Infant Feeding Policy Research Articles

Breast or bottle?: contemporary controversies in infant feeding policy and practice

Breast or bottle?: contemporary controversies in infant feeding policy and practice

‘The midwives aren't allowed to tell you’: Perceived infant feeding policy restrictions in a formula feeding culture – The Feeding Your Baby Study

Objectiveto explore the expectations and experiences of postnatal mothers in relation to infant feeding, and to identify how care could be improved. Designthis study used a qualitative, exploratory, descriptive design. Data were collected through one to one in-depth semi-structured interviews and focus groups. SettingTayside area of Eastern Scotland. Participantsseven focus group interviews (n=38 participants) and 40 semi-structured one-to-one interviews with mothers with a range of infant feeding experiences i.e. exclusively breast fed; started breast feeding but changed to formula milk before 16 weeks; exclusively formula fed; or who concurrently breast and formula fed their infant. Findingsa principal theme of ‘Mixed and missing messages’ emerged, incorporating ‘Conflicting advice’, ‘Information gaps’ and ‘Pressure to breast feed’ with a secondary theme of ‘Emotional costs’. Several problems were identified with how women were given information, how infant feeding discussions were held, and the type of support available after the infant is born. Key conclusionsthere was a strong perception that some midwives are not ‘allowed’ to discuss or provide information on formula feeding, and the women reported feeling pressurised to breast feed. Current interpretation of guidance from the UNICEF UK Baby Friendly Initiative may be restricting antenatal discussions about infant feeding. The combination of this partial preparation antenatally and postnatal support that was often inconsistent seems to incur a counter-productive emotional cost. Implications for practiceat strategic, policy and practice levels the infant feeding message needs to change to encourage a more woman-centred focus including discussions about the realities of all types of infant feeding. It is important that health providers continue to promote and support breast feeding; and that effective services are provided to women who wish to breast feed to help them to do so. However provision of information about all aspects of feeding is needed as well as support for women who do not wish to breast feed.

“What Feels Right”: Affect, Emotion, and the Limitations of Infant-Feeding Policy

This article explores the place of “feeling” in women's decisions around infant feeding (and specifically long-term breastfeeding). The argument is that policymakers and academics often overlook feeling (or an affective/emotional perspective) in favor of a focus on “informed choice” as a means of understanding and influencing behavior in this area of social life. In exploring the relationship between ideologies and bodily practices, this article therefore suggests that attention to affect and emotion might be useful in coming to a more nuanced view of how, why, and when individuals make the decisions that they do. Rather than advocating policymaking in this intimate sphere, however, the intention is to consider some of the implications of this approach for academic work around individual decision making and the regulation of society more broadly.

Achieving Baby Friendly Status Through a National Collaborative

Newborn Care Poster Presentation Purpose for the Program The National Initiative for Children's Healthcare Quality (NICHQ), working closely with Baby‐Friendly USA, has formed a nationwide collaborative titled Best Fed Beginnings. The collaborative awarded participation to 90 hospitals. The goal of the project is for hospitals to implement evidence‐based quality improvements to their maternity care services that result in increased breastfeeding support for mothers and their infants. Participation in this collaborative will help hospitals achieve Baby Friendly status. We describe the journey of Sharp Mary Birch Hospital for Women & Newborns in this collaborative from the application process through actual designation. Proposed Change Involvement in the collaborative is focused on applying the 10 steps to successful breastfeeding as outlined by Baby‐Friendly USA. Imperative to success is engaging an interdisciplinary team at the hospital, including a mother from the community. Another essential component is the collaborative hospital team's attendance at three learning sessions over the 22‐month project. Connecting with other participating hospital teams allows for sharing of best practice strategies, identifying lessons learned, overcoming common barriers, and expediting the Baby Friendly designation process. Implementation, Outcomes, and Evaluation Immersion into the collaborative began in June 2012. Established outcomes were identified and were evaluated monthly during the project: (a) 80% of staff caring for healthy mother–baby couplets will receive training on lactation support; (b) the infant feeding policy will be compliant with Baby Friendly guidelines; (c) 100% of staff will complete documentation of pertinent breastfeeding information; (d) ongoing data collection will be automated with the electronic medical record; (e) all breast milk substitutes and supplies will be purchased; and (f) 90% of healthy infants will be exclusively breastfed from birth to discharge. Implications for Nursing Practice Literature is replete with the extensive benefits of breastfeeding for mothers, infants, and society. Numerous studies also indicate that exclusive breastfeeding during the early postpartum stay is one of the most influential indicators on duration of breastfeeding after discharge. Hospitals that are designated as Baby Friendly have a demonstrated increase in exclusive breastfeeding rates compared with nondesignated hospitals. Participating in a national collaborative will assist with increasing exclusive breastfeeding rates by culturally changing the breastfeeding practices for healthcare providers and consumers. Subsequently, this will assist the entire United States in meeting the Healthy People 2020 goals.

