Kristen M. Hurley

Maternal depression and early childhood growth in developing countries: systematic review and meta-analysis

OBJECTIVE To investigate the relationship between maternal depression and child growth in developing countries through a systematic literature review and meta-analysis. METHODS Six databases were searched for studies from developing countries on maternal depression and child growth published up until 2010. Standard meta-analytical methods were followed and pooled odds ratios (ORs) for underweight and stunting in the children of depressed mothers were calculated using random effects models for all studies and for subsets of studies that met strict criteria on study design, exposure to maternal depression and outcome variables. The population attributable risk (PAR) was estimated for selected studies. FINDINGS Seventeen studies including a total of 13,923 mother and child pairs from 11 countries met inclusion criteria. The children of mothers with depression or depressive symptoms were more likely to be underweight (OR: 1.5; 95% confidence interval, CI: 1.2-1.8) or stunted (OR: 1.4; 95% CI: 1.2-1.7). Subanalysis of three longitudinal studies showed a stronger effect: the OR for underweight was 2.2 (95% CI: 1.5-3.2) and for stunting, 2.0 (95% CI: 1.0-3.9). The PAR for selected studies indicated that if the infant population were entirely unexposed to maternal depressive symptoms 23% to 29% fewer children would be underweight or stunted. CONCLUSION Maternal depression was associated with early childhood underweight and stunting. Rigorous prospective studies are needed to identify mechanisms and causes. Early identification, treatment and prevention of maternal depression may help reduce child stunting and underweight in developing countries.

A Systematic Review of Responsive Feeding and Child Obesity in High-Income Countries

Child overweight/obesity continues to be a serious public health problem in high-income countries. The current review had 3 goals: 1) to summarize the associations between responsive feeding and child weight status in high-income countries; 2) to describe existing responsive feeding measures; and 3) to generate suggestions for future research. Articles were obtained from PubMed and PsycInfo using specified search criteria. The majority (24/31) of articles reported significant associations between nonresponsive feeding and child weight-for-height Z-score, BMI Z-score, overweight/obesity, or adiposity. Most studies identified were conducted exclusively in the United States (n = 22), were cross-sectional (n = 25), and used self-report feeding questionnaires (n = 28). A recent trend exists toward conducting research among younger children (i.e. infants and toddlers) and low-income and/or minority populations. Although current evidence suggests that nonresponsive feeding is associated with child BMI or overweight/obesity, more research is needed to understand causality, the reliability and validity between and within existing feeding measures, and to test the efficacy of responsive feeding interventions in the prevention and treatment of child overweight/obesity in high-income countries.

Variation in breastfeeding behaviours, perceptions, and experiences by race/ethnicity among a low-income statewide sample of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants in the United States

The objective of this study was to examine how breastfeeding behaviours, perceptions and experiences vary by race/ethnicity among a low-income sample in the USA. Bilingual interviewers conducted a cross-sectional telephone survey of 767 white, African American or Hispanic mothers who received the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Rates of breastfeeding initiation and duration varied by race/ethnicity. Hispanic mothers were more likely to initiate breastfeeding than African American (91% vs. 65%) or white (61%) mothers. Hispanic mothers breastfed longer (mean 5 months) than either African American (mean 3.5 months) or white (mean 3 months) mothers. The most common reason for not breastfeeding was fear of difficulty or pain during breastfeeding (35.6%). Among mothers who did not initiate breastfeeding, African American and white mothers were more likely than Hispanic mothers to report perceptions of breastfeeding difficulty or pain, and Hispanic mothers were more likely than African American and white mothers to report perceptions of infant breast rejection. The most common reason reported for breastfeeding cessation was not having enough milk (23.4%). Hispanic mothers were more likely than African American and white mothers to cite perceptions of milk insufficiency and infant breast refusal than concerns regarding breast discomfort or pain. African American mothers were more likely than white mothers to report cessation to return to work. In conclusion, while breastfeeding initiation rates approach Healthy People 2010 goals, breastfeeding duration remains far below these goals. Race/ethnicity differences in experiences related to breastfeeding cessation suggest that culturally sensitive breastfeeding interventions are necessary.

The Healthy Eating Index and Youth Healthy Eating Index Are Unique, Nonredundant Measures of Diet Quality among Low-Income, African American Adolescents

