Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PROBLEM

Breast pumping practices have scope for improvement.

BACKGROUND

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

AIM

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

METHODS

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

FINDINGS

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

DISCUSSION

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

CONCLUSION

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

An evaluation of patient comfort levels during expression with a modified pumping program: a prospective proof of concept study

Introduction

This study aimed to assess if the implementation of a gentle transition of vacuum mode into a breast pump suction pattern commonly used to initiate milk production would improve user comfort while expressing during the first four days postpartum.

Methods

This prospective study was conducted at OLVG hospital in the Netherlands in two sequential phases. Breastfeeding patients delivering >36 weeks gestation with an infant aged ≤96 h old and a clinical indication to express milk with a breast pump were recruited. Intervention group 1 (n = 40) used a hospital-grade electric breast pump with a standard breast pump suction pattern. Intervention group 2 used a hospital-grade electric breast pump with a modified breast pump suction pattern (n = 40). The primary outcome was an objective assessment of comfort as measured by participants' need to reduce vacuum level during the 20 min test session. Secondary outcomes included the total expression volume (ml) in 20 min pumping.

Results

The study found that the primary outcome of comfort was significantly improved with the modified breast pump suction pattern compared to the standard pattern (OR 1.29, 95% CI 1.08 to 1.6) with 86% vs. 67% of participants not needing to reduce applied vacuum levels. The amount of milk expressed did not differ significantly between phases (group 1: 7.6 ml (2.7-25.5 ml), group 2: 12.0 ml (1.2-31.5 ml), p = 0.43).

Discussion

This study is the first to demonstrate an improvement in user comfort driven by the implementation of gentle transitions in vacuum modes in a commonly used breast pump suction pattern. Research into this novel population combining both pumping and breastfeeding in the first days after birth offers new unique insights on the requirements of breast pump suction patterns.

Trial registration

Registered on clinical trials.gov NCT04619212. Date of registration November 6, 2020.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

German Clinical Trial Register: DRKS00017755.

Breast Pumps and Mastitis in Breastfeeding Women: Clarifying the Relationship

Mastitis is a debilitating condition that can impact around 20% of mothers and is characterized by fever, flu-like symptoms and tender, swollen areas of the breasts. Despite the emerging evidence that breast milk dysbiosis is an underlying cause of mastitis, breast pumps have been implicated as a predisposing risk factor in the pathophysiology of mastitis in breastfeeding mothers. Previous studies have suggested that the use of a breast pump increases a mother's risk for developing mastitis, however, incidence rates of mastitis over the stages of lactation do not match breast pump usage rates. Furthermore, breast pumps, even when used at low vacuum, still promote some breast drainage, thus avoiding milk stasis, which is considered a key factor in the development of mastitis. As a consequence, these data suggest that the literature association of breast pumps with mastitis is more a case of reverse causation and not direct association. Moreover, it is important to note that breast pumps are actually a part of the conservative management of mastitis. In combination, these data show that the breast pump should not be considered a driver in the pathophysiology of mastitis in women.

Surveying family access: kangaroo mother care and breastfeeding policies across NICUs in Italy

BACKGROUND

Studies on the application of developmental care initiatives in Italian NICUs are rather scarce. We aimed to assess parental access to the NICUs and facilities offered to the family members and to test "the state of art" regarding kangaroo mother care (KMC) and breastfeeding policies in level III Italian NICUs.

METHODS

A questionnaire both in paper and in electronic format was sent to all 106 Italian level III NICUs; 86 NICUs (i.e., 80% of NICUs) were completed and returned. The collected data were analysed. In addition, a comparison between the 2017 survey results and those of two previous surveys conducted from 2001 to 2006 was performed.

RESULTS

In total, 53 NICUs (62%) reported 24-h open access for both parents (vs. 35% in 2001 and 32% in 2006). Parents were requested to temporarily leave the unit during shift changes, emergencies and medical rounds in 55 NICUs (64%). Some parental amenities, such as an armchair next to the crib (81 units (94%)), a room for pumping milk and a waiting room, were common, but others, such as family rooms (19 units (22%)) and adjoining accommodation (30 units (35%)), were not. KMC was practised in 81 (94%) units, but in 72 (62%), i.e., the majority of units, KMC was limited to specific times. In 11 (13%) NICUs, KMC was not offered to the father. The average duration of a KMC session, based on unit staff estimation, was longer in 24-h access NICUs than in limited-access NICUs. KMC documentation in medical records was reported in only 59% of questionnaires. Breastfeeding was successful in a small proportion of preterm infants staying in the NICU.

