Is the measure the message: the BSID and nutritional interventions.

Full text

Page 1

DOI: 10.1542/peds.2012-0934
; originally published online May 28, 2012; 2012;129;1166
Pediatrics
John Colombo and Susan E. Carlson
Is the Measure the Message: The BSID and Nutritional Interventions




http://pediatrics.aappublications.org/content/129/6/1166.full.html
located on the World Wide Web at:
The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
publication, it has been published continuously since 1948. PEDIATRICS is owned,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
at Univ Of Kansas Med Ctr on August 29, 2012pediatrics.aappublications.org Downloaded from

Page 2

Is the Measure the Message: The BSID and Nutritional
Interventions
ThisissueofPediatricscontainsameta-analysisbyQawasmietal1that
is an evaluation of the effects of long-chain polyunsaturated fatty acid
(LCPUFA) supplementation of infant formula on what is claimed to be
measuresof“infantcognition.”Theanalysisisbasedonperformanceof
different dietary groups on the Bayley Scales of Infant Development
(BSID) at ages up to 18 months. The authors conclude that LCPUFA
supplementationprovidesnobenefitforeithertermorpreterminfants.
There are now at least 4 meta-analyses or systematic reviews on this
topic published in the past 7 years.2–4All include only (or mainly)
studiesthathavemeasuredtheBSID,andallreachasimilarconclusion.
We do not disagree with the conclusion that the BSID is generally un-
affected by LCPUFA supplementation; however, we are concerned with
thenatureoftheoutcomemeasureusedtoanchor thisandothermeta-
analyses. The BSID is a global test designed to identify developmental
delay. Its role and place within the field of developmental science is
relatively well established. The BSID is, to be charitable, only modestly
relatedtoschool-agecognitivedevelopment(ie,theoutcomethatismost
meaningfultoinvestigatorsinthisfield).TheBSIDisaglobalmeasureof
developmentalstatusininfancythatassessesandaggregatesthetimely
attainmentofrelativelycrudemilestonesininfancyandearlychildhood.
It is based on assumptions of a model of general intelligence that as-
sumesthatthemorerapidattainmentofsuchmilestonesreflectshigher
intellectual ability.5Indeed, a recent study found that the BSID was not
predictive of IQ of term infants at age 6 years.6
More targeted tests of attention based on constructs of information
processing have been shown to correlate more highly with cognitive
function later in childhood.5,7,8Unfortunately, more targeted measures
of specific cognitive functions have only recently begun to be used by
pediatricians who have conducted the clinical trials of nutritional
supplementation or in evaluating the effects of other early specific
exposurestoenvironmentalcontaminants.9–11Asnotedabove,although
the BSID may have been conceptualized initially as an index of “infant
intelligence,” it is most useful as an assessment for developmental
delay in pediatric and educational settings. Indeed, another article in
this issue12properly refers to the BSID as reflecting developmental
status, although even there the measure documented only slight dif-
ferences between breastfed and non-breastfed infants (ie, groups
known todiffersubstantiallyin cognitiveoutcomes).Simply, the BSID is
not an adequate indicant of specific cognitive skills that may be dif-
ferentially affected by interventions or exposures, nutritional or oth-
erwise, and so its use to evaluate the construct of infant cognition is
seriously deficient in the context of recent advances in developmen-
tal science. Indeed, more specific measures of early cognitive func-
tion have recently been reported to show positive effects of LCPUFA
AUTHORS: John Colombo, PhDaand Susan E. Carlson,
PhDb
aDepartment of Psychology, University of Kansas, Lawrence,
Kansas; andbDepartment of Dietetics and Nutrition and
Department of Pediatrics, University of Kansas Medical Center,
Kansas City, Kansas
ABBREVIATIONS
BSID—Bayley Scales of Infant Development
LCPUFA—long-chain polyunsaturated fatty acid
Opinions expressed in these commentaries are those of the
author and not necessarily those of the American Academy of
Pediatrics or its Committees.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0934
doi:10.1542/peds.2012-0934
Accepted for publication Mar 29, 2012
Address correspondence to Susan E. Carlson, PhD, Department of
Dietetics and Nutrition, MS 4013, University of Kansas Medical
Center, 3901 Rainbow Blvd, Kansas City, KS 66160. E-mail:
scarlson@kumc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
FUNDING: Funded by the National Institutes of Health (NIH).
COMPANION PAPERS: Companions to this article can be found
on pages 1134 and 1141, and online at www.pediatrics.org/cgi/
doi/10.1542/peds.2011-3121 and www.pediatrics.org/cgi/doi/10.
1542/peds.2011-2127.
1166
COLOMBO and CARLSON
at Univ Of Kansas Med Ctr on August 29, 2012pediatrics.aappublications.org Downloaded from

