Effect of a care-coordinated responsive parenting intervention on obesogenic risk behaviours among mother–infant dyads enrolled in WIC

1 INTRODUCTION

Obesity affects one in five children in the United States.¹ Excess weight gain in infancy increases the risk of obesity and obesity-related comorbidities in later life.^{2, 3} Responsive parenting (RP) interventions that encourage developmentally appropriate, prompt and contingent parenting responses to infants' needs⁴ have improved child weight outcomes.^{5, 6} RP messaging has also improved parent feeding practices,^{7, 8} dietary intake,⁹ infant sleep,¹⁰ tummy time and reduced screen exposure,¹¹ and other modifiable obesogenic risk factors.¹² RP interventions delivered using the home-visiting model show promise in reducing these risks and promoting a healthy weight trajectory.^{5, 6} Social care settings, particularly the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), offer another opportunity for implementing RP interventions, as nearly half of U.S. children are eligible.¹³ Leveraging these established systems may offer a more sustainable, affordable and scalable approach to implementing pragmatic interventions that evaluate the real-world effectiveness of RP strategies in early childhood obesity prevention.

Children qualifying for government programmes such as WIC and Supplemental Nutrition Assistance Program Education (SNAP-Ed) may receive care in both health care and social care settings.¹⁴ However, coordinated care between settings is lacking,¹⁵ which can result in inconsistent prevention messaging that leads to inefficiencies in obesity prevention messaging and strategies.¹⁶ For example, WIC mothers reported receiving conflicting messaging and guidance on parenting and feeding from paediatric clinicians and WIC nutritionists.¹⁷ Dietz et al. proposed a clinical-community integrated framework,¹⁸ which emphasizes fostering partnerships and collaboration between health care (e.g., paediatric clinics) and social care (e.g., WIC programmes) settings to integrate and coordinate care to optimize strategies for the prevention of childhood obesity to advance health equity.¹⁹ Since integration and care coordination between health care and social care settings may hold promise in the collective effort to address childhood obesity,²⁰ it may also offer opportunities to deliver RP messaging between settings.

To address these gaps, the Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care study, a pragmatic randomized clinical trial tested the integration of health (paediatric clinicians) and social (WIC nutritionists) care delivery. The trial was effective at promoting responsive parenting and reducing infant body mass index (BMI).²¹ This secondary analysis aims to examine the effects of the WEE Baby Care RP intervention on obesogenic risk behaviours during early infancy among mother–infant dyads enrolled in WIC. We hypothesized that mothers in the RP intervention would be less likely to use obesogenic risk behaviours compared to mothers in standard care.

2 METHODS

3 MEASURES

3.2 EHL risk assessment tool

The study team developed the 15-item patient-reported EHL risk assessment tool (see Table S1), a patient-reported outcome measure, based on the Infant Feeding Practices Study II,^{26, 27} the INSIGHT study^{5, 25} and the HALF curriculum.²⁴ Two items assessed obesogenic behaviours related to infant diet, five items assessed feeding practices, four items assessed infant sleep, two items assessed parent–child interactive play, one item assessed appetitive traits and one item assessed the caregiver's relationship to the infant. The EHL risk assessment tool addresses lower health literacy and numeracy skills with the use of images and white space (Figure 1) and can be completed in ~2 min. The EHL risk assessment tool was completed when infants were approximately ages 2 and 6 months. These time periods represent critical developmental windows where rapid changes occur in various areas like dietary intake, motor skills, cognitive abilities, social–emotional interaction and language development.^28-30 Mothers in the RP intervention completed EHL risk assessment tool in the electronic health record patient portal or in the waiting room on a tablet prior to their clinic visit. Responses were immediately available in the infant's electronic health record to facilitate tailored preventative counselling by paediatric clinicians. The EHL risk assessment tool, clinical counselling and vital signs were securely shared with WIC nutritionists. Subsequently, WIC nutritionists discussed RP messaging tailored to obesogenic behaviours reported on the EHL risk assessment tool. The standard care group completed the EHL risk assessment tool online via Research Electronic Data Capture (REDCap) or paper questionnaires. These data were not integrated into the infant's electronic health record or used to facilitate tailored preventive counselling by paediatric clinicians or WIC nutritionists. Mothers who did not complete the EHL risk assessment tool at either time point (n = 60) were excluded from the current analysis, resulting in an analytic sample of 228 mother–infant dyads.

