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1.  Glucose Tolerance and Insulin Resistance in Indian Children: Relationship to Infant feeding Pattern 
Diabetologia  2011;54(10):2533-2537.
Aims/hypothesis
Our objective was to examine whether longer duration of breast-feeding and later introduction of complementary foods are associated with lower glucose concentrations and insulin resistance (IR-HOMA) in Indian children.
Methods
Breast-feeding duration (6 categories from <3 to ≥18 months) and age at introduction of complementary foods (4 categories from <4 to ≥6 months) were recorded at 1, 2 and 3 year follow-up of 568 children from a birth cohort in Mysore, India. At 5- and 9.5-years of age 518 children were assessed for glucose tolerance and IR-HOMA.
Results
All the children were initially breast-fed; 90% were breast-fed for ≥6 months and 56.7% started complementary foods at or before the age of 4 months. Each category increase in breast-feeding duration was associated with lower fasting insulin concentration (β=−0.05 pmol/L (95% CI: −0.10, −0.004); P=0.03) and IR-HOMA (β=−0.05 (95% CI: −0.10, −0.001); P=0.046) at 5-years, adjusted for the child’s sex, age, current BMI, socio-economic status, parent’s education, rural/urban residence, birthweight and maternal gestational diabetes status. Longer duration of breastfeeding was associated with higher 120-minute glucose concentration at 5-years (β=0.08 mmol/L (95% CI: 0.001, 0.15; P=0.03) but lower 120-minute glucose concentration at 9.5-years (β=−0.09 (95% CI: −0.16, −0.03; P=0.006). Age at starting complementary foods was unrelated to the children’s glucose tolerance and IR-HOMA.
Conclusions/interpretation
Within this cohort, in which prolonged breast-feeding was the norm, there was evidence of a protective effect of longer duration of breast-feeding against glucose intolerance at 9.5-years. At 5-years longer duration of breast-feeding was associated with lower IR-HOMA.
doi:10.1007/s00125-011-2254-x
PMCID: PMC3223395  PMID: 21773682
Breast-feeding; Children; Complementary foods; Glucose tolerance; India; Insulin resistance
2.  Childhood Cognitive Ability: Relationship to Gestational Diabetes Mellitus in India 
Diabetologia  2010;53(10):2134-2138.
Aims/Hypothesis
To test the hypothesis that maternal gestational diabetes mellitus (GDM) is associated with poorer cognitive ability in children born to mothers with GDM compared to children born to non-GDM mothers in India.
Methods
During 1997-98 maternal GDM status was assessed at 30±2 weeks of gestation. Between 2007-2008, at a mean age of 9.7 years, 515 children (32-offspring of GDM mothers (ODM’s); 483-offspring of non-GDM mothers (controls)) from the Mysore Parthenon birth cohort underwent cognitive function assessment using tests from the Kaufman Assessment Battery for children-second edition and additional tests measuring learning, long-term storage/retrieval, short-term memory, reasoning, attention and concentration, visuo-spatial and verbal abilities.
Results
Compared to controls, ODM’S scored higher in tests for learning, long-term retrieval/storage (p=0.008), reasoning (p=0.02), verbal ability (p=0.01) and attention and concentration (p=0.003). In multiple regression, adjusted for the child’s age, sex, gestation, neonatal weight and head circumference, maternal age, parity, BMI, parent’s socio-economic status, education and rural/urban residence, this difference remained significant only for learning, long-term retrieval/storage (β=0.4SD (95% CI: 0.01, 0.75); p=0.042) and verbal ability (β=0.5SD (95% CI: 0.09, 0.83); p=0.015) and not with other test scores.
Conclusions/interpretation
In this population of healthy Indian children, there was no evidence of lower cognitive ability in ODM’s. In fact some cognitive scores were higher in ODM’s.
doi:10.1007/s00125-010-1847-0
PMCID: PMC3428884  PMID: 20614102
Gestational diabetes mellitus; Children; Cognitive function; India
3.  Higher maternal plasma folate but not vitamin B-12 concentrations during pregnancy are associated with better cognitive function scores in 9-10 year old children in South-India1-3 
The Journal of nutrition  2010;140(5):1014-1022.
Folate and vitamin B-12 (B-12) are essential for normal brain development. Few studies have examined the relationship of maternal folate and B-12 status during pregnancy to offspring cognitive function. To test the hypothesis that lower maternal plasma folate and B-12 concentrations and higher plasma homocysteine concentrations during pregnancy, are associated with poorer neurodevelopment, cognitive function was assessed during 2007-2008 among 536 children (aged 9-10 y) from the Mysore Parthenon birth cohort. Maternal folate, B-12 and homocysteine concentrations were measured in stored plasma samples taken at 30±2 wk gestation. The children’s cognitive function was measured using 3 core tests from the Kaufman Assessment Battery and additional tests measuring learning ability, long-term storage/retrieval, attention and concentration, visuo-spatial and verbal abilities. During pregnancy 4% of mothers had low folate concentrations (<7 nmol/L), 42.5% had low B-12 concentrations (<150 pmol/L) and 3% had hyperhomocysteinemia (>10 μmol/L). There was a 0.1-0.2 SD increase in the children’s cognitive scores per SD increase in maternal folate concentration (p<0.001 for all tests). The associations with learning ability and long-term storage/retrieval, visuo-spatial ability, attention and concentration were independent of maternal age, BMI, parity, the parents’ education, socio-economic status, rural/urban residence, religion, the child’s gestational age, birth size, sex and the children’s size, educational level and folate and B-12 concentrations at 9.5 y. There were no consistent associations of maternal B-12 and homocysteine concentrations with childhood cognitive performance.
