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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.  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
3.  Two-Year Morbidity–Mortality and Alternatives to Prolonged Breast-Feeding among Children Born to HIV-Infected Mothers in Côte d'Ivoire 
PLoS Medicine  2007;4(1):e17.
Background
Little is known about the long-term safety of infant feeding interventions aimed at reducing breast milk HIV transmission in Africa.
Methods and Findings
In 2001–2005, HIV-infected pregnant women having received in Abidjan, Côte d'Ivoire, a peripartum antiretroviral prophylaxis were presented antenatally with infant feeding interventions: either artificial feeding, or exclusive breast-feeding and then early cessation from 4 mo of age. Nutritional counseling and clinical management were provided for 2 y. Breast-milk substitutes were provided for free. The primary outcome was the occurrence of adverse health outcomes in children, defined as validated morbid events (diarrhea, acute respiratory infections, or malnutrition) or severe events (hospitalization or death). Hazards ratios to compare formula-fed versus short-term breast-fed (reference) children were adjusted for confounders (baseline covariates and pediatric HIV status as a time-dependant covariate). The 18-mo mortality rates were also compared to those observed in the Ditrame historical trial, which was conducted at the same sites in 1995–1998, and in which long-term breast-feeding was practiced in the absence of any specific infant feeding intervention. Of the 557 live-born children, 262 (47%) were breast-fed for a median of 4 mo, whereas 295 were formula-fed. Over the 2-y follow-up period, 37% of the formula-fed and 34% of the short-term breast-fed children remained free from any adverse health outcome (adjusted hazard ratio [HR]: 1.10; 95% confidence interval [CI], 0.87–1.38; p = 0.43). The 2-y probability of presenting with a severe event was the same among formula-fed (14%) and short-term breast-fed children (15%) (adjusted HR, 1.19; 95% CI, 0.75–1.91; p = 0.44). An overall 18-mo probability of survival of 96% was observed among both HIV-uninfected short-term and formula-fed children, which was similar to the 95% probability observed in the long-term breast-fed ones of the Ditrame trial.
Conclusions
The 2-y rates of adverse health outcomes were similar among short-term breast-fed and formula-fed children. Mortality rates did not differ significantly between these two groups and, after adjustment for pediatric HIV status, were similar to those observed among long-term breast-fed children. Given appropriate nutritional counseling and care, access to clean water, and a supply of breast-milk substitutes, these alternatives to prolonged breast-feeding can be safe interventions to prevent mother-to-child transmission of HIV in urban African settings.
Given appropriate nutritional counseling and care, access to clean water, and supply of breast milk substitutes, replacing prolonged breast-feeding with formula-feeding appears to be a safe intervention to prevent mother-to-child transmission of HIV in this setting.
Editors' Summary
Background.
The HIV virus can be transmitted from infected mothers to their babies during pregnancy and birth as well as after birth through breast milk. Mother-to-child transmission in developed countries has been all but eliminated by treatment of mothers with the best available combination of antiretroviral drugs and by asking them to avoid breast-feeding. However, in many developing countries, the best drug treatments are not available to mothers. Moreover, breast-feeding is generally the best nutritional choice for infants, especially in areas where resources such as clean water, formula feed, and provision of healthcare are scarce. And even if formula feed is available, formula-fed babies might be at higher risk of dying from diarrhea and chest infections, which are more common in infants who are not breast-fed. International guidelines say that HIV-positive mothers should avoid all breast-feeding and adopt formula feeding instead if this option is practical and safe for them, which would require that they can afford formula feed and have easy access to clean water. If formula-feeding is not feasible, guidelines recommend that mothers should breast-feed only for the first few months and then stop and switch the baby to solid food. One of these two alternative options should be feasible in most African cities if mothers are given the right support.
Why Was This Study Done?
Several completed and ongoing studies are assessing the relative risks and benefits of the two recommended strategies for different developing country locations, and this is one of them. The study, the “Ditrame Plus” trial by researchers from France and Côte d'Ivoire, was conducted in Abidjan, an urban West African setting. The goal was to compare death rates and rates of certain diseases (such as diarrhea and chest infections) between babies born to HIV-positive mothers that were formula-fed and those that were breast-fed for a short time after birth.
What Did the Researchers Do and Find?
HIV-positive pregnant women were invited to enter the study, and they received short-term drug treatments intended to reduce the risk of HIV transmission to their babies. Women in the trial were then asked to choose one of the two feeding options and offered support and counseling for either one. This support included free formula, transport, and healthcare provision. Babies were followed up to their second birthday, and data were collected on death rates and any serious illnesses. A total of 643 women were enrolled into the study, and safety data were collected for 557 babies, of whom 295 were in the formula group and 262 were in the short-term breast-feeding group. The researchers corrected for HIV infection in the babies and found no evidence that the risk of other negative health outcomes and death rates was any different between the formula-fed babies and short-term breast-fed babies. Looking specifically at individual diseases, the researchers found that the risks for diarrhea and chest infections were slightly higher among formula-fed babies, but this did not translate into a greater risk of death or worse overall health. They also compared the death rates in this study with some historical data from a previous research project done in the same area on children born to HIV-positive mothers who had practiced long-term breast-feeding. The mother-to-child transmission rate of HIV had been much higher in that earlier trial, but looking only at the HIV-negative children, the researchers found no difference in risk for death or serious disease between the formula-fed or short-term breast-fed babies from the Ditrame Plus trial and the long-term breast-fed babies from the earlier trial.
What Do These Findings Mean?
