Effects of Breastfeeding Promotion Intervention and Dietary Treatment in Postpartum Women with Overweight and Obesity: Results from a Randomized Controlled Trial on Weight and Cardiometabolic Risk Factors.

BACKGROUND: Childbearing increases the risk of weight gain and cardiometabolic disease. The reset hypothesis suggests that lactation has protective cardiometabolic effects on the mother. The hypothesis is based on observational studies, and the possible interacting role of weight loss needs to be elucidated. OBJECTIVES: This study aimed to examine the individual and interaction effects of a breastfeeding promotion intervention (BPI) and dietary intervention for weight loss postpartum (Diet) on body weight and cardiometabolic risk factors at 6 mo postpartum. METHODS: Pregnant women (n = 156) with a prepregnancy BMI of 25 to 35 kg/m2 were randomized to 4 groups in a 2 × 2 factorial design: BPI, Diet, both treatments, or no treatment. BPI consisted of individual counseling by a lactation consultant during pregnancy, at childbirth, and monthly thereafter or more frequently based on individual needs. Diet was initiated at 11 wk postpartum. Body weight, body composition, waist and hip circumferences, markers of lipid and glucose metabolism, and blood pressure were measured at 2 wk and 6 mo postpartum.We analyzed main and interaction effects using 2-way analysis of covariance adjusted for baseline values. RESULTS: Among the participants attending both visits (n = 108), 99% practiced any breastfeeding at baseline and 97% at follow-up. The BPI did not affect rates of exclusive or partial breastfeeding, age at introduction of complementary foods, or have main effects on body weight or cardiometabolic risk factors. There was a main effect of Diet reducing body weight, fat mass, fat-free mass, percentage fat mass, waist and hip circumferences, fasting glucose, and insulin (all P ≤ 0.03), with no interactions between the treatments. CONCLUSIONS: There were no effects of BPI on body weight or cardiometabolic risk factors at 6 mo postpartum. Diet caused weight loss and had favorable effects on risk factors for cardiovascular disease and type 2 diabetes. This study was registered at clinicaltrials.gov as NCT03580057.

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.

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.

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.

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.

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.

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.

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.

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 (ß = 0.345, P = 0.010) and potentiated (ß = 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.

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.

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.

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.

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.

"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.

Obese women experience multiple challenges with breastfeeding that are either unique or exacerbated by their obesity: discoveries from a longitudinal, qualitative study.

Obese women are at risk for shorter breastfeeding duration, but little is known about how obese women experience breastfeeding. The aim of this study was to understand obese women's breastfeeding experiences. We enrolled pregnant women in upstate New York, who were either obese [n = 13; body mass index (BMI) ≥30 kg/m2 ] or normal weight (n = 9; BMI 18.5-24.9 kg/m2 ) before conception and intended to breastfeed. A longitudinal, qualitative study was conducted from February 2013 through August 2014 with semi-structured interviews during pregnancy and at specific times post-partum through 3 months. Interviews were audio recorded, transcribed and analyzed using content analysis. Themes that emerged in analysis were compared between obese and normal-weight women. Differences were identified and described. Prenatally, obese women expressed less confidence about breastfeeding than normal-weight women. Post-partum, obese women and their infants had more health issues that affected breastfeeding, such as low infant blood glucose. Compared with normal-weight women, they also experienced more challenges with latching and positioning their infants. Breastfeeding required more time, props and pillows, which limited where obese women could breastfeed. Obese women also experienced more difficulty finding nursing bras and required more tangible social support than normal-weight women. In conclusion, obese women experienced more challenges than women of normal weight; some challenges were similar to those of normal-weight women but were experienced to a greater degree or a longer duration. Other challenges were unique. Obese women could benefit from targeted care prenatally and during the hospital stay as well as continued support post-partum to improve breastfeeding outcomes. © 2016 John Wiley & Sons Ltd.

"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.

Early Breastfeeding Problems Mediate the Negative Association between Maternal Obesity and Exclusive Breastfeeding at 1 and 2 Months Postpartum.

BACKGROUND: Compared with normal-weight women, women with obesity experience poorer breastfeeding outcomes. Successful breastfeeding among women with obesity is important for achieving national breastfeeding goals. OBJECTIVES: The objectives were to determine whether the negative association between obesity and any or exclusive breastfeeding at 1 and 2 mo postpartum is mediated through breastfeeding problems that occur in the first 2 wk postpartum and if this association differs by parity. METHODS: Mothers (1151 normal-weight and 580 obese) in the Infant Feeding Practices Study II provided information on sociodemographic and psychosocial characteristics, body mass index, and breastfeeding outcomes. At 1 mo postpartum, participants reported the breastfeeding problems they experienced in the first 2 wk postpartum from a predefined list of 17 options. We used factor analysis to condense these problems into 4 explanatory variables; continuous factor scores were computed for use in further analyses. We used maximum likelihood logistic regression to assess mediation of the association between obesity and breastfeeding outcomes through early breastfeeding problems. RESULTS: No significant effect of obesity was found on any breastfeeding at 1 or 2 mo. At 1 mo postpartum, for both primiparous and multiparous women, there was a significant direct effect of obesity on exclusive breastfeeding and a significant indirect effect of obesity through early breastfeeding problems related to the explanatory mediating variable "Insufficient Milk" (throughout the remainder of the Abstract, this factor will be denoted by upper case notation). At 2 mo postpartum both the direct effect of obesity and the indirect effect through Insufficient Milk were significant in primiparous women but only the indirect effect remained significant in multiparous women. CONCLUSIONS: Early problems related to Insufficient Milk may partially explain the association between obesity and poor exclusive breastfeeding outcomes. Women who are obese, particularly those reporting breastfeeding problems that grouped in the Insufficient Milk factor in the early postpartum period, may benefit from additional breastfeeding support.

