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1.  Early child care and obesity at 12 months of age in the Danish National Birth Cohort 
Evidence suggests that the child care environment may be more obesogenic than the family home, and previous studies have found that child care use may be associated with obesity in children. Few studies, however, have focused on child care during infancy, which may be an especially vulnerable period. This study examined child care use in infancy and weight status at 12 months of age in a country where paid maternity leave is common and early child care is not as prevalent as in other developed countries.
We studied 27821 children born to mothers participating in the Danish National Birth Cohort (DNBC), a longitudinal study of pregnant women enrolled between 1997 and 2002, who were also included in the Childcare Database, a national record of child care use in Denmark. The exposure was days in child care from birth to 12 months. The outcomes were sex-specific body mass index (BMI) z-score and overweight/obesity (BMI ≥85th percentile based on the World Health Organization classification) at 12 months. We conducted multivariable linear and logistic regression analyses examining child care use and weight outcomes.
A total of 17721 (63.7%) children attended child care during their first year of life. After adjustment for potential confounders, a 30-day increment of child care was associated with a modestly higher BMI z-score at 12 months (0.03 units; 95% CI: 0.01, 0.05; p=0.003). Similarly, child care use was associated with increased odds of being overweight/obese at 12 months of age (OR 1.05; 95% CI: 1.01, 1.10; p=0.047).
Child care in the first year of life was associated with slightly higher weight at 12 months, suggesting that child care settings may be important targets for obesity prevention in infancy.
PMCID: PMC4286493  PMID: 25233894
Childcare; Obesity; Danish National Birth Cohort; Childcare Database; Denmark
2.  Is Universal Pediatric Lipid Screening Justified? 
JAMA  2012;307(3):259-260.
PMCID: PMC4349502  PMID: 22253390
3.  Gestational Weight Gain: Now and the Future 
Circulation  2012;125(11):1339-1340.
PMCID: PMC4187208  PMID: 22344036
editorials; cardiovascular risk factors; epidemiology; obesity; pregnancy; gestational weight gain
4.  Hypertension Awareness and Control Among Young Adults in the National Longitudinal Study of Adolescent Health 
Journal of General Internal Medicine  2014;29(8):1098-1104.
Young adults are less likely than older adults to be aware they have hypertension or to be treated for hypertension.
To describe rates of hypertension awareness and control in a cohort of young adults and understand the impact of health insurance, utilization of preventive care, and self-perception of health on rates of hypertension awareness and control in this age group.
Cross-sectional study of 13,512 young adults participating in Wave IV of the National Longitudinal Study of Adolescent Health in 2007–2008.
We defined hypertension as an average of two measured systolic blood pressures (SBP) ≥ 140 mmHg, diastolic blood pressures (DBP) ≥ 90 mmHg, or self-report of hypertension. We defined hypertension awareness as reporting having been told by a health care provider that one had high blood pressure, and assessed awareness among those with uncontrolled hypertension. We considered those aware of having hypertension controlled if their average measured SBP was < 140 mmHg and DBP was < 90 mmHg.
Of the 3,303 young adults with hypertension, 2,531 (76 %) were uncontrolled, and 1,893 (75 %) of those with uncontrolled hypertension were unaware they had hypertension. After adjustment for age, sex, race/ethnicity, weight status, income, education, alcohol and tobacco use, young adults with uncontrolled hypertension who had (vs. didn’t have) routine preventive care in the past 2 years were 2.4 times more likely (95 % confidence interval [CI] 1.68–3.55) to be aware, but young adults who believed they were in excellent (vs. less than excellent) health were 64 % less likely to be aware they had hypertension (OR 0.36, 95 % CI 0.23–0.57). Neither preventive care utilization nor self-rated health was associated with blood pressure control.
In this nationally representative group of young adults, rates of hypertension awareness and control were low. Efforts to increase detection of hypertension must address young adults’ access to preventive care and perception of their need for care.
PMCID: PMC4099443  PMID: 24577758
hypertension; young adult; health services accessibility; health status
5.  Effects of promoting longer-term and exclusive breastfeeding on childhood eating attitudes: a cluster-randomized trial 
Background: Observational studies suggest that breastfeeding benefits later maternal child-feeding practices, which in turn may contribute to positive eating attitudes. We investigated the effect of a randomized intervention to increase duration and exclusivity of breastfeeding on pre-adolescent eating attitudes.