This study shows that if HIV-positive mothers are well supported, either of the two feeding options currently recommended (formula-only feed, or short-term breast-feeding) are likely to be equivalent in terms of the baby's chances for survival and health. However, women in this study were offered a great deal of support and the findings may not necessarily apply to real-life situations in other settings in Africa, or outside the context of a research project. In addition to routine care after birth, access to better drugs to prevent mother-to-child transmission in developing countries remains an important goal.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/doi:10.1371/journal.pmed.0040017.
Resources from Avert (an AIDS charity) on HIV and infant feeding.
Information from the US Centers for Disease Control on mother-to-child transmission of HIV
Guidelines from the World Health Organization on mother-to-child transmission of HIV
AIDSMap pages on breast-feeding and HIV
HIV Care and PMTCT in Resource-Limited Setting contains monthly bulletins and a database devoted to HIV/AIDS infections and prevention of the mother-to-child transmission of HIV
The Ghent group is a network of researchers and policymakers in the area of prevention of mother-to-child transmission of HIV
doi:10.1371/journal.pmed.0040017
PMCID: PMC1769413  PMID: 17227132
4.  Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. 
BMJ : British Medical Journal  1998;316(7124):21-25.
OBJECTIVE: To investigate the relation of infant feeding practice to childhood respiratory illness, growth, body composition, and blood pressure. DESIGN: Follow up study of a cohort of children (mean age 7.3 years) who had detailed infant feeding and demographic data collected prospectively during the first two years of life. SETTING: Dundee. SUBJECTS: 674 infants, of whom 545 (81%) were available for study. Data on respiratory illness were available for 545 children (mean age 7.3 (range 6.1-9.9) years); height for 410 children; weight and body mass index for 412 children; body composition for 405 children; blood pressure for 301 children (mean age 7.2 (range 6.9-10.0) years). MAIN OUTCOME MEASURES: Respiratory illness, weight, height, body mass index, percentage body fat, and blood pressure in relation to duration of breast feeding and timing of introduction of solids. RESULTS: After adjustment for the significant confounding variables the estimated probability of ever having respiratory illness in children who received breast milk exclusively for at least 15 weeks was consistently lower (17.0% (95% confidence interval 15.9% to 18.1%) for exclusive breast feeding, 31.0% (26.8% to 35.2%) for partial breast feeding, and 32.2% (30.7% to 33.7%) for bottle feeding. Solid feeding before 15 weeks was associated with an increased probability of wheeze during childhood (21.0% (19.9% to 22.1%) v 9.7% (8.6% to 10.8%)). It was also associated with increased percentage body fat and weight in childhood (mean body fat 18.5% (18.2% to 18.8%) v 16.5% (16.0% to 17.0%); weight standard deviation score 0.02 (-0.02 to 0.06) v -0.09 (-0.16 to 0.02). Systolic blood pressure was raised significantly in children who were exclusively bottle fed compared with children who received breast milk (mean 94.2 (93.5 to 94.9) mm Hg v 90.7 (89.9 to 91.7) mm Hg). CONCLUSIONS: The probability of respiratory illness occurring at any time during childhood is significantly reduced if the child is fed exclusively breast milk for 15 weeks and no solid foods are introduced during this time. Breast feeding and the late introduction of solids may have a beneficial effect on childhood health and subsequent adult disease.
PMCID: PMC2665344  PMID: 9451261
5.  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
6.  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
7.  Association of Breastfeeding With Maternal Control of Infant Feeding at Age 1 Year 
Pediatrics  2004;114(5):e577-e583.
Objective
Previous studies have found that breastfeeding may protect infants against future overweight. One proposed mechanism is that breastfeeding, compared with bottle-feeding, may promote maternal feeding styles that are less controlling and more responsive to infant cues of hunger and satiety, thereby allowing infants greater self-regulation of energy intake. The objective of this study was to examine whether preponderance of breastfeeding in the first 6 months of life and breastfeeding duration are associated with less maternal restrictive behavior and less pressure to eat.
Methods
We studied 1160 mother–infant pairs in Project Viva, an ongoing prospective cohort study of pregnant mothers and their children. The main outcome measures were mothers’ reports of restricting their children’s food intake and of pressuring their children to eat more food, as measured by a modified Child Feeding Questionnaire (CFQ) at 1 year postpartum. Restriction was defined by strongly agreeing or agreeing with the following question from the modified CFQ: “I have to be careful not to feed my child too much.” We derived a continuous pressure to eat score from 5 questions of the modified CFQ. We used multiple logistic regression to examine the association between preponderance of breastfeeding in the first 6 months of life, breastfeeding duration, and mothers’ restriction of children’s access to food. We used multiple linear regression, both before and after adjusting for several groups of confounders, to predict the effects of breastfeeding on the mothers’ scores for pressuring their children to eat.
