Reported Adherence to the 10 Steps to Successful Breastfeeding Is Higher Among Baby-Friendly Hospitals.

OBJECTIVE: Quantify and compare reported breastfeeding support practices in the Baby-Friendly Hospital Initiative (BFHI) and non-BFHI facilities. DESIGN: Cross-sectional survey. SETTING: Regions across the US. PARTICIPANTS: Two hundred and eighty-six facilities (110 BFHI and 176 non-BFHI) selected by a stratified (by hospital size) random sample of 50% BFHI and 50% non-BFHI facilities. INTERVENTION: Emailed survey Fall 2019 through Spring 2020. MAIN OUTCOME MEASURE: Reported adherence to the 10 Steps to Successful Breastfeeding. ANALYSIS: Wilcoxon rank sum test with continuity correction, Pearson chi-square test of independence, and Fisher's exact test. RESULTS: Baby-Friendly Hospital Initiative facilities were more likely to report adherence to the 10 Steps to Successful Breastfeeding. Only 2 of the reported steps were not significantly different: immediate postnatal care and responsive feeding. CONCLUSIONS AND IMPLICATIONS: This research supports breastfeeding support interventions within hospitals as both BFHI and non-BFHI facilities have room for improvement. Interventions targeting non-BFHI facilities are an opportunity to close the disparity in breastfeeding care.

Supporting breastfeeding equity: A cross-sectional study of US birthing facility administrators.

Disparities in breastfeeding have continued in the United States (US) despite efforts to increase breastfeeding rates. Hospitals are in a unique position to enable breastfeeding and help reduce disparities; however, it is unclear whether hospital administration is supportive of breastfeeding equity practices or plans. This study aimed to assess birthing facility plans to support breastfeeding among women of low income and women of color across the US. We administered electronic surveys to 283 US hospital administrators between 2019 and 2020. We assessed whether facilities had a plan in place to support breastfeeding among women of low income and women of color. We assessed associations between Baby-Friendly Hospital Initiative (BFHI) status and having a plan in place. We examined reported activities provided through open-ended responses. Fifty-four percent of facilities had a plan in place to support breastfeeding among women of low income and 9% had a plan in place to support breastfeeding among women of color. Having a plan was not associated with having a BFHI designation. A lack of plan to specifically help those with the lowest rates of breastfeeding may perpetuate rather than reduce inequities. Providing anti-racism and health equity training to healthcare administrators may help birthing facilities achieve breastfeeding equity.

Food security and diet quality in a racially diverse cohort of postpartum women in the USA.

Food insecurity has been associated with poor diet, but few studies focused on the postpartum period - an important time for women's health. We examined associations between food security and diet quality in postpartum women and assessed whether participation in federal food assistance programmes modified this potential relation. Using longitudinal data, we analysed the association between food security at 3 months postpartum and a modified Alternate Healthy Eating Index-2010 (AHEI) at 6 months postpartum (excluding alcohol). We conducted multivariable linear regressions examining associations between food security and AHEI. We assessed two food assistance programmes as potential effect modifiers. The sample included 363 postpartum women from the Nurture study, located in the Southeastern USA (2013-2017). Among women, 64·4 % were Black and 45·7 % had a high school diploma or less. We found no evidence of an interaction between food security and two federal food assistance programmes. In adjusted models, marginal, low and very low food security were not associated with AHEI. However, low (ß: -0·64; 95 % CI -1·15, -0·13; P = 0·01) and very low (ß: -0·57; 95 % CI -1·02, -0·13; P = 0·01) food security were associated with greater trans fat intake. Food security status was not associated with overall diet quality but was associated with higher trans fat (low and very low) and more moderate alcohol (marginal) intake. Future studies should assess the consistency and generalisability of these findings.

Maternal Mediterranean Diet Adherence and Its Associations with Maternal Prenatal Stressors and Child Growth.

