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Objectives: To examine whether use of expressed human milk in the first two weeks postpartum is associated with cessation of human milk feeding and non-exclusive human milk feeding up to 6 months., Design: Pooled data from two prospective cohort studies SETTING: Three Canada Prenatal Nutrition Program (CPNP) sites serving vulnerable families in Toronto, Canada., Participants: 337 registered CPNP clients enrolled prenatally from 2017 to 2020; 315 (93%) were retained to 6 months postpartum., Exclusions: pregnancy loss or participation in prior related study; Study B: preterm birth (<34 weeks); plan to move outside Toronto; not intending to feed human milk; hospitalisation of mother or baby at 2 weeks postpartum., Primary and Secondary Outcome Measures: Main exposure variable: any use of expressed human milk at 2 weeks postpartum., Outcomes: cessation of human milk feeding by 6 months; non-exclusive human milk feeding to 4 months and 6 months postpartum., Results: All participants initiated human milk feeding and 80% continued for 6 months. Exclusive human milk feeding was practiced postdischarge to 4 months by 28% and to 6 months by 16%. At 2 weeks postpartum, 34% reported use of expressed human milk. Any use of expressed human milk at 2 weeks was associated with cessation of human milk feeding before 6 months postpartum (aOR 2.66; 95% CI 1.41 to 5.05) and with non-exclusive human milk feeding to 4 months (aOR 2.19; 95% CI 1.16 to 4.14) and 6 months (aOR 3.65; 95% CI 1.50 to 8.84)., Trial Registration Numbers: NCT03400605, NCT03589963., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Exclusive breastfeeding (EBF) for 6 months is a global public health goal, but measuring its achievement as a marker of population breastmilk feeding practices is insufficient. Additional measures are needed to understand variation in non-EBF practices and inform intervention priorities. We collected infant feeding data prospectively at seven time points to 6 months post-partum from a cohort of vulnerable women (n = 151) registered at two Canada Prenatal Nutrition Program sites in Toronto, Canada. Four categories of breastmilk feeding intensity were defined. Descriptive analyses included the (i) proportion of participants in each feeding category by time point, (ii) use of formula and non-formula supplements to breastmilk, (iii) proportion of participants practising EBF continuously for at least 3 months; and (iv) frequency of transitions between feeding categories. All participants initiated breastmilk feeding with 70% continuing for 6 months. Only 18% practised EBF for 6 months, but 48% did so for at least 3 continuous months. The proportion in the EBF category was highest from 2 to 4 months post-partum. Supplemental formula use was highest in the first 3 months; early introduction of solids and non-formula fluids further compromised EBF at 5 and 6 months post-partum. Most participants (75%) transitioned between categories of breastmilk feeding intensity, with 35% making two or more transitions. Our data show high levels of breastmilk provision despite a low rate of EBF for 6 months. Inclusion of similar analyses in future prospective studies is recommended to provide more nuanced reporting of breastmilk feeding practices and guide intervention designs., (© 2021 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Only one-third of Canadian infants are exclusively breastfed for the first 6 months of life as recommended. Skilled lactation support in the early postpartum period is one strategy for improving breastfeeding outcomes by building breastfeeding self-efficacy and resolving difficulties. Access to such support is limited among vulnerable women, including those who are new immigrants, low income, under-educated, young or single. The Canada Prenatal Nutrition Program (CPNP) aims to improve birth and breastfeeding outcomes among vulnerable women, but currently lacks a formal framework for providing postpartum lactation support., Methods: This pre/post intervention study will examine the effect on breastfeeding outcomes of an evidence-based in-home lactation support intervention provided through the CPNP. We will enrol 210 pregnant women who intend to breastfeed and are registered CPNP clients at two sites in Toronto, Canada. During the intervention phase, postpartum home visits by International Board Certified Lactation Consultants (IBCLCs) will be pro-actively offered to registered clients of the two sites. Double-electric breast pumps will also be provided to those who meet specific criteria. Infant feeding data will be collected prospectively at seven time points from 2 weeks to 6 months postpartum. Descriptive and regression analyses will be conducted to measure intervention effects. The primary outcome is exclusive breastfeeding at 4 months postpartum. Secondary outcomes include the duration of any and exclusive breastfeeding, timing of introduction of breastmilk substitutes and timing of introduction of solid foods. Breastfeeding self-efficacy will be assessed prenatally and at 2 weeks and 2 months postpartum. Other measures include maternal socio-demographics, infant feeding intentions, maternal depression and anxiety, and household food insecurity. Monitoring data will be used to assess the reach, uptake and fidelity of intervention delivery., Discussion: Increasing access to skilled lactation support through the CPNP may be an effective means of improving breastfeeding practices among vulnerable women and thereby enhancing health and development outcomes for their infants. This pre/post intervention study will contribute evidence on both the effectiveness and feasibility of this approach, in order to guide the development and further testing of appropriate models of integrating lactation support into the CPNP., Trial Registration: ClinicalTrials.gov ( NCT03589963 ) registered July 18, 2018.