4 RESULTS

5 DISCUSSION

This analysis examined the effect of the WEE Baby Care RP intervention on obesogenic risk behaviours at infant ages 2 and 6 months. Mothers in the RP intervention were less likely to report nighttime feedings at both time points; pressure to finish the bottle at 2 months; screen use when feeding/playing at 2 months; and putting their infant to bed after 8:00 PM at 6 months compared to mothers in standard care. There was no difference in mothers' perception that their infant was always hungry, possibly due to genetic influences and these traits being less amenable to change.³³ Reports of infants not eating enough, spitting out food or being picky eaters were rare, as these behaviours may emerge at a later age.³⁴ Mothers in the RP intervention had significantly lower total obesogenic risk behaviour scores than those in standard care at 2 months with a moderate effect size, but there were no significant differences in the obesogenic risk scores at 6 months. These findings suggest that the WEE Baby Care RP intervention positively influenced parenting behaviours related to obesity risk in early infancy among WIC mother–infant dyads. Integrating RP messaging through coordinated care between paediatric clinicians and WIC nutritionists, tailored to meet the needs of each unique family, may help reduce infant obesogenic risk behaviours and promote positive child health outcomes.

Our main findings demonstrate the effectiveness of the WEE Baby Care RP intervention in reducing obesogenic risk during infancy. By targeting multiple obesogenic risk behaviours rather than a single behaviour, this study takes a novel approach to understanding how early interventions can shape healthier infant feeding, eating, sleep and play/activity patterns. The significant reduction in total obesogenic risk behaviour scores among RP intervention participants suggests that addressing a combination of behaviours such as nighttime feedings, pressure to finish bottles, screen use and sleep timing can lead to meaningful improvements in infant health trajectories. Notably, the effectiveness of WEE Baby Care in reducing obesogenic risk behaviours did not differ by milk type (any breastmilk vs. exclusive infant formula) or parity (firstborn vs. not). This finding suggests that our intervention can benefit a wide range of families regardless of infant feeding practices or birth order. Using a total obesogenic risk behaviour score provides a more comprehensive and practical approach to assessing early obesity risk than evaluating individual behaviours in isolation. Findings suggest that the total obesogenic risk behaviour score could serve as an early screening tool. Paediatric clinicians and WIC nutritionists may use the score to identify families needing additional support and allow for tailored guidance to promote long-term healthy eating and growth patterns.

To better understand the effect of the WEE Baby Care RP intervention, we also tested the impact of our intervention on 12 key obesogenic risk behaviours. First, we observed that mothers randomized to the RP coordinated care intervention were less likely to report nighttime feeding. Previous research has shown that reducing the probability of nighttime feeding during night wakings lowered infant BMI.³⁵ Instead of feeding infants back to sleep, WEE Baby mothers were encouraged to use low-stimulus soothing strategies (e.g., rubbing their back and waiting to see if infants fall asleep alone) when their baby did not show signs of hunger.²⁴ Using low-stimulus soothing strategies may help infants learn to self-soothe without feeding,^{10, 36} which may help prevent overfeeding and promote healthy infant growth.³⁵ It is important to note that even though mothers in the RP intervention used fewer nighttime feeding strategies compared to mothers in standard care, more than half of the mothers in both groups reported nighttime feeding. These data contradict the expectation that infants typically can sleep for longer durations without feeding after 2 months of age.³⁷ More strategies to reduce nighttime feeding may be considered for this population. For example, Brown et al. found infants who consumed fewer calories in the day were more likely to have nighttime feedings, and those who received more milk or solid feedings during the day were less likely to receive nighttime feedings.³⁸

