Delayed onset lactogenesis II predicts the cessation of any or exclusive breastfeeding

Effect of brewer's yeast or beta-glucan on breast milk supply following preterm birth: the BLOOM study - protocol for a multicentre randomised controlled trial

BACKGROUND

Many individuals who experience preterm birth struggle with early breast milk supply, which can translate into suboptimal longer-term breastfeeding outcomes. Further investigations into the potential role of early non-pharmacological and pharmacological interventions in improving breast milk production soon after birth is growing. While natural galactagogues, such as brewer's yeast, are widely perceived by women to be safer than pharmaceutical galactagogues and are taken by many women, evidence to support their efficacy is largely absent. The BLOOM study has been designed to determine the efficacy and safety of brewer's yeast and beta-glucans, derived from Saccharomyces cerevisiae, when administered soon after birth for increasing early breast milk supply in mothers who have delivered preterm.

METHODS

The BLOOM study is a multicentre, double-blinded, randomised controlled trial that will assess if brewer's yeast or beta-glucan can increase early breast milk production following preterm birth. Target population are mothers of preterm infants born at less than 34 weeks' gestation who intend to provide breast milk for their infant, are less than 72 h following birth and able to give informed consent. Participants will be randomly allocated into three parallel groups at 1:1:1 ratio (n = 33 per group) to receive either brewer's yeast, beta-glucan or placebo capsules for seven days. The primary outcome is total expressed breast milk volume over a 24-hour period on day 7 of intervention. Participants and their infants will be followed until the infant reaches term corrected age or is discharged home from the neonatal unit (whichever occurs first).

DISCUSSION

The use of brewer's yeast as a galactagogue to enhance milk production is extremely common amongst breastfeeding mothers, however, there are no trials evaluating its efficacy and safety. This will be the first randomised controlled trial to evaluate the efficacy and safety of two commonly used galactagogues, brewer's yeast and beta-glucan, compared with placebo in improving maternal breast milk supply following preterm birth. The trial will also evaluate whether early intervention with galactagogues soon after a preterm birth improves longer-term breastfeeding outcomes.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12622000968774 (registered on 8 July 2022) and UTN U1111-1278-8827.

Is Maternal Body Weight or Composition Associated with Onset of Lactogenesis II, Human Milk Production, or Infant Consumption of Mother's Own Milk? A Systematic Review and Meta-Analysis

Maternal adiposity impacts lactation performance, but the pathways are unclear. We conducted a systematic review to understand whether maternal adiposity (body mass index [BMI] or percentage fat mass) is associated with onset of lactogenesis II (copious milk; hours), human milk production (expressed volume/24 h), and infant consumption of mother's own milk (volume/24 h). We used random-effects standard meta-analyses to compare the relative risk (RR) of delayed lactogenesis II (>72 h) between mothers classified as underweight (BMI <18.5 kg/m2), healthy weight (BMI, 18.5-24.9 kg/m2), and overweight/obese (BMI ≥25 kg/m2) and random-effects meta-regressions to examine associations with hours to lactogenesis II and infant milk consumption. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. We included 122 articles. Mothers with underweight (RR: 0.64; 95% CI: 0.49, 0.83; I2 = 39.48%; 8 articles/data points) or healthy weight status (RR: 0.67; 95% CI: 0.57, 0.79; I2 = 70.91%; 15 articles/data points) were less likely to experience delayed lactogenesis II than mothers with overweight/obesity. We found no association between maternal BMI and time to onset of lactogenesis II (β: 1.45 h; 95% CI: -3.19, 6.09 h; P = 0.52, I2 = 0.00%; 8 articles, 17 data points). Due to limited data, we narratively reviewed articles examining BMI or percentage fat mass and milk production (n = 6); half reported an inverse association and half no association. We found no association between maternal BMI (β: 6.23 mL; 95% CI: -11.26, 23.72 mL; P = 0.48, I2 = 47.23%; 58 articles, 75 data points) or percentage fat mass (β: 7.82 mL; 95% CI: -1.66, 17.29 mL; P = 0.10, I2 = 28.55%; 30 articles, 41 data points) and infant milk consumption. The certainty of evidence for all outcomes was very low. In conclusion, mothers with overweight/obesity may be at risk of delayed lactogenesis II. The available data do not support an association with infant milk consumption, but the included studies do not adequately represent mothers with obesity. This study was registered in PROSPERO as 285344.

Having Enough Milk to Sustain a Lactation Journey: A Call to Action

The rates of human milk feeding are suboptimal worldwide. Recommendations for healthy, term mother-infant dyads include early breastfeeding initiation, frequent skin-to-skin contact, and frequent breastfeeding. The normal physiology of lactation can be affected by prenatal factors such as diabetes, obesity, and excessive gestational weight gain. Furthermore, birth-related factors such as early-term gestation, stressful labor, unscheduled cesarean birth, and postpartum hemorrhage can additionally disrupt recommended practices such as early initiation of breastfeeding and skin-to-skin contact. Given that the first 2 to 3 days postpartum are critical to achieving timely secretory activation and establishing an adequate volume of milk, a proactive approach to care can include building awareness of risk factors and development of protocols for the effective early initiation of lactation.

Maternal inflammatory, lipid and metabolic markers and associations with birth and breastfeeding outcomes

Background

Conditions in utero influence intrauterine and postnatal infant growth and a few studies indicate that maternal inflammation and insulin resistance might affect birth and breastfeeding outcomes. Furthermore, hormones in human milk (HM) may influence infant appetite-regulation and thereby milk intake, but the associations are less understood.

Objective

(1) To investigate associations between maternal inflammatory, lipid and metabolic markers and birth and breastfeeding outcomes, and (2) to assess predictors of maternal inflammatory, lipid and metabolic markers in pregnancy.

Methods

Seventy-one mother-infant dyads participating in the Mothers, Infants and Lactation Quality (MILQ) study were included in the present study. Fasting blood samples were collected around 28th gestational week, and HM samples at three time points from 1.0 to 8.5 months, where milk intake was assessed using 24-h test weighing. Maternal plasma inflammatory, lipid and metabolic markers included high-sensitive C-reactive protein (hs-CRP), tumor-necrosis factor-α (TNFα), interferon-γ (IFNγ), Interleukin (IL)-6, IL-8, high-, low-, and very-low-density lipoprotein (HDL, LDL, VLDL), total-cholesterol, triglycerides, leptin, adiponectin, insulin, C-peptide, the homeostasis model assessment of insulin resistance (HOMA-IR) and glucose concentration at t = 120 min following an oral glucose tolerance test. Of these, TNFα, IFNγ, IL-6, IL-8, leptin, adiponectin and insulin were also measured in HM samples.

Results

HDL in pregnancy was inversely associated with gestational age (GA) at birth and GA-adjusted birthweight z-score, whereas triglycerides and glucose (t = 120) were positively associated with GA-adjusted birthweight z-score. Higher hs-CRP, VLDL and triglycerides were associated with a higher placental weight. Furthermore, higher HDL, insulin, leptin and HOMA-IR were associated with longer duration of exclusive breastfeeding (EBF). Higher pre-pregnancy BMI was the main predictor of higher levels of hs-CRP, log-TNFα, leptin, insulin, C-peptide, and HOMA-IR.

Conclusion

Maternal lipid and metabolic markers influenced birthweight z-score and placental weight as well as duration of EBF. Furthermore, pre-pregnancy BMI and maternal age predicted levels of several inflammatory and metabolic markers during pregnancy. Our findings indicate that maternal lipid and metabolic profiles in pregnancy may influence fetal growth and breastfeeding, possibly explained by overweight and/or higher placental weight.

Clinical trial registration

https://clinicaltrials.gov/, identifier NCT03254329.

