Marketing of commercial milk formula: a system to capture parents, communities, science, and policy

Associations between breastfeeding duration and adherence to complementary feeding recommendations in Scotland

We aimed to describe how breastfeeding relates to adherence to complementary feeding (CF) recommendations, diet diversification and feeding skills development and whether sociodemographic factors explain any differences observed. The Scottish Maternal Infant and Nutrition Survey for infants aged 8-12 months collected breastfeeding history, CF practices, diet and sociodemographic data using a self-completion questionnaire. Non-healthful CF practices were starting CF < 6 months, any consumption of sugar-sweetened beverages (SSBs), sweet or salty snacks (treats) or unmodified cow's milk and regular consumption of commercial baby foods. Diet diversification and feeding skills were assessed by amount of self-feeding and number of food groups, meals and snacks eaten daily. Of the 2730 mothers, 20% were solely infant formula fed (IFF) and 48% continued breastfeeding ≥6 months. Compared to IFF babies, mothers who gave any breast milk ≥6 months were more likely to start CF ≥ 6 months compared to those IFF (66% vs. 37%) and less likely to give treats (15% vs. 45%), SSBs (11% vs. 20%) and commercial baby foods (31% vs. 53%). These associations remained highly significant (p < 0.001) even after sociodemographic factor adjustment. Despite starting CF later, infants breastfed ≥6 months ate the same number of food groups and meals as those IFF, were just as likely to self-feed purees and more likely to self-feed finger foods daily (87% vs. 81% p < 0.001). Mothers who breastfeed beyond 6 months adhere more to CF recommendations and start CF later compared to IFF, but their babies eat a similarly diverse diet and have similar feeding skills.

Use of baby food products during the complementary feeding period: What factors drive parents' choice of products?

It is recommended that infants are introduced to complementary foods from 6 months old, moving from a solely milk diet to eating a family diet by 12 months old. Although home cooking of family foods is recommended, a rapidly growing market producing baby food products (BFP) such as jars, pouches and snacks has developed. These are often accompanied by marketing claims around nutritional, health and developmental impacts despite research highlighting high sugar content. Although numerous studies have explored drivers of infant formula choice and use, little research has examined the drivers of BFP use. This study used an online survey for United Kingdom parents of infants aged 4-12 months to explore use of BFP alongside perceptions and drivers to purchase products. Overall, 271 parents participated (173 used BFP and 98 did not), with a descriptive analysis of closed items and a thematic analysis for open ended text conducted. The top motivators for using BFP were convenience, time saving, and baby's perceived enjoyment of products. The most purchased puree was fruit based and the most purchased baby snacks were vegetable puffs/sticks, with snack purchases being more common than purees in this sample. Aspects such as perceived healthiness drove choice, with snack foods being seen to enhance self-feeding skills, appetite regulation and motor development. Those who did not use BFP did not trust them and preferred to feed their baby home cooked foods. The findings are important for professionals working with parents, to support them through the transition to solid foods, particularly around raising awareness of marketing techniques and how to check content of foods to make a more informed choice.

Conceptualizing the Commercialization of Human Milk: A Concept Analysis

BACKGROUND

Donor human milk is recommended when infants are unable to be fed their mother's own milk or require supplementation. For-profit companies use technologies to create human milk products for infants in the neonatal intensive care setting without consistent guidelines and regulatory frameworks in place. This commercialization of human milk is inadequately conceptualized and ill-defined.

RESEARCH AIMS

The aim of this study is to conceptualize and define the commercialization of human milk and discuss the need for policy guidelines and regulations.

METHOD

Using a concept analysis framework, we reviewed the literature on the commercialization of human milk, analyzed the antecedents and potential consequences of the industry, and developed a conceptual definition. The literature review resulted in 13 relevant articles.

RESULTS

There has been a surge in the development and availability of human milk products for vulnerable infants developed by for-profit companies. Commercialized human milk can be defined as the packaging and sale of human milk and human milk components for financial gain. Factors contributing to the commercialization of human milk include an increased demand for human milk, and consequences include potential undermining of breastfeeding. The lack of guidelines and regulations raises concerns of equity, ethics, and safety.

CONCLUSION

The industry is rapidly growing, resulting in an urgent need for consistent guidelines and regulatory frameworks. If left unaddressed, there could be potential risks for donor milk banking, the future of breastfeeding, and infant and maternal health.

The role of antibiotic exposure and the effects of breastmilk and human milk feeding on the developing infant gut microbiome

The World Health Organization (WHO) recommends exclusive breastfeeding for the first 6 months of life followed by complementary foods and sustained breastfeeding for at least 2 years, underscoring its pivotal role in reducing infant mortality and preventing various illnesses. This perspective delves into the intricate relationship between breastfeeding practices, early life antibiotic exposure, and infant gut microbiome development, highlighting their profound influence on child health outcomes. Antibiotics are extensively prescribed during pregnancy and childhood, disrupting the microbiome, and are related to increased risks of allergies, obesity, and neurodevelopmental disorders. Breastfeeding is a significant determinant of a healthier gut microbiome, characterized by higher levels of beneficial bacteria such as Bifidobacterium and lower levels of potential pathogens. Despite widespread recognition of the benefits of breastfeeding, gaps persist in healthcare practices and support mechanisms, exacerbating challenges faced by breastfeeding families. This highlights the pressing need for comprehensive research encompassing breastfeeding behaviors, human milk intake, and their impact on infant health outcomes. Additionally, promoting awareness among healthcare providers and families regarding the detrimental effects of unnecessary formula supplementation could facilitate informed decision-making and bolster exclusive breastfeeding rates. Moreover, donor human milk (DHM) is a promising alternative to formula, potentially mitigating disruptions to the infant gut microbiome after antibiotic exposure. Overall, prioritizing breastfeeding support interventions and bridging research gaps are essential steps towards improving child health outcomes on a global scale.

Maternal employment characteristics as a structural social determinant of breastfeeding after return to work in the European Region: a scoping review

BACKGROUND

The European Region has the lowest rate of exclusive breastfeeding at 6 months worldwide. Improving work-related breastfeeding issues is important given that women may have difficulties combining work and breastfeeding, especially those in precarious working situations, which adds to their adversity. This scoping review overviews research on the maternal employment characteristics that support breastfeeding continuation after return to work in the European Region.

METHODS

Studies published from 2013 to 2023 were collected from Scopus, PubMed, and PsycInfo. Quantitative and qualitative studies published in English or French that explored the association between maternal employment characteristics and any breastfeeding status, duration, or experience were included. Participants included were mothers of healthy children who continued breastfeeding after resuming work. The main determinants were work-related factors that can lead to socially differentiated working conditions, including type of employment (e.g., occupation, employed/self-employed status, type of contract, working time, occupational prestige), working conditions (e.g., work schedule, decision latitude, latitude to organize worktime), and work environment (e.g., occupational exposure, family-friendly workplace policy, social support). The geographic area encompassed countries included in the World Health Organization European Region.

RESULTS

Of the 693 single studies retrieved and screened, 13 were included in the review. Eight studies focused on combining work and breastfeeding, while the others had a broader spectrum by investigating breastfeeding determinants. The represented countries were Spain (n = 4), France (n = 4), UK (n = 2), Ireland (n = 2), and the Netherlands (n = 1). Results highlighted the heterogeneity of measures, time frames, and fields of inquiry, thus revealing a lack of conceptual framework regarding the links between work, breastfeeding, and social health inequalities. Nonetheless, being self-employed, working in a non-manual profession with time flexibility, having lactation rooms at work, being supported by co-workers, and having a breastfeeding workplace policy were salient factors that supported breastfeeding in working mothers.

