BACKGROUND Sub-saharan Africa remains to date at the forefront of the HIV/AIDS epidemic. Despite breastfeeding being a significant mode of postnatal HIV transmission it remains the main nutritional source and pillar of child survival for the majority of infants born in Africa. It is therefore, not surprising that considerable research has centred on making breastfeeding safer in terms of HIV transmission. The flash heat treatment method (HTEBM) provides a unique opportunity to safely breastfeed infants but prevent mother-to-child transmission of HIV. Cytotoxic T lymphocyte (CTL) responses have been well documented in HIVinfected adults and children. However, there is a lack of literature on CTL responses in HIV exposed low birth weight infants. This pilot study attempted to examine the association of early neonatal feeding on the clinical outcomes and CTL responses in HIV exposed low birth weight infants. METHODS Seventy-seven patients that fulfilled inclusion and exclusion criteria were enrolled. The clinical outcomes of these patients were evaluated over a 9 month period. Fifty-five of these patients were also investigated for cytotoxic T lymphocyte (CTL) responses by means of the IFNγ ELISpot (megamatrix and confirmation) assays at the 6 weeks, 3, 6,and 9 months follow-up. RESULTS Two HIV-1 infected infants generated a CTL response at a single time point using the ELISPOT matrix screening assay. These responses could not be confirmed and were undetectable at any of the consecutive visits. At the time of detection of responses the infants were fed unheated breastmilk. HIV-1 exposed uninfected infants were unable to elicit a HIV-1-specific CTL response irrespective of feed. With regards to clinical outcomes, infants born o HIV infected mothers with a CD4 count < 500cells/μl were 2x more likely to acquire other infections at birth compared to those infants born to HIV infected mothers with a CD4 count >500cells/μl. Also, infants born to HIV infected mothers with advanced disease (CD4 count 0-200 cells/μl) had a lower birth weight compared to infants born to HIV-1 infected mothers with a CD4 count > 350 cells/μl. We also investigated the feasibility of the flash heat treatment method at birth. While inhospital, 38 HIV-1 infected women fed their infants HTEBM after receiving counseling and support from the nursing staff at the King Edward VIII hospital. The numbers decreased rapidly post hospital discharge, mainly due to mixed feeding. DISCUSSION In conclusion we have shown that it is feasible for HIV infected mothers to heat treat their expressed breastmilk during hospital admission. Furthermore, we were able to demonstrate in this small cohort of patients that the clinical outcomes and growth parameters of infants fed HTEBM were similar to that of infants fed either formula or unheated breastmilk. We were unable to demonstrate HIV-specific responses in the infected infants or the uninfected infants who had been exposed to heat inactivated virus in HTEBM. Our findings indicate that this pilot study was limited in its ability to detect CTL responses in HIV exposed low birth weight infants and further studies are warranted. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.

Changes in breastfeeding practices have been accompanied by profound changes in the daily context within which women make infant-feeding decisions. The availability and promotion of breast milk alternatives, the transmission of breastfeeding knowledge and skills, and the individual and societal value placed on breastfeeding and breast milk are all issues that need to be considered. In this seminar, Aleck will provide a brief history of breastfeeding trends and policies. He will suggest that a historical understanding of the relationship between socio-cultural trends and breastfeeding patterns is essential to informing current policy development and advocacy in the area of infant feeding. Finally, he will examine the context of policy development in the twenty-first century, including the possible challenges presented by international free trade agreements, questions about federal/provincial responsibility for breastfeeding promotion, the relationship between women’s productive and reproductive work, and the need to redefine breastfeeding success at a policy level.

