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issn:1740-86.5
1.  DEVELOPMENT OF THE BREAST MILK EXPRESSION EXPERIENCE MEASURE 
Maternal & child nutrition  2012;9(3):425-430.
Introduction
Exclusive breastfeeding provides optimal nutrition through 6 months. Recent research has shown that milk expression may affect breastfeeding duration. A woman’s experience with milk expression might mediate the effect of milk expression on breastfeeding duration. The objective of this study is to develop a measure to evaluate women’s experiences of expressing milk.
Methods
Based on available literature, we developed a brief measure of the Breast Milk Expression Experience (BMEE) assessing 3 dimensions: 1) social support for milk expression, 2) ease of learning how to express milk, and 3) personal experiences of milk expression. All items used 1–5 Likert scales, with higher scores indicating better experiences. We administered the items immediately after expression to 68 mothers who expressed milk postpartum. We evaluated this measure for reliability using Cronbach’s alpha.
Results
Mothers completing the BMEE were 57% primiparous with 75% vaginal births. The BMEE demonstrated appropriate reliability with a Cronbach’s alpha of 0.703 for the summary index and 0.719–0.763 for social support, learning experience and personal experience subscales. The BMEE also indicated good predictive validity; of the 6 mothers who had a mean score <3 on the 11-item scale postpartum, 2 (33.3%) were expressing breast milk at 1 month, compared with 37 (80.4%) of the 46 mothers who had a mean score ≥3 on the 11-item scale postpartum (p=0.012).
Conclusions
The BMEE is a promising measure of milk expression experience in this population. Use of this measure may allow improved understanding of women’s experiences expressing milk.
doi:10.1111/j.1740-8709.2011.00390.x
PMCID: PMC3350756  PMID: 22236401
Breastfeeding; lactation; breast milk expression; Breastfeeding Duration; Breastfeeding Knowledge; Breastfeeding Support
2.  Use of Food Labels, Awareness of Nutritional Programs and Participation in the Special Supplemental Program for Women, Infants and Children (WIC): Results from the National Health and Nutrition Examination Survey (2005-6) 
Maternal & child nutrition  2011;9(3):299-308.
Background
Use of nutritional labels in choosing food is associated with healthier eating habits including lower fat intake. Current public health efforts have focused on the revamping of nutritional labels to make them easier to read and use for the consumer.
Objectives
To assess the frequency of use of nutritional labels and awareness of the United States Department of Agriculture (USDA) nutritional programs by women eligible and participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as surveyed in the National Health and Nutrition Examination Survey (NHANES) 2005-6 .
Results
Many low-income women do not regularly use the nutrition facts panel information on the food label and less than half had heard of the United States Department of Agriculture’s (USDA) Dietary Guidelines for Americans (38.9%). In multivariate logistic regression, we found that WIC participation was associated with reduced use of the nutrition facts panel in choosing food products (OR 0.45, 95%CI 0.22-0.91), the health claims information (OR 0.54, 95%CI 0.32-0.28) and the information on carbohydrates when deciding to buy a product (OR 0.44, 95%CI 0.20-0.97) in comparison with WIC eligible non-participants.
Conclusions
Any intervention to improve use of nutritional labels and knowledge of the USDA’s nutritional programs needs to target low-income women, including WIC participants. Future studies should evaluate possible reasons for the low use of nutrition labels among WIC participants.
doi:10.1111/j.1740-8709.2011.00382.x
PMCID: PMC4008321  PMID: 22171961
3.  Effect of multivitamin supplements on weight gain during pregnancy among HIV-negative women in Tanzania 
Maternal & child nutrition  2012;10.1111/mcn.12018.
Multivitamin supplementation has been shown to reduce the risk of low birthweight. This effect could be mediated through gestational weight gain. However, the effect of multivitamin supplementation on weight gain during pregnancy has not been fully studied. The objective of this study was to examine the effects of multivitamins on pregnancy weight gain. We enrolled 8468 HIV-negative women from Dar es Salaam, Tanzania, in a randomised, placebo-controlled trial of multivitamins on birth outcomes. Women were randomly assigned to receive either a daily oral dose of multivitamin tablets or a placebo and were weighed every 4 weeks from enrolment until the last visit before delivery. Intent-to-treat analyses were carried out to examine the effects of multivitamins on pregnancy weight gain. Multivariate linear and binomial regression models with the log-link function were used to examine the association of weight gain during pregnancy to birthweight. The overall total weight gain was 253 g (SE: 69, P: 0.0003) more, while the overall 4 weekly weight gain was 59 g greater (SE: 18, P: 0.005) among women who received multivitamins compared to placebo. Women in the lowest quartile of gestational weight gain had babies with an average birthweight of 3030 g (SD: 524), while women in the highest quartile had babies weighing 3246 g (SD: 486), on average. Prenatal multivitamin supplements increased gestational weight gain, which was a significant predictor of birthweight.
doi:10.1111/mcn.12018
PMCID: PMC3874066  PMID: 23253638
weight; pregnancy; multivitamins; birthweight; Africa
4.  Acculturative type is associated with breastfeeding duration among low-income Latinas 
Maternal & child nutrition  2011;9(2):188-198.
