Feeding practices in 105 counties of rural China

Postnatal mental health, breastfeeding beliefs, and breastfeeding practices in rural China

Background

The importance of breastfeeding in low- and middle- income countries is well recognized, yet the importance of postnatal mental health on breastfeeding practices and beliefs in these settings has been understudied. This study investigates the associations between maternal mental health problems, breastfeeding beliefs and breastfeeding practices in rural China.

Methods

Cross-sectional data were collected in November and December 2019 from 742 mothers of infants under 6 months old in rural Sichuan Province, China. Maternal mental health (depression, anxiety, and stress symptoms) was assessed using the Depression, Anxiety, and Stress Scale (short form). Breastfeeding beliefs were assessed using the Iowa Infant Feeding Attitude Scale and Breastfeeding Self-Efficacy Scale (short form). Breastfeeding practices were assessed through a 24-h dietary recall questionnaire. Ordinary least squares regression, multiple logistic regression and heterogeneous effects analyses were used to identify associations between symptoms of mental health problems and breastfeeding outcomes.

Results

The average age of sample infants was 2.7 months. Among mothers, 13% showed symptoms of depression, 16% anxiety, and 9% stress. The prevalence of exclusive breastfeeding in the previous 24 h was 38.0%. Depression symptoms were significantly associated with breastfeeding attitude (𝛽= − 1.11, 95% CI: − 2.07, − 0.14) and breastfeeding self-efficacy (𝛽= − 3.19, 95% CI: − 4.93, − 1.45). Anxiety and stress symptoms were significantly associated with breastfeeding self-efficacy (𝛽= − 1.81, 95% CI: − 3.43, − 0.18 and 𝛽 = − 2.88, 95% CI: − 4.98, − 0.78, respectively). There were no significant associations between symptoms of mental health problems and exclusive breastfeeding. The heterogeneous effects analyses revealed that less educated mothers with symptoms of stress had lower odds of exclusive breastfeeding than educated mothers without symptoms of stress (OR: 0.53, 95% CI: 0.25,1.10). Mothers of younger infants had higher odds of exclusive breastfeeding than the mother of older infants, regardless of depression, anxiety, or stress symptoms.

Conclusion

Symptoms of maternal mental health problems are significantly associated with breastfeeding attitude and self-efficacy; however, these symptoms are not associated with breastfeeding practices. Maternal educational level and infant age may play a role in mothers’ breastfeeding practices. To improve breastfeeding practices, interventions should employ a multi-dimensional approach that focuses on improving maternal mental well-being and considers demographic characteristics.

Complementary Feeding Practices among Young Children in China, India, and Indonesia: A Narrative Review

Under- and overnutrition are co-existing health issues in several countries across Asia. Poor complementary feeding (CF) is a significant determinant of malnutrition in children and a major cause of morbidity and mortality. The purpose of this narrative review is to summarize the most recent evidence regarding the CF practices in 3 countries with a high prevalence of stunting and overweight, and currently undergoing rapid economic and nutritional transition: China, India, and Indonesia. We focused particularly on the adequacy of CF, based on the WHO feeding indicators (2021) regarding timing, frequency, diversity, as well as the consumption of specific food groups. According to the findings, the majority of infants in the 3 countries are introduced to CF at an inappropriate time: either too early (particularly in urban/rural areas of China and Indonesia) or too late (India) compared with the WHO recommendation. Furthermore, in all countries, diets are characterized by a low variety and frequency of CF and consist mainly of staple foods with poor nutritional quality, such as rice, cereals, or noodles. Nutrient-dense and protein-rich foods, such as foods of animal origin, are either inadequately consumed (rural areas of China and India) or introduced too late (urban areas of China and Indonesia) in the diets of children. In all countries, the consumption of fruit and vegetables, especially during the early CF period, is poor. In contrast, a significant proportion of both urban and rural children, particularly in Indonesia and India, are consuming energy-dense/nutrient-poor snacks and sugary drinks during the CF period. The described practices may pose a significant risk for the development of energy and/or nutrient gaps, magnifying the double and triple burden of malnutrition present in these countries. Further research is warranted to understand the significance of the observed practices for stunting and/or overweight/obesity risk.

Prevalence of Malnutrition and Associated Factors of Stunting among 6-23-Month-Old Infants in Central Rural China in 2019

This study aimed to evaluate the prevalence of malnutrition and to investigate the associated factors of stunting among 6-23-month-old infants in poor rural areas of central China. The China Nutrition Improvement Project on Children in Poor Areas was conducted in 56 national-level poor counties of seven provinces in 2019. We performed a multivariate binary logistic regression analysis to determine the associated factors of stunting. This cross-sectional study included 17,193 infants. The overall prevalence of stunting was the highest (3.9%), followed by overweight (3.0%), underweight (2.1%), wasting (2.0%), and obesity (0.5%). Girls [OR = 0.55, 95% CI (0.46, 0.65)], infants meeting requirements of minimum diversity diet [OR = 0.81, 95% CI (0.67, 0.98)], and mothers with middle-school or high-school education and above decreased the prevalence of stunting. Infants with diarrhea in two weeks [OR = 1.26,95% CI (0.98, 1.62)] were at higher odds of stunting. The malnutrition status in the study areas was improved, and vulnerable infants were found to need additional and earlier monitoring to detect and fundamentally prevent undernutrition.

Predictive Model for the Risk of Severe Acute Malnutrition in Children

BACKGROUND

The nutritional status is the best indicator of the well-being of the child. Inadequate feeding practices are the main factors that affect physical growth and mental development. The aim of this study was to develop a predictive score of severe acute malnutrition (SAM) in children under 5 years of age.

METHODS

It was a case-control study. The case group (n = 263) consisted of children aged 6 to 59 months admitted to hospital for SAM that was defined by a z-score weight/height < -3 SD or presence of edema of malnutrition. We performed a univariate and multivariate analysis. Discrimination score was assessed using the ROC curve and the calibration of the score by Hosmer-Lemeshow test.

RESULTS

Low birth weight, history of recurrent or chronic diarrhea, daily meal's number less than 3, age of breastfeeding's cessation less than 6 months, age of introduction of complementary diets less than 6 months, maternal age below 25 years, parity less than 5, family history of malnutrition, and number of children under 5 over 2 were predictive factors of SAM. Presence of these nine criteria affects a certain number of points; a score <6 points defines children at low risk of SAM, a score between 6 and 8 points defines a moderate risk of SAM, and a score >8 points presents a high risk of SAM. The area under ROC curve of this score was 0.9685, its sensitivity was 93.5%, and its specificity was 93.1%.

