>> Good afternoon. Good evening. Or good morning. Depending on from when andwhere you’re joining us. I’m Dr. Phoebe Thorpe, and itis my pleasure to welcome you to CDC public healthgrand rounds. Maternal, infant andearly childhood nutrition, the 1,000 day windowof opportunity. We have an exciting session. So let’s get started. Public health grand rounds hascontinuing education available for physicians. Nurses. Veterinarians. Health educators. Pharmacists. And others. The course code ispublic health, is PHGR10. Please see our websiteor the TCO website for additional information. Grand rounds is availableon the web and all your favoritesocial media sites.Please send the questionsto firstname.lastname@example.org. And we’ll try toinclude them in the Q&A at the end of today’s session. Want to know more? We have a featuredvideo segment on YouTube and our website calledBeyond the Data. Which is posted afterthe session. This month’s segmentfeatures my interview with Lucy Sullivanfrom the 1,000 days. We have also partnered withthe CDC public health library to feature scientificarticles about this session. The full listing is availableat cdc.gov/scienceclips. In addition to ouroutstanding speakers, I’d like to take a moment to acknowledge theimportant contributions of the individuals listed here. It does take a village. Thank you. Here is a previewof our July session. Please join us on theweb at your convenience. And now for a few words from CDC’s deputydirector, Dr. Schuchat. >> Well, thanks, Phoebe. And it’s great tosee you all here. And welcome to our first inthe series of grand rounds on the Shanley campus forthose joining us in person.And welcome to ourgreat speakers. A thousand days from nowis going to be March 2022. So have that date in mind asyou learn from our speakers. The first thousand daysrefers to an important time for human growthand development. From conception through toa child’s second birthday, optimal nutrition is criticalfor brain development. Healthy growth. And lifelong health. Now, today I want togive you a challenge. You’re going to be hearingfrom four terrific speakers about what you doduring pregnancy. What you, what happens to achild in those first two years.The food they eat. The vitamins and mineralsthat they should consider. Whether they’re breastfedor not. And a number of otherfactors that turn out to be extremely importantto what happens as we develop. But as I was trying to thinkof how to begin welcoming you to this session, I was trying togo for a really simple message. And I couldn’t get there. So I would like youto be challenged to listen to what you hear. And then come up with yourown solution to the equivalent of Michael Polin’s adviceabout eating for us grown ups.The idea of, eat food. Not too much. Mostly plants. Really easy to remember. If we can do that forthe thousand days, I think that we couldhave T-shirts. So I really hope that as you’rehearing an enormous amount of really important informationthat is actionable for any of you who are pregnant or havea loved one who’s pregnant. And any of you withsmall children. That we should try to getthat really important medical and public health advice downto things that are really easy for consumers and healthcareproviders to remember. With that I’m really lookingforward to these talks. And welcome to the session. >> Thank you, Dr. Schuchat. And now for our firstspeaker, Dr. Sharma. >> Good afternoon and welcome. The first thousanddays is a continuum, beginning at pregnancyand ending at the child’s second birthday. While good nutrition isimportant throughout the lifespan, optimum nutritionduring these first 1,000 days is essential for maternal health.Child survival. Growth and neurodevelopment. And laying the foundationfor overall health and well-being throughout life. During this 1,000-dayperiod, growth rates and brain developmentare at their peak. Nearly 80 percent of braindevelopment happens before age two. Some vitamins and mineralsare particularly important to support the highrate of growth and brain metabolismduring this period. Nutritional deficienciescan have significant and severe consequences. And a well-knownexample is folic acid.A B vitamin that’sessential, that’s needed before and during early pregnancy toprevent serious birth defects of the brain and spine. Two important mineralsalso essential for growth and brain developmentare iron and iodine. During pregnancy there’sa substantial increase in the iron requirement neededto support the expansion of blood volume in the motherand fetal placental growth. Iron is required to makehemoglobin, the component of our blood cellsthat transport oxygen. Iron deficiency isa common cause of anemia or low hemoglobin. Without enough iron, tissues and organs can’t getthe oxygen they need. Iron is also a key determinant of neural developmentaffecting brain structures. Neurotransmitter systems. And myelination of nerve fibers. When iron stores are low,iron is preferentially used for hemoglobin synthesis.Leaving the brain at riskfor abnormal development, even in the absence of anemia. Iodine is also critical forbrain development and growth. Iodine is a essentialcomponent of thyroid hormones. Which are the key driversof metabolic activity. During pregnancy, thebaby’s thyroid begins to produce thyroidhormone on its own. But remains dependent onthe mother for ingestion of adequate amounts of iodine. Iron and iodine deficiencyin pregnancy and early childhoodare associated with poor birth outcomesin physical growth.Impaired cognitiveand motor development. And poor quantitativeand language abilities. And, importantly, like cracksin a foundation, deficiencies in this sensitive 1,000-dayperiod, even mild deficiencies, can result in long-lastingabnormalities. Even if the deficiencyis later resolved. During pregnancy, thehealth, nutritional status and eating habits of a pregnantwoman are directly connected to the growth andhealth of her infant. A woman’s weight whenshe becomes pregnant and her weight gain duringpregnancy are important predictors of manypregnancy and health outcomes. For example, too littleweight gain is associated with babies being borntoo small or too early. And too much weightgain is associated with high birthratecesarian delivery and postpartum weight retention. There’s specific recommendations for how much weight a womanshould gain during pregnancy, depending on herprepregnancy weight status. The