Cultural influences on infant feeding practices

Investigating short-stay admission to a neonatal intensive care unit as a risk factor for reduced breast feeding at discharge in infants ≥36 weeks' gestation: a retrospective cohort study

OBJECTIVE

This study aims to determine the effect of infant-mother separation following a short-stay (≤72 hours) admission to a Level 5 neonatal unit versus no admission on infant-feeding outcomes at hospital discharge.

DESIGN

Retrospective cohort study.

SETTING

An Australian Level 5 neonatal unit within a tertiary referral hospital.

PARTICIPANTS

Mothers and their infants born between 1 January 2018 and 31 December 2020 had a short-stay admission to the neonatal unit or no admission. All participants met admission criteria to the postnatal ward and were discharged home at ≤72 hours (n=12 540). Postnatal ward admission criteria included ≥36 weeks' gestation and birth weight ≥2.2 kg.

MAIN OUTCOME MEASURES

Infant feeding at discharge from hospital. Multivariate logistic regression analysis was conducted, adjusting for confounders associated with known breastfeeding issues. These included age, ethnicity, parity, obesity, socioeconomic score, hypertensive disorders of pregnancy, diabetes, infant gestation and birthweight centile, caesarean section birth, postpartum haemorrhage and skin-to-skin contact.

RESULTS

Of the 12 540 live births meeting inclusion criteria, 1000 (8%) infants were admitted to the neonatal unit. The primary reasons for admission were suspicion of sepsis (24%), maternal diabetes (19%) and jaundice (16%). We found a reduction in full breast feeding at hospital discharge in cases of a short admission to the neonatal unit compared with no admission (aOR 0.40; 95% CI 0.34 to 0.47; p<0.001). We identified that women of different ethnicities had differing levels of risk for formula supplementation at hospital discharge. The ethnic grouping least likely to be fully breast feeding at discharge was Southeast Asian women (aOR 0.47; 95% CI 0.39 to 0.57; p<0.001).

CONCLUSIONS

Identifying mother-infant dyads at risk of non-exclusive breast feeding at hospital discharge will help target resources for practice improvement.

Do maternal grandmothers influence breastfeeding duration and infant nutrition? Evidence from Merida, Mexico

OBJECTIVES

Breast-feeding is sensitive to somatic, hormonal, behavioral and psychological components of maternal capital. However, through grandmothering, older women may also influence breast-feeding by transferring informational resources to their daughters. We hypothesized that mothers with prolonged instrumental support from their own mother are more likely to have received advice and to have favorable attitudes/practices regarding breastfeeding, compared to those lacking such support, with implications for the grandchild's somatic capital.

METHODS

We recruited 90 mother-infant dyads (52 with grandmaternal support, 38 without) in Merida, Yucatan, Mexico. All children were first-borns, aged ~2 years. Anthropometry and body composition were assessed. Data on grandmother's breastfeeding advice and maternal breastfeeding duration were obtained by questionnaire. Maternal attitudes to breast-feeding were assessed using the Iowa Infant Feeding Attitude Scale.

RESULTS

Women with instrumental support were more likely to have received grandmaternal advice during pregnancy/infancy on exclusive breast-feeding duration (60% vs. 37%, p = 0.033) and the type of first complementary food (81% vs. 47%, p = 0.001). However, women with support had a less favorable attitude to breastfeeding than those without and breastfed their children for less time (median 5 vs. 10.5 months, p = 0.01). No group differences were found in children's length, weight, skinfolds or lean mass z-score.

DISCUSSION

Although grandmothers providing instrumental support provided advice regarding breastfeeding, their attitudes may reflect issues beyond nutritional health. Advice of maternal grandmothers did not promote extended breastfeeding, however the differences in breastfeeding attitudes were not associated with the children's nutritional status. Grandmothers should be included in public health interventions promoting breastfeeding.

Neonatal acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae in the community of a low-income country (NeoLIC): protocol for a household cohort study in Moramanga, Madagascar

INTRODUCTION

Data regarding the acquisition of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in neonates at the community level are scarce in low-income and middle-income countries (LMICs), where the burden of neonatal sepsis is high.Our study aims at identifying and quantifying the role of the different routes of ESBL-PE transmission for neonates, which are still undefined in the community in LMICs.

METHODS AND ANALYSIS

In a semirural community in Madagascar, 60 mothers and their neonates will be recruited at delivery, during which a maternal stool sample and meconium of the newborn will be collected. Home visits will be planned the day of the delivery and next at days 3, 7, 14, 21 and 28. Stool samples from the newborn, the mother and every other household member will be collected at each visit, as well as samples from the environment in contact with the newborn (food, surfaces and objects). Sociodemographic data and factors which might drive ESBL-PE acquisition will also be collected.We will analyse the isolated ESBL-PE using DNA sequencing methods to characterise clones, resistance genes and plasmids of ESBL-PE. To analyse these data globally, we will develop novel analytical approaches combining mathematical modelling and statistics. Finally, mathematical simulations will be performed to test different strategies of control of ESBL-PE transmission to neonates.In complement, we will conduct an anthropological investigation to understand local environments and practices that would contribute to neonatal ESBL-PE acquisition. In-depth interviews with members of 16 households will be conducted and 4 mother-newborn pairs will be followed by a participants' observations methodology.

ETHICS AND DISSEMINATION

The study was approved by the ethical committee in Madagascar and by the institutional review board of Institut Pasteur, Paris, France.Findings will be reported to participating families, collaborators and local government; presented at national and international conferences and disseminated by peer-review publications.

