New Methodologies for Conducting Maternal, Infant, and Child Nutrition Research in the Era of COVID-19.

The severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) outbreak rapidly became a worldwide pandemic in early 2020. In Australia, government-mandated restrictions on non-essential face-to-face contact in the healthcare setting have been crucial for limiting opportunities for COVID-19 transmission, but they have severely limited, and even halted, many research activities. Our institute's research practices in the vulnerable populations of pregnant women and young infants needed to adapt in order to continue without exposing participants, or staff, to an increased risk of exposure to COVID-19. Here, we discuss our pre-and-post COVID-19 methods for conducting research regarding nutrition during pregnancy, infancy, and early childhood. We discuss modifications to study methods implemented to avoid face-to-face contact when identifying and recruiting potential participants, gaining informed consent, conducting appointments, and collecting outcome data, and the implications of these changes. The COVID-19 pandemic has required numerous changes to the conduct of research activities, but many of those modifications will be useful in post-COVID-19 research settings.

Child-Centered Nutrition Phrases Plus Repeated Exposure Increase Preschoolers' Consumption of Healthful Foods, but Not Liking or Willingness to Try.

OBJECTIVE: To determine whether the use of child-centered nutrition phrases (CCNP) with repeated exposure (RE) improved willingness to try, liking, and consumption of healthful foods compared with RE alone. DESIGN: The researchers used a 2 × 2 × 4 fractionated within-subjects experimental design in the study: phrase condition (RE vs CCNP + RE) by time of measurement (preintervention, postintervention, and 1-month follow-up), by type of food (tomatoes, bell peppers, lentils, and quinoa). SETTING: Children were recruited from 2 early education centers; 89% participated. PARTICIPANTS: Children aged 3-6 years old (n = 87) who were predominantly white (67%) and from middle-income homes and had parents with some higher education. INTERVENTION: Adult delivery of CCNP + RE weekly for 6 weeks. MAIN OUTCOME MEASURE(S): Willingness to try, change in liking, and change in consumption. ANALYSIS: Two-level random-effects models were used to account for repeated measurements of willingness to try, liking, and consumption nested within participants. RESULTS: Children exhibited greater consumption of CCNP foods at follow-up assessment compared with RE foods (b = -16.28, SE = 5.41, t(528) = 3.01; P = .003). CONCLUSIONS AND IMPLICATIONS: Use of CCNP combined with RE may encourage healthy eating, especially for novel foods that children may typically refuse.

Position of the Academy of Nutrition and Dietetics, Society for Nutrition Education and Behavior, and School Nutrition Association: Comprehensive Nutrition Programs and Services in Schools.

It is the position of the Academy of Nutrition and Dietetics, School Nutrition Association, and Society for Nutrition Education and Behavior that comprehensive, integrated nutrition programs in preschool through high school are essential to improve the health, nutritional status, and academic performance of our nation's children. Through the continued use of multidisciplinary teams, local school needs will be better identified and addressed within updated wellness policies. Updated nutrition standards are providing students with a wider variety of fruits, vegetables, and whole grains, while limiting sodium, calories, and saturated fat. Millions of students enjoy school meals every day in the US, with the majority of these served to children who are eligible for free and reduced-priced meals. To maximize impact, the Academy, School Nutrition Association, and Society for Nutrition Education and Behavior recommend specific strategies in the following key areas: food and nutrition services available throughout the school campus, nutrition initiatives such as farm to school and school gardens, wellness policies, nutrition education and promotion, food and beverage marketing at school, and consideration of roles and responsibilities. POSITION STATEMENT: It is the position of the Academy of Nutrition and Dietetics, School Nutrition Association, and Society for Nutrition Education and Behavior that comprehensive, integrated nutrition programs in preschool through high school are essential to improve the health, nutritional status, and academic performance of our nation's children. To maximize impact, the Academy, School Nutrition Association, and Society for Nutrition Education and Behavior recommend specific strategies in the following key areas: food and nutrition services available throughout the school campus; nutrition initiatives such as farm to school and school gardens; wellness policies; nutrition education and promotion; food and beverage marketing at school; and consideration of roles and responsibilities.

Factors that contribute to effective nutrition education interventions in children: a systematic review.

