Breastfeeding and the Risk of Infant Illness in Asia: A Review

Fathers' breastfeeding knowledge, attitudes, and involvement in the Asian context: A mixed-studies review

BACKGROUND

Despite numerous initiatives attempting to enhance BF across Asia, recent studies show that exclusive BF rates remain alarmingly low. With globalization, society has shifted from traditional family roles towards more egalitarian marriages, where Asian fathers are now more involved in parenting. As fathers' involvement in breastfeeding is highly complex and context-sensitive, evaluation of a wide range of concepts and evidence within the Asian context is necessary.

OBJECTIVE

This review aims to consolidate and appraise empirical studies exploring fathers' breastfeeding knowledge, attitude, and involvement within the Asian context.

DESIGN

A systematic mixed-studies review was conducted. Six electronic databases (PubMed, CINAHL, PsycINFO, Embase, Scopus, and ProQuest Dissertations and Theses Global) were searched from each database's inception date until June 2022. Studies were appraised using the Mixed Method Appraisal Tool and data was synthesised using the results-based convergent integration method.

FINDINGS

Twenty-two studies were included in this review. The synthesis of findings identified two main themes and six sub-themes.

KEY CONCLUSIONS

Asian fathers have a varied understanding of breastfeeding and their involvement in breastfeeding is influenced by personal, cultural, religious, social, and environmental factors.

IMPLICATIONS FOR PRACTICE

Perinatal care professionals play a crucial role in engaging and enhancing fathers' involvement in breastfeeding education programmes. The findings also urge policymakers to introduce more 'father-friendly' breastfeeding guidelines and educate perinatal care professionals to be more aware and sensitive to the needs of fathers. There is also a need to introduce more flexible and economically sensitive paternal leave policies to improve fathers' breastfeeding involvement.

"Mother's milk": Is there a social reversal in breastfeeding practices along with economic development?

Previous studies suggest that macro- and micro-level factors jointly influence breastfeeding (BF) practices, but empirical evidence on the dynamics of such interactions along with the process of a country's economic development remains limited. Based on 42 Demographic Health Surveys (DHS) conducted in 15 Asian countries with a large time window (1990-2017), we thus test the existence of a reversal in the association between household wealth and BF practices throughout the development process. Four BF indicators (early initiation of BF, exclusive BF, continued BF at one year and two years) are examined, along with a standardized asset-based household wealth index allowing for cross-wave and cross-country comparisons. To highlight the dynamics of the wealth-BF association, we carry out econometric estimations, including interaction terms between household wealth and the country's level of economic development (low, medium, and high) or time. Instrumental variable estimations are also performed to limit suspected endogeneity issues. Our results confirm a transition in the wealth gradient of exclusive BF and continued BF in Asian countries. More precisely, while these practices are pro-poor in the poorest countries of the sample, they progressively spread to wealthier households along with the level of economic development. For exclusive BF, this transition has resulted in a reversal of the wealth gradient at the end of the period (i.e., exclusive BF prevalence among the rich overpassing that of the poor). We fail, however, to observe this kind of transition for early initiation of BF, this practice remaining pro-poor, whatever the level of economic development. To sum up, our results provide robust evidence of a transition in the wealth gradient of some BF practices along with economic development and time, and thus largely echo the literature exploring the social reversal hypothesis in the case of non-communicable diseases.

Ethical Issues in Breastfeeding and Lactation Interventions: A Scoping Review

BACKGROUND

Infant feeding interventions that promote and support breastfeeding are considered important contributions to global public health. As these interventions often target private settings (e.g., individuals' homes) and involve vulnerable populations (e.g., pregnant women, infants, and underprivileged families), a keen awareness of ethical issues is crucial.

RESEARCH AIM

The purpose of this scoping review was to capture the key elements of the current ethical discourse regarding breastfeeding and lactation interventions.

METHOD

A scoping review was conducted using Arksey and O'Malley's (2005) methodology to identify the ethical issues of breastfeeding and lactation interventions as they are reflected in the scholarly literature published between January 1990 and October 2022. Abstracts (N = 3715) from PubMed, ScienceDirect, JSTOR and the Cochrane Database of Systematic Reviews were screened. The final sample consisted of 26 publications.

RESULTS

The recurring ethical issues identified in these studies were: the normative assumptions of motherhood; maternal autonomy and informed choice; information disclosure, balancing risks and benefits, and counseling practices; stigma and social context; ethics of health communication in breastfeeding campaigns; and the ethical acceptability of financial incentives in breastfeeding interventions.

CONCLUSION

This review illustrated that, while a wide range of ethical arguments were examined, the emphasis has been primarily on accounting for mothers' experiences and lactating persons' choices, as well as achieving public health objectives relating to infant nutrition in breastfeeding interventions. To effectively and ethically implement breastfeeding and lactation interventions, we must consider the social, economic, and cultural contexts in which they occur. One key learning identified was that women's experiences were missing in these interventions and, in response, we suggest moving beyond the dichotomous approach of individual health versus population health.

Discordance in exclusive breastfeeding between maternal recall and deuterium dose-to-mother technique during the first 6 months of infants: A multi-country study in Asia

PURPOSE

This study aimed to assess the agreement in EBF between maternal recall and the dose-to-mother (DTM) technique.

