Objectives To evaluate the effectiveness and cost-effectiveness of interventions that promote or inhibit breastfeeding or feeding with breastmilk for infants admitted to neonatal units, and to identify an agenda for future research. Data sources Electronic databases were searched (including MEDLINE and MEDLINE In-Process Citations, EMBASE, CINAHL, Maternity and Infant Care, PsycINFO, British Nursing Index and Archive, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Science Citation Index, Pascal, Latin American and Caribbean Health Sciences, MetaRegister of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessment Database, National Research Register) from inception to February 2008. Advisors identified further published or unpublished material. Review methods All papers fulfilled eligibility criteria covering participants, interventions, study design and outcomes. Results from primary studies were assessed and summarised in a qualitative synthesis for each type of intervention and across types of intervention. To estimate long-term cost utility, a decision tree was developed to synthesise data on enhanced staff contact, breastmilk effectiveness, incidence of necrotising enterocolitis (NEC) and sepsis, resource use, survival and utilities. Results Forty-eight studies met the selection criteria for the effectiveness review, of which 65% (31/48) were RCTs, and 17% (8/48) were conducted in the UK. Seven were rated as good quality and 28 as moderate quality. No studies met the selection criteria for the health economics review. There is strong evidence that short periods of kangaroo skin-to-skin contact increased the duration of any breastfeeding for 1 month after discharge [risk ratio (RR) 4.76, 95% confidence interval (CI) 1.19 to 19.10] and for more than 6 weeks (RR 1.95, 95% CI 1.03 to 3.70) among clinically stable infants in industrialised settings. There is strong evidence for the effectiveness of peer support at home (in Manila) for mothers of term, low birthweight infants on any breastfeeding up to 24 weeks (RR 2.18, 95% CI 1.45 to 3.29) and exclusive breastfeeding from birth to 6 months (RR 65.94, 95% CI 4.12 to 1055.70), and for the effectiveness of peer support in hospital and at home for mothers of infants in Special Care Baby Units on providing any breastmilk at 12 weeks [odds ratio (OR) 2.81, 95% CI 1.11 to 7.14; p = 0.01]. There is more limited evidence for the effectiveness of skilled professional support in a US Neonatal Intensive Care Unit on infants receiving any breastmilk at discharge (OR 2.0, 95% CI 1.2 to 3.2, p = 0.004). Multidisciplinary staff training may increase knowledge and can increase initiation rates and duration of breastfeeding, although evidence is limited. Lack of staff training is an important barrier to implementation of effective interventions. Baby Friendly accreditation of the associated maternity hospital results in improvements in several breastfeeding-related outcomes for infants in neonatal units. Limited evidence suggests that cup feeding (versus bottle feeding) may increase breastfeeding at discharge and reduce the frequency of oxygen desaturation. Breastmilk expression using simultaneous pumping with an electric pump has advantages in the first 2 weeks. Pharmaceutical galactagogues have little benefit among mothers who have recently given birth. Our economic analysis found that additional skilled professional support in hospital was more effective and less costly (due to reduced neonatal illness) than normal staff contact. Additional support ranged from 0.009 quality-adjusted life-years (QALYs) to 0.251 QALYs more beneficial per infant and ranged from £66 to £586 cheaper per infant across the birthweight subpopulations. Donor milk would become cost-effective given improved mechanisms for its provision. Conclusions Despite the limitations of the evidence base, kangaroo skin-to-skin contact, peer support, simultaneous breastmilk pumping, multidisciplinary staff training and the Baby Friendly accreditation of the associated maternity hospital have been shown to be effective, and skilled support from trained staff in hospital has been shown to be potentially cost-effective. All these point to future research priorities. Many of these interventions inter-relate: it is unlikely that specific clinical interventions will be effective if used alone. There is a need for national surveillance of feeding, health and cost outcomes for infants and mothers in neonatal units; to assist this goal, we propose consensus definitions of the initiation and duration of breastfeeding/breastmilk feeding with specific reference to infants admitted to neonatal units and their mothers.

https://njl-admin.nihr.ac.uk/document/download/2001753

Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis.

The World Health Organisation recommends exclusive breastfeeding until 6 months of age and continued breastfeeding until 2 years of age or beyond. Appropriate complementary foods should be introduced in a timely fashion, beginning when the infant is 6 months old. In developing countries, early or inappropriate complementary feeding may lead to malnutrition and poor growth, but in countries such as the United Kingdom and United States of America, where obesity is a greater public health concern than malnutrition, the relationship to growth is unclear. We conducted a systematic review of the literature that investigated the relationship between the timing of the introduction of complementary feeding and overweight or obesity during childhood. Electronic databases were searched from inception until 30 September 2012 using specified keywords. Following the application of strict inclusion/exclusion criteria, 23 studies were identified and reviewed by two independent reviewers. Data were extracted and aspects of quality were assessed using an adapted Newcastle-Ottawa scale. Twenty-one of the studies considered the relationship between the time at which complementary foods were introduced and childhood body mass index (BMI), of which five found that introducing complementary foods at 6 months, may increase the risk of childhood overweight.

