Sarah Redsell

Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy

Objective To determine risk factors for childhood overweight that can be identified during the first year of life to facilitate early identification and targeted intervention. Design Systematic review and meta-analysis. Search strategy Electronic database search of MEDLINE, EMBASE, PubMed and CAB Abstracts. Eligibility criteria Prospective observational studies following up children from birth for at least 2 years. Results Thirty prospective studies were identified. Significant and strong independent associations with childhood overweight were identified for maternal pre-pregnancy overweight, high infant birth weight and rapid weight gain during the first year of life. Meta-analysis comparing breastfed with non-breastfed infants found a 15% decrease (95% CI 0.74 to 0.99; I2=73.3%; n=10) in the odds of childhood overweight. For children of mothers smoking during pregnancy there was a 47% increase (95% CI 1.26 to 1.73; I2=47.5%; n=7) in the odds of childhood overweight. There was some evidence associating early introduction of solid foods and childhood overweight. There was conflicting evidence for duration of breastfeeding, socioeconomic status at birth, parity and maternal marital status at birth. No association with childhood overweight was found for maternal age or education at birth, maternal depression or infant ethnicity. There was inconclusive evidence for delivery type, gestational weight gain, maternal postpartum weight loss and ‘fussy’ infant temperament due to the limited number of studies. Conclusions Several risk factors for both overweight and obesity in childhood are identifiable during infancy. Future research needs to focus on whether it is clinically feasible for healthcare professionals to identify infants at greatest risk.

Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood

Abstract The risk factors for childhood overweight and obesity are known and can be identified antenatally or during infancy, however, the majority of effective interventions are designed for older children. This review identified interventions designed to reduce the risk of overweight/obesity that were delivered antenatally or during the first 2 years of life, with outcomes reported from birth to 7 years of age. Six electronic databases were searched for papers reporting randomised controlled trials of interventions published from January 1990 to September 2013. A total of 35 eligible studies were identified, describing 27 unique trials of which 24 were behavioural and three were non‐behavioural. The 24 behavioural trials were categorised by type of intervention: (1) nutritional and/or responsive feeding interventions targeted at parents of infants, which improved feeding practices and had some impact on child weight (n = 12); (2) breastfeeding promotion and lactation support for mothers, which had a positive effect on breastfeeding but not child weight (n = 5); (3) parenting and family lifestyle (n = 4); and (4) maternal health (n = 3) interventions that had some impact on feeding practices but not child weight. The non‐behavioural trials comprised interventions manipulating formula milk composition (n = 3). Of these, lower/hydrolysed protein formula milk had a positive effect on weight outcomes. Interventions that aim to improve diet and parental responsiveness to infant cues showed most promise in terms of self‐reported behavioural change. Despite the known risk factors, there were very few intervention studies for pregnant women that continue during infancy which should be a priority for future research.

Estimating Overweight Risk in Childhood From Predictors During Infancy

OBJECTIVE: The aim of this study was to develop and validate a risk score algorithm for childhood overweight based on a prediction model in infants. METHODS: Analysis was conducted by using the UK Millennium Cohort Study. The cohort was divided randomly by using 80% of the sample for derivation of the risk algorithm and 20% of the sample for validation. Stepwise logistic regression determined a prediction model for childhood overweight at 3 years defined by the International Obesity Task Force criteria. Predictive metrics R2, area under the receiver operating curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: Seven predictors were found to be significantly associated with overweight at 3 years in a mutually adjusted predictor model: gender, birth weight, weight gain, maternal prepregnancy BMI, paternal BMI, maternal smoking in pregnancy, and breastfeeding status. Risk scores ranged from 0 to 59 corresponding to a predicted risk from 4.1% to 73.8%. The model revealed moderately good predictive ability in both the derivation cohort (R2 = 0.92, AUROC = 0.721, sensitivity = 0.699, specificity = 0.679, PPV = 38%, NPV = 87%) and validation cohort (R2 = 0.84, AUROC = 0.755, sensitivity = 0.769, specificity = 0.665, PPV = 37%, NPV = 89%). CONCLUSIONS: Using a prediction algorithm to identify at-risk infants could reduce levels of child overweight and obesity by enabling health professionals to target prevention more effectively. Further research needs to evaluate the clinical validity, feasibility, and acceptability of communicating this risk.

