Perspective: Should Exclusive Breastfeeding Still Be Recommended for 6 Months?

Is Maternal Body Weight or Composition Associated with Onset of Lactogenesis II, Human Milk Production, or Infant Consumption of Mother's Own Milk? A Systematic Review and Meta-Analysis

Maternal adiposity impacts lactation performance, but the pathways are unclear. We conducted a systematic review to understand whether maternal adiposity (body mass index [BMI] or percentage fat mass) is associated with onset of lactogenesis II (copious milk; hours), human milk production (expressed volume/24 h), and infant consumption of mother's own milk (volume/24 h). We used random-effects standard meta-analyses to compare the relative risk (RR) of delayed lactogenesis II (>72 h) between mothers classified as underweight (BMI <18.5 kg/m2), healthy weight (BMI, 18.5-24.9 kg/m2), and overweight/obese (BMI ≥25 kg/m2) and random-effects meta-regressions to examine associations with hours to lactogenesis II and infant milk consumption. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. We included 122 articles. Mothers with underweight (RR: 0.64; 95% CI: 0.49, 0.83; I2 = 39.48%; 8 articles/data points) or healthy weight status (RR: 0.67; 95% CI: 0.57, 0.79; I2 = 70.91%; 15 articles/data points) were less likely to experience delayed lactogenesis II than mothers with overweight/obesity. We found no association between maternal BMI and time to onset of lactogenesis II (β: 1.45 h; 95% CI: -3.19, 6.09 h; P = 0.52, I2 = 0.00%; 8 articles, 17 data points). Due to limited data, we narratively reviewed articles examining BMI or percentage fat mass and milk production (n = 6); half reported an inverse association and half no association. We found no association between maternal BMI (β: 6.23 mL; 95% CI: -11.26, 23.72 mL; P = 0.48, I2 = 47.23%; 58 articles, 75 data points) or percentage fat mass (β: 7.82 mL; 95% CI: -1.66, 17.29 mL; P = 0.10, I2 = 28.55%; 30 articles, 41 data points) and infant milk consumption. The certainty of evidence for all outcomes was very low. In conclusion, mothers with overweight/obesity may be at risk of delayed lactogenesis II. The available data do not support an association with infant milk consumption, but the included studies do not adequately represent mothers with obesity. This study was registered in PROSPERO as 285344.

Classifying early infant feeding status from clinical notes using natural language processing and machine learning

The objective of this study is to develop and evaluate natural language processing (NLP) and machine learning models to predict infant feeding status from clinical notes in the Epic electronic health records system. The primary outcome was the classification of infant feeding status from clinical notes using Medical Subject Headings (MeSH) terms. Annotation of notes was completed using TeamTat to uniquely classify clinical notes according to infant feeding status. We trained 6 machine learning models to classify infant feeding status: logistic regression, random forest, XGBoost gradient descent, k-nearest neighbors, and support-vector classifier. Model comparison was evaluated based on overall accuracy, precision, recall, and F1 score. Our modeling corpus included an even number of clinical notes that was a balanced sample across each class. We manually reviewed 999 notes that represented 746 mother-infant dyads with a mean gestational age of 38.9 weeks and a mean maternal age of 26.6 years. The most frequent feeding status classification present for this study was exclusive breastfeeding [n = 183 (18.3%)], followed by exclusive formula bottle feeding [n = 146 (14.6%)], and exclusive feeding of expressed mother's milk [n = 102 (10.2%)], with mixed feeding being the least frequent [n = 23 (2.3%)]. Our final analysis evaluated the classification of clinical notes as breast, formula/bottle, and missing. The machine learning models were trained on these three classes after performing balancing and down sampling. The XGBoost model outperformed all others by achieving an accuracy of 90.1%, a macro-averaged precision of 90.3%, a macro-averaged recall of 90.1%, and a macro-averaged F1 score of 90.1%. Our results demonstrate that natural language processing can be applied to clinical notes stored in the electronic health records to classify infant feeding status. Early identification of breastfeeding status using NLP on unstructured electronic health records data can be used to inform precision public health interventions focused on improving lactation support for postpartum patients.

In-Hospital Formula Feeding Hindered Exclusive Breastfeeding: Breastfeeding Self-Efficacy as a Mediating Factor

Breastfeeding self-efficacy (BSE), defined as a mother's confidence in her ability to breastfeed, has been confirmed to predict the uptake of exclusive breastfeeding (EBF). Early experiences during the birth hospital stay, especially in-hospital formula feeding (IHFF), can impact both EBF and maternal breastfeeding confidence. Therefore, our objective was to examine the association between IHFF and EBF outcomes and investigate whether this association is influenced by BSE. The study included 778 infants from a larger cohort study conducted in 2021, with a one-year follow-up in rural areas of Sichuan Province, China. We used a causal mediation analysis to estimate the total effect (TE), natural direct (NDE), and nature indirect effects (NIE) using the paramed command in Stata. Causal mediation analyses revealed that IHFF was negatively associated with EBF (TE odds ratio = 0.47; 95% CI, 0.29 to 0.76); 28% of this association was mediated by BSE. In the subgroup analysis, there were no significant differences in the effects between parity subgroups, as well as between infant delivery subgroups. Our study found that IHFF hindered later EBF and that BSE mediated this association. Limiting the occurrence of in-hospital formula feeding or improving maternal breastfeeding self-efficacy is likely to improve exclusive breastfeeding outcomes.

Implementation of strategies and programs for breastfeeding, complementary feeding, and malnutrition of young children in Brazil: advances and challenges

Malnutrition in all its forms has risen on global agendas due to the recognition of its magnitude and consequences for a wide range of human, social, and economic outcomes. Implementing strategies and programs with the needed scale and quality is a major challenge. The Brazilian National Survey on Child Nutrition (ENANI-2019) pointed out several advances but numerous challenges. In this paper, we reflect on the implementation progress of breastfeeding, complementary feeding and young children malnutrition strategies and programs in Brazil and how existing challenges can be overcome through the lens of implementation science. First, we present a brief history of such programs. Second, we selected two breastfeeding initiatives to illustrate and reflect on common implementation challenges. In these case studies, we used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to analyze the implementation and scaling up barriers and facilitators. We found common barriers related to unclear goals about the reach of programs, challenges in assessing effectiveness and fidelity/quality during the real-world implementation, discontinuation or lack of funding, and lack of monitoring and evaluation impacting the sustainability of programs. We also discuss the use of implementation science to achieve adequate nutrition by 2030 and present critical elements for successful scale implementation of nutrition programs based on global evidence. Despite the investment to implement different actions aimed at facing infant feeding and malnutrition, high-quality implementation research must become a priority to catalyze progress in Brazil.

Micronutrient intake of children in Ghana and Benin: Estimated contribution of diet and nutrition programs

We estimated how micronutrient needs of young children, aged 6-24 months were covered by the standard (traditional) diets in Ghana and Benin, and the contributions of partial breastfeeding and national nutrition programs aimed at improving micronutrient status to overall micronutrient intakes. Estimates of micronutrient intake from standard diets were based on previous surveys, using the food composition table of West Africa (INFOOD). Recommended micronutrient intakes were based on World Health Organization recommendations. Children were grouped in three age groups (6-8, 9-12, and 13-24 months) to capture the changing dynamics of the complementary feeding period. As expected, from 6 months of age onwards, breastmilk didn't cover the micronutrient needs. The standard diets contributed only minimal to micronutrient intakes of children ranging from 0% to 37% of recommended intakes for Ca, Fe, Zn, vitamin A, vitamin D and iodine depending on the micronutrient considered. The contribution of mass (bio)-fortification programs to the coverage of micronutrient needs varied widely, depending on the staple food considered and the country, but overall did not allow to fill the gap in micronutrient needs of children except for vitamin A in some contexts. In contrast, consumption of voluntary fortified complementary food, especially formulated for the needs in this age groups, contributed substantially to overall micronutrient intake and could fill the gap for several micronutrients. The development of young child-targeted programs including micronutrient-dense foods, associated with interventions to increase the diet diversity and meal frequency, could significantly improve micronutrients intakes of children in both Ghana and Benin.

Inequalities in anemia among Peruvian children aged 6–59 months: A decomposition analysis

Objective

To quantify the inequalities of anemia in Peruvian children aged 6–59 months and uncover its contributing factors.

Materials and methods

We conducted a cross-sectional study based on the secondary data analysis of the 2021 Peruvian Demographic and Health Survey (DHS). Our sample included Peruvian children aged 6–59 months with complete data for the variables of interest. Anemia was defined as having a hemoglobin level of less than 11 g/dL, adjusted by altitude. Erreygers Concentration Index (ECI) and concentration curves were computed to estimate the socio-economic inequality in anemia among Peruvian children. Moreover, ECI was decomposed to figure out the contributing factors to the inequality of anemia and the residual variation.

