Water supplementation in exclusively breastfed infants during summer in the tropics

Feeding Practices of Infants and Toddlers by Their Mothers in Selected Northern Emirates of the United Arab Emirates

Research on the feeding practices of infants and young children in the United Arab Emirates (UAE) is limited, especially in the northern regions of the country. A retrospective web-based survey was conducted to assess child feeding practices among the mothers of young children aged 6 months to 2.5 years in the northern emirates of the UAE. Information from a total of 475 mothers was collected on maternal socio-demographic factors, child feeding practices, and the use of vitamin and mineral supplements. For the first 6 months, 46.7% of the infants were exclusively breastfed, 43.8% were fed on both breastmilk and formula, and 9.5% were given formula only. Significant differences in the types of feeding were found correlating with maternal age (p = 0.02) and employment status (p < 0.001) but not with educational level, with a higher proportion of younger and unemployed women exclusively breastfeeding. However, although a significantly higher proportion of mothers with lower educational levels breastfed their children for ≥6 months (p = 0.026), they introduced “other milk” (non-breastmilk or formula) before the child reached the age of 12 months (p = 0.022). In this study, 22.1% of the infants and 8.1% of the toddlers did not receive an animal source of iron, while 52.6% of the children received vitamin/mineral supplements. The median daily frequency intake of sweets and savory snacks was substantially higher than the respective intake of fruits and vegetables. Intervention programs that focus on healthy infant and toddler feeding, including food sources of iron and nutrient-dense food groups, are needed in the UAE.

A systematic review of hot weather impacts on infant feeding practices in low-and middle-income countries

BACKGROUND

Increased rates of exclusive breastfeeding could significantly improve infant survival in low- and middle-income countries. There is a concern that increased hot weather due to climate change may increase rates of supplemental feeding due to infants requiring fluids, or the perception that infants are dehydrated.

OBJECTIVE

To understand how hot weather conditions may impact infant feeding practices by identifying and appraising evidence that exclusively breastfed infants can maintain hydration levels under hot weather conditions, and by examining available literature on infant feeding practices in hot weather.

METHODS

Systematic review of published studies that met inclusion criteria in MEDLINE, EMBASE, Global Health and Web of Science databases. The quality of included studies was appraised against predetermined criteria and relevant data extracted to produce a narrative synthesis of results.

RESULTS

Eighteen studies were identified. There is no evidence among studies of infant hydration that infants under the age of 6months require supplementary food or fluids in hot weather conditions. In some settings, healthcare providers and relatives continue to advise water supplementation in hot weather or during the warm seasons. Cultural practices, socio-economic status, and other locally specific factors also affect infant feeding practices and may be affected by weather and seasonal changes themselves.

CONCLUSION

Interventions to discourage water/other fluid supplementation in breastfeeding infants below 6 months are needed, especially in low-middle income countries. Families and healthcare providers should be advised that exclusive breastfeeding (EBF) is recommended even in hot conditions.

A tool to assess underlying factors to water provision among Guinean children

In many countries, water is provided to children under 6 months of age (CU6M) in addition to breast milk (BM), hence increasing the risk of child mortality and morbidity. Factors related to this practice have not been thoroughly investigated either a tool to assess them. Based on the extended theory of planned behaviour (eTPB), we aim to develop and validate a questionnaire to assess psychosocial and environmental factors that may contribute/limit the water provision in addition to BM by mothers of CU6M in the Republic of Guinea. A three‐step process was used. Ten focus group discussions (FGDs) were held to identify salient beliefs related to each of the four constructs of the eTPB. Data from FGDs were used to develop a questionnaire composed of 88 items administered to 428 mothers. Exploratory factor analyses were conducted to identify latent factors for each construct. A shorter version of the questionnaire was administered to another sample of 300 mothers. Confirmatory factor analyses (CFAs) were performed. Hancock and Mueller's H reliability indices were computed on final models to assess the tool's validity and reliability. The final questionnaire included 57 items. For all four final models, most criteria for fit indices of CFA were generally met. Reliability coefficients were all equal to or above 0.90 for each construct. This research offers a tool that could be used to investigate determinants of water provision besides BM among mothers of CU6M. Further validation in other contexts is warranted.

Correlates of infant feeding practices among HIV-positive mothers and controls in northeast Nigeria

BACKGROUND

Despite the global decline in pediatric HIV infections, infants in sub-Saharan Africa still acquire HIV infection through inappropriate feeding.

OBJECTIVE

The aim of the study was to compare knowledge and predictors of infant feeding behavior between mothers living with HIV and controls of unknown HIV status in Gombe, northeast Nigeria.

METHOD

A cross-section of clinic-based samples of 84 HIV-positive mothers and 170 controls of unknown status were interviewed using validated questionnaires. Knowledge scores and self-reported infant feeding practices were analyzed. Multivariate logistic regression models were employed to determine predictors for infant feeding practices.

RESULTS

Transmission risk perception (95.2% vs. 65.3%) (p<0.05) and adequate knowledge of infant feeding (77.4% vs. 51.2%) (p<0.05) were higher among HIV-positive mothers. Compared to mothers of unknown status (56.5%), a higher proportion of HIV-positive mothers (84.5%) reported breastfeeding the infant exclusively for 6 months (p<0.05). In contrast, mixed feeding was more prevalent among controls (19.4% vs. 4.8%) (p<0.05). Further, over a third (39.3%) of HIV-positive mothers and 27.6% of controls weaned their infants at ≥12 months (p>0.05). Antenatal attendance, hospital delivery, knowledge and positive attitude predicted infant feeding practices in both groups. The predictive roles of education and parity were limited to HIV-positive mothers, while the effects of maternal age and infant death were restricted to controls.

CONCLUSION

Risk perception, knowledge, and exclusive breastfeeding rates were higher among mothers living with HIV. Antenatal care, hospital delivery, knowledge, and attitude predicted infant feeding practices in both groups. Girl child education, antenatal care, hospital delivery, and sustained promotion of exclusive breastfeeding with antiretroviral therapy are key to HIV-free infant survival.

Current Knowledge of Breastfeeding Among Health Workers in a Developing Country Setting: A Survey in Calabar, Nigeria

Background

Health workers are in a strategic position to provide correct information to mothers on breastfeeding practice. This study assessed knowledge of breastfeeding among health workers in health facilities in Calabar.

Methods

This was a cross-sectional descriptive study. A 45-item self-administered questionnaire was used to obtain data. Ethical clearance for the study was obtained from the Cross River State Research and Ethics Committee. Data were analyzed using SPSS version 21.0 (SPSS, Inc., Chicago, USA). A knowledge score of at least 90% was considered satisfactory. Factors associated with the level of knowledge were determined using chi-square. The p-value was set at 0.05.

Result

Two hundred and twenty-five healthcare professionals were surveyed, with a mean age of 37.5 ± 9.4 years, ranging from 20 to 65 years. The commonest age group was 41 to 50 years (43.1%). Females (80.9%) formed a larger proportion of participants with a female-male ratio of 4:1. The mean percentage of knowledge score was 85.1 ± 9.0%. A satisfactory level of knowledge was found in 27.1% of respondents. About one-third (33.7%) and one-fifth (21.8%) of health workers were not aware of the weight control benefit and protection against osteoporosis of breastmilk, respectively. Approximately one-fifth (22.2%) of respondents had misconceptions concerning the effects of colostrum on the prevention of neonatal jaundice. Nurses with diploma level of training had a satisfactory level of knowledge, compared with other professions (p < 0.05).

Conclusion

Health workers’ knowledge of breastfeeding was generally good though suboptimal. Health-related professions should provide current information on the best breastfeeding practices.

Is exclusive breastfeeding an option or a necessity in Africa? A pooled study using the deuterium oxide dose-to-mother technique

Given the valuable health, development, and economic benefits of human milk Exclusive Breastfeeding (EBF) is recommended by the World Health Organisation for the first six months of an infant’s life. Many resource-limited regions in Africa do not line-up with these recommendations, therefore EBF promotion efforts on the continent need to be scaled up and monitored. This study explores the human milk intake volumes of 5 countries (Benin, Central African Republic, Morocco, South Africa and Tanzania) both at country level and in a pooled sample of children at 3 months (n= 355) and at 6 months (n=193). Mean human milk intake volumes in the pooled samples were 697.6 g/day at 3 months and 714.9 g/day at 6 months. EBF was determined both by maternal recall as well as using the deuterium oxide dose-to-mother technique, using two different cut-offs of non-milk oral intake. Comparison of these results showed substantial over-reporting of EBF by maternal recall, which suggests that actual rates of EBF are even lower than reported, thus highlighting the importance of scaling-up EBF promotion strategies.

Biopharmaceutical considerations in paediatrics with a view to the evaluation of orally administered drug products - a PEARRL review

OBJECTIVES

In this review, the current biopharmaceutical approaches for evaluation of oral formulation performance in paediatrics are discussed.

