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Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration.To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program.This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data.A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school.Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used.The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months.The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects.ClinicalTrials.gov Identifier: NCT03556462.

BackgroundLiterature on autism spectrum disorder (ASD) suggestslowerASD prevalence andhigherage of diagnosis among children of color, from lower socioeconomic backgrounds, and from families with lower educational levels. These disparities have been attributed to factors such as limited access to diagnostic and treatment services, less opportunity for upward mobility to locales with ample resources, and linguistic barriers. However, few studies describe prevalence and geographic differences of ASD diagnoses by English Language Learner (ELL) status.ObjectivesThe primary objectives of this study are to (1) spatially explore the prevalence of ASD among New York State school districts and (2) examine differences of ASD prevalence rates between ELLs and native English-speaking peers.MethodsUsing the 2016–2017 district-level data on public and non-public school age students (3–21 years old) receiving special education services in New York, we analyzed sociodemographic trends among school districts with varying percentages (low, medium, and high ranges) of students with ASD and ELLs. To do this, we conducted exploratory spatial analyses using GIS software, analysis of school district level demographic data, and multivariate linear regression.ResultsIn contrast to prior research on ASD prevalence among minority groups, we found disproportionately higher rates of ASD among school districts with higher proportions of Black and Hispanic students. Geographic analysis revealed statistically significant clustering of school districts with high ASD rates in New York City and Albany. Higher proportions of ELLs tended to be concentrated in densely populated, urban, and geographically smaller school districts and had higher proportions of Black, Hispanic, and Asian students.ConclusionsSchools with higher rates of ASD and ELL students tend to be concentrated in urban regions throughout New York and have higher representation of Black and Hispanic/Latino students, as well as higher rates of learning disabilities in general. Further research is warranted to explore possible reasons for this phenomenon.

Sociopolitical events impact population health; parents' perspective of such events crosses demographics, geography, and generations. We elicited changes in U.S. parents' hopes and worries for their children 1 year after the 2016 election via an online survey of school climate, discrimination against child, family health care and security, and macrolevel/future concerns (e.g., environment, postsecondary options). Among n = 1189 respondents, national security (39%), the environment (30.5%), and "continued place in America" (25.7%) were most worrisome. In general linear mixed models, employment buffered against social and material stressors such as discrimination (odds ratio [OR] = 0.67; 95% confidence interval [CI] = 0.49-0.92), and family health care/security (OR = 0.62; 95% CI = 0.45-0.86) while being of a dominant religion and ethnicity buffered future macrolevel (Christianity, OR = 70; 95% CI = 0.54-0.92/non-Hispanic, OR = 59; 95% CI = 0.39-0.90) and existential "continued place in America" (Christianity, OR = 69; 95% CI = 0.51-0.94/non-Hispanic, OR = 56; 95% CI = 0.36-0.88) worries. Qualitative comments underscored macrolevel worries. Parents represent a unique vantage for gauging how sociopolitical events impact health and well-being.

OBJECTIVE: To ascertain how sleep health knowledge is translated to early care and education (ECE) programs, using a multi-component environmental scan. METHODS: A website scan identified organizations’ sleep content re: recommended practices, developmental effects, and “actionable” ratings (0–2). ECE staff surveys assessed preparedness, practices, and beliefs about addressing sleep health and sleep problems in ECE programs. Semi-structured interviews with stakeholders from the ECE, pediatric and sleep communities assessed awareness, priorities, and practices at their organizations. RESULTS: Of 15 websites scanned, half lacked sleep content on links to development, optimal duration, or scientific background. ECE staff (n=31) were comfortable speaking to parents about healthy sleep, and with incorporating sleep education and guidance into ECE. Stakeholders (n=15) rated healthy sleep as a high relevance, but lower priority issue. Within ECE settings stakeholders reported that knowledge about specific links to health and development were poor, and that sleep health was often obscured by ‘safe sleep’ issues. Their recommendations included: linking sleep health to ‘hot topics’ such as obesity or preschool suspensions and expulsions, integrating it with the teaching of routines, and raising public awareness. CONCLUSION: Despite understanding that healthy sleep promotes school readiness, there is insufficient specific, actionable information in ECE training, programs, or policies. Findings suggest a need for an awareness campaign with clear, actionable messaging, dissemination of turnkey materials, and integration with policy and professional training systems. TRIAL REGISTRATION-: ClinicalTrials.Gov: NCT03556462

This paper reports on a randomized control trial involving children less than 3 years old and their mothers who were regarded at risk of maltreating their children by referral agencies. Mothers’ risk status derived from a heavy trauma burden (average exposure over the first 18 years of their lives to 10 possible adverse childhood experiences [ACEs] was >5), mental health challenges (15%–28% had experienced a prior psychiatric hospitalization), and prior removal of a child to foster care (20%). Mothers were randomly assigned to either a widely used parenting class known as Systematic Training for Effective Parenting (STEP) or the Group Attachment-Based Intervention (GABI), a multifamily 26-week treatment. The resulting mother–child pairs available for consideration in this baseline versus end-of-treatment report were 35 families in the STEP arm and 43 families in the GABI arm. The focus of this paper is the outcome measure of observed parent–child relationship assessed with the Coding of Interactive Behavior (Feldman, 1998) collected at baseline and end of treatment. In comparison to STEP, results indicated that GABI was linked to significant improvements in maternal supportive presence and dyadic reciprocity, and significant declines in maternal hostility and dyadic constriction (proxies for risk of child maltreatment). These medium-to large-sized effects remained significant even after controlling for mothers’ prior ACEs in analysis of covariance procedures. In addition, two small interaction effects of ACEs by treatment type were found, underlining the need for, and value of, treatments that are sensitive to parents’ traumatic histories.

Background This paper describes the design and methods of a multi-phase study to reduce early childhood caries and obesity in vulnerable South Asian (SA) immigrants in the United States. Early childhood caries and obesity are the most common diseases of early childhood. Risk factors for both diseases are rooted in early childhood feeding practices such as bottle feeding and intake of sweets and sweetened beverages. The Common Health/Risk Factor Approach to addressing oral health is widely promoted by the WHO and other policy makers. This approach recognizes links between oral health and other diseases of modernity. Our CHALO! (“Child Health Action to Lower Obesity and Oral health risk”--from a Hindi word meaning "Let's go!") study targets SA families at high risk for early childhood caries and obesity. CHALO! addresses common risk factors associated with these two common diseases of childhood. Methods This two part project includes a randomized controlled trial, and a Knowledge Translation campaign. A randomized controlled trial will enroll n = 360 families from pediatric practices serving South Asians in the New York metro area. The intervention group will receive home visits by SA community health workers at 6, 8, 10, 12, 14, and 16 months of age. Controls will receive culturally tailored educational material. Primary outcomes-- cariogenic and obesogenic feeding practices at 6, 12, and 18 months-- will be assessed with the MySmileBuddy iPad based tool. Secondary outcomes include: oral hygiene practices, anthropometrics, and caries incidence at 18 months. A public education campaign will focus on both families and health care providers. Discussion There are few Common Health/Risk Factor Approach published studies on obesity and oral health risk in children, despite health morbidity and costs associated with both conditions. CHALO! comprises a multi-level interventions designed to promote culturally competent, sustainable change. Trial registration ClinicalTrials.gov NCT03077425. Electronic supplementary material The online version of this article (10.1186/s12889-018-5317-9) contains supplementary material, which is available to authorized users.

