Katherine F. Kavanagh

Educational Intervention to Modify Bottle-feeding Behaviors among Formula-feeding Mothers in the WIC Program: Impact on Infant Formula Intake and Weight Gain

OBJECTIVE Formula-fed infants gain weight faster than breastfed infants. This study evaluated whether encouraging formula-feeding caregivers to be sensitive to infant satiety cues would alter feeding practices and reduce infant formula intake and weight gain. DESIGN Double-blind, randomized educational intervention, with intake and growth measured before (at 1 to 2 months) and after (4 to 5 months) the intervention. SETTING Women, Infants, and Children (WIC) clinics in Sacramento, California. PARTICIPANTS 836 caregivers of young infants were screened; 214 were eligible, and 104 agreed to participate. INTERVENTION Intervention subjects received education promoting awareness of satiety cues and discouraging bottles containing more than 6 ounces before 4 months of age; intervention and control groups received education regarding introduction and feeding of solid food after 4 months of age. MAIN OUTCOME MEASURES Formula intake (mL/24 hours) and weight gain (g/week). ANALYSIS Differences between groups evaluated using 2-way analysis of covariance (ANCOVA). RESULTS Sixty-one subjects completed baseline records, 44 attended class, and 38 completed the study. Despite a positive response to the educational intervention, there was no change in bottle-feeding behaviors (formula intake at 4 to 5 months was more than 1100 mL/day in both groups). Infant growth in the intervention group was greater than in the control group (P < .01), contrary to the hypothesis. CONCLUSIONS AND IMPLICATIONS The intervention improved knowledge of the key messages, but further research is needed to understand barriers to modifying bottle-feeding behaviors.

Breastfeeding Knowledge, Attitudes, Prior Exposure, and Intent among Undergraduate Students:

Background: Understanding breastfeeding knowledge, attitudes, and exposures among nonpregnant youth who are likely to be future parents may provide significant pathways to successfully increasing breastfeeding as the normal, accepted way of feeding infants. However, based on a recent review of the literature, only 3 studies have assessed these factors in nonpregnant, young adults in the United States in the past 10 years. Objective: The objective of this study was to gather more recent data regarding breastfeeding knowledge, attitudes, and prior exposure among undergraduate university students. Methods: This was a cross-sectional survey, conducted in November 2010. A convenience sample, consisting of undergraduates in attendance in 2 sections of an introductory nutrition class at a large research university, was used for this project (N = 248). Results: Breastfeeding knowledge was relatively good. However, overall breastfeeding attitudes were more neutral, which appeared to be explained by the belief that breastfeeding is painful, restrictive, and inconvenient, both in general and specifically for the working mother. Though support for breastfeeding in public was low, men were significantly less likely than women to believe it to be embarrassing or unacceptable. In addition, breastfeeding attitudes were more positive among older students and those who were breastfed as infants. Those who were breastfed as infants were also significantly more likely to intend to breastfeed future children. Conclusions: Though this sample indicates good breastfeeding knowledge, attitudes were more neutral, and support for breastfeeding in public appears low. This finding is contradictory and warrants further exploration.

Docosahexaenoic acid: measurements in food and dietary exposure.

The Dietary Reference Intakes (DRIs) were established to be an indicator of adequacy of dietary nutrients as well as providing levels for adequacy in reducing risk of chronic diseases such as neurodegenerative diseases, cardiovascular diseases, cancers, diabetes mellitus, etc. One particular nutrient that is increasingly discussed as a potential candidate for the generation of a DRI is the omega-3 (n-3) fatty acid docosahexaenoic acid (DHA) due to its potential benefits in reducing risk for cardiovascular disease, role in resolution of inflammation, its importance in cognitive function in infants and inhibiting the progression of neurodegenerative diseases in the elderly. Each reference value refers to and is predicated on estimates of daily nutrient intake and the goal of this paper is to review these intakes. The confidence of these values is critical in establishing dose-response relationships. This paper reports intake values for DHA and examines how these data were generated and the relative confidence in these values. The adult US population is estimated to consume 80-100 mg/d of DHA based on a nationally representative sample of > 8400 individuals as part of the National Health and Nutrition Examination Survey (NHANES). This value and those presented for women and men at various ages appear reasonable and should be used as the basis for establishing an Adequate Intake (AI) for DHA.

