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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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5

Identified Informative Studies and Elements

While scoping and mapping the literature on interventions aimed at improving infant and young child feeding, the committee identified a small number of studies with interventions and elements of interventions that are broadly informative for developing scalable new initiatives (see Chapters 2 and 3 for further information). While none are without methodologic limitations or universally effective in improving all outcome measures, they provide valuable models for future consideration. This chapter describes these “informative studies” and “informative elements” (defined in more detail below), along with key takeaways or lessons learned from each study or element.

The “informative studies” were identified based on the committee’s expert judgment and assessment of three key characteristics:

  1. Quality of methods
  2. Evidence of effectiveness
  3. Potential for scalability

Some studies that did not meet the criteria to be included as “informative studies” also contributed important ideas and insights. Those studies may have some, but not all, of the characteristics needed for the development of effective interventions. Specific elements of those studies, termed “informative intervention elements,” offer clear suggestions of features that should be considered for incorporation into a program to be tested for effectiveness and scalability. Detailed extracted information from the

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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“informative studies” and studies which had “informative intervention elements” can be found in Appendix E.

For the interventions described in the “informative studies,” the committee utilized the Template for Intervention Description and Replication (TIDieR) checklist to understand intervention delivery features for implementation and scale-up (Hoffmann et al., 2014). In addition, to examine the difficulty of scaling up the interventions described in the “informative studies,” the committee utilized the World Health Organization’s (WHO’s) ExpandNet checklist (WHO, 2011). The TIDieR tables and ExpandNet checklists can be found in Appendix F.

INFORMATIVE STUDIES

The committee identified three informative studies, one of which has led to a translational trial to assess the feasibility of implementing the interventions across a larger geographical area. The other two have not been scaled, but in the committee’s judgment, they possess the potential for scalability.

INfant Feeding, Activity, and Nutrition Trial

The INfant Feeding, Activity, and Nutrition Trial (INFANT) program is designed to be an early life, family-centered, behavioral intervention intended to improve the dietary, physical activity, and screen time outcomes of children and caregivers with the ultimate goal of reducing childhood obesity incidence in the state of Victoria in Australia. The committee identified six publications with results from the original small-scale randomized controlled trial (RCT) completed in 2008 (Cameron et al., 2014; Campbell et al., 2013; Hesketh et al., 2020; Spence et al., 2013, 2014; Zheng et al., 2022), referred to as the efficacy RCT. In 2012, INFANT was delivered as a small-scale translation trial (Laws et al., 2016; Love et al., 2019), referred to as the translational trial. As of July 2023, INFANT is being scaled-up across Victoria, Australia, and being evaluated as a hybrid implementation-effectiveness trial (Laws et al., 2021; Marshall et al., 2022), referred to as the scale-up. Of note, the translation trial and the scale-up were not identified in the scoping review but were identified by committee members who reviewed INFANT.

Efficacy

As discussed above, INFANT was initially tested through an efficacy RCT with maternal–infant dyads recruited at 3 months of age and followed up until the child was 18 months old (Campbell et al., 2008). A sub-

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

sequent publication provided the follow-up outcomes with the children at 2 and 3.5 years of age (Hesketh et al., 2020).

Target Behaviors and Conceptual Frameworks

INFANT targeted children’s behaviors in four domains (infant feeding, food provision and dietary intake, physical activity, and sedentary behaviors) and parent behaviors in four domains (dietary intake, physical activity, sedentary behaviors, and overall well-being). The study was based on a combination of robust behavior change frameworks, including anticipatory guidance, social cognitive theory, parenting support skills, and the COM-B model, which proposes three components to any behavior (B), capability (C), opportunity (O) and motivation (M) (Michie et al., 2011). The combination of these frameworks made INFANT family-centered and focused on the rapid development of children during infancy and early toddlerhood. The INFANT efficacy RCT targeted first-time parents and used 20 behavioral change techniques, including goal setting, problem solving, and self-monitoring. In the scale-up, all parents were targeted.

Delivery Modalities

The INFANT efficacy RCT provided six 2-hour group sessions delivered by research dietitians to parents of infants at 3, 6, 9, 12, 15, and 18 months of age (Campbell et al., 2008; Marshall et al., 2022). More than two-thirds of the participants (68 percent) attended at least four of the six sessions.

Curriculum

The key content of INFANT’s curriculum target behaviors is summarized in Table 5-1. The infant and toddler feeding components were evidence-based and addressed both what and how to feed, emphasizing responsive feeding principles. Ancillary materials included DVDs viewed during group sessions, handouts, and a newsletter. A unique aspect of the INFANT curriculum was that the parents’ dietary intake was considered in addition to the child’s dietary intake.

Study Findings

INFANT had a positive impact on children’s dietary quality and reduced television viewing time, based on maternal self-report (Campbell et al., 2013; Hesketh et al., 2020; Spence et al., 2013; Zheng et al., 2022). The

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

TABLE 5-1 INFANT Targeted Behaviors and Intervention Focuses

Age Infant Developmental Outcomes Undesirable Caregiver Feeding Practices Anticipatory Guidance Intervention Focus
3 months Increased muscle control, strength, and coordination Early weaning and introduction of solids. Introduction of nutrient-poor foods To introduce basic concepts regarding parental feeding styles and how these might relate to beliefs about parenting

To support parents to delay weaning/introduction of solids to 6 months
6 months Food rejection by infants

Infant starts to sit briefly unsupported, reach with one hand; roll over
Adoption by parents of a feeding style and television viewing habits To develop parents’ understanding regarding:
  • feeding styles and impact on children’s eating
  • basic nutrition principles
  • sedentary behaviors in families and limits to acceptability
9 months Infant crawls and pulls self upright and walks with handhold Increasing use of television. Parents’ increased awareness of child mobility To develop understanding regarding:
  • parental modeling of eating, sedentary, and physical activity behaviors
  • impact of eating, activity, and sedentary behaviors on health of children and adults and the provision of opportunities
12, 15, and 18 months Infant stands without support and begins to walk Increasing autonomy of child in eating and activity Continued development of themes/skills regarding:
  • eating and moving for health of parents and children
  • how to feed/how to manage food rejection and demands
  • providing fail-safe food and activity environments

SOURCE: Campbell et al., 2008.

