Promoting Sleep Health Among Families of Young Children in Head Start: Protocol for a Social-Ecological Approach.

Inadequate or poor quality sleep in early childhood impairs social-emotional and cognitive function via effects on the developing brain and increases obesity risk via hormonal and endocrine effects. The prevalence of short sleep duration, behavioral sleep problems, and sleep-disordered breathing among children aged 3 to 5 years is 20% to 50%. Healthy sleep habits increase sleep duration and prevent behavioral sleep problems. Awareness of sleep-disordered breathing symptoms leads to its timely treatment. We designed a study that aims to empower families whose children are in early childhood programs with the knowledge and skills needed to obtain healthy sleep and to recognize a sleep problem. We used the social-ecological framework to guide individual, interpersonal, organizational, community, and policy interventions. This study builds on the Sweet Dreamzzz, Inc, Early Childhood Sleep Education Program (ECSEP) in Head Start. A stepped-wedge-cluster randomized trial will test effects on child, parent, and classroom outcomes; a policy evaluation will assess the impact of knowledge-translation strategies. The study has 3 aims. The first is to adapt educational materials into multimedia formats and build the capacity of Head Start agencies to implement the study. The second aim is to enroll 540 parent-child dyads in a primary prevention trial of sleep health promotion in Head Start and to analyze effects on children's sleep duration (primary outcome); parents' knowledge, attitudes, self-efficacy, and behavior; and children's sleep difficulties. The third aim is to conduct a secondary prevention feasibility study of screening and guidance for sleep problems. Secondary outcomes are changes in classroom behaviors and policies. Integrating sleep health literacy into early childhood programs could affect the life-course development of millions of children.

Bottle and sippy cup use is associated with diet and energy intake in toddlers.

The second year of life incorporates a continued shift from a liquid- to solid-based diet. Little is known about the prevalence and dietary impact of bottle and sippy cup use. This paper describes associations between percent of energy consumed via drinking containers (bottles and sippy cups combined) and dietary outcomes, between 1 and 2 years of age. This observational study recruited n = 299 low-income, nutrition programme clients from the Bronx, NY, whose 12 month olds consumed ≥ 2 non-water bottles per day. The main exposure variable was percent of energy intake via drinking containers (PEDC), dichotomized at the median into low-percent-energy-from-drinking-containers (LOW-C) and high-percent-energy-from-drinking-containers (HIGH-C) groups, assessed quarterly, for 1 year. We report 24-hour dietary recall nutrient and food serving data by LOW-C vs. HIGH-C. We employed linear mixed models to study associations between PEDC and nutrient intake. PEDC decreased from 52% to 33% between 1 and 2 years of age in both groups. The LOW-C group had higher intake of energy, dietary fibre, iron and sodium, grains, protein-rich foods and sweets. Conversely, LOW-C group had lower intake of Vitamin D and calcium vs. the HIGH-C group. PEDC was inversely associated with total energy intake in a model controlling for baseline age, baseline-weight-for-length and gender (ß = -5.8, P = 0.029, 95% confidence interval (-10.96, -0.6). Lower bottle and sippy cup use had significant, albeit mixed association with diet quality in the second year of life, and was associated with higher energy intake. Evidence-based guidelines are needed to determine the appropriate use of those feeding methods.

Perception of weight status and its impact on gestational weight gain in an urban population.

To examine the association between actual and perceived overweight/obese status and excess gestational weight gain (GWG). As part of an infant feeding trial, multi-ethnic lower and moderate income women-completed a checklist of current health conditions, including "overweight/obesity," "asthma," and "hypertension" while pregnant. Odds of excessive GWG per the Institute of Medicine guidelines in 'accurate' versus 'inaccurate' reporters, by overweight status were analyzed with multivariate logistic regression for women with pre-or early pregnancy BMIs of ≥18.5. 775 women met study criteria. Just 21 % (n = 107) of overweight/obese women accurately identified their weight status, compared to >90 % accurate report of documented hypertension or asthma. Compared to normal-weight accurate reporters, the adjusted odds of excessive GWG in overweight/obese women was 2.3 (95 % CI 1.4, 3.7) in accurate reporters, and 2.5 (95 % CI 1.7, 3.4) in inaccurate reporters. Overweight/obesity is associated with excessive GWG, but this risk is not modified by inaccurate reporting/perception of weight-status.

