Parental factors that impact the ecology of human mammary development, milk secretion, and milk composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 1

The goal of Working Group 1 in the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project was to outline factors influencing biological processes governing human milk secretion and to evaluate our current knowledge of these processes. Many factors regulate mammary gland development in utero, during puberty, in pregnancy, through secretory activation, and at weaning. These factors include breast anatomy, breast vasculature, diet, and the lactating parent's hormonal milieu including estrogen, progesterone, placental lactogen, cortisol, prolactin, and growth hormone. We examine the effects of time of day and postpartum interval on milk secretion, along with the role and mechanisms of lactating parent-infant interactions on milk secretion and bonding, with particular attention to the actions of oxytocin on the mammary gland and the pleasure systems in the brain. We then consider the potential effects of clinical conditions including infection, pre-eclampsia, preterm birth, cardiovascular health, inflammatory states, mastitis, and particularly, gestational diabetes and obesity. Although we know a great deal about the transporter systems by which zinc and calcium pass from the blood stream into milk, the interactions and cellular localization of transporters that carry substrates such as glucose, amino acids, copper, and the many other trace metals present in human milk across plasma and intracellular membranes require more research. We pose the question of how cultured mammary alveolar cells and animal models can help answer lingering questions about the mechanisms and regulation of human milk secretion. We raise questions about the role of the lactating parent and the infant microbiome and the immune system during breast development, secretion of immune molecules into milk, and protection of the breast from pathogens. Finally, we consider the effect of medications, recreational and illicit drugs, pesticides, and endocrine-disrupting chemicals on milk secretion and composition, emphasizing that this area needs much more research attention.

Gestational weight gain according to the Brazilian charts and its association with maternal and infant adverse outcomes

BACKGROUND

The lack of gestational weight gain (GWG) recommendations for low- and middle-income countries is a significant concern.

OBJECTIVES

To identify the ranges on the Brazilian GWG charts associated with lowest risks of selected adverse maternal and infant outcomes.

METHODS

Data from 3 large Brazilian datasets were used. Pregnant individuals aged ≥18, without hypertensive disorders or gestational diabetes were included. Total GWG was standardized to gestational age-specific z-scores according to Brazilian GWG charts. A composite infant outcome was defined as the occurrence of any of small-for-gestationa lage (SGA), large-forgestationa lage (LGA), or preterm birth. In a separate sample, postpartum weight retention (PPWR) was measured at 6 and/or 12 mo postpartum. Multiple logistic and Poisson regressions were performed with GWG z-scores as the exposure and individual and composite outcomes. GWG ranges associated with the lowest risk of the composite infant outcome were identified using noninferiority margins.

RESULTS

For the neonatal outcomes, 9500 individuals were included in the sample. For PPWR, 2602 and 7859 individuals were included at 6 and 12 mo postpartum, respectively. Overall, 7.5% of the neonates were SGA, 17.6% LGA, and 10.5% were preterm. Higher GWG z-scores were positively associated with LGA birth, whereas lower z-scores were positively associated with SGA births. The risk of the selected adverse neonatal outcomes were lowest (within 10% of lowest observed risk) when individuals with underweight, normal weight, overweight, or obesity gained between 8.8-12.6; 8.7-12.4; 7.0-8.9; and 5.0-7.2 kg, respectively. These gains correspond to probabilities of PPWR ≥5 kg at 12 mo of 30% for individuals with under and normal weight, and <20% for overweight and obesity.

CONCLUSIONS

This study provided evidence to inform new GWG recommendations in Brazil.

Comparison between the Brazilian and 3 international gestational weight gain charts

BACKGROUND

Little is known about the ability of the recently released Brazilian gestational weight gain (GWG) charts to predict the occurrence of adverse birth outcomes.

OBJECTIVES

We compared the new Brazilian weight gain charts with 3 international charts and determined their ability to predict the occurrence of small-for-gestational-age (SGA) and large-for-gestational-age (LGA) births in Brazilian women.

METHODS

A subsample of 6888 adult women (43,931 weight measurements) with singleton pregnancies from a nationwide, hospital-based cohort study conducted in 2011-2012 was analyzed. Selected percentiles from Brazilian GWG charts were compared with those from American, International Fetal and Newborn Growth Consortium for the 21st Century study, and Lifecycle consortium charts. Sensitivity, specificity, and AUROC values for SGA and LGA births were estimated with 95% CIs using the classification of GWG below or above selected percentiles of each chart.

RESULTS

The weight gain corresponding to a given percentile varied among the charts, especially for women with pre-pregnancy overweight and obesity. The proportions of women with GWG classified below or above selected percentiles were closest to the expected values for all pre-pregnancy BMI categories in the Brazilian and Lifecycle charts. At the 10th percentile, the highest sensitivity for SGA births was observed for the American charts at midpregnancy (36.8%) and the highest specificity was observed using the Brazilian charts in the first trimester (93.4%). At the 90th percentile, the highest sensitivity for LGA births occurred in midpregnancy for the Lifecycle charts (26.8%) and the highest specificity occurred in the American charts using total GWG (97.1%). All the AUROCs were under 0.5 for SGA births and ranged from 0.55 (first trimester) to 0.62 (total GWG) for LGA births.

CONCLUSIONS

The charts differ in GWG trajectories, especially for women with overweight and obesity. The 4 charts had low predictive ability of SGA and LGA births and should not be considered as isolated screening tools for those outcomes.

Storytelling for persuasion: Insights from community health workers on how they engage family members to improve adoption of recommended maternal nutrition and breastfeeding behaviours in rural Bangladesh

Community health workers (CHWs) increasingly provide interpersonal counselling to childbearing women and their families to improve adoption of recommended maternal and child nutrition behaviours. Little is known about CHWs' first‐hand experiences garnering family support for improving maternal nutrition and breastfeeding practices in low‐resource settings. Using focused ethnography, we drew insights from the strategies that CHWs used to persuade influential family members to support recommendations on maternal diet, rest and breastfeeding in a behaviour change communication trial in rural Bangladesh. We interviewed 35 CHWs providing at‐home interpersonal counselling to pregnant women and their families in seven ‘Alive & Thrive’ intervention sites. In‐depth probing focused on how CHWs addressed lack of family support. Thematic coding based on Fisher's narrative paradigm revealed strategic use of three rhetorical principles by CHWs: ethos (credibility), pathos (emotion) and logos (logic). CHWs reported selectively targeting pregnant women, husbands and mothers‐in‐law based on their influence on behavioural adoption. Key motivators to support recommended behaviours were improved foetal growth and child intelligence. Improved maternal health was the least motivating outcome, even among mothers. Logically coherent messaging resonated well with husbands, while empathetic counselling was additionally required for mothers. Mothers‐in‐law were most intransigent, but were persuaded via emotional appeals. Persuasion on maternal rest was most effort‐intensive, resulting in contextually appealing but scientifically inaccurate messaging. Our study demonstrates that CHWs can offer important insights on context‐relevant, feasible strategies to improve family support and uptake of nutrition recommendations. It also identifies the need for focused CHW training and monitoring to address scientifically flawed counselling narratives.

Analysis of narratives of nutrition‐promoting, rural Bangladeshi community health workers (CHWs) suggest that behavior change communication (BCC) strategies to persuade husbands require logical and credible information (logos and ethos) to establish their support, while childbearing women may additionally require emotional appeals (pathos) to adopt promoted behaviors. Mothers‐in‐law, who traditionally influence multiple nutrition behaviors, can be persuaded via strategic use of ethos and pathos.

CHW communication strategies are useful in developing persuasive narratives that capture influential family members’ value beliefs and outcome expectancies and promote behavior change. However, additional programmatic efforts are needed to discourage use of unscientific narratives by CHWs.

