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Maternal and Child Nutrition 2013; Supplement 3

Maternal and Child Nutrition 2013, Supplement 3: 4255

2013 John Wiley & Sons Ltd

over bread. Among mothers, 40.9% drank tea during meals and
55.0% reported doing this 15 times/week. Another 77.0% of
mothers drank milk and 59.0% reported doing this either
during meals or within an hour before/after meals. Regarding
preventative measures for ID anemia; 88.8% confirmed regular
weighing of children, 91.3% confirmed de-worming, and
95.7% confirmed taking iron supplements. Only seven mothers
indicated food totems for children which included pork (forbidden for religious reasons), fish and eggs (both believed to
cause a child to become a thief), cowpea (believed to cause
malaria) and cashew nuts. For mothers, dog meat and pork
were forbidden for religious reasons.
Though mothers had some knowledge on the prevention of
ID, a significant number of half truths, myths and totally inaccurate information about ID, anemia and preventive measures
emerged from the survey, which should be addressed through
targeted education.

Poster Presentations
Knowledge attitudes and practices (KAP)
regarding iron deficiency (ID) among
mothers in an anemia endemic
population in Northern region of Ghana
B.A.Z. Abu, V.J. Louw, A. Dannhauser,
J. Raubenheimer and L.V. Van den Berg
Faculty of Health Sciences, University of the Free State, Bloemfontein,
South Africa

References
Prior assessment of the knowledge, attitude and practices
(KAP) is viewed as an effective way of determining the goals
of nutrition interventions (Stoltzfus & Dreyfuss, 1998).
Among Ghanaian women, the highest prevalence of anemia
was found among lactating mothers, women with children and
women from rural populations (GDHS, 2008). An earlier
GDHS (2003) found that 80.6% of mothers with anemia
also had a child with anemia. In Northern Ghana 59.9% of
women of reproductive age and 81.0% of children 659
months suffer from anemia (GDHS, 2008). Peoples dietary
habits and patterns are influenced by experiences with food
cultural beliefs and practices. This study assessed the KAP
of mothers in Northern Ghana, regarding known risk factors
for ID.
This was a cross-sectional descriptive study conducted
among mothers with children 659 months from two randomly selected districts in the Northern region in April 2012.
A questionnaire developed by the researchers to assess KAP
regarding the known risk factors for ID, was administered
during structured interviews. Manual content analysis was
done with open ended questions and responses categorized
into themes. SAS software was used to manage quantitative
data.
Of the 161 mothers 98.1% were Muslims, 91.9% had no
formal education, and 30.5% had their first child at 19 years
of age, and 65.5% at 2029 years of age. When asked who is
most vulnerable to anemia, 63.3% did not know, while 16.4%
thought it would be adult men, adolescent boys or menopausal
women. Most mothers (83.2%) believed that falling pregnant
at a young age caused anemia, while the rest (16.8%) believed
age at first pregnancy did not matter; and 69.4% reported
standing for long hours as a cause of anemia. Open responses
included; anemia is caused by God, or by standing in the sun,
and that adolescent boys and men develop ID from hard work.
The mothers identified tiredness (64.6%) and general weakness (73.8%) as symptoms of anemia, while also listing edema,
and itchy body. According to mothers, some causes of anemia
were stress, dirty environment, malaria, and pregnancy.
Among foods that can assist in preventing anemia, 62.5% of
mothers chose oranges over mangoes and 69.0% chose liver

Ghana Demographic and Health Survey (GDHS). (2008). Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical
Research (NMIMR), and ORC Macro. Ghana Demographic and
Health Survey 2007. Calverton, Maryland: GSS, NMIMR, and ORC
Macro. Available at http://www.measuredhs.com/pubs/pdf/FR221/
FR221.pdf. Accessed on 2nd August, 2011.
Ghana Demographic and Health Survey (GDHS). (2003). Ghana Statistical Service (GSS), Noguchi Memorial Institute for Medical
Research (NMIMR), and ORC Macro. 2004. Ghana Demographic
and Health Survey 2003. Calverton, Maryland: GSS, NMIMR, and
ORC Macro. Available at http://www.measuredhs.com/pubs/pdf/
FR152/FR152.pdf. Accessed on 3rd August, 2011.
Stoltzfus RJ., Dreyfuss Ml. (1998). Guidelines for the Use of Iron supplements to Prevent and Treat Iron Deficiency Anemia; International
Nutritional Anemia Consultative Group (INACG), World Health
Organisation (WHO), United Nations Childrens Fund (UNICEF).
International Life Sciences Institute Press. Washington DC.

Premature infants night time awakening

and their mothers attachment styles and
bedtime behaviour
R. Alia, W. Hallb, S. Wongb, F. Warnockb,
M. Whitfieldb and P. Ratnerb
a

Jordan University of Science and Technology, Irbid, Jordan and

University of British Columbia, Canada

Infants night sleep patterns, in particular problematic night

waking, are common concerns for parents. Between onequarter and one-third of infants aged six months to five years
have sleeping problems (Mindell et al 2006). In particular,
parents complain about night waking with signaling (crying);
50% of infants with problematic night waking require parental
intervention to resume sleep (Goodlin-Jones et al 2001). Many
factors can influence the development of infants night sleep
patterns and sleep problems, although none are have been
shown as causal.

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Poster Presentations

The aims of this study were threefold to: (1) investigate

the association between mothers anxious style of attachment, maternal behaviors at bedtime, family functioning,
maternal happiness, marital status, birth order and infant
health, and premature infants signaled night waking; (2) test
the independent relationship between mothers anxious
style of attachment and premature infants signaled night
waking; (3) examine the ability of mothers anxious style
of attachment and maternal behaviors at bedtime to differentiate infants with sleep problems from infants without sleep
problems.
Using a cross-sectional survey, online data were collected
from mothers of premature infants aged 56 months (corrected) across a number of English speaking countries. The
main outcome measures were frequency of signaled night
waking, total duration of signaled night waking and maternal
perception of infant sleep problems. The main predictors were
mothers anxious style of attachment and settling behaviors
at bedtime. Parental Interactive Bedtime Sleep Behaviors
and The Brief Infant Sleep Questionnaire were used to
operationalize the main study outcomes for the regression
analyses. Multiple regression analyses, adjusting for factors
such as family functioning, maternal happiness and infant birth
order, were used to investigate associations among mothers
anxious style of attachment and settling behaviors and premature infants signaled night waking.
Data were available for 105 premature infants between 5
and 6 months of age (corrected). Males represented 60% of
the sample; 63% of infants were first born. Mothers reported
that 55% percent of children had sleep problems and 17% of
mothers rated the problem as serious. Mean frequency of signaled night waking was 2.1 times/night and mean minutes of
total duration of night waking was 45.7/night. The regression
analyses revealed the total duration of night waking was significantly associated with mothers anxious style of attachment and maternal physical comforting behaviors at bedtime.
Maternal physical comforting behavior was also associated
with infants frequency of night waking and differentiated
between infants with sleep problems and without sleep
problems.
Mothers anxious style of attachment and physical comforting behaviors at bedtime were associated with premature
infants night waking and sleep problems. Knowledge of these
findings may help nurses and other healthcare practitioners
identify infants who may be at risk of developing sleep problems. The findings can heighten healthcare providers awareness of potentially relevant factors when assessing and treating
sleep problems in premature infants. Neonatal intensive care
unit nurses may incorporate this knowledge in their discharge
planning. More research is warranted to explain the mechanism of this association and to determine whether this association is causal.

43

Mindell, J. A., Kuhn, B., Lewin, D. S., Meltzer, L. J., & Sadeh, A.
(2006). Behavioural treatment of bedtime problems and night wakings
in infants and young children. Sleep, 29, 12631276.

What women want: Insight into

breastfeeding support strategies using a
patient-centered approach
K. Cadwell and C. Turner-Maffei
Union Institute & University, Cincinnati, OH, USA and Healthy Children
Project Inc, E. Sandwich, MA, USA

Breastfeeding is the recommended method of infant feeding

with few exceptions, yet few areas of the world have achieved
the optimal desirable outcome of exclusive breastfeeding for
about 6 months. The aim of our study was to investigate
whether the absence of womens voices in the planning of
breastfeeding support services and promotion strategies contributes to continuing low breastfeeding intensity.
A search review of the qualitative studies examining
womens experiences with breastfeeding and breastfeeding
support published in English using populations in Europe,
Canada, USA, UK, AUS and NZ for the prior 20 years was
conducted in 2007 and updated in 2013. Of the more than
2,400 abstracts retrieved and scanned for appropriateness, 107
articles met our criteria of study type, location and population.
Full-text of these 107 works were reviewed to extract themes of
what women want from breastfeeding support and services.
We then developed practice and policy strategies to address our
findings.
By synthesizing findings from the identified qualitative
studies, we found that the breastfeeding care women want
appears to be in stark contrast with what they receive, especially the health care system. We synthesized the themes identified into 5 practice and policy strategies using the voices of
women in order to propose more optimally crafted services to
meet the needs and expectations of childbearing women
regarding infant feeding. These strategies are:
1. Establish a staff approach to care that is woman centered
not breastfeeding centered
2. Ensure continuity and evidence-based care (e.g. implement
the Ten Steps to Successful Breastfeeding)
3. Ensure individualized assessments of breastfeeding
4. Keep hands off mothers breasts when helping
5. Give individualized, not standardized, advice
Failure to incorporate the breastfeeding support desires, expectations, and experience of childbearing mothers in the design
and evaluation of breastfeeding support programs may severely
limit their impact. Additional research and implementation of
five strategies identified above may optimize outcomes.

