Initiation of lactation in women after preterm delivery

Determinants of Successful Direct Breastfeeding at Hospital Discharge in High-Risk Premature Infants

BACKGROUND

Despite a mother's intention to breastfeed, there are many barriers to feeding preterm infants that decrease breastfeeding rates.

OBJECTIVE

The objective of this research was to determine factors associated with successful direct breastfeeding (DBF) of the preterm infant at hospital discharge.

MATERIALS AND METHODS

A retrospective chart review of 69 preterm (<34 weeks' gestational age) infants in the neonatal intensive care unit, whose mothers intended to breastfeed, was conducted. Infant-, mother-, and feeding-related factors were examined by chi-square or t test for their relationship with breastfeeding success, and by multiple logistic regression to identify predictive factors.

RESULTS

Successful DBF at discharge occurred in 64%. Mothers of infants who were breastfed were older (p < 0.0001); had less psychiatric illness (p = 0.03); and were less likely to smoke (p < 0.0001) and use recreational drugs (p = 0.04). The infants had higher birth weights (p = 0.03) and lower incidence of bronchopulmonary dysplasia (p = 0.04). A higher proportion of infants received DBF at their first oral feed (p < 0.001), and were discharged earlier (p = 0.03). Reduced milk supply was cited for breastfeeding failure in 36%. Older maternal age (odds ratio [OR] = 1.24, 95% confidence interval [CI] 1.02-1.51) and DBF at the first oral feed (OR = 7.72, 95% CI 1.37-43.6) were associated with successful DBF at discharge.

CONCLUSION

Maternal age and method of first oral feed are critical predictors of breastfeeding success in preterm infants. Mothers should be encouraged to breastfeed at the infant's first oral attempt and strategic breastfeeding support should be provided before initiation of oral feeding.

Milk Volume at 2 Weeks Predicts Mother's Own Milk Feeding at Neonatal Intensive Care Unit Discharge for Very Low Birthweight Infants

OBJECTIVE

This study sought to determine the maternal prepregnancy, pregnancy, and delivery risk factors that predicted coming to volume (CTV; achieving pumped mother's own milk [MOM] volume ≥500 mLs/day) and the continuation of MOM provision through to discharge from the neonatal intensive care unit (NICU) in mothers and their very low birthweight (VLBW; <1,500 g at birth) infants.

STUDY DESIGN

Secondary analysis of prospectively collected data from 402 mothers of VLBW infants admitted to an urban NICU, including detailed MOM pumping records for a subset (51%) of the cohort. Analyses included inverse probability weighting, multivariate regression, and chi-square statistics.

RESULTS

In this high-risk cohort (51.2% black, 27.1% Hispanic, 21.6% white/Asian; 72.6% low income; 61.4% overweight/obese prepregnancy), CTV by day 14 was the strongest predictor of MOM feeding at NICU discharge (odds ratio [OR] 9.70 confidence interval [95% CI] 3.86-24.38, p < 0.01.). Only 39.5% of mothers achieved CTV by postpartum day 14, an outcome that was predicted by gestational age at delivery (OR 1.41, 95% CI 1.15-1.73, p < 0.01), being married (OR 3.66, 95% CI 1.08-12.39, p = 0.04), black race (OR 7.70, 95% CI 2.05-28.97, p < 0.01), cesarean delivery (OR 0.22, 95% CI 0.08-0.63, p = 0.01), and chorioamionitis (OR 0.14, 95% CI 0.02-0.82, p = 0.03).

CONCLUSION

Continued provision of MOM at NICU discharge can be predicted in the first 14 postpartum days on the basis of achievement of CTV. We posit that CTV can serve as a quality indicator for improving MOM feedings in the NICU and that lactation support resources should target this early critical postbirth period.

Characterisation of sucking dynamics of breastfeeding preterm infants: a cross sectional study

BACKGROUND

Full breastfeeding is the ultimate aim for preterm infants to ensure they receive the full benefits of human milk however, preterm infants face a number of challenges associated with their immaturity and associated morbidities. In order to facilitate oral feeding, it is essential to have a sound knowledge of the sucking dynamics of the breastfed infant. The aim of this study was to measure and describe the sucking dynamics of the preterm breastfeeding infant.

METHODS

A prospective cross sectional observational study was carried out at King Edward Memorial Hospital, Perth. 38 mothers and their preterm infants (birth gestation age: 23.6-33.3 weeks; corrected gestation age 32.7 to 39.9 weeks) were recruited. Intra-oral vacuum levels, tongue movement and milk intake for a single breastfeed was measured. Statistical analysis employed linear regression and linear mixed effects models.

RESULTS

Synchronised ultrasound and intra-oral vacuum measurements show that the preterm infant generates vacuum by lowering their tongue in a parallel fashion, without distortion of the nipple/nipple shield. Baseline (B), mean (M) and (P) peak suck burst vacuums weakened over the course of a feed (B: p = 0.015; M: p = 0.018; P: p = 0.044) and mean and peak vacuums were weaker if the mother fed with a nipple shield (M: p = 0.012; P: p = 0.021). Infant milk intakes were higher when infants sucked for longer (p = 0.002), sucked for a greater proportion of the feed (p = 0.002), or had a greater sucking efficiency (p < 0.001).

CONCLUSIONS

Breastfeeding preterm infants generated intra-oral vacuum in the same manner as term infants. Nipple shields were associated with weaker intra-oral vacuums. However, vacuum strengths were not associated with milk intake rather time spent actively sucking was related to milk volumes. Further research is required to elucidate factors that influence preterm infant milk intake during breastfeeding.

Preterm Human Milk Macronutrient and Energy Composition: A Systematic Review and Meta-Analysis

This study is a systematic review of the macronutrient and energy composition of preterm human milk to enable the practicing neonatologist to make informed nutritional decisions in preterm infants. Meta-analyses were conducted in all the studies that reported total energy, true protein, fat, and lactose. Protein content decreased massively (by one-half) and significantly from day 1 to 3 at week 10 to 12. There was a significant linear increase in fat, lactose, and energy content during the same timeframe. Theoretic calculations on energy and macronutrient intake of preterm infants must be made according to a lactation time-specific manner.

After Chemotherapy Treatment for Maternal Cancer During Pregnancy, Is Breastfeeding Possible?

OBJECTIVE

To report breastfeeding complaints of women diagnosed with cancer during pregnancy and correlate success with characteristics of their treatment.

MATERIALS AND METHODS

This is a prospective cohort study of women diagnosed with cancer during pregnancy who attempted breastfeeding. We surveyed participants about breast engorgement, milk let down, and consistent breast milk production through mailed questionnaires. Treatment details, including the type and number of chemotherapy cycles given during pregnancy and antepartum or postpartum depression, were collected. A single pathologist evaluated surgical specimens to note lactational changes while blinded to patient's treatment. The primary endpoint was successful breastfeeding without reporting any lack of or decreased breast milk production.

