i Pan, PhD
ua J. Wilkin
ng, MA, Ph
ssue 2, Jul
with Prof. Y
on, MA, R
Lua Wilkinson, MA, RD
UNDERSTANDING INFANT AND YOUNG CHILD FEEDING CHALLENGES IN CHINA
Lua J. Wilkinson,* MA, RD. Cornell University
Xiaoyang Sheng, MD, PhD. Shanghai Jiaotong University School of Medicine
Sera L. Young, MA, PhD. Cornell University
This paper reviews infant feeding challenges China faces in the current
economic and social climate. Infant and young childhood is a critical period
of growth and development and losses due to under-nutrition are often
irreversible. In urban areas, there has been a rapid increase in childhood
obesity since the market reform policies of the early 1980’s, with interventions
focusing on school-aged children or young adults. Under-nutrition continues to
be widespread in many rural areas of China, and while improvements have
taken place, most efforts are focused on school-aged children. In both under-
and over-nutrition, little attention has been paid to the role infant feeding
plays. Through observations and interviews with healthcare workers, mother’s
groups and rural-urban migrant women in Shanghai and Yunnan, we attempt
to deconstruct social and economic determinants of infant and young child
feeding practices in order to illuminate specific barriers and possible solutions.
Infant feeding decisions, particularly those regarding breastfeeding, are
closely linked to cultural, economic and social values. Education, a crucial
component of improving nutritional outcomes, does not alone change infant feeding behavior. Rural-to-urban
migration, re-negotiation of family roles, and media as the main source of nutrition information for households
each pose unique barriers to providing infant and young children with proper nutrition. Infant feeding and
nutrition programs should take a multi-pronged approach that includes education, awareness, and policy.
经实施，但是大多数只关注于学龄期儿童。在城市中，自 80 年代市场改革开放以来，儿童肥胖迅速增长，而相应的干预
The recent change from a centrally planned, socialist economy to one that is market-driven has
stimulated economic growth and generated an increase in food availability scarcely seen before
in China’s history. China has decreased the number of malnourished children between 1990 and
2006 by half (United Nations, 2008), yet a divide persists between the nutritional status of rural and
urban children. Rural children are up to five times more likely to be underweight than their urban
counterparts (United Nations, 2008). In China, where the majority of children still live in rural areas,
understanding the problems contributing to malnutrition is of unprecedented importance.
Childhood obesity is also becoming a serious health threat in China. China’s approach to
economic development, i.e. promoting consumerism, has been wildly successful in urban areas by
* Corresponding author. Ms. Lua Wilkinson has worked as a pediatric dietitian for over six years. She researched
infant and young child feeding practices as a Fulbright Fellow from 2010-2011, spending her time between
Shanghai and Yunnan. She will be commencing her PhD in International Nutrition at Cornell University in the fall
of 2012. She can be reached at Lua.firstname.lastname@example.org.
improving access to capital, healthcare, education and expanding the labor market. By focusing
on consumption to alleviate poverty and malnutrition, however, China now faces a rise in obesity
and morbidity from non-communicable diseases such as congestive heart failure, chronic kidney
disease and type-2 diabetes (Gong, et al., 2012).
Before the problems of both under- and over-nutrition can be fully assessed, they must be
contextualized into China’s rapidly changing social and economic climate. For example, family
planning policies are causing a re-adjustment of family roles, especially where breastfeeding is
concerned. Consumer culture is driving an obesity epidemic in urban areas where choice and
individuality are increasingly valued. Current infant feeding messages may not resonate with
current issues families face, such as migration, consumerism, and emphasis on individuality. As more
and more mothers migrate to larger Chinese cities for employment, their children’s caretaking,
including infant feeding, is left in the hands of other family members such as grandparents. Little
research has been done to understand how infant feeding decisions are made in this context.
Therefore, our purpose is to explore rural and urban perceptions of infant and young child feeding
(IYCF) knowledge and behaviors, including education of healthcare workers and socio-cultural
barriers to optimal infant feeding practices. We endeavor to make sense of China’s IYCF and
nutrition challenges so that policy makers can begin to assess existing infant feeding practices and
implement appropriate interventions. We begin this perspective with an overview of breastfeeding
and infant nutrition, and move on to discuss childhood obesity, the use of infant formula and the
one-child policy in urban China. We then outline issues in rural China, including maternal migration
and the community health worker. We present trends in infant feeding between rural and urban
China differently in order to highlight relevant differences between the two areas. Observations are
included at the end of both sections to illuminate how individual, household, community, and
national experiences are shaped in Chinese healthcare settings. We end with a discussion on the
role of nutrition education and community participation in order to improve health outcomes.
