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NIH breastfeeding research essential to child health

May / June 2021 | Volume 20 Number 3

Woman holds a newborn baby, older child seated next to her on a cot, in a large tent clinic, other women in background.UNICEF Ethiopia/2021/Nahom Tesfaye Breastfeeding and infant nutrition in low- and middle-income countries pose complex research challenges.

By Susan Scutti

Although six months of exclusive breastfeeding (EBF) has long been recommended by the WHO to promote healthy child development, progress has stalled in some low-resource settings, jeopardizing efforts to reduce infant mortality. Only about 38% of the world’s infants benefit from EBF for the first 180 days of life.

A number of barriers exist in low- and middle-income countries (LMICs) and each poses unique research questions. In some places, cultural practices mean women discard the antibody-rich colostrum or delay nursing. Other mothers find it challenging to balance breastfeeding with formal employment or fulfilling household needs for firewood and clean water. Milk banking has proven a successful solution in some locations but is difficult to scale-up in rural areas. For moms living with HIV, drug therapies have reduced the risk of transmission through breastfeeding, but the virus is still a danger that must be managed. NIH studies have also explored other aspects of infant nutrition, such as the ability of breast milk to help LMIC infants deal with early and frequent exposure to infectious diseases. Finally, advances in microbiome research hold great potential to help scientists better understand the relationship between breastfeeding and infant health.

The notion that breastfeeding provides the healthiest start in life is founded on decades of research. “Breastfeeding alternatives in low-income settings are often both inadequate in nutritional content and also very prone to bacterial contamination, which leads to a high risk of diarrhea, and both factors contribute to the malnutrition we see with non-breast-fed babies,” explained Dr. Robert Black, a professor at Johns Hopkins University who has led child nutrition studies for decades. As a result, research programs in LMICs often focus on messaging, counseling and encouraging support for moms. For instance, studies show the program Kangaroo Mother Care facilitates EBF and helps mothers bond with their babies. Frequently examined topics include ways to encourage breastfeeding and how to achieve sufficient nutrition from complementary foods while breastfeeding within specific societies and settings, according to Black.

“Breast milk is an excellent food nutrient-wise and also contains immune factors so it protects the infant both nutritionally and also immunologically from infections,” said Black, who has served on Fogarty’s advisory board. Benefits include positive effects on cognitive development and the prevention of obesity. The WHO and public health organizations worldwide promote EBF for six months, at which time complementary foods should be introduced. Another guideline: breastfeeding should begin within the first hour of life and continue for two years. Yet only a little more than one-third of the world’s mothers manage EBF for six months, according to the WHO.

A significant factor is that employment among LMIC mothers has skyrocketed in the last 20 years, with about half now working outside the home. In a Fogarty-supported study of about 1,000 mothers of newborns in Kenya, about 40% of those with formal employment had ended EBF by three months, the maternity leave period mandated by the government. Of those, 50% said returning to work was their reason for stopping, one-third said it was time to introduce other foods and almost 15% said they thought their breastmilk was insufficient. While Kenya has recently begun requiring employers to provide private lactation spaces and flexible work schedules to support breastfeeding, this is not a common practice in many low-resource settings, the study authors said.

For premature and sick infants whose mothers cannot nurse, milk banking has proven successful in countries such as South Africa and India. PATH scientist Dr. Kiersten Israel-Ballard has studied the feasibility of expanding the practice to rural and underserved areas in LMICs. “Milk banks could play a critical role in ensuring that exclusive human milk diets are possible for all infants, especially those who are most vulnerable, such as pre-term babies, and possibly including those in emergency situations, such as conflict zones, natural disasters or other humanitarian crises,” she said. But turning this vision into reality will require an investment in implementation research and establishment of ethical guidelines and safety standards.

Studies are also needed to learn more about breast milk itself, said Dr. Dan Raiten, a program director at the NIH’s National Institute of Child Health and Human Development. “What we’re trying to do is change the paradigm and recognize the importance of this very complex biological system - the notion that human milk is more than just the sum of its parts,” Raiten noted. He recently convened a group of scientists to stimulate the infant nutrition research community, gather information about what is established science and identify research gaps. Five work groups are exploring the biology and ecology of breast milk, the impact of the infant-mother relationship, possible methodologies for advancing this research, and translation and implementation science. Raiten said the setting is of paramount concern. “Context matters - the decisions made about infant feeding are going to be different depending on your context. This initiative is a response to a global need, a domestic need and a fundamental need to understand the biology of human milk.”

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