CONCLUSION

We propose a simple and efficient prediction model for the risk of occurrence of SAM in children under 5 years of age in developing countries. This predictive model of SAM would be a useful and simple clinical tool to identify people at risk, limit high rates of malnutrition, and reduce disease and child mortality registered in developing countries.

Breastfeeding and the Risk of Illness among Young Children in Rural China

Poor rural areas in China exhibit the country’s highest rates of child mortality, often stemming from preventable health conditions such as diarrhea and respiratory infection. In this study, we investigate the association between breastfeeding and disease among children aged 6–24 months in poor rural counties in China. To do this, we conducted a longitudinal, quantitative analysis of socioeconomic demographics, health outcomes, and breastfeeding practices for 1802 child–caregiver dyads across 11 nationally designated poverty counties in southern Shaanxi Province in 2013–2014. We found low rates of continued breastfeeding that decreased as children developed: from 58.2% at 6–12 months, to 21.6% at 12–18 months, and finally to 5.2% at 18–24 months. These suboptimal rates are lower than all but one other country in the Asia-Pacific region. We further found that only 18.3% of children 6–12 months old met the World Health Organization (WHO)-recommended threshold for minimum dietary diversity, defined as consuming four or more of seven specific food groups. Breastfeeding was strongly associated with lower rates of both diarrhea and cough in bivariate and multivariate analyses. As the first analysis to use longitudinal data to examine the relationship between continued breastfeeding and child illness in China, our study confirms the need for programmatic interventions that promote continued breastfeeding in order to improve toddler health in the region.

Factors Associated with Undernutrition in Children under the Age of Two Years: Secondary Data Analysis Based on the Pakistan Demographic and Health Survey 2012⁻2013

In Pakistan, 96% of the children under the age of two years do not receive an adequate diet. The main aim of this paper is to identify the sociodemographic, nutritional, and health-related factors associated with stunting, wasting, and underweight in children under the age of two years in Pakistan. Secondary data analysis was performed based on the Pakistan Demographic and Health Survey, 2012⁻2013. The analysis was limited to children under the age of two years (n = 984). Analysis was done using bivariate and multivariable binary logistic regression. The incidence of stunting, wasting, and underweight in children was 28.3%, 12.1%, and 27.9%, respectively. The odds of stunting, wasting, and underweight increased with the child's age. The odds of stunting and underweight increased with the mother's low body mass index, low access to information, high birth order of child, consanguineous marriages, father's low education, rural settlement, poor toilet facilities, and low vitamin A consumption. The odds of wasting increased in children who were not being breastfed, but no significant relation was seen with stunting and underweight. There is a need to improve child nutritional status in Pakistan by addressing issues such as poverty, low parental education, low micronutrient intake, and targeting provinces where undernutrition was found to be higher.

[Development of a predictive score of severe acute malnutrition among children under 5 years of age]

Introduction

L’objectif de cette étude est de développer un score prédictif de la malnutrition aiguë sévère (MAS) chez les enfants de 6 à 59 mois.

Méthodes

Etude cas-témoins: les cas (n = 263) étaient les enfants de 6 à 59 mois admis à l’hôpital Sendwe de Lubumbashi pour une MAS; les témoins (n = 263) étaient les enfants de même âge admis dans le même hôpital pour une pathologie autre que la MAS. Nous avons procédé par une analyse univariée puis multivariée. La discrimination du score était évaluée à l’aide de la courbe ROC et du C-index.

Résultats

Après modélisation logistique, neuf critères ressortent comme facteurs prédictifs de MAS: le faible poids à la naissance, la diarrhée à répétition/chronique, le nombre de repas journaliers < 3, l’âge d’arrêt d’allaitement maternel < 6 mois, l’âge d’introduction d’alimentation de complément < 6 mois, l’âge maternel < 25 ans, la parité < 5, l’antécédent familial de malnutrition et le nombre d’enfants âgés de moins de 5 ans dans la fratrie ≥ 3. L’aire sous la courbe ROC est de 0,9685, la sensibilité de 93,54%, la spécificité de 93,16%, la valeur prédictive positive de 93,18% et le rapport de vraisemblance positif de 6,84%.

Conclusion

Nous proposons un score prédictif du risque de survenue de MAS dans une population de moins de 5 ans. Ce score prédictif de MAS serait un outil clinique utile et simple pour cibler la population à risque, limiter les taux élevés de malnutrition et réduire la morbidité et la mortalité infanto-juvénile enregistrés dans les pays en développement.

Early introduction of allergenic foods for the prevention of food allergy from an Asian perspective-An Asia Pacific Association of Pediatric Allergy, Respirology & Immunology (APAPARI) consensus statement

Emerging evidence for the early introduction of allergenic foods for the prevention of food allergies, such as peanut allergy in Western populations, has led to the recent publication of guidelines in the USA and Europe recommending early peanut introduction for high-risk infants with severe eczema or egg allergy. Peanut allergy is, however, much less prevalent in Asia compared to the West. Varying patterns of food allergy are seen even within Asian countries-such as a predominance of wheat allergy in Japan and Thailand and shellfish allergy in Singapore and the Philippines. Customs and traditions, such as diet and infant feeding practices, also differ between Asian populations. Hence, there are unique challenges in adapting guidelines on early allergenic food introduction to the Asian setting. In this paper, we review the evidence and discuss the possible approaches to guide the timely introduction of allergenic food in high-risk infants in Asia.

Determinants of severe acute malnutrition among children under 5 years of age in Nepal: a community-based case-control study

BACKGROUND

Malnutrition is one of the leading causes of morbidity and mortality among children under the age of 5 years in low and middle income countries like Nepal. Children with severe acute malnutrition (SAM) are nine times more likely to die than children without malnutrition. The prevalence of SAM has increased in Nepal over the past 15 years; however, the determinants of SAM have not been clearly assessed in the country.

OBJECTIVE

To assess the determinants of SAM among children aged 6-59 months in the Bara district of Nepal.

SETTING

A community-based case-control study was conducted in 12 randomly selected Village Development Committees (VDCs) of the Bara district of Nepal.