Human Breast Organoid Models for Lactation Research

The human mammary gland is the major organ involved in lactation. In the mammary gland, alveoli secrete milk and myoepithelial cells contract to propel the milk through branched structures called ducts and eventually to the nipple. It is through this process of lactation that infants receive milk, which is essential for proper infant growth and development. The lactation process is comprised of sophisticated interactive networks at the cellular level that are not well understood. Whereas the majority of published mammary gland lactation studies have relied on mouse mammary glands, recent advancements in techniques to study mammary glands enable in vitro reproduction of lactation using human-representative frameworks. Currently, the 3D breast organoid is the state-of-the-art model in human mammary gland research, utilizing induced pluripotent stem cells (iPSCs) or processed patient-derived breast tissues embedded in a special matrix that are then able to grow into complex structures that recapitulate aspects of native human breast tissue. Gaining comprehensive biological insight into the process of lactation through these breast tissue-mimetic 3D models is essential for further studies on lactation-associated human mammary gland diseases, human milk composition, and potential solutions to challenges in maternal milk accessibility. In this short review, the benefits and potential utility of 3D breast organoids in understanding the underlying science of lactation and advancing further human mammary gland studies are discussed.

Prenatal Counseling and Preparation for Breastfeeding

Breastfeeding is the gold standard of infant nutrition and current guidelines suggest exclusive breastfeeding for 6 months, with continued breastfeeding through 24 months or beyond. Obstetric care professionals can encourage and educate their patients about breastfeeding through the prenatal period when many expectant parents make decisions about their infant feeding choices. Education and support should extend through the postpartum period and include parents who may have concerns surrounding medical comorbidities, breast augmentation, or substance use disorders.

Novel At-Home Mother's Milk Conductivity Sensing Technology as an Identification System of Delay in Milk Secretory Activation Progress and Early Breastfeeding Problems: Feasibility Assessment

BACKGROUND

Prolonged exclusive breastfeeding is a public health priority and a personal desire by mothers; however, rates are low with milk supply challenges as a predominant cause. Early breastfeeding management at home is key. Milk electrolytes, mainly sodium ions, are accepted as biomarkers of secretory activation processes throughout the first weeks after birth and predictors for prolonged breastfeeding success, although they are not incorporated into routine care practice.

OBJECTIVE

The aim of this study was to test the feasibility of a novel handheld smartphone-operated milk conductivity sensing system that was designed to compute a novel parameter, milk maturation percent (MM%), calculated from milk sample conductivity for tracking individual secretory activation progress in a real-world home setting.

METHODS

System performance was initially evaluated in data collected from laboratory-based milk analysis, followed by a retrospective analysis of observational real-world data gathered with the system, on the spot in an at-home setting, implemented by lactation support providers or directly by mothers (N=592). Data collected included milk sample sensing data, baby age, and self-reported breastfeeding status and breastfeeding-related conditions. The data were retroactively classified in a day after birth-dependent manner. Results were compared between groups classified according to breastfeeding exclusivity and breastfeeding problems associated with ineffective breastfeeding and low milk supply.

RESULTS

Laboratory analysis in a set of breast milk samples demonstrated a strong correlation between the system's results and sodium ion levels. In the real-world data set, a total of 1511 milk sensing records were obtained on the spot with over 592 real-world mothers. Data gathered with the system revealed a typical time-dependent increase in the milk maturation parameter (MM%), characterized by an initial steep increase, followed by a moderate increase, and reaching a plateau during the first weeks postpartum. Additionally, MM% levels captured by the system were found to be sensitive to breastfeeding status classifications of exclusive breastfeeding and breastfeeding problems, manifested by differences in group means in the several-day range after birth, predominantly during the first weeks postpartum. Differences could also be demonstrated for the per-case time after birth-dependent progress in individual mothers.

CONCLUSIONS

This feasibility study demonstrates that the use of smart milk conductivity sensing technology can provide a robust, objective measure of individual breastfeeding efficiency, facilitating remote data collection within a home setting. This system holds considerable potential to augment both self-monitoring and remote breastfeeding management capabilities, as well as to refine clinical classifications. To further validate the clinical relevance and potential of this home milk monitoring tool, future controlled clinical studies are necessary, which will provide insights into its impact on user and care provider satisfaction and its potential to meet breastfeeding success goals.

Breast Milk Production Variability Among Mothers of Preterm Infants

Introduction: Mothers of preterm infants are at risk for inadequate milk production. Pumping logs are often used to both encourage lactation in the first week and track its efficacy. Our objectives were to determine whether mothers of preterm infants who keep pumping logs are demographically different from those who do not and to determine whether this practice affects the amount of mother's own milk (MOM) fed to their infants. We also aimed at determining whether there is a correlation between: (1) time to first breast milk expression, (2) cumulative frequency of expression in the first week, and (3) milk volume on day 7 with subsequent milk volumes and percent of infant diet consisting of MOM. Methods: Mothers of infants born ≤32 weeks and ≤1,500 g were enrolled within 48 hours of birth and encouraged to keep a pumping log. Data were collected on maternal characteristics, patterns of milk expression, and milk volumes on days 7, 14, 21, and 28 after delivery. Infant data were collected via chart review. Results: Mothers who kept pumping logs provided their own milk for a greater percentage of their infant's feeds at the time of achieving full feeds (p = 0.017). The total number of expressions in the first week was correlated with milk volume on day 21 (p = 0.016) and the provision of a higher percentage of MOM feeds at discharge (p = 0.03). Milk volume on day 7 correlated with volumes obtained at days 14, 21, and 28 (p < 0.001). Conclusions: Pumping logs may affect the availability of MOM for preterm infants. Frequency of pumping in the first week and milk volume on day 7 may impact long-term lactation success for these women.

Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases

The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.

Effect of antenatal milk expression education on lactation outcomes in birthing people with pre-pregnancy body mass index ≥25: protocol for a randomized, controlled trial

BACKGROUND

Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m², particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population.

METHODS

This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m². The assigned study treatment is delivered via four weekly online video consultations between gestational weeks 37-40. Participants assigned to AME meet with study personnel and a lactation consultant to learn and practice AME. Instructions are provided for home practice of AME between study visits. Control group participants view videos on infant care/development at study visits. Participants complete emailed surveys at enrollment (34^0/7-36^6/7 gestational weeks) and 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postpartum. Surveys assess lactation and infant feeding practices; breastfeeding self-efficacy, attitudes, and satisfaction; perception of insufficient milk; onset of lactogenesis-II; lactation support and problems; and reasons for breastfeeding cessation. Surveys also assess factors associated with lactation outcomes, including demographic characteristics, health problems, birth trauma, racial discrimination, and weight stigma. Health information and infant feeding data are abstracted from the pregnancy and birth center electronic health record. Milk samples are collected from the intervention group at each study visit and from both groups at each postpartum follow-up for future analyses. Qualitative interviews are conducted at 6 weeks postpartum to understand AME experiences. Primary outcomes of interest are breastfeeding exclusivity and breastfeeding self-efficacy scores at 2 weeks postpartum. Outcomes will be examined longitudinally with generalized linear mixed-effects modeling.

DISCUSSION

This is the first adequately powered trial evaluating the effectiveness of AME among U.S. birthing people and within a non-diabetic population with pre-pregnancy BMI ≥ 25 kg/m². This study will also provide the first evidence of acceptability and effectiveness of telelactation-delivered AME.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04258709.

Hormonal regulation of mammary gland development and lactation

Lactation is critical to infant short-term and long-term health and protects mothers from breast cancer, ovarian cancer and type 2 diabetes mellitus. The mammary gland is a dynamic organ, regulated by the coordinated actions of reproductive and metabolic hormones. These hormones promote gland development from puberty onwards and induce the formation of a branched, epithelial, milk-secreting organ by the end of pregnancy. Progesterone withdrawal following placental delivery initiates lactation, which is maintained by increased pituitary secretion of prolactin and oxytocin, and stimulated by infant suckling. After weaning, local cytokine production and decreased prolactin secretion trigger large-scale mammary cell loss, leading to gland involution. Here, we review advances in the molecular endocrinology of mammary gland development and milk synthesis. We discuss the hormonal functions of the mammary gland, including parathyroid hormone-related peptide secretion that stimulates maternal calcium mobilization for milk synthesis. We also consider the hormonal composition of human milk and its associated effects on infant health and development. Finally, we highlight endocrine and metabolic diseases that cause lactation insufficiency, for example, monogenic disorders of prolactin and prolactin receptor mutations, maternal obesity and diabetes mellitus, interventions during labour and delivery, and exposure to endocrine-disrupting chemicals such as polyfluoroalkyl substances in consumer products and other oestrogenic compounds.

Effects of Acupressure on Lactation: An Integrated Review

PURPOSE

To assess the effects of acupressure on lactation.

