Kathryn Dewey

Viral, Nutritional, and Bacterial Safety of Flash-Heated and Pretoria-Pasteurized Breast Milk to Prevent Mother-to-Child Transmission of HIV in Resource-Poor Countries A Pilot Study

Background:Heat-treated breast milk of HIV-positive mothers has potential to reduce vertical transmission. This study compared the impact of flash-heating (FH) and Pretoria pasteurization (PP) on HIV, nutrients, and antimicrobial properties in human milk. Methods:Milk samples were spiked with 1 × 108 copies/mL of clade C HIV-1 and treated with FH and PP. We measured HIV reverse transcriptase (RT) activity before and after heating (n = 5). Heat impact on vitamins A, B6, B12, and C; folate, riboflavin, thiamin, and antimicrobial proteins (lactoferrin and lysozyme) was assessed. Storage safety was evaluated by spiking with Escherichia coli or Staphylococcus aureus. Results:Both methods inactivated ≥3 logs of HIV-1. FH resulted in undetectable RT activity. Neither method caused significant decrease in any vitamin, although reductions in vitamins C and E were noted. Heat decreased immunoreactive lactoferrin (P < 0.05) but not the proportions of lactoferrin and lysozyme surviving digestion. FH seems to retain more antibacterial activity. Both treatments eliminated spiked bacteria. Conclusions:FH may be superior to PP in eliminating all viral activity; both methods retained nutrients and destroyed bacterial contamination. Heat-treated breast milk merits further study as a safe and practical infant feeding option for HIV-positive mothers in developing countries.

New and updated indicators for assessing infant and young child feeding.

The World Health Organization (WHO) and partners have released new and updated indicators for assessing infant and young child feeding practices for use in population-based surveys. The indicators reflect current recommendations for appropriate infant and young child feeding and provide important new information on feeding practices in children 6 to 23 months of age. Simple, valid, and reliable indicators are crucial for tracking progress and guiding investment to improve nutrition and health during the first 2 years of life. In 1991, WHO issued indicators for assessing breastfeeding practices that have since been used widely and have contributed to directing program efforts in many countries [1]. However, a set of indicators that could be used in population-based surveys to assess complementary feeding practices was not available. This limited the understanding of the magnitude and distribution of inadequate feeding practices and hampered progress in the development of effective program responses. Recognizing this gap, WHO, together with partners from the International Food Policy Research Institute, the Food and Nutrition Technical Assistance Project/ Academy of Educational Development, Macro International, the University of California at Davis, the United States Agency for International Development, and UNICEF jointly undertook the effort to develop new and updated indicators to assess infant and young child feeding practices. The work was guided by updated recommendations for the duration of exclusive breastfeeding [2, 3], the Guiding Principles for Complementary Feeding of the Breastfed Child [4], the Guiding Principles for Feeding Non-Breastfed Children [5], and a conceptual framework for identifying potential indicators of complementary feeding [6]. An extensive analysis of infant and young child dietary intake data from 10 sites was performed to assess relationships between dietary diversity and mean micronutrient density adequacy and between feeding frequency and energy intake [7, 8]. The results of this 5-year effort have been recently published [9]. Eight core and seven additional indicators now cover optimal breastfeeding practices and food-related aspects of appropriate feeding practices in children 6 to 23 months of age. New indicators include measures of dietary diversity, feeding frequency, and the consumption of iron-rich or iron-fortified foods. Most indicators can be derived from questions already used in widely implemented surveys, such as Demographic and Health Surveys and UNICEF Multiple Indicator Cluster Surveys. An operational guide to facilitate standardized measurement is under development. The indicators and indicator definitions are summarized in the Annex.

Effect of complementary feeding with lipid‐based nutrient supplements and corn–soy blend on the incidence of stunting and linear growth among 6‐ to 18‐month‐old infants and children in rural Malawi

Low nutritional value of complementary foods is associated with high incidence of childhood growth stunting in low-income countries. This study was done to test a hypothesis that dietary complementation with lipid-based nutrient supplements (LNS) promotes linear growth and reduces the incidence of severe stunting among at-risk infants. A total of 840 6-month-old healthy infants in rural Malawi were enrolled to a randomised assessor-blinded trial. The participants received 12-month supplementation with nothing, milk-LNS, soy-LNS, or corn-soy blend (CSB). Supplements provided micronutrients and approximately 280u2009kcal energy per day. Outcomes were incidence of severe and very severe stunting [length-for-age z-score, (LAZ)u2009<u2009-3.00 and <-3.50, respectively], and change in LAZ. The incidence of severe stunting was 11.8%, 8.2%, 9.1% and 15.5% (Pu2009=u20090.098) and that of very severe stunting 7.4%, 2.9%, 8.0% and 6.4% (Pu2009=u20090.138) in control, milk-LNS, soy-LNS and CSB groups, respectively. Between 9 and 12 months of age, the mean change in LAZ was -0.15, -0.02, -0.12 and -0.18 (Pu2009=u20090.045) for control, milk-LNS, soy-LNS and CSB groups, respectively. There was no significant between-group difference in linear growth during other age-intervals. Although participants who received milk-LNS had the lowest incidence of severe and very severe stunting, the differences between the groups were smaller than expected. Thus, the results do not provide conclusive evidence on a causal association between the LNS supplementation and the lower incidence of stunting. Exploratory analyses suggest that provision of milk-LNS, but not soy-LNS promotes linear growth among at-risk infants mainly between 9 and 12 months of age.

