Pumping Milk Without Ever Feeding at the Breast in the Moms2Moms Study

Quantifying the Association between Pump Use and Breastfeeding Duration

OBJECTIVE

To quantify the extent to which pump use is associated with breastfeeding duration.

STUDY DESIGN

We conducted a cross-sectional analysis of weighted data from the Centers for Disease Control and Prevention Pregnancy Risk Assessment Monitoring System from Maine, Michigan, New Mexico, and Utah between 2016 and 2021. Included respondents had a live-born infant at survey completion, initiated breastfeeding, and had nonmissing data for reported pump use and breastfeeding duration. Using Cox proportional hazard regression, we quantified the hazard of breastfeeding cessation and median duration (weeks) of breastfeeding by pump use. Pump use was suspected to be differentially impacted by race and ethnicity; an interaction was tested in our regression model.

RESULTS

Our sample included 19 719 mothers (weighted n = 723 808) with mean age (SD) 29.5 years (5.6). Mothers with age <18 years, Medicaid enrollment, race, and ethnicity other than non-Hispanic White, lower income or education, and unmarried status demonstrated lower pump use (P < .001). Pump use was associated with 37% lower hazard of breastfeeding cessation (adjusted hazard ratio 0.63; 95% CI: 0.56-0.70) and 21 additional weeks of breastfeeding on average. The association varied by race and ethnicity (significant interaction observed between pump use and non-Hispanic Black mothers, P = .013); stratified analysis demonstrated the lowest hazard of breastfeeding cessation among non-Hispanic Black and Native American pump users (adjusted hazard ratio 0.47 [0.40-0.54] and 0.51 [0.37-0.70], respectively).

CONCLUSIONS

Pump use was associated with longer breastfeeding duration; the greatest magnitudes of association were found among non-Hispanic Black and Native American participants, groups disproportionately affected by breastfeeding inequities. Future research examining the context around and causal impact of pump use on breastfeeding outcomes is needed.

Direct breastfeeding frequency of late preterm and term infants in the neonatal intensive care unit and availability of mother's own milk at six months of age. a retrospective cohort study

BACKGROUND

Mother's Own Milk (MOM) reduces the risk of complications in premature infants. Breastfeeding rates for late preterm and term infants in the neonatal intensive care unit (NICU) are significantly lower than that of breastfed healthy term newborns at 6 months of age.

DESIGN

This was a retrospective cohort study of neonates born at 34 weeks 0 days or later. Infants who were directly breastfed in the NICU and were discharged on breast milk were included. Logistic regression modeling was used to determine the significance of association.

RESULTS

171 mother-infant dyads were included. After adjusting for confounders, the number of breastfeeding attempts during the NICU stay was significantly associated with the availability of MOM at six months of age (p = 0.003, 95% CI 1.02 to 1.14).

CONCLUSION

This study is the first to show an association between the number of direct breastfeeding attempts in the NICU and availability of MOM at six months of age.

Pumps: A Possible Tool to Promote More Equitable Lactation Outcomes

Pregnant individuals and infants in the US are experiencing rising morbidity and mortality rates. Breastfeeding is a cost-effective intervention associated with a lower risk of health conditions driving dyadic morbidity and mortality, including cardiometabolic disease and sudden infant death. Pregnant individuals and infants from racial/ethnic subgroups facing the highest risk of mortality also have the lowest breastfeeding rates, likely reflective of generational socioeconomic marginalization and its impact on health outcomes. Promoting breastfeeding among groups with the lowest rates could improve the health of dyads with the greatest health risk and facilitate more equitable, person-centered lactation outcomes. Multiple barriers to lactation initiation and duration exist for families who have been socioeconomically marginalized by health and public systems. These include the lack of paid parental leave, increased access to subsidized human milk substitutes, and reduced access to professional and lay breastfeeding expertise. Breast pumps have the potential to mitigate these barriers, making breastfeeding more accessible to all interested dyads. In 2012, The Patient Protection and Affordable Care Act (ACA) greatly expanded access to pumps through the preventative services mandate, with a single pump now available to most US families. Despite their near ubiquitous use among lactating individuals, little research has been conducted on how and when to use pumps appropriately to optimize breastfeeding outcomes. There is a timely and critical need for policy, scholarship, and education around pump use given their widespread provision and potential to promote equity for those families facing the greatest barriers to achieving their personal breastfeeding goals.

Monitoring the Use of Human Milk, the Ideal Food for Very Low-Birth-Weight Infants-A Narrative Review

Aware of the utmost importance of feeding premature babies-especially those of lower weight-with human milk, as well as the need to monitor this important element of neonatal care, we focused on four aspects in this review. First of all, we reviewed the beneficial effects of feeding premature infants with breast milk in the short and long term. Secondly, we performed a quantitative evaluation of the rates of breastfeeding and feeding with human milk in Very-Low-Birth-Weight infants (VLBWs) during hospitalization in the Neonatal Intensive Care Unit (NICU) and at discharge. Our aim was to take a snapshot of the current status of human milk-feeding care and track its trends over time. Then we analyzed, on the one hand, factors that have been proven to facilitate the use of maternal milk and, on the other hand, the risk factors of not feeding with breast milk. We also considered the spread of human milk banking so as to assess the availability of donated milk for the most vulnerable category of premature babies. Finally, we proposed a protocol designed as a tool for the systematic monitoring of actions that could be planned and implemented in NICUs in order to achieve the goal of feeding even more VLBWs with human milk.

