Supplementary water for breast-fed babies in a hot and dry climate--not really a necessity

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Exclusive versus predominant breastfeeding in Italian maternity wards and feeding practices through the first year of life

Determinants of exclusive versus predominant breastfeeding in the maternity ward and the relationship with later feeding practices were investigated in 1656 mothers who breastfed exclusively or predominantly in the maternity ward. Mothers were interviewed through 12 months postdelivery about feeding practices. Information about the World Heath Organization's (WHO's) 10 steps was collected. At hospital stay, breastfeeding was predominant in 43% of infants. Cesarean section (odds ratio [OR] = 1.75), mother's overweight (OR = 1.74), and non-compliance with the WHO's steps 6 (OR = 1.58), 7 (OR = 1.43), and 8 (OR = 1.76) were determinants of predominant, as opposed to exclusive, breastfeeding. Mothers exclusively, rather than predominantly, breastfeeding in the hospital showed a longer duration of full breastfeeding (mean = 3.6 vs 3.1 months), later introduction of formula (3.8 vs 3.3 months), and lower rate of introduction of formula within 1 month (23% vs 30%). Hospitals need to be compliant with the WHO's steps, and Baby-Friendly Hospital Initiatives should be promoted.

Breastfeeding and the use of human milk

Considerable advances have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding. This policy statement on breastfeeding replaces the 1997 policy statement of the American Academy of Pediatrics and reflects this newer knowledge and the supporting publications. The benefits of breastfeeding for the infant, the mother, and the community are summarized, and recommendations to guide the pediatrician and other health care professionals in assisting mothers in the initiation and maintenance of breastfeeding for healthy term infants and high-risk infants are presented. The policy statement delineates various ways in which pediatricians can promote, protect, and support breastfeeding not only in their individual practices but also in the hospital, medical school, community, and nation.

24-h hydration status: parameters, epidemiology and recommendations

Hydration of individuals and groups is characterised by comparing actual urine osmolality (Uosm) with maximum Uosm. Data of actual, maximum and minimum Uosm in infants, children and adults and its major influencing factors are reviewed. There are remarkable ontogenetic, individual and cultural differences in Uosm. In the foetus and the breast-fed infant Uosm is much lower than plasma osmolality, whereas in children and adults it is usually much higher. Individuals and groups may show long-term differences in Uosm. In industrialised countries, the gender difference of Uosm is common. There are large intercultural differences of mean 24-h Uosm ranging from 860 mosm/kg in Germany, 649 mosm/kg in USA to 392 mosm/kg in Poland. A new physiologically based concept called 'free-water reserve' quantifies differences in 24-h euhydration. In 189 boys of the DONALD Study aged 4.0-6.9 y, median urine volume was 497 ml/24-h and median Uosm 809 mosm/kg. Considering mean-2 s.d. of actual maximum 24-h Uosm of 830 mosm/kg as upper level of euhydration and physiological criterion of adequate hydration in these boys, median free-water reserve was 11 ml/24-h. Based on median total water intake of 1310 ml/24-h and the third percentile of free-water volume of -156 ml/24-h, adequate total water intake was 1466 ml/24-h or 1.01 ml/kcal. Data of Uosm in 24-h urine samples and corresponding free-water reserve values of homogeneous groups of healthy subjects from all over the world might be useful parameters in epidemiology to investigate the health effects of different levels of 24-h euhydration.

Why healthcare workers give prelacteal feeds

OBJECTIVE

Because prelacteal feeds can adversely affect breastfeeding, UNICEF/WHO discourage their use unless medically indicated. The study was carried out to determine the proportion of healthcare workers who routinely give prelacteal feeds, and their reasons for doing so; further, to determine whether any differences exist between medically and non-medically trained healthcare workers in their administration of prelacteal feeds.

DESIGN

Survey.

SETTING

Primary, secondary and tertiary health facilities in Kaduna township Nigeria.

SUBJECTS

Of 1100 healthcare workers sampled, 747 (68%) responded. Of these 80% had received medical training, 20% had not.

METHODS

Use of a pretested validated questionnaire.