Page 3

supplementation,13andareportfrom
our laboratory thatis currently in prep-
aration14shows sensitivity of measures
other than the BSID at 18 months to be
sensitive to specific and general out-
come measures, out to age 6.
AsidefromtheBSIDbeinginsensitiveto
the effects of early nutritional inter-
ventions, it is also possible that the
choice to assess at 18 months may not
be the optimal age at which to observe
differencesofinterest.Eighteenmonths
isanageofconsiderablereorganization
in early development and may be too
volatile to anchor major conclusions
about the effectiveness of a nutritional
intervention.
In summary, although we do not dis-
agreewiththeauthors’conclusionthat
the BSID is generally unresponsive to
LCPUFA supplementation, we disagree
that a finding of no effect by using the
BSID is sufficient evidence to conclude
that LCPUFAs convey no benefit to
infant cognitive development. It is a
challengeforresearchers in the field to
expand their repertoire of developmen-
tal tests and to consider planning stud-
ies with the power to test children
enrolled in these studies at older ages.
We also hope that the continued educa-
tion of the pediatric community in the
area of developmental behavioral sci-
ence will foster a better understanding
ofthesubtletiesofmeasuringandinter-
preting developmental outcomes.
REFERENCES
1. QawasmiA,Landeros-WeisenbergerA,Leckman
JF, Bloch MH. Meta-analysis of long-chain
polyunsaturated fatty acid supplementation
of formula and infant cognition. Pediatrics.
2012;129(6):1141–1149
2. Schachter HM, Kourad K, Merali Z, et al.
Effects of omega-3 fatty acids on mental
health. Evidence Reports/Technology Assess-
ments No. 116 (report no: 05-E022-2). Rock-
ville, MD: Agency for Healthcare Research
and Quality; July 2005
3. Simmer K, Patole S, Rao SC. Longchain
polyunsaturated fatty acid supplementa-
tion in infants born at term. Cochrane
Database Syst Rev. 2011;12:CD000376
4. Beyerlein A, Hadders-Algra M, Kennedy K,
et al. Infant formula supplementation with
long-chain polyunsaturated fatty acids
has no effect on Bayley developmental
scores at 18 months of age—IPD meta-
analysis of 4 large clinical trials. J Pe-
diatr Gastroenterol Nutr. 2010;50(1):79–
84
5. Colombo J. Infant Cognition: Predicting Later
Intellectual Functioning. Newbury Park, CA:
Sage Publications, 1993
6. Canals J, Hernández-Martínez C, Esparó G,
Fernández-Ballart J. Neonatal Behavioral
Assessment Scale as a predictor of cogni-
tive development and IQ in full-term infants:
a 6-year longitudinal study. Acta Paediatr.
2011;100(10):1331–1337
7. McCall RB, Carriger MS. A meta-analysis of
infant habituation and recognition memory
performance as predictors of later IQ. Child
Dev. 1993;64(1):57–79
8. Bornstein MH, Sigman MD. Continuity in
mental development from infancy. Child
Dev. 1986;57(2):251–274
9. Jacobson SW, Fein GG, Jacobson JL,
Schwartz PM, Dowler JK. The effect of
intrauterine PCB exposure on visual rec-
ognition memory. Child Dev. 1985;56(4):
853–860
10. Jacobson SW, Jacobson JL, Sokol RJ. Effects
of fetal alcohol exposure on infant reaction
time. Alcohol Clin Exp Res. 1994;18(5):1125–
1132
11. Jacobson SW, Jacobson JL, Sokol RJ, Martier
SS, Ager JW. Prenatal alcohol exposure and
infant information processing ability. Child
Dev. 1993;64(6):1706–1721
12. Andres A, Cleves MA, Bellando JB, Pivik RT,
Casey PH, Badger TM. Developmental status
of 1-year-old infants fed breast milk, cow’s
milk formula, or soy formula. Pediatrics.
2012;129(6):1134–1140
13. Colombo J, Carlson SE, Cheatham CL,
Fitzgerald-Gustafson KM, Kepler A, Doty T.
Long-chain polyunsaturated fatty
supplementation in infancy reduces heart
rate and positively affects distribution of
attention. Pediatr Res. 2011;70(4):406–
410
14. Colombo J, Carlson SE, Cheatham CL, et al.
LCPUFA supplementation affects measures
of preschool cognition. Presented at the
PAS/ASPR Joint Meeting Denver, CO, April
30–May 3, 2011
acid
COMMENTARY
PEDIATRICS Volume 129, Number 6, June 2012
Downloaded from
1167
at Univ Of Kansas Med Ctr on August 29, 2012pediatrics.aappublications.org

Page 4

DOI: 10.1542/peds.2012-0934
; originally published online May 28, 2012; 2012;129;1166
Pediatrics
John Colombo and Susan E. Carlson
Is the Measure the Message: The BSID and Nutritional Interventions


Services
Updated Information &
html
http://pediatrics.aappublications.org/content/129/6/1166.full.
including high resolution figures, can be found at:
References
html#ref-list-1
http://pediatrics.aappublications.org/content/129/6/1166.full.
at:
This article cites 10 articles, 2 of which can be accessed free
Permissions & Licensing
tml
http://pediatrics.aappublications.org/site/misc/Permissions.xh
tables) or in its entirety can be found online at:
Information about reproducing this article in parts (figures,
Reprints
http://pediatrics.aappublications.org/site/misc/reprints.xhtml
Information about ordering reprints can be found online:
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
at Univ Of Kansas Med Ctr on August 29, 2012pediatrics.aappublications.orgDownloaded from