How Resources Combining Expertise and Social Support Help Breastfeeding Women Address Self-Doubt and Increase Breastfeeding Self-Efficacy: A Mixed-Methods Study

Existing research on parental information literacy focuses on parents' ability to evaluate information. This approach does not account for conflicting or unwanted information and obscures the emotional impact of unsought information. We aimed to (1) document the sources women use most frequently for accessing breastfeeding information, (2) explore the reasons women choose some sources over others, (3) test the relationship between source characteristics and breastfeeding self-efficacy, and (4) determine the extent to which four source characteristics - competence, trustworthiness, goodwill, and social support - predict breastfeeding self-efficacy. This study was conducted in two phases. The first phase consisted of interviews and focus groups, which we analyzed inductively using a grounded theory approach. In phase two, we conducted a cross-sectional survey of women who were currently breastfeeding, collecting data on the source credibility and social support associated with the source they use most frequently and the participants' breastfeeding self-efficacy. We used multiple regression to analyze our survey data. The frequency with which our participants encountered conflicting and unsought prompted them to view sources that combine expertise and social support as ideal. However, these sources are often difficult to access, leading to a reliance on online sources. This compromise has implications for breastfeeding tenure, as both competence and social support predicted breastfeeding self-efficacy. This study demonstrates how emotional aspects of information seeking shape women's preferred sources, how accessibility limits the use of preferred sources, and how source competence and social support influence breastfeeding self-efficacy.

Beliefs and Decision-Making of First-Time Mothers Planning to Use a Breast Pump

Beliefs and decision-making processes associated with breast pump use in first-time mothers providing human milk to healthy, term newborns soon after birth are explored in this qualitative, descriptive study. Eight women participated in an individual semistructured interview in a community hospital in the southeastern United States. Guided by the theory of planned behavior, conventional content analysis about prenatal and early postpartum beliefs of planning and utilizing breast pumps yielded themes of Resource Gathering, Intention Refining, and Behavior Navigating. An understanding of these beliefs gives insight into ways health professionals can increase collaboration with expectant and new mothers about the selection and safe use of breast pumps, resource availability at various stages, and infant-feeding goals.

Maternal perceptions of human milk expression output: An experimental design using photographs of milk

BACKGROUND

The widespread use of breast pumps in the United States is a recent phenomenon that is reshaping how individuals understand and perceive lactation. In the 1990s, adequacy of milk supply was primarily measured indirectly by infant weight gain and/or diapers; now >95% of all lactating persons in the United States use breast pumps and are seeing their milk regularly. How seeing milk impacts the perception of lactation sufficiency is an important area of research. Research aim/question: To understand personal and intersubjective influences of seeing expressed human milk on perceptions of milk supply among participants who express milk for their infants.

METHODS

We surveyed 805 lactating participants from the United States about their pumping practices using an online survey. Participants described pumping practices, milk output, and beliefs. They were then randomized to view one of three photographs of expressed milk (<2 oz, 4 oz, >6oz) and asked to imagine they had just pumped that amount and provide a written response; this created 4 exposure groups (2 increase and 2 decrease) and a control group (no difference).

RESULTS

Participants randomized to a higher volume reported more positive feelings and used the terms "good", "great", and "accomplished" to describe emotional responses to output. Participants randomized to lower milk volumes reported more feelings of "bad" or "depressed." A subset of participants reported feeling "annoyed" about small volumes of milk.

CONCLUSIONS

Participants in this study were very conscious of the volume of milk pumped each session; both increases and decreases were associated with emotional responses that could contribute to decisions about pumping practices, perceived milk supply, and lactation duration.

ABM Clinical Protocol #37: Physiological Infant Care-Managing Nighttime Breastfeeding in Young Infants

A central goal of the Academy of Breastfeeding Medicine (ABM) is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The ABM empowers health professionals to provide safe, inclusive, patient-centered, and evidence-based care. Pregnant and lactating people identify with a broad spectrum of genders, pronouns, and terms for feeding and parenting. There are two reasons ABM's use of gender-inclusive language may be transitional or inconsistent across protocols. First, gender-inclusive language is nuanced and evolving across languages, cultures, and countries. Second, foundational research has not adequately described the experiences of gender-diverse individuals. Therefore, ABM advocates for, and will strive to use language that is as inclusive and accurate as possible within this framework. For more explanation, please read ABM Position Statements on Infant Feeding and Lactation-Related Language and Gender (https://doi.org/10.1089/bfm.2021.29188.abm) and Breastfeeding As a Basic Human Right (https://doi.org/10.1089/bfm.2022.29216.abm).

Breastfeeding following bariatric surgery among obese women with and without diabetes mellitus

BACKGROUND

Information on exclusive breastfeeding (BF) and BF initiation following bariatric surgery (BS) among obese women with diabetes mellitus (DM) and without DM (non-DM) is limited.