METHODS

Indonesia, Malaysia, Mongolia, Pakistan, Sri Lanka, Thailand, and Vietnam participated in the study. A total of 207 and 118 mother-infant pairs were assessed at 3 and 6 months of child's age. Using a standardized questionnaire, mothers were asked to recall child feeding during the previous 24 h, at 3 and 6 months. Those recalled to be EBF proceeded to be assessed using DTM technique. Non-milk oral intake (NMOI) cutoff of 86.6 g/d was used to classify EBF.

RESULTS

According to DTM, 66% of infants were EBF at 3 months, while only 22% were EBF at 6 months. At 3 months, the overall % agreement between maternal recall and DTM method was 68%, kappa 0.06 (95% CI: 0.07-0.20), and at 6 months, the % agreement was only 21%, kappa -0.031 (95% CI -0.168 to 0.107). Human milk intakes were similar at 3 months and 6 months when expressed as g/d, but decreased when expressed as g/kg/d, with a large variation within and between countries; Pakistan being the lowest.

CONCLUSION

This study showed there were declining levels of EBF from 3 to 6 months in the participating countries from Asia and the agreement between maternal recall and DTM technique to classify EBF was low. To ensure that the DTM technique can be more widely used in evaluating breastfeeding promotion programs, consensus on the appropriate NMOI cutoff and simplification of the DTM protocol is necessary.

Setting up the first human milk bank in Uganda: a success story from Nsambya hospital

Background

The World Health Organization (WHO) strongly recommends the use of donor human milk (DHM) for low birth weight infants when mother's own milk is unavailable or insufficient. However, the use of DHM requires the availability of human milk banks (HMBs), the majority of which are in middle and high-income countries. Developing countries offer multiple opportunities and challenges regarding the establishment and operationalization of HMBs. This study describes the experience in setting up the HMB in Uganda at St. Francis Hospital Nsambya.

Methods

The establishment of the first HMB in Uganda followed a step-wise approach using the PATH's Resource Toolkit for Establishing and Integrating Human Milk Banks. The steps included: performing a facility readiness assessment, implementing quality control measures, forming and training a committee for the Baby Friendly Hospital Initiative, establishing a monitoring and evaluation system, developing a communication strategy, engaging with the Ministry of Health, providing staff training by a Human Milk Bank consultant, and maintaining regular coordination by a dedicated technical team.

Results

A total of 170 donors have been screened and of these 140 have donated milk with a mean age of 26 years since the establishment of the bank in November 2021. A total of 108 admitted neonates have received the milk; majority (88%) are preterm infants with a mean gestational age of 34 weeks. A total of 90 liters have been collected and 76 distributed. The challenges in establishment of the Human Milk bank included: lack of guidelines on human milk banking, use of unpasteurized milk, lack of communication strategy, lack of clear model infrastructure and lactation training. We addressed the challenges: by drafting guidelines, set up a human milk bank and had training on use donor pasteurized milk, designed communication messages through videos and brochures, visited Pumwani hospital and remodeled the Human Milk Bank according to the model at Pumwani, all the health workers in the human milk bank had a training on Lactation. Assessing the experiences and attitudes of mothers, donors, healthcare providers, and hospital leaders revealed concerns about milk safety and fear about potential attachments or acquired traits through the donated milk to the babies that may receive it. Donors viewed milk donation as a life-saving act, although fears of breast cancer and lumps arose from misconceptions. To address these perspectives, creative media, such as videos and messages, were designed to raise awareness, promote behavioral change, and create demand for the HMB services.

Conclusion

The establishment and integration of HMB services at hospitals in Uganda is feasible.

Postmortem minimally invasive tissue sampling in communities: exploring perceptions of families, funeral workers, religious and community leaders and healthcare providers from Pakistan

BACKGROUND

Minimally invasive tissue sampling (MITS) has increasingly been used to improve the diagnosis of disease and identification of the cause of death, particularly in underserved areas. However, there are multiple barriers to accessing those who die within the community, our study aimed to explore the perceptions and insights of community members and healthcare providers regarding the feasibility of implementing MITS in community settings.

METHODS

A qualitative exploratory study was conducted. A total of twenty one in-depth interviews were conducted with deceased infants' parents, elders of the family, religious leaders, community leaders, and funeral workers. Focus group discussions were conducted with health care providers (n = 14) in two peri-urban slum areas of Karachi, Pakistan. The duration of this study was from August to October 2020. Data was analyzed using thematic analysis and was coded and merged into categories forming eight major themes.

RESULTS

In general, participants viewed minimally invasive tissue sampling (MITS) as beneficial for improving child health, though some had concerns about disrespecting the deceased during sample collection. Misinformation, fear of needles, and medical procedures were major barriers to MITS implementation. To enhance acceptance, community and religious leaders suggested using religious rulings, obtaining parental consent, ensuring confidentiality, and increasing efforts of community engagement. Community healthcare providers, along with funeral workers, recommended providing community members with grief counseling to increase study participation. Besides concerns about sampling interfering with respect for the decease, community members also raised concerns about misinformation. Further, participants provided feedback on the design and appearance of the mobile van used to collect MITS samples from children under the age of five.

CONCLUSION

This study is critical for understanding the challenges associated with implementation of community-based MITS sampling in Pakistan. Integrating the use of a mobile van for sample collection, grief counseling along with community engagement sessions and advocacy will help address community-based misinformation and develop community trust.

Factors associated with intention to breastfeed in Vietnamese mothers: A cross-sectional study

INTRODUCTION

Breastfeeding has many benefits for mothers, children, and the environment over both the short and longr-term. Prenatal intention to breastfeed is a powerful predictor of short-term breastfeeding outcomes.

