The role of breastfeeding promotion in German hospitals for exclusive breastfeeding duration.

Breastfeeding promotion and support in hospitals is expected to have a positive impact on maternal breastfeeding outcomes. The objective of this study is to examine the association between breastfeeding promotion in maternity hospitals in Germany and exclusive breastfeeding (EBF) rates during the first 4 months. Thus, a nationwide cross-sectional web-based survey of breastfeeding promotion was conducted in 103 hospitals. Mother-infant pairs (n = 962) were recruited at these hospitals for a prospective web-based survey of breastfeeding status at five-time points, that is, during a hospital stay, at discharge as well as after 0.5, 2, and 4 months. The hospital analysis was based on the "10 Steps to Successful Breastfeeding" of the World Health Organization and the United Nations Children's Fund, adapted for Germany. Their degree of implementation was stratified by a breastfeeding promotion index (BPI) as low (≤5 steps), medium (6-8 steps), and high (≥9 steps). The association between the BPI and the odds of EBF at each of the five-time points was estimated by multivariable regression models, adjusting for various maternal factors. At all time points, the proportion of EBF among mothers from high BPI hospitals exceeded the proportion of those from medium or low BPI hospitals. A high BPI was associated with higher odds of EBF during the hospital stay and at discharge, while maternal factors for EBF such as breastfeeding experience and no early use of a pacifier persisted beyond. The high commitment of hospitals and tailored support of mothers is essential for EBF.

Breast-feeding promotion in hospitals and prospective breast-feeding rates during the first year of life in two national surveys 1997-1998 and 2017-2019 in Germany.

OBJECTIVES: The present study aimed to assess the current state of breast-feeding promotion in hospitals and the prevalence of breast-feeding during the first year of life in Germany and to compare the results with a study 20 years earlier. DESIGN: In the studies on 'breast-feeding and infant nutrition in Germany' named 'SuSe', a cross-sectional survey in hospitals was combined with a subsequent prospective survey of breast-feeding and infant nutrition during the first year of life (0·5, 2, 4, 6 and 12 months after birth) in mother-infant pairs who were recruited in the hospitals. Written questionnaires and phone calls were used in SuSe I and web-based questionnaires in SuSe II. Breast-feeding promotion and prevalence were evaluated using recommendations from the WHO and the UNICEF. SETTING: Two nationwide surveys SuSe I (1997-1998) and SuSe II (2017-2019). PARTICIPANTS: In SuSe I, 177 hospitals and 1717 mother-infant pairs and in SuSe II 109 hospitals and 962 mother-infant pairs were included. RESULTS: In SuSe II, hospitals implemented seven of the WHO 'Ten Steps to Successful Breastfeeding' to a greater extent than the hospitals in SuSe I. More mothers exclusively breastfed for 4 months (57 % v. 33 %) and continued breast-feeding until 6 (78 % v. 48 %) and 12 months (41 % v. 13 %). In both studies, exclusive breast-feeding decreased between 4 and 6 months of age due to the introduction of complementary feeding. CONCLUSIONS: In Germany, breast-feeding habits have come closer to the recommendations over the last 20 years.

[Breastfeeding and potential sensory imprinting]. / Stillen und mögliche Geschmacksprägung.

Breastmilk provides well-known nutritional and functional advantages and in addition a greater sensory variety as compared to infant formula. Volatile and soluble sensory components from the mother's diet are transmitted prenatally into the amniotic fluid and postnatally into breastmilk and can be detected by the fetus and infant. Breastfeeding is suggested to serve as a bridge from prenatal flavor experiences to the varied sensory world of complementary feeding and family diet afterwards. Nevertheless definite data to prove this plausible assumption are still missing. Randomized intervention trials with a necessary long-term follow-up are difficult to implement and rarely achieved. Lasting effects of early sensory experiences have so far been demonstrated mostly in the first year of life and by applying intensive sensory interventions, which are hardly possible in a habitual maternal diet. The practical relevance of a potential sensory imprinting by breastfeeding still remains open. Nevertheless a varied diet in pregnancy and lactation can be recommended not only for nutritional reasons but also from a hedonic sensory perspective.

