Humans are exposed to persistent organic pollutants (POPs) such as brominated flame retardants (BFRs, specifically polybrominated diphenyl ethers (PBDEs) and hexabromocyclododecane (HBCD)) and perfluoroalkyl acids (PFAAs, specifically perfluoroalkane sulfonate (PFOS) and perfluorooctanoic acid (PFOA)). They are used in consumer products found in cars, offices, homes and day care centers. Diet was earlier thought to be a major human exposure route for legacy POPs, but does not account for body burdens found for many new POPs and indoor exposure from air and dust has been hypothesized as also important. In this thesis, BFRs in air and dust, and PFAAs in dust from different indoor microenvironments in Sweden were analysed, and the results used to estimate human exposure. BFRs and PFAAs were detected in dust from all microenvironments and PBDEs in all air samples. BFR and PFAA exposure occurs mostly in peoples’ homes with toddlers having higher intakes from dust ingestion than adults. Inhalation and dust ingestion play minor roles compared to diet for humans with median exposures, but in worst case scenarios, dust ingestion may be significant for a small part of the Swedish population. Sampling using home vacuum cleaner bag dust and researcher-collected above floor dust was compared. Correlations were seen for ∑OctaBDE and ∑DecaBDE but not for ∑PentaBDE and HBCD. Higher PBDE concentrations were found in above floor dust but higher HBCD concentrations were found in vacuum cleaner bag dust. BDE-47 concentrations were correlated between vacuum cleaner bag dust and breast milk, indicating exposure through dust ingestion. Similar concentrations of PBDEs were measured in indoor and outgoing air from day care centers, apartment and office buildings. Indoor air explained 54-92% of ∑PentaBDE and 24-86% of BDE-209 total emissions to outdoor air in Sweden, supporting the hypothesis that the indoor environment is polluting ambient air via ventilation systems. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 2: Accepted. Paper 3: Accepted. Paper 4: Manuscript.</p>

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

Breast milk is considered the gold standard for infant nutrition, but many factors can hinder milk production. Mothers of infants in the Neonatal Intensive Care Unit (NICU) are especially prone to stress, which can inhibit volume of breast milk. The purpose of this study was to determine if music listening had an effect on the volume of breast milk pumped and relaxation level of mothers of infants in a NICU. A total of 28 participants, who were mothers of infants in the NICU, were included in the data analysis of this study, with 14 in the control group and 14 in the experimental group. Participants assigned to the experimental group listened to relaxing music during pumping sessions in the NICU, for the duration of their infant’s stay. Participants assigned to the control group pumped as they would normally without the music condition. Results indicated that there was a significant increase in relaxation scores in the music group, but no significant difference in volume of milk pumped. Further research should be done in this area to determine music’s effect on volume of milk pumped by mothers of infants in the NICU.

Maternal folate intake and levels of folate in milk, serum and red cells were assessed in 57 healthy, lactating women, ages 22-38 years, throughout early (0-6 months) and later (7-23 months) lactation. Average maternal folate intake from diet alone was 212 µg/day or 78.5% RDA (1989) and mean total folate intake from diet and supplements was 314% RDA (878 µg/day) at 0-6 months and 238% RDA (620 µg/day) at >6 months. Human milk folate was sufficient to meet the RDA (1989) for infants. Milk folate was not related to maternal folate intake, maternal serum or red cell folate and was unaffected by extended lactation (7-23 months), perhaps at the expense of maternal folate stores. Compared with early lactation, serum folate decreased (p=0.0004) and red cell folate tended to decrease (p=0.08) in later lactation and were both increased by folate supplementation (p < 0.001).Level of folic acid supplementation appeared to predict red cell folate concentration. An average of 884 µg supplemental folate/day was associated with red cell folate levels >400 ng/mL, which have previously been reported as optimal for prevention of folateresponsive neural tube defects. The addition of an 880 µg/day folic acid supplement to the diet of lactating women may raise red cell folate concentrations of lactating women to protective levels. / Department of Family and Consumer Sciences

