Nutrition and Nurture in Infancy and Childhood: Bio‐Cultural Perspectives

3‐Day International Conference: Mon 28, Tues 29 and Wed 30 April 2025

Organised by the Maternal, Parental and Infant Nutrition and Nurture (MAINN)

University of Lancashire, UK

KEYNOTE SPEAKERS

Peer Support for Infant Feeding In the UK: Findings From the Assets‐Based Feeding Help Before and After Birth (ABA‐Feed) Randomised Controlled Trial

Professor Kate Jolly

School of Health Sciences, University of Birmingham, United Kingdom

Background: Breastfeeding has health benefits for infants, children and mothers¹ whilst unsafe formula feeding practices increase the risk of infection and over‐feeding in babies.² Peer support is recommended by the World Health Organisation, Unicef UK Baby Friendly Initiative and National Institute of Health and Care Excellence. However, in the UK, several randomised controlled trials of peer support have failed to show a beneficial effect. The ABA‐feed intervention was developed drawing on best evidence and assessed in a previous study showing feasibility of delivery.³ The ABA‐feed trial aimed to assess the effectiveness of a proactive, woman centred, assets‐based peer support intervention by an infant feeding helper (IFH) through pregnancy to 8‐weeks postnatal compared to usual care alone.

Methods: UK based, multicentre, parallel group, randomised controlled trial in community settings in 17 UK localities between February 2022 and 30 April 2024 with primiparous women recruited within 20‐ and 35‐weeks gestation. The primary outcome was any breastfeeding at 8‐weeks post‐birth. Secondary outcomes collected at 3 days, and 8‐, 16‐ and 24‐weeks post‐birth included breastfeeding initiation, any and exclusive breastfeeding, formula feeding practices, anxiety, social support and health care utilisation. Analyses were based on the intention‐to‐treat principle.

Results: 2475 women were recruited: mean age 30.6 years (SD 4.7), 2132 (86.5%) White, 1726 (70.2%) educated to degree level. Overall, 93.5% initiated breastfeeding. 177 IFHs supported a median of seven [IQR 3,12] intervention participants each. IFHs reported a median of 19 [IQR 12, 24] contacts with each participant. Contacts were lowest in women from areas in the most deprived quintile and women aged < 25 years. 18.5% of usual care participants reported some support (usually only once) from an infant feeding counsellor or breastfeeding supporter. The primary outcome was available for 2442 of participants (98.7%). Breastfeeding outcomes, impact on formula preparation practices, anxiety, perceived social support and health care utilisation will be presented.

Conclusions: The ABA‐feed intervention was successfully delivered across a diverse range of settings across the UK. Despite intentions to recruit diverse participants we recruited a population with characteristics associated with likelihood to breastfeed.

References:

Victora CG, Bahl R, Barros AJD, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 2016;387(10017):475‐90.

Renfrew MJ, Pokhrel S, Quigley M, et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK: UNICEF, 2012.

Clarke JL, Ingram J, Johnson D, et al. The ABA intervention for improving breastfeeding initiation and continuation: Feasibility study results. Maternal & Child Nutrition 2020;16(1): e12907.

Funding: National Institute for Health and Care Research (NIHR129182)

Code Monitoring and Enforcement Using Digital Platforms: Argentina, Mexico, and Laos

Constance Ching

Alive & Thrive/FHI 360 Global Nutrition, Malaysia

Background: Aggressive and unethical marketing of breastmilk substitutes (BMS) and related products (bottles and teats and foods for infants and young children/FIYC) is a major barrier to improving breastfeeding around the globe, especially with the rampant marketing on digital platforms (Ching et al., 2021; Becker et al., 2022). Governments are obligated to adopt the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA resolutions (“the Code”) as legal measures to restrict all forms of promotion, and to ensure independent Code monitoring and enforcing legal measures. However, monitoring is often taxing due to the large number of materials that need to be collected, reviewed, and analyzed. Starting in 2022, Alive & Thrive employs innovative technology, including artificial intelligence, to support countries in their Code monitoring and enforcement efforts (Backholer et al., 2024).

Methods: A descriptive process development framework is used to describe and analyze the key steps in development and utilization of the Code Monitoring Digital Platform (CMDP) at the national level (Viet Nam, Argentina, Mexico, Laos, and Mongolia), including collaboration/partnership with UNICEF country offices, national NGOs, and government agencies, and activities in the user acceptance testing (UAT) workshops. Process maps are generated to identify limitations/bottlenecks, opportunities, and areas for improvement of implementing CMDP.

Key Preliminary Results: Limitations/bottlenecks: Governments lacking capacity to address violations, no or weak existing monitoring and enforcement mechanisms, novelty effects of AI innovations, lack of sustainable funding to ensure long term usage of innovative technology.

Opportunities: CMDP and its UAT activities can be effective in reinvigorating and raising awareness on national Code monitoring and enforcement initiatives (the ”hook” effect), especially in sensitizing enforcement officials who are not trained in health/nutrition, and connecting different agencies/organizations to co‐operate and coordinate in monitoring and enforcement. It is also useful in integrating monitoring findings into enforcement systems, for countries with existing monitoring activities.

Areas for improvement: Greater emphasis can be placed on using the CMDP for evidence and knowledge generation and dissemination, and the need to better contextualize technology/innovation in practice (not just perfunctory) and as added value.

Ultra‐Processed Foods (UPF) in the Diets of Infants and Young Children in the UK: What They Are, How They Harm Health, and What Should be Done to Reduce Intakes

Dr Vicky Sibson

First Steps Nutrition Trust, United Kingdom

Background: UPF are a new category of foods defined by extensive processing (inferred from ingredient markers like additives) and profitability. Their consumption has been associated with health harms in adults, including obesity and cardiovascular disease, and evidence is growing in young children. My presentation seeks to share available data on what UPFs infants and young children in the UK eat and to what extent, and then to explore why UPFs dominate their diets, why this is concerning, to tackle distracting controversies, and lastly, to share policy recommendations on what can be done to reduce intakes.

Methods: Literature review and review of related policies to inform policy recommendations.

Results: Most UK infants start their lives on a diet dominated by commercial milk formula, and some ultra‐processed commercial baby and toddler foods, yoghurts, wholegrain bread and high‐fibre cereals, such that total dietary energy intake from UPF has been estimated at 47% at 21 months (Conway et al, 2024) and 61% at 2‐5 years (Neri et al, 2022). Disadvantaged children consume more UPF.

Discussion: UPF intakes dominate early years diets due to demand and industry dominance (Baker et al, 2020). This is concerning because of growing evidence UPF‐rich diets in the first years displace less processed, nutritious (‘real’) foods, negatively influence dietary habits and preferences, and cause adiposity (Robels et al, 2024). The food industry sew doubt in the UPF concept, despite growing evidence of harm. However, a range of policy options are available to rebalance diets in favour of ‘real’ foods, which for the early years include enabling breastfeeding, regulating the marketing of commercial baby and toddler foods and strengthening the Healthy Start scheme.

Conclusion: High UPF intakes from birth contribute to high levels of obesity but could be reduced by policies which support breastfeeding and increased consumption of ‘real’ foods. These actions should be part of a cohesive food policy addressing poverty, inequalities, and access to healthy and sustainable diets.

References:

Baker P, Santos T, Neves PA, Machado P, Smith J, Piwoz E, Barros AJD, Victora CG, McCoy D. First‐food systems transformations and the ultra‐processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption. Matern Child Nutr. 2021 Apr;17(2):e13097. doi:10.1111/mcn.13097.

Conway, R.E., Heuchan, G.N., Heggie, L. et al. Ultra‐processed food intake in toddlerhood and mid‐childhood in the UK: cross sectional and longitudinal perspectives. Eur J Nutr 63, 3149–3160 (2024). https://doi.org/10.1007/s00394-024-03496-7.

Neri D, Steele EM, Khandpur N, Cediel G, Zapata ME, Rauber F, Marrón‐Ponce JA, Machado P, da Costa Louzada ML, Andrade GC, Batis C, Babio N, Salas‐Salvadó J, Millett C, Monteiro CA, Levy RB; NOVA Multi‐Country Study Group on Ultra‐Processed Foods, Diet Quality and Human Health. Ultraprocessed food consumption and dietary nutrient profiles associated with obesity: A multicountry study of children and adolescents. Obes Rev. 2022 Jan;23 Suppl 1:e13387. doi:10.1111/obr.13387.

Robles B, Mota‐Bertran A, Saez M, Solans M. Association between ultraprocessed food consumption and excess adiposity in children and adolescents: A systematic review. Obes Rev. 2024 Oct;25(10):e13796. doi:10.1111/obr.13796.

Water Insecurity: A Sorely Overlooked Determinant of Nutrition, Health and Well‐Being in the First 1000 Days

Professor Sera Young

Northwestern University, USA

Background: Problems with water quality and quantity are increasing in frequency and severity throughout the world, with major implications for health and well‐being, especially during the first 1000 days. High‐resolution, globally comparable data have been extremely helpful for understanding the prevalence and consequences of experiences with many global issues, e.g. food insecurity, but have not existed for water.¹

Methods: To fill this gap, we developed the Water InSecurity Experiences (WISE) Scales, the first cross‐country equivalent way of measuring water access and use.^2,3 They have now been used in more than 80 countries (www.WISEscales.org) in a variety of settings: national monitoring, clinical trials, and impact evaluations.⁴

Results: After presenting a brief overview of water security and its measurement, I will share global estimates of water insecurity. I will also lay out the evidence to date about how water insecurity shapes poor nutrition, mental health, and physical health in the first 1000 days.

Conclusion: Water insecurity is an underappreciated driver of adverse health in the first 1000 days. There are many water security‐related avenues for further research and public health interventions during this critical period of life.

References:

1. Young SL, Frongillo EA, Jamaluddine Z, Melgar‐Quiñonez H, Pérez‐Escamilla R, Ringler C, et al. Perspective: The Importance of Water Security for Ensuring Food Security, Good Nutrition, and Well‐being. Advances in Nutrition. 2021 Feb 18;12(4):1058–73.

2. Young SL, Boateng GO, Jamaluddine Z, Miller JD, Frongillo EA, Neilands TB, et al. The Household Water InSecurity Experiences (HWISE) Scale: development and validation of a household water insecurity measure for low‐income and middle‐income countries. BMJ Global Health. 2019 Sep 1;4(5):e001750.

3. Young SL, Bethancourt HJ, Ritter ZR, Frongillo EA. The Individual Water Insecurity Experiences (IWISE) Scale: reliability, equivalence and validity of an individual‐level measure of water security. BMJ Glob Health. 2021 Oct;6(10):e006460.

4. Young SL, Miller J, Bose I. Measuring human experiences to advance safe water for all. Evanston: Institute for Policy Research; 2024. Available from: https://doi.org/10.21985/n2‐xvrr‐7693.

Feed: Supporting Public Breastfeeding Through Art, Design and Culture

Elaine Speight

University of Lancashire, United Kingdom

Feed is a collaborative art project that explores experiences of breastfeeding in public and challenges cultural stigmas towards human milk and mothering. The project includes the Feeding Chair, a multimedia artwork and infant feeding seat, which invites people to feed their babies and children in indoor public venues, to take up space and to take their time. Since 2023, the chair has been touring contemporary art venues across the UK, accompanied by a series of new artworks and an evolving programme of creative engagement activities with artists, breastfeeding support groups, parents and health professionals. These activities have instigated conversations about the practicalities and politics of feeding babies and young children outside of the home and reimagined the public realm as a safe and supportive space for families and children. Through exhibitions, artworks, films and manifestos, participants have shared their views with decision makers and encouraged host venues to support and celebrate infant feeding through their policies and programmes.

In this talk, curator Elaine Speight will locate Feed within a wider tradition of artistic projects that challenge cultural attitudes towards human milk and reproductive bodies. Discussing the work of artists such as Jess Dobkin, Krissi Musiol, Catherine Opie and Conway and Young, she will describe how, by engaging people in embodied, emotional and, above all, sensory ways, art has the capacity to challenge preconceptions and make hidden experiences visible. She will also discuss how public art galleries and museums can help to destigmatise and facilitate public breastfeeding. As noncommercial, civic institutions, these venues not only provide welcoming places to feed, but can also facilitate uncomfortable feelings and conversations within a safe and inclusive space. In doing so, cultural organisations and projects such as Feed can play an important role in helping to change social perceptions of infant feeding, reframing it from an individual duty or choice to a collective responsibility. www.feedproject.art

A Population Approach to Evaluating the Impact of Neonatal Nutritional Strategies

Dr Cheryl Battersby

Imperial College London and Chelsea and Westminster Hospital, London, United Kingdom

In the UK, around 1 in 10 babies are admitted to neonatal units soon after birth. The reasons for requiring specialist care include being born prematurely, with a congenital abnormality, born term but unexpectedly sick due to a complication during labour or following birth. Nutritional management from birth is paramount and has an impact on short and longer‐term outcomes. Over the last decade, there has been growing recognition of the need to optimise nutritional provision, either by enteral or parenteral nutrition to meet a baby's nutritional requirement. What constitutes “optimal management” will vary according to the gestation, medical history and condition of the baby, and uncertainties exist due to the paucity of research.

Whilst randomised controlled trials are considered the gold standard to compare interventions, these are expensive, take a long time to conduct and may not necessarily represent real‐world clinical care or population, and often findings lack generalisability.

This talk focuses on how quasi‐experimental study designs have been applied to large observational population data to evaluate the impact of nutritional strategies (enteral and parenteral nutrition) on outcomes in different neonatal populations. The talk will address the following questions:

• Does early maternal or formula milk exposure, or probiotic exposure influence the development of necrotising enterocolitis? (1)

• Should we enterally feed term babies who are undergoing neonatal therapeutic hypothermia? (2)

• What is the optimal time to start parenteral nutrition in preterm babies? (3)

This talk will take you through how propensity matching is conducted and methodological considerations in causal inference study designs using observational data. The talk will highlight that by recognising and addressing the potential limitations through careful study design, population real‐world data can be harnessed to provide beneficial clinical utility to inform optimal neonatal nutrition.

References:

1. Battersby C, Longford N, Mandalia S, Costeloe K, Modi N; UK Neonatal Collaborative Necrotising Enterocolitis (UKNC‐NEC) study group. Incidence and enteral feed antecedents of severe neonatal necrotising enterocolitis across neonatal networks in England, 2012‐13: a whole‐population surveillance study. Lancet Gastroenterol Hepatol. 2017 Jan;2(1):43‐51. doi: 10.1016/S2468‐1253(16)30117‐0. Epub 2016 Nov 8. PMID: 28404014.

2. Gale C, Longford NT, Jeyakumaran D, Ougham K, Battersby C, Ojha S, Dorling J. Feeding during neonatal therapeutic hypothermia, assessed using routinely collected National Neonatal Research Database data: a retrospective, UK population‐based cohort study. Lancet Child Adolesc Health. 2021 Jun;5(6):408‐416. doi: 10.1016/S2352‐4642(21)00026‐2. Epub 2021 Apr 21. PMID: 33891879; PMCID: PMC8131202.

3. Uthaya S, Longford N, Battersby C, Oughham K, Lanoue J, Modi N. Early versus later initiation of parenteral nutrition for very preterm infants: a propensity score‐matched observational study. Arch Dis Child Fetal Neonatal Ed. 2022 Mar;107(2):137‐142. doi: 10.1136/archdischild‐2021‐322383. Epub 2021 Nov 18. PMID: 34795009; PMCID: PMC8867269.

CONCURRENT SESSIONS

Women's Experiences of an Assets‐Based Peer Support Intervention (ABA‐Feed) for Increasing Breastfeeding Initiation and Continuation: Findings From Qualitative Interview and Survey Data

Joanne Clarke ¹ , Nicola Crossland², Stephan Dombrowski³, Pat Hoddinott⁴, Jenny Ingram⁵, Debbie Johnson⁵, Christine MacArthur¹, Jennifer McKell⁶, Ngawai Moss⁷, Julia Sanders⁸, Nicola Savory⁸, Beck Taylor⁹, Gill Thomson², Kate Jolly¹ on behalf of the ABA‐feed research group

¹Applied Health Sciences, University of Birmingham, Birmingham, UK, ²Maternal and Infant Nutrition and Nurture Unit, University of Lancashire, Preston, UK, ³Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada, ⁴Nursing, Midwifery and Allied Health Professional Research Unit, University of Stirling, Stirling, UK, ⁵Bristol Medical School, University of Bristol, Bristol, ⁶Institute for Social Marketing and Health, University of Stirling, Stirling, UK, ⁷Patient and Public Representative, ⁸School of Healthcare Sciences, Cardiff University, Cardiff, UK, ⁹Warwick Applied Health, Warwick Medical School, University of Warwick, Warwick, UK.

Background: Breastfeeding peer support is valued by women, but UK trials have not demonstrated efficacy in improving breastfeeding rates. The ABA‐feed trial tested the ABA‐feed intervention at 17 sites in the UK. In total, 2475 women (1458 intervention) were recruited antenatally. The intervention offers proactive infant feeding peer support to first‐time mothers, regardless of feeding intention. Starting antenatally, the intervention is underpinned by behaviour change theory and an assets‐based approach.

Aims: This study aimed to explore experiences of the different ABA‐feed intervention components among women with a wide range of feeding intentions and demographic characteristics. We also aimed to explore the benefit of using open‐ended survey data to increase the generalisability of qualitative interview findings.

Methods: Semi‐structured interviews were conducted, via telephone, with women who had been offered the ABA‐feed intervention at five UK sites between 8 and 24 weeks postnatally. Interviewers used a topic guide designed to explore the acceptability of the intervention and fidelity of delivery of the key intervention components. Participants were purposively sampled to include women with different feeding intentions and demographic characteristics.

In addition, all women taking part in the trial at all 17 study sites were sent a survey to complete 8‐weeks postnatally, including two open‐text questions on feeding difficulties and experiences of support.

Interviews were audio‐recorded and transcribed. Interview data were analysed using thematic framework methods, with coding summaries produced for each woman and overall. Open‐text survey data from women assigned to the intervention were coded to the same framework as the interview data, and coding summaries produced both overall and for sub‐groups including age, education level, ethnicity, relationship status and feeding intention. Open‐text and interview coding summaries were compared.

Results: Thirty women took part in an interview and 1142/1458 (78%) women assigned to the intervention provided open‐text survey data. Interview data identified that most women received the ABA‐feed intervention with fidelity; found the intervention acceptable, valuing the continued, proactive contact starting antenatally; and appreciated the woman‐centred support enabling them to draw on social support and local assets. Open‐text data analysis confirmed findings of the interview data analysis, providing evidence that the intervention is largely acceptable across diverse groups including younger women, single women, women from ethnic minority groups, women with different feeding intentions and different education levels.

Conclusions: Findings provide insights into women's experiences of the ABA‐feed intervention. The comparison of in‐depth interview data and open‐text survey data enables us to confirm acceptability of the intervention among a diverse range of study participants.

Funding: National Institute for Health and Care Research (NIHR129182)

“I Am Going to Take It Up”: Implementing Skin‐To‐Skin Contact in Uganda

Anna Blair ¹, Karin Cadwell¹, Louise Bastarache², Kristin Svensson³, Kajsa Brimdyr¹

¹Healthy Children Project, Harwich, USA. ²Harvard Medical Faculty Physicians, Cambridge, USA. ³Karolinska Institutet, Stockholm, Sweden

Background: Timely and prolonged skin‐to‐skin contact (SSC) immediately after birth is recommended in the Ugandan Clinical Guideline, the 2023 International Research and Practice Guideline on SSC and the WHO/UNICEF Baby‐Friendly Hospital Initiative. Skin‐to‐skin contact is safe, low resource, evidence‐based and contributes to short‐ and long‐term health outcomes. However, practice is inconsistent.

Aims: After an experiential intervention, PRECESS (Practice, Reflection, Education and training, Combined with Ethnography for Sustainable Success), a mixed‐methods design evaluated the change in practice and duration of SSC at a regional referral hospital in Uganda.

Methods: In January 2024, video recordings of 92 pre‐intervention and 105 post‐intervention births and first hour neonatal behaviour were collected. The duration of SSC for the two groups was extracted and compared.

Results: Pre‐intervention duration of SSC was 2:25 min ± 2:48. Post‐intervention duration was 57:52 ± 2:43 min (p < 0.001). Fifteen key informants, including leadership and staff members, participated in semi‐structured pre‐ and post‐intervention interviews regarding barriers and solutions for implementing SSC. The interviews were analysed for themes. Three themes emerged: Commitment to consistent, evidence‐based care within constraints; Recognition of the gap in knowledge regarding the optimal practice; and Willingness to “take‐up” the practice change for the benefit of mothers and babies.

Conclusions: Our findings support the experiential method of practice change (PRECESS) to implement immediate, continuous, uninterrupted SSC for at least the first hour after birth. Despite the challenges and barriers identified in key informant interviews, significant progress was made in increasing the duration of SSC for both vaginal and caesarean births.

References

Brimdyr K, Stevens J, Svensson K, Blair A, Turner‐Maffei C, Grady J, Bastarache L, Al Alfy A, Crenshaw JT, Giugliani ERJ, Ewald U, Haider R, Jonas W, Kagawa M, Lilliesköld S, Maastrup R, Sinclair R, Swift E, Takahashi Y, Cadwell K. Skin‐to‐skin contact after birth: Developing a research and practice guideline. Acta Paediatr. 2023 Aug;112(8):1633‐1643. doi: 10.1111/apa.16842. Epub 2023 May 24. PMID: 37166443.

Mbalinda, S., Hjelmstedt, A., Nissen, E., Odongkara, B. M., Waiswa, P., & Svensson, K. (2018). Experience of perceived barriers and enablers of safe uninterrupted skin‐to‐skin contact during the first hour after birth in Uganda. Midwifery, 67, 95–102. https://doi.org/10.1016/j.midw.2018.09.009.

Sinclair, R., Swift, E., Takahashi, Y., & Cadwell, K. (2023). Skin‐to‐skin contact after birth: Developing a research and practice guideline. Acta Paediatrica (Oslo, Norway: 1992), 112(8), 1633–1643. https://doi.org/10.1111/apa.16842.

Health Professional Training in Infant Feeding: Findings From the World Breastfeeding Trends Initiative (WBTi) Assessment

Patricia Wise ¹, Alison Spiro²

¹NCT, London, United Kingdom. ²Brunel University, London, United Kingdom

Background: A World Breastfeeding Trends Initiative (WBTi) project in a country regularly monitors the implementation of the 2003 WHO Global Strategy for Infant and Young Child Feeding, to identify gaps, develop targeted recommendations for action, and show trends across ten indicators of infant feeding policy and programmes and five indicators of infant and young child feeding practices. In the UK the collaborative process was led by a Core Group comprising representatives of relevant health professional and third sector organisations as well as academics, coordinated by a Steering Group. Government representatives from the four nations formed an advisory group.

The first WBTi UK assessment (2016) found considerable gaps in the training of health professionals in supporting optimal infant feeding, particularly breastfeeding. Ideally, all new health professional graduates would have sufficient knowledge and skills to support breastfeeding. While this applies particularly to those who work with new mothers (midwives, health visitors and GPs), many other health professionals could have patients who are breastfeeding mothers or breastfed infants.

The second UK WBTi assessment was conducted from 2023 to 2024.

Aim: To assess the extent of health professional training in supporting optimal infant feeding, in line with the guidance in the WBTi Global Assessment Tool (2019, updated 2024). The assessment mapped UK‐wide standards or curricula against the 25 objectives of the 2003 WHO Education Checklist for Infant and Young Child Feeding.

Method: Pre‐registration training was the main focus. Health professionals were recruited to map their profession's standards against the Checklist objectives. The mapping was reviewed by two Steering Group members, and, where possible, a relevant professional body representative, with discussion to reach consensus.

There are also two criteria on in‐service training. Internet searching was used. Most in‐service training on supporting breastfeeding and achieving WHO Code compliance is provided in connection with UNICEF UK Baby Friendly (BFI) accreditation.

The two Steering Group members drafted the chapter and Core Group members had three opportunities to review the drafts.

Results: Midwifery standards are detailed and cover many of the objectives. Standards applying to non‐BFI‐accredited health visiting courses have many gaps. Nursing standards cover nutrition and hydration but are not explicit about infant feeding. Medical, dietitian and pharmacist standards still have many gaps. High‐level standards that are very general and not explicit about infant feeding topics can lead to considerable variation between the curricula of the training institutions.

Conclusion: Apart from midwifery, health professional training needs to cover much more about infant feeding and be more explicit about key topics. Nursing standards need to be explicit about infant feeding.

References:

1. WBTi UK Core Group. (2016). World Breastfeeding Trends Initiative UK Report 2016. https://ukbreastfeeding.org/wp-content/uploads/2017/03/wbti-uk-report-2016-part-1-14-2-17.pdf.

2. WBTi. (2019, updated 2024). WBTi Assessment tool. https://www.worldbreastfeedingtrends.org/uploads/resources/document/wbti-tool-version-march-2024.pdf.

3. WHO. (2003). Infant and young child feeding: A tool for assessing national practices, policies and programmes. https://www.who.int/publications/i/item/9241562544.

Breastfeeding Decision‐Making Process in Adolescent Mothers in LMIC Settings: A Qualitative Evidence Synthesis

Rachmawati Widyaningrum ^1,2, Nicola Gray¹, Anna Gavine¹, Albert Farre¹

¹University of Dundee, Dundee, United Kingdom. ²Universitas Ahmad Dahlan, Yogyakarta, Indonesia

Background: Breastfeeding decisions during the perinatal period are critical because they affect child health and development (Talbert et al., 2020). However, this decision‐making process can be more challenging for adolescent mothers (Müller, 2020), even more in the Low‐ and Middle‐ Income Countries (LMICs) settings, where the coverage of breastfeeding support is often low (Peven et al., 2020).

Aims: We conducted a qualitative evidence synthesis (QES) to better understand adolescent mothers' experiences in LMICs in making breastfeeding decisions and their support needs.

Methods: We systematically searched six databases. All articles were double screened by two authors independently against eligibility criteria. Included studies were critically appraised using the Critical Appraisal Skills Programme (CASP) qualitative checklist. We used a thematic approach to synthesise the data. NVivo was used to assist the data management.

Results: Seventeen articles were included. Three themes emerged from this QES. First, sociocultural challenges indicate that family and cultural influences extend beyond the mothers’ own decisions. The findings reveal that family members and cultural leaders often hold greater authority in decision‐making than the mothers themselves, most of whom appeared to encourage breastfeeding mothers to introduce additional foods to the baby. Second, challenges related to mothers and infant dyads, breastfeeding support, and decision‐making were identified. These challenges included mothers feeling overwhelmed by their baby's persistent crying, experiencing breast pain, and perceiving breastmilk insufficiency. Mothers who received support and encouragement to overcome these challenges felt more confident to continue breastfeeding. The final theme concerns the interactions between healthcare professionals and adolescent mothers. Some mothers expressed negative perceptions of healthcare professionals, such as feeling pressured towards a particular infant feeding method without appropriate discussion. This may influence their intention to seek care and support.

Conclusion: A positive breastfeeding support system for adolescent mothers is needed to encourage them to seek professional support that can assist them in overcoming challenges and making informed decisions. Additionally, culture and family significantly impact the decision‐making processes of adolescent mothers. Therefore, interventional support that engages family decision‐makers and considers the cultural context is vital. Future research is needed to determine how best to provide support in the infant feeding decision‐making process.

References:

Müller, M. (2020). Decision‐making process around teenage motherhood. In Decision‐Making Process around Teenage Motherhood. https://doi.org/10.1007/978-3-658-28775-7_4.

Peven, K., Purssell, E., Taylor, C., Bick, D., & Lopez, V. K. (2020). Breastfeeding support in low and middle‐income countries: Secondary analysis of national survey data. Midwifery, 82. https://doi.org/10.1016/j.midw.2019.102601.

