Clinical lactation practice: 20 years of evidence

Per- and Polyfluoroalkyl Substances and Breastfeeding as a Vulnerable Function: A Systematic Review of Epidemiological Studies

Milk formation in the breast during breastfeeding is a complex hormonally regulated process, potentially sensitive to the effects of endocrine-disrupting chemical exposures. The environmental chemicals, per- and polyfluoroalkyl substances (PFAS) are known endocrine disruptors. PFAS exposure have been associated with insufficient mammary gland development in mice and reduced breastfeeding duration in humans. The aim of this review was to gather the epidemiological evidence on the association between PFAS exposure and breastfeeding duration. Using PubMed and Embase, we performed a systematic literature search (on 23 January 2023) to identify epidemiological studies examining the association between maternal PFAS exposure and breastfeeding duration. Animal studies, reviews, and non-English studies were excluded. The risk of bias was assessed using the risk of bias in non-randomized studies of exposures tool. Estimates describing the association between PFAS exposure and the duration of breastfeeding were identified, and the data were synthesized separately for each type of PFAS and for the duration of exclusive and total breastfeeding. Six studies with between 336 and 2374 participants each were identified. PFAS exposure was assessed in serum samples (five studies) or based on residential address (one study). Five out of six studies found shorter total duration of breastfeeding with higher PFAS exposure. The most consistent associations were seen for perfluorooctane sulfonate (PFOS), perfluorooctanoic acid (PFOA), and perfluorononanoic acid (PFNA). The finding of a potential causal association between PFAS exposure and breastfeeding duration is in agreement with findings from experimental studies.

Pregnancy exposure to bisphenol A and duration of breastfeeding

INTRODUCTION

Bisphenol A (BPA) is frequently used in the production of plastics. It is an endocrine disruptor, and BPA exposure in mice has been associated with reduced offspring growth due to insufficient milk production. However, human studies of associations between BPA exposure and duration of breastfeeding are sparse.

METHODS

Pregnant women from the Odense Child Cohort (n = 725) donated a third trimester morning urine sample, which was analyzed for BPA by LC-MS/MS. Information about duration of exclusive and any breastfeeding was obtained through questionnaires three and 18 months postpartum, and a subgroup of women responded to weekly text messages about breastfeeding. Associations between pregnancy BPA exposure and duration of breastfeeding were analyzed using Cox regression adjusting for potential confounders.

RESULTS

The median urine BPA concentration was 1.29 ng/mL. Compared to women within the lowest tertile of BPA exposure, women in the second and third tertile were slightly more likely to terminate breastfeeding at any given time; HRs (95% CI) were 1.05 (0.87; 1.26) and 1.06 (0.89; 1.27), respectively, and to terminate exclusive breastfeeding at any time up to 20 weeks after birth, HRs (95% CI) were 1.07 (0.88; 1.28) and 1.06 (0.88; 1.27), respectively. However, confidence intervals were also compatible with no effect or even a protective effect.

DISCUSSION

This study indicated that high BPA exposure in pregnancy was associated with shorter duration of breastfeeding. Although our findings were not statistically significant, all estimates were above one suggesting increased risk of early breastfeeding termination with high exposure. Using a single spot morning urine sample to measure BPA has likely caused imprecision as it might not adequately reflect long term exposure. Future studies should consider measuring BPA more than once, including other timepoints during pregnancy and after birth.

Pregnancy Exposure to Perfluoroalkyl Substances and Associations With Prolactin Concentrations and Breastfeeding in the Odense Child Cohort

CONTEXT

Human exposure to perfluoroalkyl substances (PFAS) has been associated with reduced duration of breastfeeding, although not consistently so, and mechanisms by which PFAS might affect breastfeeding are unknown.

OBJECTIVE

To examine the association between early pregnancy serum-PFAS concentrations and breastfeeding termination and to elucidate the potential role of serum-prolactin concentrations in pregnancy.

MATERIALS AND METHODS

Pregnant women from the Odense Child Cohort provided blood samples for analysis of 5 major PFAS (n = 1300) and prolactin concentrations (n = 924). They subsequently provided information about the duration of breastfeeding in questionnaires at 3 and 18 months postpartum, and a subgroup also provided breastfeeding information via weekly cell phone text messages. Associations between serum-PFAS concentrations and breastfeeding termination were analyzed using Cox regressions, while linear regression was used to assess associations between serum-PFAS and prolactin concentrations.

RESULTS

Increased serum concentrations of perfluorooctane sulfonic acid, perfluorooctanoic acid, perfluorononanoic acid, and ∑PFAS were associated with a 16% (95% CI: 4%-30%), 14% (95% CI: 2%-26%), 14% (95% CI: 3%-27%), and 20% (95% CI: 6%-36%), respectively, increased risk of terminating breastfeeding at any given time after childbirth. Serum-PFAS concentrations were not associated with serum-prolactin concentrations.

CONCLUSIONS

These findings are of public health importance due to the global exposures to PFAS. Because breastfeeding is crucial to promote both child health and maternal health, adverse PFAS effects on the ability to breastfeed may have long-term health consequences.

Effect of a brief motivational intervention in the immediate postpartum period on breastfeeding self-efficacy: Randomized controlled trial

Brief motivational intervention (bMI) is a therapeutic approach that encourages self-efficacy and may have a positive effect on breastfeeding self-efficacy (BSE). The purpose of this study was to analyze the effectiveness of a bMI in increasing BSE in women who started breastfeeding in the immediate postpartum period and to explore the roles of general self-efficacy and other baseline variables in this relationship. A randomized, parallel-group clinical trial was carried out. A bMI was compared with an educational session on breastfeeding. Changes in BSE and its dimensions and the interaction and mediation/moderation of general self-efficacy and other variables were analyzed. BSE increased in the bMI group from a mean baseline score of 59.14 (±9.35) to 64.62 (±7.91) at 1st month (p < 0.001). An interaction was found in that only women with higher education had an improvement in BSE during the follow-up period that was attributable to the bMI (mean difference between the bMI and the attention control group: 18.25 (95% confidence interval: 5.86-30.19; p = 0.006). This interaction was not found for the changes produced in the intrapersonal thoughts dimension of BSE, whose scores were higher in the bMI group at 3 and 6 months. General self-efficacy exerted a moderating effect on the association of bMI with BSE change. The effect of bMI was no longer significant when the general self-efficacy score was above 84. Thus, bMI is effective in increasing BSE. This effectiveness was limited by the mother's educational level and moderated by baseline general self-efficacy.

