and weight.

DESIGN

Systematic review of qualitative studies using thematic synthesis.

DATA SOURCES

Sensitive searches of 18 electronic databases from 1997 to February 2010 supplemented by grey literature searches.

STUDY SELECTION

Studies produced since 1997 using qualitative methods to collect perspectives of people aged 12-18 years in the UK, reporting methods for data collection or analysis. Studies of people with eating disorders and those rated low in reliability and usefulness were excluded.

RESULTS

Searches identified 30 studies involving over 1400 young people from a range of contexts. Young people of all sizes placed considerable emphasis on personal responsibility, and on the social, rather than health implications of being overweight. Young people with experience of obesity described severe, unrelenting, size-related abuse and isolation. Regardless of their own size, young people were judgemental of individuals who were overweight, but those with experience of obesity described an environment that contained multiple barriers to weight loss. Only one study asked young people directly what might support them to have a healthy body size. Study findings were configured under three main themes, labelled with quotes from included studies: general perceptions of size and society's responses ('It's on your conscience all the time'); the experiences of young people who were overweight ('If I had the choice I wouldn't be this size') and these larger young people's experiences of trying to loose weight and suggestions for action ('Make sure, even when it's hard, you've got people there').

CONCLUSIONS

The perspectives of young people in the UK, when synthesised across the spectrum of body sizes, paint a picture of a stigmatising and abusive social world. Research and policy need to engage young people actively so as to address the social implications of obesity.

Psychosocial and educational outcomes of weight faltering in infancy in ALSPAC

OBJECTIVES

To investigate whether infants with weight faltering have impaired psychosocial and educational outcomes in later childhood.

DESIGN

Follow-up of infants with weight faltering in a large UK cohort study.

SETTING

The Avon Longitudinal Study of Parents and Children (ALSPAC).

PARTICIPANTS

11 534 term infants from ALSPAC with complete weight records. Weight gain (conditional on initial weight) was calculated for three periods: from birth to 8 weeks, 8 weeks to 9 months, and birth to 9 months. Cases of weight faltering were defined as those infants with a conditional weight gain below the 5th centile, and these were compared with the rest of the cohort as the control group.

OUTCOMES

Between 6 and 11 years, social, emotional and behavioural development was measured by direct assessment of the children and parental and teacher report. Educational outcomes included Standardised Assessment Test results at 7 and 11 years and Special Educational Needs status at age 11.

RESULTS

Differences seen on univariate analysis in attention, non-verbal accuracy, educational attainment and special educational needs became non-significant after adjustment for confounding. Children with weight faltering in infancy did not differ from controls on any measures of self-esteem, peer relationships, experience of bullying, social cognition, antisocial activities, anxiety, depression or behavioural problems.

CONCLUSIONS

Weight faltering in early infancy was associated with poorer educational outcomes in later childhood, but these associations were explained by confounding. The subsequent psychosocial development of infants with slow weight gain was not different from that of their peers.

Parents' views on child physical activity and their implications for physical activity parenting interventions: a qualitative study

BACKGROUND

Establishing healthy physical activity (PA) behaviours in early childhood is important for future PA behaviours. Parents play a central role in young children's PA. However, there is currently little research on parenting interventions to increase child PA. This study was formative work to inform the content of a pilot randomised-controlled trial.

METHODS

In-depth telephone interviews were carried out with 32 parents of 6 to 8 year old children residing in two areas that varied in their socio-economic characteristics, in Bristol, UK. Data were analysed thematically using a framework approach.

RESULTS

Most parents described their child as being active or very active and indicated that they did not perceive a need for an increase in their child's PA. Parents used a variety of visual cues to make this judgement, the most common being that they perceived their child as having lots of energy or that they did not view them as overweight. Parents reported environmental factors such as monetary cost, time constraints, lack of activity provision and poor weather as the main barriers to their child's PA. Parental support and child's enjoyment of PA appeared to be important facilitators to children participating in PA.

