Initiation of lactation in women after preterm delivery

Effect of brewer's yeast or beta-glucan on breast milk supply following preterm birth: the BLOOM study - protocol for a multicentre randomised controlled trial

BACKGROUND

Many individuals who experience preterm birth struggle with early breast milk supply, which can translate into suboptimal longer-term breastfeeding outcomes. Further investigations into the potential role of early non-pharmacological and pharmacological interventions in improving breast milk production soon after birth is growing. While natural galactagogues, such as brewer's yeast, are widely perceived by women to be safer than pharmaceutical galactagogues and are taken by many women, evidence to support their efficacy is largely absent. The BLOOM study has been designed to determine the efficacy and safety of brewer's yeast and beta-glucans, derived from Saccharomyces cerevisiae, when administered soon after birth for increasing early breast milk supply in mothers who have delivered preterm.

METHODS

The BLOOM study is a multicentre, double-blinded, randomised controlled trial that will assess if brewer's yeast or beta-glucan can increase early breast milk production following preterm birth. Target population are mothers of preterm infants born at less than 34 weeks' gestation who intend to provide breast milk for their infant, are less than 72 h following birth and able to give informed consent. Participants will be randomly allocated into three parallel groups at 1:1:1 ratio (n = 33 per group) to receive either brewer's yeast, beta-glucan or placebo capsules for seven days. The primary outcome is total expressed breast milk volume over a 24-hour period on day 7 of intervention. Participants and their infants will be followed until the infant reaches term corrected age or is discharged home from the neonatal unit (whichever occurs first).

DISCUSSION

The use of brewer's yeast as a galactagogue to enhance milk production is extremely common amongst breastfeeding mothers, however, there are no trials evaluating its efficacy and safety. This will be the first randomised controlled trial to evaluate the efficacy and safety of two commonly used galactagogues, brewer's yeast and beta-glucan, compared with placebo in improving maternal breast milk supply following preterm birth. The trial will also evaluate whether early intervention with galactagogues soon after a preterm birth improves longer-term breastfeeding outcomes.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12622000968774 (registered on 8 July 2022) and UTN U1111-1278-8827.

A Randomized Control Trial of Meditation for Mothers Pumping Breastmilk for Preterm Infants

OBJECTIVE

 Mothers of preterm infants face unique challenges in establishing milk supply. We hypothesized that daily meditation practice while pumping would increase milk volume.

STUDY DESIGN

 This was a randomized control trial examining the effect of meditation on the breastmilk supply of women delivering preterm infants. The meditation group engaged in daily use of a mindfulness-focused meditation app in addition to routine lactation support. The primary outcome was mean breastmilk volume on the infant's nineth day of life. Secondary outcomes included use of lactation-promoting behaviors, continuation of breastfeeding, and measures of mental health and breastfeeding self-efficacy by validated questionnaires. In addition to the intention to treat analysis, a per protocol analysis examined the association of frequent meditation with these breastfeeding and mental health outcomes.

RESULTS

 A total of 60 women were analyzed. Mean milk volume was 647.1 ± 467.8 mL in the meditation group and 514.9 ± 393.5 mL in the routine care group (p = 0.27). Median number of pumping sessions was 7 (interquartile range [IQR] 5-8) in the meditation group, compared to 6 (IQR 4-7) in the routine care group (p = 0.11). Other lactation-promoting behaviors, breastfeeding continuation, and questionnaire scores were similar.Adjusting for confounders, we found an increase in breastmilk production of 223.2 mL (95% CI 98.8-347.5, p = 0.001) and in pumping episodes by 0.93 (95% CI 0.16-1.70, p = 0.020) associated with frequent meditation. Skin-to-skin contact was increased to 100% (p = 0.006) among women who meditated seven or more times. Adjusted odds of a clinically significant Edinburgh Postnatal Depression Scale score of >9 was 0.057 (95% CI 0.0014-0.711, p = 0.023) with frequent meditation.

CONCLUSION

 Breastmilk production was similar in mothers practicing meditation compared to those receiving routine lactation support. For women engaging in frequent mediation, there may be an effect in establishing breastmilk supply and reduction of depression symptoms.

KEY POINTS

· Breastmilk is not increased for neonatal intensive care unit (NICU) moms asked to engage in meditation.. · Maternal mental health is not improved among NICU moms asked to meditate.. · However, higher-frequency meditation is associated with increased milk volume and lower odds of high scores on depression screening..

Pressure to provide milk among mothers of very low birth weight infants: an explorative study

BACKGROUND

Pump-dependent mothers of very low birth weight (VLBW, < 1500g) infants experience specific challenges achieving sufficient milk supply in the neonatal intensive care unit (NICU) and are therefore less frequently able to achieve (exclusive) breast milk feeding. Stress due to the limitations on participating in the infant's care may contribute to this problem. Some explorative studies suggest that pressure to provide milk may be an additional stressor in mothers. However, the type of pressure to provide milk perceived by mothers of VLBW infants has rarely been examined.

METHODS

A retrospective and anonymous questionnaire was conducted with mothers of VLBW infants aged 6 to 24 months at the time of data collection. Quantitative data and written comments were used to examine the mothers' perceptions. Descriptive and bivariate tests (Spearman´s rho, Pearson's chi2) were performed to show correlations between pressure to provide breast milk, parental stress (PSS:NICU: role alteration subscale), milk volume, and maternal factors. Pressure to provide milk was measured through two self-developed single items to differentiate between internal and external pressures.

RESULTS

Data of n = 533 mothers of VLBW infants was analysed. More than 70% of the mothers agreed that they pressured themselves to provide milk for their infant. In contrast, 34% of the mothers agreed that they felt pressure from outside to provide milk. Higher milk volume 14 days post-partum was significantly correlated with higher internal (Spearman´s rho = 0.2017, p = 0.000) and higher external pressure to provide milk (Spearman´s rho = 0.2991; p = 0.000). Higher PSS:NICU parental role alteration scores were significantly correlated with more internal (Spearman´s rho = -0.2865, p = 0.000) and more external pressure to provide milk (Spearman´s rho = -0.1478; p = 0.002). Milk volume 14 days post-partum and the PSS:NICU were not significantly correlated (Spearman´s rho = -0.0190; p = 0.701). Qualitative analyses highlighted these results and enhanced the bidirectional relationships between maternal pressure to provide milk and milk volume.

CONCLUSIONS

Especially internal pressure to provide milk is perceived by many mothers, being mutually dependent on milk supply and parental stress. Pressure to provide milk may be an important factor to decrease maternal stress in the NICU and, therefore, lead to more positive pumping and breastfeeding experiences. More research and validated instruments are needed to adequately measure pressure to provide milk with its different psychological, social, and environmental dimensions.

Milk Biomarkers of Secretory Activation in Breast Pump-Dependent Mothers of Preterm Infants: An Integrative Review

Background: Lack of mother's own milk (MOM) at discharge from the neonatal intensive care unit (NICU) is a global problem and is often attributable to inadequate MOM volume. Evidence suggests that the origins of this problem are during the first 14 days postpartum, a time period that includes secretory activation (SA; lactogenesis II, milk coming in). Objectives: To describe and summarize evidence regarding use of MOM biomarkers (MBMs) as a measure of SA in pump-dependent mothers of preterm infants in the NICU and to identify knowledge gaps requiring further investigation. Methods: An integrative review was conducted using Whittemore and Knafl methodology incorporating the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. A search using electronic databases MEDLINE (through PubMed) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) and reference lists of included articles was conducted. Results: Of the 40 articles retrieved, 6 met the criteria for inclusion. Results revealed the following five findings: (1) Achievement of SA defined by MBMs is delayed and/or impaired in mothers of preterm infants. (2) MBMs are associated with pumped MOM volume. (3) Achievement of SA defined by MBMs is associated with pumping frequency. (4) Delayed and/or impaired achievement of SA defined by MBMs may be exacerbated by maternal comorbidities. (5) There is a lack of consensus as to which MBM(s) and analysis techniques should be used in research and practice. Conclusions: MBMs hold tremendous potential to document and monitor achievement of SA in mothers of preterm infants, with multiple implications for research and clinical practice.

