How multiple episodes of exclusive breastfeeding impact estimates of exclusive breastfeeding duration: report from the eight-site MAL-ED birth cohort study

Infant and Maternal Morbidity Symptoms as Predictors for the Interruption of Exclusive Breastfeeding in Lima, Peru: A Prospective Study

INTRODUCTION

The global prevalence of exclusive breastfeeding for 6 months is 48%. This analysis examined the relationship between infant and maternal morbidity symptoms and the interruption of exclusive breastfeeding.

METHODS

Data from a cohort study among women living in a peri-urban community in Peru were used. Data were collected during pregnancy, birth, and the first 6 months postpartum among 179 dyads...

RESULTS

After the first month, interruption of exclusive breastfeeding was almost twofold (adjusted odds ration [aOR] = 1.99, 95% confidence interval [CI]: 1.14, 3.45) more likely among infants with symptoms (e.g., diarrhea, cough) than those without. Maternal morbidity symptoms (e.g., gastrointestinal, respiratory) and breast problems were positively associated with interruption of exclusive breastfeeding throughout the first 6 months (aOR = 1.77, 95% CI: 1.11, 2.82 and aOR = 3.23, 95% CI: 1.84, 5.69, respectively).

DISCUSSION

Mother-infant dyads often experience illness symptoms that are not contraindications to breastfeeding. Health professionals need to reinforce that exclusive breastfeeding should continue during illness.

Short-term dynamics of linear growth among Peruvian infants in the first year of life in a population with linear growth faltering

OBJECTIVES

Infant growth is recognized to vary over the short term, with periods of greater and lesser linear growth velocity. Our objectives were to (1) examine the potential differences in overall growth profiles between children who experienced cumulative growth faltering in the first year of life consistent with that seen by many children living in poverty in low- and middle-income countries, versus children without growth faltering and (2) test whether biological factors were associated with the timing of magnitude of growth saltations.

METHODS

Thrice-weekly measurements of length were recorded for n = 61 Peruvian infants (28 boys and 33 girls) enrolled from birth to 1 year. A total of 6040 measurements were analyzed. We tested for the evidence of saltatory growth and used hurdle models to test whether the timing and magnitude of saltations varied between children with greater or lesser growth faltering.

RESULTS

There were no differences in the duration of stasis periods or magnitude of growth saltations between children who were stunted at 1 year old (N = 18) versus those who were not stunted (N = 43). Children who experienced greater declines in LAZ in the first year of life trended toward longer periods between saltations than those with less of a decline (14.5 days vs. 13.4 days, p = .0512). A 1-unit increase in mid upper arm circumference for age Z-score in the 21 days prior was associated with 35% greater odds of a saltation occurring (p < .001), and a 0.128 cm greater saltation (p < .001).

CONCLUSIONS

After characterizing infant growth into periods of saltation and stasis, our results suggest that increases in weight preceded increases in length.

Infections and nutrient deficiencies during infancy predict impaired growth at 5 years: Findings from the MAL-ED study in Pakistan

Background

Socio-economic, nutritional, and infectious factors have been associated with impaired infant growth, but how the presence of these factors during infancy affects growth around 5 years is not well understood.

Methods

This secondary analysis of the MAL-ED cohort included 277 children from Pakistan for whom socio-demographic, breastfeeding, complementary foods, illness, nutritional biomarkers, stool pathogens and environmental enteropathy indicators between 0 and 11 months were recorded. We used linear regression models to analyze associations of these indicators with height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height (WLZ) at 54-66 months (~5 years), and Poisson regression with robust standard errors to estimate risk ratios for stunting and underweight ~5 years, controlling for gender, first available weight, and income.

Results

Among the 237 infants followed longitudinally and evaluated at about 5 years of age, exclusive breastfeeding was short (median = 14 days). Complementary feeding started before 6 months with rice, bread, noodles, or sugary foods. Roots, dairy products, fruits/vegetables, and animal-source foods were provided later than recommended (9-12 months). Anemia (70.9%), deficiencies in iron (22.0%), zinc (80.0%), vitamin A (53.4%) and iodine (13.3%) were common. Most infants (>90%) presented with diarrhea and respiratory infections in their first year. At ~5 years, low WAZ (mean-1.91 ± 0.06) and LAZ (-2.11 ± 0.06) resulted in high prevalence of stunting (55.5%) and underweight (44.4%) but a relatively low rate of wasting (5.5%). While 3.4% had concurrent stunting and wasting ~5 years, 37.8% of children had coexisting stunting and underweight. A higher income and receiving formula or dairy products during infancy were associated with a higher LAZ ~5 years, but infant's history of hospitalizations and more respiratory infections were associated with lower LAZ and higher risk of stunting ~5 years. Infants' intake of commercial baby foods and higher serum-transferrin receptors were associated with higher WAZ and lower risk of underweight ~5 years. Presence of Campylobacter and fecal neopterin >6.8 nmol/L in the first year were associated with increased risk of underweight ~5 years.