Objective
We sought to assess the relationship between acculturative type and breastfeeding outcomes among low-income Latinas, utilizing a multidimensional assessment of acculturation.
Methods
We analyzed data derived from a breastfeeding peer counseling randomized trial. Acculturation was assessed during pregnancy using a modified ASRMA-II scale. Analyses were restricted to Latinas who completed the acculturation scale and had postpartum breastfeeding data (N=114). Cox survival analyses were conducted to evaluate differences in breastfeeding continuation and exclusivity by acculturative type.
Results
Participants were classified as integrated-high (23.7%, n=27), traditional Hispanic (36.8%, n=42), integrated-low (12.3%, n=14) and assimilated (27.2%, n=31). The integrated-low group was significantly more likely to continue breastfeeding than the Traditional Hispanic, Assimilated, and Integrated-high groups (p<0.05, p<0.05, and p<0.01, respectively). The Traditional Hispanic group was marginally more likely to continue breastfeeding than the integrated-high group (p=0.06).
Conclusions
Breastfeeding continuation rates vary significantly between acculturative types in this multinational, low-income Latina sample. Multidimensional assessments of acculturation may prove useful in better tailoring future breastfeeding promotion interventions.
doi:10.1111/j.1740-8709.2011.00344.x
PMCID: PMC3275689  PMID: 21787375
5.  Trends in Breastfeeding: It’s Not Only at the Breast Anymore 
Maternal & child nutrition  2012;9(2):180-187.
Background
The past characterizations of breastfeeding as being only at the breast of the mother may no longer be applicable in the United States as mothers now frequently express their milk.
Methods
We conducted a retrospective cohort study with women who visited the Cincinnati Children’s Breastfeeding Medicine Clinic to understand breast milk feeding behaviors of healthy mothers and infants that included questions specifically about breast milk expression.
Results
All 40 mothers in the cohort expressed their milk and all 40 infants were fed expressed milk. One infant was fed another mother’s milk for 30 days. Two-thirds (13/40) of infants received their mother’s expressed milk at least a week after it was first expressed and 25% (10/40) of infants continued to be fed expressed breast milk after mothers had stopped expressing milk. There were 14 sequences of breast milk production by the mothers and 16 sequences of consumption by the infants. Early in the postpartum period, mothers started expressing milk even though their infants were consuming all of the breast milk that they needed at the breast.
Conclusions
As a result of breast milk expression by all mothers in this cohort, we observed highly variable patterns of maternal breast milk production and infant breast milk consumption, which were not necessarily synchronous within a dyad. It is now time to develop appropriate ways to characterize the production and consumption of breast milk more accurately and investigate whether these behaviors have consequences for the health of mothers and infants.
doi:10.1111/j.1740-8709.2012.00416.x
PMCID: PMC3448825  PMID: 22625407
human milk; breastfeeding; breast milk pumping; breast milk expression
6.  Weighing worth against uncertain work: The interplay of exhaustion, ambiguity, hope and disappointment in mothers breastfeeding late preterm infants 
Maternal & child nutrition  2012;10.1111/j.1740-8709.2012.00463.x.
Poor breastfeeding outcomes among late preterm infants (LPIs) have been attributed to inadequate breast milk transfer stemming from physiological immaturities. However, breastfeeding is more than a biological phenomenon, and it is unclear how mothers of LPIs manage other factors that may also impact the breastfeeding course. Using grounded theory methods and incorporating serial postpartum interviews with several novel data collection techniques, we examined breastfeeding establishment over a 6–8 week period among 10 late preterm mother-infant dyads recruited from a maternity hospital in Pittsburgh, Pennsylvania, USA. We found that breastfeeding in the LPI population was a fluctuating, cascade-like progression of trial and error, influenced by a host of contextual factors and events and culminating with breastfeeding continuation (with or without future caveats for duration or exclusivity of breastfeeding) or cessation. The trajectory was explained by the basic psychosocial process Weighing Worth against Uncertain Work, which encompassed the tension between breastfeeding motivation, the intensity of breastfeeding work, and ambiguity surrounding infant behavior and feeding cues. Several sub-processes were also identified: Playing the Game; Letting Him be the Judge vs. Accommodating Both of Us; and Questioning Worth vs. Holding out Hope. If valid, our theoretical model indicates a need for earlier, more extensive, and more qualified breastfeeding support for mothers of late preterm infants that emphasizes the connection between prematurity and observed feeding behaviors.
doi:10.1111/j.1740-8709.2012.00463.x
PMCID: PMC3535546  PMID: 23020593
late preterm; premature infant; breastfeeding; lactation; models; theoretical; qualitative research
7.  The Health of HIV-exposed Children after Early Weaning 
Maternal & child nutrition  2011;9(2):217-232.
