Faculty Bibliography

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

Parent perception of weight and feeding styles are associated with obesity in other racial groups but have not been explored in-depth in Chinese-American preschoolers. Cross-sectional survey of 253 Chinese-American parents with preschoolers was performed in a community clinic. Regression analysis was used to assess relationships between parental perception of weight and feeding styles. Parent under-perception of weight was common but more likely in boys than girls (chi2 = 4.91, p = 0.03). Pressuring was also greater in boys [adjusted mean difference (95% CI) 0.24 (0.004, 0.49)]. In girls, pressuring was lower for children perceived as overweight [adjusted mean difference in CFQ scores -0.75 (-1.27, -0.23)]; in boys, pressuring was high regardless of perceived child weight. Weight perceptions and feeding styles related to childhood obesity in other groups were identified in Chinese-American families. Parent under-perception of child weight and pressure to eat were more common in boys. These factors should be addressed in Chinese-American preschooler obesity prevention programs.

OBJECTIVE: Determine maternal and infant characteristics associated with adding cereal into the bottle. DESIGN: Secondary data analysis. PARTICIPANTS: Study participants were immigrant, low-income, urban mother-infant dyads (n = 216; 91% Hispanic, 19% US-born) enrolled in a randomized controlled trial entitled the Bellevue Project for Early Language, Literacy and Education Success. MAIN OUTCOME MEASURES: Maternal characteristics (age, marital status, ethnicity, primary language, country of origin, education, work status, income, depressive symptoms, and concern about infant's future weight) and infant characteristics (gender, first born, and difficult temperament). ANALYSIS: Fisher exact test, chi-square test, and simultaneous multiple logistic regression of significant (P < .05) variables identified in unadjusted analyses. RESULTS: Twenty-seven percent of mothers added cereal into the bottle. After adjusting for confounding variables identified in bivariate analyses, mothers who were single (P = .02), had moderate to severe depressive symptoms (P = .01) and perceived their infant had a difficult temperament (P = .03) were more likely to add cereal into the bottle. Conversely, mothers who expressed concern about their infants becoming overweight were less likely to add cereal (P = .02). CONCLUSIONS AND IMPLICATIONS: Health care providers should screen for adding cereal in infant bottles. Further research is needed to investigate the impact of adding cereal into the bottle on weight trajectories over time. Causal associations also need to be identified to effectively prevent this practice.

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

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

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

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