Background: International Board Certified Lactation Consultants (IBCLCs) are associated with increased rates and duration of breastfeeding. Recent US legislation offers opportunities for private and public insurers to include IBCLC services as a covered benefit. Objective: To explore US states’ Medicaid coverage of IBCLC services following January 2014 legislative expansions of coverage for preventive health services. Methods: To assess IBCLC reimbursement practices, 20 states, stratified by Medicaid expansion (yes/no) and 3-month exclusive breastfeeding rates, were selected to participate. An electronic survey was sent to Medicaid and Maternal Health Directors, breastfeeding coordinators, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) coordinators between July and December 2014. Email follow-ups clarified missing or ambiguous responses. Results: Of the 15 states responding, 9 had Medicaid expansion. None of the states permitted IBCLCs to bill for services autonomously. In 9 states, IBCLC services were covered with some type of stipulation, for example, billing under a physician. Of the 9 states with IBCLC coverage, 7 had accepted Medicaid expansion. States with higher rates of exclusive breastfeeding were also more likely to provide IBCLC coverage. Conclusion: Recent legislative changes to public and private insurance that could expand coverage of IBCLCs have not yielded appreciable changes, particularly in states without Medicaid expansion. There is a need for research on the effects of adopting expanded coverage for IBCLCs and advocacy to do so.

Objectives Behavioral sleep problems (BSPs) are prevalent and consequential in young children. There is a need for screening tools that identify BSPs—which are often rooted in the parent-young child relationship—and typically respond to behavior management. Such a tool would increase capacity to identify and treat BSPs. We sought to validate a short-form version of the widely used Children's Sleep Habits Questionnaire (SF-CSHQ) that omitted items that would not be responsive to behavioral strategies. Methods The original 33-item CSHQ elicits parent report of "behaviorally-based" and "medically-based" sleep items (eg, parasomnias and sleep disordered breathing). We conducted analyses to develop a SF-CSHQ that excludes its "medically-based" items, to determine (a) the SF-CSHQ threshold score corresponding to the full CSHQ clinical cut-off score (≥41), and (b) preliminary validity of this SF-CSHQ. Data were re-analyzed from the original data that established the CSHQ's psychometric properties in 4–10 year olds, and a second dataset that established its validity in 24–66 month olds. Results In both datasets, a threshold score of 30 had correlations of 0.90–0.94 with the original cut-off. This 23-item SF-CSHQ cut-off functioned as well as the full CSHQ cut-off in discriminating between children with vs without a parent-reported behavioral sleep problem, and with vs without prolonged sleep latency (per actigraphy). Conclusion We established preliminary validity of modified version of the widely-used CSHQ. This SF-CSHQ may be useful for widening screening and first-line guidance for behavioral sleep problems in young children, among professionals who are not sleep medicine specialists.

This study examined women's perceptions of early infant feeding experiences and identified early postpartum barriers to successful breastfeeding.We conducted semistructured exit interviews at 6 months postpartum with a subsample of participants (n=67) enrolled in two randomized controlled trials of breastfeeding promotion. Study arms included (1) routine pre- and postnatal visits with an International Board Certified Lactation Consultant (IBCLC) (LC group), (2) electronically prompted guidance from prenatal care providers (EP group), (3) EP+LC combined, and (4) standard of care (control group). Interview transcripts were coded using grounded theory and analyzed in MAXqda. Code matrices were used to identify early postpartum breastfeeding barriers and were further examined in relation to treatment group using a mixed methods analysis.The majority of the participants reported experiencing at least one barrier to breastfeeding. Barriers to breastfeeding were more commonly reported in the early postpartum than late postpartum period. The most common barrier during the early postpartum period was the perception of inadequate milk supply ("lactational") (n=18), followed by problems with latch, medical problems that were perceived as precluding breastfeeding, and medical staff and hospital practices. Participants frequently reported that the IBCLCs assisted them in anticipating, managing, and overcoming these barriers.Our findings underscore the importance of integrating IBCLCs into routine pre- and postpartum care because they provide critical support that effectively addresses early postpartum barriers to breastfeeding.

Research suggests that in clinical samples, almost 1/2 of children with obstructive sleep apnea have a behavioral sleep problem, and of those, most do not receive behavioral recommendations. This study extends previous research via a longitudinal investigation of the presence and comorbidity of symptoms of sleep-disordered breathing (SDB) and behavioral sleep problems in a non-clinical sample. Findings were that the prevalence of symptoms of SDB and behavioral sleep problems at each of the 4 time points was nearly identical, with a peak age of 30 months, and that 25% to 40% of children with symptoms of SDB had behavioral sleep problems. Results suggest that an interdisciplinary approach, including behavioral expertise, is warranted even if the referral concern is solely SDB.

To examine the association between actual and perceived overweight/obese status and excess gestational weight gain (GWG). As part of an infant feeding trial, multi-ethnic lower and moderate income women-completed a checklist of current health conditions, including "overweight/obesity," "asthma," and "hypertension" while pregnant. Odds of excessive GWG per the Institute of Medicine guidelines in 'accurate' versus 'inaccurate' reporters, by overweight status were analyzed with multivariate logistic regression for women with pre-or early pregnancy BMIs of ≥18.5. 775 women met study criteria. Just 21 % (n = 107) of overweight/obese women accurately identified their weight status, compared to >90 % accurate report of documented hypertension or asthma. Compared to normal-weight accurate reporters, the adjusted odds of excessive GWG in overweight/obese women was 2.3 (95 % CI 1.4, 3.7) in accurate reporters, and 2.5 (95 % CI 1.7, 3.4) in inaccurate reporters. Overweight/obesity is associated with excessive GWG, but this risk is not modified by inaccurate reporting/perception of weight-status.