Talbert, A., Jones, C., Mataza, C., Berkley, J. A., & Mwangome, M. (2020). Exclusive breastfeeding in first‐time mothers in rural Kenya: A longitudinal observational study of feeding patterns in the first 6 months of life. International Breastfeeding Journal, 15(1), 1–9. https://doi.org/10.1186/s13006-020-00260-5.

Factors Influencing Breastfeeding and Lactation Outcomes Following Neonatal Hypoxic Ischaemic Encephalopathy: A Mixed Methods Study

Sarah Edney, Anna Basu, Judith Rankin, Lindsay Pennington

Newcastle University, Newcastle upon Tyne, United Kingdom

Background: Hypoxic ischaemic encephalopathy (HIE) is the most common type of neonatal brain injury in term‐born infants. Breastfeeding and breastmilk feeding may be an important post‐HIE neurodevelopmental intervention; however, affected families often face particular challenges in these areas. As part of a wider mixed methods study of HIE‐related feeding difficulties, this study aims to identify factors that influence breastfeeding and lactation outcomes after neonatal HIE and highlight areas for service improvement and intervention development.

Methods: This explanatory‐sequential mixed methods study is made up of four components: 1) a mixed methods systematic review; 2) a retrospective analysis of data held on the National Neonatal Research Database (NNRD) for 14,082 infants born ≥ 36 weeks with HIE from 2013 to 2022; 3) a cross‐sectional questionnaire study of feeding history and outcomes for 58 families of children with HIE aged 0‐4 years; 4) interviews with 19 parents of children with HIE aged 0‐8 years. Quantitative data were analysed using logistic and linear regression techniques for associations between independent variables and outcomes (breastfeeding and breastmilk feeding). Qualitative data are being analysed using Braun and Clarke's reflexive thematic analysis methods.

Results: The systematic review included nine studies, all of which were quantitative studies of broader neuroprotective and nutritional treatments, with breastfeeding or lactation as secondary outcomes. No studies examined interventions specifically designed to improve breastfeeding or lactation, and none studied the effect of individual or social factors. Analysis of NNRD data showed exclusive breastfeeding and breastmilk feeding at neonatal discharge were negatively associated with lower gestational age at birth, lower birthweight, maternal infection, ventilation requirement, use of fortifier, nonwhite maternal ethnicity, and social deprivation. Questionnaire data analysis showed any breastfeeding or breastmilk feeding at age 0‐4 years were negatively associated with longer neonatal stay, current seizures, feeding difficulties, additional diagnoses and developmental issues, and nonwhite maternal ethnicity. Both breastfeeding and breastmilk feeding were more common among those who perceived support from family/friends and other sources (e.g. charities) to be good. However, perceived support from healthcare professionals did not significantly influence outcomes. Analyses of data from parent interviews are exploring the context and explanations for quantitative data. Parents reported outcomes to be influenced by family and social support, opportunities for physical closeness with their baby, and the knowledge and assumptions of staff. Access to multi‐skilled professionals with specialist knowledge of breastfeeding, swallowing disorders, and HIE/cerebral palsy was considered rare but important.

Conclusions: Both clinical and social factors influence breastfeeding and lactation following neonatal HIE. Parent interview data may provide important direction for the prevention and management of breastfeeding and lactation challenges faced by HIE‐affected families. Findings from this study will be used to cocreate parent resources and inform intervention development and future cohort and intervention studies

Increasing Our Understanding of Clinical Recommendations on Exclusive Human Milk Expression in a Neonatal Unit Context

Ilana Levene ^1,2, Frances O'Brien², Mary Fewtrell³, Maria Quigley¹

¹National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom. ²Newborn Care, John Radcliffe Hospital, Oxford, United Kingdom. ³Institute of Child Health, University College London, London, United Kingdom

Background: Sick and preterm infants are often too unwell or immature to breastfeed, but mother's (parent's) own milk is important to reduce their morbidity and mortality, as well as for the mother's (parent's) physical and mental health. In these cases, the mother (parent) must extract milk from the breasts (expressing), which is very challenging. International clinical recommendations are to start expressing within a few hours of birth, to express 7‐8 times per day or more, and to target milk quantity of 500‐750 ml per day by day 10‐14. These are demanding and adherence/achievement is low. There is little evidence to assess whether recommendations are optimal, or to give parents individualised information about their own lactation trajectory. We analysed a cohort of mothers (parents) expressing milk for very preterm infants (born under 32 weeks' post‐menstrual age, PMA) to provide further data on this topic.

Methods: Mothers (parents) giving birth between 23 + 0 and 31 + 6 weeks of pregnancy were recruited to a randomised trial. They provided milk expression logs on day 4, 14 and 21 after birth and reported feeding outcome at 36 weeks' PMA. Exploratory analysis of the relationship between expressing behaviours, milk quantity and feeding outcome was pre‐specified, using regression and Receiver Operating Characteristic (ROC) techniques.

Results: 132 participants were recruited in four United Kingdom neonatal units. Gestational age at birth was mean 27.8 weeks (SD 2.4). Median time to first expression attempt was 6 h. 52% expressed within 6 h of birth (62/120). Expressing within 6 h of birth was associated with higher milk yield on day 4 (88 g, 95% CI 7 to 169) and day 14 (156 g, 95% CI 12 to 299) but not day 21 (74 g, 95% CI ‐91 to 239). Expressing within 2 h of birth was not associated with further milk yield increase. Less than a quarter of participants expressed eight or more times per day. Expressing ≥ 8 times per day was associated with higher adjusted milk yield than expressing < 6 times (e.g. on day four, 147 g, 95% CI 47 to 246), but not in comparison to expressing 6‐7 times (e.g. on day four, 82 g, 95% CI –26 to 190). The following 24‐h milk quantities were identified as associated with high probability of full breastmilk at 36 weeks’ PMA: on day 4, ≥ 250 g (positive predictive value, PPV, 88%) and on day 21 ≥ 650 g (PPV 91%). The following were identified as associated with low probability of full breastmilk at 36 weeks’ PMA: on day 4 < 50 g (negative predictive value, NPV, 72%) and on day 21 < 250 g (NPV 70%).

Conclusions: Recommendations for early and frequent expression, with milk quantity targets similar to term infant intake are supported. The results can help improve individualised counselling for families.

Infant Feeding Peer Supporters’ and Coordinators’ Experiences of Delivering an Assets‐Based Peer Support Intervention (ABA‐Feed) for Increasing Breastfeeding Initiation and Continuation

Nicola Crossland ² , Joanne Clarke¹, Stephan Dombrowski³, Pat Hoddinott⁴, Jenny Ingram⁵, Debbie Johnson⁵, Christine MacArthur¹, Jennifer McKell⁶, Ngawai Moss⁷, Julia Sanders⁸, Nicola Savory⁸, Beck Taylor⁹, Gill Thomson², Kate Jolly¹ on behalf of the ABA‐feed research group

¹Applied Health Sciences, University of Birmingham, Birmingham, UK, ²Maternal and Infant Nutrition and Nurture Unit, University of Lancashire, Preston, UK, ³Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada, ⁴Nursing, Midwifery and Allied Health Professional Research Unit, University of Stirling, Stirling, UK, ⁵Bristol Medical School, University of Bristol, Bristol, ⁶Institute for Social Marketing and Health, University of Stirling, Stirling, UK, ⁷Patient and Public Representative, ⁸School of Healthcare Sciences, Cardiff University, Cardiff, UK, ⁹Warwick Applied Health, Warwick Medical School, University of Warwick, Warwick, UK.

Background: Breastfeeding peer support is valued by women and recommended in UK and international guidance, though evidence of effectiveness is uncertain. The ABA‐Feed intervention (Clarke et al., 2023) aimed to assess the effectiveness of a peer support intervention in addition to usual care compared with usual infant feeding care for breastfeeding outcomes in a randomised controlled trial at 17 UK sites. The intervention involved proactive peer support starting in the antenatal period until 8 weeks postnatal, for first‐time mothers irrespective of feeding intention. Existing or new breastfeeding peer supporters undertook additional training to become ABA‐Feed Infant Feeding Helpers (IFHs) managed by coordinators. IFHs offered woman‐centred support for infant feeding, offering information and helping women identify additional personal and local sources of support.

Aims: To describe IFHs’ and coordinators’ experiences of delivering ABA‐Feed and views on the acceptability of the intervention.

Methods: IFHs were invited to take part in an online/telephone interview or site‐specific online focus group via coordinators (who did not attend). Separate telephone or online individual or group interviews were carried out with IFH coordinators at each site. Semi‐structured topic guides were designed to explore fidelity of delivery of the key components of the intervention, acceptability, and perceptions of the intervention. IFH interviews lasted 30‐52 min and focus groups 69‐125 min. Coordinator interviews lasted 40‐74 min. All were audio recorded and transcribed. Transcripts were analysed using NVivo 12 and Excel concurrently with data collection using an approach based on Framework Analysis (Gale et al., 2013). For each data set (IFHs and IFH coordinators), data were indexed to the coding frame and code summaries were generated per site and summarised. Summaries were then categorised.

Results: From across the 17 sites, 72 IFHs participated in either a focus group (n = 64) or interview (n = 8), and 25 IFH coordinators took part in an interview. IFHs and coordinators found the intervention mostly acceptable, valuing the relationship‐building with women, the antenatal and early postnatal contact, the focus on assets and positive feedback from women. Most support was delivered remotely via videocall or text messaging. Some IFHs and coordinators had reservations about the intensity of early postnatal support. Most IFHs were positive about supporting women intending to formula feed though some expressed mixed feelings. There were varying views on whether the IFH role should be a paid versus volunteer role.

Conclusion: Findings suggest that ABA‐Feed is acceptable to those delivering and managing delivery of the intervention, and suggestions for delivering the model were highlighted.

References:

Clarke, J., Dombrowski, S.U., Gkini, E., Hoddinott, P., Ingram, J., MacArthur, C., Moss, N., Ocansey, L., Roberts, T., Thomson, G. and Sanders, J., 2023. Protocol: Effectiveness and cost‐effectiveness of Assets‐based feeding help Before and After birth (ABA‐feed) for improving breastfeeding initiation and continuation: protocol for a multicentre randomised controlled trial (Version 3.0). BMJ Open, 13(11).

Gale, N.K., Heath, G., Cameron, E., Rashid, S. and Redwood, S., 2013. Using the framework method for the analysis of qualitative data in multi‐disciplinary health research. BMC medical research methodology, 13, pp.1‐8.

Funding: National Institute for Health and Care Research (NIHR129182)

The Toolbox Approach to Inclusive Communication About Infant Feeding Decisions

Fiona Woollard ³, Matthew Cull¹, Jules Holroyd²,

¹Trinity College Dublin, Dublin, Ireland. ²University of Sheffield, Sheffield, United Kingdom. ³University of Southampton, Southampton, United Kingdom

Using inclusive language in information about pregnancy, childbirth and lactation is a key part of improving the experiences of trans and nonbinary parents [1]. Attempts at inclusive language are often well‐intentioned, but imperfectly executed, fuelling pushback and defences of ‘sexed’ language in communication around pregnancy, childbirth and lactation [2]. Common strategies for inclusive language include gender‐neutral strategies (which refrain from specifying gender) and gender‐additive strategies (which explicitly mention normally excluded genders). We argue that most problems arise from (a) failure to recognise that each of these strategies admits of different variations and that attention is needed to the reach, implications, and inclusivity of each variation; (b) attempts to adopt a single strategy in all situations. Instead, we propose a ‘toolbox approach’. The toolbox includes a range of different strategies (or tools): this may sometimes include gender‐neutral and gender‐additive approaches, but also second‐personal (“If you…”) and third‐person plural (“When we…”) devices, as well as multiple targeted messages. From this toolbox, in each particular case, the author of a message must select the ‘tool’ best suited to their specific context of communication and meeting their specific goals, as well as general moral and communicative goals of inclusion, nondiscrimination, clarity, and accuracy [3]. Making language about infant feeding decisions inclusive presents distinctive challenges. This is in part due to a lack of data about lactation in trans parents. It is in part due to a background in which parents’ abilities to make effective choices to breastfeed/chestfeed are affected by a complex interconnected system of influences [4] and in which infant feeding decisions, whether to breastfeed/chestfeed or to use infant formula, are experienced as sites of shame [5]. We use case studies to explore these distinctive challenges, and how the toolbox approach can be used to deal with them.

References:

1. Pezaro, Sally, et al. “Perinatal Care for Trans and Nonbinary People Birthing in Heteronormative “Maternity” Services: Experiences and Educational Needs of Professionals.” Gender & Society 37.1 (2023): 124‐151.

2. Gribble, Karleen D., et al. “Effective communication about pregnancy, birth, lactation, breastfeeding and newborn care: The importance of sexed language.” Frontiers in Global Women's Health 3 (2022): 3.

3. Cull, M, Holroyd, J, Woollard, F. “Caring for Everyone: Effective and Inclusive Communication in Perinatal Care” Hypatia, forthcoming.

4. Thomson G, Ingram J, Clarke J, Johnson D, Jolly K. “Who Gets to Breastfeed? A Narrative Ecological Analysis of Women's Infant Feeding Experiences in the UK.” Front Sociol. 2022 Jul 22;7:904773. doi: 10.3389/fsoc.2022.904773. PMID: 35938089; PMCID: PMC9352850.

5. Thomson G, Ebisch‐Burton K, Flacking R. Shame if you do‐‐shame if you don't: women's experiences of infant feeding. Matern Child Nutr. 2015 Jan;11(1):33‐46. doi:10.1111/mcn.12148.

Codesign of the Caregiver Responsive Infant Feeding Behaviours (CRIB) Digital Resource to Prevent Childhood Obesity

Sarah Redsell ¹, Lucy Porter¹, Helen Spiby¹, Heather Wharrad¹, Ciara Beatty², Karen Matvienko‐Sikar³

¹University of Nottingham, Nottingham, United Kingdom. ²PPIE representative, London, United Kingdom. ³University College Cork, Cork, Ireland

Codesign partners: Andre Nugent, James Williams, Joanne Fisher, Sorcha Hodge, Kallie Hazel, Akilah Darling, Kirsten Hatton

Background: Obesity prevention interventions delivered during early life that contain information and support for caregivers about responsive feeding can result in healthier weight trajectories for infants (1). However, there is currently little information and support for caregivers about responsive feeding for obesity prevention during early life. This disproportionately impacts infants living in socio‐economically deprived areas who are more likely to develop childhood overweight and obesity, together with those from minority ethnic backgrounds. To maximise responsive feeding, caregivers’ need supportive information underpinned by effective Behaviour Change Techniques (BCTs).

Aims: The COM‐B (2) model of behaviour change proposes that for an individual to engage in a Behaviour (B), Capability (C), Opportunity (O) and Motivation (M) are needed. COM‐B has been previously used to identify barriers and facilitators to responsive feeding (3). This study used COM‐B to codesign the Caregivers Responsive Infant Feeding Behaviours (CRIB) digital resource with caregivers of infants under 1 year.

Methods: Caregivers were recruited via Small Steps Big Changes (https://www.smallstepsbigchanges.org.uk/) a National Lottery Better Start site and Shifting Your Mindset https://www.shiftingyourmindset.co.uk/ a charity providing services for fathers and families. Five codesign workshops were conducted with caregivers (up to eight) and a health visitor. Six caregivers attended all five workshops, four women and two men and one health visitor. The workshops used the COM‐B process to determine key behaviours, intervention functions and BCT's. The Aim, Storyboarding, Populate specification, Implement media, Review and release prototype, and Evaluate (ASPIRE) approach was used for the digital intervention development.

Results: Two of our caregivers will share their experience of working as co‐designer partners on CRIB. They helped us map several behaviours COM‐B for inclusion in the CRIB digital resource. Behaviours included psychological capability ‐ knowledge and skills in relation to infant feeding cues, physical opportunity –distractions in feeding environment, social opportunity – conflicting advice and motivation. Seven BCTs were identified for inclusion e.g. instruction of how to perform the behaviour and demonstration of the behaviour. Caregivers’ experiences were captured on storyboards in workshops during the ASPIRE process and incorporated into CRIB. Evaluation with caregivers and healthcare professionals further refined the CRIB digital resource.

Conclusion: To our knowledge this is the first study to use COM‐B with a diverse sample including caregivers and a healthcare professional to codesign a responsive infant feeding intervention. Further research is required to test the effectiveness of CRIB on the responsive feeding behaviours of caregivers and to explore implementation within UK NHS and Local Authority Services.

References:

1. Matvienko‐Sikar, K., et al., Effects of healthcare professional delivered early feeding interventions on feeding practices and dietary intake: A systematic review. Appetite, 2018. 123: p. 56‐71.

2. Michie, S.; van Stralen, M.M.; West, R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation science: IS 2011, 6, 42‐42, doi:10.1186/1748‐5908‐6‐42.

3. Redsell SA, Slater V, Rose J, Olander E, Matvienko‐Sikar K. Barriers and enablers to Caregivers Responsive Feeding Behaviours: A systematic review to inform childhood obesity prevention. Obesity Reviews, 2021;22(7) e13228. https://doi.org/10.1111/obr.13228.

Psychosocial Predictors of Infant and Young Child Feeding Practices Among Mother‐Child Dyads in Malawi and South Africa

Taryn Smith ¹, Chikondi Mchazime², Pious Makaka², Giulia Ghillia¹, Donna Herr³, Marlie Miles³, Chloë Jacobs³, Sadeeka Williams³, Thandeka Mazubane³, Zayaan Goolam Nabi³, Michal Zieff³, Emmie Mbale², Melissa Gladstone¹, Kirsten Donald³

¹University of Liverpool, Liverpool, United Kingdom. ²Kamuzu University of Health Sciences, Blantyre, Malawi. ³University of Cape Town, Cape Town, South Africa

Background: Suboptimal feeding practices in the first 2 years of life are risk factors for poor child health, growth and development. Maternal psychosocial factors may limit a mother's ability to meet recommended infant and young child feeding (IYCF) practices and are potentially modifiable through intervention. However, there is limited research examining these associations, especially with indicators of complementary feeding.

Aim: To investigate associations between maternal depression, exposure to intimate partner violence, perceived social support, and stimulating home environments, and IYCF practices among mother‐infant dyads in Malawi and South Africa.

Methods: Khula is a longitudinal birth cohort study that aims to characterise brain development across the first 1,000 days of life. At the third study visit, when infants were approximately 10–16 months of age, mothers completed a series of psychosocial questionnaires: Edinburgh Postnatal Depression Scale (EPDS), Intimate Partner Violence Questionnaire (IPV), and Multidimensional Scale of Perceived Social Support (MSPSS). The Family Care Indicators (FCI) assessed stimulation and support for early learning within the home. Information on infant's dietary intakes during the previous 24 h was used to determine the WHO IYCF indicators: minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD). Regression modelling was used to identify associations between maternal psychosocial measures and IYCF indicators, adjusting for maternal age, education, marital status, and household socioeconomic status.

Results: Data were analysed for 153 and 255 dyads in Malawi and South Africa, respectively. Most children (97.4%) in Malawi were still being breastfed, compared to 44.3% in South Africa. IYCF practices were suboptimal in both settings, with 50–54% meeting the MDD, 68–73% the MMF, and 39–45% the MAD. In South Africa, mothers exposed to IPV in the previous 12 months were less likely to meet MDD (OR 0.38, 95% CI 0.19, 0.75; p = 0.006) and MAD (OR 0.41, 95% CI 0.20, 0.85; p = 0.02) recommendations. Higher FCI total score, indicating a more stimulating home environment (i.e., more books/toys and play activities with caregivers), was positively associated with dietary diversity score in South Africa (β 0.14, 95% CI 0.01, 0.10; p = 0.02). Malawian mothers with higher EPDS scores were less likely to continue breastfeeding at 1 year (OR 0.72, 95% CI 0.51, 1.01; p = 0.05), although this association was attenuated in adjusted analyses (p = 0.08). Reported perceived social support was not associated with IYCF indicators in either setting.

Conclusion: In this study, feeding practices were suboptimal among children from diverse communities in Malawi and South Africa. Maternal psychosocial factors were positively (caregiver behaviours) and negatively (IPV exposure, depression) associated with IYCF practices. Future research should explore opportunities for supporting mothers to provide nurturing care through existing IYCF programmes in resource‐limited settings to support children's dietary intakes, growth and development.

Fathers' Influence on Infant Feeding Decisions: A Study for Healthcare Professionals, Policymakers, and Service Providers

Jen Menzies

Northumbria University, Newcastle, United Kingdom

Background: Mothers typically decide on feeding methods for their infants, but the extent of fathers’ influence on this decision remains unclear. Infant feeding is crucial for the infant's overall health, and exclusive breastfeeding is recommended globally to provide infants with all the necessary nutrients. However, very few parents choose exclusive breastfeeding. Specifically, in the UK, where this study is focused, the breastfeeding rate is one of the lowest in Europe, with only 73.5% initiation and 55% at 6‐8 weeks. We can improve child health and parental education by examining the kind of support fathers provide to their partners, the factors that influence their decisions, and how to strengthen this support. This study aims to contribute to the existing literature and knowledge base of healthcare professionals, which can, in turn, influence policymakers and service providers.

Aim: To explore first‐time fathers' experience of supporting infant decisions and identify what influences this activity.

Methods: Semi‐structured interviews were conducted with a homogeneous sample of first‐time fathers of primiparous women at two time points: 18‐34 weeks antenatally and 6 weeks postnatally. The interviews aimed to explore infant feeding decisions before and after the baby's birth. The interviews were transcribed, and the data were analysed using interpretative phenomenological analysis to identify and explore emerging themes.

Results: The findings indicate that despite inclusion in policy and evidence, fathers receive little or no professional support to assist in support or decision‐making relating to infant feeding. The COVID pandemic has significantly impacted inclusive father practices and progresses pre‐pandemic across midwifery, health visiting services, and the information fathers receive. This impact has been observed in various ways, such as reduced face‐to‐face interactions and limited resource access. Fathers primarily obtain feeding information from family, social media, or from their partner, resulting in marketing influences and censored knowledge sources.

Conclusion: Fathers are ideally situated to enhance and support healthy feeding practices; however, isolation from inclusion is causing disengagement and mistrust of health messages and health improvement activities.

Exploring Usual Care Within the ABA‐Feed Trial

Jennifer McKell ⁶ Joanne Clarke¹, Nicola Crossland², Stephan Dombrowski³, Pat Hoddinott⁴, Jenny Ingram⁵, Debbie Johnson⁵, Christine MacArthur¹, Ngawai Moss⁷, Julia Sanders⁸, Nicola Savory⁸, Beck Taylor⁹, Gill Thomson², Kate Jolly¹ on behalf of the ABA‐feed research group

¹Applied Health Sciences, University of Birmingham, Birmingham, UK, ²Maternal and Infant Nutrition and Nurture Unit, University of Lancashire, Preston, UK, ³Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada, ⁴Nursing, Midwifery and Allied Health Professional Research Unit, University of Stirling, Stirling, UK, ⁵Bristol Medical School, University of Bristol, Bristol, ⁶Institute for Social Marketing and Health, University of Stirling, Stirling, UK, ⁷Patient and Public Representative, ⁸School of Healthcare Sciences, Cardiff University, Cardiff, UK, ⁹Warwick Applied Health, Warwick Medical School, University of Warwick, Warwick, UK.

Background: Usual care is a term used within randomised controlled trials of health‐related interventions to refer to the offer of conventional treatment or approaches as part of a trial control group which provides a comparison with the intervention being tested (1). Documenting usual care is important to understand the effects of an intervention and has implications for its implementation if found to be effective. This is further emphasised in multi‐centre randomised controlled trials where usual care may differ from one site to another. The Assets‐based infant feeding help Before and After birth trial (ABA‐Feed) compared a peer support and assets‐based intervention alongside usual care versus usual care alone for raising breastfeeding rates at 6‐8 weeks after birth in first time mothers, living in different parts of the UK.

Aim: This paper explores descriptions of usual care in trial sites and changes during the trial period.

Methods: Discussions were held with infant feeding leads, via video‐call, in all 17 trial sites in England, Scotland and Wales. These discussions provided baseline understanding of usual care for infant feeding advice and support, maternity and health visiting services and features of local areas before trial recruitment commencing in January 2022. A pre‐determined proforma detailed areas of interest and supported recording, using fieldnotes. Further discussions or email contact with infant feeding leads, 3 times up to, and soon after, the end of recruitment in February 2024, allowed researchers to document relevant changes. Publicly available data was also recorded where relevant. Site data were systematically summarised to describe usual care and wider site characteristics.

Results: Trial sites were differentiated by rural, urban or mixed urban/rural geographies and levels of deprivation. Ethnic diversity was limited and concentrated in a small number of sites. Infant feeding advice and support were integral to maternity and health visiting pathways but differed in timing and intensity. Infant feeding teams provided specialist infant feeding advice and support and sometimes coordinated peer supporters, but capacity was often limited. Peer support services varied greatly across trial sites. Most peer supporters were volunteers, but some sites had paid peer supporters. Peer support was delivered in breastfeeding groups, on social media, in hospital wards, and one‐to‐one over telephone or in home visits. Before the trial, peer support was long‐established in some sites but minimal or non‐existent in others.

Conclusions: The diversity of usual care and other site characteristics is a strength in terms of generalisability but highlights potential challenges to future implementation.

Reference:

1. Turner, K.M., Huntley, A., Yardley, T., Dawson, S. and Dawson, S. (2024). Defining usual care comparators when designing pragmatic trials of complex health interventions: a methodology review. Trials, 25(1), p.117.

Funding: National Institute for Health and Care Research (NIHR129182)

Infant Feeding in Finland and Ireland: A Multilayered Contextual Practice

Jenny Säilävaara

Maynooth University, Maynooth, Ireland

Background: This study explores infant feeding as a complex behaviour influenced by personal, cultural, and social factors, focusing on mothers from Finland and Ireland. Breastfeeding and formula feeding practices vary significantly between these two countries, reflecting differing cultural norms and societal expectations.

Aims: The aim of this study is to examine the multifaceted nature of infant feeding, including embodied experiences, and to understand the interplay between individual choices, cultural norms, and societal influences. By cantering embodiment as a key analytical lens, I seek to highlight how infant feeding is not merely a physical act but a deeply situated bodily practice that reflects and responds to cultural expectations and interpersonal relationships.

Methods: Data was collected through narrative interviews with mothers from Finland and Ireland in 2024, providing rich insights into their infant feeding experiences. The Voice‐Centered Relational Method (VCRM) was employed for analysis, allowing for a nuanced understanding of the multiple voices within each narrative, including those reflecting embodied experiences. This method facilitates a multi‐layered analysis of personal narratives, revealing the interplay between individual agency and structural constraints.

Results: Preliminary findings underscore the significance of personal histories and embodied experiences in shaping how mothers approach and navigate breastfeeding and formula feeding. Cultural factors play a crucial role in infant feeding practices. The narratives highlight contrasts between Finland, where over 70% of infants are still breastfed at 6 months, and Ireland, where breastfeeding rates are lower, and formula feeding has become more prevalent. On a social level, the narratives reveal how public attitudes, healthcare practices, and policies mediate the experience of infant feeding. The embodiment lens particularly illuminates how mothers internalize and resist societal discourses on breastfeeding, such as the idealization of “good motherhood” or the stigmatization of breastfeeding and formula feeding in public. These dynamics underscore breastfeeding as a site where personal and collective identities are negotiated and performed.

Conclusion: This study demonstrates that infant feeding is a complex behaviour deeply embedded in personal, cultural, social, and embodied contexts. By utilizing narrative interviews and the VCRM analytical approach, this study contributes to a deeper understanding of infant feeding as a multifaceted, embodied practice that extends beyond simple biological function. The comparative analysis of Finnish and Irish mothers' experiences provides valuable insights for developing effective strategies to support mothers in diverse cultural settings, potentially informing evidence‐based interventions, healthcare practices, and policies aimed at improving breastfeeding rates and overall maternal and infant well‐being.

