Maternal plasma and milk free cortisol during the first 3 days of breast-feeding following spontaneous delivery or elective cesarean section

Association between maternal stress and premature milk cortisol, milk IgA, and infant health: a cohort study

Background

Maternal stress is pervasive in the neonatal intensive care unit (NICU). Maternal stress is associated with changes in human milk (HM) immunomodulatory agents, which may impact neonatal health. We sought to determine the association between maternal stress, HM immunoglobulin A (IgA) and cortisol, and to assess how these milk components correlate with infant immune and neurodevelopmental outcomes. We then compared how these associations persist over time.

Methods

The study design involved a cohort study of exclusively breastfeeding mothers and their singleton moderately preterm (28-34 weeks) infants admitted to the NICU. We collected maternal serum, maternal saliva, and first-morning whole milk samples, and administered maternal stress questionnaires at 1 and 5 weeks postpartum. We analyzed the samples for HM IgA (using a customized immunoassay in skim milk) and for HM and salivary cortisol (using a chemiluminescent immunoassay). Infant illness was assessed using the Score for Neonatal Acute Physiology II (SNAP II) and SNAP II with Perinatal Extension (SNAPPE II), and infant neurodevelopment were assessed using the Test of Infant Motor Performance. We analyzed changes in HM IgA and cortisol over time using paired t-tests. Furthermore, we performed correlation and regression analyses after adjusting for gestational age (GA), corrected GA, and infant days of life.

Results

In our study, we enrolled 26 dyads, with a mean maternal age of 28.1 years, consisting of 69% white, 19% Black, and 8% Hispanic. Cortisol: Salivary and HM cortisol were closely associated in week 1 but not in week 5. Though mean salivary cortisol remained stable over time [2.41 ng/mL (SD 2.43) to 2.32 (SD 1.77), p = 0.17], mean HM cortisol increased [1.96 ng/mL (SD 1.93) to 5.93 ng/mL (SD 3.83), p < 0.001]. Stress measures were inversely associated with HM cortisol at week 1 but not at week 5. IgA: HM IgA decreased over time (mean = -0.14 mg/mL, SD 0.53, p < 0.0001). High maternal stress, as measured by the Parental Stressor Scale: neonatal intensive care unit (PSS:NICU), was positively associated with HM IgA at week 5 (r = 0.79, P ≤ 0.001). Higher IgA was associated with a lower (better) SNAP II score at week 1 (r = -0.74, p = 0.05). No associations were found between maternal stress, salivary cortisol, HM cortisol, or HM IgA and neurodevelopment at discharge (as assessed using the TIMP score). Furthermore, these relationships did not differ by infant sex.

Conclusion

Maternal stress showed associations with HM cortisol and HM IgA. In turn, HM IgA was associated with lower measures of infant illness.

The contributions of parental lactation on offspring development: It's not udder nonsense!

The Developmental Origins of Health and Disease (DOHaD) hypothesis describes how maternal stress exposures experienced during critical periods of perinatal life are linked to altered developmental trajectories in offspring. Perinatal stress also induces changes in lactogenesis, milk volume, maternal care, and the nutritive and non-nutritive components of milk, affecting short and long-term developmental outcomes in offspring. For instance, selective early life stressors shape the contents of milk, including macro/micronutrients, immune components, microbiota, enzymes, hormones, milk-derived extracellular vesicles, and milk microRNAs. In this review, we highlight the contributions of parental lactation to offspring development by examining changes in the composition of breast milk in response to three well-characterized maternal stressors: nutritive stress, immune stress, and psychological stress. We discuss recent findings in human, animal, and in vitro models, their clinical relevance, study limitations, and potential therapeutic significance to improving human health and infant survival. We also discuss the benefits of enrichment methods and support tools that can be used to improve milk quality and volume as well as related developmental outcomes in offspring. Lastly, we use evidence-based primary literature to convey that even though select maternal stressors may modulate lactation biology (by influencing milk composition) depending on the severity and length of exposure, exclusive and/or prolonged milk feeding may attenuate the negative in utero effects of early life stressors and promote healthy developmental trajectories. Overall, scientific evidence supports lactation to be protective against nutritive and immune stressors, but the benefits of lactation in response to psychological stressors need further investigation.

Acute decrease in mothers' cortisol following nursing and milk expression

The glucocorticoid hormone cortisol is an integral component of signaling pathways related to stress reactivity, energy balance, immune function, and other processes. In animal models, lactation is robustly associated with alterations in glucocorticoid signaling, and limited data suggest that similar changes may occur across human lactation. We asked whether milk letdown/secretion in breastfeeding mothers was associated with changes in cortisol, and whether such effects required presence of an infant. We measured changes in maternal salivary cortisol concentrations before and after nursing, the expression of breastmilk with an electric pump, or control activities. Participants conducted pre-session and post-session sampling (at 30 min) for all conditions, and provided a sample of pumped milk from one session. Both nursing and mechanical expression of breastmilk but not control were associated with equivalent declines in maternal cortisol concentration from pre-session values, indicating an effect of milk letdown on circulating cortisol independent of infant contact. Pre-session maternal salivary cortisol concentration was strongly and positively correlated with cortisol concentration in pumped milk samples, indicating that cortisol ingested by offspring provides a signal of maternal cortisol levels. Self-reported maternal stress was associated with higher pre-session cortisol concentrations, as well as with a larger drop in cortisol following nursing or pumping. These findings demonstrate that milk release-in the presence or absence of a suckling infant-regulates cortisol in mothers, and supports the potential for maternal signaling through breastmilk.

