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

Breast milk Na+ and Na+/K+ ratio predict delayed onset of lactogenesis in gestational hyperglycemia

To investigate the predictive value of breast milk Na+ concentration and Na+/K+ ratio on delayed onset of lactogenesis (DOL) in puerpera with gestational hyperglycemia. Puerpera with gestational hyperglycemia who delivered at The First Affiliated Hospital of Army Medical University in China between October 20, 2023, and April 1, 2024, were enrolled. The concentrations of Na+ and K+ in breast milk samples were examined from study participants on days 1-3 of the postpartum period. The predictive value of Na+ concentration and the Na+/K+ ratio on DOL were assessed using receiver operating characteristic (ROC) curves. Both the Na+ concentration and Na+/K+ ratio in breast milk collected on day 3 could effectively predict DOL, with areas under the curve (AUCs) of the ROC curve and 95%CI values of 94.7% (95%CI = 0.901-0.992) and 94.2% (95%CI = 0.890-0.994), respectively. The optimized cutoffs were Na+ concentration ≥ 26.25 mmol/L (sensitivity = 88.2%, specificity = 92.2.8%) and Na+/K+ ratio ≥ 1.646 (sensitivity = 79.4%, specificity = 98.4%). Both the Na⁺ concentration and Na+/K+ ratio in breast milk were found to be effective in predicting DOL in puerpera with gestational hyperglycemia.

Delayed Lactogenesis II in High-Risk Pregnancies: What Should We Care

Background: The timely initiation of lactogenesis II is crucial for postpartum women, with delays having significant clinical implications. This study aimed to evaluate the determinants of delayed lactogenesis II (DOL II) in high-risk pregnant women to guide clinical interventions and postnatal care protocols. Methods: We conducted a study involving high-risk pregnant women who gave birth and were admitted to our hospital''s obstetric intensive care unit for postpartum surveillance and treatment from February 1, 2023, to April 30, 2024. We utilized Pearson correlation analysis and logistic regression to determine factors linked to DOL II. Results: Our study included 206 high-risk pregnant women, with 85 (41.26%) experiencing DOL II. Pearson correlation analysis indicated strong associations between DOL II and maternal age (r = 0.452), gestational hypertension (r = 0.514), gestational diabetes (r = 0.487), and delayed colostrum secretion (r = 0.506), all statistically significant (p < 0.05). Logistic regression analysis identified age 35 years or older (OR = 2.115, 95%CI: 1.785-2.466), gestational hypertension (OR = 2.404, 95%CI: 2.125-3.107), gestational diabetes (OR = 2.556, 95%CI: 2.008-2.879), and colostrum secretion later than one hour postpartum (OR = 3.126, 95%CI: 2.682-3.605) as independent risk factors for DOL II, all with p < 0.05. Conclusions: The incidence of DOL II is significantly elevated in high-risk pregnant women, especially those aged 35 or older, those with gestational diabetes and hypertension, and those who delay the initiation of breastfeeding. It is imperative that clinical practices prioritize enhanced prenatal care and health education, robust lactation support, and improved lactation awareness among postpartum women to reduce the prevalence of DOL II.

Feasibility of Using Point-of-Care Biomarkers of Secretory Activation to Address Early, Unplanned Weaning Among Healthy, Term Dyads in Community Settings: A Pilot Study