Breastfeeding Knowledge, Attitudes, and Intention in a Sample of Undergraduate Students in Mainland China:

Background: Despite the high breastfeeding initiation rate in China (> 90%), the low exclusivity rate is of concern. Some traditional behaviors, combined with increasing popularity of infant formula, may negatively affect future breastfeeding rates. As suggested by the theory of planned behavior, understanding breastfeeding beliefs of young adults may help identify and address misperceptions of future parents, supporting maintenance of the current initiation rate while increasing rates of exclusivity and duration. No research has evaluated these factors among young adults in Mainland China. Objective: The objective was to explore any relationships between breastfeeding knowledge, attitudes, previous experiences, and future intention among undergraduate students in Mainland China. Methods: This was a cross-sectional, quantitative study conducted from May to June 2012. A convenience sample of 395 students from a major public university in southwest China participated in the survey. Results: Breastfeeding knowledge was moderate (76.7% of total score), and breastfeeding was considered to be painful (34.2%), to make breasts sag (43.1%), and to restrict the freedom of mothers (52.5%). In addition, 58.2% of students reported that they would feel embarrassed if they or their partners were to breastfeed in public, and acceptability of breastfeeding in public was low (34.7%). Three-fourths of the students (75.1%) expressed future breastfeeding intent, though males were more likely to report this intention (ie, to support a partner in breastfeeding) than were females (81.3% vs 71.7%, P = .04). Conclusion: To create a more breastfeeding-friendly culture, future research is warranted to explore these negative beliefs about breastfeeding and to counter misunderstandings among future parents in Mainland China.

Maternal reported indicators and causes of insufficient milk supply.

Background: Although the breastfeeding initiation rate is high in China, exclusivity is low. Not having enough breast milk has been frequently reported as a reason for supplementing and weaning. Objective: The objective was to explore maternal perception of indicators and causes of self-reported insufficient milk supply (IMS) among a sample of southwestern Chinese mothers. Methods: This was a cross-sectional study, conducted in a hospital in Chengdu, China. Results: The majority of mothers were of Han ethnicity and primiparous. Most initiated breastfeeding (n = 325, 95.3%). Among mothers who had weaned by the time of questionnaire completion, more than half (n = 52) reported IMS as a reason, and 53.8% of these mothers reported this occurring during the first 2 days postpartum. Mothers often identified IMS by using less sensitive indicators of adequate intake such as receiving a hungry look from the infant after nursing (34.6%) and not feeling the presence of milk (28.8%). More sensitive indicators of adequate intake, such as the number of wet/soiled diapers, were not reported. More than a third of mothers (39.2%) could not express a reason for the occurrence of IMS. Among those who identified reasons, nearly one-fourth of mothers attributed IMS, at least partially, to dietary factors such as poor appetite (23.5%). Conclusion: Self-reported IMS appears to be a common barrier to breastfeeding continuation among this sample of Chinese mothers. Culturally appropriate intervention, designed to inform mothers how to correctly identify and address IMS, might be an effective strategy to support optimal infant-feeding behaviors in China.

Remote Lactation Consultation A Qualitative Study of Maternal Response to Experience and Recommendations for Survey Development

Background: Use of videoconferencing technology for healthcare intervention and support is an area of tremendous potential, especially in regard to application in rural or underserved communities. Potential for cost-savings, time-savings, and increased access to care are the ultimate driving force behind use of this technology, for both providers and recipients of healthcare services. Recently, the Federal Government has initiated rulings to support the increased use of computer technology in underserved areas. Therefore, exploring novel applications of the technology of videoconferencing is timely. Remote lactation consultation may be one such novel application. Objectives: The primary objective of this pilot study was to describe the maternal experience of lactation consultation by means of videoconferencing, compared with standard face-to-face care, using grounded theory for model development. Methods: Twelve mothers participated in both a videoconferencing and a face-to-face consultation during one visit to the study site. Using grounded theory methods, responses to an in-depth phone interview occurring 3 days post-consultation were analyzed for major themes and a theoretical model proposed. Results: Three major themes emerged including maternal characteristics and interaction with technology, accuracy and trust determines acceptability for consultation type and, conditional acceptance of remote consultation use. Conclusions: Emergent themes were grounded in existing literature, and potential scales were identified to assist with development of a future tool to test the theoretical model. Responses to the videoconferencing experience were positive, but preferred use of the technology was situational.

Using grounded theory methodology to conceptualize the mother–infant communication dynamic: Potential application to compliance with infant feeding recommendations

Excessive, rapid weight gain in early infancy has been linked to risk of later overweight and obesity. Inappropriate infant feeding practices associated with this rapid weight gain are currently of great interest. Understanding the origin of these practices may increase the effectiveness of interventions. Low-income populations in the Southeastern United States are at increased risk for development of inappropriate infant feeding practices, secondary to the relatively low rates of breastfeeding reported from this region. The objective was to use grounded theory methodology (GTM) to explore interactions between mothers and infants that may influence development of feeding practices, and to do so among low-income, primiparous, Southeastern United States mothers. Analysis of 15 in-depth phone interviews resulted in development of a theoretical model in which Mother-Infant Communication Dynamic emerged as the central concept. The central concept suggests a communication pattern developed over the first year of life, based on a positive feedback loop, which is harmonious and results in the maternal perception of mother and infant now speaking the same language. Importantly, though harmonious, this dynamic may result from inaccurate maternal interpretation of infant cues and behaviours, subsequently leading to inappropriate infant feeding practices. Future research should test this theoretical model using direct observation of mother-infant communication, to increase the understanding of maternal interpretation of infant cues. Subsequently, interventions targeting accurate maternal interpretation of and response to infant cues, and impact on rate of infant weight gain could be tested. If effective, health care providers could potentially use these concepts to attenuate excess rapid infant weight gain.

