Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis

Exclusive Breastfeeding and Vitamin D Supplementation: A Positive Synergistic Effect on Prevention of Childhood Infections?

Human milk is the best food for infants. Breastfeeding has been associated with a reduced risk of viral and bacterial infections. Breast milk contains the perfect amount of nutrients needed to promote infant growth, except for vitamin D. Vitamin D is crucial for calcium metabolism and bone health, and it also has extra-skeletal actions, involving innate and adaptive immunity. As exclusive breastfeeding is a risk factor for vitamin D deficiency, infants should be supplemented with vitamin D at least during the first year. The promotion of breastfeeding and vitamin D supplementation represents an important objective of public health.

Breast Milk: A Meal Worth Having

A mother is gifted with breast milk, the natural source of nutrition for her infant. In addition to the wealth of macro and micro-nutrients, human milk also contains many microorganisms, few of which originate from the mother, while others are acquired from the mouth of the infant and the surroundings. Among these microbes, the most commonly residing bacteria are Staphylococci, Streptococci, Lactobacilli and Bifidobacteria. These microorganisms initiate and help the development of the milk microbiota as well as the microbiota of the gastrointestinal tract in infants, and contribute to developing immune regulatory factors such as cytokines, growth factors, lactoferrin among others. These factors play an important role in reducing the risk of developing chronic diseases like type 2 diabetes, asthma and others later in life. In this review, we will summarize the known benefits of breastfeeding and highlight the role of the breast milk microbiota and its cross-talk with the immune system in breastfed babies during the early years of life.

Association between maternal insecticide use and otitis media in one-year-old children in the Japan Environment and Children's Study

Otitis media (OM) is common among young children and is related to hearing loss. We investigated the association between maternal insecticide use, from conception to the first and second/third trimesters, and OM events in children in the first year of age. Data from Japan Environment and Children's Study were used in this prospective cohort study. Characteristics of patients with and without history of OM during the first year of age were compared. The association between history of OM in the first year and insecticide use was evaluated using logistic regression analysis. The study enrolled 98,255 infants. There was no significant difference in the frequency of insecticide use between groups. Insecticide use of more than once a week from conception to the first trimester significantly increased the occurrence of OM in children in the first year (odds ratio [OR] = 1.30, 95% confidence interval [CI] 1.01–1.67). The association between OM in the first year and insecticide use from conception to the first trimester was only significant in the group without daycare attendance (OR 1.76, 95% CI 1.30–2.38). Maternal insecticide use more than once a week from conception to the first trimester significantly increased OM risk in offspring without daycare attendance.

Increasing the exclusive breastfeeding rate in a private hospital in UAE through quality improvement initiatives

BACKGROUND

Mother's milk is the best, and ideal method for infant feeding. We found that this practice was not being followed in our hospital. A survey was conducted in the unit with regards to breastfeeding practices which revealed that most babies who were discharged from our nursery were on formula supplements. Our goal was to improve established breastfeeding rates in the unit by increasing the number of full-term healthy babies who were discharged on exclusive Breastfeeding.

METHOD

A project team was formed, and data were collected through direct observations and direct interviews with postnatal mothers. Exclusive Breastfeeding at discharge was defined as a baby being fully on breastfeed with no additional formula supplements for at least 12 hours prior to discharge. The primary outcome was to increase the percentage of babies being discharged on exclusive Breastfeeding. We used the FOCUS PDCA model to measure improvements and 8 PDCA cycles of 4 weeks duration were implemented to test the changes.

RESULTS

The interventions we put in place led to a considerable nine times overall improvement in the established breastfeeding rates. Among all the interventions, the most promising results were observed during the PDCA cycles involving staff education, the introduction of antenatal classes for mothers, skin to skin contact and rooming in.

CONCLUSION

Breastfeeding rates in the private sector with nursery services can be improved by reinforcing breastfeeding education for mothers in addition to training the maternal care staff, empowering them to promote and assist in breastfeeding.

Associations of Human Milk Oligosaccharides With Otitis Media and Lower and Upper Respiratory Tract Infections up to 2 Years: The Ulm SPATZ Health Study

Background: Human milk oligosaccharides (HMOs) support and concurrently shape the neonatal immune system through various mechanisms. Thereby, they may contribute to lower incidence of infections in infants. However, there is limited evidence on the role of individual HMOs in the risk of otitis media (OM), as well as lower and upper respiratory tract infections (LRTI and URTI, respectively) in children up to 2 years.

Objective: To investigate whether individual HMO concentrations measured at 6 weeks of lactation were associated with risk of OM, LRTI or URTI up to 2 years in breastfed infants. Associations with OM, LRTI and URTI were determined for the most prominent human milk oligosaccharides including 13 neutral, partly isomeric structures (trioses up to hexaoses), two acidic trioses, and lactose.

Design: HMO measurements and physician reported data on infections were available from human milk samples collected at 6 weeks postpartum (n = 667). Associations of HMOs with infections were assessed in crude and adjusted models using modified Poisson regression.

Results: Absolute concentrations (median [min, max], in g/L) of 2′-fucosyllactose (2′-FL) tended (p = 0.04) to be lower, while lacto-N-tetraose (LNT) was higher in the milk for infants with OM in the 1st year of life (p = 0.0046). In the milk of secretor mothers, LNT was significantly higher in the milk for infants with OM (RR [95% CI]: 0.98 [0.15, 2.60]) compared to infants without OM (RR [95% CI]: 0.76 [0.14, 2.90]) at 1 year (p = 0.0019). No statistically significant milk group differences and associations were observed for OM, LRTI, and URTI (p > 0.0031).

Conclusion: Our findings suggest that neither prominent neutral individual HMOs (ranging from 2′-FL to LNDFHs) nor acidic human milk sialyllactoses or lactose are significantly associated with a reduced or increased risk of infections in infants up to 2 years of age. Further research is needed to determine whether specific HMOs could potentially reduce the incidence or alleviate the course of distinct infections in early life.

Early-Life Respiratory Infections in Infants with Cow's Milk Allergy: An Expert Opinion on the Available Evidence and Recommendations for Future Research

Acute respiratory infections are a common cause of morbidity in infants and young children. This high rate of respiratory infections in early life has a major impact on healthcare resources and antibiotic use, with the associated risk of increasing antibiotic resistance, changes in intestinal microbiota composition and activity and, consequently, on the future health of children. An international group of clinicians and researchers working in infant nutrition and cow's milk allergy (CMA) met to review the available evidence on the prevalence of infections in healthy infants and in those with allergies, particularly CMA; the factors that influence susceptibility to infection in early life; links between infant feeding, CMA and infection risk; and potential strategies to modulate the gut microbiota and infection outcomes. The increased susceptibility of infants with CMA to infections, and the reported potential benefits with prebiotics, probiotics and synbiotics with regard to improving infection outcomes and reducing antibiotic usage in infants with CMA, makes this a clinically important issue that merits further research.

Does breastfeeding protect children from COVID-19? An observational study from pediatric services in Majorca, Spain

BACKGROUND

It has been demonstrated that children who had been breastfed remain better protected against various infections, and notably respiratory tract infections, well beyond infancy. Since the role of breastfeeding to explain why children are less affected by COVID-19 has not been studied until now, the aim of this study was to determine whether any history of breastfeeding reduces the incidence rate of COVID-19 in children.

