Direct vs. Expressed Breast Milk Feeding: Relation to Duration of Breastfeeding

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.

A longitudinal study of breastfeeding relationships at home during the COVID-19 pandemic: A grounded theory method

AIMS

To describe the process of breastfeeding relationships among stay-at-home mother and infant dyads at 1, 3, 5 and 6 months.

DESIGN

A longitudinal qualitative online survey design was used.

METHODS

Data were obtained at 1, 3, 5 and 6 months from 26 breastfeeding mothers who stayed home with their infants and directly breastfed at least once a day for the first 6 months between June 2022 and August 2023. Mothers' written responses to 3 open-ended questions were analysed to assess breastfeeding experiences at home, thoughts/comments while directly breastfeeding and breastfeeding concerns/problems and strategies they used. Based on grounded theory, inductive content analysis was used to analyse the data. Trustworthiness of results was established by coding to consensus, formal peer debriefing and maintaining an audit trail.

RESULTS

'Breastfeeding Relationships at Home,' the core construct, was identified and organized the process of breastfeeding relationships into 5 domains: (1) mothers' emotional well-being while breastfeeding, (2) infant-led feeding, (3) alternatives to breastfeeding, (4) evaluation of breastfeeding and (5) changes in breastfeeding as infants grow older.

CONCLUSION

Breastfeeding is not simply about feeding breast milk but also involves nurturing and developing a relationship between mother and infant. Across the domains, mutual responsiveness, a central element of the breastfeeding relationship was clear. Mothers who were committed to breastfeeding with embedded infant suckling reached emotional well-being in return for their engagement which has potential to reduce maternal stress and prevent postpartum depression.

IMPACT

Findings from the current study add to nurses' knowledge about the relationship building process between stay-at-home mothers and their infants in the first 6 months of breastfeeding during the COVID-19 pandemic. Nurses must remain sensitive to aid the development of breastfeeding relationships in the home environment to maximize mutual responsiveness.

PATIENT OR PUBLIC CONTRIBUTION

No patients or public involved.

Feeding Expressed Breast Milk Alters the Microbial Network of Breast Milk and Increases Breast Milk Microbiome Diversity over Time

Breastfeeding supplies nutrition, immunity, and hormonal cues to infants. Feeding expressed breast milk may result in de-phased milk production and feeding times, which distort the real-time circadian cues carried by breast milk. We hypothesized that providing expressed breast milk alters the microbiotas of both breast milk and the infant's gut. To test this hypothesis, we analyzed the microbiota of serial breast milk and infant fecal samples obtained from 14 mother-infant dyads who were lactating, half of which were providing expressed breast milk. Infant fecal microbiota showed lower α-diversity than breast milk microbiota. Bacterial amplicon sequence variant sharing occurred between breast milk and infant feces with no feeding group differences. However, the age-dependent gain in breast milk α-diversity was only significant in the expressed breast milk group and not in the direct breastfeeding group, suggesting that decreased contact with the infant's mouth influences the milk microbiota. Trending lower connectivity was also noted with breast milk microbes in the direct breastfeeding group, consistent with regular perturbations of the developing baby's oral microbiota by latching on the breast. The results of this preliminary study urge further research to independently confirm the effects of providing expressed breast milk and their health significance.

Quantifying the Association between Pump Use and Breastfeeding Duration

OBJECTIVE

To quantify the extent to which pump use is associated with breastfeeding duration.

STUDY DESIGN

We conducted a cross-sectional analysis of weighted data from the Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System from Maine, Michigan, New Mexico, and Utah between 2016 and 2021. Included respondents had a live-born infant at survey completion, initiated breastfeeding, and had nonmissing data for reported pump use and breastfeeding duration. Using Cox proportional hazard regression, we quantified the hazard of breastfeeding cessation and median duration (weeks) of breastfeeding by pump use. Pump use was suspected to be differentially impacted by race and ethnicity; an interaction was tested in our regression model.

RESULTS

Our sample included 19 719 mothers (weighted n = 723 808) with mean age (SD) 29.5 years (5.6). Mothers with age <18 years, Medicaid enrollment, race, and ethnicity other than non-Hispanic White, lower income or education, and unmarried status demonstrated lower pump use (P < .001). Pump use was associated with 37% lower hazard of breastfeeding cessation (adjusted hazard ratio 0.63; 95% CI: 0.56-0.70) and 21 additional weeks of breastfeeding on average. The association varied by race and ethnicity (significant interaction observed between pump use and non-Hispanic Black mothers, P = .013); stratified analysis demonstrated the lowest hazard of breastfeeding cessation among non-Hispanic Black and Native American pump users (adjusted hazard ratio 0.47 [0.40-0.54] and 0.51 [0.37-0.70], respectively).

CONCLUSIONS

Pump use was associated with longer breastfeeding duration; the greatest magnitudes of association were found among non-Hispanic Black and Native American participants, groups disproportionately affected by breastfeeding inequities. Future research examining the context around and causal impact of pump use on breastfeeding outcomes is needed.

Determinants of exclusive direct breastfeeding using constructs from the breastfeeding relationship scale

OBJECTIVES

This study examined the relationship among constructs of the Breastfeeding Relationship Scale and exclusive direct breastfeeding (EDBF) while controlling for covariates in US breastfeeding dyads in the first 3 months.

BACKGROUND

The Breastfeeding Relationship Scale was developed to measure mother-infant mutual responsiveness during breastfeeding in response to perceived insufficient milk, but there is no clear understanding about the relationships between the Breastfeeding Relationship Scale's constructs and EDBF.

METHODS

A cross-sectional design was used. The convenience sample of 589 directly breastfeeding mothers in the US whose infants were between 1 and 12 weeks of age were included for analysis using a structural equation model. Covariates for EDBF included mother's age, education, marital status, parity, prior breastfeeding experience, infant's age, weight, and sex.

RESULTS

Mother-Infant Breastfeeding Interaction and Breastfeeding Synchronicity were related (β = 0.33, p < .001), as were Breastfeeding Synchronicity and Perceived Adequate Milk Supply (β = 0.35, p < .001) and Mother-Infant Breastfeeding Interaction and Perceived Adequate Milk Supply (β = 0.08, p = .05). The relationship between Mother-Infant Breastfeeding Interaction and Breastfeeding Synchronicity with EDBF was fully mediated by Perceived Adequate Milk Supply, where the odds of EDBF was higher for mothers with higher scores on Perceived Adequate Milk Supply (OR = 1.61, p < .001) and prior breastfeeding experience (OR = 2.31, p = .006).