Background: In Canada, 91% of all mothers initiate breastfeeding, but 40-50% stop by 6 months and only 34% breastfeed exclusively for 6 months, with lower rates among socially and/or economically vulnerable women. The Canada Prenatal Nutrition Program (CPNP) aims to support breastfeeding among vulnerable women, but there is no formal framework or funding for sites to integrate proactive postnatal breastfeeding support. This research aimed to i) describe infant feeding practices among clients of one Toronto CPNP site using charitable funds to offer a lactation support program (in-home lactation consultant visits, breast pumps); ii) determine whether breastfeeding outcomes at 6 months differ based on maternal sociodemographics and food insecurity; and iii) assess utilization of the lactation support program., Methods: Infant feeding practices were collected prospectively at 2 weeks, 2, 4 and 6 months postpartum via telephone questionnaires (n = 199). Maternal sociodemographics were collected at 2 weeks and food insecurity data at 6 months postpartum. Program monitoring records were used to determine utilization of the lactation support program., Results: Ninety-one percent of participants were born outside of Canada; 55% had incomes below the Low-Income Cut-Off; and 55% reported food insecurity. All participants initiated breastfeeding, 84% continued for 6 months and 16% exclusively breastfed for 6 months. Among breastfed infants, ≥76% received vitamin D supplementation. Approximately 50% of infants were introduced to solids before 6 months. Only high school education or less and food insecurity were associated with lower breastfeeding rates. Overall, 75% of participants received at least one visit with a lactation consultant and 95% of these received a breast pump., Conclusions: This study provides initial evidence that postnatal lactation support can be delivered within a CPNP site, with high uptake by clients. While all participants initiated breastfeeding and 84% continued for 6 months, adherence to the recommended 6 months of exclusive breastfeeding was low. Further research is needed to better understand the barriers to exclusive breastfeeding and how to support this practice among vulnerable women. Study registered at clinicaltrials.gov as NCT03400605 .

The Canada Prenatal Nutrition Program (CPNP) provides a variety of health and nutrition supports to vulnerable mothers and strongly promotes breastfeeding but does not have a formal framework for postnatal lactation support. Breastfeeding duration and exclusivity rates in Canada fall well below global recommendations, particularly among socially and economically vulnerable women. We aimed to explore CPNP participant experiences with breastfeeding and with a novel community lactation support program in Toronto, Canada that included access to certified lactation consultants and an electric breast pump, if needed. Four semistructured focus groups and 21 individual interviews (n = 46 women) were conducted between September and December 2017. Data were analysed using inductive thematic analysis. Study participants reported a strong desire to breastfeed but a lack of preparation for breastfeeding-associated challenges. Three main challenges were identified by study participants: physical (e.g., pain and low milk supply), practical (e.g., cost of breastfeeding support and maternal time pressures), and breastfeeding self-efficacy (e.g., concern about milk supply and conflicting information). Mothers reported that the free lactation support helped to address breastfeeding challenges. In their view, the key element of success with the new program was the in-home visit by the lactation consultant, who was highly skilled and provided care in a non-judgmental manner. They reported this support would have been otherwise unavailable due to cost or travel logistics. This study suggests value in exploring the addition of postnatal lactation support to the well-established national CPNP as a means to improve breastfeeding duration and exclusivity among vulnerable women., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons, Ltd.)

