Infant and maternal factors influencing breastmilk sodium among primiparous mothers

Evaluating human milk as a drug delivery vehicle for clofazimine to premature infants

Human milk is proposed as a drug delivery vehicle suitable for use in neonatal patients. Clofazimine, traditionally used for the treatment of leprosy and tuberculosis, is emerging as a treatment for cryptosporidiosis in infants, however its poor aqueous solubility has led to its commercial formulation as a waxy lipid formulation in a capsule, a format that is not suitable for infants. In this study, the evaluation of pasteurised human milk for the delivery of clofazimine was investigated using an in vitro lipolysis model to simulate gastric and intestinal digestion. The total lipid composition of the human milk was characterised alongside the liberated fatty acid species following digestion for comparison to alternative lipid-based delivery systems. Small-angle X-ray scattering was used to measure the presence of crystalline clofazimine during digestion and hence the extent of drug solubilisation. High-performance liquid chromatography was used to quantify the mass of clofazimine solubilised per gram of human milk fat (drug-to-fat ratio) in digested and undigested human milk. The digestion process was essential for the solubilisation of clofazimine, with digested human milk solubilising a sufficient dose of clofazimine for treatment of a premature infant. Human milk solubilised the clofazimine to a greater extent than bovine milk and infant formula during digestion, most likely as a result of differing lipid composition and increased long-chain fatty acid concentrations. These findings show that human milk enhances the solubility of clofazimine as a model drug and may be a suitable drug delivery vehicle for infant populations requiring therapeutic treatment.

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

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

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

BACKGROUND

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

RESEARCH AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Factors Associated with the Need for Breastfeeding Information Among Women with Gestational Diabetes Mellitus: A Cross-sectional Study

PURPOSE

Analyzing information based on individual needs can maximize the effectiveness of education, leading to changes in personal health behaviors. This cross-sectional descriptive survey study aimed to identify the characteristics of mothers who experienced gestational diabetes mellitus and correlate the factors associated with their information needs.

METHODS

The participants were 298 women between the ages of 20 and 49 years who were pregnant and diagnosed with gestational diabetes at the time of the study, or who were diagnosed with gestational diabetes mellitus within five years after delivery. The average age of the participants was 34.28 years. After comparing participants' demographics, diabetes, and breastfeeding-related characteristics according to their need for information on breastfeeding, a multiple logistic regression analysis was performed.

RESULTS

Factors associated with participants' need for information on breastfeeding were economic conditions, usual body mass index, current pregnancy, and experience of breastfeeding.

CONCLUSION

The findings can be used to implement programs that meet the needs of these women and help improve maternal and pediatric health and quality of life.

Factors that positively influence in-hospital exclusive breastfeeding among women with gestational diabetes: An integrative review

PROBLEM

Women with gestational diabetes have higher rates of introducing infant formula before leaving hospital.

BACKGROUND

Despite health professional support, less women with gestational diabetes exclusively breastfeed in hospital.

AIM

To find factors that positively influence in-hospital exclusive breastfeeding practices among women with gestational diabetes.

METHODS

An online search was performed in Medline, Scopus, Pubmed, CINAHL and Cochrane databases. Studies containing the keywords gestational diabetes and breastfeeding were retrieved.

FINDINGS

Authors identified 1935 papers from search criteria. Twenty-six papers with no restrictions on research design met inclusion criteria and were included in the review. Factors were divided into personal, antenatal, intrapartum and postnatal factors. The main modifiable factors that were associated with improved in-hospital exclusive breastfeeding rates were having a strong intention to breastfeed, being confident, feeling supported and having continuity of education and support. Women's main reasons to introduce formula were related to baby's hypoglycaemia, delayed lactogenesis II and perceived low milk supply. Skin-to-skin contact after birth combined with frequent breastfeeds were effective ways to improve in-hospital exclusive breastfeeding rates.