Women with gestational diabetes mellitus (GDM) and their infants are at increased risk of developing metabolic disease; however, longer breastfeeding is associated with a reduction in these risks. We tested an intervention to increase breastfeeding duration among women with GDM.We conducted a cluster randomized trial to determine the efficacy of a breastfeeding education and support program for women with GDM. Women were enrolled between 22 and 36 weeks of pregnancy and cluster randomized to an experimental lifestyle intervention or wait-list control group. Breastfeeding duration and intensity were prespecified secondary outcomes of the trial. Duration of exclusive and any breastfeeding was assessed at 6 weeks and at 4, 7, and 10 months postpartum. We quantified differences in breastfeeding rates using Kaplan-Meier estimates, log-rank tests, and Cox regression models.We enrolled 100 women, of whom 52% were African American, 31% non-Hispanic white, 11% Hispanic, 9% American Indian or Alaskan Native, 2% Asian, 2% other, and 4% more than one race. In models accounting for within-cluster correlation and adjusted for study site, breastfeeding intention, and African American race, women allocated to the intervention group were less likely to stop breastfeeding (adjusted hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.21-0.74) or to introduce formula (adjusted HR 0.50, 95% CI 0.34-0.72).Our results suggest that targeted breastfeeding education for women with GDM is feasible and efficacious.http://clinicaltrials.gov/ct2/show/NCT01809431.

Introduction: Sleep disorders affect up to 1 in 4 adults and can adversely affect a variety of health conditions. However, little is known about detection of sleep disorders in ethnically diverse urban primary care settings. Methods: Patients in urban primary care settings completed surveys to screen for sleep problems and identify comorbid conditions. Providers were given screening results, and provided feedback regarding their clinical utility. Results: Participants (n = 95) were predominantly women (76.8%) and black, non-Hispanic (46.3%), or Hispanic (38.9%). High proportion of participants screened positive for insomnia (31.6%) and screened high risk for sleep apnea (42.1%). Only one-third (32.6%) of participants reported sleeping the recommended 7 to 9 hours per night. The presence of chronic pain (χ2 = 4.97, P = .03) was associated with clinically significant insomnia. Obesity was associated with fewer hours of sleep per night, t = 2.19(87), P = .03, and risk for sleep apnea (OR = 3.11, 95% CI = 1.28-7.50). Participants were interested in receiving help for sleep issues during their primary care visits (40%), and providers found the screening at least somewhat useful (74.4%). Discussion: Results highlight the potentially high unmet need for screening and treatment of sleep problems in ethnically diverse urban primary care settings.

This study examined women's perceptions and reported effects of routine, primary care-based interventions to increase breastfeeding.A subsample (n=67) of participants in randomized controlled trials (RCTs) completed semistructured exit interviews at 6 months postpartum. RCT arms included the following: (a) routine pre-/postnatal lactation consultant (LC) support (LC group); (b) electronic prompts (EP) guiding providers to discuss breastfeeding during prenatal care visits (EP group); (c) a combined intervention (LC+EP group); and (d) controls. Interview transcripts were coded and analyzed in MAX.qda.Key findings included the following: (1) Brief, non-directive assessment of feeding via postpartum interviews focused attention upon feeding practices. When coupled with breastfeeding promotion interventions, interviews promoted breastfeeding. (2) The EP and LC interventions were complementary: EPs influenced initiation, while LCs helped overcome barriers and sustain breastfeeding. (3) Prenatal intent to feed both breastmilk and formula was associated with the greatest receptivity to study messages.Findings underscore the need for interventions across the continuum of care. Trained LCs in prenatal/postpartum settings and prenatal care providers play important complementary roles that, when coupled with brief telephone feeding assessments, may improve breastfeeding rates.

Developing effective recruitment and retention strategies in populations with traditionally high attrition rates is critical to the success of Randomized Controlled Trials (RCTs). Data on successful participation of women from low-income, minority populations in RCTs of behavioral interventions are limited. This is problematic given the multiplicity of Healthy People 2020 goals that target health disparities in these populations. This paper reports successful recruitment and retention methods from two separately funded NIH clinical trials of primary care-based prenatal interventions to increase breastfeeding among ethnically diverse, low-income women in urban medical centers in the Bronx, NY. It also presents the required staff effort necessary to conduct such a successful RCT, in terms of full-time equivalents (FTEs). Results include timely recruitment of 941 participants over 29 months, with 98.1% completing¯¯1 follow-up interview. A recruitment and retention plan that maximized study staff access and availability to the participant, as well as strong study staff rapport with participants, addressed previously reported barriers in this population, optimizing follow-up rates. A qualitative assessment of the participants' study experience suggesting that high retention was due to strong rapport with participants, short interviews requiring little time commitment, and participants' perception of the study as informative, provides further evidence of our approach's effectiveness. Logistical protocol procedures and staff management strategies relating to successful recruitment/retention are provided to propose a practical, cost-effective and translational recruitment-retention plan for other researchers to adopt.

OBJECTIVES: Examine statistical effects of sleep-disordered breathing (SDB) symptom trajectories from 6 months to 7 years on subsequent behavior. METHODS: Parents in the Avon Longitudinal Study of Parents and Children reported on children’s snoring, mouth breathing, and witnessed apnea at ≥2 surveys at 6, 18, 30, 42, 57, and 69 months, and completed the Strengths and Difficulties Questionnaire at 4 (n = 9140) and 7 (n = 8098) years. Cluster analysis produced 5 “Early” (6–42 months) and “Later” (6–69 months) symptom trajectories (“clusters”). Adverse behavioral outcomes were defined by top 10th percentiles on Strengths and Difficulties Questionnaire total and subscales, at 4 and 7 years, in multivariable logistic regression models. RESULTS: The SDB clusters predicted ≈20% to 100% increased odds of problematic behavior, controlling for 15 potential confounders. Early trajectories predicted problematic behavior at 7 years equally well as at 4 years. In Later trajectories, the “Worst Case” cluster, with peak symptoms at 30 months that abated thereafter, nonetheless at 7 years predicted hyperactivity (1.85 [1.30–2.63]), and conduct (1.60 [1.18–2.16]) and peer difficulties (1.37 [1.04–1.80]), whereas a “Later Symptom” cluster predicted emotional difficulties (1.65 [1.21–2.07]) and hyperactivity (1.88 [1.42–2.49]) . The 2 clusters with peak symptoms before 18 months that resolve thereafter still predicted 40% to 50% increased odds of behavior problems at 7 years. CONCLUSIONS: In this large, population-based, longitudinal study, early-life SDB symptoms had strong, persistent statistical effects on subsequent behavior in childhood. Findings suggest that SDB symptoms may require attention as early as the first year of life.

