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Abstract Limited evidence exists on the long‐term effects of early feeding practices on child growth and development. We examined the relationships between infant feeding practices and child height and development at ages 2 and 6–7 years. We studied 885 mother–child dyads from a randomized controlled trial of preconception supplementation in Vietnam. Early initiation of breastfeeding (EIBF), exclusive breastfeeding (EBF), breastfeeding (BF) duration and minimum dietary diversity (MDD) were assessed using World Health Organization (WHO) guidelines. Child development was assessed by the Bayley Scales of Infant Development‐III at 2 years and the Wechsler Intelligence Scale for Children® – IV at 6–7 years. Child height‐for‐age z‐score (HAZ) was calculated from child height and age. Multivariable regression and structural equation models were used in analyses that controlled for confounding. EIBF and EBF at 6 months occurred in 52% and 62% of children, respectively. Mean breastfeeding duration was 18 months and 83% achieved MDD at 1 year. EIBF was associated with motor (β = 0.13, 95% confidence interval [CI]: 0.00, 0.28) and cognitive development at 2 years (β = 0.12, 95% CI: −0.01, 0.26), which in turn were positively associated with cognitive development at 6–7 years. EBF was directly associated with development at 6–7 years (β = 0.21, 95% CI:0.08, 0.34) whereas motor and cognitive development at 2 years explained 41%–75% of the relationship between EIBF and development at 6–7 years. HAZ at 2 years also mediated 70% of the association between MDD at 1 year and HAZ at 6–7 years. BF duration was not associated with child development and HAZ. Early infant feeding practices, especially EIBF and EBF, have important long‐term implications for optimizing child linear growth and cognition as they begin school.

BackgroundPreterm and small for gestational age (SGA) remain significant public health concerns worldwide. Yet limited evidence exists on their growth patterns during childhood from low-or middle-income countries.ObjectivesWe investigated the postnatal growth patterns of preterm and SGA compared to term appropriate for gestational age (AGA) children from birth to 10–11y, and examined the impact of birth status on child nutritional status during the school age years.MethodsChildren born to women who participated in a double-blinded randomized controlled trial of preconception micronutrient supplementation in Vietnam were classified into three groups: preterm AGA (n = 130), full-term SGA (n = 165) and full-term AGA (n = 1,072). Anthropometric data (weight and height) were collected prospectively at birth, 3, 6, 12, 18, 24 months and at 6–7 and 10–11y. We used ANOVA and multiple regression models to examine the differences in growth patterns from birth to 10–11y as well as child undernutrition and overnutrition by birth status.ResultsChildren who were born preterm exhibited rapid postnatal growth, but still had lower HAZ at 1y and 2y and showed catch up to the AGA group at 6y. Compared to those born AGA, SGA infants had higher risk of thinness (BMIZ < −2) at 2y and 6y (adjusted Odds Ratio, AOR [95% CI] 2.5 [1.0, 6.1] and 2.6 [1.4, 4.6], respectively); this risk reduced at 10–11y (1.6 [0.9, 2.8]). The risk of stunting (HAZ

Abstract Background Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment. Methods We conducted an updated systematic review (using PubMed and Cochrane Review) on low (

Abstract Background Inequity in child development is found at early age, but limited evidence exists on whether these gaps change over time and what are the mediators. Objective We aim to (1) quantify wealth related gaps in cognitive and socio-emotional development in early and middle childhood; (2) examine how these gaps were mitigated by maternal, child factors and home environment. Methods We assessed the offspring of women who participated in a randomized controlled trial of preconception micronutrient supplementation in Vietnam (n = 1599). Child development was measured by the Bayley Scales of Infant Development-III (at 1-2y) and the Wechsler Intelligence Scale for Children®—IV (at 6-7y). We used multivariable regression to estimate the changes in wealth gaps for child development over time, adjusting for potential factors that potentially influence cognitive development. Results We found significant wealth gaps in cognitive development during early childhood (gaps between top and bottom quintiles: 0.5 SD); these gaps increased substantially in middle childhood (0.9 SD). Wealth disparity in social emotion did not change over time (0.26–0.28 SD). Maternal factors, quality of home environment, and child nutritional status mitigated the wealth gap in cognitive development (7-42%) in early childhood. The contribution of these mitigating factors was smaller in middle childhood (2- 15%). Wealth gap in social emotion reduced by 13% and 43% among children with better nutritional status at 2y and higher quality of home environment at 6-7y, respectively. Conclusion Interventions focusing on improving quality of home environment, maternal education, wellbeing, and child nutrition status may help reduce developmental deficits associated with poverty.

BackgroundMaternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India.ObjectiveThis qualitative study aimed to: (1) examine pregnant women’s experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption.MethodsWe conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework.ResultsFor ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages.ConclusionKey drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.

BackgroundThere is limited evidence from prospective cohorts in low-resource settings on the long-term impact of pre-pregnancy body mass index (PPBMI) and gestational weight gain (GWG) on postpartum weight retention (PPWR) and maternal and child body composition.ObjectivesWe examined the associations between PPBMI and timing of GWG on PPWR at 1, 2, and 6–7 years and maternal and child percent body fat at 6–7 years.MethodsWe used data from the PRECONCEPT study (NCT01665378) that included prospectively collected data on 864 mother–child pairs from preconception through 6–7 years postpartum. The key outcomes were PPWR at 1, 2, and 6–7 years, and maternal and child percent body fat at 6–7 years that was measured using bioelectric impedance. Maternal conditional GWG (CGWG) was defined as window-specific weight gains (< 20wk, 21-29wk, and ≥ 30wk), uncorrelated with PPBMI and all prior body weights. PPBMI and CGWG were calculated as standardized z-scores to allow for relative comparisons of a 1 standard deviation (SD) increase in weight gain for each window. We used multivariable linear regressions to examine the associations, adjusting for baseline demographic characteristics, intervention, breastfeeding practices, diet and physical activity.ResultsMean (SD) PPBMI and GWG were 19.7 (2.1) kg/m2 and 10.2 (4.0) kg, respectively. Average PPWR at 1, 2, and 6–7 years was 1.1, 1.5 and 4.3 kg, respectively. A one SD increase in PPBMI was associated with a decrease in PPWR at 1 year (β [95% CI]: −0.21 [−0.37, −0.04]) and 2 years (−0.20 [−0.39, −0.01]); while a one SD in total CGWG was associated with an increase in PPWR at 1 year (1.01 [0.85,1.18]), 2 years (0.95 [0.76, 1.15]) and 6–7 years (1.05 [0.76, 1.34]). Early CGWG (< 20 weeks) had the greatest association with PPWR at each time point as well as with maternal (0.67 [0.07, 0.87]) and child (0.42 [0.15, 0.69]) percent body fat at 6–7 years.ConclusionMaternal nutrition before and during pregnancy may have long-term implications for PPWR and body composition. Interventions should consider targeting women preconception and early in pregnancy to optimize maternal and child health outcomes.

BackgroundThe role of changes in maternal hemoglobin (Hb) across pregnancy on child health and development (CHD) remains unclear.ObjectiveWe examined the association between maternal Hb trajectories and CHD outcomes: (a) birth outcomes (birth weight, length, gestational age, preterm, and small for gestational age); (b) child Hb at 3, 6, 12, and 24 months; and (c) motor and mental development at 12 and 24 months and cognitive functioning at age 6–7 years.MethodsWe used data from a randomized controlled trial (PRECONCEPT) conducted in Vietnam (N = 1,175 women enrolled during preconception with offspring follow-up through 6–7 years). Maternal Hb trajectories were developed using latent class analysis with Hb data at preconception, early (≤20 weeks), mid (21–29 weeks), and late (≥30 weeks) pregnancy. Multivariable linear and logistic regression models were used to assess the association between maternal Hb trajectories on CHD outcomes, adjusting for confounding variables at the maternal, child and household levels.ResultsFour distinct maternal Hb trajectories were identified. Track 1 (low initial Hb-decline) was associated with lower child Hb at 3 months (β [95% CI] −0.52 [−0.87, −0.16]), 6 months (−0.36 [−0.68, −0.05]), 12 months (−0.46 [−0.79, −0.13]), and 24 months (−0.44 [−0.72, −0.15]) and motor development at 12 months (−3.58 [−6.76, −0.40]) compared to track 4 (high initial Hb-decline). After adjustment for multiple testing, relationships remained robust with the exception of associations with child Hb at 6 months and motor development at 12 months. Track 2 (low initial Hb-improve) was the only Hb trajectory to increase across pregnancy; however, it was insufficiently powered. Track 3 (mid Hb-decline) was associated with lower child Hb at 12 months (−0.27 [−0.44, −0.10]) and 24 months (−0.20 [−0.34, −0.05]) compared to track 4 (high initial Hb-decline). Maternal Hb trajectories were not associated with birth outcomes or child development at 24 months or 6–7 years.ConclusionMaternal Hb trajectories during pregnancy are associated with child Hb concentrations across the first 1,000 days, but not with birth outcomes or later cognitive functioning. More work is needed to better understand and interpret changes in Hb levels during pregnancy especially in resource poor settings.

