WHO accused of stifling debate about infant feeding

International specialists in infant feeding expressed concern that the policy of WHO of establishing partnerships with private industry has gone too far, with the result that debate about the infant food industry's role in marketing breast milk substitutes is being stifled. Specialists, who want the WHO to recommend exclusive breast-feeding to babies up to 6 months, claim that at a recent joint meeting on infant feeding they were prevented from discussing the issue. In addition, some papers intended for the meeting were edited so that they were less critical to the infant food industry. Although 20 of the 28 consultants signed a statement saying that scientific evidence was now sufficient to warrant changing of the current WHO recommendation on the introduction of complementary feeding from age 4-6 months to about 6 months, no discussion was allowed. In response, a spokesman for the WHO stated that the current recommendation of WHO on the duration of exclusive breast-feeding was excluded in the discussion because of the WHO?s research that is under way in this connection. As far as the alleged censorship of the background papers is concerned, he explained that WHO documents have to conform to a high standard of scientific objectivity and balance. Lastly, WHO cited that the food industry continues to play an important and constructive role in relation to infant feeding.     

Perceived insufficient milk as a barrier to optimal infant feeding: examples from Bolivia

In its recently adopted Global Strategy on Infant and Young Child Feeding, the World Health Assembly called for urgent action in addressing the barriers to optimal feeding practices. This paper examines mothers' concerns about milk insufficiency as a major contributor to suboptimal infant feeding decisions, using survey data from peri-urban areas of two Bolivian cities. Mothers in the lowland modernizing city of Santa Cruz were more likely than mothers in the highland traditional city of Cochabamba to express concern about insufficient milk, and also less likely to feed their infants according to international recommendations. Furthermore, perceived milk insufficiency was particularly common among mothers of infants younger than 6 months of age -- an age at which infants are particularly vulnerable to the adverse effects of breast-feeding cessation and complementary feeding initiation. The paper concludes with policy, programme and research recommendations to address the critical problem of perceived insufficient breast milk.     

Breast-feeding promotion in Manitoba. Committee on Breast-feeding,Manitoba Pediatric Society.

During the International Year of the Child the Manitoba Pediatric Society undertook professional and public education activities to promote breast-feeding in that province. The objective was a 100% increase in the proportion of mothers who breast-fed their infants for 2 months or longer. Surveys conducted before and after the campaign showed no significant increase in the rate of breast-feeding either at the time of hospital discharge or 2 months later. The infants of Winnipeg residents were more likely to be breast-fed than those of women living on Indian reservations or in any other part of the province (termed "rural"). The rate of bottle-feeding was significantly greater among infants of young unmarried mothers. Future programs to promote breast-feeding should be longer and more intensive, should be directed to the young, to rural residents and to Indian women, and should focus on social and emotional factors as well as nutrition and health benefits.     

A qualitative study of the promotion of exclusive breastfeeding by health professionals in Niamey, Niger

Infant feeding by HIV-infected mothers has been a major global public health dilemma and a highly controversial matter. The controversy is reflected in the different sets of WHO infant feeding guidelines that have been issued over the last two decades. This thematic series, 'Infant feeding and HIV: lessons learnt and ways ahead' highlights the multiple challenges that HIV-infected women, infant feeding counsellors and health systems have encountered trying to translate and implement the shifting infant feeding recommendations in different local contexts in sub-Saharan Africa. As a background for the papers making up the series, this editorial reviews the changes in the guidelines in view of the roll out of prevention of mother to child transmission (PMTCT) programmes in sub-Saharan Africa between 2001 and 2010.     

A biocultural investigation of the weanling's dilemma in Kathmandu, Nepal: do universal recommendations for weaning practices make sense?