Non-compliance with the International Code of Marketing of Breast Milk Substitutes is not confined to the infant formula industry

Infant feeding policy and practice continues to be a contentious area of global health care. The infant formula industry is widely considered to be the bête noire with frequent claims that they adopt marketing and sales practices that are not compliant with the WHO Code. However, failure to resolve these issues over three decades suggests that there may be wider systemic failings. Review of published papers, commentaries and reports relating to the implementation and governance of the WHO Code with specific reference to issues of non-compliance. The analysis set out in this paper indicates that there are systemic failings at all levels of the implementation and monitoring process including the failure of WHO to successfully 'urge' governments to implement the Code in its entirety; a lack of political will by Member States to implement and monitor the Code and a lack of formal and transparent governance structures. Non-compliance with the WHO Code is not confined to the infant formula industry and several actions are identified, including the need to address issues of partnership working and the establishment of governance systems that are robust, independent and transparent.

Commentary: Stewart Forsyth's article - Non-compliance with the International Code of Marketing of Breast Milk Substitutes is not confined to the infant formula industry

In this paper the author implies that there is no hard evidence demonstrating consistent violations of the International Code by the baby food industry, despite the regular monitoring reports published by the International Code Documentation Centre (ICDC) (http://ibfan.org/ icdc/). And it must be pointed out that there is more than ‘an assumption’ that the baby food industry plays a part in decreasing breastfeeding rates. Studies have found that when frequency of adverts for artificial feeding increased, percentage change in breastfeeding rates decreased, while a 2006 review by the US Congressional Accountability Office found a majority of studies that examine giving free formula samples to mothers at hospital discharge found lower breastfeeding rates among mothers receiving samples. No one denies that the Code includes recommendations for stakeholders other than the baby food industry. There is also no argument that some of these stakeholders have failed as duty bearers to protect the best interest of the child. But when it comes to unethical marketing and the ensuing harm to infant and young child health, the fault must lie solely with industry. What the author describes as a ‘systematic deficiency’ in a ‘multi-stakeholder’, ‘multi-layered process’ is no excuse for the baby food industry to not comply with the minimum standard set by the International Code. Forward looking companies recognise that compliance is the price of doing business and are developing governance, risks and compliance initiatives to ensure greater corporate accountability. The baby food industry should not be looking for excuses or soft alternatives where Code commitments are concerned. FTSE4Good is one glaring example of a soft alternative. While the author points to it as an interesting initiative addressing governance of infant formula manufacturers through its breastmilk substitute criteria, many critics point out that the FTSE4Good criteria were actually weakened to allow a well-known Code violating company like Nestle to gain access to this ethical investment index, while still engaging in marketing practices prohibited by the Code. Just like Nestle (and lately Danone), the FTSE criteria now introduce a false distinction between high-risk countries (those with at least 10 per 1000 under five mortality rate) where they require an ‘acknowledgement that the adoption and adherence to the Code is a minimum requirement’ and the rest of the world where they don’t. The author endorses the Nestle/Danone /FTSE approach on the assumption that global infant feeding policy is oriented towards the poorest of nations and finds it illogical that all nations should commit to the same recommendations. This is contrary to the World Health Assembly’s position that the International Code is global and applies in all countries, since parents and infants in industrialised countries deserve the same level of protection from inappropriate and unethical marketing as those in developing nations. Interestingly, the author ignores the 2012 UNICEF-commissioned report from his own country which shows that low breastfeeding rates in the UK lead to an increased incidence of illness with significant cost to the health service. Even a moderate increase in breastfeeding rates could save £40 million in the UK health budget. If that is not considered significant for a policy review on Code implementation, one can only speculate as to what interests are at play. See also Pediatircs which reported that if 90% of US families comply with recommendations to breastfeed exclusively for 6 months, the US would save $13 billion and prevent more than 911 deaths per year.