Background: Psychosocial and physiologic stressors, such as depression and obesity, during pregnancy can have negative consequences, such as increased systemic inflammation, contributing to chronic disease for both mothers and their unborn children. These conditions disproportionately affect racial/ethnic minorities. The effects of recommended dietary patterns in mitigating the effects of these stressors remain understudied. Objectives: We aimed to evaluate the relations between maternal Mediterranean diet adherence (MDA) and maternal and offspring outcomes during the first decade of life in African Americans, Hispanics, and Whites. Methods: This study included 929 mother-child dyads from the NEST (Newborn Epigenetics STudy), a prospective cohort study. FFQs were used to estimate MDA in pregnant women. Weight and height were measured in children between birth and age 8 y. Multivariable linear regression models were used to examine associations between maternal MDA, inflammatory cytokines, and pregnancy and postnatal outcomes. Results: More than 55% of White women reported high MDA during the periconceptional period compared with 22% of Hispanic and 18% of African American women (P < 0.05). Higher MDA was associated with lower likelihood of depressive mood (ß = -0.45; 95% CI: -0.90, -0.18; P = 0.02) and prepregnancy obesity (ß = -0.29; 95% CI: -0.57, -0.0002; P = 0.05). Higher MDA was also associated with lower body size at birth, which was maintained to ages 3-5 and 6-8 y-this association was most apparent in White children (3-5 y: ß = -2.9, P = 0.02; 6-8 y: ß = -3.99, P = 0.01). Conclusions: If replicated in larger studies, our data suggest that MDA provides a potent avenue by which effects of prenatal stressors on maternal and fetal outcomes can be mitigated to reduce ethnic disparities in childhood obesity.

Associations Among Food Security, Diet Quality, and Dietary Intake During Pregnancy in a Predominantly African American Group of Women from North Carolina.

BACKGROUND: Low food security during pregnancy can negatively affect women's physical and mental health. Although many women make a greater effort to eat a healthy diet during pregnancy, the influence of low food security during pregnancy on maternal diet is not well understood. OBJECTIVE: This study aimed to assess the association between adult food security and maternal diet during pregnancy in a sample from North Carolina. DESIGN: This was a cross-sectional, secondary data analysis of food security (marginal, low, and very low vs high) and maternal diet during pregnancy. PARTICIPANTS AND SETTING: This study included 468 predominantly Black/African American women during pregnancy from the Nurture cohort, enrolled through prenatal clinics in central North Carolina between 2013 and 2016. MAIN OUTCOME MEASURE: Diet quality was assessed using the Alternate Healthy Eating Index-Pregnancy and the Mediterranean Diet Score. Dietary intake from seven food groups included in the Alternate Healthy Eating Index-Pregnancy and/or Mediterranean Diet Score was assessed as well. STATISTICAL ANALYSIS PERFORMED: Multiple linear regression models were used to examine the association between food security and diet quality and dietary intake during pregnancy, adjusting for race/ethnicity; participation in the Special Supplemental Nutrition Program for Women, Infants, and Children; education; prepregnancy body mass index; age; parity; and mean daily energy intake. RESULTS: In this study, there was no association between maternal food security status and diet quality during pregnancy. However, researchers observed an association between low and marginal food security and greater intake of red and processed meats (marginal: ß = 2.20 [P = 0.03]; low: ß = 2.28 [P = 0.04]), as well as an association between very low food security and decreased vegetable consumption (ß = -.43; P = 0.03). CONCLUSIONS: Very low food security was associated with reduced vegetable intake. In addition, low and marginal food security were associated with greater red and processed meat intake. Future research should focus on nationally representative populations and include longitudinal assessments to allow for the study of the influence of food security on health during pregnancy.

Formative evaluation of a portion control and calorie reduction campaign: Insights from focus groups with target audience.

