BACKGROUND: In 2004, World Health Organization (WHO) recommended the use of serum ferritin as a primary indicator of iron deficiency. However, there was limited data on the magnitude and distribution of iron deficiency based on ferritin. OBJECTIVE: To describe the prevalence of iron deficiency as measured by serum/plasma ferritin in different regions of the world and its relationship with demographic and health indicators. METHODS: Data from the Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia and the WHO Vitamin and Mineral Nutrition Information System Micronutrients Database were used for this analysis. Unadjusted and inflammation-adjusted low ferritin prevalence were calculated for both databases. The prevalence of low ferritin among preschool children and non-pregnant women was examined according to its relationship with national gross domestic product (GDP), infant mortality rate (IMR), and anemia rate. RESULTS: In children, the median inflammation-adjusted prevalence of low ferritin was 35.3% (1(st) and 3(rd) quartiles: 17.5% and 48.1%). In non-pregnant women, the median inflammation-adjusted prevalence of low ferritin was 28.4% (1(st) and 3(rd) quartiles: 21.4% and 42.0%). For both children and women, the correlation between the prevalence of low ferritin and GDP, IMR, or anemia was consistently stronger using inflammation-adjusted prevalences than when using unadjusted prevalences. CONCLUSIONS: The quartile values of low ferritin prevalence for children and non-pregnant women could be used to define the severity of ferritin as a public health problem.

Care immediately following birth affects breastfeeding outcomes. This analysis compared improvement in maternity care practices from 2011 to 2013 among hospitals participating in a quality improvement collaborative, Best Fed Beginnings (BFB), to hospitals that applied but were not selected (non-Best Fed Beginnings [non-BFB]), and other hospitals, using Centers of Disease Control and Prevention's Maternity Practices in Infant Nutrition and Care (mPINC) survey data to calculate total and subscores for 7 care domains. Analysis of covariance compared change in scores from 2011 to 2013 among BFB, non-BFB, and other hospitals. BFB hospitals had twice the increase in mPINC score compared to non-BFB and a 3-fold increase compared to other hospitals. Learning collaborative participation may have accelerated progress in hospitals implementing breastfeeding-supportive maternity care.

Hemoglobin (Hb), mean cell volume (MCV), and erythrocyte protoporphyrin (EP) are commonly used to screen for iron deficiency (ID), but systematic evaluation of the sensitivity and specificity of these tests is limited. The objective of this study is to determine the sensitivity and specificity of Hb, MCV, and EP measurements in screening for ID in preschool children, non-pregnant women 15-49 years of age, and pregnant women. Data from the National Health and Nutrition Examination Surveys (NHANES) (NHANES 2003-2006: n = 861, children three to five years of age; n = 3112, non-pregnant women 15 to 49 years of age. NHANES 1999-2006: n = 1150, pregnant women) were examined for this purpose. Children or women with blood lead ≥10 microg/dL or C-reactive protein (CRP) >5.0 mg/L were excluded. ID was defined as total body iron stores <0 mg/kg body weight, calculated from the ratio of soluble transferrin receptor (sTfR) to serum ferritin (SF). The receiver operating characteristic (ROC) curve was used to characterize the sensitivity and specificity of Hb, MCV, and EP measurements in screening for ID. In detecting ID in children three to five years of age, EP (Area under the Curve (AUC) 0.80) was superior to Hb (AUC 0.62) (p < 0.01) but not statistically different from MCV (AUC 0.73). In women, EP and Hb were comparable (non-pregnant AUC 0.86 and 0.84, respectively; pregnant 0.77 and 0.74, respectively), and both were better than MCV (non-pregnant AUC 0.80; pregnant 0.70) (p < 0.01). We concluded that the sensitivity and specificity of EP in screening for ID were consistently superior to or at least as effective as those of Hb and MCV in each population examined. For children three to five years of age, EP screening for ID was significantly better than Hb and similar to MCV. For both non-pregnant and pregnant women, the performance of EP and Hb were comparable; both were significantly superior to MCV.

OBJECTIVE: To examine the concentration of C-reactive protein (CRP) in relation to gestational weeks during pregnancy among Chinese women. METHODS: From a randomized control trial of prenatal supplementation with folic acid, iron-folic acid, and multiple micronutrients in China, we examined 834 pregnant women with CRP measured initially between 5 and 20 weeks and at follow-up between 28 and 32 weeks gestation. We calculated and plotted CRP geometric means by gestational weeks. The same analysis was repeated for women who had normal pregnancies (624 women) by excluding women with stillbirth, preterm, small for gestational age, body mass index <18.5 kg/m2 or >30 kg/m2 at enrollment, and hypertension or anemia during pregnancy. RESULTS: We observed a significant positive trend between log-transformed CRP and gestational age from 5 to 20 weeks and from 28 to 32 weeks both in the full sample and in the subset of women who had normal pregnancies. CRP geometric mean was 0.81 mg/l at 5-7 weeks of gestation, 2.85 mg/l at 19-20 weeks of gestation, and 3.89 mg/l at 32 weeks of gestation. A similar increasing trend in the CRP median or percentage of elevated CRP were also observed. CONCLUSION: We concluded that CRP increased with gestational age among healthy Chinese women who delivered healthy infants. Am. J. Hum. Biol., 2016. (c) 2016 Wiley Periodicals, Inc.