Conclusions
In this Indian population higher maternal folate, but not vitamin B-12 concentrations during pregnancy, predicted better childhood cognitive ability.
doi:10.3945/jn.109.118075
PMCID: PMC3672847  PMID: 20335637
4.  Relationship between adiposity and cognitive performance in 9-10 year old children in south India 
Archives of disease in childhood  2013;99(2):126-134.
Background
Studies in high-income countries have shown inverse associations between adiposity and cognitive performance in children. We aimed to examine the relationship between adiposity and cognitive function in Indian children.
Methods
At a mean age of 9.7 years, height, weight, triceps and subscapular skinfold thicknesses and waist circumference were recorded for 540 children born in Mysore, India. Body fat percentage was estimated using bio-impedance. Cognitive function was assessed using 3 core tests from the Kaufman Assessment Battery for children-II edition and additional tests measuring learning, short-term memory, reasoning, verbal and visuo-spatial abilities, attention and concentration. Data on the parents’ socio-economic status, education, occupation and income were collected.
Results
According to WHO definitions, 3.5% of the children were overweight/obese (BMI>+1SD) and 27% underweight (BMI<−2SD). Compared to normal children, overweight/obese children scored higher in tests of learning/long-term retrieval, reasoning and verbal ability (unadjusted p<0.05 for all). All the cognitive test scores increased with increase in BMI and skinfold thickness, (unadjusted β=0.10 to 0.20 SD; p<0.05 for all). The effects, though attenuated, remained mainly significant after adjustment for age, sex and socio-economic factors. Similar associations were found for waist circumference and percentage body fat.
Conclusions
In this Indian population, in which obesity was uncommon, greater adiposity predicted higher cognitive ability. These associations were only partly explained by socio-economic factors. Our findings suggest that better nutrition is associated with better cognitive function, and that inverse associations between adiposity and cognitive function in high-income countries reflect confounding by socio-economic factors.
doi:10.1136/archdischild-2013-304478
PMCID: PMC3982043  PMID: 24146284
Adiposity; Children; Cognitive function; India; Birth cohort
5.  Infant-feeding patterns and cardiovascular risk factors in young adulthood: data from five cohorts in low- and middle-income countries 
Background Infant-feeding patterns may influence lifelong health. This study tested the hypothesis that longer duration of breastfeeding and later introduction of complementary foods in infancy are associated with reduced adult cardiovascular risk.
Methods Data were pooled from 10 912 subjects in the age range of 15–41 years from five prospective birth-cohort studies in low-/middle-income countries (Brazil, Guatemala, India, Philippines and South Africa). Associations were examined between infant feeding (duration of breastfeeding and age at introduction of complementary foods) and adult blood pressure (BP), plasma glucose concentration and adiposity (skinfolds, waist circumference, percentage body fat and overweight/obesity). Analyses were adjusted for maternal socio-economic status, education, age, smoking, race and urban/rural residence and infant birth weight.
Results There were no differences in outcomes between adults who were ever breastfed compared with those who were never breastfed. Duration of breastfeeding was not associated with adult diabetes prevalence or adiposity. There were U-shaped associations between duration of breastfeeding and systolic BP and hypertension; however, these were weak and inconsistent among the cohorts. Later introduction of complementary foods was associated with lower adult adiposity. Body mass index changed by −0.19 kg/m2 [95% confidence interval (CI) −0.37 to −0.01] and waist circumference by −0.45 cm (95% CI −0.88 to −0.02) per 3-month increase in age at introduction of complementary foods.
Conclusions There was no evidence that longer duration of breastfeeding is protective against adult hypertension, diabetes or overweight/adiposity in these low-/middle-income populations. Further research is required to determine whether ‘exclusive’ breastfeeding may be protective. Delaying complementary foods until 6 months, as recommended by the World Health Organization, may reduce the risk of adult overweight/adiposity, but the effect is likely to be small.
doi:10.1093/ije/dyq155
PMCID: PMC3043278  PMID: 20852257
Infant feeding; breastfeeding; complementary feeding; blood pressure; diabetes; body composition
6.  Study of complementary feeding practices among mothers of children aged six months to two years - A study from coastal south India 
The Australasian Medical Journal  2011;4(5):252-257.
Background
Infants and young children are at an increased risk of malnutrition from six months of age onwards, when breast milk alone is no longer sufficient to meet all their nutritional requirements and complementary feeding should be started. Hence this study was undertaken to assess the practices of complementary feeding.
Method
This hospital-based cross-sectional study was conducted at two private hospitals - Dr TMA Pai Hospital Udupi and Dr TMA Pai Hospital Karkala and a public hospital, Regional Advanced Paediatric Care Centre, Mangalore, of coastal south India for a two-month period from August 2010 to October 2010. Two-hundred mothers of children between six months and two years attending the paediatric outpatient departments of the above-mentioned hospitals for growth monitoring, immunisation and minor illnesses such as upper respiratory tract infections were selected for the study. The subjects were selected for the study by the order of their arrival to the outpatient department during the study period.
Results
In the present study 77.5% mothers had started complementary feeding at the recommended time of six months. Only 32% of mothers were giving an adequate quantity of complementary feeds. The association of initiation of complementary feeding with socio-economic status, birth order, place of delivery and maternal education was found to be statistically significant. However the practice of giving an adequate quantity of complementary feeds was significantly associated only with the place of delivery.
Conclusion
In the present study, initiation of complementary feeding at the recommended time of six months was seen in the majority of children. However the quantity of complementary feeding was insufficient. Advice about breast feeding and complementary feeding during antenatal check-ups and postnatal visits might improve feeding practices.
doi:10.4066/AMJ.2011.607
PMCID: PMC3562932  PMID: 23393516
Complementary feeding; children; coastal south India
7.  Infant Feeding and School Attainment in Five Cohorts from Low- and Middle-Income Countries 
PLoS ONE  2013;8(8):e71548.
