Ishikawa et al. BMC Pediatrics (2018) 18:325
https://doi.org/10.1186/s12887-018-1292-7

RESEARCH ARTICLE

Open AccessMulti-professional meetings on healthchecks and communication in providing
nutritional guidance for infants andtoddlers in Japan: a cross-sectional,
national survey-based study
Midori Ishikawa1* , Kumi Eto2, Mayu Haraikawa3, Kemal Sasaki5, Zentaro Yamagata6, Tetsuji Yokoyama1,
Noriko Kato1,7, Yumiko Morinaga8 and Yoshihisa Yamazaki4

Abstract
Background: Health personnel must provide continuous support in response to problematic results from healthchecks of infants and toddlers (hereinafter “infant[s]”). Among this support, it is important for health personnel toprovide nutritional guidance to families as a collaborative effort between the staff from multiple disciplines andcommunity organizations. This study aimed to clarify the factors affecting collaboration with community
organizations in providing nutritional guidance to families following health checks for infants in Japan.
Methods: The design of this study consisted of a cross-sectional, multilevel survey. A self-administeredquestionnaire was mailed to all municipalities (1741 towns and cities) in Japan to be completed by the person
responsible for nutrition advice. The research was performed in August 2015. We obtained 988 valid responses(response rate of 56.7%).
To identify the factors that affect the collaboration with community organizations in providing nutritional guidance,
we determined how municipalities responded to infants needing support (five items), how municipalities evaluatedhealth guidance (five items), the number of distributed maternal and child health handbooks, and the number of
infants who received follow-up evaluations.
Results: The results of multivariate analyses showed that the factors related to successful community collaborationin providing nutritional guidance included holding a multi-professional staff meeting after health checks(post-conference; odds ratio [OR], 2.34; P = 0.001); following up children suspected of having developmental
and mental disabilities or delays before entering elementary school (OR, 1.77; P = 0.0004); and considering dental
caries data from dental checkups in providing health guidance (OR, 1.56; P = 0.003).
Conclusions: Holding a multi-professional meeting after infant health checks (post-conference) was strongly
associated with community collaboration in providing nutritional guidance for infants.
Keywords: Infant health checks, Nutritional guidance, Community collaboration, Multi-professional meeting, Japan* Correspondence: ishikawa.m.aa@niph.go.jp
1
Department of Health Promotion, National Institute of Public Health, 2-3-6
Minami, Wako, Saitama 351-0197, Japan
Full list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Ishikawa et al. BMC Pediatrics (2018) 18:325

Background
In Japan’s maternal and child health (MCH) policy,
Healthy Parents and Children 21 (Second Phase), thecollaboration between the municipality and stakeholders
in the community (e.g., kindergartens, preschools, childwelfare facilities) is required to provide ongoing support
for children and parents in need of health and nutritional care guidance [1]. By using a multi-professional
approach—in which experts collaborate to meet theneeds of the infant and parent—the appropriate qualityof healthcare support can be provided [2, 3]. For
example, there are cases of parents being unwilling to
acknowledge concerns about the delayed developmentof their child based on the results of health checks.
Parents may refuse to accept the guidance provided bypublic health nurses about their child’s development.
Other issues involve children having an unbalanced diet.
In such cases, dietitians are expected to provide nutritional guidance while considering the needs of the children and parents [2, 4]. Community collaboration may
be required to properly respond to infants and parents
needing support, health evaluation, and nutritional guidance. It is therefore important to provide nutritional
guidance based on the results of infant health checks
and as a collaborative effort between multi-professional
staff and community organizations.
One study evaluating infant health status in the UnitedStates showed that positive weight change is related toan effective network of community collaborations [5].
Access to quality childcare services using community resources on the results of infant health status assessments
is also important in improving parental behavior andreducing the need for emergency medical care for
infants [6, 7]. However, no studies in Japan have investigated this topic.
In Japan, infant health checks are required by theMaternal and Child Health Law [8]. The main purposeof infant health checks and health guidance is to clarify
explicit and potential health concerns and to support
parents and children in dealing with these concerns[8, 9]. In 2015, the participation rate for health checks
was 95.6% for infants aged 3–4 months, 95.7% for those
aged 1.6 years, and 94.3% for those aged 3 years [10].
Before or after health checks in Japan, a multi-professional meeting is convened by health staff to identify
health concerns (a “pre−/post-conference”). Although
this form of conference is not a mandate of the designated country, this form has been adopted for information sharing among staff to connect health checks andhealth guidance for children in municipalities. At the
pre-conference, the staff discuss pre-established concerns
about each child. At the post-conference, the children
who require follow-up evaluations are confirmed. In somecases, continuous support (follow-up) [11, 12], as well as

