Faculty Bibliography

The COVID-19 pandemic increased maternal depression and anxiety, imperiling both mothers' own wellbeing and that of their children. To date, however, little is known about the extent to which these increases are attributable to economic hardships commonly experienced during the pandemic: income loss, job loss, and loss of health insurance. Few studies have examined the individual impacts of these hardships, and none have lasted beyond the first year of the pandemic. This study harmonizes data from six evaluations of pediatric-based parenting programs for women with young children and low incomes across three U.S. cities (N = 1,254). Low-income mothers are of special interest because their families have been disproportionately affected by economic shocks due to COVID-19, and mothers of young children have been more distressed than other mothers by COVID-19. The studies' combined window of observation lasted from the onset of the pandemic to over three years later. Results indicate that income loss, job loss, and health insurance loss were all significantly associated with depression and anxiety. When each hardship was assessed net of the others, lost income was associated with more than a two-fold increase in the odds of anxiety, and a lost job and lost health insurance were associated with 50% and 90% greater odds of depression, respectively. Associations between hardships and maternal mental health did not diminish over time during the window of observation. These associations are likely to have been even greater in the absence of generous social policies enacted during the pandemic.

IMPORTANCE/UNASSIGNED:Infant growth predicts long-term obesity and cardiovascular disease. Previous interventions designed to prevent obesity in the first 2 years of life have been largely unsuccessful. Obesity prevalence is high among traditional racial and ethnic minority groups. OBJECTIVE/UNASSIGNED:To compare the effectiveness of adding a digital childhood obesity prevention intervention to health behavior counseling delivered by pediatric primary care clinicians. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Individually randomized, parallel-group trial conducted at 6 US medical centers and enrolling patients shortly after birth. To be eligible, parents spoke English or Spanish, and children were born after 34 weeks' gestational age. Study enrollment occurred between October 2019 and January 2022, with follow-up through January 2024. INTERVENTIONS/UNASSIGNED:In the clinic-based health behavior counseling (clinic-only) group, pediatric clinicians used health literacy-informed booklets at well-child visits to promote healthy behaviors (n = 451). In the clinic + digital intervention group, families also received health literacy-informed, individually tailored, responsive text messages to support health behavior goals and a web-based dashboard (n = 449). MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was child weight-for-length trajectory over 24 months. Secondary outcomes included weight-for-length z score, body mass index (BMI) z score, and the percentage of children with overweight or obesity. RESULTS/UNASSIGNED:Of 900 randomized children, 86.3% had primary outcome data at the 24-month follow-up time point; 143 (15.9%) were Black, non-Hispanic; 405 (45.0%) were Hispanic; 185 (20.6%) were White, non-Hispanic; and 165 (18.3%) identified as other or multiple races and ethnicities. Children in the clinic + digital intervention group had a lower mean weight-for-length trajectory, with an estimated reduction of 0.33 kg/m (95% CI, 0.09 to 0.57) at 24 months. There was also an adjusted mean difference of -0.19 (95% CI, -0.37 to -0.02) for weight-for-length z score and -0.19 (95% CI, -0.36 to -0.01) for BMI z score. At age 24 months, 23.2% of the clinic + digital intervention group compared with 24.5% of the clinic-only group had overweight or obesity (adjusted risk ratio, 0.91 [95% CI, 0.70 to 1.17]) based on the Centers for Disease Control and Prevention criteria of BMI 85th percentile or greater. At that age, 7.4% of the clinic + digital intervention group compared with 12.7% of the clinic-only group had obesity (adjusted risk ratio, 0.56 [95% CI, 0.36 to 0.88]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:A health literacy-informed digital intervention improved child weight-for-length trajectory across the first 24 months of life and reduced childhood obesity at 24 months. The intervention was effective in a racially and ethnically diverse population that included groups at elevated risk for childhood obesity. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT04042467.