Use of Videoconferencing for Lactation Consultation: An Online Cross-Sectional Survey of Mothers’ Acceptance in the United States

Background: Suboptimal breastfeeding duration and exclusivity rates are a public health concern. Therefore, there is a need for identifying effective tools for use in interventions targeting specific barriers to optimal breastfeeding outcomes. Research aim: This study aimed to assess the relationship between acceptance of remote lactation consultation using videoconferencing and (a) maternal demographic factors, (b) technology acceptance subscales, (c) maternal learning style preferences, and (d) other potentially explanatory maternal factors. Methods: This was a cross-sectional, online study. English-speaking mothers of at least 18 years of age, with an infant age 4 months or younger, and who reported initiating breastfeeding were eligible to participate. Mothers were recruited from 27 randomly selected states. One hundred one mothers completed the survey, resulting in a response rate of 71%. The main outcome was acceptance of videoconferencing use for lactation consultation. Results: No significant differences were found in acceptance by maternal demographic factors or learning style preferences. Acceptance was significantly related to perceived ease of use (r = .680, p < .001), perceived usefulness/extrinsic motivation (r = .774, p < .001), intrinsic motivation (r = .689, p < .001), desire for control of privacy (r = –.293, p < .01), and mother’s perception of the infant father’s/maternal partner’s acceptance of videoconferencing for lactation consultation (r = .432, p < .001). Only perceived usefulness/extrinsic motivation and maternal age remained in the final regression model (R2 = .616, p < .001). Although perceived usefulness/extrinsic motivation was positively associated with acceptance, maternal age was inversely related. Conclusion: This sample of mothers indicated general acceptance of videoconferencing for lactation consultation, with younger mothers and those perceiving it to be more useful demonstrating greater acceptance.

Observations and Conversations: Home Preparation of Infant Formula Among a Sample of Low-Income Mothers in the Southeastern US

Objective: Explore infant formula preparation attitudes and beliefs among low‐income, formula‐feeding, Southeastern US mothers. Design: Cross‐sectional study using in‐home observations and in‐depth interviews. Setting: Participant homes. Participants: Thirteen low‐income mothers of normal birth weight, healthy, term infants aged ≤3 months, who were predominantly feeding powdered or from‐concentrate formula. Variables Measured: Reading formula preparation instructions; order of added ingredients; leveling powdered formula scoop(s); adding cereal or other ingredients to bottles. Phenomenon of Interest: Perceptions of formula preparation or manipulation. Analysis: Descriptive statistics described sample characteristics and home observation variables. Thematic analysis of in‐depth interviews revealed the following major themes: formula preparation can be intimidating; expressions of complex heuristic perceptions about formula preparation; cost and convenience motivate maternal behaviors; and infant cues override recommendations. Data from qualitative and quantitative activities were triangulated. Results: Behaviors, including improper reconstitution and modifications/additions to prepared formula (eg, infant cereal) were observed during home observations and/or described during in‐depth interviews. Inconsistencies were detected between observed behaviors (eg, adding too much water to the bottle) and those reported during in‐depth interviews (eg, stating over‐dilution could be detrimental to the infants health). Conclusions and Implications: Targeting knowledge or skills gaps and behavioral motivators in the formula‐feeding population could positively affect infant‐feeding practices that occur outside of recommendations.

Knowledge of the Birth Process Among Undergraduates: Impact of Screening of a Documentary Featuring Natural Childbirth in Low-Risk Pregnancies

PURPOSE: Little is known about knowledge of birthing practices, among young adults in the United States; specifically, knowledge regarding the impact of these practices on mothers and newborn. Therefore, the purpose was to assess U.S. undergraduates’ knowledge regarding risks of cesarean deliveries (medically indicated or not), before and after viewing a documentary featuring unmedicated vaginal birth in low-risk pregnancy and subsequent expert panel discussion. STUDY DESIGN: Uncontrolled before/after study. MAJOR FINDINGS: Of the 225 attendees, 206 completed the pretest (91.5%) and 163 completed the posttest (72.4%). Of the 206 completing the pretest, 152 identified as undergraduates, and 123 (80%) of these 152 completed the posttest. Results indicate exposure to the documentary and expert discussion panel resulted in significant increases in knowledge of risks of cesarean deliveries, regardless of gender. In addition, witnessing or viewing birth in the media was significantly associated, at posttest, with greater increases in knowledge of some risks. MAIN CONCLUSION: These findings are important in light of the increasing trend in cesarean deliveries in the United States. Educating this population and providing credible information on delivery options should be informed by further research into these domains.