Modes of infant feeding and the occurrence of coughing/wheezing in the first year of life

Fresh Parent's Own Milk for Preterm Infants: Barriers and Future Opportunities

While direct at-the-breast feeding is biologically optimal, Neonatal Intensive Care Unit (NICU) admission due to infant immaturity or illness often necessitates the expression and storage of parent's milk. The provision of freshly expressed (never stored) parent's own milk to preterm infants is not widely prioritized, and this article provides an exploration of NICU practices and their implications for feeding premature or ill infants with parent's own milk. In this article, we discuss the potential biological benefits of fresh parent's own milk, highlighting its dynamic components and the changes incurred during storage. Research suggests that fresh milk may offer health advantages over stored milk. The authors advocate for further research, emphasizing the need for standardized definitions. Research is needed on the biological impact of fresh milk, both short- and long-term, as well as defining and understanding healthcare economics when using fresh milk.

A Qualitative Exploration of the Reasons for Expressed Human Milk Feeding Informed by the Breastfeeding Self-Efficacy Theory

BACKGROUND

There is an increasing prevalence of expressed human milk feeding. The reasons for expressed human milk feeding of healthy term infants may differ from those for preterm infants. The process of adopting expressed human milk feeding for healthy full-term infants has not been well-described in the existing literature.

RESEARCH AIM

To describe the reasons for, and antecedents to, expressed human milk feeding among Chinese women who used a high proportion of expressed human milk for feeding.

METHODS

A descriptive, prospective cross-sectional qualitative design was used. Participants (N = 25) who used a high proportion of expressed human milk feeding were recruited from a larger perspective cohort study in two public hospitals in Hong Kong. Semi-structured, in-depth, one-to-one interviews were conducted 2017-2018. Data collection and thematic analysis were guided by the Breastfeeding Self-Efficacy Theory.

RESULTS

The authors conducted thematic analysis and identified six core themes: (1) perceived maternal roles; (2) breastfeeding role models; (3) negative feedback from social networks; (4) negative direct breastfeeding experiences; (5) expressed human milk feeding as a solution to a problem; and (6) advice from health care professionals to express human milk. These themes were consistent with the four antecedents of the Breastfeeding Self-Efficacy Theory (e.g., physiological and affective state, vicarious experiences, performance accomplishments, and verbal persuasion).

CONCLUSIONS

The main reason for participants to feed expressed human milk was experiencing difficulties with direct breastfeeding. Expressed human milk feeding was used as an immediate solution for breastfeeding problems. Strengthening breastfeeding support in the early postpartum period may decrease the perceived need for human milk expression.

Factors Associated With Exclusive Direct Breastfeeding in the First 3 Months

OBJECTIVE

To identify factors associated with exclusive direct breastfeeding in the first 3 months among mother and infant dyads living in the United States.

DESIGN

A secondary analysis of data collected using a cross-sectional online survey completed over a 4-month period in late 2019.

PARTICIPANTS

We recruited a convenience sample of 370 mothers with healthy full-term singleton infants between 1 and 12 weeks of age whose feeding methods consisted of direct breastfeeding at least once a day. Mothers had not returned to work/school at the time of the survey completion.

MEASUREMENTS

The questionnaire consisted of 34 questions about maternal and infant factors that influence decisions about infant feeding, professional support, and parental preferences.

RESULTS

Mothers who practiced feeding on demand (adjusted OR [aOR] = 35.76, 95% confidence interval [CI] [2.04, 500.00]) and mothers of infants 1 to 4 weeks of age (aOR = 2.74, 95% CI [1.54, 4.85]) were more likely to use exclusive direct breastfeeding. The odds of exclusive direct breastfeeding decreased with mothers who breastfed with a nipple shield while in the hospital/birth center/home (aOR = 0.13, 95% CI [0.05, 0.35]), used pacifiers (aOR = 0.31, 95% CI [0.21, 0.65]), or had perceptions of insufficient milk (aOR = 0.11, 95% CI [0.04, 0.26]).

CONCLUSION

Demand feeding and an infant's age of 1 to 4 weeks contributed to exclusive direct breastfeeding. Lower rates of exclusive direct breastfeeding were associated with the use of nipple shields immediately after birth, pacifier use, and perceptions of insufficient milk. Further investigation is warranted to fully differentiate exclusive direct breastfeeding from exclusive breastfeeding.

