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Poverty-related disparities appear early in life in cognitive, language, and social-emotional development, and in growth, especially obesity, and have long-term consequences across the life course. It is essential to develop effective strategies to promote healthy behaviors in pregnancy and the early years of parenthood that can mitigate disparities. Primary preventive interventions within the pediatric primary care setting offer universal access, high engagement, and population-level impact at low cost. While many families in poverty or with low income would benefit from preventive services related to both development and growth, most successful interventions have tended to focus on only one of these domains. In this manuscript, we suggest that it may be possible to address both development and growth simultaneously and effectively. In particular, current theoretical models suggest alignment in mechanisms by which poverty can create barriers to parent-child early relational health (i.e., parenting practices, creating structure, and parent-child relationship quality), constituting a final common pathway for both domains. Based on these models and related empirical data, we propose a strength-based, whole child approach to target common antecedents through positive parenting and prevent disparities in both development and growth; we believe this approach has the potential to transform policy and practice. Achieving these goals will require new payment systems that make scaling of primary prevention in health care feasible, research funding to assess efficacy/effectiveness and inform implementation, and collaboration among early childhood stakeholders, including clinicians across specialties, scientists across academic disciplines, and policy makers.

Child obesity is widely prevalent, and general pediatricians play an important role in identifying and caring for patients with obesity. Appropriate evaluation and treatment require an understanding of the complex etiology of child obesity, its intergenerational transmission, and its epidemiologic trends, including racial/ethnic and socioeconomic disparities. The American Academy of Pediatrics has published screening, evaluation, and treatment guidelines based on the best available evidence. However, gaps in evidence remain, and implementation of evidence-based recommendations can be challenging. It is important to review optimal care in both the primary care and multidisciplinary weight management settings. This allows for timely evaluation and appropriate referrals, with the pediatrician playing a key role in advocating for patients at higher risk. There is also a role for larger-scale prevention and policy measures that would not only aid pediatricians in managing obesity but greatly benefit child health on a population scale.

Appetite traits and feeding practices are important determinants of child weight and obesity.This study examined whether: (1) infant appetite traits were associated with feeding practices and (2) feeding practices mediated the link between appetite traits and weight-for-age z-scores at age 3 years.We conducted a secondary data analysis from the 'Starting Early Program' of low-income, Hispanic mother-child pairs. Appetite traits were assessed using the Baby Eating Behaviour Questionnaire. Infant feeding practices were collected using 24-h dietary recalls and surveys: (1) breastfeeding exclusivity, intensity and duration; (2) early introduction to complementary foods/liquids and (3) any 100% fruit juice consumption at age 10 months. Regression and mediation analyses were used to explore associations between appetite, feeding and weight.Higher infant Slowness in Eating scores were associated with greater breastfeeding exclusivity, intensity and duration, compared to lower Slowness in Eating. Infants with higher Slowness in Eating and Satiety Responsiveness had lower odds of early introduction to complementary foods/liquids. Infants with higher Enjoyment of Food had greater odds of 100% juice consumption. Breastfeeding duration mediated the relationship between higher infant Slowness in Eating and lower weight-for-age z-scores.Appetite traits represent potential targets for early life infant feeding interventions.

Feeding concerns are common in the first 2 years of life and typically reflect maternal perceptions occurring within the larger context of the parent-child relationship. We aimed to determine whether (1) maternal depressive systems predicted perceived picky eating, mediated by maternal negative perceptions; (2) receipt of the Video Interaction Project (VIP) parenting intervention impacted perceived picky eating through this pathway; and (3) perceived picky eating was associated with child growth or subsequent dietary patterns.We performed a partial longitudinal analysis of 187 low-income, predominantly Hispanic mother-child dyads enrolled in a randomized controlled trial of the VIP. Mother-infant dyads were enrolled postpartum in an urban public hospital. Participants randomized to the VIP met with an interventionist on days of well-child visits; sessions were designed to facilitate interactions in play and shared reading through provision of learning materials and review of videotaped parent-child interaction; the curriculum did not contain feeding-specific elements. We used structural equation modeling to determine direct, indirect, and total effects of maternal depressive symptoms, maternal negative perceptions, and the VIP on perceived picky eating. We then tested associations between perceived picky eating and (1) child growth, using multivariable linear regression and multilevel modeling; and (2) subsequent child dietary consumption, using multivariable multinomial logistic regression.Maternal depressive symptoms had significant total effects on negative maternal perceptions (β = 0.32, p0.001) and perceived picky eating (β = 0.21, p0.01) after controlling for potential confounders. This effect was partially mediated by maternal negative perceptions (indirect effect: β = 0.06, p = 0.04). When used in the model as the predictor, the VIP had a significant total effect on perceived picky eating (β = -0.16, p = 0.02), which was partially mediated by maternal depressive symptoms and negative perceptions (indirect effect: β = -0.05, p = 0.02). Perceived picky eating was not associated with child diet at age 2 years or adiposity from 6 months to 3 years.Maternal concerns about picky eating may reflect deeper depressive symptoms and negative perceptions of her child's behavior. Interventions designed to facilitate positive parenting in general may lessen feeding-specific concerns, such as picky eating. Although reassurance about growth and nutritional outcomes for children perceived as picky eaters is appropriate, clinicians should also consider probing for underlying symptoms of depression that could lead to eating concerns.

BACKGROUND Privacy-protecting analytic approaches without centralized pooling of individual-level data, such as distributed regression, are particularly important for vulnerable populations, such as children, but these methods have not yet been tested in multi-center pediatric studies. METHODS Using the electronic health data from 34 healthcare institutions in the National Patient-Centered Clinical Research Network (PCORnet), we fit 12 multivariable-adjusted linear regression models to assess the associations of antibiotic use

Summary Background Limited research has addressed the obesity–COVID‐19 severity association in paediatric patients. Objective To determine whether obesity is an independent risk factor for COVID‐19 severity in paediatric patients and whether age modifies this association. Methods SARS‐CoV‐2‐positive patients at NYU Langone Health from 1 March 2020 to 3 January 2021 aged 0–21 years with available anthropometric measurements: weight, length/height and/or body mass index (BMI). Modified log‐Poisson models were utilized for the analysis. Main outcomes were 1) hospitalization and 2) critical illness (intensive care unit [ICU] admission). Results One hundred and fifteen of four hundred and ninety‐four (23.3%) patients had obesity. Obesity was an independent risk factor for critical illness (adjusted risk ratio [ARR] 2.02, 95% CI 1.17 to 3.48). This association was modified by age, with obesity related to a greater risk for critical illness in adolescents (13–21 years) [ARR 3.09, 95% CI 1.48 to 6.47], but not in children (0–12 years). Obesity was not an independent risk factor for hospitalization for any age. Conclusion Obesity was an independent risk factor for critical illness in paediatric patients, and this association was modified by age, with obesity related to a greater risk for critical illness in adolescents, but not in children. These findings are crucial for patient risk stratification and care.

