Identifying priority double-duty actions to tackle the double burden of malnutrition in infants and young children in Peru: Assessment and prioritisation of government actions by national experts.

Multiple forms of malnutrition coexist in infants and young children (IYC) in Peru. The World Health Organization has proposed double-duty actions (DDAs) to simultaneously address undernutrition and overweight/obesity. We assessed current implementation of- and priority for- government-level actions to tackle multiple forms of malnutrition in IYC in Peru. Mapping of current policy activity was undertaken against 47 indicators of good practice for five DDAs (exclusive breastfeeding, complementary feeding, food marketing, maternal nutrition, preschool nutrition; assessed by 27 indicators) and for the enabling policy environment, i.e., 'infrastructure support' (health in all policies, platforms for interactions, financing, monitoring, governance, leadership; assessed by 20 indicators). Interviews with 16 national experts explored views on the level of and barriers to implementation of DDAs and infrastructure support, as well as their prioritisation based on likely impact and feasibility. The level of implementation of actions was categorised into two groups (agenda setting/formulation vs. implementation/evaluation). Mean scores were generated for prioritisation of DDAs and infrastructure support. Deductive qualitative analysis was undertaken to identify barriers that influence policy implementation. Only 5/27 DDA indicators were reported as fully implemented by all national experts (international code that regulates the marketing of breastmilk substitutes, iron supplementation for IYC, micronutrient powders in IYC, iron/folic acid supplementation in pregnant women, paid maternity leave). Only 1/20 infrastructure support indicator (access to nutrition information) was rated as fully implemented by all experts. Barriers to implementing DDAs and infrastructure support included: legal feasibility or lack of regulations, inadequate monitoring/evaluation to ensure enforcement, commercial influences on policymakers, insufficient resources, shifting public health priorities with the COVID-19 pandemic and political instability. The experts prioritised 12 indicators across all five DDAs and eight infrastructure support indicators. Experts highlighted the need to improve implementation of all DDAs and identified ways to strengthen the enabling policy environment.

Utilising online paradigms to explore the effect of boredom and sadness on children's snack choice: The role of parental feeding practices and child temperament.

Emotional eating (EE) is defined as eating in response to negative emotions (e.g., sadness and boredom). Child temperament and parental feeding practices are predictive of child EE and may interact to shape child EE. Previous research has demonstrated that children eat more when they are experiencing sadness, however, boredom-EE (despite how common boredom is in children) has yet to be explored experimentally using remote methodologies. The current study explores whether feeding practices and child temperament interact with mood to predict children's snack selection in an online hypothetical food choice task. Using online experimental methods, children aged 6-9-years (N = 347) were randomised to watch a mood-inducing video clip (control, sadness, or boredom). Children completed a hypothetical food choice task from images of four snacks in varying portion sizes. The kilocalories in children's online snack choices were measured. Parents reported their feeding practices and child's temperament. Results indicated that the online paradigm successfully induced feelings of boredom and sadness, but these induced feelings of boredom and sadness did not significantly shape children's online food selection. Parental reports of use of restriction for health reasons (F = 8.64, p = .004, n2 = 0.25) and children's negative emotionality (F = 6.81, p = .009, n2 = 0.020) were significantly related to greater total kilocalorie selection by children. Three-way ANCOVAs found no evidence of any three-way interactions between temperament, feeding practices, and mood in predicting children's online snack food selection. These findings suggest that children's hypothetical snack food selection may be shaped by non-responsive feeding practices and child temperament. This study's findings also highlight different methods that can be successfully used to stimulate emotional experiences in children by using novel online paradigms, and also discusses the challenges around using online methods to measure children's intended food choice.

Examining parents' experiences and challenges of feeding preschool children with avid eating behaviour.

