Exploring the Feasibility and Acceptability of Providing Caregivers Who Formula-feed with Smaller Infant Bottles in a Primary Care Clinic.

OBJECTIVES: Larger bottle size is associated with faster weight gain in infants, but little is known about acceptability and feasibility of providing bottles in primary care clinics. METHODS: We randomized parent-infant dyads (N = 40) to receive a set of 4-ounce bottles or to continue using their own bottles. Demographic and anthropometric information were collected at enrollment and one follow-up visit 1-5 months later. The primary aim was to assess feasibility and acceptability of the intervention strategy. We compared components of bottle feeding, including usual bottle sizes used, number and volume of feeds with Wilcoxon rank-sum tests, and changes in weight-for-age and weight-for-length z-scores during the study period with t-tests, using p < 0.05 as an indicator of statistical significance. RESULTS: Of participants randomized to receive bottles, 90% were using the 4oz bottles at follow up. The intervention group reported a significantly lower median bottle size (4oz) than the control group (8oz) at follow up, and parents reported acceptability and continued use of the bottles. CONCLUSIONS FOR PRACTICE: An intervention to provide smaller bottles was feasible, mostly acceptable, resulted in lower median bottle size. Further research is needed to determine whether it represents a novel way to prevent rapid infant weight gain.

Influence of product placement in children's movies on children's snack choices.

BACKGROUND: Media exposure affects health, including obesity risk. Children's movies often contain food placements-frequently unhealthy foods. However, it is not known if these cues influence children's food choices or consumption after viewing. We explored whether children's snack choices or consumption differs based on: 1) recent exposure to movies with high versus low product placement of unhealthy foods; and 2) children's weight status. METHODS: Children ages 9-11 were assigned to watch a high ("Alvin and the Chipmunks," n = 54) or low ("Stuart Little," n = 60) product-placement movie. After viewing, participants selected a snack choice from each of five categories, several of which were specifically featured in "Alvin." Uneaten snacks from each participant were weighed upon completion. Snack choice and amount consumed by movie were compared by t-tests, and differences in snack choices by movie were tested with logistic regression. RESULTS: Participants consumed an average of 800.8 kcal; mean kcal eaten did not vary by movie watched. Participants who watched the high product-placement movie had 3.1 times the odds (95% CI 1.3-7.2) of choosing cheese balls (most featured snack) compared to participants who watched the low product-placement movie. Children who were overweight or obese consumed a mean of 857 kcal (95% CI: 789-925) compared to 783 kcal (95% CI: 742-823, p = 0.09) for children who were underweight or healthy weight. Children's weight status did not significantly affect their choice of snack. CONCLUSIONS: Branding and obesogenic messaging in children's movies influenced some choices that children made about snack foods immediately following viewing, especially food with greatest exposure time in the film, but did not affect total calories consumed. Future studies should examine how the accumulation of these messages affects children's long-term food choices.

A Randomized Trial of Inspiratory Training in Children and Adolescents With Obesity.

Introduction: Children with obesity suffer excess dyspnea that contributes to sedentariness. Developing innovative strategies to increase exercise tolerance and participation in children with obesity is a high priority. Because inspiratory training (IT) has reduced dyspnea, we sought to assess IT in children with obesity. Methods: We conducted a 6-week randomized IT trial involving 8- to 17-year-olds with obesity. Participants were randomized 1:1 to either high [75% of maximal inspiratory pressure (MIP)] or low resistance control (15% of MIP) three times weekly. Assessments included adherence, patient satisfaction, and changes in inspiratory strength and endurance, dyspnea scores and total activity level. Results: Among 27 randomized, 24 (89%) completed the intervention. Total session adherence was 72% which did not differ between treatment groups. IT was safe, and more than 90% felt IT benefitted breathing and general health. IT led to a mean improvement (95% CI) in inspiratory strength measured by MIP of 10.0 cm H2O (-3.5, 23.6; paired t-test, p = 0.139) and inspiratory endurance of 8.9 (1.0, 16.8; paired t-test, p = 0.028); however, there was no significant difference between high- and low-treatment groups. IT led to significant reductions in dyspnea with daily activity (p < 0.001) and in prospectively reported dyspnea during exercise (p = 0.024). Among the high- versus low-treatment group, we noted a trend for reduced dyspnea with daily activity (p = 0.071) and increased daily steps (865 vs. -51, p = 0.079). Discussion: IT is safe and feasible for children with obesity and holds promise for reducing dyspnea and improving healthy activity in children with obesity. Breathe-Fit trial NCT05412134.

Infant Television Watching Predicts Toddler Television Watching in a Low-Income Population.

OBJECTIVE: This study examines the development of active television (TV) watching behaviors across the first 2 years of life in a racially and ethnically diverse, low-income cohort and identifies caregiver and child predictors of early TV watching. METHODS: We used longitudinal data from infants enrolled in the active control group (N = 235; 39% Latino; 29% Black; 15% White) of Greenlight, a cluster randomized multisite trial to prevent childhood obesity. At preventive health visits from 2 months to 2 years, caregivers were asked: "How much time does [child's first name] spend watching television each day?" Proportional odds models and linear regression analyses were used to assess associations among TV introduction age, active TV watching amount at 2 years, and sociodemographic factors. RESULTS: Sixty-eight percent of children watched TV by 6 months, and 88% by 2 years. Age of TV introduction predicted amount of daily active TV watching at 2 years, with a mean time of 93 minutes if starting at 2 months; 64 minutes if starting at 4 or 6 months; and 42 minutes if starting after 6 months. Factors predicting earlier introduction included lower income, fewer children in household, care away from home, male sex, and non-Latino ethnicity of child. CONCLUSIONS: Many caregivers report that their infants actively watch TV in the first 6 months of life. Earlier TV watching is related to sociodemographic factors yet predicts more daily TV watching at 2 years even controlling those factors. Interventions to limit early TV watching should be initiated in infancy.

