Optimal duration of exclusive breastfeeding

Early feeding in child care in the United States: Are state regulations supporting breastfeeding?

Most women in the US are not meeting the recommendation of exclusively breastfeeding their infants for the first 6months of life. The child care environment can be especially influential in a mother's ability to continue breastfeeding after returning to employment. For this study, we reviewed child care regulations related to breastfeeding for centers and homes in all 50 states and the District of Colombia in late 2016, and compared them to 5 national standards. We coded regulations as either not meeting, partially meeting, or fully meeting each standard. We assessed correlations between number of regulations consistent with standards and 1) geographic census region and 2) last year of update. This study provides an update to a previous review conducted in 2012. No state met all 5 of the included standards, and only 2 states for centers and 1 state for homes at least partially met 4 of the 5 standards. More states had regulations consistent with standards encouraging general support for breastfeeding and requiring a designated place for mothers to breastfeed onsite. Number of regulations consistent with standards was associated with geographic census region, but not last year of update. States in the South had a greater number of regulations consistent with standards and states in the West had the fewest number of regulations consistent with standards. Overall support for breastfeeding at the state child care regulation level continues to be insufficient. States should improve child care regulations to include greater support for breastfeeding in child care facilities.

Lost in Translation: Piloting a Novel Framework to Assess the Challenges in Translating Scientific Uncertainty From Empirical Findings to WHO Policy Statements

BACKGROUND

Calls for evidence-informed public health policy, with implicit promises of greater program effectiveness, have intensified recently. The methods to produce such policies are not self-evident, requiring a conciliation of values and norms between policy-makers and evidence producers. In particular, the translation of uncertainty from empirical research findings, particularly issues of statistical variability and generalizability, is a persistent challenge because of the incremental nature of research and the iterative cycle of advancing knowledge and implementation. This paper aims to assess how the concept of uncertainty is considered and acknowledged in World Health Organization (WHO) policy recommendations and guidelines.

METHODS

We selected four WHO policy statements published between 2008-2013 regarding maternal and child nutrient supplementation, infant feeding, heat action plans, and malaria control to represent topics with a spectrum of available evidence bases. Each of these four statements was analyzed using a novel framework to assess the treatment of statistical variability and generalizability.

RESULTS

WHO currently provides substantial guidance on addressing statistical variability through GRADE (Grading of Recommendations Assessment, Development, and Evaluation) ratings for precision and consistency in their guideline documents. Accordingly, our analysis showed that policy-informing questions were addressed by systematic reviews and representations of statistical variability (eg, with numeric confidence intervals). In contrast, the presentation of contextual or "background" evidence regarding etiology or disease burden showed little consideration for this variability. Moreover, generalizability or "indirectness" was uniformly neglected, with little explicit consideration of study settings or subgroups.

CONCLUSION

In this paper, we found that non-uniform treatment of statistical variability and generalizability factors that may contribute to uncertainty regarding recommendations were neglected, including the state of evidence informing background questions (prevalence, mechanisms, or burden or distributions of health problems) and little assessment of generalizability, alternate interventions, and additional outcomes not captured by systematic review. These other factors often form a basis for providing policy recommendations, particularly in the absence of a strong evidence base for intervention effects. Consequently, they should also be subject to stringent and systematic evaluation criteria. We suggest that more effort is needed to systematically acknowledge (1) when evidence is missing, conflicting, or equivocal, (2) what normative considerations were also employed, and (3) how additional evidence may be accrued.

Protocol for establishing an infant feeding database linkable with population-based administrative data: a prospective cohort study in Manitoba, Canada

INTRODUCTION

Breast feeding is associated with many health benefits for mothers and infants. But despite extensive public health efforts to promote breast feeding, many mothers do not achieve their own breastfeeding goals; and, inequities in breastfeeding rates persist between high and low-income mother-infant dyads. Developing targeted programme to support breastfeeding dyads and reduce inequities between mothers of different socioeconomic status are a priority for public health practitioners and health policy decision-makers; however, many jurisdictions lack the timely and comprehensive population-level data on infant-feeding practices required to monitor trends in breastfeeding initiation and duration. This protocol describes the establishment of a population-based infant-feeding database in the Canadian province of Manitoba, providing opportunities to develop and evaluate breastfeeding support programme.

METHODS AND ANALYSIS

Routinely collected administrative health data on mothers' infant-feeding practices will be captured during regular vaccination visits using the Teleform fax tool, which converts handwritten information to an electronic format. The infant-feeding data will be linked to the Manitoba Population Research Data Repository, a comprehensive collection of population-based information spanning health, education and social services domains. The linkage will allow us to answer research questions about infant-feeding practices and to evaluate how effective current initiatives promoting breast feeding are.

ETHICS AND DISSEMINATION

Approvals have been granted by the Health Research Ethics Board at the University of Manitoba. Our integrative knowledge translation approach will involve disseminating findings through government and community briefings, presenting at academic conferences and publishing in scientific journals.

Cultural Norms in Conflict: Breastfeeding Among Hispanic Immigrants in Rural Washington State

Objectives To examine perceptions, experiences, and attitudes towards breastfeeding among Hispanic women living in rural Washington State. Methods Twenty parous Hispanic women of low acculturation, aged 25-48 years and residents in rural Washington State participated in an exploratory, face-to-face interview. Interviews were audio-recorded, translated and transcribed, and analyzed using a thematic content analysis approach. Results Nine emergent themes were grouped into three overarching categories: (1) Breast is best; (2) Hispanic cultural and familial expectations to breastfeed; and (3) Adapting to life in the United States: cultural norms in conflict. Women said they were motivated to breastfeed because of their knowledge and observations of its health benefits for mother and child. They said breastfeeding is ingrained in their Hispanic cultural heritage, and infant feeding choices of female family members were particularly influential in women's own decision to breastfeed. Women said they experienced embarrassment about breastfeeding in the United States and as a result, often chose to initiate formula feeding as a complement so as to avoid feelings of shame. Additionally, they faced economic pressure to work, key barriers for continued breastfeeding among Hispanics in the United States. Conclusions for Practice Knowledge of the benefits of breastfeeding for mother and child and longstanding cultural practices of breastfeeding are not enough to encourage exclusive breastfeeding to 6 months among this rural Hispanic population. Continued support through family-level interventions as well as work place policies that encourage breastfeeding are needed for rural Hispanics to reach optimal breastfeeding rates.

The Effect of Breastfeeding on Childhood Otitis Media

PURPOSE OF REVIEW

The purpose of this review is to summarize the literature regarding the association between breastfeeding and childhood otitis media (OM), with focus on the literature published within the past 5 years. The review comprises original articles and recent reviews.

RECENT FINDINGS

The effect of a protective effect of breastfeeding on the risk of OM is still being discussed. Within the past 5 years, 6 reviews and 15 original articles have been published. No randomized controlled trials have been published, and the diversity of exposure and outcome measures in the studies was significant. Also, we provide a summary of the recent literature on cost-benefit of breastfeeding and believed mechanism of protection against OM. Breastfeeding for more than 6 months seems to protect against OM during the first 6 years of life. Exclusive breastfeeding may have a more protective effect than non-exclusive breastfeeding. Introduction of formula feeding before the age of 6 months increased the risk of OM.

Association between breastfeeding and eczema during childhood and adolescence: A cohort study

Background

Breastfeeding is said to protect children from eczema (atopic dermatitis), but the available evidence is conflicting and subject to the influences of parental atopy and reverse causation (when mothers extended duration of breastfeeding because their children had eczema).

Methods

In the prospective, population-based Leicester Respiratory Cohort study, we assessed duration of breastfeeding in children aged 1–4 years. Prevalence of eczema was determined by questionnaire surveys that were repeated until the children were 17 years old. We investigated the association between having been breastfed and current eczema using generalized estimating equations, adjusting for potential confounders, and tested for effect modification by parental atopy. We also assessed the association between having been breastfed and incident eczema at ages 2, 4, and 6 years using multivariable logistic regression.

Results

Among the 5,676 children in the study, 2,284 (40%) had never been breastfed, while 1,610 (28%), 705 (12%), and 1,077 (19%) had been breastfed for 0–3, 4–6, and >6 months, respectively. Prevalence of current eczema decreased from 36% in 1-year-olds to 18% in children aged 10–17 years. Breastfeeding was not associated with current eczema. Compared with children who had never been breastfed, the adjusted odds ratios for current eczema at any age were 1.02 (95% confidence interval 0.90–1.15) for children who had been breastfed for 0–3 months, 0.97 (0.82–1.13) for children breastfed for 4–6 months, and 0.98 (0.85–1.14) for children breastfed for >6 months. There was no strong evidence for an effect modification by parental atopy (p-value for interaction term was 0.061) and no association between having been breastfed and incident eczema later in childhood.

Conclusions

This population-based cohort study found no evidence for protection of breastfeeding against childhood eczema at any age, from infancy through adolescence.

Severe childhood malnutrition

The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.

Determinants of breastfeeding initiation among mothers in Sydney, Australia: findings from a birth cohort study

Background

Breastfeeding has short-term and long-term benefits for both the infant and the mother. The objective of this study was to identify the incidence of breastfeeding initiation among women in South Western Sydney, and the factors associated with the initiation of breastfeeding.

