Journal of Pediatric Nursing (2014) 29, 108–113
Baby Steps in the Prevention of Childhood Obesity: IOM Guidelines for Pediatric Practice Kathleen F. Gaffney PhD, RN, F/PNP-BC a,⁎, Panagiota Kitsantas PhDb, Albert Brito MDc,d, Jennifer Kastello MSN, RN, WHNPa
aGeorge Mason University, School of Nursing, Fairfax, VA bDepartment of Health Administration and Policy, George Mason University cInovaCares Clinic for Children, Falls Church, VA dVirginia Commonwealth University, Richmond, VA
Key words: Obesity; Overweight; Evidence-based practice; Prevention; Intervention; Infant feeding practices; Physical activity; Growth monitoring; Sleep; Guidelines
The aim of this paper is to present an overview of the infancy-related guidelines from the Institute of Medicine ( IOM, 2011) report “Early Childhood Obesity Prevention Policies” and highlight research studies that support their implementation in pediatric practice. Findings from recent studies of infant growth monitoring, feeding, sleep, and physical activity are presented. Research strategies that may be applied to today’s clinical assessments and interventions are specified. Participation by pediatric nurses in the development of future multi-component interventions to prevent rapid infant weight gain is recommended. © 2014 Elsevier Inc. All rights reserved.
Benjamin is being seen today for his 6-month well child visit at a pediatric clinic that cares for low-income families. At birth, his weight-for-length was at the 25th percentile according to World Health Organization growth charts. Today it is at the 97th percentile. His parents are proud of his weight gain. They moved to the Washington, D.C., area from their native El Salvador three years ago. Both work in a local restaurant. A trusted friend cares for Benjamin eight hours/day, six days/week. His mother reports that for approximately five hours/day, Benjamin is strapped in a car seat in front of the television, because he “likes the movement on TV.” She is pleased with this arrangement because he is “safe.” He is breastfed in the evening; otherwise he receives infant formula. When he was two months old, his babysitter added rice cereal to his formula “to help him sleep” and gradually added other solid foods to his diet. Benjamin’s story is not uncommon.
Corresponding author: Kathleen F. Gaffney, PhD, RN, F/PNP-BC. -mail address: email@example.com.
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Childhood obesity is a global problem. The World Health Organization (WHO) estimates that over 40 million children under 5 years of age are overweight or obese. While once considered a public health issue primarily for high-income countries, childhood obesity rates are rising quickly in middle- and low-income countries, particularly in urban areas (World Health Organization, 2012). The significance of this change in child health status throughout the world is the long term health consequences of obesity, including cardiovascular morbidities and early development of type 2 diabetes.
International studies provide evidence that excess weight gain during infancy is a significant risk factor for later obesity. A population-based study of infants from the United States (US) found a positive association between rapid weight gain in the first 4 months of life and overweight status at 7 years of age (Stettler, Zemel, Kumanyika, & Stallings, 2002). For American children from low-income minority
109Prevention of Childhood Obesity: IOM Guidelines for Pediatric Practice
families, excessive weight gain in the first year of life has been associated with a nine-fold increased risk for obesity at age 3 years (Goodell, Wakefield, & Ferris, 2009). Similarly, higher weight-for-length z-scores at 6 months of age have been associated with the increased odds of obesity at 3 years of age (Taveras et al., 2009). These findings are consistent with those of the Avon Longitudinal Study of Parents and Children in England that found rapid weight gain in the first year to be a risk factor for obesity at age 7 years (Reilly et al., 2005). The accumulating research evidence from these studies points to the need for obesity prevention practice guidelines that begin early in life.
In response to the childhood obesity epidemic, the Institute of Medicine (Institute of Medicine (IOM), 2011) has developed practice guidelines for preventing childhood obesity. Unlike previous public health initiatives that have focused primarily on school age children, the IOM’s Early Childhood Obesity Prevention Policies targets factors related to overweight and obesity from birth to 5 years of age. The IOM infancy-related guidelines are focused on growth monitoring, healthy feeding, sleep, and physical activity. The purpose of this paper is to present an overview of the IOM infancy-related guidelines and highlight research studies that support their implementation in clinical practice.