BACKGROUND: Understanding state/territorial trends in obesity by race/ethnicity helps focus resources on populations at risk. OBJECTIVE: This study aimed to examine trends in obesity prevalence among low-income, preschool-aged children from 2008 through 2011 in U.S. states and territories by race/ethnicity. METHODS: We used measured weight and height records of 11.1 million children aged 2-4 years who participated in federally funded health and nutrition programmes in 40 states, the District of Columbia and two U.S. territories. We used logistic regression to examine obesity prevalence trends, controlling for age and sex. RESULTS: From 2008 through 2011, the aggregated obesity prevalence declined among all racial/ethnic groups (decreased by 0.4-0.9%) except American Indians/Alaska Natives (AI/ANs); the largest decrease was among Asians/Pacific Islanders (A/PIs). Declines were significant among non-Hispanic whites in 14 states, non-Hispanic blacks in seven states/territories, Hispanics in 13 states, A/PIs in five states and AI/ANs in one state. Increases were significant among non-Hispanic whites in four states, non-Hispanic blacks in three states, Hispanics in two states and A/PIs in one state. The majority of the states/territories had no change in obesity prevalence. CONCLUSIONS: Our findings indicate slight reductions in obesity prevalence and variations in obesity trends, but disparities exist for some states and racial/ethnic groups.

BACKGROUND: Although 80% of U.S. mothers begin breastfeeding their infants, many do not continue breastfeeding as long as they would like to. Experiences during the birth hospitalization affect a mother's ability to establish and maintain breastfeeding. The Baby-Friendly Hospital Initiative is a global program launched by the World Health Organization and the United Nations Children's Fund, and has at its core the Ten Steps to Successful Breastfeeding (Ten Steps), which describe evidence-based hospital policies and practices that have been shown to improve breastfeeding outcomes. METHODS: Since 2007, CDC has conducted the biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey among all birth facilities in all states, the District of Columbia, and territories. CDC analyzed data from 2007 (baseline), 2009, 2011, and 2013 to describe trends in the prevalence of facilities using maternity care policies and practices that are consistent with the Ten Steps to Successful Breastfeeding. RESULTS: The percentage of hospitals that reported providing prenatal breastfeeding education (range = 91.1%-92.8%) and teaching mothers breastfeeding techniques (range = 87.8%-92.2%) was high at baseline and across all survey years. Implementation of the other eight steps was lower at baseline. From 2007 to 2013, six of these steps increased by 10-21 percentage points, although limiting non-breast milk feeding of breastfed infants and fostering post-discharge support only increased by 5-6 percentage points. Nationally, hospitals implementing more than half of the Ten Steps increased from 28.7% in 2007 to 53.9% in 2013. CONCLUSIONS: Maternity care policies and practices supportive of breastfeeding are improving nationally; however, more work is needed to ensure all women receive optimal breastfeeding support during the birth hospitalization. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Because of the documented benefits of breastfeeding to both mothers and children, and because experiences in the first hours and days after birth help determine later breastfeeding outcomes, improved hospital policies and practices could increase rates of breastfeeding nationwide, contributing to improved child health.

INTRODUCTION: Racial/ethnic differences in recent obesity trends have not been reported among young low-income children. The purpose of this study is to examine trends in obesity prevalence from 1998 through 2011 by race/ethnicity among low-income children aged 2-4 years. METHODS: The study was based on measured weight and height records of 29,040,851 participants of federally funded health and nutrition programs from 30 states and the District of Columbia, which provided data each year from 1998 through 2011. More than 80% of data were collected through the Special Supplemental Nutrition Program for Women, Infants, and Children, and about 50% of eligible children were included. In 2014, joinpoint regression was used to identify the inflection years when significant changes in obesity trends occurred and piecewise logistic regression was used to examine annual changes in obesity prevalence before and after the inflection years controlling for age, sex, and race/ethnicity. RESULTS: The overall obesity prevalence increased from 13.05% in 1998 to 15.21% in 2003, and decreased slightly to 14.74% in 2011. The increasing trends among non-Hispanic white, non-Hispanic black, and Hispanic children began decreasing in 2003. Asian/Pacific Islander was the only racial/ethnic group with a continual decreasing trend in obesity prevalence from 1998 (14.34%) through 2011 (11.66%). Among American Indian/Alaska Native children, obesity prevalence consistently increased from 16.32% in 1998 to 21.11% in 2011, although the annual increases slowed since 2001. CONCLUSIONS: The study findings indicate modest recent declines in obesity prevalence for most racial/ethnic groups of low-income children aged 2-4 years. However, obesity prevalence remains high.

