Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study

Breast-feeding and atopic disease: a cohort study from childhood to middle age

BACKGROUND

The literature regarding the association between breast-feeding and atopic diseases has been contradictory.

OBJECTIVE

We have assessed the relationship between breast-feeding and atopic disorders in a cohort followed into middle age.

METHODS

The Tasmanian Asthma Study is a population-based prospective cohort study that has followed participants from the age of 7 to 44 years. Exclusive breast-feeding in the first 3 months of life was examined as a risk factor for atopic diseases by using multiple logistic regression and generalized estimating equation analyses.

RESULTS

At age 7 years, exclusively breast-fed children with a maternal history of atopy had a marginally lesser risk of current asthma than those not exclusively breast-fed (odds ratio [OR], 0.8; 95% CI, 0.6-1.0). However, after age 7 years, the risk reversed, and exclusively breast-fed children had an increased risk of current asthma at 14 (OR, 1.46; 95% CI, 1.02-2.07), 32 (OR, 1.84; 95% CI, 1.06-3.3), and 44 (OR, 1.57; 95% CI, 1.15-2.14) years. Exclusively breast-fed children also had a reduced risk of food allergy at age 7 years but an increased risk of food allergy (OR, 1.26; 95% CI, 1.1-1.5) and allergic rhinitis (OR, 1.2; 95% CI, 1.0-1.3) at 44 years.

CONCLUSION

Exclusively breast-fed babies with a maternal history of atopy were less likely to develop asthma before the age of 7 years, but more likely to develop asthma after the age of 7 years.

CLINICAL IMPLICATIONS

The current recommendation to breast-feed high-risk infants for protection against early wheezing illness can be confirmed. However, the recommendation should be reconsidered for protection against allergic asthma and atopy in the longer term.

Effect of breastfeeding on lung function in childhood and modulation by maternal asthma and atopy

RATIONALE

The protective effect of breastfeeding on early respiratory infections is well established, but its relationship to the development of subsequent asthma remains controversial.

OBJECTIVES

To clarify these complex issues, we examined the association between lung function and infant-feeding practices.

METHODS

In the Tucson Children's Respiratory Study, feeding practices were assessed prospectively based on questionnaires completed at enrollment and well-child visits. Formula introduction was categorized as having occurred before 2 months (n = 143, "early formula introduction"), from 2 and before 4 months (n = 336), or at 4 months and older (n = 200, "longer breastfed"). Lung function was measured at age 11 and 16 years. A random-effects model was used to assess the relationship of infant-feeding practices to measures of lung function.

MEASUREMENTS AND MAIN RESULTS

FVC by age 16 was increased by 103 +/- 40.0 ml (P = 0.01), and the FEV1/FVC ratio was lower (-1.9 +/- 0.6%, P = 0.004) in the longer breastfed children compared with children with early formula introduction. This effect was modified after stratifying by maternal asthma. Compared with children with early formula introduction, longer breastfed children with asthmatic mothers had an FVC that was not increased (P = 0.7) and an FEV1/FVC ratio (-5.7 +/- 2.4%, P = 0.02) that was significantly decreased by age 16. Longer breastfed children with nonatopic, nonasthmatic mothers demonstrated an increased FVC (142 +/- 71.1 ml, P = 0.047) and no decrease in FEV1/FVC (P = 0.7) compared with children with early formula introduction.

CONCLUSIONS

Longer duration of breastfeeding favorably influences lung growth in children. However, in the presence of maternal asthma, longer breastfeeding is associated with decreased airflows.

Cross-sectional study of allergic disorders associated with breastfeeding in Japan: the Ryukyus Child Health Study

Uncertainties remain as to whether breastfeeding is protective against childhood allergic disorders. Positive relationships of breastfeeding with asthma and atopic eczema were observed in two previous Japanese studies. This cross-sectional study investigated the association between the feeding pattern after birth and the prevalence of allergic disorders during the past 12 months in Japanese schoolchildren. Study subjects were 24,077 children aged 6-15 yr in Okinawa. The outcomes were based on diagnostic criteria from the International Study of Asthma and Allergies in Childhood. Allowance was made for age, sex, number of siblings, smoking in the household, paternal and maternal history of asthma, atopic eczema, and allergic rhinitis, and paternal and maternal educational level. Breastfeeding, regardless of exclusivity, for 13 months or longer and exclusive breastfeeding for 4-11 months were independently associated with a higher prevalence of atopic eczema, particularly among children without a parental allergic history. A clear positive dose-response relationship was observed between prolonged duration of breastfeeding, regardless of exclusivity, but not exclusive breastfeeding, and the prevalence of atopic eczema. We found a significant positive trend for atopic eczema across the three categories (formula milk, partial and exclusive breastfeeding) in the first 4 months of life although the odds ratio for exclusive breastfeeding was not statistically significant. No material association was found between the feeding pattern after birth and the prevalence of wheeze or allergic rhinoconjunctivitis. Prolonged breastfeeding may be associated with a higher prevalence of atopic eczema in Japanese children.

Interventions in the workplace to support breastfeeding for women in employment

BACKGROUND

In recent years there has been a rise in the participation rate of women in employment. Some may become pregnant while in employment and subsequently deliver their babies. Most may decide to return early to work after giving birth for various reasons. Unless these mothers get support from their employers and fellow employees, they might give up breastfeeding when they return to work. As a result, the duration and exclusivity of breastfeeding to the recommended age of the babies would be affected. Workplace environment can play a positive role to promote breastfeeding. For women going back to work, various types of workplace support interventions are available and this should not be ignored by employers. Notably, promoting breastfeeding in a workplace may have benefits for the women, the baby and also the employer.

OBJECTIVES

To assess the effectiveness of workplace interventions to support and promote breastfeeding among women returning to paid work after the birth of their children, and its impact on process outcomes pertinent to employees and employers.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2006), CINAHL (1982 to November week 1 2006), LILACS (2 August 2006), Social Services Abstracts (1979 to November 2006), Sociological Abstracts (1952 to November 2006), Australian Public Affairs Information Service (2003 to 2006), Australian Family and Society Abstracts (2003 to 2006), International Bibliography of the Social Sciences (1951 to 2006), ProQuest Social Science Journals (1994 to 2006), Middle Eastern and Central Asian Studies (1900 to 2006) and the Campbell Collaboration Register (C2-SPECTR) (November 2006).

SELECTION CRITERIA

Two authors independently assessed all identified studies for randomised controlled trials and quasi-randomised controlled trials that compared workplace interventions with no intervention or two or more workplace interventions against each other.

DATA COLLECTION AND ANALYSIS

Two authors planned to evaluate the methodological quality of the eligible trials and extract data.

MAIN RESULTS

There were no randomised controlled trials or quasi-randomised controlled trials identified.

AUTHORS' CONCLUSIONS

No trials have evaluated the effectiveness of workplace interventions in promoting breastfeeding among women returning to paid work after the birth of their child. The impact of such intervention on process outcomes is also unknown. Randomised controlled trials are required to establish the benefits of various types of workplace interventions to support, encourage and promote breastfeeding among working mothers.