The bulk of the research on which this perspective is based comes from 14 months the lead author
(LW) spent in China from August 2010-October 2011 collaborating with Xiaoyang Sheng and her
team at the Shanghai Jiaotong University School of Medicine. The focus of this research was to
explore IYCF practices in Shanghai and Xichou, Yunnan using the socio-ecological framework
(McLeroy, Bibeau, Steckler, & Glanz, 1988; Stokols, 1996). Specifically, we looked at individual
factors such as maternal identity in rapidly changing family and socio-economic systems, family-
level factors involving decision-making between family members, and structural factors related to
media advertising of formula and healthcare practices and policies.
Interviews with healthcare workers, mother’s groups, migrant women and nutrition researchers were
conducted in order to gain an understanding of IYCF. Relevant experiences include shadowing
SJTU medical students on an IYCF study at the Kongjiang Community Health Clinic in Shanghai,
collaborating with community advocates at La Leche League for breastfeeding education, and
observing a randomized control trial, evaluating meat as a complementary food to breastfed
infants, in rural Yunnan. Because of their exposure doing nutritional research in many provinces
across China, medical students and community health workers were invaluable sources of
information. They understood many problems in the healthcare system, including the different
needs of rural and urban areas. The ability to triangulate our findings with local cultural and
medical authorities, as well as scientific literature, provided us with a deeper insight of complex
questions surrounding infant feeding perceptions and practices.
Breastfeeding and Infant Nutrition
Breastfeeding exclusively for the first six months promotes ideal infant growth patterns, has
maternal, infant, and societal benefits, and remains the number one preventative measure to
reduce infant mortality world-wide (Agency for Healthcare Research Quality, 2007). Infant and
young child feeding practices have a direct effect on the nutritional status, growth and
development of children less than two years of age (World Health Organization, 2008). Chief
among IYCF practices that can have an effect on a child’s growth and development is
breastfeeding. Exclusive breastfeeding, defined as no liquids or solids other than breast milk, for six
months continues to be strongly recommended by the Chinese Pediatric Society. Despite efforts
such as the “Breast-feeding Friendly Hospital Initiative to promote exclusive breastfeeding for infants
until six months (Gottschang, 2007), rates of “exclusively breastfed” infants in China continue to
decline from 78% at 4 months in 1996 down to 45.3% in 2002, with large differences between
regions, ranging from a low of 22.4% of exclusive breastfeeding through 4 months in Chongqing to
a high of 76.3% at 4 months in Chengde (Xu, Qiu, Binns, & Liu, 2009). In short, women and their
families often choose a “mixed-feeding” regimen, providing both breast milk and infant formula.
The many reasons for the societal switch from exclusive breastfeeding through 6 months to mixed
feeding are multi-factorial and include families having inadequate household resources to support
a mother staying with her child, the effects of the media on influencing public opinion on
breastfeeding, and a lack of policy and educational programs directed toward the public
(Gottschang, 2007; Guldan, 2000). Families often display an inadequate understanding of the
nutritional value of breast milk, and report that infant formula is superior for an infant’s growth and
development (Jiang, et al., 2012; Wilkinson, 2011).
There are many reasons the decline in exclusive breastfeeding is concerning. First, it can be
immediately deleterious to an infant’s health. Contaminated water may be used to mix formula,
parents or other caregivers may dilute formula to save money, and families may use inappropriate
breast milk alternatives that do not meet the child’s nutritional needs, such as cow milk or rice
porridge (Li, Li, Ali, & Ushijima, 2003). If the child has an allergic reaction or does not tolerate infant
formula, there are few appropriate alternatives if the mother’s milk supply has already diminished or
ceased completely. Perhaps most concerning to Chinese parents, however, are the recent “milk
scandals” surrounding infant formula products. In 2008, a total of 296,000 children fell ill and 4 infants
died from contaminated milk powder used for infant formula (BBC News, 2010). Contaminants have
been found in infant milk powder in China as recently as June 2012, where a top selling brand
recalled 6-months worth of formula tainted with mercury (Hornby & Lee, 2012).