Prolonged maternal exposure to glucocorticoids alters selenoprotein expression in the developing brain

Aberrant activation of the stress-response system in early life can alter neurodevelopment and cause long-term neurological changes. Activation of the hypothalamic-pituitary-adrenal axis releases glucocorticoids into the bloodstream, to help the organism adapt to the stressful stimulus. Elevated glucocorticoid levels can promote the accumulation of reactive oxygen species, and the brain is highly susceptible to oxidative stress. The essential trace element selenium is obtained through diet, is used to synthesize antioxidant selenoproteins, and can mitigate glucocorticoid-mediated oxidative damage. Glucocorticoids can impair antioxidant enzymes in the brain, and could potentially influence selenoprotein expression. We hypothesized that exposure to high levels of glucocorticoids would disrupt selenoprotein expression in the developing brain. C57 wild-type dams of recently birthed litters were fed either a moderate (0.25 ppm) or high (1 ppm) selenium diet and administered corticosterone (75 μg/ml) via drinking water during postnatal days 1 to 15, after which the brains of the offspring were collected for western blot analysis. Glutathione peroxidase 1 and 4 levels were increased by maternal corticosterone exposure within the prefrontal cortex, hippocampus, and hypothalamus of offspring. Additionally, levels of the glucocorticoid receptor were decreased in the hippocampus and selenoprotein W was elevated in the hypothalamus by corticosterone. Maternal consumption of a high selenium diet independently decreased glucocorticoid receptor levels in the hippocampus of offspring of both sexes, as well as in the prefrontal cortex of female offspring. This study demonstrates that early life exposure to excess glucocorticoid levels can alter selenoprotein levels in the developing brain.

Got milk? Maternal immune activation during the mid-lactational period affects nutritional milk quality and adolescent offspring sensory processing in male and female rats

Previous studies have underscored the importance of breastfeeding and parental care on offspring development and behavior. However, their contribution as dynamic variables in animal models of early life stress are often overlooked. In the present study, we investigated how lipopolysaccharide (LPS)-induced maternal immune activation (MIA) on postnatal day (P)10 affects maternal care, milk, and offspring development. MIA was associated with elevated milk corticosterone concentrations on P10, which recovered by P11. In contrast, both milk triglyceride and percent creamatocrit values demonstrated a prolonged decrease following inflammatory challenge. Adolescent MIA offspring were heavier, which is often suggestive of poor early life nutrition. While MIA did not decrease maternal care quality, there was a significant compensatory increase in maternal licking and grooming the day following inflammatory challenge. However, this did not protect against disrupted neonatal huddling or later-life alterations in sensorimotor gating, conditioned fear, mechanical allodynia, or reductions in hippocampal parvalbumin expression in MIA offspring. MIA-associated changes in brain and behavior were likely driven by differences in milk nutritional values and not by direct exposure to LPS or inflammatory molecules as neither LPS binding protein nor interleukin-6 milk levels differed between groups. These findings reflected comparable microbiome and transcriptomic patterns at the genome-wide level. Animal models of early life stress can impact both parents and their offspring. One mechanism that can mediate the effects of such stressors is changes to maternal lactation quality which our data show can confer multifaceted and compounding effects on offspring physiology and behavior.

Factors Influencing Cortisol Concentrations in Breastmilk and Its Associations with Breastmilk Composition and Infant Development in the First Six Months of Lactation

Previous studies provided contradictory results regarding the influence of maternal, seasonal, and infant factors on breastmilk cortisol, and its associations with breastmilk composition and infant development. This study aimed to assess breastmilk cortisol levels at the first, third, and sixth months of lactation and evaluate the associations with maternal psychosocial, seasonal, and infant factors, breastmilk composition, and infant anthropometric and psychomotor development and temperament. Cortisol concentrations were assessed by ELISA in 24 h breastmilk samples obtained from 38 healthy mothers. Maternal psychological status was assessed by EPDS and PSS-10 and infant psychomotor development was assessed using the Children's Development Scale (DSR). Breastmilk cortisol was 11.2 ± 6.2, 11.2 ± 4.3, and 12.7 ± 6.2 ng/mL at the first, third, and sixth months of lactation (p > 0.05), respectively. In the spring-summer season, we observed lower and higher levels of cortisol in the first and sixth months of lactation (p ≤ 0.05), respectively, but no other associations were detected regarding maternal or infant characteristics. In the third month of lactation, cortisol was related to breastmilk crude protein (β = 0.318, 0.007-0.630) and infant BMI z-score before adjustment for infant birthweight and sex (Model 2: β = 0.359, 0.021-0.697), but no other associations with breastmilk composition, infant development, or temperament were confirmed. Our results indicated that breastmilk cortisol is unrelated to maternal and infant factors and has limited influence on breastmilk crude protein, but not on infant anthropometric and psychomotor development.

Maternal stress in the postpartum period is associated with altered human milk fatty acid composition

BACKGROUND & AIMS

Maternal stress in the postpartum period affects not only the mother, but also her newborn child who is at increased risk for a wide range of disorders later in life. The mechanisms underlying transmission of maternal stress to the child remain elusive. Human milk (HM) is a potential candidate and is an important source of fatty acid (FA), which are crucial for child (neuro)development. This study aims to investigate whether maternal psychological and biological stress influences HM FA composition over the first month postpartum.

METHODS

The Amsterdam Mother's Milk study is a prospective cohort study. We included lactating women who delivered at term with a large range of stress levels: a high stress (HS) group, women whose child was hospitalized for a minimum of 2 days (n=23) and a control (CTL) group, women who gave birth to a healthy child (n=73). HM was collected three times a day at postpartum days 10, 17 and 24. Perceived psychological stress was measured using multiple validated questionnaires, while biological stress measures were based on cortisol in hair, saliva and HM. HM FAs were analyzed by gas-chromatography and compared between groups.

RESULTS

Maternal perceived stress scores were significantly higher in the HS group (p < 0.01), whereas cortisol measurements did not differ between groups. The absolute concentrations of total FA in HM (p=0.023), including the total amount of poly unsaturated fatty acids (PUFAs) (p=0.022) and omega-6 PUFAs (p=0.018), were lower in the HS group compared to the CTL group. Relative values of FAs did not differ between groups.