PARTICIPANTS

A random sample of 292 children aged 6-59 months (146 as cases and 146 as controls) from 12 VDCs were included in this study.

RESULTS

The prevalence of SAM among children under the age of 5 years was 4.14%. The following factors were significantly associated with SAM: low socioeconomic status (adjusted odds ratio (AOR) 17.13, 95% CI 5.85 to 50.13); mother's age at birth <20 or >35 years (AOR 3.21, 95% CI 1.30 to 7.94); birth interval <24 months (AOR 4.09, 95% CI 1.87 to 8.97); illiterate father (AOR 3.65, 95% CI 1.62 to 8.20); bottle feeding (AOR 2.19, 95% CI 1.73 to 12.03); and not initiating complementary feeding at the age of 6 months (AOR 2.91, 95% CI 1.73 to 12.03). Mother's educational level, initiation of breastfeeding, colostrum feeding, and exclusive breastfeeding were not significantly associated with SAM.

CONCLUSION

The mother's age at birth, birth interval, socioeconomic status, father's educational level and initiation of complementary feeding at the age of 6 months were important determinants of SAM among children. A multi-sector approach is essential to address SAM. There is a need for further studies not only focusing on SAM but also moderate acute malnutrition.

Low Food Allergy Prevalence Despite Delayed Introduction of Allergenic Foods-Data from the GUSTO Cohort

BACKGROUND

There is mounting evidence that early introduction of allergenic food decreases the risk of food allergy development, especially in high-risk infants with eczema. However, there is a lack of data to suggest whether this association holds true in Asian populations.

OBJECTIVE

To investigate the relationship between the timing of introduction of allergenic foods and food allergy outcomes in infants in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study.

METHODS

The GUSTO cohort recruited 1152 mothers of Chinese, Malay, and Indian ethnicity who had singleton, naturally conceived pregnancies and followed their offspring prospectively. Information on demographic characteristics, child health, infant feeding practices, and a convincing history of IgE-mediated food allergy was obtained from interviewer-administered questionnaires at multiple time points. Corroborative skin prick tests to food allergens were performed at 18 and 36 months.

RESULTS

Most of the infants were introduced to egg (49.6%), peanut (88.7%), and shellfish (90.2%) after age 10 months. Food allergy prevalence was, however, very low between age 12 and 48 months: egg, 0.35% to 1.8%; peanut allergy, 0.1% to 0.3%; and shellfish, 0.2% to 0.9%. There were no significant associations between the timing of introduction of allergenic foods and the development of food allergy, adjusted for confounders including breast-feeding and eczema.

CONCLUSIONS

Food allergy rates in Singapore are low despite delayed introduction of allergenic foods. Early introduction of allergenic foods may thus not be necessary in populations in which overall food allergy prevalence is low, and thus infant feeding recommendations should be carefully tailored to individual populations.

Prevalence of Anemia and its Risk Factors among Children under 36 Months Old in China

This study aims to evaluate the prevalence and sociodemographic factors of anemia in children <36 months old in China. In this study, data of 24 235 children were investigated from 32 primary health care (PHC) facilities in 11 province-level regions. Pearson χ²-test and logistic regression model were used to estimate potential risk factors associated with anemia. The overall prevalence of anemia was 24.4%, and 32.8% children from rural areas were anemic, but no statistically significant difference was observed between male and female. Predictors of anemia are different regions of China, cesarean delivery, premature birth and neonatal asphyxia. We also found that education level and income of children's parents are important determinants of childhood anemia. In additional, feeding practice would affect anemia among children aged 6-12 months. Our results could provide some insights for prevention and control of childhood anemia in PHC facilities.

Malnutrition in acutely ill children at the paediatric emergency unit in a tertiary hospital in Nigeria

Background:

In many developing countries, malnutrition remains an important cause of morbidity and mortality particularly in under-five children. The factors responsible for malnutrition could be immediate, underlying or basic, acting either alone or together. It has been shown that children who are malnourished have poorer outcomes from other illnesses than well-nourished children. It is important therefore to periodically describe the extent and pattern of childhood malnutrition so that effective preventive measures can be put in place.

Objective:

To describe the prevalence and pattern of malnutrition in children presenting with acute illnesses at the Jos University Teaching Hospital.

Patients and Methods:

A cross-sectional descriptive study in children aged 6 to 59 months seen at the paediatric emergency unit from April to October 2012. The subjects were recruited consecutively. Each child had both clinical assessment and appropriate laboratory evaluations done alongside anthropometric measurements. The nutritional/dietary and socio-demographic histories were also obtained.

Results:

Of the 379 children, 224 (59.1%) were males and 155 (40.9%) females. The median age was 17 months, range (6-57). Wasting (WFH z-scores ≤−3 to <−1SD) was evident in one hundred children, giving an overall prevalence of 26.9%. Severe wasting (WFH z-score <−3), was present in 22 (5.9%) children indicating the prevalence of marasmus, whereas only two children (0.53%) had oedematous malnutrition (kwashiorkor). Stunting or chronic malnutrition, (HFA z-scores ≤−3 to <−1SD) was present in 67 children (18.0%). Seventeen (4.6%) were severely stunted (HFA z-score <−3).

Conclusions:

Wasting was the most common form of malnutrition in the study.

Predictors of early introduction of complementary feeding: longitudinal study

BACKGROUND

Early introduction of complementary foods prior to 6 months of age may shorten breast-feeding duration and expose the infant to increased risk of morbidity and mortality. The aims of this study were to document the ages of complementary food introduction and to identify the determinants associated with early introduction of complementary feeding in Sichuan Province.

METHODS

A prospective study on infant feeding practices was conducted during 2010-2011 in Jiangyou, China. A total of 695 mothers were recruited and interviewed at discharge. The follow-up interviews were carried out by telephone at 1, 3 and 6 months postpartum. Cox regression analysis was performed to determine factors related to early introduction of complementary feeding.

RESULTS

The median age at start of complementary feeding was 4.5 months (95% confidence interval [CI]: 4.4-4.6 months). Mothers who perceived that most of their friends breast-fed (adjusted hazard ratio [HR], 0.70; 95%CI: 0.58-0.84) and those who returned to work when the infants were at least 6 months old were less likely to initiate complementary feeding early (adjusted HR, 0.73; 95%CI: 0.58-0.91), while infants who had been introduced to infant formula regularly before 6 months of age were at a higher risk of receiving complementary foods prematurely (adjusted HR, 1.81; 95%CI: 1.42-2.31).

