Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil

Effectiveness of a large-scale home visiting programme (PIM) on early child development in Brazil: quasi-experimental study nested in a birth cohort

BACKGROUND

A large-scale parenting programme with weekly home visits (Primeira Infância Melhor (PIM)) has been implemented in the south of Brazil for nearly two decades, but lacks evaluation of its effects on early childhood development (ECD). This quasi-experimental study aimed to assess the effects of PIM in real-life settings within a population-based birth cohort study.

METHODS

Data from the 2015 Pelotas Birth Cohort Study and the state programme information system were linked to identify study children who received PIM. Propensity score matching was used to create a comparable control group (using one-to-one matching) to estimate the effect of PIM on ECD measured at age 4 years. First, the impact of any enrolment in PIM was evaluated; then the intervention group was stratified according to whether enrolment occurred during pregnancy or after birth. Double adjustment was applied in linear regression to analyse child development scores, and Poisson regression for delayed development (below the 10th percentile of whole cohort). Effect modification due to family income was explored.

RESULTS

There was no evidence that any enrolment in PIM (601 pairs) by age 4 years was associated with child development. However, PIM starting during pregnancy (estimated for 121 pairs) predicted higher development scores (0.27 SD; 95% CI 0.02 to 0.52), and 71% lower prevalence of delayed development (prevalence ratio=0.29; 95% CI 0.13 to 0.69), compared with the control group. There was strong statistical evidence (p=0.003, test of interaction) that the effect of PIM starting in pregnancy was larger than when starting after birth (480 pairs). The effect of PIM starting during pregnancy was found to be restricted to poorer families.

CONCLUSIONS

In a real-life setting, PIM was effective only when starting during pregnancy and only for poorer families. A higher-quality programme might be more effective with a broader population.

Breastfeeding in a Global Context: Epidemiology, Impact, and Future Directions

INTRODUCTION

More than 98% of infant deaths occur in low- and middle-income countries (LMICs). Breastfeeding improves infant survival and protects against certain illnesses, such as diarrhea and pneumonia, which are leading causes of deaths in those <5 years of age in LMICs. The World Health Organization (WHO) recommends early initiation of breastfeeding within 1 hour of birth, exclusive breastfeeding up to 6 months of age, and continued breastfeeding up to 2 years of age. However, fewer than half of infants in LMICs are breastfed optimally to these standards. The objectives of this article are to describe the global epidemiology and health benefits of breastfeeding with particular focus on LMICs.

METHODS

We searched PubMed to identify original research articles on breastfeeding in LMICs and reviews related to the benefits of breastfeeding, with particular focus on articles published in the past 5 years. We used reports and data published by the WHO and the United Nations Children's Fund (UNICEF) related to global breastfeeding rates, targets, and programmatic initiatives. We used the Lives Saved Tool to estimate mortality related to breastfeeding practices.

FINDINGS

Less than half of infants globally receive early, exclusive, or continued breastfeeding. Certain high-risk groups, such as premature or HIV-exposed infants, face particular challenges and benefits related to breastfeeding. The WHO, UNICEF, and other global partners have developed a multipronged strategy to promote global breastfeeding, ranging from government-level advocacy to grassroots community support groups. Using the Lives Saved Tool, we estimate that nearly 200,000 lives of those <5 years of age could be saved in LMICs from 2020 to 2030 if early, exclusive, and continued breastfeeding rates were linearly increased from current rates to meet the WHO 2030 goals of 60% to 80% coverage. If this goal were exceeded and near-universal coverage were achieved, the number of lives would increase even further such that >820,000 lives per year could potentially be saved by universal breastfeeding. In this review, we delineate the health and economic benefit of breastfeeding in LMICs, discuss breastfeeding epidemiology in the global context, and describe targeted strategies to improve breastfeeding uptake.

Factors associated with early childhood development in municipalities of Ceará, Brazil: a hierarchical model of contexts, environments, and nurturing care domains in a cross-sectional study

Background

This study aims to identify the contexts, environments, and nurturing care predictors that determine whether a child is developmentally on track in Ceará, Brazil.

Methods

We analysed data from a cross-sectional study conducted with caregivers of 6,447 children aged 0-59 months during a vaccination campaign in Ceará in October 2019. The validated Child Development Assessment Questionnaire was used to assess early childhood development (ECD) and children with a z-score ≥ -1 SD were considered developmentally on track. We conducted logistic regression models to understand the effects of contexts, environments, and nurturing care domains on ECD.

Findings

Children in the early years (< 36 months) were more likely to meet the ECD milestones if they were not born with low birth weight (AOR: 0·64; 95% CI: 0·42-0·97), were exposed to manufactured toys in their house (2·68; 1·97-3·66), their heads of household were employed (1·61; 1·16-2·23), and their caregivers had read the Child Health Handbook (1·42; 1·13-1·77) and engaged them in stimulating activities (1·71; 1·26-2·32). Children aged 36-59 months were more likely to meet the ECD milestones if they were breastfed (never: ref. / < 3 months: 3·72; 1·91-7·26 / 3-5 months: 3·21; 1·74-5·93 / 6-11 months: 3·73; 1·95-7·16 / ≥ 12 months: 3·89; 2·25-6·72), had books at home (0: ref / 1-3: 1·71; 1·22-2·40 / 4-6: 2·24; 1·27-3·94 / 7+: 2·71; 1·05-7·00), and their caregivers received information about ECD (1·49; 1·11-2·01) and engaged them in stimulating activities (1·80; 1·27-2·56). Children aged 36-59 months were less likely to meet developmental milestones if they watched TV or used tablets/smartphones for more than two hours per day (0·61; 0·44-0·84), played with household objects (0·62; 0·41-0·92), participated in governmental early childhood programmes aimed at vulnerable families (0·62; 0·45-0·86), had families that participated in income transfer programmes (0·68; 0·47-0·99) (families living in poverty or extreme poverty), and their caregivers considered slapping (0·67; 0·48-0·94) a necessary disciplinary method.

Interpretation

Having favourable socioeconomic conditions, breastfeeding, the absence of harsh discipline, caregivers who provide responsive care, and the provision of opportunities for early learning are the key factors that increase the likelihood of a child achieving their full developmental potential in Ceará, Brazil.

Funding

This study was supported by the Maria Cecília Souto Vidigal Foundation (F0245), Brazil. The funder had no role in the design, analysis, or writing of this article.

Association between Food Intake and Overweight in Children Assisted by Primary Care

Background:

The child feed in the first two years of life is of fundamental importance for a healthy growth and development.

Aims:

To verify the association between food consumption indicators and overweight in children under the age of two, followed up by primary care health professionals.

Methods:

A cross-sectional study was conducted on 232 children assisted by primary care. A structured questionnaire was used with questions on sociodemographic data of mothers or guardians and food intake and anthropometric data of children. The analysis of the association between excess weight and food intake indicators was performed using the Pearson’s chi-square test (χ2) and Fisher’s exact test (f ˂ 5).

Results:

Regarding food intake in children under 6 months of age, 35.1% of the children were exclusively breastfed. Among children at the age of 6 to 23 months: 66.3% were on continued breastfeeding; 16.7% consumed adequate foods at the age of 6 to 8 months; 90.4% consumed foods that belonged to the six food groups; 76.3% consumed food at the minimum frequency and with adequate consistency; 88.9% consumed iron-rich and vitamin A-rich foods, and 59.3% consumed ultra-processed foods. Regarding nutritional status, 24.5% of the children were overweight.

Conclusion:

There was no statistically significant association between overweight and food consumption indicators among the surveyed children. However, exclusive breastfeeding was below the recommended level, a low percentage of the introduction of complementary foods at the appropriate age and high consumption of ultra-processed foods reveal the need to improve the assistance provided by primary care to this group.

Children’s Health Capital Investment: Effects of U.S. Infant Breastfeeding on Teenage Obesity

Obesity, as a health and social problem with rising prevalence and soaring economic cost, is increasingly drawing scholarly and public policy attention. While many studies have suggested that infant breastfeeding protects against childhood obesity, empirical evidence on this causal relationship is fragile. Using the health capital development theory, this study exploited multiple data sources from the U.S. and a three-way error components model (ECM) with a jackknife resampling plan to estimate the effect of in-hospital breastfeeding initiation and breastfeeding for durations of 3, 6, and 12 months on the prevalence of obesity during teenage years. The main finding was that a 1% rise in the in-hospital breastfeeding initiation rate reduces the teenage obesity prevalence rate by 1.7% (9.6% of a standard deviation). The magnitude of this effect declines as the infant breastfeeding duration lengthens—e.g., the 12-month infant breastfeeding duration rate is associated with a 0.53% (3.7% of a standard deviation) reduction in obesity prevalence in the teenage years (9th to 12th grades). The study findings agree with both the behavioral and physiological theories on the long-term effects of breastfeeding, and have timely implications for public policies promoting infant breastfeeding to reduce the economic burden of teenage and later adult-stage obesity prevalence rates.