CONCLUSION

The number of 24-h access NICUs doubled over a period of 13 years. Some basic family facilities, such as a dedicated kitchen, rooms with dedicated beds and showers for the parents, remain uncommon. KMC and breastfeeding have become routine practices; however, the frequency and duration of KMC sessions reported by NICU professionals still do not meet the WHO recommendations.

Using a lactation room at the workplace is associated with longer breastfeeding duration in working mothers

Introduction

IIntroduction: maternal employment after childbirth is associated with abandonment of breastfeeding; however, lactation rooms in the workplace increase the practice of breastfeeding. Objective: to compare the frequency and duration of breastfeeding among working mothers based on the presence of lactation rooms in their workplaces. Methods: we included mothers from different institutions whose infants were between 6 and 35 months (n = 158), and an ad hoc questionnaire was applied to assess breastfeeding, exclusive breastfeeding (EBF), partial breastfeeding (PBF), and use of human milk substitutes (HMS). Two groups were compared: working mothers with a lactation room at their workplace (n = 76) versus working mothers without this resource (n = 82). Results: breastfeeding duration (7.5 vs. 5.0 months, p < 0.001) and EBF (3.0 vs. 1.2 months, p = 0.005) were higher in mothers who had a lactation room. HMS use was shorter in mothers who had a lactation room (2.5 vs. 10.0 months, p = 0.001). There were more working mothers who breastfed for more than six months (75.0 % vs. 48.8 %) [OR = 3.15 (95 % CI, 1.60-6.19), p = 0.001] and 12 months (31.6 % vs. 14.6 %) [OR = 2.69 (95 % CI, 1.23-5.87), p = 0.014] when lactation rooms were available in their workplaces. Conclusion: the presence of a lactation room in the workplace was associated with a higher frequency and duration of breastfeeding.

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

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

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

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

When Your Breasts Might Not Work: Anticipatory Guidance for Health-Care Professionals

There are many factors that can negatively impact a mother developing a copious milk supply and being able to exclusively breastfeed her infant. In this article, we present two case exemplars (glandular hypoplasia and breast reduction surgery) to illustrate that not all mothers may be able to develop a full milk supply, and that families should receive appropriate prenatal anticipatory education and guidance from childbirth educators and all health-care providers. Important considerations include the value of every drop of milk that the mother is able to produce, treating the milk as an important medical intervention, and developing a plan with the family for supplementation so the infant can receive adequate intake for growth.

Breast shield design impacts milk removal dynamics during pumping: A randomized controlled non-inferiority trial

INTRODUCTION

While many studies have investigated the importance of optimizing pumping patterns for milk removal, the influence of breast shield design on milk removal has not been the focus of extensive investigation. This study aimed to determine the effectiveness of breast shields with either a 105° or a 90° flange opening angle on breast drainage and milk volume expressed during pumping.

MATERIAL AND METHODS

This study was a cross-over, randomized controlled non-inferiority trial (Registration; NCT03091985). Mothers (n = 49) of breastfeeding infants participated in the study over two study sessions. Participants were randomly assigned to pump both breasts simultaneously for 15 minutes with either the 105° or 90° breast shield in the first session, and the other shield in the second session. Effectiveness (breast drainage) and efficiency (volume expressed) of both breast shields were assessed after 15 minutes of pumping. Intention-to-treat and per protocol analyses were performed to determine if the 105° breast shield was non-inferior to the 90° breast shield for breast drainage and volume expressed. Perceived comfort was assessed via questionnaire.

RESULTS

The 105° breast shield was both non-inferior and superior compared to the standard 90° shield for breast drainage (intention-to-treat, 3.87% (0.01-7.72), P = .049) and volume expressed (intention-to-treat, 9.14 mL (1.37-16.91), P=.02). In addition, the 105° shield was rated as feeling more comfortable (P < .001) and as having an improved fit to the breast (P < .001) compared to the 90° shield.

