Racial/Ethnic Disparities: a Longitudinal Study of Growth Trajectories Among US Kindergarten Children

Family stress and child BMIz during the COVID-19 pandemic: exploring the mediating effects of cortisol

BACKGROUND

Previous research has suggested that children who are exposed to chronic stress are at greater risk for childhood obesity, however little research has examined the mechanism of this association. This study aimed to investigate the association between family and household stress during the COVID-19 pandemic and children's BMIz, and whether children's hair cortisol concentration (HCC) mediates this association.

METHODS

This study used baseline data from 228 children 2-6 years from the Family Stress Study, a prospective cohort study of families with children 2-6 years. Parents responded to an online survey which assessed family and household stressors including family functioning, home chaos, financial insecurity, food insecurity, parental depression, parenting stress, stressful life events, and COVID-19 stressors. A total family chronic stress index score was calculated from parents' responses on these measures. Hair samples were collected from children to assess their HCC. The Hayes PROCESS mediation macro was used to assess the total, direct, and indirect effect of the family chronic stress index on child BMIz, adjusting for household income and child ethnicity/race.

RESULTS

We found that the family chronic stress index was associated with higher child BMIz (b = 0.815, 95% CI = 0.181-1.449), but this association was not mediated by children's HCC (b = 0.004, CI = -0.042-0.076).

CONCLUSIONS

Future research should continue to investigate hair cortisol as a measure of chronic stress among children younger than 6 years and explore other mechanisms of how chronic stress is associated with children's weight outcomes, such as through parenting practices that influence children's eating behaviour or physical activity, or children's weight-related behaviours.

Added Sugar Intake from Infant Formula and Complementary Foods: A Longitudinal Investigation and Implications for Infant Weight Gain

BACKGROUND

Infant formula contains added sugar, although national recommendations are that added sugar should be avoided for infants.

OBJECTIVES

This study aims to estimate average daily added sugar intake from formula and complementary foods and examine associations between added sugar intake from formula and complementary foods and weight status among infants in low-income households.

METHODS

Between August 2019 and November 2021, mother-infant dyads were recruited from a pediatric clinic primarily serving Medicaid recipients, regardless of feeding type. 24-h feeding recalls were conducted on infants aged 6, 9, and 12 mo. For directly breast-fed infants, we used the average expected milk volume intake by age. Weight-for-age and weight-for-length z-scores were calculated from health record measurements. Descriptives, bivariate tests, and multilevel linear growth modeling were used.

RESULTS

Most participants (n = 234) were African American (39%) or Latino (38%). Infants' daily added sugar intake was on average 7 g from complementary foods and 33 g from formula, with formula being the major source at 6 and 9 mo. Daily intake of calories due to added sugar was significantly higher among formula-fed infants compared with breast milk or sugar-free formula-fed infants (P = 0.034). For every 10 g of added sugar from formula daily, infants' weight-for-length z-scores increased by an average of 0.060 (SE = 0.018, P = 0.001).

CONCLUSIONS

Formula significantly contributes to added sugar intake among infants compared with complementary foods. A significant positive association between added sugar from formula and infant weight gain suggests the need for regulations limiting added sugar in formula and including added sugar information on formula food labels.

A Digital Health Behavior Intervention to Prevent Childhood Obesity: The Greenlight Plus Randomized Clinical Trial

Importance

Infant growth predicts long-term obesity and cardiovascular disease. Previous interventions designed to prevent obesity in the first 2 years of life have been largely unsuccessful. Obesity prevalence is high among traditional racial and ethnic minority groups.

Objective

To compare the effectiveness of adding a digital childhood obesity prevention intervention to health behavior counseling delivered by pediatric primary care clinicians.

Design, Setting, and Participants

Individually randomized, parallel-group trial conducted at 6 US medical centers and enrolling patients shortly after birth. To be eligible, parents spoke English or Spanish, and children were born after 34 weeks' gestational age. Study enrollment occurred between October 2019 and January 2022, with follow-up through January 2024.

Interventions

In the clinic-based health behavior counseling (clinic-only) group, pediatric clinicians used health literacy-informed booklets at well-child visits to promote healthy behaviors (n = 451). In the clinic + digital intervention group, families also received health literacy-informed, individually tailored, responsive text messages to support health behavior goals and a web-based dashboard (n = 449).

Main Outcomes and Measures

The primary outcome was child weight-for-length trajectory over 24 months. Secondary outcomes included weight-for-length z score, body mass index (BMI) z score, and the percentage of children with overweight or obesity.

