Early additional food and fluids for healthy breastfed full-term infants

Stakeholders' views of the Baby Friendly Initiative implementation and impact: a mixed methods study

BACKGROUND

The Baby Friendly Hospital Initiative (BFHI) was launched in 1991 as an intervention to support healthy infant feeding practices, but its global coverage remains around 10%. This study aimed to explore stakeholders' views of the Baby Friendly Initiative (BFI) programme, the barriers and facilitators to accreditation and its perceived impact.

METHODS

A mixed methods approach was used. An online survey was distributed through numerous professional networks from September 2020 to November 2020. Quantitative data were analyzed using descriptive statistics, with simple content analysis undertaken on open-ended responses. Individual semi-structured interviews were also undertaken and analyzed using inductive thematic analysis.

RESULTS

A total of 322 respondents completed the survey in part or in full, mainly from the United Kingdom. Fifteen key stakeholders and two maternity service users undertook interviews. Respondents were from various professional backgrounds and currently worked in different roles including direct care of women and their families, public health, education and those responsible for purchasing health services. Survey respondents viewed the BFI to have the greatest impact on breastfeeding initiation, duration, and infant health outcomes. Three overall themes were identified. The first was "BFI as an agent for change". Most participants perceived the need to implement the whole package, but views were mixed regarding its impact and the accreditation process. Secondly, BFI was regarded as only "one part of a jigsaw", with no single intervention viewed as adequate to address the complex cultural context and social and health inequities that impact breastfeeding. Finally, "cultural change and education" around breastfeeding were viewed as essential for women, staff and society.

CONCLUSIONS

The BFI is not a magic bullet intervention. To create a more supportive breastfeeding environment within society a holistic approach is required. This includes social and cultural changes, increased education ideally starting at school age, and advancing positive messaging around breastfeeding within the media, as well as fully banning breastmilk substitute advertising. Although the BFI comprises a whole package, few survey respondents rated all aspects as equally important. Additional evidence for the effectiveness of each element and the importance of the whole package need to be established and communicated.

Timing of complementary feeding for early childhood allergy prevention: An overview of systematic reviews

OBJECTIVE

To summarise and critically appraise systematic review (SR) evidence on the effects of timing of complementary feeding (CF) on the occurrence of allergic sensitisation and disease.

DESIGN

Overview of SRs. AMSTAR-2 and ROBIS were used to assess methodological quality and risk of bias (RoB) of SRs. RoB 2 Tool was used to assess RoB of primary randomised controlled trials (RCTs) (or extracted). The certainty of evidence (CoE) was assessed using GRADE. Findings were synthesised narratively.

DATA SOURCES

MEDLINE (via PubMed and Ovid), the Cochrane Library and Web of Science Core Collection (2010 to 27 February 2023).

ELIGIBILITY CRITERIA

SRs investigating the effects of timing of CF in infants or young children (0-3 years) on risk of developing food allergy (FA), allergic sensitisation, asthma, allergic rhinitis, atopic eczema and adverse events based on RCT evidence.

RESULTS

Eleven SRs were included. Only two SRs had low RoB; common issues were failure to report on funding of primary studies and failure to provide a list of excluded trials. Common limitations of included trials were lack of blinding of outcome assessment or detailed trial preregistration, and inadequate handling of high loss to follow up. Primary study overlap was very high for specific FA and slight to moderate for FA in general and other primary outcomes. Introducing specific foods (peanut, cooked egg) early probably reduces the risk of specific FA. Evidence for other allergic outcomes was mostly very uncertain and based on few primary studies. Trials varied regarding timing of CF, nature of complementary foods and population risk, which limited comparability between SRs.

CONCLUSIONS

For developing guidelines to support decision-making on the timing of CF as a preventive strategy, early introduction of specific foods (i.e. egg and peanut) seems promising and safe, whereas more extensive research is required regarding other allergic outcomes and potential adverse events.

Oral dextrose gel to prevent hypoglycaemia in at-risk neonates

BACKGROUND

Neonatal hypoglycaemia is a common condition that can be associated with brain injury. Current practice usually includes early identification of at-risk infants (e.g. infants of diabetic mothers; preterm, small- or large-for-gestational-age infants), and prophylactic measures are advised. However, these measures often involve use of formula milk or admission to the neonatal unit. Dextrose gel is non-invasive, inexpensive and effective for treatment of neonatal hypoglycaemia. Prophylactic dextrose gel can reduce the incidence of neonatal hypoglycaemia, thus potentially reducing separation of mother and baby and supporting breastfeeding, as well as preventing brain injury. This is an update of a previous Cochrane Review published in 2021.

OBJECTIVES

To assess the effectiveness and safety of oral dextrose gel in preventing hypoglycaemia before first hospital discharge and reducing long-term neurodevelopmental impairment in newborn infants at risk of hypoglycaemia.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and Epistemonikos in April 2023. We also searched clinical trials databases and the reference lists of retrieved articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing oral dextrose gel versus placebo, no intervention, or other therapies for the prevention of neonatal hypoglycaemia. We included newborn infants at risk of hypoglycaemia, including infants of mothers with diabetes (all types), high or low birthweight, and born preterm (< 37 weeks), age from birth to 24 hours, who had not yet been diagnosed with hypoglycaemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias. We contacted investigators to obtain additional information. We used fixed-effect meta-analyses. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included two studies conducted in high-income countries comparing oral dextrose gel versus placebo in 2548 infants at risk of neonatal hypoglycaemia. Both of these studies were included in the previous version of this review, but new follow-up data were available for both. We judged these two studies to be at low risk of bias in 13/14 domains, and that the evidence for most outcomes was of moderate certainty. Meta-analysis of the two studies showed that oral dextrose gel reduces the risk of hypoglycaemia (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95; risk difference (RD) -0.06, 95% CI -0.10 to -0.02; 2548 infants; high-certainty evidence). Evidence from two studies showed that there may be little to no difference in the risk of major neurological disability at two years of age after oral dextrose gel (RR 1.00, 95% CI 0.59 to 1.68; 1554 children; low-certainty evidence). Meta-analysis of the two studies showed that oral dextrose gel probably reduces the risk of receipt of treatment for hypoglycaemia during initial hospital stay (RR 0.89, 95% CI 0.79 to 1.00; 2548 infants; moderate-certainty evidence) but probably makes little or no difference to the risk of receipt of intravenous treatment for hypoglycaemia (RR 1.01, 0.68 to 1.49; 2548 infants; moderate-certainty evidence). Oral dextrose gel may have little or no effect on the risk of separation from the mother for treatment of hypoglycaemia (RR 1.12, 95% CI 0.81 to 1.55; two studies, 2548 infants; low-certainty evidence). There is probably little or no difference in the risk of adverse effects in infants who receive oral dextrose gel compared to placebo gel (RR 1.22, 95% CI 0.64 to 2.33; two studies, 2510 infants; moderate-certainty evidence), but there are no studies comparing oral dextrose with other comparators such as no intervention or other therapies. No data were available on exclusive breastfeeding after discharge.

AUTHORS' CONCLUSIONS

Prophylactic oral dextrose gel reduces the risk of neonatal hypoglycaemia in at-risk infants and probably reduces the risk of treatment for hypoglycaemia without adverse effects. It may make little to no difference to the risk of major neurological disability at two years, but the confidence intervals include the possibility of substantial benefit or harm. Evidence at six to seven years is limited to a single small study. In view of its limited short-term benefits, prophylactic oral dextrose gel should not be incorporated into routine practice until additional information is available about the balance of risks and harms for later neurological disability. Additional large follow-up studies at two years of age or older are required. Future research should also be undertaken in other high-income countries, low- and middle-income countries, preterm infants, using other dextrose gel preparations, and using comparators other than placebo gel. There are three studies awaiting classification and one ongoing study which may alter the conclusions of the review when published.