Healthy eating campaigns can increase awareness of healthful foods and eating patterns and prompt behavior change. Portion control can be a useful strategy in weight management efforts, and new, innovative campaigns can help invigorate messages related to portion control and weight management. This qualitative study presents results of formative testing of portion control and calorie reduction messages and infographics for a proposed campaign. We conducted 17 focus groups with 113 adults ages 18-65 years in 3 US cities. We conducted separate focus groups by weight status (overweight/healthy weight) and gender (male/female) and analyzed coded data and categorized emerging themes. Participants, especially those with healthy weights, gravitated toward specific, and achievable messages to encourage portion control and calorie reduction. Men with overweight and women with healthy weights preferred messages that had a positive, supportive tone. Participants favored messages that addressed overeating and allowed for autonomy. In particular, women and those with healthy weights preferred messages that encouraged calorie budgeting. Many participants, in particular men, provided positive feedback on messages encouraging a "fresh start" on Mondays. Additionally, participants preferred messages that were colorful, informative, realistic, attractive, and relatable. With regard to message dissemination, participants suggested that messages and infographics be positioned in high-traffic areas and men generally suggested places where food decisions are made. Moreover, participants suggested message dissemination through trusted health professionals and credible research organizations. Health organizations planning a portion control or calorie reduction campaign should consider these factors early in the development process to help ensure acceptance and success.

Associations between Maternal Cadmium Exposure with Risk of Preterm Birth and Low after Birth Weight Effect of Mediterranean Diet Adherence on Affected Prenatal Outcomes.

Prenatal cadmium exposure at non-occupational levels has been associated with poor birth outcomes. The intake of essential metals, such as iron and selenium, may mitigate cadmium exposure effects. However, at high levels, these metals can be toxic. The role of dietary patterns rich in these metals is less studied. We used a linear and logistic regression in a cohort of 185 mother-infant pairs to assess if a Mediterranean diet pattern during pregnancy modified the associations between prenatal cadmium exposure and (1) birth weight and (2) preterm birth. We found that increased cadmium exposure during pregnancy was associated with lower birth weight (ß = -210.4; 95% CI: -332.0, -88.8; p = 0.008) and preterm birth (OR = 0.11; 95% CI: 0.01, 0.72; p = 0.04); however, these associations were comparable in offspring born to women reporting high adherence to a Mediterranean diet (ß = -274.95; 95% CI: -701.17, 151.26; p = 0.20) and those with low adherence (ß = -64.76; 95% CI: -359.90, 230.37; p = 0.66). While the small sample size limits inference, our findings suggest that adherence to a Mediterranean dietary pattern may not mitigate cadmium exposure effects. Given the multiple organs targeted by cadmium and its slow excretion rate, larger studies are required to clarify these findings.

A Public Health Messaging Campaign to Reduce Caloric Intake: Feedback From Expert Stakeholders.

OBJECTIVE: To obtain expert feedback on a public health messaging campaign to reduce caloric intake in US adults. DESIGN AND SETTING: In 2018, researchers conducted semistructured telephone interviews with US-based experts in obesity prevention, mental health, and health communications. PARTICIPANTS: The research team invited 100 experts to participate using purposive and snowball sampling techniques. Of those invited, 60 completed interviews, among which 37 (62%) were obesity prevention experts, 12 (20%) were mental health experts, and 11 (18%) were health communications experts. MAIN OUTCOME MEASURE: Expert feedback regarding a public health messaging campaign to reduce caloric intake. ANALYSIS: Two researchers reviewed and coded all transcripts. The team identified major themes and summarized findings. RESULTS: Most experts identified barriers to effective calorie reduction including social and environmental factors, lack of actionable strategies, and confusion regarding healthy eating messages. Expert suggestions for effective messaging included addressing eating patterns, emphasizing nutrient density, and dissemination through multiple channels and trusted sources. In general, mental health experts more frequently voiced concerns regarding eating disorders, and communications experts raised issues regarding the dissemination of campaigns. CONCLUSIONS AND IMPLICATIONS: Professionals should identify and address barriers to delivering a calorie reduction campaign before implementation, using strategies that enhance delivery to ensure an effective campaign.

State Regulations to Support Children's Cultural and Religious Food Preferences in Early Care and Education.

