Global lessons for strengthening breastfeeding as a key pillar of food security

High wet-bulb temperatures, time allocation, and diurnal patterns of breastfeeding in Bangladeshi fisher-traders

BACKGROUND

Climate change is a growing threat to population health, with dangerous combinations of heat and humidity increasing in frequency, particularly in South Asia. Evidence suggests that high temperatures and heat stress influence breastfeeding behaviour and may lead to suboptimal infant and young child nutrition.

AIM

Few studies have quantified the relationship between ambient heat and breastfeeding. Here we evaluate associations between wet-bulb temperature and daily breastfeeding patterns in a rural community in Bangladesh.

SUBJECTS AND METHODS

We used 23 months of daily time-diary data from 68 maternal-child dyads and regional wet-bulb temperatures to test the hypothesis that increased heat and humidity negatively influence breastfeeding outcomes among Shodagor fisher-traders.

RESULTS

We found that higher wet-bulb temperatures predicted reduced daily breastfeeding time allocation, particularly among fishers, and drove shifts towards increased night-time and decreased mid/late morning feeding. Maternal occupation and the interaction of child age with heat strongly influenced diurnal breastfeeding patterns.

CONCLUSION

These results highlight an important role of maternal work on infants' vulnerability to environmental stress. Dyads' ability to behaviourally compensate for extreme heat may be constrained by extended heatwaves, humidity, and economic circumstances, suggesting that climate change will likely exacerbate heat-related risks to global child health going forward.

Applying authoritative knowledge to better understand preparation for breastfeeding

Introduction

In this qualitative study, we employ the construct of authoritative knowledge to better understand how birthing people prepare for breastfeeding experiences postpartum. This construct has seldom been applied to the postpartum period, despite its application by reproductive anthropologists to pregnancy and childbirth experiences cross-culturally. Consistent with these applications, we define authoritative knowledge domains by the purveyors. We aimed to characterize the acquisition and valuation of information sources participants used to prepare for breastfeeding.

Methods

Twenty-five participants were recruited from a hospital-based pregnancy study in Chicagoland, Illinois, USA to complete interviews between November 2020 and March 2021. Audio recorded interviews were coded using a priori themes and iterative code development. Codes were used to characterize information sources and the designation of three domains of authoritative knowledge: biomedical, social network, and lived experience.

Results

All participants received information about breastfeeding from both biomedical and social network domains, with those with prior child rearing experiences also using the personal experience domain. Use of online resources like pregnancy tracking apps and social media platforms resulted in the domains of authoritative knowledge overlapping. Participants valued information from health care providers the most but found social network information was more accessible and fulfilled their desire for experiential information.

Discussion

In this first application of authoritative knowledge within the context of infant feeding, participants consistently cited biomedical sources as the most accurate and important. However, they cited barriers to gaining this information such as the short duration of prenatal appointments and the challenge of completing prenatal education courses. Many participants sought evidence-based information about breastfeeding on apps, social media, and websites, however content and quality across platforms varies significantly. This may be an avenue to improve access to reliable and helpful breastfeeding information.

Investigation of the sustainability of breastfeeding and infant nutrition in the earthquake region based on mothers' experiences: a qualitative study

BACKGROUND

To explore the breastfeeding status of mothers with children aged 0-2 years after the major earthquake disaster in Kahramanmaraş, to reveal the obstacles to the sustainability of breastfeeding, and to reveal the problems and experiences they have in breastfeeding, preparing formula, and feeding their infants.

METHODS

This study used a qualitative, exploratory research design with a phenomenological approach. Data were collected between September and November 2023 by face-to-face interviews using a Personal Information Form and a semi-structured interview form. A total of 21 participants who breastfed their babies before the earthquake and experienced the earthquake were included in the study, which was conducted using purposive sampling technique. Data were methodologically analysed using inductive coding and thematic analysis procedures. Max Qualitative Data Analysis Analytics Pro2020 software was used to code data.

RESULTS

The results revealed four primary themes and twenty-two subcategories. The four main themes were; (i) Expectations from Health Personnel, (ii) Suggestions of Mothers, (iii) Difficulties Experienced and (iv) Experiences in Breastfeeding and Infant Feeding.

CONCLUSION

The results obtained in this study showed that mothers had problems in terms of information, support, equipment, appropriate area, and food supply related to infant feeding especially in the early post-disaster period. Insights into mothers' perspectives can help healthcare professionals understand the challenges faced by mothers during disasters and emergencies. In this way, nurses can take the lead in implementing programs designed to support continued breastfeeding and appropriate nutrition for children during disasters.