Page 2 of 9

the provision of nutritional guidance in conjunction
with community collaborations, may be required. Insuch cases, it is important to share information about
infant health checks with community organizations.
This sharing allows deciding the best approaches tosupport children and parents, evaluate responses totheir needs, and assess the outcomes of those activities [5]. However, few studies have investigated factors that affect the ability of health personnel andcommunity organizations to collaborate on providing
nutritional guidance to families [13]; moreover, no
studies have addressed this topic in Japan.
This survey aimed to clarify the proportion of municipalities in Japan cooperating with communities in providing nutritional guidance to families whose infantsreceived health checks, and to identify the factors related
to collaboration with community organizations inproviding nutritional guidance.

Methods
Study municipalities and procedure

This study was a cross-sectional survey of all 1741
municipalities in Japan. We used a self-administeredquestionnaire to determine whether infant health checks
were being carried out and whether health andnutritional guidance was being provided. A copy of thequestionnaire was mailed to each municipality. The department responsible for nutritional guidance following
infant health checks was asked to complete the questionnaire. The director of the department then returned
the questionnaire by mail or fax.
This research was performed in August 2015. In total,
1172 municipalities completed the questionnaire(response rate of 67.3%). Only questionnaires withcomplete responses to the items included in our analysis
were considered valid, providing 988 valid questionnaires for analysis (response rate of 56.7%).
Measurement

The questionnaire items included indicators of existing
policy measures and guidelines [1, 2, 14, 15] of the Ministry of Health, Labour and Welfare; these guidelines
were used in a national nutrition survey of preschool
children [16]. The reliability of the items was previously
confirmed [17–19].
The dependent variable was whether community
collaboration is involved in providing guidance on infant nutrition. The survey respondents were asked:“Does your municipality provide nutritional guidanceor education targeting infants and parents in collaboration with any organizations or groups, such as
nursery schools, kindergartens, welfare facilities, or
related agencies in the community, and do you evaluate those activities?” [18]. Health personnel wereIshikawa et al. BMC Pediatrics (2018) 18:325

asked to choose an answer from the following categories: 1) We collaborate with community organizations and evaluate the activities; 2) We collaborate
with community organizations but do not evaluate
the activities; and 3) We do not collaborate with anyorganization. We designated municipalities that answered either 1 or 2 as the collaborating group andthose that answered three as the non-collaboratinggroup.
We expected certain factors to be associated withsuch collaboration, including methods for carryingout infant health checks, methods for determining
how to respond to infants and parents needing support (five items), and methods for evaluating healthguidance (five items). We also asked about potential
confounding factors related to infant health checks.
They included the annual number of distributed
Mother and Child Health (MCH) handbooks, the annual number of infants who received a follow-up andmunicipality category by number of children eligiblefor health checks at 3 years old.
These items were chosen because they are important indicators of the health and nutrition of infants inJapan, and there are clear differences between municipalities. A copy of the MCH Handbook is provided
for all pregnant women and provides a consistent
health and information-provision record during pregnancy, delivery, and early years of child rearing. At
every infant health check, information related tohealth and nutritional status are entered in the handbook, to determine suitable follow-up.
A previous study using the same data reported thevalidity of the municipality categories for the geographical area, the population size, and the numberof children eligible for health checks at 3 years old[19]. However, the report did not show the relationship between the municipality category and community collaboration on nutritional guidance for infants.
We therefore included whether category was related
to the collaboration items, as a possible confounding
factor.
The Appendix shows the five items addressing “howstaff responded to infants and parents needing support”
and “the evaluation of health guidance.” The possible
answers were yes or no.
Statistical analysis

To determine the response to infants and parents
needing support (five items) and methods used toevaluate health guidance (five items), we performed
an analysis comparing the answers of the collaborating and non-collaborating municipalities to the survey
items about the methods used. We analyzed the results using the Cochran–Mantel–Haenszel test. Using