Breastfeeding is a highly effective preventive measure a mother can take after birth to protect the health of her infant, as well as her own. Immunologic and antiinflammatory properties of breast milk protect against numerous illnesses and diseases in children. Benefits of breastfeeding for infants include a lower risk for ear infections, atopic dermatitis, lower respiratory tract infections, sudden infant death syndrome (SIDS), necrotizing enterocolitis (NEC) in preterm infants, type 2 diabetes, asthma, and childhood obesity. For mothers, benefits of breastfeeding include a lower risk for breast cancer and ovarian cancer. Increasing rates of breastfeeding and therefore its health benefits might lower health-care costs. A recent study found that if higher rates of mothers complied with medical recommendations for breastfeeding, an estimated $2.2 billion in additional direct medical costs would be saved annually in the United States.

In 1986, the late David Barker described a link between intrauterine growth and ischemic heart disease,1 originating a field of medical and anthropological research known as the fetal origins of health and disease. More recently, the field has expanded to also consider the long-term effects of early postnatal nutrition on long-term health, now known as the developmental origins of health and disease (DOHaD).2 Evidence on the long-term consequences of infant diet is expanding rapidly. In this Pediatrics supplement, we present new data available from a follow-up study of children at age 6 years who were previously included in the longitudinal Infant Feeding Practices Study II (IFPS II), sponsored by the US Food and Drug Administration and the Centers for Disease Control and Prevention.3,4 Not all the articles in this supplement directly address DOHaD hypotheses, but they provide additional context to understanding the longitudinal associations between early feeding and subsequent outcomes. | Because of the depth of detail they provide, the IFPS II and its year 6 follow-up present a unique opportunity to examine the association of infant feeding with later health outcomes and behaviors. By following infants almost monthly from the third trimester of pregnancy to the age of 12 months, the IFPS II provides detailed information on changes in infant feeding that cannot be accurately captured through retrospective recall. The mothers of these infants were recontacted 6 years later to provide information on diet, health, and developmental outcomes. A large number of potentially confounding factors are available in both IFPS II and year 6 follow-up to reduce the chances that the associations discovered are not merely spurious.

BACKGROUND: Previous studies have shown that breastfeeding is associated with reductions in the risk of common infections among infants; however, whether breastfeeding confers longer term protection is inconclusive. METHODS: We linked data from the 2005-2007 IFPS II (Infant Feeding Practices Study II) and follow-up data collected when the children were 6 years old. Multivariable logistic regression was used, controlling for sociodemographic variables, to examine associations of initiation, duration, exclusivity of breastfeeding, timing of supplementing breastfeeding with formula, and breast milk intensity (proportion of milk feedings that were breast milk from age 0-6 months) with maternal reports of infection (cold/upper respiratory tract, ear, throat, sinus, pneumonia/lung, and urinary) and sick visits in the past year among 6-year-olds (N = 1281). RESULTS: The most common past-year infections were colds/upper respiratory tract (66%), ear (25%), and throat (24%) infections. No associations were found between breastfeeding and colds/upper respiratory tract, lung, or urinary tract infections. Prevalence of ear, throat, and sinus infections and number of sick visits differed according to breastfeeding duration, exclusivity, and timing of supplementing breastfeeding with formula (P < .05). Among children ever breastfed, children breastfed for ≥9 months had lower odds of past-year ear (adjusted odds ratio [aOR]: 0.69 [95% confidence interval (95% CI): 0.48-0.98]), throat (aOR: 0.68 [95% CI: 0.47-0.98]), and sinus (aOR: 0.47 [95% CI: 0.30-0.72]) infections compared with those breastfed >0 to <3 months. High breast milk intensity (>66.6%) during the first 6 months was associated with lower odds of sinus infection compared with low breast milk intensity (<33.3%) (aOR: 0.53 [95% CI: 0.35-0.79]). CONCLUSIONS: This prospective longitudinal study suggests that breastfeeding may protect against ear, throat, and sinus infections well beyond infancy.

OBJECTIVE: We describe methods used in the Year 6 Follow-Up (Y6FU) of children who participated in the Infant Feeding Practices Study II (IFPSII). This study consists of a questionnaire administered 6 years after the IFPSII to characterize the health, development, and diet quality of the children. METHODS: The Y6FU sample was a subset of those who participated in IFPSII. The IFPSII participants were drawn from a national consumer opinion panel; neither the IFPSII nor the Y6FU sample is nationally representative. The Y6FU sampling frame included all qualified participants who answered at least the first postnatal questionnaire. One questionnaire was administered by mail in 2012, and nonrespondents were contacted for a telephone interview. Survey topics included measures of health, development, diet, physical activity, screen time, and family medical history. We attempted to contact 2958 mothers and obtained completed questionnaires from 1542, a response rate of 52.1%. We conducted 2 sample evaluations, 1 comparing respondents and nonrespondents on data from IFPSII and the other comparing Y6FU respondents with 6-year-old participants in the National Survey of Children's Health. RESULTS: Y6FU mothers are more likely to be white, married, older, and of higher education and income than both nonresponders and nationally representative mothers. Comparisons also revealed health-related differences and similarities. CONCLUSIONS: Although not nationally representative, the Y6FU provides a valuable database because of its wide coverage of diet and health issues and its unique ability to link early feeding patterns with outcomes at age 6 years.