Avid eating behaviours, including greater responsiveness to food cues and emotional over-eating, have been linked to child overweight and obesity. Parental feeding practices are modifiable components of a child's food environment and may be key levers for behaviour change in tailored interventions to support parents of children with avid eating behaviour. However, there is a lack of research examining parents' experiences in this context. This study aimed to explore parents' experiences of feeding children with avid eating behaviour and to understand any challenges experienced in this context. Semi-structured interviews with parents (N = 15) of a preschool child (3-5 years) identified as having an avid eating behaviour profile explored how children's avid eating manifests, the parental feeding practices used to manage avid eating, and the perceived effectiveness of these strategies. Data were analysed using reflexive thematic analysis. Four core themes were generated. Theme one, 'Have they got worms? Children's insatiable hunger', captures parents' interpretation of the complex ways in which avid eating behaviour manifests. Theme two, 'Parenthood as a duty', illustrates how parents' perceived responsibilities shape their feeding practices. Theme three, 'Lifelong habits', captures parents' use of responsive feeding practices to support children's healthy relationship with food. Theme four, 'Picking battles', captures the structure- and coercive-based feeding strategies commonly used to manage children's avid eating. This novel study provides an in-depth understanding of the complex ways that children's avid eating behaviour manifests, and the strategic and creative parental feeding practices used to manage these behaviours. Such findings are valuable for informing the development of future support resources for parents/caregivers to help their children with avid eating behaviours to develop a healthy relationship with food.

Examining Parent Mood, Feeding Context, and Feeding Goals as Predictors of Feeding Practices Used by Parents of Preschool Children With Avid Eating Behavior: Protocol for an Ecological Momentary Assessment Study.

BACKGROUND: An avid eating behavior profile is characterized by a greater interest in food and a tendency to overeat in response to negative emotions. Parents use specific strategies to manage feeding interactions with children with avid eating behavior. While momentary and contextual factors, such as parental mood, have been found to influence parental feeding practices, there is a lack of research examining parents' daily experiences of feeding children with avid eating behavior. Examining this is important because parental feeding practices are key levers in tailored interventions to support children's healthy eating behavior. OBJECTIVE: We aim to describe the ecological momentary assessment methods and procedures used in the APPETItE (Appetite in Preschoolers: Producing Evidence for Tailoring Interventions Effectively) project, which aims to examine how variation in parental mood, feeding goals, and the context of eating occasions affect the parental feeding practices used to manage feeding interactions with children with an avid eating behavior profile. METHODS: Participants are primary caregivers from the APPETItE cohort who have a preschool-age child (aged 3-5 years) with an avid eating behavior profile. Caregivers complete a 10-day ecological momentary assessment period using signal- and event-contingent surveys to examine (1) mood and stress, (2) parental feeding goals, and (3) contextual factors as predictors of parental feeding practices. RESULTS: Recruitment and data collection began in October 2023 and is expected to be completed by spring 2024. The data have a 3-level structure: repeated measurements (level 1) nested within days (level 2) nested within an individual (level 3). Thus, lag-dependent models will be conducted to test the main hypotheses. CONCLUSIONS: The findings from this study will provide an understanding of caregivers' daily experiences of feeding preschool children with avid eating behavior, who are at greater risk for the development of obesity. Understanding the predictors of feeding practices at the moment they occur, and across various contexts, will inform the development of tailored resources to support caregivers in managing children's avid eating behavior. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55193.

"A good way to start the day": UK-based parents' views about offering vegetables to children for breakfast.

Children in the UK do not eat enough vegetables for optimal health and development; therefore, considering methods to increase children's vegetable intake is critical. Currently, if UK children are offered vegetables to eat, this typically occurs at midday/evening meals, and/or for snacks - children are seldom offered vegetables at breakfast time, even though there is no medical, nutritional, or physiological reason not to. Therefore, this study aimed to explore the views and experiences of parents in relation to offering children (aged 18 months to four years) vegetables to eat at breakfast time. Semi-structured interviews were conducted with 18 parents (aged 27-51 years) who were asked for their opinions about offering vegetables to children at breakfast time, and about their perceptions of their child(ren)'s behaviours in relation to vegetables at breakfast. A thematic analysis of the data identified the following themes/sub-themes relating to parents' views and experiences: 1) willingness - there was widespread willingness amongst parents to offer their chid(ren) vegetables at breakfast time; 2) barriers - relating to social/behavioural norms (parent/family and societal), practical challenges, and vegetables being commonly disliked by children; 3) facilitators - relating to young children not yet having developed social norms around foods, various practical solutions, and the need for information and awareness campaigns to highlight how and why vegetables can be incorporated into children's breakfasts. These encouraging findings for optimising children's health via this novel approach suggest that further research and dissemination around the value of offering children vegetables for breakfast is required.