Association between deleterious oral habits and asthma in children: a systematic review and meta-analysis

Deleterious oral habits (DOH) have been described as a common finding in pediatric series. Studies have investigated their association with local and systemic health problems. In this study, the association between DOH and asthma was investigated. PubMed, Scopus, Lilacs, Web of Science, Google Scholar, and OpenThesis were accessed to identify observational studies that evaluated the association between DOH (thumb sucking, pacifier use, onychophagia or nail biting, bottle feeding) and asthma in children aged 2-17 years. Information on DOH was obtained from the verbal report of the children's parents. Asthma diagnosis was performed by a physician or using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. We used a random-effects model to pool the results. The odds ratio (OR) was used as measure of association between DOH and asthma. The National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess risk of bias. The GRADE approach was used to assess the quality of evidence. Five studies were included and data from 18,733 children aged 2 to 13 years were analyzed. We found an association between bottle feeding and asthma (OR = 1.25; 95%CI 1.13-1.38; p < 0.001) with moderate level of certainty. Despite the association between pacifier use and asthma (OR = 1.11; 95%CI 1.00-1.24; p = 0.05), the quality of evidence was low. Only one study provided data on nail biting and thumb-sucking, and the individual results showed no association between these habits and asthma. This meta-analysis found an association between bottle feeding, pacifier use, and asthma in children.

Infant Feeding Practices During the First Postnatal Year and Risk of Asthma and Allergic Disease During the First 6 Years of Life

Background: Breastfeeding may protect against childhood asthma and allergic diseases. Studies have not focused on the mode of feeding human milk and followed children to school age although feeding human milk from a bottle rather than the breast may alter the risk of disease. Materials and Methods: At 12 months' postpartum, women in the Moms2Moms study (Columbus, OH) completed a survey assessing sociodemographic and infant feeding behaviors. At 6 years' postpartum, they completed a survey and pediatric medical records were abstracted to assess asthma and allergic disease diagnoses. Logistic regression models were used to estimate associations between infant feeding behaviors and asthma or allergic disease. Results: Of 285 children, 16% had asthma and 44% ever had ≥1 allergy diagnosis. Longer durations of each infant feeding behavior were not clearly associated with increased odds of asthma or allergic disease by age 6. Results suggested that longer durations of breast milk feeding (regardless of the mode of feeding) may be related to a lower risk of food allergy (e.g., odds ratio [OR]1-month, adjusted = 0.96, 95% confidence interval [CI] = 0.87-1.05; OR12-month, adjusted = 0.57, 95% CI = 0.19-1.74), but that the mode of feeding (regardless of the substance fed) may be more meaningful for environmental allergies (e.g., exclusive direct breast milk feeding OR12-month, adjusted = 0.32, 95% CI = 0.06-1.81). However, effect estimates were imprecise and CIs included the null. Conclusions: Although no clear associations between mode of breast milk feeding (breast versus expressed) and asthma and allergy outcomes were observed, future research with larger samples should further evaluate these associations.

Breastfeeding and wheeze-related outcomes in high-risk infants: A systematic review and meta-analysis

BACKGROUND

The risk of wheezing is high in infancy and is heightened in infants with a family history of asthma/atopy. The role of breastfeeding in influencing respiratory health for these high-risk infants is unclear.

OBJECTIVES

To systematically appraise evidence for the association between breastfeeding and wheeze incidences and severity in high-risk infants.

METHODS

Studies identified through electronic databases and reference lists were eligible if they assessed breastfeeding and respiratory outcomes in infants with a family history of asthma/atopy. The primary outcome was wheeze incidences in the first year of life. Secondary outcomes were wheeze incidences in the first 6 months of life, indicators of wheeze severity (recurrent wheeze, health-care utilization, and medication use), and other wheeze-related outcomes [bronchiolitis, pneumonia, croup, and incidence of lower respiratory tract infection (LRTI)] up to 12 months old. Meta-analyses were conducted where possible.

RESULTS

Of 1843 articles screened, 15 observational studies met the inclusion criteria. Breastfeeding was associated with 32% reduced odds of wheezing during the first year of life (ever vs. never: OR, 0.68; 95% CI: 0.53, 0.88; n = 9 studies); this association was even stronger in the first 6 months (OR, 0.45; 95% CI: 0.27, 0.75; n = 5 studies). Breastfeeding for a "longer" versus "shorter" time (approximately longer vs. shorter than 3 months) was associated with 50% reduced odds of wheezing at the age of 6 months (OR, 0.50; 95% CI: 0.39, 0.64; n = 3 studies).

CONCLUSIONS

Breastfeeding was associated with reduced odds of wheezing in high-risk infants, with the strongest protection in the first 6 months. More research is needed to understand the impact of breastfeeding intensity on wheezing and to examine additional respiratory outcomes, including wheeze severity. This review was registered at PROSPERO as CRD42019118631.

