How breastfeeding works

Nipple shield use in the maternity ward increases risk of exclusive breastfeeding interruption in the first six months of infant's life

OBJECTIVE

The objective of this study was to investigate the association between use of silicone nipple shields in the maternity ward and exclusive breastfeeding interruption in the first 6 months of the infant's life.

DESIGN

Cohort study.

SETTING

Interviews were conducted personally at the mother's home at 1 and 6 months postpartum and by telephone at 2 and 4 months.

PARTICIPANTS

287 mother-infant dyads.

METHODS

Lactating mothers were randomly selected at two maternity wards (one public, one private) in Porto Alegre, Brazil. Data were analyzed using Kaplan-Meier survival curves and Cox multivariate regression. The outcome of interest was exclusive breastfeeding interruption before 6 months of the infant's life.

FINDINGS

Nipple shields were used by 6.2 % of the women in the public maternity ward and by 25.8 % of those in the private setting. Median duration of exclusive breastfeeding was 11 days (95 %CI 0.0-36.9) among women who used the accessory vs. 89 days (95 %CI 60.8-117.2) among those who did not. Nipple shield use in the maternity ward was associated with exclusive breastfeeding interruption before 6 months of infant's life (adjusted risk ratio = 1.47; 95 %CI 1.01-2.15). The risk was higher in the first months of breastfeeding, ranging from 2.0 to 1.47 in the first and sixth months, respectively.

CONCLUSIONS

The use of silicone nipple shields in the maternity ward increased the risk of exclusive breastfeeding interruption before 6 months of the infant's life, especially in the first months. These findings suggest caution in recommending this accessory to new mothers.

Breastfeeding pattern and its relationship with weight gain in children older than 6 months

Introduction

According to the World Health Organization (WHO), breastfeeding is the best way to feed infants. Adoption of some inappropriate nutritional patterns along with breast milk, especially in infants older than 6 months, may lead to a delay in the child's growth. Therefore, the present study was conducted to investigate the relationship between breastfeeding and weight gain in children aged 6-24 months.

Materials and Methods

This case-control study was conducted on 120 infants aged 6-24 months and their mothers recruited from health centers of Ahvaz, southwest of Iran. The data collection tool in the present study included a questionnaire to record demographic information and information in the child's medical records in health centers. Statistical analysis of the data was done by SPSS 23 using the Chi-square test and t-test.

Results

No significant difference was observed between the control and case groups in terms of the infant's age (P = 0.741) and gender (P = 0.564) and the mothers' age (P = 0.614), her educational attainment (P = 0.389), and socioeconomic status of the infant's family (P = 0.563). The type of delivery (P = 0.650), mothers' opinion (P = 0.133), and the interval between breastfeeding and complementary feeding (P = 0.144) had no significant relationship with the infant's growth disorder. On the other hand, duration of breastfeeding per meal (P = 0.007) and frequent breastfeeding (dependency on the mother's breast) (P = 0.049) had a significant relationship with children's developmental disorders.

Conclusion

According to the results of the present study, growth disorders in infants in the case group could be attributed to their mothers' inappropriate breastfeeding patterns.

Women's perspectives on human milk banking in Ghana: results from a cross-sectional study

Background

Although political and academic interest exists in Ghana to include human milk banks (HMB) into current maternal and child health programs, efforts to establish a HMB have not yet been subjected to any real empirical inspection with the view toward implementation. Furthermore, views toward the establishment of a HMB in Ghana have not been assessed among Ghanaian women. The aims of the current study were to examine Ghanaian women's views about HMB, and to investigate women's willingness to donate to a HMB.

Methods

Quantitative and qualitative responses were received from Ghanaian females (n = 1,270) aged 18+ years. Excluding outliers and missing data (n = 321), a final sample of 949 was retained for final analysis. Chi-square tests and logistic regression analysis were computed on quantitative data; Thematic analysis was performed on the qualitative responses.

Results

In our sample, 64.7% of respondents indicated that Ghana is ready for a HMB. The majority (77.2%) were willing to donate milk, and 69.4% believed that donating to the HMB would favor their child. The main concerns for the unwillingness to donate excess milk included: (i) the idea of HMBs as strange/bizarre (n = 47), (ii) fear of infections (n = 15), (iii) religious beliefs (n = 9), and (iv) insufficient information (n = 24). This study serves as the first step toward the development of a HMB in Ghana.

Conclusions

Overall, Ghanaian women support the building of a HMB to enhance infant nutrition and reduce childhood morbidity and mortality.

Infant factors that impact the ecology of human milk secretion and composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 3

Infants drive many lactation processes and contribute to the changing composition of human milk through multiple mechanisms. This review addresses the major topics of milk removal; chemosensory ecology for the parent-infant dyad; the infant's inputs into the composition of the human milk microbiome; and the impact of disruptions in gestation on the ecology of fetal and infant phenotypes, milk composition, and lactation. Milk removal, which is essential for adequate infant intake and continued milk synthesis through multiple hormonal and autocrine/paracrine mechanisms, should be effective, efficient, and comfortable for both the lactating parent and the infant. All 3 components should be included in the evaluation of milk removal. Breastmilk "bridges" flavor experiences in utero with postweaning foods, and the flavors become familiar and preferred. Infants can detect flavor changes in human milk resulting from parental lifestyle choices, including recreational drug use, and early experiences with the sensory properties of these recreational drugs impact subsequent behavioral responses. Interactions between the infant's own developing microbiome, that of the milk, and the multiple environmental factors that are drivers-both modifiable and nonmodifiable-in the microbial ecology of human milk are explored. Disruptions in gestation, especially preterm birth and fetal growth restriction or excess, impact the milk composition and lactation processes such as the timing of secretory activation, adequacy of milk volume and milk removal, and duration of lactation. Research gaps are identified in each of these areas. To assure a sustained and robust breastfeeding ecology, these myriad infant inputs must be systematically considered.

Spike-specific T cells are enriched in breastmilk following SARS-CoV-2 mRNA vaccination

Human breastmilk is rich in T cells; however, their specificity and function are largely unknown. We compared the phenotype, diversity, and antigen specificity of T cells in breastmilk and peripheral blood of lactating individuals who received SARS-CoV-2 messenger RNA (mRNA) vaccination. Relative to blood, breastmilk contained higher frequencies of T effector and central memory populations that expressed mucosal-homing markers. T cell receptor sequence overlap was limited between blood and breastmilk. Overabundant breastmilk clones were observed in all individuals, were diverse, and contained complementarity-determining regions in three sequences with known epitope specificity, including to SARS-CoV-2 spike. SARS-CoV-2 spike-specific T cell receptors were more frequent in breastmilk compared to blood and expanded in breastmilk following a 3rd mRNA vaccine dose. Our observations indicate that the lactating breast contains a distinct T cell population that can be modulated by maternal vaccination with potential implications for passive infant protection.

HIV-Infected and HIV-Uninfected Western Kenyan Women Produce Equivalent Amounts of Breast Milk at 6 Wk and 6 Mo Postpartum: A Prospective Cohort Study Using Deuterium Oxide Dose-to-Mother Technique

BACKGROUND

Regardless of their HIV serostatus, mothers are advised to exclusively breastfeed infants ≤6 mo postpartum. How this guidance impacts breast milk intake among HIV-exposed infants in varied contexts needs to be better understood.

OBJECTIVES

The objective of this study was to compare breast milk intake of HIV-exposed and HIV-unexposed infants at 6 wk and 6 mo of age, as well as the associated factors.

METHODS

In a prospective cohort design, which we followed from a western Kenya postnatal clinic, 68 full-term HIV-uninfected infants born to HIV-1-infected mothers (HIV-exposed) and 65 full-term HIV-uninfected infants born to HIV-uninfected mothers were assessed at 6 wk and 6 mo of age. Breast milk intake of infants (51.9% female) weighing 3.0-6.7 kg (at 6 wk of age) was determined using the deuterium oxide dose-to-mother technique. Student t test for independent samples compared the variations in breast milk intake between the 2 groups. Correlation analysis detected the associations between breast milk intake and maternal and infant factors.

RESULTS

Daily breast milk intakes by HIV-exposed and HIV-unexposed infants were not significantly different at either 6 wk (721 ± 111 g/d and 719 ± 121 g/d, respectively) or 6 mo (960 ± 121 g/d and 963 ± 107 g/d, respectively) of age. Maternal factors that significantly correlated with infant breast milk intake were FFM at both 6 wk (r = 0.23; P < 0.05) and 6 mo (r = 0.36; P < 0.01) of age and weight at 6 mo postpartum (r = 0.28; P < 0.01). Infant factors that significantly correlated at 6 wk were birth weight (r = 0.27; P < 0.01), present weight (r = 0.47; P < 0.01), length-for-age z-score (r = 0.33; P < 0.01), and weight-for-age (r = 0.42; P > 0.01). At 6 mo, they were infant length-for-age (r = 0.38; P < 0.01), weight-for-length (r = 0.41; P > 0.01), and weight-for-age (r = 0.60; P > 0.01).

