This cross-sectional study evaluates reasons reported for not participating in or withdrawing participation from the Special Supplemental Nutrition Program for Women, Infants, and Children from 2019 to March 2020. | eng

We read with interest the article by Kang et al. [1], “Hemoglobin distributions and prevalence of anemia in a multiethnic United States pregnant population,” as well as the accompanying Editorial by Merz and Achebe [2], “Iron deficiency in pregnancy: a health inequity [2].” Both Kang et al. [1] and Merz and Achebe [2] incorrectly stated that the Centers for Disease Control and Prevention (CDC) recommend use of lower race-adjusted thresholds to define anemia for Black individuals. The CDC does not recommend separate diagnostic thresholds to define anemia for Black individuals or any other race/ethnic group. Here, we clarify misinterpretations in recent American Journal of Clinical Nutrition publications regarding the CDC anemia threshold recommendations. | | The 1998 “Recommendations to prevent and control iron deficiency in the United States” [3], the most recent CDC publication providing guidance on thresholds to define anemia in individuals, did not recommend race-specific cutoff values for anemia. The 1998 recommendations included criteria for anemia threshold adjustments based on age, sex, pregnancy status, gestational age, altitude, and smoking status [3]. To guide the development of these 1998 CDC recommendations, the CDC requested that the Institute of Medicine (IOM) convene an expert committee to develop recommendations for preventing, detecting, and treating iron deficiency anemia among children and women of reproductive age in United States. The IOM report published in 1993 [4] is independent and not an official institutional CDC/federal recommendations publication. The 1998 CDC recommendations considered inputs from the IOM report [4], conclusions of a CDC expert panel convened in April 1994, and from other multidisciplinary subject matter experts [3].

Overweight and obesity are pressing public health problems, and development of these conditions is linked to the earliest life stages.1 These early life stages include infancy (0 through 11 months) and toddlerhood (12 through 23 months),1 collectively referred to as birth to 24 months (B-24). Systematic reviews from the Pregnancy and Birth to 24 Months Project found that risk of childhood obesity is associated with the types of foods introduced during the complementary feeding period,2,3 which begins at about age 6 months when complementary foods and beverages are first introduced and continues to age 24 months as children transition to family foods.4 There is mounting evidence that the dietary patterns established during complementary feeding are not only associated with current and future weight status2,3,5 and health outcomes6 but also associated with diet quality in later life stages. For example, intake of fruits, vegetables, and sugar-sweetened beverages during infancy are associated with fruit and vegetable7 and sugar-sweetened beverage8 intakes at age 6 years. In fact, risk for childhood obesity may begin even before solid foods are introduced, as breastfeeding is also associated with higher diet quality and reduced risk of obesity in childhood.9, 10, 11

BACKGROUND: In 2009, the US Department of Agriculture Food and Nutrition Service's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages were revised to include more whole fruits, vegetables, whole grains, and lower-fat milk. OBJECTIVE: To describe trends over time in the consumption of fruits (total and whole), vegetables, whole grains, milk (whole, reduced fat, low-fat or nonfat (LFNF), and flavored), and added sugars, including breakfast cereals, by WIC participation status (current WIC recipient, WIC income-eligible nonrecipient, and WIC income-ineligible nonrecipient). METHODS: Dietary intakes on a given day for 1- to 4-y-old children (n = 5568) from the 2005-2018 National Health and Nutrition Examination Survey (NHANES) were analyzed to examine trends in the percentage of individuals consuming and amounts consumed over time using linear regression adjusted for age, sex, and race and Hispanic origin. RESULTS: From 2005 through 2018, the percentage of WIC recipients or WIC income-eligible nonrecipients consuming fruits and vegetables on a given day did not change, but the percentage of fruit consumed as whole fruit increased significantly among WIC recipients (36.4%-62.1%), but not among income-eligible nonrecipients. Among the WIC recipients, the percentage of consumption (5.5%-29.3%), the amount of LFNF milk servings consumed (0.1-0.4 cups), and the percentage of the total milk consumed as LFNF milk (4.8%-27%) significantly increased from 2005 to 2018. Conversely, the percentage of energy (12.3%-10.8%) and servings (11.4-10.6 teaspoons) from added sugars declined significantly. Among WIC-eligible nonrecipients, the servings of whole grains increased significantly, whereas servings and percentage of energy from added sugars declined significantly. CONCLUSIONS: From 2005 through 2018, changes in dietary patterns for WIC recipients did not always mirror those of US children of the same age. The percentage of fruit consumed as whole fruit, and the percentage and quantity of milk consumed as LFNF milk increased significantly among WIC recipients, but not among income-eligible nonrecipients. J Nutr 20XX;xx:xx-xx.