OBJECTIVES: To examine whether: 1) birthweight was associated with child appetite traits (AT) at age 2 years; and 2) ATs mediated the link between birthweight and weight at age 3 years among Hispanic children. METHODS: This study is a secondary longitudinal analysis of data collected from the “Starting Early Program” randomized controlled obesity prevention trial of low-income, Hispanic mother-child pairs (n = 533). Birthweight-for-gestational-age z-scores (BWGAz) were determined using Fenton growth curves; weight-for-age z-scores (WFAz) were determined using World Health Organization growth charts. Four ATs, including Food Responsiveness (FR), Enjoyment of Food (EF), Satiety Responsiveness (SR), and Slowness in Eating (SE), were assessed using the Child Eating Behavior Questionnaire at age 2 years. Simple linear regression analysis was used to assess direct associations between BWGAz and each AT. Bootstrapping analyses were used to assess whether ATs were significantly associated with BWGAz, and mediated the relationship between BWGAz and later child WFAz. RESULTS: Of the 401 children with both BWGAz and AT measures, 49% were male with mean birthweight of 3.4 kg. After adjusting for covariates related to child weight, infants with higher BWGAz had lower SR scores at age 2 years (B = −0.11, 95%CI = −0.18 to − 0.04, P

The benefits of antibiotic treatment during pregnancy are immediate, but there may be long-term risks to the developing child. Prior studies show an association between early life antibiotics and obesity, but few have examined this risk during pregnancy. To evaluate the association of maternal antibiotic exposure during pregnancy on childhood BMI-z at 5 years, we conducted a retrospective cohort analysis. Using electronic health record data from seven health systems in PCORnet, a national distributed clinical research network, we included children with same-day height and weight measures who could be linked to mothers with vital measurements during pregnancy. The primary independent variable was maternal outpatient antibiotic prescriptions during pregnancy (any versus none). We examined dose response (number of antibiotic episodes), spectrum and class of antibiotics, and antibiotic episodes by trimester. The primary outcome was child age- and sex-specific BMI-z at age 5 years. The final sample was 53,320 mother–child pairs. During pregnancy, 29.9% of mothers received antibiotics. In adjusted models, maternal outpatient antibiotic prescriptions during pregnancy were not associated with child BMI-z at age 5 years (β = 0.00, 95% CI −0.03, 0.02). When evaluating timing during pregnancy, dose-response, spectrum and class of antibiotics, there were no associations of maternal antibiotics with child BMI-z at age 5 years. In this large observational cohort, provision of antibiotics during pregnancy was not associated with childhood BMI-z at 5 years.

Objective Prenatal maternal stresses have been associated with infant temperament patterns linked to later behavioral difficulties. Material hardships, defined as inability to meet basic needs, are important prenatal stressors. Our objective was to determine the associations between prenatal material hardships and infant temperament at 10 months. Methods This was a longitudinal study of mother-infant pairs in a randomized controlled trial of a primary care-based early obesity prevention program (Starting Early). Independent variables representing material hardship were: housing disrepair, food insecurity, difficulty paying bills, and neighborhood stress (neighborhood safety). Dependent variables representing infant temperament were assessed using questions from 3 subscales of the Infant Behavior Questionnaire: orienting/regulatory capacity, negative affect, and surgency/extraversion. We used linear regression to investigate associations between individual and cumulative hardships and each temperament domain, adjusting for confounders, and testing for depression as a moderator. Results Four hundred twelve mother-infant pairs completed 10-month assessments. Thirty-two percent reported food insecurity, 26% difficulty paying bills, 35% housing disrepair, and 9% neighborhood stress. In adjusted analyses, food insecurity was associated with lower orienting/regulatory capacity scores (β = −0.25; 95% confidence interval [CI], −0.47 to −0.04), as were neighborhood stress (β = −0.50; 95% CI, −0.83 to −0.16) and experiencing 3 to 4 hardships (compared with none; β = −0.54; 95% CI, −0.83 to −0.21). For neighborhood stress, the association was stronger among infants of mothers with prenatal depressive symptoms (interaction term P = .06). Conclusion Prenatal material hardships were associated with lower orienting/regulatory capacity. These findings support the need for further research exploring how temperament relates to child behavior, and for policies to reduce prenatal material hardships.

Objectives Maternal stress has been associated with early child obesity through pathways related to decreased exclusive breastfeeding and increased nonresponsive maternal-infant feeding styles. We sought to gain an in-depth understanding of how maternal stress, sadness, and isolation are perceived to affect feeding, in order to inform modifiable targets of intervention. Methods We conducted semi-structured qualitative interviews with Hispanic mothers living in poverty with young infants between 3 and 7 months old (n = 32) from the intervention group of a randomized controlled trial of an early child obesity prevention intervention (Starting Early Program). Bilingual English-Spanish interviewers conducted the interviews, which were audio recorded, transcribed, and translated. Building on an existing theoretical framework developed by the National Scientific Council on the Developing Child, we used an iterative process of textual analysis to code the transcripts, until thematic saturation was reached. Results Three key themes were described: 1) maternal stress responses were varied and included positive (brief and mild), tolerable (sustained but limited long-term impacts), or toxic stress (sustained and severe); 2) buffers included support from family, infants, health care providers, social service programs, and community organizations; 3) perceived effects on infant feeding included decreased breastfeeding due to concerns about stress passing directly through breast milk and indirectly through physical closeness, and increased nonresponsive feeding styles. Conclusions Maternal stress, particularly toxic stress, was perceived to negatively affect infant feeding. Mothers reported disrupting healthy feeding to avoid infant exposure to stress. Interventions to enhance buffering may help to mitigate toxic stress and promote healthy feeding interactions.

