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An important cause of stunting is limited consumption of complementary foods, in terms of both quantities and nutrients. Although existing studies show a positive association between fathers' engagement and children's diet, programmes designed to improve complementary feeding practices often only target mothers. In response to this, maternal behaviour change communication (BCC), paternal BCC and food voucher programmes were designed and implemented in Ethiopia using a clustered randomized controlled trial design. The paternal BCC programme included gender‐equal messages to increase fathers' participation in childcare, household labour and decision making. The research reported in this paper is an examination of the BCC programmes, characterizing the behavioural, normative and control beliefs of both mothers and fathers in BCC households compared to those in control households. In this study, a total of 40 participants were included, with 13 mother–father pairs in the BCC + food voucher group, and seven pairs in the control group. Each participant was interviewed separately. We found that BCC mothers showed more gender‐equal tendencies than the control mothers despite being more rural in location. By contrast, the beliefs of BCC and control fathers were similar overall, suggesting men are more resistant to gender‐equal BCC. More work is needed to develop and test effective methods for changing fathers' beliefs and practices. Key messages: Mothers in behaviour change communication (BCC) group mothers held more gender‐equal beliefs than control mothers, while BCC and control fathers shared similar views, suggesting a male resistance to gender equality.Mothers found fathers' involvement in childcare socially acceptable but often perceived them as inexperienced, which limited their participation.Control mothers' traditional view on household chores maintained the conventional labour division, influencing fathers' involvement.Fathers typically resisted maternal control of resources; however, they agreed that the more knowledgeable should lead decision‐making. BCC mothers showed greater confidence in making household decisions as effectively as fathers. [ABSTRACT FROM AUTHOR]

Child stunting prevalence is primarily used as an indicator of impeded physical growth due to undernutrition and infections, which also increases the risk of mortality, morbidity and cognitive problems, particularly when occurring during the 1000 days from conception to age 2 years. This paper estimated the relationship between stunting prevalence and age for children 0–59 months old in 94 low‐ and middle‐income countries. The overall stunting prevalence was 32%. We found higher stunting prevalence among older children until around 28 months of age—presumably from longer exposure times and accumulation of adverse exposures to undernutrition and infections. In most countries, the stunting prevalence was lower for older children after around 28 months—presumably mostly due to further adverse exposures being less detrimental for older children, and catch‐up growth. The age for which stunting prevalence was the highest was fairly consistent across countries. Stunting prevalence and gradient of the rise in stunting prevalence by age varied across world regions, countries, living standards and sex. Poorer countries and households had a higher prevalence at all ages and a sharper positive age gradient before age 2. Boys had higher stunting prevalence but had peak stunting prevalence at lower ages than girls. Stunting prevalence was similar for boys and girls after around age 45 months. These results suggest that programmes to prevent undernutrition and infections should focus on younger children to optimise impact in reducing stunting prevalence. Importantly, however, since some catch‐up growth may be achieved after age 2, screening around this time can be beneficial. Key message: Stunting prevalence was higher for older children until around age 28 months.The age with the highest stunting prevalence was fairly consistent across UNICEF regions.However, the stunting prevalence and gradient of the rise and fall in stunting prevalence across age varied between countries, living standards and sex.Programmes to prevent undernutrition and infections should focus on younger children to optimise impact in reducing stunting prevalence.Some catch‐up growth may be achieved after age 2, so screening around this time can be beneficial. [ABSTRACT FROM AUTHOR]

There are many benefits of breastfeeding to women and their infants but meeting the recommended 6 months of exclusive breastfeeding is likely to be more challenging for women with severe mental illness (SMI). This is the first systematic review that aims to examine evidence of (a) infant feeding outcomes in women with SMI and the factors associated with this, (b) the experiences of infant feeding and infant feeding support for women with SMI, (c) interventions for supporting infant feeding among these women and (d) health care professionals' attitudes toward supporting infant feeding in women with SMI. Mixed methods systematic review was carried out using the principles of Joanna Briggs Institute's (JBI) 'convergent integrated' methodology. CINAHL, PsycINFO, Medline and MIDIRS were used to search literature between 1994 and 2022. The quality of selected articles was assessed using JBI critical appraisal tools and thematic synthesis was undertaken to obtain findings. Eighteen papers were included in the final review. Women with SMI were less likely to initiate and continue breastfeeding than women without SMI. Several challenges with breastfeeding were highlighted, and while these were often linked to women's mental health difficulties, inconsistent advice from health care professionals and poor support with breastfeeding further compounded these challenges. This review highlights that policy and practice need to take into account the individual challenges women with SMI face when planning, initiating and maintaining breastfeeding. Education and training for health care professionals are needed to enable them to provide tailored infant feeding support to women with SMI, which reflects their individual needs. Key messages: Women with severe mental illness (SMI) are less likely to initiate and maintain breastfeeding compared to women without SMI.Challenges were identified among women with SMI including poor professional support with infant feeding.Education and training are required for health care professionals to individualise infant feeding support for women with SMI and should include information regarding medication and optimising sleep while breastfeeding.No evidence of effective interventions to support breastfeeding in women with SMI were identified and there was limited evidence of women's experiences of infant feeding.Further research is required with larger sample sizes and clearly defined measures of infant feeding outcomes. [ABSTRACT FROM AUTHOR]

In India, 15 nutrition interventions are delivered and financed through the National Health Mission (NHM). Programmatic know‐how, however, on tracking nutrition budgets in health sector plans is limited. Following the four phases of the budget cycle—planning, allocations, disbursements and expenditure, this paper presents a new method developed by the authors to track nutrition budgets within health sector plans. Using the example of the Anemia Mukt Bharat (AMB) or Anemia Free India strategy, it reports preliminary findings on the application of the first two phases of the method, that is, to track and act for improved planning and allocations, covering 12 states. The paper lists out the budget heads, cost norms and developed tools to plan adequately. Supportive action was undertaken through sharing trends and trainings for AMB's budgeting to create opportunities for improvements. It was observed that the AMB budget increased over 3 years despite the COVID situation. It increased from INR 6184 million in FY 2019–2020 to INR 6293 million, a 2% increase in FY 2020–2021, and to INR 7433 million, an 18% increase in FY 2021–2022. The difference in allocations and planned budgets were low (16%, 4% and 11%, respectively) while the difference in required budgets and planned budgets were significant but reduced consistently (41%, 31% and 22%, respectively). The paper concludes that the methods adopted for tracking and acting for improved nutrition budgets helped in informing national and state governments regarding yearly trends. Such methods can be effective and be developed for other nutrition interventions. Key messages: Tracking budgets and timely action can improve planning and allocation efficiency.Support to states in planning budgets is essential. No major gaps were found in approvals.Technical partners can assist in supporting governments for improving financial efficiency. [ABSTRACT FROM AUTHOR]

Research on women's experiences of infant feeding and related moral discourse suggests that self‐conscious emotions may be highly relevant to breastfeeding support interactions. However, the emotional impact of receiving support has not been fully explored. The aim of this review is to re‐examine qualitative UK research on receiving breastfeeding support, in order to explore the role of self‐conscious emotions and related appraisals in interactions with professional and peer supporters. From 2007 to 2020, 34 studies met criteria for inclusion. Using template analysis to identify findings relevant to self‐conscious emotions, we focused on shame, guilt, embarrassment, humiliation and pride. Because of cultural aversion to direct discussion of self‐conscious emotions, the template also identified thoughts about self‐evaluation, perceptions of judgement and sense of exposure. Self‐conscious emotions were explicitly mentioned in 25 papers, and related concerns were noted in all papers. Through thematic synthesis, three themes were identified, which suggested that (i) breastfeeding 'support' could present challenges to mothering identity and hence to emotional well‐being; (ii) many women managed interactions in order to avoid or minimise uncomfortable self‐conscious emotions; and (iii) those providing support for breastfeeding could facilitate women's emotion work by validating their mothering, or undermine this by invalidation, contributing to feelings of embarrassment, guilt or humiliation. Those supporting breastfeeding need good emotional 'antennae' if they are to ensure they also support transition to motherhood. This is the first study explicitly examining self‐conscious emotions in breastfeeding support, and further research is needed to explore the emotional nuances of women's interactions with supporters. [ABSTRACT FROM AUTHOR]