Fertility intentions and child health in India: Women's use of health services, breastfeeding, and official birth documentation following an unwanted birth

This study examines the relationship between women’s prospective fertility intentions and child health, measured via access to healthcare facilities for children and postpartum maternal behaviors that are indicative of future child health. We analyze two waves of nationally representative data (2005 and 2012) from the India Human Development Survey (IHDS). The analytic sample includes 3,442 non-pregnant, currently married women aged 18–40 in 2005 who participated in both rounds of the IHDS, and had at least one birth between 2005 and 2012. We investigate the influence of women’s prospective fertility intentions on access to benefits from the Integrated Child Development Services (ICDS), indicators of breastfeeding as recommended by the World Health Organization, and official documentation of births via birth certificates or registration. We find that 58 percent of births among women in the sample were labeled as unwanted. We use an adaptation of propensity score matching—the inverse-probability-weighted regression adjustment (IPWRA) estimator—and show that, after accounting for maternal and household characteristics that are known to be associated with maternal and child health, children who resulted from unwanted births were less likely to obtain any benefits or immunizations from the ICDS, to be breastfed within one hour of birth, and to have an official birth certificate. Results from this study have direct policy significance given the evidence that women’s fertility intentions can have negative implications for child health and wellbeing in the short and longer term.

Translating fathers' support for breastfeeding into practice

Breastfeeding has numerous health benefits for the mother and child. For breastfeeding to be successful and continue for longer, women need adequate support. Fathers/partners play an important role in providing this support to women, but research suggests that fathers/partners often feel inadequately informed and supported by health professionals. Midwives and health visitors are in ideal positions to offer women and their partner's timely and relevant breastfeeding information and support throughout the perinatal period. This article discusses the benefits of breastfeeding, presents research evidence of the crucial role fathers/partners play in promoting and supporting breastfeeding, and recommends ways in which health professionals can provide breastfeeding information and support to fathers/partners.

Breast Milk Micronutrients and Infant Neurodevelopmental Outcomes: A Systematic Review

Micronutrients are fundamental for healthy brain development and deficiencies during early development can have a severe and lasting impact on cognitive outcomes. Evidence indicates that undernourished lactating individuals may produce breast milk containing lower concentrations of certain vitamins and minerals. Exclusively breastfed infants born to mothers deficient in micronutrients may therefore be at risk of micronutrient deficiencies, with potential implications for neurodevelopment. This systematic review aims to consider current knowledge on the effects of breast milk micronutrients on the developmental outcomes of infants. The databases Medline, Global Health, PsychInfo, Open Grey, and the Web of Science were searched for papers published before February 2021. Studies were included if they measured micronutrients in breast milk and their association with the neurodevelopmental outcomes of exclusively breastfed infants. Also, randomised control trials investigating neurocognitive outcomes following maternal supplementation during lactation were sought. From 5477 initial results, three observational studies were eligible for inclusion. These investigated associations between breast milk levels of vitamin B6, carotenoids, or selenium and infant development. Results presented suggest that pyroxidal, β-carotene, and lycopene are associated with infant neurodevelopmental outcomes. Limited eligible literature and heterogeneity between included papers prevented quantitative synthesis. Insufficient evidence was identified, precluding any conclusions on the relationship between breast milk micronutrients and infant developmental outcomes. Further, the evidence available was limited by a high risk of bias. This highlights the need for further research in this area to understand the long-term influence of micronutrients in breast milk, the role of other breast milk micronutrients in infant neurodevelopmental outcomes, and the impact of possible lactational interventions.

A comparative study of cumulative stress patterns within 14 days postpartum in healthy mothers and those with gestational diabetes: A prospective study

Although the number of mothers with gestational diabetes mellitus (GDM) is on the rise, only few studies have examined the cumulative stress associated with breastfeeding after childbirth. GDM mothers are susceptible to stress due to insulin resistance, and their level of stress is associated with breastfeeding. This study aimed to identify patterns of stress change over time in GDM mothers and healthy mothers and to identify the factors influencing those patterns.The participants of this study were mothers within 14 days after childbirth. The GDM group consisted of 32 mothers, and the healthy group comprised 30 mothers. Cumulative stress was measured in terms of heart rate variability, and linear mixed models were used to analyze changes over time.The cumulative stress of healthy mothers was about 8 points higher than that of mothers with GDM (t = -2.95, P = .005). The cumulative stress level was inversely associated with the mother's age (β=-1.20, P = .018), the mother's weight (β=-0.64, P = .008), and the baby's body mass index (β=-3.09, P = .038). Furthermore, an insufficient amount of breast milk was associated with higher stress (β=16.09, P = .007).GDM mothers and healthy mothers experienced different patterns of cumulative stress. Breastfeeding should be started quickly to promote health and stress reduction among mothers who are physically and psychologically vulnerable after childbirth.It is necessary to incorporate programs to promote breastfeeding considering stress levels at an appropriate time according to the mother's health condition.

The Social Value of Implementing the Ten Steps to Successful Breastfeeding in an Indonesian Hospital: A Case Study

Background: Despite the known importance of breastfeeding for women's and children's health, global exclusive prevalence among infants under 6 months old is estimated at only 41%. In 2018, Indonesia had a lower exclusive breastfeeding rate of 37% at 6 months postpartum; ranging from 20% to 56%, showing unequal breastfeeding support throughout the country. The World Health Organization (WHO) launched the Ten Steps to Successful Breastfeeding (Ten Steps) in 1989, later embedded in UNICEF's Baby-Friendly Hospital Initiative (BFHI) program in 1991. The BFHI aims to encourage maternity facilities worldwide to ensure adequate education and support for breastfeeding mothers by adhering to the Ten Steps and complying with the International Code of Marketing of Breastmilk Substitutes. An Indonesian survey in 2011 found that less than one in 10 government hospitals implemented the Ten Steps. It has been common for Indonesian health services to collaborate with infant formula companies. While no Indonesian hospitals are currently BFHI-accredited, the WHO/UNICEF Ten Steps (updated in 2018) have been adopted in Indonesia's national regulation of maternity facilities since 2012. Internationally, implementation of the Ten Steps individually and as a package has been associated with benefits to breastfeeding rates and maternal and infant health. However, to date, few studies have examined the impact of implementing the Ten Steps in economic terms. This study aims to measure the economic benefit of Ten Steps implementation in an Indonesian hospital. Methods: The study was conducted in January 2020 in Airlangga University Hospital, Surabaya, Indonesia, which has implemented the Ten Steps since it was established in 2012. To understand and generate evidence on the social value of the Ten Steps, we conducted a "Social Return on Investment (SROI)" study of implementing the Ten Steps in this maternity facility. To estimate the costs relating to the Ten Steps we interviewed the financial and nursing managers, a senior pediatrician, and senior midwife due to their detailed understanding of the implementation of the Ten Steps in the hospital. The interview was guided by a questionnaire which we developed based on the 2018 WHO/UNICEF Ten Steps to Successful Breastfeeding. The analysis was supported with peer-reviewed literature on the benefits of Ten Steps breastfeeding outcomes. Results: The total per annum value of investment (cost) required to implement Ten Steps in Airlangga University Hospital was US$ 972,303. The estimate yearly benefit was US$ 22,642,661. The social return on the investment in implementing Ten Steps in this facility was calculated to be US$ 49 (sensitivity analysis: US$ 18-65). Thus, for every US$ 1 invested in Ten Steps implementation by Airlangga Hospital could be expected to generate approximately US$ 49 of benefit. Conclusions: Investment in the Ten Steps implementation in this Surabaya maternity facility produced a social value 49 times greater than the cost of investment. This provides novel evidence of breastfeeding as a public health tool, demonstrating the value of the investment, in terms of social impact for mothers, babies, families, communities, and countries. Breastfeeding has the potential to help address inequity throughout the lifetime by providing the equal best start to all infants regardless of their background. Indonesia's initial moves towards implementing the WHO/UNICEF Ten Steps can be strengthened by integrating all elements into the national regulation and health care system.

