Low-birthweight Infant Feeding Exploration
Conditions: Low Birthweight, Pre-Term
Sponsor: Harvard School of Public Health (HSPH)

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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STUDY PROTOCOL 
 
 
LIFE 
Low-birthweight Infant Feeding Exploration 
 
 
 
Principal Investigator: Katherine Semrau, MPH, PHD 
Sponsor: Bill & Melinda Gates Foundation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol version:  
9.0 
Date:   
 
March 18, 2020 
 
 
 
 
 
 
 
 
 
 

 
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Contents 
1 Acronyms 
5 
2 Definitions of technical study terms 
6 
2.1 Defining “failure” 
7 
3 Background and problem statement 
9 
4 Study goal and objectives 
11 
5 Main study activities 
13 
5.1 Language of main study activities 
15 
6 Preliminary activities/Data Collection Preparation 
17 
6.1 Hire staff 
17 
6.2 Develop study materials 
17 
6.3 Train research staff 
17 
6.4 Data capture system 
17 
6.5 Develop Data Quality Assurance plan 
18 
6.6 Procure materials for data collection 
18 
7 Facility Context Assessments 
19 
7.1 Context assessments 
19 
7.2 Inclusion/exclusion criteria 
19 
7.3 Sample size 
19 
7.4 Data collection 
19 
7.5 Data analysis 
19 
8 In-facility observations 
20 
8.1 Consent from facility leadership 
20 
8.2 Participation and consent by clinical staff 
20 
8.3 Inclusion/exclusion criteria 
20 
8.4 Screening and recruitment 
22 
8.5 Informed consent 
22 
8.6 Observation schedule 
23 
8.6.1 During daytime shifts 
23 
8.6.2 During nighttime shifts 
24 
8.7 Sample size 
24 
8.8 Data analysis 
24 
9 Prospective cohort 
26 
9.1 Inclusion/exclusion criteria 
26 

 
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9.2 Recruitment of infants born in the facility 
28 
9.3 Recruitment of infants born outside the facility 
29 
9.4 Recruitment for 6-month extension 
30 
9.5 Replacement of infants who die in the first 72 hours 
30 
9.6 Assessment of congenital abnormalities and serious illnesses in infants 
31 
9.7 Overlap between observation and prospective cohort recruitment 
32 
9.8 Informed consent 
32 
9.9 Incentives 
33 
9.10 Benefits to participation 
33 
9.11 Maternal or infant death during study period 
33 
9.12 Sample size 
33 
9.13 Response rates 
35 
9.14 Schedule of data collection 
36 
9.15 Location of follow up visits 
37 
9.16 Data collection at sick visits 
38 
9.17 Data collection at home visits 
38 
9.18 Study measures 
39 
9.18.1 Demographics, pregnancy history and home environment 
39 
9.18.2 Gestational age (baseline visit only) 
39 
9.18.3 Infant anthropometrics 
40 
9.18.4 Maternal anthropometrics 
40 
9.18.5 Infant feeding questionnaire 
40 
9.18.6 Infant health questionnaire 
41 
9.18.7 Maternal health questionnaire 
42 
9.18.8 Follow up phone survey 
43 
9.19 Ethics 
43 
9.19.1 Risks to participants 
43 
9.19.2 Informed consent 
43 
9.20 Data analysis 
43 
10 Qualitative research 
44 
10.1 Focus group eligibility criteria 
46 
10.2 Language of focus group discussions 
47 
10.3 In-depth interview eligibility criteria 
48 
10.4 Recruitment 
49 
10.5 Informed consent 
50 
10.6 Conduct of groups and interviews 
50 

 
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10.7 Data analysis 
51 
10.8 Schedule of data collection 
51 
11 Desk research 
53 
11.1 Chart review 
53 
11.1.1 Inclusion/exclusion criteria 
53 
11.2 Literature reviews 
54 
12 Donor Human Milk Readiness Assessment Surveys 
54 
12.1 Donor Human Milk Readiness Assessments Surveys 
54 
12.2 Inclusion/exclusion criteria 
54 
12.3 Sample size 
54 
12.4 Data collection 
55 
12.5 Data analysis 
55 
13Monitoring and Quality Assurance 
55 
13.1 Quantitative data streams 
56 
13.2 Qualitative data streams 
57 
14 Partners and experts 
57 
15 Study timelines 
61 
15.1 Study Extension Timeline 
62 
16 References 
62 
17 Appendix A: Protocol for measuring infant weight, length, head circumference, and MUAC 
66 
18 Appendix C: List of hospitals where data collection will take place 
67 
19 Appendix D: List of Co-PIs 
67 
 
 
 

 
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1 Acronyms 
 
ANC 
Antenatal care  
BF 
Breastfeeding 
BMGF 
Bill & Melinda Gates Foundation 
BMS 
Breast Milk Substitute/Formula 
CASI 
Context Assessments for Successful Implementation 
CMO 
Chief Medical Officer 
DA 
Dearness Allowance 
DHM 
Donor Human Milk 
EBF 
Exclusive Breastfeeding 
FGD 
Focus Group Discussions 
HIC 
High income country 
HSPH 
Harvard TH Chan School of Public Health 
IDI 
In-depth Interviews 
IUGR 
Intrauterine Growth Retardation 
IYCF 
Infant Young Child Feeding 
JNMC 
Jawaharlal Nehru Medical College 
LAZ 
Length-for-age z-score 
LBW 
Low Birthweight  
LIFE 
Low Birthweight Infant Feeding Exploration 
LMIC 
Low- and Middle-Income country 
LMP 
Last Menstrual Period 
MOM 
Mother’s Own Milk 
MUAC 
Mid-upper arm circumference 
MUHAS 
Muhimbili University of Health & Allied Sciences 
NEC 
Necrotizing Enterocolitis 
NICU 
Neonatal Intensive Care Unit 
OHRP 
Office for Human Research Protections 
PMI 
Maternal perceived milk insufficiency 
SOC 
Standard of Care 
TAG 
Technical Advisory Group 
UNC 
University of North Carolina 
VLBW 
Very Low Birthweight 
WASH 
Water, sanitation and hygiene 
WAZ 
Weight-for-age z-score  
WHO 
World Health Organization 
WLZ 
Weight-for-length z-score 
 
 
 

 
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2 Definitions of technical study terms 
 
Term 
Operational definition for LIFE study 
Birthweights 
 
LBW 
less than 2,500 g/5.5 lbs (UNICEF 2014). 
VLBW 
<1500 g 
LBW band 1 
1500-1799 g 
LBW band 2 
1800-2199 g 
LBW band 3 
2200-2499 g 
Feeding behaviors 
 
Complementary 
feeding 
Feeding of any liquids or foods other than breastmilk or formula to an infant 
after 6 months of age. 
Predominant breastfeeding 
Breast milk as predominant source of nourishment, but may also have 
received liquids, ritual fluids and ORT, drops or syrups (Haroon et al 2013) 
Partial breastfeeding 
Giving a baby some breastfeeds and some artificial feeds, either milk or 
cereal, or other foods (Haroon et al 2013) 
No breastfeeding 
Infants receiving no breastmilk at all (Haroon et al 2013) 
Early initiation of 
breastfeeding 
Provision of mother’s breast milk to infants within one hour of birth 
Exclusive breastfeeding 
Child receiving only breast milk (including milk expressed or from a wet 
nurse) and no other type of milk or solids but could include vitamins, drops of 
other medicines and oral rehydration therapy (ORT) (Haroon et al 2013).  
Breastmilk expression 
Expression of breastmilk through any means, such as hand expression, electric 
pump, or manual pump. 
Parenteral feeding 
Any method of intravenous feeding 
Enteral feeding 
Any method of feeding through the gastrointestinal tract, including via the 
mouth. 
People 
 
Mother 
Biological mother. For this protocol, in the case of a maternal death, this term 
will refer to the primary caregiver for the infant. 
Mother-infant pair 
Both biological mother and infant together. In the case of multiples, this 
phrase includes all infants. 
Caregiver 
Anyone giving care and feeding to the infant post-discharge, such as fathers, 
family members, or friends. 
Primary caregiver 
A single person who gives the majority of care and feeding to the infant post-
discharge. Typically, the mother, but can also be a father, family member, or 
friend. 
Clinical staff 
Any member of the site staff that provide clinical care to study subjects, such 
as physicians, nurses, or midwives 
Study staff 
Anyone hired by LIFE to perform study-related activities 
Formula types 
 

 
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Standard term formula 
Designed for term infants, based on the composition of mature breast milk. 
The typical energy content is 68 kcal/100 ml. The concentration of protein, 
approximately 1.4-1.5 grams/100ml, and calcium and phosphate are not 
sufficient to provide the recommended nutrient needs for stable and growing 
preterm infants.(Cochrane Review: Henderson et al 2007) 
Preterm formula 
Calorie-enriched (approximately 80 kcal/100 ml), protein-enriched 
(approximately 2.0- 2.4 grams/100ml), and variably enriched with minerals, 
vitamins, and trace elements to support intrauterine nutrient accretion rates. 
These milks are often used for nutrition of preterm infants prior to hospital 
discharge (Cochrane Review: Henderson et al 2007) 
Post-discharge formula 
Specifically designed for a preterm infant’s post-discharge from hospital. 
These are less nutrient dense compared with preterm formulae, but are calorie 
(about 72- 74 kcal/100 ml), protein (about 1.8 grams/ 100 ml) -enriched, and 
variably enriched with minerals, vitamins, and trace elements compared to 
standard term formula milk. (Cochrane Review: Henderson et al 2007) 
Location within facilities 
 
Neonatal care facility 
Any dedicated space that offers additional neonatal care beyond the healthy 
mother-infant pairs. This space can have different names, such as NICU, 
SNCU, neonatal ward, neonatal care facility. 
KMC 
Kangaroo Mother Care 
NICU 
Neonatal Intensive Care unit, including levels I, II, or III 
Study locations 
 
Study country 
The three countries are Tanzania, Malawi, and India. 
Study site 
The four study sites are Dar es Salaam, Lilongwe, Karnataka, and Odisha. 
Study facility 
Each study site has 2 to 5 study facilities, which are individual hospitals or 
clinics. There are 12 total study facilities:  
● Lilongwe: 2 
● Dar-es-Salaam: 3 
● Karnataka: 5 
● Odisha: 2 
Study region 
The two study regions are Africa (Tanzania and Malawi) and SE Asia (India), 
which have two study sites each. 
 
 
‘ 
 
 
 
 
 
 
2.1 Defining “failure” 
 
At several points in the course of designing LIFE, the study team debated definitions for the terms 
“failure to thrive,” “failure to breastfeed,” “nutritionally at risk,” “unsuccessful breastfeeding,” and 

 
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similar terms. The idea was to generate a study-wide “bright line” definition of an infant’s clinical status 
that would trigger a referral to further care, providing a safety net for study participants.  
 
After debate, we came to consensus that this concept does not require a consistent definition across all 
study sites in LIFE. Instead, we will use the existing guidelines at each site, referring infants for further 
care based on the clinical criteria already in use at each site. This approach has several advantages: 
1. It is consistent with an observational study design. 
2. It is likely more acceptable to local ethics boards, since each definition reflects local ethical 
norms 
3. It facilitates field work because no systemic changes to clinical care will be required. 
 
As a matter of study design, this decision also aligns with our intention not to pool data across sites. 
Rather, we will analyze data from each site separately, describing the SOC in each, so each site dataset 
will have a consistent definition. 
 
When we design the follow-on LIFT trial, which will be interventional, we will establish a study-wide, 
consistent, clear, clinical definition of infants for whom breastfeeding is insufficient, as an inclusion 
criterion. At the point of designing LIFT, we will use the LIFE data to inform this definition, since we 
will know much more about breastfeeding behaviors, clinical paths, and eventual outcomes of these LBW 
infants. 
 
No matter the definition, we note a consensus to avoid the word “failure” in the name of the concept. 
 
 
 
 
 

 
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3 Background and problem statement 
 
Globally, 15% of all babies, amounting to 20 million infants each year, are born low birthweight (LBW). 
Compared to normal weight infants, LBW infants are at higher risk of morbidity, mortality, and poor 
growth (Risnes et al 2011; Larroque et al 2001; WHO 2006). The main causes of LBW are preterm birth, 
intrauterine growth restriction (IUGR), or their combination.  Preterm birth and IUGR may have different 
causes, and these conditions may carry different risks for morbidity, morality, sub-optimal feeding and 
growth (Katz et al 2013; Christian et al 2013). LBW contributes directly or indirectly to 60-80% of 
neonatal deaths (WHO 2011; Lawn et al. 2014). It is such an urgent issue that the World Health Assembly 
set out to reduce LBW by 30% by 2025 (WHO 2014). Unfortunately, there is a paucity of information 
around feeding practices and optimal feeding strategies for this population, particularly for LBW infants 
who struggle with breastfeeding or growth. 
 
In 2011, the World Health Organization released the Guidelines on Optimal Feeding for Low Birthweight 
Infants in Low-and Middle-Income Countries (LMICs). However, 70% of the guidelines are based on 
“low or very low” quality of evidence (WHO 2011), and the majority of research regarding mother’s own 
milk (MOM) alternatives has been in high-income, hospital-based settings (Blencowe 2013). There is a 
pressing lack of information about LBW infants in LMICs: existing feeding patterns; rates and causes of 
unsuccessful breastfeeding; and effective options for feeding, fortification, or supplementation with 
micronutrients. Forty global health organizations recently issued an urgent call to action to improve the 
evidence base, specifically for neonatal care units (Greenslade et al 2017). This study hopes to address 
some of these key gaps. 
 
Strong evidence does exist that breastfeeding improves outcomes for all infants and particularly for LBW 
infants. WHO and others recommend early initiation of breastfeeding within the first hour of birth and 
exclusive breastfeeding for six months with MOM (Haroon et al. 2013). Rates of early initiation of 
breastfeeding within one hour of life vary widely across the world, with a global estimate of 42% 
(UNICEF 2018) and regional estimates ranging from 14% to 93% of infants (Development Initiatives 
2017). Only 38% of infants globally are exclusively breastfed in the first six months of life (UNICEF 
2015). The rate of early and exclusive MOM feeding in LBW infants is not well known. Data are also 
lacking on the incidence of poor growth in LBW infants who are exclusively breastfed. 
 
As previously expressed, LBW is associated with a higher risk of mortality, morbidity, and suboptimal 
neurocognitive development. It is such an urgent issue that the World Health Assembly set out to reduce 
LBW by 30% by 2025 (WHO Global Nutrition Targets 2014). LBW contributes either directly or 
indirectly to 60-80% of neonatal deaths (WHO Infant Feeding Guidelines 2011). In addition to this 
increased risk of neonatal death, LBW infants are at higher risk of early growth retardation, infectious 
disease, developmental delay, adult cardiovascular disease, and death during childhood (Risnes et al 
2011; Larroque et a 2001; WHO Optimal feeding of the low birth weight infant( Technical review 2006). 
While LBW infants may catch up to normal birthweight infants by 12 months of age (Sridhar 2002; 
Jaruratanasirikul S 1999), the maximum catch growth may happen in the early period, specifically within 
the first 3 months of life (Han 2010).  This study will allow for a better understanding of growth of LBW 
infants throughout infancy. 
 
Though there is a lack of published data regarding rates of unsuccessful breastfeeding among LBW 
infants in low and middle-income countries (LMICs), anecdotal site estimates indicate that 3%-15% of 
LBW infants stop or have difficulty breastfeeding within the first six weeks. Globally, this means that 1 to 
3 million LBW infants are nutritionally at risk each year and could benefit from alternative feeding 
methods. For those unable to exclusively feed with MOM, WHO recommends donor human milk (DHM) 

 
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from a human milk bank as the next best alternative with breast milk substitute or formula (BMS) as the 
last alternative (WHO 2011). 
 