RESULTS

Large proportions of both medical and non-medically trained healthcare workers stated they routinely give prelacteal feeds (doctors, 68.2%; nurses, 70.2%; and non-medical, 73.6%). However their reasons for doing so differed significantly (P=0.00001). Nurses gave mainly for perceived breast milk insufficiency, doctors for prevention of dehydration, hypoglycaemia and neonatal jaundice and non-medical staff to prepare the gastrointestinal tract for digestion and to quench thirst.

CONCLUSIONS

Most healthcare workers (medical and non-medical) routinely and unnecessarily give prelacteal feeds. Therefore training and retraining programmes in lactation management are necessary and must include non-medical staff. These programmes, while emphasizing the danger of giving prelacteal feeds, must deal with the misconceptions of each group. Deliberate efforts have to be made to incorporate clinical training in breastfeeding in curricula of Schools of Medicine and Nursing.

Breastfeeding and jaundice

In the breastfed infant, prolongation of unconjugated hyperbilirubinemia into the third and later weeks of life in the healthy newborn is a normal and regularly occurring extension of physiologic jaundice. This is known as breastmilk jaundice. A factor in human milk increases the enterohepatic circulation of bilirubin. Insufficient caloric intake resulting from maternal and/or infant breastfeeding difficulties may also increase serum unconjugated bilirubin concentrations. This is the infantile equivalent of adult starvation jaundice. It is known as breastfeeding jaundice or "breast-nonfeeding jaundice." This increase in severity of physiologic jaundice of the newborn also results from increased enterohepatic circulation of bilirubin, but not because of a factor in human milk. In extreme cases, it may place the infant at risk for development of bilirubin encephalopathy. Optimal breastfeeding practices, which result in minimal initial weight loss and early onset of weight gain, are associated with both reduced breastfeeding jaundice and minimization of the intensity of breastmilk jaundice.

Hypoglycemia and the breastfed neonate

Healthy, full-term infants are functionally and metabolically programmed to make the transition from their intrauterine dependent environment to their extrauterine existence without the need for metabolic monitoring or interference with the natural breastfeeding process. Full-term infants are equipped with homeostatic mechanisms that preserve adequate energy substrate to the brain and other vital organs. Thermal stability and early, properly guided, frequent, exclusive breastfeeding are the keys to success. Thus, routine screening for blood glucose concentrations or feeding sugar water is not necessary and potentially counterproductive to the establishment of a healthy mother-infant dyad.

Types of drinks consumed by infants at 4 and 8 months of age: a descriptive study. The ALSPAC Study Team

OBJECTIVE

To document the type and volume of drinks given to infants and investigate whether giving supplementary drinks leads to reduced milk consumption.

DESIGN

Carers were asked to record all drinks consumed by the infants in a 24-hour period at two ages, detailing the types and volume taken.

SETTING

The Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC).

SUBJECTS

A randomly chosen population sample of over 1000 infants at 4 and 8 months of age.

RESULTS

The different types of milk feed were used to group infants, compare volumes consumed and look at the use of non-milk drinks. The average volume of drinks consumed over 24 hours at 4 months was 861 ml and at 8 months was 662 ml. At 4 months 69.7% consumed infant formula and 43.0% breast milk. The mean volume of milk consumed by those having only formula was 802 ml and for those having only breast milk was estimated at 850 ml. The volumes of milks consumed were slightly lower in the groups who also had supplementary drinks. A quarter of infants were given fruit drinks and 14.6% herbal drinks. Supplementary drinks and solids were more likely to be given to formula-fed than breast-fed infants. At 8 months, formula milk was consumed by 71.4% and breast milk use had decreased (22.9%) but fruit drink use had increased (squash/cordial: 55.8%, fruit juice: 14.9%), with 13.9% of infants having no infant milk at all. More infants were fed formula milk and less were fed cows' milk compared with a nationally representative British study conducted 5 years earlier.

CONCLUSIONS

Many infants were given supplementary drinks by 4 months; there is some evidence that this led to a small reduction in milk intake. A minority were not being given infant milks at all by 8 months, contrary to British infant feeding recommendations.

Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group on Breastfeeding

This policy statement on breastfeeding replaces the previous policy statement of the American Academy of Pediatrics, reflecting the considerable advances that have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, in the mechanisms underlying these benefits, and in the practice of breastfeeding. This document summarizes the benefits of breastfeeding to the infant, the mother, and the nation, and sets forth principles to guide the pediatrician and other health care providers in the initiation and maintenance of breastfeeding. The policy statement also delineates the various ways in which pediatricians can promote, protect, and support breastfeeding, not only in their individual practices but also in the hospital, medical school, community, and nation.

Knowledge and attitude of the Bangladeshi rural mothers regarding breastfeeding and weaning

Two hundred and forty two mothers in 7 villages of Narayanganj district, Bangladesh were interviewed to assess their knowledge and attitude regarding breastfeeding and weaning using pretested questionnaires, though 83.5% mothers knew that colostrum is good for the child, less than 8 percent of them gave it as the first food to their babies. Most mothers did not have the correct knowledge about exclusive breastfeeding and the appropriate time for introduction of weaning foods; and only 3% of them knew how to prepare proper weaning foods. The mean score of knowledge of the mothers was only 4 +/- 1.7 out of 10, indicating the need for nutrition education in this area.

The contribution of professional support, information and consistent correct advice to successful breast feeding

This paper presents qualitative and quantitative data on experiences of breast feeding in hospital from a national survey of pain relief in labour. Successful breast feeding was found to be significantly associated with satisfaction with medical care, help given with feeding by hospital staff, and the wish to have a subsequent baby in the same hospital. Information and support from staff were frequently mentioned as factors contributing to success. Lack of such help, receiving inaccurate or conflicting advice, and unsolicited and unwanted offers of artificial milk were major sources of discontent. Practical support could be improved by the provision of rooms furnished with nursing chairs where women could breast feed in comfort, benefiting from the companionship and experience of other women and the support of breast feeding counsellors. Efforts should be made to combat the problem of conflicting advice by ensuring that ward staff are conversant with up-to-date knowledge of best practices.

Water supplementation in exclusively breastfed infants during summer in the tropics

This study was designed to determine the need for water supplementation to maintain water homoeostasis in exclusively breastfed infants during summer in a tropical country. A prestudy questionnaire revealed that 97% of 34 nurses and 63% of 70 doctors advocated such supplementation. 45 healthy, male, exclusively breastfed babies, aged 1-4 months, were recruited from a well-baby clinic. 9 who had never received supplemental water plus a random selection of 14 others were allocated to group I (breastmilk only); the remaining 22 infants were allocated to group II (breastmilk plus supplemental fluid according to the mother's usual practice). The babies were studied at the hospital for 8 h; breastmilk intake was measured by weighing the infant before and after each feed, water intake by calibrated bottles, and urine output by accurate collection and measurement. The maximum room temperatures were 34-41 degrees C and relative humidities 9-60% (below 50% in all but 3 infants). In group II the mean water intake was 11% (95% confidence interval 7-16%) of the total fluid intake. Both breastmilk intake (274 vs 210 ml) and total fluid intake (274 vs 233 ml) were higher in group I than in group II (p = 0.003, p = 0.073, respectively), after adjustment for age, weight, length, room temperature, and humidity. However, there were no significant differences between the groups in urine output, urine or serum osmolality, weight change, or rectal temperature whether or not the factors adjusted for included total fluid intake. Thus, exclusively breastfed infants do not need supplemental water to maintain water homoeostasis; a reduced breastmilk intake is a potential disadvantage of this practice.

Do ambient temperature and humidity influence the breast-milk intake of babies?

This study explored the possible effect of ambient temperature and humidity on the breast-milk intakes of Australian infants (n = 35) aged 6-12 weeks. Over a 24 h period, each baby was fed only on milk from the breast; milk intakes, temperature and humidity were monitored. Milk intakes--determined by test-weighing the baby, with a correction for evaporative losses during feeds--showed a mean of 830 g/24 h, with median 818 and s.d. 152. The mean correction for evaporative losses was 46 g/24 h; omission of this correction would have led to an average underestimate of 5.5% in 24 h intakes. Ambient conditions varied substantially between subjects: 24 h mean temperatures ranged from 14 to 28 degrees C, and humidities from 48 to 97%. Over these ranges, breast-milk intakes did not appear to be significantly influenced by ambient temperature or ambient humidity; however, the rate of evaporative losses increased by 0.008 g/min for each 1 degree C rise in ambient temperature.

