Setting research priorities on multiple micronutrient supplementation in pregnancy.

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

"What Is 'Enough,' and How Do I Make It?": A Qualitative Examination of Questions Mothers Ask on Social Media About Pumping and Providing an Adequate Amount of Milk for Their Infants.

BACKGROUND: Mothers commonly cite an inadequate milk "supply" as a reason for stopping human milk feeding. Further, pumping may affect mothers' understanding of their milk production. We aimed to characterize the questions mothers ask each other online related to the adequacy of the milk they pumped and provided to their infants. MATERIALS AND METHODS: We conducted a secondary analysis of 543 posts containing questions related to pumping on an online discussion forum. These posts were provided by an open cohort of ∼25,000 women between 1 month before due date and 4.5 months postpartum. We used thematic analysis with Atlas.ti to analyze the posts. RESULTS: Mothers commonly asked how many ounces they should be pumping and inquired about strategies to increase their pump output. They also wondered how many ounces or bottles of pumped milk they should provide to their infants or store for future use. Finally, mothers reported the inadequacy of the milk they were pumping or providing to their infants as potential reasons for stopping human milk feeding. CONCLUSION: Our findings suggest that mothers may benefit from additional guidance from health care providers on the limitations of using pumps to draw conclusions about their milk production, the current evidence related to the use of herbal galactagogues, and the importance of responsive infant feeding. These findings also highlight the need for future research into how pumping or using herbal galactagogues may affect mothers' actual or perceived milk production and how styles for providing pumped milk compare to styles for feeding directly at the breast.

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.

New Opportunities for Breastfeeding Promotion and Support in WIC: Review of WIC Food Packages, Improving Balance and Choice.

Although breastfeeding (BF) is the recommended way to feed infants, this may be difficult for the low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The 2017 recommended revisions to the WIC food packages provide substantial support to both exclusively and partially BF dyads, remove barriers to partial BF choices within the first 30 days postpartum, and increase flexibility in determining the amount of formula offered to partially breastfed infants. When combined with adequate support and tailored counseling, these changes are intended to make it easier for women served by WIC to choose to breastfeed.

"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.

Pumping human milk in the early postpartum period: its impact on long-term practices for feeding at the breast and exclusively feeding human milk in a longitudinal survey cohort.

BACKGROUND: Most American mothers who feed human milk (HM) now use pumps to produce some of the HM they feed. Pumping is nationally recommended, but associations between pumping and HM-feeding durations are unknown. OBJECTIVES: We examined whether and how the pumping frequency and types of reasons for pumping between 1.5 and 4.5 mo postpartum are associated with HM-feeding durations. We classified pumping reasons as nonelective [e.g., because of a difficulty feeding at the breast (FAB)] or elective (e.g., to produce HM to mix with solids). We hypothesized that women who pumped more frequently or nonelectively would have shorter HM-feeding durations. DESIGN: We used data from 1116 mothers in a longitudinal cohort who fed and pumped HM 1.5-4.5 mo postpartum. We used χ(2) and Cox proportional hazards regression models to examine the survival of any HM feeding, exclusive HM feeding, and FAB. RESULTS: Compared with mothers who pumped for elective reasons, mothers who reported one nonelective reason had greater hazards of stopping feeding any HM (HR: 1.12; 95% CI: 1.05, 1.21) or exclusive HM (HR: 1.14; 95% CI: 1.09, 1.20) and of stopping FAB (HR: 2.07; 95% CI: 1.77, 2.42). Mothers who pumped most frequently had the highest mean hazards of stopping feeding any HM (HR: 1.82; 95% CI: 1.68, 1.93) and feeding exclusive HM (HR: 1.21; 95% CI: 1.14, 1.26). Hazards of stopping FAB varied across the year. Compared with the least-frequent pumpers, the most-frequent pumpers had a 2.6-fold higher hazard of stopping FAB at 3 mo postpartum and a 1.7-fold higher hazard at 6 mo postpartum. CONCLUSIONS: Nonelective pumping reasons and higher pumping frequency were associated with shorter HM-feeding durations. Mothers who report that they use a breast pump for reasons related to either employment or FAB difficulty and their infants may be more vulnerable to risks associated with a shorter HM-feeding duration.

Discontinuity of Breastfeeding Care: "There's No Captain of the Ship".