Methods

Child and Family Health Nurses recruited mother-infant dyads (n = 1035) to the Healthy Smiles Healthy Kids birth study in South Western Sydney, an ethnically and socio-economically diverse area, at the first post-natal home visit. A sample of 935 women completed a structured, interviewer-administered questionnaire at 8 weeks. Multivariate logistic regression analysis was used to identify those factors independently associated with the initiation of breastfeeding.

Results

In total, 92% of women (n = 860) commenced breastfeeding in hospital. Women who completed a university degree were more likely to initiate breastfeeding compared to those who did not complete high school (AOR = 7.16, 95% CI 2.73, 18.79). Vietnamese women had lower odds of breastfeeding initiation compared to Australian born women (AOR = 0.34. 95% CI 0.13, 0.87). Women who had more than one child were less likely to breastfeed than those who had one child (AOR = 0.38, 95% CI 0.19, 0.79). Women who gave birth via a caesarean section were less likely to breastfeed their baby compared to those who had a vaginal delivery (AOR = 0.27, 95% CI 0.14, 0.52). Women who drank alcohol during pregnancy had 72% lower odds to breastfeed compared to those who did not drink alcohol during pregnancy (AOR = 0.28, 95% CI 0.11, 0.71). Women who reported that their partner preferred breastfeeding were more likely to initiate breastfeeding (AOR = 11.77, 95% CI 5.73, 24.15) and women who had chosen to breastfeed before pregnancy had more than 2.5 times the odds of breastfeeding their baby compared to those women who made their decision either during pregnancy or after labour (AOR = 2.80, 95% CI 1.31, 5.97).

Conclusions

Women with lower levels of education, who consume alcohol during pregnancy, have more than one child, and make infant feeding decision after becoming pregnant, and those born in Vietnam should be targeted when implementing breastfeeding promotion programs. Further, women who deliver by caesarean section require additional breastfeeding support post-delivery and it is important to include fathers in breastfeeding related decisions and encourage them to participate in antenatal programs.

Understanding the challenges to caring for low birthweight babies in rural southern Malawi: a qualitative study exploring caregiver and health worker perceptions and experiences

BACKGROUND

Low birthweight (LBW) babies account for >80% of neonatal mortality in sub-Saharan Africa and South Asia and those who survive the neonatal period are still at risk of detrimental outcomes. LBW is a major public health problem in Malawi and strongly contributes to the country's high neonatal mortality rate. We aimed to get a better understanding of the care of LBW babies in rural Malawi in order to inform action to improve their outcomes.

METHODS

Qualitative methods were used to identify challenges faced by caregivers and health workers within communities and at the rural facility level. We conducted 33 in-depth interviews (18 with caregivers; 15 with health workers) and 4 focus group discussions with caregivers. Interviews were recorded, transcribed and translated. Thematic analysis was used to index the data into themes and develop a robust analytical framework.

RESULTS

Caregivers referred to LBW babies as weak, with poor health, stunted growth, developmental problems and lack of intelligence. Poor nutrition of the mother and illnesses during pregnancy were perceived to be important causes of LBW. Discrimination and stigma were described as a major challenge faced by carers of LBW babies. Problems related to feeding and the high burden of care were seen as another major challenge. Health workers described a lack of resources in health facilities, lack of adherence to counselling provided to carers and difficulties with continuity of care and follow-up in the community.

CONCLUSION

This study highlights that care of LBW babies in rural Malawi is compromised both at community and rural facility level with poverty and existing community perceptions constituting the main challenges. To make progress in reducing neonatal mortality and promoting better outcomes, we must develop integrated community-based care packages, improve care at facility level and strengthen the links between them.

Human Milk and Allergic Diseases: An Unsolved Puzzle

There is conflicting evidence on the protective role of breastfeeding in relation to the development of allergic sensitisation and allergic disease. Studies vary in methodology and definition of outcomes, which lead to considerable heterogeneity. Human milk composition varies both within and between individuals, which may partially explain conflicting data. It is known that human milk composition is very complex and contains variable levels of immune active molecules, oligosaccharides, metabolites, vitamins and other nutrients and microbial content. Existing evidence suggests that modulation of human breast milk composition has potential for preventing allergic diseases in early life. In this review, we discuss associations between breastfeeding/human milk composition and allergy development.

Breast-feeding and Infant Hospitalization for Infections: Large Cohort and Sibling Analysis

OBJECTIVES

Breast-feeding may protect against infections, but its optimal duration remains controversial. We aimed to study the association of the duration of full and any breast-feeding with infections the first 18 months of life.

METHODS

The Norwegian Mother and Child study (MoBa) is a prospective birth cohort which recruited expecting mothers giving birth from 2000 to 2009. We analyzed data from the full cohort (n = 70,511) and sibling sets (n = 21,220) with parental report of breast-feeding and infections. The main outcome measures were the relative risks (RRs) for hospitalization for infections from 0 to 18 months by age at introduction of complementary foods and duration of any breast-feeding.

RESULTS

Although we found some evidence for an overall association between longer duration of full breast-feeding and lower risk of hospitalizations for infections, 7.3% of breast-fed children who received complementary foods at 4 to 6 months of age compared to 7.7% of those receiving complementary foods after 6 months were hospitalized (adjusted RR 0.95, 95% confidence interval 0.88-1.03). Higher risk of hospitalization was observed in those breast-fed 6 months or less (10.0%) compared to ≥12 months (7.6%, adjusted RR 1.22, 95% confidence interval 1.14-1.31), but with similar risks for 6 to 11 months versus ≥12 months. Matched sibling analyses, minimizing the confounding from shared maternal factors, showed nonsignificant associations and were generally weaker compared with the cohort analyses.

CONCLUSIONS

Our results support the recommendation to fully breast-feed for 4 months and to continue breast-feeding beyond 6 months, and suggest that protection against infections is limited to the first 12 months.

Piecing together the stunting puzzle: a framework for attributable factors of child stunting

Reducing the burden of stunting in childhood is critical to improving health in low- and middle-income settings. However, because many aetiologies underlie linear growth failure, stunting has proved difficult to prevent and reverse. Understanding the contributions these aetiologies make to the burden of stunting can help the development of targeted, effective interventions. To begin to frame these causes, a qualitative and a quantitative framework of the primary drivers of stunting in low-resource settings were developed. Population attributable fractions (PAF) were estimated to inform the quantitative framework. According to these estimates, infectious diseases were responsible for large attributable fractions in all settings, and a combination of dietary indicators also comprised a large fraction in Africa. However, the PAF calculation was found to have several limitations, including a requirement for a binary outcome and sensitivity to confounding, which necessitate broad interpretation of the results. More robust tools to model complex causality are needed in order to understand the causal aetiology of stunting.

The Role of Breastfeeding in Childhood Otitis Media

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent literature, both systematic reviews and recently published original studies not included within those reviews, on the relationship between breastfeeding and childhood otitis media (OM).

RECENT FINDINGS

There is clear evidence that breastfeeding is associated with a reduced risk of OM in childhood with sound biological plausibility to support that the association is likely causal. Any breastfeeding reduces OM risk in early childhood by 40-50 %. Systematic reviews also support a further reduced risk for continued breastfeeding. Recent studies have estimated burden of disease savings if breastfeeding within countries and globally approached WHO guidelines. Cost savings per year for reduced cases of OM by increasing ever and exclusive breastfeeding rates are estimated to be millions of pounds or dollars for UK and Mexico. Breastfeeding reduces OM in children. The burden of disease and economic impact of increasing breastfeeding rates and duration would be substantial.

Human milk expression as a sole or ancillary strategy for infant feeding: a qualitative study

In the United States, a significant proportion of human milk (HM) is now fed to infants from bottles. This mode of infant feeding is rarely measured or described in research studies or monitored by national surveillance systems. Consequently, little is known about expressed-HM feeding as an infant feeding strategy. Our objective was to understand how mothers use HM expression and expressed-HM feeding as a sole strategy or in combination with at-the-breast feeding to feed HM to their infants. We conducted semi-structured interviews with 41 mothers with experience of HM expression and infants under three years of age. Data were analysed using a grounded theory approach for sub-themes related to the pre-selected major themes of maternal HM production and infant HM consumption. Within the major theme of maternal HM production, sub-themes related to maternal over-production of HM. Many mothers produced more HM than their infant was consuming and stored it in the freezer. This enabled some infants to consume HM weeks or months after it was expressed. Within the major theme of infant HM consumption, the most salient sub-theme related to HM-feeding strategies. Four basic HM-feeding strategies emerged, ranging from predominant at-the-breast feeding to exclusive expressed-HM feeding. The HM-feeding strategies and trajectories highlighted by this study are complex, and most mothers fed HM both at-the-breast and from a bottle-information that is not collected by the current national breastfeeding survey questions. To understand health outcomes associated with expressed-HM feeding, new terminology may be needed.