The primary objective of this report is to use data from a study of infant growth and weaning practices in Kathmandu, Nepal, to investigate universal recommendations about exclusive breast-feeding up to 6 months postpartum. A secondary objective is to demonstrate the complexity of the biocultural nature of infant feeding practices. A sample of 283 children under 5 years of age and their 228 mothers living in a peri-urban district of Kathmandu participated in this study. The children's height/length and weight were measured three times over 9 months. At each session, a demographic, child health and infant feeding survey was administered; between sessions, in-depth interviews were conducted with mothers regarding infant feeding practices. While a few of the infants under 2 months were receiving non-breast milk foods, at 3 months of age half of the sample had been introduced to non-breast milk foods and by 7 months all infants were eating non-breast milk foods. A comparison of growth indices and velocities between exclusively and partially breast-fed infants from birth to 7 months of age shows no evidence for a difference in nutritional status between the two groups. Although there are cultural rules about breast-feeding that vary by ethnic group, all mothers followed a feeding method that depended on their assessment of whether the child was getting enough breast milk. The conclusion is that exclusive breast-feeding up to 6 months may not be appropriate for all infants. In this sample, breast-feeding duration is not shortened by the early introduction of non-breast milk foods, as the median age of breast-feeding cessation is 36 months. One of the main reasons for severance was the onset of another pregnancy. Investigation of infant feeding practices must be contextualized in the local ecology of the population. While cultural beliefs about breast-feeding are relevant, mothers' individual assessments of their children's nutritional needs and demographic events in parents' lives must also be considered.     

Multi-indicator survey on children's nutrition in Croatia (MICS) (up to 5 years of age)

Multi-Indicator Survey (MICS) on children in Croatia was supported by UNICEF's Zagreb Office. The purpose of this research was to establish the present situation in terms of breastfeeding, nutrition and prevention of the most significant health problems in primary health care i.e. acute respiratory and diarrhoeal diseases in children (ARI/CDD), and the level of knowledge. The survey for MICS in Croatia included altogether 370 segments, and from each 40 households were selected. This resulted in 14,800 households being selected for the final sample. 1563 (or 10.6%) of households selected had children under 5 years of age. In the whole sample there were altogether 1937 children under 5 years of age. Having summarized all relevant data, several general conclusions and assumptions may be drawn. The breast-feeding rate is very low, and therefore unsatisfactory. At the age of 4 months, more than 50% of all mothers have already stopped breast-feeding their infants, and only 20% of infants were breast-fed after the age of 6 months. We noticed an unfavourable trend towards a decrease in the rate of breast-feeding in war areas. The was has negatively affected breast-feeding. The prevalence of feeding using diluted cow's milk during the first six months is very high (30% in the first, and 60% in the second six months). On the basis of this research, further activities should be planned.     

The use of vitamin K in the perinatal period. Fetus and Newborn Committee,Canadian Paediatric Society.

The incidence of hemorrhagic disease of the newborn (HDNB) can be expected to increase in Canada as breast-feeding becomes more popular. There are three clinical patterns of hemorrhagic disease: early HDNB (usually related to maternal drug ingestion), classic HDNB (related to breast-feeding) and late hemorrhagic disease of infancy (related to the combination of breast-feeding and diseases that cause fat malabsorption). Despite the knowledge that the disease can virtually be prevented by the administration of vitamin K, not all newborns are being routinely considered for such treatment. The Canadian Paediatric Society has made several recommendations: (a) women who take drugs that interfere with vitamin K1 metabolism should receive oral doses of vitamin K1 daily for a minimum of 2 weeks before expected delivery; (b) all healthy term infants should receive a single dose of vitamin K1, orally or intramuscularly, within 6 hours after birth; (c) all other newborns, including preterm, low-birthweight and sick infants, should receive a single intramuscular dose of vitamin K1 within 6 hours after birth; and (d) infants at high risk for secondary late-onset hemorrhagic disease due to fat malabsorption should receive vitamin K1 orally every day or intramuscularly once a month.     

Correlation between subsequent lengths of postpartum amenorrhoea in a prospective study of breast-feeding women in rural Bangladesh.

The relationship between subsequent lengths of lactational amenorrhoea for individual women in a prospective study of breast-feeding women in Bangladesh was studied. The data indicate that previous length of amenorrhoea has significant predictive value for the subsequent length of amenorrhoea. Information on previous experience with lactational amenorrhoea should be therefore incorporated into guidelines for the introduction of family planning during lactation.     