quality of a mother’s dietinfluences the availability of nutrients needed tosupport a healthy pregnancy and her baby’s developmentand nutrient stores.A prenatal vitaminis recommended to supplement the dietwith vitamins and minerals. Dr. Kominiarek will bepresenting on strategies to improve maternal nutrition. During infancy, from birththrough the first year, breastfeeding is the best sourceof nutrition for most infants. And gives baby’s thehealthiest start to life by supporting a strongimmune function. And protecting infantsfrom illness and infection.Breastfeeding reduceshealth risks for both the motherand the baby. For example, infants who arebreastfed have a reduced risk of ear and respiratoryinfections. Asthma and obesity. And among mothers,breastfeeding reduces risk of high blood pressure. Type two diabetes. And some types of cancers. Because the benefits ofbreastfeeding on health, low rates of breastfeedingadd $3 billion per year in total medical costsfor mothers and babies in the U.S.The WorldHealth Organization and the American Academyof Pediatrics recommends that babies are fed only breastmilk for about six months. And as complementaryfoods are introduced, continue breastfeeding for atleast one to two years of age. The dietary patternsestablished in infancy and early childhoodcan set the foundation for healthy eating habits. At about six months of age, children can begineating nutrient-rich, complementary foodsto help fuel growth and ongoing brain development.Giving children foodswith a variety of tastes and textures can help themdevelop fine motor skills. Chewing skills. And learn to accept andlike a variety of foods. Importantly, the nutrientrequirements relative to caloric requirementsof young children is high. So there’s littleroom for high-calorie, non-nutrient dense foods. For example, youngchildren are unlikely to get enough iron daily ifthey’re not fed iron-rich foods. Next, I’ll present someof the troubling trends in the nutritional healthof pregnant women, infants and toddlers in the U.S. Overhalf of births are to women who begin pregnancyabove a healthy weight.That is, overweightor with obesity. And there are notabledisparities across racial and ethnic groups. Further, only 1/3 of womengain weight during pregnancy within recommendationsshown here in green. Nearly 1/2 gain weight above recommendations,shown in maroon. And this is particularlycommon among women who are starting pregnancyoverweight or with obesity. With about 60 percentgaining above recommendations. Overall, 16 percentof pregnant women in the U.S. haveiron deficiency. And the prevalence of irondeficiency is lowest among non-Hispanic whites. And higher among otherracial and ethnic groups. Iron deficiency is also highestlater in pregnancy when the need for iron is at its highest. Iodine status of pregnant women in the U.S.Has beeninsufficient for many years. This is supported by the findingthat, although about 75 percent of pregnant women reporttaking a dietary supplement. Less than 20 percenttook a dietary supplement that contained iodine. Breastfeeding rates have beenincreasing in the U.S. However, the majority of babiesare still not breastfed in accordance withrecommendations. While 83 percent of infantsoverall are ever breastfed, this means almost one in fivebabies are never breastfed. We also have disparities. Nearly 1/3 of non-Hispanic blackinfants are never breastfed. Further, while manyinfants start with exclusive breastfeeding, we see that most are notmeeting recommendations in the first year. Specifically, only 25 percent of infants are exclusivelybreastfed through six months. And only 36 percent of infantsare breastfeeding at 12 months. Dr. Perez-Escamilla willbe presenting on strategies to improve breastfeeding rates. The diets of infants and toddlers mirror theadult American diet. Too few fruits and vegetables and too much addedsugars and salt. These dietary patterns areputting our children’s health and neurodevelopment at risk.One in four one-year-olds do notconsume the recommended dietary allowance of iron. And 15 percent of one-year-oldshave iron deficiency. Among one-year-oldchildren on a given day, fewer than half haveeaten a vegetable. And one in three drinks asugared-sweetened beverage. These early nutritionalpatterns can affect growth by. Two to five years of age, 14 percent of childrenhave obesity. And the burden of malnutrition,including both undernutrition and overweight and obesity, isexacerbated by food insecurity. In the U.S., nearly one infive children under six years of age live in afood-insecure household. These children are at evengreater risk of health and developmental problemscaused by poor nutrition. Our final speaker, Dr. Greer,will be presenting more on complementary feeding.There are opportunities to improve nutrition duringthese first 1,000 days in the health of mothersand children in America. And I’ll highlight two. First, the dietary guidelinesfor Americans is the cornerstone of federal nutritionpolicy and programs. And provides food-basedrecommendations to meet nutritional needs. Promote health. And prevent diet-relatedchronic disease. Today guidance is only been for individuals twoyears of age and older. However, the upcoming 2020addition will include dietary guidance for theunique nutritional needs of pregnant women andchildren from birth to age two for the first time. Second, there’s anopportunity to focus research and surveillance efforts ongaps in our understanding of nutrient intake and nutritional deficienciesamong pregnant women and children under two. Currently we have little data on nutritional deficiencies,like iron by state. And our national surveillancesystems, including NHANES, do not include enough pregnantwomen and young children to allow for precise estimates without grouping manyyears of data together. We also have no data on nutritional deficienciesamong children under one. Better research andsurveillance data can be used to improve recommendations. Target interventions. And inform policiesand programs. Our next speakers will highlightadditional opportunities to improve nutrition duringthese first critical 1,000 days.Starting with nutritionduring pregnancy, I’d like to introduceDr. Michelle Kominiarek. Thank you. [ Applause ] >> Perhaps one of the bestways to plan for a pregnancy is to optimize one’sweight and nutrition. Pregnancy is not a timefor dieting or weight loss. So issues of