Longitudinal trends in domperidone dispensing to mothers of very preterm infants and its association with breast milk feeding at infant discharge: a retrospective study

OBJECTIVE

This study aims: (a) to evaluate patterns of domperidone dispensing to mothers of very preterm (<32 weeks gestation) infants born before and after 2014 when international recommendations were made to limit its use and (b) to examine characteristics associated with domperidone dispensing and impacts on breast milk feeding rates at infant hospital discharge.

DESIGN

Retrospective audit using linked electronic medical records and hospital pharmacy records.

SETTING

Tertiary-referral neonatal intensive care unit at the Women's and Children's Hospital in South Australia.

PATIENTS

Mothers of preterm infants admitted to neonatal intensive care from January 2004 to December 2018.

MAIN OUTCOME MEASURES

Rate of domperidone dispensing compared pre-2014 and post-2014 recommendations using interrupted time series analyses, and breast milk feeding rates at infant discharge based on domperidone treatment status, adjusted for other factors known to influence breast milk production.

RESULTS

Overall, domperidone was dispensed to 691 (41%) of 1688 mothers. Prior to 2014 recommendations, the proportion of women dispensed domperidone was stable. Following the recommendations, there was a significant reduction in trend (-2.55% per half year, 95% CI -4.57% to -0.53%;), reflecting less domperidone dispensing.Breast milk feeding rates at discharge remained consistently lower in infants of women dispensed domperidone than those who were not (adjusted OR 0.58, 95% CI 0.45 to 0.75).

CONCLUSION

Domperidone dispensing in mothers of hospitalised very preterm infants has declined over time following international regulatory warnings. Breast milk feeding rates remain lower in mothers prescribed domperidone, suggesting further research is needed to optimise lactation support for mothers of very preterm infants.

Facilitators and Barriers of Human Milk Donation

PURPOSE

The purpose of this study is to examine perceptions and experiences of women who donate human milk and highlight various aspects of the breast milk donation process.

STUDY DESIGN

A cross-sectional descriptive study.

METHODS

An online survey was conducted with a convenience sample of women who donated milk at several milk banks in the United States. A questionnaire of 36 closed and open-ended items were developed and validated by the research team. Descriptive statistics and content analysis were used. Semantic content analysis involved three procedures: coding, categorizing text units, and refining the identified themes.

RESULTS

A total of 236 women who donated breast milk completed the questionnaire. Mean age of participants was 32.7±4.27 and 89.40% were non-Hispanic White women with a bachelor's degree (32.20%) or graduate degree (54.70%). Most participants were women who actively donated breast milk, ranging from one to four times. Two themes, facilitators and barriers of milk donation, were identified. Facilitators to milk donation included attitudes toward milk donation, commitment for donating, motivation in donating, and support. Barriers included personal factors, environment, milk donor process, and psychosocial factors.

CLINICAL IMPLICATIONS

Nurses, health care providers, and lactation professionals should educate women about milk donation resources and opportunities. Strategies to increase awareness about milk donation among underrepresented groups such as women of color are highly recommended. Future research is needed to further explore specific factors that increase milk donation awareness and minimize barriers to potential donors.

Breast Milk Production Variability Among Mothers of Preterm Infants

Introduction: Mothers of preterm infants are at risk for inadequate milk production. Pumping logs are often used to both encourage lactation in the first week and track its efficacy. Our objectives were to determine whether mothers of preterm infants who keep pumping logs are demographically different from those who do not and to determine whether this practice affects the amount of mother's own milk (MOM) fed to their infants. We also aimed at determining whether there is a correlation between: (1) time to first breast milk expression, (2) cumulative frequency of expression in the first week, and (3) milk volume on day 7 with subsequent milk volumes and percent of infant diet consisting of MOM. Methods: Mothers of infants born ≤32 weeks and ≤1,500 g were enrolled within 48 hours of birth and encouraged to keep a pumping log. Data were collected on maternal characteristics, patterns of milk expression, and milk volumes on days 7, 14, 21, and 28 after delivery. Infant data were collected via chart review. Results: Mothers who kept pumping logs provided their own milk for a greater percentage of their infant's feeds at the time of achieving full feeds (p = 0.017). The total number of expressions in the first week was correlated with milk volume on day 21 (p = 0.016) and the provision of a higher percentage of MOM feeds at discharge (p = 0.03). Milk volume on day 7 correlated with volumes obtained at days 14, 21, and 28 (p < 0.001). Conclusions: Pumping logs may affect the availability of MOM for preterm infants. Frequency of pumping in the first week and milk volume on day 7 may impact long-term lactation success for these women.

Breastfeeding in women with systemic lupus erythematosus: results from a Norwegian quality register

BACKGROUND

Knowledge on breastfeeding among women with systemic lupus erythematosus (SLE) is sparse. We wanted to identify the frequency of breastfeeding in SLE, and to compare breastfeeding women with SLE to non-breastfeeding women to examine possible differences in disease characteristics and self-reported health data between the groups.

METHODS

Prospective data on women with SLE from RevNatus, a consent-based Norwegian nationwide quality register was used for this study. Data were collected during January 2016 to September 2021. We used data registered at inclusion when planning pregnancy or in 1^st trimester, and 6 weeks, 6 and 12 months after delivery. Breastfeeding and non-breastfeeding patients were compared according to demographic, serological and obstetric data as well as disease activity, medication, self-reported pain, and fatigue.

RESULTS

A total of 114 pregnancies in 101 SLE women were included in the analysis. A majority of the women (78%) breastfed six weeks postpartum. Six and 12 months after delivery, breastfeeding rates were 54% and 30% respectively. Six weeks postpartum, non-breastfeeding women showed higher prevalence of emergency caesarean delivery (p = 0.038), preeclampsia (p = 0.056) and lower educational level (p = 0.046) compared to breastfeeding women. 12 months after delivery, we observed a higher frequency of multiparity among breastfeeding women (p = 0.017) compared to non-breastfeeding. Overall, we found low disease activity in both groups at all registrations in the follow-up, and disease activity did not differ between the groups. More than 70% of both breastfeeding and non-breastfeeding women used hydroxychloroquine (HCQ).

CONCLUSIONS

Breastfeeding rate in women with SLE was high six weeks postpartum. Multiparous women breastfed longer than primiparas. Disease activity, use of HCQ, and self-reported health data were comparable between the groups. Our data indicate that health professionals should encourage women with SLE to breastfeed.

The Utilization of Sodium Concentration in Human Milk from Pump-Dependent Mothers of Preterm Infants as a Measure of Milk Production

Objective: This study investigated changes in sodium concentrations in human milk from mothers of premature infants using different breast pumps for 14 days postpartum, and the correlation between the sodium concentration in mother's own milk (MOM) and the volume pumped. Study Design: This randomized controlled study recruited 66 mothers of premature infants delivered in our hospital from February to December 2018, and we assigned them to three groups using an envelope method. In intervention group 1, a hospital-grade electric breast pump was used from postpartum day 1 to 14; in intervention group 2, a hospital-grade electric breast pump was used on postpartum days 1 to 5 and a normal personal electric breast pump on postpartum days 6 to 14; in the control group, a personal normal electric breast pump was used from postpartum day 1 to 14. Data recorded included the breast milk volume pumped and milk sodium concentration. Results: The average daily volume of MOM pumped differed statistically (p < 0.05) between the intervention and control groups at postpartum days 7 and 14. The average daily volume pumped did not differ between intervention groups 1 and 2 by postpartum day 14 (p > 0.05). However, the time taken for the sodium concentrations to normalize differed significantly (p < 0.01). At postpartum day 5, the sodium concentrations of 73% of intervention group 1 and 2 mothers were within normal limits, and they were maintained until day 14. In comparison, only 41% of the controls had normal MOM sodium levels on day 5, and they were still high on day 7 in 27.3% of controls. Conclusions: In the early stage of lactation initiation (within 5 days postpartum), using a hospital-grade electric breast pump promotes lactation in mothers who deliver prematurely and the sodium concentrations normalize more quickly. Sodium can be used as an objective biomarker of MOM to evaluate the possibility of delayed lactation in mothers of premature infants, and it could assist interventions in the early postpartum period. Trial Registration: Chinese Clinical Trial Registry, ChiCTR2200061384.

Associations of Secretory Activation Breast Milk Biomarkers with Breastfeeding Outcome Measures

OBJECTIVE

The objective of this study was to explore associations between day 10 postpartum (D10) secretory activation biomarkers and the breastfeeding outcome measures.