CONCLUSIONS

Supporting working mothers who choose to breastfeed is important given the myriad of adverse factors faced by mothers and their children. These results advocate for targeted actions at the workplace such as time flexibility, breastfeeding facilities, and the promotion of breastfeeding-friendly policies.

Cross-sectional examination of commercial milk formula industry funding of international, regional and national healthcare professional associations: protocol

INTRODUCTION

Commercial milk formula manufacturers often emphasise their role in supporting infant and young child nutrition and breastfeeding, but their commercial goals to increase volume and profit margin of formula sales conflict with these declarations. Healthcare professional associations have an important role in healthcare worker education, shaping clinical practice. When healthcare professional associations enter into financial relationships with formula manufacturers, conflicts of interest arise, which may undermine education and practice that promotes optimal infant and young child feeding. The World Health Assembly calls on all parties to avoid such conflicts of interest, but it is uncertain how often this recommendation is followed. This protocol documents a systematic method to identify funding from the commercial milk formula industry among international, regional and national associations of healthcare professionals.

METHODS AND ANALYSIS

Using systematic search strategies in the Gale Directory Library and Google, we will identify international healthcare professional associations relevant to maternal and child health. Data regarding funding relationships with the commercial milk formula industry over the past 24 months will be extracted from the official websites or, in their absence, social media accounts by two independent analysts. The analysis will focus on the presence of conflict of interest or sponsorship policies and type of funding, such as sponsorship or payment for services.

ETHICS AND DISSEMINATION

This study does not require ethical approval and will use data available in the public domain. The results will be disseminated through peer-reviewed journal articles, at conferences and among the healthcare professional associations.

Assessment of Heavy Metals and Trace Elements in the Human Milk of Women Living in Latvia and an Evaluation of Influencing Factors

During lactation, heavy metals and trace elements can be mobilised from the maternal body stores and excreted via human milk. A total of 66 mature human milk samples were collected from lactating women in Latvia between 2016 and 2017 to analyse the content of As, Cd, Pb, Al, Sn, and Ni. Additionally, 50 mature human milk samples were collected between 2022 and 2023 to analyse the content of Cd and Pb. The content of heavy metals and trace elements in human milk was determined using ICP-MS. Only two individual human milk samples contained heavy metals above the method's detection limit-one with an arsenic content of 0.009 mg kg-1 and one with a lead content of 0.047 mg kg-1. The preliminary data show that human milk among lactating women in Latvia contains only insignificant amounts of heavy metals and trace elements. Concern over such content should not be a reason to choose formula feeding over breastfeeding. Nevertheless, heavy metals, trace elements and other pollutants in human milk should be continuously monitored.

Assessing conflict of interest reporting and quality of clinical trials on infant formula: a systematic review

OBJECTIVES

This study aims to assess the quality, risk of bias, and conflicts of interest (COIs) of clinical trials conducted on the effects of fortified infant formula.

STUDY DESIGN AND SETTTING

Systematic review including all randomized clinical trials targeting healthy children and using three arms: fortified infant formula; standard formula; and breastfeeding. We performed a descriptive analysis of the studies reviewed, assessed their quality using the "Risk of Bias 2- RoB 2" tool, and identified COIs.

RESULTS

A total of 40 studies were included. All showed a high overall risk of bias, with this being especially noteworthy in the "deviations from intention to treat" and "missing outcome data" domains. Of the total included studies, 29 reported conclusions in favor of the fortified formula; 15 studies reported multiple conclusions that were either contradictory or not in line with the results. COIs with industry were identified in 33 studies, and in 17 studies, these conflicts were not declared in the appropriate section.

CONCLUSION

From a methodological perspective, studies on fortified infant formula display low quality, made evident by the high risk of bias. Additionally, there are frequent COIs. These aspects must be considered by health professionals and the population when drawing up recommendations for the use of this product.

Decolonising global health research: Shifting power for transformative change

Recent debates on decolonizing global health have spurred interest in addressing the power asymmetries and knowledge hierarchies that sustain colonial ideas and relationships in global health research. This paper applies three intersecting dimensions of colonialism (colonialism within global health; colonisation of global health; and colonialism through global health) to develop a broader and more structural understanding of the policies and actions needed to decolonise global health research. It argues that existing guidelines and checklists designed to make global health research more equitable do not adequately address the underlying power asymmetries and biases that prevail across the global health research ecosystem. Beyond encouraging fairer partnerships within individual research projects, this paper calls for more emphasis on shifting the balance of decision-making power, redistributing resources, and holding research funders and other power-holders accountable to the places and peoples involved in and impacted by global health research.

[Digital marketing of commercial infant formula in Argentina: a digital ethnographic study]

Although evidence of the benefits of breastfeeding is widespread, there are several challenges to initiate and sustain it. Infant formula companies use marketing strategies that violate existing regulations, contributing to its early abandonment. We explore the digital marketing exposure of infant formulas in Argentina by analyzing people's interactions with brands and the traces of these interactions in conversations engaged in Facebook groups during 2022, from a qualitative approach based on digital ethnography. Results show that companies deploy regulatory avoidance tactics and seek contact with mothers. Users do not interact with the accounts but are exposed to their strategies given the correlation between product attributes present in advertising with their motivations and aspirations. The mediators between marketing and mothers are medical professionals, used as marketing resources. We conclude that authorities should promote new agreements on the practices of medical professionals and develop regulations taking into account digital environments.

An evaluation of patient comfort levels during expression with a modified pumping program: a prospective proof of concept study

Introduction

This study aimed to assess if the implementation of a gentle transition of vacuum mode into a breast pump suction pattern commonly used to initiate milk production would improve user comfort while expressing during the first four days postpartum.

Methods

This prospective study was conducted at OLVG hospital in the Netherlands in two sequential phases. Breastfeeding patients delivering >36 weeks gestation with an infant aged ≤96 h old and a clinical indication to express milk with a breast pump were recruited. Intervention group 1 (n = 40) used a hospital-grade electric breast pump with a standard breast pump suction pattern. Intervention group 2 used a hospital-grade electric breast pump with a modified breast pump suction pattern (n = 40). The primary outcome was an objective assessment of comfort as measured by participants' need to reduce vacuum level during the 20 min test session. Secondary outcomes included the total expression volume (ml) in 20 min pumping.

Results

The study found that the primary outcome of comfort was significantly improved with the modified breast pump suction pattern compared to the standard pattern (OR 1.29, 95% CI 1.08 to 1.6) with 86% vs. 67% of participants not needing to reduce applied vacuum levels. The amount of milk expressed did not differ significantly between phases (group 1: 7.6 ml (2.7-25.5 ml), group 2: 12.0 ml (1.2-31.5 ml), p = 0.43).

Discussion

This study is the first to demonstrate an improvement in user comfort driven by the implementation of gentle transitions in vacuum modes in a commonly used breast pump suction pattern. Research into this novel population combining both pumping and breastfeeding in the first days after birth offers new unique insights on the requirements of breast pump suction patterns.

Trial registration

Registered on clinical trials.gov NCT04619212. Date of registration November 6, 2020.

Does planning to mixed feed undermine breastfeeding?

