Human milk reduces outpatient upper respiratory symptoms in premature infants during their first year of life

Dose-dependent impact of human milk feeding on tidal breathing flow-volume loop parameters across the first 2 years of life in extremely low-birth-weight infants: a cohort study

The purpose of this study is to test the hypothesis that higher consumption of human milk (HM) in preterm infants with birth weight (BW) <1000 g is associated with improved lung function in a dose-dependent manner over the first 2 years of corrected age (CA). This retrospective study at an academic medical center included infants with BW <1000g. They had lung function assessment by the tidal breathing flow-volume loop (TBFVL) follow-up visits at 0-3-, 3-6-, 6-12-, 12-18-, and 18-24-month CA. One hundred eighty infants were included in the study with a mean (SD) gestational age 26.5 (1.90) weeks and BW 772.4 (147.0) g, 50% were female, and 60% developed BPD. 62.8% of infants received HM during the NICU stay. According to a general linear model (including GA, being small for GA (SGA), sex, human milk percentage, sepsis, and BPD), on average, each week of GA resulted in a higher tPTEF/tE of 1.24 (p = 0.039) and being SGA in a lower tPTEF/tE of 5.75 (p = 0.013) at 0-3-month CA. A higher percentage of human milk out of the total enteral intake was associated with better tPTEF/tE z-scores at 0-3 months (p = 0.004) and 18-24 months of CA (p = 0.041). BPD diagnosis was associated with a relevantly worse tPTEF/tE z-score at 6-12 months of CA (p = 0.003).

CONCLUSION

Preterm infants with higher consumption of HM had significantly less airway obstruction across the first 2 years, suggesting that human milk may contribute in a dose-dependent manner to improve lung function in early childhood in former preterm infants born ELBW.

WHAT IS KNOWN

• Human milk feeding reduces the risk of prematurity-related morbidities, including necrotizing enterocolitis, sepsis, lower respiratory tract infections, and BPD. Both exclusive and partial human milk feeding appear to be associated with a lower risk of BPD in preterm infants.

WHAT IS NEW

• This cohort study of 180 preterm infants with birth weight < 1000 g found that exposure to human milk during hospitalization improves airway obstruction markers tPTEF/tE z-score over the first 2 years of corrected age in a dose-dependent manner.

Early-Life Nutrition in Preterm Infants and Risk of Respiratory Infections and Wheezing: A Scoping Review

INTRODUCTION

Preterm birth is a common early-life event that can lead to long-term consequences. The incidence of wheezing, asthma, and respiratory tract infections is higher in children born prematurely than in the general population. The purpose of this review was to synthesize the existing literature on the role of early-life nutrition in the later risk of respiratory morbidities.

METHODS

A scoping review of the literature was performed by searching three online databases. Inclusion criteria were: infants born <37 GWk, comparing human milk versus any other type of milk feeding formulation. Our primary outcomes were wheezing or asthma or respiratory tract infections after discharge. Two authors independently screened the results and extracted study characteristics using a predefined charting form.

RESULTS

Nine articles were included (eight cohort studies and one randomized trial). Four studies supported the protective effect of breastfeeding on wheezing or respiratory infections or both. Four studies did not confirm this association. One study confirmed the protective role of breastfeeding only on the subgroup of girls. There was a high heterogeneity among the included studies, in the type of milk feeding, outcomes, and age at follow-up.

CONCLUSIONS

The current evidence is conflicting. The high heterogeneity and methodological flaws could have influenced the results of the studies. Carefully designed studies are required to define the role of early-life nutrition among preterm infants on their long-term respiratory outcomes.

Evidence-based Discharge Nutrition to Optimize Preterm Infant Outcomes

Despite abundant research comparing postdischarge hospital diets for preterm infants, the ideal clinical approach has not been determined. Dilemmas persist because randomized controlled trials of preterm versus term infant formula have yielded equivocal results and because the predominant postdischarge diet for preterm infants has shifted from formula-based to a combination that includes maternal milk and increasingly includes a plan for breastfeeding. As the investigation of the influence of the post-hospital discharge diet on preterm infant outcomes evolves, factors to consider include the infant's oral feeding ability and the maternal lactation goal. The maturation of the preterm infant's oral feeding skills may at least partially explain why increased nutrient density appears to most benefit growth outcomes when given during the first 3 to 4 months after hospital discharge. At some point in maturation, the preterm infant may develop the ability to vary intake as needed to obtain sufficient nutrition no matter the density of the diet. In addition, attention to the maternal lactation goal is critical as intake of maternal milk likely influences neurodevelopmental outcomes as much or even to a greater extent than growth trajectory.

Antibiofilm Activity of Human Milk Oligosaccharides against Multidrug Resistant and Susceptible Isolates of Acinetobacter baumannii

Acinetobacter baumannii is a serious threat to human health, per the Centers for Disease Control and Prevention's latest threat assessment. A. baumannii is a Gram-negative opportunistic bacterial pathogen that causes severe community and nosocomial infections in immunocompromised patients. Treatment of these infections is confounded by the emergence of multi- and pan-drug resistant strains of A. baumannii. A. baumannii colonizes abiotic and biotic surfaces and evades antimicrobial challenges by forming biofilms, which are three-dimensional architectural structures of cells adhered to a substrate and encased in an extracellular matrix comprised of polymeric substances such as polysaccharides, proteins, and DNA. Biofilm-inhibiting compounds have recently gained attention as a chemotherapeutic strategy to prevent or disperse A. baumannii biofilms and restore the utility of traditional antimicrobial strategies. Recent work indicates that human milk oligosaccharides (HMOs) have potent antibacterial and biofilm-inhibiting properties. We sought to test the utility of HMOs against a bank of clinical isolates of A. baumannii to ascertain changes in bacterial growth or biofilm formation. Our results indicate that out of 18 strains tested, 14 were susceptible to the antibiofilm activities of HMOs, and that the potent antibiofilm activity was observed in strains isolated from diverse anatomical sites, disease manifestations, and across antibiotic-resistant and susceptible strains.

A Review of Quantitative Instruments for Understanding Breastfeeding Dynamics

Breastfeeding, as a unique behavior of the postpartum period and an ideal source of nourishment, is profoundly impacted by the physiology and behavior of both mothers and infants. For more than three-quarters of a century, there has been an ongoing advancement of instruments that permit insight into the complex process of latching during breastfeeding, which includes coordinating sucking, swallowing, and breathing. Despite the available methodologies for understanding latching dynamics, there continues to be a large void in the understanding of infant latching and feeding. The causes for many breastfeeding difficulties remain unclear, and until a clearer understanding of the mechanics involved is achieved, the struggle will continue in the attempts to aid infants and mothers who struggle to breastfeed. In this review, the history of development for the most prominent tools employed to analyze breastfeeding dynamics is presented. Additionally, the importance of the most advanced instruments and systems used to understand latching dynamics is highlighted and how medical practitioners utilize them is reported. Finally, a controversial argument amongst pediatric otolaryngolo gists concerning breastfeeding difficulties is reviewed and the urgent need for quantification of latching dynamics in conjunction with milk removal rate through prospective controlled studies is discussed.

2'-fucosyllactose inhibits imiquimod-induced psoriasis in mice by regulating Th17 cell response via the STAT3 signaling pathway

Psoriasis is a chronic immune-mediated inflammatory cutaneous disorder with Th17 cells and Th17-related cytokines playing an important role in its development. 2'-FL (2'-fucosyllactose), which makes up about 30% of all HMOs (human milk oligosaccharides) in blood type secretor positive maternal milk, plays an essential role in supporting aspects of immune development and regulation. To explore the immunomodulatory effect of 2'-FL in psoriasis, we employed the imiquimod (IMQ)-induced psoriasis-like mouse model. Our data showed that mice administered with 2'-FL exhibited attenuated skin damage and inflammation, characterized by significantly decreased erythema and thickness and reduced recruitment of pro-inflammatory cytokines, when compared to control mice. The alleviated skin inflammation in 2'-FL treated mice was associated with a reduced proportion of Th17 cells and decreased production of Th17-related cytokines. Furthermore, we have demonstrated that 2'-FL reduced the phosphorylation of STAT3 in the skin tissue from mice with IMQ stimulation, which could account for the decreasing recruitment of Th17 cells. In vitro studies showed that 2'-FL inhibited differentiation of Th17 cells, phosphorylation of STAT3, and RORγt mRNA levels in T cells under Th17 polarization. Our results indicate that 2'-FL ameliorates IMQ-induced psoriasis by inhibiting Th17 cell immune response and Th17-related cytokine secretion via modulation of the STAT3 signaling pathway.