Challenges in the implementation of the Infant and Young Child Feeding policy to prevent mother-to-child transmission of human immunodeficiency virus in the Nelson Mandela Bay District

Objective: To assess the Infant and Young Child Feeding (IYCF) policy implementation among healthcare workers working at the Nelson Mandela Bay District (NMBD) public healthcare facilities.Design: Descriptive survey using quantitative closed structured questionnaires.Setting: Nursing professionals (n = 32) rendering maternal and child health services in 19 permanent NMBD clinics were included in a convenience sample in October 2011.Method: The closed, structured questionnaire was developed based on statements contained within the 2007 IYCF policy and administered by one interviewer. Ethics approval was obtained and respondents had to provide informed written consent. Data were analysed by means of descriptive and differential statistics.Results: Sixty-three per cent of nursing professionals were older than 40 years of age and more than half had already completed the Integrated Management of Childhood Illness (IMCI) and 20-hour IYCF training course. Respondents achieved a high mean score of 8.07 on knowledge of infant feeding in the context of human immunodeficiency virus (HIV). However, no association could be demonstrated between knowledge scores and previous training. Despite high scores on perceptions of the importance of IYCF counselling, 56% of the participants reported that they had never seen the IYCF policy before.Conclusion: Relevant training in IYCF in the context of HIV, the availability of IYCF policy guidelines and monitoring of counselling and training of health professionals and volunteers, are some of the challenges that need to be addressed to improve implementation of IYCF policy in the NMBD district.

Free formula milk in the prevention of mother-to-child transmission programme: voices of a peri-urban community in South Africa on policy change

In 2001, South Africa began implementing the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme. This programme included distribution of free formula milk for infants up to 6 months of age at all public health facilities. Effective from 1 January 2011, KwaZulu-Natal became the first province to phase out free formula milk from its PMTCT programme. On 23 August 2011, the South African National Department of Health adopted promotion of exclusive breastfeeding as the national infant feeding strategy and made a decision to withdraw free formula milk from the PMTCT programme. To explore the perceptions and understanding of households at community level on the policy decision to phase out free formula milk from the PMTCT programme in South Africa. An exploratory qualitative study was conducted amongst women enrolled in a community randomized trial known as Good Start III. Focus group discussions were held with grandmothers, fathers and teenage mothers; and in-depth interviews were performed with HIV-positive and HIV-negative mothers. Data were analysed using thematic analysis. Identified themes included: (1) variations in awareness and lack of understanding of the basis for the policy change, (2) abuse of and dysfunctional policy as perceived reasons for policy change and (3) proposed strategies for communicating the policy change. There is an urgent need to develop a multifaceted communication strategy clearly articulating the reasons for the infant feeding policy change and promoting the new breastfeeding strategy. The communication strategy should take into account inputs from the community. With a supportive environment and one national infant feeding strategy, South Africa has an opportunity to reverse years of poor infant feeding practices and to improve the health of all children in the country.

HIV and infant feeding in Malawi: public health simplicity in complex social and cultural contexts

BackgroundThe question of when and how to best wean infants born to mothers with HIV requires complex answers. There are clinical guidelines on best approaches but limitations persist when applying them in diverse low-income settings. In such settings, infant-feeding practices are not only dependent on individual women’s choices but are also subject to social and cultural pressures. However, when developing infant-feeding policies little attention has been paid to these pressures, even though they may yield useful empirical knowledge on the various forces that shape the infant-feeding dilemmas confronting women with HIV. This study aimed to a) identify the infant-feeding challenges that women with HIV faced when they were advised to wean their children at an early age of six months and b) explore how the women adhered to their infant-feeding options while facing and managing these challenges.MethodsThis study was conducted between February 2008 and April 2009 at two public health facilities where services to prevent mother-to-child transmission of HIV were implemented. Repeated in-depth interviews were conducted with 20 HIV-positive women. Two of the 20 women were also chosen for case studies which included home visits.ResultsSeveral interdependent factors including the conflicting pressures of sexual morality and the demands of nurturing and motherhood, in conditions of abject poverty, impeded the participating women from following medical advice on infant feeding. If they adhered to the medical advice, the women would encounter difficulty maintaining their ascribed roles as respected wives, mothers and members of the society at large. The necessity of upholding their moral standing through continued breastfeeding, which signified HIV-negative status, put pressure on them to ignore the medical advice.ConclusionsThe infant-feeding dilemmas for women with HIV are complex. The integration of public health efforts with context-specific socio-cultural understanding is essential. The recent 2010 WHO guidelines offer a possible way of resolving these challenges. They recommend breastfeeding for one year with an adaptation to two years for Malawi. Efforts in the PMTCT programmes to supplement existing support systems, e.g. through the mothers-to-mothers (M2M) programme or consultation with expert mothers may also help women overcome these challenges.