Infant Growth Monitoring
The IOM guideline for measuring infant growth is to plot height and weight on WHO growth charts. The rationale supporting use of WHO charts is that the data used to generate these growth curves were collected from a large cohort of children from varying cultures and countries, including Brazil, Ghana, India, Norway, Oman and the US. Additionally, the WHO charts were generated using sample inclusion criteria that specified breastfeeding up to age 12 months, introduction of solid foods at approximately age 6 months, absence of maternal smoking, and living in a household with adequate income (de Onis et al., 2004). This approach to sampling was designed to generate benchmark curves that reflect an ideal growth trajectory for comparison to individual patterns (Garza & de Onis, 2004). Further, the IOM (2011) guideline for growth monitoring in infancy calls for tracking weight-for-length changes throughout the first year and identifying babies at risk for overweight (84.1st–97.7th percentile) and over- weight (N97.7th percentile).
With respect to growth monitoring, the WHO growth charts also provide useful application for clinical practice. For parents like Benjamin’s who are from countries where food scarcity is prevalent, the overweight status of their infant as seen on the growth chart may be viewed with pride and considered to be a marker for good health and successful parenting. Misconceptions about healthy weight gain,
however, are not limited to parents from low income countries. Researchers in the Netherlands found that a substantial proportion of parents, regardless of educational attainment and socio-demographic background, did not recognize overweight status in their own children (Jansen & Brug, 2006). Similarly, a recent study in the US found that over 80% of mothers of overweight toddlers were satisfied with their child’s body size and inaccurately assessed their weight as being within a normal range for age (Hager et al., 2012). Another study used a simple assessment measure that can be easily incorporated into a regularly scheduled well child visit (Chaparro, Langellier, Kim, & Waley, 2011). The researchers asked the question “Do you consider your child be overweight, underweight, or about right weight for (his)(her) height?” Almost all mothers classified their overweight or obese child as being about the right weight (93.6% and 77.5%, respectively). While this study focused on preschoolers, using a comparable question for parents of infants may open the door for anticipatory guidance to prevent the rapid or excess infant weight gain that leads to later obesity.
The IOM’s (2011) infancy-related guidelines for the prevention of childhood obesity call for health care providers to encourage exclusive breastfeeding in the first 6 months and continuation of breastfeeding with the introduction of solid foods during the second half of infancy. Further, the report underscores the importance of helping parents recognize and respond to infant hunger and fullness cues. Examples of hunger cues in early infancy include sucking on fist, waking and tossing, and opening mouth while feeding to indicate wanting more. Conversely, infant cues to satiety or fullness include behaviors such as turning head away, sealing lips, and decreasing or stopping sucking (USDA, 2013).
To date, the findings from health care research related to the healthy infant feeding component of the IOM guidelines are inconsistent. One systematic review of eight interna- tional studies of breastfeeding duration and risk for overweight or obesity in later childhood found that only half of the studies reported a dose response of breastfeeding after adjusting for other known risk factors for obesity (Arenz, Rükerl, Koletzko, & von Kries, 2004). A meta- analysis of the same relationship was conducted using 17 studies from seven countries in Europe and North America (Harder, Bergmann, Kallischnigg, & Plagemann, 2005). The findings strongly supported a dose-dependent associ- ation between longer breastfeeding duration and reduced risk for later obesity. However, due to methodological differences across studies, adjustment for potential con- founders could not be calculated. A later study found a relationship between breastfeeding duration and over- weight at age 4 years, but when the researchers controlled
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for other social and environmental risk factors, the association diminished and was no longer statistically significant (Procter & Holcomb, 2008).