Mothers' understanding of the term 'exclusive breastfeeding': a systematic review

There is a lack of knowledge and understanding of the term exclusive breastfeeding (EBF) among health professionals. The purpose of this review was to examine the best available literature on mothers' understanding of the term EBF. A systematic search of eight electronic databases (Medline, Embase, CINAHL, CDSR, CENTRAL, Cab Abstracts, Scopus and African Index Medicus) was conducted (Protocol registration in PROSPERO: CRD42015019402). All study designs were eligible for inclusion. Studies were included if they: (1) involved mothers aged 18 years or older; (2) assessed mothers' knowledge/understanding/awareness of the term 'EBF'; (3) used the 1991 WHO definition of EBF and (4) were published between 1988 and 2015. Two reviewers retrieved articles, assessed study quality and performed data extraction. Of the 1700 articles identified, 21 articles met the inclusion criteria. Quantitative findings were pooled to calculate a proportion rate of 70.9% of mothers who could correctly define EBF, although the range varied between 3.1 and 100%. Qualitative findings revealed three themes: (1) EBF was understood by mothers as not mixing two milks; (2) the term 'exclusive' in EBF was incorrectly understood as not giving breast milk and (3) mothers believing that water can be given while exclusively breastfeeding. Research investigating aspects of self-reported EBF may consequently be unreliable. A standardised tool to assess mothers' knowledge of EBF could provide more accurate data. Public health campaigns should emphasise EBF to target mothers, while addressing the education of health professionals to ensure that they do not provide conflicting advice.

Mobile Phone Short Messages to Improve Exclusive Breastfeeding and Reduce Adverse Infant Feeding Practices: Protocol for a Randomized Controlled Trial in Yangon, Myanmar

BACKGROUND

Myanmar has a high burden of mortality for children aged younger than 5 years in which undernutrition plays a major role. Despite current efforts, the exclusive breastfeeding rate for children under 6 months is only 24%. To date there have been no interventions using mobile phones to improve breastfeeding and other feeding practices in Myanmar.

OBJECTIVE

This study aims to implement a breastfeeding promotion intervention using mobile phone text messages in Yangon, Myanmar, and evaluate its impact on breastfeeding practices.

METHODS

M528 is a 2-group parallel-arm randomized controlled trial with 9 months follow-up from recruitment until 6 months post-delivery. A total of 353 pregnant women between 28 and 34 weeks' gestation who had access to a mobile phone and were able to read and write have been recruited from the Central Women's Hospital, Yangon, and allocated randomly to an intervention or control group in a 1:1 ratio. The intervention group received breastfeeding promotional SMS messages 3 times a week while the control group received maternal and child health care messages (excluding breastfeeding-related messages) once a week. The SMS messages were tailored for the women's stage of gestation or the child's age. A formative qualitative study was conducted prior to the trial to inform the study design and text message content. We hypothesize that the exclusive breastfeeding rate in the intervention group will be double that in the control group. The primary outcome is exclusive breastfeeding from birth to 6 months and secondary outcomes are median durations of exclusive breastfeeding and other infant feeding practices. Both primary and secondary outcomes were assessed by monthly phone calls at 1 to 6 months postdelivery in both groups. Participants' delivery status was tracked through text messages, phone calls, and hospital records, and delivery characteristics were assessed 1 month after delivery. Child morbidity and breastfeeding self-efficacy scores were assessed at 1, 3, and 5 months postdelivery. Social desirability was measured at 5 months, and text messages expressing delivery success and user experience were assessed at the end of the study.

RESULTS

The targeted 353 pregnant women were recruited between January and March 2015. Baseline data have been collected; SMS messages have been developed and pretested and sent to the women from both groups. Follow-up data collection via phone calls has been completed. Data analysis is being done and results are expected soon. This is the first RCT study examining the effects of mobile text messaging for promoting exclusive breastfeeding.

CONCLUSIONS

This trial is timely in Myanmar following the telecommunications market opening in 2014. Our results will help determine whether text messaging is an effective and feasible method for promoting appropriate feeding practices and will inform further research to assess how this model could be replicated in the broader community.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12615000063516; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367704 (Archived by WebCite at http://www.webcitation.org/ 6rGif3l81).

Resistance to breastfeeding: A Foucauldian analysis of breastfeeding support from health professionals

BACKGROUND

Despite widespread consensus regarding the health benefits of breastfeeding, the prevalence of six months exclusive breastfeeding is very low in developed countries including New Zealand.

AIM

This paper aims to evaluate the role that health professionals play in promoting exclusive breastfeeding in New Zealand.

METHODS

Qualitative research involving face to face postpartum interviews conducted four to six weeks after the birth with 30 new mothers who lived in New Zealand and had identified in a short antenatal questionnaire that they intended to practice exclusive breastfeeding for six months. Themes related to exclusive breastfeeding support from health professionals were extracted from the interview transcripts and interpreted using Foucault's ideas about governmentality and bio-power.

RESULTS

Four themes related to the quality of health care support were identified in the interview transcripts. 'Breastfeeding self-efficacy support from the community midwives', 'mothers need to know more about breastfeeding during pregnancy', 'experiencing difficulties breastfeeding' as well as 'pressure and resistance to breastfeeding'.

DISCUSSION

Most mothers in this research spoke about feeling pressured to breastfeed within the New Zealand health system. However, the participating mothers acknowledged the effective support that they had received from community midwives who respected their autonomy, strengthened their self-esteem and encouraged them to breastfeed.

CONCLUSION

Negative historical experiences related to the medicalization of infant feeding in Western countries suggests that health professionals need to provide effective skill support for breastfeeding mothers so that mothers do not consider it a form of "quiet coercion" or as an exercise of "power".

Breastfeeding and Red Meat Intake Are Associated with Iron Status in Healthy Korean Weaning-age Infants

The present study investigated risk factors for iron deficiency (ID) and iron deficiency anemia (IDA) during late infancy, including feeding type and complementary feeding (CF) practice. Healthy term Korean infants (8-15 months) were weighed, and questionnaires regarding delivery, feeding, and weaning were completed by their caregivers. We also examined levels of hemoglobin, serum iron/total iron-binding capacity, serum ferritin, and mean corpuscular volume (MCV). Among 619 infants, ID and IDA were present in 174 infants (28.1%) and 87 infants (14.0%), respectively. The 288 infants with exclusively/mostly breastfeeding until late infancy (BFL) were most likely to exhibit ID (53.1%) and IDA (28.1%). The risk of ID was independently associated with BFL (adjusted odds ratio [aOR], 47.5; 95% confidence interval [CI], 18.3-122.9), male sex (aOR, 1.9; 95% CI, 1.2-2.9), fold weight gain (aOR, 2.6; 95% CI, 1.5-4.6), and perceived inadequacy of red meat intake (aOR, 1.7; 95% CI, 1.0-2.7). In addition to the risk factors for ID, Cesarean section delivery (aOR, 1.9; 95% CI, 1.1-3.2) and low parental CF-related knowledge (aOR, 2.8; 95% CI, 1.5-5.2) were risk factors for IDA. In conclusion, prolonged breastfeeding and perceived inadequacy of red meat intake may be among the important feeding-related risk factors of ID and IDA. Therefore, more meticulous education and monitoring of iron-rich food intake, such as red meat, with iron supplementation or iron status testing during late infancy if necessary, should be considered for breastfed Korean infants, especially for those with additional risk factors for ID or IDA.

Innate Immunity and Breast Milk

Human milk is a dynamic source of nutrients and bioactive factors; unique in providing for the human infant's optimal growth and development. The growing infant's immune system has a number of developmental immune deficiencies placing the infant at increased risk of infection. This review focuses on how human milk directly contributes to the infant's innate immunity. Remarkable new findings clarify the multifunctional nature of human milk bioactive components. New research techniques have expanded our understanding of the potential for human milk's effect on the infant that will never be possible with milk formulas. Human milk microbiome directly shapes the infant's intestinal microbiome, while the human milk oligosaccharides drive the growth of these microbes within the gut. New techniques such as genomics, metabolomics, proteomics, and glycomics are being used to describe this symbiotic relationship. An expanded role for antimicrobial proteins/peptides within human milk in innate immune protection is described. The unique milieu of enhanced immune protection with diminished inflammation results from a complex interaction of anti-inflammatory and antioxidative factors provided by human milk to the intestine. New data support the concept of mucosal-associated lymphoid tissue and its contribution to the cellular content of human milk. Human milk stem cells (hMSCs) have recently been discovered. Their direct role in the infant for repair and regeneration is being investigated. The existence of these hMSCs could prove to be an easily harvested source of multilineage stem cells for the study of cancer and tissue regeneration. As the infant's gastrointestinal tract and immune system develop, there is a comparable transition in human milk over time to provide fewer immune factors and more calories and nutrients for growth. Each of these new findings opens the door to future studies of human milk and its effect on the innate immune system and the developing infant.

Human milk insulin is related to maternal plasma insulin and BMI: but other components of human milk do not differ by BMI

Background

The impact of maternal BMI and insulin sensitivity on bioactive components of human milk (HM) is not well understood. As the prevalence of obesity and diabetes rises, it is increasingly critical that we understand how maternal BMI and hormones associated with metabolic disease relate to concentrations of bioactive components in HM.

