Institute of Medicine Early Infant Feeding Recommendations for Childhood Obesity Prevention: Implementation by Immigrant Mothers From Central America.

PURPOSES: Describe implementation of Institute of Medicine (IOM) early infant feeding recommendations for child obesity prevention by immigrant mothers from Central America; examine potential relationships with food insecurity and postpartum depressive symptoms. DESIGN AND METHODS: Using a cross-sectional, descriptive design, face-to-face interviews were conducted with 318 mothers of 2month old infants at a large pediatric setting for low income families. Logistic regression models assessed feeding practices, food insecurity and postpartum depressive symptoms. RESULTS: Exclusive breastfeeding rates were low (9.4%); most mothers (62.7%) both breastfed and bottle fed their infants. Mothers who bottle fed at moderate and high intensity were twice as likely to affirm that if you give a baby a bottle, you should always make sure s/he finishes it (OR=2.30, 95% CI=1.13, 4.69; OR=2.29, 95% CI=1.26, 4.14). Food insecurity was experienced by 57% of mothers but postpartum depressive symptoms were low (Possible range=0-30; M=2.96, SD =3.6). However, for each increase in the postpartum depressive symptoms score, the likelihood of affirming a controlling feeding style increased by 11-13%. CONCLUSIONS: Immigrant mothers from Central America were more likely to both breastfeed and bottle feed (las dos cosas) than implement exclusive breastfeeding. Bottle feeding intensity was associated with a controlling feeding style. PRACTICE IMPLICATIONS: Infant well visits provide the ideal context for promoting IOM recommendations for the prevention of obesity among children of immigrant mothers from Central America.

Posttraumatic stress disorder among low-income women exposed to perinatal intimate partner violence : Posttraumatic stress disorder among women exposed to partner violence.

Women exposed to intimate partner violence (IPV) and other forms of lifetime trauma may be at risk for negative mental health outcomes including posttraumatic stress disorder (PTSD). The purpose of this study was to examine potential predictors of PTSD among low-income women exposed to perinatal IPV. This study analyzed baseline cross-sectional data from 239 low-income pregnant women in the USA who participated in a nurse home visitation intervention between 2006 and 2012 after reporting recent IPV. PTSD was assessed with the Davidson Trauma Scale (DTS) in which participants answer questions about the most disturbing traumatic event (MDTE) in their lifetime that affected them the week before the interview. In total, 40 % of the women were identified as having PTSD (DTS ≥40). PTSD prevalence significantly increased with age to nearly 80 % of women ages 30 and older (n = 23). Age was also the strongest predictor of PTSD (p < 0.001). Most participants (65 %) identified non-IPV-related traumas as their MDTEs. Psychological (94 %), physical (82 %), and sexual (44 %) violence were not significantly associated with PTSD status. Despite recent exposure to IPV, most participants identified other traumatic events as more disturbing than IPV-related trauma. Further, the risk for PTSD increased with age, suggesting that the cumulative effect of trauma, which may include IPV, increases the risk for PTSD over a lifetime. Implementing comprehensive screening for trauma during prenatal care may lead to the early identification and treatment of PTSD during pregnancy in a community setting.

Predictors of Depression Symptoms Among Low-Income Women Exposed to Perinatal Intimate Partner Violence (IPV).

Women experiencing perinatal intimate partner violence (IPV) may be at increased risk for depression. Baseline data was analyzed from 239 low-income pregnant women participating in an intervention study designed to reduce exposure to IPV. Depression risk was assessed using the Edinburgh Postnatal Depression Scale (EPDS) and IPV factors were measured with the Conflict Tactics Scale-Revised (CTS-2). Stepwise regression was conducted to identify predictors of risk for depression. Race (p = 0.028), psychological IPV (p = 0.035) and sexual IPV (p = 0.031) were strongly associated with risk for depression. Regression results indicated that women experiencing severe psychological IPV were more likely to develop depression (OR 3.16, 95 % CI 1.246, 8.013) than those experiencing severe physical or sexual IPV. Experiencing severe psychological IPV during pregnancy is strongly linked to risk for depression. Routine screening for psychological IPV may increase identification and treatment of women at high risk for depression during pregnancy.

Identifying high-risk subgroups for alcohol consumption among younger and older pregnant women.