Socioeconomic inequalities in early child development in children aged under 36 months in South Asia: A systematic review.

BACKGROUND: In South Asia, 89 million children under 5 are at risk of not reaching their developmental potential. Household socioeconomic position (SEP) is a determinant of early child development (ECD). However, synthesised evidence for the association between ECD and SEP in young children in South Asia is not available. Therefore, this review synthesises evidence on the relationship of household SEP with ECD in children under 36 months of age in South Asia. METHOD: PubMed, Cochrane Library, MEDLINE and Scopus were systematically searched to identify studies from South Asian countries that reported evidence on the association between SEP and ECD. Search terms included items related to motor, cognitive, language and socioemotional development. Study quality was assessed using the QualSyst tool, with three quality levels (high/medium/low), and a narrative review for each ECD outcome was constructed (PROSPERO registration: CRD42019131533). RESULTS: Twelve of the 950 publications screened met the inclusion criteria (nine from India, two Nepal and one Bangladesh). The majority (n = 10, 83%) reported language development on its own or alongside another ECD outcome. Fewer articles assessed cognitive (n = 6, 50%), motor (n = 7, 58%) or socioemotional development (n = 3, 25%). Higher SEP was associated with better ECD for one third of the associations reported. One ECD outcome (socioemotional development) was negatively associated (with socioeconomic status) based on low quality evidence. Mother's education and family income were the major SEP constructs associated with ECD. One, four and seven studies were rated as having a low, medium and high risk of bias, respectively. CONCLUSION: This review reveals the scarcity of evidence exploring associations between household SEP and ECD in children under 36 months in South Asia, especially outside of India. Enhancing evidence for associations between ECD and SEP is needed for evidence-based policy making to reduce developmental delays associated with a disadvantaged SEP in the South Asian region.

Identifying an avid eating profile in childhood: Associations with temperament, feeding practices and food insecurity.

This study aimed to identify distinct eating behaviour profiles in young children and examine how other key predictors of children's eating behaviour, including child temperament, the experience of food insecurity, or parental feeding practices, may vary by identified profiles. An online survey was conducted with 995 parents/carers living in England and Wales (N = 995, Mage = 35.4 years, 80% female, 88% White). Participants reported on their child's eating behaviour using the Child Eating Behaviour Questionnaire and completed measures of child temperament, household food security and parental feeding practices. Latent Profile Analysis (LPA) was carried out to identify distinct eating profiles amongst the children (36-72 months, Mage = 48.8 months, 52% female). Four eating profiles emerged from the sample of children: (a) avid eating, (b) avoidant eating, (c) happy eating, and (d) typical eating. Avid eating (21.9% of children) was characterised by higher levels of food responsiveness, enjoyment of food, and emotional over-eating in combination with lower satiety responsiveness, slowness in eating and food fussiness. Children with an avid eating profile were reported to be more surgent and experienced greater food insecurity than all other eating profiles. Parents of children belonging to the avid eating profile showed significantly greater use of food for emotional regulation, varied and balanced food provision, restriction of food for health, and restriction of food for weight feeding practices than the three other eating profiles.

Exploring the feasibility of using evidence-based feeding practices to promote children's healthy eating in holiday clubs.