Variation in the durations of exclusive breastfeeding (exBF) and any breastfeeding (anyBF) is associated with socioecological factors. This plasticity in breastfeeding behavior appears adaptive, but the mechanisms involved are unclear. With this concept in mind, we investigated whether durations of exBF and anyBF in a rural Maya population covary with markers of a form of socioecological change-market integration-and whether individual factors (individual learning, physiological plasticity) and/or learning from others in the community (social learning, norm adherence) mediate these changes. Using data from 419 mother-child pairs from two Guatemalan Maya villages, we fit a bivariate linear mixed model. The model compared exBF and anyBF among children from households of varying degrees of market integration whose mothers follow what we inferred to be local infant-feeding norms. It controlled for other factors expected to affect breastfeeding durations. We found evidence that exBF is associated with whether mothers follow their population's infant feeding norms, but no evidence that exBF is associated with the household's level of market integration. Conversely, anyBF is significantly associated with the household's market integration, but not with the villages' inferred norms. Because deviations from exBF norms are likely to result in infant mortality and reduced fitness, we hypothesize that the incentive to conform is relatively strong. Relatively greater individual plasticity in anyBF allows mother-child pairs to tailor it to socioecological conditions. Deviations from anyBF norms may be tolerated because they may provide later-life health/fitness payoffs, while posing few risks to infant survival.

Objectives: Infant feeding guidelines are important public health strategies to promote optimal growth, development, and chronic disease prevention, but their effectiveness is contingent upon families' ability to adhere to them. Little is known of adherence to guidelines among nutritionally vulnerable infants, specifically those born very-low-birth-weight (VLBW) (<1500 g). This study investigated whether postdischarge feeding practices for VLBW infants align with current recommendations and explored parental and infant baseline sociodemographics related to these practices., Methods: Prospectively collected data from families of 300 VLBW infants participating in a randomized clinical trial (ISRCTN35317141) were used. Baseline demographics were obtained at enrollment and postdischarge feeding practices via monthly telephone questionnaires to 6 months corrected age (CA)., Results: At discharge, 4 and 6 months CA, 72%, 39%, and 29% of infants received any amount of mother's milk, respectively; exclusive breast-feeding rates were 49%, 20%, and 6%, respectively. Among infants receiving mother's milk, rates of vitamin D supplementation were ≥83%. Recommendations for introducing solids between 4 and 6 months CA were followed by 71% of the cohort and for iron supplementation by 58%. Overall, 12% of infants adhered to all aforementioned recommendations. Mothers with university degrees were more likely to provide mother's milk, whereas mothers of Middle Eastern/South Asian ethnicity were less likely to provide mother's milk., Conclusions: Low rates of partial and exclusive breast-feeding of VLBW infants to 6 months CA were reported. Overall adherence to iron supplementation was low. Strategies to provide increased support for mothers identified as at-risk should be developed.

