The risk of infectious pathogens in breast-feeding, donated human milk and breast milk substitutes.

OBJECTIVE: This review collates the published reports that focus on microbial and viral illnesses that can be transmitted by breast milk, donor milk and powdered infant formula (PIF). In this context, we attempt to define a risk framework encompassing those hazards, exposure scenarios, vulnerability and protective factors. DESIGN: A literature search was performed for reported cases of morbidity and mortality associated with different infant feeding modes. SETTING: Exclusive breast-feeding is the recommended for infant feeding under 6 months, or failing that, provision of donated human milk. However, the use of PIF remains high despite its intrinsic and extrinsic risk of microbial contamination, as well as the potential for adverse physiological effects, including infant gut dysbiosis. RESULTS: Viable pathogen transmission via breast-feeding or donor milk (pasteurised and unpasteurised) is rare. However, transmission of HIV and human T-cell lymphotropic virus-1 is a concern for breast-feeding mothers, particularly for mothers undertaking a mixed feeding mode (PIF and breast-feeding). In PIF, intrinsic and extrinsic microbial contamination, such as Cronobacter and Salmonella, remain significant identifiable causes of infant morbidity and mortality. CONCLUSIONS: Disease transmission through breast-feeding or donor human milk is rare, most likely owing to its complex intrinsically protective composition of human milk and protection of the infant gut lining. Contamination of PIF and the morbidity associated with this is likely underappreciated in terms of community risk. A better system of safe donor milk sharing that also establishes security of supply for non-hospitalised healthy infants in need of breast milk would reduce the reliance on PIF.

When parents won't vaccinate their children: a qualitative investigation of australian primary care providers' experiences.

BACKGROUND: Increasingly, the experiences and perceptions of parents who decline vaccination are the subject of investigation. However, the experiences of clinicians who encounter these parents in the course of their work has received little academic attention to date. This study aimed to understand the challenges faced and strategies used when general practitioners and immunising nurses encounter parents who choose not to vaccinate their children. METHODS: Primary care providers were recruited from regions identified through the Australian Childhood Immunisation Register (ACIR) as having higher than national average rates of registered objection to childhood vaccination. Interviews began with an exploration of provider experiences with parents who accept, are hesitant towards, and who decline vaccination. Participants were asked specifically about how they addressed any difficulties they encountered in their interactions. Thematic analysis focused on encounters with parents - challenges and strategies. RESULTS: Twenty-six general practitioners (GPs), community and practice nurses (PNs) were interviewed across two regions in NSW, Australia. Providers' sense of professional identity as health advocates and experts became conflicted in their encounters with vaccine objecting parents. Providers were dissatisfied when such consultations resulted in a 'therapeutic roadblock' whereby provider-parent communication came to a standstill. There were mixed views about being asked to sign forms exempting parents from vaccinating their children. These ranged from a belief that completing the forms rewarded parents for non-conformity to seeing it as a positive opportunity for engagement. Three common strategies were employed by providers to navigate through these challenges; 1) to explore and inform, 2) to mobilise clinical rapport and 3) to adopt a general principle to first do no harm to the therapeutic relationship. CONCLUSIONS: Many healthcare providers find consultations with vaccine objecting parents challenging and some, particularly more experienced providers, employ successful strategies to address this. Primary care providers, especially those more junior, could benefit from additional communication guidance to better the outcome and increase the efficiency of their interactions with such parents.

Health and nutrition content claims on websites advertising infant formula available in Australia: A content analysis.

The use of health and nutrition content claims in infant formula advertising is restricted by many governments in response to WHO policies and WHA resolutions. The purpose of this study was to determine whether such prohibited claims could be observed in Australian websites that advertise infant formula products. A comprehensive internet search was conducted to identify websites that advertise infant formula available for purchase in Australia. Content analysis was used to identify prohibited claims. The coding frame was closely aligned with the provisions of the Australian and New Zealand Food Standard Code, which prohibits these claims. The outcome measures were the presence of health claims, nutrition content claims, or references to the nutritional content of human milk. Web pages advertising 25 unique infant formula products available for purchase in Australia were identified. Every advertisement (100%) contained at least one health claim. Eighteen (72%) also contained at least one nutrition content claim. Three web pages (12%) advertising brands associated with infant formula products referenced the nutritional content of human milk. All of these claims appear in spite of national regulations prohibiting them indicating a failure of monitoring and/or enforcement. Where countries have enacted instruments to prohibit health and other claims in infant formula advertising, the marketing of infant formula must be actively monitored to be effective.

