School of Public Health, Sydney Medical School, University of Sydney, 2006, Australia. 2. ... Sydney, 2145, Australia. 4. ... Support services for breastfeeding.
Wen LM et al
Appendix: Detailed information on the Healthy Beginnings intervention and control conditions [posted as supplied by author]
Li Ming Wen, Research and Evaluation Manager*1, 2 Louise A Baur, professor of Paediatrics & Child Health, 1, 3 Judy M Simpson, professor of biostatistics,1 Chris Rissel, professor of Public Health,1 Karen Wardle, Research Coordinator 2 and Victoria M Flood, associate professor of Health Sciences4
1. School of Public Health, Sydney Medical School, University of Sydney, 2006, Australia 2. Health Promotion Service, Sydney South West Area Health Service, New South Wales, 2050, Australia
3. Discipline of Paediatrics & Child Health, Sydney Medical School, University of Sydney, 2145, Australia 4. School of Health Sciences, University of Wollongong, 2522, Australia
As part of the Healthy Beginnings RCT an intensive home-based intervention was developed to run over a two-year period and be delivered by trained community nurses to the intervention group in the antenatal period and at 1, 3, 5, 9, 12, 15 and 24 months. A description of the program and all intervention resources developed for this study is available on-line (http://www.healthybeginnings.net.au/).
To ensure consistency with the delivery of the intervention the community nurses were trained in a number of areas prior to commencement of the trial. Research components of the training included understanding the research protocol, evidence based practice, quantitative and qualitative data collection and open ended questioning. A range of
1
Wen LM et al training about early childhood was also undertaken, covering family partnership training, review of early brain development, overview of attachment and frameworks for observing and understanding infant behaviour including infant sleep and awake states and infant cues. The community nurses were also trained in understanding state modulation, techniques which caregivers can use to help infants organise their sleeping and waking states, improve feeding and enhance the quality of baby / carer interaction. Nutrition training included feeding interaction, early infant feeding, introduction of solids, water as main other drink, cup feeding, serving sizes, fruit and vegetables, family food, reading labels and healthy snacks. Emphasis was placed on physical activity for new mothers and a stage-of-change approach was used to assist mothers to return to physical activity or commence some form of activity after the birth of their baby. Mothers were trained in play and understanding normal development and milestones. The community nurses spent four hours at the Growth Centre, The Children’s Hospital Westmead, for a formal presentation on anthropometric measurements, including BMI followed by practical experience in measuring babies and toddlers.
The development of the intervention was informed by a pilot program which was based on the existing clinical practice of home visiting nurses and a review of literature of the epidemiology of overweight in early childhood, dietary intake and physical activity in young Australian children which gave key risk factors to address. Also informing the intervention was expert advice and direction from a planning reference group consisting of all chief and associate study investigators, and input from researchers with critical experience in delivering nurse-based home interventions, nutrition expertise, psychologists, occupational therapists and other external experts. A literature review informed the play component of the program and was developed in consultation with
2
Wen LM et al occupational therapists.
The program developed five key intervention messages for parents: Breast is best; No solids for me until 6 months; I eat a variety of fruit and vegetables everyday; Only water in my cup; I am part of an active family. To assist with these messages, resources were developed for the participants including a bib, bowl cup and ball.
At each home visit, the community nurses addressed four key areas: infant nutrition, your baby and physical activity, your physical activity and nutrition, and social support. Each visit covered a set of standard information with key discussion points for each area as outlined in the tables below, and appropriate resources to reinforce the information. Checklists for each visit were developed to ensure all information was adequately addressed. The visits took place face-to-face in the participant’s home and ranged in length from one to two hours. At each visit, the community nurse engaged the participant in a number of key discussion areas. There was no set order for discussion, and each visit was participant led. If discussion was outside the project protocol, this information was recorded and any necessary referrals took place.
Key discussion area one: infant nutrition Breastfeeding: encourage and support exclusive breastfeeding for first 6 months and then to continue to breastfeed to 12 months and beyond.