Methods

This longitudinal cohort design followed 48 breastfeeding mothers through the first four months of lactation, collecting fasting morning HM samples at 2-weeks and 1, 2, 3, and 4-months, and fasting maternal blood at 2-weeks and 4-months. Insulin, glucose, adipokines leptin and adiponectin, appetite regulating hormone ghrelin, marker of oxidative stress 8OHdG, and inflammatory cytokines (IL-6, IL-8, and TNF-a) were measured in HM and maternal plasma.

Results

26 normal weight (NW) (BMI=21.4±2.0 kg/m²), and 22 overweight/obese (OW/Ob) (BMI=30.4±4.2 kg/m²) were followed. Of all HM analytes measured, only insulin and leptin were different between groups - consistently higher in the OW/Ob group (leptin: p<0.001; insulin: p<0.03). HM insulin was 98% higher than maternal plasma insulin at 2-weeks and 32% higher at 4-months (p<0.001). Maternal fasting plasma insulin and HOMA-IR were positively related to HM insulin at 2-weeks (p<0.001, R²≥0.38, n=31), and 4-months (p≤0.005, R²≥0.20, n=38).

Conclusions

The concentrations of insulin in HM are higher than in maternal plasma and are related to maternal BMI and insulin sensitivity. With the exception of leptin, there were minimal other differences observed in HM composition across a wide range in maternal BMI.

Breastfeeding Mode and Risk of Breast Cancer: A Dose-Response Meta-Analysis

BACKGROUND

Breastfeeding reduces women's risk of breast cancer. Since exclusive breastfeeding has a stronger hormonal effect, it could theoretically result in a greater reduction in breast cancer risk than any breastfeeding mode. No meta-analysis has examined breast cancer risk by breastfeeding mode. Research aim: The authors conducted a meta-analysis for breast cancer risk in parous women who breastfed exclusively or in any mode versus parous women who formula fed their infants, and they estimated the summary dose-response association by the accumulated duration of any breastfeeding mode.

METHODS

A systematic review of studies published between 2005 and 2015 analyzing breastfeeding and breast cancer risk in women was conducted in PubMed and EBSCOhost. A meta-analysis ( n = 65 studies) with fixed effects (or random effects, if heterogeneity existed) was carried out stratified by breastfeeding mode and menopausal and parity status. A summary dose-response association was estimated using the generalized least-squares method.

RESULTS

The summary relative risk (SRR) for breast cancer in parous women who breastfed exclusively was 0.72, 95% confidence interval (CI) [0.58, 0.90], versus parous women who had never breastfed. For parous women who breastfed in any mode, the SRR was lower in both premenopausal women (0.86, 95% CI [0.80, 0.93]) and postmenopausal women (0.89, 95% CI [0.83, 0.95]). There was no heterogeneity or publication bias. There is weak evidence of a difference between exclusive and any breastfeeding mode ( p = .08). The summary dose-response curve was nonlinear ( p < .001).

CONCLUSION

Exclusive breastfeeding among parous women reduces the risk of breast cancer compared with parous women who do not breastfeed exclusively.

Predictors of Breastfeeding Initiation and Maintenance in an Integrated Healthcare Setting

BACKGROUND

The American Academy of Pediatrics recommends exclusive breastfeeding to age 6 months. Although breastfeeding rates in the United States have been increasing over time, further improvements are needed to meet Healthy People 2020 targets. Research aim: This study examined predictors of breastfeeding initiation and maintenance among a population of insured pregnant women.

METHODS

Participants were 1,149 pregnant women enrolled in the Pregnancy and Influenza Project in two Kaiser Permanente regions in 2010-2011. Data were collected through interviews at enrollment and 1 month and 6 months postpartum and through participants' electronic medical records.

RESULTS

Nearly all (99%) women reported initiating breastfeeding. Rates of exclusive breastfeeding were 70% and 54% at 1 month and 6 months, respectively; an additional 22% and 23% of women reported supplementing breastfeeding with formula. Of the women who supplemented, the mean ( SD) infant age at formula introduction was 53 (62) days. Of those who had stopped breastfeeding, the mean ( SD) infant age at cessation was 85 (59) days. Higher maternal education level, better maternal self-rated health, prenatal folic acid use, absence of chronic medical conditions, and infant full-term birth were significantly associated with breastfeeding maintenance.

CONCLUSION

Although rates of breastfeeding in this population were higher than national rates, a significant number of women stopped breastfeeding or introduced formula earlier than recommended. Two to 3 months postpartum may be a critical period warranting additional encouragement or intervention by healthcare providers. Mothers' education attainment, maternal health factors, and gestational age at delivery may predict likelihood of breastfeeding maintenance.

Determinants of Nonmedically Indicated In-Hospital Supplementation of Infants Whose Birthing Parents Intended to Exclusively Breastfeed

BACKGROUND

Despite high rates of intention to exclusively breastfeed, rates of exclusive breastfeeding in Canada are low. Supplementation may begin in hospital and is associated with reduced breastfeeding duration. Research aim: The aim of this investigation was to explore determinants of in-hospital nonmedically indicated supplementation of infants whose birthing parents intended to exclusively breastfeed.

METHODS

This study is a cross-sectional one-group nonexperimental design, focused on participants who intended to exclusively breastfeed for 6 months ( n = 496). Data were collected between October 2011 and October 2015 in Newfoundland and Labrador. Variables measured included age; rural/urban location; education; income; race; marital status; parity; smoking status; having been breastfed as an infant; previous breastfeeding experience; Iowa Infant Feeding Attitude Scale score; delivery mode; infant birth weight; birth satisfaction; skin-to-skin contact; length of participant's hospital stay; breastfeeding advice from a lactation consultant, registered nurse, or physician; and first impression of breastfeeding. We evaluated determinants of in-hospital nonmedically indicated supplementation using bivariate and multivariate logistic regression analyses.

RESULTS

Overall, 16.9% ( n = 84) of infants received nonmedically indicated supplementation in hospital. Multivariate modeling revealed four determinants: low total prenatal Iowa Infant Feeding Attitude Scale score (odds ratio [OR] = 1.96, 95% confidence interval [CI] [1.18, 3.27]), no previous breastfeeding experience (OR = 2.03, 95% CI [1.15, 3.61]), negative first impression of breastfeeding (OR = 2.67, 95% CI [1.61, 4.43]), and receiving breastfeeding advice from a hospital physician (OR = 2.86, 95% CI [1.59, 5.15]).

CONCLUSION

Elements of the hospital experience, self-efficacy, and attitudes toward infant feeding are determinants of nonmedically indicated supplementation of infants whose birthing parents intended to exclusively breastfeed.

Prevalence and Predictors of Breastfeeding After Childhood Abuse

OBJECTIVE

To describe the prevalence and predictors of breastfeeding intent and outcomes in women with histories of childhood maltreatment trauma (CMT), including those with posttraumatic stress disorder (PTSD).

DESIGN

Secondary analysis of a prospective observational cohort study of the effects of PTSD on perinatal outcomes.

SETTING

Prenatal clinics in three health systems in the Midwestern United States.

PARTICIPANTS

Women older than 18 years expecting their first infants, comprising three groups: women who experienced CMT but did not have PTSD (CMT-resilient), women with a history of CMT and PTSD (CMT-PTSD), and women with no history of CMT (CMT-nonexposed).

METHODS

Secondary analysis of an existing data set in which first-time mothers were well-characterized on trauma history, PTSD, depression, feeding plans, feeding outcomes, and several other factors relevant to odds of breastfeeding success.

RESULTS

Intent to breastfeed was similar among the three groups. Women in the CMT-resilient group were twice as likely to breastfeed exclusively at 6 weeks (60.5%) as women in the CMT-PTSD group (31.1%). Compared with women in the CMT-nonexposed group, women in the CMT-resilient group were more likely to exclusively breastfeed. Four factors were associated with increased likelihood of any breastfeeding at 6 weeks: prenatal intent to breastfeed, childbirth education, partnered, and a history of CMT. Four factors were associated with decreased odds of breastfeeding: African American race, PTSD, major depression, and low level of education (high school or less).

CONCLUSION

Posttraumatic stress disorder is more important than childhood maltreatment trauma history in determining likelihood of breastfeeding success. Further research on the promotion of breastfeeding among PTSD-affected women who have experienced CMT is indicated.

Validação para língua portuguesa do instrumento de avaliação do aleitamento materno LATCH

Resumo Objetivo Traduzir para a língua portuguesa e validar a escala de avaliação da amamentação LATCH. Métodos Tratou-se de um estudo do tipo metodológico, por meio da tradução e validação de instrumento. Seguiu-se as etapas estabelecidas: tradução, back-translation, comitê de juízes, pré-teste e validação. O processo de validação inclui a análise de 160 mamadas de mulheres nos primeiros dias pós-parto, durante a internação hospitalar. Resultados Os resultados obtidos indicam que o instrumento LATCH traduzido para o português pode ser utilizado na avaliação do aleitamento materno pelo profissional enfermeiro, possibilitando a detecção precoce de possíveis problemas apresentados pelo binômio mãe-bebê durante a amamentação. Conclusão O estudo cumpriu o objetivo de adaptar para a língua portuguesa e verificar as propriedades psicométricas do instrumento de avaliação de aleitamento materno LATCH. A validade do instrumento LATCH mede o que foi concebido para medir, sendo ele aplicável na prática clínica.