Bakgrund: Nyblivna mammor rekommenderas att amma under barnets första halvår. År 2008 ändrades den nationella rekommendationen till att ammande kvinnor kan dricka alkohol i måttlig mängd. Syfte: Att undersöka vilka attityder föräldrar uttrycker på föräldraforum angående alkohol under amningsperioden. Metod: Data samlades in genom att undersöka föräldrainriktade webbsidor för att hitta inlägg om föräldrars attityder till amning och alkohol.  Totalt valdes 40 inlägg med medföljande svar, skrivna mellan 2008- 2013, från tre föräldraforum ut. Data analyserades med kvalitativ innehållsanalys med manifest ansats. Resultat: Många föräldrar hade kunskap om Livsmedelsverkets rekommendation och hade olika åsikter om den. Föräldrarna betonade att amning och alkohol inte bara handlade om den medicinska risken för barnet utan också om att omsorgen av barnet kan förändras vid alkoholkonsumtion. Detta ledde in på en diskussion om pappans roll och ansvar i familjen och att amning och alkohol är ett ämne som väcker känslor. Resultaten visade att föräldrarna diskuterar frågan om amning och alkohol på internet via föräldraforum och utbyter kunskap och stöd. Slutsats: Att dricka alkohol under amningsperioden är ett kontroversiellt och mångfacetterat ämne som många har starka åsikter om. Det är viktigt för hälso- och sjukvårdspersonal att ha kunskap om och bemöta denna fråga med respekt för att främja både barns och vuxnas hälsa. Studien har visat att kvalitativ data insamlad på internetforum kan vara en användbar metod för omvårdnadsforskare, förutsatt att de etiska kraven uppfylls. / Background: New mothers are recommended to breastfeed during the child´s first six months. Since 2008, the national recommendation to breastfeeding women is that they may drink alcohol, but in moderation. Objective: To investigate the attitudes that parents express on internet forums about breastfeeding and alcohol. Method: Data were collected by searching parent- oriented websites for posts about parents' attitudes to breastfeeding and alcohol. A total of 40 postings with accompanying answers, written between 2008 and 2013, were chosen from three parent forums. Data were analyzed using qualitative content analysis with manifest approach. Results: Many parents had knowledge of The National Food Administration's new recommendation and had different opinions about it. Parents emphasized that breastfeeding and alcohol was not just about the medical risk for the child as the actual care of the child might also be changed as a result of drinking. This led into a discussion about the father's role and responsibilities in the family. Breastfeeding and alcohol is a subject that arouses emotions. Parents do discuss the issue of breastfeeding and alcohol on the internet via parenting forums and do exchange knowledge and support. Conclusion: Drinking alcohol while breastfeeding is a controversial and multifaceted topic that many people have strong opinions about. It is important for healthcare professionals to have knowledge about this issue and to respond to this question with respect in order to promote both child and adult health. The study has shown that qualitative data collected on internet forums can be a useful method for nursing researchers, provided that the ethical requirements are followed.

The human body is home for millions of bacteria. The largest microbial community is located in the gastro-intestinal (GI) tract, including the oral cavity with &gt;700 identified taxa. Lactobacillus, which is normal inhabitant of the GI tract, contributes to health by possible biofilm and immune modulation. Breast milk is a claimed source for transmittance of Lactobacillus to infants’ GI tract, but there is limited information if breastfeeding affects lactobacilli in the oral cavity. The objectives of Papers I and II of this dissertation were to compare infant oral microbiota by feeding mode, and to characterize oral lactobacilli including potential probiotic properties of the dominant Lactobacillus species. Two cohorts with a total of 340 healthy 3- to 4-month-old infants were investigated. Saliva and oral mucosal swab