Maternal Plasma Concentrations of Per- and polyfluoroalkyl Substances and Breastfeeding Duration in the Norwegian Mother and Child Cohort

Supplemental Digital Content is available in the text.

Background:

Per- and polyfluoroalkyl substances (PFASs) have been widely produced, many of them persist in the environment, and have been associated with various health effects. Previous studies have identified inverse associations between perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), and breastfeeding duration, but have been limited in investigation of other PFASs.

Methods:

We measured the associations between plasma concentrations of nine different PFASs and cessation of breastfeeding before 3 and 6 complete months using women from the Norwegian Mother and Child Cohort Study (MoBa). The study population includes 1716 primarily nulliparous women from two previous studies of MoBa participants, enrolled from 2003 to 2007. The association was measured using Cox proportional hazards model. Mixtures analyses were performed using Elastic net regularization to identify interactive effects and control for copollutant confounding.

Results:

Concentrations of PFASs in this population were lower than concentrations in the previous studies on this topic. We found associations between increasing concentrations of perfluorononanoic acid (PFNA), perfluorodecanoic acid (PFDA), perfluoroundecanoic acid (PFUnDA), and decreased breastfeeding cessation (increased duration). The strongest associations were seen between PFDA and PFUnDA and cessation before 3 months: (both hazard ratios = 0.73; 95% confidence intervals = 0.62, 0.86). In our population, the other PFASs appeared to be unassociated with breastfeeding cessation. The mixtures analyses identified meaningful interactions between PFUnDA:PFDA, perfluorohexane sulfonate (PFHXS):PFOA, and PFOA:PFOS.

Conclusions:

The identification of associations between previously unexamined PFASs concentrations and increased breastfeeding duration is novel and may be explained by differences in transplacental transfer rates.

Who Supports Breastfeeding Mothers? : An Investigation of Kin Investment in the United States

Breastfeeding is one important form of maternal investment that is influenced by support from kin and non-kin. This paper investigates who provides support for breastfeeding mothers and their children, what type of support they provide, and how support impacts breastfeeding duration. The data were derived from a survey of 594 American mothers and were analyzed using quantitative methods, including Cox regression. Analyses indicate that mothers receive significant support, particularly from spouses and maternal grandmothers. More frequent breastfeeding discussions with La Leche League and maternal grandfathers were associated with longer duration, whereas discussions with physicians were associated with shorter breastfeeding duration. Results indicate that consulting others specifically about breastfeeding may influence breastfeeding decisions. The results are consistent with the idea that social support may influence breastfeeding duration and that some types of support are more influential than others. Furthermore, support persons should be educated about breastfeeding to prevent early weaning.

Development and Evaluation of a Lactation Rotation for a Pediatric Residency Program

BACKGROUND

The American Academy of Pediatrics recommends that pediatricians promote and help manage breastfeeding. However, research has shown that they are not adequately prepared. To address this gap, a 2-week mandatory lactation rotation program was developed for first-year pediatric residents. Research aim: The aim of the study was to provide a lactation education program and to measure the residents' knowledge and perceived confidence regarding breastfeeding.

METHODS

This longitudinal self-report pretest/posttest study was conducted with a convenience sample of 45 first-year pediatric residents. Each resident spent a minimum of 50 hours with an International Board Certified Lactation Consultant. To measure breastfeeding knowledge and clinical confidence, the American Academy of Pediatrics' Breastfeeding Residency Curriculum pretest was used 4 times: first and last day of the rotation and at 6 and 12 months postrotation.

RESULTS

Test and confidence scores were evaluated. Statistically significant differences in knowledge were found between test 1 when compared with tests 2, 3, and 4 ( p < .001). No significant differences were found between tests 2, 3, and 4 ( p > .05). The abilities to "adequately address parents' questions" and to "completely manage common problems" were significant, with confidence increasing in tests 2, 3, and 4 ( p < .001).

CONCLUSION

As a result of an innovative, comprehensive educational lactation program, the pediatric residents' knowledge and perceived confidence related to breastfeeding significantly increased.

Shorter duration of breastfeeding at elevated exposures to perfluoroalkyl substances

The aim of this study was to determine whether maternal exposure to persistent perfluoroalkyl substances (PFASs) affect the capability to breastfeed. In two Faroese birth cohorts (N=1130), concentrations of five PFASs were measured in maternal serum during pregnancy or two weeks after term. Duration of breastfeeding was assessed by questionnaire and clinical interview. In adjusted linear regression models, a doubling of maternal serum PFASs was associated with a reduction in duration of both total and exclusive breastfeeding, most pronounced for perfluorooctane sulfonic acid (PFOS) where a doubling was associated with a reduction in total breastfeeding of 1.4 (95% CI: 0.6; 2.1) months and perfluorooctanoic acid (PFOA) where a doubling was associated with a reduction in exclusive breastfeeding of 0.5 (0.3; 0.7) months. The associations were evident among both primiparous and multiparous women, and thus cannot be explained by confounding from previous breastfeeding.

Breastfeeding and maternal employment: results from three national nutritional surveys in Mexico

To evaluate the association between maternal employment and breastfeeding (both duration and status) in Mexican mothers using data from three National Health and Nutrition Surveys conducted in 1999, 2006 and 2012. We analyzed data from the 1999 National Nutrition Survey, the 2006 National Nutrition and Health Survey, and the 2012 National Nutrition and Health Survey (NNS-1999, NHNS-2006 and NHNS-2012) on 5,385 mothers aged 12-49 years, with infants under 1 year. Multivariate logistic regression models were used to analyze the association between breastfeeding and maternal employment adjusted for maternal and infant's socio-demographic covariates. Maternal formal employment was negatively associated with breastfeeding in Mexican mothers with infants under 1 year. Formally employed mothers were 20 % less likely to breastfeed compared to non-formally employed mothers and 27 % less likely to breastfeed compared to unemployed mothers. Difference in median duration of breastfeeding between formally employed and unemployed mothers was 5.7 months for NNS-1999, 4.7 months for NNHS-2006 and 6.7 months for NNHS-2012 respectively (p < 0.05). In NHNS-2006 and NHNS-2012, health care access was associated with longer breastfeeding duration. Maternal employment has been negatively associated with breastfeeding in Mexican mothers of <1 year infants at least for the last 15 years. For Mexicans involved in policy design, implementation or modification, these data might offer robust evidence on this negative association, and can be used confidently as basis for conceiving a more just legislation for working lactating women.