CONCLUSIONS

Perceived Adequate Milk Supply and prior breastfeeding experience are major determinants of EDBF in the first 3 months. Breastfeeding Synchronicity can bolster Mother-Infant Breastfeeding Interaction and promote Perceived Adequate Milk. More attention should be paid to breastfeeding relationship to be the result of EDBF.

Comparison of the Effect of Direct Breastfeeding, Expressed Human Milk, and Infant Formula Feeding on Infant Weight Trajectories: A Systematic Review

Background: Formula and breastfeeding are known factors associated with infant weight trajectories. Evidence exploring the effect of expressed human milk feeding on infant weight in the community setting has not been well synthesized. Objectives: This systematic review examined (1) weight changes among infants fed expressed human milk and (2) differences in weight change between infants fed expressed human milk and infants fed at the breast or infant formula via bottle. Methods: A comprehensive search of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of each study was appraised using the Joanna Briggs Critical Appraisal Tools. Results: A total of six studies met the eligibility criteria and included a total of 5,152 infants. The within-subject analysis identified only 31 infants strictly or predominantly fed expressed human milk. The between-subject analysis comparing expressed human milk feeding to the available comparison groups (formula-fed or direct at the breastfed) revealed that higher weight gains were observed in the weight trajectories among infants in the bottle or formula-fed conditions in four of the six included studies. Conclusions: Findings from the few studies included in this review found a difference in the infant weight gain patterns among expressed human milk-fed infants when compared with their respective feeding groups (directly breastfed or formula-fed). Further research is needed to corroborate these findings and elucidate the clinical significance of the differences in weight gain patterns observed across infant feeding groups.

Meta-ethnography on the Experiences of Women From Around the World Who Exclusively Breastfed Their Full-Term Infants

OBJECTIVE

To synthesize evidence from qualitative studies on the experiences of women from around the world who exclusively breastfed their full-term infants.

DATA SOURCES

CINAHL Plus, PubMed, APA PsycInfo, Scopus, and ProQuest Dissertation & Theses Global.

STUDY SELECTION

We selected reports of qualitative studies that were conducted in high-, middle-, and low-income countries; published between January 2001 and February 2022 in English; and focused on the experiences of women who exclusively breastfed their full-term infants.

DATA EXTRACTION

We extracted the following data from included studies: methodological characteristics (i.e., country of origin, authors' disciplines, research design, sample size, sampling, data collection, and data analysis method), participants' demographics (i.e., age, parity, marital status, education, and exclusive breastfeeding duration) and direct participant quotes, and key concepts and themes about women's experiences of exclusive breastfeeding. We managed and stored extracted data using a Microsoft Excel spreadsheet.

DATA SYNTHESIS

We synthesized reciprocal translations using Noblit and Hare's approach to meta-ethnography. Five overarching themes emerged from the meta-synthesis: Favorable Conditions, Not a Smooth Journey,Support, Determination and Perseverance, and Reflections on Benefits.

CONCLUSION

In the included studies, participants experienced challenges with exclusive breastfeeding; however, they also recounted benefits. We recommend 6-month maternity leave and support from family and health care professionals to improve rates of exclusive breastfeeding.

Breastfeeding Prevalence and Factors Affecting Breastfeeding Duration Among Urban Multi-ethnic Malaysian Mothers: A Single-Center University Hospital Study

Breastfeeding rates in urban Malaysian mothers are below World Health Organization (WHO) targets. Our prospective survey identified breastfeeding prevalences at 3, 6, and 12 months of 85.5%, 77%, and 60%, respectively. Combined (direct and expressed) breastfeeding significantly sustained longer-term breastfeeding. Efforts should be focused on mothers of Indian ethnicity and on expression after one month postpartum.

Breastfeeding in US working mothers: A systematic review

BACKGROUND

Previous studies demonstrate that exclusive breastfeeding has positive long-term health effects on the mother and infant, but research has shown that nearly 50% of mothers do not breastfeed for the recommended amount of time.

OBJECTIVE

This article systematizes previous quantitative research on the impact of work on breastfeeding practices to identify the factors that correlate to the cessation of breastfeeding in working mothers.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements, we performed a systematic review that screened PubMed, CINAHL, PsycINFO, and Academic Search Complete databases for articles relating to maternal employment and breastfeeding.

RESULTS

Of the 13,106 articles assessed for eligibility, 21 studies met all requirements and were included in this systematic review. The 21 articles were divided into study type and methods, participant demographics, study outcomes, and additional factors that included stressors and stress levels, factors that increased or decreased rates of breastfeeding, and feeding methods. Articles outside of the United States were excluded due to differences in maternity leave policies of other countries impacting the data.

CONCLUSION

Cessation of breastfeeding and breastfeeding outcomes were seen to have a strong association with maternal employment, specifically with the policies and employer support in the workplace. Other factors such as race, level of education, and stress were also shown to relate to breastfeeding outcomes and are important to consider in future public health interventions and workplace policies.

Experience and perceptions of healthcare providers on clinical management and care of near-miss infants: a qualitative content analysis

INTRODUCTION

Neonatal Near Miss (NNM) refers to neonates with severe complications who almost died but survived immediately after birth. In Ethiopia, the prevalence of NNM has been assessed using a validated Neonatal Near-Miss Assessment Scale. However, understanding the experiences and perceptions of healthcare providers in the clinical management and care of NNM infants remains unexplored. The aim was to investigate the determinants contributing to the survival of neonatal near-miss babies and to identify any barriers encountered, as reported by the experiences of healthcare providers in public hospitals of Amhara Regional State, northwest Ethiopia.

METHODS

Semi structured interviews were used to collect data from 25 midwives, nurses, and pediatricians with at least six months of prior experience in one of the labor wards or neonatal intensive care units at one of the four public health hospitals in the Amhara Regional state of northwest Ethiopia included in a large intervention study assessing a NNM scale. Purposeful sampling was used, selecting participants based on their experiences related to the aim of this study. The participants had a varying level of education and years of experience to care for NNM infants. The average age of the healthcare providers was 31 years, with 7 years of work experience. The transcripts of the interviews with the healthcare providers were analyzed using qualitative content analysis.

RESULTS

The experience and perceptions of healthcare providers was described in the main category "A sense of hopelessness when caring for the baby" capturing a broader emotional and professional aspect, while the subcategories "Unclear responsibilities discharging one's mission", "Provision of kangaroo mother care" and "Quick action required at birth" are more specific and practical. Healthcare providers perceived a sense of hopelessness when caring for the NNM infant, particularly providing Kangaroo Mother Care (KMC) and quick actions when required at birth to save the life of the infant.