Lessons Learned from the Pandemic—We Can Do Better

Many breastfeeding issues can be addressed with postpartum lactation support. However, COVID-19 presented new challenges for the breastfeeding dyad with a disruption in normal healthcare practices. The objective of the study was to examine new mothers’ breastfeeding intentions and practices during the COVID-19 pandemic. A 40-question survey was administered to a convenience sample of 50 new mothers during April–June 2020. Findings revealed most mothers (52%) had the intention to breastfeed for one year or longer. However, at the time of hospital discharge only 34% of mothers were exclusively breastfeeding and 60% of mothers were supplementing with formula within the first four days of life. Recommendations for bridging the gap between the hospital and primary care setting include educating providers and nurses on breastfeeding management practices, increasing hospital lactation support, and using telelactation to provide remote support to mothers.

A nation‐wide study on the common reasons for infant formula supplementation among healthy, term, breastfed infants in US hospitals

In‐hospital infant formula supplementation of breastfed infants reduces breastfeeding duration, yet little is known about common reasons for infant formula supplementation. We examined the three most common reasons for in‐hospital infant formula supplementation of healthy, term, breastfed infants in the US reported by hospital staff. Hospital data were obtained from the 2018 Maternity Practices in Infant Nutrition and Care survey (n = 2045), which is completed by hospital staff. An open‐ended question on the top three reasons for in‐hospital infant formula supplementation was analyzed using thematic qualitative analysis and the frequencies for each reason were reported. The top three most common reasons for in‐hospital infant formula supplementation reported by hospital staff included medical indications (70.0%); maternal request/preference/feelings (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%) and medical staff/institutional practices (4.7%). These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation. Lactation management support delivered in a timely and culturally sensitive manner and targeted to mother‐infant dyads with potential medical and physical indications may reduce unnecessary in‐hospital infant formula supplementation.

The three most commonly reported reasons by hospital staff for infant formula supplementation were found to be related to medical indications (70.0%); maternal request/preference/feelings about breastfeeding such as frustration or lack of confidence (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%); and medical staff/institutional practices (4.7%).

Underlying many of the reported three most common reasons for infant formula supplementation is potentially lack of lactation management support that considers the social influences (e.g. from family and friends) and that is culturally relevant.

These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation.

Infant feeding in diverse families; the impact of ethnicity and migration on feeding practices

OBJECTIVE

To investigate differences in infant feeding practices and styles by maternal migration status.

DESIGN

Prospective cohort study.

SETTING

Maternity unit of a large hospital in Northern England PARTICIPANTS: Women recruited to the Born in Bradford longitudinal cohort study MEASUREMENTS: Breastfeeding initiation; breastfeeding at six months; breastfeeding at twelve months; timing of introduction of complementary feeding; maternal feeding style at twelve months.

FINDINGS

Migrant women were more likely to initiate breastfeeding and continue breastfeeding for longer compared to native women. Native women also introduced complementary feeding earlier than migrant women. There was evidence of feeding practices among second= generation migrants becoming increasingly more aligned with those of native women, with lower breastfeeding rates and earlier introduction of complementary feeding compared to first-generation migrants. Migrant women were more likely to adopt a 'Demanding' feeding style, with the strongest associations seen in first-generation migrants.

KEY CONCLUSIONS

Migration status is an important factor to consider in reference to infant feeding practices. This is particularly important in considering intergenerational changes in families with migration backgrounds and the potential of culture to impact on family practices.

IMPLICATIONS FOR PRACTICE

Interventions to maintain cultural norms around infant feeding in families with migration backgrounds would be beneficial, due to the observed higher rates of breastfeeding in first-generation migrants. Targeted interventions to improve breastfeeding in white British native women should consider the role that culture can play in encouraging positive health behaviours.

Determinants of infant feeding practices among Black mothers living with HIV: a multinomial logistic regression analysis

BACKGROUND

Infant feeding practices are imperative for babies' and mothers' health and emotional wellbeing. Although infant feeding may seem simple, the decisions surrounding it are complex and have far-reaching implications for women globally. This is an especially difficult concern among mothers living with HIV because breastfeeding can transmit HIV from mother to child. This is further complicated by cultural expectations in case of Black mothers living with HIV. This paper discusses determinants of infant feeding practices among Black mothers living with HIV who were on anti-retroviral therapy (ART) in two North American cites and one African city.

METHODS

A cross-sectional, multi-country survey using venue-based convenience sampling of Black mothers living with HIV was employed. The effective response rates were 89% (n = 89) in Ottawa, Canada; 67% (n = 201) in Miami, Florida, US; and 100% (n = 400) in Port Harcourt, Nigeria, equaling a total sample size of 690. Data were collected in Qualtrics and managed in Excel and SPSS. Multinomial logistic regression analyses were used to determine the factors influencing the mothers' infant feeding practices (Exclusive Formula Feeding [EFF] = 1; Mixed Feeding [MF] = 2; and Exclusive Breastfeeding [EBF while on ART] =3).

RESULTS

The results highlight socio-demographics, EFF determinants, and EBF determinants. The statistically significant determinants of infant feeding practices included national guideline on infant feeding, cultural beliefs and practices, healthcare systems, healthcare personnel, infant feeding attitudes, social support, and perceived stress. Mothers' mean ages were Ottawa (36.6 ± 6.4), Miami (32.4 ± 5.8), and Port Harcourt (34.7 ± 5.7). All sampled women gave birth to least one infant after their HIV diagnoses. Statistically significant (p < .05) determinants of EFF relative to MF were the national guideline of EFF (relative risk [RR] = 218.19), cultural beliefs (RR = .15), received healthcare (RR = 21.17), received healthcare through a nurse/midwife (RR = 3.1), and perceived stress (RR = .9). Statistically significant determinants of EBF relative to MF were received healthcare (RR = 20.26), received healthcare through a nurse/midwife (RR = 2.31), functional social support (RR = 1.07), and perceived stress (RR = .9).