Feasibility of a Psychoeducational Intervention for Empowering Chinese Parents to Optimise Feeding Practices: A Feasibility Randomised Controlled Trial

Jian Wang, Yan‐Shing Chang, Kirsty Winkley

King's College London, London, United Kingdom

Background: Parental feeding practices are crucial in preventing childhood obesity and promoting healthy eating habits. However, few interventions have been explicitly designed to improve these practices. Psychoeducational interventions integrating educational and psychological components have been shown to effectively promote positive changes in feeding practices.

Aims: This is the first study aimed to evaluate the feasibility, acceptability and preliminary effects of a novel psychoeducational intervention programme (i.e., EPO‐Feeding) specifically tailored to the Chinese context.

Methods: A parallel‐arm, feasibility randomised controlled trial (RCT) was conducted in two public kindergartens in Yangzhou, China. Participants were randomly assigned to the intervention group (EPO‐Feeding programme plus usual care) or control group (usual care). The intervention development was guided by the Medical Research Council (MRC) framework using a multiphase mixed methods approach. It involved 4 weekly modules with multiple components (e.g., sessions, goal setting, and feedback): 1) understanding children's growth process, nutrition and eating characteristics; 2) keeping a meaningful parent/child role; 3) creating a healthy food environment; and 4) adopting appropriate feeding practices. Data were collected at baseline, post‐intervention, and 1 month after intervention. Descriptive estimates assessed feasibility and acceptability. Analysis of variance (ANOVA) for repeated measures and generalised estimating equations was used to analyse continuous outcomes (e.g., feeding practices, parenting sense of competence) and categorical outcomes (e.g., child weight status) across time points, respectively.

Results: Within 2 weeks, 131 parents expressed interest and were screened for eligibility, resulting in 84 eligible participants randomly assigned to the intervention group (n = 42) and control group (n = 42). Module attendance and retention rates were high, with 83.3% (n = 35) completing all sessions and 97.6% (n = 82) completing all measurements. Satisfaction surveys indicated a high level of acceptability. Parents in the intervention group showed significant improvements, including increased encouragement of healthy eating and monitoring, decreased pressure to eat and food as rewards, improved accurate perception of child weight (self‐reported), and enhanced parenting sense of efficacy. These outcomes showed statistically significant interaction effects (p < 0.05). However, no significant interactions were observed for long‐term outcomes (i.e., children's eating behaviours and weight status).

Conclusion: This study demonstrates high feasibility and acceptability of the EPO‐Feeding programme, with all progress criteria being satisfied. The findings indicate its potential to support Chinese parents by improving their feeding practices, accurate weight perception, and parenting confidence. A full‐scale RCT is warranted.

References:

1. Wang J, Chang YS, Wei X, et al. The effectiveness of interventions on changing caregivers' feeding practices with preschool children: A systematic review and meta‐analysis. Obesity Reviews. 2024;25(4).

2. Wang J, Cao Y, Wei X, et al. Empowering parents to optimize feeding practices with preschool children (EPO‐Feeding): A study protocol for a feasibility randomized controlled trial. PLoS One. 2024;19(6):e0304707.

Understanding Why Families Begin Mixed Feeding

Karen Hall, Amy Brown, Sara Jones

Swansea University, Swansea, United Kingdom

Background: Many parents in the UK use both breast and formula milk, often known as mixed feeding, at some point in the first year. However, little is known about this experience, with research often focussing on breastfeeding or formula feeding experiences and drivers rather than considering it to be a distinct approach that parents may choose. It is also likely that not all parents who mix feed are doing so for the same reasons or in the same way. Understanding parents’ experiences of mixed feeding and the reasons that lead to them choosing or needing to do this is important to improve and tailor support for them and to enable them to maximise breastmilk intake when desired.

Method: Parents of babies under 12 months who had been mix‐fed at any time were invited to complete a survey about their experiences. As part of this parents were asked about the drivers to start mixed feeding, this included 39 tick box reasons identified from existing literature, the lead researcher's professional experience and grey literature discussions.

Exploratory factor analysis was carried out to group reasons that were consistently related to one another across the sample, to explore underlying structures in the data. Items that fell under each factor were then combined to give an overall score for each factor for each participant. A feeding satisfaction score was also developed from data on how participants felt after starting to do mixed feeding.

Results: 500 parents completed the survey, with babies ranging from under a week to a year old. The factor analysis generated six factors:

• 1.Health Professional support (51% of participants ticked these items, mainly older parents who reported lower overall satisfaction with their feeding decision).
• 2.Bonding and support from extended family (16% of participants, mainly younger parents, reporting higher overall satisfaction).
• 3.Mental health and maternal wellbeing (31% of participants, mainly younger parents, reporting higher overall satisfaction).
• 4.Cultural expectations of baby behaviour (36% of participants of all ages and experiences).
• 5.Social pressure (31% of participants, mainly younger parents, reporting higher overall satisfaction).
• 6.Rejection of breastfeeding by the baby (45% of participants, especially those who introduced formula in the first week).

These distinct groupings tell very different stories about the experience of mixed feeding, from feeling positive and purposeful, to feeling unsupported, guilty and sad, and in many cases both.

Conclusion: The identification of different patterns of mixed feeding has implications for understanding how to support parents effectively in their individual situations, and for how future research defines this varied feeding behaviour. Mixed feeding is not one thing but is experienced and understood differently in different families.

An Exploratory Analysis of Exclusive Breastfeeding Practices and Perceptions in England

Meg O'Loughlin

University of Westminster, London, United Kingdom

Background: Breastfeeding is an impactful public health intervention, playing an important role in short and long‐term infant health and cognitive development, maternal health, and reducing strain on health services. Worldwide, we are approaching the Global Nutrition Target of 50 percent of infants exclusively breastfed to 6 months and beyond. However, the rate in the UK is only one percent. England, especially, has no infant and young child feeding strategy and limited resourcing; mechanisms to support breastfeeding are insufficient or underutilised. This study explored exclusive breastfeeding (EBF) through conversations with mothers (addressing a gap in research by focusing on women who have exclusively breastfed), midwives and breastfeeding advocates, to contribute to evidence that could enable future policy and practice change.

Aim: An exploratory analysis of exclusive breastfeeding practices and perceptions in England.

Methods: Qualitative research was undertaken, allowing deep understanding of breastfeeding practices and perceptions. Semi‐structured 1:1 interviews took place with mothers and advocates, and a focus group with midwives. Data were analysed using Reflexive Thematic Analysis, generating three themes and nine subthemes. Findings were analysed through a power lens (Gaventa, 2006).

Results: Breastfeeding does not have a prominent position in society and an improved breastfeeding culture is required. Support from professionals, peers and partners is instrumental in success and the capacity to breastfeed is key. Agency, a breastfeeding mindset and the ability to advocate for self are contributing factors; along with transparent information on infant feeding. Robust maternity protection and increased marketing restrictions for the breast milk substitute industry are important, alongside promotion of, and support mechanisms for, breastfeeding. Finding solutions requires a societal commitment to enabling breastfeeding, and will involve appropriate resourcing, displacing commercial power and challenging ineffectual governance and leadership.

Conclusion: Multiple, interconnecting components are needed for an enabling breastfeeding culture, where the practice is valued and facilitated. The positioning and prioritisation of breastfeeding in society needs significant improvement, including proper utilisation of existing governance mechanisms, alongside new measures like a national infant feeding strategy. Support for breastfeeding from formal and informal sources is key. The capacity for breastfeeding, both for mothers and supporters is important, with success attributed to time, financial and human resources. The importance of agency for EBF ‐ valuing breastfeeding, understanding the benefits, committing to undertaking it and being able to advocate for it when it is not fully recognised and supported ‐ may explain instances of positive deviance. Looking ahead, the importance of a coordinated response for 1) breastfeeding protection, with an emphasis on commercial and maternal protection to address power imbalances; 2) promotion, looking at new avenues and greater visibility; and 3) increased access and availability to various and appropriately funded systemic support strands, are all key to increasing EBF rates in England.

References:

Baker, P. et al. (2023) ‘The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress’, The Lancet, 401(10375), pp. 503–524.

Gaventa, J. (2006) ‘Finding the Spaces for Change: A Power Analysis’, IDS Bulletin, 37(6), pp. 23–33.

Pérez‐Escamilla, R. et al. (2018) ‘Becoming Breastfeeding Friendly Index: Development and application for scaling‐up breastfeeding programmes globally’, Maternal & Child Nutrition, 14(3), p. e12596.

Development and Evaluation of the ABA‐Feed Infant Feeding Training for Peer Supporters and Coordinators

Joanne Clarke ¹ , Gill Thomson², Nicola Crossland², Stephan Dombrowski³, Pat Hoddinott⁴, Jenny Ingram⁵, Debbie Johnson⁵, Christine MacArthur¹, Jennifer McKell⁶, Ngawai Moss⁷, Julia Sanders⁸, Nicola Savory⁸, Beck Taylor⁹, Kate Jolly¹ on behalf of the ABA‐feed research group

¹Applied Health Sciences, University of Birmingham, Birmingham, UK, ²Maternal and Infant Nutrition and Nurture Unit, University of Lancashire, Preston, UK, ³Faculty of Kinesiology, University of New Brunswick, Fredericton, New Brunswick, Canada, ⁴Nursing, Midwifery and Allied Health Professional Research Unit, University of Stirling, Stirling, UK, ⁵Bristol Medical School, University of Bristol, Bristol, ⁶Institute for Social Marketing and Health, University of Stirling, Stirling, UK, ⁷Patient and Public Representative, ⁸School of Healthcare Sciences, Cardiff University, Cardiff, UK, ⁹Warwick Applied Health, Warwick Medical School, University of Warwick, Warwick, UK.

Background: The ABA‐feed intervention aims to increase rates of breastfeeding by offering pro‐active peer support to first‐time mothers, regardless of feeding intention. Starting antenatally, the intervention is underpinned by behaviour change theory and an assets‐based approach. Within the ABA‐feed study, existing breastfeeding peer supporters with varying experience received additional training to become ‘Infant Feeding Helpers’ (IFHs) with an accompanying handbook. Training was developed from the preceding ABA feasibility study, taking on board suggestions for improvement and shifting from an in‐person to an online format due to Covid restrictions.

Aims: We aim to describe the development and evaluation of the peer supporter training for the ABA‐feed trial.

Methods: A ‘train‐the‐trainer' model was used, with peer support coordinators at 17 sites being trained to train peer supporters locally over four 2‐h remote sessions. Training comprised: a study and intervention overview; the IFH role; role play of scenarios including using a friends and family diagram; supporting formula feeding and signposting to local assets. Questionnaires were sent to coordinators and peer supporters post‐training to assess quality of the training, confidence to deliver the intervention and suggestions for improvement, with responses received from 22/30 (73%) coordinators and 119/193 (62%) IFHs. Focus groups and interviews with IFHs (n = 72) and coordinators (n = 24) explored experience and acceptability of the training. At five sites, researchers observed recordings of the IFH training and recorded fidelity to the training topics, peer supporter engagement, and quality of delivery and discussion. Questionnaire and training observation data were analysed descriptively in Excel. Qualitative data were analysed using Framework Analysis.

Results: From questionnaires and interviews, coordinators were largely positive about the ‘train‐the‐trainers’ training. They found the information about formula feeding and the opportunity to practice antenatal conversations to be useful and felt confident to train peer supporters to deliver the intervention.

Peer supporters enjoyed the training and appreciated the knowledge and enthusiasm of their trainers. They felt prepared to deliver the intervention although some were nervous about supporting formula feeding.

Most coordinators and peer supporters appreciated the convenience of the remote training although there were some reported challenges of monitoring discussions or doing role plays in breakout rooms. Going forward, most felt that the training would be best delivered as a mix of online and in‐person. Some coordinators and peer supporters suggested the videos and training materials should be more inclusive of Black Asian and minority ethnic groups. Observations of training showed a generally high level of fidelity, quality of delivery and discussion and participant engagement. Trainers appeared confident and enthusiastic about intervention components such as woman‐centredness and the friends and family diagram.

Conclusion: The ABA‐feed training built on existing peer supporter training; was acceptable to coordinators and peer supporters and was delivered with fidelity.

Funding: National Institute for Health and Care Research (NIHR129182)

Surveying the Landscape of Breast‐Milk Substitute Marketing Practices in Four Countries

Ellie Mulpeter ¹, Jeni Stevens², Barbara O'Connor³, Anna Blair³, Marianne White⁴, Kristin Stewart³, Elisabeth Sterken⁵, Gina Sheedy⁶, Kajsa Brimdyr³, Karin Cadwell³

¹Academy of Lactation Policy and Practice, South Dennis, USA. ²Western Sydney University, Penrith, Australia. ³Healthy Children Project, Harwich, USA. ⁴National Health Service Tayside, Dundee, United Kingdom. ⁵Infant Feeding Action Coalition (INFACT) Canada, Ontario, Canada. ⁶Nepean Blue Mountains Local Health District, Kingswood, Australia

Background: In 1980 the World Health Assembly (WHA) requested that the World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF) develop the “International Code of Marketing of Breast‐Milk Substitutes” (“WHO Code”). The purpose of the Code and its subsequent Resolutions is to stop the unethical marketing of products that interferes with breastfeeding, including breast‐milk substitutes (BMS) (i.e. infant formula, toddler milks, etc.), other foods and beverages that are promoted for use before 6 months of age, and bottles and teats. For decades, the commercial milk formula (CMF) industry has used marketing strategies, designed to prey on parents' fears and concerns at a vulnerable time, to turn the feeding of young children into a multibillion‐dollar business. Aggressive marketing by the CMF industry remains an enormous challenge.

Aims: This study aims to quantify violations across four countries with poor adoption and/or implementation of the WHO Code and to compare the frequencies and types of violations found. The goal is to reduce the risk of negative health outcomes among women, children and their families because of not breastfeeding.

Methods: This study utilized Participatory Action Research (PAR) to collect and quantify the number and type of WHO Code violations across four countries – the United States, Canada, Australia and the United Kingdom. Participants were encouraged to complete “missions” listed within an application on their mobile devices by uploading photographs of violations. Enrolment and data collection occurred from July 19, 2023 through July 31, 2024.

Results: 738 individuals were eligible and enrolled. Participants from the U.S. submitted the most photos. Price reductions and other promotional deals on BMS were the most frequently reported violations. 700 in dividual violations of the WHO Code were submitted.

Conclusion: Despite three of the four countries involved in this study having signed onto the Code, CMF companies continue to produce, advertise and sell BMS and remain largely unchecked due to insufficient monitoring and a lack of implementation of the Code into national law. Inaccurately and ubiquitously advertised baby food products present a direct threat to breastfeeding and to public health.

References:

The International Code of Marketing of Breast‐milk Substitutes: Frequently Asked Questions (2017 Update), Geneva, Switzerland, World Health Organization; 2017.

Unveiling the predatory tactics of the formula milk industry. The Lancet, Volume 401, Issue 10375, 409. DOI:10.1016/S0140‐6736(23)00118‐6.

Pérez‐Escamilla, Rafael et al. Breastfeeding: crucially important but increasingly challenged in a market‐driven world. The Lancet, Volume 401, Issue 10375, 472 – 485. DOI:10.1016/S0140‐6736(22)01932‐8.

Acceptability and Sustainability of the Term ‘Snugby’ Skin‐To‐Skin Undergarment in Maternity Settings

Helen Rachel McIntyre, Beverly Cowlishaw, CRN Teams

Birmingham City University, Birmingham, United Kingdom

Background: Mother‐baby Skin‐to‐skin is recommended by UNICEF/WHO, Baby Friendly Hospital Initiative (BFHI) standards (1989, Nyqvist et al 2010). Baby benefits include stabilisation of physiological parameters (Bergman 2010, Moore 2016) increased neurological adaptability and reduced infections (Ludington‐Hoe 2011). Maternal hormone levels increase lactation and self‐esteem (Uvnas‐Moberg 2016). Maniago et al (2019) identified barriers: lack of knowledge and belief in skin‐to‐skin by staff and parents; lack of guidelines, accountability and equipment. Hospital routines were prohibitive (Seidman et al 2015). The ‘term’ Snugby observational feasibility and main study demonstrated increased mother‐baby interaction and stable baby thermoregulation (Bailey et al 2017, 2020). The benefits from skin‐to‐skin (NHS Longterm Plan 2019, Maternity Transformation Programme 2016, UNICEF/WHO (2023) and NICE (2021)) could be facilitated by widening access to a Snugby.

Aims: The study aims to:

• 1.Identify the knowledge and attitudes of staff and women/families to skin‐to‐skin before and after the use of the Snugby.
• 2.Evaluate acceptability of the Snugby following its use by women.
• 3.Assess robustness of the Snugby.

Methodology: The multi‐centred, ethically approved, Clinical‐Research‐Network adopted study included one tertiary and 3 secondary maternity units across England with different BFHI accreditations. Following written informed consent, a pre and post Snugby use questionnaire for healthcare workers and women was completed. The mother and baby dyad were issued with a ‘term’ Snugby of the appropriate maternal size (small, medium, large), shown how to use it and a temperature taken using the thermometer provided before Snugby use and after 30 min in skin‐to‐skin. A bespoke mother's diary was provided. A prepaid envelop for return of the diary, post‐questionnaire and Snugby after 2 weeks was issued and three reminders following the expected date of return. The Snugby was measured before issue and on return before hospital laundering at the required thermally disinfecting temperature. The trial was commenced on11.11.19(pre Covid‐19), stopped between 04.20(during Covid‐19) and restarted on14.6.21 and completed 01.22.

Results: A total of 199 staff maternity staff were recruited from five Trusts with a mix of BFI accreditation and acuity levels. 98% knew about skin‐to‐skin but not all benefits; this varied between professions. UNICEF‐BFI accreditation did enhance knowledge and information giving. Of the 58 women recruited, 82% knew about skin‐to‐skin with 60% receiving information from the midwife. Temperature, heart and respiratory rate and breastfeeding were recorded. Those using the Snugby had an average of 55 min per day in skin‐to‐skin and a maximum of 240 min. The Snugby encouraged 65% with more frequent and extended skin‐to‐skin but 20% disagreed. The Snugby measurements following re‐use and washing at hospital temperatures proved to be stable. Re‐use appeared acceptable.

Conclusion: More depth of knowledge and information giving is required. Anxieties around re‐use within this population were minimal.

References:

Maniago, J.D., Almazan, J.U. and Albougami, A.S. (2020) 'Nurses' kangaroo mother care practice implementation and future challenges: An integrative review', Scandinavian Journal of Caring Sciences, 34(2), pp. 293‐304.

Bailey, R. (2020) A skin to skin contact facilitating garment used by mother‐infant dyads: exploring its acceptability, usage and effect on health outcomes in the postnatal period. BCU PhD repository.

Comprehensive Maternity Protection: Emerging Global Trends and Opportunities From the Global South

Catherine Pereira‐Kotze ¹, Bongekile Mabaso²

¹South African Medical Research Council, Cape Town, South Africa. ²University of Kwazulu‐Natal, Pietermaritzburg, South Africa

Background: Comprehensive maternity protection for working women who are pregnant, around the time of childbirth or breastfeeding, includes health protection at the workplace, a period of maternity leave with accompanying cash and medical entitlements, job security and income protection, nondiscrimination, breastfeeding or expressing breaks and access to childcare support. Maternity protection is an important, sometimes overlooked, component of social protection not being realised by the most vulnerable women. Return to work is an established reason why many women stop breastfeeding and paid maternity leave is associated with increased breastfeeding duration. There are many recommendations for how access to maternity protection can be improved in various contexts. Much research has been conducted and programmes implemented to support breastfeeding in the workplace in high‐income countries (especially the USA) and such support can't always be directly applied to low‐and‐middle‐income country (LMIC) settings. With competing priorities and differing agendas, there is a risk that the significance of advancing maternity protection may be overlooked, delaying the progress needed to build sufficient momentum.

Aims:

• 1.To describe the most recent comprehensive assessment of maternity protection, globally.
• 2.To comprehensively map the landscape of existing literature on workplace breastfeeding support in LMIC between 2016 and 2024.
• 3.To provide examples of initiatives that can be used to advance momentum for progress in maternity protection.

Methods: Presentation of a global legal review done by the ILO in 2021. A scoping review of research on workplace breastfeeding support in LMIC. Presentation of case studies illustrating recent initiatives that are creating momentum for progress on maternity protection.

Results: In 2021, the duration of maternity leave is at least 14 weeks in 120 countries, the average duration of maternity leave paid at 67% of previous earnings was 18.0 weeks and 138 countries provided a right to time and income security for breastfeeding. There are over 150 studies published in LMIC between 2016 and 2024 on workplace breastfeeding support. Case studies: the FAO has recently engaged in work to understand access to paid maternity leave for the many women working in agrifood systems globally; the Motherload project is a collaborative multi‐sectoral research project aiming to improve understanding of women's disproportionate care work in the global South, including causes, impacts, and strategies for change.

Conclusions: Ensuring universal comprehensive maternity protection for all working women could encourage significant health, development, social and economic benefits for current and future generations. Lessons from research and new initiatives should be used and applied.

References:

Food and Agricultural Organization of the United Nations (FAO). 2023. The status of women in agrifood systems. Rome. https://doi.org/10.4060/cc5343en.

International Labour Organization (ILO). 2022. Care at work: Investing in care leave and services for a more gender equal world of work. Geneva: ILO. https://doi.org/10.54394/AQOF1491.

Mgongo M, Ickes SB, Leyaro BJ, Mboya IB, Grounds S, Seiger ER, Hashim TH, Conklin JL, Kimani‐Murage EW, Martin SL. 2024. Early Infant Feeding Practices among Women Engaged in Paid Work in Africa: A Systematic Scoping Review. Adv Nutr. 15(3):100179. https://doi.org/10.1016/j.advnut.2024.100179.

“There Is Already an Emergency”: A Qualitative Analysis of Health Care Professionals’ and Volunteer Breastfeeding Supporters' Perspectives on Infant and Young Child Feeding Supports on the Island of Ireland in the Context of Infant and Young Child Feeding in Emergencies

Elizabeth O'Sullivan, Lorraine Tham, Aileen Kennedy

TU Dublin, Dublin, Ireland

Background: Globally, emergencies are growing in frequency and severity. Infants and young children are among the most at‐risk during an emergency. The World Health Organization has urged all member states to be prepared to support Infant and Young Child Feeding in Emergencies (IYCF‐E) (World Health Assembly, 2018). However, neither the Republic of Ireland nor Northern Ireland has an IYCF‐E plan.

Aim: To provide information about the networks of IYCF support available for families in the Republic of Ireland and Northern Ireland from the perspectives of healthcare professionals (HCPs) who provide IYCF support and volunteers who provide, or advocate for, IYCF support.

Methods: Semi‐structured interviews of HCPs involved with IYCF support from across the island of Ireland were conducted. Braun and Clarke's (2021) reflexive thematic analysis method was used to guide the analysis of the transcribed interviews.

Results: Thirty‐six HCPs across the island were interviewed (midwives, public health nurses, GPs, IBCLCs, neonatologists, paediatric dietitians), along with 10 members of volunteer breastfeeding support or advocacy groups. Three major themes were generated from the data:

1) The “luck” factor: This theme describes how personal circumstances and luck contribute to the accessibility and quality of IYCF support individuals receive.

“…as a doctor I am very happy to take time, and I am very happy to go into my lunch break and go later if I need to [to provide breastfeeding support]. But … not everybody is going to do that.” GP

2) Critical connections: This theme describes how the connectivity of IYCF support services within the healthcare system, and across community support organisations, impacts the accessibility and delivery of IYCF support.

“I contacted [Charity] … and they can give care to the women there. So, they ended up giving her our 2‐week and our 6‐week check and provided her with supports that she needed.” Clinical Midwife Specialist.

3) “There is already an emergency": Some participants described the low breastfeeding rates in Ireland as an emergency. Participants recognised that to be best prepared to support IYCF‐E, we need to provide sufficient support in nonemergency times to increase the prevalence of breastfeeding, creating a more resilient environment.

“There is already an emergency when so many mothers are not getting the support they need to achieve their breastfeeding goals.” La Leche League of Ireland Leader.

Conclusion: Access to appropriate IYCF support is impacted by multiple factors. Streamlining critical connections between all IYCF support services is crucial in the context of emergency preparedness, to ensure equity of access to infant‐feeding supports to create a society where more children are breastfed and more resilient in the face of future emergencies.

Reference:

World Health Assembly (2018). Seventy‐first World Health Assembly: Infant and Young Child Feeding. https://apps.who.int/iris/bitstream/handle/10665/279517/A71_R9-en.pdf (accessed November 2024).

A Randomized Controlled Study on Mother‐Infant Interaction Effects Following the New Early Collaborative Intervention

Charlotte Sahlén Helmer ^1,2, Ulrika Birberg Thornberg^3,4, Thomas Abrahamsson^2,5, Evalotte Mörelius^1,6

¹Department of Health, Medicine and Caring Sciences, Division of Nursing Sciences and Reproductive Health, Linköping University, Linköping, Sweden. ²H.R.H. Crown Princess Victoria Children ´s Hospital, Linköping University Hospital, Linköping, Sweden. ³Department of Rehabilitation Medicine, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden. ⁴Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden. ⁵Department of Biomedical and Clinical Sciences, Division of Children's and Women's Health Linköping University, Linköping, Sweden. ⁶School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia

Background: Preterm birth can adversely impact maternal‐infant interaction due to factors such as separation, immature interaction cues from the infant, and maternal health issues. Parents often experience significant stress, which further impairs their ability to interact with their infant. A well‐functioning interaction can mitigate the developmental risks associated with preterm birth. The Early Collaborative Intervention, consisting of three sessions, is designed to enhance interaction between preterm infants (born between 30 and 36 weeks of gestation) and their parents. This intervention focuses on supporting both the infant and the parents, beginning in the neonatal intensive care unit and continuing post‐discharge.

Aim: The aim of this study was to evaluate the effects of the Early Collaborative Intervention on mother‐infant interaction in comparison to standard care.

Methods: A randomized controlled trial was conducted with two groups, including 143 families who were randomly assigned to either the Early Collaborative Intervention or standard care. Mother‐infant interaction was video recorded during an infant bath in the families’ homes when the infant was 1 month corrected age. The interactions were later scored using two instruments: Ainsworth's Maternal Sensitivity Scales and the Emotional Availability Scales. Both intention‐to‐treat and per‐protocol analyses were performed, with three sessions considered the minimum required to detect a difference.

Results: The per protocol analysis revealed that the intervention group exhibited significantly higher mean scores in three subscales, suggesting a more well‐functioning interaction.

Conclusions: The Early Collaborative Intervention enhanced maternal interactive behavior when all three sessions were provided.

A Mixed Methods Observational Study of Human Milk Sharing in Hong Kong

Kris Yuet Wan Lok, Junyan Li, Hoi Lam Ip, Qiuyan Liao, Jung Jae Lee

The University of Hong Kong, Hong Kong, China

Background: Human milk is widely recognized for its nutritional and immunological benefits, particularly for vulnerable infants. In regions where formal human milk banks are unavailable, peer‐to‐peer milk sharing communities have emerged as an alternative, In Hong Kong, breastfeeding is actively promoted, yet the absence of formal milk banks has led to the rise of informal milk sharing networks, often facilitated through social media platforms. Understanding the prevalence of these communities and the experiences of those involved is crucial to inform policymakers in the acceptability, feasibility and suggestions for the upcoming human milk banks in Hong Kong.

Aims: The study aims to describe the size and prevalence of online milk sharing communities in Hong Kong and explore the experiences of peer‐to‐peer human milk donation in Hong Kong.

Methods: A mixed‐method observational design was employed. Web‐crawling analysis and semi‐structured interviews were used to address the two overarching objectives. The web‐crawling analysis focused on the local Facebook page Human Milk 4 Human Babies – Hong Kong, with posts from January 2017 to December 2021 retrospectively collected. Furthermore, popular social media platforms such as Xiaohongshu and TikTok were also searched for relevant content. Semi‐structured interviews were conducted between November 2022 and April 2023 with 50 women (34 donors and 16 recipients) recruited via purposive sampling from social media groups focused on breast milk donation in Hong Kong. Participants also completed the Chinese version of the Wambach tool, which measures human milk donation behaviours based on the theory of planned behaviour.

