The WHO Code of Marketing of Breast Milk Substitute is a public health recommendation to reduce preventable causes of infant morbidity and mortality associated with malnutrition. Irresponsible marketing of infant formula in hospitals is a threat to exclusive breastfeeding. Nurses are mandated to support, encourage and protect breastfeeding and to familiarize themselves with their responsibilities under this Code. The researcher explored Geneva nurses' knowledge of the Code and its impact in practice. Eighty seven point seven percent of the participating nurses had poor level of knowledge of the Code. Poor knowledge of the Code impacts on the quality and consistency of information given to mothers in hospitals. Inadvertent violations of the Code were observed among a minority of the respondents: 7.3% indicated that they received gifts; 2.4% received sponsorships to conferences. Training about the Code and its application in counseling is recommended to complement the babyfriendly initiative at hospitals to improve nutrition outcomes. / Health Studies / M.A. (Public Health)

Contexte : L’alimentation précoce a une influence sur la croissance et le développement des habitudes alimentaires. Dans la littérature, les déterminants et les effets sur la santé des pratiques d’allaitement et de diversification alimentaire (introduction des aliments autres que le lait) ont souvent été analysés en dissociant ces deux pratiques pourtant très liées. Objectifs : Caractériser par une approche plus globale l’alimentation dans la première année de vie, mettre en évidence ses principaux déterminants et comprendre son influence sur la croissance dans les trois premières années de vie de l’enfant et ses habitudes alimentaires à 3 ans. Méthodes : Les données de la cohorte EDEN qui a recruté 2002 femmes enceintes en début de grossesse, entre 2003 et 2006 dans deux hôpitaux à Nancy et à Poitiers, ont été utilisées. L’alimentation et les paramètres anthropométriques de l’enfant ont été recueillis par questionnaires et examens cliniques à la naissance, 4, 8, 12, 24 et 36 mois. Une analyse en composantes principales a permis d’identifier des profils de pratiques alimentaires dans la première année de vie à partir de la durée d’allaitement, de l’âge d’introduction de différents groupes d’aliments et du mode de préparation des aliments utilisés (préparations « maison », plats préparés « spécifiques bébé » et plats préparés ordinaires du commerce). Des régressions linéaires et logistiques multiples ont été utilisées pour analyser les associations entre profils de pratiques alimentaires, croissance et habitudes alimentaires à 3 ans. Résultats : i) Le type de préparation infantile utilisée de manière prédominante les 4 premiers mois de vie était associé à la parité, l’éducation et le retour à l’emploi maternels mais pas à la croissance de l’enfant sur cette même période. ii) Trois profils de pratiques alimentaires dans la première année de vie ont été identifiés dans la cohorte EDEN. Des scores élevés sur le profil 1 « Diversification tardive et utilisation d’aliments spécifiques bébé » étaient associés à un revenu familial élevé, un âge et un niveau d’études maternels élevés, une parité faible et un recrutement à Nancy. Des scores élevés sur le profil 2 « Allaitement maternel long, diversification tardive et utilisation d’aliments faits maison » étaient associés un âge et un niveau d’études maternels élevés et un recrutement à Poitiers. Des scores élevés sur le profil 3 « Utilisation fréquente d’aliments ordinaires du commerce » étaient associés à un âge maternel plus faible, une parité plus élevée et un recrutement à Nancy. iii) Un score élevé sur le profil 2 était associé à une croissance staturo-pondérale plus lente entre 0 et 1 an et plus rapide entre 1 et 3 ans après ajustement sur les facteurs de confusion potentiels. Ce même profil était associé positivement à la consommation de fruits et légumes à 3 ans. Un ajustement supplémentaire sur la durée d’allaitement maternel atténuait les relations sans pour autant les faire disparaître totalement, suggérant un effet de l’ensemble de pratiques alimentaires dans la première année de vie sur les paramètres que nous avons étudiés. Conclusions : Ces résultats confirment l’importance des déterminants socioculturels sur les pratiques d’alimentation dans la première année de vie. Ils confirment également les liens entre l’alimentation précoce et d’une part la croissance dans les trois premières années de vie et d’autre part l’apprentissage des habitudes alimentaires ultérieures. La prise en compte dans la recherche de l’ensemble des pratiques alimentaires dans la première année de vie, lorsque l’on s’intéresse à leurs effets sur le développement de l’enfant doit être encouragée. / Background: Early eating patterns can determine later eating habits and food preferences and they have been related child growth. In the literature, the determinants and health effects of breastfeeding and complementary feeding practices have often been analyzed separately. Yet, breastfeeding and complementary feeding practices are interrelated and there