AIMS: Recent studies indicate that older women are more likely to consume alcohol during pregnancy, but subgroups at highest risk within the context of maternal age have not been identified. This study identifies subgroups at risk for alcohol use during pregnancy among three age categories using classification and regression trees (CART) analysis. METHODS: Using the 2002-2009 Pregnancy Risk Assessment Monitoring System (PRAMS) dataset (311,428 records of U.S. women), logistic regression and classification trees were constructed separately for age groups, ≤24, 25-29, and ≥30 years. RESULTS: Overall, 6.5% of women reported drinking alcohol during the last trimester of pregnancy. Alcohol consumption by age group was: 3.7% for ≤24, 5.7% for 25-29, and 10.1% for ≥30 years of age. Women ≤24 years were at greater risk of consuming alcohol if they also smoked (5.8%). Among nonsmokers, higher levels of education and being Hispanic were associated with a 35% increase in alcohol use. Distinct high-risk subgroups emerged for the 25-29-year-old group. Specifically, 12.8% of non-obese women who reported having experienced abuse during pregnancy also reported drinking alcohol in the last trimester. About 16% of women ≥30 years with at least 16 years of education, White or Hispanic with normal or underweight BMI, drank alcohol during their last trimester. CONCLUSIONS: Given limited health care resources for prevention and treatment, the early identification of high-risk groups for prenatal alcohol use is critical. This study provides evidence that risk factors contributing to alcohol consumption during pregnancy may differ by maternal age.

Self-Rated Mental Health: Screening for Depression and Posttraumatic Stress Disorder Among Women Exposed to Perinatal Intimate Partner Violence.

The purpose of the current study was to evaluate the validity of a single-item, self-rated mental health (SRMH) measure in the identification of women at risk for depression and posttraumatic stress disorder (PTSD). Baseline data of 239 low-income women participating in an intimate partner violence (IPV) intervention study were analyzed. PTSD was measured with the Davidson Trauma Scale. Risk for depression was determined using the Edinburgh Postnatal Depression Scale. SRMH was assessed with a single item asking participants to rate their mental health at the time of the baseline interview. Single-item measures can be an efficient way to increase the proportion of patients screened for mental health disorders. Although SRMH is not a strong indicator of PTSD, it may be useful in identifying pregnant women who are at increased risk for depression and need further comprehensive assessment in the clinical setting. Future research examining the use of SRMH among high-risk populations is needed.

Determinants of alcohol cessation, reduction and no reduction during pregnancy.

PURPOSE: Despite public health initiatives targeting the harmful effects of alcohol exposure on fetal growth, 12 % of pregnant women report current alcohol use. For women who reported drinking alcohol prior to pregnancy, we examined several factors as predictors of three alcohol use patterns during the third trimester of pregnancy: cessation, reduction and no reduction. METHODS: Using the 2002-2009 Pregnancy Risk Assessment Monitoring System (PRAMS) dataset (311,428 records), a multinomial logistic regression model was constructed to compare alcohol risk by category: (1) cessation vs. reduction (2) no reduction vs. reduction. RESULTS: In this sample, 49.4 % drank alcohol before pregnancy. Among those who drank before pregnancy, ~87 % quit drinking during pregnancy, 6.6 % reduced, and about 6.4 % reported no reduction. Older women and those with higher education were more likely to reduce than quit their alcohol use. Conversely, women who were black or Hispanic, overweight, obese, or multiparas were more likely to quit than to reduce their prenatal alcohol consumption. Several stressors such as abuse during pregnancy increased their risk of not quitting or not reducing alcohol during the last trimester of pregnancy. CONCLUSIONS: Differentiating prenatal alcohol use patterns can inform the design of targeted interventions and public health policies to meet the Healthy People 2020 objective for achieving a national rate of 98.3 % alcohol abstinence during pregnancy.

Baby steps in the prevention of childhood obesity: IOM guidelines for pediatric practice.

The aim of this paper is to present an overview of the infancy-related guidelines from the Institute of Medicine (IOM, 2011) report "Early Childhood Obesity Prevention Policies" and highlight research studies that support their implementation in pediatric practice. Findings from recent studies of infant growth monitoring, feeding, sleep, and physical activity are presented. Research strategies that may be applied to today's clinical assessments and interventions are specified. Participation by pediatric nurses in the development of future multi-component interventions to prevent rapid infant weight gain is recommended.

Maternal-child nutrition practices and pediatric overweight/obesity in the United States and Chile: a comparative study.

Childhood overweight/obesity is now epidemic in both developed countries and those undergoing economic transition. This study compared maternal and school-age child nutrition practices and body mass index in the United States and in Chile. Children (125 in the United States, 121 in Chile) and their mothers (116 in the United States, 101 in Chile) participated. Findings indicated that child nutrition practices were comparable, but mothers in the U.S. group demonstrated fewer healthy nutrition practices on behalf of their children. Significant associations were found between maternal and child nutrition practices. Substantially more children in the U.S. sample were overweight/obese. Implications for practice are presented.