Study objectives To describe the prevalence, persistence, and characteristics associated with sleep disordered breathing (SDB) symptoms in a population-based cohort followed from 6 months to 6.75 years. Design Avon Longitudinal Study of Parents and Children (ALSPAC). Setting England, 1991-1999. Participants 12,447 children in ALSPAC with parental report of apnea, snoring, or mouth-breathing frequency on any one of 7 questionnaires. Measurements Symptom prevalence rates-assessed as "Always" and "Habitually"-are reported at 0.5, 1.5, 2.5, 3.5, 4.75, 5.75, and 6.75 years of age. The proportion of children in whom symptoms develop, persist or abate between observation points is reported. Exploratory multivariate analyses identified SDB risk factors at 1.5, 4.75, and 6.75 years. Results The prevalence of apnea ("Always") is 1%-2% at all ages assessed. In contrast, snoring "Always" ranges from 3.6% to 7.7%, and snoring "Habitually" ranges from 9.6% to 21.2%, with a notable increase from 1.5- 2.5 years. At 6 years old, 25% are habitual mouth-breathers. The "Always" and "Habitual" incidence of each symptom between time points is 1%-5% and 5%-10%, respectively. In multivariate analyses of combined symptoms, socioeconomic factors have stronger, more persistent effects upon increased SDB risk than gestational age, gender, or race (aside from 1.5 years); adenoidectomy decreases risk by 40%-50%. Conclusions This is the first natural history study of the primary symptoms of SDB across a key 6-year period in the development of SDB symptoms. Snoring rates are higher and spike earlier than previously reported. Symptoms are dynamic, suggesting the need for early and continued vigilance in early childhood.

Identifying early risk factors for childhood obesity is critical, as weight in infancy and early childhood tracks to later periods. Continued bottle use – primarily from excess milk intake – is emerging as a potential risk factor for early childhood overweight. Over three fourths of US infants drink from bottles beyond the recommended weaning age of 12 months, and two thirds of UK infants use a bottle at 18 months. This paper is divided into three parts. Part 1 reviews the literature on beverage intake, weight and bottle use in young children. Part II describes pilot data on milk bottle use and weight in 12–60‐month‐olds, collected prior to a randomized controlled (RCT) trial of a bottle‐weaning intervention. Median daily milk bottle consumption at 12 months was 5.0 (interquartile range = 3–6). Among 12–36‐month‐olds, current users were significantly more likely to be >95th% weight‐for‐height (19% vs. 0%, P 85% weight‐for‐height (27% vs. 11%, P

Translating evidence-based research into practice requires data from clinical trials in real world settings. This paper presents "lessons learned" from the implementation of an RCT of breastfeeding promotion interventions at two busy, urban, prenatal care sites. Data were obtained via direct observations, qualitative interviews, and study statistics. Primary challenges include: time and space burdens, "research vs. service" mission conflict, and the provider learning curve for conducting interventions. Primary facilitators include: researcher presence for enhancing rapport with participants and staff, site staff labeling of both the research interview and intervention as "value added time," and the ability of research staff to assist the clinic beyond the scope of the clinical trial. Specific suggestions are given for building collaborative bonds between the research team, clinicians, administrators, and staff in busy urban practices.

Objective: To determine the effect of adenoidectomy and/or tonsillectomy (“adenotonsillectomy”) upon growth and growth biomarkers, in the context of sleep disordered breathing (SDB). SDB in children, primarily due to adenotonsillar hypertrophy, increases the risk of growth failure. Design: Systematic review and meta-analysis. PubMed, ERIC and Cochrane Reviews databases from January 1980 to November 2007 were searched for studies reporting: pre/post-adenotonsillectomy height and weight changes as percentage increased or decreased, raw data, z scores or centiles, or: IGF-1 and/or IGFBP-3 serum-level changes as z scores or raw data. For anthropometrics, the meta-analysis included studies presenting z scores or centiles. Setting: Observational studies. Patients: Otherwise healthy children, not selected for obesity. Main outcome measures: Pre/post-surgery changes in standardised height and weight, and IGF-1 and IGFBP-3. Results: Of 211 citations identified, 20 met systematic review criteria. SDB was an enrolment criterion in 13 of the studies, and one of several enrolment criteria in three. Meta-analysis findings for pre/post-surgery changes were: standardised height: 10 studies, 363 total children, pooled standardised mean differences (SMD) = 0.34 (95% CI 0.20 to 0.47); standardised weight: 11 studies, 390 total children, pooled SMD = 0.57 (95% CI 0.44 to 0.70); IGF-1: 7 studies, 177 total children, pooled SMD = 0.53 (95% CI 0.33 to 0.73); IGFBP-3: 7 studies, 177 total children, pooled SMD = 0.59 (95% CI 0.34 to 0.83). Conclusions: Standardised height and weight, and IGF-1 and IGFBP-3 increased significantly after adenotonsillectomy. Findings suggest that primary care providers and specialists consider SDB secondary to adenotonsillar hypertrophy when screening, treating and referring children with growth failure.

The authors' objective was to determine whether cumulative weekly breastfeeding duration by 13 weeks was associated with infant otitis media, respiratory and gastrointestinal illness, and total illness visits up to 12 months. The authors performed a secondary analysis of data from a randomized clinical trial of low-income, primarily Hispanic and Black women enrolled from 2 medical center affiliated clinics. “Breastfeeding sensitive” (BFS) outpatient and emergency room (ER) visit data for the above illnesses were obtained for 255 mother/infant dyads. Outcome measures were unadjusted and adjusted rates of outpatient and ER visits with sick and BFS diagnoses. The authors found no significant associations between breastfeeding intensity and infant visits for otitis media, respiratory and gastrointestinal illness, or total illness visits. In this low-income, multiethnic sample, breastfeeding intensity was not associated with infant health service use, in contrast to other evidence-based reports. Low exclusive breastfeeding rates and lack of coverage for health visits may be reasons for this finding. J Hum Lact. 24(1):14-22.

We interviewed women who participated in a breast‐feeding promotion intervention study about whether and how participation affected their infant feeding choices, and if they would recommend such an intervention to others. The larger study, a randomized controlled trial (RCT) of an individualized, pre‐ and post‐natal lactation consultant (LC) intervention, enrolled 382 low‐income primarily Black and Hispanic women in New York City. Twenty‐one women completed qualitative exit interviews for this study (11 from the Intervention group and 10 Controls). Several of the Controls stated that the post‐partum study interviews were a source of support, and made them more conscious of how they fed their infant. The Intervention Group was asked about contacts with the study ‘Mother–Baby specialist’ (i.e. LC), including what was and wasn’t helpful. The Intervention Group participants described the Mother–Baby Specialist as key in their decision to initiate and maintain breastfeeding. They credit her direct skills and positive reinforcement with their confidence and perseverance to breastfeed. The success of the intervention is attributed to technical assistance from a trained lactation consultant within the context of a relationship built on encouragement, guidance and support.