METHODS

This was a secondary analysis of an observational study on clinical and epidemiological characteristics of pediatric COVID-19 in Majorca. A total of 691 children were recruited during the 5 months of August-December 2020. Eligible participants were children under 14 who were tested for SARS-CoV-2 in pediatric emergency services. The independent explanatory variable was any breastfeeding. Bivariate analyses were conducted through the Chi-square test, the Fisher's Exact test or the Student's T test. All children had the same demographic, epidemiological and clinical data collected through a study team member interview and via the participants medical records.

RESULTS

Within the sample of children who visited emergency services with symptoms of potential COVID-19, we found higher prevalence of positive SARS-CoV-2 RT-PCR test results among those who were exclusively formula fed compared with those who were ever breastfed (OR 2.48; 95% CI 1.45, 3.51; P = 0.036).

CONCLUSIONS

The present study suggests that ever breastfeeding reduces the risk of COVID-19 among children, as documented for other infections.

Induction of SARS-CoV-2-Specific IgG and IgA in Serum and Milk with Different SARS-CoV-2 Vaccines in Breastfeeding Women: A Cross-Sectional Study in Northern Spain

Breastfeeding mothers were excluded from the clinical trials conducted for vaccines against SARS-CoV-2. Since the start of the vaccination, some doubts have arisen regarding its compatibility with breastfeeding. The aim of this study was to analyse the presence of anti-SARS-CoV-2 antibodies in breast milk and serum (IgG and IgA) of vaccinated breastfeeding women. The main variables of the observational study were: adverse related events after vaccination and determination of the presence of IgG and IgA isotypes antibodies in serum and in breast milk of vaccinated women against the SARS-CoV-2 antigens. Results: 110 breastfeeding mothers were included; 70 women (63.6%) were vaccinated with two doses of BNT162b2, 20 women (18.2%) with two doses of mRNA-1273, and 20 women (18.2%) with a single dose of ChAdOx1-S. Regarding adverse reactions and vaccine safety, 38 women had no adverse reactions; 20 (18.2%) had general malaise or adenopathies; 10 (9.1%) had a headache; and 7 (6.4%) had fever. When analysing IgG antibodies, significantly higher levels of antibodies were found in serum and breast milk from mothers vaccinated with BNT162b2 or mRNA-1273 vs. ChAdOx1-S (p < 0.001 and p = 0.001, respectively). Analysing IgA antibodies, significant differences were found when comparing mean values in serum from mothers vaccinated with BNT162b2 or mRNA-1273 vs. ChAdOx1-S (0.12, 0.16, and 0.02, respectively; p < 0.001) and breast milk of mothers vaccinated when comparing BNT16b2 vs. ChAdOx1-S. All vaccinated breastfeeding mothers had serum anti-S1 IgG antibodies in response to vaccination against SARS-CoV-2, regardless of the commercial vaccine administered. Conclusions: the anti-SARS-CoV-2 vaccines were well tolerated by the mothers and the breastfed infant. In addition, breastfeeding mothers offer their infants IgA and IgG isotype antibodies directed against SARS-CoV-2 protein S in breast milk.

Breastmilk Feeding during the First 4 to 6 Months of Age and Childhood Disease Burden until 10 Years of Age

BACKGROUND

Breastfeeding is recommended due to its beneficial effects on human health. However, the effect of breastfeeding on health differs, resulting in various childhood diseases.

OBJECTIVE

Our purpose was to investigate the association between breastfeeding at least in the first 4 months and the subsequent development of 15 certainly defined childhood diseases until 10 years of age, the all-cause hospitalization rate and growth at 6-7 years of age.

METHODS

Participants included propensity-score matched 188,052 children born between January 2008 and December 2009, who were followed up till 10 years of age. Data were taken from the National Investigation of birth Cohort in Korea study 2008 database. Risk ratios were obtained using a modified Poisson regression and weighted risk differences using binomial regression.

RESULTS

Compared to formula feeding, breastfeeding was associated with decreased risks of febrile convulsion, attention deficit hyperactivity disorder and autism spectrum disorder, pneumonia, acute bronchiolitis, hypertrophic pyloric stenosis, asthma, all-cause hospitalization, overweight/obesity and short stature. Exclusive breastfeeding at 4 to 6 months of age had similar results to exclusive breastfeeding over 6 months of age.

CONCLUSIONS

Breastfeeding in early infancy reduces the risk for various childhood diseases, all-cause hospitalization rate, obesity, and short stature during childhood.

Attitudes and Barriers to Breastfeeding among Mothers in Princess Nourah Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia

Background

Breastfeeding provides unsurpassed natural nutrition to the newborn and infant. It has a nearly perfect mix of food elements and vitamins that infants need to grow up. Nonetheless, the tendency for breastfeeding remains below the expected levels.

Objectives

To explore the attitudes and barriers to breastfeeding among mothers in Princess Nourah Abdulrahman University (PNU), Riyadh, Saudi Arabia.

Methods

A cross-sectional study was conducted, from January to April 2019; 399 PNU students, employees, and faculty mothers aged 18 years and above with experience of childbirth and breastfeeding were included in the study using a predesigned validated questionnaire. The questionnaire consisted of four scales: sociodemographic, attitude toward breastfeeding, barriers to breastfeeding, and induced lactation knowledge.

Results

The participants' mean age was 34.1 ± 10.4 years; most (87.8%) were Saudi; 92.8% were married; 62% had a bachelor's degree; and 43% had "enough income." While 40% of the mothers reported >6 months "exclusive breastfeeding" for the first baby, only 34.8% did so for the last baby, and 54.5% did so for most of all babies altogether. The mothers' parity ranged between 1 birth and 4 births in 23.5% and 17.5% of the participants, respectively. An overall score of breastfeeding attitude averaged 59.6 ± 7.3. The tendency for scoring a negative attitude to breastfeeding was significantly reported (p < 0.5) among 127 (31.8%) 31- to 40-year-old mothers; 153 (38.3%) bachelor's degree holders; and 157 (39.3%) employees (χ ² (4) 14.6, p = 0.006; χ ² (4) 10.4, p = 0.034; and χ ² (4) 20.4, p < 0.001, respectively). "Mother's illness" was the most commonly (63%) reported barrier to "not to breastfeed," followed by "work" (45.5%) and "father not supporting breastfeeding" (14.8%).

Conclusions

An overall negative attitude toward breastfeeding among PNU mothers was noted. Barriers included mother's sickness and work. Efforts to minimize such negative attitudes and barriers among susceptible mothers are warranted.

Human Milk for the Term Newborn

Human milk provides optimal nutrition for term newborns, but the prevalence of its use is below target, and risks have been identified. Infants of black mothers as well as term newborns admitted to the neonatal intensive care unit are at risk for not receiving human milk. To improve human milk intake, multiple individual-level interventions have been shown to be effective, but some popular system-level interventions are ineffective or harmful. Expressed milk and donor milk may be less beneficial than direct breastfeeding. Nuanced public policies can help support lactation while promoting individual choice and equity.

