Context: Despite the many initiatives implemented over the past decades as part of the global priority on child survival, there still exists high infant mortality in Southern Africa. Although studies have examined factors contributing to poor child health outcomes including the effect of the HIV/AIDS pandemic, there is paucity of studies on the possible effect of infant feeding practices on infant mortality in the region. This study examines the association between infant feeding practices and infant mortality in Southern Africa. The need to reduce infant mortality is a global health concern hence the United Nations through the Millennium Development Goals (MDGs) declared the reduction of infant and child mortality as one of its major targets by the year 2015. Methods: A merged dataset from the most recent Demographic and Health Surveys for Lesotho, Swaziland, Zambia and Zimbabwe was analysed in this study. A total number of 13, 218 infants born in the last five years preceding the surveys whose information on infant feeding practices was available formed the analysis sample. The outcome variable was infant mortality and infant feeding practices which had the categories, no breastfeeding, partial breastfeeding and exclusive breastfeeding was the main explanatory variable of the study. Other explanatory variables used in the study pertained to maternal demographic and socioeconomic characteristics as well as the infants’ bio-demographic characteristics. The Cox Hazard Regression Model was employed to examine both the unadjusted and adjusted effect of infant feeding practices on infant mortality in Southern Africa. Results: Although, exclusive breastfeeding was quite low (12%), its mortality reduction effect was significant, and infants who were exclusively breastfed exhibited a 97% lower risk of dying during infancy compared to no breastfeeding in the region. Further, variations exist by country in the levels and patterns of both infant mortality and infant feeding practices. Country, highest educational level, marital status, sex of child, preceding birth interval and birth weight were the significant predictors of infant mortality in Southern Africa. Conclusions: Overall, the study found that any form of breastfeeding whether exclusive or partial breastfeeding greatly reduces the risk of infant mortality, with the mortality reduction effect being higher among exclusively breastfed infants in the Southern African region. Thus, in order to reduce the upsurge of infant mortality, there is need to step up the effectiveness of child nutrition programmes that promote breastfeeding and put emphasis on exclusive breastfeeding of infants in the region.

In this mini-dissertation the aim was to explore and describe the safety of infant feeding practices. It is argued that safe infant feeding practices can have a positive and long term effect on the health status and growth development of all infants. World wide, countries but more specific developing countries, are faced with the growing dilemma of high mortality and morbidity rates among infants. The need to find a way to eliminate and prevent the causing factors of life-threatening infectious diseases like diarrhoea and HIV/AIDS is now more important than ever before. A sound nutritional foundation together with safe infant feeding methods play a predominant role in ensuring the very survival of the infant. A cross-sectional, descriptive research design was used in this study. Non-probability sampling was used to identify the sample who complied with the set selection criteria. The research took place in a semi-urban community as the community serves a large group of mothers and infants as well as being accessible to the researcher. The semi-urban community was also identified as an area with health care needs that could be addressed in the research project. A questionnaire was adapted from an existing WHO assessment tool. A pilot study was conducted after which the questionnaire was finalised and the questionnaires were completed with the aid of three fieldworkers. Data collection took place until the sample size (n=155) was achieved according to the calculation of the statistician. The data analysis was done by means of descriptive statistics such as frequency, percentage, mean and standard deviation by using the STATISTICA data analysis software system programme. The results of the research study indicated that the majority of participants practice mixed feeding methods which do not comply with safe infant feeding standards. Infant feeding methods are not changed during illness or disease experienced by either the mother or infant, which again may greatly compromise their health status. The uptake of HIV testing and disclosure were relatively high. Recommendations are made for nursing education, nursing research and nursing practice with special focus on establishing safe infant feeding practices. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2008.

In this mini-dissertation the aim was to explore and describe the safety of infant feeding practices. It is argued that safe infant feeding practices can have a positive and long term effect on the health status and growth development of all infants. World wide, countries but more specific developing countries, are faced with the growing dilemma of high mortality and morbidity rates among infants. The need to find a way to eliminate and prevent the causing factors of life-threatening infectious diseases like diarrhoea and HIV/AIDS is now more important than ever before. A sound nutritional foundation together with safe infant feeding methods play a predominant role in ensuring the very survival of the infant. A cross-sectional, descriptive research design was used in this study. Non-probability sampling was used to identify the sample who complied with the set selection criteria. The research took place in a semi-urban community as the community serves a large group of mothers and infants as well as being accessible to the researcher. The semi-urban community was also identified as an area with health care needs that could be addressed in the research project. A questionnaire was adapted from an existing WHO assessment tool. A pilot study was conducted after which the questionnaire was finalised and the questionnaires were completed with the aid of three fieldworkers. Data collection took place until the sample size (n=155) was achieved according to the calculation of the statistician. The data analysis was done by means of descriptive statistics such as frequency, percentage, mean and standard deviation by using the STATISTICA data analysis software system programme. The results of the research study indicated that the majority of participants practice mixed feeding methods which do not comply with safe infant feeding standards. Infant feeding methods are not changed during illness or disease experienced by either the mother or infant, which again may greatly compromise their health status. The uptake of HIV testing and disclosure were relatively high. Recommendations are made for nursing education, nursing research and nursing practice with special focus on establishing safe infant feeding practices. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2008.

