Breast-milk substitutes: a new old-threat for breastfeeding policy in developing countries. A case study in a traditionally high breastfeeding country

Socioeconomic determinants and inequalities in exclusive breastfeeding among children in Peru

Introduction

Although Latin America and the Caribbean have one of the highest prevalences of exclusive breastfeeding (EBF), the countries in this region have socioeconomic determinants that influence the frequency of this practice and do not allow achieving the 70% target recommended by the World Health Organization. Therefore, the objective of the study was to examine the socioeconomic determinants and perform a decomposition analysis of socioeconomic inequalities in EBF in Peruvian children 6 to 59 months of age.

Methods

A cross-sectional study was carried out using the 2021 Demographic and Family Health Survey. The dependent variable for the study was EBF up to 6 months of age and the wealth index variable was used to perform the inequality analysis. Poisson log generalized linear regression models were fitted to evaluate the association between EBF and the independent variables, and concentration curves and Erreygers concentration index decomposition were used to analyze inequalities in EBF.

Results

A total of 9926 surveyed participants were included. The prevalence of EBF was 70.5% (95% confidence interval: 69.2-71.8). Women who were married, self-identified as native, received EBF training, resided in the highlands and jungle, and their child was the second or older showed a higher likelihood of EBF. In the inequality analysis, EBF was concentrated among the poorest mothers and the major contributors were residing in the highlands and jungle and belonging to the middle and wealthy quintiles.

Discussion

Our findings suggest that the main strategies to encourage the practice of EBF should be focused on all mothers regardless of their socioeconomic status in order to reduce the EBF gap between richer and poorer women.

[Knowledge of breastfeeding among mothers before maternity discharge]

OBJECTIVES

The aim of our study was to assess the knowledge of parturients about breastfeeding and to analyze the factors influencing this level of knowledge.

METHODS

It was a prospective, descriptive and analytical, cross-sectional study carried out over a period of six months including 500 parturients who gave birth at the maternity unit of the National Center for Maternity and Neonatalogy of Tunis during the period from July to December 2020. Sociodemographic, obstetrical and breastfeeding related data were collected through individual interviews carried out before leaving the postpartum service using a questionnaire written in Tunisian dialectal Arabic.

RESULTS

The average age of the mothers was 31.5 years. Housewives accounted for 73.3 % of cases. Forty-four percent of the women surveyed were first-time mothers. The main source of information was relatives (74.8 %). The prevalence of breastfeeding was 93.8 %. Knowledge about breasfeeding was insufficient in 76.4 % of cases. The level of knowledge was insufficient in particular regarding signs of effective breastfeeding, signs of awakening of the newborn, lactogenesis, and diet of breastfeeding women. Unemployment of the parturient age over 30 and primiparity negatively influenced the knowledge of parturients.

CONCLUSION

The level of knowledge of parturients was heterogeneous but generally insufficient. Health education programs on MA targeting subjects most at risk of insufficient knowledge should be put in place in order to improve the knowledge base and hopefully improve the breastfeeding rates.

The Attitudes of Polish Women towards Breastfeeding Based on the Iowa Infant Feeding Attitude Scale (IIFAS)

Background: The Iowa Infant Feeding Attitude Scale (IIFAS), which is used for the assessment of attitudes towards breastfeeding, has been found to be reliable and valid in a number of countries, but has not yet been psychometrically tested in Polish women. The purpose of the study was to report on the cultural adaptation of the IIFAS to Polish settings and on its validation, to evaluate the breastfeeding attitudes in Polish women who recently gave birth, and to identify the determinants of these attitudes. Methods: The study was performed in a group of 401 women in their first postpartum days. Results: Cronbach’s α for the scale was 0.725. Discriminative power coefficients of all questionnaire items were higher than 0.2. Subscales were strongly correlated with the total score, with a correlation coefficient of 0.803 for the “favorable toward breastfeeding” subscale (p < 0.001), and 0.803 for the “favorable toward formula feeding” subscale (p < 0.05). For the item “A mother who occasionally drinks alcohol should not breastfeed her baby”, the factor loading did not reach the criterion value, and so the item was not included in further analyses. The mean IIFAS score was 63.12 (±7.34). Conclusions: The Polish version of the IIFAS is a reliable and appropriate measure of women’s attitudes towards infant feeding in Polish settings, with acceptable psychometric properties and construct validity.