RESULTS

When comparing women who underwent chemotherapy during pregnancy to women who did not, there was a significant difference in reporting a lack of or a perceived decrease in breast milk supply and the need to provide supplemental feeding to their infants (63.5% and 9%, respectively, p < 0.001). In the women who received chemotherapy, there was no significant difference in maternal age, cancer type, or stage with regard to breastfeeding difficulties. Gestational age at the first cycle and the number of cycles were significant factors associated with breastfeeding difficulties (p = 0.006 and p = 0.0003, respectively). Antepartum and postpartum depression was not associated with decreased breast milk production. A lack of lactational changes and significant lobular atrophy were noted in the women given neoadjuvant chemotherapy.

CONCLUSION

Women who undergo chemotherapy during a pregnancy are more likely to report breastfeeding difficulties.

Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mother's HM.

Factors Influencing Parent Reports of Facilitators and Barriers to Human Milk Supply in Neonatal Intensive Care Units

BACKGROUND

Successful human milk supply in neonatal intensive care units (NICUs) requires the development of family-centered services.

OBJECTIVE

This study aimed to assess parent perceptions of factors that help or hinder providing human milk to very preterm infants (VPI) in the NICU according to sociodemographic, reproductive, and obstetric characteristics.

METHODS

This cross-sectional quantitative study included 120 mothers and 91 fathers of VPI hospitalized in a level 3 NICU located in the Northern Health Region of Portugal (July 2013-June 2014). Interviewers administered structured questionnaires regarding parent characteristics and the provision and perception of factors that help or hinder human milk supply in the NICU, 15 to 22 days after birth.

RESULTS

The main facilitators of human milk supply were its contribution to infant growth and well-being (51.4%) and parents' knowledge of breastfeeding benefits (27.6%). The main barriers were worries related to inadequate milk supply (35.7%), difficulties with expressing breast milk (24.8%), and physical separation from infants (24.3%). Fathers referred less frequently to the contribution of human milk to infant growth and well-being (odds ratio [OR] = 0.57; 95% confidence interval [CI], 0.32-1.00) but more frequently to knowledge of breastfeeding benefits as facilitators (OR = 2.31; 95% CI, 1.23-4.32). Participants with > 12 years of education (OR = 1.91; 95% CI, 1.05-3.47) and those with an extremely low birth weight infant (OR = 1.90; 95% CI, 1.02-3.54) highlighted worries related to inadequate milk supply. Fathers (OR = 2.16; 95% CI, 1.11-4.19) and participants with ≤ 12 years of education (OR = 0.25; 95% CI, 0.11-0.57) more frequently reported difficulties with expressing as the main barrier.

CONCLUSION

The parent's gender and education and the infant's birth weight are crucial considerations for establishing optimal practices for supporting breastfeeding.

Introducing Donor Milk in a Neonatal Intensive Care Unit: A Developing Country's Perspective

OBJECTIVE

To replace 75 % of formula feeds by donor human milk (DHM) feeds in the first three days of life in neonates admitted to the neonatal intensive care unit (NICU).

METHODS

It was a prospective observational study in the NICU in a resource-limited set up in India. All neonates admitted during December 2013 and August 2014, were included in the study without any exclusion. Expressed DHM was administered within 2-3 h of manual expression without refrigeration or pasteurization. It was left standing at room temperature in a covered stainless steel container prior to use. Prospective entries of 2 hourly neonatal feeds, for first 3 d of life, (36 entries) were made in the charts. Main outcome was the desired percentage replacement of formula feeds.

RESULTS

Total 168 neonates were admitted to the NICU over the study period. Their median [Interquartile range (IQR); Range] gestation and birth weight was 37 (36, 38; 24-42) wk and 2300 (2100, 2700; 500-2950) g respectively. A total of 4136/6027 (68.6 %) charted feeds were of human milk and 1891(31.4 %) were of formula milk. Thus, 68.6 % of formula feeds were replaced by DHM. Neonates weighing ≤2 kg were at a lower risk of getting >25 % formula feeds.

CONCLUSIONS

A simple low cost method was effective in replacing a significant proportion of formula feeds by DHM in the first three days of life for neonates in a resource poor set up.

Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology

Lactation is a dynamic process that has evolved to produce a complex biological fluid that provides nutritive and nonnutritive factors to the nursing offspring. It has long been assumed that once lactation is successfully initiated, the primary factor regulating milk production is infant demand. Thus, most interventions have focused on improving breastfeeding education and early lactation support. However, in addition to infant demand, increasing evidence from studies conducted in experimental animal models, production animals, and breastfeeding women suggests that a diverse array of maternal factors may also affect milk production and composition. In this review, we provide an overview of our current understanding of the role of maternal genetics and modifiable factors, such as diet and environmental exposures, on reproductive endocrinology, lactation physiology, and the ability to successfully produce milk. To identify factors that may affect lactation in women, we highlight some information gleaned from studies in experimental animal models and production animals. Finally, we highlight the gaps in current knowledge and provide commentary on future research opportunities aimed at improving lactation outcomes in breastfeeding women to improve the health of mothers and their infants.

Expanding the Supply of Pasteurized Donor Milk: Understanding Why Peer-to-Peer Milk Sharers in the United States Do Not Donate to Milk Banks

BACKGROUND

Lactating women in the United States have several options for what they do with excess breast milk, including donating to milk banks that serve medically fragile infants, sharing directly with families seeking milk, and selling to individuals or for-profit entities. The World Health Organization and the US Surgeon General have issued calls to increase access to pasteurized donor milk for medically fragile infants.

OBJECTIVE

To explore how lactating women with a surplus of breast milk come to the decision to share their milk with a peer rather than donate to a milk bank.

METHODS

A qualitative design using a grounded theory approach was employed. Semistructured telephone interviews were conducted with 27 women who had shared milk with a peer but not with a milk bank.

RESULTS

Five dominant themes were identified: a strong belief in the value of breast milk, unexpected versus planned donation, sources of information regarding milk exchange, concerns and knowledge gaps about milk banks, and helping and connecting.

CONCLUSIONS

This research offers insights into potential strategies for promoting milk bank donation among peer-to-peer milk sharers, including developing donor education campaigns focused on knowledge gaps regarding milk banks and developing health care professional referral programs that can reduce barriers associated with the convenience of milk bank donation.

Strategies to increase milk volume in mothers of VLBW infants

The provision of breast milk to premature VLBW infants is associated with significant health benefits. Unfortunately, the delivery of breast milk to these vulnerable infants is often limited due to insufficient maternal milk supply. Several interventions have been investigated with respect to increasing milk volume in mothers of VLBW infants but confusion exists concerning the interventions' effectiveness. The purpose of this systematic review is to critique the evidence regarding specific milk expression strategies that aim to improve milk volume in mothers of VLBW infants.Published article references, electronic databases, dissertations and theses, and select conference proceedings were searched with the goal of finding studies that target VLBW infants and milk expression techniques in which breast milk volume was an outcome. Analysis of evidence revealed an association between increased milk volume and early initiation of expression, increased frequency of expression, and provision of kangaroo care. The use of simultaneous or sequential milk expression and duration of milk expression sessions were not found to significantly improve milk volume. These results may be used to formulate specific strategies designed to increase breast milk volume in this population.