Importance of Familial Opinions on Breastfeeding Practices: Differences Between Father, Mother, and Mother-in-Law

Background: Multiple types of individuals compose a mother's social support network. Women may value opinions of individuals' within their support network differently. Our study examined the relationship between breastfeeding opinions from individuals within the social support network and breastfeeding initiation and duration. Materials and Methods: Data from the Infant Feeding Practices Survey II were analyzed. The importance of individuals' opinions on a mother's breastfeeding decision was investigated for the baby's father, the participant's mother and mother-in-law, the infant's pediatrician, and the participant's obstetrician. The main outcomes were breastfeeding initiation (yes; no) and breastfeeding duration (weeks). Logistic regression provided the odds of never breastfeeding, while Cox proportional hazard models were used to assess the risk of breastfeeding cessation. Results: Women who stated that the father's opinion was not at all important were more likely to never breastfeed and prematurely cease breastfeeding compared to women who stated that the father's opinion was very important for their breastfeeding decisions. Conversely, women had lower odds of never breastfeeding and a decreased risk of breastfeeding cessation if they reported that the mother-in-law's opinion was not at all important or not very important compared to women who reported that the mother-in-law was very important. No statistically significant relationship was found between the participant's mother and breastfeeding initiation and cessation. Conclusion: This study found a hierarchical association between individuals in a social support network and breastfeeding initiation and duration. Inverse relationships were found between the importance of fathers' and mother-in-laws' opinions. Interventions aimed at increasing breastfeeding initiation, and duration rates should include a wider range of individuals within a social support network.

[The value of human milk for preterm infants-overview and practical aspects]

Over the last decades the immense benefit of human milk on the nutrition of preterm infants has become increasingly evident. Research has confirmed that human milk has significant advantages for the preterm infant in terms of host defense, gastrointestinal development and maturation, neurological development, reduction of necrotizing enterocolitis, retinopathy of prematurity and chronic lung disease as well as mental and physical benefits for the mother. Computing these factors into a health-cost-benefit equation, positive economic consequences for a national public health system were demonstrated.Therefore, international feeding guidelines recommend human milk to be the first choice for preterm infants, the primary source being the infant's mother. The first alternative is milk from an established donor milk bank. To meet the unique nutritional demands of preterm infants and to avoid postnatal growth restriction, human milk must be fortified with additional micro- and macronutrients. Concerns about microbial colonization and contamination and hygienic aspects concerning milk handling need to be addressed when feeding human milk to preterm infants.Early initiation and maintenance of lactation is challenging for mothers of preterm infants and their caregivers. Providing lactation support from educated staff, optimal nursing environments, and the positive attitude of an experienced NICU (neonatal intensive care unit) team will contribute to successful lactation and breastfeeding even beyond discharge of the infant.

Non-Nutritional Use of Human Milk Part 1: A Survey of the Use of Breast Milk as a Therapy for Mucosal Infections of Various Types in Poland

The use of home remedies for the treatment of moderately severe ailments is a common practice in the Polish population. Currently, the topic of the potential non-nutritional properties of human milk is attracting the attention of breastfeeding mothers. This study was aimed at understanding lactating women’s knowledge, attitudes, and practices of non-nutritional breast milk on mucous membranes. The study was conducted among lactating women, who filled out a questionnaire consisting of questions about their knowledge and experiences with non-nutritional use of human milk. Statistical calculations were conducted with chi-square test and c-Pearson coefficient. A total of 1187 women were acted on, whereby 768 of respondents claimed to have knowledge of the non-nutritional use of human milk on mucous membranes, whilst 404 of them claimed that they had used at least one method. Among the most frequently used methods were the treatment of rhinorrhea, lacrimal canaliculi obstruction, and conjunctivitis. A correlation between length of breastfeeding (p < 0.001) and knowledge of non-nutritional human milk usage in prophylaxis and treatment of mucous membrane inflammation was found. Breastfeeding duration (p < 0.001) and parity (p < 0.005) were correlated with the application of those methods in practice. Due to a high propensity to testing those methods, parents’ education in the field of possible risks and importance of medical consultations is necessary.

Discordance in Couples Pregnancy Intentions and Breastfeeding Duration: Results from the National Survey of Family Growth 2011-2013

Background

Parental disagreement in pregnancy intention elevates the risk of adverse health events for mother and child. However, research surrounding parental pregnancy intention discrepancies and breastfeeding duration is limited. This study aims to examine the relationship between couple's discordant pregnancy intention and breastfeeding duration.

Methods

Data from the 2011–2013 National Survey of Family Growth was analyzed. Parental pregnancy intention was categorized as “intended by both parents,” “unintended by both parents,” “father intended and mother unintended,” and “father unintended and mother intended.” Breastfeeding duration was categorized as “never breastfed,” “breastfed less than six months,” and “breastfed at least six months.” Multinomial logistic regression, odds ratios, and 95% confidence intervals were calculated.

Results

Couples with a concordant unintended pregnancy were more likely to have a child who was never breastfed or breastfed less than six months compared to couples with a concordant intended pregnancy. Similarly, couples with a discordant pregnancy were more likely to have a child who was never breastfed or breastfed less than six months.

Conclusions

Findings from this study show a relationship between couples' pregnancy intentions and subsequent breastfeeding behaviors. Healthcare professionals should be cognizant of parents' differing opinions surrounding pregnancy intention and the implications on breastfeeding outcomes.

The Human Milk Glycome as a Defense Against Infectious Diseases: Rationale, Challenges, and Opportunities

Each year over 3 million people die from infectious diseases with most of these deaths being poor and young children who live in low- and middle-income countries. Infectious diseases emerge for a multitude of reasons. On the social front, reasons include a breakdown of public health standards, international travel, and immigration (for financial, civil, and social reasons). At the molecular level, the modern rise of infectious diseases is tied to the juxtaposition of drug-resistant pathogens and a lack of new antimicrobials. The consequence is the possibility that humankind will return to the preantibiotic era wherein millions of people will perish from what should be trivial illnesses. Given the stakes, it is imperative that the chemistry community take leadership in delivering new antibiotic leads for clinical development. We believe this can happen through innovation in two areas. First is the development of novel chemical scaffolds to treat infections caused by multidrug-resistant pathogens. The second area, which is not exclusive to the first, is the generation of antibiotics that do not cause collateral damage to the host or the host's microbiome. Both can be enabled through advances in chemical synthesis. It is with this general philosophy in mind that we hypothesized human milk oligosaccharides (HMOs) could serve as novel chemical scaffolds for antibacterial development. We provide herein a personal account of our laboratory's progress toward the goal of using HMOs as a defense against infectious diseases.

The importance of the microbiome in pediatrics and pediatric infectious diseases

PURPOSE OF REVIEW

Emerging research on the pediatric microbiome implicates the importance of the microbiome on the development of the immune system, nervous system, and growth. Changes to the microbiome during infancy are associated with the development of chronic illnesses such as asthma and inflammatory bowel disease. Additionally, the microbiome provides protection against certain pathogens, affects vaccine responses, and alters drug metabolism. This review highlights what is known about the microbiome, the establishment of a healthy microbiome and the significance that changes to the microbiome composition have on growth and health of children and adolescents.

RECENT FINDINGS

Vaginal delivery, breastfeeding, maternal health, and nutrition help shape a healthy microbiome. Caesarian delivery, formula feeding, and antibiotic use perturb the microbiome and are associated with the development of type II diabetes, asthma, allergic diseases, and obesity later in life. Specific interventions using pre and probiotics in multiple settings are under investigation with limited success.

SUMMARY

A better understanding of the microbiome and the interaction with the immune system may help guide interventions to alter the microbiome toward a state of lifelong health.

Child feeding practices and diarrheal disease among children less than two years of age of the nomadic people in Hadaleala District, Afar Region, Northeast Ethiopia

BACKGROUND

Diarrhea is a serious public health problem in Ethiopia. It is responsible for 24-30% of all infant deaths and there is a lack of evidence on the health burdens among the nomadic people. This study was therefore designed to assess the prevalence of diarrhea among children less thanvtwo year's of age and its association with feeding practices among the nomadic people in Hadaleala district, northeast Ethiopia.

