Breast milk lead and cadmium levels from suburban areas of Ankara.

The objectives of this study were (1) to evaluate levels of lead (Pb) and cadmium (Cd) in the breast milk at 2 months postpartum, (2) to investigate the relationship between Pb and Cd levels in breast milk and some sociodemographic parameters and (3) to detect whether these levels have any influence on the infant's physical status or on postpartum depression in the mothers. Pb and Cd levels in breast milk were determined by Inductively Coupled Plasma Mass Spectroscopy (ICP-MS). The median breast milk concentrations of Pb and Cd were 20.59 and 0.67 µg/l, respectively. In 125 (87%) of 144 samples, Pb levels were higher than the limit in breast milk reported by the World Health Organization (WHO) (> 5 µg/l). Breast milk Cd levels were > 1 µg/l in 52 (36%) mothers. The mothers with a history of anemia at any time had higher breast milk Pb levels than those without a history of anemia (21.1 versus 17.9 µg/l; p=0.0052). The median breast milk Cd levels in active and passive smokers during pregnancy were significantly higher than in non-smokers (0.89, 0.00 µg/l, respectively; p=0.023). The breast milk Cd levels of the mothers who did not use iron and vitamin supplements for 2 months postpartum were found to be higher than in those who did use the supplements (iron: 0.73, 0.00 µg/l, p=0.023; vitamin: 0.78, 0.00 µg/l, p=0.004, respectively). Breast milk Cd levels at the 2nd month were correlated negatively with the z scores of head circumference and the weight for age at birth (r=-0.257, p=0.041 and r=-0.251, p=0.026, respectively) in girls. We found no correlation between the breast milk Pb and Cd levels and the Edinburgh Postpartum Depression Scale scores. Breast milk monitoring programs should be conducted that have tested considerable numbers of women over time in view of the high levels of Pb in breast milk in this study.

Maternal health behaviours during pregnancy in an Irish obstetric population and their associations with socio-demographic and infant characteristics.

BACKGROUND/OBJECTIVES: To examine the prevalence and combined occurrence of peri-conceptional folic acid (FA) supplement use, smoking and alcohol consumption during pregnancy in a sample of women in Dublin, and determine the factors associated with these health behaviours. SUBJECTS/METHODS: A prospective observational study (2004-2006) involving the recruitment of 491 pregnant women from antenatal clinics in a Dublin maternity hospital, with postpartum follow-up of 450 eligible mothers. Data on FA use, maternal smoking and alcohol consumption patterns during pregnancy were collected from the antenatal patient-administered questionnaire, which was completed by participants, and returned to the investigator on the day of recruitment. RESULTS: The median gestational age of women at recruitment was 36 weeks. A combined 24.2% of mothers commenced FA at the recommended time, avoided alcohol consumption and smoking during pregnancy. In all, 35.3% of mothers reported to consuming alcohol, 20.9% smoked during pregnancy and 44.4% commenced FA at the recommended time. Mothers <25 years were more likely to have not taken FA at the recommended time (adjusted odds ratio (aOR): 4.0, 95% confidence interval (CI): 1.64-9.77) and were more likely to have smoked during pregnancy (aOR: 3.56, 95% CI: 1.32-9.57). Irish nationality positively predicted both alcohol consumption (aOR: 4.37, 95% CI: 1.88-10.15) and smoking (aOR: 10.92, 95% CI: 1.35-87.98) during pregnancy. CONCLUSIONS: Educational efforts are still necessary to convince women of Irish nationality, in particular, of the adverse effects of smoking and alcohol consumption on fetal outcome. Women <25 years should be specifically targeted in smoking cessation and FA promotional campaigns.

Breast-feeding initiation time and neonatal mortality risk among newborns in South India.

OBJECTIVE: To examine the association between breast-feeding initiation time and neonatal mortality in India, where breast-feeding initiation varies widely from region to region. STUDY DESIGN: Data were collected as part of a community-based, randomized, placebo-controlled trial of the impact of vitamin A supplementation in rural villages of Tamil Nadu, India. Multivariate binomial regression analysis was used to estimate the association between neonatal mortality and breast-feeding initiation time (<12 h, 12 to 24 h, >24 h) among infants surviving a minimum of 48 h. RESULT: Among 10 464 newborns, 82.1% were first breast-fed before 12 h, 13.8% were breast-fed between 12 and 24 h, and 4.1% were breast-fed after 24 h. After adjusting for birth weight, gestational age and other covariates, late initiators (>24 h) were at ∼78% higher risk of death (relative risk=1.78 (95% confidence interval (CI)=1.03 to 3.10)). There was no difference in mortality risk when comparing babies fed in the first 12 h compared with the second 1 h after birth. CONCLUSION: Late (>24 h) initiation of breast-feeding is associated with a higher risk of neonatal mortality in Tamil Nadu. Emphasis on breast-feeding promotion programs in low-resource settings of India where early initiation is low could significantly reduce neonatal mortality.

