Dual modality feeders: a group of human milk feeders with unique practices and needs.

OBJECTIVE: Dual modality feeding (DMF) - feeding human milk interchangeably from the breast and from a bottle - comes with unique practical, emotional and relational challenges, as well as support needs. Yet, there is little research that explores the experiences of individuals who use DMF in the Canadian context. The aim of this study is to explore the practices, challenges, reasons and enablers of DMF. DESIGN: Repeat, semi-structured one-on-one interviews were conducted at 8 weeks and 22 weeks postpartum. Interview transcripts were thematically analysed using a critical feminist lens. SETTING: Nova Scotia, Canada. PARTICIPANTS: Ten DMF mothers. RESULTS: DMF practices were influenced by a mix of social and material circumstances, including breast-feeding challenges, the involvement of support persons, finances and access to lactation support. Individuals who predominantly fed at the breast expressed milk strategically to mitigate transitory breast-feeding challenges, for convenience under specific circumstances, and to share feeding responsibilities with other caregivers for personal and practical reasons. Individuals who mainly bottle-fed did so due to long-term breast-feeding challenges or a need to return to employment. Enablers of successful DMF were consistent between the two groups and included practical, personal and relational aspects. CONCLUSIONS: DMF is a unique practice compared to feeding human milk solely from the breast or bottle. Despite the potential growing prevalence of DMF, it is currently understudied and inadequately addressed in existing support programmes in Nova Scotia. Tailored programming and public messaging are needed to support DMF families.

Restricting diet for perceived health benefit: A mixed-methods exploration of peripartum food taboos in rural Cambodia.

Food taboos encompass food restrictions practiced by a group that go beyond individual preferences. During pregnancy and lactation, food taboos may contribute to inadequate nutrition and poor maternal and infant health. Restriction of specific fish, meat, fruits and vegetables is common among peripartum women in many Southeast Asian countries, but data from Cambodia are lacking. In this mixed-methods study, 335 Cambodian mothers were asked open-ended questions regarding dietary behaviours during pregnancy and up to 24 weeks postpartum. Descriptive statistics and content analysis were used to characterize food taboos and multiple logistic regression analyses were conducted to identify predictors of this practice. Participants were 18-44 years of age, all of Khmer ethnicity and 31% were primiparous. Sixty-six per cent of women followed food taboos during the first 2 weeks postpartum, whereas ~20% of women restricted foods during other peripartum periods. Pregnancy taboos were often beneficial, including avoidance of sugar-sweetened beverages, coffee and alcohol. Conversely, postpartum avoidances typically included nutrient-dense foods such as fish, raw vegetables and chicken. Food taboos were generally followed to support maternal and child health. No significant predictors of food taboos during pregnancy were identified. Postpartum, each additional live birth a woman had reduced her odds of following food taboos by 24% (odds ratio [95% confidence interval]: 0.76 [0.61-0.95]). Specific food taboo practices and rationales varied greatly between women, suggesting that food taboos are shaped less by a strict belief system within the Khmer culture and more by individual or household understandings of food and health during pregnancy and postpartum.

Breastfeeding in Canada: predictors of initiation, exclusivity, and continuation from the 2017-2018 Canadian Community Health Survey.

Human milk is the ideal source of nutrition for infants; however, adherence to breastfeeding recommendations is suboptimal and availability of Canadian breastfeeding data are limited. Using the 2017-2018 Canadian Community Health Survey Public Use Microdata File (Maternal Experiences Module, n = 5558, weighted n = 1 669 462) we computed breastfeeding indicators and explored sociodemographic, health, and geographical predictors of breastfeeding with univariate logistic regression models. Nationally, of all participants who gave birth in the preceding 5 years, 91% initiated breastfeeding, 43% exclusively breastfed to ≥5 months and 35% to ≥6 months, 56% reported any breastfeeding at ≥6 months, and 31% reported breastfeeding at ≥12 months. Breastfeeding cessation was most commonly attributed to insufficient milk supply (25%), but reasons differed significantly by breastfeeding duration. Breastfeeding initiation, exclusivity for ≥5 months, and extended breastfeeding ≥12 months all differed by geographic region, and by most sociodemographic and health characteristics. Positive breastfeeding outcomes were highest in British Columbia, and lowest in Quebec and the Atlantic region, and generally higher if caregivers had recently immigrated to Canada, were married, were >30 years of age, were not White, were nonsmoking, had completed postsecondary education, and had an annual household income >$40 000. These disparities indicate the need for tailored, equitable approaches to breastfeeding support, and continued regional monitoring of breastfeeding outcomes.