are arguments to suggest that both influence later health. Objectives : We aimed to characterize feeding practices over the first year of life and to examine their associations with family and infant characteristics, with growth changes in the first 3 years of life, and their relations with food intake at 3 years of age. Methodes : Subjects were participants of the EDEN mother-child cohort. The study recruited 2,002 pregnant women aged 18-45 years attending their prenatal visit before 24 weeks’ gestation at Nancy and Poitiers University Hospitals between 2003 and 2006. Dietary practices and anthropometric measurements were collected through maternal self-report and clinical examinations at birth, 4, 8, 12, 24 and 36 months. Principal component analysis was applied to derive patterns from breastfeeding duration, age of introduction of complementary foods (CF) and type of food used at 1y (ready-prepared baby foods, home-made foods, ready-prepared ordinary foods). Multiple linear and logistic regressions were used to analyze associations between feeding patterns, growth and food intake at 3 years of age. Results : i) The type infant formula (partially hydrolyzed, thickened, enriched in pre- or probiotic and others) used in the first four months of life was related to maternal return to employment, parity but not to infant growth in the same period. ii) Three major feeding patterns were identified in the EDEN study. The main source of variability in infant feeding was characterized by a pattern labeled ‘Late weaning and use of ready-prepared baby foods’. Older, more educated, primiparous women with high monthly income and recruited in Nancy ranked high on this pattern. The second pattern, labeled ‘Longer breastfeeding, late CF introduction and use of home-made foods’ was the closest to infant feeding guidelines. Mothers with high scores on this pattern were older, more educated and recruited in Poitiers. The third pattern labeled ‘Use of ordinary foods’ is more suggestive of infants having a less age-specific diet. Mothers ranking high on this pattern were often younger, multiparous and recruited in Nancy. iii) High scores on the second pattern were related to significant lower 0-1y weight and height change, higher 1-3y weight and height change and to a significant higher fruit and vegetables intake at 3 years of age after controlling for a wide range of potential confounding variables. An additional adjustment on breastfeeding duration attenuated the relationships without making them disappear completely, suggesting an effect of the overall feeding practices in the first year of life on the parameters that we studied. Conclusions : Our results confirm the importance of socio-cultural determinants on feeding practices over the first year of life. They also confirm the relations between early nutrition and growth in the first three years of life and later eating habits. Our results emphasize the need to consider infant feeding over the first year of life including breastfeeding duration, age of complementary foods introduction as well as type of foods used when examining effects of early infant feeding practices on later health.

Abstract: Introduction: Exclusive breastfeeding for the first six months of an infant's life is recommended worldwide. In 1998 the South African Demographic and Health Survey (SADHS) showed that only 10% of mothers exclusively breastfeed at three months. As the HIV virus is transmissible via breast milk, UNAIDS (2002) recommends that women in developing countries should be given a choice of feeding method after being counselled on the risks and benefits of breast feeding versus formula feeding. As a result, the Prevention of Mother-to-Child Transmission (PMTCT) programme was launched in KwaZulu-Natal with the aim of providing interventions to prevent Mother-to-Child Transmission of the HIV virus. However, research has shown that infant feeding practices are influenced by numerous factors. Ultimately mothers will feed their infants in a manner they feel comfortable with, even if it is not always the most appropriate choice. Aim: The aim of this study was to determine and compare current infant feeding practices and some of the factors that influenced these practices among Zulu mothers with 0 - 6 month old infants attending PMTCT and non-PMTCT clinics in Central Durban, KwaZulu-Natal. Methodology: A cross-sectional, descriptive survey was conducted amongst 150 mothers sampled from three non-PMTCT clinics and 150 mothers sampled from three PMTCT clinics. Systematic random sampling of mothers attending the two types of clinics was used to ensure an equal number of mothers· with infants aged 0 - < 6 weeks, 6 - < 14 weeks and 14 weeks to 6 months. The number of mothers interviewed per clinic was determined proportionate to clinic size. Interviews were conducted in Zulu by trained fieldworkers according to a structured interview schedule consisting of 87 open- and closed-ended questions. Summary of most important findings and conclusion: Overall, one quarter of the mothers attending non-PMTCT and one third of mothers at PMTCT