Estimates of congenital cytomegalovirus-attributable infant mortality in high-income countries: A review.

As many as 5%-10% of infants with symptomatic congenital cytomegalovirus (cCMV) disease, or 0.4%-0.8% of all liveborn infants with cCMV infection, die in early infancy in high-income countries. However, estimates are uncertain due to several potential biases that can result from data limitations and study designs. First, infants with cCMV infections who die prior to diagnosis, which usually occurs at 1-4 weeks after birth, may be excluded from both the count of deaths and the denominator of cCMV births, resulting in left truncation and immortal time biases. These 'biases' are features of the data and do not reflect bias on the part of researchers, but understanding the potential existence of threats to validity can help with interpretation of findings. Left truncation of infant deaths occurring prior to diagnosis of cCMV can result in understatement of the burden of infant deaths due to cCMV. Conversely, overestimation of infant deaths associated with symptomatic cCMV may occur in clinical case series owing to greater representation of relatively severely affected infants owing to ascertainment and referral biases. In this review, we summarise the characteristics of 26 studies that reported estimates of cCMV-associated infant deaths, including potential biases or limitations to which those estimates may have been subject. We discuss study designs whose implementation might generate improved estimates of infant deaths attributable to cCMV. More complete estimates of the overall public health impact of cCMV could inform current and future screening, prevention, and vaccine research.

Neurodevelopmental outcomes of children with congenital cytomegalovirus: a systematic scoping review.

BACKGROUND: With the emergence of newborn congenital cytomegalovirus (cCMV) screening programs, more infants are being diagnosed and require long-term follow-up. The objective of the study was to summarize the literature to date on neurodevelopmental outcomes in children with cCMV with attention to study-specific definitions of disease severity (symptomatic vs. asymptomatic). METHODS: This systematic scoping review included studies of children with cCMV (≤18 years-old) measuring neurodevelopment in ≥1 domain: global, gross motor, fine motor, speech/language, and intellectual/cognitive. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. PubMed, PsychInfo, and Embase databases were searched. RESULTS: 33 studies met inclusion criteria. Global development most frequently measured (n = 21), followed by cognitive/intellectual (n = 16) and speech/language (n = 8). Most (31/33) studies differentiated children by cCMV severity (symptomatic vs. asymptomatic), definitions of which ranged broadly. 15/21 studies described global development categorically (e.g., normal vs. abnormal). Across studies and domains, children with cCMV generally had equivalent or lower scores (vs. controls or normed measures). CONCLUSIONS: Variation in definitions of cCMV severity and blunt categorical outcomes may limit the generalizability of findings. Future studies should utilize standardized definitions of disease severity and in-depth measurement and reporting of neurodevelopmental outcomes in children with cCMV. IMPACT: Neurodevelopmental delays are common among children with cCMV, although gaps in the literature to have made quantification of such delays challenging. Variation in definitions of asymptomatic and symptomatic cCMV as well as the use of categorical outcomes of neurodevelopment (e.g., normal vs. abnormal) limits the generalizability and clinical utility of findings.

Developmental trajectories of eating behaviors and cross-lagged associations with weight across infancy.