The Association between a Novel Baby-Friendly Hospital Program and Equitable Support for Breastfeeding in Vietnam

Background: Rates of early initiation of breastfeeding are low in Southeast Asia, despite evidence that increased initiation of early breastfeeding would lead to better long-term infant and child health and decrease inequities in long-term health and well-being. In response, a novel performance-based, baby-friendly hospital program designates hospitals that adhere to evidence-based early essential newborn care (EENC) and breastfeeding interventions as Centers of Excellence for Breastfeeding (COE). This study examined whether hospital participation in the program was associated with better breastfeeding outcomes. Methods: Hospitals (n = 28) were invited into the program in December 2018. Hospitals developed an improvement plan for promoting a breastfeeding-friendly environment and meeting the standards of the COE accreditation process and were enrolled on a rolling basis over the course of a year. Post-partum surveys were conducted with parents (n = 9585) from January 2019 through April 2020 to assess their breastfeeding and post-partum experience. Segmented regression models were used to assess how breastfeeding outcomes evolved before and after hospital enrollment in the COE program. Results: Enrollment was associated with a 6 percentage-point (95% CI: 3, 9) increase in the level of early initiation of breastfeeding, which continued to increase in the post-enrollment period, and a 5 percentage-point (95% CI: 2, 9) increase in the level of exclusive breastfeeding during hospital stay. We did not observe evidence that enrollment was immediately associated with receipt of lactation counseling or exclusive breastfeeding at survey time. Conclusion: The prevalence of early and exclusive breastfeeding increased after enrollment in the COE program, suggesting that the program has the potential to improve breastfeeding initiation rates and longer-term child health and well-being. Further research should be conducted to examine whether the program has an impact on the overall duration of breastfeeding.

Lithium Medication in Pregnancy and Breastfeeding-A Case Series

Lithium salts are the first-line prophylaxis treatment for bipolar disorder in most guidelines. The majority of bipolar women are treated with mood stabilizers at the time they wish to get pregnant. One reason for this is the rising average age at first childbirth, at least in the high-income countries, which increases in general the likelihood of a medication with psychotropic drugs. Previously, lithium exposition during pregnancy was thought to strongly increase the risk of severe cardiac malformation. However, recent studies only point to a low teratogenic risk, so nowadays an increasing number of women are getting pregnant with ongoing lithium treatment. Regarding lithium medication during breastfeeding, there is evidence that lithium transfers to the breastmilk and can also be detected in the infants’ serum. The influence on the infant is still a largely understudied topic. Regular monitoring of the infants’ renal clearance, thyroid function, and lithium levels is warranted when breastfeeding under lithium exposure. In this case series, we present three case reports of bipolar mothers who were treated with lithium during pregnancy and breastfeeding to add to the scarce literature on this important topic. In short, we strengthen the importance of therapeutic drug monitoring due to fluctuating plasma levels during pregnancy and after birth, and we can report the birth and development of three healthy infants despite lithium medication during pregnancy and breastfeeding.

Breastfeeding Beyond 12 Months: Is There Evidence for Health Impacts?

Because breastfeeding provides optimal nutrition and other benefits for infants (e.g., lower risk of infectious disease) and benefits for mothers (e.g., less postpartum bleeding), health organizations recommend that healthy infants be exclusively breastfed for 4 to 6 months in the United States and 6 months internationally. Recommendations related to how long breastfeeding should continue, however, are inconsistent. The objective of this article is to review the literature related to evidence for benefits of breastfeeding beyond 1 year for mothers and infants. In summary, human milk represents a good source of nutrients and immune components beyond 1 year. Some studies point toward lower infant mortality in undernourished children breastfed for >1 year, and prolonged breastfeeding increases interbirth intervals. Data on other outcomes (e.g., growth, diarrhea, obesity, and maternal weight loss) are inconsistent, often lacking sufficient control for confounding variables. There is a substantial need for rigorous, prospective, mixed-methods, cross-cultural research on this topic. Expected final online publication date for the Annual Review of Nutrition, Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Breastfeeding in Primary Healthcare Setting: Evaluation of Nurses and Midwives Competencies, Training, Barriers and Satisfaction of Breastfeeding Educational Experiences in Northern Ghana

BACKGROUND

Breastfeeding education is critical in improving healthcare professionals' competencies in providing breastfeeding care to mothers. We evaluated breastfeeding competencies, training, barriers and satisfaction of breastfeeding educational experiences among nurses and midwives in the Sagnarigu Municipality, Ghana.

METHODS

This cross-sectional study included nurses and midwives providing maternal and child health services at various primary healthcare facilities in Sagnarigu Municipality.

RESULTS

Nurses and midwives had higher pre-service breastfeeding training than in-service training with a mean training score of 10.0 and 5.2, respectively. Nurses and midwives who had both pre-service and in-service training had better satisfaction score (P = .003), positive attitudes (P = .016) and higher confidence level about breastfeeding (P = .007). Approximately, 80% of the nurses and midwives reported that they need further training/updating on breastfeeding while 40% reported clinical/professional practice as the significant contributor to their breastfeeding counselling competencies. Mean satisfaction score correlated positively with confidence levels about breastfeeding counselling (r = .224, P = .022) and pre-service training (r = .342, P < .001); confidence levels about breastfeeding counselling also correlated positively with attitudes towards breastfeeding counselling (r = .348, P < .001). Commonly reported barriers to breastfeeding counselling were mother's poor compliance with breastfeeding recommendations, too much workload, inadequate time and materials for breastfeeding counselling.

CONCLUSION

Nurses and midwives in this study felt confident about breastfeeding counselling, had positive attitudes towards breastfeeding counselling and generally, satisfied with their breastfeeding educational experiences. Despite nurses and midwives agreeing that breastfeeding counselling is integral in their professional practice, their role in providing breastfeeding counselling is hindered by individual and health systems barriers.

Barriers for early initiation and exclusive breastfeeding up to six months in predominantly rural Sri Lanka: a need to strengthen policy implementation

Background

Sri Lanka was named as the first-ever ‘Green’ breastfeeding nation status by the World Breastfeeding Trends Initiative (WBTi) in January 2020. However, improvements are still needed. This study aims to identify barriers and facilitators for early initiation of breastfeeding and exclusive breastfeeding for 6 months in rural Sri Lanka.

Methods

We conducted in-depth interviews with 16 mothers with infants, who had been unable to practice early initiation of breastfeeding and/or exclusive breastfeeding (EBF), in six child-welfare clinics in Anuradhapura, Sri Lanka. Three focus group discussions were held with public health midwives (PHMs). Initial thematic analysis that built upon force field and social learning theories was performed.

Results

Main barriers for EBF were clustered at three time periods; during the first 2–3 days, 2–3 weeks, and 4–5 months postpartum. Early barriers included cesarean section pain, poor breast latch, maternal exhaustion, suboptimal maternity ward environment, and lack of support for breastfeeding. Around 2–3 weeks postpartum mothers introduced water or infant formula due to social norms and poor support. On-demand feeding was misunderstood. Around 4 and 5 months postpartum, EBF ended due to return to work. PHMs reported a heavy workload limiting their time to support breastfeeding.

Conclusion

EBF interruption was due to diverse individual- and environnmental- level barriers that varied across the first 6 months. To improve EBF, Sri Lanka should focus on strengthening policies for reducing the excessive rates of cesarean section, improving support in maternity ward facilities, fostering on-demand breastfeeding, enhancing support for working mothers and reducing the work load of PHMs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00378-0.

Human Milk Microbiota and Oligosaccharides: A Glimpse into Benefits, Diversity, and Correlations

Human milk represents a cornerstone for growth and development of infants, with extensive array of benefits. In addition to exceptionally nutritive and bioactive components, human milk encompasses a complex community of signature bacteria that helps establish infant gut microbiota, contributes to maturation of infant immune system, and competitively interferes with pathogens. Among bioactive constituents of milk, human milk oligosaccharides (HMOs) are particularly significant. These are non-digestible carbohydrates forming the third largest solid component in human milk. Valuable effects of HMOs include shaping intestinal microbiota, imparting antimicrobial effects, developing intestinal barrier, and modulating immune response. Moreover, recent investigations suggest correlations between HMOs and milk microbiota, with complex links possibly existing with environmental factors, genetics, geographical location, and other factors. In this review, and from a physiological and health implications perspective, milk benefits for newborns and mothers are highlighted. From a microbiological perspective, a focused insight into milk microbiota, including origins, diversity, benefits, and effect of maternal diet is presented. From a metabolic perspective, biochemical, physiological, and genetic significance of HMOs, and their probable relations to milk microbiota, are addressed. Ongoing research into mechanistic processes through which the rich biological assets of milk promote development, shaping of microbiota, and immunity is tackled.