Despite the well documented health benefits of breastfeeding, initiation of breastfeeding and breastfeeding duration rates among black infants in the United States are approximately 16% lower than among whites. Although many factors play a role in a woman's ability to breastfeed, experiences during the childbirth hospitalization are critical for establishing breastfeeding. To analyze whether the implementation by maternity facilities of practices that support breastfeeding varied depending on the racial composition of the area surrounding the facility, CDC linked data from its 2011 Maternity Practices in Infant Nutrition and Care (mPINC) survey to U.S. Census data on the percentage of blacks living within the zip code area of each facility. The results of that analysis indicated that facilities in zip code areas where the percentage of black residents was >12.2% (the national average during 2007-2011) were less likely than facilities in zip code areas where the percentage was ≤12.2% to meet five of 10 mPINC indicators for recommended practices supportive of breastfeeding and more likely to implement one practice; differences for the other four practices were not statistically significant. Comparing facilities in areas with >12.2% black residents with facilities in areas with ≤12.2% black residents, the largest differences were in the percentage of facilities that implemented recommended practices related to early initiation of breastfeeding (46.0% compared with 59.9%), limited use of breastfeeding supplements (13.1% compared with 25.8%), and rooming-in (27.7% compared with 39.4%). These findings suggest there are racial disparities in access to maternity care practices known to support breastfeeding.

BACKGROUND: Eating more fruits and vegetables adds underconsumed nutrients to diets, reduces the risks for leading causes of illness and death, and helps manage body weight. This report describes trends in the contributions of fruits and vegetables to the diets of children aged 2-18 years. METHODS: CDC analyzed 1 day of 24-hour dietary recalls from the National Health and Nutrition Examination Surveys from 2003 to 2010 to estimate trends in children's fruit and vegetable intake in cup-equivalents per 1,000 calories (CEPC) and trends by sex, age, race/ethnicity, family income to poverty ratio, and obesity status. Total fruit includes whole fruit (all fruit excluding juice) and fruit juice (from 100% juice, foods, and other beverages). Total vegetables include those encouraged in the Dietary Guidelines for Americans, 2010 (i.e., dark green, orange, and red vegetables and legumes), white potatoes, and all other vegetables. RESULTS: Total fruit intake among children increased from 0.55 CEPC in 2003-2004 to 0.62 in 2009-2010 because of significant increases in whole fruit intake (0.24 to 0.40 CEPC). Over this period, fruit juice intake significantly decreased (0.31 to 0.22 CEPC). Total vegetable intake did not change (0.54 to 0.53 CEPC). No socio-demographic group met the Healthy People 2020 target of 1.1 CEPC vegetables, and only children aged 2-5 years met the target of 0.9 CEPC fruits. CONCLUSIONS: Children's total fruit intake increased because of increases in whole fruit consumption, but total vegetable intake remained unchanged. Implications for Public Health Practice: Increased attention to the policies and food environments in multiple settings, including schools, early care and education, and homes might help continue the progress in fruit intake and improve vegetable intake.

BACKGROUND: Breastfeeding provides numerous health benefits for infants and mothers; however, many infants are not breastfed as long as recommended or desired by mothers. Maternal employment is frequently cited as a barrier to breastfeeding. OBJECTIVE: This study aimed to assess whether maternity leave duration and return status (full-time [FT], part-time [PT]) were associated with not meeting a mother's intention to breastfeed at least 3 months. METHODS: We used data from the Infant Feeding Practices Study II, a cohort study. Analyses were limited to women employed prenatally who intended to breastfeed 3 months or longer (n = 1172). Multivariable logistic regression was used to assess the relationship between maternity leave duration and return-to-work status (< 6 weeks/FT, < 6 weeks/PT, 6 weeks-3 months/FT, 6 weeks-3 months/PT, not working by 3 months) and meeting a mother's intention to breastfeed at least 3 months. RESULTS: Overall, 28.8% of mothers did not meet their intention to breastfeed at least 3 months. Odds of not meeting intention to breastfeed at least 3 months were higher among mothers who returned to work FT before 3 months (< 6 weeks/FT: adjusted odds ratio = 2.25, 95% confidence interval, 1.23-4.12; 6 weeks-3 months/FT: adjusted odds ratio = 1.82, 95% confidence interval, 1.30-2.56), compared with mothers not working at 3 months. CONCLUSION: Returning to work full-time before 3 months may reduce a mother's ability to meet her intention to breastfeed at least 3 months. Employer support for flexible work scheduling may help more women achieve their breastfeeding goals.

