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The purpose of this study was to determine the relationship between patterning of human milk feeding and growth of infants with congenital heart defects in the first year of life. Inclusion criteria for this prospective cohort study included infants 0-21 days, who had undergone or had planned neonatal corrective or palliative surgery prior to hospital discharge, and whose mothers planned to feed human milk. Data on anthropometric measures (weight, length, head circumference) and infant milk type (human milk, formula, other) were collected at nine time points (0.5, 1, 2, 3, 4, 6, 8, 10, 12 months). Anthropometric data were converted to weight-for-age, length-for-age, head circumference-for-age, and weight-for-length Z-scores using World Health Organization growth reference data. Cluster analysis identified three milk type feeding patterns in the first year: Infants fed human milk only with no formula supplementation, infants fed human milk who then transitioned to a mix of human milk and formula, and infants who fed human milk and transitioned to formula only. General linear models assessed the effect of milk type feeding patterns on growth parameters over time. No effect of milk type pattern × time was found on longitudinal changes in weight-for-age (p for interaction = 0.228), length-for-age (p for interaction = 0.173), weight-for-length (p for interaction = 0.507), or head circumference-for-age (p for interaction = 0.311) Z-scores. In this cohort study, human milk alone or combined with infant formula supported age-appropriate growth in infants with congenital heart defects in the first year.

OBJECTIVE: Despite an increase in twin pregnancies in recent decades, the Institute of Medicine twin weight gain recommendations remain provisional and provide no guidance for pattern or timing of weight change. We sought to characterize gestational weight change trajectory patterns and examine associations with birth outcomes in a cohort of twin pregnancies. STUDY DESIGN: Prenatal and delivery records were examined for 320 twin pregnancies from a maternal-fetal medicine practice in Austin, TX 2011-2019. Prenatal weights for those with >1 measured weight in the first trimester and ≥3 prenatal weights were included in analyses. Trajectories were estimated to 32wk (mean delivery 33.7±3.3wk) using flexible latent class mixed models with low-rank thin plate splines. Associations between trajectory classes and infant outcomes were analyzed using multivariable Poisson or linear regression. RESULTS: Weight change at delivery was 15.4±6.3kg for people with an underweight BMI, 15.4±5.8kg for healthy weight, 14.7±6.9kg for overweight, and 12.5±6.4kg for obesity. Three trajectory classes were identified: low (Class1), moderate (Class2), or high gain (Class3). Class1 (24.7%) maintained weight to 15wk, then gained an estimated 6.6kg at 32wk. Class2 (60.9%) exhibited steady gain with 13.5kg predicted total gain, and Class3 (14.4%) showed rapid gain across pregnancy with 21.3kg predicted gain. Compared to Class1, Class3 was associated with higher birthweight z-score (β =0.63, 95%CI 0.31,0.96), increased risk for large for gestational age (IRR=5.60, 95%CI 1.59, 19.67), and birth

BACKGROUND: Prevalence of obesity in Native American (NA) children is disproportionately high, indicating a higher risk of health disparities. Many children attend early care and education (ECE) programs, presenting an opportune environment to improve meal and menu quality as the intake of healthy foods is associated with lowered risk of childhood obesity. OBJECTIVES: We aimed to examine the effectiveness of food service staff training on meals and menu quality across NA ECEs. METHODS: Food service staff from 9 participating ECE programs attended a 3-h training focused on Child and Adult Care Food Program (CACFP) best practices, and received a tailored, best-practice menu, and healthy recipes. Meals and menus prepared across 1 wk were examined per CACFP serving size assumptions at baseline, 4 mos, 6 mos, and 12 mos for all 9 programs. Healthy Eating Index (HEI), CACFP requirements and best practices achievement, and food substitutions quality (classified into superior, equivalent, and inferior based on the nutritional quality) were calculated. A repeated measures ANOVA model was used to determine the differences across time points. RESULTS: The total meal HEI score increased significantly from baseline to 4 mos (71.1 ± 2.1; 78.6 ± 5.0; P = 0.004), but did not differ from baseline to 12 mos. Menu CACFP requirements and best practices achievement did not differ across time points, although achievement with CACFP requirements was already high at baseline. Superior nutrition quality substitutions declined from baseline to 6 mos (32.4 ± 8.9; 19.5 ± 10.9; P = 0.007); however, it did not differ from baseline to 12 mos. Equivalent and inferior quality substitutions did not differ across time points. CONCLUSIONS: Implementing a best-practice menu with healthy recipes showed immediate improvements in meal quality. Although the change did not sustain, this study showed evidence of an opportunity to educate and train food service staff. Robust efforts are needed for improving both meals and menus. This trial was registered ClinicalTrials.gov as NCT03251950 (https://clinicaltrials.gov/ct2/show/NCT03251950?cond=food+resource+equity&draw=2&rank=1).

