ABSTRACT
Background
The Intervention Nurses Start Infant Growing on Healthy Trajectories (INSIGHT) study's responsive parenting (RP) intervention, initiated in early infancy, prevented the use of nonresponsive, controlling feeding practices and promoted use of structure-based feeding among first-time parents compared with controls.
Objectives
We sought to examine the spillover effect of the RP intervention on maternal feeding practices with their secondborn (SB) infants enrolled in an observational-only study, SIBSIGHT, and to test the moderating effect of spacing of births.
Methods
SB infants of mothers participating in the INSIGHT study were enrolled into the observation-only ancillary study, SIBSIGHT. SBs were healthy singleton infants ≥36 weeks of gestation. Infant feeding practices (i.e., food to soothe, structure vs. control-based practices) were assessed using validated questionnaires: Babies Need Soothing Questionnaire, Infant Feeding Styles Questionnaire, and the Structure and Control in Parent Feeding Questionnaire.
Results
SBs (n = 117 [RP: 57, control: 60]; 43% male) were delivered 2.5 ± 0.8 y after firstborns (FBs). At age 1 y, the Structure and Control in Parent Feeding Questionnaire revealed that the mothers in the RP group used more consistent feeding routines (4.19 [0.43] compared with 3.77 [0.62], P = 0.0006, Cohen's D: 0.69) compared with control group mothers. From the Infant Feeding Styles Questionnaire, RP group mothers also used less nonresponsive, controlling feeding practices such as pressuring their SB infant to finish (1.81 [0.52] compared with 2.24 [0.68], P = 0.001, Cohen's D: 0.68) compared with controls. In contrast to our hypotheses, no differences were detected in bottle-feeding practices such as putting to bed with a bottle/sippy cup or adding cereal to the bottle, despite observing study group differences in FBs. Spacing of births did not moderate intervention effects.
Conclusions
RP guidance given to mothers of FBs may prevent the use of some nonresponsive, controlling feeding practices while establishing consistent feeding routines in subsequent siblings.
Keywords: obesity prevention, infancy, responsive parenting, feeding practices and styles, bottle feeding, siblings, birth order
Introduction
Overweight and rapid weight gain during infancy increase the risk of obesity and other comorbidities throughout the lifecourse (1–4). With 8.9% of US children aged 2–5 y meeting criteria for obesity (5), and 9.5% of infants at or above the 95th percentile in weight-for-length (6), early interventions are needed. Parents who use more control-based feeding practices such as the use of food to soothe and pressure to eat tend to have children who show less ability to self-regulate food intake, which can increase the risk of rapid infant weight gain (7). Children with parents who use more control-based feeding practices also tend to be more responsive to food cues (8–10) and more likely to eat in the absence of hunger, which can lead to obesity during later childhood (1, 11).
The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) trial is a randomized clinical trial comparing an early life responsive parenting (RP) intervention for the primary prevention of obesity against a safety control among first-time mother-infant dyads. RP is defined as providing prompt, developmentally appropriate, and contingent responses to a child's needs (12, 13). The INSIGHT RP intervention includes guidance on feeding, sleep, emotional regulation, and interactive play. The responsive feeding component taught parents to feed when hungry and to stop when the child shows signs of satiety, while also considering the structure, routine, and emotional context provided by the caregiver (14).
Among the firstborn (FB) participants, INSIGHT's RP intervention promoted structure-based responsive feeding while reducing controlling, nonresponsive feeding practices such as the use of pressure and food to soothe (15). The primary outcome for INSIGHT was BMI z-score at age 3 y. Secondary outcomes included weight-for-length percentile at several intervals in the first 12 mo after birth. FB infants randomly assigned to the INSIGHT RP intervention had slower weight gain during the first 6 mo after birth (16) and lower mean BMI z-scores at age 3 y compared with controls (17).
Although positive findings among FB participants are encouraging, the majority of parents in the United States have >1 child (18). Thus, the aim of this analysis was to assess the spillover effects of the INSIGHT RP intervention on infant feeding practices, beliefs, and behaviors used with secondborn (SB) infants at age 1 y enrolled in an observation-only cohort study, SIBSIGHT. Based on prior findings in FBs, the hypotheses were: 1) that mothers who received the RP intervention with their FB child would use more responsive feeding practices and less controlling practices with their SB, compared with controls; and 2) the effect of the RP intervention on SBs would be stronger in mothers who had shorter spacing between births due to their proximity to receiving intervention material and the reality of intervention fadeout (19).