Responsive feeding values and practices among families across the Canadian Maritime provinces.

Children benefit from responsive feeding practices where their internal signals of hunger and satiety are valued and met with prompt, emotionally supportive, and developmentally appropriate responses. Using an online survey, this study describes responsive feeding values and practices among parents of young children (0-5 years) (n = 1039) across 3 Canadian Maritime provinces. Independent-samples t-tests and 1-way ANOVA were performed to determine the differences in survey questions related to the responsive feeding practices and values. First-time parents and parents with younger children report implementing more consistently some of the challenging responsive feeding practices, such as avoiding pressuring their children to eat, compared with parents with multiple children and parents with children ages 3-5 years. Parents often have well-intended reasons to encourage their children to eat; however, these can coincide with non-responsive practices with food such as pressuring, rewarding, and restriction. These coercive practices may be ineffective and counterproductive as they reinforce reasons to eat unrelated to appetite and self-regulation. Preschool and early feeding interventions that support parents in understanding normal child development, including typical eating behaviours and self-regulation, could help to equip them for challenging feeding experiences and encourage long-term responsive feeding practices. Novelty: First-time parents and parents with younger children report more consistently avoiding pressuring their children to eat, compared with parents with multiple children and parents with children ages 3-5 years. Parents often have well-intended reasons to encourage their children to eat; however, these can coincide with non-responsive practices such as pressuring, rewarding, and restriction.

Article: "Too Old" and "Too Cold": Discomfort Towards Photographs of Breastfeeding Beyond Infancy and Public Breastfeeding in Nova Scotia, Canada.

BACKGROUND: Social norms and public perception of breastfeeding are well-established predictors of breastfeeding outcomes; however, little is known about perceptions of breastfeeding beyond infancy or public breastfeeding among the public in Nova Scotia, Canada. RESEARCH AIM: To explore public opinion about breastfeeding beyond infancy and public breastfeeding. METHODS: In this cross-sectional study participants were recruited from public spaces in Nova Scotia, Canada. Using photo elicitation methods, participants (N = 229) viewed six photographs of breastfeeding children aged 2 weeks, 13 months, and 2.5 years, one photograph captured at home, and the other in a public space (a café, a store, or outdoors). Participants were asked to score their self-rated comfort with each photograph on a 10.0 cm visual analog scale and asked to share their feelings about each photograph (open-ended responses). RESULTS: Mean (SD) visual analog scale comfort scores for photographs differed by location (private, 7.9 [2.2]; public, 7.3 [2.6]; p < .05) and child age (2 weeks, 8.5 [2.0]; 13 months, 7.5 [2.6]; 2.5 years, 6.9 [3.0]; p < .05). Participants who identified as women and parents self-reported significantly higher comfort with all photographs, while younger participants and urban dwellers were generally less comfortable. Open-ended responses varied considerably, but a higher proportion of negative comments were reported for older children feeding in public spaces (e.g., 2.5-year-old in public: "Inappropriate. Indecent. Abnormal."). CONCLUSION: Given the importance of social norms in supporting breastfeeding, future public health campaigns should strive to normalize breastfeeding beyond infancy, and in public spaces.

Trends and predictors of early initiation, exclusive and continued breast-feeding in Bangladesh (2004-2018): a multilevel analysis of demographic and health survey data.

