Predictors of Direct Breastfeeding in Preterm Infants

Objective: Rates of mother's own milk (MOM) provision in the neonatal intensive care unit (NICU) vary widely, despite acceptance as the gold standard for nutrition in preterm infants. Direct breastfeeding (DBF) supports long-term provision of MOM, but factors that support DBF in preterm infants are unknown. The purpose of this study was to identify factors that predict DBF at oral feeding initiation and at NICU discharge. Methods: This was a retrospective cohort study of preterm infants born at ≤ 32 weeks who were receiving MOM at 32 weeks corrected gestational age (cohort 1) and at discharge to home (cohort 2). The primary outcomes were rates of DBF at oral feeding initiation (cohort 1) and at hospital discharge (cohort 2). We examined bivariate associations between infant characteristics, maternal sociodemographic factors, and hospital practices (e.g., lactation visit timing and frequency) with DBF outcomes and then built logistic regression models to determine the adjusted odds ratio and 95% confidence interval ([adjusted odds ratio [aOR] [95%CI]) for independent predictors of the DBF outcomes. Results: Sixty-four percent of eligible infants initiated DBF, and 51% were DBF at discharge. Sociodemographic, NICU, and lactation support factors were associated with both outcomes. Post hoc analysis showed that similar factors also influenced lactation support provision. Conclusions: Lactation support, NICU and sociodemographic variables influence DBF initiation and DBF at discharge. Interventions that optimize efficient use of available lactation support, address bias, and provide ample opportunity for DBF practice could improve rates.

Neuromodulation of safety and surprise in the early stages of infant development: affective homeostatic regulation in bodily and mental functions

Developing a sense of internal safety and security depends mainly on others: numerous neuromodulators play a significant role in the homeostatic process, regulating the importance of proximity to a caregiver and experiencing feelings that enable us to regulate our interdependence with our conspecifics since birth. This array of neurofunctional structures have been called the SEPARATION DISTRESS system (now more commonly known as the PANIC/ GRIEF system). This emotional system is mainly involved in the production of depressive symptoms. The disruption of this essential emotional balance leads to the onset of feelings of panic followed by depression. We will focus on the neuropeptides that play a crucial role in social approach behavior in mammals, which enhance prosocial behavior and facilitate the consolidation of social bonds. We propose that most prosocial behaviors are regulated through the specific neuromodulators acting on salient intersubjective stimuli, reflecting an increased sense of inner confidence (safety) in social relationships. This review considers the neurofunctional link between the feelings that may ultimately be at the base of a sense of inner safety and the central neuromodulatory systems. This link may shed light on the clinical implications for the development of early mother-infant bonding and the depressive clinical consequences when this bond is disrupted, such as in post-partum depression, depressive feelings connected to, addiction, neurofunctional disorders, and psychological trauma.

The role of breastfeeding and formula feeding regarding depressive symptoms and an impaired mother child bonding

Associations between depressive symptoms and breastfeeding are well documented. However, evidence is lacking for subdivisions of feeding styles, namely exclusive breastfeeding, exclusive formula feeding and a mixed feeding style (breastfeeding and formula feeding). In addition, studies examining associations between mother-child-bonding and breastfeeding have yielded mixed results. The aim of this study is to provide a more profound understanding of the different feeding styles and their associations with maternal mental health and mother-child-bonding. Data from 307 women were collected longitudinally in person (prenatally) and by telephone (3 months postnatally) using validated self-report measures, and analyzed using correlational analyses, unpaired group comparisons and regression analyses. Our results from a multinomial regression analysis revealed that impaired mother-child-bonding was positively associated with mixed feeding style (p = .003) and depressive symptoms prenatal were positively associated with exclusive formula feeding (p = .013). Further studies could investigate whether information about the underlying reasons we found for mixed feeding, such as insufficient weight gain of the child or the feeling that the child is unsatiated, could help prevent impaired mother-child-bonding. Overall, the results of this study have promising new implications for research and practice, regarding at-risk populations and implications for preventive measures regarding postpartum depression and an impaired mother-child-bonding.

Association between breastfeeding cessation among under six-month-old infants and postpartum depressive symptoms in Nevada

BACKGROUND

Postpartum depression affects 13% of women after childbirth in the United States. Mothers who experience depression are less likely to breastfeed than those who do not experience depression. On the other hand, breastfeeding may have a positive effect on maternal mental health.

RESEARCH AIM

We aimed to analyze whether breastfeeding cessation is associated with postpartum depression symptoms among mothers of infants under six months old in Clark County, Nevada.

METHOD

A cross-sectional study was conducted in 2021 using a purposive sample of 305 mother-infant dyads. Postpartum depression symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2), and the breastfeeding cessation was determined through a 24-hour dietary recall. Descriptive, bivariate, and multivariate logistic regression analyses were conducted.

RESULTS

Most participants were between 25 and 34 years old (n = 183, 60.0%), multiparous (n = 167, 55.1%), and had a vaginal delivery (n = 204, 70.6%). High frequency of postpartum depressive symptoms was found among mothers who were young (18-24 years) (24.2%), without a partner (25.0%), had unplanned pregnancies (12.7%), and were primiparous (13.2%). Breastfeeding cessation was independently associated with postpartum depressive symptoms (AOR = 3.30, 95% CI: 1.16-9.32) after controlling for sociodemographic, environmental, and obstetric characteristics.

CONCLUSION

Breastfeeding cessation is strongly associated with postpartum depressive symptoms among mother-infant dyads in Nevada. Early identification of postpartum depressive symptoms and the promotion of breastfeeding can create a positive feedback loop to foster the well-being of mothers and infants.

The Effect of the Number of Breastfeeding Sessions per Day in the Early Postpartum Period on Postpartum Depression Scores Among Pregnant Women Without Risk Factors for Depression: A Retrospective Cohort Study

Background: The objective of this study was to investigate the relationship between the Edinburgh Postpartum Depression Scale (EPDS) score on the 10th day postpartum and the number of breastfeeding sessions per day among puerperal women (with no known depression risk factors and a low [<10] EPDS score after delivery). Materials and Methods: A total of 1,451 nulliparous, 37- to 41-week pregnant women who gave birth between August 2020 and August 2022 and who underwent routine postpartum checkups on the 10th day after delivery were included in this study. Pregnant women with risk factors for depression before pregnancy, during pregnancy, and after delivery were not included. Patients with an EPDS score of ≥10 after delivery were excluded from the study. On the 10th day after birth, the mean number of breastfeeding sessions per day of the population in the study was determined. Patients with a number of breastfeeding sessions per day above the mean value were classified as Group A (n = 45), and those with values below the mean were classified as Group B (n = 67). Results: The mean number of breastfeeding sessions per day was 10.15. The EPDS scores of Group A (6 [0-19]) were significantly lower than those of Group B (8 [0-20]) (p < 0.05). A negative linear relationship was found between the number of breastfeeding sessions per day and the EPDS scores on the 10th day postpartum (p < 0.05). No statistically significant difference was found between the EPDS scores and the education status, age, or gestational week of the patients (p > 0.05). There was no statistically significant difference between the number of breastfeeding sessions per day and the education status or age of the patients (p > 0.05). Conclusions: Higher number of breastfeeding sessions per day is associated with less risk of maternal postpartum depression. There is a need for new studies on the consequences of the number and quality of breastfeeding sessions.

Towards Preventative Psychiatry: Concurrent and Longitudinal Predictors of Postnatal Maternal-Infant Bonding

Maternal-infant bonding is important for children's positive development. Poor maternal-infant bonding is a risk factor for negative mother and infant outcomes. Although researchers have examined individual predictors of maternal-infant bonding, studies typically do not examine several concurrent and longitudinal predictors within the same model. This study aimed to evaluate the unique and combined predictive power of cross-sectional and longitudinal predictors of maternal-infant bonding. Participants were 372 pregnant women recruited from an Australian hospital. Data were collected from mothers at antenatal appointments (T0), following their child's birth (T1), and at a laboratory assessment when their child was 5-11-months-old (T2). Poorer bonding at T2 was predicted at T0 by younger maternal age, higher education, and higher antenatal depressive symptoms. Poorer bonding at T2 was predicted at T1 by younger maternal age, higher education, and higher postnatal depressive symptoms. Poorer bonding at T2 was predicted at T2 by younger maternal age, higher education, higher postnatal depression symptoms, higher concurrent perceived social support, and more difficult infant temperament, when controlling for child age at T2. To promote positive maternal-infant bonding, global and targeted interventions in the perinatal period may benefit from targeting maternal psychopathology, perceived lack of social support, and coping with difficult infant temperament.

