Maternal Feeding Beliefs and Behaviors Relate to Infant Diet and Appetite.

INTRODUCTION: Maternal feeding practices may be linked to infant obesogenic outcomes, but research to date has focused primarily on infant growth as an outcome of maternal feeding practices rather than exploring additional obesogenic outcomes like infant appetite and diet. Therefore, the current study examined the association between maternal feeding practices and beliefs and infant growth, diet, and appetite simultaneously at a critical timepoint for obesity risk development (i.e., 3-months-old). METHODS: Thirty-two 3-month-old infants and their mothers participated in this cross-sectional study. Infant anthropometrics were collected by trained staff and mothers completed questionnaires regarding maternal feeding practices and beliefs and infant diet and appetite. The data were analyzed by Spearman correlations. RESULTS: Statistically significant correlations were identified between maternal feeding practices (e.g., using food to calm, concern about infant weight) and infant satiety, appetite, food responsiveness, slow eating, and kilocalories consumed. Infant weight-for-length was related to maternal concern about infant underweight and mother-infant social interaction during feeding. DISCUSSION: These findings highlight the importance of the mother-infant feeding relationship and how these associations may influence responsive feeding practices and infant weight-related outcomes.

Maintenance Following a Randomized Trial of a Clinic and Home-based Behavioral Intervention of Obesity in Preschoolers.

OBJECTIVE: To assess maintenance of improved weight outcomes in preschoolers with obesity 6 and 12 months following a randomized clinical trial comparing a home- and clinic-based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health [LAUNCH]) to motivational interviewing and standard care. STUDY DESIGN: Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012, and June 8, 2015, were followed 6 and 12 months post-treatment. Child and caregiver weight, height, and caloric intake, child physical activity, and home environment were assessed. The primary outcome was maintenance of greater reduction of percent over the 50th percentile body mass index (BMI%50th) by LAUNCH compared with motivational interviewing and standard care at the 6- and 12-month follow-up. RESULTS: Significantly lower child BMI%50th was maintained for LAUNCH compared with motivational interviewing at 12-month follow-up and to standard care at the 6-month follow-up; however, the effect sizes were maintained for comparison with standard care at 12-month follow-up. LAUNCH had significantly lower daily caloric intake compared with motivational interviewing and standard care at both follow-ups and maintained significantly fewer high-calorie foods in the home compared with standard care at 6 and 12 months and compared with motivational interviewing at 12 months. However, caloric intake increased by 12% from post-treatment. LAUNCH caregivers did not maintain improved BMI at follow-up. CONCLUSIONS: LAUNCH showed success in reducing weight in preschoolers. However, maintaining treatment gains post-treatment is more difficult. Treatment may need to last longer than 6 months to achieve optimal results. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01546727.

Clinic and Home-Based Behavioral Intervention for Obesity in Preschoolers: A Randomized Trial.

OBJECTIVE: To test the hypotheses that an innovative skills-based behavioral family clinic and home-based intervention (LAUNCH) would reduce body mass index z score (BMIz) compared with motivational interviewing and to standard care in preschool-aged children with obesity. STUDY DESIGN: Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012 and June 8, 2015. Children were randomized to LAUNCH (an 18-session clinic and home-based behavioral intervention), motivational interviewing (delivered at the same frequency as LAUNCH), or standard care (no formal intervention). Weight and height were measured by assessors blinded to participant assignment. The primary outcome, BMIz at month 6 after adjusting for baseline BMIz, was tested separately comparing LAUNCH with motivational interviewing and LAUNCH with standard care using regression-based analysis of covariance models. RESULTS: A total of 151 of the 167 children randomized met intent-to-treat criteria and 92% completed the study. Children were 76% White and 57% female, with an average age of 55 months and BMI percentile of 98.57, with no demographic differences between the groups. LAUNCH participants demonstrated a significantly greater decrease in BMIz (mean = -0.32, SD = ±0.33) compared with motivational interviewing (mean = -0.05, SD = ±0.27), P < .001, ω2 = 0.74 and compared with standard care (mean = -0.13, SD = ±0.31), P < .004, ω2 = 0.75. CONCLUSIONS: In preschool-age children, an intensive 6-month behavioral skills-based intervention is necessary to reduce obesity. TRIAL REGISTRATION: Clinicaltrials.gov NCT01546727.

Are Preschoolers Meeting the Mark? Comparing the Dietary, Activity, and Sleep Behaviors of Preschoolers With Obesity to National Recommendations.

