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Maternal and Child Health. 2018 Sep 8;  p.Promoting exclusive breastfeeding (EBF) is a highly feasible and cost-effective means of improving child health. Regulating the marketing of breastmilk substitutes is critical to protecting EBF. In 1981, the World Health Assembly adopted the World Health Organization International Code of Marketing of Breastmilk Substitutes (the Code), prohibiting the unethical advertising and promotion of breastmilk substitutes. This comparative study aimed to (a) explore the relationships among Code enforcement and legislation, infant formula sales, and EBF in India, Vietnam, and China; (b) identify best practices for Code operationalization; and (c) identify pathways by which Code implementation may influence EBF. We conducted secondary descriptive analysis of available national-level data and seven high level key informant interviews. Findings indicate that the implementation of the Code is a necessary but insufficient step alone to improve breastfeeding outcomes. Other enabling factors, such as adequate maternity leave, training on breastfeeding for health professionals, health systems strengthening through the Baby Friendly Hospital Initiative, and breastfeeding counselling for mothers, are needed. Several infant formula industry strategies with strong conflict of interest were identified as harmful to EBF. Transitioning breastfeeding programmes from donor-led to government-owned is essential for long-term sustainability of Code implementation and enforcement. We conclude that the relationships among the Code, infant formula sales, and EBF in India, Vietnam, and China are dependent on countries' engagement with implementation strategies and the presence of other enabling factors.
Following the World Health Organization's Recommendation of Exclusive Breastfeeding to 6 Months of Age Does Not Impact the Growth of Rural Gambian Infants.
Journal of Nutrition. 2017 Feb; 147(2):248-255.BACKGROUND: The WHO recommends exclusive breastfeeding (EBF) for the first 6 mo of life. OBJECTIVE: The objective of this study was to assess the benefit of EBF to age 6 mo on growth in a large sample of rural Gambian infants at high risk of undernutrition. METHODS: Infants with growth monitoring from birth to 2 y of age (n = 756) from the ENID (Early Nutrition and Immune Development) trial were categorized as exclusively breastfed if only breast milk and no other liquids or foods were given. EBF status was entered into confounder-adjusted multilevel models to test associations with growth trajectories by using >11,000 weight-for-age (WAZ), length-for-age (LAZ), and weight-for-length (WLZ) z score observations. RESULTS: Thirty-two percent of infants were exclusively breastfed to age 6 mo. The mean age of discontinuation of EBF was 5.2 mo, and growth faltering started at approximately 3.5 mo of age. Some evidence for a difference in WAZ and WHZ was found between infants who were exclusively breastfed to age 6 mo (EBF-6) and those who were not (nEBF-6), at 6 and 12 mo of age, with EBF-6 children having a higher mean z score. The differences in z scores between the 2 groups were small in magnitude (at 6 mo of age: 0.147 WAZ; 95% CI: -0.001, 0.293 WAZ; 0.189 WHZ; 95% CI: 0.038, 0.341 WHZ). No evidence for a difference between EBF-6 and nEBF-6 infants was observed for LAZ at any time point (6, 12, and 24 mo of age). Furthermore, a higher mean WLZ at 3 mo of age was associated with a subsequent higher mean age at discontinuation of EBF, which implied reverse causality in this setting (coefficient: 0.060; 95% CI: 0.008, 0.120). CONCLUSION: This study suggests that EBF to age 6 mo has limited benefit to the growth of rural Gambian infants. This trial was registered at http://www.isrctn.com as ISRCTN49285450.
Journal of Community Nutrition & Health. 2013; 2(1):68-75.Objective: This was a prospective comparative study carried out from April 2011 to February 2012 to assess the growth pattern of exclusively breast fed (EBF) and non-exclusively breast fed infants (NEBF) in the first six months of life. Methods: A total of 213 lactating mothers and their neonates (less than 7 days) weighing 2.5kg were consecutively recruited into the study and followed up at 6,14 and 24 weeks, Infants were classified into EBF and NEBF groups based on their current feeding pattern during the follow up. Anthropometric measurements of weight and length were taken and compared with WHO reference curves. Data analysis was carried out using frequencies, percentages, means (SD) and t-test. Results: The rate of exclusive breastfeeding declined from 82.5% at delivery to 23% at the end of 24 weeks. The NEBF infants were heavier and longer at birth (P>0.05). The EBF Infants had higher weight (28 vs 22 g/day) and length gain of (0.77 Vs 0.70 cm/week) from 0 to 14 weeks than their NEBF counterpart (p>0.05). Despite a decline in weight gain of EBF infants after the 14 week, they retained the higher mean weight achieved earlier. Average cumulative weight and length gain of 3.71 kg Vs 3.31 kg and 15.33 cm vs 14.56 cm were recorded for EBF and NEBF infants, respectively during the 24 weeks follow up. The mean weight and length of the EBF infants was comparable to the World Health organization (WHO) reference curve than for the NEBF infants. Conclusion: This study has shown that exclusive breastfeeding supported adequate growth in infants studied during the first six months of life.
