Continuous infusion versus bolus injection of loop diuretics for acute heart failure.

BACKGROUND: Acute heart failure (AHF) is new onset of, or a sudden worsening of, chronic heart failure characterised by congestion in about 95% of cases or end-organ hypoperfusion in 5% of cases. Treatment often requires urgent escalation of diuretic therapy, mainly through hospitalisation. This Cochrane review evaluated the efficacy of intravenous loop diuretics strategies in treating AHF in individuals with New York Heart Association (NYHA) classification III or IV and fluid overload. OBJECTIVES: To assess the effects of intravenous continuous infusion versus bolus injection of loop diuretics for the initial treatment of acute heart failure in adults. SEARCH METHODS: We identified trials through systematic searches of bibliographic databases and in clinical trials registers including CENTRAL, MEDLINE, Embase, CPCI-S on the Web of Science, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry platform (ICTRP), and the European Union Trials register. We conducted reference checking and citation searching, and contacted study authors to identify additional studies. The latest search was performed on 29 February 2024. SELECTION CRITERIA: We included randomised controlled trials (RCTs) involving adults with AHF, NYHA classification III or IV, regardless of aetiology or ejection fraction, where trials compared intravenous continuous infusion of loop diuretics with intermittent bolus injection in AHF. We excluded trials with chronic stable heart failure, cardiogenic shock, renal artery stenosis, or end-stage renal disease. Additionally, we excluded studies combining loop diuretics with hypertonic saline, inotropes, vasoactive medications, or renal replacement therapy and trials where diuretic dosing was protocol-driven to achieve a target urine output, due to confounding factors. DATA COLLECTION AND ANALYSIS: Two review authors independently screened papers for inclusion and reviewed full-texts. Outcomes included weight loss, all-cause mortality, length of hospital stay, readmission following discharge, and occurrence of acute kidney injury. We performed risk of bias assessment and meta-analysis where data permitted and assessed certainty of the evidence. MAIN RESULTS: The review included seven RCTs, spanning 32 hospitals in seven countries in North America, Europe, and Asia. Data collection ranged from eight months to six years. Following exclusion of participants in subgroups with confounding treatments and different clinical settings, 681 participants were eligible for review. These additional study characteristics, coupled with our strict inclusion and exclusion criteria, improve the applicability of the body of the evidence as they reflect real-world clinical practice. Meta-analysis was feasible for net weight loss, all-cause mortality, length of hospital stay, readmission, and acute kidney injury. Literature review and narrative analysis explored daily fluid balance; cardiovascular mortality; B-type natriuretic peptide (BNP) change; N-terminal-proBNP change; and adverse incidents such as ototoxicity, hypotension, and electrolyte imbalances. Risk of bias assessment revealed two studies with low overall risk, four with some concerns, and one with high risk. All sensitivity analyses excluded trials at high risk of bias. Only narrative analysis was conducted for 'daily fluid balance' due to diverse data presentation methods across two studies (169 participants, the evidence was very uncertain about the effect). Results of narrative analysis varied. For instance, one study reported higher daily fluid balance within the first 24 hours in the continuous infusion group compared to the bolus injection group, whereas there was no difference in fluid balance beyond this time point. Continuous intravenous infusion of loop diuretics may result in mean net weight loss of 0.86 kg more than bolus injection of loop diuretics, but the evidence is very uncertain (mean difference (MD) 0.86 kg, 95% confidence interval (CI) 0.44 to 1.28; 5 trials, 497 participants; P < 0.001, I2 = 21%; very low-certainty evidence). Importantly, sensitivity analysis excluding trials with high risk of bias showed there was insufficient evidence for a difference in bodyweight loss between groups (MD 0.70 kg, 95% CI -0.06 to 1.46; 3 trials, 378 participants; P = 0.07, I2 = 0%). There may be little to no difference in all-cause mortality between continuous infusion and bolus injection (risk ratio (RR) 1.53, 95% CI 0.81 to 2.90; 5 trials, 530 participants; P = 0.19, I2 = 4%; low-certainty evidence). Despite sensitivity analysis, the direction of the evidence remained unchanged. No trials measured cardiovascular mortality. There may be little to no difference in the length of hospital stay between continuous infusion and bolus injection of loop diuretics, but the evidence is very uncertain (MD -1.10 days, 95% CI -4.84 to 2.64; 4 trials, 211 participants; P = 0.57, I2 = 88%; very low-certainty evidence). Sensitivity analysis improved heterogeneity; however, the direction of the evidence remained unchanged. There may be little to no difference in the readmission to hospital between continuous infusion and bolus injection of loop diuretics (RR 0.85, 95% CI 0.63 to 1.16; 3 trials, 400 participants; P = 0.31, I2 = 0%; low-certainty evidence). Sensitivity analysis continued to show insufficient evidence for a difference in the readmission to hospital between groups. There may be little to no difference in the occurrence of acute kidney injury as an adverse event between continuous infusion and bolus injection of intravenous loop diuretics (RR 1.02, 95% CI 0.70 to 1.49; 3 trials, 491 participants; P = 0.92, I2 = 0%; low-certainty evidence). Sensitivity analysis continued to show that continuous infusion may make little to no difference on the occurrence of acute kidney injury as an adverse events compared to the bolus injection of intravenous loop diuretics. AUTHORS' CONCLUSIONS: Analysis of available data comparing two delivery methods of diuretics in acute heart failure found that the current data are insufficient to show superiority of one strategy intervention over the other. Our findings were based on trials meeting stringent inclusion and exclusion criteria to ensure validity. Despite previous reviews suggesting advantages of continuous infusion over bolus injections, our review found insufficient evidence to support or refute this. However, our review, which excluded trials with clinical confounders and RCTs with high risk of bias, offers the most robust conclusion to date.