Continued breastfeeding is important for infants' health, but it is unclear whether mixed feeding increases the risk of breastfeeding cessation. We aimed to explore associations of mixed feeding and lactation problems with early cessation of breastfeeding. We analysed data from mothers who completed the Scottish National Maternal and Infant Feeding Survey and had previously breastfed their infants. At age 8-12 weeks, mothers (N = 1974) reported their feeding history and intentions, lactation problems and reasons for giving formula milk. The main outcome measure was cessation of breastfeeding before 6-8 weeks and time to cessation. By 6 weeks, 65% had mixed fed at some point, 32% had ceased breastfeeding, 22% were currently mixed feeding and 46% were exclusively breastfeeding. Lactation problems before 2 weeks were common (65%), and strongly associated with stopping breastfeeding (relative risk [RR]: 3.23, 95% confidence interval [CI]: 2.0-5.3) and with mixed feeding (RR: 3.14, 95% CI: 2.5-4.0). However, even after adjustment for breastfeeding problems mothers who planned to mixed feed (RR: 3.39, 95% CI: 2.4-4.9) and those who introduced formula for practicalities (RR: 3.21, 95% CI: 2.3-4.4) were more likely to stop breastfeeding. These variables also predicted later lactation insufficiency (planned mixed feeding RR: 1.39, 95% CI: 1.0-2.0; formula for practicalities RR: 1.76, 95% CI: 1.3-2.3). Mothers who received specialist lactation support were less likely to cease breastfeeding (RR: 0.63, 95% CI: 0.5-0.9) but nonspecialist input was unrelated to risk of cessation (RR: 1.06, 95% CI: 0.2-4.9). In conclusion, choosing to mix feed an infant is strongly associated with stopping breastfeeding, even in the absence of lactation problems.

What makes a city 'breastfeeding-friendly'? A scoping review of indicators of a breastfeeding-friendly city

A breastfeeding-friendly city is one where there is an enabling environment to support breastfeeding throughout the first 2 years or more of a child's life. Indicators of a breastfeeding-friendly city have yet to be identified. What are the indicators or criteria used to define breastfeeding friendliness in a geographic area such as a city and the settings within, which we have classified as community, healthcare and workplace? Three major databases and grey literature were searched. Records were screened to identify publications describing criteria such as indicators or descriptions of a breastfeeding-friendly setting, defined as 'criteria-sets'. These criteria-sets were then categorized and summarized by settings. The search up to 2 September 2021 found 119 criteria-sets from a range of settings: geographic locations (n = 33), community entities (n = 24), healthcare facilities (n = 28), workplaces (n = 28) and others (n = 6). Overall, 15 community, 22 healthcare and 9 workplace related criteria were extracted from the criteria-sets. Criteria that were consistently present in all settings were policy, training & education, skilled breastfeeding support and physical infrastructure. Some criteria-sets of geographic locations contained criteria only from a single setting (e.g., the presence of breastfeeding-friendly cafes). Criteria-sets were present for all settings as defined in this review, but few were actual indicators. Specifically, there were no existing indicators of a breastfeeding-friendly city. Several common components of the criteria-sets were identified, and these could be used in developing indicators of a breastfeeding-friendly city. Future studies should determine which of these are important and how each can be measured.

'Either something's wrong, or I'm a terrible parent': A systematic review of parent experiences of illness-related interpretations for unsettled babies

AIMS

To explore parents' experiences of unsettled babies and medical labels.

DESIGN

Qualitative systematic review, thematic synthesis and development of a conceptual model.

REVIEW METHODS

Systematic review and thematic synthesis of primary, qualitative research into parents' experiences of unsettled babies <12 months of age. 'Unsettled' was defined as perception of excessive crying with additional feature(s) such as vomiting, skin or stool problems. The Critical Appraisal Skills Programme (CASP) checklist was used to assess trustworthiness.

DATA SOURCES

Structured searches completed in CINAHL, Medline, Embase, PsychINFO and CochraneCT on 23 March 2022 and rerun on 14 April 2023.

RESULTS

Ten eligible studies were included across eight countries contributing data from 103 mothers and 24 fathers. Two analytical themes and eight descriptive themes were developed. Firstly, parents expressed fearing judgement, feeling guilty and out of control as a result of babies' unsettled symptoms and seeking strategies to construct an 'Identity as a "Good Parent"'. This desire for positive parenting identity underpinned the second analytical theme 'Searching for an explanation' which included seeking external (medical) causes for babies' unsettled behaviours.

CONCLUSION

Parents can become trapped in a cycle of 'searching for an explanation' for their baby's unsettled behaviours, experiencing considerable distress which is exacerbated by feelings of guilt and failure.

IMPACT AND IMPLICATIONS FOR PATIENT CARE

Insight gained from this review could inform interventions to support parents, reducing inaccurate medicalization. Health visiting teams supporting parents with unsettled baby behaviour could focus on supporting a positive parenting identity by managing expectations, normalizing the continuum of infant behaviours, reducing feelings of guilt or uncertainty and helping parents regain a feeling of control.

REPORTING METHOD

ENTREQ guidelines were adhered to in the reporting of this review.

PATIENT OR PUBLIC CONTRIBUTION

Parent input was crucial in the design phase; shaping the language used (e.g., 'unsettled babies') and in the analysis sense-checking findings.

Factors associated with informal human milk sharing among donors and recipients: A mixed-methods systematic review

BACKGROUND

The multiple benefits associated with the provision of human milk exceed individual health outcomes, engendering substantial economic, societal and environmental domains. Human milk is the absolute, unparalleled source of nutrition for infants. Informal human milk sharing is a modernistic and rapidly progressing practice. No systematic review of the factors associated with this contemporary practice among donors and recipients of informal human milk sharing exists.

AIM

The aim of this review was to identify, evaluate, synthesize and integrate the evidence on the factors associated with informal human milk sharing among donors and recipients.

METHODS

A mixed methods systematic review was conducted according to the Joanna Briggs Institute methodological guidance utilizing a convergent integrated approach. The following databases were systematically searched: CINAHL, Scopus, Medline and Embase and Web of Science between inception to August 2023. A grey literature search was conducted using multiple techniques. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Twenty-four studies were included in this review. Ten integrated findings relating to the factors associated with informal human milk sharing among donors and recipients were identified. The four integrated findings pertaining to donors included: altruistic motivation and value, resistance to commercialization and overcoming inaccessibility, uniting digital and personal connectedness and lack of awareness and acceptance of informal human milk sharing in healthcare settings. The six integrated findings relating to recipients included: maternal or infant factors, superiority and advantageous impact of breastmilk, human milk bank influences, digital connections and transparency, healthcare professional facilitation of informal human milk sharing, and professional and logistical implications.

CONCLUSION

This review highlighted a multitude of factors that motivate, facilitate and impede the practice of informal human milk sharing. Future research is required to explore these factors further within broader geographical locations to enhance the generalizability and rigor of the body of knowledge. Further studies should consider the exploration of the experiences and psychological impact of informal human milk sharing on donors and recipients. The provision of human milk to all infants is an imperative public health endeavor and thus positioning this as a key benchmark for research and practice is crucial.

Marketing and child feeding

OBJECTIVE

To carry out a narrative review on the use of marketing strategies in child nutrition, as well as potential implications for health professionals and children.

DATA SOURCE

Searches were carried out on the PubMed, SciELO, and Google platforms, using the terms "child nutrition" or "industrialized baby food" or "infant formula" or "breast milk" or "breastfeeding" and "marketing", with original articles, review articles, institutional reports, institutional position documents and websites considered relevant to the topic being analyzed.

DATA SYNTHESIS

Children's food marketing started with the industrialization of food and the resulting actions aimed at increasing sales and meeting commercial interests. Since its inception to the present, infant formulas have been the most widely used products, which has impacted breastfeeding practices. International and national institutions, that care for children's health, are searching for strategies to limit the abusive marketing of industrialized children's foods. Marketing strategies interfere with medical knowledge and actions, potentially influencing the guidance provided by pediatricians to families, and finally, compromising healthy eating practices at a critical period in life, with possible long-term effects.

CONCLUSIONS

Health professionals, especially pediatricians, must provide the best care for children and families, and need to maintain the search for quality scientific information, not influenced by conflicts of interest. Updated and critical knowledge on the part of healthcare professionals can curb marketing strategies that aim to influence their actions.