STUDY DESIGN

This prospective longitudinal descriptive study collected antepartum, D10, and day 60 postpartum (D60) questionnaire data and D10 milk samples. Protein, lactose, and citrate were analyzed with enzymatic spectrophotometric assays. Sodium and potassium were analyzed with inductively coupled plasma optical emission spectrophotometry. Group comparison data were analyzed using χ², Fisher exact, and independent sample t tests, as appropriate, using SPSS for Mac (version 28).

RESULTS

Participants (n = 92) provided a D10 breastmilk sample and completed D10 questionnaires, and 83 completed D60 questionnaires. Participants with D10 impaired secretory activation sodium (>23.0 mM) were more likely to report D10 perceived insufficient milk supply, χ² = 7.002, P < .05; and less D10 feeding/pumping frequency a day, P < .05; and partial breastfeeding at D60, P < .05. Additionally, participants with D10 impaired secretory activation sodium-to-potassium ratio (sodium: potassium) > 0.8 were more likely to partially breastfeed at D60, P < .05.

CONCLUSION

Elevated milk sodium and sodium: potassium are biomarkers related to variables indicative of low milk supply. Therefore, immediate milk testing can be useful in identifying lactation compromise and improving breastfeeding duration. Because breastfeeding affords maternal and infant health benefits, clinicians should identify ways to measure lactation compromise in conjunction with an examination and clinical history to provide early interventions to increase breastfeeding duration and exclusivity.

Infant Feeding Practices, Nutrition, and Associated Health Factors during the First Six Months of Life among Syrian Refugees in Greater Beirut, Lebanon: A Mixed Methods Study

The objective was to describe infant feeding practices, nutrition and related health aspects of infants under six months among Syrian refugees in Greater Beirut, Lebanon. A cross-sectional study was conducted among Syrian refugee mothers with infants under six months in July-October 2018 (N = 114). Additionally, eleven focus group discussions were conducted to explore supportive factors and barriers associated with early breastfeeding practices. The prevalence of pre-lacteal feeding was high (62.5%), whereas early initiation of breastfeeding was low (31%), and exclusive breastfeeding very low (24.6%). One-fifth of the infants were anemic (20.5%) and 9.6% were wasted. A significantly higher proportion of non-exclusively breastfed infants had a fever and took medicines than those who were exclusively breastfed. Supporting factors of adequate infant feeding practices comprised knowledge on maternal nutrition and exclusive breastfeeding, along with receiving support from healthcare professionals and family members. Identified barriers included preterm delivery, pre-lacteal feeding, an at-risk waist circumference and moderate to severe depression among mothers, bottle feeding, early introduction of food, maternal health reasons, breastmilk substitutes' distribution, and misinformation offered by mothers-in-law. To address sub-optimal feeding practices documented among Syrian refugees, awareness on proper breastfeeding practices, maternal nutrition, and psychosocial support should be provided to mothers and family members alike.

Manual Method vs Breast Pump for Breast Milk Expression in Mothers of Preterm Babies During First Postnatal Week: A Randomized Controlled Trial

Objectives

To compare breast milk volume between manual method and breast pump expression in mothers of preterm infants at different time point of first week.

Design

Randomized controlled trial.

Setting

Postpartum ward of Obstetrics department and tertiary level neonatal intensive care unit (NICU) in a single institution in Orissa between October, 2020 and May, 2021.

Participants

Mothers who delivered before 34 completed weeks of gestation.

Interventions

Manual breastmilk expression (ME) group using Marmet technique and breast pump milk expression (PE) group using pigeon manual breast pump, initiated milk expression within one hour of delivery.

Outcome measures

Expressed breast milk (EBM) volume in mothers of preterm infants at different time point of first week, and cumulative milk volume.

Results

Out of 170 mothers (83 PE and 87 ME group), 7-days milk volume data was available for 137 (71 ME and 66 PE) mothers. In per protocol analysis for 126 mothers (63 in each group), the median (IQR) EBM volume on day 2 and day 7 of ME and PE groups were similar [10 (5,20) vs 12 (5,28), P=0.10] and [280 (220–356) vs 280 (220–360), P=0.66]. The median (IQR) cumulative EBM volume over first 7 days in ME group was not significantly different from PE group [733 (593–995) vs 848.5 (571–1009)] P=0.55). A similar number of mothers in the PE and ME group [56 (88.9%) vs 58 (92%); P=0.14] provided exclusive breast milk for their neonates during the first week. Similar results were found on intention to treat analysis.

Conclusion

EBM volume expressed was comparable between mothers expressing manually or with breast pump.

Milk Volume Outcomes in Pump-Dependent Mothers of Critically Ill Infants

INTRODUCTION

Mother's own milk improves health outcomes in infants of all gestational ages. Although pump-dependent mothers of extremely premature infants are at risk of insufficient milk production, whether mother's milk production is impacted by gestational age and pump dependency in mothers of more mature critically ill infants is unknown.

PURPOSE

To determine whether there is a relationship between gestational age, milk production, and time to secretory activation in mothers delivering a critically ill infant.

METHODS

A convenience sample of 136 pump-dependent mothers whose infants were admitted to the neonatal intensive care unit was enrolled between 2013 and 2016 as part of a quality improvement project. Group 1 (early preterm) delivered infants at 30 to 33 weeks of gestation (n = 41), group 2 (late preterm) 34 to 36 weeks (n = 48), and group 3 (term) 37 weeks and more (n = 47). Milk volume on days 1 to 7 was measured by weighing each vial of expressed milk and compared using general linear mixed-model analysis. Time to the onset of secretory activation was compared using censored regression analysis.

RESULTS

Main effect for gestational age controlling for day was statistically significant (P = .0234). The early preterm group produced more milk over the 7-day study than the term (P = .01) and late preterm (P = .02) groups. The early preterm group achieved secretory activation earlier than the late preterm group (adjusted P = .039).

IMPLICATIONS FOR PRACTICE

Pump-dependent mothers of all infants admitted to the neonatal intensive care unit may be at risk of inadequate milk production and delayed secretory activation and may therefore benefit from early milk production monitoring and lactation support.

IMPLICATIONS FOR RESEARCH

Further studies should examine targeted interventions to increase milk production in pump-dependent mothers.

Initiation of lactation and the provision of human milk to preterm infants in German neonatal intensive care units from the mothers' perspective

Background

If infants with a very low birth weight (VLBW) are to be fed exclusively with human milk, it is essential to focus on lactation initiation. The aim of the study is to learn more about the current state of lactation initiation and human milk provision in neonatal intensive care units in Germany from the mothers' perspective.

Methods

Written surveys were conducted with mothers of VLBW infants to learn more about the timing of initiation of lactation, pumping frequency during the first three days postpartum and feeding of the preterm infant during hospitalisation.

Results

The data of 437 mothers (response rate: 44.7%) were included in the analyses. Of these, only 7.8% stated that they had initiated lactation immediately after delivery and 38.2% within 6 h. In terms of pumping frequency, 50.1% pumped 7–9 times a day within the first 3 days postpartum; 60.9% reported that their infant received formula feedings during the hospital stay.

Conclusion

Overall, deficits were still evident with regard to the initiation of lactation in mothers of VLBW infants in Germany, resulting in a large proportion of VLBW infants receiving formula in the hospital.

Trial registration

German Clinical Trial Register: DRKS00017755.

A prospective cohort study on lactation status and breastfeeding challenges in mothers giving birth to preterm infants

Background

Mothers of preterm infants face many challenges in breastfeeding, especially regarding lactation. This study aimed to investigate the lactation status and challenges in breastfeeding faced by preterm infants’ mothers.

Methods

We approached 124 mothers who gave birth to preterm infants between 26 May and 31 October 2018 in a tertiary hospital in China. Lactation status and challenges in breastfeeding on day 7 postpartum, at discharge of infants, 2 weeks post-discharge, and 3 months of corrected age were collected using questionnaires. The area under the receiver operating characteristic (ROC) curve for expressed milk volume on day 7 postpartum for predicting expressed milk volume ≥ 300 mL/d at discharge was calculated. Logistic regression analyses were performed to identify factors associated with delayed lactogenesis II onset and continuation of breastfeeding at 3 months of corrected age.