Mother-to-child transmission (MTCT) of HIV is the most significant source of HIV infection in young children. As the HI virus has been identified in cell-free and cell-associated compartments of breast milk, it is clear that breast milk is one of the ways in which mother-to-child transmission of HIV can take place in addition to in utero and intrapartum transmission. While breastfeeding carries the risk of HIV transmission, not breastfeeding carries significant health risks for infants and young children, such as an increased risk of diarrhoea and pneumonia, morbidity and mortality. When an HIV-positive mother decides to breastfeed her baby, pasteurisation of expressed breast milk (EBM) could be a possible infant-feeding option to limit transmission of the HI virus through breast milk, since this method has shown to effectively inactivate HIV type 1. Three methods of pasteurisation of human milk were investigated in this study: Holder pasteurisation, flash-heating and Pretoria pasteurisation. The systematic review is a helpful method to summarise the best-quality empirical evidence of the benefits and limitations of a specific method, such as heat treatment, and to provide recommendations for future research. Therefore, the aim of this study was to critically synthesise by means of a systematic review the best available existing evidence and to provide a clear overview of the effectiveness of heat treatment of EBM as an in-home procedure to inactivate the HI virus, and in so doing limit mother-to-child transmission of HIV. This study provides the clinical practitioner with accessible information on the effectiveness of heat treatment of EBM as an in-home procedure in terms of (1) safety, inactivation of the HI virus and retaining the protective and nutritional value of the EBM; (2) feasibility as an in-home procedure; and (3) acceptability by the mothers and their communities. This information could be used to improve clinical practitioners‟ knowledge and include it in their health education to contribute to the prevention of mother-to-child transmission. This study is based on the framework of the model for evidence-based clinical decisions of Haynes, Devereaux and Guyatt (2002). The search strategy was conducted in March/April 2009. The initial search resulted in 574 articles. After thorough screening of potentially relevant studies on heat treatment of EBM, the studies that met the inclusion criteria were critically appraised and scored based on their methodological qualities using standardised instruments. After 6 months, the search was updated. The search obtained 1 article. The final sample involved 12 articles. Conclusions were integrated and synthesised as a basis for developing a clear overview of the best available existing evidence. Finally, the findings of the study were synthesised and the research was evaluated, a conclusion was given, limitations were identified and recommendations were formulated for nursing practice, education and research. The bottom-line answer concluded that heat treatment of EBM should be emphasised as a safe alternative for feeding exposed infants (those of an HIV-positive mother, those of uncertain HIV status or during weaning if the mother cannot afford formula or cow‟s milk), but should be supported with appropriate information to the individual mother, her family and the community. Overall it can be concluded that existing evidence of the effectiveness (in terms of safety, feasibility and acceptability) of heat treatment of EBM, particularly Pretoria pasteurisation, used as a simple in-home procedure, is insufficient, and further research is required. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2010

The benefits of breastfeeding are well known. It has been shown that HIV is transmitted through breast milk. The HIV epidemic is threatening exclusive breastfeeding in South Africa. It is important that mothers make the right infant feeding choice. There are three basic infant feeding methods available for HIV infected mothers namely; breastfeeding, replacement feeding or formula feeding and heat treatment of breast milk. There are many risk factors for the transmission of HIV through breast milk. Exclusive breastfeeding may reduce the risk of mother-to-child-transmission, compared with mixed feeding. This can only take place when breastfeeding is done safely and not mixed with other food or drinks. There are many factors that influence a mother's decision to breastfeed, for example personal, social, cultural factors, facilities, environmental factors, knowledge about breastfeeding, mass media and friends. There are also many sources of information about infant feeding methods. The aim of this study was to determine which factors influence the decision on the early infant feeding choice of women who delivered at the Lower Umfolozi District War Memorial Hospital in Empangeni, KwaZulu-Natal. This may help to understand what factors health professionals should focus on in promoting appropriate infant feeding methods. A structured questionnaire was completed by a 100 women and focus group discussions were held with 22 women who delivered at the Lower Umfolozi District War Memorial Hospital. Most of the mothers (72%) did choose breastfeeding, and 58% of these mothers intended to breastfeed for only six months. The majority of the women (97%) received counseling about their infant feeding method, mostly from a health care worker at the clinic. One-third of the women (33%) were influenced by health care professionals on deciding on their infant feeding method and 44% of the participants indicated that no-one influenced them and that they decided themselves. In the focus group discussions the fear of transmission of HIV through breast milk was stated as an important reason why mothers should choose replacement feeding. In conclusion the most important results are that significantly more HIV-infected mothers chose replacement feeding as infant feeding method, and mothers who chose breastfeeding were significantly older than mothers who selected replacement feeding and they made their infant feeding decision significantly earlier than those who chose replacement feeding. According to the focus group discussion results the communities also felt that the HIV-infected mothers should not breastfeed their infants due to the fact that the virus can be transmitted through breast milk. Health professionals should still provide all the necessary information about exclusive breastfeeding for the first six months, even where the prevalence of HIV is high. In most of these areas replacement feeding will not be acceptable, feasible, affordable, sustainable and safe, due to lack of safe water, sanitation and the poor socio-economic status of these people. The dangers of mixed feeding should be emphasized. Most of the women in this study received information from health care workers and family. It is important that family members are included when information is given to women of child-bearing age. Health care workers need appropriate training to ensure that they give the right messages about safe infant feeding to the mothers. / Thesis (M.Sc. (Dietetics)--North-West University, Potchefstroom Campus, 2009.