The evidence for appropriate methodology or implementation of these other feeding strategies is lacking. 
The recommendations regarding DHM are based on a few studies from high income countries among 
VLBW infants in the first days of life during initial NICU hospitalization with different standards of 
healthcare compared to most LMIC. DHM has been used to prevent necrotizing enterocolitis (NEC) and 
infection in very preterm newborns, but it is unclear if there is any benefit of DHM after the initial 
hospitalization in terms of longer term breastfeeding rates or health outcomes. WHO guidelines also only 
offer limited insight into dosages/volumes recommended for each feeding option and into how 
micronutrient (vitamin D, calcium, phosphorus, iron, and vitamin A) fortification should be practiced. 
There is little evidence comparing fortified versus unfortified DHM on outcomes for LBW and preterm 
infants, and there remains “no evidence of an effect on survival or longer-term growth and development” 
when looking at preterm or LBW infants fed formula versus DHM (Quigley et al 2018).  
 
In addition to a lack of evidence, DHM poses substantial feasibility challenges: cold chain; facilities for 
milk acquisition, pasteurization, and distribution; and cultural acceptability. However, BMS has been 
linked to increased incidence of NEC in early preterm infants and also poses challenges with regard to 
clean water supply for mixing formula, and sanitation capabilities. For  DHM and BMS, access to safe 
water and soap, and caregivers’ consistent ability to perform hygienic practices for ensuring bottle/vessel 
cleanliness (handwashing, safe drying and storage) are critical to ensure that feeding practices are not 
responsible for introducing pathogens to infants (Menon). Many questions remain to be answered 
regarding appropriate feeding methodologies for alternate feeding options among LBW infants who 
require alternatives or supplements to MOM. 
  
As all children age, the recommendation for infant feeding transitions from exclusive breastfeeding for 
the first 6 months of life to a period of complementary feeding. Complementary feeding can be a time of 
increased morbidity, especially diarrhea or other gastrointestinal illness, and other infectious diseases, due 
to exposure to foods especially if prepared in an unhygienic way and increased contact with pathogens as 
infants become more mobile (WHO 2005; Victora 2010). This may be of significant consequence for 
LBW infants who are already vulnerable.  
  
Current WHO complementary feeding guidelines include guidance for LBW infants born >37 weeks 
gestations, but recommendations for LBW infants born at earlier gestational ages are lacking (WHO 
2005). This is a challenge globally--not just in LMIC. Additionally, there is a lack of data on long term 
morbidity for LBW infants. In a brief literature search, only 66 articles included complementary feeding 
and preterm/LBW infants.  Moreover, timing of complementary feeding initiation in preterm infants is 
debated and no clear guidance has been outlined (Vissers et al 2018).  Globally, education about 
complementary feeding to families appears to be limited (Vitta et al 2016) (Kim et al 2017). There is a 
dearth of information about optimal feeding and growth of LBW infants, particularly in their transition 
during complementary feeding to infant and family foods and the association between growth trajectories 
and outcomes in the first 6 months and 12 months of life.  
 
The Low-birthweight Infant Feeding Exploration (LIFE) and the 6-month extension will fill a critical data 
gap in the field of newborn care regarding feeding LBW infants. We 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 
months of life in LMICs.We 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.  

 
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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 
 
 
We 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, we 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.  
4 Study goal and objectives 
 
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. As shown in Table 1, the study will achieve its overall goal through three 
objectives. 
 

 
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Table 1: Study goal and objectives 
Goal 
 
Understand feeding options for LBW infants in LMIC settings, including current feeding 
practices, health outcomes, and potential interventions. 
Objectives 
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 
 
To meet the first study objective of understanding practices, routine care and standard of care (SOC) for 
LBW infant feeding, we will use a mixed methods approach. First, we will conduct focus group 
discussions (FGD) with clinicians, mothers, family members, and religious leaders to understand current 
SOC and cultural practices around infant feeding. Second, we will enroll 35 mothers and up to 60 infants 
per site (approximately 35 pairs) for close in-facility feeding observation before discharge, focusing on 
the behaviors and interactions between mother, infant, and clinic staff regarding infant feeding. These 
feeding observations may be conducted in the neonatal care unit and Neonatal Intensive Care Unit 
(NICU), if applicable. Third, we will enroll and follow a prospective cohort of approximately 300 
mothers and their LBW infants at each site. Caregivers of all LBW infants at each site will be approached 
for consent. All enrolled infants will be followed prospectively for up to six months through a regular 
schedule of clinic visits, and mothers will be regularly interviewed on their normal feeding practices and 
related topics. Anthropometric measurements will be taken across the six months of follow up. Fourth, a 
set of structured facility observations will assess the current patterns of infant feeds and maternal milk in 
the health facility to understand how infant feeds are currently provided under SOC. 
 
For the 6-month extension:  
To meet the first study objective of understanding practices, routine care and standard of care (SOC) for 
LBW infant feeding, we will use a mixed methods approach. First, we will conduct in-depth interviews 
(IDIs) with mothers to understand current SOC and cultural practices around infant feeding from 6 
months to 1 year and the role of the home environment. Second, we will enroll and follow a prospective 
cohort of approximately 300 mothers and their LBW infants at each site who have been followed already 
for the first 6 months of their lives. Caregivers of all LBW infants at each site will be approached for re-
consent at or before their infant(s) reach 6 months of age. All enrolled infants will be followed 
prospectively for up to six months through a regular schedule of 2 visits, and mothers will be regularly 
interviewed on their normal feeding practices and related topics. Anthropometric measurements will be 
taken across the six months of follow up at two time points for the infant and at one time point for the 
mother.  
 
 
The second study objective is to provide descriptive epidemiology of a variety of LBW infant feeding 
markers and outcomes. The main data source for these outcomes will be the prospective observational 
cohort. We aim to follow all cohort infants for measurement up to 12 months outcomes, including 
breastfeeding behavior, feeds given (complementary), anthropometrics and a variety of infant and 
maternal health outcomes. Further, a retrospective chart review of LBW infants at each site will 
document, to the extent possible, the same infant feeding behaviors and outcomes as measured in the 
prospective cohort. Additional data on feeding and outcomes will be collected in up to 2 sites (Tanzania 

 
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and Malawi) short phone interviews that will take place between the two study visits (when children are 
about 7.5 and 10.5 months of age). 
 
The third study objective is to assess the feasibility and acceptability of a variety of IYCF strategies. Of 
particular interest are strategies for those LBW infants who cannot successfully breastfeed, including 
options for providing MOM (such as through expression or storage), DHM (such as from human milk 
banks), and BMS (such as formula or preterm formula), all possibly with or without supplementation or 
fortification. We will primarily use qualitative methods. FGDs with mothers, clinicians, family members, 
and religious leaders will cover IYCF strategies for MOM, DHM, and BMS. Additionally, in-depth 
interviews (IDIs) on IYCF acceptability and feasibility will be carried out among three populations: 
government officials, supply chain experts, and human milk bank experts. We will also conduct facility-
level Context Assessments for Successful Implementation (CASI) to determine a facility’s capacity and 
capability to implement a new intervention. This will provide insight into the level of support required to 
implement future IYCF interventions. The DHM readiness assessment will provide information on 
whether the establishing a DHM bank for study purposes (if identified as a suitable intervention to test) 
would be possible, feasible, acceptable and safe. 
 
 
For 6 -month extension:  
The main interest around the third study objectives are strategies for those LBW infants who are 
nutritionally at risk or whose growth is faltering and who may have problems with feeding (breastmilk 
and/or complementary foods). We will used mixed methods including the prospective cohort data and 
IDIs with mothers of these infants. 
5 Main study activities 
 
To meet these objectives, this mixed-methods study will collect data from a variety of sources. The seven 
main data collection activities are shown in Table 2, along with target sample sizes and the corresponding 
study objectives. Each of these activities have different inclusion/exclusion criteria, sample sizes, consent 
processes, and study procedures, all of which are discussed in turn in this protocol. 
 
Table 2: Main study activities 
Activity 
Population 
Target N per site 
Meets 
objective 
Tanzania 
Malawi 
India - 
Karnataka 
India - 
Odisha 
1 
2 
3 
1. Facility context 
assessment 
All facilities at each 
study site (clinicians) 
3 (90) 
2 (60) 
5 (250) 
3 (90) 
 
 
✓ 
2. In-facility observations  
Mother/infant pairs  
35-45 
35-45 
35-45 
35-45 
✓ 
 
 
Clinicians 
90 
60 
250 
90 
✓ 
 
 
3. Prospective cohort/ 6-
month extension 
Mother/infant pairs 
300 
300 
300 
300 
✓ 
✓ 
✓ 
4. Focus group discussions 
(5-8 participants each) 
Health care workers 
2-4 
2-4 
2-4 
2-4 
✓ 
 
✓ 
Mothers 
4 
4 
4 
4 
✓ 
 
✓ 
Family members 
2-4 
2-4 
2-4 
2-4 
✓ 
 
✓ 

 
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Religious leaders, 
community leaders, or 
traditional healers 
2-4 
2-4 
2-4 
2-4 
✓ 
 
✓ 
5. In-depth interviews 
(individuals or in pairs) 
Clinicians 
24-60 
24-60 
24-60 
24-60 
✓ 
 
✓ 
MOH and other 
government officials 
2-4 
2-4 
2-4 
2-4 
 
 
✓ 
Supply chain experts 
2-4 
2-4 
2-4 
2-4 
 
 
✓ 
Human milk bank 
experts 
2-4 
2-4 
2-4 
2-4 
 
 
✓ 
Mothers (extension) 
16-20 
16-20 
16-20 
16-20 
✓ 
 
✓ 
6. Chart reviews 
Mother/infant pairs 
155 
155 
155 
155 
 
✓ 
 
7. Literature reviews 
n/a 
 
 
 
 
✓ 
✓ 
✓ 
8. Donor Human Milk 
Assessment Surveys  
All facilities at each 
study site 
(stakeholders) 
 
 
 
 
 
 
✓ 
 
 
Aside from the literature reviews, these activities require collecting data from a variety of populations. 
Figure 1 illustrates the relative sizes and participants in the six activities collecting data from human 
subjects. As shown in the figure, the in-facility observations and the prospective cohort may overlap; 
women may be enrolled in both, although they are not required to do so. In addition, for the 6-month 
extension, participants will overlap in the prospective cohort follow up and qualitative IDIs.  
 
 
 
Figure 1: Size and possible overlap of six study populations excluding extension  
 

 
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5.1 Language of main study activities 
 
English is a common language across all four sites, but some study activities will be conducted in the 
local languages. Table 3 presents the standard languages to be used in LIFE, along with which activities 
will be carried out in which language. This specifies the study materials that must be translated from 
English into various languages, and those that will not require translation. 
 
 

 
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16 
 
 
Table 3: Language of main study activities 
Dar-es-Salaam 
Lilongwe 
Karnataka 
Odisha 
Standard languages for use in LIFE: 
Swahili, 
English 
Chichewa, 
English 
Hindi,  
Kannada, Marathi, 
English 
Hindi, 
Oriya, 
English 
Activity 
Population 
Language for each activity 
1. Facility context 
assessment 
All facilities at 
each study site 
English 
English 
English 
English 
2. In-facility 
observations  
Mother/infant pairs 
and clinicians 
Swahili 
Chichewa 
Hindi, Kannada, 
Marathi 
Hindi, Oriya 
3. Prospective cohort Mother/infant pairs 
Swahili 
Chichewa 
Hindi, Kannada, 
Marathi 
Hindi, Oriya 
3.1 Prospective Cohort  
Extension  
Mothers/ Infant 
pairs  
Swahili 
Chichewa 
Hindi, Kannada, 
Marathi, English 
Hindi, Oriya, 
English 
4. Focus group 
discussions 
 
 
Mothers 
Swahili 
Chichewa 
Hindi, Kannada, 
Marathi 
Hindi, Oriya 
Family members 
Swahili 
Chichewa 
Hindi, Kannada, 
Marathi 
Hindi, Oriya 
Health care 
workers 
English/Swahili 
English 
English 
English 
Religious leaders, 
community 
leaders, or 
traditional healers 
Swahili 
Chichewa 
Hindi, Kannada, 
Marathi 
Hindi, Oriya 
5. In-depth interviews 
 
Clinicians 
English/Swahili 
English 
English 
English 
MOH and other 
government 
officials 
English 
English 
English 
English 
Supply chain 
experts 
English 
English 
English 
English 
Human milk bank 
experts 
English 
English 
English 
English 
5.1 In-depth interviews 
(extension) 
Mothers  
Swahili/ English  Chichewa/ English Hindi, Kannada, 
Marathi/ English  
Hindi, Oriya/ 
English  
6. Chart reviews 
Mother/infant pairs 
n/a 
n/a 
n/a 
n/a 
7. Literature reviews 
n/a 
n/a 
n/a 
n/a 
n/a 
8. Donor Human Milk 
Assessment Surveys  
All facilities at 
each study site 
English 
English 
English 
English 
 
 
 
 
 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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6 Preliminary activities/Data Collection Preparation 
6.1 Hire staff  
Each of the study sites as well as Ariadne Labs will and may need to hire additional team members to 
implement this study and include the 6 month extension. Some of the hires in the study sites will be 
required to speak local languages as well as English, since rapid translation of some materials will be 
needed.  
 
6.2 Develop study materials 
Using the protocol as a guide, we will develop a series of semi-structured interview guides for in-depth 
interviews and focus groups. We will use a qualitative knowledge management tool for systematically 
and thematically organizing key messages from the IDIs/FGDs. We will also develop a template for 
documenting observations in the clinics or at home visits that will include highly structured elements of 
behaviors and the environment, and open-ended elements to capture reflections and narrative descriptions 
of the observations.  
 
6.3 Train research staff 
Once recruited or brought in from other projects, the study staff will need to be trained on the specific 
research questions, study methodologies and tools, and data collection processes. We will develop a 
standardized training curriculum using adult learning techniques for use across sites to ensure staff are 
successfully able to collect and enter data. Trainings will be conducted in-country. All trainings for study 
staff will include background on the study aims and objectives, overview of data collection 
methodologies and tools, a discussion of research ethics (informed consent, confidentiality, etc), and data 
quality assurance mechanisms. Training on qualitative methods will additionally cover principles of rapid 
qualitative analysis, strategies for interviewing and note taking, and summarizing of IDIs/FGDs for entry 
into the knowledge management tool. Training for the prospective cohort methodology will focus on 
survey administration techniques; use of app-based data collection tools where applicable; the data 
collection tools and their components include assessment of gross and fine motor skills and proper 
measurement techniques for anthropometric outcomes (weight, length, etc) and newborn gestational aging 
tests (i.e. Dubowitz, etc.). Training on in-facility observations and context assessment will focus on 
effective observer techniques and consistency in data collection to ensure inter-observer reliability. 
Training on chart review will focus on techniques for reliable, accurate abstraction of data from medical 
records.  
 
Most sites include staff members that have previously collected quantitative and/or qualitative data in 
other research studies, which should aid in clarification of activities and responsibilities including this 6-
month extension. We will evaluate the trainees to ensure that they are adequately prepared to initiate data 
collection and data entry activities, and we will co-conduct interviews/focus groups (either mock, pilot, or 
real) until we feel that they are able to both conduct the discussions and do the rapid qualitative analysis 
independently. If there is turnover after the initial training then we plan to revisit the site and re-train new 
staff members. Staff that do not pass the evaluation will have remedial training or not be allowed to 
collect data. 
6.4 Data capture system  
We will engage with on-the-ground partners and stakeholders to use existing resources and infrastructure 
to build and adapt technical data collection processes to serve study aims. We will also work with the 
local analytic teams, Ariadne Labs, and others to construct/adapt appropriate data architecture to support 
the study. 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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6.5 Develop Data Quality Assurance plan 
We plan to develop a robust data quality assurance plan to assess and ensure data accuracy. See Section 
12 for additional information. 
 