Results

Seventy mothers were enrolled, and 51.4% had delayed lactogenesis II. Multivariate logistic regression analysis revealed that older maternal age (aOR = 1.19; 95% CI: 1.01, 1.40) and first live birth (aOR = 4.81; 95% CI 1.43, 16.18) were significant independent predictors of delayed lactogenesis II. Mothers with delayed lactogenesis II had significantly lower expressed milk volume (day 7 postpartum: 160.0 mL vs. 300.0 mL, U = 328.50, p = 0.001; at discharge: 425.0 mL vs. 612.5 mL, U = 372.00, p = 0.005), with a lower proportion of exclusive breastfeeding in their infants (at discharge: 33.3% vs. 69.8%, χ² = 12.39, df = 1, p < 0.001; 3 months of corrected age: 17.8% vs. 52.8%, χ² = 11.03, df = 1, p = 0.001). The ROC showed that expressed milk volume > 190 mL/d on day 7 postpartum significantly predicted expressed milk volume ≥ 300 mL/d at discharge. Insufficient human milk was the main reason for breastfeeding discontinuation at 3 months of corrected age. Twins were less likely to continue breastfeeding at 3 months of corrected age (aOR = 0.27; 95% CI 0.09, 0.86). In singleton infants, mother’s own milk ≥50% of total milk uptake at 2 weeks post-discharge (aOR = 32.66; 95% CI 3.00, 355.25) was an independent predictor of continuous breastfeeding at 3 months of corrected age. Feeding complications in infants, poor breastfeeding technique, and low milk output are the main challenges in breastfeeding.

Conclusion

Interventions to improve early postpartum lactation and breastfeeding techniques may increase breastfeeding adoption in mothers of preterm infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00447-4.

Updating Clinical Practices to Promote and Protect Human Milk and Breastfeeding in a COVID-19 Era

The COVID-19 pandemic has impacted breastfeeding and lactation globally, with clinical practices implemented early in the pandemic being mostly anti-breastfeeding, e.g., separation of mothers from their infants, and not evidence based. As the pandemic has progressed, evidence has emerged reconfirming the value of human milk and the importance of protecting and supporting breastfeeding, especially the initiation of lactation. However, it is clear that COVID-19 has changed the clinical care paradigm around breastfeeding and lactation support and, as such, it is imperative that practices adapt and evolve to maintain the emphasis on lactation support. We participated in a round table conference aiming to rescue and develop protocols and practices that support breastfeeding during the COVID-19 pandemic. One key area to target will be to maximize the use of the antenatal period. The early identification of lactation risk factors together with the development of person-centered methods to deliver breastfeeding information and education to parents-to-be will be critical. In addition, the establishment of a hospital culture that values breastfeeding and prioritizes the use of human milk will be integral for the motivation of health care professionals. That culture will also support active management of the initiation of lactation and the development of a 'back-up plan' toolkit to support the mother experiencing lactation difficulties. Post-discharge support will also be crucial with the development of both in-person and virtual lactation support programs, in particular for the immediate post-discharge period to benefit mothers who experience an early discharge process. These measures will allow for a new, adapted framework of practice that acknowledges the current COVID-19 paradigm and maintains the emphasis on the need to protect and support breastfeeding and the use of human milk.

Nutritional Management of Moderate- and Late-Preterm Infants Commenced on Intravenous Fluids Pending Mother's Own Milk: Cohort Analysis From the DIAMOND Trial

BACKGROUND

Exclusive breastmilk is the desired enteral nutrition for babies born moderate- and late-preterm between 32⁺⁰ and 36⁺⁶ weeks' gestation; however, this goal is often difficult to achieve.

METHODS

A prospective cohort of babies 32⁺⁰ -35⁺⁶ weeks' gestation enrolled in the DIAMOND trial were randomized to a condition specifying that babies should receive mother's own milk (MOM) as the only enteral feed. Factors associated with the successful transition to MOM, defined as MOM being the sole enteral feeding at the time of the first cessation of intravenous (IV) fluids, were investigated by logistic regression. Time to commencement of a milk other than MOM was analyzed by Kaplan-Meier survival curves.

RESULTS

A total of 151 eligible babies (60% boys) were included, 93 (63%) of whom successfully transitioned from IV fluids onto MOM only. Alternative sources of milk, mostly formula, were used to transition from IV fluids onto enteral feeds more often in multiples and Māori, and was commenced earlier in Māori than other ethnicities (p = 0.007) and in late-preterm compared with moderate-preterm babies (p=0.01). Receiving exclusively breastmilk at discharge was more likely for babies who successfully transitioned from IV fluids onto MOM only [OR (95% confidence intervals) 4.9 (2.3-10.6)] and who received only MOM in the first week after birth [4.8 (2.2-10.4)], both p < 0.0001. Receiving breastmilk exclusively at discharge was less likely for Māori than Caucasian babies [0.2 (0.1-0.6), p < 0.0006]. There was no difference in the use of alternative sources of milk in babies who received parenteral nutrition or dextrose or between small-for-gestational-age and appropriate-for-gestational-age babies.

CONCLUSIONS

Despite an intention to provide only MOM, significant numbers of moderate- and late-preterm babies received formula to transition from IV fluids, and this differed by ethnicity. The drivers underlying these decisions require further investigation. These data highlight an urgent need for quality initiatives to support and encourage mothers of moderate- and late-preterm babies in their lactation.

The relationship between prenatal attachment and postnatal adaptation, maternal anxiety and breast milk sodium level

Objective

To investigate the relationship between maternal-fetal attachment and breast milk sodium (BMS) levels.

Methods

This prospective case-control study was conducted at Baskent University. Third-trimester low-risk pregnancies were included in the study. After obtaining informed consent, the Prenatal Attachment Inventory (PAI), and the State-Trait Anxiety Inventory 1 (STAI 1) and STAI 2 were administered. After delivery, BMS values were measured at regular intervals.

Results

The mean age of the mothers and the mean gestational age were 29.6 ± 3.4 years and 38.4 ± 0.9 weeks, respectively. The mean STAI -1, STAI-2, and PAI scores were 38.2 ± 7.1, 38.8 ± 6.9, and 41.6 ± 10, respectively. When the study group was classified according to BMS levels, no differences were observed between the groups in terms of pregnancy STAI-1, pregnancy STAI-2, Muller PAI, and STAI-1 scores of the 5^th, 15^th, and 30^th days. There was no correlation between the BMS levels on the 5^th −15^th days and pregnancy STAI-1, Pregnancy STAI-2, Muller PAI, and the STAI-1 scores of the 5^th-10^th-30^th days. However, the BMS level on the 30^th day had a positive significant correlation with the STAI-1 score on the 15^th day (r = 0.473, p= .006). Additionally, the STAI-1 scores on the 30^th day showed that there was a significant correlation with STAI-1 on the 5^th day (r = 0.416, p= .015), STAI-1 on the 15^th day (r = 0.497, p= .003), and breast milk sodium levels on the 30^th day (r = 0.615, p< .001).

Conclusion

We found no relationship between PAI scores and BMS levels on the 5^th-10^th-30^th day but STAI scores on the 15^th day and 30^th day had a positive correlation with BMS levels on the 30^th day. STAI-1 and STAI-2 scores during pregnancy were positively correlated with STAI scores in the postnatal period.

•

It is known that psychosocial factors in pregnancy and mother-infant attachment have many postpartum effects via neurohumoral mechanisms.

•

There is no known data relationship between maternal-fetal bonding and breast milk sodium level.

•

This is the first study to investigate the relationship between prenatal attachment and breast milk sodium values.

•

Breast milk sodium levels seem to be more related to anxiety levels.

•

There is no relationship between PAI scores in the last trimester and breast milk sodium in low-risk pregnant women.

Human milk microbes: Strategies to improve delivery to the infant

Mother's own milk provides personalized nutrition and immune protection to the developing infant. The presence of healthy microbes plays an important role in the infant's gut by programming the microbiota and excluding potential pathogens. This review describes the important components in mother's own milk that contribute to its superiority for infant nutrition and suggest potential strategies to replicate these factors in alternative feedings when sufficient milk is unavailable. Current strategies to supplement, substitute and replicate mother's own milk including microbial restoration, use of unpasteurized donor human milk, probiotics and fortification are discussed. Critical work remains to be done in understanding the human milk microbiome and metabolome and in improving lactation support for mothers of preterm infants. Increasing delivery of mother's own milk and milk components to infants would likely positively impact infant mortality and health worldwide.