METHODS

A literature search was conducted via Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and PubMed using keyword search terms acupuncture, Tuina and breastfeeding, human lactation or human milk and excluded auricular. Inclusion criteria were articles in English with no restriction on publication date. We included acupuncture as well as acupressure to ensure that relevant articles were not missed.

RESULTS

After duplicates were removed, our initial search yielded 217 articles. Using the PRISMA checklist (Liberati et al., 2009), six articles met inclusion criteria (five research studies, one case study). Preliminary evidence suggests acupressure offers a promising and inexpensive method of enhancing secretory activation following cesarean and vaginal term and late preterm births, specifically when performed at acupoints CV 17, ST 18, and SI 1.

CLINICAL IMPLICATIONS

Human milk is the optimal source of infant nutrition. Concern of low milk supply is most often cited as the cause for early supplementation with formula as well as early cessation of breastfeeding. Acupressure may be helpful in improving milk supply in early postpartum, but more research on acupressure and lactation is warranted.

Relationship of delayed lactogenesis II to maternal perception of insufficient milk: A longitudinal study

AIM

To analyze the relationship of delayed lactogenesis II with maternal perception of insufficient milk.

METHODS

A prospective, multicenter, longitudinal observational study was conducted. Data were obtained at discharge and between 1 and 5 months postpartum on the perception of insufficient milk and related variables, by means of a self-administered questionnaire, and subsequent postal and online follow-up. Logistic regression analysis was used to develop the explanatory model.

RESULTS

A total of 260 puerperal mothers participated. Of these, 31.9% had insufficient milk and 23.6% had delayed lactogenesis II. During postpartum admission, delayed lactogenesis II (OR = 2.26; 95%CI = 1.07-4.79), difficulty in breastfeeding (OR = 1.02; 95%CI = 1.00-1.03), and professional help in breastfeeding (OR = 0.70; 95%CI = 0.50-0.97) were associated with maternal perception of insufficient milk.

CONCLUSIONS

The occurrence of breastfeeding difficulties during postpartum admission and at discharge, especially when there is delayed lactogenesis II, should be considered risk indicators, suggesting the need for additional support to standardized care. The PIM is a suitable indicator to assess the quality of professional breastfeeding support in improvement interventions.

Innovations in Breastfeeding Support

Despite the numerous benefits that breastfeeding confers to those who breastfeed and their infants, the United States' exclusive breastfeeding rates and any breastfeeding rates at 12 months remain low and inequitable. This public health crisis has been prioritized in the US Healthy People 2030 goals. Current evidence-based practices to support lactation have afforded limited progress, thus, achieving national breastfeeding goals requires innovative ideas in thinking, technology, and care. This article highlights potential innovative strategies in the field of lactation to improve outcomes and work toward achieving health equity, while underscoring the critical role that perinatal caregivers play in lactation support.

Protocol for an observational study investigating hormones triggering the onset of sustained lactation: the INSIGHT study

INTRODUCTION

Lactation is a hormonally controlled process that promotes infant growth and neurodevelopment and reduces the long-term maternal risk of diabetes, cardiovascular disease and breast cancer. Hormones, such as prolactin and progesterone, mediate mammary development during pregnancy and are critical for initiating copious milk secretion within 24-72 hours post partum. However, the hormone concentrations mediating lactation onset are ill defined.

METHODS AND ANALYSIS

The primary objective of the investigating hormones triggering the onset of sustained lactation study is to establish reference intervals for the circulating hormone concentrations initiating postpartum milk secretion. The study will also assess how maternal factors such as parity, pregnancy comorbidities and complications during labour and delivery, which are known to delay lactation, may affect hormone concentrations. This single-centre observational study will recruit up to 1068 pregnant women over a 3-year period. A baseline blood sample will be obtained at 36 weeks' gestation. Participants will be monitored during postpartum days 1-4. Lactation onset will be reported using a validated breast fullness scale. Blood samples will be collected before and after a breastfeed on up to two occasions per day during postpartum days 1-4. Colostrum, milk and spot urine samples will be obtained on a single occasion. Serum hormone reference intervals will be calculated as mean±1.96 SD, with 90% CIs determined for the upper and lower reference limits. Differences in hormone values between healthy breastfeeding women and those at risk of delayed onset of lactation will be assessed by repeated measures two-way analysis of variance or a mixed linear model. Correlations between serum hormone concentrations and milk composition and volume will provide insights into the endocrine regulation of milk synthesis.

ETHICS AND DISSEMINATION

Approval for this study had been granted by the East of England-Cambridgeshire and Hertfordshire Research Ethics Committee (REC No. 20/EE/0172), by the Health Research Authority (HRA), and by the Oxford University Hospitals National Health Service Foundation Trust. The findings will be published in high-ranking journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN12667795.

Antenatal breastfeeding promotion amongst pregnancies at high-risk for newborn admission to the NICU: A cross-sectional study

Objectives

To determine the prevalence and factors associated with antenatal promotion of breastfeeding in high-risk pregnancies.

Study design

This was a cross-sectional study of trends in breastfeeding promotion during antenatal consultation of pregnancies at high-risk for newborn admission to the neonatal intensive care unit (NICU) between January 2017 and December 2020. Eligible high-risk pregnant patients undergoing antenatal consultation in a tertiary-level fetal assessment unit were identified using an electronic clinic repository. Consult letters and fetal assessment reports were reviewed to determine baseline demographics, pregnancy history, fetal findings, and communication about breastfeeding. Descriptive and inferential statistics were used to present findings and compare outcomes between groups.

Results

316 pregnancies were included for final analysis. The mean maternal age was 28.7 years (SD 6.2) and 65 % were multiparas. Median gestational age at time of antenatal consult was 32 weeks [IQR 29–34]. The main indication for consultation was fetal anomalies (72.8%), namely cardiac defects (21.2 %). There was a significant improvement in prevalence of antenatal discussions about breastfeeding over the study period, from 48.8 % early in the study period compared to 73.7 % in the past year (p = 0.036). However, amongst consults where breastfeeding was discussed, almost one-quarter (23.8 %) of patients indicated that they were not planning on breastfeeding postnatally.

Conclusion

There has been a significant improvement in promoting breastfeeding antenatally amongst high-risk pregnancies. However, no follow-up or supports were offered to one-quarter of patients who indicated no intention of breastfeeding or using donor milk postnatally. Ongoing work is required to further advance breastfeeding promotion antenatally, increase parental supports and education, and optimize breastfeeding rates postnatally for improving outcomes of this high-risk group.

•

While there has been a significant improvement in antenatal breastfeeding promotion amongst high-risk pregnancies, it is still missing in almost one-quarter of patients.

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There are no obvious demographic or clinical differences between high-risk patients that received antenatal breastfeeding promotion versus those that did not, suggesting that a more standardized approach to antenatal discussions about infant feeding could improve breastfeeding success in the NICU.

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Ongoing work is required to further improve breastfeeding promotion antenatally along with additional postnatal supports to enhance breastfeeding success.

Structured antenatal milk expression education for nulliparous pregnant people: results of a pilot, randomized controlled trial in the United States

BACKGROUND

Hand-expression, collection, and storage of breast milk during pregnancy (i.e., antenatal milk expression or AME) is a safe, potentially effective practice to reduce early, undesired infant formula supplementation among women with diabetes. The feasibility and potential impact of AME on lactation outcomes in the United States (U.S.) and among non-diabetic birthing people is unknown.

METHODS

The purpose of this study was to examine the feasibility of a structured AME intervention among nulliparous birthing people in the United States. We recruited 45 low-risk, nulliparous individuals at 34-36^6/7 weeks of gestation from a hospital-based midwife practice. Participants were randomized to AME or a control group receiving lactation education handouts. Interventions were delivered at weekly visits at 37-40 weeks of pregnancy. The AME intervention involved technique demonstration and feedback from a lactation consultant and daily independent practice. Lactation outcomes were assessed during the postpartum hospitalization, 1-2 weeks postpartum, and 3-4 months postpartum.