Results
The mean (SD) age of the women was 32.4 (4.8) years; 24% of the women were nonwhite, and 32% were primigravidas. At 6 months postpartum, 24% of the mothers were exclusively breastfeeding, 25% were mixed feeding, 41% had weaned, and 10% had fed their infants formula only. The mean (SD) duration of breastfeeding was 6.3 (4.5) months. Thirteen percent of the mothers strongly agreed or agreed with the restriction question. The mean (SD) score on the pressure to eat scale was 5.3 (3.7), and the range was 0 to 20. After adjusting for mothers’ preexisting concerns about their children’s future eating and weight status, as well as sociodemographic, economic, and anthropometric predictors of breastfeeding duration, we found that the longer the mothers breastfed, the less likely they were to restrict their children’s food intake at age 1 year. The adjusted odds ratio was 0.89 (95% confidence interval [CI]: 0.84–0.95) for each 1-month increment in breastfeeding duration. In addition, we found that compared with mothers who were exclusively formula feeding, mothers who were exclusively breastfeeding at 6 months of age had much lower odds of restricting their children’s food intake at 1 year (odds ratio: 0.27; 95% CI: 0.10–0.72). Preponderance of breastfeeding in the first 6 months of life and breastfeeding duration (β = −0.01 points on the 0–20 scale for each additional 1 month of breastfeeding [95% CI: −0.07 to 0.05]) were not related to mothers’ pressuring their children to eat more.
Conclusion
Mothers who fed their infants breast milk in early infancy and who breastfed for longer periods reported less restrictive behavior regarding child feeding at 1 year. Additional longitudinal studies should examine the extent to which any protective effect of breastfeeding on overweight is explained by decreased maternal feeding restriction.
doi:10.1542/peds.2004-0801
PMCID: PMC1989686  PMID: 15492358
8.  Infant feeding practices among HIV-positive women in Dar es Salaam, Tanzania, indicate a need for more intensive infant feeding counselling 
Public Health Nutrition  2010;13(12):2027-2033.
Objective
To assess feeding practices of infants born to HIV-positive women in Dar es Salaam, Tanzania. These data then served as a proxy to evaluate the adequacy of current infant feeding counselling.
Design
A cross-sectional survey of infant feeding behaviours.
Setting
Four clinics in greater Dar es Salaam in early 2008.
Subjects
A total of 196 HIV-positive mothers of children aged 6–10 months recruited from HIV clinics.
Results
Initiation of breastfeeding was reported by 95·4% of survey participants. In the entire sample, 80·1%, 34·2% and 13·3% of women reported exclusive breast-feeding (EBF) up to 2, 4 and 6 months, respectively. Median duration of EBF among women who ever breast-fed was 3 (interquartile range (IQR): 2·1, 4·0) months. Most non-breast-milk foods fed to infants were low in nutrient density. Complete cessation of breast-feeding occurred within 14 d of the introduction of non-breast-milk foods among 138 of the 187 children (73·8%) who had ever received any breast milk. Of the 187 infants in the study who ever received breast milk, 19·4% received neither human milk nor any replacement milks for 1 week or more (median duration of no milk was 14 (IQR: 7, 152) d).
Conclusions
Infant feeding practices among these HIV-positive mothers resulted in infants receiving far less breast milk and more mixed complementary feeds than recommended, thus placing them at greater risk of both malnutrition and HIV infection. An environment that better enables mothers to follow national guidelines is urgently needed. More intensive infant feeding counselling programmes would very likely increase rates of optimal infant feeding.
doi:10.1017/S1368980010001539
PMCID: PMC3289716  PMID: 20587116
HIV/AIDS; Africa; Exclusive breast-feeding; Infant nutrition; PMTCT
9.  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
10.  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
11.  Breast feeding in Israel: maternal factors associated with choice and duration. 
STUDY OBJECTIVES--To determine the influence of maternal characteristics on the incidence and duration of breast feeding. DESIGN--All the women who delivered in three obstetric wards within a two year period were surveyed. These three wards cover 93% of all births in the Jerusalem district. Women were interviewed on breast feeding of the previous child on the first or second day post partum by a research nurse. PARTICIPANTS--Altogether 8486 women whose previous pregnancy had resulted in a live born singleton who survived for at least one year. MEASUREMENTS AND MAIN RESULTS--Breast feeding information was linked to demographic and health information from hospital records. Using logistic regression analysis, failure to start breast feeding was best predicted (p < 0.001) by caesarean delivery, infant's birth weight, maternal smoking habits, and mother being non-immigrant. Maternal age (< 24 or > 40 years) and father being an ultraorthodox Jew were also positively (p < 0.05) associated with the decision to breast feed. Long term breast feeding (three months or more) was strongly affected (p < 0.001) by maternal education level, with both women with the fewest and the greatest number of years of schooling more likely to breast feed. A similar association was observed in all ethnic groups. Primipara and grandmultipara (parity > 4), new immigrants, ultraorthodox Jews, and non-smokers breast fed their babies for longer. CONCLUSIONS--The importance of maternal characteristics in relation to breast feeding was shown. Caesarean delivery and the infant's birth weight were strongly related to the decision to breast feed as were the demographic characteristics of mother's age and her country of birth. Education was not related to this decision but was strongly associated with the duration of breast feeding, as was parity. The behavioural characteristics of smoking and being ultraorthodox were related to both the decision to start and the duration of breast feeding. Efforts to encourage breast feeding ought to be targeted during the hospital stay and post partum period towards women identified as being at increased risk.
PMCID: PMC1059960  PMID: 8051528
12.  HIV: prevention of mother-to-child transmission  
Clinical Evidence  2011;2011:0909.
Introduction
Over 2 million children are thought to be living with HIV/AIDS worldwide, of whom over 80% live in sub-Saharan Africa. Without antiretroviral treatment, the risk of HIV transmission from infected mothers to their children is 15% to 30% during gestation or labour, with an additional transmission risk of 10% to 20% associated with prolonged breastfeeding. HIV-1 infection accounts for most infections; HIV-2 is rarely transmitted from mother to child. Transmission is more likely in mothers with high viral loads, advanced disease, or both, in the presence of other sexually transmitted diseases, and with increased exposure to maternal blood. Mixed feeding practices (breast milk plus other liquids or solids) and prolonged breastfeeding are also associated with increased risk of mother-to-child transmission of HIV.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of measures to reduce mother-to-child transmission of HIV? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We performed a GRADE evaluation of the quality of evidence for interventions.