Objectives: The causes of variation in breastfeeding duration in humans are poorly understood, but life history factors related to maternal energetics drive much of the variation in lactation duration in nonhuman animals. With this in mind, we investigated whether four energy-related factors influence variation in breastfeeding duration in a non-industrial human population: (1) mortality risk during mother's development (assessed via mother's adult height), (2) reliance on nutrient-dense weaning foods, (3) access to and need for help with infant feeding and care ("allomaternal care"), and (4) maternal tradeoffs between current and future reproduction (measured via child's birth order)., Materials and Methods: The data pertain to 51 Kakchiquel-speaking Maya mothers and 283 children from a village in rural Guatemala. We developed a linear mixed model to evaluate the relationships between breastfeeding duration and the energy-related factors., Results: Duration of breastfeeding was associated with two of the energy-related factors in the ways we predicted but not with the other two. Contrary to predictions, taller mothers breastfed for shorter periods and we found no evidence that weanling diet quality impacts breastfeeding duration. As predicted, women who had more help with infants breastfed for shorter periods, and later-born infants breastfed longer than earlier-born ones., Discussion: The results regarding allomaternal care suggest that help reduces mothers' lactation demands. The energy saved may be redirected to increasing fecundity or investment in other children. The birth order result suggests that children born to mothers nearing reproductive senescence receive higher levels of investment, which likely impacts children's fitness., (© 2016 Wiley Periodicals, Inc.)

Objective: To examine breast-feeding and complementary feeding practices during the first 6 months of life among Norwegian infants of Somali and Iraqi family origin., Design: A cross-sectional survey was performed during March 2013-February 2014. Data were collected using a semi-quantitative FFQ adapted from the second Norwegian national dietary survey among infants in 2006-2007., Setting: Somali-born and Iraqi-born mothers living in eastern Norway were invited to participate., Subjects: One hundred and seven mothers/infants of Somali origin and eighty mothers/infants of Iraqi origin participated., Results: Breast-feeding was almost universally initiated after birth. Only 7 % of Norwegian-Somali and 10 % of Norwegian-Iraqi infants were exclusively breast-fed at 4 months of age. By 1 month of age, water had been introduced to 30 % of Norwegian-Somali and 26 % of Norwegian-Iraqi infants, and infant formula to 44 % and 34 %, respectively. Fifty-four per cent of Norwegian-Somali and 68 % of Norwegian-Iraqi infants had been introduced to solid or semi-solid foods at 4 months of age. Breast-feeding at 6 months of age was more common among Norwegian-Somali infants (79 %) compared with Norwegian-Iraqi infants (58 %; P=0·001). Multivariate analyses indicated no significant factors associated with exclusive breast-feeding at 3·5 months of age. Factors positively associated with breast-feeding at 6 months were country of origin (Somalia) and parity (>2)., Conclusions: Breast-feeding initiation was common among Iraqi-born and Somali-born mothers, but the exclusive breast-feeding period was shorter than recommended in both groups. The study suggests that there is a need for new culture-specific approaches to support exclusive breast-feeding and complementary feeding practices among foreign-born mothers living in Norway.

We aimed to determine the prevalence of, and factors associated with, breastfeeding initiation in Canadian Inuit. We used data from the Nunavut Inuit Child Health Survey, a population-based, cross-sectional survey conducted in the Canadian territory of Nunavut. Inuit children aged 3-5 years in 2007 or 2008 were randomly selected for the survey. Select household, maternal, infant and community characteristics were collected from the child's primary caregiver and entered into logistic regression models as potential predictors of breastfeeding initiation. Analyses were repeated in a subgroup of caregiver reports from biological mothers. The reported prevalence of breastfeeding initiation was 67.6% (95% CI 62.4-72.8) overall and 85.1% (95% CI 80.2-90.1) in a subgroup of caregiver reports from biological mothers. Adjusted prevalence odds ratios (pOR) indicate the primary caregiver was an important determinant of breastfeeding (adopted parent vs. biological mother: pOR = 0.03, 95% CI 0.01-0.07; other vs. biological mother: pOR = 0.33, 95% CI 0.14-0.74). Maternal smoking during pregnancy and having access to a community birthing facility were also potentially important, but not statistically significant (p > 0.05). In conclusion, data from the Nunavut Inuit Child Health Survey indicate breastfeeding is initiated for more than two-thirds of children, but rates are below the national average and this may be one of several pathways to poor health outcomes documented in many Inuit communities. Considered in the particular context of birthing facilities utilization and postnatal care arrangements in Inuit communities, these results suggest that increasing breastfeeding initiation will require health interventions that effectively engage all types of primary caregivers.