OBJECTIVE

This study aims to analyze breastfeeding intentions, including the intention to feed infants with breastmilk only and to continue exclusive breastfeeding to 6 months among pregnant mothers in Hanoi, Vietnam.

METHODS

The analysis included 1230 singleton mothers, between 24- and 36-weeks' gestation, who attended antenatal clinics in two hospitals in Hanoi in 2020.

RESULTS

The proportion of mothers with an "breastfeeding intention" (i.e., intention to feed an infant with breastmilk only) and "exclusive breastfeeding intention" to 6 months was 59.9% and 41.7%, respectively. Mothers who were 25 years or older (aOR = 1.35, 95%CI:1.00-1.81), had an undergraduate educational degree or higher (aOR = 1.38, 95%CI: 1.08-1.76), had observed another woman breastfeeding (aOR = 1.43, 95%CI: 1.03-2.00), were not living with parents-in-law (aOR = 1.34, CI: 1.05-1.70), and were multiparous (aOR = 1.60, 95%CI: 1.16-2.19) had higher odds of "exclusive breastfeeding intention" to 6 months. Among primiparous women, those who thought their husbands support breastfeeding were more likely to intend to feed an infant with breastmilk only. Among multiparous women, feeding the previous child with breastmilk exclusively before the introduction of complementary foods and not giving solid foods together with water until 6 months, were significant predictors for both breastfeeding intentions.

CONCLUSION

Mothers without exclusive breastfeeding experience should be provided with greater support to promote exclusive breastfeeding intention and outcomes.

Environmental Risk Factors, Protective Factors, and Biomarkers for Allergic Rhinitis: A Systematic Umbrella Review of the Evidence

Many potential environmental risk factors, protective factors, and biomarkers of AR have been published, but so far, the strength and consistency of their evidence are unclear. We conducted a comprehensive review of environmental risk, protective factors, and biomarkers for AR to establish the evidence hierarchy. We systematically searched Embase, PubMed, Cochrane Library, and Web of Science electronic database from inception to December 31, 2022. We calculated summary effect estimate (odds ratio (OR), relative risk (RR), hazard ratio (HR), and standardized mean difference (SMD)), 95% confidence interval, random effects p value, I2 statistic, 95% prediction interval, small study effects, and excess significance biases, and stratification of the level of evidence. Methodological quality was assessed by AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews 2). We retrieved 4478 articles, of which 43 met the inclusion criteria. The 43 eligible articles identified 31 potential environmental risk factors (10,806,206 total population, two study not reported), 11 potential environmental protective factors (823,883 total population), and 34 potential biomarkers (158,716 total population) for meta-analyses. The credibility of evidence was convincing (class I) for tic disorders (OR = 2.89, 95% CI 2.11-3.95); and highly suggestive (class II) for early-life antibiotic use (OR = 3.73, 95% CI 3.06-4.55), exposure to indoor dampness (OR = 1.49, 95% CI 1.27-1.75), acetaminophen exposure (OR = 1.54, 95% CI 1.41-1.69), childhood acid suppressant use (OR = 1.40, 95% CI 1.23-1.59), exposure to indoor mold (OR = 1.66, 95% CI 1.26-2.18), coronavirus disease 2019 (OR = 0.11, 95% CI 0.06-0.22), and prolonged breastfeeding (OR = 0.72, 95% CI 0.65-0.79). This study is registered in PROSPERO (CRD42022384320).

Cessation of exclusive breastfeeding and predictors among infants aged 0-6 months in Ararso district of the Somali region, Ethiopia. A community-based cross-sectional study

Background

Exclusive breastfeeding (EBF) is the gold standard of child feeding practice in which the infant only receives breast milk without any additional food or drink, not even water and it lasts up to 6 months after delivery. In the study area, there is a lack of data on the prevalence of cessation of EBF.

Methods

Community-based cross-sectional study design was used among 292 mothers of infants aged 0-6 months. The data was collected using a pretested structured questionnaire. Bivariate and multivariate logistic regression analyses were carried out. An odds ratio with a 95% confidence interval was used to measure the strength of the association. Statistical significance was declared at P-value <0.05.

Results

The prevalence of cessation of EBF was 57.3% with 95% CI [50.9-62.6]. This study showed being employed (working outside the home) (AOR = 2.44; 95% CI [1.32-4.53]), being rural residence (AOR = 1.87; 95% CI [1.05-3.32]), and inadequate knowledge of EBF (AOR = 2:02; 95% CI [1.19-3.43]) were independent predictors of cessation of EBF.

Conclusion and Recommendation

Our data identified a higher prevalence of cessation of EBF in the study area compared to most studies in Ethiopia and elsewhere. Efforts on improving knowledge of the importance of EBF particularly in rural areas and support for breastfeeding-employed women are recommended.