Results: Online human milk‐sharing communities in Hong Kong are prevalent, though the exact size is unspecified. A total of 43 posts were retrieved from Facebook, 107 posts from Xiaohongshu, and 46 posts from TikTok, indicating that these platforms are commonly used for milk‐sharing activities. The motivations for donating breast milk were primarily practical and altruistic. Many donors reported an oversupply of milk and insufficient storage space, leading them to donate rather than discard excess milk. However, the donation process is not without challenges. Safety and quality concerns were significant barriers, with participants expressing worries about sterilization during pumping, storage, and transportation.

Conclusion: This study provides valuable insights into the prevalence and experiences surrounding breast milk donation in Hong Kong. While practical reasons, such as oversupply and lack of storage, drive many donations, altruistic desires to help others also play a role. However, safety concerns, legal implications, and societal judgment present notable barriers. These findings highlight the need for clearer guidelines and support mechanisms to ensure the safety and effectiveness of peer‐to‐peer milk‐sharing practices in Hong Kong. It also points to greater awareness and education about milk donation to boost the sense of subjective norms and encourage more women to participate in this practice.

Why Have a Bottle When You Can Have Draught? Exploring Why Breastfed Babies Refuse to Bottle Feed

Clare Maxwell

Liverpool John Moores University, Liverpool, United Kingdom

Background: Bottle refusal by breastfed babies is a scenario that has received surprisingly little attention in the literature, given the number of mothers who appear to be experiencing it globally and the subsequent negative impact it can have.

Aims: The study builds on previous work by the author around mothers' experiences of bottle refusal by their breastfed baby, this time seeking to find possible reasons for refusal through mothers' descriptions.

Methods: A parallel two‐stage qualitative design was undertaken using 30 semi‐structured interviews with UK mothers and 597 online posts captured from parenting UK forums. Data were analysed using a thematic analysis, with a biopsychosocial model utilised to try to better understand this complex scenario.

Results: Four overarching themes are identified: ‘Breastfeeding is the answer to everything….’ ‘Bottle feeding: an alien concept… ‘ ‘Babies are individuals’ and ‘Find the right bottle and don't delay’. The psychological benefits of breastfeeding, not inherent in bottle feeding, appear to underpin refusal for some babies. For others, there is a biological expectation to be fed by the breast, thus bottle feeding is not a normal concept to them. A baby's individual personality and temperament is suggested as contributing to the scenario, and refusal is also linked to babies disliking a certain brand of bottle and being introduced to it ‘too late’.

Conclusion: This study's findings point to a complex, multi‐factorial picture underpinning bottle refusal by breastfed babies, which transcends physical, psychological and biological concepts and one which is influenced by socio‐cultural norms surrounding infant feeding. This knowledge can be translated into guidance for infant‐feeding personnel and for mothers themselves in terms of their management and decision‐making surrounding bottle refusal by their breastfed baby. Crucially, this study also adds to the evidence that babies are active participants in infant feeding, and that this is ‘something they do, rather than something that is done to them’ (Rapley, 2015).

Reference:

Rapley, G., 2015. Baby‐led weaning: The theory and evidence behind the approach. Journal of Health Visiting, 3(3), pp.144‐151.

Should Infant Formula be Provided by UK Food Banks? A Mixed Method Enquiry Into Supporting Food Insecure Parents

Charlotte Walker ¹, Sally Etheridge², Sabine Goodwin³, Aimee Grant¹, Catrin Griffiths¹, Grace Hollinrake¹, Sara Jones¹, Holly Morse¹, Rhiannon Phillips⁴, Rosalind Sharpe⁵, Vicky Sibson⁶, Lowri Stevenson¹, Vicky Thomas⁷, Amy Brown¹

¹Swansea University, Swansea, United Kingdom. ²Leicester Mammas, Leicester, United Kingdom. ³Independent Food Aid Network, Brighton, United Kingdom. ⁴Cardiff Metropolitan University, Cardiff, United Kingdom. ⁵University of Hertfordshire, Hatfield, United Kingdom. ⁶First Steps Nutrition Trust, London, United Kingdom. ⁷Great North Children's Hospital, Newcastle, United Kingdom

Background: The price of infant formula in the UK has risen above inflation during the recent cost of living crisis. Families with children are more likely to face food shortages, leaving formula‐fed infants vulnerable [1]. The Healthy Start scheme in England and Wales no longer covers the costs for a fully formula fed baby [2]. The need for families to access food banks has rapidly increased. Current policy for most UK food banks is that infant formula should not be stocked, as this would contravene UNICEF Baby Friendly initiative guidance. This guidance is not about preventing formula access but ensuring that families have consistent, reliable access, free from commercial influence. Instead, parents should be referred to their local authority for assistance [3]. Recently there has been growing interest in the media around the issue of formula insecurity, including for foodbanks to be able to freely offer formula milk. Our study, funded by the Medical Research Council, seeks to explore the most reliable, sustainable, and ethical ways of providing formula milk to those who need it.

Aims:

1. To what extent is there a need and desire for donations of formula milk to be allowed via UK food banks?

2. How do families in financial crisis currently access formula milk? How visible, transparent, acceptable and equitable are these current processes?

3. What are the potential options for families to access formula milk in crisis and how might they affect safety, consistency, equity, protection of breastfeeding and impact upon parental mental health?

Methods: Food insecure parents of babies under 12 months completed a survey exploring difficulties in obtaining formula, food bank use, and feeding practices. Health professionals, food bank staff and volunteers completed a second survey exploring their experiences of supporting food insecure families with infant feeding. Both groups reflected on different options for accessing formula milk in financial crisis and the possible risks and benefits.

Results: Both parents and professionals/volunteers described how formula insecurity impacts upon parental wellbeing and the range of strategies that used to ensure their baby was fed.

Access to formula milk in crisis was a complex issue with a balance needed between elements such as reliable and rapid access, sustainability and consistency, protection of breastfeeding and ensuring that parents felt supported.

Conclusion: Pathways need to be in place that ensure food insecure families can access formula milk when needed in a consistent, reliable and easy to access format. Food banks are unlikely to be able to meet this need. Conversely voucher schemes and cash first approaches that are in line with the cost of infant formula and provided alongside expert infant feeding guidance are more likely to offer families the support they need.

References:

1. Sibson, V., Fallon, N., and Shenker, N. (2023) How secure is our infants’ food supply? Why the government's food security assessment and emergency planning must include breastfeeding and the infant formula supply chain. Food Research Collaboration Policy Insight.

2. Lovett, D. and Davies, S. (2024) Supporting families better with the NHS Healthy Start scheme. Which? Available at: Supporting families better with the NHS Healthy Start scheme ‐ Which? Policy and insight [Accessed 26/11/2024]

3. UNICEF (2022) Supporting families with infants under 12 months experiencing food insecurity: A guide for local authorities and health boards. Available at UNICEF‐UK‐Baby‐Friendly‐Guide‐for‐Local‐Authorities‐and‐Health‐Boards. pdf [Accessed 26/11/2024]

Grandparents’ Knowledge, Attitude and Experiences Supporting Breastfeeding‐ An Intergenerational Approach to Breastfeeding Support

Jennifer Abbass‐Dick, Manon Lermonde

Ontario Tech University, Oshawa, Canada

Background: Breastfeeding is recommended for infant feeding, yet most families are not able to meet the recommendations due to challenges encountered. Grandparents’ support can impact breastfeeding outcomes. Many grandparents may not have had experiences with breastfeeding, leading to intergenerational negative impacts (Young et al., 2016). Many grandparents would benefit from education and information on how to support breastfeeding. Canadian grandparents’ breastfeeding knowledge, attitude, or experiences have not been explored. This information is necessary to identify knowledge gaps and design inclusive multigenerational education materials.

Aim: To determine grandparents’ attitudes, knowledge, and experiences with supporting breastfeeding for their grandchildren.

Methods: An online survey was sent to Canadian grandparents via social media and online platforms. Breastfeeding knowledge was measured using the Comprehensive Breastfeeding Knowledge Scale (CBKS; Abbass‐Dick et al., 2020) and attitude measured using the Iowa Infant Feeding Attitude Scale (IIFAS; de Mora et al., 1999). Additional questions explored their experiences, the information they would like to receive related to breastfeeding, and preferred modes of information delivery.

Results: Grandmothers (n = 101), grandfathers (n = 6) and great‐grandmothers (n = 5) completed the online survey. The CBKS scores (M 78.0, S.D. 5.51) and IIFAS (M 69.7 S.D. 8.71) were high. These scores were significantly positively correlated and significantly higher among those who had received breastfeeding education (p = 0.01). Responses from open ended questions identified five themes: 1) Promote breastfeeding with accessible and credible resources; 2) Information tailored to grandparents; 3) Addressing grandparents' past experiences; 4) Information that is solution focused and supportive; and 5) Letting their child take the lead.

Conclusion: The findings of this study indicate grandparents have their own breastfeeding education and support needs. Even among our study population of grandparents with high knowledge and attitude scores, challenges are experienced in this supportive role, and they would value education tailored to their needs and in person support groups or classes to discuss their role in supporting their adult children with breastfeeding their grandchildren. The findings from this study will inform the creation of educational content tailored to the grandparents’ role in supporting breastfeeding.

References:

Abbass Dick, J., Newport, A., Pattison, D., Sun, W., Kenaszchuk, C., Dennis, CL. (2020a) Development, psychometric assessment, and predictive validity of the Comprehensive Breastfeeding Knowledge Scale. Midwifery, 83, 102642. https://doi.org/10.1016/j.midw.2020.102642.

de Mora, A. D. L., Russell, D. W., Dungy, C. I., Losch, M., & Dusdieker, L. (1999). The Iowa infant feeding attitude scale: analysis of reliability and validity. Journal of Applied Social Psychology, 29(11), 2362‐2380.

Young, F., Twells, L., Joy, R., Newhook, L. A., Goodridge, J. M., & Burrage, L. (2016). Infant Feeding in Newfoundland and Labrador, Canada: Perceptions and Experiences of Maternal Grandmothers. The Journal of Perinatal Education, 25(4), 223–231. https://doi.org/10.1891/1058-1243.25.4.223.

Caregivers Experience of Complementary Feeding in the Cost‐of‐Living Crisis in the UK

Grace Hollinrake, Sophia Komninou, Laura Wilkinson, Amy Brown

Swansea University, Swansea, United Kingdom

Background: Nutrition during the first 1001 days plays an important role in shaping food preferences, eating behaviour and weight gain trajectories for later childhood and beyond (Harrison et al., 2017). The majority of research in this area has focussed on early milk feeding practices and later toddler eating behaviour with a smaller but growing evidence base around experiences during the complementary feeding period when babies are introduced to solid foods. Starting from 6 months, research suggests that exposing babies to as many new foods, tastes and textures as possible, focussing on home prepared rather than shop bought foods, and following a responsive feeding style is associated with the most positive outcomes (Ventura & Worobey, 2013). However, the current cost‐of‐living crisis is putting a strain on household budgets with households reporting food insecurity, including households on higher incomes that were previously deemed to be food secure. Although there is some evidence around the impacts of poverty upon diet and feeding particularly for milk feeding and later child diet, less is known about the complementary feeding period and income. It is important that we increase our understanding about how the broader increase in food costs and subsequent rise in food insecurity is affecting this period to be better able to support parents.

Aims: The aim of this study was to understand how household food security status impacts the diet and feeding practices for babies aged 6–18‐month‐olds, during the cost‐of‐living crisis, in the UK. Specifically, the impact upon household food security status, timing of introduction to solid foods, infant diet, responsive feeding practices and parent wellbeing was explored.

Methods: UK parents, with a baby aged 6‐18 months, completed a self‐report, online survey with open and closed questions. Items included demographic information and household food security, milk feeding, infant diet, purchasing decisions and restrictions, responsive feeding and parent wellbeing. Quantitative data was analysed descriptively, including exploration of how demographic and financial background affected infant feeding decisions and wellbeing. Open ended text boxes were analysed thematically.

Results: Household food security status impacted decisions around complementary feeding including timing, methods, foods offered and feeding styles. Financial insecurity was tied to parental wellbeing, including through experiences of introducing and feeding their baby during complementary feeding.

Conclusion: Greater support is needed for parents experiencing financial insecurity during the complementary feeding period. The cost‐of‐living crisis is affecting more families which is in turn affecting the diet and feeding practices for infants, potentially having longer term population impacts upon health and wellbeing. Policy change is needed to reduce the impact of food insecurity and support healthier choices during the complementary feeding period.

References:

Harrison, M., Brodribb, W., & Hepworth, J. (2017). A qualitative systematic review of maternal infant feeding practices in transitioning from milk feeds to family foods. Maternal & Child Nutrition, 13(2), e12360. https://doi.org/10.1111/mcn.12360.

Ventura, A., V., & Worobey, J. (2013). Early Influences on the Development of Food Preferences. Current Biology, 23(9). https://canvas.swansea.ac.uk/courses/16704/files/1628699?module_item_id=929247.

Clear, Accurate and Impartial Information: The Infant Milk Info Website. A Practical Response to Protect Families From Commercial Bias in Infant Feeding

Catherine Pereira‐Kotze, Vicky Sibson

First Steps Nutrition Trust, London, United Kingdom

Background: The market for commercial milk formula (CMF) is vast, valuable and expanding. There is significant conflict of interest (COI) between manufacturers who seek profit from product sales and increased market share, and the families who need to use infant formula. Parents and caregivers are routinely and systematically exposed to marketing that often distorts the evidence from industry‐sponsored research to imply that infant formula can deliver the same health outcomes as breastmilk. Manufacturer marketing messages imply that additional optional ingredients, that increase the cost of infant formula, will deliver better health outcomes than those of cheaper infant formulas. During 2024, the Competition and Markets Authority (CMA) launched a market study into infant and follow‐on formula in the UK. A possible measure recommended in the CMA interim report was that parents and caregivers need access to timely, clear, accurate and impartial information about formula feeding. First Steps Nutrition Trust has managed the Infant Milk Info website for over a decade. This website contains up‐to‐date information on the product ranges, nutrient composition, and costs of infant formulas available in the UK.

Aims: To describe a model for providing information on infant formula and formula feeding that is free from COI, easily accessible, and supports health workers and parents to make informed feeding decisions.

Methods: A descriptive overview will be provided in the form of a case study to present a model that could be replicated elsewhere, of how this website was conceptualized, and how it is managed.

Results: An independent website has been developed that collates information on infant milks available without prescription in the UK from manufacturers websites and presents this information in a comparable form, on a website free from branding and marketing. This independent website complies with the WHO Code of marketing of breastmilk substitutes and subsequent world health assembly resolutions. Key features include unbranded product datasheets; illustrative feeding costs over time; evidence‐based category overviews that assess the suitability of products for the target market, including risks and benefits of use and based on expert opinion, and answers to frequently asked questions. Other countries or regions could adopt this approach providing an alternative COI free source of evidence‐based information on commercial milk formulas relevant to their infant feeding environment.

Conclusions: This illustrates that there are strategies to provide clear, accurate and impartial information for health workers and parents or caregivers, on infant formula and formula feeding, that circumvents the highly targeted and influential marketing efforts of manufacturers. This is consistent with the possible measures suggested by the CMA in their November 2024 Interim Report.

References:

Infant Milk Info website by First Steps Nutrition Trust. https://infantmilkinfo.org/&nbsp.

Competition and Markets Authority (CMA). 2024. Infant formula and follow‐on formula market study: Interim report. https://www.gov.uk/government/publications/infant-formula-and-follow-on-formula-market-study-interim-report&nbsp.

A Case Study of Advocacy to Mitigate UK Infant Food Security: Leveraging Infant Formula Profiteering Towards Strengthen UK Regulations on the Marketing of Commercial Milk Formulas in Line With ‘The Code’

Victoria Sibson, Catherine Pereira‐Kotze

First Steps Nutrition Trust, London, United Kingdom

Background: Despite recommendations to breastfeed, most UK babies are fed formula. Infant formula is the only safe and suitable alternative to breastmilk in the first 6 months of life and is the recommended substitute from 6 to 12 months. All infant formula must meet strict regulations for nutrition composition to support adequate growth and development. However, prices are high and variable between products and brands and have risen during the cost‐of‐living crisis, exacerbating food insecurity for formula fed babies. Breastfeeding can also be disrupted by household food insecurity. Widespread inappropriate marketing of commercial milk formulas, both legal and in contravention of existing weak marketing regulations, contributes to high prices and to food insecurity for all UK babies.

Aims: To describe First Steps Nutrition Trust's advocacy to mitigate UK infant food insecurity, by leveraging infant formula profiteering towards strengthen UK regulations on the marketing of commercial milk formulas in line with the international Code of marketing of breastmilk substitutes (‘the Code’).

Methods: We used infant formula price data collected from our routine monitoring as the basis of our advocacy, focusing on 1. Prices comparable to the Healthy Start allowance (the national nutrition safety net), 2. Price changes over time, 3. Price differentials between products and brands. We also used existing evidence of marketing against the UK law and ‘the Code’.

Results: Using our data we highlighted that 1. The Healthy Start monetary allowance was not keeping pace with rising infant formula prices, 2. Average prices rose 24% March 2021‐April 2023 and the cheapest (only own‐brand product) rose 45%, 3. Prices of premium brands can be more than double the cost of economy brands. We showed that that pricing strategies are linked to marketing, which contravenes UK law and the Code. These findings initiated two rounds of investigation by the government watchdog, the Competition and Markets Authority (CMA), were widely reported in the media, and have instigated falling prices. The CMA's interim market study report was published in November 2024 and shared policy recommendations to Government for consultation, to which we responded. The final recommendations will be published in February 2025.

Conclusions: Use of prospectively collected data on infant formula prices, predating the cost‐of‐living crisis, has enabled highly effective advocacy towards mitigating infant food insecurity in the UK. We are hopeful that the final recommendations of the CMA will further this progress while also leading to better protections for breastfeeding.

The Cost‐Effectiveness of an Assets‐Based Infant Feeding Intervention in Increasing Breastfeeding: an Economic Evaluation Based on the ABA‐Feed Trial

Eleanor Williams ¹ , Joanne Clarke¹, Eleni Gkini¹, Kate Jolly¹, Mia Mann¹, Alice Sitch¹, Rebecca Woolley¹, and Tracy Roberts¹ on behalf of the ABA‐feed research group

¹University of Birmingham, Birmingham, United Kingdom

Background: Breastfeeding is associated with numerous health benefits for infants, extending into later childhood, as well as for mothers. However, the United Kingdom (UK) has some of the lowest breastfeeding rates globally. In 2020/21, between 31.6% and 52.7% of infants in the UK's devolved nations received any breastmilk at 6–8 weeks. A 2012 economic analysis found that increasing exclusive breastfeeding to 45% at 4 months could save the National Health Service (NHS) over £17 million annually. Infant feeding support is a significant unmet need, with evidence showing women who lack support are more likely to discontinue breastfeeding within 2 weeks postpartum. The ABA‐feed intervention was developed as a proactive, assets‐based, woman‐centred peer support approach to improve breastfeeding initiation and continuation. This study aimed to evaluate the cost‐effectiveness of the ABA‐feed intervention compared with usual care for first‐time mothers in the UK.

Methods: Two main analyses were undertaken to evaluate the cost‐effectiveness of the ABA‐feed intervention from the perspective of the NHS and Personal Social Services (PSS): (1) a within‐trial analysis comprising a cost‐consequence analysis (CCA) and cost‐utility analysis (CUA) and (2) a model‐based CUA to estimate the long‐term effects of the intervention. The within‐trial CCA assessed healthcare resource utilisation, costs and outcomes associated with the ABA‐feed intervention and usual care in a disaggregated manner. The outcomes evaluated included any and exclusive breastfeeding at 8 weeks post‐birth, any and exclusive breastfeeding at 16 weeks post‐birth, maternal anxiety and depression and maternal health‐related quality of life (HRQoL) as measured using the EQ‐5D‐5L index values. An incremental CUA was also conducted 20 multiply imputed datasets to present results in terms of cost per maternal quality‐adjusted life year (QALY). The model‐based CUA adapted a decision‐analytic model framework previously used to inform national guidelines in England. It incorporated the effects of the ABA‐feed intervention on any breastfeeding at 16 and 24 weeks and the intervention delivery costs. The model estimated the total costs and QALYs associated with changes in breastfeeding rates due to the ABA‐feed intervention on gastrointestinal and respiratory tract infections, acute otitis media, and mortality due to infectious diseases, sudden infant death syndrome, and breast cancer in mothers. Sensitivity analysis for both the within‐trial and model‐based analyses explored variations in key intervention delivery costs and characteristics.

Results: Preliminary findings from the trial‐based CCA indicate that delivering the ABA‐feed intervention – based on the mix of volunteer and paid infant feeding helpers in the trial – costs approximately £135 per woman. When accounting for other healthcare resource use, the total cost associated with the ABA‐feed intervention is around £100 more than usual care, despite minimal differences in maternal QALYs and other outcomes. The corresponding incremental cost‐effectiveness ratio (ICER) and probabilistic sensitivity analysis suggest the ABA‐feed intervention is unlikely to be cost‐effective.

Conclusion: Preliminary model‐based findings align with trial‐based findings and highlight that greater effectiveness and lower intervention delivery costs would be required for the ABA‐feed intervention to be cost‐effective in the long term.

Funding: National Institute for Health and Care Research (NIHR129182)

Does the Timing of Hands‐On “Help” by Midwives During Skin‐To‐Skin Affect Nipple Pain Incidence?

Karin Cadwell ¹, Yuki Takahashi², Kajsa Brimdyr¹

¹Healthy Children Project, Harwich, USA. ²Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan

Aim: To describe the timing and characteristics of midwives' hands‐on interruptions of newborns' behaviour while in skin‐to‐skin contact during the first hour after birth and to elucidate the relationship between these hands‐on interruptions and the incidence of nipple pain during the first 4 days postpartum.

Methods: An observational pilot study was conducted at a Baby‐Friendly® hospital in Japan from 2016 to 2018. Iterative analysis of video recordings from a larger study of the behaviour of newborns while skin‐to‐skin with their mothers in the first hour after birth found 16 full‐term newborns who were born vaginally and that met the inclusion criteria of a midwife's hands‐on intervention (HOI) interrupting the infant's progress toward breast self‐attachment. The timing of the HOI and the stage of the newborn's progress through Widström's 9 Stages was noted by two research assistants who had been blinded to the medical records. The degree of nipple pain after breastfeeding was self‐evaluated by mothers each day during their hospitalization. All data were statistically analysed.

Results: Interrupting the infant's progressive behaviours in the first hour after birth by midwives' hands‐on “help” to breastfeed, may increase nipple pain during the 4 days after birth. One hundred percent of the mothers reported nipple pain in the postpartum with the highest pain reports occurring on day 4.

Conclusion: Interrupting skin‐to‐skin contact with HOI does not decrease the incidence of nipple pain during the first days postpartum. HOI for newborn infants was not shown to support breastfeeding in the early postnatal period.

References:

Takahashi Y, Brimdyr K, Cadwell K. Does an early hands‐on breastfeeding intervention by midwives affect nipple pain incidence? An observational pilot study. Jpn J Nurs Sci. 2024 Oct;21(4):e12613. doi: 10.1111/jjns.12613. Epub 2024 Aug 13. PMID: 39138899.

Brimdyr, K., Cadwell, K., Stevens, J., & Takahashi, Y. (2018). An implementation algorithm to improve skin‐to‐skin practice in the first hour after birth. Maternal & Child Nutrition, 14(2), e12571. https://doi.org/10.1111/mcn.12571.

Baghany, R., Azhari, S., Akhlaghi, F., Tabaraei, Y., & Shokrollahi, M. R. (2013). Comparing the effects of “Hands‐on” and “Hands‐off” educational techniques on exclusive breastfeeding among primiparous mothers. Life Science Journal, 10(12 s), 202–207.

Brimdyr, K., Stevens, J., Svensson, K., Blair, A., Turner‐Maffei, C., Grady, J., Bastarache, L., Al Alfy, A., Crenshaw, J. T., Giugliani, E. R. J., Ewald, U., Haider, R., Jonas, W., Kagawa, M., Lilliesköld, S., Maastrup, R., Sinclair, R., Swift, E., Takahashi, Y., & Cadwell, K. (2023). Skin‐to‐skin contact after birth: Developing a research and practice guideline. Acta Paediatrica,112(8), 1633–1643. https://doi.org/10.1111/apa.16842.

Ten‐Year Evolution of a Virtual Community of Practice to Enhance Nutrition and Nurturing of Infants in Neonatal Wards Across Quebec, Canada: The CVP Neon@T

Sonia Semenic ¹, Marilyn Aita², Audrey Larone‐Juneau³

¹McGill University, Montreal, Canada. ²University of Montreal, Montreal, Canada. ³Sainte‐Justine University Health Center, Montreal, Canada

Background: Neonatal nurses play a critical role in enhancing short‐ and long‐term infant and parental health outcomes through the implementation of evidence‐based interventions. In 2014, we initiated the development of a community of practice (CoP) between university‐based nurse researchers and nurse leaders (i.e., managers, educators, clinical experts) across all six level 3 neonatal intensive care units (NICUs) in Quebec, Canada, to collaboratively improve four low‐cost, high impact neonatal nursing practices: breastfeeding support, skin‐to‐skin care, developmental care and family‐cantered care.

Aim: To describe the development, evaluation and sustainability of the CoP over the past 10 years.

Methods: Following consultations with stakeholders to identify preferred modalities for a CoP, a web‐based platform (the CVP Neon@t) was launched in 2016 to facilitate discussion forums, virtual networking activities and sharing of literature and clinical practice tools among nurse leaders across Quebec NICUs. In 2017, we received funding from the Quebec Order of Nurses to further develop and evaluate the impact of the CVP Neon@t. In 2018‐2019, we conducted a mixed‐methods, multiple case study to compare outcome measures of the targeted nursing care practices within each NICU, pre‐ and post‐implementation of several strategies to enhance knowledge mobilization capacity among nurses (e.g., harmonization of neonatal and parental outcome indicators, collection of baseline data, collaborative development of new practice guidelines, training of nurse leaders in QI methodologies).

Results: Post‐implementation measures across the six NICUs revealed improvements in several targeted indicators, including the rate of breastfeeding initiation; time to first feeding; time to first parent‐infant touch; maternal breastfeeding self‐efficacy; proper therapeutic positioning of infants and use of cyclical lighting. Additional benefits reported by NICU nurse leaders included enhanced recognition of their professional role, reduced sense of isolation, easy access to evidence‐based practice information, and the development of new professional contacts across the province. In 2020, a strategic committee consisting of representatives from the project team, NICUs and Quebec's Ministry of Health was established to promote the CVP Neon@t's sustainability. The CVP Neon@t was subsequently integrated into Quebec's new virtual platform for healthcare CoPs, and continued funding for animation of its’ activities was assumed by Quebec's largest pediatric center. In 2021, the CVP Neon@t was expanded to include nurse leaders from all level‐2 neonatal unit across Quebec (N = 26) and other targeted topics, and in 2022 a new advisory board was created to guide further network development. As of December 2024, the CVP Neon@t has grown to 175 registered members and continues to offer an active discussion forum and message board, monthly news bulletins, and bi‐monthly lunch‐time webinars on a variety of neonatal nursing care topics.

Conclusion: The CVP‐Neon@t has been an effective, cost‐efficient and sustainable knowledge mobilization strategy for improving neonatal nursing care across Quebec.