Eliminating HIV transmission through breast milk from women taking antiretroviral drugs

Ameena Goga and colleagues argue that frequent testing of maternal viral load is needed to eliminate HIV transmission through breast milk in low and middle income settings

Familiar but neglected: identification of gaps and recommendations to close them on exclusive breastfeeding support in health facilities in Malawi

Background

Exclusive breastfeeding is widely accepted as a key intervention with proven efficacy for improving newborn survival. Despite international commitments and targets to support and promote breastfeeding, there are still gaps in meeting and maintain coverage in many sub-Saharan African countries. This paper aimed to triangulate the perspectives of health workers, mothers, and their family members with facility assessments to identify gaps to improve breastfeeding support in in Malawi.

Methods

The study on breastfeeding barriers and facilitators was conducted in 2019 at one tertiary hospital and three secondary-level hospitals in Malawi. We conducted 61 semi-structured interviews with health workers, postnatal mothers, grandmothers, aunts, and fathers. In 2017, we carried out a neonatal care facility assessment using the World Health Organization (WHO) Integrated Maternal, Neonatal, and Child Quality of Care Assessment and Improvement Tool. Qualitative data were analysed using a thematic analysis approach within the Systems Framework for Health Policy.

Results

The district-level hospitals rated high with an average score of 4.8 out of 5 across the three facilities indicating that only minor improvements are needed to meet standards of care for early and exclusive breastfeeding. However, the score fell to an average of 3.5 out of 5 for feeding needs with sick neonates indicating that several improvements are needed in this area. The qualitative data demonstrated that breastfeeding was normalized as part of routine newborn care. However, the focus on routine practice and reliance on breastfeeding knowledge from prenatal counselling highlights inequities and neglect in specialized care and counselling among vulnerable mothers and newborns. Revitalisation of breastfeeding in Malawian facilities will require a systems approach that reinforces policies and guidelines; contextualises knowledge; engagement and empowerment of other relatives to the baby and task-sharing among health workers.

Conclusions

Breastfeeding is accepted as a social norm among health workers, mothers, grandmothers, aunts, and fathers in Malawi, yet vulnerable groups are underserved. Neglect in breastfeeding support among vulnerable populations exacerbates health inequities. Health systems strengthening related to breastfeeding requires a concerted effort among health workers, mothers, grandmothers, aunts, and fathers while remaining grounded in contexts to support family-centered hospital care.

Nurses' and midwives' perspectives on how the pursuit for the 'perfect' body image affects their own breastfeeding practices: a qualitative study in Ghana

Background

Body image concerns have been widely documented in the literature as one reason why most women shorten the breastfeeding duration of their infants. Negative body image concerns among breastfeeding mothers may lead to depressive symptoms. There is a paucity of literature on how body image affects the breastfeeding practices of nurses and midwives. Therefore, this study explored the perspectives of breastfeeding nurses and midwives on how their body image affected their breastfeeding practices.

Methods

A qualitative design was used in this study. Five focus group discussions were conducted with each group having five members. The study was conducted in the Greater Accra Region of Ghana between November and December of 2020. Participants were recruited into the study using a purposive sampling method. Focus group sessions were audiotaped and transcribed verbatim. Data were analyzed using a content analysis.

Results

Three main themes emerged from the data analysis: body image concerns and breastfeeding, sociocultural pressures and breastfeeding and coping strategies. Participants had concerns regarding weight gain due to the need to eat adequately while breastfeeding. Body image concerns included increase in abdominal size, sagging breasts and generalized weight gain. These concerns and pressures negatively affected the breastfeeding practices of participants. Body image concerns reflected sociocultural pressures such as negative comments from loved ones and in the social media. The coping strategies adopted by the mothers were self-motivation and the love they had for their children.

Conclusions

The perspectives of breastfeeding nurses and midwives on the ways their body image affected their breastfeeding practices identified the need for support in order to successfully breastfeed.

Telephone intervention to promote maternal breastfeeding self-efficacy: randomized clinical trial

OBJECTIVE

To analyze the effects of an educational intervention via telephone on maternal breastfeeding self-efficacy.

METHOD

Randomized controlled clinical trial including 240 puerperae from a secondary care hospital randomized into two groups: control and intervention. The educational intervention took place at seven, 30, 90, and 150 days postpartum and centered on self-efficacy and motivational interviewing principles. Self-efficacy was measured by the Breastfeeding Self-Efficacy Scale - Short Form. The data followed the abnormal distribution, so non-parametric tests were used.

RESULTS

The intervention group obtained higher median breastfeeding self-efficacy scores across the three outcome measures when compared to the control group (p < 0,001). Furthermore, the intervention group showed increased self-efficacy scores at all monitoring moments, which shows that the educational intervention was able to raise and maintain women's confidence in breastfeeding their child over time.

CONCLUSION

The use of a telephone-based intervention focused on self-efficacy principles and delivered by trained nurses effectively promoted maternal confidence in breastfeeding. Brazilian Clinical Trial Registry: RBR-7m7vc8.

Factors Associated with the Maintenance of Breastfeeding at One Year among Women in Chiang Mai, Thailand

This study aimed to investigate factors associated with breastfeeding for at least one year among women in Chiang Mai, Thailand. We conducted a cross-sectional study of 451 mothers with children aged between 12 and 24 months who visited the well-baby clinic among women who visited the well-baby clinic in secondary and tertiary hospitals. The data collected included maternal sociodemographic information, employment status, reasons contributing to continued breastfeeding, primary sources of information, and influential people affecting continued breastfeeding. Multivariable logistic regression analysis was used to investigate the relationship between explanatory variables and continued breastfeeding at one year. Reporting "easier to bond with baby" as a reason to continue breastfeeding (AOR 3.118, 95% CI: 2.022, 4.809) and multiparous status (AOR 1.588, 95% CI: 1.042, 2.420) were positive predictors of mothers who had breastfeeding at least one year postpartum while mothers with undergraduate education level (AOR 0.635, 95% CI: 0.404, 0.997) were more likely to discontinue breastfeeding. Our study highlighted that working mothers have lower odds of continued breastfeeding than stay-at-home mothers (SAHMs), which was found for work with day shifts (AOR 0.437, 95% CI: 0.261, 0.731), work with rotational shifts (AOR 0.481, 95% CI: 0.247, 0.934), and work from home jobs with a flexible schedule (AOR 0.439, 95% CI: 0.229, 0.838). These findings showed that both employment outside home and work from home were strong risk factors for discontinuing breastfeeding before 12 months. We suggest that a breastfeeding-friendly workplace policy is essential to enhance the continuance of breastfeeding. Additionally, working at home requires more research to explore breastfeeding barriers and establish more support strategies.

Validation of the Arabic Maternal Breastfeeding Evaluation Scale (MBFES-A) among Lebanese women

Background

Maternal satisfaction with the breastfeeding experience is an important determinant of breastfeeding success. There is currently no valid tool to measure perceived maternal satisfaction with breastfeeding in the Arab context.

Methods

This cohort study tested the Maternal Breastfeeding Evaluation Scale (MBFES) on 450 healthy Lebanese mothers for internal consistency reliability and construct validity. Participants were recruited between April 2018 and February 2020.

Results

The Cronbach’s alpha reliability coefficient of the Arabic MBFES (MBFES-A) was 0.87. Exploratory factor analysis revealed that it has three components: Infant Satisfaction/Growth, Maternal Enjoyment/Role Attainment, and Lifestyle/Body Image with reliability coefficients of 0.88, 0.87, and 0.68, respectively. Four items were deleted because of low factor loadings and three items were relocated to the Infant Satisfaction/Growth subscale based on their factor loadings. Participants who were exclusively breastfeeding at one and/or 3 months had higher mean MBFES-A total and Infant Satisfaction/Growth and Maternal Enjoyment/Role Attainment subscale scores than participants who were partially breastfeeding, and significantly higher mean scores than mothers who were not breastfeeding (all p values < 0.001), findings that support the scale’s construct validity. Moreover, scores on the Infant Satisfaction/Growth subscale correlated with exclusive breastfeeding at one (r = 0.37, p < 0.001) and 3 months (r = 0.31, p < 0.001). The MBFES-A score had positive modest correlations with maternal attitude towards breastfeeding (r = 0.30, p < 0.001), exclusive breastfeeding at one (r = 0.27) and at 3 months (r = 0.26, p < 0.001 for both), as well as with the longest previous exclusive breastfeeding (r = 0.27, p < 0.001).

Conclusions

The 26-item MBFES-A is a reliable and valid instrument to use in future breastfeeding research in Middle East North Africa countries. There is a need for replication of our findings in other Arab contexts using new constructs to establish stronger construct validity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00409-w.

Breast feeding and infant development in a cohort with sibling pair analysis: the Japan Environment and Children's Study

OBJECTIVES

To investigate the association between breast feeding and infant development during the first year of life using sibling comparison.

DESIGN

Nationwide prospective birth cohort study with sibling pair analysis.

