Nicholas P. Hays

Randomized Controlled Trial to Compare Growth Parameters and Nutrient Adequacy in Children with Picky Eating Behaviors Who Received Nutritional Counseling With or Without an Oral Nutritional Supplement

In this study, changes in growth parameters and nutrient intake were compared in Chinese children (ages 30-60 months) with picky eating (PE) behaviors and weight-for-height ≤25th percentile, who were randomized to receive nutrition counseling alone (NC; n = 76) or with a nutritional milk supplement (NC + NS; n = 77) for 120 days. Increases in weight-for-height z-scores were significantly greater in the NC + NS group at days 30 and 90 and over the entire study period (all P < 0.05), but not at day 120. Increases in weight-for-age z-scores were significantly greater in the NC + NS group at day 90 (P = 0.025) and over the entire study period (P = 0.046). Mean intakes of energy, protein, carbohydrate, docosahexaenoic acid, arachidonic acid, calcium, phosphorous, iron, zinc, and vitamins A, C, D, E, and B6 were significantly higher in the NC + NS group at days 60 and 120 (all P < 0.01). Thus, in young children with PE behaviors, nutritional supplementation given as an adjunct to NC resulted in greater improvements in nutrient intake compared with NC alone. Growth parameters differed between groups at several timepoints during the study, but not at day 120.

Nutrient intake and dietary patterns in children 2.5-5 years of age with picky eating behaviours and low weight-for-height.

BACKGROUND AND OBJECTIVES Picky eating behaviours are common in young children and may adversely affect dietary intake. This study examined the adequacy of dietary patterns and nutrient intake in preschool-aged children in China and Hong Kong with picky eating behaviours and weight-for-height in the lowest quartile of the WHO Growth Standards. METHODS AND STUDY DESIGN Dietary intake was assessed using baseline 3-day food records from a multicenter, randomized trial in Chinese children (N=151) ages 2.5-5 years characterized as picky eaters by their parents and with weight-for-height <=25th percentile of the WHO Growth Standards. Nutrient intakes were calculated using validated dietary analysis software and compared with age-appropriate Chinese Recommended Nutrient Intakes (RNIs). Dietary patterns were compared with Hong Kong Food Pyramid recommendations. RESULTS Median daily energy intake was 25% lower than the age-appropriate RNI, while median intakes of calcium, iron, zinc, and vitamins C and E ranged from 52%-73% of the RNI. Vitamin D intake was only 37% of the RNI. Total fat and sodium intakes exceeded recommendations by 10% and 56%, respectively, while >16% of daily energy was derived from foods in the sweets/beverages/snack and the fats/oils groups. Almost 75% of the children met the recommended daily servings of meat/meat substitutes and nearly half met the recommendation for daily servings of fruit. Fewer met the recommendations for daily servings of vegetables (14.7%), milk/milk products (6.3%), and grains and cereals (6.3%). CONCLUSIONS Young children with picky eating behaviours and low weight-for-height had suboptimal dietary patterns and were at risk for significant dietary and nutrient insufficiencies.

Growth and Nutritional Biomarkers of Preterm Infants Fed a New Powdered Human Milk Fortifier: A Randomized Trial

Objectives: The aim of this study was to assess growth and nutritional biomarkers of preterm infants fed human milk (HM) supplemented with a new powdered HM fortifier (nHMF) or a control HM fortifier (cHMF). The nHMF provides similar energy content, 16% more protein (partially hydrolyzed whey), and higher micronutrient levels than the cHMF, along with medium-chain triglycerides and docosahexaenoic acid. Methods: In this controlled, multicenter, double-blind study, a sample of preterm infants ⩽32 weeks or ⩽1500 g were randomized to receive nHMF (n = 77) or cHMF (n = 76) for a minimum of 21 days. Weight gain was evaluated for noninferiority (margin = –1 g/day) and superiority (margin = 0 g/day). Nutritional status and gut inflammation were assessed by blood, urine, and fecal biochemistries. Adverse events were monitored. Results: Adjusted mean weight gain (analysis of covariance) was 2.3 g/day greater in nHMF versus cHMF; the lower limit of the 95% CI (0.4 g/day) exceeded both noninferiority (P < 0.001) and superiority margins (P = 0.01). Weight gain rate (unadjusted) was 18.3 (nHMF) and 16.8 g · kg−1 · day−1 (cHMF) between study days 1 and 21 (D1–D21). Length and head circumference (HC) gains between D1 and D21 were not different. Adjusted weight-for-age z score at D21 and HC-for-age z score at week 40 corrected age were greater in nHMF versus cHMF (P = 0.013, P = 0.003 respectively). nHMF had higher serum blood urea nitrogen, pre-albumin, alkaline phosphatase, and calcium (all within normal ranges; all P ⩽ 0.019) at D21 versus cHMF. Both HMFs were well tolerated with similar incidence of gastrointestinal adverse events. Conclusions: nHMF providing more protein and fat compared to a control fortifier is safe, well-tolerated, and improves the weight gain of preterm infants.