Infant feeding practices: 1984-85 versus 1977-78.

In 1979 and 1980 the Canadian Paediatric Society''s Nutrition Committee published guidelines for professionals counselling mothers of infants on feeding practices. The practices in 1984-85 of mothers in Toronto were determined for comparison with the practices identified in a similar study conducted in Toronto and Montreal in 1977-78 to ascertain if practices had changed in favour of the recommendations. Between July 1984 and February 1985, 404 metropolitan Toronto mothers of infants were interviewed. Compared with the 1977-78 group of mothers, more of the 1984-85 mothers had chosen to breast-feed and fewer had stopped breast-feeding in the first month. As well, fewer of the 1984-85 infants had been fed unmodified cow''s milk in the first 6 months of life and introduced to solid foods before 4 months of age. We conclude that major changes in infant feeding practices had occurred since 1977-78 and that the 1984-85 practices corresponded closely to the infant feeding guidelines.     

Recomendaciones nutricionales en las distintas etapas de la vida basadas en la evidencia

We review the scientific evidence available on nutritional recommendations in the distinct stages of life through 10 key questions relating to dietary modifications throughout the life cycle, namely: how long should breast-feeding last? What are the best methods for promoting breast-feeding? Should soya infant formulas be used to prevent allergic diseases in infants at high risk? Is micronutrient supplementation indicated in infants? How should childhood obesity be prevented? Are there any valid strategies for preventing eating disorders in adolescents? Which type of diet should be recommended in pregnant and breast-feeding women? Should nutritional supplements be used in elderly individuals at risk of malnutrition? Should micronutrient supplements be used in the elderly to prevent or treat degenerative diseases?     

Infant feeding practices at routine PMTCT sites, South Africa: results of a prospective observational study amongst HIV exposed and unexposed infants - birth to 9 months

Background

We sought to investigate infant feeding practices amongst HIV-positive and -negative mothers (0-9 months postpartum) and describe the association between infant feeding practices and HIV-free survival.

Methods

Infant feeding data from a prospective observational cohort study conducted at three (of 18) purposively-selected routine South African PMTCT sites, 2002-2003, were analysed. Infant feeding data (previous 4 days) were gathered during home visits at 3, 5, 7, 9, 12, 16, 20, 24, 28, 32 and 36 weeks postpartum. Four feeding groups were of interest, namely exclusive breastfeeding, mixed breastfeeding, exclusive formula feeding and mixed formula feeding. Cox proportional hazards models were fitted to investigate associations between feeding practices (0-12 weeks) and infant HIV-free survival.

Results

Six hundred and sixty five HIV-positive and 218 HIV-negative women were recruited antenatally and followed-up until 36 weeks postpartum. Amongst mothers who breastfed between 3 weeks and 6 months postpartum, significantly more HIV-positive mothers practiced exclusive breastfeeding compared with HIV-negative: at 3 weeks 130 (42%) versus 33 (17%) (p < 0.01); this dropped to 17 (11%) versus 1 (0.7%) by four months postpartum. Amongst mothers practicing mixed breastfeeding between 3 weeks and 6 months postpartum, significantly more HIV-negative mothers used commercially available breast milk substitutes (p < 0.02) and use of these peaked between 9 and 12 weeks. The probability of postnatal HIV or death was lowest amongst infants living in the best resourced site who avoided breastfeeding, and highest amongst infants living in the rural site who stopped breastfeeding early (mean and standard deviations: 10.7% ± 3% versus 46% ± 11%).

Conclusions

Although feeding practices were poor amongst HIV-positive and -negative mothers, HIV-positive mothers undertake safer infant feeding practices, possibly due to counseling provided through the routine PMTCT programme. The data on differences in infant outcome by feeding practice and site validate the WHO 2009 recommendations that site differences should guide feeding practices amongst HIV-positive mothers. Strong interventions are needed to promote exclusive breastfeeding (to 6 months) with continued breastfeeding thereafter amongst HIV-negative motherswho are still the majority of mothers even in high HIV prevalence setting like South Africa.     

