Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil

The Importance of Making Assumptions in Bias Analysis

Quantitative bias analyses allow researchers to adjust for uncontrolled confounding, given specification of certain bias parameters. When researchers are concerned about unknown confounders, plausible values for these bias parameters will be difficult to specify. Ding and VanderWeele developed bounding factor and E-value approaches that require the user to specify only some of the bias parameters. We describe the mathematical meaning of bounding factors and E-values and the plausibility of these methods in an applied context. We encourage researchers to pay particular attention to the assumption made, when using E-values, that the prevalence of the uncontrolled confounder among the exposed is 100% (or, equivalently, the prevalence of the exposure among those without the confounder is 0%). We contrast methods that attempt to bound biases or effects and alternative approaches such as quantitative bias analysis. We provide an example where failure to make this distinction led to erroneous statements. If the primary concern in an analysis is with known but unmeasured potential confounders, then E-values are not needed and may be misleading. In cases where the concern is with unknown confounders, the E-value assumption of an extreme possible prevalence of the confounder limits its practical utility.

Frontline Science: Breast milk confers passive cellular immunity via CD8-dependent mechanisms

Most modern research into the immune effects of breast milk has focused on the impacts of immunoglobulin or oligosaccharide content. However, immediately prior to parturition, the cell populations of breast milk become selectively enriched for CD8+ T cells of an effector memory subtype. Despite this observation that the cellular content of breast milk contains a distinct leukocyte population when compared to peripheral blood, the physiologic role of these CD8+ effector memory cells is unknown. Research encompassing animal models and humans has demonstrated that leukocytes are capable of transferring antigen-specific immunity even when lysed, dialyzed to enrich for fractions less than 10 kDa, and orally administered. Our previous work built upon these reports to elucidate several aspects of this dialyzable leukocyte extract (DLE) activity: only DLE from T effector memory CD8+ cells was capable of transferring antigen-specific immunity; the DLE activity was TCRβ dependent; dendritic cells (DCs) were the cellular target of DLE; and DLE enhanced immune activity in epithelial challenge models via induction of IL-6 from DCs. Herein, we reveal that breast milk dialysate activates similar cytokine and genetic pathways as DLE taken from peripheral blood and murine spleens through TCRβ- and CD8-dependent mechanisms. These findings suggest that the CD8+ memory T cells enriched in breast milk, even after potential lysis in the infant gut, may represent a mechanism for passive transfer of cellular immunity from mother to child.

LATCH Score at Discharge: A Predictor of Weight Gain and Exclusive Breastfeeding at 6 Weeks in Term Healthy Babies

OBJECTIVES

World Health Organization recommends exclusive breastfeeding (EBF) for 6 months after birth. However, problems with the baby failing to latch properly are common in the postpartum period contributing to breastfeeding cessation. The aim of the study was to evaluate the utility of LATCH score to predict EBF and weight gain at 6 weeks postpartum along with an optimum LATCH score cutoff.

PATIENTS AND METHODS

This prospective cohort study was conducted in India. Ninety-three mother-infant dyads at term gestation were enrolled. Two LATCH score assessments were done by a lactation consultant: first within 24 hours of birth and second at discharge. Mothers with low LATCH scores were counselled before discharge. EBF rate and weight gain velocity were analyzed at 6 weeks.

RESULTS

LATCH score ≥6 at discharge has the highest sensitivity (92.1%) and specificity (66.7%) for predicting EBF at 6 weeks postpartum (RR, 95% CI; 5.63 [4.32-12.65], P = 0.0003). Receiver operating characteristic (ROC) of LATCH score at discharge and EBF at 6 weeks had an area under the curve of 0.785 with a cutoff ≥5.5, showing the highest sensitivity of 93.6% with a false-positive rate of 30.1%. LATCH score >6 at discharge was significantly associated with higher EBF rate (RR, 95% CI; 0.61 [0.39-0.94]) and appropriate weight gain (≥ 20 grams/day) at 6 weeks of age (RR, 95% CI; 0.44 [0.25-0.75]). After counselling, the LATCH score significantly improved at discharge in mothers (n = 62) with an initial score <6 (P < 0.001).

CONCLUSION

LATCH score is a simple tool to identify mothers who require breastfeeding support and counselling before discharge from the hospital to prevent early breastfeeding cessation.

Breastfeeding practices and infant feeding pattern of a tribal population region of eastern India

Background

Regular vigilance over infant feeding practices in the community is necessary for assessment of optimal growth and development and the intervention if needed.

Objective

To illustrate infant feeding practices, and socio-demographically correlated time like when weaning starts, the challenges met by mothers, and the types of complementary feeding adopted.

Methods

A structured pretested and predesigned questionnaire was used to collect information regarding sociodemographic, detail information regarding initiation and duration of breastfeeding, age of complementary feeding and type of food given during complementary feeding, minimum dietary diversity and minimum meal frequency, and also advice given during child feeding session.

Results

The study revealed that it was a predominantly Hindu tribal community where majority of infant were female and belong to joint families. Most of the mother had completed high secondary school and were housewives and belong to upper lower social class. Majority of women had more than two children, and rate of delivery at government institution was more than private institution and home delivery. Exclusive breastfeeding was practiced among 78% of infants, 46% had started breastfeeding within 1 h of birth. In total, 48% of infants were given prelacteal feed, and colostrum feeding was practiced among 62% of infants. Complementary feeding was given by 82% of infants and minimum dietary diversity, and minimum meal frequency was found among 77 and 85%, respectively.

Conclusion

This community-based study carried out among tribal population of Kalyani showed that exclusive breastfeeding and other domains like complementary feeding and minimum dietary diversity are almost satisfactory.

Biometric, nutritional, biochemical, and cardiovascular outcomes in male rats submitted to an experimental model of early weaning that mimics mother abandoning

Literature describes breast milk as the best food for the newborn, recommending exclusive breastfeeding for up to 6 months of age. However, it is not available for more than 40% of children worldwide. Pharmacological and non-pharmacological models of 3-day early weaning were developed in rodents to investigate later outcomes related solely to this nutritional insult. Thus, the present work aimed to describe biometric, nutritional, biochemical, and cardiovascular outcomes in adult male rats submitted to 3-day early weaning achieved by maternal deprivation. This experimental model comprises not only nutritional insult but also emotional stress, simulating mother abandoning. Male offspring were physically separated from their mothers at 21st (control) or 18th (early weaning) postnatal day, receiving water/food ad libitum. Analysis performed at postnatal days 30, 90, 150, and 365 encompassed body mass and food intake monitoring and serum biochemistry determination. Further assessments included hemodynamic, echocardiographic, and cardiorespiratory evaluation. Early-weaned males presented higher body weight when compared to control as well as dyslipidemia, higher blood pressure, diastolic dysfunction, and cardiac hypertrophy in adult life. Animals early deprived of their mothers have also presented a worse performance on the maximal effort ergometer test. This work shows that 3-day early maternal deprivation favors the development of cardiovascular disease in male rats.

Assessing Medical Neglect in HIV-Exposed or Infected Children

Human Immunodeficiency Virus (HIV) causes a chronic illness requiring lifelong medical care to prevent opportunistic infections and death. It is important to identify medical neglect in children that are perinatally exposed to or living with human immunodeficiency virus and to take steps to prevent it. Diagnosis of medical neglect must be considered in the context of the caregivers' understanding of the risks of harm, and the logistical, cultural and social factors that may influence their actions or non-actions. When medical neglect as failure of treatment or prevention of infection is suspected, medical providers should work collaboratively with caregivers to assess and address barriers to adherence and to provide resources and support. Medical neglect may be diagnosed if repeated preventive efforts fail.