The objective of this paper is to describe gestational weight gain (GWG), to assess the applicability of the 2009 Institute of Medicine (IOM) guidelines, and to derive a GWG adequacy classification within a French cohort. We included twins from the national, prospective, population‐based JUmeaux MODe d'Accouchement (JUMODA) cohort study (2014–2015). Following the IOM approach, we selected a 'standard' population of term pregnancies with 'optimal' birthweight (≥2500 g; n = 2562). GWG adequacy (insufficient; adequate; excessive) was defined using IOM recommendations (normal body mass index [BMI]: 16.8–24.5 kg [also utilized for underweight BMI]; overweight: 14.1–22.7 kg; obese: 11.4–19.1 kg). Additionally, using the IOM approach, we determined the 25th and 75th percentiles of GWG in our standard population to create a JUMODA‐derived GWG adequacy classification. GWG and GWG adequacy were described, overall and by BMI and parity. In the JUMODA standard population of term twin livebirths with optimal birthweight, mean GWG was 16.1 kg (standard deviation 6.3). Using IOM recommendations, almost half (46.5%) of the women had insufficient and few (10.0%) had excessive GWG, with similar results regardless of BMI or parity. The 25th and 75th percentiles of GWG in the JUMODA standard population (underweight: 13–21 kg; normal weight: 13–20 kg; overweight: 11–19 kg; obese: 7–16 kg) were lower than the IOM recommendations. The IOM recommendations classified a relatively high percentage of French women as having insufficient and a low percentage as having excessive GWG. Additional research to evaluate recommendations in relation to adverse perinatal outcomes is needed to determine whether the IOM recommendations or the JUMODA‐derived classification is more appropriate for French twin gestations. Key messages: Using the 2009 Institute of Medicine (IOM) recommendations to define gestational weight gain (GWG) adequacy in our French cohort classified almost half of women as having insufficient GWG and a relatively low percentage as having excessive GWG.The USA‐derived IOM definition for adequate GWG may not apply in France or in other non‐USA, contemporary obstetric populations.Additional research in large, population‐based contemporary cohorts with prospective GWG ascertainment and assessment of GWG adequacy classifications in relation to adverse outcomes is needed to inform evidence‐based GWG recommendations for twin pregnancies. [ABSTRACT FROM AUTHOR]

Breastfeeding rates in many Global North countries are low. Qualitative research highlights that breastfeeding in public is a particular challenge, despite mothers often having the legal right to do so. To identify barriers and facilitators, we systematically searched the qualitative research from Organisation for Economic Co‐operation and Development countries relating to breastfeeding in public spaces from 2007 to 2021. Data were analysed using the Thematic Synthesis technique. The review was registered with PROSPERO (registration number: CRD42017081504). Database searching identified 3570 unique records. In total, 74 papers, theses, or book chapters, relating to 71 studies, were included, accounting for over 17,000 mothers. Overall, data quality was high. Our analysis identified that five core factors influenced mothers' thought processes and their breastfeeding in public behaviour: legal system; structural (in)equality; knowledge; beliefs and the social environment. Macro‐level factors relating to legislation and inequality urgently require redress if breastfeeding rates are to be increased. Widespread culture change is also required to enhance knowledge, change hostile beliefs and thus the social environment in which mother/infant dyads exist. In particular, the sexualisation of breasts, disgust narratives and lack of exposure among observers to baby‐led infant feeding patterns resulted in beliefs which created a stigmatising environment. In this context, many mothers felt unable to breastfeed in public; those who breastfed outside the home were usually highly self‐aware, attempting to reduce their exposure to conflict. Evidence‐based theoretically informed interventions to remove barriers to breastfeeding in public are urgently required. Key messages: In OECD countries, there was limited evidence that women routinely breastfed outside of the home; for those who did, this experience was often uncomfortable.Legal protections for breastfeeding in public, where present, were not widely known and appeared to be under‐enforced.Mothers were aware of stigma relating to breastfeeding in public and feared conflict with strangers. This fear was not felt evenly, with mothers who were young, poor, and from marginalised ethnicities reporting increased surveillance and stigma.There is limited and dichotomous evidence relating to partners, family, and friends' roles in supporting mothers to breastfeed in public.Observers of breastfeeding in public had poor understanding of normal infant feeding behaviour and the associated need to breastfeed in public spaces. They also experienced disgusted reactions to viewing breastfeeding. [ABSTRACT FROM AUTHOR]

Child wasting is defined as a weight‐for‐height/length z‐score (WLZ/WHZ) < −2, and this indicator of nutritional status is used worldwide. However, a precise measurement is required for the assessment of a child's nutritional status, which may not always be possible due to expensive instruments, especially in poor resource settings. In some instances, mid‐upper arm circumference‐for‐age z‐score (MUACZ) is also being used for screening purposes, which is a simple and useful nutritional indicator. The objective of this paper is to identify the optimal cut‐off point for the MUACZ to identify wasted children, and also to determine if the same factors are associated with MUACZ and wasting. Data were derived from the Suchana evaluation data. The optimal cut‐off value was estimated via receiver operating characteristic (ROC) curve analysis using acute malnutrition as a gold standard with maximum sensitivity and specificity. Multiple logistic regression was used to assess the associated factors with the MUACZ. Using the gold standard indicator of nonwasting (WLZ ≥ −2), a positive outcome, the optimal cut‐off point for the MUACZ was −1.27. The area under the ROC curve was 0.88, indicating that the model had a power of 88% to differentiate between the positive and negative classes. It implies that a child's MUACZ was correlated with WLZ, and a MUACZ below −1.27 appeared to accurately identify wasting among children aged 3–23 months. MUACZ < −1.27 might be another useful indicator of childhood wasting than a WLZ < −2. Key messages: We calculated the cut‐off point for a child's mid‐upper arm circumference‐for‐age z‐score (MUACZ) that MUACZ below −1.27 appears to accurately identify acute malnutrition among children aged 3–23 months with the highest sensitivity and specificity.Determinants of a child's MUACZ < −1.27 were estimated.Measurement of MUAC would be especially helpful when large numbers of children need to be screened quickly, particularly in humanitarian aid settings.MUACZ < −1.27 may represent a more useful indicator of childhood malnutrition than a weight‐for‐length z‐score < −2. [ABSTRACT FROM AUTHOR]

Breastfeeding support is a key component in meeting the public health responsibility of increasing breastfeeding rates, with access to individualised, convenient and linked support across services central to improved outcomes. With the rise of new technology and the COVID‐19 pandemic, social media (SM) support for breastfeeding has become increasingly popular and it is important to understand how and why mothers access such support, and from whom, to optimise services and to meet mothers' needs. Increasing research is building on women's use and experience of SM for breastfeeding, although there is a paucity of UK data. This systematic review aimed to understand the impacts of SM support for breastfeeding, including benefits and challenges, to establish the evidence for wider provision within maternity services. The search was limited to studies published in English and focused on the self‐directed use of social media groups for breastfeeding (defined as platforms that facilitate group support via interactivity, allowing for user‐generated content and subsequent responses). Of 327 papers retrieved, 13 studies were included for review. The six themes identified were: breastfeeding context, including factors impacting women's decision making; the relational impact of belonging to an online community; increased self‐efficacy; critiques of SM; the nature and types of support commonly sought and received; and breastfeeding duration as an outcome. The findings confirm that mothers value SM groups for community support, which normalises breastfeeding and provides the support they attribute to improved outcomes, and highlight that UK research focused on provision linked to wider services is needed. Key messages: Joining a social media (SM) group to seek support is common among those mothers intending to breastfeed. For these mothers SM groups have the potential to provide valued support where it is lacking, or in addition to their existing networks.SM groups offer reciprocity of knowledge sharing and esteem support. Belonging to a supportive online community promotes emotional wellbeing and self‐efficacy, improving breastfeeding outcomes.Online peer support is valued and trusted as a complementary source of information and shared experience. Mothers are aware of issues of reliability, lack of regulation and the need to be discerning of online advice. [ABSTRACT FROM AUTHOR]

Child malnutrition is an enormous public health problem in low‐ and middle‐income countries (LMICs). In this paper, we study the relationship between non‐maternal adult female household members (AFHMs) and under‐5 child nutritional outcomes using nationally representative Ethiopian Demographic and Health Survey data, 2016. Because most of the primary inputs that go into the production of child health are intensive in maternal time, having additional AFHMs may ease the time constraints of the child's mother. We use anthropometric measures such as height‐for‐age z‐scores (HAZ) and weight‐for‐age z‐scores (WAZ) to measure stunting and underweight, respectively, as objective indicators of child nutritional status. Among our sampled households, we find that 40% of the children are stunted, 18% severely stunted, 27% underweight and 8% severely underweight. Furthermore, about 20% of the sampled children live with at least one extra non‐maternal AFHM. The multivariate regression results suggest that an additional AFHM is associated with significantly higher HAZ and WAZ scores and less likelihood of severe stunting compared with children living with fewer AFHMs. Finally, the paper discusses the potential pathways through which non‐maternal AFHMs can influence child nutritional status. [ABSTRACT FROM AUTHOR]