samples were collected. Bacteria were characterized by culture-dependent and -independent methods, including 16S rRNA genes sequencing, quantitative PCR, and the Human Microbe Identification Microarray (HOMIM). Inhibition of growth and adhesion were also tested. Multivariate modeling of HOMIM-detected oral bacteria clustered breastfed infants separately from formula-fed infants, and linked breastfed infants to a more health-associated flora. Lactobacilli were essentially detected in breastfed infants only. Lactobacillus gasseri was most prevalent out of six identified Lactobacillus species. Infant isolates of L. gasseri bound to saliva gp340 and MUC7 and adhered to gingival epithelial cells. Infant isolates also inhibited adhesion of Streptococcus mutans to saliva-coated hydroxyapatite, and inhibited growth of S. mutans, Streptococcus sobrinus, Actinomyces naeslundii, Actinomyces oris, Candida albicans and Fusobacterium nucleatum in a concentration-dependent fashion. Papers III and IV aimed to assess persistence of probiotic Lactobacillus reuteri, if persistence is necessary for a regrowth of mutans streptococci (MS), and if L. reuteri intake affects oral microbiota composition. Two well-documented L. reuteri strains (DSM 17938 and PTA 5289) were used in two double-blind, randomized controlled trials. In the first, 62 subjects (test=32, placebo=30) with high counts of MS were exposed to L. reuteri for 6 weeks. Exposure followed full-mouth disinfection with chlorhexidine. In the second study, 44 healthy subjects (test=22, placebo=22) consumed the L. reuteri for 12 weeks. Saliva and biofilm samples were collected before, during and up to 6 months after exposure. Analyses included culture, strain-specific PCR and 454-pyrosequencing targeting the hypervariable region V3-V4 of the 16S rRNA gene. L. reuteri test strains were detected in the mouth of approximately two thirds of test participants during intake. However, their presence decreased gradually when consumption stopped. Subjects with detectable L. reuteri had slower regrowth of MS compared to non-carriers. Pyrosequencing yielded a total of 812,547 high-quality sequencing reads. Firmicutes, Proteobacteria, Bacteroidetes, Fusobacteria and Actinobacteria were the major bacterial phyla recovered. Exposure to L. reuteri strains did not affect overall phylotype abundance, but multivariate modeling clustered 12-week-treated test subjects separately from those who received placebo. Exposure to the test strains was strongly associated with presence and increased levels of F. nucleatum and Streptococcus spp. In conclusion, the oral microbiota differed by feeding mode in infants. One third of breastfed infants had lactobacilli in the mouth, while only single formula-fed infant had it. L. gasseri, predominant in infants, displayed probiotic characteristics in vitro. Retention of probiotic L. reuteri was a prerequisite for delay of MS regrowth after disinfection. However, probiotic bacteria may not be beneficial for all, since L. reuteri DSM 17938 and PTA 5289 were retained in only 2 of 3 consumers. Finally, the altered microbiota after 12 weeks consumption of L. reuteri indicates that intake of probiotic bacteria, or at least L reuteri, has an impact on oral ecology. However, this finding needs further investigation. / Vår kropp består av fler mikroorganismer än egna celler.  De miljontals bakterier som finns på ut - och insidan av kroppen är som regel harmlösa och vissa är till och med till nytta för oss. Magtarmkanalen, som startar med munnen, är den kroppsdel som härbärgerar flest bakterier. Till exempel har man bara i munnen identifierat totalt mer än 700 olika arter. En av dessa är Lactobacillus, en bakterieart som finns i normalfloran och som har probiotiska egenskaper. Hos spädbarn anses bröstmjölk vara en källa för Lactobacillus i tarmen, men hur amning påverkar laktobacillförekomst i munnen är oklart. Den första delen i denna avhandling syftar till att jämföra mikrofloran i munnen hos spädbarn som ammas kontra de som får ersättning, att karakterisera vilka laktobaciller som finns i munnen hos respektive grupp och undersöka