WITHDRAWN: Cow's milk protein avoidance and development of childhood wheeze in children with a family history of atopy

BACKGROUND

In infants with a family history of atopy, food allergen avoidance has been advocated as means of preventing the development of atopic disease, when breast-feeding is not possible or supplemental feeding is needed. Most infant formulas are based on cow's milk protein. Alternative choices include soya based and hydrolysed cows milk formulas.

OBJECTIVES

To estimate the effect of dietary avoidance of cow's milk protein on the development of asthma or wheeze in children.

SEARCH STRATEGY

We searched the Cochrane database for eligible trials until February 2002. We obtained the full text papers of all abstracts identified as RCTs and two reviewers independently reviewed them.

SELECTION CRITERIA

We included randomised controlled trials involving children with a family history of atopy in at least one first degree relative, if feeding with cow's milk based standard formula was compared to dietary avoidance of cow's milk protein, using soya or other hypoallergenic formula during the initial four months of life or longer.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently. A priori defined subgroups were the types of hypoallergenic artificial feed and dietary restrictions on mother and/or child's diet.

MAIN RESULTS

Six trials used hydrolysed formula for at least four months, in addition to dietary restrictions and in some cases dust-mite reduction measures. The risk of infants experiencing asthma or wheeze during the first year of life was reduced compared to standard cow's milk based formula (Relative Risk 0.40, 95% Confidence Intervals 0.19 to 0.85). Feeding soya-based formula as opposed to standard cow's milk formula did not reduce the risk of having asthma or wheeze at any age.

AUTHORS' CONCLUSIONS

Breast-milk should remain the feed of choice for all babies. In infants with at least one first degree relative with atopy, hydrolysed formula for a minimum of four months combined with dietary restrictions and environment measures may reduce the risk of developing asthma or wheeze in the first year of life. There is insufficient evidence to suggest that soya-based milk formula has any benefit.

Neonatal home care practices in rural Egypt during the first week of life

OBJECTIVE

To provide information about home care practices for newborns in rural Egypt, in order to improve neonatal home care through preventive measures and prompt recognition of danger signs.

METHOD

Survey of newborn home care practices during the first week of life in 217 households in three rural Egyptian Governorates.

RESULTS

Many practices met common neonatal care standards, particularly prompt initial breastfeeding, feeding of colostrum and continued breastfeeding, and most bathing practices. However, several practices could be modified to improve neonatal care and survival. Supplemental substances were given to 44% of newborns as pre-lacteal feeds, and to more than half during the first week. Nearly half (43%) of mothers reported that they did not wash their hands before neonatal care, and only 7% washed hands after diaper changes. Thermal control was not practiced, although mothers perceived 22% of newborns to be hypothermic.

CONCLUSIONS

The practices we observed, which are critical for newborn survival, could be improved with minor modifications. We provide a framework for communicating behaviour change and setting research priorities for improving neonatal health.

Breastfeeding Best Start study: training midwives in a 'hands off' positioning and attachment intervention

The most common reasons cited by women for giving up breastfeeding early can be attributed to ineffective positioning and attachment and are therefore preventable. This study aimed to determine whether a 4-h training programme in 'hands off' positioning and attachment support increases midwives' knowledge and problem-solving skills. Using an unrelated comparison group and a pre- and post-intervention design, 108 midwives (experimental group) completed a 4-h standard breastfeeding training workshop focusing on effective positioning and attachment and the use of hands-off teaching methods. Knowledge and problem-solving skills were assessed using a modified form of the previously validated Breastfeeding Support Skills Tool. Pre- and post-training scores were compared with those of 27 student midwives (control group) who undertook the same assessments but without the breastfeeding training. Baseline knowledge scores of the midwives and the student midwives did not differ significantly (average difference 0.7 points to qualified midwives' advantage, 95% CI = -3.4 to 1.9). Following training, the qualified midwives' total scores increased significantly (7.2 points, 95% CI = 6.2-8.2). Minimal changes (1.4 points, 95% CI = -0.15 to 2.9) in students' scores were found. The additional increase owing to training above that which might be expected due to practice (i.e. the average difference in change scores between the two groups) was 5.8 points (95% CI = 3.75-7.96), representing a large effect size for the training (d = 0.95). There is a large variation in the breastfeeding knowledge of midwives working in post-natal care and, on average, they are no more skilled than senior student midwives. The study has shown that a 4-h workshop in a positioning and attachment intervention, using a 'hands-off' approach, can increase midwives' knowledge of breastfeeding support relevant to the immediate post-natal period. It is applicable to all midwives, and could be a cost-effective way of improving the ability of mothers to begin and continue to breastfeed successfully.

A comparison of antibiotic use in children between Canada and Denmark

BACKGROUND

High rates of antibiotic prescribing in children lead to antibiotic resistance in the community. Surveillance on utilization rates and comparisons with other jurisdictions are methods for benchmarking. Surveillance on antibiotic use is well established in Europe, including Denmark, but until recently, similar data from Canada were lacking.

OBJECTIVE

To compare pediatric antibiotic prescribing rates in British Columbia, Canada, with those in Denmark.

METHODS

Population-based data on antibiotic prescriptions from British Columbia and Denmark were obtained from 1999 to 2003 for children less than 15 years of age. Annual trends in prescription rates per 1000 children were analyzed by using generalized linear models for all children less than 15 years of age; they were stratified by age group (0-4, 5-9, 10-14 y) for all antibiotics. Class-specific trends were also evaluated for penicillins, cephalosporins, macrolides, sulfonamides and trimethoprim, tetracyclines, and fluoroquinolones.

RESULTS

From 1999 to 2003, the overall British Columbia prescription rate was significantly higher than that of Denmark (p < 0.0001) at all age stratifications. In 2003, the British Columbia prescription rate was twice that of Denmark, at 608 versus 385 prescriptions per 1000 children, respectively. In both jurisdictions, the majority of antibiotics used were penicillins (Anatomical Therapeutic Chemical class J01C). However, in British Columbia, most penicillins used were extended-spectrum (83% in 2003); in Denmark, 34% of penicillins used in 2003 were extended-spectrum and 56% were beta-lactamase sensitive. In British Columbia, use of penicillins (-4.5%), cephalosporins (-5.5%), trimethoprim/sulfamethoxazole (-36%), and tetracycline (-1.6%) decreased over time, whereas in Denmark, use of penicillins increased by 11% over time and non-penicillin antibiotics remained stable. A significant increase in macrolide consumption was seen in British Columbia due to use of clarithromycin and azithromycin; in contrast, macrolide consumption declined in Denmark.

CONCLUSIONS

Compared with Denmark, the antibiotic prescription rate for children is substantially higher in British Columbia. In addition, there has been a significant increase in the use of macrolides, especially the second-generation agents, in British Columbia compared with the use in Denmark. Further studies are required to delineate reasons for antibiotic prescribing patterns in these 2 jurisdictions.