CONCLUSIONS

Full-term breastfeeding infants born to HIV-1-infected and HIV-1-uninfected women attending standard Kenyan postnatal care clinics ≤6 mo of age in this resource-poor setting consume comparable amounts of breast milk. This trial was registered at clinicaltrials.gov as PACTR201807163544658.

Relationships between feeding and glucose concentrations in healthy term infants during the first five days after birth-the Glucose in Well Babies Study (GLOW)

Background

The World Health Organization recommends breastfeeding be commenced as soon as possible after birth. Amongst other benefits, early feeding is expected to support the metabolic transition after birth, but effects on blood glucose concentrations are controversial. We sought to describe the changes in interstitial glucose concentrations after feedings over the first five postnatal days.

Participants and Methods

In healthy singleton term infants, all feeds were recorded using a smart phone app. Glucose concentrations were measured by blinded interstitial monitoring, calibrated by heel-prick capillary samples 2-4 times/d. Feeding sessions were included if a start and end time were recorded, and if the interval between the start of successive feeds was >90 min. The area under the glucose concentration curve (AUC) was calculated by trapezoidal addition from baseline (median of the 3 measurements before the beginning of the session). The maximum deviation (MD) was the greatest change in glucose concentration (positive or negative) from baseline to the next feeding session or 180 min, whichever came first. Data were analyzed using Stata V17 and are presented as mean (95% CI) in mmol/L.

Results

Data were available for 62 infants and 1,770 feedings. The glucose response to breastfeeding was not different from zero on day 1 [day 1 AUC 0.05 (-0.00, 0.10), MD 0.06 (-0.05, 0.16)], but increased thereafter (day 3 (AUC 0.23 (0.18, 0.28), MD 0.41 (0.32, 0.50), day 5 AUC 0.11 (0.06, 0.16), MD 0.28 (0.18, 0.37), p < 0.001 for age effect). Glucose response increased with increased duration of breastfeeding (<30 min AUC 0.06 (0.02,0.09), MD 0.12 (0.04,0.19), >30 min AUC 0.20 (0.16, 0.23) MD 0.37 (0.30, 0.44), p < 0.001 for duration effect) and this was observed even in the first 2 days (<30 min AUC-0.02 (-0.06, 0.03), MD -0.06 (-0.15, 0.03), >30 min AUC 0.12 (0.08, 0.16), MD 0.19 (0.11, 0.27), overall p < 0.001 for age x duration interaction). In feeding sessions that were not breastfeeding, the glucose response was greater after formula than after expressed human milk [AUC 0.29 (0.15, 0.29), MD 0.48 (-0.12, 0.61)], and greater after feed volumes >20 ml than <10 ml [20-30 ml AUC 0.19 (0.01, 0.27), MD 0.23 (-0.01, 0.46)].

Conclusion

The glucose response to feeding in the days after birth increases with postnatal age and duration of the feeding episode. Breastfeeding for <30 min has little effect on glucose concentrations in the first two days.

Feeding Patterns of Healthy Term Newborns in the First 5 Days-The Glucose in Well Babies Study (GLOW)

BACKGROUND

The feeding patterns of healthy newborns have been poorly described.

RESEARCH AIM

To determine the feeding patterns of healthy term newborns soon after birth, and if these differed with sex, gestation, and mode of birth.

METHODS

This study was a prospective, longitudinal observational cohort study. Term, appropriately grown newborns (N = 66) were fed according to maternal choice and details were recorded. Data were analyzed using generalized Poisson regression for feeding frequencies, and mixed model regression of log-transformed data for durations.

RESULTS

The participants completing the study had a M = 3589 g (SD = 348 g) birthweight, with a gestation age of M = 40.1 (1.2) weeks. All participants were breastfed; 23 (35%) also received expressed human milk and 10 (15%) received formula. Participants had fewer feeding sessions on Day 1, (M = 7.3 [1.9] sessions/day) increasing to (M = 9.4 [2.4] sessions/day) by Day 3, then reducing to (M = 9.0 [2.2] sessions/day) on Day 5, p < .001. The overall duration of breastfeeding sessions varied widely (Mdn = 29 [range = 1-447] min). Feed frequency but not duration was higher in males than females (M = 8.9, SE = 0.2 vs. 8.1, 02, sessions/day, p = .03), in newborns born ≥ 40 weeks' gestation (M = 8.9, SE = 0.3 vs. 8.2, 02, sessions/day, p = .04), and in newborns born by Caesarean section (M = 9.4, SE = 0.3 vs. 8.4, 02, sessions/day, for vaginal birth, p = .003).

CONCLUSION

Feeding patterns of healthy term newborns vary widely, but frequency increases during the first 3 days, and is greater in males, newborns born late term, and born by Caesarean section.

CLINICAL TRIAL REGISTRATION

The Australian and New Zealand Clinical Trials Registry Ref: ACTRN12615000986572. The study protocol is available online: http://hdl.handle.net/2292/32066.

Women's reasons for taking complementary medicine products in pregnancy and lactation: Results from a national Australian survey

BACKGROUND

and purpose: Pregnant and breastfeeding women commonly use complementary medicine products (CMPs), including dietary supplements and herbal medicines. This study investigated women's reasons for use.

MATERIALS AND METHODS

A national, cross-sectional, online survey conducted between July-September 2019 investigated reasons for CMP use during pregnancy and lactation. Australian women who were currently pregnant and/or breastfeeding participated. Data analysis included descriptive statistics, Chi-square and principal component analyses.

RESULTS

Of the 810 women surveyed (n = 354 pregnant; n = 456 breastfeeding), most reported prior CMP use and felt that CMPs had been beneficial to maintaining and optimising their own and their children's health. However, when ill, they preferred medicines prescribed by doctors or pharmacists. Perceived benefits to their unborn or breastfeeding babies' health and their own health (both cohorts), the health of their pregnancy (pregnant participants), and benefits to the breastfeeding process and breastmilk supply (breastfeeding participants) were important reasons for women's CMP use.

CONCLUSION

Women's reasons for CMP use centred on perceived benefits to their own health and the health of their babies. Women's prior positive experiences with CMP use, combined with preferences for pharmaceutical use when ill, indicates their use of CMPs can be considered complementary, rather than alternative, to biomedical health care.

Relationship of delayed lactogenesis II to maternal perception of insufficient milk: A longitudinal study

AIM

To analyze the relationship of delayed lactogenesis II with maternal perception of insufficient milk.

METHODS

A prospective, multicenter, longitudinal observational study was conducted. Data were obtained at discharge and between 1 and 5 months postpartum on the perception of insufficient milk and related variables, by means of a self-administered questionnaire, and subsequent postal and online follow-up. Logistic regression analysis was used to develop the explanatory model.

RESULTS

A total of 260 puerperal mothers participated. Of these, 31.9% had insufficient milk and 23.6% had delayed lactogenesis II. During postpartum admission, delayed lactogenesis II (OR = 2.26; 95%CI = 1.07-4.79), difficulty in breastfeeding (OR = 1.02; 95%CI = 1.00-1.03), and professional help in breastfeeding (OR = 0.70; 95%CI = 0.50-0.97) were associated with maternal perception of insufficient milk.

CONCLUSIONS

The occurrence of breastfeeding difficulties during postpartum admission and at discharge, especially when there is delayed lactogenesis II, should be considered risk indicators, suggesting the need for additional support to standardized care. The PIM is a suitable indicator to assess the quality of professional breastfeeding support in improvement interventions.

Food insecurity and its associated factors among lactating mothers in the Chiro district, Eastern Ethiopia: A community-based cross-sectional study

Introduction

Lactating mothers are extremely vulnerable to both macro and micronutrient deficiencies due to the increased nutritional requirements and high magnitude of food insecurity in low-income countries. However, there are a dearth of studies conducted in sub-Saharan African countries regarding this study area. Thus, this study aimed to assess the magnitude of food insecurity and its associated factors among lactating mothers in the Chiro district, eastern Ethiopia.

Methods

A community-based cross-sectional study was conducted among 446 randomly selected lactating mothers from 1-30 June, 2020. Data were collected through face-to-face interviews using a structured and pre-tested questionnaire. Data were entered using EpiData version 3.1 and exported to STATA version 14.2 for cleaning and analysis. Bi-variable and multivariable binary logistic regression analyses were fitted to check the association between independent variables and food insecurity. The level of statistical significance was declared at a p-value < 0.05.

Results

The magnitude of food insecurity among lactating mothers was 68.8 % (95 % CI: 64.4, 72.9) and 12.1% (95 % CI: 9.4, 15.5) were severely food insecure. Residing in the rural (AOR =2.36, 95% CI:1.21, 4.62), poor wealth indices (AOR =4.68, 95% CI:2.02, 10.8), owning farmland of less than a hectare (AOR =2.35, 95% CI:1.06, 5.19), mothers who had less than three meals a day (AOR =2.70, 95% CI:1.33, 5.46), and who did not have their own income (AOR =2.32, 95% CI:1.36, 3.96) were significantly associated factors with food insecurity among lactating mothers.