Background: Infant feeding and caregiving by adolescent girls and young women in rural Bangladesh remains relatively understudied despite high potential vulnerability of younger mothers and their children due to poverty and high rates of early marriage and childbearing. This key knowledge gap may hamper the effectiveness of maternal, infant and child health interventions not specifically tailored to teenage mothers. This study aimed to narrow this gap by documenting key barriers to optimal infant and young child feeding and caregiving perceived by adolescent girls and young women in rural Bangladesh., Methods: Focus group discussions and in-depth semi-structured interviews were conducted with 70 adolescent girls and young women participating in a community-based adolescent empowerment program in two rural regions of northwestern Bangladesh. Participants were stratified into three groups: unmarried, married without child, and married with child(ren). Thematic analysis was performed to elucidate dominant ideas regarding challenges with child feeding and caregiving across participant strata., Results: Participants in all three strata and in both geographical regions attributed actual and anticipated caregiving difficulties to five major contextual factors: early marriage, maternal time allocation conflicts, rural life, short birth intervals, and poverty. Indications are that many girls and young women anticipate difficulties in feeding and caring for their future children from an early age, and often prior to motherhood. Participants articulated both perceived need and unmet demand for additional education in infant and young child feeding, childcare, and family planning techniques., Conclusions: Provision during adolescence of appropriate education, services and financial aid to support best practices for infant feeding and childcare could significantly improve maternal self-efficacy, mental health, nutrition security and young childcare, nutrition and health in rural Bangladesh. Lessons learned can be applied in future programs aimed at supporting adolescent women along a continuum of care.

Background: Very little population-based research has been conducted around the exclusive breastfeeding practices of Inuit Canadians., Objectives: This research aims to assess the distribution of exclusive breastfeeding among Inuit Canadians and to identify factors associated with exclusive breastfeeding as recommended., Methods: We use data from 188 infant-mother dyads who completed the Nunavut Inuit Child Health Survey, a cross-sectional, population-based survey of Inuit children aged 3 to 5 years. A series of multinomial logistic regression models were run to identify factors associated with 4 exclusive breastfeeding durations (≤ 1 month, > 1-< 5.5 months, 5.5-6.5 months, and > 6.5 months)., Results: Of infants, 23% were exclusively breastfed as recommended (ie, between 5.5 and 6.5 months; 95% CI, 16.2-29.3). Many infants (61%) were exclusively breastfed for less than 5.5 months and 16% (95% CI, 10.9-22.0) were exclusively breastfed for more than 6.5 months. Families receiving income support were less likely to discontinue exclusive breastfeeding before 5.5 months (pOR1- < 5.5 months = 0.34; 95% CI, 0.13, 0.85) relative to those not receiving income support, in adjusted models. No other measured factors were significantly related to exclusive breastfeeding duration., Conclusions: The majority of Inuit Canadian infants receive suboptimal exclusive breastfeeding. National, provincial, and community-specific interventions to protect, promote, and support exclusive breastfeeding should emphasize not only the benefits of exclusively breastfeeding to 6 months but also the importance of timely introduction of complementary foods into the infant's diet.