Nutrition interventions in women in low-income groups in the UK

In the UK the mental and physical health and well-being of millions of women are influenced by living in poverty. Low educational attainment, unemployment, low pay and poor areas of residence exacerbate the challenges of obtaining optimal food choices, dietary intake and healthy eating patterns. Poorer women are more likely to eat low amounts of fruits and vegetables, whole grains and fish, and higher amounts of sugar and sweetened drinks compared with more affluent women. Diet contributes to the health inequalities evident in high rates of diet-related morbidity (including obesity) and mortality (including IHD and stroke) and in maternal and child health considerations (including breast-feeding and family diet practices). There is a dearth of research on effective interventions undertaken with low-income women, reflecting some of the challenges of engaging and evaluating programmes with this ‘hard to reach’ subpopulation. Intervention programmes from the USA, including WISEWOMAN, the Women's Health Initiative, the American Special Supplemental Food Program for Women, Infants and Children and the Expanded Food and Nutrition Education Program provide models for changing behaviour amongst women in the UK, although overall effects of such programmes are fairly modest. Lack of evidence does not mean that that policy work should be not be undertaken, but it is essential that policy work should be evaluated for its ability to engage with target groups as well as for the behavioural change and health outcomes.

Optimal duration of exclusive breastfeeding: what is the evidence to support current recommendations?

Before 2001, the World Health Organization (WHO) recommended that infants be exclusively breastfed for 4-6 mo with the introduction of complementary foods (any fluid or food other than breast milk) thereafter. In 2001, after a systematic review and expert consultation, this advice was changed, and exclusive breastfeeding is now recommended for the first 6 mo of life. The systematic review commissioned by the WHO compared infant and maternal outcomes for exclusive breastfeeding for 3-4 mo versus 6 mo. That review concluded that infants exclusively breastfed for 6 mo experienced less morbidity from gastrointestinal infection and showed no deficits in growth but that large randomized trials are required to rule out small adverse effects on growth and the development of iron deficiency in susceptible infants. Others have raised concerns that the evidence is insufficient to confidently recommend exclusive breastfeeding for 6 mo for infants in developed countries, that breast milk may not meet the full energy requirements of the average infant at 6 mo of age, and that estimates of the proportion of exclusively breastfed infants at risk of specific nutritional deficiencies are not available. Additionally, virtually no data are available to form evidence-based recommendations for the introduction of solids in formula-fed infants. Given increasing evidence that early nutrition and growth have effects on both short- and longer-term health, it is vital that this issue be investigated in high-quality randomized studies. Meanwhile, the consequences of the WHO recommendation should be monitored in different settings to assess compliance and record and act on adverse events. The policy should then be reviewed in the context of new data to formulate evidence-based recommendations.

Advances in our understanding of the biology of human milk and its effects on the offspring

There is an intense interest in the effects of breast-feeding on the offspring and in understanding the mechanisms behind these effects. More than 50 papers are published monthly on topics such as the influence of breast-feeding on aspects of growth, immune-related effects, mental development, and noncommunicable diseases. Most breast-feeding data are observational; confounding can be difficult to rule out because some maternal factors are associated with both breast-feeding and infant outcomes (e.g., obesity and mental development). The most important short-term immunological benefit of breast-feeding is the protection against infectious diseases. There is also some evidence of lower prevalence of inflammatory bowel diseases, childhood cancers, and type I diabetes in breast-fed infants, suggesting that breast-feeding influences the development of the infant's own immune system. One of the most consistent findings of breast-feeding is a positive effect on later intelligence tests with a few test points advantage for breast-fed infants. In the last few years, several systematic reviews and meta-analyses have examined the effect of breast-feeding on noncommunicable diseases. There seems to be a small protective effect against later overweight and obesity. Blood pressure and blood cholesterol seem to be slightly lower in breast-fed infants; however, the few studies examining breast-feeding and the risk of coronary heart disease in later life did not find an association. Recent data have suggested that breast-feeding can program the insulin-like growth factor-I axis, as 3 studies found that breast-fed infants are taller as adults.

Support for breastfeeding mothers

BACKGROUND

There is extensive evidence of the benefits of breastfeeding for infants and mothers. In 2003, the World Health Organization (WHO) recommended infants be fed exclusively on breast milk until six months of age. However, breastfeeding rates in many developed countries continue to be resistant to change.

OBJECTIVES

To assess the effectiveness of support for breastfeeding mothers.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2006), MEDLINE (1966 to November 2005), EMBASE (1974 to November 2005) and MIDIRS (1991 to September 2005).

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing extra support for breastfeeding mothers with usual maternity care.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We have included 34 trials (29,385 mother-infant pairs) from 14 countries. All forms of extra support analysed together showed an increase in duration of 'any breastfeeding' (includes partial and exclusive breastfeeding) (relative risk (RR) for stopping any breastfeeding before six months 0.91, 95% confidence interval (CI) 0.86 to 0.96). All forms of extra support together had a larger effect on duration of exclusive breastfeeding than on any breastfeeding (RR 0.81, 95% CI 0.74 to 0.89). Lay and professional support together extended duration of any breastfeeding significantly (RR before 4-6 weeks 0.65, 95% 0.51 to 0.82; RR before 2 months 0.74, 95% CI 0.66 to 0.83). Exclusive breastfeeding was significantly prolonged with use of WHO/UNICEF training (RR 0.69, 95% CI 0.52 to 0.91). Maternal satisfaction was poorly reported.

AUTHORS' CONCLUSIONS

Additional professional support was effective in prolonging any breastfeeding, but its effects on exclusive breastfeeding were less clear. WHO/UNICEF training courses appeared to be effective for professional training. Additional lay support was effective in prolonging exclusive breastfeeding, while its effects on duration of any breastfeeding were uncertain. Effective support offered by professionals and lay people together was specific to breastfeeding and was offered to women who had decided to breastfeed. Further trials are required to assess the effectiveness (including cost-effectiveness) of both lay and professional support in different settings, particularly those with low rates of breastfeeding initiation, and for women who wish to breastfeed for longer than three months. Trials should consider timing and delivery of support interventions and relative effectiveness of intervention components, and should report women's views. Research into appropriate training for supporters (whether lay or professional) of breastfeeding mothers is also needed.

Special considerations for breastfeeding the infant with spina bifida

At present, no research has examined the unique breastfeeding needs of a mother and her infant with spina bifida (SB). This mother-infant dyad will face many unique challenges during the prenatal period, postdelivery, and postsurgical repair of the myelomeningocele (MMC). Each of these periods presents an opportunity for effective evidence-based nursing interventions to promote successful provision of human milk (HM). Beyond the need for nursing care during these crucial events, parents need education about the potential benefits of HM for the long-term complications of SB. Although there is no published evidence specifically related to the benefits of HM for mothers and their infants with SB, studies related to the general benefits of HM suggest that the mothers may enjoy enhanced maternal psychological adjustment while infants with SB may experience improved pain management, reduced infection rates, decreased incidence of allergy, improved cognitive development, and decreased incidence of obesity. Further research is needed to better understand the unique relationship between HM and SB.

‘Breaking the rules’ in baby-feeding practice in the UK: deviance and good practice?

OBJECTIVE

to discover the views of midwives in relation to baby feeding.

DESIGN AND METHOD

qualitative using grounded theory. Data collection used in-depth interviews with 30 midwives who volunteered to participate. Field notes of the interaction between the researcher and participant were also recorded as data. The constant comparison process was used to generate codes and subsequent conceptualisations from the data.

SETTING

two maternity units in the North of England, UK.