To further examine whether breastfeeding offers a protective factor against later obesity, a study based on the Copenhagen Perinatal Cohort compared the effects of breastfeeding duration and age of introduction to solid foods on body mass index through childhood and adulthood. The researchers found that later introduction of solids (approxi- mately 6 months of age) was protective against later overweight, but did not find a protective effect for longer breastfeeding duration (Schack-Nielsen, Sǿrensen, Morten- sen, & Michaelsen, 2010). Researchers in Northern Ireland found that infants who were introduced to solids prior to 4 months of age were heavier at 7 and 14 months than those in a comparison group who started solids later. Group differences remained significant after controlling for breast- feeding duration (Sloan, Gildea, Stewart, Sneddon, & Iwaniec, 2007). Further, a study using a nationally representative data set in the US that examined the relationship between weight at 12 months of age and adherence to clinical practice guidelines for feeding behaviors found significant associations with breastfeeding intensity during the second half of infancy and age of introduction to solid foods (Gaffney, Kitsantas, & Cheema, 2012).
In addition to monitoring the source of infant caloric consumption from breastfeeding, formula feeding and solid food, the IOM guidelines recommend that health care providers encourage infant feeding behavior that is respon- sive to hunger and satiety cues. A recent longitudinal study of infants offers potential insight into the role of sensitivity to infant feeding cues in preventing obesity. In a comparison of babies who were fed at breast with those bottle fed (either human or nonhuman milk), those who were exclusively bottle fed gained significantly more weight per month throughout infancy (Li, Fein, & Grummer-Strawn, 2010; Li, Magada, Fein, & Grummer-Strawn, 2012). This finding led researchers to conclude that infant weight gain may not only be associated with type of milk consumed but also the type of milk delivery. They proposed that the underlying processes may be that infants fed at breast develop better self- regulation of intake than bottle fed infants and that mothers who have breastfed their infants may develop improved sensitivity and responsiveness to infant cues of hunger and satiety. Support for this explanation comes from studies of maternal sensitivity that have found lower levels of responsiveness to satiety cues to be inversely associated with infant weight gain (Thompson et al., 2009; Worobey, Lopez, & Hoffman, 2009). However, a limitation of the study was the underrepresentation of Hispanic mother– infant pairs in the sample. This is particularly important in light of a recent US population-based study that found Hispanic children under 2 years of age have a greater prevalence of high weight-for-length than non-Hispanic White, or non-Hispanic Black children (14.8%, 8.4%, 8.7%, respectively; Ogden, Carroll, Kit, & Flegal, 2012).
Clinical application of the IOM recommendation for responsive infant feeding styles may be the adoption of assessment strategies used in research. For instance, a pilot study by the Project Viva clinical research team derived a “responsiveness to infant satiety” score based on the following items from the infant feeding questionnaire (Taveras et al., 2011):
1. If I did not guide or regulate my baby’s eating, he/she would eat much less than he/she should.
2. If I did not guide or regulate my baby’s eating, he/she would eat much more than he/she should.
3. My baby is never full enough. 4. My baby never seems very hungry.
Mothers were asked to respond with options ranging from strongly agree (1) to strongly disagree (4) with higher scores indicative of more responsive feeding styles. The composite scale was found to have acceptable internal reliability (Cronbach alpha = 0.70) when used with mothers of 6 month old infants. Use of this measurement tool in clinical assessments may be useful in identifying parents and caregivers, like those in our case story of Benjamin, who practice non-responsive infant feeding styles in the belief that they are doing what is best for their babies. Interventions that help them identify and respond positively to infant hunger and satiety cues may reduce the risk of excessive weight gain.
