Chengsi Ong

Background: Childhood obesity is a global health concern with long-term cardiometabolic and psychosocial consequences. Establishing healthy feeding and lifestyle behaviors from infancy is critical to population health efforts with a life course perspective. Recently, digital health applications have gained traction in reaching out to parents and promoting healthy feeding behaviors. Objective: The aim of this study was to evaluate the usability and acceptability of the Feeding, Lifestyle, Activity Goals app in providing parents with evidence-based guidance and tailored advice to promote healthier eating behaviors and lifestyle habits among infants. Methods: We conducted a mixed methods pilot study among parents of infants aged 0 to 24 months recruited from a tertiary maternity and children’s hospital in Singapore. Participants used the digital health app for 7 days. Usability was assessed using the validated System Usability Scale (score range 0‐100, with ≥70 indicating acceptable usability). Acceptability was explored via open-ended questionnaires on satisfaction, relevance, and user experience, with qualitative data analyzed thematically by 2 independent coders to ensure rigor. Results: A total of 26 parents of infants aged 3 weeks to 23 months completed the study. The app demonstrated good usability, with a mean System Usability Scale score of 71.3 (SD 11.0). Parents valued its role in organizing infant care; promoting self-reflection on parenting practices; and providing personalized, evidence-based recommendations. These benefits were particularly appreciated by first-time parents and those with multiple caregiving responsibilities. Challenges included an unintuitive user interface, high manual data entry burden, and advisory content that was occasionally overly general or text heavy. These insights highlight clear priorities for onward efforts in optimization. Conclusions: Results of our mixed methods evaluation indicate that our digital health app demonstrated good usability and acceptability among parents of infants. Targeted refinements to the interface, data entry processes, and content delivery are warranted before large-scale evaluation to determine its impact on early-life health behaviors and obesity prevention.

Introduction: Very-low-birthweight (VLBW) infants on pasteurized donor human milk (PDHM) have poorer growth compared to infants on fortified mother's milk, suggesting that standard fortification methods for PDHM are inadequate.Methods: We designed a randomized controlled trial to determine whether an enhanced method of fortification (EF) improved growth in VLBW infants compared to standard fortification (SF). VLBW infants admitted to our tertiary-level neonatal intensive care unit were randomized to receive a bovine powdered human milk fortifier (HMF) added to PDHM (SF), or specially selected high-fat PDHM (fat concentration ≥3.8 g/dL) with bovine powdered HMF and a liquid protein fortifier providing an additional 0.67 g/dL protein (EF). Primary outcome was impaired weight gain defined as weight z-score drop of ≥0.8 from birth at 37 weeks or hospital discharge, whichever earlier. Secondary outcomes included change in length and head circumference (HC) z-scores from birth, requirement for high calorie formula, and rates of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP).Results: A total of 61 infants were randomized (31 SF, 30 EF). Impaired weight gain was not significantly different (SF 83.9% vs. EF 73.3%, p = 0.347), with similar declines in weight z-scores from birth in both groups SF −1.27 [interquartile range (IQR) −1.71, −0.87] vs. EF −1.13 (IQR −1.46, −0.78), p = 0.403. However, the EF group had a smaller decline in length and HC z-scores from birth to discharge compared to the SF group [Length z-score change: −0.92 (IQR −1.64, −0.48) vs. −1.64 (IQR −2.21, −0.89), p = 0.007; HC z-score change: −0.08 (IQR −0.74,0.58) vs. −0.86 (IQR −1.81, −0.21), p = 0.014]. The EF group also required less high calorie formula supplementation [0% (IQR 0-4.1) vs. 3.8% (IQR 0 −16.9), p = 0.032]. Rates of BPD and ROP were not significantly different between groups.Conclusion: Among VLBW infants, EF did not improve weight gain, but reduced declines in HC and linear growth compared to SF.

Difficulties with breastfeeding can lead to early breastfeeding cessation. Empowering mothers through self-assessment and education of breastfeeding skills can help support them. We aimed to develop and validate a tool for self-screening and education on breastfeeding skills. A six-item tool was developed through literature review and expert interviews, covering domains of breastfeeding position, nipple shape, breast engorgement, infant latch, swallowing and intake. Eight experts assessed the tool’s relevance, clarity, simplicity and ambiguity. Scores were used to determine item-level content validity index (I-CVI) and scale-level content validity index (S-CVI). Items with values ≤ 0.83 (best possible score = 1.00) were revised. Following revision, a convenience sample of breastfeeding mothers were recruited from maternity wards and clinics to determine the tool’s internal consistency, face, criterion and construct validity. Participants and lactation consultants (LC) independently completed the tool based on the same breastfeeding episode. Internal consistency was determined by Cronbach’s alpha. Criterion validity was assessed by comparing participant and LC scores using Bland-Altman plots. Construct validity was determined by comparing scores in participants who were and were not referred to a LC. Receiver operating characteristic (ROC) curve was used to determine a cut-off score for LC referral by optimizing sensitivity and specificity. The tool demonstrated acceptable content validity, with I-CVI and S-CVI values for relevance, clarity, simplicity and ambiguity above the threshold, except for S-CVI of simplicity and ambiguity, and the tool was revised accordingly. Most mothers who completed the tool (n = 58) found it easy to understand (87.9%), relevant (91.4%) and useful (86.2%). Cronbach’s alpha was 0.66, which improved to 0.74 with the removal of the item on “engorgement”. With the remaining five items, ROC analysis showed an area under the curve of 0.79 [(95%CI 0.67–0.90), p < 0.001], with a score of ≤ 6 indicative of an LC referral (sensitivity = 86%, specificity = 55%). Bland-Altman plots showed acceptable agreement between participant and LC scores with a mean difference of 0.22 (95%CI -3.02–3.47). We developed and validated a simple five-item tool for mothers to assess and be educated about breastfeeding skills. Further study on the tool’s predictive validity and effectiveness within a clinical pathway is warranted.