FINDINGS

the core category of this study is called 'surviving' baby feeding, and the findings reported here are a significant theme that emerged. These midwives described a management strategy termed 'breaking the rules' for supporting mothers with baby feeding. The concept 'breaking the rules' represented practices that were not congruent with evidence-based, baby-feeding policy and recommendations, or with some practices that were usual in the local working environment. These midwives were aware of their actions but described how they 'hid' their behaviour from mothers and from their peers. Some of the behaviour described showed that these midwives 'broke the rules' in relation to professional requirements and the facilitation of informed decision making about feeding practices with the women in their care. However, some midwives reported examples of practice that is woman-centred, and supportive of baby feeding, but this was not acceptable to others in the working environment.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

deviant behaviour was described by these midwives in relation to informed decision making and options for mothers in baby-feeding practice. These midwives 'knowingly concealed' their deviant practices from others. These behaviours should be taken seriously as they risk being negligent in relation to UK statutory professional requirements. However, practices that depart from those that are normal in the local working environment are not always negative and detrimental to the recipients of care; they can be positive. There needs to be more research, open discussion and debate about midwifery practice that does not always 'fit in' with professional, and 'normal' expectations. In this study, the term 'baby feeding' relates to how babies' nutritional needs are met.

Racial/ethnic differences in breastfeeding initiation and continuation in the United kingdom and comparison with findings in the United States

OBJECTIVE

Patterns of breastfeeding vary considerably across different racial/ethnic groups; however, little is known about factors that might explain differences across and within different racial/ethnic groups. Here we examine patterns of breastfeeding initiation and continuation among a racially/ethnically diverse sample of new mothers and compare this with patterns seen in the United States. The effects of demographic, social, economic, and cultural factors on racial/ethnic differences in breastfeeding practices are assessed.

METHODS

The sample includes all singleton infants whose mothers participated in the first survey of the United Kingdom Millennium Cohort Study. Missing data reduced the sample to 17,474 (96%) infants with complete data.

RESULTS

After adjustment for demographic, economic, and psychosocial factors, logistic regression models showed that Indian, Pakistani, Bangladeshi, black Caribbean, and black African mothers were more likely to initiate breastfeeding compared with white mothers. Further adjustment for a marker of cultural tradition attenuated these relationships, but all remained statistically significant, suggesting that some of the difference was a consequence of cultural factors. After adjustment for demographic, economic, and psychosocial factors, Indian, Pakistani, Bangladeshi, black Caribbean, and black African mothers were more likely to continue breastfeeding at 3 months compared with white mothers. Additional adjustment for a marker of cultural tradition attenuated the relationship for Indian, Pakistani, Bangladeshi, and black African mothers, but all remained statistically significant. Models run for breastfeeding continuation at 4 and 6 months were consistent with these results.

CONCLUSIONS

We have shown that in the United Kingdom the highest breastfeeding rates are among black and Asian mothers, which is in stark contrast to patterns in the United States, where the lowest rate is seen among non-Hispanic black mothers. The contrasting racial/ethnic patterns of breastfeeding in the United Kingdom and United States necessitate very different public health approaches to reach national targets on breastfeeding and reduce health disparities. Those who implement future policies aimed at increasing breastfeeding rates need to pay attention to different social, economic, and cultural profiles of all racial/ethnic groups.

Rapid growth in infancy: balancing the interests of the child

Low birth weight is associated with a number of immediate adverse consequences, and it has been assumed that "catch-up" growth is a "good thing" because "better" nutritional status is associated with greater childhood health and survival. The same thinking applies to infants who suffer malnutrition and growth faltering during weaning. Recent studies suggest that the rapid postnatal growth of babies is associated with an enhanced risk for obesity, diabetes, hypertension, cardiovascular disease and osteopenia in later life. If this is true, it has implications for our recommendations for infant feeding. Insights from evolutionary biology, life cycle theory, animal husbandry, epidemiology and comparative zoology suggest that the energetic feeding of underweight infants should be considered in the context of the whole life cycle and balance the interests of the child with its likely fortunes in adulthood. Before we revise our current recommendations, we must consider the meaning of catch-up growth, what it involves in terms of tissues gained (fat, muscle and bone) and to what degree association represents causation. In the meantime, it will be prudent to balance the short- and long-term interests of the child by endeavoring to (1) optimize maternal nutrition and health, to avoid low birth weight, (2) breast-feed ideally, (3) consider birth weight, gestation and future "nutritional environment" when making decisions about infant feeding, (4) use appropriate growth charts, (5) avoid excessive postnatal weight gain, (6) think about the whole life span and (7) extrapolate from animal studies cautiously.

Developing practice in breastfeeding

This paper reports on an approach to practice development in breastfeeding as part of a national programme of work to address inequalities in maternal and child nutrition. The production and dissemination of evidence and guidelines is necessary but not sufficient on its own to effect change in practice, particularly when dealing with complex public health issues. In the case of breastfeeding, review evidence and national guidance have shown that multifaceted changes are essential if policy aspirations are to be realized. The objectives of the programme described here were to (1) inform and enable practice development in breastfeeding in low-income areas; (2) evaluate the impact of approaches used; and (3) develop robust approaches and appropriate material for use nationally. A conceptual framework was established, and a six-stage process is outlined. The recruitment of four sentinel sites across whole health economies, involving professionals and the voluntary sector, was an essential component of the programme. The strength of the model is that it provides a structured, cross-sectoral approach to practice development in public health. A key challenge is to identify whose responsibility it is to resource practice development when a number of disciplines and sectors are involved. This question needs to be addressed if public health guidance is to be of sustained benefit.

Breast feeding twins and high multiples

Breast feeding offers major health advantages for all infants, whether born singleton or from multiple pregnancy. Adequate quantity and quality of milk production has been documented even for high multiples. Combined efforts of parents, close family, friends, and the medical team can help to make either full or partial breast feeding of multiples possible.

Exploring women's views of breastfeeding: a focus group study within an area with high levels of socio-economic deprivation

There is ample evidence of the short- and long-term health benefits of breastfeeding for mothers and infants, yet breastfeeding rates remain low in the UK, particularly in areas of high social deprivation. It is imperative that appropriate strategies are utilized to support more women to initiate and continue breastfeeding. This study used focus group methodology to explore women's views in relation to breastfeeding. The study was conducted within an area with high levels of socio-economic deprivation in the north-east of England and aimed to identify local barriers to breastfeeding, influences on choice of infant-feeding method and strategies which might improve breastfeeding rates. Focus group discussions were conducted with low-income women, adolescent women and women from a minority ethnic group. The five key themes that emerged from the data were: society's negative attitudes towards breastfeeding; the influence of family and friends and the experience on choice of method of infant feeding; lack of knowledge of some aspects of infant feeding; perceptions of professional support; and women's positive and negative experiences of breastfeeding. Recommendations for promoting and supporting breastfeeding include improving facilities to breastfeed in public, enhancing the provision of information, addressing conflicting advice and poor professional practice and implementing support mechanisms. The findings and recommendations have been used to develop a breastfeeding strategy to meet local needs. This project was funded by the English Department of Health Infant Feeding Initiative.