A Model Infant Feeding Policy for Baby-Friendly Designation in the USA

In June 2010, the Communities Putting Prevention to Work program (Centers for Disease Control and Prevention) funded a New Jersey (NJ) Office on Nutrition and Fitness, Department of Health and Senior Services project to reduce obesity and increase exclusive breastfeeding by increased implementation of the Baby-Friendly Hospital Initiative in the state of NJ. At baseline, NJ had no Baby-Friendly hospitals and no hospital was using an infant feeding policy that conformed to standards required by Baby-Friendly USA for designation. To create a model infant feeding policy that would be adaptable for use at multiple NJ hospitals preparing for Baby-Friendly designation. Project consultants created a policy based on existent policies from the American Academy of Pediatrics, the Academy of Breastfeeding Medicine, certified Baby-Friendly hospitals, and guidance from Baby-Friendly USA. This policy was submitted to Baby-Friendly USA, the US body responsible for Baby-Friendly designation. Baby-Friendly USA requested changes; after adaptations, the policy was made available to targeted NJ hospitals via a statewide portal. The hospitals made relevant adaptations for their setting, and those that were ready submitted the policy during the Baby-Friendly designation process. The policy was acceptable to Baby-Friendly USA. A collaborative initiative can use a single breastfeeding policy template as an aid toward Baby-Friendly designation. Such work streamlines the process and saves time and resources.

Decline of exclusive breastfeeding: Practical advice and stronger policy compliance are needed in government health services in Lima, Peru

In Peru, exclusive breastfeeding (EBF) in urban areas decreased from 64.5% in 2007 to 59.9% in 2010 despite a national infant feeding policy to protect, promote and support breastfeeding (BF). Health care providers (HCPs) play an essential role in influencing mothers’ feeding decisions. This study examined infant feeding advice provided by HCPs in government health services (N=3) in a peri‐urban area of Lima using a case‐study methodology. Semi‐structured interviews were conducted with 16 HCPs and 11 mothers of infants < 6 months of age. Seven mothers participated in two focus group discussions. The health service environment and educational activities were observed. Advice was provided via growth monitoring and medical visits, nutrition counseling sessions, home visits and talks. HCPs recommended EBF for 6 months but did not provide practical advice to address common problems. Barriers to providing adequate BF counseling by HCPs included heavy client load, inadequate in‐service training, poor counseling skills, and formula industry influence. Barriers to EBF among mothers included employment, perceived breast milk insufficiency, and infant formula promotion. Improved training of HCPs, stronger monitoring of compliance and implementation of national policy are needed in government health services to protect BF behaviors. Funding: CIHR GBH‐87063; McGill University

Programming effect of breast-feeding in infant nutrition policy documents in Hungary

Aims: To identify and describe infant feeding policy documents in Hungary and compare them to the documents of other four European countries (England, Finland, Germany and Spain). The question was also addressed how the phenomenon of nutritional programming was represented in the documents. Subjects: Policy documents on infant feeding were identified and analyzed in the five European countries by using uniform methods for searching and coding. Results: Twenty-six documents were identified: 4 in England, 2 in Finland, 9 in Germany, 6 in Hungary and 5 in Spain. Altogether 203 statements linked to references were identified: benefits of breast-feeding in general (24%), protection against infections (32%), long-term advantages like the prevention of diabetes (31%) or allergy (12%). Considerable variations were found within and between countries in the evaluation of the duration and character of the positive effects. The majority of the statements in the Hungarian documents referred either to the role of breast-feeding in infection protection (n = 8), or to long-term protective effects (n = 13). Conclusion: Policy documents in the study countries varied both in their extent and in the description of the long-term effects of infant nutrition. Majority of the documents failed to contain evidence based discussion of the phenomenon of early nutritional programming. Orv. Hetil., 2011, 152, 1641–1647.