Results

Of 900 randomized children, 86.3% had primary outcome data at the 24-month follow-up time point; 143 (15.9%) were Black, non-Hispanic; 405 (45.0%) were Hispanic; 185 (20.6%) were White, non-Hispanic; and 165 (18.3%) identified as other or multiple races and ethnicities. Children in the clinic + digital intervention group had a lower mean weight-for-length trajectory, with an estimated reduction of 0.33 kg/m (95% CI, 0.09 to 0.57) at 24 months. There was also an adjusted mean difference of -0.19 (95% CI, -0.37 to -0.02) for weight-for-length z score and -0.19 (95% CI, -0.36 to -0.01) for BMI z score. At age 24 months, 23.2% of the clinic + digital intervention group compared with 24.5% of the clinic-only group had overweight or obesity (adjusted risk ratio, 0.91 [95% CI, 0.70 to 1.17]) based on the Centers for Disease Control and Prevention criteria of BMI 85th percentile or greater. At that age, 7.4% of the clinic + digital intervention group compared with 12.7% of the clinic-only group had obesity (adjusted risk ratio, 0.56 [95% CI, 0.36 to 0.88]).

Conclusions and Relevance

A health literacy-informed digital intervention improved child weight-for-length trajectory across the first 24 months of life and reduced childhood obesity at 24 months. The intervention was effective in a racially and ethnically diverse population that included groups at elevated risk for childhood obesity.

Trial Registration

ClinicalTrials.gov Identifier: NCT04042467.

BMI Growth Profiles Among Black Children from Immigrant and US-Born Families

A large body of research has documented racial/ethnic disparities in childhood obesity in the United States (US) but less work has sought to understand differences within racial groups. Longitudinal studies are needed to describe BMI trajectories across development, particularly for Black children from immigrant families who have been underrepresented in childhood obesity research. The current study utilizes BMI data collected longitudinally from ages 5 to 8 years and growth mixture modeling to (1) identify and visualize growth patterns among Black children from primarily Caribbean immigrant families, and (2) to compare these patterns to growth trajectories among Black children from US-born families. First, we identified four classes or trajectories of growth for Black children from immigrant families. The largest trajectory (70% of the sample) maintained non-overweight throughout the study period. A second trajectory developed overweight by age 8 (25%). Two small trajectory groups demonstrated high rates of moderate and severe obesity-i.e., specifically, a trajectory of accelerated weight gain ending in moderate/severe obesity (3%), and a trajectory of early severe obesity with BMI decreasing slightly with age (2%). We identified a very similar four class/trajectory model among Black children from US-born families, and compared the model to the one for children from immigrant families using multi-group growth mixture modeling. We found that the patterns of growth did not differ significantly between the populations, with two notable exceptions. Among Black children from immigrant families, ∼ 5% were classified into the two heavier BMI trajectories, compared to ∼ 11% of children from US-born families. Additionally, among children with an accelerated weight gain trajectory, children from immigrant families had lower BMIs on average at each time point than children from US-born families. These findings describe the multiple trajectories of weight gain among Black children from immigrant families and demonstrate that although these trajectories are largely similar to those of Black children from US-born families, the differences provide some evidence for lower obesity risk among Black children from immigrant families compared to Black children from US-born families. As this study is the first to describe BMI trajectories for Black children from immigrant families across early and middle childhood, future work is needed to replicate these results and to explore differences in heavier weight trajectories between children from immigrant and US-born families.

The neighborhood food environment modifies the association between infant feeding and childhood obesity

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.

Underweight in the first 2 years of life and nutrition risk in later childhood: a prospective cohort study

BACKGROUND

Children with underweight in the first 2 years have lower body mass index z-score (zBMI) and height-for-age z-score (HAZ) in later childhood. It is not known if underweight in the first 2 years is associated with nutrition risk in later childhood.

OBJECTIVE

(1) Determine the relationship between underweight (zBMI < -2) in the first 2 years and nutrition risk measured by the Nutrition Screening for Toddlers and Preschoolers (NutriSTEP) score from 18 months to 5 years. (2) Explore the relationship between underweight in the first 2 years and the NutriSTEP subscores for eating behaviours and dietary intake from 18 months to 5 years.

METHODS

This was a prospective study, including healthy full-term children in Canada aged 0-5 years. zBMI was calculated using measured heights and weights and the WHO growth standards. NutriSTEP score was measured using a parent-completed survey and ranged from 0 to 68. Nutrition risk was defined as a score ≥21. Linear mixed effects models were used.