Childhood pneumonia in Beijing: Associations and interactions among selected demographic and environmental factors

Among infectious diseases, pneumonia is the greatest cause of mortality in children less than 5 years old. Approximately 27% of Beijing's 3-8 year-old children have had pneumonia at least once. The sole reservoir of pneumonia pathogens is the human nasopharynx. We investigated associations and interactions among two kinds of environmental risk factors: i) airborne pathogens, namely closed bedroom window and shared bedroom and ii) pollutants, namely traffic pollution and environmental tobacco smoke (ETS). We evaluated breastfeeding's (BF) protective value against childhood pneumonia. The database consists of responses to a questionnaire in a cross-sectional study. Crude and adjusted Odds Ratios were assessed independently for each risk factor. Combinations of the studied risk factors were analyzed using multivariate logistic regression. Risk factors were evaluated for interactions on the additive scale using the metrics Relative Excess Risk due to Interaction (RERI), Attributable Proportion (AP) and Synergy Index (S). All independent risk factors were significant for children's pneumonia. We also found evidence of possible synergistic interaction between pairs of risk factors that was stronger when one of the risk factors was a closed bedroom window. Remarkably, window opening was associated with reduced risk of pneumonia for children living near heavy traffic pollution. Longer duration BF was more protective than shorter, and exclusive BF was more protective than partial BF against childhood pneumonia. In conclusion, low ventilation (closed bedroom windows), shared bedroom, ETS, and traffic exposure were associated with increased risk of pneumonia. Exclusive BF for more than six months had the greatest protective value against pneumonia.

Maternal Serum, Cord and Human Milk Levels of Per- and Polyfluoroalkyl Substances (PFAS), Association with Predictors and Effect on Newborn Anthropometry

BACKGROUND

The understanding of per- and polyfluoroalkyl substances (PFAS) health effects is rapidly advancing among critical populations. Therefore, the objective of this study was to assess PFAS serum levels among Lebanese pregnant women, cord serum and human milk levels, their determinants, and effects on newborn anthropometry.

METHODS

We measured concentrations of six PFAS (PFHpA, PFOA, PFHxS, PFOS, PFNA and PFDA) using liquid chromatography MS/MS for 419 participants, of which 269 had sociodemographic, anthropometric, environmental and dietary information.

RESULTS

The percentage of detection for PFHpA, PFOA, PFHxS and PFOS was 36.3-37.7%. PFOA and PFOS levels (95th percentile) were higher than HBM-I and HBM-II values. While PFAS were not detected in cord serum, five compounds were detected in human milk. Multivariate regression showed that fish/shellfish consumption, vicinity to illegal incineration and higher educational level were associated with an almost twice higher risk of elevated PFHpA, PFOA, PFHxS and PFOS serum levels. Higher PFAS levels in human milk were observed with higher eggs and dairy products consumption, in addition to tap water (preliminary findings). Higher PFHpA was significantly associated with lower newborn weight-for-length Z-score at birth.

CONCLUSIONS

Findings establish the need for further studies, and urgent action to reduce exposure among subgroups with higher PFAS levels.

Microbial Diversity and Correlation between Breast Milk and the Infant Gut

The gut microbiota is significant for infants to grow and develop in the early stages of life. The breast milk microbiota directly or indirectly influences colonizing and the development of early infant intestinal microbiota. Therefore, we wanted to study the microbial diversity and correlation between breast milk and the infant gut. By sequencing the 16S rRNA V3-V4 regions of microbiome in infant feces 1, 14, 20, 30, and 90 days after delivery as well as those in breast milk using Illumina NovaSeq, we studied the component of microbiome in both human milk and infant stools, analyzed the diversity of microbiota, and explored the relationship between them. We found that the richest bacteria in breast milk were Acinetobacter, Stenotrophomonas, Sphingopyxis, Pseudomonas, and Streptococcus, with a small amount of Lactobacillus, Bifidobacterium, and Klebsiella. The infant feces were abundant in Bifidobacterium, Escherichia-Shigella, Klebsiella, Streptococcus, Serratia, Bacteroides, and Lactobacillus, with a small number of Acinetobacter and Pseudomonas. Acinetobacter, Bifidobacterium, Klebsiella, and Lactobacillus appeared in the breast milk and infant feces, suggesting that they were transferred from the breast milk to the infant's gut.

Exclusive Breastfeeding and Childhood Morbidity: A Narrative Review

Globally, diarrheal diseases and acute respiratory infections are the leading causes of morbidity and mortality in children under 5 years old. The benefits of exclusive breastfeeding in reducing the risk of gastrointestinal and respiratory infections are well documented. Optimal breastfeeding may potentially save the lives of about 800,000 children in low-income settings. Despite the evidence, around 63% of infants from birth to 6 months are not exclusively breastfed worldwide. We searched the literature published between 2010 and 2022 in Medline, Embase, and Scopus on the association between exclusive breastfeeding and infectious diseases. We selected and reviewed 70 relevant studies. Our findings expand and confirm the positive association between exclusive breastfeeding and reduced risk of a number of gastrointestinal, respiratory, and other infections in 60 out of 70 studies observed in both low- and high-income settings. Several studies analyzing exclusive breastfeeding duration reported that a longer exclusive breastfeeding duration is protective against many infectious diseases. This review also reported a lack of standardized definition for measuring exclusive breastfeeding in many studies. Overall, the results highlight the benefits of exclusive breastfeeding in many studies and suggests reporting exclusive breastfeeding in future studies using a consistent definition to enable better monitoring of exclusive breastfeeding rates.

Exclusive Breastfeeding and Vitamin D Supplementation: A Positive Synergistic Effect on Prevention of Childhood Infections?