Provision of 10–40 g/d Lipid-Based Nutrient Supplements from 6 to 18 Months of Age Does Not Prevent Linear Growth Faltering in Malawi

BACKGROUNDnComplementing infant diets with lipid-based nutrient supplements (LNSs) has been suggested to improve growth and reduce morbidity, but the daily quantity and the milk content of LNSs affect their cost.nnnOBJECTIVEnWe tested the hypotheses that the change in mean length-for-age z score (LAZ) for infants provided with 10-40 g LNSs/d from ages 6 to 18 mo would be greater than that for infants receiving no dietary intervention at the same age and that provision of LNSs that did not contain milk would be as good as milk-containing LNSs in promoting linear growth.nnnMETHODSnWe enrolled in a randomized single-blind trial 6-mo-old infants who were allocated to 1 of 6 groups to receive 10, 20, or 40 g LNSs/d containing milk powder; 20 or 40 g milk-free LNSs/d; or no supplement until 18 mo of age. The primary outcome was change in LAZ.nnnRESULTSnOf the 1932 enrolled infants, 78 (4.0%) died and 319 (16.5%) dropped out during the trial. The overall reported supplement consumption was 71.6% of days, with no difference between the groups (P = 0.26). The overall mean ± SD length and LAZ changes were 13.0 ± 2.1 cm and -0.45 ± 0.77 z score units, respectively, which did not differ between the groups (P = 0.66 for length and P = 0.74 for LAZ). The difference in mean LAZ change in the no-milk LNS group compared with the milk LNS group was -0.02 (95% CI: -0.10, 0.06; P = 0.72).nnnCONCLUSIONnOur results do not support the hypothesis that LNS supplementation during infancy and childhood promotes length gain or prevents stunting between 6 and 18 mo of age in Malawi. This trial was registered at clinicaltrials.gov as NCT00945698.

Lipid-based nutrient supplements do not decrease breast milk intake of Malawian infants

BACKGROUNDnThe potential for small-quantity lipid-based nutrient supplements (LNS) to promote growth and development after 6 mo of age is currently being investigated. Because infants self-regulate energy intake, consumption of LNS may reduce breast milk intake and potentially decrease the beneficial effects of breast milk.nnnOBJECTIVEnThe objective was to test the hypothesis that the breast milk intake of 9- to 10-mo-old rural Malawian infants receiving LNS would not be lower than that of infants receiving no supplementation.nnnDESIGNnThis was a substudy of the International Lipid-based Nutrient Supplements (iLiNS) DOSE trial, in which 6-mo-old infants were randomly assigned to receive 10, 20, or 40 g LNS/d containing 56, 117, or 241 kcal/d, respectively, or no LNS until 18 mo of age. A subset was randomly selected to estimate breast milk intake at 9-10 mo of age with the dose-to-mother deuterium oxide dilution method. The noninferiority margin was <10% of total energy requirements.nnnRESULTSnBaseline characteristics (n = 376) were similar across groups. The mean (± SD) daily breast milk intake of unsupplemented infants was 730 ± 226 g. The differences (95% CIs) in mean intake of infants provided with 10, 20, or 40 g LNS/d, compared with controls, were +62 (-18, +143), +30 (-40, +99), and +2 (-68, +72) g/d, respectively. Non-breast milk oral water intake did not differ by group (P = 0.39) and was inversely (r = -0.22, P < 0.01) associated with breast milk intake.nnnCONCLUSIONnIn this rural Malawian population, breast milk intake at 9-10 mo of age was not reduced by supplementation with complementary foods with 10-40 g LNS/d.

Indicators for feeding practices in children.