6.6 Procure materials for data collection 
Over the course of the data preparation phase, computers, tablets, and other materials will be procured.. 
Further, anthropometric measurement tools will be acquired, as needed, to ensure standardization across 
sites. Depending on costs, we will consider central purchasing. 
 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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7 Facility Context Assessments 
 
7.1 Context assessments 
Structured context assessments will take place at each site at the end of the study. This assessment will 
use the Context Assessment for Successful Implementation (CASI) Tool, a Likert-scale survey developed 
by Ariadne Labs that assesses five domains of facility context that are associated with implementation 
success.  
 
7.2 Inclusion/exclusion criteria 
All facilities in the LIFE study will be included. These include up to 3 facilities in the Dar es Salaam site, 
2 in the Lilongwe site, 5 in the Karnataka site, and 3 in the Odisha site. 
 
The CASI will be completed by front line clinicians who participate in newborn care and IYCF, as well as 
department and facility leaders.  
 
7.3 Sample size 
Our aim is to have the CASI tool completed by a census of all clinicians and leaders at every site 
involved with labor, delivery, and the NICU. If this is not possible, then we will strive to have as 
many subjects as possible in each facility. We expect a maximum of 150 clinicians/leaders per 
site. 
 
7.4 Data collection 
The CASI will be self-administered by each facility. Respondents will not provide their names on the 
tool, but they do indicate their role at the facility.  
 
The tool will be completed either on paper or electronically if the facility has access to computers and 
Internet service. The tool will be translated into the local language at each facility. 
 
7.5 Data analysis 
Responses will be scored and interpreted by the study team and results will be shared with the facilities.  
 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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8 In-facility observations  
 
The goal of the in-facility feeding observations is to better understand early feeding practices for LBW 
infants and the lactation support available for mothers as they initiate breastfeeding. Observations will be 
carried out by trained observers using a structured instrument.  
 
8.1 Consent from facility leadership 
 
We propose to obtain overall agreement for participation from each health facility and regional health 
authority, as required by each study site. These may include national ethics committees, institutional 
ethics committees, ministries of health, district health officers, chief medical officers, medical 
superintendents, medical directors, or other appropriate officers at each site prior to the start of the study. 
8.2 Participation and consent by clinical staff 
In the preparations for the study, all clinical staff will be informed that observations will be taking place 
during the study period, so they will be aware. New staff will be oriented to the research when they are 
hired. 
Consent will be taken from individual staff members at the beginning of the study period. Staff members 
will have the option to opt out of being observed at any time. We expect up to 150 clinicians per site to be 
approached for participation.   
We will seek full approval of this arrangement from facility leadership as part of that consent process. 
 
8.3 Inclusion/exclusion criteria 
 
Inclusion criteria for the mother/infant pair for in-facility observations are: 
 
Infant birthweight between 1500 and <2500 g 
We will use the facility-based birthweight taken at the time of delivery for the eligibility 
checklist.  
 
Mother’s consent 
Only women who give written consent at the time of birth will be included. 
 
Exclusion criteria for the mother/infant pair are: 
 
Infant very low birthweight 
Children who are very low birthweight (<1500g) will have different clinical needs and 
interventions. Thus, these infants will be excluded. 
 
Congenital abnormality that interferes with feeding 
Infants will be excluded if they have a congenital abnormality that (1) directly interferes with 
feeding and (2) is readily apparent at birth, requiring no special diagnostic tools. The specific 
abnormalities for exclusion are: 
● Cleft lip or palate 
● Hydrocephalus 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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● 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, CMV, toxoplasmosis, or 
syphilis. 
 
 
Young mother 
In Tanzania and India, women under 18 will be excluded.  
 
In Malawi, women aged 16 to 17 who are married are considered legally emancipated and able to 
give independent consent, so they may participate. Women who are 16 to 17 and are unmarried 
will be excluded. All women and girls under 16 will be excluded. 
 
Infant death 
 
If the infant dies within the screening window for observation enrollment (within 6 hours after 
birth) before the mother can be approached for consent, the mother-infant pair will be excluded. 
We will also exclude infants that are part of multiple births where the other baby(ies) have died 
(even if the surviving infant is otherwise eligible). 
 
Maternal death   
The study will exclude cases of maternal death that occur during labor and delivery or within the 
6-hour post delivery enrollment period.  
 
Out-of-facility birth 
Infants born outside of the facility cannot be observed at birth. 
 
Infant >6 hours old at screening 
Infants must be enrolled in the in-facility observation study within 6 hours of birth. If the infant is 
older than 6 hours at the time of screening, s/he will be ineligible for the study. 
 
 
Mother-infant pairs with the following traits will still be eligible for the study, given that no exclusion 
criteria are met. 
 
Critical or severe illness jeopardizing early survival 
 
For the observations, we would like to understand a broad range of the feeding experiences of 
LBW infants. This small sample will yield rich information on just the first few hours and days of 
life, so we can include infants who may be at high risk of mortality within the first week of life. 
Their experiences will be informative about the range of SOC at a site. 
 
Critical or severe illness jeopardizing early survival includes: 
● Severe neonatal encephalopathy  
● Ventilator or inotropic support 
● Significant cardiorespiratory instability (hypotension, poor perfusion, or persistent 
hypoxemia while on the maximal respiratory support available in that setting) 
 
Gestational age 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
22 
 
As birthweight will be the main screening criteria for eligibility, we will enroll infants of any 
gestational age, as long as they meet the other inclusion criteria. 
 
Multiples 
Twins or triplets will be considered for enrollment in the study. Multiples have higher rates of 
LBW and greater demands on a lactating woman, so their experiences will be important to track. 
 
Maternal HIV Status 
Women who are HIV infected are eligible. We will encourage the adherence to Option B+ 
standards so that women receive HIV antiretroviral therapy in concordance with WHO and 
national guidelines. 
 
Language 
Mothers who do not speak English will still be eligible for the observations. 
 
 
8.4 Screening and recruitment 
Study staff will screen for eligibility by periodically checking the facility register for eligible participants. 
Clinical staff may also notify study staff when there are potentially eligible participants as clinical staff 
weigh newborns as part of normal practice. When potential participants are identified, study staff will use 
the checklist to ensure eligibility. 
 
The timing of screening and recruitment is important. We do not want to disturb the mother’s first few 
hours with her newborn, yet we want to begin observations fairly quickly. The target time for approaching 
a woman for screening will be between 1 and 6 hours after the birth. If it is not possible to screen the 
woman within 6 hours of giving birth, she will not be approached for inclusion in the observations. 
 
Women will not be screened or recruited before giving birth, even if they are known to be delivering 
prematurely and therefore at high risk for having a LBW baby. The reason for this is that having a 
different recruiting method for premature infants and term infants will likely bias the sample of 
observations toward premature infants. 
 
8.5 Informed consent 
Women will provide written informed consent to participate in the in-facility observations. Each 
participant will consent to: 
● observations of the care she receives from clinical staff, 
● observations of the feeding behaviors of her and her infant, 
● verbal interviews with study staff roughly every three hours until discharge, and 
● access to her medical chart and her baby’s medical chart by study staff including HIV status, 
if available. 
 
In the case of illiteracy, we will use a thumbprint for the woman’s signature, with an additional signature 
from an impartial witness to the consent process. 
 
In the case that a mother consents to participate but asks a surrogate to answer questions for her, the 
action required will be country-specific in alignment with site requirements: 
● Tanzania: Mother will complete and sign an additional “caretaker consent form”, authorizing a 
surrogate to share information about her.  

 
LIFE Protocol v9,18 March 2020 DEPLOY 
23 
 
● India: Mother’s signed consent is sufficient; no further action required.  
● Malawi: Only allowed in the case that the mother is in the ICU and unable to answer: the trusted 
guardian will sign a separate consent form (same version as mother’s consent form) 
 
8.6 Observation schedule 
From the scientific perspective, the richest and most useful data would arise from continuous observation 
with complete documentation of every feed or feeding behavior from birth until the infant is discharged 
from the facility. From a logistical and resource perspective, this is clearly not possible. Intermittent 
observations will be used, on a schedule that balances feasibility with capturing the highest priority 
information.  
 
8.6.1 During daytime shifts 
 
As shown in Table 4, the observation schedule will involve continuous observation in the first three 
hours, plus regular “spot checks” until discharge. If the facility has a regular feeding schedule for infants, 
then the spot checks will coincide with that schedule, in order to observe as many feeds as possible. If the 
facility does not have a regular feeding schedule, then facility staff will alert the observer when a feed is 
taking place. If the facility staff are not present at the time, then a mother or family member may also alert 
staff that a feed is taking place. If not notified of a feed within 3-4 hours of the previous spot check, the 
observer will perform an unprompted spot check. In this way, the spot checks will be mainly prompted by 
feeding behavior, but will take place at a minimum every 3-4 hours, when the observer will ask about any 
feeding behavior since the previous spot check. 
 
Observers will use structured checklists to record information on all infant feeds. Since the first  hours of 
the child’s life will not have been observed, the observer will ask the mother and clinicians about the 
timing and nature of any feeds that happened prior to observation. If any feeding behavior takes place 
during the spot checks, the observer will observe and record it. 
 
If the infant enters the NICU or other sick baby unit (SBU), the observer will follow the infant to the 
NICU/SBU. If the mother and infant are separated, the observer will follow the infant. When the mother 
is interviewed before discharge, the observer will ask about her nutrition and lactation during the period 
of separation from the infant. 
 
In the intervals between spot checks, the observer will collect information on WASH for feed preparation 
in the facility (up to 5 observations), using structured observations of clinicians performing feeding vessel 
preparation and storage. 
 
 
Table 4: Observation schedule 
Directly after written consent is given: 
1. 
Before initiating the baseline interview with the mother, conduct the maternal chart 
check, (include HIV status) and baby chart check  
2. 
Interview the mother about her demographics, delivery experience, and feeding 
behavior since the infant’s birth. Take baseline anthropometric measurements for the 
baby. 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
24 
 
3. 
Observe the mother/infant pair for the first three hours continuously, noting all feeds 
and feeding behavior of infant and mother.  
If the mother and infant are separated, observe the infant for the first three hours 
continuously, noting all feeds. 
4. 
Perform periodic “spot-checks,” with brief questioning of the mother or clinicians, 
and observation of any feeding behavior. 
When possible, perform spot checks when feeds occur, or at a minimum every 3-4 
hours. 
5. 
Between spot checks, observe and record WASH behavior for feed preparation in the 
facility generally. 
6. 
At discharge, record information about the baby and mother status and take 
anthropometric measurements for the baby. 
 
 
8.6.2 During nighttime shifts 
 
Study observers will not be hired to work on overnight shifts. Each morning, study staff will check the 
mother’s and baby’s charts to complete as much data as possible from the overnight records. If the 
mother-infant pair is still in the facility, then the 3-hour spot checks will resume for the day until 
discharge.  
 
8.7 Sample size 
Each site will carry out 35 to 45 observations, with a minimum of three at each facility but with no greater 
than 45 mothers. This accounts for participants lost to follow up. This equates to 35 mothers and up to 60 
infants to account for twins; thus, a total of up to 95 individuals per site. Although the total number of 
mothers and infants above add up to 105, we will never exceed 95 individuals given the twinning rates in 
the sites.  The goal of this sample is to get a deep understanding of the kinds of feeding experiences that 
LBW infants might have in each site. The sample size was determined by timeline and budget constraints; 
sites felt that this number of intensive in-facility observations was achievable. 
 
This sample may not be representative of all LBW infants at a site. However, the rich descriptive results 
from these cases will give an informative picture of the range of experiences at each site. 
 
 
8.8 Data analysis 
As most of the observational data is being used for description, we will use means, medians and standard 
deviations to describe continuous variables. Categorical variables will be analyzed with frequencies and 
proportions, as appropriate.  
 
For anthropometric analyses of the observed infants, we will use the Intergrowth charts to calculate 
stunting (length-for-age z-score, LAZ), underweight (weight-for-age z-score, WAZ), and wasting 
(weight-for-length z-score, WLZ). To determine Z-scores, we will use the INTERGROWTH-21st 
standards for preterm infants (<37 weeks gestation), and the WHO postnatal growth standards for term 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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infants (>37 weeks gestation) (Villar et al 2015).  Further, we will compare the routine care provided to 
standard of care guidelines. 
 
Any further analyses will be post-hoc and described separately. 
 
 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
26 
 
9 Prospective cohort 
 
The goal of the prospective observational cohort is to better understand feeding practices for LBW 
infants, their growth and their health outcomes over the first 12 months of life. A series of clinic visits 
(when possible) will be conducted as well as home visits, if required. 
  
9.1 Inclusion/exclusion criteria 
 
Inclusion criteria for the mother/infant pair are: 
 
Infant birthweight between 1500 and <2500 g 
Using the standard method of weighing described in Appendix A, all newborns will be weighed 
to screen for study eligibility.   
 
Residence within catchment area of facility 
Participants must reside within the catchment area of the facility, because home visits by study 
staff may be necessary, and travel time and funds are limited. The catchment areas will be defined 
by each site. 
 
Mother’s consent and/or legally accepted representative (surrogate’s consent) 
As part of the screening and enrollment process, we will conduct a thorough informed consent 
process following United States Office for Human Research Protections (OHRP) and national 
guidelines. Only women who give written informed consent for enrollment will be included. 
 
 
Exclusion criteria for the mother/infant pair are: 
 
Infant very low birthweight 
Children who are very low birthweight (<1500g) will have different clinical needs and 
interventions. Thus, these infants will be excluded. 
 
Congenital abnormality that interferes with feeding 
Infants will be excluded if they have a congenital abnormality that (1) directly interferes with 
feeding and (2) is readily apparent at birth, requiring no special diagnostic tools. The specific 
abnormalities for exclusion are: 
● 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, CMV, toxoplasmosis, or 
syphilis. 
 
 
 
 
Severe neonatal encephalopathy jeopardizing early survival 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
27 
 
For the prospective cohort, we would like to understand LBW growth and health for the first six 
months of life. Unlike for the in-facility observations, infants who die in the first few days will 
not contribute much to our understanding of the first six months, when our interventions would 
take place. For this reason, we will exclude infants who are at high risk of mortality within the 
first week of life. Specifically, we will exclude infants with severe encephalopathy as determined 
by modified Sarnat criteria.  
 
 
Some infants with other seriously life-threatening illnesses may not be diagnosed in the early 
hours and days. This is because some conditions require expensive or invasive diagnostic tests, 
and others, such as sepsis, may be undetectable for a period of time. If these infants meet all other 
criteria, then they would be enrolled in the prospective cohort even though they are at higher risk 
of mortality. Most of these cases will die before 72 hours, since neonatal mortality is concentrated 
early. In those cases we will replace the infant in the cohort sample. (See section below on 
“replacement of infants who die in the first 72 hours.”) 
 
Plans to leave the study area before end of data collection 
In order to conduct the study, we will need to be able to follow mother-infant pairs. If a mother-
infant pair plans to leave the study area within 6 months, per maternal self-report, they will not be 
enrolled. As part of the study set up, we will seek additional insight from local partners on 
practices of returning to maternal home for birth of child. 
 
Young mother 
In Tanzania and India, women under 18 will be excluded.  
 
In Malawi, women aged 16 to 17 who are married are considered legally emancipated and able to 
give independent consent, so they may participate. Women who are 16 to 17 and are unmarried 
will be excluded. All women and girls under 16 will be excluded. 
 
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.) Although the LBW infants of 
deceased mothers are particularly vulnerable and important to study, we anticipate very few, if 
any, maternal deaths in samples of roughly 300 in each site. Also, given the logistical and ethical 
complexity in recruiting and following these cases, they would likely require separate study 
processes, which would take effort and scarce study resources to prepare for, even if no deaths 
occur.  
 