Abstract Improving diet quality of preschool children is challenging in countries undergoing food environment and nutrition transition. However, few studies have sought to understand how mothers in these countries decide what and how to feed their children. This study aims to explore maternal experiences, perspectives and beliefs when making food choice decisions for preschool children in urban, peri‐urban and rural areas in northern Vietnam. Two focus group discussions and 24 in‐depth interviews were carried out and analysed using thematic analysis. The results showed that mothers across the urban–rural spectrum shared the intention to feed children safe, nutritious food for better health and weight gain while satisfying child food preferences to improve appetite and eating enjoyment. These food choice intentions were embedded within family food traditions, whereby mothers emphasised nutritious food and adopted strict feeding styles during lunch and dinner but were flexible and accommodating of child preferences during breakfast and side meals. These intentions were also embedded within the physical food environment, which provided a mix of healthy and unhealthy food through informal food retailers. Despite these intentions, mothers faced financial constraints and difficulties in managing children's refusal to chew, changes in eating mood and strong eating temperament. These findings support policies to limit the presence of unhealthy food in informal food retail and encourage meal‐specific feeding strategies to help children enjoy nutritious food, transition from soft to textured food and become more cooperative during mealtime.

Globally, increasing rates of facility-based childbirth enable early intervention for small vulnerable newborns. We describe health system-level inputs, current feeding, and discharge practices for moderately low birthweight (MLBW) infants (1500-10% less than their birthweight; 18.8% of infants were discharged with weights below facility-specific policy [1800g in India, 1500g in Malawi, and 2000g in Tanzania]. Based on descriptive analysis, we found constraints in health system inputs which have the potential to hinder high quality care for MLBW infants. Targeted LBW-specific lactation support, discharge at appropriate weight, and access to feeding alternatives would position MLBW for successful feeding and growth post-discharge.

Infants need to receive care in environments that limit their exposure to pathogens. Inadequate water, sanitation, and hygiene (WASH) environments and suboptimal infection prevention and control practices in healthcare settings contribute to the burden of healthcare-associated infections, which are particularly high in low-income settings. Specific research is needed to understand infant feeding preparation in healthcare settings, a task involving multiple behaviors that can introduce pathogens and negatively impact health. To understand feeding preparation practices and potential risks, and to inform strategies for improvement, we assessed facility WASH environments and observed infant feeding preparation practices across 12 facilities in India, Malawi, and Tanzania serving newborn infants. Research was embedded within the Low Birthweight Infant Feeding Exploration (LIFE) observational cohort study, which documented feeding practices and growth patterns to inform feeding interventions. We assessed WASH-related environments and feeding policies of all 12 facilities involved in the LIFE study. Additionally, we used a guidance-informed tool to carry out 27 feeding preparation observations across 9 facilities, enabling assessment of 270 total behaviors. All facilities had ‘improved’ water and sanitation services. Only 50% had written procedures for preparing expressed breastmilk; 50% had written procedures for cleaning, drying, and storage of infant feeding implements; and 33% had written procedures for preparing infant formula. Among 270 behaviors assessed across the 27 feeding preparation observations, 46 (17.0%) practices were carried out sub-optimally, including preparers not handwashing prior to preparation, and cleaning, drying, and storing of feeding implements in ways that do not effectively prevent contamination. While further research is needed to improve assessment tools and to identify specific microbial risks of the suboptimal behaviors identified, the evidence generated is sufficient to justify investment in developing guidance and programing to strengthen infant feeding preparation practices to ensure optimal newborn health.