OBJECTIVE: Children in low-income Hispanic families are at high risk of obesity and are more likely to live with grandparents than their non-Hispanic white counterparts. We aimed to determine if grandparent coresidence (prenatal through age two years) was associated with: 1) obesogenic feeding practices; and 2) child weight outcomes from birth to three years. METHODS: We analyzed data from 267 low-income, Hispanic mother-infant pairs in the control group of an obesity prevention trial in New York City. Linear and logistic regression tested differences in obesogenic feeding practices and weight outcomes at two and three years, dependent upon grandparent coresidence. Multilevel modeling tested associations between grandparent coresidence and WFAz over time. RESULTS: Persistent grandparent coresidence (versus none) was associated with putting cereal in the bottle (adjusted odds ratio [aOR] 3.46; 95% confidence interval [CI] 1.43, 8.40). Persistent grandparent coresidence (versus none) was associated with higher mean WFAz (2 years: B 0.83; 95% CI 0.41, 1.25; 3 years: B 0.79; 95% CI 0.32, 1.25) and higher odds of child overweight/obesity risk (two years: aOR 4.38; 95% CI 1.64, 11.69; three years: aOR 3.15; 95% CI 1.19, 8.36). In multilevel models, more occasions of grandparent coresidence were associated with higher WFAz. CONCLUSIONS: Grandparent coresidence may be associated with higher risk of child overweight/obesity in low-income, Hispanic families. Further research is needed to elucidate mechanisms of these associations and to inform obesity prevention strategies in the context of multigenerational families.

Child appetite traits (ATs) are associated with later child weight and obesity risk. Less research has focused on ATs in low-income Hispanic children or included longitudinal associations with infant weight.To determine stability of ATs during infancy and childhood and their relationship with subsequent weight and obesity risk at age 3 years among low-income Hispanic children.A secondary longitudinal analysis of data from the Starting Early Program randomized controlled obesity prevention trial.Three hundred twenty-two low-income, Hispanic mother-child pairs enrolled between 2012 and 2014 in a public hospital in New York City.ATs, including Slowness in Eating, Satiety Responsiveness, Food Responsiveness, and Enjoyment of Food were assessed using the Baby and Child Eating Behavior Questionnaires at ages 3 months, 2 years, and 3 years. Main outcome measures were child standardized weight-for-age z score (WFAz) and obesity risk (WFA≥95th percentile) at age 3 years.AT stability was assessed using correlations and multilevel modeling. Linear and logistic regression analyses examined associations between ATs and child WFAz and obesity risk at age 3 years.There was limited stability for all ATs measured over time. During infancy, Slowness in Eating was associated with lower 3-year WFAz (B = -0.18, 95% CI -0.33 to -0.04; P = 0.01). At age 2 years, Slowness in Eating and Satiety Responsiveness were associated with lower WFAz (B = -0.29, 95% CI -0.47 to -0.12; P0.01; B = -0.36, 95% CI -0.55 to -0.17; P0.01) and obesity risk (adjusted odds ratio 0.49, 95% CI 0.28 to 0.85; adjusted odds ratio 0.61, 95% CI 0.38 to 0.99) at 3 years. Increased Slowness in Eating and Satiety Responsiveness over time were associated with lower 3-year WFAz (B = -0.74, 95% CI -1.18 to -0.2 [Slowness in Eating]; B = -1.19, 95% CI -1.87 to -0.52 [Satiety Responsiveness], both P values = 0.001). Higher Enjoyment of Food over time was associated with higher 3-year WFAz (B = 0.62, 95% CI 0.24 to 1.01; P = 0.002).Infants with lower Slowness in Eating and Satiety Responsiveness may have higher levels of obesity risk and need more tailored approaches to nutrition counseling and obesity prevention.

OBJECTIVES: To determine impact of a primary care–based child obesity prevention intervention beginning during pregnancy on early childhood weight outcomes in low-income Hispanic families. METHODS: A randomized controlled trial comparing mother–infant pairs receiving either standard care or the Starting Early Program providing prenatal and postpartum nutrition counseling and nutrition parenting support groups targeting key obesity-related feeding practices in low-income groups. Primary outcomes were reduction in weight-for-age z-scores (WFAzs) from clinical anthropometric measures, obesity prevalence (weight for age ≥95th percentile), and excess weight gain (WFAz trajectory) from birth to age 3 years. Secondary outcomes included dose effects. RESULTS: Pregnant women (n = 566) were enrolled in the third trimester; 533 randomized to intervention (n = 266) or control (n = 267). Also, 358 children had their weight measured at age 2 years; 285 children had weight measured at age 3 years. Intervention infants had lower mean WFAz at 18 months (0.49 vs 0.73, P = .04) and 2 years (0.56 vs 0.81, P = .03) but not at 3 years (0.63 vs 0.59, P = .76). No group differences in obesity prevalence were found. When generalized estimating equations were used, significant average treatment effects were detected between 10-26 months (B = −0.19, P = .047), although not through age 3 years. In within group dose analyses at 3 years, obesity rates (26.4%, 22.5%, 8.0%, P = .02) decreased as attendance increased with low, medium, and high attendance. CONCLUSIONS: Mean WFAz and growth trajectories were lower for the intervention group through age 2 years, but there were no group differences at age 3. Further study is needed to enhance sustainability of effects beyond age 2.