Mothers' and health workers' exposure to breastmilk substitutes promotions in Abidjan, Côte d'Ivoire

Marketing of breastmilk substitutes (BMS) continues to undermine breastfeeding globally, and low income countries experiencing rapid economic growth are especially vulnerable as expanding BMS markets. The objective of the study was to understand the prevalence of exposure to BMS promotions among mothers of children 0-23 months, the frequency and type of contacts between BMS companies and health workers and the presence of educational/informational materials and branded equipment associated with such companies in health facilities in Abidjan using the World Health Organization's NetCode protocol. The methods included structured interviews with health workers and mothers and observations of equipment/materials in a sample of 42 facilities, 330 mothers and 129 health workers. Descriptive statistics were produced, and chi-squared tests were used to assess differences by child age and facility type. Forty-three per cent of mothers were advised to feed BMS products in the past 6 months, with a significantly higher percentage of mothers of older children (6-23 months) advised compared to infants 0-5 months. Two thirds (66%) of mothers had seen promotions outside of facilities. Among health workers, 63% were contacted by BMS companies, and only 8% were familiar with the International Code of Marketing of BMS. Differences were found between public/private facilities in the types of requests BMS companies made to health workers. Strong actions are needed in Côte d'Ivoire to prevent BMS promotion in the health system, including increasing health workers' knowledge of the International Code and national regulations, monitoring violations and reaching mothers and families to promote optimal breastfeeding practices.

Evaluation of a community-based mobile video breastfeeding intervention in Khayelitsha, South Africa: The Philani MOVIE cluster-randomized controlled trial

BACKGROUND

In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs ("mentor mothers").

METHODS AND FINDINGS

We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants' median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers' time use and eliciting their subjective experiences through in-depth interviews. At both points of follow-up, we observed no statistically significant differences between the video intervention and the control arm with regard to EBF rates and other infant feeding practices [EBF in the last 24 hours at 1 month: RR 0.93 (95% CI 0.86 to 1.01, P = 0.091); EBF in the last 24 hours at 5 months: RR 0.90 (95% CI 0.77 to 1.04, P = 0.152)]. We observed a small, but significant improvement in maternal knowledge at the 1-month follow-up, but not at the 5-month follow-up. The interpretation of the results from this causal impact evaluation changes when we consider the results of the nested mixed-methods performance evaluation. The mean time spent per home visit was similar across study arms, but the intervention group spent approximately 40% of their visit time viewing videos. The absence of difference in effects on primary and secondary endpoints implies that, for the same time investment, the video intervention was as effective as face-to-face counseling with a mentor mother. The videos were also highly valued by mentor mothers and participants. Study limitations include a high loss to follow-up at 5 months after premature termination of the trial due to the COVID-19 pandemic and changes in mentor mother service demarcations.

CONCLUSIONS

This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs' direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services.

TRIAL REGISTRATION

The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27, 2018.

'[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.

Determinants of Exclusive Breastfeeding of Infants under Six Months among Cambodian Mothers

Introduction

Practicing exclusive breastfeeding (EBF) in an infant's first six months of life is recommended by the World Health Organization because of its proven effectiveness as a method to support the infant's short- and long-term physical and cognitive development. However, many countries, including Cambodia, face contextually driven challenges in meeting this optimum standard of breastfeeding. The recent declining EBF rate in Cambodia is a concerning indicator of the impact of these challenges.

Methods

We used existing data from the 2014 Cambodian Demographic and Health Survey (CDHS) to analyze 717 Cambodian mother-infant pairs. CDHS 2014 used a two-stage stratified cluster sampling approach to select samples. A multivariable logistic regression analysis was used to assess determinants of EBF, taking into account the sampling weight in the analysis. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were calculated, and significance level was considered at p value < 0.05.

Results

Our findings indicate that among mothers with infants under six months, EBF was more likely if they resided rurally (AOR = 2.28; 95% CI 1.23-4.23) and if they delivered at a public hospital (AOR = 2.64; 95% CI 1.28-5.47). On the other hand, mothers of middle wealth index practiced EBF less than mothers of low wealth index (AOR = 0.58; 95% CI 0.34-0.99). And as expected, our analysis confirmed that the older the infants grew, the less likely they were to be exclusively breastfed than those younger than one month old (2-3 months: AOR = 0.49; 95% CI 0.26-0.92; 4-5 months: AOR = 0.25; 95% CI 0.15-0.43).

Conclusion

The findings emphasize the need to address these determinants adequately by appropriate interventions to halt the declining trend of EBF practice. We recommend a multifaceted approach to improve EBF rates in Cambodia. Advocacy around EBF at public hospitals should continue, and private hospital staff should receive training to provide EBF counselling and support to mothers.

Determinants of exclusive breastfeeding practice in Bangladesh: Evidence from nationally representative survey data

BACKGROUND

Exclusive breastfeeding (EBF) means that an infant should be breastfed only for the first six months of life to achieve optimal child development and to prevent infant morbidity and mortality. The aim of this analysis was to determine the individual-, household-, and community-level factors associated with EBF practice in Bangladesh.

METHODS

A total of 1,440 women-child pairs data were analysed extracted from 2011 and 2014 Bangladesh Demographic and Health Survey. Multilevel logistic regression models were used separately for individual-, household-, and community level factors to identify the different level of factors associated with EBF practice.

RESULTS

Around 61% women in Bangladesh practiced EBF with significant variation across several individual-, household-, and community-level factors. At the individual level, higher odds of EBF practice was found among mothers' received higher number of antenatal care and lower age of child. Mothers' higher education and engagement in formal jobs were found negatively associated with EBF practice. At the community level, higher odds of EBF was found among women live in Barishal, Dhaka, and Rajshahi divisions, and resided in the community with moderate level of female education, higher level of fertility, and higher use of antenatal and delivery care.

