Infant Feeding And Weight Gain: Separating Breast Milk From .
Infant Feeding and Weight Gain:Separating Breast Milk FromBreastfeeding and Formula From FoodMeghan B. Azad, PhD, a, b, c Lorena Vehling, MSc, a, b Deborah Chan, RN, a, b Annika Klopp, MD, a, b Nathan C.Nickel, PhD, b, d Jonathan M. McGavock, PhD, a, b Allan B. Becker, MD, a, b Piushkumar J. Mandhane, MD, eStuart E. Turvey, MD, f, g Theo J. Moraes, MD, h Mark S. Taylor, PhD, c, i Diana L. Lefebvre, PhD, jMalcolm R. Sears, MB, j Padmaja Subbarao, MD, h on behalf of the CHILD Study InvestigatorsOBJECTIVES: Studies addressing breastfeeding and obesity rarely document the method ofbreast milk feeding, type of supplementation, or feeding in hospital. We investigated thesepractices in the CHILD birth cohort.abstractMETHODS: Feeding was reported by mothers and documented from hospital records. Weightand BMI z scores (BMIzs) were measured at 12 months. Analyses controlled for maternalBMI and other confounders.RESULTS: Among 2553 mother-infant dyads, 97% initiated breastfeeding, and the medianbreastfeeding duration was 11.0 months. Most infants (74%) received solids before 6months. Among “exclusively breastfed” infants, 55% received some expressed breast milk,and 27% briefly received formula in hospital. Compared with exclusive direct breastfeedingat 3 months, all other feeding styles were associated with higher BMIzs: adjusted β: .12(95% confidence interval [CI]: .01 to .23) for some expressed milk, .28 (95% CI: .16 to .39)for partial breastfeeding, and .45 (95% CI: .30 to .59) for exclusive formula feeding.Brief formula supplementation in hospital did not alter these associations so long asexclusive breastfeeding was established and sustained for at least 3 months. Formulasupplementation by 6 months was associated with higher BMIzs (adjusted β: .25; 95% CI:.13 to .38), whereas supplementation with solid foods was not. Results were similar forweight gain velocity.CONCLUSIONS: Breastfeeding is inversely associated with weight gain velocity and BMI. Theseassociations are dose dependent, partially diminished when breast milk is fed from a bottle,and substantially weakened by formula supplementation after the neonatal period.Departments of aPediatrics and Child Health and dCommunity Health Sciences, Manitoba Centre for HealthPolicy, University of Manitoba, Winnipeg, Canada; bDevelopmental Origins of Chronic Diseases in ChildrenNetwork (DEVOTION), Children’s Hospital Research Institute of Manitoba, Winnipeg, Canada; cLondon Schoolof Hygiene and Tropical Medicine, University of London, London, United Kingdom; eDepartment of Pediatrics,University of Alberta, Edmonton, Canada; fDepartment of Pediatrics, Child and Family Research Institute andBritish Columbia Children’s Hospital, Vancouver, Canada; gDepartment of Pediatrics, University of BritishColumbia, Vancouver, Canada; hDepartment of Pediatrics, Hospital for Sick Children and University of Toronto,Toronto, Canada; iDepartment of Public Health, Faculty of Health Care and Social Work, University of Trnava,Trnava, Slovakia; and jDepartment of Medicine, McMaster University, Hamilton, CanadaDr Azad conceptualized and designed the study, performed statistical analyses, drafted the initialmanuscript, reviewed and revised the manuscript, and this work was undertaken in partialfulfillment of her MSc in Epidemiology at the London School of Hygiene and Tropical Medicine; MsVehling created the infant feeding variables and reviewed the manuscript; Ms Chan performedhospital chart reviews to validate hospital feeding data and reviewed the manuscript; Dr Kloppcreated the infant feeding mode variable and reviewed the manuscript; Dr Nickel conceptualizedWHAT’S KNOWN ON THIS SUBJECT: Breastfeeding hasbeen inconsistently associated with lower obesity risk.Most studies do not distinguish between feeding at thebreast and consuming bottled breast milk or betweensupplementation with formula versus foods, and fewaccount for feeding in hospital.WHAT THIS STUDY ADDS: In the Canadian CHILD birthcohort, breastfeeding was inversely associatedwith weight gain velocity, BMI, and overweight riskduring infancy. This association was dose dependent,diminished with formula supplementation, and weakerwhen breast milk was fed from a bottle.To cite: Azad MB, Vehling L, Chan D, et al. Infant Feeding andWeight Gain: Separating Breast Milk From Breastfeedingand Formula From Food. Pediatrics. 