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

benefits persisted through 3.5 years of age (Hesketh et al., 2020). INFANT also demonstrated positive impacts on maternal dietary knowledge, self-efficacy, and diet quality (Cameron et al., 2014; Spence et al., 2014). The intervention did not affect infant and toddler body weight indicators (Campbell et al. 2013), which may be an important consideration in programmatic decision making. The researchers concluded that INFANT was efficacious at improving dietary intake behaviors and sedentary behaviors among infants and young toddlers (Cameron et al., 2014; Campbell et al. 2013; Hesketh et al., 2020; Spence et al., 2014).

Equity

The INFANT design considered the structure of the health care system in Victoria, but it did not have reducing inequities as a stated goal. The authors conducted an effect modification analysis based on maternal education and age (Cameron et al., 2014), and found that the intervention had greater effects in children with more highly educated mothers. The same effects were seen in children with mothers under 32 years of age (Cameron et al., 2014).

Scaling and Adaptations

As discussed above, the translational trial was conducted to determine the feasibility of implementing INFANT across the state of Victoria and of any adaptations that may be needed to scale the program (Laws et al., 2016; Love et al., 2019). As a result of this trial, which included input from multiple stakeholders, INFANT was scaled up in Victoria (Laws et al., 2021; Marshall et al., 2022). The scale-up uses well-established implementation frameworks and tools (e.g., the use of an implementation advisory committee consisting of interventionists and key practice and policy stakeholders; TIDieR; trainings and guides) and will systematically document the fidelity of implementation and reasons for adaptations made to the standard operating procedures (SOPs) tested in the original INFANT efficacy RCT. This trial will also report on implementation reach (coverage), fidelity, adoption, adaptations, cost, and sustainability. The key adaptions made in the scale-up are presented in Table 5-2 (also in Appendix F). Findings from the scale-up were not available at the time of this writing.

The committee assessed the potential scalability of INFANT and scored it positively on 13 of 22 scalability items in the WHO ExpandNet checklist, illustrating strong evidence base, stakeholder engagement, evidence-informed pragmatic adaptations for scale-up, and funding mechanisms for scale-up. Attributes could not be determined for nine items, representing

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

TABLE 5-2 Key Adaptations Made in the INFANT Scale-Up

Feature Adaptions
Study Population —Initial trial recruited first-time parents. All parents are recruited in the scale-up.
Materials —Addition of app due to advances in technology and parental preference for online supplementary information.
—Removal of tangible tools from the RCT due to cost and feasibility at scale.
—Videos were reduced in length due to generational preference for briefer visual content online.
Procedures —Reduced the number of sessions and the number of activities in the sessions, allowing for reduced session time (2 hours to 1.5 hours) due to limited workforce capacity at scale and the inclusion of some of the activities in the app.
—Eight additional behavior change techniques were added
Providers —Delivery agent expanded to offer flexibility according to organization and staff capacity, given that no additional funding was provided for delivery. Evidence from small-scale translation suggested that a wider group of health professionals could deliver the intervention once trained. Online training was offered to address the challenges faced by facilitators attending face-to-face training and the logistics of waiting for a cohort of participants. This also allowed broader reach and reduced the cost of the training.
Mode of Delivery —The addition of the app facilitated the provision of all information in one place, at one time, made it possible for the app to be updated with changes in knowledge/guidelines, increased the convenience for parents and facilitators, and made the program more cost-effective over a longer term.
Location —In the scale-up, the specific venue choice was to be determined by the organization delivering the program. —To allow flexibility for implementation at scale, local organizations determined referral pathways and program setup.
When and How Much —Parents’ earlier return to work (between 9 and 12 months as opposed to 15–18 months in the original trial) necessitated condensing content into 4 rather than 6 sessions concluding at 12 months but with app support to 18 months. Addition of the app was also in response to greater availability of online information and advances in technology.
Tailoring —Formative research indicated the importance of tailored app push notifications, and the app delivery format allowed for this. Technology advances enabled the addition of this feature.
Modifications —Modifications to allow flexibility for implementation at scale, including local contexts and community characteristics.
How well —Fidelity measures adjusted according to scale-up evaluation.
Funding —Stable funding from the National Health Medical Research Council (through a partnership mechanism as opposed to a grant mechanism in original trial) and the Victorian Department of Health that uses its own funding to deliver the trainings for INFANT providers.

SOURCE: Marshall et al., 2022

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

funding sustainability and political will beyond scale-up to drive policy changes that may be needed, although the ongoing hybrid implementation trial has the potential to inform these attributes. The only attribute that scored negatively was related to equity (based on cultural, community, and gender factors) as there was no evidence of intent to address inequities in efficacy (Campbell et al., 2008), translation (Laws et al., 2016), or scale-up (Marshall et al., 2022).