Clinical practice guidelines for feeding behaviors and weight-for-age at 12 months: a secondary analysis of the Infant Feeding Practices Study II.

BACKGROUND: The World Health Organization has identified childhood obesity as a major threat to global health. Accumulating evidence indicates that excess weight early in life is predictive of later childhood and adolescent obesity. Clinical practice guidelines for infant feeding behaviors have been developed by national and international health organizations. The relationship between these guidelines and infant weight status has not been established. AIM: To examine the relationship between weight-for-age at 1 year and adherence to four clinical practice guidelines for feeding behaviors: no bottle-to-bed, minimal juice consumption, breastfeeding throughout the first year of life, and introduction to solid food no earlier than age 4-6 months. METHODS: Data were obtained from the Infant Feeding Practices Study II, a longitudinal, national survey administered by the U.S. Food and Drug Administration and Centers for Disease Control and Prevention that followed mother-infant dyads from pregnancy through 1 year postpartum. The sample was comprised of 691 infants for whom 12-month survey data were available. RESULTS: Significant associations with weight-for-age were found for juice consumption (p= 0.003), breastfeeding during the second half of infancy (p < 0.001), and introduction to solid foods prior to age 4 months (p < 0.001). A regression model that controlled for infant and maternal characteristics demonstrated that these feeding behaviors remained significant predictors of weight-for-age at 12 months. CONCLUSIONS AND IMPLICATIONS: Modifiable infant feeding behaviors contributed to weight-for-age at 1 year. Replication studies with economically and culturally diverse samples are needed. Further, testing longitudinal interventions that address infant feeding practices is likely to yield the evidence needed for shaping future clinical practice guidelines that reduce the risk for childhood obesity and related pediatric comorbidities.

Prepregnancy body mass index, socioeconomic status, race/ethnicity and breastfeeding practices.

OBJECTIVE: While socioeconomic status (SES) and race/ethnicity are known predictors of breastfeeding practices, the added disparity caused by the rising rates of obesity among women of childbearing age remains untested. The purpose of this study was to examine differences in breastfeeding initiation and duration among black, white and Hispanic women of low and middle SES within the context of prepregnancy body mass index (BMI). METHODS: Data from the Early Childhood Longitudinal Study-Birth Cohort were analyzed. Adjusted logistic regression models were built to examine differences in breastfeeding initiation and duration for the three racial/ethnic groups of low and middle SES. RESULTS: Normal BMI Hispanic women of low SES demonstrated higher rates of breastfeeding initiation (74%) compared to other groups. Overweight/obese black women of low SES had lower rates of breastfeeding initiation. Overweight/obese Hispanic women of middle SES were significantly less likely to continue breastfeeding up to 4 months (OR: 0.65, 95% CI: 0.41, 0.98) compared to their white counterparts. Among women who initiated breastfeeding, overweight/obese white women of low SES had the highest rate of stopping within two months of giving birth (66.7%). CONCLUSIONS: Examination of SES and racial/ethnic differences within the context of prepregnancy weight revealed specific groups with low rates of breastfeeding initiation and duration. Interventions tailored for these at-risk groups are needed to increase the overall proportion of mothers and infants who benefit from the positive health outcomes associated with breastfeeding.

Maternal prepregnancy body mass index in relation to Hispanic preschooler overweight/obesity.

The aim of the current study was to examine the role of maternal prepregnancy body mass index (BMI) on overweight/obesity among US Hispanic children ages 2 and 4 years old. We used US nationally representative data from preschoolers enrolled in the Early Childhood Longitudinal Study-Birth Cohort study. The findings revealed that a significantly higher percent (41.6%) of Hispanic mothers were overweight/obese prior to pregnancy compared to white mothers (34.8%). At 2 years of age, 38.3% of the children born to Hispanic mothers were overweight/obese compared to 29.4% of children born to white mothers. By the age of 4, overweight/obesity increased significantly for both racial/ethnic groups with preschoolers whose mothers were Hispanic being more likely to be overweight/obese (44.6%) compared to children whose mothers were white (34.2%). Further, preschoolers born to overweight/obese Hispanic mothers were more than twice as likely [odds ratio = 2.74 (95% confidence interval (CI) 1.60, 4.69)] to be overweight/obese than those born to Hispanic mothers of normal prepregnancy BMI. Preschoolers born to overweight/obese white mothers were approximately 1.4 (95% CI 1.05, 1.93) times more likely to be overweight/obese in comparison to those born to mothers with a normal prepregnancy BMI. Maternal prepregnancy weight is potentially a modifiable risk factor for preschooler overweight/obesity. Study findings support the design of early and targeted interventions to reduce this risk to the long-term health of Hispanic maternal and child dyads.

