Chris L. Kjolhede

High prepregnant body mass index is associated with poor lactation outcomes among white, rural women independent of psychosocial and demographic correlates.

To determine whether high prepregnant body mass index (BMI) is associated with later onset of lactogenesis II (LGII) and shorter duration of breastfeeding, we questioned 151 women about their demographic and psychosocial characteristics during pregnancy and about the onset of LGII during days 1 to 5 postpartum. Compared towomen with earlier (< 72 hours) onset of LGII, those with later onset had a higher BMI (P < .05), a higher proportion of primiparity (P < .01), and a lower infant score on the Mother-Baby Assessment (P < .05). Prepregnant BMI (P < .04) and primiparity (P < .005) were each associated with later onset of LGII, but only primiparity remained significant when both factors were considered simultaneously. These results suggest that, in addition to those who have just delivered their first infant, those with higher prepregnant BMI values also warrant extra support to decrease their risk of early discontinuation of breastfeeding. J Hum Lact. 20(1):18-29.

Clinical trial of vitamin A as adjuvant treatment for lower respiratory tract infections

OBJECTIVE To test the efficacy of a high dose of vitamin A as adjuvant treatment for radiographically confirmed cases of acute lower respiratory tract infection (ALRI). DESIGN Randomized, double-masked, placebo-controlled clinical trial. SETTING Two large urban hospitals in Guatemala City. PATIENTS Sequential sample of 263 children aged 3 to 48 months, identified in the emergency departments and admitted to the hospital. INTERVENTIONS Vitamin A (100,000 IU for children less than 1 year of age, and 200,000 IU for older children) or placebo in addition to standard treatment for ALRI which included antibiotics, oxygen, bronchodilators, and intravenously administered solutions. MEASUREMENTS AND MAIN RESULTS The children were assessed every 8 hours. There were neither statistically nor clinically significant differences by treatment group in the rate of normalization in respiratory rate, oxygen saturation, temperature, or clinical score. Duration of hospitalization was not different by treatment group. Adverse outcomes (mechanical ventilation, prolonged hospitalization, readmission or transfer, and death) were equally distributed between the two groups. CONCLUSIONS Treatment with high doses of vitamin A over and above standard care for infants and children with non-measles-related ALRI is not efficacious for the current episode. Additional trials among populations in which vitamin A deficiency is more prevalent and severe should be considered.

Interventions to increase the duration of breastfeeding in obese mothers: the Bassett Improving Breastfeeding Study.

OBJECTIVE Maternal obesity is associated with poor breastfeeding outcomes, yet no intervention has been developed to improve them. To ascertain whether increased breastfeeding support or provision of a breast pump is a feasible, effective intervention to improve breastfeeding, we enrolled obese women who intended to breastfeed in two randomized trials. METHODS In Bassett Improving Breastfeeding Study (BIBS) 1, 40 women received targeted breastfeeding support in the hospital and via telephone or usual care. Information regarding breastfeeding was collected via telephone for 7 days after delivery and at 30 and 90 days postpartum. In BIBS 2, 34 obese mothers received a manual or electric breast pump to use for 10-14 days or no pump; data collection was similar. RESULTS In both experiments, randomization failed to distribute women of differing postpartum body mass index adequately among the treatment groups. When analyses were adjusted for this, there was no difference in BIBS 1 between targeted and usual care groups and in BIBS 2 among the treatment groups in the proportion of women still breastfeeding at the times studied. CONCLUSIONS In future studies of obese women, stratified randomization may be necessary. Further development of interventions to help obese women achieve optimal breastfeeding outcomes is required.

Snacks, Sweetened Beverages, Added Sugars, and Schools

Concern over childhood obesity has generated a decade-long reformation of school nutrition policies. Food is available in school in 3 venues: federally sponsored school meal programs; items sold in competition to school meals, such as a la carte, vending machines, and school stores; and foods available in myriad informal settings, including packed meals and snacks, bake sales, fundraisers, sports booster sales, in-class parties, or other school celebrations. High-energy, low-nutrient beverages, in particular, contribute substantial calories, but little nutrient content, to a student’s diet. In 2004, the American Academy of Pediatrics recommended that sweetened drinks be replaced in school by water, white and flavored milks, or 100% fruit and vegetable beverages. Since then, school nutrition has undergone a significant transformation. Federal, state, and local regulations and policies, along with alternative products developed by industry, have helped decrease the availability of nutrient-poor foods and beverages in school. However, regular access to foods of high energy and low quality remains a school issue, much of it attributable to students, parents, and staff. Pediatricians, aligning with experts on child nutrition, are in a position to offer a perspective promoting nutrient-rich foods within calorie guidelines to improve those foods brought into or sold in schools. A positive emphasis on nutritional value, variety, appropriate portion, and encouragement for a steady improvement in quality will be a more effective approach for improving nutrition and health than simply advocating for the elimination of added sugars.