Impact of flooding on feeding practices of infants and young children in Dhaka, Bangladesh Slums: what are the coping strategies?

Previous research has shown that urban slums are hostile environments for the growth of infants and young children (IYC). Flooding is a hazard commonly found in Dhaka slums (Bangladesh) which negatively impacts IYC's nutritional and health status. This paper aims 1) to identify the impact of flooding on IYC's feeding practices, and 2) to explore the coping strategies developed by caregivers. Qualitative data (participant observation and semi-structured interviews) and quantitative data (household questionnaire and anthropometric measurements) collected in slums in Dhaka (n=18 mothers, n=5 community health workers, and n=55 children) were analysed. The subjects of the interviews were mothers and Bangladesh Rural Advancement Committee (BRAC) community health workers living and working in the slums. Research findings showed that breastfeeding and complementary feeding practices for IYC were poor and inappropriate due to lack of knowledge, time, and resources in normal times and worse during flooding. One coping strategy developed by mothers purposely to protect their IYC's nutritional status was to decrease their personal food intake. Our research findings suggest that mothers perceived the negative impact of flooding on their IYC's nutritional health but did not have the means to prevent it. They could only maintain their health through coping strategies which had other negative consequences. The results suggests a holistic approach combining 1) provision of relief for nutritionally vulnerable groups during flooding, 2) support to mothers in their working role, 3) breastfeeding counseling and support to lactating mothers with difficulties, and 4) preventing malnutrition in under 2 year old children.

Breastfeeding support - the importance of self-efficacy for low-income women.

Breastfeeding is a key determinant in promoting public health and reducing health inequality. Low-income women have a significantly lower level of breastfeeding. Midwives in the UK have been encouraged to implement the World Health Organization/United Nations Children's Fund's Ten Steps to Successful Breastfeeding, but to date, there has been no evaluation of the impact of the training initiative on the breastfeeding behaviours of low-income women. As part of a wider study, this qualitative component was designed to answer the question - what are the views and experiences of low-income women (defined by Jarman scores) in relation to their breastfeeding support received in the post-natal period? A sample of seven women was interviewed. The in-depth interviews were analysed using a qualitative, thematic approach based on the self-efficacy theory. The four themes that emerged from the data were the following: breastfeeding related to the woman's self-confidence, the social environment in which the woman lived, knowledge of breastfeeding and the influence of maternity services on breastfeeding outcomes. These themes were interpreted in relation to the self-efficacy theory. The findings suggest that the components that inform self-efficacy are consistent with the themes from the data, suggesting that midwives and other health professionals should take the psychosocial aspects of breastfeeding support into account. As this important feature of breastfeeding support is not explicitly part of the current Ten Steps to Successful Breastfeeding, we suggest that further research and debate could inform expansion of these minimum standards to include the psychosocial aspects.

Maternal vitamin D status: implications for the development of infantile nutritional rickets.

The mother is the major source of circulating 25-hydroxyvitamin D concentration in the young infant. Maternal vitamin D status is an important factor in determining the vitamin D status of the infant and their risk of developing vitamin D deficiency and infantile nutritional rickets. There is evidence that the current supplementation recommendations, particularly for pregnant and lactating women, are inadequate to ensure vitamin D sufficiency in these groups. A widespread and concerted effort is needed to ensure daily supplementation of breastfed and other infants at high risk with vitamin D 400 IU from birth and of pregnant women in high-risk communities with 2000 IU. Future studies are required to determine the optimal doses of vitamin D supplementation in pregnancy and during lactation, and for normalizing vitamin D stores in infancy to reduce the prevalence of infantile nutritional rickets. Operational research studies are needed to understand the best methods of implementing supplementation programs and the factors that are likely to impede their success.

Adherence to vitamin D recommendations among US infants.