Context: Establishing healthy dietary practices at an early age is crucial, as dietary behaviors in childhood track to adulthood. Objective: The purpose of this systematic review was to identify factors associated with successful nutrition education interventions conducted in children and published between 2009 and 2016. Data Sources: Using the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines, relevant studies were identified through the PubMed, Web of Science, ScienceDirect, and ERIC (Educational Resources Information Center) databases. Study Selection: Studies published in English between 2009 and 2016 that included a nutrition education intervention among children aged 2 to 19 years were included. Review articles, abstracts, qualitative or cross-sectional studies, and studies targeting children with special nutritional needs were excluded. Data Extraction: Four authors screened and determined the quality of the studies using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system and extracted the data from the articles. Data Analysis: Forty-one studies were included: 7 targeted preschool children, 26 targeted elementary school children, and 8 targeted secondary school children. A total of 46% met their primary objectives of nutrition education intervention, while the rest either partially achieved or did not achieve their stated objectives. Results: Successful interventions targeting school children engaged parents by means of face-to-face sessions, identified specific behaviors to be modified, and assured fidelity by training teachers or recruiting trained experts to deliver the intervention. In addition, they allowed adequate dosage, with an intervention duration of at least 6 months, and used age-appropriate activities. Conclusions: Interventions with a multicomponent approach that were age appropriate and of adequate duration (≥ 6 months), that engaged parents, and that ensured fidelity and proper alignment between the stated objectives, the intervention, and the desired outcomes were more likely to succeed.

Psychometric Assessment and Precision Remodeling of the Iowa Infant Feeding Attitude Scale to Improve Clinical Use and Efficacy Among Prenatal Women in Canada.

BACKGROUND: The 17-item Iowa Infant Feeding Attitude Scale (IIFAS) has been widely used to assess maternal attitudes toward infant feeding and to predict breastfeeding intention. The IIFAS has been validated among prenatal women located in Newfoundland and Labrador in Canada, although its length may prove challenging to complete in a clinical setting. Research aim: The authors aimed to reduce the number of items from the original 17-item IIFAS scale while maintaining reliability and validity. METHODS: A nonexperimental cross-sectional design was used among 1,283 women in their third trimester residing in Newfoundland and Labrador. Data were collected from August 2011 to June 2016. An exploratory factor analysis using principal component analysis was performed to explore the underlying structure of the IIFAS. The internal consistency of both the 17-item and reduced version was assessed using Cronbach's alpha and item-total correlation. The area under the curve and linear regression model were used to assess predictive validity of intention to breastfeed. RESULTS: Our findings revealed that a 13-item IIFAS (Cronbach's α = .870) had relatively similar internal consistency to the original IIFAS (Cronbach's α = .868). Three themes were extracted from the factor analysis, resulting in the removal of four items. The reduced scale demonstrated an excellent ability to predict breastfeeding intention (area under the curve = 0.914). CONCLUSION: The reduced 13-item version of the IIFAS is a psychometrically sound instrument that maintains its accuracy and validity when measuring maternal feeding attitudes during pregnancy and can be more time efficient in clinical settings compared with the 17-item IIFAS.

Development and Validation of a Technology-Based System for Tracking and Reporting Dietary Intake at School Meals.

OBJECTIVE: This report describes the development and validation of a technology-based system that integrates data on food choice, nutrition, and plate waste to generate feedback reports summarizing students' dietary intake at school meals. METHODS: Cafeteria staff used the system to document the school lunch choices of seventh-graders (n = 37) in an urban charter school for 5 months. Plate waste was assessed by research staff using a visual estimation method that was validated against directly weighed plate waste. RESULTS: Most food choices (97.1%) were correctly recorded through the system. Visual estimates of plate waste had excellent interrater reliability (r's ≥ .94) and agreement with direct measurements (ρ's ≥ .75). Plate waste assessment required approximately 10 s/tray. Fifty-four percent of parents received feedback reports consistently. CONCLUSIONS AND IMPLICATIONS: The technology-based system enabled staff to monitor dietary intake accurately at school meals. The system could potentially inform lunch menu modifications aimed at reducing plate waste.

What is significant about a single nursing session? An exploratory study.

OBJECTIVES: Researchers and clinicians specializing in breastfeeding often rely on measuring one nursing session to characterize the breastfeeding relationship. However, less is known about the descriptive or statistically predictive characteristics of one nursing session. The purposes of this study are twofold: (1) to explore the relationships between variables in a single nursing session; and (2) to study the association between variables in a single nursing session and infant length-for-age (LAZ) and weight-for-age (WAZ). METHODS: In 63 nursing mother-infant pairs in the United States, anthropometric measurement and observation of a single nursing session revealed six nursing session variables: fore milk fat percent, hind milk fat percent, infant milk intake, duration of session, time since last session, and time of day of session. RESULTS: A principle factor analysis, undertaken to explore latent variables underlying the six session variables, revealed two factors: (1) loaded highly on fore and hind milk fat percentage, reflecting the overall fat percent in a feed; and (2) loaded highly on milk intake and hind milk fat percentage, indicating the process of breast emptying. In multivariate analyses of all session variables on infant LAZ and WAZ, only hind milk fat percentage was significantly negatively associated with LAZ (ß = -0.14, P = .01 (two-tailed), R2 = 0.070), confirmed by a significant negative association between LAZ and factor one (ß = -0.32, P = .05 (two-tailed), R2 = 0.090). CONCLUSIONS: This research describes the dynamics of a single nursing session, and has the potential to help explain variation in infant growth and nutrition.