Combination-Feeding Causes Differences in Aspects of Systemic and Mucosal Immune Cell Phenotypes and Functions Compared to Exclusive Sow-Rearing or Formula-Feeding in Piglets

Combination feeding (human milk and formula) is common and influences immune development compared to exclusive breastfeeding. Infant formulas contain prebiotics, which influence immune development. Herein, immune development of combination-fed (CF), sow-reared (SR) and formula-fed (FF) piglets, and the effect of prebiotics was tested. Piglets (n = 47) were randomized to: SR, FF, CF, FF+prebiotic (FP), and CF+prebiotic (CP). FP and CP received formula with galactooligosaccharides and inulin (4 g/L in a 4:1 ratio). CF and CP piglets were sow-reared for until d5 and then rotated between a sow and formula every 12 h. On day 21, piglets received an intraperitoneal injection of lipopolysaccharide 2 h prior to necropsy. Immune cells from blood, mesenteric lymph nodes (MLN), and spleen were phenotyped. Classical (nitric oxide synthase) and alternative (arginase activity) activation pathways were measured in isolated macrophages. Serum IL-6 and TNF-α were measured by ELISA. SR piglets had lower (p < 0.0001) CD4+ T-helper cells and higher (p < 0.0001) B-cells in PBMC than all other groups. CP piglets had higher (p < 0.0001) arginase activity compared to all other groups. FF piglets had higher (p < 0.05) IL-6 compared to both CF and SR, but were similar to FP and CP. Thus, CF, with or without prebiotics, differentially affected immunity compared to exclusively fed groups.

Potential Issues in the Freezing of Breast Milk

Frost-free freezers affect the storage of breast milk.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations

Introduction

The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Main recommendations

We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions.

Changes in management as a result of the guidelines

A GRADE approach is used.

Targeted recommendations for both high and low risk children.

New tympanostomy tube otorrhoea section.

New Priority 5 for health services: annual and catch‐up ear health checks for at‐risk children.

Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children.

Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration.

Concurrent audiology and surgical referrals are recommended where delays are likely.

Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis.

The use of autoinflation devices is recommended for some children with persistent otitis media with effusion.

Definitions for mild (21–30 dB) and moderate (> 30 dB) hearing impairment have been updated.

New “OMapp” enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.

Identifying distinct trajectories of acute otitis media in children: A prospective cohort study

Objectives

To identify possibly distinct acute otitis media (AOM) trajectories in childhood and identify determinants associated with specific AOM trajectories. To explore which child will become prone to recurrent AOM episodes and which will not.

Design

Population‐based prospective cohort study among 7863 children from birth until 10 years and their mothers.

Methods

This study was embedded in the Generation R Study: a population‐based prospective cohort study. Data on AOM and determinants were collected by repeated parental questionnaires. Distinct AOM trajectories within the population were identified with latent‐class analyses. Next, using multivariate analysis we checked whether specific determinants were associated with specific trajectories.

Results

Three distinct trajectories were identified; that is, non–otitis prone, early AOM—that is children who suffered AOM episodes until 3 years of age but not beyond, and persistent AOM—that is children who remained otitis‐prone. Male gender (OR: 1.26, CI: 1.11‐1.43) and day‐care attendance (OR: 1.31, CI: 1.06‐1.60) were associated with increased odds of early AOM. Breastfeeding was beneficial for children in both the early‐AOM and persistent‐AOM trajectories (OR: 0.78 and 0.77, respectively). Birth in the summer or autumn as compared with birth in the spring decreased odds of AOM only in the persistent‐AOM trajectory. Half of all AOM‐prone children recovered after the age of 3 years.

Conclusion

Specific determinants are associated with different AOM trajectories. Future research is needed to better predict which child will remain otitis‐prone and which recovers after the age of 3 years to better tailor treatment towards the needs of the individual child.

A cross-sectional study on the practice of wet nursing among Muslim mothers

Background

Breastfeeding and wet nursing have been synonymous since ancient times. The practice of wet nursing of another woman’s child in Malaysia is on the rise due to the emergence of awareness among the public about the importance and advantages of breast milk. However, problems arise when there is no systematic system to record and trace the milk mother and milk child data, especially for Muslim participants as milk kinship could affect their relationship status in Islam. Therefore, this study aims to determine the practice of wet nursing among Muslim mothers in Selangor. Simultaneously, this study intends to provide the authorities with an accurate picture of the more aggressive compilation of steps to prevent duplication of consanguinity in wet nursing.

Methods

This cross-sectional study was conducted on 100 women who had breastfed another child in Selangor. Data were obtained using a validated questionnaire (Cronbach alpha = 0.8) and processed using the SPSS software.

Results

Results showed 43.0% of respondents had at least breastfed one someone else’s child. Meanwhile, there were 3.0% of the respondents were nursing seven to ten other children. A total of 237 children have been breastfed by the respondents (n = 100). Of these, 21.5% children were breastfed less than five times, while 78.5% children were breastfed less than five times. Most mothers recorded their milk child background data, and this shows that the community is aware of the importance of data documentation and it indirectly proves that the authorities should act on these current needs.

Conclusions

This study shows that there is a wet nursing practice in the society. Obviously, a phenomenon, trend and practice in the society has the ground and basis as to why it existed and is upheld. Researches related to wet nursing and matters connected to it should continue so as to bring about much good to society.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03551-9.

UNICEF UK Baby Friendly Initiative: Providing, receiving and leading infant feeding care in a hospital maternity setting-A critical ethnography

Although breastfeeding is known to improve health, economic and environmental outcomes, breastfeeding initiation and continuation rates are low in the United Kingdom. The global WHO/UNICEF Baby Friendly Hospital Initiative (BFHI) aims to reverse declining rates of breastfeeding by shifting the culture of infant feeding care provision throughout hospital maternity settings. In the United Kingdom, the global BFHI has been adapted by UNICEF UK reflecting a paradigm shift towards the experiences of women and families using maternity services. This research used a critical ethnographic approach to explore the influence of the national UNICEF UK Baby Friendly Initiative (BFI) standards on the culture of one typical maternity service in England, over a period of 8 weeks, across four phases of data collection between 2011 and 2017. Twenty‐one staff and 26 service users were recruited and engaged in moderate‐level participant observation and/or guided interviews and conversations. Basic, organising and a final global theme emerged through thematic network analysis, describing the influence of the BFI on providing, receiving and leading infant feeding care in a hospital maternity setting. Using Antonovsky's sense of coherence construct, the findings discussed in this paper highlight how the BFI offers ‘informational’ (comprehensible), ‘practical’ (manageable) and ‘emotional’ (meaningful) support for both staff and service users, strengthened by effective, local leadership and a team approach. This is juxtaposed against the tensions and demands of the busy hospital maternity setting. It is recommended that ongoing infant feeding policy, practice and leadership balance relational and rational approaches for positive infant feeding care and experiences to flourish.