Conclusion

Growth indicators ~5 years were associated with poverty, inappropriate complementary feeding, and infections during the first year of life, which supports the early start of public health interventions for preventing growth delay ~5 years.

Full breastfeeding protection against common enteric bacteria and viruses: results from the MAL-ED cohort study

BACKGROUND

Breastfeeding is known to reduce the risk of enteropathogen infections, but protection from specific enteropathogens is not well characterized.

OBJECTIVE

The aim was to estimate the association between full breastfeeding (days fed breast milk exclusively or with nonnutritive liquids) and enteropathogen detection.

METHODS

A total of 2145 newborns were enrolled at 8 sites, of whom 1712 had breastfeeding and key enteropathogen data through 6 mo. We focused on 11 enteropathogens: adenovirus 40/41, norovirus, sapovirus, astrovirus, and rotavirus, enterotoxigenic Escherichia coli (ETEC), Campylobacter spp., and typical enteropathogenic E. coli as well as entero-aggregative E. coli, Shigella and Cryptosporidium. Logistic regression was used to estimate the risk of enteropathogen detection in stools and survival analysis was used to estimate the timing of first detection of an enteropathogen.

RESULTS

Infants with 10% more days of full breastfeeding within the preceding 30 d of a stool sample were less likely to have the 3 E. coli and Campylobacter spp. detected in their stool (mean odds: 0.92-0.99) but equally likely (0.99-1.02) to have the viral pathogens detected in their stool. A 10% longer period of full breastfeeding from birth was associated with later first detection of the 3 E. coli, Campylobacter, adenovirus, astrovirus, and rotavirus (mean HRs of 0.52-0.75). The hazards declined and point estimates were not statistically significant at 3 mo.

CONCLUSIONS

In this large multicenter cohort study, full breastfeeding was associated with lower likelihood of detecting 4 important enteric pathogens in the first 6 mo of life. These results also show that full breastfeeding is related to delays in the first detection of some bacterial and viral pathogens in the stool. As several of these pathogens are risk factors for poor growth during childhood, this work underscores the importance of exclusive or full breastfeeding during the first 6 mo of life to optimize early health.

Characteristics associated with the transition to partial breastfeeding prior to 6 months of age: Data from seven sites in a birth cohort study

The WHO recommends exclusive breastfeeding for the first 6 months of life. However, the transition of the infants' diet to partial breastfeeding with the addition of animal milks and/or solids typically occurs earlier than this. Here, we explored factors associated with the timing of an early transition to partial breastfeeding across seven sites of a birth cohort study in which twice weekly information on infant feeding practices was collected. Infant (size, sex, illness and temperament), maternal (age, education, parity and depressive symptoms), breastfeeding initiation practices (time of initiation, colostrum and pre‐lacteal feeding) and household factors (food security, crowding, assets, income and resources) were considered. Three consecutive caregiver reports of feeding animal milks and/or solids (over a 10‐day period) were characterized as a transition to partial breastfeeding, and Cox proportional hazard models with time (in days) to partial breastfeeding were used to evaluate associations with both fixed and time‐varying characteristics. Overall, 1470 infants were included in this analysis. Median age of transition to partial breastfeeding ranged from 59 days (South Africa and Tanzania) to 178 days (Bangladesh). Overall, higher weight‐for‐length z‐scores were associated with later transitions to partial breastfeeding, as were food insecurity, and infant cough in the past 30 days. Maternal depressive symptoms (evaluated amongst 1227 infants from six sites) were associated with an earlier transition to partial breastfeeding. Relative thinness or heaviness within each site was related to breastfeeding transitions, as opposed to absolute z‐scores. Further research is needed to understand relationships between local perceptions of infant body size and decisions about breastfeeding.

Vulnerable families and costly formula: a qualitative exploration of infant formula purchasing among peri-urban Peruvian households

BACKGROUND

Substantial evidence exists surrounding the health risks of breast milk substitutes (BMS) in place of exclusive breastfeeding among infants < 6 months of age in resource-poor settings. Yet, mothers' experiences of selecting and purchasing BMS brands have not been well studied to date. This qualitative study explored the factors influencing BMS purchasing practices, along with the consequences of those decisions, in peri-urban Lima, Peru.