2018;142(4):e20181092Downloaded from www.aappublications.org/news by guest on September 27, 2018PEDIATRICS Volume 142, number 4, October 2018:e20181092ARTICLE
Obesity is a major public healthchallenge worldwide, 1 and it isrooted in early life. 2 Rapid weightgain during infancy is an establishedobesity risk factor, 3 and excess bodyweight tracks from infancy intochildhood 4 and adulthood.5Breastfeeding has many establishedbenefits for maternal and child health, 6but its impact on obesity is unclear.In a meta-analysis of 113 studies,it was found that breastfed infantshave a 26% reduced risk of obesitylater in life 7; however, considerableheterogeneity was observed, andthe association was attenuatedamong high-quality studies. Asidefrom methodological differences,inconsistent findings may reflectdifferences in the way breastfeedingis defined, 8, 9 measured, or practicedin different settings, but thesedifferences are rarely documented.In most studies, researchers typicallydo not distinguish between directbreastfeeding (at the breast) andconsumption of expressed breastmilk (from a bottle) or betweensupplementation with formula versusother complementary foods, and fewaccount for early feeding exposuresin hospital. These are importantdistinctions because expressing andstoring breast milk could reduce itsbioactivity, 10 feeding from a bottle maydiscourage self-regulation, 11 and evenbrief formula supplementation couldpotentially alter the developing gutmicrobiota and influence weight gain. 12In a large prospective birth cohort,we characterized the association ofbreastfeeding, infant weight gain, andbody composition in the first year oflife and further assessed the impactof feeding method, type and timing ofcomplementary feeding, and formulasupplementation during the neonatalperiod.METHODSStudy PopulationPregnant women were enrolled in theCanadian Healthy Infant Longitudinal2TABLE 1 Infant Feeding Exposure Variables in the CHILD Birth CohortExposure VariableDefinition and CategoriesBF exclusivity at3 mo No BF (formula only) Partial BF (breast milk supplemented with formula) Exclusive BF after hospital (received some formula in hospital but only breastmilk after discharge) Exclusive BFa (breast milk only, both in hospital and after discharge)BF mode at 3 mo No BF (formula only) Partial BF with formula (direct or expressed breast milk and formula) BF only, some expressed (has received some breast milk expressed with apump but no formula) BF only, all directa (no expressed milk or formula since hospital discharge)BF exclusivity at6 moCategorized in 6 groups according to BF status and type of complementaryfeeding; collapsed into 4 groups for regression modeling No BF: formula only, or formula plus solid food Partial BF with formula: breast milk plus formula, or breast milk plusformula plus solid food Partial BF without formula: breast milk plus solid food Exclusive BFa: breast milk only, with no formula or solid foodIntroduction ofsolid foodsAge of infant at first introduction of solid (or semisolid) foods, in moEvaluated as a continuous variable (for covariate adjustment) or categorized in4 groups for regression modeling: 4, 4 to 5, 5 to 6, 6a moDuration of any BFAge of infant at weaning, determined from the first reported date of breastfeedingcessation. For breastfed infants with no reported cessation date becauseof skipped questionnaires (N 367), the minimum confirmed breastfeedingduration was used. Evaluated as a continuous variable (for covariateadjustment) or categorized in 5 groups for regression modeling: neverbreastfed, 3, 3 to 6, 6 to 12, 12a moDuration ofexclusive BFAge of infant at first introduction to formula, nonhuman milk, juice, or solid foods,in mo. Water and vitamin supplements were not considered. Evaluated as acontinuous variable or categorized in 5 groups: never, 2, 2 to 4, 4 to 6, 6 moaBF, breastfeeding.a Reference categories for regression modeling, selected according to WHO recommendations. 14Development (CHILD) birth cohort(www. childstudy. ca) between 2009and 2012. 13 Infants born before38 0 weeks or missing gestationalage or anthropometric data wereexcluded from the current analysis(Supplemental Fig 3). This study wasapproved by the Human ResearchEthics Boards at the University ofLondon, McMaster University, andthe Universities of Manitoba, Alberta,Toronto, and British Columbia.Infant Feeding ExposuresSubsequent feeding was reportedby mothers at 3, 6, 12, 18, and 24months postpartum, including thefollowing: breastfeeding initiationand cessation, feeding of expressedbreast milk, use of formula, otherfluids, and foods. The end of exclusivebreastfeeding was defined as theintroduction of any formula, food,juice, or nonhuman milk. Waterand vitamin supplements were notconsidered.Feeding exposures are summarizedin Table 1. Feeding in hospitalwas recorded by nursing staffand validated by chart review forManitoba participants with availablehospital records (N 847), revealingstrong agreement for breastfeeding(98.3% agreement) and formulasupplementation (87.6%).The primary outcome was BMIz score. In large cohort studies,researchers have demonstratedits equivalence or superiority asa predictor of childhood obesity,compared with weight-for-length. 4Secondary outcomes includedoverweight, weight gain velocity,and rapid weight gain. Weight andAnthropometric OutcomesDownloaded from www.aappublications.org/news by guest on September 27, 2018AZAD et al
length were recorded at birth bynurses and at 12 months (mean:12.5 1.5 months) by CHILD staff,following a standardized protocol.Sex-specific weight-for-age (WFA)and BMI-for-age z scores werecalculated according to the WorldHealth Organization (WHO) ChildGrowth reference. 15 BMI z score wasdichotomized to define overweight(z score 2). 16 Weight gain velocitywas calculated as the change in WFAz score from birth to 12 months 3 anddichotomized to define rapid weightgain (weight gain velocity 0.67).3CovariatesPotential confounders basedon existing literature 17 weredocumented from hospitalrecords (maternal age, diabetes,mode of delivery, parity, infantsex, gestational age, and birthweight) or self-reported (maternalethnicity, education, smoking duringpregnancy, and diet quality 18)(Supplemental Table 6). Maternalprepregnancy BMI was determinedfrom measured height and selfreported prepregnancy weight (N 1751) or estimated from measuredweight 12 months postpartum(N 837). Validation against healthrecords in a subset (N 224)revealed strong agreement for bothmeasures (mean difference: 1.0 kg[95% confidence interval (CI): 1.5to 0.4] and 1.3 kg [95% CI: 0.5 to2.2], respectively).Statistical AnalysisPotential confounders were screenedin bivariate analyses (t tests, analysisof variance [ANOVA], χ2) to identifyassociations with feeding exposuresand anthropometric outcomes.Multivariable regression models wereused to estimate the independenteffects of feeding exposures onanthropometric outcomes, withadjustment for infant sex, birthweight, established obesity risk factors(maternal smoking, prepregnancyBMI), and potential confoundersidentified through bivariate screening(study site, maternal age, parity,ethnicity, education, marital status,and infant gestational age). We alsoapplied a propensity score approach,in which the same