The Diabetes and Antenatal Milk Expressing (DAME) randomised controlled trial (RCT) was conducted in 2011–2015, at six sites in Melbourne, Australia to explore the effect of advising women with diabetes in pregnancy to express breast milk from 36 weeks gestation. Infants whose mothers were randomised to express in pregnancy were more likely to be exclusively breast milk fed during their hospital stay, and there was no evidence of harm. This paper explores women's views and experiences of antenatal expressing. In this two‐arm RCT, 635 women with diabetes in pregnancy who were otherwise of low medical risk were randomised at 36–37 weeks gestation to usual care (not expressing, n = 316), or the intervention, where women were advised to hand express for 10 min twice daily until birth (n = 319). Semistructured face‐to‐face interviews were conducted with 10 women who expressed antenatally. They were asked about their experiences of antenatal expressing, including how they felt about the overall experience, the amount of breast milk they expressed, making time to express, and their experience of breastfeeding. Thematic analysis of the in‐depth interviews identified six themes: (1) learning and adapting expressing, (2) feelings and sensations associated with expressing, (3) support, (4) dis/empowerment, (5) health, and (6) the value of breast milk. Women had both positive and negative experiences of antenatal expressing. If health professionals are advising antenatal expressing to women, it is important they understand the range of outcomes and experiences. Key messages: Women's experiences of antenatal expressing were both positive and negative; it is important to understand the range of experiences.Women should be advised that some women express little or no breast milk antenatally and therefore be reassured if they are concerned.For women with diabetes in pregnancy, their diabetes management is a significant time burden, and should be considered when discussing antenatal expressing with women.Maternity care providers need to follow‐up with pregnant women advised to express, to provide education, reassurance, and reassess expressing techniques.Maternity care providers need to manage and prioritise the use of expressed breast milk. [ABSTRACT FROM AUTHOR]

South Africa has a documented high prevalence of stunting and increasing obesity in children as well as obesity in adults. The double burden of malnutrition, which can be on an individual‐, household‐ or population level, has implications for both health and the economic development of a community and country. This paper describes a large‐scale survey (N = 774) of infant feeding, growth monitoring and anthropometry among mother and child pairs aged 6 months of age in KwaZulu‐Natal (KZN), South Africa, conducted between January and August 2017. Among children, a large increase in the prevalence of stunting and obesity was seen between birth and 6 months of age increasing from 9.3% to 21.7% and 4.0% to 21.0%, respectively. 32.1% of the mothers were overweight [body mass index (BMI): 25.0–29.9] and 28.4% had obesity grade 1 (BMI: 30–<40). Although most mothers (93%; 563/605) initiated breastfeeding, the introduction of other foods started early with 17.6% (56/319) of the mothers having started giving other fluids or food to their child within the first month. At 6 months 70.6% (427/605) children were still breastfed and 23.5% were exclusively breastfed. In addition, we found that length measurements were done less frequently than weight measurements between birth and 6 months, on average 2.2 (SD: 1.3) versus 5.8 (SD: 1.5) times. Moreover, there is a need for improvement of health worker training and understanding regarding anthropometric measurements when assessing malnutrition in children in the clinics. Early detection and improved infant feeding practices are key in preventing both stunting and obesity in children. Key messages: The double burden of malnutrition is severe in KwaZulu‐Natal with high rates of maternal obesity and increasing prevalence of stunting and obesity among infants in the first 6 months of life.Breastfeeding and complementary feeding practices are suboptimal and additional support for breastfeeding is required in the post‐natal period and in the workplace to address breastfeeding challenges.Growth monitoring is inadequate in health facilities leading to many lost opportunities for early identification of malnutrition. Hence, anthropometric practices and interpretation of findings need to be strengthened. [ABSTRACT FROM AUTHOR]

We evaluate the immediate impact of a nutrition and gender behaviour change communication on dietary quality in rural communities in Myanmar and assess whether the communication helped mitigate the effect of the COVID‐19 crisis on dietary quality. The intervention was designed and implemented as a cluster‐randomised controlled trial in which 15 villages received the intervention and 15 control villages did not. The intervention was implemented from June to October 2020. This paper provides an assessment of the intervention's impact on dietary quality based on the results of two phone surveys conducted in August and October 2020. Immediate impacts of the intervention indicate an improvement in women's dietary diversity scores by half a food group out of 10. At baseline, 44% of women were likely to have consumed inadequately diverse diets; results indicate that 6% (p‐value: 0.003, SE: 0.02) fewer sample women were likely to have consumed inadequately diverse diets. More women in treatment villages consumed pulses, nuts, eggs and Vitamin A‐rich foods daily than in control villages. In response to economic shocks related to COVID‐19, households in the treatment villages were less likely to reduce the quantity of meat and fish consumption than in control villages. The long‐term impacts of the intervention need to be continuously evaluated. [ABSTRACT FROM AUTHOR]

The importance of support to breastfeeding success is well established, as are the difficulties many mothers face in accessing the support they need. With the majority of UK mothers now accessing social media for support, Breastfeeding Support Facebook (BSF) groups have increased exponentially. BSF groups vary in type (local or national/international) and in moderation—overseen by breastfeeding mothers and by midwives or trained lactation specialists. Some groups aimed at supporting mothers in a specific geographical area also have associated face‐to‐face groups, facilitated as either professional or peer support. Little is currently known about these specific local groups, their prevalence, impact or value to mothers. This paper examines mothers' experiences of using local BSF groups and why they value them as part of a larger study exploring the impact of midwife moderation on these groups. An online survey consisting of open and closed questions was completed by 2028 mothers. Findings identified that local BSF groups are widely used and highly valued for their connection with local face‐to‐face services and other mothers. They offer access to expertise and shared experience in a format mothers find convenient and timely, improving confidence and self‐efficacy. Local BSF groups enable the formation of support networks and development of breastfeeding knowledge that mothers credit with increased well‐being, motivation and breastfeeding duration. As such, they have the potential to add value to local face‐to‐face services and improve breastfeeding experiences and knowledge in communities. The findings have important implications to support the development of integrated online interventions to improve public health. [ABSTRACT FROM AUTHOR]

Infants born preterm, low birthweight or with other perinatal complications require frequent and accurate growth monitoring for optimal nutrition and growth. We implemented an mHealth tool to improve growth monitoring and nutritional status assessment of high risk infants. We conducted a pre–post quasi‐experimental study with a concurrent control group among infants enrolled in paediatric development clinics in two rural Rwandan districts. During the pre‐intervention period (August 2017–January 2018), all clinics used standard paper‐based World Health Organization (WHO) growth charts. During the intervention period (August 2018–January 2019), Kirehe district adopted an mHealth tool for child growth monitoring and nutritional status assessment. Data on length/height; weight; length/height‐for‐age (L/HFA), weight‐for‐length/height (WFL/H) and weight‐for‐age (WFA) z‐scores; and interval growth were tracked at each visit. We conducted a 'difference‐in‐difference' analysis to assess whether the mHealth tool was associated with greater improvements in completion and accuracy of nutritional assessments and nutritional status at 2 and 6 months of age. We observed 3529 visits. mHealth intervention clinics showed significantly greater improvements on completeness for corrected age (endline: 65% vs. 55%; p = 0.036), L/HFA (endline: 82% vs. 57%; p ≤ 0.001), WFA (endline: 93% vs. 67%; p ≤ 0.001) and WFL/H (endline: 90% vs. 59%; p ≤ 0.001) z‐scores compared with control sites. Accuracy of growth monitoring did not improve. Prevalence of stunting, underweight and inadequate interval growth at 6‐months corrected age decreased significantly more in the intervention clinics than in control clinics. Results suggest that integrating mHealth nutrition interventions is feasible and can improve child nutrition outcomes. Improved tool design may better promote accuracy. [ABSTRACT FROM AUTHOR]