METHODS

We conducted in-depth interviews (IDIs) with 29 mothers who had begun mixed-feeding their infants during the first 6 months of life. Interviews explored participants' reasons for initiating infant formula use and their experiences of selecting, purchasing, and providing BMS to their children. Audio recordings were transcribed, coded, and key themes and illustrative vignettes were identified.

RESULTS

The primary reported reasons for initiating infant formula use included having received a recommendation for infant formula from a healthcare provider, concerns about an infant's weight gain, and the perception of insufficient breast milk. Mothers tended to initially purchase the BMS brand that had been recommended by a doctor, which was often more expensive than the alternatives. The costs of BMS, which escalated as infants grew, often disrupted the household economy and generated significant stress. While some mothers identified alternatives allowing them to continue purchasing the same brand, others chose to switch to less expensive products. Several mothers began to feed their infants follow-on formula or commercial milk, despite their awareness that such practices were not recommended for infants under 6 months of age. The approval of family members and the absence of an infant's immediate adverse reaction influenced mothers' decisions to continue purchasing these products.

CONCLUSIONS

The high costs of BMS may deepen existing socio-economic vulnerabilities and generate new risks for infant health. The continued dedication of resources towards breastfeeding education and support is critical, and strategies would benefit from underscoring the long-term financial and health consequences of infant formula use, and from strengthening women's self-efficacy to refuse to initiate infant formula when recommended. In addition, health providers should be trained in counseling to help women to relactate or return to exclusive breastfeeding after cessation.

Factors associated with head circumference and indices of cognitive development in early childhood

BACKGROUND

While head circumference (HC) has been related to intracranial volume and brain size, its association with cognitive function remains unclear. We sought to understand the relationship among various biological and socioeconomic risk factors, HC and cognitive development.

METHODS

We analysed data across resource-poor settings in Bangladesh, India, Nepal, Peru, South Africa and Tanzania from the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development longitudinal birth cohort study. Participating children were enrolled and followed up between 2009 and 2014. A final sample of 1210 children aged 0-24 months were included in the analyses. The main outcomes were HC for age Z-score and cognitive, gross motor and language scores from Bayley Scales of Infant Development-III tests. Length, weight and HC were measured monthly, and cognitive tests were administered at 6, 15 and 24 months of age. To disentangle the associations between risk factors and HC from linear growth and to distinguish the direct and indirect effects of these risk factors on cognitive function, we conducted mediation analysis using longitudinal models to account for all data measured during follow-up.

RESULTS

Average HC-for-age Z-score (HCAZ) was -0.54 (95% CI -0.47 to -0.62) near birth and -1.01 (95% CI -0.94 to -1.08) at 24 months. Children with higher enrolment weight (p<0.0001), higher socioeconomic score (p=0.00037) and taller mothers (p=0.00084) had higher HCAZ at all ages, while enteropathogen infection (p=0.013) and more febrile episodes (p=0.013) were associated with lower HCAZ. The associations between HCAZ and enrolment weight-for-age, maternal height, socioeconomic status or pathogen burden were partly mediated through their associations with length-for-age. HCAZ showed no association with cognitive, gross motor or language skills at 6, 15 and 24 months of age.

CONCLUSIONS

The main risk factors associated with HC are similar to those associated with body length, and HC is not related to cognitive function.

Reported infant feeding practices and contextual influences on breastfeeding: qualitative interviews with women registered to MomConnect in three South African provinces

Background

Global guidelines recommend exclusive breastfeeding (EBF) for the first 6 months of life. South African EBF rates have steadily increased but still only average 32% for infants below 6 months of age. Malnutrition and developmental delays continue to contribute substantially to the morbidity and mortality of South African children. MomConnect, a national mHealth messaging system used to send infant and maternal health messages during and after pregnancy, has a specific focus on improving rates of breastfeeding and has achieved high rates of population coverage.

Methods

For this qualitative study, we interviewed women who were registered to MomConnect to investigate their breastfeeding and other infant feeding practices, decision-making pre- and post-delivery, and the role of the health system, family members and the wider community in supporting or detracting from breastfeeding intentions. Data were collected from February–March 2018 in South Africa’s KwaZulu-Natal, Free State and Gauteng provinces. Framework analysis was conducted to identify common themes.