Examining typical developmental trajectories of infant eating behaviors, correlates of those trajectories, and cross-lagged associations between eating behaviors and anthropometry, is important to understand the etiology of these behaviors and their relevance to growth early in the lifespan. Mothers (N = 276) completed the Baby Eating Behavior Questionnaire (BEBQ) and infant anthropometrics were measured at ages 1, 2, 4, 6, and 10 months. Infant and maternal characteristics were collected by maternal report. Trajectories of eating behaviors were identified using latent class growth modeling and bivariate analyses examined associations of infant eating behavior trajectory membership with infant and maternal characteristics. Cross-lagged analyses examined associations between BEBQ subscales and infant weight-for-length z-score. Infant eating behavior trajectories included: Consistently High (62%) and Consistently Moderate (38%) Enjoyment of Food; Consistently High (9%), Moderate & Decreasing (43%), and Low & Decreasing (48%) Food Responsiveness; and Consistently High (62%) and Moderate & Decreasing (38%) General Appetite. Trajectory group membership was not associated with infant sex, gestational age, birthweight, or having been exclusively fed breastmilk at 2 months. Consistently High trajectories for Enjoyment of Food, Food Responsiveness, and General Appetite were associated with maternal demographic markers of psychosocial risk (e.g., lower maternal age and educational attainment). Food Responsiveness and General Appetite tracked strongly across infancy within individuals. Cross-lagged associations of Enjoyment of Food, Food Responsiveness, and General Appetite with weight-for-length z-score across infancy were generally null. Much additional work is needed to understand eating behaviors in infancy, their development, and their etiology. Further understanding of infant eating behaviors will provide the basis for future interventions to improve life course nutrition, growth, and health.

Changes in Valganciclovir Use Among Infants with Congenital Cytomegalovirus Diagnosis in the United States, 2009-2015 and 2016-2019.

From 2009-2015 to 2016-2019, the proportion of infants in the US with congenital cytomegalovirus treated with valganciclovir roughly doubled for infants enrolled with employer-sponsored insurance (from 16% to 29%) and Medicaid (from 16% to 36%). The proportion treated with valganciclovir increased for all congenital cytomegalovirus disease severity groups.

Young adult nutrition and weight correlates of picky eating during childhood.

OBJECTIVE: To identify whether picky eating during childhood is associated with dietary intake, weight status and disordered eating behaviour during young adulthood. DESIGN: A population-based study using data from young adults who responded online or by mail to the third wave of the Project EAT (Eating and Activity in Teens and Young Adults) study in 2008-2009. Participants retrospectively reported the extent to which they were a picky eater in childhood, sociodemographic characteristics, disordered eating behaviours, usual dietary intake, and weight and height. SETTING: Participants were initially recruited in the Minneapolis/St. Paul metropolitan area of Minnesota, USA, in 1998-1999. PARTICIPANTS: The analytic sample included 2275 young adults (55 % female, 48 % non-Hispanic White, mean age 25·3 (sd 1·6) years). RESULTS: Young adults who reported picky eating in childhood were found to currently have lower intakes of fruit, vegetables and whole grains, and more frequent intakes of snack foods, sugar-sweetened beverages and foods from fast-food restaurants. No associations were observed between picky eating in childhood and young adults' weight status, use of weight-control strategies or report of binge eating. CONCLUSIONS: While young adults who report picky eating during childhood are not at higher risk for disordered eating, those who were picky eaters tend to have less healthy dietary intake. Food preferences and dietary habits established by picky eaters during childhood may persist into adulthood.

Maternal prompting types and child vegetable intake: Exploring the moderating role of picky eating.

BACKGROUND: It is unknown if using different maternal prompting types is associated with vegetable intake in children perceived to be picky versus non-picky. OBJECTIVES: 1) To test the correlation of counts of maternal prompting types with child vegetable intake, and picky eating, 2) to examine the interaction of prompting types and picky eating status on vegetable intake. DESIGN/METHODS: Low-income mother-child dyads (N = 199, mean child age 6.0 years) participated in a videotaped laboratory eating protocol with green beans, a familiar vegetable. A coding scheme was developed and reliably applied to categorize mothers' prompting types. The prompting types were: Coercive Control (Sub-Categories: Reward and Pressure-to-Eat), Autonomy Promotion (Sub-Categories: Modeling, Reasoning, Praise, and Question), and Total Prompts (sum of all prompts). Mothers completed questionnaires. Bivariate analyses tested the association between counts of maternal prompting types with amount of green beans eaten, and picky eating. Regression analyses examined the interaction of picky eating status with counts of maternal prompting type on amount of green beans eaten. RESULTS: Mothers used on average 1.66 prompts. Greater use of Coercive Control, Autonomy Promotion-Modeling, and Total Prompts were all inversely correlated with amount of green beans eaten. Greater use of Autonomy Promotion-Praise was directly correlated with amount of green beans eaten. In stratified models, greater use of Coercive Control prompts was negatively associated with amount of green beans eaten by the child in non-picky eaters, but not in picky eaters. There was no interaction between other prompting types and child picky eating status in predicting amount eaten. All p-values <0.05. CONCLUSIONS: Mothers use different prompting types to encourage their children to eat vegetables depending on their picky eating status, most of which may be correlated with reduced intake.