Results
We found 53 systematic reviews, RCTs, or observational studies that met our inclusion criteria.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiretroviral drugs, different methods of infant feeding, elective caesarean section, immunotherapy, micronutrient supplements, vaginal microbicides, and vitamin supplements.
Key Points
Without active intervention, the risk of mother-to-child transmission (MTCT) of HIV-1 is high, especially in populations where prolonged breastfeeding is the norm. Without antiviral treatment, the risk of transmission of HIV from infected mothers to their children is approximately 15% to 30% during pregnancy and labour, with an additional transmission risk of 10% to 20% associated with prolonged breastfeeding.HIV-2 is rarely transmitted from mother to child.Transmission is more likely in mothers with high viral loads, advanced HIV disease, or both.Without antiretroviral treatment (ART), 15% to 35% of vertically infected infants die within the first year of life.The long-term treatment of children with ART is complicated by multiple concerns regarding the complications associated with life-long treatment, including adverse effects of antiretroviral drugs, difficulties of adherence across the developmental trajectory of childhood and adolescence, and the development of resistance.From a paediatric perspective, successful prevention of MTCT and HIV-free survival for infants remain the most important focus.
Antiretroviral drugs given to the mother during pregnancy or labour, to the baby immediately after birth, or to the mother and baby reduce the risk of intrauterine and intrapartum MTCT of HIV-1 and when given to the infant after birth and to the mother or infant during breastfeeding reduce the risk of postpartum MTCT of HIV-1.
Reductions in MTCT are possible using multidrug ART regimens. Longer courses of ART are more effective, but the greatest benefit is derived from treatment during late pregnancy, labour, and early infancy.Suppression of the maternal viral load to undetectable levels (below 50 copies/mL) using highly active antiretroviral therapy (HAART) offers the greatest risk reduction, and is currently the standard of care offered in most resource-rich countries, where MTCT rates have been reduced to 1% to 2%. Alternative short-course regimens have been tested in resource-limited settings where HAART is not yet widely available. There is evidence that short courses of antiretroviral drugs have confirmed efficacy for reducing MTCT. Identifying optimal short-course regimens (drug combination, timing, and cost effectiveness) for various settings remains a focus for ongoing research.The development of viral resistance in mothers and infants after single-dose nevirapine and other short-course regimens that include single-dose nevirapine is of concern. An additional short-course of antiretrovirals with a different regimen during labour and early postpartum, and the use of HAART, may decrease the risk of viral resistance in mothers, and in infants who become HIV-infected despite prophylaxis.World Health Organization guidelines recommend starting prophylaxis with antiretroviral drugs from as early as 14 weeks' gestation, or as soon as possible if women present late in pregnancy, in labour, or at delivery.
Elective caesarean section at 38 weeks may reduce vertical transmission rates (apart from breast-milk transmission). The potential benefits of this intervention need to be balanced against the increased risk of surgery-associated complications, high cost, and feasibility issues. These reservations are particularly relevant in resource-limited settings.
Immunotherapy with HIV hyperimmune globulin seems no more effective than immunoglobulin without HIV antibody at reducing HIV-1 MTCT risk.
Vaginal microbicides have not been demonstrated to reduce HIV-1 MTCT risk.
There is no evidence that supplementation with vitamin A reduces the risk of HIV-1 MTCT, and there is concern that postnatal vitamin A supplementation for mother and infant may be associated with increased risk of mortality.
We don't know whether micronutrients are effective in prevention of MTCT of HIV as we found no RCT evidence on this outcome.
Avoidance of breastfeeding prevents postpartum transmission of HIV, but formula feeding requires access to clean water and health education. The risk of breastfeeding-related HIV transmission needs to be balanced against the multiple benefits that breastfeeding offers. In resource-poor countries, breastfeeding is strongly associated with reduced infant morbidity and improved child survival. Exclusive breastfeeding during the first 6 months may reduce the risk of HIV transmission compared with mixed feeding, while retaining most of its associated benefits.In a population where prolonged breastfeeding is usual, early, abrupt weaning may not reduce MTCT or HIV-free survival at 2 years compared with prolonged breastfeeding, and may be associated with a higher rate of infant mortality for those infants diagnosed as HIV-infected at <4 months of age. Antiretrovirals given to the mother or the infant during breastfeeding can reduce the risk of HIV transmission in the postpartum period. World Health Organization guidelines recommend that HIV-positive mothers should exclusively breastfeed for the first 6 months, after which time appropriate complementary foods can be introduced. Breastfeeding should be continued for the first 12 months of the infant's life, and stopped only when an adequate diet without breast milk can be provided. Heat- or microbicidal-treated expressed breast milk may offer value in particular settings.
PMCID: PMC3217724  PMID: 21477392
13.  Breast feeding in infancy and social mobility: 60‐year follow‐up of the Boyd Orr cohort 
Archives of Disease in Childhood  2007;92(4):317-321.
Objective
To assess the association of having been breast fed with social class mobility between childhood and adulthood.
Design
Historical cohort study with a 60‐year follow‐up from childhood into adulthood.
Setting
16 urban and rural centres in England and Scotland.