Water consumption in 0-6-month-old healthy infants and effective factors: A systematic review

INTRODUCTION

Early introduction of fluids and water affects the duration of breastfeeding, the infant immune system, and possibly causes infants to consume less breast milk, which may, in turn, affect their nutritional and immune status.

OBJECTIVE

This study was carried out to determine water consumption in 0-6-month-old infants and the factors affecting this consumption.

MATERIALS AND METHODS

A literature review was conducted in seven electronic databases (Medline, Web of Science, PubMed, ScienceDirect, Scopus, Cochrane Library, and TÜBITAK) for studies published until April 25, 2022, using the keywords: drinking water, infant, and breastfeeding.

RESULTS

The systematic review included 13 studies. Five studies were crosssectional, three were descriptive and quasi-experimental, and the others were case-control and cohort studies. It was reported in the examined studies that 86.2% of the infants were around 6 weeks old, 44 % of the infants were 1 month old, 77% were 3 months old, 2.5% were 4 months old, and 2.5 to 85% of the infants were around 6 months old when they first consumed water. The prominent reasons for making the infants drink water are the thought that they need it and cultural reasons.

CONCLUSIONS

The exclusive breastfeeding of 0-6-month-old infants is the recommendation of reliable health authorities. Nurses play a key role in implementing this practice. In this systematic review, it was seen that families gave their infants water at varying rates in the 0-6-month period, and the factors affecting this situation were revealed. If nurses determine which factors affect families in terms of the early introduction of fluids, they could be able to plan the necessary education and interventions.

What are the barriers preventing the screening and management of neonatal hypoglycaemia in low-resource settings, and how can they be overcome?

Over 25 years ago, the World Health Organization (WHO) acknowledged the importance of effective prevention, detection and treatment of neonatal hypoglycaemia, and declared it to be a global priority. Neonatal hypoglycaemia is common, linked to poor neurosensory outcomes and, if untreated, can cause seizures and death. Neonatal mortality in low and lower-middle income countries constitutes an estimated 89% of overall neonatal deaths. Factors contributing to high mortality rates include malnutrition, infectious diseases, poor maternal wellbeing and resource constraints on both equipment and staff, leading to delayed diagnosis and treatment. The incidence of neonatal hypoglycaemia in low and lower-middle income countries remains unclear, as data are not collected.Data from high-resource settings shows that half of all at-risk babies will develop hypoglycaemia, using accepted clinical thresholds for treatment. Most at-risk babies are screened and treated, with treatment aiming to increase blood glucose concentration and, therefore, available cerebral fuel. The introduction of buccal dextrose gel as a first-line treatment for neonatal hypoglycaemia has changed the care of millions of babies and families in high-resource settings. Dextrose gel has now also been shown to prevent neonatal hypoglycaemia.In low and lower-middle income countries, there are considerable barriers to resources which prevent access to reliable blood glucose screening, diagnosis, and treatment, leading to inequitable health outcomes when compared with developed countries. Babies born in low-resource settings do not have access to basic health care and are more likely to suffer from unrecognised neonatal hypoglycaemia, which contributes to the burden of neurosensory delay and death.

Quality of systematic reviews on timing of complementary feeding for early childhood allergy prevention

BACKGROUND

Only rigorously prepared analyses can provide the highest level of evidence to inform decision-making. Several recent systematic reviews (SRs) examined the hypothesis that the early introduction of specific allergenic complementary foods (CFs) to infants may lead to a lower incidence of one or more allergic outcomes. However, the methodological rigour and quality of reporting of SRs in this area has not yet been systematically evaluated.

METHODS

We comprehensively searched PubMed, Medline (Ovid), and Web of Science Core Collection on 13th January 2022, using a pre-specified and tested search syntax for SRs with RCT evidence on the early introduction of allergenic CFs as a means for allergy prevention in infants and children. We examined the quality and risk of bias (RoB) using AMSTAR-2 and ROBIS tools, examined adherence to the Preferred Reporting Items for SRs and Meta-Analyses (PRISMA), and checked whether certainty of the evidence was assessed.

RESULTS

Twelve SRs were included. Application of both tools resulted in similar overall judgements in terms of direction and extent for nine of the 12 SRs. Nine SRs were found to be of critically low to low quality according to AMSTAR-2 and to be at high RoB according to ROBIS. One SR received a moderate quality rating (AMSTAR-2) and high RoB rating (ROBIS). However, for two SRs, judgements between AMSTAR-2 and ROBIS were at stark variance. Only two SRs fully adhered to the PRISMA checklist. Six SRs evaluated the certainty of the body of RCT evidence. Several SRs failed to consider unpublished studies either by an explicit a priori exclusion or by inadequate search strategies.

CONCLUSIONS

Well-conducted SRs are important for decision-making and informing guideline development, the quality of their methodology should therefore be considered. The methodological rigour and the reporting quality of SRs on the timing of CF for allergy prevention must be improved.

REGISTRATION

https://osf.io/7cs4b .

Rates of and factors associated with exclusive and any breastfeeding at six months in Canada: an analysis of population-based cross-sectional data

BACKGROUND

Breastfeeding has many health, economic and environmental benefits for both the infant and pregnant individual. Due to these benefits, the World Health Organization and Health Canada recommend exclusive breastfeeding for the first six months of life. The purpose of this study is to examine the prevalence of exclusive and any breastfeeding in Canada for at least six months, and factors associated with breastfeeding cessation prior to six months.

METHODS

We performed a secondary analysis of breastfeeding-related questions asked on the cross-sectional 2017-2018 Canadian Community Health Survey. Our sample comprised 5,392 females aged 15-55 who had given birth in the five years preceding the survey. Descriptive statistics were carried out to assess the proportion of females exclusively breastfeeding and doing any breastfeeding for at least six months by demographic and behavioural factors. We also assessed, by baby's age, trends in the introduction of solids and liquids, breastfeeding cessation and the reasons females stopped breastfeeding. Multivariate log binominal regression was used to examine the association between breastfeeding at six months and selected maternal characteristics hypothesized a priori to be associated with breastfeeding behaviour.

RESULTS

Overall, for at least six months, 35.6% (95% confidence interval (CI): 33.3%-37.8%) of females breastfed exclusively and 62.2% (95% CI: 60.0%-64.4%) did any breastfeeding. The largest decline in exclusive breastfeeding occurred in the first month. Factors most strongly associated with breastfeeding for at least six months were having a bachelor's or higher degree, having a normal body mass index, being married and daily co-sleeping. Insufficient milk supply was given as the most common reason for breastfeeding cessation irrespective of when females stopped breastfeeding.

CONCLUSION

Six-month exclusive breastfeeding rates in Canada remain below targets set by the World Health Assembly. Continued efforts, including investment in monitoring of breastfeeding rates, are needed to promote and support exclusive breastfeeding, especially among females vulnerable to early cessation.

The association between early introduction of tiny tastings of solid foods and duration of breastfeeding

BACKGROUND

Conflicting advice and non-evidence-based recommendations have a negative effect on breastfeeding. Since 2011, the National Food Agency in Sweden has informed parents that they can introduce tiny tastings (1 mL of solid food, i.e. other sources of nutrition than breastmilk/formula) to infants from four months of age. It is unknown how national recommendations, which differ from the Word Health Organisation's recommendation, affect breastfeeding. We hypothesised that introduction of tiny tastings of solid foods would shorten the duration of continued breastfeeding.

METHODS

This retrospective study utilises data from the longitudinal 'Swedish Pregnancy Planning Study', in which mothers were recruited at antenatal clinics on a national level. The participants completed three questionnaires up to one year after birth (n = 1,251). Linear regression models were used to analyse the association between the introduction of solid foods and the duration of breastfeeding.

RESULTS

As hypothesised, introduction of tiny tastings shortened the duration of continued breastfeeding. Half of all infants (48%) were fed with tiny tastings already in the fourth month. The correlation analysis showed that the earlier the infants started with tiny tastings, the earlier they ate larger amounts of solid food. In a multivariate linear regression analysis, five factors were identified as having a negative effect on the duration of breastfeeding: low infant age upon introduction of tiny tastings, low maternal age, low level of maternal education, high maternal BMI and twin birth.