Child lifestyle behaviors are influenced by their caregivers. Targeting the caregiver-child relationship can establish healthy habits, especially healthful eating patterns, in both the caregiver and child. The purpose of this study was to identify the context for addressing strategies used to establish nutritious eating for the caregiver and child taken together as a unit (e.g., the caregiver-child dyad), through the perspectives of nutrition-promoting professionals. We performed purposive sampling of professionals who address healthful nutrition. Semi-structured qualitative interviews were conducted to elicit perspectives on caregiver-child eating dynamics and techniques to produce dietary behavior change. Data were coded through the constant comparative method, and subthemes and themes were identified by grouping similar codes and excerpts. We identified four themes relevant to dyadic dietary behavior change: (1) factors to consider when approaching nutrition such as family dynamics, (2) dyad-specific strategies for dietary behavior change, (3) patient-centered approaches professionals implement in interactions with the dyad, and (4) time as a barrier to dietary behavior change. In conclusion, study is novel in eliciting the perspectives of professionals across multiple settings to provide a context for dyadic dietary behavior change. Future studies can focus on developing training for lifestyle medicine professionals to approach dyad-specific behavior modification.

OBJECTIVE:To examine associations between cognitive stimulation in the home at 6 months and maternal feeding styles at 24 months, direct intervention effects of Smart Beginnings (SB) on feeding styles, and potential indirect effects of SB on feeding styles via earlier intervention effects on cognitive stimulation. STUDY DESIGN/METHODS:Single-blind, two-site randomized clinical trial (RCT) of the SB intervention. SB integrates PlayReadVIP, a universal, pediatric primary care-based program, and Family Check-Up (FCU), a targeted secondary home-based parenting intervention. Mother-infant dyads (N=327) were randomized at birth to standard pediatric care or the SB intervention. Linear regression analyses determined associations between cognitive stimulation at 6 months and maternal feeding styles at 24 months, a secondary data analysis. Direct intervention impacts on feeding styles, a secondary RCT outcome, were also assessed and mediation analyses explored intervention effects on feeding styles via earlier intervention impacts on cognitive stimulation. RESULTS:Cognitive stimulation was significantly associated with higher responsive and lower indulgent feeding styles. SB mothers were less likely to exhibit pressuring styles compared with controls (Effect Size [ES]=-0.12, p=0.02). Although no direct intervention effects were found on responsive or indulgent feeding styles, indirect effects of SB were evident on these feeding styles through intervention-induced increases in cognitive stimulation in the SB group. CONCLUSION/CONCLUSIONS:This study found positive linkages between cognitive stimulation in the home and later feeding styles. Additionally, the SB intervention was associated with less pressured feeding and indirect pathways mediated by intervention effects on cognitive stimulation. Implications for early childhood parenting interventions are discussed.

OBJECTIVE:To estimate the prevalence of post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) after infection with SARS-CoV-2 during pregnancy and to characterize associated risk factors. METHODS:In a multicenter cohort study (NIH RECOVER [Researching COVID to Enhance Recovery]-Pregnancy Cohort), individuals who were pregnant during their first SARS-CoV-2 infection were enrolled across the United States from December 2021 to September 2023, either within 30 days of their infection or at differential time points thereafter. The primary outcome was PASC , defined as score of 12 or higher based on symptoms and severity as previously published by the NIH RECOVER-Adult Cohort, at the first study visit at least 6 months after the participant's first SARS-CoV-2 infection. Risk factors for PASC were evaluated, including sociodemographic characteristics, clinical characteristics before SARS-CoV-2 infection (baseline comorbidities, trimester of infection, vaccination status), and acute infection severity (classified by need for oxygen therapy). Multivariable logistic regression models were fitted to estimate associations between these characteristics and presence of PASC. RESULTS:Of the 1,502 participants, 61.1% had their first SARS-CoV-2 infection on or after December 1, 2021 (ie, during Omicron variant dominance); 51.4% were fully vaccinated before infection; and 182 (12.1%) were enrolled within 30 days of their acute infection. The prevalence of PASC was 9.3% (95% CI, 7.9-10.9%) measured at a median of 10.3 months (interquartile range 6.1-21.5) after first infection. The most common symptoms among individuals with PASC were postexertional malaise (77.7%), fatigue (76.3%), and gastrointestinal symptoms (61.2%). In a multivariable model, the proportion PASC positive with vs without history of obesity (14.9% vs 7.5%, adjusted odds ratio [aOR] 1.65, 95% CI, 1.12-2.43), depression or anxiety disorder (14.4% vs 6.1%, aOR 2.64, 95% CI, 1.79-3.88) before first infection, economic hardship (self-reported difficulty covering expenses) (12.5% vs 6.9%, aOR 1.57, 95% CI, 1.05-2.34), and treatment with oxygen during acute SARS-CoV-2 infection (18.1% vs 8.7%, aOR 1.86, 95% CI, 1.00-3.44) were associated with increased prevalence of PASC. CONCLUSION/CONCLUSIONS:The prevalence of PASC at a median time of 10.3 months after SARS-CoV-2 infection during pregnancy was 9.3% in the NIH RECOVER-Pregnancy Cohort. The predominant symptoms were postexertional malaise, fatigue, and gastrointestinal symptoms. Several socioeconomic and clinical characteristics were associated with PASC after infection during pregnancy. CLINICAL TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov , NCT05172024.