Participants
3182 original participants in the Boyd Orr Survey of Diet and Health in Pre‐War Britain (1937–39) were sent follow‐up questionnaires between 1997 and 1998. Analyses are based on 1414 (44%) responders with data on breast feeding measured in childhood and occupational social class in both childhood and adulthood.
Main outcome
Odds of moving from a lower to a higher social class between childhood and adulthood in those who were ever breast fed versus those who were bottle fed.
Results
The prevalence of breast feeding varied by survey district (range 45–86%) but not with household income (p = 0.7), expenditure on food (p = 0.3), number of siblings (p = 0.7), birth order (p = 0.5) or social class (p = 0.4) in childhood. Participants who had been breast fed were 41% (95% CI 10% to 82%) more likely to move up a social class in adulthood (p = 0.007) than bottle‐fed infants. Longer breastfeeding duration was associated with greater odds of upward social mobility in fully adjusted models (p for trend = 0.003). Additionally controlling for survey district, household income and food expenditure in childhood, childhood height, birth order or number of siblings did not attenuate these associations. In an analysis comparing social mobility among children within families with discordant breastfeeding histories, the association was somewhat attenuated (OR 1.16; 95% CI 0.74 to 1.8).
Conclusions
Breast feeding was associated with upward social mobility. Confounding by other measured childhood predictors of social class in adulthood did not explain this effect, but we cannot exclude the possibility of residual or unmeasured confounding.
doi:10.1136/adc.2006.105494
PMCID: PMC2083668  PMID: 17301108
14.  Anthropometry and body composition of 18 year old men according to duration of breast feeding: birth cohort study from Brazil 
BMJ : British Medical Journal  2003;327(7420):901.
Objective To assess the association between duration of breast feeding and measures of adiposity in adolescence.
Design Population based birth cohort study.
Setting Pelotas, a city of 320 000 inhabitants in a relatively developed area in southern Brazil.
Participants All newborn infants in the city's hospitals were enrolled in 1982; 78.8% (2250) of all male participants were located at age 18 years when enrolling in the national army.
Main outcome measures Weight, height, sitting height, subscapular and triceps skinfolds, and body composition (body fat, lean mass).
Results Neither the duration of total breast feeding nor that of predominant breast feeding (breast milk plus non-nutritive fluids) showed consistent associations with anthropometric or body composition indices. After adjustment for confounding factors, the only significant associations were a greater than 50% reduction in obesity among participants breast fed for three to five months compared with all other breastfeeding categories (P = 0.007) and a linear decreasing trend in obesity with increasing duration of predominant breast feeding (P = 0.03). Similar significant effects were not observed for other measures of adiposity. Borderline direct associations also occurred between total duration of breast feeding and adult height (P = 0.06).
Conclusions The significant reduction in obesity among children breast fed for three to five months is difficult to interpret, as no a priori hypothesis existed regarding a protective effect of intermediate duration of breast feeding. The findings indicate that, in this population, breast feeding has no marked protective effect against adolescent adiposity.
PMCID: PMC218812  PMID: 14563746
15.  HIV: mother-to-child transmission 
Clinical Evidence  2008;2008:0909.
Introduction
Over 2 million children are thought to be living with HIV/AIDS worldwide, of whom over 80% live in sub-Saharan Africa. Without anti-retroviral treatment, the risk of HIV transmission from infected mothers to their children is 15-30% during gestation or labour, and 15-20% during breast feeding. HIV-1 infection accounts for most infections; HIV-2 is rarely transmitted from mother to child. Transmission is more likely in mothers with high viral loads and/or advanced disease, in the presence of other sexually transmitted diseases, and with increased exposure to maternal blood.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of measures to reduce mother to child transmission of HIV? We searched: Medline, Embase, The Cochrane Library and other important databases up to January 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). We performed a GRADE evaluation of the quality of evidence for interventions.
Results
We found 18 systematic reviews, RCTs, or observational studies that met our inclusion criteria.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antiretroviral drugs, different methods of infant feeding, elective caesarean section, immunotherapy, vaginal microbicides, and vitamin supplements.
Key Points
Without active intervention, the risk of mother-to-child transmission (MTCT) of HIV-1 is high, especially in populations where prolonged breast feeding is the norm. Without antiviral treatment, the risk of transmission of HIV from infected mothers to their children is approximately 15-30% during pregnancy and labour, with an additional 10-20% transmission risk attributed to prolonged breast feeding.HIV-2 is rarely transmitted from mother to child.Transmission is more likely in mothers with high viral loads and/or advanced HIV disease.Without antiretroviral treatment (ART), 15-30% of vertically infected infants die within the first year of life.The long-term treatment of children with ART is complicated by multiple concerns regarding the development of resistance, and adverse effects.From a paediatric perspective, successful prevention of MTCT remains the most important focus.
Antiretroviral drugs given to the mother during pregnancy or labour, and/or to the baby immediately after birth, reduce the risk of MTCT of HIV-1.
Reductions in MTCT are possible using simple ART regimens. Longer courses of ART are more effective, but the greatest benefit is derived from treatment during late pregnancy, labour, and early infancy.Suppression of the maternal viral load to undetectable levels (below 50 copies/mL) using highly active antiretroviral therapy (HAART) offers the greatest risk reduction, and is currently the standard of care offered in most resource-rich countries, where MTCT rates have been reduced to 1-2%. Alternative short-course regimens have been tested in resource-limited settings where HAART is not yet widely available. RCTs demonstrate that short courses of antiretroviral drugs have proven efficacy for reducing MTCT. Identifying optimal short-course regimens (drug combination, timing, and cost effectiveness) for various settings remains a focus for ongoing research.