Influence of Breastfeeding in the Adaptation of and Absenteeism of Infants in Early Childhood Centers: A Preliminary Study

Schooling of children between 0 and 3 years old involves a process of adaptation and increases their exposure to infectious diseases, which leads to school absenteeism. Breastfeeding facilitates the development of secure attachment and protects the infant against infections. This study aimed to determine whether breastfeeding facilitates the adaptation of infants between 0 and 3 years old to early childhood center and decreases school absenteeism. A cross-sectional study was carried out by collecting data through a questionnaire, which was filled out by the parents and the childcare professionals. 160 infants participated. 40% of the infants who received infant formula from birth showed dependency behaviors (inconsolable crying or do not leave the caregiver for a long time) at the time of pick-up from the center, compared with 10%, 2.7%, and 2.6% of children breastfed between 0 and 6 months, and more than 6 and 12 months, respectively (p = 0.001). The interquartile range of absenteeism days per episode was 2-3 days for infants fed infant formula versus 1-2 days for those who were breastfed for more than 12 months (p = 0.041). Breastfeeding seems to be associated with fewer dependency behaviors at the time of collection and with fewer days of absence.

Social value of maintaining baby-friendly hospital initiative accreditation in Australia: case study

BACKGROUND

Breastfeeding has positive impacts on the health, environment, and economic wealth of families and countries. The World Health Organization (WHO) launched the Baby Friendly Hospital Initiative (BFHI) in 1991 as a global program to incentivize maternity services to implement the Ten Steps to Successful Breastfeeding (Ten Steps). These were developed to ensure that maternity services remove barriers for mothers and families to successfully initiate breastfeeding and to continue breastfeeding through referral to community support after hospital discharge. While more than three in four births in Australia take place in public hospitals, in 2020 only 26% of Australian hospitals were BFHI-accredited. So what is the social return to investing in BFHI accreditation in Australia, and does it incentivize BFHI accreditation? This study aimed to examine the social value of maintaining the BFHI accreditation in one public maternity unit in Australia using the Social Return on Investment (SROI) framework. This novel method was developed in 2000 and measures social, environmental and economic outcomes of change using monetary values.

METHOD

The study was non-experimental and was conducted in the maternity unit of Calvary Public Hospital, Canberra, an Australian BFHI-accredited public hospital with around 1000 births annually. This facility provided an opportunity to illustrate costs for maintaining BFHI accreditation in a relatively affluent urban population. Stakeholders considered within scope of the study were the mother-baby dyad and the maternity facility. We interviewed the hospital's Director of Maternity Services and the Clinical Midwifery Educator, guided by a structured questionnaire, which examined the cost (financial, time and other resources) and benefits of each of the Ten Steps. Analysis was informed by the Social Return on Investment (SROI) framework, which consists of mapping the stakeholders, identifying and valuing outcomes, establishing impact, calculating the ratio and conducting sensitivity analysis. This information was supplemented with micro costing studies from the literature that measure the benefits of the BFHI.

RESULTS

The social return from the BFHI in this facility was calculated to be AU$ 1,375,050. The total investment required was AU$ 24,433 per year. Therefore, the SROI ratio was approximately AU$ 55:1 (sensitivity analysis: AU$ 16-112), which meant that every AU$1 invested in maintaining BFHI accreditation by this maternal and newborn care facility generated approximately AU$55 of benefit.

CONCLUSIONS

Scaled up nationally, the BFHI could provide important benefits to the Australian health system and national economy. In this public hospital, the BFHI produced social value greater than the cost of investment, providing new evidence of its effectiveness and economic gains as a public health intervention. Our findings using a novel tool to calculate the social rate of return, indicate that the BHFI accreditation is an investment in the health and wellbeing of families, communities and the Australian economy, as well as in health equity.

Incidental lowering of otitis-media complaints in otitis-prone children during COVID-19 pandemic: not all evil comes to hurt

Given COVID-19 pandemic periodic outpatient assessment of otitis-prone children regularly followed at our tertiary outpatient clinic of upper respiratory tract infections was discontinued since 9 March. In order to avoid leaving the patients to themselves just during the winter months, which are the most critical ones for these children, we kept in touch with the families of 102 children (mean age 41.4 ± 14.0 months) who had had a follow-up visit scheduled during the lockdown, and compensated with telemedicine assessment. This incidentally leads to the unexpected but not at all negative finding that a consistent clinical improvement had been occurred in most (82.3%) of children. A statistically significant reduction in the mean number of documented acute otitis media episodes, otorrhea episodes, and systemic antibiotic treatments during the February-April 2020 period compared with February-April 2019 was attested. Clinical evaluation performed in 27.4% cases revealed normal middle ear findings in all but three (89.3%) children.Conclusion: Our data document a global improvement of otitis-prone children in Milan during the Italian lockdown, as a fortuitous and incidental positive effect of the national lockdown. What is Know: • During COVID-19 pandemic in Italy any non-urgent medical activity including periodic outpatient assessment of otitis-prone children was discontinued. • Otitis-prone children experience acute infectious exacerbations mainly in winter. What is New: • Most of children reached by means of a telemedicine assessment during lockdown experienced a subjective clinical improvement; clinical assessment at the end of the lockdown revealed normal otoscopic findings in most cases. • Exceptional circumstances during COVID-19 pandemic had a fortuitous positive effect on otitis-prone children's clinical conditions.

Demographics and Geographic Distribution of Mothers Donating to a Nonprofit Milk Bank

Background: The Human Milk Banking Association of North America (HMBANA) is a nonprofit association that standardizes and facilitates the establishment and operation of nonprofit donor human milk banks in North America. Few studies have examined milk donor characteristics and geographic distribution, and little is known about how donor characteristics change with time. Materials and Methods: We performed a retrospective cohort study of mothers who donated to Mothers' Milk Bank Northeast (MMBNE) between January 1, 2011 and September 1, 2019. Data collected from MMBNE donor surveys and collection procedures were analyzed using descriptive and comparative statistics. Donor characteristics were examined for secular trends. Results: Donors (n = 3,764) were of mean age 32.5 years (median 32; IQR 30-35) and most donated more than once (median 2; IQR 1-3; range 1-41). The majority of donors gave birth to term infants and resided in New England; however, MMBNE donors were located in 39 states at the time of donation. Median total volume donated per donor was median 11,396 mL (380 Oz); IQR 6,020-24,242 mL. Mothers of preterm compared with term infants were more likely to be bereaved (p < 0.01) and donated larger volumes (p < 0.01). Over time, number of first-time donors increased, although donors became less likely to have preterm infants or to reside in Massachusetts or New England. Conclusions: Donors to MMBNE varied greatly in age and were broadly distributed geographically. Donor characteristics changed substantially over time. Enhanced understanding of the characteristics of donors may improve the efficiency of efforts to promote milk donation.