To determine the prevalence of prolonged bottle feeding practices in young children, and its association with body mass index (BMI) and iron deficiency anemia (IDA), we conducted a cross-sectional survey study at 3 Bronx, NY, WIC sites. Caregivers of 95 predominantly Hispanic and African-Arnerican WIC-enrolled children aged 18-56 months presenting for recertification completed questionnaires. Half were overweight (>85th% BMI) and 36% were obese (>95th% BMI); 21% met CDC criteria for anemia. Two thirds (63%) received daily bottles of milk or sweet liquids. Daily bottle use ranged from 3 to 10 (mean=3.3, median=3). Bottle use was significantly associated with obesity (>95th% BMI, p85th% BMI, p

Objectives To examine independent associations between sleep-disordered breathing (SDB), sleep duration from birth through 6.75 years, and body mass index (BMI) through 15 years of age in a population-based cohort. Study design The Avon Longitudinal Study of Parents and Children collected parent questionnaire data on child sleep duration and SDB symptoms from birth through 6.75 years and child BMI from the Avon Longitudinal Study of Parents and Children research clinics (n = 1899). For SDB, logistic regression models—minimal, confounder, and confounder + sleep duration adjusted—examined associations with BMI at 7, 10, and 15 years of age. For short sleep duration (≤10th percentile), comparable SDB-adjusted models examined associations with BMI at 15 years of age. Results Children with the worst SDB symptoms vs asymptomatic children, had increased odds of overweight at 7 (OR = 2.08, 95% CI = 1.04-4.17), 10 (OR = 1.79, 95% CI = 1.02-3.16), and 15 years of age (OR = 2.25, 95% CI = 1.27-3.97) in models adjusted for sleep duration. Similarly, short sleep duration at ≈5-6 years was associated with overweight at 15 years, independent of SDB. Children with short sleep duration at 4.75 years were more likely to be overweight at 15 years in minimally (OR = 2.21, 95% CI = 1.52-3.20), confounder (OR = 1.99, 95% CI = 1.34-2.96), and SDB-adjusted (OR = 2.04, 95% CI = 1.36-3.04) models. Conclusions Both SDB and short sleep duration significantly and independently increase children's odds of becoming overweight. Findings underscore the potential importance of early identification and remediation of SDB, along with insufficient sleep, as strategies for reducing childhood obesity.

STUDY OBJECTIVES To evaluate a novel sleep education program for low-income preschool children and their families. DESIGN Randomized trial of an educational intervention. SETTING Community-based. PARTICIPANTS Head Start preschool families (n = 152) in greater Lansing and Detroit, Michigan. INTERVENTIONS Classrooms or Head Start sites were randomized to an intervention group (prompt intervention) versus a control group (delayed intervention). Parents attended a one-time, 45-min sleep education program and preschoolers received 2 w (320 total min) of classroom sleep curriculum. MEASUREMENTS Parent knowledge, attitudes, self-efficacy, and beliefs were assessed as the primary outcomes just before the 45-min sleep intervention, immediately postintervention, and approximately 1 mo postintervention. Parents reported their child's bedtimes and wake times on 7-day sleep diaries at baseline and at 1-mo follow-up. Average weeknight sleep durations and bedtimes served as secondary outcomes. RESULTS Linear mixed models showed a time × treatment effect for parents' knowledge, attitudes, and self-efficacy (each P < 0.05) but not beliefs. These improvements were found immediately postintervention but were not retained at 1-mo follow-up. Children in the intervention group improved their weeknight sleep duration at 1-mo follow-up by 30 min (11.0 ± 0.9 h vs. 10.5 ± 1.0 hours at baseline) compared to controls (10.4 ± 0.9 h versus 10.5 ± 0.9 h at baseline) (P = 0.04 for difference between groups). Children did not show statistically significant improvements in bedtime. CONCLUSIONS Educational interventions in early childhood can have an effect on parents' sleep knowledge, attitudes, and self-efficacy, and on children's sleep behavior. However, repeated exposure to the new information may be important for parents as well as their children.

The housing status of persons with HIV/AIDS is a central issue in their care and prognosis. We conducted eight focus groups to explore the housing needs of special populations of persons with HIV/AIDS in New York State; these populations included substance users, ex-offenders, persons with documented histories of homelessness, and rural dwellers/migrant workers. For the focus groups, 52 participants were recruited from the clientele of health and social service agencies. A major theme was the potent effect that housing situations had on participants’ health. Participants frequently attributed lowered T-cell counts and increased lethargy to the stress associated with governmental rules and paperwork. Lack of money, inadequacy of entitlements, and high costs of housing were the major barriers to securing stable and appropriate housing. Furthermore, participants experienced housing discrimination based on HIV status and experience with the criminal justice system or drugs.

Objectives. We determined the effectiveness of primary care–based, and pre- and postnatal interventions to increase breastfeeding. Methods. We conducted 2 trials at obstetrics and gynecology practices in the Bronx, New York, from 2008 to 2011. The Provider Approaches to Improved Rates of Infant Nutrition & Growth Study (PAIRINGS) had 2 arms: usual care versus pre- and postnatal visits with a lactation consultant (LC) and electronically prompted guidance from prenatal care providers (EP). The Best Infant Nutrition for Good Outcomes (BINGO) study had 4 arms: usual care, LC alone, EP alone, or LC+EP. Results. In BINGO at 3 months, high intensity was greater for the LC+EP (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.08, 6.84) and LC (OR = 3.22; 95% CI = 1.14, 9.09) groups versus usual care, but not for the EP group alone. In PAIRINGS at 3 months, intervention rates exceeded usual care (OR = 2.86; 95% CI = 1.21, 6.76); the number needed to treat to prevent 1 dyad from nonexclusive breastfeeding at 3 months was 10.3 (95% CI = 5.6, 50.7). Conclusions. LCs integrated into routine care alone and combined with EP guidance from prenatal care providers increased breastfeeding intensity at 3 months postpartum.

Bottle feeding beyond the recommended weaning age of 12 months is a risk factor for childhood obesity. This paper describes a sample of toddlers at high risk for obesity: prolonged bottle users from a low‐income multi‐ethnic community. We report here baseline mealtime and feeding behaviour, 24 h dietary recall and bottle intake data for Feeding Young Children Study (FYCS) participants, by overweight (≥85% weight‐for‐length) status. FYCS enrolled 12–13‐month‐olds from urban nutrition programmes for low‐income families in the United States who were consuming ≥2 bottles per day. Our sample was predominately Hispanic (62%), 44% of mothers were born outside of the United States and 48% were male. Overall, 35% were overweight. Overweight status was not associated with mealtime/feeding behaviours, bottle use or dietary intake. Most (90%) children ate enough, were easily satisfied and did not exhibit negative (e.g. crying, screaming) mealtime behaviours, per parent report. The sample's median consumption of 4 bottles per day accounted for 50% of their total calories; each bottle averaged 7 ounces and contained 120 calories. Mean daily energy intake, 1098.3 kcal day(−1) (standard deviation = 346.1), did not differ by weight status, nor did intake of fat, saturated fat, protein or carbohydrates. Whole milk intake, primarily consumed via bottles, did not differ by weight status. Thus, overweight 12–13‐month‐olds in FYCS were remarkably similar to their non‐overweight peers in terms of several obesity risk factors. Findings lend support to the set‐point theory and prior work finding that weight and intake patterns in the first year of life alter subsequent obesity risk.