Factors associated with infant feeding of human milk at discharge from neonatal intensive care: Cross-sectional analysis of nurse survey and infant outcomes data

CONTEXT

Nurses are principal caregivers in the neonatal intensive care unit and support mothers to establish and sustain a supply of human milk for their infants. Whether an infant receives essential nutrition and immunological protection provided in human milk at discharge is an issue of health care quality in this setting.

OBJECTIVES

To examine the association of the neonatal intensive care unit work environment, staffing levels, level of nurse education, lactation consultant availability, and nurse-reported breastfeeding support with very low birth weight infant receipt of human milk at discharge.

DESIGN AND SETTING

Cross sectional analysis combining nurse survey data with infant discharge data.

PARTICIPANTS

A national sample of neonatal intensive care units (N=97), nurses (N=5614) and very low birth weight infants (N=6997).

METHODS

Sequential multivariate linear regression models were estimated at the unit level between the dependent variable (rate of very low birth weight infants discharged on "any human milk") and the independent variables (nurse work environment, nurse staffing, nursing staff education and experience, lactation consultant availability, and nurse-reported breastfeeding support).

RESULTS

The majority of very low birth weight infants (52%) were discharged on formula only. Fewer infants (42%) received human milk mixed with fortifier or formula. Only 6% of infants were discharged on exclusive human milk. A 1 SD increase (0.25) in the Practice Environment Scale of the Nursing Work Index composite score was associated with a four percentage point increase in the fraction of infants discharged on human milk (p<0.05). A 1 SD increase (0.15) in the fraction of nurses with a bachelor's degree in nursing was associated with a three percentage point increase in the fraction infants discharged on human milk (p<0.05). The acuity-adjusted staffing ratio was marginally associated with the rate of human milk at discharge (p=.056). A 1 SD increase (7%) in the fraction of infants who received breastfeeding support was associated with an eight percentage point increase in the fraction of infants discharged on human milk (p<0.001).

CONCLUSIONS

Neonatal intensive care units with better work environments, better educated nurses, and more infants who receive breastfeeding support by nurses have higher rates of very low birth weight infants discharged home on human milk. Investments by nurse administrators to improve work environments and support educational preparation of nursing staff may ensure that the most vulnerable infants have the best nutrition at the point of discharge.

An IBCLC in the Maternity Ward of a Mother and Child Hospital: A Pre- and Post-Intervention Study

Published evidence on the impact of the integration of International Board Certified Lactation Consultants (IBCLCs) for breastfeeding promotion is growing, but still relatively limited. Our study aims at evaluating the effects of adding an IBCLC for breastfeeding support in a mother and child hospital environment. We conducted a prospective study in the maternity ward of our maternal and child health Institute, recruiting 402 mothers of healthy term newborns soon after birth. The 18-month intervention of the IBCLC (Phase II) was preceded (Phase I) by data collection on breastfeeding rates and factors related to breastfeeding, both at hospital discharge and two weeks later. Data collection was replicated just before the end of the intervention (Phase III). In Phase III, a significantly higher percentage of mothers: (a) received help to breastfeed, and also received correct information on breastfeeding and community support, (b) started breastfeeding within two hours from delivery, (c) reported a good experience with the hospital staff. Moreover, the frequency of sore and/or cracked nipples was significantly lower in Phase III. However, no difference was found in exclusive breastfeeding rates at hospital discharge or at two weeks after birth.

Challenges to breastfeeding infants with phenylketonuria

Breastfeeding duration for infants with phenylketonuria (PKU) is less than other full-term infants. However, no study has examined the challenges encountered by mothers' breastfeeding infants with PKU. In 75 mothers of a child with PKU, three categories of breastfeeding challenges were identified: common breastfeeding issues, breastfeeding and PKU, and no challenges. The common breastfeeding issues can be identified in the literature but for these mothers, the issues are heightened due to frequent phenylalanine (Phe) monitoring. Even so, many mothers adapt breastfeeding to maintain desired Phe levels. A few mothers had no issues and were the exception, not the norm.

Process-oriented training in breastfeeding for health professionals decreases women's experiences of breastfeeding challenges

BACKGROUND

The World Health Organization recommends promoting exclusive breastfeeding for six months. Women often end breastfeeding earlier than planned, however women who continue to breastfeed despite problems often experience good support and counselling from health professionals. The aim of this study was to evaluate the effects of a process-oriented training in breastfeeding support counselling for midwives and child health nurses, on women's satisfaction with breastfeeding counselling, problems with insufficient breast milk and nipple pain in relation to exclusive breastfeeding shorter or longer than 3 months.

METHODS

An intervention through process-oriented training for health professionals regarding support in childbearing and breastfeeding took part in the south west of Sweden. This study was conducted in Sweden, in 2000 - 2003. Ten municipalities were paired, and within each pair, one was randomly assigned to the group of five intervention (IG) municipalities and one to the group of five control municipalities. Primiparas (n = 540) were invited to participate in a longitudinal study to evaluate the care they received. A survey was distributed at 3 days, 3 months and 9 months postpartum. Data collection for control group A (n = 162) started before the intervention was initiated. Data for control group B (n = 172) were collected simultaneously with the intervention group (IG) (n = 206). Women were also divided into two groups depending on whether they exclusive breastfed < 3 months or ≥ 3 months.