Maternal pre-pregnancy body mass index is not associated with infant and young child feeding in low-income Mexican children 1-24 months old.

Pre-pregnancy overweight and obesity is associated with shorter breastfeeding (BF) duration. Whether pre-pregnancy overweight and obesity is associated with other aspects of infant and young child feeding (IYCF) has not been investigated. We used data from 370 children born January 1999-September 2001 in a semi-urban community in Morelos, Mexico, where information on how they were fed was available at 1, 3, 6, 9, 12, 18 and 24 months of age. We modified the World Health Organization's dietary diversity indicator to assess the quality of the complementary foods. An index that included BF, quality of complementary foods and other behaviours was constructed to measure IYCF. We used survival analysis to examine the association of pre-pregnancy body mass index (pBMI) category and BF duration and mixed models for quality of complementary food and IYCF index. Mean maternal pBMI was 24.4 ± 4.1; 31% were overweight, and 9% were obese. pBMI was not associated with BF duration. Quality of complementary food improved over time (6 months, 1.3 ± 1.3; 24 months, 3.8 ± 1.04). Compared with normal-weight women, overweight and obese women were more likely to feed from more food groups (0.24 ± 0.11 point, P=0.03), but this did not improve diet diversity from 6 to 24 months. IYCF index decreased throughout follow-up (1 month, 7.8 ± 2.4; 24 months, 5.5 ± 1.8), and pBMI was not associated with IYCF (-0.11 ± 0.13 point, P=0.4). We conclude that heavier women were not engaging in IYCF behaviours that were distinct from those of normal-weight women from 1 to 24 months post-partum.

Environmental exposure to metals and children's growth to age 5 years: a prospective cohort study.

In this prospective cohort study, based on 1,505 mother-infant pairs in rural Bangladesh, we evaluated the associations between early-life exposure to arsenic, cadmium, and lead, assessed via concentrations in maternal and child urine, and children's weights and heights up to age 5 years, during the period 2001-2009. Concurrent and prenatal exposures were evaluated using linear regression analysis, while longitudinal exposure was assessed using mixed-effects linear regression. An inverse association was found between children's weight and height, age-adjusted z scores, and growth velocity at age 5 years and concurrent exposure to cadmium and arsenic. In the longitudinal analysis, multivariable-adjusted attributable differences in children's weight at age 5 years were -0.33 kg (95% confidence interval (CI): -0.60, -0.06) for high (≥95th percentile) arsenic exposure and -0.57 kg (95% CI: -0.88, -0.26) for high cadmium exposure, in comparison with children with the lowest exposure (≤5th percentile). Multivariable-adjusted attributable differences in height were -0.50 cm (95% CI: -1.20, 0.21) for high arsenic exposure and -1.6 cm (95% CI: -2.4, -0.77) for high cadmium exposure. The associations were apparent primarily among girls. The negative effects on children's growth at age 5 years attributable to arsenic and cadmium were of similar magnitude to the difference between girls and boys in terms of weight (-0.67 kg, 95% CI: -0.82, -0.53) and height (-1.3 cm, 95% CI: -1.7, -0.89).

Obesity and early cessation of breastfeeding in Denmark.

BACKGROUND: Obesity is associated with early cessation of breastfeeding. Breastfeeding is multi-factorial, and several factors contribute to this association. Our aim was to investigate to what extent socio-demographic and psychosocial characteristics, parity and prenatal conditions could explain the association between high BMI and early cessation of breastfeeding. METHODS: We used data from a randomized trial of 1597 Danish mothers of singleton infants. Self-reported maternal postnatal weight and height were available from 1375 (86%). High BMI was defined as body mass index ≥ 32 kg/m(2) at ~17 days after delivery. Outcome was cessation of exclusive breastfeeding by 17 weeks post-partum used in proportional hazards regression models. RESULTS: In the unadjusted analysis, mothers with high post-partum BMI compared with other mothers had a significantly higher rate of cessation of exclusive breastfeeding, and were more frequently characterized by socio-demographic, psychosocial, perinatal and behavioural factors known to increase the risk of early breastfeeding cessation. In the adjusted analyses (n = 1226), the association between BMI and duration of exclusive breastfeeding depended on parity (P = 0.03). Among primiparae, high BMI was associated with nearly double the risk of early cessation of exclusive breastfeeding (HR = 1.74, 95% CI 1.21-2.50). Among multiparae, the association disappeared when adjusted for socio-demographic factors and previous breastfeeding experience (HR = 0.89, 95% CI 0.62-1.28). CONCLUSION: Parity and previous breastfeeding experience are important factors to include when studying the association between BMI and breastfeeding duration. Intervention to extend the duration of lactation among obese mothers should focus on those with no or little previous breastfeeding experience.