CONCLUSION

While cultural beliefs and perceived stress favoured MF over EFF, advice of healthcare workers, and the care received from a nurse/midwife improved EFF over MF. Also while the mothers' perceived stress favoured MF over EBF, advice of their nurses or midwife and the social support improved EBF over MF. The providers advice was congruent with WHO and national guidelines for infant feeding among mothers living with HIV. These results have implications for nursing, healthcare practice, and policies on infant feeding practices for mothers living with HIV.

Motherhood among Black women living with HIV: A "north-south" comparison of sociocultural and psychological factors

We compared factors mediating motherhood experiences among Black nursing mothers living with HIV in two North American cities to one African city. Motherhood was measured with the Being a Mother Scale, and we compared their predictors between the two continents using difference in difference estimation within hierarchical linear modeling. Cultural beliefs congruent with infant feeding guidelines and social support had significant positive but differing effects on motherhood in the two continents. Perceived stress had significant negative impact on motherhood in the two continents. Due considerations to sociocultural contexts in policy development, HIV interventions and education of health care providers were recommended.

Parents' experiences of complementary feeding among a United Kingdom culturally diverse and deprived community

Complementary feeding practices and adherence to health recommendations are influenced by a range of different and often interrelating factors such as socio‐economic and cultural factors. However, the factors underlying these associations are often complex with less awareness of how complementary feeding approaches vary across the UK’s diverse population. This paper describes a qualitative investigation undertaken in a deprived and culturally diverse community in the UK which aimed to explore parents’ knowledge, beliefs and practices of complementary feeding. One hundred and ten mothers and fathers, self‐identified as being White British, Pakistani, Bangladeshi, Black African/Caribbean or Polish took part in twenty‐four focus group discussions, organised by age group, sex and ethnicity.

The findings revealed that most parents initiated complementary feeding before the World Health Organisation (WHO) recommendation of 6 months. Early initiation was strongly influenced by breast feeding practices alongside the extent to which parents believed that their usual milk; that is, breastmilk or formula was fulfilling their infants' nutritional needs. The composition of diet and parents' approach to complementary feeding was closely aligned to traditional cultural practices; however, some contradictions were noted. The findings also acknowledge the pertinent role of the father in influencing the dietary practices of the wider household. Learning about both the common and unique cultural feeding attitudes and practices held by parents may help us to tailor healthy complementary feeding advice in the context of increasing diversity in the United Kingdom.

Mixed milk feeding: a systematic review and meta-analysis of its prevalence and drivers

CONTEXT

Extensive literature is available on exclusive breastfeeding and formula-feeding practices and health effects. In contrast, limited and unstructured literature exists on mixed milk feeding (MMF), here defined as the combination of breastfeeding and formula feeding during the same period in term infants > 72 hours old (inclusion criterion).

OBJECTIVE

A systematic review and meta-analysis were performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, on the global prevalence of MMF (primary outcome) and related drivers and practices (secondary outcomes).

DATA SOURCES

The search of MMF in generally healthy populations was conducted across 6 databases, restricted to publications from January 2000 to August 2018 in English, Spanish, French, and Mandarin.

DATA EXTRACTION

Two reviewers independently performed screenings and data extraction according to a priori inclusion and exclusion criteria.

DATA ANALYSIS

Of the 2931 abstracts identified, 151 full-text publications were included for data extraction and 96 of those were included for data synthesis (the majority of those were cross-sectional and cohort studies). The authors summarized data across 5 different categories (feeding intention prenatally, and 4 age intervals between > 72 hours and > 6-23 months) and 5 regional subgroups. The overall prevalence of MMF across different age intervals and regions varied between 23% and 32%; the highest rate was found for the age group 4-6 months (32%; 95% confidence interval, 27%-38%); regional comparisons indicated highest MMF rates in Asia (34%), North and South America (33%), and Middle East and Africa together (36%), using a random effects meta-analysis model for proportions. Some drivers and practices for MMF were identified.

CONCLUSION

MMF is a widespread feeding reality. A shared and aligned definition of MMF will help shed light on this feeding practice and evaluate its influence on the duration of total breastfeeding, as well as on infants' nutrition status, growth, development, and health status in the short and long terms. PROSPERO registration number CRD42018105337.

Feeding during the first 3 days after birth other than breast milk is associated with early cessation of exclusive breastfeeding

Exclusive breastfeeding (EBF) has significant effect on morbidity and mortality. EBF is established when breastmilk alone is exclusively fed from birth until 6 months of age. However, feeding during the first 3 days after birth is often ignored for various reasons. We aimed to assess the role of feeding during the first 3 days in respect of early cessation of EBF. Data of 1,040 children aged under 6 months was derived from the baseline survey of Suchana, a large‐scale nutrition program, conducted in Sylhet, Bangladesh, and subsequently analysed. Guidelines established by World Health Organization were used to define EBF and feeding during the first 3 days. The strength of the association between feeding during the first 3 days and early cessation of EBF was established using multiple logistic regression after adjusting for other covariates. Among all children, around 62% and 13% were exclusively breastfed and were fed something other than breastmilk within the first 3 days of birth, respectively. Feeding during the first 3 days was independently and significantly associated with early cessation of breastfeeding (adjusted odds ratio: 1.94, 95% confidence interval [1.31, 2.88], p = .001). Less than four antenatal care (ANC) visits, increased child's age and increased household size were also independently associated with early cessation of EBF. Feeding during the first 3 days of birth is a significant predictor of early cessation of EBF. Simple counselling activities to discourage feeding anything within the first few days of birth may increase the prevalence of EBF in rural Bangladesh without investing additional resources.

