Incorporating nutrition into delivery care: delivery care practices that affect child nutrition and maternal health

Delayed umbilical cord clamping, early skin-to-skin contact and early initiation of exclusive breastfeeding are three simple and inexpensive delivery care practices which have the potential to improve short-term and long-term nutrition and health outcomes in mothers and infants. In preterm infants, delayed clamping prevents intraventricular haemorrhage and improves haematological status, and in full-term infants, delayed clamping improves iron status through 6 months of age. Early skin-to-skin contact, in addition to regulating neonatal temperature, improves early breastfeeding behaviours, which has important implications for long-term infant nutrition and health. Finally, early exclusive breastfeeding prevents neonatal mortality and morbidity and provides numerous health and nutritional benefits to the infant, throughout infancy and beyond, as well as to the mother. Though each practice has been the subject of controlled trials and systematic reviews, with evidence of benefit from their implementation, these practices are not common in many delivery settings, nor are their long-term effects on infant and maternal nutrition and health status adequately recognized. We discuss the immediate and long-term health and nutrition benefits of each practice, and identify the policy and programme changes needed for integration and implementation of these practices into standard delivery care.     

Maternal nutrition in rural Kenya: health and socio-demographic determinants and its association with child nutrition

High levels of food insecurity and human immunodeficiency virus (HIV) infection place most breastfeeding mothers in Kenya at high risk of malnutrition. We examined the role of selected socio-economic, demographic and health factors as determinants of nutritional status among HIV-infected and HIV-uninfected mothers in rural Kenya and further examined the interrelationship between maternal nutritional and child nutritional status within this population. A cross-sectional design was used to collect data from non-pregnant mothers with children ages 4-24 months in Kisumu District, Kenya. Over 80% of the mothers were breastfeeding at the time of the study. Mean maternal body mass index (BMI) (21.60 ± 3.15) and percent body fat (22.29 ± 4.86) values were lower than among lactating mothers in other Sub-Sahara African countries. Maternal HIV status was not significantly associated with any of the maternal nutritional indicators assessed in the study. Breastfeeding, recent severe illness and having multiple children below 2 years of age were negatively associated with maternal nutritional status, while higher maternal age, socio-economic status and household food security were each positively associated with maternal nutritional status. Significant positive association was reported between maternal weight, height, BMI, mid-upper arm circumference (MUAC), body fat and fat-free mass estimates, and children's height-for-age, weight-for-age, weight-for-height and MUAC-for-age z-score. This analysis identifies determinants of maternal nutritional status in rural Kenya and highlights the importance of interventions that address malnutrition in both HIV-infected and HIV-uninfected mothers in rural Kenya. Significant association between maternal and child nutritional status stresses the importance of addressing maternal and young child nutritional status as interrelated factors.     

Parenteral nutrition in pediatrics

OBJECTIVE: To present a review on parenteral nutrition in infants and children, characterizing the importance of nutrition therapy to support and recover their nutritional status. METHODS: Articles from specific journals were analyzed. Information was also obtained from the author s own experience in the area. RESULTS: Major recommendations; venous access; protein-energy composition (electrolyte, vitamins and trace elements); formulation; administration; clinical and laboratorial control; and complications were also discussed. CONCLUSIONS: Parenteral nutrition, if well-indicated, is very important for the management of several childhood diseases, allowing the maintenance and restoration of nutritional status     

Child nutrition and lower respiratory tract disease burden in New Zealand: a global context for a national perspective

Aim: To consider the contribution of malnutrition to acute lower respiratory infection (ALRI) disease burden in children <5 years old in New Zealand (NZ). Methods: The contribution of maternal and child malnutrition to ALRI disease burden in early childhood globally was described. A literature review was conducted to describe the nutritional status and ALRI disease burden of NZ children <5 years old. Results: The four key nutritional risk factors for ALRI disease burden globally are macronutrient undernutrition, low birthweight, zinc deficiency and suboptimal breastfeeding. In addition, maternal nutritional status and vitamin D deficiency are potentially important nutritional determinants of ALRI disease burden. Relative to other developed countries, NZ has a large ALRI disease burden in pre‐school‐aged children. Pneumonia and bronchiolitis hospitalisation rates are two to four times greater than other developed countries. The ALRI disease burden varies with ethnicity, being highest in Pacific, intermediate in Maori and lowest in European children. Three of the four key nutritional risk factors for global ALRI disease burden – low birthweight, zinc deficiency and suboptimal breastfeeding – are potential contributors to ALRI disease burden in NZ. In addition to these factors, vitamin D deficiency during early childhood and maternal vitamin D deficiency are also potentially important particularly with respect to the larger disease burden in Pacific and Maori children. Conclusion: The contribution of malnutrition to ALRI disease burden in NZ requires greater clarification. Such clarification is necessary to inform the development of nutritional policy, which seeks to improve early child health.     