The WHO Foundation in global health governance: Depoliticizing corporate philanthropy

The creation of the WHO Foundation during the COVID-19 pandemic represents a significant institutional development in the politics of financing the World Health Organization (WHO). In the context of longstanding acute financial pressures, the objective of the WHO Foundation is to widen WHO's resource base by attracting philanthropic donations from the commercial sector. In placing funding decisions 'at one remove' from WHO, the stated expectation is that the WHO Foundation will act as an intermediary, insulating the WHO from potential conflicts of interest and reputational risk through a combination of strategic distance from WHO and proximity with its norms and rules of engagement with non-state actors. Yet, whether this model has translated into practice remains understudied. In this article, we focus on emerging institutional practices within the WHO Foundation, highlighting a drift from its stated governance model. Based on analysis of WHO Foundation documents, we demonstrate how due diligence and transparency practices within the Foundation have been redesigned in ways that contradict or subvert its claims to applying alignment with WHO's governance norms, notably relating to its engagement with health harming industries such as alcohol and petrochemical companies. While this situation may seem paradoxical, we argue that, in placing funding decisions 'at one remove' from the formal institutions and structures of WHO, the creation of the Foundation has served to displace this issue to a more secluded arena where drifts in practice are less exposed to political oversight and scrutiny. Focusing on the discursive aspects of this process of depoliticisation, we contend that the Foundation has strategically managed 'fictional expectations' of accountable and transparent governance in order to mitigate concerns about its mandate and functions. This assessment provides new and important insights into the depoliticizing functions of the WHO Foundation and the significant implications this may have for global health governance.

A Qualitative Study of Breastfeeding Experiences Among Mothers Who Used Galactagogues to Increase Their Milk Supply

OBJECTIVE

To qualitatively describe breastfeeding experiences among mothers who used galactagogues to increase their milk supply.

DESIGN

One-time, semistructured phone interviews.

SETTING

US.

PARTICIPANTS

Breastfeeding mothers (n = 19) who reported ever consuming foods, beverages, or herbal supplements to increase their milk supply in a cross-sectional online survey were purposefully sampled to participate in this qualitative study. Participants were diverse in terms of race and ethnicity, education, income, infant age (0-18 months), and prior breastfeeding experience (32% first-time breastfeeding).

PHENOMENON OF INTEREST

Reasons for trying to increase milk supply, sources of information about increasing milk supply, and strategies tried to increase milk supply.

ANALYSIS

Interviews were transcribed verbatim and analyzed using reflexive thematic analysis.

RESULTS

Participants expressed determination and commitment to breastfeeding but unexpectedly struggled to breastfeed and increase their milk supply. They sought information from multiple sources and used individualized approaches to address milk supply concerns on the basis of recommendations from others, as well as the perceived convenience, cost, palatability, and safety of potential strategies.

CONCLUSIONS AND IMPLICATIONS

Results suggest a need to expand breastfeeding education and support so that lactating parents anticipate common breastfeeding challenges and are aware of evidence-based strategies for increasing their milk supply.

Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry in Brazil

BACKGROUND

The exploitative marketing of commercial milk formula (CMF) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the International Code of Marketing of Breast-Milk Substitutes (The Code) was adopted by WHO member states, many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, worldwide CMF markets have markedly expanded. In this paper, we adopt Brazil as a case study to understand the power of the baby food industry's marketing and corporate political activity, and how this influences the country's 'first-food system' in ways that promote and sustain CMF consumption.

METHODS

We used a case study design, drawing data from from documents and key informant interviews (N = 10).

RESULTS

Breastfeeding rates plummeted in Brazil to a historic low in the 1970s. A resurgence in breastfeeding from the mid-1980s onwards reflected strengthening political commitment for a national policy framework and breastfeeding protection law, resulting in-turn, from collective actions by breastfeeding coalitions, advocates, and mothers. Yet more recently, improvements in breastfeeding have plateaued in Brazil, while the industry grew CMF sales in Brazil by 750% between 2006 and 20. As regulations tightened, the industry has more aggressively promoted CMF for older infants and young children, as well as specialised formulas. The baby food industry is empowered through association with powerful industry groups, and employs lobbyists with good access to policymakers. The industry has captured the pediatric profession in Brazil through its long-standing association with the Brazilian Society of Pediatrics.

CONCLUSION

Brazil illustrates how the baby food industry uses marketing and political activity to promote and sustain CMF markets, to the detriment of breastfeeding. Our results demonstrate that this industry requires much greater scrutiny by regulators.

Determinants of health care worker breastfeeding experience and practices and their association with provision of care for breastfeeding mothers: a mixed-methods study from Northern Thailand

BACKGROUND

Improving breastfeeding rates is one of the most cost-effective ways to prevent infant deaths, but most of the world falls far below WHO recommended breastfeeding practices. Confident, informed healthcare workers are an important resource to promote breastfeeding, but healthcare workers are at risk of early breastfeeding cessation themselves. Culture, ethnicity and socio-economic status impact breastfeeding rates with some of the highest and lowest rates in Southeast Asia reported from Thailand. This study explores the relationship between workplace determinants of breastfeeding, personal breastfeeding outcomes for healthcare workers, and the breastfeeding care healthcare workers provide their patients.

METHODS

This study used a sequential exploratory design guided by a conceptual framework based on social ecological/ecological psychology models. Participants came from four clinical sites in Northern Thailand, from ethnically Burman or Karen communities with high breastfeeding rates, and Thai communities with low breastfeeding rates. In-depth interviews (July 2020-November 2020) were followed by a quantitative survey (November 2020-July 2021) derived from validated questionnaires (Australian Breastfeeding Knowledge and Attitudes Questionnaire and the Workplace Breastfeeding Support Scale) with minor local adaptations.

RESULTS

Interviews highlighted the beneficial effects of supportive workplace policies, the importance of physical spaces to facilitate proximity between mothers and infants, and the problem of low milk production. Meeting the WHO recommended practices of exclusive breastfeeding to 6 months or total breastfeeding to 2 years or more was more common in sites with higher levels of breastfeeding support (aOR 7.3, 95%CI 1.8, 29.1 for exclusive breastfeeding). Exclusive breastfeeding was also higher when staff set breastfeeding goals (aOR 4.4, 95%CI 1.7, 11.5). Staff who were able to see their infants during the work day were less likely to terminate breastfeeding because of work (aOR 0.3, 95%CI 0.1, 0.8). Staff who met both WHO recommendations themselves were more likely to report high levels of confidence caring for breastfeeding patients (aOR 2.6, 95%CI 1.1, 6.4).

CONCLUSIONS

Workplace protections including supportive maternity leave policies and child-friendly spaces can improve breastfeeding outcomes for healthcare workers. These improved outcomes are then passed on to patients who benefit from healthcare workers who are more confident and attentive to breastfeeding problems.

Promoting breastfeeding in women with gestational diabetes mellitus in high-income settings: an integrative review

BACKGROUND

Breastfeeding provides many short- and long-term health benefits for mothers and their infants and is a particularly relevant strategy for women who experience Gestational Diabetes Mellitus (GDM) during pregnancy. However, breastfeeding rates are generally lower amongst this group of women than the general population. This review's objective is to identify the factors that influence breastfeeding by exploring the experiences and outcomes of women in in high-income health care contexts when there is a history of GDM in the corresponding pregnancy.

METHODS

A comprehensive search strategy explored the electronic databases Medline, CINAHL, Web of Science and Scopus for primary studies exploring breastfeeding practices for papers published between January 2011 and June 2023. All papers were screened independently by two researchers with included papers assessed using the Crowe Critical Appraisal tool. Findings were analysed using a narrative synthesis framework.