Gene expression in breastmilk cells is associated with maternal and infant characteristics

Breastmilk is a rich source of cells with a heterogeneous composition comprising early-stage stem cells, progenitors and more differentiated cells. The gene expression profiles of these cells and their associations with characteristics of the breastfeeding mother and infant are poorly understood. This study investigated factors associated with the cellular dynamics of breastmilk and explored variations amongst women. Genes representing different breastmilk cell populations including mammary epithelial and myoepithelial cells, progenitors, and multi-lineage stem cells showed great variation in expression. Stem cell markers ESRRB and CK5, myoepithelial marker CK14, and lactocyte marker α-lactalbumin were amongst the genes most highly expressed across all samples tested. Genes exerting similar functions, such as either stem cell regulation or milk production, were found to be closely associated. Infant gestational age at delivery and changes in maternal bra cup size between pre-pregnancy and postpartum lactation were associated with expression of genes controlling stemness as well as milk synthesis. Additional correlations were found between genes and dyad characteristics, which may explain abnormalities related to low breastmilk supply or preterm birth. Our findings highlight the heterogeneity of breastmilk cell content and its changes associated with characteristics of the breastfeeding dyad that may reflect changing infant needs.

Early Provision of Mother's Own Milk and Other Predictors of Successful Breast Milk Feeding after Very Preterm Birth: A Regional Observational Study

BACKGROUND

Breast milk is associated with a lower risk of neonatal morbidity in very preterm infants. Despite the benefits, the duration of breastfeeding is shorter in very preterm infants than in term infants.

OBJECTIVE

This study aimed to investigate how early provision of mother's own milk (MOM) and maternal and infant characteristics are related to breast milk feeding (BMF) between 36 and 40 weeks postmenstrual age (PMA) after very preterm birth.

METHODS

A regional observational study of 138 singleton infants born at < 32 weeks of gestation in Stockholm, Sweden, was conducted. Data were derived from medical charts to investigate the association between early provision of MOM; maternal and infant characteristics; and exclusive, partial, or no BMF at 36 weeks PMA. Moreover, changes in BMF between 36 and 40 weeks PMA were studied.

RESULTS

Most infants (80%) received MOM at 36 weeks PMA (55% exclusively, 25% partial). High provision of MOM at postnatal day 7 was associated with exclusive BMF at 36 weeks PMA, odds ratio (OR) 1.18 per 10 mL/kg MOM (95% confidence interval [CI], 1.06-1.32). Mothers born in non-Nordic countries provided MOM exclusively less often, adjusted OR 0.27 (95% CI, 0.10-0.69), compared to Nordic mothers. Between 36 and 40 weeks PMA, BMF decreased overall. This change was not associated with investigated predictors.

CONCLUSION

It is possible to achieve high rates of BMF in very preterm infants. High intake of MOM early in the postnatal period is strongly related to exclusive BMF at 36 weeks PMA.

Daily Breastmilk Volume in Mothers of Very Low Birth Weight Neonates: A Repeated-Measures Randomized Trial of Hand Expression Versus Electric Breast Pump Expression

BACKGROUND

There are no randomized trials comparing early exclusive hand expression (HE) with early exclusive electric pump expression (electric expression [EE]) for milk removal in mothers of very low birth weight (VLBW) infants.

SUBJECTS AND METHODS

Mothers of VLBW infants were randomized to exclusively HE or EE for the first 7 days postpartum. Daily volumes of milk were compared between groups for the first 28 days, adjusting for repeated measures.

RESULTS

The HE (n=12) and the EE (n=14) groups did not differ with respect to age, parity, single versus multiple gestation, or number of expression sessions per day. There were 728 values for daily milk volumes in the first 28 days, including 105 HE and 623 EE. Mothers using exclusive HE had significantly (p<0.05) less cumulative daily milk production throughout the first 7 days postpartum compared with exclusive EE. Mean cumulative milk production among mothers using HE in the first postpartum week remained approximately half that of those using the electric pump throughout the first 28 days, without evident catch up. In multivariable analysis, each postpartum day was associated with an adjusted increase of 50 mL of human milk/day during the first 7 days postpartum and an increase of 13 mL/day between postpartum Days 8 and 28. After adjusting for repeated measures, number of expression sessions per day, and postpartum day, EE was associated with an advantage in milk production of 119 mL/day during the first 28 postpartum days compared with HE.

CONCLUSIONS

Compared with mothers using EE, mothers using HE had significantly less cumulative daily milk production during the first 7 days postpartum. This trend continued after the intervention had been discontinued, and the great majority of expressions in both groups were with EE. Further research to confirm and expand these findings is warranted.

Hospital outcomes of extremely low birth weight infants after introduction of donor milk to supplement mother's milk

AIM

This study evaluated the impact of an exclusive human milk diet to nourish extremely low birth weight infants in the neonatal intensive care unit.

MATERIALS AND METHODS

This multicenter pre-post retrospective study included all inborn infants <1,000 g admitted to four Level IV neonatal intensive care units either before or after implementing a donor human milk policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and enteral intake as mother's own milk, donor milk, and formula.

RESULTS

Two hundred one infants were enrolled. Infant growth and other clinical outcomes were similar in both groups. Exposure to mother's own milk at discharge was not different. Median time in oxygen and duration of mechanical ventilation were significantly higher among formula-fed infants (63 versus 192 hours [p=0.046] and 24 versus 60 hours [p=0.016], respectively).

CONCLUSIONS

Our results add evidence supporting the safety of donor milk. This study also found an association between exposure to formula in preterm infants and the requirement for respiratory support, a finding that warrants further investigation.

Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants

BACKGROUND

Feeding breastmilk to premature infants decreases morbidity but is often limited owing to an insufficient milk supply and delayed attainment of lactogenesis stage II. Early initiation of milk expression following delivery has been shown to increase milk production in mothers of very low-birth-weight (VLBW) infants. Although recommendations for milk expression in this population include initiation within 6 hours following delivery, little evidence exists to support these guidelines. This study compared milk volume and timing of lactogenesis stage II in mothers of VLBW infants who initiated milk expression within 6 hours following delivery versus those who initiated expression after 6 hours.

SUBJECTS AND METHODS

Forty mothers of VLBW infants were grouped according to when they initiated milk expression following delivery. Group I began milk expression within 6 hours, and Group II began expression after 6 hours. Milk volume was measured daily for the first 7 days and on Days 21 and 42. Timing of lactogenesis stage II was determined through mothers' perceptions of sudden breast fullness.

RESULTS

Group I produced more breastmilk during the initial expression session and on Days 6, 7, and 42. No difference in timing of lactogenesis stage II was observed. When mothers who began milk expression prior to 1 hour following delivery were removed from analysis, benefits of milk expression within 6 hours were no longer apparent.