Human milk-sharing practices and infant-feeding behaviours: A comparison of donors and recipients

Human milk sharing (HMS) is growing in popularity as an infant-feeding strategy in the United States. HMS families are a hidden population because HMS is a nonnormative and stigmatized behaviour. Thus, gaining access to HMS participants is challenging, and research on this topic remains limited. In particular, little is known about the broader infant-feeding behaviours of HMS parents. This study aimed to describe and compare the infant-feeding behaviours and HMS practices among a network of HMS donors and recipients. A detailed online survey was distributed to HMS parents in the Washington, DC region. Bivariate analyses were used to summarize the data by donor/recipient status when possible. Group differences were tested using analysis of variance for continuous variables and χ² tests for categorical variables. Donors and recipients did not differ in their sociodemographic characteristics. Recipients were significantly more likely than donors to have experienced complications of labour and delivery, traumatic birth, postpartum depression or a negative breastfeeding experience. Donors and recipients did not differ significantly in their duration of lactation or HM-feeding. Interestingly, 30% of recipients ever produced excess milk and 21% of donors ever had difficulty producing enough milk for their child. Compared with donors, recipients faced numerous maternal health challenges, but were still able to achieve a long duration of HM-feeding. HMS recipients represent a vulnerable group who may benefit from additional psychosocial and lactation support to improve their health and breastfeeding outcomes. Additional research is needed to investigate the associations between HMS participation, infant-feeding behaviours and lactation outcomes.

Associations of maternal birth weight, childhood height, BMI, and change in height and BMI from childhood to pregnancy with risks of preterm delivery

BACKGROUND

It remains unknown whether maternal early life body size and changes in height and BMI from childhood to pregnancy are associated with risks of having a preterm delivery.

OBJECTIVES

We investigated whether a woman's birth weight, childhood height, BMI, and changes in height and BMI from childhood to pregnancy were associated with preterm delivery.

METHODS

We studied 47,947 nulliparous women born from 1940 to 1996 who were included in the Copenhagen School Health Records Register with information on birth weight and childhood heights and weights at ages 7 and/or 13 years. Gestational age was obtained from the Danish Birth Register, as was prepregnancy BMI, for 13,114 women. Deliveries were classified as very (22 to <32 weeks) or moderately (32 to <37 weeks) preterm. Risk ratios (RRs) and 95% CIs were estimated using binomial regression.

RESULTS

A woman's birth weight and childhood height were inversely associated with having very and moderately preterm delivery. Childhood BMI had a U-shaped association with having a very preterm delivery; at age 7 years, compared to a BMI z score of 0, the RRs were 1.31 (95% CI, 1.11-1.54) for a z score of -1 and 1.18 (95% CI, 1.01-1.38) for a z score of +1. Short stature in childhood and adulthood was associated with higher risks of very and moderately preterm delivery. Changing from a BMI at the 85th percentile at 7 years (US CDC reference) to a prepregnancy BMI of 22.5 kg/m2 was associated with RRs of 1.12 (95% CI, 0.91-1.37) and 0.88 (95% CI, 0.78-0.99) for very and moderately preterm delivery, respectively, compared to a reference woman at the 50th percentile at 7 years (22.5 kg/m2 prepregnancy BMI).

CONCLUSIONS

Maternal birth weight, childhood height, and BMI are associated with very and moderately preterm delivery, although in different patterns. Consistent short stature is associated with very and moderately preterm delivery, whereas normalizing BMI from childhood to pregnancy may reduce risks of having a very preterm delivery.

Pumping supplies alter the microbiome of pumped human milk: An in-home, randomized, crossover trial

BACKGROUND

The human milk microbiome may contribute to the benefits of breastfeeding by providing bacteria to the infant gastrointestinal tract. Many women pump their milk, but the effect of pumping on the milk microbiome is unknown.

OBJECTIVES

Our objective was to determine the effects of pumping supplies on the pumped human milk microbiome.

METHODS

This was an in-home, randomized, crossover trial of 2 collection methods. Women (n = 52) pumped twice within 3.5 h, once with their own breast pumps and milk collection supplies (OWN SUPP) and once with a hospital-grade pump and sterile collection supplies (STER SUPP). Pumping order was randomized. The milk microbiome was characterized by aerobic culturing and 16S ribosomal RNA gene sequencing.

RESULTS

Milk collected with OWN SUPP yielded more total aerobic and gram-negative bacteria than milk collected with STER SUPP, reflecting a 6.6 (adjusted OR; 95% CI: 1.7, 25; P = 0.006) higher odds of containing >104 total aerobic CFU/mL and 19 (adjusted OR; 95% CI: 4.1, 88; P < 0.0001) higher odds of yielding culturable gram-negative bacteria. Milk collected with OWN SUPP yielded more Proteobacterias , including higher relative abundances of Acinetobacter and Stenotrophomonas, compared to milk collected with STER SUPP. Results were consistent across pumping-order groups.

CONCLUSIONS

We demonstrated that pumping supplies altered the milk microbiome. On average, milk collected with OWN SUPP resulted in elevated levels of culturable total and gram-negative bacteria and proteobacterial DNA compared to milk collected with STER SUPP. More research is needed to assess implications for infant health.

Prevalence and temporal trends in prepregnancy nutritional status and gestational weight gain of adult women followed in the Brazilian Food and Nutrition Surveillance System from 2008 to 2018

Prepregnancy body mass index (BMI) and gestational weight gain (GWG) are the most investigated indicators of maternal nutritional status, which is a modifiable factor that plays a vital role in maternal and infant health. This study describes prepregnancy BMI and GWG of 840,243 women with 2,087,765 weight observations in the Brazilian Food and Nutrition Surveillance System from 2008 to 2018. Prepregnancy BMI was classified according to the World Health Organization cut‐offs. Total GWG was calculated from weight measurements taken after 36 weeks of pregnancy and classified according to the Institute of Medicine guidelines. Temporal trends in prepregnancy BMI status were examined, and maps were used to evaluate changes in excessive GWG in each Brazilian federation unit. On overall, prepregnancy overweight and obesity increased from 22.6% to 28.8% and from 9.8% to 19.8%, respectively, between 2008 and 2018. The prevalence of excessive GWG rose from 34.2% to 38.7% during the same period and in 11 of the 27 Brazilian federation units between 2008 and 2016. Women with underweight showed the highest values for mean total GWG for all the compared years (overall variation from 12.3 to 13.1 kg), followed by those with normal weight (11.9 to 12.5 kg), overweight (10.1 to 10.9 kg) and obesity (from 8.2 to 8.9 kg). Within each BMI group, values remained fairly stable throughout the studied period for first‐ and second‐trimester GWG and total GWG. These results help to fill a significant gap in understanding the distribution of prepregnancy BMI and GWG in Brazilian women.

Gestational weight gain charts: results from the Brazilian Maternal and Child Nutrition Consortium

BACKGROUND

Monitoring gestational weight gain (GWG) is fundamental to ensure a successful pregnancy for the mother and the offspring. There are several international GWG charts, but just a few for low- and middle-income countries.

OBJECTIVES

To construct GWG charts according to pre-pregnancy BMI for Brazilian women.

METHODS

This is an individual patient data analysis using the Brazilian Maternal and Child Nutrition Consortium data, comprising 21 cohort studies. External validation was performed using "Birth in Brazil," a nationwide study. We selected adult women with singleton pregnancies who were free of infectious and chronic diseases, gestational diabetes, and hypertensive disorders; who delivered a live birth at term; and whose children were adequate for gestational age, and with a birth weight between 2500-4000 g. Maternal self-reported pre-pregnancy weight and weight measured between 10-40 weeks of gestation were used to calculate GWG. Generalized Additive Models for Location, Scale and Shape were fitted to create GWG charts according to gestational age, stratified by pre-pregnancy BMI.