Feeding styles among mothers of low-income children identified using a person-centered multi-method approach.

BACKGROUND: Maternal feeding styles have been associated with children's eating behaviors and obesity risk. Few works have identified maternal feeding styles using a multi-method person-centered approach. OBJECTIVES: (1) To identify maternal feeding styles using a person-centered multi-method approach, and (2) to examine the association of child weight status with maternal feeding styles. METHODS: Participants were low-income mother-child dyads (N = 255) (mean child age 5.9 years) from the United States. Mothers completed questionnaires and participated in a semi-structured interview. Interview transcripts were reliably coded for constructs of child feeding including beliefs, goals, and concerns. Family mealtime video recordings were reliably coded for feeding behaviors. Child anthropometrics were measured. Latent class analysis (LCA) was used to determine empirically-driven typologies of maternal feeding styles. Chi-square analyses tested the association of maternal feeding styles with child overweight or obese (vs. not) weight status. RESULTS: Two maternal feeding styles were identified by LCA which we term "High Coercive Control" (27% child overweight/obese) and "Low Coercive Control" (55% child overweight/obese). High Coercive Control mothers were more likely to believe their child was too thin, self-reported being more demanding in feeding and pressuring the child to eat, worried more about their child not eating enough and were observed to use more bribery. Low Coercive Control mothers were concerned about their child eating too much, and were less likely to self-report engaging in pressuring or restricting feeding behaviors. CONCLUSIONS: The findings suggest that although there is a "feeding style" characterized by substantial control, this style was most common among mothers of thinner children. The mothers of children with overweight/obesity were primarily characterized by engaging in the "recommended" feeding behaviors and being appropriately concerned about their child's risk for excess weight.

Improving Obstetric Provider Congenital Cytomegalovirus Knowledge and Practices.

Background: Congenital cytomegalovirus infection (cCMV) is the most common congenital infection. Antenatal education is proven to reduce cCMV risk. Little is known about obstetric provider knowledge and practice patterns around cCMV. Objectives: To evaluate obstetric provider knowledge and practice patterns regarding cCMV at baseline and again after a brief educational intervention. Methods: Obstetric providers (N = 53) at a US academic community hospital were invited to complete a survey regarding their knowledge and practice patterns around cCMV. Providers attended a brief presentation about cCMV and later were invited to repeat the same survey. Univariate statistics were calculated for baseline data, and prepost intervention comparison analyses were conducted. Results: Baseline cCMV knowledge was low at 49% (M = 17.54 out of a possible 36, SD 6.4), with most providers (51%) reporting never counseling pregnant patients about cCMV. Post intervention, overall cCMV knowledge increased to 80% (M = 29.33, SD 4.1, p < .001); provider intention to counsel about cCMV prevention increased to 100%. Conclusions: Obstetric provider knowledge about cCMV is low, which likely impacts their antenatal counseling. Educational initiatives to increase awareness about cCMV may increase antenatal education and thereby decrease the risk of cCMV.

Coparenting in the feeding context: perspectives of fathers and mothers of preschoolers.

