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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]

Many children in low‐ and middle‐income countries are not attaining their developmental potential. Stunting is associated with poor child development, but it is not known which correlates of stunting are impairing child development. We explored potential socioeconomic, nutritional, clinical, and household correlates of early child development among 12–59‐month‐old children with stunting in a cross‐sectional study in Uganda. Development was assessed using the Malawi Development Assessment Tool (MDAT) across four domains of gross and fine motor, language, and social skills. Linear regression analysis was used to assess correlates of development in the four domains and total MDAT score. Of 750 children included, the median [interquartile range] age was 30 [23−41] months, 55% of the children resided in rural settings with 21% from female‐headed households and 47% of mothers had no schooling. The mean ± standard deviation height‐for‐age z‐score (HAZ) was −3.02 ± 0.74, 40% of the children had a positive malaria test and 65% were anaemic (haemoglobin < 110 g/L). One‐third had children's books at home, majority (96%) used household objects to play with and most of them (70%) used toys as pretence items like those to mimic cooking. After age, sex, and site adjustments, HAZ (0.24, 95% confidence interval [CI]: 0.14−0.33) and head circumference (0.07, 95% CI: 0.02−0.12) were positive correlates of total MDAT score, whereas weight‐for‐height z‐score (WHZ) was not. Current breastfeeding was associated with 0.41 (95% CI: 0.17−0.65) lower total MDAT score. Children from households with a single income earner had 0.22 (95% CI: 0.06−0.37) lower total MDAT score. Furthermore, severe food insecurity, inflammation and positive malaria test were associated with lower scores for motor development. All family care indicator subscales (FCIs) positively correlated with the total MDAT score and this association was independent of household's socioeconomic status. In conclusion, stunting degree, head circumference, number of household income earners and stimulation by improved FCIs correlate with early child development among stunted children. The negative association with prolonged breastfeeding is likely due to reverse causality. Identified correlates may inform initiatives to support children with stunting attain their development potential. Key messages: Our findings reinforce the association between stunting and early child development.The negative association with prolonged breastfeeding is likely due to reverse causality as a result of mothers nursing their smaller, thinner, and more sickly children longer.The strong correlation between all family care indicators with development may express the benefit of improved home stimulation such as provision of reading materials and varied play materials on early child development even among already stunted children in poor settings. [ABSTRACT FROM AUTHOR]

Continued breastfeeding is important for infants' health, but it is unclear whether mixed feeding increases the risk of breastfeeding cessation. We aimed to explore associations of mixed feeding and lactation problems with early cessation of breastfeeding. We analysed data from mothers who completed the Scottish National Maternal and Infant Feeding Survey and had previously breastfed their infants. At age 8–12 weeks, mothers (N = 1974) reported their feeding history and intentions, lactation problems and reasons for giving formula milk. The main outcome measure was cessation of breastfeeding before 6–8 weeks and time to cessation. By 6 weeks, 65% had mixed fed at some point, 32% had ceased breastfeeding, 22% were currently mixed feeding and 46% were exclusively breastfeeding. Lactation problems before 2 weeks were common (65%), and strongly associated with stopping breastfeeding (relative risk [RR]: 3.23, 95% confidence interval [CI]: 2.0–5.3) and with mixed feeding (RR: 3.14, 95% CI: 2.5–4.0). However, even after adjustment for breastfeeding problems mothers who planned to mixed feed (RR: 3.39, 95% CI: 2.4–4.9) and those who introduced formula for practicalities (RR: 3.21, 95% CI: 2.3–4.4) were more likely to stop breastfeeding. These variables also predicted later lactation insufficiency (planned mixed feeding RR: 1.39, 95% CI: 1.0–2.0; formula for practicalities RR: 1.76, 95% CI: 1.3–2.3). Mothers who received specialist lactation support were less likely to cease breastfeeding (RR: 0.63, 95% CI: 0.5–0.9) but nonspecialist input was unrelated to risk of cessation (RR: 1.06, 95% CI: 0.2–4.9). In conclusion, choosing to mix feed an infant is strongly associated with stopping breastfeeding, even in the absence of lactation problems. Key messages: According to the Scottish Maternal and Infant Feeding Survey, most mothers did not intend to mixed feed but a large proportion eventually mixed fed at some time.Lactation problems were commonly present during the first 2 weeks after birth, and those mothers who initially planned to mix feed were more likely to have had early and late lactation problems compared to mothers who maintained exclusive breastfeeding.After adjusting for early problems, mothers who planned to mixed feed or introduce formula were more likely to stop breastfeeding than those who did not.Specialist breastfeeding support was associated with a reduced risk of breastfeeding cessation. [ABSTRACT FROM AUTHOR]

A breastfeeding‐friendly city is one where there is an enabling environment to support breastfeeding throughout the first 2 years or more of a child's life. Indicators of a breastfeeding‐friendly city have yet to be identified. What are the indicators or criteria used to define breastfeeding friendliness in a geographic area such as a city and the settings within, which we have classified as community, healthcare and workplace? Three major databases and grey literature were searched. Records were screened to identify publications describing criteria such as indicators or descriptions of a breastfeeding‐friendly setting, defined as 'criteria‐sets'. These criteria‐sets were then categorized and summarized by settings. The search up to 2 September 2021 found 119 criteria‐sets from a range of settings: geographic locations (n = 33), community entities (n = 24), healthcare facilities (n = 28), workplaces (n = 28) and others (n = 6). Overall, 15 community, 22 healthcare and 9 workplace related criteria were extracted from the criteria‐sets. Criteria that were consistently present in all settings were policy, training & education, skilled breastfeeding support and physical infrastructure. Some criteria‐sets of geographic locations contained criteria only from a single setting (e.g., the presence of breastfeeding‐friendly cafes). Criteria‐sets were present for all settings as defined in this review, but few were actual indicators. Specifically, there were no existing indicators of a breastfeeding‐friendly city. Several common components of the criteria‐sets were identified, and these could be used in developing indicators of a breastfeeding‐friendly city. Future studies should determine which of these are important and how each can be measured. Key messages: There were many different criteria used to describe a breastfeeding‐friendly setting, including cities, but few were actual measurable indicators.Several common criteria were identified such as policy, training & education, skilled breastfeeding support, and physical infrastructure.These could be further developed into indicators of a breastfeeding‐friendly city. [ABSTRACT FROM AUTHOR]

Nutrient needs are difficult to meet during infancy due to high nutrient requirements and the small quantities of food consumed. Guidelines to support food choice decisions are critical to promoting optimal infant health, growth and development and food pattern modeling can be used to inform guideline development. We employed the Optifood modeling system to determine if unfortified complementary foods could meet 13 nutrient targets for breastfed infants (6–11 months), and to describe food patterns that met, or came as close as possible to meeting targets. We also examined the impacts of eliminating food groups, increasing starchy staple foods or adding sentinel unhealthy foods. We collated a global food list from dietary studies in 37 countries and used this list to develop nutrient values for a set of 35 food subgroups. We analyzed infant dietary intakes from studies in eight countries to inform maximum quantities and frequencies of consumption for these subgroups in weekly food patterns. We found that unfortified foods could meet targets for most infants for 12 nutrients, but not for iron. For the smallest and youngest infants, with the lowest energy intakes, there were additional deficits for minerals. Best‐case food patterns that met targets or came as close as possible to meeting targets included ample amounts of diverse vegetables, diverse plant‐ and animal‐source protein foods, small amounts of whole grain foods and dairy and no refined grains or added fats or sugar. There were nutrient deficits if animal‐source foods or vegetables were eliminated or if unhealthy foods were included. Key messages: When diverse foods are available, affordable and acceptable, unfortified complementary foods can meet most infants' needs for a set of 12 key nutrients, but not for iron.For the smallest infants, there are deficits for calcium, iron, potassium and zinc even in best‐case food patterns.Best‐case food patterns include ample amounts of diverse vegetables, diverse plant‐ and animal‐source protein foods and small amounts of whole grain foods and dairy.These include no refined grains or added fats or sugar.Nutrient deficits arise if animal‐source foods or vegetables are eliminated, or if unhealthy foods are included. [ABSTRACT FROM AUTHOR]

Infant and young child feeding (IYCF) promotion is a key component in the set of high impact interventions to improve nutrition. The literature provides evidence of the positive impact of IYCF promotion through various platforms, including communities. In 2009, UNICEF and WHO agreed that a global, "generic" IYCF package of resources and tools to plan, implement, and monitor community‐based IYCF programmes and to build skills of community‐based workers was needed. In 2010, the UNICEF Community Infant and Young Child Feeding Counselling Package was finalized and field tested under a strategic collaboration between UNICEF New York and Nutrition Policy and Practice and the Center for Human Services/University Research Company. The Package includes 11 tools to guide adaptation of the materials, the design, planning, and implementation of IYCF programmes and the training, monitoring, supervision, and mentoring of community workers, using an interactive and experiential adult learning approach. The Package was rolled out from 2011 onwards and by 2017 was implemented in 87 countries. In 2013, UNICEF and the United States Agency for International Development‐funded Strengthening Partnerships, Results, and Innovations in Nutrition Globally project started planning the evaluation, and a study site was selected in Nigeria to assess the efficacy and effectiveness of the Package on IYCF practices, knowledge, and worker skills. This article describes the need for and development of the Package, its content and approach to skills building, as well as its current implementation. Finally, it makes the case for the evaluation of the Package, which is covered in the other papers in the Supplement in relation to the Nigeria evaluation. [ABSTRACT FROM AUTHOR]

Optimal complementary feeding between the ages of 6 and 23 months provides children with the required range of nutritious and safe foods while continuing to be breastfed to meet their needs for essential nutrients and develop their full physical and cognitive potential. The rates of exclusive breastfeeding in the first 6 months of life have increased from 32% in 2008 to 60% in 2022 in Kenya. However, the proportion of children between 6 and 23 months receiving a minimum acceptable diet remains low and has declined from 39% in 2008 to 31% in 2023. The Kenyan Ministry of Health, GAIN and UNICEF collaborated to understand the drivers of complementary feeding practices, particularly proximal determinants, which can be directly addressed and acted upon. A secondary analysis of household surveys and food composition data was conducted to outline children's dietary patterns within the different regions of Kenya and the extent to which the affordability of animal‐source foods could be improved. Ethnographic data were analyzed to identify socio‐cultural barriers to optimal complementary feeding. Furthermore, we outlined the critical steps for developing user‐friendly and low‐cost complementary feeding recipes. The results of all the analyses are presented in five of the six papers of this Special Issue with this additional paper introducing the Kenyan context and some of the critical findings. The Special Issue has highlighted multidimensional barriers surrounding the use and availability of animal‐source foods. Furthermore, it emphasizes the need for a multi‐sectoral approach in enacting policies and programmes that address these barriers. [ABSTRACT FROM AUTHOR]