Trends and determinants of exclusive and predominant breastfeeding practices for two decades (2000-2019) in Ethiopia

Background

Ethiopia has had a long-standing national commitment to improving child health. However, evidence on trends in breastfeeding has remained fragmented, and there is a paucity of information on the impacts of breastfeeding policy on breast feeding practices and associated factors influencing it. This study examined trends and determinants of exclusive and predominant breastfeeding in the last two decades.

Methods

The study employed a retrospective observational design using Ethiopian Demographic and Health Surveys (EDHS2000-2019) dataset for children aged <6 months and their mothers. Data analyses were performed via SPSS version 25. Trend analysis and multivariable logistic regression analysis were used.

Results

Exclusive and predominant breastfeeding practices have fluctuated inconsistently over the past two decades. Exclusive breastfeeding increased from 59.96% in 2000 to 66.01% in 2016 and then decreased to 59.86% in 2019. Predominant breastfeeding decreased from 40.04% in 2000 to 32.95% in 2016 and increased to 39.43% in 2019. Regional state, place of residence, and religion were significantly (p < 0.001) associated with the likelihood of practicing exclusive or predominant breastfeeding.

Conclusion

These inconsistent trends and the complex interplay of various factors suggest the limited success of previous policies and strategies and highlight the need for further investigation and revisiting current policies for a more nuanced and targeted approach in future interventions.

Allomilk: An Anthropogeny-Based Framework for Human Milk as a Climate Solution

Climate change is an urgent threat to perinatal and infant health, with the greatest effects of climate change exposures being felt disproportionately by global majority communities who have been most harmed by systems of oppression. Human milk feeding is one recognized solution to bolster climate resilience. Yet, policies and practices to support human milk as a climate solution are inconsistent and under-prioritized, which is unsurprising given the lack of alignment between human history and current cultural context with regard to lactation and human milk access. This paper presents a new framework on lactation as a climate solution, which is unique in its incorporation of the critical history of cooperative breastfeeding in our species. Rooted in anthropogeny, or the study of human origins, and antiracist principles of lactation, the Allomilk Framework highlights five concepts of the ideal application of human milk as a climate solution, bridging ancient allonursing with present-day lactation and human milk access. These ideal applications-and the proposed development of measures to operationalize them-will advance the field through a shared understanding of the qualities that should be prioritized in the assessment of policies and practices at the intersection of climate resilience and human milk access. Application of the Allomilk Framework to assess and design future policies and practices will advance the field by increasing the potential for climate resilience and climate mitigation while working with-rather than against-the importance of cooperative breastfeeding in human history.

Breastfeeding behaviours in women with obesity; associations with weight retention and the serum metabolome: a secondary analysis of UPBEAT

BACKGROUND/OBJECTIVES

Maternal obesity is associated with a decreased intention and initiation of breastfeeding as well as a shortened duration of breastfeeding. This analysis was undertaken to identify breastfeeding behaviours, and relationships with maternal anthropometry and the serum metabolome at 6-months postpartum in an ethnically diverse cohort of women with obesity.

SUBJECTS/METHODS

A cohort analysis of 715 women from the UK Pregnancies Better Eating and Activity Trial (UPBEAT); a multi-centre randomised controlled trial of an antenatal lifestyle intervention in women with obesity. Maternal data were collected in early pregnancy and included body mass index (BMI), socio-demographic characteristics and anthropometry. At 6-months postpartum, breastfeeding behaviours, anthropometry and 158 maternal metabolic measures from blood samples were recorded. Kaplan-Meier curves of breastfeeding duration were constructed and were stratified by obesity class (I: BMI 30.0-34.9 kg/m2, II: 35.0-39.9 kg/m2, III: ≥40.0 kg/m2). Relationships between breastfeeding behaviours, socio-demographic characteristics, the metabolome, and anthropometry were determined using regression analyses.

RESULTS

Eighty-two percent (591/715) of the cohort-initiated breastfeeding and at the 6-month follow-up 40% (283/715) were breastfeeding exclusively or partially. Duration of exclusive breastfeeding decreased with increasing BMI: Compared to BMI class I (mean 90.4 ± 64 days) the difference in mean for classes II and III were -15.8 days (95% confidence interval: -28.5, -3.1, p < 0.05) and -16.7 (95% CI: -32.0 to -1.35, p < 0.05), respectively. Compared to no breastfeeding, any breastfeeding at 6-months postpartum was associated with improvements in metabolites towards a healthier profile, reduced weight retention by -1.81 kg (95% CI -0.75, -2.88, p < 0.05 ) and reduced anthropometric measures, including mid-upper arm and hip circumferences. The breastfeeding related changes in anthropometry were not evident in women of Black ethnicity.