Prior research has identified a number of risk factors ranging from inadequate household sanitation to maternal characteristics as important determinants of child malnutrition and health in India. What is less known is the extent to which these individual‐level risk factors are geographically distributed. Assessing the geographic distribution, especially at multiple levels, matters as it can inform where, and at what level, interventions should be targeted. The three levels of significance in the Indian context are villages, districts, and states. Thus, the purpose of this paper was to (a) examine what proportion of the variation in 21 risk factors is attributable to villages, districts, and states in India and (b) elucidate the specific states where these risk factors are clustered within India. Using the fourth National Family Health Survey dataset, from 2015 to 2016, we found that the proportion of variation attributable to villages ranged from 14% to 63%, 10% to 29% for districts and 17% to 62% for states. Furthermore, we found that Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh were in the highest risk quintile for more than 10 of the risk factors included in our study. This is an indication of geographic clustering of risk factors. The risk factors that are clustered in states such as Bihar, Jharkhand, Madhya Pradesh and Uttar Pradesh underscore the need for policies and interventions that address a broader set of child malnutrition determinants beyond those that are nutrition specific. [ABSTRACT FROM AUTHOR]

Industrialization and urbanization processes have challenged deeply held traditional gender norms and facilitated the emergence of modern ideologies in South Africa. This paper seeks to explore the gendered roles of family members on maternal and child nutrition and investigate indications of perceived change in related practices. A qualitative secondary analysis was conducted of data from nine focus group discussions (FGDs) held with men (n = 3) and women (n = 6) aged ≥18. Data from the FGD were coded and thematic analysis conducted. We found that elderly women seem to have a central advisory role with respect to maternal and child nutrition and that men and elderly women upheld patriarchal gender divisions of labour, which entrust mothers with the primarily responsibility for young children's nutrition. Young mothers relied on elderly women for provision of childcare and nutritious foods for children; however, they demonstrated some resistance to traditionally feminized forms of food preparation. We found that men's involvement in children's nutrition was limited, though they expressed a preference to be more involved in maternal and child nutrition and care practices. A gender transformative approach to policy development, which includes elderly women and men, has the potential to promote more gender‐equitable nutrition practices, increase young women's self‐efficacy and support them to overcome barriers that could be limiting their decision making power in achieving optimal nutrition for themselves and their children. [ABSTRACT FROM AUTHOR]

Success of nutrition‐sensitive agriculture programmes targeted to women may be influenced by increased demands on women's and other household members' time and by time‐related trade‐offs to accommodate programme participation. However, evidence of how such programmes impact time use and whether changes in time‐related demands negatively influence maternal or child health and nutrition outcomes is limited. This paper examines the impact of Helen Keller International's Enhanced Homestead Food Production programme in Burkina Faso (2010–2012) on women's and men's time use and associations between changes in women's time use and maternal and child health and nutrition outcomes. We used quantitative data from a cluster‐randomized controlled trial (baseline 2010, endline 2012) and qualitative data from two rounds of process evaluation (2011, 2012). Two‐stage analyses were used to first assess programme impacts on women's and men's time use using difference‐in‐difference impact estimates and second to evaluate whether programme impacts on women's time use were associated with changes in women's and children's health and nutrition outcomes. Programme impacts were considered significant if corrected P < 0.01, and associations were considered significant if p < 0.05 and p < 0.01. Qualitative data were analysed through manual coding and by calculating the means and standard deviations for the time spent by women and men on activities in intervention and control groups. Findings show that the programme significantly increased the amount of time women spent on agriculture in the intervention compared to the control group, but this was not associated with changes in maternal or child health or nutrition outcomes. Process evaluation data supported these findings. [ABSTRACT FROM AUTHOR]

Micronutrient deficiencies remain common among women and children in Sub‐Saharan Africa (SSA); in pregnant/lactating women, the intakes of essential fatty acids may also be low. Enriching home‐prepared foods with small‐quantity lipid‐based nutrient supplements (SQ‐LNSs) is a promising new strategy of delivering additional micronutrients, essential fatty acids and good quality protein to women and children. This narrative review aimed to examine the impact of SQ‐LNSs supplementation among women and infants and young children in SSA, and to discuss the differential impact of SQ‐LNS consumption across different settings. Papers reporting randomized trials conducted in SSA in which apparently healthy women and/or ≥6‐mo‐old children received SQ‐LNSs were identified through electronic and manual searches. Prenatal SQ‐LNS consumption reduced the prevalence of low gestational weight gain in Ghana when compared with multiple micronutrients supplementation, and was associated with poorer iron/hemoglobin status when compared with iron‐plus‐folic acid supplementation. SQ‐LNSs received alone or as intervention package improved infant/child growth in two trials in Ghana and one trial each in Burkina Faso, Kenya, Zimbabwe and South Africa, but had no impact on growth in two trials in Malawi. SQ‐LNSs supplementation improved motor development in Ghana, Burkina Faso, Malawi, Kenya, and South Africa, but had no impact on language, socio‐emotional, and executive functions in Ghana and Malawi and on Griffiths' developmental scores in Malawi. SQ‐LNSs may contribute to improving child growth in SSA. More research is needed to determine the iron level in SQ‐LNSs effective for improving both maternal hemoglobin/iron status and birth outcomes. [ABSTRACT FROM AUTHOR]

Growing evidence suggests that household sanitation is associated with child nutritional status in low‐ and middle‐income countries. This paper examined whether household access to improved sanitation facilities and sources of drinking water was associated with stunting and anaemia amongst children aged 6–35 months of age in Indonesia. The sample for the analysis comprised 1,450 children aged 6–35 months who participated in the end‐line survey of the maternal and young child nutrition security project in Asia, conducted in three selected districts in Indonesia. Logistic regression models were used to determine the association between household sanitation and water source, and stunting and anaemia. Approximately 26% and 56% of children 6–35 months of age were stunted and anaemic, respectively. Children living in a household with improved sanitation facilities had 29% reduced odds of being stunted compared with those in a household with unimproved sanitation facilities, after adjusting for potential confounders including child's age and gender, maternal education, and iron–folic acid supplementation, as well as household wealth status and source of drinking water (OR = 0.68, 95% CI:0.48–0.96). No association between household sanitation and childhood anaemia was observed. Source of drinking water was not associated with stunting or anaemia amongst children. There were no synergistic effects of household sanitation and water supply on stunting and anaemia. This suggests that efforts to improve household sanitation condition may need to be considered an essential, integral part of the programmatic responses by governments and development partners for the prevention of childhood nutritional status. Further randomised research is necessary to determine the causal link. [ABSTRACT FROM AUTHOR]

Behavioural change communication interventions have been shown to be effective at improving infant and young child nutrition knowledge and practices. However, evidence in humanitarian response contexts is scarce. Using data on secondary outcomes of breastfeeding, water treatment, and knowledge from a cluster randomized control trial of the Yemen Cash for Nutrition programme's impact on child nutritional status, this paper shows that the programme significantly improved knowledge and practices for poor women with young children in the pilot districts. The intervention consisted of cash transfers and monthly group nutrition education sessions led by locally recruited community health volunteers. Data are based on self‐reports by participants. Estimating impacts among all 1,945 women in 190 clusters randomly assigned to treatment versus control and controlling for baseline levels and community characteristic and adjusting for noncompliance with randomization, the programme increased the probability of breastfeeding initiation within the first hour after delivery by 15.6% points (p <.05; control = 74.4% and treatment = 83.6%), the probability of exclusive breastfeeding during the first 6 months by 14.4% points (control = 13.5% and treatment = 25.3%), the probability of households treating water consumed by adults by 16.7% points (p <.01; control = 13.9% and treatment = 23.4%), and treating water consumed by children under two by 10.3% points (p <.10; control = 31.2% and treatment = 37.9%). Impacts on knowledge and breastfeeding are similar for both literate and illiterate women, and water treatment impacts are significantly larger for literate women. This study was registered at 3ie (RIDIE‐STUDY‐ID‐5b4eff881b29a) and funded by the Nordic Trust Fund and Consultative Group on International Agricultural Research programme on Policies, Institutions, and Markets. [ABSTRACT FROM AUTHOR]

The new millennium brought renewed attention to improving the health of women and children. In this same period, direct deaths from conflicts have declined worldwide, but civilian deaths associated with conflicts have increased. Nigeria is among the most conflict‐prone countries in Sub‐Saharan Africa, especially recently with the Boko Haram insurgency in the north. This paper uses two data sources, the 2013 Demographic and Health Survey for Nigeria and the Social Conflict Analysis Database, linked by geocode, to study the effect of these conflicts on infant and young child acute malnutrition (or wasting). We show a strong association in 2013 between living close to a conflict zone and acute malnutrition in Nigerian children, with larger effects for rural children than urban children. This is related to the severity of the conflict, measured both in terms of the number of conflict deaths and the length of time the child was exposed to conflict. Undoubtedly, civil conflict is limiting the future prospects of Nigerian children and the country's economic growth. In Nigeria, conflicts in the north are expected to continue with sporadic attacks and continued damaged infrastructure. Thus, Nigerian children, innocent victims of the conflict, will continue to suffer the consequences documented in this study. [ABSTRACT FROM AUTHOR]