Infant Feeding Decision-Making and the Influences of Social Support Persons Among First-Time African American Mothers

Background While breast milk is considered the gold standard of infant feeding, a majority of African American mothers are not exclusively breastfeeding their newborn infants. Objective The overall goal of this critical ethnographic research study was to describe infant feeding perceptions and experiences of African American mothers and their support persons. Methods Twenty-two participants (14 pregnant women and eight support persons) were recruited from public health programs and community based organizations in northern California. Data were collected through field observations, demographic questionnaires, and multiple in-person interviews. Thematic analysis was used to identify key themes. Results Half of the mothers noted an intention to exclusively breastfeed during the antepartum period. However, few mothers exclusively breastfed during the postpartum period. Many participants expressed guilt and shame for not being able to accomplish their antepartum goals. Life experiences and stressors, lack of breastfeeding role models, limited experiences with breastfeeding and lactation, and changes to the family dynamic played a major role in the infant feeding decision making process and breastfeeding duration. Conclusions for Practice Our observations suggest that while exclusivity goals were not being met, a considerable proportion of African American women were breastfeeding. Future interventions geared towards this population should include social media interventions, messaging around combination feeding, and increased education for identified social support persons. Public health measures aimed at reducing the current infant feeding inequities would benefit by also incorporating more culturally inclusive messaging around breastfeeding and lactation.

Impact of ingredients on the elemental content of baby foods

The levels of the minerals: Ca, K, Mg, Na, P, and the trace elements: Cd, Cu, Fe, Mn, Ni, Pb, Se, Zn were determined in foods for 4-6, 7+ and 10+ months old babies in a brand available on the UK market. The mineral contents in the vegetarian meals for all the age groups were similar, in contrast, when compared to the non-vegetarian options, the Ca, Na and P levels were higher in the former. Both the trace elements and minerals levels in the 4-6months vegetarian meal were the lowest of all the products analysed. The Cu, Se and Zn levels in all the meals were comparable to those in mature human breast milk. Calculations of the following molar ratios: Zn:Cu, Fe:Zn, and Fe:Mn, pairs of elements that have been shown to interaction antagonistically, were higher in the vegetarian meals.

Changes over time in early complementary feeding of breastfed infants on the island of Hispaniola

Objective.

To describe and contrast early complementary feeding (ECF) over time in breastfed infants in the Dominican Republic (DR) and Haiti, the two countries that share the island of Hispaniola.

Methods.

Secondary data analysis was conducted on cross-sectional data from Demographic and Health Surveys administered at four different time-points in both countries between 1994 and 2013. Extracted samples were composed of breastfed infants < 6 months of age whose caregivers had responded to dietary questions on food consumption in the previous 24 hours.

Results.

Plain water was the most frequently consumed complementary substance in both countries. However, the prevalence of water consumption increased in the DR over time, whereas in Haiti it decreased. Milk (non-breast) use was also common and followed a similar pattern as water over time in the two countries. Expanded use of water and milk in the DR are the major contributors to its drop in exclusive breastfeeding (EBF) rates over time. Whereas in Haiti, a reduction in a broader array of liquids and semi-solids/solids overtime appears to have contributed to its markedly improved EBF rates.

Conclusion.

Determining contributors to the differential trends in water and milk (non-breast) use between these two countries may identify targets for addressing the persistent gaps in EBF on the island of Hispaniola.

Support for healthy breastfeeding mothers with healthy term babies

BACKGROUND

There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation.

OBJECTIVES

To describe forms of breastfeeding support which have been evaluated in controlled studies, the timing of the interventions and the settings in which they have been used.To examine the effectiveness of different modes of offering similar supportive interventions (for example, whether the support offered was proactive or reactive, face-to-face or over the telephone), and whether interventions containing both antenatal and postnatal elements were more effective than those taking place in the postnatal period alone.To examine the effectiveness of different care providers and (where information was available) training.To explore the interaction between background breastfeeding rates and effectiveness of support.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (29 February 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

This updated review includes 100 trials involving more than 83,246 mother-infant pairs of which 73 studies contribute data (58 individually-randomised trials and 15 cluster-randomised trials). We considered that the overall risk of bias of trials included in the review was mixed. Of the 31 new studies included in this update, 21 provided data for one or more of the primary outcomes. The total number of mother-infant pairs in the 73 studies that contributed data to this review is 74,656 (this total was 56,451 in the previous version of this review). The 73 studies were conducted in 29 countries. Results of the analyses continue to confirm that all forms of extra support analyzed together showed a decrease in cessation of 'any breastfeeding', which includes partial and exclusive breastfeeding (average risk ratio (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.88 to 0.95; moderate-quality evidence, 51 studies) and for stopping breastfeeding before four to six weeks (average RR 0.87, 95% CI 0.80 to 0.95; moderate-quality evidence, 33 studies). All forms of extra support together also showed a decrease in cessation of exclusive breastfeeding at six months (average RR 0.88, 95% CI 0.85 to 0.92; moderate-quality evidence, 46 studies) and at four to six weeks (average RR 0.79, 95% CI 0.71 to 0.89; moderate quality, 32 studies). We downgraded evidence to moderate-quality due to very high heterogeneity.We investigated substantial heterogeneity for all four outcomes with subgroup analyses for the following covariates: who delivered care, type of support, timing of support, background breastfeeding rate and number of postnatal contacts. Covariates were not able to explain heterogeneity in general. Though the interaction tests were significant for some analyses, we advise caution in the interpretation of results for subgroups due to the heterogeneity. Extra support by both lay and professionals had a positive impact on breastfeeding outcomes. Several factors may have also improved results for women practising exclusive breastfeeding, such as interventions delivered with a face-to-face component, high background initiation rates of breastfeeding, lay support, and a specific schedule of four to eight contacts. However, because within-group heterogeneity remained high for all of these analyses, we advise caution when making specific conclusions based on subgroup results. We noted no evidence for subgroup differences for the any breastfeeding outcomes.

AUTHORS' CONCLUSIONS

When breastfeeding support is offered to women, the duration and exclusivity of breastfeeding is increased. Characteristics of effective support include: that it is offered as standard by trained personnel during antenatal or postnatal care, that it includes ongoing scheduled visits so that women can predict when support will be available, and that it is tailored to the setting and the needs of the population group. Support is likely to be more effective in settings with high initiation rates. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed with women practising exclusive breastfeeding.

Following the World Health Organization's Recommendation of Exclusive Breastfeeding to 6 Months of Age Does Not Impact the Growth of Rural Gambian Infants

BACKGROUND

The WHO recommends exclusive breastfeeding (EBF) for the first 6 mo of life.

OBJECTIVE

The objective of this study was to assess the benefit of EBF to age 6 mo on growth in a large sample of rural Gambian infants at high risk of undernutrition.

METHODS

Infants with growth monitoring from birth to 2 y of age (n = 756) from the ENID (Early Nutrition and Immune Development) trial were categorized as exclusively breastfed if only breast milk and no other liquids or foods were given. EBF status was entered into confounder-adjusted multilevel models to test associations with growth trajectories by using >11,000 weight-for-age (WAZ), length-for-age (LAZ), and weight-for-length (WLZ) z score observations.

RESULTS

Thirty-two percent of infants were exclusively breastfed to age 6 mo. The mean age of discontinuation of EBF was 5.2 mo, and growth faltering started at ∼3.5 mo of age. Some evidence for a difference in WAZ and WHZ was found between infants who were exclusively breastfed to age 6 mo (EBF-6) and those who were not (nEBF-6), at 6 and 12 mo of age, with EBF-6 children having a higher mean z score. The differences in z scores between the 2 groups were small in magnitude (at 6 mo of age: 0.147 WAZ; 95% CI: -0.001, 0.293 WAZ; 0.189 WHZ; 95% CI: 0.038, 0.341 WHZ). No evidence for a difference between EBF-6 and nEBF-6 infants was observed for LAZ at any time point (6, 12, and 24 mo of age). Furthermore, a higher mean WLZ at 3 mo of age was associated with a subsequent higher mean age at discontinuation of EBF, which implied reverse causality in this setting (coefficient: 0.060; 95% CI: 0.008, 0.120).

CONCLUSION

This study suggests that EBF to age 6 mo has limited benefit to the growth of rural Gambian infants. This trial was registered at http://www.isrctn.com as ISRCTN49285450.

Oral Microbiota in Infants Fed a Formula Supplemented with Bovine Milk Fat Globule Membranes - A Randomized Controlled Trial

Background

In a recent study, supplementation of infant formula with milk fat globule membranes (MFGM) decreased the incidence of otitis media in infants <6 months of age.

Objectives

The aim of the present study was to characterize the oral microbiota in infants fed MFGM-supplemented formula and compare it to that of infants fed standard formula or breast milk.

Methods

In a prospective double-blinded randomized controlled trial, exclusively formula-fed infants <2 months of age were randomized to be fed experimental formula (EF, n = 80) with reduced energy and protein and supplemented with a bovine MFGM concentrate, or standard formula (SF, n = 80) until 6 months of age. A breast-fed reference (BFR, n = 80) group was also recruited. The oral microbiota was analyzed at 4 (n = 124) and 12 (n = 166) months of age using Illumina MiSeq multiplex sequencing and taxonomic resolution against the HOMD 16S rDNA database of oral bacteria.