RESULTS

From an initial search result of 1037 papers, 16 papers representing five high-income nations were included in this review for analysis - the United States of America (n = 10), Australia (n = 3), Finland (n = 1), Norway (n = 1), and Israel (n = 1). Fifteen papers used a quantitative design, and one used a qualitative design. The total number of participants represented in the papers is 963,718 of which 812,052 had GDM and 151,666 did not. Women with an immediate history of GDM were as likely to initiate breastfeeding as those without it. However, they were more likely to have the first feed delayed, be offered supplementation, experience delayed lactogenesis II and or a perception of low supply. Women were less likely to exclusively breastfeed and more likely to completely wean earlier than the general population. Maternity care practices, maternal factors, family influences, and determinants of health were contextual and acted as either a facilitator or barrier for this group.

CONCLUSION

Breastfeeding education and support need to be tailored to recognise the individual needs and challenges of women with a history of GDM. Interventions, including the introduction of commercial milk formula (CMF) may have an even greater impact and needs to be very carefully considered. Supportive strategies should encompass the immediate and extended family who are major sources of influence.

Commercial milk formula marketing following increased restrictions in Singapore: A qualitative study

The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0-12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross-promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest.

"It felt like I had an old fashioned telephone ringing in my breasts": An online survey of UK Autistic birthing parents' experiences of infant feeding

Around 3% of people are Autistic. Autistic people communicate differently from non-Autistic people and experience the sensory world differently. There is limited evidence that Autistic people can face additional barriers to breastfeeding. We are an Autistic-led research team that developed an online survey following consultation with the Autistic community. Autistic people from the UK who had been pregnant were eligible to take part in the survey, which focused on the entire maternity journey. A total of 193 people participated, of whom 152 had experiences of infant feeding (137 breastfeeding, 82 formula feeding). Participants were highly motivated to breastfeed, and almost half of those who breastfed found it positive always or most of the time. However, breastfeeding-and in particular the milk let-down reflex-could result in pain and sensory difficulties, including 'feeling odd'. Expressing breastmilk always or most of the time was reported by 10% of breastfeeding participants. The intensity and unpredictability of both breast and formula feeding were challenging to manage. Parents reported that it was easy to understand how to prepare infant formula, but that it could also be a negative and anxiety-inducing experience. Support for breast and formula feeding was often considered inadequate. When parents did access breastfeeding support, this significantly improved a range of breastfeeding experiences. However, participants recommended more tailored support and continuity of carer. To meet the needs of Autistic birthing parents, those providing infant feeding support should receive training on Autism through a neurodiversity-affirming lens, which should be delivered by Autistic people.

Exclusive breastfeeding practices and its determinants in Indian infants: findings from the National Family Health Surveys-4 and 5

BACKGROUND

The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) in infants for the first 6 months of life. This analysis aims to estimate the proportion of Indian infants exclusively breastfed for the first 6 months using the National Family Health Surveys (NFHS)-4 and 5, and further, determine factors associated with EBF practices.

METHODS

EBF for this analysis was defined as when infants received only breast milk and no complementary feeds (solid food, water, animal milk, baby formula, juice, and fortified food) in the last 24 h prior to the survey. The proportion of infants exclusively breastfed was plotted from birth to 6 months as per the age of children at the time of the survey, and this was computed for individual states, union territories, and overall, for India. Univariate and multivariable logistic regression analyses were performed to examine factors influencing EBF in Indian infants.

RESULTS

The proportion of Indian infants exclusively breastfed for 6 months was 31.3% (1280/4095; 95% CI 29.9, 32.7) and 43% (1657/3853; 95% CI 41.4, 44.6) as per the NFHS-4 and 5 surveys, respectively. In NFHS-5, infants of scheduled tribes (aOR 1.5; 95% CI 1.2, 1.9) and mothers who delivered at public health facilities (aOR 1.3; 95% CI 1.1, 1.5) showed an increased odds of being exclusively breastfed at 6 months of life compared to their counterparts. Further, infants of mothers aged < 20 years (aOR 0.5; 95% CI 0.4, 0.7), low birth weight infants (aOR 0.6; 95% CI 0.4, 0.8), and infants in whom breastfeeding was initiated one hour after birth (aOR 0.8; 95% CI 0.7, 0.9) showed a reduced odds of being exclusively breastfed at 6 months compared to their counterparts.

CONCLUSIONS

The overall EBF practice showed an increasing trend in the NFHS-5 compared to the NFHS-4 survey. However, a vast gap remains unaddressed in the Indian setting with > 50% of the population still not exclusively breastfeeding their infants for the WHO recommended duration of first 6 months. Behavioral studies dissecting the complex interplay of factors influencing EBF within the heterogenous Indian population can help plan interventions to promote and scale-up EBF in Indian infants.

A long-acting prolactin to combat lactation insufficiency

Human infants are born to breastfeed. While 50% of lactating persons struggle to make enough milk, there are no governmentally-approved drugs to enhance lactation1. Here, we engineer a variant of the naturally-occurring driver of lactation, the hormone Prolactin, to increase its serum half-life and produce a viable drug candidate. Our engineered variant, Prolactin-eXtra Long-acting (Prolactin-XL), is comprised of endogenously active human prolactin fused to an engineered human IgG Fc domain designed to overcome the unique drug development challenges specific to the lactating person-infant dyad. Our Prolactin-XL has a serum half-life of 70.9h in mice, 2,625-fold longer than endogenously active prolactin alone (70.9h v. 0.027h). We demonstrate that Prolactin-XL increases milk production and restores growth of pups fed by dams with pharmacologically-ablated lactation. We show that Prolactin-XL-enhanced lactation is accompanied by reversible, lactocyte-driven changes in mammary gland morphology. This work establishes long-acting prolactins as a potentially powerful pharmacologic means to combat insufficient lactation.

Barriers and Facilitators for the Donation and Acceptance of Human Breast milk: A Scoping Review

PURPOSE OF REVIEW

Human milk is the best source of nutrients for all infants. When a mother's own milk is unavailable, the World Health Organization suggests using donor human milk for premature neonates with or without medical complications. Exploring the barriers and facilitators for breast milk donation and its acceptability is essential for developing this intervention. A scoping review was conducted based on a methodological framework developed by Arksey and O'Malley (Int J Soc Res Methodol 8:19-32, 2005). A search was conducted in PubMed (NCBI), CINAHL (EBSCO), and Web of Science (Elsevier). A two-stage sequential screening process was adopted. Data extraction was done using a piloted data extraction form.

RECENT FINDINGS

We included 20 articles for narrative synthesis. Barriers and facilitators for donating and accepting breast milk were categorized under six themes: individual, family, community, workplace, health system, and policy-related. The common individual barriers were time requirements for BMD, personal dislike of the process, lack of knowledge, insufficient milk, negative opinions, and lack of information. Family stigma, negative rumors, less educated family members, and illness of a family member were identified as family-related barriers. Community-related barriers include cultural or religious unacceptable practices, societal taboos, and distance to milk banks. The major barriers identified in relation to the health system were lack of practical and psychological support, lack of information, storing and transportation issues, lack of knowledge among HCWs, and logistical challenges of creating a milk lab. The common work-related barriers were the lack of adequate time, philosophical objections, and incomprehension at returning to work. Policy-related barriers identified include the need for hygiene requirements, donation costs, and lack of standardized guidelines. Making the donation process faster, providing pick-up services for donors, and community education and male partner engagement regarding breast milk donation could help to boost the acceptability of breast milk donation.

Perceived influence of commercial milk formula labelling on mothers' feeding choices in Great Britain: a qualitative study

OBJECTIVE

To understand how mothers use commercial milk formula (CMF) labels to inform their feeding choices and explore mothers' understanding of differences between CMF products.