This study aimed to examine the factors associated with physical growth status among children aged 12-59 months in Japan. Data from the 2010 National Growth Survey on Preschool Children, a nationwide cross-sectional survey, were used for this analysis (n = 4196). After adjustment for confounding factors, multiple logistic regression analyses showed that boys who were born small-for-gestational-age were more likely to be underweight (adjusted odds ratio [aOR]: 12.55, 95% confidence interval [CI]: [6.76-23.3], p < 0.001), stunted (aOR: 5.78, 95% CI: [3.48-9.60], p < 0.001) and wasted (aOR: 7.02, 95% CI: [3.30-15.0], p < 0.001), while boys who were large-for-gestational-age were less likely to be stunted (aOR: 0.26, 95% CI: [0.11-0.60], p < 0.01). Girls who were born small-for-gestational-age were more likely to be underweight (aOR: 5.42, 95% CI: [2.73-10.7], p < 0.001), stunted (aOR: 4.04, 95% CI: [2.43-6.73], p < 0.001) and wasted (aOR: 6.27, 95% CI: [2.55-15.4], p < 0.001), while girls who were large-for-gestational age were more likely to be overweight (aOR: 5.90, 95% CI: [1.64-21.3], p < 0.001). Moreover, the following factors were associated with the physical growth status in children: maternal prepregnancy body mass index, complications during pregnancy, continuous breastfeeding, initiation age of complementary feeding, smoking status of the father or those living with the mother during pregnancy and birth order. Further research is needed to expand support for high-risk families and to verify their effectiveness. [ABSTRACT FROM AUTHOR]

This study examined sociodemographic factors associated with mothers seeking child feeding advice from health professionals (HPs). Cross‐sectional analysis of survey data from linked randomized controlled trials was conducted. Surveys asked which sources of feeding information mothers used when their child was 6 months and 5 years old. Logistic regression was used to examine associations between sociodemographic characteristics and use of information from HPs. Here, 947 and 405 mothers completed 6‐month and 5‐year surveys, respectively. At 6 months, multiparous mothers were less likely to seek advice from child and family health nurses (CFHNs) (adjusted odds ratio [AOR]: 0.558, 95% confidence interval [95% CI]: 0.416–0.749) and other HPs (AOR: 0.706, 95% CI: 0.542–0.919), unmarried mothers were less likely to seek advice from other HPs (AOR: 0.582, 95% CI: 0.342–0.990). At 5 years, mothers with household income ≥$80,000 p.a. were less likely to seek advice from CFHNs (AOR: 0.514, 95% CI: 0.302–0.875) and working mothers less likely to seek advice from general practitioners (GPs) (AOR: 0.581, 95% CI: 0.374–0.905). Mothers born in Australia were less likely to seek information from CFHNs (AOR: 0.462, 95% CI: 0.257–0.833) and GPs (AOR: 0.431, 95% CI: 0.274–0.677). There was a greater likelihood that multiparous mothers (AOR: 2.114, 95% CI: 1.272–3.516) and mothers of children whose fathers had not attended university (AOR: 2.081, 95% CI: 1.256–3.449) had never sought advice from CFHNs, and that mothers who had not attended university (AOR: 1.769, 95% CI: 1.025–3.051), multiparous (AOR: 1.831, 95% CI: 1.105–3.035) and employed (AOR: 2.058, 95% CI: 1.135–3.733) mothers had never sought advice from other HPs. Understanding sociodemographic factors associated with seeking child feeding advice from HPs may inform priorities for engaging families in health promotion. Key messages: Many mothers seek infant and child feeding advice from primary health professionals, particularly in the first year of life, with engagement declining at age 5 years.Health promotion efforts in primary care settings should prioritize increased engagement of multiparous mothers, those without university education and those in employment.The internet and peers are important sources of infant and child feeding information for mothers, it is important that evidence‐based information is available to mothers online and through peer‐learning models. [ABSTRACT FROM AUTHOR]

Around 3% of people are Autistic. Autistic people communicate differently from non‐Autistic people and experience the sensory world differently. There is limited evidence that Autistic people can face additional barriers to breastfeeding. We are an Autistic‐led research team that developed an online survey following consultation with the Autistic community. Autistic people from the UK who had been pregnant were eligible to take part in the survey, which focused on the entire maternity journey. A total of 193 people participated, of whom 152 had experiences of infant feeding (137 breastfeeding, 82 formula feeding). Participants were highly motivated to breastfeed, and almost half of those who breastfed found it positive always or most of the time. However, breastfeeding—and in particular the milk let‐down reflex—could result in pain and sensory difficulties, including 'feeling odd'. Expressing breastmilk always or most of the time was reported by 10% of breastfeeding participants. The intensity and unpredictability of both breast and formula feeding were challenging to manage. Parents reported that it was easy to understand how to prepare infant formula, but that it could also be a negative and anxiety‐inducing experience. Support for breast and formula feeding was often considered inadequate. When parents did access breastfeeding support, this significantly improved a range of breastfeeding experiences. However, participants recommended more tailored support and continuity of carer. To meet the needs of Autistic birthing parents, those providing infant feeding support should receive training on Autism through a neurodiversity‐affirming lens, which should be delivered by Autistic people. Key messages: Many Autistic people are highly motivated to breastfeed, regardless of challenges.Autistic people may experience sensory discomfort when breastfeeding, including from the intensity of touch between themselves and their baby. Distraction and reducing sensory burdens can help.Expressing always or most of the time was relatively common (10%), and a route to maintaining exclusive breastfeeding when directly breastfeeding was too uncomfortable.Receiving breastfeeding support was significantly associated with improvements in a range of breastfeeding experiences.Breastfeeding support for Autistic people should be offered on a one‐to‐one basis with continuity of carer. [ABSTRACT FROM AUTHOR]

This research describes the proportion of children in four low‐ and middle‐income countries with adequate dietary practices at 6, 12, 18 and 24 months of age and how these practices changed over time using the World Health Organisation and UNICEF's infant young child feeding (IYCF) indicators. The associations between the IYCF indicators and anthropometric z‐scores from 6 to 24 months, and between the IYCF indicators and the family care indicators (FCIs) at 24 months are described. This was a longitudinal study of offspring from participants in the Women First Preconception Maternal Nutrition Trial conducted in Sud‐Ubangi, Democratic Republic of Congo; Chimaltenango, Guatemala; Belagavi, North Karnataka, India; and Thatta, Sindh Province, Pakistan. The frequency of the minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum adequate diet (MAD) increased between 6 and 24 months, but even at 24 months MAD remained below 50% at all sites. MDD (β = 0.12; 95% CI = 0.04−0.22) and MMF (β = 0.10; 95% CI = 0.03−0.17) were positively associated with length‐for‐age z‐score at 24 months. All IYCF indicators were positively associated with mean total FCI score: MDD (proportion ratio [PR] = 1.04; 95% CI = 1.02−1.07), MMF (PR = 1.02; 95% CI = 1.01−1.04), MAD (PR = 1.05; 95% CI = 1.02−1.08). Although there are multiple barriers to young children having an adequate diet, our results support a positive association between familial interactions and improved IYCF feeding practices. Key messages: Minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum adequate diet (MAD) increased from 6 to 24 months of age, but MAD remained below 50% frequency at all sites at 24 months.MDD and MMF were positively associated with length‐for‐age z‐scores at 24 months.The total family care indicator score was positively associated with all three infant young child feeding indicators at 24 months. [ABSTRACT FROM AUTHOR]

Human milk (HM) is a highly evolutionary selected, complex biofluid, which provides tailored nutrition, immune system support and developmental cues that are unique to each maternal–infant dyad. In the absence of maternal milk, the World Health Organisation recommends vulnerable infants should be fed with screened donor HM (DHM) from a HM bank (HMB) ideally embedded in local or regional lactation support services. However, demand for HM products has arisen from an increasing awareness of the developmental and health impacts of the early introduction of formula and a lack of prioritisation into government‐funded and nonprofit milk banking and innovation. This survey of global nonprofit milk bank leaders aimed to outline the trends, commonalities and differences between nonprofit and for‐profit HM banking, examine strategies regarding the marketing and placement of products to hospital and public customers and outline the key social, ethical and human rights concerns. The survey captured information from 59 milk bank leaders in 30 countries from every populated continent. In total, five companies are currently trading HM products with several early‐stage private milk companies (PMCs). Products tended to be more expensive from PMC than HMB, milk providers were financially remunerated and lactation support for milk providers and recipients was not a core function of PMCs. Current regulatory frameworks for HM vary widely, with the majority of countries lacking any framework, and most others placing HM within food legislation, which does not include the support and care of milk donors and recipient prioritisation. Regulation as a Medical Product of Human Origin was only in place to prevent the sale of HM in four countries; export and import of HM was banned in two countries. This paper discusses the safety and ethical concerns raised by the commodification of HM and the opportunities policymakers have globally and country‐level to limit the potential for exploitation and the undermining of breastfeeding. Key messages: The number and scope of human milk (HM) profit‐making companies is increasing globallyCurrent regulatory frameworks for HM vary widelyProducts offered by private milk companies (PMCs) are generally more expensive than from HM banksSome PMCs are adopting marketing practices traditionally associated with breast milk substitute companies.The health benefits of HM‐based fortifiers compared to bovine milk‐based fortifiers are unclear and may be marginal [ABSTRACT FROM AUTHOR]

Infant and young child feeding (IYCF) plays a crucial role in early childhood growth and development. This study summarizes recent IYCF practices in multiple refugee settings and compares them to those in the host countries. We analyzed 203 surveys conducted among refugees residing in 15 countries and 120 unique sites and assessed eight IYCF indicators available from those surveys. A total of 146 surveys were conducted in Eastern and Southern Africa (ESA) and 50 in Western and Central Africa (WCA) regions. The median prevalence across surveys of all four indicators describing intake of breast milk was relatively high: 96.6% for ever breastfed, 81.2% for initiation of breastfeeding within 1 h of birth, 76.9% for exclusive breastfeeding 0–5 months, and 75.0% for continued breastfeeding 12–23 months. The median prevalence of early initiation and exclusive breastfeeding was markedly higher in ESA than in WCA (85.0% vs. 37.5% and 83.5% vs. 56.1%, respectively). Conversely, the overall median prevalence of timely introduction of solid and semisolid foods and flesh food consumption was low: 51.8% and 16.1%, respectively. Flesh food consumption was higher in WCA than in ESA (27.4% vs. 11.6%). The median prevalence of mixed milk feeding at 0–5 months and bottle feeding was very low: 2.4% and 3.8%, respectively. Indicators describing breast milk intake were generally either similar or higher in refugees than in the host country populations, whereas the other indicators were generally higher in the host populations than in refugees. The low prevalence of timely introduction of solids and of flesh food consumption in refugees is concerning and requires substantial improvement. Key Messages: Infant and young child feeding practices need to be monitored in refugee settings where access to nutritious foods may be limited.We analyzed infant and young child feeding data from 203 population representative surveys in refugee settings conducted during 2013–2019.Prevalence of indicators describing breast milk consumption in refugees was relatively high overall and similar or higher than in local populations.Prevalence of indicators describing the consumption of other complementary foods or liquids in refugees was low overall and generally lower than in the host populations, documenting a need for improved access to such foods and change in feeding practices. [ABSTRACT FROM AUTHOR]