Magister Public Health - MPH / Background: Appropriate and adequate infant feeding practices are an important factor in achieving optimal health in infants. Inappropriate and inadequate infant feeding practices contribute significantly to ill-health in infants. Both WHO and UNICEF recommend exclusive breastfeeding for the first six months both in the context of HIV and otherwise unless exclusiv formula feeding can meet each of five conditions: acceptable, feasible, affordable, sustainable and safe (AFASS). The modes of infant feeding include exclusive breastfeeding, formula feeding and mixed feeding. Medical recommendations and social pressures related to infant feeding in high HIV-prevalence low-income communities may have shifted infant feeding practices. The aim of this study was to explore factors influencing infant feeding practices and decision making among women in one such community, Kabwata Township, in Lusaka, Zambia. Method: An exploratory qualitative study was conducted at Kabwata Health Centre in Kabwata Township in Lusaka, Zambia. Convenient sampling was used to recruit 32 women for focus group discussions and three key informants (two nurses and one social worker) for individual interviews. Verbal consent was received from all participants. Semi-structured interview guides were used to elicit discussion by all participants. Discussions were tape recorded and transcribed verbatim. Thematic data analysis was used to analyze the qualitative data. Results: Most FGD participants reported that they themselves initiated breastfeeding soon after giving birth, but not all of them breastfed exclusively for the first six months, as is currently recommended. The major factors influencing infant feeding included; influence from family and friends, stigma and discrimination, influence from health care providers, practical realities such as maternal employment and poverty, and cultural/traditional practices. Conclusion: While breastfeeding is valued and accepted, most women do not or cannot exclusively breastfeed for six (6) months for various reasons. Paradoxically, the social value of breastfeeding and the knowledge that breast milk can transmit HIV reinforce mixed feeding as the predominant feeding practice. Key informants reported that women attending health care services at Kabwata health centre were encouraged and taught to breastfeed their infants exclusively for six months. There is a need to re-look at the way the women are being encouraged, taught and supported so that the apparent knowledge and acceptance of breastfeeding can translate into improved infant feeding practices. Awareness campaigns need to include all stakeholders including family members, the community, employers and the women themselves in order to make exclusive breastfeeding easier for the women.

Thesis (MNutr)--Stellenbosch University, 2012. / Please refer to full text for abstract.

Childhood overweight and obesity are public health concerns that have negative health consequences and affect many children. Efforts are needed to identify children who are at a higher risk of developing overweight and obesity so that early detection and treatment may be offered. The intent of this study was to investigate the differences in the effects of postpartum depression on infant feeding practices and infant weight gain between Hispanic and African American women. Data were obtained from Infant Feeding Practices Study 11, a longitudinal study involving mothers in their third trimester through infants first year of life. The overall test of model coefficient of complete cases (N = 192, missing = 443) was not statistically significant (x-² = 4.842, df =2, p = 0.089). The result of the overall test after multiple imputation (n = 289) remained insignificant (on average x-² = 4.031, df = 2, p = 0.133). However, results indicated a significant association between excessive infant weight gain and feeding practices (breast feeding vs. formula feeding; r = 0.207, p = 0.01), supporting previous research on the protective effect of breast feeding on excess infant weight gain. Positive social change implications include an understanding of how maternal and infant characteristics may identify early symptoms of maternal depression, through increased awareness and reduced incidents of childhood obesity and maternal postpartum depression.