The Possible Effects of Breastfeeding on Infant Development at 3 Months: A Case-Control Study

Objective: To examine the influence of exclusive breastfeeding on infant development among 3-month-old infants in a Chinese population. Methods: Mothers and their 3-month-old infants were recruited from four maternal and child health hospitals from April 2018 to March 2019. Based on the infants' feeding patterns, the mother-infant dyads were divided into two groups: exclusive breastfeeding and formula feeding groups. Infant development was evaluated using the Chinese version of the Ages and Stages Questionnaires, 3rd edition (ASQ-C), and maternal depression, parenting confidence, and infant temperament were also assessed using the relevant scales/questionnaires. Multivariate logistic regression analysis was conducted to explore the effects of feeding patterns on infant development at 3 months. Results: The data from 417 mother-infant dyads were analyzed. For the breastfeeding group and formula feeding group, the risk of developmental delay measured by the ASQ-C was 4.1% (10/244) and 9.3% (16/173) respectively for the communication domain; 5.7% (14/244) and 8.1% (14/173) for problem-solving domain and 6.2% (15/244) and 12.1% (21/173) for personal-social domain, respectively. Compared with exclusive breastfeeding, formula feeding was a risk factor for delayed development of communication (adjusted odd ratio [aOR] = 2.60, 95% confidence interval [CI] = 1.42-4.75) problem-solving (aOR = 1.91, 95% CI = 1.06-3.45), and personal-social skills (aOR = 1.96, 95% CI = 1.12-3.42). Conclusions: Exclusive breastfeeding is important for infant communication, problem solving, and social interaction at the age of 3 months. Formula-fed infants may be at a higher risk of developmental delay than exclusively breast-fed infants. It is necessary to encourage mothers to establish and continuous breastfeeding.

Infant drug exposure via breast milk

More than half of women take medications during breastfeeding, predisposing their infants to medication exposure via breast milk. As a result, adverse drug reactions may emerge in the infant, although they are rarely reported. Disposition of maternal drugs in breast milk is described with several key parameters, which include relative infant dose (RID): infant drug intake via milk (weight- and time-adjusted) expressed as a percentage of the similarly adjusted mother's dose. Most drugs show RID values of <10%, indicating that drug concentrations in infant serum do not reach a level known to be therapeutic in adults unless drug clearance is markedly lower than the adult level on a weight basis. RID is a function of milk-to-(maternal) plasma drug concentration ratio (MP ratio) and maternal drug clearance. Therefore, MP ratio between drugs must be interpreted not by itself but with maternal drug clearance of each drug. This is why some drugs such as phenobarbital show an MP ratio of <1 but an RID as high as 50-70%, while morphine shows an MP ratio of 2 but an RID in the range of 5%. Using RID, we interpreted case reports of infant adverse outcomes, and we observed cases with relatively low infant serum concentrations of drug, consistent with low RID, as well as those with near- or above-adult therapeutic serum concentrations, with or without increased drug intake (i.e. high RID). It is important to consider both pharmacokinetic and pharmacodynamic factors in interpreting adverse outcomes in infants breastfed by a mother taking medications.

Breastfeeding initiation or duration and longitudinal patterns of infections up to 2 years and skin rash and respiratory symptoms up to 8 years in the EDEN mother-child cohort

This paper aimed to examine the effect of breastfeeding on longitudinal patterns of common infections up to 2 years and respiratory symptoms up to 8 years. To assess the incidence and reoccurrence of infections and allergic symptoms in the first years of life among 1,603 children from the EDEN mother-child cohort, distinct longitudinal patterns of infectious diseases as well as skin rash and respiratory symptoms were identified by group-based trajectory modelling. To characterize infections, we considered the parent-reported number of cold/nasopharyngitis and diarrhoea from birth to 12 months and otitis and bronchitis/bronchiolitis from birth to 2 years. To characterize allergy-related symptoms, we considered the parent-reported occurrence of wheezing and skin rash from 8 months to 8 years and asthma from 2 to 8 years. Then associations between breastfeeding and these longitudinal patterns were assessed through adjusted multinomial logistic regression. Compared with never-breastfed infants, ever-breastfed infants were at a lower risk of diarrhoea events in early infancy as well as infrequent events of bronchitis/bronchiolitis throughout infancy. Only predominant breastfeeding duration was related to frequent events of bronchitis/bronchiolitis and infrequent events of otitis. We found no significant protective effect of breastfeeding on longitudinal patterns of cold/nasopharyngitis, skin rash, or respiratory symptoms. For an infant population with a short breastfeeding duration, on average, our study confirmed a protective effect of breastfeeding on diarrhoea events in early infancy, infrequent bronchitis/bronchiolitis and, to a lesser extent, infrequent otitis events up to 2 years but not on other infections, skin rash, or respiratory symptoms4.

The economic benefits of increasing breastfeeding rates in Spain

Background

Interventions aimed at promoting breastfeeding rates are among the most effective possible health policies available, with an estimated return of US$35 per dollar invested. Indeed, some authors found that a 10% increase in exclusive breastfeeding rates in the first two years of life led to a reduction in treatment costs of US$312 million in the US, US$7.8 million in the UK, US$30 million in China, and US$1.8 million in Brazil. Among high-income countries, Spain stands out for its low breastfeeding rate.

Methods

We calculated the savings that the Spanish National Health System would have benefited from had breastfeeding rates been higher in Spain, both from the time of hospital discharge and at 6 months postpartum. We followed the methods used in similar studies carried out in the US, Italy, Australia, the Netherlands, and the UK, to conservatively estimate these potential savings by considering only the lower thresholds in all our estimates. Here we approximated the benefits of having increased exclusive breastfeeding rates based on the lower incidence of infantile pathologies among exclusively breastfed infants. Robust evidence indicates that among breastfed infants there is a lower prevalence of otitis media, gastroenteritis, respiratory infections, and necrotising enterocolitis. We obtained the estimated monetary cost of these diseases by combining their prevalences with data about their economic costs for diagnosis-related groups.

Results

The estimated effects we calculated imply that the Spanish National Health System could have saved more than €5.6 million for every percentage point increase in exclusive breastfeeding rates in Spain during 2014.

Conclusions

Breastfeeding is essential both for the health of mothers and the health and development of newborns but is rarely considered as an economic issue and remains economically invisible. In addition to the improved wellbeing of mothers and their infants, breastfeeding can positively impact society as a whole and should therefore be better defined in public policies. Thus, strategies aimed at increasing exclusive breastfeeding rates would likely contribute to lowering the fiscal burden of the Spanish National Health System. Moreover, the magnitude of these potential benefits suggests that such policies would likely be socially cost–effective.

An assets-based intervention before and after birth to improve breastfeeding initiation and continuation: the ABA feasibility RCT

Background

The UK has low levels of breastfeeding initiation and continuation, with evident socioeconomic disparities. To be inclusive, peer-support interventions should be woman-centred rather than breastfeeding-centred. Assets-based approaches to public health focus on the positive capabilities of individuals and communities, rather than their deficits and problems. The Assets-based feeding help Before and After birth (ABA) intervention offers an assets-based approach based on behaviour change theory.

Objective

To investigate the feasibility of delivering the ABA infant feeding intervention in a randomised controlled trial.

Design

This was an individually randomised controlled feasibility trial; women were randomised in a 1 : 1 ratio to either the intervention group or the comparator (usual care) group.

Setting

Two separate English sites were selected because they had an existing breastfeeding peer support service, relatively high levels of socioeconomic disadvantage and low rates of breastfeeding.

Participants

Women aged ≥ 16 years who were pregnant with their first child, irrespective of feeding intention (n = 103), were recruited by researchers in antenatal clinics.

Interventions

Proactive, woman-centred support, using an assets-based approach and including behaviour change techniques, was provided by an infant-feeding helper (a breastfeeding peer supporter trained in the ABA intervention) and delivered through face-to-face contact, telephone conversations and text messages. The intervention commenced at around 30 weeks’ gestation and could continue until 5 months postnatally.

Main outcome measures

The main outcome measures were feasibility of intervention delivery with the requisite intensity and duration; acceptability to women, infant-feeding helpers and maternity services; and feasibility of a future randomised controlled trial. Outcomes included recruitment rates and follow-up rates at 3 days, 8 weeks and 6 months postnatally, and outcomes for a future full trial were collected via participant questionnaires. A mixed-methods process evaluation included qualitative interviews with women, infant-feeding helpers and maternity services; infant-feeding helper logs; and audio-recordings of antenatal contacts to check intervention fidelity.

