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Using data from 242 exclusively breastfeeding mother-infant pairs, newborn elimination patterns were analyzed. Sensitivity (Se) and Specificity (Sp) of day 4 (72-96 hours) wet and soiled output, in addition to the timing of onset of lactation, in identifying cases of breastfeeding inadequacy (defined as neonatal weight loss ≥ 10% of birth weight) were examined. The usefulness of 2 measures in parallel was also explored. Median number of diapers (wet, soiled) on days 1, 4, and 7, respectively, was 2, 3; 5, 4; and 7, 6. The most efficient day 4 predictor of breastfeeding inadequacy was soiled diaper output ≤ 3 (Se = .75, Sp = .66). Sensitivity improved when used in parallel with delayed onset of lactation (≥ 72 hours); Se = .86 (95% confidence interval, .73-.99) and Sp = .59 (.55-.63). Fewer than 4 soiled diapers on day 4 when used in conjunction with delayed onset of lactation may be indicative of breastfeeding inadequacy, but low specificity will result in many false positives. J Hum Lact. 24(1):27-33.

Low intake of bioavailable iron from complementary foods is the major cause of the high prevalence of iron-deficiency anemia among children 6 to 24 months of age in developing countries. Increased dietary diversity and traditional food-processing techniques are generally unsuccessful at completely closing the gap between iron intake and needs. Thus, iron-fortified processed complementary foods or home fortification (using powders, crushable tablets, or fat-based products) will be needed in most populations. Several studies have demonstrated that both approaches are efficacious, though there are limited data on effectiveness on a wide scale. The choice of which product to promote may depend on the context, as well as cost constraints. No adverse effects of increasing iron intake through fortification or home fortification of complementary foods have been reported, but large-scale studies that include sufficient numbers of iron-replete children are lacking. Further research is needed to verify the safety of iron-fortification strategies, particularly in malarial areas.

Mammary candidosis in lactating women is not well defined and is most often presumptively diagnosed by signs and symptoms. This study evaluates the sensitivity, specificity, positive predictive value, and likelihood ratios of signs and symptoms of mammary candidosis based on the presence of Candida species on the nipple/areola or in the milk. In this prospective cohort study, the nipple/areola skin and milk of 100 healthy breastfeeding mothers were cultured from each breast at 2 weeks postpartum, and mothers were interviewed regarding signs and symptoms associated with mammary candidosis between 2 and 9 weeks postpartum. Positive predictive value for Candida colonization was highest when there were 3 or more signs or symptoms simultaneously or when flaky or shiny skin of the nipple/areola was reported together or in combination with breast pain. J Hum Lact. 20(3):288-295.

The World Health Organization (WHO) Multicentre Growth Study (MGRS) Middle East site was Muscat, Oman. A survey in Muscat found that children in households with monthly incomes of at least 800 Omani Rials and at least four years of maternal education experienced unconstrained growth. The longitudinal study sample was recruited from two hospitals that account for over 90% of the city's births; the cross-sectional sample was drawn from the national Child Health Register. Residents of all districts in Muscat within the catchment area of the two hospitals were included except Quriyat, a remote district of the governorate. Among the particular challenges of the site were relatively high refusal rates, difficulty in securing adherence to the protocol's feeding recommendations, locating children selected for the cross-sectional component of the study, and securing the cooperation of the children's fathers. These and other challenges were overcome through specific team building and public relations activities that permitted the successful implementation of the MGRS protocol.

This study used simple rapid-assessment techniques to test the feasibility of increasing the consumption of complementary foods by infants by asking mothers to increase meal quantity or frequency or by altering the viscosity/energy density of the food. The feasibility of using micronutrient supplements either added directly to food or administered as liquid drops was also examined. The study was conducted in rural Bangladesh and involved four separate short-term behavioral change trials. Depending on the trial, fieldworkers recruited 30 to 45 infants 6 to 12 months of age. Following recommendations to increase the amount of food provided to infants, the mean intakes from single meals increased from 40 ± 23 g on day 1 to 64 ± 30 g on day 7 (p < 0.05). In a second trial, the mean meal frequency increased from 2.2 ± 1.3 on day 1 to 4.1 ± 1.3 on day 7 (p < 0.05). Provision of high-energy-density diets, prepared by decreasing viscosity with α-amylase or by hand-mashing rice and dhal into a paste before feeding, increased single-meal energy consumption from 54 ± 35 kcal to 79 ± 52 kcal or 75 ± 37 kcal (p < 0.05), respectively. Both types of micronutrient supplements were well accepted and used according to recommendations. In conclusion, it was possible to change short-term child-feeding behaviors to promote increased food intake, meal frequency, energy density, and micronutrient consumption. Because each of these interventions lasted for only about 1 week, however, the long-term sustainability of these changes is not known. Moreover, the effect of increased feeding of complementary foods on intakes of breastmilk and total daily consumption of energy and nutrients requires further study.