Results

Nationwide, the prevalence of anemia in Peruvian children was 29.47%. We found a pro-poor inequality regarding anemia at the national level (ECI = −0.1848). The determinants included in the model explained 81.85% of the overall socio-economic inequality in anemia. The largest contribution to inequality was from household- and community-related factors. Having a higher mother’s education level (26.26%) and being from the highlands (24.91%) were the major significant contributors to the overall health inequality.

Conclusion

Almost one-third of Peruvian children have anemia. A pro-poor inequality of anemia in Peruvian children was found. Public policies ought to address the major contributing factors of anemia inequality.

Evolutionary biological perspectives on current social issues of breastfeeding and weaning

Breastfeeding and weaning are actively studied from evolutionary, medical, and social research perspectives because of their close association with infant mortality, lifetime health, and human population dynamics. Each discipline benefits from an interdisciplinary exchange of knowledge regarding the bases, processes, and consequences of these phenomena. However, current social issues related to breastfeeding and weaning have received little attention from an evolutionary biology perspective. We address this gap by reviewing current social issues related to human breastfeeding and weaning in an evolutionary framework. This approach helps build a conceptual framework with the goal of better understanding ultimate causes of or influences on these current social issues. The six social issues reviewed here fall into three categories: the spatiotemporal constraints of breastfeeding, abuse of breast milk as valuable material, and mismatch in breastfeeding practices. Some of these issues have an evolutionary basis. We analyze the structure of these social issues and discuss their possible solutions in terms of extension of the trade-off theory in evolutionary biology. Our discussion on the current social issues in breastfeeding and weaning highlights the effectiveness of an approach rooted in evolutionary theory and biological anthropology.

Feeding practices and growth patterns of moderately low birthweight infants in resource-limited settings: results from a multisite, longitudinal observational study

OBJECTIVES

To describe the feeding profile of low birthweight (LBW) infants in the first half of infancy; and to examine growth patterns and early risk factors of poor 6-month growth outcomes.

DESIGN

Prospective observational cohort study.

SETTING AND PARTICIPANTS

Stable, moderately LBW (1.50 to <2.50 kg) infants were enrolled at birth from 12 secondary/tertiary facilities in India, Malawi and Tanzania and visited nine times over 6 months.

VARIABLES OF INTEREST

Key variables of interest included birth weight, LBW type (combination of preterm/term status and size-for-gestational age at birth), lactation practices and support, feeding profile, birthweight regain by 2 weeks of age and poor 6-month growth outcomes.

RESULTS

Between 13 September 2019 and 27 January 2021, 1114 infants were enrolled, comprising 4 LBW types. 363 (37.3%) infants initiated early breast feeding and 425 (43.8%) were exclusively breastfed to 6 months. 231 (22.3%) did not regain birthweight by 2 weeks; at 6 months, 280 (32.6%) were stunted, 222 (25.8%) underweight and 88 (10.2%) wasted. Preterm-small-for-gestational age (SGA) infants had 1.89 (95% CI 1.37 to 2.62) and 2.32 (95% CI 1.48 to 3.62) times greater risks of being stunted and underweight at 6 months compared with preterm-appropriate-for-gestational age (AGA) infants. Term-SGA infants had 2.33 (95% CI 1.77 to 3.08), 2.89 (95% CI 1.97 to 4.24) and 1.99 (95% CI 1.13 to 3.51) times higher risks of being stunted, underweight and wasted compared with preterm-AGA infants. Those not regaining their birthweight by 2 weeks had 1.51 (95% CI 1.23 to 1.85) and 1.55 (95% CI 1.21 to 1.99) times greater risks of being stunted and underweight compared with infants regaining.

CONCLUSION

LBW type, particularly SGA regardless of preterm or term status, and lack of birthweight regain by 2 weeks are important risk identification parameters. Early interventions are needed that include optimal feeding support, action-oriented growth monitoring and understanding of the needs and growth patterns of SGA infants to enable appropriate weight gain and proactive management of vulnerable infants.

TRIAL REGISTRATION NUMBER

NCT04002908.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

The association between early introduction of tiny tastings of solid foods and duration of breastfeeding

BACKGROUND

Conflicting advice and non-evidence-based recommendations have a negative effect on breastfeeding. Since 2011, the National Food Agency in Sweden has informed parents that they can introduce tiny tastings (1 mL of solid food, i.e. other sources of nutrition than breastmilk/formula) to infants from four months of age. It is unknown how national recommendations, which differ from the Word Health Organisation's recommendation, affect breastfeeding. We hypothesised that introduction of tiny tastings of solid foods would shorten the duration of continued breastfeeding.

METHODS

This retrospective study utilises data from the longitudinal 'Swedish Pregnancy Planning Study', in which mothers were recruited at antenatal clinics on a national level. The participants completed three questionnaires up to one year after birth (n = 1,251). Linear regression models were used to analyse the association between the introduction of solid foods and the duration of breastfeeding.

RESULTS

As hypothesised, introduction of tiny tastings shortened the duration of continued breastfeeding. Half of all infants (48%) were fed with tiny tastings already in the fourth month. The correlation analysis showed that the earlier the infants started with tiny tastings, the earlier they ate larger amounts of solid food. In a multivariate linear regression analysis, five factors were identified as having a negative effect on the duration of breastfeeding: low infant age upon introduction of tiny tastings, low maternal age, low level of maternal education, high maternal BMI and twin birth.

CONCLUSIONS

Early introduction of tiny tastings of solid foods shortened the duration of breastfeeding. It is difficult to influence most conditions that affect breastfeeding, for example, the mother's educational level, BMI, age and if she has given birth to twins. In contrast, national guidelines can always be updated. Recommendations from the Swedish authorities should adhere to the WHO's recommendation, which states exclusive breastfeeding for six months and continued breastfeeding for at least two years or longer.

Racial and Ethnic Disparities in Breastfeeding Continuation Among U.S. Hispanic Mothers: Identification of Mechanisms

Objective: We examined the extent to which social, maternal, and infant factors and Theory of Planned Behavior (TPB) domains-attitudes, perceived control, and subjective norms-mediate the relationship between maternal race and ethnicity and birth country, and breastfeeding continuation. Materials and Methods: A nationally representative cohort of 2,810 mothers with self-reported race, ethnicity, and birth country was used. Main outcomes included any and exclusive breastfeeding at 2-6 months of infant age. A conceptual framework with the aforementioned mediators of interest was developed. Logistic regression was used to examine main associations, and structural equation modeling was used to identify the extent to which proposed mediators explained the relationship between independent and dependent variables. Results: One thousand two hundred twenty-one mothers were U.S.-born non-Hispanic white (NHW), 432 U.S.-born Hispanic, 329 Mexico-born Hispanic, 107 Central- or South America-born Hispanic, 33 Caribbean-born Hispanic, and 688 U.S.-born non-Hispanic black (NHB). No differences in breastfeeding continuation among U.S.-born NHW and U.S.-born Hispanic mothers were found. In contrast, compared with U.S.-born NHW mothers, Mexico-born (odds ratio [OR] 1.99, 95% confidence interval [CI] 1.46-2.72) and Central- or South America-born (OR 3.42, 95% CI 1.89-6.17) Hispanic mothers had higher odds, and Caribbean-born Hispanic mothers had lower odds (OR 0.45, 95% CI 0.26-0.76) of any breastfeeding. These relationships were mediated by attitudes and subjective norms. Conclusions: Breastfeeding continuation among U.S. Hispanic mothers varied by birth country, highlighting the heterogeneity of breastfeeding populations of Hispanic mothers in the United States. Tailored interventions should strengthen policies supportive of positive attitudes toward and subjective norms around breastfeeding.

Relationship of delayed lactogenesis II to maternal perception of insufficient milk: A longitudinal study

AIM

To analyze the relationship of delayed lactogenesis II with maternal perception of insufficient milk.

METHODS

A prospective, multicenter, longitudinal observational study was conducted. Data were obtained at discharge and between 1 and 5 months postpartum on the perception of insufficient milk and related variables, by means of a self-administered questionnaire, and subsequent postal and online follow-up. Logistic regression analysis was used to develop the explanatory model.

RESULTS

A total of 260 puerperal mothers participated. Of these, 31.9% had insufficient milk and 23.6% had delayed lactogenesis II. During postpartum admission, delayed lactogenesis II (OR = 2.26; 95%CI = 1.07-4.79), difficulty in breastfeeding (OR = 1.02; 95%CI = 1.00-1.03), and professional help in breastfeeding (OR = 0.70; 95%CI = 0.50-0.97) were associated with maternal perception of insufficient milk.

CONCLUSIONS

The occurrence of breastfeeding difficulties during postpartum admission and at discharge, especially when there is delayed lactogenesis II, should be considered risk indicators, suggesting the need for additional support to standardized care. The PIM is a suitable indicator to assess the quality of professional breastfeeding support in improvement interventions.

