Mothers' Reasons for Early Breastfeeding Cessation

An Integrative Review of Exclusive Breast Milk Expression

INTRODUCTION

A growing number of families are using exclusive breastmilk expression to feed their newborns. They need accurate information and support from their providers.

METHODS

The purpose of this integrative review was to explore the prevalence, characteristics, practices, and outcomes of families who fed exclusively expressed breastmilk to their infants. The electronic databases of CINAHL, Scopus, PubMed, Web of Science, and article reference lists for articles on expressing human milk for infants were searched. Results were filtered to glean published studies between 2012 and 2022, academic journals, human studies, and English language journals while excluding secondary reviews and expert opinions. Both authors screened records within Covidence systematic review management software. Selected studies were evaluated for quality of evidence using the Johns Hopkins Research Evidence Appraisal Tool.

RESULTS

Twenty-seven studies were included in this review. Most families who exclusively expressed originally planned to directly breastfeed their newborns and only began pumping after encountering problems. The most frequently recurring theme was that advice from health care personnel was inconsistent. Women described a knowledge deficit and received more help with exclusive expression from informal social media groups than their providers. Prevalence of exclusive breastmilk expression is highest in Asian countries and in the neonatal intensive care unit environment. These women had a shorter duration of human milk feeding and higher likelihood of cessation compared with women who both fed expressed milk and directly breastfed.

DISCUSSION

Only recently have breastfeeding researchers begun distinguishing the type of milk (human milk or artificial formula) from the feeding method in their publications. This approach allows clinicians to provide better guidance on the outcomes of each feeding method. As clinicians, we can help families by encouraging them and providing consistently accurate information. Solely feeding expressed human milk is a valid option when the lactating person is unable or unwilling to directly breastfeed.

Flange Size Matters: A Comparative Pilot Study of the Flange FITSTM Guide Versus Traditional Sizing Methods

BACKGROUND

Pumping is a common practice in the United States, but it can be uncomfortable and lead to concerns about milk supply. The fit of the flange, or breast shield, used while pumping can contribute to or alleviate these problems. Flanges are available in a wide variety of sizes, and there are inconsistencies in guidance provided by healthcare providers and pump manufacturers for parents choosing a size. There have been no studies comparing different methods of sizing in terms of comfort and milk output.

RESEARCH AIMS

The aim of this research was to examine differences in milk output and comfort using two methods of flange sizing.

METHOD

A within-subject cross-over design with a convenience sample of parents exclusively feeding their own human milk was used to compare comfort and milk yield between using smaller-fit and standard-fit flanges. Participants pumped for 1 week with each set of flanges and recorded milk output and comfort outcome measures. Data were collected on participant demographics, nipple measurements, and flange sizes used.

RESULTS

When compared to the newer small-size fitting, participants using the standard fit flanges had significantly less milk output (mean difference = -15.0 g, 95% CI [-25.0, -5.0], d = -0.51, p = 0.004) and less comfort (mean difference = -1.2, 95% CI [-1.6, -0.91], d = -1.23, p < 0.001).

CONCLUSION

Flange fitting is a process that should be individualized to the patient and may require a trial of one or more sizes during a pumping session. Smaller sizes determined using this individualized process and starting with nipple tip measurement may be used without compromising milk output or comfort.

Milk Composition Is Predictive of Low Milk Supply Using Machine Learning Approaches

Background/Objectives: The causes of low milk supply are multifactorial, including factors such as gene mutations, endocrine disorders, and infrequent milk removal. These factors affect the functional capacity of the mammary gland and, potentially, the concentrations of milk components. This study aimed to investigate the differences in milk composition between mothers with low and normal milk supply and develop predictive machine learning models for identifying low milk supply. Methods: Twenty-four-hour milk production measurements were conducted using the test-weigh method. An array of milk components was measured in 58 women with low milk supply (<600 mL/24 h) and 106 with normal milk supply (≥600 mL/24 h). Machine learning algorithms were employed to develop prediction models integrating milk composition and maternal and infant characteristics. Results: Among the six machine learning algorithms tested, deep learning and gradient boosting machines methods had the best performance metrics. The best-performing model, incorporating 14 milk components and maternal and infant characteristics, achieved an accuracy of 87.9%, an area under the precision-recall curve (AUPRC) of 0.893, and an area under the receiver operating characteristic curve (AUC) of 0.917. Additionally, a simplified model, optimised for clinical applicability, maintained a reasonable accuracy of 78.8%, an AUPRC of 0.776, and an AUC of 0.794. Conclusions: These findings demonstrate the potential of machine learning models to predict low milk supply with high accuracy. Integrating milk composition and maternal and infant characteristics offers a practical approach to identify women at risk of low milk supply, facilitating timely interventions to support breastfeeding and ensure adequate infant nutrition.

Distinguishing Between Lactation Failure and Breastfeeding Cessation: A Scoping Review

Background: Interchangeable terminology and definitions of breastfeeding difficulties may inadvertently influence premature cessation of breastfeeding. Lactation failure is a distinct concept from breastfeeding cessation, and it is vital to differentiate between them, especially in educating health care professionals in communicating and supporting mothers perinatally. Purpose: Comprehensively review varying terminology and definitions, providing a more nuanced understanding of lactation failure versus breastfeeding cessation, and highlighting physiological and social, emotional, mental, and commercial factors that influence breastfeeding outcomes. Method: A scoping review of published literature from medical and scientific databases such as MEDLINE (via PubMed), Scopus, and Web of Science from 2000 to 2023. Results: N = 476 publications were collected during the identification phase; N = 49 from 28 countries around the world met the inclusion criteria and were used in the review. Only N = 13 studies ventured definitions for the terms used. Factors affecting breastfeeding were categorized as physiological leading to lactation failure and distinguished from social, mental, emotional, or commercial factors leading to breastfeeding cessation. Recommendations and Conclusions: Understanding the complexity of the factors underlying lactation failure and breastfeeding cessation can be improved by delineating the terminology and definitions variations used to communicate, provide awareness, education, design and delivery of interventions and support for initiation, and continuation of breastfeeding. Further in-depth research and analysis of the complex issues and factors influencing breastfeeding practices is required.

Breastfeeding Journeys: Comparing Mothers' Experiences with Autistic and Neurotypical Infants

Breastfeeding is a complex task that requires proficiency at several key developmental skills to feed successfully. It is unclear how Autism Spectrum Disorder (ASD) affects an infant's breastfeeding experience and conflicting reports exist on shortened breastfeeding duration in infants later diagnosed with ASD. The purpose of this study was to describe the experiences of mothers breastfeeding both their autistic and neurotypical children to better understand the differences in their breastfeeding experiences and maternal and infant factors that contributed to breastfeeding cessation in their autistic child. Twenty-four mothers of an autistic child who had feeding difficulties in the first 12 months of life, initiated breastfeeding, and also had a neurotypical child participated in semi-structured interviews regarding breastfeeding initiation, cessation, and challenges encountered during breastfeeding. Analysis revealed four major themes: (1) the struggle with latch, including infant behavior that hindered latching; (2) breastfeeding challenges, including problematic breastfeeding behavior by the infant; (3) cessation of breastfeeding, including physical symptoms of the infant that lead to breastfeeding cessation; and (4) breastfeeding the neurotypical sibling, including mother's detection of different breastfeeding behaviors in neurotypical and autistic child. Breastfeeding behaviors described by mothers may indicate early signs of autism including early sensory sensitivity, lack of regulation, repetitive behaviors, and impaired social behaviors. Further research is needed to discern if these breastfeeding behaviors can be used to help identify early signs of autism and employed as additional surveillance for neurodevelopmental concerns at a young age.

Women with Gestational Diabetes Mellitus Have Greater Formula Supplementation in the Hospital and at Home Despite Intention to Exclusively Breastfeed

Background: Women with gestational diabetes mellitus (GDM) have lower rates of exclusive breastfeeding compared with women without diabetes. Objectives: To assess associations between GDM and breastfeeding intentions and attitudes, formula supplementation, reasons for formula supplementation, and knowledge of type 2 diabetes mellitus (T2DM) risk reduction associated with breastfeeding among U.S. mothers. Design/Methods: Participants completed an online survey assessing infant feeding knowledge, attitudes, and practices; demographics; and pregnancy-related medical history. Multivariable logistic regression was used to estimate adjusted odds ratios for formula supplementation in the hospital and at home. Results: Of 871 respondents, a smaller proportion of women with GDM compared with women without diabetes intended to exclusively breastfeed. There were no differences between groups in attitudes toward public breastfeeding, attitudes toward breastfeeding beyond infancy, or actual duration of any breastfeeding. Approximately one in four participants believed that breastfeeding mothers may be less likely to develop T2DM, regardless of GDM status. Among those who intended to exclusively breastfeed, GDM was associated with higher odds of formula supplementation in the hospital (adjusted odds ratio [OR] 1.75, 95% confidence interval [CI] 0.97-3.18) and at home (adjusted OR 2.02, 95% CI 1.05-3.89). "Medical reasons," which was reported as an important reason for formula supplementation, was reported more frequently by women with GDM. Conclusions: Women with GDM who intended to exclusively breastfeed had higher odds of in-hospital and at-home formula supplementation, cited medical reasons as a main reason for formula supplementation more often, and were largely unaware of T2DM risk reduction associated with breastfeeding.