Mother-to-child transmission (MTCT) of HIV is the most significant source of HIV infection in young children. As the HI virus has been identified in cell-free and cell-associated compartments of breast milk, it is clear that breast milk is one of the ways in which mother-to-child transmission of HIV can take place in addition to in utero and intrapartum transmission. While breastfeeding carries the risk of HIV transmission, not breastfeeding carries significant health risks for infants and young children, such as an increased risk of diarrhoea and pneumonia, morbidity and mortality. When an HIV-positive mother decides to breastfeed her baby, pasteurisation of expressed breast milk (EBM) could be a possible infant-feeding option to limit transmission of the HI virus through breast milk, since this method has shown to effectively inactivate HIV type 1. Three methods of pasteurisation of human milk were investigated in this study: Holder pasteurisation, flash-heating and Pretoria pasteurisation. The systematic review is a helpful method to summarise the best-quality empirical evidence of the benefits and limitations of a specific method, such as heat treatment, and to provide recommendations for future research. Therefore, the aim of this study was to critically synthesise by means of a systematic review the best available existing evidence and to provide a clear overview of the effectiveness of heat treatment of EBM as an in-home procedure to inactivate the HI virus, and in so doing limit mother-to-child transmission of HIV. This study provides the clinical practitioner with accessible information on the effectiveness of heat treatment of EBM as an in-home procedure in terms of (1) safety, inactivation of the HI virus and retaining the protective and nutritional value of the EBM; (2) feasibility as an in-home procedure; and (3) acceptability by the mothers and their communities. This information could be used to improve clinical practitioners‟ knowledge and include it in their health education to contribute to the prevention of mother-to-child transmission. This study is based on the framework of the model for evidence-based clinical decisions of Haynes, Devereaux and Guyatt (2002). The search strategy was conducted in March/April 2009. The initial search resulted in 574 articles. After thorough screening of potentially relevant studies on heat treatment of EBM, the studies that met the inclusion criteria were critically appraised and scored based on their methodological qualities using standardised instruments. After 6 months, the search was updated. The search obtained 1 article. The final sample involved 12 articles. Conclusions were integrated and synthesised as a basis for developing a clear overview of the best available existing evidence. Finally, the findings of the study were synthesised and the research was evaluated, a conclusion was given, limitations were identified and recommendations were formulated for nursing practice, education and research. The bottom-line answer concluded that heat treatment of EBM should be emphasised as a safe alternative for feeding exposed infants (those of an HIV-positive mother, those of uncertain HIV status or during weaning if the mother cannot afford formula or cow‟s milk), but should be supported with appropriate information to the individual mother, her family and the community. Overall it can be concluded that existing evidence of the effectiveness (in terms of safety, feasibility and acceptability) of heat treatment of EBM, particularly Pretoria pasteurisation, used as a simple in-home procedure, is insufficient, and further research is required. / Thesis (M.Cur.)--North-West University, Potchefstroom Campus, 2010