Human milk is the best food for infants. Breastfeeding has been associated with a reduced risk of viral and bacterial infections. Breast milk contains the perfect amount of nutrients needed to promote infant growth, except for vitamin D. Vitamin D is crucial for calcium metabolism and bone health, and it also has extra-skeletal actions, involving innate and adaptive immunity. As exclusive breastfeeding is a risk factor for vitamin D deficiency, infants should be supplemented with vitamin D at least during the first year. The promotion of breastfeeding and vitamin D supplementation represents an important objective of public health.

[Review of new evidence about the possible vertical transmission of coronavirus disease-2019]

OBJECTIVE

To conduct a systematic review of original peer-reviewed studies, containing data on the identification of SARS-CoV-2 in clinical samples of amniotic fluid, placenta or membranes, umbilical cord blood, and human milk, from women with a clinically or confirmed diagnosis of COVID-19. These studies should have been published after the guide for the management of patients with COVID-19 from World Health Organization guide (available in March 13, 2020).

RESULTS

Seventeen studies were included, in which 143 clinical samples were identified (38 of amniotic fluid; 34 of placentas or membranes; 39 from umbilical cord blood and 32 from human milk). Among the 143 samples, nine were positive for SARS-CoV-2 RNA (one amniotic fluid sample obtained before rupturing the membranes; six samples of placenta or membranes, although authors indicate the possibility of contamination by maternal blood in three of these, and two samples of human milk).

CONCLUSIONS

Following our search criteria, we found no studies that demonstrate the detection of SARS-CoV-2, in conjunction with viral isolation and the evaluation of the infective capacity of viral particles, in clinical samples of amniotic fluid, placenta or membranes, umbilical cord blood and human milk, from women with a confirmed or clinical diagnosis of COVID-19. However, vertical transmission cannot be ruled out, larger studies are required that ideally locate in situ RNA and protein of SARS-CoV-2, as well as isolation that demonstrate the infective capacity of the viral particles.

Breastfeeding Duration and Its Effective Factors in Kerman Province, Iran

Introduction

Complete cessation of breastfeeding (CCB) at the right time is as important as starting breastfeeding, as well as identifying the factors that affect the duration of breastfeeding, so that breastfeeding promotion programs focus on these causes, to increase mothers’ ability and desire to breastfeed. This study aimed to determine the time of CCB and its related factors.

Methods

This analytical cross-sectional study was conducted in 2020. This study was performed at all health centers and health homes affiliated to Kerman University of Medical Sciences, in Kerman province, Iran. A total of 802 urban and rural mothers with children aged from 30 to 36 months completed the questionnaire. The validity and reliability of the questionnaire were confirmed by Cronbach’s alpha of 85%. Data were analyzed using SPSS software version 16.

Results

The mean time of breastfeeding was 19.23 ± 7.09 months and the median was 22-month-year. About 41% of children were breastfed until 24-month. There was a significant relationship between the time of CCB with contraception, number of households, place of residence, and weight at 6-month at the level of 0.05.

Conclusion

Duration of breastfeeding is influenced by some demographic and cultural factors. The timing of the CCB is near to the suggestions of the World Health Organization (WHO) and religious teachings.

Distinct fermentation of human milk oligosaccharides 3-FL and LNT2 and GOS/inulin by infant gut microbiota and impact on adhesion of Lactobacillus plantarum WCFS1 to gut epithelial cells

Human milk oligosaccharides (hMOs) are unique bioactive components in human milk. 3-Fucosyllactose (3-FL) is an abundantly present hMO that can be produced in sufficient amounts to allow application in infant formula. Lacto-N-triaose II (LNT2) can be obtained by acid hydrolysis of lacto-N-neotetraose (LNnT). Both 3-FL and LNT2 have been shown to have health benefits, but their impact on infant microbiota composition and microbial metabolic products such as short-chain fatty acids (SCFAs) is unknown. To gain more insight in fermentability, we performed in vitro fermentation studies of 3-FL and LNT2 using pooled fecal microbiota from 12-week-old infants. The commonly investigated galacto-oligosaccharides (GOS)/inulin (9 : 1) served as control. Compared to GOS/inulin, we observed a delayed utilization of 3-FL, which was utilized at 60.3% after 36 h of fermentation, and induced the gradual production of acetic acid and lactic acid. 3-FL specifically enriched bacteria of Bacteroides and Enterococcus genus. LNT2 was fermented much faster. After 14 h of fermentation, 90.1% was already utilized, and production of acetic acid, succinic acid, lactic acid and butyric acid was observed. LNT2 specifically increased the abundance of Collinsella, as well as Bifidobacterium. The GOS present in the GOS/inulin mixture was completely fermented after 14 h, while for inulin, only low DP was rapidly utilized after 14 h. To determine whether the fermentation might lead to enhanced colonization of commensal bacteria to gut epithelial cells, we investigated adhesion of the commensal Lactobacillus plantarum WCFS1 to Caco-2 cells. The fermentation digesta of LNT2 collected after 14 h, 24 h, and 36 h, and GOS/inulin after 24 h of fermentation significantly increased the adhesion of L. plantarum WCFS1 to Caco-2 cells, while 3-FL had no such effect. Our findings illustrate that fermentation of hMOs is very structure-dependent and different from the commonly applied GOS/inulin, which might lead to differential potencies to stimulate adhesion of commensal cells to gut epithelium and consequent microbial colonization. This knowledge might contribute to the design of tailored infant formulas containing specific hMO molecules to meet the need of infants during the transition from breastfeeding to formula.