Avoidance of breast feeding prevents postpartum transmission of HIV, but formula feeding requires access to clean water and health education. The risk of breast feeding-related HIV transmission needs to be balanced against the multiple benefits that breast feeding offers. In resource-poor countries, breast feeding is strongly associated with reduced infant morbidity and improved child survival. Modified breastfeeding practices may reduce the risk of HIV transmission while retaining some of its associated benefits.In settings where formula feeding is not feasible (no clean water, insufficient health education, significant cultural barriers) modified breastfeeding practices may offer the best compromise.Early breast feeding with weaning around age 4-6 months may offer an HIV-free survival benefit compared with either formula, mixed feeding, or prolonged breast feeding.Heat- or microbicidal-treated expressed breast milk may offer value in particular settings.
Elective caesarean section at 38 weeks may reduce vertical transmission rates (apart from breast-milk transmission). The potential benefits of this intervention need to be balanced against the increased risk of surgery-associated complications, high cost, and feasibility issues. These reservations are particularly relevant in resource-limited settings.
Immunotherapy with HIV hyperimmune globulin or immunoglobulin without HIV antibody does not reduce HIV-1 MTCT risk.
Vaginal microbiocides have not been demonstrated to reduce HIV-1 MTCT risk.
There is no evidence that vitamin A or multivitamin supplementation reduces the risk of HIV-1 MTCT or infant mortality.
PMCID: PMC2907958  PMID: 19450331
16.  Breast feeding and cardiovascular disease risk factors, incidence, and mortality: the Caerphilly study 
Study objective: To investigate the association of having been breast fed with cardiovascular disease risk factors, incidence, and mortality.
Design: Prospective cohort study.
Setting: Caerphilly, South Wales.
Participants: All men aged 45–59 years living in and around the study area. Of 2818 eligible men, 2512 (89%) were seen. Altogether 1580 men (63%) obtained details of how they had been fed in infancy (ever breast fed or only bottle fed) from their mother or a close female relative. A subset of 1062 subjects reported on whether bottle fed or the duration of breast feeding if breast fed.
Main results: Breast feeding was not associated with stature, blood pressure, insulin resistance, total cholesterol, or fibrinogen. In fully adjusted models (controlling for age, birth order, and social position in childhood and adulthood), breast feeding was associated with greater body mass index than bottle feeding (difference: 0.41 kg/m2 (95% CI: 0.01 to 0.81). There was a positive association between breast feeding and coronary heart disease mortality (hazard ratio: 1.73; 1.17 to 2.55) and incidence (1.54; 1.17 to 2.04) (fully adjusted models). There was no evidence of a duration-response effect, which might be expected if an adverse effect of breast feeding was causal.
Conclusion: These data provide little evidence of a protective influence of breast feeding on cardiovascular disease risk factors, incidence, or mortality. A possible adverse effect of breast feeding on coronary heart disease incidence was observed but may have a number of explanations, including selection and information bias. In view of these limitations, further long term studies with improved measures of infant feeding are required to confirm or refute these findings.
doi:10.1136/jech.2003.018952
PMCID: PMC1732990  PMID: 15650143
17.  Association between breast feeding and asthma in 6 year old children: findings of a prospective birth cohort study 
BMJ : British Medical Journal  1999;319(7213):815-819.
Objectives
To investigate the association between the duration of exclusive breast feeding and the development of asthma related outcomes in children at age 6 years.
Design
Prospective cohort study.
Setting
Western Australia.
Subjects
2187 children ascertained through antenatal clinics at the major tertiary obstetric hospital in Perth and followed to age 6 years.
Main outcome measures
Unconditional logistic regression to model the association between duration of exclusive breast feeding and outcomes related to asthma or atopy at 6 years of age, allowing for several important confounders: sex, gestational age, smoking in the household, and early childcare.
Results
After adjustment for confounders, the introduction of milk other than breast milk before 4 months of age was a significant risk factor for all asthma and atopy related outcomes in children aged 6 years: asthma diagnosed by a doctor (odds ratio 1.25, 95% confidence interval 1.02 to 1.52); wheeze three or more times since 1 year of age (1.41, 1.14 to 1.76); wheeze in the past year (1.31, 1.05 to 1.64); sleep disturbance due to wheeze within the past year (1.42, 1.07 to 1.89); age when doctor diagnosed asthma (hazard ratio 1.22, 1.03 to 1.43); age at first wheeze (1.36, 1.17 to 1.59); and positive skin prick test reaction to at least one common aeroallergen (1.30, 1.04 to 1.61).
Conclusion
A significant reduction in the risk of childhood asthma at age 6 years occurs if exclusive breast feeding is continued for at least the 4 months after birth. These findings are important for our understanding of the cause of childhood asthma and suggest that public health interventions to optimise breast feeding may help to reduce the community burden of childhood asthma and its associated traits.
Key messagesAsthma is the leading cause of admission to hospital in Australian children and its prevalence is increasingWhether breast feeding protects against asthma or atopy, or both, is controversialAsthma is a complex disease, and the relative risks between breast feeding and asthma or atopy are unlikely to be large; this suggests the need for investigation in a large prospective birth cohort with timely assessment of atopic outcomes and all relevant exposuresExclusive breast feeding for at least 4 months is associated with a significant reduction in the risk of asthma and atopy at age 6 years and with a significant delay in the age at onset of wheezing and asthma being diagnosed by a doctorPublic health interventions to promote an increased duration of exclusive breast feeding may help to reduce the morbidity and prevalence of childhood asthma and atopy
PMCID: PMC314207  PMID: 10496824
18.  Breast feeding and obesity: cross sectional study 
BMJ : British Medical Journal  1999;319(7203):147-150.