High perceived pressure to breastfeed and poor perceived quality of health care professional support have been associated with early breastfeeding cessation, guilt, and shame. This is problematic because guilt and shame significantly predict post‐natal anxiety and depression. No previous attempts have been made to provide quantitative evidence for relationships mapped between the post‐natal social context, infant feeding method and post‐natal emotional well‐being. The current study aimed to empirically investigate aforementioned pathways. Structural equation modelling was applied to survey data provided online by 876 mothers. Guilt and shame both significantly predicted anxiety and depression. Poor health care professional support and high pressure to breastfeed increased anxiety and depression, and these effects were explained by indirect pathways through increases in guilt and shame. Formula feeding exclusivity was negatively correlated with post‐natal anxiety symptoms. This finding may be explained by feelings of relief associated with observed infant weight gain and being able to share infant feeding responsibilities others e.g., with one's partner. This relationship was counterbalanced by an indirect pathway where greater formula feeding exclusivity positively predicted guilt, which increased post‐natal anxiety score. While guilt acted as mediator of infant feeding method to increase post‐natal depression and anxiety, shame acted independently of infant feeding method. These identified differences provide empirical support for the transferability of general definitions of guilt (i.e., as remorse for having committed a moral transgression) and shame (i.e., internalisation of transgressive remorse to the self), to an infant feeding context. Recommendations for health care practitioners and the maternal social support network are discussed. Key messages: Guilt and shame are empirically evidenced as distinct, overlapping concepts: guilt is more behaviour‐orientated, while shame is more social context‐orientated.Guilt and shame both predict postnatal depression and anxiety, supporting their conceptualisation as transdiagnostic phenomena.While guilt acts indirectly through one's social context and infant feeding method to increase depression and anxiety, shame acts independently of infant feeding method. General definitions of guilt and shame are thus deemed transferable to an infant feeding context.Recommendations are made to address issues regarding perceived insufficient healthcare professional support and pressure to breastfeed, so to improve postnatal wellbeing and extend any breastfeeding continuation. [ABSTRACT FROM AUTHOR]

The nutritional adequacy of human milk (HM) from vegan/vegetarian mothers has been a matter of debate, and a variety of recommendations regarding the eligibility of these mothers as human milk donors exists. According to the latest evidence, HM from vegans/vegetarians is similar in its composition to that from omnivores, however, some differences may be observed regarding vitamin B12 and omega‐3 fatty acids concentrations. Maternal supplementation of these compounds has been proven effective in increasing their HM concentration. With this survey, we aimed to explore the practices currently in use in European human milk banks (HMBs) regarding potential donors following vegan/vegetarian diets. The online survey was distributed to European HMBs between January and July 2022. A total of 188 HMBs were contacted, and 118 replied (response rate 63%). Vegan and vegetarian mothers were recommended supplements of vitamin B12 to be accepted as donors in 27% and 26% of HMBs, respectively. Additional omega‐3 fatty acid supplementation was required in 8% HMBs. In the remaining HMBs, these mothers were either systematically excluded or included regardless of supplementation. The dosage of the recommended supplements was extremely variable. Fifty‐one percent of HMBs were following recommendations to guide their practice, national or local recommendations mainly. Great variability in European HMBs practices towards potential donors following vegan/vegetarian diets exists. Some of these practices can result in loss of donors and/or in potential nutritional deficiencies. Standardised evidence‐based recommendations on this issue and their implementation in daily HMB practice are needed. Key messages: There is significant variability among the practices of European human milk banks towards donors following a vegan or vegetarian diet.The majority of human milk banks follow no guidelines or local guidelines, rather than international ones.Some of the practices currently in use can result in the loss of potential donors and/or nutritional deficiencies for mothers, their babies, and potentially for recipients of donor human milk.Evidence‐based recommendations regarding the inclusion of these mothers in human milk donation and nutritional counselling are needed. [ABSTRACT FROM AUTHOR]

The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0–12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross‐promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest. Key message: Mothers' and health professionals' exposure to commercial milk formula (CMF) promotion was still widespread in Singapore even after the new CMF restriction was implemented in 2019.Digital marketing, distribution of free samples of milk for toddlers and mothers, dubious premium health and nutrition claims, and sponsorship from CMF industries were common tactics found in this study.Updating CMF restrictions to align with the Code, including restricting CMF marketed for toddler milk, prohibiting cross‐promotion, and disallowing sponsorship from CMF industries, together with an effective enforcement system, may facilitate better control of unethical CMF promotions in Singapore. [ABSTRACT FROM AUTHOR]

The market for commercially produced complementary foods (CPCF) is rapidly expanding in Southeast Asia; however, the existence and content of mandatory national policies, standards and legislation (binding legal measures) for CPCF in the region is unclear. To assess the status of national binding legal measures for CPCF in Southeast Asia, a legal and policy desk review was conducted in seven countries (Cambodia, Laos People's Democratic Republic, Indonesia, Malaysia, Philippines, Thailand and Viet Nam). The alignment of the national binding legal measures relevant to CPCF was assessed against guidance on CPCF nutrient composition and labelling requirements provided by Codex Alimentarius and the World Health Organization (WHO). Each of the seven countries had at least two national binding legal measures related to the nutrient composition or labelling of CPCF; however, there was limited alignment with the guidance from Codex and WHO. No country was fully aligned with the three CPCF‐specific Codex standards/guidelines and only one country was in full alignment with the recommendations related to the protection of breastfeeding from the 'WHO Guidance on ending the inappropriate promotion of foods for infants and young children'. The findings of the review indicate that the existing national binding legal measures are insufficient to ensure that the CPCF sold as suitable for older infants and young children are nutritionally adequate and labelled in a responsible manner that does not mislead caregivers. Improved and enforced national binding legal measures for CPCF, in alignment with global guidance, are required to ensure that countries protect, promote and support optimal nutrition for children 6–36 months of age. Key messages: Given the proliferation of commercially produced complementary foods (CPCF) in Southeast Asia, national binding legal measures are essential to ensure CPCF are nutritionally suitable for older infants and young children (IYC), and are labelled in a manner that does not mislead caregivers.All seven Southeast Asian countries included in this review were found to have at least two national binding legal measures related to the nutrient composition and/or labelling practices of CPCF. However, there was limited alignment between these binding legal measures and the available guidance documents.No country was fully aligned with the six relevant Codex Alimentarius (Codex) standards and only one country was fully aligned with guidance from the World Health Organization (WHO). Existing binding legal measures do not ensure that CPCF are nutritionally adequate and labelled in a responsible way that enables caregivers to make healthy choices for older IYC.Countries in Southeast Asia urgently require consolidated guidance on how to develop appropriate, legally binding and enforceable standards for CPCF nutrient composition and labelling. Existing guidance is fragmented and Codex standards are outdated and insufficient for this purpose. [ABSTRACT FROM AUTHOR]

Gaining excessive gestational weight may increase obesity risk in the offspring, while breastfeeding lowers that risk. Using data from the Special Supplemental Nutrition Programme for Women, Infants and Children (WIC) in Southern California, we examined the associations between gestational weight gain (GWG), breastfeeding during infancy and childhood obesity at 2–4 years, and determined whether breastfeeding moderated the association between GWG and childhood obesity. GWG was based on weight measurements collected during the first trimester and within a month before delivery. GWG values were standardized by gestational age (GWG z‐scores), per maternal prepregnancy body mass index (BMI) and categorized into tertiles. Fully breastfeeding duration was determined by WIC infant package data indicating the amount of infant formula received monthly. Children's length (or height) and weight measurements were used to calculate BMI‐for‐age z‐scores and identify obesity (z‐score ≥ 95th percentile). Multivariable linear and modified Poisson regression analyses were conducted. Fully breastfeeding moderated the association between GWG z‐scores tertile and obesity in the offspring. Each additional month of fully breastfeeding was associated with 3%–5% obesity risk reduction for each age group and GWG z‐scores tertile, except at age 4 years for children whose mothers had low GWG z‐scores (tertile 1). Shorter fully breastfeeding duration was associated with greater obesity risk among children of mothers with high GWG z‐scores (tertile 3), but not for those whose mothers had low GWG z‐scores. Longer fully breastfeeding duration may provide greater protection against obesity among children at higher risk due to intrauterine exposure to high gestational weight gain. Key messages: Breastfeeding may ameliorate the increased obesity risk among children that is related to high maternal weight gain during pregnancy.Shorter breastfeeding duration is related to greater childhood obesity risk, and this association may be more evident for children of mothers with higher gestational weight gain.Providing pre‐ and post‐natal breastfeeding support to Supplemental Nutrition Programme for Women, Infants and Children (WIC) women who gain more weight than recommended during pregnancy may reduce childhood obesity.Childhood obesity efforts that focus on the interconnection between a mother and her child by starting in the prenatal period (e.g., individualized gestational weight monitoring, culturally sensitive breastfeeding promotion) could be an impactful public health strategy. [ABSTRACT FROM AUTHOR]

Infants younger than 4 months are not ready for complementary foods/drinks (any solid or liquid other than breast milk or infant formula). Almost half of US infants participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which provides nutrition education and support to low‐income families. We describe the prevalence of early introduction (<4 months) of complementary foods/drinks and examine the association of milk feeding type (fully breastfed, partially breastfed or fully formula fed) with early introduction of complementary foods/drinks. We used data from 3310 families in the longitudinal WIC Infant and Toddler Feeding Practices Study‐2. We described the prevalence of early introduction of complementary foods/drinks and modeled the association of milk feeding type at Month 1 with early introduction of complementary foods/drinks using multi‐variable logistic regression. Thirty‐eight percent of infants were introduced early to complementary foods/drinks (<4 months). In adjusted models, infants who were fully formula fed or partially breastfed at Month 1 were 75% and 57%, respectively, more likely to be introduced early to complementary foods/drinks compared with fully breastfed infants. Almost two in five infants were given complementary foods/drinks early. Formula feeding at Month 1 was associated with higher odds of early introduction of complementary foods/drinks. There are opportunities to support families participating in WIC to prevent early introduction of complementary foods/drinks and promote child health. Key messages: Almost two in five infants participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were given complementary foods/drinks early.The most common food to be introduced early was infant cereal (17%), while the most common drink introduced early was plain water (24%).Formula feeding at Month 1 was associated with higher odds of early introduction of complementary foods/drinks among infants participating in WIC.These findings suggest there are opportunities to support families participating in WIC to prevent early introduction of complementary foods/drinks and promote child health. [ABSTRACT FROM AUTHOR]