Marketing Breastfeeding Substitutes: A Discussion Document

Marketing influences knowledge, attitudes, and decisions related to infant and young child nutrition, safety, development, parental confidence, and other aspects of health and wellbeing of the child. These attitudes and behaviours of parents, health workers, policy makers, and other influencers have short- and long-term effects on the child. There is an International Code of Marketing of Breast-Milk Substitutes. Is it time to have a code of marketing of breastfeeding substitutes?

Work and breast milk feeding: a qualitative exploration of the experience of lactating mothers working in ready made garments factories in urban Bangladesh

BACKGROUND

In Bangladesh 65% of children under 6 months of age were exclusively breastfed with maternal employment being a risk factor that has jeopardized exclusive breastfeeding. As Ready Made Garment (RMG) factories have been the largest employer of low income women in Bangladesh, the objective of our study was to explore the barriers and facilitators of breastfeeding and perceptions about use of expressed breast milk among mothers who worked in the RMG sector.

METHODS

This formative research was conducted during July-September 2015 in two slums of Dhaka among RMG workers who were mothers and the caregivers of 0-12 month old infants. Qualitative data was obtained from purposively selected participants of 8 in-depth interviews and 4 focus group discussions (mothers and caregivers), and 2 key informant (RMG factory official) interviews. Mothers were from multiple RMG factories while factory officials were from a single factory. Thematic analysis was conducted.

RESULTS

The main themes of qualitative exploration were knowledge and experience of breastfeeding; structural barriers (home and workplace); consequences of inadequate breastfeeding; and perception and experience of using expressed breast milk. Despite knowledge both of the benefits of breast milk and of the importance of breastfeeding for 6 months, most mothers introduced formula as early as 2 months to prepare for their return to work. Barriers such as excessive workload, inadequate crèche facilities at work, and lack of adequate caregivers at home impeded exclusive breastfeeding. Mothers and caregivers had very little knowledge about the use of expressed breast milk and were concerned about contamination.

CONCLUSION

As RMG factories are the largest employer of low-income women in Bangladesh, facilitating RMG factory working mothers' ability to use breast milk could help to promote infant health and help women remain in the workforce.

Reliability of Maternal Recall of Feeding at the Breast and Breast Milk Expression 6 Years After Delivery

Background: The reliability of long-term maternal recall of breastfeeding has been assessed previously, but not maternal milk expression (pumping) and child consumption of expressed milk. Objective: To examine the reliability of maternal recall of feeding at the breast, maternal milk expression, and child consumption of expressed milk 6 years after delivery using the Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS). Methods: At 12 months postpartum, women who delivered a singleton, live-born infant at >24 weeks of gestation at a major U.S. academic hospital completed BaByMERS. Five years later, they were recontacted to complete the same questionnaire. Kappa statistics (κ), intraclass correlation coefficient (ICC), and Bland/Altman plots examined agreement. Sociodemographics were examined through stratified comparisons. Results: Of 299 women who completed both questionnaires, 35% had a postgraduate education and 82% identified as white/Caucasian. Kappa statistics showed substantial agreement for ever breastfeeding or feeding breast milk (combined) (κ = 0.71, 95% confidence interval [CI]: 0.44-0.98) and ever feeding at the breast (κ = 0.76, 95% CI: 0.62-0.89). Recall for duration of feeding at the breast was excellent (ICC = 0.96, 95% CI: 0.95-0.97), and of maternal milk expression was slightly less so (ICC = 0.83, 95% CI: 0.80-0.97). Maternal minority race/ethnicity, lower educational attainment, unmarried marital status, public/no health insurance, and smoking were associated with lower reliability; these differences were usually small and not consistent across all feeding practices. Conclusions: Maternal recall of contemporary lactation and infant feeding using BaByMERS was strongly reliable 6 years after delivery. BaByMERS may be useful to collect recall data, with attention to subpopulations that may exhibit lower recall reliability.

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.

Breastfeeding and the Developmental Origins of Asthma: Current Evidence, Possible Mechanisms, and Future Research Priorities

Breastfeeding has many established health benefits, but its impact on asthma development is uncertain. Breastfeeding appears to have a positive and dose-dependent impact on respiratory health, particularly during early childhood and in high-risk populations; however, the strength and causality of these associations are unclear. It is challenging to compare results across studies due to methodological differences and biological variation. Resolving these inconsistencies will require well-designed, prospective studies that accurately capture asthma diagnoses and infant feeding exposures (including breastfeeding duration, exclusivity, and method of feeding), account for key confounders, evaluate dose effects, and consider effect modification and reverse causality. Mechanistic studies examining human milk bioactives and their impact on lung health and asthma development are beginning to emerge, and these will be important in establishing the causality and mechanistic basis of the observed associations between breastfeeding and asthma. In this review, we summarize current evidence on this topic, identify possible reasons for disagreement across studies, discuss potential mechanisms for a causal association, and provide recommendations for future research.

