Neighbourhood socio-economic environment predicts adiposity and obesity risk in children under two.

BACKGROUND: Neighbourhood socio-economic environment (SEE) is associated with obesity in older children and adults, but little is known about this relationship in younger children. Breastfeeding is an important preventative of adiposity in childhood, but its relationship with neighbourhood SEE is unknown. AIMS: We assessed differences in adiposity and obesity in children before age two by neighbourhood SEE, controlling for family socio-demographics and breastfeeding duration. MATERIALS AND METHODS: Family socio-demographics, child body mass index z scores (BMIz), and breastfeeding duration were collected at periodic study visits from participants in PREVAIL (n = 245), a birth cohort in Cincinnati, OH. Addresses were assigned a Deprivation Index score, a validated measure of SEE, and dichotomized into highest SEE (least deprived quartile of scores) and not highest SEE (remaining quartiles). Longitudinal and Poisson models assessed differences in BMIz by SEE over the second year of life and obesity risk at age two, respectively (highest SEE, reference), while attenuation of obesity risk by breastfeeding duration was tested in mediation models. RESULTS: Residing outside of the highest SEE neighbourhoods was associated with an increased BMIz of 0.04 (95%CI 0.02, 0.06) per month of life and increased obesity risk at age two (aRR: 3.7, 95%CI 1.2, 16.2), controlling for family socio-demographics. Breastfeeding duration attenuated >9% of the obesity risk attributable to SEE (mediated RR: 3.4, 95%CI 1.1, 14.8). DISCUSSION: In the PREVAIL Cohort, residing outside of the highest SEE neighbourhoods predicted a significant increase in BMIz and obesity risk in children before age two, a relationship that was partially mediated by breastfeeding duration. CONCLUSION: Breastfeeding support may play an important role in reducing obesity rates in children in lower SEE neighbourhoods.

Breastfeeding and post-perinatal infant deaths in the United States, A national prospective cohort analysis.

Background: Reducing infant mortality is a major public health goal. The potential impact of breastfeeding on infant deaths is not well studied in the United States (US). Methods: We analyzed linked birth-death certificates for 3,230,500 US births that occurred in 2017, including 6,969 post-perinatal deaths from 7-364 days of age as the primary outcome, further specified as late-neonatal (7-27 days) or post-neonatal (28-364 days) deaths. The primary exposure was 'ever breastfed' obtained from birth certificates. Multiple logistic regression examined associations of ever breastfeeding with post-perinatal deaths and specific causes of deaths, controlling for maternal and infant factors. Findings: We observed an adjusted reduced odds ratio (AOR)= 0·74 with 95% confidence intervals (CI)=0·70-0·79 for the association of breastfeeding initiation with overall infant deaths (7-364 days), AOR=0·60 (0·54-0·67) for late-neonatal deaths, and AOR=0·81 (0·76-0·87) for post-neonatal deaths. In race/ethnicity-stratified analysis, significant associations of breastfeeding initiation with reduced odds of overall infant deaths were observed for Hispanics [AOR=0·64 (0·55-0·74)], non-Hispanic Whites [AOR=0·75 (0·69-0·81)], non-Hispanic Blacks [AOR=0·83 (0·75-0·91)], and non-Hispanic Asians [AOR=0·51 (0·36-0·72)]. Across racial/ethnic groups, effect sizes for late-neonatal deaths were consistently larger than those for post-neonatal deaths. Significant effects of breastfeeding initiation were observed for deaths due to infection [AOR=0·81(0·69-0·94)], Sudden Unexpected Infant Death [AOR=0·85 (0·78-0·92)], and necrotizing enterocolitis [AOR=0·67 (0·49-0·90)]. Interpretation: Breastfeeding initiation is significantly associated with reduced odds of post-perinatal infant deaths in multiple racial and ethnic groups within the US population. These findings support efforts to improve breastfeeding in infant mortality reduction initiatives.

Breastfeeding Disparities and Their Mediators in an Urban Birth Cohort of Black and White Mothers.