Persistent organic pollutants (POPs) are believed to alter metabolic homeostasis during fetal development, leading to childhood obesity. However, limited studies have explored how fetal chemical exposures relate to birth and infant weight outcomes in low-income Hispanic families at the highest risk of obesity. Therefore, we sought to determine associations between neonatal POPs exposure measured in newborn dried blood spots (DBS) and prenatal diet quality, birth weight, and overweight status at 18 months old. We conducted a case-control study nested within the Starting Early Program randomized controlled trial comparing POPs concentrations in infants with healthy weight (n = 46) and overweight status (n = 52) at age 18 months. Three categories of POPs, organochlorine pesticides (OCPs), polybrominated diphenyl ethers (PBDEs) and perfluoroalkyl substances (PFASs) were measured in archived newborn DBS. We assessed correlations between prenatal diet quality and neonatal POPs concentrations. Multivariable regression analyses examined associations between POPs (dichotomized at the mean) and birth weight z-score and weight status at 18 months, controlling for confounders. Seven of eight chemicals had detectable levels in greater than 94% of the sample. Higher protein, sodium and refined grain intake during pregnancy were correlated with lower POPs in newborn DBS. We found that high concentrations of perfluorooctanesulfonate (unstandardized coefficient [B]: −0.62, 95% confidence interval [CI]: −0.96 to −0.29) and perfluorohexanesulfate (B: −0.65, 95% CI: −0.99 to −0.31) were related to lower birth weight z-scores compared to those with low concentrations. We did not find associations between PBDEs, OCPs, and the other PFASs with birth weight z-scores, or between any POPs and weight status at 18 months. In conclusion, two PFASs were associated with lower birth weight, an important indicator of child health and growth, although direct associations with infant overweight status were not found. Whether neonatal POPs exposures contribute to economic and ethnic disparities in early obesity remains unclear.

Prior studies of early antibiotic use and growth have shown mixed results, primarily on cross-sectional outcomes. This study examined the effect of oral antibiotics before age 24 months on growth trajectory at age 2-5 years.We captured oral antibiotic prescriptions and anthropometrics from electronic health records through PCORnet, for children with ≥1 height and weight at 0-12 months of age, ≥1 at 12-30 months, and ≥2 between 25 and 72 months. Prescriptions were grouped into episodes by time and by antimicrobial spectrum. Longitudinal rate regression was used to assess differences in growth rate from 25 to 72 months of age. Models were adjusted for sex, race/ethnicity, steroid use, diagnosed asthma, complex chronic conditions, and infections.430,376 children from 29 health U.S. systems were included, with 58% receiving antibiotics before 24 months. Exposure to any antibiotic was associated with an average 0.7% (95% CI 0.5, 0.9, p 0.0001) greater rate of weight gain, corresponding to 0.05 kg additional weight. The estimated effect was slightly greater for narrow-spectrum (0.8% [0.6, 1.1]) than broad-spectrum (0.6% [0.3, 0.8], p 0.0001) drugs. There was a small dose response relationship between the number of antibiotic episodes and weight gain.Oral antibiotic use prior to 24 months of age was associated with very small changes in average growth rate at ages 2-5 years. The small effect size is unlikely to affect individual prescribing decisions, though it may reflect a biologic effect that can combine with others.

OBJECTIVE: To assess relationships between material hardships, shortened sleep duration, and suboptimal sleep practices across infancy and toddlerhood in low-income Hispanic families. METHODS: We analyzed longitudinal data of 451 low-income Hispanic mother-child pairs from a child obesity prevention trial. During infancy and toddlerhood, we used adjusted linear regression to assess associations between material hardship (financial difficulty, food insecurity, housing disrepair, multiple hardships), sleep duration (24-hour, night), and the number of suboptimal sleep practices (e.g., later bedtime, co-sleeping). We used adjusted linear regression to assess the longitudinal association between the number of suboptimal sleep practices in infancy and toddlerhood, and tested whether specific or multiple hardships moderated this association. RESULTS: In infants, financial difficulty and multiple hardships were associated with decreased night sleep (B=−0.59 hours, 95% CI: −1.04, −0.14; and B=−0.54 hours, 95% CI: −1.00, −0.08). Housing disrepair was associated with decreased 24-hour sleep (B=−0.64 hours, 95% CI: −1.29, −0.01). In toddlers, each additional suboptimal sleep practice was associated with a decrease in night sleep (B=−0.19 hours, 95% CI: −0.29, −0.09). Each additional suboptimal sleep practice in infancy was associated with a 0.30 increase in the number of suboptimal sleep practices in toddlerhood (p

Hispanic women have a higher prevalence of weight associated complications in pregnancy. This ethnic disparity is likely related to behavior patterns, social circumstances, environmental exposures, and access to healthcare, rather than biologic differences. The objective was to determine associations between sociodemographic characteristics, health behaviors, and psychosocial stressors and gestational weight gain (GWG) in low-income Hispanic women. During pregnancy, information on sociodemographic characteristics, health behaviors, and psychosocial stressors were collected. Linear regression estimated mean differences in GWG by selected predictors. Multinomial logistic regression estimated odds of inadequate and excessive GWG by selected predictors. Five-hundred and eight women were included, 38% had inadequate and 28% had excessive GWG, 57% with a normal pre-pregnancy BMI had inadequate GWG. Compared to women with normal BMI, women with overweight or obesity were more likely to have excessive GWG (aRRR = 1.88, 95% CI: 1.04, 3.40 and aRRR = 1.98, 95% CI: 1.08, 3.62, respectively). Mean total GWG was higher among women who were nulliparous (&szlig, = 1.34 kg, 95% CI: 0.38, 2.29) and those who engaged in &ge, 3 h of screen time daily (&szlig, = 0.98 kg, 95% CI: 0.02, 1.94), and lower among women who were physically active during pregnancy (&szlig, = &minus, 1.00 kg, 95% CI: &minus, 1.99, &minus, 0.03). Eating breakfast daily was associated with lower risk of inadequate GWG (aRRR = 0.47, 95% CI: 0.26, 0.83). Depressive symptoms and poor adherence to dietary recommendations were prevalent, but none of the psychosocial or dietary variables were associated with GWG. In this cohort of primarily immigrant, low-income, Hispanic women, there were high rates of poor adherence to diet and physical activity recommendations, and a majority of women did not meet GWG guidelines. Modifiable health behaviors were associated with GWG, and their promotion should be included in prenatal care.