BACKGROUND: The American Academy of Pediatrics recommends 6 months of exclusive breastfeeding, however, only 16% of US infants meet this recommendation. Shorter exclusive/predominant breastfeeding durations have been observed from women who return to work early and/or full-time. OBJECTIVE: We assessed the relationship between prenatal plans for maternity leave duration and return to full-time/part-time status and plans for exclusive breastfeeding. METHODS: This study included 2348 prenatally employed women from the Infant Feeding Practices Study II (2005-2007) who planned to return to work in the first year postpartum. Bivariate analysis and logistic regression were used to describe the association of maternity leave duration and return status with plans for infant feeding. RESULTS: Overall, 59.5% of mothers planned to exclusively breastfeed in the first few weeks. Mothers planning to return to work within 6 weeks had 0.60 times the odds (95% confidence interval [CI], 0.46-0.77) and mothers planning to return between 7 and 12 weeks had 0.72 times the odds (95% CI, 0.56-0.92) of planning to exclusively breastfeed compared with mothers who were planning to return after 12 weeks. Prenatal plans to return full-time (≥ 30 hours/week vs part-time) were also associated with lower odds of planning to exclusively breastfeed (adjusted odds ratio = 0.61; 95% CI, 0.51-0.77). CONCLUSION: Mothers planning to return to work before 12 weeks and/or full-time were less likely to plan to exclusively breastfeed. Longer maternity leave and/or part-time return schedules may increase the proportion of mothers who plan to exclusively breastfeed.

Universal prenatal daily iron-folic acid (IFA) and multiple micronutrient (MM) supplements are recommended to reduce the risk of low birth weight, maternal anemia, and iron deficiency (ID) during pregnancy, but the evidence of their effect on iron status among women with mild or no anemia is limited. The aim of this study was to describe the iron status [serum ferritin (SF), serum soluble transferrin receptor (sTfR), and body iron (BI)] before and after micronutrient supplementation during pregnancy. We examined 834 pregnant women with hemoglobin > 100 g/L at enrollment before 20 wk of gestation and with iron measurement data from a subset of a randomized, double-blind trial in China. Women were randomly assigned to take daily 400 mug of folic acid (FA) (control), FA plus 30 mg of iron, or FA, iron, plus 13 additional MMs provided before 20 wk of gestation to delivery. Venous blood was collected in this subset during study enrollment (before 20 wk of gestation) and 28-32 wk of gestation. We found that, at 28-32 wk of gestation, compared with the FA group, both the IFA and MM groups had significantly lower prevalence of ID regardless of which indicator (SF, sTfR, or BI) was used for defining ID. The prevalence of ID at 28-32 wk of gestation for IFA, MM, and FA were 35.3%, 42.7%, and 59.6% by using low SF, 53.6%, 59.9%, and 69.9% by using high sTfR, and 34.5%, 41.2%, and 59.6% by using low BI, respectively. However, there was no difference in anemia prevalence (hemoglobin < 110 g/L) between FA and IFA or MM groups. We concluded that, compared with FA alone, prenatal IFA and MM supplements provided to women with no or mild anemia improved iron status later during pregnancy but did not affect perinatal anemia. This trial was registered at clinicaltrials.gov as NCT00137744.

BACKGROUND: A substantial proportion of US maternity care facilities engage in practices that are not evidence-based and that interfere with breastfeeding. The CDC Survey of Maternity Practices in Infant Nutrition and Care (mPINC) showed significant variation in maternity practices among US states. Objective: The purpose of this article is to use benchmarking techniques to identify states within relevant peer groups that were top performers on mPINC survey indicators related to breastfeeding support. METHODS: We used 11 indicators of breastfeeding-related maternity care from the 2011 mPINC survey and benchmarking techniques to organize and compare hospital-based maternity practices across the 50 states and Washington, DC. We created peer categories for benchmarking first by region (grouping states by West, Midwest, South, and Northeast) and then by size (grouping states by the number of maternity facilities and dividing each region into approximately equal halves based on the number of facilities). RESULTS: Thirty-four states had scores high enough to serve as benchmarks, and 32 states had scores low enough to reflect the lowest score gap from the benchmark on at least 1 indicator. No state served as the benchmark on more than 5 indicators and no state was furthest from the benchmark on more than 7 indicators. The small peer group benchmarks in the South, West, and Midwest were better than the large peer group benchmarks on 91%, 82%, and 36% of the indicators, respectively. In the West large, the Midwest large, the Midwest small, and the South large peer groups, 4-6 benchmarks showed that less than 50% of hospitals have ideal practice in all states. CONCLUSION: The evaluation presents benchmarks for peer group state comparisons that provide potential and feasible targets for improvement.

OBJECTIVE: To examine the incidence and reverse of obesity among young low-income children and variations across population subgroups .METHODS: We included 1.2 million participants in federally funded child health and nutrition programs who were 0 to 23 months old in 2008 and were followed up 24 to 35 months later in 2010-2011. Weight and height were measured. Obesity at baseline was defined as gender-specific weight-for-length ≥95th percentile on the 2000 Centers for Disease Control and Prevention growth charts. Obesity at follow-up was defined as gender-specific BMI-for-age ≥95th percentile. We used a multivariable log-binomial model to estimate relative risk of obesity adjusting for gender, baseline age, race/ethnicity, duration of follow-up, and baseline weight-for-length percentile. RESULTS: The incidence of obesity was 11.0% after the follow-up period. The incidence was significantly higher among boys versus girls and higher among children aged 0 to 11 months at baseline versus those older. Compared with non-Hispanic whites, the risk of obesity was 35% higher among Hispanics and 49% higher among American Indians (AIs)/Alaska Natives (ANs), but 8% lower among non-Hispanic African Americans. Among children who were obese at baseline, 36.5% remained obese and 63.5% were nonobese at follow-up. The proportion of reversing of obesity was significantly lower among Hispanics and AIs/ANs than that among other racial/ethnic groups. CONCLUSIONS: The high incidence underscores the importance of early-life obesity prevention in multiple settings for low-income children and their families. The variations within population subgroups suggest that culturally appropriate intervention efforts should be focused on Hispanics and AIs/ANs.