Background
Performance in intelligence tests tends to be higher among individuals breastfed as infants, but little is known about the association between breastfeeding and achieved schooling. We assessed the association of infant feeding with school achievement in five cohorts from low- and middle-income countries. Unlike high-income country settings where most previous studies come from, breastfeeding is not positively associated with socioeconomic position in our cohorts, thus reducing the likelihood of a spurious positive association.
Methodology and Principal Findings
Participants included 10,082 young adults from five birth cohorts (Brazil, India, Guatemala, the Philippines, and South Africa). The exposures variables were whether the subject was ever breastfed, total duration of breastfeeding, and age at introduction of complementary foods. We adjusted the estimates for age at follow up, sex, maternal age, smoking during pregnancy, birthweight and socioeconomic position at birth. The key outcome was the highest grade achieved at school. In unadjusted analyses, the association between ever breastfeeding and schooling was positive in Brazil, inverse in the Philippines, and null in South Africa; in adjusted analyses, these associations were attenuated. In Brazil, schooling was highest among individuals breastfed for 3–12 months whereas in the Philippines duration of breastfeeding was inversely associated with schooling; and null associations were observed in South Africa and Guatemala. These associations were attenuated in adjusted models. Late introduction of solid foods was associated with lower schooling achievement in Brazil and South Africa.
Conclusion
Measures of breastfeeding are not consistently related to schooling achievement in contemporary cohorts of young adults in lower and middle-income countries.
doi:10.1371/journal.pone.0071548
PMCID: PMC3748078  PMID: 23977075
8.  Association of birthweight and head circumference at birth to cognitive performance in 9-10 year old children in South India: prospective birth cohort study 
Pediatric research  2010;67(4):424-429.
To examine whether birthweight and head circumference at birth are associated with childhood cognitive ability in South-India, cognitive function was assessed using 3 core tests from the Kaufman Assessment Battery for children and additional tests measuring long-term retrieval/storage, attention and concentration, visuo-spatial and verbal abilities among 505 full-term born children (mean age 9.7-y). In multiple linear regression adjusted for age, sex, gestation, socio-economic status, parent’s education, maternal age, parity, BMI, height, rural/urban residence, and time of testing, Atlantis score (learning ability/long-term storage and retrieval) rose by 0.1 SD per SD increase in newborn weight and head circumference respectively (p<0.05 for all) and Kohs’ block design score (visuo-spatial ability) increased by 0.1 SD per SD increase in birthweight (p<0.05). The associations were reduced after further adjustment for current head circumference. There were no associations of birthweight and/or head circumference with measures of short-term memory, fluid reasoning, verbal abilities and attention and concentration. In conclusion higher birthweight and larger head circumference at birth are associated with better childhood cognitive ability. The effect may be specific to learning, long-term storage and retrieval, and visuo-spatial abilities, but this requires confirmation by further research.
doi:10.1203/PDR.0b013e3181d00b45
PMCID: PMC3073480  PMID: 20032815
9.  Breast feeding and cognitive development at age 1 and 5 years 
Archives of Disease in Childhood  2001;85(3):183-188.
AIM—To examine whether duration of breast feeding has any effect on a child's cognitive or motor development in a population with favourable environmental conditions and a high prevalence of breast feeding.
METHODS—In 345 Scandinavian children, data on breast feeding were prospectively recorded during the first year of life, and neuromotor development was assessed at 1 and 5 years of age. Main outcome measures were Bayley's Scales of Infant Development at age 13months (Mental Index, MDI; Psychomotor Index, PDI), Wechsler Preschool and Primary Scales of Intelligence (WPPSI-R), and Peabody Developmental Scales at age 5.
RESULTS—Children breast fed for less than 3 months had an increased risk, compared to children breast fed for at least 6 months, of a test score below the median value of MDI at 13 months and of WPPSI-R at 5 years. Maternal age, maternal intelligence (Raven score), maternal education, and smoking in pregnancy were significant confounders, but the increased risk of lower MDI and total IQ scores persisted after adjustment for each of these factors. We found no clear association between duration of breast feeding and motor development at 13 months or 5 years of age.
CONCLUSION—Our data suggest that a longer duration of breast feeding benefits cognitive development.


doi:10.1136/adc.85.3.183
PMCID: PMC1718901  PMID: 11517096
10.  Breast milk feeding and cognitive ability at 7-8 years 
OBJECTIVE—To examine the association between duration of breast milk feeding and cognitive ability at 7-8 years in a birth cohort of very low birthweight infants.
DESIGN—280 survivors from a national birth cohort of 413 New Zealand very low birthweight infants born in 1986 were assessed at age 7-8 years on measures of verbal and performance intelligence quotient (IQ) using the WISC-R. At the same time mothers were questioned as to whether they had elected to provide expressed breast milk at birth and the total duration of breast milk feeding.
RESULTS—Some 73% of mothers provided expressed breast milk and 37% breast fed for four months or longer. Increasing duration of breast milk feeding was associated with increases in both verbal IQ (p < 0.001) and performance IQ (p < 0.05): children breast fed for eight months or longer had mean (SD) verbal IQ scores that were 10.2 (0.56) points higher and performance IQ scores that were 6.2 (0.35) points higher than children who did not receive breast milk. These differences were substantially reduced after control for selection factors associated with receipt of breast milk. Nevertheless, even after control for confounding, there remained a significant (p < 0.05) association between duration of breast milk feeding and verbal IQ: children breast fed for eight months or longer had adjusted mean (SD) verbal IQ scores that were 6(0.36) points higher than the scores of those who did not receive breast milk.