METHODS

Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). The 65 women in the DM group (40 women with gestational, 19 with Type 2 and 6 with Type 1) was similar to 84 with non-DM in BS type: Roux-en-Y (51 vs 55%), sleeve gastrectomy (32 vs 35%), laparoscopic gastric banding (17 vs 7%) and gastro-duodenal anastomosis (0 vs 4%).

RESULTS

Women with DM were older (35 vs 33y), of advanced age (54 vs 27%), with higher prevalence of grade 3 obesity (66 vs 46%), chronic hypertension (31 vs 10%), delivery of late-preterm infants (23 vs 10%) and neonatal hypoglycemia (25 vs 12%). Although infant feeding intention was similar: BF (66 vs 79%), partial BF (9 vs 7%) or formula (25 vs 14%), at discharge women with DM had lower exclusive BF (29 vs 41%) and BF initiation rates (68 vs 76%) than those with non-DM. Women with grade 3 obesity (52% were DM) differed from those with grades 1-2 (34% were DM) in exclusive BF (27 vs 52%), and BF initiation rates (66 vs 86%).

CONCLUSION

After BS, women with DM, especially those with grade 3 obesity, had higher rates of chronic hypertension and preeclampsia and lower rates of exclusive BF and BF initiation than those who had DM but had less severe obesity.

Impact of excessive gestational weight gain on exclusive breastfeeding among women with Type 1 and Type 2 diabetes and obesity

BACKGROUND

Pregestational diabetes, obesity and gestational weight gain (GWG) are associated with adverse perinatal outcomes, however, the influence of excessive GWG on lactation at discharge is less known. Our aim is to evaluate the impact of excessive GWG using the LifeCycle project guidelines on exclusive breastfeeding (EBF) and any BF rates at discharge among 171 women with Type 1 and 294 Type 2 diabetes and obesity who intended to BF.

METHODS AND FINDINGS

Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). GWG was categorized as adequate, inadequate or excessive according to the 2019 LifeCycle Project guidelines. Women with Type 1 were younger (30 vs 33y), primiparous (51 vs 32%), delivered earlier (37 vs 38w) than women with Type 2 andwere different in grade 1 (40 vs 26%), grade 3 obesity (19 vs 49%) and median GWG (15 vs 11kg). Of all 465 women with Type 1 and Type 2 combined, 365 (78%) who had excessive GWG and 100 (22%) who had non-excessive GWG showed similar EBF (27 vs 25%) and any BF (72 vs 72%) rates. Regression analysis showed that after adjusting for potential confounders excessive GWG was not a predictor of EBF or any BF at discharge.

CONCLUSION

Type 1 and Type 2 diabetes, obesity and excessive GWG are associated with low EBF, however, excessive GWG is not an independent predictor of low EBF or any BF at discharge.

Human milk-sharing practices and infant-feeding behaviours: A comparison of donors and recipients

Human milk sharing (HMS) is growing in popularity as an infant-feeding strategy in the United States. HMS families are a hidden population because HMS is a nonnormative and stigmatized behaviour. Thus, gaining access to HMS participants is challenging, and research on this topic remains limited. In particular, little is known about the broader infant-feeding behaviours of HMS parents. This study aimed to describe and compare the infant-feeding behaviours and HMS practices among a network of HMS donors and recipients. A detailed online survey was distributed to HMS parents in the Washington, DC region. Bivariate analyses were used to summarize the data by donor/recipient status when possible. Group differences were tested using analysis of variance for continuous variables and χ² tests for categorical variables. Donors and recipients did not differ in their sociodemographic characteristics. Recipients were significantly more likely than donors to have experienced complications of labour and delivery, traumatic birth, postpartum depression or a negative breastfeeding experience. Donors and recipients did not differ significantly in their duration of lactation or HM-feeding. Interestingly, 30% of recipients ever produced excess milk and 21% of donors ever had difficulty producing enough milk for their child. Compared with donors, recipients faced numerous maternal health challenges, but were still able to achieve a long duration of HM-feeding. HMS recipients represent a vulnerable group who may benefit from additional psychosocial and lactation support to improve their health and breastfeeding outcomes. Additional research is needed to investigate the associations between HMS participation, infant-feeding behaviours and lactation outcomes.

Exclusive breastmilk pumping: A concept analysis

Aim

To analyze and examine the concept of exclusive breast pumping (EP).

Background

Breastmilk is the ideal nutrition for infants, yet when breastfeeding is unsuccessful, parents resort to informal breastmilk sharing, artificial formula feeding, or EP. A growing proportion of families exclusively pump yet they often receive guidance from social media rather than healthcare providers because healthcare providers are uninformed about this feeding method.

Data Source

Cumulative Index of Nursing and Allied Health Literature, PubMed, and Google Scholar databases were searched using the following keywords: human milk express*, breast express*, breast milk express, breastmilk express*, exclusive pump, exclusive breast pumping, and exclusive expression.

Review Methods

Concept analysis design using Walker and Avant's method.