OBJECTIVES: In November 2008, the American Academy of Pediatrics (AAP) doubled the recommended daily intake of vitamin D for infants and children, from 200 IU/day (2003 recommendation) to 400 IU/day. We aimed to assess the prevalence of infants meeting the AAP recommended intake of vitamin D during their first year of life. METHODS: Using data from the Infant Feeding Practices Study II, conducted from 2005 to 2007, we estimated the percentage of infants who met vitamin D recommendations at ages 1, 2, 3, 4, 5, 6, 7.5, 9, and 10.5 months (n = 1952-1633). RESULTS: The use of oral vitamin D supplements was low, regardless of whether infants were consuming breast milk or formula, ranging from 1% to 13%, varying by age. Among infants who consumed breast milk but no formula, only 5% to 13% met either recommendation. Among mixed-fed infants, 28% to 35% met the 2003 recommendation, but only 9% to 14% would have met the 2008 recommendation. Among those who consumed formula but no breast milk, 81% to 98% met the 2003 recommendation, but only 20% to 37% would have met the 2008 recommendation. CONCLUSIONS: Our findings suggest that most US infants are not consuming adequate amounts of vitamin D according to the 2008 AAP recommendation. Pediatricians and health care providers should encourage parents of infants who are either breastfed or consuming <1 L/day of infant formula to give their infants an oral vitamin D supplement.

A study of in-hospital midwifery practices that affect breastfeeding outcomes.

Whilst breastfeeding is undoubtedly best for both mother and baby, many factors influence a woman's decision about whether to start and when to cease feeding. This study sought to determine which variables, influenced by midwifery practice, may influence the length of breastfeeding. Mothers who had given birth to a live baby at a Perth private hospital were invited to complete a validated, anonymous questionnaire asking about their breastfeeding experience, both in hospital and following discharge. The response rate was 50% (n=266). Although 94% of women were breastfeeding on discharge from hospital, this rate reduced to 59% at 6 months and 21% at 12 months. The mean duration of breastfeeding was 7.4 months (SD +/- 4.1). Of five variables thought to be associated with an increased length of breastfeeding, only two were found to be statistically significant: whether a mother could independently attach the baby on discharge (p=0.003) and whether or not artificial baby milk was administered in hospital (p<0.001). In order to improve breastfeeding rates, education for both mothers and midwives must be targeted towards ensuring mothers are able to independently attach their baby on discharge from hospital. The findings also support the discouragement of artificial feeding unless there is a medical indication or the mother has made an informed request.

[Assessment of vitamins and minerals intake with supplements during breast-feeding]. / Ocena spozycia witamin i skladników mineralnych z suplementami diety wsród kobiet karmiacych.

Assessment of supplements intake during breast-feeding was aim of the work. Seventy three women were examined in age 19-42 years coming from the Lublin province. The information about applying supplements during breast-feeding was obtained using questionnaire method. Achieved results served for calculations of taking vitamins and minerals coming from supplements. During breast-feeding 48% women accepted supplements. Average intakes of vitamin B2 (113%), B6 (120%), folic acid (144%) and vitamin D (166%) from supplements were above 100% recommended values. The highest average consumption was noted for iron (229% of recommended value), however the lowest on level 10-35% recommendations for vitamin A (33%), calcium (11%), selenium (12%) and magnesium (20%). Nearly 100% of the norm realization was obtained in case of the vitamin C (93%), E (102%), PP (105%), B1 (107%) and zinc (99%).

Vitamin D deficiency in exclusively breast-fed infants.

Exclusive breast-feeding is recommended up to 6 months of age with all its beneficial effects on child survival. Several studies have concluded that adequate intake of vitamin D cannot be met with human milk as the sole source of vitamin D. As breast-feeding rates increase, the incidence of vitamin D deficiency rickets is also expected to rise. One of the potential sources of vitamin D synthesis is in the skin from the ultraviolet rays of sunlight. Risk factors for developing vitamin D deficiency and rickets include low maternal levels of vitamin D, indoor confinement during the day, living at higher altitudes, living in urban areas with tall buildings, air pollution, darker skin pigmentation, use of sunscreen and covering much or all of the body when outside. In a study of 50 cases of hypocalcaemia reported from an urban tertiary care children's hospital in Chennai, 13 exclusively breast-fed infants presented with hypocalcaemia due to vitamin D deficiency and most of them with seizures. None of them had received vitamin D supplementation and all their mothers had biochemical evidence for vitamin D deficiency. This review discusses the rising incidence of vitamin D deficiency in infancy and the need to consider and implement methods to prevent the same by supplementation and increased exposure to sunlight without the hazards of ultraviolet rays on the skin. Further research to define the magnitude of vitamin D deficiency in exclusively breast-fed infants as a public health and paediatric problem and to recommend programmes to prevent the same are of utmost importance.