Protective effect of breastfeeding on recurrent cough in adulthood

RATIONALE

Breastfeeding protects from respiratory infections in early life but its relationship to recurrent cough and other respiratory outcomes in adult life is not well established.

METHODS

Infant feeding practices were assessed prospectively in the Tucson Children's Respiratory Study, a non-selected birth cohort and categorised into formula from birth or introduced <1 month, formula introduced ≥1 to <4 months and exclusive breastfeeding for ≥4 months. Infant feeding was assessed as an ordinal variable representing an increasing dose of breastmilk across the three categories. Recurrent cough was defined at 22, 26 and 32 years as ≥2 episodes of cough without a cold lasting 1 week during the past year. Covariates included participant sex, race/ethnicity and smoking as well as parental smoking, education, age and asthma. Covariates were evaluated as potential confounders for the relation between infant feeding and adult outcomes.

RESULTS

Of the 786 participants, 19% breastfed <1 month, 50% breastfed ≥1 to <4 months and 31% breastfed ≥4 months. The prevalence of recurrent cough at 22, 26 and 32 years was 17%, 15% and 16%, respectively. Each ordinal increase in breastfeeding duration was associated with a decreased risk of recurrent cough in adult life: adjusted OR=0.71, (95% CI: 0.56 to 0.89), p=0.004. Additional adjustment for concurrent adult asthma, wheeze, smoking and lung volume did not change these results.

CONCLUSION

Longer duration of breastfeeding reduces the risk of recurrent cough in adult life, regardless of smoking and other respiratory symptoms, suggesting long-term protective effects on respiratory health.

Infant feeding pattern in the first six months of age in USA: a follow-up study

Background

Infant feeding may consist of direct breastfeeding (DBF), pumping and bottle feeding (P&F), formula feeding (FF), solid food feeding (SFF), and any combination. An accurate evaluation of infant feeding requires descriptions of different patterns, consistency, and transition over time.

Methods

In United States of America, the Infant Feeding Practice Study II collected information on the mode of feeding on nine occasions in 12 months. We focused on the first 6 months with six feeding occasions. To determine the longitudinal patterns of feeding the latent class transition analyses was applied and assessed the transition probabilities between these classes over time.

Results

Over 6 months, 1899 mothers provided feeding information. In month 1 the largest latent class is FF (32.9%) followed by DBF (23.8%). In month 2, a substantial proportion of the FF class included SFF; which increases over time. A not allocated class, due to missing information was identified in months 1-3, transitions to SFF starting in month 4 (8.9%). In month 1, two mixed patterns exist: DBF and P&F combined with FF (13.9%) and DBF combined with P&F (18.7%). The triple combination of DBF, P&F, and FF (13.9%) became FF in month 2 (transition probability: 24.8%), and DBF in combination with P&F (transition probability: 49.1%). The pattern of DBF combined with P&F is relatively stable until month 4, when at least 50% of these infants receive solid food. Only 23-26% of the infants receive direct breastfeeding (DBF) in months 1-4, in month 5-6 SFF is added. Mothers who used FF were less educated and employed fulltime. Mothers who smoke and not residing in the west of the United States were also more likely to practice formula feeding.

Conclusion

Infant feeding is complex. Breastfeeding is not predominant and we additionally considered the mixed patterns of feeding. To facilitate direct breastfeeding, a substantial increase in the duration of maternal leave is necessary in the United States.

Cognitive Testing of the Brief Breastfeeding and Milk Expression Recall Survey

BACKGROUND

Major U.S. federal maternal and child health surveys collect an infant feeding history for children under 6 years of age using survey questions that have changed little over decades. Yet, infant feeding and lactation practices have changed with the increasing popularity of milk expression (pumping).

SUBJECTS AND METHODS

Cognitive interviews were conducted to test the 9-item Brief Breastfeeding and Milk Expression Recall Survey (BaByMERS) with a diverse sample of 15 U.S. mothers of children 1-5 years of age. A 42-item coding scheme was applied to identify interviewer and respondent problems in fielding and answering the questions. Problems were examined in relation to demographics and infant feeding and lactation history.

RESULTS

The extent of problems was modest. Of 42 possible problem codes, only 9 were identified as actual problems for one or more respondents on one or more questions. The most common problems involved uncertainty about the timing of when one started expressing milk, making a mental shift to realize that maternal milk expression and the child's consumption of that milk could be distinct concepts, and difficulty with certain terms or phrases. Problems tended to arise among mothers with more complex infant feeding or lactation histories, who also tended to be those with higher levels of education.