CONCLUSION

Influencing factors such as women's breastfeeding intention, confidence and ongoing support are no different to the general population of women. However, promoting skin-to-skin contact after birth combined with frequent feeds are crucial for women with gestational diabetes who are more likely to introduce formula due to delayed lactogenesis II and fear of neonatal hypoglycaemia. There is a need for developing educational and supportive interventions that are tailored specifically for women who have gestational diabetes.

Perceived insufficient milk among primiparous, fully breastfeeding women: Is infant crying important?

Breastfeeding mothers often report perceived insufficient milk (PIM) believing their infant is crying too much, which leads to introducing formula and the early abandonment of breastfeeding. We sought to determine if infant crying was associated with reported PIM (yes/no) and number of problems associated with lactation (lactation problem score [LPS] 6-point Likert scale) before formula introduction. Primiparous breastfeeding mothers were recruited at birth and visited at 1, 2 and 4 weeks. Among those fully breastfeeding at 1 week (N = 230), infant crying variables based on maternal reports were not associated with PIM at 1 week, but LPS was. However, a mother's expectation that her infant would cry more than other infants was associated with increased odds of reporting PIM at 2 and 4 weeks, as were delayed onset of lactation and previous LPS. At 1 week, crying variables (frequency, difficulty in soothing) were associated with LPS along with percent weight change. Delayed onset of lactation, infant care style, number of breastfeeds and previous LPS were longitudinally associated with change in LPS from 1 to 2 weeks and 2 to 4 weeks. Our data suggest that reported infant crying is associated with PIM and LPS in the first 4 weeks of life. Guidance on what to expect in crying behaviour and the impact of infant care style may be beneficial in reducing PIM and LPS in the first month.

Association of maternal diet, micronutrient status, and milk volume with milk micronutrient concentrations in Indonesian mothers at 2 and 5 months postpartum

BACKGROUND

Maternal micronutrient deficits during preconception and pregnancy may persist during lactation and compromise human milk composition.

OBJECTIVE

We measured micronutrient concentrations in human milk and investigated their association with maternal micronutrient intakes, status, and milk volume.

METHODS

Infant milk intake (measured via a deuterium dose-to-mother technique), milk micronutrient and fat concentrations, and maternal micronutrient intakes were assessed at 2 and 5 mo postpartum in 212 Indonesian lactating mother-infant pairs. Maternal hemoglobin, ferritin, transferrin receptors, retinol binding protein (RBP), zinc, selenium, and vitamin B-12 were measured at 5 mo (n = 163). Multivariate or mixed effects regression examined associations of milk micronutrient concentrations with maternal micronutrient intakes, status, and milk volume.

RESULTS

Prevalence of anemia (15%), and iron (15% based on body iron), selenium (2.5%), and vitamin B-12 deficiency (0%) were low compared with deficiencies of zinc (60%) and vitamin A (34%). The prevalence of inadequate intakes was >50% for 7 micronutrients at 2 and 5 mo. Median milk concentrations for most micronutrients were below reference values, and nearly all declined between 2 and 5 mo postpartum and were not associated substantially with milk volume (except for β-carotene, α-carotene, and β-cryptoxanthin). At 5 mo postpartum, associations between maternal micronutrient status and corresponding milk concentrations reported as mean percentage difference in human milk concentration for each unit higher maternal biomarker were significant for hemoglobin (1.9%), iron biomarkers (ranging from 0.4 to 7%), RBP (35%), selenium (70%), and vitamin B-12 (0.1%), yet for maternal intakes only a positive association with β-carotene existed.

CONCLUSIONS

Most milk micronutrient concentrations declined during lactation, independent of changes in human milk production, and few were associated with maternal micronutrient intakes. The significant associations between maternal biomarkers and milk micronutrient concentrations at 5 mo warrant further study to investigate whether the declines in milk micronutrients are linked to shifts in maternal status.