Impacts of antenatal nursing interventions on mothers' breastfeeding self-efficacy: an experimental study

Background

A considerable amount of research demonstrates how breastfeeding self-efficacy significantly influences breastfeeding outcomes. The aim of this study was to evaluate the role of nursing intervention on mother’s breastfeeding self-efficacy.

Methods

In this experimental investigation, 130 pregnant women who attended a primary health care centre were randomly assigned to the experimental (n = 65) or control (n = 65) groups. The experimental group received two 60–90 min group breastfeeding educational sessions based on the breastfeeding self-efficacy theory along with routine care. Mothers’ knowledge, attitudes, prenatal and postnatal self-efficacy towards the breastfeeding were compared between both groups. The Iowa Infant Feeding Attitude Scale measured the attitudes. Prenatal Breastfeeding Self-Efficacy Scale measured the self-efficacy during pregnancy and Breastfeeding Self-Efficacy-Short Form measured the self-efficacy in postnatal period.

Results

Breastfeeding self-efficacy during pregnancy and following two months of delivery in the experimental group was significantly higher. The experimental group had a higher level of knowledge and attitude in comparison with subjects in the control group. In addition, the mothers who breastfed exclusively had higher levels of postnatal self-efficacy in both experimental and control groups compared to formula feeding women (52.00 vs. 39.45 in the control and 57.69 vs. 36.00 in the experimental subjects; P < 0.001).

Conclusion

The present investigation suggests that antenatal breastfeeding education is an effective way to increase the level of breastfeeding self-efficacy, which increases exclusive breastfeeding practice.

First foods: Diet quality among infants aged 6-23 months in 42 countries

Diet quality is closely linked to child growth and development, especially among infants aged 6-23 months who need to complement breastmilk with the gradual introduction of nutrient-rich solid foods. This paper links Demographic and Health Survey data on infant feeding to household and environmental factors for 76,641 children in 42 low- and middle-income countries surveyed in 2006-2013, providing novel stylized facts about diets in early childhood. Multivariate regressions examine the associations of household socioeconomic characteristics and community level indicators of climate and infrastructure with dietary diversity scores (DDS). Results show strong support for an infant-feeding version of Bennett's Law, as wealthier households introduce more diverse foods at earlier ages, with additional positive effects of parental education, local infrastructure and more temperate agro-climatic conditions. Associations with consumption of specific nutrient-dense foods are less consistent. Our findings imply that while income growth is indeed an important driver of diversification, there are strong grounds to also invest heavily in women's education and food environments to improve diet quality, while addressing the impacts of climate change on livelihoods and food systems. These results reveal systematic patterns in how first foods vary across developing countries, pointing to new opportunities for research towards nutrition-smart policies to improve children's diets.

Effects of maternal protein restriction during pregnancy and lactation on milk composition and offspring development

Before weaning, breast milk is the physiological form of neonatal nutrition, providing pups with all nutrient requirements. Maternal low-protein diet (LPD) during pregnancy and lactation induces adverse changes in key maternal organs, which have negative effects on pup development. We studied the effects of maternal LPD on liver weight, mammary gland (MG) cell differentiation, milk composition and production and pup development throughout lactation. We fed rats with control (C) or LPD (R) during pregnancy and lactation. At 7 d early, 14 d mid and 21 d late lactation stages, maternal biochemical parameters, body, liver and MG weights were analysed. MG cell differentiation was analysed by haematoxylin and eosin staining; milk nutrient composition and production were studied; pup body, liver and brain weights, hippocampal arachidonic acid (AA) and DHA were quantified. Results showed lower body and liver weights, minor MG cell differentiation and lower serum insulin and TAG in R compared with C. R milk contained less protein and higher AA at early and mid stages compared with C. R pup milk and fat intake were lower at all stages. R protein intake at early and mid stages and DHA intake at mid and late stages were lower compared with C. In R pups, lower body, liver and brain weights were associated with decreased hippocampal AA and DHA. We conclude that maternal LPD impairs liver and MG function and induces significant changes in maternal milk composition, pup milk intake and organ development.

Health-related quality of life, temperament, and eating behavior among formula-fed infants in the Philippines: a pilot study

BACKGROUND

The rising prevalence of childhood obesity in Asia has led to interest in potential risk factors such as infant health-related quality of life (HRQoL), temperament and eating behaviors. This pilot study evaluated the utility of administering parent-reported outcome measures (PROMs) to explore these factors in Filipino infants and examined the relationships between these factors and infant sex, formula intake and weight, over time.

METHODS

Forty healthy, 4-week-old, formula-fed infants (n = 20 males) were enrolled in this 6-week, prospective, uncontrolled study during which infants were exclusively fed a standard term infant formula enriched with alpha-lactalbumin. On Day-1 and 42, anthropometrics were measured and mothers completed a 97-item measure of HRQoL [Infant Toddler Quality of Life Questionnaire (ITQOL)] covering 6 infant-focused and 3 parent-focused concepts and a 24-item measure of infant temperament [Infant Characteristics Questionnaire (ICQ)]. At Day-42, mothers also completed an 18-item measure of infant appetite [Baby Eating Behaviour Questionnaire (BEBQ)]. A 3-day formula intake diary was completed before Day-42. Nonparametric statistics were used to evaluate correlations among outcomes and compare outcomes by visit and sex.