COVID-19 vaccine perceptions in New York State's intellectual and developmental disabilities community.

BACKGROUND: People with intellectual and developmental disabilities (IDD) are at disproportionate risk for severe COVID-19 outcomes, particularly those living in congregate care settings. Yet, there is limited data on vaccine perceptions in the disability community. OBJECTIVE: To explore COVID-19 vaccine perceptions in individuals with IDD, their family members, and those who work with them, to inform a statewide vaccine information and messaging project. METHODS: A national survey, adapted in five languages for the IDD community, was distributed to a convenience sample of IDD organizations throughout New York State. Constructs included vaccine intention, reasons for vaccine hesitancy, and trusted sources of vaccine information. Zip code data were used to map respondent location and vaccine preferences. RESULTS: Of n = 825 respondents, approximately 75% intended to or had received the vaccine across roles (i.e., people with developmental disabilities, family members, direct care workers) and racial/ethnic groups. Greater vaccine hesitancy was reported in younger individuals and those making decisions on behalf of a person with IDD. Concerns included side effects and the swiftness of vaccine development. Black and Hispanic participants had heightened concerns about being an "experiment" for the vaccine. Trusted sources of information included healthcare providers and family members. Respondents who intended to/received the vaccine were dispersed throughout the state. CONCLUSIONS: Vaccine preferences in this New York State disability community sample align with national data. Identified concerns suggest the need for community education that addresses misperceptions. Age and race differences in perspectives highlight the need for tailored education, delivered by trusted messengers.

Inappropriate bottle use: an early risk for overweight? Literature review and pilot data for a bottle-weaning trial.

Identifying early risk factors for childhood obesity is critical, as weight in infancy and early childhood tracks to later periods. Continued bottle use - primarily from excess milk intake - is emerging as a potential risk factor for early childhood overweight. Over three fourths of US infants drink from bottles beyond the recommended weaning age of 12 months, and two thirds of UK infants use a bottle at 18 months. This paper is divided into three parts. Part 1 reviews the literature on beverage intake, weight and bottle use in young children. Part II describes pilot data on milk bottle use and weight in 12-60-month-olds, collected prior to a randomized controlled (RCT) trial of a bottle-weaning intervention. Median daily milk bottle consumption at 12 months was 5.0 (interquartile range = 3-6). Among 12-36-month-olds, current users were significantly more likely to be >95th% weight-for-height (19% vs. 0%, P < 0.02), and more were >85% weight-for-height (27% vs. 11%, P < 0.11), vs. non-users. In contrast, current bottle use was not associated with either overweight or obesity in 37-60-month-olds. Part III describes the RCT, begun in fall 2008. It is enrolling 464 parent/12-month-old dyads from a nutrition assistance programme for low-income families. Children's bottle use, anthropometrics, dietary intake and nutrient density (via 24 h recall) are assessed quarterly through 24 months of age. For the intervention, site nutritionists employ a project-developed, visually attractive flip chart. An observational study nested within the RCT will describe dietary changes during this period of feeding transitions.

Breastfeeding and infant illness in low-income, minority women: a prospective cohort study of the dose-response relationship.

The authors' objective was to determine whether cumulative weekly breastfeeding duration by 13 weeks was associated with infant otitis media, respiratory and gastrointestinal illness, and total illness visits up to 12 months. The authors performed a secondary analysis of data from a randomized clinical trial of low-income, primarily Hispanic and Black women enrolled from 2 medical center affiliated clinics. "Breastfeeding sensitive" (BFS) outpatient and emergency room (ER) visit data for the above illnesses were obtained for 255 mother/infant dyads. Outcome measures were unadjusted and adjusted rates of outpatient and ER visits with sick and BFS diagnoses. The authors found no significant associations between breastfeeding intensity and infant visits for otitis media, respiratory and gastrointestinal illness, or total illness visits. In this low-income, multiethnic sample, breastfeeding intensity was not associated with infant health service use, in contrast to other evidence-based reports. Low exclusive breastfeeding rates and lack of coverage for health visits may be reasons for this finding.

Modified Children's sleep habits questionnaire for behavioral sleep problems: A validation study.