Objective: National health organizations and expert committees have issued recommendations for health behaviors related to obesity risk. Behavioral and family-based weight management interventions for preschoolers often target improving adherence to these recommendations, but it is unknown how the health behaviors of preschoolers with obesity enrolled in weight control treatments (WCTs) compare with these guidelines. In this study, the dietary intake, activity, and sleep behaviors of preschoolers with obesity enrolled in a family-based behavioral WCT are described and compared with national health behavior recommendations. Methods: Health behaviors of 151 preschoolers with obesity (M age = 4.60, SD = 0.93) enrolled in a clinical trial of a weight management program were measured at baseline through caregiver-report questionnaires, three 24-hr dietary recalls, and accelerometers. Results: In total, 70% of the sample exceeded daily caloric recommendations, only 10 and 5% met recommendations for fruit and vegetable intake, respectively, and only 30% met the recommendation of consuming no sugar-sweetened beverages. The majority of the sample met the daily recommendations for 60 min of moderate-to-vigorous activity (80%), < 2 hr of screen time (68%), and sleep duration (70%). Conclusions: Behavioral weight management interventions for preschoolers with obesity should target the health behaviors where children are not meeting recommendations.

Comparison of High and Normal Birth Weight Infants on Eating, Feeding Practices, and Subsequent Weight.

Objectives High birth weight (HBW ≥ 4000 g) infants are at increased risk for obesity, but research has yet to identify the mechanism for this increased risk and whether certain subsets of HBW infants are at greater risk. Methods This exploratory study examined child eating behaviors and maternal feeding practices and beliefs across 21 HBW and 20 normal birth weight (NBW, 2500-3999 g) infants at 7-8 months of age using maternal-report measures (n = 41) and a bottle feeding task (n = 16). Results HBW infants were at increased risk for high weight-for-length at 7-8 months (F (2, 38) = 6.03, p = .02) compared to NBW infants, but no statistically significance differences on weight gained per day since birth, child eating behaviors, or most maternal feeding practices and beliefs were found between HBW and NBW infants. However, HBW infants who maintained a high weight-for-length (≥ 85th percentile) at 7-8 months had a higher birth weight, gained more weight per day, and had lower maternal-reported satiety responsiveness and maternal social interactions during feedings than their HBW counterparts who were currently below the 85th percentile. Conclusions for Practice HBW infants did not differ from NBW infants on eating behaviors and feeding practices, but children born at HBW who maintain excess weight during infancy do differ from those infants who fall below the 85th percentile for weight-for-length. Future research should identify risk factors that longitudinally differentiate HBW infants at greatest risk for maintaining excess weight and develop early screening and intervention efforts for this subset of at-risk infants.

High Body Mass Index in Infancy May Predict Severe Obesity in Early Childhood.

OBJECTIVE: To characterize growth trajectories of children who develop severe obesity by age 6 years and identify clinical thresholds for detection of high-risk children before the onset of obesity. STUDY DESIGN: Two lean (body mass index [BMI] 5th to ≤75th percentile) and 2 severely obese (BMI ≥99th percentile) groups were selected from populations treated at pediatric referral and primary care clinics. A population-based cohort was used to validate the utility of identified risk thresholds. Repeated-measures mixed modeling and logistic regression were used for analysis. RESULTS: A total of 783 participants of normal weight and 480 participants with severe obesity were included in the initial study. BMI differed significantly between the severely obese and normal-weight cohorts by age 4 months (P < .001), at 1 year before the median age at onset of obesity. A cutoff of the World Health Organization (WHO) 85th percentile for BMI at 6, 12, and 18 months was a strong predictor of severe obesity by age 6 years (sensitivity, 51%-95%; specificity, 95%). This BMI threshold was validated in a second independent cohort (n = 2649), with a sensitivity of 33%-77% and a specificity of 74%-87%. A BMI ≥85th percentile in infancy increases the risk of severe obesity by age 6 years by 2.5-fold and the risk of clinical obesity by age 6 years by 3-fold. CONCLUSIONS: BMI trajectories in children who develop severe obesity by age 6 years differ from those in children who remain at normal weight by age 4-6 months, before the onset of obesity. Infants with a WHO BMI ≥85th percentile are at increased risk for developing severe obesity by age 6 years.

Barriers to Recruitment in Pediatric Obesity Trials: Comparing Opt-in and Opt-out Recruitment Approaches.

Objective: To compare the efficacy of opt-in versus opt-out recruitment methods in pediatric weight management clinical trials. Methods: Recruitment of preschoolers and school-age children across two obesity randomized controlled trials (RCTs) were compared using the same opt-in recruitment approach (parents contact researchers in response to mailings). Opt-in and opt-out strategies (parents send decline postcard in response to mailings if they do not want to participate) were then compared across two preschool obesity RCTs. Results: Opt-in strategies yielded a significantly lower overall recruitment rate among preschoolers compared with school-age children. Among preschoolers, an opt-out strategy demonstrated a significantly higher overall recruitment rate compared with an opt-in strategy with the main advantage in the number of families initially contacted. Conclusions: Opt-out recruitment strategies may be more effective in overcoming the barriers of recruitment in the preschool age-group because it does not rely on parent recognition of obesity.