Results

Of the 135 eligible women approached, 103 (76.3%) agreed to participate. The study was successful in recruiting teenagers (8.7%) and women living in areas of socioeconomic disadvantage (37.3% resided in the most deprived 40% of small areas in England). Postnatal follow-up rates were 68.0%, 85.4% and 80.6% at 3 days, 8 weeks and 6 months, respectively. Feeding status at 8 weeks was obtained for 95.1% of participants. Recruitment took place from February 2017 until August 2017. It was possible to recruit and train existing peer supporters to the infant-feeding helper role. The intervention was delivered to most women with relatively high fidelity. Among the 50 women in the intervention group, 39 received antenatal visits and 40 received postnatal support. Qualitative data showed that the intervention was acceptable. There was no evidence of intervention-related harms.

Limitations

Birth notification delays resulted in delays in the collection of postnatal feeding status data and in the offer of postnatal support. In addition, the intervention needs to better consider all infant-feeding types and did not adequately accommodate women who delivered prematurely.

Conclusion

It is feasible to deliver the intervention and trial.

Future work

The intervention should be tested in a fully powered randomised controlled trial.

Trial registration

Current Controlled Trials ISRCTN14760978.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information.

Maternal chronic disease and breastfeeding outcomes: a Canadian population-based study

Background: The prevalence of chronic disease in pregnant women has consistently risen over the past two decades. Substantial evidence demonstrates that maternal chronic disease is associated with adverse medical outcomes like preterm birth, but less research has characterized postpartum outcomes such as infant feeding practices. It is recommended that infants be exclusively breastfed from birth to 6 months given the numerous health benefits it provides.Objective: To determine the association between maternal chronic disease and breastfeeding outcomes.Methods: We analyzed cross-sectional self-report data from the 2015/2016 Canadian Community Health Survey, restricted to women who gave birth within 2 years of data collection (n = 2100, rounded). The exposure was professionally diagnosed chronic physical disease (e.g. diabetes, arthritis, heart disease). The outcomes were breastfeeding non-initiation and early cessation of breastfeeding before 6 months. Multivariable logistic regression modeling was used to estimate adjusted odds ratios (AOR) with 95% confidence intervals (CIs). Estimates were bootstrapped and weighted to represent the national population.Results: Overall, 11.9% (95% CI 9.8-14.1) of women reported chronic disease, and were more likely to be single, be Canadian born, have low education, and be overweight/obese than women without chronic disease. The mean maternal age was approximately 30 years in both groups. Women with chronic disease had similar odds of breastfeeding non-initiation (AOR 0.96, 95% CI 0.54-1.71) and early cessation of any breastfeeding (AOR 1.40, 95% CI 0.82-2.40), but over twice the odds of early cessation of exclusive breastfeeding (AOR 2.48, 95% CI 1.49-4.12) compared to unaffected women.Conclusion: Mothers with chronic disease initiate and continue some form of breastfeeding to six months as often as their unaffected peers. However, they have substantially higher odds of ceasing exclusive breastfeeding before the recommended 6 months. Findings suggest a need to investigate the reasons for this disparity to ensure that appropriate breastfeeding support is available for women with chronic disease and their children.

Environmental determinants associated with acute otitis media in children: a longitudinal study

BACKGROUND

Acute otitis media (AOM) is a common pediatric disease and frequent reason for antibiotic treatment. We aimed to identify environmental and host factors associated with AOM and assess which determinants were associated with AOM at specific ages.

METHODS

This study among 7863 children was embedded in the Generation R Study: a population-based prospective cohort study from fetal life onwards. Data on outcome and possible determinants were collected using questionnaires until 6 years. We used generalized estimating equation models to examine associations with AOM with longitudinal odds at different ages, considering correlations between repeated measurements.

RESULTS

Male gender increased odds of AOM in children at 2, 3, and 4 years but not at other ages. Postnatal household smoking, presence of siblings, and pet birds increased odds of AOM. Breastfeeding decreased AOM odds, most notably in the first 2 months of life. No association was found for season of birth, maternal age, ethnicity, aberrant birth weight for gestational age, prenatal smoking, furry pets, and daycare attendance.

CONCLUSIONS

Risk of childhood AOM varies with age. Significant association with AOM was found for gender and breastfeeding at specific ages and for household smoking, presence of siblings, and pet birds at all the studied ages.

Perspective: Human Milk Oligosaccharides: Fuel for Childhood Obesity Prevention?

Obesity begins early but has lifelong consequences for health and well-being. Breastfeeding is thought to be preventive against obesity, but the extent and cause of this association are not well understood. Human milk oligosaccharides (HMOs) are abundant in human milk and not present in commercially available infant formula. These complex sugars are thought to contribute to the development of the infant gut microbiome and immune system. Recently, they have been investigated as a potential link between breastfeeding and lower obesity risk. So far, only a few human studies have examined HMO composition of human milk in association with the infant's concurrent anthropometry or subsequent growth in infancy, with conflicting results. However, HMOs have been shown to modulate the gut microbiome profile by selectively promoting the growth of specific bacteria, such as bifidobacteria. Moreover, there are differences in the gut microbiome of lean and obese humans, and there is some evidence that the early composition of the gut microbiome can predict later obesity. Although it seems that HMOs might have a role in infant growth and adiposity, there is not enough consistent evidence to understand their potential role in obesity prevention. More data, particularly from large or longitudinal studies, are needed to clarify the functions of HMOs and other breast-milk components in determining long-term health.

Assessment of the implementation of the Baby-Friendly Hospital Initiative in Greece

INTRODUCTION

This report aims to outline the views of health professionals, working in maternity clinics, on the usefulness, benefits and difficulties of integrating the Baby-Friendly Hospital Initiative (BFHI), and to illustrate their degree of awareness about it and extent to which they are informed about BHFI.

METHODS

The method of qualitative research was used to conduct the study using an open-ended questionnaire and interview technique. Sixteen health professionals working in 4 hospitals and maternity clinics in Thessaloniki (Ippokrateio, Papageorgiou, Diabalkaniko, and Genesis) participated in the interviews with equal participation of individuals in the sample.

RESULTS

The extent to which respondents are informed about the Βaby-Friendly Hospital Initiative is relatively satisfactory, but there is no comprehensive knowledge of the steps required by the Harmonisation Directive. Harmonisation with the guidelines proposed by the BFHI is expected to improve the quality of obstetric clinic services and lead to a reduction in costs. However, there are particular difficulties in adapting hospitals to baby-friendly practices, particularly concerning the resources required.

CONCLUSIONS

Hospitals need to make significant changes in organisation, resource efficiency and utilization, and staff training, to fully integrate the BFHI, as integration of procedures is very limited and no research has been conducted in this area in Greece.

Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics: Prevention

BACKGROUND

In recent years, new information has been acquired regarding the diagnosis, treatment and prevention of acute otitis media (AOM). The Italian Pediatric Society, therefore, decided to issue an update to the Italian Pediatric Society guidelines published in 2010.

METHODS

The search was conducted on Pubmed, and only those studies regarding the pediatric age alone, in English or Italian, published between January 1, 2010 and December 31, 2018, were included. Each study included in the review was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The quality of the systematic reviews was evaluated using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 appraisal tool. The guidelines were formulated using the GRADE methodology by a multidisciplinary panel of experts.