CONCLUSIONS

One in every three children in Bangladesh do not breastfeed exclusively which needs special attention for the policymakers. In this case, educated women engaged in income generating activities and women did not use antenatal care should be given priority. At the community level, priority should be given for the women's resides in the community with lower level of antenatal and delivery healthcare services use.

Marketing of breast-milk substitutes in Zambia: evaluation of compliance to the international regulatory code

Background

We sought to assess the level of non-compliance with the International Code of Marketing breast-milk substitutes (BMS) and/or Statutory Instrument (SI) Number 48 of 2006 of the Laws of Zambia in two suburbs, Kalingalinga and Chelstone, in Zambia.

Methods

This was a cross sectional survey. Shop owners (80), health workers (8) and mothers (214) were interviewed. BMS labels and advertisements (62) were observed. The primary outcome was mean non-compliance defined as the number of article violations divided by the total 'obtainable' violations. The score ranges from 0 to 1 with 0 representing no violations in all the articles and one representing violations in all the articles.

Results

A total of 62 BMS were assessed. The mean non-compliance score by manufacturers in terms of violations in labelling of BMS was 0.33 (SD = 0.28; 95% CI: 0.26, 0.40). These violations were mainly due to labels containing pictures or graphics representing an infant. 80 shops were also assessed with mean non-compliance score in respect of violations in tie-in-sales, special display, and contact with mothers at the shop estimated as 0.14 (SD = 0.14; 95% CI: 0.11, 0.18).

Conclusions

Non-compliance with the Code and/or the local SI is high after 10 years of domesticating the Code.

The Philani MOVIE study: a cluster-randomized controlled trial of a mobile video entertainment-education intervention to promote exclusive breastfeeding in South Africa

Background

In South Africa, rates of exclusive breastfeeding remain low and breastfeeding promotion is a national health priority. Mobile health and narrative entertainment-education are recognized strategies for health promotion. In-home counseling by community health workers (CHWs) is a proven breastfeeding promotion strategy. This protocol outlines a cluster-randomized controlled trial with a nested mixed-methods evaluation of the MObile Video Intervention for Exclusive breastfeeding (MOVIE) program. The evaluation will quantify the causal effect of the MOVIE program and generate a detailed understanding of the context in which the intervention took place and the mechanisms through which it enacted change. Findings from the study will inform the anticipated scale-up of mobile video health interventions in South Africa and the wider sub-Saharan region.

Methods

We will conduct a stratified cluster-randomized controlled trial in urban communities of the Western Cape, to measure the effect of the MOVIE intervention on exclusive breastfeeding and other infant feeding practices. Eighty-four mentor-mothers (CHWs employed by the Philani Maternal Child Health and Nutrition Trust) will be randomized 1:1 into intervention and control arms, stratified by neighborhood type. Mentor-mothers in the control arm will provide standard of care (SoC) perinatal in-home counseling. Mentor-mothers in the intervention arm will provide SoC plus the MOVIE intervention. At least 1008 pregnant participants will be enrolled in the study and mother-child pairs will be followed until 5 months post-delivery. The primary outcomes of the study are exclusive breastfeeding at 1 and 5 months of age. Secondary outcomes are other infant feeding practices and maternal knowledge. In order to capture human-centered underpinnings of the intervention, we will conduct interviews with stakeholders engaged in the intervention design. To contextualize quantitative findings and understand the mechanisms through which the intervention enacted change, end-line focus groups with mentor-mothers will be conducted.

Discussion

This trial will be among the first to explore a video-based, entertainment-education intervention delivered by CHWs and created using a community-based, human-centered design approach. As such, it could inform health policy, with regards to both the routine adoption of this intervention and, more broadly, the development of other entertainment-education interventions for health promotion in under-resourced settings.

Trial Registration

The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27th, 2018.

Association of age and colostrum discarding with breast-feeding practice in Ethiopia: systematic review and meta-analyses

OBJECTIVE

To investigate whether maternal/caregiver's age, infant age (0-6 months) and discarding colostrum affects timely initiation of breast-feeding (TIBF) and exclusive breast-feeding (EBF) in Ethiopia.

DESIGN

A systematic search of PubMed, SCOPUS, EMBASE, CINHAL, Web of Science and WHO Global Health Library electronic databases was done for all articles published in English from 2000 to January 2018. Two reviewers independently screened, extracted and graded the quality of studies using Newcastle-Ottawa Scale. A weighted inverse-variance random-effects model meta-analysis, cumulative meta-analysis and mixed-effects meta-regression analysis were done.