Perspective: Human Milk Composition and Related Data for National Health and Nutrition Monitoring and Related Research

National health and nutrition monitoring is an important federal effort in the United States and Canada, and the basis for many of their nutrition and health policies. Understanding of child exposures through human milk (HM) remains out of reach due to lack of current and representative data on HM's composition and intake volume. This article provides an overview of the current national health and nutrition monitoring activities for HM-fed children, HM composition (HMC) and volume data used for exposure assessment, categories of potential measures in HM, and associated variability factors. In this Perspective, we advocate for a framework for collection and reporting of HMC data for national health and nutrition monitoring and programmatic needs, including a shared vision for a publicly available Human Milk Composition Data Repository (HMCD-R) to include essential metadata associated with HMC. HMCD-R can provide a central, integrated platform for researchers and public health officials for compiling, evaluating, and sharing HMC data. The compiled compositional and metadata in HMCD-R would provide pertinent measures of central tendency and variability and allow use of modeling techniques to approximate compositional profiles for subgroups, providing more accurate exposure assessments for purposes of monitoring and surveillance. HMC and related metadata could facilitate understanding the complexity and variability of HM composition, provide crucial data for assessment of infant and maternal nutritional needs, and inform public health policies, food and nutrition programs, and clinical practice guidelines.

Thirty Obesity Myths, Misunderstandings, and/or Oversimplifications: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of 30 common obesity myths, misunderstandings, and/or oversimplifications.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS discusses 30 common obesity myths, misunderstandings, and/or oversimplifications, utilizing referenced scientific publications such as the integrative use of other published OMA CPSs to help explain the applicable physiology/pathophysiology.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on 30 common obesity myths, misunderstandings, and/or oversimplifications is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Knowledge of the underlying science may assist the obesity medicine clinician improve the care of patients with obesity.

Multiple Indicators of Undernutrition, Infection, and Inflammation in Lactating Women Are Associated with Maternal Iron Status and Infant Anthropometry in Panama: The MINDI Cohort

Maternal infections, nutrient deficiencies, and inflammation (MINDI) co-exist in lactating indigenous women in Panama, but their impact on maternal iron status and infant growth is unknown. For this secondary analysis of cross-sectional data of lactating mothers from our MINDI cohort, we investigated associations of MINDI variables with maternal anemia, elevated serum transferrin receptor (sTfR), low serum iron, hepcidin, ferritin, and infant weight-for-age (WAZ), length-for-age (LAZ), and head-circumference-for-age (HCAZ) Z-scores in 99 mother-infant dyads. A bootstrapping resampling procedure preselected covariates for inclusion in multivariable regressions models from chronic maternal infections and nutritional status [folate, vitamins A, D, retinol-binding protein (RBP), insulin-growth factor-1 (IGF-1)] and inflammation [C-reactive protein (CRP), cytokines, platelet indices] indicators. Anemia was prevalent (53.5%) but underestimated due to widespread low plasma volume (<2.2 L, 79.9%) and was associated with indicators of malnutrition [lower IGF-1, body mass index (BMI), vitamin D, and intake of green/leafy vegetables], but not inflammation. Higher CRP was associated with lower serum iron, and higher hepcidin and ferritin, whereas maternal platelets were associated with lower HCAZ (β = −0.22), WAZ (β = −0.17), and LAZ (β = −0.17). Higher LAZ was also associated with maternal serum vitamin D (β = 0.23), whereas maternal iron supplementation lowered LAZ (β = −0.22). Assessment of iron status in this MINDI cohort is complex and supplementation strategies must consider consequences for both the mother and the infant.

Breast Milk from Non-Obese Women with a High Omega-6 to Omega-3 Fatty Acid Ratio, but Not from Women with Obesity, Increases Lipogenic Gene Expression in 3T3-L1 Preadipocytes, Suggesting Adipocyte Dysfunction

Maternal body mass index is associated with breast milk (BM) fatty acid composition. This study investigated the effects of BM omega (n)-6:n-3 polyunsaturated fatty acids (PUFAs) from non-obese women and women with obesity on the process of adipogenesis in 3T3-L1 preadipocytes. BM samples were collected from non-obese women (BMNO) and women with obesity (BMO) at one month postpartum. The fatty acid composition was measured, and BMNO and BMO groups with the lowest (Q1) and highest (Q4) quartiles of n-6:n-3 PUFA ratios were identified. 3T3-L1 preadipocytes were differentiated in the presence or absence of BM. Lipid accumulation and the expression of genes involved in lipogenesis and lipolysis were measured. Treatment with BMNO containing high (vs. low) n-6:n-3 PUFA ratios significantly increased the mRNA expression of lipogenic genes (acetyl-CoA carboxylase, fatty acid synthase, and stearoyl-CoA desaturase); however, there was no effect when cells were treated with BMO (with either low or high n-6:n-3 PUFA ratios). Treatment with BMO (high n-6:n-3 PUFA ratio) caused larger lipid droplets. Our findings demonstrated that BMNO with a high n-6:n-3 PUFA ratio was associated with a higher expression of lipogenic genes, while BMO with a high n-6:n-3 PUFA ratio showed larger lipid droplets, suggesting adipocyte dysfunction. These findings may have implications in the BM-mediated programming of childhood obesity.

What will it take to increase breastfeeding?

The introduction for the Supplement in Maternal & Child Nutrition: What will it take to increase breastfeeding? describes the contribution of each of the articles included in this Supplement to the current evidence about the major structural challenges in place to overcome to improve breastfeeding practices, as well as the evidence‐based policies and interventions that can be effective at advancing breastfeeding on a large scale to promote, protect and support breastfeeding.

Breastfeeding saves lives, improves the short‐ and long‐term health and cognitive development of infants, and the health of their mothers across the globe.

In most countries, the vast majority of women are choosing to breastfeed but very often cannot do it for as long as they wish because of major structural barriers across layers of the social‐ecological model.

Caregivers need to learn the skills to manage normal baby behaviours such as crying and fussiness without placing breastfeeding at risk.

Implementation of well‐coordinated evidence‐based programmes at the facility and community levels through a highly qualified and motivated workforce, as well as with adequate resources, is needed to improve breastfeeding.

Improving maternity benefits for women working in the formal and informal sectors and enforcing the World Health Organization Code of Marketing of Breastmilk Substitutes are key to improving breastfeeding.

Implementation science research is needed to translate into large‐scale policy and practice the vast knowledge that we have on what is needed to improve breastfeeding globally.

Risk factors for self‐reported insufficient milk during the first 6 months of life: A systematic review

The objective of this systematic review was to identify multifactorial risk factors for self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL). The review protocol was registered a priori in PROSPERO (ID# CDR42021240413). Of the 120 studies included (98 on SRIM, 18 on DOL, and 4 both), 37 (31%) studies were conducted in North America, followed by 26 (21.6%) in Europe, 25 (21%) in East Asia, and Pacific, 15 (12.5%) in Latin America and the Caribbean, 7 (6%) in the Middle East and North Africa, 5 (4%) in South Asia, 3 (2.5%) in Sub‐Saharan Africa, and 2 (1.7%) included multiple countries. A total of 79 studies were from high‐income countries, 30 from upper‐middle‐income, 10 from low‐middle‐income countries, and one study was conducted in a high‐income and an upper‐middle‐income country. Findings indicated that DOL increased the risk of SRIM. Protective factors identified for DOL and SRIM were hospital practices, such as timely breastfeeding (BF) initiation, avoiding in‐hospital commercial milk formula supplementation, and BF counselling/support. By contrast, maternal overweight/obesity, caesarean section, and poor maternal physical and mental health were risk factors for DOL and SRIM. SRIM was associated with primiparity, the mother's interpretation of the baby's fussiness or crying, and low maternal BF self‐efficacy. Biomedical factors including epidural anaesthesia and prolonged stage II labour were associated with DOL. Thus, to protect against SRIM and DOL it is key to prevent unnecessary caesarean sections, implement the Baby‐Friendly Ten Steps at maternity facilities, and provide BF counselling that includes baby behaviours.

Socioeconomic and demographic factors indicative of lower economic status increased the risk of self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL).

Timely breastfeeding (BF) initiation and avoidance of in‐hospital commercial milk formula (CMF) supplementation are likely to reduce the prevalence of SRIM and DOL.

BF counselling designed to prevent SRIM and DOL needs to strengthen maternal BF self‐efficacy, maternal understanding of baby behaviours such as fussiness and maternal wellbeing.

Research is needed to better understand how the risk of DOL and SRIM increases with primiparity, caesarean sections, maternal overweight/obesity, and poor overall maternal health.

Intervention studies specifically designed to reduce the risk of SRIM and DOL are urgently needed in low‐ and middle‐income countries.