CONCLUSIONS

Early introduction of tiny tastings of solid foods shortened the duration of breastfeeding. It is difficult to influence most conditions that affect breastfeeding, for example, the mother's educational level, BMI, age and if she has given birth to twins. In contrast, national guidelines can always be updated. Recommendations from the Swedish authorities should adhere to the WHO's recommendation, which states exclusive breastfeeding for six months and continued breastfeeding for at least two years or longer.

Do dietary factors play a role in infantile urolithiasis?

BACKGROUND

Urolithiasis is a significant cause of morbidity that may be diagnosed at a young age. However, there is little research on the role of nutrition in pediatric urolithiasis, and research on the infantile period is extremely rare. The aim of this study is to investigate the effect of dietary factors on those diagnosed with "idiopathic" infantile urolithiasis.

METHOD

The study group included 44 infants without a proven etiological factor for urolithiasis. The control group consisted of 60 fully healthy infants of matched age and gender. The parents and caregivers of each infant in the patient and control groups were carefully questioned by the same researcher for their dietary characteristics.

RESULT

The duration of formula usage and daily volume of formula were statistically higher in the study group than the control group (p = 0.041 and p = 0.003, respectively). The urolithiasis group consumed significantly more cow's milk and dairy products (p = 0.033 and p = 0.001). There was no statistically meaningful difference between the two groups in terms of starting age for free water and salty food, as well as daily water intake.

CONCLUSION

We concluded that dietary conditions could also be a risk factor for idiopathic urolithiasis. We believe that nutritional factors for infantile urolithiasis should be better described, in addition to genetic, anatomical, and metabolic factors. A higher resolution version of the Graphical abstract is available as Supplementary information.

The importance of assessing and addressing mental health barriers to PrEP use during pregnancy and postpartum in sub-Saharan Africa: state of the science and research priorities

Introduction

Pregnant and postpartum women (PPW) in sub‐Saharan Africa are at disproportionately high risk of HIV infection compared to non‐pregnant women. When used consistently, pre‐exposure prophylaxis (PrEP) can prevent HIV acquisition and transmission to the foetus or infant during these critical periods. Recent studies have demonstrated associations between mental health challenges (e.g. depression and traumatic stress associated with intimate partner violence) and decreased PrEP adherence and persistence, particularly among adolescents, younger women and women in the postpartum period. However, mental health is not currently a major focus of PrEP implementation research and programme planning for PPW.

Discussion

PrEP implementation programmes for PPW need to assess and address mental health barriers to consistent PrEP use to ensure effectiveness and sustainability in routine care. We highlight three key research priorities that will support PrEP adherence and persistence: (1) include mental health screening tools in PrEP implementation research with PPW, both to assess the feasibility of integrating these tools into routine antenatal and postpartum care and to ensure that limited resources are directed towards women whose symptoms may interfere most with PrEP use; (2) identify cross‐cutting, transdiagnostic psychological mechanisms that affect consistent PrEP use during these periods and can realistically be targeted with intervention in resource‐limited settings; and (3) develop/adapt and test interventions that target those underlying mechanisms, leveraging strategies from existing interventions that have successfully mitigated mental health barriers to antiretroviral therapy use among people with HIV.

Conclusions

For PPW, implementation of PrEP should be guided by a robust understanding of the unique psychological difficulties that may act as barriers to uptake, adherence and persistence (i.e. sustained adherence over time). We strongly encourage PrEP implementation research in PPW to incorporate validated mental health screening tools and ultimately treatment in routine antenatal and postnatal care, and we stress the potential public health benefits of identifying women who face mental health barriers to PrEP use.

Metabolic impact of infant formulas in young infants. An outlook from the urine metabolome

Introduction

Although breast milk is the ideal food source for newborns during the first six months of life, a high percentage of children receive infant formulas. There is evidence that specific diet habits may influence individual metabolic profile. Therefore, in newborns, such profile can be influenced by the use of infantile formulas given the composition differences that display compared to human milk. Up to now, there are no reports in the literature that address this issue.

Objectives

this work aims to compare the metabolic profile of full-term newborns that were feed with either breast milk (n = 32) or infantile formulas (n = 21). Methods: Metabolic profile was established based on urine analysis through gas chromatography-mass spectrometry (GC-MS) and nuclear magnetic resonance (H-NMR).

Results

our results evidenced a more gluconeogenic profile in breast-fed infants characterized by elevation of Kreb's cycle intermediaries like fumaric, succinic and ketoglutaric acids compared to infants receiving infant formula. In addition, infant formula fed infants presented urinary excretion of metabolites derived from specific compounds present in this type of diet that were not observed in breast-fed infants, for instance D-glucitol, and 4-deoxytetronic. Moreover, in infant formula fed infants there was excretion of basal levels of metabolites of clinical relevance like 3-hydroxy-3-methyl-glutaric, 2-methyl-3-keto-valeric and 3,4-dihydroxybutyric.

Conclusion

These results show the importance of understanding the metabolic impact of diet in newborn population in normal and pathological contexts.

Nutritional status and related factors among ethnic preschool children in Northern Thailand: a cross-sectional study

Purpose: This study investigated the nutritional status of ethnic (belonging to minority groups) preschool children in Northern Thailand.Methods: In this cross-sectional descriptive study, the sample group included 147 parents and 147 preschool children (2-6 years old). Participants volunteered to complete a questionnaire on the personal information of children and parents, as well as family- and school-related factors. Data were analyzed using descriptive statistics, a nutritional status calculator, and logistic regression analysis.Results: A birth weight of less than 2,500 g was related to weight-for-age and weight-for-height. Not having been breastfed and having been breastfed for less than 6 months were related to weight-for-height. An elementary school education level among parents was related to children's height-for-age. Familial unhealthy food consumption for 1-2 days per week was related to weight-for-age and height-for-age.Conclusion: This study reflects the importance of nutritional care for children at the beginning of pregnancy and continuing to the preschool age, as well as the importance of breastfeeding. Families were found to be a key factor in supporting good nutrition among children.

Application of Traditional Chinese Medical Science Characteristic Nursing Mode Based on Evidence-Based Medicine to Puerperal Breast Tenderness and Pain

Objective

To explore the effects of traditional Chinese medicine (TCM) characteristic nursing mode based on evidence-based medicine on parturients with breast tenderness and pain.

Method

100 parturients with postpartum breast pain treated at Taizhou First People's Hospital from January 2020 to December 2021 were selected. Among them, 51 cases received routine nursing intervention (general group, GG) and 49 cases received TCM characteristic nursing based on evidence-based medicine (comprehensive group, CG). The pain number (NRS) score, lactation effect, breastfeeding self-efficacy (BSES-SF) score, anxiety and depression, and nursing satisfaction of the two groups were compared. In addition, the pregnant women were followed up after discharge to investigate the rate of exclusive breastfeeding.

Result

Three days after intervention, NRS score, SAS score, and SDS score in the CG were significantly lower than those in the GG. The level of serum prolactin and total breast lactation yield in the GG were better than those in the CG. BSES-SF score, nursing satisfaction, and exclusive breastfeeding rate in the CG were higher than those in the GG.

Conclusion

Evidence-based TCM care can significantly reduce postpartum breast tenderness, increase milk production, improve exclusive breastfeeding, and help relieve emotional distress.

Oral dextrose gel for the treatment of hypoglycaemia in newborn infants

BACKGROUND

Neonatal hypoglycaemia, a common condition, can be associated with brain injury. It is frequently managed by providing infants with an alternative source of glucose, often given enterally with milk-feeding or intravenously with dextrose solution, which may decrease breastfeeding success. Intravenous dextrose also often requires that mother and baby are cared for in separate environments. Oral dextrose gel is simple and inexpensive, and can be administered directly to the buccal mucosa for rapid correction of hypoglycaemia, in association with continued breastfeeding and maternal care. This is an update of a previous review published in 2016.