References
Goodlin-Jones, B. L., Burnham, M. M., Gaylor, E. E., & Anders, T. F.
(2001). Night waking, sleep-wake organization and self-soothing in
the first year of life. Journal of Developmental and Behavioral Pediatrics, 22, 226233.

Key references
Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2007).
Listening to Mothers II: Report of the Second National U.S. Survey of
Womens Childbearing Experiences: Conducted January-February

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44

Maternal and Child Nutrition 2013; Supplement 3

2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International. The Journal of Perinatal Education:
An ASPO/Lamaze Publication, 16(4), 1517. doi:10.1624/
105812407X244778
DiGirolamo, Ann M, Grummer-Strawn, L. M., & Fein, S. B. (2008).
Effect of maternity-care practices on breastfeeding. Pediatrics, 122
Suppl 2, S4349. doi:10.1542/peds.2008-1315e
McInnes, R. J., & Chambers, J. A. (2008). Supporting breastfeeding
mothers: qualitative synthesis. Journal of advanced nursing, 62(4),
407427. doi:10.1111/j.1365-2648.2008.04618
Schmied, V, & Barclay, L. (1999). Connection and pleasure, disruption and distress: womens experience of breastfeeding. Journal of
Human Lactation: Official Journal of International Lactation Consultant Association, 15(4), 325334.
Schmied, V., Beake, S., Sheehan, A., McCourt, C., & Dykes, F. (2011).
Womens perceptions and experiences of breastfeeding support: a
metasynthesis. Birth (Berkeley, Calif.), 38(1), 4960. doi:10.1111/
j.1523-536X.2010.00446
Weimers, L., Svensson, K., Dumas, L., Navr, L., & Wahlberg, V.
(2006). Hands-on approach during breastfeeding support in a neonatal
intensive care unit: a qualitative study of Swedish mothers experiences. International Breastfeeding Journal, 1, 20. doi:10.1186/17464358-1-20.

The value of a multi-discipline: medical,

dietetic and psychotherapy approach in
treating children with adverse
feeding behaviours

Reference

J. Elfera and J. Hawdonb

a

mise of the quality of his diet to enable progress with his

feeding behaviour. The psychotherapist programme offered his
mother referral for individual support, which at that stage the
mother felt unable to embark on. She was open to monthly
psychotherapy input with her baby. Discussions focused on
how feeding was progressing alongside advice from the rest of
the team. The baby was able to play and be observed. These
psychotherapy observations allowed his mother to think with
the therapist about the babys experience of the world around
him. In this way the mother came to understand more of what
her baby needed.
Within three months the dream feeding practices had been
stopped and the baby had started to feed in his high chair and
play with his food. The quality of his diet was still limited and
vitamin supplementation was started. The quantity of food he
took was adequate and he was growing well but milk intake
remained excessive. Due to the mothers lack in confidence to
set further boundaries and follow the advice, progress was
slow. However, with continuing psychotherapy input to help
her overcome her fears, she managed to wean the milk intake at
night and to improve the quality of the babys diet. Psychotherapy also gently addressed how the mothers own view of
the world had impacted on her interpretation of the babys
responses by helping her to feel less persecuted by his
demands, without seeing his curiosity as naughty wilfulness.
Dream feeding should be strongly discouraged. A multidisciplinary approach is invaluable in helping mothers address
feeding difficulties in their children.

University College London Hospitals, London UK and Barts Health NHS

Trust London, UK

Our multi-disciplinary clinic treats children younger than 2

years of age who present with feeding and growth concerns
(Lucarelli et al., 2003). We complete initial assessments
medical (clinical problems; developmental milestones),
dietetic (growth and dietary evaluation) and psychotherapy
(emotional impact of the birth; subsequent experiences of the
mother and infant and impact on feeding).
Our case example is a 9 month old infant presenting with
feeding difficulties to the extent that he has to be swaddled and
asleep supine in his cot to accept being fed any milk or solid
food, termed as dream feeding. Apart from the main problem
stated, the medical and dietetic assessment revealed nothing
other than the texture and quality of the diet was not age appropriate. The psychotherapy assessment looked at the relationship between mother and infant and took into account the
mothers own childhood experiences of being interned in a
prisoner of war camp.
Our treatment included voicing, as a team, his risk of aspiration whilst being fed swaddled and asleep as this was the first
and main aspect to address. We agreed that a step by step programme will be needed. Medically we reassured his mother
that he will come to no harm if one bottle a day is omitted and
he is fed in a high chair instead, even if he initially accepts no
food in this position. The dietitian allowed an initial compro-

Lucarelli, L., Ambruzzi, A.M, Cimino, S., DOlimpio, F., Finistrella,

V. 2003. Feeding disorders in infancy: an empirical study on motherinfant interactions, Minerva Pediatrica, 55, 3, 24353

Determinants of neonatal mortality in

Nigeria: Evidence from 2008
Demographic and Health Survey
O.K. Ezeha, M.J. Dibleyb, J. Hallc, A.N. Paged
and K.E. Aghoa
a
School of Medicine, University of Western Sydney, Australia bSydney
School of Public Health, University of Sydney, Australia, cSchool of
Medicine and Public Health, University of Newcastle, Australia and
d
School of Science and Health, University of Western Sydney, Australia.

Nigeria continues to have one of the highest rates of neonatal

deaths in Africa. This study aimed to identify risk factors associated with neonatal death in Nigeria using the 2008 Nigeria
Demographic and Health Survey (NDHS). We used neonatal
deaths of all singleton live-born between 2003 and 2008 from
the 2008 NDHS. The 2008 NDHS was a multi-stage cluster
sample survey of 36,298 households. Of these households, survival information of 27,147 singleton live-born were obtained,
including 996 cases of neonatal mortality.
The risk of death was undertaken adjusting for confounders
relating to individual, household and community level factors

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Poster Presentations

using Cox regression. In the multivariate analysis higher birth

order of babies with a short birth interval 2 years (Hazard
Ratios (HR) = 2.19, CI = 1.682.84) and babies with a higher
birth order with a longer birth interval > 2 years (HR = 1.36,
CI = 1.051.78) were significantly associated with neonatal
mortality. Other significant factors that affected neonatal
deaths included: babies born to mothers younger than 20 years
(HR = 4.07, CI = 2.835.86); babies born to mothers residing
in rural areas compared to urban residents (HR = 1.26,
CI = 1.031.55); male babies (HR = 1.30, CI = 1.121.53);
mothers who perceived their baby body size to be smaller than
average size (HR = 2.10, CI = 1.772.50) and mothers who
delivered their babies through caesarean section (HR = 2.80,
CI = 1.844.25).
These findings suggest that Nigerian government need to
invest more in health care system to ensure quality care for
women and newborns. Community based intervention is also
needed and should focus on child spacing, childbearing at
young age and poverty eradication programmes, particularly in
rural areas, in order to reduce avoidable neonatal deaths in
Nigeria.

45

work, to share the burden and/or bonding of infant feeding, and

to maintain or increase milk supply. Mothers perceived pumps
to be less efficient than infants at emptying breasts, and perceived HME as time-consuming, costly, and unpleasant, yet
necessary to meet HM feeding goals whether bottled HM was
used as an occasional stand-in for feeding at the breast or as a
major method of HM feeding. Mothers reported using pumps
to monitor changes in or sufficiency of milk supply and to
gauge infant intake or prescribe feeding amounts to other
caregivers, who were reported to feed the majority of their
bottled HM.
This study provides the first in-depth information about the
psychosocial determinants of and strategies for implementing
HME and feeding bottled HM. This knowledge will inform
U.S. infant feeding recommendations, breastfeeding promotion programming, and clinical practices to optimize infant
health, growth, and development. Given the importance of
breastfeeding, these phenomena must be further explored.
Funded by NIH (T32DK007158) and USDA (Hatch
399449).