Chronic disease is related to poor diet quality. The Healthy Eating Index (HEI) was developed to assess diet quality. The Youth HEI (YHEI) is an adaptation of the HEI for use with children and adolescents. The objectives were to compare HEI and YHEI scores among adolescents at risk for chronic disease and to compare associations between the scores and health indicators. This cross-sectional study included 2 low-income, urban African American adolescent samples (Challenge, n = 196; Three Generation, n = 121). HEI and YHEI scores were calculated from a FFQ and compared with BMI, body composition, and micronutrient, energy, and dietary intakes. YHEI scores were lower than HEI scores across both adolescent samples (Challenge, 48.94 +/- 9.31 vs. 62.83 +/- 11.75; Three Generation, 47.08 +/- 9.65 vs. 59.93 +/- 11.27; P < 0.001). Females (64.47 +/- 11.70) had higher HEI scores than males (61.15 +/- 11.61) (P < 0.05), but there was no gender difference in YHEI scores. HEI and YHEI scores were associated with higher micronutrient and total energy intakes (r = 0.19-0.76; P < 0.05). Higher percent body/abdominal fat was associated with lower HEI scores (r = -0.17 to -0.19; P < 0.05) but not with YHEI scores. BMI was not associated with either HEI or YHEI scores. In conclusion, many adolescents were consuming diets that placed them at risk for developing chronic disease. Although both the HEI and YHEI are useful in assessing diet quality, the HEI is inversely associated with body composition, a predictor of chronic disease, and accounts for gender differences in the Dietary Guidelines, whereas the YHEI discounts nutrient-poor, energy-dense foods.

Low-income, African American Adolescent Mothers and Their Toddlers Exhibit Similar Dietary Variety Patterns

OBJECTIVE To examine the relationship between maternal and toddler dietary variety. DESIGN Longitudinal; maternal and toddler dietary data were collected at 13 months; anthropometry was collected at 13 and 24 months. SETTING Data were collected in homes. PARTICIPANTS 109 primiparous, low-income, African American adolescent mothers and toddlers. MAIN OUTCOME MEASURES Maternal and toddler dietary variety and toddler obesity at 24 months. ANALYSIS Correlations were computed to estimate associations between maternal and toddler dietary variety at 13 months; multiple logistic regression analyses were conducted to estimate associations between maternal and toddler diet and toddler growth. RESULTS Maternal and toddler fruit, vegetable, snack, meat, dairy, and soda variety were significantly correlated. There was no association between maternal and toddler dietary variety and obesity at 24 months. Adolescent mothers who purchased groceries consumed more fruits and vegetables and provided more variety for their toddlers than those who relied on others to purchase groceries. CONCLUSIONS AND IMPLICATIONS Adolescent mothers and toddlers exhibited similar dietary patterns; consuming more sweets and less fruits and vegetables than recommended. Toddlerhood is an optimal time to address healthful dietary patterns and to help adolescent mothers influence grocery purchasing decisions. Goals are to establish healthful dietary patterns and reduce pediatric obesity.

Iron deficiency and iron-deficiency anemia in the first two years of life: strategies to prevent loss of developmental potential

This article examines the association of iron deficiency (ID) and iron deficiency anemia (IDA) with childrens development and behavior, with the goal of providing recommendations to prevent the developmental loss associated with these conditions. Childrens risk for ID and IDA is particularly high during the second 6 months of life when prenatal stores are depleted. Longitudinal studies from infancy through adolescence and early adulthood suggest that socioemotional development is uniquely vulnerable to ID and IDA, perhaps being associated with shared neural pathways, and the effects of early iron deficiencies may be irreversible. In addition to direct effects on brain function, ID and IDA may also affect child development indirectly through non-responsive mother-child interactions. Maternal ID is a global problem that may contribute to high rates of maternal depression and non-responsive caregiving. Intervention trials illustrate that children benefit from both nutritional intervention and early learning interventions that promote responsive mother-child interactions. Recommendations to reduce the developmental loss associated with ID and IDA are to reduce the incidence of these conditions by efforts to prevent premature birth, delay cord clamping, ensure adequate maternal iron status, provide iron-rich complementary foods, and ensure access to postnatal interventions that promote responsive mother-infant interaction patterns and early learning opportunities for infants.

Nutrition and maternal, neonatal, and child health

This article reviews the central role of nutrition in advancing the maternal, newborn, and child health agenda with a focus on evidence for effective interventions generated using randomized controlled trials in low- and middle-income countries (LMIC). The 1000 days spanning from conception to 2 years of life are a critical period of time when nutritional needs must be ensured; failure to do so can lead to adverse impacts on short-term survival as well as long-term health and development [corrected]. The burden of maternal mortality continues to be high in many under-resourced settings; prenatal calcium supplementation in populations with low intakes can reduce the risk of pre-eclampsia and eclampsia morbidity and mortality and is recommended, and antenatal iron-folic acid use in many countries may reduce anemia, a condition that may be an underlying factor in postpartum hemorrhage. Sufficient evidence exists to promote multiple micronutrient supplementation during pregnancy to reduce fetal growth restriction and low birth weight. Early initiation of breastfeeding (within an hour), exclusive breastfeeding in the first 6 months of life, and vitamin A supplementation in the first few days of life in Asia (but not in Africa) reduce infant mortality. Biannual large-dose vitamin A supplements to children 6-59 months of age and zinc for treatment of diarrhea continue to be important strategies for improving child health and survival. Early nutrition and micronutrient status can influence child development but should be integrated with early responsive learning interventions. Future research is needed that goes beyond the 1000 days to ensure adequate preconceptional nutrition and health, with special emphasis on adolescents who contribute to a large proportion of first births in many LMIC. Thus, we make the case for integrating proven nutrition interventions with those for health in pregnant women, and with those for health and child development in neonates, infants, and young children to help advance the global MNCH agenda.