Volume marker inaccuracies: A cross-sectional survey of infant feeding bottles.

A cross-sectional examination of the accuracy of volume markers on infant feeding bottles available for sale in Australia between December 2013 and February 2014 was carried out. Ninety-one bottles representing 28 different brands were examined. Eighty-eight bottles were hard sided. Volumes in these bottles were marked in a combination of milliliters and ounces. Thirty-six (41%) bottles claimed compliance with the European standard EN14350, five (6%) with non-existent Australian standards, and forty-seven (54%) bottles had no standard claim. Nineteen bottles (22%) had at least one measured marking outside the tolerance of EN14350. Bottles claiming compliance with EN14350 were not less likely to have inaccurate markings than those that made no claim. More expensive bottles did not have fewer inaccurate markings. Three bottles were disposable liner systems and had particularly large volume inaccuracies (up to 43% outside the marked volume). Inaccurate volume markers on infant feeding bottles are a previously neglected but potentially important source of error in the reconstitution of infant formula. Over-concentrated and under-concentrated infant formula can cause serious illness or malnutrition. Over-concentrated infant formula may contribute to obesity. Bottles with inaccurate volume markers are unfit for purpose; disposable liner bottles are particularly poor in this regard and should be prohibited from having volume markers on the bottle casing. To avoid individual or public harms, well-enforced standards are needed. Guidance for parents, carers, and health professionals is needed to ensure that infant formula is accurately reconstituted.

Lost in translation: a focus group study of parents' and adolescents' interpretations of underage drinking and parental supply.

BACKGROUND: Reductions in underage drinking will only come about from changes in the social and cultural environment. Despite decades of messages discouraging parental supply, parents perceive social norms supportive of allowing children to consume alcohol in 'safe' environments. METHODS: Twelve focus groups conducted in a regional community in NSW, Australia; four with parents of teenagers (n = 27; 70 % female) and eight with adolescents (n = 47; 55 % female). Participants were recruited using local media. Groups explored knowledge and attitudes and around alcohol consumption by, and parental supply of alcohol to, underage teenagers; and discussed materials from previous campaigns targeting adolescents and parents. RESULTS: Parents and adolescents perceived teen drinking to be a common behaviour within the community, but applied moral judgements to these behaviours. Younger adolescents expressed more negative views of teen drinkers and parents who supply alcohol than older adolescents. Adolescents and parents perceived those who 'provide alcohol' (other families) as bad parents, and those who 'teach responsible drinking' (themselves) as good people. Both groups expressed a preference for high-fear, victim-blaming messages that targeted 'those people' whose behaviours are problematic. CONCLUSIONS: In developing and testing interventions to address underage drinking, it is essential to ensure the target audience perceive themselves to be the target audience. If we do not have a shared understanding of underage 'drinking' and parental 'provision', such messages will continue to be perceived by parents who are trying to do the 'right' thing as targeting a different behaviour and tacitly supporting their decision to provide their children with alcohol.

The SHED-IT community trial: a randomized controlled trial of internet- and paper-based weight loss programs tailored for overweight and obese men.

BACKGROUND: There is limited evidence for effective obesity treatment programs that engage men. PURPOSE: This study evaluated the efficacy of two gender-tailored weight loss interventions for men, which required no face-to-face contact. METHODS: This was a three-arm, randomized controlled trial: (1) Resources (n = 54), gender-tailored weight loss materials (DVD, handbooks, pedometer, tape measure); (2) Online (n = 53), Resources materials plus study website and e-feedback; and (3) Wait-list control (n = 52). The interventions lasted 3 months and were grounded in Social Cognitive Theory. RESULTS: At 6 months, significantly greater weight loss was observed for the Online (-4.7 kg; 95 % CI -6.1, -3.2) and Resources (-3.7 kg; 95 % CI -4.9, -2.5) groups compared to the control (-0.5 kg; 95 % CI -1.4, 0.4). Additionally, both intervention groups significantly improved body mass index, percent body fat, waist circumference, blood pressure, physical activity, quality of life, alcohol risk, and portion size, compared to controls. CONCLUSIONS: Men achieved significant weight loss after receiving novel, minimal-contact, gender-tailored programs, which were designed for widespread dissemination.

It's not the contents, it's the container: Australian parents' awareness and acceptance of infant and young child feeding recommendations.