Results

Most women interviewed had breastfed, including HIV-positive women. Even when women had delivered by caesarean section, they had usually been able to initiate breastfeeding a few hours after birth. Understandings of EBF varied in thoroughness and there was some confusion about the best way to cease breastfeeding. Most women felt well-equipped to make infant feeding decisions and to stick to their intentions, but returning to work or school sometimes prevented 6 months of EBF. Advice from the health system (both via clinics and MomConnect) was considered helpful and supportive in encouraging EBF to 6 months, although family influences could thwart these intentions, especially for younger women. Mothers reported a range of breastfeeding information sources that influenced their choices, including social media.

Conclusions

Efforts to improve EBF rates must include consideration of the social and economic environment surrounding women. Interventions that focus only on improving women’s knowledge are valuable but insufficient on their own. Attention should also be paid to infant behaviors, and how these affect women’s breastfeeding choices. Finally, although there is strong local policy support for EBF, more rigorous implementation of these and other broader changes to create a more enabling structural environment ought to be prioritized.

Micronutrient intake and the probability of nutrient adequacy among children 9-24 months of age: results from the MAL-ED birth cohort study

Objective:

To estimate the total energy and micronutrient intakes of children 9–24 months of age and evaluate the probability of adequacy (PA) of the diet in seven MAL-ED sites.

Design:

Cohort study. Food intake was registered monthly using 24-h recalls beginning at 9 months. We estimated PA for thirteen nutrients and overall mean PA (MPA) by site and 3-month periods considering estimated breast milk intake.

Setting:

Seven sites in Asia, Africa and Latin America.

Participants:

1669 children followed from birth to 24 months of age.

Results:

Median estimated %energy from breast milk ranged from 4 to 70 % at 9–12 months, and declined to 0–39 % at 21–24 months. Iron bioavailability was low for all sites, but many diets were of moderate bioavailability for zinc. PA was optimal for most nutrients in Brazil and South Africa, except for iron and vitamin E (both), calcium and zinc (South Africa). PA for zinc increased only for children consuming a diet with moderate bioavailability. MPA increased 12–24 months as the quantity of complementary foods increased; however, PA for vitamin A remained low in Bangladesh and Tanzania. PA for vitamins D and E and iron was low for most sites and age groups.

Conclusions:

MPA increased from 12 to 24 months as children consumed higher quantities of food, while nutrient density remained constant for most nutrients. Ways to increase the consumption of foods containing vitamins D, E and A, and calcium are needed, as are ways to increase the bioavailability of iron and zinc.

Impact of early-onset persistent stunting on cognitive development at 5 years of age: Results from a multi-country cohort study

Background

Globally more than 150 million children under age 5 years were stunted in 2018, primarily in low- and middle-income countries (LMICs), and the impact of early-onset, persistent stunting has not been well explored. To explore the association between early-onset persistent stunting in children and cognitive development at 5 years of age, and to identify the factors associated with early-onset stunting.

Methods and findings

Children from the MAL-ED cohort study were followed from birth to 5 years of age in six LMICs. The Wechsler Preschool Primary Scales of Intelligence (WPPSI) was used to assess cognitive abilities (fluid reasoning) at 5 years and was adapted for each culture. Stunting was categorized as early-onset persistent (first stunted at 1–6 months and persisting at 60 months), early-onset recovered (first stunted at 1–6 months and not stunted at 60 months), late-onset persistent (first stunted at 7–24 months and persisting at 60 months), late-onset recovered (first stunted at 7–24 months and not stunted at 60 months), and never (never stunted). Mixed effects linear models were used to estimate the relationship between stunting status and cognitive development. Children with early-onset persistent stunting had significantly lower cognitive scores (-2.10 (95% CI: -3.85, -0.35)) compared with those who were never stunted. Transferrin receptor (TfR) was also negatively associated with cognitive development (-0.31 (95% CI: -0.49, -0.13)), while the HOME inventory, an index of quality of the home environment (0.46 (95% CI: 0.21, 0.72)) and socio-economic status (1.50 (95% CI: 1.03, 1.98)) were positively associated with cognitive development.

Conclusions

Early-onset persistent stunting was associated with lower cognitive development in children at 5 years of age in this cohort of children.

Feeding practices and risk factors for chronic infant undernutrition among refugees and migrants along the Thailand-Myanmar border: a mixed-methods study

BACKGROUND

This study aims to provide a comprehensive understanding of maternal risk factors, infant risk factors and maternal infant feeding practices among refugees and migrants along the Thailand-Myanmar border.