CONCLUSIONS

Initiation of milk expression within 6 hours following delivery may not improve lactation success in mothers of VLBW infants unless initiated within the first hour.

A systematic review and meta-analysis of the nutrient content of preterm and term breast milk

Background

Breast milk nutrient content varies with prematurity and postnatal age. Our aims were to conduct a meta-analysis of preterm and term breast milk nutrient content (energy, protein, lactose, oligosaccharides, fat, calcium, and phosphorus); and to assess the influence of gestational and postnatal age. Additionally we assessed for differences by laboratory methods for: energy (measured vs. calculated estimates) and protein (true protein measurement vs. the total nitrogen estimates).

Methods

Systematic review results were summarized graphically to illustrate the changes in composition over time for term and preterm milk. Since breast milk fat content varies within feeds and diurnally, to obtain accurate estimates we limited the meta-analyses for fat and energy to 24-hour breast milk collections.

Results

Forty-one studies met the inclusion criteria: 26 (843 mothers) preterm studies and 30 (2299 mothers) term studies of breast milk composition. Preterm milk was higher in true protein than term milk, with differences up to 35% (0.7 g/dL) in colostrum, however, after postnatal day 3, most of the differences in true protein between preterm and term milk were within 0.2 g/dL, and the week 10–12 estimates suggested that term milk may be the same as preterm milk by that age. Colostrum was higher than mature milk for protein, and lower than mature milk for energy, fat and lactose for both preterm and term milk. Breast milk composition was relatively stable between 2 and 12 weeks. With milk maturation, there was a narrowing of the protein variance. Energy estimates differed whether measured or calculated, from −9 to 13%; true protein measurement vs. the total nitrogen estimates differed by 1 to 37%.

Conclusions

Although breast milk is highly variable between individuals, postnatal age and gestational stage (preterm versus term) were found to be important predictors of breast milk content. Energy content of breast milk calculated from the macronutrients provides poor estimates of measured energy, and protein estimated from the nitrogen over-estimates the protein milk content. When breast milk energy, macronutrient and mineral content cannot be directly measured the average values from these meta-analyses may provide useful estimates of mother’s milk energy and nutrient content.

Hospital readmissions and emergency department visits in moderate preterm, late preterm, and early term infants

The increased vulnerability of late preterm infants is no longer a novel concept in neonatology, with many studies documenting excess morbidity and mortality in these infants during the birth hospitalization. Because outcomes related to gestational age constitute a continuum, it is important to analyze data from the gestational age groups that bookend late preterm infants infants-moderate preterm infants (31-32 weeks) and early term infants (37-38 weeks). This article evaluates hospital readmissions and emergency department visits in the first 30 days after discharge from birth hospitalization in a large cohort of infants greater than or equal to 31 weeks' gestation.

Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants

AIM

To examine the rate and duration of breastfeeding in a cohort of women in opioid maintenance treatment (OMT) in Norway, as well as the effect of breastfeeding on the incidence and duration of neonatal abstinence syndrome (NAS).

METHODS

A national cohort of 124 women treated with either methadone or buprenorphine during pregnancy, and their neonates born between 1999 and 2009, was evaluated in three study parts. A standardized questionnaire was administered, and medical information from the hospitals and municipalities were collected to confirm self-reported data.

RESULTS

There were high initiation rates of breastfeeding (77%) for women in OMT, but also high rates of early cessation of breastfeeding. Breastfed neonates exposed to methadone prenatally had significantly lower incidence of NAS requiring pharmacotherapy (53% vs. 80%), and both the whole group of infants and the methadone-exposed neonates needed shorter pharmacological treatment of NAS (p < 0.05) than neonates who were not breastfed.

CONCLUSION

Breastfed neonates exposed to OMT medication prenatally, and methadone-exposed newborns in particular, have lower incidence of NAS and require shorter pharmacotherapy for NAS than infants who are not breastfed. The results add to the evidence regarding the benefits of breastfeeding for neonates prenatally exposed to OMT medications.

Breastfeeding peer counselors as direct lactation care providers in the neonatal intensive care unit

In 2005, the Level III neonatal intensive care unit (NICU) at Rush University Medical Center initiated a demonstration project employing breastfeeding peer counselors, former parents of NICU infants, as direct lactation care providers who worked collaboratively with the NICU nurses. This article describes the conceptualization, implementation, and evaluation of this program and provides templates for other NICUs that wish to incorporate breastfeeding peer counselors with the goal of providing quality, evidence-based lactation care.

Providing mother's own milk in the context of the NICU: a paradoxical experience

BACKGROUND

Mothers of very preterm infants continue to face challenges related to providing their expressed breast milk in the neonatal intensive care unit (NICU).

OBJECTIVE

This qualitative study sought to understand the experience of mothers of hospitalized very preterm infants related to their daily pumping routine during the NICU stay.

METHODS

Fourteen women who were pumping breast milk for their hospitalized infants were interviewed. Sequential, semistructured, audiotaped individual interviews were conducted at 2 different time points: within 2 weeks following delivery when the mothers were pumping only, and 4 to 6 weeks once breastfeeding had been initiated.

RESULTS

The central themes found were: becoming a "mother-interrupted" and negotiating a paradoxical experience of separation and connection. Unique to these findings were the paradoxical view of the pump as both a wedge and a link to their infants, the intense dislike the mothers had for the tasks required to provide their expressed breast milk, and diversionary tactics used during pumping sessions.

CONCLUSION

The complexity of thoughts, actions, and behaviors revealed in the mothers' narrative accounts provides a guide to direct future breastfeeding interventions and management.

Donor human milk largely replaces formula-feeding of preterm infants in two urban hospitals

OBJECTIVE

To determine acceptance of donor human milk (DM) for feeding preterm infants and whether offering DM, alters mothers' milk (MM) feeding.

STUDY DESIGN

Infant feeding data were collected from medical records of 650 very preterm infants enrolled between 2006-2011 in two hospital level III neonatal intensive care units (NICUs) in Cincinnati, Ohio. The study was conducted during the implementation of a program offering 14 days of DM.

RESULT

From 2006-2011, any DM use increased from 8 to 77% of infants, largely replacing formula for the first 2 weeks of life; provision of MM did not change. DM was more likely to be given in the first 2 weeks of life, if infants never received MM or were >1000 g birth weight, but DM use did not differ by sociodemographic factors.

CONCLUSION

Offering DM dramatically increased human milk feeding and decreased formula use, but did not alter MM feeding in hospital.

Human milk composition: nutrients and bioactive factors

This article provides an overview of the composition of human milk, its variation, and its clinical relevance. The composition of human milk is the biological norm for infant nutrition. Human milk also contains many hundreds to thousands of distinct bioactive molecules that protect against infection and inflammation and contribute to immune maturation, organ development, and healthy microbial colonization. Some of these molecules (eg, lactoferrin) are being investigated as novel therapeutic agents. Human milk changes in composition from colostrum to late lactation, within feeds, by gestational age, diurnally, and between mothers. Feeding infants with expressed human milk is increasing.

