Professional Documents
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Group
as
socioeconomic
status
that
contributes
to
the
positive
holistic
Group
milk (direct latch or via bottle feed) over formula milk. However, there appears to be a contrasting
viewpoint on the opinion that manufactured formula milk has significant advantages on a childs
development.
Group
between breastfeeding and cognition. In addition, researchers disagree on the effects of duration of
breastfeeding on child outcomes; some find a significant relationship (Horwood, Darlow, & Mogridge,
2001; Anderson, Johnstone, & Remley, 1999).); others, a nonlinear doseresponse relationship
(Mortensen, Michaelsen, Sanders, & Reinisch, 2002); and still others, no significant relationship after
adjusting for confounders (Rogan & Gladen, 1993).
In addition, a number of studies have found the protective effect of a longer duration of breastfeeding
on child cognition and behaviour to be an artefact of sociodemographic confounding factors rather
than a direct association. Zhou et al. (2007) highlighted that the benefits of breastfeeding were
diminished when improvements in the home environment were taken into consideration and
concluded that socioeconomic factors mediate the relationship between breastfeeding and child
cognitive development. Sacker et al. (2006) analysed a population-based cohort of infants and found
that the relationship between breastfeeding and fine motor delay could be explained by biological,
socioeconomic and psychosocial factors. However, an important point noted that adjustment for
confounders did not attenuate the protective effect for gross motor development.
Confounding Factors
Having an adequate study design is essential for any research of this nature in order to ascertain the
true effect of breast milk on infant development. A review of 24 studies found that almost all of the
studies contained one of three main methodological flaws: inadequate control for confounders,
insufficient definition of outcomes and inconsistent definitions of breastfeeding (Drane &, Logemann,
2000). This review concluded that the benefits of breast milk for cognitive development could not be
determined because of such study design limitations (Drane &, Logemann, 2000).
The major challenge in conducting such studies is to adequately control for the considerable
confounding effects of parental and family characteristics, factors which are so strongly associated
with both breastfeeding for longer periods of time and favourable developmental outcomes for
children. Given the controversies in this area, it is important to focus efforts on study designs that will
allow for the appropriate determination of any relationship between breastfeeding and early
developmental outcomes, whilst allowing adjustment for factors that are closely associated with both.
Group
Method
Participants
Participants will be sampled from a population of children who were born in 2013,
attend preschool in 2017 and be 4 years of age at the end of 2017. During the
nursery registration phase in July 2016, a total of 1000 invitation letters to
participate in the study will be sent out to 70 kindergartens in Singapore from 5
different geographical areas (Northern (15), Southern (10), Eastern (15), Western
(20) and Central (10)). We are expecting about 80%-90% replies from parents
who are interested to participate in the study.
The sample population will have a mixture of the various races; Chinese, Malays,
Indians & others. We aim to keep the racial ratio similar to the number of live
Participant
Lower-
Upper-
Middle
Middle
145
170
150
27
Povert
Lower-
Upper-
Middle
Middle
55
175
195
High
73
s
Remarks: Classification of social economic status based on total household
income
Poverty Class (<S$1500), Lower-Middle Class (S$1500-S$3000)
Upper-Middle Class (S$3001-S$5000), High Class (>S$5000)
We will approach either government or semi-government kindergartens which
are located mainly in the Housing Development Board heartland estates. This will
exclude private kindergarten centres operating mainly within or nearer to private
TABLE 2
Demographic Characteristics of the Sample and Subsamples
Characteristics
Nursery
Kindergarte
n1
Kindergart
en 2
Primary 1
Participant
gender
-Female (F)
-Male (M)
F (500)
M (490)
F (495)
M (485)
F (490)
M (485)
F(490)
M (465)
F (450)
M (440)
Participants
birth details-Normal(NL)
-Others (O)
NL (700)
NL (700)
NL (645)
NL (635)
NL (625)
O (290)
O (280)
O (280)
O (270)
O (265)
Group
1st (450)
1st (445)
1st (445)
1st (445)
1st (440)
2nd (300)
2nd (300)
2nd (300)
2nd (300)
2nd (295)
3rd (200)
3rd (195)
3rd (195)
3rd (180)
3rd (175)
4th (40)
4th (35)
4th (30)
4th (25)
4th (25)
Minimum
Parents
education level
-Primary (P)
-Secondary (S)
-Tertiary (T)
P (350)
P (340)
P (340)
P (330)
P (320)
S (450)
S (450)
S (445)
S (430)
S (430)
T (190)
T (190)
T (190)
T (190)
T (185)
Family
structure
-Nuclear(NR)
-Extended(E)
NR (700)
NR (690)
NR (685)
NR (675)
NR (670)
E (290)
E (290)
E (290)
