Combining hand techniques with electric pumping increases milk production in mothers of preterm infants

The Effect of Breast Massage and Warm Compress Application on Milk Production and Anxiety in Mothers with Premature Newborn: A Randomized Controlled Trial

Objective: The aim of this study is to examine the effects of breast massage and warm compression on milk secretion and anxiety in the mothers of premature newborns. Methods: In this randomized controlled trial, 120 mothers of premature newborns in the neonatal intensive care unit (NICU) were assigned to three intervention groups (massage, n = 30; warm compression, n = 30; massage-warm, n = 30) and one control group (n = 30). Mothers in the massage group performed massage, those in the warm compression group applied compresses, and the combined group used both methods, whereas the control group used a breast pump with no intervention. Milk production was measured in milliliters (mL) after each pumping session over 4 days, and anxiety levels were assessed at baseline and on the 4th day. Results: Mothers with premature newborns in the NICU had mean breast milk amounts of 1,321.43 ± 569.01 mL in the massage group, 1,470 ± 718.93 mL in the warm compression group, 1,484.23 ± 889.28 mL in the massage-warm group, and 913.75 ± 679.90 mL in the control group. The massage, warm compression, and massage-warm groups had significantly higher milk production than the control group (p < 0.05). In addition, anxiety levels in the intervention groups significantly decreased compared with the control group (p < 0.05). Mothers reported satisfaction with all interventions, with no significant differences between the groups (p > 0.05). Conclusion: Breast massage, warm compression, and breast massage-warm compression can be suggested as effective, simple, and cost-effective methods for increasing milk quantity and decreasing maternal anxiety.

Comparison of Two Pumping Strategies to Improve Exclusive Breastfeeding at Discharge in Mothers of VLBW Infants with Low Milk Output - A Pilot Randomized Controlled Trial

OBJECTIVES

To compare the effect of two strategies of breast pumping -power pumping (PP) vs. routine pumping (RP) over one week in mothers of very low birth weight (VLBW) infants with low milk output to improve breastfeeding rates at discharge.

METHODS

Mothers with low milk output, defined as inability to express sufficient breastmilk to meet the feeding requirements of their infant on or after post-natal day 14, were randomized to receive power pumping vs. routine pumping - once daily for 7 d coupled with routine lactation support and hand expression 3 hourly in both groups. The primary outcome was exclusive breastfeeding at discharge.

RESULTS

There was no difference in the two pumping strategies with respect to exclusive breastfeeding rates [61.1% in PP vs. 50% in RP group; (p = 0.477, RR 1.2; 95% CI 0.76 to 2.17)]. Median milk volume pumped in the individual power pumping session on 7th day of intervention was significantly higher than that in the individual routine pumping session on the 7th day (50 mL vs. 27 mL, p = 0.014). The cumulative median milk volume expressed per individual pumping session over the 7 sessions of power pumping was also higher than that with routine pumping (305 mL vs. 213 mL, p = 0.054).

CONCLUSIONS

In this pilot trial, expressed milk volume was significantly higher after each individual power pumping session compared to routine pumping. However, the exclusive breastfeeding rates at discharge were similar in the two groups.

Evaluating milk flow patterns using the high flow rate period during breast pumping

PROBLEM

Breast pumping practices have scope for improvement.

BACKGROUND

Breast milk weight measurement can be used to evaluate milk flow pattern dynamics during breast pumping.

AIM

To determine inter-individual differences in milk flow patterns and their practical implications based on high milk flow rate period (HFP) data among Japanese women expressing breast milk using an electric pump.

METHODS

This cross-sectional, observational study analysed data from 19 women (33.0 ± 3.9 years) nursing 1-6-month-old infants and with previous breast milk expression experience. Breast milk was weighed continuously during a 15-min single-breast electric pumping session. The HFP features and flow rate time (≥0.1 g/s) were analysed to determine each individual's milk flow pattern.

FINDINGS

The total expressed breast milk was 69.8 ± 42.5 g with a maximum individual flow rate of 0.5 ± 0.2 g/s. The breast milk yielded during the HFPs was 43.1 (34.4-81.3) g, accounting for 82.5 % (69.9-89.5 %) of the total expressed breast milk. HFP occurred 0-3 times during the 15-min session. Multiple discrete and continuous milk flow patterns were observed. Among those with discrete HFP, the HFP interval was 221 (68-371) s. Breast milk fat content changes and subjective residual milk measurements implied sufficient milk removal. A strong positive correlation was noted between HFP length and total breast milk expression volume.

DISCUSSION

Individual differences in milk flow patterns were observed among the women using HFP. Milk flow patterns were consistent with previous reports.

CONCLUSION

Milk flow pattern data can be used to guide individualised lactation support.

Does extremely early expression of colostrum after very preterm birth improve mother's own milk quantity? A cohort study

OBJECTIVE

Assess the relationship of time to first expression after very preterm birth and mothers' own milk quantity.

DESIGN

A cohort study (nested within a randomised trial).

SETTING

Four neonatal units in the UK.

PATIENTS

132 mothers of single or twin infants born at 23+0 to 31+6 weeks postmenstrual age.

EXPOSURES

Time to the first attempt to express after birth.

PRIMARY OUTCOMES

24-hour mother's own milk yield on days 4, 14 and 21 after birth.