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.

25 Years of Research in Human Lactation: From Discovery to Translation

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.

Indicators of Secretory Activation in Mothers of Preterm Very Low Birth Weight Infants

BACKGROUND

Inconsistent information exists regarding indicators of secretory activation in mothers delivering very low birth weight infants.

RESEARCH AIMS

To compare time to the onset of secretory activation using three separate indicators. A secondary aim examined the association between indicators of secretory activation and milk production.

METHODS

Indicators of secretory activation included maternal perception, volume attainment (production of ≥ 20 mL in two consecutive expression sessions) and biomarkers (sodium and lactose) obtained at volume attainment. Milk production was measured on Days 1-7 and then weekly for 6 weeks.

RESULTS

In 69 mothers of infants born ≤ 32 weeks' gestation and < 1500 g, we found no correlation in time to secretory activation between indicators. Earlier volume attainment was associated with increased milk production on Days 1-7, 14, 21, and 28 (all p < .007). Participants who exhibited both normal lactose and sodium levels produced more milk on Days 28 and 42 (p = .028 and .011), those with only normal lactose levels produced more on Day 42 (p = .026) and those with only normal sodium levels on Day 28 (p = .036). Earlier secretory activation by volume attainment was associated with increased expression frequency during Days 2-5 (all p < .014) and participants with normal biomarkers expressed more frequently during Days 2-5 (all p < .020).

CONCLUSION

Mothers of very low birth weight infants are at risk for delayed secretory activation, which may decrease their milk production. Frequent expression during the first 5 days postpartum may promote earlier secretory activation. Valid methods of determining secretory activation are necessary to develop interventions promoting earlier secretory activation.

Measures of Lactation Outcomes in Women Delivering Preterm Infants

BACKGROUND

Mother's own milk (MOM) is well known to decrease prematurity-related morbidities, yet mothers delivering preterm infants often produce insufficient quantities of milk to provide these benefits. Although a critical need exists for research to support lactation success in this vulnerable population, development and investigation of interventions to increase available MOM for infant consumption requires consistent, valid, and reliable measures of lactation outcomes.

OBJECTIVES

The aim of this study was to compare and contrast methods of measuring lactation outcomes in mothers of preterm infants and evaluate their advantages and disadvantages.

METHODS

Measures of lactation outcomes were reviewed and synthesized. Insights on best practices and future research directions are provided.

RESULTS

Volume of MOM produced, lactation duration, and time to onset of secretory activation are important measures of lactation success. The most valid and reliable measure of milk production is likely weighing each vial of expressed milk combined with test weighing when infants breastfeed. Measures of lactation duration should include actual days mothers lactated rather than limiting to infant consumption of MOM as a proxy for duration and include not only whether mothers are lactating at infant discharge but whether they are also lactating at other health-relevant time points during hospitalization. Although time to onset of secretory activation is an important lactation outcome, information regarding valid and reliable indicators of onset in women delivering preterm infants is limited, and investigation of such indicators is a research priority. Variables that may affect lactation outcomes, including time to initiation of expression following delivery, duration of expression sessions, expression method, time spent in skin-to-skin care, maternal demographics and comorbidities, as well as maternal intent to lactate, must be considered when researchers investigate lactation outcomes in mothers of very low birth weight infants.

DISCUSSION

Consistent and valid measures of lactation outcomes are required to produce reliable results from which evidence-based practice recommendations can be developed in order to improve lactation success in this vulnerable population.

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.

Maternal production of milk for infants in the neonatal intensive care unit

Mother's own milk (MOM) feeding is a cost-effective strategy to reduce risks of comorbidities associated with prematurity and improve long-term health of infants hospitalized in the Neonatal Intensive Care Unit (NICU). Significant racial and socioeconomic disparities exist in MOM provision in the NICU, highlighting the importance of developing strategies to reduce these disparities. Mothers of infants in the NICU experience many health concerns which may negatively impact lactation physiology. Objective measures of lactation physiology are limited but may assist in identifying mothers at particular risk. Several strategies to assist mothers of hospitalized infants are essential, including maternal education, qualified lactation professionals, early and frequent milk expression with a hospital-grade double electric breast pump, and providing support for transitioning to direct breastfeeding prior to discharge from the NICU.

Effect of Domperidone on Breast Milk Production in Mothers of Sick Neonates: A Randomized, Double-Blinded, Placebo-Controlled Trial

Objective: Mothers of many preterm babies are unable to produce sufficient milk for their babies during the prolonged hospitalization. Domperidone stimulates the release of prolactin, thereby increasing breast milk production. The primary outcome was to study the efficacy of domperidone in augmenting breast milk production in mothers with lactation failure (LF). The secondary outcomes included the effect of domperidone on prolactin levels, adverse effects of domperidone, and outcome on breastfeeding rates at discharge. Materials and Methods: This was a randomized, double-blinded, placebo-controlled trial where mothers with LF were either allocated domperidone (10 mg) or placebo, 2 tablets three times a day for 14 days. Milk volumes were recorded daily for 14 days. Serum prolactin levels were measured at the start and at day 7 of study. Results: Out of 166 women eligible for the study, 119 (71.7%) mothers were able to increase their breast milk production without pharmacological treatment after being counseled on the advantages of human milk and proper breastfeeding management. Forty-seven mothers were finally enrolled in the study; 24 in the domperidone group (DG) and 23 in the placebo group (PG). Breast milk production increased from a baseline of 156 + 141.1 to 400.9 + 239.2 mL in the DG and increased from a baseline of 175.8 + 150.7 to 260.5 + 237.5 mL in the PG, after 14 days (p < 0.01). The prolactin levels in the DG and PG increased from 72.85 (22.2-167.15) and 42.33 (14.02-93.54) ng/mL, respectively, to 223.4 (49.79-280.2) ng/mL (p = 0.005) in the DG and 60.08 (14.31-132.14) ng/mL (p = 0.232) in the PG on the 7th day of treatment. No adverse effects were recorded. Ninety-five percent of babies in the DG were exclusively breastfeeding at hospital discharge, compared with 52.4% in the PG (p = 0.008). Conclusion: Domperidone treatment can result in an increase in breast milk production with no adverse effects. The study was registered with the Thai Clinical Trials Registry ID TCTR2020091008.

Availability of Breast Milk for Preterm Neonates by Gestational Age during NICU Stay

The objective of this study was to explore the availability of expressed breast milk (EBM) volume for the premature neonates born from mothers in different gestational age groups during neonatal intensive care unit (NICU) stay. All preterm infants (extreme-preterm infant [EPTI, <28 weeks], very-preterm infant [VPTI, 28–316/7 weeks], and moderate-preterm infant [MPTI, 32–336/7 weeks]) and their mothers were included in the study. Infants not receiving mother's own milk and neonates deceased or discharged against medical advice, and the mother with illness during postpartum period were excluded from the study. A predesigned tool was used to collect information on maternal characteristics, neonatal characteristics, and milk diary for preterm neonates from the NICU case records. The primary outcome variable EBM volume available on day 7 was compared across three gestational groups. Logistic regression was used to predict EBM availability. A total of 78 preterm neonates, including 10 EPTI, 37 VPTI, and 31 MPTI, had average birth weight of 962.5 ± 228.25, 1,185.1 ± 183.14, and 1,293.2 ± 182.92 g, respectively. Receipt of exclusive breast milk among EPTI, VPTI, and MPTI was 80, 94, and 83.8%, respectively. Maternal characteristics were similar except for the mode of conception (p = 0.001), mode of delivery (p = 0.04), and antenatal steroid exposure (p = 0.02) among three gestational categories. The median (Q1–Q3) volume of EBM on day 7 were 160 (136.3–202.5), 150 (140–187.5), and 160 (150–220) mL for EPTI, VPTI, and MPTI neonates, respectively, without any statistical significance. Regression analysis suggests no effect of gestational age on EBM availability. The feasibility of mother's own milk use for extremely preterm neonates is similar to higher gestational preterm neonates.