covariates wereused to predict feeding exposures inmultinomial regression models, andoutcome models were weighted for theinverse predicted probability of feedingexposures.Next, because different feedingexposures may be interrelated,models were mutually adjusted toevaluate the independent effectsof breastfeeding exclusivity, solidfood introduction, and breastfeedingduration. For example, motherswho cease breastfeeding earliermay also introduce foods earlier totheir infant; these exposures wereevaluated together in the same modelto determine if one explained theother, or if they were independentlyassociated with infant BMI.Interaction terms were tested inregression models to evaluate the apriori hypothesis that breastfeedingeffects may be modified by maternalobesity or infant sex.Results are presented as crude andadjusted odds ratios (aORs) andadjusted β estimates (aβ) with 95% CIs.Multivariable regression analyses wereconducted for mother-infant dyadswith available feeding and covariatedata and confirmed in the full eligiblesubset (N 2553) following multipleimputation of missing covariate data.Multiple imputation (20 imputeddata sets) was performed with fullyconditional specification (chainedequations) by using the covariateslisted above. All analyses wereperformed by using SAS version 9.4(SAS Institute, Inc, Cary, NC).RESULTSPopulation CharacteristicsOf 2870 eligible term infants, 2553(89.0%) were assessed at 12 months(Supplemental Fig 3, Table 2). Themean maternal age was 32.4 4.6years, and the mean prepregnancyBMI was 24.7 5.4. The majorityof mothers were white (75.1%),had a postsecondary (57.0%) orpostgraduate (19.8%) degree, anddelivered vaginally (75.7%). Themean infant BMI z score at 12 monthswas 0.21 1.07. Nearly onefourth of infants (N 566, 22.3%)experienced rapid weight gain,and 126 (4.9%) were overweightat 12 months. Infants with missingoutcome data were more likely to beof nonwhite ethnicity, have motherswho smoked, and be breastfed for ashorter duration.Infant FeedingNearly all women in the CHILDcohort (96.6%) initiatedbreastfeeding (Supplemental Table 7, Fig 1). The majority (73.8%)continued beyond 6 months, and43.5% were still breastfeeding at12 months. The median durationof exclusive breastfeeding was 4.0months (interquartile range [IQR]:0.5–5.0), and the median duration ofany breastfeeding was 10.0 months(IQR: 5.0–14.0). Most infants (73.9%)received solid foods before 6 months,although only 17.9% received thembefore 4 months.At 3 months, 1686 infants (60.8%)were exclusively breastfed accordingto maternal report; however,460 of these infants (27.3% ofexclusively breastfed infants, 16.6%overall) briefly received formulasupplementation in hospital. Overhalf of exclusively breastfed infantshad received some expressed breastmilk (N 879, 54.6% of exclusivelybreastfed infants; 33.0% of allinfants). By 6 months, only 18.0% ofinfants were exclusively breastfed.An additional 59.4% were partiallybreastfed, including 33.6% receivingsolid foods, 5.4% receiving formula,and 20.4% receiving both formulaand solids.Downloaded from www.aappublications.org/news by guest on September 27, 2018PEDIATRICS Volume 142, number 4, October 20183
TABLE 2 Characteristics of the Study Population, Comparing Those With and Without Infant BMI DataWith BMI Data (N 2553)Mother, N, mean SDAge, yDiet quality (HEI score)Prepregnancy BMIInfant, N, mean SDGestational age, wkBirth wt, gWFA at birth, z scoreWFA at 12 mo, z scoreWt gain velocity, birth to 12 mo,change in WFA z scoreBMI at 12 mo, z scoreFeeding, N, median (IQR)Duration of exclusive BF, moDuration of any BF, moIntroduction to solid foods, moStudy site, n (%)EdmontonTorontoVancouverWinnipegMaternal ethnicity, n (%)AsianWhiteFirst NationsOtherMissingMaternal education, n (%)High school or lessSome nal marital status, n (%)Married or common-lawSingle (never married)Divorced or separatedMissingMaternal