Nutritional and Non-nutritional Composition of Human Milk Is Modulated by Maternal, Infant, and Methodological Factors

Human milk (HM) is dynamic and shows a high inter- and intra-individual variability. To characterize HM with precision, it is necessary to understand the factors that modulate its composition. The objective of this narrative review is to summarize the maternal, infant and methodological factors that affect HM composition. We searched SCOPUS and PubMed databases for articles related to factors that are known to or could potentially influence HM composition and volume across lactation periods. Our comprehensive review encompasses various maternal-, infant-related, and methodological factors that modulate aspects of HM composition including macro- and micronutrients, vitamins and minerals, as well as volume. The most profound changes were observed in HM lipids and lipophiles. Evidence exists for many of the infant-related factors known to affect the nutritive and non-nutritive components of HM (e.g., birth weight, gestational age, infant age/stage of lactation). In contrast, less is known with respect to maternal factors; where there is either limited research or conflicting evidence (e.g., maternal lifestyle, obstetric history, medical conditions), except for the mother's diet, for which there is a relatively well-established understanding. Equally, although many of the methodological factors (e.g., HM sampling, handling and analytics) are known to impact HM composition, few studies have investigated this as a primary outcome, making it an important area of future research in HM. Here we propose a systematic capture of numerous maternal- and infant-related characteristics to facilitate associative comparisons of HM data within and across studies. Additionally, it would be prudent to standardize the methodological aspects known to affect HM composition in analytics, not only for HM lipids and lipophiles, but also for those nutrients whose variability is yet less well-understood. Defining the factors determining HM composition with accuracy will open perspectives for maternal intervention to optimize milk composition for specific needs of infants.

Influence of Diabetes during Pregnancy on Human Milk Composition

Human milk (HM) is a unique nourishment believed to contain biological factors contributing to both short and long-term benefits. Considering that a mother's own milk is often considered the first choice for nutrition of neonates, an aspect of increased interest is the possible effect of diabetes on the mammary gland and therefore on breast milk composition. This article aims to review the published literature on this topic, and to offer additional insights on the role of this disease on the composition of HM. This review was performed by searching the MEDLINE, EMBASE, CINHAL and Cochrane Library databases. A total of 50 articles were selected, focused specifically on one of the two types of diabetes: gestational diabetes mellitus (21 studies) and insulin-dependent diabetes mellitus (8 studies). Overall, the findings from the literature suggest that diabetes can alter the composition of HM. Nevertheless, the studies in this field are scarce, and the related protocols present some limitations, e.g., evaluating the variability of just a few specific milk biochemical markers in association with this syndrome.

Dietary reference values for sodium

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) derived dietary reference values (DRVs) for sodium. Evidence from balance studies on sodium and on the relationship between sodium intake and health outcomes, in particular cardiovascular disease (CVD)-related endpoints and bone health, was reviewed. The data were not sufficient to enable an average requirement (AR) or population reference intake (PRI) to be derived. However, by integrating the available evidence and associated uncertainties, the Panel considers that a sodium intake of 2.0 g/day represents a level of sodium for which there is sufficient confidence in a reduced risk of CVD in the general adult population. In addition, a sodium intake of 2.0 g/day is likely to allow most of the general adult population to maintain sodium balance. Therefore, the Panel considers that 2.0 g sodium/day is a safe and adequate intake for the general EU population of adults. The same value applies to pregnant and lactating women. Sodium intakes that are considered safe and adequate for children are extrapolated from the value for adults, adjusting for their respective energy requirement and including a growth factor, and are as follows: 1.1 g/day for children aged 1-3 years, 1.3 g/day for children aged 4-6 years, 1.7 g/day for children aged 7-10 years and 2.0 g/day for children aged 11-17 years, respectively. For infants aged 7-11 months, an Adequate Intake (AI) of 0.2 g/day is proposed based on upwards extrapolation of the estimated sodium intake in exclusively breast-fed infants aged 0-6 months.

Micronutrient intakes of lactating mothers and their association with breast milk concentrations and micronutrient adequacy of exclusively breastfed Indonesian infants

BACKGROUND

Breast milk is the sole source of nutrition for exclusively breastfed infants in the first 6 mo of life, yet few studies have measured micronutrient concentrations in breast milk in light of maternal diet and subsequent infant micronutrient intakes.