The World Health Organization (WHO) Multicentre Growth Reference Study (MRGS) North American site was Davis, California. For the longitudinal cohort (0–24 months), 208 infants were enrolled between January and December 1999 from five area hospitals at which nearly all Davis women give birth. The target sample size was lower in the United States than in the other sites, because recruitment in the United States was restricted to mothers who were willing to exclusively breastfeed for at least 4 months and continue breastfeeding for at least 12 months. For the cross-sectional component, a mixed-longitudinal design was used, which required approximately 500 subjects. The subjects were recruited by going door-to-door, with the sampling scheme based on the distribution of the subjects of the longitudinal study within the city. The cross-sectional sample was recruited between January and July 2001. Major challenges during implementation were maintaining daily communication with hospital personnel and scheduling home visits.

Recent studies suggest that breastfeeding reduces the risk of child obesity to a moderate extent. Of 11 studies that examined prevalence of overweight in children older than 3 years of age and that had a sample size of ≥ 100 per feeding group, 8 showed a lower risk of overweight in children who had been breastfed, after controlling for potential confounders. The 3 “negative” studies lacked information on the exclusivity of breastfeeding. A dose-response relationship with duration of breastfeeding was observed in some, but not all, of the “positive” studies. Possible mechanisms include learned self-regulation of energy intake, metabolic programming in early life, and residual confounding by parental attributes. If the association is causal, the effect of breastfeeding is probably small compared to other factors that influence child obesity, such as parental overweight. Nonetheless, it may be of public health significance considering the current epidemic of child overweight. J Hum Lact. 19(1):9-18.

This paper provides an update to the 1998 WHO/UNICEF report on complementary feeding. New research findings are generally consistent with the guidelines in that report, but the adoption of new energy and micronutrient requirements for infants and young children will result in lower recommendations regarding minimum meal frequency and energy density of complementary foods, and will alter the list of “problem nutrients.” Without fortification, the densities of iron, zinc, and vitamin B6in complementary foods are often inadequate, and the intake of other nutrients may also be low in some populations. Strategies for obtaining the needed amounts of problem nutrients, as well as optimizing breastmilk intake when other foods are added to the diet, are discussed. The impact of complementary feeding interventions on child growth has been variable, which calls attention to the need for more comprehensive programs. A six-step approach to planning, implementing, and evaluating such programs is recommended.

In summary, numerous studies have indicated that the pattern of growth during infancy is influenced by feeding mode. Compared to formula-fed infants, breastfed infants generally gain less weight, particularly after the first few months of life. This appears to be a normal pattern among healthy, thriving infants. Although true growth faltering can certainly occur among breastfed infants, it is difficult to evaluate using the NCHS growth chart, which is based on a sample of predominantly formula-fed infants. This situation has prompted WHO to begin the process of creating a new growth chart based on breastfed infants.

Optimal nutritional care of young children requires application of feeding guidelines based on scientific knowledge of children's nutrient requirements and the ability of breastmilk and other foods to satisfy these nutritional needs. This paper reviews recent information on the appropriate duration of exclusive breastfeeding and timing of introduction of complementary foods; the relationship between frequency of feeding, dietary energy density, and total daily energy consumption; and the importance of nutrient composition and selected organoleptic characteristics of complementary foods as determinants of dietary intake. The role of child appetite is also discussed Finally, programmatic options for the promotion of enhanced complementary feeding and relevant practical experiences in Peru are reviewed.

This Supplement is the second in a series devoted to focusing attention on the need to improve maternal, infant, and young child nutrition (MIYCN) across the different stages of the key “window of opportunity” from preconception through pregnancy, the period of exclusive breastfeeding (0 to 6 months), and the target age for complementary feeding (6 to 24 months). It brings together a broad range of expertise from around the world. These papers are linked to an international dialogue to build support for MIYCN programs in a series of meetings, including those held at the Micronutrient Forum in Beijing in 2009 and the International Congress of Nutrition in Bangkok in 2009. As with last year’s Supplement [1], this volume covers topics such as how to enhance women’s nutrition, improve breastfeeding practices, and optimize the composition of complementary foods. Additionally, this Supplement includes papers discussing evaluations of programmatic interventions and why integrating child nutrition with early child development interventions can have multiple benefits for child growth and development. The role of policy, such as changes in the international Codex Alimentarius guidelines, is also highlighted. Although action is needed at each of the above stages of the life cycle, it is imperative that we find means to integrate actions to achieve greater impact and efficiency. For example, production of fortified foods that can be used for both pregnant women and young children, with minor changes in micronutrient content and serving sizes, will help address problems of anemia and other micronutrient deficiencies in both target groups, as well as low body mass index in women and stunting in children [2, 3]. Such efforts can also help to reduce costs of products and facilitate their manufacture and distribution through public–private partnerships. Linking messages on the need for iron supplementation to reduce anemia before and during pregnancy with information on immediate and exclusive breastfeeding, delayed cord clamping, and how to improve maternal–child interaction can have longlasting impacts on both maternal health and child development. Similarly, combining behavior change approaches for enhancing complementary feeding and encouraging simple play activities can help enhance child growth and development. We hope that soon we will have illustrations of how such actions have been integrated at large scale.