Breastfeeding has important consequences for women's health, including lower risk of breast and ovarian cancers as well as type 2 diabetes. Although most pregnant women want to breastfeed, a majority encounter difficulties and are not able to breastfeed as long as they want. Routine maternity care practices can pose significant barriers to successful breastfeeding. To address these practices, CDC has taken on a number of initiatives to promote hospital quality improvements in how new mothers are supported to start breastfeeding. The CDC survey on Maternity Practices in Infant Nutrition and Care is a tool to educate hospitals on how their current practices compare to recommended standards. The Best Fed Beginnings program is working with 90 hospitals across the United States to achieve optimal care and create tools for future hospital changes. CDC-funded programs in numerous state health departments have created programs to instigate improvements across the state. These efforts have begun to show success, with significant hospital quality score increases seen between 2009 and 2011. In 2011, more hospitals were designated as Baby-Friendly than in any previous year.

Obesity and extreme obesity in childhood, which are more prevalent among minority and low-income families, have been associated with other cardiovascular risk factors, increased health care costs, and premature death.1,2 Obesity and extreme obesity during early childhood are likely to continue into adulthood.3 Understanding trends in extreme obesity is important because the prevalence of cardiovascular risk factors increases with severity of childhood obesity.2 However, national trends in extreme obesity among young children living in low-income families are unknown.

There is limited data on prepregnancy obesity trends specifically among low-income women, a population at high risk for obstetric complications. Using the Pregnancy Nutrition Surveillance System, we assessed prepregnancy obesity [body mass index (BMI) ≥ 30 kg/m(2)] trends among women who participated in the Supplemental Nutrition Program for Women, Infants, and Children in 1999, 2004, and 2008. Prepregnancy BMI was calculated using measured height and self-reported prepregnancy weight. We report unadjusted contributor (state, territory or Indian tribal organization) specific trends, and both unadjusted and adjusted overall trends, to account for changes in maternal age and race-ethnic distributions, using 1999 as the referent. Of the 27 contributors in 1999, 2 had a prepregnancy obesity prevalence <20%, and 1 had a prevalence ≥30%. Of the 35 contributors in 2008, none had a prepregnancy obesity prevalence <20%, and 14 had a prevalence ≥30%. From 1999 to 2008, the overall prevalence of prepregnancy obesity increased among all racial-ethnic groups, except among American Indian/Alaskan Natives, where it remained high, but stable. Overall prepregnancy obesity increased most rapidly among Hispanics, and remained stable from 2004 to 2008 among non-Hispanic blacks. In 2008, prevalence was highest among American Indian/Alaskan Natives (36.1%) and lowest among Asians/Pacific Islanders (10.8%). The adjusted prepregnancy obesity prevalence increased from 24.8% in 1999 to 28.3% in 2008, a relative increase of 14.1%. Prepregnancy obesity among low-income women increased from 1999 to 2008 and varied by race-ethnicity. These data can be used by obesity prevention programs to better target high-risk women.

In January 2011, Surgeon General Regina Benjamin issued the Call to Action to Support Breastfeeding.1 In this document, she outlined 20 Action Steps to be carried out to improve the ways that breastfeeding women can be supported. The Action Steps focused on mothers and their families, communities, health care, employment, research and surveillance, and public health infrastructure. In the year since the Call to Action was issued, numerous programs have been undertaken to respond to the Call.

BACKGROUND: Serum soluble transferrin receptor (sTfR) is recommended as a sensitive and accurate measure of iron deficiency (ID) in populations when only a single indicator can be used. The lack of assay standardization and of representative data on the distribution of sTfR in at-risk populations currently limits its utility. METHODS: Using data from NHANES 2003-2010, we examined the distribution of sTfR and developed assay-specific cutoff values for defining elevated sTfR in 2 US populations groups: children aged 1-5 y (n=2820) and non-pregnant women aged 15-49 y (n=6575). RESULTS: On average, children had higher geometric mean sTfR concentrations (4.09mg/l; 95% CI: 4.04-4.14) than non-pregnant women (3.31mg/l; 95% CI: 3.26-3.35) (p<0.001). Among children, those aged 1-2 y (compared to those aged 3-5 y), boys (compared to girls), and non-Hispanic black (NHB) children (compared to non-Hispanic white (NHW) and Mexican-American (MA) children) had higher sTfR concentrations. Among non-pregnant women, adolescents (15-19 y) had higher sTfR concentrations than adults aged 20-34 y but not compared to adults aged 35-49 y; NHB women (compared to NHW and MA women) and multiparous women (compared to nulliparous women) had higher sTfR concentrations. The derived cutoff values (97.5th percentile in a defined healthy reference population) for defining elevated sTfR in the US were 6.00mg/l for children 1-5 y and 5.33mg/l for non-pregnant women 15-49 y. CONCLUSIONS: A different sTfR cutoff value may be needed in children and non-pregnant women to define ID.