RESULTS

Median time to first expression attempt was 6 hours. 51.7% expressed within 6 hours of birth (62/120) and 48.3% expressed more than 6 hours after birth (58/120). Expressing within 6 hours of birth was associated with higher milk yield on day 4 (88.3 g, 95% CI 7.1 to 169.4) and day 14 (155.7 g, 95% CI 12.2 to 299.3) but not on day 21 (73.6 g, 95% CI -91.4 to 238.7). There was an interaction between expressing frequency and time to first expression (p<0.005), with increased expressing frequency being associated with higher yield only in those who expressed within 6 hours. Expressing within 2 hours of birth was not associated with further milk yield increase.

CONCLUSIONS

Mothers who expressed within 6 hours of birth had higher milk yield, and a greater yield per expressing session, in the first 3 weeks after birth. This information will be highly motivating for families and the clinicians supporting them. There was no evidence of further benefit of extremely early expression (first 2 hours after birth).

TRIAL REGISTRATION NUMBER

ISRCTN 16356650.

The relationship of milk expression pattern and lactation outcomes after very premature birth: A cohort study

INTRODUCTION

Mothers of very premature infants often have difficulties expressing breastmilk, which can cause distress and potential negative impact on infant health. Clinical recommendations on breastmilk expression are extrapolated from term infants' breastfeeding patterns. This study's objective was to analyse the association of expressing pattern with lactation outcomes after very premature birth.

METHODS

132 participants were recruited after birth between 23+0 and 31+6 weeks' gestation. Participants recorded the milk expressed in several 24-hour periods in the three weeks after birth.

RESULTS

Expressing frequency was positively associated with 24-hour milk yield, with an adjusted 30.5g increase per expressing session on day four (95% CI 15.7 to 45.3) and 94.4g on day 21 (95% CI 62.7 to 126.2). Expressing ≥8 times per day was associated with higher adjusted milk yield than expressing <6 times (on day four, 146.8g, 95% CI 47.4 to 246.1), but not in comparison to expressing 6-7 times (on day four, 82.1g, 95% CI -25.9 to 190.1). Participants with six months or more prior breastmilk feeding experience had a higher adjusted milk yield than others (on day four, 204.3g, 95% CI 125.2 to 283.3). Night-time (2300-0700 hours) expressing sessions were not associated with increased milk yield after adjustment for time since the prior session. On average, participants who had a longest gap between expressions of less than six hours achieved the UK target of 750g breastmilk, whereas those with a longer gap did not.

CONCLUSION

Expressing frequency was an important determinant of milk yield. Clinical recommendations to express ≥8 times per day were supported but for some, 6-7 times was sufficient. This was particularly likely for those with six months or more of prior breastmilk feeding experience. A need to express during the night-time hours appeared to be related to minimising the gap between expressions rather than an inherent value of night-time expression.

Lactation support in neonatal intensive care units in Germany from the mothers' perspective - a mixed-method study of the current status and needs

BACKGROUND

Establishing successful lactation in mothers of very low birth weight (VLBW, <1500g) infants requires structured lactation support. Little is known about mothers' perspectives on lactation support in German neonatal intensive care units (NICUs).

METHODS

This paper features a convergent mixed-method approach that includes a retrospective, cross-sectional questionnaire and interview data to showcase mothers' perceptions of lactation support in NICUs. Content analysis of the interviews (n = 12) and a descriptive analysis of quantitative data (n = 533) were performed to illustrate the current status and need for lactation support in German NICUs.

RESULTS

The results show that lactation support in German NICUs is often inadequate and does not comply with recommendations based on the existing literature to encourage pumping and breastfeeding in mothers. The data imply that even if lactation is successfully initiated in most cases, it is often not maintained over time, which may be due to a lack of personal support and consistent information.

CONCLUSION

The overall structures and institutional guidelines for lactation support should be encouraged to promote nutrition with mother´s own milk in German NICUs.

Breastfeeding and Antepartum Breast Milk Expression (BABE): A Randomized Control Trial Utilizing an Electric Breast Pump and its Effect on Postpartum Breastfeeding

Objective: To evaluate the effect of antenatal breast milk expression (ABE) on exclusive breastfeeding. Materials and Methods: A randomized control study was performed with the primary outcome being formula use during the postpartum hospital stay. Secondary outcomes were the exclusive breastfeeding rate at 6 months postpartum and peripartum safety outcomes. Participants included multiparous and nulliparous patients who planned to breastfeed. Exclusion criteria included exclusively breastfeeding in prior pregnancies for greater than 6 months, medical contraindications for breastfeeding, multiple gestation, history of preterm delivery, or any contraindication to vaginal delivery. ABE group participants were instructed to pump for 20 minutes, three times daily, starting at 37 weeks of gestation. Results: Three-hundred four participants from two clinics were enrolled. There was no significant difference in formula use during hospital admission (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.34-1.22) or in exclusive breastfeeding at 6 months postpartum (OR 0.66, 95% CI 0.34-1.29). Colostrum use was more prevalent in the ABE group (OR 5.31, 95% CI 2.63-10.76). ABE participants were more likely to present in spontaneous labor (OR 2.09, 95% CI 1.05-4.14). Conclusion: ABE did not significantly improve exclusive breastfeeding rates, but safely provides women opportunities to become familiar with breastfeeding before delivery and can provide readily available colostrum. There was no negative secondary safety outcome related to ABE identified. Prenatal care providers can consider recommending ABE to patients with minimal to no experience with breastfeeding.