CONCLUSIONS

BaByMERS is a promising, brief tool for collecting a recalled infant feeding or lactation history among mothers with young children. Future research can evaluate additional characteristics of the tool to further confirm its utility for large epidemiological studies of maternal and child health.

Modes of Infant Feeding and the Risk of Childhood Asthma: A Prospective Birth Cohort Study

OBJECTIVE

To determine whether different modes of infant feeding are associated with childhood asthma, including differentiating between direct breastfeeding and expressed breast milk.

STUDY DESIGN

We studied 3296 children in the Canadian Healthy Infant Longitudinal Development birth cohort. The primary exposure was infant feeding mode at 3 months, reported by mothers and categorized as direct breastfeeding only, breastfeeding with some expressed breast milk, breast milk and formula, or formula only. The primary outcome was asthma at 3 years of age, diagnosed by trained healthcare professionals.

RESULTS

At 3 months of age, the distribution of feeding modes was 27% direct breastfeeding, 32% breastfeeding with some expressed breast milk, 26% breast milk and formula, and 15% formula only. At 3 years of age, 12% of children were diagnosed with possible or probable asthma. Compared with direct breastfeeding, any other mode of infant feeding was associated with an increased risk of asthma. These associations persisted after adjusting for maternal asthma, ethnicity, method of birth, infant sex, gestational age, and daycare attendance (some expressed breast milk: aOR, 1.64, 95% CI, 1.12-2.39; breast milk and formula, aOR, 1.73, 95% CI, 1.17-2.57; formula only: aOR, 2.14, 95% CI, 1.37-3.35). Results were similar after further adjustment for total breastfeeding duration and respiratory infections.

CONCLUSIONS

Modes of infant feeding are associated with asthma development. Direct breastfeeding is most protective compared with formula feeding; indirect breast milk confers intermediate protection. Policies that facilitate and promote direct breastfeeding could have impact on the primary prevention of asthma.

Infant feeding patterns and eczema in children in the first 6 years of life

BACKGROUND

Modes of infant feeding such as direct and indirect breastfeeding, and formula feeding, and their combinations may play a role in child health.

OBJECTIVE

The aim was to investigate which feeding patterns in the first 6 months pose risks of eczema/skin allergy in children up to 6 years compared to direct breastfeeding for at least 3 months.

METHODS

The Infant Feeding Practices Study II in the United States and its 6-year follow-up provided data on feeding modes in infancy and doctor's diagnosed eczema/skin allergy in the first 6 years of life (1387 infants), based on parental reports. Different feeding patterns were identified. Log-linear models were used to estimate prevalence ratios (PRs) of feeding patterns for doctor's diagnosed eczema/skin allergy in the first 6 years of life, adjusting for confounders.

RESULTS

Compared to "direct breastfeeding for at least 3 months" (DBF3m), the combination of "direct feeding at the breast (DBF), pumping and feeding breast milk (BM), and formula (FF) in the first months" (DBF/BM/FF) showed a statistically significant higher risk of eczema/skin allergy in the first 6 years of life (PR = 1.46), adjusting for confounders. DBF combined with BM for the first 3 months followed by mixed feeding also had an increased risk (PR = 1.26), although not statistically significant. Formula feeding introduced since birth had no effect on eczema. Among the confounders, paternal eczema and race/ethnicity (Hispanic vs White) were associated with a higher risk of eczema/skin allergy.

CONCLUSIONS & CLINICAL RELEVANCE

Mixed infant feeding may carry a higher risk of eczema/skin allergy compared to direct feeding at the breast. The recent epidemic of pumping and feeding in the United States and the use of mixed infant feeding modes requires additional studies to provide appropriate and renewed assessments of the risks of feeding modes for the future development of allergies.

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

BACKGROUND

More than 85% of contemporary lactating women in the United States express their milk at least sometimes. Some produce milk exclusively through pumping. We characterized women who pumped but never fed at the breast and compared their infant feeding practices with those of women who fed at the breast with or without pumping.

SUBJECTS AND METHODS

Study participants were those delivered at Ohio State University Wexner Medical Center in 2011 and completed a questionnaire at 12 months postpartum (n = 478). We used bivariate and multivariate approaches (survival analysis) to compare women who pumped but never fed at the breast with women who fed at the breast with or without pumping.