The first 1000 days begins with pregnancy and ends at the child's second birthday. Nutrition throughout the life course, and especially during the first 1000 days, supports maternal health and optimal growth and development for children. We give a high-level summary of the state of nutrition in the first 1000 days in the United States. We provide examples where continued efforts are needed. We then discus select opportunities to strengthen federal research and surveillance, programs, and communication and dissemination efforts aimed at improving nutrition and positively, and equitably, influencing the health and well-being of mothers and children. (Am J Public Health. Published online ahead of print September 19, 2022::e1-e9. https://doi.org/10.2105/AJPH.2022.307028).

Among pregnant women, anemia, a condition of low hemoglobin concentration, can increase risk for maternal and fetal morbidity and mortality, including premature delivery, and other adverse outcomes (1). Iron deficiency is a common cause of anemia, and during pregnancy, iron requirements increase (2). Surveillance of anemia during pregnancy in the United States is limited. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participant and Program Characteristics (PC) data provide an opportunity to establish national and WIC state agency-level* anemia surveillance for WIC participants. National and state agency anemia prevalences among pregnant WIC participants at enrollment were examined using 2008-2018 WIC-PC data. Across all 90 WIC agencies (50 states, the District of Columbia [DC], five territories, and 34 Indian Tribal Organizations), anemia prevalence among pregnant WIC participants at enrollment increased significantly, from 10.1% in 2008 to 11.4% in 2018 (13% increase). Anemia prevalence increased significantly in 36 (64%) of the 56 agencies in states, DC, and territories, and decreased significantly in 11 (20%). Prevalence of anemia overall and by pregnancy trimester were higher among non-Hispanic Black or African American (Black) women than among other racial or ethnic groups. Anemia prevalence was higher among women assessed during the third trimester of pregnancy than among those assessed during first or second trimesters. Routine anemia surveillance using WIC enrollment anemia data can identify groups at higher risk for iron deficiency. Findings from this report indicate that anemia continues to be a problem among low-income women and reinforces the importance of efforts that ensure these women have access to healthier, iron-rich foods before and during pregnancy. This includes ensuring that eligible women are enrolled in WIC early during pregnancy.

Background: Proper nutrition during infancy and toddlerhood is crucial for supporting healthy growth and development, including bone health. Complementary feeding is the process that starts when human milk or infant formula is complemented by other foods and beverages, beginning during late infancy and continuing to 24 mo of age. Objectives: This article aims to describe systematic reviews (SRs) conducted by the Nutrition Evidence Systematic Review team for the USDA and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project to answer these questions: what is the relationship between 1) timing of introduction of complementary foods and beverages (CFBs) or 2) types and/or amounts of CFBs consumed and bone health? Methods: The literature was searched with the use of 4 databases (CINAHL, Cochrane, Embase, and PubMed) to identify articles published from January 1980 to July 2016 that addressed these topics and met predetermined criteria for inclusion. For each study, data were extracted and risk of bias was assessed. The evidence was qualitatively synthesized to develop a conclusion statement, and the strength of the evidence was graded. Results: Three articles addressed the timing of introduction of CFBs and bone health during childhood (through 18 y of age), and 2 addressed the types and/or amounts of CFBs consumed relative to bone health. Conclusions: Insufficient evidence was available to draw conclusions about the relationships between the timing of CFB introduction and types and/or amounts of CFBs consumed and bone health. Therefore, a grade was not assignable for these SRs. The ability to draw conclusions was limited by an overall lack of research, failure to adjust for several key confounding factors, and heterogeneity in studies with regard to methodology, subject populations, and results. Additional research is needed that addresses these gaps and limitations.