References
Reference
Demographic and Health Survey, Nigeria (2008) National Population
Commission, Federal Republic of Nigeria, ICF Macro, USA

Mothers reasons for and perceptions of

human milk expression and feeding: A
longitudinal, qualitative investigation
J.P. Felicea, K.M. Rasmussena, C.M. Olsona and
S.R. Geraghtyb
a
Division of Nutritional Sciences, Cornell University, Ithaca, New York,
USA and bCincinnati Childrens Hospital Center for Breastfeeding
Medicine, and Department of Pediatrics, University of Cincinnati, USA

A majority of breastfeeding women in the U.S. use human milk

expression (HME), or pumping, to feed human milk (HM) to
their babies and meet personal goals for breastfeeding duration
and exclusivity ( Labiner-Wolfe et al 2008; Geraghty et al
2012). Yet, little is known about the reasons and strategies for
HME, mothers perceptions and attitudes toward HME, and
how HME fits with HM feeding and other feeding choices
(Geraghty et al 2005). We used qualitative methods to explore
these issues.
In upstate New York, we recruited 20 sociodemographically diverse pregnant women who were planning
to breastfeed and considering HME. We conducted a longitudinal series of in-depth, semi-structured qualitative interviews
with these women in late pregnancy, early postpartum, and at
other key times in the first year such as initiation of HME,
return to work, and introduction to solids. Interviews were
transcribed and themes were identified with content analysis.
Mothers used HME for several need- and desire-based reasons
that differed by infant age, such as latch difficulty, return to

Geraghty SR, Khoury JC, Kalkwarf HJ. Human Milk Pumping Rates
of Mothers of Singletons and Mothers of Multiples. Journal of Human
Lactation. 2005;21(4):41320
Geraghty SR, Sucharew H, Rasmussen KM. Trends in breastfeeding:
it is not only at the breast anymore. Maternal & Child Nutrition. 2012;
9(2):180187.
Labiner-Wolfe J, Fein SB, Shealy KR, Wang C. Prevalence of
Breast Milk Expression and Associated Factors. Pediatrics. 2008;
122(Supplement 2):S638.

Breast is best but not for me. A study

of young peoples attitudes to infant
feeding in a South London
comprehensive school
L. Gale, J.H. Foster, K.P. Cleaver and
P.A. Jackson
University of Greenwich, London, UK

It has long been recognised that breastfeeding has health benefits for both mother and child. More recently its benefits to
cognitive development have also been recognised (Kramer
et al., 2008), benefits which are of particular value in the
most disadvantaged groups (ISER, 2011). Earlier studies
(De-Gale, 1995, Earle, 2000) propose that young womens
decisions about infant feeding are potentially formed at an
early age and reflect their own norms and values. It has been
suggested that a lack of a breastfeeding culture in the UK
contributes to reduced breastfeeding rates (MacGregor and
Hughes, 2010).
A study of the attitudes of school pupils in years 9 and 10
towards infant feeding was undertaken in a local mixed comprehensive school. The study was not intending to assess the
pupils knowledge base but instead their attitudes towards

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Maternal and Child Nutrition 2013; Supplement 3

breast and bottle feeding. A questionnaire was used and the

data analysed using SPSS. Pupils, both boys and girls, were
asked to record whether they agreed or disagreed with a range
of statements about breastfeeding and bottle feeding. These
statements were framed to reflect either positive or negative
perceptions and were listed at random. Pupils were also asked
if they had witnessed breastfeeding and how they felt about
seeing mothers breastfeed.
Findings suggest that young people are aware that Breast is
best but that does not necessarily reflect feeding intentions.
They were aware of health benefits for the baby, but less so of
benefits for mothers. Negative perceptions were around
breastfeeding being tiring, embarrassing or uncomfortable.
When considering formula feeding, just over half the pupils
felt it to be more convenient, whilst 30% that it had health benefits for the baby. Overall the results from the survey indicate
that pupils tend to be more accepting of family or friends breast
feeding than they are of strangers breast feeding in public
places. There appeared to be conflict between breastfeeding
as physiologically natural and bottle feeding as socially
natural. There was no statistical difference in attitude for
gender, ethnicity or previous teaching.
The study suggests that the message that breast is best
has got through to young people but that a clear understanding of why it is, is not evident. The finding that some pupils
feel that bottle feeding has health benefits may indicate the
success of milk manufacturers advertising techniques in comparison to the limited advertising budget of the Department
of Health. Despite knowing it is better for baby, young people
still couldnt see it as a reality for themselves and this
appears to be a better way to approach teaching focussing
on lived experiences of young parents. Breast feeding promotion within the school environments needs to become more
widespread but also to focus less on physiological facts
and more on understanding social attitudes, including visual
cues.

References
De-Gale J (1995) Promoting breastfeeding in schools. Health Visitor
68(11): 452453.
Earle, S. (2002). Factors affecting the initiation of breastfeeding:
implications for breastfeeding promotion. Health promotion international, 17(3), 205214
Kramer, M. S., Aboud, F., Mironova, E., Vanilovich, I., Platt, R. W.,
Matush, L, et al. (2008). Breastfeeding and child cognitive development: new evidence from a large randomized trial. Archives of general
psychiatry, 65(5), 578.
MacGregor, E., & Hughes, M. (2010). Breastfeeding experiences of
mothers from disadvantaged groups: a review. Community Practitioner, 83(7), 3033

A qualitative study to investigate

healthcare workers knowledge,
perceptions and reported practice
regarding breastfeeding in Bangladesh
A. Gopferta, H.E. Nasreenb and J. Parrc
a
University of Newcastle, UK, bBRAC Research and Evaluation
Department, Bangladesh and University of Leeds, Leeds, UKc

The World Health Organisation (WHO, 2001) recommend

breastfeeding as the optimal infant feeding method. Despite
multiple initiatives to promote breastfeeding in Bangladesh,
optimal practice remains below targets; using strict measurements 12% of mothers practice exclusive breastfeeding
(Haider et al., 2010, National Institute of Population Research
and Training, 2009). Support from healthcare workers is essential for optimal breastfeeding. No studies have yet studied
knowledge and practice of Bangladeshi healthcare workers
towards breastfeeding (WHO 1989). Therefore this qualitative
study aimed to explore knowledge, perceptions and reported
practice of healthcare workers regarding breastfeeding.
Sixteen semi-structured interviews were carried out with
healthcare workers who were from urban and rural settings and
different sectors of the healthcare system. Data were analysed
using thematic content analysis. Preliminary findings were
validated in context with the NGO BRAC (Bangladesh Rural
Advancement Committee).
Participants were largely aware of optimal breastfeeding practice but were unaware of contraindications to
breastfeeding. Attitudes towards optimal breastfeeding practice were mixed. Participants reported giving inconsistent
advice to women facing common breastfeeding problems,
demonstrating a lack of understanding of the bio-psychosocial barriers to breastfeeding. Participants made suggestions
for how to improve optimal breastfeeding prevalence in Bangladesh. These were increased training of healthcare workers,
increased awareness of optimal breastfeeding practice, and
increased number of community health workers.
All participants knew of WHO recommended breastfeeding practices. Mothers may be receiving inadequate or inappropriate advice when presenting with common problems preventing optimal practice. In addition advice given to working
mothers is not sufficient to overcome barriers for exclusive
breastfeeding. Recommendations are made for additions to
training programmes for healthcare workers and implementation of policy providing guidance on support for target groups
such as working mothers.

References
Haider, et al. (2010). Breastfeeding in Infancy: identifying the
program relevant issues in Bangladesh. International Breastfeeding
Journal, 5(21).
National Institute Of Population Research And Training. (2009).
Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh; Macro International, March 2009. (Available from http://
www.measuredhs.com/pubs/pdf/FR207/FR207[April-10-2009].pdf)
2013 John Wiley & Sons Ltd Maternal and Child Nutrition (2013), 9 (Suppl. 3), pp. 4255

Poster Presentations

World Health Organisation. (1989). Protecting, Promoting and supporting breastfeeding: the special role of maternity services. Geneva,
Switzerland; WHO, 1989. Available from: http://whqlibdoc.who.int/
publications/9241561300.pdf [Accessed on 18th June 2012]
World Health Organisation. (2001). The Optimal Duration of
Exclusive Breastfeeding. Report of an Expert Consultation. Geneva,
Switzerland: WHO.