RESULTS

Four thousand nine hundred twenty-nine children were included in this study. At enrolment, 51.9% of participants were male. The prevalence of underweight children was 8.8%. Underweight in the first 2 years was associated with higher NutriSTEP (0.79, 95% CI: 0.29,1.29), higher eating behaviour subscore (0.24, 95% CI: 0.03, 0.46) at 3 years and higher odds of nutrition risk (OR: 1.39, 95% CI: 1.07,1.82) at 5 years.

CONCLUSIONS

Children with underweight in the first 2 years had higher nutrition risk in later childhood. Further research is needed to understand the factors which influence these relationships.

Ethnoracial disparities in childhood growth trajectories in Brazil: a longitudinal nationwide study of four million children

BACKGROUND

The literature contains scarce data on inequalities in growth trajectories among children born to mothers of diverse ethnoracial background in the first 5 years of life.

OBJECTIVE

We aimed to investigate child growth according to maternal ethnoracial group using a nationwide Brazilian database.

METHODS

A population-based retrospective cohort study employed linked data from the CIDACS Birth Cohort and the Brazilian Food and Nutrition Surveillance System (SISVAN). Children born at term, aged 5 years or younger who presented two or more measurements of length/height (cm) and weight (kg) were followed up between 2008 and 2017. Prevalence of stunting, underweight, wasting, and thinness were estimated. Nonlinear mixed effect models were used to estimate childhood growth trajectories, among different maternal ethnoracial groups (White, Asian descent, Black, Pardo, and Indigenous), using the raw measures of weight (kg) and height (cm) and the length/height-for-age (L/HAZ) and weight-for-age z-scores (WAZ). The analyses were also adjusted for mother's age, educational level, and marital status.

RESULTS

A total of 4,090,271 children were included in the study. Children of Indigenous mothers exhibited higher rates of stunting (26.74%) and underweight (5.90%). Wasting and thinness were more prevalent among children of Pardo, Asian, Black, and Indigenous mothers than those of White mothers. Regarding children's weight (kg) and length/height (cm), those of Indigenous, Pardo, Black, and Asian descent mothers were on average shorter and weighted less than White ones. Regarding WAZ and L/HAZ growth trajectories, a sharp decline in average z-scores was evidenced in the first weeks of life, followed by a period of recovery. Over time, z-scores for most of the subgroups analyzed trended below zero. Children of mother in greater social vulnerability showed less favorable growth.

CONCLUSION

We observed racial disparities in nutritional status and childhood growth trajectories, with children of Indigenous mothers presenting less favorable outcomes compared to their White counterparts. The strengthening of policies aimed at protecting Indigenous children should be urgently undertaken to address systematic ethnoracial health inequalities.

Current status of weight bias and stigma in pediatrics and the need for greater focus on populations at risk

PURPOSE OF REVIEW

Obesity is one of the most common pediatric chronic conditions in the United States, affecting approximately 20% of American youth and is more common amongst Black, Latino, and Indigenous and low socioeconomic populations. The condition places children and adolescents at increased risk of physical and mental health conditions partly mediated by the weight bias and stigmatization experienced during the potentially vulnerable periods of childhood and adolescence.

RECENT FINDINGS

Weight bias and the resulting stigma are pervasive in society. Children have been shown to internalize this bias and its devaluation, which have been shown to contribute to worsening metabolic and mental health outcomes independently. Studies suggest weight stigmatization more adversely affects Black, Latino, and Indigenous children, suggesting the potential for adverse synergistic effects of these historical biases on such youth.

SUMMARY

Addressing childhood obesity successfully across all racial, ethnic, and socioeconomic lines requires addressing weight bias and stigma. Steps toward this end include collaborative efforts to promote cross-cultural competence and upstander bias education and training for those who care for children, person-centered communication, and a culture of inclusivity across governmental, healthcare, educational, entertainment, and advertising sectors.

Ultra-processed food consumption and BMI-Z among children at risk for obesity from low-income households

OBJECTIVE

To evaluate the association between baseline ultra-processed food consumption in early childhood and child BMI Z-score over 36 months.

METHODS

We conducted a prospective cohort analysis as a secondary data analysis of the Growing Right Onto Wellness randomised trial. Dietary intake was measured via 24-h diet recalls. The primary outcome was child BMI-Z, measured at baseline and at 3-, 9-, 12-, 24- and 36-month timepoints. Child BMI-Z was modelled using a longitudinal mixed-effects model, adjusting for covariates and stratifying by age.