Breastfeeding has been consistently associated with higher intelligence since childhood. However, this relation could be confounded due to maternal selection bias. We estimated the association between predominant breastfeeding and intelligence in school‐age children considering potential selection bias and we simulated the intelligence gap reduction between low versus higher socioeconomic status children by increasing breastfeeding. We analysed predominant breastfeeding practices (breastmilk and water‐based liquids) of children 0–3 years included in the Mexican Family Life Survey (MxFLS‐1). Intelligence was estimated as the z‐score of the abbreviated Raven score, measured at 6–12 years in the MxFLS‐2 or MxFLS‐3. We predicted breastfeeding duration among children with censored data with a Poisson model. We used the Heckman selection model to assess the association between breastfeeding and intelligence, correcting for selection bias and stratified by socioeconomic status. Results show after controlling for selection bias, a 1‐month increase in predominant breastfeeding duration was associated with a 0.02 SD increase in the Raven z‐score (p < 0.05). The children who were predominantly breastfed for 4–6 months versus <1 month had 0.16 SD higher Raven z‐score (p < 0.05). No associations were found using multiple linear regression models. Among low socioeconomic status children, increasing predominantly breastfeeding duration to 6 months would increase their mean Raven z‐score from −0.14 to −0.07 SD and reduce by 12.5% the intelligence gap with high socioeconomic status children. In conclusion, predominant breastfeeding duration was significantly associated with childhood intelligence after controlling for maternal selection bias. Increased breastfeeding duration may reduce poverty‐driven intelligence inequities. Key messages: An increase in predominant breastfeeding duration was positively and significantly associated with intelligence in school‐aged children.The most significant increase in intelligence was found among those who were predominantly breastfed for 4–6 months compared with less than 1 month.The association was stronger among children with low socioeconomic status. Hence, increased breastfeeding duration may reduce the intelligence gap between low versus high socioeconomic‐status children.Selection bias between breastfed and nonbreastfed children should be considered in future analyses in this area. [ABSTRACT FROM AUTHOR]

The use of donor human milk (DHM) where there is a shortfall of maternal milk can benefit both infant and maternal outcomes but DHM supply is not always assured. This study aimed to understand current DHM usage in UK neonatal units and potential future demand to inform service planning. An online survey was disseminated to all UK neonatal units using Smart Survey or by telephone between February and April 2022 after development alongside neonatal unit teams. Surveys were completed by 55.4% of units (108/195) from all 13 Operational Delivery Networks. Only four units reported not using DHM, and another two units only if infants are transferred on DHM feeds. There was marked diversity in DHM implementation and usage and unit protocols varied greatly. Five of six units with their own milk bank had needed to source milk from an external milk bank in the last year. Ninety units (84.9%) considered DHM was sometimes (n = 35) or always (n = 55) supportive of maternal breastfeeding, and three units (2.9%) responded that DHM was rarely supportive of breastfeeding. Usage was predicted to increase by 37 units (34.9%), and this drive was principally a result of parental preference, clinical trials and improved evidence. These findings support the assumption that UK hospital DHM demand will increase after updated recommendations from the World Health Organization (WHO) and the British Association of Perinatal Medicine. These data will assist service delivery planning, underpinned by an ongoing programme of implementation science and training development, to ensure future equity of access to DHM nationally. Key messages: Updated recommendations from World Health Organization (WHO) and British Association of Perinatal Medicine (BAPM) are likely to increase demand for donor human milk provision from human milk banks, but there have been no recent data collected on baseline usage criteria, enteral feeding guidelines and anticipated future use.This national survey of UK neonatal units highlights the variability in donor human milk (DHM) provision and reasons for demand spikes that will be helpful for modelling future services. Almost 85% of neonatal units responded that DHM availability was supportive of maternal lactation support. Responses highlighted that DHM demand is likely to increase further in the next 2 years.Understanding demand variability will help in planning nationally equitable human milk bank services and support the development of robust national service continuity planning. The study also highlights the variability in practice, often in single regions, raising concerns related to health equity, staffing limitations and uncertainty in DHM implementation. [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]

Some women who breastfeed will experience complex ongoing difficulties, such as breastfeeding aversion response (BAR). This recently named breastfeeding challenge is defined as feelings of aversion while breastfeeding for the entire time that the child is latched. This study provides the first prevalence data for the experience of BAR in Australian breastfeeding women. A national online survey investigated the breastfeeding experience of Australian women including data on (1) participant demographics, (2) breastfeeding experience with up to four children, (3) breastfeeding challenges and prevalence of BAR, and (4) the value of available breastfeeding support. This study found that of the Australian breastfeeding women who participated (n = 5511), just over one in five self‐identified as having experienced a BAR (n = 1227, 22.6%). Most reported experiencing some breastfeeding challenges, with only 4.5% (n = 247) having had no breastfeeding complications. Importantly, despite these difficulties, 86.9% of the total women in this study rated their overall breastfeeding experience as good (n = 2052, 37.6%), or very good (n = 2690, 49.3%), and 82.5% of those who experience BAR as good (n = 471, 38.7%) or very good (n = 533, 43.8%). BAR reporting was decreased in higher education and income groups. Women who are breastfeeding for the first time are more likely to encounter difficulties with breastfeeding such as BAR. Complications with breastfeeding are pervasive, but women who can overcome breastfeeding issues often report a positive overall breastfeeding experience. Key messages: This national survey of 5511 breastfeeding women in Australia found that one in five reported having experienced a breastfeeding aversion response.There is limited evidence to guide stakeholders in supporting women who experience complex breastfeeding challenges such as breastfeeding aversion responses.Breastfeeding challenges are common for those who breastfeed however women who are supported to manage breastfeeding aversion response report a positive overall breastfeeding experience. [ABSTRACT FROM AUTHOR]

Exclusive breastfeeding (EBF) provides significant health benefits to children. However, mothers may find it difficult to continue EBF for 6 months. The present analysis aimed to examine the influence of the Suchana intervention—a large‐scale programme implemented with the aim of improving the health and nutritional status of mothers and children from poor households in the Sylhet region of Bangladesh—on EBF and stunting among children under 6 months. Baseline and endline data were obtained from the Suchana evaluation. EBF was defined as an infant (<6 months) only receiving breast milk in the previous 24 h. Childhood stunting was defined as a length‐for‐age z‐score of less than −2 among children of the same age. Multiple logistic regression analysis was used to assess the associations of the Suchana intervention with EBF and stunting. EBF prevalence improved from 64% at baseline to 85% at the endline in the intervention area, with the intervention group having 2.25 times higher odds of EBF compared to the control group. Stunting prevalence reduced from 28% at baseline to 24% at the endline in the intervention group, but after controlling for covariates, the association between stunting and the intervention was not significant. However, the interaction analysis showed significantly lower stunting prevalence among EBF children in both intervention and control areas. The Suchana intervention had a positive impact on the EBF practice of rural children in a vulnerable region of Bangladesh, and EBF was identified as a significant factor associated with stunting. The findings suggest that the continuation of the EBF intervention has the potential to have an impact on reducing stunting in the region, highlighting the importance of promoting EBF to improve child health and development. Key messages: Suchana intervention in rural Bangladesh promoted exclusive breastfeeding (EBF) among mothers in the intervention group.EBF was found to be a significant factor associated with stunting in the study population.Better integration of determinants of stunting are needed to achieve a statistically significant reduction in stunting. [ABSTRACT FROM AUTHOR]

Infant and young child feeding (IYCF) interventions in low‐resource countries mainly target pregnant women and mothers of young children; however, fathers and grandmothers also influence IYCF practices. We conducted focus group discussions with mothers, fathers and grandmothers of young children across three time points in areas where an IYCF social and behaviour change intervention was implemented in Nigeria to explore differences by participant type and shifts over time in attitudes, beliefs and social norms related to breastfeeding and dietary diversity (DD). Overall, across time points, we found more discrepancies in attitudes, beliefs and social norms for early initiation of breastfeeding (EIBF) and exclusive breastfeeding (EBF) among different participant types than for DD. Although most participants agreed EIBF and EBF are good practices, mothers believed this more strongly than fathers and grandmothers; however, at endline, a shift towards acceptance of EIBF and EBF appeared among fathers and grandmothers. Across time points, all participant types acknowledged the nutritional and health benefits of green leafy vegetables and animal‐source foods but described various barriers to feeding them to children. Across time points, all participant types also highlighted the importance of health workers and antenatal visits as important sources of IYCF knowledge and facilitators to following recommended practices. Insights from this study highlight the importance of including key influencers of IYCF practices in qualitative research. Key messages: Overall, we found more discrepancies in attitudes, beliefs, and social norms for early initiation of and exclusive breastfeeding across participant types than for dietary diversity.All types of participants across time points acknowledged the nutritional and health benefits of green leafy vegetables and animal source foods but described various barriers to feeding them to children.Across time points, all participant types highlighted the importance of health workers and antenatal visits as important sources of IYCF knowledge and facilitators to following recommended practices.This study highlights the importance of expanding the inclusion of key influencers of IYCF practices in future research. [ABSTRACT FROM AUTHOR]

Health professional competency building is one of nine national responsibilities (to achieve universal coverage and sustainability) described in the 2018 World Health Organization/UNICEF implementation guidance for the Baby‐Friendly Hospital Initiative (BFHI). Skilled breastfeeding support as a standard of newborn care is critical to the establishment of lactation and exclusive breastfeeding. This qualitative case study describes the Kyrgyz Republic's experience with health professional competency building related to breastfeeding counselling and support. We interviewed 38 key informants and reviewed national policies and international guidelines related to BFHI. The study found that although the country has a new policy reflecting BFHI global standards and guidance, the policy has not been disseminated nationally. Additionally, the policy lacks guidance on competency monitoring and verification and does not mention preservice training, even though preservice training on breastfeeding support exists. To achieve universal coverage for health professional competencies, the Kyrgyz Republic uses preservice, in‐service and refresher training. However, the main limitations to aligning with the new guidance are a lack of preservice BFHI‐ and breastfeeding‐specific curricula, experienced trainers and sufficient time and funding to dedicate to practical skill development. Conducted during the COVID‐19 pandemic, this study confirmed disruptions to BFHI training and service delivery but also documents the Kyrgyz Republic's resilient strides to mitigate impacts on breastfeeding support through facility‐level individual champions and adjustments to training such as going online. Opportunities exist for strengthening the competencies of service providers through strengthened preservice training, comprehensive and consistent in‐service training, solutions for overworked service providers and clear and sufficiently funded monitoring guidance. Key messages: The Kyrgyz Republic government has proactively enacted policies (Order 1078) reflecting the updated Baby‐Friendly Hospital Initiative (BFHI) guidance and has demonstrated a commitment to institutionalizing BFHI.Insufficient funding and the COVID‐19 pandemic derailed plans for implementing the new policy and guidance beyond the regional levels.There remain gaps in prioritizing, funding, and monitoring breastfeeding counselling and support competency building for both preservice and in‐service.Multi‐sectoral advocacy for BFHI is needed to secure national and local commitment and funding across and beyond the health system. [ABSTRACT FROM AUTHOR]