smoking, n (%)NoYesMissingParity, n (%)012 MissingInfant sex, n (%)FemaleMaleWithout BMI Data (N 317)N or nMean SD,Median (IQR),or (%)N or nMean SD,Median (IQR),or (%)25532380247632.4 4.673.0 8.524.7 5.431724810331.4 5.272.6 8.725.3 6.52553253225322553253239.9 1.03509 4430.41 0.890.30 0.98 0.11 1.05317317310——39.8 1.03482 4650.36 0.95——25530.21 1.07——2493232024474.0 (0.5–5.0)11.0 (6.0–15.0)5.0 (4.5–6.0)1971411432.3 (0.3–5.0)6.0 (2.0–11.0)5.0 2241329(47.9)(52.1)154163(48.6)(51.4)Percentages reflect proportions of nonmissing data. Comparisons by t test, Mann–Whitney test, or χ2 test. N 2870 infantsfrom the CHILD cohort born 38 0 wk gestation. BF, breastfeeding; HEI, healthy eating index. —, not applicable.Breastfeeding duration andexclusivity were positively associatedwith maternal age and education andnegatively associated with maternalobesity, smoking, cesarean delivery,4and single parenthood ( Table 3).Breastfeeding rates also differedby study site and were highest inVancouver. Formula supplementationin hospital and feeding of expressedbreast milk after discharge weremore common in first-time mothers.Many of these factors were alsoassociated with infant BMI and/orweight gain velocity ( Table 3),and all were balanced effectivelyin the propensity score analyses(Supplemental Tables 8 and 9).Infant Feeding Practices and BMIz Score at 12 Months (PrimaryOutcome)Breastfeeding Exclusivity and Type ofComplementary FeedingInfants who achieved the WHOrecommendation 14 of 6 months ofexclusive breastfeeding had a meanBMI z score of 0.04 1.06, closelymatching the WHO infant growthstandard ( Fig 2A, Table 4). BMI zscores were half a SD higher amonginfants who were not breastfed forat least 6 months (mean: 0.51 1.07 above the WHO standard; crudeβ .54; 95% CI: .41 to .67). Thisassociation remained significant afteradjustment for study site, maternalage, prepregnancy BMI, ethnicity,education, marital status, smoking,mode of delivery, parity, infant sex,gestational age, and birth weight(aβ 0.44; 95% CI: 0.30 to 0.57).Partial breastfeeding with formulasupplementation appeared to havean intermediate effect (mean: 0.30 1.08; aβ 0.25; 95% CI: 0.13 to0.38), whereas partial breastfeedingwithout formula (ie, with solid foodsonly) was not significantly associatedwith infant BMI (mean: 0.07 1.03;aβ: 0.07; 95% CI: 0.05 to 0.19).Breastfeeding Duration and Timing ofSolid Food IntroductionBreastfeeding duration was inverselyassociated with BMI z score in adose-dependent manner (aβ 0.48for 3 months, 0.29 for 3 to 6months, 0.19 for 6 to 12 months,compared with breastfeeding beyond12 months; P for trend .0001)( Fig 2A, Table 4). These associationswere relatively unchanged afterfurther adjustment for the timingof introduction to solid foods (eg,Downloaded from www.aappublications.org/news by guest on September 27, 2018AZAD et al
FIGURE 1Infant feeding practices in the CHILD cohort (N 2870 term infants). A, Proportion of infants breastfeeding, exclusively breastfeeding, receiving formula,and receiving solid food. B, Breastfeeding status in hospital and at 3, 6, 12, and 24 months of age. Exclusive breastfeeding at 3 months was furthercategorized according to formula supplementation in hospital (any or none) and feeding of expressed and bottled breast milk (any or none). Partialbreastfeeding at 6 months was further categorized according to the type of complementary feeding (formula and/or solid foods). Newborn feeding wasrecorded by hospital nurses; infant feeding was reported by mothers.Downloaded from www.aappublications.org/news by guest on September 27, 2018PEDIATRICS Volume 142, number 4, October 20185