CONCLUSIONS

Introducing complementary feeding before 6 months postpartum was widely practiced in Jiangyou. The appropriate age at which to introduce complementary foods and its benefits need to be emphasized in the future breast-feeding education strategies in Sichuan.

Maternal reported indicators and causes of insufficient milk supply

BACKGROUND

Although the breastfeeding initiation rate is high in China, exclusivity is low. Not having enough breast milk has been frequently reported as a reason for supplementing and weaning.

OBJECTIVE

The objective was to explore maternal perception of indicators and causes of self-reported insufficient milk supply (IMS) among a sample of southwestern Chinese mothers.

METHODS

This was a cross-sectional study, conducted in a hospital in Chengdu, China.

RESULTS

The majority of mothers were of Han ethnicity and primiparous. Most initiated breastfeeding (n = 325, 95.3%). Among mothers who had weaned by the time of questionnaire completion, more than half (n = 52) reported IMS as a reason, and 53.8% of these mothers reported this occurring during the first 2 days postpartum. Mothers often identified IMS by using less sensitive indicators of adequate intake such as receiving a hungry look from the infant after nursing (34.6%) and not feeling the presence of milk (28.8%). More sensitive indicators of adequate intake, such as the number of wet/soiled diapers, were not reported. More than a third of mothers (39.2%) could not express a reason for the occurrence of IMS. Among those who identified reasons, nearly one-fourth of mothers attributed IMS, at least partially, to dietary factors such as poor appetite (23.5%).

CONCLUSION

Self-reported IMS appears to be a common barrier to breastfeeding continuation among this sample of Chinese mothers. Culturally appropriate intervention, designed to inform mothers how to correctly identify and address IMS, might be an effective strategy to support optimal infant-feeding behaviors in China.

Exclusive breastfeeding is inversely associated with risk of childhood overweight in a large Chinese cohort

The association between breastfeeding status and childhood overweight is inconclusive. The aim of the present study was to investigate the relation between exclusive breastfeeding and childhood overweight risk in children 4-5 y of age in Southeast China. Among 97,424 children enrolled between 1999 and 2009 in the Jiaxing Birth Cohort, 42,550 of them were included in the final analysis with complete records on breastfeeding status and anthropometric measurements at 4-5 y of age (48-60 mo). Overweight and being at risk of overweight were identified as a body mass index (BMI)-for-age Z-score ≥ 2 and between 1 and 2, respectively. After 4-5 y of follow-up, 4845 (11.4%) children were identified as being at risk of overweight, and 1343 (3.16%) children were overweight. Adjusting for important child and maternal characteristics, longer duration of breastfeeding was associated with lower risk of childhood overweight (P-trend = 0.009) and being at risk of overweight (P-trend < 0.001). Children exclusively breastfed for 3-5 mo and ≥6 mo had 13% (RR = 0.87; 95% CI: 0.77, 0.99) and 27% (RR = 0.73; 95% CI: 0.56, 0.95) lower risk of becoming overweight compared with children exclusively breastfed for <1 mo, respectively. In boys, there were inverse associations of 3-5 mo (RR = 0.83; 95% CI: 0.71, 0.98) or ≥6 mo (RR = 0.65; 95% CI: 0.47, 0.91) of exclusive breastfeeding against becoming overweight, but there were no significant associations in girls (3-5 mo: RR = 0.96, 95% CI: 0.76, 1.22; ≥6 mo: RR = 0.92, 95% CI: 0.60, 1.41). In conclusion, the present findings suggest that longer duration of exclusive breastfeeding is associated with lower risk of becoming overweight in Chinese children.

Breastfeeding Knowledge, Attitudes, and Intention in a Sample of Undergraduate Students in Mainland China

BACKGROUND

Despite the high breastfeeding initiation rate in China (> 90%), the low exclusivity rate is of concern. Some traditional behaviors, combined with increasing popularity of infant formula, may negatively affect future breastfeeding rates. As suggested by the theory of planned behavior, understanding breastfeeding beliefs of young adults may help identify and address misperceptions of future parents, supporting maintenance of the current initiation rate while increasing rates of exclusivity and duration. No research has evaluated these factors among young adults in Mainland China.

OBJECTIVE

The objective was to explore any relationships between breastfeeding knowledge, attitudes, previous experiences, and future intention among undergraduate students in Mainland China.

METHODS

This was a cross-sectional, quantitative study conducted from May to June 2012. A convenience sample of 395 students from a major public university in southwest China participated in the survey.

RESULTS

Breastfeeding knowledge was moderate (76.7% of total score), and breastfeeding was considered to be painful (34.2%), to make breasts sag (43.1%), and to restrict the freedom of mothers (52.5%). In addition, 58.2% of students reported that they would feel embarrassed if they or their partners were to breastfeed in public, and acceptability of breastfeeding in public was low (34.7%). Three-fourths of the students (75.1%) expressed future breastfeeding intent, though males were more likely to report this intention (ie, to support a partner in breastfeeding) than were females (81.3% vs 71.7%, P = .04).

CONCLUSION

To create a more breastfeeding-friendly culture, future research is warranted to explore these negative beliefs about breastfeeding and to counter misunderstandings among future parents in Mainland China.

Risk factors for severe acute malnutrition in children below 5 y of age in India: a case-control study

OBJECTIVE

To determine the possible risk factors for severe acute malnutrition (SAM) in children below 5 y admitted in a hospital in north India.

METHODS

This case-control study was conducted in a medical college hospital in children below 5 y of age. All cases of SAM (diagnosed as per WHO definition) between 6 and 59 mo of age were compared with age-matched controls with weight for height above -2SD of WHO 2006 growth standards. Data regarding socio-demographic parameters, feeding practices and immunization were compared between the groups by univariable and multivariable logistic regression models.

RESULTS

A total of 76 cases and 115 controls were enrolled. Among the 14 factors compared, maternal illiteracy, daily family income less than Rs. 200, large family size, lack of exclusive breast feeding in first 6 mo, bottle feeding, administration of pre-lacteals, deprivation of colostrum and incomplete immunization were significant risk factors for SAM. Regarding complementary feeding, it was the consistency, rather than the age of initiation, frequency and variety which showed a significant influence on occurrence of SAM. Multivariate analysis revealed that the risk of SAM was independently associated with 6 factors, namely, illiteracy among mothers, incomplete immunization, practice of bottle feeding, consistency of complementary feeding, deprivation of colostrum and receipt of pre-lacteals at birth.