BACKGROUND: Although there has been inconsistency in recommendations regarding the optimal time for introducing complementary foods, most experts agree that introduction should not occur before 4 months. Despite recommendations, studies suggest that 20% to 40% of US infants are introduced to foods at younger than 4 months. Previous studies focused on the introduction of solid foods and are not nationally representative. OBJECTIVE: Our aims were to provide a nationally representative estimate of the timing of introduction of complementary foods and to describe predictors of early (<4 months) introduction. DESIGN: We conducted a cross-sectional analysis of 2009-2014 National Health and Nutrition Examination Survey data. PARTICIPANTS: The study included 1,482 children aged 6 to 36 months. MAIN OUTCOME MEASURES: Timing of first introduction to complementary foods (anything other than breast milk or formula) was analyzed. STATISTICAL ANALYSES PERFORMED: Prevalence estimates of first introduction to complementary foods are presented by month. Logistic regression was used to assess characteristics associated with early (<4 months) introduction. RESULTS: In this sample, 16.3% of US infants were introduced to complementary foods at <4 months, 38.3% between 4 and <6 months, 32.5% between 6 and <7 months, and 12.9% at >/=7 months of age. In unadjusted analyses, early introduction varied by breastfeeding status; race/Hispanic origin; Special Supplemental Nutrition Program for Women, Infants, and Children participation; and maternal age. In adjusted analyses, only breastfeeding status remained significant; infants who never breastfed or stopped at <4 months were more likely (odds ratio 2.27; 95% CI 1.62 to 3.18) to be introduced to complementary foods early than infants who breastfed >/=4 months. CONCLUSIONS: Despite using a broader definition of complementary foods, this analysis found a lower prevalence of early introduction in this nationally representative sample than previous studies that included only solids. However, many young children were still introduced to complementary foods earlier than recommended. Strategies to support caregivers to adhere to infant feeding guidelines may be needed.

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.

BACKGROUND: Although previous studies suggest that the intentions of mothers to breastfeed during pregnancy strongly predict actual breastfeeding practice, no studies have examined the changes in the intentions of mothers to breastfeed from the prenatal to neonatal periods. The purpose of this study was to examine changes in intended breastfeeding duration from the prenatal to neonatal periods, their association with actual duration, and predictors for shortened duration. METHODS: The Infant Feeding Practices Study II was a longitudinal study of mothers in the United States. Changes to intended breastfeeding duration were calculated as the difference from prenatal to neonatal reports (months); we compared this change to actual breastfeeding duration. By using multivariable logistic regression, we identified maternal characteristics associated with a shortened breastfeeding intention. RESULTS: Of 1780 women, 43.7% had no change to intended breastfeeding duration, 35.0% had a shorter intended duration, and 21.3% had a longer intended duration. Mothers with shortened intended duration also had shorter actual duration (P < .001). Women of Hispanic ethnicity, with a prepregnancy body mass index of ≥30 kg/m2 , who were primiparous and who smoked prenatally had increased odds of shortening their breastfeeding intention from prenatal to neonatal reports. A maternal age of ≥35 years was associated with decreased odds of shortened breastfeeding intention. CONCLUSION: Approximately one in three women shorten their intended breastfeeding duration during the early postpartum period, which negatively affects the actual duration of their breastfeeding. Women may need additional support during the early postpartum period to meet their prenatal breastfeeding intentions.