RESULTS

The cohort included 7086 women with 29,323 weight gain measurements to construct the charts and 4711 women with 31,052 measurements in the external validation. The predicted medians for GWG at 40 weeks, according to pre-pregnancy BMI, were: underweight, 14.1 kg (IQR, 10.8-17.5 kg); normal weight, 13.8 kg (IQR, 10.7-17.2 kg); overweight, 12.1 kg (IQR, 8.5-15.7 kg); obesity, 8.9 kg (IQR, 4.8-13.2 kg). The 10th, 25th, 50th, 75th, and 90th percentiles were estimated. Results for internal and external validation showed that the percentages below the selected percentiles were close to those expected.

CONCLUSIONS

The charts proposed provide a description of GWG patterns according to gestational age and pre-pregnancy BMI among healthy Brazilian women with good neonatal outcomes. The external validation indicates that this new tool can be used to monitor GWG in the primary health-care setting and to test potential recommended values.

Maternal weight change from prepregnancy to 18 months postpartum and subsequent risk of hypertension and cardiovascular disease in Danish women: A cohort study

BACKGROUND

One-fourth of women experience substantially higher weight years after childbirth. We examined weight change from prepregnancy to 18 months postpartum according to subsequent maternal risk of hypertension and cardiovascular disease (CVD).

METHODS AND FINDINGS

We conducted a cohort study of 47,966 women with a live-born singleton within the Danish National Birth Cohort (DNBC; 1997-2002). Interviews during pregnancy and 6 and 18 months postpartum provided information on height, gestational weight gain (GWG), postpartum weights, and maternal characteristics. Information on pregnancy complications, incident hypertension, and CVD was obtained from the National Patient Register. Using Cox regression, we estimated adjusted hazard ratios (HRs; 95% confidence interval [CI]) for hypertension and CVD through 16 years of follow-up. During this period, 2,011 women were diagnosed at the hospital with hypertension and 1,321 with CVD. The women were on average 32.3 years old (range 18.0-49.2) at start of follow-up, 73% had a prepregnancy BMI <25, and 27% a prepregnancy BMI ≥25. Compared with a stable weight (±1 BMI unit), weight gains from prepregnancy to 18 months postpartum of >1-2 and >2 BMI units were associated with 25% (10%-42%), P = 0.001 and 31% (14%-52%), P < 0.001 higher risks of hypertension, respectively. These risks were similar whether weight gain presented postpartum weight retention or a new gain from 6 months to 18 months postpartum and whether GWG was below, within, or above the recommendations. For CVD, findings differed according to prepregnancy BMI. In women with normal-/underweight, weight gain >2 BMI units and weight loss >1 BMI unit were associated with 48% (17%-87%), P = 0.001 and 28% (6%-55%), P = 0.01 higher risks of CVD, respectively. Further, weight loss >1 BMI unit combined with a GWG below recommended was associated with a 70% (24%-135%), P = 0.001 higher risk of CVD. No such increased risks were observed among women with overweight/obesity (interaction by prepregnancy BMI, P = 0.01, 0.03, and 0.03, respectively). The limitations of this observational study include potential confounding by prepregnancy metabolic health and self-reported maternal weights, which may lead to some misclassification.

CONCLUSIONS

Postpartum weight retention/new gain in all mothers and postpartum weight loss in mothers with normal-/underweight may be associated with later adverse cardiovascular health.

Risk of gestational diabetes mellitus in nulliparous women - Associations with early life body size and change in body mass index from childhood to adulthood

AIMS

We examined whether a woman's birthweight, childhood height, body mass index (BMI), and BMI changes from childhood to pregnancy were associated with risks of gestational diabetes mellitus (GDM).

METHODS

We studied 13,031 women from the Copenhagen School Health Records Register born 1959-1996 with birthweight and measured anthropometric information at ages 7 and/or 13. The diagnosis of GDM (n = 255) was obtained from a national health register. Risk ratios (RR) were estimated using log-linear binomial regression.

RESULTS

Own birthweight and childhood height were inversely associated with GDM. Girls with overweight at age 7 had a higher risk of GDM than girls with normal-weight (RR: 1.79, 95% CI: 1.31, 2.47). Compared to women with normal-weight in childhood and adulthood, risks of GDM were higher in women who developed overweight from age 7 to pregnancy (RR: 4.62; 3.48, 6.14) or had overweight at both times (RR: 4.71; 3.24, 6.85). In women whose BMI normalized from age 7 to pregnancy the RR for GDM was 1.08 (0.47, 2.46).

CONCLUSIONS

Lower birthweight, shorter childhood height, and higher childhood BMI are associated with increased risks of GDM. Efforts to help girls maintain a normal BMI before pregnancy may be warranted to minimize risks of GDM.

Agreement between self-reported pre-pregnancy weight and measured first-trimester weight in Brazilian women

Background

Self-reported pre-pregnancy weight and weight measured in the first trimester are both used to estimate pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) but there is limited information on how they compare, especially in low- and middle-income countries, where access to a weight scale can be limited. Thus, the main goal of this study was to evaluate the agreement between self-reported pre-pregnancy weight and weight measured during the first trimester of pregnancy among Brazilian women so as to assess whether self-reported pre-pregnancy weight is reliable and can be used for calculation of BMI and GWG.

Methods

Data from the Brazilian Maternal and Child Nutrition Consortium (BMCNC, n = 5563) and the National Food and Nutritional Surveillance System (SISVAN, n = 393,095) were used to evaluate the agreement between self-reported pre-pregnancy weight and weights measured in three overlapping intervals (30–94, 30–60 and 30–45 days of pregnancy) and their impact in BMI classification. We calculated intraclass correlation and Lin’s concordance coefficients, constructed Bland and Altman plots, and determined Kappa coefficient for the categories of BMI.

Results

The mean of the differences between self-reported and measured weights was < 2 kg during the three intervals examined for BMCNC (1.42, 1.39 and 1.56 kg) and about 1 kg for SISVAN (1.0, 1.1 and 1.2 kg). Intraclass correlation and Lin’s coefficient were > 0.90 for both datasets in all time intervals. Bland and Altman plots showed that the majority of the difference laid in the ±2 kg interval and that the differences did not vary according to measured first-trimester BMI. Kappa coefficient values were > 0.80 for both datasets at all intervals. Using self-reported pre-pregnancy or measured weight would change, in total, the classification of BMI in 15.9, 13.5, and 12.2% of women in the BMCNC and 12.1, 10.7, and 10.2% in the SISVAN, at 30–94, 30–60 and 30–45 days, respectively.

Conclusion

In Brazil, self-reported pre-pregnancy weight can be used for calculation of BMI and GWG when an early measurement of weight during pregnancy is not available. These results are especially important in a country where the majority of woman do not initiate prenatal care early in pregnancy.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12884-020-03354-4.

Breastfeeding and the origins of health: Interdisciplinary perspectives and priorities

Breastfeeding and human milk (HM) are critically important to maternal, infant and population health. This paper summarizes the proceedings of a workshop that convened a multidisciplinary panel of researchers to identify key priorities and anticipated breakthroughs in breastfeeding and HM research, discuss perceived barriers and challenges to achieving these breakthroughs and propose a constructive action plan to maximize the impact of future research in this field. Priority research areas identified were as follows: (1) addressing low breastfeeding rates and inequities using mixed methods, community partnerships and implementation science approaches; (2) improving awareness of evidence-based benefits, challenges and complexities of breastfeeding and HM among health practitioners and the public; (3) identifying differential impacts of alternative modes of HM feeding including expressed/pumped milk, donor milk and shared milk; and (4) developing a mechanistic understanding of the health effects of breastfeeding and the contributors to HM composition and variability. Key barriers and challenges included (1) overcoming methodological limitations of epidemiological breastfeeding research and mechanistic HM research; (2) counteracting 'breastfeeding denialism' arising from negative personal breastfeeding experiences; (3) distinguishing and aligning research and advocacy efforts; and (4) managing real and perceived conflicts of interest. To advance research on breastfeeding and HM and maximize the reach and impact of this research, larger investments are needed, interdisciplinary collaboration is essential, and the scientific community must engage families and other stakeholders in research planning and knowledge translation.