RESULTS

Among 595 children, median (Q1-Q3) baseline age was 4.3 (3.6-5.0) years, 52.3% of the children were female, 65.4% had normal weight, 33.8% were overweight, 0.8% were obese and 91.3% of parents identified as Hispanic. Model-based estimates suggest that, compared with low ultra-processed consumption (300 kcals/day), high ultra-processed intake (1300 kcals/day) was associated with a 1.2 higher BMI-Z at 36 months for 3-year-olds (95% CI = 0.5, 1.9; p < 0.001) and a 0.6 higher BMI-Z for 4-year-olds (95% CI = 0.2, 1.0; p = 0.007). The difference was not statistically significant for 5-year-olds or overall.

CONCLUSIONS

In 3- and 4-year-old children, but not in 5-year-old children, high ultra-processed food intake at baseline was significantly associated with higher BMI-Z at 36-month follow-up, adjusting for total daily kcals. This suggests that it might not be only the total number of calories in a child's daily intake that influences child weight status, but also the number of calories from ultra-processed foods.

Time-Varying Associations between Food Insecurity and Infant and Maternal Health Outcomes

BACKGROUND

Food insecurity (FI) is dynamic for families and adversely affects infant and maternal health. However, few studies have examined the longitudinal impact of FI on infant and maternal health.

OBJECTIVES

We aimed to examine the relation between food insecurity in the first year of life and infant and maternal health outcomes. We hypothesized FI would be associated with poorer infant and maternal health outcomes.

METHODS

We conducted a retrospective cohort study of 364 infants 12-15 months and their caregivers receiving care at a single primary care clinic. The exposure of interest was food insecurity measured during well-child checks using a validated 2-item screening tool. The primary outcome was infant weight-for-length z score. Secondary outcomes included infant log-transformed ferritin, infant hemoglobin, infant lead concentrations, and maternal depression, assessed by the Edinburgh Postnatal Depression Scale. Unadjusted and adjusted effects were estimated using generalized mixed linear models, and the linear effect of visit time was tested using likelihood ratios.

RESULTS

In adjusted models, no overall association between FI and infant weight-for-length z score was observed; however, FI male infants had lower weight-for-length z scores than female infants (P = 0.05). FI infants had 14% lower log ferritin concentrations per month of exposure to FI. FI was positively associated with maternal depression (IRR 5.01 [95% CI 2.21-11.3]).

CONCLUSIONS

Food insecurity can have longitudinal and demographically-varied associations with infant and maternal outcomes that warrant further exploration.

Neighborhood Socioeconomic Disadvantage and Childhood Body Mass Index Trajectories From Birth to 7 Years of Age

BACKGROUND

The epidemic of increasing childhood overweight and obesity is a major global health concern, with local contextual factors identified as possible contributors. Robust research is needed to establish an evidence base supporting health policy decisions to reverse the trend. We aimed to examine the association between neighborhood socioeconomic disadvantage and trajectories of body mass index (BMI) from birth to age 7.

METHODS

The present study included 11,023 children born within the Southwest Finland Birth Cohort who were free of severe conditions affecting growth with adequate exposure and growth data. We obtained child growth data until school age from municipal follow-up clinics. We based cumulative childhood neighborhood socioeconomic disadvantage on the average annual income, unemployment, and level of education in a residential area defined using a geographic grid at a spatial resolution of 250 m by 250 m.

RESULTS

Cumulative neighborhood socioeconomic disadvantage was associated with distinct childhood BMI z score trajectories from birth to age 7. Despite being born in the lowest BMI z scores, children growing up in disadvantaged neighborhoods subsequently exhibited a trajectory of increasing BMI z scores starting at 4 years of age, ending up with a higher risk of overweight at the end of the follow-up (30%) as compared with children living in more affluent neighborhoods (22%). The corresponding risk of obesity was 5 % for those in affluent neighborhoods and 9 % and those in disadvantaged neighborhoods.

CONCLUSION

Cumulative exposure to neighborhood socioeconomic disadvantage is independently associated with unfavorable BMI development and obesity in childhood.

Mixed Infant Feeding Is Not Associated With Increased Risk of Decelerated Growth Among WIC-Participating Children in Southern California

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.

