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This study explores infant-caregiver interaction in two cultures, replicating and expanding on previous cross-cultural comparisons. For this study, 132 Kenyan infants, 112 preterm U.S. infants, and 27 full-term U.S. infants were observed with their caregivers during multiple home observations. Results expand on previous work in Kenya, illustrating the importance of multiple caregivers in the lives of infants. When all caregivers are taken into account, as opposed to just mothers, similarities between Kenyan and U.S. cultures in styles of interacting with young infants become more apparent. In addition, when infant-caregiver interaction in Kenya is compared with infant-caregiver interaction with U.S. preterms, previously reported differences between Kenyan and U.S. caregiving behaviors also become less evident. These findings are particularly important in that they counter the concern that the development of children in environments such as rural Kenya is compromised by lower levels of stimulation from mothers. [ABSTRACT FROM AUTHOR]

BACKGROUND: Several studies show impairments in the social and adaptive behaviors of children prenatally exposed to alcohol. However, there remains limited consensus on whether the alcohol exposure directly affects social functioning or whether its effect is mediated by deficits in IQ. In addition, no studies have investigated whether deficits in social functioning are significantly more pronounced in children prenatally exposed to alcohol than in children referred to psychiatric treatment who were not prenatally exposed. We explored the effect of alcohol exposure on social and adaptive functioning and explored whether or not social and adaptive functioning are significantly more impaired in children prenatally exposed to alcohol than in a clinical sample of children. METHODS: A sample of 33 alcohol-exposed children was compared with a sample of 33 clinic-referred nonexposed children. The groups were compared on measures of communication, daily living skills, and socialization. The groups were matched on sex, age, IQ, and outpatient or inpatient status. RESULTS: Analyses revealed that the prenatally alcohol-exposed children did not differ significantly from the nonexposed children in any of the domains of adaptive functioning. However, with age, exposed children showed a more rapid decline in socialization standard scores compared with the nonexposed clinical sample. CONCLUSIONS: Young children who were exposed to alcohol prenatally show deficits in all domains of adaptive functioning. Although these deficits do not seem to differ from those exhibited by young children with psychiatric problems but no prenatal exposure, deficits in socialization behavior of prenatally exposed children may become more significant with age. [ABSTRACT FROM AUTHOR]

Background/objective: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides breastfeeding support to participating women in low-income households. This study aimed to determine the relationships between prenatal maternal and household characteristics and breastfeeding duration, as well as whether these characteristics modify associations of prenatal breastfeeding intention with breastfeeding duration., Methods: This is a prospective cohort study of pregnant respondents to Los Angeles County (LAC), California, WIC surveys conducted between 2005 and 2020 (n = 1014). Associations of prenatal breastfeeding intention with duration (months) of any or fully breastfeeding, determined by WIC infant food package issuance, were assessed with linear regression models., Results: Most women reported the intention to breastfeed (67.7%) and perceived breastfeeding support during pregnancy from WIC and family/friends was associated with breastfeeding intention (both p -values < 0.0001). Stronger breastfeeding intention, lower maternal BMI, greater maternal age, greater maternal education, paternal cohabitation and employment, and greater breastfeeding support from family/friends were associated with longer duration of any or fully breastfeeding in multivariable models. Stronger breastfeeding intention was more strongly associated with longer duration of any breastfeeding among women with lower BMI (interaction p -value 0.03)., Conclusions: Breastfeeding support from WIC is an important contributor to stronger breastfeeding intention. Given the robust association of breastfeeding intention with breastfeeding duration, regardless of maternal and household characteristics, WIC breastfeeding support during pregnancy represents an important mechanism to improve breastfeeding outcomes in this population. Further research is needed to understand the directionality of associations between breastfeeding support and intention among WIC participants.

Background: Few studies have evaluated trends in diet quality across early childhood, including the extent to which foods and beverages available in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Package contribute to children's diets., Objective: The objective of this study was to examine the following across ages 2 through 5 years: (1) trends in Healthy Eating Index-2020 (HEI-2020) total and component scores; (2) differences in mean HEI-2020 scores by WIC participation duration; and (3) contributions of the top 5 foods or beverages to HEI-2020 component scores by WIC duration., Design: This was a secondary analysis of a nationally representative sample of the WIC Infant and Toddler Feeding Practices Study-2 conducted between 2013 and 2019., Participants/setting: WIC Infant and Toddler Feeding Practices Study-2 participants (n = 980; weighted n = 403 726) were included., Main Outcome Measures: The outcomes were HEI-2020 scores and top contributing foods to HEI-2020 components., Statistical Analyses: Multivariate regression was conducted to examine HEI-2020 scores by WIC duration (high, intermediate, and low groups). The top 5 contributors to HEI-2020 components were averaged across ages 2 through 5 years and compared across WIC duration groups., Results: For all participants combined, the mean HEI-2020 total scores were similar across ages 2 through 5 years. Children with high WIC duration had higher total HEI-2020 scores compared with children with low WIC duration from ages 2 through 5 years (mean [SE], 58.1 [0.7] vs 55.6 [1.1]; P = .03). The percentage contributions of many of the WIC-eligible foods to HEI-2020 components were higher in the high WIC duration group compared with low WIC duration group, including higher intake of dried beans, unsweetened breakfast cereals, whole-grain breads, and 1% milk; the high WIC duration group also had lower intake of sweetened breakfast cereals and 2% milk., Conclusions: Findings illustrate how WIC-eligible foods contribute to higher diet quality scores; when children participate in WIC longer, their diets are better aligned with national dietary guidelines., (Copyright © 2024 Academy of Nutrition and Dietetics. All rights reserved.)

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental healthy foods to children aged <5 y in low-income households., Objectives: The objectives of this study were to characterize WIC benefit redemption, identify associations between benefit redemption and child dietary intake, and whether child age modifies these associations., Methods: The cross-sectional 2023 California Statewide WIC Survey, conducted with caregivers of WIC-participating children aged 1-4 y, was analyzed for this study. Included children had complete benefit redemption data, a complete National Health and Nutrition Examination Survey Dietary Screener Questionnaire (DSQ), and complete covariate data (weighted n = 2244). Monthly household category-specific benefit redemption percentage was averaged across 6 and 3 mo preceding survey completion. Associations between household redemption and child dietary intake (servings or amount/day) were assessed with multivariable linear regression and expressed as estimates and 95% confidence intervals (CI)., Results: Twenty-five percent higher redemption of breakfast cereal, whole grain bread, yogurt and whole milk in the 6 mo prior to the survey were associated with higher child intake frequency for cereal (0.02 servings/d; 95% CI: 0.00, 0.04), whole grain bread (0.02 servings/d; 95% CI: 0.00, 0.03), yogurt (0.04 servings/d; 95% CI: 0.02, 0.06), and whole milk (0.09 servings/d; 95% CI: 0.01, 0.16). Significant effect modification by child age (12 to <24 mo, 24-59 mo) was found for redemption of cheese/tofu and 100% juice (P-interaction = 0.02 and 0.001, respectively), and 25% higher redemption of these benefits were associated with lower intake frequency for cheese (-0.05 servings/d; 95% CI: -0.09, -0.02) and higher intake frequency for juice (0.12 servings/d; 95% CI: 0.06, 0.18), but only among children ages 12 to <24 mo., Conclusions: Higher redemption was associated with higher child intake of select WIC foods. Pairing the promotion of benefit redemption among program participants with nutrition education efforts may enhance dietary impacts of WIC participation., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Fruits and vegetables (FV) are a critical source of nutrients, yet children in the United States are not meeting the Dietary Guidelines for Americans (DGA). The monthly FV cash value benefit (CVB) included in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)'s food package to support child FV intake (FVI) received a substantial increase for economic relief during the COVID-19 pandemic., Objectives: To evaluate how an expansion of the monthly WIC CVB to purchase FV for WIC children ages 1-4 y is associated with diversity in FV redeemed, and how changes in redeemed FV are related to FVI., Methods: Caregivers representing 1463 WIC-participating children recruited from Los Angeles County, California, completed surveys during the CVB augmentation (T1: CVB = $9/mo; T2 = $35/mo; T3 = $24/mo). Redeemed price look-up codes (PLUs), corresponding to a food item, were assigned to its corresponding MyPlate FV group. Multivariable generalized estimating equation regression models assessed changes in amount and diversity of FV redemption across MyPlate groups and associations between changes in FV diversity and changes in FVI., Results: Slightly over half of all households were food insecure (55%), half of the children were female (52%), and most were Hispanic (78%). Compared with T1, significant increases in the number of PLUs and dollars redeemed were observed in most MyPlate FV groups. From T1 to T2, significant increases in diversity scores were observed for total fruit (β: 1.6 pts; 95% confidence interval [CI]: 1.4, 1.7), total vegetable (β: 3.6 pts; 95%CI: 3.4, 3.9), and total FV (β:7.8 pts; 95%CI: 7.4, 8.2). Similarly, increases in diversity score were observed at T3 compared with T1. Changes in FV diversity redeemed were not associated with changes in FVI., Conclusions: During the CVB augmentation, WIC participants redeemed a greater amount and variety of FV according to DGA MyPlate recommendations, supporting its permanent increase., (© 2024 The Authors.)