CONCLUSIONS

Expressing with the 105° breast shield was more efficient, effective and comfortable compared to the 90° shield. Breast shield design can significantly impact pumping outcomes, and an opening angle of 105° improves both the dynamics and comfort of milk removal.

Improving Human Milk and Breastfeeding Rates in a Perinatal Hospital in Japan: A Quality Improvement Project

The leadership team at the Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University in Tokyo, Japan sought to improve our human milk (HM) and breastfeeding rates for vulnerable infants. This article describes the quality improvement (QI) initiative, which involved the implementation of the first three steps of the Spatz 10-step model for HM and breastfeeding in vulnerable infants. Our main objectives were to ensure that: (1) families were making informed feeding decisions about HM and breastfeeding as a medical intervention; (2) mothers were pumping early and often; (3) the staff implemented HM management; and (4) the proportion of infants who received HM at 1 month of life increased. Using a QI approach led by a nursing team, we were able to achieve all our goals. Our prenatal education was effective at having more families choose HM and breastfeeding versus formula. Our time to first milk expression improved as did the mothers' adherence with pumping early and often. We purchased physical resources to ensure that all milk was efficiently delivered to the infant in appropriate storage containers. At the initiation of this QI project, exclusive HM rates at discharge were only 15%. In only a 4 months time frame, the HM rate at discharge increased threefold to 47%. During the entire year, the portion of mothers selecting formula continued to decrease and HM rates continued to rise.

Short-term rate of milk synthesis and expression interval of preterm mothers

AIM

To determine the impact of the pumping regimes of women with preterm infants on the daily milk production, and on the short-term rate of milk synthesis during early lactation to support evidence-based recommendations for optimising milk production.

METHODS

Mothers of preterm infants (n=25) recorded start time, finish time and expression volumes from every breast expression on days 10, 15-20 postpartum.

RESULTS

Expressing more often than five times per day did not result in a significant increase in daily milk production. Milk volume per expression per breast increased for intervals between expressions of between 2and6 hours then reached a plateau when the interval between expression was 7 hours or longer. The short-term rate of milk synthesis decreased as the interval between expressions increased until about 7.5 hours at which point it begun to increase (p value associated with interval between expressions^2<0.001).

CONCLUSION

The strong inverse association between the short-term rate of milk synthesis and the interval between expressions for intervals up to 7 hours suggest that the maximum interval between expressions should be 7 hours. Data suggest that, on average, the mothers should express at least five times a day to maximise daily milk production. Considering inter-individual variation, determination of an individual mother's maximum interval between expressions that does not compromise the short-term rate of milk synthesis will help to optimise daily milk production while minimising the demands on the mother's time.

Comparison of maternal milk ejection characteristics during pumping using infant-derived and 2-phase vacuum patterns

Background

Milk ejection characteristics remain consistent throughout 12 months of lactation in women who expressed breastmilk with an electric breast pump. In addition these characteristics appear to remain constant when women are breastfeeding or pumping suggesting that milk ejection is a robust physiological response. It is not known whether the stimulation of an infant at the breast in the early post partum period influences milk ejection patterns or whether this is a programmed event. However, as more data become available on the mechanisms involved in infant feeding, pumping patterns mimicking the infant more closely may provide enhanced results. The objective of this study was to compare milk ejection characteristics obtained when using a novel infant-derived pumping pattern with an established 2-phase pattern.

Methods

A convenience sample of ten lactating mothers, 1 to 40 weeks of lactation with normal milk production were recruited in 2015. Each participated in two pumping sessions in which either a 2-phase pattern or infant-derived pattern were randomly assigned. Milk volume and milk ejection characteristics were recorded and the percentage of available milk removed (PAMR) was calculated. Statistical analysis used linear mixed effects modeling to determine any differences between breasts and pump patterns with the consideration of individual variability as a random effect.