Patterns of breastfeeding practices among infants and young children in Abu Dhabi,United Arab Emirates

Background

Despite the ongoing efforts to improve infant feeding practices, low rates of breastfeeding and early introduction of complementary feeding have been reported in many countries. Systematic documentation of breastfeeding practices in the United Arab Emirates (UAE) is needed in order to directing successful strategies. The aim of this study was to evaluate breastfeeding practices among mothers in Abu Dhabi, UAE, using the World Health Organization (WHO) infant and young child feeding indicators.

Methods

In this cross-sectional study, mothers of children below the age of two were recruited from the community and health centers located in different areas in Abu Dhabi. Following informed consent, a structured questionnaire including WHO-indicators was used for in-person interviews on sociodemographics and breastfeeding. Exclusive breastfeeding (EBF) was calculated as the percentage of babies 0 – <?6?months of age who had been exclusively breastfed in the last 24?h.

Results

A total of 1822 mothers participated in the study; 95.6% (1741/1822) of mothers initiated breastfeeding and 59.8% (1089/1822) initiated breastfeeding within the first hour. Exclusive breastfeeding among infants 0–6?months was 44.3% (362/818). Although the median duration of “any breastfeeding” was 12?months (95% CI 11.2, 12.7), the median duration of EBF was 3 months (95% CI 2.8, 3.3). Most of the children (894/1004, 89%) aged 6 months and above were receiving complementary feeding, but 21.7% (218/1004) of them had had an early introduction of complementary feeding, i.e. before 6 months of age. Using “the WHO infant and young child feeding indicators” as standard for comparative evaluation, breastfeeding initiation was rated “good”, the proportion of children being exclusively breastfed until 6 months was rated “fair” and the duration of EBF was considered “poor”.

Conclusions

According to the WHO infant feeding indicators the breastfeeding practices were suboptimal in several aspects with a low proportion of children being exclusively breastfed, short breastfeeding duration and early introduction of complementary feeding, despite high socioeconomic status. These findings suggest that there is a need to understand potential barriers towards breastfeeding in order to develop appropriate strategies to promote and support breastfeeding in Abu Dhabi.

     

Brief description of WHO protocol for data collection.

WHO Simplified Methodology (1987) is being applied in several studies: the Task Force on Methods for the Natural Regulation of Fertility of the Special Program on Human Reproduction in centers in Chendu, China; Guatemala City, Guatemala; New Delhi, India; Sagamu, Nigeria; Santiago, Chile; Uppsala, Sweden; and Westmead/Sydney, Australia. 550 lactating mothers who can read and write were examined in order to provide a better understanding of the relationship between breast-feeding duration and lactational amenorrhea, and to determine whether the longitudinal study results are applicable to the general population. Protocol involved data collection of breast-feeding frequency, timing, and duration; supplementary feeding characteristics and timing; and maternal and infant health. WHO protocol is also being examined in studies in Colombo, Sri Lanka, and Sagamu, Nigeria. The study objective was to examine the effect of maternal nutritional supplementation with skimmed milk powder in Colombo and a high protein biscuit in Sagamu on the duration of lactational amenorrhea in moderately malnourished breast-feeding mothers. Followup studies are expected. Optimally, the end product should be a measure of the presence of ovulation, however, the logistics prevented this from occurring. Instead, weekly urine samples were collected and tested for the presence of estrogen and pregnanediol glucuronide. Motivation is a key determinant in the success of these projects, since detailed record keeping over a prolonged period of time is required. Motivational interventions vary between centers and may involve social contact with investigators or health care support for the mother and infant. Some preliminary results indicate that the higher the percentage receiving supplementation, the earlier the return of the menses.     