Results

Species richness in the oral samples did not differ between the EF and SF groups, but partial least square modeling identified a few taxa that were significantly associated with being in either group, e.g. lower level of Moraxella catarrhalis in the EF group. Infants in the BFR group had significantly lower species richness at 4 months of age and their microbiota pattern differed markedly from the formula-fed groups.

Conclusions

Supplementation of infant formula with MFGM yielded moderate effects on the oral microbiome. Moraxella catarrhalis was less prevalent in infants fed EF than in those fed SF and may be associated with the decrease in otitis media seen in the same group.

Childcare workers' experiences of supporting exclusive breastfeeding in Kuala Muda District, Malaysia: a qualitative study

Background

The role of childcare workers at registered nurseries in supporting exclusive breastfeeding practice is important, as many newborn babies are placed in nurseries during working hours. To increase exclusive breastfeeding rates among working mothers, understanding childcare workers’ experiences and needs relating to supporting these mothers is crucial. This study aimed to explore childcare workers’ experiences of supporting breastfeeding at registered nurseries.

Methods

We used a qualitative design to conduct in-depth, semi-structured interviews with ten childcare workers at seven registered nursery centres in Kuala Muda District, Malaysia. Attitudes towards exclusive breastfeeding practice, experiences of breastfeeding training and information, and experiences supporting exclusive breastfeeding at the nursery were explored. Participants were asked to suggest improvements for exclusive breastfeeding practice at their nursery. All interviews were audio recorded, transcribed verbatim, and translated before analysis.

Results

All participants demonstrated a positive attitude in supporting and promoting exclusive breastfeeding practice, mainly centred on the advantages of breastfeeding. Various supports have been found such as labelling bottled breastmilk, allowing the mother to come to the nursery during breaks, and providing reading materials. However, several issues emerged that include parents’ choice on infant feeding practice, insufficient content on breastfeeding topics during training, and adherence to the (not recommended) practice of bottle feeding expressed breastmilk. Recommendations to enhance breastfeeding were also suggested by participants.

Conclusion

Childcare workers may serve as another potential resource for sustaining exclusive breastfeeding at registered nurseries.

Electronic supplementary material

The online version of this article (doi:10.1186/s13006-016-0095-4) contains supplementary material, which is available to authorized users.

How acceptable is it for HIV positive African, Caribbean and Black women to provide breast milk/fluid samples for research purposes?

Background

The African, Caribbean and Black communities have been found to be reluctant to participate in health research in North America. This is partly attributed to historical experiences as well as their cultural beliefs. Cultural beliefs about the uses of breast milk/fluids could further hinder the participation of African, Caribbean, and Black communities in research involving the collection of breast milk/fluids samples.

Methods

We conducted 17 in-depth interviews and three group interviews (n = 10) with HIV+ African, Caribbean and Black women living in Ontario, Canada to explore their cultural beliefs about breast milk/fluids and their acceptance of participating in research that involves the provision of breast fluid samples.

Study design

Qualitative study involving in-depth interviews.

Results

Our respondents believed that breast milk/fluids should be used for infant feeding and for curative purposes for a variety of children’s health ailments as well as ailments experienced by other family members. The cultural belief that breast milk/fluids could be used to bewitch the baby and mother and the perception that it is intrusive (equating breast milk/fluids research to DNA testing), could prevent African, Caribbean and Black women from participating in research involving the collection of breast milk/fluids. Despite these fears, some respondents expressed that they would participate if the research results would benefit them directly, for example, by finding a cure for HIV, enabling HIV+ mothers to breastfeed, or contributing to developing new drugs or vaccines for HIV. Women’s recommendations to facilitate successful recruitment included giving incentives to participants, and employing a recruiter who was trustworthy, informed, and culturally sensitive.

Conclusion

Cultural beliefs could present barriers to recruitment and participation of Africa, Caribbean and Black communities in health research involving breast milk/fluid samples. Successful recruitment for future studies would necessitate researchers to be culturally aware of the beliefs held by African, Caribbean and Black women, to build trust, and use an appropriate recruiter. While the findings relate to breast milk/fluids, the suggested recommendations for facilitating recruitment of research participants from these communities may be useful to consider when recruiting ethnically and culturally similar participants for research involving biological samples.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-2326-6) contains supplementary material, which is available to authorized users.

Breastfeeding and infant hospitalisation: analysis of the UK 2010 Infant Feeding Survey

To investigate the contributions of overall breastfeeding duration and exclusive breastfeeding in reducing the risk of hospitalisation for infectious causes, we analysed data from a three-stage survey on infant feeding practices and health outcomes in over 10 000 UK women in 2010-2011. The main outcome measures were risk of overnight hospital admission in the first 8-10 months of infancy. A graded beneficial effect was found between longer duration of any breastfeeding and hospital admission for infectious causes and for respiratory tract infections, with a significantly lower risk in infants breastfed for at least 3 months compared with those never breastfed. The effects were stronger in the subgroup who was also exclusively breastfed. For example, among infants breastfed for 3-6 months, the reduction in risk for infectious causes for those who were also exclusively breastfed for at least 6 weeks was 0.42 (95% CI: 0.22-0.81) and for those not exclusively breastfed for 6 weeks 0.79 (95% CI: 0.49-1.26). Likewise, among infants breastfed for 6 months or more, the odds ratio for those who were also exclusively breastfed for at least 6 weeks was 0.48 (95% CI: 0.32-0.72) and for those not exclusively breastfed for 6 weeks 0.72 (95% CI: 0.48-1.08). The apparent protective effect of any breastfeeding for a long duration may in part be driven by a prolonged period of exclusive breastfeeding. Exclusive breastfeeding in the initial weeks after childbirth and continuing to breastfeed (either exclusively or partially) for at least 3 months, preferably 6 months, may reduce morbidity due to infectious illness in infants.

Does Breast-feeding Relate to Development of Atopic Dermatitis in Young Korean Children?: Based on the Fourth and Fifth Korea National Health and Nutrition Examination Survey 2007-2012

Purpose

There have been conflicting reports concerning the relationship between breast-feeding and the development of atopic dermatitis (AD) in early childhood. The objective of this study was to investigate the associations between breast-feeding and the risk of AD in early childhood in Korea.

Methods

We combined the fourth and fifth Korea National Health and Nutrition Examination Survey data collected from 2007 to 2012 and analyzed 2,015 children at 1 to 3 years old. Regression analysis was used to determine the association of the following variables: AD, feeding types, duration of breast-feeding, and others.

Results

The annual prevalence of exclusive breast-feeding and AD decreased. Parents with allergic diseases preferred breast-feeding and extended duration of feeding compared with those without. In multiple logistic regression analyses, exclusive breast-feeding in feeding type I (P=0.070; adjusted odds ratio [OR]=1.990), exclusive breast-feeding in feeding type II (P=0.095; adjusted OR=1.495) and breast-feeding duration (P=0.430; adjusted OR=1.013) were not significantly related to AD.

Conclusions

Breast-feeding was not found to be associated with an occurrence of AD in young children. Rather, parents with histories of allergic diseases tended to prefer breast-feeding and extend its duration. To clarify the role of breast-feeding in the development of AD, a nation-wide prospective study is needed.

Predictors of knowledge and practice of exclusive breastfeeding among health workers in Mwanza city, northwest Tanzania

BACKGROUND

Universal exclusive breastfeeding (EBF) for the first 6 months is estimated to reduce infant mortality by 13-15% (9 million) in resource poor countries. Although 97% of women initiate breastfeeding in Tanzania, exclusive breastfeeding for 6 months remains below 50%. Accurate knowledge and practical skills pertaining to exclusive breastfeeding among health workers is likely to improve breastfeeding rates. Our study reports the health workers' knowledge and practice on EBF in Mwanza City, northwest of Tanzania.

METHODS

One principal researcher and two research assistants conducted data collection from 11 June-6 July 2012. In total, 220 health care workers including: 64 clinicians (medical specialists, residents, registrars, assistant medical officers and clinical officers) and 156 nurses were interviewed using a structured knowledge questionnaire. Amongst 220 health workers, 106 were observed supporting Breastfeeding using a checklist. Logistic regression was used to determine factors associated with exclusive breastfeeding knowledge and desirable skills.

RESULTS

Almost half of the 220 health workers interviewed correctly described EBF as defined by the World Health Organization. Only 52 of 220 respondents had good knowledge. In the adjusted analysis, working at hospital facility level compared to dispensary (OR 2.1; 95% CI 1.1-4.0, p-value = 0.032) and attending on job training (OR 2.7; 95% CI 1.2-6.1, p-value = 0.015) were associated with better knowledge. In total, 38% of respondents had a desirable level of practical skills. Clinicians were more likely to have good practice (OR 3.6; 95% CI 1.2-10.8; p-value = 0.020) than nurses. Most of the health workers had no training on EBF, and were not familiar with breastfeeding policy.

CONCLUSION

Less than 25% of healthcare workers surveyed had good knowledge of EBF. These findings identify the need for comprehensive training and mentoring of health workers on exclusive breastfeeding, making breastfeeding policies available and understood, along with supportive supervision and monitoring.