Maternal deaths will count as an exclusion criteria 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. 
 
 
Infant death 
The study will exclude infants that die before enrollment can occur, as well as infants that are part 
of multiple births where the other baby(ies) have died (even if the surviving infant is otherwise 
eligible).  
 
Infant >72 hours old at screening 
Infants must be enrolled in the prospective cohort 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. 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
28 
 
Mother-infant pairs with the following traits will still be eligible for the study, given that no exclusion 
criteria are met. 
 
Gestational age 
As birthweight will be the main criteria for eligibility, we will enroll infants of any gestational 
age, as long as they meet the other inclusion criteria. 
 
Multiples 
Twins or triplets will be considered for enrollment in the study as multiples have higher rates of 
LBW and greater demands on a lactating woman. For the extension, they will still be considered 
as long as they are in the current prospective cohort.  If only one infant in a multiple birth 
qualifies for inclusion, that infant may be enrolled and followed as a singleton would. If both 
infants qualify, both may be enrolled. 
 
Maternal HIV Status 
Women who are HIV infected are eligible. We will encourage the adherence to Option B+ 
standards so women are receiving HIV antiretroviral therapy in concordance with WHO and 
national guidelines.  
 
Language 
Mothers who do not speak English will still be eligible for the study. 
 
Out-of-facility birth 
Infants may be born anywhere and still be eligible for the study, as long as they present at a study 
facility for weight measurement within 72 hours of birth. See details below on identification and 
recruitment of these infants. 
 
Prospective Cohort Extension study: This component will consist of enrolling mother/infant pairs. 
 
Inclusion criteria for the mother/infant pair are:  
• 
Currently enrolled in the LIFE study (follow-up from birth to 6 months of age) and fulfills all 
original inclusion criteria (infant birthweight between 1500g and <2500g, residence in catchment 
area of facilities in which born) 
• 
Mother’s and/or legally accepted representative (surrogate’s) 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 
(birthweight outside range, congenital abnormalities at birth, neonatal encephalopathy at birth, 
young mother, maternal death during labor and delivery, infant death before 72 hours of life, 
infant is more than 72 hours old at enrollment) 
 
 
9.2 Recruitment of infants born in the facility 
All LBW infants will be screened at study facilities to determine their eligibility for the prospective 
cohort. LWB infants will be identified directly after birth in the same way as for the in-facility 
observations, and study staff will be notified (described above).  
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
29 
 
Some of the inclusion/exclusion criteria are best assessed through a brief chart check or discussion with 
clinicians. Once a LBW birth is identified, study staff will record on the screening instrument: 
● Mother’s age  
● Congenital abnormalities, as defined in I/E criteria 
● Infant critical or severe illness, as defined in I/E criteria 
If the mother/infant pair is still eligible after these checks, then study staff will approach the woman to 
check the final criteria, which are whether she plans to leave the study area in the next six months. If she 
is still eligible, then we will progress to the consent process. 
 
The target time for approaching a woman for the prospective cohort will be between 1 and 6 hours after 
the birth, but not within the first hour after the birth. There is a maximum time cutoff of 72 hours for 
recruitment to the prospective cohort; women can be enrolled at any time up to their discharge from the 
facility or 72 hours (whichever was first). 
 
If an infant is born overnight when no study staff are present, then study staff will review the register or 
medical records when they arrive for their shift in the morning. Women can be approached for inclusion 
at that point. To avoid bias, we will pick the odd number admissions to select children for enrollment 
(1,3,5,7th admissions overnight) for inclusion. 
 
6-month extension: This is not applicable see section 9.4  
 
9.3 Recruitment of infants born outside the facility 
In some sites, a subset of women give birth outside of a facility, typically at home, and bring their infants 
to the facility soon after birth. We would like to recruit these women into the prospective cohort, but will 
not be able to weigh their infants at birth. Given our definition of LBW, we will be recruiting infants who 
are at least 1500 g at birth and at most 2499 g at birth. However, infants typically lose weight quickly in 
the first days after birth, so these thresholds must be adjusted for women who arrive at facilities later. 
 
We will recruit infants born outside the facility as long as they present at the facility within 72 hours of 
birth. We will evaluate for the inclusion criteria of LBW based on the elapsed time since birth and the 
baby’s weight at first visit, according to Table 5. 
 
The values in Table 5 are based on a review of several studies of weight loss among infants in the first 
few days, including weight curves for term vs. preterm infants, LBW vs. normal weight, and breastfed vs. 
formula fed (Bertini et al 2015; Flaherman et al 2015; Miller et al 2015; Anchieta et al 2004; Shaffer et al 
1987; Christensen et al 2006). Weight curves for C-section births were excluded from consideration. In 
this literature, estimates of median weight loss at 72 hours range from -2% or -3% for term, normal 
weight, formula fed infants, to about -10% for LBW, exclusively breastfed infants. This range is large, 
and the variation in observed weights increases with each day of life, producing more uncertainty in the 
estimates by day three. 
 
For these reasons, it will not be possible to know an infant’s birthweight precisely based on weight at day 
three. Also, to support the field work for the study, we require a fairly simple algorithm for classifying 
infants who are a few days old as having been LBW at birth. Taking these considerations into account, we 
took approximations of median weight loss rates in the first three days from the literature, based on initial 
birthweight and other factors, and constructed the threshold weights presented in Table 5. We accept the 
imprecision of this algorithm for estimating birthweight in order to allow recruitment from the population 
of women who give birth at home. 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
30 
 
Other than the weight criteria, all other inclusion/exclusion criteria, informed consent, and study activities 
for out of facility births will be identical to those for facility births. 
 
6-month extension: This is not applicable see section 9.4  
 
 
 
 
Table 5: Weight thresholds for inclusion of infants up to 72 hours old born outside the facility 
 
 
Weight thresholds  
for inclusion in study  
Percent change from assumed 
birthweight 
Time since birth 
Exactly 
Minimum 
weight 
Maximum 
weight 
In minimum 
weight 
In maximum 
weight 
None 
0 to < 6 hours 
1500 
< 2500 
n/a 
n/a 
12 hours 
6 hours to <18 hours 
1483 
< 2467 
-1.3% 
-1.1% 
24 hours 
18 hours to <30 hours 
1467 
< 2433 
-2.7% 
-2.2% 
36 hours 
30 hours to <42 hours 
1450 
< 2400 
-4.0% 
-3.3% 
48 hours 
42 hours to <54 hours 
1433 
< 2367 
-5.3% 
-4.4% 
60 hours 
54 hours to <66 hours 
1417 
< 2333 
-6.7% 
-5.6% 
72 hours 
66 hours to 72 hours 
1400 
< 2300 
-8.0% 
-6.7% 
 
9.4 Recruitment for 6-month extension  
 
All mother-infant pairs who are currently being followed up for the first 6 months of their infants’ lives 
are eligible to take part in this study and will be approached for re-consent to an additional 6 months of 
follow-up at or before the 6-month visit. Mothers and infants will not be screened but rather all current 
participants will be approached and asked to re-consent for continued follow-up in the study. Study staff 
will read the recruitment script before asking the participant for consent.   
 
 
9.5 Replacement of infants who die in the first 72 hours 
As described in the exclusion criteria for the prospective cohort, it will not be possible to identify all 
infants with severe or critical illness before discharge. Because not all diagnoses can be made definitively 
before discharge, some critically ill infants may end up in the prospective cohort, and may, unfortunately, 
die early.  
 
These cases will not contribute much data to the study on their growth and feeding patterns, and may 
erode our ability to achieve our target sample size. We aim for 350 mothers at enrollment with 300 still 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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enrolled at 6 months. The drop of 50 mothers is due to expected loss to follow up as well as deaths. 
However, this margin may not be large enough to cover all the deaths if we include infants who have 
serious illnesses that are not apparent at discharge. In that case, we may end up with more infants than 
expected dying in the first few days, and fewer than 300 infants by six months. 
 
For these reasons, we will consider an enrolled infant who dies within the first 72 hours to be excluded 
from the cohort, and we will recruit an additional infant in its place. In effect, this puts an additional 
inclusion criterion on this cohort, which is surviving the first 72 hours of life. If the infant dies at any time 
after 72 hours, he or she will not be replaced in the sample. 
 
Baseline data from infants who die in the first 72 hours will not be included in the formal analyses, but 
may be included in post-hoc explorations.  
 
9.6 Assessment of congenital abnormalities and serious illnesses in infants 
Some of the congenital abnormalities and serious illnesses will be readily apparent at birth, such as cleft 
lip. However, at first screening, it may not be possible for the clinicians to conclusively state whether the 
infant has some of the other congenital abnormalities or serious illnesses in our exclusion criteria. Some 
conditions may take a day or several days to fully develop. 
 
Figure 2 shows how cases will be handled. Infants who clearly have the condition or illness at the first 
screening will be ineligible, and if they clearly do not, they will be eligible. In the event that it is unclear, 
then the study staff will revisit the mother-infant pair several hours later, the amount of time depending on 
the clinical judgment of the facility staff. If at that repeat screening the infant’s condition is still not clear, 
study staff will again delay screening and revisit later.  
 
In the end, the final screening will take place when the infant is discharged or when 72 hours has elapsed 
since birth, whichever comes first. In either case, as shown in Figure 3, if the condition is still unclear, 
then the infant will be treated as eligible. If the infant is enrolled at discharge before 72 hours, and then 
happens to die within the 72 hour mark, that infant will be replaced in the prospective sample. If the 
infant is enrolled at 72 hours, it will be kept in the prospective sample even if it dies soon afterward. 
 
Figure 2. Screening for infant conditions  

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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9.7 Overlap between observation and prospective cohort recruitment 
There is no requirement for women in the observation group to participate in the prospective cohort, or 
vice versa. The consents are entirely separate. If a woman is approached for the observation and declines 
to participate, she may still be approached later for the prospective cohort. 
 
9.8 Informed consent 
The goal is to follow LBW infants for up to 12 months, with a regular schedule of visits to collect both 
survey and anthropometric data, review of medical chart, including HIV status, for visits occurring at the 
study facility, as well as observation of feeding when relevant. We will use a full informed consent 
process, involving a description of the study, discussion of risks and benefits, ability to withdraw at any 
time, and other required information. This consent will be documented with the woman’s signature. All 
women will receive a copy of the consent documentation. 
In the case of illiteracy, we will use a thumbprint for the woman’s signature, with an additional signature 
from an impartial witness to the consent process. 
 
In the case that a mother consents to participate but asks a surrogate to answer questions for her, the 
action required will be country-specific in alignment with site requirements: 
● Tanzania: Mother will complete and sign an additional “caretaker consent form”, authorizing a 
surrogate to share information about her.  
● India: Mother’s signed consent is sufficient; no further action required.  

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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● Malawi: Only allowed in the case that the mother is in the ICU and unable to answer: the trusted 
guardian will sign a separate consent form (same version as mother’s consent form) 
 
If a mother dies during the study period, we will ask permission from the family to continue following the 
infant. A new informed consent process will be conducted with the infant’s primary caregiver. 
 
6-month extension: Study staff will ask the mother to reconsent around before their 6-month study 
visit as part of their original follow-up in the LIFE study. The recruitment script will be read 
before reviewing the consent form. The study staff will give the participant time to review, ask 
questions and think about whether or not they would like to consent to their participation. 
9.9 Incentives 
Women in the prospective cohort and extension may be asked to come to the facility when they otherwise 
would not. They will be provided a standard travel allowance for each visit that they make to the facility 
for a study visit, in alignment with local site and ethics review board requirements.  
6-month extension:  
(Insert site specific location: Tanzania and or Malawi): For the follow up phone calls at around 7.5 
and 10.5 months: Participants will not incur any costs associated with receiving the phone calls. As such, 
there will be no compensation to participants for phone calls during these time points. 
9.10 Benefits to participation 
The benefits to study participants may include additional monitoring of a child’s growth and earlier 
referral to care as part of participation in the cohort study.  
 
9.11 Maternal or infant death during study period 
In the case of a maternal death during the study period, we will ask permission from the family to 
continue following the infant. A new informed consent process will be conducted with the infant’s 
primary caregiver.  
 
In the case of an infant death during the study period, we will not continue to collect study information on 
the mother; however, we will ensure that the mother is receiving adequate care, through appropriate 
referral mechanisms. 
 
Verbal autopsies of the infant would be desirable, but they were not budgeted for as part of this study. In 
Tanzania, the study team will have to perform a verbal autopsy at 40 days post-death to meet government 
regulations, so they will be available for that site. If possible, we will gather information from verbal 
autopsies. 
 
9.12 Sample size 
The sample size will be as large as possible given constraints in time, recruitment rates, and budget. We 
do not plan to do any hypothesis testing using this observational data. The main statistical results will be 
point estimates and confidence intervals for certain rates, such as the percent of LBW infants who do not 
successfully breastfeed, require tube feeding, or the percent who develop certain conditions. The final 
sample size will determine the precision of the estimate, as shown in Figure 3. For example, with a 
sample of 250 infants, a true proportion of 5% can be estimated with precision of +/- 2.7%. The 95% 
confidence interval would be 2.3% to 7.7%. 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
34 
 
 
Figure 3: Margin of error in estimation of a single proportion with a single sample 
 
 
While we would like the precision of our estimates to be as high as possible, we have no statistical 
requirement for a particular number. Instead, we propose aiming for 350 enrolled mothers at each site, 
with an estimated final sample of 300 mothers in each site due to loss to follow up and withdrawal. This 
target will give a reasonable level of precision on the point estimates and appears logistically achievable 
in the study period. 
 
The sample of mothers will be different from that of infants due to multiple births; thus we expect up to 
850 individuals be enrolled in the study if there are many sets of twins. We do expect twins to occur with 
some frequency in our samples, since we are selecting for LBW infants, and many multiples are LBW. 
The overall rates of multiple births in the general population are 7.2 per 1,000 births in India, 20.8 in 
Malawi, and 18.8 in Tanzania (Smits and Monden, 2011). We expect higher rates of multiples in our 
study population, so to be conservative, we double these estimates and assume our sample will include 
14.4 multiples per 1,000 births in India, 41.6 in Malawi, and 37.6 in Tanzania. If these rates hold, and 
assuming both twins are eligible and enroll, then our sample of 300 women would include 304 infants in 
India, 313 infants in Malawi, and 311 infants in Tanzania. This will not greatly change the precision of 
the estimates shown for a sample of 300 in Figure 3. 
 
The presence of twins will also introduce an element of clustering, since the outcomes within a set of 
twins may be highly correlated. The clustering will make the confidence intervals larger, with the degree 
of enlargement depending on two factors: 1) how many sets of twins are both enrolled in our sample, and 
2) how correlated the outcomes are within twins (intraclass correlation coefficient, or ICC). This degree 
of enlargement can be expressed as the design effect (DEFF), or the increase in the sample size that is 
required to detect the same difference at the same level of statistical power, given the clustering in the 
sample. 
 
Other research using large samples of births that include some proportion of multiples (Yellin et al, 2017) 
shows that the DEFF can be calculated as:  
 
DEFF = 1 + ⍴ γp 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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where ⍴ (rho)= ICC of the outcome within twins, and γp (gamma) is the proportion of the total sample of 
infants who are twins.This proportion is defined as: 
 
N = total number of infants in sample (as opposed to the total sample of mothers) 
MS = total number of singletons in sample 
MP = total number of pairs of twins in sample 
γp = 2MP / N   
 
To estimate the DEFF for this study, we draw ICC estimates from the literature. A review of birth 
outcomes research (Yellin et al, 2018) presents ICCs for twins for three outcomes of interest to LIFE: 
0.26 and 0.85 for admission to the NICU; 0.25 and 0.36 for any sepsis; and 0.08 and 0.17 for proven 
necrotising enterocolitis. We may not be able to predict the ICCs we observe in the LIFE sample from 
these because these estimates show such a wide range, and were drawn from developed settings. 
 