The impact of the COVID‐19 pandemic on breastfeeding (BF) practices in low‐ and middle‐income countries (LMICs) is not well understood. Modifications in BF guidelines and delivery platforms for breastfeeding education during the COVID‐19 pandemic are hypothesised to have affected BF practices. We aimed to understand the experiences with perinatal care, BF education and practice among Kenyan mothers who delivered infants during the COVID‐19 pandemic. We conducted in‐depth key informant interviews with 45 mothers who delivered infants between March 2020 and December 2021, and 26 health care workers (HCW) from four health facilities in Naivasha, Kenya. While mothers noted that HCWs provided quality care and BF counselling, individual BF counselling was cited to be less frequent than before the pandemic due to altered conditions in health facilities and COVID‐19 safety protocols. Mothers stated that some HCW messages emphasised the immunologic importance of BF. However, knowledge among mothers about the safety of BF in the context of COVID‐19 was limited, with few participants reporting specific counselling or educational materials on topics such as COVID‐19 transmission through human milk and the safety of nursing during a COVID‐19 infection. Mothers described COVID‐19‐related income loss and lack of support from family and friends as the major challenge to practising exclusive breastfeeding (EBF) as they wished or planned. COVID‐19 restrictions limited or prevented mothers' access to familial support at facilities and at home, causing them stress and fatigue. In some cases, mothers reported job loss, time spent seeking new means of employment and food insecurity as causes for milk insufficiency, which contributed to mixed feeding before 6 months. The COVID‐19 pandemic created changes to the perinatal experience for mothers. While messages about the importance of practising EBF were provided, altered HCW education delivery methods, reduced social support and food insecurity limit EBF practices for mothers in this context. Key messages: The COVID‐19 pandemic created new challenges to promoting and sustaining exclusive breastfeeding in Kenya, including changes to antenatal and postnatal breastfeeding counselling.While health care workers provided evidence‐based counselling on the safety of breastfeeding in the context of COVID‐19, changes to education formats away from group counselling and fears of accessing care at facilities created barriers for some mothers' access to breastfeeding guidance.Maternal social support, income and food security were negatively affected by the COVID‐19 pandemic, which increased stress and decreased milk sufficiency for mothers, challenging exclusive breastfeeding duration.Mothers with prior breastfeeding experience were less affected by the breastfeeding counselling constraints, and first‐time mothers more frequently reported stress and anxiety related to breastfeeding and childcare. [ABSTRACT FROM AUTHOR]

Breastfeeding initiation rates in Australia are high but duration rates fall well below the World Health Organization targets. Return to work is a known factor impacting 6 months exclusive breastfeeding and continuation into the infants second year of life. Work related factors can influence a woman's confidence in maintaining breastmilk supply after return to employment and determine whether she meets her personal breastfeeding goals. This cross‐sectional online survey is the first Australian study to explore women's experience of maintaining breastfeeding after return to work, in all work sectors. Results revealed variations across work sectors reflected in worker autonomy and confidence in speaking up about breastfeeding rights. Women who had autonomy or flexibility in planning their workday were more likely to be confident in maintaining breastmilk supply. The main predictors for milk supply confidence and meeting personal breastfeeding goals included having: a suitable place to express milk; confidence in speaking out about rights; a formal return‐to‐work plan; a supportive workplace; and returning to work after the period of exclusive breastfeeding. This study reveals that supportive workplace environments can lead to increased confidence in maintaining milk supply, extending durations of breastfeeding. Women who are confident in their rights to express breastmilk, or breastfeed at work, are more likely to meet their own breastfeeding goals. Education, and awareness raising, on the rights of breastfeeding women in the workplace, is a gender equity imperative that can improve experiences for breastfeeding women, and, increase manager and co‐worker knowledge for creating enabling workplace environments for breastfeeding employees. Key messages: Return to work after the birth of a baby impacts breastfeeding duration and personal goal attainment. Unsupportive employment factors can lead to a loss of confidence in ability to maintain adequate breastmilk supply.Having access to sufficient paid parental leave, a suitable place to express milk, autonomy, or ability to take lactation breaks, a formal return to work plan, and confidence in speaking up about breastfeeding rights, impacts meeting breastfeeding goals.Increasing knowledge and awareness on the rights of breastfeeding workers, and the components of supportive and enabling environments, will improve women's confidence in their ability to maintain adequate breastmilk supply, and meet their breastfeeding goals, after return to work. [ABSTRACT FROM AUTHOR]

The southeastern region of Kenya is prone to aflatoxin outbreaks, yet maternal and infant aflatoxin intake levels remain unclear. We determined dietary aflatoxin exposure of 170 lactating mothers breastfeeding children aged 6 months and below in a descriptive cross‐sectional study involving aflatoxin analysis of maize‐based cooked food samples (n = 48). Their socioeconomic characteristics, food consumption patterns and postharvest handling of maize were determined. Aflatoxins were determined using high‐performance liquid chromatography and enzyme‐linked immunosorbent assay. Statistical analysis was conducted using Statistical Package Software for Social Sciences (SPSS version 27) and Palisade's @Risk software. About 46% of the mothers were from low‐income households, and 48.2% had not attained the basic level of education. A generally low dietary diversity was reported among 54.1% of lactating mothers. Food consumption pattern was skewed towards starchy staples. Approximately 50% never treated their maize, and at least 20% stored their maize in containers that promote aflatoxin contamination. Aflatoxin was detected in 85.4% of food samples. The mean of total aflatoxin was 97.8 μg/kg (standard deviation [SD], 57.7), while aflatoxin B1 was 9.0 μg/kg (SD, 7.7). The mean dietary intake of total aflatoxin and aflatoxin B1 was 7.6 μg/kg/b.w.t/day (SD, 7.5) and 0.6 (SD, 0.6), respectively. Dietary aflatoxin exposure of lactating mothers was high (margin of exposure < 10,000). Sociodemographic characteristics, food consumption patterns and postharvest handling of maize variably influenced dietary aflatoxin exposure of the mothers. The high prevalence and presence of aflatoxin in foods of lactating mothers are a public health concern and calls for the need to devise easy‐to‐use household food safety and monitoring measures in the study area. Key messages: A high prevalence of aflatoxin (84.4%) and high dietary aflatoxin exposure were reported among lactating mothers in the study.The mean concentration of 90% of maize‐based cooked food samples exceeded the 2 and 10 µg/kg set limits for aflatoxin B1 and total aflatoxin, respectively.Household size, education, socioeconomic status and limited food consumption patterns were potential determinants of dietary aflatoxin exposure in lactating mothers. Within dietary diversity, the type of food constituting a diverse diet played an important role.Postharvest handling of maize could be one of the factors contributing to dietary aflatoxin exposure in the study area.The reported results call for the need to devise easy‐to‐use household food safety and monitoring measures in the study area. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID‐19) pandemic increased food insecurity among US households, however, little is known about how infants, who rely primarily on human milk and/or infant formula, were impacted. We conducted an online survey with US caregivers of infants under 2 years of age (N = 319) to assess how the COVID‐19 pandemic impacted breastfeeding, formula‐feeding and household ability to obtain infant‐feeding supplies and lactation support (68% mothers; 66% White; 8% living in poverty). We found that 31% of families who used infant formula indicated that they experienced various challenges in obtaining infant formula, citing the following top three reasons: the formula was sold out (20%), they had to travel to multiple stores (21%) or formula was too expensive (8%). In response, 33% of families who used formula reported resorting to deleterious formula‐feeding practices such as diluting formula with extra water (11%) or cereal (10%), preparing smaller bottles (8%) or saving leftover mixed bottles for later (11%). Of the families who fed infants human milk, 53% reported feeding changes directly as a result of the pandemic, for example, 46% increased their provisioning of human milk due to perceived benefits for the infant's immune system (37%), ability to work remotely/stay home (31%), concerns about money (9%) or formula shortages (8%). Fifteen percent of families who fed human milk reported that they did not receive the lactation support they needed and 4.8% stopped breastfeeding. To protect infant food and nutrition security, our results underscore the need for policies to support breastfeeding and ensure equitable and reliable access to infant formula. Key messages: One in three families who fed infants formula reported using one or more deleterious formula‐feeding practices during the coronavirus disease 2019 pandemic, likely due to formula shortages and financial strain.Of the families who fed infants human milk, 15% reported difficulties accessing lactation support directly as a result of the pandemic, although 46% of families reported increased provision of human milk.Flexible government programmes and policies are needed to ensure equitable access to lactation support and infant formula during crises. [ABSTRACT FROM AUTHOR]

This study explores common factors associated with not meeting minimum dietary diversity (MDD) among 27,072 children aged 6–23 months in Eastern and Southern Africa using data from nine Demographic and Health Surveys from 2013 to 2016. MDD was defined as consumption of more than or equals to five of eight food groups including breast milk in the past 24 h. Equity gaps were calculated as the difference in MDD prevalence between the top and bottom wealth quintiles. Logistic regression was conducted to identify common factors for not meeting MDD at the household, maternal and child levels across two or more countries to inform regional policies to improve children's diets. Kenya had the highest MDD wealth equity gap (40.4 pts), and South Africa had the smallest (14.4 pts). Equity gaps for flesh foods or eggs (up to 39.8 pp) were larger than for grain or legumes (up to 20 pp). Common risk factors for not reaching MDD included younger child age (6–11 months) (n = 9 countries), no formal maternal occupation (n = 6), not receiving vitamin‐A supplementation (n = 3), younger maternal age (n = 3), lower maternal education (n = 3), no media (n = 3) or newspaper (n = 3) exposure, lower household wealth quintile (n = 3), use of nonefficient cooking fuel (n = 2), longer time to get to the water source (n = 2), not listening to the radio (n = 2) and higher birth order (n = 2). Priorities for improving MDD in the region include introducing diverse foods at a young age from 6 months with early nutrition counselling, promoting higher maternal education, increasing food purchasing power and ensuring the support of younger mothers. Key messages: Diets of children in Eastern and Southern Africa (ESA) lack diversity.A number of common risk factors predict dietary diversity across countries.Risk factors for low dietary diversity include wealth, education and media access.Wide equity gaps were apparent for most food groups in ESA.Interventions addressing affordability and access to diverse diets are needed. [ABSTRACT FROM AUTHOR]