METHODS

A cross-sectional study was conducted in Hadaleala district. A total of 367 children less than two years of age were included using the multistage cluster sampling technique. Data were collected by a structured questionnaire. Multivariable binary logistic regression analysis was used to identify variables associated with diarrheal disease.

RESULTS

The prevalence of diarrhea among children less than two year's of age during the two week period was 31.3% (95% CI, 25.9, 36.1%). Diarrhea occurrence was associated with; children aged between 6-11 months (AOR 6.28, 95% CI, 3.00, 13.12), aged between 12-24 months (AOR 6.21, 95% CI, 3.13, 12.30), illiterate mothers (AOR 6.61, 95% CI, 2.27, 19.21), delay to initiate early breastfeeding for children aged less than six months (AOR 9.13, 95% CI, 1.78, 46.72), children less than six months of age not currently exclusively breastfed (AOR 13.33, 95% CI, 1.59, 112.12), delay to initiate early breastfeeding for children aged 6-24 months (AOR 2.87, 95% CI, 1.49, 5.51), no breastfeeding at the time of the survey (AOR 3.51, 95% CI, 1.57, 7.82), children aged 6-24 months who didn't exclusively breastfeed in the first six months (AOR 19.24, 95% CI, 8.26, 44.82), consuming uncooked foods (AOR 6.99, 95% CI, 2.89, 16.92), not eating cooked foods immediately after cooking (AOR 3.74, 95% CI, 1.48, 9.45), hand washing with only water (AOR 24.94, 95% CI, 6.68, 93.12), and rotavirus vaccination (AOR 0.09, 95% CI, 0.03, 0.29).

CONCLUSIONS

The prevalence of diarrhea among children less than two year's of age in Hadaleala district was high. To prevent diarrhea, the mothers should start breastfeeding early and practice exclusive breastfeeding. Moreover, mothers should improve the hygiene of supplementary foods.

Wide Variability in Caloric Density of Expressed Human Milk Can Lead to Major Underestimation or Overestimation of Nutrient Content

BACKGROUND

Very-low-birth-weight infants continue to face significant difficulties with postnatal growth. Human milk is the optimal form of nutrition for infants but may exhibit variation in nutrient content.

OBJECTIVE

This study aimed to perform macronutrient analysis on expressed human milk from mothers whose babies are hospitalized in the neonatal intensive care unit.

METHODS

Up to five human milk samples per participant were analyzed for protein, carbohydrate, and fat content using reference chemical analyses (Kjeldahl for protein, high pressure liquid chromatography for carbohydrates, and Mojonnier for fat). Calorie content was calculated.

RESULTS

A total of 64 samples from 24 participants was analyzed. Wide variability was found in calorie, protein, carbohydrate, and fat composition. The authors found an average of 17.9 kcal/ounce, with only 34% of samples falling within 10% of the expected caloric density.

CONCLUSION

The assumption that human milk contains 20 kcal/ounce is no longer supported based on this study. This supports promoting an individualized nutrition strategy as a crucial aspect to optimal nutrition.

Breastfeeding after Gestational Diabetes: Does Perceived Benefits Mediate the Relationship?

Introduction. Breastfeeding is recognized as one of the best ways to decrease infant mortality and morbidity. However, women with gestational diabetes mellitus (GDM) may have breastfeeding barriers due to the increased risk of neonatal and pregnancy complications. While the prevalence of GDM is increasing worldwide, it is important to understand the full implications of GDM on breastfeeding outcomes. The current study aims to investigate the (1) direct effect of GDM on breastfeeding duration and (2) indirect effect of GDM on breastfeeding duration through perceived benefits of breastfeeding. Methods. Prospective cohort data from the Infant Feeding and Practices Study II was analyzed (N = 4,902). Structural equation modeling estimated direct and indirect effects. Results. Perceived benefits of breastfeeding directly influenced breastfeeding duration (β = 0.392, p ≤ 0.001). GDM was not directly associated with breastfeeding duration or perceived benefits of breastfeeding. Similarly, GDM did not have an indirect effect on breastfeeding duration through perceived benefits of breastfeeding. Conclusions. Perceived benefits of breastfeeding are an important factor associated with breastfeeding duration. Maternal and child health care professionals should enhance breastfeeding education efforts.

Methods of milk expression for lactating women

BACKGROUND

Breastfeeding is important, however not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and costs of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2016), handsearched relevant journals and conference proceedings, and contacted experts in the field to seek additional published or unpublished studies. We also examined reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

This updated review includes 41 trials involving 2293 participants, with 22 trials involving 1339 participants contributing data for analysis. Twenty-six of the trials referred to mothers of infants in neonatal units (n = 1547) and 14 to mothers of healthy infants at home (n = 730), with one trial containing mothers of both neonatal and healthy older infants (n = 16). Eleven trials compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and pump types. Twenty studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols, pumping frequency, provision of an education and support intervention, relaxation, breast massage, combining hand expression with pumping and a breast cleansing protocol.Due to heterogeneity in participants, interventions, and outcomes measured or reported, we were unable to pool findings for most of the specified outcomes. It was not possible therefore to produce a 'Summary of findings' table in this update. Most of the included results were derived from single studies. Trials took place in 14 countries under a variety of circumstances and were published from 1982 to 2015. Sixteen of the 30 trials that evaluated pumps or products had support from the manufacturers. The risk of bias of the included studies was variable. Primary outcomesOnly one of the 17 studies examining maternal satisfaction/acceptability with the method or adjunct behaviour provided data suitable for analysis. In this study, self-efficacy was assessed by asking mothers if they agreed or disagreed with the following statement: 'I don't want anyone to see me (hand expressing/pumping)'. The study found that mothers who were using the electric pump were more likely to agree with the statement compared to mothers hand expressing, (mean difference (MD) 0.70, 95% confidence interval (CI) 0.15 to 1.25; P = 0.01, participants = 68). Mothers who were hand expressing reported that the instructions for expression were clearer compared to the electric pump, (MD -0.40, 95% CI -0.75 to -0.05; P = 0.02, participants = 68). Descriptive reporting of satisfaction in the other studies varied in the measures used, did not indicate a clear preference for one pump type, although there was satisfaction with some relaxation and support interventions.We found no clinically significant differences between methods related to contamination of the milk that compared any type of pump to hand expression (risk ratio (RR) 1.13, 95% CI 0.79 to 1.61; P = 0.51, participants = 28), manual pump compared to hand expression, (MD 0.20, 95% CI -0.18 to 0.58; P = 0.30, participants = 142) a large electric pump compared to hand expression (MD 0.10, 95% CI -0.29 to 0.49; P = 0.61, participants = 123), or a large electric pump compared to a manual pump (MD -0.10, 95% CI -0.46 to 0.26; P = 0.59, participants = 141).The level of maternal breast or nipple pain or damage was similar in comparisons of a large electric pump to hand expression (MD 0.02, 95% CI -0.67 to 0.71; P = 0.96, participants = 68). A study comparing a manual and large electric pump, reported sore nipples in 7% for both groups and engorgement in 4% using a manual pump versus 6% using an electric pump; and in one study no nipple damage was reported in the hand-expression group, and one case of nipple damage in each of the manual pump and the large electric pump groups.One study examined adverse effects on infants, however as the infants did not all receive their mothers' expressed milk, we have not included the results. Secondary outcomesThe quantity of expressed milk obtained was increased, in some studies by a clinically significant amount, in interventions involving relaxation, music, warmth, massage, initiation of pumping, increased frequency of pumping and suitable breast shield size. Support programmes and simultaneous compared to sequential pumping did not show a difference in milk obtained. No pump consistently increased the milk volume obtained significantly.In relation to nutrient quality, hand expression or a large electric pump were found to provide higher protein than a manual pump, and hand expression provided higher sodium and lower potassium compared to a large electric pump or a manual pump. Fat content was higher with breast massage when pumping; no evidence of difference was found for energy content between methods.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Variation in nutrient content across methods may be relevant to some infants. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings. Independently funded research is needed for more trials on hand expression, relaxation and other techniques that do not have a commercial potential.