Early life factors play important roles in disease susceptibility in later life. However, the relationship between dietary factors in early life on childhood growth, especially linear growth, remains unclear. This research aimed to improve our understanding of the associations between dietary factors in early life (i.e., infant feeding practices and age of introduction of solid foods) and childhood growth, especially using ulnar length as a surrogate measure of length/height, in a cross-sectional study of 1634 mother-child dyads across eight study centers in the National Children's Study Formative Research in Anthropometry in the United States from 2011-2012 (Chapter 1). Chapter 2 described the data acquisition and preprocessing procedures used in this research and provide practical guidelines of data quality control. In Chapter 3, predictive models for exclusive breastfeeding (XBR) initiation and duration was developed. Discriminant analysis revealed maternal sociodemographic factors had greater discriminating abilities to predict XBR initiation and XBR for 6 months, compared to child birth characteristics and maternal perinatal factors. Chapter 4 demonstrated that ulnar length can serve as an accurate and reliable surrogate measure of recumbent length in healthy infants/children aged 0-1.9 years and of height in healthy children aged 2-5.9 years, respectively. Bland-Altman plots and mixed-effects linear regression analyses showed that the three simple and portable tools (i.e., caliper, ruler, and grid) used to measure ulnar length could be used interchangeably in terms of prediction accuracy. Chapter 5 focused on assessing the interplay among gestational weight gain (GWG), birthweight, infant feeding practices, and childhood anthropometrics. Longer duration of breastfeeding reduced the positive associations of GWG and birthweight with weight-for-age z-scores, weight-for-height/length z-scores, and body mass index-for age z-scores in non-Hispanic Whites. These findings underscore the importance of promoting breastfeeding among women with excessive GWG to mitigate childhood obesity. Longer breastfeeding and a later age at introduction of solid foods had positive effects on ulnar length, a linear growth parameter of upper extremity, in Hispanics. Future prospective research aiming to investigate the underlying mechanisms that drive ethnic variation in these associations between early life dietary factors and childhood growth is warranted (Chapter 6). / text

Introduction A group of 317 HIV-1 infected pregnant women and 53 postpartum HIV-negative women were recruited for a two-year prospective descriptive study of psychosocial and other determinants of antenatally planned and actual postnatal feeding, associations between maternal status and infant feeding practices, and health outcomes. Methods The subjects were interviewed periodically for 2 years using structured research instruments. Anthropometric measurements, biomarkers of nutritional status and measurements of pysychosocial wellbeing were obtained from the mothers. Data was collected on infant feeding and outcomes for the babies. Results At recruitment, 74% of mothers planned to formula-feed. Significant differences between these women and those who planned to breastfeed emerged. After delivery, 25% of the women who antenatally planned to formula-feed changed their minds and actually breastfed. Conversely, half of the women who antenatally planned to breastfeed actually formula-fed. Some significant reasons emerged for these feeding changes. Most mothers were well-nourished or overweight. Breastfeeding mothers lost little weight between six weeks and six months after delivery. At the end of follow-up, 65% were obese. While there were differences between HIV-infected and uninfected women in respect of micronutrients, no deficiencies were observed. Vitamin A and selenium concentrations were higher in the HIV-infected women than uninfected women at six weeks. There were no significant micronutrient changes over time. Most mothers maintained an adequate immune status with only slow deterioration of CD4 counts. At two years postpartum, 60% had a CD4 cell count greater than 500cells/mm³, and only about 8% less than 200/mm3. HIV transmission was 15% by 24 months of follow-up. Among the 65 ever breastfed children, 16 (24.6%) were HIV-infected compared to 12.8% of never breastfed children. Most children were growing normally, suggesting that, overall, maternal HIV status did not interfere with feeding ability. Eight mothers (3%) and 33 children (11%) died. Only 12 of 33 children who had died had a positive HIV-PCR. By 2 years, 78% surviving HIV-infected children had been initiated onto ARV therapy. Maternal adherence to HAART was poor. Conclusion HIV and infant feeding counselling is inadequate in the routine PMTCT programme, with stigma and lack of disclosure continuing as major barriers to appropriate care. Whilst maternal obesity was common, most children were growing normally. Weaknesses in routine PMTCT services were identified, and compliance with HAART was poor. / Thesis (PhD)--University of Pretoria, 2010. / Paediatrics and Child Health / unrestricted