Obesity as a Risk Factor for Failure to Initiate and Sustain Lactation

It is well documented that socioeconomic status, education, race/ethnicity and social support are determinants of which women attempt to breastfeed their newborn infants.1 Although poor nutrition may compromise lactational performance,2 evidence has only recently emerged that overnutrition may also compromise lactation. Investigators in Australia3 studied women who had breastfed their infants for at least 2 wk and observed that those with a body mass index (BMI) value > 26 kg/m2 at 1 mo postpartum had 1.5 times the risk of early cessation of breastfeeding (BF) compared to those whose BMI was below this value. These findings are of particular concern because a high proportion of women have BMI values this high so soon after delivery. In addition, the proportion of women with higher BMI values is likely to grow with the increasing rates of obesity that have been observed in American women.4

Maternal Obesity: A Problem for Both Mother and Child

globulin, ovarian and adrenal androgen, and luteinizing hormone, and also because of altered insulin resistance” (5). Weight loss improves the probability of conception as it restores ovulation (6). Similarly, weight gain after one birth leads to an increase in waiting time to a subsequent conception (7). Paradoxically, obese women may also be at risk of unintended pregnancy from contraceptive failure (8). Together, these characteristics may make it more difficult for obese women to plan their pregnancies. Obese women have a significant excess risk for many complications during pregnancy, including gestational diabetes mellitus and preeclampsia (9,10). These risks increase with increasing maternal prepregnant BMI (3,10,11). Women with these complications are at risk of early development of chronic diseases (12). For instance, there is evidence that women who experience gestational diabetes mellitus are at excess risk of developing type 2 diabetes earlier than those who have not had this problem (13,14). This is also true for preeclampsia, chronic hypertension (15), and ischemic heart disease (12,16); however, the proportion of this long-term risk that is attributable to maternal obesity is unknown. Obese women are also more likely to undergo elective or emergency cesarean sections and to have their labor induced than normal-weight women (9). This results, in part, from their excess risk of delivering a large-for-gestational age infant (9). Cesarean delivery is more difficult in obese than normal-weight women (17) and is associated with excess risk of wound infection in obese women (9). Cesarean section itself is associated with a longer recovery than vaginal delivery as well as a delay in first putting the baby to the breast to nurse (18). Such delays may cause a reduction in the duration of breast-feeding (19), possibly because of a delay in the onset of copious milk secretion, although this association is not consistent (20–23). Finally, women who are obese at the time of conception are less likely to attempt breast-feeding (9,24). Among women whoever attempt to breast-feed their newborns, obese women are more likely than normal-weight women to cease breast-feeding in the first few days after delivery (25,26) and to breast-feed exclusively or to any extent for shorter periods (24–27). This association has been observed among white women in the United States (25) and elsewhere (24,27–29), Hispanic women in the United States (26) but not black women in the United States (26). Moreover, the heavier the woman, the shorter her duration of breast-feeding (29). High weight gain in pregnancy adds to the obese woman’s risk for shortened duration of breast-feeding (29,30). This reduction in breast-feeding may make it more difficult for obese women to return to their prepregnant weight postpartum. Obese women are more likely than normal-weight women to give birth to a large (>4,000 g or >90th percentile of weight-for-gestational age) baby (31,32). Having a large baby is associated with substantial obstetric morbidity (31). In addition, macrosomic babies suffer excess morbidity themselves (33), are more likely than normal-weight infants to have a low Apgar score at birth and be admitted to a special-care nursery, but they are equally likely to be breastfed (31). Of course, not all macrosomic babies are born to obese women. The latest nationally representative data show that 28.9% of American women of reproductive age (20–39 years old) are obese (BMI ≥ 30 kg/m2) and 8.0% have reached extreme obesity (BMI ≥ 40 kg/m2), an all-time high (1). These statistics are associated with other, equally disturbing trends. First, we have reached an all-time high in the proportion of women who deliver by cesarean section, 29.1% in 2004, the latest national data (2). Higher prepregnant BMI values are associated with a greater risk of cesarean delivery (3) and increases in maternal prepregnant weight as well as conditions associated with higher weight account for a substantial proportion of the recent increase in cesarean delivery (4). Second, we have also reached an all time in the proportion of children and adolescents who are overweight (≥95th percentile of ageand sex-specific BMI), 17.1% among 2–19 years olds (1). Much attention has recently been devoted to the tripling in childhood overweight that has occurred since 1980, with particular reference to genetic factors and lifestyle changes that might have contributed to this increase in prevalence. In this Perspective, we draw attention to the importance of obesity among women of reproductive age for their own later health as well as that of their children. Obese women may have difficulty becoming pregnant. This is thought to result from menstrual dysfunction and anovulation, “possibly because of altered secretion of pulsatile gonadotropinreleasing hormone, sex hormone–binding Maternal obesity: A Problem for both Mother and Child

