key: cord-1027969-scyvw838
authors: Fry, Hillary L.; Levin, Olga; Kholina, Ksenia; Bianco, Jolene L.; Gallant, Jelisa; Chan, Kathleen; Whitfield, Kyly C.
title: Infant feeding experiences and concerns among caregivers early in the COVID‐19 State of Emergency in Nova Scotia, Canada
date: 2021-02-22
journal: Matern Child Nutr
DOI: 10.1111/mcn.13154
sha: c05d37d39ba332a190943df21ca998ef18705285
doc_id: 1027969
cord_uid: scyvw838

The global emergency caused by the novel coronavirus (COVID‐19) pandemic has impacted access to goods and services such as health care and social supports, but the impact on infant feeding remains unclear. Thus, the objective of this study was to explore how caregivers of infants under 6 months of age perceived changes to infant feeding and other food and health‐related matters during the COVID‐19 State of Emergency in Nova Scotia, Canada. Four weeks after the State of Emergency began, between 17 April and 15 May 2020, caregivers completed this online survey, including the Perceived Stress Scale. Participants (n = 335) were 99% female and mostly White (87%). Over half (60%) were breastfeeding, and 71% had a household income over CAD$60,000. Most participants (77%) received governmental parental benefits before the emergency, and 59% experienced no COVID‐19‐related economic changes. Over three quarters of participants (77%) scored moderate levels of perceived stress. Common themes of concern included social isolation, COVID‐19 infection (both caregiver and infant), and a lack of access to goods, namely, human milk substitutes (‘infant formula’), and services, including health care, lactation support, and social supports. Most COVID‐19‐related information was sought from the internet and social media, so for broad reach, future evidence‐based information should be shared via online platforms. Although participants were experiencing moderate self‐perceived stress and shared numerous concerns, very few COVID‐19‐related changes to infant feeding were reported, and there were few differences by socio‐economic status, likely due to a strong economic safety net in this Canadian setting.

The World Health Organization's global infant and young child feeding recommendations include guidance to breastfeed exclusively until the introduction of safe and nutritionally adequate complementary foods at 6 months (World Health Organization, 2020a). Appropriate infant feeding plays a particularly important role in the prevention of infection during times of increased pathogen exposure, as human milk provides immunoprotective compounds, and appropriate first complementary foods contain iron and zinc which can reduce risk of infection (Eneroth, Persson, El Arifeen, & Ekström, 2011; Hassiotou et al., 2013; Yakoob et al., 2011) .

Emergencies are similarly important times for infant feeding, as

infants are often more vulnerable to health risks than older age groups, in part due to a more urgent need for appropriate nutrition and food security (American Academy of Pediatrics, 2015; Carothers & Gribble, 2014; Gribble, 2014; IFE Core Group, 2017) . For instance, emergencies such as natural disasters and infectious disease outbreaks pose a unique set of barriers to optimal infant feeding (Carothers & Gribble, 2014; IFE Core Group, 2017 ) that can result in cessation of breastfeeding or the introduction of suboptimal food or feeding practices (Ververs et al., 2019 ).

Barriers to optimal infant feeding and resulting dangerous feeding practices have been documented during past emergencies (Callaghan et al., 2007; DeYoung, Chase, Branco, & Park, 2018; Ishii et al., 2016) ; however, much of the literature documenting the impact of emergencies on infant feeding takes place in low-and middle-income countries, and those in high-income countries predominantly report on responses specific to natural disasters (DeYoung et al., 2018; Ishii et al., 2016) . Often, these reports describe emergency responses where infants and caregivers have been displaced or evacuated from their homes, are staying in precarious and often overcrowded emergency shelters and/or are without access to clean water (DeYoung et al., 2018; Hirani, Richter, Salami, & Vallianatos, 2019; Ishii et al., 2016) .

In contrast, the global COVID-19 pandemic has posed a unique emergency, layering a high risk of communicable disease exposure, and isolation rather than overcrowding, on infant feeding challenges.