OBJECTIVE: To describe mothers' exclusive breastfeeding intentions and whether Baby-Friendly hospital practices are associated with achieving these intentions. METHODS: In the 2005-2007 Infant Feeding Practices Study II, women completed a prenatal questionnaire and approximately monthly questionnaires through 12 months. Mothers met their prenatal exclusive breastfeeding intention if their duration after the hospital stay (excluding hospital supplementation) equaled or exceeded their intention. Primary predictor variables included 6 Baby-Friendly hospital practices: breastfeeding within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, and information on breastfeeding support. RESULTS: Among women who prenatally intended to exclusively breastfeed (n = 1457), more than 85% intended to do so for 3 months or more; however, only 32.4% of mothers achieved their intended exclusive breastfeeding duration. Mothers who were married and multiparous were more likely to achieve their exclusive breastfeeding intention, whereas mothers who were obese, smoked, or had longer intended exclusive breastfeeding duration were less likely to meet their intention. Beginning breastfeeding within 1 hour of birth and not being given supplemental feedings or pacifiers were associated with achieving exclusive breastfeeding intention. After adjustment for all other hospital practices, only not receiving supplemental feedings remained significant (adjusted odds ratio = 2.3, 95% confidence interval = 1.8, 3.1). CONCLUSIONS: Two-thirds of mothers who intend to exclusively breastfeed are not meeting their intended duration. Increased Baby-Friendly hospital practices, particularly giving only breast milk in the hospital, may help more mothers achieve their exclusive breastfeeding intentions.

OBJECTIVE: To better understand the mechanisms behind breastfeeding and childhood obesity, we assessed the association of weight gain with the mode of milk delivery aside from the type of milk given to infants. DESIGN: A longitudinal study of infants followed up from birth to age 1 year. Multilevel analyses were conducted to estimate infant weight gain by type of milk and feeding mode. SETTING: Pregnant women were recruited from a consumer mail panel throughout the United States between May 2005 and June 2007. PARTICIPANTS: One thousand eight hundred ninety nine infants with at least 3 weight measurements reported during the first year. MAIN EXPOSURES: Six mutually exclusive feeding categories and proportions of milk feedings given as breastmilk or by bottle. MAIN OUTCOME MEASURES: Weight measurements reported on 3-, 5-, 7-, and 12-month surveys. RESULTS: Compared with infants fed at the breast, infants fed only by bottle gained 71 or 89 g more per month when fed nonhuman milk only (P < .001) or human milk only (P = .02), respectively. Weight gain was negatively associated with proportion of breastmilk feedings, but it was positively associated with proportion of bottle-feedings among those who received mostly breastmilk. Among infants fed only breastmilk, monthly weight gain increased from 729 g when few feedings were by bottle to 780 g when most feedings were by bottle. CONCLUSIONS: Infant weight gain might be associated not only with type of milk consumed but also with mode of milk delivery. Regardless of milk type in the bottle, bottle-feeding might be distinct from feeding at the breast in its effect on infants' weight gain.

Longitudinal data with 37,964 length and weight measurements from 10,844 children who participated in the California Child Health and Development Study was used to compare the proportion of children aged ≤24 months who crossed major percentile lines on the Centers for Disease Control and Prevention (CDC) 2000 growth charts with the percentage who crossed corresponding lines on the World Health Organization (WHO) 2006 growth charts. Percentage of children aged ≤24 months who crossed at least 2 major percentile lines for length-for-age, weight-for-age, and weight-for-length according to CDC 2000 charts were compared with the percentage who did so according to WHO 2006 charts. The results from this analysis suggest that pediatricians who monitor children's growth on the basis of WHO 2006 growth charts may be more likely to refer children aged <6 months and less likely to refer those aged 6 to 12 months for further evaluation for failure to thrive.

BACKGROUND: Total body iron calculated from serum ferritin and soluble transferrin receptor concentrations allows for the evaluation of the full range of iron status. OBJECTIVE: We described the distribution of total body iron and the prevalence of iron deficiency (ID) on the basis of total body iron in US pregnant women. DESIGN: We examined data from the National Health and Nutrition Examination Survey (NHANES) in 1999-2006 for 1171 pregnant women. RESULTS: ID prevalence (+/-SE) in US pregnant women, which was defined as total body iron <0 mg/kg, was 18.0 +/- 1.4%. Pregnant women in the first trimester had a higher mean total body iron than did pregnant women in the second or third trimesters. ID prevalence in pregnant women increased significantly with each trimester (6.9 +/- 2.2%, 14.3 +/- 2.1%, and 29.5 +/- 2.7% in the first, second, and third trimesters, respectively). Pregnant women with parity ≥2 had the lowest mean total body iron and the highest prevalence of ID compared with values for pregnant women with parity of 0 or 1. The ID prevalence in non-Hispanic white pregnant women was significantly lower than in Mexican American or non-Hispanic black pregnant women. The mean total body iron and the prevalence of ID did not differ by educational level or by family income. CONCLUSIONS: To our knowledge, these are the first data on total body iron distributions for a representative sample of US pregnant women. Low total body iron is more prevalent in pregnant women in the second or third trimesters, in Mexican American pregnant women, in non-Hispanic black pregnant women, and in women with parity ≥2.