Breastfeeding up to 12 months of age not associated with increased risk of caries

Data sourcesPubMed Central, CINAHL, Embase and reference lists of identified articles.Study selectionObservational and experimental studies published in English where breastfeeding was the exposure and development of caries was the outcome of interest were considered. Two reviewers independently selected studies for inclusionData extraction and synthesisStudy quality was assessed independently by two researchers using the Newcastle Ottawa Scale (NOS). Key data items, exposure and outcome definitions and effect estimates (odds ratios (OR), relative risks, prevalence ratios) with 95% Confidence Interval (95%CI) were abstracted where available for inclusion in a meta-analysis. The aim was to assess breastfeeding in two specific time windows; up to 12 months of age and beyond 12 months of age.ResultsSixty-three papers were included. These consisted of 14 cohort studies of which six were nested within RCTs of breastfeeding promotion interventions, three case-control studies and 46 cross-sectional studies. The studies were predominantly conducted in high and middle income countries with only eight studies from low income countries. Forty-six studies were not included in the meta-analysis because of methodological differences in the measures of exposure and outcomes, or reporting of correlational analyses only.Meta-analysis of one prospective cohort and four cross-sectional studies reported odds ratios for the association between children who were exposed to more versus less breastfeeding up to 12 months OR= 0.50; (95%CI; 0.25-0.99, I² 86.8%).In the two studies which compared ever breastfeeding in the first 12 months with never breastfeeding, both showed a marked protective effect of breastfeeding on dental caries compared with other feeding. Whereas the three studies which compared a longer duration of breastfeeding in the first 12 months to a comparison group which included children who had had some exposure to breastfeeding did not (34,52,59). A meta-analysis of this three study subgroup found OR= 0.92; (95%CI; 0.69-1.23, I² 0%)Meta-analysis of two cohort studies, one case-control study and four cross-sectional studies reported odds ratios for the association between more or less breastfeeding after the age of 12 months and dental caries.Comparison groups for these studies included both those who had never been breastfed and those who had been breastfed for shorter durations. The pooled estimate was OR= 1.99; (95% CI: 1.35-2.95, I² 69.3%).Meta-analysis of one cohort, one case-control and three cross-sectional studies reported odds ratios for the association between more versus less nocturnal breastfeeding and the risk of dental caries amongst the subgroup of children breastfed longer than 12 months. OR= 7.14; (95%CI; 3.14-16.23, I² 77.1%).ConclusionsBreastfeeding up to 12 months of age is not associated with an increased risk of dental caries and in fact may offer some protection compared with formula. However, children breastfed beyond 12 months, a time during which all deciduous teeth erupt, had an increased risk of dental caries. This may be due to other factors which are linked with prolonged breastfeeding including nocturnal feeding during sleep, cariogenic foods/drinks in the diet or inadequate oral hygiene practices. Further research with careful control of pertinent confounding factors is needed to elucidate this issue and better inform infant feeding guidelines.

Infant formula feeding practices in a prospective population based study

Background

It is recommended that formula-fed infants are given standard whey-based infant formula throughout the first year of life, unless otherwise advised by healthcare professionals. To our knowledge it has not yet been explored if parents are using a whey-based infant formula throughout the first 12 months of life. Reasons for parental choice of formula are also unknown. Therefore, the objective of this paper was to describe parental administration of whey-based and non whey-based infant formula in the first year of life.

Methods

Data collected as part of the Cork BASELINE Birth Cohort Study examined infant feeding practices at 2, 6 and 12 months of age. Descriptive analysis explored infant feeding practices and parental reasons for changing from a whey-based to a non whey-based infant formula. Multiple logistic regression investigated parental and infant characteristics associated with the use of whey-based infant formula.

Results

In total, 62.4%, 40.4% and 12.8% parent(s) at 2, 6 and 12 months, respectively, gave their infant whey-based infant formula. No parental or infant characteristic was found to consistently influence the use of whey-based infant formula. The most common reason reported by parent(s) for changing their infant’s formula to a non whey-based formula was that they perceived their baby as being hungry.

Conclusion

The majority of parent(s) commence their infants on whey-based formula, but most change to non whey-based formula before 12 months of age. Parental perception of infant satiety and not healthcare advice was the most common reason for changing from a whey-based to a non whey-based infant formula. Additional research is now required to investigate the effect of whey-based and non whey-based infant formula on infant growth.

Antenatal breastfeeding education for increasing breastfeeding duration

BACKGROUND

Breast milk is well recognised as the best food source for infants. The impact of antenatal breastfeeding (BF) education on the duration of BF has not been evaluated.

OBJECTIVES

To assess the effectiveness of antenatal breastfeeding (BF) education for increasing BF initiation and duration.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register on 1 March 2016, CENTRAL (The Cochrane Library, 2016, Issue 3), MEDLINE (1966 to 1 March 2016) and Scopus (January 1985 to 1 March 2016). We contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All identified published, unpublished and ongoing randomised controlled trials (RCTs) assessing the effect of formal antenatal BF education or comparing two different methods of formal antenatal BF education, on the duration of BF. We included RCTs that only included antenatal interventions and excluded those that combined antenatal and intrapartum or postpartum BF education components. Cluster-randomised trials were included in this review. Quasi-randomised trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We assessed all potential studies identified as a result of the search strategy. Two review authors extracted data from each included study using the agreed form and assessed risk of bias. We resolved discrepancies through discussion. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review update includes 24 studies (10,056 women). Twenty studies (9789 women) contribute data to analyses. Most studies took place in high-income countries such as the USA, UK, Canada and Australia. In the first five comparisons, we display the included trials according to type of intervention without pooling data. For the 'Summary of findings' we pooled data for a summary effect.Five included studies were cluster-randomised trials: all of these adjusted data and reported adjustments as odds ratios (OR). We have analysed the data using the generic inverse variance method and presented results as odds ratios, because we were unable to derive a cluster-adjusted risk ratio from the published cluster-trial. We acknowledge that the use of odds ratio prevents the pooling of these cluster trials in our main analyses. One method of BF education with standard (routine) careThere were no group differences for duration of any BF in days or weeks. There was no evidence that interventions improved the proportion of women with any BF or exclusive BF at three or six months. Single trials of different interventions were unable to show that education improved initiation of BF, apart from one small trial at high risk of attrition bias. Many trial results marginally favoured the intervention but had wide confidence intervals crossing the line of no effect. BF complications such as mastitis and other BF problems were similar in treatment arms in single trials reporting these outcomes. Multiple methods of BF education versus standard careFor all trials included in this comparison we have presented the cluster-adjusted odds ratios as reported in trial publications. One three-arm study found the intervention of BF booklet plus video plus Lactation Consultant versus standard care improved the proportion of women exclusively BF at three months (OR 2.60, 95% CI 1.25 to 5.40; women = 159) and marginally at six months (OR 2.40, 95% CI 1.00 to 5.76; women = 175). For the same trial, an intervention arm without a lactation consultant but with the BF booklet and video did not have the same effect on proportion of women exclusively BF at three months (OR 1.80, 95% CI 0.80 to 4.05; women = 159) or six months (OR 0.90, 95% CI 0.30 to 2.70; women = 184). One study compared monthly BF sessions and weekly cell phone message versus standard care and reported improvements in the proportion of women exclusively BF at both three and six months (three months OR 1.80, 95% CI 1.10 to 2.95; women = 390; six months OR 2.40, 95% CI 1.40 to 4.11; women = 390). One study found monthly BF sessions and weekly cell phone messages improved initiation of BF over standard care (OR 2.61, 95% CI 1.61 to 4.24; women = 380). BF education session versus standard care, pooled analyses for 'Summary of findings' (SoF)This comparison does not include cluster-randomised trials reporting adjusted odds ratios. We did not downgrade any evidence for trials' lack of blinding; no trial had adequate blinding of staff and participants. The SoF table presents risk ratios for all outcomes analysed. For proportion of women exclusively BF there is no evidence that antenatal BF education improved BF at three months (RR 1.06, 95% CI 0.90 to 1.25; women = 822; studies = 3; moderate quality evidence) or at six months (RR 1.07, 95% CI 0.87 to 1.30; women = 2161; studies = 4; moderate quality evidence). For proportion of women with any BF there were no group differences in BF at three (average RR 0.98, 95% CI 0.82 to 1.18; women = 654; studies = 2; I² = 60%; low-quality evidence) or six months (average RR 1.05, 95% CI 0.90 to 1.23; women = 1636; studies = 4; I² = 61%; high-quality evidence). There was no evidence that antenatal BF education could improve initiation of BF (average RR 1.01, 95% CI 0.94 to 1.09; women = 3505; studies = 8; I² = 69%; high-quality evidence). Where we downgraded evidence this was due to small sample size or wide confidence intervals crossing the line of no effect, or both.There was insufficient data for subgroup analysis of mother's occupation or education.

AUTHORS' CONCLUSIONS

There was no conclusive evidence supporting any antenatal BF education for improving initiation of BF, proportion of women giving any BF or exclusively BF at three or six months or the duration of BF. There is an urgent need to conduct a high-quality, randomised controlled study to evaluate the effectiveness and adverse effects of antenatal BF education, especially in low- and middle-income countries. Evidence in this review is primarily relevant to high-income settings.