Because we may not be able to predict the ICCs in LIFE, we estimated DEFF for each study country at 
ICCs ranging from 0.1 to 0.8 (Figure 4). India’s DEFFs will likely be lower than the other sites’ because 
its baseline twinning rate is lower. In the most extreme case of ICCs in the 0.8 range, the largest DEFFs 
we would expect in this study would be about 1.06, or a 6% increase in sample size needed for the same 
precision at the same level of power. In a sample of 312 infants given a DEFF of 1.06, the precision of the 
point estimate would be as though we had a sample of 294 (312/1.06). This will not introduce a large 
distortion to the precision estimates. 
 
 
 
Figure 4: Estimated design effects at a range of ICCs, by study country 
 
 
9.13 Response rates 
 
The four study sites vary in annual birth volume and rate of LBW births (Table 6). The enrollment period 
for the prospective cohort will be approximately four months long (see Gantt chart), and each site expects 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
36 
 
to have an estimated number of LBW babies born in that period. The table shows the response rates 
needed in each site in order to enroll 300 women into the cohort. 
 
 
Table 6: Birth volume and response rates 
Site 
No. of study 
facilities 
Annual birth volume 
4-month study period 
All births 
LBW births 
(estimated) 
LBW births 
(estimated) 
Required response 
rate1  
Dar es Salaam 
3 
35,997 
5,550 
1,850 
16% 
Lilongwe 
2 
20,000 
1,280 
427 
70% 
Karnataka 
5 
21,000 
2,100 
700 
43% 
Odisha 
2 
19,600 
3,320 
1,107 
27% 
 
 
1  Percent of LBW births that need to be enrolled in order to achieve a total sample of 300; please note we may have 
a longer enrollment period than 4 months if required. 
 
 
9.14 Schedule of data collection 
We will collect a variety of information from the mother-infant pairs enrolled in the prospective and 
extension cohort throughout the study, as shown in Table 7. Table 7.1 shows the data collection time for 
the prospective cohort 6-month extension. The additional phone check-ins (are around 7.5 and 10.5 
months) are only applicable for Tanzania and/or Malawi. 
 
 
Table 7: Data collection schedule for prospective cohort  
 
Base- 
line 
Weekly for first 6 weeks 
Monthly 
Weeks and months of infant’s life 
0 
1 
2 
4 
6 
2 
3 
4 
6 
Demographics and pregnancy 
history  
✓ 
✓ 
 
 
 
 
 
 
 
Gestational age 
✓ 
 
 
 
 
 
 
 
 
Infant anthropometrics 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
Maternal anthropometrics 
✓ 
 
 
 
✓ 
 
 
 
✓ 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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Infant feeding/maternal lactation 
questionnaire 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
Infant health questionnaire 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
Maternal health questionnaire 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
Home Water/Sanitation Assessment 
As required 
Sick visit or inpatient data 
As required 
Mortality 
As required 
 
 
 
Table 7.1: Data collection schedule for prospective cohort extension 
 
Monthly 
Months of infant’s life 
7.5 
9 
10.5 
12 
Demographics and home 
environment 
 
✓ 
 
✓ 
Well-being 
 
✓ 
 
✓ 
Infant anthropometrics 
 
✓ 
 
✓ 
Maternal anthropometrics 
 
 
 
✓ 
Infant feeding/maternal lactation  
✓ 
✓ 
✓ 
✓ 
Infant health  
✓ 
✓ 
✓ 
✓ 
Maternal health  
✓ 
✓ 
✓ 
✓ 
       Home Water/Sanitation Assessment 
  ✓ 
 ✓ 
       Mortality 
 ✓ 
  ✓ 
 ✓ 
 ✓ 
 
 
9.15 Location of follow up visits 
Mothers will return to the facility with their infants for each follow-up visit. Based on site requirement, 
clinic-based visits or home visits will be conducted in the early neonatal period. If the mother misses a 
facility visit, then study staff will make a home visit. 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
38 
 
 6-month extension: same procedures apply though home visits will be more prevalent.   
 
 
9.16 Data collection at sick visits 
If an enrolled infant falls ill, the mother may bring the child to the facility for a sick visit, unrelated to the 
study. The sick visit will present an opportunity to collect additional data on the illness as well as 
lactation and growth of the infant.  
 
To collect this data, we would like to identify the mother-infant pair as enrolled in the study. Each site 
will establish a simple process to achieve this. For example, in Malawi, study participants will have a 
study appointment card attached to their health passport, listing the participant study number, visit 
schedule, and contact details of lead study staff. Also, study patients will be advised to come to the study 
clinic when they are sick, or to contact the study team if they seek care elsewhere or are hospitalized. In 
India, enrolled patients will be advised to return to the facility in case of illness, and also given a trial card 
with instructions to other physicians to inform the study investigator if they seek care elsewhere.  
 
For all infants presenting for a sick visit: we will ask the mother questions about the infant’s illness and 
any changes in feeding due to that illness, and we will weigh the infant at the time of the visit / admission 
to health facility. In the event that an infant is admitted to the health facility, we will ask the mother 
additional questions about the infant’s stay in the hospital, and study staff will review  chart 
documentation to gather additional data about the infant’s diagnosis. We will also weigh the infant at the 
time of discharge from the health facility. 
 
Prior to any data collection occurring at sick visits or health facility admission, the study team will 
confirm it is appropriate to proceed with data collection with the baby’s health care provider. The study 
team will also confirm the mother is comfortable with the sick study visit prior to proceeding. The study 
team will develop an internal SOP regarding culturally appropriate criteria for approaching families in the 
health facility. 
 
6-month extension sick visit: These sick visits are not applicable and will not be implemented during the 
additional 6 months of follow up. Additional information on illnesses will be collected in the revised 
prospective extension cohort follow up tool rather than a separate sick visit tool.  
 
 
9.17 Data collection at home visits 
In the event that a mother cannot come to the facility for a follow up visit, a home visit will be made by 
study staff. As above, visits in the early neonatal period will be conducted at the facility or home per site 
requirements. The mother, father, and other family members will be informed in advance of these visits 
so they are not surprised. At the home visit, study staff will complete the same measures as for the facility 
visit, unless they are not possible due to lack of equipment. 
 
The home environment, a critical factor in the safety of infant feeding, will be important to understand 
when designing a safe IYCF intervention. During the home visit, study staff may separately collect 
supplemental information on WASH in the home environment for a sample of mothers at selected follow-
up timepoints. This potential data collection would be restricted to documenting observable measures and 
equipment. We would not collect biological samples, unused supplies, or swabs of containers. 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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In addition, the mother will be asked to use the illness diary (morbidity diary) that will be provided to the 
mother during the initial 6-week visit.  The purpose of the diary is to record details on specific illnesses 
experienced by the baby (diarrhea, vomiting, fever and respiratory infections) in between study visits. At 
each follow-up visits, the mother will bring the completed illness diaries to the study team and will be 
given a fresh set of blank illness diaries for the next visit. 
 
6-month extension: Same procedures will be followed with some modification to the questions.   
 
9.18 Study measures 
9.18.1 Demographics, pregnancy history and home environment  
 
At baseline and at 9 and 12 months, we will ask the mother to respond to a questionnaire with 
basic socio-demographic information such as age, education level, marital status, and home 
environment. These variables and response categories will likely differ somewhat by site.  
 
The questionnaire will also cover a detailed pregnancy history, access to antenatal care (ANC), 
supplementation during pregnancy, food and water insecurity, household water, sanitation and 
hygiene (WASH) conditions, and related topics. Not all questions will be asked in the last 6 
months versus the first.  
 
Some demographic and household WASH questions will be asked at the Week 1 follow-up visit 
to minimize the number of questions asked to the mother at baseline (shortly after delivery)  
 
 
 
9.18.2 Gestational age (baseline visit only)  
 
Measuring gestational age is notoriously difficult. Prematurity and intrauterine growth restriction 
are the primary causes of LBW. We anticipate that there will be physiologic differences between 
these groups, but also acknowledge the challenges in accurate identification of gestational age in 
this study population due to limitations in prenatal care and use of early ultrasound. The 
availability and quality of gestational age data will be highly variable between study sites. Only 
one site (India-Karnataka site) will have access to early pregnancy ultrasonography, because of 
the presence of an existing trial for antenatal corticosteroid. In the remaining sites, the majority 
will likely not have access to ultrasound dating and will rely on last menstrual period (LMP) or 
Symphysis fundal height, as per standard of clinical care. We will capture what gestational age 
information is available from the woman’s antenatal card, ultrasound history, etc. In cases where 
ultrasound data is available (either through clinic records or maternal self-report), we will 
consider this to be the first preference for gestational age dating. We will also ask the mother the 
date of her last menstrual period (LMP), and use this information as second preference for 
gestational age dating if ultrasound results are not available. 
  
Given the poor quality and availability of antenatal dating in some sites, the LIFE study will also 
need to rely on neonatal assessment for gestational age dating.  In a recent systematic review, 18 
different neonatal assessments for gestational age dating were identified in the literature (Lee 
2017). The most commonly used, simpler and feasible assessments, such as the Ballard or 
Capurro, were inaccurate, dating pregnancies to +/- 4 weeks of ultrasound dating. The Dubowitz 
exam was found to be the most accurate, dating 95% of pregnancies within +/- 2.6 weeks of an 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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ultrasound based date.  However, the Dubowitz exam includes 21 signs including neurologic and 
external physical signs, and the feasibility of training, standardization and use in LMIC requires 
further programmatic research. 
  
We propose to use the Dubowitz exam for gestational age dating in the LIFE study, and in the 
formative phase will assess the feasibility of training and standardization of this assessment 
across the four study sites. The Every Newborn Action Plan Metrics Group prioritized the 
assessment of the feasibility of implementation of the Dubowitz exam as a research priority for 
gestational age dating in LMIC.  
 
For multiples enrolled in the study, we will determine gestational age for one baby and infer the 
same gestational age for the other twin or triplets. 
 
9.18.3 Infant anthropometrics  
 
Infant growth measures will include weight, length, head circumference, and mid-upper arm 
circumference (MUAC) according to the protocol in Appendix A. Trained members of the study 
team will be conducting the measurements per site.  
 
 
9.18.4 Maternal anthropometrics 
 
Maternal height, weight and mid-upper arm circumference will be captured at enrollment. 
Maternal weight and MUAC will be captured at 6 weeks postpartum, 6 month study visit and at 
the end of the 12-month study.   
 
9.18.5 Infant feeding questionnaire 
 
We will administer baseline and follow-up questionnaires on infant feeding/maternal lactation. An 
extended list of questions will be asked at 9 and 12 months and a shortlist may be asked during 
the check in phone calls. The infant feeding questionnaire will cover topics such as: 
 
Description of feeds 
● Feeds provided: 
■ Breastmilk (Mother’s own milk, Other mother’s milk -), colostrum (at baseline), 
Donor Human Milk 
■ Formula 
■ Supplements 
■ Other feeds (water, cow’s milk, etc.) 
■ Liquids  
■ Semi solid / solid foods and specific food groups 
● Method of feeding (direct breastfeeding, cup/palladai/spoon, bottle) 
● Who advised/decided on the type of feed (clinic staff, mother, etc) 
● Provider of feeds (mother, clinic staff, etc.) 
● Timing of introduction of complementary feeds and reasons 
● Frequency of feeds 
● Self-efficacy of complementary feeding 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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Breastfeeding (this information will not be collected during the extension as it is not applicable 
anymore): 
● Time to first latch or milk feed (global standard: within 1 hour of birth) 
● Day (post-birth) achieved full milk production/established lactation (“coming to 
volume”) 
● Exclusive breastfeeding duration 
● Number of breastfeeding or expression sessions per 24 hours 
● Expressed Breast Milk storage method (refrigerator, freezer, etc.) 
● Breastfeeding adequacy measures, like frequency of feeds (average number of 
expressions/full breastfeeding episodes per day), duration of feeds, and direct observation 
if the infant breastfeeds during the interview (WHO IMCI criteria, LATCH score, PIBBS 
scale). In addition, we will use the NeoEAT-Breastfeeding Screener Tool to assess 
symptoms of problematic infant breastfeeding based on maternal self-report. 
● Maternal Perceived milk insufficiency (PMI)  
● Incidence of infection (e.g. mastitis) or troubles breastfeeding (e.g. engorgement) 
● Reason for stopping/difficulty breastfeeding (e.g. mother decision; medically directed) 
● Breastfeeding self-efficacy and social support 
● Use of kangaroo mother care; separation of mother and infant 
● IYCF support provided/program/education availability 
● Influence of family/friends (social norms) on breastfeeding behavior 
 
9.18.6 Infant health questionnaire 
Information on infant health will be captured through a questionnaire to the mother or primary 
caregiver (i.e. self-report from mother/caregiver), and clinical records (when available). The 
infant health questionnaire will include the topics below. We will also pilot infant morbidity in-
home diaries for mothers to record daily details on selected morbidities like diarrhea, vomiting 
and respiratory infections) that are most likely to influence infant feeding and growth. Diaries 
will be introduced at the Week 6 visit (when transitioning to monthly follow-up visits), and 
mothers will be instructed to fill the diaries to use as a recall aid for subsequent visits. An 
extended list of questions will be asked at 9 and 12 months and a short list may be asked during 
the phone calls. 
 
Infant severe morbidities and need for clinical care 
● Diarrheal disease   
Including history of: 
■ Persistent diarrhea (diarrhea that lasts for >14 days, often seen in infants who are 
malnourished)  
■ Acute diarrhea (diarrhea lasting 14 days or less) 
■ Severe diarrhea: diarrhea that is associated with signs of clinical dehydration 
including sunken eyes, lack of thirst, tenting with skin pinch, etc 
■ Hospitalizations for diarrheal illnesses (Bhandari 2003) 
● Pneumonia/acute respiratory infection - possible though maternal self-report and clinic 
records. Definition: cough or difficulty breathing plus either fast breathing or chest wall 
indrawing (WHO 2013). 
● Sepsis or other severe infection 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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■ Possible serious bacterial infection in a young infant: evidence of severe clinical 
illness in an infant aged 7-59 days per IMCI criteria 
■ Very severe febrile illness: Fever + danger signs in a child 60 days or older per 
IMCI criteria 
■ Positive blood culture or CSF culture at any age. This will be documented based 
upon maternal self-report, patient personal health records, or clinic record. 
● Malaria, diagnosed by rapid test or parasitological confirmation will be documented 
based upon maternal self-report, patient personal health records, or clinic record. 
● Necrotizing Enterocolitis (NEC): Definitions (based on clinic records and maternal 
report): 
(1) confirmed NEC – modified Bell’s stage II or greater with pneumatosis or 
portal venous gas on abdominal x-ray as well as intestinal (abdominal distention, 
blood in stool, abdominal tenderness) and clinical features (temperature 
instability, apnea, bradycardia, lethargy, metabolic acidosis, thrombocytopenia). 
(Kliegman and Walsh 1987)  
(2) suspected NEC – two of the following: abdominal distention, blood in stool, 
systemic features of lethargy/apnea/hypotonia. (Quigley 2018) 
● Seizures, neonatal encephalopathy (based on clinical records) 
● Hyperbilirubinemia/Kernicterus (based on clinical records) 
● HIV diagnosis: A subset of children whose mothers’ test negative in prenatal testing may 
have subsequent exposure due to maternal peripartum HIV infection. We anticipate that 
these children will be at higher nutritional risk. Additionally, some percentage of children 
who are HIV exposed will seroconvert during the six-month follow up period. We will 
encourage testing of all children who do not grow adequately for HIV and will also 
encourage testing of all children with known HIV exposure at intervals per the country 
standard of care. 
● Hospitalization: composite hospitalization for any reason. Clinic stay duration and 
discharge timing will be captured as well as supplementary feeds (e.g. nasogastric 
feedings, fortified feedings). 
● Malnutrition: Severe acute malnutrition (SAM)/ moderate acute malnutrition (MAM) 
 
 
Infant mortality (asked at all data collection time points, including follow up phone calls) 
● Date and time of death  
● Cause of death, if available via medical record, or verbal autopsy in Dar es Salaam. 
 