Objective
To assess the impact of breast feeding on the risk of obesity and risk of being overweight in children at the time of entry to school.
Design
Cross sectional survey
Setting
Bavaria, southern Germany.
Methods
Routine data were collected on the height and weight of 134 577 children participating in the obligatory health examination at the time of school entry in Bavaria. In a subsample of 13 345 children, early feeding, diet, and lifestyle factors were assessed using responses to a questionnaire completed by parents.
Subjects
9357 children aged 5 and 6 who had German nationality.
Main outcome measures
Being overweight was defined as having a body mass index above the 90th centile and obesity was defined as body mass index above the 97th centile of all enrolled German children. Exclusive breast feeding was defined as the child being fed no food other than breast milk.
Results
The prevalence of obesity in children who had never been breast fed was 4.5% as compared with 2.8% in breastfed children. A clear dose-response effect was identified for the duration of breast feeding on the prevalence of obesity: the prevalence was 3.8% for 2 months of exclusive breast feeding, 2.3% for 3-5 months, 1.7% for 6-12 months, and 0.8% for more than 12 months. Similar relations were found with the prevalence of being overweight. The protective effect of breast feeding was not attributable to differences in social class or lifestyle. After adjusting for potential confounding factors, breast feeding remained a significant protective factor against the development of obesity (odds ratio 0.75, 95% CI 0.57 to 0.98) and being overweight (0.79, 0.68 to 0.93).
Conclusions
In industrialised countries promoting prolonged breast feeding may help decrease the prevalence of obesity in childhood. Since obese children have a high risk of becoming obese adults, such preventive measures may eventually result in a reduction in the prevalence of cardiovascular diseases and other diseases related to obesity.
Key messagesObesity is the most frequent nutritional disorder in children, and is an important risk factor for cardiovascular disease in adulthood Preventing obesity in children should be a useful strategy in preventing later heart disease because weight loss interventions in obese children are costly and rarely successfulData from a cross sectional study in Bavaria suggest that the risk of obesity in children at the time of school entry can be reduced by breast feeding: a 35% reduction occurs if children are breastfed for 3 to 5 monthsPreventing obesity and its consequences may be an important argument in the drive to encourage breast feeding in industrialised countries
PMCID: PMC28161  PMID: 10406746
19.  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
20.  Low adherence to exclusive breastfeeding in Eastern Uganda: A community-based cross-sectional study comparing dietary recall since birth with 24-hour recall 
BMC Pediatrics  2007;7:10.
Background
Exclusive breastfeeding is recommended as the best feeding alternative for infants up to six months and has a protective effect against mortality and morbidity. It also seems to lower HIV-1 transmission compared to mixed feeding. We studied infant feeding practices comparing dietary recall since birth with 24-hour dietary recall.
Methods
A cross-sectional survey on infant feeding practices was performed in Mbale District, Eastern Uganda in 2003 and 727 mother-infant (0–11 months) pairs were analysed. Four feeding categories were made based on WHO's definitions: 1) exclusive breastfeeding, 2) predominant breastfeeding, 3) complementary feeding and 4) replacement feeding. We analyzed when the infant fell into another feeding category for the first time. This was based on the recall since birth. Life-table analysis was made for the different feeding categories and Cox regression analysis was done to control for potential associated factors with the different practices. Prelacteal feeding practices were also addressed.
Results
Breastfeeding was practiced by 99% of the mothers. Dietary recall since birth showed that 7% and 0% practiced exclusive breastfeeding by 3 and 6 months, respectively, while 30% and 3% practiced predominant breastfeeding and had not started complementary feeding at the same points in time. The difference between the 24-hour recall and the recall since birth for the introduction of complementary feeds was 46 percentage points at two months and 59 percentage points at four months. Prelacteal feeding was given to 57% of the children. High education and formal marriage were protective factors against prelacteal feeding (adjusted OR 0.5, 0.2 – 1.0 and 0.5, 0.3 – 0.8, respectively).
Conclusion
Even if breastfeeding is practiced at a very high rate, the use of prelacteal feeding and early introduction of other food items is the norm. The 24-hour recall gives a higher estimate of exclusive breastfeeding and predominant breastfeeding than the recall since birth. The 24-hour recall also detected improper infant feeding practices especially in the second half year of life. The dietary recall since birth might be a feasible alternative to monitor infant feeding practices in resource-poor settings. Our study reemphasizes the need for improving infant feeding practices in Eastern Uganda.
doi:10.1186/1471-2431-7-10
PMCID: PMC1828054  PMID: 17331251
21.  Breast feeding and allergic diseases in infants—a prospective birth cohort study 
Archives of Disease in Childhood  2002;87(6):478-481.
Aims: To investigate the effect of breast feeding on allergic disease in infants up to 2 years of age.
Methods: A birth cohort of 4089 infants was followed prospectively in Stockholm, Sweden. Information about various exposures was obtained by parental questionnaires when the infants were 2 months old, and about allergic symptoms and feeding at 1 and 2 years of age. Duration of exclusive and partial breast feeding was assessed separately. Symptom related definitions of various allergic diseases were used. Odds ratios (OR) and 95% confidence intervals (CI) were estimated in a multiple logistic regression model. Adjustments were made for potential confounders.