clinics were practising exclusive breastfeeding at the time of the survey. The general trend was that mothers attending PMTCT clinics were more inclined than those attending non-PMTCT clinics to breastfeed their infants exclusively (34% versus 24% respectively) or to formula feed (16,7% versus 12,7% respectively). Furthermore, there was a significant decline in exclusive breastfeeding and predominant breastfeeding with increasing infant age in both clinic groups. The opposite held true for mixed feeding and formula feeding in that infants were more inclined to mixed feeding or formula feeding with increasing infant age. In both clinic groups, exclusive breastfeeding was the method of choice in the 0 - < 6 week age category, while a preference for mixed feeding was shown in the 6 - < 14 week category. This trend persisted in the 14 week - < 6 month age category, especially in the non-PMTCT clinics, while there was a small but pronounced increase in formula feeding amongst PMTCT mothers. Although these findings can be explained as a result of implementing the PMTCT programme, the positive trends observed in non-PMTCT clinics serve as an indicator that the Integrated Nutrition Programme (INP) and Baby Friendly Hospital initiative have also had an impact on the feeding choices mothers make. Despite the limited duration of the PMTCT programme at the time of the study, indicators of the impact of the intervention include that a lower percentage of PMTCT mothers introduced foods and/or liquids in addition to breast milk to their infants before six months of age compared to non-PMTCT mothers. Furthermore, more mothers attending PMTCT clinics were shown how to breastfeed and were more likely to have received information about formula feeding. Despite these indicators of a positive impact of the PMTCT programme, the mean age for introducing liquids and/or solids in addition to breast milk was about six weeks and the incidence of this practice was very high for both groups. The similar incidence of formula feeding observed between the two clinic groups suggests the presence of constraints to safe infant feeding choices among mothers attending PMTCT clinics. As observed, infant feeding practices were still not ideal in either of the two clinic groups. However, the high level of antenatal clinic attendance documented for both groups serves as evidence that, if opportunities for providing mothers with appropriate infant feeding advice are utilized optimally, the antenatal clinic could serve as an ideal medium through which infant feeding education can take place, especially as the clinic-based nursing staff were cited as the most important source of infant feeding information by both groups of mothers in the antenatal and postnatal phases. The documented infant feeding practices should be interpreted against the backdrop of factors such as socio-demographic characteristics of the mothers, availability of resources such as social support from peers and significant others and reigning infant feeding beliefs that could influence infant feeding decisions. Predictors of exclusive breastfeeding in PMTCT and non-PMTCT clinics were determined by means of multivariate logistic regression analysis. Significant values were obtained for both clinic groups in terms of the infant not having received liquids in addition to breast milk. No additional predictors were found amongst mothers attending non-PMTCT clinics, however predictors amongst mothers attending PMTCT clinics included whether the mother had not visited the clinic since the infant's birth, whether she practiced demand feeding and whether she was experiencing stress at the time of the study. The limited number of predictors of exclusive breastfeeding documented in this study, especially among non-PMTCT mothers may be explained by the fact that infant feeding behaviour is multifactorial by nature and the interaction between factors that influence feeding choice is strong. / Thesis (M.Sc.)-University of KwaZulu-Natal, Pietermaritzburg, 2005.

The WHO Code of Marketing of Breast Milk Substitute is a public health recommendation to reduce preventable causes of infant morbidity and mortality associated with malnutrition. Irresponsible marketing of infant formula in hospitals is a threat to exclusive breastfeeding. Nurses are mandated to support, encourage and protect breastfeeding and to familiarize themselves with their responsibilities under this Code. The researcher explored Geneva nurses' knowledge of the Code and its impact in practice. Eighty seven point seven percent of the participating nurses had poor level of knowledge of the Code. Poor knowledge of the Code impacts on the quality and consistency of information given to mothers in hospitals. Inadvertent violations of the Code were observed among a minority of the respondents: 7.3% indicated that they received gifts; 2.4% received sponsorships to conferences. Training about the Code and its application in counseling is recommended to complement the babyfriendly initiative at hospitals to improve nutrition outcomes. / Health Studies / M.A. (Public Health)