BACKGROUND: Breastfeeding rates in the United States are suboptimal. Health professionals (HPs) have a unique opportunity to support breastfeeding because of the frequency and timing of their visits with mothers and infants as well as their call by professional organizations to do so. The objective of this study was to understand HPs' perceived roles and experiences with providing breastfeeding-related care. MATERIALS AND METHODS: In-depth qualitative interviews were conducted with 34 HPs (obstetricians, midwives, pediatricians, nurses, and lactation consultants) who care for pregnant or lactating women. Interviews were audio-recorded, transcribed, and verified for accuracy; content analysis was used to identify themes using a grounded theory approach. RESULTS: The overarching theme was discontinuity in breastfeeding care across the continuum. Most HPs relied on other HPs to provide breastfeeding care, which resulted from and contributed to problematic gaps in care that were reported. A minority of HPs attempted to bridge gaps in breastfeeding care or improve continuity. Contributing to the discontinuity were a lack of time, lack of skills, inconsistent messages, and low communication across stages of care. HPs were unsure whether their help was effective and whether required follow-up was completed. CONCLUSIONS: Despite HPs' recognition of breastfeeding as the best choice for infant feeding, breastfeeding care may be disjointed and a barrier to achieving breastfeeding recommendations. These problems should be investigated and systemically addressed in future research so that maternal-infant dyad breastfeeding care can be improved.

Breastfeeding and health outcomes for the mother-infant dyad.

Worldwide, breastfeeding saves the lives of infants and reduces their disease burden. Breastfeeding also reduces the disease burden for mothers. This article examines who chooses to breastfeed and for how long in the United States. It also reviews the latest evidence about the consequences of breastfeeding for the health of the infant and mother. This review provides support for current national and international recommendations that support breastfeeding.

Setting research priorities to reduce global mortality from preterm birth and low birth weight by 2015.

AIM: This paper aims to identify health research priorities that could improve the rate of progress in reducing global neonatal mortality from preterm birth and low birth weight (PB/LBW), as set out in the UN's Millennium Development Goal 4. METHODS: We applied the Child Health and Nutrition Research Initiative (CHNRI) methodology for setting priorities in health research investments. In the process coordinated by the World Health Organization in 2007-2008, 21 researchers with interest in child, maternal and newborn health suggested 82 research ideas that spanned across the broad spectrum of epidemiological research, health policy and systems research, improvement of existing interventions and development of new interventions. The 82 research questions were then assessed for answerability, effectiveness, deliverability, maximum potential for mortality reduction and the effect on equity using the CHNRI method. RESULTS: The top 10 identified research priorities were dominated by health systems and policy research questions (eg, identification of LBW infants born at home within 24-48 hours of birth for additional care; approaches to improve quality of care of LBW infants in health facilities; identification of barriers to optimal home care practices including care seeking; and approaches to increase the use of antenatal corticosteriods in preterm labor and to improve access to hospital care for LBW infants). These were followed by priorities for improvement of the existing interventions (eg, early initiation of breastfeeding, including feeding mode and techniques for those unable to suckle directly from the breast; improved cord care, such as chlorhexidine application; and alternative methods to Kangaroo Mother Care (KMC) to keep LBW infants warm in community settings). The highest-ranked epidemiological question suggested improving criteria for identifying LBW infants who need to be cared for in a hospital. Among the new interventions, the greatest support was shown for the development of new simple and effective interventions for providing thermal care to LBW infants, if KMC is not acceptable to the mother. CONCLUSION: The context for this exercise was set within the MDG4, requiring an urgent and rapid progress in mortality reduction from low birth weight, rather than identifying long-term strategic solutions of the greatest potential. In a short-term context, the health policy and systems research to improve access and coverage by the existing interventions, coupled with further research to improve effectiveness, deliverability and acceptance of existing interventions, and epidemiological research to address the key gaps in knowledge, were all highlighted as research priorities.

Maternal, infant, and household factors are associated with breast-feeding trajectories during infants' first 6 months of life in Matlab, Bangladesh.