Methods
Subjects and study design
INSIGHT is a randomized, clinical trial where nurses delivered interventions to first-time mothers and their infants (n = 279) at 4 home visits in the first year after birth followed by clinical research center visits at ages 1, 2, and 3 y. Mothers were contacted via telephone 10–14 d following childbirth, and randomly assigned to a study group. Randomization was stratified by mothers’ intended feeding mode (breastfeeding or formula) and sex-specific birth weight for gestational age (<50th percentile or ≥50th percentile). More details on study design, recruitment/eligibility, measures, and a CONSORT diagram have been previously published (14, 16). Mothers participating in INSIGHT were invited to participate in an observation-only study involving SB siblings, SIBSIGHT, following the birth of their second child. Inclusion criteria for the SB child included 1) singleton infants ≥36 weeks of gestation, 2) no medical conditions that would impact feeding, 3) birth weight ≥2500g, and 4) families were required to plan to live in Central Pennsylvania for 1 y following the birth of their second child. Nurse home visits for data collection occurred at 3–4, 16, and 28 wk and a research center visit occurred at 1 y. This study was approved by the Human Subjects Protection Office of the Penn State College of Medicine. Screening and eligibility for SIBSIGHT can be found in Figure 1.
FIGURE 1.
SIBSIGHT CONSORT diagram.
RP feeding intervention components in FBs
A detailed description of the RP and control intervention components delivered to FBs has been published elsewhere (14). Briefly, feeding guidance during infancy included recognizing and responding appropriately to hunger and satiety cues, age-appropriate bottle-feeding practices (e.g., transitioning off bottle), and using structure-based, noncontrolling feeding practices that allow the infant to drive intake through shared control of the initiation and termination of feedings. In addition, emotion regulation intervention content included the use of alternatives to feeding to soothe a fussy, but nonhungry infant. Participants received handouts and DVDs, which they were able to keep for reference. The control group of FBs received a home safety intervention that was similar in intensity. Feeding-related messages in the safety curriculum focused on food safety and choking prevention. Importantly, no new intervention content was delivered in SIBSIGHT.
Measures
Data were collected through phone interviews (conducted by nonintervention study personnel) and surveys. Online surveys, or paper surveys for those without internet access (n = 5), were sent to participants 2–3 wk in advance of each visit. Data were collected and managed using REDCap (20). Participants provided demographic information at enrollment (e.g., SB father and SB race/ethnicity, income, marital status). Medical chart abstraction was performed to obtain maternal age, prepregnancy weight, gestational weight gain, and infant gestational age, sex, birth weight and length.
Food to soothe in SBs
Food to soothe was assessed at 3, 16, 28, and 52 wk using items from the Baby's Basic Needs Questionnaire, which was originally validated in a middle-income sample of mothers with infants (21). This scale was modified to include contexts and situations when a mother could use feeding to soothe. Scales used in this analysis include Contextual (α = 0.77) and Emotional Food to Soothe (α = 0.92). Higher scores in Contextual feeding to soothe reveal greater use of feeding to soothe a distressed infant in different contexts (e.g., in a doctor's waiting room, in the car, before bed). Higher Emotional feeding to soothe scores indicate greater use of feeding to soothe in response to either the infant's distress, or maternal stress, frustration, or anger. Efficacy of using food to soothe on a scale of 1 (does not work) to 4 (works all of the time) was also reported by mothers.
Feeding beliefs and behaviors in SBs
At 52 wk, mothers completed the Infant Feeding Styles Questionnaire which assesses parent feeding beliefs and behaviors in 5 feeding style domains: laissez-faire, pressuring, restrictive, responsive, and indulgent (22). Confirmatory factor analysis validated this measure in mothers with infants (22). In this analysis, results for the Pressuring (Pressure to Finish, α = 0.82; Pressure with Cereal, α = 0.73; Pressure to Soothe, α = 0.71), Restrictive (Restrictive Amount, α = 0.70; Restrictive Diet Quality, α = 0.79), and Responsive Satiety (α = 0.72) are reported. The Laissez-Faire Attention, Laissez-Faire Diet Quality, and Responsive Attention subscales showed poor reliability (α = 0.66, 0.48, and 0.68), and were not analyzed. The Indulgent feeding subscales were not considered developmentally appropriate and also were not analyzed. Additionally, mothers were asked about bottle-feeding practices with breastmilk or formula (e.g., adding cereal to the bottle, putting the child to bed with a bottle or sippy cup).