Background: Black mothers in the United States have shorter breastfeeding (BF) durations and less exclusive breastfeeding (EBF) than others. The factors underlying these disparities require investigation. Methods: Using longitudinal data from a CDC-sponsored birth cohort in Cincinnati, Ohio, we analyzed the factors mediating racial disparity in BF outcomes. Study mothers were enrolled in prenatal clinics associated with two large birth hospitals. Analysis was restricted to racial groups with sufficient numbers in the cohort, non-Hispanic Black (n = 92) and White (n = 113) mothers, followed to at least 6 months postpartum. Results: Black mothers were 25 times more likely to reside in socioeconomically deprived neighborhoods and 20 times more likely to have an annual household income <$50,000/year than White mothers (p < 0.001). The gap in EBF for 6 weeks was 45 percentage points by racial group (13%-Black mothers versus 58%-White mothers, p < 0.001); in any BF at 6 months was 37 percentage points (28%-Black mothers versus 65%-White mothers, p < 0.001); and in mothers meeting their own intention to BF at least 6 months was 51 percentage points (29%-Black mothers versus 80%-White mothers, p < 0.001). Racial disparity in EBF at 6 weeks was mediated in logistic regression models by inequities in socioeconomic position, maternal hypertension, and BF intention. Racial disparities in BF at 6 months or meeting 6-month BF intention were mediated by inequities in socioeconomic position, maternal obesity, and EBF at 6 weeks. Not all BF disparities could be explained by models used in these analyses. Conclusions: Efforts to lessen BF disparities should address the underlying structural inequities that disproportionately affect Black mothers and children, should incorporate maternal health, and focus on breastfeeding exclusivity and duration. Few Black mothers achieved EBF at 6 weeks, which contributed to disparity in BF duration. Greater attention to Black mother-infant pairs is a public health priority.

Associations Between Breastfeeding Initiation and Infant Mortality in an Urban Population.

Background: Breastfeeding promotion and support are not universally accepted in the United States as a strategy to reduce infant mortality. We investigated associations between breastfeeding and infant mortality in an urban population with high infant mortality and low breastfeeding rates. Methods: A retrospective epidemiologic study linked birth-infant death data for 148,679 live births in Shelby County, Tennessee from January 2004 to December 2014. Births <500 g, deaths ≤7 days, deaths because of congenital anomalies or malignant neoplasms, and records with missing breastfeeding status were excluded. Main outcomes were infant death before the first birthday, neonatal death <28 days, and postneonatal death ≥28 days by ever or never breastfed. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for breastfeeding initiation were adjusted for maternal factors and infant factors. Results: Initiation of breastfeeding was associated with a significant reduction in total infant mortality (OR = 0.81, 95% CI = 0.68-0.97, p = 0.023). Neonatal mortality was also significantly reduced with any breastfeeding (OR = 0.49, 95% CI = 0.34-0.72, p = 0.001). Postneonatal mortality was not significantly associated with breastfeeding initiation in the overall population (OR = 0.95, 95% CI = 0.78-1.17, p = 0.65), but was significant in the nonblack population (OR = 0.63, 95% CI = 0.41-0.98, p = 0.039). An association was observed between breastfeeding initiation and infant mortality from infectious disease (OR = 0.49, 95% CI = 0.32-0.77, p = 0.002). Conclusions: In an urban area with high infant mortality and low breastfeeding rates, initiation of breastfeeding was significantly associated with reductions in overall infant mortality, neonatal mortality, and infection-related deaths. Breastfeeding promotion, protection, and support should be an integral strategy of infant mortality reduction initiatives.

Use of a body proportionality index for growth assessment of preterm infants.

OBJECTIVE: To evaluate the utility of weight-for-length (defined as gm/cm(3), known as the "ponderal index") as a complementary measure of growth in infants in neonatal intensive care units (NICUs). STUDY DESIGN: This was a secondary analysis of infants (n=1214) of gestational age 26 to 29 weeks at birth, included in a registry database (1991-2003), who had growth data at birth and discharge. Weight-for-age and weight-for-length were categorized as small (<10th percentile), appropriate, or large (>90th percentile). RESULTS: Statistical agreement between the weight-for-age and weight-for-length measures was poor (kappa=0.02 at birth, 0.10 at discharge; Bowker test for symmetry, P< .0001). From birth to discharge, the percentage of small-for-age infants increased from 12% to 21%, the percentage of small-for-length infants decreased from 10% to 4%, the percentage of large-for-age infants remained similar (<1%), and the percentage of large-for-length infants increased from 5% to 17%. At discharge, 92% of the small-for-age infants were appropriate or large-for-length, and 19% of the appropriate-for-age infants were large-for-length. CONCLUSIONS: Weight-for-age and weight-for-length are complementary measures. Weight-for-length or other measures of body proportionality should be considered for inclusion in routine growth monitoring of infants in the NICU.