Energy intake from human milk covers the requirement of 6-month-old Senegalese exclusively breast-fed infants.
British Journal of Nutrition. 2013 Nov; 110(10):1849-55.Exclusive breast-feeding until 6 months is advised by the WHO as the best practice to feed infants. Yet, some studies have suggested a gap between energy requirements and the energy provided by human milk for many infants at 6 months. In order to assess the adequacy of WHO recommendations in 6-month-old Senegalese lactating infants, a comprehensive study was designed to measure human milk intake by the dose-to-the mother 2H2O turnover method. Infants' energy intakes were calculated using daily breast milk intake and the energy content of milk was estimated on the basis of creamatocrit. Of the fifty-nine mother-infant pairs enrolled, fifteen infants were exclusively breast-fed (Ex) while forty-four were partially breast-fed (Part). Infants' breast milk intake was significantly higher in the Ex group (993 (SD 135) g/d, n 15) compared with the Part group (828 (SD 222) g/d, n 44, P(1/4)0.009). Breast milk energy content as well as infants' growth was comparable in both groups. However, infants' energy intake from human milk was significantly higher (364 (SD 50) kJ/kg per d (2586 (SD 448) kJ/d)) in the Ex group than in the Part group (289 (SD 66) kJ/kg per d (2150 (SD 552) kJ/d), P,0.01). Compared with WHO recommendations, the results demonstrate that energy intake from breast milk was low in partially breast-fed infants while exclusively breast-fed 6-month-old Senegalese infants received adequate energy from human milk alone, the most complete food for infants. Therefore, advocacy of exclusive breast-feeding until 6 months should be strengthened.
Birth. 2011 Sep; 38(3):238-45.BACKGROUND: The World Health Organization (WHO) developed the Baby-Friendly Hospital Initiative to improve hospital maternity care practices that support breastfeeding. In Hong Kong, although no hospitals have yet received the Baby-Friendly status, efforts have been made to improve breastfeeding support. The aim of this study was to examine the impact of Baby-Friendly hospital practices on breastfeeding duration. METHODS: A sample of 1,242 breastfeeding mother-infant pairs was recruited from four public hospitals in Hong Kong and followed up prospectively for up to 12 months. The primary outcome variable was defined as breastfeeding for 8 weeks or less. Predictor variables included six Baby-Friendly practices: breastfeeding initiation within 1 hour of birth, exclusive breastfeeding while in hospital, rooming-in, breastfeeding on demand, no pacifiers or artificial nipples, and information on breastfeeding support groups provided on discharge. RESULTS: Only 46.6 percent of women breastfed for more than 8 weeks, and only 4.8 percent of mothers experienced all six Baby-Friendly practices. After controlling for all other Baby-Friendly practices and possible confounding variables, exclusive breastfeeding while in hospital was protective against early breastfeeding cessation (OR: 0.61; 95% CI: 0.42-0.88). Compared with mothers who experienced all six Baby-Friendly practices, those who experienced one or fewer Baby-Friendly practices were almost three times more likely to discontinue breastfeeding (OR: 3.13; 95% CI: 1.41-6.95). CONCLUSIONS: Greater exposure to Baby-Friendly practices would substantially increase new mothers' chances of breastfeeding beyond 8 weeks postpartum. To further improve maternity care practices in hospitals, institutional and administrative support are required to ensure all mothers receive adequate breastfeeding support in accordance with WHO guidelines. (c) 2011, Copyright the Authors. Journal compilation (c) 2011, Wiley Periodicals, Inc.