 
 
9.18.7 Maternal health questionnaire 
The questionnaire for the mother will cover self-reported incident conditions, i.e. illnesses. 
 
It will also assess symptoms of anxiety and depression using the PHQ-2 survey, which has 2 
questions with Likert responses. The PHQ-2 survey has been translated and validated in 
Chichewa and Swahili, Hindi, Kannada, Marathi, and Oriya. An extended list of questions will be 
asked at 9 and 12 months and a shortlist may be asked during the phone calls. 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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9.18.8 Follow up phone survey  
(Insert local partner name if applicable) 
 
In order to minimize loss to follow up, there will be additional touch points between the 6- and 9-
month visit (at around 7.5 months) and the 9- and 12-month visits (at around 10.5 months). This 
will be done in the form of a phone call. These calls will last approximately 15-20 minutes. 
Where a participant cannot be reached after numerous attempts, a home visit may be made. A 
short survey will be administered at these touch points asking mainly about the status of the infant 
and mother and about feeding. 
 
9.19 Ethics  
9.19.1 Risks to participants 
 
This study does not involve an experimental treatment or intervention. It does involve identification of a 
vulnerable population of infants who are low birthweight and who are nutritionally at risk given 
anthropometrics and growth trajectory. These patients will be managed per the current SOC and routine 
processes at each study site. A goal of this study is to gain better understanding about the SOC for 
management of this population. We anticipate that the SOC will vary by site. 
 
The risk to subjects will be minimized through adherence to local SOC. When an infant is identified as at 
risk, they will be referred to health officials to receive the local SOC feeding therapies. For the 
prospective cohort, will continue to follow enrolled participants through 12 months postpartum, including 
if the infant is admitted to a facility.  
 
The proposed study activities pose minimal, if any, added health risk to study participants. The population 
in this study is intrinsically at high risk for morbidity and mortality due to underlying LBW, but we do 
not anticipate that the study would contribute to these underlying risks.  
 
Because HIV positive mothers will be eligible for inclusion in the study, the risk of mother-to-child 
transmission will exist. However, HIV testing and treatment among pregnant women is high in the study 
sites, and thus the risk of transmission of HIV through breastfeeding is low.  
 
Less severe risks may include burden of travel and loss of economic productivity for families enrolled in 
the prospective cohort who report to the clinics for follow-up, as clinic attendance may be costly from 
both a monetary and time perspective 
 
There could also be inconvenienced or experience discomfort in direct observation of feeding practices 
immediately after childbirth and subsequently.  We will mitigate this by obtaining informed consent, 
emphasizing the right to opt out at any time, and employing female observers and providers.  
 
 
9.19.2 Informed consent 
 
The informed consent process for each of the data collection streams is described in their respective 
sections of this protocol.  
 
9.20 Data analysis 
As most of the quantitative data collected is being used for descriptive epidemiology of LBW infants, we 
will use means, medians and standard deviations to describe continuous variables. Categorical variables 

 
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will be analyzed with frequencies and proportions, as appropriate. Confidence intervals around all 
measures will be constructed to take any clustering into account. 
 
For anthropometric analyses, we will use the INTERGROWTH charts to describe growth velocity and 
trajectories for the infants, including stunting (length-for-age z-score, LAZ), underweight (weight-for-age 
z-score, WAZ), and wasting (weight-for-length z-score, WLZ). To determine Z-scores, we will use the 
INTERGROWTH-21st standards for preterm infants (<37 weeks gestation), and the WHO postnatal 
growth standards for term infants (>37 weeks gestation) (Villar et al 2015).   
 
Where possible, we will relate these anthropometric measures with reported infant feeding, using 
correlations for continuous variables or cross-tabulations of categorical variables. Any further analyses 
will be post-hoc and described separately. 
 
6-month extension:  
As with the original LIFE study, we will utilize mixed methods to fully understand the growth 
trajectories and care for LBW infants during the first 12 months of life. We will use the full cohort 
from 0 to 12 months of age to assess growth trajectories and velocities over time, evaluating the 
impact of complementary feeding (food types and timing) on infant anthropometrics, and assessing 
morbidities over time.  
  
We will use descriptive methods for initial description of the LBW cohort with means, medians and 
standard deviations for continuous variables. Categorical variables will be analyzed with frequencies 
and proportions, as appropriate. Confidence intervals around all measures will be constructed to take 
any clustering into account.  
  
For anthropometric analyses, for preterm infants we will use the INTERGROWTH-21st postnatal 
growth standards for preterm infants to describe growth velocity and trajectories for the infants up to 
12 months of age, including stunting (length-for-age z-score, LAZ), underweight (weight-for-age z-
score, WAZ), and wasting (weight-for-length z-score, WLZ). To determine Z-scores, we will use the 
INTERGROWTH-21st standards for preterm infants (<37 weeks gestation), and the WHO postnatal 
growth standards for term infants (>37 weeks gestation).  
  
We will use longitudinal multilevel models to assess the contribution of infant feeding and morbidity 
as well as maternal and household characteristics. Such models will also allow us to test whether 
there are differences in growth patterns related to gestational age and size for gestational age at birth, 
and whether the effects of care, feeding, and morbidity differ according to birth characteristics.  
 
 
 
10 Qualitative research 
 
As shown in Table 8, we will conduct FGDs and/or IDIs with a variety of stakeholders including 
clinicians, first-time and experienced mothers, family members, religious leaders, community leaders, 
traditional health care providers, supply chain and milk bank experts, and Ministry of Health officials. We 
might also speak with individuals that have been identified through the interviews as having a specific set 
of expertise or experience relating to the domains below. We recommend a minimum and maximum 
number of FGDs or IDIs for each of the populations that allows sites flexibility for religious leaders, 
community leaders, and traditional healers based on their context and which group is the most appropriate 

 
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to approach for these discussions. Each discussion will cover the domains listed – as well as others as 
they arise – corresponding directly to one or more of our study objectives. 
 
 
Table 8: Focus groups and in-depth interviews, with domains for discussion 
Meets 
objective 
Focus group discussions 
8-12  
total 
Domains for discussion 
1 
2 
3 
Mothers of preterm LBW 
infants aged 0-3 months 
1 
Beliefs and norms around IYCF practices 
Feasibility and acceptability of IYCF options 
Preferences around IYCF support 
Barriers and facilitators to IYCF 
✓ 
 
✓ 
Mothers of full-term LBW 
infants aged 0-3 months 
1 
Mothers of preterm LBW 
infants aged 4-7 months 
1 
Mothers of full-term LBW 
infants aged 4-7 months 
1 
Male family members of LBW 
infants 
1-2 
Beliefs and norms around IYCF practices 
Feasibility and acceptability of IYCF options 
Role of family and community in IYCF practices 
✓ 
 
✓ 
Female family members of 
LBW infants 
1-2 
Religious leaders 
2-4 
Beliefs and norms around IYCF practices 
Barriers and facilitators to IYCF implementation 
Feasibility and acceptability of IYCF options 
Religious and community leaders only:  
Role of religious or community leaders in IYCF 
Religious or community beliefs and rules around IYCF 
✓ 
 
✓ 
Community leaders 
Traditional healers 
 
Health Care Workers: 
Nurses, nurse midwives, 
midwives 
8-20 
Current SOC for LBW infants 
Feasibility and acceptability of IYCF options 
Barriers and facilitators to IYCF implementation 
Prior IYCF strategies and lessons learned 
✓ 
 
✓ 
In-depth interviews 
38-84 
total 
Domains for discussion 
1 
2 
3 
Health Care Workers: 
Doctors 
8-20 
Current SOC for LBW infants 
Feasibility and acceptability of IYCF options 
Barriers and facilitators to IYCF implementation 
Prior IYCF strategies and lessons learned 
✓ 
 
✓ 
 
 
Community health workers 
8-20 
MOH and other govt. 
officials 
2-4 
Commitment to LBW infant feeding strategies 
Possible risks and their mitigation 
Prior IYCF strategies and lessons learned 
✓ 
 
✓ 

 
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Recommendations for implementation 
Supply chain experts 
2-4 
How BMS and bottled water can be distributed reliably in 
the community 
How external factors affect the supply chain 
Barriers and facilitators to a reliable supply chain 
 
 
✓ 
Human milk bank experts 
2-4 
How DHM can be distributed reliably in the community 
How external factors affect the supply of DHM 
Barriers and facilitators to establishing human milk banks 
 
 
✓ 
In-depth interviews(extension)  
16-20 
total 
Domains for discussion 
1 
2 
3 
Mothers of LBW infants aged 
9-12 months, male, growing 
well 
4 
Feeding practices 
Home environment 
Maternal and infant well-being 
Growth of infant 
 
✓ 
 
✓ 
Mothers of LBW infants aged 
9-12 months, female, 
growing well 
4 
Mothers of LBW infants aged 
9-12 months, male, not 
growing well 
4 
Mothers of LBW infants aged 
9-12 months, female, not 
growing well 
4 
 
 
 
 
 
 
 
10.1 Focus group eligibility criteria 
 
Mothers 
These four focus groups will include mothers of LBW infants only. Two groups will include 
mothers of LBW infants aged 0-3 months, and two for mothers of LBW infants aged 4-7 months. 
The groups will be further stratified by preterm and full-term infants.  
 
Mothers with healthy birthweight infants or VLBW infants will be excluded. Mothers with HIV 
will be eligible for participation. Mothers under the age of 18 will be excluded in India and 
Tanzania, and unmarried mothers under the age of 16 will be excluded in Malawi.  
 
Mothers’ participation in the prospective and observational studies will not impact their eligibility 
for participation in the focus group discussions. Should sites find it difficult to recruit mothers for 
focus group discussions then they will be able to conduct individual interviews instead. 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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Mother’s family members 
Family members with the following relationship to a mother of a LBW infant up to 7 months old 
are eligible to participate: husbands, guardians, mother’s parents, mother’s in-laws, 
grandmothers, sisters, and sisters-in-law. The focus groups will be separated by gender: fathers, 
husbands, and grandfathers in their own group, and sisters, sisters-in-law, and grandmothers in a 
separate group. In India, the female focus groups will be further separated into family members 
from the mother’s generation (sisters, sisters in law) and those from the older generation 
(mothers-in-law, grandmothers.) 
 
To be eligible, relatives must play a role in providing opinions, care, or support for the mother 
related to IYCF. Eligible family members do not need to be family members of the participating 
mothers in the project; they only need to be family members of a current mother with a LBW 
infant. Family members are eligible to participate even if the mother has died or if the mother is 
not participating in the focus groups, observation, or prospective components of the study. 
 
 
Religious leaders, community leaders, or traditional healers  
 
The aim of these focus groups is to capture the social norms and pressures on breastfeeding 
behavior in the community beyond women’s immediate families. The intent is that the three 
categories of people can inform the study of religious, social, and naturopathic norms in each site.  
 
For each focus group, sites can decide the best composition for the group. For example, the FGDs 
can be segregated by role (i.e. only religious leaders in a single group) or by gender (i.e. female 
community leaders and female traditional healers in a single group), but the compositions are not 
limited to these options. While both men and women will be eligible for these focus groups, they 
need not be separated by gender. All sites will conduct between 2-4 FGDs and determine which 
roles are appropriate to participate in focus groups based on what is relevant for that context.  
 
Religious leaders will be eligible if they are recognized leaders of the community’s primary 
religion(s). Community leaders or elders will be eligible if they are viewed as opinion leaders or 
having significant influence over IYCF practices in the area. Traditional healers are those in the 
community who provide non-Western medical care, and these individuals will be eligible for 
participation if they provide care directly to mothers or infants related to IYCF practices, or 
advise other people who carry out, support, or influence infant feeding.  
 
Health care workers 
Health care workers who are currently involved in providing support for IYCF will be eligible. 
They must either provide care directly to mothers or infants, provide advice to people who feed or 
support/influence feeding, or support or supervise other clinicians that directly provide care to 
mothers or infants. Health care workers who could be involved in the future in providing support 
for IYCF will also be eligible. Examples of healthcare workers include nurses, nurse midwives, 
and midwives. We will exclude health care workers who have been at their position for less than 
six months 
 
 
 
10.2 Language of focus group discussions 
 

 
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Focus group discussions with health care workers will be in English. Focus group discussions with 
mothers, family members, religious leaders, community leaders, and traditional healers will be conducted 
in the local language. As shown in Table 3 above, these FGDs will be carried out in Chichewa in 
Lilongwe, and in Swahili in Dar es Salaam. In Odisha, there are two main local languages, Oriya and 
Hindi, so we will split the focus groups by language. For example, of the two FGDs with mothers of 
infants 0-3 months old, one will be conducted in Hindi and the other in Oriya. Similarly, in Karnataka, 
there are three local languages, Kannada, Marathi, and Hindi, and we will split FGDs by language. 
 
 
10.3 In-depth interview eligibility criteria 
Clinicians 
Clinicians who are currently involved in providing support for IYCF will be eligible. They must 
either provide care directly to mothers or infants, provide advice to people who feed or 
support/influence feeding, or support or supervise other clinicians that directly provide care to 
mothers or infants. Clinicians who could be involved in the future in providing support for IYCF 
will also be eligible. Examples of doctors include OB/GYN, neonatologists, outpatient 
physicians, and pediatricians. The nurse cohort may include nurses, nurse midwives, and lactation 
nurses. We are also interested in speaking with community health workers that are connected to a 
study facility. While we provide clinician examples here, in-depth interviews may not be limited 
to these types of providers. 
 
We will exclude clinicians who have been at the facility for less than six months.  
 
Of note, some sites might determine that the nurse cohort or other health care worker cadres are 
better suited as a focus group discussion instead of an in-depth interview. In this case, the 
eligibility criteria remain the same, and interview facilitators will use the same interview guide 
with clearly marked questions for the focus group discussions. 
 
Ministry of Health and other government officials 
 
Any members of the MOH or other government officials whose responsibilities include 
supporting (e.g., human resource or budget) or participating in IYCF studies, quality 
improvement initiatives, or implementation programs, or whose support would be necessary for 
the success of an IYCF program, are eligible for inclusion.  
 
We will exclude officials who have been in their post for less than six months. 
 
Supply chain experts 
 
Individuals who are involved in or provide oversight for the local supply chain of resources 
potentially needed for an IYCF intervention, or who has expert knowledge about local supply 
chains, is eligible for inclusion. These may be government employees or staff of independent 
NGOs, either domestic or international.  
 
The interviews will include people knowledgeable about centralized, systemic distribution of 
supplies needed for an IYCF intervention, such as managers of drug stores, vaccine depots, or 
public health supplies. We will also include individuals in the local study  facility that order or 
receive the supplies needed for an IYCF intervention. 
 
Human milk bank experts 

 
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Anyone who has knowledge or experience with local human milk banks or the establishment and 
operation of human milk banks in other LMICs is eligible for inclusion. This could include those 
who have established HMB, have tried to, or are currently planning their development. This could 
include global leaders or those in-country that have experience with HMB or are familiar with the 
concept. Examples of in-country individuals could be community leaders involved with nutrition 
or newborn or maternal health. 
 
      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. These mother-
infant pairs will be divided by growth status (faltering vs not faltering based on z-scores) and by 
sex of the infant.  
 