This paper aimed to examine the effect of breastfeeding on longitudinal patterns of common infections up to 2 years and respiratory symptoms up to 8 years. To assess the incidence and reoccurrence of infections and allergic symptoms in the first years of life among 1,603 children from the EDEN mother–child cohort, distinct longitudinal patterns of infectious diseases as well as skin rash and respiratory symptoms were identified by group‐based trajectory modelling. To characterize infections, we considered the parent‐reported number of cold/nasopharyngitis and diarrhoea from birth to 12 months and otitis and bronchitis/bronchiolitis from birth to 2 years. To characterize allergy‐related symptoms, we considered the parent‐reported occurrence of wheezing and skin rash from 8 months to 8 years and asthma from 2 to 8 years. Then associations between breastfeeding and these longitudinal patterns were assessed through adjusted multinomial logistic regression. Compared with never‐breastfed infants, ever‐breastfed infants were at a lower risk of diarrhoea events in early infancy as well as infrequent events of bronchitis/bronchiolitis throughout infancy. Only predominant breastfeeding duration was related to frequent events of bronchitis/bronchiolitis and infrequent events of otitis. We found no significant protective effect of breastfeeding on longitudinal patterns of cold/nasopharyngitis, skin rash, or respiratory symptoms. For an infant population with a short breastfeeding duration, on average, our study confirmed a protective effect of breastfeeding on diarrhoea events in early infancy, infrequent bronchitis/bronchiolitis and, to a lesser extent, infrequent otitis events up to 2 years but not on other infections, skin rash, or respiratory symptoms4. In an infant population with a short breastfeeding duration and using longitudinal patterns of infection, skin rash and respiratory symptoms, on average, our study confirmed a protective effect of breastfeeding on diarrhea events in early infancy, infrequent bronchitis/bronchiolitis and, to a lesser extent,infrequent otitis events up to 2 years but not on cold/ nasopharyngitis, skin rash or respiratory symptoms. [ABSTRACT FROM AUTHOR]

Breastfeeding is beneficial to both the mother and infant, yet many infants are either partially or fully fed with formula milk. Those parents feeding with formula receive less support from professional sources than those breastfeeding and may rely on more non‐professional sources for advice, and this contributes to negative emotional experiences such as guilt. This paper explores the sources of advice for formula feeding, factors associated with using professional or non‐professional sources and compares these sources with those used for breastfeeding advice. A secondary analysis of Australian survey data from 270 mothers was performed. Mothers of six‐month‐old infants participated in an online survey, providing information on advice they received or read about formula feeding and/or breastfeeding from professional and non‐professional sources. A fifth of mothers who were formula feeding did not receive any formula feeding advice from professional sources, and only a small fraction (4.5%) of mothers breastfeeding did not received any breastfeeding advice from professional sources. Compared with those mothers breastfeeding receiving breastfeeding advice, fewer mothers formula feeding receive formula feeding advice from both professional and non‐professional sources. The tin of formula was the most used source of formula advice. Mothers feeding with formula at six months were more likely to have received formula feeding advice from professional sources if they had been fully formula feeding before their infant was under the age of three months. Further research is needed to understand the specific barriers to accessing formula feeding advice and what other factors influence access to formula feeding advice. [ABSTRACT FROM AUTHOR]

Abstract: Breastfeeding is challenging for mothers of preterm infants. The aim of this paper is to describe risk factors for ceasing breastfeeding and methods of feeding until 12 months postnatal age in mothers who breastfed their preterm infants at discharge from neonatal intensive care units (NICUs). The data come from a randomised controlled trial, which evaluated the effectiveness on exclusive breastfeeding at 8 weeks of proactive telephone support compared with reactive support offered to mothers of preterm infants following discharge from NICU. Six NICUs across Sweden randomised a total of 493 mothers. We used regression and survival analyses to assess the risk factors for ceasing breastfeeding and the long‐term outcomes of the intervention. The results showed that 305 (64%) of the infants were breastfed at 6 months and 49 (21%) at 12 months. Partial breastfeeding at discharge, low maternal educational level, and longer length of stay in the NICU increased the risk for ceasing breastfeeding during the first 12 months. Furthermore, the Kaplan–Meier analysis showed that the proportion of mothers who ceased breastfeeding did not differ between the intervention (n = 231) and controls (n = 262) during the first 12 months (log‐rank test p = .68). No difference was found between groups on method of feeding. More than 85% of the infants were fed directly at the breast. These findings provide important insights for health professionals who are supporting mothers of preterm infants to breastfeed long term. Registered in www.clinicaltrials.gov (NCT01806480). [ABSTRACT FROM AUTHOR]

Abstract: Improving infant and young child feeding practices is critical for improving growth and reducing child mortality and morbidity. This paper aims to compare predictors of minimum dietary diversity, an important indicator of adequate complementary feeding practices, in Bangladesh in 2011 and 2014. The 2011 and 2014 Bangladesh Demographic and Health Survey were used to examine predictors of minimum dietary diversity among 6–23 months. An additional analysis was conducted for the 18–23‐month group, because a significant increase in meeting minimum dietary diversity recommendations was seen in this age group only. Factors found to be associated with practices were compared across time points. In 2011, minimum dietary diversity was 23.8% and increased to 28.8% in 2014. Among children 18–23 months, in 2011, minimum dietary diversity was 32.5% and increased to 42.8% in 2014. Among all children, wealth, education, exposure to media, and antenatal care were significant predictors of dietary diversity. In the 18–23‐month age group, significant predictors in 2011 were wealth and decision making. In 2014, significant predictors were education and exposure to media. Demographic trends indicated a significant increase in education and exposure to media between 2011 and 2014. As these were significant for minimum dietary diversity in 2014 overall and for 18–23 months, they might be important targets of future interventions, specifically utilizing media channels and tailoring special strategies for women with low education and limited exposure to media. [ABSTRACT FROM AUTHOR]

Abstract: Caregivers make decisions about how to feed their infants and young children based on complex interactions of knowledge, beliefs, and values, as well as assessments of situational determinants, including economic and social constraints and opportunities. Because of the relationship of these factors to the adoption of new feeding behaviours, the development of nutrition interventions for this age group must be grounded in knowledge about the target population. This paper presents the results of a study that used cognitive mapping techniques to gain insight into mothers' knowledge and perceptions of foods for infants and young children and examine their significance for feeding decisions in Saint‐Louis, northern Senegal. Guided by mixed‐methods protocols from the Focused Ethnographic Study for Infant and Young Child Feeding Manual, in‐depth interviews that included qualitative discussions and cognitive mapping techniques were conducted with 46 mothers in rural and peri‐urban communities. We explored mothers' perceptions about five dimensions that affect food decision‐making—healthiness, convenience, child acceptance, appeal, and modernity—and the relationship of these dimensions to 38 local food items. Data analysis entailed a combination of qualitative thematic analysis and descriptive statistics. In both communities, “healthiness” was the most valued dimension for food decision‐making by a large margin, followed by child acceptance, appeal, modernity, and convenience. We explore how different interpretations and definitions of these dimensions, and their relationship to specific local food items, may influence the design and planning of nutrition interventions. The results support the importance of mixed‐methods formative research to illuminate the emic perspectives of caregivers. [ABSTRACT FROM AUTHOR]

Breastfeeding is recommended until 6 months of age, but a wide range of infant formula is available for nonbreastfed or partially breastfed infants. Our aim was to describe infant formula selection and to examine social- and health-related factors associated with this selection. Analyses were based on 13,291 infants from the French national birth cohort Etude Longitudinale Française depuis l'Enfance. Infant diet was assessed at Month 2 by phone interview and monthly from Months 3 to 10 via internet/paper questionnaires. Infant formulas were categorized in 6 groups: extensively or partially hydrolysed, regular with or without prebiotics/probiotics, and thickened with or without prebiotics/probiotics. Associations between type of infant formula used at 2 months and family or infant characteristics were assessed by multinomial logistic regressions. At Month 2, 58.1% of formula-fed infants were fed with formula enriched in prebiotics/probiotics, 31.5% with thickened formula, and 1.4% with extensively hydrolysed formula. The proportion of formula-fed infants increased regularly, but the type of infant formula used was fairly stable between 2 and 10 months. At Month 2, extensively hydrolysed formulas were more likely to be used in infants with diarrhoea or regurgitation problems. Partially hydrolysed formulas were more often used in families with high income, with a history of allergy, or with infants with regurgitation issues. Thickened formulas were used more with boys, preterm infants, infants with regurgitation issues, or in cases of early maternal return to work. The main factors related to the selection of infant formula were family and infant health-related ones. [ABSTRACT FROM AUTHOR]