Psychometric testing of the modified breastfeeding self-efficacy scale (short form) among mothers of ill or preterm infants

OBJECTIVE

To psychometrically assess the modified Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) among mothers of ill or preterm infants.

DESIGN

Methodological study.

SETTING

Three neonatal intensive care units (NICUs) located in two hospitals in a central Canadian city.

PARTICIPANTS

One hundred forty-four (144) breastfeeding mothers of ill or preterm infants.

METHODS

Mothers completed the BSES-SF modified for mothers of ill or preterm infants, the Hill and Humenick (H&H) Lactation Scale, and demographic questions.

RESULTS

The Cronbach's alpha coefficient for internal consistency for the BSES-SF revised for mothers of ill or preterm infants was 0.88. Construct validity was assessed using comparison of contrasted groups (mothers who continued to breastfeed and those who discontinued) and correlation with the construct of maternal perceptions of insufficient milk supply. Support for predictive validity was demonstrated through significant mean differences between mothers who were breastfeeding (M = 83.44, SD = 8.23) and those who discontinued breastfeeding and breast pumping (M = 75.51, SD = 10.08) at 6-weeks post-infant hospital discharge.

CONCLUSION

Demographic response patterns suggest that the modified BSES-SF is a unique tool to identify breastfeeding mothers of ill or preterm infants at risk of prematurely discontinuing. This study provides evidence that the modified BSES-SF may be a valid and reliable measure of breastfeeding self-efficacy among a sample of mothers of ill or preterm infants.

Factors associated with initiation and exclusive breastfeeding at hospital discharge: late preterm compared to 37 week gestation mother and infant cohort

Background

To investigate and examine the factors associated with initiation of, and exclusive breastfeeding at hospital discharge of, late preterm (34 ^0/7 - 36 ^6/7 weeks) compared to 37 week gestation (37 ^0/7 - 37 ^6/7 week) mother and baby pairs.

Methods

A retrospective population-based cohort study using a Perinatal National Minimum Data Set and clinical medical records review, at the Royal Hobart Hospital, Tasmania, Australia in 2006.

Results

Late preterm and 37 week gestation infants had low rates of initiation of breastfeeding within one hour of birth, 31 (21.1%) and 61 (41.5%) respectively. After multiple regression analysis, late preterm infants were less likely to initiate breastfeeding within one hour of birth (OR 0.3 95% CI 0.1, 0.7 p = 0.009) and were less likely to be discharged exclusively breastfeeding from hospital (OR 0.4 95% CI 0.1, 1.0 p = 0.04) compared to 37 week gestation infants.

Conclusion

A late preterm birth is predictive of breastfeeding failure, with late preterm infants at greater risk of not initiating breastfeeding and/or exclusively breastfeeding at hospital discharge, compared with those infants born at 37 weeks gestation. Stratifying breastfeeding outcomes by gestational age groups may help to identify those sub-populations at greatest risk of premature cessation of breastfeeding.

Is the macronutrient intake of formula-fed infants greater than breast-fed infants in early infancy?

Faster weight gain early in infancy may contribute to a greater risk of later obesity in formula-fed compared to breast-fed infants. One potential explanation for the difference in weight gain is higher macronutrient intake in formula-fed infants during the first weeks of life. A systematic review was conducted using Medline to assess the macronutrient and energy content plus volume of intake in breast-fed and formula-fed infants in early infancy. All studies from healthy, term, singleton infants reporting values for the composition of breast milk during the first month of life were included. The energy content of colostrum (mean, SEM: 53.6 ± 2.5 kcal/100 mL), transitional milk (57.7 ± 4.2 kcal/100 mL), and mature milk (65.2 ± 1.1 kcal/100 mL) was lower than conventional infant formula (67 kcal/100 mL) on all days analyzed. The protein concentration of colostrum (2.5 ± 0.2 g/100 mL) and transitional milk (1.7 ± 0.1 g/100 mL) was higher than formula (1.4 g/100 mL), while the protein content of mature milk (1.3 ± 0.1 g/100 mL) was slightly lower. Formula-fed infants consume a higher volume and more energy dense milk in early life leading to faster growth which could potentially program a greater risk of long-term obesity.

Breastfeeding support in neonatal intensive care: a national survey

BACKGROUND

The incidence of breastfeeding of preterm infants is affected by the support provided at the hospital and in the neonatal intensive care unit (NICU). However, policies and guidelines promoting breastfeeding vary both nationally and internationally.

OBJECTIVES

The aim of this survey was to describe breastfeeding support in Danish NICUs, where approximately 98% of mothers initiate lactation.

METHODS

A national survey of all 19 Danish NICUs was conducted in 2009. Four NICUs were at designated Baby-Friendly hospitals, and 5 had a lactation consultant. In all NICUs, it was possible for some parents to stay overnight; 2 units had short restrictions on parents' presence. Five NICUs had integrated postpartum care for mothers. Breastfeeding policies, written guidelines, and systematic breastfeeding training for the staff were common in most NICUs. Seventeen NICUs recommended starting breast milk expression within 6 hours after birth, and mothers were encouraged to double pump. Most NICUs aimed to initiate skin-to-skin contact the first time the parents were in the NICU, and daily skin-to-skin contact was estimated to last for 2-4 hours in 63% and 4-8 hours in 37% of the units. The use of bottle-feeding was restricted.

CONCLUSIONS

The Danish NICUs described the support of breastfeeding as a high priority, which was reflected in the recommended policies for breast milk pumping, skin-to-skin contact, and the parents' presence in the NICU, as well as in the restricted use of bottle-feeding. However, support varied between units, and not all units supported optimal breastfeeding.

High pregnancy-related anxiety and prenatal depressive symptoms as predictors of intention to breastfeed and breastfeeding initiation

BACKGROUND

Perinatal mood disorders affect up to 20% of women in the United States. Little is known about how disorders in maternal mood may affect rates of breastfeeding.

OBJECTIVE

To determine the impact of prenatal depressive symptoms and high pregnancy-related anxiety on (1) prenatal intention to breastfeed and (2) breastfeeding initiation.

METHODS

We prospectively followed 1436 pregnant women enrolled in the cohort study Project Viva. The main outcome measures were (1) mother's second trimester self-report of intention to use all or mostly formula in the first week of life and (2) failure to initiate breastfeeding. We defined prenatal depressive symptoms as a second trimester Edinburgh Postpartum Depression Scale (EPDS) score of > or =13 and high pregnancy-related anxiety as a "very much" response to three or more questions on a first trimester pregnancy anxiety scale.