The novel coronavirus disease COVID-19, caused by SARS-CoV-2 infection, is transmitted via respiratory droplets and aerosols, prompting public health guidelines of physical distancing (Lackey et al., 2020; Tang et al., 2020) . In Nova Scotia, Canada, a provincial State of Emergency was declared on 22 March 2020, triggering subsequent orders to limit direct social contact, leading to closures of schools and day cares, limitations to public transportation and restricted opening hours for businesses, in turn limiting access to goods and services (Government of Nova Scotia, 2020a) . Importantly, many Nova Scotians lost income or were put at higher risk of contracting COVID-19 by continuing to work (Government of Canada, 2020a) .

In Nova Scotia, breastfeeding women tend to be older, more highly educated, partnered and have higher incomes (Brown et al., 2013) . Here, breastfeeding rates are among the lowest in Canada, with only 22% of infants breastfed exclusively to 6 months (vs. 33% nationally) despite an initiation rate of 86%, and the issue of infant food insecurity is a growing concern (Frank, 2020; Statistics Canada, 2018) . This State of Emergency had the potential to present unique challenges to the caregivers of young infants, thus exacerbating these existing issues, increasing the vulnerability of infants. Given the novelty of COVID-19, there is a gap in understanding of how caregivers could experience this State of Emergency, how it could impact young infants, and how to best support caregivers during a potential second wave of virus transmission and emergency-related social restrictions and/or future pandemics. Therefore, the purpose of this study was to explore COVID-19 State of Emergency-related changes in feeding practices among caregivers of young infants in Nova Scotia. • Many participants felt unsupported and socially isolated due to the cancellation of routine post-partum appointments, lactation support services, public health home visits, and organized support or play groups.

• Some breastfeeding participants reported delayed growth monitoring and subsequent introduction of infant formula to more closely control their infant's intake.

• Formula-feeding participants were concerned about access to, and retail stock-outs of, infant formula, particularly specialized forms (e.g., lactose free and hydrolysed). 2020), there were cumulatively 1034 confirmed positive cases of COVID-19 in the province (Government of Nova Scotia, 2020b) . Nova Scotians were instructed to limit social gatherings to five people (including household members) and to only leave home for essential items, maintaining social distancing when doing so (Government of Nova Scotia, 2020a Depending on the caregiver's responses about feeding modality, they received questions about breastfeeding, feeding infant formula, or both. The Perceived Stress Scale, a widely used measure of stress which has been previously validated among breastfeeding and bottle-feeding mothers (Cohen, Kamarck, & Mermelstein, 1983; Mezzacappa, 2004) , was also employed.

Descriptive statistics were computed and presented as n (%) or mean (95% CI). Chi-square tests were used to assess for differences in the following sociodemographic characteristics by feeding modality:

infant age, sex and ethnicity; caregiver age, gender, relationship to infant, parity, ethnicity, marital status and education level; household income, parental benefits, geographic area and population density, number of adults and children in the household, changes in income and changes in childcare; and pumping, usual pumping frequency, type of infant formula and form of infant formula. When applicable (findings differed from expected values; P < 0.05), a Bonferroni post hoc correction was employed to determine where differences existed (Beasley & Schumacker, 1995) . The same statistical tests were used for comparisons for COVID-19-related information-seeking behaviours and household income (categorized above and below CAD $60,000, the median Nova Scotian household income; Government of Nova Scotia: Finance and Treasury Board, 2017) and age (categorized above and below 35 years, the cut-off for advanced maternal age; Benzies, 2008; Bushnik & Garner, 2008) . Participants' cumulative score for the Perceived Stress Scale was used to categorize participants as experiencing self-perceived low, moderate or high stress (Cohen et al., 1983) . Data analyses were performed using IBM SPSS Significantly more of the breastfeeding caregivers, as compared with formula and mixed feeders, were married or in common-law relationships (n = 187, 94%), had completed a graduate or professional degree (n = 48, 24%) and had household income over CAD$60,000 per year (n = 161, 82%) (P < 0.05).