A randomized controlled trial examining an exam room poster to prompt communication about weight.

BACKGROUND: Recognition of childhood weight status is important to the adoption of healthy lifestyle behaviours. OBJECTIVES: We assessed whether an exam room educational poster addressing weight and healthy lifestyle behaviours was acceptable to parents, prompted parent-provider communication or improved parental weight perception accuracy. METHODS: In this multi-site randomized controlled trial, exam rooms were randomized to display the posters (English and Spanish) or not. Children ages 3 to 8 years (N = 965) attending well visits were weighed and roomed per usual clinic protocol. After the visit, parents completed a questionnaire assessing demographics, child weight status perceptions and whether they discussed weight status with provider or were shown growth charts. We used separate logistic regression analyses to examine associations between intervention status and: asking provider about child weight, being shown growth charts, and accuracy of weight perception, adjusting for covariates and clustering by exam room. RESULTS: Of the parents who saw the poster, 97% liked seeing it and reported greater understanding of weight status visualization (96%) and healthy lifestyle behaviours (94%). Parents who saw the poster were more likely to report being shown a growth chart (OR 1.87, 95% 1.06, 3.30) but were not more likely to ask about their child's weight status nor accurately report their child's weight status. CONCLUSIONS: An educational exam room poster about healthy weight was well-received by parents and prompted providers to show the child's growth chart but did not prompt parent-initiated conversations about weight status nor improve parental weight perception accuracy.

Concordance of Child and Parent Reports of Children's Screen Media Use.

OBJECTIVE: Little is known about the concordance of parent and child reports of children's media consumption, even though parents are often asked to report for their children in clinical care settings. Our objective was to understand how parent and child reports of children's media consumption differ in an era of changing screen media consumption via personal devices. METHODS: As part of a larger study about the reception of health-related cues from children's media, children ages 9 to 11 years (N = 114) and their parents independently completed identical questionnaires about specific media use and health behaviors. To examine concordance between child and parent reports of children's screen media use, we calculated the mean number of minutes per day and proportions reported by the child and parent and assessed concordance with t-tests and chi-square tests. RESULTS: On a typical day, children reported nearly an hour each of video and app game use, computer use, and television exposure. Overall, child and parent reports were similar, usually within 10 minutes of each other; however, among 3 measures of TV use, parents consistently reported less TV exposure than children. There was significant discordance in the percentages of parents and children reporting the presence of a TV in the child's room. CONCLUSIONS: Parent and child reports of children's media use were generally concordant; however, there were important disagreements, such as TV use in the child's room and during meals. We discuss possible causes of discrepancies and implications.

Implicit Weight Bias in Children Age 9 to 11 Years.

OBJECTIVES: Assess implicit weight bias in children 9 to 11 years old. METHODS: Implicit weight bias was measured in children ages 9 to 11 (N = 114) by using the Affect Misattribution Procedure. Participants were shown a test image of a child for 350 milliseconds followed by a meaningless fractal (200 milliseconds), and then they were asked to rate the fractal image as "good" or "bad." We used 9 image pairs matched on age, race, sex, and activity but differing by weight of the child. Implicit bias was the difference between positive ratings for fractals preceded by an image of a healthy-weight child and positive ratings for fractals preceded by an image of an overweight child. RESULTS: On average, 64% of abstract fractals shown after pictures of healthy-weight children were rated as "good," compared with 59% of those shown after pictures of overweight children, reflecting an overall implicit bias rate of 5.4% against overweight children (P < .001). Healthy-weight participants showed greater implicit bias than over- and underweight participants (7.9%, 1.4%, and 0.3% respectively; P = .049). CONCLUSIONS: Implicit bias toward overweight individuals is evident in children aged 9 to 11 years with a magnitude of implicit bias (5.4%) similar to that in studies of implicit racial bias among adults.

Obesogenic Behavior and Weight-Based Stigma in Popular Children's Movies, 2012 to 2015.

BACKGROUND: Obesity-promoting content and weight-stigmatizing messages are common in child-directed television programming and advertisements, and 1 study found similar trends in G- and PG-rated movies from 2006 to 2010. Our objective was to examine the prevalence of such content in more recent popular children's movies. METHODS: Raters examined 31 top-grossing G- and PG-rated movies released from 2012 to 2015. For each 10-minute segment (N = 302) and for movies as units, raters documented the presence of eating-, activity-, and weight-related content observed on-screen. To assess interrater reliability, 10 movies (32%) were coded by more than 1 rater. RESULTS: The result of Cohen's κ test of agreement among 3 raters was 0.65 for binary responses (good agreement). All 31 movies included obesity-promoting content; most common were unhealthy foods (87% of movies, 42% of segments), exaggerated portion sizes (71%, 29%), screen use (68%, 38%), and sugar-sweetened beverages (61%, 24%). Weight-based stigma, such as a verbal insult about body size or weight, was observed in 84% of movies and 30% of segments. CONCLUSIONS: Children's movies include much obesogenic and weight-stigmatizing content. These messages are not shown in isolated incidences; rather, they often appear on-screen multiple times throughout the entire movie. Future research should explore these trends over time, and their effects.