Controversies and Conundrums in Newborn Feeding

Breastfeeding is the biologic norm for newborn feeding, and exclusive breastfeeding for the first 6 months of life is universally endorsed by leading global and national organizations. Despite these recommendations, many people do not meet their breastfeeding goals and controversies surrounding breastfeeding problems exist. Medical issues can present challenges for the clinician and parents to successfully meet desired feeding outcomes. There are studies evaluating these common controversies and medical conundrums, and clinicians should provide evidence-based recommendations when counseling families about newborn feeding.

Early pumping frequency and coming to volume for mother's own milk feeding in hospitalized infants

OBJECTIVE

To identify daily pumping frequencies associated with coming to volume (CTV: producing > 500 milliliters of milk per day by postnatal day 14) for mothers of infants in the neonatal intensive care unit (NICU).

STUDY DESIGN

We compared demographics and daily pumping frequencies for mothers who did and did not experience CTV.

RESULTS

Of 427 mothers who produced milk, 201 (50.1%) experienced CTV. Race, insurance, delivery type and birthweight were associated with CTV. For mothers who experienced CTV, average pumping episodes increased daily, stabilizing at 5 pumping episodes per day by postnatal day 5 (5 × 5). Women who experienced CTV were also more likely to have pumped between 0100 and 0500 (AM pumping). In multivariable analysis birthweight, 5 × 5 and AM pumping were each independently associated with CTV.

CONCLUSION

Supporting mothers of NICU infants to achieve 5 or more daily pumping sessions by postnatal day 5 could improve likelihood of achieving CTV.

Nonpharmacologic Factors Affecting Milk Production in Pump-Dependent Mothers of Critically Ill Infants: State of the Science

BACKGROUND

Improved health outcomes for critically ill infants including neurodevelopmental, immunological, and cost benefits are dependent upon the dose and duration of mother's own milk feedings. However, mothers of infants admitted to the neonatal intensive care unit (NICU) must express their milk (pump-dependent) and often struggle with milk production.

PURPOSE

To examine the state of the science on nonpharmacologic modifiable expression factors that may influence milk production in pump-dependent mothers of critically ill infants admitted to the NICU.

DATA SOURCES

PubMed, Embase, and CINAHL databases from 2005 to 2020.

SEARCH STRATEGY

Guided by the lactation conceptual model, the authors searched for peer-reviewed studies with terms related to milk volume, pump dependency, critically ill infants, and modifiable factors, which may influence milk volume and assessed 46 eligible studies.

DATA EXTRACTION

Data were extracted by 3 reviewers with a systematic staged review approach.

RESULTS

Evidence from 26 articles found expressed milk volume may be influenced by multiple potentially modifiable factors. Simultaneous expression with a hospital-grade electric pump at least 5 times per day beginning 3 to 6 hours after delivery, and adding complementary techniques including hand expression, hands-on-pumping, music, breast massage, warm compresses, skin-to-skin care, and the mother expressing near her infant may promote increased milk volume.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Healthcare providers should assist pump-dependent mothers with early initiation and frequent milk removal with a hospital-grade breast pump. Further research is needed to explore optimal frequency of expressions, dose and timing of skin-to-skin care, and other targeted strategies to improve expressed milk volume.

Midwives experiences of interventions to improve breast expression following preterm birth: A qualitative study

OBJECTIVE

Preterm birth impacts approximately 10% of women globally. Midwives are often the first point of care after the birth of a preterm infant providing mothers with information and support for breast expression. However, despite guidelines that suggest expression within the first hour of birth, most first expressions occur much later. This study aimed to seek an understanding of midwives' experiences with the first expression for mothers of preterm infants, including the barriers and facilitators that midwives may face.

DESIGN

A qualitative design using semi-structured interviews via focus groups. Thematic analysis was used to identify relevant themes and sub-themes.

PARTICIPANTS

Participants included midwives providing care to women in preterm labour and birth at a tertiary maternity hospital in Australia (N=12). All participating midwives cared for mothers of preterm infants between 28 and 35 weeks' gestation up to six hours following birth.

FINDINGS

Two major themes resulted from the data, including the changing expectations of infant feeding and the responsibility versus expectation to support a woman to express in the first hour of birth with other competing clinical and organisational tasks.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Whilst individual philosophies on the benefits of human milk were positive, expressing in the birth suite was dictated by essential clinical tasks and by the institutions value placed on expressing in the first hour. Clear objectives to undertake expressing within the first hour or within the birth suite stay, need to be included in policy and supported by management and team leaders, to increase early expressing rates.

Benefits and issues of education program for nurse-midwives on milk expression care for preterm mothers in postpartum period

Background and aims

Breastfeeding is important for preterm mothers and infants. However, evidence-based practice and standardized education remain inadequate. To implement evidence-based practice, continuous education is mandatory for nurse-midwives. We previously implemented our developed education program on early essential milk expression care for preterm mothers among Japanese nurse-midwives. Herein, we aimed to assess the effects of our education program on nurse-midwives' knowledge of milk expression care for preterm mothers in terms of changes in their correct answer rates for 20 specific knowledge items before and after the education program implementation. We also aimed to identify program-related issues from nurse-midwives' comments to improve the program.

Methods

We conducted a secondary analysis of our previous data and surveyed the knowledge of 36 nurse-midwives who received a similar face-to-face education program on milk expression care for mothers three months before (Pre-1), just before (Pre-2), just after (Post-1), and three months after (Post-2) the program. We obtained their comments at Post-2 and identified issues for program improvement.

Results

The knowledge items, in which the correct answer rates of Post-1 were significantly higher than those of Pre-2, were Verification of the motivation and intent, Benefits of breastfeeding for mothers and infants, Milk volume on the fourth day and at around the second week after birth, Lactogenesis stage 3, Autocrine control, Time between birth and the initiation of milk expression, Early initiation of milk expression, Frequent milk expression, and Duration of pumping. The issues identified were practical training, knowledge retention, and misunderstanding knowledge.