An Investigation of the Impact of Nocturnal Enuresis on Children's Self-Concept

Objective: This study sought to evaluate the relationship between the self-esteem and the self-image of children with nocturnal enuresis and to examine these in relation to various aspects of clinical and demographic variables. Previous studies investigating the self-esteem of bedwetting children have had mixed findings. Some studies report that children with nocturnal enuresis have a lower self-esteem than their non-bedwetting peers, but other studies report that children with nocturnal enuresis perceive themselves similarly to non-bedwetting children. However, what have not been studied to date are the self-perceptions of bedwetting children treated in community clinics. Material and Methods: A total of 114 bedwetting children treated in community clinics provided the sample. School nurses conducted a routine first-visit assessment, collected baseline demographic and social information and invited children to complete the Butler Self-Image Profile and the Coopersmith Self-Esteem Inventory. Results: Age and extent of wetting were not significantly related to self-concept measures. Girls had significantly ( p = 0.008) higher scores on positive self-image compared with boys. Children with secondary enuresis also scored higher on positive self-image compared with those with primary nocturnal enuresis ( p = 0.02). The Butler self-image scores indicated a number of significant links between positive self-image and enuresis variables, whereas the Coopersmith self-esteem scores generally failed to distinguish between the enuresis variables and closely reflected those of the negative self-image scores. Conclusions: These findings suggest that amongst children with nocturnal enuresis, the most vulnerable in terms of self-image are male, those with primary enuresis and those with a greater number of wet nights a week.

UK health visitors' role in identifying and intervening with infants at risk of developing obesity

Childhood obesity is associated with a number of modifiable risk factors that can be identified during infancy or earlier. In the UK, health visitors advise parents about infant feeding, but little is known about their role in obesity prevention. The aim of this study was to investigate the beliefs and current practices of UK health visitors in relation to recognising and intervening with infants at risk of developing obesity. Thirty members of the health visiting team were interviewed. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was applied using an interpretative, inductive approach. Health visitors were aware of some of the modifiable risk factors for childhood obesity such as infant feeding practices. They felt they had a role in advising parents about diet but did not formally identify and/or intervene with larger infants. Infant overweight was considered a sensitive issue that was difficult to raise with parents. They believed some parents preferred larger infants and were unaware that their feeding practices might be contributing to obesity risk. A need for training and guidance was identified together with strategies to overcome system barriers. Health visitors do not currently target parents of infants at risk of obesity largely because they do not perceive they have appropriate guidance and skills to enable them to do so. There is an urgent need for tools and training to enable all health care professionals to recognise and manage infants at risk of developing obesity without creating a sense of blame.

Motor Development Interventions for Preterm Infants: A Systematic Review and Meta-analysis

CONTEXTS: Preterm infants are at an increased risk of neurodevelopmental delay. Some studies report positive intervention effects on motor outcomes, but it is currently unclear which motor activities are most effective in the short and longer term. OBJECTIVE: The aim of the study was to identify interventions that improve the motor development of preterm infants. DATA SOURCES: An a priori protocol was agreed upon. Seventeen electronic databases from 1980 to April 2015 and gray literature sources were searched. STUDY SELECTION: Three reviewers screened the articles. DATA EXTRACTION: The outcome of interest was motor skills assessment scores. All data collection and risk of bias assessments were agreed upon by the 3 reviewers. RESULTS: Forty-two publications, which reported results from 36 trials (25 randomized controlled trials and 11 nonrandomized studies) with a total of 3484 infants, met the inclusion criteria. A meta-analysis was conducted by using standardized mean differences on 21 studies, with positive effects found at 3 months (mean 1.37; confidence interval 0.48–2.27), 6 months (0.34; 0.11–0.57), 12 months (0.73; 0.20–1.26), and 24 months (0.28; 0.07–0.49). At 3 months, there was a large and significant effect size for motor-specific interventions (2.00; 0.28–3.72) but not generic interventions (0.33; –0.03 to –0.69). Studies were not excluded on the basis of quality; therefore, heterogeneity was significant and the random-effects model was used. LIMITATIONS: Incomplete or inconsistent reporting of outcome measures limited the data available for meta-analysis beyond 24 months. CONCLUSIONS: A positive intervention effect on motor skills appears to be present up to 24 months’ corrected age. There is some evidence at 3 months that interventions with specific motor components are most effective.