Lessons Learned

INFANT is an example of a promising evidence-based intervention that can be scaled. Although the real-world effectiveness of INFANT on a larger scale is still being studied, the systematic process being followed by the investigators is based on robust implementation science principles and offers important lessons for others interested in improving infant and young child feeding practices and other lifestyle behaviors. Overall, the process to scale INFANT offers the following lessons for scaling up infant and young child feeding programs:

  1. Co-design (with stakeholders) a multicomponent program based on a family-centered approach grounded in robust behavior change conceptual frameworks.
  2. Co-design a program with diverse stakeholders, taking health care systems context into account. It is vital to consider the system(s) that will need to engage with program implementation at scale, beginning at program conception.
  3. Include an equity framework, such as the Health Equity Framework (Peterson et al., 2021), and corresponding metrics at program inception to ensure that equity is intentionally and substantively addressed throughout program co-design and implementation.
  4. Use evidence-based curricula that adhere to current national or international dietary guidelines and pedagogical approaches.
  5. Test the impact of the intervention under “ideal conditions” using an efficacy trial once the intervention SOP have been fully developed.
  6. If the intervention proves to be efficacious, follow the efficacy trial with translational feasibility studies that use robust implementation frameworks, clearly documenting the rationale for any adaptations needed for scaling.
  7. Consider the cost of implementation and the stability of funding sources as key drivers of program sustainability. For example, the addition of an app to the scaled INFANT intervention allowed for the number of sessions and session duration to be reduced while adding and reinforcing behavioral change targets.
Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×
  1. Prior to scaling, a hybrid implementation trial should be conducted to assess: (1) program implementation, reach (coverage), fidelity, adoption, adaptations, cost, and sustainability; and (2) real-world effectiveness.
  2. Disseminate the program findings and changes to stakeholders and keep them engaged throughout program implementation and scaling.
  3. If the program works at scale, disseminate the SOP to other locations, including the process of adaptation to the local context without sacrificing the core functions of the program and monitoring and evaluation procedures, including a quality assurance system.

The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) Study

The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) was a responsive parenting intervention delivered to U.S. families via home visiting with the overarching goal of early childhood obesity prevention.

Efficacy

INSIGHT was tested through a RCT. The research team recruited first-time mothers and their infants from a single maternity ward in Hershey, Pennsylvania, from January 2012 to March 2014 and followed the children until 1 year of age (Harris et al., 2020; Hohman et al., 2017; Savage et al., 2016, 2018). A follow-up observational cohort study (SIBSIGHT) enrolled a subset of mothers who underwent INSIGHT and had a second child (Hohman et al., 2020).

Target Behaviors and Conceptual Frameworks

INSIGHT aimed to encourage caregiver responsive feeding practices (e.g., not pressuring the child to eat or using food to soothe or reward the child) (Savage et al., 2018), the use of recommended bottle or cup feeding practices (Savage et al., 2018), and broad improvement in child diet quality (Hohman et al., 2017, 2020). A conceptual or theoretical framework for INSIGHT beyond the responsive parenting framework was not specified.

Delivery Modalities

Research nurses conducted four one-on-one home visits with families at infant ages 3‒4 weeks, 16 weeks, 28 weeks, and 40 weeks (Savage et al.,

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

2016). Almost all mothers (>89 percent) participated in the home visits at every time point. The study retention rate was 86 percent, with 125 of the 145 participants who had been randomized into the responsive parenting group completing the data collection visit when the child was 1 year old (Savage et al., 2016). Retention of those in the intervention was almost identical to that of the comparison group, which was a dose-matched home safety curriculum (Savage et al., 2016).

Curriculum

INSIGHT nurses provided caregivers with guidance on interacting with their infant during drowsy, sleepy, fussy, and alert behavioral states (Savage et al., 2016). Nutrition-specific education, demonstrations, discussion, and resources (e.g., The Happiest Baby on the Block video) were focused on helping caregivers recognize child hunger and satiation cues; provide age-appropriate portion sizes and repeated exposures to new foods and beverages; model healthy behaviors; avoid using food as a reward, punishment, or sole source of soothing; establish regular routines and limits; and understand growth charts. In addition, nurses provided caregivers with guidance and resources related to promoting healthy infant sleep, active play, and emotional regulation, and setting screen time limits. Of note, parental or family eating habits were not addressed within this intervention.

Study Findings

INSIGHT positively affected outcomes related to how to feed. When the child was 1 year of age, mothers in the intervention group were significantly more likely to report having consistent feeding routines and setting limits, and significantly less likely to soothe the child with food or pressure the child to finish their bottle or food (Savage et al., 2018). Mothers that received the responsive parenting content were also less likely to add cereal to the bottle at 20 weeks of age, prop the child’s bottle at 28 weeks of age, or use a bottle or give the infant a bottle at bedtime at 1 year of age (Savage et al., 2018), feeding practices that are not recommended by experts.

INSIGHT had less impact on outcomes related to what to feed. At 9 months of age, almost two-thirds of children across study groups had diets that were low in fruits and vegetables or high in fruit juice, sugar-sweetened beverages (SSBs), and sweet or salty snacks (Hohman et al., 2017). Within the group of infants who were predominantly formula fed, there was evidence that the INSIGHT intervention positively impacted diet quality (Hohman et al., 2017). However, there were limited differ-

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

ences between study groups in child dietary intake at one year of age. Mothers in the intervention group reported via a food frequency questionnaire that their children ate salty snacks less frequently and vegetables more frequently than children of mothers in the comparison group, but there were no observed differences in fruit, juice, SSB, fried food, or sweets intake (Savage et al., 2018). INSIGHT had a positive effect on the variety and frequency of vegetable consumption for the next child in the family, independent of any additional intervention beyond maternal receipt of INSIGHT home visits for the first child (Hohman et al., 2020).