Using the Skin‐To‐Skin Algorithm to Assess Care Flow Barriers to Early Breastfeeding

Kajsa Brimdyr ¹, Anna Blair¹, Kristin Svensson², Louise Bastarache³, Karin Cadwell¹

¹Healthy Children Project, Harwich, USA. ²Karolinska Institutit, Stockholm, Sweden. ³Harvard Medical Faculty Physicians, Cambridge, USA

Background: Skin‐to‐skin care during the first hour after birth is an acknowledged pathway to early breastfeeding but implemented inconsistently. The Healthy Children Skin‐to‐Skin Algorithm (HCP‐S2S‐IA) has been used to illuminate care flow barriers to self‐attached suckling in the first hour after birth. In Uganda, where skin‐to‐skin care is a 2018 Sharpened Plan goal, application of the algorithm describes current and optimized practice.

Methods: This cross‐sectional descriptive study recorded and analysed videos of newborn behaviour including self‐attached suckling during the first hour after birth. Demographics were collected from patient charts. The setting was a referral hospital in Uganda. Cohort A newborns were recorded receiving standard care. Education of staff and policy change to reflect the International Guidelines on Skin‐to‐Skin Care followed immediately after Cohort A was closed. Cohort B received the new standard care, and Cohort C newborns were recorded 6 weeks later. Consent was obtained to video‐record the newborns.

Results: Results were separately analysed on Cohort A, B and C algorithms, tables of Robson Classification and first hour interruptions. 51 of 92 Cohort A newborns had immediate skin‐to‐skin contact and 0 achieved the standard or self‐attached suckling. 102 of 105 Cohort B newborns had immediate skin‐to‐skin contact and 28 achieved the self‐attached suckling. 125 of 128 Cohort C newborns had immediate skin‐to‐skin contact and 55 self‐attached and suckled. Analysis of Robson's classification indicates that newborns of multiparas were more likely to self‐attach and suckle. The Interruptions Table showed improvement from A to B and B to C cohorts.

Discussion: Use of the Implementation Algorithm with the novel expansion of the Interruptions Table and Robson's classification allows for a deeper understanding of the practice of skin‐to‐skin contact related to newborns self‐attaching and suckling in the first hour after birth.

Building the Foundations: Supporting Breastmilk Feeding for Infants in Foster Care

Vicky Mitchell¹, Marianne White ², Shona Shinwell¹, Camila Biazus‐Dalcin¹

¹University of Dundee, Dundee, United Kingdom. ²NHS Tayside, Dundee, United Kingdom

Worldwide, around 2.7 million children are not in the care of their parents. In the UK, the number of infants entering foster care is on the rise. Despite recommendations that infants are exclusively breastfed for the first 6 months of life and continued until they are 2 years of age, facilitating infants' access to breastmilk is often absent from foster care policies. The cessation of breastfeeding may negatively influence children's health by impairing physical, psychological, neurocognitive, and nutritional development and impacts mother's health and attachment.

Aim: To explore how foster families, health and social workers and mothers with infants in care can be supported in providing breastfeeding and expressed breastmilk (EBM) by identifying known barriers and facilitators.

Method: A scoping review was conducted following JBI guidelines to answer the research aims. A search of available databases CINAHL and MEDLINE and grey literature was conducted in March 2023. Papers meeting the inclusion criteria were identified through a two‐stage screening process conducted by two researchers. Relevant data was extracted and thematically analysed.

Results: In total, 11 papers were included, five peer‐reviewed and six from grey literature. Of the 11 included papers, five were co‐authored by Gribble. The thematic analysis identified five themes: ‘Is this safe?’, ‘Substance use: Protecting the breastfeeding rights of mothers and infants’, ‘Making milk accessible through breastfeeding and EBM’, ‘Where are the policies’? and ‘Attitudes around breastfeeding’. The review findings highlight the challenges of supporting breastmilk provision for infants in foster care. Foster parents expressed safety concerns around feeding infants in their care breastmilk, including hygiene, transportation, transmission of unknown substances through breastmilk and the potential impact on the infant. Health and social care professionals who should support mothers and foster families with breastmilk provision can lack sufficient knowledge to reassure and guide on the safe provision of breastmilk. For infants to receive breastmilk while living in foster care, a team of well‐informed, multi‐disciplinary professionals working with a positive rights‐based ethos to breastmilk provision, trained to support both mothers and foster carers, is required.

Conclusion: The lack of peer‐reviewed and grey literature evidence exploring the facilitation of breastfeeding and EBM for infants in foster care highlights that breastfeeding is not prioritised when an infant is placed into foster care. Access to breastmilk is a public health priority for protecting the health and development of infants. However, the breastfeeding rights of some of society's most vulnerable infants and their mothers are not currently sufficiently addressed in policies and guidelines to facilitate safe and person‐centred infant feeding. Further research is required to develop guidance for health and social care workers and foster families to improve and facilitate breastfeeding and EBM feeding for mothers and their infants in foster care.

Peer Support and Community Interventions Targeting Breastfeeding in the UK: Systematic Review of Evidence to Identify Inequities in Participants' Experiences

Sean Harrison¹, Joelle Kirby¹, Claire Tatton¹, Rabeea'h Aslam², Sophie Robinson¹, Caitlyn Donaldson², Siang I Lee³, Joht Singh Chandan³, Ruth Garside¹, Jo Thompson‐Coon¹, Joanne Clarke³, Stephanie J Hanley³, Kate Jolly³, Rhiannon Evans ², G.J. Melendez‐Torres¹

¹University of Exeter, Exeter, United Kingdom. ²Cardiff University, Cardiff, United Kingdom. ³University of Birmingham, Birmingham, United Kingdom

Background: Peer‐led and community interventions may increase breastfeeding rates, but current knowledge is limited by a lack of understanding about whether these interventions generate, maintain, exacerbate, or mitigate health inequities.

Aims: This review aimed to find equity‐focused components used by relevant interventions evaluated in underserved populations, and how these components related to breastfeeding outcomes.

Methods: We updated the search of a Cochrane review from 2022 to 24 August 2024. Screening was conducted independently by at least two reviewers. Eligible studies were randomised controlled trials that reported results of a peer support or community breastfeeding intervention in a high‐income country evaluated in an underserved population. Intervention component analysis was used to identify equity‐focused intervention components. Meta‐analysis was used for breastfeeding outcomes, and meta‐regression was used to determine whether any individual intervention components or equity tailoring affected intervention effectiveness for breastfeeding outcomes.

Results: 31 trials (comprising 73 reports) were included in this review. Mothers in underserved populations who received interventions were around 10% less likely to stop breastfeeding up to 1 year. Trial results were relatively consistent, even with heterogeneous populations and interventions. We generated four categories of intervention components relevant to underserved groups: overarching themes, contextual fit, delivery, and wayfinding. There was, however, no conclusive evidence for differential effectiveness of interventions by individual intervention components or equity tailoring.

Conclusion: This systematic review provides one of the first syntheses examining how breastfeeding peer support interventions are explicitly tailored to underserved groups. The lack of conclusive evidence for individual intervention components affecting intervention effectiveness may be due to the limited number of small trials and the relative lack of statistical inconsistency in the results of the trials. This could be because the interventions were specifically designed to serve different populations, so were similarly effective.

Review of the UNICEF UK Baby Friendly Initiative Community Standards

Sarah Pickford

UNICEF Baby Friendly Initiative, London, United Kingdom

Background: The Baby Friendly Initiative is a programme of UNICEF and the World Health Organization. It is guided by the UNCRC which recognises the universality of child rights. In the UK, the UK Committee for UNICEF (UNICEF UK) Baby Friendly Initiative enables public services to support families with infant feeding and developing close and loving relationships so that all babies get the best possible start in life.

Initially launched as a ‘Ten Step’ hospital‐based programme in the UK in 1994, it rapidly became apparent that expansion into community services was needed to plug the gap in post‐midwifery care and address ongoing issues around poor breastfeeding continuation rates. Based on the Ten Steps to Successful Breastfeeding, The Seven Point Plan for Sustaining Breastfeeding in the Community was introduced in 1998. As an ever‐evolving and evidence‐based programme, a significant review of the standards for all services in 2012 enhanced support for families who were formula feeding and introduced standards around responsiveness and relationship building based on the growing body of evidence.

Aims and rationale: In 2022, the UNICEF UK Baby Friendly Initiative committed to review the community standards. The rationale for this was:

• increased interest in the early years’ agenda.

• changes in care provision across community services.

• reduction in services during the Covid‐19 pandemic.

• challenges with staffing, including a shortage of health visitors and wider use of skill mix.

• to ensure that the standards consistently meet the needs of babies, mothers and families.

• to bring together the considerable body evidence and experience of what works in practice to create a set of standards suitable for the current environment.

• to use a child rights approach to underpin the review and outcomes.

Method: We utilised internal knowledge and experience in the Baby Friendly team about what works well and what is less effective with the aim of developing a set of proposed standards. This became part of a broader consultation with a key stakeholder group who revised and fine‐tuned the proposal. The outcome of this was shared widely though the Baby Friendly Annual Conference in November 2022 and was accompanied by a full consultation. Quantitative and qualitative feedback was sought and considered. Development of key tools was initiated and piloted which supported finalization of the standards.

Results: The findings were positive towards the implementation of the proposed standards, including the benefit of strengthened foundation standards and increased collaboration between services. Initial concerns about the proposed timeline were addressed. A robust communication strategy was implemented to share the final documents, with multiple opportunities for questions. Initial reaction has been positive with services already using updated audit tools and excitement about assessment under the new standards.

Conclusion: The development of the revised community standards followed a normative Baby Friendly process which enabled review of the evidence, expert experience and supporters’ views to contribute to the outcome.

A Scoping Review of Factors Influencing Breastfeeding Knowledge and Attitudes Among Nonpregnant, Nulliparous Women of Reproductive Age

Maryam Malekian, Prof. Vanora Hundley, Dr. Michelle Irving

Centre for Midwifery & Women's Health, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth Gateway Building, Bournemouth, BH8 8GP, United Kingdom

Background: Despite the well‐established benefits of breastfeeding for both mothers and infants, global breastfeeding rates remain suboptimal. Low levels of knowledge and negative attitudes are significant barriers to achieving optimal breastfeeding outcomes. This scoping review aims to systematically map the factors influencing breastfeeding knowledge and attitudes, as well as the levels of knowledge and attitudes, with a particular focus on nonpregnant, nulliparous women of reproductive age. These women are more receptive to new information before pregnancy, making it an ideal time to address knowledge gaps and promote positive attitudes toward breastfeeding.

Methods: The scoping review is being conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews and PRISMA‐ScR guidelines, and its protocol was registered with Open Science Framework on 13 November 2024. This review uses the PCC framework to define the search question: Population (P): nonpregnant, nulliparous women of reproductive age; Concepts (C): knowledge and attitudes toward breastfeeding; Context (C): all countries. A comprehensive search has been conducted across multiple electronic databases, including EBSCO, SCOPUS, PubMed, Web of Science, Cochrane Library, and OVID. Search terms include breastfeeding, nulliparous, knowledge, and attitude, using keywords, synonyms, MeSH terms, and related concepts, screened with a research librarian at Bournemouth University. Each Keyword has been carefully adapted to each database's specific requirements and Forward citation and reference searching are conducted across the included studies. Evidence selection follows a two‐stage screening process, with two reviewers assessing studies against predefined inclusion criteria. Inclusion criteria focus on a specific population of women who are nonpregnant, nulliparous, and of reproductive age. English language studies are included with no restrictions on publication date. Of the initial 1,580 records screened, 32 studies are selected for data extraction. Data charting is being performed using a standardised pre‐designed extraction form, capturing study details, participant characteristics, and key findings. The quality of the included studies is being appraised.

Results: Included studies were published between 1994 and 2024, spanning 22 different countries. The review is in the process of synthesising evidence on the factors influencing breastfeeding knowledge and attitudes, as well as the levels of knowledge and attitudes, among the target population. Findings will be presented through narrative summaries, tables, and graphs, organized by key themes related to knowledge and attitude scales. A detailed synthesis of the results will be available for the conference presentation.

Conclusion: This scoping review will provide a comprehensive overview of the factors influencing breastfeeding knowledge and attitudes among nonpregnant, nulliparous women of reproductive age. The findings are expected to inform future research and interventions aimed at promoting better breastfeeding practices and outcomes.

Olfactory Communication in the First Weeks of Life: From Chemical Mechanisms to Improving Breastfeeding Outcomes

Vivien Swanson ¹, Katerina Roberts¹, Craig Roberts¹, Benoist Schaal²

¹University of Stirling, Stirling, United Kingdom. ²University of Burgogne, Dijon, France

Background: Successful breastfeeding promotes growth, health and enhanced wellbeing. However, breastfeeding difficulties mean that fewer than half of infants worldwide are exclusively breastfed for the WHO's recommended time. Breastfeeding challenges could be ameliorated by recognising, understanding, and facilitating olfactory mechanisms that regulate maternal‐infant relationships in early life, but these are not explicitly discussed in current guidelines.

Aims: Our international research programme aims to identify key biochemical mechanisms underpinning maternal‐infant odour communication during breastfeeding, understand behavioural and physiological responses, and identify key behaviours and practices that can facilitate or impair olfactory communication. We provide an overview of plans for a series of individual work programmes, highlighting implications for new mothers and practice in maternal and infant health.

Methods: Experimental work informing this interdisciplinary collaboration has confirmed olfactory signals are present in breastmilk in mammals. Building on this we will use an interdisciplinary approach to measure real‐time changes in odour chemistry across breastfeeding cycles using novel methodologies¹. The first stage is to identify specific chemosignals in breastmilk using atmospheric methods. Having isolated functional compounds, we aim to experimentally confirm that these can stimulate behavioural and physiological responses in mothers and infants, including changes in relation to signals of need, such as distress or hunger. The work will take place across genetically and culturally diverse contexts, including UK, France, Czech Republic, Japan and Bolivia to confirm the evolutionary value of the mechanism.

We will concurrently carry out a series of systematic reviews, ethnographic studies, interviews, and focus groups with mothers, health professionals and others to identify sociocultural barriers and facilitators of olfactory communication in breastfeeding in different cultural contexts. For example, some practices (e.g. skin‐to‐skin contact) may facilitate odour exchange, while others (e.g. washing the newborn) may inhibit it. Similarly, culturally specific practices—such as discarding colostrum may impede natural signals. An international survey of mothers will aim to identify barriers to and facilitators of olfactory communication and identify specific practices which might be relevant in different contexts.

Conclusions: We will seek to apply findings through identifying culturally tailored pathways for implementation and developing best‐practice recommendations. For example, synthetic versions of natural odours could be used to support breastfeeding where establishing it is difficult, such as in unwell mothers or neonatal intensive care units. Our diverse approach should enable us to develop practical interventions and recommendations that can improve breastfeeding success worldwide.

Reference:

1 Roberts SC, Misztal PK, Langford B. 2020 Decoding the social volatilome by tracking rapid context‐dependent odour change. Phil. Trans. R. Soc. B 375: 20190259. https://doi.org/10.1098/rstb.2019.025.

Surviving the Storm: Building Consensus for an Infant and Young Child Feeding in Emergencies Preparedness Plan for Ireland

Aileen Kennedy, Elizabeth J O'Sullivan

Technological University Dublin, Dublin, Ireland

Background: Infant and Young Child Feeding in Emergencies (IYCF‐E) is vital for ensuring the survival, development, and long‐term health of infants during crises. Disruptions to access to healthcare, food, water, and other resources in emergencies often hinders adherence to recommended IYCF practices. The World Health Organization has urged member states to develop emergency feeding plans, yet Ireland currently lacks such a plan.

Aims: To identify challenges and priorities for IYCF‐E and establish a framework for developing an ICYF‐E preparedness plan for Ireland.

Methods: Experts in infant feeding, emergency management and policy development in Ireland were surveyed (n = 125) to establish consensus on barriers and supports for IYCF‐E during emergencies using an online survey. This survey was developed using expert knowledge, and the results from interviews with healthcare professionals, breastfeeding volunteers, and parents. Data were analysed using SPSS.

Results: Most participants were female (95%) and working in clinical or public health roles (71.9%). While 76.6% reported a high level of expertise in IYCF‐E, only 21.6% of respondents had received specific training in the area. Participants rated food insecurity (68.6%), homelessness (66.1%), and formula shortages (63.6%) as the most critical emergencies that might affect IYCF. Homeless families (89.3%), individuals with low socioeconomic status (78.5%), and refugees (69.4%) were identified as the most at‐risk within this vulnerable population. Respondents indicated that the responsibility for IYCF within evacuation centres should lie with the Health Service Executive (79.3%) and Local Authorities (61.2%). Key barriers to successful ICYF within evacuation centres were limited kitchen facilities (68.6%), insufficient breastfeeding support (64.5%), and lack of clean water (58.7%). There was strong support for the Department of Health (86.8%) and the Department of Children, Equality, Disability, Integration and Youth (77.7%) to lead the development of a national IYCF‐E plan. Despite current emergency management plans being under the jurisdiction of Local Authorities, which fall within the Department of Housing, Local Government, and Heritage, only 32.2% chose this department as responsible. Interestingly, the least favoured option was the Department of the Taoiseach, which coordinated the previous interdepartmental response during the COVID‐19 crisis.

Conclusion: This study highlights the urgent need for a comprehensive Irish IYCF‐E plan to address the challenges and gaps identified in emergency preparedness. Despite high levels of expertise among respondents, the lack of specific training in IYCF‐E and the absence of a coordinated national plan present significant barriers to successful infant feeding in emergencies. The study also reveals the critical role of the local authorities and health services in managing IYCF‐E at evacuation centres, as well as the need for a multi‐sectoral strategy, involving key government departments and agencies to establish an effective, inclusive IYCF‐E plan for Ireland, ensuring that infants' nutritional needs are met during future emergencies.

“I Felt Like I Was In the Dark and No One Would Help Me”: Exploring the Experiences of Mother's Who Breastfeed Infants With Food Allergies

Johanna Myddleton

De Montfort University, Leicester, United Kingdom

Background: Prevalence of food allergies (FA) are increasing, with the UK having the highest rates of CMPA globally. WHO and NICE guidelines recommend breastfeeding (BF) infants with FA for a minimum of 2 years yet there has been little‐ to‐no research on the support and information needs of the BF mothers, nor the psychosocial consequences of continuing to BF. Research shows food allergy parents face mental health challenges, and breastfeeding mothers in particular are vulnerable in the perinatal period and may face higher psychosocial risks if unsupported.

Aims:

• 1.To understand how breastfeeding mothers experience the diagnosis journey, and the methods through which they seek information and support, to continue breastfeeding when a food allergy is suspected and/or diagnosed.
• 2.To explore the psychosocial impacts that breastfeeding an infant with food allergies has on the breastfeeding parent.

Methods: Online semi‐structured interviews were conducted with 13 women who were either currently, or had recently ceased, breastfeeding an infant with a food allergy. Breastfeeding duration ranged between 4 months and 2.5 years and infants had either a diagnosis FA by a GP or allergy clinic or were awaiting a formal diagnosis. Participants were a mix of first‐ and second‐time mothers, some of whom had previously had a child with a food allergy. Interviews were transcribed verbatim and analysed using thematic analysis.

Results: Mothers were dissatisfied with the support and information from Health Care Professionals (HCPs), citing delays in diagnosis, limited knowledge, and inadequate practical guidance for breastfeeding on exclusionary diets. Advice was often contradictory, leading mothers to seek information from online sources and peers for symptom understanding and breastfeeding tips while avoiding allergens. Mothers valued support from partners, friends, and family but often felt misunderstood or not taken seriously about breastfeeding a baby with food allergies. They frequently experienced loneliness, worry, guilt, and conflict, especially after accidental allergen ingestion, which left some feeling they had "poisoned" their child.

Conclusions: Mothers breastfeeding infants with food allergies require better information and support from HCPs during and after diagnosis. They often face low mood, loneliness, and anxiety, which require attention from researchers and HCPs. Despite challenges, mothers showed resilience, offering essential insights into breastfeeding continuation.

The Canadian Breastfeeding Research Network (CBRN): Building Research Capacity to Enhance Breastfeeding Protection, Promotion and Support in Canada

Sonia Semenic ^1,2, Jennifer Abbass‐Dick³

¹Ingram School of Nursing, McGill University, Montreal, Canada. ²Research Institute of the McGill University Health Center, Montreal, Canada. ³Faculty of Health Sciences, Ontario Tech University, Toronto, Canada

Background: Although the majority of Canadian families initiate breastfeeding, rates of breastfeeding duration and exclusivity remain well below global recommendations, particularly among marginalized populations. Limited national surveillance data on breastfeeding and research silos across Canadian universities impedes mobilization of knowledge required to improve breastfeeding rates.

Aim: To create an interdisciplinary network of Canadian researchers in the field of breastfeeding and human lactation, to accelerate efforts to develop and implement effective practices and programs to protect, promote and support breastfeeding in Canada.

Methods: Canadian researchers in the field of breastfeeding and human lactation were identified through an environmental scan of Canadian universities and snow‐ball sampling. The researchers were invited by e‐mail to participate in a 2‐day virtual planning meeting held in June 2023, to present their breastfeeding research programs, identify Canadian breastfeeding research priorities, and define a research group structure. Participant interactions were facilitated using Google Meet technology, and an online platform (breastfeedingresearchers. ca) was developed to support continued communication and network activities.

Results: Thirty‐seven researchers from diverse disciplines and regions attended the initial planning meeting. The participants’ research foci were categorized into 14 different specialty areas. Collaboratively identified research priorities included standardizing breastfeeding indicators; improving national collection of data on breastfeeding rates; enhancing knowledge translation of research findings; and reducing health inequities by testing and scaling up effective strategies for supporting breastfeeding among high‐risk populations. Actions taken to sustain and evolve the network included the creation of the network's Advisory Board, the launch of quarterly 90‐min webinars where members present and discuss research related to the network's priority areas; improvement of the CBRN website and the development of a secure member communication channels to share news, announcements and recent publications; and the establishment of virtual working groups to address breastfeeding research priorities. Our new digital communication strategy includes social media posts and quarterly newsletters to members and subscribers. The network's membership continues to grow with 50 registered researchers and trainees profiled on our website and over 70 researchers on our newsletter mailing list. Next steps for the CBRN are to secure funding to expand the network to include community‐based partner and other stakeholders, and to support interdisciplinary collaborative research on the network's research priorities to impact breastfeeding outcomes on a national level.

Conclusions: This project catalysed the creation of a multidisciplinary research network that continues to work on our mission: “To bring together diverse Canadian researchers in the field of breastfeeding and human lactation to foster partnerships, enhance innovation, catalyse new research initiatives, ensure equitable, diverse, and inclusive research methods and practices, and build capacity for future generations of Canada‐based researchers (including research on the benefits of human milk and diverse clinical and cultural human milk feeding practices).”

High Rates of Exclusive Breastfeeding At 2 Months Postpartum in a Home‐Based Swedish Midwifery Care Program ‐ an Observational Study

Eva Åsman ^1,2,3, Elisabeth Mangrio², Christine Rubertsson^1,3, Cecilia Häggsgård^1,4

¹Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden. ²Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden. ³Department of Obstetrics and Gynaecology, Skåne University Hospital, Malmö, Sweden. ⁴Department of Obstetrics

Background: The global recommendation regarding breastfeeding is to breastfeed exclusively for 6 months due to health benefits for mother and child. In Sweden rates of exclusive breastfeeding (EB) are declining, being 61% 2 months postpartum in 2021. In recent years home‐based postnatal midwifery care (HBPMC) has increased in Sweden. Mothers express high satisfaction with HBPMC, and it is the preferred model for future postpartum care (1). It is considered a person‐centred and flexible model of care where the midwife is available and present. Being in the home environment has been described as comfortable and giving a feeling of security. It also promotes bonding to the infant and partner involvement (2). The rate of EB among women receiving HBPMC is however unknown.

Aims: The aim of this study was to investigate the frequency of EB 2 months after birth and to identify risk factors associated with EB cessation in women participating in a HBPMC program.

Methods: This prospective study with observational design uses data from medical records together with telephone interviews 2 months after birth, with women included in a HBPMC program. The study was conducted between November 2023 and March 2024 at two Swedish maternity units. Associations between EB cessation 2 months after birth and risk factors for EB cessation were analysed by multivariable logistic regression. This study received ethical approval from The Swedish Ethical Review Authority (DNR 2023‐03650‐01).

Results: A total of 219 women participated in the study, with 211 of them being interviewed. Among those interviewed, 83,9% reported exclusively breastfeeding at 2 months. The most common reasons given for EB cessation were women's own preferences and perceived insufficient milk supply. Identified risk factors associated with EB cessation were not exclusively breastfeeding at discharge from HBPMC (1 week postpartum), having a body mass index ≥ 30 and being born outside of Sweden. There was no difference in EB at 2 months between primiparous and multiparous women.

Conclusion: High breastfeeding rates were reported in women receiving HBPMC compared to national data. HBPMC seems to promote EB besides being an appreciated model of care. To further reach global EB recommendations, identification of women at risk for early cessation needs to be addressed to provide targeted breastfeeding support and promote breastfeeding duration.

References:

1. Johansson M, Thies‐Lagergren L, Wells MB. Mothers’ experiences in relation to a new Swedish postnatal home‐based model of midwifery care–A cross‐sectional study. Midwifery. 2019;78:140‐9.

2. Johansson M, Östlund P, Holmqvist C, Wells MB. Family life starts at home: Fathers’ experiences of a newly implemented Swedish home‐based postnatal care model–an interview study. Midwifery. 2022;105:103199.

'Navigating d‐MER Waves’: A Classic Grounded Theory of Women's Experiences of Dysphoric Milk Ejection Reflex (d‐MER)

Charlie Middleton‐Woulfe, Alison McFadden, Elaine Lee, Jenna Breckenridge

University of Dundee, Dundee, United Kingdom

Background: Dysphoric milk ejection reflex (d‐MER) is a poorly understood phenomenon characterised by sudden onset dysphoria which occurs before and during milk ejection, typically lasting between 30 s and 2 min in duration (Heise & Wiessinger 2011). Some women describe a hollow or guilty feeling, while others report feelings of rage and suicidal ideation (Heise, 2008; Heise & Wiessinger, 2011). For some, d‐MER episodes diminish after the first few weeks of pregnancy (Heise & Wiessinger, 2011) while others experience d‐MER for much longer. Existing research suggests d‐MER is distinct from perinatal mood disorders (Heise & Wiessinger, 2011) and is physiological rather than psychological in origin (Heise & Wiessinger, 2011). As d‐MER remains largely unresearched, it's prevalence and cause are not well understood.

Aims: The aim of this project is to generate a Classic Grounded Theory which explains the main concerns of women who experience d‐MER and how these concerns are processed and/or resolved.

This study addresses the following questions:

• What are the main concerns of women who experience d‐MER?

• How are these concerns processed and/or resolved?

Methods: The study design is Classic Grounded Theory using a pragmatic approach. Participants were recruited online via a purposive, theoretical sampling strategy. Data were collected via 1‐1, in‐depth, semi‐structured interview undertaken online. In accordance with Classic Grounded Theory methodology, data were simultaneously collected and analysed via constant comparison.

Results: A total of n = 22 women participated. ‘Navigating d‐MER waves’ emerged as the core category which conceptualises both the main concerns of women who experience d‐MER and how these concerns are processed and resolved. Navigating d‐MER waves is a process theory in which women move through three stages; assimilating, adjusting and reconciling via a progressively refined cycle of meaning making, adapting and integrating.

Conclusion: ‘Navigating d‐MER waves’ explains the main concerns of women who experience d‐MER and how these concerns are both processed and resolved. Limited awareness of d‐MER means women typically lack adequate support and are therefore self‐directed in learning to navigate life with d‐MER. Navigating d‐MER waves may fit with extant theory.

Reference:

Heise, A.M. and Wiessinger, D., (2011) Dysphoric milk ejection reflex: A case report. International breastfeeding journal, 6(1), p.6.

