Ethical Challenges in Infant Feeding Research

The Association Between Exclusive Breastfeeding and Diarrhoea Morbidity in Infants Aged 0-6 Months: A Rapid Review and Meta-Analysis

Diarrhoea remains a major cause of mortality among children under five, despite global efforts to reduce childhood morbidity and mortality. Exclusive breastfeeding (EBF) has been recognised as an effective and cost-effective intervention to reduce diarrhoeal disease burden in infants. This rapid review and meta-analysis aimed to assess the association of EBF on diarrhoea morbidity in early childhood, a critical period for growth and development, while addressing existing gaps by employing standardised definitions of EBF. A systematic search was conducted in Medline, Scopus, Embase, and Web of Science databases for studies published between 2010 and 2024. Seventeen studies met inclusion criteria and underwent quality assessment using the Joanna Briggs Institute (JBI) critical appraisal tool. Data from the identified studies were extracted, and a meta-analysis was conducted using random effects models to calculate the pooled effect size, with odds ratios (OR) and 95% confidence intervals (CI). This review found that EBF significantly reduces the risk of diarrhoeal diseases in infants under 6 months of age across diverse geographical regions and study designs. The meta-analysis of the association between exclusive breastfeeding and diarrhoea in infants aged 0-6 months resulted in a pooled OR of 0.57 (95% CI: 0.51, 0.63; I² = 57.66%). These findings underscore the critical role of promoting and supporting EBF as a pivotal public health strategy to enhance early childhood health outcomes and contribute to achieving global child health goals.

Effectiveness of a new breastfeeding counselling intervention on breastfeeding prevalence, infant growth velocity and postpartum weight loss in overweight women: a randomized controlled trial

BACKGROUND

Maternal overweight is a risk factor for child obesity. Breastfeeding may decrease this risk, but breastfeeding prevalence is low in overweight or obese mothers.

METHODS

We conducted a randomized trial in 90 overweight/obese pregnant women in Bogotá-Colombia during 2019, to evaluate the effects of a new exclusive breastfeeding (EBF) counselling intervention for overweight/obese mothers, based on Carl Rogers' client-centered theory. The Intervention included individualized breastfeeding counseling, empowerment sessions, and a set of problem-solving strategies based on Carl Rogers' client-centered theory, conducted during late pregnancy, first week postpartum, 1 and 3 months postpartum. Primary outcomes were EBF during the last 24 h prevalence at 4 months postpartum, infant growth, and maternal weight loss at 4 months postpartum; secondary outcomes were serum and breast milk prolactin concentration, breast milk energy and macronutrient content, estimated breast milk volume at 1 and 4 months and EBF prevalence at interim time-points. Mothers were randomised in late pregnancy to intervention (new breastfeeding counselling; IG) or control group (standard breastfeeding support; CG).

RESULTS

The IG had significantly higher EBF prevalence at 4 months (82.8%) compared to the CG (30.6%) (Prevalence ratio or PR = 2.7; 95% CI = 1.6, 4.5). There were no intervention effects on infant growth velocity, maternal weight loss or secondary outcomes.

DISCUSSION

The intervention, which could be implemented in primary care settings, was highly effective for increasing the prevalence of EBF in overweight/obese mothers at 4 months postpartum. The results should, however, be interpreted in the context of the small sample size, short follow-up period and loss to follow-up. Further evaluation of the intervention is required in a larger sample including longer-term infant follow-up.

TRIAL REGISTRATION

(UTN) U1111-1228-9913 20 February 2019; ISRCTN15922904, retrospectively registered.

Diagnosis and management of food allergy-induced constipation in young children-An EAACI position paper

The recognition of constipation as a possible non-Immunoglobulin E (IgE)-mediated allergic condition is challenging because functional constipation (unrelated to food allergies) is a common health problem with a reported worldwide prevalence rate of up to 32.2% in children. However, many studies in children report challenge proven cow's milk allergy and constipation as a primary symptom and have found that between 28% and 78% of children improve on a cow's milk elimination diet. Due to the paucity of data and a focus on IgE-mediated allergy, not all food allergy guidelines list constipation as a symptom of food allergy. Yet, it is included in all cow's milk allergy guidelines available in English language. The Exploring Non-IgE-Mediated Allergy (ENIGMA) Task Force (TF) of the European Academy for Allergy and Clinical Immunology (EAACI) considers in this paper constipation in the context of failure of standard treatment and discuss the role of food allergens as culprit in constipation in children. This position paper used the Delphi approach in reaching consensus on both diagnosis and management, as currently published data are insufficient to support a systematic review.