Infants in the intervention group had lower mean weight-for-length percentiles and less overweight prevalence at 1 year of age than infants in the comparison group (Savage et al., 2016). The study is unique in that it looked at a wide variety of outcomes related to both what to feed and how to feed. In addition, the intervention had long-term impacts, such that it affected feeding outcomes in the second-born child.

Equity

INSIGHT did not explicitly state having a goal to reduce health disparities. Mothers included in the study had high annual household incomes and education levels and were predominantly White and married.

Scaling and Adaptions

No translational trial has been conducted for INSIGHT. There was also no identified existing U.S. home visiting model that could be used for the scale up process. However, within the U.S. context, the intensity of the intervention (four visits) could potentially be feasible for most home visiting models. It could be difficult to have a nurse deliver a scaled-up intervention, as many U.S. home visiting models are implemented by other professionals (e.g., social workers) or trained paraprofessionals. However, it is likely that all home visitors could be trained on the INSIGHT curriculum content, which is well aligned with positive parenting practices and child development content already included as part of the curriculum for many home visiting models. For INSIGHT, there was no reported community engagement in the curriculum design or study implementation. INSIGHT intervention content might need to be adapted to improve the acknowledgement of family economic and social challenges and cultural sensitivity, since the intervention was tested with a homogenous, privileged population.

The committee assessed the potential scalability of the INSIGHT intervention using the WHO ExpandNet checklist, and it scored positively on 5 out of 22 scalability items, in that it tested as an intervention

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

that is broadly compatible with U.S. home visiting infrastructure and child health priorities. However, with only one efficacy trial conducted in one community with a homogenous, privileged group of participants and no evidence of community or stakeholder engagement in the design of the curriculum, the INSIGHT program would likely need substantial additional study and adaptation to be scaled up successfully.

Family Spirit Nurture

Family Spirit Nurture is a nutrition-focused home visiting intervention for U.S. Tribal communities with the overarching goal of early childhood obesity prevention.

Efficacy

Family Spirit Nurture (Part 1) was initially tested in the Navajo Nation (Shiprock, New Mexico) through an RCT. The research team recruited mothers and their infants from a pediatric clinic or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic and via word of mouth from March 2017 to May 2018 (Rosenstock et al., 2021). The intervention began when a child was age 3–6 months, with the children and their mothers followed until the child was 1 year of age.

A more intensive version of Family Spirit Nurture (Part 2) was tested through an RCT conducted with two Navajo communities and one White Mountain Apache community (Fort Apache Indian Reservation) (Ingalls et al., 2019). The research team recruited expectant mothers starting in October 2017 and intervened from maternal pregnancy to until the child reached an age of 18 months, following the mother–child pairs until the children were 2 years of age.

Target Behaviors and Conceptual Frameworks

Family Spirit Nurture uses the same format and delivery system as Family Spirit, a national home visiting model designed by and for Tribal communities which meets the U.S. Department of Health and Human Services criteria to be designated as evidence-based (Bleiweiss-Sande et al., 2022; Rosenstock et al., 2021). The conceptual model for the project was based on G.R. Paterson’s family systems ecological developmental theory and is represented in Figure 5-1 (Ingalls et al., 2019). It proposes that early childhood parenting behaviors are a central influence on child nutrition and physical activity behaviors and weight outcomes while acknowledging that an ecological approach that supports maternal mental health, household food and water security, and access to food and physical activ-

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×
Image
FIGURE 5-1 Conceptual model for Family Spirit Nurture (Part Two).
NOTE: PA = physical activity.
SOURCE: Ingalls et al., 2019.

ity opportunities is essential to promoting optimal parenting behaviors (Ingalls et al., 2019). The family health coaches that deliver Family Spirit Nurture are culturally matched and trained to be empathetic and to model healthy behaviors, based on social cognitive theory (Ingalls et al., 2019).

Family Spirit Nurture (Part 1) aimed to encourage caregiver responsive feeding practices (e.g., identifying infant’s hunger and satiation cues, modeling healthy eating) and recommended complementary feeding practices and to reduce child access to SSB (Rosenstock et al., 2021). Family Spirit Nurture (Part 2) had similar child-focused aims. Additionally, it was also aimed to promote maternal psychosocial well-being and safe and reliable home environments (Ingalls et al., 2019).

Delivery Modalities

For Family Spirit Nurture (Part 1), Navajo paraprofessionals conducted six one-on-one, approximately 45-minute home visits with families from infant ages 3 to 6 months (Rosenstock et al., 2021). Of the 68 mothers randomized to the Family Spirit Nurture group, 60 received at least one home visit (88 percent). Assessments were completed by 77–92 percent of families at infant ages 6, 9, and 12 months, and there was no difference in attrition between the Family Spirit Nurture group and the comparison group, which received three home visits from infant ages 3 to 5 months that were focused on injury prevention (Rosenstock et al., 2021).

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

Family Spirit Nurture (Part 2) was also delivered by Navajo paraprofessionals (family health coaches). It is much more intensive and comprehensive than Family Spirit Nurture (Part 1), involving 36 one-on-one home visits, which last up to 60 minutes and occur bi-weekly from 28 weeks gestation until birth, weekly from birth to infant age 3 months, biweekly from infant ages 3 to 6 months, and monthly from child ages 6 to 18 months (Ingalls et al., 2019). The program intensity was based on evidence of the visit frequency used by effective home visiting programs (approximately 60 planned visits over 1–5 years, with completion of at least one-third to half of the visits) (Ingalls et al., 2019).