Results

Three defining attributes of (1) absence of direct breastfeeding, (2) breastmilk expression, (3) and an enduring infant feeding pattern of feeding expressed breastmilk only via a bottle were identified. All three attributes are required to confirm the presence of the concept of exclusive pumping. Definitions, antecedents, consequences, and empirical referents are described. Model and contrary cases are discussed.

Conclusion

This exclusive pumping concept analysis allows for consistency in terminology in practice and research. EP is a feeding method which can increase the proportion of infants who are fed breastmilk and may reduce the risks that arise from artificial formula feeding.

'Is there any point in me doing this?' Views and experiences of women in the Diabetes and Antenatal Milk Expressing (DAME) trial

The Diabetes and Antenatal Milk Expressing (DAME) randomised controlled trial (RCT) was conducted in 2011–2015, at six sites in Melbourne, Australia to explore the effect of advising women with diabetes in pregnancy to express breast milk from 36 weeks gestation. Infants whose mothers were randomised to express in pregnancy were more likely to be exclusively breast milk fed during their hospital stay, and there was no evidence of harm. This paper explores women's views and experiences of antenatal expressing. In this two‐arm RCT, 635 women with diabetes in pregnancy who were otherwise of low medical risk were randomised at 36–37 weeks gestation to usual care (not expressing, n = 316), or the intervention, where women were advised to hand express for 10 min twice daily until birth (n = 319). Semistructured face‐to‐face interviews were conducted with 10 women who expressed antenatally. They were asked about their experiences of antenatal expressing, including how they felt about the overall experience, the amount of breast milk they expressed, making time to express, and their experience of breastfeeding. Thematic analysis of the in‐depth interviews identified six themes: (1) learning and adapting expressing, (2) feelings and sensations associated with expressing, (3) support, (4) dis/empowerment, (5) health, and (6) the value of breast milk. Women had both positive and negative experiences of antenatal expressing. If health professionals are advising antenatal expressing to women, it is important they understand the range of outcomes and experiences.

Women's experiences of antenatal expressing were both positive and negative; it is important to understand the range of experiences.

Women should be advised that some women express little or no breast milk antenatally and therefore be reassured if they are concerned.

For women with diabetes in pregnancy, their diabetes management is a significant time burden, and should be considered when discussing antenatal expressing with women.

Maternity care providers need to follow‐up with pregnant women advised to express, to provide education, reassurance, and reassess expressing techniques.

Maternity care providers need to manage and prioritise the use of expressed breast milk.

Exclusive breastfeeding among women with type 1 and type 2 diabetes mellitus

Objective

To compare exclusive breastfeeding (BF) and BF initiation among 185 women with Type 1 and 212 women with Type 2 pregestational diabetes who intended exclusive or partial BF and delivered at ≥34 weeks of gestation.

Methods

Retrospective cohort study. At discharge, exclusive BF is direct BF or BF complemented with expressed breast milk. BF initiation is defined by exclusive or partial BF.

Results

Type 1 and Type 2 groups were similar in prior BF experience (69 vs 67%) but were different in intention to BF exclusively (92 vs 78%) and partially (8 vs 22%). Women in the Type 1 group were younger (median age 30 vs 33y), likely to be primiparous (47 vs 25%), have a lower median BMI (32 vs 36 kg/m²) and deliver by primary cesarean (37 vs 26%). Infants born to Type 1 women were more likely to be admitted to the NICU (44 vs 18%) and to have hypoglycemia (59 vs 41%). At discharge, exclusive BF among Type 1 was higher (34 vs 23%), partial BF was similar (47 vs 46%) while FF (formula feeding) was lower (19 vs 31%) than in the Type 2 group. BF initiation occurred in 81% of Type 1 and 69% of Type 2 women.

Conclusion

Intention to BF exclusively was higher in Type 1 women compared to Type 2. At discharge, exclusive BF and BF initiation were lower and FF higher in the Type 2 group highlighting the need for different strategies if lactation in this special population is to be improved.

Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus

OBJECTIVE

To compare breastfeeding (BF) initiation among 317 women with chronic hypertension (CHTN) and 106 women with CHTN superimposed on pregestational diabetes (CHTN-DM) who intended exclusive or partial BF.

METHODS

Retrospective cohort study of women who delivered at≥34 weeks of gestation. At discharge, exclusive BF was defined by direct BF or BF complemented with expressed breast milk (EBM) while partial BF was defined by formula supplementation.

RESULTS

CHTN and CHTN-DM groups were similar in prior BF experience (42 vs 52%), intention to BF exclusively (89 vs 79%) and intention to partially BF (11 vs 21%). Women in the CHTN group were younger (31 vs 33y), more likely primiparous (44 vs 27%), and delivered vaginally (59 vs 36%) at term (85 vs 75%). Women in the CHTN-DM group had higher repeat cesarean rates (32 vs 18%), preterm birth (25 vs 15%), neonatal hypoglycemia (42 vs 14%) and NICU admission (38 vs 16%). At discharge, exclusive BF rates among CHTN was higher (48 vs 19%), while rates of partial BF (34 vs 44%) and FF (18 vs 37%) were lower than in the CHTN-DM group. BF initiation (exclusive plus partial BF) occurred in 82%of CHTN and in 63% of CHTN-DM.