We examined the prevalence of, and factors associated with unmet health service needs among persons with HIV disease. Data were examined from 1,851 participants in the U.S. AIDS Cost and Service Utilization Study, drawn from 26 medical care providers in 10 cities. Geographic areas with large numbers of AIDS cases, and health care providers within them were chosen as study sites. After completing a screener questionnaire, potential participants at each site were stratifed by illness stage, HIV exposure route, and insurance status; a systematic random sample within those strata were selected for the study. Participants completed a comprehensive survey of HIV-related service use and costs, which also asked them to identify unmet health service needs. Analyses identified the relationship between unmet needs and: stage of illness, type of insurance, source of care, living arrangement, and AIDS prevalence of respondents' geographic region. At least one unmet need was reported by 20% of the sample. Needs for non-institutional services, e.g., dental care, mental health, and medications were more likely to be unmet than need for emergency room and hospital care. While most factors significantly affected the odds of having an unmet need, the greatest effects were found for private insurance and HIV asymptomatic status, both of which decreased the odds of unmet needs by approximately 50%. These findings suggest that insurance coverage for services required during the chronic phase of HIV illness is inadequate and should be augmented.

Although Adverse Childhood Experiences (ACEs) are linked to increased health problems and risk behaviors in adulthood, there are no studies on the association between ACEs and adults' states of mind regarding their early childhood attachments, loss, and trauma experiences. To validate the ACEs questions, we analyzed the association between ACEs and emotional support indicators and Adult Attachment Interview (AAI) classifications in terms of unresolved mourning regarding past loss or trauma and discordant states of mind in cannot classify (U/CC) interviews. Seventy-five urban women (41 clinical and 34 community) completed a questionnaire on ACEs, which included 10 categories of abuse, neglect, and household dysfunction, in addition to emotional support. Internal psychological processes or states of mind concerning attachment were assessed using the AAI. ACE responses were internally consistent (Cronbach's α=.88). In the clinical sample, 84% reported≥4 ACEs compared to 27% among the community sample. AAIs judged U/CC occurred in 76% of the clinical sample compared to 9% in the community sample. When ACEs were≥4, 65% of AAIs were classified U/CC. Absence of emotional support in the ACEs questionnaire was associated with 72% of AAIs being classified U/CC. As the number of ACEs and the lack of emotional support increases so too does the probability of AAIs being classified as U/CC. Findings provide rationale for including ACEs questions in pediatric screening protocols to identify and offer treatment reducing the intergenerational transmission of risk associated with problematic parenting.

OBJECTIVES: To examine associations between sleep-disordered breathing (SDB) and behavioral sleep problems (BSPs) through 5 years of age and special educational need (SEN) at 8 years. METHODS: Parents in the Avon Longitudinal Study of Parents and Children reported on children’s snoring, witnessed apnea, and mouth-breathing at 6, 18, 30, 42, and 57 months, from which SDB symptom trajectories, or clusters, were derived. BSPs were based on report of ≥5 of 7 sleep behaviors at each of the 18-, 30-, 42-, and 57-month questionnaires. Parent report of SEN (yes/no) at 8 years was available for 11 049 children with SDB data and 11 467 children with BSP data. Multivariable logistic regression models were used to predict SEN outcome by SDB cluster and by cumulative report of SEN. RESULTS: Controlling for 16 putative confounders, previous history of SDB and BSPs was significantly associated with an SEN. BSPs were associated with a 7% increased odds of SEN (95% confidence interval [CI] 1.01–1.15), for each ∼1-year interval at which a BSP was reported. SDB, overall, was associated with a near 40% increased odds of SEN (95% CI 1.18–1.62). Children in the worst symptom cluster were 60% more likely to have an SEN (95% CI 1.23–2.08). CONCLUSIONS: In this population-based longitudinal study, history of either SDB or BSPs in the first 5 years of life was associated with increased likelihood of SEN at 8 years of age. Findings highlight the need for pediatric sleep disorder screening by early interventionists, early childhood educators, and health professionals.

Objective. This article describes the development of educational materials for a Women, Infants, and Children (WIC)–based randomized controlled trial of an intervention encouraging timely bottle weaning. Method. Following a systematic process to develop of patient education materials, messages were first tested in 4 focus groups with 26 caregivers of WIC toddlers aged 7 to 36 months of age at the 2 study sites. Following review and revision, the materials were retested in one-on-one nutritional counseling sessions with 10 clients at the WIC sites who met the study’s eligibility criteria. Results. Materials development was an iterative process requiring several levels of input, review, and revision. Use of a systematic process guided by steps adapted from the health education literature was crucial in ensuring continuous feedback from stakeholders, experts, and priority populations and to develop an intervention instrument that met the needs and expectations of all groups. Conclusions and implications. The content, theoretical orientation, and format of the materials were influenced at every turn by feedback from frontline WIC nutritionists, WIC policy staff at the state level, and WIC clients. Development of effective, easy to use materials requires constant input from key stakeholders.

Maternal knowledge and comfort with breastfeeding affect prenatal feeding intentions, and these intentions are strong predictors of feeding outcomes. However, predictors of exclusive breastfeeding intention have not been well characterized.We measured the association between intentions to exclusively breastfeed and knowledge of infant health benefits, feeding guidelines, and comfort related to breastfeeding in social settings. Participants were lower-income, ethnically diverse women in two randomized, controlled trials of breastfeeding support. We compared results with data from the national Infant Feeding Practices Study II.Among 883 women in our trials, exclusive breastfeeding, mixed feeding, and exclusive formula feeding intentions were 45.9%, 46.1%, and 8.0%, respectively. In multivariate-adjusted models, women who disagreed that "Infant formula is as good as breastmilk" were more likely to intend exclusive breastfeeding versus exclusive formula feeding (odds ratio 3.44, 95% confidence interval 1.80-6.59) compared with women who agreed with this statement. Increasing levels of agreement that breastfed infants were less likely to develop ear infections, respiratory infections, diarrhea, and obesity were positively associated with intentions to exclusively breastfeed (p for trend 0.001 for all). Compared with the national sample, our study participants were more likely to agree with all of these statements. Women who felt comfortable breastfeeding in public intended to exclusive breastfeed for 0.84 month longer (95% confidence interval 0.41-1.28) than those who felt uncomfortable.Maternal knowledge about infant health benefits, as well as comfort with breastfeeding in social settings, was directly related to intention to exclusively breastfeed. Prenatal interventions that address these issues may increase exclusive breastfeeding intention and duration.