Background/Objectives: Food insecurity during pregnancy is associated with higher risks of negative physical outcomes for both mother and child. This study aims to understand experiences of food insecurity among low-income Singaporean pregnant women and its impact on nutritional status. Methods: In this cross-sectional, mixed-methods study, 49 food-insecure pregnant women were recruited from KK Women’s and Children’s Hospital between November 2021 and November 2023, among which 11 in-depth interviews were conducted. Questionnaires, anthropometric measurements, 24-Hour dietary recalls, metabolic and nutritional blood tests were conducted for all subjects. Descriptive quantitative analysis was performed and integrated with qualitative thematic analysis to explain findings. Results: On average, women were overweight pre-pregnancy (body mass index 26.1 ± 6.9 kg/m²) and had low haemoglobin and 25-hydroxyvitamin D levels. Calorie intake and intake from major food groups did not meet recommendations during pregnancy, except for “Grains”. From interviews, effects of financial constraints, how participants managed their food supply and pregnancy-related symptoms, supported findings from 24-Hour dietary recalls. Conclusions: Food insecurity led to suboptimal nutritional status and diets in Singaporean pregnant women despite appearing well-nourished. Further exploration of perspectives of food-insecure mothers, healthcare providers and welfare organisations is needed to devise long-term solutions to improve food security and alleviate malnutrition.

IMPORTANCE: Quadriceps thickness (QT) and rectus femoris cross-sectional area (RF_CSA) are both used to evaluate muscle changes in critically ill children. However, their correlation and association with physical function has not been compared. OBJECTIVES: To compare QT with RF_CSA changes, and their association with physical function in critically ill children. DESIGN, SETTING, AND PARTICIPANTS: Secondary analysis of a prospective cohort study of children 0–18 years old admitted to a tertiary mixed PICU between January 2015 and October 2018 with PICU stay greater than 48 hours and greater than or equal to one organ dysfunction. MAIN OUTCOMES AND MEASURES: Ultrasound QT and RF_CSA were measured at PICU admission, PICU discharge, hospital discharge, and 6 months post-discharge. QT and RF_CSA changes from baseline were compared with each other and with change in motor function, physical ability, and physical health-related quality of life (HRQOL). RESULTS: Two hundred thirty-seven images from 66 subjects were analyzed. RF_CSA change was not significantly different from QT change at PICU (–8.07% [interquartile range (IQR), –17.11% to 4.80%] vs –4.55% [IQR, –14.32% to 4.35%]; p = 0.927) or hospital discharge (–5.62% [IQR, –15.00% to 9.42%] vs –8.81% [IQR, –18.67% to 2.39%]; p = 0.238) but was significantly greater than QT change at 6 months (32.7% [IQR, 5.74–109.76%] vs 9.66% [IQR, –8.17% to 25.70%]; p < 0.001). Motor function change at PICU discharge was significantly associated with RF_CSA change (adjusted β coefficient, 0.02 [95% CI, 0.01–0.03]; p = 0.013) but not QT change (adjusted β coefficient, –0.01 [95% CI, –0.02 to 0.01]; p = 0.415). Similar results were observed for physical HRQOL changes at hospital discharge (adjusted β coefficient for RF_CSA change, 0.51 [95% CI, 0.10–0.92]; p = 0.017 and adjusted β coefficient for QT change, –0.21 [–0.76 to 0.35]; p = 0.458). Physical ability was not significantly associated with RFCSA or QT changes at 6 months post-discharge. CONCLUSIONS AND RELEVANCE: Ultrasound derived RF_CSA is associated with PICU motor function and hospital discharge physical HRQOL changes, unlike QT, and may be more useful for in-hospital muscle monitoring in critically ill children.