PURPOSE: This study examined how fathers and mothers coparent around child feeding. METHODS: Father-mother pairs (N = 30) of preschool-aged children (M child age = 4.1 years old) participated in joint or group interview sessions. RESULTS: Three themes emerged from the qualitative analysis: (1) couples' division of labor regarding feeding tasks seemed to align with stereotypical gender roles; (2) couples noted that they attempted healthier family eating habits in comparison to families of origin and recognized the influence of extended family on their attempts at healthier feeding; (3) couples agreed on the importance of family mealtime, routines, and healthy meals, yet disagreed on strategies to limit unhealthy foods and achieve harmonious family meals. CONCLUSIONS: This study identified processes of coparenting and child feeding areas that were particularly challenging to manage among parents, which could be important targets for childhood obesity interventions. LEVEL OF EVIDENCE: V, descriptive study.

Do children with obesity have worse table manners? Associations between child table manners, weight status and weight gain.

BACKGROUND: Children with obesity experience stigma stemming from stereotypes, one such stereotype is that people with obesity are "sloppy" or have poor manners. Teaching children "proper table manners" has been proposed as an obesity prevention strategy. Little is known about the association between children's weight status and table manners. OBJECTIVES: To examine correlates of child table manners and to examine the association of child table manners with child obese weight status and prospective change in child body mass index z-score (BMIz). METHODS: Mother-child dyads (N = 228) participated in a videotaped laboratory eating task with cupcakes. Coding schemes to capture child table manners (making crumbs, chewing with mouth open, getting food on face, shoving food in mouth, slouching, and getting out of seat), and maternal attentiveness to child table manners, were reliably applied. Anthropometrics were measured at baseline and at follow-up two years later. Regression analyses examined the association of participant characteristics with child table manners, as well as the associations of child table manners with child obese weight status, and prospective change in BMIz/year. RESULTS: Predictors of poorer child table manners were younger child age, greater cupcake consumption, and greater maternal attentiveness to child table manners. Poorer child table manners were not associated with child obese (vs. not) weight status, but were associated with a prospective decrease in BMIz/year in children with overweight/obesity. CONCLUSIONS: Obesity interventions to improve table manners may be perpetuating unfavorable stereotypes and stigma. Future work investigating these associations is warranted to inform childhood obesity guidelines around table manners.

Selective eating behaviors in children: An observational validation of parental report measures.

Selective eating in children is commonly measured by parental report questionnaires, yet it is unknown if parents accurately estimate their child's selective eating behavior. The objectives of this study were to test the validity and stability of two measures of selective eating using observed child behavior. Low-income mother-child dyads participated in a videotaped laboratory eating protocol at two time points (baseline: mean child age = 5.9 years; follow-up: mean child age = 8.6 years), during which they were presented with a familiar and an unfamiliar vegetable. Videos were reliably coded for child selective eating behaviors: amount consumed, child hedonic rating of vegetables, child compliance with maternal prompts to eat, latency to first bite, number of bites, and negative utterances. Mothers completed the Child Eating Behavior Questionnaire Food Fussiness (CEBQ FF) scale and the Food Neophobia Scale (FNS) at both time points. Questionnaire validity, stability of measured behaviors, and discriminant validity of questionnaires were examined in the full sample. CEBQ FF scores and FNS scores were both inversely correlated with the quantity consumed, child hedonic rating, and compliance with prompts to eat for both familiar and unfamiliar vegetables at baseline and at follow up. CEBQ FF and FNS scores were inversely correlated with number of bites (for both foods), positively correlated with latency to first bite (for both foods), and inversely correlated with child negative utterances (for the familiar food only). Notably, FNS scores correlated with observed behavior for both familiar and unfamiliar foods, rather than demonstrating a specific association with unfamiliar foods only. This study supports the validity of the CEBQ FF and FNS in low-income early school-aged children.

Maternal discouragement and child intake of a palatable dessert: A multilevel sequential analysis.