In April 2006, the World Health Organization (WHO) released new international growth charts for children aged 0-59 months. Similar to the 2000 CDC growth charts, these charts describe weight for age, length (or stature) for age, weight for length (or stature), and body mass index for age. Whereas the WHO charts are growth standards, describing the growth of healthy children in optimal conditions, the CDC charts are a growth reference, describing how certain children grew in a particular place and time. However, in practice, clinicians use growth charts as standards rather than references. In 2006, CDC, the National Institutes of Health, and the American Academy of Pediatrics convened an expert panel to review scientific evidence and discuss the potential use of the new WHO growth charts in clinical settings in the United States. On the basis of input from this expert panel, CDC recommends that clinicians in the United States use the 2006 WHO international growth charts, rather than the CDC growth charts, for children aged <24 months (available at https://www.cdc.gov/growthcharts). The CDC growth charts should continue to be used for the assessment of growth in persons aged 2--19 years. The recommendation to use the 2006 WHO international growth charts for children aged <24 months is based on several considerations, including the recognition that breastfeeding is the recommended standard for infant feeding. In the WHO charts, the healthy breastfed infant is intended to be the standard against which all other infants are compared; 100% of the reference population of infants were breastfed for 12 months and were predominantly breastfed for at least 4 months. When using the WHO growth charts to screen for possible abnormal or unhealthy growth, use of the 2.3rd and 97.7th percentiles (or ±2 standard deviations) are recommended, rather than the 5th and 95th percentiles. Clinicians should be aware that fewer U.S. children will be identified as underweight using the WHO charts, slower growth among breastfed infants during ages 3-18 months is normal, and gaining weight more rapidly than is indicated on the WHO charts might signal early signs of overweight.

Childhood obesity continues to be a leading public health concern that disproportionately affects low-income and minority children. Children who are obese in their preschool years are more likely to be obese in adolescence and adulthood and to develop diabetes, hypertension, hyperlipidemia, asthma, and sleep apnea. One of the Healthy People 2010 objectives (19-3) is to reduce to 5% the proportion of children and adolescents who are obese. CDC's Pediatric Nutrition Surveillance System (PedNSS) is the only source of nationally compiled obesity surveillance data obtained at the state and local level for low-income, preschool-aged children participating in federally funded health and nutrition programs. To describe progress in reducing childhood obesity, CDC examined trends and current prevalence in obesity using PedNSS data submitted by participating states, territories, and Indian tribal organizations during 1998-2008. The findings indicated that obesity prevalence among low-income, preschool-aged children increased steadily from 12.4% in 1998 to 14.5% in 2003, but subsequently remained essentially the same, with a 14.6% prevalence in 2008. Reducing childhood obesity will require effective prevention strategies that focus on environments and policies promoting physical activity and a healthy diet for families, child care centers, and communities.

BACKGROUND: Breastfeeding has large benefits for mothers and infants. The short-term benefits for child survival and reduced morbidity differ by population subgroup because of differences in underlying risk factors. Although breastfeeding is more common among poor than well-off women, how breastfeeding patterns change between these subgroups is important from a policy perspective as the poor will benefit more from increased duration of breastfeeding. METHODS: We use nationally representative data from eight countries in Latin America and the Caribbean to document changes in breastfeeding duration between 1986 and 2005, and separate the overall change into the portion attributable to changing population characteristics and the portion resulting from changing breastfeeding behaviour within population subgroups. RESULTS: Breastfeeding duration increased in six out of the eight countries and the changes observed are largely explained by changing behaviour within population subgroups rather than changing population characteristics. Changes in breastfeeding duration did not tend to be equitably distributed, but in four countries (Bolivia, Brazil, Colombia and Peru) the population subgroups whose children are most at risk for mortality and increased morbidity from not being breastfed were least likely to show improvements in breastfeeding duration. Between 1986 and 2004 in Peru, breastfeeding duration declined by 0.6 months among rural women while increasing by 9.7 months among urban women; it increased by 6.3 months among women with prenatal care but only by 3.7 months among women with no prenatal care. Changes in breastfeeding in Guatemala and Haiti tended to favour the well-off compared with the poor, though not consistently. In Nicaragua changes in breastfeeding duration tended to favour the less well-off. DISCUSSION: While promoting breastfeeding is a must for all women, to maximize its benefits for child survival and health, additional efforts are needed to reach poorly educated and rural women with little access to health care.