OBJECTIVES

To assess the effectiveness of oral dextrose gel in correcting hypoglycaemia in newborn infants from birth to discharge home and reducing long-term neurodevelopmental impairment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase from database inception to October 2021.  We also searched international clinical trials networks, the reference lists of included trials, and relevant systematic reviews identified in the search.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing oral dextrose gel versus placebo, no treatment, or other therapies for the treatment of neonatal hypoglycaemia in newborn infants from birth to discharge home.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data; they did not assess publications for which they were study authors. We contacted investigators to obtain additional information. We used fixed-effect models and the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included two studies conducted in high-income countries, involving 312 late preterm and at-risk term infants and comparing oral dextrose gel (40% concentration) to placebo gel. One study was at low risk of bias, and the other (an abstract) was at unclear to high risk of bias. Oral dextrose gel compared with placebo gel probably increases correction of hypoglycaemic events (rate ratio 1.08, 95% confidence interval (CI) 0.98 to 1.20; rate difference 66 more per 1000, 95% CI 17 fewer to 166 more; 1 study; 237 infants; moderate-certainty evidence), and may result in a slight reduction in the risk of major neurological disability at age two years or older, but the evidence is uncertain (risk ratio (RR) 0.46, 95% CI 0.09 to 2.47; risk difference (RD) 24 fewer per 1000, 95% CI 41 fewer to 66 more; 1 study, 185 children; low-certainty evidence). The evidence is very uncertain about the effect of oral dextrose gel compared with placebo gel or no gel on the need for intravenous treatment for hypoglycaemia (RR 0.78, 95% CI 0.46 to 1.32; RD 37 fewer per 1000, 95% CI 91 fewer to 54 more; 2 studies, 312 infants; very low-certainty evidence). Investigators in one study of 237 infants reported no adverse events (e.g. choking or vomiting at the time of administration) in the oral dextrose gel or placebo gel group (low-certainty evidence).  Oral dextrose gel compared with placebo gel probably reduces the incidence of separation from the mother for treatment of hypoglycaemia (RR 0.54, 95% CI 0.31 to 0.93; RD 116 fewer per 1000, 95% CI 174 fewer to 18 fewer; 1 study, 237 infants; moderate-certainty evidence), and increases the likelihood of exclusive breastfeeding after discharge (RR 1.10, 95% CI 1.01 to 1.18; RD 87 more per 1000, 95% CI 9 more to 157 more; 1 study, 237 infants; moderate-certainty evidence).   AUTHORS' CONCLUSIONS: Oral dextrose gel (specifically 40% dextrose concentration) used to treat hypoglycaemia in newborn infants (specifically at-risk late preterm and term infants) probably increases correction of hypoglycaemic events, and may result in a slight reduction in the risk of major neurological disability at age two years or older. Oral dextrose gel treatment probably reduces the incidence of separation from the mother for treatment and increases the likelihood of exclusive breastfeeding after discharge. No adverse events have been reported. Oral dextrose gel is probably an effective and safe first-line treatment for infants with neonatal hypoglycaemia in high-income settings.  More evidence is needed about the effects of oral dextrose gel treatment on later neurological disability and the need for other treatments for hypoglycaemia. Future studies should be conducted in low-and middle-income settings, in extremely and moderately preterm infants, and compare oral dextrose gel with other therapies such as intravenous dextrose. There are two ongoing studies that may alter the conclusions of this review when published.

Timing of Complementary Feeding, Growth, and Risk of Non-Communicable Diseases: Systematic Review and Meta-Analysis

No consensus currently exists on the appropriate age for the introduction of complementary feeding (CF). In this paper, a systematic review is conducted that investigates the effects of starting CF in breastfed and formula-fed infants at 4, 4–6, or 6 months of age (i) on growth at 12 months of age, (ii) on the development of overweight/obesity at 3–6 years of age, (iii) on iron status, and (iv) on the risk of developing (later in life) type 2 diabetes mellitus (DM2) and hypertension. An extensive literature search identified seven studies that evaluated the effects of the introduction of CF at the ages in question. No statistically significant differences related to the age at which CF is started were observed in breastfed or formula-fed infants in terms of the following: iron status, weight, length, and body mass index Z-scores (zBMI) at 12 months, and development of overweight/obesity at 3 years. No studies were found specifically focused on the age range for CF introduction and risk of DM2 and hypertension. Introducing CF before 6 months in healthy term-born infants living in developed countries is essentially useless, as human milk (HM) and formulas are nutritionally adequate up to 6 months of age.

Exclusive Breastfeeding and Factors Influencing Its Abandonment During the 1st Month Postpartum Among Women From Semi-rural Communities in Southeast Mexico

INTRODUCTION

In this study we describe breastfeeding practices among women from semi-rural communities in southeast Mexico, and explore which factors, modifiable or not, are associated with such practices.

MATERIALS AND METHODS

This was a formative cross-sectional study that included 143 mothers with infants 4-6 months old, from semi-rural communities in Tabasco, Mexico. We collected data on two categories of factors: (1) women's sociodemographic characteristics, and (2) maternal / infant factors. We first analyzed the frequency of various breastfeeding practices. Then, we classified participants into the up to 1 month of exclusive breastfeeding group ( ≤ 1 m-EBF) and the beyond 1 month EBF group (>1 m-EBF), if they practiced EBF for less or more than 1 month, respectively. We compared the two categories of factors between groups and then, using logistic regression models, explored which factors were associated with practicing >1 m-EBF.

RESULTS

By the end of the 1st month postpartum, 51.7% of participants had abandoned EBF, introduced milk formula (35%), other food (9.1%), non-nutritive liquids (7.7%), or had stopped breastfeeding completely. In the next months, EBF practice fell sharply and mixed feeding grew importantly.Logistic regression models showed that women were more likely to be in the >1 m-EBF group if they lived with the baby's father, had complications during pregnancy, delivered vaginally and attended a health center at least three times postpartum. To the contrary, women were less likely to be practice >1 m-EBF if they gave infants other liquids during their hospital stay; experienced pain or discomfort in breasts/nipples, or used a pacifier after hospitalization; had larger bodies (i.e., higher BMI); and believed that you should give the infant powdered milk or some other food when the baby is not full.

CONCLUSION

Many factors associated with abandoning EBF, particularly in the early postpartum period, are modifiable and can be altered through timely interventions that include giving correct information and ensuring its comprehension; assertive personal counseling and accompaniment must be provided to mothers; and reinforcement during the early postpartum at health facilities and other settings.

Eating Behaviors of Children with Autism-Pilot Study

Autism Spectrum Disorder (ASD) is the most recognized neuropsychiatric disorder of childhood. Comorbid conditions (such as feeding disorders) are more common among people with autism than among the general population. The most frequent somatic disorders in autistic children include the gastrointestinal disorders observed in 46–91% of patients. The purpose of this study was the evaluation of the nutrition of children with autism, with particular emphasis placed on feeding in the first year of life, in comparison to the group of healthy peers. Participants included 75 Caucasian children (41 children diagnosed with pure autism, and the control group consisting of 34 children without autistic traits). The analysis was performed based on a questionnaire of own design with the first part devoted to the eating practices of the early infancy. Results: Autistic children, as compared to the healthy peers, presented a shortened time of breastfeeding (the children fell asleep at the breast) (p = 0.04), a delayed introduction of dairy products (p = 0.001), the need of more trials to introduce new foods (p = 0.006), a delayed introduction of foods with solid and lumpy structure (p = 0.004), a longer duration of bottle feeding (p = 0.005), delayed attempts to eating using own hands (p = 0.006) and needed a greater support of parents to divert their attention from food during eating (p = 0.05). Conclusions: 1. The dietary problems are more common among children with the autism spectrum disorder than among the population of healthy children, during the first year of life from the time of introducing the complementary foods. 2. The autistic children experience difficulties with eating and require their parents’ additional involvement significantly more often than their healthy peers.