mutually adjusted β 0.48, 0.32, 0.18 for 3 months) ( Table 4).Introducing solid foods before 5months was associated with a higherBMI z score (aβ 0.17; 95% CI: 0.04to 0.29) compared with introductionafter 6 months. This associationwas attenuated after adjusting forbreastfeeding duration (mutuallyadjusted β 0.12; 95% CI: 0.01to 0.25). By contrast, introducingsolid foods between 5 and 6 monthswas not significantly associated withBMI z score (mutually adjusted β 0.05; 95% CI: 0.06 to 0.16). Thus,consistent with the above results,shorter breastfeeding duration andintroduction of solid foods before5 months (but not between 5 and 6months) was associated with a higherBMI z score at 12 months.Breastfeeding Exclusivity and DurationMutual adjustment for breastfeedingexclusivity and durationrevealed that these factors wereindependently associated with infantBMI ( Table 4). Effect estimates forpartial breastfeeding with formulawere attenuated but remainedsignificant after adjustment forbreastfeeding duration (eg, aβ 0.24; 95% CI: 0.14 to 0.35 forformula supplementation before 3months; attenuated to aβ 0.14;95% CI: 0.03 to 0.26 after adjustmentfor breastfeeding duration).Mode of BreastfeedingExclusively breastfed infantsreceiving some expressed breast milkhad higher BMI z scores than thosereceiving only direct breast milk(mean: 0.14 1.00 vs 0.02 1.06; aβ 0.12; 95% CI: 0.01 to 0.23)( Fig 2A, Table 4); however, theyremained leaner than infants whowere partially breastfed (aβ 0.28;695% CI: 0.16 to 0.39) or not breastfed(aβ 0.45; 95% CI: 0.30 to 0.59).Brief Formula Supplementation inHospitalAmong infants who were “exclusivelybreastfed” for at least 3 monthsaccording to maternal report,those who briefly received formulasupplementation as neonates hadslightly higher BMI z scores at 12months (mean: 0.11 1.04 vs 0.04 1.04); however, this differencewas not significant in crude oradjusted models (aβ 0.05; 95% CI: 0.07 to 0.17) ( Fig 2A, Table 4).Infant Feeding Practices, OverweightRisk, and Weight Gain Velocity(Secondary Outcomes)Consistent with BMI z score results,there was an inverse dose-dependentassociation between breastfeedingduration and the risk of overweightat 12 months (P .0001) ( Table 4).The risk of overweight was threefoldhigher among infants who were notbreastfed at 6 months comparedwith those who were exclusivelybreastfed (8.3% vs 2.4%, aOR 3.20, 95% CI: 1.58 to 6.51). Therewas an intermediate association forpartial breastfeeding with formula(6.1%, aOR 2.03, 95% CI: 1.00 to4.11) and no association for partialbreastfeeding without formula (3.2%,aOR 0.93, 95% CI: 0.44 to 1.97).Brief formula supplementation inhospital was not associated withoverweight risk. Similar patterns ofassociation were observed for weightgain velocity and risk of rapid weightgain ( Fig 2B, Table 5).Sensitivity Analyses and EffectModificationResults were confirmed afterinverse probability weighting forpropensity scores and essentiallyunchanged with multiple imputationof missing data (SupplementalTable 10). There was no evidence ofeffect modification by infant sex ormaternal obesity (not shown).DISCUSSIONIn the prospective CHILD birthcohort, we found that breastfeedingwas inversely associated withweight gain velocity, BMI, andoverweight risk in the first year oflife. These associations were dosedependent (stronger with longerand more exclusive breastfeeding)and independent of maternal BMIand socioeconomic status, usingmultiple approaches to addressconfounding bias. After controllingfor these and other potentialconfounders, breastfeeding cessationbefore 6 months was associatedwith a twofold increased risk ofrapid weight gain, a 0.44 SDincrease in BMI by 12 months of age,and a threefold increased risk ofoverweight, compared with exclusivebreastfeeding. These effects aresubstantial, surpassing the estimatedeffect of maternal obesity ( 0.20, inthe same multivariable model).Further analysis of specific feedingpractices revealed stronger associationsfor direct breastfeeding versusexpressed breast milk and strongerattenuation from supplementation withformula versus solid foods. Finally, briefformula supplementation during theneonatal period did not measurablyalter these associations, so long asexclusive breastfeeding was establishedand sustained for at least 3 months afterhospital discharge.Strengths and LimitationsA major strength of this study isthe prospective collection of infantfeeding data, including manydetails that are rarely captured inother studies. Still, these exposuremeasurements were limited by alack of quantitative informationabout the amount of expressed milkDownloaded from www.aappublications.org/news by guest on September 27, 2018AZAD et al