weightand nutrition need to be addressed priorto pregnancy. Several national societies,such as the American College of Obstetriciansand Gynecologists, recommend weight loss priorto pregnancy for women with overweight or obesity. However, the magnitude ofthe weight loss varies. With some recommending that women reach a normal bodymass index prior to pregnancy. And others recommending aweight loss of 5 to 7 percent from their current weight. Health behavior changes,such as diet and exercise, are typically the firstapproach to weight loss. In fact, the 2012 United StatesPreventive Services Task Force Guidelines state that all adultswith a body mass index greater than or equal to 30 shouldbe offered or referred to intensive multicomponentbehavior interventions for weight loss. In response to theguidelines, the American College of Obstetricians and Gynecologists createdan obesity toolkit.This toolkit offers resources to help providers addressoverweight and obesity in their daily practices. The toolkit contains severalresources for providers. For example, it has downloadableforms and web links on how to screen patients for obesity. How to assess theirreadiness for weight loss. And how to assess forobesity-related risk factors. Resources for treatmentoptions — such as lifestyle, medications and surgery — are also availablein several formats. The toolkit also hasresources for coding. Optimum nutrition is just asimportant to achieve prior to pregnancy as isoptimal weight. Nutrition during pregnancyhas a direct influence, not only on fetalgrowth, but also on infant and childhood outcomes. Several decades ago welearned of the association between folate and neuraltube defects or spina bifida. All women who are pregnantor who are planning or able to become pregnant shouldtake a daily supplement of folic acid dailyto reduce the risk for neural tube defects. There are also associationsbetween iodine intake and fetal brain development. Several societies, includingthe American Thyroid Association and the American Academy ofPediatrics, recommend that women who are planning a pregnancysupplement their iodine intake.Because maternal anemia islinked to adverse outcomes, women should also optimize ironstores prior to conception. One of the easiest ways tomeet these requirements is to take a prenatal vitamin daily at least one monthprior to conception. The current guidelines forweight gain were published in 2009 by the Instituteof Medicine. Now known as the NationalAcademy of Medicine. And they’re shown inthe accompanying table. Of note, the guidelinesare based on a woman’s body massindex prior to pregnancy. Such that women whoare underweight prior to pregnancy are recommended togain a higher amount of weight. And women with obesity priorto pregnancy are recommended to gain a lower amountof weight. Inadequate or excessiveweight gain is associated with several maternaland offspring outcomes, as Dr. Sharma mentionedin her presentation. According to studies fromnational databases, the majority of women in the United Statesexceed their weight gain goals. Prenatal care providershave an important role in helping women meettheir weight gain goals.Providers often comment that they don’t haveadequate training in nutrition or weight management issues. And, as a result, they donot feel comfortable talking to patients aboutdiet and weight. Providers also may not be awarethat the guidelines that need to be adapted for a woman’s bodymass index prior to pregnancy. Instead of just recommendingthe same amount of weight to all women. When patients are asked abouttheir weight gain counseling, many don’t recallbeing counseled. And weight gain goals below and above the guidelinesare commonly reported. It is important for providers to communicate thecorrect weight gain goals. Because studies show that womenwho recall receiving counseling with the correct goals actuallywere more likely to reach them. Next, we’ll reviewstrategies that providers and patients can use tohelp women meet their goals.Here are some suggestionsfor providers. Providers can dispelmyths about eating in their everydayprenatal care practices. Women receive advice fromfamily, friends and social media about health behaviorsduring pregnancy. Many of which contradictclinical advice and evidence-based medicine. Themes such as eating fortwo and the harms of exercise to a fetus are examplesof conflicts. Providers can dispel thesemyths by saying that eating for two means eating twice ashealthy, not twice as much. Most women only need to consume300 additional calories per day in the second andthird trimesters. The figure in this slide givessix examples of serving sizes that all contained 300 calories. But patients arefrequently surprised to learn that a greater amount of fruitsand vegetables can be consumed in comparison toservings that are higher in simple carbohydrates. Physical activity issafe during pregnancy. Very few women havecontraindications to exercise during pregnancy. The physical activity guidelines for Americans recommend150 minutes per week of moderate intensity, aerobicactivity during pregnancy. The American Collegeof Obstetricians and Gynecologists also recommendthat women engage in 30 minutes of physical activityevery day during pregnancy to maintain physical fitness.The box gives examples ofexercises that are safe to perform in pregnancy. As shown in the top box. As well as activities that should be avoidedduring pregnancy. As shown in the boxon the bottom. Behavior interventionsare interventions designed to affect the actionsthat individuals take with regard to their health. During interventions forweight gain, women either meet with nutritionists toreceive counseling on diet. Food choices. And food portions. Or meet with exercisephysiologists or coaches to learn about and performsafe exercises routinely during pregnancy. In some instances theinterventions combine both diet and exercise regimens. Meta analysis of 49 randomizedcontrolled trials consisting of over 11,000 women hadvery promising findings. Compared to the controlgroup, women who participated in either diet or exerciseintervention during pregnancy were 20 percent less likelyto have excessive weight gain.Health behavior interventions for weight gain areactive areas of research. However, there aresome limitations to the current studies. For example, not all womenand providers have access to these intensivelifestyle interventions. And