MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester

Assignment - Research Proposal

Group

Infant Nutrition in the Early Formative Years and its

Effects on the Holistic Developmental Progress of
Preschoolers
Mohd Eleazhar On
Mohd Narul Azrin
Nadia Begam
Vineeta
National Institute of Education, Singapore
Abstract
Motivated by Singapores Health Promotion Boards (2014) continual efforts to
encourage the feeding of breast milk exclusively for the first six months of a
childs life, the authors sought to examine the impact of breast milk in
comparison to formula milk in the holistic developmental domains - (i) physical,
(ii) social & emotional, (iii) cognitive and (iv) speech & language. The authors
obtained the participatory consent from 990 parents of preschoolers at the
Nursery level in Singapore kindergartens and followed the children through the
end of Primary 1 for this study. Results affirm that while it is beneficial for a child
to be fed breast milk exclusively in the first six months, there are other factors
such

as

socioeconomic

status

that

contributes

to

the

positive

holistic

development of the child. Regardless of the familys socioeconomic status, a

child stands to benefit in many ways when they are fed breast milk exclusively
in their early formative years.
Key words: breast milk, early formative years, positive holistic development,
socioeconomic status
The link between the duration of breastfeeding and the subsequent cognitive, psychomotor and
behavioural functioning of infants has been the subject of significant scientific enquiry. A number of
studies have found striking results pertaining to the relative advantages that breastfeeding can confer
on a childs neurodevelopment. Health practitioners have long advocated the benefits of giving breast

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Assignment - Research Proposal

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.

Benefits of breast milk on infant development

Breast milk has long been known to be extremely beneficial for infants and young children. It contains
most, if not all, the superior nutrients required by an infant for their proper growth, health and
development (Alimoradi, Javadi, Barikani, Kalantari, & Ahmadi, 2014). It contains long-chain
polyunsaturated fatty acids (LCPUFAs) [27]. LCPUFAs, particularly n - 3 docosahexaenoic (DHA)
and n - 6 arachidonic acid(AA), which are essential for retinal and neural development (Jiang, Foster
& Gibson-Davis, 2010). Its importance should not be undermined as more than 500,000 children out
of 3.1 million cases of child deaths that occur annually due to undernutrition, can be saved (World
Health Organization, 2016) by being fed breast milk.
Park et. al (2014) have also suggested a protective effect of breastfeeding on childhood behavioral
outcomes with a partial mediation of this effect by the childs IQ. Another study ( Oddy et. al, 2010)
found that infants who were breastfed for a minimum of 6 months were less likely to exhibit
behavioural problems throughout childhood and into adolescence from age 214 years. Dee, Lee &
Grummer-Strawn, (2007) found that breastfeeding may protect against delays in language and motor
skill development in young children. They found fewer concerns pertaining to language and motor skill
development evident for children who were breastfed for at least 3 months, and the concerns
generally decreased as breastfeeding continued for 9 months or longer.
Past research
While numerous studies have suggested that breastfeeding has a long-term influence on brain
development, interpretation of these findings poses a challenge due to the presence of many potential
confounding factors. It is important to note that there has been some debate regarding the association

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Assignment - Research Proposal

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.

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Assignment - Research Proposal

Group

Purpose of the Study

The study aims to examine the effects of breastfeeding in the first 6 months of an infants life and its
effects on the childs developmental progress in terms of four domains, namely, (i) physical, (ii) social
& emotional, (iii) cognitive and (iii) speech & language development, controlling for socioeconomic
status of the child. Many previous studies have examined these domains independently. Our study
aims to track the progression of the children in these four domains during the 4 key stages of the their
development while taking into consideration the factor of socioeconomic status of the family on the
type of nutrition given in the first 6 months of a childs life.
To examine the effect of socioeconomic status and impact of breast milk on a childs holistic
developmental progress at the 4 key stages through this correlational study, we posed the following
research questions: i) How do children who are given breast milk during their early formative years
develop holistically in Nursery, Kindergarten 1, Kindergarten 2 and Primary 1 in comparison to their
peers who are given formula milk and ii) How does socioeconomic status influence the parents
decision on the type of nutrition to give to a child during the early formative years?