The benefits of breastfeeding are well known. It has been shown that HIV is transmitted through breast milk. The HIV epidemic is threatening exclusive breastfeeding in South Africa. It is important that mothers make the right infant feeding choice. There are three basic infant feeding methods available for HIV infected mothers namely; breastfeeding, replacement feeding or formula feeding and heat treatment of breast milk. There are many risk factors for the transmission of HIV through breast milk. Exclusive breastfeeding may reduce the risk of mother-to-child-transmission, compared with mixed feeding. This can only take place when breastfeeding is done safely and not mixed with other food or drinks. There are many factors that influence a mother's decision to breastfeed, for example personal, social, cultural factors, facilities, environmental factors, knowledge about breastfeeding, mass media and friends. There are also many sources of information about infant feeding methods. The aim of this study was to determine which factors influence the decision on the early infant feeding choice of women who delivered at the Lower Umfolozi District War Memorial Hospital in Empangeni, KwaZulu-Natal. This may help to understand what factors health professionals should focus on in promoting appropriate infant feeding methods. A structured questionnaire was completed by a 100 women and focus group discussions were held with 22 women who delivered at the Lower Umfolozi District War Memorial Hospital. Most of the mothers (72%) did choose breastfeeding, and 58% of these mothers intended to breastfeed for only six months. The majority of the women (97%) received counseling about their infant feeding method, mostly from a health care worker at the clinic. One-third of the women (33%) were influenced by health care professionals on deciding on their infant feeding method and 44% of the participants indicated that no-one influenced them and that they decided themselves. In the focus group discussions the fear of transmission of HIV through breast milk was stated as an important reason why mothers should choose replacement feeding. In conclusion the most important results are that significantly more HIV-infected mothers chose replacement feeding as infant feeding method, and mothers who chose breastfeeding were significantly older than mothers who selected replacement feeding and they made their infant feeding decision significantly earlier than those who chose replacement feeding. According to the focus group discussion results the communities also felt that the HIV-infected mothers should not breastfeed their infants due to the fact that the virus can be transmitted through breast milk. Health professionals should still provide all the necessary information about exclusive breastfeeding for the first six months, even where the prevalence of HIV is high. In most of these areas replacement feeding will not be acceptable, feasible, affordable, sustainable and safe, due to lack of safe water, sanitation and the poor socio-economic status of these people. The dangers of mixed feeding should be emphasized. Most of the women in this study received information from health care workers and family. It is important that family members are included when information is given to women of child-bearing age. Health care workers need appropriate training to ensure that they give the right messages about safe infant feeding to the mothers. / Thesis (M.Sc. (Dietetics)--North-West University, Potchefstroom Campus, 2009.

Typescript. / Thesis (Ph. D.)--University of Hawaii at Manoa, 1985. / Bibliography: leaves 210-235. / Photocopy. / Microfilm. / xiv, 235 leaves, bound 29 cm

[Truncated abstract] Mothers who deliver prematurely often have a delay in lactogenesis II and subsequent milk supply. Furthermore, due to the inability of their babies to breastfeed immediately after birth, these mothers are 'pump dependent' during both initiation and establishment of lactation. Apparently, there are no evidence based guidelines for the expression regime but some data suggesting that expression regimes for both breasts should be at least five times per day and at least 100 minutes expressing time per day. The project was set out to document the self selected current expression regimes of the preterm mothers from day 10 to 60 postpartum. It defined how various aspects of breast expression, such as frequency and interval, impact on the synthesis and production of milk. In addition, it determined the variations in the composition of preterm mother's milk. The collection of 24hr expression data and milk samples at each expression of each breast, each day, of 25 preterm mothers (<32 gestation age) from the neonatal intensive care unit in King Edward Memorial Hospital, Western Australia on day 10, 15-20, 30, 40, 50 and 60 postpartum showed that during the 'pump dependent' period (day 10 20), the frequency of expression for both breasts was 6, 6-7, 3-9 times per day (median, IQR, range) and total duration with the pump was 115, 80-160, 32-320 minute per day (median, IQR, range). Furthermore, during the 'transition from exclusively expressing to exclusively breastfeeding' period (day 30-60), frequency of expression/breastfeed and total duration of milk removal (both expressing and breastfeeding) for both breasts were 6, 5-7, 1-9 and 135, 75-170, 25-320, respectively (median, IQR, range). ... These nutrients make up the energy content of milk, thus the energy content of milk also varied greatly between mothers. Therefore, milk from individual preterm mothers varies greatly for individual values for fat, total protein, lactose and energy and this should be taken into account when calculating the level of fortification required for individual babies. The results suggest that when fortifying mother's milk, weekly measurement of fat and protein in milk would provide good estimates on which to base fortification requirements. The concentration of sIgA plus lactoferrin formed 32% of the total proteins in breastmilk. However there was large variations in the concentration of sIgA and lactoferrin (median, IQR, range: 0.82, 0.59-1.13, 0.05-2.93g/l and 2.41, 1.52-3.52, 0.04-8.82g/l, respectively) between mothers. Therefore the level of protection provided by these two proteins could differ greatly between babies. Further research on the relationship between the concentration of sIgA and lactoferrin in milk and the onset of infection would indicate the minimum amount of these proteins needed for the babies to benefit from the immune protection provided by their mother's milk. The hourly breast expression method and regression analysis of actual milk yield and interval since previous expression provides information that identifies the potential milk synthesis capacity of the breasts of the mothers and the impact of the interval between expressions on the milk production of the mothers. This information can be applied to individualize the interval between expression regimes to optimise milk production and minimize the demand on the mother. In addition, determining the changes in the milk composition of individual mothers would provide a more precise base to fortify their milk for their preterm babies.