RESULTS

The importance of eliminating risk factors (passive smoking, environmental pollution, use of pacifier, obesity, limitation of day-care center attendance) and the promotion of breastfeeding and hygiene practices (nasal lavages) was confirmed. The importance of pneumococcal vaccination in the prevention of AOM was reiterated with regard to the prevention of both the first episode of AOM and recurrences. Grommets can be inserted in selected cases of recurrent AOM that did not respond to all other prevention strategies. Antibiotic prophylaxis is not recommended for the prevention of recurrent AOM, except in certain carefully selected cases. The use of complementary therapies, probiotics, xylitol and vitamin D is not recommended.

CONCLUSIONS

The prevention of episodes of AOM requires the elimination of risk factors and pneumococcal and influenza vaccination. The use of other products such as probiotics and vitamin D is not supported by adequate evidence.

Formula feeding increases the risk of antibiotic prescriptions in children up to 2 years: results from a cohort study

Association between the use of infant formula and risks for infants' health is seldom studied in western countries. We set up a historical cohort based on record linkage analysis, combining the data from administrative databases providing individual data. Infants receiving the second dose of pediatric immunization between 2015 and 2017 were included. The main outcome measure was antibiotic prescriptions from enrolment up to 24 months of age, by infant feeding category at enrolment. The extended Cox regression technique was used to account for recurrent events. The infants' cohort included 40,258 5-month-old infants; during the study period, 60,932 antibiotic prescriptions were filled. Compared with infants fully breastfed, children fed with both maternal milk and formula received 106 more antibiotic prescriptions per 1000 children/year, whereas infants receiving formula only had 138 excess prescriptions per 1000 children/year. The association with infant feeding was statistically significant and remained unchanged after adjustment for common confounders (adjusted hazard ratio, HR, for complementary feeding vs full breastfeeding 1.09; 95%CI 1.05 to 1.12; formula only versus full breastfeeding adj. HR 1.12; 95%CI 1.08 to 1.16).Conclusion: In our cohort, we observed a positive association between infant formula use considered a proxy of infections antibiotic prescription rate, considered a proxy of infections. The association followed a gradient.What is Known:• Formula feeding is associated with increased morbidity and mortality even in western countries, but still, it is common.• Information on formula are seldom unbiased; thus, public perception of risks is distorted.What is New:• In a large Italian cohort of infants, formula feeding at 5 months of age results to be associated with an increased rate of antibiotic prescription (considered to be a proxy of infection) up to 24 months of age: the association follows a dose-response relationship.• Record linkage analysis using administrative databases provides useful information at a limited cost.

Individualized intervention to improve rates of exclusive breastfeeding: A randomised controlled trial

BACKGROUND

Despite breastfeeding is significant benefits for maternal and infant, the discontinuation of breastfeeding is high. Some of studies showed that the effect of intervention in improving the rate of exclusively breastfeeding is unclear. The aim of this study is to investigate the effectiveness of individualized intervention compared with routine care in improving rates of exclusive breast feeding.

METHODS

Women were divided into two groups. We provided individual antenatal breastfeeding education and postnatal lactation support to intervention group. Control group received routine care. Significance was set at P < .05.

RESULTS

We recruited 352 women of whom 176 were randomized to intervention group, 176 to control group. In total, 293 (83.2%) completed 4 months of follow-up. At discharge from hospital, 43.2% of women randomized to intervention group were exclusively breastfeeding compared with 30.0% of women in control group (relative risk 1.78; 95% confidence interval [CI] 1.12-2.82). At 4 months, 70.9% of women in the intervention group were exclusively breastfeeding compared with 46.2% of the women in the control group (2.84; 1.76-4.60). At discharge from hospital, 95.1% of women in the intervention group were breastfeeding on demand compared with 68.1% of women receiving routine care (9.00; 4.09-19.74). At 4 months, 94.6% of women in intervention group were breastfeeding on demand compared with 75.9% of women in the control group (5.57; 2.48-12.49).

CONCLUSION

The regular ongoing individualized antenatal education and postnatal support can effective increase the rates of exclusive breastfeeding from delivery to postpartum 4 months and change the breastfeeding behavior.

Breast Milk Feeding Practices and Barriers and Supports Experienced by Mother–Infant Dyads With Cleft Lip and/or Palate

Objective:

To examine trends in breast milk provision and to characterize the breast milk feeding practices experienced by mother–infant dyads with cleft lip and/or palate (CL/P) in a large US sample.

Design:

Cross-sectional study.

Methods:

An online survey was distributed through cleft-related social media sites in the United States and in a single cleft lip and palate clinic. Statistical analyses included Kruskal-Wallis H tests and post hoc Mann-Whitney tests to examine group differences based on cleft type and prenatal versus postnatal cleft diagnosis. Linear regression was used to estimate associations between obtained variables.

Participants:

One hundred fifty biological mothers of infants (8-14 months of age) with CL/P (15% cleft lip, 29% cleft palate, 56% cleft lip and palate).

Results:

Forty-six percent of mothers of infants with CL/P provided breast milk to their infant for at least 6 months. Five percent of infants ever fed at breast, and 43% received pumped breast milk via bottle. The most commonly reported supports included lactation consultants, nurses, feeding therapists, and online support groups. Feeding therapy was received by 48% of infants.

Conclusions:

A lower percentage of mothers of infants with CL/P reported providing breast milk compared to national estimates of the general population of infants without clefting. Results suggested there are multiple barriers, as well as numerous medical and psychosocial supports that facilitated breast milk feeding success. Implications for care are discussed.

The relationship between breastfeeding and reported respiratory and gastrointestinal infection rates in young children

BACKGROUND

Although breastfeeding is touted as providing many health benefits to infants, some aspects of this relationship remain poorly understood.

METHODS

The Environmental Determinants of Diabetes in the Young (TEDDY) is a prospective longitudinal study that follows children from birth through childhood, and collects data on illness events, breastfeeding duration, and time to introduction of formula or foods at 3 month intervals up until 4 years of age and at 6 months intervals thereafter. Exclusive and non-exclusive breastfeeding is examined in relation to the 3-month odds of a respiratory or gastrointestinal infection for 6861 children between the ages of 3-18 months, and 5666 children up to the age of 4 years. Analysis was performed using logistic regression models with generalized estimating equation methodology. All models were adjusted for potential confounding variables.

RESULTS

At 3-6 months of age, breastfeeding was found to be inversely associated with the odds of respiratory infections with fever (OR = 0.82, 95% CI = 0.70-0.95), otitis media (OR = 0.76, 95% CI = 0.62-0.94), and infective gastroenteritis (OR = 0.55, 95% CI = 0.46-0.70), although the inverse association with respiratory illnesses was observed only for girls during the winter months. Between 6 and 18 months of age, breastfeeding within any 3 month period continued to be inversely associated with the odds of ear infection and infective gastroenteritis, and additionally with the odds of conjunctivitis, and laryngitis and tracheitis, over the same 3 month period within this age range. However, breastfeeding in this group was associated with increased reports of common cold. Duration of exclusive breastfeeding was inversely associated with the odds of otitis media up to 48 months of age (OR = 0.97, 95% CI = 0.95-0.99) after breastfeeding had stopped.

CONCLUSIONS

This study demonstrates that breastfeeding can be protective against multiple respiratory and gastrointestinal acute illnesses in some children up to at least 6 months of age, with duration of exclusive breastfeeding being somewhat protective of otitis media even after breastfeeding has stopped.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00279318 . Date of registration: January 17, 2006 (proactively registered). First Posted: January 19, 2006.