CONCLUSION

Improving parents' knowledge of the PA recommendations for children, and increasing their awareness of the benefits of PA beyond weight status may be an important first step for a parenting PA intervention. Although parents commonly perceive environmental factors as the main barriers to their child's PA, parental concern about low levels of child PA, their capacity to support behaviour change, child motivation, self confidence and independence may be key areas to address within an intervention to increase child PA. Effective methods of helping parents address the latter have been developed in the context of generic parenting programmes.

'Now I understand': consulting parents on chart design and parental information for the UK-WHO child growth charts

BACKGROUND

Regular assessment of growth is an important part of child health surveillance in the UK and most parents are very interested in their child's growth. UK parents are given a personal child health record (PCHR), including growth charts, which are plotted during baby clinic visits. Parents were consulted as part of the process of designing new UK charts to incorporate the World Health Organization growth standard. This paper describes the main themes that emerged and how they influenced the final design.

METHOD

Three sets of consultations with 47 parents were conducted to collect preliminary information, and to evaluate proposed chart designs, instructions and written information for parents.

RESULTS

  At every consultation, the impact of the depiction of the 50th centile line in bold was mentioned spontaneously by parents. They also found aspects of the charts unclear, including the implications of a recorded weight on any particular centile, the difficulty of understanding existing text about charts in the PCHR, their preference for using pounds and ounces rather than metric weights and confusion about how frequently babies should be weighed. This led to the production of parental information including explanation of these issues which were then tested in two further sets of focus groups.

CONCLUSION

Involving parents in the process of designing growth charts and information influenced the finished design and the text in the PCHR. Ensuring information meets parents' needs is important to ensure successful growth monitoring.

Urban parents' perceptions of healthy infant growth

To examine how urban parents' perceptions of healthy infant size and growth relate to objective weight-for-length percentiles of their children, parents of 222 (69% minority) 6- to 27-month-old infants were surveyed. In all, 41% of parents said growth charts had never been explained to them, and 31% were not confident they understood the meaning of chart percentiles. A total of 20% of parents preferred their child weigh ≥75th percentile, and these children had higher mean weight-for-length percentiles than their peers (P = .05). Similarly, 37% of parents agreed that "a chubby baby is a healthy baby," and these children had higher mean weight-for-length percentiles than others in the cohort ( P = .02). Additionally, 58% of parents ranked a growth curve with consistent growth at the 10th percentile as the "least healthy" of 6 infant growth curves. Growth charts are not consistently explained to or understood by urban parents, and many prefer early life growth patterns associated with later obesity.

Levers and barriers to patient-centred care with children: findings from a synthesis of studies of the experiences of children living with type 1 diabetes or asthma

BACKGROUND

The last 50 years have seen a sea change in approaches to health care with children, from a time when children were routinely separated from parents while in hospital, to current recognition of the importance of placing the experiences of children and their families at the heart of care. Yet, there is a gap in the evidence about how children's involvement might be best achieved.This study aimed to synthesize findings of children's experiences of long-term illness and, from this, to identify levers and barriers to patient-centred care with children.

METHODS

A synthesis of studies of the experiences of children living with type 1 diabetes or asthma.

DATA SOURCES

Eight health and social care databases, bibliography searches and consultation with field experts and first authors of included studies.

ELIGIBILITY CRITERIA

Qualitative studies with children 10 years (mean) and younger on their experiences of living with type 1 diabetes or asthma.

MAIN RESULTS

Findings suggest key 'levers' to patient-centred care with children include: (1) engagement with children's expertise about their own lives: their personal and social experiences of their care, including how these are affected by their relative lack of power in some settings; (2) exploring children's understandings and preferences in terms of their physical sensations and day-to-day experiences; (3) willingness to find resources to engage with even the youngest children; (4) avoiding age-based assumptions about children's contributions to their care.

DISCUSSION AND CONCLUSIONS

Action on the above 'levers' may present a range of challenges in healthcare settings not least because it represents a move away from medicine's historical focus on children's developing competencies to engage rather with children's social realities from the earliest ages.

