Panagiota Kitsantas

Evaluation of breastfeeding promotion, support, and knowledge of benefits on breastfeeding outcomes:

We examined how prenatal exposure to breastfeeding information from various media sources, maternal knowledge of benefits, family and clinician support, and peer practices influence breastfeeding outcomes in early infancy. Initiation of breastfeeding, any breastfeeding at two months, and exclusivity of breastfeeding at two months were examined in a cohort of US women using data from the Infant Feeding Practices Study II. Descriptive statistics, chi-square analyses and logistic regression were conducted. Approximately 85 percent of the women initiated breastfeeding. At two months, 63.8 percent continued breastfeeding, while only 38.1 percent breastfed exclusively. Mothers with greater knowledge about breastfeeding benefits were 11.2 (95% CI: 6.87–18.45) times more likely to initiate breastfeeding and 5.62 (95% CI: 4.19–7.54) times more likely to breastfeed at two months than those with lower levels of knowledge. Women whose families prenatally supported exclusive breastfeeding were 8.21(5.12–13.2) times more likely to initiate and continue breastfeeding (OR 3.21, 95% CI: 2.51–4.11). Clinicians who supported breastfeeding only also increased the odds of a woman initiating breastfeeding (OR 1.95, 95% CI: 1.31–2.88). Interventions to increase maternal knowledge of breastfeeding benefits and family and clinician support of breastfeeding in the prenatal period may help increase breastfeeding rates. The encouragement of breastfeeding needs to be a priority among health care providers to improve the health of mothers and infants.

Maternal obesity, health status during pregnancy, and breastfeeding initiation and duration

Objective. The purpose of this study was to determine whether maternal prepregnancy overweight/obesity has independent effects on breastfeeding initiation and duration and whether these effects are different for women who experience medical problems during pregnancy or labor/delivery complications in comparison with those who have no medical or labor/delivery complications. Methods. We used the early childhood longitudinal study-birth cohort data. Kaplan–Meier survival functions, logistic, and Cox regression modeling were used in the analyses. Results. Findings indicate that overweight/obese women with medical or labor/delivery complications were less likely to initiate breastfeeding in comparison with their counterparts of normal weight. We did not find an independent effect of prepregnancy overweight/obesity on breastfeeding initiation among women with no medical problems. This group of women, however, had an 11% increased risk of stopping breastfeeding with each additional month of breastfeeding duration in comparison to those of normal weight. Conclusions. It is important to evaluate the health history and pregnancy complications among overweight/obese mothers in developing interventions for successful initiation and duration of breastfeeding.

Using classification trees to assess low birth weight outcomes

OBJECTIVE Low birth weight (LBW) is a major public health problem. Compared to normal weight infants, LBW is positively associated with infant mortality and negatively associated with normative childhood cognitive and physical development. In the past two decades, research has identified important risk factors of LBW. In this study, we used classification trees to study the interactive nature of these factors. In particular we: (1) identify subgroups of women who are at a high risk of a LBW outcome in seven geographical regions of Florida, and (2) study the predictive performance of classification trees by comparing the tree-based results to those obtained using logistic regression. METHODS The data, 181,690 singleton births, were derived from Florida birth certificates recorded in 1998. Classification trees and logistic regression models were built based on seven geographical regions. The outcome variable consisted of two classes, namely LBW (< 2500 g) and normal birth weight (> or = 2500 g) cases, while a large number of known risk factors was examined. Tree and logistic regression models were compared using Receiving Operating Curves, and sensitivity and specificity analyses. RESULTS The use of classification trees has revealed a number of high-risk subgroups. For instance, White, Hispanic or Other non-white mothers who were healthy and smoked with a weight gain less than 20 lbs had a higher risk of a LBW birth compared to those with the same characteristics but with a weight gain of more than 20 lbs. Factors such as parity and marital status were important predictors for pregnancy outcomes among nonsmoker White, Hispanic or Other non-white mothers. Furthermore, we found that Black mothers were directly classified as a high-risk subgroup in the regions of Panhandle, Northeast, North Central, while in the Southern regions a series of other characteristics further defined the high-risk subgroup of Black mothers. Overall, the differences in predictive performance between tree models and logistic regression were minimal. CONCLUSION The present study demonstrated that classification trees can be used to identify high-risk subgroups of mothers who are at risk of LBW outcomes. Although these exploratory tree analyses revealed a number of distinctive variable interactions for each geographical area, the variable selection was similar across all seven regions. This study also demonstrated that classification trees did not outperform logistic regression models or vice versa; both approaches provided useful analyses of the data.