SETTING

All observational studies conducted in Ethiopia.ParticipantsMothers of children aged less than 2 years.ResultA total of forty articles (fourteen studies on TIBF and twenty-six on EBF) were included. TIBF was associated with colostrum discarding (OR=0·38; 95 % CI 0·21, 0·68) but not with maternal/caregiver's age (OR=0·98; 95 % CI 0·83, 1·15). In addition, colostrum discarding (OR=0·53; 95 % CI 0·36, 0·78) and infant age (OR=1·77; 95 % CI 1·38, 2·27) were significantly associated with EBF but not maternal/caregiver's age (OR=1·09; 95 % CI 0·84, 1·41).

CONCLUSIONS

There was no association between maternal/caregiver's age and breast-feeding practice (EBF and TIBF). Colostrum discarding was associated with both EBF and TIBF. This evidence could be helpful to counsel all mothers of reproductive age and who discard colostrum.

ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Breastfeeding rates and barriers: a report from the state of Qatar

Objective

The aim of the study was to outline breastfeeding barriers faced by women residing in the State of Qatar.

Methods

A cross-sectional study through a telephone interview was conducted at Hamad Medical Corporation, the only tertiary care and accredited academic institution in the State of Qatar. Mothers of children born between the period of January 1, 2012 and December 31, 2012 in the State of Qatar were contacted.

Results

Of the total 840 mothers who were contacted for the telephone survey, 453 mothers agreed to be interviewed (response rate 53.9%), while 364 (43.3%) did not answer the phone, and 21 (2.5%) answered the phone but refused to participate in the study. The overall breastfeeding initiation rate among the mothers was 96.2%, with 3.8% mothers reporting that they had never breastfed their baby. The percentage of mothers who exclusively breastfed their children in the first 6 months was 24.3%. The most common barriers to breastfeeding as perceived by our participants were the following: perception of lack of sufficient breast milk after delivery (44%), formula is easy to use and more available soon after birth (17.8%), mom had to return to work (16.3%), lack of adequate knowledge about breastfeeding (6.5%), and the concept that the infant did not tolerate breast milk (4.9%).

Conclusion

Exclusive breastfeeding barriers as perceived by women residing in the State of Qatar, a wealthy rapidly developing country, do not differ much from those in other nations. What varies are the tremendous medical resources and the easy and comfortable access to health care in our community. We plan to implement a nationwide campaign to establish a prenatal breastfeeding counseling visit for all expecting mothers.

The impact of maternal socio-demographic characteristics on breastfeeding knowledge and practices: An experience from Casablanca, Morocco

Background

Breastfeeding is universally recognized by the World Health Organization as the best way of feeding infants. Therefore, several countries have initiated health promotion interventions to support successful breastfeeding based on the factors influencing breastfeeding outcomes.

Objective

To examine the association between the knowledge of breastfeeding and maternal socioeconomic and demographic characteristics, and to determine any impact on child nutritional status.

Methods

A cross-sectional study using both qualitative and quantitative methods was conducted with mothers of infants aged six- to twenty-four months. Data was collected by a semi-structured questionnaire and face-to-face, in-depth interviews with mothers to get an insight into their breastfeeding perceptions and experiences. Educational achievement and occupational class were used as indicators of socio-demographic status. Nutritional status was assessed by anthropometric measurements.

Results

A significant relationship between exclusive breastfeeding and the mother's education (P < .001) and socio-economic status (P < .001) has been highlighted. A significant link was pointed out between breastfeeding and length-for-age Z score (LAZ) (P < .001), and weight-for-age Z score (WAZ) (P = .005). Moreover, a strong association was found between maternal employment and exclusive breastfeeding (P < .001).

Conclusions

Our findings shed some light on challenges faced by mothers, as well as an association between socio-demographic characteristics and practices for facilitating exclusive breastfeeding to guide the mothers in breastfeeding management.

Interventions Designed to Promote Exclusive Breastfeeding in High-Income Countries: A Systematic Review Update

BACKGROUND

Worldwide, women seldom reach the recommended target of exclusive breastfeeding up to 6 months postpartum. The aim of the current study was to update a previously published review that presented a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding up to 6 months in high-income countries.

MATERIALS AND METHODS

A systematic search of leading databases was conducted for scholarly, peer-reviewed, randomized controlled trials published from June 2013 to December 2016. Twelve new articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence in regard to duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A significant increase in the duration of exclusive breastfeeding was found in 4 of the 12 studies. All four successful interventions had long-duration postpartum programs, implemented by telephone, text message, or through a website. Some of the successful interventions also included prenatal education or in-hospital breastfeeding support.

CONCLUSIONS

Results from this review update correspond closely with previous findings, in that all of the successful interventions had lengthy postnatal support or an education component. More studies assessed intervention fidelity than in the previous review; however, there was little discussion of maternal body-mass index. While a pattern of successful interventions is beginning to emerge, further research is needed to provide a robust evidence base to inform future interventions, particularly with overweight and obese women.

Exclusive breastfeeding practices among mothers in urban slum settlements: pooled analysis from three prospective birth cohort studies in South India

BACKGROUND

The World Health Organization (WHO) recommends six months of exclusive breastfeeding. Despite documented health, social and economic benefits, the practice of exclusive breastfeeding is quite low and information on influencing factors is limited especially from slum settlements. Our goal is to assess the prevalence and evaluate factors associated with early cessation of exclusive breastfeeding in the first six months of life among mothers in urban slums of Vellore, Southern India.