CONCLUSION

Unclear responsibilities and a sense of hopelessness could have acted as barriers, hindering the ability of healthcare providers to fulfill their mission of taking swift actions and providing KMC to NNM infants, thus impacting their ability to save the lives of these infants. Healthcare providers' and parents' attitudes must be changed towards hope rather than hopelessness when caring for NNM infants.

Experiences of expressed human milk feeding: A qualitative study

OBJECTIVE

The objective of this study was to understand and describe the breastfeeding experiences of Chinese women with a high proportion of expressed human milk feeding.

METHODS

A qualitative descriptive design was used to describe the usual practices of expressed human milk feeding among breastfeeding women. We conducted semi-structured, in-depth, one-to-one interviews with participants (N = 25) who had a high proportion of expressed human milk feeding. Thematic analysis was used to analyze the data.

RESULTS

We identified three main themes: a sense of control, a sense of security, and milk expression challenges. Participants described that expressed human milk feeding provided a greater sense of control over their time and provided more freedom as they were no longer restricted by their infant's feeding schedule. Furthermore, knowing the amount of milk and having a stored milk supply provided a sense of security. However, providing expressed human milk can be time-consuming and has a lower intimacy level when compared with direct breastfeeding.

CONCLUSION

Expressed human milk feeding can provide a greater sense of control and was used as an immediate solution to direct breastfeeding problems. However, some participants experienced challenges in expressed human milk feeding, and some preferred breastfeed directly. Therefore, it is crucial to strengthen the breastfeeding support provided in the early postpartum period to ensure that all breastfeeding persons can breastfeed directly.

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.

Wayfinding through the "ocean of the great unknown": how lactating parents establish a direct breastfeeding relationship with an infant with critical CHD

INTRODUCTION

Lactating parents of infants hospitalised for critical congenital heart disease (CHD) face significant barriers to direct breastfeeding. While experiences of directly breastfeeding other hospitalised neonates have been described, studies including infants with critical CHD are scarce. There is no evidence-based standard of direct breastfeeding care for these infants, and substantial practice variation exists.

AIM

To explain how direct breastfeeding is established with an infant hospitalised for critical CHD, from lactating parents' perspectives.

MATERIALS & METHODS

This study is a qualitative grounded dimensional analysis of interviews with 30 lactating parents of infants with critical CHD who directly breastfed within 3 years. Infants received care from 26 United States cardiac centres; 57% had single ventricle physiology. Analysis included open, axial, and selective coding; memoing; member checking; and explanatory matrices.

RESULTS

Findings were represented by a conceptual model, "Wayfinding through the 'ocean of the great unknown'." The core process of Wayfinding involved a nonlinear trajectory requiring immense persistence in navigating obstacles, occurring in a context of life-and-death consequences for the infant. Wayfinding was characterised by three subprocesses: navigating the relationship with the healthcare team; protecting the direct breastfeeding relationship; and doing the long, hard work. Primary influencing conditions included relentless concern about weight gain, the infant's clinical course, and the parent's previous direct breastfeeding experience.

CONCLUSIONS

For parents, engaging in the Wayfinding process to establish direct breastfeeding was feasible and meaningful - though challenging. The conceptual model of Wayfinding explains how direct breastfeeding can be established and provides a framework for research and practice.

Evolution of Feeding and Developmental Outcomes in Infants With Moderate Hypoxic-Ischemic Encephalopathy: A Pilot Study

The purpose of the study was to describe the evolution of outcomes among full-term infants with moderate hypoxic-ischemic encephalopathy (HIE); from their early swallowing and feeding abilities during hospitalization, to their later developmental outcomes at 6 and 12 months. Four participants with moderate HIE were recruited. Early feeding and swallowing were assessed using the Neonatal Feeding Assessment Scale and video fluoroscopic swallow studies. Developmental assessments were conducted at 6 and 12 months using the Rossetti Infant-Toddler Language Scale and Vineland-3 Scale. All participants displayed atypical outcomes throughout the study, including oropharyngeal dysphagia initially during hospitalization. All participants were discharged on oral feeds but some breastfeeding difficulties persisted. Variable but pervasive developmental delays were found among all participants at 6 and 12 months. This study emphasizes the need for consistent early intervention from the neonatal period onward, for all infants with moderate HIE. Future studies should use larger cohorts, longer follow-up, and correlational designs.

Feeding Strategies in Newborns and Infants During the COVID-19 Pandemic-Polish Cross-Sectional Study

Objective: We aimed to analyze factors affecting feeding strategies of newborns and infants during the COVID-19 pandemic in Poland. Methods: The cross-sectional study using a self-developed CAWI questionnaire was conducted between February and April 2021 among Polish mothers. The analysis included responses from 1,485 women who delivered during the COVID-19 pandemic restrictions. The inferential analysis uses Parson's chi-square test and the series of logistic models. The data were weighted to adjust age and educational level distribution. Results: When hospitalized, lack of skin-to-skin contact (OR = 0.094; p < 0.001, 95% CI [0.057 0.156]), not being informed about direct breastfeeding in the pandemic (OR = 0.195, p = 0.006, 95% CI [0.61 0.62]) and being suspected for COVID-19 (OR = 0.379, p < 0.001, 95% CI [0.223 0.642]) reduced the probability of breastfeeding. Feeding plans and feeding after leaving the hospital were impacted only by the educational level (OR = 2.463, p = 0.028, 95% CI [1.1 5.518]). Conclusion: While the mother's education level plays a key role in the nutrition plans and long-term feeding strategy, PUI status and hospital practices (lack of skin-to-skin and proper information) had a major negative impact on breastfeeding rates in the hospital.