Racial and Ethnic Disparities in Childhood Growth Trajectories

Childhood overweight and obesity are a primary social and public health concern. Over the past 30 years, rates of childhood overweight and obesity in the United States of America (USA) have drastically increased, particularly among Black and Latino/a populations. However, they tend to be underrepresented in the childhood obesity literature. This study expands previous literature by identifying different BMI growth trajectories for Black, Latino/a, and White children from birth to age nine. This study found a high prevalence rate of overweight and obesity in a predominantly low-income minority group. Using growth-based trajectory modeling, this study also found different growth trajectories by racial/ethnic groups, with Latino/a children having the most concerning growth trajectories from birth to 9 years. These findings demonstrate that ethnic/racial disparities in childhood overweight and obesity start as early as birth, indicating the need to devote more attention from researchers and health policy-makers to address these disparities as early as possible.

Perinatal determinants of growth trajectories in children born preterm

BACKGROUND

A growing amount of evidence indicates in utero and early life growth has profound, long-term consequences for an individual's health throughout the life course; however, there is limited data in preterm infants, a vulnerable population at risk for growth abnormalities.

OBJECTIVE

To address the gap in knowledge concerning early growth and its determinants in preterm infants.

METHODS

A retrospective cohort study was performed using a population of preterm (< 37 weeks gestation) infants obtained from an electronic medical record database. Weight z-scores were acquired from discharge until roughly two years corrected age. Linear mixed effects modeling, with random slopes and intercepts, was employed to estimate growth trajectories.

RESULTS

Thirteen variables, including maternal race, hypertension during pregnancy, preeclampsia, first trimester body mass index, multiple status, gestational age, birth weight, birth length, head circumference, year of birth, length of birth hospitalization stay, total parenteral nutrition, and dextrose treatment, were significantly associated with growth rates of preterm infants in univariate analyses. A small percentage (1.32% - 2.07%) of the variation in the growth of preterm infants can be explained in a joint model of these perinatal factors. In extremely preterm infants, additional variation in growth trajectories can be explained by conditions whose risk differs by degree of prematurity. Specifically, infants with periventricular leukomalacia or retinopathy of prematurity experienced decelerated rates of growth compared to infants without such conditions.

CONCLUSIONS

Factors found to influence growth over time in children born at term also affect growth of preterm infants. The strength of association and the magnitude of the effect varied by gestational age, revealing that significant heterogeneity in growth and its determinants exists within the preterm population.

Predicting Early Emergence of Childhood Obesity in Underserved Preschoolers

OBJECTIVE

To determine the magnitude of risk of factors that contribute to the emergence of childhood obesity among low-income minority children.

STUDY DESIGN

We conducted a prospective cohort analysis of parent-child pairs with children aged 3-5 years who were nonobese (n = 605 pairs) who participated in a 3-year randomized controlled trial of a healthy lifestyle behavioral intervention. After baseline, height and weight were measured 5 times over 3 years to calculate body mass index (BMI) percentiles and classify children as normal, overweight, or obese. Multivariable logistic regression was used to estimate the odds of obesity after 36 months. Predictors included age, sex, birth weight, gestational age, months of breastfeeding, ethnicity, baseline child BMI, energy intake, physical activity, food security, parent baseline BMI, and parental depression.

RESULTS

Among this predominantly low-income minority population, 66% (398/605) of children were normal weight at baseline and 34% (n = 207/605) were overweight. Among normal weight children at baseline, 24% (85/359) were obese after 36 months; among overweight children at baseline, 55% (n = 103/186) were obese after 36 months. Age at enrollment (OR 2.11, 95% CI 1.64-2.72), child baseline BMI (OR 3.37, 95% CI 2.51-4.54), and parent baseline BMI (OR for a 6-unit change 1.36, 95% CI 1.09-1.70) were significantly associated with the odds of becoming obese for children.

CONCLUSIONS

The combination of child age, parent BMI, and child overweight as predictors of child obesity suggest a paradigm of family-centered obesity prevention beginning in early childhood, emphasizing the relevance of child overweight as a phenotype highly predictive of child obesity.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01316653.

Environmental and birth characteristics as predictors of short stature in early childhood

AIM

To evaluate for environmental and birth characteristic predictors of short stature in a large nationally representative sample.

METHODS

We evaluated 10 127 children from the Early Childhood Longitudinal Study-Kindergarten 2011 cohort, using univariate and multivariable linear and logistic regression to evaluate factors associated with short stature (height <3rd percentile) at kindergarten through second grade. Predictors included birthweight, preterm status, sex, parental education, parental income and race/ethnicity.