SETTING

15 regional centres that participated in the Japan Environment and Children's Study.

PARTICIPANTS

This study included 77 119 children (singleton, term birth and no malformation/severe diseases) whose mothers were registered between January 2011 and March 2014, including 3521 duos or trios of siblings.

PRIMARY OUTCOME MEASURES

The primary outcome was developmental delay at 6 and 12 months of age, assessed using the Japanese translation of the Ages and Stages Questionnaires, third edition. Multivariable regression analyses adjusted for confounders were performed to estimate the risk ratios of delay associated with any or exclusive breast feeding. Pairs of siblings discordant for statuses were selected, and conditional regression analyses were conducted with a matched cohort design.

RESULTS

Developmental delay was identified in 6162 (8.4%) and 10 442 (14.6%) children at 6 and 12 months of age, respectively. Any breast feeding continued until 6 months or 12 months old was associated with reduced developmental delay at 12 months of age (adjusted risk ratio (95% CI): 0.81 (0.77 to 0.85) and 0.81 (0.78 to 0.84), respectively). Furthermore, exclusive breast feeding until 3 months was associated with reduced developmental delay at 12 months of age (adjusted risk ratio, 0.86 (95% CI 0.83 to 0.90)). In sibling pair analysis, the association between any breast feeding until 12 months and reduced developmental delay at 12 months of age persisted (adjusted risk ratio, 0.64 (95% CI 0.43 to 0.93)).

CONCLUSIONS

The present study demonstrated the association of continuous breast feeding with reduced developmental delay at 1 year of age using sibling pair analysis, in which unmeasured confounding factors are still present but less included. This may provide an argument to promote breastfeeding continuation.

Determinants of the practice of exclusive breastfeeding in Guinea: evidence from 2018 Guinean demographic and health survey

BACKGROUND

Exclusive breastfeeding is critical for infant survival and development. However, the rate of exclusive breastfeeding in the first 6 months of life is low in sub-Saharan Africa. With the current trend in breastfeeding rates in many countries including in Guinea, the World Health Assembly target of at least 50% of children aged less than 6 months being exclusively breastfeed by 2025 is likely to be compromised and lives a numerous infant that are be at risk. The objective of this study was to identify the individual and contextual determinants of the practice of Exclusive Breastfeeding (EBF) in Guinea.

METHOD

We conducted a secondary analysis of data from the 2018 Guinea Demographic and Health Survey (DHS). The study population consisted of women who gave birth between the ages of 15 and 49. Our sample consisted of women who had their last birth six (06) months prior to collection. The enumeration areas were our second level. A multilevel logistic regression was performed using Stata version 15.1 software. Three statistical models were implemented: The final model was obtained using the bottom-up step-by-step method. The intra-class correlation coefficient was calculated.

RESULTS

On the 851 women included in our study, 33% reported having exclusively breastfed during the first 6 months of life of their children. After a multivariate analysis, the variables associated with exclusive breastfeeding are: children aged 2-3 months (OR = 0.53 CI95% = [0.36-0.79]) and children aged 4-5 months (OR = 0.23 IC95% = [0.14-0.36]), women in the Faranah area (OR = 2.69 IC95% = [1.21-5.94]) and those in Mamou (OR = 2.27 IC95% = [1.00-5.94]), women who gave birth in a health facility (OR = 1.94 IC95% = [1.34-2.80]) and women living in polygamous households (OR = 0.68 IC95% = [0.48-0.98]).

CONCLUSION

The practice of exclusive breastfeeding remains low in Guinea. For the achievement of Sustainable Development Goals, particularly the improvement of exclusive breastfeeding practices, the individual and contextual determinants identified in this study should be taken into consideration in policies and programmes.

Maternal, neonatal and socio-economic factors associated with intellectual development among children from a coal mining region in Brazil

Coal is the most aggressive energy sources in the environment. Several adverse outcomes on children's health exposure to coal pollutants have been reported. Pollutants from coal power plants adversely affect the intellectual development and capacity. The present study aimed to evaluate the intellectual development and associated factors among children living a city under the direct influence (DI) and six neighboring municipalities under the indirect influence (II) of coal mining activity in the largest coal reserve of Brazil. A structured questionnaire was completed by the child's guardian, and Raven's Progressive Color Matrices were administered to each child to assess intellectual development. A total of 778 children participated. In general, no significant difference was observed between the two cities. The DI city had better socioeconomic conditions than the II municipalities according to family income (< 0.001). The prevalence of children who were intellectually below average or with intellectual disabilities was 22.9%, and there was no significant difference (p > 0.05) between municipalities. In both unadjusted and adjusted analyses, intellectual development was associated with maternal age, marital situation and maternal education level, birth weight, breast feeding, frequent children's daycare, paternal participation in children's care and child growth. Living in the DI area was not associated with intellectual disability. The results suggest that socioeconomic conditions and maternal and neonatal outcomes are more important than environmental factors for intellectual development of children living in a coal mining area.

Risk factors for and protective factors against breastfeeding interruption before 2 years: a birth cohort study

BACKGROUND

Little is known about the factors associated with the World Health Organization (WHO) recommendation of breastfeeding for at least 2 years. The objective of this study was to identify risk factors for and protective factors against breastfeeding interruption before 2 years of age.

METHODS

In this live birth cohort, mother and infant dyads were followed for 2 years. Data collection was performed at the maternity ward and subsequently at the children's homes, monthly during the first 6 months of life and then at 9, 12, 18, and 24 months. The outcome of interest was breastfeeding interruption before 2 years of age. Median duration of breastfeeding was estimated using Kaplan-Meier's survival analysis, and the associations were tested using Cox's hierarchical multivariate model. Significance was set at 5%.

RESULTS

Data from a total of 1344 dyads were assessed. Median breastfeeding duration was 385 days. The following risk factors for breastfeeding interruption were identified: white skin color (adjusted hazard ratio [HRa]: 1.31; 95% confidence interval [95%CI]: 1.10-1.56), primiparity (HRa: 1.21; 95%CI: 1.05-1.40), working outside the home (HRa: 1.52; 95%CI: 1.30-1.77), child sex male (HRa: 1.18; 95%CI: 1.03-1.35) and use of a pacifier (HRa: 3.46; 95%CI: 2.98-4.01). Conversely, the following protective factors were identified: lower family income (HRa: 0.81; 95%CI: 0.71-0.94), mother-infant bed-sharing (HRa:0.61, 95%CI: 0.52-0.73), on-demand breastfeeding in the first month (HRa: 0.64; 95%CI: 0.47-0.89) and exclusive breastfeeding at 4 months (HRa: 0.58, 95%CI: 0.48-0.70).

CONCLUSIONS

The findings allowed to identify both risk factors for and protective factors against breastfeeding interruption before 2 years of age. Knowledge of these factors may help prevent this event and aid in the development of programs that help women maintain breastfeeding for at least 2 years, as recommended by the WHO.

All day-long pacifier use and intelligence quotient in childhood: A birth cohort study

BACKGROUND

Literature on pacifier use remains controversial, but mostly suggests an inverse association with childhood intelligence.

OBJECTIVES

The objective of this study was to assess the association between pacifier use and intelligence quotient (IQ) in six-year-old children from a birth cohort.

METHODS

Data from 3532 children from the 2004 Pelotas (Brazil) Birth Cohort were analysed. Children were recruited and assessed at birth and followed up at 3 months, and 1, 2, 4, and 6 years. Data on pacifier use duration and intensity were obtained via interviews with mothers in all six follow-up visits. IQ was estimated at 6 years using the Wechsler Intelligence Scale for Children and standardised for the analyses. Crude and adjusted coefficients were calculated (linear regression) for all the data collected in follow-up assessments for pacifier use.

RESULTS

IQ was inversely associated with all pacifier use indicators. Children who used a pacifier all day long (ADL) at any follow-up showed an IQ 0.18 (95% confidence interval [CI] 0.11, 0.24) standard deviations below those who never used it ADL, after adjusting for confounders. The strength of association increased with number of assessments reporting ADL pacifier use, from a reduction in IQ of 0.13 (95% CI 0.06, 0.21) to 0.34 (95% CI 0.15, 0.52) standard deviations for ADL use in one and in all four follow-up visits, respectively.

CONCLUSIONS

We found a strong association between intense pacifier use up to 4 years of age and lower IQ at 6 years. A dose-response gradient was observed, with greater IQ deficits in children who used a ADL pacifier for longer durations. The mechanisms underlying this association need to be clarified. One hypothesis is that children using a pacifier, especially those who use it more intensely, are less stimulated.

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.