Endogenous GLP-1 levels play an important role in determining the efficacy of DPP-IV Inhibitors in both prediabetes and type 2 diabetes.

Background: In contrast to Western population, glucagon-like peptide-1 (GLP-1) levels are preserved in some East Asian population with type 2 diabetes (T2D), explaining why dipeptidyl peptidase-IV (DPP-IV) inhibitors are more effective in East Asians. We assessed whether differences in endogenous GLP-1 levels resulted in different treatment responses to DPP-IV inhibitors in prediabetes and T2D. Methods: A prospective 12-week study using linagliptin 5mg once daily in 50 subjects (28 prediabetes and 22 T2D) who were stratified into high versus low fasting GLP-1 groups. A 75-g oral glucose tolerance test (OGTT) was performed at week 0 and 12. Primary outcomes were changes in HbA1c, fasting and post-OGTT glucose after 12 weeks. Secondary outcomes included changes in insulin resistance and beta cell function indices. Results: There was a greater HbA1c reduction in subjects with high GLP-1 compared to low GLP-1 levels in both the prediabetes and T2D populations [least-squares mean (LS-mean) change of -0.33% vs. -0.11% and -1.48% vs. -0.90% respectively)]. Linagliptin significantly reduced glucose excursion by 18% in high GLP-1 compared with 8% in low GLP-1 prediabetes groups. The reduction in glucose excursion was greater in high GLP-1 compared to low GLP-1 T2D by 30% and 21% respectively. There were significant LS-mean between-group differences in fasting glucose (-0.95 mmol/L), 2-hour glucose post-OGTT (-2.4 mmol/L) in the high GLP-1 T2D group. Improvement in insulin resistance indices were seen in the high GLP-1 T2D group while high GLP-1 prediabetes group demonstrated improvement in beta cell function indices. No incidence of hypoglycemia was reported. Conclusions: Linagliptin resulted in a greater HbA1c reduction in the high GLP-1 prediabetes and T2D compared to low GLP-1 groups. Endogenous GLP-1 level play an important role in determining the efficacy of DPP-IV inhibitors irrespective of the abnormal glucose tolerance states.

Fasting and stimulated glucagon-like peptide-1 exhibit a compensatory adaptive response in diabetes and pre-diabetes states: A multi-ethnic comparative study.