Breastfeeding technique and associated factors among lactating mothers visiting Gondar town health facilities, Northwest Ethiopia: observational method

BACKGROUND

The breastfeeding technique is explained positioning, attachment, and suckling during breastfeeding. Ineffective breast feeding technique is one of the factors leading to premature discontinuation of breastfeeding and malnutrition. There is a limited study on the assessments of BFT and associated factors among lactating mothers in the study area. Therefore, the study aimed to assess breastfeeding technique and the associated factors among lactating mothers visiting Gondar town health facilities, Northwest Ethiopia.

METHODS

An institution-based cross-sectional study was conducted from February 20 to March 20, 2020. An observational checklist and structured interviewer-administered questionnaire were applied to collect the data. The data were entered into Epi-Data 4.6 version and transferred to analyzed using SPSS version 20. Bi-variable and multivariable logistic regressions were performed to identify the association. The strength of association was identified using odds ratio with a 95% confidence interval (), and a p-value of 0.05 was declare as statistically significant.

RESULTS

The proportion of effective BFT was 48% (95%, CI: 43.0-53.0%). The likelihood of applying proper BFT among age group of 18-20 years was 70% lower than (AOR = 0.3; 95% CI: 0.11-0.83) age group > 30 years. The odds of effective BFT in primipara mothers were 49% (AOR = 0.51; 95% CI: 0.32-0.82) lower compared to multiparous mothers. Likewise, the provability of effective BFT was 55% (AOR = 0.45; 95% CI: 0.29-0.70) times lower in women who had no counseling immediately after delivery compared to their counterparts. Moreover, effective breast feeding technique mothers who have breast problem was 78% lower than (AOR = 0.22; 95% CI: 0.07-0.68) mothers who have no breast problem. And mothers who had counselling of BFT during ANC follow up was 55% (AOR = 0.45; 95% CI: 0.29, 0.70) lower than mothers who had no counseling.

CONCLUSION

Just under half of the women in the study area applied proper breast feeding technique Younger and primipara mothers poorly performed to effective BFT. But women having counseling during antenatal care follow-up and immediately after delivery and not having breast problems applied BFT effectively. Hence, special emphasis have to give for younger and primipara mothers. Besides, educate the mother for preventing breast problems and working on enhancing counseling at postnatal clinic.

Global prevalence of WHO infant feeding practices in 57 LMICs in 2010-2018 and time trends since 2000 for 44 LMICs

BACKGROUND

The World Health Assembly set a global target of increasing exclusive breastfeeding for infants under 6 months to at least 50% by year 2025. However, little is known about the current status of breastfeeding practice, as well as the trends in breastfeeding practices during recent years. We examined global prevalence of the World Health Organization (WHO) feeding practices in 57 low- and middle-income countries (LMICs) and time trends since 2000 for 44 selected countries.

METHODS

We included 57 eligible LMICs that had completed data on breastfeeding and complementary feeding in 2010-2018 from the Demographic and Health Surveys (DHS) for examining current feeding status. We further selected 44 LMICs that had two standard DHS surveys between 2000 and 2009 and 2010-2018 to examine time trends of feeding status. We calculated global, regional, and national weighted prevalence estimates and 95% confidence intervals (CIs) for five breastfeeding indicators and two complementary feeding indicators.

FINDINGS

In 57 LMICs during 2010-2018, global weighted prevalence was 51.9% for early initiation of breastfeeding, 45.7% for exclusive breastfeeding under 6 months, 32.0% for exclusive breastfeeding at 4-5 months, 83.1% for continued breastfeeding at 1 year, 56.2% for continued breastfeeding at 2 years, 14.9% for introduction of solid, semi-solid or soft foods under 6 months, and 63.1% for introduction of solid, semi-solid or soft foods at 6-8 months. Eastern Mediterranean (34.5%) and European regions (43.7%) (vs. South-East Asia/Western Pacific (55.2%)), and upper middle-income countries (38.4%) (vs. lower middle-income countries (47.4%)) had poorer performance of exclusive breastfeeding under 6 months. South-East Asia/Western Pacific regions (51.0%) (vs. other regions (68.3%-84.1%)) and low-income (66.4%) or lower middle-income countries (58.2%) (vs. upper middle-income countries (81.7%)) had lower prevalence of introduction of solid, semi-solid or soft foods at 6-8 months. In 44 selected LMICs from 2000 to 2009 to 2010-2018, total weighted prevalence presented an increase of 10.1% for exclusive breastfeeding under 6 months, but a 1.7% decrease for continued breastfeeding at 1 year. Over this period, the Eastern Mediterranean region had a 5.3% decrease of exclusive breastfeeding under 6 months, and the European region had a 2.0% increase for introduction of solid, semi-solid or soft foods under 6 months. The prevalence of introduction of solid, semi-solid or soft foods at 6-8 months decreased in South-East Asia/Western Pacific region by 15.2%, and in lower middle-income countries by 24.4%.

INTERPRETATION

Breastfeeding practices in LMICs have continued to improve in the past decade globally, but practices still lag behind the WHO feeding recommendations. Breastfeeding practices differed greatly across WHO regions, with the Eastern Mediterranean and European regions, and upper middle-income countries facing the greatest challenges in meeting targets. Continued efforts are needed to achieve the 2025 global breastfeeding target.