RESULTS

Women in IG were more satisfied with the breastfeeding counselling (p = 0.008) and felt the breastfeeding counselling was more coherent (p = 0.002) compared to control groups, when exclusive breastfeeding was < 3 months. In addition fewer women in the IG, among the group exclusively breastfeeding < 3 months, had problems with insufficient breast milk compared to the control groups (p = 0.01).

CONCLUSION

A process-oriented training for health professionals in support influenced women's ability to solve breastfeeding problems such as the experience of insufficient breast milk production. Women with exclusive breastfeeding lasting ≥ 3 months more often had breastfeeding duration in line with their planned breastfeeding duration, compared to women who had breastfeeding duration < 3 months.

TRIAL REGISTRATION

ACTRN12611000354987.

Characteristics of the NICU work environment associated with breastfeeding support

PURPOSE

The provision of breastfeeding support in the neonatal intensive care unit (NICU) may assist a mother to develop a milk supply for the NICU infant. Human milk offers unique benefits and its provision unique challenges in this highly vulnerable population. The provision of breastfeeding support in this setting has not been studied in a large, multihospital study. We describe the frequency of breastfeeding support provided by nurses and examined relationships between NICU nursing characteristics, the availability of a lactation consultant (LC), and breastfeeding support.

SUBJECTS AND DESIGN

This was a secondary analysis of 2008 survey data from 6060 registered nurses in 104 NICUs nationally. Nurse managers provided data on LCs. These NICUs were members of the Vermont Oxford Network, a voluntary quality and safety collaborative.

METHODS

Nurses reported on the infants (n = 15,233) they cared for on their last shift, including whether breastfeeding support was provided to parents. Breastfeeding support was measured as a percentage of infants on the unit. The denominator was all infants assigned to all nurse respondents on that NICU. The numerator was the number of infants that nurses reported providing breastfeeding support. Nurses also completed the Practice Environment Scale of the Nursing Work Index (PES-NWI), a nationally endorsed nursing care performance measure. The NICU nursing characteristics include the percentages of nurses with a BSN or higher degree and with 5 or more years of NICU experience, an acuity-adjusted staffing ratio, and PES-NWI subscale scores. Lactation consultant availability was measured as any/none and in full-time equivalent positions per 10 beds.

RESULTS

The parents of 14% of infants received breastfeeding support from the nurse. Half of the NICUs had an LC. Multiple regression analysis showed a significant relationship between 2 measures of nurse staffing and breastfeeding support. A 1 SD higher acuity-adjusted staffing ratio was associated with a 2% increase in infants provided breastfeeding support. A 1 SD higher score on the Staffing and Resource Adequacy PES-NWI subscale was associated with a 2% increase in infants provided breastfeeding support. There was no association between other NICU nursing characteristics or LCs and nurse-provided breastfeeding support.

CONCLUSIONS

Nurses provide breastfeeding support around the clock. On a typical shift, about 1 in 7 NICU infants receives breastfeeding support from a nurse. Lactation consultants are not routinely available in NICUs, and their presence does not influence whether nurses provide breastfeeding support. Better nurse staffing fosters nurse provision of breastfeeding support.

Risk factors of breast problems in mothers and its effects on newborns

BACKGROUND

During lactation, especially the first few days after birth, some breast problems can cause pain and inadequate milk emptying.

OBJECTIVES

This study aimed to investigate the risk factors of breast problems and their effect on neonatal complications.

PATIENTS AND METHODS

This case-control study was conducted on 566 infants referred to Mashhad Ghaem Hospital clinic (from 2008 to 2012) in Iran. Researchers filled out the questionnaire with the relevant neonatal and maternal information. They also recorded the mothers' breasts problems after examination. Then the infants were divided into two groups: Infants whose mothers complained from breast problems (case group), and the infants whose mothers did not have any breast problems (control group). Finally, two groups were compared with respect to the maternal and neonatal risk factors.

RESULTS

THE TWO GROUPS WERE MATCHED ON THESE VARIABLES: parity (P = 0.861), maternal weight (P = 0.577), education level (P = 0.807), pregnancy complications (P = 0.383), gestational age (P = 0.161), Apgar score (P = 0.530), birth weight (P = 0.090), infant gender (P = 0.439), and infant age (P = 0.152). Case group vs. control group showed significant differences regarding prenatal care, mode of delivery, lactation status and the letdown reflex, serum sodium, frequency of urination and defecation, new weight and supplementation (P < 0.05).

CONCLUSIONS

According to our study, breast problems were fewer in mothers who had prenatal care, normal vaginal delivery, proper breastfeeding position, and let down reflex. Neonatal complications of breast problems include pathologic weight loss and decrease in the frequency of urination. Therefore, special attention to mother's breasts during pregnancy and in the early days of delivery, and their appropriate treatment may reduce breast problems and related neonatal complications.

Validation of the breastfeeding experience scale in a sample of Iranian mothers

Objectives. The aim of this study was to validate the breastfeeding experience scale (BES) in a sample of Iranian mothers. Methods. After translation and back translation of the BES, an expert panel evaluated the items by assessing the content validity ratio (CVR) and content validity index (CVI). 347 of mothers visiting health centers completed the Farsi version of the BES in the first month postpartum. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed to indicate the scale constructs. Reliability was assessed by Cronbach's alpha coefficient. Results. CVR and CVI scores for the BES were 0.96 and 0.87, respectively. Cronbach's alpha coefficient for the BES was 0.83. The results of the EFA revealed a new 5-factor model. The results of the CFA for the BES indicated a marginally acceptable fit for the proposed model and acceptable fit for the new model (RMSEA = 0.064, SRMR = 0.064, χ²/df = 2.4, and CFI = 0.95). Mothers who were exclusively breastfeeding at the first month postpartum had less breastfeeding difficulties score (30.3 ± 7.6) than mothers who were on partial breastfeeding (36.7 ± 11.3) (P < 0.001). Conclusions. The Farsi version of the BES is a reliable and valid instrument to assess postpartum breastfeeding difficulties in Iranian mothers.

Evidence-based interventions to support breastfeeding

Considerable progress has been made in the past decade in developing comprehensive support systems to enable more women to reach their breastfeeding goals. Given that most women in the United States participate in some breastfeeding, it is essential that each of these support systems be rigorously tested and if effective replicated. Additional research is needed to determine the best methods of support during the preconception period to prepare women to exclusively breastfeed as a cultural norm.