National Infant Feeding Responses to the COVID‐19 Pandemic: Findings From the World Breastfeeding Trends Initiative (WBTi) UK Assessment

Helen Gray

London School of Hygiene and Tropical Medicine, London, United Kingdom

Background: The first World Breastfeeding Trends initiative (WBTi) assessment of UK infant feeding policies and programmes¹, published in 2016, found no national planning for infant and young child feeding in emergencies (IYCFE). Since then, the UK has experienced the global emergency of the COVID‐19 pandemic, along with national crises including supply chain issues, a cost‐of‐living crisis, and worsening climate emergencies such as storms and flooding. A second UK WBTi assessment was conducted in 2023‐2024, led by a Core Group of organisations and agencies working in maternal and infant health.

Aim: The WBTi assessment of IYCFE monitors the implementation of global guidance on infant feeding in emergencies. The second UK WBTi assessment aimed to explore infant feeding policy responses to COVID‐19 and other UK crises, as well as national emergency planning.

Methods: The WBTi questionnaires were drawn from the 2019 edition of the WBTI Assessment Tool. Each criterion on the questionnaire on IYCFE has detailed actions drawn from global guidance and standards. Purposive sampling was used and the questionnaires, along with additional questions on planning for and response to COVID‐19 and other crises, were distributed to government teams responsible for maternal and infant health policy in the health agencies of all four UK nations. In addition, the breastfeeding support organisations were invited to submit a response on how they supported families with infants during the pandemic.

Results: None of the four nations had developed a national strategy to plan for infant feeding in emergencies, however, all four governments and their health/public health departments did respond to the impact of the COVID‐19 pandemic on mothers and infants. From July 2020 onwards, joint guidance from the Royal Colleges² supported WHO guidance on keeping mothers and babies together and recommending breastfeeding after the publication of Renfrew et al.'s³ rapid review of the evidence, commissioned by the Royal College of Midwives. National health departments worked with UNICEF UK Baby Friendly Initiative (BFI) who developed guidance for health professionals that were disseminated across the country. Some NHS services and third sector support groups moved online. Staff shortages were also an issue, due to illness, isolation, and redeployment. During the pandemic, guidance and resources to support infant feeding were drawn up, however no national overarching strategies for emergencies were developed.

Conclusions: The COVID‐19 pandemic exposed the fact that there is no national planning for infant feeding in emergencies in any of the four nations of the UK. However, each nation did mount a rapid response, by producing guidance and resources with BFI, which could serve as the foundation for future national emergency planning.

References:

1. WBTi UK Core Group. (2016). World Breastfeeding Trends Initiative UK Report 2016. https://ukbreastfeeding.org/wp-content/uploads/2017/03/wbti-uk-report-2016-part-1-14-2-17.pdf.

2. Royal College of Obstetricians and Gynaecologists. (2020, July 24). Coronavirus (COVID‐19) Infection in Pregnancy: Information for healthcare professionals. Version 11.

3. Renfrew, M. J., Cheyne, H., Dykes, F., Entwistle, F., McGuire, W., Shenker, N., & Page, L. (2020, June 24). Optimising mother‐baby contact and infant feeding in a pandemic. Royal College of Midwives.

‘Eyes on the Baby’: Implementing Multi‐Agency Sudi Prevention in Northumberland

Helen Ball, Margaret Randall, Sophie Lovell‐Kennedy

Durham University, Durham, United Kingdom

Background: In the UK, Sudden Unexpected Death in Infancy (SUDI) is clustered in priority families for whom existing universal infant sleep safety guidance is not effective. Reports have identified the need for a multi‐agency workforce (MAW) approach delivering targeted SUDI prevention to address this inequality. Two years ago, we presented on the design and piloting of Eyes on the Baby, a new training and implementation initiative in County Durham [1, 2]. Here we will share the outcomes of the first full‐scale roll‐out of Eyes on the Baby in Northumberland.

Aims: Working with a local Steering Committee to oversee the project we aimed to a) engage staff encountering priority families as part of their roles across Northumberland, b) provide training in infant sleep safety, emphasising what to see, what to say and what to do them, c) offer resources and engagement activities to support them in SUDI prevention, and d) evaluate their responses to MAW SUDI prevention, and their ability to translate training into practice.

Methods: Graded training (involving three strands) was delivered by the research team via an online learning platform. Normalisation Process Theory was used to support user engagement and embed SUDI prevention into everyday practice. Pre‐and post‐training surveys assessed staff knowledge and confidence with SUDI prevention, and the NOMAD survey was adapted to capture staff feedback and engagement.

Results: Staff in 187 roles across 25 services were invited to participate, with 1007 staff registering for training. Eyes on the Baby training increased SUDI prevention knowledge and confidence across all three training strands. Knowledge remained high 2 months after completion and staff commitment to SUDI prevention was sustained. Some Strand 1 staff were initially dubious about their role in SUDI prevention, while others expressed strong enthusiasm. SUDI Champions played an active role in embedding SUDI prevention into everyday practice and Family Hubs were extremely active in parent engagement. Health Professionals were strongly in favour of a multi‐agency approach to SUDI prevention and partnership working on SUDI prevention in priority families with colleagues across services, and found the training refreshed their knowledge and increased their confidence to have difficult conversations with families [3].

Conclusions: The Eyes on the Baby programme was successful in training and implementing a large‐scale SUDI prevention programme for the multi‐agency workforce. It has now been permanently adopted by the local authority, NHS trust and Family Hubs, working in partnership. As a consequence of this project Eyes on the Baby has now been made available to the entire North East Ambulance Service. We will now move on to evaluating the initiative with priority families as the intended beneficiaries and continue to monitor SUDI incidents in Northumberland.

References:

1. Ball, H. L., Keegan, A.‐A., Whitehouse, D. R., Cooper, L. S., Lovell‐Kennedy, S. R., Murray, L. M., Newbury‐Birch, D., Cleghorn, N. J., & Healy, A. (2023). Multiagency approaches to preventing sudden unexpected death in infancy (SUDI): a review and analysis of UK policies. BMJ Public Health, 1(1), e000017. https://doi.org/10.1136/bmjph-2023-000017.

2. Ball, H. L., Grieve, L. M., Keegan, A.‐A., Cooper, L., Lovell‐Kennedy, S., Newbury‐Birch, D., Cleghorn, N., & Healy, A. (2024). Piloting Eyes on the Baby: A Multiagency Training and Implementation Intervention Linking Sudden Unexpected Infant Death Prevention and Safeguarding. Health & Social Care in the Community, 2024, 4944268. https://doi.org/10.1155/2024/4944268.

3. Durham Infancy & Sleep Centre (2024) Eyes on the Baby: Multi‐agency SUDI Prevention for Northumberland Final Report https://eyesonthebaby.org.uk/wp-content/uploads/2024/04/Northumberland-EotB-Final-Report.pdf.

Harnessing Digital Innovation and Ppie to Enhance Antenatal Education and Parent‐Infant Relationships: Insights From Anya's Greater Manchester Pilot

Shel Banks, Charlotte Treitl

Anya Health, Cirencester, United Kingdom ‐ parenting@anya. health

Introduction: The first 1001 days ‐ spanning conception to a child's second birthday ‐ are a transformative window of opportunity for shaping lifelong health and wellbeing. During this time parental experiences, availability and quality of support, and access to trusted information can significantly influence outcomes for both parent and child. However, many parents face barriers to the resources and guidance they need, which can exacerbate health inequalities, including maternal mental health issues.

Anya, a women's health, pregnancy and parenting app, is dedicated to addressing these challenges through innovative, evidence‐based digital solutions.

Methodology: Anya co‐designed two impactful programmes ‐ a tailored antenatal programme and a fourth‐trimester programme ‐ through robust Public and Patient Involvement and Engagement (PPIE) in a pilot across the whole of Greater Manchester backed by the UK Government's SBRI (Small Business Research Initiative). These programmes aim to empower parents through pregnancy, prepare them to approach birth with confidence and make informed choices, and help them build skills in infant feeding, all while nurturing the vital parent‐infant bond that lays the foundation for lifelong wellbeing. Our pilot has provided encouraging results from a two‐stage evaluation survey.

Results:

• Parents feeling in control during birth increased from 18% to 56%, after 6 weeks of antenatal app usage.

• Unplanned c/section rate 10.9% lower in those using Anya antenatally.

• Self‐reported confidence in successful latching rose by 22% with overall breastfeeding confidence up by 30%.

• Strengthened Parent‐Infant relationships: 50% of all app users felt more confident in settling their baby when upset.

• Parental anxiety after using the app reduced by 7%.

• Trusted 24/7 Support: 90% users trust Anya's information, and valued round‐the‐clock accessibility.

• No significant differences in breastfeeding rates or mental health outcomes between deprivation indices, ethnicity or language.

Parents’ feedback also highlighted key features such as 3D interactive animations as particularly supportive. User testimonials illustrate Anya's role in empowering new parents, fostering confidence, and reducing the need for additional healthcare interventions. Cost benefit analysis showed substantial benefit per user, with the most value driven by reduced Caesarean section, reduced need for mental health support and unnecessary community appointments being avoided.

Conclusion: This pilot has demonstrated how evidence based digital health tools such as Anya can transform parental support during the critical early years, addressing health inequalities and providing a trusted companion for parents when they need it most.

Improving Nutrition Service and Enabling Environment: The Case of Mbeya Region, Tanzania

Charles Msigwa ¹, Josephine Mwaijengo¹, Benson Sanga², Hawa Msola³, Anna Godfrey¹

¹Catholic Relief Services (CRS), Tanzania. ²Regional Secretariat, Mbeya region, Tanzania. ³UNICEF, Tanzania

Introduction: Adequate financial resources and proper financial management are key to ensuring adequate, equitable and quality nutrition service delivery¹. Tanzania regions face substantial challenges in providing adequate nutrition services². In the financial year 2021/22, the Mbeya Regional Secretariat and long‐term development partners conducted a nutrition budgetary review for Local Government Authorities (LGAs) to understand the progress to date and inform future financial management and nutrition interventions.

Methods: The review covered spending from LGAs’ own sources over the past five fiscal years (2017/18‐2021/22) and included three main pillars of analysis: i) LGAs’ fund expenditure in the nutrition sector, ii) nutrition compact indicators performance, and iii) enabling environment for community interventions.

Results:

i) LGAs’ fund expenditure in the nutrition sector

For Mbeya region, a total expenditure for nutrition interventions increased from TZS 32,518,667 (11% of the allocated budget) in FY 2017/18 to TZS 554,666,786 (91% of the allocated budget) in FY 2021/22, totalling an increase of 80 percentage points. This remarkable progress results from the region utilizing existing platforms such as Compact Review Meetings, Quarterly Multi‐Sectoral Steering Committees for Nutrition, and pre‐planning budget sessions to strengthen fund allocation and expenditure practices for nutrition, with joint efforts from NGOs such as CRS.

ii) Nutrition compact indicators performance

With increased fund allocation and utilization for nutrition interventions, as well as commitment of the RS, LGA leaders, and major implementing partners such as CRS towards the signed nutrition compact agreement, the region has achieved significant improvement in Nutrition Compact indicators with all indicators scoring more than 85%.

iii) Enabling Environment for Community Interventions

The region and its districts have also increased financial investment in nutrition services: in FY 2021/22, Mbeya region purchased job aid materials such as 335 weigh scales for frontline workers. Districts such as Chunya and Mbeya have invested in IDs, T‐shirts, and transport for CHWs. CHW allowances have also gone up from TZS 72,960,000 (FY 2021/22) to TZS 115,481,000 (FY 2022/23).

Conclusions: Remarkable progress results from utilizing existing platforms including Compact Review Meetings, Quarterly Multi‐Sectoral Steering Committees for Nutrition, and pre‐planning budget sessions to strengthen fund allocation and expenditure practices for nutrition, with joint efforts from NGOs such as CRS and COUNSENUTH. By showing that through their own sources, councils can improve the enabling environment for community interventions, Mbeya region has provided valuable experience and lessons learned for other Low Middle Income Countries (LMICs).

References:

Carrera C., Azrack A., Begkoyian G. et al. (2012). The comparative cost‐effectiveness of an equity‐focused approach to child survival, health, and nutrition: a modelling approach. The Lancet, 380, pp. 1341–51, doi:10.1016/S0140‐6736(12)61378‐6.

Nuhu, S., Mpambije, C.J. & Ngussa, K. (2020). Challenges in health service delivery under public‐private partnership in Tanzania: stakeholders’ views from Dar es Salaam region. BMC Health Serv Res 20, 765, https://doi.org/10.1186/s12913-020-05638-z.

The View From the Ground: Parent and Carer Perceptions of Infant Feeding Public Health Messaging

Rebecca Selby, Gill Thomson, Victoria Moran

University of Lancashire, Preston, Lancashire

Background: Infant feeding public health messaging aims to support evidence‐based decision‐making for parents and carers. However, in high‐income countries, sociodemographic factors such as maternal education, socioeconomic status, and caregiver support significantly influence infant feeding outcomes (Chan et al., 2023). In contexts of socioeconomic disadvantage, there is growing concern that traditional top‐down health messaging fails to connect with lived realities. This study explores how parents and carers in a deprived UK coastal community perceive and engage with current infant feeding messages — capturing a “view from the ground” historically underrepresented in public health communication design.

Methods: A constructivist grounded theory approach underpinned this qualitative study. Semi‐structured interviews were conducted with 21 participants — parents and carers of children under three — residing on the North West Coast of the UK, an area marked by persistent health inequalities (Giebel et al., 2020; Whitty, 2021). Data collection included one in‐person interview, three online individual interviews, three paired interviews, and two group interviews. Participants were shown example infant feeding messages as prompts to explore their interpretations and experiences. Data were analysed inductively, generating core categories and themes, which informed the development of a mapping framework grounded in tailored health communication approaches.

Results: Participants shared diverse and nuanced perceptions of infant feeding public health messaging. While some message components were positively received, the consensus was that current messaging lacks resonance with real‐life contexts. Themes emerged around the tone, content, delivery, and accessibility of messages. Participants often described messages as prescriptive, idealised, or guilt‐inducing, highlighting a need for compassionate, realistic, and co‐designed alternatives. The mapping framework developed from the findings identifies the potential disconnect between institutional messaging and community needs, offering a structure to inform more effective, audience‐informed communication strategies.

Conclusion: This study underscores a persistent disconnect between infant feeding messaging and the lived experiences of families in socioeconomically disadvantaged communities. By adopting a constructivist grounded theory lens and developing a mapping framework informed by tailored communication approaches, the research offers practical and actionable guidance for designing inclusive, responsive, and human‐centred public health campaigns — with the potential to reduce communication inequities in early childhood nutrition.

References:

Chan, K., Labonté, J. M., Francis, J., Zora, H., Sawchuk, S., & Whitfield, K. C. (2023). Breastfeeding in Canada: Predictors of initiation, exclusivity, and continuation from the 2017–2018 Canadian Community Health Survey. Applied Physiology, Nutrition, and Metabolism, 48(3), 256–269. https://doi.org/10.1139/apnm-2022-0333.

Giebel, C., McIntyre, J. C., Alfirevic, A., Corcoran, R., Daras, K., Downing, J., Gabbay, M., Pirmohamed, M., Popay, J., Wheeler, P., Holt, K., Wilson, T., Bentall, R., & Barr, B. (2020). The longitudinal NIHR ARC North West Coast Household Health Survey: Exploring health inequalities in disadvantaged communities. BMC Public Health, 20(1), 1257. https://doi.org/10.1186/s12889-020-09346-5.

Whitty, C. (2021). Chief Medical Officer's Annual Report 2021—Health in Coastal Communities (Independent Report 2; Chief Medical Officer's Annual Report, p. 259). Department of Health and Social Care. https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2021-health-in-coastal-communities.

Implementing and Sustaining the International Guidelines for Skin‐To‐Skin Contact in the First Hour After Birth in Uganda

Kajsa Brimdyr ¹, Anna Blair¹, Kristin Svensson², Louise Basterache³, Karin Cadwell¹

¹Healthy Children Project, Harwich, USA. ²Karolinska Institute, Stockholm, Sweden. ³Harvard Medical Faculty Physicians, Cambridge, USA

Background: Skin‐to‐skin contact during the first hour after birth has significant benefits for mother, newborn and breastfeeding. However, optimal implementation is highly variable. The 2023 International Guidelines on skin‐to‐skin contact in the first hour after birth place high confidence in the evidence that immediate, continuous, uninterrupted skin‐to‐skin contact should be routine for all mothers and all babies over 1000 grams, regardless of mode of delivery. The PRECESS (Practice Reflection Education and Training Combined with Ethnography for Sustainable Success) modality provides evidence‐based education, process‐oriented practice, experiential learning and Interactive Analysis Labs to achieve sustainable best practice. This study aimed to determine if, by using PRECESS methodology, the 2023 guideline could be fully implemented and sustained in a regional teaching and referral hospital in Uganda, and would this result in an increase of breastfeeding initiation in the first hour after birth.

Methods: Baseline data on 92 dyads was collected, and video recordings made of each newborn during the first hour after birth. After collecting this baseline data, the intervention began with an evidence‐based lecture for staff describing the optimal practice of skin‐to‐skin contact and first‐hour newborn behaviors. Practice experience followed the lecture with staff support for 105 dyads, who were also video recorded during the first hour. Interactive Analysis Labs allowed key informants to provide reflection on barriers and solutions. Approximately 6 weeks after the initial intervention, 128 dyads were observed, and video recorded to determine sustainability of the procedure.

Results: Implementation of skin‐to‐skin contact in the first hour after birth using PRECESS resulted in significantly more time in skin‐to‐skin contact than pre‐intervention (2m25s +‐ 2m48s vs 57m51s + ‐2m53s p < 0.001), although the percentages of newborns who were breastfed in the first hour after birth were not significantly different (29% in baseline, 28% after intervention, p = 0.871). After 6 weeks, skin‐to‐skin contact in the first hour after birth remained high, at 58m17s + ‐2m02s. Breastfeeding in the first hour after birth increased to 44% (p = 0.012).

Conclusions: PRECESS provided a fast‐track methodology for improving skin‐to‐skin contact and breastfeeding in the first hour after birth in a regional teaching and referral hospital in Uganda.

References:

Brimdyr K, Stevens J, Svensson K, Blair A, Turner‐Maffei C, Grady J, et al. Skin‐to‐skin contact after birth: Developing a research and practice guideline. Acta Paediatrica. 2023 Aug;112(8):1633–43.

Crenshaw JT, Cadwell K, Brimdyr K, Widström AM, Svensson K, Champion JD, et al. Use of a video‐ethnographic intervention (PRECESS Immersion Method) to improve skin‐to‐skin care and breastfeeding rates. Breastfeed Med. 2012. Apr;7(2):69–78.

Moore ER, Bergman N, Anderson GC, Medley N. Early skin‐to‐skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016 25;11:CD003519.

Preventing Sudden Unexpected Death in Infancy: Barriers to Following Safer Sleep Guidance in Northumberland

Sophie Lovell‐Kennedy, Helen Ball

Durham University, Durham, United Kingdom

Background: Sudden Unexpected Death in Infancy (SUDI) is defined as the death of an infant under the age of 1 year that was not predicted 24 h previously. There are several hundred deaths a year, clustered amongst priority families. Many SUDI cases occurring in England and Wales today have modifiable risk factors, demonstrating that current SUDI prevention campaigns are failing to reach the most vulnerable. This project aimed to establish barriers to following SUDI prevention guidance in Northumberland, exploring the ways in which people received safer sleep guidance, and whether this was viewed as useful or effective.

Methods: Funded by the Economic and Social Research Council's Northern Irish and North Eastern Doctoral Training Program, this project is part of a PhD based out of Durham University's Infancy and Sleep Centre. After attending baby groups in Northumberland's Family Hubs, the researcher invited families attending these baby groups to partake in focus groups. Following analysis of qualitative data, the researcher then went back to the families to feedback the findings and ensure that what was said was representative of their lived experience.

Results: The focus groups were well attended, and families were keen to share their experiences. Families expressed concern over the conflicting advice around safer sleep, often referring to different professionals expressing different advice about bedsharing and co‐sleeping and the confusion that this caused: “I got told not to bedshare and then I got told I could bedshare so I was just like, well what do I do?”. This highlights the importance of consistent safer sleep training for all staff who may come into contact with families. Parents also expressed a desire for tangible resources rather than always being directed online and highlighted the challenges of retaining information when it was all spoken: “I know we talked about it, but I can't remember.” Additionally, parents stressed their frustration at sleep products being sold that were not recommended for baby sleep: “you just assume if it's being sold, it's got to be safe” and suggested that there needs to be more awareness around this topic.

Conclusions: The results of this project will be used to inform the next phase of this PhD, in which parents will work with the researcher to coproduce a campaign stressing the importance of tangible resources for safer sleep; and to coproduce critical‐thinking tools to support parents in decision‐making about sleep products and their safety.

Health Care Providers’ and Parents’ Perspectives of Adaptations Needed to an Ehealth Breastfeeding Resource for Implementation in Clinical Settings to Standardize Education Across a Health Region

Jennifer Abbass‐Dick ¹, Manon Lemonde²

¹Ontario Tech University, Oshawa, Canada. ²Ontario Tech Univrsity, Oshawa, Canada

Background: Many families have limited breastfeeding knowledge resulting in low health literacy and report receiving inconsistent information from various health care providers over the perinatal period (Deo et al., 2023). Our study team is working to standardize breastfeeding education throughout a health region with the implementation of an evidence‐based breastfeeding co‐parenting eHealth resource in health care organizations across a health region (Abbass‐Dick et al, 2023). Our previous work has identified concerns among health care providers regarding the use of web‐based resources in clinical settings, highlighting the need to adapt these innovations to the local context before implementation (Abbass‐Dick et al., 2024).

Aim: The aim of this phase of the study was to survey and interview parents and health care providers to determine their perspectives on how to best adapt the resource for use in clinical interactions. Then, based on these findings, to create prototype resources and adapt the eHealth resource to the local context before implementation.

Methods: Health care providers were surveyed (n = 93) and interviewed (n = 10) to determine the ways they provide breastfeeding education, their needs in relation to educational resources, and how to best adapt our eHealth resource for use in clinical interactions. Parents were also surveyed (n = 78) and interviewed (n = 5) to determine their experiences and needs regarding breastfeeding education. The findings were used to create prototype resources to showcase at an event to collect parents' and health care providers' feedback before final development.

Results: The findings from this study indicate that breastfeeding education is provided by various health care providers across the perinatal period, the majority of which is being provided in the hospital via oral communication. Breastfeeding education and support can be difficult to access and there are varied approaches taken by health care providers based on their knowledge, skills and interest. Designing accessible educational content using both print and digital modes, using language that is trauma informed and supportive of parents with varied breastfeeding experiences, having small amounts of information presented with key messages that can be expanded on as needed, and including information on where to accessed specialized lactation support were suggested for resources designed for use in clinical settings to standardize breastfeeding education.

Conclusions: Based on these findings prototype resources were created that included 1) creating a brand for the educational material, 2) revising the eHealth resource to increase ease of navigation, 3) revising content wording to align with a wellness model approach, 4) organizing content around key messages, and 5) creating print material to advertise and supplement the content in the eHealth resource. Future work will continue to evaluate the implementation of these resources in clinical setting to standardize breastfeeding education, and increase parents' health literacy and their ability to meet their breastfeeding goals.

References:

Abbass‐Dick, J., Sun, W., Newport, A., Xie, F., Micallef, J., & Dubrowski, A. (2023). Maternal and co‐parental experiences and satisfaction with a co‐parenting breastfeeding eHealth intervention in Canada. Journal of Pediatric Nursing, 72, 135‐145. doi:10.1016/j.pedn.2023.07.013.

Abbass‐Dick, J., Dubrowski, A., Micallef, J., Harvie, L., Newport, A., Pigeau, K., Jeronymo, H., & Lemonde, M. (2024). Health providers’ perceptions of barriers, facilitators, and acceptability of an eHealth resource: Descriptive study. International Health Trends and Perspectives, 4(1), 68–87. doi.org/10.32920/ihtp.v4i1.1938.

Deo, H., Ojukwu, E., & Boschma, G. (2023). Contextualizing the Health Promotion of Breastfeeding: An integrative Review of Parent and Provider experiences in Canada. Aporia, 15(2).

Formative Research for the Development and Implementation of a Smartphone Application to Report Breaches to the International Code of Marketing of Breast‐Milk Substitutes in Mexico

Mishel Unar‐Munguia¹, Marena Ceballos‐Rasgado ², Pedro Mota‐Castillo¹, Andrea Santos‐Guzman¹, Valerria Aureoles‐García¹, Victoria Moran², Matthias Sachse³

¹Instituto Nacional de Salud Pública, Cuernavaca, Mexico. ²University of Lancashire, Preston, United Kingdom. ³United Nations International Children's Emergency Fund, Mexico City, Mexico

Background: Almost 40 years after the adoption of the International Code of Marketing of Breast‐Milk Substitutes (‘the Code’) in Mexico, noncompliance continues to exist. Smartphone reporting applications for Code noncompliance have been effective in other countries.

Aim: This study aimed to inform the design and usability of a new public health surveillance mobile application (app) to monitor breaches to the Code and explore the barriers and facilitators influencing parents’ and key‐stakeholders’ use of it.

Methods: Semi‐structured interviews (n = 34) and focus groups discussions (n = 14) with key stakeholders (n = 81) including parents and caregivers, health care personnel, representatives of academia, civil society organizations and government entities were conducted between August and December 2023. Transcripts were analysed in MAXQDA 20 software using grounded theory ‘lite’.

Results: Four categories were constructed from the coding process: a) Knowledge and perspectives about the Code; b) Attitudes towards reporting breaches to the Code and consequences; c) Stakeholders perspectives on monitoring the Code; d) Perspectives on the app. In this study, Mexican stakeholders supported the development of an app and associated website to monitor the Code, indicated a willingness to report breaches, and believed that a national committee and state bodies should oversee surveillance and monitoring activities of the Code. Adapting legal measures with appropriate sanctions and making infractions public were recommended.

Conclusions: The establishment of a national monitoring system, with the aid of technology that enables society to detect and report breaches and promoting the Code, is crucial to regulate commercial milk formula marketing.

Operationalizing Resources for Care in Nutrition Research, Programs, and Policy: Reflecting on 25 Years of Evidence

Scott Ickes ¹, Doreen Alumaya², Lisa Sherburn³, Paige Harrigan⁴, Amanda Zongrone⁵, Stephanie Martin²

¹William & Mary, Williamsburg, VA, USA. ²Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. ³Hellen Keller International, Kathmandu, Nepal. ⁴Virginia Tech, Blacksburg, VA, USA. ⁵Independent Consultant, College Park, MD, USA

Background: Adequate care was first highlighted as an underlying determinant of child growth, development, and survival in the 1990 UNICEF conceptual framework for malnutrition. Care refers to behaviors that affect child nutrition, health, and development. Resources for Care include tangible and intangible resources that caregivers need to practice nurturing care. In 1999, Engle, Menon, and Haddad published the seminal article “Care and Nutrition: Concepts and Measurement” adding Resources for Care as another determinant to the UNICEF framework. In the 25 years since the concept of Resources for Care has been widely recognized and used; however, a systematic investigation of its application and impact was needed.

Aims: We conducted a systematic citation analysis and scoping review of the 1999 Engle et al. “Resources for Care” article to understand how the concept of resources for care has been studied, applied, and operationalized in nutrition research and programs.

Methods: We searched four databases to screen for studies that examined the role of caregiver resources in child nutrition and feeding. We constructed a definition of “Resources for Care‐Focused” to select studies with a stated objective to examine the role of resources for care in nutrition, development, or health outcomes. We further identified the geographic region and focal outcome for studies and characterized the modifications or proposed revisions to the 1999 framework.