Background: As part of a healthy diet, limiting intakes of excess sodium, added sugars, saturated fat, and trans fat has been recommended. The American Heart Association recommends that children aged <2 y should avoid added sugars.Objective: We sought to determine commercial complementary infant-toddler food categories that were of potential concern because of the sodium, added sugar, saturated fat, or trans fat content.Design: Nutrition label information (e.g., serving size, sodium, saturated fat, trans fat) for 1032 infant and toddler foods was collected from manufacturers' websites and stores from May to July 2015 for 24 brands, which accounted for >95% of infant-toddler food sales. The presence of added sugars was determined from the ingredient list. Reference amount customarily consumed (RACC) categories were used to group foods and standardize serving sizes. A high sodium content was evaluated on the basis of the Upper Intake Level for children aged 1-3 y and the number of potential servings per day ([i.e., 1500 mg/7 servings (>210 mg/RACC)], a sodium amount >200 mg/100 g, or a mean sodium density >1000 mg/1000 kcal.Results: In 2015, most commercial infant-only vegetables, fruit, dinners, and cereals were low in sodium, contained no saturated fat, and did not contain added sugars. On average, toddler meals contained 2233 mg Na/1000 kcal, and 84% of the meals had >210 mg Na/RACC (170 g), whereas 69% of infant-toddler savory snacks had >200 mg Na/100 g. More than 70% of toddler's meals, cereal bars and breakfast pastries, and infant-toddler grain- or dairy-based desserts contained ≥1 sources of added sugar. Approximately 70% of toddler meals contained saturated fat (mean: 1.9 g/RACC), and no commercial infant-toddler foods contained trans fats.Conclusion: Most commercial toddler meals, cereal bars and breakfast pastries, and infant-toddler snacks and desserts have high sodium contents or contain added sugars, suggesting a need for continued public health efforts to support parents in choosing complementary foods for their infants and toddlers.

BACKGROUND: Exclusive breastfeeding is recommended for the first 6 months of life. However, many barriers to breastfeeding exist. We examine public opinions about the benefits of breastfeeding and the infant health risks associated with formula feeding. METHODS: A national public opinion survey was conducted in 2013. Participants indicated their level of agreement with four breastfeeding-related statements. Except for the last one, all statements were positively worded with agreement representing positive opinions toward breastfeeding. To focus on the prevalence of positive opinions, we estimated percentage agreement with the first three statements, but disagreement with the fourth. Multiple logistic regression was used to examine how odds of these positive opinions varied by socio-demographic factors. RESULTS: Seventy-eight percent of participants agreed that breastmilk is nutritionally designed for infants, but few believed breastfeeding protects against overweight (12%). Approximately one-quarter agreed that formula feeding increases the chance of illness, whereas 45 percent disagreed that infant formula is equivalent to breastmilk. Older, less-educated, unmarried, and non-Hispanic black participants were less likely to agree that formula feeding increases the risk of infant illness. Races other than non-Hispanic white, participants aged 30-44 years and 45-59 years, unmarried, and less-educated participants were less likely to disagree with the equivalence of infant formula to breastmilk. DISCUSSION: The nutritional value of breastmilk is well known. Fewer adults believe that breastfeeding protects against childhood overweight or that formula feeding increases the chance of infant illness. Communication efforts may increase public awareness of the health benefits of breastfeeding.

Iron, calcium, and zinc are important nutrients for the young, developing child. This study describes the usual intake of iron, calcium, and zinc among US children in the second year of life using two days of dietary intake data from the National Health and Nutrition Examination Survey 2003-2012. Estimates were calculated using PC-SIDE to account for within and between person variation. Mean usual iron, calcium, and zinc intakes were 9.5 mg/day, 1046 mg/day, and 7.1 mg/day, respectively. Over a quarter of children had usual iron intakes less than the Recommended Dietary Allowance (RDA) (26.1%). Eleven percent of children had usual calcium intakes below the RDA and over half of children had usual intakes of zinc that exceeded the tolerable upper intake level (UL). Two percent or less had usual intakes below the Estimated Average Requirement (EAR) for iron, calcium, and zinc. Our findings suggest that during 2003-2012, one in four children and one in ten children had usual intakes below the RDA for iron and calcium, respectively. Children who are not meeting their nutrient requirements could be at increased risk for developing deficiencies such as iron deficiency or could lead to a shortage in adequate nutrients required for growth and development. One in every two children is exceeding the UL for zinc, but the interpretation of these estimates should be done with caution given the limited data on adverse health outcomes. Continued monitoring of zinc intake and further assessment for the potential of adverse health outcomes associated with high zinc intakes may be needed.

