Influence of the COVID-19 pandemic on breastfeeding support for healthy mothers and the association between compliance with WHO recommendations for breastfeeding support and exclusive breastfeeding in Japan

Challenging the utility of 24-hour recall of exclusive breast feeding in Japan

INTRODUCTION

WHO recommends exclusive breast feeding from birth to 6 months. However, to monitor populations, it recommends using the proportion of infants under 6 months who were exclusively breastfed during the previous 24 hours. To assess the usefulness of 24-hour recall, we (1) compared the prevalence of exclusive breast feeding measured by since-birth recall to the prevalence measured by 24-hour recall and (2) quantified each indicator's association with WHO-recommended, well-established methods for in-hospital breastfeeding support.

METHODS

We conducted two online surveys of mothers in Japan (total n=4247) who had a healthy singleton delivery in the previous 25 months. They reported on their breast feeding (a) from birth to 5 months; or (b) during the previous 24 hours, for those with infants under 5 months; or (c) both, for those who participated in the initial survey and also in the follow-up survey. All mothers also reported on their in-hospital support. The strength of each indicator's association with provision of in-hospital support was quantified as the area under the curve (AUC).

RESULTS

The prevalences of exclusive breast feeding by since-birth recall were 4.4% (first survey) and 2.5% (second survey). By 24-hour recall, the prevalence appeared to be 29.8%. More in-hospital support was moderately well associated with more exclusive breast feeding measured by since-birth recall: AUC 0.72 (95%CI 0.66 to 0.78). That association is consistent with the known benefits of in-hospital support. In contrast, when exclusive breast feeding was measured by 24-hour recall, its association with in-hospital support appeared to be extremely weak: AUC 0.59 (95% CI 0.54 to 0.65).

CONCLUSION

Using 24-hour recall substantially overestimates the prevalence of exclusive breast feeding since birth, and it conceals the benefits of in-hospital breastfeeding support. To monitor population achievement of exclusive breast feeding for the first 6 months, or to evaluate breastfeeding interventions, 24-hour recall of exclusive breast feeding should not be used alone.

Sudden Infant Death Syndrome, Pulmonary Edema, and Sodium Toxicity: A Grounded Theory

Sudden Infant Death Syndrome (SIDS) occurs unexpectedly in an otherwise healthy infant with no identifiable cause of death following a thorough investigation. A general hypervolemic state has been identified in SIDS, and fluid in the lungs suggests the involvement of pulmonary edema and hypoxia as the cause of death. The present perspective paper reviews pathophysiological, epidemiological, and dietary evidence in SIDS. A grounded theory is presented that proposes an association of SIDS with sodium toxicity from excessive sodium chloride intake, mediated by noncardiogenic pulmonary edema, hypoxia, and alveolar damage. The peak of SIDS cases occurs in infants 2-4 months of age, who are less efficient in excreting excessive dietary sodium load. Evidence implicating sodium toxicity in SIDS includes increased levels of sodium associated with fever and with inflammatory/immune responses in the lungs. Conditions in near-miss SIDS cases are linked to dysregulated sodium, and increased sodium dietary intake suggests that sodium toxicity from a high-salt diet potentially mediates the association of seasonality and socioeconomic status with SIDS incidence. In addition, exposure to sodium toxicity meets three main criteria of the triple risk model of SIDS. The proposed pathophysiological effects of pulmonary edema related to sodium toxicity in SIDS merit further investigations.