There are potential health risks associated with the use of early weaning to prevent mother-to-child transmission of HIV in resource-poor settings. Our objective was to examine growth and nutrient inadequacies among a cohort of children weaned early. Children participating in the Breastfeeding Antiretrovirals and Nutrition (BAN) Study in Lilongwe, Malawi, had HIV-infected mothers, were weaned at 6 months and fed LNS until 12 months. 40 HIV-negative, BAN-exited children were compared to 40 HIV-negative, community children matched on age, gender and local health clinic. Nutrient intake was calculated from 24-hour dietary recalls collected from BAN-exited children. Anthropometric measurements were collected from BAN-exited and matched community children at 15-16 months, and 2 months later. Longitudinal random effects sex-stratified models were used to evaluate anthropometric differences between the 2 groups. BAN-exited children consumed adequate energy, protein, and carbohydrates but inadequate amounts of fat. The prevalence of inadequate micronutrient intakes were: 46% for vitamin A; 20% for vitamin B6; 69% for folate; 13% for vitamin C; 19% for iron; 23% for zinc. Regarding growth, BAN-exited girls gained weight at a significantly lower rate (0.02g/kg/day [95%CI: 0.01, 0.03] than their matched comparison (0.05g/kg/day [95%CI: 0.03, 0.07]); BAN girls grew significantly slower (0.73cm/month [95%CI: 0.40,1.06]) than their matched comparison (1.55cm/month [95%CI: 0.98, 2.12]). Among this sample of BAN-exited children, early weaning was associated with dietary deficiencies and girls experienced reduced growth velocity. In resource-poor settings, HIV prevention programs must ensure that breastfeeding stop only once a nutritionally adequate and safe diet without breastmilk can be provided.
doi:10.1111/j.1740-8709.2011.00369.x
PMCID: PMC3787136  PMID: 22099216
LNS; early breastfeeding cessation; HIV; Malawi; child growth
8.  A comparison of infant and toddler feeding practices of mothers with and without histories of eating disorders 
Maternal & child nutrition  2012;10.1111/j.1740-8709.2012.00429.x.
This preliminary study surveyed the feeding practices of mothers with eating disorder histories through evaluation of mothers’ reported feeding styles, child diet composition, and restrictive special approaches to feeding. For this non-randomized cohort study, 25 mothers with eating disorder histories and 25 mothers with no history of an eating disorder with children ages 6–36 months were selected such that the groups were similar based on child age group and child sex. Mothers were compared on self-reported feeding style using the Infant Feeding Styles Questionnaire and on child diet composition and special feeding approaches using a modified version of the Toddler Diet Questionnaire from the Women, Infants, and Children program. Mothers with eating disorder histories scored lower on the restrictive feeding style subscale than controls. No significant differences were detected between groups in child diet including the percentage of mothers who breastfed, duration of breastfeeding, age at solid food introduction, daily number of meals or snacks, or daily frequency of consumption of fruits, vegetables, or protein foods. Mothers with eating disorder histories were more likely to report taking a restrictive special approach to feeding such as limiting processed foods or feeding organic foods only. Although mothers with eating disorder histories may not differ greatly from control mothers in terms of child diet composition (smaller effects may not have been detected due to limited sample size), they may be more likely to take restrictive special approaches to feeding which mirror dietary rules common in individuals with eating disorders.
doi:10.1111/j.1740-8709.2012.00429.x
PMCID: PMC3473145  PMID: 22784046
eating disorders; feeding behavior; maternal behavior; restrictive feeding; infant; toddler
9.  Examination of facilitators and barriers to home-based supplemental feeding with ready-to-use food for underweight children in western Uganda 
Maternal & child nutrition  2010;8(1):10.1111/j.1740-8709.2010.00260.x.
Poor complementary feeding practices and low quality complementary foods are significant causes of growth faltering and child mortality throughout the developing world. Ready-to-use foods (RUF) are energy dense, lipid-based products that do not require cooking or refrigeration, that have been used to prevent and treat malnutrition among vulnerable children. The effectiveness of these products in improving child nutritional status depends on household use by caregivers. To identify the key facilitators and barriers that influence appropriate in-home RUF consumption by supplemental feeding program beneficiaries, we conducted individual interviews among caregivers (n=80), RUF producers (n=8) and program staff (n=10) involved in the Byokulia Bisemeye mu Bantu (BBB) supplemental feeding program in Bundibugyo, Uganda. By documenting caregiver perceptions and feeding practices related to RUF, we developed a conceptual framework of factors that affect appropriate feeding with RUF. Findings suggest that locally produced RUF is well received by caregivers and children, and is perceived by caregivers and the community to be a healthy supplemental food for malnourished children. However, child feeding practices, including sharing of RUF within households, compromise the nutrient delivery to the intended child. Interventions and educational messages informed by this study can help to improve RUF delivery to targeted beneficiaries.
doi:10.1111/j.1740-8709.2010.00260.x
PMCID: PMC3886188  PMID: 22136223
Complementary Feeding; Cultural Context; Ethnographic Methods; Undernutrition; Nutritional Interventions; Food Intake
10.  Cluster-randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth, and development among rural Indian toddlers 
Maternal & child nutrition  2012;9(1):99-117.