Feeding Infants at the Breast or Feeding Expressed Human Milk: Long-Term Cognitive, Executive Function, and Eating Behavior Outcomes at Age 6 Years

OBJECTIVE

To examine how expressed milk feeding diverges from feeding at the breast in its association with neurodevelopment and behavior. We hypothesized that longer and exclusive feeding at the breast only (ie, no formula, no feeding expressed milk) would be associated with the optimal cognitive developmental, executive function, and eating behaviors and that expressed milk feeding would be associated with less-optimal outcomes.

STUDY DESIGN

The Moms2Moms cohort (Ohio, US) reported infant feeding practices at 12 months postpartum and children's global cognitive ability, executive function, and eating behaviors at 6 years. Linear and log-binomial regression models estimated associations with durations of feeding at the breast, expressed milk, human milk (modes combined), and formula.

RESULTS

Among 285 participants, each month of exclusive feeding at the breast only was associated with a decreased risk of clinically meaningful executive function (working memory) deficit (adjusted relative risk [RR] 0.78, 95% CI 0.63-0.96) but was unassociated with inhibition (adjusted RR 0.92, 95% CI 0.85-1.01). Feeding expressed milk was not clearly related to executive function outcomes. No associations with global cognitive ability were observed. Weak associations were observed with eating behaviors for some feeding practices.

CONCLUSIONS

Feeding at the breast may offer advantages to some aspects of executive function that expressed milk may not. Large, prospective studies exploring mechanisms could further distinguish the effect of feeding mode from that of nutrients.

Factors Associated with the Need for Breastfeeding Information Among Women with Gestational Diabetes Mellitus: A Cross-sectional Study

PURPOSE

Analyzing information based on individual needs can maximize the effectiveness of education, leading to changes in personal health behaviors. This cross-sectional descriptive survey study aimed to identify the characteristics of mothers who experienced gestational diabetes mellitus and correlate the factors associated with their information needs.

METHODS

The participants were 298 women between the ages of 20 and 49 years who were pregnant and diagnosed with gestational diabetes at the time of the study, or who were diagnosed with gestational diabetes mellitus within five years after delivery. The average age of the participants was 34.28 years. After comparing participants' demographics, diabetes, and breastfeeding-related characteristics according to their need for information on breastfeeding, a multiple logistic regression analysis was performed.

RESULTS

Factors associated with participants' need for information on breastfeeding were economic conditions, usual body mass index, current pregnancy, and experience of breastfeeding.

CONCLUSION

The findings can be used to implement programs that meet the needs of these women and help improve maternal and pediatric health and quality of life.

Geodemographies of Breastfeeding Support

BACKGROUND

Mother-to-mother breastfeeding support organizations provide important information and guidance for helping mothers initiate and maintain breastfeeding, postpartum. However, the availability of this support is limited by a constellation of barriers, including race, culture, socioeconomic status, and geography.

RESEARCH AIMS

To identify the geodemographic composition of communities where breastfeeding support was available from the mother-to-mother support organizations Breastfeeding USA and La Leche League, identify underlying issues of equity, and highlight locations where more support resources may be needed.

METHODS

The locations of mother-to-mother support meetings were collected by ZIP code (N = 180) and were combined with a geodemographic database and exploratory spatial data analysis to explore the compositional characteristics of communities served (N = 1,173).

RESULTS

Significant gaps in the geographic distribution of breastfeeding support existed. While many metropolitan areas benefited from numerous mother-to-mother support groups and peer counselors, the geographic footprint of this support favored communities that were white, affluent, and suburban.

CONCLUSION

Spatial analytics combined with geodemographic analysis provide a unique perspective into the diverse landscape of mother-to-mother breastfeeding support groups at a local level. Our results highlighted inequities in the distribution of support provided and prescriptive guidance regarding where more resources may be needed.

The impact of donor breast milk on metabolic bone disease, postnatal growth, and neurodevelopmental outcomes at 18 months' corrected age

BACKGROUND

Preterm infants are at risk for metabolic bone disease (MBD). Analysis of donor breast milk (DBM) shows lower levels of macronutrients compared with mother's own milk (MOM). The purpose of this study was to investigate the prevalence of MBD, rate of postnatal growth, and long-term neurodevelopmental outcomes in infants fed predominantly MOM vs DBM.

METHODS

Retrospective observational study of infants born <1500g and <32 weeks at New York University Langone Health or Bellevue Hospital from January 2014 to January 2018. Infants were divided into two groups: those who received >70% of feeds with either MOM or DBM by 34 weeks' corrected age (CA). MBD was assessed using alkaline phosphatase (AlkPO4) levels and radiographic findings. Data was also collected on growth, feeding tolerance, and long-term neurodevelopmental outcomes.

RESULTS

A total of 210 infants were included (MOM =156 and DBM =54). The DBM group had higher AlkPO4 levels for the first 3 weeks of life (P < .01). Growth was similar between the groups, and both groups demonstrated catch-up growth after discharge. No difference was seen in feeding intolerance, incidence of necrotizing enterocolitis, or sepsis. The DBM group had lower cognitive (odds ratio [OR], 0.93 [0.88-0.98]; P < .01) and language (OR, 0.95 [0.90-0.99]; P < .01) scores at 18 months' CA.

CONCLUSION

Infants fed predominantly DBM had elevated AlkPO4 levels suggestive of MBD but did not develop osteopenia. Despite appropriate growth and comparable short-term outcomes, infants fed DBM had lower cognitive and language scores at 18 months' CA.

Association of Breastfeeding and Child IQ Score at Age 5 Years

OBJECTIVE

To evaluate whether breastfeeding and its duration are associated with a reduced risk of low IQ scores or other neurodevelopmental problems.

METHODS

We conducted a secondary analysis of two parallel multicenter, double-blinded randomized controlled trials in which participants with a singleton pregnancy and either subclinical hypothyroidism or hypothyroxinemia were treated with thyroxine or placebo. Our primary outcome was a low IQ score (less than 85 on the WPPSI-III [Wechsler Preschool and Primary Scale of Intelligence III] at age 5 years). Secondary outcomes included performance measures on other validated neurodevelopmental tests. Univariable and multivariable analyses were performed to evaluate the association between breastfeeding and neurodevelopmental outcomes. Stepwise backward proceeding linear and logistic regression models were used to develop the final adjusted models.

RESULTS

Of the 772 participants studied, 614 (80%) reported breastfeeding. Of these, 31% reported breastfeeding for less than 4 months, 19% for 4-6 months, 11% for 7-9 months, 15% for 10-12 months and 23% for more than 12 months. IQ scores were available for 756 children; mean age-5 scores were higher with any breastfeeding (96.7±15.1) than without (91.2±15.0, mean difference 5.5, 95% CI 2.8-8.2), and low IQ scores were less frequent with any breastfeeding (21.5%) than with no breastfeeding (36.2%, odds ratio 0.48, 95% CI 0.33-0.71). In adjusted analyses, breastfeeding remained associated with reduced odds of low IQ score (adjusted odds ratio [aOR] 0.62, 95% CI 0.41-0.93), and each additional month of breastfeeding was associated with lower odds of a low IQ scores (aOR 0.97, 95% CI 0.939-0.996). No significant associations between breastfeeding and other neurodevelopmental outcomes were identified in adjusted analyses.

CONCLUSION

Breastfeeding and its duration are associated with lower odds of low IQ score at age 5 years.

Impact of Early Life Nutrition on Children's Immune System and Noncommunicable Diseases Through Its Effects on the Bacterial Microbiome, Virome and Mycobiome

The first 1000 days of life, including the intrauterine period, are regarded as a fundamental stepping stone for the development of a human. Unequivocally, nutrition during this period plays a key role on the proper development of a child, both directly through the intake of essential nutrients and indirectly by affecting the composition of the gut microbiota. The gut microbiota, including bacteria, viruses, fungi, protists and other microorganisms, is a highly modifiable and adaptive system that is influenced by diet, lifestyle, medicinal products and the environment. Reversely, it affects the immune system in multiple complex ways. Many noncommunicable diseases (NCDs) associated with dysbiosis are "programmed" during childhood. Nutrition is a potent determinant of the children's microbiota composition and maturation and, therefore, a strong determinant of the NCDs' programming. In this review we explore the interplay between nutrition during the first 1000 days of life, the gut microbiota, virome and mycobiome composition and the development of NCDs.

Breastfeeding education, early skin-to-skin contact and other strong determinants of exclusive breastfeeding in an urban population: a prospective study

OBJECTIVE

The current study aims to demonstrate independent associations between social, educational and health practice interventions as determinants of exclusive breastfeeding in an urban Ecuadorian population.

DESIGN

Prospective survival analyses.

SETTING

Ecuadorian mother-child dyads in urban settings.