Dietary Approaches to Iron Deficiency Prevention in Childhood—A Critical Public Health Issue

Iron is an essential nutrient, and individual iron status is determined by the regulation of iron absorption, which is driven by iron requirements. Iron deficiency (ID) disproportionately affects infants, children, and adolescents, particularly those who live in areas with unfavorable socioeconomic conditions. The main reason for this is that diet provides insufficient bioavailable iron to meet their needs. The consequences of ID include poor immune function and response to vaccination, and moderate ID anemia is associated with depressed neurodevelopment and impaired cognitive and academic performances. The persistently high prevalence of ID worldwide leads to the need for effective measures of ID prevention. The main strategies include the dietary diversification of foods with more bioavailable iron and/or the use of iron-fortified staple foods such as formula or cereals. However, this strategy may be limited due to its cost, especially in low-income countries where biofortification is a promising approach. Another option is iron supplementation. In terms of health policy, the choice between mass and targeted ID prevention depends on local conditions. In any case, this remains a critical public health issue in many countries that must be taken into consideration, especially in children under 5 years of age.

The Effectiveness of the Rolling Massage Technique on Breast Milk Adequacy for the Baby in the COVID-19 Pandemic

BACKGROUND: Rolling massage is one of the actions for postpartum mothers that can increase breast milk production (ASI). There are many benefits of rolling massage for babies. Still, there are no studies that discuss the effectiveness of rolling messages on the adequacy of breast milk in infants during the COVID-19 pandemic. AIM: This study aims to identify the effectiveness of rolling massage on the adequacy of breast milk during the COVID-19 pandemic. METHODS: This research is quantitative research with a quasi-experimental approach. The sample selection used a random method with a total sample of 63 postpartum mothers divided into two groups, namely, 32 samples in the intervention group and 31 in the control group. The rolling massage was performed on mothers in the intervention group on days 1, 3, and 7 postpartum. Data were analyzed using the ANOVA test. RESULTS: The results showed a significant difference between the adequacy of breastfeeding in the control group and the intervention group, which was seen from the difference in the frequency of urination (p = 0.036), satisfaction with breastfeeding (p = 0.001), and the increase in infant weight (p = 0.001) at measurements 7 and 30 postpartum day. CONCLUSION: Rolling massage is very effective for postpartum mothers to achieve adequate milk intake for babies. Therefore, it is highly recommended to do it in the first days after giving birth to increase the mother’s milk production to meet the needs of breast milk intake for the baby.

Blood-Stained Colostrum: A Rare Phenomenon at an Early Lactation Stage

The phenomenon described in the literature as rusty pipe syndrome is a rare condition (the estimated incidence is 0.1% in the population of breastfeeding women) where the prenatal milk and the colostrum are rust- or blood-colored. Due to the rare occurrence of this phenomenon and the related nature of the baby’s regurgitated discharge—green, brown or blood-stained, there is a general fear of latching a newborn or continuing to breastfeed if the regurgitation persists. In this care report, a patient’s milk was tested to determine its microbiological and morphological content. No significant abnormalities were noted in these tests. The nutritional profile of the blood-stained colostrum was normal. Breast milk has an indisputably invaluable impact on the newborn’s further development and there is no connection between rusty pipe syndrome, as described in the literature, and any clinical complications. This is crucial to encourage mothers to keep breastfeeding even if they observe blood-stained colostrum.

Randomized controlled trial of early, small-volume formula supplementation among newborns: A study protocol

Childhood undernutrition is a major health burden worldwide that increases childhood morbidity and mortality and causes impairment in infant growth and developmental delays that can persist into adulthood. The first weeks and months after birth are critical to the establishment of healthy growth and development during childhood. The World Health Organization recommends immediate and exclusive breastfeeding (EBF). In infants for whom EBF may not meet nutritional and caloric demands, early, daily, small-volume formula supplementation along with breastfeeding may more effectively avoid underweight wasting and stunting in early infancy than breastfeeding alone. The primary objective of this randomized controlled trial is to evaluate the efficacy of formula for 30 days among low birth weight (LBW) infants <6 hours of age and those not LBW with weights <2600 grams at 4 days of age. We will compare breastfeeding and formula (up to 59 milliliters administered daily) through 30 days of infant age vs recommendations for frequent EBF without supplementation, and test the hypothesis that formula increases weight-for-age z-score at 30 days of infant age. The trial will enroll and randomize 324 mother-infant pairs in Guinea-Bissau and Uganda, and follow them for 6 months for outcomes including growth, intestinal microbiota, breastfeeding duration, infant dietary intake, and adverse events. Conservatively estimating 20% loss to follow up, this sample size provides ≥80% power per weight stratum for intervention group comparison to detect a difference of 0.20 with respect to the outcome of WAZ at day 30. This trial was approved by the University of California, San Francisco Institutional Review Board (19-29405); the Guinea-Bissau National Committee on Ethics in Health (Comite Nacional de Etica na Saude, 075/CNES/INASA/2020); the Higher Degrees, Research and Ethics Committee of Makerere University (871); and the Uganda National Council of Science and Technology (HS1226ES). We plan to disseminate study results in peer-reviewed journals and international conferences. Trial registration number: NCT04704076.

Zinc and iron adequacy and relative importance of zinc/iron storage and intakes among breastfed infants

Neonatal nutrient storage and supplies from breast milk contribute to nutrient status and growth of infants during their early life. This study investigated the adequacy of zinc and iron intakes among breastfed infants during the first 4 months and determined the relative importance of zinc/iron storage versus nutrient intakes with infant's biochemical status and growth. A longitudinal study followed lactating women and their breastfed infants from birth to 4 months postpartum. Cord zinc and ferritin concentrations, as indicators of nutrient storages, were determined. Zinc and iron intakes from breast milk were determined by measurement of breast milk volume together with milk zinc and iron concentrations at 2 and 4 months postpartum. Inadequacy of nutrient intakes was determined using average requirement (AR) which were 1.6 and 0.24 mg/day for zinc and iron respectively. Infant's serum zinc and ferritin were determined at 4 months of age. The data were collected from 64 and 56 participants at 2 months and 4 months postpartum. Inadequate zinc intake was found in 14.5 and 40% of infants at 2 and 4 months old, respectively. The prevalence of biochemical zinc and iron deficiency in infants were 76 and 11%, respectively. Iron endowment was significantly associated with serum ferritin at 4 months. The cumulative zinc intake was positively associated with weight gain and weight-for-length Z-score, but not length. This study provides quantitative data on zinc and iron intakes, and demonstrates the relative importance of nutrient storage versus intakes on biochemical status and growth of breastfed infants.

High levels of breastmilk feeding despite a low rate of exclusive breastfeeding for 6 months in a cohort of vulnerable women in Toronto, Canada

Exclusive breastfeeding (EBF) for 6 months is a global public health goal, but measuring its achievement as a marker of population breastmilk feeding practices is insufficient. Additional measures are needed to understand variation in non-EBF practices and inform intervention priorities. We collected infant feeding data prospectively at seven time points to 6 months post-partum from a cohort of vulnerable women (n = 151) registered at two Canada Prenatal Nutrition Program sites in Toronto, Canada. Four categories of breastmilk feeding intensity were defined. Descriptive analyses included the (i) proportion of participants in each feeding category by time point, (ii) use of formula and non-formula supplements to breastmilk, (iii) proportion of participants practising EBF continuously for at least 3 months; and (iv) frequency of transitions between feeding categories. All participants initiated breastmilk feeding with 70% continuing for 6 months. Only 18% practised EBF for 6 months, but 48% did so for at least 3 continuous months. The proportion in the EBF category was highest from 2 to 4 months post-partum. Supplemental formula use was highest in the first 3 months; early introduction of solids and non-formula fluids further compromised EBF at 5 and 6 months post-partum. Most participants (75%) transitioned between categories of breastmilk feeding intensity, with 35% making two or more transitions. Our data show high levels of breastmilk provision despite a low rate of EBF for 6 months. Inclusion of similar analyses in future prospective studies is recommended to provide more nuanced reporting of breastmilk feeding practices and guide intervention designs.

Factors associated with longitudinal changes in B-vitamin and choline concentrations of human milk

BACKGROUND

Little is known regarding the associations between maternal factors and B-vitamin and choline concentrations in early milk and the trajectories of these vitamins during lactation.

OBJECTIVES

In this hypothesis-generating study, we modeled the association between maternal and offspring factors and longitudinal changes in milk B-vitamin and choline concentrations throughout lactation.

METHODS

A hundred women were studied in a prospective birth cohort and milk samples from 52 women were collected at 2-8 d, 76 women at 28-50 d, and 42 women at 88-119 d postpartum. Maternal dietary intake during pregnancy and lactation was assessed by an FFQ. Linear mixed-effects models with interaction terms were used to evaluate changes in milk B-vitamin and choline concentrations over time based on maternal factors and the early postpartum concentrations of these micronutrients.