Methods: Long-term follow-up of the Promotion of Breastfeeding Intervention Trial (PROBIT), a cluster-randomized trial in 31 maternity hospitals and affiliated polyclinics in Belarus. Sites were randomly assigned an experimental intervention to promote longer duration and exclusivity of breastfeeding in mothers who initiated breastfeeding (n = 16 sites), or a control intervention of continuing usual care (n = 15 sites); 17 046 healthy infants were enrolled in 1996–7, of whom 13 751 (80.7%) completed the Children’s Eating Attitude Test (ChEAT) at 11.5 years of age. A ChEAT score ≥22.5 (85th percentile) was used as an indicator of problematic eating attitudes. Analysis was based on intention-to-treat, accounting for clustering within hospitals/clinics.
Results: Compared with the control arm, the experimental intervention substantially increased breastfeeding exclusivity (43.3% vs 6.4% exclusively breastfed at 3 months of age) and duration of any breastfeeding throughout infancy. The proportion of children with ChEAT scores ≥22.5 was lower in the experimental than control arm (boys 11.4% vs 17.2%; girls 18.5% vs 23.4%) [cluster-adjusted odds ratio (OR), boys: 0.44; 95% confidence interval (CI): 0.21,0.93; girls: 0.51; 95% CI: 0.27,0.99). Results were robust to adjustment for potential confounders and using a ChEAT score ≥25.5 (91st percentile) as the outcome (OR: 0.53; 95% CI: 0.28,1.03).
Conclusions: An intervention to improve the duration and exclusivity of breastfeeding among term infants in Belarus was associated with a reduction in problematic eating attitudes at 11.5 years of age.
PMCID: PMC4121559  PMID: 24706729
Breastfeeding; problematic eating attitudes; cluster-randomized trial
6.  Acculturation and Maternal Health Behaviors 
Although prior studies have shown disparities in maternal health behaviors according to race/ethnicity and acculturation, whether these patterns are evident among new immigrant populations remains unclear.
To examine the associations among proxies of acculturation and maternal smoking during pregnancy and breastfeeding initiation within each major ethnic group in Massachusetts.
Data were from the Standard Certificate of Live Births on 1,067,375 babies by mothers from 31 ethnic groups for 1996–2009. Mothers reported whether they smoked during pregnancy and the birth facility recorded whether mothers started breastfeeding. The acculturation proxy combined mothers’ country of birth and language preference: U.S.-born, foreign-born English-speaking, and foreign-born non-English speaking. For each ethnic group, adjusted logistic regression models were conducted to examine associations between the acculturation proxy and whether mothers smoked or initiated breastfeeding. Data were analyzed from 2012 to 2013.
A lower proportion of foreign-born mothers had a high school degree or private insurance than U.S.-born mothers. However, foreign-born mothers who were English (range of AORs=0.07–0.93) or non-English speakers (AORs=0.01–0.36) were less likely to smoke during pregnancy than their U.S.-born counterparts. Foreign-born mothers who were English (AORs=1.22–6.52) or non-English speakers (AORs=1.35–10.12) were also more likely to initiate breastfeeding compared to U.S.-born mothers, except for some mothers with Asian ethnicities.
The consistency of the associations of being foreign-born with less smoking and more breastfeeding suggests that for the majority of ethnic groups studied, acculturation in the U.S. results in poorer maternal health behaviors.
PMCID: PMC4106991  PMID: 24951043
7.  Associations of Prenatal Maternal Blood Mercury Concentrations with Early and Mid-Childhood Blood Pressure: A Prospective Study 
Environmental research  2014;133:327-333.
Childhood blood pressure (BP) is an important determinant of adult cardiovascular disease. Prenatal exposure to methylmercury through maternal fish consumption has been reported to increase the BP of children years later.
Mother-child pairs were enrolled from Project Viva, a prospective cohort study in Massachusetts. From second trimester maternal blood samples, we measured erythrocyte mercury concentration. Systolic BP in children, measured up to 5 times per visit in early and mid-childhood (median ages 3.2 and 7.7 years), was the primary outcome. We used mixed-effect regression models to account for variation in the number of BP measurements and to average effects over both time points.
Among 1,103 mother-child pairs, mean (SD) second trimester total erythrocyte mercury concentration was 4.0 (3.9) ng/g among mothers whose children were assessed in early childhood and 4.0 (4.0) ng/g for children assessed in mid-childhood. Mean (SD) offspring systolic BP was 92.1 (10.4) mm Hg in early childhood and 94.3 (8.4) mm Hg in mid-childhood. After adjusting for mother and infant characteristics, mean second trimester blood mercury concentration was not associated with child systolic BP (regression coefficient, 0.1 mm Hg; 95% CI, −1.3 to 1.5 for quartile 4 vs. quartile 1) at either time period. Further adjusting for second trimester maternal fish consumption, as well as docosahexaenoic acid and eicosapentaenoic acid consumption, did not substantially change the estimates.
The results of this study demonstrate an absence of association between childhood blood pressure and low-level mercury exposure typical of the general US population.