RESULTS

Between December 2016 and February 2018, 63 individuals were approached and screened for eligibility, and 45 enrolled into the study (71%). Of 22 participants assigned to AME, 18 completed at least one AME study visit. Participants reported practicing AME on at least 60% of days prior to their infant's birth. Most were able to express milk antenatally (15/18), more than half collected and froze antenatal milk (11/18), and 39% (7/18) supplemented their infants with antenatal milk after birth. No major problems were reported with AME. Perinatal and lactation outcomes, including infant gestational age at birth, neonatal intensive care unit admissions, delayed onset of lactogenesis II, and use of infant formula were similar between AME and control groups. Among participants in both groups who were feeding any breast milk at each assessment, breastfeeding self-efficacy increased and perceptions of insufficient milk decreased over the postpartum course.

CONCLUSIONS

In a small group of nulliparous birthing people in the U.S., AME education and independent practice beginning at 37 weeks of pregnancy was feasible. In some cases, AME provided a back-up supply of milk when supplementation was indicated or desired. The relationship between AME and lactation outcomes requires further study with adequately powered samples.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov on May 11, 2021 under the following registration ID: NCT04929301. https://clinicaltrials.gov/ct2/show/NCT04929301 .

Milk Volume Outcomes in Pump-Dependent Mothers of Critically Ill Infants

INTRODUCTION

Mother's own milk improves health outcomes in infants of all gestational ages. Although pump-dependent mothers of extremely premature infants are at risk of insufficient milk production, whether mother's milk production is impacted by gestational age and pump dependency in mothers of more mature critically ill infants is unknown.

PURPOSE

To determine whether there is a relationship between gestational age, milk production, and time to secretory activation in mothers delivering a critically ill infant.

METHODS

A convenience sample of 136 pump-dependent mothers whose infants were admitted to the neonatal intensive care unit was enrolled between 2013 and 2016 as part of a quality improvement project. Group 1 (early preterm) delivered infants at 30 to 33 weeks of gestation (n = 41), group 2 (late preterm) 34 to 36 weeks (n = 48), and group 3 (term) 37 weeks and more (n = 47). Milk volume on days 1 to 7 was measured by weighing each vial of expressed milk and compared using general linear mixed-model analysis. Time to the onset of secretory activation was compared using censored regression analysis.

RESULTS

Main effect for gestational age controlling for day was statistically significant (P = .0234). The early preterm group produced more milk over the 7-day study than the term (P = .01) and late preterm (P = .02) groups. The early preterm group achieved secretory activation earlier than the late preterm group (adjusted P = .039).

IMPLICATIONS FOR PRACTICE

Pump-dependent mothers of all infants admitted to the neonatal intensive care unit may be at risk of inadequate milk production and delayed secretory activation and may therefore benefit from early milk production monitoring and lactation support.

IMPLICATIONS FOR RESEARCH

Further studies should examine targeted interventions to increase milk production in pump-dependent mothers.

Role of Perinatal Biological Factors in Delayed Lactogenesis II Among Women With Pre-pregnancy Overweight and Obesity

BACKGROUND

Pre-pregnancy overweight and obesity are negatively associated with delayed onset of lactogenesis II (OL), but the mechanisms by which these conditions affect OL are still unclear.

OBJECTIVES

To identify biological factors related to pre-pregnancy overweight/obesity and determine whether these biological factors were associated with delayed OL in this population.

METHODS

In this prospective observational study, we assigned 72 primipara to a pre-pregnancy overweight/obese group (n = 36) and a normal-weight group (n = 36). Blood samples were collected at 37 w of gestation and 48 h postpartum and assayed for levels of the following hormones: leptin, insulin, estradiol, prolactin (PRL), progesterone, and oxytocin. The primary outcome was timing of OL, estimated by maternal perception of breast fullness. We used linear-regression analysis to determine associations between hormones and delayed OL.

RESULTS

Sixty-three participants (87.5%) had complete data. OL occurred later in overweight/obese than in normal-weight women (p < .001). Compared with the normal-weight group, the overweight/obese group showed higher leptin levels at both times of observation and exhibited a slower drop in estrogen concentrations from 37 w of gestation to 48 h postpartum (all p < .05). After adjusting for confounding factors, leptin concentrations in late pregnancy and the magnitudes of decline in estrogen concentrations at 48 h postpartum were correlated with OL.

CONCLUSION

Women who were overweight/obese before pregnancy had elevated leptin levels in late pregnancy and a delayed decline in estrogen concentrations at 48 h postpartum. Both of these phenomena were related to delayed OL in this population.

Risk factors for self‐reported insufficient milk during the first 6 months of life: A systematic review

The objective of this systematic review was to identify multifactorial risk factors for self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL). The review protocol was registered a priori in PROSPERO (ID# CDR42021240413). Of the 120 studies included (98 on SRIM, 18 on DOL, and 4 both), 37 (31%) studies were conducted in North America, followed by 26 (21.6%) in Europe, 25 (21%) in East Asia, and Pacific, 15 (12.5%) in Latin America and the Caribbean, 7 (6%) in the Middle East and North Africa, 5 (4%) in South Asia, 3 (2.5%) in Sub‐Saharan Africa, and 2 (1.7%) included multiple countries. A total of 79 studies were from high‐income countries, 30 from upper‐middle‐income, 10 from low‐middle‐income countries, and one study was conducted in a high‐income and an upper‐middle‐income country. Findings indicated that DOL increased the risk of SRIM. Protective factors identified for DOL and SRIM were hospital practices, such as timely breastfeeding (BF) initiation, avoiding in‐hospital commercial milk formula supplementation, and BF counselling/support. By contrast, maternal overweight/obesity, caesarean section, and poor maternal physical and mental health were risk factors for DOL and SRIM. SRIM was associated with primiparity, the mother's interpretation of the baby's fussiness or crying, and low maternal BF self‐efficacy. Biomedical factors including epidural anaesthesia and prolonged stage II labour were associated with DOL. Thus, to protect against SRIM and DOL it is key to prevent unnecessary caesarean sections, implement the Baby‐Friendly Ten Steps at maternity facilities, and provide BF counselling that includes baby behaviours.

Socioeconomic and demographic factors indicative of lower economic status increased the risk of self‐reported insufficient milk (SRIM) and delayed onset of lactation (DOL).

Timely breastfeeding (BF) initiation and avoidance of in‐hospital commercial milk formula (CMF) supplementation are likely to reduce the prevalence of SRIM and DOL.

BF counselling designed to prevent SRIM and DOL needs to strengthen maternal BF self‐efficacy, maternal understanding of baby behaviours such as fussiness and maternal wellbeing.

Research is needed to better understand how the risk of DOL and SRIM increases with primiparity, caesarean sections, maternal overweight/obesity, and poor overall maternal health.

Intervention studies specifically designed to reduce the risk of SRIM and DOL are urgently needed in low‐ and middle‐income countries.

Early Postpartum Patterns of Breastfeeding Exclusivity and Perceived Insufficient Milk by Prepregnancy Body Mass Index

OBJECTIVE

To explore trajectories of breastfeeding exclusivity and perceived insufficient milk (PIM) over the first 8 weeks postpartum among primiparous women and the association of these trajectories with prepregnancy body mass index (BMI).

DESIGN

Secondary analysis of data from a randomized controlled trial.

SETTING

Recruitment for the primary study was conducted in Pittsburgh, Pennsylvania.

PARTICIPANTS

One hundred twenty-two primiparous women with intention to exclusively breastfeed.

METHODS

We used group-based trajectory modeling to classify participants into breastfeeding exclusivity and PIM trajectory groups. We used logistic regression to explore the predictive relationship between prepregnancy BMI and breastfeeding exclusivity and PIM trajectory group memberships.

RESULTS

We identified two trajectories each for breastfeeding exclusivity and PIM over the first 8 weeks postpartum. For breastfeeding exclusivity, one group (n = 60, 49%) had low initial probability of exclusive breastfeeding with linear decline in likelihood of exclusivity over time. The other group (n = 62, 51%) had greater initial probability of exclusive breastfeeding, which remained constant over time. For PIM, one group (n = 41, 34%) had consistently greater probability of endorsing PIM at each time point, whereas the other group (n = 81, 66%) had consistently low probability of endorsing PIM over time. Prepregnancy BMI did not predict group membership in breastfeeding exclusivity, χ²(1) = 2.8, p = .094, or PIM, χ²(1) = 0.72, p = .397.

CONCLUSION

Breastfeeding exclusivity and PIM appeared to be relatively stable phenomena in the postpartum period among a sample of predominately White primiparous women who intended to breastfeed. We did not find a clear association with prepregnancy BMI.

Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads, Revised 2022

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Associations of Metabolic and Obstetric Risk Parameters with Timing of Lactogenesis II

Lactogenesis II is the onset of copious milk production following parturition. Delayed onset of lactogenesis II (DLII) often contributes to poorer lactation performance, which may adversely affect maternal and child health. The present study aims to identify the metabolic and obstetric risk factors for DLII in a secondary analysis of a prospective cohort study following pregnant women through postpartum. We defined the onset of lactogenesis II as delayed if it occurred ≥72 h postpartum. Multiple logistic regression analyses were conducted to evaluate the associations of metabolic and obstetric variables with DLII. Median onset of lactogenesis II was 72.4 h (IQR 60.4–91.6) postpartum, and 55.4% (98 of 177) of women experienced DLII. Time to first breast contact ≥ 2 h postpartum compared to ≤1 h postpartum was associated with DLII (OR 2.71 95% CI 1.12–6.53) with adjustment for age, race, pregravid BMI, primiparity, and mode of delivery, while metabolic variables were not significantly associated with DLII. In this comprehensive examination of potential metabolic and obstetric parameters, earlier timing of putting the infant to the breast remained significantly associated with earlier onset of milk coming in after consideration of the other potential risk factors. Obstetrical practices, including putting the baby to the breast later, may have an important impact on the timing of lactation, and interventions are needed to address this concern.

A prospective cohort study on lactation status and breastfeeding challenges in mothers giving birth to preterm infants

Background

Mothers of preterm infants face many challenges in breastfeeding, especially regarding lactation. This study aimed to investigate the lactation status and challenges in breastfeeding faced by preterm infants’ mothers.

Methods

We approached 124 mothers who gave birth to preterm infants between 26 May and 31 October 2018 in a tertiary hospital in China. Lactation status and challenges in breastfeeding on day 7 postpartum, at discharge of infants, 2 weeks post-discharge, and 3 months of corrected age were collected using questionnaires. The area under the receiver operating characteristic (ROC) curve for expressed milk volume on day 7 postpartum for predicting expressed milk volume ≥ 300 mL/d at discharge was calculated. Logistic regression analyses were performed to identify factors associated with delayed lactogenesis II onset and continuation of breastfeeding at 3 months of corrected age.

Results

Seventy mothers were enrolled, and 51.4% had delayed lactogenesis II. Multivariate logistic regression analysis revealed that older maternal age (aOR = 1.19; 95% CI: 1.01, 1.40) and first live birth (aOR = 4.81; 95% CI 1.43, 16.18) were significant independent predictors of delayed lactogenesis II. Mothers with delayed lactogenesis II had significantly lower expressed milk volume (day 7 postpartum: 160.0 mL vs. 300.0 mL, U = 328.50, p = 0.001; at discharge: 425.0 mL vs. 612.5 mL, U = 372.00, p = 0.005), with a lower proportion of exclusive breastfeeding in their infants (at discharge: 33.3% vs. 69.8%, χ² = 12.39, df = 1, p < 0.001; 3 months of corrected age: 17.8% vs. 52.8%, χ² = 11.03, df = 1, p = 0.001). The ROC showed that expressed milk volume > 190 mL/d on day 7 postpartum significantly predicted expressed milk volume ≥ 300 mL/d at discharge. Insufficient human milk was the main reason for breastfeeding discontinuation at 3 months of corrected age. Twins were less likely to continue breastfeeding at 3 months of corrected age (aOR = 0.27; 95% CI 0.09, 0.86). In singleton infants, mother’s own milk ≥50% of total milk uptake at 2 weeks post-discharge (aOR = 32.66; 95% CI 3.00, 355.25) was an independent predictor of continuous breastfeeding at 3 months of corrected age. Feeding complications in infants, poor breastfeeding technique, and low milk output are the main challenges in breastfeeding.

Conclusion

Interventions to improve early postpartum lactation and breastfeeding techniques may increase breastfeeding adoption in mothers of preterm infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00447-4.

Cesarean section and breastfeeding outcomes in an Indigenous Qom community with high breastfeeding support

BACKGROUND AND OBJECTIVES

Cesarean section may lead to suboptimal breastfeeding outcomes, though evidence has been mixed. Factors, such as premature birth, birth weight and maternal age may independently increase risk of cesarean and hinder breastfeeding initiation, while maternal preferences, support and sociostructural barriers may influence breastfeeding practices beyond the immediate postpartum period.

METHODOLOGY

We assessed impacts of cesarean section and gestational factors on breastfeeding duration among Indigenous Qom mothers in Argentina who have strong traditional breastfeeding support. We modeled transitions from exclusive breastfeeding to complementary feeding and from complementary feeding to full weaning in a Bayesian time-to-event framework with birth mode and gestational covariates (n = 89 infants).

RESULTS

Estimated median time to full weaning was 30 months. Cesarean-delivered babies were weaned an average of 5 months later adjusting for gestational age, maternal parity and infant sex. No factors were associated with time-to-complementary feeding, and time-to-complementary feeding was not associated with time-to-full weaning.

CONCLUSIONS AND IMPLICATIONS

Among Indigenous Qom mothers in Argentina, cesarean section was not associated with suboptimal breastfeeding outcomes. Although some Qom mothers do experience early breastfeeding problems, particularly following first birth, problems are not more frequent following cesarean delivery. Traditional postpartum kin and community support during prolonged postpartum periods may be instrumental in helping mothers to overcome early breastfeeding problems due to cesarean or other risk factors.

The Trajectory of Expressed Colostrum Volume in the First 48 Hours Postpartum: An Observational Study

Objective: Colostrum, the first form of human milk, is strongly encouraged for infants due to its benefits. During the early postpartum (PP) period, the secreted colostrum volume can be minimal, causing concerns among mothers about sufficient milk supply. Few studies have examined temporal changes in the colostrum. This study aimed to elucidate the trajectory of expressed colostrum volume in the first 48 hours after delivery. Materials and Methods: This was a cross-sectional observational study performed at Kagawa National Children's Hospital. One hundred five mothers who did not directly breastfeed in the first 48 hours after delivery were enrolled in the study. Well-trained midwives instructed the mothers on how to express human milk, and mothers started to express as soon as possible after delivery. Mothers were advised to express human milk every 3 hours, and the milk volume was measured. Results: Within 3 hours PP, 60% of mothers expressed milk, and the median frequency of expression was 14 (interquartile range, 11-16) times in the first 48 hours. At 0-3 and 3-6 hours PP, the volume of initially expressed milk was 0.4 (0.0-2.0) mL and 1.0 (0.0-6.0) mL, respectively. Subsequently, milk volume decreased. The volume remained low until 30 hours PP and increased dramatically; this phenomenon is termed secretory activation, which began later in primiparous women than in multiparous women. Conclusion: The decline in expressed milk volume during the early PP period caused concern among mothers. Therefore, mothers should be informed of the PP trajectory of human milk volume.

Human Milk Glucose, Leptin, and Insulin Predict Cessation of Full Breastfeeding and Initiation of Formula Use

Objective: We aimed to investigate prospective associations between milk bioactives related to metabolic health (glucose, insulin, leptin, C reactive protein [CRP], and interleukin 6 [IL-6]) and incident formula initiation at 3 and 6 months postpartum. Design: This study included 363 mother-infant dyads who were fully breastfed at 1 month and participated in the prospective Mothers and Infants Linked for Healthy Growth study from pregnancy to 6 months postpartum. Associations between milk glucose, leptin, insulin, CRP, and IL-6 at 1 and 3 months and incident formula feeding (FF) at 3 and 6 months, respectively, were tested using multiple logistic regression, adjusting for numerous potential confounders such as maternal age and prepregnancy body mass index. Results: At 3 months postpartum, 1-month glucose (odds ratio [OR] 0.45 [95% confidence interval (CI): 0.27-0.75], p ≤ 0.01) and smaller decreases in glucose from 1 to 3 months (OR 0.51 [95% CI: 0.28-0.92], p = 0.03) were associated with lower odds of FF, whereas 1-month leptin (OR 2.30 [95% CI: 1.30-4.07], p < 0.01) and larger increase in insulin (OR 1.86 [95% CI: 1.23-2.81], p < 0.01) and leptin (OR 2.17 [95% CI: 1.29-3.68], p < 0.01) from 1 to 3 months were associated with increased odds of FF. At 6 months, insulin increases (OR 2.08 [95% CI: 1.03-4.17], p = 0.04) were associated with higher odds of FF. Conclusions: In a cohort of women with established lactation, 1-month milk glucose, insulin, and leptin predicted initiation of FF at 3 months. Early milk composition may provide a window into mammary gland function, allowing identification of women at risk of not meeting their breastfeeding goals.