even though there may be apositive affect on weight gain, the studies have not shownas great of an improvement in other important outcomes. Such as cesariandelivery and birth weight. Another way that both providersand patients can work together to achieve weight gain goals is to track their weightgain across the pregnancy. There are paper versions of thecharts I’ve shown in the figure. But many electronic medicalrecord systems have the ability to graphically displayweight gain across pregnancy. Weight gain trackers arealso available in apps or online for patients. In this technicalage of smartphones and activity trackers,the graphical depiction of the weight changes helpswomen understand their progress and track their own goals. In doing so, this empowers women to take ownership oftheir health care.Next, we’ll addresssome nutritional aspects of pregnancy. As we heard in the prior talk, iron needs increaseduring pregnancy. Iron deficiency isthe leading cause of anemia during pregnancy. And anemia in pregnancy,particularly when it’s severe, increases the riskfor preterm birth. Low birth weight. And maternal death dueto postpartum hemorrhage. Non-Hispanic black women and woman who’ve had bariatricsurgery are the groups at highest risk foriron deficiency. Routine screening for anemiaduring pregnancy is recommended at the first prenatal visit andagain in the third trimester. Iron deficiency can betreated with diet adjustments to increase iron-rich foodsand oral iron supplementation. But parenteral or intravenousiron is the next line of treatment if there’s noimprovement from the oral iron. At every delivery the umbilicalcord is clamped and cut. During a process calleddelayed cord clamping, the procedure is the same,but the timing occurs at least 30 secondsafter the delivery. Studies have shown thatdelayed cord clamping improves hemoglobin levels at birth.And iron stores for the firstseveral months for infants that are born at term. Studies have also showed that delayed cordclamping improves transitional circulation. Decreases the needfor blood transfusion. And lowers the incidenceof adverse outcomes. Such as necrotizingenterocolitis and intraventricularhemorrhage in preterm infants. Delayed cord clampingis a practice that is becoming more routinelyperformed during deliveries in the United States. There’s also evidence that delayed umbilical cordclamping cannot only improve iron parameters, but alsoincrease brain myelin. And this is according to arandomized controlled trial in infant follow-upat four months. Current studies are targetingthe relationship between iron and critical neurodevelopmentaloutcomes. Another active area of research. So concerns for maternalnutrition do not end at delivery. Women are still advised toconsume additional calories, approximately 500 a day. Providers frequently recommend to continue a prenatal vitaminsupplement during breastfeeding. But most women may notrequire supplements if they have a balanceddiet and no known vitamin or mineral deficiencies. The amount of weight gain duringpregnancy is still an important topic, as up to 75percent of women weigh more than their prepregnancyweight at one year postpartum.Postpartum weightretention or the failure to lose weight gainedduring pregnancy by one year postpartum increasesthe risk for adverse outcomes in future pregnancies. And influences awoman’s long-term health by increasing her risk for developing problemslater in life. Such as hypertensionand diabetes. In summary, optimalnutrition before and during pregnancyrequires attention to, not only diet quality,but diet quantity. As well as vitamin andmineral supplements. Excessive weight gain isvery common for women. But meeting weight gain goals through health behaviorinterventions is an active area of research. Approaches to improve anemia and iron deficienciesinclude routine screening for anemia during pregnancy. And delayed umbilicalcord clamping. Next Dr. Perez-Escamilla willtalk to us about the importance of breastfeedingfor infant outcomes. And how we can supportwomen during breastfeeding. Thank you. [ Applause ] >> Good afternoon everyone.As previously shownby Dr. Sharma, breastfeeding offersmany health advantages to children and their mothers. Making it a highlycost-effective intervention. This is not surprising as breastfeeding involves manybeneficial hormonal changes. And human milk is acomplex biological substance that contains a constellationof nutrients and other value-activesubstances. Including stem cells. Human milk oligosaccharides. Antibodies. And live bacteria. Human milk composition changeswithin a single nursing episode, and as a child develops,in food consistency with her physiological needs. Furthermore, there isnow strong evidence that the bioactivesubstance profile of human milk variesdramatically among healthy diets. Very likely as a result of dietlevel tailoring or optimization to their environments. Including exposureto diverse pathogens. Which is why breastfeedingis indeed considered as personalized medicine. A good example that illustratesthe powerful benefits from bioactive substancesin human milk is illustrated by the cognitive developmentbenefit attributed to it based on sound randomizedcontrolled trials. Observational studies. As well as neuralimaging studies.For example, findings fromBlesa and colleagues and colleagues have recentlyshown through neural imaging that a higher proportionof exclusive breast milk in the weeks after pretermbirth was associated with substantially improvedstructural connectivity of developing networksin the brain. A milk composition-basedmechanism by which this happensis related to the fact that human milk is rich inomega three polyunsaturated fatty acids.Which are essential forthe proper myelination of the neural axons. A process that inturn is crucial for the proper development ofthe central nervous system. So given how much weknow about the benefits of human milk and breastfeeding. And how cost effectivebreastfeeding interventions are. A key question is why stillthe great majority of women in the world who are choosingto breast feed don’t do it as long as they would like? In response to thesequestion my research group at Yale developed thebreastfeeding year model based on a complex adaptivesystems analysis. Analogous to an engine,this model proposes the need for eight gears that needto operate in synchrony for the proper functioning of large-scale