Conclusions

Nurse-midwives' unacquired knowledge of milk expression care for preterm mothers was effectively supplemented by the education program. Pre-education knowledge items with low correct answer rates must be strengthened during in-service education. Practical training, knowledge retention, and misunderstanding knowledge can be improved.

Breastfeeding rates at discharge for very low birthweight neonates and their determinants: An observational study from a tertiary care neonatal intensive care unit in India

BACKGROUND

Mother's milk is the best milk for neonates. Preterm very low birthweight (VLBW) neonates face many challenges leading to low rates of breastfeeding at discharge.

AIMS

(i) To determine the proportion of <32 weeks preterm VLBW neonates who are exclusively breastfed (EB) at discharge and (ii) determinants of exclusive breastfeeding (EBF) at discharge.

METHODS

An observational study was conducted for a duration of 1 year, from May 2019 to April 2020 in a tertiary care neonatal intensive care unit (NICU) in North India. Consecutive <32 weeks preterm VLBW neonates admitted within 72 h of birth and on full enteral feeds (FEF) within 10 days of birth were included in this study and followed up till discharge.

RESULTS

Forty-four of 97 (45.4%) preterm VLBW neonates were exclusively breastfed and 31/97 (32%) received more than 80% mother's own milk (MOM) at discharge. Male sex (P = 0.03), those whose first feed had any amount of MOM (P = 0.038) or exclusive MOM in their first feed or when initiated on first FEF (P = 0.002), and neonates with longer duration of hospital stay (P = 0.035) had an increased chance of being exclusively breastfed at discharge.

CONCLUSION

Preterm VLBW neonates who receive any amount of MOM in their first feed or first FEF, male infants and those who stay longer in hospital are more likely to be exclusively breastfed at discharge.

Increasing early exposure to mother's own milk in premature newborns

OBJECTIVE

Increase the proportion of ≤33 weeks newborns exposed to mother's own milk (MOM) oral care by 12 h of age by 20% over 2 years to support a healthier microbiome.

STUDY DESIGN

We implemented interventions to support early expression of colostrum and reliable delivery of resultant MOM to premature newborns. Statistical process control charts were used to track progress and provide feedback to staff. Proportions of newborns exposed to MOM by 12 h were compared relative to baseline.

RESULTS

There were 46, 66, and 46 newborns in the baseline, implementation, and sustainability periods, respectively. The primary outcome improved from 48% to 61% in the implementation period (relative change 1.27, 95% CI 0.89, 1.81, p = 0.2), to 69% in sustainability period (relative to baseline 1.45, 95% CI 1.02, 2.08, p = 0.03).

CONCLUSION

An interdisciplinary team-based, multicycle, quality improvement intervention resulted in increased rates of early exposure to MOM.

The Effect of Circular and Oscillating Breast Massage on the Amount of Breast Milk Produced: An Innovative Method

Background: In addition to suffering stress and anxiety owing to being separated from their babies, mothers whose babies are hospitalized in neonatal intensive care units suffer breastfeeding problems. Moreover, their breast milk production may decrease over time. Objective: Examining the effect of circular and oscillating breast massage on the amount of breast milk produced. Materials and Methods: This randomized controlled experimental study used a pretest-posttest model. The participants included 120 mothers (experimental group: 60, control group: 60) who went to a breast milk pumping unit of a hospital between December 1, 2017, and July 31, 2019. A circular and oscillating breast massage device was used to massage both breasts for 10 to 15 minutes, three times a day, for 3 days, and milk production was measured daily. The sociodemographic characteristics, perceptions regarding breast massage, and daily breast milk amounts of the mothers were collected. Results: The average age of the mothers that participated in the study was 30.21 ± 5.58 years; the average birth week of their babies was 32.31 ± 4.10 weeks. There were no significant differences in the mothers' amounts of milk production before the procedure in the experimental and control groups. In the study group, milk production increased by 7.92%, 5.25%, and 5.02% on days 1, 2, and 3 of the procedure, respectively. The mothers' total amount of milk production before and after the procedure (3 days) increased by 22.28%. Significant differences were found between the study groups on days 1, 2, and 3 and the total amount of milk produced after the procedure. Conclusion: Our study found circular and oscillating breast massage increased the amount of breast milk produced and decreased breast pain and swelling. Similar studies on the clinical use of this treatment should be conducted in line with the results of this study.

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.

Evaluation of a new lactation device 'Lactamo' designed to apply massage, heat or cold, and compression to the breast

BACKGROUND

Common approaches to manage breastfeeding problems such as pain, blocked ducts, and milk production issues include breast compression, breast massage, application of warmth or cold, medications, and breastmilk expression. Several devices are available to apply heat or cold to the breast, however, none promote breast compression and/or massage simultaneously. A new device 'Lactamo' has been developed to address this.

METHODS

This study was a pre-market evaluation of the Lactamo device. The aims were to determine user safety, and satisfaction of Lactamo. The study was conducted in an Australian tertiary maternity hospital in 2019-2020. Women who were less than 3 months post-partum and were currently breastfeeding participated in the study. We conducted structured telephone surveys at 1 and 4 weeks post supply of Lactamo. Questions included demographic information, feedback on safety, usage, and perceived benefits of Lactamo.