Adherence to public health recommendations around infant and young child feeding is poor amongst Australian parents. This study aimed to investigate Australian parents' awareness and acceptance of public health recommendations about infant feeding. A cross-sectional design was used to survey a convenience sample of Australian parents. A total of 439 surveys were collected by intercept over 2 days from parents of children less than 5 years old, including those expecting a first baby, at the Pregnancy, Babies and Children (PBC) Expo held in Sydney in May 2008. Only 58.3% were aware of the WHO and NHMRC recommendation of 6 months exclusive breastfeeding. Fewer than 70% of respondents indicated that they thought breastfeeding should continue to 12 months or later, in accordance with the NHMRC guidelines, and only 12.3% thought breastfeeding should continue to 24 months or later, in accordance with WHO recommendations. This research suggests that awareness and acceptance of infant feeding recommendations in Australia is poor.

Relax, you're soaking in it: sources of information about infant formula.

Although the advertising of infant and follow-on formula products in Australia is prohibited by the Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement (1992), toddler milk is advertised without restriction. Recent research suggests that Australian mothers perceive advertisements for toddler milk to also be advertisements for infant formula. Furthermore, they tend to accept the messages they encounter in these advertisements uncritically. This study used established qualitative market research strategies to investigate what mothers, and those who influence mothers, know about formula milk products. This included exploration of commonly used sources of information, how toddler milk advertisements are interpreted and how the claims made in these advertisements are evaluated. Eight interviews were conducted: two individual interviews (involving a General Practitioner and a Community Dietitian) and six discussion groups (two groups of two mothers, two groups of two grandmothers, one group of two child and family health nurses and one group of five Child and Family Health Nurses). The results suggest that mothers seek advice about formula milk products from health professionals, their friends and their own mothers. The responses also suggest that all of these groups understand toddler milk advertisements to be advertising formula milk products and tend to rely on the messages contained in them to inform their decisions or advice about infant feeding products. It may therefore be difficult for mothers to access independent information upon which to base their decisions about infant feeding products. Further research is needed on whether sufficient independent information about infant feeding products is available to health professionals and mothers.

The SHED-IT community trial study protocol: a randomised controlled trial of weight loss programs for overweight and obese men.

BACKGROUND: Obesity is a major cause of preventable death in Australia with prevalence increasing at an alarming rate. Of particular concern is that approximately 68% of men are overweight/obese, yet are notoriously difficult to engage in weight loss programs, despite being more susceptible than women to adverse weight-related outcomes. There is a need to develop and evaluate obesity treatment programs that target and appeal to men. The primary aim of this study is to evaluate the efficacy of two relatively low intensity weight loss programs developed specifically for men. METHODS AND DESIGN: The study design is an assessor blinded, parallel-group randomised controlled trial that recruited 159 overweight and obese men in Newcastle, Australia. Inclusion criteria included: BMI 25-40 (kg/m2); no participation in other weight loss programs during the study; pass a health-screening questionnaire and pre-exercise risk assessment; available for assessment sessions; access to a computer with e-mail and Internet facilities; and own a mobile phone. Men were recruited to the SHED-IT (Self-Help, Exercise and Diet using Internet Technology) study via the media and emails sent to male dominated workplaces. Men were stratified by BMI category (overweight, obese class I, obese class II) and randomised to one of three groups: (1) SHED-IT Resources - provision of materials (DVD, handbooks, pedometer, tape measure) with embedded behaviour change strategies to support weight loss; (2) SHED-IT Online - same materials as SHED-IT Resources plus access to and instruction on how to use the study website; (3) Wait-list Control. The intervention programs are three months long with outcome measures taken by assessors blinded to group allocation at baseline, and 3- and 6-months post baseline. Outcome measures include: weight (primary outcome), % body fat, waist circumference, blood pressure, resting heart rate, objectively measured physical activity, self-reported dietary intake, sedentary behaviour, physical activity and dietary cognitions, sleepiness, quality of life, and perceived sexual health. Generalised linear mixed models will be used to assess all outcomes for the impact of group (Resources, Online, and Control), time (treated as categorical with levels baseline, 3-months and 6-months) and the group-by-time interaction. These three terms will form the base model. 'Intention-to-treat' analysis will include all randomised participants. DISCUSSION: Our study will compare evidence-based and theoretically driven, low cost and easily disseminated strategies specifically targeting weight loss in men. The SHED-IT community trial will provide evidence to inform development and dissemination of sustainable strategies to reduce obesity in men. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12610000699066).

It's all formula to me: women's understandings of toddler milk ads.