Role of the school nurse in providing school health services

The American Academy of Pediatrics recognizes the important role school nurses play in promoting the optimal biopsychosocial health and well-being of school-aged children in the school setting. Although the concept of a school nurse has existed for more than a century, uniformity among states and school districts regarding the role of a registered professional nurse in schools and the laws governing it are lacking. By understanding the benefits, roles, and responsibilities of school nurses working as a team with the school physician, as well as their contributions to school-aged children, pediatricians can collaborate with, support, and promote school nurses in their own communities, thus improving the health, wellness, and safety of children and adolescents.

A description of lactation counseling practices that are used with obese mothers.

Maternal overweight and obesity are associated with failure to initiate breastfeeding successfully and to sustain breastfeeding adequately. The purpose of this study was to describe how health care providers counsel obese mothers about breastfeeding. The authors surveyed (by telephone or in-person interview) health care providers who counsel mothers about breastfeeding in rural upstate New York (n = 89). They also surveyed lactation consultants (n = 31) from New York, New Jersey, Florida, Nebraska, California, and Texas by e-mail. The authors found that the majority of health care providers surveyed neither believed that there was a difference in the success rate between obese mothers and normal-weight mothers nor advised obese mothers differently about breastfeeding. Given the excess risk for premature lactation failure among obese women, these findings suggest that those who care for such women need to be made aware of this risk so that they can develop and provide appropriate services.

Breastfeeding Duration and Weight Gain Trajectory in Infancy

BACKGROUND AND OBJECTIVES: Short breastfeeding duration may exacerbate accelerated early growth, which is linked to higher obesity risk in later life. This study tested the hypothesis that infants at higher risk for obesity were more likely to be members of a rising weight-for-length (WFL) z score trajectory if breastfed for shorter durations. METHODS: This prospective, observational study recruited women from an obstetric patient population in rural central New York. Medical records of children born to women in the cohort were audited for weight and length measurements (n = 595). We identified weight gain trajectories for infants’ WFL z scores from 0 to 24 months by using maximum likelihood latent class models. Individual risk factors associated with weight gain trajectories (P ≤ .05) were included in an obesity risk index. Logistic regression analysis was performed to investigate whether the association between breastfeeding duration (<2 months, 2–4 months, >4 months) and weight gain trajectory varied across obesity risk groups. RESULTS: Rising and stable weight gain trajectories emerged. The obesity risk index included maternal BMI, education, and smoking during pregnancy. High-risk infants breastfed for <2 months were more likely to belong to a rising rather than stable weight gain trajectory (odds ratio, 2.55; 95% confidence interval, 1.14–5.72; P = .02). CONCLUSIONS: Infants at the highest risk for rising weight patterns appear to benefit the most from longer breastfeeding duration. Targeting mothers of high-risk infants for breastfeeding promotion and support may be protective against overweight and obesity during a critical window of development.

Medical versus nonmedical immunization exemptions for child care and school attendance

Routine childhood immunizations against infectious diseases are an integral part of our public health infrastructure. They provide direct protection to the immunized individual and indirect protection to children and adults unable to be immunized via the effect of community immunity. All 50 states, the District of Columbia, and Puerto Rico have regulations requiring proof of immunization for child care and school attendance as a public health strategy to protect children in these settings and to secondarily serve as a mechanism to promote timely immunization of children by their caregivers. Although all states and the District of Columbia have mechanisms to exempt school attendees from specific immunization requirements for medical reasons, the majority also have a heterogeneous collection of regulations and laws that allow nonmedical exemptions from childhood immunizations otherwise required for child care and school attendance. The American Academy of Pediatrics (AAP) supports regulations and laws requiring certification of immunization to attend child care and school as a sound means of providing a safe environment for attendees and employees of these settings. The AAP also supports medically indicated exemptions to specific immunizations as determined for each individual child. The AAP views nonmedical exemptions to school-required immunizations as inappropriate for individual, public health, and ethical reasons and advocates for their elimination.