Does an early hands-on breastfeeding intervention by midwives affect nipple pain incidence? An observational pilot study

AIM

To describe the timing and characteristics of midwives' hands-on interruptions of newborns' behavior while in skin-to-skin contact during the first hour after birth and to elucidate the relationship between these hands-on interruptions and the incidence of nipple pain during the first 4 days postpartum.

METHODS

An observational pilot study was conducted at a Baby-Friendly® hospital in Japan from 2016 to 2018. Iterative analysis of video recordings from a larger study of the behavior of newborns while skin-to-skin with their mothers in the first hour after birth found 16 full-term newborns who were born vaginally and that met the inclusion criteria of a midwife's hands-on intervention (HOI) interrupting the infant's progress toward breast self-attachment. The timing of the HOI and the stage of the newborn's progress through Widström's 9 Stages was noted by two research assistants who had been blinded to the medical records. The degree of nipple pain after breastfeeding was self-evaluated by mothers each day during their hospitalization. All data were statistically analyzed.

RESULTS

Interrupting the infant's progressive behaviors in the first hour after birth by midwives' hands-on "help" to breastfeed,  may increase nipple pain during the 4 days after birth. One hundred percent of the mothers reported nipple pain in the postpartum with the highest pain reports occurring on day 4.

CONCLUSION

Interrupting skin-to-skin contact with HOI does not decrease the incidence of nipple pain during the first days postpartum. HOI for newborn infants was not shown to support breastfeeding in the early postnatal period.

Reliability and validity of the German version of the Iowa infant feeding attitude scale (IIFAS-G) and relations to breastfeeding duration and feeding method

BACKGROUND

Public health initiatives (e.g., the Baby Friendly Hospital Initiative) have led to an increase in breastfeeding rates worldwide. However, as (exclusive) breastfeeding duration is still below WHO recommendations, it is crucial to understand the factors that influence decisions on breastfeeding practice. Modifiable psychological factors such as intention to breastfeed have therefore become targets of recent interventions. As the intention to breastfeed is among the strongest predictors of breastfeeding duration, reliable tools for measuring the intention to breastfeed are needed. The Iowa Infant Feeding Attitude Scale (IIFAS) measures attitudes towards infant feeding and is used in various languages and across different cultural contexts. However, there has been no German version of the IIFAS (IIFAS-G) so far. The aim of this study was to investigate reliability, validity, and associations of the IIFAS-G with feeding method and breastfeeding duration.

METHODS

Between August and November 2022, a total of 353 mothers (Mage = 35 years, SDage = 4.2 years) of singleton infants (47.3% female (1 undetermined), Mage = 10.8 months, SDage = 4.7 months, age range: 3-547 days; 90.4% living in Switzerland) participated in an online survey. The IIFAS-G was administered as a part of a larger study on early child development and infant feeding method.

RESULTS

The translated IIFAS-G showed unsatisfactory model fit for the two factor 17-item solution. Four items showed low factor loadings. After item reduction, a 13-item two factor solution showed satisfactory model fit (CFI = 0.92, TLI = 0.90, RMSEA = 0.07) and high internal consistency (Cronbach's α = 0.85). The IIFAS-G score was higher for mothers who exclusively breastfed their infants compared to mothers who additionally or exclusively fed infant formula. Moreover, mothers with higher IIFAS-G scores were less likely to stop breastfeeding their child over the course of 1.5years (HR = 0.87).

CONCLUSION

A shorter two-factor IIFAS-G is proposed to investigate attitudes towards breastfeeding and formula feeding in German-speaking mothers.

Monitoring of the Main Reasons for Early Abandonment of Breastfeeding during the First Six Months of Life: A Secondary Analysis

The rate of six-month-old infants exclusively breastfed in Spain remains below the recommended rate. This study aimed to explore in detail the evolution of feeding during the first six months of life of a group of newborns, as well as to identify the reasons reported by the mothers for feeding change. A secondary analysis of two prospective longitudinal observational studies was conducted. In both studies, women participants, during the clinical puerperium, opted for exclusive breastfeeding for their newborns. The participants were followed up during the infants' first six months. A sample size of 314 participants was obtained, of which 77.1% (n = 232) were of Spanish origin, and 51% (n = 160) were primiparous. The prevalence of exclusive breastfeeding at six months was 55.4% (n = 174). During the first four months of life, the main reason for early abandonment of breastfeeding was the perception of insufficient milk production. After the fourth month, the predominant reason was starting work. Statistically significant differences were observed between the reasons for giving up and the total weeks of exclusive breastfeeding (p < 0.001) and total weeks of breastfeeding (p = 0.002). Early weaning from breastfeeding is a multifactorial phenomenon. However, depending on the moment cessation occurs, some reasons predominate over others and, in many cases, can be prevented. These results indicate the need to continue investing efforts to promote and protect breastfeeding in Spain.

The Influence of Prenatal Breastfeeding Self-Efficacy on Breastfeeding Behavior of Taiwanese Pregnant Women

BACKGROUND

The benefits of breastfeeding for mothers and infants are well known. However, in Taiwan, the average breastfeeding rate remains below the World Health Organization recommendations. Breastfeeding self-efficacy is a known predictor of breastfeeding.

RESEARCH AIMS

To determine: (1) the relationship of sociodemographic factors to prenatal breastfeeding self-efficacy, and (2) the relationship of sociodemographic factors and prenatal breastfeeding self-efficacy to breastfeeding behavior at 8 weeks postpartum among women living in Taiwan.

METHODS

This was a prospective cohort study of 206 pregnant women collected in an outpatient clinic located in Taiwan. The validated Chinese version of the Prenatal Breastfeeding Self-Efficacy Scale (PBSES) was used to measure self-efficacy for breastfeeding during pregnancy. At 8 weeks postpartum, participants were contacted by telephone to obtain information regarding infant feeding method and duration.

RESULTS

The mean age of the pregnant women was 32 years, and the mean prenatal breastfeeding self-efficacy score was 78.6 (SD = 10.6). Scores differed across levels of maternal education, previous breastfeeding experience, and support systems. Prenatal breastfeeding self-efficacy scores were highest among participants reporting spouse support versus other types of support. Maternal age and prenatal breastfeeding self-efficacy were predictive of breastfeeding duration. A 1-year increase in maternal age was associated with a 6% lower likelihood of breastfeeding for at least 2 months postpartum, and a 1-point increase in the prenatal breastfeeding self-efficacy score was associated with a 14% increase in the likelihood of breastfeeding for at least 2 months postpartum.

CONCLUSIONS

Prenatal breastfeeding self-efficacy may help predict breastfeeding continuation among Taiwanese women in the first 2 months postpartum.

A randomized controlled trial of the Happy, Healthy, Loved personalized text-message program for new parent couples: impact on breastfeeding self-efficacy and mood

BACKGROUND

Breastfeeding self-efficacy has been identified as an important influence on breastfeeding outcomes. Among new parent couples, partners are uniquely positioned to be sources of support for developing breastfeeding self-efficacy, yet few breastfeeding programs have attempted to involve partners directly. The purpose of this study was to test the impact of a novel program, Happy, Healthy, Loved, on breastfeeding self-efficacy and maternal mood through emphasizing partner support and actively addressing postpartum-specific stress management in a tailored text message delivery program.

METHODS

A randomized trial was conducted in which primiparous mother-partner dyads intending to exclusively breastfeed were recruited at midwestern hospitals 2-3 days after delivery. The clinical trial was pre-registered at clinicaltrials.gov (#NCT04578925, registration date 7/24/2020). Couples were randomized to receive intervention or an attentional control. Couples randomized to the intervention group then completed a brief interactive educational tablet program together (Happy, Healthy, Loved), followed by 6 weeks of tailored text messages providing reminders, coping strategies, and motivational milestones to improve breastfeeding self-efficacy. Participants in the control group received usual care followed by 6 weeks of attentional control text messages about infant development. Surveys were delivered at baseline, 6 weeks, and 6 months postpartum to both mother and partner to assess breastfeeding self-efficacy, mood, and social support (n = 62 couples).

RESULTS

Outcomes of ANCOVA with baseline self-efficacy as a covariate showed a significant effect of intervention on 6 months breastfeeding self-efficacy when compared to control group. No other significant differences were found at 6 weeks or 6 months postpartum in breastfeeding self-efficacy, depressive or anxious symptoms.

CONCLUSIONS

Results of the present investigation suggest that a text-based dyad intervention improved breastfeeding self-efficacy at 6 months, but not 6 weeks, postpartum, indicating that text-based mother-partner interventions are a promising direction to continue exploring in postpartum health research.

TRIAL REGISTRATION

Clinicaltrials.gov #NCT04578925.

Comparison of human milk bottle with infant/toddler test weights in the community setting

BACKGROUND

The accuracy of infant intake using test weights (TWs), the change in weight before and after an infant feeds, has only been validated in hospitalized premature infants. This study's primary aim was to identify how accurate parent infants/toddler (< 2 years old) TWs are at measuring infant intake.

METHODS

Data were collected from 101 paired bottle and infant/toddler TWs with 31 participants. Parents participated in the feeding sessions by completing infant/toddler TWs blinded to the researcher. Research assistants completed human milk bottle TWs. Infants were fed previously expressed human milk, initially 30 g, but volumes were increased to not exceed the scale's capacity.