BACKGROUND: Family mealtimes are often marked by parent-child conflict, which may arise when children's eating behaviors do not match parental expectations. Little is known about how children respond to parents' comments to discourage eating. OBJECTIVE: The objective of this study was to examine the likelihood of a child taking a bite following a maternal statement to discourage child intake. METHODS: 50 mother-child dyads (mean child age 71.8 months) participated in a laboratory eating task with cupcakes. Video recordings were reliably coded for maternal statements to discourage child intake (varying by domains of affective valence and directness) and child bites. Multilevel sequential analysis was performed to determine differences in pairs' antecedent statement to discourage child intake and a child's discouraged bite. RESULTS: Children were significantly more likely to be non-compliant by taking a bite following negative (vs. positive), indirect (vs. direct) and negative direct (vs. positive direct) statements to discourage child intake (that is, a "discouraged bite"). There were no differences in children taking discouraged bites following a negative indirect vs. positive indirect statement to discourage child intake. CONCLUSIONS: Children may be more apt to comply with their mother's mealtime commands if they are delivered with a direct approach and a positive affective valence. Future work should examine the longitudinal effects of using positive direct mealtime commands on children's food intake, weight gain and emotional health.

Methodological considerations for observational coding of eating and feeding behaviors in children and their families.

BACKGROUND: Behavioral coding of videotaped eating and feeding interactions can provide researchers with rich observational data and unique insights into eating behaviors, food intake, food selection as well as interpersonal and mealtime dynamics of children and their families. Unlike self-report measures of eating and feeding practices, the coding of videotaped eating and feeding behaviors can allow for the quantitative and qualitative examinations of behaviors and practices that participants may not self-report. While this methodology is increasingly more common, behavioral coding protocols and methodology are not widely shared in the literature. This has important implications for validity and reliability of coding schemes across settings. Additional guidance on how to design, implement, code and analyze videotaped eating and feeding behaviors could contribute to advancing the science of behavioral nutrition. The objectives of this narrative review are to review methodology for the design, operationalization, and coding of videotaped behavioral eating and feeding data in children and their families, and to highlight best practices. METHODS: When capturing eating and feeding behaviors through analysis of videotapes, it is important for the study and coding to be hypothesis driven. Study design considerations include how to best capture the target behaviors through selection of a controlled experimental laboratory environment versus home mealtime, duration of video recording, number of observations to achieve reliability across eating episodes, as well as technical issues in video recording and sound quality. Study design must also take into account plans for coding the target behaviors, which may include behavior frequency, duration, categorization or qualitative descriptors. Coding scheme creation and refinement occur through an iterative process. Reliability between coders can be challenging to achieve but is paramount to the scientific rigor of the methodology. Analysis approach is dependent on the how data were coded and collapsed. CONCLUSIONS: Behavioral coding of videotaped eating and feeding behaviors can capture rich data "in-vivo" that is otherwise unobtainable from self-report measures. While data collection and coding are time-intensive the data yielded can be extremely valuable. Additional sharing of methodology and coding schemes around eating and feeding behaviors could advance the science and field.

Maternal encouragement and discouragement: Differences by food type and child weight status.

Childhood obesity prevention practice guidelines recommend that parents encourage the intake of certain types of foods and discourage the intake of others. It is unknown if parents of children of different weight statuses encourage or discourage their child's intake differently based on food type. The objective of this study was to determine the association of child weight status with maternal encouragement and discouragement of for four different types of food. A total of 222 mother-child dyads were video-taped during the standardized, sequential presentation of four foods to both participants: cupcakes (familiar dessert), green beans (familiar vegetable), halva (unfamiliar dessert) and artichoke (unfamiliar vegetable). Mother's encouragements and discouragements of child intake were reliably coded for each food type. Poisson regression models were used to test the independent association of child weight status (normal weight, overweight and obese) with encouragement and discouragement for each food type. Mothers of an obese, vs. normal or overweight child, had lower rates of encouragement for a familiar dessert (p = 0.02), and a higher rates of discouragements for a familiar dessert (p = 0.001), a familiar vegetable (p = 0.01), and an unfamiliar vegetable (p = 0.001). There were no differences in encouragements or discouragements between mothers of an overweight, vs. obese child, for any of the 4 food types. Mothers of obese children may alter their feeding behavior differentially based on food type. Future work should examine how interventions promoting maternal encouragement or discouragement of different food types impact child weight status.