Conclusion

Food insecurity is highly prevalent in lactating mothers' households. Therefore, the government and other stakeholders need to take action that addresses factors affecting mothers' food security status through strengthening nutrition-sensitive interventions.

Spike-specific T cells are enriched in breastmilk following SARS-CoV-2 mRNA vaccination

Human breastmilk is rich in T cells; however, their specificity and function are largely unknown. We compared the phenotype, diversity, and antigen specificity of T cells in the breastmilk and peripheral blood of lactating individuals who received SARS-CoV-2 mRNA vaccination. Relative to blood, breastmilk contained higher frequencies of T effector and central memory populations that expressed mucosal-homing markers. T cell receptor (TCR) sequence overlap was limited between blood and breastmilk. Overabundan t breastmilk clones were observed in all individuals, were diverse, and contained CDR3 sequences with known epitope specificity including to SARS-CoV-2 Spike. Spike-specific TCRs were more frequent in breastmilk compared to blood and expanded in breastmilk following a third mRNA vaccine dose. Our observations indicate that the lactating breast contains a distinct T cell population that can be modulated by maternal vaccination with potential implications for infant passive protection.

One-Sentence Summary

The breastmilk T cell repertoire is distinct and enriched for SARS-CoV-2 Spike-specificity after maternal mRNA vaccination.

Comparing the effect of a lactation-specific relaxation and visualisation intervention versus standard care on lactation and mental health outcomes in mothers of very premature infants (the EXPRESS trial): study protocol for a multi-centre, unmasked, randomised, parallel-group trial

Background

Premature birth is the leading cause of neonatal death and can cause major morbidity. Maximising the amount of maternal breastmilk given to very premature infants is important to improve outcomes, but this can be challenging for parents. Parents of infants receiving neonatal care also have high rates of anxiety and distress. There is growing evidence for the impact of maternal relaxation interventions on lactation, as well as mental health. The trial will assess whether a brief self-directed relaxation and visualisation intervention, recommended for use several times a day during expression of milk, improves lactation and mental health outcomes for mothers of very premature infants.

Methods

Multi-centre, randomised, controlled, unmasked, parallel-group trial with planned 132 participants who have experienced premature birth between 23 weeks and 31 weeks and 6 days of gestation and plan to express milk for at least 14 days. The primary outcome is the highest 24-h expressed milk yield recorded on any of day 4, day 14 or day 21 after birth. Secondary outcomes include exclusive breastmilk feeding at 36 weeks post-menstrual age and at 4 months after the estimated date of delivery, Spielberger State Trait Anxiety Index at day 21 and Post-traumatic stress Check List (for DSM 5) at day 21.

Discussion

Breastmilk feeding for premature infants is an important research priority, but there are few randomised controlled trials assessing interventions to help parents reach lactation goals in this challenging context. This trial will assess whether a no cost, easily scalable relaxation tool has a role in this setting. Given the lack of harm and potential for immediate dissemination, even a small benefit could have an important global impact.

Trial registration

ISRCTN16356650. Date assigned: 19/04/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06570-9.

Stressful life events in pregnancy: A risk factor for exclusive breastfeeding among high-income mothers

OBJECTIVE

The aim of this study was to examine the association between prenatal stressful life events in pregnancy and breastfeeding initiation, exclusivity, and duration, defined according to the WHO.

STUDY DESIGN

Feeding practices were prospectively collected from 425 puerperae living in an industrialized area of Northeast Italy starting on the second day post-partum, when they filled out the Life Experience Survey (LES, 1978).

RESULTS

In this sample, analysis revealed that at discharge 65/358 (18.16 %) puerperae presented with a negative LES score and 293/358 (81.84 %) with a positive LES score. Puerperae with negative LES scores were more likely to adopt formula at discharge, either to complement breast milk or to substitute breast milk altogether (16/65; 24.62 % vs 43/293; 14.68 %; RR = 1.64 and 95 % CI: 1.01-2.70), and they were also more likely to adopt exclusive formula feeding at the 3rd month of life (8/48; 16.66 % versus 18/242; 7.44 %; RR = 2.03 and 95%CI: 1.06-3.86). At the 6th month of life, there were significantly less puerperae with a negative LES score who were breastfeeding exclusively (1/48; 2.08 vs 44/249; 17.67 %; RR = 0.11 and 95 % CI: 0.01-0.84) and correspondingly there were significantly more puerperae with a negative LES score who were using formula feeding with weaning practices (20/48; 41.67 % vs 35/249; 14.06 %; RR =3.14 and 95 % CI: 1.82-5.04).

CONCLUSIONS

Identification of specific barriers to breastfeeding related to negative life events in pregnancy may help direct providers' anticipatory guidance to improve breastfeeding rates in high-risk populations.

Undernutrition among khat-chewer and non-chewer lactating women in Chiro district, eastern Ethiopia: Comparative cross-sectional study

Objectives:

This study aims to assess the prevalence of undernutrition and factors associated with it among khat-chewer and non-chewer lactating women at Chiro district, west Hararghe zone, eastern Ethiopia.

Methods:

A community-based comparative cross-sectional study was conducted among 446 (223 khat chewers and 223 non-chewers) randomly selected lactating women who have children aged 6 and 23 months. Data were collected through face-to-face interviews using structured questionnaires followed by weight and height measurements to calculate and categorize nutritional status based on body mass index (kg/m²). Data were entered into EpiData version 3.1 and analyzed using STATA version 14.2. A binary logistic regression model was fitted to check the association between independent variables and undernutrition. The level of statistical significance was declared at a p-value less than 0.05.

Results:

The overall prevalence of undernutrition among lactating women was 30.7% (95% confidence interval = 26.6, 35.2). Undernutrition was significantly higher among khat chewers, 39.0% (95% confidence interval = 32.8, 45.6) than non-chewers, 22.4% (95% confidence interval = 17.4, 28.4), (χ² (degree of freedom) = 14.4231, p < 0.0001). Chewing daily (adjusted odds ratio = 3.14, 95% confidence interval = 1.08, 9.15), reducing number of meals after chewing (adjusted odds ratio = 3.45, 95% confidence interval = 1.29, 9.20), and unavailability of latrine (adjusted odds ratio = 2.98, 95% confidence interval = 1.02, 8.75) were significantly associated with undernutrition among khat-chewer lactating women. Furthermore, age at first pregnancy (<18 years) (adjusted odds ratio = 3.17, 95% confidence interval = 1.17, 8.60), not taking any additional meals (adjusted odds ratio = 3.41, 95% confidence interval = 1.08, 10.7), and hand washing after toilet use (adjusted odds ratio = 6.10, 95% confidence interval = 2.51, 14.8) were significantly associated with undernutrition among non-chewer lactating women.

Conclusion:

The overall prevalence of undernutrition is higher than previous studies and is alarming among khat-chewer lactating mothers. Thus, nutritional and public health interventions should target khat-chewer lactating mothers particularly focusing on daily chewer either to improve their dietary practice during and after chewing or to stop khat chewing if possible, in order to reduce the effect of khat on food absorption. Besides, improving latrine coverage and use, and prevention of early pregnancy are of paramount importance in reducing undernutrition among lactating mothers.

Lactation in Anesthesiology

There are several work-related barriers to breastfeeding among physician mothers including: lack of appropriate place for breastmilk expression, unpredictable and inflexible schedules, and lack of time to breastfeed or express milk. In a survey of physician mothers, those who were in surgical and procedural subspecialties, including anesthesiology, reported a lack of lactation facilities in close proximity to the operating room as a barrier to breastfeeding. Unlike other physicians and clinicians in different health care environments, anesthesiology is unique in that there is often no built-in time for breaks or a predictable end time to the operating room schedule. A break system is typically established, within an institution, for meal break relief for trainees, Certified Registered Nurse Anesthetist, and Anesthesia Assistants. This system for breaks may not be sufficient to accommodate the frequency or length required for lactation sessions. In addition, these break systems do not typically provide relief for supervising anesthesiologists for meals or lactation sessions. A study of physician mothers across specialties identified anesthesiologists as significantly more likely than women of other medical specialties to self-report maternal discrimination. The study defined maternal discrimination as discrimination based on pregnancy, maternity leave, or breastfeeding. As a workforce and specialty, we must support our breastfeeding anesthesiologists and facilitate lactation needs on return to the workplace.

Cortisol, Prolactin, and Breastmilk Volume; A Promising Pattern for Reducing Postpartum Depression

BACKGROUND: Research shows postnatal depression and shorter breastfeeding are consistently related, but their causal effect remains debatable. To reduce the impact of mental disorders in the perinatal period, lactation may give a significant neuroendocrine effect. AIM: This study aimed to examine hormonal patterns and estimated breastmilk volume of mothers with depression. MATERIALS AND METHODS: This study was conducted during the three-trimester to 6-week postnatal period. It involved 60 pregnant women from South Sulawesi, Indonesia. Analysis of variance with repeated measures was used to compare and review fluctuations and effect sizes of cortisol, prolactin, and breastmilk volume of mothers with depression symptoms. RESULTS: The mean cortisol levels rose in the 4th week and decreased in the 6th week in both groups. There was no substantial difference in the cortisol levels between these periods (p = 0.534; p = 0.553; and p = 0.660), but the prolactin levels continuously increased by 2 weeks and substantially progressed in the 4th and 6th weeks (p < 0.028, p < 0.009), respectively. There was no positive association between cortisol and prolactin levels (p = 0.384). The breastmilk volume was higher every week only in mothers without depression and it slightly decreased in other categories. This study emphasized the prolactin’s protective effect size on a stressful environment characterized by high cortisol; a significant rise in prolactin levels occurred in the 2nd and 4th weeks of postnatal, marking the higher lactation. CONCLUSIONS: Breastfeeding hormones may provide protection against postpartum depression in moms. It is critical to establish a history of prior trauma in nursing mothers in order to facilitate diagnosis and proper care.