Validation, Optimal Threshold Determination, and Clinical Utility of the Infant Risk of Overweight Checklist for Early Prevention of Child Overweight

BACKGROUND Previous research has demonstrated the predictive validity of the Infant Risk of Overweight Checklist (IROC). This study further establishes the predictive accuracy of the IROC using data from the Avon Longitudinal Study of Parents and Children (ALSPAC) and examines the optimal threshold for determining high risk of childhood overweight. METHODS Using the IROC algorithm, we calculated the risk of being overweight, based on International Obesity Task Force criteria, in the first year of life for 980 children in the ALSPAC cohort at 5 years. Discrimination was assessed by the area under the receiver operating curve (AUC c-statistic). Net reclassification index (NRI) was calculated for risk thresholds ranging from 2.5% to 30%, which determine cutoffs for identifying infants at risk of becoming overweight. RESULTS At 5 years of age, 12.3% of boys and 19.6% of girls were categorized overweight. Discrimination (AUC c-statistic) ranged from 0.67 (95% confidence interval [CI], 0.62-0.72) when risk scores were calculated directly to 0.93 (95% CI, 0.88-0.98) when the algorithm was recalibrated and missing values of the risk factor algorithm were imputed. The NRI showed that there were positive gains in reclassification using risk thresholds from 5% to 20%, with the maximum NRI being at 10%. CONCLUSIONS This study confirms that the IROC has moderately good validity for assessing overweight risk in infants and offers an optimal threshold for determining high risk. The IROC algorithm has been imbedded into a computer program for Proactive Assessment of Obesity Risk during Infancy, which facilitates early overweight prevention through communication of risk to parents.

Children and young people's participation in healthcare consultations in the emergency department.

Approximately 4 million children attend emergency departments (ED) in England, United Kingdom, per annum. It is important for children and young people to have an active say in their assessment and treatment during each emergency care episode. However the reality of hearing the child or young persons voice within active participation in health care consultations remains low at approximately 6% of voices recorded. In the context of policy drivers and patient benefits, there is a need to increase the level of participation by children and young people within the emergency care environment. However, noise, child and parental anxiety and distress, professional time pressure, and severity of child illness or injury add to the inherent complexity of triadic communication (parent, child, healthcare professional) in the ED. Research examining child participation in decision-making in ED is sparse and guidance for all parties is limited. Therefore methods drawn from the wider literature on child participation are discussed which may be implemented, validated and evaluated with an ED context.

Devising and establising the face and content validity of explicit criteria of consultation competence in UK primary care nurses

AIM The aims of this study were (a) to devise a set of prioritised criteria of consultation competence which primary care nurses need to acquire and (b) to determine the face and content validity of these criteria. METHOD The criteria of consultation competence as contained in the Leicester Assessment Package (LAP) were modified for use with primary care nurses and sent to a stratified sample of UK primary care nurses (n=1126) to determine their face and content validity. RESULTS Support for the seven categories of consultation competence varied from 93-98% and for the 39 component competences from 88-98%. There was no consensus for alternative or additional categories or components. CONCLUSIONS; We have established the face and content validity of the derived competences. These are suitable for the teaching and assessment of consultation skills of primary care nurses, at all stages of their professional development, when incorporated within an educational package.

Health visitors’ perception of their role in the universal childhood immunisation programme and their communication strategies with parents

Aim: This study explored health visitors’ perception of their role in the universal childhood immunisation programme with particular emphasis on influencing factors and communication strategies. Background: The majority of parents’ consent to immunisation, but some find decision-making in this area difficult and have unmet information needs. In the United Kingdom, health visitors routinely provide immunisation information for parents, whereas general practitioners (GPs) and practice nurses tend to administer vaccines and respond to parents/carers’ questions. Research has investigated health professionals’ views and knowledge about immunisation, but less is understood about health visitors’ role and how they communicate with parents. Method: Following the Local Research Ethics and Research Governance permissions, all health visitors (n5120) working in one county in the United Kingdom were invited to participate in the study. Semistructured interviews (n522) were undertaken using a prompt guide. The interviews were transcribed verbatim. Thematic analysis using an iterative approach was used to explore the data facilitated by NVIVOTM software. Findings: Five themes emerged from the interviews. These were health visitors’professional role; identity and perceived barriers and communication strategies, parents’ right to choose, confidence in measles, mumps, and rubella (MMR) vaccination and communicating with migrant families about immunisation. There were differences between the health visitors in their perceptions of their roles, skills and knowledge and communication strategies. Health visitors perceived that GPs and practice nurses took a paternalistic approach to the provision of immunisation information, while they used a parental decision making model. Health visitors reported a loss of professional confidence following the MMR crisis. Conclusion: Given the evidence that some parents find it difficult to gain the information they need about immunisation and health visitors’ acknowledgement that their usual communication models were not effective during the MMR crisis, we feel specific communication skills training is needed to enable health professionals to provide parents with appropriate decision support.