Factors associated with sub-optimal

complementary feeding practices among
children aged 623 months in six
Francophone West African countries
A.I. Issakaa, K.E. Aghoa, D. Mahnsa,
P. Burnsa and M.J. Dibleyb
a

School of Medicine, University of Western Sydney, Australia and

Sydney School of Public Health, University of Sydney, Australia

Inappropriate complementary feeding practices play a crucial

role in childrens health and development in the first two years
of life (Kabir et al 2012). This period has been recognized as
the critical window for the promotion of optimal growth,
health, and development of a child ( Pan American Health
Organization & World Health Organization 2003). Children
may become stunted if they do not receive sufficient quantities
of quality complementary foods after 6 months of age even if
they receive optimum breastfeeding (Black et al 2008). By
ensuring optimal complementary feeding an estimated 6% of
under-five deaths can be prevented (Black et al 2003). Malnutrition (a consequence of sub-optimal complementary feeding)
is currently the leading cause of the global burden of
disease(Ezzati et al 2002) and has been identified as the
underlying factor in about 50% of deaths of children under 5
years of age in developing countries (Black et al 2003). The
objective of this research paper is to comprehensively assess
factors associated with complementary feeding practices in six
Francophone West African countries (Benin, Burkina Faso,
Guinea, Mali, Niger and Senegal).
This study included 19,108 children aged 623 months
from the six countries concerned (Benin: 4549 children;
Burkina Faso: 2805 children; Guinea: 1,653 children, Mali:
4,549 children, Niger: 2,645 children and Senegal: 2,907
children). The most recent Demographic and Health Surveys
(DHS) of the various countries were used as data sources.
The four complementary feeding indicators (introduction of
solid, semi-solid or soft foods; minimum dietary diversity;
minimum meal frequency; and minimum acceptable diet)
were examined against a set of individual, household
and community level factors using multiple regression
analyses.
The rates of introduction of solid, semi-solid or soft foods
among children aged 68 months in Benin, Burkina Faso,
Guinea, Mali, Niger and Senegal were 61%; 36%; 47%;
30%, 62% and 57% respectively. Minimum dietary diversity
rates among children aged 623 months were alarmingly low

47

for all six countries. These rates ranged from 26%-16% in

Senegal, Benin and Guinea and varied from 10%3% in
Niger, Burkina Faso and Mali. Benin recorded relatively
better rates for minimum meal frequency (50%), followed by
Niger (41%), Senegal (39%), Burkina Faso (31%), Guinea
(30%) and Mali (20%). Minimum acceptable diet rates
among breastfed children aged 623 months were alarmingly
low (from 22%-3%) for all six countries. Multivariate analyses indicated that children aged 611 months, geographic
region, limited access to mass media and household income
are the main common factors associated with the complementary feeding indicators.
Overall, in the six Francophone West African countries,
complementary feeding practices were well below levels recommended by the WHO. Hence, public health interventions
to improve complementary feeding practices are needed at
national level with special focus on high risk groups.

References
Black RE, Morris SS, Bryce J. Where and why are 10 million children
dying every year?. The Lancet. 2003;361:222634.
Black RE, Allen LH, Bhutta ZA, Caulfield LE, Onis MD,
Ezzati M. Maternal and child undernutrition: global and regional
exposures and health consequences. The Lancet. 2008;371(9608):
24360.
Ezzati M, Lopez AD, Rodgers A, Van der Hoom S, J MC, Group
tCRAC. Selected major risk factors and global and regional burden of
disease. The Lancet. 2002;360:134760.
Kabir I, Khanam M, Agho KE, Mihrshahi S, Dibley MJ, Roy SK.
Determinants of inappropriate complementary feeding practices in
infant and young children in Bangladesh: secondary data analysis of
Demographic Health Survey 2007. Maternal & Child nutrition.
2012;8:1127.
Pan American Health Organization, World Health Organization.
Guiding Principles for Complementary Feeding of the Breastfed
Child. Washington, DC/Geneva 2003.

Optimising baby to breast attachment

(OBBA): A pilot randomised controlled
trial of a complex intervention
T. Kellya, E. McCollb, D. Carrick-Sena, T. Finchb
and S. Robsonb
a

Newcastle Hospitals NHS Foundation Trust Tyne & Wear, UK and

Newcastle University, Tyne & Wear, UK

A large number of mothers in the UK who initiate

breastfeeding give up prior to six weeks because of feeding
problems. Around 80% of these may arise because of poor
baby-to-breast attachment (BBA) (International Lactation
Consultant Association, 2008). In 3 phases the OBBA study:
refined, tested feasibility, and evaluated a complex intervention
designed to optimise baby-to-breast attachment.

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Maternal and Child Nutrition 2013; Supplement 3

Phase 1 used cognitive interviewing techniques to elicit

feedback from mothers receiving the intervention (n = 23). In
the intervention, a nursery nurse undertook a breastfeeding
assessment and delivered a 10 minute education session
about optimising BBA to the new mother prior to discharge
from hospital. A supporting information booklet and flip
book were supplied to take home. The nursery nurse completed a home follow up visit at 7 days to undertake a further
assessment and reinforce earlier teaching. In phase 2 healthy
women who delivered a healthy term infant were randomised
to a control group (standard care) or intervention group
(standard care plus the intervention) (n = 106). Outcomes
measured at 7 days and 6 weeks were: feeding method; satisfaction with breastfeeding experience; breastfeeding selfefficacy (BFSE); and number of breastfeeding problems.
Phase 3 involved a qualitative sub-study involving in-depth
interviews with women who took part in the pilot RCT and
focus groups with different levels of staff.
The feasibility of undertaking an RCT of the intervention
was demonstrated; of 547 women screened 215 (39.3%) were
eligible of which 176 (81.9%) were approached and 106
(60.2%) agreed to participate. All but one woman received her
allocated intervention. Additional methods of collecting
primary outcome data using telephone, text and email contact
with women and health professionals were developed resulting
in all but one primary outcome obtained at 7 days and all but
two at 6 weeks. Minor ambiguities were highlighted in the data
collection tools which can easily be addressed in a future
definitive trial.
Compared to the control group at 7 days the intervention
group scored higher for satisfaction [median 7.0 (IQR 3.0)
vs. median 8.0 (IQR 2.0) p = 0.04] and BFSE [median 50.0
(IQR 17.5) vs. median 59.0 (IQR 14.5) p = 0.006], and
reported fewer problems [median 5.0 (IQR 6.75) vs. median
3.0 (IQR 2.75) p = 0.02]. At 6 weeks compared to the control
group the intervention group had higher satisfaction scores
[median 8.0 (IQR 2.0) vs. median 9.0 (IQR 3.0) p = 0.06];
higher BFSE scores [median 59.0 (IQR 11.0) vs. median 64.0
(IQR 12.5) p = 0.05]; and reported slightly fewer problems
(median 2.5 (3.0) vs. median 2.0 (IQR 2.0) p = 0.297].
Breastfeeding rates at 6 weeks in the intervention group
were 71% (n = 37/52) and 67% (n = 35/52) in the control
group.
This pilot RCT demonstrates that an intervention to optimise BBA can be delivered within the clinical area and that
a focus on optimising BBA may reduce the number of
breastfeeding problems, increase confidence in breastfeeding,
and increase satisfaction with breastfeeding experience. A
definitive trial is required to establish if optimising BBA can
impact breastfeeding duration.

Reference
International Lactation Consultation Association 2008. Core Curriculum for Lactation Consultant Practice, Boston, Jones & Bartlett

The impact of early infant feeding on the

development of atopic disease
E. Loughrill, L. Harbige, B.Z. Chowdhry and
N. Zand
School of Science, University of Greenwich, Medway Campus, Chatham
Maritime, Kent, UK

The prevalence of allergic disease has increased over the last

three to four decades, decreasing quality of life and causing a
significant amount of health burden with 25% of the paediatric
population in the industrialised world suffering from an atopic
disease (atopic dermatitis, asthma, food allergies etc.) in early
life. Although genetic predisposition is evident in many cases,
it cannot completely explain the increase in atopic disease. The
earliest manifestation observed in infancy is usually eczema
and food allergy; 80% of affected children go on to develop
inhalant allergies such as asthma and allergic rhinitis; this is
referred to as the atopic march (Jennings and Prescott 2010).
Evidence suggests that exclusive breastfeeding for 6 months
can decrease the incidence of atopic disease; especially in
infants with a first degree family history of atopy (Jackson and
Nazar 2006). The aim of this review is to identify and appraise
the published scientific evidence concerning the effects of diet
and specific nutrients in early childhood on the risks of developing atopic disease in order to provide a better understanding
of the relationship between early infant feeding and allergic
disorders.
The preliminary findings of this review has identified four
main focus areas concerning nutrition and allergic disease: a)
nutritional dietary selection patterns during pregnancy, lactation, and the first year of life that may affect the development
of atopy; b) the impact of decreased consumption of fresh
fruit, vegetables and minerals in the western diet on the
prevalence of allergic disease; c) the relationship between
increased consumption of n-6 polyunsaturated fatty acids
(PUFA) and decreased consumption of n-3 PUFA with atopic
disease; and d) improved hygiene standards as a possible
stimulant factor for elevated allergic responses and possible
benefits of adding prebiotics and probiotics into the diet.
Given the importance of vitamin D on immune functions
and the finding of low vitamin D status in many western populations and its link to chronic inflammatory disease, including
asthma, it would be pertinent to investigate its occurrence in
infant feeds particularly as requirements are controversial. It
has been suggested that the earlier interventions are made, the
greater the effect they will have on atopic disease. Dietary
restrictions of potentially allergenic foods during pregnancy
and infancy have not proved beneficial for the prevention of
atopic disease. There is no conclusive evidence to suggest the
role of specific nutrients, food types and dietary patterns on the
prevalence of asthma. Furthermore there are many limitations
with the studies conducted into infant nutrition and the effect it
has on atopic diseases. The limitations include only a single
exposure of the allergen over a limited time, data collection
methods basedon recall bias and limited use of biomarkers of
actual nutritional exposure. The dietary factors examined give

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conflicting conclusions indicating the need to use longitudinal

studies.