CONCLUSIONS—These findings add to a growing body of evidence to suggest that breast milk feeding may have small long term benefits for child cognitive development.


doi:10.1136/fn.84.1.F23
PMCID: PMC1721196  PMID: 11124919
11.  Duration of Exclusive Breastfeeding and Subsequent Child Feeding Adequacy 
Ghana Medical Journal  2013;47(1):24-29.
Summary
Objective
Mothers of young children in Ghana believe that breastfeeding exclusively for six months impairs subsequent introduction of other foods. The current study was designed to determine whether feeding adequacy among 9–23 months old children is influenced by duration of exclusive breastfeeding.
Design
We surveyed 300 mother-infant pairs attending child-welfare-clinic at the University of Ghana Hospital, Accra. Data collected included sociodemographic characteristics, morbidity, breastfeeding history, and maternal practices and perception on child feeding and temperament. Current child feeding was assessed using 24-hour dietary recall. Adequately fed children were defined as 9–23 month old children meeting three basic feeding adequacy thresholds: 1) was fed complementary foods, at least three times in the last 24 hours, 2) was fed from at least three food groups, and 3) received breast milk in the last 24 hours. Multiple logistic regressions were used to identify independent predictors of child feeding adequacy.
Results
About 66% of children were exclusively breastfed for six months and only 56% were adequately fed in the in the 24 hours preceding the survey. Child feeding adequacy was unrelated to duration of exclusive breastfeeding (OR=0.73; p=0.30). After controlling for child sex, age, and maternal education, the independent determinants of feeding adequacy included recent child morbidity (OR=0.41; p=0.03), number of caregivers who feed child (OR=1.33; p=0.03), and maternal perception that child does not like food (OR=0.25; p<0.01).
Child temperament was unrelated to feeding adequacy.
Conclusion
Child feeding adequacy is not affected by duration of exclusive breastfeeding. The study provides evidence to address misperceptions about exclusively breastfeeding for six months.
PMCID: PMC3645185  PMID: 23661852
Exclusive breastfeeding; child; dietary diversity; feeding adequacy; duration
12.  The apparent breastfeeding paradox in very preterm infants: relationship between breast feeding, early weight gain and neurodevelopment based on results from two cohorts, EPIPAGE and LIFT 
BMJ Open  2012;2(2):e000834.
Context
Supplementation of breast milk is difficult once infants suckle the breast and is often discontinued at end of hospitalisation and after discharge. Thus, breastfed preterm infants are exposed to an increased risk of nutritional deficit with a possible consequence on neurodevelopmental outcome.
Objective
To assess the relationship between breast feeding at time of discharge, weight gain during hospitalisation and neurodevelopmental outcome.
Design
Observational cohort study.
Setting
Two large, independent population-based cohorts of very preterm infants: the Loire Infant Follow-up Team (LIFT) and the EPIPAGE cohorts.
Patients
2925 very preterm infants alive at discharge.
Main outcome measure
Suboptimal neurodevelopmental outcome, defined as a score in the lower tercile, using Age and Stages Questionnaire at 2 years in LIFT and Kaufman Assessment Battery for Children Test at 5 years in EPIPAGE. Two propensity scores for breast feeding at discharge, one for each cohort, were used to reduce bias.
Results
Breast feeding at time of discharge concerned only 278/1733 (16%) infants in LIFT and 409/2163 (19%) infants in EPIPAGE cohort. Breast feeding is significantly associated with an increased risk of losing one weight Z-score during hospitalisation (LIFT: n=1463, adjusted odd ratio (aOR)=2.51 (95% CI 1.87 to 3.36); EPIPAGE: n=1417, aOR=1.55 (95% CI 1.14 to 2.12)) and with a decreased risk for a suboptimal neurodevelopmental assessment (LIFT: n=1463, aOR=0.63 (95% CI 0.45 to 0.87); EPIPAGE: n=1441, aOR=0.65 (95% CI 0.47 to 0.89) and an increased chance of having a head circumference Z-score higher than 0.5 at 2 years in LIFT cohort (n=1276, aOR=1.43 (95% CI 1.02 to 2.02)) and at 5 years in EPIPAGE cohort (n=1412, aOR=1.47 (95% CI 1.10 to 1.95)).
Conclusions
The observed better neurodevelopment in spite of suboptimal initial weight gain could be termed the ‘apparent breastfeeding paradox’ in very preterm infants. Regardless of the mechanisms involved, the current data provide encouragement for the use of breast feeding in preterm infants.
Article Summary
Key messages
The observed better neurodevelopment in spite of suboptimal initial weight gain could be termed the ‘apparent breastfeeding paradox’ in very preterm infants.
Regardless of the mechanisms involved, the current data provide encouragement for the use of breast feeding in preterm infants.
Strengths and limitations of this study
The same effect was observed in two large distinct cohorts.
Observational study: despite the use of propensity score, a few potential confounder can remain.
doi:10.1136/bmjopen-2012-000834
PMCID: PMC3323805  PMID: 22492388
13.  Diet patterns are associated with demographic factors and nutritional status in South Indian children 
Maternal & Child Nutrition  2013;10(1):145-158.