Inadequate feeding and care may contribute to high rates of stunting and underweight among children in rural families in India. This cluster-randomized trial tested the hypothesis that teaching caregivers appropriate complementary feeding, and strategies for how to feed and play responsively through home-visits would increase children’s dietary intake, growth, and development compared to home-visit-complementary feeding education alone or routine care. Sixty villages in Andhra Pradesh were randomized into 3 groups1 of 20 villages with 200 mother-infant dyads in each group. The Control Group (CG), received routine Integrated Child Development Services (ICDS); the Complementary Feeding Group (CFG), received the ICDS plus the World Health Organization recommendations on breastfeeding and complementary foods; and the Responsive Complementary Feeding & Play Group (RCF&PG) received the same intervention as the CFG plus skills for responsive feeding and psychosocial stimulation. Both intervention groups received bi-weekly visits by trained village women. The groups did not differ at 3 months on socioeconomic status, maternal and child nutritional indices and maternal depression. After controlling for potential confounding factors using the mixed models approach, the twelve-month intervention to the CFG and RCF&PG significantly (p<0.05) increased median intakes of energy, protein, Vitamin-A, calcium (CFG), iron and zinc, reduced stunting (0.19, CI: 0.0–0.4) in the CFG (but not RCF&PG) and increased (p<0.01) Bayley Mental Development scores(Mean=3.1, CI: 0.8–5.3) in the RCF&PG (but not CFG) compared to CG. Community-based educational interventions can improve dietary intake, length (CFG), and mental development (RCF&PG) for children under two years in food-secure rural Indian families.
doi:10.1111/j.1740-8709.2012.00413.x
PMCID: PMC3434308  PMID: 22625182
feeding methods; responsive complementary feeding; toddler; growth and development
11.  Trade-offs underlying maternal breastfeeding decisions: A conceptual model 
Maternal & child nutrition  2011;9(1):90-98.
This paper presents a new conceptual model that generates predictions about breastfeeding decisions and identifies interactions that affect outcomes. We offer a contextual approach to infant feeding that models multi-directional influences by expanding on the evolutionary parent–offspring conflict and situation-specific breastfeeding theories. The main hypothesis generated from our framework suggests that simultaneously addressing breastfeeding costs and benefits, in relation to how they are interpreted by mothers, will be most effective. Our approach focuses on contributors to the attitudes and commitment underlying breastfeeding outcomes, beginning in the prenatal period. We conclude that some maternal–offspring conflict is inherent with the dynamic infant feeding relationship. Guidance that anticipates and addresses family trade-offs over time can be incorporated into breastfeeding support for families.
doi:10.1111/j.1740-8709.2011.00378.x
PMCID: PMC3746010  PMID: 22188564
breastfeeding; breastfeeding support; evolution; infant feeding decisions; multidisciplinary approaches; research methodology
12.  Heightened attention to supplementation is needed to improve the vitamin D status of breastfeeding mothers and infants when sunshine exposure is restricted 
Maternal & child nutrition  2012;10.1111/j.1740-8709.2012.00422.x.
Although exclusively breastfed infants are at increased risk of vitamin D (vit D) deficiency if vit D supplementation is lacking and sun exposure is limited, assessment of both risk factors in the first year of life is lacking. We evaluated contribution of vit D intake and sunlight exposure to vit D status in 120 healthy, breastfeeding mother-infant dyads, who were followed for 1 year. Vitamin D intake and skin sunlight exposure were evaluated using questionnaires. Serum 25(OH)D, PTH and ALP levels were determined postnatally in mothers at 4 weeks and in infants at 4, 26 and 52 weeks. Vitamin D supplementation was low (<20%) and sunlight exposure was common (93%) in study infants. At 4 weeks, 17% of mothers were vit D deficient (<50 nmol/L) and 49% were insufficient (50-<75 nmol/L), while 18% of infants were severely vit D deficient (<25 nmol/L) and 77% were deficient (<50 nmol/L). At 26 weeks, winter/spring birth season and shorter duration of months of exclusive breastfeeding were protective of vit D deficiency in infants. Vitamin D deficiency in infants decreased to 12% at 52 weeks with sunlight exposure. Serum PTH levels were significantly higher in severely vit D deficient than sufficient infants. Vitamin D deficiency was widespread in early postpartum breastfeeding mothers and infants and declined to 1 in 8 infants at 52 weeks due mostly to sunshine exposure. When sunlight exposure is limited or restricted intensified vit D supplementation of breastfeeding mothers and infants is needed to improve vit D status.
doi:10.1111/j.1740-8709.2012.00422.x
PMCID: PMC3461108  PMID: 22708508
Vitamin D deficiency; breastfeeding; sunlight exposure; infants; mothers
13.  Fatty acid composition in the mature milk of Bolivian forager-horticulturalists: controlled comparisons with a US sample 
Maternal & child nutrition  2012;8(3):10.1111/j.1740-8709.2012.00412.x.