TABLE 3 Univariate Associations of Potential Confounders With Infant Feeding, Weight Gain, and BMI in the First Year of LifeInfant Feeding ExposuresNFormula Feedingin gMaternal age, y 3030–35 35Prepregnancy BMI 25 25–30 30Diabetes in pregnancyNoYesMaternal ethnicityAsianWhiteFNOtherMaternal educationHigh school or lessSome postsecondaryPostsecondaryPostgraduateMarital statusMarriedSingleDiet quality (HEI score) 7070–75 75Parity01 2Maternal smokingNoYesInfant sexFemaleMaleBirth modeCS, electiveCS, emergencyVaginalInfant gestational age, wk3839–4041Infant birth wt, g 30003000 to 35003500 to 4000 4000Expressed MilkFeedinga at 3 MoSolid FoodsIntroducedBefore 4 MoAnthropometric OutcomesExclusiveBreastfeedingat 6 MoAnyBreastfeedingat 12 MoWt Gain Velocityb0–12 MoMean SDBMI z Score at12 MoMean SD%%%%%287025.056.917.118.146.6 0.11 1.060.21 964.142.8 0.04 1.12** 0.05 1.00 0.10 1.07 0.21 1.040.36 1.12***0.37 1.010.11 1.040.06 .910.012.6***18.922.835.4***49.753.8 0.08 1.11 0.11 1.03 0.13 1.050.20 1.110.19 1.060.24 524.319.5**18.512.652.1***46.429.4 0.11 1.03 0.12 1.11 0.10 1.130.12 1.07***0.26 1.040.48 39.8 0.11 1.06 0.15 1.150.21 1.080.24 7.9 0.10 1.05 0.13 1.050.04 1.000.05 1.180.01 1.02**0.22 1.060.48 1.060.28 .648.158.5 0.14 1.13 0.04 1.04 0.13 1.06 0.11 1.040.27 1.130.31 1.060.19 1.070.13 7.5**35.0 0.12 1.06**0.11 1.070.20 1.060.27 514.413.2***18.621.236.2***44.855.0 0.09 1.09 0.11 1.05 0.13 1.040.24 1.030.21 1.090.18 .216.716.620.019.346.347.346.10.04 1.04*** 0.28 1.05 0.32 1.070.23 1.060.15 1.080.26 049.0***22.6 0.14 1.05***0.22 1.100.19 1.07**0.43 246.0 0.14 1.04 0.08 1.080.18 1.030.23 7.013.317.019.037.5**45.348.10.04 1.07 0.13 1.02 0.12 1.060.37 1.07**0.31 1.030.17 9.315.918.618.838.9**47.751.00.27 1.02*** 0.14 1.04 0.42 1.030.29 1.060.18 1.060.20 .72 1.00***0.15 0.91 0.32 0.94 0.97 1.05 0.14 1.06***0.06 1.020.35 1.060.57 1.10N 2870 infants from the CHILD cohort born 38 0 wk gestation. BF, breastfeeding; CS, cesarean delivery; FN, First Nations; HEI, healthy eating index.Of those reporting any breast milk feeding at 3 mo.b Change in WFA z score from birth to 12 mo. Comparisons by χ2 test, ANOVA, or t test.*** P .001;** P .01;* P .05.aDownloaded from www.aappublications.org/news by guest on September 27, 2018PEDIATRICS Volume 142, number 4, October 20187
or formula consumed. Also, becauseof the high breastfeeding initiationrates in this cohort, we had limitedpower to examine the impact ofnever breastfeeding, which is animportant concern in other settings.Another limitation is that we didnot capture information aboutmothers’ intentions to breastfeed,feeding styles (eg, paced bottlefeeding, infant-led weaning, levelof maternal control), or reasonsfor supplementing, pumping, andweaning.We used multiple statisticalapproaches to consider manypotential confounders, includingsociodemographic factors (maternalage, ethnicity, education, andmarital status) to address the socialpatterning of breastfeeding that isreported in other populations 17 andconfirmed in our cohort. However,residual confounding remainspossible in this observational study.Finally, although breastfeeding ratesin the CHILD cohort are nationallyrepresentative, 19 our findings maynot apply in other settings withdifferent breastfeeding practices andpolicies or in populations challengedwith undernutrition and stuntingrather than overnutrition andobesity.Breastfeeding Exclusivity andDuration: Dose EffectsOur findings are consistent withprevious observational studies,demonstrating that breastfeedingis inversely associated with infantgrowth velocity, 20 BMI, 21 andoverweight. 