OBJECTIVE: We developed a mother-child dyad trajectories model of weight and body composition spanning from conception to adolescence to understand how early life-exposures shape childhood body composition. METHODS: African American (49.3%) and Dominican (50.7%) pregnant mothers (n=337) were enrolled during pregnancy, and their children (47.5% female) were followed from ages 5 to 14. Gestational weight gain (GWG) was abstracted from medical records. Child weight, height, percentage body fat (%fat) and waist circumference were measured. GWG and child body composition trajectories were jointly modeled with a flexible latent class model with a class membership component that included prepregnancy BMI. RESULTS: Four prenatal and child body composition trajectory patterns were identified, and sex-specific patterns were observed for joint GWG-postnatal body composition trajectories with more distinct patterns among girls but not boys. Girls of mothers with high GWG across gestation had the highest BMIZ, waist circumference and %fat trajectories from ages 5 to 14; however, boys in this high GWG group did not show similar growth patterns. CONCLUSIONS: Jointly modeled prenatal weight and child body composition trajectories showed sex-specific patterns. Growth patterns from childhood though early adolescence appear to be more profoundly affected by higher GWG patterns in females, suggesting sex-differences in developmental programming.

Gestational weight gain (GWG) and anthropometric trajectories may affect foetal programming and are potentially modifiable.To assess concomitant patterns of change in weight, circumferences and adiposity across gestation as an integrated prenatal exposure, and determine how they relate to neonatal body composition.Data are from a prospective cohort of singleton pregnancies (n = 2182) enrolled in United States perinatal centres, 2009-2013. Overall and by prepregnancy BMI group (overweight/obesity and healthy weight), joint latent trajectory models were fit with prenatal weight, mid-upper arm circumference (MUAC), triceps (TSF) and subscapular (SSF) skinfolds. Differences in neonatal body composition by trajectory class were assessed via weighted least squares.Six trajectory patterns reflecting co-occurring changes in weight and MUAC, SSF and TSF across pregnancy were identified overall and by body mass index (BMI) group. Among people with a healthy weight BMI, some differences were observed for neonatal subcutaneous adipose tissue, and among individuals with overweight/obesity some differences in neonatal lean mass were found. Neonatal adiposity measures were higher among infants born to individuals with prepregnancy overweight/obesity.Six integrated trajectory patterns of prenatal weight, subcutaneous adipose tissue and circumferences were observed that were minimally associated with neonatal body composition, suggesting a stronger influence of prepregnancy BMI.

OBJECTIVES: Current gestational weight change (GWC) recommendations were established by the Institute of Medicine (IOM) with limited evidence for pattern and timing of weight change across pregnancy. Likewise, the recommendation of 5–9kg for women with obesity does not differentiate by severity of obesity. We sought to describe GWC trajectory patterns among a large, contemporary cohort of women with obesity. METHODS: Electronic medical records were abstracted for 22,987 women with obesity (BMI ≥ 30.0) who delivered a singleton pregnancy at Kaiser Permanente Northern California between 2008–2013. We modeled GWC for women with a measured prepregnancy weight, at least three prenatal visit weights, and a normal oral glucose tolerance test at 20 wk gestation. Weight change trajectories were modeled using flexible latent class mixed modeling (package LCMM) in R. RESULTS: Before pregnancy, 60.4% of women had class 1 obesity (BMI 30.0–34.9kg/m(2)), 24.8% class 2 (35.0–39.9), and 14.8% class 3 (≥40.0). Most women identified as White (37.3%) or Hispanic (37.3%), with 12.4% Black and 8.5% Asian. Five GWC trajectory groups across pregnancy were identified, each with a distinct pattern of weight change before 15 wk followed by weight gain thereafter (15 wk): 12.2% exhibited HighLoss/SteadyGain with mean GWC at delivery of 0.9 ± 3.1kg (mean ± sd); 25.8% LowLoss/SteadyGain (6.4 ± 2.4); 30.4% LowGain/ModerateGain (11.4 ± 2.5); 23.0% ModerateGain/HighGain (16.8 ± 3.1); and 8.6% HighGain/HighGain (24.5 ± 5.0). Prepregnancy obesity classes were represented across GWC trajectory groups but were predominantly in two groups: those with class 1 obesity exhibited LowGain/ModerateGain (32.1%), class 2 was split between LowGain/ModerateGain (29.0%) and LowLoss/SteadyGain (28.8%), and class 3 exhibited LowLoss/SteadyGain (31.8%). Only the LowLoss/SteadyGain (25.8%) group demonstrated total GWC at delivery within the IOM recommendation. CONCLUSIONS: Among women with obesity, GWC was not linear or uniform, and current recommendations do not reflect nuances of the prenatal period. Gestational weight change in women with obesity can be flexibly modeled using latent classes, an important next step for prenatal weight change guidance. FUNDING SOURCES: ANDF, KPNC.