Background: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) issues infant formula to infants who are not fully breastfed, and prior research found elevated obesity risk among children receiving lactose-reduced infant formula with corn syrup solids (CSSF) issued by WIC. This study was conducted to evaluate associations between a broader set of specialty infant formulas issued by WIC and child obesity risk, whether neighborhood context (e.g. neighborhood food environment) modifies associations, and whether racial/ethnic disparities in obesity are partly explained by infant formula exposure and neighborhood context., Methods: WIC administrative data, collected from 2013-2020 on issued amount (categorical: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and type of infant formula (standard cow's milk formula, and three specialty formulas: any CSSF, any soy-based formula, and any cow's milk-based formula with added rice starch) and obesity at ages 2-4 years (defined as a Body Mass Index z-score ≥ 95th percentile according to World Health Organization growth standard) were used to construct a cohort (n = 59,132). Associations of infant formula exposures and race/ethnicity with obesity risk were assessed in Poisson regression models, and modification of infant feeding associations with obesity by neighborhood context was assessed with interaction terms., Results: Any infant formula exposure was associated with significantly higher obesity risk relative to fully breastfeeding. Receipt of a CSSF was associated with 5% higher obesity risk relative to the standard and other specialty infant formulas (risk ratio 1.05, 95% confidence interval 1.02, 1.08) independent of breastfeeding duration and receipt of other specialty infant formulas. The association between CSSF and obesity risk was stronger in neighborhoods with healthier food environments (10% higher risk) compared to less healthy food environments (null). Racial/ethnic disparities in obesity risk were robust to adjustment for infant formula exposure and neighborhood environment., Conclusions: Among specialty infant formulas issued by WIC, only CSSFs were associated with elevated obesity risk, and this association was stronger in healthier food environments. Future research is needed to isolate the mechanism underlying this association., (© 2024. The Author(s).)

Purpose: To determine associations between child and household characteristics and sleep duration among low-income children in Los Angeles County., Design: Cross-sectional study., Setting: Survey data collected in 2017 and 2020 in Los Angeles County, California., Sample: Special Supplemental Nutrition Program for Women, Infants and Children (WIC) households with children ages 4-60 months., Measures: Sleep duration for children 4-60 months old (less than recommended (LTR), recommended range, more than recommended (MTR)), household food insecurity (HFI), sociodemographics, and daily servings of sugar-sweetened beverages (SSB)., Analysis: Multinomial logistic regression, stratified by child age, was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for associations between household/child characteristics and LTR or MTR sleep compared to recommended duration among WIC participating children 4-60 months old., Results: The final sample included 3512 children ages 4-23 months and 6035 children ages 24-60 months. In the study population, 32% (3-5 years old) to 44% (4-11months) of children under 5 did not meet the recommended hours of sleep per night. HFI was associated with higher odds of LTR (OR 1.27, CI 1.12-1.45) and MTR (OR 1.46, CI 1.15-1.87) sleep among 24-60 month-old children. Each additional daily SSB serving was associated with higher odds of LTR sleep (4-23 months: OR 1.10, CI 1.02-1.19; 24-59 months: OR 1.12, CI 1.08-1.17)., Conclusions: HFI and SSB intake are associated with not getting the recommended amount of sleep among low-income WIC participating children. Nutrition assistance program participants may benefit from receiving information about recommended sleep duration for young children and how to establish sleep routines to optimize sleep duration., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition support for racially and ethnically diverse populations. In 2021, the monthly cash value benefit (CVB) for the purchase of fruits and vegetables increased from $9 to $35 and was later adjusted to $24. This study investigated, by racial and ethnic groups, whether CVB increases were associated with increases in CVB redemption, household food security, child fruit and vegetable intake, satisfaction with CVB amount, and likelihood of continued participation in WIC if the CVB returned to $9 per month., Methods: We conducted a longitudinal study of WIC participants (N = 1,770) in southern California at 3 time points, from April 2021 through May 2022; the CVB amount was $9 at baseline, $35 at Survey 2, and $24 at Survey 3. Racial and ethnic groups were Hispanic English-speakers, Hispanic Spanish-speakers, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Other, and non-Hispanic White. We used mixed-effect and modified Poisson regressions to evaluate outcomes by group., Results: At baseline, groups differed significantly in dollars of CVB redeemed, percentage of CVB redeemed, household food security, and satisfaction with CVB amount. After the increase in CVB, we found increases in all groups in CVB redemption, household food security, and satisfaction. Non-Hispanic Black and Hispanic English-speaking groups, who had low levels of satisfaction at baseline, had larger increases in satisfaction than other groups. Reported likelihood of continued WIC participation if the monthly CVB returned to $9 also differed significantly by group, ranging from 62.5% to 90.0%., Conclusion: The increase in CVB for children receiving WIC benefited all racial and ethnic groups. Continued investment in an augmented CVB could improve health outcomes for a racially and ethnically diverse WIC population.

Objective: To help inform decisions regarding the equitable implementation of obesity interventions, we examined whether interventions were equitably reaching the most vulnerable communities, identified communities that received fewer interventions than expected, and estimated the effect of 'dose' of interventions on obesity prevalence., Methods: We created a database to identify and characterize obesity-related interventions implemented in Los Angeles County from 2005 to 2015 linked to community-level sociodemographic and obesity prevalence data. We ran generalized linear models with a Gamma distribution and log link to determine if interventions were directed toward vulnerable communities and to identify communities that received fewer interventions than expected. We ran fixed-effects models to estimate the association between obesity prevalence and intervention strategy count among preschool-aged children enrolled in the Special Supplemental Nutrition Assistance Program for Women Infants and Children., Results: We found that interventions targeted vulnerable communities with high poverty rates and percentages of minority residents. The small cluster of communities that received fewer interventions than expected tended to have poor socioeconomic profiles. Communities which received more intervention strategies saw greater declines in obesity prevalence (β = -0.023; 95 % CI: -0.031, -0.016)., Conclusions: It is important to determine if interventions are equitably reaching vulnerable populations as resources to tackle childhood obesity become available. Evaluating the population impact of multiple interventions implemented simultaneously presents methodological challenges in measuring intervention dose and identifying cost-effective strategies. Addressing these challenges must be an important research priority as community-wide interventions involve multiple intervention strategies to reduce health disparities., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to low-income households, including infant formula for infants not fully breastfeeding. Issuance of lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with elevated risk of obesity in early life, but associations between formula type and dietary intake have not been examined., Objectives: To evaluate associations between infant formula (amount and type) issued by WIC with subsequent child diet at ages 12-59 mo., Methods: Dietary data from 2014, 2017, and 2020 Los Angeles County WIC Survey respondents ( n = 1339 children, 12-59 mo of age) were merged with WIC administrative data on infant feeding (amount and type of infant formula at ages 0-12 mo). Intake frequencies were available for sweetened beverages, sweets, juice, fast food, water, fruit, vegetables, and milk. Infant feeding was categorized by amount of WIC-issued formula (descending: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and issuance of a CSSF (any, none). Associations between infant feeding (infant formula amount and type) and child diet were evaluated in multivariable generalized estimating equation negative binomial regression models, stratified by child age (12 to <24 mo, 24 to <60 mo)., Results: Any infant formula issuance in the first year of life was adversely associated with subsequent dietary intake. This included 21%-23% higher 100% juice intake at 24 to <60 mo and 11%-13% (at 24 to <60 mo) or 20%-22% (at 12 to <24 mo) lower water intake. CSSF receipt compared with only other infant formula was not consistently associated with subsequent child diet., Conclusions: Any infant formula amount, but not CSSF receipt compared with other formula types, was associated with less healthful beverage intake patterns among WIC-participating children. WIC nutrition education may have a stronger impact if tailored based on infant feeding practices., (© 2024 The Author(s).)