RESULTS

Of the 1436 participants, 9% (n = 125) had prenatal depressive symptoms indicative of depression, and 10% (n = 141) reported high pregnancy-related anxiety; 11% (n = 159) intended to give mostly or only formula in the first week of life, and 86% (n = 1242) initiated breastfeeding. In multivariate analyses, women with prenatal depressive symptoms (OR 1.92, 95% CI 1.11, 3.33) and high pregnancy-related anxiety (OR 1.99, 95% CI 1.12, 3.54) were roughly two times more likely than women without these mood disorders to plan to formula feed. However, neither prenatal depressive symptoms (OR 1.06, 95% CI 0.61, 1.84) nor high pregnancy-related anxiety (OR 1.28, 95% CI 0.74, 2.20) was associated with failure to initiate breastfeeding.

CONCLUSIONS

In a healthcare setting highly supportive of breastfeeding, women with prenatal depressive symptoms and possibly those with high pregnancy-related anxiety were less likely to plan prenatally to breastfeed, although this tendency did not translate into lower breastfeeding initiation rates.

Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study

OBJECTIVE

The purpose of this randomized pilot study was to collect preliminary data regarding the feasibility and effects of early initiation of milk expression on the onset of lactogenesis stage II and milk volume in mothers of very low birth weight (VLBW) infants.

STUDY DESIGN

Twenty women were randomized to initiate milk expression within 60 min (group 1) or 1 to 6 h (group 2) following delivery. Milk volume and timing of lactogenesis stage II was compared between groups using Wilcoxon's rank sum tests.

RESULT

Group 1 produced statistically significantly more milk than group 2 during the first 7 days (P=0.05) and at week 3 (P=0.01). Group 1 also demonstrated a significantly earlier lactogenesis stage II (P=0.03).

CONCLUSION

Initiation of milk expression within 1 h following delivery increases milk volume and decreases time to lactogenesis stage II in mothers of VLBW infants.

Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants

OBJECTIVE

The objective of this study was to compare the effectiveness, efficiency, comfort and convenience of newly designed breast pump suction patterns (BPSPs) that mimic sucking patterns of the breastfeeding human infant during the initiation and maintenance of lactation.

STUDY DESIGN

In total, 105 mothers of premature infants ≤34 weeks of gestation were randomly assigned to 1 of 3 groups within 24 h post-birth. Each group tested two BPSPs; an initiation BPSP was used until the onset of lactogenesis II (OOL-II) and a maintenance BPSP was used thereafter.

RESULT

Mothers who used the experimental initiation and the standard 2.0 maintenance BPSPs (EXP-STD group) demonstrated significantly greater daily and cumulative milk output, and greater milk output per minute spent pumping.

CONCLUSION

BPSPs that mimic the unique sucking patterns used by healthy-term breastfeeding infants during the initiation and maintenance of lactation are more effective, efficient, comfortable and convenient than other BPSPs.

Premature delivery influences the immunological composition of colostrum and transitional and mature human milk

Human breast milk is the ideal nutrition for the newborn, and in addition to its nutritional contribution, necessary for infant growth and development, it contains various immune bioactive factors that confer some of the numerous beneficial effects of breastfeeding. The current study analyzed the concentrations of IgA, growth factors such as epidermal growth factor (EGF), TGFβ1, and TGFβ2, cytokines IL-6, IL-8, IL-10, IL-13, and TNFα, and TNF-receptor I (TNF-RI) in colostrum and transitional and mature milk from mothers with mature, premature, and very premature infants. Human milk samples were collected from mothers delivering at term (T), preterm (PT), and very preterm (VPT). Milk from all the mothers was collected at 3 different time points after delivery corresponding to colostrum and transitional and mature milk. After obtaining milk whey, IgA, EGF, TGFβ1, and TGFβ2 were determined by ELISA and IL-6, IL-8, IL-10, IL-13, TNFα and TNF-RI by cytometric bead array immunoassay. The colostrum of the PT group was extremely rich in most of the factors studied, but higher concentrations than in the T group were only found for IL-6 (P = 0.051), TGFβ1, and TGFβ2 (P < 0.05). Conversely, the colostrum of the VPT group had lower concentrations of IgA, IL-8, IL-10, and TNFα than those in the T group (P < 0.05). Results suggest that maternal lactogenic compensatory mechanisms accelerating the development of immature breast-fed preterm infants may take effect only after wk 30 of gestation.

Effects of recombinant human prolactin on breast milk composition

OBJECTIVE

The objective of this study was to determine the impact of recombinant human prolactin (r-hPRL) on the nutritional and immunologic composition of breast milk.

METHODS

We conducted 2 trials of r-hPRL treatment. In the first study, mothers with documented prolactin deficiency were given r-hPRL every 12 hours in a 28-day, open-label trial. In the second study, mothers with lactation insufficiency that developed while they were pumping breast milk for their preterm infants were given r-hPRL daily in a 7-day, double-blind, placebo-controlled trial. Breast milk characteristics were compared before and during 7 days of treatment.

RESULTS

Among subjects treated with r-hPRL (N = 11), milk volumes (73 ± 36 to 146 ± 54 mL/day; P < .001) and milk lactose levels (155 ± 15 to 184 ± 8 mmol/L; P = .01) increased, whereas milk sodium levels decreased (12.1 ± 2.0 to 8.3 ± 0.5 mmol/L; P = .02). Milk calcium levels increased in subjects treated with r-hPRL twice daily (2.8 ± 0.6 to 5.0 ± 0.9 mmol/L; P = .03). Total neutral (1.5 ± 0.3 to 2.5 ± 0.4 g/L; P = .04) and acidic (33 ± 4 to 60 ± 6 mg/L; P = .02) oligosaccharide levels increased in r-hPRL-treated subjects, whereas total daily milk immunoglobulin A secretion was unchanged.

CONCLUSIONS

r-hPRL treatment increased milk volume and induced changes in milk composition similar to those that occur during normal lactogenesis. r-hPRL also increased antimicrobially active oligosaccharide concentrations. These effects were achieved for women with both prolactin deficiency and lactation insufficiency.

Improving the use of human milk during and after the NICU stay

The feeding of human milk (milk from the infant's own mother; excluding donor milk) during the newborn intensive care unit (NICU) stay reduces the risk of costly and handicapping morbidities in premature infants. The mechanisms by which human milk provides this protection are varied and synergistic, and appear to change over the course of the NICU stay. The fact that these mechanisms include specific human milk components that are not present in the milk of other mammals means that human milk from the infant's mother cannot be replaced by commercial infant or donor human milk, and the feeding of human milk should be a NICU priority. Recent evidence suggests that the impact of human milk on improving infant health outcomes and reducing the risk of prematurity-specific morbidities is linked to specific critical exposure periods in the post-birth period during which the exclusive use of human milk and the avoidance of commercial formula may be most important. Similarly, there are other periods when high doses, but not necessarily exclusive use of human milk, may be important. This article reviews the concept of "dose and exposure period" for human milk feeding in the NICU to precisely measure and benchmark the amount and timing of human milk use in the NICU. The critical exposure periods when exclusive or high doses of human milk appear to have the greatest impact on specific morbidities are reviewed. Finally, the current best practices for the use of human milk during and after the NICU stay for premature infants are summarized.