A narrative review of skeletal muscle atrophy in critically ill children: pathogenesis and chronic sequelae Chengsi Ong, Jan Hau Lee, Melvin K. S. Leow, Zudin A. Puthucheary

Introduction: Vaccination is critical in controlling the coronavirus disease 19 (COVID-19) pandemic. However, vaccine perception and acceptance among pregnant and lactating women is unknown in Singapore. We aimed to determine the acceptance of COVID-19 vaccination among these two groups of women in Singapore, and factors associated with vaccine acceptance. Methods: We conducted an anonymous, online survey on the perception and acceptance of the COVID-19 vaccine in pregnant and lactating women at a tertiary hospital in Singapore from 1 ^st March to 31 ^st May 2021. Information on demographics and knowledge were collected, and these factors were assessed for their relationship with vaccine acceptance. Results: A total of 201 pregnant and 207 lactating women participated. Vaccine acceptance rates in pregnant and lactating women were 30.3% and 16.9% respectively. Pregnant women who were unsure or unwilling to take the vaccine cited concerns about safety of the vaccine during pregnancy (92.9%), while lactating women were concerned about potential long-term negative effects on the breastfeeding child (75.6%). Other factors significantly associated with vaccine acceptance included a lower monthly household income or education level, appropriate knowledge regarding vaccine mechanism and higher perceived maternal risk of COVID-19. Most pregnant (70.0%) and lactating women (83.7%) were willing to take the vaccine only when more safety data during pregnancy and breastfeeding were available. Conclusions: COVID-19 vaccine acceptance was low among pregnant and lactating women in Singapore. Addressing safety concerns when more data is available and education on mechanism of vaccine action will likely improve acceptance among these women.

Muscle weakness and wasting is increasingly recognized as a problem in children admitted to the pediatric intensive care unit (PICU). Muscle weakness and wasting could potentially affect a child’s function and development, imposing a burden on the child and their families. We aimed to summarize the literature on muscle weakness and wasting in critically ill children, discuss methods to measure muscle changes as well as areas for future research. Intensive care unit weakness in children has been reported through numerous case reports and a cohort study. These papers demonstrated that muscle weakness can be persistent in critically ill children, with reduced strength reported even after hospital discharge. A prevalence of approximately 2% has been reported in critically ill children, lower than that reported in adults. This may be related to an under-detection of muscle weakness in critically ill children, as identification of muscle weakness and wasting in critically ill children can be challenging. Some methods that have been used to assess muscle changes in critically ill children include arm muscle circumference derived from triceps skinfold thickness and upper-arm circumference, ultrasound-derived limb and diaphragm muscle size, lean body mass from bioelectrical impedance analysis. Using these methods, various patterns have been reported including increase, decrease and no change in muscle. However, studies have not explored the relationship between muscle changes and function. Evidence suggests that there is heterogeneity in the muscle changes that critically ill children may experience. Future research may need to consider differences in age, illness severity and body composition in interpreting changes in muscle size and strength in critically ill children. Importantly, understanding the role of nutrition and physical rehabilitation in relation to muscle changes and function is an important direction in optimizing long-term outcomes in critically ill children.

OBJECTIVES: To describe functional and skeletal muscle changes observed during pediatric critical illness and recovery and their association with health-related quality of life. DESIGN: Prospective cohort study. SETTING: Single multidisciplinary PICU. PATIENTS: Children with greater than or equal to 1 organ dysfunction, expected PICU stay greater than or equal to 48 hours, expected survival to discharge, and without progressive neuromuscular disease or malignancies were followed from admission to approximately 6.7 months postdischarge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Functional status was measured using the Functional Status Scale score and Pediatric Evaluation of Disability Inventory—Computer Adaptive Test. Patient and parental health-related quality of life were measured using the Pediatric Quality of Life Inventory and Short Form-36 questionnaires, respectively. Quadriceps muscle size, echogenicity, and fat thickness were measured using ultrasonography during PICU stay, at hospital discharge, and follow-up. Factors affecting change in muscle were explored. Associations between functional, muscle, and health-related quality of life changes were compared using regression analysis. Seventy-three survivors were recruited, of which 44 completed follow-ups. Functional impairment persisted in four of 44 (9.1%) at 6.7 months (interquartile range, 6–7.7 mo) after discharge. Muscle size decreased during PICU stay and was associated with inadequate energy intake (adjusted β, 0.15; 95% CI, 0.02–0.28; p = 0.030). No change in echogenicity or fat thickness was observed. Muscle growth postdischarge correlated with mobility function scores (adjusted β, 0.05; 95% CI, 0.01–0.09; p = 0.046). Improvements in mobility scores were associated with improved physical health-related quality of life at follow-up (adjusted β, 1.02; 95% CI, 0.23–1.81; p = 0.013). Child physical health-related quality of life at hospital discharge was associated with parental physical health-related quality of life (adjusted β, 0.09; 95% CI, 0.01–0.17; p = 0.027). CONCLUSIONS: Muscle decreased in critically ill children, which was associated with energy inadequacy and impaired muscle growth postdischarge. Muscle changes correlated with change in mobility, which was associated with child health-related quality of life. Mobility, child health-related quality of life, and parental health-related quality of life appeared to be interlinked.