Introduction Breastfed newborns are often given non-breast milk supplements in the hospital, which can negatively impact breastfeeding outcomes. Efforts to improve maternity care practices include reducing supplementation of breastfed newborns. Methods The Maternity Practices in Infant Nutrition and Care (mPINC) survey is administered every 2 years to all hospitals in the United States and territories with registered maternity beds. We examined provision of non-breast milk supplements to healthy, full-term breastfed newborns from 2009 to 2013. Results Hospitals that provided non-breast milk supplements to at least 50 % of breastfed newborns decreased from 31.5 % in 2009 to 23.3 % in 2013. Among hospitals providing any supplements, there was no change in the percent that supplemented with infant formula; whereas, supplementing with water declined from 8.8 % in 2009 to 4.2 % in 2013 and with glucose water from 23.4 % to 12.5 %, respectively. In 2013, 64.9 % of breastfed infants were supplemented with formula for "mother's choice," 25.0 % for "doctor's orders," and 8.7 % for "nurse's recommendation." Discussion Despite improvements in maternity care practices, nearly one-fourth of hospitals are still providing at least 50 % of healthy, full-term breastfed newborns with non-breast milk supplements. While there has been no change in the proportion of hospitals providing infant formula supplements, the proportion supplementing with water and glucose water have declined. Additional education and support of mothers during the early post-partum period and training of physicians may address reasons breastfed infants are supplemented.

BACKGROUND: Epidemiological evidence suggests that timing of introduction of solid foods may be associated with subsequent obesity, and the association may vary by whether an infant is breastfed or formula-fed. METHODS: We included 1181 infants who participated in the Infant Feeding Practices Study II (IFPS II) and the Year 6 Follow Up (Y6FU) study. Data from IFPS II were used to calculate the primary exposure and timing of solid food introduction (<4, 4-<6, and ≥6 months), and data from Y6FU were used to calculate the primary outcome and obesity at 6 years of age (BMI ≥95th percentile). We used multivariable logistic regression to assess the association between timing of the introduction of solids and obesity at 6 years and test whether this association was modified by breastfeeding duration (breastfed for 4 months vs. not). RESULTS: Prevalence of obesity in our sample was 12.0%. The odds of obesity was higher among infants introduced to solids <4 months compared to those introduced at 4-<6 months (odds ratio [OR] = 1.66; 95% CI, 1.15, 2.40) in unadjusted analysis; however, this relationship was no longer significant after adjustment for covariates (OR = 1.18; 95% CI, 0.79, 1.77). Introduction of solids ≥6 months was not associated with obesity. We found no interaction between breastfeeding duration and early solid food introduction and subsequent obesity. CONCLUSIONS: Timing of introduction of solid foods was not associated with child obesity at 6 years in this sample. Given the inconsistency in findings with other studies, further studies in larger populations may be needed.

Iron deficiency and anemia are associated with impaired neurocognitive development and immune function in young children. Total body iron, calculated from serum ferritin and soluble transferrin receptor concentrations, and hemoglobin allow for monitoring of the iron and anemia status of children in the United States. The purpose of this analysis is to describe the prevalence of iron deficiency (ID), anemia, and iron deficiency anemia (IDA) among children 1-5 years using data from the 2007-2010 National Health and Nutrition Examination Survey (NHANES). Prevalence of ID, anemia, and IDA among children 1-5 years was 7.1% (5.5, 8.7), 3.2% (2.0, 4.3), and 1.1% (0.6, 1.7), respectively. The prevalence of both ID and anemia were higher among children 1-2 years (p < 0.05). In addition, 50% of anemic children 1-2 years were iron deficient. This analysis provides an update on the prevalence of ID, anemia, and IDA for a representative sample of US children. Our results suggest little change in these indicators over the past decade. Monitoring of ID and anemia is critical and prevention of ID in early childhood should remain a public health priority.

Researchers hypothesize that pregnancy and lactation are part of a continuum, with lactation meant to "reset" the adverse metabolic profile that develops as a part of normal pregnancy, and that when lactation does not occur, women maintain an elevated risk of cardio-metabolic diseases. Several large prospective and retrospective studies, mostly from the United States and other industrialized countries, have examined the associations between lactation and cardio-metabolic outcomes. Less evidence exists regarding an association of lactation with maternal postpartum weight status and dyslipidemia, whereas more evidence exists for an association with diabetes, hypertension, and subclinical and clinical cardiovascular disease. Expected final online publication date for the Annual Review of Nutrition Volume 36 is July 17, 2016. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.