African Journal of Primary Health Care and Family Medicine. 2009 May 7; 1(1):4 p.Background: Breastfeeding is nearly universal in Kenya. However, supplementation of breast milk starts too early, thereby exposing the infants to diarrhoea and other infections. Despite the recommendation of the World Health Organization (WHO) of exclusive breastfeeding (EB) from birth to six months, EB is rare and poorly timed and complementary feeding (CF) practices are still common. The study describes feeding practices of children aged 0 to 24 months in the Mumias Division of the Kakamega district in Kenya. Method: Using a cross-sectional study, 180 mothers of infants/children were interviewed using a structured questionnaire. Data on socio-demographic characteristics, feeding practices and sources of information on the same were obtained from the mothers. Results: Whereas 92.1% of the children were breastfed, only 12.2% of the mothers practiced EB up to 4 to 6 months. Mothers introduced liquids and complementary foods at a mean age of 2.7 months and by the fourth month, more than one-third (34.5%) of the mothers had initiated CF. Apart from water, fresh milk, tea, commercial juices, maize-meal/millet porridge, mashed potatoes, bananas and fruits were also introduced. The perceived reasons for introducing these foods included the child being old enough (33.8%), another pregnancy (25%), insufficient milk (20.3%), sickness of the mother or child (10.5%) and in order for the child to eat other foods (11.4%). Over half (53.3%) of the mothers obtained information on BF and CF from friends, neighbours, media advertisements and health workers. Conclusion: Breastfeeding is common; however, mothers do not seem to practice the WHO recommendations. Mothers in this study area and other rural communities need to be empowered with information on the correct BF and CF practices through existing government health services, nongovernmental organisations and other community-based networks, especially in the light of the HIV/AIDS pandemic.
Implications of the new WHO guidelines on HIV and infant feeding for child survival in South Africa.
Bulletin of the World Health Organization. 2011 Jan 1; 89(1):62-7.The World Health Organization released revised principles and recommendations for HIV and infant feeding in November 2009. The recommendations are based on programmatic evidence and research studies that have accumulated over the past few years within African countries. This document urges national or subnational health authorities to decide whether health services should mainly counsel and support HIV-infected mothers to breastfeed and receive antiretroviral interventions, or to avoid all breastfeeding, based on estimations of which strategy is likely to give infants in those communities the greatest chance of HIV-free survival. South Africa has recently revised its clinical guidelines for prevention of mother-to-child HIV transmission, adopting many of the recommendations in the November 2009 World Health Organization's rapid advice on use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants. However, one aspect of the new South African guidelines gives cause for concern: the continued provision of free formula milk to HIV-infected women through public health facilities. This paper presents the latest evidence regarding mortality and morbidity associated with feeding practices in the context of HIV and suggests a modification of current policy to prioritize child survival for all South African children.
Journal of Human Lactation. 2010 Aug; 26(3):297-303.The objective of this study was to translate and psychometrically assess a Portuguese version of the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). The original English version of the BSES-SF was translated to Portuguese and tested among a sample of 89 mothers in southern Brazil from the 2nd to 12th postpartum week followed by face-to-face interviews. The mean total score of the Portuguese version of the BSES-SF was 63.6 +/- 6.22. The reliability analysis of each item in the scale attained significant Cronbach's alphas of 0.63 or superior. The Cronbach's alpha generated by the entire range of 14 questions was 0.71. A factor analysis identified one factor that contributed to 20% of the variance. This study demonstrates that the original English version of the BSES-SF was successfully adapted to Portuguese. The Portuguese version of the BSES-SF constitutes a reliable research instrument for evaluating breastfeeding self-efficacy in Brazil.