Risk for postpartum depression, breastfeeding practices, and mammary gland permeability.

In a cross-sectional study, 163 breastfeeding women completed the Edinburgh Postnatal Depression Scale (EPDS), a questionnaire on demographics and infant feeding and hand-expressed breast milk for Na and K quantification, between 2 and 12 weeks postpartum. Forty women (24.5%) had an EPDS score compatible with the risk of a depressive episode, and 63 (41%) did not feel confident about breastfeeding. These 2 variables were significantly correlated to each other and individually correlated to breastfeeding exclusiveness. Weeks postpartum was correlated to breastfeeding exclusiveness and Na:K in milk (all P < .001). A logistic regression model showed that supplementation increased the risk of high Na:K in milk by 209%, whereas a longer time postpartum lowered the risk for mammary gland permeability. This study suggests that postpartum depression and low breastfeeding confidence, which may be present concomitantly, are associated with increased mammary gland permeability, only to the extent in which depression dissuades the mother from exclusive breastfeeding.

Breastfeeding practice in the UK: midwives' perspectives.

Despite breastfeeding prevalence increasing, many mothers in developed countries are dissatisfied with care provided by midwives. However, a paucity of research exists related to midwives' experiences of supporting breastfeeding mothers. This study explored the experiences of English midwives' during their breastfeeding support role. A qualitative study using grounded theory principles was used. Data were collected using in-depth interviews and analysed using constant comparative techniques. The setting was two maternity hospitals in the North of England, UK. Thirty midwives who cared for normal, healthy babies participated. Volunteers were recruited using theoretical sampling techniques. The core category that emerged is called 'surviving baby feeding' and relates to midwives' experiences when supporting mothers. The results reported in this paper refer to one category called 'doing well with feeding' which has three main themes: (1) communicating sensitively, (2) facilitating breastfeeding, and (3) reducing conflicting advice. Participating midwives reported practice that suggests that they valued breastfeeding, attempted to provide realistic information and advice, and tried to minimise confusion for mothers. However, some midwives used an authoritative manner when conversing with mothers. English midwives' reported practice demonstrates that these midwives appreciated that breastfeeding mothers required specific support. However, breastfeeding education that encourages midwives to develop effective skills in ascertaining mother's needs, but also encourages mothers to effectively participate in their care, should be provided. Further research is needed to clarify breastfeeding mothers' expectations and needs.

A cohort study of haemoglobin and zinc protoporphyrin levels in term Zambian infants: effects of iron stores at birth, complementary food and placental malaria.

OBJECTIVE: To examine zinc-protoporphyrin (ZPP) and haemoglobin levels, and to determine predictors of iron deficiency anaemia (IDA) in Zambian infants. SUBJECTS AND METHODS: Ninety-one women and their normal birth weight (NBW) infants were followed bi-monthly during the first 6 months of life, and iron status, food intake, malaria parasitaemia and growth were monitored. At 4 months, the infants were divided into two groups, and the data were analysed according to whether or not they were exclusively breastfed. RESULTS: Almost two-third of infants were born with low iron stores as defined by ZPP levels, and this proportion increased with age. Over 50% had developed IDA by 6 months. Exclusive breastfeeding at 4 months could be a protective factor for IDA (odds ratio (OR): 0.2; 95% confidence interval (CI): 0.0-1.1). Exclusively breastfed infants had higher haemoglobin values at 4 and 6 months (mean difference 0.6; 95% CI: 0.1-1.2 g/dl and mean difference 0.9; 95% CI: 0.2-1.7 g/dl, respectively), compared with infants with early complementary feeding. In univariate analysis, past or chronic placental malaria appeared to be a predictor of IDA at 4 and 6 months, but the significance was lost in multivariate analysis. CONCLUSIONS: Zambian NBW infants are born with low iron stores and have a high risk to develop IDA in the first 6 months of life. Continuation of exclusive breastfeeding after 4 months is associated with a reduction of anaemia. The effect of placental malaria infection on increased risk of infant IDA could not be proven.

[Breast feeding determinants on the first year of life of children in a city of Midwestern Brazil]. / Determinantes da amamentação no primeiro ano de vida em Cuiabá, Mato Grosso.