RESULTS

Women (n = 33, 6.9%) who pumped but never fed at the breast comprised a diverse group but were more likely to have delivered preterm and were of lower socioeconomic status on average. They initiated pumping and formula feeding earlier (median = day 1 after delivery) and were more likely to report difficulty making enough milk compared with women who fed at the breast with or without pumping. They had much shorter total duration of milk production (adjusted hazard ratio = 3.3, 95% confidence interval: 2.1, 5.2) after controlling for clinical and sociodemographic confounders.

CONCLUSIONS

Pumping without feeding at the breast is associated with shorter milk feeding duration and earlier introduction of formula compared with feeding at the breast with or without pumping. Establishing feeding at the breast, rather than exclusive pumping, may be important for achieving human milk feeding goals.

Human milk expression as a sole or ancillary strategy for infant feeding: a qualitative study

In the United States, a significant proportion of human milk (HM) is now fed to infants from bottles. This mode of infant feeding is rarely measured or described in research studies or monitored by national surveillance systems. Consequently, little is known about expressed-HM feeding as an infant feeding strategy. Our objective was to understand how mothers use HM expression and expressed-HM feeding as a sole strategy or in combination with at-the-breast feeding to feed HM to their infants. We conducted semi-structured interviews with 41 mothers with experience of HM expression and infants under three years of age. Data were analysed using a grounded theory approach for sub-themes related to the pre-selected major themes of maternal HM production and infant HM consumption. Within the major theme of maternal HM production, sub-themes related to maternal over-production of HM. Many mothers produced more HM than their infant was consuming and stored it in the freezer. This enabled some infants to consume HM weeks or months after it was expressed. Within the major theme of infant HM consumption, the most salient sub-theme related to HM-feeding strategies. Four basic HM-feeding strategies emerged, ranging from predominant at-the-breast feeding to exclusive expressed-HM feeding. The HM-feeding strategies and trajectories highlighted by this study are complex, and most mothers fed HM both at-the-breast and from a bottle-information that is not collected by the current national breastfeeding survey questions. To understand health outcomes associated with expressed-HM feeding, new terminology may be needed.

Development, Construct Validity, and Reliability of the Questionnaire on Infant Feeding: A Tool for Measuring Contemporary Infant-Feeding Behaviors

BACKGROUND

The breastfeeding surveillance tool in the United States, the National Immunization Survey, considers the maternal-infant dyad to be breastfeeding for as long as the infant consumes human milk (HM). However, many infants consume at least some HM from a bottle, which can lead to health outcomes different from those for at-the-breast feeding.

OBJECTIVE

Our aim was to develop a construct-valid questionnaire that categorizes infants by nutrition source, that is, own mother's HM, another mother's HM, infant formula, or other and feeding mode, that is, at the breast or from a bottle, and test the reliability of this questionnaire.

DESIGN

The Questionnaire on Infant Feeding was developed through a literature review and modified based on qualitative research. Construct validity was assessed through cognitive interviews and a test-retest reliability study was conducted among mothers who completed the questionnaire twice, 1 month apart.

PARTICIPANTS/SETTING

Cognitive interviews were conducted with ten mothers from upstate New York between September and December 2014. A test-retest reliability study was conducted among 44 mothers from across the United States between March and May 2015.

MAIN OUTCOME MEASURES

Equivalence of questions with continuous responses about the timing of starting and stopping various behaviors and the agreement between responses to questions with categorical responses on the two questionnaires completed 1 month apart.

STATISTICAL ANALYSES PERFORMED

Reliability was assessed using paired-equivalence tests for questions about the timing of starting and stopping behaviors and weighted Cohen's κ for questions about the frequency and intensity of behaviors.

RESULTS

Reliability of the Questionnaire on Infant Feeding was moderately high among mothers of infants aged 19 to 35 months, with most questions about the timing of starting and stopping behaviors equivalent to within 1 month. Weighted Cohen's κ for categorical questions indicated substantial agreement.

CONCLUSIONS

The Questionnaire on Infant Feeding is a construct-valid tool to measure duration, intensity, and mode of infant HM consumption and duration of maternal HM production that is reliable within 19 to 35 months postpartum. Criterion-validity testing of these questions will improve the utility of the Questionnaire on Infant Feeding as a surveillance tool.