Breastfeeding difficulties and supports and risk of postpartum depression in a cohort of womenwho have given birth in Calgary: a prospective cohort study

BACKGROUND

A link exists between breastfeeding difficulties and postpartum depression, and evidence shows that some breastfeeding promotion initiatives may increase maternal stress and contribute to risk of the condition. We conducted a prospective cohort study to determine whether breastfeeding difficulties affect the risk of postpartum depression and whether breastfeeding support modifies the relationship between breastfeeding difficulties and postpartum depression.

METHODS

Between June and October 2010, we recruited 442 women who intended to breastfeed from all maternity hospitals in Calgary within 72 hours of giving birth to full-term, singleton infants. We administered questionnaires at birth and 6 weeks and 6 months postpartum, measuring breastfeeding difficulties, exposure to breastfeeding supports and postpartum depression. We used qualitative inquiry to measure breastfeeding support experiences. Postpartum depression was defined as a score of 10 or greater on the Edinburgh Postnatal Depression Scale or a self-reported diagnosis of depression in the first 6 months postpartum.

RESULTS

A total of 386 women (87.3%) reported moderate to severe breastfeeding difficulties and 437 (98.9%) received some form of breastfeeding advice, help or support. Among women with breastfeeding difficulties, those who did not report a negative breastfeeding support experience were at decreased risk of postpartum depression (risk ratio 0.36). In the final regression model a negative breastfeeding support experience was a significant effect modifier of the relationship between breastfeeding difficulties and postpartum depression.

INTERPRETATION

The quality of breastfeeding support is important not only for breastfeeding promotion but also for maternal mental health. Educating front-line caregivers to ensure that support experiences of breastfeeding women are positive can reduce the risk of postpartum depression.

Perceived Infant Feeding Preferences of Significant Family Members and Mothers' Intentions to Exclusively Breastfeed

BACKGROUND

Breastfeeding intention is a significant predictor of initiation and duration. The decision to breastfeed may be influenced by the opinions of family and friends.

OBJECTIVE

This study aimed to examine the relationship between maternal perception of the infant feeding preferences of the baby's father and the maternal grandmother and the woman's intention to breastfeed.

METHODS

This study analyzed data from the Infant Feeding Practices Survey II (2005-2007).

RESULTS

The sample included 4690 women, of whom approximately 82% were white, 67% were married, 68% were multiparous, and 66% had some college education or beyond. In adjusted analyses, the odds of intending to exclusively breastfeed in the first few weeks postpartum were higher among mothers who perceived that the baby's father or the maternal grandmother preferred exclusive breastfeeding (vs preferred other feeding) (fathers: odds ratio [OR] = 7.44; 95% confidence interval [CI], 6.20-8.92; maternal grandmothers: OR = 2.45; 95% CI, 2.01-2.99). Mothers in each of the racial/ethnic groups examined were more likely to intend to exclusively breastfeed in the first few weeks postpartum if they perceived that the expectant father preferred exclusive breastfeeding (vs preferred other feeding methods) (white: OR = 7.67; 95% CI, 6.25-9.41; black: OR = 11.76; 95% CI, 4.85-28.51; Hispanic: OR = 7.01; 95% CI, 3.44-14.28; other: OR = 7.51; 95% CI, 3.39-16.67).

CONCLUSION

These results suggest that significant family members should be counseled on the benefits of breastfeeding and the risks of formula feeding along with pregnant mothers.

Methods of milk expression for lactating women

BACKGROUND

This is an update of a 2008 Cochrane review. Breastfeeding is important. However, not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, contamination and cost implications of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2014), CINAHL (1982 to March 2014), conference proceedings, secondary references and contacted researchers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials, extracted data and assessed risk of bias.

MAIN RESULTS

This updated review includes 34 studies involving 1998 participants, with 17 trials involving 961 participants providing data for analysis. Eight studies compared one or more types of pump versus hand expression and 14 studies compared one type of pump versus another type of pump, with three of these studies comparing both hand expression and multiple pump types. Fifteen studies compared a specific protocol or adjunct behaviour including sequential versus simultaneous pumping protocols (five studies), pumping > 4 times per day versus < 3 times per day (one study), provision of a milk expression education and support intervention to mothers of preterm infants versus no provision (one study), provision of audio/visual relaxation to mothers of preterm infants versus no specific relaxation (two studies), commencing pumping within one hour of delivery versus between one to six hours (one study), breast massage before or during pumping versus no massage (two studies, of which one also tested a second behaviour), therapeutic touch versus none (one study), warming breasts before pumping versus not warming breasts (one study), combining hand expression with pumping versus pumping alone (one study) and a breast cleansing protocol versus no protocol (one study).There were insufficient comparable data on outcomes to undertake meta-analysis and data reported relates to evidence from single studies.Only one of the 17 studies examining maternal satisfaction/acceptability provided data in a way that could be analysed, reporting that mothers assigned to the pumping group had more agreement with the statement 'I don't want anyone to see me pumping' than mothers in the hand expression group and the statement 'I don't want anyone to see me hand expressing' (n = 68, mean difference (MD) -0.70, 95% confidence interval (CI) -1.25 to -0.15, P = 0.01), and that mothers found instructions for hand expression were clearer than for pumping (n = 68, MD 0.40, 95% CI 0.05 to 0.75, P = 0.02). No evidence of a difference was found between methods related to adverse effects of milk contamination (one study, n = 28, risk ratio (RR) 0.89, 95% CI 0.62 to 1.27, P = 0.51), (one study, n = 142 milk samples, MD 0.20, 95% CI -0.18 to 0.58, P = 0.30), (one study, n = 123 milk samples, MD 0.10, 95% CI -0.29 to 0.49, P = 0.61), (one study, n = 141 milk samples, MD -0.10, 95% CI -0.46 to 0.26, P = 0.59 ); or level of maternal breast or nipple pain or damage (one study, n = 68, MD 0.02, 95% CI -0.67 to 0.71, P = 0.96).For the secondary outcomes, greater volume was obtained when mothers with infants in a neonatal unit were provided with a relaxation tape or music-listening interventions to use while pumping, when the breasts was warmed before pumping or massaged while pumping.Initiation of milk pumping within 60 minutes of birth of a very low birthweight infant obtained higher mean milk quantity in the first week than the group who initiated pumping later. No evidence of difference in volume was found with simultaneous or sequential pumping or between pumps studied. Differences between methods was found for sodium, potassium, protein and fat constituents; no evidence of difference was found for energy content.No consistent effect was found related to prolactin change or effect on oxytocin release with pump type or method. Economic aspects were not reported.Most studies were classified as unclear or low risk of bias. Most studies did not provide any information regarding blinding of outcome assessment. Fifteen of the 25 studies that evaluated pumps or products had support from the manufacturers.

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low-cost interventions including early initiation when not feeding at the breast, listening to relaxation music, massage and warming of the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Small sample sizes, large standard deviations, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings.

An ethical case for the provision of human milk in the NICU

Despite recommendations from the World Health Organization, the United Nations Children's Fund, the American Academy of Pediatrics Section on Breastfeeding, and others, only a small percentage of infants in the United States receive exclusive human milk for the first 6 months of life. In the United States, decisions related to infant feeding are determined by surrogate or proxy in place of the neonatal voice, using the "best interest principle" as the guiding ethical focus. Given the established research on the benefits of an exclusive human milk diet compared with artificial nutrition (infant formula), infant feeding decisions made for the critically ill neonate should rest entirely in the infant's best interest, not solely in parental authority. If the mother's own milk is not available or its use is contraindicated, the American Academy of Pediatrics recommends donor human milk. However, the preverbal voice of the neonate makes it difficult to isolate the best interest of the infant separated from the family unit. Using a case exemplar, it is proposed that the means in which infant feeding decisions are made for the critically ill infant should rest entirely in the infant's best interest, not parental authority, during the course of care in the hospital setting. The best interest principle, surrogate decision making, parental authority, and proxy consent are reviewed. Furthermore, a case for the best interest principle to further illustrate the importance of the infant's voice in relationship to enteral feeding decisions is provided. Finally, implications for clinical practice are offered.

The Effect of a Donor Milk Policy on the Diet of Very Low Birth Weight Infants

BACKGROUND

Use of donor milk (DM) to supplement mother's own milk (MOM) in the neonatal intensive care unit (NICU) is steadily increasing based on health and developmental benefits to premature infants. A paucity of data exists documenting the effect of DM use on the diet of very low birth weight (VLBW) infants related to the implementation of a DM policy.