Objective: To quantify self-reported difficulty accessing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-issued infant formula among participants early in the coronavirus disease 2019 (COVID-19) pandemic, to determine if infant formula redemption was associated with self-reported difficulty accessing infant formula, and to quantify changes in formula redemption during the 2022-2023 US infant formula shortages., Design: A cross-sectional study and time series data., Setting: Families participating in the WIC program in the Los Angeles metropolitan area from November 2019 to June 2023., Participants: Families with infants (aged 0-12 months) issued infant formula by WIC with a completed 2020 Los Angeles County WIC Survey (n = 1,897) or issued infant formula by a large WIC program in Southern California between November 2019 and June 2023 (n = 109,135)., Main Outcome Measures: Incidence of ≥ 30% reduction in infant formula redemption and interval-scaled infant formula redemption., Analysis: Special Supplemental Nutrition Program for Women, Infants, and Children formula redemption data were matched to 2020 Los Angeles County WIC Survey data to determine if self-reported difficulty accessing infant formula was associated with administrative infant formula redemption data using negative binomial regression and were used to quantify the prevalence and severity of incomplete formula redemption during 2020-2023 formula shortages using ordinal logistic regression (outcome: interval-scaled formula redemption)., Results: Few (13.0%) caregivers reported difficulty accessing the WIC-issued formula early in the COVID-19 pandemic. The 2.8% who reported an unresolved shortage early in the COVID-19 pandemic had 201% higher rates of ≥ 30% declines in formula redemption (incidence rate ratio [IRR], 3.01; 95% confidence interval, 1.57-5.79, P < 0.001) than those with no difficulties. Incomplete formula redemption odds were significantly elevated throughout the COVID-19 pandemic from March 2020 to January 2022 and increased further during the 2022-2023 infant formula shortages from February 2022 to June 2023, reaching 342% higher in October 2022 than February 2020 (odds ratio, 4.42; 95% confidence interval, 4.14-4.72; P < 0.001)., Conclusions and Implications: Special Supplemental Nutrition Program for Women, Infants, and Children redemption data are an adequate proxy for population-level infant formula access issues among households with low income but are insufficiently sensitive for screening at a household level. US formula shortages (2020-2023) demonstrate the need for improved coordination between nutrition assistance programs, regulatory bodies, and commercial food systems, particularly during acute supply crises., (Copyright © 2023 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food benefit redemption is associated with discontinuing WIC participation, failure to recertify, overall and by race/ethnicity-language preference and participant category., Design: Retrospective cohort study, using multivariable modified Poisson regression to determine risk ratios (RR) and 95 % CI for associations between household-level food benefit redemption (interval-scaled benefit redemption percent, averaged across WIC benefit subcategories, for the final 3, 6 and 12 months of certification) and failure to recertify in WIC, overall and within strata of race/ethnicity-language preference and participant category., Setting: WIC administrative data collected November 2019-July 2021 in Southern California., Participants: WIC-participating children ages 0-3 years at initial certification from November 2019 to May 2020 ( n 41 263)., Results: In all time periods, and for all subgroups, every 10 % lower food benefit redemption was associated with increased risk of failure to recertify. Among households without missing food benefit data, failure to recertify risk peaked at 505 % higher (RR = 6·05, 95 % CI (5·63, 6·51)) in households with average 12-month redemption <10 % compared with households with ≥70 % redemption., Conclusions: Lower WIC benefit redemption was associated with higher risk of failing to recertify among participants. Focused nutrition education around benefit redemption may improve WIC retention and child health through incremental increases in food benefit redemption.

Background: In Los Angeles County (LAC), California, the demand for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services increased during the COVID-19 pandemic, concurrent with the shift to fully remote WIC service delivery in March 2020. Technologies for facilitating remote services were critical for accommodating increases in participation during the COVID-19 pandemic., Objective: The objective of this study was to quantify patterns of remote-service utilization and to determine whether use of remote services (phone, interactive texting, e-mail, online education, video appointments) was associated with higher rates of recertification among WIC participants early in the COVID-19 pandemic., Design: Cross-sectional survey with administrative data for follow-up PARTICIPANTS AND SETTING: This study used data from the 2020 LAC WIC Survey and WIC administrative data to evaluate remote service utilization across LAC WIC agencies (unweighted n = 3,510; weighted n = 3,540)., Main Outcome Measures: Recertification on WIC, determined by the issuance of a food package in the first 2 months after the end-date of the prior certification period., Statistical Analysis: Survey data were merged to WIC administrative data to determine whether participants completed a recertification; the association of utilization of each remote service with the odds of recertification among WIC-participating children 0 to 3 years of age was assessed with multivariable logistic regression., Results: Most survey respondents reported using phone appointments (95.5%), interactive texting (77.3%), e-mail (60.1%), and online education (71.2%) to access WIC services during 2020, and over 82% of children successfully recertified. Interactive texting utilization was associated with 27% higher recertification odds (95% confidence interval, 1%-59%); associations between all other remote services and odds of recertification were not statistically significant., Conclusions: These results suggest that WIC investment in interactive texting technological infrastructure, and appropriate staff training, can help local WIC agencies successfully reach and provide high-quality services to WIC participants., (Copyright © 2023 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a critical source of nutrition support for young children in low-income families, providing access to healthy foods and a cash value benefit (CVB) for the purchase of fruits and vegetables (FV). In 2021, the WIC CVB increased substantially for women and children aged 1 to 5 years., Objective: To investigate whether or not the increased WIC CVB for purchasing FV was associated with greater redemption of the FV benefit, satisfaction, household food security, and child FV intake., Design: Longitudinal study of WIC participants receiving WIC benefits from May 2021 through May 2022. Through May 2021, the WIC CVB for children aged 1 to 4 years was $9/month. The value increased to $35/month from June through September 2021, and changed to $24/month starting October 2021., Participants and Setting: WIC participants from seven WIC sites in California with one or more child aged 1 to 4 years during May 2021 and one or more follow-up surveys during September 2021 or May 2022 (N = 1,770)., Main Outcomes and Measures: CVB redemption (in US dollars), satisfaction with the amount (prevalence), household food security (prevalence), and child FV intake (cups per day)., Statistical Analyses: Associations of increased CVB issuance following the June 2021 CVB augmentation with child FV intake and CVB redemption were assessed using mixed effects regression, and associations with satisfaction and household food security were assessed using modified Poisson regression., Results: The increased CVB was associated with significantly greater redemption and satisfaction. At the second follow-up (May 2022), household food security increased by 10% (95% CI 7% to 12%); total FV intake decreased by 0.03 c/day (95% CI -0.06 to -0.01) in the overall sample, but increased by 0.23 c/day (95% CI 0.17 to 0.29) among children with the lowest baseline FV intake., Conclusions: This study documented benefits of augmentation to the CVB for children. WIC policy augmenting the value of WIC food packages to increase access to FV had the intended effects, lending support to making the increased FV benefit permanent., (Copyright © 2023 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages for children ages 1 to 4 y include a cash value benefit (CVB) redeemable for fruits and vegetables (FVs) with participating vendors. The CVB value was increased beginning in June 2021., Objectives: This study evaluated associations of the augmented CVB with the amount and diversity of redeemed FVs., Methods: Price look-up codes (PLUs) in redemption data determined outcomes including any redemption (any, none), amount redeemed (United States dollars [USD]/mo), and percent of total CVB redemption (percent) in 54 FV commodity groups among a cohort of 1770 WIC-participating children in Southern California. Outcomes across all commodity groups for fresh fruits, fresh vegetables, and all FVs were evaluated including dollar amount redeemed , percentage of redemption , and diversity of produce redeemed (variety and balance among items redeemed). Comparisons were made between augmented CVB periods (35 USD/mo in June-September 2021, 24 USD/mo October 2021-June 2022) and the preaugment period (9 USD/mo in June 2020-May 2021). Associations were tested in multivariable generalized estimating equation Poisson (any redemption) and linear (amount, percent, diversity) regression models., Results: The augmented CVB was associated with higher any redemption prevalence and amount redeemed for 53 of 54 commodity groups at both 35 USD/mo and 24 USD/mo compared with 9 USD/mo. Redemption diversity increased for both fruits, vegetables, and all produce during both augment periods, and modestly greater increases in redeemed fruits relative to vegetables were observed at 35 USD/mo. The most commonly redeemed vegetables were tomatoes, onions, cucumbers, peppers, and avocados and the most commonly redeemed fruits were bananas, apples, grapes, limes, and melons., Conclusions: The augmented CVB was associated with greater redeemed FV amount and greater redeemed FV diversity. Data on FV intake diversity among WIC-participating children are needed to understand dietary impacts of the CVB increase., (© 2023 The Authors.)

Purpose: Identify the prevalence and predictors of substantial postpartum weight retention (SPPWR) among WIC mothers in Southern California during their first postpartum year., Design: Secondary data analysis., Setting: The 2020 Los Angeles County WIC Survey., Subjects: Mothers of children up to 1-year-old (N = 1019)., Measures: Outcome variable: SPPWR (≥5 kg above pre-pregnancy weight). Predictors: child's age, mother's age, race, education, employment status since having child, healthcare coverage, food insecurity, depressed mood, instrumental support, emotional support, spouse's participation in child's life, gestational weight gain (GWG), pre-pregnancy BMI, any breastfeeding, and gestational diabetes., Analysis: Weighted descriptive statistics and binary logistic regression., Results: The prevalence of SPPWR was 31%. We found that for every 1 month increase in the child's age (proxy for postpartum duration), the likelihood of SPPWR increased by 9% (AOR = 1.09, CI = 1.04-1.15). Mothers were more likely to have SPPWR when they exceeded GWG guidelines (AOR = 3.43, CI = 2.46-4.79). Compared to mothers with normal pre-pregnancy BMIs, mothers with overweight (AOR = .64, CI = .44-.94) and obese (AOR = .39, CI = .26-.58) pre-pregnancy BMIs were less likely to experience SPPWR., Conclusion: Postpartum duration and maternal anthropometric characteristics were associated with SPPWR during the first postpartum year. Extending WIC eligibility for postpartum mothers to 2 years through the Wise Investment in Children Act may give WIC providers the opportunity to work closely with Southern California WIC mothers to achieve a healthy weight after pregnancy.