RESULTS

The mean difference between the bottle TWs measured using the Tanita and OHAUS scales was not significantly different from zero (95% CI (Tanita - OHAUS): (-0.251, 0.108) g). The mean difference between infant/toddler and bottle TWs was significantly different from 0 (95% CI (infant-bottle): (-3.45, -0.915 g or -3.57, -0.95 mL). Infant/toddler and bottle TWs were in agreement with a difference of 2.18 g (SD = 6.63) or 2.25 mL within the scale stated accuracy.

CONCLUSIONS

The Tanita infant digital scale accurately measures bottle TWs. The differences in parent infant/toddler TWs are within a clinically acceptable range.

Breastfeeding Intention and Breastfeeding Postpartum Outcomes between High-Risk and Low-Risk Pregnant Women: A Greek Prospective Cohort Study

BACKGROUND

This prospective cohort study, conducted from pregnancy to six months postpartum and grounded in STROBE methodology, quantitatively explores the relationship between antenatal breastfeeding intentions and subsequent breastfeeding outcomes among high-risk pregnant women, compared to a low-risk pregnancy group.

METHODS

The study was conducted in one of the largest public hospitals in Attica that provides care to pregnant women, enrolling 380 participants divided into high-risk (n = 200) and low-risk (n = 180) cohorts. Data were collected over 20 months (starting from the end of May 2020 until January 2022), spanning from pregnancy to six months postpartum, via comprehensive questionnaires.

RESULTS

Statistical analysis revealed a pronounced correlation between prenatal breastfeeding intentions and actual breastfeeding behaviors across both groups. Specifically, 81.1% of women in the high-risk group and 82.5% in the low-risk group expressed intentions of exclusively breastfeeding during pregnancy. By six months postpartum, 54.9% of the high-risk and 64.3% of the low-risk pregnancy group managed to sustain breastfeeding. Extended antenatal hospitalization emerged as a statistically significant factor (p = 0.045) negatively impacting exclusive breastfeeding intentions among high-risk pregnancies.

CONCLUSION

The findings illuminate the critical influence of antenatal intentions on breastfeeding outcomes, particularly among high-risk pregnancies. Moreover, the study identifies the detrimental effect of prolonged hospital stays on breastfeeding aspirations. These insights underscore the necessity for nuanced, supportive interventions aimed at bolstering breastfeeding rates, thereby advancing maternal and neonatal health objectives aligned with World Health Organization recommendations.

Perceived pressure to breastfeed negatively impacts postpartum mental health outcomes over time

Introduction

Positive maternal mental health is associated with improved outcomes for infants, and yet the consideration of maternal mental health is often neglected in breastfeeding interventions. Breastfeeding interventions typically focus on breastfeeding promotion, and do not always include supports for the mother. This may result in isolated perceived pressure to breastfeed, the mental health impacts of which are not well understood.

Methods

This mixed-methods, longitudinal study examined whether perceived pressure to breastfeed was associated with depression, suicide ideation, anxiety, birth trauma and stress concurrently and 4 weeks later for postpartum mothers. It also examined qualitative experiences of feeding.

Results

Perceived pressure to breastfeed was associated with increased anxiety, stress and birth trauma symptoms four weeks later. Thematic analysis suggested this may be due to difficulties living up to the "breast is best" ideal, believing breastfeeding was part of success as a mother, lack of choices and autonomy in feeding choices for infants and general lack of support.

Discussion

As such it appears we may be doing more harm than good by focusing our interventions for breastfeeding primarily on increasing pressure to breastfeed, and interventions should consider strategies for promoting positive maternal mental health alongside breastfeeding.

Effectiveness of a Postpartum Breastfeeding Support Group Intervention in Promoting Exclusive Breastfeeding and Perceived Self-Efficacy: A Multicentre Randomized Clinical Trial

There are numerous recognized benefits of breastfeeding; however, sociocultural, individual, and environmental factors influence its initiation and continuation, sometimes leading to breastfeeding rates that are lower than recommended by international guidelines. The aim of this study was to evaluate the effectiveness of a group intervention led by midwives supporting breastfeeding during the postpartum period in promoting exclusive breastfeeding, as well as to assess the impact of this intervention on perceived self-efficacy. This was a non-blind, multicentric, cluster-randomized controlled trial. Recruitment started October 2021, concluding May 2023. A total of 382 women from Andalusia (Spain) participated in the study. The results showed that at 4 months postpartum there was a higher prevalence of breastfeeding in the intervention group compared to formula feeding (p = 0.01), as well as a higher prevalence of exclusive breastfeeding (p = 0.03), and also at 6 months (p = 0.01). Perceived self-efficacy was similar in both groups for the first two months after delivery, which then remained stable until 4 months and decreased slightly at 6 months in both groups (p = 0.99). The intervention improved the average scores of perceived self-efficacy and indirectly caused higher rates of exclusive breastfeeding (p = 0.005). In conclusion, the midwife-led group intervention supporting breastfeeding proved to be effective at maintaining exclusive breastfeeding at 6 months postpartum and also at increasing perceived self-efficacy.

Laid-back breastfeeding: knowledge, attitudes and practices of midwives and student midwives in Ireland

BACKGROUND

Despite concerted efforts by policy developers, health professionals and lay groups, breastfeeding rates in Ireland remain one of the lowest in world, with 63.6% of mothers initiating breastfeeding at birth, dropping to 37.6% of mothers breastfeeding exclusively on hospital discharge. Nipple trauma and difficulties with baby latching are major contributors to the introduction of formula and discontinuation of breastfeeding. Research shows laid-back breastfeeding (LBBF) significantly reduces breast problems such as sore and cracked nipples, engorgement, and mastitis as well as facilitating a better latch. Although the benefits of LBBF are well documented, this position does not seem to be routinely suggested to mothers as an option when establishing breastfeeding. This study aims to determine midwives' and student midwives' knowledge, attitudes, and practices of using laid-back breastfeeding in Ireland.

METHOD

A cross-sectional descriptive survey distributed to midwives and student midwives in three maternity hospitals in Ireland and two online midwifery groups based in the Republic of Ireland, during June, July, and August 2021.

RESULTS

Two hundred and fifty-three valid responses were received from nine maternity units. Most participants (81.4%) were aware of laid-back breastfeeding. However, only 6.8% of respondents cited it as the position they most frequently use. Over one-third (38.34%) had never used this position with mothers. Those more likely to suggest LBBF had personal experience of it, were lactation consultants or working towards qualification, or had participated in specific education about LBBF. Barriers included lack of education, confidence, time, and experience. Further issues related to work culture, a tendency to continue using more familiar positions and concerns about mothers' anatomy and mothers' unfamiliarity with LBBF.

CONCLUSION

Although there was a high level of awareness of laid-back breastfeeding among midwives and student midwives, there are challenges preventing its use in practice. Education specifically related to using LBBF in practice is required to overcome the barriers identified. A greater understanding of mothers' and babies' intrinsic feeding capacities may give midwives more confidence to recommend this method as a first choice, potentially leading to more successful breastfeeding establishment and maintenance.

"I didn't want to let go of the dream": Exploring women's personal stories of how their low milk supply was discovered

PROBLEM

Low milk supply is the most common reason women give for stopping breastfeeding early and yet there is a lack of understanding about these women's experiences.

BACKGROUND

Most women plan to breastfeed but many experience challenges such as low milk production, leading them to seek help and support.

AIM

To explore women's personal stories of how their low supply was discovered.

METHODS

Inductive template analysis was used to analyse free-text online survey responses of women from the United States of America, Australia and the United Kingdom.

FINDINGS

384 women responded to the open-ended survey item between October 2021 and January 2022. We identified three themes: (i) Events and observations: From 'risk factors' to 'failure of breast changes' to 'my baby was so unhappy', (ii) Seeking support and taking action: 'I tried everything' and (iii) A rollercoaster of emotion: 'I didn't want to let go of the dream'.

DISCUSSION

Our findings emphasise women's need to feel heard and understood and their quest to find answers. The rollercoaster of emotions they experienced largely stemmed from a gap between the expectations and reality of breastfeeding. Some participants described accepting a different feeding journey.

CONCLUSION

Findings underscore the need for quality and accessible psychosocial support for women experiencing low milk supply, in addition to the provision of evidence-based advice.

Development and Validation of a Breastfeeding Health Literacy Scale (BFHLS) for Taiwanese Pregnant Women

BACKGROUND

Breastfeeding is the best source of nutrition for infants. Health literacy is a critical factor affecting breastfeeding rates.

RESEARCH AIMS

The aim of this research was to develop and test the Breastfeeding Health Literacy Scale to determine its validity and reliability.

METHODS

This study featured a cross-sectional telephone survey design. Researchers reviewed the literature and used expert opinions to develop the content-validated 30-item Breastfeeding Health Literacy Scale covering five dimensions. We examined internal consistency, exploratory factor analysis, and confirmatory factor analysis to assess reliability and construct validity. A Taiwanese government organization provided potential participants' contact information. After mailing an invitation letter, researchers phoned all participants to invite participation, obtain oral consent and complete a Breastfeeding Health Literacy Scale and collect demographic data.