E (280)
E (270)
No. of children
-Only child (1)
-Two children
(2)
-Three children
(3)
-Four or more
(4+)
1 (400)
1 (400)
1 (400)
1 (400)
1 (390)
2 (300)
2 (300)
2(300)
2 (300)
2 (280)
3 (200)
3 (200)
3 (200)
3 (175)
3 (165)
4+ (90)
4+ (80)
4+ (75)
4+(70)
4+ (60)
Socioeconomic
status (Class)
- Poverty (P)
P (200)
P (190)
P (185)
P (175)
P (160)
LM (345)
LM (345)
LM (340)
LM (330)
LM (300)
- Lower-middle
(LM)
UM (345)
UM (345)
UM (345)
UM (345)
UM (340)
H (100)
H (100)
H (100)
H (100)
H (90)
- Upper-middle
(UM)
- High (H)
We will be using MANOVA (Multivariate Analysis of Variance) to analyse the data
from from the tests as we will be making a comparison between the two groups;
breast milk fed participants against the formula fed participants. Socioeconomic
status plays an important role in the holistic development of the child due to the
various exposures a child has within a family which will vary the degree of
outcomes in the child whether breast milk fed or formula milk fed. To what extent
these measures will affect the childs holistic development will be analysed in the
Group
TABLE 3
Summary of Variables and Outcomes
Control
Dependent
Independent
Outcomes
Socioeconomic
- Physical (height
- Children on
- Children on
status
breastmilk
- Poverty Class
- Lower Middle
age)
- Social &
- Children on
formula milk
less likely to be
overweight
Emotional
- Children on
(conduct grades
- Upper Middle
and teachers
better behaved
Class
feedback)
- High Class
- Cognitive
(Stanford-Binet
better cognitive
Intelligence Test
functions
Class
scores)
- Children on
- Children on
- Speech &
Language
better speech
(Peabody Picture
and language
Vocabulary Test
skills
scores)
10
Group
Following the acceptance by the respective school principals and clearance from
the Institutional Review Board, 1000 letters will be sent out during nursery
registration phase to parents inviting them to participate in the study. We hope
to receive all replies by the last week of November before the commencement of
the class in January 2017.
A meeting will be set up with parents to brief and orientate them on the study as
well as obtain a signed consent for the childs participation. Parents are required
to complete an early nutrition questionnaire by UNICEF which will allow the
authors to divide the children into 2 distinct groups (children exclusively fed with
breast milk for 6 months and those given formula milk). The questionnaire
includes questions that summarizes the personal family data (combined monthly
income, total number of children, nucleus/extended family, house type,
enrichment classes for the child). Teachers from the Preschool Centre will be
informed and briefed by their Principal regarding the nature of the childrens
involvement in the study.
We will take several days to compile data from the questionnaires into a working
Microsoft Office Spreadsheet. The participants will first be categorised into the 2
different groups based on their nutrition information provided by the parents.
The participants will then be placed in sub groups within the 2 main groups
according to their familys socioeconomic status.
At the start of Term 4 in 2017, health booklets will be collected for researchers to
extract the height and weight of each child. The process will take 3 groups of 2
researchers approximately 2 days for each kindergarten. During this time,
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Data obtained over the years will be compiled and stored in a central database
and be made accessible to the authors. As it spans over a long period of time,
huge amount of data will be collected and it will be very difficult to look through.
The first step will be to prepare, clean up and organize the data into the
appropriate categories. As data is mainly valued test results, except for the
feedback from their kindergarten teachers, there is no need to score the data
and can be used for analysis directly.
Test scores, height and weight will be left as it is to increase the accuracy as
opposed to scoring them in intervals. This will allow for minute variances to be
plotted because differences between the childrens scores can be very small in a
sitting but cumulatively significant over the years.
categorically along a time interval scale for each child (eg; height/weight in year
1, year 2 and so on).
There will be 2 independent variables (IV1: exclusive breast milk for 6 months,
IV2: exclusive formula milk), 4 dependent variables (DV: height & weight,
Stanford-Binet Intelligence Scale test scores, Peabody Picture Vocabulary Test
scores, conduct grades) and 1 control variable (socioeconomic status of
participants caregivers).
Predicting Holistic Developmental Progress in Pre-schoolers
The primary question in this study focused on the impact of nutrition, specifically
breast milk versus formula milk, and parents socioeconomic status on the
holistic developmental progress in pre-schoolers. We will perform multivariate
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