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Background We aimed to analyse the outcome of universal newborn hearing screening (UNHS) and high-risk hearing screening in neonatal intensive care unit (NICU) graduates in a tertiary care unit. Methods The hearing screen programme comprises a 2-stage automated auditory brainstem response protocol followed by a high-risk hearing screen at 3-6 months. This study is a retrospective study of NICU graduates born between April 2002 and December 2009. Data on hearing screening, audiological assessment, and management were extracted from a computerized data management system (HITRACK). Results Of 100,225 newborn infants, 2.9% were admitted to the NICU during the study period. The overall incidence of hearing loss (HL) of any type/severity was 35/1,000 infants. Of infants with HL, 92.4% had their first automated auditory brainstem response at/before 1 month of corrected age. The incidence of congenital permanent HL identified by the UNHS was 15.4/1,000. The corrected median age of diagnosis was 4.5 months (1-23.5 months). Of 2,552 NICU graduates who passed the UNHS, 75.5% were retested at 3-6 months of life. Twelve infants with permanent late-onset HL were identified, raising the overall incidence of permanent HL to 19.9/1,000; 1.1/1,000 had auditory neuropathy. Of the 92 infants with HL, 89 (96.7%) had multiple risk factors. Conclusions There is a high incidence of HL in NICU graduates; 22.6% were late in onset. An early rescreen in those who pass the UNHS is a beneficial step for this high risk population.

(1) Background: Breastfeeding has been shown to support glucose homeostasis in women after a pregnancy complicated by gestational diabetes mellitus (GDM) and is potentially effective at reducing long-term diabetes risk. (2) Methods: Data from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study were analyzed to understand the influence of breastfeeding duration on long-term dysglycemia (prediabetes and diabetes) risk in women who had GDM in the index pregnancy. GDM and dysglycemia four to seven years postpartum were determined by the oral glucose tolerance test (OGTT). A Poisson regression model with a robust error variance was used to estimate incidence rate ratios (IRRs) for dysglycemia four to seven years post-delivery according to groupings of the duration of any breastfeeding (&lt, 1, &ge, 1 to &lt, 6, and &ge, 6 months). (3) Results: Women who had GDM during the index pregnancy and complete breastfeeding information and OGTT four to seven years postpartum were included in this study (n = 116). Fifty-one women (44%) had postpartum dysglycemia. Unadjusted IRRs showed an inverse association between dysglycemia risk and &ge, 1 month to &lt, 6 months (IRR 0.91, 95% confidence interval [CI] 0.57, 1.43, p = 0.68) and &ge, 6 months (IRR 0.50, 95% CI 0.27, 0.91, p = 0.02) breastfeeding compared to &lt, 1 month of any breastfeeding. After adjusting for key confounders, the IRR for the &ge, 6 months group remained significant (IRR 0.42, 95% CI 0.22, 0.80, p = 0.008). (4) Conclusions: Our results suggest that any breastfeeding of six months or longer may reduce long-term dysglycemia risk in women with a history of GDM in an Asian setting. Breastfeeding has benefits for mothers beyond weight loss, particularly for those with GDM.

The Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO) is a preconception, longitudinal cohort study that aims to study the effects of nutrition, lifestyle, and maternal mood prior to and during pregnancy on the epigenome of the offspring and clinically important outcomes including duration of gestation, fetal growth, metabolic and neural phenotypes in the offspring. Between February 2015 and October 2017, the S-PRESTO study recruited 1039 Chinese, Malay or Indian (or any combinations thereof) women aged 18 to 45 years and who intended to get pregnant and deliver in Singapore, resulting in 1032 unique participants and 373 children born in the cohort. The participants were followed up for 3 visits during the preconception phase and censored at 12 months of follow up if pregnancy was not achieved (N=557 censored). Women who successfully conceived (N=475) were characterised at gestational weeks 6-8, 11-13, 18-21, 24-26, 27-28 and 34-36. Follow up of their index offspring (N=373 singletons) is on-going at birth, 1, 3 and 6 weeks, 3, 6, 12, 18, 24 and 36 months and beyond. Women are also being followed up post-delivery. Data is collected via interviewer-administered questionnaires, metabolic imaging (magnetic resonance imaging), standardized anthropometric measurements and collection of diverse specimens, i.e. blood, urine, buccal smear, stool, skin tapes, epithelial swabs at numerous timepoints. S-PRESTO has extensive repeated phenotypic data collected which include genetic and epigenetic sampling from preconception which is unique in mother-offspring epidemiological cohorts This enables prospective assessment of a wide array of potential determinants of future health outcomes in women from preconception to post-delivery and in their offspring across the earliest development from embryonic stages into early childhood. In addition the S-PRESTO study, draws from the three major Asian ethnic groups that represent 50% of the global population, increasing the relevance of its findings to global efforts to address non-communicable diseases.

