+----------------+-----------------------------------------------------+
| # Insert Sta   | #                                                   |
| te/County Logo |                                                     |
|                | # The \[Con                                         |
|                | tributor\] Pediatric Nutrition Surveillance System  |
+----------------+-----------------------------------------------------+

**\
**

The \[contributor\] Pediatric Nutrition Surveillance System (PedNSS) is
a child-based public health surveillance system that monitors the
nutritional status of low-income children in federally funded maternal
and child health programs. Data on birthweight, short stature,
underweight, overweight, anemia, and breastfeeding are collected for
children who visit public health clinics for routine care and nutrition
services, including education and supplemental food. Data are collected
at the clinic level, and then aggregated at the state level and
submitted to the Centers for Disease Control and Prevention (CDC) for
analysis.

Data for the \[contributor\] 2002 PedNSS were collected from children
enrolled in federally funded programs that serve low-income children:
the Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC) (\_\_%); the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Program (\_\_%); the Title V Maternal and Child Health
Program (\_\_%); and Head Start and other programs (\_\_%). The goal of
PedNSS is to collect, analyze, and disseminate surveillance data to
guide public health policy and action. PedNSS information is used to set
priorities and plan, implement, and evaluate nutrition programs. This
report summarizes 2002 data and highlights trends from 1993 through
2002.

**Demographic Characteristics**

**\
**In the \[contributor\] 2002 PedNSS, \_\_% of the records were from
non-Hispanic white children, \_\_% from Hispanic children, \_\_% from
non-Hispanic black children, \_\_% from Asian or Pacific Islander
children, \_\_% from American Indian or Alaska Native children, and
\_\_% from children of all other or unspecified races and ethnicities.
Most PedNSS records (\_\_%) were from children aged 1 to 5 years; \_\_%
were from infants aged less than 1 year.

**\
**

**Pediatric Health Indicators**

***Low Birthweight***

The single most important factor affecting neonatal mortality and a
significant determinant of postneonatal mortality is low birthweight (\<
2,500 grams). Low-birthweight infants who survive are at increased risk
for health problems ranging from neurodevelopmental disabilities to
respiratory disorders. In the \[contributor\] 2002 PedNSS, \_\_% of
infants were low birthweight, compared with 7.8% of U.S. infants.^1^ One
of the *Healthy People 2010* objectives (16-10a) calls for a reduction
in low birthweight to no more than 5% of all live births.^2^

The overall prevalence of low birthweight decreased slightly from \_\_%
in 1993 to \_\_% in 2002; however, variations were observed among racial
and ethnic groups (Figure 1). During this time period, low-birthweight
rates improved for Hispanic infants; remained the same for black,
American Indian or Alaska Native, and Asian or Pacific Islander infants;
and worsened for white infants.

**\[Add graph\] Figure 1. Trends in prevalence of low birthweight by
race and ethnicity**

*Low Birthweight: Less than 2,500 grams at birth.*

***High Birthweight***

High birthweight (\> 4,000 grams) puts infants at increased risk for
death and birth injuries such as shoulder dystocia. In the
\[contributor\] 2002 PedNSS, \_\_% of infants were high birthweight,
compared with 9.2% of U.S. infants.^1^

The overall prevalence of high birthweight decreased slightly from 1993
(\_\_%) to 2002 (\_\_%); however, the greatest decrease (\_\_%) was
among white infants. An increase of \_\_% occurred among Asian or
Pacific Islander infants.

*High Birthweight: More than 4,000 grams at birth.*

***Short Stature***

Short stature (low length/height-for-age) may reflect the long-term
health and nutritional status of a child or a population. Although short
stature can be associated with short parental stature or low
birthweight, it can also result from growth retardation due to chronic
malnutrition caused by inadequate food intake, recurrent illness, or
both. In the \[contributor\] 2002 PedNSS, \_\_% of children from birth
to age 5 were of short stature, compared with 2.3% of U.S. children
(unpublished data, Dr. Zuguo Mei, CDC, 2003). The prevalence of short
stature in the \[contributor\] PedNSS population is somewhat above the
expected level (5%) and does not meet the *Healthy People 2010*
objective (19-4) to reduce growth retardation among low-income children
under 5 years of age to 5%.^2^ The prevalence of short stature declined
slightly from \_\_% in 1993 to \_\_% in 2002. A slight decrease in short
stature was evident in all racial and ethnic groups; the largest
decrease was in Asian or Pacific Islander children (Figure 2). The
highest prevalence of short stature was in black infants younger than
age 1 (\_\_%), which may reflect the high rate of low birthweight in
this group.