Breast feeding in infants diagnosed with phenylketonuria (PKU): a scoping review

BACKGROUND

Phenylketonuria (PKU) is the most common inherited disease of amino acid metabolism, characterised by elevated levels of phenylalanine (Phe). There is a lack of infant feeding guidance for those with PKU. From birth to 6 months of age, breast feeding is the optimal nutrition for an infant and continuing breast feeding for infants with PKU is recommended by European guidelines. However, human breast milk contains Phe in varying quantities, and therefore, the effects breast feeding might have on infants with PKU needs careful consideration.

AIM

To assess the effects of breast feeding (exclusive or partial) compared with low-Phe formula feeding in infants diagnosed with PKU, on blood Phe levels, growth and neurodevelopmental scores.

METHODS

The Cochrane Inborn Errors of Metabolism Trials Register, MEDLINE and Embase were searched (date of latest search: 9 August 2022). Studies were included if they looked at the effects of breast feeding in infants diagnosed with PKU compared with formula feeding. Predetermined outcomes included blood Phe levels, growth in the first 2 years of life and neurodevelopmental scores.

RESULTS

Seven observational studies (282 participants) met the inclusion criteria. All studies compared continuation of breast feeding with low-Phe formula versus formula feeding only. While most studies concluded that there was no difference in mean serum Phe levels in their follow-up period, two reported that breastfed infants were more likely to have a normal mean Phe level. Two studies described no difference in mean weight gain after birth, while one found that breastfed infants were more likely to have higher mean weight gain. Two studies commented that breastfed infants achieved higher developmental scores in childhood as compared with formula fed infants.

CONCLUSION

Although there are no randomised trials, observational evidence suggests that continuation of breast feeding and supplementation with low-Phe formula is safe and may be beneficial for infants diagnosed with PKU.

Maasai mother's knowledge on complementary feeding practices and nutritional status of children aged 6-24 months in Monduli District, Arusha, Tanzania: A case study of Naitolia village

Despite Tanzania's achievement in reducing childhood problems, undernutrition is still a problem. Little is known about how mothers' knowledge on complementary feeding practice affects their children nutritional status. Therefore, the study determined how nutritional status of Maasai children aged 6-24 months is related to their mothers or caregivers' knowledge on complementary feeding. A semistructured questionnaire was used in analytical cross-sectional study including 286 Maasai mothers and their 6-24-month-old children. A convenient and snowball sampling were employed in choosing households and mothers. Using SPSS version 20 and ENA for SMART software, demographic variables, mother's complementary feeding knowledge and practices, and anthropometric data were examined. Respondents were mostly young female aged 29 ± 9.5 years, married (89.2%), housewives (88.8%), with no formal education (39.1%). Maasai mothers (51.1%) introduced complementary foods at 4 months. Of all children, 75.2% did not attain minimum acceptable diet, whereas 66.1% and 57.3% did not meet minimum number of meals per day and recommended variety of foods, respectively. Based on complementary feeding practices, underweight was associated with timely introduction of complementary foods (p = .000), minimum dietary diversity (p = .001), and minimum acceptable diet (p = .001). Stunting was associated with minimum acceptable diet (p = .0027). Regarding mother's knowledge, underweight was associated with breastfeeding duration (p = .000) and meals adequacy (p = .014). Wasting was associated with breastfeeding duration (p = .027). Maasai mothers' weaning practices were unsatisfactory and children's nutritional status was poor. Children's nutritional status was significantly associated with mother's understanding on complementary feeding, which was only somewhat adequate.

Defining ethical challenge(s) in healthcare research: a rapid review

BACKGROUND

Despite its ubiquity in academic research, the phrase 'ethical challenge(s)' appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of 'ethical challenge(s)' and closely related terms as used in current healthcare research literature.

METHODS

Rapid review to identify peer-reviewed reports examining 'ethical challenge(s)' in any context, extracting data on definitions of 'ethical challenge(s)' in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher's Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

RESULTS

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of 'ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to 'ethical challenge(s)' within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

CONCLUSIONS

Only 12/72 studies contained an explicit definition of 'ethical challenge(s)', with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Integrating approaches for quality guideline development in LactaMap, an online lactation care support system

Background

Health professionals caring for women and infants experiencing difficulty with breastfeeding have reported deficiencies in evidence-based lactation knowledge. LactaMap is an online lactation care support system with more than 100 clinical practice guidelines to support breastfeeding care. Clinical practice guidelines support medical decision-making by summarising scientific evidence into systematically developed statements for specific clinical circumstances. Both common-sense and theory-based approaches have been used for guideline development and debate continues regarding which is superior. LactaMap clinical practice guidelines were created over the course of 5 years using a common-sense approach that was refined inductively. The aim of this study was to incorporate a theory-based framework approach into the methodology for ongoing update and review of LactaMap clinical practice guidelines.