Learning from mothers' success in breastfeeding maintenance: coping strategies and cues to action

This study aimed to gain insight from mothers who were successful in breastfeeding maintenance to develop interventions for promoting breastfeeding maintenance. Following the phenomenological framework, this qualitative study recruited mothers who had maintained breastfeeding for at least 4 months for in-depth interviews. A total of 30 in-depth interviews were completed. We found that almost all participants had experienced an initial adjustment period. During this period, a social support network, personal perseverance in "trying" breastfeeding and "pumping," and adjusting expectations for breastfeeding to relieve themselves from the pressure of exclusive breastfeeding were important coping strategies. All participants then entered a stage of getting more attuned when breastfeeding was easier. During this period, seeking support from the online mother groups, deliberating medication that might affect breastfeeding, adjusting to accommodate breastfeeding and lives, and managing breastfeeding in public were the main strategies. For working mothers, despite workplace and employers' support, proactive adjustment for using the facilities and lactation breaks for breast milk expression was essential for breastfeeding continuation after returning to work. Throughout the whole journey, positive cues identified from their breastfeeding experiences that helped breastfeeding maintenance included enjoying breastfeeding, breastfeeding as a personal achievement, a healthy and thriving child, positive social feedback, bodily response, the convenience of breastfeeding, and breastfeeding as a motherhood commitment. To conclude, while mothers should be mentally prepared for the difficulties of breastfeeding, they should also be encouraged that things will always get easier as they persevere. Adjustments should be made to accommodate lives and other personal needs. Future studies should consider integrating relevant cues into existing psychosocial interventions for promoting breastfeeding maintenance.

Exclusive breastmilk pumping: A concept analysis

AIM

To analyze and examine the concept of exclusive breast pumping (EP).

BACKGROUND

Breastmilk is the ideal nutrition for infants, yet when breastfeeding is unsuccessful, parents resort to informal breastmilk sharing, artificial formula feeding, or EP. A growing proportion of families exclusively pump yet they often receive guidance from social media rather than healthcare providers because healthcare providers are uninformed about this feeding method.

DATA SOURCE

Cumulative Index of Nursing and Allied Health Literature, PubMed, and Google Scholar databases were searched using the following keywords: human milk express*, breast express*, breast milk express, breastmilk express*, exclusive pump, exclusive breast pumping, and exclusive expression.

REVIEW METHODS

Concept analysis design using Walker and Avant's method.

RESULTS

Three defining attributes of (1) absence of direct breastfeeding, (2) breastmilk expression, (3) and an enduring infant feeding pattern of feeding expressed breastmilk only via a bottle were identified. All three attributes are required to confirm the presence of the concept of exclusive pumping. Definitions, antecedents, consequences, and empirical referents are described. Model and contrary cases are discussed.

CONCLUSION

This exclusive pumping concept analysis allows for consistency in terminology in practice and research. EP is a feeding method which can increase the proportion of infants who are fed breastmilk and may reduce the risks that arise from artificial formula feeding.

Postnatal women's breastfeeding beliefs, practices, and support during the COVID-19 pandemic: a cross-sectional comparative study across five countries

Background

Women with COVID-19 experienced numerous concerns and doubts about the safety of breastfeeding their babies, and lack of support may have impacted breastfeeding practices. This study aims to compare breastfeeding beliefs, practices, and contact with healthcare professionals regarding the level of postnatal feeding support provided during the COVID-19 pandemic in Brazil, South Korea, Taiwan, Thailand, and the United Kingdom.

Methods

A multi-country cross-sectional study was conducted with postnatal women in five countries. Women up to six months postpartum were invited to complete an online survey concerning the transmission of preventative measures, beliefs toward breastfeeding, infant feeding practices in the last 24 hours and experiences of postnatal infant feeding support between July to November 2021. Bivariate and multivariate analyses were performed to identify the association.

Results

Of the 3,253 eligible responses received, 39.5% of children were aged between one and two months, but in Taiwan (36%) and South Korea (42.8%) they were between three and four months. The mean of the belief score was significantly different among countries (p < 0.0001). Women in Brazil and the UK had a higher rate of breastfeeding at the breast (90.7% and 85.4%, respectively) compared to the three Asian countries (p < 0.0001) while feeding with expressed breastmilk in Thailand (59.9%), Taiwan (52.6%), and South Korea (50.4%) was higher than the others (p < 0.0001). Brazil and UK mothers (mean = 16.0 and 14.5 respectively) had a higher mean score for belief toward breastfeeding during the COVID-19 than the others. These results are inversely associated with breastfeeding but positively related to formula feeding practice. Postnatal feeding support during the COVID-19 pandemic was mainly provided by healthcare professionals (67.1%) and peers / family through face-to-face personal contact (51.6%) in all countries.

Conclusion

Some differences were found in breastfeeding beliefs during the COVID-19 pandemic in Asian countries. A positive breastfeeding belief was associated with the practice of breastfeeding at the breast. Women from all countries received postpartum infant feeding support from health professionals and peers / family through personal contacts. Governments need to emphasize and disseminate the importance of breastfeeding safety, especially in Asian countries.

The Association Between Breastfeeding Self-Efficacy and Mode of Infant Feeding

Introduction: It is well established that low breastfeeding self-efficacy is associated with early breastfeeding cessation. Over the past several decades, expressed human milk feeding has increased among parents of healthy infants. Researchers have hypothesized an association between maternal breastfeeding confidence and expressed human milk feeding, but it has not been empirically examined. Therefore, the primary objective of this study was to assess the associations between breastfeeding self-efficacy and human milk expression practices. The secondary objective was to assess the effect of breastfeeding self-efficacy on breastfeeding duration and exclusivity. Methods: This study used a prospective cohort design. From 2017 to 2018, we recruited 821 healthy mothers with term births in two public hospitals in Hong Kong. Participants completed a self-administered questionnaire in the immediate postpartum period, which gathered information about sociodemographic characteristics and Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). Participants were followed up for 6 months or until infants were weaned. The proportion and type of infant feeding were assessed at telephone follow-up. Results: The overall mean BSES-SF score in our sample was 46.5 (standard deviation = 10.1). Every one-point increase in the BSES-SF score was associated with 4-5% lower risk of any expressed human milk feeding and 4-7% higher odds of breastfeeding continuation across the first 6 months postpartum. Conclusion: Higher breastfeeding self-efficacy is associated with a lower risk of expressed human milk feeding and a longer duration of any and exclusive breastfeeding. Further studies should explore how improving breastfeeding self-efficacy may affect the mode of human milk feeding.

Factors Associated With Exclusive Direct Breastfeeding in the First 3 Months

OBJECTIVE

To identify factors associated with exclusive direct breastfeeding in the first 3 months among mother and infant dyads living in the United States.

DESIGN

A secondary analysis of data collected using a cross-sectional online survey completed over a 4-month period in late 2019.

PARTICIPANTS

We recruited a convenience sample of 370 mothers with healthy full-term singleton infants between 1 and 12 weeks of age whose feeding methods consisted of direct breastfeeding at least once a day. Mothers had not returned to work/school at the time of the survey completion.

MEASUREMENTS

The questionnaire consisted of 34 questions about maternal and infant factors that influence decisions about infant feeding, professional support, and parental preferences.