OBJECTIVE: Encouraging healthy eating is a public health priority in the United Kingdom (UK), given the high prevalence of poor diet and overweight/obesity among school-aged children. Holiday clubs are organisations providing childcare and activities during the school holidays and frequently provide food to children at risk of food insecurity, primarily through government-funded programmes like the Holiday Activities and Food programme. However, the research suggests that holiday clubs could do more to maximise opportunities to promote children's healthy eating by using evidence-based feeding practices. DESIGN: During August-September 2020, video-based interviews were conducted exploring staff perceptions of the feasibility of using four evidence-based feeding practices to promote children's healthy eating: modelling; involvement in food choice; involvement in food preparation and cooking and involvement in meal planning. Feasibility was assessed using four dimensions of a feasibility framework (acceptability, demand, practicality and implementation). SETTING: UK holiday clubs. PARTICIPANTS: Twenty-five staff actively involved in delivering UK holiday clubs (project leaders, coordinators, cooks and coaches/youth workers). RESULTS: Staff generally reported good acceptability (dimension 1) and demand (dimension 2) for the feeding practices. However, the practicality (dimension 3) of using the practices was dependent on various factors (logistics, resources, staff readiness, children, peers and parents). Promisingly, in the fourth feasibility dimension (implementation), staff provided numerous practical solutions to overcome these barriers. CONCLUSIONS: Evidence-based feeding practices can be implemented in numerous ways and are therefore generally feasible in holiday clubs. Holiday clubs should be empowered to use evidence-based feeding practices through training resources, sharing networks and provision of sustainable funding.

A conceptual framework of urban food security and nutrition in low- and middle-income country settings applied to the Asia-Pacific region.

A conceptual framework is presented for enhancing food security and nutrition in urban areas in low- and middle-income countries, highlighting key influencing factors, including food supply chains, community food environments, community infrastructure and services, and numerous underlying individual and household determinants, such as behaviours and dietary practices.

An intervention mapping adaptation framework to develop a self-help intervention for athletes with eating disorder symptoms.

OBJECTIVE: This research forum describes the use of the intervention mapping for adaptation (IMA) framework to develop and evaluate a novel intervention for athletes with mild eating disorder (ED) symptoms. METHODS: The six IMA steps were followed. In step 1 (needs assessment), we conducted a systematic review of athlete ED interventions and held interviews/focus groups with athletes and sports professionals to inform intervention format and delivery. In step 2 (intervention search), needs assessment information guided the search for an evidence-based intervention suitable for adaptation to athletes. In steps 3 and 4 (intervention development), the identified intervention was adapted and feedback sought from athletes and sport professionals. In steps 5 and 6 (implementation and evaluation), a feasibility study was conducted with athletes (n = 35; females: n = 27; Mage = 27.1). RESULTS: The review highlighted poor evidence for the acceptability and relative efficacy of existing interventions, which were all delivered face-to-face in groups. Interview/focus group data suggested a need for more accessible intervention formats (e.g., self-help). One non-athlete self-help intervention was determined suitable for adaptation to athletes, and adaptations were made. Initial feedback suggested the adapted intervention was relevant within sport settings. The feasibility study revealed that the intervention (MOPED-A: Motivational and Psycho-Educational Self-Help Programme for Athletes with Mild Eating Disorder Symptoms) can be feasibly implemented, is acceptable to athletes and shows potential for reducing ED symptoms. DISCUSSION: IMA is a useful framework for developing participant-centered and evidence-based interventions. The findings and approach taken provide a framework for other researchers and clinicians in developing similar interventions in the ED domain. PUBLIC SIGNIFICANCE: The novel self-help intervention described in this article was developed using intervention mapping and provides promise as a tool for reducing eating disorder symptoms in athletes. We describe how adopting and systematically following a health intervention development approach, such as intervention mapping, can ensure that eating disorder interventions are participant-centered, contextually relevant, and evidence-based, which in turn could help to maximize their reach and effectiveness.

What is missing in our understanding of urban slum environments and maternal, infant and young child nutrition from publicly available data in Asia and the Pacific?