Women's breast-feeding patterns are complex, and existing definitions of breast-feeding behavior do not capture this complexity adequately. We used results from a prior qualitative study to define trajectories for feeding during the first half of infancy, and then examined household-, maternal-, and infant-level determinants of these trajectories using logistic regression analysis. The 1472 women in the study cohort lived in rural Bangladesh and were participants in the Maternal and Infant Nutrition Intervention in Matlab trial. The 3 infant feeding trajectories included women who fed only breast milk and water [full breast-feeding trajectory (FBT)]; offered mixed feeding continuously when their babies were 0-4 mo old [continuous mixed feeding trajectory (CMFT)]; and practiced any other type of breast-feeding [intermittent feeding trajectory (IFT)], which was the normative feeding behavior in this community. In adjusted regression models, women who lived in rural areas [odds ratio (OR), 2.1; 95% CI, 1.2, 3.4], came from the poorest households (OR, 3.4; 95% CI, 1.5, 7.7), and offered prelacteal (OR, 1.7; 95% CI, 1.0-2.7) were more likely to be in the FBT. Women from the richest households (OR, 1.6; 95% CI, 1.1, 2.6), employed mothers (OR, 1.7; 95% CI, 1.1, 2.6), and older mothers (OR, 1.02; 95% CI, 1.0, 1.1) were more likely to be in the CMFT, and women with higher birth-weight infants (OR, 0.6; 95% CI, 0.4-0.8) were less likely to be in the CMFT. Thus, these trajectories were associated with distinct groups of women and these results provide information useful for developing interventions to improve breast-feeding practices.

Predictors of improvement in hemoglobin concentration among toddlers enrolled in the Massachusetts WIC Program.

OBJECTIVE: Nutrition supplementation programs are generally targeted to those members of the population who are thought to be at risk of an undesirable outcome, but not all who participate in such programs respond to them. We sought to identify determinants of improvement in hemoglobin concentration among young children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN: We conducted an observational study using data from 9,930 children who were enrolled in the Massachusetts WIC program and had data available on their hemoglobin values at both 1 and 2 years of age. Predictors of change in hemoglobin concentration between these ages were studied using multivariate statistical modeling. RESULTS: Overall, hemoglobin concentrations increased from age 1 to 2 years in those who had been breastfed 25 or more weeks (P < .0001) and were female (P < .01), and decreased with increasing weight at 1 year of age (P < .001). The determinants of change in hemoglobin concentration differed from the determinants of hemoglobin concentration at age 1 year. CONCLUSIONS: The analytical approach used here could be extended to identify subgroups of WIC participants likely to improve in other outcomes. If current efforts to increase the duration of breastfeeding among WIC participants are successful, the importance of WIC in improving hemoglobin concentration among young children also will increase.

Risk factors for childbearing during adolescence in a population-based birth cohort in southern Brazil.

OBJECTIVE: To use a case-control study to analyze risk factors associated with teenage childbearing among adolescents who were in a birth cohort study that began in 1982 in the city of Pelotas, Rio Grande do Sul, Brazil. METHODS: Adolescent mothers in Pelotas who gave birth between January 1995 and March 2001 and who had been born in 1982 were identified through the local birth information system. These subjects from the 1982 birth cohort were compared to adolescents from the same cohort who had not given birth before March 2001. Standardized interviews were used in 2001 to obtain information about socioeconomic, maternal reproductive, demographic, and lifestyle characteristics. This information was combined with data obtained in earlier phases of this 1982 birth cohort study. Unconditional logistic regression was used to analyze the risk factors associated with childbearing during adolescence. RESULTS: A total of 420 parous adolescents from the 1982 birth cohort were identified and then compared with 408 cohort adolescents who had not given birth by March 2001. Higher family income in 1982 and more parental schooling in 1982 were inversely related to childbearing among the birth cohort adolescents. Cohort girls whose mothers were under age 20 when they gave birth in 1982 had a higher risk of becoming pregnant while still an adolescent. Cohort girls who, during childhood, lived with siblings from different fathers were twice as likely to become an adolescent mother. Compared to cohort adolescents who had not failed during the first four years of school, those girls who had done so had twice the risk of giving birth during adolescence. Among the cohort girls a positive association was found between younger age at first intercourse and childbearing in adolescence. CONCLUSIONS: The results indicate that the educational level of the adolescent mothers must be considered in planning policies that attempt to disrupt successive cycles of socioeconomic deprivation. Early interventions to improve sex education and to increase the motivation of young girls to achieve higher levels of education are needed. The interventions should aim for a reduction in the risk of long-term poverty and poorer educational achievements of teenage mothers and their children.