CONCLUSION

Maternal stress in the first month postpartum was associated with overall lower levels of FA in HM. This possibly indicates a route of transmission of maternal stress signals to the infant. Future research should investigate if these stress-induced changes in HM FAs have consequences for child development.

Human milk metabolome is associated with symptoms of maternal psychological distress and milk cortisol

The composition of human milk is subject to considerable variation, but the effects of maternal stress are largely unknown. We studied differences in human milk metabolome between Finnish mothers (n = 120, secretors) with symptoms of prenatal symptoms of psychological distress and milk cortisol concentrations. Human milk samples acquired at 2.5 months postpartum were analyzed using targeted ¹H NMR metabolomics. Self-reported scores for depression (EPDS), overall anxiety (SCL-90), and pregnancy-related anxiety (PRAQ) were used to evaluate psychological distress. Prenatal psychological distress was positively associated with concentrations of short-chain fatty acids, caprate, and hypoxanthine (q < 0.0012). Milk cortisol was positively associated with lactate concentration (q < 0.05). Changes in the human milk metabolome were shown to be associated with maternal psychological distress and concentration of milk cortisol in a dissimilarly, suggesting alterations in bacterial and energy metabolism of the mother, respectively.

Associations between maternal socioeconomic, psychosocial and seasonal factors, infant characteristics and human milk cortisol concentrations

OBJECTIVES

Glucocorticoids are one component of human milk (HM) potentially affecting offspring development. Previous studies have identified various maternal, obstetric and socioeconomic characteristics that are associated with HM cortisol concentration but the literature is still scarce concerning these determinants in human populations. We aimed to identify which factors are linked with HM cortisol concentration at 2 months postpartum.

METHODS

We analyzed data from 340 lactating Finnish mothers using ordinary least squares regression with log-transformed HM cortisol concentration as the dependent variable. Potential predictors included obstetric and maternal factors (maternal age, parity status, delivery mode, gestational age, pre-pregnancy obesity, and smoking in pregnancy), socioeconomic status (education and socioeconomic class), subjective economic well-being, maternal psychosocial factors (postpartum depression and anxiety symptoms), infant sex and age, and HM sample characteristics (time of the day and season of the year at sample collection).

RESULTS

The strongest and most robust predictors were season of the year of sample collection and parity status. HM cortisol concentration was significantly higher for primiparas than multiparas. HM samples collected in summer showed significantly higher cortisol concentrations than those collected in winter, spring or autumn.

CONCLUSIONS

The findings suggest that parity and season of the year at sample collection may be important factors to control for when examining HM cortisol. The strongest and most robust associations were related to maternal and sample characteristics and not to socioeconomic and psychosocial distress. This may be related to the fact that the study was conducted in a low-risk population.

Human Milk Glucocorticoid Levels Are Associated With Infant Adiposity and Head Circumference Over the First Year of Life

Human milk (HM) is a complex and dynamic biological fluid, which contains appreciable concentrations of the glucocorticoids, cortisol and cortisone. Experimental studies in non-human primates suggest the HM glucocorticoids' impact on infant growth and body composition. In this current study, analysis is made of the relationships between HM glucocorticoid concentrations and the infant growth and development over the first year of life. HM was collected by lactating healthy women (n = 18), using a standardized protocol, at 2, 5, 9, and 12 months after childbirth. Cortisol and cortisone concentrations in the HM were measured using liquid chromatography mass spectrometry. Infant weight, length and head circumference were measured by standard protocols and percentage fat mass (% FM) determined by whole body bioimpedance. Cortisol and cortisone concentrations were unaltered over the analyzed lactation period (2–12 months), and were altered by infant sex. Although, HM cortisol was positively associated with infant percentage fat mass (% FM) (p = 0.008) and cortisone positively associated with infant head circumference (p = 0.01). For the first 12 months of life, the concentration of HM glucocorticoids levels was positively associated with infant adiposity (%FM) and head circumference. This preliminary evidence provides insight to a possible relationship between ingested HM glucocorticoids and infant body composition. Further studies are required to determine the mechanisms regulating HM glucocorticoids.

Interactions between cortisol and lipids in human milk

Background

Human breast milk is one of the key early postnatal biological exposures for the developing child. It includes bioactive compounds, such as cortisol and fatty acids, which may be linked via the mother’s lipid metabolism.

Methods

This study investigated the associations between cortisol and lipids in human milk at the infant age of 2.5 months. Human milk cortisol concentrations were measured using luminescence immunoassay, and two groups of milks (n = 50 each) were formed based on either high (> 10 nmol/L) or low (< 3 nmol/L) cortisol levels. Lipids, as fatty acid content and composition of neutral (triacylglycerol-rich) and polar (phospholipid-rich) lipids, were measured with gas chromatography. The samples originated from the FinnBrain Birth Cohort Study.

Results

The percentage of phospholipid-rich lipids of total lipids was 33.08% ± 1.33%. In triacylglycerol-rich lipids, high cortisol level in milk was associated with higher lauric (12:0, mass % and mg/mL), myristic (14:0, mass % and mg/mL), eicosenoic (20:1n − 9, mass %), docosenoic (22:1n − 9, mass %, and mg/mL) acids, and to lower palmitic acid (16:0, mass %) compared with low cortisol levels in milk. In phospholipid-rich lipids, high cortisol level was associated with higher myristic (14:0, mass %) and docosenoic (22:1n − 9, mass %) acids. After adjusting for pre-pregnancy BMI and sampling time by linear regression, the milk cortisol remained a significant predictor for lauric and myristic acids in triacylglycerol-rich lipids, and myristic and docosenoic acid in phospholipid-rich lipids (β = 0.23 to 0.38 and p < 0.05 for each).