The influence of culture on breast-feeding decisions by African American and white women

The purpose of this study was to examine how culture influenced breast-feeding decisions in African American and white women, using the Theory of Culture Care Diversity and Universality as a framework. One hundred eighty-six participants responded to the following: The word culture means beliefs and traditions passed down by your family and friends. How has culture affected how you plan to feed your baby? Qualitative content analysis was used to analyze the data. Four categories of responses were identified: influences of family, known benefits of breast-feeding, influences of friends, and personal choice. The findings suggest that race alone may not be as influential in infant feeding decisions as other factors. Although some women acknowledged the effect of their cultural background and experiences, most women reported that their culture did not affect their infant feeding decision. In this population, breast-feeding decisions were based on the influences of family, friends, self, and the perceived knowledge of breast-feeding benefits. Although breast-feeding statistics are commonly reported by race, cultural influences on infant feeding decisions may transcend race and include the influence of family and friends, learned information from impersonal sources, and information that is shared and observed from other people.

Breastfeeding status and some related factors in northern iran

OBJECTIVES

The main objective of this study is to assess the Breastfeeding Duration, Exclusive Breastfeeding Duration and other related factors among children aged less than 5 years old in rural areas of Northern Iran.

METHODS

This is a descriptive cross-sectional conducted on 2520 children aged 6-60 months (male: 1309, female: 1211) chosen by cluster random sampling from 20 out of 118 villages. Data were collected from mothers using a questionnaire. The duration of breastfeeding was computed only for children aged over 24 months old. Breastfeeding duration and Exclusive Breastfeeding Duration were classified based on WHO definition. SPSS Version 16 was used for data analysis.

RESULTS

The mean Exclusive Breastfeeding Duration was 5.59 months, while 66.4% of children had exclusive breastfeeding for at least 6 months. The lowest Exclusive Breastfeeding Duration and the highest Breastfeeding Duration were observed among the Turkman ethnic group. Exclusive Breastfeeding duration of at least 5 months was 14.6%, thus the results were significantly higher than in the Turkman ethnic group (p=0.001). Meanwhile, the results showed that exclusive breastfeeding duration significantly increased with maternal education level (p=0.004). The study found that the mean breastfeeding duration was 20.6 months, and 89.3% and 74.7% of children were breastfed for at least 18 and 24 months, respectively. A positive correlation was reported between breastfeeding duration and family size, birth order, maternal age and children nutritional status, (p<0.05). Additionally, lactation period in underweight children was significantly higher than in obese children, (p=0.023).

CONCLUSION

The study found that two-thirds of children exclusively breastfed during the first six months of life and the mean breastfeeding duration was 20.6 months. While both exclusive breastfeeding duration and breastfeeding duration were influenced by socio-demographic factors in the rural areas of Northern Iran.

An exploration of the attitudes and experiences of mothers in the United Kingdom who chose to breastfeed exclusively for 6 months postpartum

BACKGROUND

Levels of exclusive breastfeeding are negligible in the United Kingdom despite World Health Organization recommendations to practice exclusive breastfeeding for the first 6 months postpartum. Although numerous studies have explored the reasons behind low levels of breastfeeding, few have examined the behaviors of women who do breastfeed successfully. However, understanding the influences upon the decision to breastfeed exclusively is important in supporting women to continue breastfeeding.

METHODS

In the current study, 33 women with an infant 6-12 months old who exclusively breastfed for the first 6 months postpartum took part in an interview to explore their motivation and experiences while breastfeeding. The interview explored issues such as sources of support, difficulties, and familial and peer behavior.

RESULTS

Mothers reported high levels of confidence and determination in their decision despite difficulties in reaching their goal and discussed a range of techniques they adopted to overcome issues faced.

CONCLUSIONS

Ingrained and strong beliefs that their choice of feeding method was the normal and healthiest way to feed an infant enabled mothers to overcome problems and continue breastfeeding.

Defining lactation acuity to improve patient safety and outcomes

While substantial evidence exists identifying risks factors associated with premature weaning from breastfeeding, there are no previously published definitions of patient acuity in the lactation field. This article defines evidence-based levels of lactation acuity based on maternal and infant characteristics. Patient acuity, matching severity of illness to intensity of care required, is an important determinant of patient safety and outcomes. It is often used as part of a patient classification system to determine staffing needs and acceptable workloads in health care settings. As acuity increases, more resources, including more skilled clinicians, are needed to provide optimal care. Developing an evidence-based definition of lactation acuity can help to standardize terminology, more effectively distribute health care staff resources, encourage research to verify the validity and reliability of lactation acuity, and potentially improve breastfeeding initiation and duration rates.

Breastfeeding educational interventions for health professionals: a synthesis of intervention studies

PURPOSE

The purpose of this synthesis was to review intervention studies that focused on increasing the breastfeeding knowledge, self-confidence, and supportive behaviors of healthcare professionals.

DESIGN AND METHODS

Fourteen articles were identified through database searches as the basis for this review.

RESULTS

Breastfeeding education can be effective in increasing the knowledge and confidence of nurses. Duration and exclusivity rates for breastfeeding may also be improved.

PRACTICE IMPLICATIONS

Improving nurses' knowledge of breastfeeding is a modifiable factor that is important in supporting a mother in her decision to breastfeed.

Health care and social service providers' descriptions of pacific islander mothers' breastfeeding patterns

INTRODUCTION

Despite recommendations and numerous health benefits attributed to breastfeeding, rates in the United States are below desired levels, particularly within vulnerable populations. In Hawaií, breastfeeding rates are higher than national averages except in Native Hawaiian and other Pacific Islander populations. Health care and social service providers are integral to successful breastfeeding promotion efforts. They are in an ideal position to reflect on the context in which their clients live and on its relationship to breastfeeding activities. The aim of this study was to describe health care and social service providers' perceptions of the influences on the breastfeeding patterns of Pacific Islander women.

METHODS

Focus ethnographic methods were used to collect interview data from health care and social service providers (N=20) serving Native Hawaiian and Pacific Islander women in one rural community. An iterative analysis process of coding and categorizing, followed by conceptual abstraction into patterns, was completed.