The early initiation of breast-feeding (EIBF) within 1 h of birth, exclusive breast-feeding (EBF) to 6 months and continued breast-feeding (CBF) to 2 years are key infant and young child feeding guidelines promoted globally for optimal child health and development. Using publicly available national survey data from the five most recent, consecutive Bangladesh Demographic and Health Surveys (2004, 2007, 2011, 2014 and 2017-2018), we assessed the trends in these key breast-feeding indicators. Multiple multilevel logistic regression models were built to assess socio-demographic predictors of breast-feeding using the latest 2017-2018 data set. Both EIBF and EBF have increased significantly between 2004 and 2017-2018, from 26 % to 60 % and 36 % to 68 %, respectively, and CBF decreased from 94 % to 85 %. Caesarean section delivery conferred lower EIBF practice (OR = 0·34, 95 % CI 0·27, 0·42) compared with vaginal delivery. Women who were currently working had 32 % lower odds of EBF (OR = 0·68, 95 % CI 0·48, 0·95). Compared with delivery at home, women who delivered in a health facility had 81 % higher odds of EBF (OR = 1·81, 95 % CI 1·25, 2·34). Larger family size (≥5) also predicted EBF (OR = 1·70, 95 % CI 1·21, 2·40). Rural residency was associated with 2·39 (95 % CI 1·32, 4·31) times of higher odds of CBF. Regional variation was also predictive of the various breast-feeding indicators. Although Bangladesh currently exceeds the 2019 global prevalence rates for these three breast-feeding indicators, efforts should be made to continue improving EIBF and EBF and to prevent future decreases in CBF.

Thiamine supplementation holds neurocognitive benefits for breastfed infants during the first year of life.

Women reliant on mostly rice-based diets can have inadequate thiamine intake, placing breastfed infants at risk of thiamine deficiency and, in turn, physical and cognitive impairments. We investigated the impact of maternal thiamine supplementation doses on infants' cognitive, motor, and language development across the first year. In this double-blind, four-parallel-arm, randomized controlled trial, healthy mothers of exclusively breastfed newborn infants were recruited in Kampong Thom, Cambodia. At 2 weeks postnatal, women (n = 335) were randomized to one of four treatment groups to consume one capsule/day with varying amounts of thiamine for 22 weeks: 0, 1.2, 2.4, and 10 mg. At 2, 12, 24, and 52 weeks of age, infants were assessed with the Mullen Scales of Early Learning (MSEL) and the Caregiver Reported Early Development Instrument (CREDI). Multiple regression and mixed effects modeling suggest that by 6 months of age, the highest maternal thiamine dose (10 mg/day) held significant benefits for infants' language development, but generally not for motor or visual reception development. Despite having achieved standardized scores on the MSEL that approximated U.S. norms by 6 months, infants showed a significant drop relative to these norms in both language domains following trial completion, indicating that nutritional interventions beyond 6 months may be necessary.

Low-dose thiamine supplementation of lactating Cambodian mothers improves human milk thiamine concentrations: a randomized controlled trial.

BACKGROUND: Infantile beriberi-related mortality is still common in South and Southeast Asia. Interventions to increase maternal thiamine intakes, and thus human milk thiamine, are warranted; however, the required dose remains unknown. OBJECTIVES: We sought to estimate the dose at which additional maternal intake of oral thiamine no longer meaningfully increased milk thiamine concentrations in infants at 24 wk postpartum, and to investigate the impact of 4 thiamine supplementation doses on milk and blood thiamine status biomarkers. METHODS: In this double-blind, 4-parallel arm randomized controlled dose-response trial, healthy mothers were recruited in Kampong Thom, Cambodia. At 2 wk postpartum, women were randomly assigned to consume 1 capsule, containing 0, 1.2 (estimated average requirement), 2.4, or 10 mg of thiamine daily from 2 through 24 weeks postpartum. Human milk total thiamine concentrations were measured using HPLC. An Emax curve was plotted, which was estimated using a nonlinear least squares model in an intention-to-treat analysis. Linear mixed-effects models were used to test for differences between treatment groups. Maternal and infant blood thiamine biomarkers were also assessed. RESULTS: In total, each of 335 women was randomly assigned to1 of the following thiamine-dose groups: placebo (n = 83), 1.2 mg (n = 86), 2.4 mg (n = 81), and 10 mg (n = 85). The estimated dose required to reach 90% of the maximum average total thiamine concentration in human milk (191 µg/L) is 2.35 (95% CI: 0.58, 7.01) mg/d. The mean ± SD milk thiamine concentrations were significantly higher in all intervention groups (183 ± 91, 190 ± 105, and 206 ± 89 µg/L for 1.2, 2.4, and 10 mg, respectively) compared with the placebo group (153 ± 85 µg/L; P < 0.0001) and did not significantly differ from each other. CONCLUSIONS: A supplemental thiamine dose of 2.35 mg/d was required to achieve a milk total thiamine concentration of 191 µg/L. However, 1.2 mg/d for 22 wk was sufficient to increase milk thiamine concentrations to similar levels achieved by higher supplementation doses (2.4 and 10 mg/d), and comparable to those of healthy mothers in regions without beriberi. This trial was registered at clinicaltrials.gov as NCT03616288.