RESULTS

Participants (N = 300) had a mean age of 31.8 (SD = 4.66) years. The item-level content validity index was 0.67 to 1.00 and scale-content validity index was 0.94. After performing exploratory factor analysis, three factors were extracted. Examining content factor analysis for the three factors resulted in χ2/df = 2.05; p < .001; goodness of fit index = 0.90; Comparative Fit Index (CFI) = 0.96; and Root Mean Square Error of Approximation (RMSEA) = 0.06. Cronbach's alphas on the total scale and the subscales ranged from 0.87 to 0.94. Women with multigravida, breastfeeding information from physicians and nurses, and previous breastfeeding experience had better breastfeeding health literacy.

CONCLUSIONS

Psychometric analysis demonstrated that the newly developed 20-item Breastfeeding Health Literacy Scale is a valid self-assessment instrument. Improving breastfeeding health literacy during pregnancy could help enable breastfeeding success.

New Validated Tool to Diagnose Breastfeeding Dysfunction

BACKGROUND

Breastfeeding behaviors and experiences exist on a continuum. What differentiates normal from dysfunctional is defined by frequency and severity. No current validated tool addresses the subjective experience of dyads with a predictive score that can be followed over time.

RESEARCH AIM

To create and validate a self-report tool to assess breastfeeding and evaluate its ability to predict risk of breastfeeding dysfunction.

METHODS

This study used a cross-sectional design to determine the validity of a novel instrument to assess breastfeeding dysfunction. We gave the initial questionnaire to 2085 breastfeeding dyads. We assessed content validity by comparison with other tools. We used exploratory factor analysis with varimax rotation for concept identification and Cronbach's alpha for internal consistency. We employed logistic regression to assess the tool's ability to differentiate between normal breastfeeding and breastfeeding dysfunction.

RESULTS

Factor analysis mapped 17 questions to four concepts to create a score (FLIP; flow, latch, injury [to the nipple], and post-feed behavior). Internal consistency and reliability of the scores in these concepts were acceptable (Cronbach's alpha ≥ 0.087 for all measures). A logistic regression model that controlled for infant age, with a breastfeeding dysfunction risk classification threshold of 60%, yielded a correct classification of 88.7%, with 93.1% sensitivity, 64.6% specificity, and a 6.5% false positive rate.

CONCLUSIONS

The FLIP score was determined to be a valid and reliable instrument for quantifying the severity of breastfeeding dysfunction in children under 1 year old. Further studies will assess its usefulness in the management of breastfeeding dysfunction.

An Educational Intervention to Explore and Overcome Nursing Students' Breastfeeding Barriers: A Mixed-Methods Quasi-experimental Study

BACKGROUND

Nursing and midwifery students do not feel adequately prepared during their clinical training to support women who breastfeed, demanding more effective communication skills and knowledge.

AIM

The aim was to evaluate changes in students' breastfeeding knowledge.

METHODS

This was a mixed-methods quasi-experimental design. Forty students voluntarily participated. Using a 1:1 ratio, 2 groups were randomly created and completed the validated questionnaire ECoLaE (pre-post). The educational program consisted of focus groups, a clinical simulation, and a visit to the local breastfeeding association.

FINDINGS

The control group's posttest scores ranged from 6 to 20 (mean = 13.1, standard deviation [SD] = 3.0). The intervention group ranged from 12 to 20 (mean = 17.3, SD = 2.3). A Student's t test for independence samples was calculated ( P < .005, t = 4.5, median = 4.2). The intervention group had a mean difference of 10 points in improvement (mean =10.53, SD = 2.20, min = 7, max = 14), whereas the control group had a mean of 6 points (mean = 6.80, SD = 3.03, min = 3, max = 13). The multiple linear regression explained the intervention's effect. The regression model had statistical significance ( F = 4.87, P = 0.004), with an adjusted R2 = 0.31. The linear regression between the posttest scores and group variables after adjusting by age showed an increment of 4.1 points in the intervention posttest scores ( P < .005, 95% confidence interval [CI] = 2.1-6.1).

CONCLUSIONS

The educational program "Engage in breaking the barriers to breastfeeding" improved nursing students' knowledge.

Understanding the pathway between work and health outcomes for women during the preconception, pregnancy, and postpartum periods through the framing of maternal obesity

The link between work and health outcomes for preconception, pregnant, and postpartum (PPP) working women is complex. Further, innovation and enhanced understanding are required to address the work-related determinants of maternal obesity. However, workplace health promotion is not typically systems-based nor attuned to the specific needs and context of individual PPP women. We propose that to improve health outcomes for PPP women, we must understand the pathways between paid work and health for the individual woman by taking a systems-thinking approach. In this paper, we (a) outline the rationale for why the oversimplification or "dilution" of individual context may occur; (b) present a systems-informed pathway model (the "Context-Exposure-Response" Model) and overview of potential work-related impacts on health and wellbeing outcomes for PPP women using maternal obesity to provide context examples; (c) further investigate the role of motivational factors from a systems perspective; and (d) briefly examine the implications for policy, practice, and intervention design. It is anticipated that this research may act as a starting point to assist program developers, researchers, and policymakers to adopt a systems-focused perspective while contributing to the health improvement and obesity prevention of PPP women.

Continuous Lactation Support Provided Through the WhatsApp Messaging Application: A Randomized Controlled Trial

BACKGROUND

Although WhatsApp can be used to provide continuous lactation support, there are few studies on this subject.

RESEARCH AIMS

To determine the influence of lactation support provided through WhatsApp on the duration and exclusivity of breastfeeding, initiation of complementary feeding, breastfeeding problems, breastfeeding difficulties score, and the use of bottles and pacifiers.

METHODS

We conducted a randomized controlled trial assessing the efficacy of education and support provided through the cell phone based WhatsApp application. There were 129 primiparous participants recruited while attending a Baby-Friendly Hospital in Istanbul, Turkey. Participants were randomized to intervention (n = 64) and control (n = 65) groups. All participants received the same routine postpartum breastfeeding education in the hospital, and the intervention group received additional continuous breastfeeding education for 6 months. For both groups, data was collected by telephone interview on Days 7 and 15, and Months 1, 2, 4, and 6 months. T-tests were used to assess inter-group differences in duration of exclusivity of breastfeeding. Mixed-model ANOVA was used to compare breastfeeding difficulties scores. Chi-square tests were used to compare breastfeeding problems, feeding practices, and the proportion of the use of bottles and pacifiers.

RESULTS

The mean duration of exclusive breastfeeding for groups receiving breastfeeding support was higher (4.75, SD = 1.72) than that of the control group (2.21, SD = 1.98; p = 0.001). The change in the mean breastfeeding difficulties severity score between the initial and final measurements (17.03, SD = 8.66) was more in the intervention group than the control group (11.42, SD = 10.34, F = 4.081, p = 0.001). The proportion of exclusive breastfeeding in the 6th month was higher in the intervention group (62.5%) than in the control group (10.8%; p = 0.001).

CONCLUSIONS

The use of cellphone applications are accessible to both patients and health workers and offer a low-cost alternative for providing uninterrupted breastfeeding support.

Barriers to optimal breastfeeding of medically complex children in the UK paediatric setting: a mixed methods survey of healthcare professionals

BACKGROUND

Breastfeeding is indisputably significant for infants and children, as well as their mothers. However, when breastfed children are admitted to the paediatric ward, they may experience breastfeeding modification due to clinical challenges, lack of staff training and institutional barriers. Although previous research has identified multiple barriers to optimal feeding within the maternity, neonatal and community settings, we know less about the barriers that exist in paediatrics. Paediatric healthcare staff attitudes, training and awareness as well as ward culture are likely to have an impact on the experiences of families but are relatively unresearched in the paediatric setting, especially with regard to the multidisciplinary nature of clinical paediatric care. The aim of this study was to explore the attitudes, awareness and perceived barriers to effective breastfeeding support provision, as well as healthcare professional perception of barriers for families.

METHODS

This was a mixed methods study utilising a questionnaire which was completed by 409 healthcare professionals who identified as working within the paediatric setting. It included responses from paediatricians of all training grades, nurses, healthcare assistants and allied health professionals. Qualitative data from professionals were analysed to develop themes around professional and perceived parent barriers to optimal breastfeeding.

RESULTS

This study explored the barriers experienced by staff, as well as professionals' perception of parent barriers. These included lack of knowledge of how to help, a default formula culture, the pressure of maintaining strict fluid balance and breastfeeding being a low priority in the face of critical illness. Of the paediatric departments represented by this sample of healthcare professionals, most had a relatively poor culture of supporting breastfeeding, with multiple institutional barriers identified. Most professionals felt that there was not enough support for breastfeeding families on an average shift, and a large proportion identified as being one of just a few breastfeeding advocates on their ward.

CONCLUSION

In this relatively motivated and experienced sample of healthcare professionals, there were many identified barriers to optimal breastfeeding which could potentially be addressed by training that is carefully nuanced for the paediatric population. Ensuring that paediatric multidisciplinary healthcare professionals have sufficient skills and knowledge would address the identified challenge of poor awareness of breastfeeding and of how to overcome clinical lactation obstacles. Further improvements at policy level need to address the systemic lack of resourcing in paediatrics, as well as the lack of embedded breastfeeding-friendly organisational structures.