KEY FINDINGS

The paediatric gastrointestinal (GI) tract undergoes numerous morphological and physiological changes throughout its development and growth. Some physiological parameters are yet to be investigated, limiting the use of the existing in vitro biopharmaceutical tools to predict the in vivo performance of paediatric formulations. Meals and frequencies of their administration evolve during childhood and affect oral drug absorption. Furthermore, the establishment of a paediatric Biopharmaceutics Classification System (pBCS), based on the adult Biopharmaceutics Classification System (BCS), requires criteria adjustments. The usefulness of computational simulation and modeling for extrapolation of adult data to paediatrics has been confirmed as a tool for predicting drug formulation performance. Despite the great number of successful physiologically based pharmacokinetic models to simulate drug disposition, the simulation of drug absorption from the GI tract is a complicating issue in paediatric populations.

SUMMARY

The biopharmaceutics tools for investigation of oral drug absorption in paediatrics need further development, refinement and validation. A combination of in vitro and in silico methods could compensate for the uncertainties accompanying each method on its own.

Prevalent infant feeding practices among the mothers presenting at a tertiary care hospital in Garhwal Himalayan region, Uttarakhand, India

Introduction:

There is paucity of studies on infant feeding practices from the rural areas of garhwal Himalayas of the state of uttarakhand. The present study was designed to assess the infant feeding practices in Garhwal region. Infant feeding practices have significant implications on a child's health. Early nutritional status especially during the first year of life has been shown to have a significant effect on child health and development. Optimal infant feeding practices are crucial for nutritional status, growth, development, health, and ultimately the survival of infants and young children. The study of infant feeding practices is essential before formulation of any interventional programme.

Settings and Design:

A study was conducted in HNB Base Hospital and Teaching Institute with the aim to assess the infant feeding practices and the prevalence of malnutrition in the study population reporting at the hospital in garhwal region of uttarakhand.

Methods and Material:

This is an observational cross sectional study. 275 infants were included in the study. After taking informed consent, case study forms were filled by interviewing the infants' mothers. Weight, length and head circumference of each infant was also measured. The information thus obtained was compiled, tabulated and analysed statistically.

Results:

The study findings revealed that 46.4% infants in the age group 0-5 months were breastfed within 1 hour of birth. 52.8% infants aged 0-5 months of were exclusively breastfed. 33.6% infants in age group 0-5 months received prelacteal feeds. 53.12% infants in age group 6-8 months received solid, semi-solid or soft food, in addition to breast milk. 53.33% infants were partially or fully bottle fed. Age appropriate feeding was found in 56% infants. The percentage of wasting, stunting and underweight in 0-5 months was 33.6%,30.4% and 36.8% respectively . The percentage of wasting, stunting and underweight in 6-11 months was 28%, 26.5% and 30.7% respectively. There appeared to be an association between longer duration of exclusive breastfeeding and lower prevalence of stunting and underweight at 6 months of age.

Conclusions:

This study shows that undesirable infant feeding practices are still prevalent in the community. Lower prevalence of stunting and underweight was observed in infants with longer duration of exclusive breastfeeding. A comprehensive plan to address the problems in infant feeding should be formulated. Antenatal counselling of mothers should be done. Revitalization of the Baby Friendly Hospital Initiative(BHFI) in health facilities is recommended.

Infant feeding practices and determinant variables for early complementary feeding in the first 8 months of life: results from the Brazilian MAL-ED cohort site

OBJECTIVE

The present study aimed to describe breast-feeding, complementary feeding and determining factors for early complementary feeding from birth to 8 months of age in a typical Brazilian low-income urban community.

DESIGN

A birth cohort was conducted (n 233), with data collection twice weekly, allowing close observation of breast-feeding, complementary feeding introduction and description of the WHO core indicators on infant and young child feeding. Infant feeding practices were related to socio-economic status (SES), assessed by Water/sanitation, wealth measured by a set of eight Assets, Maternal education and monthly household Income (WAMI index). Two logistic regression models were constructed to evaluate risk factors associated with early complementary feeding.

RESULTS

Based on twice weekly follow-up, 65 % of the children received exclusive breast-feeding in the first month of life and 5 % in the sixth month. Complementary feeding was offered in the first month: 29 % of the children received water, 15 % infant formulas, 13 % other milks and 9·4 % grain-derived foods. At 6 months, dietary diversity and minimum acceptable diet were both 47 % and these increased to 69 % at 8 months. No breast-feeding within the first hour of birth was a risk factor for the early introduction of water (adjusted OR=4·68; 95 % CI 1·33, 16·47) and low WAMI index a risk factor for the early introduction of other milks (adjusted OR=0·00; 95 % CI 0·00, 0·02).

CONCLUSIONS

Data suggest local policies should promote: (i) early breast-feeding initiation; (ii) SES, considering maternal education, income and household conditions; (iii) timely introduction of complementary feeding; and (iv) dietary diversity.

Infant feeding pattern in the first six months of age in USA: a follow-up study

Background

Infant feeding may consist of direct breastfeeding (DBF), pumping and bottle feeding (P&F), formula feeding (FF), solid food feeding (SFF), and any combination. An accurate evaluation of infant feeding requires descriptions of different patterns, consistency, and transition over time.

Methods

In United States of America, the Infant Feeding Practice Study II collected information on the mode of feeding on nine occasions in 12 months. We focused on the first 6 months with six feeding occasions. To determine the longitudinal patterns of feeding the latent class transition analyses was applied and assessed the transition probabilities between these classes over time.

Results

Over 6 months, 1899 mothers provided feeding information. In month 1 the largest latent class is FF (32.9%) followed by DBF (23.8%). In month 2, a substantial proportion of the FF class included SFF; which increases over time. A not allocated class, due to missing information was identified in months 1-3, transitions to SFF starting in month 4 (8.9%). In month 1, two mixed patterns exist: DBF and P&F combined with FF (13.9%) and DBF combined with P&F (18.7%). The triple combination of DBF, P&F, and FF (13.9%) became FF in month 2 (transition probability: 24.8%), and DBF in combination with P&F (transition probability: 49.1%). The pattern of DBF combined with P&F is relatively stable until month 4, when at least 50% of these infants receive solid food. Only 23-26% of the infants receive direct breastfeeding (DBF) in months 1-4, in month 5-6 SFF is added. Mothers who used FF were less educated and employed fulltime. Mothers who smoke and not residing in the west of the United States were also more likely to practice formula feeding.

Conclusion

Infant feeding is complex. Breastfeeding is not predominant and we additionally considered the mixed patterns of feeding. To facilitate direct breastfeeding, a substantial increase in the duration of maternal leave is necessary in the United States.

Changes over time in early complementary feeding of breastfed infants on the island of Hispaniola

Objective.

To describe and contrast early complementary feeding (ECF) over time in breastfed infants in the Dominican Republic (DR) and Haiti, the two countries that share the island of Hispaniola.

Methods.

Secondary data analysis was conducted on cross-sectional data from Demographic and Health Surveys administered at four different time-points in both countries between 1994 and 2013. Extracted samples were composed of breastfed infants < 6 months of age whose caregivers had responded to dietary questions on food consumption in the previous 24 hours.

Results.

Plain water was the most frequently consumed complementary substance in both countries. However, the prevalence of water consumption increased in the DR over time, whereas in Haiti it decreased. Milk (non-breast) use was also common and followed a similar pattern as water over time in the two countries. Expanded use of water and milk in the DR are the major contributors to its drop in exclusive breastfeeding (EBF) rates over time. Whereas in Haiti, a reduction in a broader array of liquids and semi-solids/solids overtime appears to have contributed to its markedly improved EBF rates.

Conclusion.

Determining contributors to the differential trends in water and milk (non-breast) use between these two countries may identify targets for addressing the persistent gaps in EBF on the island of Hispaniola.

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

BACKGROUND

Health organisations recommend exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries. Recently, research has suggested that introducing solid food at around four months of age while the baby continues to breastfeed is more protective against developing food allergies compared to exclusive breastfeeding for six months. Other studies have shown that the risks associated with non-exclusive breastfeeding are dependent on the type of additional food or fluid given. Given this background we felt it was important to update the previous version of this review to incorporate the latest findings from studies examining exclusive compared to non-exclusive breastfeeding.