Second, we found that mothers in the RP intervention were less likely to use screens during feeding or playing at 2 months, consistent with a previous study that demonstrated infants in the RP intervention group were more likely to meet the AAP guidelines for daily screen time duration.¹¹ However, it is notable that no such effects were observed at 6 months, suggesting a potential decline in adherence to guidance. Similarly, previous research has shown an increase in screen time as the infant ages.³⁹ Establishing long-term goals to meet AAP recommendations⁴⁰ may increase parent motivation to reduce screen time during parent-infant interactions. Additionally, two other screen or television exposure-related behaviours—using cellphone or TV while playing and having the TV on in the room when the infant sleeps—were not significantly different between RP intervention and standard care. Screen time and television exposure have been associated with risks such as being overweight,⁴¹ poor sleep⁴² and reduced parent–child interactions.⁴³ Given these risks, it is important to consider enhanced intervention strategies, specifically focusing on reducing screen-based activities during parent-infant interactions.

Our third key finding showed that mothers in the RP intervention were less likely to put their infant to bed after 8:00 PM at age 6 months. Although sleep duration was not collected in this study, previous research suggests that earlier bedtimes are associated with longer sleep duration at night.⁴⁴ In addition, the AAP recommends that parents put infants to bed drowsy but awake instead of waiting until infants are asleep,²⁴ and our study observed that more mothers in the RP intervention followed this guidance at 2 months of age. This finding is particularly notable as prior research has highlighted the positive effects of RP messaging on earlier bedtimes, longer sleep duration, self-soothing and fewer night wakings in a predominantly white, middle-income sample.¹⁰ In contrast, our study extends these findings by including mother–infant dyads enrolled in WIC, a low-income context, which presents unique challenges in establishing healthy sleep habits. Family living in low-income context may experience noise,⁴⁵ bed- or room-sharing⁴⁶ and unpredictable work schedules,⁴⁷ which could be barriers to setting goals and intentions for establishing and maintaining bedtime routines. These challenges should be considered in future interventions targeting families with lower incomes.

Engaging the parent in self-assessment via the EHL risk assessment tool provides clinicians with comprehensive data that complements BMI screening and informs personalized preventive counselling. The validation of this EHL risk assessment tool is currently underway, which would contribute to its implementation and dissemination to achieve broader public health impact. Beyond RP, this analysis enhanced our understanding of integration between clinical and WIC settings to coordinate care and contributes to the advancement of strategies to integrate health and social care delivery.¹⁹ In this analysis, mothers' responses recorded in the EHL risk assessment tool, clinical notes and clinician counselling in the RP intervention were shared with WIC nutritionists to boost preventive counselling in the social care setting,²³ which benefited BMI outcomes,²¹ as previously reported. Other studies have demonstrated associations between parent assessments of behavioural and environmental factors in clinical care and healthier BMI outcomes among children.^{48, 49} Further efforts are necessary to promote equitable access to the EHL risk assessment tool and clinician utilization,⁵⁰ as well as coordinate health and social care delivery¹⁹ to optimize healthy child growth and development.

6 CONCLUSION

A patient-centred, care-coordinated RP intervention decreased the use of obesogenic risk behaviours in feeding and sleep among WIC-enrolled mother–infant dyads. Findings from this study suggest that behaviour-based assessment tools allow parents to evaluate obesogenic risk behaviours and practices with paediatric clinicians and WIC nutritionists to intervene upon them. Findings indicate that personalized screenings for obesogenic risk behaviours impacted the total obesogenic risk behaviour score among a high-risk population. Promoting coordinated care between health care and social care settings may facilitate patient-centred, evidence-based and consistent RP messaging delivery, thereby enhancing efforts to reduce childhood obesity in low-income populations.

AUTHOR CONTRIBUTIONS

Conceptualization: YM, AMM, CFR, JSS; Formal analysis: YM, AMM, JSS; Writing—original draft preparation: YM; Writing—intellectual content, review and editing: LB-D, AMM, CFR, CFM, JSS; Supervision: AMM, JSS; Funding acquisition: LB-D, JSS. All authors have read and approved the final version of the manuscript.

FUNDING INFORMATION

Health Resources and Services Administration of the U.S. Department of Health and Human Services, Maternal and Child Health Field-initiated Innovative Research Studies Program. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award Number TL1TR002016. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

CONFLICT OF INTEREST STATEMENT

The authors have no financial relationships relevant to the article to disclose.