Associations of childhood BMI and change in BMI from childhood to adulthood with risks of hypertensive disorders in pregnancy

BACKGROUND

Maternal overweight (including obesity) is an established risk factor for gestational hypertension and pre-eclampsia. However, it is largely unknown whether body size before adulthood relates to these diseases.

OBJECTIVES

We examined whether childhood BMI (in kg/m2) and changes in BMI from childhood to adulthood were associated with gestational hypertension and pre-eclampsia.

METHODS

Using the Copenhagen School Health Records Register, we studied 49,600 women born between 1940 and 1996 with height and weight measurements at 7 y and/or 13 y who had their first singleton birth between ages 18 and 45 y. Women with gestational hypertension (n = 496) and pre-eclampsia (n = 1804) were identified from the International Classification of Disease codes in the Danish National Patient Register. Adult overweight (including obesity) was defined as a BMI ≥25. We used log-linear binomial regression to estimate risk ratios (RRs) and 95% CIs.

RESULTS

At 13 y, as BMI increased above average (z score >0, or the 42nd percentile of the CDC BMI reference), RR for gestational hypertension was 1.66 (95% CI: 1.42, 1.94) and that for pre-eclampsia was 1.57 (95% CI: 1.46, 1.70) per BMI z score. In a subset of 13,160 women, development of overweight from childhood to adulthood and having overweight at both ages were associated with higher risks of the outcomes than in those with a normal BMI at both ages. No increased risks were observed in women whose BMI normalized from childhood to adulthood: RR was 2.04 (95% CI: 0.93, 4.47) for gestational hypertension and 1.11 (95% CI: 0.63, 1.93) for pre-eclampsia.

CONCLUSIONS

Above-average childhood BMI values and development of overweight from childhood to adulthood were associated with increased risks of gestational hypertension and pre-eclampsia, whereas normalizing BMI from childhood to conception attenuated the risks. Thus, interventions aiming at normalizing BMI in girls with high values may be warranted to help prevent these obstetric diseases.

Information Available Online That Answers Common Questions About Breast Pumping: A Scoping Review

Background: In light of the widespread use of breast milk pumping, or, "pumping," mothers are seeking clear, adequate breast pumping guidelines. We aimed at characterizing the information in web pages that mothers might find online when searching for answers related to breast pumping. Materials and Methods: We used Google to search for answers to 10 questions about pumping that mothers might ask. This search used Boolean search. We screened the first three pages of search results for each computer Google search. Each eligible hit (web pages) was evaluated for accuracy, readability, and credibility of its source. Results: Our search strategy produced 241 hits eligible for analysis. The majority of these contained accurate, readable information and were authored by credible sources. The proportion of eligible hits from questions that had a quantifiable (numeric) answer, (e.g., number of days that refrigerated milk remains safe for consumption) differed significantly (p = 0.024) from searches that did not. Search inquiries related to milk supply adequacy produced a disproportionately high number of inaccurate hits. Conclusion: Our findings indicate that accurate and credible information about breast pumping is accessible on the internet. However, practitioners should be aware that inaccurate information is present among mothers' likely hits. Our findings also underscore the fact that there are aspects of breast pumping that do not yet have guidelines available, and that these areas warrant further research. In addition, there is a need for guidelines that reflect the individual nature of the experience of breast pumping.

Assessing statistical similarity in dietary intakes of women of reproductive age in Bangladesh

Women of reproductive age (WRA) need adequate nutrient intakes to sustain a healthy pregnancy, support fetal growth, and breastfeed after childbirth. However, data on women's dietary intake in low‐ and middle‐income countries (LMICs) are limited, and assessment of differences between dietary intakes of pregnant or lactating women compared with that of nonpregnant, nonlactating (NPNL) women is untested. Using single, multiple‐pass 24‐h dietary recall data from a sample of WRA residing in rural Bangladesh, we examined women's dietary intakes for energy, protein, calcium, iron, vitamin A, and dietary diversity for three groups: NPNL (n = 2,903), pregnant (n = 197), and lactating women (n = 944). We used equivalence testing to examine similarity in adjusted intakes for pregnant versus NPNL women and lactating versus NPNL women with a predetermined equivalence threshold based on recommendations specific for each reproductive stage. On average, both pregnant and lactating women had insufficient intakes for all dietary measures. Although statistically significant differences were observed between pregnant and NPNL women for energy intake and dietary diversity and between lactating and NPNL women for energy and protein intake, the magnitudes of these differences were too small to reject equivalence. Statistical similarity was also evident in all micronutrients and dietary diversity for both two‐group comparisons. Understanding statistical differences and similarities between dietary measures of women in distinct reproductive stages has important implications for the relevance, appropriateness, and evaluation of maternal diet‐enhancing interventions in LMICs, especially during pregnancy and lactation, when demand for macronutrients and micronutrients is elevated.

Brazilian Maternal and Child Nutrition Consortium: establishment, data harmonization and basic characteristics

Pooled data analysis in the field of maternal and child nutrition rarely incorporates data from low- and middle-income countries and existing studies lack a description of the methods used to harmonize the data and to assess heterogeneity. We describe the creation of the Brazilian Maternal and Child Nutrition Consortium dataset, from multiple pooled longitudinal studies, having gestational weight gain (GWG) as an example. Investigators of the eligible studies published from 1990 to 2018 were invited to participate. We conducted consistency analysis, identified outliers, and assessed heterogeneity for GWG. Outliers identification considered the longitudinal nature of the data. Heterogeneity was performed adjusting multilevel models. We identified 68 studies and invited 59 for this initiative. Data from 29 studies were received, 21 were retained for analysis, resulting in a final sample of 17,344 women with 72,616 weight measurements. Fewer than 1% of all weight measurements were flagged as outliers. Women with pre-pregnancy obesity had lower values for GWG throughout pregnancy. GWG, birth length and weight were similar across the studies and remarkably similar to a Brazilian nationwide study. Pooled data analyses can increase the potential of addressing important questions regarding maternal and child health, especially in countries where research investment is limited.

Setting research priorities on multiple micronutrient supplementation in pregnancy

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

Maternal reproductive history and premenopausal risk of hypertension and cardiovascular disease: a Danish cohort study

OBJECTIVES

The metabolic changes of pregnancy resemble a cardiovascular risk profile and may persist postpartum, with body mass index (BMI) as a potential modifier. We examined the association between the number of live-birth pregnancies and maternal premenopausal risks of hypertension and cardiovascular disease (CVD), accounting for pre-pregnancy BMI as well as abortions and stillbirths.

DESIGN

A prospective cohort study.

SETTING

Mothers from the Danish National Birth Cohort (1996 to 2002). For each of these women, registry data on all pregnancies from 1973 to 2011 were obtained, as were self-reported pre-pregnancy weight and height.

PARTICIPANTS

A total of 44 552 first-time mothers in the Danish National Birth Cohort.

OUTCOME MEASURES

Risks of hypertension and CVD during and between live-birth pregnancies separately and combined as live-birth cycles.

RESULTS

After adjustment for abortions, stillbirths, pre-pregnancy BMI and other covariates, a higher risk of hypertension was observed in the first (HR 1.53, 95% CI: 1.37 to 1.72) and fourth and subsequent live-birth cycles (HR 1.72, 95% CI: 1.15 to 2.58), compared with the second. However, as number of live-birth pregnancies increased, risk of hypertension decreased during live-birth pregnancies and increased between live-birth pregnancies (tests for trend, p<0.01). For CVD, we found an overall J-shaped but non-significant association with number of live-birth pregnancies. No interaction with pre-pregnancy BMI (<25 versus ≥25 kg/m²) was observed.

CONCLUSIONS

Premenopausal women had the highest risk of hypertension and CVD during their first live-birth pregnancy and after their fourth live-birth pregnancy. All risks were independent of BMI before the first live-birth pregnancy and of number of abortions and stillbirths.