PMCID: PMC4364915  PMID: 25019468
mercury; prenatal exposure; blood pressure
8.  Physical Activity–Related and Weather-Related Practices of Child Care Centers From 2 States 
Young children’s physical activity (PA) is influenced by their child care environment. This study assessed PA practices in centers from Massachusetts (MA) and Rhode Island (RI), compared them to best practice recommendations, and assessed differences between states and center profit status. We also assessed weather-related practices.
Sixty percent of MA and 54% of RI directors returned a survey, for a total of 254. Recommendations were 1) daily outdoor play, 2) providing outdoor play area, 3) limiting fixed play structures, 4) variety of portable play equipment, and 5) providing indoor play area. We fit multivariable linear regression models to examine adjusted associations between state, profit status, PA, and weather-related practices.
MA did not differ from RI in meeting PA recommendations (β = 0.03; 0.15, 0.21; P = .72), but MA centers scored higher on weather-related practices (β = 0.47; 0.16, 0.79; P = .004). For-profit centers had lower PA scores compared with nonprofits (β = −0.20; 95% CI: −0.38, −0.02; P = .03), but they did not differ for weather (β = 0.12; −0.19, 0.44; P = .44).
More MA centers allowed children outside in light rain or snow. For-profit centers had more equipment—both fixed and portable. Results from this study may help inform interventions to increase PA in children.
PMCID: PMC4509502  PMID: 24763142
gross motor; play equipment; preschool
9.  Preventing obesity in infants and toddlers in child care: Results from a pilot randomized controlled trial 
Maternal and child health journal  2014;18(5):1246-1257.
Few interventions have focused on very young children for obesity prevention. This study evaluated a pilot intervention to improve the nutrition and physical activity environments of child care centers serving infants and toddlers.
This randomized controlled trial took place in 32 centers in Boston, Massachusetts. The intervention aimed to improve policies and practices related to nutrition and physical activity within the center. For the outcome, observers assessed center environments using the Environment and Policy Assessment and Observation (EPAO) instrument (range 0-320 points) at baseline and the six-month follow-up. We fit linear regression models with change in EPAO score from baseline to follow-up, controlling for potential confounders for total score, nutrition sub-score, and physical activity sub-score.
Intervention centers had a mean (SD) of 98.2 (144.8) children enrolled, while control centers had 59.2 (34.5). In intervention centers, 47.5% of children were white, compared to 46.2% in controls. Fewer intervention centers had outdoor play areas on site (75% vs. 100%) but more had indoor play space (67% vs. 25%). At baseline, intervention centers had a mean (SD) EPAO score of 134.5 (7.0) points and controls had 146.8 (4.8) points. Compared with controls, intervention centers improved their EPAO scores at follow-up by 18.5 points (95% CI 0.1, 37.0; p=0.049), chiefly through greater improvement in physical activity (12.2; 95% CI -1.6, 26.0; p=0.075) and not nutrition (6.4; 95% CI -7.1, 19.8; p=0.385).
The pilot showed promise as an intervention to improve center environments, but future studies should include child-level outcomes.
PMCID: PMC3965661  PMID: 24065371
Child care; infant; nutrition; physical activity; toddler
10.  Maternal Prepregnancy Folate Intake and Risk of Spontaneous Abortion and Stillbirth 
Obstetrics and gynecology  2014;124(1):23-31.
To evaluate prospectively the relationship between prepregnancy folate intake and risk of spontaneous abortion and stillbirth.
Women in the Nurses’ Health Study-II who self-reported a pregnancy between 1992 and 2009 were included in this analysis. Dietary folate and supplement use was assessed every 4 years, starting in 1991, by a food-frequency questionnaire. Pregnancies were self-reported, with case pregnancies lost spontaneously (spontaneous abortion <20 weeks of gestation and stillbirth 20+ weeks of gestation) and comparison pregnancies ending in ectopic pregnancy, induced abortion, or live birth.
Among the 11,072 women, 15,950 pregnancies were reported of which 2,756(17.3%) ended in spontaneous abortion and 120(0.8%) ended in stillbirth. Compared to women in the lowest quintile of prepregnancy folate intake (<285μg/day), those in the highest quintile (>851μg/day) had a relative risk (RR) of spontaneous abortion of 0.91 (95% CI 0.82,1.02) after multivariable adjustment (P-trend=0.04). This association was primarily attributable to intake of folate from supplements. Compared to women without supplemental folate intake (0μg/day), those in the highest category (>730μg/day) had a RR of spontaneous abortion of 0.80 (95% CI 0.71,0.90) after multivariable adjustment (P-trend=<0.001). The association of prepregnancy supplemental folate with risk of spontaneous abortion was consistent across gestational period of loss. A similar inverse trend was observed with the risk of stillbirth, which fell short of conventional significance (P-trend=0.06).