Conclusions

This study revealed certain significant associations between milk cortisol and the fatty acid composition of human milk, indicating that cortisol might be one of the factors affecting the origin of the lipids in human milk.

'Optimising' breastfeeding: what can we learn from evolutionary, comparative and anthropological aspects of lactation?

BACKGROUND

Promoting breastfeeding is an important public health intervention, with benefits for infants and mothers. Even modest increases in prevalence and duration may yield considerable economic savings. However, despite many initiatives, compliance with recommendations is poor in most settings - particularly for exclusive breastfeeding. Mothers commonly consult health professionals for infant feeding and behavioural problems.

MAIN BODY

We argue that broader consideration of lactation, incorporating evolutionary, comparative and anthropological aspects, could provide new insights into breastfeeding practices and problems, enhance research and ultimately help to develop novel approaches to improve initiation and maintenance. Our current focus on breastfeeding as a strategy to improve health outcomes must engage with the evolution of lactation as a flexible trait under selective pressure to maximise reproductive fitness. Poor understanding of the dynamic nature of breastfeeding may partly explain why some women are unwilling or unable to follow recommendations.

CONCLUSIONS

We identify three key implications for health professionals, researchers and policymakers. Firstly, breastfeeding is an adaptive process during which, as in other mammals, variability allows adaptation to ecological circumstances and reflects mothers' phenotypic variability. Since these factors vary within and between humans, the likelihood that a 'one size fits all' approach will be appropriate for all mother-infant dyads is counterintuitive; flexibility is expected. From an anthropological perspective, lactation is a period of tension between mother and offspring due to genetic 'conflicts of interest'. This may underlie common breastfeeding 'problems' including perceived milk insufficiency and problematic infant crying. Understanding this - and adopting a more flexible, individualised approach - may allow a more creative approach to solving these problems. Incorporating evolutionary concepts may enhance research investigating mother-infant signalling during breastfeeding; where possible, studies should be experimental to allow identification of causal effects and mechanisms. Finally, the importance of learned behaviour, social and cultural aspects of primate (especially human) lactation may partly explain why, in cultures where breastfeeding has lost cultural primacy, promotion starting in pregnancy may be ineffective. In such settings, educating children and young adults may be important to raise awareness and provide learning opportunities that may be essential in our species, as in other primates.

No Association between Glucocorticoid Diurnal Rhythm in Breastmilk and Infant Body Composition at 3 Months

Objective: Glucocorticoids (GCs) in breastmilk have previously been associated with infant body growth and body composition. However, the diurnal rhythm of breastmilk GCs was not taken into account, and we therefore aimed to assess the associations between breastmilk GC rhythmicity at 1 month and growth and body composition at 3 months in infants. Methods: At 1 month postpartum, breastmilk GCs were collected over a 24-h period and analyzed by LC-MS/MS. Body composition was measured using air-displacement plethysmography at 3 months. Length and weight were collected at 1, 2, and 3 months. Results: In total, 42 healthy mother–infant pairs were included. No associations were found between breastmilk GC rhythmicity (area-under-the-curve increase and ground, maximum, and delta) and infant growth trajectories or body composition (fat and fat free mass index, fat%) at 3 months. Conclusions: This study did not find an association between breastmilk GC rhythmicity at 1 month and infant’s growth or body composition at 3 months. Therefore, this study suggests that previous observations linking breastmilk cortisol to changes in infant weight might be flawed by the lack of serial cortisol measurements and detailed information on body composition.

The Association between Breastmilk Glucocorticoid Concentrations and Macronutrient Contents Throughout the Day

Background: Glucocorticoids (GCs) in breastmilk follow the maternal hypothalamus–pituitary–adrenal axis activity and may affect the offspring’s growth and neurodevelopment. There is some evidence suggesting that macronutrients in breastmilk also fluctuate throughout the day. We aimed to research whether GCs and macronutrients are correlated in multiple breastmilk samples obtained over a 24-h period. Methods: A total of 10 mothers provided 45 breastmilk samples collected over a 24-h period. Cortisol and cortisone levels were determined by LC–MS/MS, and macronutrients were measured with mid-infrared spectroscopy. Correlations between breastmilk GCs and macronutrients were assessed with Pearson correlations and linear mixed models. Results: No associations were found between breastmilk GCs and macronutrients (cortisol: β-0.1 (95% confidence interval: −1.0 to 0.7), −4.9 (−12.9 to 3.1) for fat, protein, and carbohydrates, respectively; and −0.3 (−5.6 to 5.0) and cortisone: 0.0 (−2.5 to 2.5), −17.4 (−39.8 to 5.0), and −2.7 (−17.7 to 12.3)) for fat, protein, and carbohydrates, respectively. Adjusting for the time of collection to account for GC rhythmicity did not change the results. Conclusion: We found no associations between GCs and macronutrients in human breastmilk. The excretion of GCs in breastmilk and the effects of breastmilk GCs on offspring are, therefore, likely independent of the excretion and effects of the macronutrients.

Feeding-Induced Cortisol Response in Newborn Infants

CONTEXT

Understanding the biological rhythms and stress response in sick newborns is important to minimize the negative effects of intensive care. Salivary cortisol has been used as a noninvasive surrogate marker of adrenal function; however, understanding of its control variables is insufficient.

OBJECTIVE

To investigate the presence of feeding-induced cortisol response and its control variables in newborns.

DESIGN, SETTING, AND PATIENTS

Fifty-three newborn infants, who were between 30 and 40 weeks' corrected age and were on 3-hourly regular oral/enteral feeding, were recruited between January 2013 and June 2014.

MAIN OUTCOME MEASURE

Saliva samples were collected before and 1 hour after regular feeding. Dependence of cortisol levels (adjusted for postnatal age) and their feeding-related elevation on clinical variables was assessed by using generalized estimating equations.