RESULTS

Four patterns emerged: shaped by connections, lived unfamiliarity, stressed by circumstance, and missed opportunities. Participants' insights concerning the needs of this population yielded population-specific issues and health care system issues affecting breastfeeding promotion. A number of gaps in breastfeeding services were identified.

DISCUSSION

Sociocultural, maternal knowledge, and workload barriers to successful breastfeeding predominated providers' perspectives. Broader system and community level issues were implied, but not directly addressed. The nature of successful breastfeeding support and promotion requires inclusion of this broader level perspective.

Relactation, translactation, and breast-orogastric tube as transition methods in feeding preterm babies

The transition from tube feeding to exclusive breastfeeding represents an important period for preterm babies because of their clinical fragility and immature development. This study describes this transition in preterm infants in relation to different feeding approaches: relactation, translactation, and breast-orogastric (OG) tube, considering the duration of the transition, weight gain in the transition, feeding-related problems, and breastfeeding status at discharge. This is a descriptive study of a series of 432 babies using retrospective data from the medical records at the IMIP Kangaroo Mother Care Unit, in the northeast of Brazil. At discharge, the percentage of babies who were exclusively breastfed in the relactation, translactation, and breast-OG tube groups were 85%, 100%, and 100%, respectively, with a satisfactory transition time and weight gain and with 1.6% of cases with feeding-related problems. The results showed that the relactation, translactation, and breast-OG tube seem to be efficient methods in the feeding transition of preterm infants.

Variables associated with breastfeeding duration

OBJECTIVE

To identify the variables associated with breastfeeding duration.

DATA SOURCES

The health science reference databases of CINAHL, PubMed, and the Cochrane Database of Systematic Reviews.

STUDY SELECTION

Meta-analyses, Cochrane reviews, literature reviews, and quantitative and qualitative studies published in English from 1998 through 2008.

DATA EXTRACTION

Data included all variables, both positive and negative, that were found to influence the outcome of breastfeeding duration.

DATA SYNTHESIS

Demographic factors that influence breastfeeding duration are race, age, marital status, education, socioeconomics, and Special Supplemental Nutrition Program for Women, Infants, and Children status. Biological variables consisted of insufficient milk supply, infant health problems, maternal obesity, and the physical challenges of breastfeeding, maternal smoking, parity, and method of delivery. Social variables included paid work, family support, and professional support. Maternal intention, interest, and confidence in breastfeeding were psychological variables.

CONCLUSION

Human lactation is a complex phenomena and the duration of breastfeeding is influenced by many demographic, physical, social, and psychological variables.

Cold storage of human milk: effect on its bacterial composition

OBJECTIVES

In the last few years, it has been proved that human milk contains bacteria that constitute an important factor in the initiation and development of the neonatal gut microbiota. In this context, the objective of this study was to evaluate the effect of cold storage on the natural bacterial composition of breast milk.

MATERIALS AND METHODS

Breast milk samples provided by 34 healthy women and collected either by manual expression (n = 27) or breast pump (n = 7), were plated onto several culture media immediately after arrival at the laboratory (day 0) and after storage at -20 degrees C for 6 weeks. A high number of isolates from 8 of the women were identified at the species level.

RESULTS

No statistically significant differences were observed between the counts obtained at both sampling times in those media in which growth was detected. In all of the culture media, bacterial counts in pump-collected samples were higher than in those obtained by manual expression. Staphylococci and streptococci were the predominant bacteria in both fresh and frozen samples, Staphylococcus epidermidis being the most abundant species at both sampling times. Lactic acid bacteria and bifidobacteria were also present in fresh and frozen breast milk samples, but among them, only 1 species (Lactobacillus gasseri) could be isolated at both sampling times.

CONCLUSIONS

The results of this study suggest that cold storage of milk at -20 degrees C for 6 weeks does not significantly affect either the quantitative or the qualitative bacterial composition of breast milk.

Clinical translational research hits the road: RCT of breastfeeding promotion interventions in routine prenatal care

Translating evidence-based research into practice requires data from clinical trials in real world settings. This paper presents "lessons learned" from the implementation of an RCT of breastfeeding promotion interventions at two busy, urban, prenatal care sites. Data were obtained via direct observations, qualitative interviews, and study statistics. Primary challenges include: time and space burdens, "research vs. service" mission conflict, and the provider learning curve for conducting interventions. Primary facilitators include: researcher presence for enhancing rapport with participants and staff, site staff labeling of both the research interview and intervention as "value added time," and the ability of research staff to assist the clinic beyond the scope of the clinical trial. Specific suggestions are given for building collaborative bonds between the research team, clinicians, administrators, and staff in busy urban practices.

Doação de leite humano: experiência de mulheres doadoras

OBJETIVO: Descrever características do comportamento de doação e identificar motivos, crenças e sentimentos relativos a essa prática, segundo relatos de mulheres doadoras. Foram investigados ainda aspectos pessoais e socioambientais de mulheres doadoras e ex-doadoras que parecem afetar a conduta de doação. MÉTODOS: Foi realizado estudo exploratório, descritivo e transversal com mulheres doadoras cadastradas em dois bancos de leite da rede pública de saúde do Distrito Federal, com coleta de dados no período de julho a setembro de 2005. Participaram 36 mulheres com idades que variaram de 14 a 33 anos (média=24,78; dp=5,22), com diferentes níveis de escolaridade, sendo 58,3% primigestas. O procedimento de coleta de dados baseou-se em entrevistas domiciliares. Além das análises estatísticas descritivas, procedeu-se à análise de conteúdo categorial dos dados qualitativos. RESULTADOS: Os motivos mais citados para a doação de leite foram altruísmo e excesso de produção lática. O intervalo de tempo mais freqüente para a concretização da doação foi de 13 dias após o parto. Contato telefônico com o banco de leite foi a conduta adotada pela maioria das participantes (n=22) para obtenção de informações que favoreceram o início do processo de doação. CONCLUSÕES: Foram identificados aspectos psicossociais e experiências de mulheres doadoras que poderão contribuir para o fortalecimento da rede de apoio social formal e informal para doação, além de servir de estímulo para a implementação de estratégias técnicas e políticas que favoreçam a prática de doação.