IMPORTANCE/UNASSIGNED:Most research to understand postacute sequelae of SARS-CoV-2 infection (PASC), or long COVID, has focused on adults, with less known about this complex condition in children. Research is needed to characterize pediatric PASC to enable studies of underlying mechanisms that will guide future treatment. OBJECTIVE/UNASSIGNED:To identify the most common prolonged symptoms experienced by children (aged 6 to 17 years) after SARS-CoV-2 infection, how these symptoms differ by age (school-age [6-11 years] vs adolescents [12-17 years]), how they cluster into distinct phenotypes, and what symptoms in combination could be used as an empirically derived index to assist researchers to study the likely presence of PASC. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Multicenter longitudinal observational cohort study with participants recruited from more than 60 US health care and community settings between March 2022 and December 2023, including school-age children and adolescents with and without SARS-CoV-2 infection history. EXPOSURE/UNASSIGNED:SARS-CoV-2 infection. MAIN OUTCOMES AND MEASURES/UNASSIGNED:PASC and 89 prolonged symptoms across 9 symptom domains. RESULTS/UNASSIGNED:A total of 898 school-age children (751 with previous SARS-CoV-2 infection [referred to as infected] and 147 without [referred to as uninfected]; mean age, 8.6 years; 49% female; 11% were Black or African American, 34% were Hispanic, Latino, or Spanish, and 60% were White) and 4469 adolescents (3109 infected and 1360 uninfected; mean age, 14.8 years; 48% female; 13% were Black or African American, 21% were Hispanic, Latino, or Spanish, and 73% were White) were included. Median time between first infection and symptom survey was 506 days for school-age children and 556 days for adolescents. In models adjusted for sex and race and ethnicity, 14 symptoms in both school-age children and adolescents were more common in those with SARS-CoV-2 infection history compared with those without infection history, with 4 additional symptoms in school-age children only and 3 in adolescents only. These symptoms affected almost every organ system. Combinations of symptoms most associated with infection history were identified to form a PASC research index for each age group; these indices correlated with poorer overall health and quality of life. The index emphasizes neurocognitive, pain, and gastrointestinal symptoms in school-age children but change or loss in smell or taste, pain, and fatigue/malaise-related symptoms in adolescents. Clustering analyses identified 4 PASC symptom phenotypes in school-age children and 3 in adolescents. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This study developed research indices for characterizing PASC in children and adolescents. Symptom patterns were similar but distinguishable between the 2 groups, highlighting the importance of characterizing PASC separately for these age ranges.

OBJECTIVE:To examine associations between prolonged early household food insecurity (FI) during pregnancy, infancy, and toddlerhood, and child feeding practices, and the mediating role of dysfunctional parent-child interactions. METHODS:We conducted secondary longitudinal analyses of data from the Starting Early Program (StEP) randomized controlled trial, which studied a primary care-based child obesity prevention program for low-income Hispanic families. Our independent variable was FI, using the USDA Food Security Module, during the third trimester of pregnancy and at child ages 10- and 19-months. Frequency of reported FI was defined by the number of periods with FI (0, 1, 2, or 3). Our dependent variables were feeding practices at child age 28-months using the Comprehensive Feeding Practices Questionnaire. Our mediating variable was dysfunctional parent-child interactions using the Parenting Stress Index subscale at age 19-months. We used linear regression to determine associations between frequency of reported FI and feeding practices adjusting for covariates, and mediation analyses to determine if dysfunctional parent-child interactions mediate these associations. RESULTS:Three hundred and forty four mothers completed assessments at child age 28-months. Of the 12 feeding practices examined, higher frequency of reported FI was positively associated with using food as a reward, restriction of food for weight control, and using food for emotional regulation, and was negatively associated with monitoring of less healthy foods. There was a significant indirect effect of frequency of reported FI on these practices through dysfunctional parent-child interactions. CONCLUSION/CONCLUSIONS:Higher frequency of reported FI was associated with four feeding practices, through dysfunctional parent-child interactions. Understanding these pathways can inform preventive interventions.