OBJECTIVE: To describe total and trimester-specific gestational weight gain (GWG) among low-income Hispanic women and determine whether these GWG exposures are associated with infant anthropometric outcomes at birth and 6 months. STUDY DESIGN: Data were from 448 mother-infant pairs enrolled in the Starting Early child obesity prevention trial. Prenatal weights were used to calculate total GWG and 2(nd) and 3(rd) trimester GWG rates (kg/week) and categorized as inadequate, adequate, and excessive according to the 2009 Institute of Medicine recommendations. Multivariable linear and modified Poisson regressions estimated associations of infant anthropometric outcomes (birthweight, small-for-gestational age [SGA], large-for-gestational age [LGA], rapid weight gain, and weight-for-age, length-for-age, and weight-for-length z-scores at 6 months) with GWG categories. RESULTS: For total GWG, 39% and 27% of women had inadequate and excessive GWG, respectively. 57% and 46% had excessive GWG rates in the 2(nd) and 3(rd) trimesters, respectively, with 29% having excessive rates in both trimesters. Inadequate total GWG was associated with lower infant weight and length outcomes (ß range for z-scores= −0.21 to −0.46, p

OBJECTIVES: The National Patient-Centered Clinical Research Network (PCORnet) supports observational and clinical research using healthcare data. The PCORnet Antibiotics and Childhood Growth Study is one of PCORnet’s inaugural observational studies. The objectives of this manuscript are to describe (1) the processes used to integrate and analyze data from children across 36 participating institutions and (2) the cohort characteristics and prevalence of antibiotic use. METHODS: We included children in the cohort if they had at least one same-day height and weight measured in each of three age periods: 1) before 12 months, 2) 12 to 30 months, and 3) after 24 months. We distributed statistical queries that each institution ran on its local version of the PCORnet Common Data Model, with aggregate data returned for analysis. We defined overweight or obesity as age-sex-specific body mass index ≥ 85(th), obesity ≥95(th) percentile, and severe obesity ≥120% of the 95(th) percentile. RESULTS: 681,739 children met the cohort inclusion criteria and were racially/ethnically diverse (24.9% black, 17.5% Hispanic). Before 24 months, 55.2% of children received at least one antibiotic prescription; 21.3% received a single antibiotic prescription, 14.3% received four or more, and 33.3% received a broad spectrum antibiotic. Overweight and obesity prevalence was 27.6% at 4 to

Parent perception of weight and feeding styles are associated with obesity in other racial groups but have not been explored in-depth in Chinese-American preschoolers. Cross-sectional survey of 253 Chinese-American parents with preschoolers was performed in a community clinic. Regression analysis was used to assess relationships between parental perception of weight and feeding styles. Parent under-perception of weight was common but more likely in boys than girls (χ2 = 4.91, p = 0.03). Pressuring was also greater in boys [adjusted mean difference (95% CI) 0.24 (0.004, 0.49)]. In girls, pressuring was lower for children perceived as overweight [adjusted mean difference in CFQ scores −0.75 (−1.27, −0.23)]; in boys, pressuring was high regardless of perceived child weight. Weight perceptions and feeding styles related to childhood obesity in other groups were identified in Chinese-American families. Parent under-perception of child weight and pressure to eat were more common in boys. These factors should be addressed in Chinese-American preschooler obesity prevention programs.

Objective To determine whether prenatal social support was associated with infant adiposity in the first 18 months of life in a low-income, Hispanic sample, known to be at high risk of early child obesity. Study design We performed a longitudinal analysis of 262 low-income, Hispanic mother-infant pairs in the control group of the Starting Early child obesity prevention trial. Prenatal social support was measured using an item from the Maternal Social Support Index. We used multilevel modeling to predict weight-for-length z-score trajectories from birth to age 18 months and logistic regression to predict macrosomia and overweight status at ages 6, 12, and 18 months. Results High prenatal social support was independently associated with lower infant adiposity trajectories from birth to age 18 months (B = −0.40; 95% CI, −0.63 to −0.16), a lower odds of macrosomia (aOR = 0.35; 95% CI, 0.15-0.80), and a lower odds of overweight at ages 12 (aOR = 0.28; 95% CI, 0.10-0.74) and 18 months (aOR = 0.35; 95% CI, 0.14-0.89). Prenatal social support was not significantly associated with overweight status at age 6 months. Conclusions Prenatal social support may protect against excessive infant adiposity and overweight in low-income, Hispanic families. Further research is needed to elucidate mechanisms underlying these associations and to inform preventive strategies beginning in pregnancy.

[This corrects the article DOI: 10.1371/journal.pone.0215571.].

Objective To determine the relations between household material hardships and having a low internal locus of control over the prevention of child obesity in low-income Hispanic pregnant women. Methods We performed a cross-sectional analysis of baseline data collected during a third trimester prenatal visit from women participating in the Starting Early Study, a randomized controlled trial to test the efficacy of a primary care-based family-centered early child obesity prevention intervention. Using multiple logistic regression analyses, we determined whether 4 domains of material hardship (food insecurity, difficulty paying bills, housing disrepair, neighborhood stress), considered individually and also cumulatively, were associated with having a low internal locus of control over the prevention of child obesity. Results The sample included 559 low-income Hispanic pregnant women, with 60% having experienced at least 1 hardship. Food insecurity was independently associated with a low internal locus of control over the prevention of child obesity (adjusted odds ratio, 2.38; 95% confidence interval, 1.50–3.77), controlling for other hardships and confounders. Experiencing a greater number of material hardships was associated in a dose-dependent relationship with an increased odds of having a low internal locus of control. Conclusions Prenatal material hardships, in particular food insecurity, were associated with having a lower prenatal internal locus of control over the prevention of child obesity. Longitudinal follow-up of this cohort is needed to determine how relations between material hardships and having a low internal locus of control will ultimately affect infant feeding practices and child weight trajectories.

Approximately 20% of all children in the United States live in poverty, which exists in rural, urban, and suburban areas. Thus, all child health clinicians need to be familiar with the effects of poverty on health and to understand associated, preventable, and modifiable social factors that impact health. Social determinants of health are identifiable root causes of medical problems. For children living in poverty, social determinants of health for which clinicians may play a role include the following: child maltreatment, child care and education, family financial support, physical environment, family social support, intimate partner violence, maternal depression and family mental illness, household substance abuse, firearm exposure, and parental health literacy. Children, particularly those living in poverty, exposed to adverse childhood experiences are susceptible to toxic stress and a variety of child and adult health problems, including developmental delay, asthma and heart disease. Despite the detrimental effects of social determinants on health, few child health clinicians routinely address the unmet social and psychosocial factors impacting children and their families during routine primary care visits. Clinicians need tools to screen for social determinants of health and to be familiar with available local and national resources to address these issues. These guidelines provide an overview of social determinants of health impacting children living in poverty and provide clinicians with practical screening tools and resources.