OBJECTIVE: To assess risk factors for breastfeeding discontinuation and weaning among children less than one year old. METHODS: A cross-sectional study was carried out in children under one year of age brought by their caregivers to immunization units in the city of Cuiabá, Midwestern Brazil, in 2004. Sampling first comprised drawing immunization units and then children in each unit were systematically drawn. Data was collected through semi-structured questionnaires applied to children's caregivers investigating social and demographic variables, as well as variables related to birth and maternal characteristics, pacifier use and feeding on the first day at home. Descriptive statistical and logistic regression analyses of risk factors by age group were conducted and odds ratios and 95% confidence intervals were estimated. RESULTS: A total of 920 children under one year of age were studied, of which 205 were less than 120 days old and 275 were less than 180 days old. Pacifier use, offering tea to children on their first day at home, and being a child of a mother with first or second grade schooling or primapara posed an increased risk for not being on exclusive breastfeeding at the age of 120 days. All these factors were also significantly associated in those under 180 days old, except tea offering, which was not investigated for this age group. Among children less than one year old, pacifier use was the only variable that remained significant. CONCLUSIONS: Social and cultural factors were determinants of breastfeeding status. Maternal education and awareness are crucial to prevent practices that can negatively affect breastfeeding.

Breastfeeding and complementary feeding of children up to 2 years of age.

Appropriate breastfeeding and complementary feeding practices are fundamental to children's nutrition, health, and survival during the first 2 years of life. The World Health Organization recommends exclusive breastfeeding until 6 months of age and continued breastfeeding for at least 2 years, along with the timely introduction of adequate amounts of complementary foods of suitable nutritional and microbiological quality. The amounts of energy and micronutrients required from complementary foods have been estimated as the difference between the total physiological requirements of these food components and the amounts transferred to the child in breast milk. Recommendations for the energy density of complementary foods and their frequency of feeding have also been proposed. Intakes of several micronutrients, including iron, zinc, calcium, selected B vitamins and (in some settings) vitamin A, remain problematic because commonly available, low-cost foods contain inadequate amounts of these nutrients to provide the shortfall in breast milk. Alternative strategies to provide these nutrients include adding animal source foods to the diet, providing fortified, processed complementary foods, administering micronutrient supplements, or offering some combination of these approaches. Advantages, disadvantages, and possible risks of these different strategies are discussed.

Full breastfeeding duration and risk for iron deficiency in U.S. infants.

BACKGROUND: National and international authorities recommend exclusive breastfeeding for an infant's first 6 months. Effects of these recommendations on iron status of U.S. children are unknown. OBJECTIVE: To ascertain if full breastfeeding for 6 months versus 4 months places U.S. children at greater risk for iron deficiency. DESIGN/METHODS: Data regarding 2268 children ages 6 to <24 months from NHANES III, a nationally representative cross-sectional survey conducted from 1988-1994, were analyzed. Similar analyses were conducted for 526 children ages 12 to <24 months from NHANES 1999-2002. Anemia (low hemoglobin or history of anemia) and iron status (serum ferritin) were compared for five groups: formula fed only (n = 1142), or full breastfeeding for: 1 month "FullBF<1" (n = 425), 1 to <4 months "FullBF1-3+" (n = 343), 4 to <6 months "FullBF4-5+" (n = 222), and >or= 6 months "FullBF6" (n = 136). Laboratory data were available for children 12 to 24 months (n = 745). SUDAAN software was used to account for the complex sampling design. Logistic regression adjusted for confounding factors. RESULTS: In unadjusted analyses (NHANES III), 10.0% of "FullBF6+" versus 2.3% of "FullBF4-5+" had a history of anemia (p = 0.007) but unadjusted between group serum ferritin and hemoglobin differences were insignificant in both surveys. Adjusting for birth weight and demography revealed persistently lower risk of history of anemia (NHANES III, odds ratio [OR] 0.20, confidence interval [CI] 0.06, 0.63) and low serum ferritin (NHANES 1999-2002, OR 0.19, CI 0.06, 0.57) but not low hemoglobin at time of survey "FullBF4-5+" versus "FullBF6." CONCLUSIONS: Young children in the United States fully breastfed for 6 months may be at increased risk of iron deficiency. Adequate iron may not be provided by typical complementary infant foods. Healthcare providers should be vigilant to prevent iron deficiency in this group of infants.

Breast-feeding, dietary intakes and their associations with subclinical vitamin A deficiency in children in Anhui Province, China.

OBJECTIVE: This study aimed to explore the associations between breast-feeding, dietary intakes and other related factors and subclinical vitamin A deficiency (SVAD) in children aged 0-5 years in an area in China where mild vitamin A deficiency (VAD) is found. METHODS: Data were from a population-based cross-sectional study with 1052 children aged 0-5 years. SVAD cases were identified by the indicator of serum retinol