Longer-term concerns include the protective role that exclusive breastfeeding plays against
obesity. There are strong correlations between bottle-feeding and obesity in children, including
among children in China (Liu, et al., 2009). Infant formula may be obesogenic for multiple reasons,
including promoting prolonged bottle use (Gooze, Anderson, & Whitaker, 2011), inappropriate
programming of leptin receptors (Singhal, et al., 2002), increased insulin response from formula
(Lucas, et al., 1980), and the inability of formula-fed infants to self-regulate their intake as effectively
as breastfed infants (Dewey, Heinig, Nommsen, Peerson, & Lonnerdal, 1993).
Market reforms during the late 1970’s and early 1980’s have revolutionized life in urban China,
creating improved standards of living for millions with an emphasis on consumption to promote
economic growth. At the same time, family planning policies have changed family dynamics, with
single-children attended to by multiple family members. Known as “Little Emperors” (French &
Crabbe, 2010), these children often garner the exclusive attention of their parents and
grandparents. Together, economic demands and the one-child policy have affected IYCF
practices and outcomes, including increased dependence on infant formula, perceptions of
overweight infants as “healthy”, and changing caregiver-infant feeding behaviors.
Trends in Infant Feeding
Almost unheard of prior to market reforms thirty years ago, rates of childhood obesity in Shanghai
are now up to 13.25% (Luo, Shen, & Tu, 2004), and incidence of type 2 diabetes has tripled among
school-aged children (French & Crabbe, 2010). Discussions centered around infant feeding and its
effect on obesity are especially salient as rapid weight gain in infancy is positively correlated with
obesity later in life (Monteiro & Victora, 2005).
• Use of Infant Formula
Economic demands of life in urban China require that many new mothers retain employment after
birth, which may interfere with exclusive breastfeeding. As women continue working through their
child’s infancy, infant formula becomes an attractive option for busy, working mothers. At the same
time, infant formula companies continue to increase spending on artificial infant feeding research
as well as ad campaigns in China. Nestlé, for example, paid $11.85 billion U.S. dollars to acquire
Pfizer’s baby food market in China in early 2012 (Jones & Mao, 2012), and Mead Johnson boasted
a 12% increase in net income, led by China and Hong Kong (The Associated Press, 2012).
• Perceptions of Overweight Infants
Positive attitudes towards overweight and “chubby” babies continue to be pervasive throughout
Chinese society, where overweight children are featured in advertisements and television shows
(French & Crabbe, 2010) and may be perceived as the healthy growth pattern for infants and
children. Indeed, many parents in China perceive their children being underweight when they are
normal or normal when they are overweight (von Deneen, Wei, Tian, & Liu, 2011). Due to past years
of famine and poverty, having an overweight infant may be seen as a sign of prosperity. Due to
beliefs of the nutritional superiority of infant formula, a woman who wishes to exclusively breastfeed
may be discouraged if her child is not growing “normally” according to her perceptions (Jiang, et
al., 2012). In these cases, caregivers often add formula to promote perceived ideals of growth.
• Complementary Foods
Delaying complementary foods until 6 months shows a protective effect against obesity (Schack-
Nielsen, Sorensen, Mortensen, & Michaelsen, 2010). Grandparents often become the caregiver of
choice when both parents are working, are most likely the ones who initiate complementary foods.
As primary caregiver, grandparents set the stage for feeding behaviors once the mother returns to
work. As is typical in Chinese culture, these first foods include rice porridge (粥), egg yolks, but may
quickly turn to higher calorie sweets or “junk” foods. Later, praise and affection is oftentimes given
through snacks, food “treats”, fast-food and pocket-money (French & Crabbe, 2010).
Kongjiang Community Health Center is situated in a typical middle-class neighborhood in
Shanghai, where observations of SJTU medical students conducting an infant feeding study were
made during the winter/spring of 2011 (Ma, et al., In press 2012). Infant feeding questionnaires were
administered orally to caregivers (either grandparents, parents, or nannies) about breastfeeding
duration, bottle-feeding, and introduction of complementary foods. In addition, counseling was
provided to caregivers on proper IYCF techniques. Multiple family members would often
accompany single infants, each of whom was actively engaged in asking questions, caring for the
child, and interacting with clinicians. The average adult to infant ratio was between 3-4 adults to
every child. Posters promoting formula were prominently displayed on the clinic walls, and a glass
cabinet showcased “proper” infant feeding techniques, which included introducing
complementary foods at 1-2 months.