Stability of maternal depressive symptoms among urban, low-income, African American adolescent mothers

BACKGROUND Maternal depressive symptomatology is an important public health issue with negative consequences for both mothers and infants. METHODS This study examined prevalence and patterns of depressive symptoms among 181 urban, low-income, first-time, African American adolescent mothers recruited from urban hospitals following delivery. Follow-up evaluations were conducted at 6 (N=148; 82%) and 24 (N=147; 81%) month home visits. Depressive symptoms were measured with Beck Depression Inventory (BDI). RESULTS Half of mothers (49%) had BDI scores >9 at baseline, with significant correlations between BDI scores across all visits (r=0.28-0.50). Depressive symptom trajectories analyzed using group-based trajectory modeling revealed three trajectories of depressive symptoms: Low (41%), Medium (45%), and High (14%). The high depressive symptom group reported lower self-esteem, more negative life events, and lower parenting satisfaction than the low and moderate depressive symptoms groups. LIMITATIONS Depressive symptoms were self-reported and not verified with a clinical interview. Findings are limited to urban, low-income, African American adolescent mothers and may not be generalizable to other populations. CONCLUSIONS The high prevalence and relative stability of depressive symptoms through 2years of parenting suggest the need for early identification and treatment of maternal depressive symptoms. Brief screening for maternal depressive symptoms conducted during pediatric well-child visits is a feasible and effective method for identifying mothers with depressive symptoms, however, screening measures can not differentiate between high and low levels of depressive symptoms. Brief intervention may be an effective treatment for mothers with mild symptoms of depression; mothers with moderate to severe symptoms may require more intensive intervention.

Commercial Baby Food Consumption and Dietary Variety in a Statewide Sample of Infants Receiving Benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children

Dietary variety and exposure to fruits and vegetables in infancy have been associated with nutritional benefits and later acceptance of these foods. The objective of this study was to examine the prevalence of fruit and vegetable commercial baby food consumption and its relation to dietary variety during infancy. A cross-sectional statewide telephone survey of 733 Maryland mothers and infants receiving benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) was conducted between July 2004 and July 2005. A 24-hour dietary recall was examined to assess infant dietary variety. Among infants from birth to age 5 months, 54% had consumed complementary foods in the past 24 hours; 60% received commercial baby foods. Among infants aged 6 to 12 months, 98% had consumed complementary foods in the past 24 hours; 81% received commercial baby foods. In the latter age range, the average daily number of different types of fruits and vegetables consumed was 1.5±1.2, range 0 to 6). In a multivariate model, infants aged 6 to 12 months who received commercial baby foods consumed a greater variety of fruits and vegetables (β=.54, 95% confidence interval 0.26-0.84; P<0.001) than infants who did not, characterized by a diet that was lower in white potatoes (14% vs 22%) and higher in dark-green (6% vs 5%) and deep-yellow (35% vs 10%) vegetables. Commercial baby food is consumed by a majority of WIC infants, although many mothers introduce it before the recommended age of 6 months. Among infants aged 6 to 12 months, commercial baby food is associated with dietary variety in fruits and vegetables. By encouraging consumption of fruits and vegetables after 6 months of age, either through the provision of commercial baby foods and/or education and resources related to the preparation of fruits and vegetables for infants, WIC can increase dietary variety and appropriate introduction of complementary foods among infants.

Integrating nutrition and early child-development interventions among infants and preschoolers in rural India

This article describes the development, design, and implementation of an integrated randomized double‐masked placebo‐controlled trial (Project Grow Smart) that examines how home/preschool fortification with multiple micronutrient powder (MNP) combined with an early child‐development intervention affects child development, growth, and micronutrient status among infants and preschoolers in rural India. The 1‐year trial has an infant phase (enrollment age: 6–12 months) and a preschool phase (enrollment age: 36–48 months). Infants are individually randomized into one of four groups: placebo, placebo plus early learning, MNP alone, and MNP plus early learning (integrated intervention), conducted through home visits. The preschool phase is a cluster‐randomized trial conducted in Anganwadi centers (AWCs), government‐run preschools sponsored by the Integrated Child Development System of India. AWCs are randomized into MNP or placebo, with the MNP or placebo mixed into the childrens food. The evaluation examines whether the effects of the MNP intervention vary by the quality of the early learning opportunities and communication within the AWCs. Study outcomes include child development, growth, and micronutrient status. Lessons learned during the development, design, and implementation of the integrated trial can be used to guide large‐scale policy and programs designed to promote the developmental, educational, and economic potential of children in developing countries.