Curriculum

The Family Spirit Nurture (Parts 1 and 2) curricula were co-designed with the Tribal communities involved in the study (Ingalls et al., 2019; Rosenstock et al., 2021). Researchers sought cultural and contextual input on the curricula via one-on-one and group meetings with community leaders, home visitors, and other stakeholders (Ingalls et al., 2019).

Family Spirit Nurture (Parts 1 and 2) curriculum topics were aligned with the targeted behaviors for each project (Ingalls et al., 2019; Rosenstock et al., 2021). Lessons were delivered one-on-one in the family home or at another private location using tabletop flipcharts that included drawings by Indigenous artists and illustrative stories or scenarios (Ingalls et al., 2019). Family health coaches used motivational interviewing techniques and the VISION (visualize goal, identify sub-goals, set timeline, identify barriers, overcome roadblocks, nurture sources of support) tool to facilitate goal setting and problem solving with families at each visit (Ingalls et al., 2019). Of note, parental or family eating habits were not addressed within this intervention.

Study Findings

Family Spirit Nurture (Part 1) demonstrated some impact on all targeted behaviors. Relative to the comparison group, mothers in the intervention group reported significantly greater use of responsive feeding at child ages 6 and 9 months and significantly less child consumption of SSB at child ages 9 and 12 months. Infants in the intervention group had significantly lower changes in body mass index (BMI) z-scores at 6 and 9 months of age relative to infants in the comparison group (Rosenstock et al., 2021). Although the effects were no longer significant at child age 12 months, mothers in the intervention group continued to report greater use of responsive feeding, and child BMI z-scores remained lower relative to the comparison group.

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

Family Spirit Nurture (Part 2) completed data collection in February 2023. At the time this report was written, results from Family Spirit Nurture (Part 2) were not yet published.

Equity

Family Spirit Nurture was tested in communities that have been marginalized and exploited in the United States. Cultural sensitivity was explicitly considered during the project’s design and implementation. The curricula were co-designed with Navajo and White Mountain Apache communities and delivered by culturally matched paraprofessionals (Ingalls et al., 2019; Rosenstock et al., 2021).

Scaling and Adaptions

A translational trial has not been conducted for Family Spirit Nurture. However, the original Family Spirit home visiting model is currently being implemented in more than 130 tribal communities in 21 U.S. states (Rosenstock et al., 2021), providing a ready-made network that could rapidly scale-up Family Spirit Nurture. While the number of visits included in the Family Spirit Nurture (Part 2) curriculum might be a challenge, the program’s intensity was modeled after other successful home visiting models, indicating feasibility (Ingalls et al., 2019).

The potential scalability of Family Spirit Nurture was assessed using the WHO ExpandNet checklist, and it scored positively for 10 of 22 scalability items, with strong engagement of stakeholders and an accessible, nationwide network of affiliates already implementing the original, evidence-based Family Spirit home visiting model in rural and reservation-based communities which are disproportionately affected by obesity and its cardiometabolic consequences (see Appendix F). As translation and scale-up trials have not been conducted for Family Spirit Nurture, several items that could not be scored or that scored negatively were related to studying the implementation process and marshaling support for scale-up activities.

SELECT INFORMATIVE ELEMENTS FROM IDENTIFIED STUDIES IN THIS REPORT

In addition to the informative studies identified by the committee during the scoping review, other studies contained informative elements of specific utility for designing and scaling effective complementary feeding interventions. These study aspects can inform the design of future interventions.

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

Technology Intervention Elements: Grow2Gether

Overview

Grow2Gether is an RCT designed to foster healthy infant growth by encouraging healthful feeding behaviors for infants born to mothers with low-income attending obstetric clinics in Philadelphia, Pennsylvania (Fiks et al., 2017).

The development of the Grow2Gether intervention was informed by social learning theory, which emphasizes the importance of observing others performing a behavior and receiving positive feedback when a behavior is performed (Bandura, 1977). Before the initial Grow2Gether intervention was developed, a pilot study was conducted among 29 publicly insured Black mothers with low-income in Philadelphia (Gruver et al., 2016). The intervention in the pilot study incorporated the principles of social learning theory by organizing online, moderated social media peer groups that allowed participants to observe behavior among their peers and receive positive feedback in response to desired behaviors (Bandura, 1977; Gruver et al., 2016).

Following the initial pilot, the Grow2Gether RCT enrolled 87 pregnant people in Philadelphia who were overweight or obese and randomly assigned them to either the Grow2Gether intervention or to a control (Fiks et al., 2017). The study population was 100 percent publicly insured and 88 percent Black; 42 percent of the population was food insecure, and 3 percent had a bachelor’s degree or higher level of education. Peer groups were formed, each consisting of 9 to 13 pregnant people with a similar estimated date of delivery.

The intervention was a private Facebook peer group for participants that concentrated on healthy parenting and infant growth (Fiks et al., 2017). The intervention was initiated approximately 2 months prior to each participant’s expected due date and was continued through 9 months after delivery. Groups were facilitated by a psychologist and were structured around short videos that were posted weekly through 6 months of age and then biweekly through 9 months of age. Participants responded to the video curriculum by posting to the group, discussing parenting topics, and uploading photos and questions about parenting.

The investigators used several approaches to ensure privacy and human subject protections. First, access to the Facebook group was limited to enrolled participants and study staff. Second, participant posts were not put online until after they had been reviewed by study staff; posts that were critical or offensive were removed without posting. Third, the group was established using the highest available privacy setting, “secret.” Fourth, participants were reminded that the group was not for urgent medical needs and that confidentiality could not be assured.