OBJECTIVES

To assess the benefits and harms of additional food or fluid for full-term healthy breastfeeding infants and to examine the timing and type of additional food or fluid.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2016) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 trials (2542 randomised infants/mothers). Nine trials (2226 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one primary (breastfeeding duration) and one secondary (weight change) outcome. None of the trials reported on physiological jaundice. Infant mortality was only reported in one trial.For the majority of older trials, the description of study methods was inadequate to assess the risk of bias. Most studies that we could assess showed a high risk of other biases and over half were at high risk of selection bias.Providing breastfeeding infants with artifical milk, compared to exclusive breastfeeding, did not affect rates of breastfeeding at hospital discharge (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.97 to 1.08; one trial, 100 infants; low-quality evidence). At three months, breastfeeding infants who were provided with artificial milk had higher rates of any breastfeeding compared to exclusively breastfeeding infants (RR 1.21, 95% CI 1.05 to 1.41; two trials, 137 infants; low-quality evidence). Infants who were given artifical milk in the first few days after birth before breastfeeding, had less "obvious or probable symptoms" of allergy compared to exclusively breastfeeding infants (RR 0.56, 95% CI 0.35 to 0.91; one trial, 207 infants; very low-quality evidence). No difference was found in maternal confidence when comparing non-exclusive breastfeeding infants who were provided with artificial milk with exclusive breastfeeding infants (mean difference (MD) 0.10, 95% CI -0.34 to 0.54; one study, 39 infants; low-quality evidence). Rates of breastfeeding were lower in the non-exclusive breastfeeding group compared to the exclusive breastfeeding group at four, eight, 12 (RR 0.68, 95% CI 0.53 to 0.87; one trial, 170 infants; low-quality evidence), 16 and 20 weeks.The addition of glucose water resulted in fewer episodes of hypoglycaemia (below 2.2 mmol/L) compared to the exclusive breastfeeding group, reported at 12 hours (RR 0.07, 95% CI 0.00 to 1.20; one trial, 170 infants; very low-quality evidence), but no significant difference at 24 hours (RR 1.57, 95% CI 0.27 to 9.17; one trial, 170 infants; very low-quality evidence). Weight loss was lower for infants who received additional glucose water (one trial, 170 infants) at six, 12, 24 and 48 hours of life (MD -32.50 g, 95% CI -52.09 to -12.91; low-quality evidence) compared to the exclusively breastfeeding infants but no difference between groups was observed at 72 hours of life (MD 3.00 g, 95% CI -20.83 to 26.83; very low-quality evidence). In another trial with the water and glucose water arms combined (one trial, 47 infants), we found no significant difference in weight loss between the additional fluid group and the exclusively breastfeeding group on either day three or day five (MD -1.03%, 95% CI -2.24 to 0.18; very low-quality evidence) and (MD -0.20%, 95% CI -0.86 to 0.46; very low-quality evidence).Infant mortality was reported in one trial with no deaths occurring in either group (1162 infants). The early introduction of potentially allergenic foods, compared to exclusively breastfeeding, did not reduce the risk of "food allergy" to one or more of these foods between one to three years of age (RR 0.80, 95% CI 0.51 to 1.25; 1162 children), visible eczema at 12 months stratified by visible eczema at enrolment (RR 0.86, 95% CI 0.51 to 1.44; 284 children), or food protein-induced enterocolitis syndrome reactions (RR 2.00, 95% CI 0.18 to 22.04; 1303 children) (all moderate-quality evidence). Breastfeeding infants receiving additional foods from four months showed no difference in infant weight gain (g) from 16 to 26 weeks compared to exclusive breastfeeding to six months (MD -39.48, 95% CI -128.43 to 49.48; two trials, 260 children; low-quality evidence) or weight z-scores (MD -0.01, 95% CI -0.15 to 0.13; one trial, 100 children; moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found no evidence of benefit to newborn infants on the duration of breastfeeding from the brief use of additional water or glucose water. The quality of the evidence on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. The majority of studies showed high risk of other bias and most outcomes were based on low-quality evidence which meant that we were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence to disagree with the current international recommendation that healthy infants exclusively breastfeed for the first six months.

Age of introduction of first complementary feeding for infants: a systematic review

Background

Despite a World Health Organization recommendation for exclusive breastfeeding of all full-term infants to 6 months of age, it is not clear what the health implications may be. Breast milk alone may not meet the nutrition needs for all growing infants, leaving them at risk for deficiencies. The objective of this study was to investigate the relationship between moderate (4 months) versus late (6 months) introduction of complementary foods to the full-term breastfed infant on iron status and growth.

Methods

An electronic search of peer-reviewed and gray-literature was conducted for randomized control trials (RCTs) and observational studies related to the timing of introduction of complementary foods. Iron status and growth data from the relevant RCTs were analyzed using RevMan 5.2.11.

Results

Three RCTs and one observational study met the inclusion criteria. Meta-analysis showed significantly higher hemoglobin levels in infants fed solids at 4 months versus those fed solids at 6 months in developing countries [mean difference [MD]: 5.0 g/L; 95 % CI: 1.5, 8.5 g/L; P = 0.005]. Meta-anaysis also showed higher serum ferritin levels in the 4-month group in both developed and developing countries [MD: 26.0 μg/L; 95 % CI: -0.1, 52.1 μg/L, P = 0.050], [MD: 18.9 μg/L; 95 % CI: 0.7, 37.1 μg/L, P = 0.040]. Short follow-up periods and small sample sizes of the included studies were the major limitations.

Conclusions

RCT evidence suggests the rate of iron deficiency anemia in breastfed infants could be positively altered by introduction of solids at 4 months.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0409-5) contains supplementary material, which is available to authorized users.

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

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2014) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted data and assessed risk of bias.

MAIN RESULTS

We included eight trials (984 randomised infants/mothers). Six trials (n = 613 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one secondary outcome (weight change). The trials that provided outcome data compared exclusively breastfed infants with breastfed infants who were allowed additional nutrients in the form of artificial milk, glucose, water or solid foods.In relation to the majority of the older trials, the description of study methods was inadequate to assess the risk of bias. The two more recent trials, were found to be at low risk of bias for selection and detection bias. The overall quality of the evidence for the main comparison was low.In one trial (170 infants) comparing exclusively breastfeeding infants with infants who were allowed additional glucose water, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), with more infants in the exclusive breastfed group still exclusively breastfeeding. Conversely in one small trial (39 infants) comparing exclusive breastfed infants with non-exclusive breastfed infants who were provided with artificial milk, fewer infants in the exclusive breastfed group were exclusively breastfeeding at one week (RR 0.58, 95% CI 0.37 to 0.92) and at three months (RR 0.44, 95% CI 0.26 to 0.76) and there was no significant difference in the proportion of infants continuing any breastfeeding at three months between groups (RR 0.76, 95% CI 0.56 to 1.03).For infant morbidity (six trials), one newborn trial (170 infants) found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference (MD) 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24 mmol/L, 95% CI -0.51 to 0.03). Weight loss was also higher (grams) in infants at six, 12, 24 and 48 hours of life in the exclusively breastfed infants compared to those who received additional glucose water (MD 7.00 g, 95% CI 0.76 to 13.24; MD 11.50 g, 95% CI 1.71 to 21.29; MD 13.40 g, 95% CI 0.43 to 26.37; MD 32.50 g, 95% CI 12.91 to 52.09), but no difference between groups was observed at 72 hours of life. In another trial (47 infants analysed), we found no significant difference in weight loss between the exclusively breastfeeding group and the group allowed either water or glucose water on either day three or day five (MD 1.03%, 95% CI -0.18 to 2.24) and (MD 0.20%, 95% CI -1.18 to 1.58).Three trials with four- to six-month-old infants provided no evidence to support any benefit from the addition of complementary foods at four months versus exclusive breastfeeding to six months nor any risks related either morbidity or weight change (or both).None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence of benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water, and the quality of the evidence from a small pilot study on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer-term effects on infants and mothers, though randomising infants to receive supplements without medical need may be problematic.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

Effect of sequencing of complementary feeding in relation to breast-feeding on total intake in infants

OBJECTIVE

The aim of the present study was to evaluate whether the order of complementary feeding in relation to breast-feeding affects breast milk, semisolid, or total energy intake in infants.

METHODS

The present study was designed as a randomized crossover trial. The study was conducted in a tertiary care hospital. The study participants were 25 healthy infants between the ages of 7 and 11 months who were exclusively breast-fed for at least 6 months and were now receiving complementary foods for at least 1 month in addition to breast-feeding. Infants were randomized to follow a sequence of either complementary feeding before breast-feeding (sequence A) or complementary feeding after breast-feeding (sequence B) for the first day (24 hours) of the study period using simple randomization. For the next day, the sequence was reversed for each child. All babies received 3 actively fed complementary food meals per day (morning, afternoon, and evening). A semisolid study diet was prepared in the hospital by cooking rice and pulse with oil using a standard method, ensuring the energy density of at least 0.6 kcal/g. The infants were allowed ad libitum breast-feeding during the observation period. Semisolid intake was directly measured and breast milk intake was quantified by test weighing method. Energy intake from complementary foods was calculated from the product of energy density of the diet served on that day and the total amount consumed. The total energy intake and energy intake from breast milk and complementary foods between the 2 sequences were compared.