CONCLUSION

Although intention to BF was similar, BF initiation rates were higher for the CHTN compared to the CHTN-DM group. Exclusive BF was low in the CHTN and even lower in the CHTN-DM group signaling the need for targeted interventions if BF initiation rates are to be improved.

Advice from Canadian Mothers Who Express Human Milk: An Interpretive Description Qualitative Study

OBJECTIVES

Human milk expression has become an increasingly common means for providing milk to an infant, with women expressing to address breastfeeding problems or to allow for flexible feeding options. This study explored the experiences and recommendations of mothers who expressed human milk, with this paper reporting on the advice mothers would offer to other mothers to address common challenges.

METHODS

Interpretive description was used in this qualitative project. Using purposive sampling, mothers of infants aged 0-24 months who expressed human milk were recruited to participate from two health regions in western Canada. Individual, audio-taped interviews were completed with 35 women. NVIVO™ software was used for data analysis.

RESULTS

Mothers reported the desire to offer experiential advice to other mothers navigating milk expression and encouraged other mothers to seek guidance from health care professionals such as lactation consultants, peer support online, and from family and friends. Experiential knowledge shared included: (a) product recommendations, (b) expression tips, (c) support for workplace expression, (d) encouragement to seek help, and (e) moral support.

CONCLUSIONS

Healthcare professionals should include evidence-based expression information as part of routine lactation support, while recognizing the importance of mother-to-mother knowledge transfer and emotional support. Services that assist mothers to determine and access pumps appropriate to their unique breastfeeding needs and goals should be offered, and the opportunity for peer support through creation of, or referral to, appropriate in-person or online support groups should be made available.

Clinical Characteristics and Breastfeeding Outcomes in Term Dyads Following In-Hospital Supplementation with Pasteurized Donor Human Milk or Formula

Background: Pasteurized donor human milk (PDHM) supplementation for healthy infants is an emerging practice. Little is known about demographics or breastfeeding outcomes for dyads whose mothers choose PDHM versus formula. Research Aims: To identify relationships between in-hospital supplementation choice and (1) dyad characteristics and breastfeeding intent, and (2) breastfeeding outcomes at 1 month. Materials and Methods: This exploratory prospective cohort study surveyed healthy dyads requiring medically indicated supplementation. Participants completed questionnaires including demographics, breastfeeding intent, and self-efficacy during hospitalization, and self-efficacy and lactation outcomes at 1 month. Results: Of 39 participants, 24 (62%) supplemented with formula and 15 (38%) with PDHM. Formula dyads were more likely than PDHM dyads to have a delivery body mass index (BMI) ≥30 kg/m² (58% versus 20%, p = 0.02), and less likely to have attained greater than a college degree (33% versus 7%, p = 0.02); formula dyads also reported lower breastfeeding intent scores (12.0 versus 15.5, p = 0.002). Breastfeeding self-efficacy scores were similar but decreased for both groups over 1 month. At 1 month, mothers who chose formula were more likely to continue to provide breast milk to their infants (84% versus 72%). Direct breastfeeding rates were similar (72% versus 68%); of participants directly breastfeeding at 1 month, PDHM dyads were 1.5 times more likely to provide maternal expressed milk. Conclusions: Differences in maternal education, BMI, and breastfeeding intent were found between feeding groups. Results suggest an association between PDHM choice and initial breastfeeding intent and breastfeeding self-efficacy and provision of maternal expressed milk at 1 month.

Privacy, Early Colostrum, and Gestational Age are Associated with Exclusive Breastfeeding in Preterm and Sick Term Infants

Our study was designed to assess the rates of exclusive breastfeeding (defined as direct breastfeeding) and the use of mother's own milk (MOM) in preterm infants and sick term infants at discharge and to identify potential influencing factors such as gestational age, early colostrum, and privacy. The study was conducted at a German level III neonatal department. All preterm and sick term infants admitted to the neonatal intensive care unit, the pediatric intensive care unit, the intermediate care unit, and the low care ward were included in the study. Infants were recruited between March and October 2015 (phase 1) and April to July 2016 (phase 2). Due to an emergency evacuation, privacy was limited during the first phase. Breastfeeding and the use of MOM were assessed daily using a self-designed score. In total, 482 infants of 452 mothers were included. More than 90% initiated breastfeeding and one-third were exclusively breastfed at discharge. Extremely immature infants and late preterm infants were less likely to be exclusively breastfed at discharge. Privacy (p<0.001) and early colostrum (p=0.002) significantly increased exclusive breastfeeding. Conclusion Extremely immature and late preterm infants were least likely to be exclusively breastfed at discharge and need special support. Interventions such as privacy and early colostrum should be promoted to increase breastfeeding.

Association between expressed breast milk feeding and breastfeeding duration in Hong Kong mothers

BACKGROUND

Expressed breast milk feeding has increased substantially in the past two decades. Once used primarily for preterm infants, feeding expressed breast milk is now more common in mothers giving birth to healthy term infants. However, the effect of expressed breast milk feeding on breastfeeding duration is unclear.