Complementary Feeding: Recommendations for the Introduction of Allergenic Foods and Gluten in the Preterm Infant

Background: The aim of this systematic review is to analyze the available literature on the introduction of allergenic foods and gluten among preterm infants. Methods: A systematic review of published studies concerning the introduction of gluten and allergenic foods in preterm infants was performed on PubMed and on the Cochrane Library. Results: Of the 174 PubMed results, 15 papers were considered suitable for the review. A total of 83 records were identified through the Cochrane Library search; eight papers were included in the review. Additional papers were identified from the reference lists of included studies. A secondary search was conducted on the same databases to find recommendations and advice regarding healthy full-term infants that could be translated to preterm infants. Therefore, 59 additional papers were included in the review. Conclusions: Current guidelines for the introduction of solid food cannot be directly transposed to preterm infants. Further research is needed to provide evidence-based guidelines regarding weaning in preterm infants. To date, we can suggest that in preterm infants allergenic foods and gluten may be introduced when complementary feeding is started, any time after 4 months of corrected age, avoiding delayed introduction and irrespective of infants’ relative risk of developing allergy. Avoiding large amounts of gluten during the first few weeks after gluten introduction and during infancy is advised, despite limited evidence to support this recommendation.

Breastfeeding patterns and factors associated with early weaning in the Western Amazon

OBJECTIVE

To characterize breastfeeding patterns in the first six months of life and factors associated with early weaning in a birth-cohort in Rio Branco, state of Acre.

METHODS

This is a prospective study with all babies born between April and June 2015. The mothers were interviewed soon after birth and between 6 and 15 months postpartum. At hospital discharge, breastfeeding was defined as exclusively (EBF), and breastfeeding (BF). In the follow-up, breastfeeding patterns were exclusive breastfeeding (EBF), predominant breastfeeding (PBF), and breastfeeding (BF). The interruption of breastfeeding in the first six months was classified as early weaning. The Kaplan Meier method (log-rank: 95%) was used to estimate the conditional probability of change in breastfeeding pattern, and early weaning risk. Crude and adjusted proportional Cox regression models, and their respective 95% confidence intervals (95%CI), were used to analyze the factors associated with early weaning.

RESULTS

The study included 833 infants in EBF (95.4%) and BF (4.6%) at hospital discharge. During the first six months of life, the infant likely discharged in EBF remaining in EBF, becoming PBF, and BF, were respectively 16.4%, 32.3%, and 56.5%. The weaning likely at six months was statistically higher for infants discharged in BF (47.4%) when compared with those discharged in EBF (26%). Factors associated with early weaning were BF at hospital discharge (HR = 1.82; 95%CI 1.06-3.11), no mother cross-breastfeeding (HR = 2.50; 95%CI 1.59-3.94), pacifier use (HR = 6.23; 95%CI 4.52-8.60), less than six months of breastfeeding intention (HR = 1.93; 95%CI 1.25-2.98), lack of breastfeeding in the first hour of life (HR = 1.45; 95%CI 1.10-1.92), and pregnancy alcohol consumption (HR = 1.88; 95%CI 1.34-2.90).

CONCLUSION

Compared to infants in EBF, those in BF at hospital discharge were more likely to wean. Public health efforts should prioritize EBF at hospital discharge, promote breastfeeding in the first hour of life, and prevent alcohol consumption risks during pregnancy, cross-breastfeeding and pacifier use.

Oral dextrose gel to prevent hypoglycaemia in at-risk neonates

BACKGROUND

Neonatal hypoglycaemia is a common condition that can be associated with brain injury. Current practice usually includes early identification of at-risk infants (e.g. infants of diabetic mothers; preterm, small- or large-for-gestational-age infants), and prophylactic measures are advised. However, these measures usually involve use of formula milk or admission to the neonatal unit. Dextrose gel is non-invasive, inexpensive and effective for treatment of neonatal hypoglycaemia. Prophylactic dextrose gel can reduce the incidence of neonatal hypoglycaemia, thus potentially reducing separation of mother and baby and supporting breastfeeding, as well as preventing brain injury.  This is an update of a previous Cochrane Review published in 2017.  OBJECTIVES: To assess the effectiveness and safety of oral dextrose gel given to newborn infants at risk of hypoglycaemia in preventing hypoglycaemia and reducing long-term neurodevelopmental impairment.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 10) in the Cochrane Library; and Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R) on 19 October 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing oral dextrose gel versus placebo, no intervention, or other therapies for the prevention of neonatal hypoglycaemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. We contacted investigators to obtain additional information. We used fixed-effect meta-analyses. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included two studies conducted in high-income countries comparing oral dextrose gel versus placebo in 2548 infants at risk of neonatal hypoglycaemia. Of these, one study was included in the previous version of this review. We judged these two studies to be at low risk of bias, and that the evidence for most outcomes was of moderate certainty. Meta-analysis of the two studies showed that oral dextrose gel reduces the risk of hypoglycaemia (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95; risk difference (RD) -0.06, 95% CI -0.10 to -0.02; 2548 infants; high certainty evidence). One study reported that oral dextrose gel probably reduces the risk of major neurological disability at two years' corrected age (RR 0.21, 95% CI 0.05 to 0.78; RD -0.05, 95% CI -0.09 to 0.00; 360 infants; moderate certainty evidence). Meta-analysis of the two studies showed that oral dextrose gel probably reduces the risk of receipt of treatment for hypoglycaemia during initial hospital stay (RR 0.89, 95% CI 0.79 to 1.00; 2548 infants; moderate certainty evidence) but makes little or no difference to the risk of receipt of intravenous treatment for hypoglycaemia (RR 1.01, 0.68 to 1.49; 2548 infants; moderate certainty evidence). Oral dextrose gel may have little or no effect on the risk of separation from the mother for treatment of hypoglycaemia (RR 1.12, 95% CI 0.81 to 1.55; two studies, 2548 infants; low certainty evidence). There is probably little or no difference in the risk of adverse events in infants who receive oral dextrose gel compared to placebo gel (RR 1.22, 95% CI 0.64 to 2.33; two studies, 2510 infants; moderate certainty evidence), but there are no studies comparing oral dextrose with other comparators such as no treatment, standard care or other therapies. No data were available on exclusive breastfeeding after discharge.

AUTHORS' CONCLUSIONS

Oral dextrose gel reduces the risk of neonatal hypoglycaemia in at-risk infants and probably reduces the risk of major neurological disability at two years of age or greater without increasing the risk of adverse events compared to placebo gel. Additional large follow-up studies at two years of age or older are required. Future research should also be undertaken in low- and middle-income countries, preterm infants, using other dextrose gel preparations, and using comparators other than placebo gel. There are three studies awaiting classification and one ongoing study which may alter the conclusions of the review when published.

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

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

Prevalence of prelacteal feeding and associated risk factors in Indonesia: Evidence from the 2017 Indonesia Demographic Health Survey

Background

Prelacteal feeding (PLF) is a recognised challenge to optimal breastfeeding but remains common in Indonesia. Meanwhile, PLF-related epidemiological research is limited, particularly in this setting. This study examines the prevalence and determinants of overall PLF as well as common PLF types (formula, other milk, and honey) in Indonesia.

Methods

Data from 6127 mothers whose last child was ≤23-month-old were drawn from the 2017 Indonesia Demographic and Health Survey. Multivariable modified Poisson regression was used to measure the prevalence ratio (PR) for selected PLF risk factors. PLF was defined as anything to drink other than breast milk within three days after birth, before breastmilk flows. Additional analyses were performed on mothers who gave formula, other milk, and honey.