Page 3 of 9

correspondence analysis, we analyzed the relationships
between the 11 items (one item on collaborating with
community organizations; five items on determining
responses to infants and parents; and five items on
evaluating health guidance).
We performed univariate analysis for each factor using
a logistic regression model based on the results of thecorrespondence analysis. The analyzed factors were
those that were expected to be associated with collaboration in nutritional guidance: implementing a
pre-conference; sharing medical records; sharing
verbal information with responsible staff; implementing a post-conference; providing feedback to publichealth nurses and related organizations; evaluating
health guidance for parents; using dental caries datain health guidance; evaluating health guidance andfollow-up; and providing follow-up evaluations for
infants before or after beginning elementary school.
To identify factors important for community collaboration, we performed stepwise logistic regression
using
the
following
variables:
holdingpre-conferences; sharing medical records; sharing verbal information with staff; holding post-conferences;providing feedback to public health nurses and related organizations; evaluating health guidance forparents; using dental caries information in healthguidance; evaluating health guidance and follow-up;
and providing follow-up evaluations for children who
have entered or not entered elementary school. These
data were adjusted for the annual number of distributed MCH handbooks, the annual number of infants
who received follow-up evaluations, and the annual
number of 3-year-olds who underwent health checks(model 1).
Statistical analysis was conducted using SAS
software, version 9.2 (SAS Institute, Inc., Cary, NC,
USA). A P value of < 0.05 was considered statisticallysignificant.

Results
Table 1 shows the comparison between community
collaboration to provide nutritional guidance with
distribution of MCH Handbook, number of infants
who received follow-up, and municipality category by
number of children eligible for health checks at
3 years old. The proportion of municipalities that collaborated with community organizations in providing
nutritional guidance based on infant health checks(collaborating group) was 69.5%. The proportion that
did not collaborate with any community organizations(non-collaborating group) was 30.5%. There were no
significant differences between the two groups for theannual number of MCH handbooks distributed, theannual number of infants who received follow-up andIshikawa et al. BMC Pediatrics (2018) 18:325

Page 4 of 9

Table 1 Comparison between community collaboration in providing nutritional guidance with distribution of MCH Handbook,number of infants who received follow-up, and municipality category by number of children eligible for health checks at 3 years oldn = 988

Number of distributions of MCH Handbook/year

Collaborating group

Non-collaborating group

no

%

no

%

687

69.5

301

30.5

mean

SD

mean

SD

693.7

1703.9698.41197.5

0.240
0.899

Number of infants who received follow-up/year

58.3

140.7

70.0

164.5

Municipality category by scale of number of subjects to healthchecks for 3-year-old children

no

%

no

%

I<8

I

11

1.6

10

3.3

8 ≤ II < 54

II

119

17.3

43

14.3

54 ≤ III < 391

III

301

43.8

123

40.9

39 ≤ IV < 2916

IV

218

31.7

106

35.2

2916 ≤ V

V

38

5.5

19

6.3

p

0.239

p for homogeneity between 2 groups by Cochran-Mantel-Haenszel

the municipality category by number of children
eligible for health checks at 3 years old.
Table 2 shows the relationship between community
collaboration to provide nutritional guidance for infants and parents, decisions on how staff responded
to infants and parents needing support (five items),
and methods used to evaluate health guidance (fiveitems).
Collaborating municipalities were more likely to implement a pre-conference (P = 0.014) and a post-conference(P < 0.001) and to provide feedback to public healthnurses (P = 0.023). The collaborating group also consisted of more municipalities that evaluated healthguidance for parents (P = 0.002), used dental caries
information in health guidance (P = 0.001), followed
up children prior to elementary school (P = 0.001),
and evaluated the relevance of health guidance andfollow-ups (P = 0.005).
Figure 1 maps the results of the correspondence
analysis for the relationships between community
collaboration in providing nutritional guidance, decisions on the response to infants and parents needing
support, and evaluation of health guidance. Items on
the evaluation of health guidance were closer tocommunity collaboration in provision of nutritional
guidance than items on determining the response toinfants and parents. A post-conference was closely
associated with community collaboration in providing
nutritional guidance in items addressing decisions on
the response to infants and parents needing support.
The positions of the pre-conference and post-conference were far apart, which indicates that these conferences might have different roles.