NIH workshop on human milk composition: summary and visions

Nationally representative data from mother-child dyads that capture human milk composition (HMC) and associated health outcomes are important for advancing the evidence to inform federal nutrition and related health programs, policies, and consumer information across the governments in the United States and Canada as well as in nongovernment sectors. In response to identified gaps in knowledge, the National Institute of Diabetes and Digestive and Kidney Diseases of the NIH sponsored the "Workshop on Human Milk Composition-Biological, Environmental, Nutritional, and Methodological Considerations" held 16-17 November 2017 in Bethesda, Maryland. Through presentations and discussions, the workshop aimed to 1) share knowledge on the scientific need for data on HMC; 2) explore the current understanding of factors affecting HMC; 3) identify methodological challenges in human milk (HM) collection, storage, and analysis; and 4) develop a vision for a research program to develop an HMC data repository and database. The 4 workshop sessions included 1) perspectives from both federal agencies and nonfederal academic experts, articulating scientific needs for data on HMC that could lead to new research findings and programmatic advances to support public health; 2) information about the factors that influence lactation and/or HMC; 3) considerations for data quality, including addressing sampling strategies and the complexities in standardizing collection, storage, and analyses of HM; and 4) insights on how existing research programs and databases can inform potential visions for HMC initiatives. The general consensus from the workshop is that the limited scope of HM research initiatives has led to a lack of robust estimates of the composition and volume of HM consumed and, consequently, missed opportunities to improve maternal and infant health.

Awareness and prevalence of human milk sharing and selling in the United States

There are limited data available about the prevalence of human milk (HM) sharing and selling in the general population. We aimed to describe attitudes toward HM selling among participants in a qualitative-interview study and prevalence of HM sharing and selling among a national sample of U.S. mothers. Mothers (n = 41) in our qualitative-interview study felt that sharing or donating HM was more common than selling; none had ever purchased or sold HM. Three themes related to HM selling emerged from this work: questioning the motives of those selling HM, HM selling limits access to HM to those with money, and HM selling is a legitimate way to make money. Some mothers had reservations about treating HM as a commodity and the intentions of those who profit from the sale of HM. Nearly all participants in our national survey of U.S. mothers (94%, n = 429) had heard of infants consuming another mother's HM. Approximately 12% had provided their milk to another; half provided it to someone they knew. Fewer mothers (6.8%) reported that their infant had consumed another mother's HM; most received this HM from someone they knew. A smaller proportion of respondents (1.3%) had ever purchased or sold HM. Among a national sample of U.S. mothers, purchasing and selling HM was less common than freely sharing HM. Together, these data highlight that HM sharing is not uncommon in the United States. Research is required to create guidelines for families considering HM sharing.

Nutrition for women and children-Are we doing the right things in the right way?

The Guest Editors for the PLOS Medicine Special Issue on Maternal and Child Health & Nutrition discuss the published research in the context of global priorities for women's and children's health.

Comparing Alternative Breast Milk Feeding Questions to U.S. Breastfeeding Surveillance Questions

Background: Most mothers in the United States express their milk, which is then bottle fed to their infants. The National Immunization Survey (NIS), used to report national breastfeeding prevalence, asks about infant breast milk consumption, regardless of whether it is consumed at the mother's breast or from a bottle. The NIS data are often erroneously interpreted, however, to mean prevalence of at-the-breast feeding. We hypothesized that over half of infants classified as breastfed at 3, 6, and 12 months by the NIS questions would also be consuming expressed breast milk. Materials and Methods: A convenience sample of 456 mothers of infants 19-35 months of age recruited through ResearchMatch.org completed an online infant-feeding questionnaire. The questionnaire included both the NIS questions and more-detailed questions about feeding mode, distinguishing between at-the-breast and bottle. Results: Based on responses of our sample to the NIS questions, it could be interpreted that 74%, 64%, and 39% of mother-infant dyads were at-the-breast feeding at 3, 6, and 12 months, respectively. However, at each time point, most infants consumed at least some breast milk from a bottle. As infants got older, the proportion of breast milk consumed from a bottle increased. Conclusions: In this U.S. sample, the predominant breast milk feeding style involves both at-the-breast and expressed breast milk feeding. Future research and national surveillance should consider including separate measures of maternal breast milk expression and infant consumption of expressed breast milk to enable meaningful exploration of maternal and infant outcomes associated with these asynchronous behaviors.

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries

Inadequate micronutrient intakes are relatively common in low- and middle-income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost-effectiveness of MMS compared with IFA. Recent meta-analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual-participant data meta-analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost-effective method to reduce the risk of adverse birth outcomes.

Association of Full Breastfeeding Duration with Postpartum Weight Retention in a Cohort of Predominantly Breastfeeding Women

Full breastfeeding (FBF) is promoted as effective for losing pregnancy weight during the postpartum period. This study evaluated whether longer FBF is associated with lower maternal postpartum weight retention (PPWR) as compared to a shorter FBF duration. The MILK (Mothers and Infants Linked for Healthy Growth) study is an ongoing prospective cohort of 370 mother-infant dyads, all of whom fully breastfed their infants for at least 1 month. Breastfeeding status was subsequently self-reported by mothers at 3 and 6 months postpartum. Maternal PPWR was calculated as maternal weight measured at 1, 3, and 6 months postpartum minus maternal prepregnancy weight. Using linear mixed effects models, by 6 months postpartum, adjusted means ± standard errors for weight retention among mothers who fully breastfed for 1-3 (3.40 ± 1.16 kg), 3-6 (1.41 ± 0.69 kg), and ≥6 months (0.97 ± 0.32 kg) were estimated. Compared to mothers who reported FBF for 1-3 months, those who reported FBF for 3-6 months and ≥6 months both had lower PPWR over the period from 1 to 6 months postpartum (p = 0.04 and p < 0.01, respectively). However, PPWR from 3 to 6 months was not significantly different among those who reported FBF for 3-6 versus ≥6 months (p > 0.05). Interventions to promote FBF past 3 months may increase the likelihood of postpartum return to prepregnancy weight.

Dietary patterns before and during pregnancy and maternal outcomes: a systematic review

BACKGROUND

Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) are common maternal complications during pregnancy, with short- and long-term sequelae for both mothers and children.

OBJECTIVE

Two systematic review questions were used to examine the relation between 1) dietary patterns before and during pregnancy, 2) HDP, and 3) GDM.

METHODS

A search was conducted from January 1980 to January 2017 in 9 databases including PubMed, Embase, and Cochrane. Two analysts independently screened articles using a priori inclusion and exclusion criteria; data were extracted from included articles, and risk of bias was assessed. After qualitative synthesis, a conclusion statement was drafted for each question and the evidence supporting the conclusion was graded.

RESULTS

Of the 9103 studies identified, 8 [representing 4 cohorts and 1 randomized controlled trial (RCT)] were included for HDP and 11 (representing 6 cohorts and 1 RCT) for GDM. Limited evidence in healthy Caucasian women with access to health care suggests dietary patterns before and during pregnancy that are higher in vegetables, fruits, whole grains, nuts, legumes, fish, and vegetable oils and lower in meat and refined grains are associated with reduced risk of HDP, including preeclampsia and gestational hypertension. Limited but consistent evidence suggests certain dietary patterns before pregnancy are associated with reduced risk of GDM. These protective dietary patterns are higher in vegetables, fruits, whole grains, nuts, legumes, and fish and lower in red and processed meats. Most of the research was conducted in healthy, Caucasian women with access to health care. Insufficient evidence exists on the associations between dietary patterns before and during pregnancy and risk of HDP in minority women and those of lower socioeconomic status, and dietary patterns during pregnancy and risk of GDM.

CONCLUSIONS

Although some conclusions were drawn from these systematic reviews, more research is needed to address gaps and limitations in the evidence.