Infant feeding knowledge and practice vary by maternal HIV status: a nested cohort study in rural South Africa

Background

We investigate whether correct infant feeding knowledge and practice differ by maternal HIV status in an era of evolving clinical guidelines in rural South Africa.

Methods

This cohort study was nested within the MONARCH stepped-wedge cluster-randomised controlled trial (www.clinicaltrials.gov: NCT02626351) which tested the impact of continuous quality improvement on antenatal care quality at seven primary care clinics in KwaZulu-Natal, from July 2015 to January 2017. Women aged ≥18 years at delivery were followed up to 6 weeks postpartum. Clinical data were sourced from routine medical records at delivery. Structured interviews at early postnatal visits and the 6-week postnatal immunisation visit provided data on infant feeding knowledge and feeding practices respectively. We measured the relationship between maternal HIV status and (i) correct infant feeding knowledge at the early postnatal visit; and (ii) infant feeding practice at 6 weeks, using Poisson and multinomial regression models, respectively.

Results

We analysed data from 1693 women with early postnatal and 471 with 6-week postnatal interviews. HIV prevalence was 47% (95% confidence interval [CI] 42, 52%). Women living with HIV were more knowledgeable than women not living with HIV on correct infant feeding recommendations (adjusted risk ratio, aRR, 1.08, p <  0.001). More women living with HIV (33%; 95% CI 26, 41%) were not breastfeeding than women not living with HIV (15%; 95% CI 11, 21%). However, among women who were currently breastfeeding their infants, fewer women living with HIV (5%; 95% CI 2, 9%) mixed fed their babies than women not living with HIV (21%; 95% CI 14, 32%). In adjusted analyses, women living with HIV were more likely to avoid breastfeeding (adjusted relative risk ratio, aRRR, 2.78, p <  0.001) and less likely to mixed feed (aRRR 0.22, p <  0.001) than women not living with HIV.

Conclusions

Many mothers in rural South Africa still do not practice exclusive breastfeeding. Women living with HIV were more knowledgeable but had lower overall uptake of breastfeeding, compared with women not living with HIV. Women living with HIV were also more likely to practice exclusive breastfeeding over mixed feeding if currently breastfeeding. Improved approaches are needed to increase awareness of correct infant feeding and exclusive breastfeeding uptake.

Intergenerational breastfeeding practices among parents and children: 1993 Pelotas (Brazil) birth cohort

The objective of this study was to investigate intergenerational breastfeeding practices according to parental sex and age at delivery in the 1993 Pelotas (Brazil) birth cohort study. This is a prospective birth cohort study, and at the 22‐year follow‐up, a substudy with all children of the cohort members who had become parents was conducted (93Cohort‐II). First generation breastfeeding data were collected at 3 months and 4‐year‐old follow‐ups. In the 93Cohort‐II, parents answered a questionnaire about their children's breastfeeding practices. Adjusted Tobit and Poisson regression models with robust variance were applied to estimate the association between predominant parental breastfeeding duration and exclusive breastfeeding duration of the children at 3 and 6 months. Out of 3,810 cohort participants, 955 (25%) had delivered at least one live‐born infant, and 1,222 children were assessed. Fifty‐four percent of parents were ≤19 years old. Direct effects of predominant parental breastfeeding duration on exclusive breastfeeding duration of their children were only observed when data were stratified by parental age: children born to parents aged ≥20 years old and who were predominantly breastfed for at least 3 months presented higher exclusive breastfeeding duration and higher prevalence of being exclusively breastfed for at least 3 months. When analyses were stratified by mothers and fathers, the result remained significant only among mothers. Longer predominant breastfeeding duration in the first generation was associated with longer exclusive breastfeeding duration in the second generation, but only among older mothers. Education and social support surrounding breastfeeding should be intensified among fathers and younger parents to create a positive environment supportive of breastfeeding.

Does early weaning shape future endocrine and metabolic disorders? Lessons from animal models

Obesity and its complications occur at alarming rates worldwide. Epidemiological data have associated perinatal conditions, such as malnutrition, with the development of some disorders, such as obesity, dyslipidemia, diabetes, and cardiovascular diseases, in childhood and adulthood. Exclusive breastfeeding has been associated with protection against long-term chronic diseases. However, in humans, the interruption of breastfeeding before the recommended period of 6 months is a common practice and can increase the risk of several metabolic disturbances. Nutritional and environmental changes within a critical window of development, such as pregnancy and breastfeeding, can induce permanent changes in metabolism through epigenetic mechanisms, leading to diseases later in life via a phenomenon known as programming or developmental plasticity. However, little is known regarding the underlying mechanisms by which precocious weaning can result in adipose tissue dysfunction and endocrine profile alterations. Here, the authors give a comprehensive report of the different animal models of early weaning and programming that can result in the development of metabolic syndrome. In rats, for example, pharmacological and nonpharmacological early weaning models are associated with the development of overweight and visceral fat accumulation, leptin and insulin resistance, and neuroendocrine and hepatic changes in adult progeny. Sex-related differences seem to influence this phenotype. Therefore, precocious weaning seems to be obesogenic for offspring. A better understanding of this condition seems essential to reducing the risk for diseases. Additionally, this knowledge can generate new insights into therapeutic strategies for obesity management, improving health outcomes.

Nutritional Feeding Strategies in Pediatric Intestinal Failure

Intestinal failure is defined as a critical reduction of the gut mass or function, below the minimum needed to absorb nutrients and fluids. The ultimate goal in intestinal failure is to promote bowel adaptation and reach enteral autonomy while a healthy growth and development is maintained. The condition is heterogeneous and complex. Therefore, recommendations for the type and duration of parenteral, enteral, and oral nutrition are variable, with the child's age as an additional key factor. The aim of this review is to provide an overview of nutritional feeding strategies in this heterogeneous population. Different perspectives on nutritional management, nutrition and adaptation, and microbiome and nutrition will be discussed.

A population-based cross-sectional study to determine the practices of breastfeeding among the lactating mothers of Patiala city

Introduction:

The present study was undertaken to study the breastfeeding practices and the influence of literacy and prevailing cultural factors on different aspects of breastfeeding.

Materials and Methods:

A community-based cross-sectional study was conducted at Badungar, a semi-urban area in Patiala city including a total of 370 mothers. Mothers were interviewed using pre-formed, semi-structured Performa. The participant's demographic information, awareness and practices regarding breastfeeding were recorded by paying house to house visits. Data were analyzed using SPSS ver. 21.

Results:

Only 27.30% of the mothers knew that breastfeeding should be initiated within 1 hour of birth. A total of 51.62% mothers considered prelacteal feed to be the right practice while 55.95% considered colostrum bad for the baby. Only 53.78% of the lactating mothers knew the correct meaning of exclusive breastfeeding. Only 24.86% mothers started breastfeeding within an hour after birth. Colostrum was not given by 57.29% of the lactating mothers while Prelacteal feeds were given by 50.81% mothers. Exclusive breastfeeding till 6 months was given by 45.67% mothers. A significant association was observed in high mother's education, high socio-economic status, nuclear status of family, history of antenatal care registration, and hospital delivery with exclusive breastfeeding (P < 0.01).

Conclusion:

Study concluded that breastfeeding practices were not optimum; hence promotion of knowledge regarding the right practices of breastfeeding and focus on the factors affecting them is highly warranted in this area.

Breastfeeding exclusivity and duration: trends and inequalities in four population-based birth cohorts in Pelotas, Brazil, 1982-2015

Background

Brazil has made substantial improvements in the duration of breastfeeding. We use data from four population-based cohorts to examine how trends and inequalities in breastfeeding indicators changed over time in a Brazilian city.

Methods

Data from four birth cohorts, each including all births in a calendar year (1982, 1993, 2004 and 2015) in the city of Pelotas were used. Information on breastfeeding was collected when children were aged between 3 and 20 months. The prevalences of continued breastfeeding at 1 year of age and of exclusive breastfeeding at 3 months were calculated according to family income, maternal skin colour and sex.