References
Jennings, S. and Prescott, S. L. (2010) Early dietary exposures and
feeding practices: role in pathogenesis and prevention of allergic
disease? Postgrad Med J, 86 (1012):949
Jackson, K. M. and Nazar, A. M. (2006) Breastfeeding, the
immune response, and long-term health J Am Osteopath Assoc, 106:
2037.

Exploring the training needs of clinicians

to support breastfeeding in postnatal
wards of a tertiary centre in Womens
Hospital, School of Medicine, Zhejiang
University, Zhejiang Province, China
Y.Y. Maa, L.M. Wallaceb, S.M. Lawb and
L.Q. Qiua
a
Womens Hospital, School of Medicine, Zhejiang University, Hangzhou,
China bApplied Research Centre in Health and Life Sciences, Faculty of
Health and Life Sciences, Coventry University, UK

In 1992, Chinas Ministry of Health launched Baby Friendly

Hospital Initiative (BFI) to increase the nations exclusive
breastfeeding rate and since then, 6745 large or medium-sized
hospitals and 3475 small hospitals have achieved Baby
Friendly Initiative accreditation. In 2011 the Ministry of
Health reported that there were 1027 BFI-accredited hospitals
in Zhejiang Province, but most BFI accredited hospitals have
not been reassessed. In the Womens Hospital School of Medicine, which is BFI accredited, 96.9% of the mothers initiated
breastfeeding. However, the exclusive breastfeeding rate on
discharge from hospital was 50.3%, suggesting problems with
support by post-natal clinicians. This study aimed to explore
clinicians views of their knowledge and practice, and training
needs for breastfeeding support in hospital.
Interviews were conducted with 10 participants, including
public health experts, midwife leaders, nurses, midwives
and BFI trainers. This included perceptions of current
training content and delivery, improvements needed, local
breastfeeding policies, how BFI training is implemented, practices to support breastfeeding, their views on their patients
beliefs and practices relating to infant feeding. Individual interviews were conducted using a semi-structured instrument to
guide the discussion. All interviews were audiotaped and transcribed before being translated to English before being
analyzed thematically. Results were presented on practices and
policies and broad areas where implementing new policies and
training would be needed.
Most of those interviewed knew that BFI strategies
including the Ten Steps had been implemented in the hospital to improve the rate of breastfeeding. They all believed
that BFI had brought a great change to the practice of

49

breastfeeding and had increased rates. Everyone interviewed

had been trained in breastfeeding. They believed that
knowledge and skills, such as the benefits of breastfeeding,
positioning and attachment and how to tackle problems
confronted by mothers, were very important in supporting
mothers to breastfeed successfully. Professionals all hoped
for further training on evidence based knowledge and
breastfeeding skills. They believed that most mothers stopped
breastfeeding because of returning to work after three months
and they lacked support from skilled professionals when they
had problems during breastfeeding.
Understanding clinicians perspectives, prior to objectively assessing the knowledge and skills of post-natal ward
clinicians is a first step in designing appropriate training. The
next stage is to develop a Chinese version of the Coventry
University Breastfeeding Assessment (CUBA) on line knowledge and skills tool. A usability study with 10 staff will establish their views of CUBA. The translated CUBA will be used
with frontline staff (midwives, health visitors and nurses) to
establish the levels of knowledge achieved via current training
methods. A training programme, modeled on a culturally
adapted version of the successful Coventry University
Breastfeeding Workbook and Essential Skills DVD, will be
developed to support practices on breastfeeding in the hospital. The effectiveness of the training will be assessed using a
Chinese version of CUBA and by measuring breastfeeding
rates at discharge from hospital.

References
Health Department of Zhejiang Province. (2012) http://www
.zjwst.gov.cn/art/2012/8/16/art_262_196355.html
Niu, X., Y. Zhao, et al. (1993). Education Outline of Chinese
Childrens Development Plan in the 1990s. Beijing, Central Broadcasting and Television University.
Qiu, L., Zhao, Y., Binns, C. W., Lee, A. H., and Xie, X. (2009) Initiation of Breastfeeding and Prevalence of Exclusive Breastfeeding at
Hospital Discharge in Urban, Suburban and Rural Areas of Zhejiang
China. International Breastfeeding Journal 4, 1-1
Song, L. (1999) International breastfeeding week. Maternal and
Child Health Care of China 14, 5624

Risk of aflatoxin M1 exposure from

breast milk in infants under six months of
age in Rombo, Tanzania
H. Magohaa,b, M. Kimanyac, D. Roberfroidd,
C. Lachata, B. De Meulenaera,d and
P. Kolsterena,d
a
Faculty of Bioscience Engineering, Ghent University, Belgium, bOpen
University of Tanzania (OUT), Tanzania, cNelson Mandela African
Institute of Science and Technology, Tanzania and dPrince Leopold
Institute of Tropical Medicine, Antwerpen, Belgium

Aflatoxins are carcinogenic toxins produced by fungal and can

be found in food. Through consuming aflatoxin contaminated
foods lactating mothers are likely to have Aflatoxin B1

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Maternal and Child Nutrition 2013; Supplement 3

metabolites known as Aflatoxin M1 (AFM1) in their breast

milk to which Infants can be exposed through breastfeeding
(Lamplugh, et al 1988). This study was conducted to assess the
occurrence of AFM1 in breast milk, exposure rates and impacts
to breastfeeding infants under six months of age.
A total number of 145 infants and their mothers were progressively and purposively recruited and three follow-up
visits were made at 1st, 3rd and 5th months of age. Breast milk
samples and data on anthropometric measurements of infants
and 24hr dietary recall of the mother were collected. AFM1
extraction from breast milk was done by immune-affinity
clean up columns and determination was done using HPLC
(Navas et al 2005, Shundo et al., 2009). Assessment of exposure was computed by multiplying contamination level (ng/
ml) by Milk intake (mls per kg body weight (bw) per day). To
compare the risk of AFM1 exposure in infants the margin of
exposure (MoE) was computed as recommended by EFSA
(2005).
All breast milk samples were contaminated with
AFM1, the contamination ranging between 0.010.55 ng/ml.
Ninety percent (90%) of samples exceeded the limit of
0.025 ng/ml set by EU for infants foods. A minor increase in
the number of contaminated samples with values above the
EU limit (0.05 ng/ml) of AFM1 in dairy milk and milk
products was observed over lactation stages. Exposure for
AFM1 ranged from 1.1366.79 ng/kg body weight per day
and the highest exposure was observed at the 1st month of
infants age. The MoE for AFM1 in all infants were below
10,000.
Though infants can be exposed to AFM1 via breast milk, it
is however difficult to regulate AFM1 contamination in breast
milk. It is thus important to monitor the food sources of AFB1
contamination in the maternal diet and intercept the problem in
advance.

References
EFSA. (2005). Opinion of the scientific committee on a request from
EFSA related to A harmonised approach for risk assessment of substances which are both genotoxic and carcinogenic. EFSA Journal,
2005(282), 131.
Lamplugh, S., Hendrickse, R., Apeagyei, F., & Mwanmut, D. (1988).
Aflatoxins in breast milk, neonatal cord blood, and serum of pregnant
women. British Medical Journal (Clinical Research Edition),
296(6627), 968.
Navas, S., Sabino, M., Rodriguez-Amaya, D. (2005). Aflatoxin M1
and ochratoxin A in a human milk bank in the city of So Paulo, Brazil.
Food Additives and Contaminants. 22(5), 457462.
Shundo, L., Navas, S.A., Lamardo, L.A., Ruvieri, V., & Sabino, M.
(2009). Estimate of aflatoxin M1 exposure in milk and occurrence in
Brazil. Food Control, 20, 655657.