The majority of caregivers (87%) actively sought out COVID-19-related information, with 73% searching for this information once or more per N differs due to participants skipping some questions. b Other baby's ethnicities included Filipino (n = 3), Black (n = 2), South Asian (n = 2), Arab (n = 1) and Mexican (n = 1). c Other ethnicities included Filipino (n = 3), South Asian (n = 3), Acadian (n = 2), Black (n = 2), Arab (n = 2) and Latin American (n = 2). d 'Monetary parental benefits' refers to governmental parental EI in Canada which provides up to 55% of a caregiver's preleave earnings to a maximum of CAD$573 per week for 50 weeks and/or any voluntary 'top-ups' from employers. e In Canada, EI and CERB benefits during the pandemic were available to any adult 15 years or older who lost their job through no fault of their own, including because of COVID-19 and provided up to CAD$500 per week starting on 15 March 2020 throughout the entire data collection period.

f Other changes to income due to COVID-19 included increase in income (i.e., 'hero pay', new job; n = 12), top-up from employer ended (n = 4), increase in hours worked without an increase in income (n = 2), self-employed: decrease in business (n = 2) and loss of overtime hours (n = 1).

T A B L E 2 COVID-19-related information-seeking behaviours of participating Nova Scotian caregivers to infants < 6 months Other frequencies of information seeking included looking monthly (n = 3), looking more often at the beginning of the State of Emergency but less or not at all now (n = 4), only see information passively (n = 2), looked once or twice (n = 4), only checked to see if breastfeeding was possible if infected (n = 1) and every couple weeks to see if information has changed (n = 1).

T A B L E 3 Infant feeding-related changes experienced by participating caregivers of infants aged < 6 months due to COVID- • 'Baby needed more than I produced, so we changed to formula'

• 'Breast couldn't produce enough milk' ▪ 'We spend most of our days topless and skin to skin so she has fed a lot more unrestricted than if we were permitted to go places or have visitors'.

▪ 'Less bottle feeding since I am apart from baby less' ▪ 'Had to breast feed more to try to make up for lack of calories due to running out of formula' 

Quotes selected to illustrate prominent themes regarding the impact of the COVID-19 State of Emergency on the participating caregiverinfant dyads and infant feeding are presented in Box 1. Common concerns emerged around the impact of isolation on both infants and caregivers, access to health care and related potential health consequences and mixed feelings of relief and concern around infant feeding. Open-ended responses also demonstrated difficulties accessing infant formula, particularly specialized formulas, causing concern about running out.

The majority of participants were categorized as experiencing moderate perceived stress (n = 252, 77%) based on their responses to the Perceived Stress Scale, with only 19 (6%) experiencing high perceived stress (see Figure 1 ). Of investigator-generated potential concerns, 'I went from breastfeeding to formula feeding after a month of my son being born. I feel like the stress of being isolated and him not getting the proper attention from public health visits to doctors visits (since they have all been over the phone) made me unable to produce enough milk for him. Also, me not knowing his weight weekly (public health and doctors) scared me into switching to formula since it guaranteed him gaining weight. It was scary trying to find a good formula for him and making sure he was able to have access to it at these times since a lot of people stockpiled the first couple weeks and I was behind'. Multiparous formula-feeding mother, 28 years old 'I find it especially stressful and guilt inducing to be formula feeding. I already felt guilty because of all of the "breast is best" encouragement; and I tried so hard to breastfeed. I felt like a failure for not succeeding with it and have been ashamed. Now formula is hard to acquire and I'm worried about the supply chain'. Primiparous formula-feeding mother, 32 years old 'Not being able to find my daughter's formula. I've spent hours crying over this. She has an intolerance to lactose and is on

[Brand] formula … Now with people stock piling and hoarding formula I worry I won't find this for her. I keep one case ahead if possible in case of a temporary shortage'. Multiparous formula-feeding mother, 30 years old '[The baby] growing properly because I switched to a lesser known, cheaper brand of formula'. Primiparous formula-feeding mother, 26 years old 'Try to break [feeding] up to conserve formula, give water in between'. Multiparous formula-feeding mother, 24 years old Access to health care 'Concerned that [the baby] is not getting the follow up care that was provided prior to COVID-19 pandemic. This is the reason that his weight gain issues were only caught at 4 weeks'. Primiparous breastfeeding mother, 36 years old 'Our biggest issue was losing our lactation consultants due to COVID-19. We dealt with a tongue tie, thrush, and hard letdown within a few weeks of the COVID measures being put in place, and essentially had to deal with these on our own. We were able to get the tongue tie clipped right as measures were being introduced, but all follow up visits were cancelled and we felt overwhelmed trying to figure out feeding and healing without any professional help'. Primiparous breastfeeding mother, 31 years old high household incomes and levels of education in our sample, and therefore, results may not represent the experiences of caregivers with lower household incomes or education levels who may be the most vulnerable. 