 
10.4 Recruitment  
 
The recruitment method for each population will be somewhat different, as described below: 
 
Clinicians and health care workers 
 
Site clinicians and health care workers will be approached in person by study staff members when 
convenient. Identification of clinicians might come from site leadership members or other 
clinicians that participate in the focus group discussions.  
 
Mothers of LBW infants 
 
Recruitment of mothers of LBW infants for the focus group discussions will be done by study 
staff members during clinic hours. They will approach women at a convenient time when they are 
at the facility. This could be before discharge or when the woman comes in for a postnatal visit 
for either herself or her baby. 
 
Family members of mothers of LBW infants 
 
Recruitment of family members of mothers of LBW infants will be done by study staff members. 
Individuals can be recruited in two primary ways: 1) through the mothers that participate in the 
FGDs or 2) if they accompany the woman to a postnatal visit at the facility. A secondary method 
of recruitment is through the facility’s Community Advisory Board that provides outreach to 
community members. 
 
Religious and community leaders 
 
Religious and community leaders will be recruited by either study staff members or Community 
Advisory Board members.  
 
Traditional healers 
 
Traditional healers will be recruited by study staff members or Community Advisory Board 
members. 
 

 
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MOH and other government officials 
 
Recruitment of Ministry of Health or other government officials will be done by senior study staff 
members and project partners. We will recruit by the individual’s function in the government, and 
their relation to IYCF policies. Recruitment might also be done by snowball sampling as 
interviewees might identify others with expert knowledge in IYCF practices, policies, and 
guidelines. 
 
Supply chain experts 
 
Recruitment of supply chain experts will be done by study staff members. We will request contact 
information for individuals that are involved with the distribution of IYCF supplies as well as 
facility staff members that order and receive IYCF supplies. We will employ snowball sampling 
for the identification and recruitment of supply chain experts. 
 
Human milk bank experts 
 
In India only, human milk bank experts will be recruited by study staff members. We will request 
contact information for individuals to conduct interviews with and employ snowball sampling for 
further recruitment. 
 
Mothers (6-month extension) 
 
Mothers will be recruited by study staff in person when they are at facility for a clinic visit or via 
phone. They will approach women at a convenient time when they are at the facility. All mothers 
who will be approached will be current participants in the prospective cohort study. Study staff 
members will approach these individuals and read the consent form and recruitment script in 
private. If recruited for the IDIs, the study staff will schedule a time to conduct the interview 
either at home or before/after a scheduled facility visit.    
10.5 Informed consent 
The study team will obtain written informed consent from all participants before the start of the interview 
or focus group discussion. 
 
10.6 Conduct of groups and interviews 
If key informants are unable to participate in FGDs then they will be interviewed individually or in pairs.  
 
All parties participating in a focus group discussion or interview will be provided a study fact / 
recruitment sheet prior to the interview or focus group.  
 
All IDIs and FGDs will be conducted by a facilitator and 1-2 note takers in a private location that is 
convenient for participants. If possible, the interviews may be done at the facility or participant’s office, 
as appropriate. At the study start, trainers may also attend to observe the facilitator to ensure the quality of 
data collection. All discussions will be audio recorded. Notes for FGDs and IDIs will be taken in either 
English or the local language based on the note taker, and any notes taken in the local language will be 
translated into English immediately following the conversations. Discussions will be analyzed using rapid 
qualitative analysis, which involves taking notes during interviews and focus groups then writing 
summaries of key messages immediately following the conversation based on recall of the conversation 
and the notes.  

 
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For the extension: The interview guides will be analyzed using thematic coding of the interview 
transcripts 
10.7 Data analysis 
Messages will be organized by themes/topics in the knowledge management tool. Content of each 
transcript or theme/topic will be reviewed on a regular basis (after every several interviews/focus groups).  
Learnings from earlier conversations can inform iterations of interview and focus group guides to explore 
some areas more in-depth or new areas of interest. A comprehensive analysis of the key messages will be 
done at the end of the data collection phase to inform intervention, study, and implementation 
recommendations. 
 
Audio recordings of IDIs and FGDs may be transcribed and translated for potential future analyses and to 
ensure that a complete data set is available. All IDIs performed during the extension will be transcribed 
and translated.  
 
  
10.8 Schedule of data collection 
 
Each site is planning for a total of 8-12 focus groups. The focus groups will be broken down by 
respondent type, with 2-4 focus groups (consisting of approximately 5-8 participants per group) with each 
of the following cohorts: mothers, family members, and recognized community members (includes 
community leaders, traditional healers, and religious leaders). We expect a maximum of 384 individuals 
participating in focus groups across all sites. 
 
Each site is planning for 6-12 semi-structured in-depth interviews with non-clinicians. The interviews will 
be broken down by respondent type, with 2-4 interviews among each of the following cohorts: 
government officials, supply chain experts, and human milk bank experts. Sites will also conduct in-depth 
interviews with clinicians with a maximum of 40 clinicians and or community health workers at each 
study facility. For example, this could be up to 24 clinician interviews in Malawi’s two study facilities. 
Sites will determine the number of clinicians and clinician roles included in the interviews based on who 
would be most appropriate to speak with in their context and the number of clinicians on staff. Dependent 
on the number and size of facilities, as well as individual staffing characteristics, there will be up to 38-84 
data collection events per site over the period allotted in the study timeline. The timing of data collection 
will depend on the subjects’ and interviewers’ availability, and sites and the study team will be flexible 
with the proposed timing. We expect a maximum of 288 individuals participating in in-depth interviews 
across all sites. For the 6-month extension, in total, up to 20 mothers per study site will participate in the 
IDIs. We expect a maximum of 80 mothers participating in the in-depth interviews across all sites. 
 
 
10.9 Ethics  
 
The risks to participants in the FGDs are the possibility of feeling uncomfortable sharing their opinions or 
hearing the opinions of others, or having others from the group think poorly of them because of their 
opinions or the experiences they choose to share. However, participants will be told that they do not need 
to answer any questions that they are not comfortable answering, and participants can choose what they 
do and do not want to share with the group. All participants will be asked to keep the discussion 
confidential and not share the identities of participants, but we will not be able to ensure compliance with 
this request. Again, participation, lack thereof, or withdrawal of consent will not affect clinical care of 
patient participants, or employment of clinical staff participants. 

 
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The risk to participants in the IDIs is the possibility of feeling uncomfortable sharing their opinions. 
However, participants will be told that they do not need to answer any questions that they are not 
comfortable answering and participants can choose what they do and do not want to share. 
 
Participants in IDIs and FGDs will receive reimbursement for their participation, as identified by sites 
(Table 9) 
 
 
 
Table 9: Reimbursements for participation in FGDs and IDIs 
Study Site 
Incentive 
Karnataka 
Participants will receive loss of wages, travel allowance and dearness allowance (DA) for 
each study visit, not to exceed US $15 
Odisha 
Participants will receive loss of wages, travel allowance and dearness allowance (DA) for 
each study visit, not to exceed US $15 
Lilongwe 
Participants will receive the Malawi Kwacha equivalent to US $10 for participating. This 
amount is to cover the costs of transport expenses to and from the interview / focus group. 
Snacks and sodas will also be provided for focus group participants. 
Dar es Salaam 
Participants will receive travel allowances for participating in the focus group, not to exceed 
US $25. 
 
Participants in IDIs and FGDs will not receive direct benefits from participating, other than transportation 
reimbursement in some sites. They may feel personal satisfaction knowing that they are contributing to 
the development of an IYCF that may benefit themselves or others in their community. 
 
 

 
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11 Desk research 
 
11.1 Chart review 
The goal of the chart review is to document the routine and SOC at each site prior to the start of the study. 
Although LIFE is non-interventional, the extra attention that the study will bring to infant feeding issues 
in the facilities may affect the SOC we observe. In particular, having an observer present may alter 
clinicians’ or mothers’ behaviors in ways that are difficult to measure. The chart review data will allow us 
to compare the SOC we observe in LIFE to what was occurring just before LIFE began. This will 
augment our picture of the true SOC. 
 
We will review 155 retrospective charts of LBW births at each study site; the number of individuals 
included will be up to155 mothers (to account for errors) and their infants (up to 200 infants, accounting 
for twins). Cases will be selected by the inclusion/exclusion criteria (see below), taking all qualifying 
cases that occurred as chronologically close as possible to the start of the LIFE study. Since the purpose is 
to understand routine and SOC before the LIFE study, we will not review any cases admitted after the 
study launch. 
 
We will abstract information on infant feeding volume and frequency, status at discharge and information 
given, as well as any available health outcomes (anthropometrics, morbidities, etc.). As much as possible, 
the data collected in the chart review will mirror that collected in the in-facility observations. 
 
11.1.1 Inclusion/exclusion criteria 
 
These criteria for the chart review are nearly the same as those for the in-facility observations. See that 
section above for definitions of each. 
 
The inclusion criteria for the mother/infant pair for the chart review are: 
 
Infant birthweight between 1500 and <2500 g 
Discharged before the launch of LIFE at site (specific date TBD) 
 
Exclusion criteria for the mother/infant pair are: 
 
Infant very low birthweight 
Congenital abnormality that interferes with feeding 
Young mother 
Maternal death  (occurring at any time before the baby’s discharge from the facility) 
Out-of-facility birth 
Infant death at facility within 72 hours of birth 
 
Mother-infant pairs with the following traits will still be eligible for the chart review, given that no 
exclusion criteria are met. 
 
Nighttime birth 
These cases are excluded from the in-facility observations because of the difficulty of having 
study staff present overnight. However, no such restriction applies to the chart review cohort, so 
we will take the opportunity to document these infants’ experiences. 
Critical or severe illness jeopardizing early survival 
Gestational age 

 
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Multiples 
Maternal HIV Status 
Language 
 
 
11.2 Literature reviews 
We will conduct two literature reviews to support the study aims. The first will be carried out in the early 
study period, while the protocols are with ethics boards. This literature review will cover topics in infant 
feeding research in the three study countries, including documented SOC for LBW infants, how clinical 
guidelines are applied in SOC, previous IYCF interventions involving LBW infants, facilitators and 
barriers to implementation of interventions, current procurement practices for BMS and DHM, and 
volume requirements for BMS and DHM. 
 
The second will be carried out as data collection for the prospective cohort is winding down and data 
analysis is beginning (see study timeline). This “umbrella” literature review will survey other literature 
reviews and meta-analyses on LBW infant nutrition in LMICs, as well as reviews of IYCF interventions 
in LMICs. The results of this review will inform the country-level analysis workshops, synthesis of 
findings, and overall design of the IYCF intervention. 
 
12 Donor Human Milk Readiness Assessment Surveys 
 
12.1 Donor Human Milk Readiness Assessments Surveys 
There are a number of different tools that will be used for this activity depending on whether a site has a 
DHM bank, had government buy-in to a DHM bank and the comfort of the study staff. There are 4 
different tools: (1) a validated DHM assessment of an existing DHM bank in India-Karnataka, (2) a 
validated India-specific DHM readiness assessment tool for other facilities in India, (3) a general 
validated DHM readiness assessment tool to be used outside India and (4) a qualitative guide to use for 
observation of flow and discussion with key informants at facilities. 
This activity is designed to collect information needed to inform future research activities that may utilize 
existing donor human milk banks or establish donor human milk banks for research. PATH and /or the 
study staff will provide consent forms to participants and will ask  for verbal consent before proceeding 
with the survey questions.  
 
12.2 Inclusion/exclusion criteria 
• 
Frontline clinicians who participate in maternal and newborn care as well as department and 
facility leaders/ stakeholders at LIFE study health facilities in India, Malawi and Tanzania. 
• 
Those who are willing to participate and provide verbal consent 
 
 
12.3 Sample size 
 

 
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For the validated tool: to assess the functioning of the existing DHM bank at one facility in India-
Karnataka – completed by PATH in consultation with facility staff. The total number completed tools will 
be one for only one facility with a DHM bank in India-Karnataka.  
 
For the mixed methods validated tool: to assess DHM readiness that will be completed per study facility - 
completed by PATH with the help of up to 14 key stakeholders. The total number completed tools per site 
will be up to 5. The total number of tools completed across all sites will be up to 12. 
For the qualitative tool: to assess DHM readiness, the questions in the tool guide will be asked of up to 10 
key informants based on their availability during the tour of each study facility. This will only be used in 
Tanzania and in up to 3 facilities in total.  
 
12.4 Data collection 
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. 
 
Participants will not be formally recruited and do not need to give their name or any identifying 
information. Some key stakeholder at the facility level will be alerted about when data collection will take 
place and those who are available at the time of the facility visit/tour will be consulted and read the 
recruitment script. They will be given a copy of the consent form and asked to verbally consent.   
 
After reading the recruitment script and confirming eligibility, study staff/ PATH team will administer the 
consent script to verbally consent the clinicians/leaders, ensuring that they describe the trial, risks, 
benefits, what will be involved and answer any questions that the participants may have. Data collectors 
(the PATH team) will speak with clinicians who are present at the study facility at the time of the 
assessment/ tour to supplement observations of readiness and answer questions about the facility. 
 
 
12.5 Data analysis 
We will conduct a descriptive analysis of the flow and infrastructure of facilities related to the possible 
establishment of DHM banks.  We will also conduct thematic coding of qualitative data.  
 
13Monitoring and Quality Assurance 
Designated study personnel at Ariadne Labs and country sites will be responsible for the data monitoring 
activities, which will occur frequently throughout the study. Planned meetings will occur on a regular 
basis to review study implementation and address any concerns regarding data collection tools or data 
quality. Given the formative, multi-site nature of the study, we will work closely with sites to adapt 
current processes and data infrastructure to ensure accuracy and reliability of data collection across study 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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sites. We will integrate cycles of change into our technology development to enable adaptability as the 
study evolves.  
 
13.1 Quantitative data streams 
Data quality will be ensured through the following mechanisms: 
 
● Standardized data collection methodologies through adapting existing systems or utilizing new 
systems, at our partner sites, with the option for  web-based, mobile, tablet, or netbook app if 
possible, which allows for offline data collection and syncing when connectivity is available. 
● For sites using the CommCare electronic data capture application from Dimagi, for one or more 
data streams, data will be encrypted and stored according to each country’s data privacy 
regulations.  Data transfer will use industry-standard HTTPS or Secure File transfer protocols. 
● For sites that use their own data collection tools for one or more data streams, we will establish 
controls for data security and transfer in accordance with all site requirements. 
● Front end checks in data entry templates will be implemented in the electronic data capture 
applications whenever possible. For example, the in-Facility Observation, Chart Reviews, and 
Prospective Cohort data collection forms where possible will have built-in validation and logic 
checks, data type restrictions, and drop-down or multiple choice options to minimize data entry 
errors. 
● Back-end checks to enable comparison of multiple data sources, which will aid in validating 
accuracy and concordance of collected data. 
● Development and review of a Data Quality Assurance protocol in coordination with sites and 
study collaborators to assess data validity, reliability, and accuracy. The DQA protocol will set 
forth procedures for the data entry range and logic checks mentioned above, data cleaning 
protocols, and ongoing data review and feedback. We will explore the possibility of conducting 
double entry validation to ensure data quality and coaching of poor performing data collectors.  
● Construction of Universal ID’s based on local data, using a longitudinal system to register 
patients at initial point of contact and then follow up for multiple points of reassessment.   
 
All data transferred to Ariadne Labs will be stored on an Amazon Web Services server in a secure 
environment approved by Harvard University Information Technology (HUIT). Additionally, data may be 
stored on the secure Harvard shared drive. The information security controls for all stored data will equal 
or exceed HUIT requirements for the applicable level of data sensitivity classification, such as the 
following best practice controls:  
● all data will be encrypted in transit and at rest 
● servers containing sensitive data will not be exposed to the internet 
● access will be restricted to authorized personnel by role via proxy servers using AWS security 
groups and private subnets.  
● users will be required to login and passwords will be a minimum of 8 characters and be 
alphanumeric.  
● vulnerability scanning will be performed daily and all user activity will be logged. 
 