RESULTS

The mean (standard deviation) energy intake from breast milk during 12 hours of daytime by following sequence A (complementary feeding before breast-feeding) was 132.0 (67.4) kcal in comparison with 135.9 (56.2) kcal in sequence B, which was not statistically different (P = 0.83). The mean (standard deviation) energy consumed from semisolids in sequences A and B was also comparable (88.6 [75.5] kcal vs. 85.5 [89.7] kcal; P = 0.58). The total energy intake during daytime in sequence A was 220.6 (96.2) kcal in comparison with 221.5 (94.0) kcal in sequence B, which was also comparable (P = 0.97). The results related to energy intake through breast milk and total energy intake were not different when insensible losses during feeding were adjusted in both groups.

CONCLUSIONS

Altering the sequence of complementary feeding in relation to breast-feeding does not affect total energy intake.

Management strategies in the treatment of neonatal and pediatric gastroenteritis

Acute gastroenteritis, characterized by the onset of diarrhea with or without vomiting, continues to be a major cause of morbidity and mortality in children in mostly resource-constrained nations. Although generally a mild and self-limiting disease, gastroenteritis is one of the most common causes of hospitalization and is associated with a substantial disease burden. Worldwide, up to 40% of children aged less than 5 years with diarrhea are hospitalized with rotavirus. Also, some microorganisms have been found predominantly in resource-constrained nations, including Shigella spp, Vibrio cholerae, and the protozoan infections. Prevention remains essential, and the rotavirus vaccines have demonstrated good safety and efficacy profiles in large clinical trials. Because dehydration is the major complication associated with gastroenteritis, appropriate fluid management (oral or intravenous) is an effective and safe strategy for rehydration. Continuation of breastfeeding is strongly recommended. New treatments such as antiemetics (ondansetron), some antidiarrheal agents (racecadotril), and chemotherapeutic agents are often proposed, but not yet universally recommended. Probiotics, also known as "food supplement," seem to improve intestinal microbial balance, reducing the duration and the severity of acute infectious diarrhea. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the European Society of Paediatric Infectious Diseases guidelines make a stronger recommendation for the use of probiotics for the management of acute gastroenteritis, particularly those with documented efficacy such as Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii. To date, the management of acute gastroenteritis has been based on the option of "doing the least": oral rehydration-solution administration, early refeeding, no testing, no unnecessary drugs.

Introducing solids and water to Australian infants

BACKGROUND

Recommendations for the introduction of solids and fluids to an infant's diet have changed over the past decade. Since these changes, there has been minimal research to determine patterns in the introduction of foods and fluids to infants.

METHODS

This retrospective cohort study surveyed mothers who birthed in Queensland, Australia, from February 1 to May 31, 2010, around 4 months postpartum. Frequencies of foods and fluids given to infants at 4, 8, 13, and 17 weeks were described. Logistic regression determined associations between infant feeding practices, the introduction of other foods and fluids at 17 weeks, and sociodemographic characteristics.

RESULTS

Response rate was 35.8%. At 17 weeks, 68% of infants were breastfed and 33% exclusively breastfed. Solids and water had been introduced in 8.6% and 35.0% of infants, respectively. The introduction of solids by 17 weeks was associated with younger maternal age and the infant being given water and infant formula at 4 weeks. The infant being given water at 17 weeks was associated with younger maternal age, the infant being given infant formula at 4 weeks, level of education, relative socioeconomic disadvantage, parity, and birth facility.

CONCLUSION

Over the past decade, there has been a significant reduction in the proportion of infants in Australia who have been given solids by 17 weeks. Sociodemographic characteristics and formula feeding practices at 4 weeks were associated with the introduction of solids and water by 17 weeks. Further research should examine these barriers to improve compliance with current infant feeding recommendations.

Patterns and determinants of breastfeeding and complementary feeding practices of Emirati Mothers in the United Arab Emirates

BACKGROUND

Breastfeeding is the preferred method of feeding for the infant. The present study aimed at investigating the different infant feeding practices and the influencing factors in the United Arab Emirates (UAE).

METHODS

A convenient sample of 593 Emirati mothers who had infants up to 2 years of age was interviewed. The interviews included a detailed questionnaire and conducted in the Maternal and Child Health Centers (MCH) and Primary Health Centers (PHC) in three cities.

RESULTS

Almost all the mothers in the study had initiated breastfeeding (98%). The mean duration of breastfeeding was 8.6 months. The initiation and duration of breastfeeding rates were influenced by mother's age (P<0.034)and education(P<0.01), parity(OR=2.13; P<0.001), rooming in(OR=21.70; P<0.001), nipple problem(P<0.010) and use of contraception(P<0.034). As for the feeding patterns, the results of the multiple logistic analyses revealed that rooming in (OR=4.48; P<0.001), feeding on demand (OR=2.29; P<0.005) and feeding more frequently at night (P<0.001) emerged as significant factors associated with exclusive or predominantly breastfeeding practices. Among the 593 infants in the study, 24.1% had complementary feeding, 25% of the infants were exclusively breastfed, and 49.4% were predominantly breastfed since birth. About 30% of the infants were given nonmilk fluids such as: Anis seed drink (Yansun), grippe water and tea before 3 months of age. The majority of the infants (83.5%) in the three areas received solid food before the age of 6 months. A variety of reasons were reported as perceived by mothers for terminating breastfeeding. The most common reasons were: new pregnancy (32.5%), insufficient milk supply (24.4%) and infant weaned itself (24.4%).

CONCLUSIONS

In conclusion, infant and young child feeding practices in this study were suboptimal. There is a need for a national community-based breastfeeding intervention programme and for the promotion of exclusive breastfeeding as part of a primary public health strategy to decrease health risks and problems in the UAE.

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

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However the addition of other fluids or foods before six months is common practice in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials; three extracted data and assessed risk of bias.

MAIN RESULTS

We included six trials (814 infants). Two trials in the early days after birth that reported data did not indicate that giving additional fluids was beneficial. For duration of breastfeeding, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), indicating that supplements may contribute to reducing the duration.For infant morbidity (three trials), one newborn trial found a statistically, but not clinically, significant difference in temperature at 72 hours (MD 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24mmol/l, 95% CI -0.51 to 0.03). Two trials with four- to six-month-old infants did not indicate any benefit to supplemented infants to 26 weeks nor any risks related to morbidity or weight change.None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation .We found no benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water. For infants at four to six months, we found no benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer term effects on infants and mothers, though randomising infants to receive supplements without medical need may be considered unethical.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

Reduction of unnecessary intake of water and herbal teas on breast-fed infants: a randomized clinical trial with adolescent mothers and grandmothers

PURPOSE

To evaluate the efficacy of counseling sessions on breast-feeding for adolescent mothers and maternal grandmothers on the reduction of unnecessary water and herbal teas intake on breast-fed infants.

METHODS

A randomized clinical trial was conducted involving adolescent mothers, newborn infants, and maternal grandmothers allocated into four groups: mother and grandmother not cohabitating, without intervention; mother and grandmother not cohabitating, with intervention directed only toward mother; mother and grandmother cohabitating, without intervention; and mother and grandmother cohabitating, with intervention directed toward both. The intervention consisted of six counseling sessions on breastfeeding: in the maternity ward, and after birth on days 7, 15, 30, 60, and 120 at home. The data about feeding practices were collected by telephone every month until the end of the sixth month of the baby's life. The effect of the intervention was measured by comparing the medians and the survival curves for initiation of water and/or tea intake in the first 6 months of life, and Cox regression was used to estimate its magnitude.

RESULTS

The intervention had a positive effect for the group in which the adolescent mothers cohabitated with the baby's grandmother (hazard ratio = .53; 95% confidence interval = .35-.80), and also for the group in which they did not cohabitate with the baby's grandmother (hazard ratio = .48; 95% confidence interval = .31-.76). By comparing the medians of the time of initiation of water and/or tea intake between control and intervention groups, it was observed that the intervention postponed the use of these liquids in 67 days in the group in which mothers and grandmothers cohabitated and in 44 days in the group in which they did not live together.

CONCLUSION

Multiple counseling sessions on infant feeding in the first 4 months postpartum for adolescent mothers and maternal grandmothers, when they cohabitate, proved to be an effective strategy to postpone the unnecessary water and/or tea intake of breast-fed infants.

Knowledge, beliefs, and practices regarding exclusive breastfeeding of infants younger than 6 months in Mozambique: a qualitative study

Only 37% of infants younger than 6 months in Mozambique are exclusively breastfed. A qualitative assessment was undertaken to identify the knowledge, beliefs, and practices around exclusive breastfeeding--specifically, those of mothers, fathers, grandmothers, and nurses--and to identify the support networks. Results show many barriers. In addition to receiving breast milk, infants receive water, traditional medicines, and porridges before 6 months of age. Many mothers had heard of the recommendation to exclusively breastfeed for 6 months. However, other family decision makers had heard less about exclusive breastfeeding, and many expressed doubts about its feasibility. Some of them expressed willingness to support exclusive breastfeeding if they were informed by health workers. Nurses know the benefits of exclusive breastfeeding and pass this information on verbally but have insufficient counseling skills. Interventions to improve exclusive breastfeeding should target family and community members and include training of health workers in counseling to resolve breastfeeding problems.