Use of structure and control in SBs
The Structure and Control in Parent Feeding Questionnaire assessed controlling feeding practices at 52 wk using the Pressure to Eat (α = 0.70) and Restriction (α = 0.72) subscales, and structure-based feeding practices with the Consistent Feeding Routines subscale (α = 0.80) and the Limiting Exposure to Unhealthy Foods subscale (α = 0.73) (23). This questionnaire has been validated in a sample of mothers with young children and is associated with similar constructs in the Caregiver Feeding Styles Questionnaire (23).
Statistical analysis
Data were analyzed using SAS 9.4 (SAS Institute). Logistic regression assessed the effect of study group on categorical outcomes and ANCOVA assessed the effect on continuous variables. ORs and Cohen's D were calculated as indicators of effect size for logistic regression and ANCOVA analyses, respectively. Spacing of births was tested as a potential moderator, due to the potential of intervention effects diminishing over time. No significant main effects of birth spacing or interactions with study group were observed. Therefore, simpler models were fit, controlling for these effects. Other covariates included infant sex, weight-for-age z-score at birth, and predominant milk-feeding type at 16 wk (breast compared with formula). Significance was defined as P <0.05. Mixed linear models using a compound symmetry covariance structure examined the use and mother perceived efficacy of food to soothe, in a repeated measures analysis framework to assess intervention group effects over time (within person).
Results
From the original INSIGHT cohort, 138 mothers had a second child born within the time frame of recruitment between June 2013 and March 2017 (Figure 1). Among them, 117 SB mother-infant dyads (57 RP, 60 Control) were eligible and agreed to participate in SIBSIGHT. Informed consent for participation was completed upon delivery. All 117 mother-SB dyads (100%) remained in the study at 1 y. Participant characteristics are reported in Table 1. Mothers were predominantly white, non-Hispanic, married, and college-educated. Approximately 50% reported annual household incomes above $75,000. RP SB infants were born 2.4 y ± 0.9 after FB and control SB infants were born 2.6 y ± 0.8 after FBs. There were no significant differences in demographic characteristics between mothers and SBs in families randomly assigned to INSIGHT's RP and control groups. Frequency of predominant breastfeeding was 69.6% in SB RP infants at 16 wk and 50.0% in SB control infants (P = 0.03).
TABLE 1.
Secondborn demographics by study group (n = 117)
| Responsive parenting (n = 57) | Control (n = 60) | |
|---|---|---|
| Infant | ||
| Male sex, n (%) | 22 (38.6) | 28 (46.7) |
| Gestational age, wk (mean ± SD) | 38.9 ± 1.2 | 39.1 ± 0.9 |
| Birth weight, kg (mean ± SD) | 3.4 ± 0.4 | 3.5 ± 0.4 |
| Birth length, cm (mean ± SD) | 51.1 ± 2.2 | 51.1 ± 2.2 |
| Spacing between siblings, y (mean ± SD) | 2.4 ± 0.9 | 2.6 ± 0.8 |
| Mother | ||
| Age, y (mean ± SD) | 32.1 ± 4.2 | 31.1 ± 4.1 |
| Prepregnancy BMI, kg/m2 (mean ± SD) | 25.8 ± 5.1 | 26.0 ± 6.0 |
| Gestational weight gain, kg (mean ± SD) | 11.1 ± 5.5 | 11.3 ± 6.5 |
| Diabetes during pregnancy, n (%) | 3 (5.3) | 6 (10.0) |
| Smoked during pregnancy, n (%) | 2 (3.5) | 1 (1.7) |
| Predominant breastfeeding at 16 wk, % | 69.6 | 50.0 |
| Race, n (%) | ||
| Black | 2 (3.5) | 1 (1.7) |
| White | 53 (93.0) | 58 (96.7) |
| Asian | 2 (3.5) | 1 (1.7) |
| Ethnicity, n (%) | ||
| Hispanic/Latino | 0 (0.0) | 1 (1.7) |
| Non-Hispanic/Latino | 56 (100) | 59 (98.3) |
| Marital status, n (%) | ||