OBJECTIVES: HIV-exposed and uninfected (HEU) infants may experience altered growth compared to HIV-unexposed and uninfected (HUU) infants. Most studies to date have used analytic techniques that do not reflect the dynamic trends in infant growth patterns. We therefore sought to evaluate growth patterns using 3 different analytic methods and examine the role of HIV on growth with each method. METHODS: Repeated measures for infant anthropometrics were taken from 6 wk to 23 mo of age in the former Nyanza region, Kenya (n = 310, 52% HEU, 50% male). We used (1) Latent Class Mixed Modeling (LCMM) to identify length-for-age z-score (LAZ) trajectory classes and then multinomial logistic regression to assess how HIV exposure status predicted trajectory class membership, adjusting for covariates (e.g., maternal height, food insecurity); (2) SuperImposition by Translation and Rotation (SITAR) to estimate length in terms of size and velocity (rate of growth) differences by maternal HIV status; and (3) longitudinal regression, the conventional method for analyzing growth, to estimate differences in length and LAZ based on HIV exposure. RESULTS: At 6 wks of age, HEU infants had a mean LAZ score of −1.03 ± 1.85 compared to −1.10 ± 1.83 for HUU infants. LCMM identified four LAZ trajectory classes (average 5.1 measurements/infant). Across time, class one LAZ scores remained near 1; class two declined 0 to −1; class three remained near −1; and class four fluctuated between −2 and −3. In logistic regression models, HEU infants were less likely to belong to classes one (RR = 0.3; 95% CI: 0.1,0.9) and two (RR = 0.4; 95% CI: 0.2,0.7) relative to class three. Similarly, SITAR estimated that HEU infants were on average 0.62 cm shorter than HUU infants across the study (95% CI: −1.3,0.1) but there were no differences in mean linear growth velocities. Longitudinal regression models predicted that mean stature for HEU infants was 0.8 cm (95% CI: −1.5, −0.1) shorter and that mean LAZ for HEU infants was 0.4 points (95% CI: −0.7, −0.1) lower compared to HUU infants. CONCLUSIONS: Across the 3 methods, HEU infants were shorter than HUU infants during the first 23 mo of life. Compared to longitudinal regression, advanced modeling with LCMM and SITAR allows for a more flexible assessment of the altered growth patterns HEU infants experience. FUNDING SOURCES: NIH.

OBJECTIVES: Breastfeeding is a potentially modifiable factor associated with less postpartum weight retention; however, in the United States women with lower socioeconomic status (SES) are less likely to initiate breastfeeding and, therefore, may be at higher risk for long-term weight retention. We sought to describe associations between duration of breastfeeding with postpartum weight retention and later BMI, and to determine whether associations varied by SES. METHODS: Maternal and infant data (n = 2144 dyads) are from the Geographic Research on Wellbeing survey (GROW), a follow-up study of California's annual statewide-representative Maternal and Infant Health Assessment. Pre-pregnancy BMI was obtained from self-report; at 4–10y postpartum, breastfeeding history and self-reported body weight were collected. Multivariable linear regression was used to examine associations between breastfeeding and long-term maternal body size. SES was calculated as a composite score of % federal poverty threshold plus education and was dichotomized. RESULTS: Overall, mean prepregnancy BMI was 24.9 kg/m,(2) while long-term weight retention 4–10 y postpartum was 4.0 kg. The sample average breastfeeding duration was 8.5 months with 61% meeting the World Health Organization (WHO) recommendations for 6 months of breastfeeding. In adjusted models, compared to women who did not meet recommendations, women who met WHO recommendations had slightly lower long-term postpartum weight retention (b = −1.06 kg, CI: −1.93, −0.25, p = 0.01) and a small reduction in BMI (b = −0.4 kg/m,(2) 95% CI −0.74, −0.08; p = 0.02). Compared to higher SES women, fewer lower SES women ever breastfed (89% vs 74%, p