CONCLUSIONS

The present study identifies certain risk factors which need to be focused on during health planning and policy making related to children with SAM in India.

Predicators for weight gain in children treated for severe acute malnutrition: a prospective study at nutritional rehabilitation center

Introduction. Despite being an important health problem in developing countries, there is little information available on factors affecting the severe acute malnutrition, especially nondietary factors. Objective. To study the impact of various factors, especially nondietary ones affecting directly or indirectly the weight gain in children with severe acute malnutrition. Method. A total of 300 children in the age group of 6 to 60 months meeting the WHO criteria for severe acute malnutrition were enrolled in the study. These children were provided special therapeutic diet as recommended by WHO/UNICEF protocol. Children were called for followup every 15 days up to 2 months after discharge to evaluate whether these children have achieved a final target weight gain of 15% of their admission weight. The impact of nondietary factors related to child, mother, and socioeconomic status was evaluated. Data collected through structured questionnaire were analyzed. Result. 172 (57.4%) of the total 300 children did not gain final target weight despite giving adequate diet. We observed that impact of various nondietary factors like mother's educational status and her knowledge about feeding practices, socioeconomic status, previous history, and present evidence of infection in child was important in determining the weight of child. No association was found with gender of child, BMI of mother, and father's educational status on the weight gain of child. Conclusion. The findings of this study confirm the association of many nondietary factors with weight gain in children treated for severe acute malnutrition. To reduce malnutrition emphasis should be given on these factors.

A survey of undernutrition in children under three years of age in rural Western China

Background

Childhood undernutrition adversely impacts child health and is one of China’s largest health burdens. However, there is limited information on the current rate of childhood undernutrition in rural Western China. The purpose of this study was to investigate the prevalence of childhood undernutrition and explore its association with socio-economic characteristics in Western China.

Methods

A total of 13,532 children of 0 ~ 36 months of age were recruited as subjects from 45 counties and 10 provinces in Western China with a 3-stage probability proportion to size sampling. The composite index of anthropometric failure (CIAF) was used to assess the childhood undernutrition. The association between socio-economic characteristics and childhood undernutrition was analyzed using a two-level logistic regression.

Results

Based on CIAF, the prevalence of undernutrition among children under three years of age in rural Western China in 2005 was 21.7%. The two-level logistic analysis presented a large difference in undernutrition among the 10 provinces with the highest odds ratio in Guizhou (OR: 2.15, 95%CI: 1.50, 3.08). Older children had a higher prevalence of undernutrition. As compared to girls, boys were more likely to be undernourished (OR 1.27, 95% CI: 1.16, 1.39). The likelihood of undernutrition was lower in subjects of Han ethnicity as opposed to subjects of minority ethnicities (OR 0.77, 95%CI: 0.65, 0.90). In addition, the education levels of the mother as well as wealth index were both negatively associated with childhood undernutrition.

Conclusions

Childhood undernutrition still remains a large health challenge in rural Western China. This study has important policy implications for the Chinese government to improve childhood undernutrition in the surveyed areas.

Breastfeeding rates in central and western China in 2010: implications for child and population health

OBJECTIVE

To describe breastfeeding practices in rural China using globally recommended indicators and to compare them with practices in neighbouring countries and large emerging economies.

METHODS

A community-based, cross-sectional survey of 2354 children younger than 2 years in 26 poor, rural counties in 12 central and western provinces was conducted. Associations between indicators of infant and young child feeding and socioeconomic, demographic and health service variables were explored and rates were compared with the most recent data from China and other nations.

FINDINGS

Overall, 98.3% of infants had been breastfed. However, only 59.4% had initiated breastfeeding early (i.e. within 1 hour of birth); only 55.5% and 9.4% had continued breastfeeding for 1 and 2 years, respectively, and only 28.7% of infants younger than 6 months had been exclusively breastfed. Early initiation of breastfeeding was positively associated with at least five antenatal clinic visits (adjusted odds ratio, aOR: 3.48; P < 0.001) and negatively associated with delivery by Caesarean (aOR: 0.53; P < 0.001) or in a referral-level facility (aOR: 0.6; P = 0.014). Exclusive breastfeeding among children younger than 6 months was positively associated with delivery in a referral-level facility (aOR: 2.22; P < 0.05). Breastfeeding was not associated with maternal age or education, ethnicity or household wealth. Surveyed rates of exclusive and continued breastfeeding were mostly lower than in other nations.

CONCLUSION

Despite efforts to promote breastfeeding in China, rates are very low. A commitment to improve infant and young child feeding is needed to reduce mortality and morbidity.

Specific infant feeding practices do not consistently explain variation in anthropometry at age 1 year in urban United States, Mexico, and China cohorts

Infant feeding practices generally influence infant growth, but it is unclear how introduction of specific foods affects growth across global populations. We studied 3 urban populations in the Global Exploration of Human Milk study to determine the association between infant feeding and anthropometry at 1 y of age. Three hundred sixty-five breastfeeding mother-infant pairs (120 US, 120 China, and 125 Mexico) were recruited soon after the infant's birth. Enrollment required agreement to breastfeed ≥75% for at least 3 mo. Weekly, 24-h, food frequency data were conducted on infants for 1 y and exclusive breastfeeding (EBF) duration and timing of specific complementary food introduction were calculated. Weight and length were measured at age 1 y and anthropometry Z-scores calculated using WHO standards. Cohorts in the 3 urban populations (Shanghai, China; Cincinnati, USA; and Mexico City, Mexico) differed by median EBF duration (5, 14, and 7 wk, respectively; P < 0.001), timing of introduction of meat/eggs/legumes (4.8, 9.3, and 7.0 mo, respectively; P < 0.0001), and other feeding practices. By age 1 y, infants in Shanghai were heavier and longer than Cincinnati and Mexico City infants (P < 0.001). Adjusting for nonfeeding covariates, the only feeding variable associated with anthropometry was EBF duration, which was modestly inversely associated with weight-for-age but not length-for-age or BMI Z-scores at 1 y. Although feeding variables differed by cohort, their impact on anthropometry differences was not consistent among cohorts. Overall, across these urban, international, breast-fed cohorts, differences in specific feeding practices did not explain the significant variation in anthropometry.