RESULTS

The cohort (n = 30) consisted of equal number of primiparous and multiparous women, 50% were born in Australia and the remainder from 11 other countries. A total of 41 telephone surveys were conducted with 27 women. Of these, 26 (96%) had used Lactamo, and the one that did not, felt she did not have a lactation concern to warrant using it. All women indicated that the device was safe to use and had no concerns, apart from one woman who experienced itching because of the device but continued to use it over clothing as she found it beneficial. Most women used it at room temperature or warmed. The frequency of use varied from once per week (17%) to daily (33%), and use was often prompted by a lactation concern such as engorgement, pain, blocked ducts, and low supply.

CONCLUSION

Lactamo was found to be safe, and a valuable aid for breastfeeding women. More research is needed to understand the efficacy of the device in treating breastfeeding problems such as pain, blocked ducts, and milk production issues.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

The challenges of medically complex breastfed children and their families: A systematic review

Exclusive breastfeeding for the first 6 months and then alongside solid food for the first 2 years and beyond is the gold standard in young child nutrition. There is an abundance of literature relating to the preventative nature of breastmilk and breastfeeding against many infectious diseases and chronic conditions. However, despite medically complex infants and children being a group that could benefit most from continued breastfeeding, breastfeeding duration and exclusivity are lower among more complex paediatric populations. The reasons for this are not well known, and there is a paucity of data relating to supporting infants who have acute or chronic illness, disability or congenital anomaly to breastfeed. This systematic review aimed to understand the challenges of breast/chestfeeding the medically complex child and to establish the gaps in healthcare provision that act as barriers to optimal infant and young child feeding. The search was limited to studies published in English, focused on breastfed sick infants in hospital, with no date limits as there is no previous systematic review. Of 786 papers retrieved, 11 studies were included for review, and seven themes identified. Themes included practical and psychological challenges of continuing to breastfeed in a hospital setting, complications of the condition making breastfeeding difficult, lack of specialist breastfeeding support from hospital staff and a lack of availability of specialist equipment to support complex breastfeeding. The findings affirm the lack of consistent high-quality care for lactation support in paediatric settings and reinforce the need for further focused research in this area.

Use and experiences of galactagogues while breastfeeding among Australian women

Background

Galactagogues are substances thought to increase breast milk production, however evidence to support their efficacy and safety remain limited. We undertook a survey among Australian women to examine patterns of use of galactagogues and perceptions regarding their safety and effectiveness.

Methods

An online, cross-sectional survey was distributed between September and December 2019 via national breastfeeding and preterm birth support organisations, and networks of several research institutions in Australia. Women were eligible to participate if they lived in Australia and were currently/previously breastfeeding. The survey included questions about galactagogue use (including duration and timing), side effects and perceived effectiveness (on a scale of 1 [Not at all effective] to 5 [Extremely effective]).

Results

Among 1876 respondents, 1120 (60%) reported using one or more galactagogues. Women were 31.5 ± 4.8 years (mean ± standard deviation) at their most recent birth. Sixty-five percent of women were currently breastfeeding at the time of the survey. The most commonly reported galactagogues included lactation cookies (47%), brewer’s yeast (32%), fenugreek (22%) and domperidone (19%). The mean duration of use for each galactagogue ranged from 2 to 20 weeks. Approximately 1 in 6 women reported commencing galactagogues within the first week postpartum. Most women reported receiving recommendations to use herbal/dietary galactagogues from the internet (38%) or friends (25%), whereas pharmaceutical galactagogues were most commonly prescribed by General Practitioners (72%). The perceived effectiveness varied greatly across galactagogues. Perceived effectiveness was highest for domperidone (mean rating of 3.3 compared with 2.0 to 3.0 among other galactagogues). Over 23% of domperidone users reported experiencing multiple side effects, compared to an average of 3% of women taking herbal galactagogues.

Conclusions

This survey demonstrates that galactagogues use is common in Australia. Further research is needed to generate robust evidence about galactagogues’ efficacy and safety to support evidence-based strategies and improve breastfeeding outcomes.

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.

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.

The Acceptability, Feasibility, and Effectiveness of Breast Massage Combined with Acupoint Stimulation to Promote the Volume of Human Milk in Mothers with Preterm Infants: A Pilot Study

Background. Preterm infant mothers have always encountered difficulties in human milk production. For this reason, an intervention of breast massage combined with acupoint stimulation was designed to increase the production. Purpose. Through a pilot randomized trial, we assessed the acceptability, feasibility, and effectiveness of breast massage combined with acupoint stimulation and the study procedures. Methods. 40 participants of preterm infants born at less than 34 weeks of gestation were randomly allocated to the CG (control group) or the EG (group with breast massage combined with acupoint stimulation). Data related to the acceptability, feasibility, and effectiveness of the intervention and research procedures were collected and analysed. Results. The daily volume progressively increased each day in the first 7 days in both groups and a significant difference was observed between the groups ( $P$  < 0.001). The initiation time of lactogenesis stage II was 50.06 ± 6.78 (40.00–64.00) hours in the EG and 66.18 ± 14.64 (48.00–96.00) hours in the CG, where a significant difference was detected ( $P$  < 0.05). The mean score of satisfaction with the intervention in the EG was 4.56 ± 0.32 (4.0–5.0), while the retention rates were 82.5% and 85.5% (17/20) in the CG, and 80% (16/20) in the EG. Conclusion. This pilot study was oriented towards the effectiveness of breast massage combined with acupuncture stimulation for the increase of human milk production in the participants. The intervention was accepted well and the study process was reasonable. A large-scale RCT will be able to determine the beneficial effects of this intervention on human milk production.