The burden of non-communicable chronic disease (NCD) in India is increasing. Diet and body composition ‘track’ from childhood into adult life and contribute to the development of risk factors for NCD. Little is known about the diet patterns of Indian children. We aimed to identify diet patterns and study associations with body composition and socio-demographic factors in the Mysore Parthenon Study cohort. We collected anthropometric and demographic data from children aged 9.5 years (n = 538). We also administered a food frequency questionnaire and measured fasting blood concentrations of folate and vitamin B12. Using principal component analysis, we identified two diet patterns. The ‘snack and fruit’ pattern was characterised by frequent intakes of snacks, fruit, sweetened drinks, rice and meat dishes and leavened breads. The ‘lacto-vegetarian’ pattern was characterised by frequent intakes of finger millet, vegetarian rice dishes, yoghurt, vegetable dishes and infrequent meat consumption. Adherence to the ‘snack and fruit’ pattern was associated with season, being Muslim and urban dwelling. Adherence to the lacto-vegetarian pattern was associated with being Hindu, rural dwelling and a lower maternal body mass index. The ‘snack and fruit’ pattern was negatively associated with the child's adiposity. The lacto-vegetarian pattern was positively associated with blood folate concentration and negatively with vitamin B12 concentration. This study provides new information on correlates of diet patterns in Indian children and how diet relates to nutritional status. Follow-up of these children will be important to determine the role of these differences in diet in the development of risk factors for NCD including body composition.
doi:10.1111/mcn.12046
PMCID: PMC3920637  PMID: 23819872
child; chronic disease; diet pattern; India; nutritional status
14.  Long term effect of breast feeding: cognitive function in the Caerphilly cohort 
Study objective: There is evidence suggesting that artificial feeding is associated with a reduction in cognitive function in infants and children, in contrast with breast feeding, but the available evidence suffers from confounding by social and educational factors. An opportunity arose in the Caerphilly cohort study to examine relations between cognitive function in older men and their feeding as infants, when breast feeding was usual.
Design: A prospective cohort study.
Setting: Caerphilly, South Wales, UK, was a deprived coal mining community when the men had been born in 1920–35. Most had been breast fed as infants.
Participants: 779 men aged 60–74 years when tested. The men had earlier been asked to obtain from their mothers their birth weight, and how they had been fed as infants.
Results: Complete data were obtained for 779 men. In those whose birth weight had been at or above the median, the adjusted mean cognitive function was only slightly and non-significantly lower in those who had been artificially fed. In the men whose birth weight had been below the median, having been artificially fed was associated with significantly lower results in both a test of reasoning (the AH4) and word power (the national adult reading test (NART)). Two standard deviations below the median birth weight, artificial feeding was associated with a reduction of six points (70% of a SD) on word power (the NART).
Conclusions: In men whose birth weight had been low, having been artificially fed is associated with poorer cognitive function in late adult life.
doi:10.1136/jech.2004.022913
PMCID: PMC1732991  PMID: 15650144
15.  Impact of maternal education about complementary feeding and provision of complementary foods on child growth in developing countries 
BMC Public Health  2011;11(Suppl 3):S25.
Background
Childhood undernutrition is prevalent in low and middle income countries. It is an important indirect cause of child mortality in these countries. According to an estimate, stunting (height for age Z score < -2) and wasting (weight for height Z score < -2) along with intrauterine growth restriction are responsible for about 2.1 million deaths worldwide in children < 5 years of age. This comprises 21 % of all deaths in this age group worldwide. The incidence of stunting is the highest in the first two years of life especially after six months of life when exclusive breastfeeding alone cannot fulfill the energy needs of a rapidly growing child. Complementary feeding for an infant refers to timely introduction of safe and nutritional foods in addition to breast-feeding (BF) i.e. clean and nutritionally rich additional foods introduced at about six months of infant age. Complementary feeding strategies encompass a wide variety of interventions designed to improve not only the quality and quantity of these foods but also improve the feeding behaviors. In this review, we evaluated the effectiveness of two most commonly applied strategies of complementary feeding i.e. timely provision of appropriate complementary foods (± nutritional counseling) and education to mothers about practices of complementary feeding on growth. Recommendations have been made for input to the Lives Saved Tool (LiST) model by following standardized guidelines developed by Child Health Epidemiology Reference Group (CHERG).
Methods
We conducted a systematic review of published randomized and quasi-randomized trials on PubMed, Cochrane Library and WHO regional databases. The included studies were abstracted and graded according to study design, limitations, intervention details and outcome effects. The primary outcomes were change in weight and height during the study period among children 6-24 months of age. We hypothesized that provision of complementary food and education of mother about complementary food would significantly improve the nutritional status of the children in the intervention group compared to control. Meta-analyses were generated for change in weight and height by two methods. In the first instance, we pooled the results to get weighted mean difference (WMD) which helps to pool studies with different units of measurement and that of different duration. A second meta-analysis was conducted to get a pooled estimate in terms of actual increase in weight (kg) and length (cm) in relation to the intervention, for input into the LiST model.
Results
After screening 3795 titles, we selected 17 studies for inclusion in the review. The included studies evaluated the impact of provision of complementary foods (±nutritional counseling) and of nutritional counseling alone. Both these interventions were found to result in a significant increase in weight [WMD 0.34 SD, 95% CI 0.11 – 0.56 and 0.30 SD, 95 % CI 0.05-0.54 respectively) and linear growth [WMD 0.26 SD, 95 % CI 0.08-0.43 and 0.21 SD, 95 % CI 0.01-0.41 respectively]. Pooled results for actual increase in weight in kilograms and length in centimeters showed that provision of appropriate complementary foods (±nutritional counseling) resulted in an extra gain of 0.25kg (±0.18) in weight and 0.54 cm (±0.38) in height in children aged 6-24 months. The overall quality grades for these estimates were that of ‘moderate’ level. These estimates have been recommended for inclusion in the Lives Saved Tool (LiST) model. Education of mother about complementary feeding led to an extra weight gain of 0.30 kg (±0.26) and a gain of 0.49 cm (±0.50) in height in the intervention group compared to control. These estimates had been recommended for inclusion in the LiST model with an overall quality grade assessment of ‘moderate’ level.
