In a recently released article in Pediatrics,Dr. Charles Wood and colleagues (10.1542/peds.2018-0519) examined the antecedents of obesity among infant born extremely premature. The study team used data gained prospectively from the ELGAN (Extremely Low Gestational Age Newborn) Study, which enrolled infants born prior to the 28^th week of gestation, and followed them to age 10 years. Of the original cohort of 1,506 infants, 871 former premature infants had height and weight data at age 10 years, representing a remarkable 74% of survivors.  Full neonatal and perinatal information, infant weight at birth and ages 1 and 2 years, as well as maternal characteristics including pre-pregnancy BMI (body mass index), were available for the analysis. The authors took this treasure trove of data and used a “TORM” or “time-oriented risk model” to conduct the analysis; the statistics are explained very clearly and non-statisticians will feel comfortable that they have grasped the essence of the approach throughout.

The initial examination identified multiple factors potentially associated with overweight and obesity at age 10 years, but the final model which took these variables into account showed that just a few of these factors were significantly associated with the overweight and obesity outcomes. While I hope you will enjoy learning what these key significant factors are, I’d like to focus on the one I think is most potentially modifiable: rate of weight gain in the first and second years.

Since by age 1-2 years most infants are receiving well child care from primary providers in the community, we as providers have a great opportunity to make a difference. It’s hard not to initially celebrate every ounce of weight gain outside of the hospital as a major achievement! What we can do, though, is then introduce parents to the same thinking we apply to the routine well care of former full term infants. For infants, we can focus on cue-based feeding: what are the signs the baby is giving that he or she is hungry, and just as importantly, what are the signs that he or she is getting full?¹ The signs of satiety may be subtle and include shorter sucking bursts with fewer sucks, hand relaxing and fist opening, a milk drizzle at the corner of the mouth and outright sucking pauses. Rather than urging the baby on to an “empty plate” (i.e. empty bottle), parental attentiveness to satiety cues may build self-regulation skills for eating, which may mitigate risk for future overweight and obesity. Additional research in this fascinating area of infant-to-parent feeding cue communication is needed.² The toddler years give additional opportunity for supporting healthy eating habits, for example, turning the television off during meals, and neither using food as a reward nor pressuring the child to eat.³ I agree with the study authors that “…attention [should] be paid to rapid growth in the first years of life, even in this vulnerable population of children.”  This simple yet elegant ELGAN follow up is a terrific example of how a well-designed and large prospective study can bear fruit well beyond what was initially expected.

References

1. Shloim N, Vereijken CMJL, Blundell P, Hetherington MM. Looking for cues - infant communication of hunger and satiation during milk feeding. Appetite. 2017;108:74-82.

2. McNally J, Hugh‐Jones S, Caton S, Vereijken C, Weenen H, Hetherington M. Communicating hunger and satiation in the first 2 years of life: a systematic review. Maternal & Child Nutrition. 2016;12:205-228.

3. Russell CG, Haszard JJ, Taylor RW, Heath AM, Taylor B, Campbell KJ. Parental feeding practices associated with children's eating and weight: What are parents of toddlers and preschool children doing? Appetite. 2018;128:120-128.