Parent-child dysfunctional interactions (PCDI) are known to contribute to children's weight status. However, the underlying mechanisms in how dysfunctional interactions between parent and child influence child weight are not clear. This study investigates the impact of PCDI on toddlers' weight, focusing on the potential serial mediation by maternal emotional feeding and child appetite traits. We conducted a secondary analysis of longitudinal data from a larger intervention trial to prevent childhood obesity in low-income Hispanic families. A total of 241 mother-child dyads were included in these analyses. Measurements were taken at various stages: PCDI at child age 19 months, maternal emotional feeding at 28 months, and both child appetite traits and weight-for-age z-score (WFAz) at 36 months. Serial mediation analyses revealed a significant indirect effect of early PCDI on later child WFAz through maternal emotional feeding and two child food approach traits (food responsiveness, emotional overeating) out of the eight child appetite traits assessed. PCDI at 19 months was associated with increased use of emotional feeding in mothers at 28 months, which was associated with heightened food responsiveness and emotional overeating in children at 36 months, which in turn was linked to greater child WFAz at 36 months. The findings of this study expand the understanding of the mechanisms underlying PCDI and child weight, emphasizing the interplay between maternal feeding practices and child appetite in the context of adverse parent-child interactions during early childhood.

Estimates of post-acute sequelae of SARS-CoV-2 infection (PASC) incidence, also known as Long COVID, have varied across studies and changed over time. We estimated PASC incidence among adult and pediatric populations in three nationwide research networks of electronic health records (EHR) participating in the RECOVER Initiative using different classification algorithms (computable phenotypes). Overall, 7% of children and 8.5%-26.4% of adults developed PASC, depending on computable phenotype used. Excess incidence among SARS-CoV-2 patients was 4% in children and ranged from 4-7% among adults, representing a lower-bound incidence estimation based on two control groups - contemporary COVID-19 negative and historical patients (2019). Temporal patterns were consistent across networks, with peaks associated with introduction of new viral variants. Our findings indicate that preventing and mitigating Long COVID remains a public health priority. Examining temporal patterns and risk factors of PASC incidence informs our understanding of etiology and can improve prevention and management.

IMPORTANCE/OBJECTIVE:The prevalence, pathophysiology, and long-term outcomes of COVID-19 (post-acute sequelae of SARS-CoV-2 [PASC] or "Long COVID") in children and young adults remain unknown. Studies must address the urgent need to define PASC, its mechanisms, and potential treatment targets in children and young adults. OBSERVATIONS/METHODS:We describe the protocol for the Pediatric Observational Cohort Study of the NIH's REsearching COVID to Enhance Recovery (RECOVER) Initiative. RECOVER-Pediatrics is an observational meta-cohort study of caregiver-child pairs (birth through 17 years) and young adults (18 through 25 years), recruited from more than 100 sites across the US. This report focuses on two of four cohorts that comprise RECOVER-Pediatrics: 1) a de novo RECOVER prospective cohort of children and young adults with and without previous or current infection; and 2) an extant cohort derived from the Adolescent Brain Cognitive Development (ABCD) study (n = 10,000). The de novo cohort incorporates three tiers of data collection: 1) remote baseline assessments (Tier 1, n = 6000); 2) longitudinal follow-up for up to 4 years (Tier 2, n = 6000); and 3) a subset of participants, primarily the most severely affected by PASC, who will undergo deep phenotyping to explore PASC pathophysiology (Tier 3, n = 600). Youth enrolled in the ABCD study participate in Tier 1. The pediatric protocol was developed as a collaborative partnership of investigators, patients, researchers, clinicians, community partners, and federal partners, intentionally promoting inclusivity and diversity. The protocol is adaptive to facilitate responses to emerging science. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:RECOVER-Pediatrics seeks to characterize the clinical course, underlying mechanisms, and long-term effects of PASC from birth through 25 years old. RECOVER-Pediatrics is designed to elucidate the epidemiology, four-year clinical course, and sociodemographic correlates of pediatric PASC. The data and biosamples will allow examination of mechanistic hypotheses and biomarkers, thus providing insights into potential therapeutic interventions. CLINICAL TRIALS.GOV IDENTIFIER/BACKGROUND:Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT05172011.