Racial/ethnic disparities in infant mortality.

AIMS: This study examines predictors of neonatal and postneonatal mortality among infants born to black, white, and Hispanic women. METHODS: Linked birth/infant death records from North Carolina for the period 1999-2007 were the source of data. Logistic regression models were constructed to estimate the effect of maternal and infant characteristics on neonatal (<28 days) and postneonatal (28-364 days) mortality. RESULTS: Analyses revealed no racial/ethnic differences in neonatal mortality, but increased risk among black infants for postneonatal death. Inadequate prenatal care was associated with an increased risk for neonatal mortality across all three racial/ethnic groups. Younger maternal age and lower educational levels were associated with postneonatal deaths for black and white women, but not Hispanic. A previous child loss, being unmarried and labor/delivery complications increased the risk for postneonatal mortality only among white women. Black infants had higher rates of death attributed to sudden infant death syndrome (SIDS), infections, low birth weight (LBW)/prematurity, respiratory conditions, and injuries. CONCLUSIONS: Early initiation of prenatal care, access to risk-appropriate obstetric and neonatal services, and participation in intervention programs that support parenting of LBW/preterm infants throughout the first year of life are likely to yield the greatest impact in reducing infant mortality.

Two decades of nurse-led research on smoking during pregnancy and postpartum: concept development to intervention trials.

Tobacco use during pregnancy and postpartum is a leading cause of preventable morbidities for women and their infants. Over the past two decades, nursing research has addressed this recalcitrant clinical problem from a variety of conceptual and methodological perspectives. The 64 published studies (1988-2009) that met inclusion criteria for this systematic review represent the full research trajectory from concept development to intervention testing. Meta-analysis demonstrated an overall significant trend in nursing intervention efficacy (OR = 1.14, 95% CI = 1.08-1.2) for studies that examined comparable prenatal and postpartum smoking cessation outcomes. Implications for future nursing research and evidence-based policy are presented.

The influence of maternal life stressors on breastfeeding outcomes: a US population-based study.

OBJECTIVE: The purpose of this study was to examine the contribution of maternal financial, emotional, traumatic, and partner-associated stressors on breastfeeding initiation and duration. METHODS: Data (216,756 records) from the Pregnancy Risk Assessment Monitoring System surveys were used in the analysis. Logistic regressions were conducted to estimate the magnitude and direction of associations between maternal stressors occurring in the 12 months prior to infant birth and both breastfeeding initiation and duration up to 4 weeks infant age. RESULTS: A substantial proportion of mothers (42%) reported having experienced one or two major stressors during the 12 months prior to the birth of their infant. Mothers who reported at least one major life stressor in the year before their baby was born were less likely to initiate breastfeeding and more likely to cease by 4 weeks infant age. Emotional and traumatic stressors were found to have the greatest impact on breastfeeding outcomes. CONCLUSIONS: Findings support the design and implementation of screening protocols for major maternal life stressors during regularly scheduled prenatal and newborn visits. Screening for at-risk mothers may lead to more targeted anticipatory guidance and referral with positive effects on breastfeeding outcomes and overall well-being of the mothers and their families.

Knowledge of intrapartum care among obstetric care providers in rural Kenya.

BACKGROUND: Kenya did not meet its maternal mortality ratio (MMR) target under the Millennium Development Goals. The aim of this study was to examine the gaps in knowledge of intrapartum care among obstetric care providers (OCPs) in rural Nandi County, Kenya. METHODS: This cross-sectional study in 2015 surveyed 326 nurses, midwives, clinical officers and physicians about their knowledge, attitudes and practices related to normal labor and childbirth, immediate newborn care and management of obstetric complications. RESULTS: Self-reported intrapartum knowledge among OCPs was insufficient according to accepted international standards. The mean total knowledge score for all OCPs based on a validated 30-question inventory was 62% (range 23-90%). Only 14 providers (4%) scored as 'competent' (a score ≥80%). Scores were higher for OCPs who had received pre- and postemployment emergency obstetric care training and those with higher levels of confidence in their skills. Survey respondents identified a lack of knowledge as one of the greatest barriers to high-quality patient care. CONCLUSIONS: Increasing training opportunities for OCPs may improve the quality of obstetric care provided to women in Kenya and other high-MMR locations in sub-Saharan Africa and enable progress toward achieving the ambitious Sustainable Development Goals target for maternal survival.

Early Life Factors for Overweight Risk Among Infants of Hispanic Immigrant Mothers.