CONCLUSIONS

Greater emphasis on enabling breastfeeding for women with obesity could improve duration, women's weight management and metabolic health. The lack of breastfeeding related anthropometric effects in Black women requires further investigation.

CLINICAL TRIAL REGISTRY

ISRCTN reference 89971375.

Complex intertwined association between breastfeeding practices and household food insecurity: Systematic review and meta-analysis

Breastfeeding offers ideal food and nutrition for infants; however, structural barriers may amplify breastfeeding inequities. We aimed to identify whether household food insecurity (HFI) is associated with exclusive and continued breastfeeding (EBF and CBF) as recommended by the World Health Organization/United Nations Children's Fund (UNICEF) Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, literature searches using 'breastfeeding', 'food insecurity' and 'infant' terms were conducted in PubMed/MEDLINE, Embase, CINAHL, Global Health and LILACS from inception through November 2023, without language restrictions, yielding 1382 publications (PROSPERO:CRD42022329836). Predetermined eligibility criteria yielded the 12 included studies (nine cross-sectional and three cohorts). The risk of bias was assessed through the Effective Public Health Practice Project. Meta-analysis was performed for studies assessing EBF (n = 10), and metaregression was used to explore heterogeneity across studies. Prevalence of EBF ranged from 1.6% to 85.3%, with a lower prevalence among HFI. The pooled effect of the association between HFI and EBF presented an odds ratio (OR) of 0.61 (95% CI = 0.49-0.76) with consistent results across marginal (OR = 0.72, 95% CI = 0.55-0.94), moderate (OR = 0.59, 95% CI = 0.41-0.84) and severe HFI (OR = 0.49, 95% CI = 0.32-0.76). High heterogeneity was found only when HFI was dichotomized. The prevalence of CBF ranged from 35.4% to 78.0%, with inconsistent prevalence among HFI; a meta-analysis was not performed due to the low number of studies (n = 3). We concluded that HFI levels are associated with lower odds of EBF. Integrating service and policy-level strategies, such as screening, referrals, skilled breastfeeding counseling and access to comprehensive nutrition and social programs, could reduce structural inequities and promote adherence to the World Health Organization/UNICEF breastfeeding recommendations among food-insecure families.

Inequalities in large-scale breastfeeding programmes in Bangladesh, Burkina Faso and Vietnam

Inequalities in breastfeeding programmes and practices have slowed global progress in providing the life-saving protection of breastfeeding for millions of infants despite well-known life-long impacts. As breastfeeding interventions are scaled up, inequalities in coverage and breastfeeding practices should be tracked, particularly in disadvantaged groups, who are likely to suffer the most serious health and developmental impacts of poor childhood nutrition. The literature provides evidence of inequalities in breastfeeding practices, but research is limited on socioeconomic disparities in the coverage of breastfeeding interventions. This paper (1) compares inequalities in breastfeeding practices in intervention and nonintervention areas and (2) documents inequalities in programme coverage by type of intervention. We disaggregated endline evaluation surveys in Bangladesh, Burkina Faso and Vietnam, where rigorous evaluations had documented significant overall improvements, and analysed whether inequalities in breastfeeding practices and programme coverage differed by treatment areas. We used Erreygers index to quantify inequalities and found that breastfeeding practices were largely pro-poor; intervention coverage was not consistently pro-poor. While counselling coverage often favoured women from the poorest quintile, public education/media coverage consistently favoured better-off women. Inequalities favoured more educated mothers in the coverage of combined interventions. None of the programmes had explicit equality objectives. The results indicate the need for introducing specific actions to reduce inequalities in breastfeeding policies and programmes. This is a priority unfinished agenda for nutrition programming.

"A Vulnerable Time To Be a Young Family in an Emergency": Qualitative Findings From an Exploration of an Emergency Perinatal and Infant Feeding Hotline in Louisiana

BACKGROUND

Birthmark Doula Collective, a cooperative that provides doula and lactation services in the Greater New Orleans area, mounted an emergency response after two Category 4 storms: Hurricane Laura (2020) and Hurricane Ida (2021). The response included activating a no-cost emergency perinatal and infant feeding hotline. Both disasters coincided with a resurgence of COVID-19 infections in Louisiana.

RESEARCH AIM

The aim of this study is to understand how an emergency perinatal and infant feeding hotline supported infant and young child feeding in emergencies during hurricanes in Louisiana.