Full breastfeeding and hospitalization as a result of infections in the first year of life

OBJECTIVE

Our objective was to assess the effect of breastfeeding on the probability of hospitalization as a result of infectious processes during the first year of life

METHODS

We followed 1385 infants from birth to age 1 year between 1996 and 1999. Recruitment and data collection were done at the 6-month well-infant visit under the National Child Health Program. Full breastfeeding, hospital admission, and other relevant variables related to the delivery, infant, mother, health services system, and sociologic aspects were recorded. The statistical analysis included Kaplan-Meier test, Cox regression to obtain the hazard ratio, and the adjusted attributable risk.

RESULTS

Full breastfeeding at discharge after delivery and at 3, 4, and 6 months of age were 85%, 52%, 41%, and 15%, respectively; 78 hospital admissions as a result of infections were recorded (38 respiratory tract, 16 gastrointestinal tract). Mean age at admission was 4.1 months. After estimating the attributable risk, it was found that 30% of hospital admissions would have been avoided for each additional month of full breastfeeding. Seemingly, 100% of full breastfeeding among 4-month-old infants would avoid 56% of hospital admissions in infants who are younger than 1 year.

CONCLUSIONS

On the basis of the present data, we conclude that full breastfeeding would lower the risk for hospital admission as a result of infections among infants who are younger than 1 year within an industrialized country.

Maternal fish oil supplementation during lactation does not affect blood pressure, pulse wave velocity, or heart rate variability in 2.5-y-old children

Maternal (n-3) PUFA deficiency is associated with higher blood pressure (BP) later in life in rat offspring, and early intake of (n-3) PUFA in formula-fed infants was shown to modify later BP. BP, heart rate (HR), and heart rate variability (HRV) are affected by dietary (n-3) PUFA in adults. In this study, we investigated whether fish oil (FO) supplementation of lactating mothers could modify BP, pulse wave velocity (PWV), and HRV in their children after 2 y. Mothers with low fish intake were randomly assigned to FO or olive oil (OO) supplementation for the first 4 mo after delivery. A reference group of mothers with a high habitual fish intake (HFI) was also followed. At the follow-up study at 2.5 y of age, BP and PWV were measured, and electrocardiograms were recorded for 0.5 h. FO supplementation significantly increased RBC levels of long-chain (n-3) PUFA of the 4 mo-old children, but at 2.5 y, the FO and OO groups did not differ. BP, PWV, HR, and HRV also did not differ among the groups. However, for all 3 groups, the children's intake of (n-3) PUFA at 2.5 y was negatively correlated with mean arterial pressure after adjustment for outdoor temperature (r = -0.245, P = 0.04). In conclusion, maternal FO supplementation had no overall effect on BP, PWV, or HRV of the children, indicating that (n-3) PUFA intake of Danish mothers may be sufficient in this sense. However, children's dietary intake of (n-3) PUFA might have a beneficial effect on BP in childhood.

Composition, structure and absorption of milk lipids: a source of energy, fat-soluble nutrients and bioactive molecules

Milkfat is a remarkable source of energy, fat-soluble nutrients and bioactive lipids for mammals. The composition and content of lipids in milkfat vary widely among mammalian species. Milkfat is not only a source of bioactive lipid components, it also serves as an important delivery medium for nutrients, including the fat-soluble vitamins. Bioactive lipids in milk include triacylglycerides, diacylglycerides, saturated and polyunsaturated fatty acids, and phospholipids. Beneficial activities of milk lipids include anticancer, antimicrobial, anti-inflammatory, and immunosuppression properties. The major mammalian milk that is consumed by humans as a food commodity is that from bovine whose milkfat composition is distinct due to their diet and the presence of a rumen. As a result of these factors bovine milkfat is lower in polyunsaturated fatty acids and higher in saturated fatty acids than human milk, and the consequences of these differences are still being researched. The physical properties of bovine milkfat that result from its composition including its plasticity, make it a highly desirable commodity (butter) and food ingredient. Among the 12 major milk fatty acids, only three (lauric, myristic, and palmitic) have been associated with raising total cholesterol levels in plasma, but their individual effects are variable-both towards raising low-density lipoproteins and raising the level of beneficial high-density lipoproteins. The cholesterol-modifying response of individuals to consuming saturated fats is also variable, and therefore the composition, functions and biological properties of milkfat will need to be re-evaluated as the food marketplace moves increasingly towards more personalized diets.

Relationships between paediatricians and infant formula milk companies

Paediatricians should recognise the influence of infant formula milk companies and avoid intentionally or inadvertently promoting them

Pesticide exposure and stunting as independent predictors of neurobehavioral deficits in Ecuadorian school children

OBJECTIVES

To examine possible effects on blood pressure, neurological function, and neurobehavioral tests in school-aged children with and without prenatal pesticide exposure in an area where stunting is common.

METHODS

In a community of Northern Ecuador with intensive floriculture and a high female employment rate, we invited 79 children attending the 2 lowest grades of a public school for clinical examinations. In addition to a thorough physical examination, we administered simple reaction time, Santa Ana dexterity test, Stanford-Binet copying, and Wechsler Intelligence Scale for Children-Revised Digit Spans forward. Maternal interview included detailed assessment of occupational history to determine pesticide exposure during pregnancy. Recent and current pesticide exposure was assessed by erythrocyte acetylcholine esterase activity and urinary excretion of organophosphate metabolites.

RESULTS

All eligible children participated in the study, but 7 children were excluded from data analysis due to other disease or age >9 years. A total of 31 of the remaining 72 children were classified as stunted based on their height for age. Maternal occupational history revealed that 37 children had been exposed to pesticides during development. After confounder adjustment, prenatal pesticide exposure was associated with a higher systolic blood pressure than in the controls. On neurological examination, 14 exposed children and 9 controls showed > or =1 abnormalities. Of 5 neurobehavioral tests, the Stanford-Binet copying test showed a lower drawing score for copying designs in exposed children than in controls. Stunting was associated with a lower score on this test only, and both risk factors remained statistically significant in a multiple regression analysis with adjustment for demographic and social confounders. Increased excretion of dimethyl and diethyl metabolites of organophosphates was associated with increased reaction time and no other outcomes.

CONCLUSION

Prenatal pesticide exposure may cause lasting neurotoxic damage and add to the adverse effects of malnutrition in developing countries. The effects differ from those due to acute pesticide exposure.

Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age

BACKGROUND

Although dual-energy X-ray absorptiometry (DXA) is considered the most accurate measure of adiposity in children, it has rarely been used to examine the relation between infant feeding and adiposity during childhood.

OBJECTIVE

The objective was to ascertain whether adiposity at age 5 y was related to breastfeeding, to the timing of the introduction of complementary foods during infancy, or to both.

DESIGN

Body composition was measured in 313 children at age 5 y by using DXA. Data on breastfeeding, formula feeding, and the timing of the introduction of complementary foods were obtained from the mothers when the children were 3 y old. Regression analysis was used to examine the relation between infant feeding and fat mass after adjustment for lean body mass, sex, birth weight, maternal obesity, race, and other sociodemographic variables.

RESULTS

Fifty-three percent of the children were boys, 80% were white, and 20% were black. There was no significant difference in adjusted fat mass between those ever breastfed and those never breastfed (x +/- SE: 4.48 +/- 0.09 and 4.76 +/- 0.17 kg, respectively; P = 0.17). Children who were breastfed for a longer duration and those who were breastfed without concurrent formula feeding did not have significantly lower fat mass than did those children who were never breastfed. Children did not differ significantly in fat mass if they were introduced to complementary foods before or after 4 mo of age (4.49 +/- 0.12 and 4.63 +/- 0.12 kg, respectively; P = 0.42).