OBJECTIVE: In July 2018 the Academy of Nutrition and Dietetics released a benchmark encouraging early care and education (ECE) programs, including child care centers and family child care homes, to incorporate cultural and religious food preferences of children into meals. We examined the extent to which states were already doing so through their ECE licensing and administrative regulations prior to the release of the benchmark. This review may serve as a baseline to assess future updates, if more states incorporate the benchmark into their regulations. METHODS: For this cross-sectional study, we reviewed ECE regulations for all 50 states and the District of Columbia (hereafter states) through June 2018. We assessed consistency with the benchmark for centers and homes. We conducted Spearman correlations to estimate associations between the year the regulations were updated and consistency with the benchmark. RESULTS: Among centers, eight states fully met the benchmark, 11 partially met the benchmark, and 32 did not meet the benchmark. Similarly for homes, four states fully met the benchmark, 13 partially met the benchmark, and 34 did not meet the benchmark. Meeting the benchmark was not correlated with the year of last update for centers (P = 0.54) or homes (P = 0.31). CONCLUSIONS: Most states lacked regulations consistent with the benchmark. Health professionals can help encourage ECE programs to consider cultural and religious food preferences of children in meal planning. And, if feasible, states may consider additional regulations supporting cultural and religious preferences of children in future updates to regulations.

Associations of maternal diet with infant adiposity at birth, 6 months and 12 months.

OBJECTIVES: To assess associations between maternal prenatal diet quality and infant adiposity. DESIGN: The design was a prospective birth cohort. SETTING: We used data from the Nurture study, a cohort of women and their infants residing in the southeastern USA. PARTICIPANTS AND EXPOSURE ASSESSMENT: Between 2013 and 2015, we enrolled 860 women between 20 and 36 weeks' gestation. After reconsenting at delivery and excluding women with implausible calorie intakes, we measured dietary intake using the Block food frequency questionnaire, and assessed diet quality using a modified Alternate Healthy Eating Index 2010 (AHEI-2010), which assessed intake of 10 food categories, including fruits, vegetables, whole grains, nuts/legumes, fats, meats, beverages and sodium (excluding alcohol). OUTCOMES: We assessed birth weight for gestational age z-score, small and large for gestational age, low birth weight and macrosomia. Outcomes at 6 and 12 months were weight-for-length z-score, sum of subscapular and triceps skinfold thickness (SS+TR) and subscapular-to-triceps skinfold ratio (SS:TR). RESULTS: Among mothers, 70.2% were black and 20.9% were white; less than half (45.2%) reported having a high school diploma or less. Among infants, 8.7% were low birth weight and 8.6% were small for gestational age. Unadjusted estimates showed that a higher AHEI-2010 score, was associated with a higher birth weight for gestational z-score (ß=0.01; 95% CI 0.002 to 0.02; p=0.02) and a greater likelihood of macrosomia (OR=1.04; 95% CI 1.004 to 1.09; p=0.03). After adjustment, maternal diet quality was not associated with infant adiposity at birth, 6 or 12 months. CONCLUSIONS: Although poor maternal diet quality during pregnancy was not associated with infant adiposity in our study, maternal diet during pregnancy may still be an important and modifiable factor of public health importance.

Periconceptional Maternal Mediterranean Diet Is Associated With Favorable Offspring Behaviors and Altered CpG Methylation of Imprinted Genes.

