A Better Start National Science Challenge and Whānau Āwhina Plunket recently held a webinar, Watch Me Grow, which explored the latest research in infant growth.

A Better Start Deputy Director Barry Taylor and Whānau Āwhina Plunket’s Chief Nurse Dr Jane O’Malley were joined by three guest speakers:

  • Dr Denise Guy – Child psychiatrist and founding trustee for Incredible Families
  • Waikura Kamo – Whānau Āwhina Plunket National Clinical Nurse Educator Māori
  • Dr Lisa Daniels – A Better Start National Science Challenge Post-doctoral Fellow

There were a large number of questions from the audience, which our chairs and guest speakers have answered below.

If you missed the webinar, you can watch it here

Is there any research about breast milk transfer of glycaemic tolerance? For obese women is breastfeeding best?

Breastfeeding is definitely best for babies whose mothers are overweight. The mothers may need more support to get positioning and suck right, but if they persist and can do it, it is best for the babies. It is important to not push too hard here as, if the pressure is high, the let down reflex and feeding is actually more difficult. Support and relaxation rather than more pressure!

Are we able to offer meal or exercise plans for whānau to use as a guide? The resource we have to give out to families physically is limited – are there more resources Plunket can give out and discuss with families for bettering their health and lifestyle?

There are useful resources for whānau including the new Healthy Eating Guidelines for New Zealand Babies and Toddlers (0-2 years old). https://www.health.govt.nz/publication/healthy-eating-guidelines-new-zealand-babies-and-toddlers-0-2-years-old

Alongside these there are the guideline eating statements for New Zealand babies and toddlers that are for sharing with whānau:

HealthEd offers booklets for whānau including the Eating for Healthy Children aged 2 to 12 booklet https://www.healthed.govt.nz/resource/eating-healthy-children-aged-2-12ng%C4%81-kai-t%C5%8Dtika-m%C5%8D-te-hunga-k%C5%8Dhungahunga

Sit Less, Move More, Sleep Well: Active play guidelines for under-fives https://www.healthed.govt.nz/resource/eating-healthy-children-aged-2-12ng%C4%81-kai-t%C5%8Dtika-m%C5%8D-te-hunga-k%C5%8Dhungahunga

Eating and Activity Guidelines for New Zealand Adults, which has an updated section for pregnant and breastfeeding women https://www.health.govt.nz/publication/eating-and-activity-guidelines-new-zealand-adults

There is also information on the Plunket public website that is useful to guide whānau to. We will continue to review the latest evidence and work with the providers of best evidence to ensure we are providing relevant and current resources to whānau and our people.

Is there any relationship between high BMI and lower socio-economic status?

Yes, there is evidence that BMI increases as deprivation worsens or socio-economic status lessens.  The mechanisms are multiple and complex – less expensive foods tend to be higher in fat, and families are time-poor which can mean the opportunity to spend time planning and cooking nutritious meals may be limited. Which means more highly processed pre-prepared meals and takeaways become attractive options. There is also evidence that rates of maternal smoking are higher in areas of increased deprivation (which is a strong risk factor for increased weight in children). Opportunities for increasing activity are also more limited where there is less green space and time available to achieve these. As outlined, there are many interacting factors to explain this.

In relation to growth norms, are their ethnic differences specific to Māori and Pacific peoples?

The growth rates of Māori and Pasifika children do appear to be steeper than for reference children, so it is important to keep in mind. Whether different cut-points are appropriate needs further research. In general, we know that BMI is highly associated with higher percent body fat in children of all ethnicities so it is a good measure for identifying the largest children and being able to track children’s growth. Over time it will be useful for determining unhealthy growth trajectories, regardless of ethnicity.

Can you please give us the BMI calculation to use for under 2 year olds?

The calculation is no different for those under 2 years.

I noticed while working with young mothers that the mums are so stressed about the nutrition input of their babies that the stress leads to the kids growing up with stress-related feeding, which then impacts the child’s attitude towards food. How do we address this?

Talking to the whānau about their worries and how we can support them with finding ways to manage this stress will enable you to work in a whanau-led way. Mealtimes are culturally and socially important for helping children learn how to eat and how to think about food, and mealtimes are occasions for building strong relationships between family members. The aim to make mealtimes fun and low stress.

The following is some information you could share as part of this conversation

  • Feeding in response to a baby’s or toddler’s hunger or fullness cues (responsive feeding), helps protect the baby’s or toddler’s natural ability to self-regulate their food intake according to appetite.
  • Relaxed, enjoyable mealtimes, without distractions such as television and other screens, provide a positive eating experience.
  • Family mealtimes help a child learn to eat as young children will copy what parents, siblings, whānau and peers do. It also provides opportunities for social interaction.
  • It is the parent’s role to decide what food is offered to a baby or toddler. This includes limiting access to energy-dense, nutrient-poor foods that displace healthy foods.