"It has changed my life": unconditional cash transfers and personalized infant feeding support- a feasibility intervention trial among women living with HIV in western Kenya

BACKGROUND

The syndemic effects of poverty, food insecurity and living with HIV are recognized as global health priorities, including through the United Nations Sustainability Goals 1, 2 and 3. Today, women and girls account for 63% of all new HIV infections in eastern and southern Africa, including Kenya. Pregnant and postpartum women living with HIV in this setting face unique challenges including increased financial insecurity as women leave the work force to care for their newborn infants. This contributes to poverty, food scarcity and stress.

METHODS

To address financial insecurity, improve infant feeding and reduce stress among mothers living with HIV in this setting, we developed a multilevel intervention, Supporting Healthy Mothers, consisting of 10 monthly unconditional cash transfers (10,000 KES, ~$75 USD/month) and personalized infant feeding support from pregnancy to 7 months postpartum. We conducted a non-randomized feasibility trial of this intervention among women engaged in HIV care in Kisumu, Kenya. From February 23, 2022 to March 23, 2022, we enrolled a total of 40 women who were 20-35 weeks pregnant-20 women to the intervention group at a public clinic, and 20 women to the control group at a similar clinic. Our aim was to assess feasibility, acceptability, and the potential impact of the intervention on food security, infant feeding and maternal mental health.

RESULTS

Analyzing data from all 40 participants, we found a significant reduction in food insecurity scores from baseline for the intervention group when compared to the control group at 6 weeks and 6 months postpartum (p = 0.0008 and p < 0.0001, respectively). Qualitative exit interviews with intervention group participants confirmed women felt more financially secure and had newly acquired practical knowledge and skills related to infant feeding. Women found the two intervention components highly acceptable and described an overall positive impact on wellbeing.

CONCLUSIONS

The Supporting Healthy Mothers intervention has potential to positively impact women across the perinatal period and beyond by increasing financial security and supporting women to overcome infant feeding challenges and should be assessed in larger trials.

TRIAL REGISTRATION

Supporting Healthy Mothers was registered with ClinicalTrials.gov Protocol Registration and Results System, initially published on February 1, 2022.

CLINICALTRIALS

gov ID: NCT05219552 Protocol ID: K23MH116807.

A Feasibility Study to Assess Sleep and Subsequent Breast Milk Volume Among Mothers With Hospitalized Preterm Infants

BACKGROUND

Sleep is essential for optimal health, and disturbed postpartum sleep is associated with compromised infant attachment. The postpartum experience of mothers with preterm infants is unlike the biological norm, as they are separated from their infants and often express breast milk.

PURPOSE

The purpose of this study was to examine the feasibility of conducting a clinical research study among women with hospitalized preterm infants. We also explored for associations between maternal sleep patterns and sleep-related psychological states and subsequent breast milk volume.

METHODS

Participants were recruited from Magee-Womens Hospital, located in Pittsburgh, Pennsylvania New mothers completed daily sleep and pumping logs and scales to measure stress, trauma, depression, fatigue, and sleep quality.

RESULTS

A total of 78 women were screened, 18 women consented, and a total of 8 participants completed the study. Screening from the postpartum unit increased recruitment. The participants experience worsening sleep quality over time, moderate stress, and fatigue. Stress, postnatal depression, and fatigue are negatively associated with milk volume.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Postpartum recruitment with frequent follow-ups improved recruitment and retention. We present a preliminary association between maternal stress, fatigue, and depression, and subsequent breast milk volume. Sleep-related psychological states may negatively influence milk volume.

Primary health level screening for postpartum depression during well-child visits: Prevalence, associated risk factors, and breastfeeding

Postpartum depression (PPD) is a public health problem that is associated with detrimental effects on the wellbeing of the mother, child and family. Early detection for PPD at the primary health level provides an opportunity for intervention. We aim to examine: (1) the prevalence rate of PPD in the primary care population, (2) acceptance and attendance rates of intervention for women who screened positive for PPD, (3) sociodemographic and maternal risk factors of PPD, and (4) the impact of PPD on breastfeeding. We implemented a mother-child dyadic screening program using the modified Patient Health Questionnaire-2 during routine well-child visits at 2 or 3 months postpartum between July 2019 and December 2021. We performed multivariable logistic regression to identify independent risk factors for PPD and described using adjusted odds ratio (OR) with corresponding 95 % confidence intervals. Among 5561 mothers, the prevalence rate of probable PPD was 2.4 %. About half (54.4 %) of mothers who screened positive accepted intervention and of these, about two-thirds accepted onward referrals to tertiary care and community mental health service, with higher attendance at the latter. In the final adjusted model, mothers who had probable PPD were more likely to be older than age 35 years (OR 1.88, 95 % CI 1.05-3.45; p < 0.05) and not breastfeeding (OR 1.9, 95 % CI 1.06-3.38; p < 0.05). Overall, our findings highlight the importance of early PPD screening and management in primary care. These findings can help inform maternal mental health service development and utilization, thereby optimizing maternal and infant outcomes.

Acute decrease in mothers' cortisol following nursing and milk expression

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

The evolved nest, oxytocin functioning, and prosocial development

Prosociality, orientation to attuned, empathic relationships, is built from the ground up, through supportive care in early life that fosters healthy neurobiological structures that shape behavior. Numerous social and environmental factors within early life have been identified as critical variables influencing child physiological and psychological outcomes indicating a growing need to synthesize which factors are the most influential. To address this gap, we examined the influence of early life experiences according to the evolved developmental niche or evolved nest and its influence on child neurobiological and sociomoral outcomes, specifically, the oxytocinergic system and prosociality, respectively. To-date, this is the first review to utilize the evolved nest framework as an investigatory lens to probe connections between early life experience and child neurobiological and sociomoral outcomes. The evolved nest is comprised of characteristics over 30 million years old and is organized to meet a child's basic needs as they mature. Converging evidence indicates that humanity's evolved nest meets the needs of a rapidly developing brain, optimizing normal development. The evolved nest for young children includes soothing perinatal experiences, breastfeeding, positive touch, responsive care, multiple allomothers, self-directed play, social embeddedness, and nature immersion. We examined what is known about the effects of each evolved nest component on oxytocinergic functioning, a critical neurobiological building block for pro-sociomorality. We also examined the effects of the evolved nest on prosociality generally. We reviewed empirical studies from human and animal research, meta-analyses and theoretical articles. The review suggests that evolved nest components influence oxytocinergic functioning in parents and children and help form the foundations for prosociality. Future research and policy should consider the importance of the first years of life in programming the neuroendocrine system that undergirds wellbeing and prosociality. Complex, interaction effects among evolved nest components as well as among physiological and sociomoral processes need to be studied. The most sensible framework for examining what builds and enhances prosociality may be the millions-year-old evolved nest.

Mother-Child Bond through Feeding: A Prospective Study including Neuroticism, Pregnancy Worries and Post-Traumatic Symptomatology

Post-traumatic stress disorder (PTSD) is a common postpartum problem and influences maternal bonding with the infant. However, the relationship between this disorder, maternal personality, and the infant's emotional state during feeding is not clear. The aim of the present study was to explore the contribution of neuroticism on the infant's emotional state during feeding, by attending to the mediating role of postpartum PTSD (P-PTSD) symptoms and the moderating role of worries during pregnancy. A prospective design study was developed with 120 women with a low pregnancy risk. They responded to a questionnaire assessing maternal personality (first trimester), worries during pregnancy (third trimester), P-PTSD symptoms, and mother-baby bonding (4 months postpartum). The results showed a positive association among neuroticism, infant irritability during feeding, and P-PTSD symptoms, suggesting the latter plays a mediating role in the relationship between neuroticism and infant irritability (B = 0.102, standard error (SE) = 0.03, 95% coefficient interval (CI) [0.038, 0.176]). Excessive worries, related to coping with infant care, played a moderating role between neuroticism and P-PTSD symptoms (B = 0.413, SE = 0.084, p = 0.006, 95% CI [0.245, 0.581]). This relationship was interfered with by depressive symptoms in the first trimester (covariate) (B = 1.820, SE = 0.420, p = 0.016, ci [2.314, 0.251]). This study contributes to a better understanding of the role of neuroticism as an influential factor in the occurrence of P-PTSD symptoms, and in the impairment of infant bonding during feeding. Paying attention to these factors may favor the development of psychological support programs for mothers, with the aim of strengthening the bond with their child.