Introdução: Intervenções educacionais que preparam as equipes de saúde para a promoção e apoio a práticas alimentares saudáveis na infância podem ser efetivas na melhoria dos desfechos relacionados à saúde, nutrição e desenvolvimento infantil. Objetivo: Avaliar se a utilização de um material de educação permanente, elaborado para apoiar o tutor da Estratégia Amamenta e Alimenta Brasil (EAAB), é efetivo em melhorar indicadores de implementação da EAAB e indicadores de alimentação infantil em crianças menores de um ano. Métodos: Estudo de intervenção do tipo antes e depois realizado no município de Embu das Artes, SP. A intervenção consistiu em disponibilizar o Manual como material de apoio às atividades educativas sobre aleitamento materno e alimentação complementar que poderia ser usado por tutores da EAAB. Os tutores realizaram atividades de treinamento com as equipes de saúde durante oito meses. A coleta de dados ocorreu nos momentos pré e pós intervenção e em ambos foram aplicados: teste de conhecimentos sobre aleitamento materno (AM) e alimentação complementar (AC) aos tutores e profissionais de saúde; questionário auto aplicado junto aos gerentes para caracterização das UBS quanto às ações de promoção do AM e AC e entrevistas junto às mães sobre as práticas de alimentação da criança. Análise de dados: a tese gerou 3 manuscritos: No primeiro com o objetivo de avaliar as práticas de alimentação complementar das crianças de 6 a 12 meses utilizou-se análise de regressão de Poisson com modelagem hierarquizada para determinar os fatores associados ao consumo de alimentos ultra processados. O segundo e o terceiro manuscritos avaliaram os efeitos da intervenção. O segundo teve como foco a aplicação do Manual e sua influência na implementação da EAAB, utilizando duas abordagens: na quantitativa foram analisados dimensões e indicadores do processo de implementação com base no modelo lógico da intervenção e na qualitativa foi avaliada a percepção dos tutores acerca do processo de utilização do Manual. O terceiro manuscrito avaliou a efetividade do Manual na melhoria dos indicadores de alimentação infantil e para tanto utilizou-se análise de regressão de Poisson multinível com modelagem hierarquizada. Resultados: Manuscrito 1. A prevalência de consumo de alimentos ultra processados foi de 43,1% entre os menores de um ano. Baixa escolaridade materna e falta de atendimento na primeira semana de vida da criança foram fatores associados ao consumo de alimentos ultra processados. Manuscrito 2. O Manual foi utilizado por 9 dos 13 tutores do município e a intervenção em algum grau foi realizada em 11 de 13 UBS. Em média foram realizadas 3,5 [0-5] atividades complementares por UBS. A média de acertos dos tutores no teste de conhecimentos inicial foi 31,43 ± 5,25 e final 34,86 ± 4,45; p= 0,021. Entre os trabalhadores a média no pré-teste foi 26,09 ± 4,45 e no pós-teste 30,28 ± 3,55; p= 0,002. Em média o número de critérios de certificação alcançados pelas UBS foi maior depois da intervenção (pré 3 [1-6] versus pós 5 [3-6]) e apresentou consistência com a percepção de mudanças dos gerentes assim como com o número de atividades conduzidas pelos tutores. A avaliação da intervenção sob a ótica dos tutores revelou contribuições do uso do Manual para sua atuação. Manuscrito 3. A intervenção foi efetiva para a redução da falta de diversidade alimentar mínima e da falta de adequação alimentar, indicador que avalia a frequência, consistência e diversidade da AC. Porém, não se verificou efeito sobre a interrupção do AME. Conclusões: A investigação das práticas de alimentação infantil na população estudada evidenciou um alto consumo de alimentos ultra processados, reforçando a necessidade de intervenções que promovam práticas alimentares saudáveis na infância. O uso do Manual de Apoio ao Tutor melhorou o conhecimento dos tutores e trabalhadores da atenção básica e promoveu mudanças no processo de trabalho das equipes, refletidas no alcance dos critérios de certificação na EAAB, evidenciando o potencial de uma intervenção educativa usando metodologia crítico-reflexiva. Além disso, a intervenção mostrou-se efetiva para melhorar as práticas de alimentação complementar na população estudada. / Introduction - Educational interventions that prepare healthcare teams to promote infant feeding practices can be effective in improving outcomes related to health, nutrition and child development. Objective - To evaluate whether a continuing education tool (the Manual to Support Estratégia Amamenta e Alimenta Brasil (EAAB) Tutors) can improve EAAB implementation indicators and feeding practices in infants under one year of age. Methods - A before and after study was conducted at 13 primary healthcare units (PHU) in Embu das Artes, São Paulo. The intervention consisted in providing the Manual to support educational activities on breastfeeding and complementary feeding that could be used by tutors of EAAB. Tutors performed comprehensive training activities with healthcare teams over eight months. In both cross-sectional studies (pre and post intervention) a questionnaire was applied to the managers from the 13 PHU to characterize the healthcare service and actions to promote breastfeeding and complementary feeding; knowledge tests were also applied to tutors and health workers indicators of breastfeeding and complementary feeding practices were assessed by interviewing 1,159 mothers. Analysis: the thesis resulted in three manuscripts - The first one aimed to evaluate the complementary feeding practices of children from 6 to 12 months with a focus on the consumption of ultraprocessed foods (UPF) and multiple hierarchical models were performed. The second and third manuscripts evaluated the effects of the intervention. The second evaluated the application of the Manual and its influence on the implementation of EAAB, with two approaches: in the quantitative, the dimensions and indicators of the implementation process were analyzed based on the logical model of the intervention; in the qualitative approach the perception of the tutors about the process of manuals\' use was evaluated. The third manuscript evaluated the effectiveness of the Manual in improving indicators of infant feeding practices. Multivariate analysis was performed using Poisson multilevel regression Results: Manuscript 1: The prevalence of UPF consumption was 43.1% among children. Lower maternal education and lack of early assistance at the PHU were factors associated with higher UPF consumption. Manuscript 2: The Manual was used by 9 of 13 tutors and the intervention was performed in 11 of 13 PHU. In average, 3.5 [0-5] comprehensive training activities (CAs) were performed by PHU. The mean scores of tutors in the initial knowledge test were 31.43 ± 5.25 and final 34.86 ± 4.45; p = 0.021. Among health workers, the mean in the pre-test was 26.09 ± 4.45 and in the post-test 30.28 ± 3.55; p = 0.002. In average, the number of certification criteria fulfilled by the PHS was higher after intervention (before 3 [1-6]; after 5 [3-6]) and was consistent with the changes perceived by managers as well as with the number of CAs carried out by tutors. Tutors\' perception revealed contributions of the Manual for their action. Manuscript 3: The intervention was effective in reducing the lack of minimum food diversity and the lack of food adequacy, an indicator that evaluates the frequency, consistency and diversity of complementary feeding. However, there was no effect on interruption of exclusive breastfeeding. Conclusions: The investigation of infant feeding practices in the study population evidenced a high ultra-processed foods consumption, reinforcing the need of interventions to promote healthy eating practices in childhood. The use of the Manual to Support EAAB Tutors improved the knowledge of tutors and primary healthcare workers and promoted improvements in the work process of healthcare teams, reflected in the achievement of the EAAB certification criteria, evidencing the potential of an educational intervention using problem-based learning methodology. In addition, the intervention proved to be effective in improving complementary feeding practices in the study population.