Breast milk fatty acid (FA) composition varies greatly among individual women, including in percentages of the long-chain polyunsaturated FAs (LCPUFA) 20:4n-6 (arachidonic acid, AA) and 22:6n-3 (docosahexaenoic acid, DHA), which are important for infant neurological development. It has been suggested that owing to wide variation in milk LCPUFA and low DHA in Western diets, standards of milk FA composition should be derived from populations consuming traditional diets. We collected breast milk samples from Tsimane women at varying lactational stages (6–82 weeks). The Tsimane are an indigenous, natural fertility, subsistence-level population living in Amazonia Bolivia. Tsimane samples were matched by lactational stage to samples from a US milk bank, and analysed concurrently for FA composition by gas-liquid chromatography. We compared milk FA composition between Tsimane (n = 35) and US (n = 35) mothers, focusing on differences in LCPUFA percentages that may be due to population-typical dietary patterns. Per total FAs, the percentages of AA, DHA, total n-3 and total n-6 LCPUFA were significantly higher among Tsimane mothers. Mean percentages of 18:2n-6 (linoleic acid) and trans FAs were significantly higher among US mothers. Tsimane mothers’ higher milk n-3 and n-6 LCPUFA percentages may be due to their regular consumption of wild game and freshwater fish, as well as comparatively lower intakes of processed foods and oils that may interfere with LCPUFA synthesis.
doi:10.1111/j.1740-8709.2012.00412.x
PMCID: PMC3851016  PMID: 22624983
lactation; diet; docosahexaenoic acid; arachidonic acid; breast milk; infant and child nutrition
14.  Infant Difficulty and Early Weight Gain: Does Fussing Promote Overfeeding? 
Maternal & child nutrition  2012;10.1111/j.1740-8709.2012.00410.x.
Objective
Authors have recently suggested that difficult temperament in infancy may be associated with rapid weight gain, but none of the previous studies actually report associations between temperament and feeding as a response to infant distress. The purpose of the present study was to examine whether greater infant difficulty elicits more feeding, which in turn leads to more rapid weight gain in early infancy.
Methods
Mother-infant pairs (N=154) were visited at 3- and 6-months in their homes. Besides anthropometric measures, mothers kept a 24-hour diary of their infants’ sleep, cry, and feed patterns, and answered questions regarding feeding and infant difficultness.
Results
Feeding occurred as a response to nearly half (48%) of the crying intervals recorded, though it more often occurred in the absence of crying (83%). Mothers were most likely to report holding or rocking their infant as the first strategy they would employ if their baby fussed or cried. A regression analysis that included crying, feeding, weaning, sleep and infant weight revealed maternal reports of numbers of feeds per day as the only variable that predicted weight gain from 3-6 months.
Conclusion
Infant crying is often followed by feeding, and more frequent feeding may promote more rapid weight gain. However, feeding frequency in the first few months appears to be more a matter of maternal discretion than a yoked response to temperamental difficulty. This does not preclude the possibility that overfeeding in later infancy could be tied to temperamental difficulty and subsequently related to overweight in early childhood.
doi:10.1111/j.1740-8709.2012.00410.x
PMCID: PMC3424391  PMID: 22591002
15.  Maternal autonomy is inversely related to child stunting in Andhra Pradesh, India 
Maternal & child nutrition  2009;5(1):10.1111/j.1740-8709.2008.00161.x.
Child stunting, an outcome of chronic undernutrition, contributes to poor quality of life, morbidity and mortality. In South Asia, the low status of women is thought to be one of the primary determinants of undernutrition across the lifespan. Low female status can result in compromised health outcomes for women, which in turn are related to lower infant birthweight and may affect the quality of infant care and nutrition. Maternal autonomy (defined as a woman’s personal power in the household and her ability to influence and change her environment) is likely an important factor influencing child care and ultimately infant and child health outcomes. To examine the relationship between maternal autonomy and child stunting in Andhra Pradesh, India, we analysed data from National Family Health Survey (NFHS)-2. We used cross-sectional demographic, health and anthropometric information for mothers and their oldest child <36 months (n = 821) from NFHS-2. The main explanatory variables of autonomy are presented by four dimensions – decision making, permission to travel, attitude towards domestic violence and financial autonomy – constructed using seven binary variables. Logistic regression models were used to test associations between indicators of female autonomy and the risk of having a stunted child. Women with higher autonomy {indicated by access to money [odds ratio (OR) = 0.731; 95% confidence interval (CI) 0.546, 0.981] and freedom to choose to go to the market [OR = 0.593; 95% CI 0.376, 0.933]} were significantly less likely to have a stunted child, after controlling for household socio-economic status and mother’s education. In this south Indian state, two dimensions of female autonomy have an independent effect on child growth, suggesting the need for interventions that increase women’s financial and physical autonomy.
doi:10.1111/j.1740-8709.2008.00161.x
PMCID: PMC3811039  PMID: 19161545
child stunting; maternal autonomy; India
16.  Pregravid body mass index, psychological factors during pregnancy, and breastfeeding duration: is there a link? 
Maternal & child nutrition  2011;8(4):423-433.