Factors associated with common mental disorders among breastfeeding mothers in tertiary hospital nurseries in Nigeria

BACKGROUND

Several studies have shown that the impact of maternal mental health disorders on newborns' well-being in low and middle-income countries (LMIC) are underreported, multi-dimensional and varies over time and differs from what is reported in high-income countries. We present the prevalence and risk factors associated with common mental disorders (CMDs) among breastfeeding mothers whose infants were admitted to Nigerian tertiary care facilities.

METHODS

This was a national cross-sectional study involving mothers of hospitalised babies from eleven Nigerian tertiary hospitals. We used the WHO self-reporting Questionnaire 20 and an adapted WHO/UNICEF ten-step breastfeeding support package to assess mothers' mental health and breastfeeding support.

RESULTS

Only 895 of the 1,120 mothers recruited from eleven tertiary healthcare nurseries in six geopolitical zones of Nigeria had complete datasets for analysis. The participants' mean age was 29.9 ± 6.2 years. One in four had CMDs; 24.0% (95% CI: 21.235, 26.937%). The ages of mothers, parity, gestational age at delivery, and length of hospital stay were comparable between mothers with and those without CMDs. Antenatal care at primary healthcare facilities (adjusted odds ratio [aOR:13], primary education [aOR:3.255] living in the south-southern region of the country [aOR 2.207], poor breastfeeding support [aOR:1.467], polygamous family settings [aOR:2.182], and a previous history of mental health disorders [aOR:4.684] were significantly associated with CMDs. In contrast, those from the middle and lower socioeconomic classes were less likely to develop CMDs, with [aOR:0.532] and [aOR:0.493], respectively.

CONCLUSION

In Nigeria, the prevalence of CMDs is relatively high among breastfeeding mothers with infants admitted to a tertiary care facility. Prior history of mental illness, polygamous households, mothers living in the southern region and low or no educational attainment have a greater risk of developing CMDs. This study provides evidence for assessing and tailoring interventions to CMDs among breastfeeding mothers in neonatal nurseries in LMIC.

Postpartum depression and ADHD in the offspring: Systematic review and meta-analysis

BACKGROUND

Postpartum depression (PPD) is a disorder that has a severe impact on a woman's mental state and mood after birth. Research has shown that postnatal levels of family adversity and maternal psychopathology are associated with Attention Deficit Hyperactivity Disorder (ADHD). This paper is intended to examine the association among maternal PPD and the risk of ADHD in the offspring.

METHODS

Keyword search was conducted for PsycINFO, PubMed, Google Scholar, and Embase up to Feb 28, 2021; studies in English were deemed eligible. Random-effects meta-analysis and meta-regression analysis took place. Subgroup analyses by study design, geographical region, level of adjustment and study setting were performed.

RESULTS

Nine cohort studies and two case-control studies published from 2003 to 2019 were included in the qualitative synthesis; among them, eight studies were synthesized in the meta-analysis. Overall, maternal PPD was associated with an increased risk of ADHD in the offspring (pooled relative risk, RR = 1.69, 95%CI: 1.27-2.26). Significant associations were noted in the subsets of cohort studies, studies implementing multivariate analyses and registry-based surveys.

LIMITATIONS

Overall, a larger number of studies of the field are needed. Data collection relied on self-report and attrition bias limited the validity of eligible studies. Studies from developing countries were underrepresented. There was significant publication bias (p = 0.035, Egger's test).

CONCLUSIONS

The relationship between PPD and ADHD in children was found to be significant in this systematic review and meta-analysis and reveals the need for further investigation in various geographical regions.

Risk factors for postpartum depression in women undergoing elective cesarean section: A prospective cohort study

Background

Postpartum depression (PPD) has adverse effects on maternal and child health. Cesarean section (CS) is suggested to be associated with PPD, but no study has examined the risk factors for PPD in women who underwent CS. Therefore, this study aimed to investigate this association.

Methods

A prospective observational study was conducted between December 2020 and September 2021. In total, 590 women who underwent elective CS participated in this study. Data were collected using a questionnaire through a face-to-face interview at three time points: 32nd week of gestation, 2 days postpartum, and 6 weeks postpartum. PPD was defined by an Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 11 at 6 weeks postpartum. Multivariate logistic regression analysis was performed to identify the risk factors for PPD.

Results

Among the 590 women, 25.4% had PPD (142/590). After adjustment for the confounding factors, high antenatal self-rating anxiety scale score (OR = 1.10, 95% CI = 1.04–1.16), PPD symptoms (EPDS ≥ 11) at 2 days postpartum (OR = 6.17, 95% CI = 1.35–28.31), and pain at 6 weeks postpartum (OR = 2.14, 95% CI = 1.24–3.69) were independently associated with PPD.

Conclusion

Prenatal anxiety, PPD symptoms occurring at an early postoperative stage, and pain at 6 weeks postpartum may be associated with an increased risk of PPD among women who undergo CS.

Efficacy of behavioral interventions to improve maternal mental health and breastfeeding outcomes: a systematic review

BACKGROUND

Despite extensive benefits and high intentions, few mothers breastfeed exclusively for the recommended duration. Maternal mental health is an important underlying factor associated with barriers and reduced rates of breastfeeding intent, initiation, and continuation. Given evidence of a bidirectional association between maternal mental health and breastfeeding, it is important to consider both factors when examining the efficacy of interventions to improve these outcomes. The purpose of this manuscript is to review the literature on the efficacy of behavioral interventions focused on both maternal mental health and breastfeeding outcomes, examining the intersection of the two.

METHODS

This systematic review was completed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Studies were selected if they were available in English, used primary experimental design, and used a behavioral intervention type to examine maternal mental health and breastfeeding outcomes. Articles were identified from PubMed, CINAHL, Embase, and PsycINFO from database inception to 3 March 2022. Study quality was assessed using the Cochrane Risk of Bias tool. Results were synthesized by intervention success for 1. Mental health and breastfeeding, 2. Breastfeeding only, 3. Mental health only, and 4. No intervention effect. PROSPERO CRD42021224228.

RESULTS

Thirty interventions reported in 33 articles were identified, representing 15 countries. Twelve studies reported statistically significant positive effect of the intervention on both maternal mental health and breastfeeding; most showing a decrease in self-report depressive and/or anxiety symptoms in parallel to an increase in breastfeeding duration and/or exclusivity. Common characteristics of successful interventions were a) occurring across pregnancy and postpartum, b) delivered by hospital staff or multidisciplinary teams, c) offered individually, and d) designed to focus on breastfeeding and maternal mental health or on breastfeeding only. Our results are not representative of all countries, persons, experiences, circumstances, or physiological characteristics.

CONCLUSIONS

Interventions that extend the perinatal period and offer individualized support from both professionals and peers who collaborate through a continuum of settings (e.g., health system, home, and community) are most successful in improving both mental health and breastfeeding outcomes. The benefits of improving these outcomes warrant continued development and implementation of such interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021224228.