Consistent with findings elsewhere (Jiang, et al., 2012), caregivers at the Kongjiang Community
Health Center were concerned with the child being underweight when they were normal. Few
caregivers were concerned with their child being overweight even as the prevalence of
overweight and obese infants was high at almost 33% at 12 months, the majority of which were
already obese at 6 months (Ma, et al., In press 2012).
Infant formula advertisements were seen throughout clinic walls, tolerated by clinicians who
understood that women had to be away from their infants for large stretches of the day when
working, or that grandparents and other family members wanted to take part in feeding the
newborn. Education materials in the display case also recommended adding foods at as young as
1 month. Whether explicitly counseled by the clinic’s practitioners or not, the message from the
display is that breast milk is not enough.
Clinicians and medical students showed a clear understanding of the dichotomy between infant
feeding messages from health organizations (exclusive breastfeeding until 6 months is
recommended, then continuing to breastfeeding with the addition of complementary foods until
two years) and practice (mixed-feeding with infant formula and premature addition of
complementary foods). Breastfeeding discussions regarding the nutritional superiority of breast milk
often became less relevant than concerns regarding work, family opinion, and insufficient milk
supply. These messages, coupled with the display case and posters on the walls promoting infant
formula, illustrate ways in which this particular clinic does not promote 6 months of exclusive
La Leche League (LLL), an international organization that supports breastfeeding through mother-
to-mother support, has formed groups in Shanghai and Beijing. In China, mothers as well as fathers,
grandparents and nannies attend meetings. Run exclusively by volunteers, the meetings take place
in a semi-formal lecture format, with families socializing casually with each other before and after.
Certified Lactation Consultants and physicians were available for specific questions in Shanghai,
which were answered to the group. In this way, family members have the opportunity to ask
questions freely and obtain answers from healthcare professionals.
This environment was much more attuned to the needs of new mothers and families for a number
of reasons. First, families are free to mingle with each other and exchange advice on how to
optimize breastfeeding outcomes while a competent healthcare professional gently guides new
mothers through difficulties. Barriers could be discussed with professionals or other families, and
myths are quickly dispelled. Infant feeding education in a community setting such as LLL is much
more suited to the new socio-economic environment where collective “parenting” of mothers,
fathers, and grandparents is reality.
The economic and social status of rural Chinese has greatly improved over the last thirty years.
Compared to urban Chinese, however, those living in rural areas overall have unequal access to
food, healthcare, and resources (Wang, Wang, & Kang, 2005). While malnutrition in infancy and
early childhood is closely linked to poverty in rural areas, inappropriate infant feeding and care,
limited access to health services, and inaccurate health and nutrition information also contribute.
Poverty alleviation and improving the quality of rural life in China will no doubt help improve
nutritional status of rural infants, but an examination of China’s urban obesity epidemic suggests
that appropriate policies addressing other issues related to nutrition education are needed as well.
Treating malnutrition with consumption leads to obesity.
Trends in Infant Feeding
Historically in China, breastfeeding was commonplace in rural areas up through twelve months and
later (Shen, Habicht, & Chang, 1996). Recent trends show while breastfeeding rates remain high
(98.22%), a smaller number of infants are exclusively breastfed (24.36%). These rates are much lower
compared to urban areas (52%), due to early introduction of complementary foods (Wang, et al.,
2005).Those who are exclusively breastfed show lower rates of pneumonia and diarrhea, leading to
better growth and development.
If the mother is unable to breastfeed, there is often little for her infant in terms of breast milk
alternative support. This is especially true after the 2008 Sanlu Milk Powder scandal, where families in
China have become extremely cautious about what brand of infant formula they feed their
children (Seror, Amar, Braz, & Rouzier, 2010). This has had a positive effect on breastfeeding rates
overall in China, but poses a special challenge to rural mothers. Caregivers will often buy foreign
brand formulas in urban areas to avoid domestic tainted formula; this tends to be prohibitively
expensive for rural families, who often have no choice but to buy domestic formula.