Behaviour change communication (BCC) can improve infant and young child nutrition (IYCN) knowledge, practices, and health outcomes. However, few studies have examined whether the improved knowledge persists after BCC activities end. This paper assesses the effect of nutrition sensitive social protection interventions on IYCN knowledge in rural Bangladesh, both during and after intervention activities. We use data from two, 2-year, cluster randomised control trials that included nutrition BCC in some treatment arms. These data were collected at intervention baseline, midline, and endline, and 6-10 months after the intervention ended. We analyse data on IYCN knowledge from the same 2,341 women over these 4 survey rounds. We construct a number correct score on 18 IYCN knowledge questions and assess whether the impact of the BCC changes over time for the different treatment groups. Effects are estimated using ordinary least squares accounting for the clustered design of the study. There are 3 main findings: First, the BCC improves IYCN knowledge substantially in the 1st year of the intervention; participants correctly answer 3.0-3.2 more questions (36% more) compared to the non-BCC groups. Second, the increase in knowledge between the 1st and 2nd year was smaller, an additional 0.7-0.9 correct answers. Third, knowledge persists; there are no significant decreases in IYCN knowledge 6-10 months after nutrition BCC activities ended. [ABSTRACT FROM AUTHOR]

An alternative Community-based Management of Acute Malnutrition model with community health workers (CHWs) delivering treatment for uncomplicated severe acute malnutrition (SAM) was piloted in Mali. The capacity of the CHWs to evaluate, classify, and treat cases of uncomplicated SAM, to provide nutritional counselling to caretakers of children receiving treatment for SAM, malaria, pneumonia or diarrhoea and to correctly refer cases of complicated SAM, was assessed. This was done using direct observation by trained enumerators of the management of SAM cases using checklists, re-diagnosing the cases admitted for treatment and reviewing admissions cards and registers. One hundred twenty-five cases, assessed and treated by the CHWs, were observed. The majority of children were correctly assessed for the presence of major clinical signs (cough, diarrhoea, fever, and vomiting; 97.6%), and similarly most children were checked for the presence of danger signs (95.2%). Mid-upper arm circumference was correctly assessed in 96.8% of children and oedema was correctly assessed in 78.4% (The composite indicator, which includes all essential tasks to provide high-quality treatment, was achieved in 79.5% of cases. This paper concludes that well-trained and supervised CHWs are capable of managing cases of uncomplicated SAM. This suggests that such a strategy is an opportunity to increase access to quality treatment in Mali for SAM cases. However, further evidence is required to ensure that this level of care can be achieved at scale. [ABSTRACT FROM AUTHOR]

Appropriate feeding practices are crucial for survival, growth, and development in childhood. This paper analyzes Pakistan's Demographic and Health Survey 2012-2013 to fill the knowledge gap in risk factors of poor complementary feeding practices in Pakistani children. Multilevel models were applied to fit the multistage cluster sample of 2,827 children aged 6-23 months from 489 communities. Introduction of solid, semi-solid, or soft foods (intro) was achieved in 67% infants aged 6-8 months. Among children aged 6-23 months, the proportion of children meeting minimum meal frequency, dietary diversity (MDD), and acceptable diet criteria were 63%, 22% and 15%, respectively. Consumption of legumes and nuts, flesh foods, and vitamin A-rich fruits and vegetables was low in all children (6-19%), even among children who met the MDD criteria (15-55%). Younger child age, especially between 6 and 11 months and delayed maternal postnatal checkup were significant individual-level risk factors that consistently increased the odds of not meeting all four criteria examined. Fewer antenatal care visits predicted the odds of achieving intro and minimum meal frequency while younger maternal age and household poverty predicted the odds of achieving MDD and minimum acceptable diet. Community-level factors included geographic region and general access to maternal and child health care services. The overall poor quality of children's complementary diets in Pakistani calls for stronger policy and program action to promote the consumption of key nutrient-dense foods while prioritizing interventions for the most vulnerable children and populations. [ABSTRACT FROM AUTHOR]

Studies have identified an association between watching television (TV) and childhood obesity. This review adds context to existing research by examining the associations between TV viewing, whilst eating, and children's diet quality. Web of Science and PubMed databases were searched from January 2000 to June 2014. Cross-sectional trials of case control or cohort studies, which included baseline data, measuring the associations between eating whilst watching TV and children's food and drink intake. Quality of selected papers was assessed. Thirteen studies, representing 61,674 children aged 1-18 yrs, met inclusion criteria. Of six studies reporting overall food habits, all found a positive association between TV viewing and consumption of pizza, fried foods, sweets, and snacks. Of eight studies looking at fruit and vegetable consumption, seven identified a negative association with eating whilst watching TV ( p < .0001). Four out of five studies identified a positive association between watching TV whilst eating and servings of sugar-sweetened beverages ( p < .0001). Four studies identified an association between low socioeconomic status and increased likelihood of eating whilst watching TV ( p ≤ .01). Family meals did not overcome the adverse impact on diet quality of having the TV on at mealtimes. Eating whilst watching television is associated with poorer diet quality among children, including more frequent consumption of sugar-sweetened beverages and high-fat, high-sugar foods and fewer fruits and vegetables. Although these differences in consumption are small, the cumulative effect may contribute to the positive association between eating whilst watching TV and childhood obesity. [ABSTRACT FROM AUTHOR]

Millions of children in low-income and middle-income countries falter in linear growth and neurobehavioral development early in life. This faltering may be caused by risk factors that are associated with both growth and development, such as insufficient dietary intake and infection in infancy. Alternatively, these risk factors may be indicative of an environment that constrains both linear growth and development through different mechanisms. In a cluster-randomized trial in Burkina Faso, we previously found that provision of lipid-based nutrient supplements plus malaria and diarrhoea treatment from age 9 to 18 months resulted in positive effects of ~0.3 standard deviation on length-for-age z-score (LAZ) and of ~0.3 standard deviation on motor, language and personal-social development scores at age 18 months. In this paper, we examined whether the effect of the intervention on developmental scores was mediated by the effect on LAZ, or, alternatively, whether the intervention had independent effects on growth and development. For motor, language, and personal-social z-scores, the effect of the intervention decreased from 0.32 to 0.21, from 0.33 to 0.27 and from 0.35 to 0.29, respectively, when controlling for change in LAZ from 9 to 18 months. All effects remained significant. These results indicate that the intervention had independent positive effects on linear growth and development, suggesting that these effects occurred through different mechanisms. © 2016 John Wiley & Sons Ltd [ABSTRACT FROM AUTHOR]

Pregnancy and lactation are a time when adequate calcium consumption is essential for the development of the fetus and to ensure the health of the mother. Over 50% of Canadian women of childbearing and rearing age fail to meet the recommended daily intake of calcium. Identification of effective behavioural intervention strategies for increasing calcium intake is needed within this specific population. This paper brings together all published behavioural interventions designed to increase calcium consumption in pregnant, lactating or post‐partum mothers in a systematic review. Relevant studies were obtained through searches of MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library with no date restrictions. Studies were evaluated using previously published criteria for evaluating calcium behaviour change interventions. This systematic literature review identified five behavioural calcium interventions conducted within this population. Three interventions aimed to improve overall dietary behaviours, the fourth aimed to promote breastfeeding (including increasing calcium consumption) and the fifth aimed to increase daily servings of yoghurt. Only one of the five interventions yielded large effect sizes, with a mean change of 954 mg of calcium per day post‐intervention. The number of behavioural change techniques did not appear to be related to intervention efficacy. Only one study used a theoretical framework to guide the intervention. This review highlights the lack of research examining behaviour change interventions aimed at increasing calcium consumption in pregnant, lactating and post‐partum women and provides practical suggestions for researchers wishing to intervene with this population in the future. [ABSTRACT FROM AUTHOR]

