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Background: Suboptimal breastfeeding results in 800 000 child deaths annually. There are multiple causes of suboptimal breastfeeding, including marketing of breast-milk substitutes. Objectives: To describe sales and marketing of breast-milk substitutes and their influence on World Health Organization-recommended breastfeeding behaviors, focusing on low-and middle-income countries. Methods: Literature review. Results: Global sales of breast-milk substitutes reached US$40 billion in 2013. Growth in sales exceeds 10% annually in many low-and middle-income countries, while it is close to stagnant in high-income countries. Breast-milk substitutes are marketed directly to consumers via mass media and print advertisements and indirectly via incentives, free supplies, and promotions to and through health workers and facilities, retailers, and policy makers. Internet marketing via company web sites and social media is on the rise. Marketing influences social norms by making formula use seem to be extensive, modern, and comparable to or better than breast milk. Clear evidence of a negative impact is found when breast-milk substitutes are provided for free in maternity facilities and when they are promoted by health workers and in the media. Influences through other channels are plausible, but rigorous studies are lacking. It was not possible with the data available to quantify the impact of marketing relative to other factors on suboptimal breastfeeding behaviors. Marketing remains widespread even in countries that have adopted the International Code of Marketing of Breast-milk Substitutes to restrict such activities. Conclusion: Adoption of stricter regulatory frameworks coupled with independent, quantitative monitoring and compliance enforcement are needed to counter the impacts of formula marketing globally.

Concerns about the increasing rates of obesity in developing countries have led many policy makers to question the impacts of maternal and early child nutrition on risk of later obesity. The purposes of the review are to summarise the studies on the associations between nutrition during pregnancy and infant feeding practices with later obesity from childhood through adulthood and to identify potential ways for preventing obesity in developing countries. As few studies were identified in developing countries, key studies in developed countries were included in the review.Poor prenatal dietary intakes of energy, protein and micronutrients were shown to be associated with increased risk of adult obesity in offspring. Female offspring seem to be more vulnerable than male offspring when their mothers receive insufficient energy during pregnancy.By influencing birthweight, optimal prenatal nutrition might reduce the risk of obesity in adults. While normal birthweights (2500-3999 g) were associated with higher body mass index (BMI) as adults, they generally were associated with higher fat-free mass and lower fat mass compared with low birthweights (<2500 g). Low birthweight was associated with higher risk of metabolic syndrome and central obesity in adults.Breastfeeding and timely introduction of complementary foods were shown to protect against obesity later in life in observational studies. High-protein intake during early childhood however was associated with higher body fat mass and obesity in adulthood.In developed countries, increased weight gain during the first 2 years of life was associated with a higher BMI in adulthood. However, recent studies in developing countries showed that higher BMI was more related to greater lean body mass than fat mass. It appears that increased length at 2 years of age was positively associated with height, weight and fat-free mass, and was only weakly associated with fat mass.The protective associations between breastfeeding and obesity may differ in developing countries compared to developed countries because many studies in developed countries used formula feeding as a control. Future research on the relationship between breastfeeding, timely introduction of complementary feeding or rapid weight gain and obesity are warranted in developing countries.The focus of interventions to reduce risk of obesity in later life in developing countries could include:1. improving maternal nutritional status during pregnancy to reduce low birthweight; 2. enhancing breastfeeding (including durations of exclusive and total breastfeeding); 3. timely introduction of high-quality complementary foods (containing micronutrients and essential fats) but not excessive in protein; 4. further evidence is needed to understand the extent of weight gain and length gain during early childhood are related to body composition in later life.

This paper examines the usefulness of various anthropometric classification systems of nutritional status in prognosticating the subsequent risk of mortality among 2019 children aged 13 to 23 months residing in a rural area of Bangladesh. The indices investigated included: weight-for-age; weight-for-height; height-for-age; arm circumference-for-age; arm circumference-for-height; weight quotient; and height quotient. Cross-sectional anthropometry was conducted during October 1975 to January 1976 and the mortality experience of the study children was followed prospectively over 24 months. Results indicated that severely malnourished children, according to all indices, experienced substantially higher mortality risk. Normal, mild, and moderately malnourished children all experienced the same risk. All indices were found to discriminate mortality risk; weight/age and arm circumference/age were strongest and weight/height weakest. For each index, a threshold level was noted below which mortality risk climbed sharply. The discriminating power of anthropometry was enhanced when maternal weight, maternal height, or housing size were included.

Omega-3 and omega-6 fatty acids, particularly docosahexaenoic acid (DHA), are known to play an essential role in the development of the brain and retina. Intakes in pregnancy and early life affect growth and cognitive performance later in childhood. However, total fat intake, alpha-linolenic acid (ALA) and DHA intakes are often low among pregnant and lactating women, infants and young children in developing countries. As breast milk is one of the best sources of ALA and DHA, breastfed infants are less likely to be at risk of insufficient intakes than those not breastfed. Enhancing intake of ALA through plant food products (soy beans and oil, canola oil, and foods containing these products such as lipid-based nutrient supplements) has been shown to be feasible. However, because of the low conversion rates of ALA to DHA, it may be more efficient to increase DHA status through increasing fish consumption or DHA fortification, but these approaches may be more costly. In addition, breastfeeding up to 2 years and beyond is recommended to ensure an adequate essential fat intake in early life. Data from developing countries have shown that a higher omega-3 fatty acid intake or supplementation during pregnancy may result in small improvements in birthweight, length and gestational age based on two randomized controlled trials and one cross-sectional study. More rigorous randomized controlled trials are needed to confirm this effect. Limited data from developing countries suggest that ALA or DHA supplementation during lactation and in infants may be beneficial for growth and development of young children 6-24 months of age in these settings. These benefits are more pronounced in undernourished children. However, there is no evidence for improvements in growth following omega-3 fatty acid supplementation in children >2 years of age.

To evaluate programmatic efforts to improve dietary intake and growth in 6-to 12-month-old

Undernutrition in infants and young children is a global health priority while overweight is an emerging issue. Small-scale studies in low- and middle-income countries have demonstrated consumption of sugary and savoury snack foods and soft drinks by young children. We assessed the proportion of children 6–23 months of age consuming sugary snack foods in 18 countries in Asia and Africa using data from selected Demographic and Health Surveys and household expenditures on soft drinks and biscuits using data from four Living Standards Measurement Studies (LSMS). Consumption of sugary snack foods increased with the child's age and household wealth, and was generally higher in urban vs. rural areas. In one-third of countries, >20% of infants 6–8 months consumed sugary snacks. Up to 75% of Asian children and 46% of African children consumed these foods in the second year of life. The proportion of children consuming sugary snack foods was generally higher than the proportion consuming fortified infant cereals, eggs or fruit. Household per capita daily expenditures on soft drinks ranged from $0.03 to $0.11 in three countries for which LSMS data were available, and from $0.01 to $0.04 on biscuits in two LSMS. Future surveys should include quantitative data on the purchase and consumption of snack foods by infants and young children, using consistent definitions and methods for identifying and categorising snack foods across surveys. Researchers should assess associations between snack food consumption and stunting and overweight, and characterise household, maternal and child characteristics associated with snack food consumption.

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