Results: We identified 696 publications that cited Engle et al. A total of 264 met the criteria for Resources for Care Focused with recent examples of its application, followed by a facilitated discussion to consider future research, potential evidence‐based updates, and program and policy applications. Ninety‐five (35.9%) of the included studies were conducted in sub‐Saharan Africa, 56 (21.2%) in South Asia, 43 (16.3%) were conducted in East Asia and the Pacific, and 27 were conducted in Latin America/the Caribbean. Forty‐three (16.3%) studies were conducted in multiple regions and/or globally. Thirty‐three (12.5%) studies included the Engle et al. figure. Thirty‐three (12.5%) manuscripts were reports of interventions. The most common nutrition focus was growth and nutritional status (stunting, wasting, BMI, underweight, overweight), followed by breastfeeding, and complementary feeding. Key recommendations related to caregiver resources included increasing male partner engagement, reducing violence against women, improving standardization and measurement of caregiver resource constructs for comparison across contexts, and sharing learning about strategies for improving child nutrition outcomes through targeting or strengthening resources for care. The most assessed Resources for Care were maternal mental health and autonomy.

Conclusion: The Resources for Care framework has played a major role in shaping the nutrition and care literature for the past 25 years, with global impact and application. While many studies have been guided by this influential framework, limited research has recommended improvements or advancements to this influential framework.

The Nine Stages of Instinctive Behaviour for Premature and Full‐Term Infants

Karin Cadwell, Kajsa Brimdyr

Healthy Children Project, Harwich, USA

Background: The competence of a newborn born premature infant mirror the 9 instinctive stages of a full‐term infant, although a full term infant moves through those stages in 1 h after birth, and a premature infant may take days, weeks or months.

Method: Using Widström's 9 Instinctive stages as the template (Widström et al., 2020), we use the full‐term newborn's instinctive behaviour during the first hour after birth while skin‐to‐skin to investigate the pre‐feeding behaviors of pre‐term infants who were videorecorded while being held skin‐to‐skin by a parent.

Results: Analysis of videos demonstrates that the premature infant can be seen to progress through the same stages as does the full‐term newborn when in skin‐to‐skin contact with the mother, albeit over days and weeks, rather than 1 h. The template of behaviours includes those described as the 9 stages, the Birth Cry, Relaxation, Awakening, Activity, Rest, Crawling, Familiarisation, Suckling, and Sleeping. (Widström et al., 2019).

Conclusion: Both the full‐term newborn and the preterm infant have been training for and are prepared for this experience after birth: to find the breast and to initiate breastfeeding. Rigorous research is needed to examine not just the premature infant's suckling behaviour, but the journey to suckling. All newborns, whether full‐term or premature, should be guaranteed the opportunity to utilise their template of practised survival skills while experiencing skin‐to‐skin contact.

References:

Brimdyr, K., & Cadwell, K. (2021). Connecting the dots between fetal, premature and full‐term behaviour while in skin‐to‐skin contact: The nine stages of instinctive behaviour. Breastfeeding Review, 29(3), 17–24.

Widström, A.‐M., Brimdyr, K., Svensson, K., Cadwell, K., & Nissen, E. (2019). Skin‐to‐skin contact the first hour after birth, underlying implications and clinical practice. Acta Paediatrica, 108(7), 1192–1204. https://doi.org/10.1111/apa.14754.

Widström, A.‐M., Brimdyr, K., Svensson, K., Cadwell, K., & Nissen, E. (2020). A plausible pathway of imprinted behaviors: Skin‐to‐skin actions of the newborn immediately after birth follow the order of fetal development and intrauterine training of movements. Medical Hypotheses, 134, 109432. https://doi.org/10.1016/j.mehy.2019.109432.

Associations Between Caregiver Nutrition and Responsive Care and Early Learning: A Scoping Review

Taryn Smith, Alice Fortune, Melissa Gladstone

University of Liverpool, Liverpool, United Kingdom

Background: The Nurturing Care Framework highlights good health, adequate nutrition, responsive caregiving, early learning opportunities, and security and safety for optimal child development. Responsive caregiving and stimulating caregiver interactions have been identified as key caregiving behaviours that promote child cognitive and psychosocial health across diverse settings. Poor nutritional status of caregivers likely limits their ability to provide optimal nurturing care. Parenting programmes often integrate child development (e.g. stimulation, play and communication) and child nutrition interventions (e.g. supplementation), but rarely include interventions to simultaneously improve caregiver nutrition. Greater impacts on child development could potentially be attained if programmes effectively addressed caregiver nutrition in addition to child‐level factors.

Aim: To synthesise existing evidence on caregiver nutrition and psychosocial caregiving behaviours.

Methods: Medline was searched in July 2024 using search terms specific to the population group, nutrition exposures and caregiving outcomes. Observational and experimental studies were included if they: 1) included pregnant or postpartum women or mother‐child dyads where the child was < 5 years, 2) included any measure of maternal nutrition (e.g. anthropometry, biomarkers of nutritional status, dietary intakes/indicators) or any intervention that provided women with nutrient/food supplements, 3) included psychosocial outcome measures (e.g. mother‐child interactions/relationships, responsive caregiving, stimulation).

Results: A total of 23 articles met the inclusion criteria (n = 17 observational and n = 6 randomised controlled trials [RCTs]). The majority (n = 15) were conducted in low‐ and middle‐income countries. Observational studies measured caregiver anthropometry (n = 8), dietary intakes/diversity/quality (n = 6), anaemia (n = 6) and vitamin B₆ status (n = 1). RCTs supplemented pregnant and/or postpartum women with iron (n = 2), multiple micronutrients (n = 2), fish oil (n = 1) and food‐based snacks (n = 1). Most articles (n = 18) employed either live or videotaped observations of caregiver‐child interactions in the home, health clinics or research laboratories; the remaining (n = 5) utilised caregiver self‐reported measures of stimulation or caregiver‐child bonding/relationship. Less optimal dietary intakes, food insecurity, caregiver under‐ and overnutrition, anaemia and low vitamin B₆ status were associated with less responsive and sensitive caregiving and fewer opportunities for early learning through play and stimulation. Children's dietary intakes and nutritional status additionally, and sometimes more strongly, influenced caregiving behaviours, although this was considered in few studies. Iron repletion of anaemic women following iron supplementation positively altered caregiver‐child interactions. Findings were mixed for other supplementation trials and varied with method of assessing caregiving behaviours (direct mother‐child interaction observation vs. brief observation and self‐report combined).

Conclusion: Caregiver and child nutritional status should be simultaneously considered to understand the influences of nutrition on caregiving behaviours. Interventions aimed at enhancing nurturing care should consider caregiver nutrition as a potential target to improve outcomes for both children and their caregivers. Direct observation of caregiver‐child interactions may be less biased and more sensitive to detect changes in caregiving behaviours than self‐reported measures, particularly in intervention studies.

Working With the World Health Organisation (WHO) to Conduct Systematic Reviews for the WHO Donor Human Milk Guidelines Development Group

Tanya Cassidy ¹, Magdelena Babiszewska‐Aksamit², Agnieszka Bzikowska‐Jura³, Laura Cavallarin⁴, Serena Gandino⁵, Marzia Giribaldi⁴, Karolina Karcz³, Daniel Klotz⁶, Chiara Peila⁷, Carolyn Smith⁵, Bartłomiej Walczak⁸, Aleksandra Wesołowska³

¹Maynooth University, Maynooth, Ireland. ²Human Milk Bank Foundation, Warsaw, Poland. ³Warsaw Medical University, Warsaw, Poland. ⁴Italian National Research Council CNR, Turin, Italy. ⁵Oxford University, Oxford, United Kingdom. ⁶University of Bielefeld, Bielefeld, Germany. ⁷University of Turin, Turin, Italy. ⁸University of Warsaw, Warsaw, Poland

Introduction: With the increasing interest in human milk banks, WHO identified the need for global guidelines on the quality and safety of human milk banking, and convened an interdisciplinary international development group in 2022. The WHO Guidelines Development Group (GDG) seven formulated important scientific questions regarding the selection and screening of potential donors, transportation, storage and handling of milk, processing procedures, pasteurization and equitable distribution. Then in the process of developing guidelines for human milk banking from donors, WHO commissioned several systematic reviews which were linked to the considerations of populations, interventions, comparison and outcomes, or PICOs standardised model. Responding to the WHO's call, in November 2023 an international group of experts gathered by the Polish Human Milk Bank Foundation was selected to carry out two reviews. Our team, which has ties to the European Milk Banking Association (EMBA), includes clinical expertise from Poland, Germany, and Italy, along with experts from the biological and social sciences, many of whom have previous experiences with systematic reviews.

Methods: The WHO put a call out for seven questions on which they wanted systematic reviews. We were asked by the WHO to conduct two systematic reviews to answer their questions 5 and 7:

Question 5. What is the impact of feeding expressed breastmilk using varying expression practices/techniques or with treated/pasteurized milk on health and growth outcomes of infants fed their own mothers milk?

Question 7. What is the impact of feeding milk from donors with varying lactation stages, health concerns, varying expression practices/techniques, or with various treatment or testing methods on health and growth outcomes of infants fed donor milk?

Following best practice, we developed a detailed protocol for each of these questions, following the same methods, but specifically addressing the WHO questions. These were then registered on PROSPERO (Q5:IDD = CRD42024523299 Q7ID: CRD42024522015). With permission from the WHO, these protocols have recently been published in the British Medical Journal (BMJ) Open (Klotz, et al, 2024; Gandino, et al, 2025). Currently, again with permission from the WHO, we are preparing versions of the final reports for publication. We conducted the systematic data searches supported by a librarian from the University of Oxford Bodleian Health Care Libraries and received 29207 references for Question 5 and 14937 references for Question 7. We split into two teams, a larger team for Q5 since there were more articles to review. Using the industry leading systematic review software tool Covidence described by Cochrane training to be “the primary screening and data extraction tool for Cochrane authors”. Each title and abstract was reviewed and voted on by two members of the team. We then conducted full text reviews on references for Q5 and Q7. And then the next step was to conduct data extraction for both Q5 and Q7. At the same time, two of the authors with research methods expertise also conducted systematic quality assessment for all references included for data extraction. Each review contacted an ongoing RCT team to obtain yet to be published information. In addition, we conducted qualitative evidence synthesis on several of these studies. All of which contributed to the writing of our final review. Both reviews concentrated on health and growth outcomes for infants, clinical considerations often not part of other research on this topic.

Results: First, the PICOs for Q5 included infants who received expressed mother's own milk, either exclusively or with donor milk or formula, we did exclude studies about infants who received donor milk or formula exclusively, or infants who were exclusively fed at the breast. We determined three sub‐interventions in our review, including 1) mother's milk being expressed in different methods, 2) different hygiene practices or setting used during expression of mother's milk, 3) mother's milk is treated with different methods. And outcomes were breastfeeding status, growth, morbidity and mortality, CMV transmission, HTLV, and feeding tolerance. We did not have any results for hygiene practices or settings. We had limited results about different methods and implications for clinical outcomes, although we had some evidence about the use of hindmilk expression. And finally, most of the research was linked to different methods to treat mother's own milk. For Q7 the participants were defined as infants who received any donor human milk. We broke the WHO question down into 8 interventions, but we only had results for three interventions, including 2) donor characterised by birth outcomes (preterm vs. term), 5) donors are characterised by different health status (acute or chronic illness, BMI), 8) donated milk is treated with different methods (homogenization, concentration/fortification, heat treatment, containers for storage).

Conclusions: For Q5 we have the following conclusions:

• 1.Overall Gaps: nutrient deficiencies and neurodevelopmental outcomes are not covered by the retrieved studies.
• 2.Hindmilk could be useful to optimize the growth of preterm infants before fortification, or in resource‐limited settings.
• 3.Pasteurization is effective in reducing viral transmission but results on tolerance, BPD and ROP should be further investigated.
• 4.Freeze‐thawing is not effective in reducing viral transmission, but this might be due to mixed feeding diets; the effect on BPD and tolerance should be further investigated.

For Q7 we have the following conclusions:

• 1.Our analysis revealed a significant paucity of clinical data for several interventions and a complete lack of evidence for most of our research questions.
• 2.Available Evidence is based on 558 patients, only two RCTs out of those published with results had a reasoned sample size with a power calculation.
• 3.Currently insufficient evidence to assess the clinical efficacy of interventions in question.

We conclude with a discussion about the value of this overall process, including working with the WHO, and working with an interdisciplinary, international team to conduct two systematic reviews of the highest standards to inform global policy makers around the world.

Funding: This study was supported by a grant from the World Health Organization.

Acknowledgement: We are thankful to the back office team at the Human Milk Bank Foundation, the guarantor of this WHO research, including Dominika Sawczuk for financial supervision.

POSTERS

Infant Food Insecurity ‐ A National Approach: From Development to Implementation of a National Toolkit

Gillian McMillan ¹, Carolyn Wilson², Pam Amabile², Emma Williams³

¹NHS Tayside, Dundee, United Kingdom. ²Scottish Government, Edinburgh, United Kingdom. ³NHS Grampian, Aberdeen, United Kingdom

In the UK, Scotland has been the only nation to date to take a national‐level action on infant food insecurity and have led the way in developing a toolkit to provide supportive resources to aid local agencies, front line workers and volunteers in supporting families with infants with money worries, including those who are struggling to afford infant formula, before and at crisis point. This resource was developed through the lens of child poverty, and helps guide agencies and staff to provide support which is appropriate to the needs of these families, taking a cash first approach through providing cash payments or cash equivalents (such as shopping cards). It also explores how to support exclusively breastfed infants who do not need formula milk but the family may need support in other ways to protect breastfeeding and support the mother to continue breastfeeding, or where an infant is fed through a combination of breastfeeding and formula, maximising breastfeeding through sustainable support. NHS Grampian and NHS Tayside have started the journey of implementing pathways locally to respond to and prevent infant food insecurity utilising this toolkit. Their work highlights a number of enablers including, but not limited to; Child Rights being in law, infants being formally recognised as vulnerable and therefore a priority group across national policies and frameworks, the extensive time and effort put into coordinating key actors and working across sectors, capacity building across specialism's and the importance of the Unicef Baby Friendly implementation in the absence of adequate WHO Code legislation.

Psychometric Properties of the Lactation Assessment and Comprehensive Intervention Tool (LAT)

Julie Grady¹, Anna Blair ², Kajsa Brimdyr², Karin Cadwell²

¹Curry College, Milton, USA. ²Healthy Children Project, Harwich, USA

Background: Despite short and long term acknowledged benefits of breastfeeding for mothers and their infants, worldwide rates trail behind international goals. Prior research confirms that problems with latching the baby and painful breastfeeding rank high among the reasons given for not continuing to breastfeed. The Lactation Assessment Tool (LAT^TM) was previously evaluated in a study conducted in Latvia by Nurse Midwives. Use of the LAT to assess breastfeeding and suggesting corrective interventions was shown to promote healing in traumatized nipples and decrease pain. The inter‐rater reliability for that study was by test/retest amongst participating researcher midwives. The aim of the current study is to expand the understanding of LAT inter‐rater reliability to include novice and expert assessors.

Methods: Twenty participants, including both novices and experts, assessed 4 videos of breastfeeding dyads using the assessment tool, the LAT. All elements of the LAT that could be visually evaluated were included, with each element appearing in at least 2 of the videos.

Results: Acceptable internal consistency of the LAT tool was found, with Cronbach's alpha measuring .799, .740, .756 and .735 for each video respectively.

Conclusions: The LAT is a reliable tool for trained novices and experts to assess breastfeeding positioning and latch.

References:

Davra, K., Chavda, P., Pandya, C., Dave, D. and Mehta, K. (2022). Breastfeeding position and attachment practices among lactating mothers: An urban community‐based cross‐sectional study from Vadodara city in western India. Clinical Epidemiology and Global Health, 15, p.101009.

Gavine, A., Shinwell, S.C., Buchanan, P., Farre, A., Wade, A., Lynn, F., Marshall, J., Cumming, S.E., Dare, S. and McFadden, A. (2022). Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of Systematic Reviews, (10).

Joshi, H., Magon, P. and Raina, S. (2016). Effect of mother–infant pair's latch‐on position on child's health: A lesson for nursing care. Journal of Family Medicine and Primary Care, 5(2), pp.309–313.

A Qualitative Study of the Experiences of Lactation Support Providers Who Provided Care During the Initial COVID‐19 Outbreak in the United States

Ellie Mulpeter ¹, Julie Grady², Kajsa Brimdyr³, Karin Cadwell³

¹Academy of Lactation Policy and Practice, South Dennis, USA. ²Curry College, Milton, USA. ³Healthy Children Project, Harwich, USA

Background: The COVID‐19 pandemic disrupted healthcare systems and services including along the childbearing continuum. The aim of this study was to explore the experiences and perceptions of professional lactation support providers who cared for breastfeeding families during the early months of the pandemic (March 2020 – August 2020) in the United States.

Methods: Participants, recruited via email from the national database of Certified Lactation Counselors were asked to describe their experiences during the early months of the COVID epidemic in the United States. Qualitative survey responses were analyzed thematically following the framework method.

Results: 674 Certified Lactation Counselors responded to the survey from June to July of 2022. The overarching theme was the rescinding evidence‐based care and practices that had been in place before the pandemic including limits on access to care and insinuating stigma and bias based on COVID‐19 status: separation of the mother and their infant became the norm. Decisions made by management seemed to be grounded in fear and uncertainty, rather than on the evidence‐based principles that had been in place before the pandemic.

Conclusion: A lack of coordination, consistency and support, along with fear of the unknown, troubled lactation support providers and impacted their ability to provide evidence‐based care and to maintain access to care for all families.

References:

Grady J, Mulpeter E, Brimdyr K, Cadwell K. Rescinding evidence‐based care and practices during the initial COVID‐19 outbreak in the United States: a qualitative study of the experiences of lactation support providers. Front Public Health. 2023 Aug 10;11:1197256. doi: 10.3389/fpubh.2023.1197256. PMID: 37637806; PMCID: PMC10450022.

Perrine, CG, Chiang, KV, Anstey, EH, Grossniklaus, DA, Boundy, EO, Sauber‐Schatz, EK, et al. Implementation of hospital practices supportive of breastfeeding in the context of COVID‐19 — United States, July 15–august 20, 2020. MMWR Morb Mortal Wkly Rep. (2020) 69:1767–70. doi: 10.15585/mmwr. mm6947a3

Renfrew, MJ, Bradshaw, G, Burnett, A, Byrom, A, Entwistle, F, King, K, et al. Sustaining quality education and practice learning in a pandemic and beyond: I have never learnt as much in my life, as quickly, ever. Midwifery. (2021) 94:102915. doi: 10.1016/j. midw.2020.102915

Lancashire and South Cumbria Infant Feeding Network Maternity and Newborn Alliance

Ellen Dicicco, Alexandra Murphy

Lancashire and South Cumbria ICB, Preston, United Kingdom

The Lancashire and South Cumbria Infant feeding network maternity and newborn alliance was set up to address inequalities across the footprint in access to infant feeding support. The aims were to increase skills and knowledge throughout the workforce, to provide increased leadership capacity, increased specialist knowledge and governance. This has been largely achieved by standardising training for staff across the services. Bespoke train the trainer was provider to leads across the organisations. Implementing the BFI accreditation with all trusts across the patch at minimum working towards accreditation, and now some providers having GOLD accreditation. As part of this the ICB funded places for professionals working in health visiting, midwifery, and neonatal services to undertake International Board‐Certified Lactation Consultant training and exams in 2022, these staff continue to work across the different specialities to provide specialist breastfeeding support. There are now specialist breastfeeding clinics in some of the areas with plans to extend this across the patch. The network has developed an infant feeding policy and is currently in the process of reviewing it. The ICB has also commissioned the completion of a service analysis and strategy completion, which will guide further work in addressing inequalities by highlighting where there are gaps in current service. Governance is provided by regular supervision for staff members, regular BFI audit across the services and having an up‐to‐date ratified infant feeding policy to refer to. The network meet bi‐monthly, and have regular clinical supervision sessions. Sharing case studies to constantly reflect on a learn from practice. The ICB are currently composing an ongoing educational plan to support IBCLCs working in practice to maintain their registration. This will support them to attend education sessions, keep up to date with evidencing their work and maintain the knowledge base required to be an IBCLC. The network aims to achieve the best outcomes for families by striving to offer equality of services across the Lancashire and South Cumbria footprint whilst also trying to provide equity and reach seldom heard groups. The professionals involved regularly meet to share best practice. Highlighting where things have worked well and looking at how resource can be shared. The aspiration is to have more user insight into the work of the infant feeding network and a stronger patient voice as we move forward. To provide equity by focusing on projects in areas of greatest need. To do this it is important to continue to support the staff that are leading these programmes and invest in their education while supporting them to grow the infant feeding workforce. This will support further increase in breastfeeding rates and parent knowledge and self‐efficacy across all demographics.

Using Design‐Thinking to Explore Diverse Healthcare Providers’ and Preconception Women's Perceptions of Challenges Associated With Standardizing Breastfeeding Education

Julia Micallef, Adam Dubrowski, Manon Lemonde, Jennifer Abbass‐Dick

Ontario Tech University, Oshawa, Canada

Background: Despite breastfeeding being widely recommended by health authorities for its significant health benefits, breastfeeding rates remain suboptimal, and inadequate resources and support from trained healthcare providers (HCPs) contributes to this. A collaboration between the university, health department, and hospital was established to address the fragmented breastfeeding education offered during the perinatal period. Previous research conducted through this collaboration focused on HCPs' perceptions of an eHealth resource designed to increase parents’ health literacy by providing comprehensive, accessible standardizing breastfeeding education (Abbass‐Dick et al., 2024). Although HCPs acknowledged the resource's quality, they highlighted challenges related to its navigation and usability in clinical settings.

Aim: This project aimed to engage HCPs and preconception women to better understand their experiences with breastfeeding education and identify their needs for more accessible standardized resources.

Methods: The methodology utilized a design‐thinking approach, a user‐centric method focused on human experiences to tackle complex challenges, structured into five phases—empathize, define, ideate, prototype, and test (McLaughlin et al., 2019). The first three phases were explored over two design‐thinking sessions held with HCPs (n = 8), including hospital nurses, lactation consultants, and public health nurses, and preconception women (n = 3). The first session focused on the challenges faced by HCPs, while the second involved both groups in ideating potential solutions.

Results: Key barriers identified included the timing of breastfeeding education, accessibility issues, parents' lack of awareness of the need for breastfeeding education, and inconsistencies within the healthcare system. Participants proposed solutions such as initiating breastfeeding education earlier in the perinatal period, improving resource accessibility through innovative tools, ensuring consistent messaging, and adopting a wellness model for education. Suggestions included having educational resources provide information in engaging, visually appealing ways delivered in small amounts at a time, with scaffolding of information that is easily accessible to meet the learners’ needs. This information should be promoted across clinical and community settings where future parent can assess information on how their body works well before birth. Key topics should include the importance of breastfeeding, frequency of feeds, supply and demand, what to expect, as well as knowing how and when to get help.

Conclusions: The insights from these design‐thinking sessions align with strategies for increasing breastfeeding health literacy suggested by Abbass‐Dick et al. (2023) that include provide accessible resources using multiple modes of information delivery, provide education throughout the perinatal period, have seamless support with consistent messaging across community and hospital settings, and have HCPs engage in discussions to validate parents’ knowledge and misconceptions. Our findings will inform the creation of resources in multiple modes, including technology enhanced resources aimed at supporting HCPs in delivering standardized breastfeeding education throughout the health region.

References:

Abbass‐Dick, J., Dubrowski, A., Micallef, J., Harvie, L., Newport, A., Pigeau, K., Jeronymo, H., Harvie, L., & Lemonde, M. (2024). Health care providers’ perceptions of barriers, facilitators, and acceptability of an eHealth resource: Descriptive study. International Health Trends and Perspectives, 4(1), 68‐87. https://doi.org/10.32920/ihtp.v4i1.1938.

Abbass‐Dick, J., McQueen, K., Lemonde, M., Dubrowski, A., & Dennis, C. L. (2023). Health literacy: A missing link to breastfeeding protection, promotion and support? International Health Trends and Perspectives, 3(3), 365‐374. https://doi.org/10.32920/ihtp.v3i3.1935.

McLaughlin, J. E., Wolcott, M. D., Hubbard, D., Umstead, K., & Rider, T. R. (2019). A qualitative review of the design thinking framework in health professions education. BMC Medical Education, 19, 1‐8. https://doi.org/10.1186/s12909-019-1528-8.

A Targeted Breastfeeding Education for Staff in the Neonatal Setting‐ a Clinical improvement Project

Kajsa Kling

H.R.H. Crown Princess Victoria's Children's Hospital, NICU, Linköping, Sweden

Background: Newborns requiring neonatal care often breastfeed at lower rates compared to other newborns. For sick or prematurely born infants, breast milk is an essential component. The aspirations of parents for successful breastfeeding following the birth of a sick or premature infant are supported by healthcare staff who are proficient in assisting the family in their endeavour. In a neonatal context, an educational initiative needs to be designed to be effective both in delivery and reception. Research indicates that the capacity of mothers to breastfeed preterm infants is influenced by the knowledge and attitudes of healthcare staff regarding breastfeeding. Assistant nurses, who frequently work in close proximity to families, often have limited access to specialized training on this subject. To address this gap, we designed a comprehensive educational initiative combining digital resources with nurse‐led group participation, specifically aimed at assistant nurses working in neonatal intensive care units.

Aim: The aim of this pre‐ and post‐intervention study was to evaluate neonatal intensive care unit (NICU) assistant nurses' confidence in their ability to provide breastfeeding support before and after a targeted breastfeeding education. Thereby increasing the number of infants who are breastfed upon discharge from the neonatal unit.

Methods: This study utilized a pre‐ and post‐intervention design to evaluate the impact of a targeted educational initiative. The Breastfeeding Support Confidence Scale (BSCS), consisting of 11 validated questions, was employed to assess whether the training enhanced assistant nurses confidence in supporting breastfeeding. The educational program consisted of 4 h of individual digital training and 8 h of group‐based training, distributed across 4 sessions. Additionally, demographic data were collected from all participating assistant nurses to contextualize the findings. The quality improvement project was conducted in a neonatal intensive care unit (NICU) in Sweden during 2024. To measure breastfeeding outcomes following hospital discharge, data were obtained from the Swedish Neonatal Quality Registry (SNQ).

Results: As of now, a total of 21 assistant nurses have participated in the educational program. Preliminary data indicate that the training led to an improvement in the assistant nurses' confidence in providing breastfeeding consultations. Furthermore, exclusive breastfeeding rates within the neonatal intensive care unit increased during 2024, suggesting a potential positive impact of the intervention on breastfeeding outcomes.

Conclusions: A combined digital and group‐based educational initiative appears to have a positive effect on assistant nurses' confidence in providing breastfeeding support, as well as on increasing exclusive breastfeeding rates upon discharge from the neonatal intensive care unit (NICU). Looking ahead, the Breastfeeding Support Confidence Scale (BSCS) can be utilized as a screening tool to identify individuals who would benefit the most from targeted educational interventions.

Pregnancy, Birth and Early Parenting Content From Social Media Influencers: A Scoping Review

Lucy Hives, Emma Bray, Rebecca Nowland, Gill Thomson

University of Lancashire, Preston.

Introduction: Social media influencers create a range of health‐related content, including on pregnancy, birth, and early parenting. Influencer content remains unregulated; it can be shared by parents or healthcare professionals (Marsh, Hundley, Luce & Richens, 2023; Ouvrein, 2024) and is often not evidence‐based. There is concern that social media influencers shape women's attitudes and decisions during the first 1000 days (Chee, Capper & Muurlink, 2024) thereby significantly impacting children's health (European Foundation for the Care of Newborn Infants, 2018). It is important that healthcare professionals are aware of the information women and parents are accessing online to ensure adherence to the best available evidence; particularly for those who may be more vulnerable such as younger women, those expecting their first baby, and those where English is not their first language.

This scoping review aimed to map the existing evidence on social media influencers and pregnancy, birth and early parenting content.

Methods: A comprehensive search (co‐designed by mothers and pregnant women) of 10 academic databases and 5 registries was run in July 2024. Primary research studies of influencers or followers creating or accessing pregnancy, birth, and early parenting content were included.