Infant‐feeding practices and associated factors of HIV‐positive mothers at Gert Sibande, South Africa

To assess knowledge, infant-feeding education and practices, factors that affect choice of infant feeding option, determinants of mixed feeding, psychosocial challenges and attitudes of HIV-positive women with infants between ages 3-6 months who attended prevention of mother-to-child transmission of HIV services in Gert Sibande district. A cross-sectional study was conducted with 815 HIV-positive mothers at 47 postnatal clinics. Trained field workers collected data at health facilities, using structured questionnaires. HIV-infected women who were at least 18 years of age were interviewed. The mean age was 27.7 years (SD 6.4). Seventy-eight percent agreed that HIV could be transmitted by breastfeeding. Fifty per cent were exclusively formula feeding, 35.6% breastfed exclusively and 12.4% mixed fed. In multivariate analysis, having a vaginal delivery, infant hospital admissions, and currently pregnant were associated with mixed feeding. Being older, knowing the HIV status of the infant and higher knowledge on HIV transmission through breastfeeding were associated with formula feeding. The study identified gaps in prevention of mother-to-child transmission (PMTCT) knowledge and infant feeding policy which seem to affect appropriate infant feeding. Various determinants of mixed feeding and exclusive formula feeding in the context of PMTCT were identified that can guide infant feeding counselling and support services of PMTCT programmes.

Lifetime health outcomes of breast-feeding: a comparison of the policy documents of five European countries

To (i) identify and describe prevailing infant feeding policy documents in five diverse European countries; (ii) analyse types of health outcomes for the infant that are associated with feeding breast milk rather than formula milk in the documents of different countries; and (iii) assess the extent to which documents reflect the WHO global recommendation of exclusive breast-feeding for 6 months. Documentary review and analysis. Five geographically dispersed countries of Europe (England, Finland, Germany, Hungary and Spain). Policy documents on infant feeding were identified; statements that linked choice between breast- and formula-feeding to a health outcome for the infant were extracted. Twenty-six documents (varied authorships, dates, length and character) were identified: four from England; two from Finland; nine from Germany; six from Hungary; and five from Spain. There was no consistency in the way in which health outcomes were cited as factors in the recommendations for breast- rather than formula-feeding. Seven documents contained no reference to the health implications of infant feeding choice. Of 203 statements in remaining documents citing health outcomes, 24.1 % mentioned general health effects, 32.5 % protection against infections, 31.5 % long-term conditions (e.g. diabetes, CVD) and 11.8 % mentioned allergy. Health outcomes were linked to exclusive breast-feeding in only 25 % of statements. Policy documents in the study countries varied in the extent to which they reflect the health outcomes for the baby of breast-feeding, and this may limit effective promotion by health professionals. There is scope to improve the process of bringing evidence and recommendations into policy documents.

The Risks of Not Breastfeeding

The Risks of Not Breastfeeding

"On our own, we can't manage": experiences with infant feeding recommendations among Malawian mothers living with HIV

BackgroundInfant feeding in communities with a high prevalence of HIV and AIDS is a potential challenge for mothers who must ultimately decide how to feed their infants within contexts that constrain their choices.MethodsWe investigated how infant feeding policy recommendations translate into maternal infant feeding decisions and practices using ethnographic research conducted between August 2004 and June 2005 among women participating in a prevention of mother-to-child transmission (PMTCT) program in Lilongwe, Malawi.ResultsQualitative findings are that maternal ability to adhere to recommendations to breastfeed exclusively for the first six months of infant life was constrained by expectations and psycho-social support. The most salient were women's pre-existing views on breastfeeding, their understanding of the medico-scientific information, and the quality of counselling received. In contrast, maternal decisions to wean were largely influenced by household economic factors and food insecurity.ConclusionsWe conclude that PMTCT programs delivered in ways which "download" the responsibility of adhering to recommendations to women in the absence of adequate psycho-social and livelihood supports contribute to substantial maternal psychosocial distress in this and, likely, similar settings.

Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1?