Conclusion
Provision of appropriate complementary food, with or without nutritional education, and maternal nutritional counseling alone lead to significant increase in weight and height in children 6-24 months of age. These interventions can significantly reduce the risk of stunting in developing countries and are recommended for inclusion in the LiST tool.
doi:10.1186/1471-2458-11-S3-S25
PMCID: PMC3231899  PMID: 21501443
16.  Canadian infants' nutrient intakes from complementary foods during the first year of life 
BMC Pediatrics  2010;10:43.
Background
Complementary feeding is currently recommended after six months of age, when the nutrients in breast milk alone are no longer adequate to support growth. Few studies have examined macro- and micro-nutrient intakes from complementary foods (CF) only. Our purpose was to assess the sources and nutritional contribution of CF over the first year of life.
Methods
In July 2003, a cross-sectional survey was conducted on a nationally representative sample of mothers with infants aged three to 12 months. The survey was administered evenly across all regions of the country and included a four-day dietary record to assess infants' CF intakes in household (tablespoon) measures (breast milk and formula intakes excluded). Records from 2,663 infants were analyzed for nutrient and CF food intake according to 12 categories. Mean daily intakes for infants at each month of age from CF were pooled and compared to the Dietary Reference Intakes for the respective age range.
Results
At three months of age, 83% of infants were already consuming infant cereals. Fruits and vegetables were among the most common foods consumed by infants at all ages, while meats were least common at all ages except 12 months. Macro- and micro-nutrient intakes from CF generally increased with age. All mean nutrient intakes, except vitamin D and iron, met CF recommendations at seven to 12 months.
Conclusions
Complementary foods were introduced earlier than recommended. Although mean nutrient intakes from CF at six to 12 months appear to be adequate among Canadian infants, further attention to iron and vitamin D intakes and sources may be warranted.
doi:10.1186/1471-2431-10-43
PMCID: PMC2905348  PMID: 20565759
17.  The Impact of Nutrition on Child Development at 3 Years in a Rural Community of India 
Background:
In India, child malnutrition is mostly the result of high levels of exposure to infection and inappropriate infant and young child feeding and caring practices and has its origins almost entirely during the first 2 to 3 years of life. This study aims in assessing the impact of breast feeding on child development of children at 3 years.
Methods:
About 530 children at 3 years were assessed for developmental delay by Ages and Stages Questionnaire (ASQ). Growth measurements and hemoglobin estimation were carried out at the time of developmental evaluation. Physical growth was assessed by using World Health Organization growth charts. Children were assessed for their duration of breast feeding and weaning period. They were analyzed for the feeding practices versus developmental outcome. Chi-square test was used to compare the categorical variables. Differences were considered significant at P < 0.05 level.
Results:
Children who were exclusively breastfed for at least 6 or more months had significantly higher ASQ scores with P value for communication (0.003), gross motor (0.004), fine motor (0.007) and problem solving (0.013) except personal social (0.059) compared with children who had exclusively breastfed for less than 6 months. Children, who were weaned beyond 12th month, had significantly higher ASQ scores with P value for communication (0.004), gross motor (0.091), fine motor (0.044), problem solving (0.001) and personal social (0.012) as against those who were weaned at 6th month or earlier in all domains.
Conclusion:
Breast feeding has a positive effect on the overall development of the child and should be promoted in the present generation. In India, child malnutrition is responsible for a higher percentage of the country's burden of disease. Undernutrition also affects cognitive and motor development and undermines educational attainment; and ultimately impacts on productivity at work and at home, with adverse implications for income and economic growth.
PMCID: PMC4018599  PMID: 24829738
Breast feeding; child development; undernutrition
18.  Breast-feeding Duration, Age of Starting Solids, and High BMI Risk and Adiposity in Indian Children 
Maternal & child nutrition  2011;9(2):199-216.
This study utilized data from a prospective birth cohort study on 568 Indian children, to determine whether a longer duration of breast-feeding and later introduction of solid feeding was associated with a reduced higher body mass index (BMI) and less adiposity. Main outcomes were high BMI (>90th within-cohort sex-specific BMI percentile) and sum of skinfold thickness (triceps and subscapular) at age 5. Main exposures were breast-feeding (6 categories from 1-4 to ≥21 months) and age of starting regular solid feeding (4 categories from ≤3 to ≥6 months). Data on infant feeding practices, socioeconomic and maternal factors were collected by questionnaire. Birthweight, maternal and child anthropometry were measured. Multiple regression analysis which accounted for potential confounders, demonstrated a small magnitude of effect for breast-feeding duration or introduction of solid feeds on the risk of high BMI but not for lower skinfold thickness. Breast-feeding duration was strongly negatively associated with weight gain (0-2 years) (adjusted β= −0.12 SD 95% CI: −0.19 to −0.05 per category change in breast-feeding duration, p=0.001) and weight gain (0-2 years) was strongly associated with high BMI at 5 years (adjusted OR = 3.8, 95 % CI: 2.53 to 5.56, p<0.001). In our sample, findings suggest that longer breast-feeding duration and later introduction of solids has a small reduction on later high BMI risk and a negligible effect on skinfold thickness. However, accounting for sampling variability, these findings cannot exclude the possibility of no effect at the population-level.
doi:10.1111/j.1740-8709.2011.00341.x
PMCID: PMC3378477  PMID: 21978208
Breast-feeding duration; Complementary feeds; Childhood body mass index; Adiposity; Infant weight gain; India
19.  Infant- and Young Child-feeding Practices in Bankura District, West Bengal, India 
A community-based, cross-sectional descriptive study was conducted during June-July 2008 to assess the infant- and young child-feeding (IYCF) practices in Bankura district, West Bengal, India. In total, 647 children aged less than two years selected through revised 40-cluster sampling using the indicators of the Integrated Management of Neonatal and Childhood Illness (IMNCI) and World Health Organization. The proportions of infants with early initiation of breastfeeding (13.6%) and exclusive breastfeeding under six months (57.1%) and infants who received complementary feeding at the age of 6–8 months (55.7%) were low. Appropriate feeding as per the IMNCI protocol was significantly less among infants aged 6–11 months (15.2%) and children aged 12–23 months (8.7%) compared to infants aged less than six months (57.1%), which could be attributable to low frequency and amount of complementary feeding. The main problems revealed from the study were late initiation of breastfeeding, low rates of exclusive breastfeeding, and inappropriate complementary feeding practices.