A Preschool Obesity Treatment Clinical Trial: Reasons Primary Care Providers Declined Referrals.

OBJECTIVE: To examine referral by primary care providers (PCPs) of preschool children with obesity (≥95th percentile for body mass index [BMI]) to a weight management intervention when offered through a randomized clinical trial (RCT), and identify reasons for not referring children. STUDY DESIGN: In phase I, 3 experts in obesity, psychology, and nutrition completed an open card sort and classified PCPs' reasons for declining referral into groups based on similarity of reasons. Categories were then defined and labeled. In phase II, 2 independent sorters placed each decline into 1 of the categories defined in phase I. RESULTS: PCPs referred 78% of eligible children to the RCT. Compared with children declined for referral, referred children had a significantly higher weight (48.4 lb vs 46.1 lb; P < .001) and BMI percentile (97.6 vs 97.0; P < .001). Eleven categories for decline were identified in phase I. In phase II, excellent reliability was obtained between each independent sorter and the phase I categories, and also between the 2 independent sorters (κ values, 0.72-1.0). The most common reason for declining was "family not a good fit" (23.6%), followed by "doesn't believe weight is a problem" (13.9%), "family would not be interested" (12%), and "doesn't believe measurement is accurate" (11.5%). Appropriately, exclusionary criteria of the RCT was a reason as well (11.8%). CONCLUSION: The availability of weight management for preschoolers through RCTs appeared to overcome barriers of resources, time, and credible treatment cited in previous studies. However, concerns about the family's response or interest in a weight management program remained barriers, as did PCPs' perceptions about obesity in young children. TRIAL REGISTRATION: ClinicalTrials.gov:NCT01546727.

A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers.

OBJECTIVE: Tested two family-based behavioral treatments for obesity in preschool children, one meeting the Expert Committee guidelines for Stage 3 obesity intervention criteria (LAUNCH-clinic) and one exceeding Stage 3 (LAUNCH with home visit [LAUNCH-HV]), compared with a Stage 1 intervention, pediatrician counseling (PC). METHODS: In all, 42 children aged 2-5 years with a body mass index (BMI) percentile of ≥95th were randomized. A total of 33 met intent-to-treat criteria. Assessments were conducted at baseline, Month 6 (posttreatment), and Month 12 (6-month follow-up). RESULTS: LAUNCH-HV demonstrated a significantly greater decrease on the primary outcome of change in BMI z-score (BMIz) pre- to posttreatment compared with PC (p = .007), whereas LAUNCH-clinic was not significantly different from PC (p = .08). Similar results were found for secondary outcomes. CONCLUSIONS: LAUNCH-HV, but not LAUNCH-clinic, significantly reduced BMIz compared with PC by posttreatment, indicating the need for intensive behavioral intervention, including home visitation, to address weight management in obese preschool children.

The Role of the Pediatrician in the Promotion of Healthy, Active Living.

Few children and adolescents meet federal nutrition or physical activity recommendations, and many experience poor or inadequate sleep and negative health effects from screen use and social media. These lifestyle factors exacerbate physical and mental health risks for children and adolescents. This clinical report provides guidance to help pediatricians address the nutritional, physical activity, sleep, media and screen use, and social-emotional factors that affect child and adolescent health and wellness. The recommendations in this clinical report aim to promote health and wellness practices for infants, children, and adolescents across several domains of influence, including the individual, interpersonal, institutional, community, and public policy levels.

STEP IN: Supporting Together Exercise and Play and Improving Nutrition; a Feasibility Study of Parent-Led Group Sessions and Fitness Trackers to Improve Family Healthy Lifestyle Behaviors in a Low-Income, Predominantly Black Population.

BACKGROUND: Pediatric obesity is prevalent and challenging to treat. Although family-centered behavioral management is the gold standard, many families face structural inequities to its access and efficacy. Identifying ways to manage pediatric obesity within primary care is needed. METHODS: This feasibility study included three sequential trials of peer-led group sessions occurring biweekly or monthly between 3/2016 and 2/2017. Parent-child dyads were recruited from a large academic primary care clinic via mailed invitations, prioritizing patients living in local zip codes of historical disinvestment. Eligible patients were 6 to 12 years with a body mass index ≥85th percentile, with parent and child interest in making healthy lifestyle changes, and English speaking. RESULTS: 27 dyads participated, 77% were non-Hispanic Black. Retention and attendance rates were highest in the initial four-session biweekly pilot (100%, 0 dropouts), high in the full six-session biweekly cohort (83%, 1 dropout), and moderate in the monthly cohort (62.7%, 4 dropouts). Families reported high satisfaction with the sessions (4.75/5). Qualitative comments suggested social connections had motivated behavior change in some families. CONCLUSION: Parent-led group sessions for pediatric weight management show promise in engaging families. A future large trial is needed to assess behavior change and anthropometric outcomes.