RESULTS

Thirty-nine infants completed the study; similar results were observed in males and females. Completion of PROMs was 100% with no missing responses, but Cronbach's α was low for many concept scales scores. ITQOL scores [range 0 (worst)-100 (best)] were generally high (median ≥ 80) except for Day-1 and Day-42 Temperament and Mood and Day-1 General Health Perceptions scores. ITQOL but not ICQ temperament scores improved significantly between Day-1 and Day-42 (P < 0.01). Mean ± standard deviation BEBQ scores (range 1-5) were high for Enjoyment of Food (4.59 ± 0.60) and Food Responsiveness (3.53 ± 0.81), and low for Satiety Responsiveness (2.50 ± 0.73) and Slowness in Eating (1.71 ± 0.60). Better HRQoL scores were significantly (P < 0.05) associated with high General Appetite scores (3 ITQOL concepts, r = 0.32 to 0.54), greater Enjoyment of Food (4 ITQOL concepts, r = 0.35 to 0.42) and low levels of Slowness in Eating (7 ITQOL concepts, r = - 0.32 to - 0.47).

CONCLUSION

Findings demonstrated the utility of the ITQOL, ICQ and BEBQ for measuring HRQoL, temperament and eating behavior, and the need for further adaptations for use in Filipino infants.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02431377; Registered May 1, 2015.

Early Initiation of Breastfeeding Among Maya Mothers in the Western Highlands of Guatemala: Practices and Beliefs

BACKGROUND

Guatemala exhibits the sixth highest rate of child stunting worldwide, and stunting disproportionately affects Guatemala indigenous communities. In a country struggling to combat this result of malnutrition, early child nutrition is especially critical. Specifically, early initiation of breastfeeding is important for the development of newborn infants. Understanding beliefs and practices related to early initiation of breastfeeding in Maya Guatemala may provide an avenue to guide nutrition interventions in indigenous communities. Research aim: This study aimed to determine major beliefs and practices associated with early initiation of breastfeeding among Maya mothers in Lake Atitlán, Guatemala.

METHODS

As part of a larger study to assess child nutrition in the Lake Atitlán region, we created a series of semistructured interview questions to document breastfeeding practices and beliefs among mothers. We conducted and audio-recorded in-person interviews that were translated from Kaqchikel, the local language, to Spanish by a community assistant.

RESULTS

We conducted 178 interviews with mothers; 76% practiced early initiation. Early initiation was associated with the village and complementary feeding practices. Mothers held a variety of beliefs about the value of colostrum, and these beliefs were associated with the village. Mothers who held negative beliefs toward colostrum were more likely to delay breastfeeding initiation.

CONCLUSION

Although most Maya mothers practice early initiation, the intervillage disparity in breastfeeding practices demonstrates a need to geographically focus breastfeeding interventions. Our novel insights into the breastfeeding beliefs among Maya mothers will serve as a guide to structure culturally competent breastfeeding education interventions in indigenous communities.

Patterns of cultural consensus and intracultural diversity in Ghanaian complementary feeding practices

Designing effective interventions to improve infant and young child (IYC) feeding requires knowledge about determinants of current practices, including cultural factors. Current approaches to obtaining and using research on culture tend to assume cultural homogeneity within a population. The purpose of this study was to examine the extent of cultural consensus (homogeneity) in communities where interventions to improve IYC feeding practices are needed to address undernutrition during the period of complementary feeding. A second, related objective was to identify the nature of intracultural variation, if such variation was evident. Selected protocols from the Focused Ethnographic Study for Infant and Young Child Feeding Manual were administered to samples of key informants and caregivers in a peri-urban and a rural area in Brong-Ahafo, Ghana. Cultural domain analysis techniques (free listing, caregiver assessment of culturally significant dimensions, and food ratings on these dimensions), as well as open-ended questions with exploratory probing, were used to obtain data on beliefs and related practices. Results reveal generally high cultural consensus on the 5 dimensions that were assessed (healthiness, appeal, child acceptance, convenience, and modernity) for caregiver decisions and on their ratings of individual foods. However, thematic analysis of caregiver narratives indicates that the meanings and content of the constructs connoted by the dimensions differed widely among individual mothers. These findings suggest that research on cultural factors that affect IYC practices, particularly cultural beliefs, should consider the nature and extent of cultural consensus and intracultural diversity, rather than assuming cultural homogeneity.

Dirty and 40 days in the wilderness: Eliciting childbirth and postnatal cultural practices and beliefs in Nepal

Background

Pregnancy and childbirth are socio-cultural events that carry varying meanings across different societies and cultures. These are often translated into social expectations of what a particular society expects women to do (or not to do) during pregnancy, birth and/or the postnatal period. This paper reports a study exploring beliefs around childbirth in Nepal, a low-income country with a largely Hindu population. The paper then sets these findings in the context of the wider global literature around issues such as periods where women are viewed as polluted (or dirty even) after childbirth.

Methods

A qualitative study comprising five in-depth face-to-face interviews and 14 focus group discussions with mainly women, but also men and health service providers. The qualitative findings in Nepal were compared and contrasted with the literature on practices and cultural beliefs related to the pregnancy and childbirth period across the globe and at different times in history.