Anemia, malnutrition and their correlations with socio-demographic characteristics and feeding practices among infants aged 0-18 months in rural areas of Shaanxi province in northwestern China: a cross-sectional study

BACKGROUND

The first 18 months of life are the most important for long-term childhood well-being. Anemia and malnutrition occurring in this key period have serious implications for individuals and societies, especially in rural areas in developing country. We conducted a cross-sectional study as the baseline survey to provide data for developing a policy-based approach to controlling infant anemia and malnutrition in rural areas of Shaanxi province in northwestern China.

METHODS

We randomly sampled 336 infants aged 0-18 months in 28 rural villages from 2 counties of Shaanxi province. Anthropometric measurements and household interviews were carried out by well-trained researchers. The hemoglobin concentration was measured for 336 infants and serum concentrations of iron, zinc, and retinol (vitamin A) were measured for a stratified subsample of 55 infants. Anemia was defined using World Health Organization (WHO) standards combined with the Chinese standard for infants<6 months old. Logistic regression modeling was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for anemia with non-anemic group as a reference.

RESULTS

We found that 35.12% of infants in rural Shaanxi suffered from anemia, and the malnutrition prevalence rates were 32.14% for underweight, 39.58% for stunting, and 11.31% for wasting. Anemia was significantly associated with malnutrition (underweight, OR: 2.42, 95%CI: 1.50-3.88; stunting, OR: 1.65, 95%CI: 1.05-2.61; wasting, OR: 2.89, 95%CI: 1.45-5.76). Low birth weight, more siblings, less maternal education, low family income, crowded living conditions, and inappropriate complementary food introduction significantly increased the risk for infant anemia. Serum concentrations of iron, zinc, and retinol (vitamin A) were significantly lower in anemic infants compared with non-anemic infants.

CONCLUSIONS

Specific socio-demographic characteristics and feeding patterns were highly associated with infant anemia in rural areas of Shaanxi province. Health education focusing on feeding practices and nutrition education could be a practical strategy for preventing anemia and malnutrition in young children.

Anemia, malnutrition and their correlations with socio-demographic characteristics and feeding practices among infants aged 0-18 months in rural areas of Shaanxi province in northwestern China: a cross-sectional study

BACKGROUND

The first 18 months of life are the most important for long-term childhood well-being. Anemia and malnutrition occurring in this key period have serious implications for individuals and societies, especially in rural areas in developing country. We conducted a cross-sectional study as the baseline survey to provide data for developing a policy-based approach to controlling infant anemia and malnutrition in rural areas of Shaanxi province in northwestern China.

METHODS

We randomly sampled 336 infants aged 0-18 months in 28 rural villages from 2 counties of Shaanxi province. Anthropometric measurements and household interviews were carried out by well-trained researchers. The hemoglobin concentration was measured for 336 infants and serum concentrations of iron, zinc, and retinol (vitamin A) were measured for a stratified subsample of 55 infants. Anemia was defined using World Health Organization (WHO) standards combined with the Chinese standard for infants<6 months old. Logistic regression modeling was used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for anemia with non-anemic group as a reference.

RESULTS

We found that 35.12% of infants in rural Shaanxi suffered from anemia, and the malnutrition prevalence rates were 32.14% for underweight, 39.58% for stunting, and 11.31% for wasting. Anemia was significantly associated with malnutrition (underweight, OR: 2.42, 95%CI: 1.50-3.88; stunting, OR: 1.65, 95%CI: 1.05-2.61; wasting, OR: 2.89, 95%CI: 1.45-5.76). Low birth weight, more siblings, less maternal education, low family income, crowded living conditions, and inappropriate complementary food introduction significantly increased the risk for infant anemia. Serum concentrations of iron, zinc, and retinol (vitamin A) were significantly lower in anemic infants compared with non-anemic infants.

CONCLUSIONS

Specific socio-demographic characteristics and feeding patterns were highly associated with infant anemia in rural areas of Shaanxi province. Health education focusing on feeding practices and nutrition education could be a practical strategy for preventing anemia and malnutrition in young children.

Optimal duration of exclusive breastfeeding

BACKGROUND

Although the health benefits of breastfeeding are widely acknowledged, opinions and recommendations are strongly divided on the optimal duration of exclusive breastfeeding. Since 2001, the World Health Organization has recommended exclusive breastfeeding for six months. Much of the recent debate in developed countries has centred on the micronutrient adequacy, as well as the existence and magnitude of health benefits, of this practice.

OBJECTIVES

To assess the effects on child health, growth, and development, and on maternal health, of exclusive breastfeeding for six months versus exclusive breastfeeding for three to four months with mixed breastfeeding (introduction of complementary liquid or solid foods with continued breastfeeding) thereafter through six months.

SEARCH METHODS

We searched The Cochrane Library (2011, Issue 6), MEDLINE (1 January 2007 to 14 June 2011), EMBASE (1 January 2007 to 14 June 2011), CINAHL (1 January 2007 to 14 June 2011), BIOSIS (1 January 2007 to 14 June 2011), African Index Medicus (searched 15 June 2011), Index Medicus for the WHO Eastern Mediterranean Region (IMEMR) (searched 15 June 2011), LILACS (Latin American and Caribbean Health Sciences) (searched 15 June 2011). We also contacted experts in the field.The search for the first version of the review in 2000 yielded a total of 2668 unique citations. Contacts with experts in the field yielded additional published and unpublished studies. The updated literature review in December 2006 yielded 835 additional unique citations.

SELECTION CRITERIA

We selected all internally-controlled clinical trials and observational studies comparing child or maternal health outcomes with exclusive breastfeeding for six or more months versus exclusive breastfeeding for at least three to four months with continued mixed breastfeeding until at least six months. Studies were stratified according to study design (controlled trials versus observational studies), provenance (developing versus developed countries), and timing of compared feeding groups (three to seven months versus later).

DATA COLLECTION AND ANALYSIS

We independently assessed study quality and extracted data.