DESIGN

Qualitative study with recruitment via social media. Online semistructured interviews, including a product mapping exercise and thematic analysis.

PARTICIPANTS

Mothers (n=25) using CMF for children <3 years living in Great Britain (GB).

RESULTS

Mothers were drawn to brands they recognised from years of exposure to CMF advertising. CMF products were assumed to vary according to brand and stage, but participants found on-pack information did not explain how. This added to anxiety about choosing 'the best one' and mothers would have liked guidance from healthcare professionals (HCPs). Wide availability of CMF for older infants and children, and on-pack messaging suggesting progression from one product to the next, led many to believe these products were necessary. There was confusion over the appropriate use of specialist products. While mothers rarely mentioned on-pack health and nutrition claims, they were attracted to the overall appearance of packs and messaging relating to science, research and nature. References to breast milk and a logo perceived to represent a breastfeeding mother were taken as indicators of closer similarity to breast milk.

CONCLUSIONS

CMF legislation in GB should be updated to restrict brand advertising and the use of on-pack text and images that mothers perceive as indicating products have a closer similarity to breast milk. Greater input from HCPs was desired by new mothers and would support them to make more informed choices about CMF.

Trends and determinants of early initiation of breastfeeding in Indonesia: A multivariate decomposition analysis

BACKGROUND

Early initiation of breastfeeding (EIBF) is key to reducing neonatal morbidity and mortality, however, little is known about the determinants of the trends of EIBF prevalence in Indonesia. This study aims to assess the contributing factors to the changes in the prevalence of EIBF between 2007 and 2017.

METHODS

We analysed data from the 2007, 2012, and 2017 Indonesia Demographic and Health Surveys to estimate the trends in EIBF. A multivariate logistic decomposition model was fitted to examine variables associated with changes in the percentage of EIBF from 2007 to 2017. The contributing factors to changes in EIBF prevalence were categorized into either compositional or behavioural changes, with each of them divided into portions or percentages of contribution (pct) of the independent variables. The former refers to the changes in the distribution of samples, while the latter refers to the changes in the behavioural responses toward EIBF in both surveys. All analyses accounted for the complex study design and potential confounding factors.

RESULTS

An increase in the prevalence of EIBF from 49.9% to 56.5% was recorded between 2012 and 2017, with an overall increase of 16.9 percentage points from 2007 to 2017. At the aggregate level, the compositional differences did not significantly contribute to the changes in the percentage of EIBF, while 98.3pct (p < 0.001) was associated with changes in mothers' behavioural response towards EIBF. The composition changes in the geographical region of Sumatra, and caesarean delivery negatively contributed to the changes in EIBF prevalence with -0.6pct and -14.2pct, respectively. However, the compositional differences in those living in Kalimantan & Sulawesi, first-time mothers, and small-born infants positively contributed to the change. Behaviour changes in mothers with higher education (8.8pct), from higher income households (-17.5pct), and those residing in Sumatra (-8.2pct) and Kalimantan & Sulawesi (-10.2pct) significantly contributed to the upward trend in EIBF prevalence.

CONCLUSIONS

Almost half of the newborns experienced delayed breastfeeding initiation despite the improvement in the prevalence of EIBF. Therefore, further research and interventions on behaviour change in mother's attitudes towards EIBF, especially among those undergoing caesarean delivery, living in Kalimantan or Sulawesi, and from wealthier households, are recommended to close this gap.

Healthcare professionals and commercial milk formula recommendations in the urban Mexican context

Introduction

Breastfeeding (BF) is considered an essential component of optimal care for child health and development. In the past two decades, global data have shown improvements in some, but not all, BF indicators. Despite these positive changes sales and per capita intake of commercial milk formula (CMF) have increased globally. The CMF industry invests millions of dollars in marketing, which targets families and healthcare professionals (HCP). In Mexico, more than half of the mothers (53%) who feed their infants with CMF chose their Brand on the recommendation of HCP. Understanding the reasons behind the current recommendations for the use of CMF by HCP is important for the design of BF interventions. The primary objective of this study was to explore Mexican HCP' beliefs, attitudes, perceptions, and practices about early infant feeding practices, and reasons for recommending CMF. The secondary objective was to explore pregnant women and mother's perceptions of the infant feeding recommendations they received from HCP, and of the factors that influenced their infant feeding decisions.

Methods

The study was based on a secondary qualitative data analysis of a WHO/UNICEF multi-country study. We analyzed focus group discussions (FGDs) and in-depth interviews (IDIs) from Mexico. Data were collected through convenience sampling in Mexico City and Guadalajara. HCP (n = 34) analysis was based on IDIs, and pregnant women or mothers of children 0-18 months (n = 74) on FGDs and IDIs.

Results

Through a thematic analysis, we identified the socioecology of BF and triangulated HCP and women's accounts. HCP, pregnant women, and mothers recognized that several factors might have influenced their infant feeding decisions including healthcare facilities' policies and maternal work conditions. Although HCP believed that BF is the best way to feed newborns and young children, they routinely recommended CMF. On the other hand, pregnant women and mothers had a strong belief that BF is the best way to feed their babies. However, when women sought support from HCP, the latter often recommended switching to CMF.

Discussion

This study highlights the discordance between HCP perceptions and mothers' experiences of HCP recommendations about infant feeding. Our findings support a national call for policy actions.

Case Report: I feel like a mother to other babies: experiences and perspectives on bereavement and breastmilk donation from Vietnam

There is a growing recognition globally that care regarding lactation following a perinatal death needs to potentially offer the opportunity for maternal donation. This article discusses this experience and perspectives from a human milk bank (HMB) in Vietnam. This is a descriptive exploratory case study that has a long tradition in both the social and health sciences. Triangulated data collection involved a review of video data, interview data with the donor, and data review for the Da Nang HMB, a Center for Excellence in Breastfeeding. We found that although it is common for mothers in Vietnam to donate breastmilk to HMBs, it is less common for this to occur following perinatal loss. We offer a descriptive case study of the maternal loss of twins and a subsequent choice to donate for approximately 1 month to the Da Nang HMB, the first HMB in Vietnam. We discuss four reasons derived from this case regarding donation following perinatal loss. (1) A strong motivation to donate breastmilk when aware of the service, (2) donating breastmilk helped her deal with grief, (3) family members supported her through this tough time and supported her decision, and (4) health staff supported her decision. While human milk sharing (e.g., wet nursing) has been practiced in Vietnam, breastmilk donation from bereaved mothers has neither been discussed nor well-researched. Because maternal grief is complex and individual, deciding to donate breastmilk is a personal decision that needs to be supported, without creating guilt for those who do not wish to donate.

How the marketing practices of commercial milk formula companies impact infant breastfeeding practices in China

BACKGROUND

The marketing practices used by commercial milk formula (CMF) companies undermine breast feeding. However, it remains unclear how specific types of marketing practices result in suboptimal breast feeding.

OBJECTIVES

We aimed to examine the associations of CMF marketing practices with breastfeeding outcomes, determine the influencing pathways, how it changes the perceptions and attitudes of mothers towards CMF, and how it impacts breastfeeding outcomes.

METHODS

A cross-sectional survey was conducted in Beijing and Jinan, China that mapped the CMF marketing practices in 2020. Mothers were interviewed about the feeding practices for the youngest child under the age of 18 months. Maternal attitude towards CMF was assessed using a set of five questions. Six common CMF marketing practices were reviewed. A logistic regression was performed to examine the associations between the CMF marketing practices and predominant breast feeding, with adjustments for maternal age, education, occupation, socioeconomic class and caesarean section. Furthermore, a path analysis was conducted to explore the pathways between the CMF marketing practices, maternal attitude towards CMF and predominant breast feeding.