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

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Group
Assignment - Research Proposal
births in Singapore for the year 2013 (Chinese: 60.1%, Malays: 15.3%, Indians:
11.7%, others: 12.9%). The different number of PCF kindergartens available
within each district may make maintaining the ratio impossible. This is due to the
different concentrations of each race in a specific district.
The group will be purposively sampled into two groups: (i) Participants who are
exclusively fed breast milk for 24 weeks/ 6 months which is the optimal duration
compared to 4-6 months (WHO, 2001) or less and (ii) those exclusively on
formula milk. Participants who were fed a mixture of both breast milk and
formula during the first 6 months will be excluded from the study.
The two groups will then be further subdivided into 4 different categories based
on their familys social and economic statuses; Poverty: <$1500, Lower-Middle:
$1500-$3000, Upper-Middle: $3001-$5000 & High: >$5000 (CPF Board, 2011),
yielding a total of 8 distinct sample groups.
TABLE 1
Projected Distribution of Participants by Social Economic Status (SES)
Groups
SES

Participant

Exclusive Breast Milk

Povert

Lower-

Upper-

Middle

Middle

145

170

150

Exclusive Formula Milk

High

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

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Group
Assignment - Research Proposal
housing clusters. Therefore, the bulk of participants will comprise both the lowermiddle and upper-middle groups, with those whose income being more than
S$5000 contributing to less than 10% of the sample group.
Measures
We defined four dependent variables; Physical , Social and Emotional , Cognitive,
Speech and Language and evaluated the literature that examined the
comparison between the exclusive breast milk fed versus formula milk fed
participants on these four domains. 1) Studies that compared participants that
were exclusively fed breast milk with participants who were only formula fed. 2)
Studies in which participants were tested from preschool to Primary school. 3)
Studies that compared one or more four domains on participants who were
exclusively breast milk fed versus formula fed.
The questionnaire (UNICEF & WHO, 2009) for the selection of participants that
will be given to the participants mothers and encompasses questions such as
the babys birth details, the type of nutrition provided, feeding habits, feeding
frequency and others will provide us with the data on the samples for use in our
research study.
In evaluating the physical domain progress, height-for-age, weight-for-age and
body mass index-for-age measurement data (Health Promotion Board, 2015)
issued by the Ministry of Health, Singapore will be used as the benchmark for
Singaporean students. The data obtained from will then be quantified to observe
the growth progress of the participants. The details of the social economic status
can also be gathered from the information in the health booklet which provide
details of the parents profession and residential status.

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Group
Assignment - Research Proposal
To assess the social & emotional domain, we will be looking at the conduct grade
given throughout the childs preschool years as well as in Primary school at the
end of the assessment year. This will provide an indication of participants social
emotional development and behaviour in the social context amongst peers. We
will also be taking into account teachers feedback on the participants behaviour
in the classroom and in school. The data collected will be quantified by
categorizing the participants according to their conduct grades; excellent, very
good, good, fair and poor.
Cognitive development of the participants will be measured using the StanfordBinet Intelligence Scale(5th edition); a valid standardised test that is reliable and
widely used to test children from the age of 2 years old onwards. It is the
successor of the Binet-Simon scale which was developed in 1905 and
subsequently became the norm for intelligence test (Marom, 2003). This test will
provide us with insights to the participants intelligence quotient scores coupled
with schools test scores at the end of the Primary 1 to observe the cognitive
progress from Nursery to Primary 1 between the 2 groups of participants.
The Peabody Picture Vocabulary Test (PPVT-4) score would be used to assess the
participants speech and language proficiency as it has been widely used from
the ages of 2 to 40 years old. The test "measures an individual's receptive
(hearing) vocabulary for Standard American English and provides, at the same
time, a quick estimate of verbal ability or scholastic aptitude" (Dunn and Dunn,
1981). The test will be modified to Standard British English to fit the language
medium used to teach the participants. The test comprises five training items
that are administered at the beginning of the PPVT assessment in order to
familiarize children with the task. The first item, or starting point, is determined

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Group
Assignment - Research Proposal
based on the participants PPVT age. Starting at an age-specific level of difficulty,
it is intended to reduce the number of items that are too easy or too difficult, in
order to minimize boredom or frustration.
Table 2 displays the expected demographics of our sample and subsamples. As
seen from the table, the sample size decreased from 990 to 890 at the end of the
study due to various factors; the socioeconomic status where the dropout rate of
the sample below the poverty line could be higher due to movement from their
place of residence and/or school. The movement at Primary 1 could be due to
participants moving to another school further away and their inability to join the
study. Other reasons could be the absence of the participants for a prolonged
period due to illness or other unforeseen factors.

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)

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Assignment - Research Proposal
Participants
Rank
-1st
-2nd
-3rd
-4th

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

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Assignment - Research Proposal
outcome of the study.

Group

TABLE 3
Summary of Variables and Outcomes
Control

Dependent

Independent

Outcomes

Socioeconomic

- Physical (height

- Children on

- Children on

status

and weight for

breastmilk

breast milk are

- Poverty Class
- Lower Middle

age)
- Social &

- Children on
formula milk

less likely to be
overweight

Emotional

- Children on

(conduct grades

breast milk are

- Upper Middle

and teachers

better behaved

Class

feedback)

- High Class

- Cognitive

breast milk have

(Stanford-Binet

better cognitive

Intelligence Test

functions

Class

scores)

- Children on

- Children on

- Speech &

breast milk have

Language

better speech

(Peabody Picture

and language

Vocabulary Test

skills

scores)