Infant feeding experiences and concerns among caregivers early in the COVID-19 State of Emergency in Nova Scotia, Canada.

The global emergency caused by the novel coronavirus (COVID-19) pandemic has impacted access to goods and services such as health care and social supports, but the impact on infant feeding remains unclear. Thus, the objective of this study was to explore how caregivers of infants under 6 months of age perceived changes to infant feeding and other food and health-related matters during the COVID-19 State of Emergency in Nova Scotia, Canada. Four weeks after the State of Emergency began, between 17 April and 15 May 2020, caregivers completed this online survey, including the Perceived Stress Scale. Participants (n = 335) were 99% female and mostly White (87%). Over half (60%) were breastfeeding, and 71% had a household income over CAD$60,000. Most participants (77%) received governmental parental benefits before the emergency, and 59% experienced no COVID-19-related economic changes. Over three quarters of participants (77%) scored moderate levels of perceived stress. Common themes of concern included social isolation, COVID-19 infection (both caregiver and infant), and a lack of access to goods, namely, human milk substitutes ('infant formula'), and services, including health care, lactation support, and social supports. Most COVID-19-related information was sought from the internet and social media, so for broad reach, future evidence-based information should be shared via online platforms. Although participants were experiencing moderate self-perceived stress and shared numerous concerns, very few COVID-19-related changes to infant feeding were reported, and there were few differences by socio-economic status, likely due to a strong economic safety net in this Canadian setting.

Modeling thiamine fortification: a case study from Kuria atoll, Republic of Kiribati.

In 2014, there was an outbreak of beriberi on Kuria, a remote atoll in Kiribati, a small Pacific Island nation. A thiamine-poor diet consisting mainly of rice, sugar, and small amounts of fortified flour was likely to blame. We aimed to design a food fortification strategy to improve thiamine intakes in Kuria. We surveyed all 104 households on Kuria with a pregnant woman or a child 0-59 months. Repeat 24-h dietary recalls were collected from 90 men, 17 pregnant, 44 lactating, and 41 other women of reproductive age. The prevalence of inadequate thiamine intakes was >30% in all groups. Dietary modeling predicted that rice or sugar fortified at a rate of 0.3 and 1.4 mg per 100 g, respectively, would reduce the prevalence of inadequate thiamine intakes to <2.5% in all groups. Fortification is challenging because Kiribati imports food from several countries, depending on price and availability. One exception is flour, which is imported from Fiji. Although resulting in less coverage than rice or sugar, fortifying wheat flour with an additional 3.7 mg per 100 g would reduce the prevalence of inadequacy to under 10%. Kiribati is small and has limited resources; thus, a regional approach to thiamine fortification is needed.

Assessment of salt intake to consider salt as a fortification vehicle for thiamine in Cambodia.

Thiamine deficiency is a public health issue in Cambodia. Thiamine fortification of salt has been proposed; however, the salt intake of lactating women, the target population, is currently unknown. We estimated salt intakes among lactating women (<6 months postpartum) using three methods: repeat observed-weighed intake records and 24-h urinary sodium excretions (n = 104), and household salt disappearance (n = 331). Usual salt intake was estimated by adjusting for intraindividual intakes using the National Cancer Institute method, and a thiamine salt fortification scenario was modeled using a modified estimated average requirement (EAR) cut-point method. Unadjusted salt intake from observed intakes was 9.3 (8.3-10.3) g/day, which was not different from estimated salt intake from urinary sodium excretions, 9.0 (8.4-9.7) g/day (P = 0.3). Estimated salt use from household salt disappearance was 11.3 (10.7-11.9) g/person/day. Usual (adjusted) salt intake from all sources was 7.7 (7.4-8.0) g/day. Assuming no stability losses, a modeled fortification dose of 275 mg thiamine/kg salt could increase thiamine intakes from fortified salt to 2.1 (2.0-2.2) mg/day, with even low salt consumers reaching the EAR of 1.2 mg/day from fortified salt alone. These findings, in conjunction with future sensory and stability research, can inform a potential salt fortification program in Cambodia.