Background: Delayed and/or impaired secretory activation (SA) achievement is a risk factor for early unplanned lactation cessation. This pilot study (1) evaluated the feasibility of in-home daily milk collection; (2) compared daily maternal self-report of breast fullness with mother's own milk (MOM) biomarkers of SA; and (3) examined SA patterns in association with lactation outcomes through 3 months postpartum. Methods: Twelve mother-infant dyads were enrolled at term (median gestational age (GA) = 39.9 weeks, range = 38.3-41.1 weeks). After birth, participants self-reported breast fullness and collected milk samples daily for a week. Infant weight gain and milk intake by test-weights were assessed postpartum during a week 1 routine infant outpatient visit and again during a week 2 home visit. Milk samples were tested for sodium (Na) and potassium (K) using portable ion selective electrodes. Timing of SA achievement was denoted as the first day breast fullness was self-rated ≥ 3, Na concentration was < 12 mmol/L, or the Na/K ratio was < 0.6. Breastfeeding duration and exclusivity were measured at 1, 2, and 3 months postpartum. Results: By day 6, all mothers self-reported SA achievement, while only 72-82% achieved SA using MOM biomarkers. Cohen's kappa between the timing of SA by maternal self-report and MOM biomarkers showed lack of agreement (κ = 0.05 and 0.08), but was high between MOM Na and Na/K ratio (κ = 0.87). Three patterns of SA by MOM biomarkers emerged (mature and stable, impermanent, and delayed) with implications for infant weight loss/gain at 1 week postpartum. These patterns were not associated with breastfeeding exclusivity through 3 months postpartum in this highly motivated sample. Conclusion: MOM biomarkers of SA achievement are feasible and have significant potential for use in community settings.

Gestational Diabetes Mellitus, Breastfeeding, and Progression to Type 2 Diabetes: Why Is It So Hard to Achieve the Protective Benefits of Breastfeeding? A Narrative Review

Women diagnosed with gestational diabetes mellitus (GDM) face a significantly heightened risk of developing type 2 diabetes mellitus (T2DM) later in life. Breastfeeding (BF) has been identified as a potential strategy to delay or prevent T2DM; however, women with GDM often encounter barriers in initiating and maintaining adequate BF practices compared to those with uncomplicated pregnancies. This paradox prompts an exploration into the causes of these BF challenges and considers the possibility of reverse causation: Does prolonged and intensive BF mitigate the risk of subsequent glucose dysregulation and T2DM? Alternatively, do women with compromised insulin secretion and sensitivity, who are predisposed to T2DM, struggle to sustain intensive BF practices? This narrative review aims to explore the interplay between GDM, BF, and T2DM development by examining the different factors that present BF challenges among women with GDM. Understanding these dynamics is crucial for establishing realistic BF expectations and developing effective clinical and public health strategies to support BF in this high-risk population.

Incidence and factors influencing delayed onset of lactation: a systematic review and meta-analysis

BACKGROUND

Breastfeeding has many benefits for mothers and infants. Lactogenesis II is one of the key steps in the implementation of breastfeeding. If lactogenesis II occurs more than 72 h after delivery, it is termed delayed onset of lactation (DOL). DOL is associated with decreased milk production, shortened breastfeeding time, and pathological neonatal weight loss. A comprehensive summary of the incidence and factors influencing DOL is needed to provide a basis for improving breastfeeding practices and health outcomes.

METHODS

Studies on the incidence and factors influencing DOL were retrieved from 13 Chinese and English databases (PubMed, Embase, Web of Science, Cochrane Library, CINAHL, etc.) from database inception to August 2023. Two researchers independently conducted the study screening, data extraction and quality evaluation. Stata 16.0 SE software was used for data analysis, and sensitivity analysis and publication bias tests were also performed. The qualitative description method was used to analyse studies that could not be combined quantitatively.

RESULTS

A total of 35 studies involving 19,176 parturients, including 4,922 who had DOL, were included. The mean Newcastle‒Ottawa scale score of the included studies was ≥ 6, indicating that the quality was relatively high. Finally, the incidence of DOL was 30%, and 13 factors influencing DOL with robust results and no publication bias were obtained: prepregnancy body mass index (overweight or obesity), gestational diabetes, gestational hypertension, thyroid disease during pregnancy, serum albumin levels (< 35 g/L), parity, (unscheduled) caesarean section, caesarean section history, daily sleep duration, gestational age, birth weight (< 2.5 kg), breastfeeding guidance and daily breastfeeding frequency. However, there were still six influencing factors with undetermined associations: age, gestational weight gain, birth weight (≥ 4 kg), anxiety, time of first breastfeeding session (maternal separation) and breast massage or treatment.