**\[Add graph\] Figure 2. Trends in prevalence of short stature among
children aged \<5 years, by race and ethnicity**

*Short Stature: Based on the 2000 CDC growth chart percentiles of less
than the 5th percentile length-forage for children younger than 2 years
of age and less than the 5th percentile height-for-age for children 2
years of age or older.*

***Underweight***

Data on underweight (low weight-for-length/BMI^†^-for-age) in children
from birth to age 5 indicate that acute malnutrition is not a public
health problem in the \[contributor\] 2002 PedNSS population; the
prevalence of \_\_% is similar to the expected level (5%). The
prevalence of underweight for U.S. children in this age group is 4.8%
(unpublished data, Dr. Zuguo Mei, CDC, 2003). The highest prevalence of
underweight in PedNSS was in black children (\_\_%). Black infants aged
0--11 months had an underweight rate of \_\_%, which may reflect the
high rate of low birthweight in this group. The overall prevalence of
underweight decreased from \_\_% in 1993 to \_\_% in 2002.

*Underweight: Based on the 2000 CDC growth chart percentiles of less
than the 5th percentile weight-for-length for children younger than 2
years of age and less than the 5th percentile BMI -for-age for children
2 years of age or older.*

† *To calculate BMI (body mass index): Weight (kg) ÷ Stature (cm) ÷
Stature (cm) x 10,000 **or** Weight (lb) ÷ Stature (in) ÷ Stature (in) x
703.*

***Overweight and Risk of Overweight***

Overweight (high weight-for-length/BMI-for-age) in children and
adolescents has reached epidemic proportions in recent years. In the
\[contributor\] 2002 PedNSS the prevalence of overweight in children
from birth to age 5 is \_\_%. Overweight in children younger than age 2
does not pose the same risk as it does for children aged 2 or older
because a weak association has been found between their weight and
increased risk for adult obesity.^3^ Expert committees have recommended
a two-level screening for overweight in children aged 2 years or older.
The recommendations are to use BMI-for-age at or above the 95th
percentile to define overweight and between the 85th and 95^th^
percentiles to define risk of overweight^.4-6^

**\[Add graph\] Figure 3. Prevalence of overweight and risk of
overweight\* among children aged 2 to 5 years, by race and ethnicity**

In PedNSS, the prevalence of overweight in children aged 2 to 5 years
was \_\_%. The highest rates were among Hispanic (\_\_%) and American
Indian or Alaska Native (\_\_%) children; the lowest (\_\_%) were among
both black and white children (Figure 3). Of particular concern is that
the prevalence of overweight in children aged 2 to 5 has steadily
increased from \_\_% in 1993 to \_\_% in 2002 (Figure 4). This is a
relative increase in overweight of \_\_% between 1993 and 2002.
Overweight has increased among all racial and ethnic groups; however,
the greatest increase occurred among white children.

**\[Add graph\] Figure 4. Trends in prevalence of overweight among
children aged 2 to 5 years, by race and ethnicity**

The prevalence of risk of overweight in children aged 2 to 5 years
increased from \_\_% in 1993 to \_\_% in 2002. This increase was seen
among all racial and ethnic groups. American Indian and Alaska Native
children have a prevalence of risk of overweight (\_\_%) that is
consistently higher than all other groups. Findings from PedNSS are
consistent with trends of increasing overweight in children aged 2 to 5
years in the U.S. population; however, the prevalence of overweight
(10.4%) and risk of overweight (10.2%) is considerably lower for U.S.
children aged 2 to 5 years.^7^