Objective The objective of this study was to characterize phenotypes of sleep disordered breathing (SDB) in early childhood that clinicians may find useful while monitoring symptom progression and associated SDB morbidity. Methods We performed a cluster analysis of SDB's primary symptoms: snoring, mouth-breathing, and apnea. Parents in the Avon Longitudinal Study of Parents and Children (ALSPAC) reported SDB symptoms by questionnaire for their child at 6, 18, 30, 42, 57, 69, and 81 months of age. Participants were those from the original cohort exclusive of children with congental or other medical conditions predisposing growth aberrations or respiratory problems (i.e. cleft palate, heart surgery and associated conditions, genetic syndromes—primarily Down's, cancer or kidney conditions, celiac disease, congenital adrenal hyperplasia), missing SDB measures for ≥2 timepoints, or missing birth length plus 2 subsequent height measures. Results Five clusters emerged from 10,441 children and were characterized according to patterns of mean severity of SDB symptoms over time. “Normals” (50%) were asymptomatic throughout. The “late snores and mouth-breathing” cluster (20%) remained asymptomatic until 4 years old. The “early snores” (10%) and “early apnea” (10%) clusters had peak symptoms at 6 and 18 months, respectively. In “all SDB after infancy” (10%), symptoms peaked from 30 to 42 months and remained elevated. Exploratory analyses found that “early snores” were significantly shorter than “normals.” Associations with tonsillectomies and wheezing frequency supported external validation. Conclusions Cluster analysis has elucidated the dynamic multi-symptom expression of SDB. The utility of cluster analysis will be evaluated in future analyses to predict growth, cognition and behavior outcomes.

Too often, breastfeeding educational events fail to attract or benefit individuals of diverse professional views. We are thus pleased to report on a recent day-long workshop by Miriam Labbok, MD, IBCLC. The impetus for the workshop was the training of IBCLC interventionists for 2 related NIH-funded trials of breastfeeding promotion interventions.1,2 Held at Albert Einstein College of Medicine in New York on January 30, 2008, the event drew 14 MDs, 3 MD/IBCLCs, 19 IBCLCs, 2 PhDs, 3 RNs, 7 RN/IBCLCs, and 9 others. The workshop’s success was in providing a forum for this diverse group to interact and share best practices, especially during breakout sessions on effective strategies for promoting exclusive breastfeeding (EBF) and tackling obstacles to EBF in the prenatal, hospital, and postpartum periods. Many novel strategies were presented. For example, a participating family physician said she helps mothers understand the importance of EBF by offering analogies that appeal to the particular patient’s religious beliefs. She said she compares choosing EBF to choosing only one God or husband. Her comments reflect the clinical challenges presented by the fact that although breastfeeding initiation rates have increased, the rate of EBF has not.3 Participants expressed above all the importance of women establishing support networks that include providers, partners, family, and friends to maintain EBF. Consensus on the need for support underscores Dr. Labbok’s discussion of breastfeeding from a human rights perspective. Dr. Labbok explains that when breastfeeding is understood within the human rights framework, the duties concomitant to a child’s right to be breastfed lie not only with the mother, but with society, government and family.4 One of the greatest frustrations expressed by participants was that the shift that removed breastfeeding from the scope of what was “normal” resulted in societal neglect of these duties and institutions that create obstacles to EBF. Participants cited hospital rooming policies, early cord clamping, and swaddling among these barriers. Several attendees, including Miriam Labbok, noted the rarity of having many physicians in attendance at a breastfeeding workshop. Research has shown that providers have an unparalleled positive impact upon breastfeeding initiation and exclusivity, supporting the importance of breastfeeding education for all clinicians.5–7 Attendance at this workshop shows that physicians are recognizing their role within the multidisciplinary approach to supporting breastfeeding that is essential to ensuring that mothers receive breastfeeding support and assistance at each point during their care.

To the Editor .— The evidence base for the public health import of exclusive, prolonged breastfeeding continues to expand, as shown in the article “Breastfeeding and Hospitalization for Diarrheal and Respiratory Infection in the United Kingdom Millennium Cohort Study,”1 which comes on the heels of the new Healthy People 2010 (HP2010) exclusive breastfeeding goals2 (objective 16 now reflects exclusive breastfeeding at 16–19 d and e as objectives approved for HP2010). Achieving the new HP2010 goals will require substantial effort, given dismally low rates of exclusive breastfeeding in the United States. Several years ago, Pediatrics published an analysis of federal research funding that depicted an incongruity between national priorities for breastfeeding on the one hand and research aimed at achieving Healthy People 2000 (HP2000) breastfeeding goals on the other hand.3 By the mid-2000s this incongruity had grown starker, even as the new HP2010 targets justifiably raise the bar for this public health objective. The revised HP2010 breastfeeding objectives adopted in December 2006 set targets for 60% of women …

Inappropriate baby bottle use is associated with tooth decay, anemia, and overweight, and it may adversely affect dietary patterns. Parents often do not follow guidance to wean by 18 months of life. We piloted a brief, counseling-based weaning intervention in an urban WIC agency among primarily Hispanic parent/toddler dyads. At baseline (n = 48), toddlers consumed a mean 4.7 bottles/day. At follow-up (n = 39), the intervention group consumed fewer mean bottles/day than controls (0.09 vs 2.0 bottles/day, P < .045). Half the toddlers in the experimental group and one third of the control groups weaned completely. Parents of weaned children were satisfied with the outcome.

Objective To determine whether infants of women randomized to a prenatal and postpartum lactation support intervention incur fewer otitis media–, respiratory tract–, or gastrointestinal-related visits than controls. Design Randomized, unmasked controlled trial recruiting women from prenatal care settings. Breastfeeding sensitive (BFS) illness visits for otitis media or respiratory tract or gastrointestinal complaints were obtained up to 12 months. Setting Two urban community health centers. Participants Analytic sample of 338 low-income, primarily Hispanic and/or black mother-infant dyads (n = 163 for the intervention group and n = 175 for the control group). Intervention Study lactation consultants attempted 2 prenatal meetings, 1 postpartum hospital and/or home visit, and telephone calls as needed. Controls received the standard of care. Main Outcome Measures Combined outpatient and emergency department visits with illness and BFS illness diagnoses. Results There was a significant interaction between treatment and Medicaid; among those not receiving Medicaid, the number of otitis media visits was higher among controls (P≤.03). Visits for any illness and BFS, gastrointestinal, or respiratory tract illnesses did not differ by treatment group. Intervention group infants received more breast milk than controls, but exclusive breastfeeding rates remained low and did not differ between groups at any point. Conclusions Only the number of otitis media visits was reduced, in a subset of the intervention group. The intervention did not reduce visits for respiratory tract or gastrointestinal illness. Limited intervention contact and low exclusive breastfeeding rates may have attenuated intervention effects. Future interventions designed to yield markedly increased breastfeeding rates may show greater effects in low-income multiethnic samples. Health coverage for visits may moderate intervention effects.

