• Weight-for-age z-score [ Time Frame: At 6 month of age; at 12 month of age. ]
  Child's weight-for-age z-score (kg)
• Percentage of children who are nutritionally at risk in first 12 months of life [ Time Frame: 0-12 months of age. ]
  Using a combination of traditional anthropometric measures we will define children who don't meet expected growth standards.

The Low-birthweight Infant Feeding Exploration (LIFE)(original grant 0-6 months of age) and the 6- month extension (6-12 months of age) will fill a critical data gap in the field of newborn care regarding vulnerability and feeding of LBW infants. The investigators aim to establish the background information required to set up and test the most efficient and feasible infant feeding strategies for LBW infants: first to support breastfeeding, and then to support infants who are nutritionally at risk in the first 6 month of life in low and middle income countries (LMIC). The investigators will explore all three infant feeding options currently included in the WHO guidelines for LBW infants (WHO 2011), namely mother's own milk (MOM), donor human milk (DHM), and breast milk substitute or formula (BMS), in that order. This work will provide much-needed evidence to inform infant feeding guidelines.

In addition, this 6-month extension will allow for a more comprehensive exploration and understanding of feeding options for LBW infants from 6 to 12 months of age, accounting for timing of introduction of complementary liquids and foods, changes in feeding types, growth and health outcomes over the entire infancy period. This will contribute significantly and allow for high quality data to describe the burden of disease across sites. Specifically, we will be able to describe the following for LBW infants:

• Growth trajectories from 0 to 12 months of age
• Patterns and timing of complementary feeding and continued breastfeeding/breastmilk consumption
• Common infant morbidities and timing of mortality
• Maternal demographics, well-being and environmental factors affecting infant feeding and growth

The overall study goal is to understand feeding options for LBW infants in LMIC settings, including current feeding practices, health outcomes, and potential interventions. The study will take place in four study sites located in three countries: Tanzania, Malawi, and India. Each study site will encompass 2 to 5 individual study facilities. The three study objectives under the goal include:

1. Understand the current practices and standard of care (SOC) for feeding LBW infants
2. Define and document the key outcomes (including growth, morbidity, and lack of success on MOM) for LBW infants under current practices
3. Assess the acceptability and feasibility of a system-level IYCF intervention and the proposed infant feeding options for LBW infants

The investigators will also use the results of this work to design ways to support exclusive breastfeeding (including strategies for feeding with MOM), and to support other options, when mother's own milk (MOM) is unavailable or infants are nutritionally at risk. To do this, the investigators will engage in discussion and consensus-building activities among study staff and key stakeholders, using the collected study data to inform feasible, acceptable Infant and Young Child Feeding (IYCF) strategies for LBW infants that include specific options for those who are nutritionally at risk. The strategies will be tailored to the country as much as possible. A primary product for this later stage will be a white paper documenting key findings from the research and proposing feeding strategies for LBW infants in study sites.

• Low Birthweight
• Pre-Term

• In-facility Observations
  Mothers and their LBW babies will be observed starting within 6 hours of birth until the baby is discharged from the health facility.
• Prospective cohort study - Quantitative
  Mothers and their low-birth weight babies will be enrolled 72 hours after birth and followed through 12 months postpartum. The prospective cohort survey (which includes anthropometric measurements and feeding observations) occurs at multiple time points over this 12-month period.
• Prospective cohort study - Qualitative

  Research specialists at each site will be speaking to key informants (includes doctors, nurses, midwives, community health workers (CHWs), Ministry of Health (MOH) officials, supply chain & milk bank experts) who are knowledgeable about breastfeeding policy, supply chain, or milk banks. Clinicians in study health facilities who work on labor and delivery, postnatal, newborn and neonatal ICU wards. They participate in In-depth interviews. Mothers, family members and health care workers of LBW babies, as well as community leaders (including religious leaders) who are knowledgeable about infant feeding in their communities will participate in focus group discussions. Focus group discussion will take up to 2 hours. In-depth interviews will take up to 1 hour.

  Mothers (6-month extension): Mothers chosen and consented for IDIs will include those currently enrolled in the prospective cohort. Additionally, their infants need to be between 9 and 12 months of age.

• Retrospective Chart review
  The retrospective chart review is a review of secondary data of mothers and their LBW babies who were born in the study health facilities prior to the start of the study.
• Donor Human Milk Readiness Assessment

  Key stakeholders in the area of newborn health who determine policy and procedures or who are directly involved with the provision of care. This includes clinicians, nurses, lactation/nutrition specialists, hospital leadership and/or Ministry of Health officials present in the study health facilities.

  This is a one-time data collection exercise in the form of either: (1) a largely qualitative facility readiness assessment tool with some qualitative questions for facility staff or (2) a facility tool observing the "flow of milk" along with key informant interviews in the study facilities. This could take anywhere from 1hr to a day depending on the tool administered, key informants involved and size of the study facility.

Inclusion Criteria:

• Infant birthweight between 1500 and <2500g (according to chart and then verified by study staff).
• Residence within catchment area of facility.
• Mother's consent obtained for herself and infant.
• Newborns must be enrolled within 72 hours of birth.
• Women (mothers) who are of age of majority in their respective countries.

Exclusion Criteria:

• Mother does not meet the local age of majority.
• Infant very low birthweight <1500g.
• Infant has congenital abnormality that interferes with feeding, which includes: Cleft lip or palate; Hydrocephalus; Gastrointestinal tract anomalies including gastroschisis, omphalocele, or anal atresia; Neural tube defects; Congenital cardiac defects; Suspected Trisomy 21; Suspected TORCH infection such as congenital rubella, cytomegalovirus (CMV), toxoplasmosis, or syphilis.
• Critical or severe illness jeopardizing early survival, specifically, investigators will exclude infants with severe encephalopathy as determined by modified Sarnat criteria.
• If the Infant dies before enrollment can occur.
• Infant has a twin or triplet that has died.
• Plans to leave the study area before end of data collection.
• Infants must be enrolled in the prospective study within 72 hours of birth. If the infant is older than 72 hours at the time of screening, s/he will be ineligible for the study.
• Maternal death: The study will exclude cases of maternal death that occur during labor and delivery (or at any time before the consenting process would begin for this study).

• Maternal deaths will count as an exclusion criterion for the prospective cohort if they occur before enrollment. In the event that a mother dies at any time after enrollment the infant will still be retained in the cohort.

  6-Month Extension Study Criteria:

Inclusion criteria for the mother/infant pair are:

• Currently enrolled in the LIFE study and fulfills all original inclusion criteria.
• Mother's or surrogate consent obtained for herself and infant for another 6 months of follow up.

Exclusion criteria for the mother/infant pair are:

• Not previously enrolled in the LIFE study in addition to all original exclusion criteria.

• Bill and Melinda Gates Foundation
• Emory University
• Boston Children's Hospital
• Brigham and Women's Hospital
• PATH
• University of North Carolina, Chapel Hill
• Jawaharlal Nehru Medical College
• Muhimbili University of Health and Allied Sciences
• University of North Carolina
• Ariadne Labs