Given the recent, rapid urbanisation in Asia and the Pacific region, coupled with increases in the triple burden of malnutrition, we need to better understand maternal, infant and young child nutrition (MIYCN) for populations living in urban slum environments. This research used existing large-scale datasets to explore MIYCN indicators for those living in urban slum, compared with urban nonslum, areas. Data since 2015 from available Demographic and Health Surveys (DHS; Afghanistan, India, Indonesia, Myanmar, Pakistan and the Philippines) and Multiple Indicator Cluster Surveys (MICS; Bangladesh, Fiji, Kiribati, Mongolia, Nepal, Thailand and Tuvalu) were analysed. Most urban children in the 13 countries from the region were breastfed within 24 h of birth, with slightly higher rates for those living in slums. Conversely, almost all indicators of infant and young child malnutrition were worse for those in urban slums. For mothers living in slums, underweight prevalence and iron deficiency anaemia were higher while maternal overweight and obesity prevalence were lower. Analysis revealed disparities across countries in the wealth status of those living in slum versus nonslum areas. What is currently missing is representative sampling of households, adequate collection of data both within and across countries, and accurate representation of slum-dwellers in large-scale surveys. Given that limited data for the region show urban poor slum populations are vulnerable to poor nutrition indicators, more data are needed on the poorest urban slum populations to enable effective resource allocation to support optimal MIYCN.

Role-model, reoffer, reward: A thematic analysis and TDF mapping of influences on families' use of evidence-based vegetable feeding practices.

Children's vegetable intake is low, despite benefits for immediate and long-term health. Repeatedly reoffering vegetables, role-modelling consumption, and offering non-food rewards effectively increase children's vegetable acceptance and intake. However, a number of barriers prevent families from reoffering previously-rejected vegetables. This study used the Theoretical Domains Framework (TDF) and the COM-B model of behaviour to explore barriers and enablers to reoffering, role-modelling and offering non-food rewards among parents of 2-4-year-old children. Twenty-five semi-structured interviews were conducted, from which eleven core inductive themes were generated: 'Child factors', 'Eating beliefs', 'Effectiveness beliefs', 'Past experience', 'Current family behaviours', 'Harms', 'Knowledge', 'Need for change', 'Parent effort', 'Parent values' and 'Practical issues'. The codes underpinning these themes were inductively mapped to 11 of the 14 TDF domains, and five of the six COM-B components. Previously-reported influences on families' vegetable feeding practices were confirmed, including concerns about child rejection of foods/meals, cost of vegetables, and food waste. Novel findings included some parents' perceptions that these practices are pressurising, and that certain beliefs/knowledge about children's eating behaviour can provide a "protective mindset" that supports families' perseverance with reoffering over time. Future interventions should be tailored to better reflect the diversity of needs and previous experiences of feeding that families have, with some families likely to find that troubleshooting and further signposting is appropriate for their needs while others might benefit from more persuasive and educational approaches. The mapping of codes to the TDF and COM-B will facilitate the identification of appropriate intervention functions and behaviour change techniques when designing new interventions to support families with increasing their children's vegetable intake.

Reciprocal associations between parental feeding practices and child eating behaviours from toddlerhood to early childhood: bivariate latent change analysis in the Gemini cohort.

BACKGROUND: Parental feeding practices (PFPs) are a key component of a child's food environment. Parent-child feeding relationships are hypothesised to be bidirectional; however, to date, few large prospective studies have examined this, instead focussing on unidirectional relationships. As such, the direction of relationships between PFPs and children's eating behaviours remains unclear. METHODS: Data were from Gemini, a population-based sample of children born in England and Wales in 2007. Children's eating behaviours and PFPs were measured at 15/16 months and 5 years using validated psychometric measures (n = 1,858 children). Bivariate Latent Change Score Modelling was used to examine the nature of relationships between PFPs and children's eating behaviours at 15/16 months and 5 years. Models were adjusted to account for clustering of twins within families and for sex of the child, socioeconomic status, gestational age and age of the child at measurement time points. RESULTS: A reciprocal relationship was observed between instrumental feeding and emotional overeating, with greater instrumental feeding predicting greater increases in emotional overeating (ß = .09; 0.03-0.15; p = .004) and vice versa (ß = .09; 0.03-0.15; p = .005). Reciprocity was also observed between encouragement to eat nutritious foods and children's enjoyment of food, with greater encouragement predicting greater increases in enjoyment of food (ß = .08; 0.02-0.13; p = .006) and vice versa (ß = .07; 0.02-0.11; p = .003). Parent-child associations and child-parent associations were also observed. CONCLUSION: These findings are consistent with the hypothesis that certain feeding practices are used as a 'natural' response to a child expressing a greater interest in and enthusiasm for food, but at the same time, such practices impact the development of eating behaviours by nurturing and encouraging the expression of higher emotional overeating and greater enjoyment of food in preschool years. The findings provide important insights into the PFPs and eating behaviour traits that could be targeted as part of a tailored feeding intervention to support parents of children during the preschool formative years.