| Married | 55 (96.5) | 56 (93.3) |
| Not married, living with partner | 2 (3.5) | 3 (5.0) |
| Single | 0 (0.0) | 1 (1.7) |
| Annual household income, n (%) | ||
| < $10,000 | 1 (1.9) | 0 (0.0) |
| $10,000–$24,999 | 0 (0.0) | 1 (1.8) |
| $25,000–$49,999 | 2 (3.7) | 4 (7.3) |
| $50,000–$74,999 | 13 (24.1) | 13 (23.6) |
| $75,000–$99,999 | 17 (31.5) | 9 (16.4) |
| $100,000 or more | 21 (38.9) | 28 (50.9) |
| Education, n (%) | ||
| HS graduate | 3 (5.3) | 5 (8.3) |
| Some college | 11 (19.3) | 9 (15.0) |
| College graduate | 25 (43.9) | 30 (50.0) |
| Graduate degree + | 18 (31.6) | 16 (26.7) |
Maternal use of food to soothe SBs
Figure 2 shows that RP group mothers used less Contextual (P <0.0001, Cohen's D: 0.57) and Emotional Food to Soothe over time at 3, 16, 28, and 52 wk (P <0.0001, Cohen's D: 0.52) compared with control group mothers. There were no significant differences between RP and control group mothers in their beliefs about the efficacy of food or beverages to soothe infant distress over time. No significant interactions were found between time and study group or study group and spacing of births in the use or efficacy of food to soothe.
FIGURE 2.
Mixed linear model results revealed that responsive parenting group mothers (n = 57) reported less context- (A) and emotion-based (B) food to soothe compared with control group mothers (n = 60) (P <0.0001).
Beliefs and behaviors at 1 y
As shown in Table 2, RP group mothers were less likely to report using pressure, defined as trying to get their child to finish breastmilk/formula (P = 0.009, OR: 0.40 [0.2, 0.8]) or food (P = 0.0005, OR: 0.3 [0.1, 0.6]) compared with controls. Yet, when asked how often they encouraged their SB infant to finish the bottle if they stopped drinking before the milk was gone, there was no difference by study group (P = 0.19, OR: 0.5 [0.2, 1.4]). RP group mothers reported significantly lower scores on Pressure to Finish (P = 0.001, Cohen's D: 0.68) and Pressure to Soothe (P = 0.006, Cohen's D: 0.57) than controls, but there were no differences on restrictive feeding practices. Mothers in the RP group also reported significantly higher use of structure-based Consistent Feeding Routines (P = 0.0006, Cohen's D: 0.69) compared with control group mothers. There were no study group differences on specific bottle-feeding practices such as weaning infants from the bottle or putting their SB child to bed with a bottle (Table 2). No significant interactions between study group and spacing of births were found in feeding beliefs and behaviors.
TABLE 2.
Effect of responsive parenting intervention in firstborns on parent feeding practices in secondborns
| Responsive parenting (n = 57) | Control (n = 60) | P value | OR (CI) or Cohen's D | |
|---|---|---|---|---|
| Parental use of pressure to finish | ||||
| Child is encouraged to finish a bottle if infant stops drinking before the milk is all gone (≥sometimes), % | ||||
| 52 wk | 54.3 | 72.5 | 0.19 | 0.5 (0.2, 1.4) |
| Try to get my child to finish breastmilk or formula, % | ||||
| 52 wk | — | — | 0.009 | 0.4 (0.2, 0.8) |
| Never | 47.9 | 23.5 | ||
| Rarely | 27.1 | 33.3 | ||
| Half of the time | 16.7 | 19.6 | ||
| Most of the time | 8.3 | 19.6 | ||
| Always | 0.0 | 3.9 | ||
| Try to get my child to finish his/her food, % | ||||
| 52 wk | — | — | 0.0005 | 0.3 (0.1, 0.6) |
| Never | 28.6 | 11.5 | ||
| Rarely | 40.8 | 23.1 | ||
| Half of the time | 18.4 | 40.4 | ||
| Most of the time | 12.2 | 17.3 | ||
| Always | 0.0 | 7.7 | ||
| Infant Feeding Styles Questionnaire – 52 wk | ||||
| Pressure/overfeeding to finish, mean ± SD | 1.81 ± 0.52 | 2.24 ± 0.68 | 0.001 | 0.68 |