Abstract In‐hospital infant formula supplementation of breastfed infants reduces breastfeeding duration, yet little is known about common reasons for infant formula supplementation. We examined the three most common reasons for in‐hospital infant formula supplementation of healthy, term, breastfed infants in the US reported by hospital staff. Hospital data were obtained from the 2018 Maternity Practices in Infant Nutrition and Care survey (n = 2045), which is completed by hospital staff. An open‐ended question on the top three reasons for in‐hospital infant formula supplementation was analyzed using thematic qualitative analysis and the frequencies for each reason were reported. The top three most common reasons for in‐hospital infant formula supplementation reported by hospital staff included medical indications (70.0%); maternal request/preference/feelings (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%) and medical staff/institutional practices (4.7%). These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation. Lactation management support delivered in a timely and culturally sensitive manner and targeted to mother‐infant dyads with potential medical and physical indications may reduce unnecessary in‐hospital infant formula supplementation.

Background Attributable fractions (AF) of anemia are often used to understand the multifactorial etiologies of anemia, despite challenges interpreting them in cross-sectional studies. We aimed to compare different statistical approaches for estimating AF for anemia due to inflammation, malaria, and micronutrient deficiencies including iron, vitamin A, vitamin B12, and folate. Methods AF were calculated using nationally representative survey data among preschool children (10 countries, total N = 7,973) and nonpregnant women of reproductive age (11 countries, total N = 15,141) from the Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia (BRINDA) project. We used the following strategies to calculate AF: 1) Levin’s formula with prevalence ratio (PR) in place of relative risk (RR), 2) Levin’s formula with odds ratio (OR) in place of RR, and 3) average (sequential) AF considering all possible removal sequences of risk factors. PR was obtained by 1) modified Poisson regression with robust variance estimation, 2) Kleinman-Norton’s approach, and 3) estimation from OR using Zhang-Yu’s approach. Survey weighted country-specific analysis was performed with and without adjustment for age, sex, socioeconomic status, and other risk factors. Results About 20–70% of children and 20–50% of women suffered from anemia, depending on the survey. Using OR yielded the highest and potentially biased AF, in some cases double those using PR. Adjusted AF using different PR estimations (Poisson regression, Kleinman-Norton, Zhang-Yu) were nearly identical. Average AF estimates were similar to those using Levin’s formula with PR. Estimated anemia AF for children and women were 2–36% and 3–46% for iron deficiency, Conclusion AF of anemia can be estimated from survey data using Levin’s formula or average AF. While different approaches exist to estimate adjusted PR, Poisson regression is likely the easiest to implement. AF are a useful metric to prioritize interventions to reduce anemia prevalence, and the similarity across methods provides researchers flexibility in selecting AF approaches.

Abstract Background Low birthweight (LBW) infants are at increased risk of morbidity and mortality. Exclusive breastfeeding up to six months is recommended to help them thrive through infection prevention, growth improvements, and enhancements in neurodevelopment. However, limited data exist on the feeding experiences of LBW infants, their caregivers and key community influencers. The qualitative component of the Low Birthweight Infant Feeding Exploration (LIFE) study aimed to understand practices, facilitators, and barriers to optimal feeding options in the first six months for LBW infants in low-resource settings. Methods This study was conducted in four sites in India, Malawi, and Tanzania from July 2019 to August 2020. We conducted 37 focus group discussions with mothers and family members of LBW infants and community leaders and 142 in-depth interviews with healthcare providers, government officials, and supply chain and donor human milk (DHM) experts. Data were analyzed using a framework approach. Results All participants believed that mother’s own milk was best for LBW infants. Direct breastfeeding was predominant and feeding expressed breast milk and infant formula were rare. DHM was a new concept for most. Adequate maternal nutrition, lactation support, and privacy in the facility aided breastfeeding and expression, but perceived insufficient milk, limited feeding counseling, and infant immaturity were common barriers. Most believed that DHM uptake could be enabled through community awareness by overcoming misconceptions, safety concerns, and perceived family resistance. Conclusion This study fills an evidence gap in LBW infant feeding practices and their facilitators and barriers in resource-limited settings. LBW infants face unique feeding challenges such as poor latching and tiring at the breast. Similarly, their mothers are faced with numerous difficulties, including attainment of adequate milk supply, breast pain and emotional stress. Lactation support and feeding counseling could address obstacles faced by mothers and infants by providing psychosocial, verbal and physical support to empower mothers with skills, knowledge and confidence and facilitate earlier, more and better breast milk feeding. Findings on DHM are critical to the future development of human milk banks and highlight the need to solicit partnership from stakeholders in the community and health system.