Higher intake of folate from supplements was associated with reduced risk of spontaneous abortion. Women at risk of pregnancy should use supplemental folate for neural tube defect prevention and because it may decrease the risk of spontaneous abortion,.
PMCID: PMC4086728  PMID: 24901281
11.  A Randomized Comparative Effectiveness Study of Healthy Directions 2—A Multiple Risk Behavior Intervention for Primary Care 
Preventive medicine  2014;64:96-102.
To evaluate the effectiveness of the Healthy Directions 2 (HD2) intervention in the primary care setting.
HD2 was a cluster randomized trial (conducted 3/09 – 11/11). Primary sampling unit was provider (n=33), with secondary sampling of patients within provider (n=2,440). Study arms included: 1) usual care (UC); 2) HD2-- a patient self-guided intervention targeting 5 risk behaviors; or 3) HD2 plus 2 brief telephone coaching calls (HD2+CC). The outcome measure was proportion of participants with a lower multiple risk behavior score (MRB) by follow-up.
At baseline, only 4% of participants met all behavioral recommendations. Both HD2 and HD2+CC led to improvements in MRB score, relative to UC, with no differences between the two HD2 conditions. Twenty-eight percent of UC participants had improved MRB scores at 6 mo., vs. 39% and 43% in HD2 and HD2+CC respectively (p’s≤.001); results were similar at 18 mo. (p≤.05). The incremental cost of one risk factor reduction in MRB score was $319 in HD2 and $440 for HD2+CC.
Self-guided and coached intervention conditions had equivalent levels of effect in reducing multiple chronic disease risk factors, were relatively low cost, and thus are potentially useful for routine implementation in similar health settings.
PMCID: PMC4204110  PMID: 24642140
12.  Chronic Sleep Curtailment and Adiposity 
Pediatrics  2014;133(6):1013-1022.
To examine the extent to which chronic sleep curtailment from infancy to mid-childhood is associated with total and central adiposity.
We studied 1046 children participating in a prospective cohort study. At age 6 months and yearly from age 1 to 7 years, mothers reported their children’s sleep duration in a usual 24-hour period. The main exposure was a sleep curtailment score from age 6 months to 7 years. The range of the total score was 0 to 13, where 0 indicated the maximal sleep curtailment and 13 indicated never having curtailed sleep. Outcomes in mid-childhood were BMI z score, dual X-ray absorptiometry total and trunk fat mass index (kg/m2), and waist and hip circumferences (cm).
The mean (SD) sleep score was 10.2 (2.7); 4.4% scored a 0 to 4, indicating multiple exposures to sleep curtailment between age 6 months to 7 years, 12.3% scored 5 to 7, 14.1% scored 8 to 9, 28.8% scored 10 to 11, and 40.3% scored 12 to 13. In multivariable models, children who had a sleep score of 0 to 4 had a BMI z score that was 0.48 U (95% confidence interval, 0.13 to 0.83) higher than those who had a sleep score of 12 to 13. We observed similar associations of higher total and trunk fat mass index and waist and hip circumferences, and higher odds of obesity (odds ratio, 2.62; 95% confidence interval, 0.99 to 6.97) among children who had a score of 0 to 4 vs 12 to 13.
Chronic sleep curtailment from infancy to school age was associated with higher overall and central adiposity in mid-childhood.
PMCID: PMC4035591  PMID: 24843068
sleep curtailment; adiposity; fat mass index; BMI; obesity; early childhood
13.  Peanut, milk, and wheat intake during pregnancy is associated with reduced allergy and asthma in children 
Maternal diet during pregnancy may influence childhood allergy and asthma.
To examine the associations between maternal intake of common childhood food allergens during early pregnancy and childhood allergy and asthma.
We studied 1277 mother-child pairs from a United States pre-birth cohort unselected for any disease. Using food frequency questionnaires administered during the first and second trimesters, we assessed maternal intake of common childhood food allergens during pregnancy. In mid-childhood (mean age 7.9 years), we assessed food allergy, asthma, allergic rhinitis, and atopic dermatitis by questionnaire and serum specific IgE levels. We examined the associations between maternal diet during pregnancy and childhood allergy and asthma. We also examined the cross-sectional associations between specific food allergies, asthma, and atopic conditions in mid-childhood.