MAIN RESULTS

We identified 23 independent studies meeting the selection criteria: 11 from developing countries (two of which were controlled trials in Honduras) and 12 from developed countries (all observational studies). Definitions of exclusive breastfeeding varied considerably across studies. Neither the trials nor the observational studies suggest that infants who continue to be exclusively breastfed for six months show deficits in weight or length gain, although larger sample sizes would be required to rule out modest differences in risk of undernutrition. In developing-country settings where newborn iron stores may be suboptimal, the evidence suggests that exclusive breastfeeding without iron supplementation through six months may compromise hematologic status. Based on the Belarusian study, six months of exclusive breastfeeding confers no benefit (versus three months of exclusive breastfeeding followed by continued partial breastfeeding through six months) on height, weight, body mass index, dental caries, cognitive ability, or behaviour at 6.5 years of age. Based on studies from Belarus, Iran, and Nigeria, however, infants who continue exclusive breastfeeding for six months or more appear to have a significantly reduced risk of gastrointestinal and (in the Iranian and Nigerian studies) respiratory infection. No significant reduction in risk of atopic eczema, asthma, or other atopic outcomes has been demonstrated in studies from Finland, Australia, and Belarus. Data from the two Honduran trials and from observational studies from Bangladesh and Senegal suggest that exclusive breastfeeding through six months is associated with delayed resumption of menses and, in the Honduran trials, more rapid postpartum weight loss in the mother.

AUTHORS' CONCLUSIONS

Infants who are exclusively breastfed for six months experience less morbidity from gastrointestinal infection than those who are partially breastfed as of three or four months, and no deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for six months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea. Although infants should still be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided, the available evidence demonstrates no apparent risks in recommending, as a general policy, exclusive breastfeeding for the first six months of life in both developing and developed-country settings.

Aflatoxins and growth impairment: a review

Aflatoxins, fungal toxins produced by Aspergillus flavus and Aspergillus parasiticus in a variety of food crops, are well known as potent human hepatocarcinogens. Relatively less highlighted in the literature is the association between aflatoxin and growth impairment in children. Foodborne aflatoxin exposure, especially through maize and groundnuts, is common in much of Africa and Asia--areas where childhood stunting and underweight are also common, due to a variety of possibly interacting factors such as enteric diseases, socioeconomic status, and suboptimal nutrition. The effects of aflatoxin on growth impairment in animals and human children are reviewed, including studies that assess aflatoxin exposure in utero and through breastfeeding. Childhood weaning diets in various regions of the world are briefly discussed. This review suggests that aflatoxin exposure and its association with growth impairment in children could contribute a significant public health burden in less developed countries.

Infant care practices in rural China and their relation to prenatal care utilisation

Studies describing postpartum childcare practices and the influence of prenatal care on infant care outcomes in rural China are scarce. This study looked at data for 1479 women who had given birth during the preceding 2 years (median age of the child was 8 months). Data were available from a Knowledge, Attitude and Perception cross-sectional survey collected from 2001 to 2003, after a prenatal care intervention in Anhui County, China, with a response rate of 97%. Prenatal care utilisation was categorised using the Adequacy of Prenatal Care Utilisation index. Logistic regression was used to study the association between prenatal care utilisation and infant care practices. Mothers' uptake of breastfeeding, introduction of milk formula, cereal/porridge, meat and uptake of any immunisation were found to be in accordance with national recommendations. Intermediate prenatal care uptake was positively associated with never breastfeeding and early introduction of cereal/porridge. Inadequate care was positively associated with never breastfeeding, early introduction of milk formula and cereal/porridge, and early start of work after delivery. Initiation to prenatal care after the third month was positively associated with early introduction of milk formula and cereal/porridge. Having no prenatal care was positively associated with never breastfeeding and early introduction of milk formula. Mothers' uptake of infant care practices in this population was largely in accordance with national recommendations. Women with less than adequate utilisation of prenatal care and those who had initiated prenatal care late were less likely to follow recommendations on infant care.

Breastfeeding in China: a review

This review aims to describe changes in breastfeeding and summarise the breastfeeding rates, duration and reasons of discontinuing 'any breastfeeding' or 'exclusive breastfeeding' in P.R. China. Breastfeeding rates in China fell during the 1970s when the use of breast milk substitutes became widespread, and reached the lowest point in the 1980s. As a result many efforts were introduced to promote breastfeeding. The breastfeeding rate in China started to increase in the 1990s, and since the mid-1990s 'any breastfeeding' rates in the majority of cities and provinces, including minority areas, have been above 80% at four months. But most cities and provinces did not reach the national target of 'exclusive breastfeeding' of 80%. The 'exclusive breastfeeding' rates in minority areas were relatively lower than comparable inland provinces. The mean duration of 'any breastfeeding' in the majority of cities or provinces was between seven and nine months. The common reasons for ceasing breastfeeding, or introducing water or other infant food before four months, were perceived breast milk insufficiency, mother going to work, maternal and child illness and breast problems. Incorrect traditional perceptions have a strong adverse influence on 'exclusive breastfeeding' in less developed areas or rural areas. China is a huge country, geographically and in population size, and there is considerable ethnic diversity. Therefore breastfeeding rates in different parts of China can vary considerably.

Development and evaluation of a Chinese-language newborn feeding hotline: a prospective cohort study

BACKGROUND

Preference for formula versus breast feeding among women of Chinese descent remains a concern in North America. The goal of this study was to develop an intervention targeting Chinese immigrant mothers to increase their rates of exclusive breastfeeding.

METHODS

We convened a focus group of immigrant women of Chinese descent in Vancouver, British Columbia to explore preferences for method of infant feeding. We subsequently surveyed 250 women of Chinese descent to validate focus group findings. Using a participatory approach, our focus group participants reviewed survey findings and developed a priority list for attributes of a community-based intervention to support exclusive breastfeeding in the Chinese community. The authors and focus group participants worked as a team to plan, implement and evaluate a Chinese language newborn feeding information telephone service staffed by registered nurses fluent in Chinese languages.

RESULTS

Participants in the focus group reported a strong preference for formula feeding. Telephone survey results revealed that while pregnant Chinese women understood the benefits of breastfeeding, only 20.8% planned to breastfeed exclusively. Only 15.6% were breastfeeding exclusively at two months postpartum. After implementation of the feeding hotline, 20% of new Chinese mothers in Vancouver indicated that they had used the hotline. Among these women, the rate of exclusive breastfeeding was 44.1%; OR 3.02, (95% CI 1.78-5.09) compared to women in our survey.