OBJECTIVE

This study aimed to compare VLBW enteral intake type in the first 28 days of life before versus after establishing a DM policy.

METHODS

This single-center pre-post prospective cohort study included all inborn infants ≤ 1500 grams in a level 4 NICU remaining hospitalized at 28 days and admitted either before (pre-DM period, October 2009-March 2010) or after (DM period, October 2010-September 2012) implementing a DM policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and daily volume of enteral intake as MOM, DM, and formula. The proportion of enteral feeds from these sources during the first 28 days of life was compared pre-DM versus DM.

RESULTS

Compared to pre-DM baseline, formula exposure was significantly decreased, and human milk exposure and proportion of diet as human milk increased. The proportion of infants fed exclusively human milk increased. Exposure to and proportion of diet as MOM was unchanged. Infants were fed earlier in the DM period.

CONCLUSION

Establishment of a DM policy was associated with reduced exposure to formula, promoting an exclusively human milk diet, with earlier initiation of feeds and no decrease in use of MOM.

Direct evidence for the presence of human milk oligosaccharides in the circulation of breastfed infants

Background

It has been hypothesized that human milk oligosaccharides (HMOs) confer systemic health benefits to breastfed infants; however, plausible mechanisms for some effects, such as systemic immunomodulation, require HMOs to access the bloodstream of the developing infant. While small concentrations of HMOs have been detected in the urine of breastfed infants there are no published studies of these oligosaccharides accessing the plasma compartment of breastfed infants. Here we determined the relative fractions of several ingested HMOs in infant urine and plasma. Plasma from formula-fed infants was used as a control.

Methods

Using gas chromatography/mass spectrometry (GC/MS), liquid chromatography/mass spectrometry/tandem mass spectrometry (LC/MS/MS), and high performance liquid chromatography (HPLC), we analyzed the urine and plasma from 17 healthy formula-fed infants and 16 healthy breast-fed infants (and the milk from their mothers).

Results

Multiple HMOs were detected in the urine and plasma of breastfed infants, but not in formula-fed infants. Levels of 2′-fucosyllactose (2′FL), 3FL and lacto-N-neotetraose (LNnT) in both plasma (r = 0.98, p<0.001; r = 0.75, p = 0.002; r = 0.71, p = 0.004) and urine (r = 0.81, p<0.001; r = 0.56, p = 0.026; NS) correlated significantly with concentrations in the corresponding breast milk. The relative fractions of HMOs were low, 0.1% of milk levels for plasma and 4% of milk levels for urine. Within the breastfed cohort, there were significant differences between secretor and nonsecretor groups in levels of several fucosylated HMOs.

Conclusion

At least some ingested HMOs are absorbed intact into the circulation and excreted in the urine and their concentrations in these fluids correlate with levels of the corresponding mother's milk. While relative fractions of absorbed HMOs were low, these levels have been shown to have biological effects in vitro, and could explain some of the postulated benefits of human milk.

Outcomes and factors associated with breastfeeding for <8 weeks among preterm infants: findings from 6 states and NYC, 2004-2007

To examine breastfeeding outcomes and factors associated with breastfeeding <8 weeks among preterm infants. Pregnancy Risk Assessment Monitoring System (PRAMS) data for seven sites from 2004 to 2007 were used. Logistic regression was used to identify correlates of short breastfeeding duration among preterm infants. Among preterm infants, short breastfeeding duration (<8 weeks) was associated with maternal age ≤19 years (OR 1.75; 95 % CI: 1.22, 2.50), infant birth weight between 1,500 and 2,499 g (OR 1.29; 95 % CI: 1.01, 1.65), maternal obesity (OR 1.52; 95 % CI: 1.17, 1.98), smoking (OR 2.61; 95 % CI: 1.87, 3.63), and hypertension (OR 1.34; 95 % CI: 1.06, 1.69). Receiving a phone number for breastfeeding help (OR 0.59; 95 % CI: 0.44, 0.78) and not receiving a gift pack with formula (OR 0.64; 95 % CI: 0.47, 0.87) were associated with decreased odds of short duration. Speaking with a provider about breastfeeding prenatally was associated with increased odds of short duration (OR 1.75; 95 % CI: 1.33, 2.30). These findings strengthen the hypothesis that infant and maternal health are determinants of breastfeeding preterm infants and suggest a need to provide additional support to smokers, obese and hypertensive women, and mothers of infants with birth weights between 1,500 and 2,499 g, to help them sustain breastfeeding. Support from hospitals, such as providing a telephone number for breastfeeding help, and not providing a gift pack with formula, can also make a difference. These practices should be adopted by hospitals.

Fortification of human milk in very low birth weight infants (VLBW <1500 g birth weight)

The American Academy of Pediatrics supports the feeding of human milk for all infants. Very-low-birth-weight and extremely low-birth-weight infants especially can benefit from the immune and neurodevelopmental effects of human milk. However, human milk alone is nutritionally inadequate for the rapid growth of the very-low-birth-weight infant during a critical window for brain development and requires fortification to meet current recommendations. There are a variety of products, devices, and strategies that can be used to fine tune nutritional support of these very vulnerable infants.

Quality initiatives related to moderately preterm, late preterm, and early term births

Most premature infants born in the United States each year are classified as either moderately preterm (MPT) or late preterm (LPT) infants. Unnecessary variation in care and lack of evidence-based practices may contribute to the morbidities of prematurity. Quality-improvement (QI) initiatives designed for neonates have primarily focused on extremely low-gestational-age newborns. However, the lessons learned in this group of infants could be applied to decreasing unnecessary variation among MPT and LPT infants. Practice variation in the timing of nonindicated preterm deliveries, the use of progesterone, respiratory care practices, feeding management, and discharge planning are particularly in need of QI.

WIC participation and breastfeeding in South Carolina: updates from PRAMS 2009-2010

Few studies examined breastfeeding initiation and duration among mothers who were eligible for the Women Infants Children (WIC) program and did not participate. This study is sought to understand the role of WIC participation and poverty level in breastfeeding initiation and duration in South Carolina. The data came from the 2009-2010 South Carolina Pregnancy Risk Assessment Monitoring System (unweighted N = 1,796). All participants were classified as WIC participants, income-eligible non-WIC participants, and income-ineligible non-WIC participants. Logistic regression models were used to analyze the association between breastfeeding initiation and WIC participation. The Kaplan-Meier method and Cox proportional hazards models were used to determine whether the continuation of breastfeeding and hazards of discontinuing breastfeeding differed by WIC participation groups. In South Carolina, two out of three women (67.2%) initiated breastfeeding. The breastfeeding initiation rate was higher among income-ineligible (84.0%) and income-eligible (78.9%) non-WIC participants than among WIC participants (55.5%). Compared to WIC participants, both income-ineligible [odds ratio (OR) = 2.1, 95% confidence interval (CI) 1.2-4.0] and income-eligible (OR = 2.6, 95% CI 1.1-4.3) non-WIC participants were more likely to initiate breastfeeding. Among mothers who already initiated breastfeeding, after adjusting covariates, the hazard ratios for weaning within 34 weeks postpartum were not significantly different by WIC participation groups. This study confirmed WIC participants were less likely to initiate breastfeeding. Once initiated, WIC participation did not significantly impact breastfeeding duration in the early postpartum period. Poverty status may not play an important role in explaining disparities in breastfeeding initiation between WIC and non-WIC participants.

Creamatocrit analysis of human milk overestimates fat and energy content when compared to a human milk analyzer using mid-infrared spectroscopy

BACKGROUND AND OBJECTIVE

Human milk (HM) is the preferred feeding for human infants but may be inadequate to support the rapid growth of the very-low-birth-weight infant. The creamatocrit (CMCT) has been widely used to guide health care professionals as they analyze HM fortification; however, the CMCT method is based on an equation using assumptions for protein and carbohydrate with fat as the only measured variable. The aim of the present study was to test the hypothesis that a human milk analyzer (HMA) would provide more accurate data for fat and energy content than analysis by CMCT.