RESULTS

The women with higher early postpartum milk concentrations of niacin (βinteraction = -0.02; SE = 0.00; P < 0.001), pantothenic acid (βinteraction = -0.10; SE = 2.56; P < 0.001), vitamin B-12 (βinteraction= -0.10; SE = 0.03; P < 0.001), and choline (βinteraction= -0.90; SE = 0.18; P < 0.001) exhibited a decrease in their concentrations throughout lactation. The participants with overweight and obesity prepregnancy experienced an increase in milk vitamin B-12 concentrations over time (βinteraction = 0.04; SE = 0.02; P = 0.06). In contrast, a decrease in vitamin B-12 concentration was observed among women with vitamin B-12 intake below the RDA during pregnancy (βinteraction= -0.08; SE = 0.05; P = 0.07). The women with niacin intake below the RDA during lactation experienced an increase in milk concentrations over time (βinteraction = 0.01; SE = 0.01; P = 0.03). A gestational age at birth >40 wk was associated with an increase in milk choline concentration throughout lactation (βinteraction = 0.54; SE = 0.16; P< 0.01).

CONCLUSIONS

Changes in B-vitamin and choline concentrations in human milk over time may be associated with the early concentrations of these micronutrients in milk, maternal prepregnancy BMI, dietary intake, and gestational age at delivery.

Effect on breastfeeding practices of providing in-home lactation support to vulnerable women through the Canada Prenatal Nutrition Program: protocol for a pre/post intervention study

Background

Only one-third of Canadian infants are exclusively breastfed for the first 6 months of life as recommended. Skilled lactation support in the early postpartum period is one strategy for improving breastfeeding outcomes by building breastfeeding self-efficacy and resolving difficulties. Access to such support is limited among vulnerable women, including those who are new immigrants, low income, under-educated, young or single. The Canada Prenatal Nutrition Program (CPNP) aims to improve birth and breastfeeding outcomes among vulnerable women, but currently lacks a formal framework for providing postpartum lactation support.

Methods

This pre/post intervention study will examine the effect on breastfeeding outcomes of an evidence-based in-home lactation support intervention provided through the CPNP. We will enrol 210 pregnant women who intend to breastfeed and are registered CPNP clients at two sites in Toronto, Canada. During the intervention phase, postpartum home visits by International Board Certified Lactation Consultants (IBCLCs) will be pro-actively offered to registered clients of the two sites. Double-electric breast pumps will also be provided to those who meet specific criteria. Infant feeding data will be collected prospectively at seven time points from 2 weeks to 6 months postpartum. Descriptive and regression analyses will be conducted to measure intervention effects. The primary outcome is exclusive breastfeeding at 4 months postpartum. Secondary outcomes include the duration of any and exclusive breastfeeding, timing of introduction of breastmilk substitutes and timing of introduction of solid foods. Breastfeeding self-efficacy will be assessed prenatally and at 2 weeks and 2 months postpartum. Other measures include maternal socio-demographics, infant feeding intentions, maternal depression and anxiety, and household food insecurity. Monitoring data will be used to assess the reach, uptake and fidelity of intervention delivery.

Discussion

Increasing access to skilled lactation support through the CPNP may be an effective means of improving breastfeeding practices among vulnerable women and thereby enhancing health and development outcomes for their infants. This pre/post intervention study will contribute evidence on both the effectiveness and feasibility of this approach, in order to guide the development and further testing of appropriate models of integrating lactation support into the CPNP.

Trial registration

ClinicalTrials.gov (NCT03589963) registered July 18, 2018.

Global prevalence of WHO infant feeding practices in 57 LMICs in 2010-2018 and time trends since 2000 for 44 LMICs

BACKGROUND

The World Health Assembly set a global target of increasing exclusive breastfeeding for infants under 6 months to at least 50% by year 2025. However, little is known about the current status of breastfeeding practice, as well as the trends in breastfeeding practices during recent years. We examined global prevalence of the World Health Organization (WHO) feeding practices in 57 low- and middle-income countries (LMICs) and time trends since 2000 for 44 selected countries.

METHODS

We included 57 eligible LMICs that had completed data on breastfeeding and complementary feeding in 2010-2018 from the Demographic and Health Surveys (DHS) for examining current feeding status. We further selected 44 LMICs that had two standard DHS surveys between 2000 and 2009 and 2010-2018 to examine time trends of feeding status. We calculated global, regional, and national weighted prevalence estimates and 95% confidence intervals (CIs) for five breastfeeding indicators and two complementary feeding indicators.

FINDINGS

In 57 LMICs during 2010-2018, global weighted prevalence was 51.9% for early initiation of breastfeeding, 45.7% for exclusive breastfeeding under 6 months, 32.0% for exclusive breastfeeding at 4-5 months, 83.1% for continued breastfeeding at 1 year, 56.2% for continued breastfeeding at 2 years, 14.9% for introduction of solid, semi-solid or soft foods under 6 months, and 63.1% for introduction of solid, semi-solid or soft foods at 6-8 months. Eastern Mediterranean (34.5%) and European regions (43.7%) (vs. South-East Asia/Western Pacific (55.2%)), and upper middle-income countries (38.4%) (vs. lower middle-income countries (47.4%)) had poorer performance of exclusive breastfeeding under 6 months. South-East Asia/Western Pacific regions (51.0%) (vs. other regions (68.3%-84.1%)) and low-income (66.4%) or lower middle-income countries (58.2%) (vs. upper middle-income countries (81.7%)) had lower prevalence of introduction of solid, semi-solid or soft foods at 6-8 months. In 44 selected LMICs from 2000 to 2009 to 2010-2018, total weighted prevalence presented an increase of 10.1% for exclusive breastfeeding under 6 months, but a 1.7% decrease for continued breastfeeding at 1 year. Over this period, the Eastern Mediterranean region had a 5.3% decrease of exclusive breastfeeding under 6 months, and the European region had a 2.0% increase for introduction of solid, semi-solid or soft foods under 6 months. The prevalence of introduction of solid, semi-solid or soft foods at 6-8 months decreased in South-East Asia/Western Pacific region by 15.2%, and in lower middle-income countries by 24.4%.

INTERPRETATION

Breastfeeding practices in LMICs have continued to improve in the past decade globally, but practices still lag behind the WHO feeding recommendations. Breastfeeding practices differed greatly across WHO regions, with the Eastern Mediterranean and European regions, and upper middle-income countries facing the greatest challenges in meeting targets. Continued efforts are needed to achieve the 2025 global breastfeeding target.

'[The pediatrician] said that maybe my milk, instead of doing good, no longer helped': the ecology of infant formula in rural communities in Central Mexico

OBJECTIVE

As Mexico continues to develop, an epidemiological and nutritional transition has led to an increase in infant formula use in its rural and indigenous communities. Our objective was to determine the social and cultural factors that influence the use of formula in such populations in Central Mexico.

DESIGN

Qualitative study using a data collection instrument based on the socio-ecological framework.

SETTING

Two rural and indigenous communities in Central Mexico.

PARTICIPANTS

Mothers, fathers, grandparents and healthcare providers.

RESULTS

Breast-feeding was favoured in both communities; however, several cultural traditions hindered exclusive breast-feeding. As these communities became more developed, emerging ideas of modernity led to negative connotations about breast-feeding and many mothers began to view formula as a complement for breast-feeding. Formula was seen as a convenient solution for breast pain, insufficient milk and body image. Healthcare providers promoted the use of formula through their own beliefs, information, communication and conflicts of interest with formula industry representatives. The recent social and economic changes in these communities combined with the increased advertising and availability of breast milk substitutes have facilitated the preference for formula.

CONCLUSIONS

Women in rural, indigenous communities in Central Mexico are increasingly using formula. Efforts at the policy and institutional levels are needed to protect mothers and their children from the detrimental consequences of unregulated formula promotion and the formula culture that it brings with it.

Lactation as a programming window for metabolic syndrome

The concept of developmental origins of health and disease (DOHaD) was initially supported by the low birth weight and higher risk of developing cardiovascular disease in adult life, caused by nutrition restriction during foetal development. However, other programming windows have been recognized in the last years, namely lactation, infancy, adolescence and even preconception. Although the concept has been developed in order to study the impact of foetal calorie restriction in adult life, it is now recognized that maternal overweight during programming windows is also harmful to the offspring. This article explores and summarizes the current knowledge about the impact of maternal obesity and obesogenic diets during lactation in the metabolic programming towards the development of metabolic syndrome in the adult life. The impact of maternal obesity and obesogenic diets in milk quality is discussed, including the alterations in specific micro and macronutrients, as well as the impact of such alterations in the development of metabolic syndrome-associated features in the newborn, such as insulin resistance and adiposity. Moreover, the impact of milk quality and formula feeding in infants' gut microbiota, immune system maturation and in the nutrient-sensing mechanisms, namely those related to gut hormones and leptin, are also discussed under the current knowledge.