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Both intervention and control group participants received text message reminders of recommended well-child visits (Fiks et al., 2017). The control group received no additional intervention beyond the text message reminders.

Informative Aspects for Purpose of This Study

Four Facebook groups were formed, with an average of 30 participant posts per week per group, indicating a high degree of participant engagement. At the final follow-up, 88 percent of participants agreed with the statements, “I would recommend this program” and “This program was helpful.” These findings suggest that the use of Facebook to deliver a social learning complementary feeding intervention is easily implementable and accepted.

At 9 months, participants in the intervention group had higher mean overall feeding behavior scores on the Infant Feeding Style Questionnaire and were less likely to report pressuring their children to finish food than controls (Fiks et al., 2017). Participants assigned to the intervention were also less likely to report feeding cereal in a bottle at 6 months. This suggests that this intervention element can positively influence behavioral outcomes. However, no differences in weight-for-length z-score were observed between the groups.

Limitations

A limitation of this study was its small sample size (n=87).

Takeaways

Grow2Gether is an example of a social media intervention, in this case a private social media peer group, that was feasible and acceptable to U.S. participants in an at-risk population. This study was given consideration by the committee because social media is an increasingly important tool for the dissemination of information, has the potential for scalability in a cost-effective manner, and may be convenient for families with young children.

Technology Intervention Elements: Early Food for Future Health

Overview

The Early Food for Future Health study is an example of an eHealth intervention aimed at improving the diet of young children (Helle et al., 2019a,b). This RCT was conducted and designed by researchers in

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Norway. The intervention was directed at mothers with children 5.5 months old at baseline. The majority of mothers had a college/university degree and were native Norwegians; both first-time mothers and mothers with older children were included. A total of 718 women were recruited through Facebook advertising and emails to health clinics. The intervention was delivered over 6 months via a website that featured monthly online video clips (a total of seven, each lasting 3‒5 minutes) on age-appropriate feeding topics coupled with cooking films and recipes. Video topics included adequate and varied intake of fruit and vegetables, appropriate foods and textures, the development of taste preferences, and responsive feeding practices. Outcome measures were completed by 455 mothers at the end of the intervention when children were approximately 12 months old. A 1-year post-intervention assessment was completed by 295 mothers when children were approximately 24 months old.

Informative Aspects for the Purpose of This Study

Having access to the web-based child feeding videos, along with cooking films and recipes, resulted in improvements in frequency of intake of fruits and vegetables and variety of vegetables tasted by children at age 12 months; no differences were observed in intake of discretionary foods (e.g., cookies, other sweets, potato chips, sugary drinks). At 12 months, children in the intervention group also exhibited better mealtime habits, including being more likely to eat breakfast and dinner with family and eat the same dinner as family and being less likely to play or watch TV while eating. No differences were observed in maternal feeding practices as measured by the Infant Feeding Questionnaire (Baughcum et al., 2001). At 24 months, after a year without the intervention, these differences no longer remained.

The Early Food for Future Health study also included an evaluation of uptake and satisfaction with the intervention. Most mothers (85 percent) reported watching all or most of the video clips, 96 percent said they were easy to understand, and 11 percent said that they did not learn something new from them. Regarding the cooking films, 66 percent watched all/most, 92 percent said they were easy to understand, and only 9 percent reported not learning something new. Collectively, these findings suggest that online videos may be an acceptable way to affect child feeding practices during the first year of life.

Limitations

Although the tools used for assessments had been previously evaluated for validity, the measures relevant to this study were collected

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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by mothers’ self-report (Helle et al., 2019a,b). The study was powered to detect differences in maternal feeding practices outcomes with an expected total sample size of 800 at 12 months. However, recruitment was less than expected, and attrition was more than expected, resulting in only about half as many participants as were estimated to be needed to detect significant differences in feeding practices. Mothers lost to follow-up were slightly but significantly younger (29.8 years versus 30.8 years old) and less likely to have a college or university degree (77 percent versus 84 percent) than those who remained in the study. The high socioeconomic status of the sample limits generalizability to lower-resourced populations.

Takeaways

The findings suggest that an accessible web-based intervention shows promise in terms of being potentially scalable and having positive impacts on what and how to feed young children, at least over the short term during the first year of life, and with relatively well-educated mothers. The finding that the intervention’s impacts diminished after a year when the intervention was no longer in place (albeit partially attributable to the reduced sample size at 24 months) suggest the need for a life-course approach wherein ongoing boosters are provided. Additional studies will be needed to confirm that this web-based intervention has similar impacts with more diverse samples of parents.

Technology Intervention Elements: SMS WIC

Overview

The Short Messaging Service (SMS) WIC study is important as its primary focus is on an approach, interactive texting, that may be instrumental in supportive behavior change related to complementary feeding (Gibby et al., 2019; Macchi et al., 2022; Palacios et al., 2018). This intervention involved interactive text messages sent to caregivers participating in WIC in Puerto Rico and Hawai’i, with the goals of (1) understanding the impact of texting on energy, nutrient, and food group intake (Gibby et al., 2019; Macchi et al., 2022; Palacios et al., 2018) on infant feeding practices and weight gain (Palacios et al., 2018); and (2) demonstrating the acceptability of interactive text messaging among WIC participants (Gibby et al., 2019). Based on the transtheoretical model of health and behavior change, the intervention involved sending caregivers one text message per week for 18 weeks starting from the time the caregiver’s infant was enrolled in WIC (generally between birth and 2 months) until 4 months later. Messages were sent in English or Spanish, and were about human

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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milk feeding, preventing overfeeding, delaying solids, and delaying and reducing juice consumption. A comparison group received text messages with the same periodicity, but on the topics of general infant health issues such as placing the infant on his or her back to sleep and proper use of car seats. Outcomes were measured using an infant food frequency questionnaire previously evaluated for validity at the end of the intervention (Macchi et al., 2022); an infant feeding practices questionnaire with questions about the type of infant feeding (breast or bottle-feeding), the age of introduction of solids and juices, methods of feeding the baby (use of bottles, spoons, adding foods to bottles), the caregiver’s response to bottle feeding (e.g., encouraging the infant to finish a bottle), and distractions during feeding (e.g., using screens, eating with the rest of the family) (Palacios et al., 2018); assessments of infant weight and length (Palacios et al., 2018); and quantitative and qualitative measures of the acceptability of the intervention (Gibby et al., 2019).