Using logistic analysis

Table 3 shows the factors in the health check activities thatwere related to successful community collaboration in
nutritional guidance. Following normalization (Model 1),
these factors included the following: having a
pre-conference (odds ratio [OR] = 1.45; 95% confidence
interval [CI]: 1.08–1.94; P = 0.014), having a post-conference (OR = 2.82; 95% CI: 1.72–4.61; P < 0.001), providing
feedback to public health nurses and related stakeholders(OR = 1.54; 95% CI: 1.11–2.15; P = 0.010), evaluating
health guidance for parents needing support (OR = 1.70;
95% CI: 1.22–2.37; P = 0.002), using data about dental caries in health guidance (OR = 1.82; 95% CI: 1.37–2.42; P <0.001), following up children before they began elementary school (OR = 2.01; 95% CI: 1.48–2.73; P < 0.001), andevaluating the relevance of health guidance (OR = 1.58;
95% CI: 1.14–2.18; P = 0.005).
In the multivariate analysis, the factors related tosuccessful community collaboration in nutritional guidance included the following: having post-conferences(OR = 2.34; 95% CI: 1.39–3.94; P = 0.001), following up
children before they entered elementary school (OR =1.77; 95% CI: 1.29–2.43; P = 0.0004), and using data on
dental caries in health guidance (OR = 1.56; 95% CI:
1.16–2.10; P = 0.003).

Discussion
Factors related to community collaboration in nutritional
guidance

In this study, community collaboration in providing nutritional guidance was strongly related to the implementationof a multi-professional meetings after health checks (post-conferences). This finding is consistent with previous

Ishikawa et al. BMC Pediatrics (2018) 18:325

Page 5 of 9

Table 2 Relationship between community collaboration in nutritional guidance for infants and parents, decisions on how staff
responded to infants and parents needing support, and methods used to evaluate health guidancen = 988
Collaborating group

Non-collaborating group

no

%

no

%

687

69.5

301

30.5

p
0.014

How staff responded to infants and parents needing support (5 items)
Implement a pre-conference

Share medical records

Share verbal information with responsible staff

Implement a post-conference

Provide feedback to public health nurses and related organizations

Yes

510

74.2

200

66.5

No

177

25.8

101

33.6

Yes

458

66.7

203

67.4

No

229

33.3

98

32.6

Yes

426

62.0

181

60.1

No

261

38.0

120

39.9

Yes

654

95.2

264

87.7

No

33

4.8

37

12.3

Yes

547

79.6

220

73.1

No

140

20.4

81

26.9

Yes

195

28.4

57

18.9

No

492

71.6

244

81.1

Yes

316

46.0

97

32.2

No

371

54.0

204

67.8

Yes

272

69.6

74

24.6

0.812

0.577

<.0001

0.023

Methods used to evaluate health guidance (5 items)
Evaluate health guidance for parents

Use dental caries data in health guidance

Provide follow-up evaluations for infants before beginning elementary school

No

415

60.4

227

75.4

Provide follow-up evaluations for infants after beginning elementary school

Yes

11

1.6

4

1.3

No

676

98.4

297

98.7

Evaluate health guidance and follow-up

Yes

206

30.0

64

21.3

No

481

70.0

237

78.7

0.002

<.0001<.0001

0.747

0.005

p for homogeneity between 2 groups by Cochran-Mantel-Haenszel

reports in which sharing information among staff enabled
professionals to both create a shared vision, strong leadership, and broad collective goals and to clarify strengths
and priorities for developing and launching projects [20].
The importance of selecting the most appropriate approach to create a collaboration has been reinforced byhealth data and reliable information showing the results ofenvironmental and behavioral change [21]. If staff areunable to share child health information, then it will be
unclear whether a particular response or approach isappropriate [22]. It is necessary to confirm why somemunicipalities do not conduct post-conferences. Post-conferences may help to establish a better system for healthchecks and nutritional improvement for infants.

Multidisciplinary collaboration for nutritional support inthe community

In Japan, health checks are used to make an accurate
assessment of the needs of infants and their parents.