Mixed Milk Feeding: A New Approach to Describe Feeding Patterns in the First Year of Life Based on Individual Participant Data from Two Randomised Controlled Trials

'Mixed Milk Feeding' (MMF), whereby infants are fed with both breastmilk and infant formula during the same period, is a common feeding practice. Despite its high prevalence, knowledge regarding MMF practices and their association with (health) outcomes is limited, potentially because MMF behaviours are highly variable and difficult to standardise longitudinally. In this paper, we applied a statistical clustering algorithm on individual infant feeding data collected over the first year of life from two clinical trials: 'TEMPO' (n = 855) and 'Venus' (n = 539); these studies were conducted in different years and world regions. In TEMPO, more than half of infants were MMF. Four distinct MMF clusters were identified: early exclusive formula feeding (32%), later exclusive formula feeding (25%), long-term MMF (21%), and mostly breastfeeding (22%). The same method applied to 'Venus' resulted in comparable clusters, building trust in the robustness of the cluster approach. These results demonstrate that distinct MMF patterns can be identified, which may be applicable to diverse populations. These insights could support the design of future research studying the impact of infant feeding patterns on health outcomes. To standardise this in future research, it is important to establish a unified definition of MMF.

Feasibility of a Web-Based Intervention to Prevent Perinatal Depression and Promote Human Milk Feeding: Randomized Pilot Trial

BACKGROUND

Mothers who identify as Black or African American are more likely to report depressed moods in late pregnancy and early postpartum and have the lowest rates of human milk feeding compared with all other racial groups in the United States. Internet interventions offer the potential to extend preventative and supportive services as they address key barriers, particularly for those navigating the complex and vulnerable early postpartum period. However, there is limited evidence on the feasibility of such interventions for preventing perinatal mental health disorders and improving human milk feeding outcomes in Black mothers.

OBJECTIVE

This pilot study aimed to assess the feasibility and preliminary findings of a web-based cognitive behavioral therapy-based internet intervention, with and without human milk feeding education and support, to prevent perinatal depression and promote human milk feeding in Black mothers.

METHODS

Participants were Black-identifying individuals between 20 and 28 weeks of pregnancy with human milk feeding intention and mild to moderate depressive symptoms (Patient Health Questionnaire scores 5-14). Participants were randomized to either Sunnyside, a 6-week cognitive behavioral therapy-based web-based intervention, or Sunnyside Plus, which included additional education and support to promote human milk feeding. Assessments occurred at baseline, third trimester (end of antenatal treatment), 6 weeks postpartum (end of postpartum treatment), and 12 weeks postpartum. The primary focus of this randomized pilot trial was the feasibility and preliminary outcomes of mental health and human milk feeding.

RESULTS

A total of 22 tertiary-educated participants were randomized. The mean number of log-ins was 7.3 (SD 5.3) for Sunnyside and 13.8 (SD 10.5) for Sunnyside Plus. Scores of depression and anxiety measures remained below the clinical threshold for referral to treatment in both groups. All the participants initiated human milk feeding (18/18, 100%). Most participants reported at least some human milk feeding at both 6 and 12 weeks postpartum (6/7, 86%; 11/11, 100%, or 10/10, 100%, for Sunnyside and Sunnyside Plus, respectively).

CONCLUSIONS

The results suggest that tertiary-educated Black mothers at risk for perinatal depression and who intended to human milk feed were receptive to and satisfied with a web-based cognitive behavioral therapy-based internet intervention, with and without human milk feeding education and support. Preliminary findings indicate that both Sunnyside and Sunnyside Plus interventions have the potential to affect symptoms of depression, anxiety, and human milk feeding outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04128202; https://www.clinicaltrials.gov/ct2/show/NCT04128202.

A Retrospective Cohort Study of the Impact of Upper Lip Tie Release on Breastfeeding in Infants

Objectives: Lingual frenotomies for the purpose of improving infant breastfeeding remain controversial, whereas maxillary frenotomies are even more so given the scant data and differing opinions on the matter. This study aimed at further elucidating the effect that maxillary frenula have on breastfeeding difficulties in infants. Methods: A retrospective chart review was performed on infants approximately aged 0-3 months who presented to a tongue tie/breastfeeding clinic from January to December of 2019. All analyzed infants had both lip and tongue ties classified by a clinician. Data on pre-frenotomy pain scores, lingual Coryllos classification, maxillary Kotlow classification, post-frenotomy complications, and breastfeeding success were captured. Results: Of the 316 infants, 224 underwent their first procedure at the tongue tie/breastfeeding clinic. Two hundred eleven out of 224 infants received a lingual frenotomy only, whereas the remaining 13 (5.8%) underwent both lingual and maxillary frenotomy procedures. Of the group of 211, 207 (98.1%) had successful feeding after 1 procedure; the remaining 4 underwent revision procedures to achieve successful feeding. All maxillary frenulum releases (n = 13) led to successful feeding without the need for revision procedures. Coryllos and Kotlow classification scores were significantly higher in the infants receiving both a maxillary and lingual frenulum release as compared with those receiving solely a lingual frenulum release. Conclusions: The majority (98.1%) of infants receiving a lingual frenulum release alone had successful feeding after only one procedure, and only 5.8% of all infants receiving any intervention required a maxillary frenulum release for successful feeding, calling into question the relative necessity of performing maxillary frenulum releases for breastfeeding difficulties.

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.

Healthy Habits and Emotional Balance in Women during the Postpartum Period: Differences between Term and Preterm Delivery

Breastfeeding could be considered as a vulnerable period, rising the risk to shift from optimism to pessimism. Preterm delivery is an event that increases postpartum maternal stress and depression, which can have a negative impact on breastfeeding and maternal–filial wellbeing. The adherence to healthy habits may have a positive influence on this vulnerable population. We aimed to analyze the impact of prematurity on maternal psychological aspects during postpartum and to study if adherence to the Healthy Food Pyramid influences psychological variables. Fifty-five breastfeeding women being attended in the Hospital Clínico San Carlos (Madrid, Spain) were recruited during the first day postpartum. The medical data were collected from the obstetrical records. The women answered an auto-administered questionnaire with several sections: sociodemographic characteristics, Perceived Stress Scale (PSS), and Life Orientation Test (LOT), at 14 days and 6 months postpartum, Adherence to the Healthy Food Pyramid Questionnaire (AP-Q) at 28 days postpartum and the Edinburgh Postpartum Depression Scale (EPDS) at 6 months postpartum. The PSS and LOT scores were not statistically different in mothers with preterm compared to term delivery either at 14 days or at 6 months postpartum. Longitudinally, the PSS did not show significant differences, but the LOT score was lower at 6 months compared to 14 days postpartum (p-Value = 0.046). A higher EPDS score was significantly found in mothers with preterm delivery (9.0 ± 4.7) than those with a term delivery (5.4 ± 4.2; p-value = 0.040). A significant and positive correlation was observed between the AP-Q score and LOT both at 14 days and 6 months postpartum. Conclusively, maternal optimism decreases during the postpartum period, women with preterm delivery being at risk of postpartum depression. Furthermore, there is a relationship between optimism and adherence to healthy habits. Healthcare professional counseling is essential during the entire breastfeeding period, particularly in vulnerable mothers with preterm delivery.

Early exclusive breastfeeding cessation and postpartum depression: Assessing the mediating and moderating role of maternal stress and social support

Background

Early termination of exclusive breastfeeding (EBF) and postpartum depression (PPD) are both recognized as global health problems. Recent literature reviews demonstrate a notable link between PPD and breastfeeding outcomes, however, the underlying mechanisms linking the two remain unclear.

Objectives

The aim of the study is to: 1) explore the comparative risk for PPD among new mothers who terminated EBF before the 6-month mark, compared to those who did not; and 2) test whether maternal stress and social support operate to mediate and/or moderate the relationship between EBF and PPD.

Methods

Between October 2015 and January 2016, a cross-sectional study was carried out among 426 new mothers of Bangladesh who were six months postpartum.

Results

Based on the multivariate logistic regression model, non-exclusively breastfeeding mothers were 7.58-fold more likely to experience PPD (95% CI [3.94, 14.59]) than exclusively breastfeeding mothers. Additionally, maternal stress and social support not only partially mediate the relationship between EBF and PPD but also substantially moderate this relationship. Specifically, the odds of PPD are significantly higher among mothers who had early EBF interruption in conjunction with increased stress levels and limited social support.

Conclusions

Current evidence suggests that concurrent screening for EBF difficulties and maternal stress are important red flags that might hint at complications even before mother’s screen positive for PPD. Support and care from family members can provide assistance in overcoming this issue.