RESULTS

Higher cortisol levels were associated with corrected age ≥37 weeks and saliva samples collected after feeding (both P < 0.001). Oral feeding was associated with a greater feeding-induced cortisol response compared with exclusive enteral feeding (P = 0.034), whereas a prolonged feeding duration (≥30 minutes) was associated with a reduced cortisol response compared with brief feeding (<30 minutes) (P < 0.001). Gestational age, corrected age, antenatal/postnatal glucocorticoids, type of milk, and daily feeding volume had no effect on cortisol response.

CONCLUSIONS

Feeding-induced cortisol response was observed in newborns. The cortisol response was more prominent following oral feeding and was reduced with prolonged feeding. Future studies may investigate whether feeding-induced cortisol response plays a role in the acquisition of adrenal ultradian and diurnal rhythms.

Human milk cortisol concentration predicts experimentally induced infant fear reactivity: moderation by infant sex

Little consideration has been given to the possibility of human infant development being shaped via lactocrine programming, and by breast milk cortisol levels specifically. Despite animal models indicating that glucocorticoid (GC) exposure via lactation might modify brain development and behavior, only one study has reported that milk cortisol levels were positively associated with infant negative affectivity, especially fearfulness and sadness-early emerging risk factors for internalizing difficulties such as anxiety. The aim of the current study was to investigate whether human milk cortisol is associated with mother-reported fearfulness and experimentally induced infant fear reactivity. Mother-infant dyads (n = 65) enrolled in the FinnBrain Cohort Study participated. Breast milk samples were obtained 2.5 months postpartum, and milk cortisol concentrations were ascertained using validated luminescence immunoassay methodology. Infant fear reactivity was assessed using maternal reports 6 months postpartum and in a laboratory 8 months postpartum. There was a significant interaction between infant sex and milk cortisol such that higher milk cortisol was related to higher infant fear reactivity in a laboratory setting in girls (β = 0.36, p = .04) but not in boys (β = -0.15, p = .40). Milk cortisol was not associated with mother-reported infant fearfulness. Results suggest that higher human milk cortisol concentrations are associated with elevated experimentally induced fear in infancy. Findings support lactocrine programming, and suggest that mothers may "communicate" vital information about stressful environments via cortisol contained in breast milk, shaping girls' early emotional reactivity.

Nutritional programming by glucocorticoids in breast milk: Targets, mechanisms and possible implications

Vertical transmission of glucocorticoids via breast milk might pose a mechanism through which lactating women could prepare their infants for the postnatal environment. The primary source of breast-milk glucocorticoids is probably the systemic circulation. Research from our group showed that milk cortisol and cortisone concentrations follow the diurnal rhythm of maternal hypothalamus-pituitary-adrenal axis activity, with a higher abundance of cortisone compared to cortisol. Measurement of breast-milk glucocorticoid concentrations is challenging due to possible cross-reactivity with progestagens and sex steroids, which are severely elevated during pregnancy and after parturition. This requires precise methods that are not hindered by cross reactivity, such as LC-MS/MS. There are some data suggesting that breast-milk glucocorticoids could promote intestinal maturation, either locally or after absorption into the systemic circulation. Breast-milk glucocorticoids might also have an effect on the intestinal microbiome, although this has not been studied thus far. Findings from studies investigating the systemic effects of breast-milk glucocorticoids are difficult to interpret, since none took the diurnal rhythm of glucocorticoids in breast milk into consideration, and various analytical methods were used. Nevertheless, glucocorticoids in breast milk might offer a novel potential pathway for signal transmission from mothers to their infants.

Cortisol in Neonatal Mother's Milk Predicts Later Infant Social and Cognitive Functioning in Rhesus Monkeys

Milk provides not only the building blocks for somatic development but also the hormonal signals that contribute to the biopsychological organization of the infant. Among mammals, glucocorticoids (GCs) in mother's milk have been associated with infant temperament. This study extended prior work to investigate rhesus monkey (Macaca mulatta) mother-infant dyads (N = 34) from birth through 8 months postpartum. Regression analysis revealed that cortisol concentrations in milk during the neonatal period predicted impulsivity on a cognitive task, but not global social behaviors, months later. During this time period, sex-differentiated social behavior emerged. For female infants, milk cortisol concentrations predicted total frequency of play. Collectively, these findings support and extend the "lactational programming" hypothesis on the impact of maternal-origin hormones ingested via milk.

Breast-Milk Cortisol and Cortisone Concentrations Follow the Diurnal Rhythm of Maternal Hypothalamus-Pituitary-Adrenal Axis Activity

BACKGROUND

Very preterm infants often receive donor milk from mothers who deliver at term, but its composition differs from that of their own mother's milk. Because breast-milk glucocorticoids can support developing neonates, we explored concentration variability within and between mothers.

OBJECTIVE

We hypothesized that breast-milk glucocorticoid concentrations would be higher after very preterm delivery [gestational age (GA) <32 wk; study 1] and would follow the diurnal rhythm of maternal adrenocortical activity (study 2).

METHODS

Study 1 assessed differences in milk cortisol, cortisone, and the cortisone-to-(cortisol+cortisone) ratio of mothers who delivered at (median) GA: 28.6 wk or at term weekly during the first month postpartum. Study 2 assessed variations in milk cortisol, cortisone, and the cortisone-to-(cortisol+cortisone) ratio over 24 h, and tested Pearson correlations between milk and salivary concentrations in mothers who delivered at term (median GA: 38.9 wk) during week 4 postpartum. In these studies, foremilk glucocorticoids were measured by liquid chromatography-tandem mass spectrometry. Associations of milk cortisol, milk cortisone, and the milk cortisone-to-(cortisol+cortisone) ratio with prematurity (study 1) or collection time (study 2) were studied with longitudinal data analyses.