Effect of Postpartum Depo Medroxyprogesterone Acetate on Lactation in Mothers of Very Low-Birth-Weight Infants

Objective: This study examined the effect of postpartum administration of depo medroxyprogesterone acetate (DMPA) on milk production, time to onset of secretory activation, lactation duration, and infant consumption of mother's own milk (MOM) in mothers of preterm very low-birth-weight (VLBW) infants. Materials and Methods: We conducted a secondary analysis of data from mothers who delivered infants weighing ≤1,500 g and at ≤32 weeks' gestation. The volume of milk produced was measured on days 1-7, 14, and 21 by weighing all expressed milk on an electronic scale. Time to secretory activation was determined through self-report of a feeling of breast fullness. Information on lactation duration and the percent of feeds consisting of MOM consumed by infants was obtained from the medical records. Results: Mothers who received postpartum DMPA were more likely to be African American (72.4% versus 31.4%; p = 0.0006), unemployed (65.5% versus 44.5%; p = 0.027), and Medicaid eligible (89.7% versus 67.2%; p = 0.019). There were no differences in daily milk production between mothers who received DMPA before hospital discharge (n = 29) compared with those who did not (n = 141). When mothers who reached secretory activation before receiving DMPA were removed from analysis, receiving DMPA was associated with a later onset of secretory activation (103.7 versus 88.6 hours; p = 0.028). There were no statistically significant differences between the study groups in lactation duration or infant MOM consumption. Conclusions: DMPA, when administered postpartum to mothers of preterm VLBW infants, delayed secretory activation, but had no detrimental effect on milk production or lactation duration. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT01892085.

Association of prenatal medical risk with breastfeeding outcomes up to 12 months in the All Our Families community-based birth cohort

Background

Prenatal medical risk describes physical health issues or biological factors that predate or arise during pregnancy which heighten the risk of adverse outcomes, and often warrant specialized obstetric care. The influence of the nature and magnitude of prenatal risk on breastfeeding outcomes remains poorly understood. The objective of this study was to determine the association between prenatal medical risk and breastfeeding initiation and duration up to 1 year postpartum.

Methods

We analysed a subset of data from the All Our Families longitudinal cohort (n = 2706) of women in Calgary, Canada who delivered a liveborn infant between 2008 and 2010. Data were collected from self-report questionnaires and medical records. Women with complete data on prenatal medical risk factors and breastfeeding outcomes were included in this analysis. Prenatal medical risk was operationalized as one integer score of risk severity and four binary risk types capturing pre-pregnancy characteristics, past obstetric problems, current obstetric problems, and substance use. Outcomes were breastfeeding initiation defined as the infant ever receiving breast milk, and duration operationalized as still breastfeeding at 4 months, at 12 months, and time to breastfeeding cessation in weeks. We used logistic regression and Cox regression with right censoring at 52 weeks or attrition to calculate odds ratios (OR) and hazard ratios (HR), respectively, adjusting for sociodemographic vulnerability, parity, mode of delivery, and gestational age.

Results

Prenatal medical risk severity and type were not significantly associated with breastfeeding initiation, with the exception of pre-pregnancy risk type (OR 0.45; 95% CI 0.26, 0.77). Risk severity was associated with lower odds of breastfeeding to 4 months (OR 0.94; 95% CI 0.90, 0.99), 12 months (OR 0.93; 95% CI 0.87, 0.98), and earlier breastfeeding cessation (HR 1.05; 95% CI 1.02, 1.08). Associations with shorter breastfeeding length across the first postpartum year were observed for pre-pregnancy, current obstetric, and substance use risk types, but not past obstetric problems.

Conclusion

Prenatal medical risk is associated with shortened duration of breastfeeding. Women with prenatal medical risk may benefit from the proactive arrangement of lactation support before and following delivery to promote continued breastfeeding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00413-0.

Metabolic Conditions Including Obesity, Diabetes, and Polycystic Ovary Syndrome: Implications for Breastfeeding and Breastmilk Composition

Breastfeeding is internationally recognized as the recommended standard for infant nutrition, informed by evidence of its multiple benefits for both mother and baby. In the context of common metabolic conditions such as polycystic ovary syndrome, diabetes (type 1, type 2, and gestational), and obesity, breastfeeding may be particularly beneficial for both mother and infant. However, there is evidence of delayed lactogenesis and reduced breastfeeding rates and duration in women with these conditions, and the effects of altered maternal metabolic environments on breastmilk composition (and potentially infant outcomes) are incompletely understood. In this review, we explore the relationships between maternal metabolic conditions, lactogenesis, breastfeeding, and breastmilk composition. We examine relevant potential mechanisms, including the central role of insulin both in lactogenesis and as a milk-borne hormone. We also describe the bioactive and hormonal components of breastmilk and how these may link maternal and infant health.

Indicators of Secretory Activation in Mothers of Preterm Very Low Birth Weight Infants

BACKGROUND

Inconsistent information exists regarding indicators of secretory activation in mothers delivering very low birth weight infants.

RESEARCH AIMS

To compare time to the onset of secretory activation using three separate indicators. A secondary aim examined the association between indicators of secretory activation and milk production.

METHODS

Indicators of secretory activation included maternal perception, volume attainment (production of ≥ 20 mL in two consecutive expression sessions) and biomarkers (sodium and lactose) obtained at volume attainment. Milk production was measured on Days 1-7 and then weekly for 6 weeks.

RESULTS

In 69 mothers of infants born ≤ 32 weeks' gestation and < 1500 g, we found no correlation in time to secretory activation between indicators. Earlier volume attainment was associated with increased milk production on Days 1-7, 14, 21, and 28 (all p < .007). Participants who exhibited both normal lactose and sodium levels produced more milk on Days 28 and 42 (p = .028 and .011), those with only normal lactose levels produced more on Day 42 (p = .026) and those with only normal sodium levels on Day 28 (p = .036). Earlier secretory activation by volume attainment was associated with increased expression frequency during Days 2-5 (all p < .014) and participants with normal biomarkers expressed more frequently during Days 2-5 (all p < .020).

CONCLUSION

Mothers of very low birth weight infants are at risk for delayed secretory activation, which may decrease their milk production. Frequent expression during the first 5 days postpartum may promote earlier secretory activation. Valid methods of determining secretory activation are necessary to develop interventions promoting earlier secretory activation.

Maternal production of milk for infants in the neonatal intensive care unit

Mother's own milk (MOM) feeding is a cost-effective strategy to reduce risks of comorbidities associated with prematurity and improve long-term health of infants hospitalized in the Neonatal Intensive Care Unit (NICU). Significant racial and socioeconomic disparities exist in MOM provision in the NICU, highlighting the importance of developing strategies to reduce these disparities. Mothers of infants in the NICU experience many health concerns which may negatively impact lactation physiology. Objective measures of lactation physiology are limited but may assist in identifying mothers at particular risk. Several strategies to assist mothers of hospitalized infants are essential, including maternal education, qualified lactation professionals, early and frequent milk expression with a hospital-grade double electric breast pump, and providing support for transitioning to direct breastfeeding prior to discharge from the NICU.