Background: Impaired secretion of glucagon-like peptide-1 (GLP-1) among Caucasians contributes to reduced incretin effect in type 2 diabetes mellitus (T2DM) patients. However, studies emanating from East Asia suggested preserved GLP-1 levels in pre-diabetes (pre-DM) and T2DM. We aimed to resolve these conflicting findings by investigating GLP-1 levels during oral glucose tolerance test (OGTT) among Malay, Chinese, and Indian ethnicities with normal glucose tolerance (NGT), pre-DM, and T2DM. The association between total GLP-1 levels, insulin resistance, and insulin sensitivity, and GLP-1 predictors were also analyzed. Methods: A total of 174 subjects were divided into NGT (n=58), pre-DM (n=54), and T2DM (n=62). Plasma total GLP-1 concentrations were measured at 0, 30, and 120 min during a 75-g OGTT. Homeostasis model assessment of insulin resistance (HOMA-IR), HOMA of insulin sensitivity (HOMA-IS), and triglyceride-glucose index (TyG) were calculated. Results: Total GLP-1 levels at fasting and 30 min were significantly higher in T2DM compared with pre-DM and NGT (27.18 ± 11.56 pmol/L vs. 21.99 ± 10.16 pmol/L vs. 16.24 ± 7.79 pmol/L, p=0.001; and 50.22 ± 18.03 pmol/L vs. 41.05 ± 17.68 pmol/L vs. 31.44 ± 22.59 pmol/L, p<0.001; respectively). Ethnicity was a significant determinant of AUCGLP-1, with the Indians exhibiting higher GLP-1 responses than Chinese and Malays. Indians were the most insulin resistant, whereas Chinese were the most insulin sensitive. The GLP-1 levels were positively correlated with HOMA-IR and TyG but negatively correlated with HOMA-IS. This relationship was evident among Indians who exhibited augmented GLP-1 responses proportionately to their high insulin-resistant states. Conclusion: This is the first study that showed GLP-1 responses are augmented as IR states increase. Fasting and post-OGTT GLP-1 levels are raised in T2DM and pre-DM compared to that in NGT. This raises a possibility of an adaptive compensatory response that has not been reported before. Among the three ethnic groups, the Indians has the highest IR and GLP-1 levels supporting the notion of an adaptive compensatory secretion of GLP-1.

Designing the next generation of implementation research training for learners in low- and middle-income countries.

Efficacious health interventions tested through controlled trials often fail to show desired impacts when implemented at scale. These challenges can be particularly pervasive in low- and middle-income settings where health systems often lack the capacity and mechanisms required for high-quality research and evidence translation. Implementation research is a powerful tool for identifying and addressing the bottlenecks impeding the success of proven health interventions. Implementation research training initiatives, although growing in number, remain out of reach for many investigators in low- and middle-income settings, who possess the knowledge required to contextualize challenges and potential solutions in light of interacting community- and system-level features. We propose a realigned implementation research training model that centers on team-based learning, tailored didactic opportunities, learning-by-doing, and mentorship.

Inequities in Children's Reading Skills: The Role of Home Reading and Preschool Attendance.

OBJECTIVE: Children from socioeconomically disadvantaged backgrounds have poorer learning outcomes. These inequities are a significant public health issue, tracking forward to adverse health outcomes in adulthood. We examined the potential to reduce socioeconomic gaps in children's reading skills through increasing home reading and preschool attendance among disadvantaged children. METHODS: We drew on data from the nationally representative birth cohort of the Longitudinal Study of Australian Children (N = 5107) to examine the impact of socioeconomic disadvantage (0-1 year) on children's reading skills (8-9 years). An interventional effects approach was applied to estimate the extent to which improving the levels of home reading (2-5 years) and preschool attendance (4-5 years) of socioeconomically disadvantaged children to be commensurate with their advantaged peers, could potentially reduce socioeconomic gaps in children's reading skills. RESULTS: Socioeconomically disadvantaged children had a higher risk of poor reading outcomes compared to more advantaged peers: absolute risk difference = 20.1% (95% confidence interval [CI]: 16.0%-24.2%). Results suggest that improving disadvantaged children's home reading and preschool attendance to the level of their advantaged peers could eliminate 6.5% and 2.1% of socioeconomic gaps in reading skills, respectively. However, large socioeconomic gaps would remain, with disadvantaged children maintaining an 18.3% (95% CI: 14.0%-22.7%) higher risk of poor reading outcomes in absolute terms. CONCLUSION: There are clear socioeconomic disparities in children's reading skills by late childhood. Findings suggest that interventions that improve home reading and preschool attendance may contribute to reducing these inequities, but alone are unlikely to be sufficient to close the equity gap.

Racial discrimination and socioemotional and sleep problems in a cross-sectional survey of Australian school students.