Maternal serum per- and polyfluoroalkyl substances during pregnancy and breastfeeding duration

Per- and polyfluoroalkyl substances (PFAS) are endocrine-disrupting chemicals that may affect breastfeeding duration. We examined associations between maternal PFAS concentrations during pregnancy and breastfeeding cessation. We investigated potential effect modification by parity status.

Methods

Among 555 women enrolled in the Healthy Start study (2009-2014), we quantified maternal serum concentrations of 5 PFAS during mid- to late-pregnancy (mean 27 weeks of gestation). Participants self-reported their breastfeeding practices through 18-24 months postnatally. Among all participants and stratified by parity, we estimated associations between maternal PFAS concentrations and breastfeeding discontinuation by 3 and 6 months, using Poisson regression, and breastfeeding duration, using Cox regression.

Results

Median PFAS concentrations were similar to those in the general US population. Associations between PFAS and breastfeeding duration differed by parity status. After adjusting for covariates, among primiparous women, associations between PFAS and breastfeeding cessation by 3 and 6 months were generally null, with some inverse associations. Among multiparous women, there were positive associations between perfluorohexane sulfonate, perfluorooctane sulfonate, perfluorooctanoate (PFOA), and perfluorononanoate and breastfeeding cessation by 3 and 6 months. For example, per ln-ng/mL increase in PFOA, the risk ratio for breastfeeding discontinuation by 6 months was 1.45 (95% confidence interval, 1.18, 1.78). Hazard ratios reflected similar patterns between PFAS and breastfeeding duration.

Conclusions

Among primiparous women, we did not find evidence for associations between PFAS concentrations and breastfeeding duration. In contrast, among multiparous women, PFAS serum concentrations were generally inversely associated with breastfeeding duration, though estimates may be biased due to confounding by unmeasured previous breastfeeding.

University campus breastfeeding, knowledge, and perceptions of support: An exploratory study

Breastfeeding is often considered principally a biological issue but success is impacted by the socio-ecological environment of the lactating parent. Identifying current attitudes towards breastfeeding is essential in the effort toward normalizing breastfeeding in communities, including university campuses. The study explored campus community knowledge, awareness, and attitudes about breastfeeding, including available resources and applicable laws on two university campuses in the southern United States. This cross-sectional, self-reporting study utilized the Iowa Infant Feeding Attitude Scale and an adaptation of the Breastfeeding Behavior Questionnaire to survey a convenience sample. Results revealed decreased awareness of protective laws, availability of private lactation space, and insufficient public appreciation of breastfeeding's unique advantages to both lactating parent and infant as barriers to breastfeeding. These findings will help develop additional breastfeeding strategies to improve university campus community breastfeeding initiatives.

No such thing as a free lunch: The direct marginal costs of breastfeeding

Understanding costs associated with breastfeeding is critical to developing maximally effective policy to support breastfeeding by addressing financial barriers. Breastfeeding is not without cost; direct costs include those of equipment, modified nutritional intake, and time (opportunity cost). Breastfeeding need not require more equipment than formula feeding, though maternal equipment use varies by maternal preference. Meeting increased nutritional demands requires increased spending on food and potentially dietary supplementation, the marginal cost of which depends on a mother's baseline diet. The opportunity cost of the three to four hours per day breastfeeding demands may be prohibitively high, particularly to low-income workers. These costs are relatively highest for low-income individuals, a group disproportionately comprising racial and ethnic minorities, and who demonstrate lower rates of breastfeeding than their white and higher-income peers. Acknowledging and addressing these costs and their regressive nature represents a critical component of effective breastfeeding policy and promotion.

Tethered Oral Tissue Release Among Breastfed Infants: Maternal Sources of Information and Treatment

BACKGROUND

Despite limited clinical consensus regarding surgery for tethered oral tissues ("tongue-tie") for resolving breastfeeding-related issues, the procedure has been increasing in the United States. Greater understanding of maternal experiences with obtaining surgical release may help to improve breastfeeding outcomes.

RESEARCH AIM

To explore experiences of breastfeeding mothers with infants having undergone "tongue-tie" surgery.

METHOD

This online, cross-sectional, observational survey occurred between August and September 2020. Eligibility included being ≥ 18 years of age and previously or currently breastfeeding an infant with ≥ 1 tissue surgically released. Of 463 screens, 318 mothers were eligible and 115 consented. The final sample was 90.

RESULTS

The sample was predominantly white (n = 86; 95%), non-Hispanic (n = 84; 93%), married/cohabitating (n = 85; 94%), and currently providing their own milk (n = 81; 89%).Difficult latch was the primary reason for seeking help. Participants reported lingual (n = 84; 93%), labial (n = 79; 88%), and buccal (n = 16; 17%) tissue-release, with 80% (n = 73) reporting > 1 released. For each tissue released, > 80% (n = 72) of participants felt "very confident" in their ability to correctly identify it and 97% (n = 87) felt "very involved" and "strongly agreed" with surgical release. International Board Certified Lactation Consultants^® were the most frequently identified source of information (n = 45; 50%) and referrals (n = 38; 42%), while pediatric dentists most frequently performed interventions (n = 60; 67%).

CONCLUSIONS

Participants reported being confident, involved, and in agreement with surgical release and lactation support professionals were frequent information and referral sources.

Effectiveness of a community-based support programme to reduce social inequality in exclusive breastfeeding: study protocol for a cluster-randomised trial

BACKGROUND

Breastmilk is the ideal nutrition for infants, and breastfeeding protects infants and mothers from a range of adverse health outcomes. In Denmark, most mothers initiate breastfeeding but many cease within the first months resulting in just 14% reaching the World Health Organization recommendation of six months of exclusive breastfeeding. Furthermore, the low breastfeeding proportion at six months is characterised by a marked social inequality. A previous intervention tested in a hospital setting succeeded in increasing the proportion of mothers breastfeeding exclusively at six months. However, most breastfeeding support is provided within the Danish municipality-based health visiting programme. Therefore, the intervention was adapted to fit the health visiting programme and implemented in 21 Danish municipalities. This article reports the study protocol, which will be used to evaluate the adapted intervention.

METHODS

The intervention is tested in a cluster-randomised trial at the municipal level. A comprehensive evaluation approach is taken. The effectiveness of the intervention will be evaluated using survey and register data. Primary outcomes are the proportion of women who breastfeed exclusively at four months postpartum and duration of exclusive breastfeeding measured as a continuous outcome. A process evaluation will be completed to evaluate the implementation of the intervention; a realist evaluation will provide an understanding of the mechanisms of change characterising the intervention. Finally, a health economic evaluation will assess the cost-effectiveness and cost-utility of this complex intervention.

DISCUSSION

This study protocol reports on the design and evaluation of the Breastfeeding Trial - a cluster-randomised trial implemented within the Danish Municipal Health Visiting Programme from April 2022 to October 2023. The purpose of the programme is to streamline breastfeeding support provided across healthcare sectors. The evaluation approach is comprehensive using a multitude of data to analyse the effect of the intervention and inform future efforts to improve breastfeeding for all.

TRIAL REGISTRATION

Prospectively registered with Clinical Trials NCT05311631 https://clinicaltrials.gov/ct2/show/NCT05311631.

Comparing Experiences of Women Who Were Direct Breastfeeding and Women Who Used Expressed Breast Milk to Feed Their Infants

PURPOSE

To provide understanding about feeding experiences of women who provide breast milk through direct breastfeeding and exclusive expression and to compare these experiences.

STUDY DESIGN AND METHODS

A qualitative study was conducted to gather experiences from the perspectives of women who had given birth to a healthy, term infant within the past 12 months and exclusively fed breast milk for at least 2 weeks. The sample was recruited from motherhood and breastfeeding support groups on Facebook. Groups had state- or national-based memberships. Interviews were examined for themes that were compared between feeding groups using thematic analysis.

RESULTS

Fifteen new mothers participated. Under the primary themes of Similarities and Differences, seven subthemes were identified: Fatigue, Importance of Support, Finding Joy in a Common Goal, Mixed Feelings, Trusting versus Tracking, Latching versus Body Failure, and Pumping in Isolation.

CLINICAL IMPLICATIONS

Mothers who provide breast milk share common experiences and feelings of satisfaction. Expressed breast milk feeding offers some mothers a way to provide the benefits of breast milk while preserving a balance between maternal and infant physical and mental health needs. Understanding the different ways in which women manage breast milk feeding while balancing maternal and infant needs can prepare nurses to discuss various methods of breast milk feeding and provide individualized support.

Women's experiences with using domperidone as a galactagogue to increase breast milk supply: an australian cross-sectional survey

BACKGROUND

Domperidone is one of the most commonly utilised pharmacological galactagogues, with evidence of increasing use in clinical practice. However, the use of domperidone as a galactagogue remains controversial, with mixed evidence on safety and efficacy, leading to variable clinical practice recommendations. We sought to evaluate contemporary patterns of domperidone use and examine maternal experiences related to perceived safety and effectiveness.

METHODS

In 2019, we conducted an online, cross-sectional survey of Australian breastfeeding women to examine individual experiences related to domperidone use, in addition to perceptions of safety and effectiveness.