Caregivers' top ranked sources for information about COVID-19

were the internet and social media, particularly parent support groups and specific organizations/institutions (e.g., the WHO) or social media pages (e.g., the Leaky Boob). This aligns with the findings of a recent survey in Taiwan (n = 1904), where 81% of participants found COVID-19 information online (Ko et al., 2020) . As demonstrated by participants in the current study, social media is also an important source of information and support, despite high levels of problematic misinformation known to be circulating on social media (Asiodu, Waters, Dailey, Lee, & Lyndon, 2015; Holtz, Smock, & Reyes-Gastelum, 2015) , especially regarding COVID-19 (Bastani & Bahrami, 2020) . When asked to self-report knowledge, a small proportion of participants (4%) cited incorrect feeding recommendations, such as the need to isolate a mother from her infant and to cease feeding at the breast. Similarly concerning, many (29%) reported not knowing anything regarding infant feeding during the COVID-19 pandemic. However, 42% of our participant group correctly identified that breastfeeding should continue as usual regardless of mother's COVID-19 infection status (World F I G U R E 1 Self-rated caregiver concerns about various activities and issues with potential to be impacted by the COVID-19 State of Emergency, displayed by participants' Perceived Stress Scale score 'I would of like to meet with my doctor. My 6-week appointment got cancelled and a doctor never followed up with me since I gave Health Organization, 2020c). Although some participants specifically referenced looking for information from credible government and/or health organizations such as the WHO, most information was sought from social media pages that were likely more familiar to caregivers before the pandemic, such as parent support groups.

As such, credible sources should investigate paying for ads or partnering with social media influencers or popular parenting sites to ensure accurate, up-to-date, evidence-based information is shared where caregivers are most likely to see it.

Caregivers who fed their infants infant formula reported stockpiling or buying the product more often during the State of Emergency.

This is not surprising, as stockpiling has also become common prac- Human milk expression ('pumping') has become a common practice for caregivers in high-income countries (Johns et al., 2013) .

Before the COVID-19 State of Emergency, this practice was typically related to medical lactation issues such as mastitis or nipple pain, oversupply or undersupply of milk, to avoid breastfeeding in public, to allow other people to feed the infant, or to return to work or other work-related constraints (Johns, Forster, Amir, & McLachlan, 2013) . As circumstances have changed due to COVID-19, so have caregivers' pumping behaviours. Participants who indicated pumping less frequently referenced 'stay at home' orders, explaining that they did not have to breastfeed in public or in the presence of other people, and having expressed human milk ready to be fed by another person, such as a babysitter, was no longer necessary. This may be one of various unanticipated positive effect of the pandemic, as increased breastfeeding at the breast can improve responsiveness during feeding, which has been shown to have long-lasting health benefits for the infant (Bartok & Ventura, 2009; Ventura, 2017) .

Though there were many reported negative impacts of the COVID-19 pandemic, participants also reported unanticipated positive experiences, including less pressure and more time with their baby, which has been reported by others. Like those in our study, Nova Scotian caregivers who responded to an open-ended survey on post-partum experiences during the COVID-19 pandemic also described a complex time, reporting not only negative themes, such as isolation, but also 'blessings', such as freedom from social expectations and more family bonding time (Joy et al., 2020) . 

The (Hirani et al., 2019) , where people experience increased fears associated with morbidity and mortality (Hall, Hall, & Chapman, 2008) compounded by the closure of schools and businesses (Van Bortel et al., 2016) . Higher than normal levels of stress were also observed in China during the current COVID-19 pandemic, particularly among women (C. Wang, Pan, et al., 2020) . Similar to previous research (Maehara et al., 2017) , we did not find significant differences in stress levels between breastfeeding and infant formula-feeding caregivers; however, the observed challenges and emotions experienced by each were very different.

There is a common misconception that mothers cannot breastfeed during emergencies because the stress will limit the quality and/or quantity of milk produced (Hirani et al., 2019) .