om dessa har probiotiska egenskaper. Totalt studerades saliv och prov från munslemhinnan från 340 friska 3-4 månader gamla spädbarn. Proven karakteriserades med odling, sekvensering, kvantitativ PCR och en microarraymetod (Human Microbe Identification Microarray, HOMIM), och isolerade laktobacillers effekt på växt och vidhäftning av andra munbakterier studerades. Ammade barn hade en mer hälsoassocierad mikroflora i munnen. Laktobaciller fanns bara hos ammade barn, men bara hos vart 3:e ammat barn. Av totalt sex identifierade laktobacillarter var Lactobacillus gasseri den i särklass mest förekommande arten. L. gasseri isolerade från spädbarnen band till salivproteinerna gp-340 och MUC7 samt till orala epitelceller. L. gasseri kunde även förhindra adhesion av Streptococcus mutans till konstgjord tandemalj och hämma växt av S. mutans, Streptococcus sobrinus, Actinomyces naeslundii, Actinomyces oris, Candida albicans och Fusobacterium nucleatum. Laktobaciller förekommer i många hälsoprodukter med påstådd probiotisk effekt. Andra delen av denna avhandling syftade till att bedöma om intag av tabletter med den probiotiska arten Lactobacillus reuteri påverkar ekologin i mikrofloran i munnen, om arten etablerar sig hos alla vid exponering, och om etablering är nödvändig för probiotisk effekt (mätt som hämmad återväxt av kariesassocierade mutansstreptokocker efter antimikrobiell behandling). Två stammar L. reuteri (DSM 17938 and PTA 5289) användes i två dubbelblinda, randomiserade studier. I båda studierna intog deltagarna i testgruppen tabletter med L. reuteri-stammarna och de i kontrollgruppen identiska tabletter utan bakterier. I den första studien deltog 62 deltagare (32 test, 30 kontroll) i 6 veckor och i den andra 44 personer (22 test, 22 placebo) under 12 veckor. Saliv och biofilmsprover samlades in vid studiestart, under och upp till 6 månader efter avslutad testperiod. Proverna analyserades med odling, PCR och 454-pyrosekvensering. L. reuteri etablerade sig hos 2/3 av testpersonerna under testperioden men mängden minskade gradvis efter avslutat intag. Bland de som fick L. reuteri hade deltagarna med påvisbara teststammar fördröjd återväxt av mutansstreptokocker jämfört med de som inte hade det. Pyrosekvensering visade att totalantalet phylotyper inte skiljde sig mellan de som fick aktiva kontra placebotabletter, men att ekologin i bakteriefilmerna hos de som ätit de aktiva tabletterna ändrades. Att exponeras för L. reuteri var starkt associerat med förhöjda nivåer av F. nucleatum and Streptococcus spp. Sammanfattningsvis visar dessa studier att amning är associerad med att ha probiotiska laktobaciller i munnen men bara vissa etablerar arten i munnen. Hos vuxna försenade L. reuteri återkolonisation av mutansstreptokocker efter antibakteriell behandling, och påverkade ekologin i bakteriefilmerna i munnen. Även hos vuxna ledde exponering till etablering bara hos vissa individer.

The prevalence of obesity in the paediatric population is on the increase and there is speculation that suboptimal breastfeeding patterns may be contributing to the present obesity epidemic. We described the prevalence and trends in underweight and overweight among 3 052 school aged children over a ten year period, and patterns of exclusive and any infant breastfeeding among 671 mothers over a 6 year period on Montserrat a small British colony which forms part of the chain of Caribbean islands, and experienced the eruption of the Soufriere Hills volcano in July 1995. / The results revealed for 11 year old children there was an excess risk of being overweight in the post volcanic period compared to the pre volcanic period (OR=2.1, 95% CI 1.5-2.7). / The rate of exclusive breastfeeding at 6 months of age was exceptionally low (3.4%) in relation to the international recommendations, but the prevalence of any breastfeeding at 4-6 months was relatively high 67.1%. Maternal age was the only significant variable associated with exclusive breastfeeding. / These findings highlight the need for promoting and prolonging exclusive breastfeeding and that overweight is increasing in the children on Montserrat.