Dietary patterns before and during pregnancy and birth outcomes: a systematic review

BACKGROUND

Maternal diet before and during pregnancy could influence fetal growth and birth outcomes.

OBJECTIVE

Two systematic reviews aimed to assess the relationships between dietary patterns before and during pregnancy and 1) gestational age at birth and 2) gestational age- and sex-specific birth weight.

METHODS

Literature was searched from January, 1980 to January, 2017 in 9 databases including PubMed, Embase, and Cochrane. Two analysts independently screened articles using predetermined inclusion and exclusion criteria. Data were extracted from included articles and risk of bias was assessed. Data were synthesized qualitatively, a conclusion statement was drafted for each question, and evidence supporting each conclusion was graded.

RESULTS

Of the 9103 studies identified, 11 [representing 7 cohorts and 1 randomized controlled trial (RCT)] were included for gestational age and 21 (representing 19 cohorts and 2 RCTs) were included for birth weight. Limited but consistent evidence suggests that certain dietary patterns during pregnancy are associated with a lower risk of preterm birth and spontaneous preterm birth. These protective dietary patterns are higher in vegetables; fruits; whole grains; nuts, legumes, and seeds; and seafood (preterm birth, only), and lower in red and processed meats, and fried foods. Most of the research was conducted in healthy Caucasian women with access to health care. No conclusion can be drawn on the association between dietary patterns during pregnancy and birth weight outcomes. Although research is available, the ability to draw a conclusion is restricted by inconsistency in study findings, inadequate adjustment of birth weight for gestational age and sex, and variation in study design, dietary assessment methodology, and adjustment for key confounding factors. Insufficient evidence exists regarding dietary patterns before pregnancy for both outcomes.

CONCLUSIONS

Maternal dietary patterns may be associated with a lower preterm and spontaneous preterm birth risk. The association is unclear for birth weight outcomes.

"What Is 'Enough,' and How Do I Make It?": A Qualitative Examination of Questions Mothers Ask on Social Media About Pumping and Providing an Adequate Amount of Milk for Their Infants

BACKGROUND

Mothers commonly cite an inadequate milk "supply" as a reason for stopping human milk feeding. Further, pumping may affect mothers' understanding of their milk production. We aimed to characterize the questions mothers ask each other online related to the adequacy of the milk they pumped and provided to their infants.

MATERIALS AND METHODS

We conducted a secondary analysis of 543 posts containing questions related to pumping on an online discussion forum. These posts were provided by an open cohort of ∼25,000 women between 1 month before due date and 4.5 months postpartum. We used thematic analysis with Atlas.ti to analyze the posts.

RESULTS

Mothers commonly asked how many ounces they should be pumping and inquired about strategies to increase their pump output. They also wondered how many ounces or bottles of pumped milk they should provide to their infants or store for future use. Finally, mothers reported the inadequacy of the milk they were pumping or providing to their infants as potential reasons for stopping human milk feeding.

CONCLUSION

Our findings suggest that mothers may benefit from additional guidance from health care providers on the limitations of using pumps to draw conclusions about their milk production, the current evidence related to the use of herbal galactagogues, and the importance of responsive infant feeding. These findings also highlight the need for future research into how pumping or using herbal galactagogues may affect mothers' actual or perceived milk production and how styles for providing pumped milk compare to styles for feeding directly at the breast.

Effects of Breastfeeding on Maternal Health and Well-Being

Lactation occurs as part of a reproductive and may have different effects on maternal nutritional status, depending on its duration and intensity. Thus, its effect on maternal health will differ with cultural setting and level of development. Lactation helps women to maintain a healthy body weight. Among well-nour-shed women, it may help to prevent obesity. Among poorly pour/shed women, breastfeeding also leads to weight loss, but with adequate birth spacing brought about by lactational anovulation, maternal depletion can be avoided. Lactation is probably not responsible for osteoporosis. Current evidence suggests that breastfeeding helps to prevent pre-menopausal breast cancer and is not associated with post-menopausal disease Furthermore, breastfeeding may also help reduce ovarian cancer. Positive effects of breastfeeding occur at all levels of development and are most likely when biological, political, and sociocultural conditions interact to support its initiation and continuation.

Experiences and Perspectives About Breastfeeding in "Public": A Qualitative Exploration Among Normal-Weight and Obese Mothers

BACKGROUND

Women face societal and cultural barriers to breastfeeding. These challenges have been investigated in international studies and U.S. public opinion polls; however, mothers' experiences with breastfeeding in public in the United States remain unexplored. Research aim: The aim of this study was to describe the experiences of obese and normal-weight women with breastfeeding in public in central New York.

METHODS

Pregnant women ( N = 26) in central New York who intended to breastfeed and were either normal weight or obese were enrolled during their third trimester. A longitudinal, qualitative study was conducted to obtain information about women's experiences from birth through 3 to 6 months postpartum. Interviews were audio recorded, transcribed, and verified for accuracy. Transcripts were analyzed iteratively using conventional content analysis.

RESULTS

The concept of "public" was situational rather than a set of physical places; women experienced challenges while breastfeeding around others in private locations that were indistinguishable from those they encountered in places typically considered public. Women experienced social and physical awkwardness including perceived lack of acceptability, fear of confrontation, exposure, and positioning difficulties. They used strategies to reduce awkwardness, for example, being "discreet" and minimizing breastfeeding around other people. Obese women experienced similar challenges but to a greater degree than normal-weight women.

CONCLUSION

"Breastfeeding around others" described mother's experiences more accurately than "breastfeeding in public" and was experienced as awkward both socially and physically, particularly by obese women. Strategies are needed to normalize breastfeeding in the United States and to prepare mothers for the challenges of breastfeeding around others.

Breastfeeding and later maternal risk of hypertension and cardiovascular disease - The role of overall and abdominal obesity

In this study, we examined how any, full, and partial breastfeeding durations were associated with maternal risk of hypertension and cardiovascular disease (CVD), and how prepregnancy body mass index (BMI) and waist circumference 7 years postpartum influenced these associations. A total of 63,260 women with live-born singleton infants in the Danish National Birth Cohort (1996-2002) were included. Interviews during pregnancy and 6 and 18 months postpartum provided information on prepregnancy weight, height, and the duration of full and partial breastfeeding. Waist circumference was self-reported 7 years postpartum. Cox regression models were used to estimate hazard ratios of incident hypertension and CVD, registered in the National Patient Register from either 18 months or 7 years postpartum through 15 years postpartum. Any breastfeeding ≥4 months was associated with 20-30% lower risks of hypertension and CVD compared to <4 months in both normal/underweight and overweight/obese women. At follow-up starting 7 years postpartum, similar risk reductions were observed after accounting for waist circumference adjusted for BMI. Partial breastfeeding >2 months compared to ≤2 months, following up to 6 months of full breastfeeding, was associated with 10-25% lower risk of hypertension and CVD. Compared with short breastfeeding duration, additional partial breastfeeding was as important as additional full breastfeeding in reducing risk of hypertension and CVD. Altogether, longer duration of breastfeeding was associated with lower maternal risk of hypertension and CVD irrespective of prepregnancy BMI and abdominal adiposity 7 years after delivery. Both full and partial breastfeeding contributed to an improved cardiovascular health in mothers.

Early, regular breast-milk pumping may lead to early breast-milk feeding cessation

OBJECTIVE

To estimate the effect of early, regular breast-milk pumping on time to breast-milk feeding (BMF) and exclusive BMF cessation, for working and non-working women.

DESIGN

Using the Infant Feeding Practices Survey II (IFPS II), we estimated weighted hazard ratios (HR) for the effect of regular pumping (participant defined) compared with non-regular/not pumping, reported at month 2, on both time to BMF cessation (to 12 months) and time to exclusive BMF cessation (to 6 months), using inverse probability weights to control confounding.