Thiamine fortification strategies in low- and middle-income settings: a review.

Thiamine (vitamin B1 ) is an essential micronutrient in energy metabolism and cognitive and neurological health. Thiamine deficiency disorders (TDDs) have a range of clinical presentations that result in various morbidities and can be fatal if not promptly recognized and treated, especially in infants. To intervene, thiamine intakes by breastfeeding mothers and others at risk of thiamine deficiency should be increased to ensure adequate thiamine intake. Although thiamine fortification programs have a long history in high-income countries, there are few mandatory fortification programs to address TDDs in low- and middle-income countries (LMICs), particularly in the regions of greatest concern, South and Southeast Asia. This review highlights essential aspects for consideration in the development of a mandatory fortification program in LMICs, including an overview of the data required to model fortification dosing schemes, available thiamine fortificants, and potential fortification vehicles, as well as identifies current knowledge gaps.

Micronutrient intake and prevalence of micronutrient inadequacy among women (15-49 y) and children (6-59 mo) in South Kivu and Kongo Central, Democratic Republic of the Congo (DRC).

Iron biofortified beans and carotenoid enriched cassava are proposed as a solution to combat iron and vitamin A deficiencies, respectively, in the Democratic Republic of Congo (DRC). To inform the need for biofortified foods, we conducted a survey in 2014 in two provinces of the DRC, South Kivu and Kongo Central. Unexpectedly, women of reproductive age (WRA; 15-49 y) and their children (6-59 m) had a low prevalence of biochemical iron and vitamin A deficiency, based on ferritin and retinol binding protein, respectively. To better understand the lack of biochemical deficiency of these nutrients, we examined the prevalence of inadequate intake for these and other select nutrients. Dietary intake was assessed using 24-hour recalls among 744 mother-child dyads. Repeat recalls on a non-consecutive day were conducted with a subsample of the study population to account for intra-individual variation and estimate usual intake. In WRA, the prevalence of inadequate iron intakes were 33% and 29% in South Kivu and Kongo Central, respecitvely. The prevalence of inadequate vitamin A intakes among WRA was low in South Kivu (18%) and negligible in Kongo Central (1%). Iron inadequacy was highest in infants (6-11 m) at 82% and 64% in South Kivu and Kongo Central, respectively. Among older children (12-59 m) in both provinces, the prevalence of iron inadequacy was similar at ~20%. There was a high prevalence of inadequate zinc intake in women and children (i.e. 79-86% among WRA and 56-91% among children 6-59 m) consistent with our findings of a high prevalence of low serum zinc in the same sample. Dietary data here corroborate the low prevalence of biochemical vitamin A deficiency but not iron. However, any change to the supply of red palm oil (primary source of vitamin A) would dramatically reduce population vitamin A intakes, thus a carotenoid enriched cassava program may be beneficial as a safety net measure. Crops biofortified with zinc also appear warranted. We caution that our findings cannot be extrapolated to the entire Congo where diverse agro-ecological landscape exist or when political and environmental shocks occur which challenge food production.

The Homozygous Hemoglobin EE Variant Is Associated with Poorer Riboflavin Status in Cambodian Women of Reproductive Age.