The IOM infancy-related guidelines for obesity preven- tion call on health care providers to help families achieve age-appropriate sleep duration for their babies. While most research about the link between sleep and childhood obesity has been conducted with older children, two studies have examined the relationship between sleep duration in infancy and weight gain. One study of 6 month old infants found that shorter nighttime sleep duration, as measured by both actigraph sleep percentages and parental surveys, was correlated with higher infant weight-for-length ratios. The significance of this relationship persisted after adjusting for potential confounders, such as infant gender, birth weight, and gestational age (Tikotzky et al., 2010). Another study used multivariate regression analyses to predict the effects of infant sleep duration (b12 h/d vs.≥12 h/d) on weight status among preschoolers. The researchers found that infant sleep less than 12 h/d was associated with higher BMI and increased odds of overweight at 3 years of age (Taveras, Rifas-Shiman, Oken, Gunderson, & Gillman, 2008). Repli- cation and extension of these studies with larger and more diverse samples will add the body of evidence that informs practice in this area.
Further, the IOM (2011) guidelines call for testing strategies that address the behavioral factors that lead to healthy sleep hygiene for infants. Proposed actions include
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encouraging sleep-promoting behaviors, such as calming routines at bedtime, and self-regulation of sleep by putting infants to sleep drowsy but awake. Evidence to-date that supports the effectiveness of these strategies is limited.
To address this gap, two pilot intervention studies have been conducted. The First Steps for Mommy and Me study tested the preliminary efficacy of a multi-component intervention that was focused on breastfeeding exclusivity/ duration, delayed introduction of solid foods, increased sleep duration and quality, TV avoidance, and responsiveness to satiety cues. Intervention delivery occurred within the context of well child visits, home visits, and parent workshops during the first 6 months after birth. Researchers found that infants in the intervention group had increased nocturnal sleep duration and larger reductions in nighttime wakefulness when compared to a usual care group. The change in weight-for-length z-scores from birth to 6 months appeared to be lower for the intervention group, but the difference was not statistically different. However, fewer of the intervention infants were in the highest weight-for-length quartile at 6 months of age (22% vs. 42%; Taveras et al., 2011).
As part of the implementation of this pilot study, researchers assessed maternal “feed-to-soothe” behavior with an item that pediatric nurses may find to be a useful adjunct to the four responsive feeding style items listed above. Specifically, mothers in the study signified their level of agreement with the statement that “The best way to soothe a crying baby is to feed her/him.” with response options ranging from strongly agree (1) to strongly disagree (4). Fewer mothers in the intervention group agreed or strongly agreed with this statement than those in the usual care group (12% vs. 24%). In the clinical setting, this item may help identify parents and caregivers most in need of information about non-feeding strategies for soothing a fussy or irritable baby to enhance sleep duration.
In the second pilot study, mothers also were taught alternative strategies to feeding as a first response to nocturnal crying and fussiness. Through instruction about hunger and satiety cues, parents learned to distinguish these cues from other causes of infant distress, such as boredom, anger, or the discomfort of a soiled diaper. Intervention content included alternative soothing and calming techniques that allowed the non-hungry infant to experience being comforted without being fed, learn to self-soothe, and become drowsy and return to sleep without feeding. The infants of mothers who participated in this “soothe/sleep” instruction as well as an intervention about healthy approaches to the introduction of solid foods had a mean weight-for-length at 1 year of age significantly lower (33rd percentile vs. ≥50th–56th percentile) than comparison groups that experienced only one or no part of the intervention (Paul et al., 2011). One initial implication for clinical practice is that multi-component behavioral in- terventions may be required to effectively overcome the
rapid weight gain in infancy that places children at risk for long term obesity. The findings from both pilot studies provide valuable insights for the design of future randomized controlled trials that are likely to provide higher level evidence for practice.
Infant Physical Activity
To increase physical activity and decrease sedentary behavior, the IOM (2011) guidelines call for more daily opportunity for infants to move freely both indoors and outdoors, spend time on the ground engaging in adult–infant interactions, and, for babies under 6 months of age, to experience more “tummy time” (time in the prone position). Additionally, the plan calls for limiting the long term use of confining baby equipment such as car seats, strollers, bouncer seats and playpens. In his award-winning book, entitled Last Child in the Woods (2008), Robert Louv observed that infants around the globe are increasingly being raised more indoors than outdoors and are spending more time being contained in smaller spaces. He points out that infants are spending more time in “car seats, high chairs, and even baby seats for watching TV” (p. 35).