METHODS

Fifty-one well-mixed samples of previously frozen expressed HM were obtained after thawing. Previously assayed "control" milk samples were thawed and also run with unknowns. All milk samples were prewarmed at 40°C and then analyzed by both CMCT and HMA. CMCT fat results were substituted in the CMCT equation to reach a value for energy (kcal/oz). Fat results from HMA were entered into a computer model to reach a value for energy (kcal/oz). Fat and energy results were compared by paired t test with statistical significance set at P < 0.05. An additional 10 samples were analyzed locally by both methods and then sent to a certified laboratory for quantitative analysis. Results for fat and energy were analyzed by 1-way analysis of variance with statistical significance set at P < 0.05.

RESULTS

Mean fat content by CMCT (5.8 ± 1.9 g/dL) was significantly higher than by HMA (3.2 ± 1.1 g/dL, P < 0.001). Mean energy by CMCT (21.8 ± 3.4 kcal/oz) was also significantly higher than by HMA (17.1 ± 2.9, P < 0.001). Comparison of biochemical analysis with HMA of the subset of milk samples showed no statistical difference for fat and energy, whereas CMCT was significantly higher than for both fat (P < 0.001) and energy (P = 0.002).

CONCLUSIONS

The CMCT method appears to overestimate fat and energy content of HM samples when compared with HMA and biochemical methods.

Relationship between feeding modes and infant weight gain in the first month of life

Breast-feeding and human milk are beneficial for both mothers and their children. This retrospective study aimed to clarify whether differences in feeding mode influence infant weight gain in the first month of life. We analyzed the pregnancy charts of 422 women who delivered at a birthing center in rural Japan between August 1998 and September 2007. The inclusion criteria were low-risk, full-term pregnancy (duration, 37-42 weeks), spontaneous vaginal delivery, and a healthy infant (1 min Apgar score of ≥8) who underwent a health check-up at 1 month postpartum. The subjects were classified into three groups on the basis of feeding modes: exclusive breast-feeding group (28.9%), mixed-feeding group (55.9%) and exclusive formula-feeding group (15.2%). The weight gain/day was 39.7±9.3 g (range, 18.5-67.4 g), 39.5±9.4 g (range, 13.8-64.5 g) and 39.0±9.5 g (range, 14.4-65.3 g) in the exclusive breast-feeding, mixed-feeding and exclusive formula-feeding groups, respectively. Apart from the rate of maternal smoking, which was lower in the exclusive breast-feeding group, no other significant differences were observed among the three groups. This study revealed that there were no differences in weight gain among infants raised exclusively on breast milk and those raised exclusively on formula milk.

Antenatal breastfeeding education for increasing breastfeeding duration

BACKGROUND

Breastfeeding (BF) is well recognised as the best food for infants. The impact of antenatal BF education on the duration of BF has not been evaluated.

OBJECTIVES

To evaluate the effectiveness of antenatal BF education for increasing BF initiation and duration.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 December 2011), CENTRAL (The Cochrane Library 2011, Issue 11), MEDLINE (1966 to 30 November 2011) and Scopus (January 1985 to 30 November 2011). We contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All identified published, unpublished and ongoing randomised controlled trials (RCTs) assessing the effect of formal antenatal BF education or comparing two different methods of formal antenatal BF education, on duration of BF. We excluded RCTs that also included intrapartum or postpartum BF education.

DATA COLLECTION AND ANALYSIS

We assessed all potential studies identified as a result of the search strategy. Two review authors extracted data from each included study using the agreed form and assessed risk of bias. We resolved discrepancies through discussion.

MAIN RESULTS

We included 19 studies with 8506 women in the review and 16 studies involving 8262 women contributed data to the analyses. We did not carry out any meta-analysis because there was only one study for each comparison.Five studies compared a single method of BF education with routine care. Peer counselling significantly increased BF initiation.Three studies compared one form of BF education versus another. No intervention was significantly more effective than another intervention in increasing initiation or duration of BF.Seven studies compared multiple methods versus a single method of BF education. Combined BF educational interventions were not significantly better than a single intervention in initiating or increasing BF duration. However, in one trial a combined BF education significantly reduced nipple pain and trauma.One study compared different combinations of interventions. There was a marginally significant increase in exclusive BF at six months in women receiving a booklet plus video plus lactation consultation (LC) compared with the booklet plus video only.Two studies compared multiple methods of BF education versus routine care. The combination of BF booklet plus video plus LC was significantly better than routine care for exclusive BF at three months.

AUTHORS' CONCLUSIONS

Because there were significant methodological limitations and the observed effect sizes were small, it is not appropriate to recommend any specific antenatal BF education.There is an urgent need to conduct RCTs with adequate power to evaluate the effectiveness of antenatal BF education.

Associated morbidities to congenital diaphragmatic hernia and a relationship to human milk

The majority of what is known in the recent literature regarding human milk studies in the neonatal intensive care setting is specific to term and/or preterm infants (including very-low-birth-weight preterm infants). However, there is a lack of human milk and breastfeeding literature concerning infants with congenital anomalies, specifically infants diagnosed with congenital diaphragmatic hernia (CDH). By applying human milk research conducted among other populations of infants, this article highlights how human milk may have a significant impact on infants with CDH. Recent human milk studies are reviewed and then applied to the CDH population in regard to respiratory and gastrointestinal morbidities, as well as infection and length of stay. In addition, clinical implications of these relationships are discussed and suggestions for future research are presented.

Influence of breastfeeding on maternal blood pressure at one month postpartum

BACKGROUND

The benefits of breastfeeding for improved health and developmental outcomes in mothers and their infants have been widely recognized. The purpose of the present study was to assess whether feeding modes influence maternal blood pressure at one month postpartum.

METHODS

The pregnancy charts of 407 women who delivered at a birthing center in rural Japan between August 1998 and September 2007 were analyzed. The criteria for inclusion were low-risk, full-term pregnancy (duration, 37-42 weeks) resulting in spontaneous vaginal deliveries, intrapartum hemorrhage < 500 mL, and a healthy infant (Apgar score ≥ 8 at one minute).

RESULTS

The subjects were classified into three groups based on feeding modes. The proportion of each mode was 28.3% in the breastfeeding group, 56.5% in the mixed-feeding group, and 15.2% in the formula-feeding group. The systolic blood pressure (SBP) in mothers at one month postpartum for each feeding mode was 118.4 ± 8.7 mmHg in the breastfeeding group, 120.6 ± 9.3 mmHg in the mixed-feeding group, and 122.0 ± 9.9 mmHg in the formula-feeding group. SBP at one month postpartum in the breastfeeding group was significantly lower than that in the other groups. No significant differences were observed in diastolic blood pressure in the three groups at one month postpartum.

CONCLUSION

Breastfeeding resulted in lower SBP in mothers at one month postpartum compared with those using other feeding modes, thus indicating an effect of breastfeeding on maternal blood pressure.

Breastfeeding the infant with congenital diaphragmatic hernia post extracorporeal membrane oxygenation

Infants born with congenital diaphragmatic hernia (CDH) often require extracorporeal membrane oxygenation (ECMO). Infants on ECMO may experience a long period of being nothing by mouth (NPO) while receiving parenteral nutrition. Once the infant with CDH is repaired and off ECMO, human milk should be used to initiate enteral feedings. Human milk provides immunologic, developmental, and nutritional protection for these highrisk infants and may be crucial in decreasing morbidities commonly associated with post-ECMO survivors. These mother-infant dyads require extensive lactation support to ensure maintenance of milk supply and successful transition to direct breastfeeding. Three case studies are presented as exemplars to demonstrate how breastfeeding success can be achieved even in the most vulnerable infants.

Methods of milk expression for lactating women

BACKGROUND

This is an update of a 2008 Cochrane review. Breastfeeding is important. However, not all infants can feed at the breast and methods of expressing milk need evaluation.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on composition, contamination and cost implications of methods of milk expression.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 January 2011), CINAHL (1982 to January 2011), conference proceedings, secondary references and contacted researchers.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing methods at any time after birth, and crossover trials commencing at least 28 days after birth.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trials, extracted data and assessed risk of bias. Data were checked for accuracy.