METHODS

This study employed a mixed-methods approach with two components: (1) cross-sectional survey (n = 390) and (2) focus group discussions (n = 63). Participants were chosen from one of three clinics providing antenatal and delivery services for Karen and Burman refugees and migrants along the border. Participants were pregnant women and mother-infant dyads.

RESULTS

Refugee and migrant mothers demonstrated high rates of suboptimal breastfeeding and low rates of minimum dietary diversity and acceptable diet. Multivariable regression models showed infant stunting (AOR: 2.08, 95% CI: 1.12, 3.84, p = 0.020) and underweight (AOR: 2.26, 95% CI: 1.17, 4.36, p = 0.015) to have increased odds among migrants, while each 5 cm increase in maternal height had decreased odds of stunting (AOR: 0.50, 95% CI: 0.38, 0.66, p < 0.001) and underweight (AOR: 0.64, 95% CI: 0.48, 0.85, p = 0.002). In addition, small-for-gestational-age adjusted for length of gestation, infant age and gender increased odds of infant's stunting (AOR: 3.42, 95% CI: 1.88, 6.22, p < 0.001) and underweight (AOR: 4.44, 95% CI: 2.36, 8.34, p < 0.001). Using the Integrated Behavioural Model, focus group discussions explained the cross-sectional findings in characterising attitudes, perceived norms, and personal agency as they relate to maternal nutrition, infant malnutrition, and infant feeding practices.

CONCLUSIONS

Inadequate infant feeding practices are widespread in refugee and migrant communities along the Thailand-Myanmar border. Risk factors particular to maternal nutrition and infant birth should be considered for future programming to reduce the burden of chronic malnutrition in infants.

Minimizing the Relationship Between Early Formula Use and Breastfeeding Cessation by Limiting Formula Volume

Objective: Early exposure to formula can interfere with successful long-term breastfeeding. The objective of this study was to determine whether limiting the volume of formula used in the first month attenuates formula's detrimental impact on long-term breastfeeding success. Materials and Methods: Using detailed data on dietary intake from a randomized clinical trial, we conducted a secondary analysis of the association between volume of formula received in the first month and breastfeeding cessation before 6 and 12 months of age. We used descriptive statistics and multivariable logistic regression, respectively, to explore this association without and with adjustment for demographic and clinical predictors of infant feeding. Results: Among 199 breastfeeding infants, 80 (40%) received formula daily at 1 month of age, and breastfeeding cessation before 6 and 12 months of age was higher for these infants (46% and 67%) than for those breastfed exclusively (6% and 27%) (p < 0.0005 for each). The risk of cessation did not differ between those who received ≤4 fl oz daily in the first month (11%) and those who did not receive formula in the first month (6%) (p = 0.42). Adjusting for gestational age, race/ethnicity, income, and intention to breastfeed exclusively, the odds ratio for the outcome of cessation before 6 months was 1.15 (95% confidence interval = 0.20-6.67) for infants who received ≤4 fl oz daily compared with those who breastfed exclusively. Conclusion: Limiting formula volumes to ≤4 fl oz daily may attenuate the deleterious association between early formula use and subsequent successful breastfeeding.

Factors associated with exclusive breastfeeding practice in a cohort of women from Cali, Colombia

Introduction:

Breastfeeding promotion is one of the most effective strategies to prevent child malnutrition; it reduces costs to families, health services and society. In Colombia, exclusive breastfeeding is practiced only by 10% of women.

Objective:

To identify factors associated with the duration of exclusive breastfeeding.

Methods:

A cohort of 438 primiparous women was followed during 6 months by means of 8 home interviews, in order to determine the duration of exclusive breastfeeding. Individual, family and health service factors were studied; and survival analysis was carried out.

Results:

At 8 days, only a few more than half of the participants maintained exclusive breastfeeding; at month 6 of follow-up, this proportion was reduced to 1.4%. The duration of exclusive breastfeeding was determined by: initiation of breastfeeding in the first 4 hours after delivery (HR= 4.07, 95% CI: 0.96-16.67), self-perceived sureness for breastfeeding (HR= 1.28, 95% CI: 1.04 -1.58), positive opinion of the baby's father regarding breastfeeding (HR= 1.26, 95% CI: 1.01-1.57), and newborn weight (HR= 1.23, 95% CI: 1.00-1.53).

Conclusion:

There are factors before delivery and in the immediate puerperium that determine, partially, the duration of exclusive breastfeeding.