Interaction between nutrition and measles

Malnutrition and infection are the two major public health problems in develpping countries. In India, severe forms of protein energy malnutrition are seen in 1–2% of preschool children. The condition is particularly serious during the post-weaning period and is often associated with infection. Much has been written about the synergestic interaction and infection in turn adversely affects the nutritional status. Although this relationship is well documented with respect to bacterial infections, it is not clear whether nutrition can influence the incidence or course of viral diseases. Measles is one of the most common viral infections that occur during childhood. The interactions between measles and nutritional status acquire considerable importance in situations where as a result of inadequate food intake, chronic malnutrition is widespread among children.     

呵护早产儿从母乳喂养开始

母乳喂养是降低新生儿死亡率的重要干预手段之一,对早产儿尤其如此。早产母乳中的成分与足月母乳不同,其营养价值和生物学功能更适合早产儿的需求。在NICU积极推进母乳喂养能降低早产相关疾病的发生率,改善神经行为发育,降低成年慢性非传染性疾病的发病风险。对低出生体质量早产儿,强化母乳喂养是最佳的喂养方式,能优化蛋白质摄入,促进早产儿体格增长和骨骼矿化。应当以积极的支持策略来保证早产儿母乳喂养的顺利实施。     

Interaction of nutrition and infection in clinical practice.

Resistance to infection is determined by a great many interralted factors, but one of the most significant variables is nutritional status of the host. The interaction between nutrition and infection has been described as synergistic, with malnutrition reducing resistance to infection, and infection, in turn, negatively affecting nutritional status. There are qualitative if not quantitative similarities between the evidence that has been gathered from studies of children living in vast areas of the developing countries, in which high rates of both severe malnutrition and infectious diseases are linked with high mortality rates, and evidence from studies of disadvantages children living in the United States in economically depressed migrant camps, Indian reservations, or rural and urban poverty, or children compromised by debilitating chronic diseases. Maternal nutritional status during pregnancy must receive more attention as a factor in the newborn's resistance to infection. Intrauterine malnutrition may cause impaired cellular immune function in the small-for-date infant which persists throughout the first year of life. Further research is needed to clarify this relationship. The optimal management of infections includes management or maintenance of nutritional status, and, in turn, management of nutritional deficiencies include prevention and treatment of infections.     

Exclusive breastfeeding and nutritional status in Bangladesh

Objective : The purposes of the study were to assess exclusive breastfeeding practice and examine the factors effect on nutritional status of children from 0 to 24 months age.Method : Data from a national survey entitled “Surveillance on Breastfeeding and Weaning Situation and Child and Maternal Health in Bangladesh were used to investigate the exclusive breastfeeding practice and to examine the factors having influence on child nutrition. Information was collected from mothers of 2781 children between 0 and 24 months of age.Results : It was that 16% of women still exclusively breastfed their children for less than 6 months. Of the children 38.1% were stunted and 38% were under weight for their age. Overall, 46% of children were suffering from diseases. Bivariate analysis showed that maternal education and family income were important correlates of exclusive breastfeeding (Chi-square p<0.001). Exclusively breastfed children were nutritionally better off (p<0.001). Logistic regression analysis showed that the children of illiterate women were nutritionally more vulnerable than children of women who had secondary and higher education (OR=1.69, 95% Cl=1.33–2.15). The children of older age women were less likely to be stunted than children of younger age women (OR=0.78, 95% CI=0.64–0.96).Conclusion : Despite efforts of different government agencies and NGOs, exclusive breastfeeding rate was still low in Bangladesh. Traditional cultural barriers still exist. In order to remove the harmful cultural beliefs and to spread the messages of the benefit of exclusive breastfeeding for survival and nutritional status of the children more behaviour change communication should be made to promote, protect and support breastfeeding.     