Breast MRI during pregnancy and lactation: clinical challenges and technical advances

The breast experiences substantial changes in morphology and function during pregnancy and lactation which affects its imaging properties and may reduce the visibility of a concurrent pathological process. The high incidence of benign gestational-related entities may further add complexity to the clinical and radiological evaluation of the breast during the period. Consequently, pregnancy-associated breast cancer (PABC) is often a delayed diagnosis and carries a poor prognosis. This state-of-the-art pictorial review illustrates how despite currently being underutilized, technical advances and new clinical evidence support the use of unenhanced breast MRI during pregnancy and both unenhanced and dynamic-contrast enhanced (DCE) during lactation, to serve as effective supplementary modalities in the diagnostic work-up of PABC.

Drinking frequency in wild lactating chimpanzees (Pan troglodytes schweinfurthii) and their offspring

Maintaining water balance is essential for organismal health, and lactating females must balance individual needs with milk production and offspring hydration. Primate milk is dilute and presumed to be the primary source for infant hydration for a considerable time period. Few studies have investigated the hydration burden that lactation may place on female primates. In this study, we investigated sources of variation in female and offspring drinking frequency among wild chimpanzees (Pan troglodytes). We hypothesized females would experience seasonal and lactation hydration burdens and adjust their drinking behavior to accommodate these, but this hydration burden would vary between females of different dominance ranks. We also predicted that parity would relate to maternal drinking frequency since primiparous females are still investing in their own growth. Finally, we predicted that offspring would drink more in the dry season and as they aged and lost milk as a water source, but that offspring of high-ranking females would be buffered from these effects. Using 41 years of long-term data on the behavior of mothers and offspring of Gombe National Park, we found that mothers drank more in the dry season, but there was no significant difference between mothers of different ranks during this period. Low-ranking females drank significantly more than mid- and high-ranking females during late lactation. Offspring also drank more in the dry season and as they aged, but there was no evidence of buffering for those with high-ranking mothers. While chimpanzees in our study population drank infrequently, they do demonstrate noticeable shifts in drinking behavior that suggests seasonal and reproductive hydration burdens.

Influence of exclusive breastfeeding on hippocampal structure, satiety responsiveness, and weight status

Longer exclusive breastfeeding duration has been associated with differences in neural development, better satiety responsiveness, and decreased risk for childhood obesity. Given hippocampus sensitivity to diet and potential role in the integration of satiety signals, hippocampus may play a role in these relationships. We conducted a secondary analysis of 149, 7–11‐year‐olds (73 males) who participated in one of five studies that assessed neural responses to food cues. Hippocampal grey matter volume was extracted from structural scans using CAT12, weight status was assessed using age‐ and sex‐adjusted body mass index (%BMI_p85), and parents reported exclusive breastfeeding duration and satiety responsiveness (Children's Eating Behaviour Questionnaire). Separate path models for left and right hippocampus tested: (1) the direct effect of exclusive breastfeeding on satiety responsiveness and its indirect effect through hippocampal grey matter volume; (2) the direct effect of hippocampal grey matter volume on %BMI_p85 and its indirect effect through satiety responsiveness. %BMI_p85 was adjusted for maternal education, yearly income, and premature birth while hippocampal grey matter volume was adjusted for total intercranial volume, age, and study from which data were extracted. Longer exclusive breastfeeding duration was associated with greater bilateral hippocampal grey matter volumes. In addition, better satiety responsiveness and greater left hippocampal grey matter volume were both associated with lower %BMI_p85. However, hippocampal grey matter volumes were not associated with satiety responsiveness. Although no relationship was found between breastfeeding and child weight status, these results highlight the potential impact of exclusive breastfeeding duration on the hippocampal structure.

Longer exclusive breastfeeding was associated with greater bilateral hippocampal grey matter volume but not satiety responsiveness in children.

While exclusive breastfeeding duration was not directly associated with weight status, better satiety responsiveness and greater left hippocampal grey matter volume were both associated with lower weight status in children.

This study highlights the potential impact of exclusive breastfeeding on hippocampal structure, providing a possible mechanism in which breastfeeding may reduce the risk for excess childhood weight gain.

Future studies need to determine the relative impact that complementary periods of breastfeeding may have on regional brain development and satiety responsiveness.

Maternal Psychological Distress and Lactation and Breastfeeding Outcomes: a Narrative Review

PURPOSE

Despite recommendations from the World Health Organization and the American Academy of Pediatrics to exclusively breastfeed infants for their first 6 months of life, 75% of women do not meet exclusive breastfeeding guidelines, and 60% do not meet their own breastfeeding goals. Numerous observational studies have linked maternal psychological distress (eg, perceived stress, anxiety, and depression) with nonoptimal breastfeeding outcomes, such as decreased proportion and duration of exclusive breastfeeding. The physiological mechanisms underlying these associations, however, remain unclear.

METHODS

For this narrative review, we evaluated the evidence of relationships between maternal psychological distress and lactation and breastfeeding outcomes in pregnancy and post partum and the possible physiological mechanisms that facilitate these relationships. We searched PubMed using the following terms: stress, anxiety, depression, breastfeeding, and lactation. Additional search by hand was conducted to ensure a thorough review of the literature.

FINDINGS

Among the studies examined, methods used to assess maternal psychological distress were not uniform, with some studies examining perceived distress via a variety of validated tools and others measuring biological measures of distress, such as cortisol. Evidence supports a role for psychological distress in multiple breastfeeding outcomes, including delayed secretory activation and decreased duration of exclusive breastfeeding. One physiological mechanism proposed to explain these relationships is that psychological distress may impair the release of oxytocin, a hormone that plays a critical role in milk ejection during lactation. Continued impairment of milk ejection may lead to decreased milk production because of incomplete emptying of the breast during each feed. Maternal distress may also yield elevated levels of serum cortisol and decreased insulin sensitivity, which are associated with decreased milk production. The relationship between psychological distress and breastfeeding is likely to be bidirectional, however, in that breastfeeding appears to reduce maternal distress, again possibly via effects on the pleasure or reward pathway and calming effects of oxytocin on the mother. This finding suggests that interventions to support lactation and breastfeeding goals in women who score high on measures of psychological distress would be beneficial for both maternal and infant well-being.

IMPLICATIONS

Evidence to date suggests that maternal psychological distress may impair lactation and breastfeeding outcomes, but stronger study designs and rigorous assessment methods are needed. A better understanding of the physiological mechanisms leading to impaired lactation may assist in the development of early interventions for mothers experiencing distress. In addition, stress-reducing programs and policies should be investigated for their potential to improve breastfeeding outcomes.

The association of maternal gestational hyperglycemia with breastfeeding duration and markers of milk production

BACKGROUND

Previous studies focusing on the association between gestational diabetes and breastfeeding duration have been inconclusive.

OBJECTIVES

We aimed to determine whether maternal gestational hyperglycemia is associated with the duration of breastfeeding and the concentrations of markers linked to breastmilk production.

METHODS

Data from the prospective, multiethnic Growing Up in Singapore Towards Healthy Outcomes study were used to assess the association of fasting plasma glucose (FPG) and 2-h postglucose challenge (2hPG) measured at 26-28 wk of gestation with duration of breastfeeding and concentrations of protein, lactose, citrate, sodium, potassium, and zinc in breastmilk 3 wk postpartum.

RESULTS

Of the 1035 participants, 5.2% and 9.5% had elevated FPG and 2hPG, respectively, consistent with a diagnosis of gestational diabetes mellitus based on International Association of Diabetes and Pregnancy Study Groups criteria. FPG ≥5.1 mmol/L was associated with a crude reduction in median breastfeeding duration of 2.3 mo. In a model adjusted for maternal prepregnancy BMI and intention to breastfeed, FPG ≥5.1 mmol/L predicted earlier termination of any breastfeeding (adjusted HR: 1.47; 95% CI: 1.04, 2.08) but not full breastfeeding (adjusted HR: 1.08; 0.76, 1.55). 2hPG ≥8.5 mmol/L was not significantly associated with the durations of any (adjusted HR: 0.86; 95% CI: 0.62, 1.19) or full (adjusted HR: 0.85; 95% CI: 0.62, 1.18) breastfeeding. Maternal FPG was significantly and positively associated with breastmilk sodium (adjusted coefficient: 1.28; 95% CI: 1.08, 1.51) and sodium-to-potassium ratio (adjusted coefficient: 1.29; 95% CI: 1.08, 1.54) but not with other measured breastmilk components.