10

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Assignment - Research Proposal
Procedures

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,

11

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Group
Assignment - Research Proposal
teachers are also given a feedback form, providing them with a platform to
elaborate on their students behaviour and conduct. Teachers have 10 weeks in
total to complete the behavioural and conduct evaluation process and the
feedback forms will be collected at the end of Week 10.
In the next phase, the Stanford-Binet and Peabody Picture Vocabulary tests will
be administered to the children on different days over a period of 5 weeks. Each
session will last a maximum of 30 minutes to prevent the children from getting
too tired, affecting the accuracy of the tests. A researcher will sit in with each
child to oversee the process, maintain integrity and provide any necessary
assistance. Test scores will then be updated into central data bank.
In week 9 of Term 4 before the end of year school holiday, authors will gather the
conduct grades from the progress reports. The childs conduct is graded
differently between different centres. Authors will take about 2 days to quantify
the different grades on a categories scale; Excellent, Very good, Good, Fair and
Poor, for each child.
This process will be repeated for the cohort for the following 3 years, up until
they complete their Primary 1 education. Similar to the start of the study,
Principals of the childrens new school will be informed of the study and teachers
will also be briefed. In this final year of study, students will undergo school-based
assessments, either formative or otherwise. Their results (raw scores) will be
collated and appended to data from the previous three years.
We will then spend about 3 months to organize and analyze data before
discussing the outcomes & implications and presenting the findings in a
published paper.

12

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Assignment - Research Proposal
Data Analysis/ Results

Group

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.

Data will be recorded

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

13

MED871 Educational Inquiry 1 (TG 3)

June 2016 Inter-Semester
Group
Assignment - Research Proposal
analysis of variance (MANOVA) analysis to examine the impact of nutrition
between the two main groups ; exclusively breast milk fed versus formula fed on
their holistic developmental progress in Nursery, Kindergarten 1, Kindergarten 2
and Primary 1 stages. The data gathered and findings will be used as a
benchmark to support our earlier hypotheses that i) children who are given
breast milk during their early formative years are more likely to develop better
holistically than children who are given formula milk and ii) socioeconomic status
is a likely factor that has influence on the type of nutrition given to a child during
the early formative years.

References
(To arrange by author alphabetically AND strictly follow APA referencing
format)
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Overview of Importance of Breastfeeding. Journal of Comprehensive Pediatrics,
5(2). DOI: 10.17795/compreped-14028
Amir, L. H.(2011). Social Theory And Infant Feeding. International
Breastfeeding Journal. doi :10.1186/1746-4358-6-7.
Anderson, J.W., Johnstone, B. M., Remley D.T. (1999). Breast-feeding and
cognitive development: A meta-analysis. The American Journal of Clinical
Nutrition. 1999;70:525-35
Ashley, M.(2012, June).Dairy reporter.com:Infant formula brain development
benefits within range of breast milk-report. Retrieved from
http://dairyreporter.com/content/view/print/642490
Chua L., Mya Win A. (2013). Prevalence of Breastfeeding in Singapore.
Statistics Singapore Newsletter, 12. Retrieved from
https://www.singstat.gov.sg/docs/default-source/default-document-

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June 2016 Inter-Semester
Assignment - Research Proposal

Group

library/publications/publications_and_papers/health/ssnsep13-pg10-14.pdf
Dee, D. L., Li, R., Lee, L. C., Grummer-Strawn, L. M. (2007). Associations
between breastfeeding practices and young childrens language and motor skill
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Drane, D. L., Logemann, J. A. (2000). A critical evaluation of the evidence on
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Fergusson, D. M., (1987). Breast feeding and Subsequent Social Adjustment in
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Horwood, L. J., & Fergusson, D.M. (1998). Breastfeeding And Later Cognitive
And Academic Outcomes. PEDIATRICS 101.1 (1998): e9-e9. Web.
Horwood, L. J., Darlow, B. A., & Mogridge, N. (2001). Breastmilk feeding and
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Jiang, M., Foster, E. M., Gibson-Davis, C. M. (2010). Breastfeeding and the Child
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Oddy W. H., Kendall G.E., Li J., Jacoby P., Robinson M., de Klerk N.H. (2010) The
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development. Early Human Development, 31(3), 181193.

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June 2016 Inter-Semester
Assignment - Research Proposal

Group

Sacker, A., Quigley, M. A., Kelly, Y. .J. (2006). Breastfeeding and developmental
delay: Findings from the millennium cohort study. Pediatrics; 118: e6829.
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D. P., & Barros. F. C. (2015). Association between breastfeeding and
intelligence, educational attainment, and income at 30 years of age: a
prospective birth cohort study from Brazil. The Lancet Global Health. 3(4). DOI:
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Woodword, L. J. & Kathleen A. L. (2008). Breastfeeding And Child Psychosocial
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not duration of breast-feeding, predicts intelligence quotient of children at four
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