Perinatal psychological interventions to promote breastfeeding: a narrative review

Background

Emotional distress in mothers inhibits the let-down reflex, thus affecting breastfeeding self-efficacy. A breastfeeding mother may have to cope with both physical discomfort and psychological distress. However, literature on initiatives to improve breastfeeding rates has focused mainly on providing community-based peer support, or social policies. The aim of this review is to assess evidence on the effectiveness of a broad range of psychological interventions to facilitate breastfeeding for mothers facing difficulties around the time of delivery.

Methods

The review of the literature is derived from a search on Cochrane Library, PubMed, EBSCOhost, and PsycINFO for papers published since 1980. The approach was to explore quantitative and qualitative parameters. Quantitative parameters included breastfeeding initiation, duration, and composition. Qualitative parameters recorded the evaluation of maternal perceptions on breastfeeding success. The high heterogeneity of the studies led to a narrative review; 20 selected papers that report on breastfeeding outcomes and psychological programs met the inclusion criteria.

Results

The evidence on breastfeeding support through psychotherapy is heterogeneous and scant. Out of the included studies, 11 were randomized controlled trials, two were non-randomised trials, and two used a quasi-experimental design. None of the studies reported an increase in adverse breastfeeding outcomes. Three studies failed to report an association between psychological procedures and improved breastfeeding outcomes. A literature review showed that 17 (85%) analyses support stress-releasing techniques to facilitate breastfeeding.

Conclusions

This review suggests that relaxation interventions carefully tailored to address perinatal emotional distress may lead to important health benefits, including improvement in breastfeeding outcomes. There is also some indication that psychotherapy support while breastfeeding may have more impact than routine counselling. Conversely, this review did not find an association between self-hypnosis and breastfeeding outcomes. Data from this study can be used in designing prevention programs and future research with appropriate theoretical underpinning.

How stress can influence brain adaptations to motherhood

Research shows that a woman's brain and body undergo drastic changes to support her transition to parenthood during the perinatal period. The presence of this plasticity suggests that mothers' brains may be changed by their experiences. Exposure to severe stress may disrupt adaptive changes in the maternal brain and further impact the neural circuits of stress regulation and maternal motivation. Emerging literature of human mothers provides evidence that stressful experience, whether from the past or present environment, is associated with altered responses to infant cues in brain circuits that support maternal motivation, emotion regulation, and empathy. Interventions that reduce stress levels in mothers may reverse the negative impact of stress exposure on the maternal brain. Finally, outstanding questions regarding the timing, chronicity, types, and severity of stress exposure, as well as study design to identify the causal impact of stress, and the role of race/ethnicity are discussed.

Infant feeding initiation practices in the context of COVID-19 lockdown

OBJECTIVE

Limited information is available regarding barriers to breastfeeding during the COVID-19 lockdown.

STUDY DESIGN

This study was designed as a non-concurrent case-control study on breastfeeding initiation practices, defined according to WHO, in women giving birth during lockdown, between March 8 and May 18, 2020, in the COVID-19 'hotspot' in Northeastern Italy (study group), with an antecedent puerperae-matched group (control group). Exclusive, complementary, and formula feeding practices were collected from maternal charts at hospital discharge, on the second day post-partum, when puerperae filled out the Edinburg Postnatal Depression Scale (EPDS).

RESULTS

The COVID-19 study group presented significantly lower exclusive breastfeeding rates than the control group who members gave birth the previous year (-15%, p = 0.003), as a consequence of the significantly higher prevalence of complementary feeding practices in the former (+20%, p = 0.002). Conversely, the COVID-19 study group showed significantly higher EPDS scores (8.03 ± 4.88 vs. 8.03 ± 4.88, p < 0.005) and higher anhedonia (0.56 ± 0.65 vs. 0.18 ± 0.38, p < 0.001) and depression (0.62 ± 0.60 vs. 0.39 ± 0.44, <0.001) subscale scores. In the general linear model analysis, women practicing exclusive breastfeeding showed significantly lower EPDS scores in comparison with those practicing complementary (p = 0.003) and formula feedings (p = 0.001). Furthermore, the highest EPDS scores were observed in women adopting formula feeding, mainly during the COVID-19 quarantine (p = 0.019).

CONCLUSION

This study indicates that hospital containment measures adopted during lockdown in the 'hotspot' COVID-19 epidemic area of Northeastern Italy have a detrimental effect on maternal emotions and on breastfeeding exclusivity practices.

Improvement of the breastfeeding self-efficacy and postpartum mental health after lactation consultations - Observational study

OBJECTIVE

Maternal self-efficacy in breastfeeding may be undermined by common mental health difficulties in the postpartum, leading to an early breastfeeding cessation. The relationship may also be the opposite: problems with effective breastfeeding and breastfeeding cessation may increase the postpartum mental health difficulties. The purpose of this study was the assessment of the effectiveness of lactation consultations in strengthening the breastfeeding self-efficacy and maternal postpartum mental health.

DESIGN AND PARTICIPANTS

160 Polish women (90 consultation participants and 70 controls) completed a structured interview, the General Health Questionnaire, and the Breastfeeding Self-Efficacy Scale twice: before lactation consultation and one month later.

SETTING

Research was conducted in the city of Gdańsk, Poland.

FINDINGS

Study revealed that women seeking lactation support exhibited greater mental health difficulties while their breastfeeding self-efficacy was similar to the control group. Initial breastfeeding self-efficacy was negatively correlated with the severity of the postpartum mental health problems. One month after lactation consultations, a significant increase in the breastfeeding self-efficacy and significantly reduced symptoms of mental health difficulties (somatic symptoms, functional disorders, and anxiety and insomnia) were observed among mothers.

KEY CONCLUSIONS

Women willing to benefit from the lactation consultations may exhibit symptoms of mental health difficulties that may be associated with difficulties in breastfeeding. Strengthening the breastfeeding confidence during lactation consultations, may reflect in the improvement of the woman's mental health.

IMPLICATIONS FOR PRACTICE

Midwives and lactation consultants can make a difference in the mental health promotion by offering breastfeeding interventions which address the emotional needs of a mother.

Association between Maternal Postpartum Depression, Stress, Optimism, and Breastfeeding Pattern in the First Six Months

Early breastfeeding cessation is a major public health problem. Several factors can affect breastfeeding pattern, and psychological aspects have been poorly explored. We hypothesize that psychological factors and breastfeeding pattern have a relationship. We have assessed in mothers during the first six months of lactation if breastfeeding pattern is associated with maternal stress, postpartum depression, and dispositional optimism, and if these psychological factors play a role on breastfeeding adherence. In total, 711 women participated, answering online the following questionnaires: sociodemographic, perceived stress scale, Edinburgh postpartum depression scale, life orientation test, and breastfeeding adherence score. Women were categorized according to infant feeding practices as exclusive breastfeeding (EBF) or mixed breastfeeding (MBF). The EBF group had a lower score of perceived stress compared to those giving MBF (first month: EBF = 1.5 [1.1; 1.9], MBF = 1.8 [1.5; 2.0]; p-Value = 0.030; third month: EBF = 1.6 [1.2; 2.0], MBF = 1.8 [1.5; 2.4]; p-Value = 0.038) and also had a lower score of postpartum depression (third month: EBF = 8.0 [6.0; 11.0], MBF = 11.0 [9.0; 15.0]; p-Value = 0.001). The breastfeeding adherence score showed a positive correlation with maternal perceived stress (first month: ρ = 0.27; p-Value = 0.018), and postpartum depression (third month: ρ = 0.30; p-Value < 0.001), and a negative correlation with maternal dispositional optimism (second month: ρ = −0.20; p-Value = 0.028). MBF was positively associated with breastfeeding adherence score (odd ratio (OR) = 1.4 [1.2–1.6]; p-Value < 0.001) and with postpartum depression (OR = 1.1 [1.0; 1.1]; p-Value = 0.020). In the third month of breastfeeding, women with MBF exhibited higher perceive stress and postpartum depression compared to those with EBF and no difference in dispositional optimism. The maternal psychological aspects are associated with breastfeeding pattern. Evaluation of maternal psychological concerns and providing support to lactating mothers may help improving breastfeeding adherence.