Similarity of the CDC and WHO weight-for-length growth charts in predicting risk of obesity at age 5 years

The World Health Organization (WHO) 2006 weight-for-length (WFL) or BMI growth charts are now recommended as the new standard for children under 24 months. The objective of this study was to examine associations of ever being overweight during 1-24 months, based on the older Centers for Disease Control and Prevention (CDC) and WHO cutpoints, with risk of obesity at age 5 years. From well-child visits to a Massachusetts multi-site group practice during 1980-2008, we studied 15,488 children with length/height and weight measurements at 1, 6, 12, 18, and 24 months, and at 5 years. The main exposures were ever being overweight during 1-24 months using each of three cutpoints: CDC WFL ≥ 95th percentile, WHO WFL or BMI ≥ 97.7th percentile. The main outcome was obesity at 5 years (CDC BMI ≥ 95th percentile). We calculated multivariable odds ratios (ORs), adjusted for age, sex, race/ethnicity, and year. At 5 years, 10.8% of participants were obese. During 1-24 months, 21.3, 18.3, and 20.2% were ever overweight using CDC WFL, WHO WFL, and WHO BMI cutpoints, respectively. ORs (95% confidence interval (CI)) for associations of ever being overweight during 1-24 months with obesity at 5 years were 6.0 (5.4, 6.6), 6.3 (5.7, 7.0), and 6.0 (5.4, 6.7), respectively. Ever being overweight in the first 2 years of life is a strong predictor of obesity at 5 years. CDC WFL, WHO WFL, and WHO BMI cutpoints for overweight in early childhood provided similar estimates of later obesity risk.     

Rate of growth in length of Bangladeshi infants as a function of attained length.

We examine variation in the rate of growth in length of breast-feeding infants from rural Bangladesh. These data were collected between November 1985 and February 1986 from two rural sites. Eighty-eight infants, ranging from birth to 4 months of age at the start of the study and their mothers were measured monthly for 4 months. Length increased linearly with age over this 4-month period (infants' average bias-adjusted R2 = 0.90). The relationship between infant rate of growth in length and attained length was analyzed by two different methods: Oldham's (1962) method of regressing rate of growth on mean length and Blomqvist's (1977) method of regressing rate of growth on estimated initial length. The methods gave similar results. The rate of growth was negatively associated with mean infant length over the 4-month period (p less than 0.001); that is, shorter infants grew at a faster rate than longer infants. For every centimeter shorter the infant was, the rate of growth was 0.1 cm/mo faster on average; the effect was greater among males than among females. The average rate of growth was greater for males than for females and greater in financially solvent households and varied by site. Infant growth rate was slower among older infants than among younger infants, as expected. However, after adjusting for mean infant length, age was no longer significantly associated with infant growth rate, although mean infant length remained highly significant. Forty-one percent of the variation in infant rate of growth in length was explained by mean infant length, sex, sex by length interaction, household financial solvency, and site.     

Experimental strategies to assess the biological ramifications of multiple drivers of global ocean change—A review

Marine life is controlled by multiple physical and chemical drivers and by diverse ecological processes. Many of these oceanic properties are being altered by climate change and other anthropogenic pressures. Hence, identifying the influences of multifaceted ocean change, from local to global scales, is a complex task. To guide policy‐making and make projections of the future of the marine biosphere, it is essential to understand biological responses at physiological, evolutionary and ecological levels. Here, we contrast and compare different approaches to multiple driver experiments that aim to elucidate biological responses to a complex matrix of ocean global change. We present the benefits and the challenges of each approach with a focus on marine research, and guidelines to navigate through these different categories to help identify strategies that might best address research questions in fundamental physiology, experimental evolutionary biology and community ecology. Our review reveals that the field of multiple driver research is being pulled in complementary directions: the need for reductionist approaches to obtain process‐oriented, mechanistic understanding and a requirement to quantify responses to projected future scenarios of ocean change. We conclude the review with recommendations on how best to align different experimental approaches to contribute fundamental information needed for science‐based policy formulation.     