MAIN RESULTS

We included 23 studies with 10 studies (632 mothers) providing data for analysis.Mothers provided with a relaxation tape produced more milk than mothers who were not (mean difference (MD) 34.70 ml/single expression, 95% confidence interval (CI) 9.51 to 59.89, P = 0.007). A lower milk volume over six days was reported when comparing hand expression to the electric pump (standardised mean difference (SMD) -1.00 ml, 95% CI -1.64 to -0.36, P = 0.002); other studies of the same pump using different measures did not find a significant difference (12 to 36 hours postpartum SMD -0.38 cc, 95% CI -0.86 to 0.10, P = 0.12); day five postpartum SMD -0.62 ml/day, 95% CI -1.43 to 0.19, P = 0.13). No evidence of difference in volume was found with simultaneous or sequential pumping, or between manual and electric pumps studied. One study reported a higher sodium concentration in hand expressed milk compared to a manual pump (SMD 0.59 mmol/L, 95% CI 0.22 to 0.96, P = 0.002) and to an electric pump (SMD 0.70 mmol/L, 95% CI 0.32 to 1.09, P = 0.0003), and lower potassium concentration compared to a manual pump (MD -0.37 mmol/L, 95% CI 0.00 to 0.73, P = 0.05) or to an electric pump (SMD -0.32 mmol/L, 95% CI -0.69 to 0.06, P = 0.10). No evidence of difference was found for energy content, milk contamination or adverse effects. Reports of maternal views were not comparable. Economic aspects were not reported.  

AUTHORS' CONCLUSIONS

The most suitable method for milk expression may depend on the time since birth, purpose of expression and the individual mother and infant. Low cost interventions including early initiation when not feeding at the breast, relaxation, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps for some outcomes. Small sample sizes, large standard deviations, small number of studies reviewed, and the diversity of the interventions argue caution in applying these results beyond the specific method tested in the specific settings.

The gustatory and olfactory systems during infancy: implications for development of feeding behaviors in the high-risk neonate

This article reviews the development of the senses of taste and smell, which provide information on the flavor of foods, and discusses how innate predispositions interact with early-life feeding experiences to form children's dietary preferences and habits. A basic understanding of the development and functioning of the chemical senses during early childhood may assist in forming evidence-based strategies to improve children's diets, especially for those who experience a discontinuity or disruption in early flavor experiences.

Antenatal breastfeeding education for increasing breastfeeding duration

BACKGROUND

Breastfeeding (BF) is well recognised as the best food for infants. The impact of antenatal BF education on the duration of BF has not been evaluated.

OBJECTIVES

To evaluate the effectiveness of antenatal BF education for increasing BF initiation and duration.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 April 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE (1966 to April 2010) and SCOPUS (January 1985 to April 2010). We contacted experts and searched reference lists of retrieved articles. We updated the search of the Pregnancy and Childbirth Group's Trials Register on 28 September 2011 and added the results to the awaiting classification section of the review.

SELECTION CRITERIA

All identified published, unpublished and ongoing randomised controlled trials (RCTs) assessing the effect of formal antenatal BF education or comparing two different methods of formal antenatal BF education, on duration of BF. We excluded RCTs that also included intrapartum or postpartum BF education.

DATA COLLECTION AND ANALYSIS

We assessed all potential studies identified as a result of the search strategy. Two review authors extracted data from each included study using the agreed form and assessed risk of bias. We resolved discrepancies through discussion.

MAIN RESULTS

We included 17 studies with 7131 women in the review and 14 studies involving 6932 women contributed data to the analyses. We did not do any meta-analysis because there was only one study for each comparison.Five studies compared a single method of BF education with routine care. Peer counselling significantly increased BF initiation.Three studies compared one form of BF education versus another. No intervention was significantly more effective than another intervention in increasing initiation or duration of BF.Seven studies compared multiple methods versus a single method of BF education. Combined BF educational interventions were not significantly better than a single intervention in initiating or increasing BF duration. However, in one trial a combined BF education significantly reduced nipple pain and trauma.One study compared different combinations of interventions. There was a marginally significant increase in exclusive BF at six months in women receiving a booklet plus video plus lactation consultation (LC) compared with the booklet plus video only.Two studies compared multiple methods of BF education versus routine care. The combination of BF booklet plus video plus LC was significantly better than routine care for exclusive BF at three months.

AUTHORS' CONCLUSIONS

Because there were significant methodological limitations and the observed effect sizes were small, it is not appropriate to recommend any antenatal BF education.There is an urgent need to conduct RCTs study with adequate power to evaluate the effectiveness of antenatal BF education.

Human milk macronutrient analysis using point-of-care near-infrared spectrophotometry

OBJECTIVE

To demonstrate that the real-time nutritional analysis of human milk carbohydrate, fat and protein with near-infrared (NIR) spectrophotometric methods is accurate.

STUDY DESIGN

A prospective study of the measurement of the macronutrient content of human milk. Milk was first analyzed on the SpectraStar 2400 Near Infrared Analyzer (Unity Scientific, Columbia, MD, USA), and then sent for primary chemical analysis for fat, protein and carbohydrate. Forty-two samples were used to create a calibration file. Ten samples were then used to validate the machine.

RESULT

After logistic regression analysis, the validation set had a correlation (r (2)) of 0.91 for carbohydrates, 0.95 for fat and 0.95 for protein.

CONCLUSION

This study demonstrates the feasibility of the use of NIR for nutrient analysis of human milk. NIR offers the potential for analysis and adjustable fortification of human milk to optimize nutrient intake for the high-risk neonate.

Environmental Modifiers of Chronic Lung Disease of Prematurity During Infancy

Chronic lung disease is a common complication of prematurity with substantial mortality and morbidity. Although the variation seen in bronchopulmonary dysplasia has a strong genetic component, the limited environmental variation in neonatal intensive care units may lead to underestimates of the contribution of environmental factors to lung disease variation. Once discharged from the hospital, preterm infants are exposed to a variety of environmental factors that likely worsen their disease. Recognition of these factors may lead to improved outcomes in this vulnerable population through more effective guidelines and counseling. This review examines the role of selected outpatient environmental factors on respiratory outcomes during infancy in preterm infants with lung disease.

Outcomes of human milk-fed premature infants

Significant benefits to infant host defense, sensory-neural development, gastrointestinal maturation, and some aspects of nutritional status are observed when premature infants are fed their mothers' own milk. A reduction in infection-related morbidity in human milk-fed premature infants has been reported in nearly a dozen descriptive, and a few quasi-randomized, studies in the past 25 years. Human milk-fed infants also have decreased rates of rehospitalization for illness after discharge. Studies on neurodevelopmental outcomes have reported significantly positive effects for human milk intake in the neonatal period and long-term mental and motor development, intelligence quotient, and visual acuity through adolescence. Body composition in adolescence also is associated with human milk intake in the neonatal intensive care unit. Finally, human milk intake is less associated with the development of the metabolic syndrome than infant formula feeding.

Donor human milk in preterm infant feeding: evidence and recommendations

In preterm infants, feeding with human milk (HM) is a very effective intervention for the prevention of infections and necrotizing enterocolitis (NEC), and for potentially improved neurocognitive and cardiovascular outcomes in the long-term. Hospitals and physicians are advised to recommend HM for preterm and other high-risk infants either by direct breastfeeding and/or using the mother's own expressed milk. Donor HM is the preferred feeding when the mother's own milk is not available in sufficient quantity. While in some countries donor HM has been considered an effective tool in the delivery of health care to infants, skepticism regarding its nutritional and immunological quality has limited its distribution in other countries. The purpose of this paper is to summarize the clinical benefits of donor HM in preterm infants, and to discuss common concerns limiting its distribution as standard care. Clinically, the use of donor HM has been shown to prevent NEC, reduce feeding intolerance and improve long-term outcomes in premature infants. Common concerns, such as slow growth and loss of important biological components of donor HM due to storage and pasteurization, should not be a reason for denial of donor milk. Optimization of banking procedures and of HM fortification is available and should be applied. Banked donor milk should be promoted as standard component of health care for premature infants.

Optimization of human milk fortification for preterm infants: new concepts and recommendations

Preterm infants fed fortified human milk (HM) in standard (STD) fashion grow slower than preterm formula fed infants. Recently, low protein intake has been proven to be the primary limiting factor responsible for this growth failure. The main reason of protein undernutrition despite fortification is that STD fortification is based on the customary assumptions about the composition of HM. However, the protein concentration of preterm HM is variable and decreases with the duration of lactation. Also, the protein concentration of banked donor milk, which is most often provided by mothers of term infants, is likely to be lower. Hence, most of the HM fed to preterm infants during the fortification period is likely to have an inadequately low protein concentration. This hypothesis has been confirmed very recently by comparing the assumed and actual protein intakes in preterm infants fed fortified HM. Novel fortification models have been devised to deal with the problem of ongoing protein undernutrition. Individualized fortification is the recommended method to optimize HM fortification. There are two models of individualization: "adjustable fortification" and "targeted fortification". Both ways are feasible and effective in improving protein intakes and growth. Adjustable fortification has the advantage of being practical and avoids excessive protein intakes.