RESULTS

Among 1876 survey responses, 19% (n = 355) reported using domperidone. Domperidone use was significantly higher in women who were primiparous, gave birth preterm, delivered by caesarean section, had self-perceived low milk supply, and saw a lactation consultant. Nearly 20% of women commenced domperidone use in the first week postpartum (19%, n = 67). The median duration of use was six weeks (interquartile range 3-16 weeks). Maximum reported doses of domperidone used ranged from 20 mg/day to 160 mg/day. Half (n = 178, 50%) of women reported using a dose of 30 mg/day or less, 44% (n = 155) reported using a dose between 31 and 60 mg/day, and 6% (n = 22) reported using a dose greater than 61 mg/day. Nearly half of the respondents reported domperidone as 'very' or 'extremely effective' (45%, n = 161), with only 8% (n = 27) reporting it was 'not at all effective'. Almost half (n = 172, 48%) of all women using domperidone reported side effects, including weight gain (25%), headaches (17%) and dry mouth (13%). Higher doses were associated with an increased likelihood of any side effects (≤ 30 mg/day, 38%; >31-≤60 mg/day, 48%, > 61 mg/day 73%; P < 0.004), with 31 (9%) stopping domperidone because of side effects.

CONCLUSION

We identified widespread variation in domperidone utilisation patterns, with domperidone broadly perceived to be effective in increasing breast milk supply. Side effects associated with domperidone treatment were common, appeared to be dose-related, and were frequently associated with treatment cessation. These findings highlight the importance of improved clinical practice recommendations and generation of evidence from additional high-quality clinical trials evaluating the efficacy and safety of domperidone. More conclusive clinical trials are needed to determine the efficacy, as well as optimal dose and duration, of domperidone use.

Exploring the reasons why mothers do not breastfeed, to inform and enable better support

Introduction

Infant and maternal breastfeeding benefits are well documented, globally. Despite efforts to increase global breastfeeding rates, the majority of high-income settings fall short of recommended targets. Breastfeeding rates in the UK are especially poor, and physiological difficulties (e.g., inverted nipples), fail to account for the observed breastfeeding intention-behaviour gap.

Method

The current online study sought to investigate the infant feeding experiences of 624 UK formula feeding mothers, through open text survey responses.

Results

A content analysis identified the following clusters of reasons for formula feeding: Feeding Attitudes, Feeding Problems, Mental Health, and Sharing the Load.

Discussion

Feeding Attitudes explained a large percentage of reasons given for formula feeding. Recommendations are made to improve antenatal breastfeeding education and to develop an intervention with an aim to improve maternal breastfeeding attitudes and subsequent practice. Feeding Problems also explained a large portion of combination feeding and started but stopped infant feeding accounts. The current paper calls for more comprehensive and tailored antenatal breastfeeding education to refine practical breastfeeding skills necessary for successful breastfeeding establishment and maintenance. Mental Health explained relatively small coverage. Suggestions are therefore made to train mental health practitioners on infant feeding with an aim to provide more extensive support, which may serve to disrupt the bidirectional relationship between poor mental health and poor breastfeeding outcomes. Finally, Sharing the Load explained moderate coverage across never breastfed, combination fed, and started but stopped feeding groups. Recommendations are made, in light of these findings, to tighten workplace legislation to protect breastfeeding women.

Initiating and Supporting Breastfeeding: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Exclusive breastfeeding is recommended for children for the first 4 to 6 months of life, with complementary foods added thereafter. It is the most ecological way of protecting the child's and mother's health. Training of health professionals is required to avoid transmitting inconsistent information in 3 areas: 1) implementing these 3 predictors: safe skin-to-skin, first breastfeed, and rooming-in 24/7; 2) teaching and monitoring: i) early signs of waking and feeding rhythms, ii) positioning and latching, and iii) signs of effective transfer; and 3) referring women to specialized support services if difficulties arise (eg, inadequate milk production, pain, cracked nipples, engorgement). Breastfeeding should continue during mastitis or an abscess. Ultrasound-guided needle aspiration is beneficial in treating an abscess. Précis: Information is provided to enable health professionals to better support breastfeeding and help women with the most common difficulties, thus promoting breastfeeding initiation and duration.

Muslim women's attitudes toward infant feeding in Qatar: An exploration using the Iowa infant feeding attitude scale

BACKGROUND

Maternal attitude toward infant feeding is an important determinant of breastfeeding. The Islamic faith encourages breastfeeding, yet many Muslim women do not breastfeed as per the World Health Organization recommendations. In the Middle East, research has not addressed attitudes toward infant feeding among Muslim women. Assessing women's attitudes toward infant feeding choices is crucial to improve breastfeeding rates among Muslim women.

AIM

The aims of this study are to (a) examine postpartum Muslim women's attitudes toward infant feeding, (b) identify the determinants of these attitudes, and (c) determine whether attitudes can predict breastfeeding intention among Muslim women. A secondary aim is to examine the psychometric attributes of the Iowa Infant Feeding Attitude Scale among Muslim women.

METHOD

A convenience sample of postpartum Muslim women (N = 414) were recruited between November 2019 and January 2020 in a large maternity facility in Qatar. A pre-developed questionnaire and the IIFAS were used to collect data. Both Arabic (n = 228) and English (n = 186) versions of the IIFAS were distributed postnatally to measure Muslim women's attitudes towards breastfeeding. A total attitude score was computed with higher scores indicating a more positive attitude toward breastfeeding.

FINDINGS

The mean age of participants was 30.3 ± 5.2 years; 65.2% had a university degree and only 20.5% were employed. The mean attitude score was 61.8 ± 7.8. A significant association was found between the IIFAS attitude score and ethnicity, favouring Non-Qatari Arab women who had significantly higher attitude scores (p < .001). Women with full-time or part-time work had significantly higher scores than those not working (p = .008, p = .023). Older women had significantly lower attitude scores (adjusted slope = -0.230, p = .008). Cronbach's alpha reliability coefficient of the Arabic and English versions of the IIFAS ranged from 0.69 to 0.80.

CONCLUSION

Ethnicity, employment status, and age are determinants of infant feeding attitudes among Muslim women. In Qatar, Muslim women's attitudes related to breastfeeding trend toward positive; however, attitude is not a predictor of antenatal breastfeeding intention. Further research employing a larger sample with a focus on a culturally sensitive approach is recommended. The IIFAS has a moderate reliability level and needs to be culturally adapted to be used among a Muslim population.

Lactation Outcomes After Participation in a Tailored Prenatal Nutrition Consultation Among Women With Infants With Congenital Anomalies

OBJECTIVE

To describe lactation outcomes among of a cohort of mother-infant dyads in which the women had an individualized prenatal nutrition consultation intervention.

DESIGN

Descriptive cohort study.

SETTING

A free-standing children's hospital with a center for fetal diagnosis and treatment and a specialized maternity unit.

PARTICIPANTS

A total of 160 women who had prenatal nutrition consultations in 2014 to 2017 and gave birth to infants with known congenital anomalies and required intensive care after birth.

METHODS

We surveyed women regarding their lactation outcomes after the Breastfeeding Report Card metrics of the Centers for Disease Control and Prevention and obtained permission to abstract demographic and clinical information from the setting's electronic health record. We analyzed data with standard descriptive statistics.

RESULTS

Among the cohort, 86.9% (n = 139) of participants intended to provide human milk or combination feeding in the prenatal period. A total of 128 (92.1%) infants were first exposed to human milk enterally. At the time of discharge, 92.1% (n = 128) of the infants received human milk. The breastfeeding outcomes of the cohort significantly surpassed national data: initiation (98.1% vs. 84.1% national), breastfeeding at 3 months (89.4%), exclusive breastfeeding at 3 months (60% vs. 46.9% national), breastfeeding at 6 months (76.9% vs. 58.3% national), exclusive breastfeeding at 6 months (45% vs. 25.6% national), breastfeeding at 12 months (50.6% vs. 35.3% national), and breastfeeding beyond 12 months (34.4%).

CONCLUSIONS

Lactation outcomes among women who had prenatal nutrition consultations far surpassed national data, and this intervention has implications for family-centered prenatal care, informed decision making, and improved breastfeeding outcomes in the hospital setting and postdischarge.

Investigating the Impact of Moringa oleifera Supplemented to Kenyan Breastfeeding Mothers on Maternal and Infant Health: A Cluster Randomized Single-Blinded Controlled Pilot Trial Protocol

Undernutrition contributes to up to 45% of deaths globally in children <5 years, with an optimal time for intervention before 24 months of age. Breastmilk microbiome helps establish the infant intestinal microbiome and impacts infant intestinal and nutritional health. Inadequacies in breastmilk composition such as low vitamin A contribute to infant nutrient deficiencies. Changes in milk fatty acid composition (reduced saturated and increased unsaturated fatty acids) may reduce susceptibility to enteric infection and increase protective intestinal bacteria. Moringa oleifera leaves (moringa) provide high nutrient concentrations (including protein, iron, vitamin A) and increase milk production; this may enhance breastmilk quantity and quality and improve infant health.

Objective

To investigate the role of moringa supplementation to improve maternal and infant nutritional and intestinal health via changes in maternal milk quantity and quality.

Methods

Fifty mother-infant pairs exclusively breastfeeding will be enrolled in a single-blinded randomized controlled trial in Kombewa County Hospital and Chulaimbo SubCounty Hospital, Kisumu, Kenya.