Food allergy was common (5.6%) in mid-childhood, as was sensitization to at least one food allergen (28.0%). Higher maternal peanut intake (each additional z-score) during the first trimester was associated with 47% reduced odds of peanut allergic reaction (OR 0.53, 95%CI 0.30–0.94). Higher milk intake during the first trimester was associated with reduced asthma (OR 0.83, 95%CI 0.69–0.99) and allergic rhinitis (OR 0.85, 95%CI 0.74–0.97). Higher maternal wheat intake during the second trimester was associated with reduced atopic dermatitis (OR 0.64, 95%CI 0.46–0.90). Peanut, wheat, and soy allergy were each cross-sectionally associated with increased childhood asthma, atopic dermatitis, and allergic rhinitis (ORs 3.6 to 8.1).
Higher maternal intake of peanut, milk, and wheat during early pregnancy was associated with reduced odds of mid-childhood allergy and asthma.
PMCID: PMC4004710  PMID: 24522094
maternal diet; pregnancy; food allergy; sensitization; asthma; allergic rhinitis; peanut; milk; wheat; childhood
14.  Television Viewing, Bedroom Television, and Sleep Duration From Infancy to Mid-Childhood 
Pediatrics  2014;133(5):e1163-e1171.
Television and insufficient sleep are associated with poor mental and physical health. This study assessed associations of TV viewing and bedroom TV with sleep duration from infancy to midchildhood.
We studied 1864 children in Project Viva. Parents reported children’s average daily TV viewing and sleep (at 6 months and annually from 1–7 years) and the presence of a bedroom TV (annually 4–7 years). We used mixed effects models to assess associations of TV exposures with contemporaneous sleep, adjusting for child age, gender, race/ethnicity, maternal education, and income.
Six hundred forty-three children (35%) were racial/ethnic minorities; 37% of households had incomes ≤$70 000. From 6 months to 7 years, mean (SD) sleep duration decreased from 12.2 (2.0) hours to 9.8 (0.9) hours per day; TV viewing increased from 0.9 (1.2) hours to 1.6 (1.0) hours per day. At 4 years, 17% had a bedroom TV, rising to 23% at 7 years. Each 1 hour per day increase in lifetime TV viewing was associated with 7 minutes per day (95% confidence interval [CI]: 4 to 10) shorter sleep. The association of bedroom TV varied by race/ethnicity; bedroom TV was associated with 31 minutes per day shorter sleep (95% CI: 16 to 45) among racial/ethnic minority children, but not among white, non-Hispanic children (8 fewer minutes per day [95% CI: −19 to 2]).
More TV viewing, and, among racial/ethnic minority children, the presence of a bedroom TV, were associated with shorter sleep from infancy to midchildhood.
PMCID: PMC4006444  PMID: 24733878
television; sleep duration; sleep hygiene; childhood
15.  Vitamin D Status and Hypertensive Disorders in Pregnancy 
Annals of epidemiology  2014;24(5):399-403.e1.
Several studies have reported increased risk of preeclampsia when 25-hyrdoxyvitamin D (25[OH]D) levels are low. The extent to which 25(OH)D may lower risk for hypertensive disorder during pregnancy remains unclear.
Among women enrolled in the Project Viva prenatal cohort in Massachusetts, we examined associations of 25(OH)D levels obtained at 16.4 –36.9 weeks of gestation (mean 27.9 weeks) with hypertensive disorders of pregnancy, including preeclampsia (56/1591, 3.5%) and gestational hypertension (109/1591, 6.9%).
We did not detect an association between plasma 25(OH)D concentration (mean 58, SD 22 nmol/L) and preeclampsia. For each 25 nmol/L increase in 25(OH)D, the adjusted odds ratio for preeclampsia was 1.14 (95% confidence interval: 0.77, 1.67). By contrast and contrary to hypothesis, higher 25(OH)D concentrations were associated with higher odds of gestational hypertension: adjusted odds ratio for gestational hypertension was 1.32 (95% confidence interval: 1.01, 1.72) per each 25nmol/L increment in 25(OH)D. Vitamin D intake patterns suggest this association was not because of reverse causation. While the elevated hypertension risk may be due to chance, randomized trials of vitamin D supplementation during pregnancy should monitor for gestational hypertension.
These data do not support the hypothesis that higher 25(OH)D levels lower the overall risk of hypertensive disorders of pregnancy.
PMCID: PMC4011985  PMID: 24631523
Pregnancy; Pre-Eclampsia; Hypertension; Pregnancy-Induced; Vitamin D; 25-hydroxyvitamin D
16.  Participant characteristics and intervention processes associated with reductions in television viewing in the High Five for Kids study 
Preventive medicine  2014;62:64-70.
To evaluate the High Five for Kids intervention effect on television (TV) within subgroups, examine participant characteristics associated with process measures and assess perceived helpfulness of TV intervention components.