Parents may continue to experience difficulties and require support throughout their child’s early years [2, 16].
It is therefore important to establish a system thatenables continuous support of infants and parents in thecommunity [2, 21, 23].
According to Japan’s national infant nutritional
survey, an unbalanced diet (including snacks and softdrinks) leads to dietary issues in children. The proportion of children with such diets is significantly
higher in low-income households [16]. Other studies
have reported a relationship between the consumptionof sugary drinks and poor eating behavior among infants and children [24–26].
One of the main objectives of community collaboration is to monitor the progress of infants andparents who require particular support in certain
areas, including nutrition [21]. A multi-sectorial
approach is required to address various dimensionsof maternal and child healthcare, including environmental health [27].

Ishikawa et al. BMC Pediatrics (2018) 18:325

Page 6 of 9

Fig. 1 Relationships between “community collaboration for nutritional guidance”, and items on “how staff responded to infants and parents
needing support” and “methods used to evaluate health guidance”, from the correspondence analysis. Key: ◆: How staff responded to infants andparents needing support (5 items); ●: Methods used to evaluate health guidance (5 items)

Health professionals such as dietitians can then be
involved in deciding whether further assistance is necessary or whether the issues have been resolved withthe support provided [2, 5]. It is important that staff
from multiple health disciplines and community
groups are involved in discussions about infants andparents at post-conferences, as this involvement
enables a consensus on the need for monitoring,
continued support, or follow-up evaluations withhome visits [6, 23].
This study found that the factors strongly related
to community collaboration in providing nutritional
guidance included sharing information about infantdental checkups and the results of follow-up
activities before children entered elementary school.
Sharing this information will lead to ongoing support
throughout the child’s education [10]. The life course
perspective is a critical addition to this work: it highlights the importance of ensuring that infants andchildren live in supportive community environmentsthat will foster optimal health, development, andwell-being throughout their lives [3, 7].
It is important to develop long-term support systems for
infants and parents by sharing information, especially aboutfood and nutrition, between community organizations suchas nursery schools, pediatric clinics, kindergartens,
child welfare facilities, associations for the promotionof better dietary habits, community cafeterias for children, and other governmental and non-governmentalorganizations [10].
This study had some limitations. First, its cross-sectional design suggests that no causal relationships canbe inferred, such that reverse causation or simple correlation could account for the observations. Second,
the final response rate of 56.7% was relatively low.
The questionnaire was not administered to individuals, and it covered a broad range of disciplines;
moreover, staff operating in different fields may have
responded differently to certain items. Local government staff may also have the lacked time to complete
the questionnaire during working hours and, inparticular, to obtain a consensus from other staff
members. Characteristics of municipalities that did
not respond (around one third in total) were almost
the same as those that did, including population size
(small, medium and large population). One of thereasons why some municipalities did not respond may
have been because that they have no full-time staff incharge of nutrition. During the study period, several
municipalities responded to explain that they onlyIshikawa et al. BMC Pediatrics (2018) 18:325

Page 7 of 9

Table 3 Factors in health check activities that are related to successful community collaboration in nutritional guidance, assessed bylogistic analysis
n = 988

Model 1aitem

OR

95% CI
1.08

Stepwisep

OR

95% CI

p

1.22

0.89

1.66

0.212

1.39

3.94

0.001

1.16

2.10

0.003

1.29

2.43

0.000

How staff responded to infants and parents needing support (5 items)
Implement a pre-conference

Share medical records

Share verbal information with responsible staff

Implement a post-conference

Provide feedback to public health nurses and related organizations

Yes

1.45

No

1.00

Yes

1.01

No

1.00

Yes

1.13

No

1.00

Yes

2.82

No

1.00

Yes

1.54

No

1.00

Yes

1.70

No

1.00

Yes

1.82

No

1.00

Yes

2.01

No

1.00

Yes

1.19

No

1.00

Yes

1.58

No

1.00

1.94

0.014

1.00
0.74

1.38

0.949

0.85

1.52

0.405

1.72

4.61

<.0001

2.34
1.00

1.11

2.15

0.010

1.22

2.37

0.002

1.37

2.42

<.0001

1.48

2.73<.0001

0.37

3.76

0.772

1.14

2.18

0.005

Methods used to evaluate health guidance (5 items)
Evaluate health guidance for parents