BACKGROUND: Riboflavin is required for erythropoiesis, which is increased in people with hemoglobinopathies due to increased hemolysis and erythrocyte turnover. Dietary intake and status of riboflavin is poor in Cambodia, where hemoglobinopathies are common. OBJECTIVE: We assessed the association between genetic hemoglobin disorders and riboflavin status in women of reproductive age in Cambodia. METHODS: Venous blood samples from 515 Cambodian women of reproductive age, 18-45 y, were analyzed for biomarker status of riboflavin [erythrocyte glutathione reductase activation coefficient (EGRac)], genetic hemoglobin (Hb) disorders, and hematological indices. Linear regression analysis was used to estimate the association between EGRac with Hb, ferritin, and Hb genotypes. EGRac was log transformed in the analyses, and the regression coefficients represent the geometric mean differences. RESULTS: Genetic Hb disorders were present in 57% of the population, with the homozygous hemoglobin E variant (Hb EE) occurring in ∼10% of women (n = 53). Deficient (EGRac ≥1.40) or marginal riboflavin status (EGRac ≥1.30 and <1.40) was observed in 92% (n = 475) of women. The variant Hb EE genotype was associated with 18% (95% CI: 9%, 28%) higher geometric mean EGRac values than the normal Hb AA genotype (P < 0.001). CONCLUSIONS: Although riboflavin biomarker deficiency or marginal status is widely prevalent in Cambodian women, lower riboflavin status was observed more frequently in women with the Hb EE genotype than in women with normal Hb AA. The relation between genetic Hb disorders and riboflavin warrants further investigation. This trial was registered at clinicaltrials.gov as NCT01593423 and NCT02481375.

Interpretation of vitamin B-12 and folate concentrations in population-based surveys does not require adjustment for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project.

BACKGROUND: Vitamin B-12 and folate deficiencies in women and children have important public health implications. However, the evidence is conflicting and limited on whether the influence of inflammation on biomarker concentrations may be sufficiently and consistently influenced by inflammation to require adjustment for interpreting concentrations or estimating population prevalence of deficiencies. OBJECTIVE: We examined correlations between concentrations of the inflammation biomarkers C-reactive protein (CRP) and α1-acid glycoprotein (AGP) and serum vitamin B-12 and serum and RBC folate among nonpregnant women of reproductive age (WRA; 15-49 yr) and preschool children (PSC; 6-59 mo). METHODS: We analyzed cross-sectional data from 16 nationally representative nutrition surveys conducted in WRA (n = 32,588) and PSC (n = 8,256) from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project. Spearman correlations between CRP or AGP and vitamin B-12 or folate concentrations were examined, taking into account complex survey design effects. RESULTS: Correlations between inflammation and vitamin B-12 or folate were weak, with no clear pattern of association in either WRA or PSC. Correlation coefficients between CRP and vitamin B-12 for WRA and PSC ranged from -0.25 to 0.16, and correlations between AGP and vitamin B-12 ranged between -0.07 and 0.14. Similarly, correlations between CRP and serum folate ranged from -0.13 to 0.08, and correlations between AGP and serum folate between -0.21 and 0.02. Only 3 surveys measured RBC folate, and among them, correlations for WRA ranged from -0.07 to 0.08 for CRP and -0.04 for AGP (1 country). CONCLUSIONS: Based on the weak and inconsistent correlations between CRP or AGP and vitamin B-12 or folate biomarkers, there is no rationale to adjust for inflammation when estimating population prevalence of vitamin B-12 or folate deficiencies in WRA or PSC.

Macro- and Micronutrients in Milk from Healthy Cambodian Mothers: Status and Interrelations.