No need for water supplementation for exclusively breast-fed infants under hot and arid conditions

This study was conducted in 4 villages in India during the hottest and driest season of the year to determine whether exclusively breast-fed infants need additional water under extremely hot and dry climatic conditions. The ambient temperature was 35-40 degrees C and the relative humidity 10-35%, except during the early morning hours. 63 urine samples were collected from 31 infants below 6 months of age and 28 samples from 13 infants aged 6-10 months, all of whom were receiving nothing but breast milk. Specific gravity (and corresponding osmolality) of urine samples from the younger group ranged from 1.004 (66 mosmol/litre) to 1.036 (1234 mosmol/litre), with a mean of 1.011 (322 mosmol/litre). For the older group the range was 1.005 (103 mosmol/litre) to 1.029 (978 mosmol/litre) and the mean was 1.015 (468 mosmol/litre). These values are well below levels of urine concentrations known to be attainable by infants of corresponding ages. Thus, even under hotter and drier climatic conditions than have previously been studied, healthy exclusively breast-fed infants do not require additional water. Exclusive breast feeding for the first 4-6 months is therefore a reasonable public health recommendation; it is imperative in areas where contaminated drinking water may contribute to infant morbidity, diarrhoeal disease in particular.

Infant feeding. The physiological basis

A mother's nutritional status during pregnancy has important implications for both her own health and her ability to produce and breast-feed a healthy infant. Knowledge about adequate maternal nutrition during pregnancy is incomplete, however, and there is still considerable debate about the level of extra energy needed by a pregnant woman. A woman's usual nutritional requirements increase during pregnancy to meet her needs and those of the growing fetus. Additional energy is needed because of increased basal metabolism, the greater cost of physical activity, and the normal accumulation of fat as the energy reserve. The protein, vitamin and mineral requirements of the mother also increase during pregnancy, but the precise amounts for the last two are still a matter for discussion. A woman's weight increments during pregnancy vary between privileged and underprivileged communities. In addition to calcium, phosphorus and iron, a mother provides considerable amounts of protein and fat for fetal growth. Placental metabolism and placental blood flow, which are interrelated, are the most critical factors for fetal development.The nutritional requirements of healthy newborns vary widely according to their weight, gestational age, rate of growth, as well as environmental factors. However, recommendations for some components may be derived from the average composition of early human milk and the amounts consumed by healthy, mature newborns who are following a normal postpartum clinical course. The water requirements of infants are related to their caloric consumption, activity, rate of growth, and the ambient temperature. A postnatal weight loss of 5-8% of body weight is usual during the first few days of life in mature newborn infants; in contrast, infants who experienced intrauterine malnutrition lose little or no weight at all.The dynamic process of mother-newborn interaction from the first hours of life is intimately related to successful early breast-feeding. If this process is delayed, however, it may take longer and may be more difficult to achieve. Close mother-infant contact immediately after birth also helps infants to adapt to their new unsterile environment. Because drugs can interfere with bonding and breast-feeding, such substances should be given only when necessary and their effects should be evaluated. In general, young infants, especially newborns, have very irregular feeding intervals. It is advisable for numerous reasons to feed them whenever they indicate a need.

Jaundice in full term healthy neonates--a population study

A geographically based population of 498 full term, appropriate for gestational age, healthy, singleton neonates was used to study the effect of obstetric and nursery practices on the occurrence of neonatal jaundice. At 3-4 days 56% of babies became visibly jaundiced (plasma bilirubin (PB) greater than 100 mumol/l) and 10% were hyperbilirubinaemic (PB greater than 200 mumol/l). Less mature babies, those slow to pass meconium and those who had lost weight at 4 and 7 days were more likely to be jaundiced. Obstetric practices, drugs given during labour, mother's or baby's blood group, natural illumination, plethora, extravasated blood or mode of feeding were found to have no effect. No benefit from giving supplementary milk or dextrose to breast fed babies was discovered. At 6-7 days at least 9% of babies, all but one of whom were breast fed, were visibly jaundiced. The frequency of prolonged jaundice (breast milk jaundice) was 3.8% of breast fed babies at 3 weeks and zero by 7 weeks. The proportion of babies receiving phototherapy was 2.2%.