Uncovering the barriers to exclusive breastfeeding for mothers living in Dhaka's slums: a mixed method study

Background

Despite the substantial impact on child and maternal health, breastfeeding practices for infants remain at the suboptimum level in Bangladesh. Yet the understanding of why these practices are suboptimal, especially surrounding urban slum dwelling mothers, is unclear. The purpose of this study was to assess early infant feeding practices, examine associations with maternal factors, and uncover the facilitators and barriers to early feeding practices in selected slums of Dhaka, Bangladesh.

Methods

A mixed method study was conducted from June to September 2016 using both quantitative and qualitative methods among mothers with children under the age of 6 months. The survey included 342 mother-infant pairs and 18 in-depth interviews were conducted. Univariate and multiple logistic regression was used to determine status of early infant feeding practices and factors associated with exclusive breastfeeding (EBF) within the previous 24 h. Transcripts were coded to uncover the facilitators and barriers surrounding early infant feeding practices.

Results

Sixty four percent (220/342) of mothers initiated breastfeeding within 1 h, 96.5% (330/342) reported feeding colostrum, and 36.3% (124/342) infants were EBF in the last 24 h. After adjusting for child gender, maternal age, education, diet and household income; infant’s age (adjusted odds ratio (AOR) for 61–120 days 6.42; 95% CI 3.42, 12.1; AOR for 121–180 days 45.6; 95% CI 18.33, 113.45), prelacteal feeding (AOR 2.53; 95% CI 1.14, 4.58), lack of planning for EBF during pregnancy (AOR 4.06; 95% CI 1.09, 15.12) and infants delivered by cesarean section (AOR 2.76; 95% CI 1.34, 5.67) were negatively associated with EBF. During the 18 interviews, eight mothers reported a cesarean delivery and none of these mothers initiated breastfeeding within 1 h or exclusively breastfed. Moreover, all eight mothers gave their infants prelacteal feeds.

Conclusions

The status of early infant feeding practices in Dhaka’s slums was poor. The negative impact of cesarean section on all early infant feeding practices was evident in both quantitative and qualitative analysis.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Relationships among Common Illness Symptoms and the Protective Effect of Breastfeeding in Early Childhood in MAL-ED: An Eight-Country Cohort Study

Children in low-income countries experience multiple illness symptoms in early childhood. Breastfeeding is protective against diarrhea and respiratory infections, and these illnesses are thought to be risk factors of one another, but these relationships have not been explored simultaneously. In the eight-site MAL-ED study, 1,731 infants were enrolled near birth and followed for 2 years. We collected symptoms and diet information through twice-weekly household visits. Poisson regression was used to determine if recent illness history was associated with incidence of diarrhea or acute lower respiratory infections (ALRI), accounting for exclusive breastfeeding. Recent diarrhea was associated with higher risk of incident diarrhea after the first 6 months of life (relative risk [RR] 1.10, 95% confidence interval [CI] 1.04, 1.16) and with higher risk of incident ALRI in the 3- to 5-month period (RR 1.23, 95% CI 1.03, 1.47). Fever was a consistent risk factor for both diarrhea and ALRI. Exclusive breastfeeding 0-6 months was protective against diarrhea (0-2 months: RR 0.39, 95% CI 0.32, 0.49; 3-5 months: RR 0.83, 95% CI 0.75, 0.93) and ALRI (3-5 months: RR 0.81, 95% CI 0.68, 0.98). Children with recent illness who were exclusively breastfed were half as likely as those not exclusively breastfed to experience diarrhea in the first 3 months of life. Recent illness was associated with greater risk of new illness, causing illnesses to cluster within children, indicating that specific illness-prevention programs may have benefits for preventing other childhood illnesses. The results also underscore the importance of exclusive breastfeeding in the first 6 months of life for disease prevention.

Childhood stunting in relation to the pre- and postnatal environment during the first 2 years of life: The MAL-ED longitudinal birth cohort study

BACKGROUND

Stunting is the most prevalent manifestation of childhood malnutrition. To characterize factors that contribute to stunting in resource-poor settings, we studied a priori selected biological and social factors collected longitudinally in a cohort of newborns.