Racial and socioeconomic disparities in breast milk feedings in US neonatal intensive care units

Very low birth weight (VLBW; <1500 g birth weight) infants are substantially more likely to be born to black than to non-black mothers, predisposing them to potentially preventable morbidities that increase the risk for costly lifelong health problems. Mothers' own milk (MOM) may be considered the ultimate "personalized medicine" since milk composition and bioactive components vary among mothers and multiple milk constituents provide specific protection based on shared exposures between mother and infant. MOM feedings reduce the risks and associated costs of prematurity-associated morbidities, with the greatest reduction afforded by MOM through to NICU discharge. Although black and non-black mothers have similar lactation goals and initiation rates, black VLBW infants are half as likely to receive MOM at NICU discharge in the United States. Black mothers are significantly more likely to be low-income, single heads of household and have more children in the home, increasing the burden of MOM provision. Although rarely considered, the out-of-pocket and opportunity costs associated with providing MOM for VLBW infants are especially onerous for black mothers. When MOM is not available, the NICU assumes the costs of inferior substitutes for MOM, contributing further to disparate outcomes. Novel strategies to mitigate these disparities are urgently needed. IMPACT: Mother's own milk exemplifies personalized medicine through its unique biologic activity. Hospital factors and social determinants of health are associated with mother's own milk feedings for very low-birth-weight infants in the neonatal intensive care unit. Notably, out-of-pocket and opportunity costs associated with providing mother's own milk are borne by mothers. Conceptualizing mother's own milk feedings as an integral part of NICU care requires consideration of who bears the costs of MOM provision-the mother or the NICU?

Influence of NICU Nurse Education on Intention to Support Lactation Using Tailored Techniques: A Pilot Study

BACKGROUND

Preterm infants' outcomes improve when fed their mothers' milk. Low percentages of neonatal intensive care unit (NICU) nurses support mothers facing barriers to establishing and sustaining adequate milk supplies. Nurses' motivations and attitudes are instrumental, but understudied, factors in their intention to promote maternal lactation.

PURPOSE

Using the Theory of Reasoned Action, this study explored (1) NICU nurses' attitudes, social pressures, feelings of preparedness, perceptions of comfort, and intention to support lactation; and (2) magnitude of relationships among these concepts before and after undertaking an educational module.

METHODS

A descriptive pre-/postintervention design included a sample of 24 NICU nurses who completed a module, including general lactation and hands-on expressing information. The Nursing Support for Breastfeeding Questionnaire was administered before and after completing the module.

RESULTS

Attitudes, social norms, perception of preparedness, and intention were moderate to high before and after completion of the module. Perception of comfort was moderate. When comparing pre- and postintervention, effect sizes for intention and perception of comfort were moderate. Magnitude of the relationship between attitudes and intention was strong before intervention and moderate after intervention. Subjective norms demonstrated stronger relationships with attitudes and intention after intervention. Preparedness and comfort had stronger relationships with attitudes than with intention both before and after intervention.

IMPLICATIONS FOR PRACTICE

Nurses' attitudes, perception of preparedness, and comfort are modifiable considerations in developing strategies to support evidence-based lactation techniques.

IMPLICATIONS FOR RESEARCH

Additional studies are needed with fully powered and stronger designs to validate findings to guide interventions for nurse support for NICU mothers to optimize lactation.

Enabling Breastfeeding to Support Lifelong Health for Mother and Child

The health benefits of breastfeeding are well documented, and more than 80% of US women initiate breastfeeding; however, mothers in the United States face substantial challenges in meeting their personal breastfeeding goals, with approximately 60% weaning earlier than they had intended. In addition, there are significant racial/ethnic inequities in infant-feeding behaviors, and these inequities are a major public health concern. Enabling women to meet their breastfeeding goals is a public health priority. Infant feeding should be addressed as a modifiable health behavior, rather than a lifestyle choice.

Breastfeeding the Critically Unwell Child: A Call to Action

Introduction

Breastfeeding rates among children who have a serious illness or congenital condition are lower than the general population. There are many barriers to maintaining lactation during a child's illness, and specific training issues among staff working in pediatric departments.

Method

This is a narrative review of some of the most common challenges highlighted during a literature search prior to a research study that is being undertaken to explore this phenomenon in greater detail.

Results

There are many identified challenges for families of sick children. Lactation may be threatened or discontinued if the barriers are not adequately addressed. Lactation professionals working in any setting may work with families who are coping with difficulties that require more support.

Conclusion

Breastfeeding sick children, and those with complex medical conditions, requires adaptations and more specialized skills. Many families feel unsupported by their medical teams. Recommendations are made for collaborative working between pediatric medicine and surgery, nursing, oncology, radiology, dietetics, anesthetics, pain management, play therapy, child psychology, palliative care, social support, and lactation support.

Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks' gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Nipple Deformation and Peripheral Pressure on the Areola During Breastfeeding

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

A Case Study of Biological Nurturing

INTRODUCTION

This case of a mother and her two children, born 20 years apart, highlights how Biological Nurturing (BN) supported a woman in meeting her personal breastfeeding goals. We know lack of breastfeeding support contributes to early weaning. Applying the principles of BN (unrestricted and laid-back breastfeeding) enabled this mother to return to breastfeeding without supplements.

MAIN ISSUE

After giving birth to her first son prematurely in 1997, the dyad was separated, and formula introduced. These interventions, combined with inadequate breastfeeding support, resulted in low milk supply and unplanned weaning by week six. In 2017, a full term sibling baby girl was born, with breastfeeding again beginning with concerns of low milk supply.