Effect of domperidone on the composition of preterm human breast milk

OBJECTIVE

Domperidone is increasingly prescribed to improve breast milk volume despite a lack of evidence regarding its effects on breast milk composition. We examined the effect of domperidone on the nutrient composition of breast milk.

PATIENTS AND METHODS

Forty-six mothers who had delivered infants at <31 weeks' gestation, who experienced lactation failure, were randomly assigned to receive domperidone or placebo for 14 days. Protein, energy, fat, carbohydrate, sodium, calcium, and phosphate levels in breast milk were measured on days 0, 4, 7, and 14, serum prolactin levels were measured on days 0, 4, and 14, and total milk volume was recorded daily. Mean within-subject changes in nutrients and milk volumes were examined.

RESULTS

Maternal and infant characteristics, serum prolactin level, and breast milk volume and composition were not significantly different between domperidone and placebo groups on day 0. By day 14, breast milk volumes increased by 267% in the domperidone-treated group and by 18.5% in the placebo group (P = .005). Serum prolactin increased by 97% in the domperidone group and by 17% in the placebo group (P = .07). Mean breast milk protein declined by 9.6% in the domperidone group and increased by 3.6% in the placebo group (P = .16). Changes in energy, fat, carbohydrate, sodium, and phosphate content were also not significantly different between groups. Significant increases were observed in breast milk carbohydrate (2.7% vs -2.7%; P = .05) and calcium (61.8% vs -4.4%; P = .001) in the domperidone versus placebo groups. No significant adverse events were observed among mothers or infants.

CONCLUSION

Domperidone increases the volume of breast milk of preterm mothers experiencing lactation failure, without substantially altering the nutrient composition.

Antiestrogenic constituents of the Thai medicinal plants Capparis flavicans and Vitex glabrata

Antiestrogenic compounds were investigated from Thai indigenous plants for galactogogues since estrogen is reported to suppress lactation in breastfeeding women. The aerial parts of the Thai medicinal plant Capparis flavicans, which has traditionally been used to promote lactation, gave the new compound capparoside A (1), along with 28 known compounds. The leaves of Vitex glabrata belong to the same genus as the chaste tree (Vitex agnus-castus), which is used traditionally to support lactation, and afforded the new compounds khainaoside A (14), khainaoside B (15), and khainaoside C (16), together with six known compounds. The isolates were tested for their biological activity using the estrogen-responsive human breast cancer cell lines MCF-7 and T47D. Syringaresinol (3) and principin (6), from C. flavicans, and khainaoside A (14) showed the most potent inhibitory effects on estrogen-enhanced cell proliferation among all compounds isolated. These results suggest that the lactation-promoting properties of C. flavicans might be related to the inhibitory effect on excess estrogen of women who experience insufficient breastfeeding and highlight the possibility of using V. glabrata leaves for their antiestrogenic properties.

Breastfeeding the late preterm infant

Late preterm infants comprise the fastest growing segment of babies born prematurely. They arrive with disadvantages relative to feeding skills, stamina, and risk for conditions such as hypoglycemia, hyperbilirubinemia, and slow weight gain. Breastfeeding these babies can be difficult and frustrating. Individualized feeding plans include special considerations to compensate for immature feeding skills and inadequate breast stimulation. Breastfeeding management guidelines are described that operate within the late preterm infant's special vulnerabilities.

A comparison of the efficiency, efficacy, comfort, and convenience of two hospital-grade electric breast pumps for mothers of very low birthweight infants

OBJECTIVE

Many mothers of very low birthweight infants are breast pump-dependent for weeks or months and need a breast pump that is efficient, effective, comfortable, and convenient.

STUDY DESIGN

This multisite, blinded, randomized clinical trial compared the efficiency, efficacy, comfort, and convenience of the Symphony breast pump (Medela, McHenry, IL) (SBP) to the Classic breast pump (Medela) (CBP) and also compared these same outcome measures for single- and multiphase suction patterns used in the SBP. All 100 mothers initiated lactation with the CBP and were randomized to single- and multiphase suction patterns in the SBP when daily milk output was at least 350 mL/day. Protocol I included 35 mothers who compared each of three suction patterns in the SBP on two separate occasions (six observations) in the neonatal intensive care unit and used the CBP for all other pumpings. Protocol II included 65 mothers who compared single- and multiphase patterns in the SBP for 7 days and then returned to the CBP for 5 days.

RESULTS

The onset of milk ejection was quicker (P < 0.05) for the single- versus multiphase patterns in the SBP, suggesting that mothers had become conditioned to the unphysiolologic single-phase pattern in the CBP. However, all other measures of efficiency and efficacy were not significantly different, including milk output at 5-minute intervals. When asked to compare the SBP and the CBP, mothers in Protocol 1 rated the SBP as significantly more efficient, effective, comfortable, and convenient than the CBP (P < 0.05), regardless of the suction pattern in the SBP. Similarly, mothers in Protocol II rated the SBP significantly (P < 0.05) more comfortable than the CBP, regardless of the specific pattern in the SBP.

CONCLUSIONS

These findings suggest that the SBP was as efficient and effective as the CBP but was significantly more comfortable to use for pump-dependent mothers of very low birthweight infants.

Application of the baby friendly hospital initiative to neonatal care: suggestions by Swedish mothers of very preterm infants

The aim of this study was to obtain suggestions from mothers of very preterm infants regarding modification of the Baby Friendly Hospital Initiative (BFHI) 10 Steps to Successful Breastfeeding. Thirteen mothers were interviewed 2 to 6 months after their infants' discharge from the hospital. The interviews generated 13 steps, which partly agree with the BFHI steps. The new steps address respect for mothers' individual decisions about breastfeeding, education of staff in specific knowledge and skills, antenatal information about lactation in the event of preterm birth, skin-to-skin (kangaroo mother) care, breast milk expression, early introduction of breastfeeding, facilitation of mothers' 24-hour presence in the hospital, preference for mother's own milk, semi-demand feeding before transition to demand breastfeeding, special benefits of pacifier sucking, alternative strategies for reduction of supplementation, use of bottle-feeding when indicated, a family-centered and supportive physical environment, support of the father's presence, and early transfer of infants' care to parents.

Dose-effect study of domperidone as a galactagogue in preterm mothers with insufficient milk supply, and its transfer into milk

AIMS

To investigate the possibility of a dose-response relationship for the use of domperidone in treating insufficient milk supply in mothers of preterm infants, and to quantify the exposure of the breastfed infant to domperidone.

METHODS

Six preterm mothers received domperidone (30 mg daily or 60 mg daily) in a double-blind, randomized, crossover trial. Milk production and serum prolactin were measured before and during the trial, and domperidone concentration in milk was measured during drug treatment.