OBJECTIVES: Behavioral sleep problems (BSPs) are prevalent and consequential in young children. There is a need for screening tools that identify BSPs-which are often rooted in the parent-young child relationship-and typically respond to behavior management. Such a tool would increase capacity to identify and treat BSPs. We sought to validate a short-form version of the widely used Children's Sleep Habits Questionnaire (SF-CSHQ) that omitted items that would not be responsive to behavioral strategies. METHODS: The original 33-item CSHQ elicits parent report of "behaviorally-based" and "medically-based" sleep items (eg, parasomnias and sleep disordered breathing). We conducted analyses to develop a SF-CSHQ that excludes its "medically-based" items, to determine (a) the SF-CSHQ threshold score corresponding to the full CSHQ clinical cut-off score (≥41), and (b) preliminary validity of this SF-CSHQ. Data were re-analyzed from the original data that established the CSHQ's psychometric properties in 4-10 year olds, and a second dataset that established its validity in 24-66 month olds. RESULTS: In both datasets, a threshold score of 30 had correlations of 0.90-0.94 with the original cut-off. This 23-item SF-CSHQ cut-off functioned as well as the full CSHQ cut-off in discriminating between children with vs without a parent-reported behavioral sleep problem, and with vs without prolonged sleep latency (per actigraphy). CONCLUSION: We established preliminary validity of modified version of the widely-used CSHQ. This SF-CSHQ may be useful for widening screening and first-line guidance for behavioral sleep problems in young children, among professionals who are not sleep medicine specialists.

Randomized controlled trial of a prenatal and postnatal lactation consultant intervention on infant health care use.

OBJECTIVE: To determine whether infants of women randomized to a prenatal and postpartum lactation support intervention incur fewer otitis media-, respiratory tract-, or gastrointestinal-related visits than controls. DESIGN: Randomized, unmasked controlled trial recruiting women from prenatal care settings. Breastfeeding sensitive (BFS) illness visits for otitis media or respiratory tract or gastrointestinal complaints were obtained up to 12 months. SETTING: Two urban community health centers. PARTICIPANTS: Analytic sample of 338 low-income, primarily Hispanic and/or black mother-infant dyads (n = 163 for the intervention group and n = 175 for the control group). INTERVENTION: Study lactation consultants attempted 2 prenatal meetings, 1 postpartum hospital and/or home visit, and telephone calls as needed. Controls received the standard of care. MAIN OUTCOME MEASURES: Combined outpatient and emergency department visits with illness and BFS illness diagnoses. RESULTS: There was a significant interaction between treatment and Medicaid; among those not receiving Medicaid, the number of otitis media visits was higher among controls (P

Sleep health literacy in head start families and staff: exploratory study of knowledge, motivation, and competencies to promote healthy sleep.

CONTEXT: Healthy child development requires sufficient, quality sleep. Sleep problems in early childhood impair social-emotional and cognitive function and increase obesity risk. From a health literacy framework, "sleep health literacy" denotes the knowledge, motivation, and competencies to promote healthy sleep and to recognize a sleep problem. DESIGN: To explore the untapped potential of early childhood education (ECE) programs to promote sleep health literacy, we surveyed staff (n=63) and parents (n=196) in Head Start about sleep-related knowledge, attitudes/beliefs, sleep hygiene, and sleep problems. Head Start is the largest ECE program in the United States. RESULTS: Most parents believed that their child had healthy sleep habits (81%); few believed that he or she had a sleep problem (10%). Yet, unhealthy bedtime practices and insufficient sleep for age were reported in 50% and 33% of children, respectively. Between 10% and 12% of children had 1 or more sleep onset or awakening problems. Every unhealthy bedtime practice but one was associated with a sleep problem; parental presence at bedtime was associated with the most problems. Insufficient sleep was significantly associated with unhealthy sleep practices. More children with late vs early bedtimes (48% vs14%, P < .01) and frequent vs less frequent parental presence at bedtime (50% vs 26%-30%, P < .02) failed to obtain sufficient sleep. Staff members are more comfortable discussing healthy sleep with parents (87%) than counseling them (45%). CONCLUSION: Among parents, there is a "disconnect" between actual and perceived sleep hygiene. Similarly, staff perceived a gap between their competencies to promote healthy sleep in families and their capacity to address sleep problems. US health literacy goals include the need to embed accurate, accessible, and actionable health information in ECE programs. Study findings strongly support the need to work toward sleep health literacy in ECE programs.