[Monitoring breastfeeding in Germany-the current need for action and perspectives]. / Stillmonitoring in Deutschland ­ aktueller Handlungsbedarf und Perspektiven.

Breastfeeding monitoring is understood to be the systematic assessment of current, comprehensive and precise data on breastfeeding rates, breastfeeding behaviour and relevant framework conditions at a national and regional level, with the aim of optimal breastfeeding support. For this purpose, in 2009, the National Breastfeeding Committee in Germany presented an integrative monitoring concept that included different assessment instruments and assessment fields. The hitherto fragmented implementation is still insufficient; in particular, the implementation of longer-term and sustainable concepts within the structures of the healthcare system is still lacking.To systematically collect breastfeeding data, it is mandatory to integrate the different modules. Longitudinal data on selected core breastfeeding indicators should be collected within the quality assurance structures of perinatal medicine and within the regular school entrance examinations, and be integrated into the health surveillance system. Detailed epidemiological studies on breastfeeding and infant nutrition should be carried out every 5 years, covering influencing factors from pregnancy until the end of the first year of life. The monitoring of high-risk groups should take place with systematic interventions within the institutionalized frameworks of "Early Preventions" (local support systems offering assistance to parents and children) and health authorities with social compensatory activities, with the immediate transfer to of the results into practice.The integrative concept of breastfeeding monitoring in Germany is in accordance with international criteria, tailored to existing structures and experiences, and can be presented internationally. Sufficient centralized resources are needed to coordinate and implement this concept.

[Is breastfeeding in public socially accepted? : Experiences and attitudes of the general population and breastfeeding mothers]. / Ist Stillen in der Öffentlichkeit gesellschaftlich akzeptiert? : Erfahrungen und Einstellungen der Bevölkerung und stillender Mütter.

BACKGROUND: Despite the undeniable benefits, breastfeeding in public has led in the past to controversies that gained a lot of media coverage. For this reason, the attitudes of the general population towards breastfeeding in public and the experiences of mothers who breastfeed in public were examined. OBJECTIVE: The objectives were to collect current data on the perception and acceptance of breastfeeding in public. MATERIALS AND METHODS: We surveyed 1003 respondents from the general population aged 14 years and over and 306 mothers with children of breastfeeding age on the subject of breastfeeding in public by means of computer-assisted web interviewing. RESULTS: Of mothers, 6% reported that their experiences of breastfeeding in public tended to be rather or very negative. Of the general population sample, 66% held the fundamental opinion that breastfeeding should be possible everywhere at all times, compared to 80% of mothers (p < 0.05). Special differences can be seen for breastfeeding in restaurants and cafes. Although only just under 50% of the population sample approves of breastfeeding in these locations, it is not avoided by the majority of mothers (54%). Overall, knowledge of the benefits of breastfeeding is associated with increased acceptance of breastfeeding in public. No special demographic characteristics were observed for the group of persons with a negative attitude towards breastfeeding in public (6%). CONCLUSIONS: No special target group for improving acceptance of breastfeeding in public can be identified in the population on the basis of the present findings. A conflict potential was identified for certain places and situations, however, which enables the development of strategies to increase acceptance.

Getting breastfeeding started under pandemic visiting restrictions: lessons learned in Germany.