OBJECTIVE: To determine the prevalence of direct and vicarious racial discrimination experiences from peer, school and societal sources, and examine associations between these experiences and socioemotional and sleep outcomes. METHODS: Data were analysed from a population representative cross-sectional study of n=4664 school students in years 5-9 (10-15 years of age) in Australia. Students reported direct experiences of racial discrimination from peers, school and societal sources; vicarious discrimination was measured according to the frequency of witnessing other students experiences of racial discrimination. Students self-reported on the Strengths and Difficulties Questionnaire, with the total difficulties, conduct, emotional and prosocial behaviour subscales examined. Sleep problems included duration, latency, and disruption. RESULTS: 41.56% (95% CI 36.18 to 47.15) of students reported experiences of direct racial discrimination; Indigenous and ethnic minority students reported the highest levels. 70.15% (95% CI 63.83 to 75.78) of students reported vicarious racial discrimination. Direct and vicarious experiences of racial discrimination were associated with socioemotional adjustment (eg, for total difficulties, total direct racism: beta=3.77, 95% CI 3.11 to 4.44; vicarious racism: beta=2.51, 95% CI 2.00 to 3.03). Strong evidence was also found for an effect of direct and vicarious discrimination on sleep (eg, for sleep duration, total direct: beta=-21.04, 95% CI -37.67 to -4.40; vicarious: beta=-9.82, 95% CI -13.78 to -5.86). CONCLUSIONS: Experiences of direct and vicarious racial discrimination are common for students from Indigenous and ethnic minority backgrounds, and are associated with socioemotional and sleep problems in adolescence. Racism and racial discrimination are critically important to tackle as social determinants of health for children and adolescents.

Health service utilisation and unmet healthcare needs of Australian children from immigrant families: A population-based cohort study.

Compared with most other Organization for Economic Co-operation and Development (OECD) countries, information about the patterns of health service use for children from immigrant families in Australia is currently limited, and internationally, data on unmet healthcare needs are scarce. This study aims to examine the distribution of health service utilisation and unmet healthcare needs for immigrant children aged 10-11 years in Australia. We drew on data from the Longitudinal Study of Australian Children Birth (B; n = 5,107) and Kindergarten (K; n = 4,983) cohorts. The exposure was family immigration background collected at 0-1 (B-cohort) and 4-5 (K-cohort) years. Outcomes were parent-reported child health service use and unmet healthcare needs (defined as the difference between services needed and services received) at 10-11 years. Logistic regression analyses were used to examine associations between family immigration background and health service use/unmet healthcare needs, adjusting for potential confounders. Results showed that one-third of Australian children (B-cohort: 29.0%; K-cohort: 33.4%) came from immigrant families. There were similar patterns of health service use and unmet healthcare needs between children from English-speaking immigrant and Australian-born families. However, children from non-English-speaking immigrant families used fewer health services, including paediatric, dental, mental health and emergency ward services. There was a disparity between the services used when considering children's health needs, particularly for paediatric specialist services (B-cohort: OR = 2.43, 95% CI 1.11-5.31; K-cohort: OR = 2.72, 95% CI 1.32-5.58). Findings indicate that Australian children from non-English-speaking immigrant families experience more unmet healthcare needs and face more barriers in accessing health services. Further effort is needed to ensure that the healthcare system meets the needs of all families.

Experiences of racial discrimination and cardiometabolic risk among Australian children.

Cardiometabolic disease is a leading cause of adult morbidity and mortality globally. There is considerable evidence that childhood adversity is associated with markers of cardiometabolic disease risk in childhood, including obesity, blood pressure trajectories, and chronic inflammation. Experiences of racial discrimination may be an important, yet under explored, form of childhood adversity influencing childhood cardiometabolic risk. This study aimed to examine associations between self-reported racial discrimination and cardiometabolic risk markers among children. A total of 124 children (73 female) aged 11.4 years (SD 0.71) participated in the study. Most children (n = 79) identified as being from an Indigenous or an ethnic minority background. Markers of cardiometabolic risk were BMI, waist circumference, weight height ratio, systolic and diastolic blood pressure, and five inflammatory markers (C-reactive protein (CRP), Interleukin (IL)-1ß, IL-6, IL-8, and TNF-α). Results showed that two or more reported experiences of racial discrimination were associated with increased BMI z-score (Beta 0.58, 95% CI 0.18, 0.99), waist circumference (Beta 4.91 cm, 95% CI 0.71, 9.1), systolic blood pressure (Beta 2.07 mmHg, 95% CI 0.43, 3.71) and IL-6 (Beta 0.13, 95% CI 0.00, 0.27) and marginally associated with TNF-α (Beta 0.22, 95% CI -0.09, 0.54) after adjusting for socio-demographic covariates. Findings from this study suggest the need to address racism and racial discrimination as important social determinants of cardiometabolic risk and of the inequitable burden of cardiometabolic disease experienced by those from Indigenous and minoritized ethnic backgrounds.