• Health benefits of breastfeeding • Strategies to address barriers associated with breastfeeding • What to expect in hospital • Advice on establishment including length and number of feeds, positioning and attachment • Management of problems (painful nipples, breast fullness, engorgement, blocked ducts, mastitis, supply, thrush, refusal) • Maternal diet • Breastfeeding and work / expressing • Support services for breastfeeding • Safe infant formula feeding if not breastfeeding
3
Wen LM et al Introduction of solids: commence solids around 6 months and to be eating a full range of family food by 12 months
• Child development / feeding relationship • Guidelines / recommendations for introduction of solids • How to know if baby is ready for solids • Introducing solids - first foods, how to start • Food safety - preparation, freezing, thawing, cooking, cleaning • Portion sizes, fruit and vegetables • Family foods, fussy eaters, eating together • Lunch box ideas, gardening ideas • Reinforce the continuation of breastfeeding • No infant formula after 12 months • Cup feeding • Drinks for toddlers - milk intake, water other liquids
Drinks: discuss baby only needs breast or formula until 6 months then small amounts of cooled boiled water can be given by a cup
Health resources - Breastfeeding your Baby, Starting Family foods, Breastfeed and Shape Up, Teach your baby to drink from a cup, Go For 2 & 5 Children & Young People go for 2 & 5 Healthy Beginnings resources - Infant Formula Feeding, Solids quick notes, Introducing Solids to the Allergy Prone Infant, Healthy Beginnings Fussy Eaters, Family Foods Gardening Ideas Lunch box Ideas
Key discussion area two: your baby and physical activity Tummy Time: differentiate between tummy time and SIDS guidelines
• Why tummy time for play • When and how long should tummy time be
Sleep and settling: empowering mothers to understand patterns of behaviour and importance of parent/child interaction
• Sleep cycles and feeding patterns • Baby cues / tired signs / crying • Settling strategies
Movement : Understanding baby and toddler movement and playtime
• • • •
Infant reflexes / sense perception Tummy time / infant play Activities to help develop strength and control Baby relating and interacting with the important people in their lives • Child development (motor skill, emotional, social, language) • Physical activity guidelines • Unstructured play ideas (balance, body movement, playing with objects) • Structured play idea (balance, body movement, playing with objects) • Providing play areas / floor time • Screen time Healthy Beginnings resources – play resources 1 - 10
Key discussion area three: physical activity and nutrition Exercise during pregnancy: Maintaining a safe level of exercise
• •
4
Exercise and sport during pregnancy Benefits of exercise while pregnant
Wen LM et al during pregnancy
• •
Activities during pregnancy Abdominal / pelvic floor exercise
Postnatal physical activity: Commencing or starting activity following birth
• Benefits of physical activity after birth • Pelvic floor exercises • Ways to increase activity • Enablers and barriers to physical activity • Ideas for being active as a family Nutrition for adults -particularly new • Australian dietary guidelines • Breastfeeding mothers mothers What you eat as a new mum • Quick meal ideas gives you the energy you need each • Food preparation ideas day. Preparing nourishing meals is important; breastfeeding mothers have • Fruit and vegetables • What to drink some extra nutritional needs • Recipe tips and ideas • Food labelling Health Resources: Food for Health Australian Dietary Guidelines NHMRC, National PA Guidelines For Adults Department of Health and Ageing, Go for 2 & 5 it’s easy to find a way to get some extra fruit and veggies in your day, Go for 2 & 5 Thrifty Ways to go for 2 & 5, Exercises Before and After Birth, One In Three Women Who Ever Had A Baby Wet Themselves. The National Continence Management Strategy
Healthy Beginnings Resources: Physical Activity Resource for New Mothers, Activity Postnatal Physical Activity Planner, Fruit & Vegetables, Recipe Book, Food Labelling resource, Healthy Food Fast
Key discussion area four – social support Many factors affect first time mothers
• •
• • •
Relationships with partner, family and friends while pregnant and following birth Being a new parent: Over the first 6 months many things impact on a new parent, lifestyles and relationships change and develop. New mothers groups Work and Family returning to work can be a major step. Toddler behaviour
The control group received a first home visit by the community nurse and a package of home safety information sent through the mail at 1, 3, 5, 9 and 18 months. At 12 and 24 months a package of information was given face to face at the data collection visit. Parents were initially provided with an overview of home safety issues by completing a checklist and then given more specific information over the two years on the main issues that affected childhood safety. The main preventable issues covered were falls prevention
5
Wen LM et al (from nursery equipment and falls while obtaining walking skills/environment), scalds, poisoning, SIDs, car restraints and water safety. Tobacco control was also addressed under the NSW Health “Car and home, smoke free home” campaign via the reduction of Environmental Tobacco Smoke, and participants were provided opportunities to quit smoking. Participants received a range of resources including a wrap for the baby, cupboard locks, non-slip socks, thermal coffee mug and sunhat. Training for the home safety component included tobacco updates and visiting the Kids Safe house at Westmead Children Hospital which gave an overview of child safety.
6