• Complementary Feeding
Very little is currently known about complementary feeding practices in rural China or what drives
weaning behavior (Guldan, et al., 2000). Protein intake in infants is most likely insufficient because of
a lack of health knowledge, and rural people may be more influenced by traditional feeding
practices than nutritional recommendations from clinicians. The extent of caregiver’s knowledge
has not been systematically studied.
• Maternal Migration
Due to urban growth and development, rural Chinese are migrating to urban areas in order to find
better financial opportunities. According to China’s State Council, there are now over 221 million
Chinese migrants, representing over 17% of China’s total population (Wang, 2011). Women of
childbearing years represent more than one-third of these workers. Pregnant women will many
times deliver their child in their natal township and return to work in the city post-partum in order to
provide needed income to their family. Children and infants of migrant women are often left
behind in their natal village with grandparents as caregivers when the mother migrates. Estimates
put these “left-behind children” at 58 million (Stack, 2010).
While statistics show that overall breastfeeding rates in rural areas are high, infant feeding patterns
and preferences of migrant women have not been studied.
• Community Health Workers
China’s rural healthcare system is comprised of government run village clinics, township health
centers, and county hospitals run by doctors and nurses who are mainly educated through a junior
college or secondary school programs (Meng, Yuan, Jing, & Zhang, 2009). Training programs
typically take two years, but may be more or less depending on the needs and resources of the
community (Anand, et al., 2008). Responsibilities range from providing vaccinations to HIV
Community health workers are often extremely effective as health educators in rural areas as they
have an intimate understanding of how traditional beliefs can be incorporated into nutrition and
health education. Successful intervention studies based on community based participation, led by
community health workers, (Israel, Eng, Schulz, Parker, & Satcher, 2005) have been effective in
reducing the prevalence and incidence of infant malnutrition among certain minority populations
in rural areas of China (Y. Li, et al., 2007). These programs have taken into account traditional and
cultural beliefs of individual women and families, and have coupled them with participation at the
community level. The role of the community health worker in IYCF programs in rural China warrants
further investigation, as there is promising evidence that this cadre can help nutrition and growth
outcomes to be successful (Zhang, Shi, Wang, & Wang, 2009).
Xichou is a rural community in southern Yunnan province, where two authors (LW and XS) worked
with a team of physicians at the Xichou Women and Children’s Preventative Hospital. Throughout
discussions on IYCF, poverty and inadequate education were the two most frequently mentioned
reasons for undernutrition among children in rural areas. When asked about major nutrition
challenges in rural areas, many turned directly to economic policy. “It is more important to
influence economic policy so [rural people] can buy a refrigerator for meat”, explained one urban
medical student who had spent time in Xichou. Many parents must migrate to an urban area to
find economic opportunities in order to alleviate poverty. A young mother expressed financial
hardship by explaining how she had to make the painful choice of leaving her child in the village
while she moved to the city to make money for her aging parents, whose farm was unable to
support a family in the current economic environment.
One young woman we spoke with had to leave her son when he was two-months old as her
husband was from a different rural area than she, neither of them sharing a hukou, China’s
household registration system. An individual’s hukou determines many social services, including
insurance, childcare, and education. Her parents were taking care of her son, and she expressed
concern about having to give him domestic infant formula because of the “milk scandal”.
Structural barriers such as these pose challenging difficulties for migrant women to be with their
infants. In order to promote successful programs, these women will need additional support to
translate the desire to breastfeed with the ability for her to be with her baby.
Along with attention being paid to structural barriers, multiple physicians and community health
workers also noted nutrition education as an important component of improving the health of rural
Chinese infants. According to the Department Head of Pediatrics at the Xichou Women and
Children’s Preventative Hospital, Xichou has between 225-270 community healthcare workers to
serve a population of 200,000. Interviews revealed perceptions of community health workers being
too busy with other tasks to bother with infant feeding education. Grandparents and individuals
reported low level of understanding of child appropriate foods (foods high in iron, zinc, or protein),
but according to both rural physicians and urban medical students working in rural areas,
community healthcare workers also knew very little in terms of IYCF nutrition. This has been reported
elsewhere in the literature (Wang, et al., 2005).