This article reports on breastfeeding intentions of Hispanic and black women by country of origin (continental US born or foreign born) in a low-income population that has experienced demographic shifts. Data were derived from prenatal interviews with 382 women from 2 community clinics. Primary outcome measures were intentions to formula feed, breastfeed, or formula and breastfeed. Foreign-born women were significantly more likely to intend to only breastfeed (42% vs 24% for continental US born, P < .05). In multivariate analyses, country of origin and having breastfed a previous child were the only significant predictors of breastfeeding intention. In contrast to previous work, black (non-Hispanic) and Hispanic women’s breastfeeding plans were similar. This finding coincides with dramatic increases in the numbers of blacks from West Indian countries—where breastfeeding is the norm—in the study locale.

To determine whether age of bottle-weaning is associated with overweight in young children, National Health and Nutrition Examination Survey III data for 3027 children aged 3-5 years were analyzed. The main outcome measure, the child’s body mass index (BMI), was measured as: 95%. Mean bottle-weaning age was 18.78 months. After adjustment for potential confounders, each additional month of bottle use corresponded to a 3% increase in the odds of being in a higher BMI category (95% CI 0.0099-0.0535). Prolonged bottle use in young children is associated with increased risk of overweight. From a preventive medicine standpoint, decreasing exposure to this potential risk for childhood overweight is indicated.

Decisions about care at the end of life are not only influenced by doctor-patient-family relationships and physician practice, but also by institutional "culture." An institutional assessment of the quality of care provided to dying hospitalized patients was undertaken to characterize and identify factors influencing it and to find opportunities for improvement. An analysis of hospital data, three physician and nursing focus group discussions, structured review of records of targeted patients (61) who had an "expected death," and interviews with 31 surviving family members of the targeted patients served as the basis for an institutional needs assessment intended to precede the development of a quality improvement program to improve hospital care of patients at the end of life. Data were primarily gathered regarding older adults, including a significant number of nursing home residents. The assessment led to a methodology for developing a quality improvement program based upon feedback to physicians and nurses regarding the quality of end-of-life care.

Gay men and lesbians have special interests in documenting their preferences regarding advance care planning and end-of-life care. A 64-item survey instrument was developed to ascertain the preferences of this community regarding approaches to end-of-life care, viewpoints on physician-assisted suicide (PAS) and euthanasia, and practices regarding advance care planning. The survey was completed by 575 participants recruited through community-based health care and social service organizations serving the lesbian and gay community, primarily in the New York metropolitan area. Respondents represent a diverse group of women (36%) and men (63%) from various age, racial/ethnic, and religious/spiritual backgrounds; 10% were human immunodeficiency virus (HIV)-positive. Respondents' perspectives on end-of-life care are generally consistent with findings from other attitudinal studies of U.S. adults: a majority supported legalization of PAS and preferred a palliative approach to end-of-life care. However, the gay community sample revealed even stronger support for assisted suicide and palliative care. Although respondents completed advance directives at a higher rate than adults generally, the legal importance for gay men and lesbians to execute directives should encourage health care providers and community organizations to assume a larger educational role on advance care planning. Results confirm other reports on the need to address provider communication skills. It is speculated that the HIV epidemic was a major influence behind these results because of the overwhelming personal impact of the epidemic on most gay men and lesbians during the past two decades.

To understand the scope and magnitude of housing needs among persons with HIV/AIDS in New York State.Both housing providers and non-housing providers were identified through state-wide lists and regional resource guides. All identified housing providers and a random sample of identified non-housing providers, by region, were approached. Interviewers conducted telephone interviews with qualified representatives from each organization.All major providers of HIV/AIDS housing services (n = 144) and a random sample of other providers of HIV/AIDS services (n = 87) were interviewed. VARIABLES UNDER STUDY: Data that were gathered included: agency profiles, client demographics, and clients' need for and use of housing services.One-third of housing agency clients were either homeless or living in a welfare hotel, while one-tenth of non-housing agency clients lived under such conditions. Nearly one-third of all clients were living doubled-up, and half had problems paying for rent or utilities. The majority of clients required supportive services such as substance abuse treatment or mental health care.With the advent of protease inhibitor therapy, stable and adequate housing has become especially critical for persons with HIV/AIDS. However, public assistance "reforms" are likely to exacerbate their housing needs, and may ultimately compromise the potential benefits of treatment.

Objective To evaluate 3 research questions: (1) Does a Women, Infants, and Children (WIC)-based counseling intervention reduce (milk) bottle use?; (2) Does this intervention reduce energy intake from bottles?; and (3) Does this intervention reduce the risk of a child being >85th percentile weight-for-length? Study design Parents of n=300 12-month-olds consuming >2 bottles/d were randomized to a bottle-weaning intervention or control group. Nutritionists at WIC Supplemental Feeding Program sites delivered the intervention. Researchers assessed dietary intake and beverage container use via computer-guided 24-hour recalls, and anthropometrics at 15, 18, 21, and 24 months old. Intent-to-treat analyses controlled for baseline measures of outcomes and months post-baseline. Results At 1 year follow-up, the intervention group had reduced use of any bottles (OR = 0.23, 95% CI=0.08-0.61), calories from milk bottles (OR = 0.36, 95% CI=0.18-0.74), and total calories (β = −1.15, P = .043), but did not differ from controls in risk of overweight status (ie, >85th percentile weight-for-length (OR = 1.02, 95% CI=0.5-2.0). The intervention group's decreased bottle usage at 15 and 18 months was paralleled by increased "sippy cup" usage. Conclusion A brief intervention, during WIC routine care, reduced early childhood risk factors for overweight—bottle use and energy intake—but not risk of overweight. The intervention group's increased use of sippy cups may have attenuated an intervention effect upon risk of overweight. Toddlers consume a high proportion of their calories as liquid. Parents should be counseled about excess intake from bottles and sippy cups. WIC is an ideal setting for such interventions.

This study sought to identify the prevalence of unstable housing situations, and for whom they occurred, and to examine differences in health care utilization by housing status. Housing status and inpatient and outpatient health care utilization of 1,851 HIV-infected individuals was ascertained through interviews. Nine percent of respondents were in unstable housing situations. Unstable housing was associated with significantly lower functional status. The unstably housed were more likely to visit an emergency room (p < 0.05) and had fewer ambulatory visits than persons with stable housing (p < 0.03). They incurred nearly five more hospital days and their average hospitalization was approximately 1.5 days longer than the stably housed, although these differences were not significant. Utilization of ambulatory care is lower among unstably housed persons with HIV disease, which may have led to their increased reliance upon emergency rooms and hospitals. Helping HIV-infected individuals maintain adequate housing could reverse this pattern.