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Effectiveness of home based early intervention on children’s BMI at age 2: randomised controlled trial

Objective To assess the effectiveness of a home based early intervention on children’s body mass index (BMI) at age 2. Design Randomised controlled trial. Setting The Healthy Beginnings Trial was conducted in socially and economically disadvantaged areas of Sydney, Australia, during 2007-10. Participants 667 first time mothers and their infants. Intervention Eight home visits from specially trained community nurses delivering a staged home based intervention, one in the antenatal period, and seven at 1, 3, 5, 9, 12, 18 and 24 months after birth. Timing of the visits was designed to coincide with early childhood developmental milestones. Main outcome measures The primary outcome was children’s BMI (the healthy BMI ranges for children aged 2 are 14.12-18.41 for boys and 13.90-18.02 for girls). Secondary outcomes included infant feeding practices and TV viewing time when children were aged 2, according to a modified research protocol. The data collectors and data entry staff were blinded to treatment allocation, but the participating mothers were not blinded. Results 497 mothers and their children (75%) completed the trial. An intention to treat analysis in all 667 participants recruited, and multiple imputation of BMI for the 170 lost to follow-up and the 14 missing, showed that mean BMI was significantly lower in the intervention group (16.53) than in the control group (16.82), with a difference of 0.29 (95% confidence interval −0.55 to −0.02; P=0.04). Conclusions The home based early intervention delivered by trained community nurses was effective in reducing mean BMI for children at age 2. Trial registration Australian Clinical Trial Registry No 12607000168459.

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 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 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. • 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