Results

Prevalence of breastfeeding at 12 months increased from 16% to 41% in the 33-year period. The prevalence of exclusive breastfeeding at 3 months increased from 7% in 1993 to 45% in 2015. Increases in exclusive breastfeeding at 3 months were seen in all socioeconomic groups, but the 2015 rates remain highest (57.2%) among the women in the richest quintile, and lowest among those in the poorest quintile (34.6%). Black mothers were more likely to breastfeed at 12 months than Whites in the four cohorts. In the earlier cohorts, breastfeeding at 12 months was more common among the poor, but by 2015 these differences had disappeared.

Conclusions

There were important positive changes in breastfeeding practices during this period, but less than half of the children in 2015 were receiving the full benefits of breast milk. Improved breastfeeding practices are being adopted by high-income women to a greater extent than by poor women.

Factors affecting exclusive breastfeeding in the first month of life among Amazonian children

Early life feeding practices can directly affect the growth, development, and survival of a child. This study aimed to estimate the frequency of and factors associated with exclusive breastfeeding (EBF) in the first month of life among Amazonian infants. We used data of 1,523 mother-child pairs of the MINA-Brazil birth cohort study. Mothers were interviewed soon after delivery at baseline and by telephone at 30-45 days postpartum (n = 962, 63.2% of those eligible). Kaplan-Meier survival analysis and accelerated failure-time (AFT) models were used to estimate the probability of EBF and the factors associated with EBF duration in the first month. At 30 days of age, 36.7% of the studied population (95% confidence interval [CI] 33.6-39.8) were exclusively breastfed, with a median duration of 16 days. Considering all eligible children for follow-up, the probability of EBF in the first month was 43.7% (95% CI 40.4-46.8), and the median duration was 30 days. The duration of EBF (time-ratio, TR) was 28% longer among multiparous mothers (TR 1.28; 95% CI 1.11-1.48). The use of a pacifier and the occurrence of wheezing were associated with a reduced EBF duration by 33% (TR 0.67; 95% CI 0.58-0.77) and 19% (TR 0.80; 95% CI 0.70-0.93), respectively. These results highlight that EBF among children in the Brazilian Amazon is considerably below international recommendations, and indicate the immediate need to plan and implement actions to promote and support breastfeeding early in life.

Infant and young child feeding practices, sociodemographic factors and their association with nutritional status of children aged &lt;3 years in India: findings of the National Nutrition Monitoring Bureau survey, 2011-2012

OBJECTIVE

To study infant and young child feeding (IYCF) practices and their association with nutritional status among young children.

DESIGN

A community-based, cross-sectional study was carried out in ten states of India, using a multistage random sampling method. Anthropometric measurements such as length/height and weight were conducted and nutritional assessment was done using the WHO child growth standards.

SETTING

National Nutrition Monitoring Bureau survey, 2011-2012.ParticipantsChildren aged &lt;3 years and their mothers.

RESULTS

Only 36 % of infants received breast-feeding within an hour of birth and 50 % were exclusively breast-fed up to 6 months. Prevalence of underweight, stunting and wasting was 38, 41 and 22 %, respectively. The chance of undernutrition among &lt;3-year-old children was significantly higher among those from scheduled caste/scheduled tribe communities, the lowest-income group, with illiterate mothers and lack of sanitary latrine. Among infants, the chance of undernutrition was significantly higher among low-birth-weight babies, and among children whose mother had not consumed iron-folic acid tablets during pregnancy. Immunization practices and minimum dietary diversity were observed to be associated with undernutrition among 12-23-month-old children.

CONCLUSIONS

Undernutrition is still an important public health problem in India and observed to be associated with low socio-economic status, illiteracy of mother, low birth weight and dietary diversity. Improving socio-economic and literacy status of mothers can help in improving maternal nutrition during pregnancy and thus low birth weight. Also, improving knowledge of mothers about IYCF practices will help in improving children's nutritional status.

Protective Effect of Breastmilk against Infection

There is strong evidence that breastfeeding protects infants against infection in environments where clean water cannot be guaranteed, leading to substantial reductions in morbidity and mortality. This is particularly evident in the protection against gastrointestinal disease, although there is also evidence for protection against respiratory infection and otitis media. The evidence for a protective effect of breastfeeding against infection in developed countries has been more controversial, with criticisms being levelled at the methodology of many studies. Evidence is presented from a study in a developed country that met key methodological criteria to show that breastfeeding for 13 weeks offers substantial and continuing protection against gastrointestinal illness. Smaller, but still potentially important, protective effects against respiratory illness also occur. The results add strong support to policies that promote breastfeeding in both developed and developing countries.

Infection and Disease: The Impact of Early Weaning

Although the protective effect of breastfeeding against infectious diseases has been long suspected, it has only recently been adequately quantified This article reviews the available epidemiologic evidence. Breastfeeding provides marked protection against diarrhoeal morbidity and severity (as measured by its duration, level of dehydration, or case-fatality rate), and mortality. This is true for acute watery diarrhoea as well as for dysentery and persistent diarrhoea. A dose-response pattern is observed: the risk level for children receiving both breastmilk and artificial milk is between that of exclusively breasfed children and that of completely weaned children. Even the introduction of water or herbal teas to a previously exclusively breasfed infant increases the risk of morbidity and mortality. The protection is greatest for young infants, and the period immediately after weaning seems to carry the highest risk. Although breastfeeding does not seem to have an appreciable effect on the incidence of acute respiratory infections as a whole, there is evidence of an effect on the incidence of pneumonia, on the incidence of hospitalization for pneumonia, and on mortality from respiratory infections. The level of protection against pneumonia, however, is lower than that against diarrhoea. Breastfeeding also protects against onus media and other infections, including neonatal sepsis, meningitis, and bacteraemia, although the number of relevant studies is small. A simulation exercise shows that a 40% reduction in the prevalence of nonbreastfeeding would prevent up to 15% of diarrhoea deaths and 7% of pneumonia deaths occurring in regions with a short breastfeeding duration, such as urban Latin America. In regions where breastfeeding durations are longer, the emphasis should be on maintaining these high rates and increasing the proportion of young infants who are exclusively breastfed. The present review confirms that breastfeeding promotion is an essential child survival strategy.

Factors Related to the Duration of Breast-Feeding in Ankara, with Special Reference to Sociocultural Aspects

A questionnaire designed to elicit information on the relationship between certain sociocultural factors and the duration of breast-feeding was administered to 1,500 mothers. Giving colostrum, demand feeding, night feeding, feeding with both breasts, rooming-in, and planned pregnancy were factors found to have a positive effect on the duration of breast-feeding. Factors having a negative association included the use of prelacteal foods, mothers’ educations, smoking, and maternal employment. For employed mothers, paid maternity leave before and after delivery did not affect the duration of breast-feeding, but unpaid maternity leave and milk leave had a positive effect.

Infant feeding patterns and eczema in children in the first 6 years of life

BACKGROUND

Modes of infant feeding such as direct and indirect breastfeeding, and formula feeding, and their combinations may play a role in child health.

OBJECTIVE

The aim was to investigate which feeding patterns in the first 6 months pose risks of eczema/skin allergy in children up to 6 years compared to direct breastfeeding for at least 3 months.

METHODS

The Infant Feeding Practices Study II in the United States and its 6-year follow-up provided data on feeding modes in infancy and doctor's diagnosed eczema/skin allergy in the first 6 years of life (1387 infants), based on parental reports. Different feeding patterns were identified. Log-linear models were used to estimate prevalence ratios (PRs) of feeding patterns for doctor's diagnosed eczema/skin allergy in the first 6 years of life, adjusting for confounders.