Results

About 45% babies in Indonesia received PLF with formula being the most frequent (25%), followed by other milk (14%), plain water (5%), and honey (3%). Factors associated with higher prevalence of any PLF were higher wealth quintiles in rural area (PR 1.07; 95% CI 1.03–1.11 per increase in quintile), baby perceived to be small at birth (PR 1.23; 95% CI 1.12–1.35), caesarean deliveries at either public (PR 1.27; 95% CI 1.13–1.44) or private facilities (PR 1.15; 95% CI 1.01–1.31), and not having immediate skin-to-skin contact after birth (PR 1.32; 95% CI 1.23–1.42). PLF was less prevalent among mothers who gave birth to second/subsequent child (PR 0.82; 95% CI 0.76–0.88) and who had an antenatal card (PR 0.89; 95% CI 0.80–0.99). These patterns did not apply uniformly across all PLF types. For example, honey was more common among home births than deliveries at health facilities, but formula and other milk were more common among caesarean deliveries.

Conclusions

Mapping risk factors for PLF, especially by types, could help to design more targeted interventions to reduce PLF and improve breastfeeding practices in Indonesia.

Longer shared parental leave is associated with longer duration of breastfeeding: a cross-sectional study among Swedish mothers and their partners

BACKGROUND

Breastfeeding is associated with health benefits for both the mother and infant and is therefore important to support; moreover, parental leave is a beneficial factor for breastfeeding. The Swedish parental leave is generous, allowing each parent to take 90 days; additionally, a further 300 days can be taken by either parent. Generally, mothers take 70% of the parental leave days, mainly during the first year. However, breastfeeding duration has declined in the last decade, and it is not known how shared parental leave is associated with the duration of breastfeeding.

AIM

To investigate how parental leave is associated with the duration of exclusive and partial breastfeeding of the infant during the first 12 months after birth. An additional aim was to describe infants' and parents' characteristics and mode of birth in association with the duration of exclusive and partial breastfeeding.

METHODS

This cross-sectional study was part of the Swedish Pregnancy Planning Study, conducted in Sweden in 2012-2015. The parents were recruited at 153 antenatal clinics in nine counties. In total, 813 couples completed a follow-up questionnaire 1 year after birth. Linear regression models were used to analyse the association between parental leave and the duration of breastfeeding.

RESULTS

Infants were exclusively breastfed for, on average, 2.5 months (range 0-12 months) and partially breastfed, on average, 7 months (range 0-12 months). Most of the parental leave was taken by the mother (mean = 10.9 months) during the infant's first 12 months, while the partner took 3 months, on average. The parental leave (used and planned) during the infant's first 24 months were, on average, 21 months. In the multivariate linear regression analysis, mothers' and partners' high level of education (p < 0.001, p = 0.044, respectively), mothers' higher age (p = 0.049), non-instrumental vaginal birth (p = 0.004) and longer parental leave for the first 24 months (p < 0.001) were associated with longer duration of partial breastfeeding.

CONCLUSION

The duration of partial breastfeeding was associated with higher parental educational level, higher age, non-instrumental vaginal birth and longer parental leave.

High confidence, yet poor knowledge of infant feeding recommendations among adults in Nova Scotia, Canada

In Canada, adherence to the national 'Nutrition for Healthy Term Infants' recommendations of infant and young child feeding (IYCF; 0-24 months) is suboptimal. While maternal knowledge of IYCF is commonly assessed, that of the general public has rarely been explored. Our objective was to assess the knowledge of, and confidence in answers to, Canadian IYCF recommendations among a diverse sample of adults in Nova Scotia, Canada. Between March and May 2018, a self-administered questionnaire examining IYCF knowledge, self-rated confidence, and sociodemographic information was conducted among Nova Scotians (≥19 years) in public locations. We surveyed 229 adults; 60% (n=134) were women. Mean (95% CI) age was 44 (41,46) years, 73% self-identified as white, 77% were born in Canada, and 69% were parents. Knowledge deficits were: age to terminate breastfeeding (18.3 (16.7,19.9) months; recommendation: ≥24 months), age to introduce solids (9.2 (8.2,10.2) months; recommendation: 6 months), vitamin D supplementation (10% correct), and optimal complementary foods (only 37% indicated iron-rich foods). Correct IYCF knowledge was lower among men, non-parents, young adults (19-29 years) and low-income adults (<$50,000/year). Mean self-rated confidence (out of 10) was high (7.2 (6.9,7.5)), and not different (p>0.05) between correct and incorrect responses for: best food for a newborn, age to terminate any breastfeeding, and age to start family meal foods. We found low knowledge of IYCF guidelines, yet high confidence in responses regardless of accuracy, among adults in Nova Scotia. General public knowledge deficits may contribute to an unsupportive culture around IYCF practices and low adherence to current recommendations.

Las Dos Cosas Versus Exclusive Breastfeeding: A Culturally and Linguistically Exploratory Intervention Study in Hispanic Mothers Living in Kentucky

INTRODUCTION

Formula supplementation among infants of breastfeeding Hispanic immigrants is common practice known as las dos cosas. The purpose of this study was to assess the feasibility, effectiveness, and acceptability of a culturally and linguistically diverse intervention to promote exclusive breastfeeding (EBF) for the first 6 months.

METHODS

A sample of 39 Hispanic pregnant women was recruited and randomly assigned to intervention (n = 20) and control groups (n = 19). The intervention included a peer counselor and professional support, and mothers were followed from pregnancy to 6 months after birth.

RESULTS

After the study, women assigned to the intervention group were over three times more likely to EBF their baby through all four postpartum assessed time points (odds ratio = 3.1, 95% confidence interval: 1.1-8.7).

DISCUSSION

This culturally and linguistically diverse intervention contributed to increased EBF duration and decreased formula supplementation in Hispanic mothers up to 6 months postpartum.

The association of infant feeding patterns with food allergy symptoms and food allergy in early childhood

Background

The role of infant feeding for food allergy in children is unclear and studies have not addressed simultaneous exposures to different foods. The goal of this study was to analyze existing data on feeding practices that represent realistic exposure and assess the risk of food allergy symptoms and food allergy in children.

Methods

The Infant Feeding Practices Study II conducted by the CDC and US-FDA enrolled pregnant women and collected infant feeding information using nine repeated surveys. Participants were re-contacted after 6 years. Food allergy data were collected at 4, 9, 12, and 72 months. In total, 1387 participants had complete infant feeding pattern data for 6 months and information on food allergy symptoms and doctors’ diagnosed food allergy. Feeding patterns constituted six groups: 3-months of feeding at breast followed by mixed feeding, 3-months of breast milk and bottled milk followed by mixed feeding, 1-month of feeding at breast followed by mixed feeding, 6-months of mixed feeding i.e., concurrent feeding of breast milk, bottled milk and formula, 2–3 months of formula followed by formula and solid food, and formula and solid food since the first month. To estimate risks of food allergy, we used linear mixed models, controlling for potential confounders.

Results

Of the 328 children with food allergy symptoms in infancy and at 6 years, 52 had persistent symptoms from infancy. Children exposed to mixed feeding had a higher risk of food allergy symptoms (Risk Ratio [RR] 1.54; 95% Confidence Interval [CI] 1.04, 2.29) compared to 3-months of feeding at breast adjusted for confounding. No statistically significant risk of infant feeding patterns was found for doctors’ diagnosed food allergy. Paternal allergy posed a higher risk for food allergy symptoms (RR 1.36; 95% CI 1.01, 1.83). Prenatal maternal smoking increased the risk for doctors’ diagnosed food allergy (RR 2.97; 95% CI 1.53, 5.79).

Conclusions

Analysis of this prospective birth cohort suggest that introduction of multiple feeding source may lead to food allergy symptoms. Future efforts are needed to determine acceptable approaches to improve the ascertainment of food allergy in children and the role of infant feeding.

Relationship between breast feeding and motor development in children: protocol for a systematic review and meta-analysis

INTRODUCTION

The recommendations of most health organisations encourage mothers to keep exclusive breast feeding during the first 6 months and combining breast feeding with complementary feeding at least during the first and second years, due to the numerous immunologic, cognitive developmental and motor skill benefits that breast feeding confers. Although the influence of breast feeding on motor development during childhood has been studied, the findings are inconsistent, and some studies have even reported no effect. This manuscript presents a protocol for a systematic review and meta-analysis, with the aim of reviewing the relationship between breast feeding and motor skill development in children in terms of duration, exclusivity or non-exclusivity of breast feeding.