Methods

The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was chosen as the framework-based approach to appraise LactaMap guideline quality. The study was conducted in two phases. The first phase appraised all 103 original LactaMap guidelines. The second phase appraised a subset of 15 updated LactaMap guidelines using improved methodology guided by phase 1, as well as 15 corresponding original (un-updated) guidelines.

Results

Mean Domain scores for 103 LactaMap original guidelines were above 75% in 3 of the 6 AGREE II quality Domains and no mean Domain score rated poorly. Update of guideline methodology was guided by phase 1 appraisals. Improved documentation of methods relating to questions in the Rigour of Development Domain resulted in improvement in mean Domain score from 39 to 72%.

Conclusions

This study showed that a theory-based approach to guideline development methodology can be readily integrated with a common-sense approach. Factors identified by AGREE II theory-based framework provided practical guidance for changes in methodology that were integrated prior to LactaMap website publication. Demonstration of high quality in LactaMap clinical practice guideline methodology ensures clinicians and the public can have trust that the content founded on them is robust, scientific and of highest possible quality.

Breastfeeding and the Risk of Infant Illness in Asia: A Review

Infancy remains the most vulnerable period of human life for death, illness, and establishing a lifetime trajectory of growth and health. It is estimated that there are 5.3 million deaths under five years of age worldwide and approximately 800,000 lives could be saved by improving breastfeeding rates and duration. In Asia, an estimated 300,000-350,000 child deaths could be prevented with optimal breastfeeding and the majority would be under 12 months of age. We present a systematic review of studies of infection and breastfeeding in infants in Asia and further review interactions of selected infectious diseases and breastfeeding. Initially, 2459 records of possible interest were identified, 153 full text papers were reviewed in detail, and 13 papers describing diarrhoeal disease and/or acute respiratory tract infection were selected for inclusion in the review. Additional papers were selected to discuss specific diseases and their relationship to breastfeeding. The review found that a variety of methods were used with differing definitions of breastfeeding and diseases. Overall, breastfeeding when compared to the use of infant formula, is associated with significantly lower rates of diarrhoeal disease and lower respiratory tract infection, with a reduction of 50% or more to be expected, especially in infants under six months of age. The relationship between breastfeeding and specific diseases including measles and HTLV1 were reviewed. Breastfeeding reduces some disease rates, but there remain a few conditions where breastfeeding may be contra-indicated.

Mother's Own Milk and Bronchopulmonary Dysplasia: A Systematic Review and Meta-Analysis

Background: Bronchopulmonary dysplasia (BPD) is the most common complication of very preterm birth and can lead to lifelong health consequences. Optimal nutrition is a cornerstone in the prevention and treatment of BPD. In very preterm infants, mother's own milk (MOM) feeding is associated with lower risks of necrotizing enterocolitis, retinopathy of prematurity, and sepsis. Although several studies have shown that MOM may protect against BPD, a systematic analysis of the evidence has not been performed to date. Methods: A comprehensive literature search was conducted using PubMed/MEDLINE and EMBASE, from their inception to 1 December 2017. Longitudinal studies comparing the incidence of BPD in preterm infants fed with exclusive MOM, MOM supplemented with preterm formula (PF), and/or exclusively fed with PF were selected. A random-effects model was used to calculate the Mantel Haenszel risk ratio (RR) and 95% confidence interval (CI). Results: Fifteen studies met the inclusion criteria (4,984 infants, 1,416 BPD cases). Use of exclusive MOM feedings was associated with a significant reduction in the risk of BPD (RR 0.74, 95% CI 0.57-0.96, 5 studies). In contrast, meta-analysis could not demonstrate a significant effect on BPD risk when infants fed with more than 50% MOM were compared with infants fed with <50% MOM (RR 0.98, 95% CI 0.77-1.23, 10 studies) or when infants fed with MOM supplemented with PF were compared with infants fed with exclusive PF (RR 1.00, 95% CI 0.78-1.27, 6 studies). Meta-regression showed that differences in gestational age were a significant confounder of the effect of MOM. Conclusion: To our knowledge, this is the first systematic review and meta-analysis that specifically evaluates the role of MOM on BPD. Our data indicate that MOM may reduce the incidence of BPD when used as an exclusive diet, but this result needs to be interpreted with caution. We did not find the same difference in analyses with other dosages of MOM. Further studies adequately powered to detect changes in BPD rates and that adjust for confounders are needed to confirm the beneficial effects of MOM on BPD.