"Breastfeeding" but not at the breast: Mothers' descriptions of providing pumped human milk to their infants via other containers and caregivers

As pumping has become more prevalent among American women, pumped human milk (HM) is on the rise in their infants' diets in place of some or all feeding at the breast. We aimed to fill a gap in knowledge about mothers' motivations, practices and perceptions related to pumping, and about mothers' and other caregivers' motivations, practices, and perceptions related to feeding pumped HM. Results related to providing pumped HM are reported here, and results related to pumping are reported elsewhere. We conducted in-depth, semi-structured interviews among a diverse sample of mothers whose infants were fed pumped HM (n = 20), following each up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Nearly all mothers felt bottles were necessary to meet infant HM-feeding goals. Nearly all pumped HM was fed by other caregivers because mothers typically preferred and prioritized feeding at the breast for convenience and maintaining their milk supply. Infants were bottle-fed HM for several reasons that changed over time, such as mother's absence, latch difficulty, or desire to share the burden and bonding of feeding. Feeding practices differed between feeds from bottles versus at the breast; some infants were bottle-fed on schedules but fed at the breast on demand. Mothers' methods for storing, transporting, and preparing HM varied substantially and included practices associated with loss of nutrients and microbial contamination. Mothers' reasons for bottle-feeding HM may affect how much their infants are bottle-fed. Consumption of pumped HM may not provide the same benefits to infants as feeding at the breast. These findings highlight important avenues for future research into the relationships between bottle-feeding HM and infant health, growth, and developmental outcomes.

"Breastfeeding" without baby: A longitudinal, qualitative investigation of how mothers perceive, feel about, and practice human milk expression

Most American mothers who produce human milk (HM) now pump in place of some or all feeding at the breast, and most American infants are now fed pumped HM. We aimed to investigate mothers' perceptions of, attitudes toward, and practices for pumping and providing pumped HM. Results related to pumping are reported here. We conducted in-depth, semi-structured interviews among a diverse sample of 20 mothers who pumped, following each from pregnancy through infant HM-feeding cessation up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Mothers' reasons for pumping changed over time and reflected their needs and desires (e.g., latch difficulty, return to work, and increasing their milk supply). Mothers reported that pump type and quality were important to pumping success and that pumping was time-consuming, costly, and unpleasant compared to feeding at the breast. Regardless of how often mothers pumped, most felt pumping was necessary to meet their infant HM-feeding goals and was a welcome means of sharing with other caregivers the bonding opportunity and tasks they associated with feeding infants. Mothers interpreted output from pumping sessions to understand their ability to provide enough milk to meet their infants' needs. Mothers' reasons for pumping may signal constraints to infant HM feeding that may be addressed with policy changes. Mothers' attitudes and perceptions toward pumping indicate that, although pumping fills important and welcome roles for many mothers, the reality of its practice may make it an unacceptable or infeasible substitute for some.

Association Between Infant Feeding Modes and Gastroesophageal Reflux: A Repeated Measurement Analysis of the Infant Feeding Practices Study II

BACKGROUND

Gastroesophageal reflux in neonates is frequently reported by parents, potentially motivating changes in infant feeding mode and/or addition of solid food.

OBJECTIVE

The authors prospectively analyzed associations between repeated measurement of feeding modes and reflux in infancy.

METHODS

The Infant Feeding Practices Study II, conducted between 2005 and 2007 (2,841 infants), provides data on reflux and feeding modes at nine time points from months 1 to 12. Feeding modes were defined based on direct breastfeeding, feeding of bottled human milk, formula feeding, their combinations, and use of solid food. Repeated measurements were investigated using 1-month delayed models to estimate risk ratios (RRs) and their 95% confidence intervals (CIs). Risk ratios of different feeding modes were estimated for reflux; addressing a reverse association, RRs for feeding mode were estimated as responses to prior reflux.

RESULTS

Compared to direct breastfeeding, combinations with formula feeding showed a statistically significant risk for reflux (bottled human milk plus formula feeding: RR = 2.19, 95% CI [1.11, 4.33]; formula feeding: RR = 1.95, 95% CI [1.39, 2.74]; and mixed breastfeeding plus formula feeding: RR = 1.59, 95% CI [1.40, 2.42]). Addition of solid food was not protective (RR = 1.21, 95% CI [0.86, 1.70]). Analyses of reverse association (reflux → feeding) showed fewer breastfed infants among those with reflux in the prior month.

CONCLUSION

Any combination of infant feeding with formula seems to be a risk for reflux. Although breastfeeding was protective, mothers with a child with reflux were more likely to wean their child.

An Ecological Momentary Assessment of Primiparous Women's Breastfeeding Behavior and Problems From Birth to 8 Weeks

BACKGROUND

Primiparous women are at risk for early, unintended breastfeeding reduction and cessation. Breastfeeding patterns that contribute to these outcomes require further exploration. Research aim: This study aimed to describe early, "real-time" breastfeeding behaviors and perceived problems of primiparous women.

METHODS

First-time mothers intending to exclusively breastfeed downloaded a commercial infant-feeding app during their postpartum hospitalization. Women logged feedings and their breastfeeding experiences, as they occurred, through 8 weeks postpartum. Additional feeding and background data were collected via electronic medical records and questionnaires administered at enrollment and 2 and 8 weeks postpartum. Summary statistics were compiled to examine weekly breastfeeding behaviors and problems.