Role of carbohydrate modification in weight management among obese children: a randomized clinical trial.

OBJECTIVE: To compare the effectiveness and safety of carbohydrate (CHO)-modified diets with a standard portion-controlled (PC) diet in obese children. STUDY DESIGN: Obese children (n=102) aged 7-12 years were randomly assigned to a 3-month intervention of a low-CHO (LC), reduced glycemic load (RGL), or standard PC diet, along with weekly dietary counseling and biweekly group exercise. Anthropometry, dietary adherence, and clinical measures were evaluated at baseline and 3, 6, and 12 months. Analyses applied intention-to-treat longitudinal mixed models. RESULTS: Eighty-five children (83%) completed the 12-month assessment. Daily caloric intake decreased from baseline to all time points for all diet groups (P<.0001), although LC diet adherence was persistently lower (P<.0002). At 3 months, body mass index z score was lower in all diet groups (LC, -0.27 ± 0.04; RGL, -0.20 ± 0.04; PC, -0.21 ± 0.04; P<.0001) and was maintained at 6 months, with similar results for waist circumference and percent body fat. At 12 months, participants in all diet groups had lower body mass index z scores than at baseline (LC, -0.21 ± 0.04; RGL, -0.28 ± 0.04; PC, -0.31 ± 0.04; P<.0001), and lower percent body fat, but no reductions in waist circumference were maintained. All diets demonstrated some improved clinical measures. CONCLUSION: Diets with modified CHO intake were as effective as a PC diet for weight management in obese children. However, the lower adherence to the LC diet suggests that this regimen is more difficult for children to follow, particularly in the long term.

Utility of a pediatric fast magnetic resonance imaging protocol as surveillance scanning for traumatic brain injury.

OBJECTIVE: Traumatic brain injury (TBI) is a prevalent pediatric pathology in the modern emergency department. Computed tomography (CT) is utilized for detection of TBI and can result in cumulatively high radiation exposure. Recently, a fast brain magnetic resonance imaging (fbMRI) protocol has been employed for rapid imaging of hydrocephalus in pediatric patients. The authors investigate the utility of a modified trauma-focused fbMRI (t-fbMRI) protocol as an alternative to surveillance CT in the setting of acute TBI in pediatric patients, thus reducing radiation exposure while improving diagnostic yield. METHODS: A retrospective review was performed at the authors' institution for all pediatric patients who had undergone t-fbMRI within 72 hours of an initial CT scan, using a 1.5- or 3-T MR scanner for trauma indications. Forty patients met the study inclusion criteria. The authors performed a comparison of findings on the reads of CT and fbMRI, and a board-certified neuroradiologist conducted an independent review of both modalities. RESULTS: T-fbMRI outperformed CT in specificity, sensitivity, and negative predictive value for all injury pathologies measured, except for skull fractures. T-fbMRI demonstrated a sensitivity of 100% in the detection of extraaxial bleed, intraventricular hemorrhage, and subarachnoid hemorrhage and had a sensitivity of 78% or greater for epidural hematoma, subdural hematoma, and intraparenchymal hemorrhage. T-fbMRI yielded a specificity of 100% for all types of intracranial hemorrhages, with a corresponding negative predictive value that exceeded that for CT. CONCLUSIONS: In pediatric populations, the t-fbMRI protocol provides a valid alternative to CT in the surveillance of TBI and intracranial hemorrhage. Although not as sensitive in the detection of isolated skull fractures, t-fbMRI can be used to monitor pathologies implicated in TBI patients while minimizing radiation exposure from traditional surveillance imaging.

Pediatric Metabolic and Bariatric Surgery: Evidence, Barriers, and Best Practices.

Severe obesity among youth is an "epidemic within an epidemic" and portends a shortened life expectancy for today's children compared with those of their parents' generation. Severe obesity has outpaced less severe forms of childhood obesity in prevalence, and it disproportionately affects adolescents. Emerging evidence has linked severe obesity to the development and progression of multiple comorbid states, including increased cardiometabolic risk resulting in end-organ damage in adulthood. Lifestyle modification treatment has achieved moderate short-term success among young children and those with less severe forms of obesity, but no studies to date demonstrate significant and durable weight loss among youth with severe obesity. Metabolic and bariatric surgery has emerged as an important treatment for adults with severe obesity and, more recently, has been shown to be a safe and effective strategy for groups of youth with severe obesity. However, current data suggest that youth with severe obesity may not have adequate access to metabolic and bariatric surgery, especially among underserved populations. This report outlines the current evidence regarding adolescent bariatric surgery, provides recommendations for practitioners and policy makers, and serves as a companion to an accompanying technical report, "Metabolic and Bariatric Surgery for Pediatric Patients With Severe Obesity," which provides details and supporting evidence.