METHODS AND FINDINGS

We enrolled 1,868 children across 7 resource-poor settings in Bangladesh, Brazil, India, Nepal, Peru, South Africa, and Tanzania shortly after birth and followed them for 24 months between 2 November 2009 and 28 February 2014. We collected longitudinal anthropometry, sociodemographic factors, maternal-reported illnesses, and antibiotic use; child feeding practices; dietary intake starting at 9 months; and longitudinal blood, urine, and stool samples to investigate non-diarrheal enteropathogens, micronutrients, gut inflammation and permeability, and systemic inflammation. We categorized length-for-age Z-scores into 3 groups (not stunted, ≥-1; at risk, <-1 to -2; and stunted, <-2), and used multivariable ordinal logistic regression to model the cumulative odds of being in a lower length-for-age category (at risk or stunted). A total of 1,197 children with complete longitudinal data were available for analysis. The prevalence of having a length-for-age Z-score below -1 increased from 43% (range 37%-47% across sites) shortly after birth (mean 7.7 days post-delivery, range 0 to 17 days) to 74% (16%-96%) at 24 months. The prevalence of stunting increased 3-fold during this same time period. Factors that contributed to the odds of being in a lower length-for-age category at 24 months were lower enrollment weight-for-age (interquartile cumulative odds ratio = 1.82, 95% CI 1.49-2.23), shorter maternal height (2.38, 1.89-3.01), higher number of enteropathogens in non-diarrheal stools (1.36, 1.07-1.73), lower socioeconomic status (1.75, 1.20-2.55), and lower percent of energy from protein (1.39, 1.13-1.72). Site-specific analyses suggest that reported associations were similar across settings. While loss to follow-up and missing data are inevitable, some study sites had greater loss to follow-up and more missing data than others, which may limit the generalizability of the findings.

CONCLUSIONS

Neonatal and maternal factors were early determinants of lower length-for-age, and their contribution remained important throughout the first 24 months of life, whereas the average number of enteropathogens in non-diarrheal stools, socioeconomic status, and dietary intake became increasingly important contributors by 24 months relative to neonatal and maternal factors.

Epidemiology of enteroaggregative Escherichia coli infections and associated outcomes in the MAL-ED birth cohort

Background

Enteroaggregative E. coli (EAEC) have been associated with mildly inflammatory diarrhea in outbreaks and in travelers and have been increasingly recognized as enteric pathogens in young children with and without overt diarrhea. We examined the risk factors for EAEC infections and their associations with environmental enteropathy biomarkers and growth outcomes over the first two years of life in eight low-resource settings of the MAL-ED study.

Methods

EAEC infections were detected by PCR gene probes for aatA and aaiC virulence traits in 27,094 non-diarrheal surveillance stools and 7,692 diarrheal stools from 2,092 children in the MAL-ED birth cohort. We identified risk factors for EAEC and estimated the associations of EAEC with diarrhea, enteropathy biomarker concentrations, and both short-term (one to three months) and long-term (to two years of age) growth.

Results

Overall, 9,581 samples (27.5%) were positive for EAEC, and almost all children had at least one detection (94.8%) by two years of age. Exclusive breastfeeding, higher enrollment weight, and macrolide use within the preceding 15 days were protective. Although not associated with diarrhea, EAEC infections were weakly associated with biomarkers of intestinal inflammation and more strongly with reduced length at two years of age (LAZ difference associated with high frequency of EAEC detections: -0.30, 95% CI: -0.44, -0.16).

Conclusions

Asymptomatic EAEC infections were common early in life and were associated with linear growth shortfalls. Associations with intestinal inflammation were small in magnitude, but suggest a pathway for the growth impact. Increasing the duration of exclusive breastfeeding may help prevent these potentially inflammatory infections and reduce the long-term impact of early exposure to EAEC.

Enteroaggregative E. coli (EAEC) are pathogens that infect the intestine and can cause diarrhea. They are also commonly identified among young children in low-resource settings, who can carry the pathogen without symptomatic diarrhea. We examined the risk factors for EAEC infections and their associations with child health outcomes over the first two years of life in eight low-resource settings of the MAL-ED study. EAEC infections were detected using molecular methods in more than 30,000 stools collected from 2,092 children in the MAL-ED study. We identified risk factors for EAEC and estimated the associations of EAEC with diarrhea, markers of intestinal health, and child growth. Almost all children were infected with EAEC at least once by two years of age. Exclusive breastfeeding, higher enrollment weight, and recent macrolide antibiotic use were protective against these infections. Although not associated with diarrhea in these children, EAEC infections were associated with intestinal inflammation and reduced length at two years of age. EAEC may impact child development, even in the absence of diarrhea, by causing intestinal inflammation and impairing child growth.