CONCLUSIONS

Women with FPG ≥5.1 mmol/L during pregnancy breastfeed for a shorter duration. Future work involving measurement of milk production is needed to determine whether low milk production predicts breastfeeding duration among women with elevated FPG. This trial was registered at www.clinicaltrials.gov as NCT01174875.

Is There an Association Between Breast Hypoplasia and Breastfeeding Outcomes? A Systematic Review

Introduction: Insufficient milk supply is the most common reason for premature breastfeeding cessation. Breast hypoplasia is one reason why women may be inherently unable to make a full milk supply. This review aimed to systematically explore the relationship between breast hypoplasia and breastfeeding duration, milk supply, and lactation onset. Materials and Methods: Medline, CINAHL, ProQuest Central, and the Cochrane Library databases were searched using the keywords "insufficient glandular tissue" or "mammary hypoplasia" or "breast hypoplasia" or "mammary gland hypoplasia" or "droopy breasts" or "snoopy deformity" or "tubular breast*" or "tuberous breast*" AND breastfeeding or "breast feeding" or breast-feeding or lactation. After initially screening 20 records, including reference lists, 9 full texts were assessed for eligibility; 2 were excluded as no breastfeeding outcomes were reported, leaving 7 studies (N = 42 women). Results: The studies in this review drew on results from the oldest included study and plastic surgery literature to define breast hypoplasia. Most women in this review (40/42) ceased exclusive breastfeeding before 1 month postpartum. One case study reported 24-hour milk production, which was 52 mL at 26 weeks postpartum. Conclusion: The relationship between breast hypoplasia and breastfeeding outcomes is underresearched. The co-occurring medical conditions (e.g., polycystic ovary syndrome) of some women provide avenues for future research into the possible pathogenesis of breast hypoplasia resulting in insufficient milk supply. Research is needed to evaluate the reliability of measuring and classifying markers of breast hypoplasia, and prospective studies can help determine the role of breast hypoplasia in milk production. PROSPERO registration number CRD42020191228.

Potential Loss among Infant Feeding Options

Introduction: The conceptual relationship between economics and breastfeeding is still mathematically invaluable, while the family's economic burden increases along with babies born. Indicating potential loss when a family chooses other than breastmilk is a progressive way to manage campaign messages about exclusive breastmilk and prolonged breastfeeding. Descriptive studies are needed to magnify all of these indicators and transform them into measuring instruments generalized to assess family expenditures related to infant feeding.Methods: This study uses a quantitative descriptive design, questionnaire draft upon qualitative open questions containing all micro indicators impacted financially during the baby’s first year. Data collection was carried out in Makassar based on telephone surveys with 330 preliminary samples. After structural analysis and data reduction, the expenditure indicators were divided into medical and non-medical expenses.Results: The study show there is a difference in the average amount of family expenses of those who provide formula milk compared to breastmilk. This outcome is 21.1 times higher in non-medical components and 2.5 times higher in the medical component. One of the highest contributions in medical expenses is the cost of a recurrent visit to a pediatrician due to a history of illness such as allergies, respiratory infections, and diarrhea.Conclusion: This empirical fact stated the strong affirmation of how families should consider wisely to choose the best feeding pattern for babies aged 0-12 months.

Preterm human milk: associations between perinatal factors and hormone concentrations throughout lactation

BACKGROUND

Infants born moderate to late preterm constitute the majority of preterm births, yet guidelines for their nutritional care are unclear. Maternal milk is the most appropriate nutrition for these infants; however, its composition can be influenced by environmental factors. The present study therefore investigated perinatal predictors of human milk composition in a preterm cohort.

METHODS

Milk was collected during the DIAMOND trial (DIfferent Approaches to Moderate and late preterm Nutrition: Determinants of feed tolerance, body composition and development) from 169 mothers of 191 infants at three time-points (5 and 10 days post partum and 4 months' corrected age). Leptin, adiponectin and insulin-like growth factor-1 (IGF-1) were analysed by enzyme-linked immunosorbent assay. Generalised mixed models were used to evaluate associations between milk composition and maternal/infant/perinatal factors.

RESULTS

Most findings were independent of collection time-point. Gestational diabetes was associated with lower adiponectin. Higher adiponectin and lower leptin were associated with higher socioeconomic status, higher maternal education and ability to fully breastfeed at discharge from hospital. Higher leptin was associated with high perceived stress during hospital admission. Milk IGF-1 displayed sex-specific patterns in association with maternal social deprivation.

CONCLUSION

Maternal, infant and environmental factors during the perinatal period were associated with milk compositional profiles throughout lactation. Further clinical trials should investigate the impact of such changes in terms of long-term infant outcomes.

IMPACT

Human milk is the best nutrition for the infant. However, its composition may be susceptible to alterations determined by pathological conditions mother and infant may face throughout pregnancy and in the perinatal period. This study found that perinatal factors are associated with human milk composition from early to late lactation. If human milk composition throughout lactation is "programmed" during pregnancy or early lactation, infants who were exposed in utero to environmental insults may still be exposed to them during lactation. The impact of human milk compositional alteration on infant growth following perinatal pathological events requires further investigation.

Factors Affecting the Composition of Expressed Fresh Human Milk

Breast milk is considered the ideal and preferred feeding for all infants through the first 4-6 months of life. It provides many short and long-term benefits to the infant and mother. In the absence of breastfeeding, expressed breast milk is the best way to provide nutrition. In the United States, the majority of breastfeeding mothers express milk at some point during the course of lactation. Breast milk is a dynamic fluid and its content changes with duration of lactation and varies between and among women. Many factors such as maternal diet and medications affect the constituents of breast milk. In addition, method of breast milk expression, handling, and storage can also influence its contents.

Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants

BACKGROUND

Many women express concern about their ability to produce enough milk, and insufficient milk is frequently cited as the reason for supplementation and early termination of breastfeeding. When addressing this concern, it is important first to consider the influence of maternal and neonatal health, infant suck, proper latch, and feeding frequency on milk production, and that steps be taken to correct or compensate for any contributing issues. Oral galactagogues are substances that stimulate milk production. They may be pharmacological or non-pharmacological (natural). Natural galactagogues are usually botanical or other food agents. The choice between pharmacological or natural galactagogues is often influenced by familiarity and local customs. Evidence for the possible benefits and harms of galactagogues is important for making an informed decision on their use.

OBJECTIVES

To assess the effect of oral galactagogues for increasing milk production in non-hospitalised breastfeeding mother-term infant pairs.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), Health Research and Development Network - Phillippines (HERDIN), Natural Products Alert (Napralert), the personal reference collection of author LM, and reference lists of retrieved studies (4 November 2019).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (including published abstracts) comparing oral galactagogues with placebo, no treatment, or another oral galactagogue in mothers breastfeeding healthy term infants. We also included cluster-randomised trials but excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Pregnancy and Childbirth methods for data collection and analysis. Two to four review authors independently selected the studies, assessed the risk of bias, extracted data for analysis and checked accuracy. Where necessary, we contacted the study authors for clarification.

MAIN RESULTS

Forty-one RCTs involving 3005 mothers and 3006 infants from at least 17 countries met the inclusion criteria. Studies were conducted either in hospitals immediately postpartum or in the community. There was considerable variation in mothers, particularly in parity and whether or not they had lactation insufficiency. Infants' ages at commencement of the studies ranged from newborn to 6 months. The overall certainty of evidence was low to very low because of high risk of biases (mainly due to lack of blinding), substantial clinical and statistical heterogeneity, and imprecision of measurements. Pharmacological galactagogues Nine studies compared a pharmacological galactagogue (domperidone, metoclopramide, sulpiride, thyrotropin-releasing hormone) with placebo or no treatment. The primary outcome of proportion of mothers who continued breastfeeding at 3, 4 and 6 months was not reported. Only one study (metoclopramide) reported on the outcome of infant weight, finding little or no difference (mean difference (MD) 23.0 grams, 95% confidence interval (CI) -47.71 to 93.71; 1 study, 20 participants; low-certainty evidence). Three studies (metoclopramide, domperidone, sulpiride) reported on milk volume, finding pharmacological galactagogues may increase milk volume (MD 63.82 mL, 95% CI 25.91 to 101.72; I² = 34%; 3 studies, 151 participants; low-certainty evidence). Subgroup analysis indicates there may be increased milk volume with each drug, but with varying CIs. There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints, such as tiredness, nausea, headache and dry mouth (very low-certainty evidence). No adverse effects were reported for infants. Natural galactagogues Twenty-seven studies compared natural oral galactagogues (banana flower, fennel, fenugreek, ginger, ixbut, levant cotton, moringa, palm dates, pork knuckle, shatavari, silymarin, torbangun leaves or other natural mixtures) with placebo or no treatment. One study (Mother's Milk Tea) reported breastfeeding rates at six months with a concluding statement of "no significant difference" (no data and no measure of significance provided, 60 participants, very low-certainty evidence). Three studies (fennel, fenugreek, moringa, mixed botanical tea) reported infant weight but could not be meta-analysed due to substantial clinical and statistical heterogeneity (I² = 60%, 275 participants, very low-certainty evidence). Subgroup analysis shows we are very uncertain whether fennel or fenugreek improves infant weight, whereas moringa and mixed botanical tea may increase infant weight compared to placebo. Thirteen studies (Bu Xue Sheng Ru, Chanbao, Cui Ru, banana flower, fenugreek, ginger, moringa, fenugreek, ginger and turmeric mix, ixbut, mixed botanical tea, Sheng Ru He Ji, silymarin, Xian Tong Ru, palm dates; 962 participants) reported on milk volume, but meta-analysis was not possible due to substantial heterogeneity (I² = 99%). The subgroup analysis for each intervention suggested either benefit or little or no difference (very low-certainty evidence). There was limited reporting of adverse effects, none of which could be meta-analysed. Where reported, they were limited to minor complaints such as mothers with urine that smelled like maple syrup and urticaria in infants (very low-certainty evidence). Galactagogue versus galactagogue Eight studies (Chanbao; Bue Xue Sheng Ru, domperidone, moringa, fenugreek, palm dates, torbangun, moloco, Mu Er Wu You, Kun Yuan Tong Ru) compared one oral galactagogue with another. We were unable to perform meta-analysis because there was only one small study for each match-up, so we do not know if one galactagogue is better than another for any outcome.