Affordable housing is necessary for the health and well-being of children and families. The coronavirus disease 2019 (COVID-19) pandemic affected the ability of low-income families to pay for housing. The aim of this study is to evaluate associations between household characteristics of participants of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and housing-cost burden during the pandemic. WIC is a federally-funded nutrition assistance program for low-income mothers, infants, and children up to the age of 5. Data were from a 2020 survey of a random sample of WIC households (n = 5815) in Los Angeles County. Ordinal logistic regression determined the odds of being housing-cost burdened by parent respondent's race/ethnicity, household composition, employment, residence, and housing cost. Logistic regression determined if the pandemic contributed to the housing-cost burden. A total of 61% of households reported housing-cost burden, with two-thirds attributing the burden to the pandemic. Spanish-speaking Hispanic parents and white parents reported a higher prevalence of pandemic-related burden, while Asian, Black, and English-speaking Hispanic parents reported a higher prevalence of burden unrelated to the pandemic. Single-parent households, those experiencing residential instability, and those with high housing costs had higher odds of burden. Spanish-speaking Hispanic parents, white parents, homeowners, and those with high housing costs were more likely to attribute the burden to the pandemic. To ensure that existing inequities are not exacerbated, it is vital that housing assistance be available to low-income households that were disproportionately affected by the pandemic., (© 2021. W. Montague Cobb-NMA Health Institute.)

Understanding satisfaction of nutrition education and other services provided in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is needed to ensure the program is responsive to the needs of diverse populations. This study examined the variation of WIC participants’ perceptions and satisfaction with WIC nutrition education and services by race, ethnicity, and language preference. Phone surveys were conducted in 2019 with California WIC families with children aged 1−4 years. While most participants (86%) preferred one-on-one nutrition education, online/mobile apps were also favored (69%). The majority (89%) found nutrition education equally important to receiving the WIC food package. Racial/ethnic groups differed in which WIC service they primarily valued as 20% of non-Hispanic White people rated the food package as more important than nutrition education compared to 5% of Spanish- and 6% of English-speaking Hispanic people, respectively. More Spanish (91%) and English-speaking Hispanic people (87%) than non-Hispanic white (79%) or Black people (74%) changed a behavior because of something they learned at WIC (p < 0.001). Spanish-speaking Hispanic people (90%) had the highest satisfaction with WIC nutrition education. Preferential differences among participants suggest that providing flexible options may improve program satisfaction and emphasizes the need for future studies to examine WIC services by race and ethnicity.

Background: The US Department of Agriculture granted waivers to allow flexibility in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) operations during the coronavirus disease 2019 (COVID-19) pandemic; however, research examining the associations between waiver introduction and changes in perceptions, practices, and challenges of WIC participants' and agency directors' experiences is limited., Objective: The objective of this study was to assess California WIC participants' and agency directors' perceptions and practices of remote WIC services during the COVID-19 pandemic. A secondary aim was to understand other COVID-19 challenges related to maintaining access to healthy foods by WIC participants., Design: A qualitative study that included semistructured interviews was conducted between June 2020 and March 2021., Participants and Setting: One hundred eighty-two WIC participants with a child aged 0 to 5 years from three regions of California (Southern, Central, and Northern) and 22 local WIC agency directors across the state were interviewed., Main Outcome Measures: WIC participants' and agency directors' perceptions, practices, and other challenges during COVID-19., Statistical Analyses Performed: Interviews were recorded, transcribed, and analyzed using a grounded theory approach., Results: Participants shared that they valued the information received from WIC and were very satisfied with remote WIC services. Participants reported that enrolling in WIC remotely was easier than coming in person. All waivers and changes to WIC operations, namely the physical presence, remote benefit issuance, and separation of duties waivers, and remote work and remote delivery of nutrition education, were largely viewed by WIC agency directors as options that should be continued postpandemic. Further, a majority (63%) of households reported experiencing food insecurity, and half of respondents received food from a food bank or pantry during the pandemic., Conclusions: Findings suggest WIC will attract and retain the most families by offering a hybrid model of services, incorporating both onsite services and remote options to work more efficiently and effectively., (Copyright © 2022 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal nutrition assistance program supporting low-income families, serves half of United States-born infants, most of whom are issued infant formula by age 2 mo. Obesity prevalence is high among children of low-income households, particularly formula-fed children., Objectives: This study was conducted to determine whether glucose-based lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with increased obesity risk compared with non-CSSFs that are lactose based., Design: WIC administrative data on infant formula issuance and child weights and lengths were collected prospectively in Southern California between 2012 and 2020. Included children stopped breastfeeding by 3 mo, were issued cow's milk-based formula through 12 mo, and were enrolled through the final year of WIC eligibility at age 4 y ( n = 15,246). CSSF issuance was assessed continuously (range 0-13 mo) and dichotomously (any, none). Poisson and linear risk regression with robust SE estimates generated risk ratios (RRs), risk differences, and CIs for child obesity [BMI for age (in kg/m 2) ≥95th percentile]., Results: Any CSSF was issued to 23% of children, and 25% were obese at age 4 y. Children with any CSSF issuance had 10% higher obesity risk (RR: 1.10; 95% CI: 1.02, 1.20) than children with no CSSF issuance at age 2 y. Associations remained significant through age 4 y (RR: 1.07; 95% CI: 1.01,1.14), independent of maternal weight status, total formula issued and breastfeeding duration, and were not modified by child race or sex. Obesity risk increased with additional mo of CSSF exposure, reaching 16% higher risk (RR: 1.16; 95% CI: 1.05, 1.28) at age 2 y for children with 12 mo of CSSF., Conclusions: CSSF issuance is associated with increased obesity risk in the first 5 y life in a dose dependent manner, independently of maternal weight status, breastfeeding duration, and total formula issuance., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Child physical activity and play are critical for healthy development, and parks/playgrounds are important public spaces that provide physical activity/play opportunities. This study was conducted to assess changes in park/playground utilization by Special Supplemental Nutrition Program for Women, Infants and Children (WIC)-participating children from 2008 to 2020, and whether the COVID-19 pandemic was associated with lower park/playground utilization and racial/ethnic disparities in park/playground utilization. Cross-sectional data from the 2008-2020 triennial Los Angeles County WIC Survey (n = 21,886) were used, and analyses stratified by child age (4-23 months, 24-59 months). Odds ratios (OR) and 95 % confidence intervals (CI) for the relationship between year and park/playground utilization frequency were determined from multinomial logistic regression, and racial/ethnic disparities were assessed by interacting year with race/ethnicity. Among children 24-59 months of age, park/playground utilization increased compared to never from 2011 to 2017 compared to 2008 (Every day, 2011-2017: OR [95 % CI]: 2.69 [1.93, 3.75], 4.71 [3.23, 6.86], 10.20 [6.91, 15.06]; 3-6 days/week 2011-2017: 1.54 [1.13, 2.10], 3.11 [2.18, 4.45], 3.94 [2.71, 5.72]; 1-2 days/week, 2014-2017; 1.53 [1.08, 2.18], 1.63 [1.13, 2.37]). Associations reversed in 2020, with 36 % lower odds of every day (OR [95 % CI]: 0.64 [0.48, 0.85]), 85 % lower odds of 3-6 days/week (0.15 [0.11, 0.20]) and 89 % lower odds of 1-2 days/week (0.11 [0.09, 0.15]) park/playground utilization compared to never than in 2008. Park/playground utilization frequency increased from 2008 to 2017, but progress reversed during the COVID-19 pandemic in 2020. Results for children ages 4-23 months were similar. Future public health restrictions to public recreation facilities should consider realistic limitations to potential benefits and the potential for unintended consequences before implementation., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

The United States Department of Agriculture approved an increase to the Cash Value Benefit (CVB) for the purchase of fruits and vegetables issued to participants receiving an eligible Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package. In order to understand satisfaction, perceptions, and the overall impact of additional benefits for fruits and vegetables at the household level, a qualitative study consisting of structured phone interviews was conducted with families served by WIC in Southern California from November to December 2021 (n = 30). Families were selected from a large longitudinal study sample (N = 2784); the sample was restricted by benefit redemption and stratified by language and race. WIC participants were highly satisfied with the CVB increase, reporting increased purchasing and consumption of a variety of fruits and vegetables. Respondents noted the improved quality and variety of fruits and vegetables purchased due to the increased amount. Findings are expected to inform policy makers to adjust the CVB offered in the WIC food package with the potential to improve participant satisfaction and increase participation and retention of eligible families with benefits from healthy diets supported by WIC.