This study utilised semi-structured interviews to investigate how women expecting a first baby perceived print advertisements for 'toddler milks' in order to determine whether they function as indirect advertising for infant and follow-on formula. Examination of the marketing literature, analysis of the advertisers' websites and the advertisements themselves provided sources of triangulation. Fifteen women expecting a first baby were recruited from antenatal classes conducted by staff of the Northern Sydney Central Coast Area Health Service. These respondents clearly understood toddler milk advertisements to be promoting a range of products that included infant and follow-on formula and accepted their claims quite uncritically These claims contradicted public health messages about breastfeeding and the evidence of health risks associated with formula feeding. Toddler milk advertisements appear to function as indirect advertising for infant and follow-on formula. The Marketing in Australia of Infant Formula: Manufacturers' and Importers' Agreement is failing to protect the Australian community from the advertising of breastmilk substitutes as required by World Health Assembly Resolution 33.47, the International Code of Marketing of Breastmilk Substitutes. Further research is recommended to determine whether the responses of this group of primiparous women from a single area in NSW are representative of the wider population of Australian mothers.

Underpinning of the sharing knowledge about immunisation (SKAI) communication approach: A qualitative study using recorded observations.

OBJECTIVE: To refine communication strategies to assist clinician conversations with vaccine hesitant and declining parents as part of the Sharing Knowledge About Immunisation (SKAI) package. METHODS: We recorded and analysed consultations held in two Specialist Immunisation Clinics in tertiary hospitals in Australia between consenting clinicians and parents. We undertook content analysis that was both iterative and informed by the Calgary Cambridge Model of health communication and motivational interviewing. RESULTS: We found common strengths and opportunities in clinician's communication styles. Strengths included: rapport building; communicating care for both the parent and child; exhibiting depth of vaccination-specific communication skill and content knowledge. Opportunities for strengthening communication practices included: eliciting parents' concerns to saturation early in the consultation; structuring the consultation to prioritise and address parents' concerns; recognising and responding to parents' motivation to vaccinate; effectively closing consultations. CONCLUSION: This study has synthesised clinical communication strategies from expert vaccination communicators using well-established communication frameworks to advance a unique approach to the challenging task of addressing vaccine hesitancy and refusal. PRACTICE IMPLICATIONS: The clinic observations helped us to create a structured consultation guide that can enhance and provide greater structure to a clinician's existing communication skills.

Sharing knowledge about immunisation (SKAI): An exploration of parents' communication needs to inform development of a clinical communication support intervention.

INTRODUCTION: The SKAI (Sharing Knowledge About Immunisation) project aims to develop effective communication tools to support primary health care providers' consultations with parents who may be hesitant about vaccinating their children. AIM: This study explored parents' communication needs using a qualitative design. METHODS: Parents of at least one child less than five years old were recruited from two major cities and a regional town known for high prevalence of vaccine objection. Focus groups of parents who held similar vaccination attitudes and intentions were convened to discuss experiences of vaccination consultations and explore their communication needs, including preferences. Draft written communication support tools were used to stimulate discussion and gauge acceptability of the tools. RESULTS: Important differences in communication needs between group types emerged. The least hesitant parent groups reported feeling reassured upon reading resources designed to address commonly observed concerns about vaccination. As hesitancy of the group members increased, so did their accounts of the volume and detail of information they required. Trust appeared to be related to apparent or perceived transparency. More hesitant groups displayed increased sensitivity and resistance to persuasive language forms.

Why (not) alcohol energy drinks? A qualitative study with Australian university students.

INTRODUCTION AND AIMS: Alcohol energy drinks (AEDs) are a recent entry to the ready-to-drink market, but there is an absence of research into the reasons young people consume these products and their consumption-related experiences. The aim of the current study was to investigate university students' perceptions of, and experiences with, pre-mixed AEDs. DESIGN AND METHODS: Four focus groups with undergraduate university students in a large regional city in New South Wales; with transcripts coded for key themes. RESULTS: Participants reported a number of benefits of AED consumption, many of which were similar to other ready-to-drinks, such as taste and image. However, the primary benefits of AEDs related to their capacity to wake the drinker up at the beginning of the evening and facilitate partying and drinking over a longer period. Many of the participants reported experiencing or observing negative effects from drinking AEDs, some quite severe, but this did not appear to act as a deterrent to their consumption. DISCUSSION AND CONCLUSIONS: Given the popularity and perceived benefits of AEDs-and evidence from previous research that their consumption is associated with increases in intoxication levels, risky behaviours and harmful alcohol-related consequences-there is a need to consider a range of strategies to reduce harmful consumption of AEDs. While educational interventions may be of benefit, there is also a role for regulation of the packaging and marketing of a product that is associated with substantial harms.