Clinical Practice Guidelines for Feeding Behaviors and Weight-for-Age at 12 months: A Secondary Analysis of the Infant Feeding Practices Study II

BACKGROUND The World Health Organization has identified childhood obesity as a major threat to global health. Accumulating evidence indicates that excess weight early in life is predictive of later childhood and adolescent obesity. Clinical practice guidelines for infant feeding behaviors have been developed by national and international health organizations. The relationship between these guidelines and infant weight status has not been established. AIM To examine the relationship between weight-for-age at 1 year and adherence to four clinical practice guidelines for feeding behaviors: no bottle-to-bed, minimal juice consumption, breastfeeding throughout the first year of life, and introduction to solid food no earlier than age 4-6 months. METHODS Data were obtained from the Infant Feeding Practices Study II, a longitudinal, national survey administered by the U.S. Food and Drug Administration and Centers for Disease Control and Prevention that followed mother-infant dyads from pregnancy through 1 year postpartum. The sample was comprised of 691 infants for whom 12-month survey data were available. RESULTS Significant associations with weight-for-age were found for juice consumption (p= 0.003), breastfeeding during the second half of infancy (p < 0.001), and introduction to solid foods prior to age 4 months (p < 0.001). A regression model that controlled for infant and maternal characteristics demonstrated that these feeding behaviors remained significant predictors of weight-for-age at 12 months. CONCLUSIONS AND IMPLICATIONS Modifiable infant feeding behaviors contributed to weight-for-age at 1 year. Replication studies with economically and culturally diverse samples are needed. Further, testing longitudinal interventions that address infant feeding practices is likely to yield the evidence needed for shaping future clinical practice guidelines that reduce the risk for childhood obesity and related pediatric comorbidities.

Postpartum Depression, Infant Feeding Practices, and Infant Weight Gain at Six Months of Age

INTRODUCTION This study examined postpartum depression (PPD) as a potential risk factor for non-adherence to infant feeding guidelines and subsequent infant weight gain. METHODS Participants were mother-infant dyads from the Infant Feeding Practices Study II (N = 1447). Main study variables were PPD, breastfeeding intensity, addition of cereal to infant formula, and age of introduction to solid foods. RESULTS In logistic models adjusted for sociodemographic factors, mothers with PPD were 1.57 times (95% confidence interval [CI]: 1.16, 2.13) more likely to breastfeed at low intensity and 1.77 times (95% CI: 1.16, 2.68) more likely to add cereal to infant formula. Although PPD was associated with the early introduction to solid foods (odds ratio: 1.42; 95% CI: 1.07, 1.89), this relationship was not significant after adjusting for potential confounders. A small but significantly greater average weight gain at 6 months was observed among infants of mothers with PPD (10.15 lb, SD = 2.32 vs. 9.85 lb, SD = 2.32). DISCUSSION Screening for PPD at well-child visits may lead to improved maternal health outcomes and the prevention of early life risk factors for childhood obesity.

Prepregnancy body mass index, socioeconomic status, race/ethnicity and breastfeeding practices

Abstract Objective: While socioeconomic status (SES) and race/ethnicity are known predictors of breastfeeding practices, the added disparity caused by the rising rates of obesity among women of childbearing age remains untested. The purpose of this study was to examine differences in breastfeeding initiation and duration among black, white and Hispanic women of low and middle SES within the context of prepregnancy body mass index (BMI). Methods: Data from the Early Childhood Longitudinal Study-Birth Cohort were analyzed. Adjusted logistic regression models were built to examine differences in breastfeeding initiation and duration for the three racial/ethnic groups of low and middle SES. Results: Normal BMI Hispanic women of low SES demonstrated higher rates of breastfeeding initiation (74%) compared to other groups. Overweight/obese black women of low SES had lower rates of breastfeeding initiation. Overweight/obese Hispanic women of middle SES were significantly less likely to continue breastfeeding up to 4 months (OR: 0.65, 95% CI: 0.41, 0.98) compared to their white counterparts. Among women who initiated breastfeeding, overweight/obese white women of low SES had the highest rate of stopping within two months of giving birth (66.7%). Conclusions: Examination of SES and racial/ethnic differences within the context of prepregnancy weight revealed specific groups with low rates of breastfeeding initiation and duration. Interventions tailored for these at-risk groups are needed to increase the overall proportion of mothers and infants who benefit from the positive health outcomes associated with breastfeeding.

Availability and capacity of substance abuse programs in correctional settings: A classification and regression tree analysis

UNLABELLED OBJECTIVE TO BE ADDRESSED: The purpose of this study was to investigate the structural and organizational factors that contribute to the availability and increased capacity for substance abuse treatment programs in correctional settings. We used classification and regression tree statistical procedures to identify how multi-level data can explain the variability in availability and capacity of substance abuse treatment programs in jails and probation/parole offices. METHODS The data for this study combined the National Criminal Justice Treatment Practices (NCJTP) Survey and the 2000 Census. The NCJTP survey was a nationally representative sample of correctional administrators for jails and probation/parole agencies. The sample size included 295 substance abuse treatment programs that were classified according to the intensity of their services: high, medium, and low. The independent variables included jurisdictional-level structural variables, attributes of the correctional administrators, and program and service delivery characteristics of the correctional agency. RESULTS The two most important variables in predicting the availability of all three types of services were stronger working relationships with other organizations and the adoption of a standardized substance abuse screening tool by correctional agencies. For high and medium intensive programs, the capacity increased when an organizational learning strategy was used by administrators and the organization used a substance abuse screening tool. Implications on advancing treatment practices in correctional settings are discussed, including further work to test theories on how to better understand access to intensive treatment services. This study presents the first phase of understanding capacity-related issues regarding treatment programs offered in correctional settings.