MANAGEMENT

Consultation with an International Board Certified Lactation Consultant successfully addressed common breastfeeding problems, including vasospasm and insufficient milk supply. Continuous emotional support helped this mother overcome perceived insufficient milk supply. Introducing BN led to breastfeeding without supplementation, by enabling the dyad to experience enjoyment, comfort and feeding autonomy.

CONCLUSION

While the repeated experience of insufficient milk supply two decades apart constituted a psychological barrier to exclusive breastfeeding, BN enabled reaching this mother's breastfeeding goals. BN appears to be a powerful tool for both breastfeeding initiation and overcoming breastfeeding difficulties, potentially setting new best practice standards.

Feasibility and Acceptability of Metformin to Augment Low Milk Supply: A Pilot Randomized Controlled Trial

BACKGROUND

Metformin improves insulin action, but feasibility in treating low milk supply is unknown.

RESEARCH AIM

To determine the feasibility of a metformin- versus-placebo definitive randomized clinical trial in women with low milk production and signs of insulin resistance.

METHODS

Pilot trial criteria included: Mother 1-8 weeks postpartum (ideally 1-2 weeks), low milk production, and ≥1 insulin resistance sign; and singleton, healthy, term infant. Eligible mothers were randomly assigned 2:1 (metformin:placebo) and instructed in frequent milk removal for 28 days with option to stop at 14 days.

RESULTS

From 02/2015 through 06/2016, we screened 114 women, completed baseline assessments on 46, and trialed 15 (median, 36 days postpartum). Comparing metformin-assigned ( n = 10) to placebo ( n = 5), 70% versus 80% continued to day 28; peak median change in milk output was +8 versus -58 mL/24 hr ( p = .31) and 80% peaked at Day 14 for both groups; 0% versus 20% desired to continue assigned drug after study completion; 44% versus 0% reported nausea/vomiting. Post-hoc, median peak change in milk output was +22 (metformin completers, n = 8) versus -58 mL/24 hr (placebo + non-completers, n = 7, p = .07). At baseline assessment, median milk production was significantly lower in those with ( n = 31), versus those without ( n = 15) signs of insulin resistance ( p = .002).

CONCLUSIONS

Although results trend toward hypothesized direction, trial feasibility concerns include late enrollment and only 20% of metformin-assigned participants sustaining improved milk output to Day 28, with none perceiving metformin worthwhile. Better tools are needed to identify and treat metabolically-driven low milk production. Registered at ClinicalTrials.gov (NCT02179788) on 02/JUL/2014.

Improving Access to Lactation Consultation and Early Breast Milk Use in an Outborn NICU

Introduction

Increasing the use of breast milk in critically ill neonates is an important priority to improve neonatal care. Lactation consultants (LCs) educate mothers about evidence-based benefits of breast milk and provide technical support. LC support can lead to increased breastfeeding initiation. The project aim was to improve access to lactation services for mothers of patients admitted at <48 hours after birth to an exclusively outborn level III/IV neonatal intensive care unit (NICU).

Methods

The interventions included (1) implementation of an automatic electronic admission order for a lactation consult, (2) initiation of a daily lactation team notification, (3) assignment of a consistent NICU LC, and (4) targeted education. The percent of mothers who received lactation consults, the time to the first consultation, and the percent of patients receiving breast milk at 7 days of age were measured over 32 months and analyzed using statistical process control charts.

Results

The lactation consultation rate increased significantly from 74% to 88% with a shift in the mean by statistical process control chart analysis that was sustained over time. Concurrently, the time to first lactation consultation significantly decreased from hospital days 5 to 3.3, and variation decreased. Rates of breast milk use at 7 days of age also significantly increased from 75.6% to 89.6%.

Conclusions

Targeted quality improvement interventions led to an increased rate of lactation consultations, decreased time to first lactation consult, and increased rate of breast milk use at 7 days of age. These interventions could feasibly be implemented in similar referral NICU settings.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Facilitating Colostrum Collection by Hospitalized Women in the Early Postpartum Period for Infant Trophic Feeding and Oral Immune Therapy

Administration of colostrum for early trophic feedings and colostrum oral immune therapy for neonates in the NICU is essential to enhance gut maturation and lower risk of infections. However, it is often difficult for women to collect early colostrum because of its thick viscosity and low volume. Women may be unable to sit upright during pumping sessions because of postsurgical pain, acute or chronic illness, or birth complications and may need assistance. In this article, we describe specific techniques that providers can use to help women to collect colostrum when they are unable to accomplish collection on their own. Helping women collect and administer colostrum to their neonates in the NICU may engage and motivate them to continue to pump and provide breast milk for their hospitalized neonates.

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.

ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018

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

Educational videos for practitioners attending Baby Friendly Hospital Initiative workshops supporting breastfeeding positioning, attachment and hand expression skills: Effects on knowledge and confidence

UNICEF Baby Friendly Initiative (BFHI) is the global standard for maternity and community services requiring all practitioners to be trained to support mothers in the essential skills of supporting positioning and attachment, and hand expression. These studies aim to rigorously assess knowledge in nurses, midwives, and doctors in these skills, tested before and after watching short videos demonstrating these skills. Practitioners were attending BFHI education, and the video study was additional. In Phase 1 clinicians in England were randomised to one of two videos (practitioner role play or clinical demonstration). The results showed improvements in knowledge and confidence, and a preference for clinical demonstration by mothers and infants. The clinical demonstration video was evaluated in China in Phase 2 where expert trainers viewed the video after completing the BHFI workshop, and in Phase 3 practitioners viewed the video before the BHFI workshop. Phase 2 with expert trainers only showed improvement in knowledge of hand expression but not positioning and attachment. In Phase 3 clinicians showed improved knowledge for both skills. In all Phases there were statistically significant improvements in confidence in practice in both skills. Viewing short videos increased knowledge, particularly about teaching hand expression, and confidence in both skills.