Parental feeding practices as a response to child appetitive traits in toddlerhood and early childhood: a discordant twin analysis of the Gemini cohort.

BACKGROUND: Parental feeding practices (PFPs) have been implicated in the development of children's eating behaviours. However, evidence suggests that feeding practices may also develop in response to their child's weight or emerging appetitive traits. We used the twin design to test the hypothesis that parents develop their feeding practices partly in response to their child's appetite. METHODS: Data were from Gemini, a population-based cohort of 2402 British families with twins born in 2007. Psychometric measures of PFPs and appetite were completed by parents when their twins were 16-months and 5-years. Within-family analyses including all twins with available data in the sample (n = 1010-1858 pairs), examined if within-pair differences in PFPs were associated with differences in appetitive traits, controlling for differences in birth weight-SDS, early feeding method and child sex. In a subsample of twin pairs who were considerably discordant for appetitive traits by ≥ 1SD (n = 122-544 pairs), the direction and magnitude of within-pair differences in feeding practices was explored. RESULTS: Within-family variation in parental feeding practices in toddlerhood and early childhood was low (discordance ranged from 0.1 to 6% of the sample), except for pressure to eat (toddlerhood: 19%; early childhood: 32%). Within-pair differences in all appetitive traits were associated with differential use of 'pressure to eat' at both 16-months and 5-years. In the subsample of twins most discordant for appetitive traits, parents used more pressure with the twin expressing lower food responsiveness, lower emotional overeating, lower food enjoyment, higher satiety responsiveness, slower speed of eating, higher emotional undereating and greater fussiness in toddlerhood and early childhood (p-values < 0.001). Effect sizes were small to large at 16-months (η2=0.02-0.09) and 5-years (η2=0.05-0.21). CONCLUSION: Parents rarely varied their feeding practices between twins in toddlerhood and early childhood, except for pressure. Parents exerted greater pressure on their twin who expressed a poorer appetite compared to their co-twin, suggesting that parents develop a pressuring feeding style when their child expresses a poorer appetite or lower interest in, and enthusiasm for, eating. These findings could be used to guide interventions seeking to support parents in feeding their children in a way that nurtures the development of healthy eating behaviours.

Prospective associations between parental feeding practices used in toddlerhood and preschool children's appetite vary according to appetite avidity in toddlerhood.

Parental feeding practices are a key modifiable component of children's food environments. Evidence suggests that certain feeding practices may differentially influence children's eating behaviour or weight, depending on the child's temperament (e.g. emotionality). Building on this work, we tested the hypothesis that feeding practices during toddlerhood influence children's developing eating behaviours differently, depending on their appetite avidity (which is characterised by a larger appetite and greater interest in food). Data were from Gemini, a population-based cohort of British twin children born in 2007. Parental feeding practices were assessed at 15/16-months, and child appetite at 15/16-months and 5-years, using validated psychometric measures (n = 1858 children). Complex samples general linear models examined prospective associations between PFPs at 15/16-months and child appetitive traits at 5-years, adjusting for clustering of twins within families and for the corresponding child appetitive trait at 15/16-months, difference in age between timepoints, child sex, gestational age, and socioeconomic status. Moderation analyses revealed that pressuring a child to eat led to greater increases in emotional overeating from 15/16-months to 5-years, only for children with high (1 SD above the mean: B = 0.13; SE± = 0.03,p < 0.001) or moderate emotional overeating (mean: B = 0.07 ± 0.03,p < 0.001) in toddlerhood. Greater covert restriction predicted greater reductions in emotional overeating and food responsiveness from 15/16-months to 5-years, only for children with high emotional overeating (1 SD above the mean: B = -0.06 ± 0.03,p = 0.03) and low food responsiveness (1 SD below the mean: B = -0.06 ± 0.03,p = 0.04) in toddlerhood. These findings are consistent with the hypothesis that children with a more avid appetite in toddlerhood are differentially affected by parental feeding practices; caregivers of toddlers may therefore benefit from feeding advice that is tailored to their child's unique appetite.