Intervention

Dietary Supplementation of 20 g of Moringa oleifera leaf powder divided twice daily in corn porridge consumed daily for 3 months while control comparator will receive porridge daily for 3 months.

Outcomes

Change in infant growth and maternal milk output (primary); maternal and infant vitamin A and iron status, changes in infant and maternal intestinal health (secondary).

Participating Centers

Pamoja Community Based Organization, Kombewa Sub-County Hospital, and Chulaimbo Sub-County Hospital.

Young Child Nutrition: Knowledge and Surveillance Gaps across the Spectrum of Feeding

The first 1000 days is a critical window to optimize nutrition. Young children, particularly 12-24 month-olds, are an understudied population. Young children have unique nutrient needs and reach important developmental milestones when those needs are met. Intriguingly, there are differences in the dietary patterns and recommendations for young children in the US vs. globally, notably for breastfeeding practices, nutrient and food guidelines, and young child formulas (YCFs)/toddler drinks. This perspective paper compares these differences in young child nutrition and identifies both knowledge gaps and surveillance gaps to be filled. Parental perceptions, feeding challenges, and nutrition challenges are also discussed. Ultimately, collaboration among academia and clinicians, the private sector, and the government will help close young child nutrition gaps in both the US and globally.

Feasibility of the automatic ingestion monitor (AIM-2) for infant feeding assessment: a pilot study among breast-feeding mothers from Ghana

OBJECTIVE

Passive, wearable sensors can be used to obtain objective information in infant feeding, but their use has not been tested. Our objective was to compare assessment of infant feeding (frequency, duration and cues) by self-report and that of the Automatic Ingestion Monitor-2 (AIM-2).

DESIGN

A cross-sectional pilot study was conducted in Ghana. Mothers wore the AIM-2 on eyeglasses for 1 d during waking hours to assess infant feeding using images automatically captured by the device every 15 s. Feasibility was assessed using compliance with wearing the device. Infant feeding practices collected by the AIM-2 images were annotated by a trained evaluator and compared with maternal self-report via interviewer-administered questionnaire.

SETTING

Rural and urban communities in Ghana.

PARTICIPANTS

Participants were thirty eight (eighteen rural and twenty urban) breast-feeding mothers of infants (child age ≤7 months).

RESULTS

Twenty-five mothers reported exclusive breast-feeding, which was common among those < 30 years of age (n 15, 60 %) and those residing in urban communities (n 14, 70 %). Compliance with wearing the AIM-2 was high (83 % of wake-time), suggesting low user burden. Maternal report differed from the AIM-2 data, such that mothers reported higher mean breast-feeding frequency (eleven v. eight times, P = 0·041) and duration (18·5 v. 10 min, P = 0·007) during waking hours.

CONCLUSION

The AIM-2 was a feasible tool for the assessment of infant feeding among mothers in Ghana as a passive, objective method and identified overestimation of self-reported breast-feeding frequency and duration. Future studies using the AIM-2 are warranted to determine validity on a larger scale.

A behavioral economic demand analysis of mothers' decision to exclusively breastfeed in the workplace

The present study determined whether behavioral economic demand analysis could characterize mothers' decision to exclusively breastfeed in the workplace. Females, aged between 18 and 50 who have given birth in the past three years, completed a novel demand task with hypothetical scenarios, in which they returned to work with a 2-month-old baby. Participants rated their likelihood of breastfeeding their baby at a workplace lactation room versus formula-feeding their baby at their desk. The distance to the lactation room ranged from 10 s to 60 min. This assessment was conducted with and without hypothetical financial incentives for 6-month exclusive breastfeeding. Primary dependent measures were demand intensity and change in demand elasticity, which could conceptually represent initiation and continuation of breastfeeding, respectively. Demand for breastfeeding was more intense and less elastic (i.e., more likely to initiate and continue breastfeeding) among mothers with an experience of 6-month exclusive breastfeeding and under the condition with the financial incentives. The novel demand task can potentially provide a useful behavioral marker for quantifying mothers' decision to initiate and continue exclusive breastfeeding in the workplace, informing workplace policy regarding lactation rooms, identifying risk for early cessation, and developing and individualizing an intervention to assist mothers to exclusively breastfeed in the workplace.

The Role of Motor Coordination, ADHD-Related Characteristics and Temperament among Mothers and Infants in Exclusive Breastfeeding: A Cohort Prospective Study

Although exclusive breastfeeding is recommended for the first 6 months of life, breastfeeding rates are low. Motor skills and ADHD-related characteristics have not yet been examined as breastfeeding barriers. The aim of this study was to explore whether mothers' and infants' motor skills, mothers' ADHD-related characteristics and infants' temperament are associated with exclusive breastfeeding at 6 months after birth. Participants were 164 mothers and their infants recruited 2 days after birth. Mothers completed a demographic and delivery information questionnaire, the Infant Feeding Intentions Scale and the Iowa Infant Feeding Attitude Scale. At 6 months, mothers completed the Adult DCD (developmental coordination disorder)/Dyspraxia Checklist, the Adult ADHD (attention deficit hyperactivity disorder) Self-Report Scale Symptom Checklist-v1.1, and the Infant Characteristics Questionnaire, and provided information about their breastfeeding status. They were then divided into two groups accordingly: EBF (exclusive breastfeeding) and NEBF (non-exclusive breastfeeding). Infants were observed using the Test of Sensory Functions in Infants and the Alberta Infant Motor Scale. At 6 months, NEBF mothers reported higher prevalence of DCD (10.2% vs. 1.9%, χ2 = 5.561, p = 0.018) and ADHD (20.3% vs. 8.6%, χ2 = 4.680, p = 0.030) compared to EBF mothers. EBF infants demonstrated better motor coordination (t = 2.47, p = 0.016, d = 0.511), but no temperament differences compared to NEBF infants. Maternal DCD, ADHD and poor infant motor coordination are associated with non-exclusive breastfeeding and may become exclusive breastfeeding barriers. These findings may assist in identifying women at risk of not exclusively breastfeeding and encourage tailoring interventions for achieving higher exclusive breastfeeding rates.

A Retrospective Cohort Study of the Impact of Upper Lip Tie Release on Breastfeeding in Infants

Objectives: Lingual frenotomies for the purpose of improving infant breastfeeding remain controversial, whereas maxillary frenotomies are even more so given the scant data and differing opinions on the matter. This study aimed at further elucidating the effect that maxillary frenula have on breastfeeding difficulties in infants. Methods: A retrospective chart review was performed on infants approximately aged 0-3 months who presented to a tongue tie/breastfeeding clinic from January to December of 2019. All analyzed infants had both lip and tongue ties classified by a clinician. Data on pre-frenotomy pain scores, lingual Coryllos classification, maxillary Kotlow classification, post-frenotomy complications, and breastfeeding success were captured. Results: Of the 316 infants, 224 underwent their first procedure at the tongue tie/breastfeeding clinic. Two hundred eleven out of 224 infants received a lingual frenotomy only, whereas the remaining 13 (5.8%) underwent both lingual and maxillary frenotomy procedures. Of the group of 211, 207 (98.1%) had successful feeding after 1 procedure; the remaining 4 underwent revision procedures to achieve successful feeding. All maxillary frenulum releases (n = 13) led to successful feeding without the need for revision procedures. Coryllos and Kotlow classification scores were significantly higher in the infants receiving both a maxillary and lingual frenulum release as compared with those receiving solely a lingual frenulum release. Conclusions: The majority (98.1%) of infants receiving a lingual frenulum release alone had successful feeding after only one procedure, and only 5.8% of all infants receiving any intervention required a maxillary frenulum release for successful feeding, calling into question the relative necessity of performing maxillary frenulum releases for breastfeeding difficulties.

Breastfeeding initiation and duration after high exposure to perfluoroalkyl substances through contaminated drinking water: A cohort study from Ronneby, Sweden

BACKGROUND

The drinking water in parts of Ronneby was heavily contaminated with perfluoroalkyl substances (PFAS) for decades. Although PFAS has endocrine-disrupting properties and may interfere with breastfeeding, the effects in populations with a point source of high exposure are unknown.

OBJECTIVES

To investigate associations between high PFAS exposure and 1) initiation and 2) duration of breastfeeding.

METHODS

We retrieved data on infant feeding practices for 2374 children born between 1999 and 2009 from Child Health Care centers in Ronneby and a reference municipality. Residential address before delivery was used as a proxy for exposure, and confounders were obtained from charts and registers. We used modified Poisson regressions to estimate the relative risks (RR) of not initiating breastfeeding, not breastfeeding exclusively after 3 months, and not breastfeeding at all at 6 months. We also estimated hazard ratios (HR) of cessation of exclusive breastfeeding before 6 months and any breastfeeding before 12 months.

RESULTS

Mothers who had received contaminated water seemed to have a higher risk of not initiating breastfeeding (RR = 2.4; 95% CI: 0.8, 6.7). Primiparous mothers from the exposed area were at a 1.2 times increased risk (95% CI: 0.9, 1.6) of not exclusively breastfeeding at 3 months and a 1.6 times increased risk (95% CI: 1.2, 2.1) of not breastfeeding at 6 months. The results were confirmed by the Cox regressions, which further showed that the HR for cessation of any breastfeeding was time dependent and higher in early lactation, thereafter decreasing as lactation progressed. We observed no overall associations in multiparous mothers.