Accounting for inflammation is necessary to assess iron deficiency using ferritin. A limitation of existing inflammation-adjustment methods is reliance on cross-sectional data to evaluate method performance. The study objective was to evaluate three inflammation-adjustment methods using longitudinal data from two controlled trials where apparently healthy adults (n = 52) were exposed to norovirus. Correction factors (CF), the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) regression correction (BRC), and restricted cubic splines (RCS) were used to adjust the influence of inflammation on ferritin using alpha-1-acid glycoprotein (AGP) and/or C-reactive protein (CRP). Blood was collected at baseline (day 0, pre-exposure to norovirus) and at 9 time points post-exposure (days 1, 2, 3, 4, 7, 14, 21, 28, and 35). Inflammation-adjusted ferritin concentrations were compared with 1) baseline, 2) endline, 3) the average of baseline and endline, and 4) predicted ferritin concentrations among subjects with infection, expressed as percent difference. The predicted ferritin concentrations were modeled using data from 26 subjects without infection in a linear mixed model. Adjusting for CRP or AGP, the median differences between adjusted ferritin using CF, BRC, and RCS were respectively [0.2%, 2.5%], [-22.2%, -20.8%], [-16.7%, -7.1%] compared with the average of baseline and endline values and were 0%, [-16.8%, -18.5%], [-8.9%, -2.8%] compared with predicted ferritin concentrations. For BRC, adjusting for both CRP and AGP tended to result in more over-adjustment of ferritin compared to using a single inflammatory protein. The BRC appeared to overcorrect ferritin in this study setting, while the CF yielded adjusted ferritin concentrations closer to the average baseline and endline concentrations and the predicted concentrations. Longitudinal studies with larger sample sizes exposed to other infectious agents are needed to further evaluate inflammation-adjustment methods and the need for including multiple inflammation biomarkers.

Access to informal fresh food markets plays a vital role in household food security and dietary quality in transitioning rural economies. However, it is not well understood if market access also improves child nutrition and if the improvement applies to all socioeconomic groups. In this secondary research study, we combined a national listing of food markets (n = 503) with a national household survey to examine the associations of market access with diet and height across wealth groups in children aged 6 to 23 months in rural Cambodia. All children under two years of age with dietary data (n = 1537) or anthropometry data (n = 989) were selected from the household survey. Food markets were geocoded using Google Maps or villages' geographical coordinates publicly available in the Open Development Mekong data platform. Regression calibration was then used to estimate household distance to the nearest market. Descriptive results indicated a highly uneven distribution of food markets with median household distance to the nearest markets ranging between 4 km (IQR: 3-8 km) in the lowland areas and 9 km (IQR: 4-17 km) in the highland areas. Results from the multivariate linear regressions showed that distance to the nearest market was modestly associated with child dietary diversity score (β: -0.17; 95% CI: -0.29, -0.05) but it was not related to child height-for-age z-score, and that household wealth did not modify the associations between distance to markets and child dietary diversity score. These findings suggest that improving access to food markets alone might not lead to meaningful improvement in child diet. Detailed surveys on household food acquisition are needed to clarify the role of food markets relative to other food sources such as subsistence fisheries, subsistence gardening and mobile food traders.