The influence of nutrition on clinical outcomes in children with cancer

Adequate and appropriate nutrition is essential for growth and development in children; all put at risk in those with cancer. Overnutrition and undernutrition at diagnosis raise the risk of increased morbidity and mortality during therapy and beyond. All treatment modalities can jeopardize nutritional status with potentially adverse effects on clinical outcomes. Accurate assessment of nutritional status and nutrient balance is essential, with remedial interventions delivered promptly when required. Children with cancer in low‐ and middle‐income countries (LMICs) are especially disadvantaged with concomitant challenges in the provision of nutritional support. Cost‐effective advances in the form of ready‐to‐use therapeutic foods (RUTF) may offer solutions. Studies in LMICs have defined a critical role for the gut microbiome in the causation of undernutrition in children and have demonstrated a beneficial effect of selected RUTF in redressing the imbalanced microbiota and improving nutritional status. Challenges in high‐income countries relate both to concerns about the potential disadvantage of preexisting obesity in those newly diagnosed and to undernutrition identified at diagnosis and during treatment. Much remains to be understood but the prospects are bright for offsetting malnutrition in children with cancer, resulting in enhanced opportunity for healthy survival.     

Maternal nutritional knowledge and child nutritional status in the Volta region of Ghana

The relationship between mother's nutritional knowledge, maternal education, and child nutritional status (weight-for-age) was the subject of investigation in this study. The data were collected in Ghana on 55 well nourished and 55 malnourished mother-child pairs. A questionnaire designed to collect data on mother's knowledge and practices related to child care and nutrition was administered to the mothers. Data on mother's demographic and socio-economic characteristics as well as child anthropometric data were also collected. A nutrition knowledge score was calculated based on mother's responses to the nutrition related items. Bivariate analysis gave significant associations between child nutritional status and the following variables: time of initiating of breastfeeding, mother's knowledge of importance of colostrum and whether colostrum was given to child, age of introduction of supplementary food, and mother's knowledge about causes of kwashiorkor. The two groups also showed significant differences in their nutrition knowledge scores. Maternal formal education, and marital status were also found to be associated with child nutritional status in bivariate analyses. Further analysis with logistic regression revealed that maternal nutrition knowledge was independently associated with nutritional status after the effects of other significant variables were controlled for. Maternal education on the other hand was not found to be independently associated with nutritional status. These results imply that mother's practical knowledge about nutrition may be more important than formal maternal education for child nutrition outcome.     

Infant and young child feeding practices and stunting in two highland provinces in Ecuador

The first two years of life are critical for growth and development. Little is known about infant and young child feeding (IYCF) practices in the Ecuadorian highlands and how they contribute to stunting. With the objective of understanding nutritional status and the influencing factors to design an intervention, we assessed the nutritional status of 293 infants and children between 0 and 24 months of age, living in 14 communities in the provinces of Tungurahua and Chimborazo using a cross‐sectional study design. We used the WHO IYCF indicators to assess feeding practices; estimated dietary intake with 24‐h recalls; and identified nutritious local foods by food frequency questionnaires. Multiple regression modelling was performed to identify correlates of nutritional status. Stunting was found in 56.2% of children. Mean protein, vitamin A and vitamin C intakes were above recommendations for all ages. Only infants 6.0 to 8.9 months of age and non‐breastfed children 12–23.9 months of age consumed energy intakes below recommendations. Younger age groups had below recommended intakes for iron and calcium. While mean complementary food densities met recommendations for protein, vitamin A, vitamin C and energy, those for zinc, iron and calcium were lower than recommended. Older age, respiratory infections and being male were predictors of lower HAZ, whereas early initiation of breastfeeding, higher socioeconomic status, consumption of iron‐rich foods and higher dietary protein density were protective. Interventions that promote and support optimal breastfeeding practices and enable increased consumption of nutritious local foods have potential to contribute to reducing stunting in this vulnerable population. © 2016 John Wiley & Sons Ltd     

Women's bargaining power and child feeding in Nepal: Linkages through nutrition information

Women's intra‐household bargaining power is an important determinant of child nutritional status, but there is limited evidence on how it relates to infant and young child feeding (IYCF) practices. We conducted a cross‐sectional analysis using 2012 baseline data from the impact evaluation of Suaahara, a multisectoral programme in Nepal, focusing on households with children 0–23 months (n = 1787). We examined if women's bargaining power was related to exposure to IYCF information and if exposure to IYCF information was in turn associated with improved IYCF practices: early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency and dietary diversity. Bargaining power consisted of four domains: (i) ownership and control of assets; (ii) social participation; (iii) workload; and (iv) household decision‐making control and were primarily measured using additive scales. We used generalized structural equation modelling to examine if exposure to IYCF information mediated the relationship between the bargaining domains and the four IYCF practices, separately. Social participation was positively associated with exposure to IYCF information (β = 0.266, P < .001), which in turn was related to early initiation (β = 0.241, P = .001). We obtained similar results for the relationship between social participation and dietary diversity. Decision‐making control was directly associated with exclusive breastfeeding (β = 0.350, P = .036). No domains were associated with minimum meal frequency. Different domains of women's bargaining power may relate to exposure to nutrition information and IYCF behaviours. Understanding specific domains of bargaining power is critical to developing interventions that can effectively address gender‐related issues that underlie child nutrition outcomes.     