Mother's Own Milk Biomarkers Predict Coming to Volume in Pump-Dependent Mothers of Preterm Infants

OBJECTIVE

To assess serial secretory activation biomarker concentrations (sodium [Na], potassium [K], Na:K, protein, lactose, and citrate) in mother's own milk (MOM) from breast pump-dependent mothers of preterm infants to determine associations with coming to volume (CTV), defined as producing at least 500 mL/day MOM by day 14 postpartum.

STUDY DESIGN

We collected serial MOM samples and pumped MOM volume data for 14 days postpartum in mothers who delivered at <33 weeks of gestation. Regression models and the Mann-Whitney U test were used to evaluate associations.

RESULTS

Among 40 mothers, 39 (mean gestational age, 28.8 weeks; 67% overweight/obese; 59% nonwhite) had paired MOM volume and biomarker data; 33% achieved CTV between postpartum days 6 and 14. In univariate models, MOM Na on postpartum day 5 and Na:K on days 3 and 5 were associated with CTV. Mothers achieving CTV were more likely to have postpartum Na:K ≤1 on day 3 (75% vs 25%; P = .06) and ≤0.8 on day 5 (69% vs 10%; P < .01). In a multivariable regression model, day 5 Na:K (1 unit decrease in Na:K: OR, 18.7; 95% CI, 1.13-311.41; P = .049) and maternal prepregnancy body mass index (BMI) (1 unit increase in BMI: OR, 0.88; 95% CI, 0.78-0.99; P = .04) were associated with CTV between postpartum days 6 and 14.

CONCLUSIONS

Secretory activation and CTV were compromised in breast pump-dependent mothers with preterm delivery. CTV was predicted by MOM Na level and Na:K. These biomarkers have potential as objective point-of-care measures to detect potentially modifiable lactation problems in a high-risk population.

Timing of milk expression following delivery in mothers delivering preterm very low birth weight infants: a randomized trial

OBJECTIVE

To determine the effect of timing of expression initiation on mother's own milk production and time to secretory activation in mothers of preterm infants.

STUDY DESIGN

180 mothers delivering infants ≤1500 grams and ≤32 weeks gestation were randomized to begin expression within 60 (early), 61-180 (intermediate) or 181-360 (late) minutes following delivery. Milk volume was measured on days 1-7 and weekly for 6 weeks. Time to secretory activation was determined through self-report.

RESULTS

The late group produced more milk than the early group in the first 3 days (p = 0.015-0.031) and over 6 weeks (p = 0.045). The late group had more expressions on day 1 (early: p = 0.049; intermediate; p = 0.048).

CONCLUSION

Initiation of expression at 181-360 min following delivery was associated with increased milk production for 6 weeks following delivery. Further research is needed to determine the effect of expression frequency on milk production in the first days following birth.

Strategies to increase the use of mother's own milk for infants at risk of necrotizing enterocolitis

High-dose mother's own milk (MOM) feedings during the first 14 days post birth reduce the risk of necrotizing enterocolitis in very low birthweight (VLBW; <1500 g birthweight). However, high-dose MOM feedings are only possible if mothers provide sufficient quantities of MOM in a timely manner, and data indicate that the lack of MOM during the early post-birth period is a global problem. This paper reviews the modifiable and unmodifiable barriers to accessing adequate quantities of MOM during the early post-birth period and proposes evidence-based strategies to increase and improve the use of MOM during the neonatal intensive care unit (NICU) hospitalization with an emphasis on the critical first 2 weeks post birth.

A Systematic Review of Collection and Analysis of Human Milk for Macronutrient Composition

BACKGROUND

As human milk (HM) composition varies by time and across even a single feed, methods of sample collection can significantly affect the results of compositional analyses and complicate comparisons between studies.

OBJECTIVE

The aim was to compare the results obtained for HM macronutrient composition between studies utilizing different sampling methodologies. The results will be used as a basis to identify the most reliable HM sampling approach.

METHODS

EMBASE, MEDLINE/PubMed, Cochrane Library, Scopus, Web of Science, and ProQuest databases were searched for relevant articles. Observational and interventional studies were included, and at least 2 authors screened studies and undertook data extraction. Quality assessment was conducted using the Newcastle-Ottawa scale and previously published pragmatic score.

RESULTS

A total of 5301 publications were identified from our search, of which 101 studies were included (n = 5049 breastfeeding women). Methods used for HM collection were divided into 3 categories: collection of milk from all feeds over 24 h (32 studies, n = 1309 participants), collection at one time point (62 studies, n = 3432 participants), and "other methods" (7 studies, n = 308 participants). Fat and protein concentrations varied between collection methods within lactation stage, but there were no obvious differences in lactose concentrations. There was substantial variability between studies in other factors potentially impacting HM composition, including stage of lactation, gestational age, and analytical method, which complicated direct comparison of methods.

CONCLUSIONS

This review describes the first systematic evaluation of sampling methodologies used in studies reporting HM composition and highlights the wide range of collection methods applied in the field. This information provides an important basis for developing recommendations for best practices for HM collection for compositional analysis, which will ultimately allow combination of information from different studies and thus strengthen the body of evidence relating to contemporary HM composition. This trial was registered at PROSPERO as CRD42017072563, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017072563.

Macronutrient analysis of donor human milk labelled as 24 kcal/oz

OBJECTIVE

To measure the macronutrient content (MNC) of donor human milk labelled as 24 kcal/oz ("high-calorie DHM," hcDHM), compare to bank-labelled MNC, and examine variability of hcDHM MNC among milk banks.

STUDY DESIGN

MNC was measured with near-infrared spectroscopy for 75 convenience samples from five milk banks collected during September 2016-July 2017. Concordance of measured MNC with labelled values was evaluated using three different thresholds: within ±20%, similar to FDA labelling standards for class II nutrients in foods; ±10%; and ±5%.

RESULTS

Protein and caloric content differed significantly between measured and labelled values and varied significantly among milk banks. Measured caloric content ranged from 16.50 to 30.27 kcal/oz, with 89.3% of hcDHM samples within ±20%, 58.7% within ±10%, and 18.7% within ±5% of labelled content.

CONCLUSIONS

MNC of hcDHM used in clinical practice shows variation that may result in differences from desired diet. The clinical implications of such differences are unexplored.

Measures of Secretory Activation for Research and Practice: An Integrative Review

Background: Maternal concern about inadequate milk volume commonly emerges in the first 2 weeks postpartum, a critical lactation period that includes secretory activation. This review summarizes the biology of secretory activation and evaluates the accuracy and feasibility of published measures of secretory activation. Materials and Methods: A systematic search of measures of secretory activation for mothers of healthy term and preterm infants yielded 62 abstracts. Following additional screening, 15 publications qualified for quantitative synthesis review and were evaluated with respect to accuracy (validated with another measure of secretory activation in the same mother) and feasibility (accessibility, cost, and ease of use). Results:Maternal perception of milk coming in (MP) is the most feasible measure, but its accuracy has not been established. Patterns of increase in maternal milk volume have been validated with maternal milk-borne biomarkers in breastfeeding, and breast pump-dependent mothers and normal values have been published. Accuracy of serial maternal urinary lactose concentrations has not been established for secretory activation and lacks feasibility. Maternal milk biomarkers are the accurate standard to which other measures are compared but currently lack feasibility for routine use. Conclusions: Use of secretory activation measures can personalize lactation care by matching maternal risk with appropriate diagnostics. Priorities for research and practice include validation of MP as a population-based screening tool, implementation of techniques that measure patterns of increase in milk volume for moderate risk populations, and the development of milk biomarker science for point-of-care use in the most complicated lactation scenarios.

Differences in Current Procedures for Handling of Expressed Mother's Milk in Danish Neonatal Care Units

BACKGROUND

Mother's own milk (MOM) is preferred when feeding preterm infants. When expressed mother's milk is stored and handled, there is a risk of bacterial contamination, decreased immunological activity, and less nutritional potential.

PURPOSE

The aim of this study was to investigate current routines when handling MOM in Danish neonatal intensive care units (NICUs).

METHODS

A survey was sent to all 17 NICUs in Denmark in which current practices regarding human milk handling, storage, and preparation were evaluated. Furthermore, one question sought to establish when mother's milk was believed to be colostrum. Respondents of the survey were neonatal nurses.

RESULTS

All 17 units responded to the survey. Only 5 of 17 units answered that human colostrum was defined as milk from the first week after birth. Refrigerator storage time varied between 24 and 72 hours. In 6 of 17 units, parents were in charge of mixing milk and fortifier. Heating of human milk was done by using microwave ovens in 4 of 17 of the units.