Results

The themes that emerged from the analysis included: (a) cord cutting & placenta rituals; (b) rest & seclusion; (c) purification, naming & weaning ceremonies and (d) nutrition and breastfeeding. Physiological changes in mother and baby may underpin the various beliefs, ritual and practices in the postnatal period. These practices often mean women do not access postnatal health services.

Conclusions

The cultural practices, taboos and beliefs during pregnancy and around childbirth found in Nepal largely resonate with those reported across the globe. This paper stresses that local people’s beliefs and practices offer both opportunities and barriers to health service providers.

Maternity care providers need to be aware of local values, beliefs and traditions to anticipate and meet the needs of women, gain their trust and work with them.

Physiological mechanisms, behavioral and psychological factors influencing the transfer of milk from mothers to their young

This article is part of a Special Issue "Parental Care".Producing milk to support the growth of their young is a central element of maternal care in mammals. In spite of the facts that ecological constraints influence nursing frequency, length of time until weaning and the composition of milk, there is considerable similarity in the anatomy and physiology of milk production and delivery across mammalian species. Here we provide an overview of cross species variation in nursing patterns and milk composition as well as the mechanisms underlying mammary gland development, milk production and letdown. Not all women breastfeed their infants, thus in later sections we review studies of factors that facilitate or impede the initiation and duration of breastfeeding. The results of these investigations suggest that the decisions to initiate and maintain breastfeeding are influenced by an array of personal, social and biological factors. Finally, studies comparing the development of breastfed and formula fed infants as well as those investigating associations between breastfeeding, maternal health and mother/infant interaction are reviewed. Leading health agencies including the World Health Organization and CDC advocate breastfeeding for at least the first 6months postpartum. To achieve these rates will require not only institutional support but also a focus on individual mother/infant dyads and their experience.

The Influence of Early Infant-Feeding Practices on the Intestinal Microbiome and Body Composition in Infants

Despite many years of widespread international recommendations to support exclusive breastfeeding for the first six months of life, common hospital feeding and birthing practices do not coincide with the necessary steps to support exclusive breastfeeding. These common hospital practices can lead to the infant receiving formula in the first weeks of life despite mothers' dedication to exclusively breastfeed. Consequently, these practices play a role in the alarmingly high rate of formula-feeding worldwide. Formula-feeding has been shown to alter the infant gut microbiome in favor of proinflammatory taxa and increase gut permeability and bacterial load. Furthermore, several studies have found that formula-feeding increases the risk of obesity in later childhood. While research has demonstrated differences in the intestinal microbiome and body growth between exclusively breast versus formula-fed infants, very little is known about the effects of introducing formula to breastfed infants either briefly or long term on these outcomes. Understanding the relationships between mixed-feeding practices and infant health outcomes is complicated by the lack of clarity in the definition of mixed-feeding as well as the terminology used to describe this type of feeding in the literature. In this commentary, we highlight the need for hospitals to embrace the 10 steps of the Baby Friendly Hospital Initiative developed by UNICEF and the WHO for successful breastfeeding. We present a paucity of studies that have focused on the effects of introducing formula to breastfed infants on the gut microbiome, gut health, growth, and body composition. We make the case for the need to conduct well-designed studies on mixed-feeding before we can truly answer the question: how does brief or long-term use of formula influence the health benefits of exclusive breastfeeding?

Race/Ethnic Differences in Birth Size, Infant Growth, and Body Mass Index at Age Five Years in Children in Hawaii

BACKGROUND

Factors at birth and infancy may increase risk of being overweight in childhood. The aim of this study was to examine the relationship of birth size and infant growth (2-24 months) with BMI at age 5 years in a multiethnic population.

METHODS

This was a retrospective study (using electronic medical records of a health maintenance organization in Hawaii) of singleton children born in 2004-2005, with linked maternal and birth information, infant weights (n = 597) and lengths (n = 473) in the first 2 years, and BMI measures at age 5 years (n = 894). Multiple regression models were used to estimate the association of BMI at age 5 years with birth size and infant growth.

RESULTS

Birth weight was positively associated with BMI at age 5 years, adjusting for gestational age, sex, race/ethnicity, and maternal prepregnancy weight, age, education, and smoking. A greater change in infant weight was associated with a higher BMI at age 5 years, though the effect of birth weight on BMI was neither mediated nor modified by infant growth rate. Birth weight, change in infant weight, and BMI at age 5 years varied by race/ethnicity. Change in infant BMI in the first 2 years was higher in other Pacific Islanders and whites (Δ = 0.966; confidence interval [CI] = 0.249-1.684; p = 0.02) than in Asian, other, and part Native Hawaiian race/ethnic groups.

CONCLUSIONS

Early biological measures of birth weight and infant weight gain varied by race/ethnicity and positively predicted BMI at age 5 years.

The Timing of Infant Food Introduction in Families With a History of Atopy

OBJECTIVE

To describe the timing of introduction and type of food introduced to infants with a family history of atopy.

METHODS

We conducted a secondary analysis of foods introduced each month to an interventional birth cohort of 149 infants at risk for atopy.

RESULTS

Seven percent of infants received solid food prior to 4 months of age; 13% after 6 months of age. Hyperallergenic foods were introduced on average in the following order: wheat (8.7 months); eggs (11.2 months); soy (13.0 months); fish (13.4 months); peanut (20.2 months); tree nuts (21.8 months); and other seafood (21.8 months). Asian race (odds ratio 3.94; 95% CI 1.14-13.58) and maternal history of food allergy (odds ratio 3.86; 95% CI 1.29-11.56) were associated with late food introduction.