<p>Promotion of exclusive breastfeeding (EBF), (giving breast milk only without any solids or liquids), has proved to be very challenging in the South African context, although this infant feeding practice has been found to protect babies against diarrhoea and respiratory tract infections and to carry a lower risk of HIV infection than mixed feeding (breastfeeding combined with formula or solids). Study design: The PROMISE-EBF study is a multi-country cluster randomised trial to examine peer support to promote exclusive breastfeeding in Africa. For the South African site in the PROMISE-EBF study, three sites, Paarl, Rietvlei and Umlazi, were selected because of their different geographic settings and each site operated as a separate stratum for cluster selection and randomisation purposes. The clusters were then randomised into intervention and control arms making a total of 17 clusters in each arm. HIV positive and negative women in the intervention arm received support on their choice of infant feeding from the peer supporters who visited them at their homes while the women in the control group only received the standard infant feeding counselling and support provided by health care&nbsp / workers at health facilities. Data collection: Mothers were interviewed at recruitment during the antepartum period to establish eligibility, obtain informed consent and data on socio-economic status. Home visits were scheduled for data collection by trained data collectors at 3, 6, 12 and 24 weeks after birth. Analysis of results: This mini-thesis was a secondary analysis of the PROMISE-EBF data focusing on the South African data only. The data was adjusted for clustering and analysed using SAS. Comparison of variables between the intervention and control groups within sites was done. Results: A significant difference, regarding counselling and infant feeding practices, was observed among all women who received peer support compared to those who received the standard antenatal counselling, with more women in the intervention group (20.5%) practising EBF than those in the control group (12.8%) by Week 3. When the women‟s HIV status was considered, more than 65% of HIV positive and 40% of HIV negative women practised MF and EFF (giving formula milk only with no breast milk) throughout the study, respectively, regardless of the group they were in. For women who hadintended to practise EBF at recruitment, 33% in the control group and 20% in the intervention group actually practised EBF by Week 3. Regarding disclosure and feeding choice, 77.4% of women who had disclosed their HIV status actually practised MF versus 8.6% who practised EBF by Week 3.Conclusion: Community peer counselling should be strengthened as the results from this study showed that a high percentage of women who practised EBF were those who had received counselling, irrespective of their HIV status. The high percentage of HIV positive women who practised high risk feeding, despite receiving infant counselling, is of concern. Disclosure of the women‟s HIV status did not translate to them practising low risk infant feeding methods, which may suggest that there are other issues that determine the women‟s choice of infant feeding.</p>