Risk factors for childbearing during adolescence in a population-based birth cohort in southern Brazil / Factores de riesgo asociados con ser madre adolescente en una cohorte de nacimiento tomada de la población en el sur del Brasil

OBJETIVO: Utilizar un estudio de casos y testigos para analizar los factores de riesgo asociados con ser madre adolescente en un grupo de jóvenes que participaron en un estudio de cohorte iniciado en 1982 en la ciudad de Pelotas, Rio Grande do Sul, Brasil. MÉTODOS: Por medio del sistema local de datos de natalidad, se identificó a todas las madres adolescentes en Pelotas que habían dado a luz entre enero de 1995 y marzo de 2001 y que habían nacido en 1982. Estas mujeres de la cohorte de 1982 se compararon con adolescentes de su misma cohorte que no habían dado a luz antes de marzo de 2001. En 2001 se aplicaron entrevistas estandarizadas para recoger información sobre las características socioeconómicas, reproductivas, demográficas y de estilo de vida de las mujeres. Dicha información se combinó con datos obtenidos en fases más tempranas del estudio de la cohorte de 1982. Se empleó un modelo de regresión logística incondicionada para analizar los factores de riesgo asociados con dar a luz durante la adolescencia. RESULTADOS: Un total de 420 adolescentes parturientas de la cohorte de 1982 fueron identificadas y comparadas con 408 adolescentes de la misma cohorte que no habían dado a luz antes de marzo de 2001. Se observó entre las adolescentes de la cohorte que tener un ingreso familiar más alto y padres con una mayor escolaridad se asociaban inversamente con dar a luz. Las jóvenes de la cohorte cuyas madres no habían cumplido los 20 años de edad cuando dieron a luz en 1982 mostraron un riesgo mayor de ser madres adolescentes. Las jóvenes de la cohorte que durante la niñez habían vivido con hermanos que eran hijos de distintos padres mostraron un riesgo doble de ser madres adolescentes. Cuando se compararon con adolescentes que no habían suspendido las clases en los primeros cuatro años de asistir a la escuela, las que sí las habían suspendido tuvieron el doble del riesgo de dar a luz durante la adolescencia. En las jóvenes pertenecientes a la cohorte el haber tenido la primera relación sexual a una edad más temprana se asoció directamente con dar a luz en la adolescencia. CONCLUSIONES: Los resultados del estudio...

Objective. To use a case-control study to analyze risk factors associated with teenage childbearing among adolescents who were in a birth cohort study that began in 1982 in the city of Pelotas, Rio Grande do Sul, Brazil. Methods. Adolescent mothers in Pelotas who gave birth between January 1995 and March 2001 and who had been born in 1982 were identified through the local birth information system.These subjects from the 1982 birth cohort were compared to adolescents from the same cohort who had not given birth before March 2001. Standardized interviews were used in 2001 to obtain information about socioeconomic, maternal reproductive, demographic, and lifestyle characteristics. This information was combined with data obtained in earlier phases of this 1982 birth cohort study. Unconditional logistic regression was used to analyze the risk factors associated with childbearing during adolescence. Results. A total of 420 parous adolescents from the 1982 birth cohort were identified and then compared with 408 cohort adolescents who had not given birth by March 2001. Higher family income in 1982 and more parental schooling in 1982 were inversely related to childbearing among the birth cohort adolescents. Cohort girls whose mothers were under age 20 when they gave birth in 1982 had a higher risk of becoming pregnant while still an adolescent. Cohort girls who, during childhood, lived with siblings from different fathers were twice as likely to become an adolescent mother. Compared to cohort adolescents who had not failed during the first four years of school, those girls who had done so had twice the risk of giving birth during adolescence. Among the cohort girls a positiveassociation was found between younger age at first intercourse and childbearing in adolescence. Conclusions. The results indicate that the educational level of the adolescent mothers must be considered in planning policies that attempt to disrupt successive cycles of socioeconomic deprivation. Early interventions to improve sex education and to increase the motivation of young girls to achieve higher levels of education are needed. The interventions should aim for a reduction in the risk of long-term poverty and poorer educational achievements of teenage mothers and their children

Community-based school feeding during Indonesia's economic crisis: implementation, benefits, and sustainability.

The Indonesian Government initiated a community-based national school-feeding program in 1996. Implementation was decentralized and involved multiple participants. In 1998 we evaluated the implementation of the program and the perceived benefits for community stakeholders using a survey of principals in 143 randomly selected schools and follow-up with in-depth interviews and observations in a subsample of 16 communities. The evaluation covered the period of the 1998 Asian economic crisis, affording the opportunity to assess its impact on the program. The program was implemented in all targeted schools, with excellent community participation. Feeding was sustained through the crisis, in spite of a dramatic escalation in food costs. The families of schoolchildren, farmers, and those who prepared food received economic benefits. The snacks replaced those sold at schools and were of better nutritional value. The children benefited because the snacks compensated for losses in the home diet resulting from the economic crisis. Characteristics of the program that may be important in explaining its success include the involvement of a range of community stakeholders, engagement with existing village administrative structures, scope for local community adaptation and innovation, and the use of local foods that dispersed benefits and ensured sustained implementation during the crisis.