METHODS

We pooled data from three similar birth cohort studies (n = 1088) conducted between 2002 and 2009. Breastfeeding information was obtained soon after birth and then from follow-up home visits conducted once every two weeks by the field workers. Multivariable Cox regression analyses were used to assess factors associated with early cessation of exclusive breastfeeding.

RESULTS

The prevalence of exclusive breastfeeding for the first six months was 11.4%, based on prospective data since birth. Results from multivariable analyses revealed maternal education (Adjusted Hazard Ratio [AHR] 1.18 , 95% CI 1.03, 1.35), pucca type of house (AHR 1.25 , 95% CI 1.10, 1.43), two or more number of children in the family (AHR 1.26 , 95% CI 1.10, 1.43), joint family structure (AHR 1.20 , 95% CI 1.02, 1.40) and birth during summer (AHR 1.16, 95% CI 1.01, 1.31) were associated with early cessation of exclusive breastfeeding in the first six months.

CONCLUSIONS

Our results indicate that exclusive breastfeeding rates are well below the recommended levels. Educational interventions providing comprehensive breastfeeding information to mothers and their families can be evaluated to assess its effect on improving infant feeding practices.

Selection of complementary foods based on optimal nutritional values

Human milk is beneficial for growth and development of infants. Several factors result in mothers ceasing breastfeeding which leads to introduction of breast-milk substitutes (BMS). In some communities traditional foods are given as BMS, in others they are given as complementary foods during weaning. Improper food selection at this stage is associated with a high prevalence of malnutrition in children under 5 years. Here we listed the traditional foods from four continents and compared them with human milk based on their dietary contents. Vitamins such as thiamine (~[2-10] folds), riboflavin (~[4-10] folds) and ascorbic acid (<2 folds) contents of Asian and African foods were markedly lower. In order to extend the search for foods that includes similar dietary constituents as human milk, we designed a strategy of screening 8654 foods. 12 foods were identified and these foods were evaluated for their ability to meet the daily nutritional requirement of breastfed and non-breastfed infants during their first year of life. Genome-scale models of infant's hepatocytes, adipocytes and myocytes were then used to simulate in vitro growth of tissues when subjected to these foods. Key findings were that pork ham cured, fish pudding, and egg lean white induced better tissue growth, and quark with fruit, cheese quarg 45% and cheese cream 60% had similar lactose content as human milk.

Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned?

Exclusive breastfeeding, one of the best natural resources, needs protection and promotion. The International Code of Marketing of Breast-milk Substitutes (the Code), which aims to prevent the undermining of breastfeeding by formula advertising, faces implementation challenges. We reviewed frequently overlooked challenges and obstacles that the Code is facing worldwide, but particularly in Southeast Asia. Drawing lessons from various countries where we work, and following the example of successful public health interventions, we discussed legislation, enforcement, and experiences that are needed to successfully implement the Code. Successful holistic approaches that have strengthened the Code need to be scaled up. Community-based actions and peer-to-peer promotions have proved successful. Legislation without stringent enforcement and sufficient penalties is ineffective. The public needs education about the benefits and ways and means to support breastfeeding. It is crucial to combine strong political commitment and leadership with strict national regulations, definitions, and enforcement. National breastfeeding committees, with the authority to improve regulations, investigate violations, and enforce the laws, must be established. Systematic monitoring and reporting are needed to identify companies, individuals, intermediaries, and practices that infringe on the Code. Penalizing violators is crucial. Managers of multinational companies must be held accountable for international violations, and international legislative enforcement needs to be established. Further measures should include improved regulations to protect the breastfeeding mother: large-scale education campaigns; strong penalties for Code violators; exclusion of the formula industry from nutrition, education, and policy roles; supportive legal networks; and independent research of interventions supporting breastfeeding.

Insect Consumption to Address Undernutrition, a National Survey on the Prevalence of Insect Consumption among Adults and Vendors in Laos

Background

Insect consumption (entomophagy) is a potentially high nutritious and healthy source of food with high fat, protein, vitamin, fiber and micronutrient content. At least 2 billion people globally eat insects (over 1900 edible species) though this habit is regarded negatively by others. There is a limited amount of data on the perception and consumption of insects. We conducted a national cross-sectional survey in the Lao People’s Democratic Republic (Laos) to assess the prevalence and characteristics of insect consumption among adult lay people and insect vendors.

Methods

We conducted a multi stage randomized national survey in 1303 households in 96 villages in 16 Lao provinces. Three insect vendors or collectors per village were also included. A standardized pretested questionnaire addressed the following issues: socioeconomic characteristics, type of insects consumed and frequency of consumption, reasons and trends in consumption as well as reports on side effects, over the last 10 years.