Annals of Saudi Medicine. 2009 Jan-Feb; 29(1):20-3.BACKGROUND AND OBJECTIVE: The WHO recommends exclusive breastfeeding in the first 6 months of life. Our objective was to evaluate trends in infant nutrition in Saudi Arabia and the degree of compliance with WHO recommendations. SUBJECTS AND METHODS: A nationwide nutritional survey of a sample of Saudi households was selected by the multistage probability sampling procedure. A validated questionnaire was administered to mothers of children less than 3 years of age. RESULTS: Of 5339 children in the sample, 4889 received breast milk at birth indicating a prevalence of initiation of 91.6%. Initiation of breastfeeding was delayed beyond 6 hours after birth in 28.1% of the infants. Bottle feeding was introduced by 1 month of age to 2174/4260 (51.4%) and to 3831/4260 (90%) by 6 months of age. The majority of infants 3870/4787 (80.8%) were introduced to "solid foods" between 4 to 6 months of age and whole milk feedings were given to 40% of children younger than 12 months of age. CONCLUSIONS: The current practice of feeding of Saudi infants is very far from compliance with even the most conservative WHO recommendations of exclusive breastfeeding for 4 to 6 months. The high prevalence of breastfeeding initiation at birth indicates the willingness of Saudi mothers to breastfeed. However, early introduction of complementary feedings reduced the period of exclusive breastfeeding. Research in infant nutrition should be a public health priority to improve the rate of breastfeeding and to minimize other inappropriate practices.
Promotion of WHO feeding recommendations: A model evaluating the effects on HIV-free survival in African children.
Journal of Human Lactation. 2008 May; 24(2):140-149.In Africa, HIV and feeding practices deeply affect child mortality. To prevent mother-to-child transmission, the World Health Organization recommends exclusive breastfeeding for 6 months and replacement feeding when acceptable, feasible, affordable, and sustainable. Determining the proportion and number of children saved with exclusive breastfeeding and replacement feeding is essential to design and implement crucial nationwide policies. Using data on 31 sub-Saharan countries and a decision tree for risk assessment, the authors estimated the number of children's lives potentially saved according to 6 scenarios that combine exclusive breastfeeding for 6 months or replacement feeding with 3 promotion strategies. Among all HIV-negative children born to HIV-positive mothers who die in sub-Saharan Africa per year, 52 315 (9.6%) would be saved yearly with exclusive breastfeeding versus 21 638 (4.0%) with replacement feeding. Promotion support would double these numbers (110 625 vs 45 330; ie, 20.3% vs 8.3%), and with additional prenatal group education, 132 633 versus 54 192 lives would be saved (24.3% vs 9.9%). Wherever replacement feeding is not possible, exclusive breastfeeding with promotion support and prenatal group education would save 1 of 4 exposed children. (author's)
Use of stable-isotope techniques to validate infant feeding practices reported by Bangladeshi women receiving breastfeeding counseling.
American Journal of Clinical Nutrition. 2007 Apr; 85(4):1075-1082.The World Health Organization recommends exclusive breastfeeding until age 6 mo. Studies relying on mothers' selfreported behaviors have shown that lactation counseling increases both the rate and duration of exclusive breastfeeding. We aimed to validate reported infant feeding practices in rural Bangladesh; intakes of breast milk and nonbreast-milk water were measured by the dose-given-to-the mother deuterium dilution technique. Subjects were drawn from the large-scale Maternal and Infant Nutrition Interventions, Matlab, study of combined interventions to improve maternal and infant health, in which women were randomly assigned to receive either exclusive breastfeeding counseling or standard health care messages. Data on infant feeding practices were collected by questionnaire at monthly visits. Intakes of breast milk and nonbreast-milk water were measured in a subsample of 98 mother-infant pairs (mean infant age: 14.3 wk) and compared with questionnaire data reporting feeding practices. Seventy-five of the 98 subjects reported exclusive breastfeeding. Mean (+or-SD) breast milk intake was 884 +or- 163 mL/d in that group and 791 +or- 180 mL/d in the group reported as nonexclusively breastfed (P = 0.0267). Intakes of nonbreast-milk water were 40 _ 80.6 and 166 +or- 214 mL/d (P < 0.0001), respectively. Objective cross-validation using deuterium dilution data showed good accuracy in reporting of feeding practices, although apparent misreporting was widely present in both groups. The dose-given-to-the-mother deuterium dilution technique can be applied to validate reported feeding behaviors. Whereas this technique shows that the reports of feeding practices were accurate at the group level, it is not adequate to distinguish between feeding practices in individual infants. (author's)