Background: Disparities in obesity-promoting feeding patterns begin in pregnancy and infancy, underscoring the need for early primary prevention in high-risk groups. We sought to determine the impact of a primary care-based child obesity prevention intervention beginning during pregnancy on maternal infant feeding practices, knowledge, and styles at 10 months in low-income Hispanic families. Methods: The Starting Early Program (StEP) randomized controlled trial enrolled pregnant women at a third trimester visit. Women (n = 533) were randomized to standard care or an intervention with prenatal/postpartum individual nutrition counseling and nutrition and parenting support groups coordinated with pediatric visits. Feeding practices (breastfeeding, family meals, juice, and cereal in the bottle) were assessed using questions from the Infant Feeding Practices Study II. Feeding styles were assessed using the Infant Feeding Style Questionnaire. We analyzed impacts on feeding practices, knowledge, and styles using regression analyses adjusting for covariates. Results: Four hundred twelve mothers completed 10-month assessments. Intervention mothers were more likely to give breast milk as the only milk source [adjusted odds ratio (AOR) 1.65, 95% confidence interval (CI) 1.06–2.58] and have daily family meals (AOR 1.91, 95% CI 1.19–3.05), and less likely to give juice (AOR 0.60, 95% CI 0.39–0.92) or cereal in the bottle (AOR 0.54, 95% CI 0.30–0.97) compared to controls. Intervention mothers were more likely to exhibit lower pressuring, indulgent and laissez-faire feeding styles, and to have higher knowledge. Attending a greater number of group sessions increased intervention impacts. Conclusions: StEP led to reduced obesity-promoting feeding practices and styles, and increased knowledge and provides great potential for population-scalability.

OBJECTIVES: This study examined the association of infant appetite traits and exclusive breastfeeding (EBF), BF intensity, early introduction of complementary foods/liquids and 100% fruit juice consumption among Hispanic infants during the first year of life. METHODS: This study is a cross-sectional analysis of data collected from the “Starting Early Program" randomized controlled obesity prevention trial of low-income, Hispanic mother-child pairs (n = 533). Four infant appetite traits including Food Responsiveness (FR), Enjoyment of Food (EF), Satiety Responsiveness (SR), and Slowness in Eating (SE) were assessed using the Baby Eating Behavior Questionnaire. Each appetite trait was based on a 5-point Likert frequency scale. Infant feeding measures were collected using 24-hour recall methodology and survey based on the Infant Feeding Practices Study II. Linear and logistic regressions assessed the associations between appetite traits and infant feeding practices, specifically 1) EBF, 2) BF intensity (% of daily milk consumption that is breast milk), 3) early introduction to complementary foods/liquids defined as receiving prior to infant age 4 months, and 4) Any 100% fruit juice consumption at age 10 months. RESULTS: Of the 473 children with both appetite and infant feeding measures, 48% were male with mean birth weight of 3.4 kg. After adjusting for confounders, infants with higher SE scores had higher odds of EBF duration (≥3 months) (OR = 1.7, P 80%) BF intensity (OR = 1.8, P = 0.002; OR = 2.5, P

The goal of this study was to assess biomarkers of exposure to glyphosate and assess potential associations with renal function in children. Glyphosate is used ubiquitously in agriculture worldwide. While previous studies have indicated that glyphosate may have nephrotoxic effects, few have examined potential effects on kidney function in children. We leveraged three cohorts across different phases of child development and measured urinary levels of glyphosate. We evaluated associations of glyphosate with three biomarkers of kidney injury: albuminuria (ACR), neutrophil gelatinase-associated lipocalin (NGAL), and kidney injury marker 1 (KIM-1). Multivariable regression analyses examined associations of glyphosate with kidney injury biomarkers controlling for covariates. We identified glyphosate in 11.1% of the total participants. The herbicide was particularly detected more frequently in the neonate population (30%). Multivariable regression models failed to identify significant associations of log-transformed glyphosate with any of the kidney injury biomarkers, controlling for covariates age, sex, and maternal education. While we confirm detectability of glyphosate in children’s urine at various ages and stages of life, there is no evidence in this study for renal injury in children exposed to low levels of glyphosate. Further studies of larger sample size are indicated to better understand putative deleterious effects of the herbicide after different levels of exposure.

Background Low-income Hispanic women are at-risk of poor prenatal diet quality. Correlates associated with prenatal diet quality in this group of women are understudied. Objective The objective of this study was to examine the associations between financial, cultural, psychosocial, and lifestyle correlates and prenatal diet quality in low-income Hispanic women. Design This cross-sectional analysis used data from pregnant women enrolled in the Starting Early Trial, a randomized-controlled trial of a primary-care based child obesity prevention program beginning in pregnancy. The trial enrolled women from clinics affiliated with a large urban medical center in New York City from 2012 to 2014. Financial, cultural, psychosocial, and lifestyle variables were collected using a comprehensive baseline questionnaire. Usual dietary intakes over the past year were assessed using the Block Food Frequency Questionnaire 2005 bilingual version. Participants The study enrolled low-income Hispanic women between 28 and 32 gestational weeks (N=519). Main outcome measures Prenatal diet quality was measured by the Healthy Eating Index 2015. Statistical analyses performed Unadjusted and adjusted multivariable linear regression analyses were performed to determine independent associations between financial, cultural, psychosocial, and lifestyle correlates and Healthy Eating Index 2015 total score. Results Overall prenatal diet quality was poor (mean Healthy Eating Index 2015 total score=69.0±9.4). Most women did not meet the maximum score for total vegetables (65.3%), whole grains (97.1%), dairy (74.8%), fatty acids (84.4%), refined grains (79.8%), sodium (97.5%), saturated fats (92.9%), and added sugars (66.5%). Women who reported screen time ≤2 hours/day, physical activity before and/or during pregnancy, and being born outside the United States had higher mean Healthy Eating Index 2015 total score than women with screen time >2 hours/day, no physical activity, and those born in the United States. Conclusions Prenatal diet quality of low-income pregnant Hispanic women was suboptimal. This cross-sectional study revealed associations between cultural and lifestyle factors and prenatal diet quality in low-income Hispanic women. Longitudinal studies are needed to determine long-term influences and specific behaviors to target for effective intervention studies.