RESULTS

Compared to "direct breastfeeding for at least 3 months" (DBF3m), the combination of "direct feeding at the breast (DBF), pumping and feeding breast milk (BM), and formula (FF) in the first months" (DBF/BM/FF) showed a statistically significant higher risk of eczema/skin allergy in the first 6 years of life (PR = 1.46), adjusting for confounders. DBF combined with BM for the first 3 months followed by mixed feeding also had an increased risk (PR = 1.26), although not statistically significant. Formula feeding introduced since birth had no effect on eczema. Among the confounders, paternal eczema and race/ethnicity (Hispanic vs White) were associated with a higher risk of eczema/skin allergy.

CONCLUSIONS & CLINICAL RELEVANCE

Mixed infant feeding may carry a higher risk of eczema/skin allergy compared to direct feeding at the breast. The recent epidemic of pumping and feeding in the United States and the use of mixed infant feeding modes requires additional studies to provide appropriate and renewed assessments of the risks of feeding modes for the future development of allergies.

Ontogeny of CD4+ T Lymphocytes With Phenotypic Susceptibility to HIV-1 During Exclusive and Nonexclusive Breastfeeding in HIV-1-Exposed Ugandan Infants

Background

Among infants exposed to human immunodeficiency virus (HIV) type 1, mixed breastfeeding is associated with higher postnatal HIV-1 transmission than exclusive breastfeeding, but the mechanisms of this differential risk are uncertain.

Methods

HIV-1-exposed Ugandan infants were prospectively assessed during the first year of life for feeding practices and T-cell maturation, intestinal homing (β7hi), activation, and HIV-1 coreceptor (CCR5) expression in peripheral blood. Infants receiving only breast milk and those with introduction of other foods before 6 months were categorized as exclusive and nonexclusive, respectively.

Results

Among CD4+ and CD8+ T cells, the expression of memory, activation, and CCR5 markers increased rapidly from birth to week 2, peaking at week 6, whereas cells expressing the intestinal homing marker increased steadily in the central memory (CM) and effector memory T cells over 48 weeks. At 24 weeks, when feeding practices had diverged, nonexclusively breastfed infants showed increased frequencies and absolute counts of β7hi CM CD4+ and CD8+ T cells, including the HIV-1-targeted cells with CD4+β7hi/CCR5+ coexpression, as well as increased activation.

Conclusions

The T-cell phenotype associated with susceptibility to HIV-1 infection (CCR5+, gut-homing, CM CD4+ T cells) was preferentially expressed in nonexclusively breastfed infants, a group of infants at increased risk for HIV-1 acquisition.

The Effect of Message-Framing on Breastfeeding Self-Efficacy Among Nulliparous Women in Shushtar, Iran

Introduction

Exclusive breastfeeding for 6 months and continuing it for 2 years, along with complementary feeding, are the primary objectives of public health plans and nutrition around the world. Self-efficacy is a theoretical framework that could be a strong predictive for breastfeeding. This study aimed to determine the effect of message-framing on self-efficacy of breastfeeding in nulliparous women in Shushtar.

Methods

This quasi-experimental study was conducted in 2015 on 210 nulliparous women in Shushtar (Iran). The participants were randomly allocated into intervention and control groups. The study tool was the short form of breastfeeding self-efficacy scale that was completed on arrival of the study (days 3–5), at the end of week four and at the end of week eight. Data were analyzed by SPSS 19, using Chi-square, ANOVA, and repeated measurements.

Results

Mean age of participants was 24.52 years old with standard deviation of 95.4. Mean score of breastfeeding self-efficacy in gain-framed group at days 3–5, week four and week eight was 47.94, 57.43 and 52.8 respectively; in loss-framed group it was 47.76, 56.11 and 52.64 respectively; and in control group it was 45.16, 48.68 and 45.31 respectively. No significant difference was observed between the score of average self-efficacy of days 3–5 and week eight in control group (p=0.93). However, in gain-framed group (p=0.001) and loss-framed group (p=0.004), a significant difference was observed.

Conclusion

Results of this study showed that message-framing promotes breastfeeding self-efficacy in nulliparous women and in this regard, there is no difference between gain-framed and loss-framed messages.

Formula-Feeding of HIV-Exposed Uninfected African Children Is Associated with Faster Growth in Length during the First 6 Months of Life in the Kesho Bora Study

Background: Early feeding patterns may affect the growth of HIV-exposed children and thus their subsequent health and cognition.Objective: We assessed the association of infant feeding (IF) mode with length-for-age z score (LAZ) and stunting from age 2 d to 18 mo in HIV-exposed African children within a controlled randomized trial, which evaluated triple antiretrovirals initiated during pregnancy and continued for 6 mo postpartum to prevent HIV transmission.Methods: HIV-infected pregnant women with CD4⁺ counts of 200-500 cells/mm³ from Burkina Faso, Kenya, and South Africa were advised to exclusively breastfeed for up to 6 mo or to formula-feed from birth. Factors associated with LAZ were investigated in all uninfected children by using mixed-effects linear models; those associated with stunting (LAZ <-2) at 6 or 12 mo were assessed in multiple logistic regression after exclusion of children stunted at age 2 d. Independent variables were IF mode: formula feeding (FF), exclusive breastfeeding (EBF) <3 mo, or EBF ≥3 mo (reference); sex; trial arm; maternal characteristics; and site.Results: Among 728 children, FF was associated with a greater increase in LAZ from 2 d to 6 mo (+0.07 z score/mo, P < 0.001). Between 6 and 18 mo, FF and EBF <3 mo were both associated with greater mean LAZ than was EBF ≥3 mo (+0.52 z scores and +0.43 z scores, respectively, P < 0.001). Among children not stunted at 2 d, FF was independently associated with a reduced risk of stunting at 6 mo (OR: 0.24; 95% CI: 0.07, 0.81; P = 0.021), whereas EBF <3 mo was not (OR: 0.49; 95% CI: 0.22, 1.10; P = 0.09).Conclusions: In this observational study of HIV-exposed uninfected infants, growth in length in the first 6 mo of life was faster in formula-fed infants than in exclusively breastfed infants. The plausibility of residual confounding and reverse causality is discussed. This trial was registered at www.controlled-trials.com as ISRCTN71468401.

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.

Effects of Health and Nutrition on Cognitive and Behavioural Development in Children in the First Three Years of Life: Part 1: Low Birthweight, Breastfeeding, and Protein-Energy Malnutrition

The following paper and its accompanying paper (Grantham-McGregor SM, et al. Effects of health and nutrition on cognitive and behavioural development in children in the first three years of life. Part 2: Infections and micronutrient deficiencies: iodine, iron, and zinc. Food Nutr Bull 1999;20:76–99) review the literature on the conditions that are prevalent and considered to be likely to affect child development and are therefore of public health importance. the reviews are selective, and we have generally focused on recent work, particularly in areas that remain controversial. the reviews are restricted to nutritional and health insults that are important in the first three years of life. Where possible, we have discussed the better studies. This paper considers the effects of low birthweight (focusing on small-for-gestational-age babies) and early childhood protein-energy malnutrition on mental, motor, and behavioural development. We have also included a section on breastfeeding because of its importance to child health and nutrition programmes.