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental healthy foods and nutrition education to children under age 5 y in low-income households., Objectives: We aimed to identify characteristics associated with duration of WIC participation and assess how participation duration relates to household food insecurity (HFI), child diet quality, and child weight status at age 60 mo., Methods: This analysis of the WIC Infant and Toddler Feeding Practices Study-2, a prospective cohort of WIC-participating children enrolled in 2013, included children with complete baseline-60 mo data (n = 836). Outcomes assessed with WIC participation duration in multivariable regression were HFI (USDA 6-item Household Food Security Screener), child diet quality on a given day [Healthy Eating Index (HEI)-2015], and obesity (CDC BMI-for-age ≥95th percentile)., Results: Factors associated with longer WIC participation included male sex; lower household income; reported diet changes in response to WIC nutrition education; household Supplemental Nutrition Assistance Program participation; English-speaking Hispanic, Spanish-speaking Hispanic, and non-Hispanic other maternal race-ethnicity and language preference; an ever-married mother; lower maternal education; higher maternal age; earlier enrollment during pregnancy; and reporting a subsequent pregnancy. Longer WIC participation was associated with lower HFI odds (OR: 0.69; 95% CI: 0.51, 0.95), higher total HEI-2015 (β: 0.73; 95% CI: 0.20, 1.25), and higher obesity odds (OR: 1.20; 95% CI: 1.05, 1.37) in multivariable-adjusted regression models., Conclusions: Longer WIC participation was associated with reduced HFI and higher diet quality, and unexpectedly with higher obesity odds, at 60 mo. Further research is needed to confirm and understand mechanisms underlying the unexpected associations identified with longer WIC participation (e.g., male sex, obesity). Groups with shorter participation durations may benefit from targeted WIC retention efforts to maximize nutrition security., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: Infants with greater temperamental negative affectivity are at higher risk for overfeeding and excess weight gain., Objective: To examine whether strategies to promote responsive bottle-feeding within WIC promoted healthier maternal feeding practices and infant weight status among infants with greater negative affectivity., Methods: Secondary analysis of data from a matched-pair cluster randomized trial. Policy, systems and environmental change (PSE) strategies to promote responsive bottle-feeding were implemented at three WIC clinics; these clinics were compared with three matched control clinics. Linear mixed models tested whether infant negative affectivity interacted with PSE strategies to predict feeding and weight outcomes when infants were 4-6 months old., Results: Significant interactions between infant negative affectivity and PSE strategies were noted. Among infants with high negative affectivity, mothers in PSE clinics reported less frequent use of food to soothe (p = 0.009) compared with mothers in control clinics. Among infants with moderate (p = 0.008) or high (p = 0.029) negative affectivity, infants in PSE clinics had healthier weight status compared with infants in control clinics., Conclusions: Promotion of responsive bottle-feeding is an effective way to support WIC mothers and reduce risk for overfeeding and excess weight gain, particularly for mothers of infants with greater negative affectivity., (© 2022 World Obesity Federation.)

Compared to other food groups, vegetable intakes are lowest relative to recommendations. Breastfeeding and initial introduction to vegetables may help infants establish long-lasting taste preferences. We examined the relationship between breastfeeding and initial vegetable introduction and vegetable intake in early childhood (ages 13-60 months). This repeated cross-sectional study used data from the national WIC Infant and Toddler Feeding Practices Study-2 collected from low-income mother/caregivers about infants from around birth through age 5 (60 months; n = 3773). Survey-weighted adjusted regression models assessed associations between breastfeeding and vegetable introduction measures with vegetable consumption at child ages 13, 24, 36, 48, and 60 months. Longer breastfeeding duration was associated with a slightly, but significantly, greater variety of vegetables consumed/day in early childhood. There was also a small but positive statistically significant association between the number of different types of vegetables consumed on a given day at 9 months and the amount and variety of vegetables consumed/day in early childhood. Age of initial vegetables introduction and whether vegetables were the first/second food introduced were not consistently related to the amount or variety of vegetables consumed later in childhood. Longer breastfeeding and introduction to a greater variety of vegetables at 9 months may be behaviors to target to increase consumption of a greater variety of vegetables by young children.

Many Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics implemented alternatives to in-person service delivery in response to the COVID-19 pandemic, including virtual visits and electronic document sharing. The objective of this cross-sectional study was to describe WIC participants' experiences with remote service delivery and recertification during the pandemic. Participants included mothers and infants who participated in a WIC-based intervention between June 2019-August 2020. All participants (N = 246) were invited to complete a follow-up survey between November 2020-February 2021; 185 mothers completed the survey. The survey assessed sociodemographics, employment, food security, experiences with remote WIC recertification and service delivery, and experiences with obtaining WIC foods during the pandemic. Average age for mothers was 29.2 ± 6.3 years and for infants was 17.7  ± .2 months; 80% (n = 147) identified as Hispanic. Approximately 34% (n = 62) of participants reported very low or low food security and 40% (n = 64) had difficulties buying WIC foods during the pandemic. Among participants who recalled providing documentation of income and address virtually, the majority felt comfortable providing information via email (60%) and text messaging (72%). Participants reported high levels of satisfaction with remote methods of service delivery, as well as overall satisfaction with the WIC program during the pandemic. While ~ 25% of study participants preferred for all WIC services to remain remote, 75% still desired at least some in-person contact with WIC staff after the pandemic. In conclusion, remote methods of WIC service delivery addressed existing barriers to WIC participation and were well-received by study participants., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To evaluate if children of families with a longer duration of participation in the Special Supplementation Nutrition Program for Women, Infants, and Children (WIC) consume fewer sugar-sweetened beverages (SSB) and more water., Design: A repeated cross-sectional study., Setting: Conducted among representative samples of WIC-participating families in Los Angeles County, California, in 2014, 2017, and 2020., Participants: Children aged 4-59 months participating in WIC., Main Outcome Measures: Daily servings of total SSBs, daily servings of specific types of SSBs, and daily servings of water., Analysis: Multivariable count regression models were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for associations of the duration of family WIC participation with daily servings of total SSBs, water, and specific types of SSBs. Zero-inflated negative binomial regression models were used for total SSBs and specific types of SSBs, and Poisson regression was used for water., Results: Children of families with 2 years of WIC participation consumed significantly fewer daily servings of total SSBs (IRR, 0.95; 95% CI, 0.93-0.98; P = 0.002), fruit-flavored SSBs (IRR, 0.95; 95% CI, 0.91-0.99; P = 0.02), soda (IRR, 0.86; 95% CI, 0.76-0.98; P = 0.02), and water (IRR, 0.99; 95% CI, 0.98 to < 1.00; P = 0.03) than children of families with 1 year of WIC participation. Protective associations for total SSBs, fruit-flavored SSBs, and soda remained statistically significant and increased in magnitude through 10 years of family WIC participation., Conclusions and Implications: Duration of WIC participation was associated with decreased SSB intake by young children. Given the role that increasing water intake in lieu of SSBs plays in child obesity, improving the effectiveness of WIC nutrition education on parental perceptions and provision of fruit-flavored SSBs and water to their children merits detailed evaluation., (Copyright © 2021 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

This study assessed relationships of duration of family Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participation with racial/ethnic disparities in child sugar-sweetened beverage (SSB) and water intake. Child beverage intake and family duration on WIC were collected during three cross-sectional surveys of WIC-participating families in Los Angeles County, California (2014, 2017 and 2020; n = 11,482). The associations of family duration of WIC participation, a proxy for the amount of WIC services received, with daily intake of total SSBs, fruit-flavored SSBs and water were assessed in race/ethnicity strata with multivariable negative binomial and Poisson regression models. Among English-speaking Hispanic children, those of families reporting 10 years of WIC participation consumed 33% and 27% fewer servings of total and fruit-flavored SSBs compared to those of families reporting 1 year on WIC. Among Black children, those from families reporting 5 and 10 years of participation in WIC consumed 33% and 45% more daily servings of fruit-flavored SSBs than those from families reporting 1 year on WIC. Disparities in daily total and fruit-flavored SSB intake between Black and White children increased with longer family duration on WIC. Duration of family WIC participation is associated with healthier beverage choices for infants and children, but does not appear to be equally beneficial across racial/ethnic groups in Los Angeles County.