High Five (RCT of 445 overweight/obese 2–7 year-olds in Massachusetts [2006–2008]) reduced TV by 0.36 hours/day. 1-year effects on TV, stratified by subgroup, were assessed using linear regression. Among intervention participants (n=253), associations of intervention component helpfulness with TV reduction were examined using linear regression and associations of participant characteristics with processes linked to TV reduction (choosing TV and completing intervention visits) were examined using logistic regression.
High Five reduced TV across subgroups. Parents of Latino (v. white) children had lower odds of completing >=2 study visits (OR 0.39 [95%CI: 0.18, 0.84]). Parents of black (v. white) children had higher odds of choosing TV (OR: 2.23 [95% CI: 1.08, 4.59]), as did parents of obese (v. overweight) children and children watching >=2 hours/day (v. <2) at baseline. Greater perceived helpfulness was associated with greater TV reduction.
Clinic-based motivational interviewing reduces TV in children. Low cost education approaches (e.g., printed materials) may be well-received. Parents of children at higher obesity risk could be more motivated to reduce TV.
PMCID: PMC4106410  PMID: 24518002
18.  Maternal intake of vitamin D during pregnancy and risk of recurrent wheeze in children at 3 y of age1–3 
Vitamin D deficiency and asthma are common at higher latitudes. Although vitamin D has important immunologic effects, its relation with asthma is unknown.
We hypothesized that a higher maternal intake of vitamin D during pregnancy is associated with a lower risk of recurrent wheeze in children at 3 y of age.
The participants were 1194 mother-child pairs in Project Viva—a prospective prebirth cohort study in Massachusetts. We assessed the maternal intake of vitamin D during pregnancy from a validated food-frequency questionnaire. The primary outcome was recurrent wheeze, ie, a positive asthma predictive index (≥2 wheezing attacks among children with a personal diagnosis of eczema or a parental history of asthma).
The mean (±SD) total vitamin D intake during pregnancy was 548 ± 167 IU/d. By age 3 y, 186 children (16%) had recurrent wheeze. Compared with mothers in the lowest quartile of daily intake (median: 356 IU), those in the highest quartile (724 IU) had a lower risk of having a child with recurrent wheeze [odds ratio (OR): 0.39; 95% CI: 0.25, 0.62; P for trend <0.001]. A 100-IU increase in vitamin D intake was associated with lower risk (OR: 0.81; 95% CI: 0.74, 0.89), regardless of whether vitamin D was from the diet (OR: 0.81; 95% CI: 0.69, 0.96) or supplements (OR: 0.82; 95% CI: 0.73, 0.92). Adjustment for 12 potential confounders, including maternal intake of other dietary factors, did not change the results.
In the northeastern United States, a higher maternal intake of vitamin D during pregnancy may decrease the risk of recurrent wheeze in early childhood.
PMCID: PMC4406411  PMID: 17344501
Vitamin D; pregnancy; dietary intake; childhood wheeze; asthma
19.  To What Extent Is the Protective Effect of Breastfeeding on Future Overweight Explained by Decreased Maternal Feeding Restriction? 
Pediatrics  2006;118(6):2341-2348.
Previous studies have found that breastfeeding may protect infants against future overweight. One proposed mechanism is that breastfeeding, as opposed to bottle feeding, promotes maternal feeding styles that are less controlling and more responsive to infant cues of hunger and satiety, thereby allowing infants greater self-regulation of energy intake. The objective of this study was to determine the extent to which the protective effect of breastfeeding on future overweight is explained by decreased maternal feeding restriction.
We studied 1012 mother-infant pairs in Project Viva, an ongoing prospective cohort study of pregnant mothers and their children. The main exposure was breastfeeding duration, assessed at 1 year postpartum. At 3 years of age, the main outcomes were age- and gender-specific BMI z score and the sum of subscapular and triceps skinfold thicknesses, with overweight defined as a BMI ≥95th percentile. We defined maternal restriction of infant’s access to food as strongly agreeing or agreeing, with the following question from the Child Feeding Questionnaire: “I have to be careful not to feed my child too much.” To examine the association between breastfeeding duration and our outcomes, we used multivariate linear and logistic models, adjusting for several potential confounders. In subsequent models, we also adjusted for maternal restriction of infant’s access to food.
The mean duration of breastfeeding was 6.5 months, and 12% of women strongly agreed or agreed with the restriction question. At age 3, mean for BMI z score was 0.47. Each 3-month increment in breastfeeding duration was associated with a reduction of 0.045 BMI z score. After adjusting for maternal restriction, the estimate was −0.039, a 13% attenuation.
The protective effect of breastfeeding on future overweight seems to be explained only partially by decreased maternal feeding restriction.
PMCID: PMC4406417  PMID: 17142517
breastfeeding; body mass index; BMI; infant feeding; maternal feeding restriction
20.  Prenatal Air Pollution Exposure and Newborn Blood Pressure 
Environmental Health Perspectives  2015;123(4):353-359.