[Exclusive and mixed breastfeeding in a maternity unit in France, 2003]

PURPOSE

To assess how exclusive and mixed breastfeeding varied depending on the characteristics of the mother, the newborn, and place of birth.

METHODS

A national representative sample of births included 14,580 live births. During the hospital stay, mothers were asked if the infant was exclusively breastfed, breast and bottle-fed (mixed), or only bottle-fed. The factors associated with exclusive breastfeeding and those associated with mixed breastfeeding were compared using a multinomial logistic regression model.

RESULTS

Of the women studied, 56.3% breastfed exclusively and 6.3% used mixed breastfeeding. Exclusive and mixed breastfeeding were higher among primiparous, non-French, and highly educated women. Non-French nationality had a stronger effect on mixed breastfeeding than on exclusive breastfeeding (adjusted odds ratio [aOR], 9.9 and 5.2, respectively, among women from North Africa). A high level of education played a greater role in exclusive breastfeeding (aOR, 2.5) than mixed breastfeeding (aOR, 1.8). Breastfeeding was higher in the Ile-de-France, East, Central-East, and Mediterranean regions, with stronger variations in mixed breastfeeding than in exclusive breastfeeding.

CONCLUSION

Clear social disparities in exclusive and mixed breastfeeding exist depending on maternal social class and nationality, and region of birth. Particular breastfeeding promotion actions could target groups or regions where women are less likely to breastfeed.

An analysis of infant feeding content found within the Hong Kong print media

Worldwide public media greatly affect women's decisions about infant feeding and may not reflect evidence-based practices. The aims of this research were to (1) describe the characteristics of printed articles having infant-feeding content, (2) describe this thematic content, and (3) compare the thematic content found in groupings based on media type and language (English and Chinese). Four Chinese-language newspapers, the English-language newspaper, and 3 bilingual parenting magazines were analyzed. A multiphase qualitative and quantitative content analysis found 5 themes (social context, mothers' information, effects on baby, the value of breast milk, and the utility of formula). Significant differences were found based on media type and language. Although breastfeeding was usually positively framed in all the media, Chinese media had more inaccurate information. Through this analysis, areas where actions could be taken to improve the quality of information about infant feeding received by the public have been identified.

Breast feeding initiation and duration: comparison of French and German mothers

BACKGROUND

approximately 56% of babies in France are breast fed at birth compared with approximately 91% in Germany. Few studies have compared these neighbouring countries despite the similarities in their social systems.

OBJECTIVES

to compare breast-feeding initiation and duration from birth to 3 months post partum between French and German mothers, as well as reasons for breast-feeding cessation in the first 3 months.

DESIGN

mothers were contacted twice during the study: immediately after childbirth and at 3 months post partum.

PARTICIPANTS

126 French mothers were recruited during their maternity stay in hospital, and 80 German women were recruited by their midwives and contacted via regular mail. All women were primiparous.

METHODS

breast-feeding rates at birth and 3 months post partum were collected and compared. In addition, reasons for breast-feeding cessation in the first 3 months were explored and analysed.

RESULTS

96% of German women initiated breast feeding at birth and 83% were still breast feeding at 3 months post partum. In comparison, 67% of French women initiated breast feeding at birth and 34% were still breast feeding at 3 months post partum.

CONCLUSION

there is a need for postnatal follow-up care for French mothers who breast feed. Follow-up care available for German mothers shows encouraging results.

Breastfeeding practice in the UK: midwives' perspectives

Despite breastfeeding prevalence increasing, many mothers in developed countries are dissatisfied with care provided by midwives. However, a paucity of research exists related to midwives' experiences of supporting breastfeeding mothers. This study explored the experiences of English midwives' during their breastfeeding support role. A qualitative study using grounded theory principles was used. Data were collected using in-depth interviews and analysed using constant comparative techniques. The setting was two maternity hospitals in the North of England, UK. Thirty midwives who cared for normal, healthy babies participated. Volunteers were recruited using theoretical sampling techniques. The core category that emerged is called 'surviving baby feeding' and relates to midwives' experiences when supporting mothers. The results reported in this paper refer to one category called 'doing well with feeding' which has three main themes: (1) communicating sensitively, (2) facilitating breastfeeding, and (3) reducing conflicting advice. Participating midwives reported practice that suggests that they valued breastfeeding, attempted to provide realistic information and advice, and tried to minimise confusion for mothers. However, some midwives used an authoritative manner when conversing with mothers. English midwives' reported practice demonstrates that these midwives appreciated that breastfeeding mothers required specific support. However, breastfeeding education that encourages midwives to develop effective skills in ascertaining mother's needs, but also encourages mothers to effectively participate in their care, should be provided. Further research is needed to clarify breastfeeding mothers' expectations and needs.

Outcomes of a breastfeeding educational intervention for baccalaureate nursing students

Educational institutions have the responsibility to provide students with knowledge and practical experiences of best practices and international standards of care. Worldwide, international standards for appropriate and effective breastfeeding promotion and services often have not been met. The aim of this study was to determine the effectiveness of an infant feeding educational intervention on student nurses' knowledge levels about (1) evidence-based breastfeeding promotion, (2) evidence-based beliefs about outcomes of breastfeeding and formula-feeding, (3) evidence-based attitudes toward breastfeeding and formula-feeding, and (4) intention to perform evidence-based breastfeeding promotion behaviors. A quasi-experimental intervention with a non-equivalent control group was conducted at a major university in Hong Kong. The intervention group (n=111) received 10h of didactic instruction and an 8-week perinatal clinical rotation while the control group (n=162) did not. The intervention group was significantly more likely to associate breastfeeding with positive maternal and child outcomes. Attitudes toward breastfeeding and formula-feeding were not significantly affected by the educational intervention. On the 19-item knowledge survey, the control group (M=6.84; SD=2.95) scored significantly lower than the intervention group (M=10.30; SD=2.51). A public health breastfeeding promotion strategy frequently overlooked is professional-level curricular interventions. Improving evidence-based practices in nursing programs has the potential to impact many breastfeeding families in the hospital and the community.