RESULTS

Mothers who practiced feeding on demand (adjusted OR [aOR] = 35.76, 95% confidence interval [CI] [2.04, 500.00]) and mothers of infants 1 to 4 weeks of age (aOR = 2.74, 95% CI [1.54, 4.85]) were more likely to use exclusive direct breastfeeding. The odds of exclusive direct breastfeeding decreased with mothers who breastfed with a nipple shield while in the hospital/birth center/home (aOR = 0.13, 95% CI [0.05, 0.35]), used pacifiers (aOR = 0.31, 95% CI [0.21, 0.65]), or had perceptions of insufficient milk (aOR = 0.11, 95% CI [0.04, 0.26]).

CONCLUSION

Demand feeding and an infant's age of 1 to 4 weeks contributed to exclusive direct breastfeeding. Lower rates of exclusive direct breastfeeding were associated with the use of nipple shields immediately after birth, pacifier use, and perceptions of insufficient milk. Further investigation is warranted to fully differentiate exclusive direct breastfeeding from exclusive breastfeeding.

Associations between use of expressed human milk at 2 weeks postpartum and human milk feeding practices to 6 months: a prospective cohort study with vulnerable women in Toronto, Canada

OBJECTIVES

To examine whether use of expressed human milk in the first two weeks postpartum is associated with cessation of human milk feeding and non-exclusive human milk feeding up to 6 months.

DESIGN

Pooled data from two prospective cohort studies SETTING: Three Canada Prenatal Nutrition Program (CPNP) sites serving vulnerable families in Toronto, Canada.

PARTICIPANTS

337 registered CPNP clients enrolled prenatally from 2017 to 2020; 315 (93%) were retained to 6 months postpartum.

EXCLUSIONS

pregnancy loss or participation in prior related study; Study B: preterm birth (<34 weeks); plan to move outside Toronto; not intending to feed human milk; hospitalisation of mother or baby at 2 weeks postpartum.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main exposure variable: any use of expressed human milk at 2 weeks postpartum.

OUTCOMES

cessation of human milk feeding by 6 months; non-exclusive human milk feeding to 4 months and 6 months postpartum.

RESULTS

All participants initiated human milk feeding and 80% continued for 6 months. Exclusive human milk feeding was practiced postdischarge to 4 months by 28% and to 6 months by 16%. At 2 weeks postpartum, 34% reported use of expressed human milk. Any use of expressed human milk at 2 weeks was associated with cessation of human milk feeding before 6 months postpartum (aOR 2.66; 95% CI 1.41 to 5.05) and with non-exclusive human milk feeding to 4 months (aOR 2.19; 95% CI 1.16 to 4.14) and 6 months (aOR 3.65; 95% CI 1.50 to 8.84).

TRIAL REGISTRATION NUMBERS

NCT03400605, NCT03589963.

Unseen, unheard: a qualitative analysis of women's experiences of exclusively expressing breast milk

BACKGROUND

Breast milk feeding has numerous benefits for women and infants. Positive maternal experiences with breast milk feeding impacts exclusivity, duration, and maternal mental health. Most research focuses on women feeding directly at the breast. Some women elect to feed exclusively expressed milk to their healthy, term infants rather than feed directly at the breast. Little is known about what constitutes a positive experience among this population. Therefore, the aim of this study was to explore women's experiences of exclusive expression (EE).

METHODS

Interviews were conducted via Microsoft Teams to collect qualitative data from a purposive sample of 21 women practicing EE. Interviews were analyzed for themes.

RESULTS

Three themes: Unseen and Unheard, Doing it My Way, and Getting into the Groove, and 8 subthemes: Breast is Best, Missed Opportunities for Healthcare Provider Support, Fighting for it, What Works for Us, A Sense of Control, Preparation, Tricks of the Trade, and Making it Manageable were identified. Despite challenges, including a lack of support from healthcare providers and a lack of acknowledgement as breastfeeding mothers, exclusive expression offered participants a method to continue breast milk feeding in a way that they found to be satisfying.

CONCLUSION

This study provides insight into experiences of exclusive expression that clinicians can use to improve their support of breast milk feeding during perinatal encounters. Societal pressure to feed from the breast may have negative emotional consequences for women electing to exclusively express. There is a need for more information and support for breast milk expression from healthcare providers along with a reframing of how breast milk feeding is discussed and promoted.

Privacy, Early Colostrum, and Gestational Age are Associated with Exclusive Breastfeeding in Preterm and Sick Term Infants

Our study was designed to assess the rates of exclusive breastfeeding (defined as direct breastfeeding) and the use of mother's own milk (MOM) in preterm infants and sick term infants at discharge and to identify potential influencing factors such as gestational age, early colostrum, and privacy. The study was conducted at a German level III neonatal department. All preterm and sick term infants admitted to the neonatal intensive care unit, the pediatric intensive care unit, the intermediate care unit, and the low care ward were included in the study. Infants were recruited between March and October 2015 (phase 1) and April to July 2016 (phase 2). Due to an emergency evacuation, privacy was limited during the first phase. Breastfeeding and the use of MOM were assessed daily using a self-designed score. In total, 482 infants of 452 mothers were included. More than 90% initiated breastfeeding and one-third were exclusively breastfed at discharge. Extremely immature infants and late preterm infants were less likely to be exclusively breastfed at discharge. Privacy (p<0.001) and early colostrum (p=0.002) significantly increased exclusive breastfeeding. Conclusion Extremely immature and late preterm infants were least likely to be exclusively breastfed at discharge and need special support. Interventions such as privacy and early colostrum should be promoted to increase breastfeeding.

Association between expressed breast milk feeding and breastfeeding duration in Hong Kong mothers

BACKGROUND

Expressed breast milk feeding has increased substantially in the past two decades. Once used primarily for preterm infants, feeding expressed breast milk is now more common in mothers giving birth to healthy term infants. However, the effect of expressed breast milk feeding on breastfeeding duration is unclear.

OBJECTIVES

To assess the association between breast milk expression practices and breastfeeding duration in women giving birth to healthy infants.

METHODS

From 2017 to 2018, we recruited 821 new mothers from two public hospitals in Hong Kong. Participants were followed up at 1.5, 3, and 6 months postpartum or until they stopped breastfeeding. The proportion, type, and mode of all milk feeding were assessed at each follow-up.