DISCUSSION

Exposure to high levels of PFAS seemed to be associated with increased risks of not initiating breastfeeding and shorter breastfeeding duration in primiparous mothers. The findings imply that the ability of first-time mothers to establish breastfeeding is a sensitive outcome after high exposure to PFAS.

Evolution of breastfeeding indicators and early introduction of foods in Latin American and Caribbean countries in the decades of 1990, 2000 and 2010

Background

Early introduction of liquid/solid food before 6 months of age is one of the major barriers to exclusive breastfeeding. Our objective was to analyze the evolution of infant feeding practices for infants under 6 months of age in Latin American and Caribbean countries in the decades of 1990, 2000 and 2010.

Method

Cross-sectional time series study with data from Demographic and Health Surveys carried out between 1990 and 2017 in six Latin America and Caribbean countries: Bolivia (1994 to 2008), Colombia (1995 to 2010), Dominican Republic (1996 to 2013), Guatemala (1995 to 2015), Haiti (1994/1995 to 2016/2017), Peru (1996 to 2018). Pooled sample comprised of 22,545 infants under the age of 6 months. Surveys were grouped in three decades: 1990s for surveys from 1990 to 1999, 2000s for surveys from 2000 to 2009, and 2010s for surveys from 2010 to 2017. Exclusive breastfeeding (EBF), predominant breastfeeding (PBF), mixed breastfeeding (mixed BF), supplemented breastfeeding (supplemented BF) and non-breastfeeding (non-BF), and individual foods (water, liquids, milk, infant formula, semi-solid/solid) were analyzed. Prevalence of breastfeeding and food indicators were calculated in pooled sample, according to the infant monthly age groups, decade of survey and residence area(rural/urban).

Results

Between 1990s and 2010s, there was an increase in the exclusive breastfeeding prevalence (1990s = 38.1%, 2010s = 46.6%) and a reduction in the PBF prevalence (1990s = 51.7%, 2010 s = 43.1%). There was a decrease in the liquids (1990s = 40.7%, 2010s = 15.8%) and milk prevalence (1990s = 20.4%, 2010s = 8.3%) and an increase in water (1990s = 32.3%, 2010s = 37.6%), and infant formula (1990s = 16.6%, 2010s = 25.5%) prevalence. All breastfeeding indicators, except exclusive breastfeeding, progressively increased according to the monthly age group in three decades, and EBF prevalence sharply decreased from 2 to 3 months of age in all decades. Exclusive breastfeeding prevalence was higher in rural area in the three decades (1990s _rural = 43.8%, 1990s _urban = 32.4%, 2010s _rural = 51.1%, 2010s _urban = 42.4%) and infant formula prevalence was higher in urban area (1990s _rural = 8.6%, 1990s _urban = 24.6%, 2010s _rural = 15.9%, 2010s _urban = 34.1%).

Conclusions

In the last three decades, in all age groups, there was an increase in exclusive breastfeeding prevalence, as well as a significant reduction in liquids and milk. In the rural area, EBF prevalence remains higher than in urban. Increased water and infant formula feeding are the main barriers to achieving the Global Nutrition Target 2025 for exclusive breastfeeding.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00477-6.

Gestational weight gain and patterns of breastfeeding among patients with class III obesity

BACKGROUND

Maternal obesity is associated with delayed lactogenesis and shorter duration of breastfeeding compared to patients with a normal BMI.

RESEARCH AIM/QUESTION

We investigated the impact of excessive gestational weight gain, defined as greater than the Institute of Medicine guidelines (>9.1 kg), on the initiation and duration of breastfeeding in patients with class III obesity.

METHODS

Retrospective cohort of patients with body mass index ≥40 in first trimester, delivering a singleton term infant at a tertiary care center between July 2013 and December 2017. Primary outcome was exclusive breastfeeding at discharge and at postpartum visit. Secondary outcomes included any breastfeeding at discharge and postpartum visit, and cessation of breastfeeding by the postpartum visit. Descriptive statistics were used to compare those whose gestational weight gain exceeded (eIOM) versus met (mIOM) Institute of Medicine guidelines. Regression models were performed to adjust for baseline confounding factors.

RESULTS

Of 294 women included, 117(39.8%) were in the eIOM group. These women were more likely to be primigravida, have a higher delivery BMI, greater delivery blood loss, and have a neonate admitted to the intensive care unit. Exclusive breastfeeding at discharge was not different between eIOM and mIOM (66.7% vs 70.9%, p = .44), nor did eIOM impact likelihood of exclusive breastfeeding at postpartum visit (40.1% vs 34.2%, p = .31). When controlling for confounding factors, breastfeeding at discharge (aOR 1.54 95% CI [0.68-3.49]) or postpartum visit (aOR 0.67[0.31-1.47]) did not differ between eIOM compared to mIOM.

CONCLUSIONS

Among women with class III obesity, excessive gestational weight gain did not impact the rate of exclusive breastfeeding at discharge or postpartum visit.

Why do first-time mothers not intend to breastfeed? --A qualitative exploratory study on the decision-making of non-initiation in Jingzhou, China

Background

Although breastfeeding is one of the top priorities for public health in China, the rate of breastfeeding is still low and a large number of women do not initiate breastfeeding due to various reasons. Hence, this study aimed to understand the decision-making of non-initiation and reveal the underlying reasons in order to protect, support, and promote breastfeeding.

Methods

In-depth, exploratory interviews were carried out with 13 new mothers who did not initiate breastfeeding. The collected data were analyzed by inductive content analysis.

Results

Although mothers generally understood the protective effects of breastfeeding, they believed that formula milk is a good alternative to human milk and even better in some aspects. Five core themes related to non-initiation decision-making emerged: (1) expected breastfeeding stress; (2) maladjustment to the maternal role; (3) concerns about physiological issues; (4) the lack of knowledge about the risks of artificial feeding; (5) belief that it is better not to initiate than to interrupt.

Conclusions

The environment for mothers to breastfeed in China is not supportive enough, and the medical staff and families should be held responsible for the non-initiation of breastfeeding. More professionals are needed to support mothers to solve their problems and breastfeeding education should be further expanded.

Risk factors for discontinuation of exclusive breast feeding within 1month: a retrospective cohort study in Japan

BACKGROUND

While breastfeeding provides benefits for infants and the mother, many women either do not breastfeed or terminate breastfeeding earlier than recommended. The aim of this analysis was to identify factors associated with early discontinuation of breastfeeding in Japanese women.

METHODS

This study used data from medical records of women delivering a singleton live birth between March 2017 and August 2019 in Iwase General Hospital, Fukushima Prefecture, Japan to assess cessation of breastfeeding by the 1-month postpartum appointment. Demographic (age at birth, and employment status), medical (parity, and physical and mental condition of the mother; and infant medical factors, such as sex, Apgar score, and jaundice, among other), and family factors (husband/partner, family members living at the same house, among others) in 734 women who had initiated breastfeeding during their delivery hospital stay were examined, and multiple logistic regression was used to determine significant predictors of early cessation of exclusive breastfeeding.

RESULTS

Bivariate analysis revealed that women who were primipara, unmarried, exposed to secondhand smoke, and employed; those who smoked before pregnancy; and those who had asthma were more likely to discontinue exclusive breastfeeding than other women. Infant factors associated with discontinuation were lower birthweight, earlier gestational age, neonatal intensive care unit admission, treatment for jaundice, or lower weight gain. Multivariable analysis revealed that primiparity, passive smoking before pregnancy, maternal employment, and neonatal jaundice therapy were associated with discontinuation of breastfeeding.

CONCLUSIONS

In particular, women whose partners smoked before pregnancy may need to be targeted for additional support for breastfeeding.

Maternal Worry About Infant Weight and its Influence on Artificial Milk Supplementation and Breastfeeding Cessation

BACKGROUND

Maternal worry about infant weight has inconsistently been reported as a breastfeeding barrier. Weight monitoring is a critical tool to assess adequacy of infant feeding. Yet, little is known about the intensity of maternal worry about infant weight or associated breastfeeding outcomes.

RESEARCH AIMS

To examine (1) the frequency and intensity of maternal worry about infant weight; (2) the relationship between worry about weight and use of artificial milk; and 3) the relationship between worry about weight and breastfeeding cessation.

METHODS

A prospective cross-sectional design was used. A questionnaire was completed by women in the United States (N = 287) from 12 web-based maternal support groups.

RESULTS

Sixty-three percent of women (n = 182) had some worry about infant weight. Participants breastfeeding for the first time had more worry (p = .035). Participants still breastfeeding had less worry about weight compared to those who had stopped (67%, n = 147 vs. 41%, n = 28). Exclusive breastfeeding participants had less worry (p < .001) compared to those who supplemented with artificial milk. Increased worry was associated with the use of artificial milk within 1 week of birth (p < .001) and early breastfeeding cessation (p < .001).

CONCLUSIONS

Worry about weight is a significant breastfeeding barrier. It is associated with first time breastfeeding, less exclusive breastfeeding, use of artificial milk, and earlier breastfeeding cessation. Lactating mothers need anticipatory guidance about expected neonatal weight changes and interventions to help relieve worry about infant weight.