Air pollution exposure has been associated with increased blood pressure in adults.
We examined associations of antenatal exposure to ambient air pollution with newborn systolic blood pressure (SBP).
We studied 1,131 mother–infant pairs in a Boston, Massachusetts, area pre-birth cohort. We calculated average exposures by trimester and during the 2 to 90 days before birth for temporally resolved fine particulate matter (≤ 2.5 μm; PM2.5), black carbon (BC), nitrogen oxides, nitrogen dioxide, ozone (O3), and carbon monoxide measured at stationary monitoring sites, and for spatiotemporally resolved estimates of PM2.5 and BC at the residence level. We measured SBP at a mean age of 30 ± 18 hr with an automated device. We used mixed-effects models to examine associations between air pollutant exposures and SBP, taking into account measurement circumstances; child’s birth weight; mother’s age, race/ethnicity, socioeconomic position, and third-trimester BP; and time trend. Estimates represent differences in SBP associated with an interquartile range (IQR) increase in each pollutant.
Higher mean PM2.5 and BC exposures during the third trimester were associated with higher SBP (e.g., 1.0 mmHg; 95% CI: 0.1, 1.8 for a 0.32-μg/m3 increase in mean 90-day residential BC). In contrast, O3 was negatively associated with SBP (e.g., –2.3 mmHg; 95% CI: –4.4, –0.2 for a 13.5-ppb increase during the 90 days before birth).
Exposures to PM2.5 and BC in late pregnancy were positively associated with newborn SBP, whereas O3 was negatively associated with SBP. Longitudinal follow-up will enable us to assess the implications of these findings for health during later childhood and adulthood.
van Rossem L, Rifas-Shiman SL, Melly SJ, Kloog I, Luttmann-Gibson H, Zanobetti A, Coull BA, Schwartz JD, Mittleman MA, Oken E, Gillman MW, Koutrakis P, Gold DR. 2015. Prenatal air pollution exposure and newborn blood pressure. Environ Health Perspect 123:353–359;
PMCID: PMC4384198  PMID: 25625652
21.  Effect of Treatment of Gestational Diabetes Mellitus on Obesity in the Next Generation 
Diabetes Care  2010;33(5):964-968.
Gestational diabetes mellitus (GDM) may cause obesity in the offspring. The objective was to assess the effect of treatment for mild GDM on the BMI of 4- to 5-year-old children.
Participants were 199 mothers who participated in a randomized controlled trial of the treatment of mild GDM during pregnancy and their children. Trained nurses measured the height and weight of the children at preschool visits in a state-wide surveillance program in the state of South Australia. The main outcome measure was age- and sex-specific BMI Z score based on standards of the International Obesity Task Force.
At birth, prevalence of macrosomia (birth weight ≥4,000 g) was 5.3% among the 94 children whose mothers were in the intervention group, and 21.9% among the 105 children in the routine care control group. At 4- to 5-years-old, mean (SD) BMI Z score was 0.49 (1.20) in intervention children and 0.41 (1.40) among controls. The difference between treatment groups was 0.08 (95% CI −0.29 to 0.44), an estimate minimally changed by adjustment for maternal race, parity, age, and socio-economic index (0.08 [−0.29 to 0.45]). Evaluating BMI ≥85th percentile rather than continuous BMI Z score gave similarly null results.
Although treatment of GDM substantially reduced macrosomia at birth, it did not result in a change in BMI at age 4- to 5-years-old.
PMCID: PMC2858199  PMID: 20150300
22.  Predicting Prediabetes and Diabetes 
PMCID: PMC4350017  PMID: 20124151
23.  Compliance with the Baby-Friendly Hospital Initiative and impact on breastfeeding rates 
To examine compliance with the Baby-Friendly Hospital Initiative (BFHI) as well as evaluate the BFHI and its components on breastfeeding initiation and duration overall and according to maternal education level.
Quasi-experimental study using data from the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2004 to 2008.
Birth facilities in Maine.
915 mothers who gave birth in four hospitals that were BFHI-accredited or became accredited and 1099 mothers from six matched non-BFHI facilities. Mothers reported on seven (of 10) BFHI practices (breastfeeding practice score 0–7) and receipt of a gift pack with formula (yes/no).
Main outcome measures
Self-report of breastfeeding initiation, any breast feeding for ≥4 weeks, exclusive breast feeding for ≥4 weeks.
