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      Does Cesarean delivery impact infant weight gain and adiposity over the first year of life?

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          Potentially driven by the lack of mother-to-infant transmission of microbiota at birth, Cesarean delivery has been associated with higher offspring obesity. Yet, no studies have examined when delivery-mode differences in adiposity begin to emerge. In this study, we examine differences in infant weight and adiposity trajectories from birth to 12 months by delivery mode.


          From 2013 to 2015, we recruited pregnant women into the Nurture Study and followed up their 666 infants. We ascertained maternal delivery method and infant birth weight from medical records. We measured weight, length, and skinfolds (subscapular, triceps, abdominal) when infants were 3, 6, 9 and 12 months of age. The main outcome, infant weight-for-length z score, was derived based on the WHO Child Growth Standards. We used linear regression to assess the difference at each time point and used linear mixed models to examine the growth rate for infant weight and adiposity trajectories. We controlled for maternal age, race, marital status, education level, household income, smoking status, maternal pre-pregnancy body mass index, and infant birth weight.


          Of the 563 infants in our final sample, 179 (31.8%) were Cesarean delivered. From birth to 12 months, the rate of increase in weight-for-length z score was 0.02 units/month (p=0.03) greater for Cesarean-delivered than vaginally-delivered infants. As a result of more rapid growth, Cesarean-delivered infants had higher weight-for-length z score (0.26 units, 95% CI 0.05–0.47) and sum of subscapular and triceps (SS+TR) skinfolds (0.95mm, 95% CI 0.30–1.60)—an adiposity indicator—at 12 months, compared to vaginally-delivered infants.


          Compared to vaginal delivery, Cesarean delivery was associated with greater offspring rate of weight gain over the first year and differences in adiposity that appear as early as 3 months of age. Monitoring Cesarean-delivered infants closely for excess weight gain may help guide primordial prevention of obesity later in life.

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          Most cited references 20

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          The impact of cesarean section on offspring overweight and obesity: a systematic review and meta-analysis.

           H-t Li,  Y-b Zhou,  J.-m. Liu (2013)
          Studies have reported inconsistent results concerning the association of cesarean section with offspring obesity. We performed a systematic review and meta-analysis to examine whether cesarean section increases the risk of later overweight and obesity. Pubmed, Embase and Web of Science were searched using different combinations of two groups of keywords: 'cesarean' and 'overweight/obesity'. Cohort or case-control studies that reported the association of cesarean section with childhood (3-8 years), adolescence (9-18 years) and/or adult (>19 years) overweight/obesity were eligible. Where possible, adjusted risk estimates were pooled using a random effects model; otherwise unadjusted estimates were pooled. Statistical heterogeneity was assessed with I(2) statistics; the values of 25%, 50% and 75% were considered to indicate low, medium and high heterogeneity, respectively. We conducted a subgroup analysis to identify the sources of heterogeneity according to study quality defined on the basis of the Newcastle-Ottawa Scale. In total, two case-control and seven cohort studies were identified for the literature review and 15 separate risk estimates were included in the meta-analysis. The overall pooled odds ratio (OR) of overweight/obesity for offspring delivered by cesarean section compared with those born vaginally was 1.33 (95% confidence interval (CI) 1.19, 1.48; I(2)=63%); the OR was 1.32 (1.15, 1.51) for children, 1.24 (1.00, 1.54) for adolescents and 1.50 (1.02, 2.20) for adults. In subgroup analysis, the overall pooled OR was 1.18 (1.09, 1.27; I(2)=29%) for high-quality studies and 1.78 (1.43, 2.22; I(2)=24%) for medium-quality (P for interaction=0.0005); no low-quality studies were identified. The ORs for children, adolescents and adults all tended to be lower for high-quality studies compared with medium-quality studies. Our results indicated that cesarean section was moderately associated with offspring overweight and obesity. This finding has public health implications, given the increase in cesarean births in many countries.
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            Delivery by caesarean section and risk of obesity in preschool age children: a prospective cohort study.

            To examine whether delivery by caesarean section is a risk factor for childhood obesity. Prospective prebirth cohort study (Project Viva). Eight outpatient multi-specialty practices based in the Boston, Massachusetts area. We recruited women during early pregnancy between 1999 and 2002, and followed their children after birth. We included 1255 children with body composition measured at 3 years of age. BMI score, obesity (BMI for age and sex ≥95th percentile), and sum of triceps plus subscapular skinfold thicknesses at 3 years of age. 284 children (22.6%) were delivered by caesarean section. At age 3, 15.7% of children delivered by caesarean section were obese compared with 7.5% of children born vaginally. In multivariable logistic and linear regression models adjusting for maternal prepregnancy BMI, birth weight, and other covariates, birth by caesarean section was associated with a higher odds of obesity at age 3 (OR 2.10, 95% CI 1.36 to 3.23), higher mean BMI z-score (0.20 units, 95% CI 0.07 to 0.33), and higher sum of triceps plus subscapular skinfold thicknesses (0.94 mm, 95% CI 0.36 to 1.51). Infants delivered by caesarean section may be at increased risk of childhood obesity. Further studies are needed to confirm our findings and to explore mechanisms underlying this association.
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              Searching for the optimal rate of medically necessary cesarean delivery.

              Over the past three decades, the World Health Organization expert panel proposed cesarean delivery rate of 10-15 percent was used as a doctrine for an optimal rate of cesarean delivery despite the lack of concrete evidence. We set out to compile cesarean delivery rates, socioeconomic indicators, and health outcomes by countries in the last three decades to explore the optimal rates for medically necessary cesarean delivery.

                Author and article information

                Int J Obes (Lond)
                Int J Obes (Lond)
                International journal of obesity (2005)
                8 September 2018
                22 October 2018
                23 April 2019
                [1 ]Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
                [2 ]Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD
                [3 ]Department of Biological Sciences, 3510 Thomas Hall, North Carolina State University, Raleigh, NC
                [4 ]Department of Community and Family Medicine, 2200 West Main Street, Duke University Medical Center, Durham, NC
                [5 ]Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
                Author notes
                Correspondence to: Sara E. Benjamin-Neelon, Department of Health, Behavior and Society, Johns Hopkins, Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, sara.neelon@

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                Nutrition & Dietetics


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