Offering vegetables to children at breakfast time in nursery and kindergarten settings: the Veggie Brek feasibility and acceptability cluster randomised controlled trial.

BACKGROUND: In many Westernised countries, children do not consume a sufficient amount of vegetables for optimal health and development. Child-feeding guidelines have been produced to address this, but often only promote offering vegetables at midday/evening meals and snack times. With guidance having limited success in increasing children's vegetable intake at a population level, novel approaches to address this must be developed. Offering vegetables to children at breakfast time in nursery/kindergarten settings has the potential to increase children's overall daily vegetable consumption as children typically attend nursery/kindergarten and many routinely eat breakfast there. However, the feasibility and acceptability of this intervention (Veggie Brek) to children and nursery staff has not been investigated. METHODS: A feasibility and acceptability cluster randomised controlled trial (RCT) was undertaken in eight UK nurseries. All nurseries engaged in one-week baseline and follow-up phases before and after an intervention/control period. Staff in intervention nurseries offered three raw carrot batons and three cucumber sticks alongside children's main breakfast food each day for three weeks. Control nurseries offered children their usual breakfast. Feasibility was assessed by recruitment data and nursery staff's ability to follow the trial protocol. Acceptability was assessed by children's willingness to eat the vegetables at breakfast time. All primary outcomes were assessed against traffic-light progression criteria. Staff preference for collecting data via photographs versus using paper was also assessed. Further views about the intervention were obtained through semi-structured interviews with nursery staff. RESULTS: The recruitment of parents/caregivers willing to provide consent for eligible children was acceptable at 67.8% (within the amber stop-go criterion) with 351 children taking part across eight nurseries. Both the feasibility and acceptability of the intervention to nursery staff and the willingness of children to consume the vegetables met the green stop-go criteria, with children eating some part of the vegetables in 62.4% (745/1194) of instances where vegetables were offered. Additionally, staff preferred reporting data using paper compared to taking photographs. CONCLUSIONS: Offering vegetables to children at breakfast time in nursery/kindergarten settings is feasible and acceptable to children and nursery staff. A full intervention evaluation should be explored via a definitive RCT. TRIAL REGISTRATION: NCT05217550.

COVID-19 and coping: Absence of previous mental health issues as a potential risk factor for poor wellbeing in females.

COVID-19 has caused unprecedented disruption to everyday life. Unsurprisingly, this has resulted in increased prevalence of poor mental wellbeing. While previous mental health issues have been consistently flagged as a risk factor, the absence of these may also leave individuals vulnerable due to a lack of psychological coping strategies. This study explored the change in symptoms of anxiety, depression, and trauma in 167 females who provided data at four timepoints over the course of the first year of the pandemic. There was a significant effect of time on the extent of the change in depression but, for all wellbeing measures, those with current or previous mental health issues experienced a similar magnitude of change as those with no previous issues. This suggests that low-risk individuals may be faring worse, relatively. Ensuring that this group is not overlooked will be imperative in protecting and re-building the wellbeing of the nation.

Strategies and behaviors used by mothers in interactions with their young children during a mealtime in peri-urban areas of Huánuco, Peru.

This study aimed to gain an in-depth understanding about different strategies used by mothers to feed their 6-23-month-old children, as well as to learn about mothers' behaviors in response to situations of food refusal by her child, in order to generate evidence that contributes to the information gap on responsive feeding in Peru. The study was conducted in the city of Huánuco, a peri-urban area of Peru, with mothers of children in the complementary feeding stage participating. An in-depth 5-hour home observation was conducted in eight mother-child dyads. Both the mothers' and children's mealtime and food-related behaviors were coded and an inductive thematic analysis was applied. The primary objective of many of the strategies used by the mothers was to get their child to eat a little more. Six strategies were identified: pressure, encouragement, facilitating intake, acceptance, negotiation and reasoning. Certain differences were found in the strategies employed by the mother according to the age of her child, with mothers of younger children using more encouragement and mothers of older children using more pressure for their child to eat. The mothers' behavior in response to the child's refusal of food was both responsive and non-responsive (controlling), depending on the reason for the refusal. The findings are of great value for understanding about the feeding interactions of mother-child dyads in Peru and they start to address the information gap and can support the development of nutritional intervention strategies for use with children.