Results

A total of 1059 adults (Sex ratio F/M: 1.2, 30 ethnic groups), and 256 vendors were enrolled. A total of 1025 (96.8%) lay people were currently insect consumers, 135 (13.0%) daily or weekly consumers, and 322 (31.1%) consumed several times per month. For the majority (575, 55.6%) the consumption was infrequent (less than a few times per year) and only 22 (2%) had never eaten insects. Consumption started in childhood. Insect availability was seasonal (670, 63.2%) and respondents would have eaten more insects, if they had been more available (919, 86.7%). Hmong and Leu ethnic groups had significantly lower consumption levels than the general population. Eggs of weaver ants, short-tailed crickets, crickets, grasshoppers, and cicadas were the top 5 insects consumed. Consumption had decreased in the last decade, mostly due to less availability (869; 84.0%) and change of life (29; 5.5%). Of 1059, 80 (7.5%) reported allergy problems and 106 (10.0%) reported some use in traditional medicine. A total of 874 (82.6%) were regular collectors.

Insect vendors (Sex ratio F/M: 5.3) were also collectors (185; 72.2%). They dedicated a mean time of 4.7 hours during the last harvesting period. The majority sold insects at markets (141, 55.0%). They had earned, on average, USD 6.0 the day before. Five insects (weaver ant eggs; bamboo worms; short-tailed crickets; crickets; wasps) represented 85% of the market.

Conclusion

Entomophagy is general in Laos, and well accepted despite a decreasing trend in consumption over the last decade. Its contribution to the Lao diet is limited to a minority of frequent consumers. Income through insect sales benefits mostly women. Consumption varies according to ethnicity, residence and season. Development of insect farming is still at an early stage. It could however increase availability of insects and contribute to the generation of income.

Exclusive breastfeeding practices reported by mothers and the introduction of additional liquids

AIM

To assess the concept of exclusive breastfeeding held by nursing women by comparing the period they consider that they perform it and the infants' age at the introduction of additional liquids.

METHOD

Cross-sectional descriptive study conducted with 309 women who delivered babies at a university hospital in the interior of São Paulo, Brazil. The data were subjected to descriptive analysis; the variables of interest were crossed using the non-parametric Kruskal-Wallis test, the chi-square test and Fisher's exact test.

RESULTS

Approximately 30% of the women reported having introduced additional liquids before the infants reached aged six months old, while asserting that they were performing exclusive breastfeeding. The following variables were associated with early introduction of liquids: lack of employment (p = 0.0386), younger maternal age (p = 0.0159) and first pregnancy (p = 0.003).

CONCLUSION

The concept of exclusive breastfeeding might not be fully clear to women, as they seem to believe that it means not to feed the children other types of milk but that giving other liquids is allowed. These results show that promotion of breastfeeding should take beliefs and values into consideration to achieve effective dialogue and understanding with mothers.

Factors influencing breastfeeding exclusivity during the first 6 months of life in developing countries: a quantitative and qualitative systematic review

Breastfeeding is the most advantageous feeding option for infants, and epidemiological studies provide evidence for its promotion. The objective of this review was to comprehensively delineate the barriers and facilitators of exclusive breastfeeding of infants aged 0-6 months old by mothers in developing countries. A search of CINAHL, MEDLINE and PsycINFO was carried out to retrieve studies from January 2001 to January 2014. Using our inclusion criteria, we selected studies that described barriers and facilitators of exclusive breastfeeding. Qualitative and quantitative studies were considered. Twenty-five studies involving 11 025 participants from 19 countries were included. Barriers and facilitators of exclusive/full breastfeeding were identified, analysed tabulated and summarised in this review. Maternal employment was the most frequently cited barrier to exclusive breastfeeding. Maternal perceptions of insufficient breast milk supply was pervasive among studies while medical barriers related to illness of mothers and/or infants as well as breast problems, rather than health care providers. Socio-cultural factors such as maternal and significant other's beliefs about infant nutrition also often constitute strong barriers to exclusive breastfeeding. Despite these barriers, mothers in developing countries often possess certain personal characteristics and develop strategic plans to enhance their success at breastfeeding. Health care providers should be informed about the determinants of exclusive breastfeeding and provide practical anticipatory guidance targeted at overcoming these barriers. In so doing, health care providers in developing countries can contribute to improving maternal and child health outcomes.

Birth and breastfeeding dynamics in a modernizing indigenous community

BACKGROUND

Changes in health care access and birthing practices may pose barriers to optimal breastfeeding in modernizing rural populations.

OBJECTIVES

We evaluated temporal and maternal age-related trends in birth and breastfeeding in a modernizing Maya agriculturalist community. We tested 2 hypotheses: (1) home births would be associated with better breastfeeding outcomes than hospital births, and (2) vaginal births would be associated with better breastfeeding outcomes than cesarean births.

METHODS

We interviewed 58 Maya mothers (ages 21-85) regarding their births and breastfeeding practices. General linear models were used to evaluate trends in birthing practices and breastfeeding outcomes (timing of breastfeeding initiation, use of infant formula, age of introduction of complementary feeding, and breastfeeding duration). We then compared breastfeeding outcomes by location (home or hospital) and mode of birth (vaginal or cesarean).