Acolhimento e características maternas associados à oferta de líquidos a lactentes

OBJETIVO: Identificar características maternas e ações de acolhimento às mães de crianças menores de seis meses associadas à oferta precoce de líquidos. MÉTODOS: Estudo transversal realizado em 2007 com amostra representativa de mães de crianças menores de seis meses (n = 1.057) usuárias de unidades básicas de saúde (UBS) na cidade do Rio de Janeiro, RJ. Para estimar a associação entre as variáveis explicativas e a oferta de líquidos utilizou-se um modelo de regressão logística multivariado com ponderação, efeito de desenho e controlado pela idade da criança. RESULTADOS: Das mães, 32% não recebeu o cartão de acolhimento na maternidade, 47% não recebeu orientação sobre amamentação na primeira ida à UBS após o parto e 55% relatou a oferta de líquidos aos lactentes. Mulheres sem experiência pregressa em amamentar por pelo menos seis meses apresentaram chance de oferta de líquidos maior que aquelas com experiência (OR = 1,57; IC 95%: 1,16;2,13). As que não receberam orientação sobre amamentação na primeira ida à UBS após o parto tiveram chance 58% maior de oferecer líquidos que aquelas que receberam orientação. A oferta de líquidos mostrou-se positivamente associada com a adolescência entre mulheres com companheiro (OR = 2,17; IC 95%: 1,10;4,30) e negativamente associada com a adolescência entre aquelas sem companheiro (OR = 0,31; IC95%: 0,11;0,85). Entre mulheres com menos de oito anos de estudo, as que não receberam orientação sobre amamentação após o nascimento da criança apresentaram chance de oferta de líquidos 1,8 vez maior que aquelas que receberam orientação. CONCLUSÕES: Idade, situação conjugal e experiência pregressa em amamentar são características maternas associadas à oferta de líquidos para crianças menores de seis meses. O recebimento de orientação precoce sobre aleitamento materno pode reduzir o oferecimento de líquidos aos lactentes.

Assessing exclusive breastfeeding practices, dietary intakes and body mass index (BMI) of nursing mothers in Ekiti State of Nigeria

Breastfeeding is an unequalled way of providing ideal food for the infants. The benefits of breastfeeding practices to infants and mothers are well documented. However, information on breastfeeding practices and its effect on body mass index (BMI) of mothers are scarce, particularly in Ekiti State of Nigeria. Therefore, the present study is designed to assess breastfeeding practices and its association with BMI of mothers. A descriptive and cross-sectional study was conducted among breastfeeding mothers that attended postnatal clinic of the state specialist hospitals and maternity centers in the study location. The specialist hospital and two-third of the nine maternity centers were purposively selected because of their health facilities and personnel. The mother-child pairs (200 respondents) were randomly selected from the study locations. Information on demographic characteristic, socio-economic parameters, nutritional knowledge of breastfeeding and dietary intakes of mothers were collected using questionnaires. BMI of mothers was determined as described by World Health Organization. Age distribution of mothers was between 25-34 years; and almost half of respondents had good educational background and were engaged in different occupations. The respondent monthly income ranged between = N = 3500 - 26000 ($26.92 - $200); and their dietary intakes varied between starchy and protein-based food. The result also showed that the respondent consumed enough nutrients to meet up the recommended daily allowance for protein, carbohydrate, fat, zinc, magnesium, sodium and phosphorous requirements. The BMI classifications showed that over three-fifth of respondents were normal, while the remaining were underweight (6%) and overweight/obese (26.5%). Also, large proportion of respondents engaged in exclusive breastfeeding and with good knowledge of breastfeeding practices. Statistically, exclusive breastfeeding practices had no correlation between the BMI and frequency of breastfeeding. The study, therefore, concluded that mothers had good knowledge of breastfeeding practice; and that there was no association between breastfeeding practices and BMI.

Hydration status of exclusively and partially breastfed near-term newborns in the first week of life

An in-hospital prospective, observational cohort study was conducted to assess the effects of type of feeding (exclusively breastfed [EBF] vs partially breastfed [PBF]) on the hydration status of near-term newborns in the first week of life. A total of 205 babies of 35 to 37 weeks of completed gestation were enrolled (82 in the EBF group and 123 in the PBF group). The overall incidence of significant weight loss (>or=10%) was 18% with no significant difference between EBF and PBF groups (18.3% vs 17.9%, P=.94). The incidence of hypernatremia (serum NA>or=150 meq/L) was 2.4% in the EBF group and 5.7% in the PBF group (P=.32). The factors associated with significant weight loss in the total cohort were having a mother with previous negative breastfeeding experience (adjusted odds ratio [OR]=16.5, 95% confidence interval [CI]=2.1-115.7), exposure to phototherapy (adjusted OR=9.0, 95% CI=2.5-31.8), and cesarean delivery (adjusted OR=6.7, 95% CI=2.3-19.7).

Analysis of advertisements of infant food commercialized in the city of Natal, Rio Grande do Norte, Brazil

The advertising about maternal milk substitutes has been pointed as one of the factors responsible for the breastfeeding low rates. In this way, legal support was created to assure that the use of such products would not interfere on the healthy breastfeeding habit of the population. This study, developed between June 2006 and May 2008 in the city of Natal, state of Rio Grande do Norte, analyzed the food advertisements divulged under the validity of Law # 11.265/2006, which controls in Brazil the food commercialization and the publicity addressed to parents or keepers of nursling and children in the first childhood. 220 advertisements, being 141 of technical-scientific nature, and 79 for strictly commercial promotion, were collected and evaluated according to legal requirements. The results from this analysis showed that 100% of the advertisements of technical-scientific nature overstepped the clause V; 18.4% the clause IV and 14.2% the clauses I, II and III of article 19th of Law # 11265/2006. In 42% of the advertisements strictly for commercial promotion, the mandatory information mentioned at clauses I and II of the article 5th were not shown. In 8.7% of the advertisements containing such information, it was placed in an area that embarrassed its identification and reading, due to used fonts size and/or color; similarly as occurred with the information required by article 19th, in the advertisements of technical-scientific nature.

Determinantes da amamentação no primeiro ano de vida em Cuiabá, Mato Grosso

OBJETIVO: Avaliar os fatores de risco para a interrupção de aleitamento materno e desmame em crianças menores de um ano. MÉTODOS: Estudo transversal analítico com crianças menores de um ano de idade que compareceram aos postos de vacinação do município de Cuiabá, Mato Grosso, em 2004, acompanhadas de seus responsáveis. Para definição da amostra, foram sorteadas as unidades de vacinação, seguindo-se o sorteio das crianças em cada unidade, de forma sistemática. Para coleta de dados, aplicou-se um questionário semi-estruturado aos acompanhantes das crianças, investigando variáveis características sociodemográficas, referentes ao nascimento da criança e maternas, uso de chupeta e alimentação no primeiro dia em casa. Foram realizadas análise descritiva e regressão logística dos fatores de risco para cada faixa etária, apresentadas em odds ratio e intervalos de confiança. RESULTADOS: No total, 920 crianças menores de um ano foram avaliadas, das quais 205 menores de 120 dias e 275 menores de 180 dias. Verificou-se que usar chupeta, tomar chá no primeiro dia em casa, ter mãe com escolaridade até o primeiro ou segundo graus ou primípara, representam maior risco de não estar em amamentação exclusiva aos 120 dias de vida. Tais fatores se mostraram significativos também para menores de 180 dias, com exceção do consumo de chá, que não foi indagado para essa faixa etária. Nos menores de um ano, o uso de chupeta foi a única variável que manteve significância estatística. CONCLUSÕES: Fatores socioculturais mostraram-se determinantes da situação de aleitamento materno. Ressalta-se a importância da instrução e conscientização maternas, que refletem sobre as práticas que podem prejudicar a amamentação.

Evolução do aleitamento materno em uma capital da Região Centro-Oeste do Brasil entre 1999 e 2004

Um estudo de caráter transversal foi realizado durante o primeiro dia da Campanha Nacional de Vacinação de 2004, em Cuiabá, Mato Grosso, Brasil, com o objetivo de conhecer a evolução do aleitamento materno entre 1999 e 2004, no primeiro ano de vida. A determinação da amostra seguiu dois passos, considerando o número de unidades de vacinação e as crianças em cada unidade. Um inquérito nutricional contendo um recordatório alimentar de 24 horas foi aplicado a 921 acompanhantes das crianças menores de um ano. Houve incremento positivo em todas as faixas etárias na modalidade de aleitamento materno exclusivo. Observou-se, ao final dos 180 dias, baixo percentual de crianças em aleitamento materno exclusivo, sendo menos de 5% (em 1999) e de 10% (em 2004). A prevalência do aleitamento materno exclusivo dobrou em cinco anos nas crianças menores de 120 dias, passou de 17,7% para 28,5%. As ações realizadas para promoção do aleitamento materno foram efetivas, porém, insuficientes para a grave situação. Mais ações são necessárias, bem como o aperfeiçoamento dos programas existentes.