PARTICIPANTS

We followed-up 363 mother-baby dyads who attended healthcare centres in Portoviejo, province of Manabi, for a median time (P25-P75) of 125 days (121-130 days).

MAIN OUTCOME MEASURES

We performed a survival analysis, by setting the time-to-abandonment of exclusive breastfeeding measured in days of life, that is, duration of exclusive breastfeeding, periodically assessed by phone, as the primary outcome. Crude and adjusted mixed-effects Cox proportional hazards model were performed to estimate HRs for each explanatory variable.

RESULTS

The incidence rate of abandonment of breastfeeding was 8.9 per 1000 person-days in the whole sample. Multivariate analysis indicated the three most significant protective determinants of exclusive breastfeeding were (a) sessions of prenatal breastfeeding education with an HR of 0.7 (95% CI: 0.5 to 0.9) per each extra session, (b) self-perception of milk production, with an HR of 0.4 (95% CI: 0.3 to 0.6) per each increase in the perceived quantity of milk production and (c) receiving early skin-to-skin contact with an HR of 0.1 (95% CI: <0.1 to 0.3) compared with those not receiving such contact, immediately after birth.

CONCLUSIONS

Prenatal education on breastfeeding, self-perception of sufficient breast-milk production and early skin-to-skin contact appear to be strong protectors of exclusive breastfeeding among urban Ecuadorian mother-baby dyads.

Effects of maternal folic acid supplementation during the second and third trimesters of pregnancy on neurocognitive development in the child: an 11-year follow-up from a randomised controlled trial

BACKGROUND

Maternal folic acid (FA) supplementation before and in early pregnancy prevents neural tube defects (NTD), but it is uncertain whether continuing FA after the first trimester has benefits on offspring health. We aimed to evaluate the effect of FA supplementation throughout pregnancy on cognitive performance and brain function in the child.

METHODS

Follow-up investigation of 11-year-old children, residing in Northern Ireland, whose mothers had participated in a randomised trial of Folic Acid Supplementation in the Second and Third Trimesters (FASSTT) in pregnancy and received 400 μg/day FA or placebo from the 14th gestational week. Cognitive performance (Full Scale Intelligence Quotient, Verbal Comprehension, Working Memory, Perceptual Reasoning, and Processing Speed) was assessed using the Wechsler Intelligence Scale for Children. Neuronal function was assessed using magnetoencephalographic (MEG) brain imaging.

RESULTS

Of 119 mother-child pairs in the FASSTT trial, 68 children were assessed for neurocognitive performance at 11-year follow-up (Dec 2017 to Nov 2018). Children of mothers randomised to FA compared with placebo scored significantly higher in two Processing Speed tests, i.e. symbol search (mean difference 2.9 points, 95% CI 0.3 to 5.5, p = 0.03) and cancellation (11.3 points, 2.5 to 20.1, p = 0.04), whereas the positive effect on Verbal Comprehension was significant in girls only (6.5 points, 1.2 to 11.8, p = 0.03). MEG assessment of neuronal responses to a language task showed increased power at the Beta (13-30 Hz, p = 0.01) and High Gamma (49-70 Hz, p = 0.04) bands in children from FA-supplemented mothers, suggesting more efficient semantic processing of language.

CONCLUSIONS

Continued FA supplementation in pregnancy beyond the early period currently recommended to prevent NTD can benefit neurocognitive development of the child. MEG provides a non-invasive tool in paediatric research to objectively assess functional brain activity in response to nutrition and other interventions.

TRIAL REGISTRATION

ISRCTN ISRCTN19917787 . Registered on 15 May 2013.

Impact of breastfeeding interventions among United States minority women on breastfeeding outcomes: a systematic review

BACKGROUND

In the U.S., strong ethnic/racial, socioeconomic, demographic, and geographic breastfeeding (BF) inequities persist, and African American and Hispanic women are less likely to meet their breastfeeding goals compared to White women. This systematic review (SR) was designed to answer the question: What is the impact of breastfeeding interventions targeting ethnic/racial minority women in the U.S. on improving BF initiation, duration and exclusivity rates?

METHODS

The SR was conducted following the Institute of Medicine Guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The study protocol was developed and registered a priori in PROSPERO (ID#CRD42020177764). The electronical databases searched was MEDLINE All (Ovid). Search strategies were led by the team's expert public health librarian using both controlled vocabulary and free text queries and were tested against a validated set of relevant papers included in existing reviews. The GRADE methodology was used to assess the quality of the studies.

RESULTS

We included 60 studies that had randomized (n = 25), observational (n = 24), quasi-experimental (n = 9), or cross-sectional (n = 2) designs. The studies focused on populations that were multi-ethnic/racial (n = 22), only Hispanic (n = 24), only Black (n = 13), and only American Indian (n = 1). The study interventions were classified following the socioecological model: macrosystem/policy level (n = 6); community level (n=51), which included healthcare organizations (n = 34), The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) (n = 9), and community organizations/public health institutions (n = 8); and  interpersonal level (n = 3).

CONCLUSIONS

Policy and community level interventions delivered through WIC, healthcare facilities, and community agencies) are likely to improve BF outcomes among women of color. The combination of interventions at different levels of the socioecological model has not been studied among minority women in the U.S. Implementation science research is needed to learn how best to scale up and sustain effective BF interventions, taking into account the needs and wants of minority women. Thus, it is strongly recommended  to conduct large scale implementation research studies addressesing how to strengthen the different health and social environments surrounding women of color in the U.S. to improving their BF outcomes.

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

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

Human milk composition promotes optimal infant growth, development and health

Human milk is a living dynamic fluid that promotes optimal nutrition and development of the infant and impacts health across the lifespan. This review reports on the diverse range of nutrients, immune protection factors, hormones, microbes and metabolites in human milk and their impacts on infant nutrition and health. While many of these components are stable across lactation and similar between women, some vary over time, and in response to maternal and infant health status, maternal diet and geographic location. Human milk may be considered as personalized nutrition, with many components working synergistically to stimulate and support the infant's immature immune system, while enhancing appropriate development, growth and body composition.

Maternity leave and children's health outcomes in the long-term

This paper assesses the impact of the length of maternity leave on children's health outcomes in the long-run. My quasi-experimental design evaluates an expansion in maternity leave coverage from two to six months, which occurred in the Federal Republic of Germany in 1979. The expansion came into effect after a sharp cutoff date and significantly increased the time working mothers stayed at home with their newborns during the first six months after childbirth. Using this cutoff date as a source of exogenous variation, I exploit German hospital registry data, which contains detailed information on the universe of inpatients' diagnoses from 1995-2014. By tracking the health of treated and control children from age 16 up to age 35, this study provides new insights into the trajectory of health differentials over the life-cycle. I find that the legislative change generated positive long-term health effects: My intention-to-treat estimates show that children born after the implementation of the reform experience fewer hospital admissions and are less likely to be diagnosed with mental and behavioral disorders.

Are Mothers Certain About Their Perceptions of Recalled Infant Feeding History?

INTRODUCTION

Maternal recall of infant feeding, a potential measurement bias, is used to identify the relationship between mothers' own milk (MOM) feeding and subsequent health outcomes. This study describes maternal recall certainty of MOM feedings at four time periods.

METHOD

In this secondary analysis, mothers of children ages 4-36 months describe infants' MOM feeding and rate certainty of their recall.

RESULTS

MOM was the first feeding for 78.5% of infants and received by 83% the first week, 85% the first month, and 62% the fourth month. Ratings of recall certainty were > 95% for each time period. Recall certainty was significantly different for four time periods (χ² = 9.67, p = 0.02), with no two periods significantly different in post hoc analyses.

DISCUSSION

Maternal recall certainty of infant feeding was high regardless of elapsed time. Measuring maternal recall certainty may be useful in clinical practice and studies linking MOM exposure to subsequent health outcomes.