7, 17, 21 In contrast, arandomized trial of breastfeedingpromotion did not affect infantWFA 22; however, it did not includea nonbreastfed control group, andthrough observational analyses,it was confirmed that infantsexclusively breastfed for at least 6months had lower WFA comparedwith those weaned or supplementedearlier. 228We provide new evidence for theindependent and dose-dependenteffects of breastfeeding exclusivityand duration, which are rarelyexamined simultaneously. In ourstudy, these effect estimates wereattenuated but remained significantin mutually adjusted models. Theattenuation is expected becauseformula supplementation candecrease milk supply or may reflectbreastfeeding difficul
(z score 2).16 Weight gain velocity was calculated as the change in WFA z score from birth to 12 months3 and dichotomized to define rapid weight gain (weight gain velocity 0.67).3 Covariates Potential confounders based on existing literature17 were documented from hospital records (maternal age, diabetes, mode of delivery, parity, infant
2.3 Feeding the infant/young child under "normal" circumstances 18 2.4 Feeding the Infant/Young Child of a working mother at work places 20 2.5 Feeding the Infant/ Young Child who is exposed to HIV 22 2.6 Feeding Infant and Young Child in Other Specific Situations 23 Chapter 3 : Implementation Strategy 3.1 Implementation framework 28
Infant Feeding Counselling Cards This counselling card flip chart is based on the National Infant and Young Child Feeding Policy. These counselling cards have been created to help health workers trained in infant feeding counselling to support HIV-positive mothers. All HIV-positive mothers should receive counselling on how to feed their babies.
This resource provides information on infant and toddler feeding from birth through twenty-three months of age, including information on feeding, infant formula, the introduction of solid foods and infant safety while eating. Keep in mind that every infant is different, and their diets may vary depending
the protection, promotion, and support of optimal infant and young child feeding practices is a priority lifesaving intervention. Infant feeding practices in Lebanon fall short of recommendations. In Lebanon, there's a lack of national-level data on nutrition among the Lebanese population routine infant and young child feeding practices
Infant & Young Child feeding from an Indian perspective (including Human Milk Banking, infant feeding in the HIV situation and Micronutrients). Recommendations: Appropriate and Optimal Infant and Young Child Feeding: Early initiation of breastfeeding, exclusive breastfeeding for the first six
The historical evolution of feeding practices for a full-term infant immediately after birth includes wet nursing, the feeding bottle, and formula use. Thepurpose ofthis article istoexploreeach compo-nent and their combined impact on current infant-feeding trends and child health. Weprovide a review ofwet nursing,the feeding bottle, and the use .
your Infant Car Seat, as described in the instruction manual provided by the Infant Car Seat manufacturer. † WHEN USING ONLY ONE INFANT CAR SEAT ADAPTER OR TWO FOR TWINS, THE FOLLOWING INFANT CAR SEATS CAN BE USED: † If your Infant Car Seat is not one of the models listed above, DO NOT use your infant car seat with this car seat adapter.
Child First Language Acquisition Babbling Words Sounds and Pronunciation Syntax Morphology Is Language Behavior? 5 Is Language Behavior? B.F. Skinner (1904-1990) claimed that language is just another form of behavior. It is a response to stimuli in the environment. And it is learned. Children’s creativity with language is a problem for this .