breastfeedingprograms. First, evidence-based advocacygenerates the political wheel that is needed to developand pass legislation to protect breastfeedingand release needed resources for proper protection. Promotion. And support of breastfeeding. These resources supportimplementation and enforcement of key protection measures. Including maternity protectionfor women employed in formal and informal economy sectors.And the WHO code. They are also needed for developing theworkforce responsible for incrementingkey health facility and community-based initiatives. Demand creation for breastfeeding servicescan strongly be supported through sound behaviorchange-based social marketing campaigns. Operational research is key for identifying implementationbottlenecks and addressing them on time. At the heart of the breastfeeding yearmodel is a master gear. Which is responsible foroverall coordination. Including timelycommunication across. And monitoring ofpre-established goals based on multilevel decentralizedmanagement information systems that allow forevidence-informed, local decision- making. I am very pleased to report that the breastfeeding yearmodel feasibility and utility to guide large-scaleimplementation efforts has now been confirmed ineight countries across five world regions overthe past 3.5 years of work. Effective scaling up of breastfeeding programscan be greatly facilitated by the fact that key initiativesneeded to make it work at scale have been extensivelytested and operationalized. A prime example is, indeed, the baby friendlyhospital initiative.Which is based onthe implementation of the ten steps consisting of a best practicepackage that includes. Breastfeeding protectionpolicies. Monitoring and evaluation. And staff training. And as we all know, clinicalprocedures such as rooming in. Well-supervised skin-to-skincontact immediately after birth. Breastfeeding supportand counseling. And breastfeedingsupport coordination after hospital discharge. Given that there is veryconsistent evidence indicating that the ten steps work. And that there is those responserelationship between the number of steps implemented andbreastfeeding outcomes, as shown with data from the CDCinfant feeding practices study.It is important tofollow the advice from the World HealthOrganization that all facilitiesproviding maternity and newborn services worldwideincrease their efforts implementing the ten steps. For this reason it is veryencouraging that the percentage of maternity facilities thathave implemented at least five of the ten steps has rapidlyincreased over time in the U.S., as documented by the CDCmPINC impressive monitoring system. However, still one,only about 1/4 of births in the U.S. are happeningat baby friendly facilities. And as this map shows, specialattention needs to be paid to inequities in baby friendlyhospital coverage across states.I will now move on tobreastfeeding counseling. Which is a second keyglobal strategy for scaling up effective breastfeedingprograms. Based on the large amount ofevidence that has accumulated over the past decadesin my countries. Including the U.S. The WorldHealth Organization recently released its firstever guideline on breastfeeding counseling. Highlighting the need forbreastfeeding support during that prenatal, perinatal aswell as postnatal period. The guideline emphasizesthe great importance of breastfeeding supportduring the first hours and days after birth. As well as a need toprovide anticipatory guidance for mothers. So that they know what to expectregarding the different milk production phasesthat are awaiting them in the near future.As an illustrative example of how powerful breastfeedingcounseling is, this slide shows findings from an RCT clearlydocumenting the strong impact that breastfeedingpeer counseling after hospital discharge has on improving exclusivebreastfeeding rates. This instance among womendelivering in Northern Brazil in a baby friendly hospital. A comparison of the blue withthe orange bars, clearly shows that the major short-termeffects of the baby friendly hospital on exclusive breastfeedingwas only sustained as such if intervention groupreceived the home visits from breastfeedingpeer counselors. And this is not uniqueto breastfeeding. Similar findings have beendocumented among low-income mothers in Connecticut. Where, again, prenatal,perinatal and postnatal breastfeedingcounseling support increased substantially the prevalenceof exclusive breastfeeding.Family friendly maternityprotection policies are also recognized in the breastfeedingyear model as being crucial for enabling the environmentfor women to breastfeed as long as they want to. Two important pillars for breastfeeding protectionare paid maternity leave. And breaks during theworkday for breastfeeding or breast milk extraction. Paid maternity leavehas been associated with improved breastfeedingoutcomes. As well as reductionsin infant mortality. Unfortunately, the U.S. isthe only high-income country that does not have legislationfor paid maternity leave. As a result, one in four womenreturn to work by ten days after giving birthin our country. Additional evidence informedmaternity protection policies that have been endorsed to support breastfeeding includefamily friendly work policies once employed womenreturn to work. Including breaksduring the workday. Lactation rooms forbreast milk expression. Flexible work hours. And affordable, highquality childcare services in proximity to the workplace. The International LaborOrganization Maternity Protection Conventionalso recommends parental or father’s leave inaddition to maternity leave. A recommendation thathas also been associated with positive breastfeedingoutcomes.In conclusion, as presentedby Dr. Sharma, breastfeeding and human milk is a majorcost-saving intervention. Family friendly social andeconomic policies are needed to enable the breastfeedingenvironments. The baby friendlyhospital initiative works. Community-based breastfeedingcounseling works. There is a need for betterintegration of facility and community-basedbreastfeeding support to assure the qualityof the continuum of care for breastfeeding moms. Investing more in evidence-informedbreastfeeding protection, promotion and supportshould be a top priority in the U.S. and beyond. Thank you very much. [ Applause ] And it is now my great pleasure to introduce my colleagueFrank Greer. >> Thanks, Rafael. Let’s