CONCLUSION

Neither breastfeeding nor the timing of the introduction of complementary foods was associated with adiposity at age 5 y.

Baby-Friendly: snappy slogan or standard of care?

Breastfeeding offers significant protection against illness for the infant and numerous health benefits for the mother, including a decreased risk of breast cancer. In 1991, UNICEF and WHO launched the Baby-Friendly Hospital Initiative with the aim of increasing rates of breastfeeding. "Baby-Friendly" is a designation a maternity site can receive by demonstrating to external assessors compliance with the Ten Steps to Successful Breastfeeding. The Ten Steps are a series of best practice standards describing a pattern of care where commonly found practices harmful to breastfeeding are replaced with evidence based practices proven to increase breastfeeding outcome. Currently, approximately 19,250 hospitals worldwide have achieved Baby-Friendly status, less than 500 of which are found in industrialised nations. The Baby-Friendly initiative has increased breastfeeding rates, reduced complications, and improved mothers' health care experiences.

Breast-feeding in women with hypertensive disorders in pregnancy

AIMS

Breast feeding is particularly important and difficult in children born prematurely, especially after hypertensive diseases in pregnancies (HDP). Therefore, we aimed to investigate breast feeding in women who developed HDP.

METHODS

Data on breast-feeding was collected within a nationwide research project on psychosocial factors in HDP. A self-administered questionnaire was given to 2600 women with a suspected history of HDP and 1233 controls. After matching and confirming diagnosis according to ISSHP criteria, 877 women with HDP and 623 controls were included into the study.

RESULTS

Control women initiated (48.9/39.2%; P<0.001) and continued (42.2/37.2%; P<0.005) breast-feeding significantly more often than women with HDP. This holds particularly for women who developed HELLP syndrome (48.9/34.7%; P<0.0001, 42.2/33.5%; P<0.0001). A delivery before the 32(nd) gestational week (19.5/81.8%; P<0.0001) and a birth weight of less than 1500 g (18.8/75%; P<0.0001) were associated with the decision not to breast-feed.

CONCLUSIONS

Women affected by HDP breast fed significantly less often than control women. This effect is at least partly caused by the increased rate of prematurity. Encouraging and supporting these women in breast-feeding is important to improve neonatal physical and mental development.

Discordant twin growth in utero and differences in blood pressure and endothelial function at 8 years of age

OBJECTIVE

Low birth weight is associated with increased prevalence of hypertension and cardiovascular disease in adults. The aim of this study was to evaluate genetic and intrauterine environmental contributions to blood pressure (BP) and vascular functions in twins with discordant growth in utero.

SUBJECTS

We studied 31 twin pairs (21 monozygous and nine dizygous), mean age 8 years) with large within-pair differences in birth weight. Among the monozygous pairs, nine had suffered from twin-to-twin-transfusion syndrome (TTTS).

METHODS

Apart from BP, we determined diameters and elasticity of the carotid artery and abdominal aorta with ultrasonography, and endothelial function in skin vessels with a laser Doppler technique, before and after transdermal delivery of acetylcholine and nitroglycerin.

RESULTS

Eight of 62 twin subjects had a systolic BP above the 90th percentile in a North-American reference population. Among these, seven/eight were monozygous with a history of poor fetal growth and/or TTTS. In monozygous twin pairs without TTTS, systolic BP and pulse pressure were higher and vascular endothelial function was impaired in the lower birth weight twin. In the TTTS group, the lighter twin had a narrower carotid artery but there was no within-pair difference in arterial elasticity. Pre-eclampsia during the index pregnancy enhanced within-pair differences in BP but abolished within-pair differences in endothelial function.

CONCLUSIONS

Severe fetal growth retardation contributes to higher BP, arterial narrowing and endothelial dysfunction in childhood. Pre-eclampsia may act both as an effect modifier and confounder of these associations.

Barriers to compliance with infant-feeding recommendations among low-income women

Focus groups were used to examine relationships among maternal beliefs, feeding intentions, and infant-feeding behaviors among 65 Women, Infants and Children-eligible (28 English-speaking and 37 Spanish-speaking) mothers. Participants shared common beliefs that breast-feeding was beneficial; nevertheless, many believed that early introduction of formula and solid foods was unavoidable in certain situations. Medical providers and Women, Infants and Children staff were sources of infant-feeding information, and the Spanish-speaking mothers attempted to adhere to the guidance. However, the English-speaking mothers often ignored this advice if it was not perceived as working for the family's circumstances. Mothers, believing that providers would not understand that they were compelled to reject infant-feeding recommendations, would not ask for assistance when facing difficulties. Instead, mothers relied on relatives and others for infant-feeding guidance. Educational efforts should acknowledge mothers' true circumstances, target support to each situation, and emphasize the health value of complementary foods rather than their association with infant motor development.

Type of kindergarten and other potential determinants of overweight in pre-school children

OBJECTIVE

The study aimed to assess the relationship of various types of kindergarten differing in length of care and food availability with the development of overweight in pre-school children.

DESIGN, SETTING AND SUBJECTS

A cross-sectional study was carried out in 2002 in Stuttgart, Germany, as part of the school entrance examination. Height and weight of 2140 children (participation 70.2%) were measured and information on type of kindergarten and other potential determinants of overweight was collected by a parental questionnaire. Change in relative body mass index (BMI) position between the ages of 4 and 6 years was assessed using medical records.

RESULTS

The prevalence of overweight or change in relative BMI position did not differ according to the type of kindergarten. For the prevalence of overweight in German children, adjusted odds ratios (OR) comparing institutions that open only in the morning with those opening in the morning and afternoon or for the full day were 0.86 (95% confidence interval (CI) 0.40, 1.83) and 0.63 (95% CI 0.25, 1.58), respectively. Parental BMI and duration of television watching were positively associated, and maternal educational status and duration of breast-feeding were negatively associated, with overweight and/or change in relative BMI position. The prevalence of overweight was substantially higher among non-German than among German children (adjusted OR 2.17 (95% CI 1.53, 3.07)).

CONCLUSIONS

These data show no association between different types of kindergarten and the development of overweight in early childhood. Duration of television watching and breast-feeding, as well as the relatively high prevalence of overweight in ethnic minorities, deserve further attention.

Duration of exclusive breast-feeding: introduction of complementary feeding may be necessary before 6 months of age

The WHO recommends exclusive breast-feeding for the first 6 months of life. At present, <2 % of mothers who breast-feed in the UK do so exclusively for 6 months. We propose the testable hypothesis that this is because many mothers do not provide sufficient breast milk to feed a 6-month-old baby adequately. We review recent evidence on energy requirements during infancy, and energy transfer from mother to baby, and consider the adequacy of exclusive breast-feeding to age 6 months for mothers and babies in the developed world. Evidence from our recent systematic review suggests that mean metabolisable energy intake in exclusively breast-fed infants at 6 months is 2.2-2.4 MJ/d (525-574 kcal/d), and mean energy requirement approximately 2.6-2.7 MJ/d (632-649 kcal/d), leading to a gap between the energy provided by milk and energy needs by 6 months for many babies. Our hypothesis is consistent with other evidence, and with evolutionary considerations, and we briefly review this other evidence. The hypothesis would be testable in a longitudinal study of infant energy balance using stable-isotope techniques, which are both practical and valid.