Bovine Milk-Derived Emulsifiers Increase Triglyceride Absorption in Newborn Formula-Fed Pigs

Efficient lipid digestion in formula-fed infants is required to ensure the availability of fatty acids for normal organ development. Previous studies suggest that the efficiency of lipid digestion may depend on whether lipids are emulsified with soy lecithin or fractions derived from bovine milk. This study, therefore, aimed to determine whether emulsification with bovine milk-derived emulsifiers or soy lecithin (SL) influenced lipid digestion in vitro and in vivo. Lipid digestibility was determined in vitro in oil-in-water emulsions using four different milk-derived emulsifiers or SL, and the ultrastructural appearance of the emulsions was assessed using electron microscopy. Subsequently, selected emulsions were added to a base diet and fed to preterm neonatal piglets. Initially, preterm pigs equipped with an ileostomy were fed experimental formulas for seven days and stoma output was collected quantitatively. Next, lipid absorption kinetics was studied in preterm pigs given pure emulsions. Finally, complete formulas with different emulsions were fed for four days, and the post-bolus plasma triglyceride level was determined. Milk-derived emulsifiers (containing protein and phospholipids from milk fat globule membranes and extracellular vesicles) showed increased effects on fat digestion compared to SL in an in vitro digestion model. Further, milk-derived emulsifiers significantly increased the digestion of triglyceride in the preterm piglet model compared with SL. Ultra-structural images indicated a more regular and smooth surface of fat droplets emulsified with milk-derived emulsifiers relative to SL. We conclude that, relative to SL, milk-derived emulsifiers lead to a different surface ultrastructure on the lipid droplets, and increase lipid digestion.

The Role of Fetal, Infant, and Childhood Nutrition in the Timing of Sexual Maturation

Puberty is a crucial developmental stage in the life span, necessary to achieve reproductive and somatic maturity. Timing of puberty is modulated by and responds to central neurotransmitters, hormones, and environmental factors leading to hypothalamic-pituitary-gonadal axis maturation. The connection between hormones and nutrition during critical periods of growth, like fetal life or infancy, is fundamental for metabolic adaptation response and pubertal development control and prediction. Since birth weight is an important indicator of growth estimation during fetal life, restricted prenatal growth, such as intrauterine growth restriction (IUGR) and small for gestational age (SGA), may impact endocrine system, affecting pubertal development. Successively, lactation along with early life optimal nutrition during infancy and childhood may be important in order to set up timing of sexual maturation and provide successful reproduction at a later time. Sexual maturation and healthy growth are also influenced by nutrition requirements and diet composition. Early nutritional surveillance and monitoring of pubertal development is recommended in all children, particularly in those at risk, such as the ones born SGA and/or IUGR, as well as in the case of sudden weight gain during infancy. Adequate macro and micronutrient intake is essential for healthy growth and sexual maturity.

Do breastfed children have a lower chance of developing mouth breathing? A systematic review and meta-analysis

OBJECTIVE

Determine the association between breastfeeding and the development of mouth breathing in children.

MATERIALS AND METHODS

Seven databases were searched for studies investigating the association between the type of feeding and the development of the breathing pattern in children. Descriptive analysis and meta-analysis were performed, with the calculation of the prevalence and likelihood (odds ratios (95% CI)) of mouth breathing according to the duration of breastfeeding.

RESULTS

The overall prevalence of mouth breathing was 44% (95% CI: 38-49) (N total = 1182). Breastfeeding was a protection factor against the development of mouth breathing (OR = 0.62; 95% CI: 0.41-0.93). The likelihood of developing mouth breathing was 41% and 34% lower among children that were breastfed for more than 12 and more than 24 months, respectively. No association was found between exclusive breastfeeding for up to 6 months and the occurrence of mouth breathing (OR = 0.60; 95% CI: 0.31-1.18).

CONCLUSIONS

Due to the scarcity of cohort studies that met the inclusion criteria and the low certainty of the evidence, no strong evidence-based conclusion can be drawn. However, breastfeeding should be encouraged due to its possible protective effect, evidenced by the substantial reduction in the prevalence of mouth breathing pattern when performed for up to 2 years. Exclusive breastfeeding was not associated with the development of the breathing pattern.

CLINICAL RELEVANCE

The results reveal that breastfeeding can protect children from the development of mouth breathing. Thus, healthcare providers should offer support so that mothers feel prepared and encouraged to perform breastfeeding.

TRIAL REGISTRATION

PROSPERO registry: CRD42017062172.

Vulnerable families and costly formula: a qualitative exploration of infant formula purchasing among peri-urban Peruvian households

BACKGROUND

Substantial evidence exists surrounding the health risks of breast milk substitutes (BMS) in place of exclusive breastfeeding among infants < 6 months of age in resource-poor settings. Yet, mothers' experiences of selecting and purchasing BMS brands have not been well studied to date. This qualitative study explored the factors influencing BMS purchasing practices, along with the consequences of those decisions, in peri-urban Lima, Peru.

METHODS

We conducted in-depth interviews (IDIs) with 29 mothers who had begun mixed-feeding their infants during the first 6 months of life. Interviews explored participants' reasons for initiating infant formula use and their experiences of selecting, purchasing, and providing BMS to their children. Audio recordings were transcribed, coded, and key themes and illustrative vignettes were identified.

RESULTS

The primary reported reasons for initiating infant formula use included having received a recommendation for infant formula from a healthcare provider, concerns about an infant's weight gain, and the perception of insufficient breast milk. Mothers tended to initially purchase the BMS brand that had been recommended by a doctor, which was often more expensive than the alternatives. The costs of BMS, which escalated as infants grew, often disrupted the household economy and generated significant stress. While some mothers identified alternatives allowing them to continue purchasing the same brand, others chose to switch to less expensive products. Several mothers began to feed their infants follow-on formula or commercial milk, despite their awareness that such practices were not recommended for infants under 6 months of age. The approval of family members and the absence of an infant's immediate adverse reaction influenced mothers' decisions to continue purchasing these products.

CONCLUSIONS

The high costs of BMS may deepen existing socio-economic vulnerabilities and generate new risks for infant health. The continued dedication of resources towards breastfeeding education and support is critical, and strategies would benefit from underscoring the long-term financial and health consequences of infant formula use, and from strengthening women's self-efficacy to refuse to initiate infant formula when recommended. In addition, health providers should be trained in counseling to help women to relactate or return to exclusive breastfeeding after cessation.

Breastfeeding, prenatal depression and children's IQ and behaviour: a test of a moderation model

Background

We aimed to determine the associations between breastfeeding and children’s neurodevelopment indexed by intelligence quotient (IQ) and emotional and behavioural problems through mid-childhood adjusting for prenatal and postnatal depression and multiple confounders; and to test the novel hypothesis that breastfeeding may moderate the effects of prenatal depression and anxiety on children’s neurodevelopment.

Methods

The study is based on women and their children from the longitudinal Avon Longitudinal Study of Parents and Children (n=11,096). Children’s IQ was derived from standardized in-person testing; behaviour problems were assessed according to parent-report; information on breastfeeding, prenatal depression and anxiety and multiple confounders were derived from self-report questionnaires. We conducted hierarchical multiple regression adjusting for several covariates.

Results

43% women were exclusively breastfeeding at 1 month and an additional 16.8% were engaged in mixed or partial breastfeeding. Both exclusive breastfeeding (B = 2.19; SD = 0.36, p =.00) and mixed feeding (B = 1.59; SD= 0.52; p=.00) were positively associated with IQ at 8 years of age, after adjusting for covariates. Exclusive breastfeeding was negatively associated with hyperactivity/attention deficit at 4 years (B = −.30, SD = .05; p < .01); mixed feeding was related to hyperactivity/attention deficit at age 9 (B = .20; SD = .08; p = .03) after adjustments. There was no association between breastfeeding and emotional or conduct problems. Breastfeeding did not moderate the association between prenatal depression and anxiety and children’s neurodevelopment.

Conclusions

The selective association between breastfeeding and neurodevelopmental measures suggests a nutritional rather than broader beneficial psychological effect on child neurodevelopment. Breastfeeding did not moderate the associations between prenatal depression and anxiety and child neurodevelopment, suggesting separate mechanisms of action.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03520-8.

Maternal education and equity in breastfeeding: trends and patterns in 81 low- and middle-income countries between 2000 and 2019

BACKGROUND

In low- and middle-income countries (LMICs), low levels of formal maternal educational are positively associated with breastfeeding whereas the reverse is true among women with higher levels of formal education. As such, breastfeeding has helped to reduce health equity gaps between rich and poor children. Our paper examines trends in breastfeeding and formula consumption by maternal educational in LMICs over nearly two decades.

METHODS

We used 319 nationally representative surveys from 81 countries. We used WHO definitions for breastfeeding indicators and categorized maternal education into three categories: none, primary, and secondary or higher. We grouped countries according to the World Bank income groups and UNICEF regions classifications. The trend analyses were performed through multilevel linear regression to obtain average absolute annual changes in percentage points.