Timing of the introduction of complementary feeding and risk of childhood obesity: a systematic review

Socio-cultural studies have suggested that, even in societies where it is a commonplace practice, infant feeding with formula milk can compromise women's identity as 'good mothers.' This proposition is explored in this paper. We first provide a brief review of literature that has considered the broad socio-cultural context for infant feeding, that of 'intensive motherhood.' Attention is drawn to the idea that this context is one in which feeding babies formula milk is constructed as risky, for physical health but also for the mother-child relationship. Drawing on data from a study of mothers living in the UK, the paper then explores how mothers actually experience infant feeding with formula milk and how they live with a context that deems their actions risky. Maternal experience is found to include variously moral collapse, feelings of confidence, expressions of defiance and defensiveness, and opting to go it alone in response to 'information overload.' Despite these variations in how mothers live with risk, the conclusion is drawn that the current cultural context does appear to be one overall in which mothers who formula feed often have to struggle hard to maintain a positive sense of themselves as mothers.

Living with risk in the age of ‘intensive motherhood’: Maternal identity and infant feeding

Background
The objective of this study was to determine whether there was an association between mothers’ light drinking during pregnancy and risk of behavioural problems, and cognitive deficits in their children at age 3 years.
Methods
Data from the first two sweeps of the nationally representative prospective UK Millennium Cohort study were used. Drinking patterns during pregnancy and behavioural and cognitive outcomes were assessed during interviews and home visits. Behavioural problems were indicated by scores falling above defined clinically 15 relevant cut-offs on the parent-report version of the Strengths and
Difficulties Questionnaire (SDQ). Cognitive ability was assessed using the naming vocabulary subscale from the British Ability Scale (BAS) and the Bracken School Readiness Assessment (BSRA).
Results 
There was a J-shaped relationship between mothers drinking
20 during pregnancy and the likelihood of high scores (above the cut-off) on the total difficulties scale of the SDQ and the conduct problems, hyperactivity and emotional symptom SDQ subscales. Children born to light drinkers were less likely to score above the cut-offs compared with children of abstinent mothers. Children 25 born to heavy drinkers were more likely to score above the cut-offs
compared with children of abstinent mothers. Boys born to mothers who had up to 1–2 drinks per week or per occasion were less likely to have conduct problems (OR 0.59, 95% CI 0.45–0.77) and hyperactivity (OR 0.71, 95% CI 0.54–0.94). These effects remained 30 in fully adjusted models. Girls were less likely to have emotional symptoms (OR 0.72, 95% CI 0.51–1.01) and peer problems (OR 0.68, 95% CI 0.52–0.92) compared with those born to abstainers. These effects were attenuated in fully adjusted models. Boys born to light drinkers had higher cognitive ability test scores [standard
35 deviations, (95% CI)] BAS 0.15 (0.08–0.23) BSRA 0.24 (0.16–0.32) compared with boys born to abstainers. The difference for BAS was attenuated on adjustment for socio-economic factors, whilst the difference for BSRA remained statistically significant.
Conclusions
Children born to mothers who drank up to 1–2 drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioural difficulties or cognitive deficits compared with children of abstinent mothers. Heavy drinking 5 during pregnancy appears to be associated with behavioural problems and cognitive deficits in offspring at age 3 years whereas light drinking does not.

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Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age?

Diabetes in pregnancy has been shown to induce long-term effects in offspring. While considerable attention is focused on the increased incidence of type 2 diabetes mellitus (T2DM) in adult offspring from diabetic mothers, cardiovascular alterations, including hypertension, are also part of lifelong consequences of in-utero exposure to increased glucose concentrations. This review examines the epidemiologic and mechanistic issues involved in the developmental programming of long-term consequences in offspring of diabetic mothers, with a particular emphasis on the renal and vascular mechanisms of hypertension. The factors of increased incidence of T2DM and of obesity in adults born after exposure to diabetes during pregnancy are also discussed, as evidence is accumulating that a vicious circle involving lifelong consequences of diabetes in pregnancy in offspring contributes to the current worldwide epidemic of T2DM.

Offspring of diabetic pregnancy: long-term outcomes.

This survey contains information collected regarding the feeding of infants from birth to nine months old. The survey provides information on the feeding practices adopted by mothers in the early weeks up to around 9 months after the baby's birth. It includes data on initial incidence of breastfeeding and duration, the use of formula and cows milk, factors associated with mothers' feeding intentions and cessation of breastfeeding, when mothers introduce solid foods and what is given and why. The survey also includes information on mothers' smoking and drinking behaviour during pregnancy and birth. The Infant Feeding Survey has been conducted every five years since 1975. The 2005 Infant Feeding Survey was the seventh national survey of infant feeding practices to be conducted. The main aims of the survey are to: - Establish how infants are fed and to provide national figures on the incidence, prevalence and duration of breastfeeding - Examine recent trends in infant feeding practices over recent years - Investigate the factors associated with mothers' feeding intentions and with the feeding practices adopted. This survey has a Northern Ireland component

United Kingdom

Papers

Infant Feeding Survey