INTRODUCTION: This study examined postpartum depression, food insecurity, and underestimation of infant size as potential early life factors for overweight risk at 12 months among infants of Hispanic immigrant mothers. METHOD: Weight-for-length (WFL) measurements and face-to-face interviews were completed during well child visits. Regression models estimated the impact of early life factors (0-6 months) on overweight risk at 1 year. RESULTS: WFL ≥ 85th percentile was found among 2.4% at birth and 42.7% at 1 year. Most mothers (78.6%) experienced food insecurity, a factor that increased the likelihood of infant overweight risk by 2.29 times (1.03-5.09). Maternal underestimation of infant size increased the likelihood of overweight risk 5.07 times (2.57-9.99). Postpartum depression risk did not contribute to infant weight status. DISCUSSION: Assessment for maternal food insecurity and underestimation of infant weight status during early infancy may help reduce overweight risk and subsequent obesity for this vulnerable population.

Mothers' reflections about infant irritability and postpartum tobacco use.

BACKGROUND: Recent research has shown that most women who stop or substantially reduce cigarette smoking during pregnancy return to previous levels of tobacco use soon after delivery. The determinants of postpartum tobacco use have not been adequately identified. To address this gap, the present study examined one potential contributor to postpartum smoking, namely, unexplained infant crying and fussiness. The purpose of this study was to describe mothers' reflections about perceived infant irritability and postpartum tobacco use. METHODS: A qualitative descriptive approach was applied to the responses of low-income women who participated in a mixed methods study of smoking relapse among mothers of infants. The subset of mothers for the present study (n = 86) was composed of women who intended to be nonsmokers after delivery. Thematic content analysis was conducted of the texts from their interviews. RESULTS: Four major themes were identified with respect to perceptions of infant irritability and postpartum tobacco use: not knowing what to do, seeking renewal, seeking relief, and evaluating self. CONCLUSIONS: The reflections of the study participants suggest that the challenges of handling infant irritability often trigger thoughts of smoking or smoking behavior. Health practitioners may strengthen cessation interventions by using strategies to help mothers cope with this experience, which is unique to the first few months after delivery.

Tobacco use triggers for mothers of infants: implications for pediatric nursing practice.

PURPOSE: To extend current knowledge of tobacco use by exploring whether subsets of mothers of infants have unique triggers for smoking relapse during the early stages of becoming a mother. METHOD: Using data from a study of smoking relapse among mothers of infants (N = 133), comparative analyses were conducted for groups formed on the basis of their intention to be nonsmokers after delivery (yes/no) and their actual smoking behavior during the first 2 weeks of infant life (yes/no). FINDINGS: The identified groups of mothers were found to be significantly different from one another in several ways, including self-reports that their baby's crying episodes caused them to think about smoking and their level of self-confidence to not smoke as response to infant crying. CONCLUSIONS: Pediatric nurses in primary and acute care settings are in a unique position to support mothers for whom the challenge of handling infant cry episodes is a trigger for smoking behavior. Interventions that teach mothers how to cope with infant irritability are likely to support the smoking cessation efforts, and consequently, interrupt the intergenerational cycle of tobacco-related maternal and child health morbidities.

Sensitive Timing for Risk of Overweight Among Infants of Low-Income Hispanic Immigrants.

INTRODUCTION: This study examined the association between early weight gain (0-6 months) and risk for overweight, as defined by the Institute of Medicine, at 1 year among infants of low-income Hispanic immigrant mothers. METHOD: Weight-for-age data were extracted from electronic medical records of 335 infants with gestations of 37 weeks or longer and birthweights appropriate for gestational age and without medical problems likely to interfere with growth or feeding. Logistic regression models were constructed to examine the impact of early weight changes on weight status at 1 year. RESULTS: By 12 months, 36.7% of infants had crossed weight-for-age of 84.1% or greater on World Health Organization growth charts. In adjusted models, infants had 20.8 (95% confidence interval = [19.8, 44.0]) times the odds of reaching this benchmark at 1 year for each z score increase at 0 to 6 months. DISCUSSION: The study highlights a time-sensitive opportunity for interventions to reduce risk for overweight for this vulnerable population.

Postpartum tobacco use: developing evidence for practice.

Most women who quit smoking during pregnancy return to tobacco use within 6 months after delivery. Findings demonstrate that minimal intervention effectiveness exists with strategies to prevent postpartum smoking relapse. This article provides a synthesis of current research on postpartum tobacco use. Whether in the labor and delivery suite, the postpartum floor, or the neonatal ICU, acute and critical care nurses have a valuable role to help reduce the incidence of tobacco-related maternal and child outcomes.