Breastfeeding rates in the U.S. are low and one possible reason may be the high prevalence of overweight/obesity among women of childbearing age. This analysis examined the association between pregravid body mass index (BMI) and breastfeeding duration and explored whether depressive symptoms, perceived stress and anxiety during pregnancy mediated this relationship. Participants (n = 550) in the Pregnancy, Infection, and Nutrition Postpartum Study were recruited through prenatal clinics prior to 20 weeks gestation and followed to 12 months postpartum. Duration of any breastfeeding was categorized as: none, less than 4 months, 4 to 6 months, 7 to 12 months, and more than 12 months (referent). Exclusive breastfeeding was categorized as less than 1 month, 1 to less than 4 months, and 4 months or more (referent). Being overweight/obese before pregnancy (35.7% of 550) was inversely associated with the durations of any and exclusive breastfeeding. Women who entered pregnancy overweight or obese were more likely to not initiate breastfeeding [RRR =5.39 (95% CI: 2.41, 12.04)] and to breastfeed less than four months [RRR = 2.38 (1.33, 4.27)] compared to women of normal weight status. Among women who initiated breastfeeding, being overweight or obese versus normal weight was related to exclusively breastfeeding less than 1 month [RRR = 2.09 (1.24, 3.51)]. We did not find evidence to support mediation by depressive symptoms, perceived stress or anxiety during pregnancy. Future research needs to explore the reasons behind the association between overweight/obesity and breastfeeding duration.
doi:10.1111/j.1740-8709.2011.00335.x
PMCID: PMC3329574  PMID: 21951308
Overweight; obesity; pregravid BMI; pregnancy; breastfeeding duration; depressive symptoms; stress; anxiety
17.  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
18.  Identifying priorities to improve maternal and child nutrition among the Khmu ethnic group, Laos: a formative study 
Maternal & child nutrition  2012;9(4):452-466.
Chronic malnutrition in children remains highly prevalent in Laos, particularly among ethnic minority groups. There is limited knowledge of specific nutrition practices among these groups. We explored nutritional status, cultural beliefs and practices of Laos’ Khmu ethnic group to inform interventions for undernutrition as part of a Primary Health Care (PHC) project. Mixed methods were used. For background, we disaggregated anthropometric and behavioural indicators from Laos’ Multiple Indicator Cluster Survey. We then conducted eight focus group discussions and 33 semi-structured interviews with Khmu villagers and health care workers, exploring beliefs and practices related to nutrition.The setting was two rural districts in Luang Prabang province, in one of which the PHC project had been established for 3 years. There was a higher prevalence of stunting in the Khmu than in other groups. Disaggregation showed nutrition behaviours were associated with ethnicity, including exclusive breastfeeding. Villagers described strong adherence to post-partum food restrictions for women, while little change was described in intake during pregnancy. Most children were breastfed, although early introduction of pre-lacteal foods was noted in the non-PHC district. There was widespread variation in introduction and diversity of complementary foods. Guidance came predominantly from the community, with some input from health care workers. Interventions to address undernutrition in Khmu communities should deliver clear, consistent messages on optimum nutrition behaviours. Emphasis should be placed on dietary diversity for pregnant and post-partum mothers, encouraging exclusive breastfeeding and timely, appropriate complementary feeding. The impact of wider governmental policies on food security needs to be further assessed.
doi:10.1111/j.1740-8709.2012.00406.x
PMCID: PMC3496764  PMID: 22515273
beliefs; child feeding; community based; education; Laos; Khmu; maternal nutrition
19.  Relationship between the nutritional status of breast-feeding Mayan mothers and their infants in Guatemala 
Maternal & child nutrition  2012;10.1111/j.1740-8709.2012.00404.x.
Objective
A case-control study was conducted to determine the association between maternal height and infant length-for-age and to evaluate how this association is modified by either maternal or infant nutritional status. We hypothesized that maternal excess caloric intake (measured as BMI) would increase the association while infant nutrition (measured in main meals consumed in addition to breast feeding) will diminish the effect.
Methods
Mother and infant pairs in Chimaltenango, Guatemala were measured for anthropometric values and nutritional status, and mothers were interviewed to elicit nutritional and socio-economic information. Infant length was converted into z-scores based on the World Health Organization's (WHO) standards. Odds ratios (OR), associated 95% confidence intervals (CIs) and the relative excess risk due to interaction (RERI) were calculated. Cases were infants below 2 z-scores of the WHO's length-for-age while controls were infants within the -2 to 2 z-score range.
Results
Cases (n=84) had an increased odds (OR 3.00, 95% CI 1.57-5.74) of being born to a stunted mother (below 145 cm) when compared to controls (n=85). When adjusted for potential confounders, the OR decreased to 2.55 (95% CI 1.30-5.02) . Negative RERI values were produced for the joint exposure of maternal BMI ≥25 and maternal stuntedness (RERI -0.96) as well as for the joint exposure of maternal stuntedness and infant nutrition (RERI -2.27).
Conclusion
Our results confirm that maternal stuntedness is a significant contributor to infant stuntedness; however, this association is modified negligibly by maternal nutritional status and significantly by infant nutritional status, each in a protective manner.
doi:10.1111/j.1740-8709.2012.00404.x
PMCID: PMC3390441  PMID: 22462552
stunting; complementary feeding; infant growth; breast-feeding and maternal nutritional status; chronic malnutrition; Guatemala; Mayan populations
20.  Infant Responsiveness, Alertness, Hemoglobin and Growth in Rural Sidama, Ethiopia 
Maternal & child nutrition  2012;10.1111/j.1740-8709.2011.00391.x.