Nutritional interventions or exposures in infants and children aged up to 3 years and their effects on subsequent risk of overweight, obesity and body fat: a systematic review of systematic reviews

This study, performed as part of the international EarlyNutrition research project (http://www.project-earlynutrition.eu), provides a systematic review of systematic reviews on the effects of nutritional interventions or exposures in children (up to 3 years of age) on the subsequent risk of obesity, overweight and adiposity. Electronic databases (including MEDLINE, Embase and Cochrane Library) were searched up until September 2015. Forty systematic reviews were included. A consistent association of breastfeeding with a modest reduction in the risk of later overweight and obesity in childhood and adulthood was found (the odds decreased by 13% based on high-quality studies), but residual confounding cannot be excluded. Lowering the protein content of infant formula is a promising intervention to reduce the risk of later overweight and obesity in children. There is no consistent evidence of an association of the age of introducing complementary foods, sugar-sweetened beverage or energy intake in early childhood with later overweight/obesity, but there are some indications of an association of protein intake during the complementary feeding period with later overweight/obesity. There was inadequate evidence to determine the effects of other nutritional interventions or exposures, including modifications of infant formula composition, fat intake or consumption of different food groups.

Exclusive breastfeeding duration and infant infection

BACKGROUND/OBJECTIVES

We estimated the risk of infection associated with the duration of exclusive breastfeeding (EBF).

SUBJECT/METHODS

We analysed the data on 15 809 term, singleton infants from the UK Millennium Cohort Study. Infants were grouped according to months of EBF: never, <2, 2-4, 4-6 and 6 (the latter being World Health Organisation (WHO) policy since 2001: 'post-2001 WHO policy'). Among those EBF for 4-6 months, we separated those who started solids, but not formula, before 6 months, and were still breastfeeding at 6 months (that is, WHO policy before 2001: 'pre-2001 WHO policy'), from other patterns. Outcomes were infection in infancy (chest, diarrhoeal and ear).

RESULTS

EBF was not associated with the ear infection, but was associated with chest infection and diarrhoea. EBF for <4 months was associated with a significantly increased risk of chest infection (adjusted risk ratios (RR) 1.24-1.28) and diarrhoea (adjusted RRs 1.42-1.66) compared with the pre-2001 WHO policy. There was an excess risk of the chest infection (adjusted RR 1.19, 95% confidence interval (CI): 0.97-1.46) and diarrhoea (adjusted RR 1.66, 95% CI: 1.11, 2.47) among infants EBF for 4-6 months, but who stopped breastfeeding by 6 months, compared with the pre-2001 WHO policy. There was no significant difference in the risk of chest infection or diarrhoea in those fed according to the pre-2001 versus post-2001 WHO policy.

CONCLUSIONS

There is an increased risk of infection in infants EBF for <4 months or EBF for 4-6 months who stop breastfeeding by 6 months. These results support current guidelines of EBF for either 4-6 or 6 months, with continued breastfeeding thereafter.

Interventions for women who have a caesarean birth to increase uptake and duration of breastfeeding: A systematic review

Rates of breastfeeding uptake are lower after a caesarean birth than vaginal birth, despite caesarean rates increasing globally over the past 30 years, and many high-income countries reporting overall caesarean rates of above 25%. A number of factors are likely to be associated with women's infant feeding decisions following a caesarean birth such as limited postoperative mobility, postoperative pain, and ongoing management of medical complications that may have triggered the need for a caesarean birth. The aim of this systematic review was to evaluate evidence of interventions on the initiation and duration of any and exclusive breastfeeding among women who had a planned or unplanned caesarean birth. Seven studies, presenting quantitative and qualitative evidence, published in the English language from January 1994 to February 2016 were included. A limited number of interventions were identified relevant to women who had had a caesarean birth. These included immediate or early skin-to-skin contact, parent education, the provision of sidecar bassinets when rooming-in, and use of breast pumps. Only one study, an intervention that included parent education and targeted breastfeeding support, increased initiation and continuation of breastfeeding, but due to methodological limitations, findings should be considered with caution. There is a need to better understand the impact of caesarean birth on maternal physiological, psychological, and physical recovery, the physiology of lactation and breastfeeding and infant feeding behaviors if effective interventions are to be implemented.

Early infant adipose deposition is positively associated with the n-6 to n-3 fatty acid ratio in human milk independent of maternal BMI

Background/Objectives

Excessive infant weight gain in the first 6-months of life is a powerful predictor of childhood obesity and related health risks. In mice, omega-6 fatty acids (FA) serve as potent ligands driving adipogenesis during early development. The ratio of omega-6 relative to omega-3 (n-6/n-3) FA in human milk (HM) has increased 3-fold over the last 30 years, but the impact of this shift on infant adipose development remains undetermined. This study investigated how maternal obesity and maternal dietary FA (as reflected in maternal red blood cells (RBC) composition) influenced HM n-6 and n-3 FAs, and whether the HM n-6/n-3 ratio was associated with changes in infant adipose deposition between 2-weeks and 4-months postpartum.

Subjects/Methods

Forty-eight infants from normal-weight (NW), overweight (OW) and obese (OB) mothers were exclusively or predominantly breastfed over the first 4 months of lactation. Mid-feed HM and maternal RBC were collected at either transitional (2-weeks) or established (4-months) lactation, along with infant body composition assessed using air-displacement plethysmography. The FA composition of HM and maternal RBC was measured quantitatively by lipid mass spectrometry.

Results

In transitional and established HM, DHA was lower (P=0.008; 0.005) and the AA/DHA+EPA ratio was higher (P=0.05; 0.02) in the OB relative to the NW group. Maternal prepregnancy BMI and AA/ DHA+EPA ratios in transitional and established HM were moderately correlated (P=0.018; 0.001). Total infant fat mass was increased in the upper AA/DHA+EPA tertile of established HM relative to the lower tertile (P=0.019). The amount of changes in infant fat mass and % body fat were predicted by AA/EPA+DHA ratios in established HM (P=0.038; 0.010).

Conclusions

Perinatal infant exposures to a high AA/EPA+DHA ratio during the first 4-months of life, which is primarily reflective of maternal dietary FA, may significantly contribute to the way infants accumulate adipose.

Birth Weight, Breastfeeding, Maternal Smoking and Caries Trajectories

Evidence for the effects of low birth weight, breastfeeding and maternal smoking on childhood caries is mainly cross-sectional. We examined the association of these 3 putative early life factors with caries increment over a 4-y period among young children. We used data from a 4-y longitudinal caries-risk assessment study carried out among Scottish children. Early life factors were measured when children were aged 1 y (baseline). Caries assessment was repeated annually from ages 1 to 4, and the number of decayed, missing and filled primary tooth surfaces (dmfs) were used as a repeated outcome measure. The associations of low birth weight, breastfeeding and maternal smoking with dmfs at baseline and over time (trajectories) were assessed in linear mixed models. A total of 1,102 children were included in this analysis. Birth weight, breastfeeding and maternal smoking were not associated with dmfs at baseline. However, low birth weight and maternal smoking were associated with the rate of change in dmfs. By wave 4, the predicted mean difference in dmfs was 1.86 between children with low and normal birth weight, and 1.66 between children of smoking and non-smoking mothers. Children with low birth weight and smoking mothers had greater caries increments than those with normal weight and non-smoking mothers, respectively. There was no association between breastfeeding duration and childhood caries, either at baseline or over time.

High Awareness but Low Coverage of a Locally Produced Fortified Complementary Food in Abidjan, Côte d'Ivoire: Findings from a Cross-Sectional Survey

Poor complementary feeding practices among infants and young children in Côte d’Ivoire are major contributing factors to the country’s high burden of malnutrition. As part of a broad effort to address this issue, an affordable, nutritious, and locally produced fortified complementary food product was launched in the Côte d’Ivoire in 2011. The objective of the current research was to assess various levels of coverage of the program and to identify coverage barriers. A cross-sectional household survey was conducted among caregivers of children less than 2-years of age living in Abidjan, Côte d’Ivoire. Four measures of coverage were assessed: “message coverage” (i.e., has the caregiver ever heard of the product?), “contact coverage” (i.e., has the caregiver ever fed the child the product?), “partial coverage” (i.e., has the caregiver fed the child the product in the previous month?), and “effective coverage” (i.e., has the caregiver fed the child the product in the previous 7 days?). A total of 1,113 caregivers with children between 0 and 23 months of age were interviewed. Results showed high message coverage (85.0%), moderate contact coverage (37.8%), and poor partial and effective coverages (8.8% and 4.6%, respectively). Product awareness was lower among caregivers from poorer households, but partial and effective coverages were comparable in both poor and non-poor groups. Infant and young child feeding (IYCF) practices were generally poor and did not appear to have improved since previous assessments. In conclusion, the results from the present study indicate that availability on the market and high awareness among the target population is not sufficient to achieve high and effective coverage. With market-based delivery models, significant efforts are needed to improve demand. Moreover, given the high prevalence of malnutrition and poor IYCF practices, additional modes of delivering IYCF interventions and improving IYCF practices should be considered.