RESULTS

Timing of breastfeeding initiation and the rate of formula feeding both increased significantly over time. Younger mothers introduced complementary foods earlier, breastfed for shorter durations, and formula fed more than older mothers. Vaginal hospital births were associated with earlier breastfeeding initiation and longer breastfeeding durations than home births. Cesarean births were associated with later breastfeeding initiation, shorter breastfeeding durations, and more formula feeding than vaginal hospital births.

CONCLUSION

We have observed temporal and maternal age-related trends toward suboptimal breastfeeding patterns in the Maya community. Contrary to our first hypothesis, hospital births per se were not associated with negative breastfeeding outcomes. In support of our second hypothesis, cesarean versus vaginal births were associated with negative breastfeeding outcomes.

Breastfeeding trends in Cambodia, and the increased use of breast-milk substitute-why is it a danger?

A cross-sectional analysis of the Cambodia Demographic Health Surveys from 2000, 2005 and 2010 was conducted to observe the national trends in infant and young child feeding practices. The results showed that rates of exclusive breastfeeding among infants aged 0–5.9 months have increased substantially since 2000, concurrent with an increase in the rates of early initiation of breastfeeding and a reduction in the giving of pre-lacteal feeds. However, the proportion of infants being fed with breast-milk substitutes (BMS) during 0–5.9 months doubled in 5 years (3.4% to 7.0%) from 2000 to 2005, but then did not increase from 2005, likely due to extensive public health campaigns on exclusive breastfeeding. BMS use increased among children aged 6–23.9 months from 2000 to 2010 (4.8% to 9.3%). 26.1% of women delivering in a private clinic provided their child with breast-milk substitute at 0–5.9 months, which is five times more than women delivering in the public sector (5.1%), and the greatest increase in bottle use happened among the urban poor (5.8% to 21.7%). These findings are discussed with reference to the increased supply and marketing of BMS that is occurring in Cambodia.

Compliance with the International Code of Marketing of breast-milk substitutes: an observational study of pediatricians' waiting rooms

Abstract The importance of breastmilk as a primary preventative intervention is widely known and understood by most healthcare providers. The actions or non-actions that heathcare providers take toward promoting and supporting breastfeeding families make a difference in the success and duration of breastfeeding. Recognizing this relationship, the World Health Organization developed the International Code of Marketing of Breast-milk Substitutes (the Code), which defines best practices in breastfeeding promotion, including physicians' offices. The pediatric practices' waiting rooms are often a family's first experience with pediatric care. The specific aims of this study were to describe (1) Code compliance, (2) the demographic factors affecting the Code compliance, and (3) the amount and type of breastfeeding-supportive materials available in the pediatricians' waiting rooms. An observational cross-sectional design was used to collect data from 163 (82%) of the pediatric practices in Maricopa County, Arizona. None of the 100 waiting rooms that had any materials displayed (61%) was found to be completely Code compliant, with 81 of the offices having formula-promotional materials readily available. Waiting rooms in higher income areas offered more non-Code-compliant materials and gifts. Breastfeeding support information and materials were lacking in all but 18 (18%) offices. A positive relationship (t97=-2.31, p=0.02) occurred between the presence of breastfeeding educational materials and higher income areas. We were able to uncover some practice-related patterns that impact families and potentially undermine breastfeeding success. To move current practices toward breastfeeding-friendly physicians' offices, change is needed.

Interventions designed to promote exclusive breastfeeding in high-income countries: a systematic review

BACKGROUND

Worldwide, women fail to reach the recommended exclusive breastfeeding target of 6 months postpartum. The objective of this study was to present a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding to 6 months in high-income countries.

MATERIALS AND METHODS

A systematic search of leading databases was conducted for scholarly peer-reviewed randomized trials published between January 2000 and June 2013. Seventeen articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence, regarding duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A significant increase in the duration of exclusive breastfeeding was found in eight of the 17 studies, with most interventions using supportive or educational approaches. Interventions in pregnancy focused on educating mothers on the benefits of exclusive breastfeeding. Fifteen interventions took place, at least in part, in the postnatal period and provided educational and emotional support to mothers. Of the eight successful interventions, five took part in the postnatal period in the mothers' own homes. The quality of the evidence for duration of exclusive breastfeeding was moderate.

CONCLUSIONS

The most successful interventions were conducted in the postnatal period and over a long period of time; however, the findings were inconsistent. No study assessed intervention fidelity, and only two studies noted maternal body mass index, a variable known to affect exclusive breastfeeding rates. Further research is needed to provide a robust evidence base to inform future interventions.

Cross-border promotion of formula milk in Lao People's Democratic Republic

AIM

This study aims to examine the influence of formula milk promotion via the media from Thailand to Lao People's Democratic Republic (PDR), where a cultural and linguistic proximity are shared.