Breastfeeding dynamically changes endogenous oxytocin levels and emotion recognition in mothers

Breastfeeding behaviours can significantly change mothers' physiological and psychological states. The hormone oxytocin may mediate breastfeeding and mothers' emotion recognition. This study examined the effects of endogenous oxytocin fluctuation via breastfeeding on emotion recognition in 51 primiparous mothers. Saliva oxytocin was assessed before and after the manipulation (breastfeeding or holding an infant), and emotion recognition tasks were conducted. Among mothers who breastfed daily, mothers with more increased levels of oxytocin after breastfeeding showed more reduced negative recognition and enhanced positive recognition of adult facial expressions. These oxytocin functions accompanying breastfeeding may support continued nurturing behaviours and also affect the general social cognition of other adults beyond any specific effect on infants.

Parasympathetic nervous activity is associated with oxytocin in multiparous, but not primiparous, women during the perinatal period

Oxytocin (OXT) is thought to have antidepressant/anxiolytic effects in postpartum women. Primiparous women tend toward an attenuated lactation compared with multiparous women. However, so far, little is known about the relationship between OXT and autonomic nervous activity (ANA) in perinatal women and whether it may be different in primiparous and multiparous women. Therefore, the objective of this study was to answer this question by determining both ANA and salivary OXT levels in primiparous and multiparous perinatal women. In 18 primiparous and 18 multiparous women, who underwent a physical and physiological examination, ANA measurement by heart rate variability and saliva sampling were performed during the perinatal period. Saliva OXT concentration was determined by a highly sensitive ELISA. OXT release into saliva was obtained from multiplying saliva OXT concentration by saliva flow rate. In the postpartum period, multiparous women had higher parasympathetic nervous activity (PNA) and lower physical stress index (PSI) compared with primiparous women. Furthermore, multiparous postpartal women had higher OXT compared with primiparous or multiparous prepartal women. In addition, in multiparous perinatal women, OXT correlated positively with PNA, but negatively with PSI. These results suggest that after parturition, multiparous mothers may switch over to the "feed and breed" system more quickly due to increased OXT compared with primiparous mothers. Our findings support antidepressant/anxiolytic and anti-stress effects of OXT. In postpartal women exposed to synthetic OXT, ANA measurement may provide a clue to clarify the effects of exogenous OXT on postpartum psychiatric disorders.

Neuroendocrine Effects of Lactation and Hormone-Gene-Environment Interactions

While correlational studies suggest that lactation may confer a certain level of protection from mental illness, this benefit is not uniformly expressed in all women who choose to breastfeed. We propose here that the neuroendocrine "resetting" induced by lactation may predispose toward positive affect states in a subset of hormone-sensitive mothers, with hormone-gene and hormone-environment interactions determining the ultimate psychological outcome. We find evidence to suggest that higher secretion of prolactin/oxytocin as well as lower secretion of vasopression/androgens in lactating mothers may protect against postpartum depression and anxiety, decrease levels of irritability, and optimize stress responses. On the other hand, while the abrupt withdrawal of estradiol/progesterone in the immediate postpartum period tends to be associated with adverse psychological outcomes, the chronic suppression of estrogens/progestogens induced by lactation may have antidepressant and anxiolytic effects over time. Finally, the hypo-cortisolemic state seen in lactating mothers appears to be associated with improved stress reactivity and circadian rhythms. We also discuss hormone-gene and hormone-environment interactions likely to modulate any potential psychological benefits related to lactation and focus on those factors that are either easy to screen for or known to be modifiable. In sum, neuroendocrine alterations induced by lactation may play a key role in determining reproductive psychiatric risk in a subset of hormone-sensitive women. Using these neuroendocrine factors as an individualized index of risk can help in devising targeted programs to support these women in pursuing lactation or, for those not able or willing, accessing psychological interventions in a timely manner.

The association between breastfeeding and attachment: A systematic review

OBJECTIVE

In the popular and scientific literature an association between breastfeeding and attachment is often supposed although this has not been systematically investigated. This is the first review that provides a systematic overview of the current state of research on the association between breastfeeding and attachment. The objective is to determine whether breastfeeding is associated with child attachment as well as if maternal attachment is associated with breastfeeding behaviour.

DESIGN

A systematic electronic literature search for English language articles published from 1963 to 2019 using the databases Web of Science, PubMed, PsycInfo, and PsycArticles was conducted. Studies were included if (1) the association between breastfeeding and attachment of the child or maternal attachment style and breastfeeding was investigated, (2) participants were mothers or mother-child dyads, and (3) quantitative measures of breastfeeding and attachment were used. Study quality was rated using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies.

PARTICIPANTS

Studies examining mothers or mother-child dyads were reviewed. Sample sizes varied between N = 60 and N = 8900 participants. On average, mothers were between 27.56 and 32.50 years old.

FINDINGS

Eleven studies were eligible for inclusion. Of seven studies examining breastfeeding and child attachment, four found that a longer duration of breastfeeding was significantly associated with higher levels of attachment security after controlling for various covariates. No significant differences in attachment security between breastfeeding and bottle-feeding were reported, but one study found higher levels of attachment disorganization for bottle-feeding, although mean levels were below a clinically relevant level. The initiation of breastfeeding directly after childbirth was not related to child attachment. Of four studies examining maternal attachment and breastfeeding, three found a significant association between secure attachment of the mother and breastfeeding behaviour. Secure attached mothers initiated breastfeeding more often and preferred breast- over bottle-feeding than insecure attached mothers. Mixed results were found for breastfeeding duration. Most studies had limitations regarding adequate sample size, and valid and reliable measurement of breastfeeding.

KEY CONCLUSIONS

The findings provide some evidence that breastfeeding might contribute to child attachment security. Furthermore, maternal attachment style might play a role in breastfeeding behaviour. However, more prospective studies are needed to draw a solid conclusion.

IMPLICATIONS FOR PRACTICE

With regard to breastfeeding recommendations, health professionals should be aware of and communicate towards clients that the effect of breastfeeding on child attachment might be rather small. Screening of maternal attachment style as a part of maternity practice could be useful to support insecure attached mothers experiencing breastfeeding difficulties.

Postpartum depression: A multi-disciplinary approach to screening, management and breastfeeding support

Postpartum depression (PPD) is a common condition affecting 11%-20% of all postpartum women. Depression can have significant consequences for both mother and infant. There are many risk factors associated with PPD, all of which contribute to an inflammatory response in the mother. An inverse relationship exists between PPD and breastfeeding; women with PPD are less likely to have a positive breastfeeding experience which can lead to early weaning, while long-term exclusive breastfeeding is associated with decreased rates of PPD. A multi-disciplinary approach to managing PPD, including strong breastfeeding support, will lead to improved mental health outcomes for women and their children.

Effect of the Sacred Hour on Postnatal Depression in Traumatic Childbirth: a Randomized Controlled Trial

Introduction: the implementation of the baby’s nine instinctive stages as a sacred hour after birth is very effective in starting breastfeeding. About half of newly delivered mothers have reported a traumatic childbirth experience often associated with mental health problems. The present study aimed to examine the effect of the sacred hour on the depression in traumatic childbirths.

Methods: In this clinical trial, 84 mothers who had experienced a traumatic childbirth were randomly allocated into the intervention (n = 42) and control (n = 42) groups. The intervention group received sacred hour (baby’s nine instinctive responses), but the control group received only the routine care. Postnatal depression was evaluated as primary outcome at 2 week, 4-6 week and 3 month intervals after the delivery. The data were analyzed using t test, chi-square test and the repeated measures analysis of variance.

Results: The results showed that the marginal total mean (SD: standard deviation) scores of depression in the intervention and control groups were 7.5 (2.6) and 9.6 (2.6); therefore, the mean difference (95% CI) between the groups (-2.1, (-3.2,-0.95)) was significant.

Conclusion: The implementation of the sacred hour is recommended as a preventive approach to reduce the postnatal depression in women with a traumatic childbirth experience.