*Overweight: Based on the 2000 CDC growth chart percentiles of greater
than or equal to the 95th percentile weight-for-length for children less
than 2 years of age and greater than the 95th percentile BMI-for-age for
children 2 years of age or older.*

*Risk of Overweight: Based on the 2000 CDC growth chart percentiles of
the 85th to the 95th percentile BMI-for-age for children 2 years of age
or older.*

***Anemia***

Anemia (low hemoglobin/hematocrit) is an indicator of iron deficiency,
the most common known nutrient deficiency in the world. Iron deficiency
in children is associated with developmental delays and behavioral
disturbances. In the \[contributor\] 2002 PedNSS, the prevalence of
anemia was \_\_%, compared with 2.8% for U.S. children less than 5 years
of age (unpublished data, Dr. Zuguo Mei, CDC, 2003), indicating a wide
difference between these populations. The highest prevalence of anemia
in both the \[contributor} PedNSS and U.S. children is in children
younger than age 2; the prevalence decreases as children get older. The
prevalence of anemia varies among racial and ethnic groups in PedNSS;
black children have the highest prevalence (\_\_%). The overall
prevalence of anemia in PedNSS declined from \_\_% in 1993 to \_\_% in
2002. While a decline was observed among all racial and ethnic groups,
black and Asian or Pacific Islander children had the smallest declines
during this period (Figure 5).

**\[Add graph\] Figure 5. Trends in prevalence of anemia among children
aged \<5 years, by race and ethnicity**

*Anemia: Children aged 1 to 2 years are considered anemic if their
hemoglobin (Hb) concentration is less than 11.0 g/dL or their hematocrit
(Hct) level is less than 33.0%; children aged 2 to 5 years are
considered anemic if their Hb concentration is less than 11.1 g/dL or
their Hct level is less than 33.3%.^8^*

***Breastfeeding***

The nutritional, immunologic, allergenic, economic, and psychologic
advantages of breastfeeding are well recognized. In the \[contributor\]
2002 PedNSS, \_\_% of infants were ever breastfed, \_\_% were breastfed
for at least 6 months, and \_\_% were breastfed for at least 12 months.
The *Healthy People 2010* objective (16-19a-c) to increase the
proportion of children ever breastfed to 75%, of children breastfed at 6
months to 50%, and at 1 year to 25%2 is far from being achieved in the
\[contributor\] PedNSS population National data from other sources
indicate that 70.1% of mothers ever breastfed; 33.2% were still
breastfeeding at 6 months, and 19.7% at 12 months.^9^

The prevalence of breastfeeding for children in PedNSS has increased
more than \_\_% from the 1993 rate of \_\_%, and these improved
breastfeeding rates are evident among all racial and ethnic groups
(Figure 6). Although black infants still have the lowest prevalence of
breastfeeding (\_\_% in 2002), this prevalence has increased by more
than \_\_% since 1993, when the rate was \_\_%. National data from other
sources indicate that the ever breastfed rate for all U.S. mothers
increased from 55.9% in 1993 to 70.1% in 2002.^9^

**\[Add graph\] Figure 6. Trends in percentage of infants ever
breastfed,\* by race and ethnicity**

*Breastfeeding: Child ever breastfed or breastfed until 6 months of age
or breastfed until 12 months of age.*

**\
\
**

**Infant and Child Health Advances and Concerns**

Several advances in nutrition and health indicators were observed in the
\[contributor\] PedNSS population from 1993 to 2002. Small improvements
were made in both low and high birthweight, with the largest improvement
in low birthweight among Hispanic infants. Short stature decreased
slightly, with the greatest improvement among Asian or Pacific Islander
children. Major reductions occurred in the prevalence of anemia. A
decrease occurred among all racial and ethnic groups, with the greatest
change among white and Hispanic children. Major improvements have
occurred in both the prevalence of infants ever breastfed and those
breastfed for at least 6 months. While the prevalence of breastfeeding
remains lowest for black infants, this group showed the largest
improvement in prevalence of ever breastfed and breastfed for at least 6
months.