CONCLUSION

Initiation of a language-specific newborn feeding telephone hotline reached a previously underserved population and may have contributed to improved rates of exclusive breastfeeding.

Initiation of breastfeeding and prevalence of exclusive breastfeeding at hospital discharge in urban, suburban and rural areas of Zhejiang China

BACKGROUND

Rates of exclusive breastfeeding in China are relatively low and below national targets. The aim of this study was to document the factors that influence exclusive breastfeeding initiation in Zhejiang, PR China.

METHODS

A cohort study of infant feeding practices was undertaken in Zhejiang Province, an eastern coastal region of China. A total of 1520 mothers who delivered in four hospitals located in city, suburb and rural areas during late 2004 to 2005 were enrolled in the study. Multivariate logistic regression analysis was used to explore factors related to exclusive breastfeeding initiation.

RESULTS

On discharge from hospital, 50.3% of the mothers were exclusively breastfeeding their infants out of 96.9% of the mothers who had earlier initiated breastfeeding. Exclusive breastfeeding was positively related to vaginal birth, baby's first feed being breast milk, mother living in the suburbs or rural areas, younger age of mother, lower maternal education level and family income.

CONCLUSION

The exclusive breastfeeding rate in Zhejiang is only 50.3% on discharge and does not reach Chinese or international targets. A number of behaviours have been identified in the study that could be potentially incorporated into health promotion activities.

Changing dietary habits of ethnic groups in Europe and implications for health

A systematic review of the literature suggests the dietary habits of some ethnic groups living in Europe are likely to become less healthy as individuals increase consumption of processed foods that are energy dense and contain high levels of fat, sugar, and salt. Such products often replace healthy dietary components of the native diet, such as fruits, vegetables, nuts, and grains. Mixed food habits are emerging mainly amongst younger people in the second and third generations, most likely due to acculturation and adoption of a Western lifestyle. Age and immigrant generation are the major factors accounting for changes in dietary habits, whilst income, level of education, dietary laws, religion, and food beliefs are also important factors. Obesity, cardiovascular disease, diabetes, and hypertension present major problems for the mainstream European population. However, the risk of chronic disease is reported to be higher in ethnic populations, particularly South Asians, African Caribbeans, and Mexicans.

Optimal duration of exclusive breastfeeding

BACKGROUND

: Although the health benefits of breastfeeding are widely acknowledged, opinions and recommendations are strongly divided on the optimal duration of exclusive breastfeeding. Much of the debate has centered on the so-called 'weanling's dilemma' in developing countries: the choice between the known protective effect of exclusive breastfeeding against infectious morbidity and the (theoretical) insufficiency of breast milk alone to satisfy the infant's energy and micronutrient requirements beyond four months of age. The debate over whether to recommend exclusive breastfeeding for four to six months versus 'about six months' has recently become heated and acrimonious.

OBJECTIVES

: The primary objective of this review was to assess the effects on child health, growth, and development, and on maternal health, of exclusive breastfeeding for six months versus exclusive breastfeeding for three to four months with mixed breastfeeding (introduction of complementary liquid or solid foods with continued breastfeeding) thereafter through six months. A secondary objective was to assess the child and maternal health effects of prolonged (greater than six months) exclusive breastfeeding versus exclusive breastfeeding for six months followed by mixed breastfeeding thereafter.

SEARCH STRATEGY

: Two independent literature searches were carried out, together comprising the following databases: MEDLINE (as of 1966), Index Medicus (prior to 1966), CINAHL, HealthSTAR, BIOSIS, CAB Abstracts, EMBASE-Medicine, EMBASE-Psychology, Econlit, Index Medicus for the WHO Eastern Mediterranean Region, African Index Medicus, Lilacs (Latin American and Caribbean literature), EBM Reviews-Best Evidence, the Cochrane Database of Systematic Reviews (The Cochrane Library Issue 3, 2000), and the Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2000). No language restrictions were imposed. The two searches yielded a total of 2,668 unique citations. Contacts with experts in the field yielded additional published and unpublished studies.

SELECTION CRITERIA

: We selected all internally-controlled clinical trials and observational studies comparing child or maternal health outcomes with exclusive breastfeeding for six or more months versus exclusive breastfeeding for at least three to four months with continued mixed breastfeeding until at least six months. Studies were stratified according to study design (controlled trials versus observational studies), provenance (developing versus developed countries), and timing of compared feeding groups (three to seven months versus later).

DATA COLLECTION AND ANALYSIS

: Two reviewers independently assessed study quality (using a priori assessment criteria) and extracted data.

MAIN RESULTS

: Twenty independent studies meeting the selection criteria were identified by the literature search: nine from developing countries (two of which were controlled trials in Honduras) and 11 from developed countries (all observational studies). The two trials did not receive high methodologic quality ratings but were nonetheless superior to any of the observational studies included in this review. The observational studies were of variable quality; in addition, their nonexperimental designs were not able to exclude potential sources of confounding and selection bias. Definitions of exclusive breastfeeding varied considerably across studies. Neither the trials nor the observational studies suggest that infants who continue to be exclusively breastfed for six months show deficits in weight or length gain, although larger sample sizes would be required to rule out modest differences in risk of undernutrition. The data are conflicting with respect to iron status, but at least in developing country settings where newborn iron stores may be suboptimal, suggest that exclusive breastfeeding without iron supplementation through six months may compromise hematologic status. Based primarily on an observational analysis of a large randomized trial in Belarus, infants who continue exclusive breastfeeding for six months or more appear to have a significantly reduced risk of one or more episodes of gastrointestinal infection. No significant reduction in risk of atopic eczema, asthma, or other atopic outcomes has been demonstrated in studies from Finland, Australia, and Belarus. Data from the two Honduran trials suggest that exclusive breastfeeding through six months is associated with delayed resumption of menses and more rapid postpartum weight loss in the mother.

REVIEWER'S CONCLUSIONS

: We found no objective evidence of a 'weanling's dilemma'. Infants who are exclusively breastfed for six months experience less morbidity from gastrointestinal infection than those who are mixed breastfed as of three or four months, and no deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for six months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea. Although infants should still be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided, the available evidence demonstrates no apparent risks in recommending, as a general policy, exclusive breastfeeding for the first six months of life in both developing and developed country settings. Large randomized trials are recommended in both types of setting to rule out small effects on growth and to confirm the reported health benefits of exclusive breastfeeding for six months or beyond.