CONCLUSIONS

The incidence of DOL is high. Clinicians should pay attention to parturients at high risk of DOL and formulate targeted prevention strategies according to the influencing factors to reduce the occurrence of DOL and promote better maternal and infant outcomes.

TRIAL REGISTRATION

PROSPERO (ID: CRD42023458786), September 10, 2023.

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.

Beliefs and Decision-Making of First-Time Mothers Planning to Use a Breast Pump

Beliefs and decision-making processes associated with breast pump use in first-time mothers providing human milk to healthy, term newborns soon after birth are explored in this qualitative, descriptive study. Eight women participated in an individual semistructured interview in a community hospital in the southeastern United States. Guided by the theory of planned behavior, conventional content analysis about prenatal and early postpartum beliefs of planning and utilizing breast pumps yielded themes of Resource Gathering, Intention Refining, and Behavior Navigating. An understanding of these beliefs gives insight into ways health professionals can increase collaboration with expectant and new mothers about the selection and safe use of breast pumps, resource availability at various stages, and infant-feeding goals.

Determinants of delayed onset of lactogenesis II among women who delivered via Cesarean section at a tertiary hospital in China: a prospective cohort study

BACKGROUND

Cesarean birth is associated with a higher prevalence of delayed onset of lactogenesis II (DOLII) than vaginal birth. DOLII refers to the delayed initiation of copious milk production beyond 72 h after birth. This study aimed to determine the prevalence of, and factors associated with, DOLII among women who delivered via Cesarean section in China.

METHODS

This prospective longitudinal cohort study recruited 468 women who delivered via Cesarean section at a tertiary hospital in China from 9 October 2021 to 17 May 2022. Face-to-face interviews were conducted during their delivery hospital stay to obtain information about demographic, medical, and breastfeeding factors. We assessed the onset of lactogenesis on postpartum day four, based on the maternal perception of changes in breast fullness. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for postpartum depression. Women with DOLII were interviewed via telephone or WeChat daily for one week postpartum to determine the timing of the onset of lactogenesis II. Univariate and multivariable logistic regression analyses were used to identify the determinants of DOLII.

RESULTS

DOLII was experienced by 156 of 468 participants (33.3%). After adjusting for potential confounders, the odds of DOLII were 95% higher in primiparous women than multiparous women (adjusted odds ratio [aOR] 1.95; 95% confidence interval [CI] 1.29, 2.98), 75% higher in women with a serum albumin concentration < 35 g / L than women with normal serum albumin concentrations (aOR 1.78; 95% CI 1.09, 2.99), increased by 2.03-fold in women with an EPDS score ≥ 10 than women with an EPDS score < 10 (aOR 2.03; 95% CI 1.35, 3.07), and decreased in women with a higher number of breastfeeding sessions in the first 48 h postpartum (aOR 0.88; 95% CI 0.83, 0.93).

CONCLUSIONS

One-third of women with Cesarean section delivery experienced DOLII. DOLII was more likely in women who were primiparous, had a serum albumin concentration < 35 g / L, had a lower frequency of breastfeeding sessions, and had an EPDS score ≥ 10. Women with these risk factors who deliver via Cesarean section may need early breastfeeding support to ensure successful lactation.

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.

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 .

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.

Learning needs of family physicians, pediatricians, and obstetricians to support breastfeeding and inform physician education

BACKGROUND

Physicians require breastfeeding education appropriate to their roles. The aim of this survey was to determine physician learning needs and to inform development of breastfeeding education for physicians.

METHODS

A cross sectional survey was distributed to family physicians, pediatricians and obstetricians in a tertiary institution. Importance of knowledge to practice and confidence to manage was assessed for 18 learning topics proposed by a multi-specialty physician working group. Descriptive statistics, ANOVA and tests for equality of variances were calculated. Mean values of importance to practice and confidence to manage for each topic suggested learning priorities.