RESULTS

At 1.5 months postpartum, 47.9%, 37.7%, and 14.4% of participants were feeding by direct breastfeeding only, mixed-mode feeding, and expressed breast milk only, respectively. Participants feeding expressed breast milk only were more likely to be supplementing with infant formula. When compared with participants who provided only direct breastfeeding, participants who gave only expressed breast milk at 1.5 months had 57% lower odds of breastfeeding continuation at three months postpartum. After stratification by infant formula supplementation, expressed breast milk feeding only at 1.5 months was associated with an increased risk of breastfeeding cessation in participants supplementing with infant formula (adjusted hazard ratio [aHR] = 1.86, 95% CI = 1.17-2.95).

CONCLUSION

In the first six months postpartum, giving only expressed breast milk is associated with early breastfeeding cessation, especially in participants who are also supplementing with infant formula.

Comparing breastfeeding experiences between mothers spending the traditional Chinese confinement period in a confinement centre and those staying at home: a cohort study

Background

Ethnic Chinese mothers in Malaysia adhere to 30 days of traditional postpartum practices (the “confinement period”) aimed at recuperation after delivery. Recently there has been an emergence of confinement centres (CCs) where mothers stay and receive traditional confinement care. Ethnic Chinese mothers have low breastfeeding rates. There are concerns that practices in CCs could contribute to this but no data exists. We described mothers’ breastfeeding experiences at CCs and identified areas for potential improvement in breastfeeding support.

Methods

Ethnic Chinese mothers intending to breastfeed their healthy infants were recruited post-delivery between August and October 2017 then, at 1 and 6 months, they were telephone interviewed about their experience. For every participant going to a CC after the birth, another mother going home (“home”) for her confinement was recruited. Chi-square test was used to compare groups and multiple logistic regression was used to assess the effect of confinement place on exclusive breastfeeding.

Results

Of 187 mothers, 88 (47%) went to CCs. Significantly more were primipara and fewer had previous breastfeeding experience. Response rates for the 1- and 6- month interviews were 88% (CC) versus 97% (home); and 77% (CC) versus 87% (home) respectively.

Exclusive breastfeeding rates were similar between the groups: 62% (CC) versus 56% (home) at 1 month (p = 0.4); and 37% (CC) versus 42% (home) at 6 months (p = 0.5). Multiple logistic regression did not show that CCs were a factor affecting exclusive breastfeeding rates at 1 month, (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 0.9, 3.3), or 6 months (aOR 0.9, 95% CI 0.4, 1.7). However, significantly more CC participants only fed expressed breast milk. Despite 66% of CC participants reporting that their centre supported breastfeeding, only 6 (8%) CC participants compared to 66 (69%) of home participants roomed-in with their baby (p < 0.001). The proportion encountering breastfeeding difficulties were similar between groups. CC participants sought help for breastfeeding problems mainly from CC staff and support groups while home participants obtained help from friends and healthcare professionals.

Conclusions

Breastfeeding rates appeared to be similar at CCs and at home during the confinement period, but there were gaps in how CCs supported breastfeeding. Targeted training to CC staff to support breastfeeding may result in better outcomes for mothers staying in CCs.

Mechanisms of support for exclusive breastmilk expressers in the community: a scoping review

BACKGROUND

The World Health Organization recommends that infants be exclusively breastfed until the age of six months. Breastfeeding is generally understood to mean the provision of human breastmilk to the infant by direct feeding at the breast, and interventions aimed at supporting exclusive breastfeeding are therefore targeted at this activity. However, breastfeeding is actually an umbrella term covering the provision of breastmilk to an infant by any means. Our population of interest is mothers who exclusively feed their infants indirectly using expressed breastmilk. Some research suggests that any expressing, and exclusively expressing in particular, can be a risk factor for early cessation of exclusive breastmilk provision, so we were interested to identify whether any specific support existed for exclusively expressing mothers outside of the context of premature infants and the Neonatal Intensive Care Unit setting.

METHODS

A scoping review following the Joanna Briggs Institute approach was used to explore the phenomenon of formal and informal supports in the community for exclusively expressing mothers. Searches were run across academic databases and of government websites and infant feeding support organisations. Finally, an informal internet search was run using a simple search string.

RESULTS

On analysis of results, there were no studies or articles that met the search criteria. An informal internet search linked us directly with websites and blogs that could be considered a form of support intervention. These informal results suggest that support material or programs could possibly exist in other modalities but we cannot find them in the context of this type of scoping review.

CONCLUSIONS

The results of the search corroborated what we had suspected - that exclusively expressing mothers are not specifically supported by usual channels for new parents and that it is also difficult to find acknowledgement that exclusive expression exists. The absence of results demonstrates the relevance of this study: exclusively expressing mothers are an under-served population. If we wish to strive towards achievement of World Health Organization breastfeeding goals, exclusively expressing mothers require targeted support to assist in their infant feeding experience, and there is little formal evidence of it currently being provided.

Physical Analysis of the Breast After Direct Breastfeeding Compared with Hand or Pump Expression: A Randomized Clinical Trial

Background: Expressing human milk using commercially available pumps has increased. Most women use mechanical means to transfer their milk at some point during lactation. Yet, there is very little quantification of any breast tissue changes that occur when using mechanical devices to facilitate milk transfer. Objective: Women comfortable with breastfeeding were recruited to participate in a study to measure physical changes of the breast with a variety of human milk transfer modalities under close observation. Materials and Methods: Direct breastfeeding with their infant, hand expression, and mechanical milk transfer using two commonly available breast pumps were utilized over four milk transfer sessions with each participant. Each participant directly breastfed on the first milk transfer session and the remaining modalities were randomized. Measurements were taken before and after each modality using digital calipers. Participants completed a modified pain scale after each observation. Measurements taken after breastfeeding were used as the control for data interpretation for each participant. After a 20-minute rest period, breast tissue was again examined, and tissue appearance was recorded. Within-subject modality differences were calculated, and paired analysis mean difference and standard error of the mean are presented. Results: Fifty eligible women were approached with 92% participating. The "before" measurements were not significant for all the modalities. The "after" measurements were significantly different at p < 0.003 for breast pumps but not for breastfeeding or hand expressing. Many participants indicated pain with pumping. Conclusion: Mechanical pump use correlated with significantly increased length and diameter of the nipple compared with the post-breastfeeding and hand expressing dimensions. Pump use correlated with significant pain scores and resulted in localized inflammatory changes. Understanding how pumps affect breast tissue is helpful in improving experiences with breast pumps and may improve breastfeeding outcomes. Additional research is needed to better understand ramifications of long-term use of breast pumps.