IMPLICATIONS FOR PRACTICE

This national survey established that there is significant variability in the way mother's milk is handled. Some of the procedures performed may affect the quality of the milk. It is important to implement evidence-based practice regarding storage and handling of expressed mother's milk to ensure that the quality of the milk is the best possible alternative for all preterm infants.

IMPLICATIONS FOR RESEARCH

Prospective studies are needed to examine the association between handling of human milk and changes in composition and nutritional potential of the milk.

Predictors of Mother's Own Milk Feeding at Discharge in Preterm Infants

BACKGROUND

The dose-response benefits of human milk for preterm infants are well documented. Understanding factors that influence duration of mother's own milk (MOM) receipt may have important clinical implications.

PURPOSE

To identify variables that significantly affect whether or not preterm infants receive their own mother's milk at discharge.

METHODS

Maternal-infant dyads were eligible for inclusion if the infant was born between August 1, 2010, and July 31, 2015, was born at 32 weeks' gestation or less, or was 1800 g or less (institutional donor milk receipt criteria). Bivariate and multivariable regression analyses were performed.

RESULTS

Of 428 observations, 258 (60.3%) received MOM at discharge and 170 (39.7%) did not. Maternal characteristics that were protective for MOM receipt at discharge were non-Hispanic race, married, partner support, more educated, and private insurance. Protective infant characteristics were higher gestational age at birth, higher percentage of MOM feedings, fewer ventilator days, and more days of direct lactation. In multivariable logistic regression, the odds of receiving MOM at discharge significantly (odds ratio = 1.93; 95% confidence interval, 1.72-2.16; P < .001) increased with the increasing proportion of MOM. Regression analysis showed that gestational age and increased maternal age increased the likelihood of MOM receipt at discharge.

IMPLICATIONS FOR PRACTICE

Clinicians will understand the significant effects even small increases in milk volume have on duration of MOM receipt at discharge, informing them of the importance of strategies to encourage and improve milk expression.

IMPLICATIONS FOR RESEARCH

Future research studying critical time periods when mothers are most likely to reduce milk expression may have significant clinical importance.

Feasibility of Standardized Human Milk Collection in Neonatal Care Units

Research in human lactation is a growing field. However, difficulties in studying human milk originate from the dynamicity of its composition. Using standardized collection protocols is mandatory to minimize variation and warrant comparability of findings across different studies. Yet, information on the feasibility of collecting human milk with standardized procedures, especially in neonatal units, are lacking. The present study aims to report on the feasibility and difficulties to collect human milk according to a standardized protocol, during early lactation from women who gave birth to preterm infants. Human milk was collected from 129 mothers of moderate- to late-preterm infants according to two variations of a standard protocol which differed for number of collection time-points. Collection rates and adherence to the sampling protocol were evaluated together with reason for missed collection. Collection of ≥1 sample was successful for 80% of the mothers. However adherence to the standard protocol was overall low (36% and 27%). Collection rates were different between the two protocol variations (73% against 92%, p ≤ 0.001). Amongst the reason for missed collection, low milk supply was the most recurrent (40%). Our findings show that while collecting human milk in neonatal units is achievable, obtaining standard and comparable samples results challenging.

Considerations for Preterm Human Milk Feedings When Caring for Mothers Who Are Overweight or Obese

BACKGROUND

Mother's milk is the recommended source of nutrition for all newborns. Preterm infants may be further compromised by maternal factors that impede successful lactation and alter milk composition.

PURPOSE

To review and summarize the state of the science regarding implications of maternal overweight and obesity on successful lactation and associated alterations in preterm mother's milk composition.

METHODS/SEARCH STRATEGY

PubMed, EMBASE, and Web of Science searches were performed using relevant key words to identify references addressing maternal overweight or obesity, prematurity, human milk, and lactation.

FINDINGS/RESULTS

In the United States, more than half of women enter pregnancy with an overweight or obese body mass index. These women have increased risk of adverse pregnancy outcomes and obstetric complications that can undermine successful initiation and continuation of lactation, including preterm birth. Maternal overweight and obesity are also associated with alterations in mother's milk composition.

IMPLICATIONS FOR PRACTICE

Mother-preterm infant dyads affected by maternal overweight and obesity are at risk for barriers to initiation and continuation of lactation. Support for early initiation of milk expression is needed. Continued support, especially during the first weeks of lactation, can facilitate sustained milk production.

IMPLICATIONS FOR RESEARCH

Considerable knowledge gaps remain in this area of human milk science. Future research is needed to facilitate more comprehensive understanding of differences in milk composition associated with maternal overweight and obesity and their impact on clinical outcomes in the preterm infant.

What Evidence Do We Have for Pharmaceutical Galactagogues in the Treatment of Lactation Insufficiency?-A Narrative Review

Inadequate breast milk supply is a frequently reported reason for early discontinuation of breastfeeding and represents a critical opportunity for intervening to improve breastfeeding outcomes. For women who continue to experience insufficient milk supply despite the utilisation of non-pharmacological lactation support strategies, pharmacological intervention with medications used to augment lactation, commonly referred to as galactagogues, is common. Galactagogues exert their pharmacological effects through altering the complex hormonal milieu regulating lactation, particularly prolactin and oxytocin. This narrative review provides an appraisal of the existing evidence regarding the efficacy and safety of pharmaceutical treatments for lactation insufficiency to guide their use in clinical practice. The greatest body of evidence surrounds the use of domperidone, with studies demonstrating moderate short-term improvements in breast milk supply. Evidence regarding the efficacy and safety of metoclopramide is less robust, but given that it shares the same mechanism of action as domperidone it may represent a potential treatment alternative where domperidone is unsuitable. Data on remaining interventions such as oxytocin, prolactin and metformin is too limited to support their use in clinical practice. The review provides an overview of key evidence gaps and areas of future research, including the impacts of pharmaceutical galactagogues on breast milk composition and understanding factors contributing to individual treatment response to pharmaceutical galactagogues.

Breastfeeding of preterm newborn infants following hospital discharge: follow-up during the first year of life

This paper aims to evaluate the prevalence of breastfeeding among premature infants following hospital discharge. Cohort (< 33 gestation weeks) followed up to 12 months (adjusted age).

VARIABLES

breastfeeding, anthropometric measurements, social and family information. The proportion of breastfeeding during follow-up was calculated. Survival analysis was conducted to estimate breastfeeding duration. In total, 242 of the 258 infants (93.7%) returned to follow-up; 170 (69.9%) at 6 months and 139 (57.2%) at 12 months (adjusted age). A history of miscarriages (27.5%), stillbirths (11.7%), neonatal deaths (9.5%) and preterm births (21.1%) was noted in 65.5% of women. At hospital discharge: 5.5% received exclusive breastfeeding, 65.8% breastfeeding and formula, 28.6% formula. At month 1, 81.3% received breastfeeding, decreasing to 68.5% at month 2, 62.4% at month 3, 48.1% at month 4 and 22.4% at month 6 (adjusted age). The median of breastfeeding duration was 4 months. Breastfeeding occurred up to four months adjusted age in almost half of the population. Despite the need to improve these rates, the results could reflect the profile of the Child-Friendly Hospital Initiative Unit. Maintaining breastfeeding amongst preterm infants following hospital discharge is still a challenge, for both mothers and health professionals.

Evaluation of an intervention supporting breastfeeding among late-preterm infants during in-hospital stay

BACKGROUND

Late-preterm infants show lower breastfeeding rates when compared with term infants. Current practice is to keep them in low-risk wards where clinical guidelines to support breastfeeding are well established for term infants but can be insufficient for late-preterm.

OBJECTIVE

The aim of this study was to evaluate an intervention supporting breastfeeding among late-preterm infants in a maternity service in the Basque Country, Spain.

METHODS

The intervention was designed to promote parents' education and involvement, provide a multidisciplinary approach and decision-making, and avoid separation of the mother-infant dyad. A quasi-experimental study was conducted with a control (n=212) and an intervention group (n=161). Data was collected from clinical records from November 2012 to January 2015. Feeding rate at discharge, breast-pump use, incidence of morbidities, infant weight loss and hospital stay length were compared between the two groups.