Use dental caries data in health guidance

Provide follow-up evaluations for infants before beginning elementary school

Provide follow-up evaluations for infants after beginning elementary school

Evaluate health guidance and follow-up

1.56
1.00
1.77
1.00

a

Model 1: Adjusted for category of subject in 3-year-old infant health examinations, number of Mother Child Handbooks distributed per year, and number of
infants followed up per year
OR Odds ratio, CI Confidence interval

had part-time staff responsible for nutritional guidance, so could not cooperate. In future surveys, it will
be necessary to consider the investigation method toensure that municipalities are not excluded becauseof the employment situation of staff in charge ofproviding nutritional guidance. Responses to thesurvey may also have been limited to municipalities
that actively conduct health checks. A follow-up study
using face-to-face interviews with health workers
should be considered. Fourth, our analysis was restricted to items that could apply to all municipalities.
Future investigations should examine whether the
response options are unique to Japan. Municipal
income was not included as a confounding factor inthis survey, but should be included in a future study.
Despite these limitations, this study found relationships between community collaboration in providing
nutritional guidance and the implementation of
post-conferences, the follow-up evaluation of children

suspected of having developmental and mental difficulties before they enter elementary school, and theuse of dental checkup results in health guidance forparents and their children. The results of this study
are significant because very few studies to date haveexamined the links between nutritional guidance andinfant health checks.

Conclusions
This study found that sharing information in a
multi-professional meeting following infant healthchecks (a post-conference) was strongly associatedwith successful community collaboration in providing
nutritional guidance. It highlights the importance ofensuring that infants and children live in supportive
community environments that will foster optimal
health, development, and well-being throughout theirlives.

Ishikawa et al. BMC Pediatrics (2018) 18:325

Appendix
Table 4 Items of questionaiire on factors to be associated with
community collaboration in nutritional guidance for infants andparents

Page 8 of 9Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.

How staff responded to infants and parents needing support (5 items)
Do you share information with staff from different disciplines atmeetings before health checks (pre-conference)?

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Do you share medical record information?
Do you verbally share information with responsible public health staff?
Do you share information with staff from different disciplines atmeetings after health checks (post-conference)?
Do you provide feedback on infant health information to the publichealth nurse responsible for the area of residence and related
stakeholders?
Methods used to evaluate health guidance (5 items)
Do you evaluate the relevance of health guidance for parents whoare having difficulties raising their child?
Do you use data about dental caries from dental health checks inhealth guidance?

Author details
1
Department of Health Promotion, National Institute of Public Health, 2-3-6
Minami, Wako, Saitama 351-0197, Japan. 2Faculty of Nutrition, Kagawa
Nutrition University, 3-9-21 Chiyoda, Sakado, Saitama 350-0288, Japan.
3
Department of Child Studies, Faculty of Child Studies, Seitoku University,
550 Iwase, Matsudo, Chiba 271-8555, Japan. 4Child Health Center, Aichi
Children’s Health and Medical Center, 426-7, Morioka, Obu, Aichi 474-8710,
Japan. 5Department of Food and Health Sciences, Jissen Women’s University,
4-1-1 Osakaue, Hino, Tokyo 191-8510, Japan. 6Faculty of Medicine, University
of Yamanashi, 1110 Shimokato, Chuo, Yamanashi 409-3898, Japan. 7Present
Address: Department of Early Childhood Care and Education, Jumonji
University, 2-1-28 Sugasawa, Niizashi, Saitama 352-8510, Japan. 8Faculty of
Medicine, School of Nursing Public Health Nursing, Kagawa University,
1750-1, Ikenobe, Miki, Kita, Kagawa 761-0793, Japan.

Do you follow up children who are suspected of having
developmental or mental disabilities or delays before entering
elementary school?

Received: 20 September 2017 Accepted: 27 September 2018

Do you follow up children suspected of having developmental ormental disabilities or delays after entering elementary school?