METHODS AND ANALYSIS

The search will be conducted using Medline (via PubMed), EMBASE, Web of Science and Cochrane Library from inception to December 2019. Observational studies (cross-sectional and follow-up studies) written in English or Spanish that investigate the association between breast feeding and motor development in children will be included. This systematic review and meta-analysis protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. The Critical Appraisal Checklist for Analytical Cross-Sectional Studies and The Newcastle-Ottawa Quality Assessment Scale for longitudinal studies will be used to assess the quality of included studies. The effect of breast feeding on motor skill development will be calculated as the primary outcome. Subgroup analyses will be carried out based on the characteristics of motor skill development and the population included.

ETHICS AND DISSEMINATION

Ethical approval is not required because the data used will be obtained from published studies, and there will be no concerns about privacy. The findings from this study will be relevant information regarding the association of breast feeding with motor development in children and could be used encourage to improve breastfeeding rates. The results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42018093706.

Effect of Early Limited Formula on Breastfeeding Duration in the First Year of Life: A Randomized Clinical Trial

IMPORTANCE

Breastfeeding through 6 and 12 months are 2 goals of the Centers for Disease Control and Prevention Healthy People 2020 initiative, but the 6-month goal is met for only 52% of US infants and the 12-month goal for 30% of US infants.

OBJECTIVE

To determine whether structured, short-term formula supplementation for at-risk neonates affects the proportion still breastfeeding at 6 and 12 months.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial conducted at 2 US academic medical centers enrolled 164 exclusively breastfeeding mother-infant dyads of mothers who were not yet producing copious milk and infants who were 24 to 72 hours old with newborn weight loss at or above the 75th percentile for age. Participants were enrolled from January 2015 through September 2016.

INTERVENTIONS

Early Limited Formula (ELF), a structured formula supplementation protocol (10 mL formula fed after each breastfeeding until mothers produced copious milk), compared with control dyads, who continued exclusive breastfeeding and received a safety teaching intervention.

MAIN OUTCOMES AND MEASURES

The study's primary outcome was any breastfeeding at 6 months. Secondary outcomes included age at breastfeeding cessation and any breastfeeding at 12 months. All outcomes were assessed by maternal phone survey.

RESULTS

Eighty-two newborns were randomized to ELF and 82 to the control group. Mean (SD) maternal age was 31.4 (5.9) years, and 114 (69.5%) self-identified as non-Hispanic white; 20 (12.2%), Hispanic; 17 (10.4%), Asian; 5 (3.0%), non-Hispanic black; and 7 (4.3%), other. Compared with controls, mothers randomized to ELF were less likely to be married (n = 53 [64.6%] vs n = 66 [80.5%]; P = .03) and had shorter mean (SD) intended duration of breastfeeding (8.6 [3.4] vs 9.9 [4.4] months; P = .049). Median (interquartile range) duration of breastfeeding in the cohort was 9 (6-12) months. At 6 months, 47 (65%) infants randomized to ELF were breastfeeding, compared with 60 (77%) of the control infants (absolute difference, -12%; 95% CI, -26% to 3%; P = .12). At 12 months, 21 of the 71 ELF infants available for analysis (29.6%) were breastfeeding, compared with 37 of the available 77 (48.1%) control infants (risk difference, -18%; 95% CI, -34% to -3%). Marital status and intended breastfeeding duration were both associated with breastfeeding duration; models adjusting for these found a hazard ratio for time-to-event of breastfeeding cessation through 12 months of 0.74 (95% CI, 0.48-1.14) for ELF infants compared with infants in the control group.

CONCLUSIONS AND RELEVANCE

In this cohort with high breastfeeding prevalence, ELF was not associated with any improvement in breastfeeding duration. Future research should examine the effect of ELF in populations at higher risk of early cessation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02313181.

Infant Feeding, Vitamin D and IgE Sensitization to Food Allergens at 6 Years in a Longitudinal Icelandic Cohort

Nordic Nutrition Recommendations (NNR) recommend exclusive breastfeeding until 6 months, partial breastfeeding until 1 year or longer and irrespective of breastfeeding, avoiding solid foods before 4 months. Strong evidence was found for benefits of breastfeeding regarding growth and infections but limited/inconclusive evidence regarding atopic disease and asthma. Vitamin D is of special interest in the Nordic diet. The aim of this prospective study was to compare infant feeding and vitamin D between immunoglobulin E (IgE) sensitized (n = 14) and non-sensitized (n = 130) children at 6 years. Information on diet and vitamin D supplement use were collected with dietary recall (<5 months), 1-d food records (5 and 6 months) and 3-d weighed food records (12 months and 6 years). Serum-specific IgE-antibodies against milk, egg, cod, wheat, soy and peanut (cut-off specific IgE ≥ 0.35 kUA/L) were measured at 6 years and serum 25-hydroxyvitamin D at 12 months and 6 years. At 4 months, 57% of IgE sensitized vs. 23% of non-sensitized children (p < 0.01) had received solid food. At 12 months, IgE sensitized children had a lower intake of vitamin D (median (25th, 75th percentiles): 3.9 μg/d (3.2, 7.2) vs. 8.1 μg/d (4.4, 12.3), p = 0.03) and at 6 years, fewer used vitamin D supplements regularly (23% vs. 56%, p = 0.03). Introduction of solid foods prior to 4 months increased the odds of IgE-sensitization, OR = 4.9 (95%, CI = 1.4–16.6) and vitamin D supplement at 6 years decreased the odds of IgE-sensitization, OR = 0.2 (95%, CI = 0.1–0.98), adjusting for maternal smoking. These observations support the NNR in their recommendation against introducing complementary solid foods before the age of 4 months. Furthermore, they support encouraging vitamin D intake for young children at northern latitudes.

[Research advances in influencing factors for immune tolerance to food allergens in children]

Food allergen-specific immune tolerance is defined as nonresponsiveness of the adaptive immune system to food antigens. Failed development or inhibition of such tolerance may cause food allergy. With the increasing incidence rate of food allergy year by year, more and more studies have found the association between food allergy and various diseases. The development of food allergen-specific immune tolerance in childhood has been taken more and more seriously. In recent years, many studies have shown that the development of food allergen-specific immune tolerance is influenced by various factors, which can be roughly divided into antigens, organisms, and environment. This article reviews the influencing factors for the development of immune tolerance to food allergens in children, in order to provide help for reducing the incidence of food allergy and improving the prognosis of food allergy.

The Long-Term Effects of Dietary Nutrient Intakes during the First 2 Years of Life in Healthy Infants from Developed Countries: An Umbrella Review

The role of both qualitative and quantitative early nutrient intakes on later health has been suggested for decades and supported by observational studies on humans, mainly preterm and low-birth-weight infants, and animal models. However, to date, no comprehensive review has been conducted to evaluate the full impact of nutritional variables on healthy full-term infants. This umbrella review considers meta-analyses and systematic reviews on the health effects of different nutritional exposures or interventions in the first 2 y of life of healthy full-term infants in developed countries. The systematic reviews and meta-analyses published by March 2018 in MEDLINE, EMBASE, and Cochrane Database of Systematic Reviews were included. The following outcomes were considered: growth and obesity, cardiovascular disease, neurodevelopment, allergy and autoimmunity, infections, and malignancy. Breastfeeding and complementary feeding were considered separately and analyzed by means of their differences in delivering heterogeneous food-related variables. The resulting data on the long-term effect of early nutritional differences in healthy full-term infants were found to be inconclusive. Only breastfeeding has a beneficial effect, which is nevertheless slight and limited to just a few outcome measures, whereas the type and duration required to be effective are still unclear. As regards the complementary feeding period, no clear effects of different dietary interventions emerge in terms of health outcomes. Available evidence on the health effects of differences in early nutrition in healthy full-term infants still remains largely inconclusive.