Methods of milk expression for lactating women

BACKGROUND

Breastfeeding is important, however not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and costs of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2016), handsearched relevant journals and conference proceedings, and contacted experts in the field to seek additional published or unpublished studies. We also examined reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

This updated review includes 41 trials involving 2293 participants, with 22 trials involving 1339 participants contributing data for analysis. Twenty-six of the trials referred to mothers of infants in neonatal units (n = 1547) and 14 to mothers of healthy infants at home (n = 730), with one trial containing mothers of both neonatal and healthy older infants (n = 16). Eleven trials compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and pump types. Twenty studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols, pumping frequency, provision of an education and support intervention, relaxation, breast massage, combining hand expression with pumping and a breast cleansing protocol.Due to heterogeneity in participants, interventions, and outcomes measured or reported, we were unable to pool findings for most of the specified outcomes. It was not possible therefore to produce a 'Summary of findings' table in this update. Most of the included results were derived from single studies. Trials took place in 14 countries under a variety of circumstances and were published from 1982 to 2015. Sixteen of the 30 trials that evaluated pumps or products had support from the manufacturers. The risk of bias of the included studies was variable. Primary outcomesOnly one of the 17 studies examining maternal satisfaction/acceptability with the method or adjunct behaviour provided data suitable for analysis. In this study, self-efficacy was assessed by asking mothers if they agreed or disagreed with the following statement: 'I don't want anyone to see me (hand expressing/pumping)'. The study found that mothers who were using the electric pump were more likely to agree with the statement compared to mothers hand expressing, (mean difference (MD) 0.70, 95% confidence interval (CI) 0.15 to 1.25; P = 0.01, participants = 68). Mothers who were hand expressing reported that the instructions for expression were clearer compared to the electric pump, (MD -0.40, 95% CI -0.75 to -0.05; P = 0.02, participants = 68). Descriptive reporting of satisfaction in the other studies varied in the measures used, did not indicate a clear preference for one pump type, although there was satisfaction with some relaxation and support interventions.We found no clinically significant differences between methods related to contamination of the milk that compared any type of pump to hand expression (risk ratio (RR) 1.13, 95% CI 0.79 to 1.61; P = 0.51, participants = 28), manual pump compared to hand expression, (MD 0.20, 95% CI -0.18 to 0.58; P = 0.30, participants = 142) a large electric pump compared to hand expression (MD 0.10, 95% CI -0.29 to 0.49; P = 0.61, participants = 123), or a large electric pump compared to a manual pump (MD -0.10, 95% CI -0.46 to 0.26; P = 0.59, participants = 141).The level of maternal breast or nipple pain or damage was similar in comparisons of a large electric pump to hand expression (MD 0.02, 95% CI -0.67 to 0.71; P = 0.96, participants = 68). A study comparing a manual and large electric pump, reported sore nipples in 7% for both groups and engorgement in 4% using a manual pump versus 6% using an electric pump; and in one study no nipple damage was reported in the hand-expression group, and one case of nipple damage in each of the manual pump and the large electric pump groups.One study examined adverse effects on infants, however as the infants did not all receive their mothers' expressed milk, we have not included the results. Secondary outcomesThe quantity of expressed milk obtained was increased, in some studies by a clinically significant amount, in interventions involving relaxation, music, warmth, massage, initiation of pumping, increased frequency of pumping and suitable breast shield size. Support programmes and simultaneous compared to sequential pumping did not show a difference in milk obtained. No pump consistently increased the milk volume obtained significantly.In relation to nutrient quality, hand expression or a large electric pump were found to provide higher protein than a manual pump, and hand expression provided higher sodium and lower potassium compared to a large electric pump or a manual pump. Fat content was higher with breast massage when pumping; no evidence of difference was found for energy content between methods.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Variation in nutrient content across methods may be relevant to some infants. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings. Independently funded research is needed for more trials on hand expression, relaxation and other techniques that do not have a commercial potential.

Immunology of breast milk

Summary In the critical phase of immunological immaturity of the newborn, particularly for the immune system of mucous membranes, infants receive large amounts of bioactive components through colostrum and breast milk. Colostrum is the most potent natural immune booster known to science. Breastfeeding protects infants against infections mainly via secretory IgA (SIgA) antibodies, but also via other various bioactive factors. It is striking that the defense factors of human milk function without causing inflammation; some components are even anti-inflammatory. Protection against infections has been well evidenced during lactation against, e.g., acute and prolonged diarrhea, respiratory tract infections, including otitis media, urinary tract infection, neonatal septicemia, and necrotizing enterocolitis. The milk’s immunity content changes over time. In the early stages of lactation, IgA, anti-inflammatory factors and, more likely, immunologically active cells provide additional support for the immature immune system of the neonate. After this period, breast milk continues to adapt extraordinarily to the infant’s ontogeny and needs regarding immune protection and nutrition. The need to encourage breastfeeding is therefore justifiable, at least during the first 6 months of life, when the infant’s secretory IgA production is insignificant.

Rooming-in for new mother and infant versus separate care for increasing the duration of breastfeeding

BACKGROUND

Mother-infant proximity and interactions after birth and during the early postpartum period are important for breast-milk production and breastfeeding success. Rooming-in and separate care are both traditional practices. Rooming-in involves keeping the mother and the baby together in the same room after birth for the duration of hospitalisation, whereas separate care is keeping the baby in the hospital nursery and the baby is either brought to the mother for breastfeeding or she walks to the nursery.

OBJECTIVES

To assess the effect of mother-infant rooming-in versus separation on the duration of breastfeeding (exclusive and total duration of breastfeeding).

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) investigating the effect of mother-infant rooming-in versus separate care after hospital birth or at home on the duration of breastfeeding, proportion of breastfeeding at six months and adverse neonatal and maternal outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and assessed trial quality. Two review authors extracted data. Data were checked for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included one trial (involving 176 women) in this review. This trial included four groups with a factorial design. The factorial design took into account two factors, i.e. infant location in relation to the mother and the type of infant apparel. We combined three of the groups as the intervention (rooming-in) group and the fourth group acted as the control (separate care) and we analysed the results as a single pair-wise comparison. Primary outcomesThe primary outcome, duration of any breastfeeding, was reported by authors as median values because the distribution was found to be skewed. They reported the overall median duration of any breastfeeding to be four months, with no difference found between groups. Duration of exclusive breastfeeding and the proportion of infants being exclusively breastfed at six months of age was not reported in the trial. There was no difference found between the two groups in the proportion of infants receiving any breastfeeding at six months of age (risk ratio (RR) 0.84, 95% confidence interval (CI) 0.51 to 1.39; one trial; 137 women; low-quality evidence). Secondary outcomesThe mean frequency of breastfeeds per day on day four postpartum for the rooming-in group was 8.3 (standard deviation (SD) 2.2), slightly higher than the separate care group, i.e. seven times per day. However, between-group comparison of this outcome was not appropriate since every infant in the separate care group was breastfed at a fixed schedule of seven times per day (SD = 0) resulting in no estimable comparison. The rate of exclusive breastfeeding on day four postpartum before discharge from hospital was significantly higher in the rooming-in group 86% (99 of 115) compared with separate care group, 45% (17 of 38), (RR 1.92; 95% CI 1.34 to 2.76; one trial, 153 women; low-quality evidence). None of our other pre-specified secondary outcomes were reported.

AUTHORS' CONCLUSIONS

We found little evidence to support or refute the practice of rooming-in versus mother-infant separation. Further well-designed RCTs to investigate full mother-infant rooming-in versus partial rooming-in or separate care including all important outcomes are needed.

Feeding practices and nutritional status of HIV-exposed and HIV-unexposed infants in the Western Cape

Background

Optimal infant- and young child-feeding practices are crucial for nutritional status, growth, development, health and, ultimately, survival. Human breast milk is optimal nutrition for all infants. Complementary food introduced at the correct age is part of optimal feeding practices. In South Africa, widespread access to antiretrovirals and a programme to prevent mother-to-child transmission of HIV have reduced HIV infection in infants and increased the number of HIV-exposed uninfected (HEU) infants. However, little is known about the feeding practices and nutritional status of HEU and HIV-unexposed (HU) infants.

Objective

To assess the feeding practices and nutritional status of HIV-exposed and HIV-unexposed (HU) infants in the Western Cape.