RESULTS

Infants in the control group were 50.7% exclusive breastfeeding, 37.8% breastfeeding, and, 11.5% formula feeding at discharge, whereas in the intervention group, frequencies were 68.4%, 25.9%, and 5.7%, respectively (p=0.002). Mothers in the intervention group were 2.66 times more likely to use the breast-pump after almost all or all feeds and 2.09 times more likely to exclusively breastfeed at discharge. There were no significant differences in morbidities and infant weight loss between groups. Hospital stay was longer for infants who required phototherapy in the intervention group (p=0.009).

CONCLUSION

The intervention resulted in a higher breastfeeding rate at discharge. Interventions aimed to provide specific support among late-pretem infants in maternity services are effective.

Strategies for the Preservation, Restoration and Modulation of the Human Milk Microbiota. Implications for Human Milk Banks and Neonatal Intensive Care Units

Studies carried in the last years have revealed that human milk contains a site-specific microbiota and constitutes a source of potentially beneficial bacteria to the infant gut. Once in the infant gut, these bacteria contribute to the assembly of a physiological gut microbiota and may play several functions, contributing to infant metabolism, protection against infections, immunomodulation or neuromodulation. Many preterm neonates are fed with pasteurized donor’s human milk (DHM) or formula and, therefore, are devoid of contact with human milk microbes. As a consequence, new strategies are required to allow the exposition of a higher number of preterm infants to the human milk microbiota early in life. The first strategy would be to promote and to increase the use of own mother’s milk (OMM) in Neonatal Intensive Care Units (NICUs). Even small quantities of OMM can be very valuable since they would be added to DHM in order to microbiologically “customize” it. When OMM is not available, a better screening of donor women, including routine cytomegalovirus (CMV) screening of milk, may help to avoid the pasteurization of the milk provided by, at least, a relevant proportion of donors. Finally, when pasteurized DHM or formula are the only feeding option, their supplementation with probiotic bacteria isolated from human milk, such as lactic acid bacteria or bifidobacteria, may be an alternative to try to restore a human milk-like microbiota before feeding the babies. In the future, the design of human milk bacterial consortia (minimal human milk microbiotas), including well characterized strains representative of a healthy human milk microbiota, may be an attractive strategy to provide a complex mix of strains specifically tailored to this target population.

A Decision Tree for Donor Human Milk: An Example Tool to Protect, Promote, and Support Breastfeeding

Despite decades of breastfeeding promotion, exclusive breastfeeding rates for the first 6 months of life remain low: around 40% globally. Infants that are admitted to a neonatal ward are even less likely to be exclusively breastfed. Lactogenesis is frequently delayed in mothers that deliver early, with the added burden of separation of the unstable newborn and mother. For such vulnerable infants, donor human milk is recommended by the World Health Organization, UNICEF, and professional organizations as the next best alternative when mother's own milk is unavailable and can serve as a bridge to full feeding with mother's own milk. Hospital support of optimal breastfeeding practices is essential with thoughtful integration of donor human milk policies for those infants that need it most. We propose a decision tree for neonatal wards that are considering the use of donor human milk to ensure donor human milk is used to replace formula, not to replace mothers' own milk. By first evaluating barriers to full feeding with mother's own milk, healthcare workers are encouraged to systematically consider the appropriateness of donor human milk. This tool also seeks to prevent overuse of donor human milk, which has the potential to undermine successful lactation development. In settings where donor human milk supplies are limited, prioritization of infants by medical status is also needed. Readily available and easy-to-use tools are needed to support healthcare staff and mothers in order to improve lactation development and neonatal nutrition.

Comparison of Inductively Coupled Plasma Optical Emission Spectrometry with an Ion Selective Electrode to Determine Sodium and Potassium Levels in Human Milk

Sodium (Na), potassium (K), and the ratio Na:K in human milk (HM) may be useful biomarkers to indicate secretory activation or inflammation in the breast. Previously, these elements have been measured in a laboratory setting requiring expensive equipment and relatively large amounts of HM. The aim of this study was to compare measurements of Na and K in HM using inductively coupled plasma optical emission spectrometry (ICP-OES) with small portable ion selective electrode probes for Na and K. Sixty-five lactating women donated 5 mL samples of HM. Samples were analyzed with two ion selective probes (Na and K) and also ICP-OES. The data were analyzed using paired t-test and Bland⁻Altman plots. Na concentrations were not significantly different when measured with ion selective electrode (6.18 ± 2.47mM; range: 3.59⁻19.8) and ICP-OES (5.91 ± 3.37 mM; range: 2.59⁻21.5) (p = 0.20). K concentrations measured using the ion selective electrode (11.7 ± 2.21 mM: range: 7.69⁻18.1) and ICP-OES (11.1 ± 1.55 mM: range: 7.91⁻15.2) were significantly different (p = 0.01). However, the mean differences of 0.65 mM would not be clinically relevant when testing at point of care. Compared to ICP-OES, ion selective electrode is sufficiently accurate to detect changes in concentrations of Na and K in HM associated with secretory activation and inflammation in the mammary gland.

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.

Early initiation and regular breast milk expression reduces risk of lactogenesis II delay in at-risk Singaporean mothers in a randomised trial

INTRODUCTION

Lactogenesis II (LaII) failure can be prevented in at-risk mothers with simple proactive interventions. In a randomised trial, we investigated the efficacy of early and regular breast milk expression in establishing LaII, using an electric double-breast pump.

METHODS

Mothers with uncomplicated singleton deliveries were randomised to intervention (n = 31) or control (n = 29) groups. The former commenced breast milk expression with an electric pump within one hour of delivery and maintained regular expression with direct breastfeeding. Control mothers directly breastfed without regular pump expression. Expressed milk volumes were analysed for citrate, lactose, sodium and protein.

RESULTS

Median time of LaII was Day 3 (interquartile range [IQR] 1 day) with intervention and on Day 4 (IQR 1 day) among controls (p = 0.03). Biochemical steady-state concentrations were achieved around early Day 4 (sodium, total protein) and Days 4-5 (citrate, lactose). Sodium, protein and lactose levels were similar in both groups over seven days, at 5.80 mM, 0.68 mM and -13.38 mM, respectively. Mean daily milk volume with intervention was 73.9 mL on Day 3 and 225.2 mL on Day 7, greater than controls (25.4 mL on Day 3 and 69.2 mL on Day 7; p < 0.2). Mean infant weights were similar on Day 8 at 3,477 g with intervention and 3,479 g among controls.

CONCLUSION

LaII is established by postnatal Day 3 with early initiation of regular breast milk expression, a useful intervention for mothers at risk of early-onset breastfeeding failure.

Human Milk Biomarkers of Secretory Activation in Breast Pump-Dependent Mothers of Premature Infants

OBJECTIVE

Mothers of premature infants confront barriers to coming to volume (CTV; ≥500 mL/day mother's own milk [MOM] by postpartum day 14), a strong predictor of continued MOM provision at neonatal intensive care unit (NICU) discharge. We sought to determine concentrations of secretory activation biomarkers (MOM sodium, total protein, lactose, and citrate) during the first 14 postpartum days and to describe relationships among these biomarkers, pumped MOM volume, CTV, and pumping frequency.

STUDY DESIGN

This descriptive observational study collected serial MOM samples, pumped MOM volume, and pumping frequency during the first 14 postpartum days in 16 breast pump-dependent mothers who delivered <33 weeks gestation. Daily biomarker concentrations were compared to published normal values for mothers of term infants. Relationships among biomarkers, pumped MOM volume, and pumping frequency were determined.

RESULTS

On postpartum day 5, only 40% of MOM samples revealed normal concentrations of all four biomarkers, and normalcy was not maintained throughout the first 14 days. All eight mothers (50%) who achieved CTV had normal concentrations for four biomarkers at 5.4 ± 3.5 days postpartum and had more cumulative pumping sessions by day 5 (p = 0.03). A dose-response relationship between number of normal biomarkers and pumped MOM volume was demonstrated for postpartum days 3 (p = 0.01) and 5 (p = 0.04).

CONCLUSION

Secretory activation is delayed in mothers who deliver prematurely and is closely tied to CTV, MOM volume, and pumping frequency. MOM biomarkers hold promise as objective research outcome measures and for point-of-care testing to identify and proactively manage mothers at risk for compromised lactation.

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.