RESULTS

Significant increases in prevalence were observed for early initiation and exclusive breastfeeding across all education categories, but more prominently in women with no formal education for early breastfeeding and in higher level educated women for exclusive breastfeeding. Small decreases in prevalence were seen mostly for women with no formal education for continued breastfeeding at 1 and 2 years. Among formula indicators, only formula consumption between 6 and 23 months decreased significantly over the period for women with primary education. Analysis by world regions demonstrated that gains in early and exclusive breastfeeding were almost universally distributed among education categories, except in the Middle East and North Africa where they decreased throughout education categories. Continued breastfeeding at 1 and 2 years increased in South Asia, Latin America and the Caribbean, and Eastern Europe and Central Asia for primary or higher education categories. Declines occurred for the group of no formal education in South Asia and nearly all education categories in the Middle East and North Africa with a decline steeper for continued breastfeeding at 2 years. With a few exceptions, the use of formula is higher among children of women at the highest education level in all regions.

CONCLUSIONS

Over the course of our study, women with no formal education have worsening breastfeeding indicators compared to women with primary and secondary or higher education.

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.

Monitoring breastfeeding indicators in high-income countries: Levels, trends and challenges

Monitoring indicators of breastfeeding practices is important to protect and evaluate the progress of breastfeeding promotion efforts. However, high‐income countries lack standardized methodology to monitor their indicators. We aimed to update and summarize nationally representative annual estimates of breastfeeding indicators in high‐income countries and to describe methodological issues pertaining to the data sources used. A review was conducted through population‐based surveys with nationally representative samples or health reports from nationally representative administrative data of electronic surveys or medical records. Methodological aspects and rates of all breastfeeding indicators available were summarized by country. The median and annual growth of breastfeeding in percentage points within countries with time‐series data were estimated. Data from 51 out of 82 high‐income countries were identified. The data were obtained through surveys (n = 32) or administrative data (n = 19). Seventy‐one percent of countries have updated their indicators since 2015. Ever breastfed was the indicator most frequently reported (n = 46), with a median of 91%. By 6 months of age, the median equals 18% for exclusive and 45% for any breastfeeding. At 12 months, the median of continued breastfeeding decreased to 29%. The annual growth rate for ever breastfed, exclusive and any breastfeeding at 6 months and continued at 12 months varied from 1.5 to −2.0, 3.5 to −3.1, 5.0 to −1.0 and 5.0 to −1.9, respectively, with positive changes for most countries. Stronger interventions are needed to promote breastfeeding in high‐income countries as a whole, and investments are required to monitor trends with standardized methodologies.

Sialylated human milk oligosaccharides program cognitive development through a non-genomic transmission mode

Breastmilk contains bioactive molecules essential for brain and cognitive development. While sialylated human milk oligosaccharides (HMOs) have been implicated in phenotypic programming, their selective role and underlying mechanisms remained elusive. Here, we investigated the long-term consequences of a selective lactational deprivation of a specific sialylated HMO in mice. We capitalized on a knock-out (KO) mouse model (B6.129-St6gal1^tm2Jxm/J) lacking the gene responsible for the synthesis of sialyl(alpha2,6)lactose (6'SL), one of the two sources of sialic acid (Neu5Ac) to the lactating offspring. Neu5Ac is involved in the formation of brain structures sustaining cognition. To deprive lactating offspring of 6'SL, we cross-fostered newborn wild-type (WT) pups to KO dams, which provide 6'SL-deficient milk. To test whether lactational 6'SL deprivation affects cognitive capabilities in adulthood, we assessed attention, perseveration, and memory. To detail the associated endophenotypes, we investigated hippocampal electrophysiology, plasma metabolomics, and gut microbiota composition. To investigate the underlying molecular mechanisms, we assessed gene expression (at eye-opening and in adulthood) in two brain regions mediating executive functions and memory (hippocampus and prefrontal cortex, PFC). Compared to control mice, WT offspring deprived of 6'SL during lactation exhibited consistent alterations in all cognitive functions addressed, hippocampal electrophysiology, and in pathways regulating the serotonergic system (identified through gut microbiota and plasma metabolomics). These were associated with a site- (PFC) and time-specific (eye-opening) reduced expression of genes involved in central nervous system development. Our data suggest that 6'SL in maternal milk adjusts cognitive development through a short-term upregulation of genes modulating neuronal patterning in the PFC.

Risk factors for obsessive-compulsive symptoms. Follow-up of a community-based youth cohort

Environmental factors are at least as important as genetic factors for the development of obsessive-compulsive symptoms (OCS), but the identification of such factors remain a research priority. Our study aimed to investigate the association between a broad scope of potential risk factors and OCS in a large community cohort of children and adolescents. We evaluated 1877 participants and their caregivers at baseline and after 3 years to assess various demographic, prenatal, perinatal, childhood adversity, and psychopathological factors. Mean age at baseline was 10.2 years (SD 1.9) and mean age at follow-up was 13.4 years (SD 1.9). Reports of OCS at baseline and follow-up were analyzed using latent variable models. At preliminary regression analysis, 15 parameters were significantly associated with higher OCS scores at follow-up. At subsequent regression analysis, we found that eight of these parameters remained significantly associated with higher follow-up OCS scores while being controlled by each other and by baseline OCS scores. The significant predictors of follow-up OCS were: lower socioeconomic status (p = 0.033); lower intelligence quotient (p = 0.013); lower age (p < 0.001); higher maternal stress level during pregnancy (p = 0.028); absence of breastfeeding (p = 0.017); parental baseline OCS (p = 0.038); youth baseline anxiety disorder (p = 0.023); and youth baseline OCS scores (p < 0.001). These findings may better inform clinicians and policymakers engaged in the mental health assessment and prevention in children and adolescents.

Breastfeeding practices in Mexico: Results from the National Demographic Dynamic Survey 2006-2018

Although actions have been taken to improve breastfeeding in Mexico, trends over the last decade and their associated factors have not been analysed. We estimated trends in breastfeeding practices at the national, rural/urban, and regional level indigenous ethnicity and socio-economic level, and their associated factors using the National Demographic Dynamics Survey (2006, 2009, 2014 and 2018). We assessed breastfeeding indicators of women with children <24 months according to The World Health Organization recommendations. Logistic regressions models of pooled data were used to estimate trends and associations with biological and sociodemographic characteristics. Between 2006 and 2018, the prevalence of ever breastfed increased from 91.8% to 94.2% (p < 0.001), whereas early initiation of breastfeeding increased from 40.8% to 59.7% (p < 0.001), with similar increments by urban/rural level. Between 2009 and 2018, the prevalence of exclusive breastfeeding in children <6 months increased from 13.0% to 20.7% (p < 0.001). The largest increase was seen in Mexico City, in nonindigenous women and those with a high socio-economic status, whereas indigenous women and those from the South had the lowest or no improvements. Breastfeeding education during pregnancy [odds ratio (OR) 1.3; 95% confidence interval (CI) 1.1-1.5] was positively associated with exclusive breastfeeding, whereas being employed (OR 0.8; 95% CI 0.6-0.9) was negatively associated. Breastfeeding practices improved but are still far from recommendations. Implementing strategies like breastfeeding counselling and programmes and policies that promote and support breastfeeding for poor, indigenous, single and working mothers should be a priority for the government to ensure that all children have the best start in life.

Motivos associados à interrupção do aleitamento materno exclusivo até seis meses de idade em lactentes acompanhados em Estratégias de Saúde da Família da cidade de Registro, São Paulo

Objetivo: Identificar os motivos associados à interrupção do aleitamento materno exclusivo entre nutrizes durante os primeiros seis meses de vida do lactente. Métodos: Estudo exploratório, descritivo, transversal, com abordagem quantitativa, conduzido com 911 mães/responsáveis de crianças de zero a 23 meses. Foram coletadas informações sociodemográficas e relato dos motivos que levaram a interrupção do aleitamento materno exclusivo antes dos seis meses de idade do lactente. Resultados: As participantes do estudo eram predominantemente brancas, com companheiro, com ensino médio, sem vínculo empregatício, com dois a quatro filhos, com renda familiar ≤ 1 salário mínimo, com moradia própria, na faixa etária ≥ 20 anos. Em sua maioria, as mães/responsáveis relataram ter recebido orientações sobre a alimentação de seu filho com maior frequência realizada pelo enfermeiro e 28,5% afirmaram ter interrompido o aleitamento materno exclusivo antes dos seis meses de vida do lactente. Possuir moradia própria, usar de tabaco e álcool foram associados à interrupção do aleitamento materno exclusivo. Os motivos que predominaram na interrupção do aleitamento materno exclusivo estiveram ligados principalmente ao relato de leite materno insuficiente, retorno ao trabalho/escola e recusa inexplicada. Conclusão: Os motivos para abandono do aleitamento materno exclusivo identificado neste estudo foram desde o relato de choro da criança à alegação de leite materno insuficiente. A identificação dos motivos que levam ao desmame precoce pode auxiliar no planejamento de estratégias para evitar a interrupção do aleitamento materno.