Design

Prospective substudy on feeding practices nested in a pilot study investigating the innate immune abnormalities in HEU infants compared to HU infants. The main study commenced at week 2 of life with the nutrition component added from 6 months. Information on children's dietary intake was obtained at each visit from the caregiver, mainly the mother. Head circumference, weight and length were recorded at each visit. Data were obtained from 6-, 12- and 18-month visits. World Health Organization feeding practice indicators and nutrition indicators were utilised.

Setting

Tygerberg Academic Hospital, Western Cape. Mothers were recruited from the postnatal wards.

Subjects

Forty-seven mother-infant pairs, 25 HEU and 22 HU infants, participated in this nutritional substudy. Eight (17%) infants, one HU and seven HEU, were lost to follow-up over the next 12 months. The HEU children were mainly Xhosa (76%) and HU were mainly mixed race (77%).

Results

The participants were from poor socio-economic backgrounds. In both groups, adherence to breastfeeding recommendations was low with suboptimal dietary diversity. We noted a high rate of sugar- and salt-containing snacks given from a young age. The HU group had poorer anthropometric and nutritional indicators not explained by nutritional factors alone. However, alcohol and tobacco use was much higher amongst the HU mothers.

Conclusion

Adherence to breastfeeding recommendations was low. Ethnicity and cultural milieu may have influenced feeding choices and growth. Further research is needed to understand possible reasons for the poorer nutritional and anthropometric indicators in the HU group.

Timing of breastfeeding initiation and exclusivity of breastfeeding during the first month of life: effects on neonatal mortality and morbidity--a systematic review and meta-analysis

The purpose of this study was to review the evidence on the effect of initiation of breastfeeding early after birth and of exclusive breastfeeding during the first month in reducing neonatal mortality and morbidity. We searched Cochrane and PubMed databases for all available papers addressing our review questions and identified eleven papers. Data were extracted using a standard abstraction form. Evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system. Meta-analysis was done using STATA 11.0. Early initiation of breastfeeding was associated with a reduced risk of neonatal mortality. Initiating breastfeeding after the first hour doubled the risk of neonatal mortality. Exclusively breastfed neonates had a lower risk of mortality and infection-related deaths in the first month than partially breastfed neonates. Exclusively breastfed neonates also had a significantly lower risk of sepsis, diarrhea and respiratory infections compared with those partially breastfed. The pooled evidence indicates that substantial benefits in reducing neonatal mortality and morbidity can be achieved with effective promotion of early initiation of breastfeeding and exclusive breastfeeding during the first month of life.

High Rates of Exclusive Breastfeeding in Both Arms of a Peer Counseling Study Promoting EBF Among HIV-Infected Kenyan Women

BACKGROUND

Exclusive breastfeeding (EBF) is recommended for 6 months after delivery as the optimal infant feeding method and is especially important for prevention of mother-to-child HIV transmission (PMTCT). However, EBF promotion efforts among HIV-infected mothers in sub-Saharan Africa have achieved mixed success and require context-specific interventions.

METHODS

HIV-positive, pregnant women from six clinics in Nairobi were enrolled into a clinic-level, before-after counseling intervention study. All women received standard perinatal and HIV care. Women in the intervention arm were offered three counseling sessions that promoted EBF, described its benefits, and explained breastfeeding techniques. Mother-infant pairs were followed until 14 weeks postpartum, with infant HIV testing at 6 weeks. EBF prevalence at 14 weeks postpartum was compared between study arms using log-binomial regression. Proportions of 6-week HIV-free survival and 14-week infant survival were assessed using Cox regression. Risk estimates were adjusted for clinic, relationship status, and antiretroviral therapy.

RESULTS

Between 2009 and 2013, 833 women were enrolled of whom 94% planned to practice EBF for 6 months and 95% were taking therapeutic or prophylactic antiretrovirals. Median age was 27 years; median CD4 count was 403 cells/μL. EBF prevalence at 14 weeks postpartum was 86% in the control and 81% in the intervention group (p = 0.19). No differences were observed between groups for 6-week HIV-free survival and 14-week infant survival.

CONCLUSION

Women who received breastfeeding counseling were not more likely to breastfeed exclusively, in part due to high overall EBF prevalence in this study population. The high EBF prevalence is an important finding, given recent efforts to promote EBF in Kenya.

Factors That Predict Differences in Childhood Mortality in Nigerian Communities: A Prognostic Model

OBJECTIVE

To identify predictors of variations of childhood mortality between Nigerian communities and to identify high-risk communities where childhood mortality was higher than expected.

STUDY DESIGN

Secondary analysis of the 2013 Nigeria Demographic and Health Survey data using prognostic univariable and multivariable mixed Poisson regression models. Likelihood ratio test, Hosmer-Lemeshow goodness-of-fit, and variance inflation factor were used to evaluate the fitness of the final model.

RESULTS

The final adjusted model revealed that communities with high rating of multiple childhood deprivation (relative risk 1.14, 95% CI 1.09-1.19) and maternal socioeconomic deprivation (relative risk 1.22, 95% CI 1.14-1.29) were associated significantly with the risk of childhood mortality. Communities with enhanced maternal hospital-based health-seeking behaviors and more advantageous environmental conditions had reduced risks of childhood mortality. Similarly, children living in communities with high ethnic diversity were significantly less likely to die before their fifth birthday (relative risk 0.96, 95% CI 0.94-0.97). About 64% of the observed heterogeneity in childhood mortality in these communities was explained by the final model. Eleven of the 896 communities had higher than expected childhood mortality rates during the study period.

CONCLUSIONS

Of the 31 482 children included in this survey, 2886 had died before their fifth birthday (128 deaths per 1000 live births). There are variations in childhood mortality across Nigerian communities that are not determined only by health system functions but also by factors beyond the scope of health authorities and healthcare delivery systems.

Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis

AIM

To synthesise the evidence for effects of optimal breastfeeding on all-cause and infection-related mortality in infants and children aged 0-23 months.

METHODS

We conducted a systematic review to compare the effect of predominant, partial or nonbreastfeeding versus exclusive breastfeeding on mortality rates in the first six months of life and effect of no versus any breastfeeding on mortality rates between 6 and 23 months of age. A systematic literature search was conducted in PubMed, Cochrane CENTRAL and CABI.

RESULTS

The risk of all-cause mortality was higher in predominantly (RR 1.5), partially (RR 4.8) and nonbreastfed (RR14.4) infants compared to exclusively breastfed infants 0-5 months of age. Children 6-11 and 12-23 months of age who were not breastfed had 1.8- and 2.0-fold higher risk of mortality, respectively, when compared to those who were breastfed. Risk of infection-related mortality in 0-5 months was higher in predominantly (RR 1.7), partially (RR 4.56) and nonbreastfed (RR 8.66) infants compared to exclusive breastfed infants. The risk was twofold higher in nonbreastfed children when compared to breastfed children aged 6-23 months.

CONCLUSION

The findings underscore the importance of optimal breastfeeding practices during infancy and early childhood.

Compliance Audit of Processed Complementary Foods in Urban Ghana

Background and objectives

Although processed complementary foods (PCFs) can contribute to meeting dietary needs of infants and young children, it has been associated with unethical marketing practices, which undermine practice of exclusive breastfeeding for 6 months. The current study assessed PCF labeling compliance to the International Code of Marketing of Breast Milk Substitutes (CMBMS) and the National Breastfeeding Promotion Regulation (NBPR) in Ghana.

Methods

A variety of PCF were purchased from child welfare clinics, fuel station shops, supermarkets, “mother/baby” care shops, and pharmacies in the La and Osu Klottey sub-metropolitan areas in Accra. The labels were evaluated against the best practice indicators proposed by the Maternal, Infant, and Young Child Nutrition Working Group based on the international CMBMS, and also indicators based on the NBPR. An overall compliance estimate was determined based on intensity of compliance to the indicators.