The need to study human milk as a biological system

Critical advancement is needed in the study of human milk as a biological system that intersects and interacts with myriad internal (maternal biology) and external (diet, environment, infections) factors and its plethora of influences on the developing infant. Human-milk composition and its resulting biological function is more than the sum of its parts. Our failure to fully understand this biology in a large part contributes to why the duration of exclusive breastfeeding remains an unsettled science (if not policy). Our current understanding of human-milk composition and its individual components and their functions fails to fully recognize the importance of the chronobiology and systems biology of human milk in the context of milk synthesis, optimal timing and duration of feeding, and period of lactation. The overly simplistic, but common, approach to analyzing single, mostly nutritive components of human milk is insufficient to understand the contribution of either individual components or the matrix within which they exist to both maternal and child health. There is a need for a shift in the conceptual approach to studying human milk to improve strategies and interventions to support better lactation, breastfeeding, and the full range of infant feeding practices, particularly for women and infants living in undernourished and infectious environments. Recent technological advances have led to a rising movement towards advancing the science of human-milk biology. Herein, we describe the rationale and critical need for unveiling the multifunctionality of the various nutritional, nonnutritional, immune, and biological signaling pathways of the components in human milk that drive system development and maturation, growth, and development in the very early postnatal period of life. We provide a vision and conceptual framework for a research strategy and agenda to change the field of human-milk biology with implications for global policy, innovation, and interventions.

Complementary feeding of infants and young children 6 to 23 months of age

Complementary feeding, when foods are introduced to complement a milk-based diet, generally occurs between 6 and 23 months of age. It is a critical period for both physical and cognitive development. During this period, the growth rate of the brain is one of the fastest during the life span and, consequently, the timing, dose, and duration of exposure to specific nutrients can result in both positive and negative effects. Complementary feeding is more than ensuring an adequate intake of nutrients; it also is about avoiding excess intakes of calories, salt, sugars, and unhealthy fats. Meals are cultural and social events where young children observe, imitate, learn about foods to like or dislike, and form lifelong eating habits and practices. Meals are also when a child learns to touch foods and connect food tastes to how foods look and feel. Ideally, complementary feeding is responsive and promotes child autonomy, but it can also be used to manage behavior problems or overly indulge a child, resulting in long-term consequences for nutrition and health. Therefore, in addition to what a child is fed, attention to how a child is fed is also important. In this review, 12 topics relevant for updating global guidance on complementary feeding were identified: age of introduction of complementary foods; continued breastfeeding; responsive feeding; safe preparation and storage of complementary foods; food textures, flavors, and acceptance; energy and meal and snack frequency; fats, protein, and carbohydrates; dietary diversity; milks other than breast milk; fluid needs; unhealthy foods and beverages; and use of vitamin and mineral supplements or supplementary foods.

Breastfeeding rates are high in a prenatal community support program targeting vulnerable women and offering enhanced postnatal lactation support: a prospective cohort study

BACKGROUND

In Canada, 91% of all mothers initiate breastfeeding, but 40-50% stop by 6 months and only 34% breastfeed exclusively for 6 months, with lower rates among socially and/or economically vulnerable women. The Canada Prenatal Nutrition Program (CPNP) aims to support breastfeeding among vulnerable women, but there is no formal framework or funding for sites to integrate proactive postnatal breastfeeding support. This research aimed to i) describe infant feeding practices among clients of one Toronto CPNP site using charitable funds to offer a lactation support program (in-home lactation consultant visits, breast pumps); ii) determine whether breastfeeding outcomes at 6 months differ based on maternal sociodemographics and food insecurity; and iii) assess utilization of the lactation support program.

METHODS

Infant feeding practices were collected prospectively at 2 weeks, 2, 4 and 6 months postpartum via telephone questionnaires (n = 199). Maternal sociodemographics were collected at 2 weeks and food insecurity data at 6 months postpartum. Program monitoring records were used to determine utilization of the lactation support program.

RESULTS

Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump.

CONCLUSIONS

This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women. Study registered at clinicaltrials.gov as NCT03400605 .

The "weanling's dilemma" revisited: Evolving bodies of evidence and the problem of infant paleodietary interpretation

Breastfeeding is known to be a powerful mediator of maternal and childhood health, with impacts throughout the life course. Paleodietary studies of the past 30 years have accordingly taken an enduring interest in the health and diet of young children as a potential indicator of population fertility, subsistence, and mortality patterns. While progress has been made in recent decades toward acknowledging the agency of children, many paleodietary reconstructions have failed to incorporate developments in cognate disciplines revealing synergistic dynamics between maternal and offspring biology. Paleodietary interpretation has relied heavily on the "weanling's dilemma," in which infants are thought to face a bleak choice between loss of immunity or malnutrition. Using a review of immunological and epidemiological evidence for the dynamic and supportive role that breastfeeding plays throughout the complementary feeding period, this article offers context and nuance for understanding past feeding transitions. We suggest that future interpretative frameworks for infant paleodietary and bioarchaeological research should include a broad knowledge base that keeps pace with relevant developments outside of those disciplines.

Perceived insufficient milk among primiparous, fully breastfeeding women: Is infant crying important?

Breastfeeding mothers often report perceived insufficient milk (PIM) believing their infant is crying too much, which leads to introducing formula and the early abandonment of breastfeeding. We sought to determine if infant crying was associated with reported PIM (yes/no) and number of problems associated with lactation (lactation problem score [LPS] 6-point Likert scale) before formula introduction. Primiparous breastfeeding mothers were recruited at birth and visited at 1, 2 and 4 weeks. Among those fully breastfeeding at 1 week (N = 230), infant crying variables based on maternal reports were not associated with PIM at 1 week, but LPS was. However, a mother's expectation that her infant would cry more than other infants was associated with increased odds of reporting PIM at 2 and 4 weeks, as were delayed onset of lactation and previous LPS. At 1 week, crying variables (frequency, difficulty in soothing) were associated with LPS along with percent weight change. Delayed onset of lactation, infant care style, number of breastfeeds and previous LPS were longitudinally associated with change in LPS from 1 to 2 weeks and 2 to 4 weeks. Our data suggest that reported infant crying is associated with PIM and LPS in the first 4 weeks of life. Guidance on what to expect in crying behaviour and the impact of infant care style may be beneficial in reducing PIM and LPS in the first month.

Does cereal, protein and micronutrient availability hold the key to the malnutrition conundrum? An exploratory analysis of cereal cultivation and wasting patterns of India

Background: High prevalence of maternal malnutrition, low birth-weight and child malnutrition in India contribute substantially to the global malnutrition burden. Rural India has disproportionately higher levels of child malnutrition. Stunting and wasting are the primary determinants of child malnutrition and their district-level distribution shows clustering in different geographies and regions. Methods: The last round of National Family Health Survey (NFHS4) has disaggregated data by district, enabling a more nuanced understanding of the prevalence of markers of malnutrition. We used data from NFHS4 and agricultural statistics datasets to analyse relationship of area under cereal cultivation with the prevalence of malnutrition at the district level. We analysed malnutrition through data on under-5 stunting and wasting; maternal malnutrition was assessed through prevalence of women’s low BMI and short stature by district.  Results: Stunting and wasting patterns across districts show a distinct geographical and age distribution; districts with higher wasting showed relatively high prevalence of 40% before six months of age. Wasting was associated with higher cultivation of millets, with a stronger association seen for jowar and other millets (Kodo millet, little millet, proso millet, barnyard millet and foxtail millet). Stunting was associated with cultivation of all crops except other millets. Low women’s BMI was seen associated with cultivation of rice and millets. The analysis was limited by lack of fine-scale data on prevalence of low birth-weight and type of cereal consumed. Conclusions: Multi-site observational studies of long-term effects of type of cereals consumed could help explain the ecogeographic distribution of malnutrition in India. Cereals, particularly millets constitute the bulk of protein intake among the poor, especially in rural areas in India where high prevalence of  wasting persists.

Maternal Knowledge, Attitudes, and Practices of Complementary Feeding and Child Undernutrition in the Vakinankaratra Region of Madagascar: A Mixed-Methods Study

BACKGROUND

Data are limited on how feeding knowledge and practices relate to child undernutrition in the highlands of Madagascar.

OBJECTIVES

This study assessed maternal knowledge and practices of complementary feeding and their associations with anthropometrics of children aged 6-23 mo in the Vakinankaratra region of Madagascar.

METHODS

Knowledge was assessed using WHO recommendations on child feeding, and WHO infant and young child feeding (IYCF) indicators were used to evaluate feeding practices. Child growth was measured as length-for-age, weight-for-age, and weight-for-length z-scores using the 2006 WHO growth standards. A z-score less than -2 was classified as child undernutrition. Logistic regression models were used to determine associations between independent variables and outcomes. Focus group discussions among mothers and in-depth interviews with key informants were conducted; barriers and facilitators of optimal feeding practices were identified using a thematic analysis approach.