The Burden of Sleep Problems: A Pilot Observational Study in an Ethnically Diverse Urban Primary Care Setting.

INTRODUCTION: Sleep disorders affect up to 1 in 4 adults and can adversely affect a variety of health conditions. However, little is known about detection of sleep disorders in ethnically diverse urban primary care settings. METHODS: Patients in urban primary care settings completed surveys to screen for sleep problems and identify comorbid conditions. Providers were given screening results, and provided feedback regarding their clinical utility. RESULTS: Participants (n = 95) were predominantly women (76.8%) and black, non-Hispanic (46.3%), or Hispanic (38.9%). High proportion of participants screened positive for insomnia (31.6%) and screened high risk for sleep apnea (42.1%). Only one-third (32.6%) of participants reported sleeping the recommended 7 to 9 hours per night. The presence of chronic pain (χ(2) = 4.97, P = .03) was associated with clinically significant insomnia. Obesity was associated with fewer hours of sleep per night, t = 2.19(87), P = .03, and risk for sleep apnea (OR = 3.11, 95% CI = 1.28-7.50). Participants were interested in receiving help for sleep issues during their primary care visits (40%), and providers found the screening at least somewhat useful (74.4%). DISCUSSION: Results highlight the potentially high unmet need for screening and treatment of sleep problems in ethnically diverse urban primary care settings.

Country of origin and race/ethnicity: impact on breastfeeding intentions.

This article reports on breastfeeding intentions of Hispanic and black women by country of origin (continental US born or foreign born) in a low-income population that has experienced demographic shifts. Data were derived from prenatal interviews with 382 women from 2 community clinics. Primary outcome measures were intentions to formula feed, breastfeed, or formula and breastfeed. Foreign-born women were significantly more likely to intend to only breastfeed (42% vs 24% for continental US born, P < .05). In multivariate analyses, country of origin and having breastfed a previous child were the only significant predictors of breastfeeding intention. In contrast to previous work, black (non-Hispanic) and Hispanic women's breastfeeding plans were similar. This finding coincides with dramatic increases in the numbers of blacks from West Indian countries-where breastfeeding is the norm-in the study locale.

Prolonged bottle use and its association with iron deficiency anemia and overweight: a preliminary study.

To determine the prevalence of prolonged bottle feeding practices in young children, and its association with body mass index (BMI) and iron deficiency anemia (IDA), we conducted a cross-sectional survey study at 3 Bronx, NY, WIC sites. Caregivers of 95 predominantly Hispanic and African-American WIC-enrolled children aged 18-56 months presenting for recertification completed questionnaires. Half were overweight (>85th% BMI) and 36% were obese (>95th% BMI); 21% met CDC criteria for anemia. Two thirds (63%) received daily bottles of milk or sweet liquids. Daily bottle use ranged from 3 to 10 (mean=3.3, median=3). Bottle use was significantly associated with obesity (>95th% BMI, p<0.0005), not significant with overweight (>85th% BMI, p<0.06) and statistically significant with IDA.

Prevalence and persistence of sleep disordered breathing symptoms in young children: a 6-year population-based cohort study.

STUDY OBJECTIVES: To describe the prevalence, persistence, and characteristics associated with sleep disordered breathing (SDB) symptoms in a population-based cohort followed from 6 months to 6.75 years. DESIGN: Avon Longitudinal Study of Parents and Children (ALSPAC). SETTING: England, 1991-1999. PARTICIPANTS: 12,447 children in ALSPAC with parental report of apnea, snoring, or mouth-breathing frequency on any one of 7 questionnaires. MEASUREMENTS: Symptom prevalence rates-assessed as "Always" and "Habitually"-are reported at 0.5, 1.5, 2.5, 3.5, 4.75, 5.75, and 6.75 years of age. The proportion of children in whom symptoms develop, persist or abate between observation points is reported. Exploratory multivariate analyses identified SDB risk factors at 1.5, 4.75, and 6.75 years. RESULTS: The prevalence of apnea ("Always") is 1%-2% at all ages assessed. In contrast, snoring "Always" ranges from 3.6% to 7.7%, and snoring "Habitually" ranges from 9.6% to 21.2%, with a notable increase from 1.5- 2.5 years. At 6 years old, 25% are habitual mouth-breathers. The "Always" and "Habitual" incidence of each symptom between time points is 1%-5% and 5%-10%, respectively. In multivariate analyses of combined symptoms, socioeconomic factors have stronger, more persistent effects upon increased SDB risk than gestational age, gender, or race (aside from 1.5 years); adenoidectomy decreases risk by 40%-50%. CONCLUSIONS: This is the first natural history study of the primary symptoms of SDB across a key 6-year period in the development of SDB symptoms. Snoring rates are higher and spike earlier than previously reported. Symptoms are dynamic, suggesting the need for early and continued vigilance in early childhood.