Influence of infant-feeding practices on nutritional status of under-five children

OBJECTIVES

To study the nutritional status of under-five children and to assess whether infant feeding practices are associated with the undernutrition in anganwari (AW) areas of urban Allahabad.

METHODS

Under-five-years children and their mothers in selected four anganwari areas of urban Allahbad (UP) participated in the study. Nutritional assessment by WHO criterion (SD- classification) using summary indices of nutritional status: weight-for-age, height-for-age and weight-for-height was done. Normal test of proportions, Chi-square test for testing association of nutritional status with different characteristics and risk analysis using odds ratios with 95% confidence intervals was also done.

RESULTS

Among all under five children surveyed, 36.4% underweight (< 2SD weight- for -age), 51.6% stunted (< 2SD height- for- age) and 10.6% wasted (< 2SD weight- for- height). Proportions of underweight (45.5%) and stunting (81.8%) were found maximum among children aged 13-24 months. Wasting was most prevalent (18.2%) among children aged 37-48 months. Initiation of breast-feeding after six hours of birth, deprivation from colostrum and improper complementary feeding were found significant (P< 0.05) risk factors for underweight. Wasting was not significantly associated (P>0.10) with any infant feeding practice studied. ICDS benefits received by children failed to improve the nutritional status of children.

CONCLUSION

Delayed initiation of breast-feeding, deprivation from colostrum and improper weaning are significant risk factors for undernutrition among under-fives. There is need for promotion and protection of optimal infant feeding practices for improving nutritional status of children.

Breastfeeding patterns, beliefs and attitudes among Kurdish mothers in Diyarbakir, Turkey

AIM

The aim was to rapidly assess existing breastfeeding patterns, beliefs and attitudes in the province of Diyarbakir, a socio-economically disadvantaged region of Turkey.

METHODS

A cross-sectional survey exploring demographic and breastfeeding patterns was carried out among 921 mothers with children 6-18 mo of age. Results were quantitatively analysed. Focus group interviews dealing with beliefs and attitudes were separately carried out among 107 mothers and analysed by qualitative content analysis.

RESULTS

Nearly all mothers had breastfed their infants at some time, but exclusive breastfeeding was rare. About 62.2% of the mothers had waited for at least 24 h before initiating breastfeeding. Almost half of the infants received sweetened water as a first feeding. There was agreement on the superiority of breastfeeding and awareness of its contraceptive effect. Early introduction of sugared water, water and supplementary feeds was considered desirable. Working in the fields and pregnancy were considered situations counteracting breastfeeding.

CONCLUSION

The attitude to breastfeeding was highly positive, but more information is needed to encourage the use of colostrum, discourage early supplementation and promote exclusive breastfeeding during the first 6 mo of life.

Health benefits of selected global breastfeeding recommendations among children 0-6 months in Nigeria

The survey examined the appropriateness of selected global breastfeeding recommendations in an environment where the recommendations contradicted local knowledge and culture. Specifically, the survey assessed the implications of pre-lacteal feeding, feeding of colostrum, exclusive breastfeeding for the first 6 months of life and the use of feeding bottles for child health. Eligible mother-infant pairs were recruited for the survey by cluster sampling technique. Data was collected about the mother-infant pairs with the aid of a pre-designed questionnaire that sought information on the social and demographic characteristics of the mothers and infants, current breastfeeding practices and illnesses that the index infants had in the 2 weeks preceding the survey day. Information was canvassed from 2466 mother-infant pairs. All the infants were aged 0-6 months. Compliance with the selected recommendations were: 74.4% reported exclusive breastfeeding; 87.5% did not give pre-lacteal feeds, 78.3% were not using feeding bottles while 92.9 gave colostrum. Mothers who reported compliance with the recommendations also reported fewer episodes of the common signs of illnesses surveyed. The study confirmed the appropriateness and relevance of the selected recommendations in the study area.

Effects of early extra fluid and food intake on breast milk consumption and infant nutritional status at 5 months of age in an urban and a rural area of Burkina Faso

OBJECTIVE

To assess the effects of early extra fluid and food intake on breast milk consumption and the effects of food intake on 5-month-old infant nutritional status.

DESIGN

Cross-sectional surveys. Infants were selected by random choice.

SETTINGS

Urban and rural Burkina Faso.

SUBJECTS

A total of 97 urban and 69 rural infants were recruited, but 67 and 51, respectively, completed the surveys. Infant selection criteria were: age (5 +/- 0.5-month old), thriving, breastfed, having Burkinabè parents in study area for a year, study conditions accepted by parents.

INTERVENTION

Surveys were conducted respectively in January and February 2001 (urban), and 2002 (rural) during the cool season. They were performed by home visit. With the help of health workers and traditional midwives, families were informed of the studies' objectives and gave agreement. Food intakes were estimated by test-weighing for breast milk and precise weighing techniques for other foods. Socioeconomic status of households, anthropometry of infants and mothers were also recorded. Breast milk samples were collected from each mother's breast and analysed for lipid and fatty acid concentrations.

RESULTS

Daily breast milk intake did not differ between urban (776 +/- 262 g) and rural areas (835 +/- 265 g). Porridge intake was, respectively, 128 +/- 105 and 96 +/- 49 g. Median extra fluid intake was, respectively, 79 and 122 g. In both areas, porridge and fluid intake had no effect on breast milk consumption. In urban areas, infant nutritional status at 5 months was better than at birth.

CONCLUSION

Breast milk intake and nutritional status of predominantly breastfed infants at 5 months of age, living in both urban and rural settings, were not affected by the consumption of extra fluid or food intake.

Breast milk and energy intake in exclusively, predominantly, and partially breast-fed infants

OBJECTIVE

To investigate the extent to which breast milk is replaced by intake of other liquids or foods, and to estimate energy intake of infants defined as exclusively (EBF), predominantly (PBF) and partially breast-fed (PartBF).

DESIGN

Cross-sectional.

SETTING

Community-based study in urban Pelotas, Southern Brazil.

SUBJECTS

A total of 70 infants aged 4 months recruited at birth.

MAIN OUTCOME MEASURES

Breast milk intake measured using a "dose-to-the-mother" deuterium-oxide turnover method; feeding pattern and macronutrient intake assessed using a frequency questionnaire.

RESULTS

Adjusted mean breast milk intakes were not different between EBF and PBF (EBF, 806 g/day vs PBF, 778 g/day, P=0.59). The difference between EBF and PartBF was significant (PartBF, 603 g/day, P=0.004). Mean intakes of water from supplements were 10 g/day (EBF), 134 g/day (PBF) and 395 g/day (PartBF). Compared to EBF these differences were significant (EBF vs PBF, P=0.005; EBF vs PartBF, P<0.001). The energy intake of infants receiving cow or formula milk (BF+CM/FM) in addition to breast milk tended to be 20% higher than the energy intake of EBF infants (EBF, 347 kJ/kg/day vs BF+CM/FM, 418 kJ/kg/day, P=0.11).

CONCLUSIONS

There was no evidence that breast milk was replaced by water, tea or juice in PBF compared to EBF infants. The energy intake in BF+CM/FM infants tended to be 20% above the latest recommendations (1996) for breast-fed and 9% above those for formula-fed infants. If high intakes are maintained, this may result in obesity later in life.

SPONSORSHIP

International Atomic Energy Agency through RC 10981/R1.

Growth pattern of exclusively breast-fed infants during the first six months of life in Ile-Ife, Osun State, Nigeria

Several studies to determine the growth pattern of exclusively breast fed infants have provided varying conclusions as to the sufficiency of breast milk alone to support adequate growth for the first six months of life. Disagreement exists concerning the optimal timing of introduction of complementary foods to exclusively breast fed infants. This prospective study thus examined the adequacy of breast milk alone to support normal growth during the first six months of life in our environment. The overall objective was to propose a scientifically sound national recommendation on the appropriate timing for the introduction of complementary feeding in Nigeria. Three hundred and fifty-two mother/infant pairs were serially recruited into the study; all babies were aged 14 days or less and weighed 2.5 kg and above. Three hundred and forty-five (98%) were successfully followed up till the infants were six months old. By six months, 264 (76.5%) were exclusively breast-fed, while 81 (23.5%) had commenced complementary feeding. Growth curves of exclusively breast-fed infants showed increasing weight from birth to six months. Although the 50th percentile birth weight for both boys and girls were the same (3.2 kg), boys gained weight faster than the girls from the age of one month to six months and were heavier at six months. Additionally, the 50th percentile curves of these infants (both genders) for the first six months were above the 50th percentile curve of the World Health Organisation and National Centre for Health Statistics (WHO/NCHS) reference currently used on our national "road to health" (growth monitoring) cards. It was concluded that exclusive breast-feeding supported adequate growth during the first six months of life for most of the children studied and that our national recommendation that infants be introduced to complementary feeding at six months is appropriate.