BACKGROUND: The COVID-19 pandemic contact restrictions considerably changed maternal visiting contacts during the time in which breastfeeding is initiated. We wanted to know how maternity ward staff and mothers rated the conditions of starting breastfeeding under contact restrictions. METHODS: In the Breastfeeding in North Rhine-Westphalia (SINA) study, Germany, 2021/22, chief physicians as well as ward staff from 41 (out of 131) maternity hospitals (82 members of the healthcare sector in total) were surveyed by telephone concerning structural and practical conditions for breastfeeding support before and during the pandemic; 192 (out of 426 eligible) mothers answered an online-questionnaire about their breastfeeding experiences at 2 weeks and 2 months after birth. RESULTS: In almost all of the hospitals, visits were restricted due to the pandemic, with the exception of the primary support person. After more than one year of pandemic experience, the ward staff were convinced that the restrictions were mostly positive for the mothers (97.6%) and for the ward staff themselves (78.0%). A total of 80.5% of the ward staff would maintain the restrictions beyond the pandemic. The mothers themselves mostly rated the restrictions in the hospital as being just right; moreover, many mothers voluntarily maintained the restrictions at home, at least in part. CONCLUSIONS: The unprecedented visiting restrictions in hospitals during the pandemic were like an "experiment" born out of necessity. Restricting visiting arrangements may be an underestimated beneficial component for the development of the mother-infant dyad in perinatal breastfeeding care, particularly in healthcare systems where almost all births occur in the maternity hospital. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) (DRKS00027975).

Adherence to recommendations for nutrient supplementation related to pregnancy in Germany.

Supplementation of certain micronutrients is recommended to ensure their adequate supply during pregnancy and lactation. In Germany, this applies particularly to folic acid and iodine. There is no nationwide data on adherence to the supplementation guidelines. The aim of this cross-sectional study was to determine the prevalence and predictors of the recommended supplementation of both folic acid and iodine in mothers of a nationwide birth cohort. Data on supplementation, before, during, and shortly after pregnancy, were collected retrospectively 14 days postpartum in a sample of 962 mother-infant pairs participating in the second nationwide study on breastfeeding and infant nutrition in Germany, called "SuSe II" (2017-2019). Folic acid and iodine supplementation were classified as recommended according to the German guidelines if supplementation was provided for both essential periods: for folic acid before and during pregnancy and for iodine during pregnancy and lactation. Univariable tests and multivariable logistic regression analysis were performed. The vast majority of mothers did not adhere to the recommendations, with only 36.2% supplementing folic acid and 31.9% supplementing iodine during the recommended periods, and only 15.2% adhering to the recommendations for both nutrients. Main predictors of adherence to recommendations of both nutrients were lifestyle attributes and nutrition-related intentions like previous breastfeeding experience and breastfeeding intentions, but not common sociodemographic characteristics. The data suggest widespread dissemination of the time-specific recommendations covering the entire period from preconception to lactation that could help to sensitize women and healthcare providers.

Cross-country variation in stillbirth and neonatal mortality in offspring of Turkish migrants in northern Europe.

BACKGROUND: Diverse early-life mortality outcomes have been documented in immigrant populations in northern Europe. A recent meta-analysis has suggested that national integration policy is a key factor in understanding this heterogeneous pattern. In this study, we investigated the variation of stillbirth and neonatal mortality between societies in northern Europe in one minority population, the Turkish. METHOD: Data on stillbirth and neonatal deaths in 239 387 births during 1990-2005, where the mother was of Turkish origin, was drawn from birth registries or surveys in nine northern European countries. Rates were compared with births from mothers who were born in the society of residence. Logistic regression was used to calculate odds ratios adjusted for year of birth of the offspring. RESULTS: The risks for stillbirth were, or tended to be, elevated for Turkish mothers in all countries compared with the native population, with the highest risk in Austria (odds ratio (OR) 1.7; 95% confidence interval (CI) 1.4-2.1) and Switzerland (OR 1.6; 1.4-1.9). For neonatal mortality the results were heterogeneous, indicating no excess risk for Turkish-born children in the Netherlands, the UK and Norway, and elevated risks in Denmark (OR 1.3; 1.0-1.6), Switzerland (OR 1.3; 1.1-1.5), Austria (OR 1.4; 1.0-1.8) and Germany (OR 1.3; CI 1.2-1.5). CONCLUSION: This study suggests that preventable society-specific determinants are important for early-life mortality in Turkish migrants in Europe. An active integration policy is consistent with a favourable neonatal mortality outcome in continental Europe, but not with patterns in Scandinavia and the UK.

Cultural Competence and Global Health: Perspectives for Medical Education - Position paper of the GMA Committee on Cultural Competence and Global Health.