Results: Nineteen studies were included from 14 countries. Studies were published from 2019 to 2024. Instagram was the most studied social media platform. In 15 studies the participants were influencers and in five studies were followers. Two studies included influencers who were healthcare professionals (midwives and obstetrician gynaecologists). Influencer content included parenting, sharenting and family life; marketing; health and exercise; pregnancy and birth; pregnancy loss; and anti‐vaccine content.

Most research focused on how influencers represent family life and how they promote mother‐baby products online. Two papers looked at the impact of influencers promoting mother‐baby products (packaged baby food and environmentally friendly products), with both finding that it was unclear if influencers affected parents’ intentions to buy these products. Two further studies found that influencers in Indonesia and Mexico promote breastmilk substitutes but they may be unaware of why this is problematic.

A survey study of 85 pregnant women and parents in Australia revealed that most felt that influencers had affected their beliefs, decisions and behaviours. Some felt less vulnerable to influencers as their parenting journey progressed. Another survey in Belgium and the Netherlands found that regular exposure to influencers was related to higher parental self‐efficacy for first‐time pregnant women (n = 98), but lower parental self‐efficacy for mothers (n = 652).

Conclusions: Influencers create wide‐ranging content about pregnancy, birth and early parenting. There is limited research in this area, and only four UK studies. More research is needed on parent's experiences of accessing influencer content, and the impact influencers have on parent's attitudes, behaviours and decision‐making throughout pregnancy and early parenting. Due to the rise of healthcare professionals who have an online presence, more research is needed to understand their experiences of creating this content. Education is needed for influencers on their impact and the importance of evidence‐based information. Regulation is vital on issues such as promoting breastmilk substitutes online.

References:

Chee, R. M., Capper, T. S., & Muurlink, O. T. (2024). Social media influencers' impact during pregnancy and parenting: A qualitative descriptive study. Research in nursing & health, 47(1), 7‐16.

European Foundation for the Care of Newborn Infants. Why the first 1000 days of life matter. 2018. Available: www.efcni.org [Accessed 13 Sep 2024].

Marsh, A., Hundley, V. A., Luce, A., & Richens, Y. (2023). The perfect birth: a content analysis of midwives' posts about birth on Instagram. BMC pregnancy and childbirth, 23(1), 422.

Ouvrein, G. (2024). Mommy influencers: Helpful or harmful? The relationship between exposure to mommy influencers and perceived parental self‐efficacy among mothers and primigravida. New Media and Society, 26(4), 2295‐2314.

Developing the Action4Breastfeeding Toolkit to Support Implementation and Evaluation of Evidence‐Based Breastfeeding Support in the NHS

Alison McFadden ¹, Albert Farre¹, Sara Cumming¹, Gillian McManus², Kimberley Davidson²

¹University of Dundee, Dundee, United Kingdom. ²NHS Tayside, Dundee, United Kingdom

Background: The Action4Breastfeeding (A4B) toolkit is the main output of a UK‐wide study that synthesised global and UK evidence on the effectiveness and implementation of breastfeeding support interventions for healthy women and women living with long‐term conditions in the NHS (Gavine et al 2024).

Aims: To codevelop a user‐friendly toolkit to support implementation and evaluation of evidence‐based breastfeeding support in NHS settings.

Methods: The A4B toolkit was co‐developed in two phases. First, a draft toolkit was co‐designed through stakeholder engagement activities, comprising online discussions, a modified Delphi study, focus group discussions and codesign workshops with parents, NHS staff and representatives from third sector organisations providing breastfeeding. In phase two, we refined the content and design of the toolkit with input from a graphic designer and two further codesign workshops, one in person and one online. The workshop attendees engaged in activities to develop and refine the content of the toolkit based on how it could be integrated in existing services. Following the workshops, the toolkit content was finalised and the graphic artist worked with the research team to develop a visually engaging format that could be adapted to be web‐based and as a hard copy manual. Concurrent to the phase two workshops, the prototype toolkit was piloted in an area of high deprivation and low breastfeeding rates in the east of Scotland. Regular meetings between the research team and the NHS team implementing the A4B programme informed further development of the toolkit. Data were collected on breastfeeding rates and are being analysed descriptively.

Results: The final toolkit comprises three sections: (1) A selection of the highest quality evidence‐based components for breastfeeding support services (the A4B programme), including clinical examples and recommendations to meet the needs of women living with long‐term conditions; (2) Recommendations for implementing the A4B programme at team and organisational levels, including suggested materials and guidance to support programme delivery; and (3) Practical considerations for evaluating the A4B programme and suggested appropriate outcomes to be evaluated. The pilot of the A4B programme ran from October 2023 for 12 months. Data on the outcomes and experiences of the pilot are currently being analysed and will be presented.

Conclusions: The A4B toolkit is based on the strongest evidence available for what works to support healthy women and women living with long‐term conditions to breastfeed, and provides evidence‐based recommendation on how to implement and evaluate breastfeeding support. The toolkit is complementary to UNICEF‐UK Baby Friendly Initiative standards and hopefully will support NHS teams and third sector organisations to improve breastfeeding support and increase breastfeeding rates in their local areas.

“I Didn't Want Permission to Stop, I Didn't Want to be Told to Let It Go”: A Qualitative Analysis of Mother's Perspectives on Breastfeeding Support on the Island of Ireland in the Context of Preparing a Plan for Infant and Young Child Feeding in Emergencies

Marina Ferrari, Elizabeth J O'Sullivan, Aileen Kennedy

Technological University Dublin, Dublin, Ireland

Background: Infant and young children feeding (IYCF) can be easily disrupted in emergencies by the lack of access to resources, placing infants at risk. Breastfeeding minimises the need for additional resources and should be promoted in emergencies. However, emergencies impact parents' access to support, hindering adherence to IYCF recommendations. Despite the World Health Organization's call for member states to establish IYCF in Emergencies (IYCF‐E) plans¹, the island of Ireland has yet to implement one.

Aims: To inform on relevant opportunities for improvements for IYCF‐E, this study aims to identify recipients' views on barriers encountered in IYCF support across Ireland to meet breastfeeding goals.

Methods: Semi‐structured interviews were conducted to explore individual experiences and unmet needs in IYCF support. Interviews were transcribed verbatim and analysed by a female lactation consultant on her mid‐30s who has no children using reflexive thematic analysis², focusing on themes relevant to breastfeeding goals and barriers.

Results: Twenty‐one mothers across the island of Ireland were interviewed between September/2023 and August/2024, all with children aged 7 weeks to 5 years who intended to breastfeed, some still breastfeeding. Three themes were generated from the data:

1. The easy way out: This theme explores how breast milk substitutes (BMS) were presented as a convenient solution to early feeding challenges, with mothers feeling their intentions were overlooked. Participants reported easy availability of BMS in hospitals, which was seen as influencing both healthcare providers' and patients' decisions to use it.

“I do remember her just saying 'just go get some formula, this will sort out all your problems'.”

“Whenever anything happens in the hospital (…) [breastfeeding is] the first thing to be killed and you're very much supported in transitioning away from it”

2. Barriers to access support: This theme explores experiences of support not always being available or offered to mothers. Mothers felt these barriers put breastfeeding at risk and often described they "had to persist" to receive support.

“I do feel you have to reach out to [support] (…) and it does feel a little bit like an uphill battle at times.”

3. Navigating mixed feeding: This theme examines the experiences of absence of guidance about combining BMS use with breastfeeding and returning to exclusive breastfeeding after introducing BMS.

“It was hard to find information on combi[nation]‐feeding. So much seemed to be one or the other.”

“But there is not that plan (…) 'we are going to review, we are going to have an exit plan'. There is no exit plan.”

Conclusion: Filling the gaps in breastfeeding support will help mothers who wish to breastfeed to achieve their goals. This is key in enhancing child health and safety while optimising the use of infant feeding resources, particularly during emergencies.

References:

1. Zakarija‐Grković, I., Cattaneo, A., Bettinelli, M.E., Pilato, C., Vassallo, C., Borg Buontempo, M., Gray, H., Meynell, C., Wise, P., Harutyunyan, S. and Rosin, S., 2020. Are our babies off to a healthy start? The state of implementation of the Global strategy for infant and young child feeding in Europe. International breastfeeding journal, 15, pp.1‐12.

2. Braun, V. and Clarke, V., 2021. Thematic analysis: a practical guide. 1st edn. London: SAGE Publications

Mothers’ Experiences of Formula Feeding Support in the UK and Ireland: A Qualitative Systematic Review

Joanne Clarke ¹, Eilish James^2,1, Daniel Lange¹, Kate Jolly¹

¹University of Birmingham, Birmingham, United Kingdom. ²Sandwell MBC, Sandwell, United Kingdom

Background: Breastfeeding has health benefits for infants and mothers, however women decide to formula feed for a variety of reasons, including necessity, external influences, and personal choice. Over two‐thirds of UK mothers feed their baby formula milk in the first 12 months. A 2009 mixed‐methods review found that information and support for mothers who formula feed may put the health of their babies at risk, with unsafe formula‐feeding practices associated with risks of infection and overfeeding (Lakshman et al., 2009), concluding that while it is important to promote breastfeeding, it is also necessary to ensure that the needs of formula feeding mothers are met. The UNICEF UK Baby Friendly Initiative (BFI) highlights support for parents who formula feed. The National Institute for Health and Care Excellence (NICE) postnatal care guidance and quality standards for infant feeding specifies that parents should receive face‐to‐face support during every routine postnatal appointment, with interventions including assistance for those who formula feed.

Aims: This qualitative systematic review aims to explore mothers’ experiences of formula feeding support in the UK and Ireland. Objectives are: 1) identify, summarise, and synthesize available evidence exploring mothers’ experiences of formula feeding support in UK and Ireland, and 2) identify improvements in the provision of support that would increase mothers’ knowledge of and ability to implement safe formula feeding practices.

Methods: A comprehensive search was performed to identify published qualitative studies exploring mothers’ experiences, views and perceptions of formula feeding support in the UK and Ireland from 1992 onwards. Databases searched included Medline, CINAHL, PsychINFO, Web of Science, and ASSIA. Two reviewers carried out the screening, study selection, quality assessment and data extraction. Studies were selected against inclusion criteria and critically appraised using the CASP. Data extraction used a predefined form before thematic synthesis was undertaken.

Results: Twelve studies of medium to high quality were included for analysis from the UK (no studies were found from Ireland), representing the views of 333 women. Fifteen descriptive themes were distributed across five analytical themes: 1) Formula feeding support in practice, 2) Mothers’ perceptions of formula feeding support experiences, 3) Implications for formula feeding practice, 4) Emotional health and wellbeing impact on mother, and 5) Centrality of the Healthcare Practitioner (HCP).

Conclusion: This is the first systematic review to synthesise qualitative studies on UK women's experiences of formula feeding support. In keeping with previous research in other high‐income countries, this study's findings highlight the need to strengthen formula feeding support provided by healthcare professionals, thus safeguarding maternal emotional wellbeing, ensuring safe formula feeding and reducing stigma associated with this practice.

Reference:

Lakshman R, Ogilvie D, Ong KK. Mothers’ experiences of bottle feeding: a systematic review of qualitative and quantitative studies. Arch Dis Child 2009;94:596–601.

Family‐Level Cultural Factors on Breastfeeding Continuation between White and Asian Mothers in Scotland: A Comparative Study

Aliya Nur Zahira

University of Stirling, Stirling, United Kingdom

Background: Breastfeeding is the healthiest infant feeding method for both mother and baby. Unfortunately, many mothers in the world face difficulties in continuing breastfeeding, which can lead them to unwanted stops even at early times (e.g., 2‐8 weeks postpartum). Previous findings revealed that how mothers decide to continue breastfeeding depends much on family‐level determinants, where there are variations of incorporated cultural values and beliefs within different ethnic groups (1‐4). Few of prior studies in Scotland compare its variation across ethnicities.

Aims: This study aimed to identify family‐level cultural facilitators and barriers to breastfeeding continuation between ethnicities in Scotland and to explore how these factors influence a mother's decision to continue breastfeeding for a longer duration.

Methods: Mixed methods study consisted of online survey (n = 178) and follow‐up interview (n = 13) to multi‐ethnic breastfeeding mothers of baby more than 3 months old, living in Scotland, were used. However, only White and Asian mothers could be captured in the interview. Cramer's V, Gamma, Chi‐square test along with multiple linear regression were used to analyse the survey, and thematic analysis was adopted to analyse the interview results.

Results: The correlation results showed that cultural facilitators are more likely to be found in BAME or mixed ethnicities (γ = 0.8893; V = 0.5628; p = 0.000), while White ethnicities tend to have a neutral influence. The model (r2 = 0.31, p = 0.000) implied some sociodemographic factors such as coming from an Asian country, using English and another language at home, and has been living in Scotland for 10‐19 years or 40‐43 years are significant predictors to a longer breastfeeding duration. Social and family encouragement, public acceptance, socioeconomic and religious teachings were found to be cultural facilitators for Asian mothers. White mothers favoured public acceptance and higher quality of health professional support as the facilitators. The potential barriers were discouragement of public and prolonged breastfeeding, and affordability to formula milk; irrespective of ethnicity. Taboo perception of breastfeeding arose as potential barrier specifically in Asian family. All facilitators were found influencing mothers to breastfeed longer by 1) being the first exposure to breastfeeding continuation, 2) positive inspiration, knowledge, and memories, 3) giving substantial help to mother's breastfeeding practice, and 4) helping mothers to normalise breastfeeding continuation.

Conclusions: Specific cultural facilitators and barriers to breastfeeding continuation in White and Asian mothers were found. The way it influences mothers to continue breastfeed may suggests 4 possible promising strategies to improve breastfeeding continuation rates across Scotland: Underlining the health and psychological benefits of prolonged breastfeeding, improving public attitude to public prolonged‐breastfeeding, normalising breastfeeding older baby through media exposure; added with acknowledging religious teaching and engaging family members in the breastfeeding discussion specifically for Asian family. This study offers an invaluable knowledge‐transfer both between ethnicities, specifically Asian and White group, and to the health professional and policymaker to optimise breastfeeding continuation rates and benefits in Scotland.

References:

Chang, Y.S., Li, K.M.C., Li, K.Y.C., Beake, S., Lok, K.Y.W. and Bick, D. (2021). Relatively speaking? Partners' and family members’ views and experiences of supporting breastfeeding: a systematic review of qualitative evidence. Philosophical Transactions of the Royal Society B, 376(1827), p.20200033.

Marvin‐Dowle, K., Soltani, H. and Spencer, R. (2021). Infant feeding in diverse families; the impact of ethnicity and migration on feeding practices. Midwifery, 103, p.103124.

Snyder, K., Hulse, E., Dingman, H., Cantrell, A., Hanson, C. and Dinkel, D. (2021). Examining supports and barriers to breastfeeding through a socio‐ecological lens: a qualitative study. International Breastfeeding Journal, 16(1), pp.1‐8.

Rajkumar, R.P. (2023). The relationship between national cultural dimensions, maternal anxiety and depression, and national breastfeeding rates: An analysis of data from 122 countries. Frontiers in Communication, 8, p.966603.

Factors Influencing Mother's Infant Feeding Decisions in the United Kingdom: A Rapid Review and Qualitative Synthesis Using the COM‐B System and Theoretical Domains Framework

Alaw Thomas‐Davies, Rachel Bath

Public Health Wales, Cardiff, United Kingdom

Background: Breastfeeding is important for infant and maternal health and can mitigate health inequalities. Despite WHO recommendations breastfeeding rates in Wales are concerningly low. Numerous systematic reviews have explored the reasons for low breastfeeding rates internationally. However, a review of how the attitudes, values, and beliefs of UK mothers may present barriers to or facilitate decisions to breastfeed and how these relate to behaviour change theory to inform intervention development and implementation is lacking.

Aim: This study aims to describe the qualitative evidence regarding the attitudes, values and beliefs of mothers using the Behaviour Change Wheel (BCW) as a framework and provide behavioural science informed recommendations to address low breastfeeding rates in Wales.

Method: A systematic literature search was carried out in six databases. Identified studies underwent title and abstract screening and critical appraisal. Included studies underwent thematic analysis and codes were mapped to the COM‐B Model and the Theoretical Domains Framework (TDF).

Results: Sixteen UK qualitative studies were included. A total of 272 coded items pertaining to barriers and 193 coded items pertaining to facilitators were extracted, generating 35 themes which were mapped to 10 of the 14 TDF domains. The most reported barrier‐related themes were support from family, realistic expectations of breastfeeding, infant feeding culture, feelings about breastfeeding in public. The most reported facilitator‐related themes were support from peers, support from health care professionals and access to the resources needed for breastfeeding. Inductive themes were coded most frequently to the following TDF domains: 1) Social influence; 2) Beliefs about consequences; 3) Environmental context and resources; 4) Emotions; 5) Beliefs about capability; 6) Knowledge and 7) Memory, attention, and decision‐making processes.

Conclusions: This review highlighted the complex nature of women's behaviours regarding infant feeding and the need for interventions to be comprehensive, considering the interplay between domains. Understanding influences through the lens of the TDF lays the groundwork for a comprehensive behavioural analysis to develop targeted interventions to promote breastfeeding and improve breastfeeding rates in Wales.

Commercial Baby Foods: Nutrition, Marketing and Motivations for Use. A Narrative Review

Jasmine Brand‐Williamson ^1,2 , Ada L. Garcia², Alison Parrett², Vicky Sibson¹

¹First Steps Nutrition Trust, London, ²University of Glasgow

Background: In 2019, Public Health England¹ (PHE) identified that UK commercial baby foods (CBFs) failed to promote healthy diets, recommending improved nutrient composition, reduced sugar, particularly in snacks, and limiting misleading marketing and labelling. The UK's CBF market continues to grow and is valued at £774 million in 2023, £70 million more than the previous year². The complementary feeding period is crucial for optimal growth and development. Currently, one in eight UK toddlers are living with obesity before they start school³. As such, there is a public health need to ensure children gain a healthy start in life and reduce childhood obesity prevalence. Considering new research since 2019, this study aimed to consolidate the literature relevant to the UK's CBF market and policy environment to determine progress since PHE's 2019 recommendations.

Aims: We aimed to summarise, evaluate and appraise the literature on CBFs in the UK, Europe, Australia and New Zealand published between 2019 and 2024.

Methods: A systematic PubMed and Web of Science search was conducted on three CBF topics; 1) Nutritional Composition, Flavour Profile and Texture, 2) Marketing and Labelling, and 3) Parental Choice and Preferences. Studies were included if conducted in English in the UK, Europe, Australia and New Zealand and published between 2019 and early 2025, and on CBFs for children aged 0‐36 months.

Results: Out of 3,143 studies screened, 31 full papers were separated into three topics and reviewed.

Topic 1: Out of all products sampled, 56% were pureed and 18% were snacks. The median sugar content per 100 g (IQR) was 10.4 g(1.0) in purees, 20.3 g (9.9) in snacks in snacks, and 14.7 g (14.4) in cereals. Nearly half of all products in n = 13 studies contained added or free sugars, and 62% when looking at snacks alone (n = 6 studies).

Topic 2: Six out of 9 studies had ‘no added sugar’ claims, and eight studies reported finding claims related to health or nutrition.

Topic 3: All studies reported that health/development/nutrition were motivations to purchase CBFs, and 75% mentioned ‘baby's enjoyment’, ‘convenience/time’, and ‘safety’. Conclusions

Conclusions: This narrative review highlights that despite PHE's advice in 2019 to improve the nutritional composition, marketing, and labelling of CBFs, the same recurring issues remain. Purees and snacks dominate the market, and snacks are especially high in sugar. Marketing claims are misleading and exploit parents’ fears to motivate use. Policy improvements regarding CBFs are necessary to enable parents/carers to make informed decisions when feeding their children. These include strengthened, mandatory nutritional composition, marketing and labelling regulations, independent monitoring and enforcement, and clarifying NHS complementary feeding advice.

References:

1. Public Health England. (2019). Foods and drinks aimed at infants and young children: evidence and opportunities for action.

2. Mintel. (2024). UK Baby Food and Drink Market Report 2024

3. NHS England. One in eight toddlers and primary school aged children obese Retrieved December 2024 from https://www.england.nhs.uk/2024/09/one-in-eight-toddlers-and-primary-school-aged-children-obese/.

Peer Support and Community Interventions Targeting Breastfeeding: Systematic Review

Rhiannon Evans ¹ , Caitlyn Donaldson¹, Rabeea'h Aslam¹, Joelle Kirby², Sophie Robinson², Joanne Clarke³, Stephanie J Hanley³, Siang Lee³, Joht Singh Chandan³, Ruth Garside², Jo Thompson‐Coon², Kate Jolly³, Kath Maguire², Sean Harrison², G.J. Melendez‐Torres²

¹Cardiff University, Cardiff, United Kingdom. ²University of Exeter, Exeter, United Kingdom. ³University of Birmingham, Birmingham, United Kingdom

Background: Rates of breastfeeding remain low in the UK, with variations between population groups. Peer and community interventions are intended to increase breastfeeding, but there is limited understanding if they cause inequities in participants’ experiences.

Aims: We conducted a systematic review synthesizing qualitative evidence from the UK to understand: 1) What social characteristics are relevant to participants’ experiences of interventions? and 2) How are participants’ experiences influenced by different social characteristics?

Methods: The scope of the review was informed through stakeholder consultation with women (n = 7) and peer supporters (n = 6). Searches of nine databases updated an existing systematic review. We screened relevant systematic reviews and undertook citation tracking. We conducted framework synthesis and assessed certainty of evidence with GRADE‐CERQual.

Results: Fifty‐five studies, with 68 linked reports, were included. Inequity generating experiences were identified across the course of intervention participation: 1) Lack of information about intervention eligibility and culturally appropriate recruitment procedures; 2) Limited accessible provision for continued attendance; 3) Inadequate consideration of participation needs related to socioeconomic status, socio‐cultural background, physical characteristics, and individuals’ breastfeeding journeys; and 4) Enduring structural barriers (e.g. community norms) to breastfeeding inhibiting sustained behaviour post‐intervention.

Conclusion: Evidence suggests that differential intervention experiences may lead to inequities in outcomes, particularly among individuals from different socioeconomic and ethnic backgrounds. Peer and community provision needs to be tailored to the social characteristics of different underserved populations. Future qualitative research needs to move beyond participants’ general intervention experiences and consider specific issues pertaining to recruitment, drop‐out and post‐intervention behavioural maintenance.

Mapping Digital Data Management Systems for Donor Human Milk Services Globally

Tanya Cassidy ¹, Rudolf Ascherl,², Tuan Nguyen³

¹Maynooth University, Maynooth, Ireland. ²University of Liepzig, Liepzig, Germany. ³Alive & Thrive, Ha Noi, Vietnam

Introduction: Donor human milk is one of the oldest medically controlled health services, and in this century, has been expanding exponentially globally (Cassidy and Dykes, 2019). As part of this service ideal monitoring management systems have long been advocated, originally pen and paper based, but increasing part of the digital health service expansion occurring around the world. By looking at this service we can have a detailed view of both benefits and potential difficulties associated with the complex transformations occurring around the world with digital health monitoring management systems.

Aims: Our research aims to explore the platforms used for the monitoring systems of human milk banks (HMBs) worldwide. Specifically, for each HMB, we examine:

• 1.The overall functions of the HMB.
• 2.The description and functions of the HMB monitoring system.
• 3.The facility where the HMB is hosted.

The information gathered will be used to enhance knowledge and interventions aimed at improving the global HMB network. The aggregated global, regional, and national findings will be shared with all countries. These findings can also be disseminated through presentations, briefs, and a peer‐reviewed publication. Given the nature of this study, we follow the Checklist for Reporting Results of Internet E‐Surveys (CHERRIES), adapted from Eysenbach (2004). In addition, we consider key features argued to be part of best practice for online survey research connected with breastfeeding studies (Ball, 2019). The study was conducted in accordance with the guidelines of the Declaration of Helsinki (World Medical Association, 2001), following approval by the Institutional Review Boards of FHI 360 and Leipzig University. The first page of the questionnaire includes an introduction outlining the study's purpose, procedures, and requirements, as well as details on data protection and usage. Participants' consent was indicated by their decision to continue with the survey.

Methods: We created an online survey using MS Forms, hosted and secured on the SharePoint of Tanya M. Cassidy at Maynooth University, Maynooth, Ireland (the presenting author). Only three key researchers/authors (Tuan Nguyen, Tanya M. Cassidy, and Rudolf Georg Ascherl) have access to the editable survey form. We tested the questionnaire in both paper‐based and web‐based formats (using a public link) with key experts in HMB. This included checking the clarity after being Google translated into other languages spoken by countries with many HMBs. We then revised and finalized the questionnaire based on comments and suggestions from the key experts. Upon completing the revisions to the draft questionnaire, cleared the data from the online form in preparation for the start of the survey. The survey was made available online from January 2025 for 9 weeks. There are more than 700 HMBs globally. Given there were no updated and reliable list of HMB, and contacts and people would more likely be responding to survey when it is suggested by someone they know. We have identified and engaged with key stakeholders in various regions and countries and promoted the survey through them. If key stakeholders in select countries or regions could not be identified, we looked for alternative lists of HMBs in the public domain or through personal connections. We will then send the survey to them. The survey was directed toward target HMBs. Respondents are staff from each HMB, aged 18 years or older. Data will be exported from Microsoft Forms to an Excel file for further visualization and analysis. We will use the Power Pivot function in Microsoft Excel to summarize the data and create relevant figures, with the data presented in tables as rounded percentages (%). The response rate will be calculated as the total number of records received from the 700 potential HMBs globally. Descriptive statistics will be based on the sample of those who submit the questionnaires, excluding any unanswered questions from the analysis. Since we are not attempting to generalize these descriptive findings, we will not perform any statistical corrections, such as item weighting or propensity score adjustments, to account for the nonrepresentative sample. These data will also be analysed using theoretical concepts presented between the interface of Anthropology and Science, Technology and Society (STS), where global dialogs and interdisciplinary exchanges are key (de la Cadena, et al, 2015).

Conclusion: Digital health monitoring systems are an important part of the future of health services globally. Not only with this help to potentially improve patient outcomes, and enhance preventative care, but it will also increase equity of access while also potentially reducing costs. By looking at the specific case of donor human milk services globally we can add not only to the knowledge connected to this increasingly recognized lifesaving intervention, but also for society in general by supporting breastfeeding, which is a key catalyst needed for this service. At the same time, studying digital health monitoring systems globally can illuminate potential risks associated with this type of research, including needs to safeguard privacy, consider ethical issues. We also need to take care not to become over reliant on technology and create technology divides around the world. In addition, we need to be careful not to create data overloads, for often already stretched healthcare providers. By studying donor human milk service management systems globally, we can not only improve this service, but potentially present key lessons for more general discussions about digital health monitoring. Finally, this study will validate the list and contact information of the global HMB network to facilitate knowledge sharing and further research.

References:

Ball HL. Conducting Online Surveys. Journal of Human Lactation. 2019;35(3):413‐417. doi:10.1177/0890334419848734.

Cassidy, T., & Dykes, F. (2019). Banking on Milk: An Ethnography of Donor Human Milk Relations (1st ed.). Routledge. https://doi.org/10.4324/9780203713051.

de la Cadena, M., Lien, M. E., Blaser, M., Jensen, C. B., Lea, T., Morita, A., Swanson, H., Ween, G. B., West, P., & Wiener, M. (2015). Anthropology and STS: Generative interfaces, multiple locations. HAU: Journal of Ethnographic Theory, 5(1), 437–475. doi:10.14318/hau5.1.020.

Eysenbach G. Improving the Quality of Web Surveys: The Checklist for Reporting Results of Internet E‐Surveys (CHERRIES). J Med Internet Res 2004;6(3):e34. doi:10.2196/jmir.6.3.e34.

The European Parliament and The Council of the European Union. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation). https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32016R0679.

World Medical Association. (‎2001)‎. World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects. Bulletin of the World Health Organization, 79 (‎4)‎, 373‐374. World Health Organization. https://iris.who.int/handle/10665/268312.