Results

The PCF purchased included cereal-based products, fruit juices, fruit and vegetable purees, milk-based products, and combination meals; 75% of PCF were imported. One hundred of the 108 products identified were labeled in English and thus included in analysis. None of the products complied with all labeling requirements of CMBMS or NBPR; 84 and 17% of product labels complied with at least 50% of NBPR and 50% of CMBMS indicators, respectively. Only 5% of labels had content indicating importance of exclusive breastfeeding for 6 months. Additionally, only 5% of labels warned against the hazard of introducing PCF earlier than 6 months as required by the NBPR.

Conclusion

Labeling of most PCF sold by selected retailers in Accra did not comply with NBPR and CMBMS labeling requirements. Enforcement of local law on labeling of PCF is urgently needed.

Fatores associados ao início tardio da amamentação em hospitais do Sistema Único de Saúde no Município do Rio de Janeiro, Brasil, 2009

Resumo O objetivo do trabalho foi analisar os fatores associados com o início tardio da amamentação (não amamentar na primeira hora de vida). Estudo transversal conduzido em 2009 com 673 puérperas internadas em hospitais do Sistema Único de Saúde (SUS) do Município do Rio de Janeiro, Brasil. Um modelo de regressão logística multinível com dois níveis (individual e hospitalar) foi utilizado nas análises estatísticas. A prevalência de início tardio da amamentação foi de 49,2%. O parto em Hospital Amigo da Criança (HAC) teve um efeito protetor contra o atraso no início da amamentação (OR = 0,17; IC95%: 0,05-0,55), enquanto a cesariana (OR = 5,95; IC95%: 3,88-9,12) e o desconhecimento do resultado do exame anti-HIV até o parto (OR = 2,16; IC95%: 1,04-4,50) aumentaram a chance de atraso. Redução das taxas de cesariana, adesão aos protocolos de atenção pré-natal e ampliação do credenciamento dos hospitais como HAC são estratégias importantes para promover o aleitamento materno na primeira hora de vida.

Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study

We report the infant feeding experiences in the first month of life for 2,053 infants participating in "Malnutrition and Enteric Infections: Consequences for Child Health and Development" (MAL-ED). Eight sites (in Bangladesh, India, Nepal, Pakistan, Brazil, Peru, South Africa, Tanzania), each followed a cohort of children from birth (by day 17), collecting detailed information on infant feeding practices, diet and illness episodes. Mothers were queried twice weekly regarding health status, breastfeeding and the introduction (or no) of non-breast milk liquids and foods. Here, our goal is to describe the early infant feeding practices in the cohort and evaluate factors associated with termination of exclusive breastfeeding in the first month of life. With data from enrollment to a visit at 28-33 days of life, we characterized exclusive, predominant or partial breastfeeding (using a median of 6-9 visits per child across the sites). Only 6 of 2,053 infants were never breastfed. By one month, the prevalences of exclusive breastfeeding were < 60% in 6 of 8 sites, and of partial breastfeeding (or no) were > 20% in 6 of 8 sites. Logistic regression revealed that prelacteal feeding (given to 4-63% of infants) increased the likelihood of partial breastfeeding (Odds Ratio (OR): 1.48 (95% confidence interval (CI): 1.04, 2.10), as did the withholding of colostrum (2-16% of infants) (OR: 1.63:1.01, 2.62), and being a first-time mother (OR: 1.38:1.10, 1.75). Our results reveal diversity across these sites, but an overall trend of early transition away from exclusive breastfeeding in the first month of life. Interventions which introduce or reinforce the WHO/UNICEF Ten Steps for Successful Breastfeeding are needed in these sites to improve breastfeeding initiation, to reinforce exclusive breastfeeding and delay introduction of non-breast milk foods and/or liquids.

Methods of milk expression for lactating women

BACKGROUND

This is an update of a 2008 Cochrane review. Breastfeeding is important. However, not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and cost implications of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2014), CINAHL (1982 to March 2014), conference proceedings, secondary references and contacted researchers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials, extracted data and assessed risk of bias.

MAIN RESULTS

This updated review includes 34 studies involving 1998 participants, with 17 trials involving 961 participants providing data for analysis. Eight studies compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and multiple pump types. Fifteen studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols (five studies), pumping > 4 times per day versus < 3 times per day (one study), provision of a milk expression education and support intervention to mothers of preterm infants versus no provision (one study), provision of audio/visual relaxation to mothers of preterm infants versus no specific relaxation (two studies), commencing pumping within one hour of delivery versus between one to six hours (one study), breast massage before or during pumping versus no massage (two studies, of which one also tested a second behaviour), therapeutic touch versus none (one study), warming breasts before pumping versus not warming breasts (one study), combining hand expression with pumping versus pumping alone (one study) and a breast cleansing protocol versus no protocol (one study).There were insufficient comparable data on outcomes to undertake meta-analysis and data reported relates to evidence from single studies.Only one of the 17 studies examining maternal satisfaction/acceptability provided data in a way that could be analysed, reporting that mothers assigned to the pumping group had more agreement with the statement 'I don't want anyone to see me pumping' than mothers in the hand expression group and the statement 'I don't want anyone to see me hand expressing' (n = 68, mean difference (MD) -0.70, 95% confidence interval (CI) -1.25 to -0.15, P = 0.01), and that mothers found instructions for hand expression were clearer than for pumping (n = 68, MD 0.40, 95% CI 0.05 to 0.75, P = 0.02). No evidence of a difference was found between methods related to adverse effects of milk contamination (one study, n = 28, risk ratio (RR) 0.89, 95% CI 0.62 to 1.27, P = 0.51), (one study, n = 142 milk samples, MD 0.20, 95% CI -0.18 to 0.58, P = 0.30), (one study, n = 123 milk samples, MD 0.10, 95% CI -0.29 to 0.49, P = 0.61), (one study, n = 141 milk samples, MD -0.10, 95% CI -0.46 to 0.26, P = 0.59 ); or level of maternal breast or nipple pain or damage (one study, n = 68, MD 0.02, 95% CI -0.67 to 0.71, P = 0.96).For the secondary outcomes, greater volume was obtained when mothers with infants in a neonatal unit were provided with a relaxation tape or music-listening interventions to use while pumping, when the breasts was warmed before pumping or massaged while pumping.Initiation of milk pumping within 60 minutes of birth of a very low birthweight infant obtained higher mean milk quantity in the first week than the group who initiated pumping later. No evidence of difference in volume was found with simultaneous or sequential pumping or between pumps studied. Differences between methods was found for sodium, potassium, protein and fat constituents; no evidence of difference was found for energy content.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.Most studies were classified as unclear or low risk of bias. Most studies did not provide any information regarding blinding of outcome assessment. Fifteen of the 25 studies that evaluated pumps or products had support from the manufacturers.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including early initiation when not feeding at the breast, listening to relaxation music, massage and warming of the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings.

Effects of Birth Month on Child Health and Survival in Sub-Saharan Africa

Birth month is broadly predictive of both under-5 mortality rates and stunting throughout most of sub-Saharan Africa (SSA). Observed factors, such as mother's age at birth and educational status, are correlated with birth month but are not the main factors underlying the relationship between birth month and child health. Accounting for maternal selection via a fixed-effects model attenuates the relationship between birth month and health in many SSA countries. In the remaining countries, the effect of birth month may be mediated by environmental factors. This study found that birth month effects on mortality typically do not vary across age intervals; the differential mortality rates by birth month are evident in the neonatal period and continue across age intervals. The male-to-female sex ratio at birth did not vary by birth month, which suggests that in utero exposures are not influencing fetal loss, and that therefore the birth month effects are not likely a result of selective survival during the in utero period. In one-third of the sample, the birth month effects on stunting diminished after the age of 2 years; therefore, some children were able to catch up. Policies to improve child health should target pregnant women and infants and must take seasonality into account.