Ethical Challenges in Infant Feeding Research.

Infants have a complex set of nutrient requirements to meet the demands of their high metabolic rate, growth, and immunological and cognitive development. Infant nutrition lays the foundation for health throughout life. While infant feeding research is essential, it must be conducted to the highest ethical standards. The objective of this paper is to discuss the implications of developments in infant nutrition for the ethics of infant feeding research and the implications for obtaining informed consent. A search was undertaken of the papers in the medical literature using the PubMed, Science Direct, Web of Knowledge, Proquest, and CINAHL databases. From a total of 9303 papers identified, the full text of 87 articles that contained discussion of issues in consent in infant feeding trials were obtained and read and after further screening 42 papers were included in the results and discussion. Recent developments in infant nutrition of significance to ethics assessment include the improved survival of low birth weight infants, increasing evidence of the value of breastfeeding and evidence of the lifelong importance of infant feeding and development in the first 1000 days of life in chronic disease epidemiology. Informed consent is a difficult issue, but should always include information on the value of preserving breastfeeding options. Project monitoring should be cognisant of the long term implications of growth rates and early life nutrition.

Nutrition in the preterm infant: what's new?

PURPOSE OF REVIEW: The increasing recognition of the role of nutritional care for preterm infants continues to result in a proliferation of review articles, systematic reviews, observational studies and trials. In this article, we review a selection of important studies published in the last 12­18 months. RECENT FINDINGS: The selected studies demonstrate the potential importance of light protecting parenteral nutrition solutions, the benefits of standardized concentrated parenteral nutrition solutions and the importance of insulin-like growth factor I in early life. Trials of immunonutrients (such as bile salt-stimulated lipase) and other bioactive peptides such as lactoferrin are in progress, and emerging data highlight the importance of vitamin D for immune regulation, and therefore its role in sepsis and gut function. Early oro-pharyngeal administration of colostrum appears to safely improve early immune development, and supports the increasingly common practice of immediate commencement of mothers' own breast milk. Despite this, studies continue to show that breastfeeding continuation rates could be improved. Data also highlight the potential role of macronutrient supply on other functional outcomes, such as retinopathy of prematurity. Finally, the importance of the unique nutritional needs of late and moderately preterm infants is starting to be recognized ­ a much larger group than the extremely preterm infants in whom many studies are focused. SUMMARY: Earlier, more aggressive nutrient supply and feeding regimes, including optimal support of breastfeeding mothers to ensure adequate provision of own mother's milk, appear to improve growth and neurodevelopmental outcomes. The addition of bioactive proteins shows promise. Special focus needs to be reestablished for late and moderately preterm infants, who have particular nutritional and feeding support requirements. This review has highlighted the need for further research particularly in the areas of early parenteral nutrition, the optimal regime to improve early growth and neuronal effects, the optimal rate of growth and/or catch-up, and the role of immune nutrients.

Working group reports: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project.

The "Evaluation of the Evidence to Support Practice Guidelines for the Nutritional Care of Preterm Infants: The Pre-B Project" is the first phase in a process to present the current state of knowledge and to support the development of evidence-informed guidance for the nutritional care of preterm and high-risk newborn infants. The future systematic reviews that will ultimately provide the underpinning for guideline development will be conducted by the Academy of Nutrition and Dietetics' Evidence Analysis Library (EAL). To accomplish the objectives of this first phase, the Pre-B Project organizers established 4 working groups (WGs) to address the following themes: 1) nutrient specifications for preterm infants, 2) clinical and practical issues in enteral feeding of preterm infants, 3) gastrointestinal and surgical issues, and 4) current standards of infant feeding. Each WG was asked to 1) develop a series of topics relevant to their respective themes, 2) identify questions for which there is sufficient evidence to support a systematic review process conducted by the EAL, and 3) develop a research agenda to address priority gaps in our understanding of the role of nutrition in health and development of preterm/neonatal intensive care unit infants. This article is a summary of the reports from the 4 Pre-B WGs.