METHODS

A cross-sectional study was conducted through a structured questionnaire survey and focus group discussion (FGD) with mothers who had children under 2 years of age and lived in Vientiane Capital, Lao PDR. Multivariate logistic regression models were constructed for quantitative data analysis. Content analysis was used for qualitative data analysis.

RESULTS

Among infants aged 6-23 months, exclusive breastfeeding (EBF) rate for 6 months was 16.1% (n = 106/658). Among infants aged 0-5 months, 17.6% (n = 61/346) was exclusively breastfed at the time of survey (24 h recall). Of 1022 mothers, 89.9% reported frequent exposure to the Thai media's promotion of formula milk through TV commercials and 79.1% identified TV commercial as influential for them to develop a positive attitude towards the use of formula milk. In multivariate logistic regression analyses, mothers who reported a positive attitude towards Thai TV commercial on the formula use (n = 449) were approximately 75% less likely to practice EBF for 6 months than those who reported a negative attitude (n = 64). FGD further revealed that the participants tend to believe in the information in TV commercial for formula milk.

CONCLUSION

The promotion of formula milk via media from Thailand negatively affects breastfeeding mothers in Lao PDR. Cross-border impacts of promoting formula milk should be addressed globally.

Modernization is associated with intensive breastfeeding patterns in the Bolivian Amazon

For many traditional, non-industrialized populations, intensive and prolonged breastfeeding buffers infant health against poverty, poor sanitation, and limited health care. Due to novel influences on local economies, values, and beliefs, the traditional and largely beneficial breastfeeding patterns of such populations may be changing to the detriment of infant health. To assess if and why such changes are occurring in a traditional breastfeeding population, we document breastfeeding patterns in the Bolivian Tsimane, a forager-horticulturalist population in the early stages of modernization. Three predictions are developed and tested to evaluate the general hypothesis that modernizing influences encourage less intensive breastfeeding in the Tsimane: 1) Tsimane mothers in regions of higher infant mortality will practice more intensive BF; 2) Tsimane mothers who are located closer to a local market town will practice more intensive BF; and 3) Older Tsimane mothers will practice more intensive BF. Predictions were tested using a series of maternal interviews (from 2003 to 2011, n = 215) and observations of mother-infant dyads (from 2002 to 2007, n = 133). Tsimane breastfeeding patterns were generally intensive: 72% of mothers reported initiating BF within a few hours of birth, mean (±SD) age of CF introduction was 4.1 ± 2.0 months, and mean (±SD) weaning age was 19.2 ± 7.3 months. There was, however, intra-population variation in several dimensions of breastfeeding (initiation, frequency, duration, and complementary feeding). Contrary to our predictions, breastfeeding was most intensive in the most modernized Tsimane villages, and maternal age was not a significant predictor of breastfeeding patterns. Regional differences accounted for variation in most dimensions of breastfeeding (initiation, frequency, and complementary feeding). Future research should therefore identify constraints on breastfeeding in the less modernized Tsimane regions, and examine the formation of maternal beliefs regarding infant feeding.

Breastfeeding mothers' experiences: the ghost in the machine

We critically review qualitative research studies conducted from 2000 to 2012 exploring Western mothers' breastfeeding experiences. We used the search criteria "breastfeeding," "qualitative," and "experiences" to retrieve 74 qualitative research studies, which were reduced to 28 when the terms "existential'' and "research'' were applied. We found that the impact of technology and the pervasive worldwide marketing of infant formula devalued breastfeeding mothers' narratives in a number of ways. Women's bodies were viewed as machine-like objects and the breast was seen as a disembodied object. Dominated by technological narrative, women's bodies were considered unpredictable and hormonal, needing to be managed by health care professionals. This means the disseminating breastfeeding discourse needs to be reinterpreted for practical use. We found that some of the researchers utilized narrative informed by phenomenological philosophy that appears to edge closer to understanding mothers' experiences in a more profound way than nonphenomenological research. However, we need to be mindful of the transparency of terms in replacing one form of technological narrative with another.

Associated factors with adherence to antiepileptic drug in the capital city of Lao PDR

Available medical care for epilepsy and antiepileptic drugs (AED) are provided in Vientiane Municipality by district hospitals supported by a non-governmental organization, which is referred to as a community-based intervention (CB), and reference hospital which is referred to as hospital-based interventions (HB). Identifying underlying factors of AED adherence is of public health interest. A community-based cross-sectional survey among randomly selected patients with epilepsy (PWE) who were being cared in Vientiane Municipality was undertaken in 2010. The Morisky scale was used to assess the level of adherence. Univariate and multivariate logistic regression analyses were performed to address predictive factors. Overall, 99 PWE were included in the study. Overall adherence was estimated at 57.6%, 57.1% and 58.0% for the HB and CB group, respectively. High level of adherence was related to illiteracy, being on monotherapy and experiencing fewer seizures. Implementing closer medical care at primary level to PWE improves the likelihood of reducing primary and secondary treatment gap which is related to PWEs' adherence. An active intervention through a downstream channel of training of medical health staff from reference level to community level enhances the prescription of adequate AED, the improvement of the quality of relation between PWE and medical staff.