Life Stressors and Barriers to Timely Prenatal Care for Women with High-Risk Pregnancies Residing in Rural and Nonrural Areas

PURPOSE To identify the contribution of life stressors and barriers to the untimely initiation of prenatal care for women with high-risk pregnancies living in rural and nonrural areas. METHODS Data collected in 10 U.S. states by the 2006-2008 Pregnancy Risk Assessment Monitoring System (PRAMS) were used (n = 34,161). Data were weighted to reflect the PRAMS complex survey design. Separate logistic regression models derived adjusted odds ratios for untimely prenatal care initiation based on several life stressors and barriers. RESULTS Women with high-risk pregnancies living in rural areas were more likely to report late initiation of prenatal care (17.5% vs. 14.6%). The most frequently reported life stressors were the same for both cohorts: Moving, having a very sick family member, arguing more than usual with their partners, and having bills they could not pay. The most frequently cited barriers were also the same for both groups: Not having enough money or insurance for health care visits and not being able to get an appointment when they wanted one. Having two or more barriers increased the risk of late prenatal care initiation by 2.85-fold for rural women and 2.01-fold for nonrural women. CONCLUSION To increase timely prenatal care initiation, preconception interventions are needed that address common life stressors and barriers shared by women living in rural and nonrural areas.

Chronic physical health conditions among children of different racial/ethnic backgrounds

OBJECTIVES It is estimated that 20% of children in the USA are affected by at least one chronic disease. Although the burden of chronic conditions is greater for minority populations of children, research that has explored the prevalence and risk factors of chronic disease across different racial/ethnic groups is scarce. The aim of this study was to examine racial/ethnic disparities in the prevalence rates of common physical, chronic diseases in White, Black and Hispanic children; and assess the effect of several factors on the risk of having a chronic disease. METHODS Using the 2007 National Survey of Childrens Health, prevalence estimates were calculated for asthma, hearing impairment, visual impairment, joint/bone/muscle problems, brain injury and other illnesses for each racial/ethnic group. Multivariate logistic regression analyses were conducted to examine the effects of several risk factors on the risk of each of these health conditions. RESULTS The findings show that the prevalence for all health conditions was significantly higher (25.3%) among Black children than White (19.8%) and Hispanic (18.6%) children. Furthermore, 19.5% of Black children have had or currently have asthma compared with 12.2% of White and Hispanic children. More Black and Hispanic children were covered by public health insurance, while 19% of Hispanic children were currently uninsured. White children whose mothers had a health problem were associated with asthma, hearing impairment, visual impairment and joint/bone/muscle problems, while Black children were more likely to report asthma and Hispanics reported visual impairment and joint/bone muscle problems. Hispanic children who were living in poverty or were uninsured were at lower risk for any chronic disease. Regardless of race/ethnicity, children living in a single-parent household were more likely to be associated with any health condition. CONCLUSIONS This study provides evidence that racial/ethnic disparities in chronic physical conditions and health care among US children are extensive. It underscores that uninsured children who do not have access to the healthcare system are not being screened for chronic diseases, or are not obtaining medical care for such health problems. Healthcare providers should educate families about prevention measures and community services that might be able to assist them in improving the health of their children.

Classification tree analysis of stunting in Malian adolescent girls

This study examines relationships between growth data and energy expenditure, economic status, and family structure among Malian adolescent girls, aged 10–17 years living in the Segou Region of Mali. Classification and regression trees (CART) were used as the primary methodology to identify high‐risk subgroups for stunting (measured as height‐for‐age) in a sample of 1,103 Malian adolescents. Because CART has been used rarely to examine growth and development, this study provides a new way to better understand how economic status, family structure, and energy expenditure related factors influence stunting in Mali. The findings indicate that the greater the number of sisters and women in a household, the poorer the nutritional status of adolescent girls. The data also show that the presence of servants within the household may predict better nutritional success of young girls. Energy expenditure was an important predictor in the context of family structure regarding the number of sisters and the presence of servants. Wealth indicators did not appear in the final tree, suggesting that wealth may not play as great a role in predicting poor growth and nutritional status as family size and structure. In conclusion, classification trees may assist in understanding the interactive nature of predictive factors of stunting in this population, and further provide evidence for intervention programs aimed at improving the health and nutritional status of Malian adolescent girls. Am. J. Hum. Biol., 2008.