Dietary intake during pregnancy influences maternal health. Poor dietary practices during pregnancy have been linked to maternal complications. The objective was to determine the effect of dietary intervention before or during pregnancy on pregnancy outcomes. A systematic review was conducted without date restrictions. Randomised controlled trials (RCTs) evaluating whole diet or dietary components and pregnancy outcomes were included. Two authors independently identified papers for inclusion and assessed methodological quality. Meta‐analysis was conducted separately for each outcome using random effects models. Results were reported by type of dietary intervention: (1) counselling; (2) food and fortified food products; or (3) combination (counselling + food); and collectively for all dietary interventions. Results were further grouped by trimester when the intervention commenced, nutrient of interest, country income and body mass index. Of 2326 screened abstracts, a total of 28 RCTs were included in this review. Dietary counselling during pregnancy was effective in reducing systolic [standardised mean difference (SMD) −0.26, 95% confidence interval (CI) −0.45 to −0.07; P < 0.001] and diastolic blood pressure (SMD −0.57, 95% CI −0.75 to −0.38; P < 0.001). Macronutrient dietary interventions were effective in reducing the incidence of preterm delivery (SMD −0.19, 95% CI −0.34 to −0.04; P = 0.01). No effects were seen for other outcomes. Dietary interventions showed some small, but significant differences in pregnancy outcomes including a reduction in the incidence of preterm birth. Further high‐quality RCTs, investigating micronutrient provision from food, and combination dietary intervention, are required to identify maternal diet intakes that optimise pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Global recommendations on strategies to improve infant feeding, care and nutrition are clear; however, there is limited literature that explains methods for tailoring these recommendations to the local context where programmes are implemented. This paper aims to: (1) highlight the individual, cultural and environmental factors revealed by formative research to affect infant and young child feeding and care practices in Baitadi district of Far Western Nepal; and (2) outline how both quantitative and qualitative research methods were used to design a context‐specific behaviour change strategy to improve child nutrition. Quantitative data on 750 children aged 12–23 months and their families were collected via surveys administered to mothers. The participants were selected using a multistage cluster sampling technique. The survey asked about knowledge, attitude and behaviours relating to infant and young child feeding. Qualitative data on breastfeeding and complementary feeding beliefs and practices were also collected from a separate sample via focus group discussions with mothers, and key informant interviews with mothers‐in‐law and husbands. Key findings revealed gaps in knowledge among many informants resulting in suboptimal infant and young child feeding practices – particularly with relation to duration of exclusive breastfeeding and dietary diversity of complementary foods. The findings from this research were then incorporated into a context‐specific nutrition behaviour change communication strategy. [ABSTRACT FROM AUTHOR]

The effects of prophylactic iron during pregnancy on maternal and child health in developing settings with endemic malaria and high prevalence of HIV remain unclear. This paper describes the rationale, implementation and success of a pragmatic randomised controlled trial comparing routine iron supplementation vs. screening and treatment for anaemia during pregnancy. The setting was two health centres in Maputo, Mozambique. Pregnant women (≥12-week gestation; ≥18 years old; and not with a high-risk pregnancy, n = 4326) were recruited. The main outcomes are preterm delivery and low birthweight. The women were randomly assigned to one of two iron administration policies: a routine iron group ( n = 2184) received 60 mg of ferrous sulphate plus 400 μg of folic acid daily while a selective iron group ( n = 2142) had screening and treatment for anaemia and a daily intake of 1 mg of folic acid. The recruitment, follow-up, and collection of follow-up data were successful; both groups were similar to each other in all the trial stages. Collection of delivery data was challenging and data on about 40% of births is missing. These are currently being traced through different hospitals and health centres. The compliance of the study personnel and the women with regard to regular measurement of haemoglobin and intake of the iron and folic acid tablets was high and similar in both trial arms. Taking into account the various constraints encountered, the stages of the present trial prior to delivery were carried out well. [ABSTRACT FROM AUTHOR]

Micronutrient powders (MNP) have the potential to increase micronutrient intake, yet documentation of implementation lessons remains a gap. This paper presents results of a pilot in Uganda comparing community‐ and facility‐based delivery of MNP and documenting experiences of caregivers and distributors. The pilot's mixed method evaluation included a cross‐sectional endline survey, monthly household visits, and midline and endline interviews. Primary outcomes were ever‐covered (received ≥1 MNP packet), repeat‐coverage (received ≥2 MNP packets), and adherence (consumed no more than 1 MNP sachet per day, consumed MNP with food, and consumed MNP 3+ days in past week). An adjusted Wald chi‐square test compared differences in programme outcomes between arms, and logit regression identified predictors to adherence. Key informant interviews were coded thematically. Most programme outcomes in the endline survey were statistically significantly higher in the community arm, although in both arms, adherence was lower than other outcomes (adherence 31.4% in facility vs. 58.3% in community arm). Counselling, receipt of communication materials, perceived positive effects, MNP knowledge, and child liking MNP were consistent predictors of adherence in both arms. Qualitative findings corroborated survey results, revealing that social encouragement and advocacy facilitated use and that forgetting to give MNP was a barrier. Facility arm caregivers also cited distance, time, and transportation cost as barriers. Distributors had positive experiences with training and supervision but experienced increased workloads in both arms. MNP programme design is context‐specific but could benefit from strengthened community sensitization, continued and more effective counselling for caregivers, and increased support for distributors. [ABSTRACT FROM AUTHOR]

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change. [ABSTRACT FROM AUTHOR]

Adequate complementary feeding (CF) practices are essential for achieving optimal growth but challenging to measure comprehensively. This paper describes CF practices in 2,034 children aged 6–23 months and investigates their relationships with length‐for‐age z‐score (LAZ) and stunting, using cross‐sectional data collected from May to July 2014 in rural Northern Togo. The World Health Organization infant and young child feeding indicators were computed, along with ancillary indicators on feeding style and timing of introduction of complementary foods. The associations between those indicators and children's LAZ and stunting were assessed using linear and logistic regressions after stratification by age group and adjustment for children, maternal, and household characteristics. CF practices were suboptimal, and their associations with child's growth varied across indicators and age groups. In children aged 6–11 months, reaching the minimum dietary diversity and the minimum acceptable diet was associated with higher LAZ (p < .05). In 18‐ to 23‐month‐old children, only the consumption of iron‐rich food was associated with both LAZ (p = .02) and stunting (p = .05). The late introduction of family foods was associated with higher odds of being stunted and lower LAZ in children aged 12–17 months (p < .001). The untimely introduction of porridge was associated with higher odds of stunting in children aged 9–23 months (p < .05). Unexpectedly, helping the child to eat was negatively associated with linear growth in all age groups. These findings nurture the ongoing process of review of the World Health Organization infant and young child feeding indicators showing that, in their current version, they hardly capture the links between CF and child's growth at different ages. [ABSTRACT FROM AUTHOR]

Micronutrient powders (MNP) are an efficacious intervention in terms of reducing anaemia among young children, yet challenges remain regarding implementation at scale. Research that can guide effective implementation of nutrition interventions and facilitate integration into existing health care platforms is needed. This paper seeks to advance the implementation science knowledge base by presenting our multiphased strategy and findings for scaling‐up MNP in Rwanda. The multiphased implementation strategy, spanning a 5‐year period (2011–2016), included (a) a feasibility study involving formative research, (b) a 30‐day trial of improved practices (n = 60 households), (c) a 12‐month pilot that included an effectiveness study (n = 1,066 caregiver/child pairs), and (d) a staggered approach to national scale‐up. At the end of Phase 4, the programme had been implemented in 19 of Rwanda's 30 districts with the scale‐up in the final 11 districts completed in the following year. The caregivers of over 270,000 eligible children 6–23 months of age received a box of 30 MNP sachets in the final 3‐month assessment period, representing a coverage rate of 87%. Initial problems with the supply chain and distribution and ongoing challenges to monitoring and reporting have been the largest obstacles. Continued success will be dependent on adequate resources for capacity development, refresher training, and responsive monitoring. Rwanda is one of the first countries to successfully scale‐up home fortification subnationally with MNP. Lessons learned have implications for other countries. [ABSTRACT FROM AUTHOR]

The Baby‐Friendly Community Initiative (BFCI) is an extension of the 10th step of the Ten Steps of Successful Breastfeeding and the Baby‐Friendly Hospital Initiative (BFHI) and provides continued breastfeeding support to communities upon facility discharge after birth. BFCI creates a comprehensive support system at the community level through the establishment of mother‐to‐mother and community support groups to improve breastfeeding. The Government of Kenya has prioritized community‐based programming in the country, including the development of the first national BFCI guidelines, which inform national and subnational level implementation. This paper describes the process of BFCI implementation within the Kenyan health system, as well as successes, challenges, and opportunities for integration of BFCI into health and other sectors. In Maternal and Child Survival Program (MCSP) and UNICEF areas, 685 community leaders were oriented to BFCI, 475 health providers trained, 249 support groups established, and 3,065 children 0–12 months of age reached (MCSP only). Though difficult to attribute to our programme, improvements in infant and young child feeding practices were observed from routine health data following the programme, with dramatic declines in prelacteal feeding (19% to 11%) in Kisumu County and (37.6% to 5.1%) in Migori County from 2016 to 2017. Improvements in initiation and exclusive breastfeeding in Migori were also noted—from 85.9% to 89.3% and 75.2% to 92.3%, respectively. Large gains in consumption of iron‐rich complementary foods were also seen (69.6% to 90.0% in Migori, 78% to 90.9% in Kisumu) as well as introduction of complementary foods (42.0–83.3% in Migori). Coverage for BFCI activities varied across counties, from 20% to 60% throughout programme implementation and were largely sustained 3 months postimplementation in Migori, whereas coverage declined in Kisumu. BFCI is a promising platform to integrate into other sectors, such as early child development, agriculture, and water, sanitation, and hygiene. [ABSTRACT FROM AUTHOR]