Simple, valid, and reliable indicators are crucial to track progress and guide investment to improve nutrition and health during the fi rst 2 years of life. Indicators that assess breastfeeding are useful to monitor trends, to develop and evaluate programmes, and for advocacy. Until now, however, we have lacked indicators for populationbased surveys to measure feeding practices for children 6–24 months of age. Limited knowledge about the scale and distribution of inadequate feeding practices and consequences for childrens’ survival, health, and physical and mental development has hampered investment and action to improve these practices, as argued by Jennifer Bryce and colleagues in last week’s Lancet. The development of indicators for child-feeding practices poses conceptual and analytical challenges in that these practices are multidimensional, inter-related, and change rapidly within short age-intervals. Unlike ex clusive breastfeeding, which can be summarised in a single indicator, the measurement of feeding practices for children aged 6 months and older involves assess ing various dimensions simultaneously. These dimen sions include continued breastfeeding, appropriate timing of intro duction of complementary foods, and optimum quan tity and quality (micronutrient density) of the foods consumed. With the scientifi c rationale for the various dimen sions of child feeding defi ned for breastfed and non-breastfed children, WHO and partners developed indicators to assess child feeding for the ages 6–24 months and updated the breastfeeding indicators. Partners were the International Food Policy Research Institute, the Food and Nutrition Technical Assistance Project at the Academy of Educational Development, Macro Inter national, the University of California at Davis, the US Agency for International Development, UNICEF, and a group of collaborating researchers. This 5-year eff ort resulted in a set of core and optional indicators. The former include new indicators for dietary diversity (a proxy for nutrient-density ade quacy), feeding frequency (a proxy for adequate energy intake from food), and consumption of iron-rich or iron-fortifi ed foods in breastfed and non-breastfed children aged 6–24 months. The indicators focus on selected food-related dimensions of child feeding that can be measured in large surveys. Other dimensions of optimum feeding, such as responsive feeding and adequate texture of food, are likely to require more complex measurement approaches. The core list also includes previously used breastfeeding indicators and updated indicators for exclusive breastfeeding in infants aged less than 6 months and appropriate breastfeeding in children aged less than 24 months. Most of the proposed indicators can be derived from questions already in widely implemented population-based surveys, such as the Demographic and Health Surveys and UNICEF Multiple Indicator Cluster Surveys; others will require the addition of simple questions. These same questions can easily be added to other surveys. An earlier version of these indicators showed the gravity of problems with feeding of infants and young children and the scale of the challenges ahead. For example, in 13 of 18 countries with nationally representative data number of studies that address this shortage of solid evidence on which to base policy. But evaluations of social programmes need to use a theory-based approach.

Feasibility of using flash-heated breastmilk as an infant feeding option for HIV-exposed, uninfected infants after 6 months of age in urban Tanzania.

Objective:Heat-treating expressed breastmilk is recommended as an interim feeding strategy for HIV-exposed infants in resource-poor countries, but data on its feasibility are minimal. Flash-heating (FH) is a simple in-home technique for heating breastmilk that inactivates HIV although preserving its nutritional and anti-infective properties. Our primary objective was to determine, among HIV-infected mothers, the feasibility and protocol adherence of FH expressed breastmilk after 6 months of exclusive breastfeeding. Design:Prospective longitudinal. Participants:One hundred one HIV-infected breastfeeding mothers Setting:Dar es Salaam, Tanzania Intervention:Peer counselors provided in-home counseling and support on infant feeding from 2 to 9 months postpartum. Mothers were encouraged to exclusively breastfeed for 6 months followed by FH expressed breastmilk if her infant was HIV negative. Clinic-based staff measured infant growth and morbidity monthly, and mothers kept daily logs of infant morbidity. FH behavior was tracked until 9 months postpartum using daily logs, in-home observations, and clinic-based and home-based surveys. Bacterial cultures of unheated and heated milk samples were performed. Results:Thirty-seven of 72 eligible mothers (51.4%) chose to flash-heat. Median (range) frequency of milk expression was 3 (1–6) times daily and duration of method use on-study was 9.7 (0.1–15.6) weeks. Mean (SD) daily milk volume was 322 (201) mL (range 25–1120). No heated and 32 (30.5%) unheated samples contained bacterial pathogens. Conclusions:FH is a simple technology that many HIV-positive women can successfully use after exclusive breastfeeding to continue to provide the benefits of breastmilk while avoiding maternal-to-child transmission associated with nonexclusive breastfeeding. Based on these feasibility data, a clinical trial of the effects of FH breastmilk on infant health outcomes is warranted.

U-shaped curve for risk associated with maternal hemoglobin, iron status, or iron supplementation