OBJECTIVES

We evaluated the adequacy of micronutrient intakes of exclusively breastfed Indonesian infants by measuring milk volume and micronutrient concentrations and assessed maternal micronutrient intakes and their relationship with milk concentrations.

METHODS

Mother-infant (2-5.3 mo) dyads (n = 113) were recruited for this cross-sectional study. Volume of breast-milk intake via the deuterium dose-to-mother technique over 14 d and analyzed micronutrient concentrations were used to calculate micronutrient intakes of exclusively breastfed infants. Maternal 3-d weighed food records were collected to assess median (IQR) micronutrient intakes. Multivariate regression analyses examined the association of usual maternal micronutrient intakes with milk micronutrient concentrations after adjustment for confounding variables.

RESULTS

Mean ± SD intake of breast-milk volume was 787 ± 148 mL/d. Median daily infant intakes of iron, zinc, selenium, magnesium, sodium, and B-vitamins (thiamin, riboflavin, niacin, pantothenic acid, B-6, and B-12) were below their respective Adequate Intakes. Inadequacies in maternal intakes (as % < estimated average requirements) were >40% for calcium, niacin, and vitamins A, B-6, and B-12. Significant positive associations existed between maternal usual intakes of vitamin A, niacin and riboflavin and milk retinol, nicotinamide, and free riboflavin concentrations in both unadjusted and adjusted (for infant age, milk volume, and parity) analyses (all P < 0.05).

CONCLUSIONS

The majority of micronutrient intakes for these exclusively breastfed infants and their mothers fell below recommendations, with associations between maternal intakes and breast-milk concentrations for 3 nutrients. Data on nutrient requirements of exclusively breastfed infants are limited, and a better understanding of the influence of maternal nutritional status on milk nutrient concentrations and its impact on the breastfed infant is needed.

Interracial couples and breastfeeding initiation in the United States

In the past decade, the prevalence of interracial couples has steadily increased. Recent reports state that nearly one in five marriages are between spouses of different races. Interracial couples receive less social support and are more likely to separate. As a result, children born to these couples may be at an increased risk of poor health outcomes. This study aims to investigate the relationship between interracial couples and breastfeeding initiation. Data from the 2014 Vital Statistics Natality Birth database were analyzed. Data were restricted to singleton births and infants with no congenital malformations. Racial composition of parents was categorized as non-Hispanic (NH) white, NH black; Hispanic; NH white/NH black; NH white/Hispanic; and NH black/Hispanic. Breastfeeding initiation (yes; no) was categorized according to information from the child's birth certificate file. Multiple logistic regression was used to generate crude and adjusted odds ratios and 99% confidence intervals. After adjusting for confounders, all interracial couples with at least one Hispanic parent had increased odds of breastfeeding initiation. Interracial white and black parents had 18% lower odds of breastfeeding initiation. The lowest odds of breastfeeding initiation were observed among intraracial black parents, who had 43% lower odds of breastfeeding initiation compared to intraracial white parents. Breastfeeding non-initiation continues to pose the greatest risk for infants with at least one black parent. Nurses, midwives, physicians, and other medical staff should discuss potential barriers that may be unique to interracial couples and provide additional breastfeeding education and support.

Late onset hyponatremia in preterm newborns: is the sodium content of human milk fortifier insufficient?

Introduction: In this study, we aimed to define the incidence and time to detection of late onset hyponatremia (LOH) as well as factors affecting its development in preterm newborns. We also aimed to determine the daily sodium requirement of these patients.Methods: We studied a total of 145 very low birth weight infants with a full or nearly full enteral diet and followed them up until discharge. We recorded demographic and clinic characteristics. We measured serum sodium (SNa) levels at least once a week after the second week. We compared infants with LOH with other infants to analyze possible risk factors.Results: Twenty-nine (20%) infants developed LOH in an average of 23.4 ± 7.8 days. The mean SNa level of these infants was 124.6 ± 5.6 mmol/L. Logistic regression analysis showed that a birth weight of less than 1000 g, preterm early membrane rupture, and nutrition with fortified human milk alone were risk factors for LOH. The mean daily amount of sodium added to the nutrition of hyponatremic preterm infants was 3.6 ± 2.1 mmol/L. Subgroup analysis showed that the incidence of LOH was two times higher (39.2%) in infants with a birth weight of less than 1000 g.Conclusion: We observed the development of LOH within three to four weeks in nearly half of preterm infants fed with fortified human milk, especially those with a birth weight of less than 1000 g. We believe that the sodium content of currently used human milk fortifiers should be increased.