| Pressure/overfeeding to soothe, mean ± SD | 1.74 ± 0.56 | 2.17 ± 0.74 | 0.006 | 0.57 |
| Pressure/overfeeding with cereal, mean ± SD | 1.25 ± 0.48 | 1.45 ± 0.64 | 0.32 | 0.20 |
| Restrictive/amount, mean ± SD | 2.89 ± 0.96 | 2.83 ± 0.96 | 0.65 | 0.09 |
| Restrictive/diet quality, mean ± SD | 3.54 ± 0.73 | 3.50 ± 0.81 | 0.62 | 0.10 |
| Responsive satiety, mean ± SD | 4.50 ± 0.44 | 4.39 ± 0.48 | 0.25 | 0.23 |
| Structure and control in parenting feeding (SCPF) – 52 wk | ||||
| Limit exposure, mean ± SD | 3.98 ± 0.47 | 3.92 ± 0.51 | 0.85 | 0.04 |
| Consistent feeding routines, mean ± SD | 4.19 ± 0.43 | 3.77 ± 0.62 | 0.0006 | 0.69 |
| Pressure to eat, mean ± SD | 1.72 ± 0.51 | 1.94 ± 0.54 | 0.07 | 0.36 |
| Restriction, mean ± SD | 2.30 ± 0.12 | 2.07 ± 0.81 | 0.28 | 0.21 |
| Bottle-feeding practices – 52 wk | ||||
| Using bottle, % | 71.4 | 78.9 | 0.65 | 0.8 (0.3, 2.1) |
| Ever used sippy cup, % | 89.1 | 82.1 | 0.41 | 1.6 (0.5, 5.1) |
| Ever used regular cup, % | 32.7 | 17.9 | 0.20 | 1.8 (0.7, 4.7) |
| Currently adding cereal to bottle (yes), % | 8.6 | 2.4 | 0.30 | 3.5 (0.3, 37.4) |
| Puts child to bed with bottle/sippy cup (yes), % | 18.5 | 17.7 | 0.29 | 1.8 (0.6, 5.8) |
All models adjusted for birth spacing, predominant feeding mode at 16 wk, weight-for-age z-score at birth, and infant sex.
Discussion
Consistent with our hypotheses, and similar to what was observed among FBs, the INSIGHT RP intervention influenced how SB infants were reportedly fed. The INSIGHT RP intervention prevented the use of controlling, nonresponsive feeding practices (e.g. pressure, food to soothe) and encouraged establishing structure-based consistent feeding routines in SBs. These effects were also reported for FBs, suggesting a spillover effect of the INSIGHT RP intervention on SBs. Together, these findings suggest that the INSIGHT RP curriculum for FBs was robust enough to impact many feeding practices of SBs. This is remarkable because mothers of SBs received no INSIGHT RP booster messaging in the observation-only evaluation.
The new findings presented in this article make INSIGHT the first obesity prevention intervention to demonstrate protective effects of a first-time parent-directed responsive feeding intervention spilling over to subsequent offspring. Yet, our findings are consistent with a growing literature showing the protective effects of RP on parent feeding and other child health outcomes in FBs (24–26). A common criticism of resource-intensive interventions delivered in the home is the lack of sustainability and scale-up, however, findings from this study demonstrate a continued benefit to laterborn siblings and a potential cost-effective strategy to prevent obesity within a family.
The INSIGHT RP messages specific to the use of food to soothe appear to have spilled over to SBs. RP group mothers of SBs reported using less food to soothe related to emotion and context compared with control mothers across time points, in line with what we hypothesized. These findings are similar to those in FBs (15). The INSIGHT curriculum had overlapping messages on using alternatives to food to soothe included in both the feeding and emotion regulation domains. Despite this finding and mothers receiving overlapping messages of food to soothe in multiple domains in FBs, we did not observe a study group difference in the efficacy of food or beverages to soothe over time in SBs. The increase in caregiving responsibilities and household chaos associated with increasing family size may cause mothers to perceive lower efficacy of these strategies than with their FB.