Both iron deficiency (ID) and excess can lead to impaired health status. There is substantial evidence of a U-shaped curve between the risk of adverse birth outcomes and maternal hemoglobin concentrations during pregnancy; however, it is unclear whether those relations are attributable to conditions of low and high iron status or to other mechanisms. We summarized current evidence from human studies regarding the association between birth outcomes and maternal hemoglobin concentrations or iron status. We also reviewed effects of iron supplementation on birth outcomes among women at low risk of ID and the potential mechanisms for adverse effects of high iron status during pregnancy. Overall, we confirmed a U-shaped curve for the risk of adverse birth outcomes with maternal hemoglobin concentrations, but the relations differ by trimester. For low hemoglobin concentrations, the link with adverse outcomes is more evident when hemoglobin concentrations are measured in early pregnancy. These relations generally became weaker or nonexistent when hemoglobin concentrations are measured in the second or third trimesters. Associations between high hemoglobin concentration and adverse birth outcomes are evident in all 3 trimesters but evidence is mixed. There is less evidence for the associations between maternal iron status and adverse birth outcomes. Most studies used serum ferritin (SF) concentrations as the indicator of iron status, which makes the interpretation of results challenging because SF concentrations increase in response to inflammation or infection. The effect of iron supplementation during pregnancy may depend on initial iron status. There are several mechanisms through which high iron status during pregnancy may have adverse effects on birth outcomes, including oxidative stress, increased blood viscosity, and impaired systemic response to inflammation and infection. Research is needed to understand the biological processes that underlie the U-shaped curves seen in observational studies. Reevaluation of cutoffs for hemoglobin concentrations and indicators of iron status during pregnancy is also needed.

Impact of small quantity lipid-based nutrient supplements on infant and young child feeding practices at 18 months of age: results from four randomized controlled trials in Africa.

Abstract Optimal infant and young child feeding (IYCF) practices can help ensure nutrient adequacy and support healthy growth and development. Small‐quantity lipid‐based nutrient supplements (SQ‐LNS) have been proposed to help fill nutrient gaps, but little is known about the impact of provision of SQ‐LNS on breastfeeding or complementary feeding practices. In the context of four coordinated randomized controlled nutrient supplementation trials in diverse sites in Africa, we compared IYCF practices at infant age 18 months (after 9–12 months of supplementation) between those receiving and not receiving SQ‐LNS. Practices were assessed by caregiver recall. Continued breastfeeding ranged from 74% (Ghana site) to 97% (Burkina Faso site) and did not differ between groups in any site; prevalence of frequent breastfeeding also did not differ. In two sites (Burkina Faso and Malawi), infants receiving SQ‐LNS were more likely to meet the World Health Organization recommendations for frequency of feeding (percentage point differences of 12–14%, P < 0.0001 and P = 0.005, respectively; the remaining two sites did not have data for this indicator). Most indicators of infant dietary diversity did not differ between groups in any site, but in the same two sites where frequency of feeding differed, infants receiving SQ‐LNS were less likely to have low frequency of consumption of animal‐source foods in the previous week (percentage point differences of 9–19% for lowest tertile, P = .02 and P = 0.04, respectively). We conclude that provision of SQ‐LNS did not negatively impact self‐reported IYCF practices and may have positively impacted frequency of feeding.

Lipid-Based Nutrient Supplements Increase Energy and Macronutrient Intakes from Complementary Food among Malawian Infants

BACKGROUNDnLow intakes of good-quality complementary foods (CFs) contribute to undernutrition and consequently negatively affect health, growth, and development. Lipid-based nutrient supplements (LNSs) are designed to ensure dietary adequacy in micronutrients and essential fatty acids and to provide some energy and high-quality protein. In populations in which acute energy deficiency is rare, the dose-dependent effect of LNSs on CF intakes is unknown.nnnOBJECTIVEnThe objective of this study was to evaluate the difference in energy and macronutrient intakes from CF between a control (no supplement) group and 3 groups that received 10, 20, or 40 g LNS/d.nnnMETHODSnWe collected repeated interactive 24-h dietary recalls from caregivers of rural Malawian 9- to 10-mo-old infants (n = 748) to estimate dietary intakes (LNS and all non-breast-milk foods) of energy and macronutrients and their dietary patterns. All infants were participating in a 12-mo randomized controlled trial to investigate the efficacy of various doses of LNS for preventing undernutrition.nnnRESULTSnDietary energy intakes were significantly higher among infants in the LNS intervention groups than in the control group (396, 406, and 388 kcal/d in the 10-, 20-, and 40-g LNS/d groups, respectively, compared with 345 kcal/d; each pairwise P < 0.05), but no significant differences were found in energy intakes between groups who were administered the different LNS doses (10 g LNS/d compared with 20 g LNS/d: P = 0.72; 10 g LNS/d compared with 40 g LNS/d: P ≥ 0.67; 20 g LNS/d compared with 40 g LNS/d: P = 0.94). Intakes of protein and fat were significantly higher in the LNS intervention groups than in the control group. No significant intergroup differences were found in median intakes of energy from non-LNS CFs (357, 347, and 296 kcal/d in the 10-, 20-, and 40-g LNS/d groups, respectively, compared with 345 kcal/d in the control group; P = 0.11).nnnCONCLUSIONnLNSs in doses of 10-40 g/d increase intakes of energy and macronutrients among 9- to 10-mo-old Malawian infants, without displacing locally available CFs. This trial was registered at clinicaltrials.gov as NCT00945698.