OBJECTIVES

To assess the association between breast milk expression practices and breastfeeding duration in women giving birth to healthy infants.

METHODS

From 2017 to 2018, we recruited 821 new mothers from two public hospitals in Hong Kong. Participants were followed up at 1.5, 3, and 6 months postpartum or until they stopped breastfeeding. The proportion, type, and mode of all milk feeding were assessed at each follow-up.

RESULTS

At 1.5 months postpartum, 47.9%, 37.7%, and 14.4% of participants were feeding by direct breastfeeding only, mixed-mode feeding, and expressed breast milk only, respectively. Participants feeding expressed breast milk only were more likely to be supplementing with infant formula. When compared with participants who provided only direct breastfeeding, participants who gave only expressed breast milk at 1.5 months had 57% lower odds of breastfeeding continuation at three months postpartum. After stratification by infant formula supplementation, expressed breast milk feeding only at 1.5 months was associated with an increased risk of breastfeeding cessation in participants supplementing with infant formula (adjusted hazard ratio [aHR] = 1.86, 95% CI = 1.17-2.95).

CONCLUSION

In the first six months postpartum, giving only expressed breast milk is associated with early breastfeeding cessation, especially in participants who are also supplementing with infant formula.

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.

Improved exclusive breastfeeding rates in preterm infants after a neonatal nurse training program focusing on six breastfeeding-supportive clinical practices

BACKGROUND

Early breast milk expression, prolonged skin-to-skin contact, rooming-in, use of test-weighing and minimizing use of pacifiers are positively associated with exclusive breastfeeding of preterm infants, whereas use of nipple shields is negatively associated.

AIM

To test whether a training program for neonatal nurses with a focus on these six breastfeeding-supportive clinical practices affects the rate of preterm infants exclusively breastfed at discharge to home, the postmenstrual age at establishment of exclusive breastfeeding, and maternal self-reported use of the practice in the neonatal intensive care unit, the.

METHODS

A quasi-experimental multi-centre intervention study from 2016-2019 including a control group of 420 preterm mother-infant dyads, an intervention with a training program for neonatal nurses and implementation of weekly breastfeeding meetings for neonatal nurses, and an intervention group of 494 preterm mother-infant dyads.

RESULTS

Significantly more preterm infants in the intervention group were exclusively breastfed at discharge to home (66.6%) than in the control group (58.1%) p = 0.008. There was no significant difference in postmenstrual age at establishment of exclusive breastfeeding between control and intervention group (37.5 vs.37.8 weeks, p = 0.073). Compared to the control group the number of infants continuing daily skin-to-skin contact after incubator care increased (83.2% vs. 88.3%, p = 0.035), infants using a nipple shield decreased (61.8% vs. 54.2%, p = 0.029), and the number of mothers initiating breast milk expression before six hours post-partum increased (32.6% vs. 42.4%, p = 0.007). There was a significant correlation between percentage of neonatal nurses participating in the breastfeeding training program and changes in exclusive breastfeeding rates (Pearson Correlation 0.638, p = 0.047).

CONCLUSION

Exclusive breastfeeding rates in preterm infants and maternal self-reported use of breastfeeding-supportive practices increased by training neonatal nurses in the six clinical practices. It is important to include all nurses in the breastfeeding training program to ensure positive effect on exclusive breastfeeding rates.

Breastfeeding initiation among women with preeclampsia with and without severe features

BACKGROUND

Timely delivery and magnesium sulfate (MgSO4) are mainstay in the treatment of preeclampsia with severe features (PWSF). Premature delivery, severity of illness and mother-infant separation may increase the risk for breastfeeding (BF) initiation failure.

OBJECTIVE

To compare BF initiation among women with late-onset PWSF treated with MgSO4 to women with late-onset preeclampsia without severe features (WOSF) who did not receive MgSO4.

METHODS

Retrospective study of 158 women with PWSF and 104 with WOSF who delivered at ≥34 weeks. Intention to BF, formula feed (FF) or partially BF was declared prenatally. At discharge, exclusive BF included direct BF or direct BF with expressed breast milk (EBM).

RESULTS

PWSF and WOSF groups were similar in age, race, and obstetric history. PWSF and WSOF differed in primiparity (65 & 51%), late preterm births (73 vs 15%), admission to NICU (44 &17%) and mother (5 & 4d) and infant (6 & 3d) hospital stay. Both groups were similar in intention to BF (80 & 84%), to FF (16 & 13%) and to partially BF (5 & 5%). At discharge, exclusive BF (37 & 39%), partial BF (33 & 31%) and FF (30 & 30%) were similar. Exclusive BF in the PWSF group was 43% direct BF, 28% direct BF and EBM and 29% EBM alone whereas in the WOSF group exclusive BF was 93% direct BF and 7% direct BF and EBM.

CONCLUSION

BF initiation rates for women with PWSF and WOSF were similar. EBM alone or with direct BF enabled infants in the PWSF group to exclusively BF at discharge.