Results

The number of milk ejections and milk ejection characteristics did not differ between patterns. Milk volumes removed were 53.6 ± 28.5 ml (PAMR 58.2 ± 28.4) for the 2-phase pattern and and 54.2 ± 26.3 ml (PAMR 52.2 ± 22.3) for the infant derived pattern. Peak milk flow rates were positively associated with the available milk (p = 0.0003) and PAMR (p = 0.0001), as was the volume of milk removed during each milk ejection (p = 0.001 and p = 0.0001).

Conclusion

An experimental pumping pattern designed to resemble infant sucking characteristics did not alter milk ejection characteristics or milk removal parameters compared with an established 2-phase pattern. Theses findings provide further evidence that milk ejection is a robust physiological response.

Hourly Breast Expression to Estimate the Rate of Synthesis of Milk and Fat

Objective measurement of the rate of synthesis of breast milk and fat in breastfeeding mothers requires test-weighing of each breastfeed and the measurement of each expression from each breast over 24 h, with the collection of milk samples before and after each breastfeed and expression. We sought an abbreviated technique for measuring these rates of synthesis. Participants completed a 24-h breastfeeding milk profile, and expressed their breasts on arrival at the research room and each hour thereafter for 3 h (4 expressions). The hourly rate of milk synthesis, as measured by the yield of milk from the fourth expression, was closely related to the hourly rate of milk synthesis calculated from the 24-h milk profile. The hourly rate of fat synthesis, calculated from the fat content of small samples of the first and last milk expressed during the fourth expression, was different from the rate of fat synthesis calculated from the fat content and volumes of all the breastfeeds and expressions during the 24-h milk profile. The study confirms the use of an abbreviated technique to measure the rate of breast milk synthesis, but is not reliable as a measure of the rate of fat synthesis for an individual.

Milk ejection patterns remain consistent during the first and second lactations

OBJECTIVE

Milk ejection is a critical physiological process for successful lactation in humans and without it little milk can be removed. Individual milk ejection patterns have been shown to remain consistent between breasts at different lactation stages and using different vacuum patterns with an electric breast pump. Little is known about the milk ejection characteristics during the second lactation period in the same mother. The objective of this study was to examine milk ejection characteristics in the same woman over two lactations.

METHODS

One mother took part in two pumping studies during consecutive lactations. One pumping study examined milk ejection characteristics during simultaneous breast expression during the first lactation. The second pumping study (second lactation) used two different pumping patterns. Three distinct milk ejections were measured during each pumping session.

RESULTS

Measurements of milk flow were used to compare the duration and time taken to reach the peak of each milk ejection for two pumping sessions from each of the lactations. There were no significant differences in milk ejection characteristics between breasts, using different pumping patterns, or between lactations in this mother (P > .05).

CONCLUSION

Milk ejection appears to be a physiological response that is consistent across consecutive lactations within the same mother. This suggests that milk ejection characteristics are established during or prior to the first lactation. The infant appears to have little influence on the milk ejection characteristics of the mother.

Breastmilk Production in the First 4 Weeks after Birth of Term Infants

Breastmilk provides the ideal nutrition for the infant, and exclusive breastfeeding is recommended for the first 6 months. Adequate milk production by the mother is therefore critical, and early milk production has been shown to significantly affect milk production during established lactation. Previous studies indicate that milk production should reach the lower limit of normal for established lactation (440 mL per day) by day 11 after birth. We have used test-weighing of term infants before and after each breastfeed over 24 h to measure milk production in the first 4 weeks of lactation in mothers with and without perceived breastfeeding problems to provide information on how often milk production is inadequate. Between days 11 and 13, two-thirds of the mothers had a milk production of less than 440 mL per day, and between days 14 and 28, nearly one-third of the mothers had a milk production of less than 440 mL per day. The high frequency of inadequate milk production in early lactation and the consequence of suboptimal milk production in later lactation if left untreated suggest that objective measurement of milk production can identify mothers and infants at risk and support early intervention by a lactation specialist.

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.

Skin-to-skin contact is associated with earlier breastfeeding attainment in preterm infants

AIM

This study investigated the effects of skin-to-skin contact on breastfeeding attainment, duration and infant growth in preterm infants, as this has not been sufficiently explored.