start with acouple definitions. Complementary foods. This refers to the nutrientand energy containing solid, semisolid or liquid foodsfed to infants in addition to human milk or formula.The complementary feedingperiod generally occurs between six months and thechild’s second birthday. With a regression froma fully liquid diet to the mixed dietof family foods. I note that this takes up 500 ofthe first thousand days as shown on this slide by the yellow bar. So, indeed, this is acritical period for growth and brain development. Well, the history of complementary foodintroduction is a long and tortuous one asyou can see here. This goes over about 100 years. In 1900s, infants typicallydidn’t receive complementary foods until 11 to12 months of age. The recommendationgradually changed over time. And by the mid-50s, it wasdown to introduce foods between 1.5 and 2 months. Increased up to around for aboutsix months by the year 2000. Which is where it is today. I’d like to note that this slidemimics the slide of the decline of breastfeeding, rise and fall of breastfeeding inthe United States. Breastfeeding reachedits low point in 1958, with only 25 percent ofU.S. infants breastfed at seven days, letalone six months. But what drives the introductionof complementary foods? It’s a balance betweennutritional benefits versus developmental readiness.The nutritional benefits of breastfeeding havebeen well described here. And the strongest evidenceI note in Western countries, Westernized countries is forthe first four months of life. Developmental readinessvaries widely. But typically occurs betweenfour and six months of age. Sitting upright withlittle or no support and oral motor skills. I’d like to note as a father andnow more times as a grandfather that when the infants joins thedinner table, he will tell you when they’re developmentallyready. There are nutritionallimitations of exclusive breastfeedingafter six months however. These include the need foradditional iron and zinc.And the gradually increasingneeds for additional calories and protein which cannotbe supplied by human milk. Well, where are wecomplementary foods today in the United States? Two recent surveys haveshown that 16 percent of infants are introduced to complementary foodsearlier than four months. Which is too early. 13 percent are introduced at seven months ora little too late. And the remaining infantsare mainly introduced to complementary foodsbetween the beginning of the fourth monthof life and the end of the sixth month of life.Well, what do we knowabout macronutrient intakes in complementary fed infants,toddlers aged 12 to 23 months? Well, the goal of protein is 5to 20 percent of energy intake. From two recent surveyswe know that 94 percent of toddlers aged 12 to23 months meet the goals. Carbohydrate goal is 45 to65 percent of energy intake. And 84 percent oftoddlers meet these goals. The goal for fat is 30 to40 percent of energy intake. And much to everybody’s surprisein these recent surveys, about 28 percent oftoddlers have less than the recommended fat intake. Not enough. And as fat intake isessential for brain growth and development, people arewondering if this is something to be concerned about. This is pretty amazingwhen you think about the currentobesity epidemic.Well, what about themicronutrients supplied by complementary foods? There’s no question thatiron is the most important. That’s because the ironrequirements are relatively large compared to all the othermicronutrients, as you’ve heard. In the yellow boxhere on the right, you see the ironrequirement for a 7 to 12-month-old is11 milligrams a day. For ages 12 to 36 months,it falls to 7 milligrams. And there’s very strong evidence that supports consumingcomplementary foods with substantial amounts ofiron, i.e., in meat and cereals with iron, maintain iron status and prevent irondeficiency anemia. I will add that thebenefits for infants who consume iron-fortifiedformula, which contains 12 million gramsper liter, are less evidenced than for breastfed infants. What is the source of ironin complementary tools? Well, it’s heme iron. That’s found in red meatand dark poultry meat. With as much as 2 milliongrams per 100 grams of food. Iron is bound to animal proteinand thus absorbed intact. This gives it thehighest absorption rate of any dietary source ofiron at 25 to 35 percent.Unfortunately, or to some peoplefortunately, it’s not common as a complementaryfood before 12 months. Non-heme iron, on the other,hand found in green vegetables and eggs is poorly absorbed. At most 10 percent,generally less. Iron salts addedto infant formulas and cereals are themost poorly absorbed of all at 2 to 5 percent. But they’re added issuch large amounts that they offset poorabsorption rates. Well, there is something newabout complementary feeding which I’m really excitedto talk about that today. And that is the earlyintroduction of allergenic complementaryfoods. Historically, we have notrecommended allergenic foods be introduced to the humandiet until the second to third year of life. Allergenic foods, which arenutrient-rich, include peanuts. Eggs. Milk. Fish. And wheat. New evidence does not supportdelaying the introduction of allergenic foods beyond6 to 11 months of age.In fact, the evidenceis strongest for introducing peanutsbetween 4 and 11 months of age in high-risk infants. High-risk infants are thosethat have severe eczema or an egg allergy at the timethat peanuts are introduced. Until recently whatpediatrician, dietician or family member wouldput a kid on peanuts who has eczema andan egg allergy? Well, they did this in the study which I’ll show youon the next slide. And it reduced peanut allergy atsix years of age by 80 percent. An amazing study publishedin the “New England Journal of Medicine” in 2015, alsoknown as the LEAP trial. And they looked at prevalence ofpeanut allergy at age six years in a group of 600randomized infants. The no peanut groupreceived no peanuts until they were fiveyears of age. The peanut groupstarted peanuts, 2 grams three times a week,between 4 and 11 months. And continued thisthrough five years of age. And you can see adramatic, dramatic decline in peanut allergyin the peanut group. There’s very few dietary studies that ever showed this muchsignificant difference.So very informative study. There are some complementaryfoods, on the other hand, that should not be introduced. These include 100percent