Background Without the use of standardized screening tools, only 30% of the estimated 5–15% of children with developmental delay can be identified, potentially delaying intervention. Aim 1) To evaluate the ASQ-3's reliability and validity at 9, 18, and 24 months and to compare the results with normative USA data. 2) To determine the risk factors for a screen positive result, which requires further evaluation. Methods Study of 649 low-risk children was part of a larger longitudinal cohort study, the GUSTO project. Socio-demographic and ASQ3 data were analyzed to estimate reliability, validity, mean ASQ scores, and cut-off scores. Results ASQ-3 showed an acceptable to good internal consistency (0.49–0.83) and a medium level of correlations (0.22–0.59) between the five domains but differed significantly compared to normative USA data. Using local cut-off scores, 12.6–13.6% of the cohort had a positive screen in ≥ 1 domain at 9, 18, or 24 months. ASQ-3 screening categorization was consistent, with only 3–11% of children showing change in categorization longitudinally. On regression, lower family income (OR 3.3–9.42) and maternal education (OR2.65–3.03) were predictive of a positive screen across domains and age intervals. Interpretation ASQ-3 is a useful, valid screening tool in Singapore. Further research is needed to investigate item functioning and to assess its concurrent validity with a criterion standard tool for culturally sensitive developmental screening.

Individual differences in children's eating behaviours emerge early. We examined the relationship between breastfeeding exposure and subsequent eating behaviours among children from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort. Children (n = 970) were grouped according to their breastfeeding exposure: high (full breastfeeding ≥ 4 months with continued breastfeeding ≥ 6 months), low (any breastfeeding < 3 months or no breastfeeding) and intermediate (between low and high breastfeeding categories). Aspects of eating behaviour from ages 15 months to 6 years were captured using a combination of maternal reports (Child Eating Behaviour Questionnaire; Infant Feeding Questionnaire; Preschooler Feeding Questionnaire) and laboratory-based measures of meal size, oral processing behaviours (e.g. average eating speed and bite size) and tendency to eat in the absence of hunger. Most children had low (44%) or intermediate (44%) breastfeeding exposure; only 12% had high exposure. After adjusting for confounders, multivariable linear regression analyses indicated the high (but not intermediate) breastfeeding group was associated with significantly lower reported food fussiness at 3 years compared to low breastfeeding group (−0.38 [-0.70, −0.06]), with similar but non-significant trends observed at 6 years (−0.27 [-0.66, 0.11]). At 3 years, mothers in the high breastfeeding group also reported the least difficulty in child feeding compared to low breastfeeding group (−0.22 [-0.43, −0.01]). However, high breastfeeding was not associated with any other maternal-reports of child feeding or eating behaviours, and no significant associations were observed between breastfeeding exposure and any of the laboratory measures of eating behaviour at any of the time points. These results do not strongly support the view that increased breastfeeding exposure alone has lasting and consistent associations with eating behaviours in early childhood.

Background:The home literacy environment (HLE) and joint parent–child book reading are key factors in children’s language and literacy acquisition. Child-centered literacy orientation (CCLO) refers to the child’s level of engagement in literacy events.Aim:To describe the HLE and identify demographic and HLE variables associated with a poor CCLO at 12 months of age.Methods:Parents of Singaporean children enrolled in the Growing Up in Singapore Towards healthy Outcomes (GUSTO; n = 1152, birth cohort 2009–2010) completed a childhood literacy questionnaire at 12 months to obtain scores on HLE (0–17) and CCLO (0–6). Logistic regression analyses were employed to identify predictors of low CCLO.Results:Parents of 525 children completed the questionnaire. Mothers were the main caregivers in half the households. Mandarin was the main language (34%). Majority of the respondents had a library card that was used less than weekly, and had fewer than 10 children’s books. 18% of parents read to the child daily, of whom one-quarter read at bedtime. Amongst half of the families who had a CCLO score of 0, two-thirds had the lowest HLE scores (0–2). Correlational analyses indicated significant association between HLE with CCLO at 12 months ( p < 0.001). Non-English speaking caregivers and mothers who had only completed primary education were at high risk of a poor 12-month CCLO.Conclusion:A literacy-rich home environment is associated with 12-month child-centered literacy orientation. Pediatricians and early years’ professionals may be able to promote benefits of literacy related activities to families at risk of poor child-centered literacy orientation.

BACKGROUND: Confinement (restrictions placed on diet and practices during the month right after delivery) represents a key feature of Asian populations. Few studies, however, have focused specifically on ethnic differences in confinement practices. This study assesses the confinement practices of three ethnic groups in a multi-ethnic Asian population.METHODS: Participants were part of a prospective birth cohort study that recruited 1,247 pregnant women (57.2% Chinese, 25.5% Malay, and 17.3% Indian) during their first trimester. The 1,220 participants were followed up 3 weeks postpartum at home when questionnaires were administered to ascertain the frequency of adherence to the following confinement practices: showering; confinement-specific meals; going out with or without the baby; choice of caregiver assistance; and the use of massage therapy.RESULTS: Most participants reported that they followed confinement practices during the first 3 weeks postpartum (Chinese: 96.4%, Malay: 92.4%, Indian: 85.6%). Chinese and Indian mothers tended to eat more special confinement diets than Malay mothers (p < 0.001), and Chinese mothers showered less and were more likely to depend on confinement nannies during this period than mothers from the two other ethnic groups (p < 0.001 for all). Malay mothers tended to make greater use of massage therapy (p < 0.001), whilst Indian mothers tended to have their mothers or mothers-in-law as assistant caregivers (p < 0.001).CONCLUSION: Most Singapore mothers follow confinement practices, but the three Asian ethnic groups differed in specific confinement practices. Future studies should examine whether ethnic differences persist in later childrearing practices.