34.6% of mothers from BFHI-accredited facilities reported experiencing all seven BFHI breastfeeding practices, while 28.4% reported being given a gift pack with formula. Among mothers with lower education, the BFHI increased breastfeeding initiation by 8.6 percentage points (adjusted coefficient, 0.086 [95% CI, 0.01 to 0.16]) and, independently, each additional breastfeeding practice was associated with an average increase in breastfeeding initiation of 16.2 percentage points (adjusted coefficient, 0.162 [95% CI, 0.15 to 0.18]). Among all mothers and mothers with higher education, there was no effect of the BFHI on breastfeeding rates.
Compliance with BFHI practices among BFHI-accredited facilities is not optimal and needs to be monitored, as greater compliance may have an even larger impact on breastfeeding rates and potentially reduce socio-economic disparities in breast feeding.
PMCID: PMC4090088  PMID: 24277661
24.  Assessing care providers’ perceptions and beliefs about physical activity in infants and toddlers: baseline findings from the Baby NAP SACC study 
BMC Public Health  2015;15:100.
As children now spend increasing amounts of time in out-of-home care, care providers play an important role in promoting positive health behaviors. Little is currently known about providers’ perceptions and beliefs about physical activity, particularly for very young children. This study describes providers’ perceptions and beliefs about infants’ and toddlers’ physical activity, and assesses their knowledge of physical activity guidelines, to establish if and where providers may need support to promote physical activity in child care settings.
We analyzed baseline data from a pilot randomized-controlled trial conducted in 32 child care centers in Massachusetts, USA. Providers completed physical activity-related questionnaires from which we compared twenty perception and belief questions for infant and toddler care providers.
203 care providers (96% female, mean ± SD age: 32.7 ± 11.2 years) from 29 centers completed questionnaires. A large proportion of providers (n = 114 (61.9%)) believed that infants should be active for 45 minutes or less each day, and only 56 providers (29.7%) perceived toddlers to require more than 90 minutes of activity per day. 97% of providers perceived it was their job to ensure children engaged in a healthy amount of physical activity and most (94.1%) perceived physical activity to be important to own their health, despite 13.3% finding it hard to find the energy to be physically active.
This study is the first to assess the physical activity perceptions and attitudes of providers caring for infants and toddlers. Though all providers believed toddlers should engage in more physical activity than infants, most providers believed that young children require only a short amount of physical activity each day, below recommended guidelines. How provider perceptions influence children’s physical activity behavior requires investigation.
PMCID: PMC4334406  PMID: 25886506
Infants; Toddlers; Physical activity; Child care; Baby NAPSACC
25.  Effects of Promoting Longer Term and Exclusive Breastfeeding on Cardiometabolic Risk Factors at Age 11.5 Years: A Cluster-Randomized, Controlled Trial 
Circulation  2013;129(3):321-329.
The duration and exclusivity of breastfeeding in infancy have been inversely associated with future cardiometabolic risk. We investigated the effects of an experimental intervention to promote increased duration of exclusive breastfeeding on cardiometabolic risk factors in childhood.
Methods and results
We followed-up children in the Promotion of Breastfeeding Intervention Trial, a cluster-randomized trial of a breastfeeding promotion intervention based on the World Health Organization/United Nations Children’s Fund Baby-Friendly Hospital Initiative. 17,046 breastfeeding mother-infant pairs were enrolled in 1996/7 from 31 Belarussian maternity hospitals and affiliated polyclinics (16 intervention vs 15 control sites); 13,879 (81.4%) children were followed-up at 11.5 years, with 13,616 (79.9%) fasted and without diabetes. The outcomes were blood pressure; fasting insulin, adiponectin, glucose and apolipoprotein A1; and presence of metabolic syndrome. Analysis was by intention to treat, accounting for clustering within hospitals/clinics. The intervention substantially increased breastfeeding duration and exclusivity compared with the control arm (43% vs. 6% and 7.9% vs. 0.6% exclusively breastfed at 3 and 6 months, respectively). Cluster-adjusted mean differences at 11.5 years between experimental vs control groups were: 1.0mmHg (95% CI: −1.1, 3.1) for systolic and 0.8mmHg (−0.6, 2.3) for diastolic blood pressure; −0.1mmol/l (−0.2, 0.1) for glucose; 8% (−3%, 34%) for insulin; −0.33μ/ml (−1.5, 0.9) for adiponectin; and 0.0g/l (−0.1, 0.1) for ApoA1. The cluster-adjusted odds ratio for metabolic syndrome, comparing experimental vs control groups, was 1.21 (0.85, 1.72).
An intervention to improve breastfeeding duration and exclusivity among healthy term infants did not influence cardiometabolic risk factors in childhood.
Clinical Trial Registration Information
Current Controlled Trials: ISRCTN37687716 (; Identifier: NCT01561612.
PMCID: PMC3946966  PMID: 24300437
Breastfeeding; lactation; blood pressure; fasting insulin; glucose; adiponectin; lipids; randomized controlled trial; childhood

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