Hypervitaminosis A in experimental nonhuman primates: evidence,causes, and the road to recovery

One of the great underlying assumptions made by all scientists utilizing primate models for their research is that the optimal nutritional status and health of the animals in use has been achieved. That is, no nutrient deficiency or excess has compromised their health in any detectable way. To meet this assumption, we rely on the National Research Council's (NRC's) nutritional recommendations for nonhuman primates to provide accurate guidance for proper dietary formulations. We also rely on feed manufacturers to follow these guidelines. With that in mind, the purpose of this commentary is to discuss three related points that we believe have significant ramifications for the health and well being of captive primates as well as for their effective use in biomedical research. First, our laboratory has shown that most experimental primates are likely in a state of hypervitaminosis A. Second, it is apparent that many primate diets are providing vitamin A at levels higher than the NRC's recommendation. Third, the recommendation itself is based on inadequate information about nutrient needs and is likely too high, especially when compared with human requirements. Am. J. Primatol. 71:813–816, 2009. © 2009 Wiley‐Liss, Inc.     

From autonomy to accountability: the role of clinical practice guidelines in professional power

Evidence-based medicine (EBM) aims to address the persistent problem of clinical practice variation with the help of various tools, including standardized practice guidelines. Based on a systematic evaluation of the available scientific evidence, these guidelines offer recommendations for clinicians about details of patient care and clinical decision making. Because clinical practice guidelines specify how health care should be performed, they could be considered a threat to clinical and professional autonomy. Inspired by the theory of countervailing powers, this article explores how clinical practice guidelines have shifted the focus of professional power from autonomy to accountability. Professional organizations develop clinical practice guidelines as a service to their members but do not require strict adherence to the guidelines. Indeed, implementation studies show at best a modest change in clinical behavior. Such non-adherence might render a profession vulnerable, however, when third parties seize upon guidelines and offer financial incentives to keep clinicians accountable for delivering optimal patient care.     

Lactational amenorrhoea in well-nourished Toba women of Formosa, Argentina

The proximate causes of the contraceptive effect of lactation are still a matter of productive debate. This study sought to disentangle the relative impact that intense breast-feeding practices and maternal nutrition have on the regulation of ovarian function in nursing women. A mixed-longitudinal, direct-observational, prospective study was conducted of the return to postpartum fecundity in 113 breast-feeding, well-nourished Toba women. A sub-sample of 70 women provided data on nursing behaviour, daily activities, diet quality and urinary levels of oestrone and progesterone metabolites. Well-nourished, intensively breast-feeding Toba women experienced a relatively short period of lactational amenorrhoea (10.2 +/- 4.3 months) and a high lifetime fertility (TFR=6.7 live births/woman). Duration of lactational amenorrhoea was not correlated with any of the nursing parameters under study or with static measures of maternal nutritional status. The results indicated that the pattern of resumption of postpartum fertility could be explained, at least partly, by differences in individual metabolic budgets. Toba women resumed postpartum ovulation after a period of sustained positive energy balance. As the relative metabolic load hypothesis suggests, the variable effect of lactation on postpartum fertility may not depend on the intensity of nursing per se but rather on the energetic stress that lactation represents for the individual mother.     

The recovery of fertility during breast-feeding in Assiut, Egypt

A longitudinal study of twenty-six breast-feeding and twelve non-breast-feeding postpartum women was conducted in Assiut, Egypt in order to determine the time that ovulation resumed after childbirth, and the effect of breast-feeding frequency on the period of lactational anovulation. Breast-feeding women experienced the onset of follicular development, vaginal bleeding, ovulation and pregnancy significantly later than women who did not breast-feed. Ovulatory and non-ovulatory breast-feeders reported similar frequencies of breast-feeding episodes. The introduction of dietary supplements commonly preceded ovulation. An algorithm using three simple variables observable to the breast-feeding mother was found to predict up to 100% of the first ovulations. All breast-feeding women who did not give supplements and did not have a vaginal bleeding episode by 6 months postpartum were anovular by strict criteria for ovulation. Ovulation did not precede bleeding or supplementation in the women who experienced these events before 6 months, yielding a highly effective formula for preventing unplanned pregnancy by the informed use of breast-feeding.