Interventions distributing micronutrient powders (MNPs) and small‐quantity lipid‐based nutrient supplements (SQ‐LNS), or home fortification products (HFPs), have the potential to improve infant and young child feeding (IYCF) practices and children's nutrition. We systematically searched for studies on the effect of interventions distributing HFP on IYCF practices. We identified 12 (8 MNP, 4 SQ‐LNS) studies: seven programmes with IYCF behaviour change communications (BCC) and MNP (IYCF‐MNP) and one provided MNP without IYCF BCC (MNP only). Three SQ‐LNS studies came from randomised trials without an IYCF component (SQ‐LNS only) and one from a programme with both IYCF BCC and SfQ‐LNS (IYCF‐SQ‐LNS). Five IYCF‐MNP programmes reported positive associations with some IYCF practices—four with minimum dietary diversity, two with minimum meal frequency, four with minimum acceptable diet, and three with the initiation of complementary foods at 6 months. Two reported no association between MNP and IYCF indicators, and one reported a decline in IYCF practices during the intervention, although it also reported significant changes to the IYCF programme during the evaluation period. Two studies from interventions that distributed SQ‐LNS (one from a related set of randomised controlled trials and the sole IYCF‐SQ‐LNS programme) reported a positive association with IYCF practices; one trial reported no change in breast milk intake with the provision of SQ‐LNS and one found no association with IYCF practices. SQ‐LNS and MNP can address nutrient gaps for young children in low‐resource settings; our findings indicate that programmes that combine HFP with IYCF interventions may also contribute to improved IYCF practices in some settings. Key messages: We identified 12 studies distributing home fortification products (HFP) that assessed infant & young child feeding (IYCF) outcomes; few used experimental or quasi‐experimental study designs.Interventions associated with improved IYCF practices were predominantly programs that integrated HFP with a new, intensive IYCF behavior change strategy.HFP can fill nutrient gaps for infants and children in low‐resource settings; programs that combine HFP with IYCF interventions may also contribute to improved IYCF practices in some settings. [ABSTRACT FROM AUTHOR]

Bottle refusal by breastfed babies is a scenario that has received surprisingly little attention in the literature, given the number of mothers who appear to be experiencing it globally and the subsequent negative impact it can have. In line with this, we undertook a study to explore mothers' views on why their breastfed baby refuses to bottle feed. A parallel, two-stage, exploratory qualitative design was employed using 30 semi-structured interviews and 597 online forum posts. Data were analysed using a thematic analysis, and a biopsychosocial model was applied resulting in four overarching themes being identified: 'Breastfeeding is the answer to everything....' 'Bottle feeding: an alien concept... 'Babies are individuals' and 'Find the right bottle and don't delay'. The psychological benefits of breastfeeding, not inherent in bottle feeding, appeared to underpin some mothers' views on their baby's refusal. Other mothers explained refusal as being down to a baby's biological expectation to be fed by the breast; therefore, bottle feeding was not a normal concept to them. A baby's individual personality and temperament were also suggested as contributing to the scenario and refusal was linked to babies disliking a certain brand of bottle and being introduced to it 'too late'. This study's findings point to a complex, multifactorial picture underpinning bottle refusal by breastfed babies, which transcends physical, psychological and biological concepts, and is influenced by socio-cultural norms surrounding infant feeding. Recognition of these contributing factors is needed to aid those supporting mothers experiencing the scenario and, importantly, to underpin mothers' decision-making around managing it. [ABSTRACT FROM AUTHOR]

There is a paucity of literature exploring the challenges of breastfeeding sick children in hospital. Previous research has focused on single conditions and hospitals which limits understanding of the challenges in this population. Although evidence suggests that current lactation training in paediatrics is often inadequate, it is unclear where the specific training gaps are. This qualitative interview study of UK mothers aimed to explore the challenges of breastfeeding sick infants and children on a paediatric ward or paediatric intensive care unit. From 504 eligible respondents, a sample of 30 mothers of children aged 2-36 months with various conditions and demographic backgrounds was purposively chosen, and a reflexive thematic analysis undertaken. The study identified previously unreported impacts such as complex fluid needs, iatrogenic withdrawal, neurological irritability and changes to breastfeeding behaviour. Mothers described breastfeeding as emotionally and immunologically meaningful. There were many complex psychological challenges such as guilt, disempowerment, and trauma. Wider struggles such as staff resistance to bedsharing, inaccurate breastfeeding information, lack of food and inadequate breast pump provision made breastfeeding more challenging. There are numerous challenges related to breastfeeding and responsively parenting sick children in paediatrics, and these also impacted maternal mental health. Staff skill and knowledge gaps were widespread, and the clinical environment was not always conducive to supporting breastfeeding. This study highlights strengths in clinical care and provides insight into what measures are perceived as supportive by mothers. It also highlights areas for improvement, which may inform more nuanced paediatric breastfeeding standards and training. [ABSTRACT FROM AUTHOR]

Despite the well-known benefits of breastfeeding, breastfeeding rates remain suboptimal, particularly for women with lower socioeconomic position. Although popular, breastfeeding apps are often poor quality; their impact on breastfeeding knowledge, attitudes, confidence and intentions is unknown. A mixed method pre- post feasibility study was conducted to: 1) explore the feasibility of the My Baby Now app in providing perinatal breastfeeding support; 2) examine the impact on breastfeeding knowledge, attitudes, confidence and intentions; 3) to examine any differences in acceptability and impact of the app according to maternal education. The My Baby Now app was offered to pregnant women 20-30 weeks gestation. Breastfeeding knowledge and intentions were collected at baseline (T1) and 36-38 weeks gestation (T2); attitudes and confidence were collected at baseline, T2 and T3 (8-12 weeks post-partum). App engagement was measured via app analytics. Qualitative interviews were conducted with a purposeful sample following T3. Of 266 participants recruited, 169 (64%) completed T2 and 157 (59%) completed T3. Mothers without university education rated the app to be higher quality, more useful and impactful than mothers with university education. From T1-T2, breastfeeding knowledge (59.6% vs. 66.5%, p < 0.001) and exclusive breastfeeding intentions (76.6% vs. 80.9%, p < 0.001) increased. Breastfeeding attitudes and confidence scores also increased significantly across T1-T2 and T1-T3. App engagement during pregnancy predicted changes in breastfeeding attitudes from T1-T2 among participants without university education. App engagement did not predict changes in breastfeeding knowledge, confidence or intentions. Future randomised controlled studies should examine the effectiveness of mHealth interventions on breastfeeding outcomes. [ABSTRACT FROM AUTHOR]

Exclusive breastfeeding is recommended for 6 months; however, many childbearing people wean their infants before 6 months. Psychosocial factors such as stress, social support and race are significant determinants of breastfeeding; however, few studies have longitudinally explored the effect of perceived stress and various forms of social support on exclusive breastfeeding. We used quantitative methodologies to examine exclusive breastfeeding, perceived stress and social support among 251 participants from the Postpartum Mothers Mobile Study. Participants between 18 and 44 years were recruited during pregnancy (irrespective of parity) and completed surveys in real-time via Ecological Momentary Assessment up to 12 months postpartum from December 2017 to August 2021. We measured perceived stress with the adapted Perceived Stress Scale and perceived social support with the Multi-dimensional Social Support Scale. Received social support was measured using a single question on breastfeeding support. We conducted a mixed-effects logistic regression to determine the effect of stress, race and social support on exclusive breastfeeding over 6 months. We examined the moderation effect of perceived social support and breastfeeding support in the relationship between perceived stress and exclusive breastfeeding. Black, compared with White, participants were less likely to breastfeed exclusively for 6 months. Participants who reported higher perceived stress were less likely to breastfeed exclusively for 6 months. Perceived social support moderated the relationship between perceived stress and exclusive breastfeeding (odds ratio: 0.01, 95% confidence interval: 0.001-0.072). However, breastfeeding support directly increased the likelihood of exclusive breastfeeding over 6 months. Perceived stress is negatively associated with exclusive breastfeeding. Birthing people who intend to breastfeed may benefit from perinatal support programs that include components to buffer stress. [ABSTRACT FROM AUTHOR]

Agricultural development projects increasingly aim to improve health and nutrition outcomes, often by engaging women. Although evidence shows such projects can improve women's and children's health and nutrition and empower women, little is known about their impacts on women's health- and nutrition-related agency and the extent to which impacts emerge through women's empowerment, largely due to a lack of instruments that measure the dimensions of women's agency that are directly relevant to health and nutrition outcomes. We developed an optional, complementary module for the project-level women's empowerment in agriculture index (pro- WEAI) to measure health- and nutrition-related agency (pro-WEAI + HN). Our method for developing related indicators used data collected from six agricultural development programmes implemented across Bangladesh, Burkina Faso and Mali (pooled sample = 12,114) and applied psychometric analysis (exploratory and confirmatory factor analysis) and the Alkire-Foster methodology. Results revealed seven indicators covering women's agency in the areas of her own health and diet; her health and diet during pregnancy; her child's diet; breastfeeding and weaning; purchasing food and health products; and acquiring food and health products. Multigroup confirmatory factor analysis revealed measurement invariance across contexts and samples. Tests of association (Cramer's V) and redundancy suggest that the pro-WEAI + HN indicators measured aspects of agency that are distinct from the core pro-WEAI. The uptake of these indicators in studies of nutrition-sensitive agricultural development projects may strengthen the evidence on how such programming can enhance women's empowerment to improve health and nutrition outcomes for themselves and their children. [ABSTRACT FROM AUTHOR]

Breastfeeding plays an important role in the growth and development of preterm infants, and exclusive breastfeeding (EBF) in the first 6 weeks post-partum is the key to continuous breastfeeding. This study was designed to explore the influencing factors that contribute to breastfeeding attrition among mothers of preterm infants at Week 6 post-partum based on the theory of planned behaviour (TPB). We herein adopted a prospective observational study design in which 97 mothers who exclusively breastfed at Week 6 post-partum at a tertiary specialised hospital in Shanghai from June 2021 to February 2022 were taken as the EBF group, and 179 mothers without EBF were assigned to the EBF attrition group. Through an extensive literature review and expert consultation, we determined the possible factors influencing EBF attrition, analysed those factors that showed statistical significance in our univariate analysis by applying binary logistic regression, and constructed a nomogram model for predicting EBF attrition. The results revealed that negative breastfeeding sentiment (odds ratio [OR] = 1.006; 95% confidence interval [CI], 1.000-1.011) generated a greater risk of breastfeeding attrition. However, positive breastfeeding sentiment (OR = 0.991; 95% CI, 0.983-0.999), social and professional support (OR = 0.993; 95% CI, 0.987-0.999), breastfeeding control (OR = 0.945; 95% CI, 0.896-0.996), knowledge (OR = 0.893; 95% CI, 0.799-0.998), and intention to EBF at Week 6 post-partum (OR = 0.522; 95% CI, 0.276-0.988) were the protective factors and facilitated the development of our nomogram model. The Hosmer-Lemeshow goodness-of-fit test generated a χ2 value of 11.344 (p = 0.183) and an area under the curve of 0.822 (95% CI, 0.771-0.873). The C-index was 0.800 in the internal bootstrap validation, indicating that the nomogram model possessed favourable predictive accuracy and discrimination. [ABSTRACT FROM AUTHOR]