Breastmilk Pumping for the Mental Health of the NICU Mother

Objective

While much is known about breastfeeding and postpartum depression, little is known about breast milk pumping's impact on postpartum depression among mothers with infants in the neonatal intensive care unit (NICU).

Methods

Thirty-two mothers of infants admitted to a Level III NICU between February and July 2017 were screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS). They were also surveyed for current breastmilk pumping activities and demographic factors. Multivariable logistic regression was used to assess the associations between postpartum depression and breast milk pumping, adjusting for confounding variables.

Results

After controlling for confounding variables, mothers who did not pump breast milk (relative to mothers who did) were 11 times more likely to have lower EPDS depression scores indicative of probable postpartum depression (OR = 11.7, p-value .05).

Conclusions

Our results suggest a significant reduction in probable postpartum depression among NICU mothers who express breastmilk.

Breastmilk feeding for mothers and infants with opioid exposure: What is best?

With rare exception, breastfeeding is the optimal way to feed infants, and has special benefits for women and infants with perinatal opioid exposure. Infants breastfed and/or fed their mother's own breastmilk experience less severe opioid withdrawal symptoms, have shorter hospital stays, and are less likely to be treated with medication for withdrawal. The specific impact of mothers' milk feeding on opioid withdrawal may be related to the act of breastfeeding and associated skin-to-skin contact, qualities of breastmilk, healthier microbiome, small amounts of opioid drug in breastmilk, or a combination of these. Women with opioid use disorder face significant breastfeeding obstacles, including psychosocial, behavioral, concomitant medications, and tobacco use and thus may require high levels of support to achieve their breastfeeding goals. They often don't receive information to make informed infant feeding decisions. Hospital practices such as prenatal education, rooming-in and having a policy that minimizes barriers to breastfeeding are associated with increased breastfeeding rates.

Breastfeeding, Antidepressants, and Depression in the Mercy Pregnancy and Emotional Well-Being Study

BACKGROUND:

Depression is consistently shown to predict lower rates of breastfeeding. In a handful of studies, breastfeeding has predicted lower depression symptoms. However, studies demonstrating the latter are limited in their measurement of both depression and breastfeeding and have not followed participants from pregnancy across the postpartum period.

RESEARCH AIM:

The primary aim of this study was to describe breastfeeding intentions and behaviors for the first 12 months postpartum among nonmedicated depressed, antidepressant-exposed, and control participants. The secondary aim was to examine group differences in the association between depressive symptoms and breastfeeding duration up to 12 months postpartum.

METHODS:

First-trimester women ( N = 212) were recruited into a prospective longitudinal study. Depressive disorders at baseline were diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders, and depressive symptoms were measured at the first and second trimesters and 6 and 12 months postpartum using the Edinburgh Postnatal Depression Scale. Breastfeeding duration, support from family and employers, and perceptions of participants' experience were measured.

RESULTS:

Depressed women and antidepressant-exposed women reported a trend toward lower rates of intention, initiation, and duration, but this did not reach statistical significance. There was a statistically significant difference on depressive symptoms for women taking antidepressants during pregnancy, compared with controls, when they continued to breastfeed for 12 months postpartum.

CONCLUSIONS:

This study did not find a strong association between depression or antidepressant use and intention to breastfeed, partner breastfeeding support, or initiation or duration of breastfeeding. However, for women who took antidepressants, there was evidence that breastfeeding for 12 months was associated with lower depressive symptoms.

Duration of Breastfeeding, Bottle-Feeding, and Parafunctional Oral Habits in Relation to Anxiety Disorders Among Children

OBJECTIVE

The aim of the present study is to investigate the duration of breastfeeding in relation to various parafunctional oral habits in children with anxiety disorders.

MATERIALS AND METHODS

The study includes 195 children and adolescents with anxiety disorders and age- and gender-matched 255 healthy control subjects. Diagnoses were made with semistructured interview (K-SADS). Information about breastfeeding and parafunctional oral habits was investigated via a questionnaire prepared for the study.

RESULTS

The mean age was 11.50 ± 2.50 years for clinical group and 11.27 ± 2.33 years for controls. Fifty-four percent of the clinical group and 56% of the control group were female subjects. Duration of exclusive (4.72 ± 2.86, 5.55 ± 2.36; p = 0.002) and total breastfeeding (12.38 ± 10.32, 15.89 ± 9.09; p < 0.001) was significantly lower and duration of bottle-feeding (22.30 ± 19.54, 16.64 ± 12.79; p = 0.005) was higher than controls in the clinical group. Duration of exclusive breastfeeding was significantly correlated with duration of bottle-feeding (r = -0.263, p < 0.001) and duration of pacifier use (r = -0.249, p = 0.001). Multiple regression analysis showed that duration of exclusive breastfeeding (β = 0.88, p = 0.006) and bottle-feeding (β = 1.02, p = 0.005), as well as various oral habits, was associated with diagnosis of an anxiety disorder.

CONCLUSION

Nutrition methods in early years of life may result in long-term consequences regarding anxiety disorders for children. Clinicians should encourage parents for a shorter duration of bottle-feeding and a longer duration of exclusive breastfeeding.

Dietary Protein Intake, Breast Feeding and Growth in Human Milk Fed Preterm Infants

Protein intakes of preterm infants are frequently below recommendations, but few studies report accurate intakes due to the difficulty of analysing human milk clinically. This observational analysis from a randomised trial of infants born <31 weeks’ gestation, investigating two levels of protein fortification, reports protein intakes compared with requirements and determines the association of direct breastfeeding on growth. Ninety-two infants (median gestational age 28 weeks, Interquartile range (IQR) 26–29; mean birth weight 1040 g, SD 300 g) were studied. Infants born weighing <1000 g were underfed protein compared with recommendations (median (IQR) intake of 3.0 (2.0–3.7) g/kg/day in week 2 versus recommendation of 4–4.5 g/kg/day), while those born weighing ≥1000 g met recommended protein intakes after the first week of life (median (IQR) intake of 3.7 (3.0–4.0) g/kg/day in week 2 versus recommendation of 3.5–4.5 g/kg/day). A moderate, negative correlation between the mean number of breast feeds and change in rate of weight gain (r = −0.37, p = 0.001) was found. Protein intakes of infants <1000 g did not meet recommendations and all infants were underfed protein and energy in the first week of life. Current protein fortification is inadequate for infants born <1000 g. Exploratory analysis showed faltering rate weight gain associated with increasing number of breast feeds and these results warrant confirmation.

Pregnancy, perinatal and postpartum complications as determinants of postpartum depression: the Rhea mother-child cohort in Crete, Greece

AIMS

Few epidemiological studies evaluated associations between perinatal complications and maternal mood at the early postpartum period and the findings are inconsistent. We aimed at investigating a wide range of complications during pregnancy, at delivery, and at the early postpartum period as determinants of postpartum depression (PPD) at 8 weeks postpartum.

METHODS

A total of 1037 women who enrolled in the Rhea mother-child cohort in Crete, Greece participated in the present study. Information on pregnancy, perinatal and postpartum complications was obtained from clinical records or by questionnaires. Postpartum depressive symptoms were assessed at 8 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multivariable linear and logistic regression models were fit to estimate the association between pregnancy, perinatal and postpartum complications and maternal depressive symptoms, adjusting also for potential confounders.

RESULTS

The prevalence of women with probable depression (EPDS score ≥ 13) was 13.6% at 8 weeks postpartum. Gestational hypertension and/or preeclampsia (β coefficient 1.86, 95% CI: 0.32, 3.41) and breastfeeding difficulties (β coefficient 0.77, 95% CI: 0.02, 1.53) were significantly associated with higher PPD symptoms. Sleep patterns during pregnancy, such as sleep deprivation (OR = 3.57, 95% CI: 1.91, 6.67) and snoring (OR = 1.81, 95% CI: 1.11, 2.93), and breastfeeding duration less than 2 months (OR = 1.77, 95% CI: 1.19, 2.64) were significantly associated with increase in the odds for PPD. Some other complications, such as unplanned pregnancy and hospitalisation during pregnancy were also associated with EPDS score, but these associations were explained by socio-demographic characteristics of the mother.