Breastfeeding helps explain racial and socioeconomic status disparities in adolescent adiposity.

OBJECTIVES: Studies suggest that breastfeeding is protective for later obesity; however, this association has not held among all racial and socioeconomic status groups. Racial and socioeconomic status differences in breastfeeding behavior have also been noted. In this study, we formally test whether breastfeeding mediates the relationship between race and socioeconomic status with adolescent adiposity. METHODS: Data were analyzed from 739 black and white 10- to 19-year-old adolescents who participated in a large, school-based study. Parents provided information on parental education, used to measure socioeconomic status, and whether the child was breastfed as an infant. BMI was used to measure adolescent adiposity and was analyzed as a continuous measure (BMI z score) using linear regression and categorically (BMI > or = 85th and > or = 95th percentile) using logistic regression. RESULTS: Black adolescents and those without a college-educated parent were less likely to have been breastfed for > 4 months. Race and parental education were each independent predictors of BMI z score and of having BMI > or = 85th percentile or BMI > or = 95th percentile. When added to the model, being breastfed for > 4 months was also independently associated with lower BMI z score and lower odds of having BMI > or = 85th percentile or BMI > or = 95th percentile. Inclusion of being breastfed for > 4 months resulted in a 25% decrease in racial and parental education differences in adolescent BMI z score, supporting partial mediation. CONCLUSIONS; Having been breastfed for > 4 months was associated with lower adolescent BMI z score and lower odds of having a BMI > or = 85th percentile or BMI > or = 95th percentile, independent of race or parental education. Furthermore, these analyses suggest that being breastfed for > 4 months partially explains the relationship between social disadvantage and increased adiposity. Increasing breastfeeding duration could result in lower adolescent adiposity for all racial and socioeconomic status groups and potentially minimize socioeconomic disparities in adiposity.

Pediatricians' adherence to pneumococcal conjugate vaccine shortage recommendations in 2 national shortages.

OBJECTIVES: The goals were (1) to compare pediatricians' heptavalent pneumococcal conjugate vaccine shortage experience and adherence to shortage recommendations during 2 heptavalent pneumococcal conjugate vaccine shortages, (2) to assess factors associated with nonadherence to second shortage recommendations, and (3) to assess opinions about national immunization policy during vaccine shortages. METHODS: We mailed surveys to all pediatrician immunization providers in the greater Cincinnati, Ohio, metropolitan area. We assessed heptavalent pneumococcal conjugate vaccine supply and immunization practices during the shortages and provider attitudes regarding immunization shortage policy. RESULTS: The response rate was 61% (171 of 282 providers). Most pediatricians experienced heptavalent pneumococcal conjugate vaccine shortages (first shortage: 86%; second shortage: 84%). The rate of adherence to recommendations to defer the fourth heptavalent pneumococcal conjugate vaccine dose for healthy children was significantly higher during the second shortage, compared with the first shortage (first shortage: 62%; second shortage: 89%). Adherence to recommendations to administer the fourth dose to high-risk children remained unchanged (first shortage: 43%; second shortage: 45%). Controlling for other factors, pediatricians who reported a severe second shortage had greater odds of not fully vaccinating high-risk children, compared with those who reported no shortage. Contrary to recommendations, many pediatricians did not maintain tracking systems during the heptavalent pneumococcal conjugate vaccine shortages (first shortage: 37%; second shortage: 46%). Most pediatricians (91%) thought that national vaccine shortage recommendations were needed to protect them from liability. CONCLUSIONS: The rate of adherence to recommendations to defer heptavalent pneumococcal conjugate vaccine doses for healthy children increased significantly from the first shortage to the second shortage. The nonadherent practice of deferring the fourth dose for high-risk children was associated with more severe shortages and, potentially, an inability to vaccinate.

Determinants of optimal breast-feeding in peri-urban Guatemala City, Guatemala.