BACKGROUND: Except for low thiamin content, little is known about vitamins or macronutrients in milk from Cambodian mothers, and associations among milk nutrients. OBJECTIVES: We measured fat-soluble vitamins (FSVs) and water-soluble vitamins (WSVs), and macronutrients, and explored internutrient associations in milk from Cambodian mothers. METHODS: Milk from women (aged 18-45 y, 3-27 wk postpartum, n = 68) who participated in a thiamin-fortification trial were analyzed for vitamins B-2 (riboflavin, FAD), B-3 (nicotinamide), B-5, B-6 (pyridoxal, pyridoxine), B-7, B-12, A, E [α-tocopherol and γ-tocopherol (γ-TPH)], carotenoids, carbohydrate (CHO), fat, and protein. Milk vitamin B-1 [thiamin, thiamin monophosphate (TMP), thiamin pyrophosphate (TPP)] was previously assessed for fortification effects. Milk nutrient concentrations were compared with the Adequate Intake (AI) values for infants aged 0-6 mo. Pearson correlation was used to examine internutrient associations after excluding nutrients affected by fortification. RESULTS: Fortification increased thiamin and B-1 and decreased γ-TPH. Less than 40% of milk samples met the AIs for all vitamins, and 10 samples did not reach any AI values for the analyzed nutrients. CHO, fat, and energy values were met in 1.5-11.8%, and protein in 48.5%, of the samples. Whereas fat, protein, and energy were related (all r < 0.5; P < 0.001) and associated with FSVs and WSVs, CHO correlated only with some WSVs. TPP was not correlated with B-1 vitamers, but with other WSVs (r = 0.28-0.58; P < 0.019). All FSVs, except α-carotene, were correlated with each other (r = 0.42-0.98; P < 0.002). TPP, FAD, B-2, and B-3 were associated with almost all FSVs (r = 0.24-0.63; P < 0.044). CONCLUSIONS: Cambodian women might not provide sufficient nutrients to their exclusively breastfeeding infants. Besides thiamin, all other vitamins measured were much lower than the AI. There were many strong correlations among macronutrients and vitamins; the extent to which these are explained by maternal diet, milk volume, maternal physiology, or genetics requires additional exploration.

High confidence, yet poor knowledge of infant feeding recommendations among adults in Nova Scotia, Canada.

In Canada, adherence to the national 'Nutrition for Healthy Term Infants' recommendations of infant and young child feeding (IYCF; 0-24 months) is suboptimal. While maternal knowledge of IYCF is commonly assessed, that of the general public has rarely been explored. Our objective was to assess the knowledge of, and confidence in answers to, Canadian IYCF recommendations among a diverse sample of adults in Nova Scotia, Canada. Between March and May 2018, a self-administered questionnaire examining IYCF knowledge, self-rated confidence, and sociodemographic information was conducted among Nova Scotians (≥19 years) in public locations. We surveyed 229 adults; 60% (n=134) were women. Mean (95% CI) age was 44 (41,46) years, 73% self-identified as white, 77% were born in Canada, and 69% were parents. Knowledge deficits were: age to terminate breastfeeding (18.3 (16.7,19.9) months; recommendation: ≥24 months), age to introduce solids (9.2 (8.2,10.2) months; recommendation: 6 months), vitamin D supplementation (10% correct), and optimal complementary foods (only 37% indicated iron-rich foods). Correct IYCF knowledge was lower among men, non-parents, young adults (19-29 years) and low-income adults (<$50,000/year). Mean self-rated confidence (out of 10) was high (7.2 (6.9,7.5)), and not different (p>0.05) between correct and incorrect responses for: best food for a newborn, age to terminate any breastfeeding, and age to start family meal foods. We found low knowledge of IYCF guidelines, yet high confidence in responses regardless of accuracy, among adults in Nova Scotia. General public knowledge deficits may contribute to an unsupportive culture around IYCF practices and low adherence to current recommendations.

Exploring Breastfeeding Knowledge and Attitudes among Noncaregivers: A Narrative Review.

Exclusive breastfeeding to 6 months with continued breastfeeding up to 2 years and beyond are well-established infant feeding recommendations based on evidence that breastfeeding has unparalleled maternal and infant health benefits as well as environmental and economic benefits. As with many high-income countries, breastfeeding rates remain suboptimal with only a quarter of Canadian and European infants receiving breast milk exclusively for the first 6 months. Breastfeeding promotion efforts have largely targeted caregivers in the prenatal and postnatal period; however, breastfeeding outcomes have been shown to be associated with broader sociocultural factors. Noncaregivers play an influential role in infant feeding at both an individual level (e.g., cues and input from health care practitioners and caregivers' social networks; as future parents) as well as a broader population level (sociocultural norms and policy decisions). This paper outlines recent research on breastfeeding knowledge and attitudes of noncaregivers by population subgroup. Positive correlations have been identified between breastfeeding attitudes, infant feeding knowledge, breastfeeding exposure, and breastfeeding intention among different subgroups; however, key knowledge gaps, lack of exposure to breastfeeding, and negative public perceptions of breastfeeding persist. Dietitians can advocate for breastfeeding promotion strategies that consider the role of noncaregivers to address sociocultural norms around breastfeeding.