CONCLUSIONS

We found that several pregnancy, perinatal and postpartum complications may have an adverse effect on maternal mood at the early postpartum period. These findings have considerable implications for developing effective prevention and early psychoeducational intervention strategies for women at risk of developing PPD.

Postpartum-specific anxiety as a predictor of infant-feeding outcomes and perceptions of infant-feeding behaviours: new evidence for childbearing specific measures of mood

Studies of pregnancy-specific anxiety suggest that it is a distinct construct which predicts perinatal outcomes more effectively than other general measures of anxiety. In response, a novel measure of postpartum-specific anxiety (PSAS) has been developed and validated, but it is not yet clear whether it possesses the same predictive power as its pregnancy-specific counterparts. The aim of this short-term prospective study was to (a) test the predictive validity of the PSAS in the context of one specific perinatal outcome, infant-feeding, and (b) examine whether the PSAS may be more efficacious at predicting infant-feeding outcomes and behaviours than the more commonly used general measures. Eight hundred mothers of infants aged between 0 and 6 months completed the PSAS alongside general measures of anxiety and depression at baseline. A subsample (n = 261) returned to complete a follow-up questionnaire examining infant-feeding outcomes and behaviours two weeks later. Hierarchical regression models revealed that the PSAS was associated with lower odds of breastfeeding exclusively, and breastfeeding in any quantity in the first 6 months postpartum. PSAS scores were also significantly associated with infant-feeding behaviours including a lower perceived enjoyment of food, and greater perceived food responsiveness and satiety responsiveness in the infant. As hypothesised, the PSAS was a stronger predictor of infant-feeding outcomes and behaviours than general anxiety and depression. The findings provide evidence for the predictive validity of the PSAS and call for the use of childbearing specific measures of mood when attempting to predict perinatal outcomes. Replication of these findings across other indices of maternal and infant health is now necessary.

The synergistic effect of breastfeeding discontinuation and cesarean section delivery on postpartum depression: A nationwide population-based cohort study in Korea

BACKGROUND

The relationships between breastfeeding discontinuation and cesarean section delivery, and the occurrence of postpartum depression (PPD) remain unclear. Therefore, we aimed to investigate the association of breastfeeding discontinuation and cesarean section delivery with PPD during the first 6 months after delivery.

METHODS

Data were extracted from the Korean National Health Insurance Service-National Sample Cohort for 81,447 women who delivered during 2004-2013. PPD status was determined using the diagnosis code at outpatient or inpatient visit during the 6-month postpartum period. Breastfeeding discontinuation and cesarean section delivery were identified from prescription of lactation suppression drugs and diagnosis, respectively. Cox proportional hazards models were used to calculate adjusted hazard ratios.

RESULTS

Of the 81,447 women, 666 (0.82%) had PPD. PPD risk was higher in women who discontinued breastfeeding than in those who continued breastfeeding (hazard ratio=3.23, P<0.0001), in women with cesarean section delivery than in those with vaginal delivery (hazard ratio=1.26, P=0.0040), and in women with cesarean section delivery who discontinued breastfeeding than in those with vaginal delivery who continued breastfeeding (hazard ratio=4.92, P<0.0001).

LIMITATIONS

Study limitations include low PPD incidence; use of indirect indicators for PPD, breastfeeding discontinuation, and working status, which could introduce selection bias and errors due to miscoding; and potential lack of adjustment for important confounders.

CONCLUSIONS

Breastfeeding discontinuation and cesarean section delivery were associated with PPD during the 6-month postpartum period. Our results support the implementation of breastfeeding promoting policies, and PPD screening and treatment programs during the early postpartum period.

Body Shape and Weight Loss as Motivators for Breastfeeding Initiation and Continuation

Breastfeeding rates in the UK are low. Efforts to promote breastfeeding typically include the known health benefits for mother and child, many of which are not immediate. Gaining immediate benefits can be effective motivators of behaviour. Body-related changes resulting from breastfeeding could be an immediate benefit. This study explored breastfeeding mothers’ reports of body-related changes as benefits of breastfeeding. Mothers (N = 182) who currently, or had recently, breastfed an infant completed a survey detailing their infant feeding choices and the perceived benefits of breastfeeding on their bodies. Half of the mothers felt that breastfeeding had a positive effect on their body. Benefits were grouped into five themes: (1) Returning to pre-pregnancy body shape; (2) Health benefits; (3) Physical benefits; (4) Eating benefits; (5) Psychological benefits. These themes highlight the numerous body-related benefits that mothers identified as resulting from breastfeeding and suggest that immediate, personal, and appearance-related gains of breastfeeding are highly valued. These findings indicate that interventions would likely benefit from emphasising the more immediate physical and psychological benefits of breastfeeding, alongside the health and bonding benefits, as a way to promote breastfeeding initiation and continuation in more women. This may be particularly effective for groups such as young mothers, where breastfeeding rates are low and whose emphasis on body image may be greater.

Postpartum Anxiety and Infant-Feeding Outcomes

There is increasing evidence for the effect of postpartum anxiety (PPA) on maternal and infant health outcomes. Despite evidence linking suboptimal infant-feeding outcomes with other indices of maternal mental health, the relationship between PPA and infant feeding has not yet been reviewed. A systematic review with narrative synthesis was conducted to examine the relationship between PPA and infant-feeding outcomes. Electronic searches were performed using specific keywords (eg, "postnatal anxiet*"; "breastfeed*"). A hand search of selected journals and reference lists of included articles was then conducted. All studies were considered that provided information related to PPA and infant-feeding outcomes. One hundred and two studies were identified, of which 33 were eligible. Two authors independently extracted data including study design, participants, and results. Results indicated that women with symptoms of PPA are less likely to breastfeed exclusively and more likely to terminate breastfeeding earlier. Some evidence also suggests that those experiencing PPA are less likely to initiate breastfeeding and more likely to supplement with formula in the hospital. In those who do breastfeed, PPA reduces self-efficacy, increases breastfeeding difficulties, and may negatively affect breastfeeding behaviors and breast milk composition. Heterogeneous outcomes and methodological limitations somewhat limit the comparability of findings. However, in combination with a review linking depression with similar negative infant-feeding sequelae, the findings provide evidence for the effect of negative postpartum mood on breastfeeding. Additional support for breastfeeding mothers with PPA is warranted.

Postnatal Depression

Although breastfeeding has multiple benefits for baby and mother, including maternal mental well-being, many mothers terminate breastfeeding earlier than they desire. We examined two key factors in breastfeeding duration and maternal mental health––breastfeeding efficacy and family–work conflict. Specifically, we examined the moderating role of family–work conflict in the process of breastfeeding efficacy as a predictor of maternal depression by way of duration. In a sample of 61 first-time mothers, we found that breastfeeding duration mediated the relation between prenatal breastfeeding efficacy and depression at 9 months postpartum for working mothers who experienced low levels of family-to-work conflict. That is, for mothers with low family-to-work conflict, higher expected breastfeeding efficacy during pregnancy predicted a longer duration of breastfeeding, which in turn was associated with lower depression at 9 months postpartum. However, for working mothers with high family-to-work conflict, breastfeeding duration did not emerge as an indirect effect on the relation between efficacy and depression. These findings have important implications for a healthy family–work balance to help new mothers adjust when they return to the workforce and as they transition to parenthood.

Human milk and breastfeeding: An intervention to mitigate toxic stress

The American Academy of Nursing has identified toxic stress in childhood as a health policy concern of high priority. Adult diseases (e.g., obesity, diabetes, hypertension and cardiovascular disease) should be viewed as developmental disorders that begin early in life that could be reduced with the alleviation of toxic stress in childhood. The provision of human milk/breastfeeding is an evidence-based intervention that may hold the greatest potential to mitigate the effects of toxic stress from the moment of birth. Assisting families to make an informed choice to initiate and continue breastfeeding from birth has the potential to address both the disparity in the quality of nutrition provided infants and the economic stress experienced by families who purchase formula. The Expert Panel on Breastfeeding endorses initiatives to improve the initiation, duration, and exclusivity of breastfeeding to mitigate the effects of toxic stress in this call to action for research to build the evidence to support these critical relationships.