Background: Maternal diet during pregnancy has been shown to influence the child neuro-developmental outcomes. Studies examining effects of dietary patterns on offspring behavior are sparse. Objective: Determine if maternal adherence to a Mediterranean diet is associated with child behavioral outcomes assessed early in life, and to evaluate the role of differentially methylated regions (DMRs) regulating genomically imprinted genes in these associations. Methods: Among 325 mother/infant pairs, we used regression models to evaluate the association between tertiles of maternal periconceptional Mediterranean diet adherence (MDA) scores derived from a Food Frequency Questionnaire, and social and emotional scores derived from the Infant Toddler Social and Emotional Assessment (ITSEA) questionnaire in the second year of life. Methylation of nine genomically imprinted genes was measured to determine if MDA was associated with CpG methylation. Results: Child depression was inversely associated with maternal MDA (Bonferroni-corrected p = 0.041). While controlling for false-discovery, compared to offspring of women with the lowest MDA tertile, those with MDA scores in middle and high MDA tertiles had decreased odds for atypical behaviors [OR (95% CI) = 0.40 (0.20, 0.78) for middle and 0.40 (0.17, 0.92) for highest tertile], for maladaptive behaviors [0.37 (0.18, 0.72) for middle tertile and 0.42 (0.18, 0.95) for highest tertile] and for an index of autism spectrum disorder behaviors [0.46 (0.23, 0.90) for middle and 0.35 (0.15, 0.80) for highest tertile]. Offspring of women with the highest MDA tertile were less likely to exhibit depressive [OR = 0.28 (0.12, 0.64)] and anxiety [0.42 (0.18, 0.97)] behaviors and increased odds of social relatedness [2.31 (1.04, 5.19)] behaviors when compared to low MDA mothers. Some associations varied by sex. Perinatal MDA score was associated with methylation differences for imprinted control regions of PEG10/SGCE [females: Beta (95% CI) = 1.66 (0.52, 2.80) - Bonferroni-corrected p = 0.048; males: -0.56 (-1.13, -0.00)], as well as both MEG3 and IGF2 in males [0.97 (0.00, 1.94)] and -0.92 (-1.65, -0.19) respectively. Conclusion: In this ethnically diverse cohort, maternal adherence to a Mediterranean diet in early pregnancy was associated with favorable neurobehavioral outcomes in early childhood and with sex-dependent methylation differences of MEG3, IGF2, and SGCE/PEG10 DMRs.

State Regulations Promoting Infant Physical Activity in Early Care and Education.

BACKGROUND: State policies have the potential to improve early care and education (ECE) settings, but little is known about the extent to which states are updating their licensing and administrative regulations, especially in response to national calls to action. In 2013, we assessed state regulations promoting infant physical activity in ECE and compared them with national recommendations. To assess change over time, we conducted this review again in 2018. METHODS: We reviewed regulations for all US states for child care centers (centers) and family child care homes (homes) and compared them with three national recommendations: (1) provide daily tummy time; (2) use cribs, car seats, and high chairs for their primary purpose; and (3) limit the use of restrictive equipment (e.g., strollers). We performed exact McNemar's tests to compare the number of states meeting recommendations from 2013 to 2018 to evaluate whether states had made changes over this period. RESULTS: From 2013 to 2018, we observed significant improvement in one recommendation for homes-to use cribs, car seats, and high chairs for their primary purpose (odds ratio 11.0; 95% CI 1.6-47.3; p = 0.006). We did not observe any other significant difference between 2013 and 2018 regulations. CONCLUSIONS: Despite increased awareness of the importance of early-life physical activity, we observed only modest improvement in the number of states meeting infant physical activity recommendations over the past 5 years. In practice, ECE programs may be promoting infant physical activity, but may not be required to do so through state regulations.

DNA methylation of imprinted genes at birth is associated with child weight status at birth, 1 year, and 3 years.

Background: This study assessed the associations between nine differentially methylated regions (DMRs) of imprinted genes in DNA derived from umbilical cord blood leukocytes in males and females and (1) birth weight for gestational age z score, (2) weight-for-length (WFL) z score at 1 year, and (3) body mass index (BMI) z score at 3 years. Methods: We conducted multiple linear regression in n = 567 infants at birth, n = 288 children at 1 year, and n = 294 children at 3 years from the Newborn Epigenetics Study (NEST). We stratified by sex and adjusted for race/ethnicity, maternal education, maternal pre-pregnancy BMI, prenatal smoking, maternal age, gestational age, and paternal race. We also conducted analysis restricting to infants not born small for gestational age. Results: We found an association between higher methylation of the sequences regulating paternally expressed gene 10 (PEG10) and anthropometric z scores at 1 year (ß = 0.84; 95% CI = 0.34, 1.33; p = 0.001) and 3 years (ß = 1.03; 95% CI = 0.37, 1.69; p value = 0.003) in males only. Higher methylation of the DMR regulating mesoderm-specific transcript (MEST) was associated with lower anthropometric z scores in females at 1 year (ß = - 1.03; 95% CI - 1.60, - 0.45; p value = 0.001) and 3 years (ß = - 1.11; 95% CI - 1.98, - 0.24; p value = 0.01). These associations persisted when we restricted to infants not born small for gestational age. Conclusion: Our data support a sex-specific association between altered methylation and weight status in early life. These methylation marks can contribute to the compendium of epigenetically regulated regions detectable at birth, influencing obesity in childhood. Larger studies are required to confirm these findings.