THE ROLE OF INFANT FEEDING EDUCATION
In the changing landscape of an increasingly mobile society, designing nutrition education
programs that are easily translatable from urban to rural areas is essential. As the disease burden
shifts from communicable to non-communicable, healthcare policies that promote better IYCF
practices must be implemented across economic regions.
With China’s family planning policy, nearly all mothers are inexperienced with infant feeding and
rely heavily on advice from close relatives or media sources such as the internet and
advertisements. New mothers in China are influenced more by family members than healthcare
workers in IYCF practices (Zhang, et al., 2009), yet perinatal information regarding breastfeeding is
rarely directed at entire families. If healthcare workers are able to reach out to the whole family for
breastfeeding education, however, breastfeeding is likely to be more successful (Hector, King,
Webb, & Heywood, 2005; Jiang, et al., 2012; Wilkinson, 2011).
Accurate, unbiased information regarding appropriate breastfeeding practices is difficult to find in
the new consumer-driven economic system (Gottschang, 2007). Formula companies have
opportunities to capitalize on low public understanding of optimal infant nutrition and may provide
inaccurate or inadequate information to healthcare practitioners who have been charged with
public health education. Providing proper IYCF training to healthcare workers, who can then be
trained to educate mothers and their families, should be a priority of policy-makers and healthcare
Table 1. Barriers to optimal infant and young child feeding
Level Urban Rural
Individual Mother returning to work
Perceived inadequate milk production Migration
Household Desirability of overweight infants
One-child policy causing restructuring of
Grandparents as primary caregivers
Lack of knowledge
Community Consumer culture driving formula use
Poorly trained community health
National Corporate advertising
Absence of IYCF
Exclusive breastfeeding through 6 months, and continued breastfeeding with the addition of
complementary foods until two years thereafter, continues to be recommended for all infants in
China. Due to the current economic and social situation, however, women and families often lack
appropriate support for the success of exclusive breastfeeding. On one hand, clinicians and
families understand that breastfeeding is the preferred method to infant feeding. On the other,
issues such as migration, economic stability, the one-child policy, and cultural perceptions of
healthy infants reduce exclusive breastfeeding.
As China moves towards an urban, consumer-based society, childhood obesity rates rise, and
influencing factors of under- and over-nutrition are continually affected by fluid changes in
economic, political, social and technological systems. In rural areas, barriers include the separation
of parents from their child, a decline in breastfeeding rates, and low-level understanding of age-
appropriate foods. In urban areas we also observe a decline in breastfeeding rates, although there
we see a rise in childhood obesity and an increase in morbidity from non-communicable disease.
Costs from health problems associated with obesity promise to be massive due to rising demand for
healthcare (French & Crabbe, 2010). Lifestyle habits and choices that may lead to obesity are
much easier to shape from early childhood. Obesity programs for adults tend to be costly and have
Up to 600,000 deaths could be avoided each year if exclusive breastfeeding and appropriate
weaning practices were utilized worldwide. Societal costs of undernutrition include hospitalizations
and loss of future income due to cognitive difficulties. Breastfeeding promotion remains the single
most cost-effective intervention to decrease child mortality (Jones, et al., 2003).
Policy-makers should focus on reforms that promote more appropriate infant-feeding practices that
span geographic and economic regions, including cultivating nutrition-training programs,
breastfeeding promotion that welcomes family participation, and limiting infant formula
Community participatory techniques have been successfully piloted in rural China and should be
utilized wherever feasible. In Beijing and Shanghai, La Leche League utilizes community
participation in order to promote breastfeeding, and comparable programs would likely succeed
in rural areas, headed by a trained community healthcare worker. This is an extremely cost-
effective way to improve outcomes associated with infant feeding practices in China.
In summary, revising IYCF programs to acknowledge barriers such as migration, household
resources, and the effects of the media and advertisements in shaping public opinions must be
addressed before successful breastfeeding policies and programs can be created. We suggest
that along with enhancing nutrition education of community health workers, larger issues of family
dynamics and community participation must be investigated further. Infant feeding programs can
be an incredibly cost-effective lever for improving population health, and can and should be
seized to help China fully realize its potential.