The Critical Window of Opportunity: Lactation Initiation Following Cesarean Birth

Introduction: Cesarean birth is reported to be risk factor for the delayed onset of maternal lactation. The purpose of this study was to describe the timing of lactation initiation, subsequent feeding/milk expression patterns, and daily milk volumes among women who had a cesarean birth of an infant with a known congenital anomaly during the 3-day postpartum hospital stay. Materials and Methods: Retrospective descriptive cohort study. The electronic medical records of dyads, between 2014 and 2017 at the study setting, were abstracted for demographic and clinical data. Milk expression and milk volume data were abstracted from maternal lactation logs. Data were analyzed using descriptive statistics. Results: Among the cohort (n = 468 dyads), the mean time from infant delivery by cesarean to lactation initiation was 257.5 minutes. The cohort was divided into three groups by the timing of lactation initiation: EARLY (≤60 minutes; n = 112), MID (>60 minutes to ≤360 minutes; n = 309), and LATE (>360 minutes; n = 47). Statistically significant differences are seen between groups for the daily means: number of feeds/pumps and maternal milk volumes (irrespective of the presence of lactation risk factors). Discussion: This is the first study to explore the relationship of lactation initiation among women postcesarean birth whose infants have a known congenital anomaly. The time between the infant's birth and the first feed/milk expression, and the patterns of feeding/milk expression during the postpartum hospital stay, are key drivers for maternal milk supply.

Perceived insufficient milk among primiparous, fully breastfeeding women: Is infant crying important?

Breastfeeding mothers often report perceived insufficient milk (PIM) believing their infant is crying too much, which leads to introducing formula and the early abandonment of breastfeeding. We sought to determine if infant crying was associated with reported PIM (yes/no) and number of problems associated with lactation (lactation problem score [LPS] 6-point Likert scale) before formula introduction. Primiparous breastfeeding mothers were recruited at birth and visited at 1, 2 and 4 weeks. Among those fully breastfeeding at 1 week (N = 230), infant crying variables based on maternal reports were not associated with PIM at 1 week, but LPS was. However, a mother's expectation that her infant would cry more than other infants was associated with increased odds of reporting PIM at 2 and 4 weeks, as were delayed onset of lactation and previous LPS. At 1 week, crying variables (frequency, difficulty in soothing) were associated with LPS along with percent weight change. Delayed onset of lactation, infant care style, number of breastfeeds and previous LPS were longitudinally associated with change in LPS from 1 to 2 weeks and 2 to 4 weeks. Our data suggest that reported infant crying is associated with PIM and LPS in the first 4 weeks of life. Guidance on what to expect in crying behaviour and the impact of infant care style may be beneficial in reducing PIM and LPS in the first month.

Differences in Human Milk Lactose and Citrate Concentrations Based on Gestational Diabetes Status

Background: Exclusive breastfeeding is the optimal manner of early infant nutrition but women with gestational diabetes mellitus (GDM) often experience challenges with lactation in the early postpartum period. Increases in the colostral metabolites of lactose and citrate have been found to indicate increased milk production. Materials and Methods: A follow-up study of 133 postpartum women with and without GDM was conducted to examine differences in specific colostral metabolite levels using enzymatic methods to determine transition to lactogenesis II during the first week postpartum. We used linear mixed models for repeated measures over time to examine the effect of GDM on colostral metabolite levels at baseline and follow-up with fixed effects of GDM status, time, covariates, and interactions between time and GDM, between time and time, and between time, time and GDM into the model allowing quadratic trends over time. Results: Over time, lactose and citrate levels increased for all mothers (p < 0.001 and p < 0.001, respectively), although mothers with GDM had consistently lower lactose and citrate levels compared with nondiabetic mothers (p = 0.004 and p = 0.014, respectively). Age, prepregnancy body mass index, mode of birth, and parity did not independently influence colostral concentrations of lactose and citrate. Conclusions: Findings suggest that the rate of change overtime in lactose and citrate concentrations differ by GDM status. Further research examining the trajectory of colostral metabolite levels by GDM status is warranted.

ADIPS 2020 guideline for pre-existing diabetes and pregnancy

This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.

ADIPS position paper on pre-existing diabetes and pregnancy

This is an executive summary of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The summary focuses on the main clinical practice points for the management of women with type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The full guideline is available at https://doi.org/10.1111/ajo.13265.

Maternal Sense of Control During Childbirth and Infant Feeding Method

OBJECTIVE

To estimate whether maternal sense of control in labor is associated with breastfeeding at 4-8 weeks postpartum.

METHODS

This is a secondary analysis of data from a multicenter randomized controlled trial of elective induction of labor at 39 weeks of gestation in low-risk nulliparous women. In this trial, women completed the Labor Agentry Scale, a validated measure of women's feelings of control over the childbirth process, 6-96 hours after delivery. The Labor Agentry Scale score, which is higher with more perceived control during childbirth, was analyzed both as a continuous and a categorical variable (quintiles). Self-reported breastfeeding at 4-8 weeks postpartum was categorized as exclusive breastfeeding, breastfeeding and formula feeding, or exclusive formula feeding. Women were included in this analysis if they labored, filled out a Labor Agentry Scale questionnaire, had a neonate who survived until the postpartum visit, and provided information on infant feeding. Multinomial logistic regression was used to adjust for confounders.

RESULTS

Of 5,185 women, 32.9% (n=1,705) were exclusively breastfeeding, 31.2% (n=1,620) were breastfeeding and formula feeding, and 35.9% (n=1,860) were exclusively formula feeding 4-8 weeks after delivery. Overall Labor Agentry Scale score ranged from 34 to 203 (median 167, interquartile range 145-182). The median Labor Agentry Scale score was 169 (interquartile range 151-183) for women exclusively breastfeeding, 166 (interquartile range 142-182) for women who were breastfeeding and formula feeding, and 164 (interquartile range 142-181) for women who were only formula feeding (P<.001). In the unadjusted multinomial model, women with Labor Agentry Scale scores in the lowest two quintiles (ie, those with lower perceived control during childbirth) were less likely to be exclusively breastfeeding (as compared with those exclusively formula feeding) than women in the highest Labor Agentry Scale quintile. When controlling for confounders, however, this association was no longer significant.

CONCLUSION

After adjustment for confounders, perceived control during childbirth was not associated with breastfeeding at 4-8 weeks postpartum among nulliparous women.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01990612.

Timing of milk expression following delivery in mothers delivering preterm very low birth weight infants: a randomized trial

OBJECTIVE

To determine the effect of timing of expression initiation on mother's own milk production and time to secretory activation in mothers of preterm infants.

STUDY DESIGN

180 mothers delivering infants ≤1500 grams and ≤32 weeks gestation were randomized to begin expression within 60 (early), 61-180 (intermediate) or 181-360 (late) minutes following delivery. Milk volume was measured on days 1-7 and weekly for 6 weeks. Time to secretory activation was determined through self-report.

RESULTS

The late group produced more milk than the early group in the first 3 days (p = 0.015-0.031) and over 6 weeks (p = 0.045). The late group had more expressions on day 1 (early: p = 0.049; intermediate; p = 0.048).

CONCLUSION

Initiation of expression at 181-360 min following delivery was associated with increased milk production for 6 weeks following delivery. Further research is needed to determine the effect of expression frequency on milk production in the first days following birth.

Patterns and predictors of exclusive breastfeeding in Chinese Australian mothers: a cross sectional study

BACKGROUND

While exclusive breastfeeding is recommended to 6 months of age, just 15% of mothers in Australia achieve this. The rate appears to be even lower among mothers born in China, where 90% have introduced infant formula by this time. This study aimed to examine infant feeding patterns in the first 12 months of life and the factors associated with exclusive breastfeeding at 4 months of age and infant formula introduction by 1 month of age among Chinese Australian mothers.

METHODS

Chinese Australian women with a child aged 1 to 4 years born in Australia were recruited through social media and asked to complete an online survey. Chinese ethnicity was defined as the mother or her parents having been born in mainland China, Taiwan or Hong Kong. Infant feeding practices since birth and a range of psychosocial and cultural factors were assessed. A total of 289 Chinese Australian mothers completed the survey. The relationships between exposure variables and exclusive breastfeeding at 4 months or infant formula use by 1 month were examined using multivariable logistic regression.

RESULTS

Almost all (93%) mothers initiated breastfeeding, however by 1 month of age exclusive breastfeeding rates reduced to 44%, with a further decline to 33 and 18% at 4 and 6 months respectively. Concurrently, 7% of parents reported infant formula feeding at birth increasing to 55 and 63% at 1 and 6 months of age respectively. The rates of any breastfeeding were 81% at 6 months and 50% at 12 months of age. Breastfeeding intention, self-efficacy and awareness of the infant feeding guidelines were key factors associated with sustained exclusive breastfeeding to 4 months.