Clinical translational research hits the road: RCT of breastfeeding promotion interventions in routine prenatal care.

Translating evidence-based research into practice requires data from clinical trials in real world settings. This paper presents "lessons learned" from the implementation of an RCT of breastfeeding promotion interventions at two busy, urban, prenatal care sites. Data were obtained via direct observations, qualitative interviews, and study statistics. Primary challenges include: time and space burdens, "research vs. service" mission conflict, and the provider learning curve for conducting interventions. Primary facilitators include: researcher presence for enhancing rapport with participants and staff, site staff labeling of both the research interview and intervention as "value added time," and the ability of research staff to assist the clinic beyond the scope of the clinical trial. Specific suggestions are given for building collaborative bonds between the research team, clinicians, administrators, and staff in busy urban practices.

Mother's reactions to a skills-based breastfeeding promotion intervention.

We interviewed women who participated in a breast-feeding promotion intervention study about whether and how participation affected their infant feeding choices, and if they would recommend such an intervention to others. The larger study, a randomized controlled trial (RCT) of an individualized, pre- and post-natal lactation consultant (LC) intervention, enrolled 382 low-income primarily Black and Hispanic women in New York City. Twenty-one women completed qualitative exit interviews for this study (11 from the Intervention group and 10 Controls). Several of the Controls stated that the post-partum study interviews were a source of support, and made them more conscious of how they fed their infant. The Intervention Group was asked about contacts with the study 'Mother-Baby specialist' (i.e. LC), including what was and wasn't helpful. The Intervention Group participants described the Mother-Baby Specialist as key in their decision to initiate and maintain breastfeeding. They credit her direct skills and positive reinforcement with their confidence and perseverance to breastfeed. The success of the intervention is attributed to technical assistance from a trained lactation consultant within the context of a relationship built on encouragement, guidance and support.

Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months.

OBJECTIVE: To determine whether an individualized, prenatal and postnatal, lactation consultant intervention resulted in increased cumulative intensity of breastfeeding up to 52 weeks. DESIGN: The randomized, nonblinded, controlled trial recruited women from prenatal care. Baseline prenatal interviews covered demographic data and breastfeeding experience, intention, and knowledge. Interviews at 1, 2, 3, 4, 6, 8, 10, and 12 months after birth collected data on weekly feeding patterns, infant illness, and infant health care use. SETTING: Two community health centers serving low-income, primarily Hispanic and/or black women. PARTICIPANTS: The analytic sample included 304 women (intervention: n = 145; control: n = 159) with > or = 1 postnatal interview. INTERVENTION: Study lactation consultants attempted 2 prenatal meetings, a postpartum hospital visit, and/or home visits and telephone calls. Control subjects received the standard of care. OUTCOME MEASURES: Cumulative breastfeeding intensity at 13 and 52 weeks, based on self-reports of weekly feeding, on a 7-level scale. RESULTS: The intervention group was more likely to breastfeed through week 20 (53.0% vs 39.3%). Exclusive breastfeeding rates were low and did not differ according to group. In multivariate analyses, control subjects had lower breastfeeding intensity at 13 weeks (odds ratio [OR]: 1.90; 95% confidence interval [CI]: 1.13-3.20) and 52 weeks (OR: 2.50; 95% CI: 1.48-4.21). US-born control subjects had lowest breastfeeding intensity at 13 weeks (OR: 5.22; 95% CI: 2.43-11.22) and 52 weeks (OR: 5.25; 95% CI: 2.44-11.29). There were no significant differences in breastfeeding intensity among the US-born intervention, foreign-born intervention, and foreign-born control groups. CONCLUSIONS: This "best-practices" intervention was effective in increasing breastfeeding duration and intensity. Breastfeeding promotion should focus on US-born women and exclusive breastfeeding.