AUTHORS' CONCLUSIONS

Due to extremely limited, very low certainty evidence, we do not know whether galactagogues have any effect on proportion of mothers who continued breastfeeding at 3, 4 and 6 months. There is low-certainty evidence that pharmacological galactagogues may increase milk volume. There is some evidence from subgroup analyses that natural galactagogues may benefit infant weight and milk volume in mothers with healthy, term infants, but due to substantial heterogeneity of the studies, imprecision of measurements and incomplete reporting, we are very uncertain about the magnitude of the effect. We are also uncertain if one galactagogue performs better than another. With limited data on adverse effects, we are uncertain if there are any concerning adverse effects with any particular galactagogue; those reported were minor complaints. High-quality RCTs on the efficacy and safety of galactagogues are urgently needed. A set of core outcomes to standardise infant weight and milk volume measurement is also needed, as well as a strong basis for the dose and dosage form used.

Breast Milk, a Source of Beneficial Microbes and Associated Benefits for Infant Health

Human breast milk is considered the optimum feeding regime for newborn infants due to its ability to provide complete nutrition and many bioactive health factors. Breast feeding is associated with improved infant health and immune development, less incidences of gastrointestinal disease and lower mortality rates than formula fed infants. As well as providing fundamental nutrients to the growing infant, breast milk is a source of commensal bacteria which further enhance infant health by preventing pathogen adhesion and promoting gut colonisation of beneficial microbes. While breast milk was initially considered a sterile fluid and microbes isolated were considered contaminants, it is now widely accepted that breast milk is home to its own unique microbiome. The origins of bacteria in breast milk have been subject to much debate, however, the possibility of an entero-mammary pathway allowing for transfer of microbes from maternal gut to the mammary gland is one potential pathway. Human milk derived strains can be regarded as potential probiotics; therefore, many studies have focused on isolating strains from milk for subsequent use in infant health and nutrition markets. This review aims to discuss mammary gland development in preparation for lactation as well as explore the microbial composition and origins of the human milk microbiota with a focus on probiotic development.

Comparison of maternal milk ejection characteristics during pumping using infant-derived and 2-phase vacuum patterns

Background

Milk ejection characteristics remain consistent throughout 12 months of lactation in women who expressed breastmilk with an electric breast pump. In addition these characteristics appear to remain constant when women are breastfeeding or pumping suggesting that milk ejection is a robust physiological response. It is not known whether the stimulation of an infant at the breast in the early post partum period influences milk ejection patterns or whether this is a programmed event. However, as more data become available on the mechanisms involved in infant feeding, pumping patterns mimicking the infant more closely may provide enhanced results. The objective of this study was to compare milk ejection characteristics obtained when using a novel infant-derived pumping pattern with an established 2-phase pattern.

Methods

A convenience sample of ten lactating mothers, 1 to 40 weeks of lactation with normal milk production were recruited in 2015. Each participated in two pumping sessions in which either a 2-phase pattern or infant-derived pattern were randomly assigned. Milk volume and milk ejection characteristics were recorded and the percentage of available milk removed (PAMR) was calculated. Statistical analysis used linear mixed effects modeling to determine any differences between breasts and pump patterns with the consideration of individual variability as a random effect.

Results

The number of milk ejections and milk ejection characteristics did not differ between patterns. Milk volumes removed were 53.6 ± 28.5 ml (PAMR 58.2 ± 28.4) for the 2-phase pattern and and 54.2 ± 26.3 ml (PAMR 52.2 ± 22.3) for the infant derived pattern. Peak milk flow rates were positively associated with the available milk (p = 0.0003) and PAMR (p = 0.0001), as was the volume of milk removed during each milk ejection (p = 0.001 and p = 0.0001).

Conclusion

An experimental pumping pattern designed to resemble infant sucking characteristics did not alter milk ejection characteristics or milk removal parameters compared with an established 2-phase pattern. Theses findings provide further evidence that milk ejection is a robust physiological response.

Perspective: Should Exclusive Breastfeeding Still Be Recommended for 6 Months?

The WHO recommends exclusive breastfeeding of infants for the first 6 mo of life (EBF-6). We reviewed the evidence behind concerns related to this recommendation. The risk of iron deficiency among EBF-6 infants can be significantly reduced if delayed cord clamping is performed in all newborns. At the moment there is no population-level evidence indicating that exclusive breastfeeding for 6 mo compared with <6 mo increases the risk of developing food allergies. Mild to moderate maternal undernutrition may reduce amounts of some nutrients in breast milk but does not directly diminish milk volume. Persistent reports of insufficient milk by women globally are likely to be the result of lack of access to timely lactation counseling and social support rather than primary biological reasons. All newborns should have their growth, hydration status, and development carefully monitored. In instances where formula supplementation is required, it should be done under the guidance of a qualified provider taking into account that early introduction of breast-milk supplements is a risk factor for early termination of exclusive breastfeeding and any breastfeeding. We found no evidence to support changes to the EBF-6 public health recommendation, although variability in inter-infant developmental readiness is recognized. We suggest that infant and young feeding guidelines make clear that complementary foods should be introduced at around 6 mo of age, taking infant developmental readiness into account.

Nipple Deformation and Peripheral Pressure on the Areola During Breastfeeding

Breastfeeding is a complex process where the infant utilizes two forms of pressure during suckling, vacuum and compression. Infant applied compression, or positive oral pressure, to the breast has not been previously studied in vivo. The goal of this study is to use a methodology to capture the positive oral pressure values exerted by infants' maxilla (upper jaw) and mandible (lower jaw) on the breast areola during breastfeeding. In this study, the positive and negative (vacuum) pressure values are obtained simultaneously on six lactating mothers. Parallel to the pressure data measurements, ultrasound images are captured and processed to reveal the nipple deformations and the displacements of infants' tongues and jaw movements during breastfeeding. Motivated by the significant differences in composition between the tissue of the breast and the nipple–areola complex, the strain ratio values of the lactating nipples are obtained using these deformation measurements along with pre- and postfeed three-dimensional (3D) scans of the breast. The findings show an oscillatory positive pressure profile on the breast under both maxilla and mandible, which differs from clinical indications that only the mandible of an infant moves during breastfeeding. The strain ratio varies between mothers, which indicates volume changes in the nipple during feeding and suggests that previous assumptions regarding strain ratio for nonlactating breasts will not accurately apply to breast tissue during lactation.

Impact of Maternal Diet on Human Milk Composition Among Lactating Women in Latvia

Background and objectives: Many studies indicate that the maternal diet is an important factor affecting human milk composition. Human milk composition among lactating women in Latvia, as well as the maternal diet during lactation, has not been sufficiently studied. The aim of this research was to assess dietary habits and macronutrient intake among lactating women in Latvia and to examine the effect of diet on human milk composition. Materials and Methods: Research was conducted between November 2016 and December 2017. Mature human milk samples (n = 61) along with a 72h food diary, a food frequency questionnaire (FFQ), and a questionnaire about maternal and infant characteristics were obtained from voluntary women who were recruited via an invitation published in a social media member group for nursing mothers. Fat content in human milk was determined by LVS ISO 2446:2008, protein content was determined by LVS EN ISO 8968-1:2014, lactose was determined by ISO 22662:2007, and the fatty acid profile was analyzed using gas chromatography. Dietary data were evaluated using the Finnish food composition database Fineli, release 19 (3 March 2018). Results: Median values for fat, protein, and lactose in mature human milk were 4.40%, 1.08%, and 6.52%, respectively. Predominant fatty acids in human milk were oleic acid (C18:1 n9c), palmitic acid (C16:0), and linoleic acid (C18:2 n6c) at 34.60%, 24.00%, and 11.00% of total fatty acids, respectively. The trans elaidic acid (C18:1 n9t) level was <0.10% in all human milk samples. Significant, positive associations (p < 0.05) were found between maternal dietary intake of linoleic, α-linolenic, docosahexaenoic, total cis-monounsaturated, total cis-polyunsaturated, and total n-6 and n-3 polyunsaturated fatty acids, the ratio of n-6/n-3, and the level of these fatty acids in human milk. Total energy and carbohydrate intake among participants were lower, but total fat, saturated fat, and sugar intake were higher than recommended. Protein, linoleic acid, and α-linolenic acid intake were adequate, but docosahexaenoic acid intake was noticeably lower than recommended. Women should be supported with information regarding their nutritional needs during lactation and the possible impact of diet on human milk composition. Conclusion: Macronutrient (fat, protein, and lactose) content in human milk is not affected by maternal diet. Conversely, the human milk fatty acid profile is affected by the immediate diet consumed by the mother. Habitual dietary habits can also impact the fatty acid profile of human milk.