Childcare Providers' Possession or Use of Marijuana, Tobacco, or Alcohol While Caring for Children: A Comparison of US State Regulations.

OBJECTIVES: To evaluate US state regulations regarding marijuana, tobacco, and alcohol to determine the extent to which states attempt to govern these substances in early care and education (ECE) settings. METHODS: Two independent reviewers assessed regulations enacted by December 2016 for all states and the District of Columbia. Reviewers compared regulations to national standards on the possession or use of marijuana, tobacco, and alcohol in ECE settings. RESULTS: Fewer states regulated marijuana than tobacco or alcohol in ECE settings. More states restricted the use of these 3 substances than they restricted the possession of them. CONCLUSIONS: Most states address alcohol or tobacco possession or use in their regulations but should consider updating these provisions to align with national standards. Public Health Implications. Updating and strengthening state childcare regulations regarding marijuana, tobacco, and alcohol possession and use may help protect children in ECE settings, where many children spend a substantial portion of time. As more states legalize marijuana, they may consider updating their regulations and including precise language to better protect children from unintended pediatric marijuana exposure or impaired childcare providers.

Achieving Breastfeeding Equity: A Study of a National Breastfeeding Initiative.

BACKGROUND: Equity in breastfeeding could reduce excess morbidity and mortality among children and mothers of color. Few programs that support breastfeeding have been evaluated for their capacity to create equity. The aim of this study was to assess the extent to which a diverse set of national breastfeeding programs actively promoted equity. SUBJECTS AND METHODS: Qualitative data collection was conducted between December 2012 and July 2013 by visits to 29 of 58 breastfeeding programs selected by the funder. Programs underwent a site visit with open-ended interviews of staff. Investigators used Atlas.ti software to code data and content analysis of qualitative evaluation data. Key categories and themes were identified to answer the questions: how do the programs conceptualize equity? and how do the organizations operationalize an approach to equity? RESULTS: Programs had widely divergent and often limited conceptualizations of equity. Nine categories describe the equity approaches' programs used. The social, political, and environmental contexts in which programs operated varied in the degree of challenge they pose for implementing equity-focused breastfeeding methods. We found only a few programs that matched the social, cultural, and economic realities and context of women of color. CONCLUSIONS: Breastfeeding equity programs need to explicitly define and envision outcomes, and need to identify equity inhibiting policies and practices. Equity attainment is more likely to emerge from institutional transformational processes that collaborate with the populations at risk. These findings have implications for other programs addressing equity in health.

Media and Young Minds: Comparing State Screen Media Use Regulations for Children Under 24 Months of Age in Early Care and Education to a National Standard.

Introduction Excessive screen media use has been associated with a number of negative health outcomes in young children, including increased risk for obesity and comparatively lagging cognitive development. The purpose of this study was to assess state licensing regulations restricting screen media use for children under 24 months old in early care and education (ECE) and to compare regulations to a national standard. Methods We reviewed screen media use regulations for all US states for child care centers ("centers") and family child care homes ("homes") and compared these regulations to a national standard discouraging screen media use in children under 24 months of age. We assessed associations between state geographic region and year of last update with the presence of regulations consistent with the standard. In centers, 24 states had regulations limiting screen media use for children under 24 months of age and 19 states had regulations limiting screen media use in homes. Results More states in the South and fewer states in the Midwest had regulations limiting screen media use. The association between geographic region and regulations was not significant for centers (p = 0.06), but was for homes (p = 0.04). The year of last update (within the past 5 years versus older than 5 years) was not associated with regulations for centers (p = 0.18) or homes (p = 0.90). Discussion Many states lacked screen media use regulations for ECE. States should consider adding screen media use restrictions for children under 24 months based on current research data and current recommendations in future regulations updates.