We will also establish reporting services, which will provide data back to mobile or web users through a 
web-portal or notification service. Reports will be generated in three broad categories: 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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● Monitoring and managing Operations, such as site progress reports, day-to-day task lists for field 
workers, lost to follow up rates and risks, etc. 
● Monitoring and managing Data Quality 
● Supporting execution of activities 
 
We will align these processes with the site and local IRB requirements. 
 
13.2 Qualitative data streams 
 
With a multidisciplinary team including representatives from each test site, we will develop semi-
structured interview guides for the focus groups and individual interviews that will be primarily 
consistent across the sites but with some site-specific questions. The guides will be pilot tested in each 
site and revised as needed. Along with these guides, we will develop a knowledge management tool for 
qualitative data to ensure consistency and completeness in reporting. Staff will be trained on how to 
document key themes and engage in rapid qualitative analysis, and how to enter this content into the 
knowledge management tool.  
 
These data will be reviewed on an ongoing basis and feedback and/or additional re-training will be 
provided, as needed. In order to ensure that IDIs and FGDs are being conducted consistently and 
appropriately across all sites, all IDI/FGD facilitators will be trained to lead these discussions (see 
training section above), and we will expedite a small number of transcripts from each facilitator to be 
transcribed and translated for review by our team. For this review process, we will develop and 
implement a quality control checklist for best practices for conducting IDIs and FGDs, and if we find that 
facilitators are deviating from the checklist, we will provide feedback and if necessary, re-train staff. 
Additional review of translated transcripts will be conducted until each facilitator is performing at a 
satisfactory level. IDI transcripts and FGD notes will be translated into English by the 
facilitators/notetakers/transcriber immediately following each interview/FGD, and these translated notes 
will be reviewed on an ongoing basis by our team. 
14 Partners and experts 
 
We will bring together a range of partners and experts to design, monitor, and implement LIFE (Table 
10). We will work with three country partners that will engage in on the ground implementation in 
Malawi (1 site), Tanzania (1 site), and India (2 sites). We will engage with a range of partners to provide 
world class expertise in donor human milk and milk bank design in LMICs, nutrition, feeding, 
neonatology, etc. to provide design, monitoring and implementation input into all aspects of the research. 
We will also develop relationships with state and national governments, as well as the World Health 
Organization, to ensure buy-in and support for the work and results. 
 
Table 10: Study partners 
Partner 
Role and area of expertise 
Bill and Melinda 
Gates Foundation 
Funder & Steering Committee Member 
Harvard TH Chan 
School of Public 
Health/ Ariadne 
Labs 
Project Leadership. Ariadne Labs will provide both scientific and management leadership for the 
project design, monitoring and implementation of this project, overseeing all partners and 
ensuring their coordination. 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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Ariadne Labs is a joint center between Brigham and Women’s Hospital and the Harvard T.H. 
Chan School of Public Health. Ariadne Labs’ mission is to create scalable health care solutions 
that deliver better care at the most critical moments in people’s lives, everywhere. Ariadne Labs’ 
solutions and tools are simple, practical and designed to have global impact. The work of Ariadne 
Labs is rooted in rigorous scientific methodology and best practices in industry for 
implementation. Each body of work is built on a foundation of innovative use of informatics, 
measurement, implementation and improvement science, and professional program management.  
 
Ariadne Labs has unique experience and success in designing and managing successful large 
scale, complex trials in maternal and newborn health. Areas of expertise include: large scale 
coordination; complex trial implementation in Asia and Africa; applied solutions and driving 
scale; data capture and feedback; community and facility-based follow up; formative and 
qualitative research; and practical field applications of solutions. 
Jawaharlal Nehru 
Medical College 
(JNMC), 
Belgaum 
Site Implementation. The central team of investigators from the Women’s and Children’s Health 
Research Unit (WCRU) of JNMC Belgaum will lead the implementation of the project in 2 
geographies/sites in India (5 facilities in Karnataka State and 3 facilities in Odisha State). 
 
The facilities in Karnataka with capacity to eventually run an efficacy trial are located in different 
parts of the state. Clinical and cultural practices are known to be significantly different between 
the facility sites, as such it is recommended to capture data from the 5 sites. Some of the data 
collection support processes have been centralized to do this in an efficient way. 
 
The WCRU at JNMC has vast experience of implementing both facility and community based 
clinical trials in the area of maternal and newborn health since 2001, when the unit was 
established with NICHD funding. Complementary work has included establishing five regional 
data centers towards a maternal newborn health registry, training research faculty, and 
strengthening IRB and study management systems. The center is skilled in community-based 
interventions and research. 
 
The proposed team includes expertise in neonatology care for preterm and LBW infants; milk 
bank design; and large-scale implementation of clinical trials in LMIC. 
 
SCB Medical College will act as the partner in Odisha State for implementation. Their site is 
experienced in coordinating with JNMC for the implementation of two recent WHO clinical 
trials.  
 
MUHAS/ HSPH, 
Tanzania 
Site Implementation. The MUHAS-Harvard team will lead the implementation of the project 
across 3 facilities in Dar-es-Salaam, Tanzania. 
 
The MUHAS-Harvard partnership recently celebrated the 25th year of collaboration during which 
the team has conducted more than 20 randomized trials of nutrition and infection interventions 
and many other bilateral research and training activities in Tanzania and Boston.  These trials 
have evaluated the effect of maternal and child micronutrient supplementation, antibiotics, 
antiretrovirals and other maternal and child health interventions on child survival, growth and 
broader development. The site investigators have also participated in large collaborative multi-
country trials. The partnership has developed a strong follow-up system that uses a combination 
of facility and community based tracking activities.  
 
The proposed team includes expertise in nutrition, infant feeding supplementation, and 
implementation of efficacy trials in Tanzania.  
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
59 
 
UNC Project 
Malawi 
(UNCPM) 
Site Implementation and expert technical assistance . The UNC Project Malawi team will lead the 
implementation of the project across two facilities in Lilongwe, Malawi. Additionally, four 
faculty from UNC-Chapel Hill will provide subject matter expertise in neonatology, infant 
feeding and human nutrition. 
 
UNC Project Malawi (UNCPM) is a clinical research site (CRS) for the UNC Global HIV 
Clinical Trials Unit. It is a biomedical research institution in Malawi. Its mission is to identify 
innovative, culturally acceptable, and affordable methods to improve the health of the people of 
Malawi through research, health service strengthening, prevention, training and care. It has three 
main areas of work; research, training and clinical care service support.  
 
UNCPM is a >20-year collaboration between the University of North Carolina at Chapel Hill and 
the Malawi Ministry of Health. UNCPM has been an active Clinical Research Site for the 
National Institutes of Health Division of AIDS since 2001.  
Current ongoing research studies are from grants mainly sponsored by the NIH, Centers for 
Disease Control and Prevention (CDC), Bill and Melinda Gates Foundation, and the EDCTP. The 
institution manages grants in the excess of $12 million annually. In the past 5 years, the 
institution has enrolled more than 12,000 participants onto 40 randomized clinical trials. 
 
The proposed team includes expertise in the conduct of research in Malawi, pediatrics, and infant 
feeding strategies for low birthweight infants. 
Emory University Expert technical assistance. Provide expert guidance in the nutrition, WASH, Infant and Young 
Child Feeding, and behavioral health and education aspects of the project and provide inputs as 
required for the tasks outlined under the scope of work, and aid in formative research, program 
implementation and evaluation and write up. 
 
The Hubert Dept Global Health at the Rollins School of Public Health at Emory University seeks 
to improve health services and delivery systems around the world through research, teaching and 
service.  
 
The proposed team includes expertise in maternal nutrition, breastfeeding and child nutrition and 
WASH. 
Brigham and 
Women’s 
Hospital 
Expert technical assistance. Provide expert guidance in the care of vulnerable infants aspects of 
the project and provide inputs as required for the tasks outlined under the scope of work, and aid 
in formative research, program implementation and evaluation and write up.  
 
The Brigham and Women’s Hospital (BWH) Global Newborn Health Lab is dedicated to 
improving the survival, health, and potential of mothers and newborns in low-income countries. 
Research at the BWH Global Newborn Health Lab is focused on the prevention, management, 
and improvement of outcomes for the major newborn illnesses in low-income countries. The Lab 
aims to (1) improve epidemiologic evidence on the major causes of newborn morbidity and 
mortality in low-income settings and (2) design and evaluate innovative, high-impact, and 
scalable public health interventions that target the major causes of neonatal morbidity and 
mortality in low-income settings. 
 
Dr. Lee has expertise in pediatric and newborn care, as well as clinical trials in LMIC. Dr. Lee 
will provide guidance on outcomes determination and the safety-monitoring plan. 
PATH 
Expert technical assistance. Provide expert guidance in the facility assessment, flow of the milk, 
and human milk bank aspects of the project and provide inputs as required for the tasks outlined 
under the scope of work. 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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PATH is a global team of innovators working to accelerate health equity so all people and 
communities can thrive. They advise and partner with public institutions, businesses, grassroots 
groups, and investors to solve the world’s most pressing health challenges. 
 
The proposed team includes expertise in IYCF, breastfeeding and human milk banks. 
 
 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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15 Study timelines 
Year 1 (2019) 
Year 2 (2020) 
Q1 
Q2 
Q3 
Q4 
Q1 
Q2 
Q3 
Q4 
No De Ja Fe Ma Ap Ma Jn Jl Au Se Oc No De Ja Fe Ma Ap Ma Jn Jl Au Se Oc 
Activity 
Details 
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 
Preliminary activities 
Issue subcontracts 
Develop protocol, methodology, consent forms, 
translations 
Approvals from ethics boards, governments 
Data Collection Preparation 
Personnel 
Hiring, on-boarding, training 
Develop data 
processes  
SOPs, data architecture, data 
quality assurance plan 
Procurement 
Assets: tablets, computers, 
measurement tools 
Relationship 
development 
Stakeholder buy-in (national and 
facility level) 
In-facility observations of LBW infants 
Data collection 
Target N = 45/site 
Data analysis  
Prospective cohort 
Data collection 
Enrollment period, N=300/site 
Follow up period 
Data analysis  
6-week outcomes 
6-month outcomes  
Facility Context Assessments 
Data collection 
Administered at end of study at 
each site 
Data analysis 
Qualitative research 
Data collection 
FDGs, IDIs, 
Translation/Transcription 
Data analysis 
Desk research: Chart review 
Data collection 
Target n = 155 per site 
Data analysis  
6-wk and 6-mo outcomes 
Desk research: Literature review 
Initial review 
Main review 
Propose a Strategy for Testing 
Synthesis of findings Analyze data streams together 
where possible 
Interpretation of 
findings 
Country-level analysis 
workshops 
Design IYCF 
strategies 
Draft IYCF design, write white 
paper, refine strategies with 
stakeholders 
 
 

 
LIFE Protocol v9,18 March 2020 DEPLOY 
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15.1 Study Extension Timeline  
 
 
Year 1 (2020) 
Year 2 (2021) 
Q1 
Q2 
Q3 
Q4 
Q1 
Q2 
Q3 
Q4 
No De Ja Fe Ma Ap Ma Jn Jl Au Se Oc No De Ja Fe Ma Ap Ma Jn Jl Au Se Oc 
Activity 
Details 
1 
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 
Prospective cohort 
Data collection 
Enrollment period, N=300/site 
Follow up period 
Data analysis  
9-month outcomes 
12-month outcomes  
Qualitative research 
Data collection 
IDI, Translation/Transcription 
Data analysis 
 
 
 
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17 Appendix A: Protocol for measuring infant weight, length, head 
circumference, and MUAC 
 
All measures will be taken by trained study personnel.  
 
Weight will be measured using a digital weighing scale with 10 gram precision consistent across sites. 
The scale will be placed on a flat, hard surface and will be tared to zero prior to each measurement. The 
infant is to be naked with no clothing or diaper, and should be calm prior to the measurement. The infant 
will be weighed three times and three weights will be documented.  
 
Length will be measured using an infantometer with measurements to the nearest 1mm that is placed on a 
raised, flat surface. The infant is to be naked with no clothing or diaper, and should be calm prior to the 
measurement. One person will hold the infant’s legs and move the foot board. An assistant will stand at 
the headboard and position the infant’s head so that it touches the top of the headboard and is in the 
Frankfort Vertical Plane, such that a vertical line from the ear canal to the lateral corner of the eye is 
perpendicular to the horizontal board. The infant will be gently straightened. The measurement will be 
recorded to the nearest 1mm. The measurements will be taken two more times and the three values will be 
averaged.  
 
Head circumference will be obtained using a non-elastic tape with measurements to the nearest 1mm. The 
infant will be held on the mother’s lap. Study personnel will anchor the tape immediately above the 
infant’s eyebrows, wrapping it around the head with positioning over the fullest protuberance of the skull 
in the back. A second measurer can help with appropriate positioning. The tape will be pulled such that is 
it is gently taut around the infant’s head, and a measurement will be read to within 1mm. The 
measurement will be taken two more times and the three values will be averaged.  
 
Mid upper arm circumference will be measured three times using a special tape at the midpoint between 
the tips of the infant’s left shoulder and elbow, per standard guidance. To measure: 
1. Ask the mother to remove any clothing that may cover the child's left arm. If possible, the child 
should stand erect and sideways to the measurer. 
2. Estimate the midpoint of the left upper arm. 
3. Straighten the child's arm and wrap the tape around the arm at the midpoint. Make sure the 
numbers are right side up. Make sure the tape is flat around the skin. 
4. Inspect the tension of the tape on the child's arm. Make sure the tape has the proper tension and 
is not too tight or too loose. Repeat any steps as necessary. 
5. When the tape is in the correct position on the arm with correct tension, read the measurement 
to the nearest 0.1 cm. 
6. Immediately record the measurement. 
 
 
 
 

 
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18 Appendix C: List of hospitals where data collection will take place 
 
Country Site 
Hospital/Clinic Names where Data collection will take place 
 
 
Tanzania Site 
Muhimbili National Hospital 
Temeke District Hospital 
Mbagala Rangi Tatu Hospital 
Amana Regional Referral Hospital 
Malawi Site 
EMMW- Kamuzu Central Hospital 
Bwaila Hospital 
India/Karnataka Site KLES Dr Prabhakar Kore Charitable Hospital, Belagavi 
S S Institute of Medical Sciences & Research Centre, Davangere 
Bapuji Child Health Institute & Research Centre, Davanagere 
Women & Children Hospital, Davanagere 
Chigateri District Hospital, Davanagere 
India/Odisha Site 
Srirama Chandra Bhanja (SCB) Medical College and Hospital, Cuttack 
Sardar Vallavbhai Patel Post Graduate Institute of Paediatrics, Cuttack 
City Hospital Oriya Bazar, Cuttack 
 
 
19 Appendix D: List of Co-PIs 
 
Co-PIs 
Institution 
Linda Vesel PhD, MPH 
Harvard School of Public Health (HSPH) 
Shivaprasad Goudar, MD, MPHE 
Jawaharlal Nehru Medical College (JNMC), 
Belgaum 

 
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Tisungane Mvalo, MD 
UNC Project Malawi (UNCPM) 
Dr. Karim Manji, MBBS, MMED, MPH, 
FTAAS, FRCP(Lon) FRCPCH (Lon) 
MUHAS/ HSPH, Tanzania 
Chris Sudfeld, ScD 
MUHAS/ HSPH, Boston 
Melissa Young, PhD 
Emory University 
CC Lee, MD, MPH 
Brigham and Women’s Hospital 
Irving F Hoffman, PA, MPH 
University of North Carolina