Nurturing children's development through healthy eating and active living: Time for policies to support effective interventions in the context of responsive emotional support and early learning.

Fostering the growth, development, health, and wellbeing of children is a global priority. The early childhood period presents a critical window to influence lifelong trajectories, however urgent multisectoral action is needed to ensure that families are adequately supported to nurture their children's growth and development. With a shared vision to give every child the best start in life, thus helping them reach their full developmental potential, we have formed the International Healthy Eating Active Living Matters (HEALing Matters) Alliance. Together, we form a global network of academics and practitioners working across child health and development, and who are dedicated to improving health equity for children and their families. Our goal is to ensure that all families are free from structural inequality and oppression and are empowered to nurture their children's growth and development through healthy eating and physical activity within the context of responsive emotional support, safety and security, and opportunities for early learning. To date, there have been disparate approaches to promoting these objectives across the health, community service, and education sectors. The crucial importance of our collective work is to bring these priorities for early childhood together through multisectoral interventions, and in so doing tackle head on siloed approaches. In this Policy paper, we draw upon extensive research and call for collective action to promote equity and foster positive developmental trajectories for all children. We call for the delivery of evidence-based programs, policies, and services that are co-designed to meet the needs of all children and families and address structural and systemic inequalities. Moving beyond the "what" is needed to foster the best start to life for all children, we provide recommendations of "how" we can do this. Such collective impact will facilitate intergenerational progression that builds human capital in future generations.

Improving early childhood development in the context of the nurturing care framework in Kenya: A policy review and qualitative exploration of emerging issues with policy makers.

Introduction: The Nurturing Care Framework (NCF) describes "nurturing care" as the ability of nations and communities to support caregivers and provide an environment that ensures children's good health and nutrition, protects them from threats, and provides opportunities for early learning through responsive and emotionally supportive interaction. We assessed the extent to which Kenyan government policies address the components of the NCF and explored policy/decision makers' views on policy gaps and emerging issues. Methods: A search strategy was formulated to identify policy documents focusing on early childhood development (ECD), health and nutrition, responsive caregiving, opportunities for early learning and security and safety, which are key components of the NCF. We limited the search to policy documents published since 2010 when the Kenya constitution was promulgated and ECD functions devolved to county governments. Policy/decision-maker interviews were also conducted to clarify emerging gaps from policy data. Data was extracted, coded and analyzed based on the components of the NCF. Framework analysis was used for interview data with NCF being the main framework of analysis. The Jaccard's similarity coefficient was used to assess similarities between the themes being compared to further understand the challenges, successes and future plans of policy and implementation under each of the NCF domains. Results: 127 policy documents were retrieved from government e-repository and county websites. Of these, n = 91 were assessed against the inclusion criteria, and n = 66 were included in final analysis. The 66 documents included 47 County Integrated Development Plans (CIDPs) and 19 national policy documents. Twenty policy/decision-maker interviews were conducted. Analysis of both policy and interview data reveal that, while areas of health and nutrition have been considered in policies and county level plans (coefficients >0.5), the domains of early learning, responsive caregiving and safety and security face significant policy and implementation gaps (coefficients ≤ 0.5), particularly for the 0-3 year age group. Inconsistencies were noted between county level implementation plans and national policies in areas such as support for children with disabilities and allocation of budget to early learning and nutrition domains. Conclusion: Findings indicate a strong focus on nutrition and health with limited coverage of responsive caregiving and opportunities for early learning domains. Therefore, if nurturing care goals are to be achieved in Kenya, policies are needed to support current gaps identified with urgent need for policies of minimum standards that provide support for improvements across all Nurturing Care Framework domains.