• Optimal infant feeding is critical for the health of a nation, and can reduce both over- and
• In urban China, major barriers to optimal infant nutrition include re-negotiating the role of the
working mother, the desirability of overweight infants, the one-child policy causing a
restructuring of family roles, and a consumer culture driving formula advertisement and use
• In rural China, major barriers to optimal infant nutrition include rural-to-urban migration,
grandparents as the primary caregivers, a lack of knowledge, poorly trained community health
workers, and economic inequality
• Solutions to optimize IYCF practices include taking a community-based participatory approach
to infant feeding education, including the entire family in infant feeding discussions, and limiting
infant formula marketing.
The authors would like to acknowledge pediatricians Dr’s Tian-jiang Jiang (蒋天江) and Qiong Li (李
琼) from the Xichou Women and Children’s Preventative Hospital , Dr. Nancy Krebs from the
University of Colorado Health Sciences Center, and Shanghai Jiaotong University medical students
Jing-qiu Ma (马静秋), Yanqi Hu (胡燕琪), Jinrong Liu (刘金荣).
Agency for Healthcare Research Quality (2007). Breastfeeding and Maternal and Infant Health
Outcomes in Developed Countries. Boston: Tufts-New England Medical Center.
Anand, S., Fan, V. Y., Zhang, J., Zhang, L., Ke, Y., Dong, Z., et al. (2008). China's human resources for
health: quantity, quality, and distribution. The Lancet, 372(9651), 1774-1781.
BBC News (2010). Timeline: China milk scandal, from http://news.bbc.co.uk/2/hi/7720404.stm
Dewey, K. G., Heinig, M. J., Nommsen, L. A., Peerson, J. M., & Lonnerdal, B. (1993). Breast-fed infants
are leaner than formula-fed infants at 1 y of age: the DARLING study. Am J Clin Nutr, 57(2), 140-
French, P., & Crabbe, M. (2010). Fat China: How expanding wastlines are changing a nation. New
York City: Anthem Press.
Gong, P., Liang, S., Carlton, E. J., Jiang, Q., Wu, J., Wang, L., et al. (2012). Urbanisation and health in
China. The Lancet, 379(9818), 843-852.
Gooze, R., Anderson, S., & Whitaker, R. (2011). Prolonged bottle use and obesity at 5.5 years of age
in US children. The Journal Of Pediatrics, 159, 431-436.
Gottschang, S. Z. (2007). Maternal Bodies, Breast-Feeding, and Consumer Desire in Urban China.
Medical Anthropology Quarterly, 21(1), 64-80.
Guldan, G. S. (2000). Paradoxes of Plenty: China's Infant-and Child-Feeding Transition. In J. Jing (Ed.),
Feeding China's Little Emperors. Stanford: Stanford University Press.
Guldan, G. S., Fan, H.-C., Ma, X., Ni, Z.-Z., Xiang, X., & Tang, M.-Z. (2000). Culturally Appropriate
Nutrition Education Improves Infant Feeding and Growth in Rural Sichuan, China. The Journal of
Nutrition, 130, 1204-1211.
Hector, D., King, L., Webb, K., & Heywood, P. (2005). Factors affecting breastfeeding practices.
Applying a conceptual framework. New South Wales Public Health Bulletin, 16(4), 52-55.
Hornby, L., & Lee, J. L. (2012). Safety scandals give foreign dairies a boost in China. Reuters, from
Israel, B., Eng, E., Schulz, A., Parker, E., & Satcher, D. (Eds.). (2005). Methods in Community-Based
Participatory Research for Health. San Francisco: Jossey-Bass Publishers.
Jiang, H., Li, M., Yang, D., Wen, L. M., Hunter, C., He, G., et al. (2012). Awareness, Intention, and
Needs Regarding Breastfeeding: Findings from First-Time Mothers in Shanghai, China.
Breastfeeding Medicine, 0(0).
Jones, D., & Mao, S. (2012, April 24). China's moms key to Nestle baby milk deal. Reuters, from
Jones, G., Steketee, R. W., Black, R. E., Bhutta, Z. A., Morris, S. S., & the Bellagio Child Survival Study
Group (2003). How many child deaths can we prevent this year? The Lancet, 362, 65-71.
Li, L., Li, S., Ali, M., & Ushijima, H. (2003). Feeding practice of infants and their correlates in urban
areas of Beijing, China. Pediatrics International, 45, 400-406.