Factors Associated with Maternal Worry about Her Young Child Exhibiting Choosy Feeding Behaviour

Choosiness in young children is a normal behaviour that sometimes worries parents. The study aimed to investigate factors that are associated with a mother being worried about her child’s choosy feeding behaviour. Parents of singleton children from the Avon Longitudinal Study of Parents and Children (n = 5710) completed a questionnaire assessing perception of their child’s choosy feeding behaviour at 15 months of age and whether this choosiness worried them. Feeding behaviours and practices throughout the first 15 months were captured. Multinomial logistic regression models with three levels of worry (not at all, a bit and greatly) as the dependent variables tested associations with variables from pregnancy and infancy. Half of the children (56%) were described as choosy at 15 months; of these 27% had mothers who were a bit worried and 5% greatly worried. Mothers showed greater odds of being worried if the child was first born, difficult to feed or refused solids by 6 months of age. Worried mothers had shown greater odds of introducing lumpy foods late (after 9 months). Feeding vegetables regularly by 6 months was associated with lower odds of worry at 15 months. Support and advice to parents at the start of complementary feeding could help to alleviate worry. Parents should be reassured that choosiness is a normal part of child development.

Infant Feeding Regimens and Gastrointestinal Tolerance: A Multicenter, Prospective, Observational Cohort Study in China:

To study feeding tolerance in infants fed formula with increased sn-2 palmitate and oligofructose (sn-2+OF) in a real-world setting, healthy Chinese infants were enrolled in this 48-day observational study on their current feeding regimens: exclusively breastfed (BF; n = 147), exclusively sn-2+OF formula-fed (FF; n = 150), or mixed-fed with breast milk and sn-2+OF formula (MF; n = 163). Throughout the study, incidence (90% confidence interval) of hard stools was ≤2.1% (0.0-5.3) in FF and 0.8% (0.0-3.5) in MF, with no hard stools in BF. Incidence of watery stools was ≤5.0% (1.0-9.2) in FF and ≥5.1% (2.4-9.3) in MF and BF. Gastrointestinal tolerance scores, although low in all groups (lower scores indicating better tolerance), were slightly higher (P ≥ .03) in FF (17.5 ± 4.8) and MF (18.2 ± 5.0) versus BF (16.3 ± 3.2) at mid-study; this difference disappeared at study end. Overall, low incidences of hard and watery stools and good feeding tolerance were observed in infants fed sn-2+OF formula.

PS-268 Stool Characteristics And Gastrointestinal Tolerance Of Chinese Infants Fed Term Formula Containing Increased Sn-2 Palmitate And Oligofructose: An Observational Study

Background and aims Formula containing increased sn-2 palmitate with oligofructose (sn-2+OF) may improve stool consistency. We hypothesised that hard and watery stool incidence among infants fed α-lactalbumin-enriched formula with sn-2+OF would be ≤2.5% (upper limit of 80% CI < 5.0%). Methods Healthy term infants (n = 440) aged ~42 days were enrolled in this 48-day study on their current feeding regimens: formula-fed (n = 142), HM-fed (n = 143), or mixed-fed (n = 155). Stool consistency was assessed at 4 visits using a 3-day diary with validated 5-point scale (1 = watery, 5 = hard). Gastrointestinal (GI) tolerance was assessed using a validated questionnaire (score range = 13–65; lower values indicate better tolerance). Results Incidence of hard stools across visits ranged from 0.7% [80% CI: 0.1–2.7] to 2.1% [0.8–4.6] for formula-fed infants, with incidence rates ≤0.8% in mixed-fed, and no hard stools reported in HM-fed groups. Incidence of watery stools ranged from 2.8% [1.2–5.4] to 5.0% [2.8–8.3] for formula-fed infants, which was lower than the incidence rates for mixed-fed (≤8.2%) and HM-fed (≤16.3%) groups. Stool consistency score (2 = runny, 3 = mushy soft) of formula-fed infants (2.9) was higher than HM-fed infants (2.4–2.5; p Conclusions Formula with sn-2+OF fed to Chinese infants results in soft stools and low incidence of hard and watery stools. Low GI tolerance scores indicate the formula is well tolerated.

Effects on Fatty Acid Metabolism of a New Powdered Human Milk Fortifier Containing Medium-Chain Triacylglycerols and Docosahexaenoic Acid in Preterm Infants

Preterm infants require fortification of human milk (HM) with essential fatty acids (FA) to ensure adequate post-natal development. As part of a larger randomized controlled study, we investigated FA metabolism in a subset of 47 clinically stable preterm infants (birth weight ≤1500 g or gestational age ≤32 weeks). Infants were randomized to receive HM supplemented with either a new HM fortifier (nHMF; n = 26) containing 12.5 g medium-chain FA (MCFA), 958 mg linoleic acid (LA), 417 mg α-linolenic acid (ALA), and 157 mg docosahexaenoic acid (DHA) per 100 g of powder (in compliance with the latest guidelines) or a fat-free HMF (cHMF; n = 21). Plasma phospholipid (PL) and triacylglycerol (TAG), and red blood cell phosphatidylcholine (RBC-PC) and phosphatidylethanolamine (RBC-PE) FA profiles were assessed before and after 21 days of feeding. In the nHMF group, significantly increased levels of n-9 monounsaturated fatty acids were observed, formed most likely by elongation and desaturation of dietary saturated fatty acids present in HM. ALA fortification increased ALA assimilation into plasma TAG. Similarly, DHA fortification enriched the DHA content in RBC-PE, which, in this compartment, was not associated with lower arachidonic acid levels as observed in plasma TAG and phospholipids. RBC-PE, a reliable indicator of FA metabolism and accretion, was the most sensitive compartment in this study.