RESULTS

Lower birthweight was associated with short stature, with each decreasing kilogram having a 2.45 adjusted odds ratio (aOR; 95% confidence interval [CI] 1.81, 3.33) of short stature for term children in second grade. Preterm children (compared to term children) had an aOR of 2.23 (CI 1.32, 3.78) for short stature. Other predictors of short stature included female sex and lower parental income. African American children had a lower risk of short stature (aOR 0.34, CI 0.14, 0.82) compared to white children.

CONCLUSION

Predictors of short stature include lower birthweight, preterm status, female sex and parental income. Socio-economic disparities and race/ethnicity further influenced height. These data may assist paediatricians in considering contributors to stature outcomes by early school age.

Not so implausible: impact of longitudinal assessment of implausible anthropometric measures on obesity prevalence and weight change in children and adolescents

PURPOSE

Implausible anthropometric measures are typically identified using population outlier definitions, conflating implausible and extreme measures. We determined the impact of a longitudinal outlier approach on prevalence of body mass index (BMI) categories and mean change in anthropometric measures in pediatric electronic health record data.

METHODS

We examined 996,131 observations from 147,375 children (10-18 years) in the ADVANCE Clinical Data Research Network, a national network of community health centers. Sex-stratified, mixed effects, linear spline regression modeled weight, height, and BMI as a function of age. Longitudinal outliers were defined as observations with studentized residual greater than |6|; population outliers were defined by Centers for Disease Control-defined z-score thresholds.

RESULTS

At least 99.7% of anthropometric measures were not extreme by longitudinal or population definitions (agreement ≥ 0.995). BMI category prevalence after excluding longitudinal or population outliers differed by less than 0.1%. Among children greater than 85th percentile at baseline, annual mean changes in anthropometric measures were larger in data that excluded longitudinal (girls: 1.24 inches, 12.39 pounds, 1.53 kg/m2; boys: 2.34, 14.08, 1.07) versus population outliers (girls: 0.61 inches, 8.22 pounds, 0.75 kg/m2; boys: 1.53, 11.61, 0.48).

CONCLUSIONS

Longitudinal outlier methods may reduce underestimation of anthropometric change in children with elevated baseline values.

Exploring Brazilian Immigrant Mothers' Beliefs, Attitudes, and Practices Related to Their Preschool-Age Children's Sleep and Bedtime Routines: A Qualitative Study Conducted in the United States

In the United States (US), racial/ethnic minority children, low-income children, and children of immigrant families are at increased risk of childhood obesity. Mounting evidence documents that sleep duration and sleep quality are important modifiable factors associated with increased risk of obesity among preschool-aged children. The number of Brazilian immigrants in the US is increasing, yet no existing research, to our knowledge, has examined factors affecting sleep and bedtime routines of children of Brazilian immigrant families. Therefore, the purpose of this qualitative study was to explore Brazilian immigrant mothers' beliefs, attitudes, and practices related to sleep and bedtime routines among preschool-aged children. Seven focus group discussions (FGDs) were conducted with 37 Brazilian immigrant mothers of preschool-age children living in the US. The audio-recordings of the FGDs were transcribed verbatim in Portuguese without identifiers and analyzed using thematic analyses. Mothers also completed a brief questionnaire assessing socio-demographic and acculturation. Analyses revealed that most mothers were aware of the importance of sleep and sleep duration for their children's healthy growth and development. Mothers also spoke of children needing consistent bedtime routines. Nevertheless, many mothers reported inconsistent and suboptimal bedtime routines (e.g., lack of predictable and orderly bedtime activities such as bath, reading, etc. and use of electronics in bed). These suboptimal routines appeared to be influenced by day-to-day social contextual and environmental factors that are part of Brazilian immigrant families' lives such as parents' work schedule, living with extended family, living in multi-family housing, neighborhood noise, etc. Analyses identified several modifiable parenting practices related to young children's sleep and bedtime routines (e.g., irregular bedtime, late bedtime, inconsistent bedtime routines, use of electronics in bed, etc.) that can be addressed in parenting- and family-based obesity prevention interventions. Interventions should consider the social context of the home/family (e.g., parents' work schedules) and the environment (e.g., multi-family housing; neighborhood noise, etc.) faced by Brazilian immigrant families when developing health promotion messages and parenting interventions tailored to this ethnic group.