Infant Nutritional Status, Feeding Practices, Enteropathogen Exposure, Socioeconomic Status, and Illness Are Associated with Gut Barrier Function As Assessed by the Lactulose Mannitol Test in the MAL-ED Birth Cohort

The lactulose mannitol (LM) dual sugar permeability test is the most commonly used test of environmental enteropathy in developing countries. However, there is a large but conflicting literature on its association with enteric infection and host nutritional status. We conducted a longitudinal cohort using a single field protocol and comparable laboratory procedures to examine intestinal permeability in multiple, geographically diverse pediatric populations. Using a previously published systematic review to guide the selection of factors potentially associated with LM test results, we examined the relationships between these factors and mucosal breach, represented by percent lactulose excretion; absorptive area, represented by percent mannitol excretion; and gut barrier function, represented by the L/M ratio. A total of 6,602 LM tests were conducted in 1,980 children at 3, 6, 9, and 15 months old; percent lactulose excretion, percent mannitol excretion, and the L/M ratio were expressed as age- and sex-specific normalized values using the Brazil cohort as the reference population. Among the factors considered, recent severe diarrhea, lower socioeconomic status, and recent asymptomatic enteropathogen infections were associated with decreased percent mannitol excretion and higher L/M ratios. Poorer concurrent weight-for-age, infection, and recent breastfeeding were associated with increased percent lactulose excretion and increased L/M ratios. Our results support previously reported associations between the L/M ratio and factors related to child nutritional status and enteropathogen exposure. These results were remarkably consistent across sites and support the hypothesis that the frequency of these exposures in communities living in poverty leads to alterations in gut barrier function.

The Role of Early Maternal Support in Balancing Full-Time Work and Infant Exclusive Breastfeeding: A Qualitative Study

INTRODUCTION

Support of others is a key factor for mothers who choose to breastfeed their infants, including those who balance work outside the home and breastfeeding. However, little research has been done to understand how maternal support during the postpartum period impacts mothers' ability to later balance work and breastfeeding, in particular full-time work and exclusive breastfeeding. The results of this qualitative study indicate that the timing of support plays a key role in mothers' ability to successfully overcome barriers during the early postpartum period, thus building maternal self-efficacy in addressing problems encountered when they return to work.

METHODS

To understand the experience of low-income women who successfully balance full-time work and exclusive breastfeeding for the recommended 6 months, interviews were conducted with women who met study criteria for income level, work status, and exclusive breastfeeding. Breastfeeding peer counselors were also interviewed as key informants. Interviews were recorded, transcribed, and coded for themes. The results of both sets of interviews were triangulated with a focused literature review to assure the soundness of the qualitative analysis.

RESULTS

Timing of support included acute support, such as help establishing a successful latch needed during the first 2 weeks after delivery, to deal with breastfeeding problems that mothers perceived as being mentally and emotionally overwhelming and longer-term support needed to overcome problems perceived as being less intense.

CONCLUSIONS

The research invites further exploration into the relationship between breastfeeding support provided by mothers' support system, including healthcare professionals, during the postpartum period and rates of breastfeeding duration and exclusivity.

How multiple episodes of exclusive breastfeeding impact estimates of exclusive breastfeeding duration: report from the eight-site MAL-ED birth cohort study

The duration of exclusive breastfeeding (EBF) is often defined as the time from birth to the first non‐breast milk food/liquid fed (EBFLONG), or it is estimated by calculating the proportion of women at a given infant age who EBF in the previous 24 h (EBFDHS). Others have measured the total days or personal prevalence of EBF (EBFPREV), recognizing that although non‐EBF days may occur, EBF can be re‐initiated for extended periods. We compared breastfeeding metrics in the MAL‐ED study; infants' breastfeeding trajectories were characterized from enrollment (median 7 days, IQR: 4, 12) to 180 days at eight sites. During twice‐weekly surveillance, caretakers were queried about infant feeding the prior day. Overall, 101 833 visits and 356 764 child days of data were collected from 1957 infants. Median duration of EBFLONG was 33 days (95% CI: 32–36), compared to 49 days based on the EBFDHS. Median EBFPREV was 66 days (95% CI: 62–70). Differences were because of the return to EBF after a non‐EBF period. The median number of returns to EBF was 2 (IQR: 1, 3). When mothers re‐initiated EBF (second episode), infants gained an additional 18.8 days (SD: 25.1) of EBF, and gained 13.7 days (SD: 18.1) (third episode). In settings where women report short gaps in EBF, programmes should work with women to return to EBF. Interventions could positively influence the duration of these additional periods of EBF and their quantification should be considered in impact evaluation studies. © 2016 John Wiley & Sons Ltd