CONCLUSIONS

While Chinese Australian mothers had comparable exclusive breastfeeding rates at 6 months to the general Australian population, twice as many had introduced infant formula by 1 month of age. There is an urgent need to support Chinese Australian mothers in the perinatal period to strengthen their knowledge, intention and confidence to delay early introduction of infant formula and promote exclusive breastfeeding in the early postpartum period.

Delayed Lactogenesis Is Associated with Suboptimal Breastfeeding Practices: A Prospective Cohort Study

BACKGROUND

Breastfeeding has many established health benefits to both babies and mothers. There is limited evidence on the association between delayed lactogenesis and breastfeeding practices.

OBJECTIVE

We assessed the association between delayed lactogenesis and breastfeeding practices in women initiating breastfeeding.

DESIGN

We used data from a prospective cohort study in Wuhan, China, which enrolled pregnant women at 8-16 weeks of gestation and followed up to postpartum. Women were included who had a singleton live birth, initiated breastfeeding, and provided information on infant feeding. Maternal lactogenesis status was assessed by face-to-face interview at day 4 postpartum. Breastfeeding practices (full breastfeeding and/or any breastfeeding) were queried by telephone interview at 3, 6, and 12 mo postpartum. Poisson regression and Cox regression were used to identify the association between delayed lactogenesis and breastfeeding practices.

RESULTS

Delayed lactogenesis was reported by 17.9% of the 2877 participants. After adjusting for potential confounders, when compared with timely lactogenesis, delayed lactogenesis was significantly associated with higher risk of inability to sustain full breastfeeding at 3 mo postpartum (RR: 1.24, 95% CI: 1.10, 1.39) and 6 mo postpartum (RR: 1.14, 95% CI: 1.04, 1.24). Delayed lactogenesis was also significantly associated with early termination of any breastfeeding (HR: 1.15, 95% CI: 1.01, 1.30) in the adjusted model. In a combined analysis, women with higher gestational weight gain (GWG, ≥16 kg for underweight and normal weight, 15 kg for overweight/obesity) and who subsequently experienced delayed lactogenesis had the highest risk of ending any breastfeeding earlier (adjusted HR: 1.32, 95% CI: 1.11, 1.55) compared with those who gained less GWG and experienced timely lactogenesis.

CONCLUSIONS

This study shows that delayed lactogenesis was associated with low rate of full breastfeeding and shorter duration of any breastfeeding. Greater efforts to promote breastfeeding should be targeted towards women with delayed lactogenesis.

Maternal chronic disease and breastfeeding outcomes: a Canadian population-based study

Background: The prevalence of chronic disease in pregnant women has consistently risen over the past two decades. Substantial evidence demonstrates that maternal chronic disease is associated with adverse medical outcomes like preterm birth, but less research has characterized postpartum outcomes such as infant feeding practices. It is recommended that infants be exclusively breastfed from birth to 6 months given the numerous health benefits it provides.Objective: To determine the association between maternal chronic disease and breastfeeding outcomes.Methods: We analyzed cross-sectional self-report data from the 2015/2016 Canadian Community Health Survey, restricted to women who gave birth within 2 years of data collection (n = 2100, rounded). The exposure was professionally diagnosed chronic physical disease (e.g. diabetes, arthritis, heart disease). The outcomes were breastfeeding non-initiation and early cessation of breastfeeding before 6 months. Multivariable logistic regression modeling was used to estimate adjusted odds ratios (AOR) with 95% confidence intervals (CIs). Estimates were bootstrapped and weighted to represent the national population.Results: Overall, 11.9% (95% CI 9.8-14.1) of women reported chronic disease, and were more likely to be single, be Canadian born, have low education, and be overweight/obese than women without chronic disease. The mean maternal age was approximately 30 years in both groups. Women with chronic disease had similar odds of breastfeeding non-initiation (AOR 0.96, 95% CI 0.54-1.71) and early cessation of any breastfeeding (AOR 1.40, 95% CI 0.82-2.40), but over twice the odds of early cessation of exclusive breastfeeding (AOR 2.48, 95% CI 1.49-4.12) compared to unaffected women.Conclusion: Mothers with chronic disease initiate and continue some form of breastfeeding to six months as often as their unaffected peers. However, they have substantially higher odds of ceasing exclusive breastfeeding before the recommended 6 months. Findings suggest a need to investigate the reasons for this disparity to ensure that appropriate breastfeeding support is available for women with chronic disease and their children.

Maternal and Neonatal Hair Cortisol Levels and Psychological Stress Are Associated With Onset of Secretory Activation of Human Milk Production

BACKGROUND

Several factors can influence the production of mothers' own milk.

PURPOSE

To assess the influence of maternal psychological stress, maternal cortisol levels, and neonatal hair cortisol levels on timing of secretory activation.

METHODS

A prospective study was conducted at 2 public health centers in Andalusia, Spain. Participants were 60 pregnant women and their 60 neonates. Hair cortisol levels and psychological stress (pregnancy-specific stress [Prenatal Distress Questionnaire, PDQ] and perceived stress [Perceived Stress Scale, PSS]) were evaluated during the third trimester and the postpartum period. This study was part of the GESTASTRESS cohort study on the effects of stress during pregnancy.

RESULTS

Higher PDQ and PSS scores (P < .05) in the third trimester were associated with later onset of secretory activation. Higher postpartum maternal hair cortisol levels were associated with a delayed secretory activation of mother's own milk (P < .05).

IMPLICATIONS FOR RESEARCH

Future studies should look at the influence of psychological stress and cortisol levels on hormones involved in mother's own milk production.

IMPLICATIONS FOR PRACTICE

Neonatal nurses and other healthcare providers should be familiar with levels of neonates' exposure to maternal prenatal stress prior to birth.

Perspective: Should Exclusive Breastfeeding Still Be Recommended for 6 Months?

The WHO recommends exclusive breastfeeding of infants for the first 6 mo of life (EBF-6). We reviewed the evidence behind concerns related to this recommendation. The risk of iron deficiency among EBF-6 infants can be significantly reduced if delayed cord clamping is performed in all newborns. At the moment there is no population-level evidence indicating that exclusive breastfeeding for 6 mo compared with <6 mo increases the risk of developing food allergies. Mild to moderate maternal undernutrition may reduce amounts of some nutrients in breast milk but does not directly diminish milk volume. Persistent reports of insufficient milk by women globally are likely to be the result of lack of access to timely lactation counseling and social support rather than primary biological reasons. All newborns should have their growth, hydration status, and development carefully monitored. In instances where formula supplementation is required, it should be done under the guidance of a qualified provider taking into account that early introduction of breast-milk supplements is a risk factor for early termination of exclusive breastfeeding and any breastfeeding. We found no evidence to support changes to the EBF-6 public health recommendation, although variability in inter-infant developmental readiness is recognized. We suggest that infant and young feeding guidelines make clear that complementary foods should be introduced at around 6 mo of age, taking infant developmental readiness into account.

"It gave me so much confidence": First-time U.S. mothers' experiences with antenatal milk expression

Antenatal milk expression (AME) involves maternal hand-expression, collection, and storage of breast milk during pregnancy for the purposes of reducing the early formula use in breastfed infants. AME is not widely practiced in the United States, despite its growing popularity elsewhere. In this study, we examined the experiences of first-time mothers recruited from a U.S. midwife practice who engaged in AME within the context of a pilot randomized controlled trial. The AME intervention involved demonstration and practice of AME with a lactation consultant beginning at 37 weeks of gestation, reinforcement at weekly study visits until delivery, and daily home practice. Nineteen women participated in a semistructured interview at 1-2 weeks postpartum regarding their study experiences. Major themes included (1) perceived benefits and impact of AME, (b) AME implementation, and (c) use of AME milk. Women perceived multiple benefits of AME, most notably that it increased their confidence that they would be able to make milk and breastfeed successfully postpartum. Women expressed some concern that no/little milk expressed could be indicative of postpartum milk production problems. Regarding implementation, women found that the AME protocol fit well into their daily routine. There was mixed feedback regarding comfort with practicing AME in the presence of partners. Reasons for postpartum use of AME milk varied; barriers to provision included inadequate milk storage options at the birth hospital and unsupportive hospital providers/staff. With few caveats, AME appears to be an acceptable breastfeeding support intervention among a sociodemographically homogeneous group of first-time mothers in the United States.