RESULTS

The study group included 75 physicians. The most important topics were "informed choice when supporting newborn feeding," "analgesics, antidepressants and other medications while breastfeeding" and "community resources for breastfeeding support." Confidence to manage was lowest for "latch assessment," "what mom can do during pregnancy to promote milk production," and "risk factors for delayed lactogenesis." Preferred learning formats were 15-minute online modules and grand rounds.

CONCLUSIONS

Physicians acknowledged the importance of all topics but report lowest confidence to manage latch assessment, prenatal interventions to support lactogenesis and management of delayed lactogenesis. Participants placed relatively low importance on learning about latch assessment despite the central nature of this skill in supporting early breastfeeding.

Measures of Lactation Outcomes in Women Delivering Preterm Infants

BACKGROUND

Mother's own milk (MOM) is well known to decrease prematurity-related morbidities, yet mothers delivering preterm infants often produce insufficient quantities of milk to provide these benefits. Although a critical need exists for research to support lactation success in this vulnerable population, development and investigation of interventions to increase available MOM for infant consumption requires consistent, valid, and reliable measures of lactation outcomes.

OBJECTIVES

The aim of this study was to compare and contrast methods of measuring lactation outcomes in mothers of preterm infants and evaluate their advantages and disadvantages.

METHODS

Measures of lactation outcomes were reviewed and synthesized. Insights on best practices and future research directions are provided.

RESULTS

Volume of MOM produced, lactation duration, and time to onset of secretory activation are important measures of lactation success. The most valid and reliable measure of milk production is likely weighing each vial of expressed milk combined with test weighing when infants breastfeed. Measures of lactation duration should include actual days mothers lactated rather than limiting to infant consumption of MOM as a proxy for duration and include not only whether mothers are lactating at infant discharge but whether they are also lactating at other health-relevant time points during hospitalization. Although time to onset of secretory activation is an important lactation outcome, information regarding valid and reliable indicators of onset in women delivering preterm infants is limited, and investigation of such indicators is a research priority. Variables that may affect lactation outcomes, including time to initiation of expression following delivery, duration of expression sessions, expression method, time spent in skin-to-skin care, maternal demographics and comorbidities, as well as maternal intent to lactate, must be considered when researchers investigate lactation outcomes in mothers of very low birth weight infants.

DISCUSSION

Consistent and valid measures of lactation outcomes are required to produce reliable results from which evidence-based practice recommendations can be developed in order to improve lactation success in this vulnerable population.

Gestational Diabetes Mellitus and Risk of Delayed Onset of Lactogenesis: A Systematic Review and Meta-Analysis

Background: Gestational diabetes mellitus (GDM) may be associated with delayed onset of lactogenesis (DOL), but it is still inconclusive. Objectives: The study aimed to evaluate the association between GDM and DOL, the prevalence and risk factors of DOL in GDM women. Materials and Methods: A comprehensive search was performed in 10 electronic databases from inception to June 1, 2020. To find more eligible studies, the references of finally eligible studies and relevant reviews were traced manually. A meta-analysis was conducted to calculate the pooled estimates of association, prevalence, and risk factors using random- or fixed-effects models. Results: Eleven eligible articles involving 8,150 women were included in this study. GDM women had a higher risk of DOL (odds ratio [OR] = 1.84, 95% confidence interval [CI] [1.34-2.52]). The prevalence of delayed lactogenesis onset in GDM women was 35.0% (effect size [ES] = 0.35, 95% CI [0.30-0.40]). Primipara (OR = 2.54, 95% CI [1.89-3.42]), advanced age (OR = 1.05, 95% CI [1.03-1.08]), prepregnancy obesity (OR = 1.55, 95% CI [1.19-2.03]), and insulin treatment (OR = 3.07, 95% CI [1.71-5.47]) were risk factors of delayed lactogenesis onset in GDM women. Conclusion: GDM negatively affects the timing of lactogenesis onset. The prevalence of delayed lactogenesis onset in GDM women is 35.0%. Primipara, advanced age, prepregnancy obesity, and insulin treatment are independent risk factors of delayed lactogenesis onset in GDM women.