Affective tone of mothers' statements to restrict their children's eating.

Maternal restrictive feeding behaviors have been associated with child weight status. The affective tone of mothers' statements intended to restrict their children's eating has not been examined. The objectives of this study were to describe the affective tone of mothers' restrictive feeding behaviors (positive or negative), and to test the association of child and mother characteristics with rates of Restriction with Positive Affect, Restriction with Negative Affect and Total Restriction. A total of 237 low-income child-mother dyads (mean child age 5.9 years) participated in a videotaped standardized laboratory eating protocol, during which mothers and children were both presented with large servings of cupcakes. A coding scheme was developed to count each restrictive statement with a positive affective tone and each restrictive statement with a negative affective tone. To establish reliability, 20% of videos were double-coded. Demographics and anthropometrics were obtained. Poisson regression models were used to test the association between characteristics of the child and mother with counts of Restriction with Positive Affect, Restriction with Negative Affect, and Total Restriction. Higher rates of Restriction with Positive Affect and Total Restriction were predicted by child obese weight status, and mother non-Hispanic white race/ethnicity. Higher rates of Restriction with Negative Affect were predicted by older child age, child obese weight status, mother non-Hispanic white race/ethnicity, and lower mother education level. In conclusion, in this study mothers of obese (vs. non-obese) children had higher rates of restriction in general, but particularly higher rates of Restriction with Negative Affect. Rather than being told not to restrict, mothers may need guidance on how to sensitively restrict their child's intake. Future studies should consider the contributions of maternal affect to children's responses to maternal restriction.

"You've got to settle down!": Mothers' perceptions of physical activity in their young children.

BACKGROUND: Mothers are important mediators of children's physical activity (PA) level and risk of obesity, however previous studies of maternal perceptions of child PA have been limited. Furthermore, it is unknown if maternal perceptions of child PA are predicted by family, mother and child characteristics. Therefore objectives of this study were to 1) evaluate maternal perceptions of PA in their children and 2) test associations of family, mother and child characteristics with these perceptions. METHODS: 278 low-income mothers of children (mean age 70.9 months) participated in an audio-taped semi-structured interview. Transcripts were systematically analyzed using the constant comparative method and themes were generated. A coding scheme to classify the themes appearing in each transcript was developed and reliably applied. Anthropometrics were measured. Demographics and questionnaires (the Confusion, Hubbub and Order Scale, The Parenting Scale, and the Child Behavior Questionnaire (CBQ)) were collected. Logistic regression models were used to test the associations of family, mother and child characteristics with each theme. RESULTS: In this sample of low-income United States mothers, two themes emerged: 1) Mothers perceive their children as already very active (87.8%, n = 244), predicted by the child being younger, the child not being overweight, and higher child CBQ Activity Level; and 2) Mothers view their children's high activity level as problematic (27.0%, n = 75), predicted by lower Parenting Laxness, the child being male and lower child CBQ Inhibitory Control. CONCLUSIONS: Low-income United States mothers have unique perceptions of PA in their children; these beliefs are associated with characteristics of the child and mother but not characteristics of the family. Further understanding of contributors to maternal perceptions of child PA may inform future childhood obesity interventions. The influence of these perceptions on physical activity outcomes in low-income children should be pursued in future research.

The case of the missing testicle: blunt scrotal trauma in the pediatric emergency department.

Serious blunt scrotal trauma in the pediatric population is rare and can pose significant danger to the viability of the testes. The following case describes an adolescent boy who presented with a single testis in his scrotum after low-impact perineal trauma, consistent with testicular dislocation. The literature regarding scrotal trauma includes few cases of testicular dislocation from low-impact perineal trauma. Included is a brief review of the most recent data including epidemiology, differential diagnosis, acute management, and complications pertinent to the pediatric emergency clinician.