The purpose of this study was to determine the efficacy of infant feeding choices and support provided in the current PMTCT programme in KwaZulu-Natal. A case study format was utilised. Follow-up was done over six months with ten HIV positive women enrolled in the PMTCT programme at St. Apollinaris Hospital. Transcripts of interviews were made, pattern-matching was done, and the process of replication was used to develop a cross-case report as the final analysis of the study. All of the women decided to and intended to exclusively breastfeed for between four and six months at the time of the first interview. There was a poor rate of return for follow-up interviews, therefore the actual feeding practice of half of the women after six weeks could not be determined. The case studies were developed with the information available, and thus conclusions were reached during cross-case analysis. Decision-making ability and the capacity to overcome the barriers to the maintenance of their original feeding choice were related to the women's educational levels, employment status, financial and social circumstances and support systems, knowledge and experience of HIV/AIDS, quality of PMTCT education and support, cultural beliefs, and parenting and family values. The age of respondents and differences in marital status had no obvious correlation to maintenance of feeding choice. Parity and level of education had only a limited effect on maintenance of feeding choice. Cues to mixed feeding included a fatalistic view and a loss of hope for preventing transmission of HIV to their infants. Some of the women did not seem to believe that maintaining a specific infant feeding regime was enough to prevent transmission of HIV to their infants. Fear of stigmatisation due to disclosure of their positive HIV status led to non-disclosure of many women, and this in turn led to a lack of support for their feeding choice. Cues to exclusive feeding included an internal pressure to succeed and so decrease the chances of HIV transmission to her infant. Those women who disclosed their HIV status to a significant other and established a good support system were more likely to maintain their original decision. Although none of the women enjoyed good social circumstances, those who were more financially secure, employed, and who had a stable home environment were more likely to maintain their exclusive feeding regime. / Thesis (M.N.)-University of KwaZulu-Natal, Durban, 2004.

An adequate ingestion of essential fatty acids is required for optimal development of the central nervous system and visual acuity in infants. For breast feeding mothers, it is important that a diet containing an adequate balance of essential fatty acids of the n-6 and n-3 series be consumed as this is reflected in breast milk. The objective of this investigation was to determine the essential fatty acid status of breast feeding women and their infants in Havana, Cuba, with particular focus on the n-3 series. The group of 56 Cuban mothers and infants under investigation did not show biochemical or functional signs of poor essential fatty acid status. Based on the biochemical and functional data collected, it is conceivable to conclude that n-3 fatty acid deficiencies must be exceedingly rare, if they exist at all, in the population of breast feeding women and their infants residing in Havana, Cuba. (Abstract shortened by UMI.)

Newborn morbidity and mortality remains high despite a remarkable decline in the infant mortality and under five mortality rates in Nepal over the last decade (1996-2006). Research shows that newborns’ health outcome is associated with maternal and other factors. This study was designed to understand the factors that have an impact on three good newborn care practices: safe cord cutting, early breastfeeding and delayed bathing. The study used the interview data of 815 married women aged 15-49 years who delivered a live baby between February 2008 and February 2009, collected for the baseline survey of the Community-Based Maternal and Newborn Health program implemented in the Sindhuli district of Nepal. The mean age of the sample women was 26 years. Two-thirds of them were from disadvantaged indigenous caste/ethnicity groups, about 70% were uneducated and the majority were poor. Safe cord cutting, early breastfeeding and delayed bathing practices were studied for 803, 810 and 812 women respectively and 70.7%, 46.7%, and 16.6% of the eligible samples demonstrated the practices respectively. The logistic regression method was used to examine the association of independent factors with the outcome variables. Social gradient was found to be associated with all three practices. Rich women were more likely to demonstrate good practices and bearing a child at the prime age (20-34 years) was likely to result in safe cord cutting. Disadvantaged indigenous and ‘other’ caste/ethnicity women demonstrated unsafe cord cutting practices and dalit caste/ethnicity women demonstrated poor bathing practices. Maternal knowledge also emerged as a strong predictor of early breastfeeding and delayed bathing practices. Antenatal care from a SBA determined good breastfeeding and advice from a FCHV determined good bathing practices. The results showed that the uptake of antenatal and delivery services from a skilled birth attendant is unacceptably low in rural Nepal, which is a challenge for meeting the millennium development goals. The study recommends programmes for improving economic status as a key to improving newborn care practices. As the vast majority of the deliveries are still assisted by traditional birth attendants; including them in maternal health programmes is crucial. Increasing women’s access to a skilled birth attendant and boosting the spirit of the FCHVs to increase their efficiency is also recommended. Future research on newborn health should focus on identifying other determinants of newborn care practices and survival. Qualitative studies to understand the cultural perspectives of newborn care practices are also recommended.