METHODS

A prospective longitudinal study on Kangaroo mother care was carried out, comprising 104 infants with a gestational age of 28 + 0 to 33 + 6 and followed up to one year of corrected age. Parents and staff recorded the duration of skin-to skin contact during the stay in the neonatal intensive care unit (NICU). Medical data were collected through patient records, and follow-up questionnaires were filled in by parents.

RESULTS

The 53 infants who attained full breastfeeding in the NICU did so at a median (range) of 35 + 0 (32 + 1 to 37 + 5) weeks of postmenstrual age, and skin-to-skin contact was the only factor that influenced earlier attainment in the regression analysis (R(2) 0.215 p < 0.001). The daily duration of skin-to-skin contact during the stay in the NICU did not affect the duration of breastfeeding or infant growth after discharge. Furthermore, infant growth was not affected by the feeding strategy of exclusive, partial breastfeeding or no breastfeeding.

CONCLUSION

A longer daily duration of skin-to-skin contact in the NICU was associated with earlier attainment of exclusive breastfeeding.

Impact of Measuring Milk Production by Test Weighing on Breastfeeding Confidence in Mothers of Term Infants

AIM

The duration of exclusive breastfeeding is affected by maternal confidence and perception of milk supply, but objective measurement of milk supply is rarely used. Mothers of preterm infants have found measuring milk supply by in-home test weighing to be helpful to ascertain their infants' breastfeeding intake. This study aimed to determine if this technique affects breastfeeding confidence of mothers of term infants.

MATERIALS AND METHODS

Participants filled in a survey of their breastfeeding confidence and perceptions of breastfeeding behavior prior to and after a 24-hour period of recording the times of feeds, amounts of each breastfeed or bottle feed (expressed breastmilk or formula), and amounts of breastmilk expressed.

RESULTS

The breastfeeding confidence of at least 66% of mothers who were initially confident was maintained, and the breastfeeding confidence of at least 11% of mothers who were initially not confident was improved after objective measurement of milk supply and breastfeeding behavior.

CONCLUSIONS

Measurement of actual milk supply and breastfeeding behavior provides objective information that can guide clinicians in the management of lactation. It can also help to maintain or improve breastfeeding confidence.

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.

Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations

In the World Health Organization/United Nations Children's Fund document Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, neonatal care is mentioned as 1 area that would benefit from expansion of the original Ten Steps to Successful Breastfeeding. The different situations faced by preterm and sick infants and their mothers, compared to healthy infants and their mothers, necessitate a specific breastfeeding policy for neonatal intensive care and require that health care professionals have knowledge and skills in lactation and breastfeeding support, including provision of antenatal information, that are specific to neonatal care. Facilitation of early, continuous, and prolonged skin-to-skin contact (kangaroo mother care), early initiation of breastfeeding, and mothers' access to breastfeeding support during the infants' whole hospital stay are important. Mother's own milk or donor milk (when available) is the optimal nutrition. Efforts should be made to minimize parent-infant separation and facilitate parents' unrestricted presence with their infants. The initiation and continuation of breastfeeding should be guided only by infant competence and stability, using a semi-demand feeding regimen during the transition to exclusive breastfeeding. Pacifiers are appropriate during tube-feeding, for pain relief, and for calming infants. Nipple shields can be used for facilitating establishment of breastfeeding, but only after qualified support and attempts at the breast. Alternatives to bottles should be used until breastfeeding is well established. The discharge program should include adequate preparation of parents, information about access to lactation and breastfeeding support, both professional and peer support, and a plan for continued follow-up.

Preterm birth: Strategies for establishing adequate milk production and successful lactation

Whilst human milk has not evolved to meet the unique requirements of the preterm infant there are unquestionable benefits to be gained via breast milk in terms of the development and health of the infant. Many mothers of preterm infants struggle to achieve a full milk production for many reasons the mechanisms of which are still unclear. Strategies to enhance milk volume include early, frequent simultaneous expression of milk combined with breast massage and a reduction of stress. However, these are not always successful, therefore a greater understanding of lactation physiology is required to devise more effective interventions to increase milk supply. The difficulty these infants experience transitioning to oral feeding and ultimately full breastfeeding further complicates lactation. In order to improve the health of these already compromised infants it is critical that more research be directed to this area so that they reap all the benefits that can be gained from breastfeeding.