Results: Children exclusively breast fed during four months or more exhibited less asthma (7.7% v 12%, ORadj = 0.7, 95% CI 0.5 to 0.8), less atopic dermatitis (24% v 27%, ORadj = 0.8, 95% CI 0.7 to 1.0), and less suspected allergic rhinitis (6.5% v 9%, ORadj = 0.7, 95% CI 0.5 to 1.0) by 2 years of age. There was a significant risk reduction for asthma related to partial breast feeding during six months or more (ORadj = 0.7, 95% CI 0.5 to 0.9). Three or more of five possible allergic disorders—asthma, suspected allergic rhinitis, atopic dermatitis, food allergy related symptoms, and suspected allergic respiratory symptoms after exposure to pets or pollen—were found in 6.5% of the children. Exclusive breast feeding prevented children from having multiple allergic disease (ORadj = 0.7, 95% CI 0.5 to 0.9) during the first two years of life.
Conclusion: Exclusive breast feeding seems to have a preventive effect on the early development of allergic disease—that is, asthma, atopic dermatitis, and suspected allergic rhinitis, up to 2 years of age. This protective effect was also evident for multiple allergic disease.
doi:10.1136/adc.87.6.478
PMCID: PMC1755833  PMID: 12456543
22.  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
23.  Patterns and determinants of breastfeeding and complementary feeding practices in urban informal settlements, Nairobi Kenya 
BMC Public Health  2011;11:396.
Background
The World Health Organisation (WHO) recommends exclusive breastfeeding during the first six months of life for optimal growth, development and health. Breastfeeding should continue up to two years or more and nutritionally adequate, safe, and appropriately-fed complementary foods should be introduced at the age of six months to meet the evolving needs of the growing infant. Little evidence exists on breastfeeding and infant feeding practices in urban slums in sub-Saharan Africa. Our aim was to assess breastfeeding and infant feeding practices in Nairobi slums with reference to WHO recommendations.
Methods
Data from a longitudinal study conducted in two Nairobi slums are used. The study used information on the first year of life of 4299 children born between September 2006 and January 2010. All women who gave birth during this period were interviewed on breastfeeding and complementary feeding practices at recruitment and this information was updated twice, at four-monthly intervals. Cox proportional hazard analysis was used to determine factors associated with cessation of breastfeeding in infancy and early introduction of complementary foods.
Results
There was universal breastfeeding with almost all children (99%) having ever been breastfed. However, more than a third (37%) were not breastfed in the first hour following delivery, and 40% were given something to drink other than the mothers' breast milk within 3 days after delivery. About 85% of infants were still breastfeeding by the end of the 11th month. Exclusive breastfeeding for the first six months was rare as only about 2% of infants were exclusively breastfed for six months. Factors associated with sub-optimal infant breastfeeding and feeding practices in these settings include child's sex; perceived size at birth; mother's marital status, ethnicity; education level; family planning (pregnancy desirability); health seeking behaviour (place of delivery) and; neighbourhood (slum of residence).
Conclusions
The study indicates poor adherence to WHO recommendations for breastfeeding and infant feeding practices. Interventions and further research should pay attention to factors such as cultural practices, access to and utilization of health care facilities, child feeding education, and family planning.
doi:10.1186/1471-2458-11-396
PMCID: PMC3118248  PMID: 21615957
24.  Factors associated with stunting among children of age 24 to 59 months in Meskan district, Gurage Zone, South Ethiopia: a case-control study 
BMC Public Health  2014;14(1):800.
Background
Stunting is one of the major causes of morbidity among under-five children Knowledge about risk factors of stunting is an important precondition for developing and strengthening nutritional intervention strategies. The purpose of this study was to assess factors associated with stunting among children of age 24 to 59 months in Meskan District of Gurage Zone, South Ethiopia.
Methods
Community based case-control study was conducted among children of age 24 to 59 months. A multistage sampling technique was used to select the study participants. Cases were stunted children while controls were not stunted children. A total of 121 cases and 121 controls were studied.. Data were analyzed using SPSS 16.0 statistical software.
Results
Children living in households with eight to ten [Adjusted Odds Ratio (AOR) = 4.44, 95% CI: 1.65, 11.95] and five to seven [AOR = 2.97, 95% CI: 1.41, 6.29] family members were more likely to be stunted than those living in households with two to four family members. Similarly, children living in households with three under-five children [AOR = 3.77, 95% CI: 1.33, 10.74] were more likely to develop stunting than those living in households with one under-five child. Children whose mothers worked as merchants [AOR = 4.03, 95% CI: 1.60, 10.17] were more likely to be stunted than children whose mothers worked as house wives. Children who breast fed for <2 years [AOR = 5.61, 95% CI: 1.49, 11.08] were more likely to be stunted than those who breast fed ≥2 years. Children who were exclusively breast fed for <6 months [AOR = 3.27, 95% CI: 1.21, 8.82]were more likely to develop stunting than children who were exclusively breast fed for the first 6 months. Children who bottle fed [AOR =3.30, 95% CI: 1.33, 8.17)] were more likely to be stunted than children who fed their complementary food using spoon/cup.
Conclusions
Family size, number of under-five children in the household, maternal occupation, duration of exclusive breastfeeding, duration breast feeding, and method of feeding complementary food were independently associated with stunting. Thus, public health intervention working on improving child nutrition should consider these determinants.
doi:10.1186/1471-2458-14-800
PMCID: PMC4131046  PMID: 25098836
Stunting; Children; Factors; Ethiopia
25.  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

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