Li, Y., Hotta, M., Shi, A., Li, Z., Yin, J., Go, G., et al. (2007). Malnutrition improvement for infants under
18 months old of Dai minority in Luxi, China. Pediatrics International, 49, 273-279.
Liu, W., Yang, F., Liu, D., Yang, S., Mao, M., Yang, H., et al. (2009). Effects of different feeding types
on the physical growth of infants. Sichuan Da Xue Xue Bao Yi Xue Ban, 40(3), 548-550.
Lucas, A., Blackburn, A. M., Aynsley-Green, A., Sarson, D. L., Adrian, T. E., & Bloom, S. R. (1980). Breast
vs Bottle: Endocrine responses are different with formula feeding. The Lancet, 315(8181), 1267-
Luo, F. H., Shen, S. X., & Tu, Y. Z. (2004). The prevalence of obesity in Shanghai children and
adolescents aged 6-18 years. Chinese Journal of Diabetes, 2004年6期.
Ma, J.-Q., Zhou, L.-l., Hu, Y.-q., Liu, J.-R., Liu, S.-S., Zhang, J., et al. (In press 2012). Feeding and growth
of normal birthweight infants during the first year of life in Shanghai. Early Human Development.
McLeroy, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health
promotion programs. Health Education Quarterly, 15(4), 351-377.
Meng, Q., Yuan, J., Jing, L., & Zhang, J. (2009). Mobility of primary health care workers in China.
Human Resources for Health, 7(24).
Monteiro, P. O., & Victora, C. G. (2005). Rapid growth in infancy and childhood and obesity in later
life--a systematic review. Obes Rev, 6(2), 143-154.
Schack-Nielsen, L., Sorensen, T., Mortensen, E. L., & Michaelsen, K. F. (2010). Late introduction of
complementary feeding, rather than duration of breastfeeding, may protect against adult
overweight. Am J Clin Nutr, 91(3), 619-627.
Seror, J., Amar, A., Braz, L., & Rouzier, R. (2010). The Google News effect: Did the tainted milk
scandal in China temporarily impact newborn feeding patterns in a maternity hospital? Acta
Obstet Gynecol Scand, 89, 823-827.
Shen, T., Habicht, J.-P., & Chang, Y. (1996). Effect of economic reforms on child growth in urban and
rural areas of China. The New England Journal of Medicine, 335(6), 400-406.
Singhal, A., Farooqi, I. S., O'Rahilly, S., Cole, T. J., Fewtrell, M., & Lucas, A. (2002). Early nutrition and
leptin concentrations in later life. Am J Clin Nutr, 75(6), 993-999.
Stack, M. K. (2010, September 29, 2010). China raising a generation of left-behind children. Los
Angeles Times, from http://articles.latimes.com/2010/sep/29/world/la-fg-china-left-behind-
Stokols, D. (1996). Translating social ecological theory into guidelines for community health
promotion. American Journal of Health Promotion, 10(4), 282-298.
The Associated Press (2012, April 26 ). Mead Johnson 1Q profit rises, raises 2012 guidance.
Bloomberg Businessweek, from http://www.businessweek.com/ap/2012-04/D9UCKINO0.htm
United Nations (2008). The Millennium Development Goals Report 2008. New York: United Nations.
von Deneen, K., Wei, Q., Tian, J., & Liu, Y. (2011). Obesity in China: What are the Causes? Current
Pharmaceutical Design, 17, 1132-1139.
Wang, F. (2011). Wakeup Call in Beijing, from Census Takers Retrieved June 17, 2012, from
Wang, X., Wang, Y., & Kang, C. (2005). Feeding practices in 105 counties of rural China. Child Care
Health Dev, 31(4), 417-423.
Wilkinson, L. (2011, Food Allergies On The Rise In China.
World Health Organization (2008). Indicators for assessing infant and young child feeding practices
Part 1: Definitions. Washington DC: US AID, AED, Food and Nutrition Technical Assistance, UC
Davis, unicef, WHO.
Xu, F., Qiu, L., Binns, C., & Liu, X. (2009). Breastfeeding in China: a review. International Breastfeeding,
Zhang, J., Shi, L., Wang, J., & Wang, Y. (2009). An infant and child feeding index is associated with
child nutritional status in rural China. Early Human Development, 85, 247-252.