Background Melamine and cyanuric acid, which are currently used in a variety of common consumer products and present in foods, have been implicated in the development of urolithiasis and acute kidney injury in Chinese children. To determine whether US children have measurable concentrations of these chemicals in their bodies and whether they are at greater risk of acute kidney injury, we measured melamine and cyanuric acid exposure in a cohort of US children and determined their relationship with markers of kidney injury. Methods We measured urinary melamine and cyanuric acid in a convenience sample of 109 children (4 months – 8 years) from Seattle, WA and New York City, NY using liquid chromatography with tandem mass spectrometry. We measured several urinary markers of kidney injury: fatty acid binding protein 3 (FABP3), kidney injury molecule 1 (KIM1), neutrophil gelatinase-associated lipocalin (NGAL) using Luminex xMAP methods, and urine urea was measured using standard laboratory methods. We described urinary melamine and cyanuric acid concentrations and assessed predictors of the exposures. We used multivariable linear regression to assess relationships between melamine/cyanuric acid and kidney injury markers in unadjusted and adjusted (creatinine, age, sex) analyses. Results Melamine and cyanuric acid were above the limit of detection (LOD) in 78% and 95% of all samples, respectively. The mean concentrations (SD) for melamine and cyanuric acid were 27.4 ng/ml (141.9 ng/ml) and 35.3 ng/ml (42.4 ng/ml). In unadjusted analyses, we observed statistically significant increases in the percentages of FABP3 and KIM1 in relation to a one log unit change in melamine and cyanuric acid, respectively. In adjusted analyses, we observed a 55% (95% CI 0, 141) increase in KIM1 in relation to a one log unit increase in cyanuric acid. Conclusions US children have detectable concentrations of melamine and cyanuric acid in urine, and these concentrations are higher than those reported in children from other countries. This is a novel finding that improves upon previous exposure estimates using questionnaires only and suggests widespread exposure in the population. Cyanuric acid is associated with increased KIM 1 concentrations, suggesting kidney injury. Given the potential widespread exposure, future analyses should examine melamine and cyanuric acid in relation to chronic kidney disease and markers of kidney injury in a larger cohort that is representative of the general population.

Food insecurity, or the limited access to food, has been associated with maternal child feeding styles and practices. While studies in other parenting domains suggest differential and additive impacts of poverty-associated stressors during pregnancy and infancy, few studies have assessed relations between food insecurity during these sensitive times and maternal infant feeding styles and practices. This study sought to analyze these relations in low-income Hispanic mother-infant pairs enrolled in a randomized controlled trial of an early obesity prevention program (Starting Early). Food insecurity was measured prenatally and during infancy at 10 months. Food insecurity timing was categorized as never, prenatal only, infancy only, or both. Regression analyses were used to determine relations between food insecurity timing and styles and practices at 10 months, using never experiencing food insecurity as the reference, adjusting for family characteristics and material hardships. 412 mother-infant pairs completed 10-month assessments. Prolonged food insecurity during both periods was associated with greater pressuring, indulgent and laissez-faire styles compared to never experiencing food insecurity. Prenatal food insecurity was associated with less vegetable and more juice intake. If food insecurity is identified during pregnancy, interventions to prevent food insecurity from persisting into infancy may mitigate the development of obesity-promoting feeding styles and practices.

BackgroundSedentary behaviors, including screen time (i.e., time spent using televisions, computers, and smart phones), are associated with unhealthy dietary behaviors and obesity. However, it rema...

Although disparities in child obesity exist during infancy, the underlying mechanisms are unclear. Assessing dissimilarities in feeding practices, styles, and beliefs may provide a better understanding of these mechanisms. This study sought to identify modifiable maternal-infant feeding behaviors that may contribute to disparities in early child obesity.This study is a cross-sectional analysis comparing mothers with infants (2 weeks to 6 months old) in a low-risk group of high-income white mothers to a high-risk group of low-income Hispanic mothers. Regression analysis was used to explore relationships between each group and (1) infant feeding practices, including breastfeeding, giving juice, and adding cereal to bottles, (2) controlling feeding styles, (3) beliefs about infant hunger and satiety, and (4) infant weight status.The sample included 412 mothers (low-risk group, n = 208; high-risk group, n = 204). The high-risk group was less likely to exclusively breastfeed (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.22-0.83), more likely to introduce juice (AOR, 12.25; 95% CI, 3.44-43.62), and add cereal to the bottle (AOR, 10.61; 95% CI, 2.74-41.0). The high-risk group exhibited greater restrictive and pressuring feeding styles and was more likely to believe that mothers can recognize infant hunger and satiety and less likely to believe that infants know their own hunger and satiety. High-risk infants were more likely to have a weight-for-length percentile85th percentile (AOR, 2.66; 95% CI, 1.10-6.45).Differences in infant feeding behaviors may contribute to disparities in early child obesity. Longitudinal studies are needed to determine the effect of these differences on child obesity.

BackgroundBecause of the strong link between childhood obesity and adulthood obesity comorbidities, and the difficulty in decreasing body mass index (BMI) later in life, effective strategies are needed to address this condition in early childhood. The ability to predict obesity before age five could be a useful tool, allowing prevention strategies to focus on high risk children. The few existing prediction models for obesity in childhood have primarily employed data from longitudinal cohort studies, relying on difficult to collect data that are not readily available to all practitioners. Instead, we utilized real-world unaugmented electronic health record (EHR) data from the first two years of life to predict obesity status at age five, an approach not yet taken in pediatric obesity research.Methods and findingsWe trained a variety of machine learning algorithms to perform both binary classification and regression. Following previous studies demonstrating different obesity determinants for boys and girls, we similarly developed separate models for both groups. In each of the separate models for boys and girls we found that weight for length z-score, BMI between 19 and 24 months, and the last BMI measure recorded before age two were the most important features for prediction. The best performing models were able to predict obesity with an Area Under the Receiver Operator Characteristic Curve (AUC) of 81.7% for girls and 76.1% for boys.ConclusionsWe were able to predict obesity at age five using EHR data with an AUC comparable to cohort-based studies, reducing the need for investment in additional data collection. Our results suggest that machine learning approaches for predicting future childhood obesity using EHR data could improve the ability of clinicians and researchers to drive future policy, intervention design, and the decision-making process in a clinical setting.