The Baby‐Friendly Hospital Initiative (BFHI) has shown to strengthen health providers' skills in the provision of breastfeeding counselling and support, which have led to improvements in breastfeeding outcomes. In Malawi, where BFHI was introduced in 1993 but later languished due to losses in funding, the Maternal and Child Survival Program supported the Malawi Ministry of Health (MOH) in the revitalization and scale‐up of BFHI in 54 health facilities across all 28 districts of the country. This paper describes the revitalization and scale‐up process within the context of an integrated health project; successes, challenges, and lessons learned with BFHI implementation; and the future of BFHI in Malawi. More than 80,000 mothers received counselling on exclusive breastfeeding following childbirth prior to discharge from the health facility. Early initiation of breastfeeding was tracked quarterly from baseline through endline via routine MOH health facility data. Increases in early initiation of breastfeeding were seen in two of the three regions of Malawi: by 2% in the Central region and 6% in the Southern region. Greater integration of BFHI into Malawi's health system is recommended, including improved preservice and in‐service trainings for health providers to include expanded BFHI content, increased country financial investments in BFHI, and integration of BFHI into national clinical guidelines, protocols, and nutrition and health policies. [ABSTRACT FROM AUTHOR]

This study reviews the performance of a community‐based nutrition programme in preventing and treating wasting without complications among children under age three in urban informal settlements of India. Implemented by a non‐profit organization, with national (Integrated Child Development Services [ICDS]) and city‐level (Municipal Corporation of Greater Mumbai [MCGM]) government partners, the programme screened 7,759 children between May 2014 and April 2015. During this period, the programme admitted 705 moderately wasted and 189 severely wasted children into the treatment group and 6,820 not wasted children into the prevention group. Both prevention and treatment groups received growth monitoring, referrals to public health facilities, and home‐based counselling (if <6 months) by community health workers. Treatment groups received additional home‐based counselling and access to medical screenings. Severely wasted children also received access to ready‐to‐use therapeutic food. The study assessed default rates, wasting status, and average weight gain 3 months after admission. Factors associated with growth faltering in the prevention group were explored using logistic regression. Default rates for the severely wasted, moderately wasted, and prevention group were 12.7%, 20.4%, and 22.1%, respectively. Recovery rate was 42.4% for the severely wasted and 61.3% for the moderately wasted. For the moderately wasted, mean weight gain was 2.1 g/kg/day, 95% confidence interval (CI) [1.6, 2.6], and 4.5 g/kg/day for the severely wasted, 95% CI [3.1, 5.9]. Among prevention group children, 3.6% faltered into wasting—3.2% into moderate and 0.4% into severe. The paper gives insights into ways in which ICDS and MCGM can successfully integrate large‐scale community‐based acute malnutrition programming. [ABSTRACT FROM AUTHOR]

Suboptimal nutrition has been largely associated with poorer perinatal outcomes. However, an inability to compare data between biologically and geographically diverse cohorts has complicated determination of the role of diet in such conditions. The aim of this paper is to describe the design, development, and evaluation of the Maternal Outcomes and Nutrition Tool (MONT), a novel cross‐cultural digital dietary data collection tool. The tool was modelled on previously validated food frequency questionnaires and designed for exclusive administration in the digital environment, featuring minimal language and emphasis on images. Participants were recruited by both passive and active means. A total of 502 women were recruited; descriptive statistics were used to describe the cohort. Pregnant women constituted the majority of subjects recruited (n = 376, 74.9%), 63% of which were nulliparous. Women were recruited from 13 ethnicities and 20 countries of birth. Of the 341 women who commenced the surveys (68%), 114 submitted complete datasets (33.5%). Maintenance and recruitment costs equated to $5.64 per completion. Total processing and analysis time for the pilot dataset equated to 12 s per survey. The MONT was used successfully by women from a variety of continents and cultures and proved to be practical and economical in terms resource management. [ABSTRACT FROM AUTHOR]

Anemia remains one of the most intractable public health challenges in South Asia. This paper analyzes individual‐level and household‐level determinants of anemia among children and women in Nepal and Pakistan. Applying multivariate modified Poisson models to recent national survey data, we find that the prevalence of anemia was significantly higher among women from the poorest households in Pakistan (adjusted prevalence ratio [95% CI]: 1.10 [1.04–1.17]), women lacking sanitation facilities in Nepal (1.22 [1.12–1.33]), and among undernourished women (BMI < 18.5 kg/m2) in both countries (Nepal: 1.10 [1.00–1.21] and Pakistan: 1.07 [1.02–1.13]). Similarly, children in both countries were more likely to be anemic if stunted (Nepal: 1.19 [1.09–1.30] and Pakistan: 1.10 [1.07–1.14]) and having an anemic mother (Nepal: 1.31 [1.20–1.42] and Pakistan: 1.21 [1.17–1.26]). Policies and programs need to target vulnerable and hard‐to‐reach subpopulations who continue to bear a disproportionate burden of anemia. Covariates of poverty underpin rates of anemia among children and their mothers, but income growth alone will not suffice to resolve such deeply entrenched problems. Greater understanding of the relative role of various diet, health, sanitation, and educational factors by local context should guide investments to resolve anemia in tandem with stunting and maternal underweight. [ABSTRACT FROM AUTHOR]

This paper examines Helen Keller International's model for nutrition‐sensitive poultry production using a programme implemented in four diverse African contexts—three rural and one urban. Consecutive cross‐sectional surveys conducted every 5 months among ~15% of participating households show that despite project‐provided training and inputs, there was only limited uptake of many "best practices." Few households constructed improved henhouses; vaccination rates varied and were highest when support was provided. Poultry mortality was high. Egg productivity remained average for village poultry systems, and egg consumption remained low (two to six eggs consumed per household per fortnight). However, children whose mothers were exposed to project messages on nutrition were more likely to eat eggs, and consumption was consistently higher among households with chickens. Women's involvement in chicken rearing was widespread, but their control over revenues from the sale of poultry products was limited. Key lessons learned from implementation were as follows: (a) strong behaviour change communication is needed to encourage egg consumption, (b) nutrition‐sensitive village poultry programmes should often focus more on improved practices than improved breeds, (c) supporting women's chicken production is not a route to empowerment without complementary activities that directly support women's ownership and decision making. There is also a need for rigorous research on the role of village poultry in livelihoods, food systems, and consumption as well as the structure of poultry and egg markets in low‐resource areas. [ABSTRACT FROM AUTHOR]

Fathers' support can influence mothers' breastfeeding decisions and behavior. Potentially supportive behaviors have been reported in previous studies, but no studies have directly examined which, if any, of those actions are actually more likely to result in desired breastfeeding outcomes. The two studies reported in this paper address this gap by examining relationships between fathers' reported breastfeeding support and mothers' perceptions of received support and breastfeeding intentions, satisfaction, and duration. The Partner Breastfeeding Influence Scale (PBIS) was used in an online survey with 64 women and 41 men (34 couples) and a telephone survey with 80 mothers and 65 fathers (63 couples). Fathers' and mothers' reports of how often fathers engage in the types of support measured by the PBIS were used to predict breastfeeding intentions, satisfaction, and duration. In Study 1, responsiveness predicted breastfeeding success and satisfaction for men and satisfaction for women. However, mothers' intended breastfeeding duration was shorter when fathers both wanted them to breastfeed for a long time and were more appreciative and savvy about breastfeeding. In Study 2, when fathers reported being more appreciative and directly involved in breastfeeding, mothers reported shorter breastfeeding duration. In both studies, mothers' perceptions of their partners' responsiveness and fathers' reports of their own responsiveness predicted longer breastfeeding intentions and duration. These findings suggest that the most effective breastfeeding support is delivered using a sensitive, coordinated teamwork approach that is responsive to the mother's needs. [ABSTRACT FROM AUTHOR]