Background: Bottle-fed infants are at greater risk for overfeeding and rapid weight gain (RWG); evidence-based strategies for promoting healthy bottle-feeding practices are needed., Objective: Our aim was to assess whether policy, systems, and environmental (PSE) strategies for promoting responsive bottle-feeding practices within the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were associated with lower risk for RWG., Design: We conducted a matched-pair cluster randomized trial. PSE strategies were implemented at 3 WIC clinics in Los Angeles County. PSE clinics were compared with 3 matched control clinics. Mothers and infants were assessed when infants were newborn and 3 months and 6 months of age., Participants/setting: Participants were mothers (n = 246) who enrolled their newborn infants (younger than 60 days) into WIC between May and August 2019., Main Outcome Measures: Infant weight was assessed and standardized to sex- and age-specific z scores. RWG was defined as weight-for-age z score change > 0.67. Mothers completed questionnaires assessing responsive and pressuring feeding styles, breast- and bottle-feeding patterns, and perceptions of WIC experiences., Statistical Analyses Performed: Logistic regression with estimation via generalized estimating equations and linear mixed models with repeated measures assessed effects of PSE strategies on categorical and continuous outcomes, respectively., Results: Infants in PSE clinics had significantly lower likelihood of exhibiting RWG (P = .014) than infants in control clinics. Mothers in PSE and control clinics reported similar levels of responsive and pressuring feeding style and similar prevalence of breastfeeding and bottle-feeding. Mothers in PSE clinics trended toward feeling better supported with respect to their decision to bottle-feed (P = .098) and had more stable intentions to stay in the WIC program (P = .002) compared with mothers in control clinics., Conclusions: PSE strategies focused on promoting more inclusive assessment of infant feeding, tailored bottle-feeding counseling, and increased education and support for responsive bottle-feeding were associated with lower risk for RWG among WIC infants., (Copyright © 2022 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the impact of the coronavirus disease 2019 (COVID-19) pandemic on breastfeeding outcomes among participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Southern California. Materials and Methods: Data from the 2020 Los Angeles County triennial WIC Survey were used to examine the impact of COVID-19 on breastfeeding outcomes among WIC participants. Chi-square tests were used to explore the association between the COVID-19 pandemic and breastfeeding outcomes along with hospital-friendly practices. Results: Compared with infants born before March 2020, the percentage of infants who received any breastfeeding at 1 month decreased from 79.66% to 76.96% ( p  = 0.139). The percentage of infants who received any breastfeeding at 3 and 6 months significantly decreased from 64.57% to 56.79% ( p  = 0.001) and from 48.69% to 38.62% ( p  = 0.0035), respectively. The percentage of infants fully breastfed at 1, 3, and 6 months significantly decreased at all time points. Examining hospital practices, there were no differences between the before and during COVID-19 groups. Conclusions: The prevalence of any breastfeeding at 3 and 6 months and fully breastfeeding at 1, 3, and 6 months was significantly lower among mothers who gave birth during the pandemic compared with mothers who gave birth before the pandemic. The shift to remote services delivery and the corresponding reduction in live support of WIC services owing to the pandemic may explain the decline in the breastfeeding rate. As the nation and the WIC program prepare for the postpandemic life, it is critical to ensure that breastfeeding support is met in a hybrid of remote and face-to-face settings.

Early in the COVID-19 pandemic, the U.S. Department of Agriculture (USDA), State governments, and school districts took unprecedented steps to mitigate the pandemic's impact on students' nutrition. To examine the effect of emergency responses on 6-year-old children's nutritional outcomes, this study analyzed longitudinal data from a national study of children's feeding practices, the Special Supplemental Nutrition Program for Women, Infants, and Children-Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2). Findings include no differences in food insecurity prevalence; however, there were shifts in sources of food, with children in the post-COVID-emergency-declaration (post-ED) group consuming more dietary energy from stores and community food programs and less from restaurants and schools than children in the pre-COVID-emergency-declaration (pre-ED) group ( p < 0.01 for all comparisons). Examination of within-person mean differences in 2015 Healthy Eating Index scores and nutrient intakes between ages 5 and 6 years revealed few statistically significant differences between the two groups: children in the post-ED group consumed slightly fewer vegetables ( p = 0.02) and less sodium ( p = 0.01) than their pre-ED peers. Findings suggest emergency efforts to maintain children's nutrition were largely successful in the early months of the pandemic. Research is needed to understand the mechanisms by which emergency efforts contributed to these findings.

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to half of infants born in the United States. The nationally representative WIC Infants and Toddler Feeding Practices Study-2 (ITFPS-2) reported a caloric deficit at 7 months among infants receiving WIC mixed feeding packages, suggesting these infants may be at risk for growth deceleration/faltering. Methods: Longitudinal administrative data collected prospectively from WIC participants in Southern California between 2010 and 2019 were used ( n = 16,255). Infant lengths and weights were used to calculate weight-for-length (WLZ), weight-for-age (WAZ) and length-for-age (LAZ) z-scores at different time points. Growth deceleration/faltering was determined at 9, 12, 18, and 24 months by the change in z-score from the last measurement taken ≤ 6 months of age. Infant feeding was categorized by the food package (breastfeeding, mixed feeding, and formula feeding) infants received from WIC at 7 months. Poisson regression models were used to evaluate the association between WIC infant package at 7 months and deceleration/faltering at 9, 12, 18, and 24 months. Results: The proportion of infants displaying decelerated/faltering growth was low for all infant food package groups. Receiving the WIC mixed feeding package at 7 months of age was not associated with WLZ, WAZ, and LAZ deceleration/faltering growth. Conclusions: Growth deceleration/faltering rates were very low among WIC participating children in Southern California, highlighting the critical role of nutrition assistance in supporting adequate growth in early childhood., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Anderson, Whaley, Crespi, Wang and Chaparro.)

Objective: To determine whether a previously reported association between the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package change and reduced child obesity risk among WIC-participating children in Los Angeles County holds across levels of family income and neighbourhood poverty., Design: Analysis of prospectively collected WIC administrative data. The outcome was obesity at age 4 years (BMI-for-age ≥ 95th percentile). Poisson regression was applied to a matched sample (n 79 502) to determine if the association between the WIC food package change and child obesity was modified by family income (<50 % federal poverty level (FPL), 50-100 % FPL, >100 % but <185 % FPL) and neighbourhood poverty., Setting: Los Angeles County, California., Participants: Children who participated in WIC in Los Angeles County between 2003 and 2016; children were grouped as receiving the old WIC food package (2003-2009) or the new WIC food package (2010-2016)., Results: Receiving the new WIC food package (i.e., post-2009) was associated with 7-18 % lower obesity risk across all family income categories. Neither family income nor neighbourhood poverty significantly modified the association between the WIC food package and child obesity. However, certain sub-groups seemed to benefit more from the food package change than others. In particular, boys from families with income above poverty but residing in the poorest neighbourhoods experienced the greatest reductions in obesity risk (relative risk = 0·77; 95 % CI 0·66, 0·88)., Conclusions: The WIC food package revisions were associated with reduced childhood obesity risk among all WIC-participating families in Los Angeles County, across levels of income eligibility and neighbourhood poverty.

Background: We estimated longitudinal trajectories of body mass index (BMI) z-score and percentile, weight for height (WFH) z-score and percentile, and percentage of the 95th BMI percentile (BMIp95) among low-income Hispanic children ages 2-5 years to provide normative data for this population and compare the behavior of different measures., Methods: Longitudinal height and weight measurements obtained from 18,072 Hispanic children aged 2-5 years enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children in Los Angeles County were analyzed. Trajectories of adiposity-related measures were estimated using mixed models, stratified by sex and BMI percentile at age 2 years., Results: For children in the 5th-85th BMI percentile at age 2 years, all adiposity-related measures rose during ages 2-3.5 years; during ages 3.5-5 years, BMI-based measures increased, BMIp95 decreased, and WFH-based measures were stable. For children exceeding the 85th BMI percentile at age 2 years, measures generally trended downward during ages 2-5 years, except for BMIp95, which had variable trends., Conclusions: Adiposity measures changed at different rates as children grew during ages 2-3.5 years compared to ages 3.5-5 years, and different measures displayed different trends. Studies should consider examining multiple measures and focusing on change relative to a comparison group., Impact: To address the childhood obesity epidemic, information on normative trajectories of adiposity-related measures in at-risk populations of young children is needed. Longitudinal analysis of data collected from low-income Hispanic children during ages 2-5 years revealed different patterns for different adiposity measures and for ages 2-3.5 years versus 3.5-5 years. Child obesity studies should consider examining multiple adiposity measures and focus on change relative to a comparison group to avoid misinterpreting longitudinal patterns.

Objective: Substantial literature has documented adverse childhood experiences' (ACEs) link with poor health in childhood and adulthood. Despite many American low-income families spending more than a third of their income toward housing costs, little research has been published about a link between severe housing-cost burden and ACEs. The objective of this study was to examine the association of severe housing-cost burden to the ACEs to which young, low-income children are exposed., Methods: Participants were 2-5-year-olds who participated in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Los Angeles County. We used data from the 2017 Los Angeles County WIC Survey, a survey of a random sample of all WIC participants living in Los Angeles County. Separate multiple logistic regression analyses were conducted to examine the association of severe housing-cost burden (very difficult to pay for housing) with the ACEs of financial hardship (household food insecurity, extreme poverty, parent's unemployment and underemployment), household dysfunction (parent's poor mental well-being and parent's separation), housing insecurity (doubled up and residential instability), and parent's experience with homelessness., Results: Sixteen percent of children lived in severe housing-cost burdened households and 14% experienced at least 4 ACEs. After adjusting for sociodemographic characteristics and social support, severe housing-cost burden was associated with an increase in the odds of each of the ACEs., Conclusions for Practice: While further research is needed, findings highlight the need for policymakers to provide resources and support for housing-cost burdened children. Also, service providers should identify ACEs among housing cost-burdened children.