Fifteen-minute consultation: Breastfeeding in the first 2 weeks of life-a hospital perspective

The beneficial health and economic impacts of breastfeeding are considerable. However the majority of babies in the UK are not exclusively breastfeeding by 6 weeks of age. The first few weeks of life are therefore a critical period to facilitate breastfeeding. Health professionals must have a thorough knowledge of normal breastfeeding patterns in order to minimise unnecessary interference, and an understanding of how to protect the breastfeeding relationship when medical problems occur.

"What Is 'Enough,' and How Do I Make It?": A Qualitative Examination of Questions Mothers Ask on Social Media About Pumping and Providing an Adequate Amount of Milk for Their Infants

BACKGROUND

Mothers commonly cite an inadequate milk "supply" as a reason for stopping human milk feeding. Further, pumping may affect mothers' understanding of their milk production. We aimed to characterize the questions mothers ask each other online related to the adequacy of the milk they pumped and provided to their infants.

MATERIALS AND METHODS

We conducted a secondary analysis of 543 posts containing questions related to pumping on an online discussion forum. These posts were provided by an open cohort of ∼25,000 women between 1 month before due date and 4.5 months postpartum. We used thematic analysis with Atlas.ti to analyze the posts.

RESULTS

Mothers commonly asked how many ounces they should be pumping and inquired about strategies to increase their pump output. They also wondered how many ounces or bottles of pumped milk they should provide to their infants or store for future use. Finally, mothers reported the inadequacy of the milk they were pumping or providing to their infants as potential reasons for stopping human milk feeding.

CONCLUSION

Our findings suggest that mothers may benefit from additional guidance from health care providers on the limitations of using pumps to draw conclusions about their milk production, the current evidence related to the use of herbal galactagogues, and the importance of responsive infant feeding. These findings also highlight the need for future research into how pumping or using herbal galactagogues may affect mothers' actual or perceived milk production and how styles for providing pumped milk compare to styles for feeding directly at the breast.

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.

Bariatric Surgery Does Not Appear to Affect Women's Breast-Milk Composition

Background

The breast-milk composition in the first 6 wk postpartum of women who have undergone bariatric surgery (BS) is unknown.

Objective

The aim of this study was to examine 1) the breast-milk macronutrient and vitamin A composition in women who had and who had not undergone BS and 2) the impact of maternal diet on the breast-milk composition. We hypothesized that the milk of women who had undergone BS would be less energy dense and have a lower vitamin A concentration than that of other women.

Methods

A multicenter prospective substudy was conducted at 2 university hospitals. Breast-milk samples were collected from 24 normal-weight [NW; mean ± SD body mass index (BMI; kg/m2): 21.5 ± 1.7; mean ± SD age: 29 ± 6 y], 39 overweight (OW; BMI: 26.9 ± 1.5; aged 29 ± 5 y), and 12 obese women (BMI: 35.0 ± 5.7; aged 29 ± 5 y) as well as from 11 women who had undergone BS (BMI: 28.0 ± 4.4; aged 30 ± 4 y) from day 3 until week 6 of lactation. Milk energy and macronutrients (Human Milk Analyzer; Miris) and vitamin A concentrations (iCheck Fluoro; BioAnalyt) were determined at the end of each week. Maternal diet (food-frequency questionnaire) and physical activity (Kaiser Physical Activity Survey) were measured during the third trimester of pregnancy and on day 3 or 4 and during week 6 of lactation. Statistical analyses include 1-factor ANOVA, Spearman and Pearson correlations, and multiple linear regression.

Results

In all women, a weekly increase in milk energy, total fat, and total carbohydrates was seen, whereas a weekly decrease in proteins and vitamin A was found during the first 2 wk of lactation, followed by a stable concentration of all nutrients. At week 4, milk protein concentrations were higher in women who had undergone BS (14 g/L) compared with NW (8 g/L; P = 0.005) and OW (9 g/L; P = 0.019) women. At week 5, milk carbohydrate concentrations were higher in women who had undergone BS (74 g/L) compared with NW women (68 g/L; P = 0.042).

Conclusions

Breast milk of women who have undergone BS appears to be adequate in energy, macronutrients, and vitamin A during the first 6 wk of lactation. This supports the conclusion that breast feeding should not be discouraged in this group of women. This trial was registered at http://www.clinicaltrials.gov as NCT02515214.

Normal Human Lactation: closing the gap

With the exception of infant growth, there are no well-defined parameters describing normal human lactation. This represents a major gap in the continuum of care that does not exist for other major organs. Biological normality occurs naturally and is characterized by well-integrated function. We have proposed a definition that highlights four key elements that describe parameters for biological normality: comfort, milk supply, infant health, and maternal health. Notwithstanding the current limitations, published data have been collated to provide preliminary markers for the initiation of lactation and to describe objective tests once lactation is established. Reference limits have been calculated for maternal markers of secretory activation, including progesterone in maternal blood and total protein, lactose, sodium, and citrate in maternal milk. Objective measurements for established lactation, including 3-hourly pumping and 24-hour milk production, together with pre-feed to post-feed milk fat changes (a useful indicator of the available milk removed by the infant) have been outlined. Considered together with the parameters describing normal function, this information provides a preliminary objective framework for the assessment of human lactation.

ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Supporting Mothers of Very Preterm Infants and Breast Milk Production: A Review of the Role of Galactogogues

Human milk, either mother’s own milk or donor human milk, is recommended as the primary source of nutrition for very preterm infants. Initiatives should be in place in neonatal units to provide support to the mother as she strives to initiate and maintain a supply of breast milk for her infant. The use of galactogogues are considered when these initiatives alone may not be successful in supporting mothers in this endeavor. Although there are non-pharmacologic compounds, this review will focus on the pharmacologic galactogogues currently available and the literature related to their use in mothers of very preterm infants.

Vitamin B-12 in Human Milk: A Systematic Review

Despite the critical role of vitamin B-12 in infant development, existing recommendations for infant and maternal intake during lactation are based on milk vitamin B-12 concentrations analyzed with outdated methods in a sample of 9 Brazilian women. Accurate quantification of vitamin B-12 in the milk matrix requires effective hydrolysis of the vitamin from haptocorrin, its binding protein. The objective of the present systematic review is to consider and critique evidence of associations between milk vitamin B-12 concentration and time postpartum, maternal vitamin B-12 consumption, maternal vitamin B-12 status, and sample collection methodology. A systematic search of published literature was undertaken using the US National Library of Medicine's MEDLINE/PubMed bibliographic search engine. Observational and intervention studies were included if research was original and vitamin B-12 concentration in human milk was measured using an appropriate method during the first 12 mo of lactation. Eleven studies met inclusion criteria. Vitamin B-12 concentration was highest in colostrum and decreased in a poorly delineated trajectory over the first 3-4 mo of lactation. There was some evidence of a positive association between habitual maternal vitamin B-12 intake and milk vitamin B-12 concentration in marginally nourished women. Supplementation with 50-250 µg vitamin B-12/d during pregnancy and lactation raised human milk vitamin B-12 concentrations while intervention was ongoing, whereas supplementation with 2.6-8.6 µg/d was effective in a population with poor baseline vitamin B-12 status but not in other populations. Whether milk vitamin B-12 concentration varies with maternal circulating vitamin B-12 concentrations or sampling methodology requires further research as existing data are conflicting. Additional research is needed to bridge knowledge gaps in the understanding of human milk vitamin B-12 concentrations. Reference values for vitamin B-12 in human milk and recommended intakes during infancy and lactation should be reevaluated using modern methods of analysis.

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.