SETTING

USA, 2005-2007.

SUBJECTS

BMF (n 1624) and exclusively BMF (n 971) IFPS II participants at month 2.

RESULTS

The weighted HR for time to BMF cessation was 1·62 (95 % CI 1·47, 1·78) and for time to exclusive BMF cessation was 1·14 (95 % CI 1·03, 1·25). Among non-working women, the weighted HR for time to BMF cessation was 2·05 (95 % CI 1·84, 2·28) and for time to exclusive BMF cessation was 1·10 (95 % CI 0·98, 1·22). Among working women, the weighted HR for time to BMF cessation was 0·90 (95 % CI 0·75, 1·07) and for time to exclusive BMF cessation was 1·14 (95 % CI 0·96, 1·36).

CONCLUSIONS

Overall, regular pumpers were more likely to stop BMF and exclusive BMF than non-regular/non-pumpers. Non-working regular pumpers were more likely than non-regular/non-pumpers to stop BMF. There was no effect among working women. Early, regular pumpers may need specialized support to maintain BMF.

Capturing Changes in HIV-Infected Breastfeeding Mothers' Cognitive Processes from Before Delivery to 5 Months Postpartum: An Application of the Pile-Sorting Technique in Haiti

BACKGROUND

The cognitive processes involved in individuals' perceptions and prioritization of information, and how these change with experience or exposure to interventions, are rarely examined in the evaluation of nutrition interventions. Exclusive breastfeeding counseling is a common infant and young-child feeding intervention and is used to promote HIV-free survival in the prevention of mother-to-child transmission programs. However, it is often designed without adequate attention to the changes in mothers' perceptions over the course of their early breastfeeding experiences.

OBJECTIVE

The aim of this study was to identify HIV-infected breastfeeding mothers' cognitive structure (their organization of messages and ideas) of infant feeding messages and to characterize whether their cognitive organization of infant feeding messages changed from pregnancy through the first 5 mo postpartum.

METHODS

With the use of semistructured interviews and the cognitive mapping technique of pile sorting, we interviewed 30 HIV-infected breastfeeding mothers in Port-au-Prince, Haiti. We asked them to sort and rate 18 infant feeding messages 3 times (during pregnancy, 0- to 1-mo postpartum, and 3- to 5-mo postpartum). We analyzed their responses by using multidimensional scaling, property fitting, and partition analyses.

RESULTS

At all 3 visits, we found consistency in women's cognitive mapping of messages. For example, mothers consistently differentiated messages pertinent for exclusive breastfeeding compared with those that pertained to other practices. However, subtle variations in mothers' cognition over time were also evident, particularly at 0- to 1-mo postpartum, when message proximity was tightly clustered compared with the earlier and later periods.

CONCLUSIONS

We conclude that mothers share a common cognitive organization of infant feeding messages and that this organization changes over time. Attention to variations in cognition can support context-sensitive, patient-centered counseling by practitioners and improve the effectiveness of nutrition interventions. Pile sorting is an efficient, systematic technique to examine cognitive processes related to health and nutrition.

The Pathways from a Behavior Change Communication Intervention to Infant and Young Child Feeding in Bangladesh Are Mediated and Potentiated by Maternal Self-Efficacy

Background

Although self-efficacy is a potential determinant of feeding and care behaviors, there is limited empirical analysis of the role of maternal self-efficacy in low- and middle-income countries. In the context of behavior change interventions (BCIs) addressing complementary feeding (CF), it is possible that maternal self-efficacy can mediate or enhance intervention impacts.

Objective

In the context of a BCI in Bangladesh, we studied the role of maternal self-efficacy for CF (MSE-CF) for 2 CF behaviors with the use of a theoretically grounded empirical model of determinants to illustrate the potential roles of MSE-CF.

Methods

We developed and tested a locally relevant scale for MSE-CF and included it in a survey (n = 457 mothers of children aged 6-24 mo) conducted as part of a cluster-randomized evaluation. Qualitative research was used to inform the selection of 2 intervention-targeted behaviors: feeding green leafy vegetables in the last 24 h (GLV) and on-time introduction of egg (EGG) between 6 and 8 mo of age. We then examined direct, mediated, and potentiated paths of MSE-CF in relation to the impacts of the BCI on these behaviors with the use of regression and structural equation modeling.

Results

GLV and EGG were higher in the intensive group than in the nonintensive control group (16.0 percentage points for GLV; P < 0.001; 11.2 percentage points for EGG; P = 0.037). For GLV, MSE-CF mediated (β = 0.345, P = 0.010) and potentiated (β = 0.390, P = 0.038) the effect of the intensive group. In contrast, MSE-CF did not mediate or potentiate the effect of the intervention on EGG.

Conclusions

MSE-CF was a significant mediator and potentiator for GLV but not for EGG. The divergent findings highlight the complex determinants of individual specific infant and young child feeding behaviors. The study shows the value of measuring behavioral determinants, such as MSE-CF, that affect a caregiver's capability to adopt intervention-targeted behaviors.

Trajectories of maternal weight from before pregnancy through postpartum and associations with childhood obesity

Background: Prepregnancy body mass index [BMI (in kg/m²)], gestational weight gain, and postpartum weight retention may have distinct effects on the development of child obesity, but their combined effect is currently unknown.Objective: We described longitudinal trajectories of maternal weight from before pregnancy through the postpartum period and assessed the relations between maternal weight trajectories and offspring obesity in childhood.Design: We analyzed data from 4436 pairs of mothers and their children in the National Longitudinal Survey of Youth 1979 (1981-2014). We used latent-class growth modeling in addition to national recommendations for prepregnancy BMI, gestational weight gain, and postpartum weight retention to create maternal weight trajectory groups. We used modified Poisson regression models to assess the associations between maternal weight trajectory group and offspring obesity at 3 age periods (2-5, 6-11, and 12-19 y).Results: Our analysis using maternal weight trajectories based on either latent-class results or recommendations showed that the risk of child obesity was lowest in the lowest maternal weight trajectory group. The differences in obesity risk were largest after 5 y of age and persisted into adolescence. In the latent-class analysis, the highest-order maternal weight trajectory group consisted almost entirely of women who were obese before pregnancy and was associated with a >2-fold increase in the risk of offspring obesity at ages 6-11 y (adjusted RR: 2.39; 95% CI: 1.97, 2.89) and 12-19 y (adjusted RR: 2.74; 95% CI: 2.13, 3.52). In the analysis with maternal weight trajectory groups based on recommendations, the risk of child obesity was consistently highest for women who were overweight or obese at the beginning of pregnancy.Conclusion: These findings suggest that high maternal weight across the childbearing period increases the risk of obesity in offspring during childhood, but high prepregnancy BMI has a stronger influence than either gestational weight gain or postpartum weight retention.

The Meaning of "Breastfeeding" Is Changing and So Must Our Language About It

For millennia, the word "breastfeeding" has meant feeding an infant at his/her own mother's breast. With the recent introduction of high-efficiency breast pumps, other possibilities are now widely used, including feeding an infant his/her own mother's milk from a cup or bottle. This milk may be recently pumped or stored for a short or long time. Infants also may be fed another mother's milk. As a result, the use of the term "breastfeeding" to describe these different behaviors now inhibits clear communication among and between healthcare providers, researchers, mothers, and members of the lay public. We propose a comprehensive set of terms to describe these and related behaviors. Adoption and consistent use of these terms would facilitate communication among all interested parties on the topic of maternal lactation and infant feeding.