Human milk fatty acids and growth of infants in Brazzaville (The Congo) and Ouagadougou (Burkina Faso)

OBJECTIVE

To estimate the role of human milk n-6 and n-3 polyunsaturated fatty acids (PUFA) in term infant growth in two African urban populations.

DESIGN

Observational study. Weight gains at 5 months of age and dietary habits were compared between Congolese infants (n=102) and Burkinabè infants (n=101). Socio-economic status and anthropometry of the mothers were also recorded.

SETTING

One suburban district in Brazzaville (capital of The Congo) and one in Ouagadougou (capital of Burkina Faso).

SUBJECTS

Two random samples of nursing mothers and their 5-month-old infants.

RESULTS

All infants were born at term and there was no difference in birth weights. At 5 months of age, infants in Ouagadougou were thinner but not shorter than their counterparts in Brazzaville (average weight gain (standard deviation): 614 (168) g month-1 vs. 720 (176) g month-1; P= 0.0001). Drastic differences were found in infant diets with regard to extra fluid intake and n-6 and n-3 PUFA concentrations in breast milk. In Ouagadougou, all infants were given fluids other than milk from birth. Breast milk had highly unbalanced 18:2n-6/18:3n-3 and n-6/n-3 long-chain PUFA ratios (53:1 and 5:1, respectively). In Brazzaville, half of the infants received fluids other than milk, and breast milk showed balanced 18:2n-6/18:3n-3 and n-6/n-3 long-chain PUFA ratios (12:1 and 1:1, respectively). A non-linear relationship between 18:2n-6/18:3n-3 ratio and growth was established in Brazzaville (P= 0.0027). The 18:2n-6/18:3n-3 ratio adjusted with covariates had an even more significant effect on weight gain (P= 0.0011). Applying the same model in Ouagadougou did not show such a relation.

CONCLUSION

: Data strongly suggest that a balanced ratio of 18:2n-6/18:3n-3 (between 5:1 and 15:1) in breast milk leads to higher weight gain of infants during the first 5 months of life.

Alimentos complementares e fatores associados ao aleitamento materno e ao aleitamento materno exclusivo em lactentes até 12 meses de vida em Itapira, São Paulo, 1999

OBJETIVOS: analisar as práticas alimentares no primeiro ano de vida e fatores associados ao aleitamento materno e ao aleitamento materno exclusivo, no município de Itapira, SP. MÉTODOS: inquérito realizado em 1999 com 679 lactentes menores de 12 meses no Dia Nacional de Vacinação como parte do projeto Amamentação & Municípios. A associação entre o aleitamento e as variáveis independentes condições de nascimento, uso de mamadeira, chupeta e característica maternas, foi verificada por meio de regressão logística múltipla. RESULTADOS: a idade média da mãe foi de 25,5 anos, sendo 41,8% primíparas e 51,7% dos partos cirúrgicos. O peso médio ao nascer foi de 3.223g. Observou-se que 98,1% dos lactentes foram amamentados nos primeiros 30 dias, porém houve introdução precoce de chá, água e outros leites. A prevalência do aleitamento materno exclusivo foi de 64,8% no primeiro mês, caindo para 45% e 30,1% aos quatro e seis meses, respectivamente. Aos 12 meses 61,6% dos lactentes eram amamentados. As variáveis associadas ao desmame foram: usar chupeta (OR 5,58; IC95%: 3,94 -7,89), baixo peso ao nascer (OR 2,74; IC95%: 1,46 - 5,13) e hospital de nascimento (OR 1,76; IC95%: 1,22 - 2,52). Para interrupção da amamentação exclusiva, nos primeiros seis meses, os resultados foram: usar chupeta (OR 4,41; IC95%: 2,57 - 7,59) e parto cesárea (OR 1,78; IC95%: 1,09-2,91). CONCLUSÕES: a prevalência observada, do aleitamento materno e aleitamento materno exclusivo, ainda está distante das atuais recomendações da OMS.

The monetary value of human milk in Francophone west Africa: a PROFILES analysis for nutrition policy communication

Using a simple and conservative methodology, we estimated the volume and monetary value of the human milk produced by lactating women in Francophone West Africa. In that region, children zero to 35.9 months old consume over 1.1 billion liters of human milk per year. However, suboptimal breastfeeding practices account for the loss of 175 million liters of human milk annually. If the human milk consumed by children zero to 35.9 months old were to be adequately replaced using commercial breastmilk substitutes, an annual expenditure of about 2 billion US dollars would be needed. At the household level, the annual replacement cost of human milk would amount to US$412 per infant. This is beyond the reach of most families in West Africa, where as many as 61% of families in some countries live on less than one US dollar per day. Appropriate policies to foster breastfeeding need to be developed and adequately implemented. Such policy action is more likely to occur if decision makers fully appreciate the monetary value of human milk.

Knowledge, attitude and practice of health workers in Keffi local government hospitals regarding Baby-Friendly Hospital Initiative (BFHI) practices

OBJECTIVE

To assess the knowledge, attitude and practice of health workers towards Baby Friendly Hospital Initiative (BFHI) practices and thereafter plan an advocacy on BFHI training of the workers.

DESIGN

A randomised cross-sectional study. SETING: Ten out of 16 health facilities reflecting all the levels of healthcare provision in Keffi Local Government Area in Nassarawa State, Nigeria, were selected. Staff of these health facilities had not received BFHI training, although breastfeeding is the norm in this population, exclusive breastfeeding is almost zero.

SUBJECTS

A total of 250 health workers (six doctors, 160 nurses and 84 auxiliary staff) met in the health facilities at the time of interview.

INTERVENTION

A structured questionnaire based on 10 steps to successful breastfeeding was administered by one of the authors and a Lactad nurse between July and October 1995.

RESULTS

Fifty-two (20.8%) were aware of the need for initiating breastfeeding within 30 min of birth and 92 (36.8%) were aware of breastfeeding support groups. However, there were significant differences in the level of awareness among the doctors compared to the other categories of health staff (P<0.05). Also, 48 (19.2%) of the health workers believed that babies less than 6 months of age should not be given water (statistical difference (P<0.05) between doctors' attitude and that of the other health workers). Thirteen (5.22%) health workers could demonstrate correct positioning and attachment.

CONCLUSION

There was general lack of awareness of some major recommended practices in the hospitals that will promote and sustain breastfeeding. There is therefore the need for policy changes and BFHI training for the staff of these health facilities to respond to the concern and growing need for proper infant/young child feeding.

Breastfeeding knowledge and beliefs among adults in eastern Tobago

Using a cross-sectional survey, the knowledge and beliefs about breastfeeding were evaluated among adults in Eastern Tobago (N = 509). Of the respondents, 95%, 69%, and 48% indicated that a baby should be exclusively breastfed at birth, 3 months, and 6 months, respectively. The baby's mother was thought to have the greatest influence on breastfeeding decisions. Of the respondents, 63% and 80% were unaware of expressed breast milk and cup-feeding a neonate, whereas 82% believed that a solely breastfed baby should receive water. Additionally, 23% and 44% felt that breastfeeding should be terminated before 6 months and between 6 and 12 months, respectively. Inadequate maternal nutrition and employment were reported as the principal factors affecting breastfeeding. There is a lack of knowledge about the anatomy and physiology of lactation and about the benefits of exclusive breastfeeding. These findings are useful for guiding the development and implementation of interventions to promote breast-feeding in Tobago.

Effect of early complementary feeding on nutritional status in term infants in rural Nigeria

Breastfeeding is common in developing countries, but exclusive breastfeeding is rare, and complementary foods are introduced at an early age. The objective of the present study is to determine the effect of early complementary feeding on the nutritional status of infants. Weight-for-age (WA) indices have been determined for 82 infants 3 to 4 months old participating in a breastfeeding study. They included 42 that started complementary feeding early (before 2 months) and 40 that started later. Weight-for-age indices were significantly lower for the early group than for the later group (t = 3.00, p = 0.004). The prevalence of underweight (WA SD scores below -2.0) was 7.5% in the later complementary feeding group and 28.6% in the early group (chi(2) = 4.76, p = 0.0292). Severe underweight (WA SD scores below -3.0) prevalences were 0% and 14.3% respectively (p = 0.0259). Thus, poorer nutritional status was significantly associated with earlier complementary feeding. The results suggest that exclusive breastfeeding, (together with promotion of weaning education and growth monitoring) should be vigorously promoted in these rural communities.