Learning outcomes of children with teacher-identified emerging health and developmental needs.

OBJECTIVES: Children's additional health and developmental needs are often first identified by teachers when they begin school. This study estimates the Grade 3 literacy and numeracy outcomes of children with teacher-identified additional needs emerging in the first year of school, including the added burden conferred by socioeconomic disadvantage. METHODS: Population linked data (n = 42,619) were analysed from the Australian Early Development Census, which include teacher reports on children's health and development at school entry, and the National Assessment Program-Literacy and Numeracy, a direct assessment of reading and numeracy skills at Grade 3. Linear regression analyses were used to estimate associations between emerging needs and learning outcomes, adjusted for sociodemographic characteristics. The combined effect of emerging needs and low maternal education (an indicator of socioeconomic disadvantage) on academic outcomes was examined by estimating the relative excess risk due to interaction (RERI). RESULTS: Emerging health and developmental needs at school entry were associated with lower reading (b = -26.86, 95% CI = -29.19, -24.52) and numeracy (b = -24.39, 95% CI = -26.43, -22.35) outcomes at Grade 3. The combined effect of emerging needs and socioeconomic disadvantage was greater than expected when their individual effects are summed (RERI = 0.38, 95% CI 0.22, 0.55 for reading and RERI = 0.27, 95% CI 0.10, 0.43 for numeracy). CONCLUSION: In the current study, emerging health and developmental needs identified by teachers at the outset of schooling were associated with poorer literacy and numeracy skills at Grade 3, and family socioeconomic disadvantage appeared to further amplify this effect. Meeting the needs of these children will require timely and coordinated supports across the health and education systems, particularly for those children who are also disadvantaged.

The controlled direct effect of temperament at 2-3 years on cognitive and academic outcomes at 6-7 years.

There is widespread interest in temperament and its impact upon cognitive and academic outcomes. Parents adjust their parenting according to their child's temperament, however, few studies have accounted for parenting while estimating the association between temperament and academic outcomes. We examined the associations between temperament (2-3 years) and cognitive and academic outcomes (6-7 years) when mediation by parenting practices (4-5 years) was held constant, by estimating the controlled direct effect. Participants were from the Longitudinal Study of Australian Children (n = 5107). Cognitive abilities were measured by the Peabody Picture Vocabulary Test (verbal) and the Matrix Reasoning test (non-verbal). Literacy and numeracy were reported by teachers using the Academic Rating Scale. Mothers reported children's temperament using the Short Temperament Scale for Toddlers (subscales: reactivity, approach, and persistence). Parenting practices included items about engagement in activities with children. Marginal structural models with inverse probability of treatment weights were used to estimate the controlled direct effect of temperament, when setting parenting to the mean. All temperament subscales were associated with cognitive abilities, with persistence showing the largest associations with verbal (PPVT; ß = 0.58; 95%CI 0.27, 0.89) and non-verbal (Matrix Reasoning: ß = 0.19; 0.02, 0.34) abilities. Higher persistence was associated with better literacy (ß = 0.08; 0.03, 0.13) and numeracy (ß = 0.08; 0.03, 0.13), and higher reactivity with lower literacy (ß = -0.08; -0.11, -0.05) and numeracy (ß = -0.07; -0.10, -0.04). There was little evidence that temperamental approach influenced literacy or numeracy. Overall, temperament had small associations with cognitive and academic outcomes after accounting for parenting and confounders.

Socioeconomic Disadvantage in Infancy and Academic and Self-Regulation Outcomes.