This study aimed to document whether food insecurity was associated with beliefs and attitudes towards exclusive breastfeeding (EBF) among urban Kenyan women. We conducted structured interviews with 75 human immunodeficiency virus (HIV)-affected and 75 HIV-status unknown, low-income women who were either pregnant or with a child ≤24 months and residing in Nakuru, Kenya to generate categorical and open-ended responses on knowledge, attitudes and beliefs towards EBF and food insecurity. We facilitated six focus group discussions (FGD) with HIV-affected and HIV-status unknown mothers (n = 50 women) to assess barriers and facilitators to EBF. Of 148 women with complete interview data, 77% were moderately or severely food insecure (FIS). Women in FIS households had significantly greater odds of believing that breast milk would be insufficient for 6 months [odds ratio (OR), 2.6; 95% confidence interval (95% CI), 1.0, 6.8], that women who EBF for 6 months would experience health or social problems (OR, 2.7; 95% CI, 1.0, 7.3), that women need adequate food to support EBF for 6 months (OR, 2.6; 95% CI, 1.0, 6.7) and that they themselves would be unable to follow a counsellor's advice to EBF for 6 months (OR, 3.2; 95% CI, 1.3, 8.3). Qualitative analysis of interview and FGD transcripts indicated that the maternal experience of hunger contributes to perceived milk insufficiency, anxiety about infant hunger and a perception that access to adequate food is necessary for successful breastfeeding. The lived experience of food insecurity among a sample of low-income, commonly FIS, urban Kenyan women reduces their capacity to implement at least one key recommended infant feeding practices, that of EBF for 6 months., (© 2010 Blackwell Publishing Ltd.)

This is a longitudinal cohort study investigating the association between maternal HIV status and the reported onset of lactation. The Research to Improve Infant Nutrition and Growth project recruited 442 mothers from 3 antenatal clinics in the eastern region of Ghana, based on positive, negative, and unknown HIV status. Onset of lactation was assessed by maternal perception and validated with 2 subsamples: measurement of infant breast milk intake (n = 40) and daily infant weight measurement for 2 weeks (n = 150). Multivariate logistic regression was used to identify predictors of very early onset of lactation (onset of lactation < 6 hours). Predictors of very early onset of lactation include HIV-negative status (odds ratio = 2.68; P = .014), multiparity (odds ratio = 2.93; P = .009), vaginal delivery (odds ratio = 2.55; P = .035), and having a male child (odds ratio = 1.86; P = .032). The findings indicate an association between maternal HIV status and very early onset of lactation.

The effects of maternal academic skills on infant-feeding practices are not clear. From 1996 to 1999, the authors collected information on infant-feeding practices from birth on infants born to 279 mothers from 4 rural villages in Guatemala. They examined associations between maternal academic skills and indicators for the initiation of exclusive breastfeeding (EBF) and timely introduction of complementary foods (CF). Mothers in the highest category of academic skills had greater odds of initiating EBF, but this association failed to remain significant after adjusting for schooling. Compared with mothers with < 1 year of school, mothers with > 3 to 6 years of school had greater odds of introducing CF early, while mothers with >or= 1 to

Mothers of infants (n = 328) born between 1996 and 1999 in four Guatemalan communities were interviewed every 2 wk until 6 mo postpartum (pp) to collect prospective breast-feeding data and assess the association between delayed (>3 d pp) onset of lactation (OL) and the risk of ending full breast-feeding. Cox proportional hazards regression was used to examine the association between delayed OL and the hazard of ending full breast-feeding in the first 6 mo, adjusted for potential confounders and effect modifiers. A significant interaction with community was found (community-specific hazard ratios: HR(A) = 2.87, 95% CI = 1.25, 6.60; HR(B) = 3.43, 95% CI = 1.55, 7.59; HR(C) = 0.26, 95% CI = 0.06, 1.14; HR(D) = 1.11, 95% CI = 0.44, 2.77). Supplementation before OL (preonset supplementation) was associated with delayed OL [odds ratio (OR) = 4.87, 95% CI = 2.29, 10.36] and an increased risk of ending full breast-feeding (HR = 1.49, 95% CI = 1.05, 2.11). In the two communities in which mothers who experienced delayed OL had a significantly greater risk of ending full breast-feeding than did mothers experiencing normal OL, the association between delayed OL and full breast-feeding was mediated in part by preonset supplementation. Further analyses suggest that this was due to delayed OL leading to nonbreast milk feeds, rather than to introduction of supplements delaying OL. We conclude that some mothers who experience delayed OL are less likely to continue full breast-feeding in the first 6 mo and that further research should examine the contextual factors that modify this relationship.