BACKGROUND: Despite the benefits of breastfeeding, rates in the United States are low. Shorter maternity leave is associated with lower initiation and shorter durations of breastfeeding; however, little is known about how paid maternity leave may influence breastfeeding rates. METHODS: We used data from the 2006-2010 U.S. National Survey of Family Growth on the most recent birth to employed women who delivered a child within the previous 5 years. Separate multivariable logistic regression models were used to describe the associations between paid leave duration (0, 1-5, 6-11, ≥ 12 weeks, maternity leave not taken) and three outcomes: 1) breastfeeding initiation, 2) 6-month duration, and 3) 6-month duration among initiators. RESULTS: Twenty-eight percent of prenatally employed women received no paid leave. Women who received 12 or more weeks of paid leave were more likely to initiate breastfeeding compared to women with no paid leave (87.3% vs 66.7%, adjusted odds ratio [aOR] 2.83 [95% confidence interval {CI} 1.23-6.48]). Similarly, women with 12 or more weeks of paid leave were more likely to breastfeed at 6 months, compared to women with no paid leave (24.9% vs 50.1%, aOR 2.26 [95% CI 1.20-4.26]). Among women who initiated breastfeeding, having received 12 or more weeks' paid leave increased the odds of breastfeeding for 6 or more months; however, the association was not statistically significant in the adjusted model (aOR 1.81 [95% CI 0.93-3.52]). CONCLUSIONS: Employed women who received 12 or more weeks of paid maternity leave were more likely to initiate breastfeeding and be breastfeeding their child at 6 months than those without paid leave.

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.

Most Americans do not eat enough fruits and vegetables with significant variation by state. State-level self-reported frequency of fruit and vegetable consumption is available from the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS). However, BRFSS cannot be used to directly compare states' progress toward national goals because of incongruence in units used to measure intake and because distributions from frequency data are not reflective of usual intake. To help states track progress, we developed scoring algorithms from external data and applied them to BRFSS 2011 data to estimate the percentage of each state's adult population meeting US Department of Agriculture Food Patterns fruit and vegetable intake recommendations. We used 24-hour dietary recall data from the National Health and Nutrition Examination Survey, 2007-2010, to fit sex- and age-specific models that estimate probabilities of meeting recommendations as functions of reported consumption frequency, race/ethnicity, and poverty-income ratio adjusting for intraindividual variation. Regression parameters derived from these models were applied to BRFSS to estimate the percentage meeting recommendations. We estimate that 7%-18% of state populations met fruit recommendations and 5%-12% met vegetable recommendations. Our method provides a new tool for states to track progress toward meeting dietary recommendations.

BACKGROUND: Breastfeeding rates are lower among infants living in rural areas of the United States, yet there are limited data on whether hospital breastfeeding support differs between rural and urban areas. OBJECTIVE: This study aimed to describe whether maternity care practices supportive of breastfeeding vary by level of urbanization. METHODS: We linked data from the 2007, 2009, and 2011 Maternity Practices in Infant Nutrition and Care (mPINC) surveys with Rural-Urban Continuum Codes to categorize hospital counties as metropolitan urbanized, nonmetropolitan urbanized, less urbanized, and thinly populated. RESULTS: From 2007 to 2011, the average hospital mPINC score, a composite quality score ranging from 0 to 100, increased from 64 to 71 in metropolitan urbanized counties and from 54 to 65 in thinly populated areas. Scores were lowest in thinly populated counties in 2007 and 2009 and in less urbanized counties in 2011. Examination of 2011 mPINC scores by 7 domains of care revealed that hospitals in less urbanized counties had lower scores than those in metropolitan urbanized counties for feeding of breastfed infants, breastfeeding assistance, staff training, and structural and organizational aspects of care delivery; for 3 of these practices, scores were 10 or more points lower-breastfeeding assistance, structural and organizational aspects of care, and staff training. In contrast, hospitals in thinly populated areas had higher scores than in metropolitan areas for mother-infant contact and facility discharge care; differences were less than 10 points. CONCLUSION: Interventions that specifically target rural hospitals may reduce the gap in access to hospital maternity care practices supportive of breastfeeding by population density.