RESULTS

Maternal knowledge scores regarding child feeding averaged 6.4 of 11. Better knowledge scores were associated with higher odds of appropriate complementary feeding practices before and after covariate adjustments. The proportions of children achieving the minimum dietary diversity (35.8%), minimum acceptable diet (30.2%), and consuming meat, fish, and poultry (14.1%) were low. Only consumption of iron-rich foods was associated with lower odds of underweight (adjusted OR = 0.3; 95% CI: 0.1, 0.7; P < 0.05). None of the IYCF indicators were associated significantly with stunting or wasting. Maternal attitudes about complementary foods, as well as mothers' workload and very low income, were identified as barriers to optimal feeding practices. Maternal perceived benefits of giving appropriate complementary foods as well as their positive relationship with the community health workers were the main facilitators of optimal child feeding.

CONCLUSIONS

Integrated nutrition-sensitive interventions addressing these barriers while enhancing the facilitators are critical in promoting better feeding practices in the Vakinankaratra region.

Promoting Sustained and Exclusive Breastfeeding among Chinese American Pregnant Women

This study investigated prenatal goal setting and breastfeeding attitudes and intentions for 210 Chinese American pregnant women. In addition, this study assessed impact of person-centered versus factual messages on breastfeeding attitudes and intentions. While pregnant women reported receiving information about Baby-Friendly designated hospitals from healthcare providers, most received no breastfeeding information from those same providers. Although women had positive attitudes toward breastfeeding, they showed lack of knowledge about colostrum, general approval for using infant formula, as well as early introduction of complementary foods. By extension, these attitudes suggested they misunderstood the meaning of exclusive breastfeeding. No differences were observed based on parity, trimester of pregnancy, level of education or income. Person-centered and factual messages were judged as equally effective messages, but intention to breastfeed was more affected by the factual message. Reasons for this result are discussed. Healthcare providers are positioned to proactively engage in maternal preparedness for exclusive breastfeeding. These results suggested a missed opportunity for healthcare providers to communicate the value of sustained exclusive breastfeeding for the recommended first 6 months of an infant's life and underscore a need for all antenatal healthcare providers to collaboratively ensure that breastfeeding information is comprehensively provided throughout the span of antenatal care.

In-Hospital Formula Feeding and Breastfeeding Duration

BACKGROUND

In-hospital formula feeding (IHFF) of breastfed infants is associated with shorter duration of breastfeeding. Despite evidence-based guidelines on when IHFF is appropriate, many infants are given formula unnecessarily during the postpartum hospital stay. To account for selection bias inherent in observational data, in this study, we estimate liberal and conservative bounds for the association between hospital formula feeding and duration of breastfeeding.

METHODS

Infants enrolled in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children were selected. Breastfed infants given formula were matched with infants exclusively breastfed (n = 5310) by using propensity scoring methods to adjust for potential confounders. Cox regression of the matched sample was stratified on feeding status. A second, more conservative analysis (n = 4836) was adjusted for medical indications for supplementation.

RESULTS

Hazard ratios (HR) for weaning increased across time. In the first analysis, the HR across the first year was 6.1 (95% confidence interval [CI] 4.9-7.5), with HRs increasing with age (first month: HR = 4.1 [95% CI 3.5-4.7]; 1-6 months: HR = 8.2 [95% CI 5.6-12.1]; >6 months: HR = 14.6 [95% CI 8.9-24.0]). The second, more conservative analysis revealed that infants exposed to IHFF had 2.5 times the hazard of weaning compared with infants who were exclusively breastfed (HR = 2.5; 95% CI 1.9-3.4).

CONCLUSIONS

IHFF was associated with earlier weaning, with infants exposed to IHFF at 2.5 to 6 times higher risk in the first year than infants exclusively breastfed. Strategies to reduce IHFF include prenatal education, peer counseling, hospital staff and physician education, and skin-to-skin contact.

Does cereal, protein and micronutrient availability hold the key to the malnutrition conundrum? An exploratory analysis of cereal cultivation and wasting patterns of India

Background: High prevalence of maternal malnutrition, low birth-weight and child malnutrition in India contribute substantially to the global malnutrition burden. Rural India has disproportionately higher levels of child malnutrition. Stunting and wasting are the primary determinants of malnutrition and their district-level distribution shows clustering in different geographies and regions. Methods: The last round of National Family Health Survey (NFHS4) has disaggregated data by district, enabling a more nuanced understanding of the prevalence of markers of malnutrition. We used data from NFHS4 and agricultural statistics datasets to analyse relationship of cereal cultivation with the prevalence of child malnutrition. We studied the current science on growth-related nutrient-sensing pathways to explain this pattern.  Results: Stunting and wasting patterns across districts show a distinct geographical and age distribution; districts with higher wasting showed early prevalence of 40% at six months of age. Wasting was associated with higher cultivation of millets, with a stronger association seen for jowar and other millets. Low maternal BMI in districts with higher wasting could be linked to the consumption of millets as staple. We conceptualised a hypothetical schematic pathway linking early origin of wasting in children with millet-based diet, driven by inhibition of critical intra-cellular pathways controlling growth covering pre-natal, post-natal and early childhood. The analysis was limited by lack of fine-scale data on prevalence of low birth-weight and type of cereal consumed. Conclusions: Multi-site observational studies of long-term effects of type of cereals consumed could help explain the ecogeographic distribution of malnutrition in India. Cereals, particularly millets constitute the bulk of protein intake among the poor, especially in rural areas in India where wasting persists. Policies and programs targeting malnutrition need to address type of cereal consumed in order to impact childhood malnutrition in parts of India where subsistence cultivation of millets for staple consumption is prevalent.

Predictors of Food Sensitization in Children and Adults Across Europe

BACKGROUND

The geographical variation and temporal increase in the prevalence of food sensitization (FS) suggest environmental influences.

OBJECTIVE

To investigate how environment, infant diet, and demographic characteristics, are associated with FS in children and adults, focusing on early-life exposures.

METHODS

Data on childhood and adult environmental exposures (including, among others, sibship size, day care, pets, farm environment, and smoking), infant diet (including breast-feeding and timing of introduction to infant formula and solids), and demographic characteristics were collected from 2196 school-age children and 2185 adults completing an extensive questionnaire and blood sampling in the cross-sectional pan-European EuroPrevall project. Multivariable logistic regression was applied to determine associations between the predictor variables and sensitization to foods commonly implicated in food allergy (specific IgE ≥0.35 kU_A/L). Secondary outcomes were inhalant sensitization and primary (non-cross-reactive) FS.

RESULTS

Dog ownership in early childhood was inversely associated with childhood FS (odds ratio, 0.65; 95% CI, 0.48-0.90), as was higher gestational age at delivery (odds ratio, 0.93 [95% CI, 0.87-0.99] per week increase in age). Lower age and male sex were associated with a higher prevalence of adult FS (odds ratio, 0.97 [95% CI, 0.96-0.98] per year increase in age, and 1.39 [95% CI, 1.12-1.71] for male sex). No statistically significant associations were found between other evaluated environmental determinants and childhood or adult FS, nor between infant diet and childhood FS, although early introduction of solids did show a trend toward prevention of FS.

CONCLUSIONS

Dog ownership seems to protect against childhood FS, but independent effects of other currently conceived environmental and infant dietary determinants on FS in childhood or adulthood could not be confirmed.

A detailed exploration of early infant milk feeding in a prospective birth cohort study in Ireland: combination feeding of breast milk and infant formula and early breast-feeding cessation

Breast-feeding initiation and continuation rates in the UK and Ireland are low relative to many European countries. As a core outcome of the prospective Cork Nutrition and Development Maternal-Infant Cohort (COMBINE) study (Cork, Ireland), we aimed to describe infant milk feeding practices in detail and examine the prevalence and impact of combination feeding of breast milk and infant formula on breast-feeding duration. COMBINE recruited 456 nulliparous mothers (2015-2017) for maternal-infant follow-up via interview at hospital discharge (median 3 (interquartile range (IQR) 2, 4) d (n 453)), 1 (n 418), 2 (n 392), 4 (n 366), 6 (n 362) and 9 (n 345) months of age. Median maternal age was 32 (IQR 29, 34) years, 97 % of mothers were of white ethnicity, 79 % were Irish-born and 75 % were college-educated. Overall, 75 % breastfed to any extent at discharge and 44 % breastfed solely. At 1, 2, 4, 6 and 9 months, respectively, 40, 36, 33, 24 and 19 % breastfed solely. Combination feeding of breast milk and infant formula was common at discharge (31 %) and 1 month (20 %). Reasons for combination feeding at 1 month included perceived/actual hunger (30 %), healthcare professional advice (31 %) and breast-feeding difficulties (13 %). Of mothers who breastfed to any extent at discharge, 45 % stopped within 4 months. Mothers who combination fed were more likely to cease breast-feeding than those who breastfed solely (relative risk 2·3 by 1 month and 12·0 by 2 months). These granular data provide valuable insight to early milk feeding practices and indicate that supporting early breast-feeding without formula use may be key to the successful continuation of breast-feeding.