Age of solid introduction, diet and food

preferences in 9 month old infants:
A descriptive analysis of data from the
GO-CHILD birth cohort
A. Ntouvaa, A. Macadama, P. Emmettb,
S. Mukhopadhyayc, K. Basuc, S. Inglisd,
A. Memone and I. Rogersa
a
School of Pharmacy and Biomolecular Sciences, University of Brighton,
Brighton, UK, bCentre for Child and Adolescent Health, Department of
Community Based Medicine, University of Bristol, Bristol, UK,
c
Department of Pediatrics, Royal Alexandra Childrens Hospital,
Brighton and Sussex Medical School, Brighton, UK, dBiomedical Research
Centre, University of Dundee, Dundee, UK and eDivision of Primary Care
and Public Health, Brighton and Sussex Medical School, Falmer, UK

Since the adoption of the WHO recommendation of exclusive

breastfeeding for the first six months of life (WHO 2001) by
the UK Department of Health, there have been limited
studies looking into whether this advice has resulted in a subsequent shift in the age of solid introduction in infants. The
aim of this study is to assess the eating habits and behaviours
of 9 month old infants in relation to the age they were introduced to solids.
The GO-CHILD trial is a multicentre birth cohort aiming to
explore the interaction between genetic and environmental
factors that may contribute to childhood diseases. This paper is
based on the information provided by 244 mothers from
Sussex and Fife when their infants were aged around 9 months.
The questionnaire included information about infant feeding
practices, age of solid introduction, introduction and consumption of specific food items and eating behaviours such as
feeding problems and perceived fussy eating. The age of solid
introduction and the age of introduction of lumpy solids
(before and after 6 months) were considered in relation to
introduction of selected foods, perceived fussy eating and food
preferences.
37.5% (84/224) of infants were introduced to solids at/after
6 months, 31.7% (71/224) at 5 months and 27.2% (61/224) at 4
months. Most of the infants (95.1%, 232/244) had already tried
foods with lumpier texture by 9 months with the majority
trying lumps at 7 months (38.8%, 92/237). By 9 months, 77.7%
of infants had tried red meat (188/242), 84.8% (151/178) fish,
63.6% (154/242) eggs, 86.6% (207/239) cheese, 64.6% (153/
237) pulses, 92.5% (223/241) yoghurt, 15.5% (37/237)
peanuts or peanut butter and 8.4% (20/237) other nuts. There
were no differences in the proportion of infants introduced to
any of the above foods between those first given solids before
or at/after 6 months (red meat: P = 0.34, fish: P = 0.89, eggs:
P = 0.85, cheese: P = 0.58 pulses: P = 0.59, yoghurt: P = 0.17
peanuts or peanut butter: P = 0.21, other nuts: P = 0.26). 84.9%
of mothers (141/166) reported that their infant would eat
almost anything, 13.3% said they were quite choosy whereas
1.8% said their infant was very choosy. There were no differences between those introduced to solid food before compared
to at/after 6 months and perceived fussy eating (P = 0.81),
meat preferences (P = 0.47), fruit preferences (P = 0.46) or

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Poster Presentations

vegetable preferences (P = 0.48). The same was true for introduction of lumps.
Compared to the UK 2010 infant feeding survey (Health
and Social Care Information Centre 2012) a considerably
higher proportion of infants in our study were introduced to
solids at six months (35.5% versus 6%), highlighting a trend
towards the government recommendations. However, the
timing of solid or lump introduction did not seem to have an
effect on food preferences and fussy eating at 9 months. More
in-depth analysis is required to explore confounding factors
that could have potentially influenced the results of this study.
Acknowledgements
Special thanks to Dr. Paul Seddon, Dr. Heike Rabe (NHS
Sussex, Brighton) and Dr. Patrick Chien, Dr. Donald
Macgregor (NHS Tayside, Dundee) for their contribution to
the study.

References
Health and Social Care Information Centre, IFF Research (2012).
Infant Feeding Survey 2010. Available at: http://www.ic.nhs.uk/pubs/
infantfeeding10final Accessed November 2012
World Health Organisation (2001). The optimal duration of exclusive
breastfeeding. Report of an Expert Consultation. Geneva, Switzerland

Nutritional status and dietary iron intake

of adolescent expectant mothers
attending antenatal clinics in Eldoret
West District- Kenya
L.A. Omondi, G.A. Ettyang and A.M. Kwena
School of Public Health, Moi University, Eldoret, Kenya

Adolescent pregnancy is a major public health issue in both

developed and developing countries and is associated with
nutritional, economical and sociological risks. There is an
increased need for nutrients during this phase and therefore
adequate supply of nutrients is required to maintain the delicate balance between the needs of the mother and the growing
fetus. Deficiency of all the nutrients is likely to poor nutritional
status of the mother and poor pregnancy outcome and intervention measures needed to address this problem. The objectives
of this study were to: assess adequacy of nutrient intake, determine haemoglobin levels, establish nutritional status and identify factors affecting the iron intake of adolescent expectant
mothers
A cross sectional study of 384 expectant adolescents aged
1519 years who attended antenatal clinics in Turbo and
Huruma Health Centers was conducted. Dietary intake was
determined by a pretested interviewer administered Food Frequency Questionnaire. A nutrient calculator was used to calculate mean daily nutrient intake with adequacy of nutrient intake
based on Estimated Average Requirement (EAR). Blood
samples were used to determine haemoglobin levels for the
prevalence of anaemia based on World Health Organization
criteria (Hb < 11 g/dL). Sahli method a qualitative diagnosis

51

of malaria using blood slide and microscopy was carried out.

Mid-upper arm circumference (MUAC cut-off for < 230 mm)
and triceps skin fold (TSF) were used to estimate mid- upper
arm muscle area (MUAMA) using non-stretchable measuring
tape and skin fold caliper model Gima Plicometro respectively.
Chi-square test of association and t-test were used to determine
the factors associated with dietary iron intake. Data was
analyzed using SPSS V.16.0 and 5% level was considered statistically significant.
The majority (n = 304, 79.4%) of the study participants
were married. Their mean age was 17.6 (1.3 SD) years. Half
(n = 195, 50.8%) had attained primary level of education.
More than three quarters (n = 278, 76.1%) were earning less
than 5,000 Kenya shillings per month. The proportion of adolescents who had inadequate intake of vitamin C, folate and
proteins were 72%, 50% and 44% respectively. Mean energy
intake was 2303 (802.2 SD) calories. The prevalence of
anaemia was 57% (n = 219) and 32% of the study participants
were undernourished (MUAC < 230 mm). Mean Mid-upper
arm muscle area (MUAMA) was 35.5 (11.6 SD) cm. Nutritional education was a significant predictor of dietary iron
intake (OR: 95% CI: 1.65: 1.0052.708).
The study found that nutrition education was a predictor
factor for dietary iron intake. There is need therefore to
repackage nutrition education and target the needs of expectant
adolescents.

Barriers and facilitators to

population-wide implementation of the
WHOs Baby-Friendly1Initiative: Lessons
learned from Quebec, Canada
S. Semenica, D. Groleaua, K. Gray-Donalda,
J. Lauziereb and L. Haieka,c
a
McGill University, Quebec, Canada, bLaval University, Quebec City,
Canada and cQuebec Ministry of Health and Social Services, Canada

Despite irrefutable evidence for the benefits of breastfeeding

and the well-documented, positive impact of the World Health
Organization (WHO)s Baby Friendly Initiative (BFI) on
breastfeeding outcomes, the number of Baby-Friendlydesignated health care facilities in the industrialized world
remains low (Semenic et al, 2012a). In 2001, the government
of Quebec, Canada launched a major initiative to promote
implementation of the BFI in all hospital, birthing centers, and
community health centers in the province (Semenic et al,
2012b). This study aimed to identify social processes acting as
barriers or factilitators to the adoption of the BFI in Quebec, in
order to inform future public health policies related to
breastfeeding promotion and support.
We conducted a qualitative, multiple case study with
embedded units of analysis to explore factors influencing
implementation of the BFI in a diversity of health care settings
across Quebec. The selected cases varied in size (small,
medium or university hospitals and their affiliated community

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health centers) as well as level of BFI implementation (low vs.

high). Data were collected via in-depth interviews with health
care managers and BFI leaders (N = 42), and focus group discussions with hospital and community-based health care providers (N = 95 participants), and breastfeeding mothers
(N = 52 participants). Interview data were transcribed; coded
and analysed using thematic content analysis; and interpreted
using concepts from critical theory, institutional theory, and
diffusion of innovation theory.
Key obstacles to the pursuit of Baby-Friendly accreditation
included concerns that over-promotion of breastfeeding would
instill maternal guilt; inadequate resources and staffing to
enable all personnel to receive breastfeeding training or invest
time in breastfeeding support; resistance to change and the
absence of designated leaders with protected time to coordinate BFI implementation activities (or lack of leaders with
credibility or powers of influence among colleagues); poor
continuity of breastfeeding promotion and support activities
across hospitals, community-health centers and private physician offices; and lack of availability or access to communitybased breastfeeding services and support groups. Our
recommendations for strengthening implementation of the BFI
targeted stakeholders at the provincial, regional, and local
levels, including the allocation of sufficient funds for the multiple costs of BFI implementation, are: designation of dedicated
and credible leaders for the BFI implementation process; adoption of a multidiscipinary, participatory and non-dogmatic
approach to the BFI; integration and coordination of hospital
and community-based services related to breastfeeding
support and promotion; facilitating networking and mentoring
among health care organizations working towards BabyFriendly designation; creation of more flexible and innovative
breastfeeding education programs for health care providers as
well as parents; empowering mothers to make informed decisions about breastfeeding; and social marketing strategies to
promote greater social acceptance of breastfeeding.
In conclusion, the BFI is a complex practice change process
that requires dedicated financial and human resources, skilled
leadership, and effective change-management strategies. Recognition of breastfeeding as a clinical or public health priority
and support from all levels of the health care system is needed
to implement evidence-based breastfeeding programs such as
the BFI at the population level.