Longitudinal study of the frequency and duration of breastfeeding in rural Bangladeshi women

A 27-month longitudinal study of 140 Bangladeshi mothers living in three tea gardens examined the effect of maternal factors (mother's age, number of live births, birth interval, and mother's work status) and sex of the infant on the duration and bout frequency of breastfeeding over 8-hr daytime periods. Prolonged breastfeeding of the infant was observed, but there was a sharp decline in duration of breastfeeding over the first 6 months, followed by a more gradual diminution thereafter. The feeding bouts showed a different pattern, with a more gradual decline over time. Housewives consistently showed a greater duration and bout frequency than women in paid employment as tea-pluckers. Over the first 6 months, primigravid mothers breastfed more frequently, but not thereafter. Older mothers (>35 years of age) breastfed with higher frequency during the first 2 months, but thereafter, the bout frequency decreased with increasing age of the infant. Over the 27-month study, maternal work status was the main factor associated with the duration and frequency of breastfeeding, with significantly higher frequency and duration among housewives. However, in the first 6 months after birth, there was very little difference in frequency or duration of breastfeeding between tea-workers and housewives, indicating that working mothers probably adjusted their time to breastfeed their infants before going, or after coming back, from work.

Breast-feeding initiation and exclusive duration at 6 months by social class--results from the Millennium Cohort Study

OBJECTIVES

To assess breast-feeding initiation and rates of exclusive breast-feeding for the first 6 months after birth, and to examine social class differences in breast-feeding rates.

DESIGN

First sweep of a longitudinal population-based survey, the Millennium Cohort Study.

SETTING

Four countries of the UK.

SUBJECTS

Subjects were 18 125 singletons born over a 12-month period spanning 2000-01. Data were collected by parental interview on the initiation of breast-feeding and exclusivity at 1, 4 and 6 months after birth.

RESULTS

Overall breast-feeding was initiated for 71% of babies, and by 1, 4 and 6 months of age the proportions being exclusively breast-fed were 34%, 3% and 0.3%, respectively. There were clear social class differences and mothers with routine jobs with the least favourable working conditions were more than four times less likely (odds ratio (OR) 0.22, 95% confidence interval (CI) 0.18-0.29) to initiate breast-feeding compared with women in higher managerial and professional occupations. Women in routine jobs were less likely to exclusively breast-feed their infants at 1 month (OR 0.42, 95% CI 0.36-0.50) and 4 months (OR 0.5, 95% CI 0.31-0.77) compared with women in higher managerial and professional occupations.

CONCLUSIONS

Clear social class differences in breast-feeding initiation and exclusivity for the first 4 months were apparent in this large UK sample. By 6 months, less than 1% of babies were being exclusively breast-fed. A co-ordinated multi-faceted strategy is required to promote breast-feeding, particularly among lower-income women.

Physicians Ask for More Problem-Solving Information to Promote and Support Breastfeeding

Physicians (n=262) were surveyed about their breastfeeding promotion practices, knowledge, and areas in which they need more information in order to be more influential with patients in the initiation and duration of the process. Over half (51%) reported no or limited education in breastfeeding, whereas only 9% reported adequate education. A knowledge assessment indicated almost half (42%) did not know certain viruses can be transmitted through breast milk. There were also mixed responses to the need for vitamin D supplementation. Promotion practices included most (82%) thinking the physician has a primary role in the feeding decision, and most did discuss the benefits with patients; however, only 54% would recommend breastfeeding to a patient who had decided to bottle-feed. Problem-solving was the main area physicians reported needing more education. Partnerships with dietetics professionals may fill the gaps in the support needed to increase rates of breastfeeding.

[Feeding practices in infants: a 6-month prospective cohort study]

The aims of this work were to assess timing of complementary feeding in infants and to precise the underlying factors that may cause inappropriate complementary feeding.

PATIENTS AND METHODS

A cohort of 167 newborns, born in the same maternity ward during a 6 week-period, was prospectively analyzed. Only healthy neonates were included in the study. A phone questionnaire was filled at 4 and 6 months of age to evaluate modality of complementary feeding. Multivariate analysis (segmentation tree, analyse by multiple correspondence) was used to study factors associated with inappropriate diversification.

RESULTS

Out of the 167 neonates included in the study, 132 mothers could be contacted at 4 months and 116 at 6 months of age. Sixty-seven per cent of mothers started breast feeding at birth. Among these, 33% still breastfed -at least partially- at 4 months and 17% at 6 months. Fifty-two percent of mothers started complementary feeding before 4 months, and 24% of infants received gluten at 4 months of age. Multi-gravida mothers, mothers aged more than 35 years old and mothers who gave infant or follow-up formulae before 4 months, started complementary feeding significantly earlier (P<0.05). Infants who were formula fed received more frequently complementary feeding before the age of 4 months than breast fed infants (57% vs 33%, P<0.05).

CONCLUSION

Our study showed that half of infants were introduced solid food too early and allowed to identify a population at risk that could benefit from nutritional intervention programs.

The atopic march: the pattern of allergic disease development in childhood

The sequential development of allergic disease manifestations during early childhood is often referred to as the atopic march. Various epidemiologic and birth-cohort studies have begun to elucidate the evolution of allergic disease manifestations and to identify populations at risk for disease. These studies, along with intervention studies, emphasize the effects of environmental factors and genetic predisposition on the atopic march. This article discusses the populations at risk for the development of atopic conditions and the interventions that have been explored in attempts to modify the progression of allergic disease.

Breastfeeding and the cultural configuration of social space among Vietnamese immigrant woman

This study aimed to identify cultural factors involved in the abandonment of breastfeeding amongst Vietnamese immigrant women in Canada. Qualitative interviews were conducted with 19 mothers, exploring their perinatal experience from Vietnam to Canada. The results suggest that the decision to bottle-feed was not related to acculturation to local practices as has been claimed in previous studies but to conflicts between Vietnamese cultural practices and the configuration of the new social space in Canada. Living in Canada did not allow specific family members to conduct postnatal traditional rituals thus jeopardizing mothers' perceived health and the quality of their milk. Culturally appropriate strategies to promote breastfeeding among migrants must consider the social and spatial organization of cultural practices.

The contribution of parental and community ethnicity to breastfeeding practices: evidence from the Millennium Cohort Study

BACKGROUND

The association of ethnic and social factors at the individual and community level with inequalities in starting, and continuing, to breastfeed remains unclear. We explored these factors using data from the Millennium Cohort Study.

METHODS

We obtained data for 11 286 natural mothers [8207 (85%) white] of singleton infants, living in England at age 9 months. Breastfeeding mothers were defined as the proportion of all mothers who reported: putting their baby to the breast at least once and giving any breastmilk (initiation); and having started, continuing for at least 1 month (continuation).