RESULTS

In study 1, giving birth to a very preterm infant was associated with reductions in milk cortisol and cortisone concentrations of 50% (β: 0.50; 95% CI: 0.26, 0.99; P = 0.05) and 53% (β: 0.53; 95% CI: 0.30, 0.93; P = 0.03), respectively, when adjusted for collection time. In study 2, concentrations of milk cortisol and cortisone were associated with collection time (both P < 0.01), peaking at ∼0700. Milk and salivary concentrations of cortisol (r = 0.92, P < 0.01) and cortisone (r = 0.93, P < 0.01) as well as the cortisone-to-(cortisol+cortisone) ratio (r = 0.64, P < 0.01) were correlated with one another.

CONCLUSIONS

Breast-milk glucocorticoid concentrations follow the diurnal rhythm of maternal hypothalamus-pituitary-adrenal axis activity and are lower in mothers who deliver very preterm.

How to assess stress biomarkers for idiographic research?

Associations between stress-related biomarkers, like cortisol or catecholamines, and somatic or psychological symptoms have often been examined at the group level. Studies using this nomothetic approach reported equivocal findings, which may be due to high levels of intra-individual variance of stress biomarkers. More importantly, analyses at the group level provide information about the average patient, but do not necessarily have meaning for individual patients. An alternative approach is to examine data at the level of individual patients in so-called idiographic research. This method allows identifying individuals in whom symptoms are explained by preceding alterations in specific stress biomarkers, based on time series of symptoms and stress biomarkers. To create time series of sufficient length for statistical analysis, many subsequent stress biomarker measurements are needed for each participant. In the current paper, different matrices (i.e. saliva, urine, nail and hair) are discussed in light of their applicability for idiographic research. This innovative approach might lead to promising new insights in the association between stress biomarkers and psychological or somatic symptoms. New collection tools for stress biomarkers, like the use of sweat pads, automated microdialysis systems, dried blood spots, or smartphone applications, might contribute to the feasibility and implementation of idiographic research in the future.

Correlation between maternal and infant cortisol varies by breastfeeding status

OBJECTIVE

The objective of this study was to examine associations of mother and infant salivary cortisol, measured three times over the course of a day, and assess whether these varied by breastfeeding status.

METHODS

We conducted a cross-sectional study of 54 mothers and their infants aged 4-11 months. Mothers collected their own saliva and that of their infants upon awakening, 30min after waking and at bedtime. Breastfeeding status was reported by mothers and cortisol level was measured in saliva in μg/dl using standard techniques. We used generalized linear models to evaluate relationships between maternal and infant cortisol levels, and assessed whether the relationship differed by breastfeeding status: formula only compared to partial and full breastfeeding, adjusting for infant sex, race, age, maternal education, and family income.

RESULTS

Thirty-four infants received formula only and 20 were either partially or fully breastfed. Breastfeeding was associated with higher household income, higher maternal education, and white race. Cortisol levels were higher among breastfed infants at all three time points. After adjustment, maternal cortisol levels were related with infant cortisol at bedtime only (regression estimate 0.06; 95% CI: 0.10, 1.1; p=0.02). The adjusted association between bedtime maternal and infant cortisol was stronger among breastfeeding dyads than among formula-feeding dyads (regression estimate 1.0; 95% CI: 0.1, 2.0; p=0.04 vs. 0.6; CI: -0.1, 1.3; p=0.10). In addition, we assessed the influence of maternal education and household income in our adjusted model; income strengthened the observed association, whereas maternal education did not change the estimate.

CONCLUSIONS

Breastfeeding mothers and infants had significant correlations for cortisol at bedtime, while formula-feeding dyads did not. These data suggest that several factors may contribute to cortisol synchrony observed in mother/infant dyads, including the transfer of cortisol in human milk, physical interaction such as skin-to-skin contact, and shared environment. In addition, our findings support household income as a possible contributor.

Prenatal maternal stress predicts stress reactivity at 2½ years of age: the Iowa Flood Study

Prenatal maternal stress (PNMS) predicts psychosocial development in offspring. It has been hypothesized that during PNMS, glucocorticoids pass the placenta, reaching the foetus, leading to a long-term reprogramming and dysregulation of the foetal hypothalamic-pituitary-adrenal (HPA) axis. However, results are inconsistent across PNMS studies. One problem may be the confounding of objective degrees of hardship due to the stressor and subjective degrees of distress in the mother. The present study investigated the association between objective and subjective PNMS due to a natural disaster, the June 2008 Iowa floods, and stress reactivity in the offspring at 2½ years of age. Women who were pregnant during the floods were recruited, on average, within three months of the floods and their stress levels assessed. Mothers and their toddlers (n = 94 dyads) participated in a brief mother-toddler separation to induce physiological stress responses in the offspring. Salivary cortisol samples were collected four times during the procedure. We computed absolute change in cortisol (baseline to 20-minute post-stressor; baseline to 45-minute post-stressor) and Area Under the Curve with respect to increase and ground (AUCi; AUCg). Objective and subjective PNMS were positively correlated with AUCi, as was timing in gestation: the later in pregnancy the exposure occurred, the greater the cortisol increase. Controlling for objective hardship and other covariates, sex-by-subjective PNMS interactions showed a significant and positive association between subjective PNMS and Absolute Increase (45 min) and AUCi in females only, with little effect in males. These results suggest that PNMS leads to long-term alterations in the functioning of the HPA axis, evident as early as 30-months of age.

Using natural disasters to study prenatal maternal stress in humans

Animal studies of prenatal maternal stress permit random assignment of pregnant animals to stress and no-stress groups, and allow total control of the type, severity, and timing of the stressor in utero. Human studies have obvious constraints that make the use of experimental methods nearly impossible. Studying pregnant women who experience natural disasters during pregnancy, however, approximates the random assignment to groups enjoyed by animal studies, and can characterize the timing of the stressor in utero with great precision. In this chapter, we briefly describe our three ongoing prospective longitudinal studies of children exposed to prenatal maternal stress from natural disasters. We present results from Project Ice Storm in detail, showing effects of prenatal maternal stress on cognitive and neurodevelopment. We contrast these results with preliminary findings from the Iowa Flood Study and introduce the QF2011 Queensland Flood Project. In the "Discussion" section, we present conclusions to date and discuss the relative effects of the severity of maternal objective disaster exposure and maternal subjective distress levels, the moderating effects of fetal sex and the timing of the stressor in utero, and the longevity of the effects. Finally, we discuss some possible mechanisms that may mediate the effects of prenatal maternal stress on the neurodevelopment of children.