Dietary Patterns of Breastfeeding Mothers and Human Milk Composition: Data from the Italian MEDIDIET Study

(1) Background: Several studies have reported associations between maternal diet in terms of single foods or nutrients and human milk compounds, while the overall role of maternal diet and related dietary patterns has rarely been investigated. (2) Methods: Between 2012 and 2014, we enrolled 300 healthy Italian mothers, who exclusively breastfed their infant. During a hospital visit at 6 weeks postpartum, a sample of freshly expressed foremilk was collected and information on maternal dietary habits in the postpartum period was obtained through an interviewer-administered food frequency questionnaire. We applied principal component factor analysis to selected nutrients in order to identify maternal dietary patterns, and assessed correlations in human milk macronutrients and fatty acids across levels of dietary patterns. (3) Results: Five dietary patterns were identified, named “Vitamins, minerals and fibre”, “Proteins and fatty acids with legs”, “Fatty acids with fins”, “Fatty acids with leaves”, “Starch and vegetable proteins”. These dietary patterns were correlated with some milk components, namely fatty acids, and in particular ω-3 and its subcomponents. (4) Conclusions: This study showed that overall maternal dietary habits during breastfeeding may influence human milk composition, suggesting the importance of adequate maternal nutrition during lactation not only for the mother herself but also to provide the infant with milk containing adequate amount and quality of nutrients for a balanced nutrition.

Benzodiazepine Concentrations in the Breast Milk and Plasma of Nursing Mothers: Estimation of Relative Infant Dose

Objective: Benzodiazepines are common therapies for mental illness and insomnia, and are used during pregnancy and lactation. Although benzodiazepines have been shown to be transferred into breast milk, the amount transferred is small and compatible with breastfeeding. However, information is not available for all drugs. Therefore, we aimed to determine the milk to plasma (M/P) ratio and relative infant dose (RID), which are used as indicators of drug transfer to breast milk, to determine the safety of such drugs for lactating women and breastfeeding infants. Methods: The study comprised of 11 pregnant women who visited the obstetrics department of Hokkaido University Hospital (approval number: 017-0131) and Tenshi Hospital (approval number: 103) for childbirth. The samples were analyzed using liquid chromatography-tandem mass spectrometry, and the M/P ratio and RID were calculated. The condition of the mother and baby at 1 month after delivery was determined from the clinical information. The target benzodiazepines were alprazolam, brotizolam, clonazepam, clotiazepam, etizolam, ethyl loflazepate, flunitrazepam, and lorazepam. Results: For all drugs, the M/P ratios were <1 and remained constant over time. For drugs other than ethyl loflazepate, the RID values were <10%, which are considered safe; however, even with ethyl loflazepate, it was only slightly >10%. No abnormalities were found in breastfeeding infants whose mothers were receiving these medications. Conclusions: The RID results of this study suggest that drug exposure through breast milk is small; thus, maternal drug treatment and breastfeeding are compatible.

Climate Change, Food Supply, and Dietary Guidelines

Food production is affected by climate change, and, in turn, food production is responsible for 20-30% of greenhouse gases. The food system must increase output as the population increases and must meet nutrition and health needs while simultaneously assisting in achieving the Sustainable Development Goals. Good nutrition is important for combatting infection, reducing child mortality, and controlling obesity and chronic disease throughout the life course. Dietary guidelines provide advice for a healthy diet, and the main principles are now well established and compatible with sustainable development. Climate change will have a significant effect on food supply; however, with political commitment and substantial investment, projected improvements will be sufficient to provide food for the healthy diets needed to achieve the Sustainable Development Goals. Some changes will need to be made to food production, nutrient content will need monitoring, and more equitable distribution is required to meet the dietary guidelines. Increased breastfeeding rates will improve infant and adult health while helping to reduce greenhouse gases.

WeChat-based intervention to support breastfeeding for Chinese mothers: protocol of a randomised controlled trial

Background

Exclusive breastfeeding for the first 6 months of life is the optimal way to feed infants. However, recent studies suggest that exclusive breastfeeding rates in China remain low and are well below the recommended target. There has been evidence that a lack of awareness of, or exposure to, breastfeeding information is associated with poor breastfeeding practices. WeChat, the most widely used social networking platform in China, has shown some potential to promote health behaviours. We thus hypothesised that a breastfeeding intervention program delivered via WeChat would achieve at least a 10% increase in exclusive breastfeeding prevalence at 6 months compared to the control group.

Methods

A two-arm, parallel, multicentre randomised controlled trial of 1000 pregnant women will be conducted at four maternity hospitals of Chengdu, China. Eligible women who consent to participate in the trial will be recruited at 28–30 weeks of gestation, and randomly allocated to either the intervention group (participants receive breastfeeding-related information from WeChat) or the control group (participants receive non-breastfeeding information from WeChat) using a central randomisation system on a 1:1 ratio at each participating site. The primary outcomes are exclusive breastfeeding rate and full breastfeeding rate at 6 months postpartum. All randomised participants will be included in the outcome analyses with missing data being imputed based on the best-case and worst-case scenarios. Multilevel mixed regression models will be used in the primary analyses to assess the effectiveness of intervention program on the breastfeeding rates.

Discussion

This trial uses the most widely used social media program as a means of delivering messages to mothers to increase exclusive breastfeeding in China. Increasing exclusive breastfeeding will contribute to meeting the health and environmental goals of the Sustainable Development Guidelines.