There is useful information about nutrition and following the infant’s cues in the new Healthy Eating guidelines for New Zealand Babies and Toddlers (0-2 years old). https://www.health.govt.nz/publication/healthy-eating-guidelines-new-zealand-babies-and-toddlers-0-2-years-old Alongside these there are the guideline eating statements for New Zealand babies and toddlers that are for sharing with whānau.

My concern is that in Plunket we do less visits from the 36-month age, where the issues are found for childhood obesity.

The evidence presented in the study by Lindholm et al. (Acta Paediatrica 2019) showed that while the crossing of z-score of 1 (at risk of overweight) occurs on average around 24-36 months in overweight and obese boys and girls, their trajectories of growth before this age (from birth) were also higher than normal weight boys and girls and hence the importance of having conversations and potentially tracking BMI from an early age. These discussions need to be a part of all of the conversations about healthy nutrition and activity during the first years particularly.

Is there research that shows whether there are different indications for BMI with different cultures i.e Pacific people and Māori higher percentiles? And if so, how do we gauge cultural aspects vs obesity?

This is a more complex question. Pacific children in particular have heavier bones and more muscle than the usual norms but balancing that is that the risk of high BMI’s is greater. So, at present the recommendation is to use the same cut points for overweight and obesity for all ethnicities.

Does the BMI research distinguish between the growth trajectories of different modes of feeding e.g. breastfed, bottle fed, mixed fed, formula fed?

The research presented was from population studies where the method of feeding was not an inclusion or exclusion criteria and therefore included all children regardless of the way they were fed.

Is there a possibility of EPHR having a BMI chart, and is the computer able to calculate the BMI independently when weight and height is entered, or would we have to calculate each visit?

It is relatively easy to get the computer to calculate the BMI whenever you put in a height (or length) and weight measurement. The graph should then display this against the normal for that age and show any previous measurements so you can see the trajectory of growth. This could be done as an automated step in ePHR, and is something we could review if the decision was taken to include BMI as a weight assessment tool in the national schedule.

What work is being done to support and educate whānau about feeding cues – what/how much/how often early on so we can reduce the incidence of this “weight” kōrero later down the line? What can we do better in this area?

Babies and toddlers are good at knowing when they have had enough to eat. It is important that a caregiver notices when their baby or toddler is making hunger signs and offer food as soon as possible, then stop feeding when the baby makes any of the signs of being full.

There are more useful resources for whanau in the new Healthy Eating Guidelines for New Zealand Babies and Toddlers (0-2 years old) to guide discussions about feeding cues. https://www.health.govt.nz/publication/healthy-eating-guidelines-new-zealand-babies-and-toddlers-0-2-years-old Alongside these there are the guideline eating statements for New Zealand babies and toddlers that are for sharing with whānau.

If the parents are in normal physical range, but are worried about growth chart of baby (higher range), is there room for concern if Mum is breastfeeding exclusively? I understood that a baby is at low risk if this is the case? In other words, is it true that you can’t overfeed a baby on breastmilk alone?

Exclusively/fully breastfed babies do not tend to overeat like their formula feeding counterparts. One of the key physiological factors at play here is that breastmilk contains growth factors, cytokines and hormones that are involved in food intake regulation and energy balance. These include leptin, adiponectin, IGF-I, ghrelin, obestatin and resistin. It is thought that, for example, leptin in breastmilk could play a role in the short-term control of food intake in neonates by acting as a satiety signal and could also exert a long-term effect on energy balance and body weight regulation.

We do have to be careful here in dissuading a mother from offering the breast to a baby when it is not likely hunger but a need for comfort, security, or connection. Breastfeeding fulfils these needs for an infant beyond hunger. However, there are times when it is difficult for parents to identify if crying is a sign of hunger.

On the issue of babies who do “overeat” at the breast, this can be due to their mother’s robust milk supply or even due to the infant’s personality/temperament (some babies have an increased or high need for maternal contact and suckling). Another factor to consider is that there are mothers who have higher fat content in their milk. It’s important for a WellChild RN, practice RN or GP that a holistic approach is always taken in regards to interpreting BMI, especially with regard to the feeding method in the first 6-12 months and then with the introduction of solid foods, and advice would need to be tailored based on that.

Will Plunket be introducing BMI at a younger age? Currently it is just at the B4 School Check.

If this were a recommendation and the national schedule was modified, this could be included.