Feasibility and Psychometric Properties of the Infant Toddler Quality of Life (ITQOL) Questionnaire in a Community-Based Sample of Healthy Infants in China

Objective Evaluate the feasibility and psychometric properties of the Infant Toddler Quality of Life (ITQOL) questionnaire as a measure of health-related quality of life (HRQOL) in a sample of Chinese infants. Methods The linguistically validated Simplified Chinese version of the ITQOL was used in a multicenter, observational study of healthy, term infants (N = 427), age 6 weeks at enrollment, in China. At Days 1 and 48, parents/guardians completed the ITQOL, the Short Form Health Survey (SF-12v2) and the Infant Gastrointestinal Symptom Questionnaire (IGSQ). ITQOL feasibility, reliability, ceiling/floor effects, concurrent validity and discriminatory validity were evaluated. Results Feasibility of administering the ITQOL was supported by strong response rates (> 97%) with < 1% missing items for all scales except physical abilities. Reliability was acceptable (Cronbach’s alpha > 0.70) for all scales except Day 1 General Health (0.67). Floor effects were minimal (< 2%), except Day 1 physical abilities (7%). Ceiling effects increased from Days 1 to 48 across all scales. Concurrent validity was demonstrated by correlations between ITQOL infant-focused scales and IGSQ score (r = −0.20 to − 0.34, p < 0.001) and between parent-focused scales and SF-12v2 mental health composite (MCS) scores (r = 0.29–0.46, p < 0.001). ITQOL scales discriminated between infant subgroups based on illness-related outcomes (sick visits, adverse events) and between parent subgroups based on SF-12v2 MCS scores. Conclusion The Simplified Chinese version of the ITQOL performed well in a community-based sample of Chinese infants, with evidence supporting the instrument’s feasibility, reliability, and validity. These data support the ITQOL as a valuable tool to assess HRQOL in Chinese infants.

Growth and body composition in children who are picky eaters: a longitudinal view

Background/objectivesPicky eating may be associated with higher risk of being underweight and poor growth over time or conversely, being overweight. Our aim was to investigate if children identified as picky eaters showed differences in height, weight and body composition from their non-picky peers.Subjects/methodsPicky eaters were identified in the Avon Longitudinal Study of Parents and Children cohort at 3 years of age. Height and weight were measured on seven occasions (age 7–17 years). Body composition was measured on five occasions by dual-energy x-ray absorptiometry (age 9–17 years). Participants were classified as thin/normal/overweight or obese at each age point using body mass index (BMI) classifications. Data were analysed with adjusted multiple regression analysis and mixed-design repeated measures ANOVA.ResultsThere was a main effect of being a picky child on height and weight (and on BMI and lean mass index (LMI) in boys) (lower in the picky children, all p ≤ 0.044), but not on percentage body fat or fat mass index (and not on BMI and LMI in girls) (all p > 0.2). The mean heights, weights and BMIs of picky eaters were consistently above the 50th centiles of reference growth charts. More than two-thirds of picky eaters were not thin at any age point. However, being a picky eater was predictive of being thin at a few age points.ConclusionsThe growth trajectories of children who were picky eaters were reassuring. The prevalence of thinness amongst some picky eaters is notable, suggesting that some children may need specific early identification, intervention and growth surveillance.

Antecedents of picky eating behaviour in young children

Background Picky eating behaviour in young children is a common concern for parents. Objective To investigate early life factors which are associated with a child becoming a picky eater. Design Singleton children from the Avon Longitudinal Study of Parents and Children were studied prospectively (n = 5758–6608). Parental-completion questionnaires were used to define ‘picky eating’ status at age 3 years, and child and parental feeding behaviours and practices throughout the first 2 years of life. Multinomial logistic regression models with 3 levels of picky eating (not, somewhat and very picky) as the dependant variables tested associations with antecedent variables, from pregnancy, and the first and second year of life, separately, then combining all significant variables in a final model. Results Feeding difficulties during complementary feeding and late introduction of lumpy foods (after 9 months) were associated with increased likelihood of the child being very picky. A strong predictor was the child being choosy at 15 months, particularly if the mother was worried about this behaviour. Many children (56%) were considered to be choosy at 15 months: 17% went on to be very picky at 3 years if the mother was not worried, compared with 50% if the mother was very worried by the choosiness. The mother providing fresh fruit and eating the same meal as the child were protective against later ‘picky eating’, while feeding ready-prepared food was predictive. Conclusion Advice and support to parents could help to reduce picky eating behaviour. Parents should be encouraged to introduce lumpy foods by 9 months, to feed fresh foods particularly fruit, and to eat with their children. Parents should be reassured that choosiness is normal and to continue to provide a variety of foods.