Parent perception of healthy infant and toddler growth

We hypothesized that parents of infants prefer growth at higher percentiles and are averse to growth at lower percentiles. Of 279 participating parents, only 10% desired their child's weight to be in the lowest quartile. For children weighing in the lowest quartile, 57% of parents thought their child's weight was "too low." In contrast, 66% of parents whose child's weight was in the top quartile preferred their child weigh that much. When viewing hypothetical infant growth trajectories, 47% ranked a growth chart demonstrating growth along the 10th percentile for weight as "least healthy" of 6 growth patterns, and 29% chose charts showing an infant at the 90th percentile for weight at age 1 as "healthiest." In conclusion, parents are averse to growth at the bottom of the weight growth chart but are much less likely to feel negatively about growth at higher percentiles. This is troubling given the childhood obesity epidemic.

Why no adult stunting penalty or height premium? Estimates from native Amazonians in Bolivia

Among adults of industrial nations, growth stunting (<-2 SD height Z score) is associated with worse indicators of adult well-being (e.g., income). Does adult stunting also inflict private costs in traditional societies? Adult stunting penalties or height premiums might only emerge when traditional societies modernize. Here we estimate the association between adult stunting and indicators of adult well-being using data from a panel study in progress among the Tsimane', a foraging-farming society of native Amazonians in Bolivia. Subjects included 248 women and 255 men >or=age 22 measured annually during 5 consecutive years (2002-2006). Nine outcomes (wealth, monetary income, illness, access to credit, mirth, schooling, math skills, plant knowledge, forest clearance) were regressed separately against a stunting dummy variable and a wide range of control variables. We found no significant association between any of the indicators of own well-being and adult stunting. Additional analysis showed that stunting bore an association only with poorer mid-arm muscle area. Height premiums and stunting penalties, though evident and marked in modern societies, might not be common in all traditional societies.

Early nutrition and long-term health: a practical approach

Nutrition in early life, a critical period for human development, can have long-term effects on health in adulthood. Supporting evidence comes from epidemiological studies, animal models and experimental interventions in human subjects. The mechanism is proposed to operate through nutritional influences on growth. Substantial evidence now supports the hypothesis that 'accelerated' or too fast infant growth increases the propensity to the major components of the metabolic syndrome (glucose intolerance, obesity, raised blood pressure and dyslipidaemia), the clustering of risk factors that predispose to cardiovascular morbidity and mortality. The association between infant growth and these risk factors is strong, consistent, shows a dose-response effect and is biologically plausible. Moreover, experimental data from prospective randomised controlled trials strongly support a causal link between infant growth and later risk factors for atherosclerosis. Evidence that infant growth affects the development of atherosclerosis therefore suggests that the primary prevention of CVD should begin from as early as the first few months of life. The present review considers this evidence, the underlying mechanisms involved and its implications for public health.

Mothers' experiences of bottle-feeding: a systematic review of qualitative and quantitative studies

OBJECTIVE

Most babies receive at least some formula milk. Variations in formula-feeding practices can have both short- and long-term health consequences. The literature on parents' experiences of bottle-feeding was systematically reviewed to understand how formula-feeding decisions are made.

METHODS

Relevant English-language papers, identified by searching 12 electronic databases, reference lists and related articles and by contacting first authors of included papers, were systematically searched for and appraised. The included studies were analysed and synthesised using a combination of narrative and thematic approaches. Consensus on the final inclusion, interpretation and synthesis of studies was reached across the research team.

RESULTS

Six qualitative studies and 17 quantitative studies (involving 13 263 participants) were included. Despite wide differences in study design, context, focus and quality, several consistent themes emerged. Mothers who bottle-fed their babies experienced negative emotions such as guilt, anger, worry, uncertainty and a sense of failure. Mothers reported receiving little information on bottle-feeding and did not feel empowered to make decisions. Mistakes in preparation of bottle-feeds were common. No studies examined how mothers made decisions about the frequency or quantity of bottle-feeds.

CONCLUSIONS

Inadequate information and support for mothers who decide to bottle-feed may put the health of their babies at risk. While it is important to promote breastfeeding, it is also necessary to ensure that the needs of bottle-feeding mothers are met.