Informative Aspects for Purposes of This Study

The study’s findings demonstrated that interactive texting was a highly accepted method of receiving education among women with low-income served by WIC. Most participants receiving the intervention text messages reported that all messages were useful and that the messages led them to make changes in the way they fed their infants (Gibby et al., 2019). Acceptability was high for both English- and Spanish-speakers. Impacts on measured behavior changes were mixed. At 4‒6 months of age, compared with the control group, the intervention group had significantly higher intakes of total grains, protein, calcium, and zinc, but no differences were seen in other food groups (Macchi et al., 2022). There were no significant improvements in feeding practices or in weight with the text message intervention (Palacios et al., 2018).

Limitations

Technical hurdles in establishing a web-based texting platform were the primary limitations in this study. Due to the capabilities of the text messaging platform used, participants only had a 12-hour window to send an interactive response. In addition, different servers were needed to support texting to different phone carriers, causing a small number of participants in Puerto Rico to receive only 28–67 percent of messages. The study also did not include other caregivers who were directly involved in infant feeding. Finally, the optimal “dose” of texting cannot be determined from this study, as all caregivers received one text per week over a 4-month period.

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
×

Takeaways

A WIC-based texting campaign is highly implementable, as it is fairly low burden and low cost. This method of intervention could be implemented across settings within and outside of WIC.

Other Intervention Elements: Repetition Counts

Overview

The Repetition Counts study was carried out in the United Kingdom with the goal of comparing the effectiveness of different learning strategies in promoting the intake of a novel vegetable (Caton et al., 2013). Children aged between 9 and 38 months were recruited to participate from private child care nurseries; nursery managers were given details on the study and distributed participant information sheets and consent. To increase ethnic diversity, nurseries were selected for participation from a variety of locations in West and South Yorkshire, United Kingdom. The children (n=72) were randomly assigned to one of three conditions: repeated exposure, flavor–flavor learning, or flavor–nutrient learning. Each child was offered 10 exposures to their version of a novel vegetable (artichoke). The amounts of artichoke puree and carrot puree (control vegetable) consumed before and after the intervention were measured.

At pre-intervention, carrot intake was significantly higher than artichoke intake. The intake of both vegetables increased over time; however, artichoke intake increased significantly more the carrot intake, even after controlling for higher carrot intake at baseline. Artichoke intake increased to the same extent in all three conditions, and this effect was persistent up to 5 weeks post-intervention. Five exposures were sufficient to increase intake compared with the first exposure.

Based on the study conclusion, repeated exposure to three variants of a novel vegetable was sufficient to increase intake of this vegetable, regardless of the addition of a familiar taste or energy. It indicates that repetition is a critical factor in promoting novel vegetable intake in children under the age of 2.

Informative Aspects for Purposes of This Study

There are several informative elements of this research study. It uses associative learning theory and outlines interventions aimed at improving infant feeding behaviors (Baranowski, 2008). The intervention was conducted in an early care and education (ECE) setting in a

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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high-income country (United Kingdom) and addresses aspects of both what (vegetable intake) and how to feed young children (repeated exposure to vegetables through flavor–flavor learning and flavor–nutrient learning for children).

Limitation(s)

This study did not assess environmental and other factors that could affect vegetable consumption, such as the home environment, exposure to vegetables in the home, and parental feeding practices. A relatively small sample size per condition may have weakened the strength of the effects observed. Future studies should extend findings by offering the vegetables in their pure form to children old enough to no longer need purees. This would ensure that both the taste and texture of the vegetables are experienced, and not just the taste in puree form. A control group was not used for this study. Therefore, it is difficult to know if increases in intake would have been observed in the absence of repeated exposure.

Takeaways

This study suggests that repeated exposure is a simple technique that can be used in both home and child care settings to improve acceptance of novel vegetables. Using cycle menus in ECE settings that participate in the Child and Adult Care Food Program (CACFP) could allow the repeated exposure concept to be further incorporated within existing CACFP program guidelines.

Other Intervention Elements: EniM Clinical Trial

Overview

The EniM study was conducted in Spain to evaluate the effectiveness of an educational program for parents of children 1 to 2 years of age that was focused on the acquisition of healthy eating habits for the parents themselves and their children (Roset-Salla et al., 2016). The study was conducted in 12 child care centers, with parents at the participating child care centers being invited to informational meetings with pamphlets and posters. No details were given on how the child care centers were recruited. The study design was a multicenter, multidisciplinary RCT carried out in a community setting.

The intervention group received four educational lessons at the beginning of the study that covered both theoretical and practical con-

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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tent on food groups, the Mediterranean diet, physical activity, food labels, and progressive introduction to food groups for children; outcome measures were assessed via questionnaires and other metrics during workshops. There was one reminder workshop at 4 months. Parents in the control group received non-nutrition education classes on a different topic.