Monitoring In-Vivo the Mammary Gland Microstructure during Morphogenesis from Lactation to Post-Weaning Using Diffusion Tensor MRI

Lactation and the return to the pre-conception state during post-weaning are regulated by hormonal induced processes that modify the microstructure of the mammary gland, leading to changes in the features of the ductal / glandular tissue, the stroma and the fat tissue. These changes create a challenge in the radiological workup of breast disorder during lactation and early post-weaning. Here we present non-invasive MRI protocols designed to record in vivo high spatial resolution, T₂-weighted images and diffusion tensor images of the entire mammary gland. Advanced imaging processing tools enabled tracking the changes in the anatomical and microstructural features of the mammary gland from the time of lactation to post-weaning. Specifically, by using diffusion tensor imaging (DTI) it was possible to quantitatively distinguish between the ductal / glandular tissue distention during lactation and the post-weaning involution. The application of the T₂-weighted imaging and DTI is completely safe, non-invasive and uses intrinsic contrast based on differences in transverse relaxation rates and water diffusion rates in various directions, respectively. This study provides a basis for further in-vivo monitoring of changes during the mammary developmental stages, as well as identifying changes due to malignant transformation in patients with pregnancy associated breast cancer (PABC).

Physiology of milk secretion

Milk is a unique and complete nutritive source for the mammal neonate, also providing immune protection and developmental signals. Lactation is a complex process, proper to the mother and child dyad, and including numerous variables ranging from psychological aspects to the secretory functioning of the mammary epithelial cells, all contributing to a successful breastfeeding. This review gives an integrated overview of the physiology of lactation with a particular focus on cellular and molecular mechanisms involved in milk product secretion and their regulations.

"Breastfeeding" but not at the breast: Mothers' descriptions of providing pumped human milk to their infants via other containers and caregivers

As pumping has become more prevalent among American women, pumped human milk (HM) is on the rise in their infants' diets in place of some or all feeding at the breast. We aimed to fill a gap in knowledge about mothers' motivations, practices and perceptions related to pumping, and about mothers' and other caregivers' motivations, practices, and perceptions related to feeding pumped HM. Results related to providing pumped HM are reported here, and results related to pumping are reported elsewhere. We conducted in-depth, semi-structured interviews among a diverse sample of mothers whose infants were fed pumped HM (n = 20), following each up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Nearly all mothers felt bottles were necessary to meet infant HM-feeding goals. Nearly all pumped HM was fed by other caregivers because mothers typically preferred and prioritized feeding at the breast for convenience and maintaining their milk supply. Infants were bottle-fed HM for several reasons that changed over time, such as mother's absence, latch difficulty, or desire to share the burden and bonding of feeding. Feeding practices differed between feeds from bottles versus at the breast; some infants were bottle-fed on schedules but fed at the breast on demand. Mothers' methods for storing, transporting, and preparing HM varied substantially and included practices associated with loss of nutrients and microbial contamination. Mothers' reasons for bottle-feeding HM may affect how much their infants are bottle-fed. Consumption of pumped HM may not provide the same benefits to infants as feeding at the breast. These findings highlight important avenues for future research into the relationships between bottle-feeding HM and infant health, growth, and developmental outcomes.

"Breastfeeding" without baby: A longitudinal, qualitative investigation of how mothers perceive, feel about, and practice human milk expression

Most American mothers who produce human milk (HM) now pump in place of some or all feeding at the breast, and most American infants are now fed pumped HM. We aimed to investigate mothers' perceptions of, attitudes toward, and practices for pumping and providing pumped HM. Results related to pumping are reported here. We conducted in-depth, semi-structured interviews among a diverse sample of 20 mothers who pumped, following each from pregnancy through infant HM-feeding cessation up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Mothers' reasons for pumping changed over time and reflected their needs and desires (e.g., latch difficulty, return to work, and increasing their milk supply). Mothers reported that pump type and quality were important to pumping success and that pumping was time-consuming, costly, and unpleasant compared to feeding at the breast. Regardless of how often mothers pumped, most felt pumping was necessary to meet their infant HM-feeding goals and was a welcome means of sharing with other caregivers the bonding opportunity and tasks they associated with feeding infants. Mothers interpreted output from pumping sessions to understand their ability to provide enough milk to meet their infants' needs. Mothers' reasons for pumping may signal constraints to infant HM feeding that may be addressed with policy changes. Mothers' attitudes and perceptions toward pumping indicate that, although pumping fills important and welcome roles for many mothers, the reality of its practice may make it an unacceptable or infeasible substitute for some.

Associations between Maternal Body Composition and Appetite Hormones and Macronutrients in Human Milk

Human milk (HM) appetite hormones and macronutrients may mediate satiety in breastfed infants. This study investigated associations between maternal adiposity and concentrations of HM leptin, adiponectin, protein and lactose, and whether these concentrations and the relationship between body mass index and percentage fat mass (%FM) in a breastfeeding population change over the first year of lactation. Lactating women (n = 59) provided milk samples (n = 283) at the 2nd, 5th, 9th and/or 12th month of lactation. Concentrations of leptin, adiponectin, total protein and lactose were measured. Maternal %FM was measured using bioimpedance spectroscopy. Higher maternal %FM was associated with higher leptin concentrations in both whole (0.006 ± 0.002 ng/mL, p = 0.008) and skim HM (0.005 ± 0.002 ng/mL, p = 0.007), and protein (0.16 ± 0.07 g/L, p = 0.028) concentrations. Adiponectin and lactose concentrations were not associated with %FM (0.01 ± 0.06 ng/mL, p = 0.81; 0.08 ± 0.11 g/L, p = 0.48, respectively). Whole milk concentrations of adiponectin and leptin did not differ significantly over the first year of lactation. These findings suggest that the level of maternal adiposity during lactation may influence the early appetite programming of breastfed infants by modulating concentrations of HM components.

Concurrent iron and zinc deficiencies in lactating mothers and their children 6-23 months of age in two agro-ecological zones of rural Ethiopia

PURPOSE

The aim of this study is to examine the co-occurrences of low serum ferritin and zinc and anaemia among mothers and their children in two agro-ecological zones of rural Ethiopia.

METHODS

Data were collected from 162 lactating mothers and their breast fed children aged 6-23 months. The data were collected via a structured interview, anthropometric measurements, and blood tests for zinc, ferritin and anaemia. Correlation, Chi-square and multivariable analysis were used to determine the association between nutritional status of mothers and children, and agro-ecological zones.

RESULTS

Low serum levels of iron and zinc, anaemia and iron deficiency anaemia were found in 44.4, 72.2, 52.5 and 29.6% of children and 19.8, 67.3, 21.8, 10.5% of mothers, respectively. There was a strong correlation between the micronutrient status of the mothers and the children for ferritin, zinc and anaemia (p < 0.005). Deficiency in both zinc and ferritin and one of the two was observed in 19.1, and 53.7% of the mothers and 32.7 and 46.3%, of their children, respectively. In the 24 h before the survey, 82.1% of mothers and 91.9% of their infants consumed foods that can decrease zinc bioavailability while only 2.5% of mothers and 3.7% of their infants consumed flesh foods.

CONCLUSION

This study shows that micronutrient deficiencies were prevalent among lactating mothers and their children, with variation in prevalence across the agro-ecological zones. This finding calls for a need to design effective preventive public health nutrition programs to address both the mothers' and their children's needs.

High levels of omega-3 fatty acids in milk from omega-3 fatty acid-supplemented mothers are related to less immunoglobulin E-associated disease in infancy

AIM

We previously reported a protective effect of maternal omega-3 fatty acid supplements on the development of immunoglobulin E (IgE)-associated disease in infancy. This study assessed omega-3 long-chain polyunsaturated fatty acids (LCPUFA) in maternal milk in relation to omega-3 LCPUFA supplementation and the development of allergic disease in their infants.

METHODS

This study randomised 95 pregnant women at risk of having an allergic infant, to daily supplements of 2.6 g omega-3 LCPUFA or a placebo of 2.7 g soya bean oil from gestational week 25 until 3 months of lactation. Breast milk samples were collected as colostrum, at one and 3 months. Milk fatty acids were related to allergic outcome in the infants at 24 months.

RESULTS

Omega-3 milk fatty acids were higher in women who received omega-3 supplements than the placebo group (p < 0.01). Higher proportions of milk eicosapentaenoic acid and docosahexaenoic acid and a lower arachidonic/eicosapentaenoic acid ratio were associated with an absence of IgE-associated disease in the infants. None of the children developed IgE-associated atopic eczema above a level of 0.83 mol% eicosapentaenoic acid in colostrum. [Correction added on 7 July 2016, after online publication: In the preceding sentence, the correct word should be "above" instead of "below" and this has been amended in this current version.] CONCLUSION: High omega-3 LCPUFA milk levels in mothers who received omega-3 LCPUFA supplements were related to fewer allergies in their children.

Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology

The majority of new mothers in the United States use breast pumps in the first 4 months postbirth in order to achieve their personal human milk feeding goals. Although these mothers seek guidance from health-care professionals with respect to the type and use of breast pumps, there are few evidence-based guidelines to guide this professional advice. This paper reviews the evidence to facilitate professional individualization of breast pump recommendations using three categories of literature: the infant as the gold standard to which the pump is compared; the degree of maternal breast pump dependency (for example, the extent to which the breast pump replaces the infant for milk removal and mammary gland stimulation); and the stage of lactation for which the pump replaces the infant. This review can also serve to inform public and private payers with respect to individualizing breast pump type to mother-infant dyad characteristics.