This paper describes a successful hearing screening programme for infants in KK Women's and Children's Hospital (KKH). Between April 2002 and January 2010, 100,237 (99.8% of all eligible babies) were screened, surpassing the international benchmark of 95%; 0.5% were referred for audiological investigations, significantly below the international benchmark of 4%. The median age of diagnosis in 280 infants diagnosed with Hearing Impairment (HI) [4.8months (1–24)] was lower than in HI children in special schools in Singapore [20.8 months (0–86)]. Hearing aids were fitted for 84 infants at a median age of 7.6 months (2–45) which was higher than the international benchmark of six months, but much lower than in special school children [42.2months (1–120)]. Twenty infants received a cochlear implant at a median age of 20 months (8–38). 69.3% of infants with risk factors for HI were rescreened at three to six months of life. This identified a further 88 infants with HI. Nine were fitted with hearing aids. The incidence of HI in KKH was 3.7 per 1000 infants. The KKH programmes identified 69% of infants with HI born in the restructured hospitals in Singapore, providing the opportunity for early intervention and increased likelihood of a hearing and talking child with HI.

BACKGROUND: Many countries in Asia report low breastfeeding rates and the risk factors for early weaning are not well studied. We assessed the prevalence, duration, and mode of breastfeeding (direct or expressed) among mothers of three Asian ethnic groups. METHODS: Participants were 1,030 Singaporean women recruited during early pregnancy. Data collected included early breastfeeding experiences, breastfeeding duration, and mode of breastfeeding. Full breastfeeding was defined as the intake of breast milk, with or without water. Cox regression models were used to identify factors associated with discontinuation of any and full breastfeeding. Logistic regression analyses assessed the association of ethnicity with mode of breastfeeding. RESULTS: At 6 months postpartum, the prevalence of any breastfeeding was 46 percent for Chinese mothers, 22 percent for Malay mothers, and 41 percent for Indian mothers; prevalence of full breastfeeding was 11, 2, and 5 percent, respectively. More Chinese mothers fed their infants expressed breast milk, instead of directly breastfeeding them, compared with the other two ethnic groups. Duration of any and full breastfeeding were positively associated with breastfeeding a few hours after birth, higher maternal age and education, and negatively associated with irregular breastfeeding frequency and being shown how to breastfeed. Adjusting for maternal education, breastfeeding duration was similar in the three ethnic groups, but ethnicity remained a significant predictor of mode of breastfeeding. CONCLUSIONS: The low rates and duration of breastfeeding in this population may be improved with breastfeeding education and support, especially in mothers with lower education. Further work is needed to understand the cultural differences in mode of feeding and its implications for maternal and infant health.

Background: Studies examining direct vs. expressed breast milk feeding are scarce. We explored the predictors of mode of breastfeeding and its association with breastfeeding duration in a multi-ethnic Asian population. Methods: We included 541 breastfeeding mother—infant pairs from the Growing Up in Singapore Toward healthy Outcomes cohort. Mode of breastfeeding (feeding directly at the breast, expressed breast milk (EBM) feeding only, or mixed feeding (a combination of the former 2 modes)) was ascertained at three months postpartum. Ordinal logistic regression analyses identified predictors of breast milk expression. Cox regression models examined the association between mode of breastfeeding and duration of any and of full breastfeeding. Results: Maternal factors independently associated with a greater likelihood of breast milk expression instead of direct breastfeeding were Chinese (vs. Indian) ethnicity, (adjusted odds ratio, 95% CI; 3.41, 1.97–5.91), tertiary education (vs. secondary education or lower) (2.22, 1.22–4.04), primiparity (1.54, 1.04–2.26) and employment during pregnancy (2.53, 1.60–4.02). Relative to those who fed their infants directly at the breast, mothers who fed their infants EBM only had a higher likelihood of early weaning among all mothers who were breastfeeding (adjusted hazard ratio, 95% CI; 2.20, 1.61–3.02), and among those who were fully breastfeeding (2.39, 1.05–5.41). Mothers who practiced mixed feeding, however, were not at higher risk of earlier termination of any or of full breastfeeding. Conclusions: Mothers who fed their infants EBM exclusively, but not those who practiced mixed feeding, were at a higher risk of terminating breastfeeding earlier than those who fed their infants directly at the breast. More education and support are required for women who feed their infants EBM only.