We estimated how micronutrient needs of young children, aged 6-24 months were covered by the standard (traditional) diets in Ghana and Benin, and the contributions of partial breastfeeding and national nutrition programs aimed at improving micronutrient status to overall micronutrient intakes. Estimates of micronutrient intake from standard diets were based on previous surveys, using the food composition table of West Africa (INFOOD). Recommended micronutrient intakes were based on World Health Organization recommendations. Children were grouped in three age groups (6-8, 9-12, and 13-24 months) to capture the changing dynamics of the complementary feeding period. As expected, from 6 months of age onwards, breastmilk didn't cover the micronutrient needs. The standard diets contributed only minimal to micronutrient intakes of children ranging from 0% to 37% of recommended intakes for Ca, Fe, Zn, vitamin A, vitamin D and iodine depending on the micronutrient considered. The contribution of mass (bio)- fortification programs to the coverage of micronutrient needs varied widely, depending on the staple food considered and the country, but overall did not allow to fill the gap in micronutrient needs of children except for vitamin A in some contexts. In contrast, consumption of voluntary fortified complementary food, especially formulated for the needs in this age groups, contributed substantially to overall micronutrient intake and could fill the gap for several micronutrients. The development of young child-targeted programs including micronutrient-dense foods, associated with interventions to increase the diet diversity and meal frequency, could significantly improve micronutrients intakes of children in both Ghana and Benin. [ABSTRACT FROM AUTHOR]

This implementation research study sought to examine the impact of the COVID-19 pandemic on maternal and infant nutrition practices, and related aspects of health and food systems in Nairobi and Uasin Gishu Counties, Kenya. The study triangulated in-depth interviews with 16 pregnant women, 31 lactating women (including COVID-19 positive), 10 facility health workers, 10 community health volunteers, 6 focus group discussions (FGDs) with food vendors, 4 FGDs and 15 stakeholder interviews with government and implementing partners. Trends from Kenyan Health Information System indicators (i.e., exclusive breastfeeding and initiation of breastfeeding, antenatal care) were also examined. During the COVID-19 pandemic, a decline in attendance of antenatal care, and maternity facilities was observed, and corroborated by Kenyan Health Information System data. Lack of clarity among health workers on COVID-19 breastfeeding guidance and fear of COVID-19 infection early in the pandemic were key drivers of early infant formula use, mother-child separation following delivery and delayed initiation of breastfeeding. Most women exclusively breastfed due to Government of Kenya restrictions in movement. Unemployment and job loss was linked to food insecurity and worsened by increased food prices and limited social protection measures. In response, pregnant and lactating women resorted to skipping meals and reducing quantity and variety of foods consumed. Efforts to build forward from COVID-19 in Kenya should include facility and community health education to prevent disruptions in breastfeeding and to support maternal dietary intake, and in the provision of targeted social protection measures alongside other multisectoral interventions (i.e., psychosocial support) for Kenyan pregnant and lactating women. [ABSTRACT FROM AUTHOR]

Low coverage of effective nutrition interventions in many high‐burden countries, due to service provision and demand factors, result in poor uptake of recommended practices and nutrition outcomes. We examined the factors that influence maternal nutrition and early breastfeeding practices and determined the extent that the key factors could improve these practices in two regions in Burkina Faso. We used household survey data among pregnant (n = 920) and recently delivered women (n = 1840). Multivariable regression analyses were conducted to identify the determinants of a diverse diet and iron‐folic acid (IFA) supplement consumption, weight monitoring during pregnancy and early initiation of breastfeeding (EIBF). Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal conditions of interventions that address the modifiable determinants. During pregnancy, 21% of women achieved minimum diet diversity (MDD‐W), 70% consumed 90+ IFA tablets and 65% were weighed 4+ times; EIBF was 40%. Nutrition knowledge was associated with MDD‐W (odds ratio [OR]: 3.2), 90+ IFA (OR: 1.5) and EIBF (OR: 1.9). Positive social norms and family support were associated with 90+ IFA (OR: 1.5). Early and 4+ ANC visits were associated with 90+ IFA (OR: 1.5 and 10) and 4+ weight monitoring (OR: 6.2). Nutrition counselling was associated with 90+ IFA (OR: 2.5) and EIBF (OR: 1.5). Under optimal programme conditions, 41% of women would achieve MDD‐W, 93% would consume 90+ IFA, 93% would be weighed 4+ times and 57% would practice EIBF. Strengthening the delivery and uptake of interventions targeted at these modifiable factors has the potential to improve maternal nutrition practices. Key messages: In our Burkina Faso study, maternal nutrition practices were low to moderate, with 21% of pregnant women consuming at least 5 food groups, 70% of women consuming at least 90 daily iron and folic acid (IFA) tablets and 65% weighed at least 4 times during their last pregnancy, and 40% of women initiating breastfeeding within 1 h after birth.Various individual, household and health service level factors were modifiable through interventions for improving maternal nutrition and breastfeeding practices, but practices were associated with different combinations of factors.Under optimal conditions of interventions that address the modifiable determinants, we estimated that nearly all women would be able to achieve consumption of 90+ IFA tablets and receipt of weight monitoring 4+ times, and nearly half or more of the women would be able to achieve minimum dietary diversity and early initiation of breastfeeding. [ABSTRACT FROM AUTHOR]

Breastfeeding (BF) has been identified as a protective factor against childhood obesity. However, evidence of the association between BF duration and adiposity remains inconclusive. Few studies have been conducted among Southeast Asian infants that have measured body composition during infancy using the gold standard stable isotope method. This study aimed to evaluate the association between BF duration and body composition during infancy. Healthy full‐term Thai infants aged 6–8 months (n = 60) receiving exclusive or predominant BF for at least 3 months were recruited. Skinfold thickness (SFT) was measured by well‐trained investigators. Body composition was assessed by the deuterium dilution technique. Infants with longer BF duration (>6 months; mean 7.5 ± 0.5 months, n = 29) had a higher subscapular SFT z‐score than those with shorter BF duration (≤6 months; mean 5.3± 0.9 months, n = 31) by 0.48 (95% confidence interval [CI]: 0.01–0.94). After adjustment for age and sex, BF duration and age at introduction of complementary feeding (CF) were positively associated with fat mass and fat mass index at 6–8 months. One month increase in BF duration and CF age was associated with a 0.37 (95% CI: 0.05, 0.69) kg/m2 and 0.76 (95% CI: 0.18, 1.34) kg/m2 increase in the fat mass index, respectively. After adjusting for infant body mass index (BMI) during the earlier infancy period, the strength of the association was attenuated. This finding may reflect reverse causality where infants with lower BMI received formula or CF earlier. A longitudinal study with follow‐up into childhood is warranted to confirm the effects of BF on adiposity in infancy and childhood. Key points: Previous evidence found that the duration of breastfeeding (BF) and infant feeding practice may be associated with adiposity during infancy and later life.Our study found that infants who received BF solely for a longer duration had a significantly higher fat mass and fat mass index at age 6–8 months based on anthropometry and the isotope dilution technique compared with infants with a shorter BF duration.Older age at introduction complementary feeding was associated with higher adiposity at age 6–8 months.Further longitudinal tracking up to childhood is warranted to confirm the effects of BF on adiposity in infancy and beyond. [ABSTRACT FROM AUTHOR]

Media can be a powerful communication tool to promote breastfeeding, influence mothers' breastfeeding behaviour, create positive social norms and generate support among stakeholders and policymakers for breastfeeding. However, negative stories could deter women from starting or continuing to breastfeed. This study aimed to describe the breadth and focus of the media coverage of breastfeeding and the message frames that are found in three of the most widely read national newspapers and three popular women's magazines in Great Britain over a 12‐month period, as part of the Becoming Breastfeeding Friendly in Great Britain (BBF‐GB) study. For this retrospective media analysis, 77 articles were identified and 42 were included in the study for coding and analysis. We conducted two content analyses to examine the articles' (1) message framing and (2) alignment with the eight components of an 'enabling breastfeeding environment' using the BBF Gear framework. Articles featuring breastfeeding appear in British newspapers and women's magazines all year round. Twenty‐four per cent had a neutral tone, while 59% predominantly focused on the positive aspects or positive social support for breastfeeding, and 17% were predominantly focused on the negative aspects or negative social attitudes towards breastfeeding. The articles mainly focused on personal stories reflecting societal barriers and positive shifts (68%), with 12% presenting an analysis of breastfeeding evidence or barriers. There were fewer references to the legislation (5%) and availability of funding (2%) and support (9%). There was no coverage of national coordination and strategy, evaluation systems, or the political will to raise breastfeeding rates. Key messages: During the one‐year study period, articles featuring breastfeeding appeared in the included British newspapers and women's magazines all year round rather than being focused on specific events, such as World Breastfeeding Week.Articles mainly focused on personal stories and were initiated by social media posts or discussions on television by mothers, often celebrity mothers.While articles discussed the difficulties mothers face during breastfeeding, they also detailed positive support for breastfeeding, presenting a more balanced view.The articles did not fully reflect BBF's Gear Model components for an enabling breastfeeding environment. Most were categorised as promotion articles with fewer advocacy pieces. There was little coverage of legislation, services and funding while political support, breastfeeding data and strategic oversight were not covered. [ABSTRACT FROM AUTHOR]

Breastfeeding is the most accessible and cost‐effective activity available to public health and has been shown to be one of the most effective preventive measures mothers can take to protect their children's health. Despite the well‐documented benefits, the UK has one of the lowest breastfeeding rates in the world. The Becoming Breastfeeding Friendly (BBF) toolkit was developed through highly structured technical and academic collaboration, led by Yale University. It provides an evidence‐based process to help countries assess their breastfeeding status and readiness to scale up, and identifies concrete measures countries can take to sustainably increase breastfeeding rates, based on data‐driven recommendations. BBF is grounded in the Breastfeeding Gear Model complex adaptive systems framework which is made up of eight simultaneous conditions that sustain breastfeeding. In 2018, a committee of multi‐agency stakeholders implemented the BBF process in England, collecting evidence to score the 'gear' components of England's breastfeeding environment against 54 benchmarks. The Training and Programme Delivery gear received the highest score, attributable to existing learning outcomes for health professionals and practitioners, peer supporters and specialist services, although there is a need for greater coordination and integration. The lowest scores were given for Promotion and Coordination, Goals and Monitoring due to the lack of a dedicated national strategy for breastfeeding and poor sharing of localised strategies and programmes. The process generated clear recommendations highlighting the need for more robust routine infant feeding data collection and reporting, and the necessity for strengthening leadership, monitoring and oversight to scale up and sustain breastfeeding. Key messages: England's overall weighted Becoming Breastfeeding Friendly (BBF) Index score was 1.1 (range 0–3) representing a moderate scaling up environment (range 1.1–2.0). Five gears: Political Will, Legislation and Policies, Funding and Resources; Training and Programme Delivery and Research and Evaluation scored at a moderate gear strength, while the remaining three gears—Advocacy, Promotion and Coordination Goals and Monitoring—were weak.The BBF process for England highlighted substantial gaps in the current breastfeeding practice data and recommended that more robust routine, population‐level infant feeding data collection and reporting is initiated that goes beyond 6–8 weeks and up to 2 years.The process identified that the lack of a national infant feeding co‐ordinator role or national breastfeeding committee had resulted in no dedicated workplan and a lack of advocacy for breastfeeding programmes. The need for greater future coordination, strategic goal setting and consistent monitoring was recommended to strengthen the breastfeeding environment. [ABSTRACT FROM AUTHOR]