Several recent studies have supported relations between infant behavior (alertness and responsiveness) and nutrition (e.g. Dempsey 2008, Wachs et al 2005) in addition to investigating infant behavior within the context of changes in iron status over time (e.g. Black et al. 2004, Murray-Kolb & Beard 2009). Existing research is typically limited to investigation of the effects of a single vitamin or mineral and no studies have been found that examined the influence that early alertness and responsiveness have on growth in early infancy, despite the fact that relations between behavior and nutritional status may be bidirectional (Hulthén 2003). The current study used a sample of Ethiopian infants and investigated anthropometrics, hemoglobin, the frequency of alertness, and the frequency of responsiveness at 6 and 9 months of age. Six-month weight-for-age predicted 9-month frequency of alertness, while 6-month hemoglobin predicted 9-month frequency of responsiveness. Compared to responsive infants, non-responsive infants at 6 months remained more non-responsive at 9 months, though weight-for-age for both groups converged at 9 months. Results support relations between nutrition and behavior (alertness and responsiveness) and provide evidence of a potentially useful tool (the Laboratory Temperament Assessment Battery [Lab-TAB]) that was adapted to evaluate these relations in Ethiopia.
doi:10.1111/j.1740-8709.2011.00391.x
PMCID: PMC3326179  PMID: 22233352
development; infant growth; hemoglobin; alertness; responsiveness; international nutrition
21.  Postnatal anemia and iron deficiency in HIV-infected women and the health and survival of their children 
Maternal & child nutrition  2012;8(3):287-298.
Prenatal iron supplementation may improve pregnancy outcomes and decrease the risk of child mortality. However, little is known about the importance of postnatal maternal iron status for child health and survival, particularly in the context of HIV infection. We examined the association of maternal anemia and hypochromic microcytosis, an erythrocyte morphology consistent with iron deficiency, with child health and survival in the first two to five years of life. Repeated measures of maternal anemia and hypochromic microcytosis from 840 HIV-positive women enrolled in a clinical trial of vitamin supplementation were prospectively related to child mortality, HIV infection, and CD4 T-cell count. Median duration of follow-up for the endpoints of child mortality, HIV infection and CD4 cell count was 58, 17 and 23 months, respectively. Maternal anemia and hypochromic microcytosis were associated with greater risk of child mortality (HR for severe anemia=2.58, 95% CI: 1.66-4.01, P trend<0.0001; HR for severe hypochromic microcytosis=2.36, 95% CI: 1.27-4.38, P trend=0.001). Maternal anemia was not significantly associated with greater risk of child HIV infection (HR for severe anemia=1.46, 95% CI: 0.91, 2.33, P trend=0.08) but predicted lower CD4 T-cell counts among HIV-uninfected children (difference in CD4 T-cell count/μL for severe anemia:-93, 95% CI: -204-17, P trend=0.02). The potential child health risks associated with maternal anemia and iron deficiency may not be limited to the prenatal period. Efforts to reduce maternal anemia and iron deficiency during pregnancy may need to be expanded to include the postpartum period.
doi:10.1111/j.1740-8709.2011.00389.x
PMCID: PMC3330171  PMID: 22236211
anemia; iron deficiency; postnatal; HIV; child
22.  Breastfeeding and long-chain polyunsaturated fatty acid intake in the first 4 post-natal months and infant cognitive development: an observational study 
Maternal & child nutrition  2011;8(4):471-482.
The aim of this study was to examine infant feeding and the long-chain polyunsaturated fatty acid (LCPUFA) concentration of breast milk and formulas in relation to infant development. The prospective Pregnancy, Infection and Nutrition Study (n = 358) collected data on breastfeeding, breast milk samples and the formulas fed through 4 months post-partum. At 12 months of age, infants’ development was assessed (Mullen Scales of Early Learning). Linear regression was used to examine development in relation to breastfeeding, breast milk docosahexaenoic acid (DHA) and arachidonic acid (AA) concentration, and DHA and AA concentration from the combination of breast milk and formula. The median breast milk DHA concentration was 0.20% of total fatty acids [interquartile range (IQR) = 0.14, 0.34]; median AA concentration was 0.52% (IQR = 0.44, 0.63). Upon adjustment for preterm birth, sex, smoking, race and ethnicity and education, breastfeeding exclusivity was unrelated to development. Among infants exclusively breastfed, breast milk LCPUFA concentration was not associated with development (Mullen composite, DHA: adjusted β = −1.3, 95% confidence interval: −10.3, 7.7). Variables combining DHA and AA concentrations from breast milk and formula, weighted by their contribution to diet, were unassociated with development. We found no evidence of enhanced infant development related to the LCPUFA content of breast milk or formula consumed during the first four post-natal months.
doi:10.1111/j.1740-8709.2011.00326.x
PMCID: PMC3617566  PMID: 21615865
arachidonic acid; breast milk; docosahexaenoic acid; infant feeding; polyunsaturated fatty acids; breastfeeding
23.  Household food insecurity is associated with depressive symptoms among low-income pregnant Latinas 
Maternal & child nutrition  2010;7(4):421-430.