References
Semenic S, Childerhose JE, Lauziere J & Groleau, D 2012, Barriers,
facilitators, and recommendations related to implementing the BabyFriendly Initiative (BFI): An integrative review, Journal of Human
Lactation 28, 317334.
Semenic S, Groleau D, Rodriquez C, Gray-Donald K, Bell L, Haiek L,
Sibeko L 2012, valuation de la mise en oeuvre des lignes directrices
en matire dallaitement maternel au Qubec, Fonds qubcois de la
recherche sur la socit et la culture (FQRSC).

Examining the influences, behaviours

and feeding practices of parents with
pre-school children on fruit and
vegetable consumption
C. Smitha, F. Dykesa, N. Loweb and
V. Hall Morana
a
Maternal & Infant Nutrition & Nurture Unit (MAINN), University of
Central Lancashire, Preston, UK and bInternational Institute of
Nutritional Science and Food Safety Studies, University of Central
Lancashire, Preston, UK

Epidemiological studies indicate that regular consumption of

fruit and vegetables could help prevent major chronic diseases
such as cardiovascular diseases and some cancers (WHO
2003). Despite this, consumption of fruit and vegetables has
been shown to fall below recommended levels in all age groups
(Krebs-Smith et al, 2010, National Diet and Nutrition Survey
2011). Positive development of good child dietary behaviour is
crucially influenced by their parents and their use of appropriate child feeding practices (Darling & Steinberg, 1993).
Current UK dietary interventions reflect these knowledgebehaviour associations by promoting healthy food choices
such as the Healthy Start and 5-a-day initiatives. These interventions assume that, by improving knowledge and awareness,
behaviour change will follow. The majority of such initiatives
concentrate on educating parents on what to feed their children
with regards to a balanced and healthy diet, though this is only
part of more complex picture. Often, however, such initiatives
do not address how parents could and often do implement these
child feeding practices despite there being a large body of
research to bridge this gap between parental knowledge and the
application of child feeding practices.
The objective of this literature review was to examine past
research around the feeding behaviours, influences and practices of parents of pre-school children and examine the impact
these had specifically on fruit and vegetable consumption, as
well as general food consumption behaviours. Studies were
divided into two main categories: papers that examined the
impact of general feeding behaviours and practices of parents
attempting to encourage a greater consumption of fruit and
vegetables; and those that were specifically targeted actions for
increased consumption of fruits and vegetables.
Studies examining exposure to general food items found
that frequent exposure to an unfamiliar food resulted in
increased consumption, liking, and preference for that food
(Wardle et al. 2003a; Wardle et al. 2003b), whilst others suggested that children are more likely to eat restricted foods once
they are reintroduced into the home environment (Reinaerts
et al. 2007). Baranowski et al (1999) suggested that making
fruits and vegetables more easily accessible by putting them in
a place where the child can easily reach them and preparing
them into sizes that are easy to eat may increase the childs
intake of these foods. Research examining the size of serving
portions established that a childs intake at a single time point
was of a greater amount (in grams and calories) when given
larger portion sizes, suggesting that large portion sizes may

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Poster Presentations

overwhelm a childs ability to self-regulate caloric intake

(Fisher 2007). Findings from studies assessing behaviour modelling showed that parents can indirectly influence their childrens eating habits by modelling good eating behaviours
(Brown and Ogden 2004, Addessi et al. 2005) and modelling
can be enhanced by positive social responses that are tied to the
food (Hendy and Raudenbush 2000).
Studies of more targeted feeding behaviours reported that
prompting to eat by simply offering food to a child in an openended manner was associated with elevated child weight and
increased total eating time (Klesges et al. 1983, 1986),
although other studies found no association (Koivisto et al
1994) or a modest negative association (McKenzie et al. 1991).
Rewards have been found to impact on food preference by
increasing the value of the reward item and decreasing the preference for the required item (Newman and Taylor 1992), but
their use may override a childs self-regulatory ability to determine when to stop eating (satiety cues) (Birch et al. 1987).
Restricting access to desired foods was found to result in
greater intake of the food when it was no longer being
restricted (Fisher and Birch 1999) and an altered sensitivity to
internal satiety cues (Rhee 2006).
The evidence presented in this review suggests that the role
of parents in helping to control childrens food consumption is
multifaceted and complex. Although parents may use childfeeding behaviours with the intention of modifying childrens
dietary intake and possibly even their weight, the evidence suggests that many traditional child-feeding behaviours may have
unintended consequences for child weight. Initiatives need to
educate parents of the possible consequences of inappropriate
child-feeding behaviours, in order to inadvertently avoid
promote negative child feeding behaviours.

References
Addessi, E, Galloway, A, Visalberghi, E, and Birch, L. 2005. Specific
social influences on the acceptance of novel foods in 25-year-old
children. Appetite 45:26471.
Baranowski, T, Cullen, K and Baranowski, J. 1999. Psychosocial correlates of dietary intake: Advancing dietary intervention. Annu Rev
Nutr 19:1740.
Bates, B, Lennox, A and Swan, G. The National Diet and Nutrition
Survey: adults aged 19 to 64 years. Volume 1: Types and quantities of
foods consumed. TSO (London 2011).
Birch, L., and Deysher, M. 1986. Caloric compensation and sensory
specific satiety: Evidence for self-regulation of food intake by young
children. Appetite 7:32331.
Birch LL (1998) Development of food acceptance patterns in the first
years of life. Proc Nutr Soc 57, 617624.
Brown, R, and Ogden, J. 2004. Childrens eating attitudes and behaviour: A study of the modelling and control theories of parental influence. Health Educ Res 19:26171.
Darling, N, & Steinberg, L. (1993). Parenting style as context. An integrative model. Psychological Bulletin, 113, 487496.
Fisher, J, and Birch, L. 1999. Restricting access to foods and childrens eating. Appetite 32:40519.
Fisher, J. 2007. Effects of age on childrens intake of large and selfselected food portions. Obesity (Silver Spring) 15:40312.
Gibson, E, Wardle, J, Watts, C. Fruit and vegetable consumption,
nutritional knowledge and beliefs in mothers and children. Appetite
1998;31(2):205228.

53

Hendy, H and Raudenbush, B. 2000. Effectiveness of teacher modeling to encourage food acceptance in preschool children. Appetite
34:6176.
Krebs-Smith, S, Reedy, J, Bosire, C. Healthfulness of the U.S. food
supply: little improvement despite decades of dietary guidance. Am J
Prev Med. 2010;38:4727.
Newman, J and Taylor, A. 1992. Effect of a means-end contingency on
young childrens food preferences. J Exp Child Psychol 53:200216.
Nicklas, T, Baranowski, T, Baranowski, J, Cullen, K, Rittenberry, L
and Olvera, N. 2001. Family and child-care provider influences on
preschool childrens fruit, juice, and vegetable consumption. Nutrition Reviews 59:22435.
Reinaerts, E, Nooijer, J, Candel, M and Vries, N. 2007. Explaining
school childrens fruit and vegetable consumption: The contributions
of availability, accessibility, exposure, parental consumption and habit
in addition to psychosocial factors. Appetite 48:24858.
Rhee, K, Lumeng, J Appugliese, D Kaciroti, N and Bradley, R. 2006.
Parenting styles and overweight status in first grade. Pediatrics
117:204754.
Wardle, J, Cooke, L, Gibson, EL, Sapochnik, M, Sheiham, A, Lawson
M. 2003a. Increasing childrens acceptance of vegetables; a
randomized trial of parent-led exposure. Appetite 40:15562.
Wardle, J, Herrera, ML, Cooke, L, Gibson EL. 2003b. Modifying childrens food preferences: The effects of exposure and reward on
acceptance of an unfamiliar vegetable. Eur J Clin Nutr 57:34148.
World Health Organization. Diet, Nutrition and the Prevention of
Chronic Disease: Report of a Joint WHO/FAO Expert Consultation.
Geneva, Switzerland: World Health Organization; 2003. WHO Technical Report Series, No. 916

Maternal mediators of a health

promotion intervention to improve child
diet quality: results of The Melbourne
InFANT Program
A. Spence, K. Campbell, S. McNaughton,
D. Crawford and K. Hesketh
Centre for Physical Activity and Nutrition Research, Deakin University
Melbourne, Australia

Appropriate nutrition in early childhood is important to

promote health in the short and long term. Dietary preferences
and intakes in early life are likely to track across life stages and
have a long term influence on nutrition and health. While
dietary intakes in children under two years of age have not been
well studied, those studies available suggest that low intakes of
fruits and vegetables and high intakes of non-core foods are
already prevalent in this age group. Consideration of influences
on child nutrition is important to determine ways to improve
child intakes. For young children, parental knowledge, modelling, feeding practices and self-efficacy in feeding are likely to
be important influences on child intakes and therefore important targets of health promotion interventions. It is important to
investigate whether such maternal factors act as mediators
of intervention effects on childrens diets, in order to better
understand ways in which an intervention is effective and
where interventions need to be strengthened.