Human milk cortisol is associated with infant temperament

The implications of the biologically active elements in milk for the mammalian infant are largely unknown. Animal models demonstrate that transmission of glucocorticoids through milk influences behavior and modifies brain development in offspring. The aim of this study was to determine the relation between human milk cortisol levels and temperament of the breastfed infant. Fifty-two mother and infant pairs participated when the infants were three-months old. Milk cortisol levels were assessed and each mother completed the Infant Behavior Questionnaire (IBQ), a widely used parent-report measure of infant temperament. Analyses revealed a positive association between milk cortisol and the negative affectivity dimension of the IBQ (partial r=.37, p<.01). No correlation was found between elevated cortisol levels and the surgency/extraversion or the orienting/regulation dimensions. Further, the positive association between increased maternal milk cortisol and negative affectivity was present among girls (β=.59, p<.01), but not among boys. (Although, the sex by milk cortisol interaction term was not statistically significant, suggesting that these results require replication.) Environmental factors such as maternal demographics and negative maternal affect (depression and perceived stress) at the time of assessment did not account for the positive association. The findings support the proposal that exposure to elevated levels of cortisol in human milk influences infant temperament. The findings further suggest that mothers have the ability to shape offspring phenotype through the transmission of biologically active components in milk.

Breastfeeding after cesarean delivery: a systematic review and meta-analysis of world literature

BACKGROUND

The rate of exclusive breastfeeding remains low in many countries. Furthermore, cesarean delivery (CD) is increasing and may affect breastfeeding success.

OBJECTIVE

The objective was to conduct a systematic review and meta-analysis of observational studies to determine whether CD (prelabor or in-labor) is associated with a lower rate of breastfeeding compared with vaginal delivery (VD).

DESIGN

Studies published before January 2011 that reported breastfeeding up to 6 mo postpartum and compared outcomes after CD or VD, including foreign language publications, were identified through PubMed and bibliographic review. Prespecified data were extracted independently by multiple observers. The types of CD [prelabor (elective/scheduled) or in-labor (emergency)] were compared by subgroup analyses. Potential sources of study-level bias were analyzed by using meta-regression and sensitivity analyses.

RESULTS

The systematic review included 53 studies (554,568 subjects, 33 countries); 25 authors contributed additional data (245,455 subjects), and 48 studies (553,306 subjects, 31 countries) were included in the meta-analysis. Rates of early breastfeeding (any initiation or at hospital discharge) were lower after CD compared with after VD (pooled OR: 0.57; 95% CI: 0.50, 0.64; P < 0.00001) and lower after prelabor but not after in-labor CD (prelabor OR: 0.83; 95% CI: 0.80, 0.86; P < 0.00001; in-labor OR: 1.00; 95% CI: 0.97, 1.04; P = 0.86). In mothers who initiated breastfeeding, CD had no significant effect on any breastfeeding at 6 mo (OR: 0.95; 95% CI: 0.89, 1.01; P = 0.08).

CONCLUSIONS

There was a negative association between prelabor CD and early breastfeeding. If breastfeeding is initiated, mode of delivery has no apparent effect on the number of mothers still breastfeeding at 6 mo. Women and health care workers should be aware of the negative associations between CD and early breastfeeding and consequent implications for infants' well-being.

Cortisol concentrations in the milk of rhesus monkey mothers are associated with confident temperament in sons, but not daughters

One pathway by which infant mammals gain information about their environment is through ingestion of milk. We assessed the relationship between stress-induced cortisol concentrations in milk, maternal and offspring plasma, and offspring temperament in rhesus monkeys. Milk was collected from mothers after a brief separation from their infants at 3-4 months postpartum, and blood was drawn at this time for both mothers and infants. Offspring temperament was measured at the end of a 25-hr assessment. Cortisol concentrations in milk were in a range comparable to those found in saliva, and were positively correlated with maternal plasma levels. Mothers of males had higher cortisol concentrations in milk than did mothers of females, and cortisol concentrations in maternal milk were related to a Confident temperament factor in sons, but not daughters. This study provides the first evidence that naturally occurring variation in endogenous glucocorticoid concentrations in milk are associated with infant temperament.

Maternal cortisol in late pregnancy and hypothalamic-pituitary-adrenal reactivity to psychosocial stress postpartum in women

Hypothalamic-pituitary-adrenal (HPA) activity is altered postpartum and has been associated with several puerperal disorders. However, little is known about the association of maternal HPA activity during pregnancy with maternal HPA responsiveness to stress after parturition. Within a longitudinal study with an experimental component, we assessed in 22 women the salivary cortisol awakening response (CAR) at the 36th week of gestation and 6 weeks postpartum, as well as pituitary-adrenal and emotional responses to a psychosocial laboratory stressor at 8 weeks postpartum. CAR in late pregnancy negatively predicted maternal adrenocorticotropin (ACTH; ss = - 0.60; P = 0.003), plasma cortisol (ss = - 0.69, P < 0.001), and salivary cortisol (ss = - 0.66; P = 0.001) but not emotional stress reactivity (all P>0.05) at 8 weeks postpartum, whereas CAR at 6 weeks postpartum failed to predict hormonal (ACTH: ss = 0.02; P = 0.933, plasma cortisol: ss = - 0.23; P = 0.407, salivary cortisol: ss = - 0.15; P = 0.597) or emotional (all P>0.05) stress responses at 8 weeks postpartum. The activity of the HPA axis during pregnancy is associated with maternal HPA responsiveness to stress postpartum. Putative biological underpinnings warrant further attention. A better understanding of stress-related processes peripartum may pave the way for the prevention of associated puerperal disorders.