fruit juices, not before 12 months of age. And then limited to fourounces per day thereafter. Because these displacenutrient-rich foods such as whole milk. You should never introducesugar-sweetened beverages before two years. And very limited thereafterbecause they are associated with weight gain andobesity later in life. Cow’s milk, particularlywhole cow’s milk should not be introduced before 12 months. Because of its excess protein,calcium and phosphorus. And there’s no need forflavored cows milk at any time in the first year of lifebecause of their added sugar. First two years of lifebecause of their added sugar. Plant-based milks shouldgenerally be avoided. With perhaps theexception of soy milk for those desiring avegan diet or concerned about cow milk intolerance.Well, what do we know aboutthe process of infant feeding? We really don’t know very much. It has been demonstratedthough that repeated exposure of a fruit or vegetableevery day for eight to ten days increasesthe acceptability between the ages 4 to 24 months. Another thing werecently learned. Sequential introductionof foods, whether it’s green vegetablesbefore yellow vegetables. Vegetables before meator fruits, et cetera. Is not supported by anyevidence whatsoever. Sequencing doesn’tmake any difference. Infants with infrequent intakesof fruits and vegetables, we’ve already heard about today. But less than one per dayat age 11 months are likely to continue thispattern at age six years. Well, you’ve all heardabout responsive feeding. You provide, your child decides. And that’s recognizinga child’s hunger and satiety cues cansupport feeding practices that lead to healthy growth.And this includes allfeedings beginning at birth through two years of age. Including breastfeedingand formula feeding. We also know that some caregiverfeeding practices are associated with children’s weight. And these includingrestricting food or pressuring a child to eat. And these are generallyassociated with a healthy weight. And generally anunhealthy weight gain. Evidence suggestsintroducing a variety of foods across all food groups, routinemeal times promotes good dietary habits later in life. I summarize my point by readingyou the current recommendations for complementary feeding by the American Academyof Pediatricians. Number one, introducecomplementary foods at about six months. Two, introduce a variety of nutrient-densecomplementary foods.Especially iron-rich foods. Do not introduce cow’s milk or 100 percent fruitjuices before 12 months. Avoid foods and beverageswith added sugar and salt. Avoid plant-basedmilks in general. Introduce allergeniccomplementary foods sooner rather than later. Again, this is the big change. No need to delay introductionbeyond the age of six months. And there’s even an exceptionfor introducing peanuts between four and six monthsof age for the infants with eczema and egg allergy. And, finally, we need to encourage a lot morehigh-quality research on the timing ofintroduction, types and amounts of complementary foods. I mean, just look what onewell-controlled randomized trial with peanuts did. It changed decadesof recommendations which were all basedon expert opinion. So in summary for thegroup, opportunities to improve nutrition in thethousand day window include, of course, promotingbreastfeeding. Empowering parentsand care providers with understandingand best practices. Promoting the 2020dietary guidelines when we finally get them. And giving everybody access tohigh-quality care, medical care. Thank you. [ Applause ] >> All right, sowe’ll take questions. If you have a question, pleasecome up to the, in the room.Come up to the microphone. And, Susan, do we haveany questions online? >> First, I want to remind ouronline audiences they can send their questions email@example.com. We’ll get in as many as we can. But everyone willreceive a response. Our first question from Meagan. Should routine vitamin and mineral supplementationduring pregnancy be recommended at the population level asa universal recommendation? Or just on an individual basis? >> Thank you for the question. So there’s some discrepanciesin terms of current recommendations. With some societiesrecommending supplemental, like prenatal vitaminsfor all women. And some suggesting that notall women may necessarily need a supplement.In the United Statesthere is such a wide range of baseline health, so tospeak, going into pregnancy that women have adequate stores. Whether it’s related tocertain vitamins or nutrients, they may not necessarilyneed the additional intake. But we currently don’thave the recommendation or the capability just toscreen all pregnant women that are either beginning apregnancy or prior to pregnancy for nutritional deficiencies. And because the intake of a single prenatal vitaminis relatively inexpensive and without side effects. It is one of the morecommon recommendations that as providers we give to ourpatients for women preparing for and during a pregnancy. >> Question here. >> Hi, thank you allfor your presentations. Very interesting.My question’s for Dr.Greer specifically. I’m curious as to whyplant-based milks are never, or recommended against. Is it because theytake the place of a more nutrient-dense food? Or just generally why? Thanks. >> Yeah. They’re not, you know,the, I guess I just speak to. You know, there aresomething like none nutrients which are found in human milk. Mainly potassium and thingslike, found in cow’s milk, that are recommended by theUSDA and dietary guidelines.So that’s basically why. Most of the milks don’tcontain the same nutrients to the same degree. A lot of them are fortified. But we don’t have a lotof experience with things like almond milk, for instance. And there are a bunch of others. But soy milk, we have alot of experience with. That’s generally whythey recommended it if that be the alternative. >> Quick follow-up question. Just in your opinion, do youthink an additional testing with new milk products thatwould be found to be of more, you know, nutritionalcomposition? Or is it pretty standard that they’ll neverkind of reach the same? >> I don’t know the answerto that question, but. >> Makes sense. Thank you. >> Any questions online? >> I also want to comment that we had fouradditional questions, both through the box and, aswell as online about the issue of plant-based proteins. So I think it’s important that we let those peopleknow, we did get those.But