METHOD

This study used a cross-sectional, retrospective qualitative design in a population with low breastfeeding rates. We conducted a content analysis of 97 hotline call logs from Hurricanes Laura and Ida, focus groups with lactation support providers who staffed the hotline during either storm (n = 5), and interviews with mothers who called during Hurricane Ida (n = 2). Focus groups and interviews lasted 30 and 60 minutes, respectively. Transcripts were analyzed using thematic analysis techniques.

RESULTS

Call logs revealed infant feeding needs (e.g., mastitis, low milk supply, relactation, and infant formula requests) and non-infant feeding needs (e.g., infant supplies, perinatal and infant care referrals, shelter information). Infant formula was the most requested supply during both hurricanes. Maternal participants discussed family vulnerabilities during Hurricane Ida. Staff described training and strategies to provide support while maintaining their own well-being.

CONCLUSION

Providing a free emergency hotline service is one way to support pregnant and postpartum people and their families seeking infant feeding advice, supplies, and support in the immediate aftermath of a disaster.

Emergency response and preparedness among Polish human milk banks: a comparison of the COVID-19 pandemic and the 2022 Ukrainian refugee crisis

Introduction

In recent years, Poland has faced two major emergencies: the COVID-19 pandemic, a global-scale public health emergency in 2020, and the outbreak of a full-scale war in Ukraine, which forced over 9 million Ukrainians-mostly women and children-to flee from their country through the Polish-Ukrainian border in 2022.

Methods

In 2020 and 2022, we conducted two online questionnaires with human milk bank personnel to assess the impact of these emergencies on the human milk banking sector and its preparedness to face them. All 16 human milk bank entities operating in Poland were contacted and invited to participate in the study. For the first questionnaire, which was distributed in 2020, we obtained a 100% response rate. For the second questionnaire, the response rate was 88%, i.e., 14 out of 16 human milk banks completed the questionnaire. We compared these two emergencies in terms of the extent to which the potential of the Polish human milk bank network was exploited to support vulnerable infants who were not breastfed.

Results and discussion

Our findings indicate that recommendations to provide donor human milk to infants separated from their mothers during the COVID-19 pandemic were never fully implemented. Meanwhile, during the refugee crisis, national legislation allowing equal access to public healthcare for Ukrainian citizens were rapidly implemented, enabling a more effective response by human milk banks to support vulnerable infants. However, no specific measures were introduced to support refugees outside the standard criteria for donor human milk provision. Our results highlight the limited response from the sector during emergencies and the underutilization of the potential of a nationwide network of professional human milk banks. Drawing on Polish experiences, we emphasize the importance of having procedures and legal regulations regarding human milk banking in place even in non-crisis settings, which would facilitate a rapid emergency response. We also emphasize the need to include the implementation of emergency procedures in building a strong and resilient human milk banking system.

The epidemiology and associated factors of non-exclusive breastfeeding: a comparative cross-sectional study of livelihood-secure and insecure areas

Introduction

Regardless of national commitment, non-exclusive breastfeeding (NEBF) is a public health problem that worsens over time. It can be associated with sociodemographic, economic, and environmental factors and may vary depending on livelihood security. Hence, this study aimed to determine the magnitude of NEBF and identify its associated factors by considering two areas with varied degrees of livelihood security.

Methods

This study represented a comparative cross-sectional survey of 1,060 under 6 months (u6m) infant-mother pairs. Both descriptive and analytic statistics were evaluated using STATA version 17 packages. A binary logistic regression was used to identify associated factors of NEBF. The odds ratio (OR) with a 95% confidence interval (CI) was used to measure the significance of the association at a p-value of <0.05.

Results

The pooled magnitude of 51% of NEBF mothers (95% CI: 48.0, 54.0) was 53.1% (95% CI: 49.2, 57.0) and 48.1% (95% CI: 43.4, 52.8) in livelihood-secure and livelihood-insecure areas, respectively. The lack of recollecting the infant's birth date by mothers (AOR = 2.4; 95% CI = 1.15-4.40) had the highest odds of NEBF while household heads with tertiary education (AOR = 0.14; 95% CI = 0.01-0.54) and the poorest households (AOR = 0.43; 95%CI = 0.20-0.82) had the lowest odds of NEBF in livelihood-secure areas but not in livelihood-insecure areas. Moreover, mothers with male infants (AOR = 1.9; 95% CI = 1.18-2.92) had high odds of NEBF in livelihood-insecure areas but not in livelihood-secure areas. Infants of 2 to less than 4-month-old (AOR = 8.5; 95% CI = 3.47-18.63) and 4 to less than 6-month-old (AOR = 22.2; 95% CI = 8.02-51.97) in livelihood-secure areas and infants of 2 to less than 4-month-old (AOR = 4.3; 95% CI = 1.29-11.67) and 4 to less than 6-month-old (AOR = 8.3; 95% CI = 2.44-22.39) in livelihood-insecure areas had high odds of NEBF.