Objective:Adequate dietary intake during pregnancy is vital for the health and nutritional status of both mother and fetus. The nutritional status of reproductive age women in Pakistan is poor, with 14 % being underweight (BMI < 18·5) and 42 % experiencing Fe deficiency anaemia. This may stem from beliefs, practices and other barriers influencing dietary intake. This qualitative study seeks to determine which factors impact dietary intake during pregnancy in rural Punjab.Design:In-depth interviews and focus group discussions were conducted and then analysed using thematic analysis.Setting:Three purposively selected rural districts (Sahiwal, Okara and Pakpatan) with the highest prevalence of maternal and child malnutrition in the province of Punjab, PakistanParticipants:Mothers with children under age two (n 29) and healthcare providers with at least 5 years of experience working in the district (n 12).Results:We identified a combination of physiological, socio-cultural and structural barriers that inhibited healthful dietary intake during pregnancy. The primary physiological barriers to optimal dietary intake and dietary practices included food aversions and food cravings. Food classification, fear of a difficult childbirth, fear of high blood pressure and household food politics were the principal socio-cultural barriers. Additionally, two structural barriers, inadequate antenatal counseling and a lack of affordable food options, were identified.Conclusions:Our study demonstrates that complex barriers prevent pregnant women in the Punjab area from consuming adequate dietary intake and that antenatal health education programmes and structural interventions are needed to support healthful dietary practices during this critical period.

Background Preschool children consume two thirds of their dietary requirements at Early Care and Education (ECE) programs. Programs in tribal communities face unique challenges like rural location and reduced food access. Evaluation of ECE menus is an efficient method to examine dietary quality of foods and find opportunity to enhance nutrition quality through training and interventions for programs including those serving Native American children. Objective Determine nutrient content, Child and Adult Care Food Program (CACFP) compliance, food substitution to assess menu quality in tribally affiliated ECE programs. Study Design, Setting, Participants Cross-sectional analysis was conducted as the baseline assessment in FRESH, a community-based participatory research study. Menus and recipes were collected from 9 sites and foods served to children were photographed. Measurable Outcome/Analysis Food Processor was used for nutrient analyses of fiber, saturated fat, and energy content. A quantitative index assessed the revised 2017 CACFP requirement, best practice, and combined compliance (possible score of zero to 100 percent for each). Food substitutions were classified as nutritionally equivalent, nutritionally superior (higher nutrient quality), or nutritionally inferior (poorer nutrient quality), and summed. Means, standard deviation, medians, and interquartile ranges were calculated for all variables. Results Mean fiber, saturated fat, and energy content of menus were 3.5g ± 0.5g, 10.5g ± 3.4g, and 643.7 ± 106.6 kcals, respectively. Menus were 74.4%, 61.4%, and 88.1% compliant with the total CACFP guidelines, best practices, and requirements, respectively. In 1 week, 54.8% of the foods were substituted; 44.3% were equivalent quality substitutions, 32.6% superior, and 23.1% inferior. Conclusion Menus need to provide two thirds of the daily requirement of fiber (12-16g) to match the CACFP guidelines. More than 10% of total calories came from saturated fat and menus did not provide two thirds of total energy requirement (666-1067 kcals). Menus were fairly compliant with the CACFP guidelines however, there is a room for improvement. Foodservice personnel training may enhance nutritional quality of meals and substitutions.

OBJECTIVES: Maternal weight and anthropometric trajectories may affect both fetal programming and maternal pregnancy health outcomes. We developed a statistical model that categorized concomitant changes in weight and body composition across gestation. METHODS: We conducted a secondary analysis of a prospective cohort of singletons (n = 2,353) enrolled from 11 US perinatal centers, 2009–2013. Weight, mid-upper arm circumference (MUAC), plus triceps and subscapular skinfold thickness (TSF, SSF) were measured up to 5 times across gestation. Prenatal weights were also abstracted from medical records. Gestational weight change (GWG) trajectories and time-varying, region-specific body composition (MUAC, TSF, SSF) were modeled jointly with a flexible latent class trajectory model, adjusting for prepregnancy BMI. RESULTS: Most women had prepregnancy normal weight (56.4%), while fewer were classified as overweight (27.2%) or obese (16.4%). Five trajectory patterns for weight and body composition were identified. (1) InitalHighSteadyGain (12.5%) had the highest 1(st) trimester weight gain and steady gain thereafter, with high model estimated total GWG (36.1 lbs). (2) InitialModerateSlowGain (19.8%) had moderate 1(st) trimester gain, then slow steady gain with the lowest total GWG (28.7 lbs). InitalHighSteadyGain and InitialModerateSlowGain showed relatively stable MUAC, while SSF and TSF increased in 1(st) and 2(nd) trimesters and decreased in 3(rd) trimester. Other GWG trajectory groups showed (3) 1(st) trimester weight loss (LossSteadyGain, 8.2%), (4) stability (StableSteadyGain, 21.5%), or (5) low gain (LowSteadyGain, 38.2%), then steady GWG in the 2(nd) and 3(rd) trimesters with estimated total GWG of 35.7, 36.8 and 32.8 lb, respectively. Small increases in MUAC and SSF were observed in LowSteadyGain across pregnancy, while TSF increased up to 30 wk and then decreased. LossSteadyGain and StableSteadyGain groups showed similarities in initial MUAC, TSF and SSF measurements with small increases in MUAC and TSF, and moderate increases in SSF over time. CONCLUSIONS: Joint modeling of prenatal weight and regional body composition changes identified five trajectory patterns, which offers a more advanced understanding of how these trajectories concomitantly change during pregnancy. FUNDING SOURCES: NICHD; HHS.