Who knows what: An exploration of the infant feeding message environment and intracultural differences in Port-au-Prince, Haiti

Worldwide, mothers with young children receive many messages about infant feeding. Some messages are generated by health providers and others by the households, communities, and social contexts in which women live. We aimed to determine the scope of infant feeding messages in urban Haiti and to examine intracultural differences in salience of these messages and their alignment with international guidelines. We applied the method of free listing with 13 health workers and 15 human immunodeficiency virus (HIV)-infected and 15 HIV-uninfected mothers with infants 0-6 months old at Groupe Haïtien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince, Haiti. Participants listed all messages women receive about infant feeding and specifically about HIV and infant feeding. Message salience was determined by frequency of mention and recall order; messages were coded for key themes. For all groups, the World Health Organization infant feeding recommendations were salient, especially those related to exclusive breastfeeding. Messages across all groups focused on infant health outcomes, with less emphasis on maternal outcomes. Cultural beliefs were also elicited and showed higher salience for mothers than health workers, particularly for consequences of poor maternal nutrition. Health workers' free lists were poorly correlated to those of mothers, whereas those of mothers were highly correlated, regardless of HIV status. Inasmuch as many salient messages were culturally generated, and differences existed between mothers and health workers, we conclude that it is important for health workers to acknowledge the broader infant feeding message environment, and discrepancies within that environment, to address successes and failures in the messages reaching mothers, given potential consequences for mothers' breastfeeding behaviours.

New Opportunities for Breastfeeding Promotion and Support in WIC: Review of WIC Food Packages, Improving Balance and Choice

Although breastfeeding (BF) is the recommended way to feed infants, this may be difficult for the low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The 2017 recommended revisions to the WIC food packages provide substantial support to both exclusively and partially BF dyads, remove barriers to partial BF choices within the first 30 days postpartum, and increase flexibility in determining the amount of formula offered to partially breastfed infants. When combined with adequate support and tailored counseling, these changes are intended to make it easier for women served by WIC to choose to breastfeed.

Human milk expression as a sole or ancillary strategy for infant feeding: a qualitative study

In the United States, a significant proportion of human milk (HM) is now fed to infants from bottles. This mode of infant feeding is rarely measured or described in research studies or monitored by national surveillance systems. Consequently, little is known about expressed-HM feeding as an infant feeding strategy. Our objective was to understand how mothers use HM expression and expressed-HM feeding as a sole strategy or in combination with at-the-breast feeding to feed HM to their infants. We conducted semi-structured interviews with 41 mothers with experience of HM expression and infants under three years of age. Data were analysed using a grounded theory approach for sub-themes related to the pre-selected major themes of maternal HM production and infant HM consumption. Within the major theme of maternal HM production, sub-themes related to maternal over-production of HM. Many mothers produced more HM than their infant was consuming and stored it in the freezer. This enabled some infants to consume HM weeks or months after it was expressed. Within the major theme of infant HM consumption, the most salient sub-theme related to HM-feeding strategies. Four basic HM-feeding strategies emerged, ranging from predominant at-the-breast feeding to exclusive expressed-HM feeding. The HM-feeding strategies and trajectories highlighted by this study are complex, and most mothers fed HM both at-the-breast and from a bottle-information that is not collected by the current national breastfeeding survey questions. To understand health outcomes associated with expressed-HM feeding, new terminology may be needed.

Development, Construct Validity, and Reliability of the Questionnaire on Infant Feeding: A Tool for Measuring Contemporary Infant-Feeding Behaviors

BACKGROUND

The breastfeeding surveillance tool in the United States, the National Immunization Survey, considers the maternal-infant dyad to be breastfeeding for as long as the infant consumes human milk (HM). However, many infants consume at least some HM from a bottle, which can lead to health outcomes different from those for at-the-breast feeding.

OBJECTIVE

Our aim was to develop a construct-valid questionnaire that categorizes infants by nutrition source, that is, own mother's HM, another mother's HM, infant formula, or other and feeding mode, that is, at the breast or from a bottle, and test the reliability of this questionnaire.

DESIGN

The Questionnaire on Infant Feeding was developed through a literature review and modified based on qualitative research. Construct validity was assessed through cognitive interviews and a test-retest reliability study was conducted among mothers who completed the questionnaire twice, 1 month apart.

PARTICIPANTS/SETTING

Cognitive interviews were conducted with ten mothers from upstate New York between September and December 2014. A test-retest reliability study was conducted among 44 mothers from across the United States between March and May 2015.

MAIN OUTCOME MEASURES

Equivalence of questions with continuous responses about the timing of starting and stopping various behaviors and the agreement between responses to questions with categorical responses on the two questionnaires completed 1 month apart.

STATISTICAL ANALYSES PERFORMED

Reliability was assessed using paired-equivalence tests for questions about the timing of starting and stopping behaviors and weighted Cohen's κ for questions about the frequency and intensity of behaviors.

RESULTS

Reliability of the Questionnaire on Infant Feeding was moderately high among mothers of infants aged 19 to 35 months, with most questions about the timing of starting and stopping behaviors equivalent to within 1 month. Weighted Cohen's κ for categorical questions indicated substantial agreement.

CONCLUSIONS

The Questionnaire on Infant Feeding is a construct-valid tool to measure duration, intensity, and mode of infant HM consumption and duration of maternal HM production that is reliable within 19 to 35 months postpartum. Criterion-validity testing of these questions will improve the utility of the Questionnaire on Infant Feeding as a surveillance tool.

"Breastfeeding" but not at the breast: Mothers' descriptions of providing pumped human milk to their infants via other containers and caregivers

As pumping has become more prevalent among American women, pumped human milk (HM) is on the rise in their infants' diets in place of some or all feeding at the breast. We aimed to fill a gap in knowledge about mothers' motivations, practices and perceptions related to pumping, and about mothers' and other caregivers' motivations, practices, and perceptions related to feeding pumped HM. Results related to providing pumped HM are reported here, and results related to pumping are reported elsewhere. We conducted in-depth, semi-structured interviews among a diverse sample of mothers whose infants were fed pumped HM (n = 20), following each up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Nearly all mothers felt bottles were necessary to meet infant HM-feeding goals. Nearly all pumped HM was fed by other caregivers because mothers typically preferred and prioritized feeding at the breast for convenience and maintaining their milk supply. Infants were bottle-fed HM for several reasons that changed over time, such as mother's absence, latch difficulty, or desire to share the burden and bonding of feeding. Feeding practices differed between feeds from bottles versus at the breast; some infants were bottle-fed on schedules but fed at the breast on demand. Mothers' methods for storing, transporting, and preparing HM varied substantially and included practices associated with loss of nutrients and microbial contamination. Mothers' reasons for bottle-feeding HM may affect how much their infants are bottle-fed. Consumption of pumped HM may not provide the same benefits to infants as feeding at the breast. These findings highlight important avenues for future research into the relationships between bottle-feeding HM and infant health, growth, and developmental outcomes.

"Breastfeeding" without baby: A longitudinal, qualitative investigation of how mothers perceive, feel about, and practice human milk expression

Most American mothers who produce human milk (HM) now pump in place of some or all feeding at the breast, and most American infants are now fed pumped HM. We aimed to investigate mothers' perceptions of, attitudes toward, and practices for pumping and providing pumped HM. Results related to pumping are reported here. We conducted in-depth, semi-structured interviews among a diverse sample of 20 mothers who pumped, following each from pregnancy through infant HM-feeding cessation up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Mothers' reasons for pumping changed over time and reflected their needs and desires (e.g., latch difficulty, return to work, and increasing their milk supply). Mothers reported that pump type and quality were important to pumping success and that pumping was time-consuming, costly, and unpleasant compared to feeding at the breast. Regardless of how often mothers pumped, most felt pumping was necessary to meet their infant HM-feeding goals and was a welcome means of sharing with other caregivers the bonding opportunity and tasks they associated with feeding infants. Mothers interpreted output from pumping sessions to understand their ability to provide enough milk to meet their infants' needs. Mothers' reasons for pumping may signal constraints to infant HM feeding that may be addressed with policy changes. Mothers' attitudes and perceptions toward pumping indicate that, although pumping fills important and welcome roles for many mothers, the reality of its practice may make it an unacceptable or infeasible substitute for some.