Objective: Assess alignment of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant preferences with the National Academies of Sciences, Engineering, and Medicine WIC child food package recommendations and compare differences by race/ethnicity., Methods: Cross-sectional examination of survey responses collected between January and May 2019 from 2,993 California WIC families with children aged 1-4 years., Results: Over half of WIC participants (56.1%) wanted an increase in the amount allocated for fruits and vegetables. Many WIC participants (69.6%) thought the amount of juice offered by WIC was just right. Overall, the majority (91.0%) wanted to substitute more fruits and vegetables for juice. Most were satisfied with the amount of beans (78.4%), peanut butter (78.7%), and milk (88.3%). Preferences differed by race/ethnicity., Conclusions and Implications: Preferences of California WIC participants are highly aligned with the proposed National Academies of Sciences, Engineering, and Medicine changes for increasing fruits and vegetables. Notable differences by race/ethnicity suggest the need for more flexibility., (Copyright © 2020 Society for Nutrition Education and Behavior. All rights reserved.)

Background: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides enough formula to meet the known nutritional needs of infants up to 6 months of age whose mothers report not breastfeeding, but many mothers report WIC providing insufficient formula, indicating potential overfeeding., Objective: To estimate the prevalence of potential overfeeding among formula-feeding WIC participants and identify associated factors., Methods: Potential overfeeding was identified among participants of the longitudinal Infant and Toddler Feeding Practices Study-2 (ITFPS-2) receiving the fully formula-feeding WIC infant package at 1 month of age (n = 1235, weighted n = 197 079). Associations of potential overfeeding with caloric intake, weight and participant characteristics were assessed., Results: Potential overfeeding was identified among 37.41% (95% CI = 33.57-41.25%) of fully formula-feeding infants. Potentially overfed infants were 0.18 kg heavier (P-value = .01), consumed 26 more calories daily (P-value = .004) and were more likely Non-Hispanic White or English-speaking Hispanic (P-value = .007) and highly active at 5 months of age (P-value = .01). Mothers of potentially overfed infants were less likely to agree that breastfeeding is easier than bottle feeding, only mothers can feed breastfed infants, turning away from the bottle indicates satiation, and crying always indicates hunger (P-values .04, .002, .04 and .04 respectively), and more likely to report WIC provides insufficient formula early (1-5 months, P-value <.0001) and late (6-13 months, P-value = .007) in infancy., Conclusions: Potential overfeeding occurs in 37% of fully formula-feeding infant WIC-participants <6 months old. Mothers of these infants may benefit from additional education about the formula needs of their infants and how to recognize infant satiation cues., (© 2020 World Obesity Federation.)

Background: Research has found breastfeeding to be protective of obesity; however, this link remains contentious. We examined longitudinal associations between exclusive breastfeeding duration, growth trajectories and obesity at 4 years among children participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and whether these associations differed in the context of the 2009 WIC food package change, implemented to improve alignment with dietary guidelines and promote breastfeeding., Methods: Longitudinal data from 260 935 WIC-participating children in Los Angeles County, California, 2003-2016, were used to assess the relationship between duration of receipt of the fully breastfeeding package (an exclusive breastfeeding proxy) with childhood growth and obesity using mixed effects and Poisson regression models., Results: Children exclusively breastfed for longer duration had healthier growth trajectories and lower obesity risk at age 4. Compared with infants with no fully breastfeeding package receipt, any receipt (a breastfeeding initiation proxy) was associated with reduced obesity risk. Obesity risk was lowest for boys and girls exclusively breastfed for 7 (risk ratio (RR)=0.73, 95% CI=0.64 to 0.82) and 13 months (RR=0.63, 95% CI=0.58 to 0.69), respectively. Exclusive breastfeeding duration increased, but associations between exclusive breastfeeding duration and growth and obesity were not modified, following the 2009 WIC food package change., Conclusion: Increased duration of exclusive breastfeeding was associated with reduced obesity risk. The greatest incremental benefit was observed going from none to any exclusive breastfeeding, and the maximum cumulative benefit was among children receiving the fully breastfeeding package for more than 6 months. Breastfeeding promotion in WIC remains important for obesity prevention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To describe Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) site-level breastfeeding support practices and associations with breastfeeding outcomes., Design: Secondary analysis of WIC Infant and Toddler Feeding Practices Study-2, including data from interviews with caregivers of infants and interviews and surveys with staff from 27 WIC state agencies and 80 study sites., Participants: A total of 1,235 mothers of breastfed infants participating in the WIC Infant and Toddler Feeding Practices Study-2., Main Outcome Measure: Any and fully breastfeeding 2, 6, and 12 months postpartum., Analysis: Descriptive statistics described WIC site-level breastfeeding supports. Multilevel mixed modeling of breastfeeding at 2, 6, and 12 months, controlling for site- and participant-level characteristics., Results: Five WIC site-level supports were significantly and independently associated with any and fully breastfeeding: access to breastfeeding peer counselors, access to International Board Certified Lactation Consultants, postnatal home visits, allowing any WIC staff member to provide breast pump education, and having a policy not to provide formula during the first 30 days postpartum. Likelihood of any and fully breastfeeding increased with each additional site-level support present (odds ratio = 1.09, 95% confidence interval, 1.06-1.12; and odds ratio = 1.26, 95% confidence interval, 1.21-1.31, respectively)., Conclusions and Implications: Positive associations between site-level supports and breastfeeding at 2, 6, and 12 months were observed. Additional research is needed to understand how site-level supports interrelate and whether specific combinations are more effective, and to identify variations in implementation of breastfeeding supports., (Copyright © 2020 Society for Nutrition Education and Behavior. All rights reserved.)

Objective: To examine factors associated with Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation through 2 years of age., Design: Longitudinal data from the WIC Infant and Toddler Feeding Practices Study-2., Setting: Eighty WIC sites., Participants: The WIC Infant and Toddler Feeding Practices Study-2 participants interviewed through 2 years of age (n = 1,250)., Main Outcome Measure: WIC participation through 2 years of age., Analysis: Multivariate logistic regression and odds ratios., Results: Infants in households with incomes ≤100% of the federal poverty level (FPL) were more than twice as likely as those with incomes above 100% FPL to continue WIC participation through 2 years (odds ratio = 2.22; 95% confidence interval [CI], 1.34-3.66). The odds of WIC participation through 2 years were 2.84 times higher for infants fully breastfed for 6 months or longer compared with infants breastfed for less than 6 months (95% CI, 1.43-5.66). Infants in households in which caregivers reported they made a change in how they fed their family on the basis of something they learned from WIC had 2.60 higher odds of continued WIC participation than infants in households in which caregivers did not report making a change (95% CI, 1.67-4.07)., Conclusions and Implications: In addition to lower household income, longer breastfeeding duration and application of WIC nutrition education are important predictors of WIC participation through 2 years of age., (Copyright © 2019 Society for Nutrition Education and Behavior. All rights reserved.)