PMCID: PMC2980895  PMID: 20635641
Breastfeeding; Child-feeding practices; Cross-sectional studies; Descriptive studies; Exclusive breastfeeding; Infant-feeding practices; India
20.  Potential impact of infant feeding recommendations on mortality and HIV-infection in children born to HIV-infected mothers in Africa: a simulation 
Background
Although breast-feeding accounts for 15–20% of mother-to-child transmission (MTCT) of HIV, it is not prohibited in some developing countries because of the higher mortality associated with not breast-feeding. We assessed the potential impact, on HIV infection and infant mortality, of a recommendation for shorter durations of exclusive breast-feeding (EBF) and poor compliance to these recommendations.
Methods
We developed a deterministic mathematical model using primarily parameters from published studies conducted in Uganda or Kenya and took into account non-compliance resulting in mixed-feeding practices. Outcomes included the number of children HIV-infected and/or dead (cumulative mortality) at 2 years following each of 6 scenarios of infant-feeding recommendations in children born to HIV-infected women: Exclusive replacement-feeding (ERF) with 100% compliance, EBF for 6 months with 100% compliance, EBF for 4 months with 100% compliance, ERF with 70% compliance, EBF for 6 months with 85% compliance, EBF for 4 months with 85% compliance
Results
In the base model, reducing the duration of EBF from 6 to 4 months reduced HIV infection by 11.8% while increasing mortality by 0.4%. Mixed-feeding in 15% of the infants increased HIV infection and mortality respectively by 2.1% and 0.5% when EBF for 6 months was recommended; and by 1.7% and 0.3% when EBF for 4 months was recommended. In sensitivity analysis, recommending EBF resulted in the least cumulative mortality when the a) mortality in replacement-fed infants was greater than 50 per 1000 person-years, b) rate of infection in exclusively breast-fed infants was less than 2 per 1000 breast-fed infants per week, c) rate of progression from HIV to AIDS was less than 15 per 1000 infected infants per week, or d) mortality due to HIV/AIDS was less than 200 per 1000 infants with HIV/AIDS per year.
Conclusion
Recommending shorter durations of breast-feeding in infants born to HIV-infected women in these settings may substantially reduce infant HIV infection but not mortality. When EBF for shorter durations is recommended, lower mortality could be achieved by a simultaneous reduction in the rate of progression from HIV to AIDS and or HIV/AIDS mortality, achievable by the use of HAART in infants.
doi:10.1186/1471-2334-8-66
PMCID: PMC2396166  PMID: 18485200
21.  Factors influencing the relation of infant feeding to asthma and recurrent wheeze in childhood 
Thorax  2001;56(3):192-197.
BACKGROUND—The relationship between infant feeding and childhood asthma is controversial. This study tested the hypothesis that the relation between breast feeding and childhood asthma is altered by the presence of maternal asthma.
METHODS—Healthy non-selected newborn infants (n=1246) were enrolled at birth. Asthma was defined as a physician diagnosis of asthma plus asthma symptoms reported on ⩾2 questionnaires at 6, 9, 11or 13 years. Recurrent wheeze (⩾4 episodes in the past year) was reported by questionnaire at seven ages in the first 13 years of life. Duration of exclusive breast feeding was based on prospective physician reports or parental questionnaires completed at 18 months. Atopy was assessed by skin test responses at the age of 6years.
RESULTS—The relationship between breast feeding, asthma, and wheeze differed with the presence or absence of maternal asthma and atopy in the child. After adjusting for confounders, children with asthmatic mothers were significantly more likely to have asthma if they had been exclusively breast fed (OR 8.7, 95% CI 3.4 to 22.2). This relationship was only evident for atopic children and persisted after adjusting for confounders. In contrast, the relation between recurrent wheeze and breast feeding was age dependent. In the first 2 years of life exclusive breast feeding was associated with significantly lower rates of recurrent wheeze (OR 0.45, 95% CI 0.2 to 0.9), regardless of the presence or absence of maternal asthma or atopy in the child. Beginning at the age of 6 years, exclusive breast feeding was unrelated to prevalence of recurrent wheeze, except for children with asthmatic mothers in whom it was associated with a higher odds ratio for wheeze (OR 5.7, 95% CI 2.3 to 14.1), especially if the child was atopic.
CONCLUSION—The relationship between breast feeding and asthma or recurrent wheeze varies with the age of the child and the presence or absence of maternal asthma and atopy in the child. While associated with protection against recurrent wheeze early in life, breast feeding is associated with an increased risk of asthma and recurrent wheeze beginning at the age of 6 years, but only for atopic children with asthmatic mothers.


doi:10.1136/thorax.56.3.192
PMCID: PMC1758780  PMID: 11182011
22.  Perception of Infant Feeding Practices among mothers-to-be:An Urban-based school study 
This study on the perception of infant feeding practices was conducted among unmarried girls from two randomly selected Saudi public schools in Al-Khobar. Though it was encouraging to note that the attitude of the, girls was largely in favour of breast feeding, many deficiencies were identified in their knowledge of infant feeding. 67.1 % students were unaware of the importance of colostrum and 70.5% opted for scheduled feeding over demand feeding. To 40.2% girls an optimum duration of 18-24 months for breast Feeding was not desirable. A large proportion of students lacked knowledge on the methods of promoting lactation such as early suckling (51.4%), frequent suckling (40%) and “rooming-in” (37.9%). Only 28% of the girls knew the correct age of introducing solid food. With the present trend of decline in the duration of breastfeeding in Saudi Arabia, the schools could play an important role in training and motivating future mothers for proper infant feeding practices.