RESULTS

In England, 72% of all mothers started breastfeeding, and of these 70% continued for at least 1 month. White mothers were the least likely to start breastfeeding (70%), as were multiparous mothers (69%), younger mothers, those with no academic qualifications (51%), in routine occupations (59%), or living in disadvantaged communities (60%). For white mothers, having a partner of a different ethnic group was independently and positively associated with breastfeeding initiation and continuation to 1 month [adjusted rate ratios (95% CI): 1.14 (1.07-1.21) and 1.09 (1.03-1.16), respectively]. White lone mothers were more likely to initiate breastfeeding if they lived in high ethnic minority communities [adjusted rate ratio (95% CI): 1.42 (1.15-1.76)] rather than disadvantaged areas. For all mothers, maternal age at first motherhood was positively associated with breastfeeding [adjusted rate ratio (95% CI): 1.06 (1.04-1.08) per 5 year increase].

CONCLUSIONS

Significant inequalities in breastfeeding practices remain within the UK. White women are less likely to breastfeed and, for these women, partner and community ethnicity have an important relation to starting and continuing to breastfeed. Our findings suggest that public health strategies to increase breastfeeding need to be focussed on mothers who are young at first motherhood and address support offered by partners and the communities in which women live. Measures to evaluate the effectiveness of these strategies over time and between places should take account of changes in ethnic composition of the child-bearing population.

Breast is best for babies

Breastfeeding is the optimal method of infant feeding. Breast milk provides almost all the necessary nutrients, growth factors and immunological components a healthy term infant needs, Other advantages of breastfeeding include reduction of incidences and severity of infections; prevention of allergies; possible enhancement of cognitive development; and prevention of obesity, hypertension and insulin-dependent diabetes mellitus. Health gains for breastfeeding mothers include lactation amenorrhea, early involution of the uterus, enhanced bonding between the mother and the infant, and reduction in incidence of ovarian and breast cancer. From the economic perspective, breastfeeding is less expensive than formula feeding. In most cases, maternal ingestion of medications and maternal infections are not contraindications to breastfeeding. Breastfeeding, however, is contraindicated in infants with galactosemia. The management of common breastfeeding issues, such as breast engorgement, sore nipples, mastitis and insufficient milk, is discussed. Breastfeeding should be initiated as soon after delivery as possible. To promote, protect and support breastfeeding, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) developed the Baby-Friendly Hospital Initiative (BFHI) 10 Steps to Successful Breastfeeding. Healthcare professionals have an important role to play in promoting and protecting breastfeeding.

Breast feeding and cardiovascular disease risk factors, incidence, and mortality: the Caerphilly study

STUDY OBJECTIVE

To investigate the association of having been breast fed with cardiovascular disease risk factors, incidence, and mortality.

DESIGN

Prospective cohort study.

SETTING

Caerphilly, South Wales.

PARTICIPANTS

All men aged 45-59 years living in and around the study area. Of 2818 eligible men, 2512 (89%) were seen. Altogether 1580 men (63%) obtained details of how they had been fed in infancy (ever breast fed or only bottle fed) from their mother or a close female relative. A subset of 1062 subjects reported on whether bottle fed or the duration of breast feeding if breast fed.

MAIN RESULTS

Breast feeding was not associated with stature, blood pressure, insulin resistance, total cholesterol, or fibrinogen. In fully adjusted models (controlling for age, birth order, and social position in childhood and adulthood), breast feeding was associated with greater body mass index than bottle feeding (difference: 0.41 kg/m(2) (95% CI: 0.01 to 0.81). There was a positive association between breast feeding and coronary heart disease mortality (hazard ratio: 1.73; 1.17 to 2.55) and incidence (1.54; 1.17 to 2.04) (fully adjusted models). There was no evidence of a duration-response effect, which might be expected if an adverse effect of breast feeding was causal.

CONCLUSION

These data provide little evidence of a protective influence of breast feeding on cardiovascular disease risk factors, incidence, or mortality. A possible adverse effect of breast feeding on coronary heart disease incidence was observed but may have a number of explanations, including selection and information bias. In view of these limitations, further long term studies with improved measures of infant feeding are required to confirm or refute these findings.

Long-term programming effects of early nutrition -- implications for the preterm infant

The current focus of nutritional science has shifted from meeting needs to determining the biological effects that nutrition has on immediate and lifetime health. Of particular interest is the concept of programming, the idea that "a stimulus or insult during a critical or sensitive period of development can have long-term or lifetime effects on an organism." Evidence that early nutrition has such "programming" effects in animals is overwhelming. In humans, retrospective observations show a relationship between adult disease and size in early life, though it is difficult to prove nutritional cause from observational associations and therefore difficult to use such data to underpin health policy. However, the results of randomized intervention trials of early nutrition with long-term follow-up are emerging. These experimental studies show that nutrition in early life has a major impact on health into early adulthood, notably on cardiovascular disease risk, bone health and cognitive function. These new findings have major biological, social and medical implications and should increasingly underpin health practices.

Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence

OBJECTIVE

To examine the influence of initial infant feeding on obesity in later life.

METHODS

A systematic review of published studies investigating the association between infant feeding and a measure of obesity was performed with Medline (1966 onward) and Embase (1980 onward) databases, supplemented with manual searches. Data extraction was conducted by 2 authors. Analyses were based on odds ratios of obesity among initially breastfed subjects, compared with formula-fed subjects, pooled with fixed-effects models.

RESULTS

Sixty-one studies reported on the relationship of infant feeding to a measure of obesity in later life; of these, 28 (298900 subjects) provided odds ratio estimates. In these studies, breastfeeding was associated with a reduced risk of obesity, compared with formula feeding (odds ratio: 0.87; 95% confidence interval [CI]: 0.85-0.89). The inverse association between breastfeeding and obesity was particularly strong in 11 small studies of <500 subjects (odds ratio: 0.43; 95% CI: 0.33-0.55) but was still apparent in larger studies of > or =500 subjects (odds ratio: 0.88; 95% CI: 0.85-0.90). In 6 studies that adjusted for all 3 major potential confounding factors (parental obesity, maternal smoking, and social class), the inverse association was reduced markedly (from an odds ratio of 0.86 to 0.93) but not abolished. A sensitivity analysis examining the potential impact of the results of 33 published studies (12505 subjects) that did not provide odds ratios (mostly reporting no relationship between breastfeeding and obesity) showed little effect on the results.

CONCLUSIONS

Initial breastfeeding protects against obesity in later life. However, a further review including large unpublished studies exploring the effect of confounding factors in more detail is needed.

The cup-versus-bottle debate: a theme from an ethnographic study of the supplementation of breastfed infants in hospital in the United kingdom

This article reports 1 theme from an ethnographic study that aimed to describe the experiences, expectations, and beliefs of mothers and health care professionals concerning supplementation in a UK maternity unit. Observation was conducted on the postnatal ward and the newborn infant unit, and 30 mothers, 17 midwives, 4 neonatal nurses, 3 health care assistants, 3 senior house officers, and 3 senior pediatricians gave in-depth interviews during a 9-month period in 2002. One of the major themes that emerged was the cup-versus-bottle debate. There were 3 categories strongly linked to this theme: difficulties returning to the breast, ease of use, and necessary skills and knowledge. It appears there is an urgent need to determine which is the best method of giving supplementary feeds, so that full, accurate information can be given to mothers, appropriate policies be devised, and the necessary resources and staff training be provided.