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.

OBJECTIVES: To examine the association of timing of introduction and frequency of fruit and vegetable intake during infancy with frequency of fruit and vegetable intake at age 6 years in a cohort of US children. METHODS: We analyzed data on fruit and vegetable intake during late infancy, age of fruit and vegetable introduction, and frequency of fruit and vegetable intake at 6 years from the Infant Feeding Practices Study II and the Year 6 Follow-Up (Y6FU) Study. We determined the percent of 6-year-old children consuming fruits and vegetables less than once per day and examined associations with infant fruit and vegetable intake using logistic regression modeling, controlling for multiple covariates (n = 1078). RESULTS: Based on maternal report, 31.9% of 6-year-old children consumed fruit less than once daily and 19.0% consumed vegetables less than once daily. In adjusted analyses, children who consumed fruits and vegetables less than once daily during late infancy had increased odds of eating fruits and vegetables less than once daily at age 6 years (fruit, adjusted odds ratio: 2.48; vegetables, adjusted odds ratio: 2.40). Age of introduction of fruits and vegetables was not associated with intake at age 6 years. CONCLUSIONS: Our study suggests that infrequent intake of fruits and vegetables during late infancy is associated with infrequent intake of these foods at 6 years of age. These findings highlight the importance of infant feeding guidance that encourages intake of fruits and vegetables and the need to examine barriers to fruit and vegetable intake during infancy.

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: Evidence suggests an association of breastfeeding with a maternal feeding style (MFS) that is less controlling than formula feeding, which, in turn, may improve a child's self-regulation of eating. This study examines associations of bottle-feeding practices during infancy with MFS and children's eating behavior (CEB) at 6 years old. METHODS: We linked data from the Infant Feeding Practices Study II to the Year 6 Follow-Up, which include 8 MFS and CEB measures adapted from previous validated instruments. Bottle-feeding practices during the first 6 months estimated by using the Infant Feeding Practices Study II were bottle-feeding intensity (BFI), mother's encouragement of infant to finish milk in the bottle, and infant finishing all milk in the bottle. Adjusted odds ratios (aORs) for associations of bottle-feeding practices with MFS and CEB at 6 years old were calculated by using multivariable logistic regressions controlling for sociodemographic characteristics and other feeding practices (N = 1117). RESULTS: Frequent bottle emptying encouraged by mothers during infancy increased odds of mothers encouraging their child to eat all the food on their plate (aOR: 2.37; 95% confidence interval [CI]: 1.65-3.41] and making sure their child eats enough (aOR: 1.62; 95% CI: 1.14-2.31) and of children eating all the food on their plate at 6 years old (aOR: 2.01; 95% CI: 1.05-3.83). High BFI during early infancy also increased the odds of mothers being especially careful to ensure their 6-year-old eats enough. CONCLUSIONS: Bottle-feeding practices during infancy may have long-term effects on MFS and CEB. Frequent bottle emptying encouraged by mothers and/or high BFI during early infancy increased the likelihood of mothers pressuring their 6-year-old child to eat and children's low satiety responsiveness.