Latinas experience high rates of poverty, household food insecurity, and prenatal depression. To date, only one U.S. study has examined the relationship between household food insecurity and prenatal depression, yet it focused primarily on non-Latina white and non-Latina Black populations. Therefore, this study examined the independent association of household food insecurity with depressive symptoms among low-income pregnant Latinas. This cross-sectional study included 135 low income pregnant Latinas living in Hartford, Connecticut. Women were assessed at enrollment for household food security during pregnancy using an adapted and validated version of the U.S. Household Food Security Survey Module. Prenatal depressive symptoms were assessed using the Center for Epidemiological Studies Depression Scale (CES-D). A cutoff of ≥ 21 was used to indicate elevated levels of prenatal depressive symptoms (EPDS). Multivariate backwards stepwise logistic regression was used to identify risk factors for EPDS. Almost one third of participants had EPDS. Women who were food insecure were more likely to experience EPDS compared to food secure women (OR=2.59; 95% CI=1.03–6.52). Being primiparous, experiencing heartburn and reporting poor/fair health during pregnancy, as well as having a history of depression were also independent risk factors for experiencing EPDS. Findings from this study suggest the importance of assessing household food insecurity when evaluating depression risk among pregnant Latinas.
doi:10.1111/j.1740-8709.2010.00266.x
PMCID: PMC3008302  PMID: 20735732
24.  Predictors of breastfeeding cessation among HIV-infected women in Dar es Salaam,Tanzania 
Maternal & child nutrition  2010;7(3):273-283.
This paper examines predictors of breastfeeding cessation among a cohort of human immunodeficiency virus (HIV)-infected women. This was a prospective follow-up study of HIV-infected women who participated in a randomized micronutrient supplementation trial conducted in Dar es Salaam, Tanzania. 795 HIV-infected Tanzanian women with singleton newborns were utilized from the cohort for this analysis. The proportion of women breastfeeding declined from 95% at 12 months to 11% at 24 months. The multivariate analysis showed breastfeeding cessation was significantly associated with increasing calendar year of delivery from 1995 to 1997 [risk ratio (RR), 1.36; 95% confidence interval (CI) 1.13–1.63], having a new pregnancy (RR 1.33; 95% CI 1.10–1.61), overweight [body mass index (BMI) ≥25 kg m−2; RR 1.37; 95% CI 1.07–1.75], underweight (BMI <18.5 kg m−2; RR 1.29; 95% CI 1.00–1.65), introduction of cow’s milk at infant’s age of 4 months (RR 1.30; 95% CI 1.04–1.63). Material and social support was associated with decreased likelihood of cessation (RR 0.83; 95% CI 0.68–1.02). Demographic, health and nutritional factors among women and infants are associated with decisions by HIV-infected women to cease breastfeeding. The impact of breastfeeding counselling programs for HIV-infected African women should consider individual maternal, social and health contexts.
doi:10.1111/j.1740-8709.2009.00236.x
PMCID: PMC3366265  PMID: 21689270
cessation; breastfeeding; HIV; pregnancy; social support
25.  Maternal knowledge of infant feeding guidelines and label reading behaviours in a population of new mothers in San Francisco, California 
Maternal & child nutrition  2009;5(3):223-233.
The objective of this study was to evaluate the relationship between maternal nutrition knowledge and maternal socio-demographics including participation in the Special Supplemental Women, Infants and Children’s (WIC) Program. A cross-sectional study of new mothers at two San Francisco hospitals was conducted using some of the American Academy of Pediatrics’ guidelines in a structured questionnaire to assess maternal nutritional knowledge. Maternal nutritional attitudes towards product nutrient labels were also assessed in a questionnaire format. Logistic regression models were used to evaluate the odds of having high maternal nutrition knowledge and of infrequently reading nutrition labels. In multivariate logistic regression models, higher maternal nutrition knowledge (defined as answering all four nutrition questions correctly) was associated with higher income levels defined as ≥$25 000/year, odds ratio (OR) 10.03 95% confidence interval (CI) (1.51–66.74), and in linear models, higher nutritional knowledge was associated with having more children (P < 0.01), a higher income (P = 0.01) and not being a WIC participant (P < 0.01). Mothers with higher incomes were also more likely to read product nutritional labels OR 4.24, 95% CI (1.24–14.51), compared with mothers with lower incomes as were mothers with higher education levels OR 3.32, 95% CI (1.28–8.63). In San Francisco, lower income mothers are at greatest risk for low maternal nutrition knowledge and not reading product nutritional labels. Higher household income was independently associated with increased maternal nutrition knowledge and likelihood of reading nutritional labels. More comprehensive interventions need to target low-income mothers including current WIC participants to help close the nutritional advantages gap conferred by income and education.
doi:10.1111/j.1740-8709.2009.00181.x
PMCID: PMC3252047  PMID: 19888918
maternal nutrition knowledge; nutrient labels; WIC Program

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