Objective: To explore Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants' perspectives about why formula-fed infants are less likely to be recertified at 1 year compared with breastfed infants., Design: Four focus groups of WIC mothers, stratified by language spoken (English or Spanish) and feeding mode (breastfeeding [BF] or formula-feeding [FF])., Setting: Two WIC sites within Los Angeles County, CA., Participants: Mothers of 6- to 12-month-old infants (n = 31) in the WIC program., Phenomenon of Interest: Mothers' perceptions of (1) how WIC supports BF and FF mothers; and (2) experiences of FF mothers in WIC, with a focus on how these experiences may affect desire to recertify their infant in WIC at age 1 year., Analysis: Thematic analysis of verbatim transcripts., Results: Mothers in all focus groups discussed the perceived positive value of BF support, food assistance, nutrition education, referrals, convenient WIC services, and social support from staff. Themes related to experiences of FF mothers included feeling judged for not BF, perceptions of WIC as a formula provider, and perceived difficulties obtaining formula. Mothers indicated that these experiences affected motivations to recertify., Conclusions and Implications: Although WIC provides important and effective support to low-income families, especially related to BF, some FF mothers may feel underserved with respect to support for their feeding decisions., (Copyright © 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about duration of exposure to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in relation to children's diet quality., Objective: The objective of the study was to examine the association between duration of WIC participation and diet quality of 24-month-old children., Design: A national longitudinal observational study was conducted with participants initially enrolled in WIC in 2013. Telephone interviews were conducted with study mothers from 2013 to 2016. Duration of WIC participation was categorized as high, medium, or low based on the number of interviews during which participants reported receiving WIC benefits., Participants: Participants in the WIC Infant and Toddler Feeding Practices Study 2 who had completed a baseline interview and all interviews through 24 months were included; participants who reported discontinuing WIC due to perceived program ineligibility were excluded from analyses (N=1,250). Data were weighted to represent the study-eligible population., Main Outcome Measure: Healthy Eating Index 2015 scores of children at age 24 months were calculated based on 24-hour dietary recalls., Statistical Analyses Performed: Unadjusted analysis of variance examined Healthy Eating Index 2015 scores by WIC participation duration. Multivariate linear regression analysis tested independent effects of WIC duration on Healthy Eating Index 2015 total scores, controlling for sociodemographic factors., Results: After controlling for covariates, WIC participation duration was significantly associated with diet quality. Children in the high duration group had significantly higher Healthy Eating Index 2015 total scores (adjusted mean 59.3, 95% CI 58.6 to 60.1) than children in the low duration group (adjusted mean 55.3, 95% CI 51.6 to 59.0) (P=0.035)., Conclusions: Children who received WIC benefits during most of the first 2 years of life had better diet quality at age 24 months than children who, despite remaining eligible for benefits, discontinued WIC benefits during infancy. Findings suggest nutritional benefits for eligible children who stay in the program longer., Competing Interests: Author Contributions N. S. Weinfield, C. Borger, L. E. Au, S. E. Whaley, L. D. Ritchie, and D. Berman developed the study question. N. S. Weinfield oversaw study management and data collection. C. Borger oversaw data analysis. N. S. Weinfield wrote the first draft of the manuscript with contributions from L. E. Au and L. D. Ritchie. All authors reviewed and commented on subsequent drafts of the manuscript., (Copyright © 2020 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Food packages provided by the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were revised in 2009 to better align them with the Dietary Guidelines for Americans. This study was conducted to evaluate whether the effect of the food package change on childhood obesity varied by the food environment in the neighborhoods where WIC-participating children live., Methods: Administrative data from participating children in Los Angeles County, California (2003-2016) were merged with geocoded food vendor information by neighborhood of residence. Obesity risk at age 4 was compared between children receiving old (2003-2009) and new (2010-2016) WIC food packages using sex-stratified Poisson regression models, with interaction terms between WIC package and neighborhood density (number per square mile) of healthy and unhealthy food outlets., Results: The new food package was associated with a significant decrease in obesity risk. Among boys, the new food package was associated with 8 to 18% lower obesity risk at all healthy and unhealthy food outlet densities, and the association was not modified by neighborhood food outlet density. Among girls, the association of the new food package with obesity risk was protective in neighborhoods with high healthy and low unhealthy food outlet densities, and adverse in neighborhoods with high unhealthy and low healthy food outlet densities. The effect of the new food package among girls was modified by unhealthy food outlet density, with significantly smaller (p-value = 0.004) decreases in obesity risk observed in neighborhoods with higher unhealthy food outlet density., Conclusions: The impact of the food package change was modified by the neighborhood food environment among girls only. Future policy changes should incorporate consideration of ways to mitigate potentially inequitable geographic distribution of the health benefits of policy changes.

Background: Breastfeeding has clear benefits. Yet, breastfeeding practices fall short of recommendations in low-income populations including participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). To promote breastfeeding, it is important to understand breastfeeding-related behaviors such as initiation and maintenance within the context of a complex societal system. For individual women, making choices about infant feeding (whether to breastfeed or formula-feed a newborn, or when to stop breastfeeding) is a dynamic process involving interactions with health professionals, family, peers and workplaces. Integrating behavioral change theories with systems science tools such as agent-based modeling can help illuminate patterns of breastfeeding behaviors, identify key factors affecting breastfeeding behaviors within this complex dynamic system, and estimate the population impact of hypothetical interventions., Methods: An agent-based model (ABM) was developed to investigate the influences of multiple levels of factors affecting breastfeeding behaviors among WIC participants. Health behavioral change theories were applied and stakeholder input obtained to improve the model, particularly during the conceptual design and model specification steps. The model was then used to identify critical points for intervention and assess the effects of five common interventions (improving knowledge through education, implementing Baby-Friendly Hospital Initiative practices, providing postpartum breastfeeding counselling, strengthening partner support, and fostering supportive workplace environments.)., Results: The ABM developed in this study produced outcomes (i.e., breastfeeding rates) that were concordant with empirical data. Increasing the coverage of the five selected interventions produced various levels of improvement in breastfeeding practices in the target population. Specifically, improving breastfeeding knowledge had a positive impact on women's intent to breastfeed, while increasing the availability of the Baby-Friendly Hospital Initiative improved breastfeeding initiation rates. However, neither of these two interventions showed a significant impact on breastfeeding maintenance, which was supported by postpartum breastfeeding counseling, partner support and a supportive workplace environment. These three intervention strategies each improved breastfeeding rates at 6 months from 55.6% to 57.1%, 59.5% and 59.3%, respectively. Increasing the coverage of multiple interventions simultaneously had a synergistic effect on breastfeeding maintenance with their effects being greater than the cumulative effects of increasing the coverage of these interventions individually., Conclusion: The ABM we developed was helpful for understanding the dynamic process of decision-making regarding infant feeding modalities in a low-income population, and for evaluating the aggregated population-level impact of breastfeeding promotion interventions., Competing Interests: The authors have declared that no competing interests exist.

Background: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages were updated. WIC-participating children in Los Angeles County receiving the new food package, compared with the old, had lower obesity risk at age 4., Objective: To determine if the association between the new WIC food package and obesity varies by type of infant WIC food package received., Design: Longitudinal study using administrative data on children participating in WIC in Los Angeles County continuously from birth until age 4. Children were compared across periods: Before (period 1: born 2003-2004), straddling (period 2: born 2005-2008), and after (period 3: born 2009-2011) the food package change. Children were further grouped as Fully Breastfed, Mostly Breastfed, Mostly Formula Fed, and Fully Formula Fed based on the type of food packages received during the first year of life., Participants/setting: WIC-participating children in Los Angeles County between 2003 and 2016 (N=116,991)., Main Outcome Measures: Weight-for-height z-score growth trajectories from 0 to 4 years and obesity (body mass index-for-age≥95th percentile) at age 4., Statistical Analyses Performed: Children were matched across periods on infant feeding group; age, sex, race or ethnicity, and initial weight status; maternal education and language; and family poverty. Sex-stratified piecewise linear spline mixed models and Poisson regression models were fit to the data., Results: No differences across periods were observed for children in the Fully Breastfed group. Boys in the Mostly Breastfed (relative risk [RR]=1.27, 95% CI=1.17 to 1.38), Mostly Formula Fed (RR=1.07, 95% CI=1.02 to 1.13), and Fully Formula Fed (RR=1.13, 95% CI=1.06 to 1.20) groups in period 1 had higher obesity risk than their counterparts in period 3; girls in the Mostly Breastfed group in period 1 had a higher obesity risk than those in period 3 (RR=1.17, 95% CI=1.07 to 1.28)., Conclusions: The association between the WIC food package change and obesity varied by type of infant food package received, with the strongest associations observed for those who were mostly breastfed., (Copyright © 2020 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed the food packages provided to its participants in 2009, to better align them with the Dietary Guidelines for Americans. Previous research found that the 2009 WIC food package change was associated with reduced obesity risk, particularly among breastfed infants but also among those who were never breastfed. The objective of this study was to determine if the new child food package introduced in 2009, including more produce and whole grains for 1-4-year old children, was associated with healthier growth trajectories and reduced obesity risk at age 4 years among children who were exclusively formula fed during infancy., Methods: Administrative data on WIC-participating children in Los Angeles County, 2003-2016, were used (N = 74,871), including repeated measures of weight and length (or height); child's age, gender, and race/ethnicity; maternal education and language; and family poverty. Gender-stratified spline mixed models were used to examine weight-for-height z-score (WHZ) growth trajectories from 0 to 4 years and Poisson regression models were used to assess obesity (BMI-for-age > 95th percentile) at age 4. The main independent variable was duration of receipt (dose) of the new child package, categorized as 0, > 0 to < 1, 1 to < 2, 2 to < 3, 3 to < 4, and 4 years., Results: WHZ growth trajectories were similar for children across new child package dose groups. Boys and girls who were fully formula fed during infancy but received the new child food package for 4 years had a 7% (RR = 0.93; 95%CI = 0.89-0.98) and a 6% (RR = 0.94; 95%CI = 0.89-0.99) lower obesity risk, respectively, compared to children who received the new child food package for 0 years. There were no differences in obesity risk for children receiving < 4 years of the new child package vs. 0 years., Conclusions: Providing healthy foods during childhood to children who were exclusively formula fed as infants was associated with modest improvements in obesity outcomes. While breastfeeding promotion should still be prioritized among WIC participants, providing healthy foods during childhood may provide health benefits to formula fed children, who comprise a sizeable proportion of children served by WIC.