Health professional knowledge of breastfeeding: are the health risks of infant formula feeding accurately conveyed by the titles and abstracts of journal articles?

Effective promotion of breastfeeding is constrained if health professionals' knowledge on its importance is deficient. This study asks whether formula feeding is named as the risk factor in published research or whether it is considered the unspoken norm. A systematic analysis is conducted of the information content of titles and abstracts of 78 studies that report poorer health among formula-fed infants. This shows a surprising silence in the studies examined; formula is rarely named in publication titles or abstracts as an exposure increasing health risk. In 30% of cases, titles imply misleadingly that breastfeeding raises health risk. Only 11% of abstracts identify formula feeding as a health risk exposure. Initiatives to increase breastfeeding have described the importance of accurate language and well-informed health professional support. If widespread, this skew in communication of research findings may reduce health professionals' knowledge and support for breastfeeding.

Preterm infants fed fortified human milk receive less protein than they need

OBJECTIVE

The aim of this study was to compare the actual nutrient intakes observed in a previously reported study with assumed nutrient intakes based on the customary assumptions about the composition of human milk.

STUDY DESIGN

Fortified human milk is assumed to provide adequate amounts of nutrients for premature infants. This assumption holds if milk has the composition of milk expressed by mothers of premature infants during weeks 2 to 3 of lactation. The assumption does not necessarily hold for milk expressed after 2 to 3 weeks lactation. It also does not hold for donor milk, which is typically provided by mothers of term infants. The size of the disparity between assumed and actual nutrient intakes is not known. Actual nutrient intakes were available for 32 preterm infants participating in the study. Assumed nutrient intakes were calculated for these infants by substituting assumed nutrient concentrations for observed nutrient concentrations. Data were compared separately for each of the 3 study weeks.

RESULT

Actual protein intakes were significantly and consistently lower than assumed protein intakes during each study week. The differences in mean intakes were large, ranging from 0.5 to 0.8 g kg(-1) per day. Differences in energy intake were small and not consistently significant.

CONCLUSION

Actual intakes of protein by preterm infants fed fortified human milk are substantially lower than assumed intakes. The discrepancy may in part explain why preterm infants frequently show postnatal growth failure.

Role of gut microbiota in early infant development

Early colonization of the infant gastrointestinal tract is crucial for the overall health of the infant, and establishment and maintenance of non-pathogenic intestinal microbiota may reduce several neonatal inflammatory conditions. Much effort has therefore been devoted to manipulation of the composition of the microbiota through 1) the role of early infant nutrition, particularly breast milk, and supplementation of infant formula with prebiotics that positively influence the enteric microbiota by selectively promoting growth of beneficial bacteria and 2) oral administration of probiotic bacteria which when administered in adequate amounts confer a health benefit on the host. While the complex microbiota of the adult is difficult to change in the long-term, there is greater impact of the diet on infant microbiota as this is not as stable as in adults. Decreasing excessive use of antibiotics and increasing the use of pre- and probiotics have shown to be beneficial in the prevention of several important infant diseases such as necrotizing enterocolitis and atopic eczema as well as improvement of short and long-term health. This review addresses how the composition of the gut microbiota becomes established in early life, its relevance to infant health, and dietary means by which it can be manipulated.

Ontogeny and phagocytic function of baboon lung dendritic cells

Dendritic cells (DCs) are the most potent antigen-presenting cells, but the ontogeny and functions of lung DCs are not known during prenatal period. Here, we isolated lung DC population from fetal (125 −175dGA) and adult baboons. The cells were stained with fluorochrome-conjugated-HLA-DP, DQ, DR, CD1a, CD11c, CD14, CD40, CD80, CD86, CD209, CMKLR1, ILT7-specific antibodies, and staining was analyzed by Flow-cytometry. The phagocytic function was investigated by incubating the cells with fluorescent-labeled Escherichia coli bioparticles and analyzed by Flow-cytometry and fluorescence microscopy. The fetal baboon lung DCs expressed low levels of HLA-DP, DQ, DR, CD11c and CD86 as compared to adult baboon lung DCs and showed distinct DC morphology. The fetal lung DCs were also less capable of phagocytosing E. coli as compared to the adult lung DCs (p<0.05). In conclusion, the fetal lung DCs are not only phenotypically immature, but also less efficient in phagocytosing E. coli.

Methods of milk expression for lactating women

BACKGROUND

Breastfeeding is important for health. However, not all infants can feed at the breast and effective methods of expressing milk have not been adequately evaluated.

OBJECTIVES

To assess acceptability, effectiveness, safety, effect on milk composition, bacterial contamination of milk and cost implications of a range of methods of milk expression, including hand expression and manual, battery and electric pumps.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2007), CINAHL (1982 to July 2007), handsearched relevant journals and conference proceedings, scanned secondary references and contacted experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared one method or technique of milk expression or pumping with other(s), at any time after birth, and cross-over trials that commenced at least 28 days after birth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We sought additional information from the trial authors.

MAIN RESULTS

Twelve studies met the inclusion criteria of which six (397 mothers) provided data that could be used in the analyses. Compared with hand expression, one study found a significantly greater total volume of milk expressed over six days both with the electrical pump (373.10 ml, 95% confidence interval (CI) 161.09 to 585.11), and with the foot-operated pump (212.10 ml, 95% CI 9.39 to 414.81); however, the difference found between the foot pump and the electric pump was not significant. Mothers provided with a relaxation tape produced a greater volume of milk at one expression than women not provided with the tape (34.70 ml, 95% CI 9.51 to 59.89). Simultaneous pumping took less time than sequential pumping in one study (3.50 hours/week, 95% CI 1.39 to 5.61). No evidence of difference was found in volume with simultaneous or sequential pumping, or for milk contamination, breastfeeding at discharge, fat content of milk, serum prolactin by method of pumping. Maternal satisfaction, adverse effects on mothers and economic effects of interventions were poorly reported.

AUTHORS' CONCLUSIONS

Mothers appear to obtain greater total volumes of milk in six days after birth using the electric or foot powered pump tested compared to hand expression, and a greater volume at one expression during the second week when provided with a relaxation tape. Simultaneous pumping takes less time compared to sequential pumping. Further research with larger numbers and more comprehensive reporting is needed, and mothers' reasons for expressing linked to their evaluation of effectiveness rather than market-led research on equipment performance.

Structural and functional aspects of prebiotics used in infant nutrition

Breast-feeding is associated with several benefits. Among them, the balanced postnatal development of the immune system is 1 of the key functions of breast-feeding. Although this effect is of multifactorial origin, it is widely accepted that the entire intestinal microbiota of breast-fed infants represents an important stimulating factor of the postnatal development of the immune system. The effect of breast-feeding on the intestinal microbiota can not be attributed to a single compound, but there is accumulating evidence that human milk oligosaccharides play a crucial role. Because there is a broad consensus that the intestinal microbiota plays an important physiological role for the host, many attempts have been made to influence the intestinal flora by dietary interventions. This article summarizes results of intervention studies in which nonmilk oligosaccharides have been used to mimic the prebiotic effect of breast-feeding. A second focus has been related to the question of whether the prebiotic activity has beneficial effects on the postnatal development of the immune system. The data clearly demonstrate that prebiotics of nonmilk origin can mimic the prebiotic effect of breast-feeding, and this has positive consequences for the postnatal development of the immune system.

Transitioning premature infants from gavage to breast

Breast milk provides physiologic and neurodevelopmental protection for premature infants. Most hospitals are breast-milk friendly, but the number of premature infants breastfeeding successfully at discharge is relatively small. There are evidence-based techniques to improve the odds of premature infants breastfeeding at discharge and into the first year of life. Measures that help the infant make the transition to the breast include kangaroo care, nonnutritive sucking, avoidance of bottles, and consistent and supportive staff. A guide to management of the transition process is provided in this article.