Infant Feeding Guidelines for the Asia Pacific Region

Good nutrition for infants, during the first 1000 days from conception, is one of the most important determinants of a healthy long life. Breastfeeding is the most important component of infant nutrition and reduces morbidity and mortality. With the changes to the climate currently occurring, issues of nutrition and food supply are only going to increase in importance. The Sustainable Development Goals of the United Nations, place nutrition at the forefront of world development and a sustainable planet. The vision of Asia-Pacific Academic Consortium for Public Health (APACPH) is to "achieve the highest possible level of health of all the people of the nations of the Asia-Pacific region." Much of the burden of disease, early deaths, and disability in the Asia Pacific region could be reduced with public health efforts to address the major risk factors, including nutrition-related causes and smoking. The United Nations Decade of Action on Nutrition 2016-2025 has recently been launched with the aim of reducing the global burden of inappropriate nutrition. The goals include increasing rates of exclusive breastfeeding to 6 months, reducing wasting and stunting, and reducing the rates of low birthweight. This is the position endorsed in these guidelines along with the principles of the Baby Friendly Hospital Initiative. These guidelines expand the information on infants that was included in the 2016 APACPH Dietary Guidelines. APACPH covers many different environments, geographical areas, cultures, and socioeconomic groups. These guidelines are generally applicable to all infants in our region, specific local advice may sometimes be needed.

Infant formula feeding practices associated with rapid weight gain: A systematic review

Excess or rapid weight gain during the first 2 years of life is associated with an increased risk of later childhood and adult overweight and obesity. When compared with breastfed infants, formula fed infants are more likely to experience excess or rapid weight gain, and this increased risk in formula fed infant populations may be due to a number of different mechanisms. These mechanisms include the nutrient composition of the formula and the way formula is prepared and provided to infants. This systematic literature review examines the association between formula feeding practice and excess or rapid weight gain. This review explores these different mechanisms and provides practical recommendations for best practice formula feeding to reduce rapid weight gain. Eighteen studies are included in this review. The findings are complicated by the challenges in study design and accuracy of measurements. Nevertheless, there are some potential recommendations for best practice formula feeding that may reduce excess or rapid weight gain, such as providing formula with lower protein content, not adding cereals into bottles, not putting a baby to bed with a bottle, and not overfeeding formula. Although further well designed studies are required before more firm recommendations can be made.

Maternal obesity during lactation may protect offspring from high fat diet-induced metabolic dysfunction

Background/Objectives

The current obesity epidemic has spurred exploration of the developmental origin of adult heath and disease. A mother’s dietary choices and health can affect both the early wellbeing and lifelong disease-risk of the offspring.

Subjects/Methods

To determine if changes in the mother’s diet and adiposity have long-term effects on the baby’s metabolism, independently from a prenatal insult, we utilized a mouse model of diet-induced-obesity and cross-fostering. All pups were born to lean dams fed a low fat diet but were fostered onto lean or obese dams fed a high fat diet. This study design allowed us to discern the effects of a poor diet from those of mother’s adiposity and metabolism. The weaned offspring were placed on a high fat diet to test their metabolic function.

Results

In this feeding challenge, all male (but not female) offspring developed metabolic dysfunction. We saw increased weight gain in the pups nursed on an obesity-resistant dam fed a high fat diet, and increased pathogenesis including liver steatosis and adipose tissue inflammation, when compared to pups nursed on either obesity-prone dams on a high fat diet or lean dams on a low fat diet.

Conclusion

Exposure to maternal over-nutrition, through the milk, is sufficient to shape offspring health outcomes in a sex- and organ-specific manner, and milk from a mother who is obesity-prone may partially protect the offspring from the insult of a poor diet.

Donor Human Milk Protects against Bronchopulmonary Dysplasia: A Systematic Review and Meta-Analysis

Bronchopulmonary dysplasia (BPD) is the most common complication after preterm birth. Pasteurized donor human milk (DHM) has increasingly become the standard of care for very preterm infants over the use of preterm formula (PF) if the mother's own milk (MOM) is unavailable. Studies have reported beneficial effects of DHM on BPD. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies on the effects of DHM on BPD and other respiratory outcomes. Eighteen studies met the inclusion criteria. Meta-analysis of RCTs could not demonstrate that supplementation of MOM with DHM reduced BPD when compared to PF (three studies, risk ratio (RR) 0.89, 95% confidence interval (CI) 0.60-1.32). However, meta-analysis of observational studies showed that DHM supplementation reduced BPD (8 studies, RR 0.78, 95% CI 0.67-0.90). An exclusive human milk diet reduced the risk of BPD, compared to a diet with PF and/or bovine milk-based fortifier (three studies, RR 0.80, 95% CI 0.68-0.95). Feeding raw MOM, compared to feeding pasteurized MOM, protected against BPD (two studies, RR 0.77, 95% CI 0.62-0.96). In conclusion, our data suggest that DHM protects against BPD in very preterm infants.

Nutrients in Infancy: Progress and Prospects

This monograph, based on a special issue of Nutrients, contains 31 papers-5 reviews and 26 original publications-that reflect the wide spectrum of current research on nutrients and infancy [...].