Scientific underpinnings for the IOM infancy-related recommendations for physical activity are limited. One study found that percentage of body fat at ages 6, 9, and 12 months was inversely related to infant activity level and that this relationship was stronger with increasing age (Li, O’Connor, Buckley, & Specker, 1995). Other studies have examined the relationships among infant activity, motor development and weight status. For example, a study of the influence of wakeful prone positioning on infant motor development found that the duration of prone positioning predicted the acquisition age of three developmental milestones: rolling, crawling-on-abdomen, and crawling- on-all-fours (Kuo, Liao, Chen, Hsieh, & Hwang, 2008). Another study found that the frequency of gross motor delays was significantly higher among infants whose weights-for- length ratios were between the 85th to 94th percentiles compared to those who were not overweight (Shibli, Rubin, Akons, & Shaoul, 2008). A longitudinal study of low-income mother–infant dyads examined the associations of both weight status and subcutaneous fat with motor development in the first 18 months of life. Risks for gross motor delay were found to be 1.8 times greater for overweight infants and 2.3 times greater for those with high levels of subcutaneous fat when compared to infants whose anthropometric indices were not in those categories (Slining, Adair, Goldman, Borja, & Bentley, 2010). Based on these findings, the authors suggested that gross motor developmental delays among overweight infants and those with high subcutaneous fat may lead to a cascade of increased risk for reduced physical activity and limited exploration of the environment “beyond arm’s reach” (p. 24).
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Going Forward Toward Evidence-Based Practice
Current research provides initial support for the IOM’s Early Childhood Obesity Prevention Policies. In particular, evidence has been utilized to develop recommendations for identifying and addressing the early life risk factors for overweight and obesity through infant growth monitoring and strategies to promote healthful feeding, sleeping, and physical activity. Going forward, further clinical research is needed to inform practice. Replication and extension studies are needed to better understand the role of infant self- regulation versus caregiver “finish the bottle” feeding behavior on the risk for excess weight gain. Infant sleep studies are needed to understand more fully how nurses may effectively guide parents to provide restful environments conducive to lifelong sleep regulation and reduced obesity risk. The pediatric world is beginning to alert families to issues that Robert Louv (2008) described in terms of infants contained in small spaces with limited physical activity and restricted opportunities for normal gross motor development and exploration.
Research to support evidence-based practice in this new area of clinical observation is sparse. Pediatric nurses need to provide content expertise for future studies that will ensure that research questions are significant and intervention methods are feasible and acceptable for families from diverse socioeconomic and racial/ethnic groups.
Further, multi-component clinical interventions that implement IOM (2011) guidelines are needed. The pilot studies by the Project Viva clinical research team (Taveras et al., 2011) and the soothe/sleep infant interventionists (Paul et al., 2011) give clinical nurse researchers a template for study design. Their intervention content and delivery methods mirror the long and successful nursing research history of effective strategies for promoting maternal–infant health. These strategies have included assessment of sensitivity to infant cues during infant feeding (Barnard & Kelly, 1990), development of nurse home visitation programs (Brooten et al., 1986) and implementation of an intervention that demonstrates ways to calm and soothe irritable infant babies that extend beyond the “feed-to- soothe” approach to infant crying (Keefe et al., 2006). Each of these pediatric nurse-led clinical initiatives has potential application to the issues of infant growth, feeding, sleep, and physical activity specified in IOM (2011) guidelines. By transferring knowledge from prior clinical applications for maternal–infant health promotion, we can advance current practice guidelines and contribute to a healthier future for infants like Benjamin.
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- Baby Steps in the Prevention of Childhood Obesity: IOM Guidelines for Pediatric Practice
- Infant Growth Monitoring
- Infant Feeding
- Infant Sleep
- Infant Physical Activity
- Going Forward Toward Evidence-Based Practice