References
1. Ministry of Health, Labour and Welfare (MHLW): Healthy Parents and.
Children 21(second), 2015(in Japanese) http://www.mhlw.go.jp/file/06Seisakujouhou-11900000-Koyoukintoujidoukateikyoku/0000067539.
pdf#search=%27%E5%81%A5%E3%82%84%E3%81%8B%E8%A6%AA%
E5%AD%9021%E7%AC%AC%E4%BA%8C%E6%AC%A1%27.
Accessed 5 Sep 2017.
2. Study group on health checkup and health guidance for maternal and childhealth through multi-occupational cooperation (SGHC): Standard healthcheckup and health guidance in infant and early childhood. 2015
(in Japanese) http://www.mhlw.go.jp/file/06-Seisakujouhou-11900000Koyoukintoujidoukateikyoku/tebiki.pdf. Accessed 5 Sep 2017.
3. Shrimali P, Luginbuhl J, Malin C, Flournoy R, Siegel A. The building blocks
collaborative: advancing a life course approach to health equity throughmulti-sector collaboration. Maternal Child Health J. 2014;18:373–9.
4. Mustila T, Keskinen P, Luoto R. Behavioral counseling prevent childhood
obesity-study protocol of a pragmatic trial in maternity and child healthcare. BMC Pediatr. 2012;12(93) https://doi.org/10.1186/1471-2431-12-93.
5. Darnell AJ, Barile JP, Weaver SR, Harper CR, Kupermine GP, Emshoff JG.
Testing effects of community collaboration on rates of low infantbirthweight at county level. Am J Community Psychol. 2013;51:398–406.
https://doi.org/10.1007/s10464-012-9559-x.
6. Dodge KA, Goodman WB, Murphy RA, O’Donnell K, Sato J, Guptill S.
Implementation and randomized controlled trial evaluation of universal
postnatal nurse home visiting. Am J Public Health. 2014;104:S143
https://doi.org/10.2105/AJPH.2013.301361.
7. Komro KA, Tobler AL, Delisile AL, O’Mara RJ, Wagenaar AC. Beyond theclinic; improving cild health through evidemce^based community
development. BMC Pediatr. 2013;13(72) https://doi.org/10.1186/1471-243113-172.
8. Ministry of Health, Labour and Welfare (MHLW). Maternal and Child Health
Act (in Japanese) http://law.e-gov.go.jp/htmldata/S40/S40HO141.html
Accessed 5 Aug 2017.
9. Kuo DZ, Houtrow AJ, Arango P, Kuhthau KA, Simmons JM, Neff JM. Familycentered care: current applications and future directions in pediatric healthcare. Matern Child Health J. 2014(12):297–305 https://doi.org/10.1007/
s10995-011-0751-7.
10. Ministry of Health, Labour and Welfare (MHLW). Report on Regional Public
Health Services and Health Promotion Services 2015 (in Japanese)
http://www.mhlw.go.jp/toukei/saikin/hw/c-hoken/15/dl/kekka1.pdf.
Accessed 5 Sep 2017.
11. Nakamura Y. Maternal and child health handbook in Japan. Int Med Comm.
2010;53:259–65.

Do you evaluate the relevance of health guidance and follow-ups,
including for children who are not unhealthy but where there is somecause for concern?

Abbreviations
CI: Confidence interval; MCH: maternal and child health; MHLW: Ministry of
Health, Labour and Welfare; OR: Odds ratio; SD: Standard deviation
Acknowledgements
This study was supported by the Japan Agency for Medical Research andDevelopment Grants and Health and Labour Sciences Research Grants,
Japan. We also thank the municipalities who participated in this study.
Funding
This study was supported by the Japan Agency for Medical Research andDevelopment Grants (H27–28 16gk0110010j1002) and Health and Labour
Sciences Research Grants (H29Sukoyaka-Ippan 003). This research did notreceive any specific grant from funding agencies in the commercial, or
not-for-profit sectors.
Availability of data and materials
The dataset analyzed during the current study available from thecorresponding author on reasonable request and with permission of YY.
Authors’ contributions
MI designed the study, collected and analyzed the data and drafted themanuscript; KE, MH, KS, ZY, KN, YM and YY conceived and designed thestudy, collected the data and helped draft the manuscript; and TY helped
analyze the data and draft the manuscript. All authors have read andapproved the final version of the manuscript and agree with the order ofpresentation of the authors.
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the Faculty of Medicine
at the Aichi Children’s Health and Medical Center, Obu, Aichi, Japan(#201518, July 31, 2015). We sent the request document to the survey to allmunicipalities. Responses to questionnaires from municipalities wereregarded as a consent.