Introduction: Routine medical care in Germany, Austria and Switzerland is being increasingly impacted by the cultural and linguistic diversity of an ever more complex world. Both at home and as part of international student exchanges, medical students are confronted with different ways of thinking and acting in relation to health and disease. Despite an increasing number of courses on cultural competence and global health at German-speaking medical schools, systematic approaches are lacking on how to integrate this topic into medical curricula. Methodological approach: This paper is based on a structured consensus-building process by a multidisciplinary committee composed of faculty and students. In a first step, a qualitative online survey was carried out in order to establish an inventory of definitions and concepts. After the second step, in which a literature search was conducted and definitions of global health and transcultural and intercultural competence were clarified, recommendations were formulated regarding content, teaching and institutional infrastructure. Based on small-group work and large-group discussions, different perspectives and critical issues were compiled using multiple feedback loops that served to ensure quality. Results: An inventory on the national and international level showed that great heterogeneity exists in regard to definitions, teaching strategies, teaching formats and faculty qualification. Definitions and central aspects considered essential to medical education were thus established for the use of the terms "cultural competence" and "global health". Recommendations are given for implementation, ranging from practical realization to qualification of teaching staff and education research. Outlook: High-quality healthcare as a goal calls for the systematic internationalization of undergraduate medical education. In addition to offering specific courses on cultural competence and global health, synergies would be created through the integration of cultural competence and global health content into the curricula of already existing subject areas. The NKLM (the national competence-based catalogue of learning objectives for undergraduate medical education) would serve as a basis for this.

Feeding patterns in breast-fed and formula-fed infants.

AIM: The intention of this study performed in healthy breast- and formula-fed infants was to characterize physiological feeding patterns as a basis for counseling parents to feed their infants on demand. METHODS: Ingested milk volumes of 10 breast-fed and 14 formula-fed infants were measured during five 72-hour investigation periods during the 3rd, 6th, 9th, 13th, and 17th weeks of life. RESULTS: A comparable diurnal distribution of feeds was observed in both groups during the first 9 weeks of life, with a day-night asymmetry of feeding first observed at the age of 6 weeks. Thereafter, formula-fed infants showed a further decrease in their nightly milk intake. Within the investigation period, the milk volume per feed rose from 100 (range 40-200) g to 140 (range 30-300) g in the breast-fed group and from 100 (range 20-200) g to 200 (range 20-450) g in formula-fed infants. From the 6th week of life onwards, formula-fed infants had significantly higher feeding volumes. CONCLUSIONS: Parents should be informed about the variability of infant demands per feed and of feeding at night observed in breast-fed infants. The results suggest that feeding patterns similar to those of breast-fed infants are difficult to accomplish in formula-fed infants.

Supplemental feeding in the first days of life -- effects on the recipient infant.

AIM: Since clinical indications may necessitate the feeding of supplements to newborn infants, the effects of different supplemental feedings on the recipient infants were studied. METHODS: Two groups of healthy, term newborn infants (n = 64 in each group) were investigated. The mothers breast-fed their infants, and by indication the babies were additionally fed supplement A (supplementary neonatal formula, 78 kcal/dl) or the traditionally used supplement B (glucosaccharide solution, 100 kcal/dl). The differences in volume and energy intake, weight development and rate of hyperbilirubinemia were assessed in the hospital. The frequency of breast-feeding was evaluated using a structured telephone interview at the ages of 4 and 8 weeks. RESULTS: The energy intake of group B was higher prior to the 3rd day of study (p < 0.05). Afterwards a higher mean intake of human milk, a faster weight gain but a lower frequency of exclusive breast-feeding at discharge were observed in study group A. Hyperbilirubinemia was more frequent in the group B. Fifty-five percent (group A) and 52% (group B) of the participants were exclusively breast-fed at the age of 8 weeks. CONCLUSIONS: Despite differences in milk intake and weight gain in the early postpartum period, the breast-feeding patterns at 4 and 8 weeks were not significantly influenced by the use of different supplements.