CONCLUSION

Variation in timing of food introduction may reflect cultural preferences and/or previous experience with food allergy, as well as the ambiguous state of current recommendations.

Cultural determinants of optimal breastfeeding practices among indigenous Mam-Mayan women in the Western Highlands of Guatemala

BACKGROUND

Among indigenous Mam-Mayan women, breastfeeding practices may be intertwined with cultural influences during the early postpartum period.

OBJECTIVES

Our study explored whether beliefs regarding transmission of emotions through breast milk, the feeding of agüitas or temascal (traditional sauna) use were associated with achievement of the World Health Organization infant feeding recommendations and if these cultural practices served as moderators of the relationship between optimal breastfeeding practices and infant anthropometry.

METHODS

We recruited 190 mother-infant dyads at infant age < 46 days. Data on breastfeeding and cultural practices were collected via questionnaire. Infant length, weight, and head circumference were measured and z scores were calculated. Multiple linear and logistic regression analyses were used to examine determinants of initiation of breastfeeding within 1 hour, breastfeeding frequency, breastfeeding exclusivity, and infant weight-for-age z score (WAZ).

RESULTS

Mothers who delivered at the traditional midwife's house (odds ratio [OR] = 2.5) and those who did not believe in the transmission of susto (fright) through breast milk (OR = 2.4) were more likely to initiate breastfeeding within 1 hour postpartum. Higher breastfeeding frequency was observed among mothers who spent more time in the temascal. Initiating early breastfeeding within 1 hour postpartum was the sole infant feeding practice positively associated with exclusive breastfeeding and WAZ.

CONCLUSIONS

Our investigation in the Western Highlands of Guatemala has highlighted the link between cultural practices and beliefs during lactation, breastfeeding practices and infant growth. Public health practitioners need to understand how local cultural practices influence early initiation of breastfeeding to promote adequate infant weight.

A qualitative study to understand cultural factors affecting a mother's decision to breast or formula feed

BACKGROUND

The presence of barriers is not sufficient to explain breastfeeding rate disparities. A relatively unexplored area in coping with breastfeeding barriers is culture.

OBJECTIVE

This research aims to better understand the role of culture in a woman's infant feeding decision by using race and socioeconomic status as indicators of culture.

METHODS

Focus groups and individual interviews were conducted with 42 pregnant women or mothers of infants younger than 12 months. Focus group composition was determined by self-identified African American or white race and self-reported eligibility for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) or ineligibility (non-WIC).

RESULTS

Most participants acknowledged that breastfeeding was best, yet differences arose between groups in the perception of, and reaction to, breastfeeding barriers. WIC and non-WIC participants of both races indicated that some circumstances necessitated formula use. WIC participants felt that this was personally and socially acceptable due to need, whereas non-WIC participants felt that this was personally and socially unacceptable. When a barrier arose, WIC participants of both races felt that the infant feeding choice was not theirs and formula use might be inevitable. In contrast, non-WIC participants of both races expressed that they persevered to continue breastfeeding and did so by establishing small, achievable goals and seeking mentors.

CONCLUSION

Educational and public health efforts to reduce breastfeeding disparities may be enhanced if support is tailored to acknowledge cultural differences among women and address factors that make either breastfeeding or formula feeding acceptable, or even preferable, within their communities.

Infant Feeding Attitudes and Breastfeeding Intentions of Black College Students

Breastfeeding rates are lowest among Black women than women of other races. An understanding of infant feeding attitudes may help improve breastfeeding rates among Black women. The theory of planned behavior guided this study to explore infant feeding attitudes of Black college students and the contribution of attitudes to breastfeeding intentions after controlling for age, gender, income, and education level. A sample of 348 Black college students below 45 years old with no children and no history of pregnancies were recruited for this study. The Iowa Infant Feeding Attitude Scale and a Demographic Questionnaire were used to collect data. Participants agreed that breast milk is the ideal food for infants and 48% indicated high probability of breastfeeding intentions. Infant feeding attitudes also explained approximately 30% (Nagelkerke R2) of the variance in breastfeeding intentions. Therefore, breastfeeding interventions targeting Black women should focus on improving breastfeeding attitudes.

Increased breastfeeding rates in black women after a treatment intervention

There has been a considerable increase in rates of breastfeeding in the United States. Despite these trends, black women continue to fall below medical recommendations. Impoverished and poorly educated women also have a comparatively lower rate of breastfeeding. Provider encouragement and supportive interventions increase breastfeeding initiation among women of all backgrounds. The data presented come from a three-site randomized controlled bilingual depression treatment trial from 2005 to 2011 that examined the comparative effectiveness of interpersonal psychotherapy and a parenting education program. Breastfeeding education and support were provided for the majority of participants in each intervention. Breastfeeding status was queried at postpartum week 4. We found higher rates of breastfeeding in black women compared with those reported in national surveys. The black breastfeeding rate did not significantly differ from that of white or Hispanic women. American-born black women were just as likely to breastfeed as American-born white women, both at significantly greater rates than American-born Hispanic women. We also found no differences in breastfeeding rate in poorly educated and impoverished women. These data must be seen against the backdrop of a significant intervention to treat depression. Because breastfeeding interventions have been shown to increase breastfeeding rates, the support provided in our study likely increased rates in groups that lag behind.