Milk feeding and dietary patterns predict weight and fat gains in infancy

Current guidelines recommend that infants are exclusively breast fed for the first 6 months of life, with particular solid foods being gradually introduced from 6 months. Our objective was to compare the growth of infants whose feeding most closely followed current guidelines with the growth of infants with other feeding practices. Participants were 1740 infants in a prospective cohort study in Southampton, UK. At 6 and 12 months, infants' milk feeding was recorded, diets assessed using food frequency questionnaires (FFQ), and anthropometry performed. Principal components analysis was used to identify patterns of foods in the diet using the food intakes assessed by the FFQs. Two patterns ('infant guidelines' and 'adult foods') explained most variance in infant diet at 6 and 12 months of age. The main outcomes were conditional growth in weight, length and skinfold thickness from 0-6 and 6-12 months. Infants who were breast fed from 0-6 months gained weight, length and adiposity more slowly than formula-fed infants, independent of age at introduction of solids and maternal factors: compared with infants who were breast fed from 0-6 months, formula-fed infants gained 0.21 standard deviation scores (SDS) in weight [95% confidence interval (CI) 0.00, 0.42]. Infants whose dietary pattern was most similar to current feeding guidelines, with high frequencies of fresh fruit and vegetables, home-prepared foods and breast milk, gained weight and skinfold thickness more rapidly from 6 to 12 months than other infants, independent of milk feeding, age at introduction of solids and maternal factors. Compared with infants in the lowest quarter, infants in the highest 'infant guidelines' score quarter gained 0.24 SDS [95% CI 0.06, 0.43] in weight and 0.26 SDS [95% CI 0.07, 0.45] in skinfold thickness. Conversely, infants whose diets had the highest frequencies of breads and processed foods gained weight less rapidly from 6 to 12 months than other infants. The extent to which the patterns of diet and growth we have described will influence the current or later health of infants is unknown. We are following up the infants in this study to assess the impact of these patterns beyond the first year of life. These associations should also be examined in other settings and populations.

The importance of size and growth in infancy: integrated findings from systematic reviews of scientific evidence and lay perspectives

BACKGROUND

Associations between growth and size during infancy and adult disease have led some to recommend that interventions in infancy might benefit lifelong health. Any such recommendations should be informed by both the scientific evidence for relationships between infancy and later outcomes and the views and opinions of those who care for babies.

METHODS

Separate, but interlinked, systematic reviews were conducted of the epidemiological evidence relating infant size or growth to later health and of lay perspectives on infant size and growth. Findings were compared and integrated to consider policy implications.

RESULTS

Lay and scientific perspectives both cast infant growth and size as an indicator of other aspects of an infant's life, rather than being of fundamental importance. While the scientific literature is most often concerned with infants at the extreme ends of the population distribution, and towards long-term outcomes, the literature on lay perspectives suggests a focus on defining the 'normal' range, and on current health.

CONCLUSIONS

Differences and similarities between scientific and lay perspectives on health can highlight areas of agreement, as well as areas of potential misunderstanding or miscommunication.

Confusing terminology attempts to define the undefinable

Perspective on the papers by Olsen et al(see page 109) and Lucas et al(see page 120)

Image or reality: why do infant size and growth matter to parents?

Perspective on the paper by Lucas et al(see page 120)

Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews

BACKGROUND

The inclusion of qualitative studies in systematic reviews poses methodological challenges. This paper presents worked examples of two methods of data synthesis (textual narrative and thematic), used in relation to one review, with the aim of enabling researchers to consider the strength of different approaches.

METHODS

A systematic review of lay perspectives of infant size and growth was conducted, locating 19 studies (including both qualitative and quantitative). The data extracted from these were synthesised using both a textual narrative and a thematic synthesis.

RESULTS

The processes of both methods are presented, showing a stepwise progression to the final synthesis. Both methods led us to similar conclusions about lay views toward infant size and growth. Differences between methods lie in the way they dealt with study quality and heterogeneity.

CONCLUSION

On the basis of the work reported here, we consider textual narrative and thematic synthesis have strengths and weaknesses in relation to different research questions. Thematic synthesis holds most potential for hypothesis generation, but may obscure heterogeneity and quality appraisal. Textual narrative synthesis is better able to describe the scope of existing research and account for the strength of evidence, but is less good at identifying commonality.