In-Hospital Feeding Practices of Infants Born to Mothers With Gestational Diabetes Mellitus or Type 2 Diabetes Mellitus: Evaluating Policy Implementation Effectiveness.

OBJECTIVES: Women with diabetes in pregnancy may experience unique breastfeeding challenges. Few studies have examined the effectiveness of hospital policy to support breastfeeding in this patient population. This study aimed 1) to describe infant feeding practices of mother-infant pairs with gestational diabetes mellitus (GDM) or type 2 diabetes in pregnancy before and after introduction of an in-hospital policy and, 2) to compare feeding practices before and after policy introduction. METHODS: A retrospective chart audit of mother-infant pairs (n=120) was performed: 60 at 1 year before and 60 after policy introduction. The primary outcome was provision of breast milk at discharge; a chi-square test was completed to compare pre- and postpolicy groups. Secondary outcomes included participant and infant feeding characteristics. RESULTS: There was no significant difference in the number of infants receiving breast milk at discharge between pre- (58% [35 of 60]) and postpolicy (58% [35 of 60]) groups (p=0.64). The number of infants receiving breast milk exclusively throughout the hospital stay also did not differ by group (37% [22 of 60] before; and 43% [26 of 60] after; p=0.39). Information for each feed was infrequently recorded in charts for the method of feeding (34% [704 of 2,064]), infant state (96% [1,991 of 2,064]) and feeding description (96% [1,987 of 2,064]). CONCLUSIONS: This practice-based research has highlighted a need for continuation of this work, examining an in-hospital policy to support breastfeeding in those with GDM or type 2 diabetes in pregnancy. Initially, feedback could be collected from health-care providers to understand perceived facilitators and barriers to policy application and the use of job aids (e.g. record keeping tools).

Thiamine dose response in human milk with supplementation among lactating women in Cambodia: study protocol for a double-blind, four-parallel arm randomised controlled trial.

INTRODUCTION: Thiamine (vitamin B1) deficiency remains a concern in Cambodia where women with low thiamine intake produce thiamine-poor milk, putting their breastfed infants at risk of impaired cognitive development and potentially fatal infantile beriberi. Thiamine fortification of salt is a potentially low-cost, passive means of combating thiamine deficiency; however, both the dose of thiamine required to optimise milk thiamine concentrations as well as usual salt intake of lactating women are unknown. METHODS AND ANALYSIS: In this community-based randomised controlled trial, 320 lactating women from Kampong Thom, Cambodia will be randomised to one of four groups to consume one capsule daily containing 0, 1.2, 2.4 or 10 mg thiamine as thiamine hydrochloride, between 2 and 24 weeks postnatal. The primary objective is to estimate the dose where additional maternal intake of thiamine no longer meaningfully increases infant thiamine diphosphate concentrations 24 weeks postnatally. At 2, 12 and 24 weeks, we will collect sociodemographic, nutrition and health information, a battery of cognitive assessments, maternal (2 and 24 weeks) and infant (24 weeks only) venous blood samples (biomarkers: ThDP and transketolase activity) and human milk samples (also at 4 weeks; biomarker: milk thiamine concentrations). All participants and their families will consume study-provided salt ad libitum throughout the trial, and we will measure salt disappearance each fortnight. Repeat weighed salt intakes and urinary sodium concentrations will be measured among a subset of 100 participants. Parameters of Emax dose-response curves will be estimated using non-linear least squares models with both 'intention to treat' and a secondary 'per-protocol' (capsule compliance ≥80%) analyses. ETHICS AND DISSEMINATION: Ethical approval was obtained in Cambodia (National Ethics Committee for Health Research 112/250NECHR), Canada (Mount Saint Vincent University Research Ethics Board 2017-141) and the USA (University of Oregon Institutional Review Board 07052018.008). Results will be shared with participants' communities, as well as relevant government and scientific stakeholders via presentations, academic manuscripts and consultations. TRIAL REGISTRATION NUMBER: NCT03616288.