RESULTS

A total of 750 mothers were interviewed, with 20.0% of mothers predominantly breast feeding their young children. Two marketing practices, online engagement with CMF companies and promotions and discounts, were statistically associated with a lower likelihood of predominant breast feeding, with an adjusted ORs of 0.53 (95% CI 0.35 to 0.82) and 0.45 (95% CI 0.22 to 0.92). Furthermore, per CMF marketing practice increase mothers concurrently exposed to was associated with a 0.79 (95% CI 0.68 to 0.92) times lower likelihood of predominant breast feeding. In addition, online engagement and free formula samples distributed in hospitals had indirect effects on suboptimal breastfeeding outcomes, which was partly mediated by positive maternal attitude towards CMF.

CONCLUSIONS

CMF marketing practices were associated with a lower likelihood of optimal breastfeeding through influencing the maternal attitude towards CMF.

Law matters - assessment of country-level code implementation and sales of breastmilk substitutes in South Asia

Objectives

This study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka).

Design

A mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country's barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data.

Findings

There are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries.

Recommended actions include

(1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women's rights jurist networks.

Barriers to optimal breastfeeding of medically complex children in the UK paediatric setting: a mixed methods survey of healthcare professionals

BACKGROUND

Breastfeeding is indisputably significant for infants and children, as well as their mothers. However, when breastfed children are admitted to the paediatric ward, they may experience breastfeeding modification due to clinical challenges, lack of staff training and institutional barriers. Although previous research has identified multiple barriers to optimal feeding within the maternity, neonatal and community settings, we know less about the barriers that exist in paediatrics. Paediatric healthcare staff attitudes, training and awareness as well as ward culture are likely to have an impact on the experiences of families but are relatively unresearched in the paediatric setting, especially with regard to the multidisciplinary nature of clinical paediatric care. The aim of this study was to explore the attitudes, awareness and perceived barriers to effective breastfeeding support provision, as well as healthcare professional perception of barriers for families.

METHODS

This was a mixed methods study utilising a questionnaire which was completed by 409 healthcare professionals who identified as working within the paediatric setting. It included responses from paediatricians of all training grades, nurses, healthcare assistants and allied health professionals. Qualitative data from professionals were analysed to develop themes around professional and perceived parent barriers to optimal breastfeeding.

RESULTS

This study explored the barriers experienced by staff, as well as professionals' perception of parent barriers. These included lack of knowledge of how to help, a default formula culture, the pressure of maintaining strict fluid balance and breastfeeding being a low priority in the face of critical illness. Of the paediatric departments represented by this sample of healthcare professionals, most had a relatively poor culture of supporting breastfeeding, with multiple institutional barriers identified. Most professionals felt that there was not enough support for breastfeeding families on an average shift, and a large proportion identified as being one of just a few breastfeeding advocates on their ward.

CONCLUSION

In this relatively motivated and experienced sample of healthcare professionals, there were many identified barriers to optimal breastfeeding which could potentially be addressed by training that is carefully nuanced for the paediatric population. Ensuring that paediatric multidisciplinary healthcare professionals have sufficient skills and knowledge would address the identified challenge of poor awareness of breastfeeding and of how to overcome clinical lactation obstacles. Further improvements at policy level need to address the systemic lack of resourcing in paediatrics, as well as the lack of embedded breastfeeding-friendly organisational structures.

What is Known About Cow's Milk Protein Allergy in Preterm Infants?

Background: Cow's milk protein allergy (CMPA) is well described in term infants, as opposed to preterm infants. In preterm infants, CMPA shares many gastrointestinal symptoms with necrotizing enterocolitis (NEC). Objectives: To evaluate the presentation of CMPA in preterm infants and to investigate the different diagnostic and therapeutic options. Materials and Methods: We searched for the relevant literature using the medical databases PubMed, Web of Science, and the Cochrane Library. We performed a post hoc analysis on the 25 case reports included in this study. Results: Literature was scarce and heterogeneous. The majority of preterm infants with CMPA were exposed to bovine-based milk proteins before the development of symptoms. The most common clinical manifestations were bloody stools, vomiting, and abdominal distension. Of the 25 cases, only 7 (28%) retained human milk in their diet after diagnosis. In the larger studies, no study has human milk as primary feeding choice after diagnosis. Conclusions: Preterm infants exposed to a type of cow's milk-based formula in their first days of life have a higher risk of developing CMPA. Most of the preterm infants are no longer fed with human milk after the diagnosis of CMPA is made, which is in contrast with current nutrition guidelines in preterm infants. We strongly advocate that human milk with mothers on a cow's milk-free diet is the first choice of feed after the diagnosis of CMPA. Prospective studies are necessary to obtain more information regarding clinical presentation, diagnostic tools, and therapeutic approaches.

Rebalancing commercial and public interests in prioritizing biomedical, social and environmental aspects of health through defining and managing conflicts of interest

Biomedical research is intended to benefit human beings and their health. Toward that end, scientific norms involve examining and criticizing the work of others and prioritizing questions that should be studied. Yet, in areas of health research where industry is active, it has often utilized well-honed strategies aimed at evading scientific standards and at dominating the research agenda, largely through its financial support and lack of transparency of its research practices. These tactics have now been documented to uniformly support industry products. Commercial entities are aided in this pursuit by public policy that has significantly embedded commercial interests and agendas into federal research funding and infrastructure. Therefore, to understand the resulting landscape and its effect on priority in health research agendas, traditional definitions of individual conflicts of interest (COI) and the less well developed institutional COI must be supplemented by a new construct of structural COI, largely operating as intellectual monopolies, in support of industry. These arrangements often result in financial and reputational resources that assure dominance of commercial priorities in research agendas, crowding out any other interests and ignoring justified returns to the public from investment of its tax dollars. There is no sustained attention to mechanisms by which public interests can be heard, normative issues raised, and then balanced with commercial interests which are transparently reported. Focus on research supporting approval of commercial products ignores social and environmental determinants of health. Commercial bias can invalidate regulatory research protections through obscuring valid risk-benefit ratios considered by IRBs.

Role of Pediatricians in Promoting and Supporting Breastfeeding: A Position Paper of the International Pediatric Association Strategic Advisory Group on Infant, Child, and Adolescent Nutrition

BACKGROUND

Promoting and supporting breastfeeding is an important public health intervention with multiple benefits for both infants and mothers. Even modest increases in the prevalence and duration of breastfeeding could significantly reduce healthcare costs and improve maternal and child health outcomes. However, widespread adoption of breastfeeding recommendations remains poor in most settings, which contributes to widening health and social inequalities. Pediatricians have a duty to advocate for improving child health, including promoting and supporting breastfeeding.

SUMMARY

This paper, from the International Pediatric Association Special Advisory Group on Nutrition, considers common barriers to breastfeeding and addresses how pediatricians can better promote and support breastfeeding, both at an individual level and by influencing practice and policy. All pediatricians need to understand the basics of breastfeeding, including lactation physiology, recognize common breastfeeding problems, and advise mothers or refer them for appropriate support; training curricula for general pediatricians and all pediatric subspecialties should reflect this. Even in the situation where their day-to-day work does not involve direct contact with mothers and infants, pediatricians can have an important influence on policy and practice. They should support colleagues who work directly with mothers and infants, ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression. Pediatricians and pediatric organizations should also promote policies aimed at promoting and supporting breastfeeding at local, regional, national, and international levels.

KEY MESSAGES

Pediatricians have a duty to promote and support breastfeeding, regardless of their day-to-day role and responsibilities. Pediatric training curricula should ensure that all trainees acquire a good understanding of breastfeeding so they are able to effectively support mothers in their personal practice but also influence breastfeeding practice and policy at a local, regional, national, and international level.