Maternal-newborn nurses? experiences of inconsistent professional breastfeeding support

AIM

This paper is a report of a study to describe the meaning and significance of common, essential elements of inconsistent professional breastfeeding support as revealed through the experiences of maternal-newborn nurses in a hospital.

BACKGROUND

Professional breastfeeding support has been found to have a beneficial effect on breastfeeding, although mothers also report that inconsistent professional breastfeeding support has a negative influence on their breastfeeding efforts.

METHOD

An existential-phenomenological approach was used, and interviews were conducted with 12 maternal-newborn nurses between October 2005 and January 2006. Interview transcripts were subjected to thematic analysis.

FINDINGS

Inconsistency in professional breastfeeding support was directly related to the fact that 'supporting' breastfeeding is a dynamic, multidimensional process with relational, contextual and situational components. Eight themes were identified: Inconsistencies still exist but things are changing; A need for 'buy in'; There is no escaping personal experience; What works for one does not work for all; Time impacts recommendations; We have a privileged vantage point; 'My job': what it is and what it is not and After all, breastfeeding is a maternal 'choice'.

CONCLUSION

Addressing inconsistent professional breastfeeding support involves understanding the multiple institutional and personal factors that influence this phenomenon. Because multiple practitioners assist each mother-infant dyad in learning to breastfeed, fostering strong collaborative relationships within this support team is essential. Regular opportunities for all team members to dialogue and actively participate in the updating of breastfeeding policies may increase 'buy in', promote greater collaboration and decrease both conflict and inconsistencies.

Differential trends in breastfeeding according to maternal and hospital characteristics: results from the French National Perinatal Surveys

AIM

To assess breastfeeding trends in hospital, between 1998 and 2003, according to several characteristics of mothers and maternity units.

METHODS

Two representative national samples of births, comprising 13,600 live births in 1998 and 14,580 in 2003 were used. Data were collected during hospital stay. All newborns fed entirely or partly on breast milk were considered 'breastfed'. Univariate and multivariate analyses were used to compare the results for the 2 years.

RESULTS

Breastfeeding increased in all groups, but this increase varied slightly according to maternal age and the size of the maternity unit. For example, high rates of breastfeeding tended to be concentrated in large maternity units (> or = 1500 deliveries per year) in 1998, but were also found in middle-size units (1000-1499 deliveries per year) in 2003. In 2003, women were more likely to breastfeed if they were at least 25 years old, primiparous, non-French or from a highly qualified occupational group, or if they gave birth in a university hospital or in a maternity unit with more than 1000 deliveries per year.

CONCLUSION

Despite recent efforts to increase the breastfeeding rate, clear social disparities persist and further efforts are required, targeting particular groups of mothers less likely to breastfeed.

Influence of intimate partner violence during pregnancy and early postpartum depressive symptoms on breastfeeding among chinese women in Hong Kong

Numerous studies show that breastfeeding is beneficial to both mothers and babies. This study explores two understudied correlates that may influence breastfeeding initiation: intimate partner violence during pregnancy and early postnatal depressive symptoms. A cross-sectional comparative study design investigated the correlates of feeding modes of 1200 Chinese mother and infant pairs in a university-affiliated regional hospital in Hong Kong. The prevalence rates of breastfeeding and mixed feeding were 42.25% and 26.25%, respectively. Women who had no experience of intimate partner violence during pregnancy were significantly more likely to initiate breastfeeding (adjusted odds ratio = 1.84; 95% confidence interval, 1.16-2.91) after adjustment for demographic, socioeconomic, and obstetric variables. Early postnatal depressive symptoms were not significantly associated with feeding modes in a multinomial logistic regression model. Midwives are in a key position to identify and intervene to encourage more successful breastfeeding practice.

Barriers and facilitators for breastfeeding among working women in the United States

OBJECTIVE

To review the literature and describe the barriers and facilitators to the continuation of breastfeeding for at least 6 months by working women in the United States.

DATA SOURCES

A search of PubMed, CINAHL, Sociological Abstracts, ISI, PsychInfo, and ProQuest.

STUDY SELECTION

Twenty studies based on the inclusion criteria and published between January 1, 1995, and January 2006.

DATA EXTRACTION

An ecologic framework, which includes the individual (microsystem), social support and relationships (mesosystem), and the workplace environment (exosystem).

DATA SYNTHESIS

When working mothers possess certain personal characteristics and develop a strategic plan, breastfeeding is promoted. When social support is available and when support groups are utilized, lactation is also facilitated. Part-time work, lack of long mother-infant separations, supportive work environments and facilities, and child care options facilitate breastfeeding.

CONCLUSIONS

Health care providers can use the findings of this review to promote breastfeeding among working women by using tactics geared toward the mother, her social network, and the entire community.

Policies and Practices for Maternal Support Options during Childbirth and Breastfeeding Initiation After Cesarean in Southeastern Hospitals

OBJECTIVE

To describe policies, practices, and associated rationales of hospital obstetric units regarding mothers' support person options during childbirth and to explore practices concerning support of breastfeeding initiation after cesarean delivery.

DESIGN

Descriptive telephone survey.

SETTING

Hospitals in the southeastern region of the United States.

PARTICIPANTS

Convenience sample of 154 obstetric nurse manager and nurse representatives employed by the participating hospitals.

MAIN OUTCOME MEASURES

Types of policies regarding mothers' support person options during childbirth and immediate postpartum stage, initiation of breastfeeding after cesarean birth, and attitudes about policies.

RESULTS

All hospitals allowed two or more support persons during vaginal births, 89% permitted only one support person during nonemergent cesareans, and 58.0% of the nurse representatives believed that mothers should be allowed a second support person. Less than one third (31.2%) of the hospitals considered a mother's request to breastfeed in the operating room, and most (78.6%) allowed mothers to breastfeed in the recovery room.

CONCLUSIONS

Overall, maternal support policies, practices, and nurse representatives' attitudes were mother and family friendly, particularly related to vaginal births. Though breastfeeding initiation after cesarean birth was encouraging, support person options during nonemergent cesarean births and related rationales warrant further examination.