As expected, RP group mothers of SBs also reported using more consistency in meals and feeding routines than control mothers. In contrast to our hypotheses, there was no difference on pressure related to adding cereal to the bottle, limiting exposure to unhealthy foods, putting to bed with a bottle/sippy cup, or weaning from the bottle at 1 y, despite observing study group differences in FBs (15). One plausible explanation is that parents may relax nutrition standards due to increasing caregiving responsibilities with the addition of a second child (27). Mothers may need a booster on structure (related to foods provided) with subsequent births. Because other messages may not have resonated as much with their SB, mothers could also benefit from training in strategies specific to each infant, as mothers may perceive needs differently, based on individual differences in appetite or temperament between siblings. In addition, it is important to note that a limitation of the current study is that Infant Feeding Style Questionnaire measures were assessed at 28 wk in FBs and 1 y in SBs. It is possible that pressuring with cereal, a behavior less commonly reported in FB RP group mothers than controls but not SBs, may be less relevant for older infants (15). Lastly, the use of restriction did not show significant study group effects in FBs or SBs. One reason could be that restriction may not be as relevant to the developmental stage we assessed at 1 y (i.e., the time point data was collected). Study group differences in restrictive feeding practices may emerge after age 1 y as a more diverse diet is introduced. Contrary to our interaction hypothesis, birth spacing did not moderate intervention effects on SB feeding practices. Our birth spacing variable was restricted based on recruitment from June 2013 to March 2017 and may not represent all possible spacing and fadeout effects.
This is the first RP obesity prevention intervention to examine spillover effects to SB siblings. Examples from the parenting and developmental literature support our findings of spillover effects of interventions to younger siblings. One study, which examined a family support intervention provided to parents of FBs resulted in better school attendance, less supportive services needed, and better school progress for untreated siblings in the intervention group compared with controls (28). Public health interventions in developing countries surrounding food provisions have also shown spillover effects of feeding interventions targeting malnutrition onto growth of younger siblings (29), even if unintentional (30). These results suggest the impact that an intervention in 1 child in a family can have on outcomes of another sibling. However, given that some practices did not spillover to SBs and there are a lack of prospective sibling studies in the obesity literature, other innovative strategies are warranted, such as developing mechanisms for intervention booster messaging as well as an enhanced focus on individual differences during subsequent pregnancies or shortly after the birth of a second child.
One limitation of the current study is that data relied on parent self-report, a common practice in behavioral research. To discourage socially desirable responses, the research team emphasized the importance of truthful responding, permitted participants to skip questions, and allowed participants to take surveys in the privacy of their own home. Additionally, our participants are mostly white, with a limited sample of low income, and this limits the generalizability of our findings. More work is needed to tailor this intervention to be effective in ethnically and economically diverse samples. Because of our limited sample size of 117 SBs compared with 279 FBs, it may have been more difficult to detect study group differences in SBs and we were not powered to detect differences in more complex interactions, such as study group and the sex of each sibling. The current analysis does not assess individual differences; this will be explored in future analyses.
In summary, the INSIGHT RP intervention delivered to mothers of FB infants impacted feeding practices in the SB child, specifically pressure, consistent routines, and food to soothe. This multicomponent intervention not only affected various outcomes in FBs (16, 31–34), but results from the present study suggest some spillover effects of feeding practices in this observation-only cohort of SBs, demonstrating that intervening with first-time mothers may be an effective way to promote responsive feeding in subsequent siblings.
Acknowledgments
We acknowledge Jessica Beiler, Jennifer Stokes, Patricia Carper, Heather Stokes, Susan Rzucidlo, Lindsey Hess, and Eric Loken for their assistance with this project. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the NIH Award Number TL1TR002016. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
The authors’ contributions were as follows—JSS, LLB, and IMP: designed and conducted the research; CFR and EEH: analyzed data; CFR: wrote the paper; CFR: had primary responsibility for final content; and all authors read and approved the final manuscript. The authors report no conflicts of interest.
Notes
This work was supported by the National Institutes of Health (NIDDKR01DK099364 and TL1TR002016).
Data described in the article, code book, and analytic code will be made available upon request pending application and approval.
Abbreviations used: FB, firstborn; INSIGHT, Intervention Nurses Start Infants Growing on Healthy Trajectories; RP, responsive parenting; SB, secondborn.
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