Combining breastfeeding and other forms of work is desirable from both public health and labour productivity perspectives. This is often challenging, especially in low- or middle-income fast-growing urban settings. The aim of this thesis was to gain a deeper understanding of mothers’ perspectives on combining breastfeeding and other work in the urban contexts of Dar es Salaam, Tanzania, and New Delhi, India. Individual semi-structured interviews were conducted with community mothers (n=8) and health worker mothers (n=12) in Dar es Salaam, and mothers working in the health (n=10) and education sectors (n=10) in New Delhi. The methods of analysis were:  qualitative content analysis, grounded theory approach, and directed and general inductive content analyses. Mothers’ agency manifested in several ways. Striving to integrate or segment the competing domains of home and work was a goal of these mothers to reduce conflicts in managing breastfeeding and other work. Spatial and time constraints led mothers to engage in an array of carefully planned actions and troubleshooting tactics that included ways of ensuring proximity between them and their baby and efficient time managing. The timing of these strategic actions spanned from pregnancy, over maternity leave, to the return to employment. Managing breastfeeding and work triggered emotions such as stress, frustration and guilt, but also satisfaction and joy. Mothers negotiated with family, employers, colleagues and informal networks to gain support for their strategies, displaying both individual, collective and proxy agency. Changing family structures and roles highlight the potentially greater supportive role of the partner/husband. Work/Family Border Theory and Bandura’s agency constructs provided frameworks for a deeper understanding of mothers’ perspectives, but using existing family relationship constructs would better diffentiate between various modes of agency. Workplaces and maternity protection conditions were generally inadequate. Interventions are required: to strengthen the breastfeeding mother’s own agential capacity using an individual approach; to provide information to families and communities; to improve regulatory, structural and attitudinal conditions at workplaces, and to strengthen health and social services to adequately support mothers in managing breastfeeding and other work.

Background: Exclusively breastfeeding a child during the first six months of life reduces the risk of mortality by 14 times. 42 % of mothers in Indonesia breastfed their infant exclusively in 2012. It is the registered nurses´ responsibility to provide information about consequences of their decision to the patient. Aim: The aim of this study was to investigate how registered nurses describe how they provide patient education about breastfeeding to newly delivered mothers and how registered nurses experience their role as a patient educator. Method: It was an empirical, qualitative study based on a focus group interview with four registered nurses and two midwives. The interview was based on a semi-structural interview design. The focus group interview was transcribed and analyzed using a qualitative content analysis. Result: Three major themes were found in this study, “strategically using different techniques while educating”, ”patient and family centered care” and “the registered nurse as a significant source of knowledge”. The first theme describes how the registered nurses used different techniques to encourage the mothers to breastfeed. The second theme describes the importance to include the entire family in the education and to adjust the education depending on the patient. The third theme describes how the registered nurses saw themselves as significant sources of knowledge and that it was their responsibility to provide evidence-based knowledge. Discussion: All registered nurses and midwives described the importance of evaluating the education. Families had a great influence over the patient in the Indonesian culture, hence, it was crucial to involve them in the education. The registered nurses felt that they were in the right position to give crucial information and education about breastfeeding.