Single-center assessment of nutritional counseling in preventing excessive weight gain in pediatric renal transplants recipients.

Post-transplantation obesity is a common complication that is associated with a higher risk for decreased allograft function and hypertension. However, the role of diet intervention on reducing post-transplantation obesity is relatively unknown. We investigated the clinical relevance of dietary counseling on the prevalence of overweight/obesity during the first two yr following renal transplantation. The computerized patient records of 42 recipients (31 males) aged 6.3 ± 4.8 yr at transplantation were reviewed. All patients systematically underwent yearly dietary assessment/counseling (motivational interviewing technique) and measurement of renal function and ABPM. At transplantation, 14.2% of patients were overweight/obese, which increased to 42.8% by two yr post-transplantation (p = 0.004). The majority of patients experienced a significant increase in BMI SDS during the first six months post-transplantation that remained sustained throughout the duration of the follow-up period (p = 0.001). By two yr post-transplantation, there were no observable differences between patients classified as having normal BMI or being overweight/obese with regard to renal function and controlled hypertension. The application of yearly tailored dietary assessment/counseling had a poor effect on preventing post-transplantation weight gain, suggesting the need for more comprehensive interventions to reduce post-transplant obesity.

[The system of the quality control and the safety of baby food, the prospects of its development].

In the article there is considered the substantiation of raise demands to the chemical composition of children's food and indices of their safety, with taking into account the immaturity of metabolic and physiological processes and limitations of "depot" of nutrients in babies. Based on research results of leading experts in the field of children's nutritiology and according to the recommendations of the Codex Alimentarius of the Commission of FAO/WHO, ESPGHAN Committee on Nutrition, the EFSA recommendations and EUDirectives there were specified requirements for the ingredient composition, content of essential components and indices of the nutritional value of substitutes for human milk and functional products for the nutrition of infants of the first year of life. There are shown stages of the development of the Russian system of hygienic requirements for baby food, and the direction of its harmonization with international and European standards, particularly for substitutes for human milk and products of dietary therapeutic and dietary preventive nutrition for babies. There are considered aspects of the introduction ofproducts and weaning food dishes into the food ration of infants. There is presented the classification ofproducts of children's food and the assortment of each group of weaning foods. There is provided the modern legislative framework in the field of the quality and safety for infant nutrition. There was shown the difference between domestic legislation and regulatory framework of the EurAsEC Customs Union of the European countries in the field offood products safety for children older three years. There are presented proposals on the creation of the single regulatory base within the framework of the EurAsEC Customs Union for control the quality and safety of all the baby foods.

Attrition in Long-Term Nutrition Research Studies: A Commentary by the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition Early Nutrition Research Working Group.

Long-term follow-up of randomised trials and observational studies provide the best evidence presently available to assess long-term effects of nutrition, and such studies are an important component in determining optimal infant feeding practices. Attrition is, however, an almost inevitable occurrence with increasing age at follow-up. There is a common assumption that studies with <80% follow-up rates are invalid or flawed, and this criticism seems to be more frequently applied to follow-up studies involving randomised trials than observational studies. In this article, we explore the basis and evidence for this "80% rule" and discuss the need for greater consensus and clear guidelines for analysing and reporting results in this specific situation.

Epigenetics in Paediatric Gastroenterology, Hepatology, and Nutrition: Present Trends and Future Perspectives.

Epigenetics can be defined as stable, potentially heritable changes in the cellular phenotype caused by mechanisms other than alterations to the underlying DNA sequence. As such, any observed phenotypic changes including organ development, aging, and the occurrence of disease could be driven by epigenetic mechanisms in the presence of stable cellular DNA sequences. Indeed, with the exception of rare mutations, the human genome-sequence has remained remarkably stable over the past centuries. In contrast, substantial changes to our environment as part of our modern life style have not only led to a significant reduction of certain infectious diseases but also seen the exponential increase in complex traits including obesity and multifactorial diseases such as autoimmune disorders. It is becoming increasingly clear that epigenetic mechanisms operate at the interface between the genetic code and our environment, and a large body of existing evidence supports the importance of environmental factors such as diet and nutrition, infections, and exposure to toxins on human health. This seems to be particularly the case during vulnerable periods of human development such as pregnancy and early life. Importantly, as the first point of contact for many of such environmental factors including nutrition, the digestive system is being increasingly linked to a number of "modern" pathologies. In this review article, we aim to give a brief introduction to the basic molecular principals of epigenetics and provide a concise summary of the existing evidence for the role of epigenetic mechanisms in gastrointestinal health and disease, hepatology, and nutrition.