A randomised controlled trial of the effectiveness of a breastfeeding training DVD on improving breastfeeding knowledge and confidence among healthcare professionals in China

BACKGROUND

Despite almost all babies being breastfed initially, the exclusive breastfeeding rate at six months is less than 30% in China. Improving professionals' knowledge and practical skill is a key government strategy to increase breastfeeding rates. This study aimed to test the effectiveness of a breastfeeding DVD training method for clinicians on improving their knowledge and confidence in the breastfeeding support skills of teaching mothers Positioning and Attachment (P & A) and Hand Expression (HE).

METHODS

A randomised controlled trial was conducted in three hospitals in Zhejiang province, China in 2014. Participants were recruited before their routine breastfeeding training course and randomly allocated to intervention group (IG) and control group (CG). The 15 min "Breastfeeding: Essential Support Skills DVD" was the intervention for IG and a vaginal delivery DVD was used for CG. All participants completed questionnaires of job information, knowledge and confidence in the two skills before (baseline) and immediately after viewing the DVD (post DVD).

RESULTS

Out of 210 participants, 191 completed knowledge assessments before and after watching the DVD (IG n = 96, CG n = 95), with the response rate of 91.0%. At baseline, there are no significant differences in job variables, total knowledge scores and confident scores. The total knowledge score significantly increased post-DVD for IG (pre-DVD: M = 5.39, SD = 2.03; post-DVD: M = 7.74, SD = 1.71; t (95) = - 10.95, p < 0.01), but no significant change in total knowledge score for CG between pre- and post-DVD (pre-DVD: M = 5.67, SD = 1.70; post-DVD: M = 5.56, SD = 1.63; t (94) = 0.85). The total confidence scores were significantly higher post-DVD than pre-DVD in IG (pre-DVD: M = 66.49, SD = 11.27; post- DVD: M = 71.81, SD = 9.33; t (68) = - 4.92, p < 0.01), but no significant difference was seen in CG between pre- and post-DVD total confidence scores (pre-DVD: M = 68.33, SD = 11.08; post-DVD: M = 68.35, SD = 11.40; t (65) = - 0.25). Personal and job variables did not mediate these effects.

CONCLUSIONS

The breastfeeding training DVD improved professionals' knowledge and confidence of the two breastfeeding support skills. However, the effect on professionals' practice and on breastfeeding outcomes needs to be examined in the future.

Sustained Breastfeeding and Related Factors for Late Preterm and Early Term Infants

The purpose of this pilot study was to determine the prevalence of sustained breastfeeding in late preterm and early term breastfeeding infants at 1 and 2 months of age and to identify the factors that were related to sustained breastfeeding. Subjects were identified through purposive sampling and completed the Breastfeeding Self-Efficacy Scale and data were collected on lactation support, hospital course details, and demographic factors. At 1 and 2 months of age, structured telephone interviews determined the current feeding status and postdischarge lactation support. Of 126 mothers, 82% sustained breastfeeding at 1 month and 71.2% at 2 months. Factors associated with sustained breastfeeding at 2 months included a college education (P = .014), higher day 1 breastfeeding scores (P = .007), higher Breastfeeding Self-Efficacy scores (P = .046), and continued maternal skin-to-skin contact (P = .007). High after day 1 breastfeeding scores were associated with sustained breastfeeding at 1 month (P = .000) and 2 months (P = .001). Unsustained breastfeeding at 1 and 2 months was associated with the occurrence of supplemental feedings (P = .001) and pumping at discharge (1 month, P = .002; 2 months, P = .015). Identifying the factors associated with the high-sustained breastfeeding rate in this population helps nurses focus on how to best support their breastfeeding experience.

Effect of pumping pressure on onset of lactation after caesarean section: A randomized controlled study

Caesarean section is associated with weaker newborn suction pressure. This nonblinded, randomized trial explored the effect of suction pressures generating by a breast pump on mothers' onset of lactation and milk supply after caesarean section. A high pressure group (-150 mmHg), a low pressure group (-100 mmHg), and a control group (none) were generated under computer random assignment with concealed allocation in 2 tertiary hospitals. The breast pumping began within 2 hr after caesarean operation (6 times a day and 30 min per time) until onset of lactation. The primary outcomes were the timing of onset of lactation, milk supply, and mother's satisfaction in lactation, using both intention-to-treat and per-protocol analyses. The secondary endpoints were the pumping-related pain, nipple injury, and maternal fatigue. All 164 women randomized were included in analysis. The breast pumping at -150 mmHg optimally advanced the timing of the onset of lactation and increased daytime milk supply. The pumping also appeared to boost mothers' confidence in lactation. The results in the per-protocol population (n = 148) were consistent with those of intention-to-treat population (n = 164). However, the pumping aggravated maternal nipple pain and fatigue, though there was no statistical significance. The findings suggest that a higher pumping pressure within the range of normal vaginally born infant suction could promote onset of lactation and milk supply among mothers giving birth by caesarean section. The pumping could also enhance mothers' confidence in breastfeeding.