Iron balance and iron nutrition in infancy

At birth, the total body iron content is approximately 75 mg/kg, twice that of an adult man in relation to weight. During the first 6 mo of life, total iron body content increases slightly and exclusive breastfeeding is sufficient to maintain an optimal iron balance. Thereafter, iron body content substantially increases and the infant becomes critically dependent on dietary iron, provided by complementary foods. Numerous factors may contribute to nutritional iron deficiency in infancy, the most important being low body iron content at birth, blood loss, high postnatal growth rate, and a low amount and/or bioavailability of dietary iron. We have documented that the prevalence of iron deficiency declined in Italy as iron nutrition improved and that early feeding on fresh cow's milk is the single most important determinant of iron deficiency in infancy. Healthy full-term infants should maintain optimal iron balance by consuming a good diet, which can be summarized as follows: breastfeeding should be continued exclusively for at least 5 mo and then together with complementary foods containing highly bioavailable iron; infants who are not breastfed or are partially breastfed should receive an iron-fortified formula, containing between 4.0 and 8.0mg/L iron, from birth to 12 mo of age; fresh cow's milk should be avoided before 12 mo of age.     

Iron balance and iron nutrition in infancy

At birth, the total body iron content is approximately 75 mg/kg, twice that of an adult man in relation to weight. During the first 6 mo of life, total iron body content increases slightly and exclusive breastfeeding is sufficient to maintain an optimal iron balance. Thereafter, iron body content substantially increases and the infant becomes critically dependent on dietary iron, provided by complementary foods. Numerous factors may contribute to nutritional iron deficiency in infancy, the most important being low body iron content at birth, blood loss, high postnatal growth rate, and a low amount and/or bioavailability of dietary iron. We have documented that the prevalence of iron deficiency declined in Italy as iron nutrition improved and that early feeding on fresh cow's milk is the single most important determinant of iron deficiency in infancy. Healthy full-term infants should maintain optimal iron balance by consuming a good diet, which can be summarized as follows: breastfeeding should be continued exclusively for at least 5 mo and then together with complementary foods containing highly bioavailable iron; infants who are not breastfed or are partially breastfed should receive an iron-fortified formula, containing between 4.0 and 8.0 mg/L iron, from birth to 12 mo of age; fresh cow's milk should be avoided before 12 mo of age.     

Experiences of breastfeeding during COVID‐19: Lessons for future practical and emotional support

The COVID‐19 pandemic and subsequent lockdown and social distancing led to changes to breastfeeding support available to women in the United Kingdom. Face‐to‐face professional support was reduced, and face‐to‐face peer support was cancelled. Anecdotal media accounts highlighted practices separating some mothers and babies in hospitals, alongside inaccurate stories of the safety of breastfeeding circulating. Meanwhile, new families were confined to their homes, separated from families and support networks. Given that we know breastfeeding is best supported by practices that keep mother and baby together, high‐quality professional and peer‐to‐peer support, and positive maternal well‐being, it is important to understand the impact of the pandemic upon the ability to breastfeed. To explore this, we conducted an online survey with 1219 breastfeeding mothers in the United Kingdom with a baby 0–12 months old to understand the impact of the pandemic upon breastfeeding duration, experiences and support. The results highlighted two very different experiences: 41.8% of mothers felt that breastfeeding was protected due to lockdown, but 27.0% of mothers struggled to get support and had numerous barriers stemming from lockdown with some stopped breastfeeding before they were ready. Mothers with a lower education, with more challenging living circumstances and from Black and minority ethnic backgrounds were more likely to find the impact of lockdown challenging and stop breastfeeding. The findings are vital in understanding how we now support those women who may be grieving their loss of breastfeeding and are affected by their negative experiences and how we can learn from those with a positive experience to make sure all breastfeeding women are better supported if similar future events arise.     