Exclusive breast-feeding is unambiguously the optimal infant feeding practice and is universally promoted in the absence of human immunodeficiency virus (HIV-1). It is associated with reduced morbidity and mortality from diarrheal and respiratory diseases. Recent findings suggest that exclusive breast-feeding may pose less risk of HIV-1 transmission than the more common practice of mixed feeding (i.e., breast-feeding concurrent with the feeding of water, other fluids, and foods), which has important infant feeding policy implications for low-resource settings. This paper reviews the biologic mechanisms associated with exclusive breast-feeding that provide protection against gastrointestinal, respiratory, and atopic diseases, and evaluates the relevance of these mechanisms for HIV-1 transmission. Potential mechanisms include reduction in dietary antigens and enteric pathogens that may maintain integrity of the intestinal mucosal barrier and limit inflammatory responses of the gut mucosa; promotion of beneficial intestinal microflora that may increase resistance to infection and modulate the infant's immune response; alteration in specific antiviral or anti-inflammatory factors in human milk that may modulate maternal hormonal or immunologic status; and maintenance of mammary epithelial integrity that may reduce viral load in breast milk.

HIV, infant feeding and more perils for poor people: new WHO guidelines encourage review of formula milk policies

The release of the new WHO guidelines on HIV and infant feeding, in a global context of widespread impoverishment, requires countries to re-examine their infant-feeding policies in relation to broader socioeconomic issues. This widening scope is necessitated by compelling new reports on the scale of global underdevelopment in developing countries. This paper explores these issues by addressing feeding choices made by HIV-infected mothers and programmes supplying free formula milks within a global environment of persistent poverty. Accumulating evidence on the increase in malnutrition, morbidity and mortality associated with the avoidance or early cessation of breastfeeding by HIV-infected mothers, and the unanticipated hazards of formula feeding, demand a deeper assessment of the measures necessary for optimum policies on infant and child nutrition and for the amelioration of poverty. Piecemeal interventions that increase resources directed at only a fraction of a family's impoverishment, such as basic materials for preparation of hygienic formula feeds and making flawed decisions on choice of infant feeding, are bound to fail. These are not alternatives to taking fundamental steps to alleviate poverty. The economic opportunity costs of such programmes, the equity costs of providing resources to some and not others, and the leakages due to temptation to sell capital goods require careful evaluation. Providing formula to poor populations with high HIV prevalence cannot be justified by the evidence, by humanitarian considerations, by respect for local traditions or by economic outcomes. Exclusive breastfeeding, which is threatened by the HIV epidemic, remains an unfailing anchor of child survival.

Infant feeding in the time of HIV: rapid assessment of infant feeding policy and programmes in four African countries scaling up prevention of mother to child transmission programmes

Objective:To assess the infant feeding components of prevention of mother to child HIV transmission (PMTCT) programmes.Methods:Assessments were performed across Botswana, Kenya, Malawi and Uganda. 29 districts offering PMTCT were selected...

Breastfeeding and HIV transmission – Authors' reply

In their Comment on the paper by Hoosen Coovadia and colleagues Wendy Holmes and Felicity Savage expose their personal biases by warmly embracing the papers findings and fail to contextualise its importance. The paper describes the risks of mixed feeding (both formula and breast feeding) compared with exclusive breast feeding in infants of HIV-positive women. Coovadia and colleagues note mortality in the first 3 months of life was roughly doubled in the group receiving formula feeding compared with the exclusive breast feeding group (15% vs 6%) and cautiously describe this as a concern without offering any explanation. They do however acknowledge an obvious selection bias in that mothers who chose to formula feed were significantly more likely (p<0.0003) to have CD4-cell counts of less than 200 per microL than were mothers who exclusively breastfed. Holmes and Savage fail to recognise or choose to ignore this major bias and instead highlight the finding as important in adding to the accumulation of new evidence on the hazards of formula feeding. They support this assertion by oddly referencing a Botswanian study that found breastfeeding plus zidovudine prophylaxis was not as effective as formula feeding in preventing postnatal HIV transmission and was associated with a similar mortality rate at 18 months. A more balanced Comment could have discussed the limitations of comparing mortality outcomes at 6 months (as opposed to say 2 or 5 years when the full effect of HIV-infection-related deaths secondary to breastfeeding would be overt) the feasibility of supporting exclusive breastfeeding in nonresearch settings and the papers relevance to the development of infant feeding policies for urban HIV-positive parents who might prefer formula feeding recognising its acceptability safety and efficacy in diverse urban settings such as Abidjan Cote dIvoire; Soweto South Africa; and Bangkok Thailand. (excerpt)