Breastfeeding progression in late preterm infants from birth to one month

This study aimed to describe and compare breastfeeding progression, infants' feeding behaviours, maternal feeding difficulties, and mothers' usage of breastfeeding interventions for singleton late preterm (LPT) and term infants. A further aim was to identify associated factors for exclusive breastfeeding at breast at 1 month in LPT infants. This was a cohort study where mothers of LPT infants from a neonatal unit (n = 60), LPT infants from a maternity unit (n = 62), and term infants from a maternity unit (n = 269) answered a questionnaire approximately 1 month after delivery. Findings showed no significant differences in exclusive breastfeeding at breasts between LPT infants admitted to the neonatal unit compared with the maternity unit, during the first week at home (38% vs. 48%), or at 1 month of age (52% vs. 50%). Term infants were more likely to be exclusively breastfed at the breast (86% and 74%, p < 0.05) compared with LPT infants. Multiple regression analysis showed that usage of a nipple shield, not feeding breast milk exclusively during the first week at home, or feeding less than 10 times per day at 1 month were statistically significant for not exclusively breastfeed at the breast. A protective factor was the mothers' experience of having an abundance of milk during the first week at home. In conclusion, LPT infants are less likely to be exclusively breastfed at the breast than term infants, highlighting the need for further research to guide interventions aimed at optimising exclusive breastfeeding rates.

Preventive Health Application to Increase Breastfeeding

Background: Mother-infant dyads are not meeting recommended breastfeeding goals. There is lack of consensus regarding any program's ability to increase breastfeeding duration to meet the recommended guidelines, and effective strategies are needed moving forward to help families meet those goals. Primary prevention utilizing consistent visits with lactation professionals with a group of new mothers may efficiently address this care gap. Methods: Mother-infant dyads attending a newborn care clinic for 6 weeks received feeding assessment and standard-of-care guidance from an Internationally Board-Certified Lactation Consultant (IBCLC). Regression analysis was completed with outcome variables "exclusive direct breastfeeding" (EDB) and "any breastfeeding" (AB) at 6 weeks postpartum (PP) and odds ratios were calculated. Results: The number and timing of IBCLC visits was correlated with EDB at 6 weeks PP. Maternal/infant dyads seen at day 3 had 2.5 times higher odds of EDB at 6 weeks than those not receiving IBCLC standard-of-care feeding assessment. Dyads seen at days 3 and 14 had 3.4 times higher odds of EDB than those with less follow-up. Bottle use correlated with decreased odds of AB at 6 weeks PP; similarly, dyads seen only at day 14 PP had decreased odds of EDB. When looking at timing of the first involvement, dyads seen at 3 days had higher odds of EDB than dyads first seen at day 14 PP. Conclusions: This primary prevention strategy of early minimal intervention using an IBCLC increased the odds of EDB and AB at 6 weeks PP. These data support the conclusion that early feeding assessment the first 2 weeks PP with an IBCLC may increase breastfeeding at 6 weeks PP.

Short-term efficacy of two breast pumps and impact on breastfeeding outcomes at 6 months in exclusively breastfeeding mothers: A randomised trial

The provision of breast pumps is a potential strategy to increase breastfeeding duration. This trial compared the effectiveness and acceptability of two breast pumps in mothers exclusively breastfeeding (EBF) their healthy term infant. It also tested whether provision of pumps versus vouchers of equivalent value influenced breastfeeding or attainment of mothers' goals at 3 and 6 months. Mothers were randomised at 3- to 4-week post-partum (Beijing [n = 30], Moscow [n = 34], London [n = 45], New York [n = 3]) to groups A (Philips single-electric pump, Natural bottle), B (Medela Swing single-electric pump, Calma bottle), or C (Control; vouchers). At 6 weeks, group A and B mothers expressed for 10 min/breast; milk weight and opinions of pump/bottle were recorded. Feeding practices were assessed using questionnaires at 3 and 6 months. Milk weight/flow pattern did not differ between groups. Pump A scored significantly better for ease-of-use, cushion-feel, need-to-lean-forward, pleasant, comfort. At 3 and 6 months, %EBF or meeting their goal was not significantly different; (3 months: 86%, 85%, 84%; 6 months: 20%, 15%, 26%; meeting goal 24%, 17%, 27% for A, B, and C). Expressed breast milk (EBM) provision was higher in groups A and B (3 months: 76%, 76%, 24% (p < 0.001); 6 months: 83%, 87%, 32% (p < 0.001); and negatively predicted EBF at 6 months (OR no EBM 5.07, 95% CI [1.56, 16.5]). The pumps were equally effective for milk expression at 6 weeks. Pump provision did not significantly influence breastfeeding practices or attainment of goals but resulted in higher EBM provision, which was associated with lower EBF but not other breastfeeding categories at 6 months.

Women's views about a free breast pump service: Online survey informing intervention development

Improving breastfeeding outcomes is a global priority; however, in the United Kingdom, continuation of breastfeeding remains low. Growing empirical evidence suggests a free breast pump service might be an acceptable and feasible incentive intervention to improve breastfeeding outcomes and reduce heath inequalities. To inform intervention development, we conducted an online survey with women recruited via social media using snowball sampling. Data were analysed descriptively (closed questions) with qualitative thematic analysis (free text). The survey was completed by 666 women, most of whom had recently breastfed and used a breast pump. Participants agreed that free pump hire (rental/loan; 567 women; 85.1%) or a free pump to keep (408; 61.3%) should be provided. Free text comments provided by 408 women (free pump) and 309 women (free hire) highlighted potential benefits: helping women to continue breastfeeding; express milk; overcome difficulties; and pump choice. Concerns are possible effect on breast milk supply, reduced breastfeeding, pumps replacing good support for breastfeeding, and pump hire hygiene. Personal and societal costs are important issues. Some suggested a pump service should be for low-income mothers, those with feeding difficulties or sick/preterm infants. A one-size service would not suit all and vouchers were proposed. Some suggested fees and deposits to prevent waste. To our knowledge, this is the first study reporting views about the acceptability of providing a free breast pump hire service. Mothers support and wish to have a say in breast pump service development. Future evaluations should address impact on feeding outcomes, professional support, hygiene for hired pumps, and costs.

Nutrients or nursing? Understanding how breast milk feeding affects child cognition

Purpose

To explore the associations between type of milk feeding (the “nutrients”) and mode of breast milk feeding (the “nursing”) with child cognition.