Breastfeeding in children born small for gestational age and future nutritional and metabolic outcomes: a systematic review

ObjectiveTo systematically review evidence related to nutritional and cardiometabolic outcomes in children born at term and small for gestational age and the association with breastfeeding.Source of dataTwo independent reviewers searched the MEDLINE, LILACS, SciELO, and Embase databases without time or language restrictions. The PRISMA tool was used, and studies that evaluated infants born at term and small for gestational age, breastfed, and with an evaluation of cardiometabolic outcomes were included. Studies with preterm infants, those that did not have information on breastfeeding, and those with lack of evaluation of the outcome variables were excluded. Also excluded were review articles, editorials, and series of cases.Summary of dataOnly seven articles were found that met the abovementioned criteria. There was a great variability in the type of evaluation, as well as in the age of these children. It was demonstrated that breastfeeding promoted growth without body composition alteration and without increased insulin resistance in children with exclusive breastfeeding, when compared to children receiving a higher calorie formula, except for one article that observed an increase in fat mass in exclusively breastfed children.ConclusionBreastfeeding seems to be a safe feeding practice for infants born at term and small for gestational age, showing no association with deleterious short-term outcomes. Breastfeeding stimulation in these populations seems to be a way of preventing the health problems associated with the high risk of chronic noncommunicable diseases and obesity.     

Current challenges in pediatric nutrition

In pediatric nutrition the most important overall theme is breastfeeding. While there is no alternative in most mammals--and offspring would die if the mother had no milk or could not feed the newborn--human mothers were offered alternative ways of infant feeding. Today restoring breastfeeding is a major goal for pediatricians, midwifes, and lactation advisers. Feeding the premature baby and adding long chain fatty acids and prebiotics to formula is an area of growing interest. Undernutrition is a special challenge for nutritional care because even in recent years severely undernourished children die of inadequate management with too much volume and too much protein in the initial phase. Much knowledge has been gained about parenteral nutrition for children with gut failure. Even children with very short bowel length at birth have a good prognosis and can often achieve enteral adaptation. New solutions for parenteral nutrition, new materials, and new care concepts have been identified. Problems considered inherent to parenteral nutrition are widely preventable.     

Federal nutrition support programs for children.

In summary, the physician as a concerned citizen, contributing taxpayer, and key provider of child health care can provide responsible leadership in assuring that nutrition support services for children include assessment of their nutritional status, provision of a safe food supply adequate in quality and quantity, nutrition counseling for specific nutritional problems, and sound nutrition education for children, parents, and all other caretakers of children.     

The benefits,challenges and impacts of accessing social media group support for breastfeeding: A systematic review

Breastfeeding support is a key component in meeting the public health responsibility of increasing breastfeeding rates, with access to individualised, convenient and linked support across services central to improved outcomes. With the rise of new technology and the COVID‐19 pandemic, social media (SM) support for breastfeeding has become increasingly popular and it is important to understand how and why mothers access such support, and from whom, to optimise services and to meet mothers’ needs. Increasing research is building on women''s use and experience of SM for breastfeeding, although there is a paucity of UK data. This systematic review aimed to understand the impacts of SM support for breastfeeding, including benefits and challenges, to establish the evidence for wider provision within maternity services. The search was limited to studies published in English and focused on the self‐directed use of social media groups for breastfeeding (defined as platforms that facilitate group support via interactivity, allowing for user‐generated content and subsequent responses). Of 327 papers retrieved, 13 studies were included for review. The six themes identified were: breastfeeding context, including factors impacting women''s decision making; the relational impact of belonging to an online community; increased self‐efficacy; critiques of SM; the nature and types of support commonly sought and received; and breastfeeding duration as an outcome. The findings confirm that mothers value SM groups for community support, which normalises breastfeeding and provides the support they attribute to improved outcomes, and highlight that UK research focused on provision linked to wider services is needed.     

Fathers' experiences of supporting breastfeeding: challenges for breastfeeding promotion and education

Increasing breastfeeding rates is a strategic priority in the UK and understanding the factors that promote and encourage breastfeeding is critical to achieving this. It is established that women who have strong social support from their partner are more likely to initiate and continue breastfeeding. However, little research has explored the fathers' role in breastfeeding support and more importantly, the information and guidance he may need. In the current study, 117 men whose partner had given birth in the previous 2 years and initiated breastfeeding at birth completed an open‐ended questionnaire exploring their experiences of breastfeeding, the information and support they received and their ideas for future breastfeeding education and promotion aimed at fathers and families. Overall, the findings showed that fathers were encouraging of breastfeeding and wanted to be able to support their partner. However, they often felt left out of the breastfeeding relationships and helpless to support their partner at this time. Many reported being excluded from antenatal breastfeeding education or being considered unimportant in post‐natal support. Men wanted more information about breastfeeding to be directed towards them alongside ideas about how they could practically support their partner. The importance of support mechanisms for themselves during this time was also raised. The results highlight the need for health professionals to direct support and information towards fathers as well as the mother–infant dyad and to recognise their importance in promoting and enabling breastfeeding.