Morbidity in relation to feeding mode in African HIV-exposed, uninfected infants during the first 6 mo of life: the Kesho Bora study

BACKGROUND

Refraining from breastfeeding to prevent HIV transmission has been associated with increased morbidity and mortality in HIV-exposed African infants.

OBJECTIVE

The objective was to assess risks of common and serious infectious morbidity by feeding mode in HIV-exposed, uninfected infants ≤6 mo of age with special attention to the issue of reverse causality.

DESIGN

HIV-infected pregnant women from 5 sites in Burkina Faso, Kenya, and South Africa were enrolled in the prevention of mother-to-child transmission Kesho Bora trial and counseled to either breastfeed exclusively and cease by 6 mo postpartum or formula feed exclusively. Maternal-reported morbidity (fever, diarrhea, and vomiting) and serious infectious events (SIEs) (gastroenteritis and lower respiratory tract infections) were investigated for 751 infants for 2 age periods (0-2.9 and 3-6 mo) by using generalized linear mixed models with breastfeeding as a time-dependent variable and adjustment for study site, maternal education, economic level, and cotrimoxazole prophylaxis.

RESULTS

Reported morbidity was not significantly higher in nonbreastfed compared with breastfed infants [OR: 1.31 (95% CI: 0.97, 1.75) and 1.21 (0.90, 1.62) at 0-2.9 and 3-6 mo of age, respectively]. Between 0 and 2.9 mo of age, never-breastfed infants had increased risks of morbidity compared with those of infants who were exclusively breastfed (OR: 1.49; 95% CI: 1.01, 2.2; P = 0.042). The adjusted excess risk of SIEs in nonbreastfed infants was large between 0 and 2.9 mo (OR: 6.0; 95% CI: 2.2, 16.4; P = 0.001). Between 3 and 6 mo, the OR for SIEs was sensitive to the timing of breastfeeding status, i.e., 4.3 (95% CI: 1.2, 15.3; P = 0.02) when defined at end of monthly intervals and 2.0 (95% CI: 0.8, 5.0; P = 0.13) when defined at the beginning of intervals. Of 52 SIEs, 3 mothers reported changes in feeding mode during the SIE although none of the mothers ceased breastfeeding completely.

CONCLUSIONS

Not breastfeeding was associated with increased risk of serious infections especially between 0 and 2.9 mo of age. The randomized controlled trial component of the Kesho Bora study was registered at Current Controlled Trials (www.controlled-trials.com) as ISRCTN71468401.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2014) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted data and assessed risk of bias.

MAIN RESULTS

We included eight trials (984 randomised infants/mothers). Six trials (n = 613 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one secondary outcome (weight change). The trials that provided outcome data compared exclusively breastfed infants with breastfed infants who were allowed additional nutrients in the form of artificial milk, glucose, water or solid foods.In relation to the majority of the older trials, the description of study methods was inadequate to assess the risk of bias. The two more recent trials, were found to be at low risk of bias for selection and detection bias. The overall quality of the evidence for the main comparison was low.In one trial (170 infants) comparing exclusively breastfeeding infants with infants who were allowed additional glucose water, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), with more infants in the exclusive breastfed group still exclusively breastfeeding. Conversely in one small trial (39 infants) comparing exclusive breastfed infants with non-exclusive breastfed infants who were provided with artificial milk, fewer infants in the exclusive breastfed group were exclusively breastfeeding at one week (RR 0.58, 95% CI 0.37 to 0.92) and at three months (RR 0.44, 95% CI 0.26 to 0.76) and there was no significant difference in the proportion of infants continuing any breastfeeding at three months between groups (RR 0.76, 95% CI 0.56 to 1.03).For infant morbidity (six trials), one newborn trial (170 infants) found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference (MD) 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24 mmol/L, 95% CI -0.51 to 0.03). Weight loss was also higher (grams) in infants at six, 12, 24 and 48 hours of life in the exclusively breastfed infants compared to those who received additional glucose water (MD 7.00 g, 95% CI 0.76 to 13.24; MD 11.50 g, 95% CI 1.71 to 21.29; MD 13.40 g, 95% CI 0.43 to 26.37; MD 32.50 g, 95% CI 12.91 to 52.09), but no difference between groups was observed at 72 hours of life. In another trial (47 infants analysed), we found no significant difference in weight loss between the exclusively breastfeeding group and the group allowed either water or glucose water on either day three or day five (MD 1.03%, 95% CI -0.18 to 2.24) and (MD 0.20%, 95% CI -1.18 to 1.58).Three trials with four- to six-month-old infants provided no evidence to support any benefit from the addition of complementary foods at four months versus exclusive breastfeeding to six months nor any risks related either morbidity or weight change (or both).None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence of benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water, and the quality of the evidence from a small pilot study on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer-term effects on infants and mothers, though randomising infants to receive supplements without medical need may be problematic.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

[The prevalence of exclusive breastfeeding and associated factors: a cross-sectional study of teenage mothers between 14 and 16 years of age in the city of Porto Alegre in the State of Rio Grande do Sul, Brazil]

This is a cross-sectional study to verify the prevalence and associated factors related to exclusive breastfeeding in adolescent mothers between 14 and 16 years of age with 6-month-old or younger babies, born in Porto Alegre in the State of Rio Grande do Sul, Brazil, in 2009. The sample was based on 50% of the newborn babies from the population surveyed. A total of 341 adolescent mothers were interviewed in their homes. The variables considered as potential determinants of exclusive breastfeeding were social and demographic, pre- and post-natal assistance, emotional aspects of the mother, birth conditions and baby characteristics. Prevalence ratios (PR) were estimated by Poisson regression by means of hierarchical analysis. The prevalence of exclusive breastfeeding ranged from 47.8% in the first month of life up to 13.8% after six months and declined, on average, 24% for each month of life (RP = 0.76; CI95%: 0.68-0.85). Besides the baby's age, the factors associated with exclusive breastfeeding were maternal education (PR=1.53; CII95%: 1.18-1.98) and multiple births (PR=1.57; CI95%:1.02-2.46), the latter observed in only 4.7% of the sample. Teenage mothers with higher schooling and with live children from earlier pregnancies manifested higher prevalence of exclusive breastfeeding.

Mortalidade infantil na percepção de gestores e profissionais de saúde: determinantes do seu declínio e desafios atuais em município do sul do Brasil

Este estudo objetivou analisar a percepção de gestores e profissionais da saúde sobre os determinantes para o declínio da mortalidade infantil nas últimas décadas, bem como os desafios para a continuidade da redução dos valores desse indicador em Londrina (PR). Foi realizado uma pesquisa qualitativa com análise de entrevistas de 38 gestores, profissionais de saúde e pesquisadores, selecionados pela técnica da bola de neve. Na visão dos entrevistados, os determinantes para a redução da mortalidade infantil foram melhorias das condições de vida e medidas implantadas por políticas públicas e ações setoriais e extrassetoriais. Os desafios atuais dizem respeito, principalmente, à qualificação da assistência pré-natal, à redução da gravidez na adolescência, à melhoria da atenção hospitalar ao recém-nascido prematuro, à prevenção da prematuridade e ao financiamento do Sistema Único de Saúde (SUS). O aumento da proporção de mortes neonatais torna mais complexo e difícil reduzir a mortalidade infantil. Compreender as dificuldades e identificar os desafios, sob a percepção de gestores e profissionais da saúde, pode contribuir para o planejamento das ações necessárias para a melhoria da saúde das crianças menores de 1 ano e para a redução da mortalidade infantil.