RESULTS

For milk production, two of the mothers were 'nonresponders', whereas the other four were 'responders' and showed a significant increase in milk production from 8.7 +/- 3.1 g h(-1) in the run-in phase (mean +/- SEM), 23.6 +/- 3.9 g h(-1) for the 30-mg dose (P = 0.0217) and 29.4 +/- 6.6 g h(-1) for the 60-mg dose (P = 0.0047). In all participants, serum prolactin was significantly increased for both doses, but the response was not dose dependent. Median (interquartile range) domperidone concentrations in milk over a dose interval at steady-state were 0.28 microg l(-1) (0.24-0.43) and 0.49 microg l(-1) (0.33-0.72) for the 30-mg and 60-mg doses, respectively. The mean relative infant dose was 0.012% at 30 mg daily and 0.009% at 60 mg daily.

CONCLUSION

In one-third of mothers, domperidone did not increase milk production. In the remainder, milk production increased at both domperidone doses, and there was a trend for a dose-response relationship. The amount of domperidone that transfers into milk was extremely low, and infant exposure via breastfeeding was not considered to be significant.

Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women

OBJECTIVE

The onset of copious milk secretion after birth is known as lactogenesis II. The objective of this study was to investigate the effect of preterm birth and antenatal corticosteroids on the timing of lactogenesis II after birth.

METHODS

Women who had received antenatal betamethasone treatment and were expressing for a preterm infant whose gestational age was <34 weeks (N = 50) were included. On days 1 to 10 postpartum, participants measured the volume of milk expressed in 24-hour periods and collected milk samples. Lactose and citrate levels were analyzed in the milk.

RESULTS

The gestational age at delivery was 31 weeks (range: 24.2-33.7). Milk volume was recorded by 46 women on 320 expression days and was positively associated with gestational age. Gestational age modified the effect of interval between betamethasone administration and delivery on milk volume. At gestational age 28 to 34 weeks, women who delivered 0 to 2 days after betamethasone treatment obtained significantly greater volumes than women who delivered 3 to 9 days after treatment. Milk samples (N = 324) were collected by 42 mothers. Mean +/- SD lactose and citrate levels were 156.800 +/- 36.217 and 3.458 +/- 1.442 mM, respectively. There was a significant positive effect of gestational age on milk lactose levels but not citrate levels. Betamethasone treatment did not alter lactose or citrate levels in milk.

CONCLUSIONS

Delivery at extremely preterm gestational ages caused a significant delay in the onset of lactogenesis II. The volume of milk was reduced further when antenatal corticosteroids were administered between 28 and 34 weeks' gestation and delivery occurred 3 to 9 days later. In view of the advantages of mothers' own milk, additional support with lactation is recommended for mothers of preterm infants, particularly those who have been treated with corticosteroids before the delivery.

How breastfeeding works

Human milk is a complex secretion that is the sole ideal food for babies for at least the first 6 months of life. The amount and composition of the milk is largely independent of the mother's diet. The composition of the milk changes during lactogenesis II, and these changes can be used as biochemical markers of the onset of copious milk secretion. After 1 month of lactation, there are few further changes in the composition of milk until the volume of milk decreases substantially as the baby weans completely. The amount of milk produced depends on the amount of milk removed from the breast. Successful, exclusively breastfeeding babies show a three-fold variation in the amount of milk they take per day, and in the frequency of breastfeeds and amount of milk consumed during each breastfeed. The fat intake of the baby is independent of the feeding frequency. If a baby is growing normally, the mother can be confident that her baby does not need to follow prescribed breastfeeding regimes. She should respond to her baby's cues for the frequency of breastfeeds, and whether the baby requires one or both breasts for a meal. Continuing research into the physiology of breastfeeding provides a foundation for evidence-based treatment of breastfeeding difficulties.

Optimising the provision of human milk for preterm infants

The benefits of breast milk for preterms can be realised by teaching mothers simple but effective milk expression techniques

The lactating breast: an overview from down under

My research into the physiology of lactation began at the University of Sydney in the early 1960s with funding from the Australian Dairy Industry. In 1972 I moved to The University of Western Australia to teach medical students and initiated a research program in human lactation. Coincidentally this was a very significant time for human lactation because 1972 was the nadir for breastfeeding in many Western countries, including Australia. In Western Australia the proportion of women choosing to breastfeed increased from <50% to the current rate of approximately 95%. Because the invasive conventional techniques used to study lactation in laboratory and domestic animals could not be applied to investigation of the regulation of milk synthesis in lactating women, it was necessary to develop new approaches to the study of mammary gland metabolism in women. These methods have included measuring breast volume using a computerized breast measurement system, measuring milk macro- and micro-components on small volumes of breast milk, bioluminescent metabolomic assays, and ultrasound analysis of breast function. Currently, my research is directed toward understanding the control of synthesis, secretion, and removal of milk in women with the aim of developing clinical protocols for the assessment of the normal and abnormal function of the lactating breast.

Milk volume on day 4 and income predictive of lactation adequacy at 6 weeks of mothers of nonnursing preterm infants

Lactating mothers of preterm infants who are pump-dependent are at high risk for difficulty maintaining an adequate milk supply. This article reports the naturally occurring volume of milk removed from the breast by mechanical expression over time for 81 mothers of nonnursing preterm infants from 4 tertiary care centers in the Midwest. Baseline variables (infant gestation in weeks; intended length in weeks to breastfeed; number of hours post-delivery to first breast stimulation; infant weight in grams; timing of decision to provide mother's milk; income; maternal education, kangaroo care during week 1; previous breastfeeding experience; white, non-Hispanic) and day 4 variables (milk volume, frequency of pumping) were explored for predicting milk adequacy at week 6. Using the significant predictive variables of milk levels at day 4 and income, the logistic regression accurately classified 85% of the 40 mothers with inadequate milk production (<500 mL/d) and 85.5% of the 41 mothers with adequate milk production (> or = 500 mL/d). While controlling for income, the 27 mothers with lowest milk production at 4 days were 9.5 times more likely to have an inadequate milk supply at 6 weeks than the 54 mothers with higher milk production. While controlling for day 4 milk production, lower annual income mothers (< dollar 50,000) were 5 times more at risk of inadequate milk production than those with high income (> or = dollar 50,000) at week 6. This study emphasizes the importance of the amount of milk volume expressed in the early postpartum period during lactogenesis. In addition, neonatal nurses need to be cognizant that income levels may make a difference in milk production.

Sharing the science on human milk feedings with mothers of very-low-birth-weight infants

Mother's milk provides protection from serious and costly morbidity for very-low-birth-weight infants (<1500 g), including enteral feeding intolerance, nosocomial infection, and necrotizing enterocolitis. However, NICU and maternity nurses may be hesitant to encourage mothers to initiate lactation because of a reluctance to make mothers feel guilty or coerced. This article reviews the evidence for the health outcomes of mothers' milk feeding in very-low-birth-weight infants and provides examples of ways to share this science with mothers so that they can make an informed feeding decision.