OBJECTIVES: A comprehensive understanding of how timing of exposure to disadvantage affects long-term developmental risk is needed for greater precision in child health policy. We investigated whether socioeconomic disadvantage in infancy (age 0-1 years) directly affects academic and self-regulation problems in late childhood (age 10-12 years), independent of disadvantage at school entry (age 4-6 years). METHODS: Analyses were replicated in 2 population-based cohorts: the Australian Temperament Project (ATP; N = 2443) and the Longitudinal Study of Australian Children (LSAC; N = 5107). Generalized linear models were used to estimate the crude and adjusted effects. Marginal structural models were used to estimate the controlled direct effect of socioeconomic disadvantage in infancy on academic and self-regulation outcomes in late childhood, independent of disadvantage at school entry. RESULTS: In both cohorts, socioeconomic disadvantage in infancy and at school entry was associated with poorer academic and self-regulation outcomes. Socioeconomic disadvantage in infancy had a direct effect on academic outcomes not mediated by disadvantage at school entry (ATP: risk ratio [RR] = 1.42; 95% confidence interval [CI]: 1.09-1.86; LSAC: RR = 1.87; 95% CI: 1.52-2.31). Little evidence was found for a direct effect of disadvantage in infancy on self-regulation (ATP: RR = 1.22; 95% CI: 0.89-1.65; LSAC: RR = 1.19; 95% CI: 0.95-1.49). CONCLUSIONS: Socioeconomic disadvantage in infancy had a direct effect on academic but not self-regulation outcomes in late childhood. More precise public policy responses are needed that consider both the timing of children's exposure to disadvantage and the specific developmental domain impacted.

The impact of multidimensional disadvantage over childhood on developmental outcomes in Australia.

Background: Understanding the relationship between different aspects of disadvantage over time and domains of child development will facilitate the formulation of more precise policy responses. We examined the association between exposure to aspects of disadvantage over the childhood period (from 0-9 years) and child development at 10-11 years. Methods: We used data from the nationally representative birth cohort of the Longitudinal Study of Australian Children (n = 4979). Generalized linear models with log-Poisson link were used to estimate the association between previously derived disadvantage trajectories (in each of four lenses of sociodemographic, geographic environments, health conditions and risk factors, and a composite of these) and risk of poor child developmental outcomes. Population-attributable fractions were calculated to quantify the potential benefit of providing all children with optimal conditions for each developmental outcome. Results: Trajectories of disadvantage were associated with developmental outcomes: children in the most disadvantaged composite trajectory had seven times higher risk of poor outcomes on two or more developmental domains, compared with those most advantaged. Trajectories of disadvantage in different lenses were varyingly associated with the child development domains of socio-emotional adjustment, physical functioning and learning competencies. Exposure to the most advantaged trajectory across all lenses could reduce poor developmental outcomes by as much as 70%. Conclusions: Exposure to disadvantage over time is associated with adverse child development outcomes. Developmental outcomes varied with the aspects of disadvantage experienced, highlighting potential targets for more precise policy responses. The findings provide evidence to stimulate advocacy and action to reduce child inequities.

More than a snapshot in time: pathways of disadvantage over childhood.

Background: Disadvantage rarely manifests as a single event, but rather is the enduring context in which a child's development unfolds. We aimed to characterize patterns of stability and change in multiple aspects of disadvantage over the childhood period, in order to inform more precise and nuanced policy development. Methods: Participants were from the Longitudinal Study of Australian Children birth cohort (n = 5107). Four lenses of disadvantage (sociodemographic, geographic environment, health conditions and risk factors), and a composite of these representing average exposure across all lenses, were assessed longitudinally from 0 to 9 years of age. Trajectory models identified groups of children with similar patterns of disadvantage over time for each of these lenses and for composite disadvantage. Concurrent validity of these trajectory groups was examined through associations with academic performance at 10-11 years. Results: We found four distinct trajectories of children's exposure to composite disadvantage, which showed high levels of stability over time. In regard to the individual lenses of disadvantage, three exhibited notable change over time (the sociodemographic lens was the exception). Over a third of children (36.3%) were exposed to the 'most disadvantaged' trajectory in at least one lens. Trajectories of disadvantage were associated with academic performance, providing evidence of concurrent validity. Conclusions: Children's overall level of composite disadvantage was stable over time, whereas geographic environments, health conditions and risk factors changed over time for some children. Measuring disadvantage as uni-dimensional, at a single time point, is likely to understate the true extent and persistence of disadvantage.