Although there is a physiologically plausible pathway by which stress could impair lactation (Lau, 2001) , to date, there is limited evidence that maternal stress can adversely impact milk supply. However, breastfeeding relaxation interventions have been shown to improve breastfeeding outcomes, and a recent meta-analysis has shown improved milk production with musical therapy for relaxation (Düzgün & Özer, 2020; Shukri, Husna, Wells, & Fewtrell, 2018 

Over the last decade, researchers have argued that Canadian mothers feel pressure to breastfeed due to the prevailing societal view that breastfeeding is an integral aspect of 'good motherhood' (Andrews & Knaak, 2013; Knaak, 2010) , with formula-feeding caregivers often expressing feelings of guilt, remorse and shame due to their perceived failure to achieve this standard (Lee, 2008; Taylor & Wallace, 2019; Thomson, Ebisch-Burton, & Flacking, 2015) . Similarly, during the COVID-19 State of Emergency, related issues with access to formula have were described by some participants as the cause for feelings of guilt and shame for 'choosing' a less reliable feeding method. In contrast, some breastfeeding participants described feelings of gratitude and perceived being 'lucky' or 'blessed' for being able to continue breastfeeding (Box 1). Mental health was a similarly important theme in the New Mum Study in the United Kingdom, where the majority of participants reported symptoms of low mood, anxiety and loneliness during the COVID-19 pandemic (Dib, Rougeaux, Vázquez-Vázquez, Wells, & Fewtrell, 2020) . These results emphasize the importance of caregiver mental health care during and after the COVID-19 State of Emergency, especially for caregivers who have experienced difficulty feeding their infants. The results of the current study particularly highlight the importance to support not only breastfeeders but also formula feeders, who are more vulnerable to supply chain issues, and potentially, to mental health issues, during emergencies.

This study was the first to explore caregivers' perceptions of infant feeding and health in Atlantic Canada. Researchers recently identified low knowledge of infant and young child feeding recommendations in the general population of Nova Scotia (Chan & Whitfield, 2020) , which has one of the lowest breastfeeding rates in the country (Statistics Canada, 2018) . A strength of this study is the use of both

closed-and open-ended questions, which were used complementarily to gain a holistic view of caregivers' experiences. A limitation of this study is the study population, which, through convenience sampling, was made up primarily of White, breastfeeding women with high socio-economic status, despite efforts to recruit participants from different populations by promoting the study across numerous social media platforms and groups. This may be because we sought caregivers with infants less than 6 months of age, so responses were almost entirely from caregivers who were at home with their infants and earning parental benefits rather than those in low-paying, and often essential, jobs that would yield lower government parental benefits. Likewise, our focus on web-based advertising may have excluded those with poorer English literacy or without access to internet. Therefore, these results may not reflect the experiences of those in more challenging circumstances who may be more vulnerable to the impacts of the pandemic.

The COVID-19 State of Emergency has impacted the Nova Scotian caregivers who participated in this study, resulting in stress, feelings of isolation and lack of support (family, friends and health care), and some limited adverse feeding practices such as early cessation of breastfeeding or introduction of solid foods. These issues have potential to result in life-long impacts on the health of the infant. As infants are a highly vulnerable group, every effort should be made on the level of the government, community and individual, to support caregivers in feeding their infants, especially during emergencies.

Therefore, interventions to increase access to health care services in the post-partum period, allow for personal lactation and infant feeding supports, and implementing systems to ease access to infant foods (e.g., online inventory system) could reduce barriers currently experienced by caregivers in Nova Scotia. Lessons from this unique emergency may inform future public health programmes, in future COVID-19 outbreaks or other prolonged emergencies.

We thank all the participants of this study. This study was funded by 

Authors declare no conflicts of interest. The funder had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

HLF and KCW conceived the study, and KCW obtained funding. HLF, OL, KK, JLB, JG and KC designed the study tools and assisted with data collection. HLF, OL, KK, JLB, JG and KC analysed the data, overseen by KCW. HLF and KCW drafted the manuscript. All authors have contributed to the intellectual content of and have read and approved the manuscript; KCW is responsible for the final version of the manuscript.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Kyly C. Whitfield https://orcid.org/0000-0001-8315-8927

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