Background Native American (NA) children have a high prevalence of obesity contributing to lifespan health disparities. Dietary intake is important to promote healthy weight gain, growth, and development. In 2017, the USDA enforced changes to the Child and Adult Care Food Program (CACFP). The CACFP provides reimbursement to qualifying Early Care and Education (ECE) programs that serve foods that uphold the program's nutrition requirements. Objective This study had the following 2 objectives: 1) Describe a novel index to evaluate ECE menus based on revised CACFP requirements (accounting for food substitutions) and best practices for 3- to-5-y-old children, and 2) analyze CACFP requirement and best practice compliance and nutrient changes in 9 NA ECE programs before and after enforcement of the revised CACFP requirements. Methods This longitudinal study is within a larger community-based participatory research study. Menus and meals served were evaluated for 1 wk at each of 9 programs before and after enforcement of the revised meal patterns. Nutrient analysis, CACFP requirement and best practice compliance, and substitution quality were evaluated. Differences were determined using a paired t-test or Wilcoxon matched test. This trial was registered at clinicaltrials.gov as NCT03251950. Results Total grams of fiber consumed increased (5.0 ± 1.2 compared with 5.9 ± 0.8 g, P = 0.04) and total grams of sugar consumed decreased (53.8 ± 12.6 compared with 48.4 ± 7.9 g, P = 0.024), although room for further improvement exists. Although total grams of fat remained unchanged, grams of saturated fat significantly increased (7.8 ± 1.4 compared with 10.5 ± 3.4, P = 0.041). Other nutrients remained unchanged. Overall CACFP requirement and best practice compliance scores improved, although this finding was not statistically significant. No significant changes in food quality associated with substitutions occurred. Conclusions This study provides early evidence to support the beneficial impact of the revised CACFP requirements. Understanding barriers to compliance within rural NA communities would be an important next step in enhancing the health of vulnerable children.

OBJECTIVES: New Child and Adult Care Food Program (CACFP) meal patterns and best-practices were implemented nationally in 2017 to address the need to prevent chronic diseases. Young Native American children have disproportionately higher risk of chronic disease. Some Native American tribes operate early care and education (ECE) programs and have the opportunity to participate in the CACFP. The purpose of this paper is to describe a CACFP best-practice menu and training developed and implemented as part of the Food Resource Equity and Sustainability for Health (FRESH) study. METHODS: FRESH is a community-based participatory research (CBPR) intervention implemented within ECE programs in the Osage Nation of Oklahoma. Site managers and cooks from each of the nine ECE programs attended meetings and provided feedback to investigators which shaped the best-practice menu and training. Each site participated in a three-hour training in January 2018 to discuss the best-practice menu and ways to overcome implementation barriers. Goals of the menu aimed to increase intake of fruit and vegetables and whole grains and reduce pre-fried and processed foods without increasing cook burden. Training included application activities individually and in small and large groups. RESULTS: Though the project is still underway, lessons learned have emerged including the need for technical assistance, improved communication between ECE program staff and food supply vendors, and infrastructure barriers (e.g., limited space, lack of supplies) that challenge work-flow. CONCLUSIONS: Efforts to improve menus in rural and low-income ECE programs must consider these issues in developing feasible intervention strategies. Collaboration with the site manager and cook is essential to fully understand perceived and actual barriers to provide training that can provide necessary background rationale for nutrition recommendations as well as beneficial and productive activities and hands-on training to effect change outside the training. FUNDING SOURCES: This study was funded by the National Institute on Minority Health and Health Disparities (R01MD011266). The funding agency did not participate in the study design, data collection, analysis, decision to publish, or preparation of the manuscript.