Infant temperament, maternal feeding behaviours and the timing of solid food introduction

Despite guidance from the World Health Organization and the U.K. Department of Health, many mothers introduce solid food before their infant is 6 months old. The current study aimed to investigate relationships between maternal feeding behaviours (preintroduction and postintroduction to solids), infant temperament, and the timing of introduction to solid food. Eighty‐one women were recruited on low‐risk maternity units and were contacted at 1 week, 3, and 6 months postpartum. Mothers of infants (45 males, 36 females, mean birth weight 3.52 kg [SD 0.39]) completed the behaviours component of the Infant Feeding Style Questionnaire via telephone interview at 3 months. At 6 months, they were observed feeding their infant solid food at home and reported infant temperament using the Infant Behaviour Questionnaire‐Revised (short form). Partial correlations (covariates: birth weight, maternal age, breastfeeding duration, and postnatal depression) revealed negative associations between age of introduction to solid food and temperament (smiling and laughter) and laissez‐faire milk feeding behaviours; and positive associations between age of introduction to solid food and restrictive milk feeding behaviours and verbal involvement during an observed mealtime. Hierarchical multiple regression analysis revealed that an infant's birth weight and the degree to which their mothers perceive them to smile and laugh are key predictors of when they will be introduced to solid food, over and above other variables of interest (e.g., maternal milk feeding behaviours, breastfeeding duration, and postnatal depression).

Parental concerns of allergy or hypersensitivity and the infant's diet

AIM

To investigate a possible association between children's current diet and parents' reported avoidance of appropriate foods in the child's diet at the age of 10 months, due to fears of allergic or hypersensitivity reactions.

DESIGN

A cross-sectional study.

METHODS

In 10 randomly selected municipalities willing to participate, 686 children represented by their parents visiting the child health centre were enrolled in the study. From January 2015-January 2017, 440 (64%) parents completed a semi-quantitative food frequency questionnaire concerning their child.

RESULTS

Thirty-four percent of parents reported that they avoided introducing some food items due to fears of allergy or hypersensitivity in their child. A statistically significant relationship emerged between this reporting and parents wanting more information about food for infants and toddlers. However, the reported fear was not associated with dietary restrictions regarding actual feeding of the child.

Effectiveness of targeting fathers for breastfeeding promotion: systematic review and meta-analysis

BACKGROUND

Further research gaps exist in relation to the promotion of breastfeeding. Robust scientific evidence obtained by a meta-analysis would provide objectively summarized data while enabling the assessment of consistency of findings. This review includes the first documented meta-analysis done on the effectiveness of targeting fathers for promoting breastfeeding (BF). Assessments have been done for a primary outcome and for six more secondary outcomes.

METHODS

PubMed, EMBASE, Google Scholar, CENTRAL databases and unpublished researches were searched. Selections of randomized-controlled trials and quasi-experimental studies were done in three rounds. Heterogeneity and potential publication bias were assessed. Eight studies were included in meta-analysis and others in narrative synthesis of the outcomes. Pooling was done with the Mental- Haenszel method using risk ratio (RR). Summary-of-Findings table was composed by Review-Manager (version 5.3) and GRADEproGDT applications. Subsequent sensitivity analysis was done.

RESULTS

Selected eight interventional studies included 1852 families. Exclusive BF at six months was significantly higher (RR = 2.04, CI = 1.58-2.65) in the intervention groups. The RR at 4 months was 1.52 (CI = 1.14 to 2.03). Risk of full-formula-feeding (RR = 0.69, CI = 0.52-0.93) and the occurrence of lactation-related problems were lower in the intervention groups (RR = 0.24, CI = 0.10-0.57). More likelihood of rendering support in BF-related issues was seen in intervention groups (RR = 1.43, CI = 1.22-1.68). Increase of maternal knowledge and favorable attitudes on BF were higher in the intervention groups (P ≤; 0.001). The quality of evidence according to GRADE was "low" (for one outcome), "moderate" (for four outcomes), and "high" (for two outcomes).

CONCLUSIONS

Targeting fathers in promotion of BF has provided favorable results for all seven outcomes with satisfactory quality of evidence. This review was registered in the PROSPERO-registry (ID: 2017-CRD42017076163) prior to its commencement.

Timing of complementary feeding and associations with maternal and infant characteristics: A Norwegian cross-sectional study

Norwegian Health authorities recommend solid food to be introduced between child age 4-6 months, depending on both the mother´s and infant's needs. The aim of this paper is to describe timing of complementary feeding in a current sample of Norwegian mother/infant-dyads and explore potential associations between timing of introduction to solid foods and a wide range of maternal and infant characteristics known from previous literature to influence early feeding interactions. The paper is based on data from the Norwegian randomized controlled trial Early Food for Future Health. In 2016, a total of 715 mothers completed a web-based questionnaire at child age 5.5 months. We found that 5% of the infants were introduced to solid food before 4 months of age, while 14% were not introduced to solid food at 5.5 months of age. Introduction of solid food before 4 months of age was associated with the infant not being exclusive breastfed the first month, receiving only formula milk at 3 months, the mother being younger, not married/cohabitant, smoking, less educated and having more economic difficulties. Not being introduced to solid food at 5.5 months was associated with the infant being a girl, being exclusive breastfed the first month, receiving only breastmilk at 3 months, the mother being older, married and having 3 or more children. This study shows that there are still clear socioeconomic differences regarding timing of complementary feeding in Norway. Infants of younger, less educated and smoking mothers are at higher risk of not being fed in compliance with the official infant feeding recommendations. Our findings emphasize the importance of targeting socioeconomically disadvantaged mothers for support on healthy feeding practices focusing on the infant`s needs to prevent early onset of social inequalities in health.

The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature

There is no doubt regarding the multiple benefits of breastfeeding for infants and society in general. Therefore, the World Health Organization (WHO) in a conjoint effort with United Nations International Children's Emergency Fund (UNICEF) developed the "Ten Steps to Successful Breastfeeding" in 1992, which became the backbone of the Baby Friendly Hospital Initiative (BFHI). Following this development, many hospitals and countries intensified their position towards creating a "breastfeeding oriented" practice. Over the past two decades, the interest increased in the BFHI and the Ten Steps. However, alongside the implementation of the initiative, extensive research continues to evaluate the benefits and dangers of the suggested practices. Hence, it is our intention to make a critical evaluation of the current BFHI and the Ten Steps recommendations in consideration of the importance of providing an evidence-based breastfeeding supported environment for our mothers and infants.

Intravenous immunoglobulin treatment in multiple sclerosis: A prospective, rater-blinded analysis of relapse rates during pregnancy and the postnatal period

BACKGROUND

Multiple sclerosis (MS) affects predominantly young women. Currently available disease-modifying drugs have neither been approved during pregnancy nor nursing.

AIMS

Evaluating the effect of treatment with intravenous immunoglobulin (IVIg) in MS patients with desire to have a baby.

METHODS

In all, 70 MS patients were either treated with IVIg before conception, during first trimester of pregnancy and 12 months postnatal (group I, n = 38) or started IVIg after delivery for 12 months (group II, n = 23) or were untreated (group III, n = 9). Relapse rates and disease progression were analyzed.

RESULTS

Pre-gestational relapse rates differed between groups. Lowest relapse rates were observed during late pregnancy, followed by an elevated relapse rate after delivery compared to the pre-pregnancy year and the first trimester. Only in group I, the postnatal relapse rate did not exceed the relapse rate before conception. IVIg treatment did not influence disease progression after delivery.

CONCLUSIONS

In MS patients, IVIg treatment during and/or after delivery is an option to reduce the incidence of relapses during pregnancy and the postnatal period. Surprisingly, untreated patients becoming pregnant showed an increase in the relapse rate in the first trimester compared with the pre-gestational period. How alterations of hormone status during pregnancy affect disease activity in MS has to be further investigated.