it got asked in the room. And this one is to ourgrand rounds e-mail box. In cases where breastfeedingmay not be an option. Such as for the LGBTQ communityand other adoptive parents. Are there supplements besidesformula to mimic the benefits of breastfeeding in orderto ensure maximum nutrition in the first two years of life? >> That’s called infant formula. There’s no and ifs or buts. Infant formula isa complete food. It has everything aninfant needs to grow on. >> Other opportunities mightbe breastfeeding banks. Where, sorry, other opportunities might bebreastfeeding banks as well. >> Again, from thegrand rounds e-mail box. Where do you stand on cholinesupplementation for pregnancy? >> I don’t have an opinion on choline supplementationfor pregnancy. >> I can keep going. That’s fine. Again, from the e-mail box. >> Get information online too. >> Okay. If we haveadequate intake values of most micronutrients, ironand zinc are exceptions.For children youngerthan two years of age, how the dietary guidelines for this age group aregoing to be supported? If we use adequate intake,the percent of children with inadequate diets is going to be much largerthan the reality. And this is goingto push for the use of micronutrient supplementsprobably without a need. Do you have an opinion on that? >> My opinion is that thisquestion illustrates the enormous urgencyon investing more on improving our assessments ofinfant nutrient requirements.Because I agree they are notvery reliable, most of them. They are dated, many,many of them. And it is very difficultto issue dietary guidelines or standards for foodproducts targeting infants if we don’t have reasonableestimates for the kids. >> Hi, thank you so muchfor your presentations. I think some of youtouched on research gaps. And I’d be curious to hear fromeach of you areas of research that you see as beingcritical over the next, let’s call it the nextthousand days for, you know, greater attentionand investment? And then maybe asecond question. We talked a lot aboutwhat’s needed in the first thousand days. But can you comment alittle bit about sort of the long-termimplications of what happens in the first thousand days? Thank you. >> So I want to comment that within the WorldHealth Organization, one of the divisions that hasbecome the strongest champion for the first 1,000 daysis the noncommunicable diseases division.Because they’re very persuadedby all the emerging evidence that the metabolic [inaudible]regulations that occur with regards to sugar metabolismand lipid metabolism and so on. Really get established, a blueprint for those getsestablished during the first 1,000 days. So I would say that interms of basic research, the whole epigenetic question as to how those poordietary practices end up interacting with a genome. And transfer from onegeneration to the next to determine metabolicrisk 30, 40 years upstream. I think to me that’s a very, should be a veryhigh priority area. >> And since we’ve alreadyscored points with peanuts, think about the valueof fish and eggs. And use some of the samerandomized control trials for introducing fish and eggs. I mean, fish is hardlyintroduced in the U.S. diet as a complementary food. I know there’s somefood manufacturers that are working on this. But, gee, that reallynutrient-dense foods, both of them. And yet kids commonly haveallergies to both eggs and fish. >> So to answer your firstquestion about research gaps. I think the alarmingstatistic that over, or at least 50 percent of women in the United States exceedtheir weight gain goals, to me really targetsthe opportunity to help women meet thosegoals during pregnancy.And it’s also impressive that, even though the health behaviorinterventions to date show that there’s some benefit to theinterventions during pregnancy. In many of the studies there’sstill a large percentage of women that continue toexceed the weight gain goals. So I think we need tofind different avenues to reach patients andproviders on different types of health behaviorinterventions. Such as diet and exercise. And to answer yoursecond question about beyond the thousand days.Pregnancy is a window ofopportunity to talk to women about their healthand health behaviors. And many women are motivatedto have a healthy pregnancy. And the health behaviorsthat are established in the first pregnancyaffect their health in a future pregnancy. And in their later life. >> And I was going to say some of the same stuffthat Michelle said. But I’ll just add, there’salso surveillance gaps. So I know you askedabout research. But I think in understandingthe deficiencies and nutritional status of youngchildren will be critical. And that will alsohelp drive some of the research needs and stuff.Is how do we improvedeficiencies? Or how do we target programs? Same also with pregnancyas well. There’s, we justhave a lot of gaps. And how do we improvenutritional status. >> Question online. >> Yes. From Regina. While the benefits ofbreastfeeding are clear. It’s important to stress thata fed baby is more important than an exclusivelybreastfed baby. How do we help support or notstigmatize and shame women who might not be able to exclusively breastfeedsuccessfully? >> So, you know, atthe end of the day, I think it is a woman’s choice.The one that hasto be respected. And no matter what her choiceis, it should be supported. The work that I do and othercolleagues of mine do is to try to help establish a morelevel playing field. Where the vast majorityof women who are choosing to breastfeed can breastfeedas long as they want. And this includes providing them with breastfeedingcounseling and support. Including lactation managementsupport during the first hours, days and weeks after birth. Where many, many, many of the human lactation problemshappen and can be resolved. And it’s especially importantto offer these services to first-time mothers. And also to women who aresocioeconomically vulnerable. And in their groups, theyare less likely to have that support for breastfeeding.>> Phoebe. >> And I just might add to that. Any breast milk isbetter than none. If it’s two weeks. Three weeks. Four weeks. Five weeks. Six weeks. That’s great. And you shouldn’t bestigmatized if you have to introduce formulaat some point. >> All right. Please join me in giving athank you to the speakers for an excellent presentation. [ Applause ] And please join us next monthfor public health grand rounds..