OBJECTIVE: This survey was conducted to identify factors affecting early initiation of breast-feeding and exclusive breast-feeding among mothers in peri-urban Guatemala City, Guatemala. MATERIALS AND METHODS: In early November 1999 a census was begun in four communities of peri-urban Guatemala City, Guatemala, to identify all children < 6 months old as well as all pregnant women who were expected to deliver during the two-month data-gathering period. After the census was completed, a survey of breast-feeding practices was administered to all mothers of infants < 6 months of age. RESULTS: The most important determinant of early initiation of breast-feeding was place of delivery. Children born at home (odds ratio (OR) = 4.1, 95% confidence interval (CI): 1.2-13.3) and at Ministry of Health health centers (OR = 4.9, 95% CI: 1.6-15.0) were significantly more likely than children born at private hospitals to initiate breast-feeding early. The most important determinant of exclusive breast-feeding was whether or not the mother worked outside the home. After controlling for infant's age and sex and mother's ethnicity, women who did not work outside the home were 3.2 times as likely (95% CI: 1.6-6.4) to exclusively breast-feed as were women who worked outside the home. Lack of exclusive breast-feeding was often associated with giving a bottle. CONCLUSIONS: Our findings suggest that global efforts must be continued to improve breast-feeding practices in delivery hospitals. In addition, community-based support of breast-feeding is needed well after delivery. Mothers who work outside the home should be provided with options to maintain exclusive breast-feeding when they are physically separated from their infants due to the demands of work.

Determinants of optimal breast-feeding in peri-urban Guatemala City, Guatemala / Determinantes de la amamantación óptima en la zona periurbana de la ciudad de Guatemala

Objective. This survey was conducted to identify factors affecting early initiation of breast-feeding and exclusive breast-feeding among mothers in peri-urban Guatemala City, Guatemala. Materials and Methods. In early November 1999 a census was begun in four communities of peri-urban Guatemala City, Guatemala, to identify all children < 6 months old as well as all pregnant women who were expected to deliver during the two-month data-gathering period. After the census was completed, a survey of breast-feeding practices was administered to all mothers of infants < 6 months of age. Results. The most important determinant of early initiation of breast-feeding was place of delivery. Children born at home (odds ratio (OR) = 4.1, 95 percent confidence interval (CI): 1.2- 13.3) and at Ministry of Health health centers (OR = 4.9, 95 percent CI: 1.6-15.0) were significantly more likely than children born at private hospitals to initiate breast-feeding early. The most important determinant of exclusive breast-feeding was whether or not the mother worked outside the home. After controlling for infant's age and sex and mother's ethnicity, women who did not work outside the home were 3.2 times as likely (95 percent CI: 1.6-6.4) to exclusively breast-feed as were women who worked outside the home. Lack of exclusive breast-feeding was often associated with giving a bottle. Conclusions. Our findings suggest that global efforts must be continued to improve breast-feeding practices in delivery hospitals. In addition, community-based support of breast-feeding is needed well after delivery. Mothers who work outside the home should be provided with options to maintain exclusive breast-feeding when they are physically separated from their infants due to the demands of work

Objetivos. El objetivo de esta encuesta consistió en identificar los factores que influyen sobre el comienzo temprano de la amamantación y la lactancia exclusivamente materna en mujeres de la zona periurbana de la ciudad de Guatemala. Métodos. A principios de noviembre de 1999 se inició un censo en cuatro comunidades periurbanas de la ciudad de Guatemala para identificar a todos los niños de menos de 6 meses y a todas las embarazadas que esperaban dar a luz durante los dos meses que duró el período de recolección de los datos. Una vez completado el censo, se realizó una encuesta sobre las prácticas de amamantación a todas las madres de niños de menos de 6 meses. Resultados. El principal determinante del inicio temprano de la amamantación fue el sitio donde tuvo lugar el parto. La probabilidad de iniciar tempranamente la amamantación fue significativamente mayor en los niños nacidos en casa [razón de posibilidades (odds ratio: OR) = 4,1; intervalo de confianza del 95% (IC95): 1,2 a 13,3)] y en en los nacidos en hospitales privados. A su vez, el principal factor determinante de la lactancia exclusivamente materna fue que la madre trabajara o no fuera de casa. Después de controlar los efectos de la edad y el sexo del niño y de la etnia de la madre, las mujeres que no trabajaban fuera de casa tenían mayor probabilidad de alimentar a sus hijos exclusivamente con leche materna que las que trabajaban fuera de casa (OR = 3,2; IC95: 1,6 a 6,4). Conclusiones. Estos resultados indican que hay que proseguir los esfuerzos generales para mejorar las prácticas de amamantación en las maternidades, pero además es necesario seguir proporcionando apoyo a la lactancia materna en la comunidad mucho después del parto. A las madres que trabajan fuera de casa se les deberían proporcionar alternativas para seguir con la lactancia exclusivamente materna cuando las