Sociocultural factors and the promotion of exclusive breastfeeding in rural Yoruba communities of Osun State, Nigeria

Child survival strategies include prolonged and intensive breastfeeding, together with its early initiation, and breastmilk only for the first six months of life. This paper reports on local knowledge and attitudes of breastfeeding and the sociocultural factors that shape its practice in poor rural Yoruba communities of Southwestern Nigeria. The study has conducted 10 focus group discussions among homogeneous groups of grandmothers, pregnant women, lactating mothers, husbands, and community health workers, and a questionnaire survey of 256 third trimester pregnant women. All women in these communities breastfeed their infants on demand, and for up to two years, because breastmilk is universally accepted as the best food for babies, and breastfeeding spaces births. Prelacteal feedings of water herbal infusions and ritual fluids are the norm, and breastmilk is supplemented, from birth, with water and teas. Exclusive breastfeeding is considered dangerous to the infant: the baby has an obligatory requirement for supplementary water to quench its thirst and promote its normal development, and for herbal teas which serve as food and medicine. Colostrum is discarded because it is dirty, "like pus", and therefore potentially harmful to the infant, although 24% of the survey sample would give it to their babies. Expressed breastmilk is suspect as it can get contaminated, poisoned or bewitched. Complementary foods are introduced as early as two months because of perceived lactation insufficiency. The commonest supplement is a watery maize porridge of low nutrient density. Breastfeeding can also be dangerous, as toxins and contaminants can be passed to the infant through breastmilk. The most serious conflict with the WHO/UNICEF recommendations is the lack of local credibility of exclusive breastfeeding. According to local knowledge, the early introduction of water, herbal teas, and of complementary foods is designed to enhance child survival, while these are supposed to do the exact opposite by the WHO/UNICEF rationale, by exposing the infant to contaminants early, thereby increasing diarrheal morbidity and mortality. Child survival interventions need to address this conflict.

Maternal education, breastfeeding behaviours and lactational amenorrhoea: studies among two ethnic communities in Ile Ife, Nigeria

Breastfeeding is an important child survival strategy. This report aims to describe the unique contributions of education, ethnicity, and other variables to breastfeeding outcomes. The study was conducted among two groups of lactating mothers in Ile Ife, southwestern Nigeria, using structured questionnaires focusing on their breastfeeding history and current practice. Breastfeeding initiation was delayed in both groups, and primary education is the most significant predictor of initiation of breastfeeding within 6 hours of delivery (OR = 3.92, p = 0.0117). Breastfeeding duration (SD) was 13.7 (4.3) months for the Yorubas and 17.5 (3.4) for the Hausas. Its only significant predictors are education (p < = 0.0001), with an average decrease in breastfeeding duration of 3.2 and 6.6 months with mother's education to the primary and post-primary levels respectively, compared with mothers with no education. In turn, breastfeeding duration is the most significant predictor of the duration of lactational amenorrhoea (p = 0.0000). Mothers with some formal education are also more likely to start feeding human milk substitutes at 2 weeks (OR = 3.83, p = 0.024). The most important variable determining breastfeeding in this study is education. The educated mother is more likely to be involved in economic activity away from the home. To protect breastfeeding in these communities, there is a need for programmes to support the breastfeeding mother who works.

The concept of weaning: definitions and their implications

"Weaning" is usually said to refer to the entire process during which the infant changes from full dependence on breast milk to complete independence from it. However, "wean" is sometimes used to refer to provision of an "educational diet" during the first six months when exclusive breastfeeding is the ideal; to complementary feeding; to replacement of breastmilk; or to the cessation of breastfeeding. The processes involved are illustrated by a graph that theoretically compares the infant's nutritional needs with the proportion of those needs that can come from breastmilk under ideal circumstances. The development of consistent, relevant research, policies and programs on young child feeding may be particularly hindered by the failure to discriminate between complementation and replacement.

Rethinking current recommendations to introduce solid food between four and six months to exclusively breastfeeding infants

The World Health Organization and UNICEF currently recommend to start weaning between four and six months and no later than six months with the gradual introduction of solid food. However, some studies show that voluntary exclusive breastfeeding for about nine months is feasible and can sustain adequate weight gain and iron status in infants. It is therefore appropriate to review and evaluate the evidence presently used to set feeding policy. It appears that the alleged insufficiency of breast milk volume after four to six months is most likely due to management errors such as introducing supplements and spacing nursing bouts at wide intervals, both of which reduce milk yield. Women in developed countries who wish to breastfeed exclusively beyond four to six months should therefore not be discouraged from doing so. In developing countries, health authorities and non-governmental organisations should actively endorse exclusive breastfeeding for eight to nine months to protect infants against malnutrition and infections.

Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomised intervention study in Honduras

In developing countries, the age at which breastfed infants are first given complementary foods is of public health importance because of the risk of diarrhoeal disease from contaminated weaning foods, and the potential risk of growth faltering if foods are inappropriately delayed. To evaluate whether there are any advantage of complementary feeding prior to 6 months, low-income primiparous mothers who had exclusively breastfed for 4 months were randomly assigned to one of 3 groups: continued exclusive breastfeeding to 6 months (EBF) (n = 50); introduction of complementary foods at 4 months with ad libitum nursing from 4-6 months (SF) (n = 47); and introduction of complementary foods at 4 months, with maintenance of baseline nursing frequency from 4-6 months (SF-M) (n = 44). Baby foods in jars were provided to the SF and SF-M groups from 4 to 6 months. Subjects were visited weekly and provided with lactation guidance; at 4, 5, and 6 months measurements were made of infant intake and breast milk composition. At 4 months, breast milk intake averaged 797 (139) g per day (no difference among groups). Between 4 and 6 months, breast milk intake was unchanged in EBF infants (+6) but decreased in the SF (-103), and SF-M (-62) groups (p < 0.001). Change in total energy intake (including solid foods) and infant weight and length gain did not differ significantly between groups. Weight and length gain from 4-6 months were comparable to those of breastfed infants in an affluent USA population. The results indicate that breastfed infants self-regulate their total energy intake when other foods are introduced. As a result, there is no advantage in introducing complementary foods before 6 months in this population, whereas there may be disadvantages if there is increased exposure to contaminated weaning foods.

Additional water is not needed for healthy breast-fed babies in a hot climate

In Lahore, Pakistan, a community-based study was conducted to investigate whether or not it was necessary to give water to breast-fed infants. From May to November 1986, 2-4-month-old, breast-fed infants (n = 26) were selected. During the study period the maximum temperature ranged between 27.4 and 40.7 degrees C and humidity varied between 24 and 77%. Each infant was followed up for 15 days. Water was not allowed from day 1 to day 8 and water was allowed ad libitum from day 8 to day 15. All infants were subjected to a DDAVP test to estimate the renal concentrating capacity on day 15. A significant gain in weight (p < 0.001) was observed between day 1 to 8 and 8 to 15. The differences in the values of haematocrit and serum sodium between day 8 and 1 and between day 15 and 8 were not significant. This indicates that the infants were not dehydrated when water was withheld. Furthermore, no significant difference was observed for urine specific gravity between day 8 and 1, but urine specific gravity increased significantly after the administration of DDAVP (p < 0.001), indicating that, if needed, the infants could concentrate urine when water was restricted. It was concluded that 2-4-month-old, breast-fed, healthy infants showed no signs of dehydration if additional water was not given during the summer season.

Early child health in Lahore, Pakistan: V. Feeding patterns

The feeding practices of children (n = 1476) from birth to 24 months, as determined in a longitudinal study, in Lahore, Pakistan, are presented. Four socioeconomic groups at various levels of urbanization were included; a village, periurban slum, urban slum and an upper middle class. Initiation of breastfeeding was delayed in all the neonates. Sixty-five percent of the periurban slum mothers and 45% of the village mothers had not started breastfeeding at 48 hours after the birth of the infant. Prelacteal feedings, especially of herb water and honey, were the norm. Breastfeeding was highly prevalent. Eighty-seven to 98% of the infants in all the areas were breastfed at one month of age. Exclusive breastfeeding was rare, with 9% at one month, declining rapidly with age and being highly influenced by season. Partial breastfeeding was the most common mode of feeding. Water in addition to human milk was given by 45-73% of the mothers living in the urban slum, village and periurban slum at one month of age. Fresh animal milk and/or commercial formula was already being given at 1 month by 22-64% of the mothers in all areas. Commercial formula was the preferred food in the upper middle class, while in the other three areas it was rare and fresh animal milk was mainly used. More than 50% of the mothers in the village and in the periurban slum gave diluted animal milk even beyond the age of 10-15 months. In the upper middle class 50% of the infants were fed semisolids at the age of four months, while in the village, the periurban and the urban slum at 6 months of age only 10%, 12% and 47% of the infants received semisolids. The results of this study indicate that breastfeeding was highly prevalent in the three poorest areas. However, in all the areas initiation of breastfeeding was delayed and prelacteal feeding was the norm. Exclusive breastfeeding was rare, feeding bottles were used by 82-100% of the mothers to feed supplements and human milk substitutes, in the four areas.