Regarding child-focused outcomes, the study found that adherence to the Mediterranean diet improved in the intervention group compared with the control group, although there were no significant differences in observed nutrient intakes between the two groups of children. Among the parents, those in the intervention group showed significant improvement in Mediterranean diet adherence; increased consumption of vegetables, fish, olive oil, and vitamins C and D; and decreased intake of butter, margarine, and industrial bakery products compared with the control group. The study concluded that an educational intervention for parents at the time children are incorporated into the family table can significantly increase parental adherence to the Mediterranean diet, suggesting future improvement in other indicators of health and an expected influence on the diet of their children.

Informative Aspects for Purposes of This Study

This research study outlines interventions aimed at improving adult and child feeding behaviors in an ECE setting within a high-income country (Spain). The intervention itself addressed what to feed (e.g., dietary fats and fiber consistent with a Mediterranean diet) by focusing on the diets of both the caregiver and the child. While how to feed was not included in the intervention, human milk feeding was assessed as a comparative factor between the intervention group and the control group.

Limitation(s)

Those who did not finish the study were likely to have lower education levels. Participants had specific socioeconomic and cultural characteristics (high education level, employment), which may limit the generalizability of the findings.

Takeaways

Providing an educational program to parents in existing ECE programs has efficacy for improving infant and young child dietary intake and may facilitate programmatic implementation.

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Other Intervention Elements: Early Childhood Obesity Prevention Program

Overview

The Early Childhood Obesity Prevention (ECHO) Program is a multi-component pilot RCT of a obesity prevention program for mother–newborn dyads with a community focus (Cloutier et al., 2018). The study aim is to test the feasibility of an ecologic approach to obesity prevention in children in the first year of life. Mother–newborn dyads were recruited from one of six low-income neighborhoods in Hartford, Connecticut, that were served by a Brighter Future Family (BFF) Center that was linked to the Nurturing Families Network (NFN) home visiting program. BFF Centers were paired by socioeconomic status and racial/ethnic composition and were randomly assigned to conduct either the standard NFN home visiting program or the intervention NFN home visiting program. People who were pregnant or postpartum and eligible for participation in NFN were screened for eligibility for ECHO. Participants received the standard NFN home visitation program or an enhanced program (NFN+) that incorporated behavioral change strategies (e.g., goal setting, problem solving) and focused on six obesity-associated behaviors (human milk feeding, juice/SSB, solids, infant sleep, television/screen time, and soothability) with linkages to community resources.

Participants who completed the ECHO program were less likely to have introduced juice/SSB at 6 months of age and more likely to have introduced juice at an older age than to those who did not complete the program. Fruit and vegetable intake did not differ between groups. Those who stayed in the NFN+ program longer also had human milk fed for a longer time at 12 months. Infants of completers had a higher BMI than infants of non-completers at birth, but a lower BMI at 6 and 12 months. Infants whose mothers completed ECHO had a lower weight-for-length z-score at 12 months than those who did not complete the program.

Informative Aspects for Purposes of This Study

The ECHO program is grounded in theory and uses an ecologic framework to support partnerships across community sectors to support family behavioral change (Cloutier et al., 2018). The study outlines interventions aimed at improving infant feeding behaviors and was conducted in a diverse low-income community in the United States. The intervention occurred in the home visiting context and addressed what to feed (related to SSB, juice, solids, fruits, and vegetables) and how to feed (including cup use and human milk feeding). The strength of the ECHO program is the use of an existing evidence-based home visiting program to deliver an intervention.

Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Limitation(s)

The study sample size was small because it was designed as a pilot/feasibility study.

The dropout rate during the intervention for the NFN dyads was high, although it was similar to the rate for NFN enrollees and the rates observed in other studies.

Takeaways

The ECHO program delivered module elements in 10–20-minute segments over multiple home visits. This study demonstrates that it is feasible to conduct an ecological intervention in an existing home visiting program. If demonstrated to be effective, the program could be a sustainable intervention capable of wide dissemination.

SUMMARY

This chapter describes the efficacy and scaling of the three informative studies and key takeaways of the six informative intervention elements. These informative studies were conducted within the health care setting and home visit setting, while the informative intervention elements were conducted within health care, ECE, WIC, and home visiting settings. These studies provide evidence for and elements of scalable intervention elements. However, due to these studies’ reliance on participant-reported outcomes such as changes in attitudes and beliefs, the impact of the interventions on key public health metrics such as obesity is unknown.

The next chapter describes considerations for scaling infant and young child feeding programs based on the informative studies and informative elements reviewed by the committee, along with considerations related to settings and systems responsible for implementing complementary feeding interventions.

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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Suggested Citation:"5 Identified Informative Studies and Elements." National Academies of Sciences, Engineering, and Medicine. 2023. Complementary Feeding Interventions for Infants and Young Children Under Age 2: Scoping of Promising Interventions to Implement at the Community or State Level. Washington, DC: The National Academies Press. doi: 10.17226/27239.
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Complementary feeding refers to the introduction of foods other than human milk or formula to an infants diet. In response to a request from the Centers for Disease Control and Prevention, the National Academies Health and Medicine Division convened the Committee on Complementary Feeding Interventions for Infants and Young Children under Age 2 to conduct a consensus study scoping review of peer-reviewed literature and other publicly available information on interventions addressing complementary feeding of infants and young children. The interventions studied took place in the U.S. and other high-income country health care systems; early care and education settings; university cooperative extension programs; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); home visiting programs; and other settings. This consensus study report summarizes evidence and provides information on interventions that could be scaled up or implemented at a community or state level.

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