Breastfeeding and the provision of human milk is established as protecting infant and maternal health. However, breastfeeding rates in many countries, including Wales, are low. Given the significant health, economic and environmental impacts of this, the need to strengthen breastfeeding promotion, protection and support is paramount. As part of this, the becoming breastfeeding friendly: a guide to global scale‐up (BBF) initiative sets out a methodology to enable countries to assess their readiness to scale up breastfeeding protection, promotion and support by gathering data and scoring progress under eight areas, termed 'gears', shown to be essential for large‐scale change. Recently, Wales took part in the BBF initiative. A cross‐sector committee, including stakeholders from Universities, Welsh Government, Public Health Wales and Health Boards alongside critical friends scored Wales' support for breastfeeding across the eight gears. The overall score for Wales was 1.1 out of a possible 0–3, representing a moderate scaling up the environment for breastfeeding. Six gears were rated in the moderate gear strength category and two ('Promotion' and 'Advocacy') in the weak gear strength category. Gaps in breastfeeding support were identified and 31 recommendations covering six themes for change were put forward. These included a strategic action plan, consistent and long‐term funding, a nuanced, cocreated engagement and promotion framework, strengthened education and training, robust monitoring and evaluation mechanisms and ensuring maternity rights and the International Code of Marketing of Breastmilk Substitute are upheld. Taken together, the analysis and recommendations present a clear vision for protecting and not merely promoting breastfeeding in Wales. Highlights: Wales is a small nation with devolved health legislation that should take advantage of its power to enact countrywide, universal breastfeeding policy and strategy.Policy, promotion and support should be nuanced and cocreated by communities to meet the needs of the diverse Welsh population.Policy must be supported by sustainable investment and political, positional and operational buy‐in across government, health and social services.Strategy must be evidence‐based with an emphasis on women's experiences and voices. Robust monitoring and evaluation mechanisms must be put in place so that data are up to date and meaningful. [ABSTRACT FROM AUTHOR]

The Becoming Breastfeeding Friendly (BBF) in Great Britain study was conducted during 2017–2019 comprising three country studies: BBF England, Wales and Scotland. It was part of an international project being coordinated during the same period by the Yale School of Public Health across five world regions to inform countries and guide policies to improve the environment for the promotion, protection and support of breastfeeding. This paper reports on the application of the BBF process that is based on an implementation science approach, across the countries that constitute Great Britain (England, Wales and Scotland). The process involves assessing 54 benchmarks across eight interlocking gears that drive a country's 'engine' towards a sustainable policy approach to supporting, promoting and protecting breastfeeding. It takes a consensus‐oriented approach to the evaluation of benchmarks and the development of recommendations. This paper provides a critical overview of how the process was conducted, the findings and recommendations that emerged and how these were managed. We draw on critical theory as a theoretical framework for explaining the different outcomes for each country and some considerations for future action. Key messages: Undertaking an international, comparable approach to develop evidence‐based policy recommendations for scaling up the breastfeeding environment can provide useful data on which to draw explanations and conclusions on national variation.The findings from the BBF process across England, Scotland and Wales suggest that improving breastfeeding in Great Britain is dependent on the degree of political will and having a coordinated national breastfeeding strategy in place or not, along with access to robust breastfeeding data.A critical theory lens helps to bring to light some differences in the research and policy process that can explain differences between countries in the United Kingdom. [ABSTRACT FROM AUTHOR]

Evidence‐based policy toolboxes are essential for decision makers to effectively invest in and scale up maternal‐child health and nutrition programs, and breastfeeding is no exception. This special issue focuses on the experiences implementing the Becoming Breastfeeding Friendly (BBF) toolbox in England, Scotland, and Wales. BBF is an initiative that includes a toolbox for decision making based on the Complex Adaptive System‐based Breastfeeding Gear Model. The BBF initiative experience in Great Britain presented in this special issue illustrates how versatile BBF is as it can be readily adapted to the specific application context. In this instance one country, England was trained by the Yale School of Public Health team that developed BBF. England, in turn, trained and assisted Scotland and Wales with the implementation and oversight of BBF in those countries. The positive experience implementing BBF in Great Britain is fully consistent with findings related to this initiative in other countries with contrasting economic, social, political and health care systems; including Germany, Ghana, Mexico, Myanmar, and Samoa. In all instances BBF has led to breastfeeding policy improvements with strong implications for enabling breastfeeding environments including maternity benefits, workforce development, the Baby Friendly Hospital Initiative and behavior change communication campaigns. In conclusion, BBF is a powerful tool to help guide the effective scaling up of evidence‐based programmes to advance breastfeeding protection, promotion and support globally. Key messages: Evidence‐based policy toolboxes are essential for decision makers to effectively invest in and scale up breastfeeding programmes.Becoming Breastfeeding Friendly (BBF) is an initiative that includes a toolbox for decision making based on the Complex Adaptive System‐based Breastfeeding Gear Model.BBF is implemented by scoring each of the gears using evidence‐based indicators that have been clearly define.BBF scoring is done by an interdisciplinary committee with representation from diverse government entities, civil society organizations, international agencies and academics.BBF has been successfully implemented and is informing breastfeeding policy across eight countries with contrasting health care, economic and social systems. [ABSTRACT FROM AUTHOR]

Despite strong policy support in Scotland, United Kingdom, key challenges to scaling up promotion, protection and support for breastfeeding remain. These include low breastfeeding rates and socioeconomic and regional inequalities. The Becoming Breastfeeding‐Friendly (BBF) process was implemented to highlight actions that could address these challenges. The Scottish BBF committee employed an iterative process of documentary analysis and evidence reviews supplemented by 18 interviews with key informants. The data were mapped to BBF benchmarks and each gear was scored accordingly. Nineteen draft recommendations addressing policy and practice gaps were prioritised. Ten recommendations were grouped into eight themes, which cross‐cut the BBF gears. The process took place from May 2018 to May 2019. The overall BBF Index score for Scotland was 2.4 indicating a strong scaling‐up environment for breastfeeding. Five gears were assessed as strong gear strength, and the remaining three were judged as moderate gear strength. Three recommendation themes illuminate strengths and areas for development. The theme 'reinforcing political will' showed effective leadership, strong policies and significant investment in supporting breastfeeding and highlights actions to sustain this. The theme 'strengthening and coordinating breastfeeding messages' revealed a need for coordination between government, health services and the third sector. The theme 'promoting a supportive return to work environment' highlighted that, while employment legislation is not devolved to the Scottish government, action could be taken by employers to optimise an enabling environment for breastfeeding. The BBF process identified strengths and triggered actions to enhance breastfeeding promotion, protection and support in Scotland. Key messages: Scotland has a strong scaling‐up environment for the promotion, protection and support of breastfeeding as assessed by the Becoming Breastfeeding Friendly process;The BBF process is a helpful tool that led to specific recommendations that together have the potential to improve the rates and experiences of breastfeeding in Scotland;Scotland has a strong political commitment to breastfeeding evidenced by effective leadership, strong policies and significant investment and this needs to be sustained;Further co‐ordination of breastfeeding activities and messages between government, health services and the third sector is needed;A supportive environment of breastfeeding women returning to work could be enhanced through employer guidelines and increasing women's awareness of their rights. [ABSTRACT FROM AUTHOR]

Associations between breastfeeding intention, duration and post‐natal depression (PND) have been shown in pre‐COVID‐19 studies. However, studies during COVID‐19 have not examined the associations between breastfeeding intention, breastfeeding practices, and PND in an international sample of post‐natal women, taking into consideration COVID‐19 related factors. This is the first study to address this gap as both PND and breastfeeding may be affected by COVID‐19, and have important long‐term effects on women's and infant's health. A cross‐sectional internet‐based survey was conducted with 3253 post‐natal women from five countries: Brazil, South Korea, Taiwan, Thailand, and the United Kingdom from July to November 2021. The results showed that women who intended to breastfeed during pregnancy had lower odds of having PND than women who did not intend to. Women who had no breastfeeding intention but actually breastfed had greater odds (AOR 1.75) of having PND than women who intended to breastfeed and actually breastfed. While there was no statistical significance in expressed breast milk feeding in multivariable logistic regression models, women who had shorter duration of breastfeeding directly on breast than they planned had greater odds (AOR 1.58) of having PND than those who breastfed longer than they planned even after adjusting for covariates including COVID‐19‐related variables. These findings suggested the importance of working with women on their breastfeeding intention. Tailored support is required to ensure women's breastfeeding needs are met and at the same time care for maternal mental health during and beyond the pandemic. Key messages: This study identified independent associations of breastfeeding intention and actual breastfeeding practices with PND after adjustment for COVID‐19‐related covariates.Although women who intended to breastfeed during pregnancy were less likely to have PND, those who did not intend to breastfeed but did breastfeed were more likely to have PND than those who intended to breastfeed and breastfed.Women with shorter (vs. longer) than planned duration of breastfeeding on breast were more likely to have PND.Health care providers and policymakers should ensure tailored support is available for women's infant feeding plans and mental health. [ABSTRACT FROM AUTHOR]

In the extended UNICEF framework of early childhood nutrition, parents' stress is associated with parental feeding style. However, no comprehensive review has examined the association between parents' stress and feeding styles and practices. The objective of our review was to synthesise the current literature examining the association between parents' stress and their feeding practices and/or styles, among parents of children ≤ 5 years old. We searched; MEDLINE, EMBASE, PSYCHINFO and CINAHL from 2019 to 2021. Two investigators independently extracted relevant data and assessed the study quality and the certainty of evidence. Data were pooled using generic inverse variance with fixed effects (<5 comparisons) or random effects (≥5 comparisons) and expressed as correlation coefficients with 95% confidence intervals (CI). Between study heterogeneity was assessed using Cochran's Q and quantified with I2. We identified 6 longitudinal and 11 cross‐sectional studies, of which 4 studies provided sufficient data to be pooled. A very small correlation between general stress and restrictive feeding practices was observed (r = 0.06 [95% CI: 0.01−0.12]; no substantial heterogeneity (I2 = 0.00%, PQ < 0.85, very low certainty). No correlation between general stress and feeding pressure was identified (r = 0.06 [95% CI: −0.02 to 0.15]). Results showed that both general and parenting stress were associated with suboptimal breastfeeding practices and unresponsive feeding styles. Conclusion: This study demonstrated a low‐to‐moderate quality of literature for the inclusion of parents' stress in the extended UNICEF care model of child nutrition. Future research needs to explore this relationship longitudinally and in ethnic diverse populations to inform tailored interventions that promote responsive feeding practices. Key messages: General stress has a small correlation with parental restriction feeding practices.Parenting stress is associated with uninvolved feeding styles.The specific relation between general and parenting stress and feeding style and/or practice needs to be further explored to inform tailored interventions to promote responsive feeding practices. [ABSTRACT FROM AUTHOR]