BACKGROUND AND OBJECTIVE: Breastfeeding has been associated with early infant food preferences, but less is known about how breastfeeding is associated with later child diet. The objective of this study was to assess whether any and exclusive breastfeeding duration are associated with child diet at 6 years. METHODS: We linked data from the Infant Feeding Practices Study II and Year 6 Follow-Up. We used approximately monthly questionnaires throughout infancy to calculate any and exclusive breastfeeding duration (n = 1355). We calculated median daily frequency of intake of water, milk, 100% juice, fruits, vegetables, sugar-sweetened beverages, sweets, and savory snacks at 6 years from a dietary screener and examined frequency of consumption of each food or beverage group by any and exclusive breastfeeding duration. We used separate multivariable logistic regression models to calculate odds of consuming more than the median daily frequency of intake of food or beverage items, adjusting for confounders. RESULTS: Intake of milk, sweets, and savory snacks at 6 years was not associated with any or exclusive breastfeeding duration in unadjusted analyses. Frequency of consumption of water, fruits, and vegetables was positively associated, and intake of sugar-sweetened beverages was inversely associated with any and exclusive breastfeeding duration in adjusted models; 100% juice consumption was inversely associated with exclusive breastfeeding duration only. CONCLUSIONS: Among many other health benefits, breastfeeding is associated with a number of healthier dietary behaviors at age 6. The association between breastfeeding and child diet may be an important factor to consider when examining associations between breastfeeding and child obesity and chronic diseases.

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/OBJECTIVES: Vitamin D deficiency in children remains a global concern. Although literature exists on the vitamin D status and its risk factors among children in the Middle East, findings have yielded mixed results, and large, representative community studies are lacking. SUBJECTS/METHODS: In a nationally representative survey of 1077 Jordanian children of preschool age (12-59 months) in Spring 2010, we measured 25(OH)D3 concentrations by liquid chromatography-tandem mass spectrometry and calculated prevalence ratios for deficiency associated with various factors. RESULTS: Results showed 19.8% (95% confidence interval (CI): 16.4-23.3%) deficiency (<12 ng/ml) and 56.5% (95% CI: 52.0-61.0%) insufficiency (<20 ng/ml). In adjusted models, prevalence of deficiency was higher for females compared with males (prevalence ratio (PR)=1.74, 95% CI: 1.22-2.47, P=0.002) and lower for children 24-35 months of age (PR=0.64, 95% CI: 0.44-0.92, P=0.018) compared with children 12-23 months of age. In rural areas, there was no difference in prevalence of vitamin D deficiency between those whose mothers had/did not have vitamin D deficiency (P=0.312); however, in urban areas, prevalence of vitamin D deficiency was 3.18 times greater among those whose mothers were vitamin D deficient compared with those whose mothers were not deficient (P=0.000). CONCLUSIONS: Vitamin D deficiency and insufficiency pose significant public health problems in Jordanian children with female children disproportionately affected. Strong associations between vitamin D status in children and urban residency and maternal vitamin D status suggest that the behaviors related to sun exposure in urban mothers likely also affect the sun exposure and thus vitamin D status of their children.

In the United States, about 25% of women choose not to initiate breastfeeding, yet little is known about how opinions of individuals in a woman's support network influence her decision to breastfeed. In the 2005-2007 Infant Feeding Practices Study II, women completed questionnaires from the last trimester of pregnancy until 12 months postpartum. Mothers indicated prenatally their family members' and health care providers' opinion on how newborns should be fed: breastfed only, formula fed only, breast and formula fed, or no opinion/don't know. Breastfeeding initiation was determined by asking mothers around 4 weeks postpartum (n=2,041) whether they ever breastfed. Logistic regression was used to examine the association between mothers' perception of family members' and health care providers' opinion on how to feed the infant and the initiation of breastfeeding, adjusting for sociodemographic characteristics. Nearly 14% of mothers surveyed did not initiate breastfeeding. Mothers who believed their family members or health care providers preferred breastfeeding only were least likely not to initiate breastfeeding. Never breastfeeding was significantly associated with the following perceptions: the infant's father (odds ratio [OR]=110.4; 95% CI 52.0 to 234.4) or maternal grandmother (OR=15.9; 95% CI 7.0 to 36.0) preferred only formula feeding; the infant's father (OR=3.2; 95% CI 1.7 to 5.9) or doctor (OR=2.7; 95% CI 1.2 to 6.2) preferred both breast and formula feeding; and the infant's father (OR=7.6; 95% CI 4.5 to 12.7), maternal grandmother (OR=5.4; 95% CI 2.6 to 11.0), or doctor (OR=1.9; 95% CI 1.0 to 3.7) had no opinion/didn't know their feeding preference. The prenatal opinions of family members and health care providers play an important role in a woman's breastfeeding decisions after the infant's birth.

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.