Trial registration ClinicalTrials.gov, NCT04499404. Registered 5 August 2020—Retrospectively registered, https://clinicaltrials.gov/show/NCT04499404

Maternal and Early-Life Nutrition and Health

Nutritional challenges prior to and during gestation, lactation, and early life are known to influence the lifelong health of the infant. In this editorial, I briefly discuss the 13 articles published in this Special Issue, “Maternal and Early-Life Nutrition and Health”. This Special Issue discusses topics including maternal nutrition behaviors, maternal overnutrition/obesity, maternal iron deficiency, breastfeeding, and others. This issue paves the way to better understand perinatal nutrition and how it can impact maternal and offspring health.

Improving Breastfeeding by Empowering Mothers in Vietnam: A Randomised Controlled Trial of a Mobile App

Breastfeeding provides benefits to the infant and mother; however, the rates of breastfeeding, particularly exclusive breastfeeding, remain below optimal levels in many Asian countries. The aim of this study is to review the benefits of breastfeeding to mothers and infants and current rates of breastfeeding in Vietnam, and to evaluate the effectiveness of a mobile application on exclusive breastfeeding among mothers in Vietnam. A two-arm, parallel triple-blinded randomised controlled trial will be conducted among 1000 mothers in Hanoi City, Vietnam, during 2020-2021. Eligible participants are pregnant women who will seek antenatal care from health facilities at 24-36 weeks of gestation and plan to deliver at two participating hospitals, own a smartphone, and carry a singleton foetus. Permuted-block randomisation method stratified by maternal age, education and parity will be used to ensure an equal number of participants in each group. A smartphone app will be developed to deliver breastfeeding and non-breastfeeding information to the intervention and control group, respectively. Data will be collected at baseline, before hospital discharge, and at 1, 4, and 6 months postpartum. This study envisages demonstrating whether a smartphone-based intervention can be effective at improving breastfeeding in Vietnam. Trials registration: ACTRN12619000531112.

Dietary patterns and their association with breast milk macronutrient composition among lactating women

BACKGROUD

Breast milk is the optimal food for infant growth and development. The purpose of this study was to evaluate the association between breast milk macronutrient composition with dietary pattern among lactating women.

METHODS

A total of 220 lactating women from 2011 to 2012 in Changsha, a city of south-central China, was recruited using a multi-stage sampling method. Breast milk was collected, and the protein, fat, lactose, total dry matter, and energy contents of breast milk were measured. A 24 h recall method on three consecutive days was used to collect the dietary information of lactating women and an exploratory factor analysis was performed was to identify dietary patterns. The association between the concentration of a breast milk component and dietary pattern was assessed using a multivariable linear regression model.

RESULTS

Three major dietary patterns were classified. Lactating women with dietary pattern 1 mainly ate fresh vegetables and fresh legumes. Those with dietary pattern 2 mainly ate red meat, cereals and eggs, and those with dietary pattern 3 mainly ate fungi and algae, dries legumes and soy milk. Pattern 2 was positively associated with the concentration of protein (B = 0.07, 95% CI 0.00, 0.15), total dry matter (B = 0.20, 95% CI 0.02, 0.38) and energy (B = 1.66, 95% CI 0.03, 3.30) in breast milk. Morever, lactation period was negatively associated with the protein and total dry matter concentrations and positively associated with lactose.

CONCLUSIONS

The results show the lactation period was an important factor affecting milk composition and a dietary pattern with high intake of red meat, cereals, and eggs was associated with higher protein, total dry matter, and energy contents in breast milk. These findings show that the dietary patterns of lactating women can affect breast milk macronutrient composition and provide a foundation for improving child health.

Guidelines for Complementary Feeding of Infants in the Asia Pacific Region: APACPH Public Health Nutrition Group

Good nutrition in the first "1000 days," including breastfeeding and appropriate complementary foods, prepares for a healthy childhood and adult life, also contributes to the prevention of the double burden of malnutrition. Exclusive breastfeeding provides all required nutrients until an infant is around 6 months of age when complementary foods are needed. A literature review was undertaken of complementary foods in the Asia Pacific region. The foods being used at present are often of low nutrient density may provide insufficient amounts of some critical nutrients, and generally the variety is limited. Guidelines for complementary feeding are provided to assist in education and in public health planning.

Surface Electromyographic Analysis of the Suprahyoid Muscles in Infants Based on Lingual Frenulum Attachment during Breastfeeding

Muscle electrical activity analysis can aid in the identification of oral motor dysfunctions, such as those resulting from an altered lingual frenulum, which consequently impairs feeding. Here, we aim to analyze the suprahyoid muscle electrical activity of infants via surface electromyography, based on lingual frenulum attachment to the sublingual aspect of the tongue and floor of the mouth during breastfeeding. In the present study, we have studied full-term infants of both genders, aged between 1 and 4 months old. The mean muscle activities were recorded in microvolts and converted into percent values of the reference value. Associations between the root mean square and independent variables were tested by one-way analysis of variance and Student’s t-test, with a significance level of 5% and test power of 95%, respectively. We evaluated 235 infants. Lower mean muscle electrical activity was observed with the lingual frenulum attached to apex/lower alveolar ridge, followed by attachment to the middle third/lower alveolar ridge, and between the middle third and apex/lower alveolar ridge. Greater suprahyoid muscle activity was observed with lingual frenulum attachment to the middle third of the tongue/sublingual caruncles, showing a coordination between swallowing, sucking, and breathing. Surface electromyography is effective in diagnosing lingual frenulum alterations, the attachment points of which raises doubt concerning the restriction of tongue mobility. Thus, it is possible to identify oral motor dysfunctions.