A focused ethnographic assessment of Middle Eastern mothers' infant feeding practices in Canada

The aim of this study was to examine the barriers to following complementary feeding guidelines among Middle Eastern mothers and the cultural considerations of practitioners from an emic perspective. This is a two-phase focused ethnographic assessment of infant feeding among 22 Middle Eastern mothers in Western Canada who had healthy infants aged <1 year. Data were collected through four focus groups conducted in Arabic/Farsi, and were further complemented by comprehensive survey data collected in the second phase of study. Mothers' main criterion for choosing infant foods was whether or not foods were Halal, while food allergens were not causes for concern. Vitamin D supplements were not fed to 18/22 of infants, and mashed dates (Halawi), rice pudding (Muhallabia/Ferni) and sugared water/tea were the first complementary foods commonly consumed. Through constant comparison of qualitative data, three layers of influence emerged, which described mothers' process of infant feeding: socio-cultural, health care system and personal factors. Culture was an umbrella theme influencing all aspects of infant feeding decisions. Mothers cited health care professionals' lack of cultural considerations and lack of relevance and practicality of infant feeding guidelines as the main reasons for ignoring infant feeding recommendations. Early introduction of pre-lacteal feeds and inappropriate types of foods fed to infants among immigrant/refugee Middle Eastern mothers in Canada is cause of concern. Involving trained language interpreters in health teams and educating health care staff on cultural competency may potentially increase maternal trust in the health care system and eventually lead to increased awareness of and adherence to best practices with infant feeding recommendations.

Exploring Middle-Eastern mothers' perceptions and experiences of breastfeeding in Canada: an ethnographic study

The aim of this study was to explore from the Middle-Eastern mothers' perspective, the experience of breastfeeding and their perceptions of attributes of the health care system, community and society on their feeding decisions after migration to Canada. New immigrant mothers from the Middle East (n = 22) were recruited from community agencies in Edmonton, Canada. Qualitative data were collected through four focus groups using an ethnographic approach to guide concurrent data collection and analysis. Survey data were collected on socio-demographic characteristics via pre-tested questionnaires. All mothers, but one who was medically exempt, breastfed their infants from birth and intended to continue for at least 2 years. Through constant comparison of data, five layers of influence emerged which described mothers' process of decision making: culture/society, community, health care system, family/friends and mother-infant dyad. Religious belief was an umbrella theme that was woven throughout all discussions and it was the strongest determining factor for choosing to breastfeed. However, cultural practices promoted pre-lacteal feeding and hence, jeopardising breastfeeding exclusivity. Although contradicted in Islamic tradition, most mothers practised fasting during breastfeeding because of misbeliefs about interpretations regarding these rules. Despite high rates of breastfeeding, there is a concern of lack of breastfeeding exclusivity among Middle-Eastern settlers in Canada. To promote successful breastfeeding in Muslim migrant communities, interventions must occur at different levels of influence and should consider religious beliefs to ensure cultural acceptability. Practitioners may support exclusive breastfeeding through cultural competency, and respectfully acknowledging Islamic beliefs and cultural practices.

Development of eating behavior: biology and context

Eating is necessary for survival, gives great pleasure, and can be perturbed leading to undernutrition, overnutrition, and eating disorders. The development of feeding in humans relies on complex interplay between homeostatic mechanisms; neural reward systems; and child motor, sensory, and socioemotional capability. Furthermore, parenting, social influences, and the food environment influence the development of eating behavior. The rapid expansion of new knowledge in this field, from basic science to clinical and community-based research, is expected to lead to urgently needed research in support of effective, evidence-based prevention and treatment strategies for undernutrition, overnutrition, and eating disorders in early childhood. Using a biopsychosocial approach, this review covers current knowledge of the development of eating behavior from the brain to the individual child, taking into account important contextual influences.

Annual Research Review: All mothers are not created equal: neural and psychobiological perspectives on mothering and the importance of individual differences

Quality of mothering relies on the integrity of multiple physiological and behavioral systems and on two maternal factors, one proximal and one distal, that have a great impact on how a mother mothers: postpartum depression and early experiences. To mother appropriately requires the action of systems that regulate sensation, perception, affect, reward, executive function, motor output and learning. When a mother is at risk to engage in less than optimal mothering, such as when she is depressed or has experienced adversity in childhood, the function of many or all of maternal and related systems may be affected. In this paper, we will review what is currently known about the biological basis of mothering, with attention to literature on hormones but with a particular focus on recent advances in the fields of functional neuroimaging. Instead of discussing strictly 'maternal' brain imaging studies, we instead use a systems approach to survey important findings relevant to brain systems integral to and/or strongly related to the mothering experience: (a) social behavior; (b) reward and affect; (c) executive function; and (d) maternal behavior. We find that there are many commonalities in terms of the brain regions identified across these systems and, as we would expect, all are sensitive to the influence of, or function differently in the context of, depression and adverse early experience. It is likely that the similarity and cross-talk between maternal, affect and stress systems, observed behaviorally, hormonally and in the context of brain function, allows for mood disturbance and early adverse experiences to have a significant impact on the quality of mothering and the motivation to mother.

Survival and health benefits of breastfeeding versus artificial feeding in infants of HIV-infected women: developing versus developed world

Infant feeding policies for HIV-infected women in developing countries differ from policies in developed countries. This article summarizes the epidemiologic data on the risks and benefits of various infant feeding practices for HIV-infected women living in different contexts. Artificial feeding can prevent a large proportion of mother-to-child HIV transmission but also is associated with increases in morbidity and mortality among exposed-uninfected and HIV-infected children. Antiretroviral drugs can be used during lactation and reduce risks of transmission. For most of the developing world, the health and survival benefits of breastfeeding exceed the risks of HIV transmission, especially when antiretroviral interventions are provided.