Ishikawa et al. BMC Pediatrics (2018) 18:325

12. Takeuchi J, Sakagami Y, Perez R. The mother and child health handbook in
Japan as a health promotion tool. Global Pediatric Health. 2016;
https://doi.org/10.1177/2333794X16649884.
13. Martin KS, Wolff M, Lonczak M, Chambers M, Cooke C, Whitney G. Formative
research to examine collaboration between special supplemental nutrition
program for women, infants, and children and head start programs. Matern
Child Health J. 2014;18:326–32.
14. Ministry of Health, Labour and Welfare (MHLW). Report on the Study Groupon the ideal way to foster children's health through food and nutrition
2004; 13 (in Japanese) http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/
0000134208.html Accessed 5 Sep 2017.
15. Ministry of Health, Labour and Welfare (MHLW). Maternal and Child Health
Handbook, Japan (in Japanese) http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kodomo/kodomo_kosodate/boshi-hoken/kenkou-04.html Accessed 5
Sep 2017.
16. Ministry of Health, Labour and Welfare (MHLW). Report on National
nutrition survey on preschool children.2016 (in Japanese) http://www.mhlw.
go.jp/stf/seisakunitsuite/bunya/0000134208.html. Accessed 5 Sep 2017.
17. Takahashi N, Haraikawa M, Niimi S, Eto K, Ishikawa M, Kato N, et al.
Characteristics of concerns about maternal and childhood nutrition which
was described by nutrition educating staff in municipal maternal and childhealth activities-an analysis of open-ended question on pregnant women,
infants, and children. Japanese J Public Health. 2016;63:569–77.
18. Eto K, Ishikawa M, Takahashi N, Haraikawa M, Niimi S, Sasaki K, et al.
Implementation status and contents of nutritional guidance for infants andyoung children in municipalities in Japan. J Health Welf Stat. 2017;64:27–34(in Japanese).
19. Sasaki K, Niimi S, Yamagata Z, Sato T, Akiyama C, Ogura K, et al. A
nationwide survey on the subject age of 3-year old child health checkup.
J Health Welf Stat. 2016;63:8–13 (in Japanese).
20. Aquino R, Oliveira NF, Barreto ML. Impact of the family health program on
infant mortality in Brazilian municipalities. Am J Public Health. 2009;99:87–93
https://doi.org/10.2105/AJPH.2007.127480.
21. Bosch SO, Duch H. The role of cognitive stimulation at home in low-incomepreschoolers’ nutrition. Physical activity and body mass index. BMC Pediatr.
2017;17(178) https://doi.org/10.1186/s12887-017-0918-5.
22. Olson BH, Horodynski M, Herb HB, Iwanski KC. Health professionals’
perspectives on the infant feeding practices of low income mothers.
Maternal Child Health Journal. 2010;14:75–85.
23. Martin MA, Rothschild SK, Lynch E, Christoffel K, Pagan MM, Rodriguez JL, et
al. Addressing asthma and obesity in children with community healthworkers: proof-of-concept intervention development. BMC Pediatr.
2016;16(198) https://doi.org/10.1186/s12887-016-0745-0.
24. Sogabe R, Maruyama R, Nakamura F, Tsuchiya R, Inoue M, Goseki M:
Development of oral function and eating habits of infants living in a cityarea of Japan; In relation to results of dental health examinations of infants
aged 14 months at public health centers. Japanese Journal of Public Health.
2010, 57: 641–648. doi: https://doi.org/10.11236/jph.57.8_641
25. Okubo H, Miyake Y, Sasaki S, Tanaka K, Hirota Y. Early sugar-sweetened
beverage consumption frequency is associated with poor quality of later
food and nutrient intake patterns among Japanese young children: theOsaka Maternal and Child Health Study. Nutr Res. 2016;36:594–602
https://doi.org/10.1016/j.nutres.2016.01.008.
26. Ueno Y. Saeki K, Yoshimura S: the relationship between tooth eruption andingestion of 15 food items among children aged 18-20 months. Japanese
J Public Health. 2017;64:143–9 https://doi.org/10.11236/jph.64.3_143.
27. Horii N, Habi O, Dangana A, Maina A, Aizouma S, Charbit Y. Communitybased behavior change promoting child health care: a response to socioeconomic disparity. J Health, Promot Nutri. 2016;35:12 https://doi.org/10.
1186/s41043-016-0048-y.

Page 9 of 9