Journal of Tropical Pediatrics. 2007 Apr; 53(2):125-130.Health experts worldwide recognize breastmilk as the superior infant food. Recommendations from the American Academy of Pediatrics and the World Health Organization (WHO) identify exclusive breastfeeding for the first half-year of life and continuation of breastfeeding into toddlerhood as offering maximum protection from illness, providing a substrate for immunological protection. Data from developed countries identify increasing morbidity and mortality rates for infants who have never received breastmilk in life and demonstrate that infants benefit from exclusive breastfeeding, especially, in areas of severe poverty. Preterm infants, most at risk for morbidity and mortality in developing countries, are identified as needing their own mother's milk for survival. Exclusive feeding of own mothers' milk (OMM) is associated with improved infant survival; however, inadequate maternal milk volume (MMV) often necessitates adding artificial feedings or exogenous substances to OMM. The objective of this study was to compare mean daily MMV for mothers of premature or sick infants in special care nurseries (SCN) using one of three methods of OMM expression: electric breast pump, non-electric pedal breast pump, and hand (manual) expression. We studied 65 mothers whose infants were cared for in two SCN in Africa (Kenya and Nigeria) and were unable to feed directly at the breast. In this randomized trial, mothers were randomly assigned to one of three milk expression groups at birth. MMV, the dependent variable, was measured for an average of 8.7 days. MMV for the electric and pedal pump and hand milk expression was 578 ± 228 ml (n = 22), 463 ± 302 ml (n = 24) and 323 ±199 ml (n = 19), respectively. Data were evaluated using a one-way ANOVA (p = 0.014). The Tukey revealed significant differences (p<0.01) between electric breast pump expression and hand expression but not between the electric and pedal pump or the pedal pump and hand expression. Findings revealed greater MMV with electric breast pumps than hand-expression for mothers of infants in African nurseries. This data has important implications for international policy if exclusive OMM feeding is to be achieved for the vulnerable infant. Funded by West Virginia University Department of Research and Graduate Studies HSC Grant # 2U023U; Non-monetary donations of breast pumps and breast pump kits were made by Medela. (author's)
Differences between international recommendations on breastfeeding in the presence of HIV and the attitudes and counselling messages of health workers in Lilongwe, Malawi.
International Breastfeeding Journal. 2006 Mar 9; 1(1):2.To prevent postnatal transmission of HIV in settings where safe alternatives to breastfeeding are unavailable, the World Health Organization (WHO) recommends exclusive breastfeeding followed by early, rapid cessation of breastfeeding. Only limited data are available on the attitudes of health workers toward this recommendation and the impact of these attitudes on infant feeding counselling messages given to mothers. As part of the Breastfeeding, Antiretroviral, and Nutrition (BAN) clinical trial, we carried out an in-depth qualitative study of the attitudes, beliefs, and counselling messages of 19 health workers in Lilongwe, Malawi. Although none of the workers had received formal training, several reported having counseled HIV-positive mothers about infant feeding. Health workers with counselling experience believed that HIV-infected mothers should breastfeed exclusively, rather than infant formula feed, citing poverty as the primary reason. Because of high levels of malnutrition, all the workershad concerns about early cessation of breastfeeding. Important differences were observed between the WHO recommendations and the attitudes and practices of the health workers. Understanding these differences is important for designing effective interventions. (author's)
Weaning practices of the Makushi of Guyana and their relationship to infant and child mortality: A preliminary assessment of international recommendations.
American Journal of Human Biology. 2006 May-Jun; 18(3):312-324.The World Health Organization (WHO) recommends exclusive breastfeeding (EBF) for the first 6 months of life, primarily because of potential immunological benefits which are deemed to outweigh nutritive costs for infants. This recommendation is controversial, as studies of the relationship between the term of EBF and infant and child health have produced conflicting results. The purpose of this paper is to evaluate the relationship between the term of EBF and infant and child mortality among a group of swidden-horticulturalists in lowland South America. Consistent with the WHO, we hypothesized that EBF < 6 months will compromise the survival of the infant or child. This relationship was assessed via recall data generated in 2001 in structured interviews with 60 Makushi Amerindian women in Guyana's North Rupununi region. The data were analyzed with t-tests, Fisher's exact test, and logistic regression. The results do not support our hypothesis; the term of EBF is not found to be related to infant or child mortality. This is surprising given the potential for contamination in nonbreast-milk foods in this environment. Notably, this is occurring among mothers who are not energetically stressed. We propose that the apparent lack of benefit of EBF = 6 months is due to insufficient energy supply from breast milk alone, which may predispose the child to morbidity when subsequently stressed. This study concurs with others which revealed no significant benefits to the infant of EBF > 6 months, and the recognition that universal recommendations must be situated within local ecological contexts. (author's)