Background Di-2-ethylhexylphthalate (DEHP) is an ester of phthalic acid commonly found in processed foods. DEHP may contribute to obesity and insulin resistance in children and adolescents, yet dietary exposures have been not been studied in this vulnerable subpopulation. Objective To assess diet and its relation to urinary phthalates in a nationally representative sample of US children and adolescents. Design Cross-sectional analysis of 24-h dietary recall and urinary phthalate metabolites from 2743 6–19 year olds participating in the 2003–8 National Health and Nutrition Examination Surveys. Regression analyses examined relationships of food consumption with log-transformed metabolite concentrations, examined as low-molecular weight, high molecular weight and di-2-ethylhexylphthalate categories, controlling for urinary creatinine, age group, body mass index category, race/ethnicity, caloric intake and gender. Results We identified a −0.04% (95% CI: −0.08, −0.01) increment in di-2-ethylhexylphthalate metabolite concentration/additional gram fruit consumption, a +0.01% increment/additional calorie dietary intake (95% CI: +0.003, +0.02), and a +0.09% (95% CI: +0.02, +0.17) increment/additional gram meat/poultry/fish consumption. Soy consumption (−0.40% increment/additional gram consumed, 95% CI: −0.66, −0.14) was inversely associated with di-2-ethylhexylphthalate, while poultry (+0.23% increment/additional gram consumed, 95% CI: +0.12, +0.35) was positively associated. Findings were robust to examination of metabolite concentrations per unit body mass index and weight, and inclusion of fasting time. Conclusions Diet contributes to urinary phthalate concentrations in children and adolescents. Further study is needed to examine the implications of di-2-ethylhexylphthalate exposure, especially earlier in life, when more permanent metabolic changes may occur.

Objective To describe infant activity at 3 months old and to test the efficacy of a primary care-based child obesity prevention intervention on promoting infant activity in low-income Hispanic families. Methods This study was a randomized controlled trial (n = 533) comparing a control group of mother–infant dyads receiving standard prenatal and pediatric primary care with an intervention group receiving “Starting Early,” with individual nutrition counseling and nutrition and parenting support groups coordinated with prenatal and pediatric visits. Outcomes included infant activity (tummy time, unrestrained floor time, time in movement-restricting devices). Health literacy was assessed using the Newest Vital Sign. Results Four hundred fifty-six mothers completed 3-month assessments. Infant activity results were: 82.6% ever practiced tummy time; 32.0% practiced tummy time on the floor; 34.4% reported unrestrained floor time; 56.4% reported ≥1 h/d in movement-restricting devices. Inadequate health literacy was associated with reduced tummy time and unrestrained floor time. The intervention group reported more floor tummy time (OR 2.16, 95% CI 1.44-3.23) and unrestrained floor time (OR 1.69, 95% CI 1.14-2.49) compared to controls. No difference in the time spent in movement-restricting devices was found. Conclusions Tummy time and unrestrained floor time were low. Primary care-based obesity prevention programs have potential to promote these activities.

Objective Determine maternal and infant characteristics associated with adding cereal into the bottle. Design Secondary data analysis. Participants Study participants were immigrant, low-income, urban mother–infant dyads (n = 216; 91% Hispanic, 19% US-born) enrolled in a randomized controlled trial entitled the Bellevue Project for Early Language, Literacy and Education Success. Main Outcome Measures Maternal characteristics (age, marital status, ethnicity, primary language, country of origin, education, work status, income, depressive symptoms, and concern about infant's future weight) and infant characteristics (gender, first born, and difficult temperament). Analysis Fisher exact test, chi-square test, and simultaneous multiple logistic regression of significant ( P Results Twenty-seven percent of mothers added cereal into the bottle. After adjusting for confounding variables identified in bivariate analyses, mothers who were single ( P = .02), had moderate to severe depressive symptoms ( P = .01) and perceived their infant had a difficult temperament ( P = .03) were more likely to add cereal into the bottle. Conversely, mothers who expressed concern about their infants becoming overweight were less likely to add cereal ( P = .02). Conclusions and Implications Health care providers should screen for adding cereal in infant bottles. Further research is needed to investigate the impact of adding cereal into the bottle on weight trajectories over time. Causal associations also need to be identified to effectively prevent this practice.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Objective To determine the effects of a child obesity prevention intervention, beginning in pregnancy, on infant feeding practices in low-income Hispanic families. Study design The Starting Early randomized controlled trial enrolled pregnant women at a third trimester visit. Women (n = 533) were randomly allocated to a standard care control group or an intervention group participating in prenatal and postpartum individual nutrition/breastfeeding counseling and subsequent nutrition and parenting support groups coordinated with well-child visits. Outcome measures included infant feeding practices and maternal infant feeding knowledge at infant age 3 months, using questions adapted from the Infant Feeding Practices Study II and an infant 24-hour diet recall. Results A total of 456 families completed 3-month assessments. The intervention group had higher prevalence of exclusive breastfeeding on the 24-hour diet recall (42.7% vs 33.0%, P = .04) compared with controls. The intervention group reported a higher percentage of breastfeeding vs formula feeding per day (mean [SD] 67.7 [39.3] vs 59.7 [39.7], P = .03) and was less likely to introduce complementary foods and liquids compared with controls (6.3% vs 16.7%, P = .001). The intervention group had higher maternal infant feeding knowledge scores (Cohen d, 0.29, 95% CI .10-.48). The effect of Starting Early on breastfeeding was mediated by maternal infant feeding knowledge (Sobel test 2.86, P = .004). Conclusions Starting Early led to increased exclusive breastfeeding and reduced complementary foods and liquids in 3-month-old infants. Findings document a feasible and effective infrastructure for promoting breastfeeding in families at high risk for obesity in the context of a comprehensive obesity prevention intervention. Trial registration ClinicalTrials.gov: NCT01541761.