Breastfeeding and the origins of health: Interdisciplinary perspectives and priorities

Breastfeeding and human milk (HM) are critically important to maternal, infant and population health. This paper summarizes the proceedings of a workshop that convened a multidisciplinary panel of researchers to identify key priorities and anticipated breakthroughs in breastfeeding and HM research, discuss perceived barriers and challenges to achieving these breakthroughs and propose a constructive action plan to maximize the impact of future research in this field. Priority research areas identified were as follows: (1) addressing low breastfeeding rates and inequities using mixed methods, community partnerships and implementation science approaches; (2) improving awareness of evidence-based benefits, challenges and complexities of breastfeeding and HM among health practitioners and the public; (3) identifying differential impacts of alternative modes of HM feeding including expressed/pumped milk, donor milk and shared milk; and (4) developing a mechanistic understanding of the health effects of breastfeeding and the contributors to HM composition and variability. Key barriers and challenges included (1) overcoming methodological limitations of epidemiological breastfeeding research and mechanistic HM research; (2) counteracting 'breastfeeding denialism' arising from negative personal breastfeeding experiences; (3) distinguishing and aligning research and advocacy efforts; and (4) managing real and perceived conflicts of interest. To advance research on breastfeeding and HM and maximize the reach and impact of this research, larger investments are needed, interdisciplinary collaboration is essential, and the scientific community must engage families and other stakeholders in research planning and knowledge translation.

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.

"We Just Kind of Had to Figure It Out": A Qualitative Exploration of the Information Needs of Mothers Who Express Human Milk

BACKGROUND

Human milk expression, primarily by pump, is practiced by the majority of breastfeeding mothers in affluent countries. Existing literature is focused on determining prevalence and duration rates and the factors behind this trend. There is less research exploring mothers' perspectives and experiences related to expression.

RESEARCH AIM

To gather the experiential wisdom of mothers with a focus on their information needs and sources related to human milk expression.

METHODS

Audiotaped interviews were conducted with 35 mothers of infants, aged birth to 24 months, who had expressed milk at least once in western Canada. This study was guided by interpretive description, an applied qualitative research approach.

RESULTS

Registered nurses and international board-certified lactation consultants were the most common sources of information, with Internet, friends/family, and other mothers also important. Inconsistent expression advice was confusing for participants, and many reported health care providers did not address all their expression learning needs. Desired topic areas included practical advice on how to express, determining expression frequency/timing/duration, milk storage guidelines, the influence of expression on milk supply, product information, and general support/encouragement.

CONCLUSIONS

Assessment of expression learning needs should be part of routine lactation support at each encounter. Nonjudgmental, factual guidance will assist mothers in making evidence-informed decisions related to expression practices that are consistent with their unique breastfeeding goals. This should be supplemented by reputable online resources that provide timely and accurate information as well as efforts to connect mothers with peer support groups.

Mechanisms of support for exclusive breastmilk expressers in the community: a scoping review

Background

The World Health Organization recommends that infants be exclusively breastfed until the age of six months. Breastfeeding is generally understood to mean the provision of human breastmilk to the infant by direct feeding at the breast, and interventions aimed at supporting exclusive breastfeeding are therefore targeted at this activity. However, breastfeeding is actually an umbrella term covering the provision of breastmilk to an infant by any means. Our population of interest is mothers who exclusively feed their infants indirectly using expressed breastmilk. Some research suggests that any expressing, and exclusively expressing in particular, can be a risk factor for early cessation of exclusive breastmilk provision, so we were interested to identify whether any specific support existed for exclusively expressing mothers outside of the context of premature infants and the Neonatal Intensive Care Unit setting.

Methods

A scoping review following the Joanna Briggs Institute approach was used to explore the phenomenon of formal and informal supports in the community for exclusively expressing mothers. Searches were run across academic databases and of government websites and infant feeding support organisations. Finally, an informal internet search was run using a simple search string.

Results

On analysis of results, there were no studies or articles that met the search criteria. An informal internet search linked us directly with websites and blogs that could be considered a form of support intervention. These informal results suggest that support material or programs could possibly exist in other modalities but we cannot find them in the context of this type of scoping review.

Conclusions

The results of the search corroborated what we had suspected – that exclusively expressing mothers are not specifically supported by usual channels for new parents and that it is also difficult to find acknowledgement that exclusive expression exists.

The absence of results demonstrates the relevance of this study: exclusively expressing mothers are an under-served population. If we wish to strive towards achievement of World Health Organization breastfeeding goals, exclusively expressing mothers require targeted support to assist in their infant feeding experience, and there is little formal evidence of it currently being provided.

Breastfeeding experiences and perspectives on support among Chinese mothers separated from their hospitalized preterm infants: a qualitative study

Background

Chinese mothers of preterm infants often face obstacles to breastfeeding and commonly experience prolonged maternal-infant separation when their high-risk infants are hospitalized in a Neonatal Intensive Care Unit (NICU). This separation hinders mother-infant attachment and the establishment of breastfeeding. Currently, little is known about Chinese mothers’ experiences breastfeeding their preterm infants, or their support needs. The aim of this study was to develop an understanding of mothers’ experiences breastfeeding a hospitalized preterm infant and the support needed to establish a milk supply during the period separation from their infants.