Methods

Healthy children from the GUSTO (Growing Up in Singapore Toward healthy Outcomes) cohort participated in repeated neurodevelopmental assessments between 6 and 54 months. For “nutrients”, we compared children exclusively bottle-fed according to type of milk received: formula only (n = 296) vs some/all breast milk (n = 73). For “nursing”, we included only children who were fully fed breast milk, comparing those fed directly at the breast (n = 59) vs those fed partially/completely by bottle (n = 63).

Results

Compared to infants fed formula only, those who were bottle-fed breast milk demonstrated significantly better cognitive performance on both the Bayley Scales of Infant and Toddler Development (Third Edition) at 2 years [adjusted mean difference (95% CI) 1.36 (0.32, 2.40)], and on the Kaufman Brief Intelligence Test (Second Edition) at 4.5 years [7.59 (1.20, 13.99)]. Children bottle-fed breast milk also demonstrated better gross motor skills at 2 years than those fed formula [1.60 (0.09, 3.10)]. Among infants fully fed breast milk, those fed directly at the breast scored higher on several memory tasks compared to children bottle-fed breast milk, including the deferred imitation task at 6 months [0.67 (0.02, 1.32)] and relational binding tasks at 6 [0.41 (0.07, 0.74)], 41 [0.67 (0.04, 1.29)] and 54 [0.12 (0.01, 0.22)] months.

Conclusions

Our findings suggest that nutrients in breast milk may improve general child cognition, while nursing infants directly at the breast may influence memory.

Electronic supplementary material

The online version of this article (10.1007/s00394-019-01929-2) contains supplementary material, which is available to authorized users.

Breastfeeding Intention Compared With Breastfeeding Postpartum Among Women Receiving Medication-Assisted Treatment

BACKGROUND:

Women taking methadone or buprenorphine are encouraged to breastfeed if stable without polysubstance use.

RESEARCH AIM:

We aimed to determine the difference between stated intention to breastfeed prenatally in women taking methadone or buprenorphine compared with breastfeeding at discharge and 2 months postpartum. Secondary outcomes were determining whether breastfeeding was more common in women taking buprenorphine, in women without hepatitis C infection, and in women without a history of heroin use, and whether breastfeeding reduced the need for pharmacological treatment of neonatal opioid withdrawal syndrome.

METHODS:

This was a retrospective cohort study of 228 women enrolled in a perinatal substance abuse treatment program. Electronic medical records were reviewed to abstract data on mother-infant dyads. Chi-square tests were used to analyze our outcomes.

RESULTS:

Women taking buprenorphine had a higher prevalence of breastfeeding compared with women taking methadone (83% [ n = 100] vs. 71% [ n = 76]; χ² = 4.35, p = .03), despite no difference in their prenatal intention to breastfeed (87% vs. 81%; χ² = 1.28, p = .25). Only 31% ( n = 38) of women taking buprenorphine and 19.6% ( n = 21) of women taking methadone exclusively breastfed at discharge (χ² = 5.43, p = .06). Exclusively breastfed infants required less pharmacological treatment for neonatal opioid withdrawal syndrome compared with formula-fed infants (15.8% [ n = 21] vs. 47.4% [ n = 38]; χ² = 19.72, p < .05).

CONCLUSION:

Despite most women reporting a high prenatal intention to breastfeed, exclusive breastfeeding at hospital discharge postpartum was low. Breastfeeding was associated with a decreased likelihood of pharmacological treatment for neonatal opioid withdrawal syndrome.

Mother⁻Infant Physical Contact Predicts Responsive Feeding among U.S. Breastfeeding Mothers

Responsive feeding—initiating feeding in response to early hunger cues—supports the physiology of lactation and the development of infant feeding abilities, yet there is a dearth of research examining what predicts responsive feeding. In non-Western proximal care cultures, there is an association between responsive feeding and mother–infant physical contact, but this has not been investigated within Western populations. In two studies, we tested whether mother–infant physical contact predicted feeding in response to early hunger cues versus feeding on a schedule or after signs of distress among U.S. breastfeeding mothers. With an online questionnaire in Study 1 (n = 626), physical contact with infants (via co-sleeping and babywearing) predicted increased likelihood of self-reported responsive feeding. Mothers who reported responsive feeding were more likely to exclusively breastfeed for the first six months, breastfeed more frequently throughout the day, and had a longer planned breastfeeding duration than mothers who reported feeding on a schedule or after signs of infant distress. In Study 2 (n = 96), a three-day feeding log showed that mother–infant physical contact predicted feeding in response to early hunger cues but mother–infant proximity (without physical contact) did not. In sum, our results demonstrate that physical contact with infants may shape breastfeeding behavior among U.S. mothers, highlighting a connection between social interaction and infant nutrition that warrants further investigation.

Direct Feeding at the Breast Is Associated with Breast Milk Feeding Duration among Preterm Infants

BACKGROUND

In spite of high rates of initiating breast milk feeding (BMF) among preterm infants, a significant rate of discontinuation occurs shortly after discharge.

AIM

To investigate the effect of mode (direct feeding at the breast vs. expressing) and exclusivity (breast milk combined with formula vs. breast milk only) as well as maternal perceptions on the duration of BMF among preterm infants.

METHODS

The study included mothers whose infants were born before 32 weeks gestation, between January 2012 and August 2015 at Sheba Medical Center (SMC). Perinatal data were collected retrospectively from infants' computerized charts. Mothers were approached >12 months postpartum and were asked to complete a questionnaire. Those who agreed to participate were asked (during their visit to the follow-up clinic or by phone or mail) to complete a questionnaire regarding mode and duration of BMF as well as reasons for its discontinuation. Mothers were also asked about their pre-partum intentions to feed directly at the breast.

RESULTS

Out of 162 eligible mothers, 131 (80.8%) initiated BMF during their intensive care unit (ICU) hospitalization. Of these, 66 (50.3%) discontinued BMF earlier than six months postpartum. BMF ≥ 6 months was significantly associated with direct feeding at the breast, duration of exclusive BMF, and singleton birth. Regression analysis revealed that direct feeding at the breast (any or only) and duration of BMF exclusivity were the only significant variables associated with BMF duration (Odds ratio (OR) 5.5 and 95% confidence interval (CI) 2.00-15.37; OR 1.5 and 95% CI 1.25-1.88, respectively). Milk supply (inadequate or nonexistent) was the most commonly reported cause for BMF discontinuation <6 months. Direct feeding at the breast was significantly associated with BMF duration and was more common among singletons.

CONCLUSIONS

Direct feeding at the breast and duration of exclusive BMF are associated with duration of BMF among infants born <32 weeks of gestational age (GA). These findings suggest that targeting these two factors may play a key role in prolonging BMF duration among preterm infants.