Associations of parental food-choice control and use of food to soothe with adiposity in childhood and adolescence.

BACKGROUND: Associations of parental feeding techniques with adiposity are mixed and largely rely on cross-sectional studies. We examined associations between parental food-choice control and using food to soothe at 3.5 years on adiposity at 7 and 15 years. METHODS: Participants were from the Avon Longitudinal Study of Parents and Children (n = 7312). Food-choice control was assessed using the item 'how much choice do you allow him/her in deciding what foods he eats at meals?'. Use of food to soothe was reported by mothers on the item 'how often do you use sweets or other foods to stop his/her crying or fussing?'. BMI at 7 and 15 years was converted to sex- and age-adjusted z-scores. Fat mass was assessed at 15 years using dual energy X-ray absorptiometry. RESULTS: In fully-adjusted models, children given the least choice had 0.08 lower BMI z-score at age 7 years and 0.12 lower BMI z-score,1.46 kg lower fat mass at 15 years than children with the most choices. There was no evidence of an association between using food to soothe and adiposity. CONCLUSIONS: Contrary to some studies, higher parental control over food choice was associated with lower adiposity, but use of food to soothe was not associated with adiposity at ages 7 and 15.

Parenting Practices at 24 to 47 Months and IQ at Age 8: Effect-Measure Modification by Infant Temperament.

Cognitive development might be influenced by parenting practices and child temperament. We examined whether the associations between parental warmth, control and intelligence quotient (IQ) may be heightened among children in difficult temperament. Participants were from the Avon Longitudinal Study of Parents and Children (n = 7,044). Temperament at 6 months was measured using the Revised Infant Temperament Questionnaire and classified into 'easy' and 'difficult'. Parental warmth and control was measured at 24 to 47 months and both were classified into 2 groups using latent class analyses. IQ was measured at 8 years using the Wechsler Intelligence Scale for Children and dichotomized (<85 and ≥85) for analyzing effect-measure modification by temperament. Linear regression adjusted for multiple confounders and temperament showed lower parental warmth was weakly associated with lower IQ score [ß = -0.52 (95% CI 1.26, 0.21)], and higher parental control was associated with lower IQ score [ß = -2.21 (-2.95, -1.48)]. Stratification by temperament showed no increased risk of having low IQ in temperamentally difficult children [risk ratio (RR) = 0.97 95% CI 0.65, 1.45)] but an increased risk among temperamentally easy children (RR = 1.12 95% CI 0.95, 1.32) when parental warmth was low. There was also no increased risk of having low IQ in temperamentally difficult children (RR = 1.02 95% CI 0.69, 1.53) but there was an increased risk among temperamentally easy children (RR = 1.30 95% CI 1.11, 1.53) when parental control was high. For both parental warmth and control, there was some evidence of negative effect-measure modification by temperament on the risk-difference scale and the risk-ratio scale. It may be more appropriate to provide parenting interventions as a universal program rather than targeting children with difficult temperament.

How many infants are temperamentally difficult? Comparing norms from the Revised Infant Temperament Questionnaire to a population sample of UK infants.

The original norms for the Revised Infant Temperament Questionnaire (RITQ) were published in 1978 and were based on a small sample from the US. The aim of this study is to compare temperament scores from the original RITQ against scores from a large population-based cohort of infants from the UK. This study consists of 10,937 infants from the Avon Longitudinal Study of Parents and Children (ALSPAC) born between April 1991 and December 1992 in the southwest of England. Infant temperament at 6 months of age was reported by parents using the adapted RITQ. Responses were scored according to the RITQ manual and then categorized into temperament groups (easy, intermediate low, intermediate high, and difficult) using either the RITQ norms or norms derived from the data. The scores for each temperament subscale and the proportion of children in each temperament group were compared across the two methods. Subscale scores for the ALSPAC sample were higher (more "difficult") than the RITQ norms for rhythmicity, approach, adaptability, intensity, and distractibility. When RITQ norms were applied, 24% infants were categorized as difficult and 25% as easy, compared with 15% difficult and 38% easy when ALSPAC norms were used. There are discrepancies between RITQ norms and the ALSPAC norms which resulted in differences in the distribution of temperament groups. There is a need to re-examine RITQ norms and categorization for use in primary care practice and contemporary population-based studies.