Trends of breastfeeding indicators in Brazil from 1996 to 2019 and the gaps to achieve the WHO/UNICEF 2030 targets

BACKGROUND

The comprehension of breastfeeding patterns and trends through comparable indicators is essential to plan and implement public health policies.

OBJECTIVE

To evaluate the trends of breastfeeding indicators in Brazil from 1996 to 2019 and estimate the gap to achieve the WHO/UNICEF 2030 targets in children under 5 years.

METHODS

Microdata from two National Surveys on Demography and Health of Women and Children (PNDS-1996 and PNDS-2006) and the Brazilian National Survey on Child Nutrition-2019 were used. The indicators of early initiation of breastfeeding (EIBF), exclusive breastfeeding of infants 0-5 months of age (EBF<6 mo), continued breastfeeding at 1 year of age (CBF1yr) and CBF at 2 years of age (CBF2yr) were analysed using prevalence and 95% CI. The average annual variation and years to achieve the WHO/UNICEF 2030 targets were calculated for Brazil and the macroregions. Statistical analyses considered the survey's complex sample design for each database.

RESULTS

EIBF increased from 36.3% (95% CI 33.6% to 39.0%) in 1996 to 60.9% (95% CI 56.5% to 65.3%) in 2006 (statistically significant) and 62.5% (95% CI 58.3% to 66.6%) in 2019. EBF<6 mo increased from 26.9% (95% CI 21.3% to 31.9%) in 1996 to 39.0% (95% CI 31.0% to 47.1%) in 2006 and 45.8% (95% CI 40.9% to 50.7%) in 2019 (significant increases for 1996-2019 for Brazil, Northeast and Midwest regions). CBF1yr rose from 36.6% (95% CI 30.8% to 42.4%) in 1996 to 48.7% (95% CI 38.3% to 59.0%) in 2006, and 52.1% (95% CI 45.4% to 58.9%) in 2019. CBF2yr increased from 24.7% (95% CI 19.5% to 29.9%) in 1996 to 24.6% (95% CI 15.7% to 33.5%) in 2006 and 35.5% (95% CI 30.4% to 40.6%) in 2019 (significant increase for 1996-2019). The South and Southeast regions need to double the 2019 prevalence to reach the target for the CBF1yr and CBF2yr; the Northeast and North need to increase 60% the current prevalence for the indicator of EBF<6 mo.

CONCLUSION

A substantial improvement in breastfeeding indicators occurred in Brazil from 1996 to 2019, although at an insufficient rate to achieve the WHO/UNICEF 2030 targets.

"Stronger with Breastmilk Only" Initiative in 5 African Countries: Case Study on the Implementation Process and Contribution to the Enabling Environment for Breastfeeding

Background

The practice of giving water before 6 mo of age is the biggest barrier to exclusive breastfeeding in West and Central Africa. To address this challenge, a regional initiative, "Stronger with Breastmilk Only" (SWBO), was rolled out at country level in several countries of the region.

Objective

We examined the implementation process of the SWBO initiative and the contribution of its advocacy component to a more supportive environment for breastfeeding policies and programs.

Methods

This study was based on 2 assessments at the national level carried out in 5 countries (Burkina Faso, Chad, Democratic Republic of the Congo, Senegal, and Sierra Leone) using qualitative methods. We combined 2 evaluative approaches (contribution analysis and outcome harvesting) and applied 2 theoretical lenses (Breastfeeding Gear Model and Consolidated Framework for Implementation Research) to examine the implementation process and the enabling environment for breastfeeding. Data sources included ∼300 documents related to the initiative and 43 key informant interviews collected between early 2021 and mid-2022.

Results

First, we show how a broad initiative composed of a set of combined interventions targeting multiple levels of determinants of breastfeeding was set up and implemented. All countries went through a similar pattern of activities for the implementation process. Second, we illustrate that the initiative was able to foster an enabling environment for breastfeeding. Progress was achieved notably on legislation and policies, coordination, funding, training and program delivery, and research and evaluation. Third, through a detailed contribution story of the case of Burkina Faso, we illustrate more precisely how the initiative, specifically its advocacy component, contributed to this progress.

Conclusion

This study shed light on how an initiative combining a set of interventions to address determinants of breastfeeding at multiple levels can be implemented regionally and contributes to fostering an enabling environment for breastfeeding at scale.

Factors influencing breastfeeding continuation and formula feeding beyond six months in rural and urban households in Indonesia: a qualitative investigation

BACKGROUND

Global and Indonesian guidelines suggest that breastfeeding should continue for at least the first two years of life. While many studies have focused on six-month exclusive breastfeeding practices, little is known about why mothers do not sustain breastfeeding beyond this period. This qualitative study aimed to explore factors influencing breastfeeding continuation and formula feeding beyond six months, regardless of any additional food consumed, focusing on Indonesia's rural and urban areas.

METHODS

We collected the data through 46 in-depth interviews in Pati District and Surakarta City, Central Java, Indonesia. Participants were mothers, grandmothers, health care practitioners, and village kader (frontline female health workers). We used thematic analysis combining deductive and inductive techniques for analysing the data.

RESULTS

Rural mothers practised breastfeeding and intended to breastfeed for a longer duration than urban mothers. Maternal attitude towards breastfeeding, breastfeeding knowledge, previous experiences, and other breastfeeding strategies (e.g., enhancing maternal dietary quality) positively influenced breastfeeding sustainability. In the urban setting, mothers encountered several breastfeeding barriers, such as perceived breast milk insufficiency and child hunger and satiety, child biting, and breastfeeding refusal, causing them to provide formula milk as a breast milk substitute or supplement. In addition, families, communities, health practitioners, and employment influenced maternal decisions in breastfeeding continuation and formula-feeding practices.

CONCLUSIONS

Optimal breastfeeding practices up to two years of age are determined by the individual and setting (i.e., community, healthcare, employment) factors. Providing breastfeeding education covering practical breastfeeding guidance will encourage mothers to breastfeed for longer. Such interventions should involve families, communities, health workers, and the work environment as a breastfeeding support system. Policymakers should develop, enforce, and monitor the implementation of breastfeeding policies to protect, promote, and support breastfeeding in households, communities, health systems, and work settings.

Global lessons for strengthening breastfeeding as a key pillar of food security

Breastfeeding is identified as a central pillar of food security by the World Health Organization, however globally significant challenges remain in achieving breastfeeding targets for early initiation, exclusive breastfeeding for 6 months, and continued breastfeeding for 2 years and beyond. Inadequate support in health systems, poor maternity protections and workplace policies, and insufficient regulation of commercial milk formulas, among other barriers, continue to undermine this key pillar across nations. This paper highlights the central importance of breastfeeding for food security across diverse global settings by examining three case studies: Honduras, Pakistan and the USA. The cases highlight the complex layering and intersections of key challenges that threaten breastfeeding in the era of pandemics, the climate crisis, conflict and global inequality. Lessons drawn from these case studies, combined with additional insights, reinforce the importance of multisectorial collaboration to scale up investment in creating equitable, enabling environments for breastfeeding. These structural and systems approaches can successfully strengthen the breastfeeding ecosystem to ensure greater first food system resilience in the face of global crises, which compound maternal and infant vulnerabilities. Additionally, the cases add urgency for greater attention to prioritizing breastfeeding and incorporating IYCF-E protocols into disaster preparedness and management into the policy agenda, as well as ensuring that first food security is considered in energy policy. An integrated approach to policy change is necessary to recognize and strengthen breastfeeding as a pivotal part of ensuring food security across the globe.