Breastfeeding Initiation, Duration, and Supplementation Among Mexican-Origin Women in Texas

BACKGROUND

Mexican-origin women breastfeed at similar rates as white women in the United States, yet they usually breastfeed for less time. In our study, we seek to identify differences in Mexican-origin women's breastfeeding intentions, initiation, continuation, and supplementation across nativity and country-of-education groups.

METHODS

The data are from a prospective cohort study of postpartum women ages 18 to 44 recruited from 8 Texas hospitals. We included 1235 Mexican-origin women who were born and educated in either Texas or Mexico. Women were interviewed at delivery and at 3, 6, 12, 18, and 24 months post partum. Breastfeeding intentions and initiation were reported at baseline, continuation was collected at each interview, and weeks until supplementation was assessed for both solids and formula. Women were classified into 3 categories: born and educated in Mexico, born and educated in the United States, and born in Mexico and educated in the United States.

RESULTS

Breastfeeding initiation and continuation varied by nativity and country of birth, although all women reported similar breastfeeding intentions. Women born and educated in Mexico initiated and continued breastfeeding in higher proportions than women born and educated in the United States. Mexican-born and US-educated women formed an intermediate group. Early supplementation with formula and solid foods was similar across groups, and early supplementation with formula negatively impacted duration across all groups.

CONCLUSIONS

Nativity and country of education are important predictors of breastfeeding and should be assessed in pediatric and postpartum settings to tailor breastfeeding support. Support is especially warranted among US-born women, and additional educational interventions should be developed to forestall early supplementation with formula across all acculturation groups.

Infant Formula Consumption Is Positively Correlated with Wealth, Within and Between Countries: A Multi-Country Study

BACKGROUND

In contrast with the ample literature on within- and between-country inequalities in breastfeeding practices, there are no multi-country analyses of socioeconomic disparities in breastmilk substitute (BMS) consumption in low- and middle-income countries (LMICs).

OBJECTIVE

This study aimed to investigate between- and within-country socioeconomic inequalities in breastfeeding and BMS consumption in LMICs.

METHODS

We examined data from the Demographic Health Surveys and Multiple Indicator Cluster Surveys conducted in 90 LMICs since 2010 to calculate Pearson correlation coefficients between infant feeding indicators and per capita gross domestic product (GDP). Within-country inequalities in exclusive breastfeeding, intake of formula or other types of nonhuman milk (cow/goat) were studied for infants aged 0-5 mo, and for continued breastfeeding at ages 12-15 mo through graphical presentation of coverage wealth quintiles.

RESULTS

Between-country analyses showed that log GDP was inversely correlated with exclusive (r = -0.37, P < 0.001) and continued breastfeeding (r = -0.74, P < 0.0001), and was positively correlated with formula intake (r = 0.70, P < 0.0001). Continued breastfeeding was inversely correlated with formula (r = -0.79, P < 0.0001), and was less strongly correlated with the intake of other types of nonhuman milk (r = -0.40, P < 0.001). Within-country analyses showed that 69 out of 89 did not have significant disparities in exclusive breastfeeding. Continued breastfeeding was significantly higher in children belonging to the poorest 20% of households compared with the wealthiest 20% in 40 countries (by ∼30 percentage points on average), whereas formula feeding was more common in the wealthiest group in 59 countries.

CONCLUSIONS

BMS intake is positively associated with GDP and negatively associated with continued breastfeeding in LMICs. In most countries, BMS intake is positively associated with family wealth, and will likely become more widespread as countries develop. Urgent action is needed to protect, promote, and support breastfeeding in all income groups and to reduce the intake of BMS, in light of the hazards associated with their use.

Human Milk Oligosaccharide Profile Variation Throughout Postpartum in Healthy Women in a Brazilian Cohort

Human milk oligosaccharide (HMO) composition varies throughout lactation and can be influenced by maternal characteristics. This study describes HMO variation up to three months postpartum and explores the influences of maternal sociodemographic and anthropometric characteristics in a Brazilian prospective cohort. We followed 101 subjects from 28–35 gestational weeks (baseline) and throughout lactation at 2–8 (visit 1), 28–50 (visit 2) and 88–119 days postpartum (visit 3). Milk samples were collected at visits 1, 2 and 3, and 19 HMOs were quantified usinghigh-performance liquid chromatography with fluorescence detection (HPLC-FL). Friedman post-hoc test, Spearman rank correlation for maternal characteristics and HMOs and non-negative matrix factorization (NMF) were used to define the HMO profile. Most women were secretors (89.1%) and presented high proportion of 2′-fucosyllactose (2′FL) at all three sample times, while lacto-N-tetraose (LNT, 2–8 days) and lacto-N-fucopentaose II (LNFPII, 28–50 and 88–119 days) were the most abundant HMOs in non-secretor women. Over the course of lactation, total HMO weight concentrations (g/L) decreased, but total HMO molar concentrations (mmol/L) increased, highlighting differential changes in HMO composition over time. In addition, maternal pre-pregnancy body mass index (BMI) and parity influence the HMO composition in healthy women in this Brazilian cohort.

A qualitative analysis of text message conversations in a breastfeeding peer counselling intervention

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) breastfeeding peer counselling (BFPC) program supports optimal early life nutrition by providing evidenced‐based breastfeeding protection, promotion, and support. The Lactation Advice Through Texting Can Help (LATCH) study was a randomized controlled trial that tested the effectiveness of a text messaging intervention designed to augment the BFPC program. The purpose of the present study was to understand the topics discussed during the text message exchanges between breastfeeding peer counsellors (PCs) and their clients in the intervention arm of the LATCH study, from the time of enrollment up to two‐weeks postpartum. Text messaging data were first coded and analysed for one‐ and two‐way text message exchanges. Text messages of participants with a high volume of two‐way exchanges were then analysed qualitatively. Four domains were identified in both the prenatal and postpartum periods: the mechanics of breastfeeding, social support, baby's nutrition, and PCs maintaining contact with participants. Additional themes and subthemes identified in the postpartum period included the discussion of breastfeeding problems such as latching trouble engorgement, plugged ducts, pumping, other breastfeeding complications, and resuming breastfeeding if stopped. Two‐way text messaging in the context of the WIC BFPC program provides an immediate and effective method of substantive communication between mothers and their PC.

Strengthening counseling on barriers to exclusive breastfeeding through use of job aids in Nampula, Mozambique

Introduction

While the Government of Mozambique has galvanized action around exclusive breastfeeding (EBF) as a national priority, only 43% of Mozambican children under six months of age are exclusively breastfed. In the absence of skilled lactation support, challenges mothers experience with breastfeeding may inhibit initiation, exclusivity and duration. There is insufficient evidence on how to strengthen health providers’ competencies to address breastfeeding challenges in low- and middle-income countries. The objectives of this study were to 1) assess EBF challenges, from the perspectives of health providers and mothers; 2) ascertain the quality of health provider counseling to address EBF challenges; and 3) gain an understanding of the usefulness of job aids to improve counseling within routine health contact points in Nampula, Mozambique.

Methods

This implementation science study was conducted in Meconta and Mogovolas districts, Nampula province, Mozambique from July-November 2018. In Phase 1, 46 in-depth interviews with mothers and providers, and 11 observations of counseling sessions were conducted. In Phase 2, health providers were trained to use three job aids (i.e., facility, community or maternity contacts) to identify and address EBF problems during routine health services. In Phase 3, 30 in-depth interviews with mothers and providers were conducted to assess the experience with job aid use. In both Phase 1 and 3, we conducted a thematic analysis using a grounded theory approach involving a step-wise coding process.

Results

Poor latch and positioning, perceived insufficient breastmilk and breast engorgement emerged as barriers to EBF. Providers often lacked the knowledge, skillset, and self-efficacy to manage EBF problems, with little counseling provided at community or facility levels. Following job aid rollout, providers reported improved assessment of breastfeeding technique, and increased self-efficacy and motivation to identify and resolve EBF problems.

Conclusions

Integration of job aids, with clear lactation management guidance, into maternal and child health training curricula and supportive supervision is critical to building providers’ skillsets and competencies to provide quality lactation counseling and support.

Breastfeeding in the 21st century: How we can make it work

There is abundant knowledge on the major health and social benefits of breastfeeding, and on how to protect, promote, and support breastfeeding. Hence, it is surprising that recommended breastfeeding behaviors continue to be suboptimal in the 21st Century among large segments of the population, globally. Moving forward, it is crucial to enable the breastfeeding environments for women through family friendly employment policies and to enforce the WHO Code for Marketing of Breastmilk Substitutes. It is also key to invest more in training the workforce for successful large-scale implementation and sustainability of the Baby Friendly Hospital Initiative, community-based breastfeeding counseling, and to prevent conflicts of interests with infant formula companies. Behavior change social marketing interventions that include social media need to be designed following social network science and behavioral economics principles. Evidence-informed policy tools are now available to help policy makers invest in and guide the scaling-up of cost-effective breastfeeding programs.