Methods

A qualitative descriptive study was conducted in Beijing in 2017. A total of 11 Chinese mothers were individually interviewed while separated from their infants. The interviews were audio-recorded and transcribed verbatim. A thematic analysis involving a seven-step protocol identified key themes.

Results

Mothers of preterm infants reported physically and mentally challenging breastfeeding experiences during the period they were separated from their babies. They viewed expressing breast milk as integral to their maternal role, even though some found expressing breastmilk exhausting. With little professional support available, the mothers depended upon nonprofessionals to establish breastfeeding.

Conclusions

The study identified the difficulties mothers experienced establishing a milk supply while separated from their preterm infants, and the importance of access to health professional support.

Improved Estimation of Breastfeeding Rates Using a Novel Breastfeeding and Milk Expression Survey

Background: Increasing the proportion of infants who are breastfed and extending breastfeeding duration are high-priority U.S. goals. Evaluation of progress is based on federal survey data, but federal survey questions do not reflect contemporary feeding practices. Materials and Methods: Our objective was to evaluate the Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS) in estimating breast milk feeding and milk expression practices and compare to estimates from simultaneously administered federal survey questions. We surveyed women with child(ren) younger than the age of 6 years attending a large children's hospital for urgent or primary care. We estimated the proportions who participated in various breast milk feeding and milk expression practices and the durations of each and examined agreement between the surveys. We compared respondents with high versus low disagreement using log-binomial regression. Results: Of 225 respondents, 51% had less than a Bachelor's degree, and 44% identified as a race other than white. Similar proportions on each survey reported ever having breastfed or fed breast milk (84%). Proportions still breastfeeding or feeding breast milk at 6 and 12 months differed slightly by survey. Dyads (9%) who fed at the breast and fed expressed milk for nonidentical periods had estimates for the duration of breastfeeding or feeding breast milk that were lower per the federal survey. Respondents who answered the federal survey before the BaByMERS were more likely to provide discrepant responses (risk ratio = 3.40, 95% confidence interval: 1.18-9.80). Conclusions: This study offers further validation of brief interviewer-administered questions to collect quality data recalled about infant feeding and lactation for research purposes.

Comparing Alternative Breast Milk Feeding Questions to U.S. Breastfeeding Surveillance Questions

Background: Most mothers in the United States express their milk, which is then bottle fed to their infants. The National Immunization Survey (NIS), used to report national breastfeeding prevalence, asks about infant breast milk consumption, regardless of whether it is consumed at the mother's breast or from a bottle. The NIS data are often erroneously interpreted, however, to mean prevalence of at-the-breast feeding. We hypothesized that over half of infants classified as breastfed at 3, 6, and 12 months by the NIS questions would also be consuming expressed breast milk. Materials and Methods: A convenience sample of 456 mothers of infants 19-35 months of age recruited through ResearchMatch.org completed an online infant-feeding questionnaire. The questionnaire included both the NIS questions and more-detailed questions about feeding mode, distinguishing between at-the-breast and bottle. Results: Based on responses of our sample to the NIS questions, it could be interpreted that 74%, 64%, and 39% of mother-infant dyads were at-the-breast feeding at 3, 6, and 12 months, respectively. However, at each time point, most infants consumed at least some breast milk from a bottle. As infants got older, the proportion of breast milk consumed from a bottle increased. Conclusions: In this U.S. sample, the predominant breast milk feeding style involves both at-the-breast and expressed breast milk feeding. Future research and national surveillance should consider including separate measures of maternal breast milk expression and infant consumption of expressed breast milk to enable meaningful exploration of maternal and infant outcomes associated with these asynchronous behaviors.

Women's views about a free breast pump service: Online survey informing intervention development

Improving breastfeeding outcomes is a global priority; however, in the United Kingdom, continuation of breastfeeding remains low. Growing empirical evidence suggests a free breast pump service might be an acceptable and feasible incentive intervention to improve breastfeeding outcomes and reduce heath inequalities. To inform intervention development, we conducted an online survey with women recruited via social media using snowball sampling. Data were analysed descriptively (closed questions) with qualitative thematic analysis (free text). The survey was completed by 666 women, most of whom had recently breastfed and used a breast pump. Participants agreed that free pump hire (rental/loan; 567 women; 85.1%) or a free pump to keep (408; 61.3%) should be provided. Free text comments provided by 408 women (free pump) and 309 women (free hire) highlighted potential benefits: helping women to continue breastfeeding; express milk; overcome difficulties; and pump choice. Concerns are possible effect on breast milk supply, reduced breastfeeding, pumps replacing good support for breastfeeding, and pump hire hygiene. Personal and societal costs are important issues. Some suggested a pump service should be for low-income mothers, those with feeding difficulties or sick/preterm infants. A one-size service would not suit all and vouchers were proposed. Some suggested fees and deposits to prevent waste. To our knowledge, this is the first study reporting views about the acceptability of providing a free breast pump hire service. Mothers support and wish to have a say in breast pump service development. Future evaluations should address impact on feeding outcomes, professional support, hygiene for hired pumps, and costs.