2013 John Wiley & Sons Ltd Maternal and Child Nutrition (2013), 9 (Suppl. 3), pp. 4255

54

Maternal and Child Nutrition 2013; Supplement 3

The Melbourne Infant Feeding, Activity and Nutrition

Trial (InFANT) Program was a cluster-randomised controlled
trial aiming to reduce obesity in early childhood by improving child nutrition. When children were four months of age,
542 first-time mothers were recruited via existing parents
groups which operate in Victoria, Australia. Randomisation
was at the group level. The intervention involved six information sessions over 15 months, focussing on improving maternal knowledge, modelling, feeding practices and self-efficacy
in child feeding. Written resources and a DVD were also provided on these topics. Post intervention, when children were
18 months of age, child diets were assessed using three 24
hour recalls. Child diet quality was determined using a
measure incorporating intakes of fruits, vegetables and noncore foods. Additionally, maternal self-efficacy in child
feeding and knowledge of child feeding and nutrition were
assessed utilising purpose designed items grouped into factor
scores. Maternal modelling of diet was assessed with a previously validated food frequency questionnaire (Hodge et al.
2000), and maternal feeding practices were assessed
using the Comprehensive Feeding Practices Questionnaire
(Musher-Eizenman and Holub 2007).
Post-intervention, children in the intervention arm had
significantly better diet quality than those in the control arm
(scores of 15.6 and 14.5 out of 30 respectively, p = 0.01).
When assessed by mediation analysis, higher maternal
knowledge of child feeding and nutrition, and lower maternal
use of foods as rewards in the intervention arm, were
shown to mediate the direct intervention effect on child diet
quality.
This research demonstrates the potential of health promotion interventions in this age group to positively impact on
child diets. It highlights the importance of targeting maternal
mediators of early childhood nutrition, particularly the value
of improving maternal knowledge and reducing use of
rewards in child feeding. Determining ways to more effectively reach mothers and improve other maternal feeding
practices, modelling and self-efficacy will be important for
future research.

References
Hodge, A, Patterson AJ, Brown WJ, Ireland P and Giles G (2000). The
Anti Cancer Council of Victoria FFQ: relative validity of nutrient
intakes compared with weighed food records in young to middle-aged
women in a study of iron supplementation. Australian and New
Zealand Journal of Public Health 24(6): 576583.
Musher-Eizenman, D and Holub S (2007). Comprehensive
Feeding Practices Questionnaire: validation of a new measure of
parental feeding practices. Journal of Pediatric Psychology 32(8):
960972.

Keeping up appearances: womens

experiences of infant feeding
R. Spencer, S. Greatrex-White and D.M. Fraser
School of Health Sciences, Academic Division of Midwifery, University of
Nottingham, UK

Despite an increasing research base about what helps or

hinders breastfeeding, there is a dramatic drop in breastfeeding
prevalence within the first six weeks (East Midlands Public
Health Observatory, (EMPHO), 2012; Health and Social Care
Information Centre (HSCIC), 2012). The latest national Infant
Feeding Survey (HSCIC, 2012) results and local breastfeeding
data (EMPHO, 2012) would appear to suggest that there is a
gap between womens experiences of breastfeeding in society
and professional practice to promote, support and increase
breastfeeding continuation.
Using an interpretive phenomenological methodology
(Heidegger, 1962) this study was designed to capture mothers
own interpretations of their experiences. In-depth interviews
with 22 women from the city and surrounding areas of Lincoln
about their experiences of breastfeeding were conducted and
analysed. These primiparous and multiparous mothers had
infants ranging in ages from three to six months. The women
had all breastfed for at least 2 weeks and some were still
breastfeeding at the time of their interview.
Analysis of the data resulted in the emergence of three
central themes: reality shock, illusions of compliance and
tensions. This presentation will focus on the second theme,
illusions of compliance. Women described how they felt pressured to initiate breastfeeding in order to comply with societal expectations and those of the health care professionals.
They also maintained a public pretence in relation to how
they themselves were feeling about breastfeeding, presenting
themselves as a coping mother, even though they may not
have felt like one. Maternal guilt was expressed if they
stopped exclusive breastfeeding, or if their baby was not
gaining weight or settling between feeds. Some of the women
felt undermined by family and friends regarding their
breastfeeding ability, particularly if their baby appeared
unsettled between feeds or fed frequently. The women
described their own management of infant feeding, taking
ownership from the methods and guidance advocated by
some health care professionals. Maintaining an illusion of
compliance, they did not adhere strictly to the evidence-based
breastfeeding guidance and advice which they viewed as
rigid and inflexible, but sought a pragmatic approach to
breastfeeding that met their own needs and those of their
family and friends. This story reveals that women deliberately and strategically maintain a pretence with breastfeeding
to meet cultural ideals of motherhood.
These findings, whilst not widely generalizable, indicate a
mismatch between the interpretation of policy drivers and the
needs of breastfeeding women in Lincolnshire. The recommendations from this study incorporate recommendations for
policy, clinical practice, education of healthcare professionals
and wider research in this important area.

2013 John Wiley & Sons Ltd Maternal and Child Nutrition (2013), 9 (Suppl. 3), pp. 4255

Poster Presentations

Reference
East Midlands Public Health Observatory (2012) Breastfeeding in
Lincolnshire County by Local Authority. Leicester, EMPHO.
Health and Social Care Information Centre (2012) Infant Feeding
Survey 2010. London, TSO.
Heidegger, M. (1962) Being and Time. Oxford, Blackwell Scientific.

The midwives arent allowed to tell you:

infant feeding policy restrictions in a
formula feeding culture the feeding
your baby study
H. Whitforda, J. Dalzellb, B. Laganc and
A. Symona
a
School of Nursing and Midwifery, University of Dundee, Dundee,
Scotland, UK, bDirectorate of Public Health, NHS Tayside, Dundee,
Scotland, UK and cSchool of Nursing & Health Research, University of
Ulster at Jordanstown, Newtownabbey, County Antrim, N.Ireland

There is clear and established evidence that breastfeeding has

short and long term health benefits. In the context of low
breastfeeding rates in Scotland (Information and Statistics Division 2011) and the challenge of achieving government targets
for improved exclusive breastfeeding rates at 68 weeks (Scottish Government 2007), this study aimed to explore the factors
influencing womens experiences of infant feeding.
This study used a qualitative, exploratory, descriptive
design. Women in Eastern Scotland were recruited in the

55

third trimester of pregnancy. Interviews/focus groups were

held in the postnatal period asking women with a range
of infant feeding experiences to reflect on their infant
feeding expectations and experiences. Seven focus group
interviews (n = 38 participants) and 40 semi-structured
one-to-one interviews took place between May and September 2010. A Framework approach was used to analyse the
data.
Three main themes were identified: Hidden truths;
Mixed and missing messages; and Emotional costs. Several
problems were identified with how women were given information, how infant feeding discussions were held and the type
of support available after the baby is born. There was a strong
perception that some midwives are not allowed to discuss or
provide information on formula feeding, and women reported
feeling pressurised to breastfeed.
At strategic, policy and practice levels the infant feeding
message needs to change to encourage a more womancentred focus including discussions about the realities of all
types of infant feeding. It is important that health providers
continue to promote and support breastfeeding; and that
effective services are provided to help women who wish to
breastfeed. However provision of information about all
aspects of feeding is needed as well as support for women
who do not wish to breastfeed.

References
Information and Statistics Division, NHS Scotland, 2011.
Breastfeeding Statistics Financial Year 2010/11 Report. Available at:
www.isdscotland.org/Health-Topics/Child-Health/Infant-Feeding/
Scottish Government, 2007. Better Health, Better Care. The Scottish
Government: Edinburgh.

2013 John Wiley & Sons Ltd Maternal and Child Nutrition (2013), 9 (Suppl. 3), pp. 4255