Circumventing the WHO Code? An observational study.

BACKGROUND: This study compares the formula milk advertisements that appeared in parenting magazines published in two countries that have enacted measures to restrict the advertising of infant formula products in response to the international code with two that have not. METHODS: Content analysis was used to compare the type and frequency of formula milk advertisements that appeared in parenting magazines collected from the USA, Canada, the UK and Australia during 2007, and to examine whether there was a relationship between these frequencies and advertising regulations. FINDINGS: Advertisements that promoted formula products or brands occurred in all of the magazines sampled but the type of product advertised differed. Follow-on formula advertisements occurred more frequently in titles from the UK, where infant formula advertising is prohibited (RR 3.82, 95% CI 2.65 to 5.50, p<0.0001) than they did in titles from the USA/Canada where infant and/or follow-on formula advertising is permitted. Toddler milk advertisements appeared more frequently in titles from Australia, where infant and follow-on formula advertising is prohibited, than they did in titles from countries where direct-to-consumer infant and/or follow-on formula advertising is permitted. Rate ratios were as follows: UK only 0.03 (95% CI 0.01 to 0.11, p<0.0001); USA/Canada only 0.02 (95% CI 0.01 to 0.06, p<0.0001). INTERPRETATION: Bans on the advertising of infant formula products do not prevent companies from advertising (follow-on or toddler formula). These products are presented in ways that encourage consumers to associate the claims made in them with a group of products (a product line) that includes infant formula.

Emergency preparedness for those who care for infants in developed country contexts.

Emergency management organisations recognise the vulnerability of infants in emergencies, even in developed countries. However, thus far, those who care for infants have not been provided with detailed information on what emergency preparedness entails. Emergency management authorities should provide those who care for infants with accurate and detailed information on the supplies necessary to care for them in an emergency, distinguishing between the needs of breastfed infants and the needs of formula fed infants. Those who care for formula fed infants should be provided with detailed information on the supplies necessary for an emergency preparedness kit and with information on how to prepare formula feeds in an emergency. An emergency preparedness kit for exclusively breastfed infants should include 100 nappies and 200 nappy wipes. The contents of an emergency preparedness for formula fed infants will vary depending upon whether ready-to-use liquid infant formula or powdered infant formula is used. If ready-to-use liquid infant formula is used, an emergency kit should include: 56 serves of ready-to-use liquid infant formula, 84 L water, storage container, metal knife, small bowl, 56 feeding bottles and teats/cups, 56 zip-lock plastic bags, 220 paper towels, detergent, 120 antiseptic wipes, 100 nappies and 200 nappy wipes. If powdered infant formula is used, an emergency preparedness kit should include: two 900 g tins powdered infant formula, 170 L drinking water, storage container, large cooking pot with lid, kettle, gas stove, box of matches/lighter, 14 kg liquid petroleum gas, measuring container, metal knife, metal tongs, feeding cup, 300 large sheets paper towel, detergent, 100 nappies and 200 nappy wipes. Great care with regards hygiene should be taken in the preparation of formula feeds. Child protection organisations should ensure that foster carers responsible for infants have the resources necessary to formula feed in the event of an emergency. Exclusive and continued breastfeeding should be promoted as an emergency preparedness activity by emergency management organisations as well as health authorities. The greater the proportion of infants exclusively breastfed when an emergency occurs, the more resilient the community, and the easier it will be to provide effective aid to the caregivers of formula fed infants.

Breast is no longer best: promoting normal infant feeding.

The recent release of new growth charts by the World Health Organization (WHO) heralds a fresh understanding of what constitutes normal infant growth and development. The Multicenter Growth Reference Study that underpins these new growth standards 'establish[es] breastfed infants as the normative model for growth and development'. This is in contrast to past practice, which treated breastfeeding as the optimal, rather than the normal, way to feed babies. This idealization of breastfeeding has been counterproductive, because it has reinforced a perception that formula feeding is the standard way of feeding babies. It is, therefore, suggested that breastfeeding promotion and education programmes should abandon the 'breast is best' message in favour of messages that normalize breastfeeding, and that future research ought to use infants breastfed according to WHO recommendations as the norm reference or control group in every instance.