Conclusion

Over half of the mothers were practicing NEBF, which represents a failure to meet national and international targets. Area vulnerability to livelihood security modifies factors of NEBF. Male infants in insecure areas, infants of unknown age in secure areas, and infants aged 2 months or older, regardless of setting, were more vulnerable to NEBF. However, households with the lowest wealth and higher household head educational status in livelihood-secure areas were less vulnerable to NEBF. Hence, livelihood-based interventions targeting mothers of 2 to less than 6-month-old infants, with emphasis on these factors, may help address and reduce NEBF.

The Association Between Prenatal Food Insecurity and Breastfeeding Initiation and Exclusive Breastfeeding Duration: A Longitudinal Study Using Oregon PRAMS and PRAMS-2, 2008-2015

Background: In the United States, 11.1% of households experience food insecurity; however, pregnant women are disproportionately affected. Maternal food insecurity may affect infant feeding practices, for example, through being a source of chronic stress that may alter the decision to initiate and continue breastfeeding. Thus, we sought to determine whether prenatal food insecurity was associated with breastfeeding (versus not) and exclusive breastfeeding duration among Oregon women. Method: The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) data of live births from 2008 to 2015 and the Oregon PRAMS-2 follow-up survey were used (n = 3,624) in this study. Associations with breastfeeding initiation and duration were modeled with multivariable logistic regression and accelerated failure time (AFT), respectively. Models were adjusted for maternal sociodemographic and pre-pregnancy health characteristics. Results: Nearly 10% of women experienced prenatal food insecurity. For breastfeeding initiation, unadjusted models suggested non-significant decreased odds (odds ratio (OR) 0.88 [confidence intervals (CI): 0.39, 1.99]), whereas adjusted models revealed a non-significant increased odds (OR 1.41 [CI: 0.58, 3.47]). Unadjusted AFT models suggested that food-insecure mothers had a non-significant decrease in exclusive breastfeeding duration (OR 0.76 [CI: 0.50, 1.17]), but adjustment for covariates attenuated results (OR 0.89 [CI: 0.57, 1.39]). Conclusions: Findings suggest minimal differences in breastfeeding practices when exploring food security status in the prenatal period, though the persistence of food insecurity may affect exclusive breastfeeding duration. Lower breastfeeding initiation may be due to other explanatory factors correlated with food insecurity and breastfeeding, such as education and marital status.

The Climate Crisis and Breastfeeding: Opportunities for Resilience

The climate crisis is an emerging global challenge that poses potential risks to breastfeeding practices and outcomes. There are multifaceted effects of climate change affecting the breastfeeding dyad across environmental, societal, and human health dimensions. Breastfeeding support in the face of climate change will require solutions at the structural level-healthcare, community, and workplace settings-and at the mother-infant dyad level. Breastfeeding can additionally be an adaptive response to crisis situations and can mitigate some of the environmental challenges associated with climate change. Despite the undeniable significance of climate change on breastfeeding (and vice versa), our perspective as experts in the field is that this topic has not been systematically addressed. Although we highlight some of the challenges, potential solutions, and co-benefits of breastfeeding in the context of climate change, there are numerous issues that could be further explored and necessitate additional preparedness planning.

A long-acting prolactin to combat lactation insufficiency

Human infants are born to breastfeed. While 50% of lactating persons struggle to make enough milk, there are no governmentally-approved drugs to enhance lactation1. Here, we engineer a variant of the naturally-occurring driver of lactation, the hormone Prolactin, to increase its serum half-life and produce a viable drug candidate. Our engineered variant, Prolactin-eXtra Long-acting (Prolactin-XL), is comprised of endogenously active human prolactin fused to an engineered human IgG Fc domain designed to overcome the unique drug development challenges specific to the lactating person-infant dyad. Our Prolactin-XL has a serum half-life of 70.9h in mice, 2,625-fold longer than endogenously active prolactin alone (70.9h v. 0.027h). We demonstrate that Prolactin-XL increases milk production and restores growth of pups fed by dams with pharmacologically-ablated lactation. We show that Prolactin-XL-enhanced lactation is accompanied by reversible, lactocyte-driven changes in mammary gland morphology. This work establishes long-acting prolactins as a potentially powerful pharmacologic means to combat insufficient lactation.