PMCID: PMC3437185  PMID: 23008538
breast-feeding; weaning; school health education
23.  Relationship between Breastfeeding and Obesity in Childhood 
A cross-sectional study was conducted to investigate the weight status and the relationship of infant-feeding variables, birthweight and birth order with BMI in a group of Iranian children. Five hundred and eleven students of both sexes at the first grade in elementary schools (aged 7 years) were recruited randomly from all 19 educational districts of Tehran. Weights and heights of children and their mothers were measured. Data on breastfeeding (BF), formula-feeding, the timing of introduction of complementary foods (CF), birthweight, and birth order were collected from the mothers. The 2007 WHO reference value was used for determining child's weight status. Regression analysis in single and a 2-level linear regression models was used for examining the independent relationships of infant-feeding variables, birthweight and birth order with childhood BMI. The prevalence of underweight and overweight in this group of children was 7.6% and 19.7%, respectively. Total time of BF and duration of exclusive BF were not associated with childhood BMI. The timing of introduction of CF was inversely related to childhood BMI after controlling for other variables (β:-0.34; 95% CI:-0.58,-0.10). Children with an early introduction of CF had significantly higher mean BMI (p for linear trend=0.012). Birth order and birthweight were related to childhood BMI significantly. These data suggest that overweight and obesity are nutritional problems among 7 years old Teharani children. The timing of introduction of CF, birth order, and birthweight were independent predictors of childhood BMI. Neither total time of BF nor duration of exclusive breastfeeding was associated with adiposity in children.
PMCID: PMC3489946  PMID: 23082632
Birthweight; Breastfeeding; Childhood; Infant-feeding; Introduction of complementary feeding; Obesity; Iran
24.  Randomised controlled trial of support from volunteer counsellors for mothers considering breast feeding 
BMJ : British Medical Journal  2004;328(7430):26.
Objective To investigate whether offering volunteer support from counsellors in breast feeding would result in more women breast feeding.
Design Randomised controlled trial.
Setting 32 general practices in London and south Essex.
Participants 720 women considering breast feeding.
Main outcome measures Primary outcome was prevalence of any breast feeding at six weeks. Secondary outcomes were the proportion of women giving any breast feeds, or bottle feeds at four months, duration of any breast feeding, time to introduction of bottle feeds, and satisfaction with breast feeding.
Results Offering support in breast feeding did not significantly increase the prevalence of any breast feeding to six weeks (65% (218/336) in the intervention group and 63% (213/336) in the control group; relative risk 1.02, 95% confidence interval 0.84 to 1.24). Survival analysis up to four months confirmed that neither duration of breast feeding nor time to introduction of formula feeds differed significantly between control and intervention groups. Not all women in the intervention group contacted counsellors postnatally, but 73% (123/179) of those who did rated them as very helpful. More women in the intervention group than in the control group said that their most helpful advice came from counsellors rather than from other sources.
Conclusions Women valued the support of a counsellor in breast feeding, but the intervention did not significantly increase breastfeeding rates, perhaps because some women did not ask for help.
PMCID: PMC313903  PMID: 14703543
25.  Cognition, behaviour and academic skills after cognitive rehabilitation in Ugandan children surviving severe malaria: a randomised trial 
BMC Neurology  2011;11:96.
Background
Infection with severe malaria in African children is associated with not only a high mortality but also a high risk of cognitive deficits. There is evidence that interventions done a few years after the illness are effective but nothing is known about those done immediately after the illness. We designed a study in which children who had suffered from severe malaria three months earlier were enrolled into a cognitive intervention program and assessed for the immediate benefit in cognitive, academic and behavioral outcomes.
Methods
This parallel group randomised study was carried out in Kampala City, Uganda between February 2008 and October 2010. Sixty-one Ugandan children aged 5 to 12 years with severe malaria were assessed for cognition (using the Kaufman Assessment Battery for Children, second edition and the Test of Variables of Attention), academic skills (Wide Range Achievement Test, third edition) and psychopathologic behaviour (Child Behaviour Checklist) three months after an episode of severe malaria. Twenty-eight were randomised to sixteen sessions of computerised cognitive rehabilitation training lasting eight weeks and 33 to a non-treatment group. Post-intervention assessments were done a month after conclusion of the intervention. Analysis of covariance was used to detect any differences between the two groups after post-intervention assessment, adjusting for age, sex, weight for age z score, quality of the home environment, time between admission and post-intervention testing and pre-intervention score. The primary outcome was improvement in attention scores for the intervention group. This trial is registered with Current Controlled Trials, number ISRCTN53183087.
Results
Significant intervention effects were observed in the intervention group for learning mean score (SE), [93.89 (4.00) vs 106.38 (4.32), P = 0.04] but for working memory the intervention group performed poorly [27.42 (0.66) vs 25.34 (0.73), P = 0.04]. No effect was observed in the other cognitive outcomes or in any of the academic or behavioural measures.
Conclusions
In this pilot study, our computerised cognitive training program three months after severe malaria had an immediate effect on cognitive outcomes but did not affect academic skills or behaviour. Larger trials with follow-up after a few years are needed to investigate whether the observed benefits are sustained.
Trial registration
ISRCTN: ISRCTN53183087
doi:10.1186/1471-2377-11-96
PMCID: PMC3171314  PMID: 21816079

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