Are breast-fed infants more resilient? Feeding method and cortisol in infants

The effect of feeding method on stress hormone levels in infants is unknown. We studied infants from birth to 1 year and found salivary cortisol 40% higher in breast-fed infants compared with formula-fed infants. The higher cortisol levels among breast-fed children may be involved in the analgesic effect of breastfeeding.

Postnatal maternal cortisol levels predict temperament in healthy breastfed infants

BACKGROUND

The implications of the biologically active elements in breast milk for the breastfed infant are largely unknown. Animal models suggest that ingestion of glucocorticoids during the neonatal period influences fear behavior and modifies brain development.

AIMS

To determine the association between postnatal maternal cortisol levels and temperament in breastfed infants.

STUDY DESIGN

The relation between maternal cortisol and infant temperament was examined in breastfed and formula-fed infants. Plasma cortisol was used as a surrogate measure for breast milk cortisol levels (plasma and milk levels are correlated in the 0.6 to 0.7 range; [Patacchioli FR, Cigliana G, Cilumbriello A, Perrone G, Capri O, Alemà GS, et al. Maternal plasma and milk free cortisol during the first 3 days of breast-feeding following spontaneous delivery or elective cesarean section. Gynecologic and Obstetric Investigations 1992;34:159-163.]. If exposure to elevated cortisol levels during infancy influences temperament, then a relation between the two should be found among the breastfed infants, but not among the formula-fed infants.

SUBJECTS

Two hundred fifty-three two-month-old infants and their mothers.

OUTCOME MEASURES

Fearful temperament assessed with the Infant Behavior Questionnaire [Garstein MR, Rothbart MK. Studying infant temperament via the revised infant behavior questionnaire. Infant Behavior and Development 2003;26:64-86].

RESULTS

Among the breastfed infants, higher maternal cortisol levels were associated with reports of increased infant fear behavior (partial r=0.2; p<0.01). This relation did not exist among the formula-fed infants. Negative maternal affect at the time of assessment did not account for the positive association in the breastfed group.

CONCLUSIONS

The findings are consistent with our proposal that exposure to cortisol in breast milk influences infant temperament. Biologically active components in breast milk may represent one avenue through which the mother shapes the development of the human infant during the postnatal period.

Human milk as a carrier of biochemical messages

Not only does breast milk provides an ideal nutrient composition for the newborn, but it also contains a variety of substances that may actively influence growth and development of the infant and stimulate neonatal protection against gastrointestinal diseases. Hormones, growth factors, cytokines and even whole cells are present in breast milk and act to establish biochemical and immunological communication between mother and child. In addition, milk nutrients such as nucleotides, glutamine and lactoferrin have been shown to influence gastrointestinal development and host defense. The unique properties of milk as a mediator of biochemical messages will be presented and the clinical significance of breastfeeding in the prevention of neonatal gastrointestinal diseases will be discussed.

The effect of postoperative analgesia with continuous epidural bupivacaine after cesarean section on the amount of breast feeding and infant weight gain

The purpose of this study is to determine the effect of postoperative analgesia on the amount of breast feeding and infant weight gain. Thirty parturients undergoing elective cesarean section under spinal anesthesia were randomly allocated to receive postoperative pain management with (S-E group, n = 15) or without epidural bupivacaine (S group, n = 15). Epidural analgesia was performed for 3 days with a continuous epidural infusion (0.7 mL/h) of 0.25% bupivacaine. Diclofenac was available on demand in all patients. The weight of milk fed by breast and the infant weight were measured for 11 days after cesarean section. In the S-E group, the visual analog pain score after surgery was significantly lower and both the weight of milk fed by breast and the infant weight during the study were significantly more than the respective values in the S group. The S group required a larger dose of diclofenac after the operation than did the S-E group. We suggest that satisfactory postoperative pain relief with continuous epidural bupivacaine for 3 days after cesarean section improved the amount of breast feeding and the gain of infant weight.

The hypothalamus-pituitary--adrenocortical axis: epigenetic determinants changes with aging, involvement of NGF

In order to study the hypothesis that maternal corticosterone (B) influences the hippocampus/hypothalamus-pituitary-adrenocortical axis system in the adult rat, we induced a moderate increase in maternal plasma level of B by adding the hormone to the drinking water of the dams (200 micrograms/ml) from the day of delivery to weaning. B-nursed male rats had, at 3 months of age, a lower basal concentration of ACTH and B, as well as a lower stress (2 min restraint) induced increase. The reduced stress response was also present at 12 months. These endocrine differences were parallel to behavioural modifications. In the adult offspring of mothers that were hypercorticosteronemic during lactation, an improved spatial learning ability, a reduced emotional performance in a conflict procedure and a better performance in a conditioned active avoidance test was observed. Finally, the analysis of hippocampal adrenocorticoid receptors revealed that the postnatal endocrine manipulation induced an increase in the Type I receptor density in the adult offspring. Our findings point to an epigenetic effect of maternal B on the maturational process of the hypothalamus-pituitary-adrenocortical (HPA) axis and the hippocampus with endocrine and behavioural consequences in adulthood. The aging process has been shown to alter the normal functioning of the HPA axis. This alteration might arise from a reduced hippocampal negative feedback control, as suggested by the age-dependent loss of hippocampal adrenocorticoid receptors. Among the hypothalamic factors endowed with corticotropin secretagogue activity, corticotropin-releasing hormone (CRH) and vasopressin are considered the major physiological mediators of hypothalamic control of ACTH release.(ABSTRACT TRUNCATED AT 250 WORDS)