Areas of concern remain, however. No racial or ethnic group achieved the
*Healthy People 2000*^10^ objective to reduce the low-birthweight
prevalence to 5%, and increases in low birthweight occurred among white
infants. Although there has been a decrease in the prevalence of anemia,
it is still high among all racial and ethnic groups. The \[contributor\]
PedNSS population did not achieve the *Healthy People 2000*^10^
objective that 75% of infants initiate breastfeeding. Overweight is a
major public health problem that has steadily increased; \_\_% more
children aged 2 to 5 years are overweight than in 1993. Although
Hispanic and American Indian or Alaska Native children have the highest
prevalence of overweight, increases occurred among all racial and ethnic
groups, with the largest increase among white children aged 2 to 5
years.

35**\
Pediatric Nutrition Recommendations**

The \[contributor\] PedNSS data indicate that national and state public
health programs are needed to support the following actions:

• Implement innovative strategies to reverse the rising trend of
overweight in young children by increasing breastfeeding, increasing
physical activity, promoting increased consumption of fruits and
vegetables, and decreasing television viewing.

• Promote and support breastfeeding through medical care systems, work
sites, and communities.

• Promote adequate dietary iron intake and the screening of children at
risk for iron deficiency.

• Prevent low birthweight by providing preconception nutrition care and
outreach activities to promote early identification of pregnancy and
early entry into comprehensive prenatal care, including the Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC)
and the Title V Maternal and Child Health Program.

Additional recommendations are as follows:

• Expand participation of states, U.S. territories, and tribal
governments in PedNSS and increase collaboration between CDC and
participating government agencies to establish and maintain nutrition
surveillance systems and improve data quality.

• Routinely screen for overweight and risk of overweight using
BMI-for-age as recommended by the American Academy of Pediatrics Policy
Statement.^11^

**References**

1\. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson
ML. Births: final data for 2002. *National Vital Statistics Reports*
2003; 52(10):1-114. Available at
http://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_10.pdf.

2\. U.S. Department of Health and Human Services. *Healthy People 2010*.
2nd edition. Two volumes. Washington, DC: U.S. Government Printing
Office; 2000. Available at http://www.healthypeople.gov/Publications/.

3\. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting
obesity in young adulthood from childhood and parental obesity. *New
England Journal of Medicine* 1997;337(13):869-873.

4\. Bellizzi MC, Dietz WH. Workshop on childhood obesity: summary of the
discussion. *American Journal of Clinical Nutrition*
1999;70(1):173S-175S.

5\. Barlow SE, Dietz WH. Obesity evaluation and treatment: expert
committee recommendations. *Pediatrics* (serial online)1998;102(3):e29.

Available at http://www.pediatrics.org/cgi/content/full/102/3/e29.

6\. Himes JH, Dietz WH. Guidelines for overweight in adolescent
preventive services: recommendations from an expert committee. The
Expert Committee on Clinical Guidelines for Overweight in Adolescent
Preventive Services. *American Journal of Clinical Nutrition*
1994;59(2):307-316.

7\. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends
in overweight among U.S. children and adolescents, 1999-2000. *Journal
of the American Medical Association*2002;288(14):1728-1732.

8\. Centers for Disease Control and Prevention. Recommendations to
prevent and control iron deficiency in the United States. *Morbidity and
Mortality Weekly Report Recommendations and Reports* 1998;47(RR-3):1-30.

9\. Mothers Survey, Ross Products Division, and Abbott Laboratories.
Breastfeeding Trends Through 2002. Columbus, OH: Abbott Laboratories;
2003.

10\. U.S. Public Health Service. *Healthy People 2000: National Health
Promotion and Disease Prevention Objectives*. Washington, DC: U.S.
Department of Health and Human Services, Public Health Service; 1991.
Publication No. PHS 91-50212.

11\. American Academy of Pediatrics Committee on Nutrition. Policy
statement. Prevention of pediatric overweight and obesity. *Pediatrics*
(serial online) 2003; 112(2):424-430. Available at
http://aappolicy.aappublications.org/cgi/

content/full/pediatrics;112/2/424?fulltext=pediatrics+overweight&searchid=QID_NOT_SET.