Maternal work and exclusive breastfeeding practice: a community based cross-sectional study in Efutu Municipal, Ghana

BACKGROUND

Maternal work has been identified as one of the factors that affect exclusive breastfeeding in the first six months of life. In Ghana, mothers engaged in the formal sector of employment are unable to exclusively breastfeed after maternity leave because facilities at their work places and conditions of work do not support exclusive breastfeeding. Even though maternal work and exclusive breastfeeding does not seem well matched, not all maternal work are incompatible with the practice of exclusive breastfeeding. This study seeks to identify the features of maternal work associated with exclusive breastfeeding in Effutu Municipal in the Central Region of Ghana. To achieve the above aim, I discuss the different types of maternal work, their characteristics, and how the work may influence exclusive breastfeeding.

METHODS

The study is a community based cross-sectional study involving 225 mother-infant pairs attending community based Child Welfare Clinics in Effutu Municipal, Ghana. Data were collected through face-to-face structured interviews and focus group discussions over a period of five months in 2015. Data on breastfeeding is based on the breastfeeding practice in the 24 h preceding the survey. Chi-square test is used to identify strength of association between the features of maternal work and exclusive breastfeeding practice.

RESULTS

The exclusive breastfeeding rate among mothers with infants between the ages of 0 - 5 months is 72%. The mean and median number of breastfeeds per day is 11 ± 2.7 and 13.5 respectively. A significant difference in exclusive breastfeeding was established between mothers in the formal (16%) and informal (84%) sectors of employment (p = 0.020). The study also established a significant difference in breastfeeding frequency between mothers in the formal (9%) and informal (91%) sectors of employment (p = 0.001). There was also a significant difference in breastfeeding frequency among respondents that go to work with their infant (64%) and those who do not go to work with their infant (36%) (p = 0.000).

CONCLUSION

Interventions to promote exclusive breastfeeding should include the use of existing family structures, supportive cultural beliefs, and practices and promotion of an infant-friendly work environment.

The Relation between Breast Milk Sodium to Potassium Ratio and Maternal Report of a Milk Supply Concern

We report that, among exclusively breastfeeding mothers at day 7 postpartum, those with milk supply concerns were significantly more likely to exhibit biochemical evidence of less progress toward mature lactation (elevated ratio of breast milk sodium to potassium concentration). Furthermore, an elevated ratio of breast milk sodium to potassium concentration was predictive of early weaning.

The Effects of Mild Gestational Hyperglycemia on Exclusive Breastfeeding Cessation

Gestational diabetes increases the risk of a range of adverse perinatal outcomes, including breastfeeding failure, but the best cut-off point for gestational diabetes is unknown. The purpose of this study was to evaluate the association between mild gestational glucose tolerance impairment and the early cessation of exclusive breastfeeding (EBF). This is an observational study of 768 women with full term pregnancies that were screened for gestational diabetes at 24–28 weeks gestation. Subjects were divided into two groups: those with a normal 1-h glucose challenge test and those with an elevated 1-h glucose challenge test but still did not qualify for gestational diabetes. We constructed multivariable logistic regression models using data from 616 women with normal gestational glucose tolerance and 152 women with an isolated positive 1-h glucose challenge test. The risk of early exclusive breastfeeding cessation was found to increase in women with mildly impaired glucose tolerance during pregnancy (adjusted OR, 1.65; 95% CI: 1.11, 2.45). Risks of early EBF cessation were also independently associated with the amount of neonatal weight loss and admission to the neonatal ward. Instead, parity was associated with a decreased risk for shorter EBF duration. Insulin resistance—even in the absence of gestational diabetes mellitus—may be an impeding factor for EBF.