"We black women have to kill a lion everyday": An intersectional analysis of racism and social determinants of health in Brazil.

The concept of intersectionality has been used to analyze and understand how multiple forms of identity and oppression interact to shape life experiences of marginalized groups. We conducted a qualitative study to explore how Black Brazilian women experience the intersections of race, class, and gender and the ways in which these intersecting experiences act as social determinants of health. Nine focus groups were conducted with Black, White, and mixed-race women of childbearing age (n = 37), social and health activists (n = 11), and health professionals (n = 20). The focus groups took place in two cities in the Brazilian state of Bahia during October and November 2012. Using a comparative approach, we describe participants' responses regarding the life experiences of women of differing racial and class backgrounds. Our findings highlight how the intersectional relationship between race, class, and gender alters women's social context and life course opportunities, as well as their stressors and protective buffers. We argue that the differing intersectional experiences of women due to race and class create unique social contexts that define the parameters of health and wellness. In addition, we argue that the experiences at each intersection (i.e., raceXclass, raceXgender, classXgender, raceXclassXgender) have a unique character that can be qualitatively described. Improved specification of exposures experienced by marginalized populations who experience intersecting forms of oppression can help explain intra- and inter-group differences in health outcomes, and may also lead to improved intervention models.

State Variations in Infant Feeding Regulations for Child Care.

OBJECTIVES: Early care and education (ECE) settings have become primary targets for policy change in recent years. In our 2008 study, we assessed state and regional variation in infant feeding regulations for ECE and compared them to national standards. We conducted the same regulatory review to assess change over time. Because all but 2 states have updated their regulations, we hypothesized that states would have made substantial improvements in the number of regulations supporting infant feeding in ECE. METHODS: For this cross-sectional study, we reviewed infant feeding regulations for all US states for child care centers (centers) and family child care homes (homes). We compared regulations with 10 national standards and assessed the number of new regulations consistent with these standards since our previous review. RESULTS: Comparing results from 2008 and 2016, we observed significant improvements in 7 of the 10 standards for centers and 4 of the 10 standards for homes. Delaware was the only state with regulations meeting 9 of the 10 standards for centers in 2008. In 2016, Delaware and Michigan had regulations meeting 8 of the 10 standards. Previously, Arkansas, the District of Columbia, Minnesota, Mississippi, Ohio, and South Carolina had regulations consistent with 4 of the 10 standards for homes. In 2016, Delaware, Mississippi, and Vermont had regulations meeting 7 of the 10 standards. CONCLUSIONS: Evidence suggests that enacting new regulations may improve child health outcomes. Given that many states recently enacted regulations governing infant feeding, our findings point to the growing interest in this area.

Early feeding in child care in the United States: Are state regulations supporting breastfeeding?

Most women in the US are not meeting the recommendation of exclusively breastfeeding their infants for the first 6months of life. The child care environment can be especially influential in a mother's ability to continue breastfeeding after returning to employment. For this study, we reviewed child care regulations related to breastfeeding for centers and homes in all 50 states and the District of Colombia in late 2016, and compared them to 5 national standards. We coded regulations as either not meeting, partially meeting, or fully meeting each standard. We assessed correlations between number of regulations consistent with standards and 1) geographic census region and 2) last year of update. This study provides an update to a previous review conducted in 2012. No state met all 5 of the included standards, and only 2 states for centers and 1 state for homes at least partially met 4 of the 5 standards. More states had regulations consistent with standards encouraging general support for breastfeeding and requiring a designated place for mothers to breastfeed onsite. Number of regulations consistent with standards was associated with geographic census region, but not last year of update. States in the South had a greater number of regulations consistent with standards and states in the West had the fewest number of regulations consistent with standards. Overall support for breastfeeding at the state child care regulation level continues to be insufficient. States should improve child care regulations to include greater support for breastfeeding in child care facilities.