RESULTS

In this sample of 61 primarily highly educated, White women committed to breastfeeding, 38% ( n = 23) used formula during the postpartum hospitalization and 68% ( n = 34) used formula at least once by 2 weeks. Nine women stopped breastfeeding during the study. Women using any formula in the hospital and those with less positive baseline attitudes toward breastfeeding were less likely to be exclusively breastfeeding at 2 and 8 weeks, respectively ( p < .05). There was a trend toward declining at-breast feeds and high rates of milk expression during the study. Breastfeeding problems peaked at Week 2, with 81% of women ( n = 39) endorsing at least one problem at that time. The most prevalent problems included perception of inadequate milk, pain, latching, and inefficient feeds.

CONCLUSION

Interventions to address suboptimal breastfeeding in primiparous women should consider the pervasiveness of early milk expression and in-hospital formula supplementation in this population, as well as the trajectory of common problems.

Mothers' Use of Social Media to Inform Their Practices for Pumping and Providing Pumped Human Milk to Their Infants

Despite U.S. mothers’ wide adoption of pumps and bottles to provide human milk (HM) to their infants, mothers lack comprehensive, evidence-based guidelines for these practices. Thus, some women use online sources to seek information from each other. We aimed to characterize the information women sought online about pumping. We used data provided by ~25,000 women in an open cohort within a discussion forum about parenting. We examined 543 posts containing questions about providing pumped HM cross-sectionally and longitudinally in three time intervals: prenatal, 0 through 1.5 months postpartum, and 1.5 to 4.5 months postpartum. We used thematic analysis with Atlas.ti to analyze the content of posts. During pregnancy, women commonly asked questions about how and where to obtain pumps, both out-of-pocket and through insurance policies. Between 0–1.5 months postpartum, many mothers asked about how to handle pumped HM to ensure its safety as fed. Between 1.5–4.5 months postpartum, mothers sought strategies to overcome constraints to pumping both at home and at work and also asked about stopping pumping and providing their milk. Women’s questions related to ensuring the safety of pumped HM represent information women need from health professionals, while their questions related to obtaining pumps suggest that women may benefit from clearer guidelines from their insurance providers. The difficulties women face at home and at work identify avenues through which families and employers can support women to meet their goals for providing HM.

Reflux Incidence among Exclusively Breast Milk Fed Infants: Differences of Feeding at Breast versus Pumped Milk

The practice of feeding infants expressed breast milk is increasing in the United States, but the impacts on infant and maternal health are still understudied. This study examines the monthly incidence of regurgitation (gastro-esophageal reflux) in exclusively breast milk fed infants from ages two to six months. Among infants whose mothers participated in the Infant Feeding Practices II Study (IFPS II; 2005-2007), data on reflux and feeding mode were collected by monthly questionnaires. A longitudinal, repeated measures analysis was used, with feeding mode lagged by one month in order to compare reflux incidence among infants fed directly at the breast to infants receiving pumped breast milk. Mothers in both feeding groups had similar characteristics, although a greater proportion feeding at least some pumped milk were primiparous. The number of exclusively breastfed infants decreased steadily between months 2 and 6, although the proportion fed at the breast remained similar over time. An association between feeding mode and reflux incidence was not found; however, the analyses were limited by a small number of reported reflux cases. More studies are needed to further explain the relationship between different feeding modes and infant reflux.

[Epigenetic effects of human breastfeeding]

Breastfeeding is well-known for its benefits of preventing communicable and non-communicable diseases. Human breastmilk consists not only of nutrients, but also of bioactive substances. What's more, the epigenetic effects of human breast milk may also play an important role. Alterations in the epigenetic regulation of genes may lead to profound changes in phenotype. Clarifying the role of human breast milk on genetic expression can potentially benefit the infant's health and his later life. This review article makes a brief summary of the epigenetic mechanism of breast milk, and its epigenetic effects on neonatal necrotizing enterocolitis, infectious diseases, metabolism syndrome, cognitive function and anaphylactic diseases.

Factors associated to recurrent wheezing in infants under one year of age in the province of Salamanca, Spain: Is intervention possible? A predictive model

OBJECTIVES

Wheezing is a very common problem in infants in the first months of life. The objective of this study is to identify risk factors that may be acted upon in order to modify the evolution of recurrent wheezing in the first months of life, and to develop a model based on certain factors associated to recurrent wheezing in nursing infants capable of predicting the probability of developing recurrent wheezing in the first year of life.

METHODS

The sample was drawn from a cross-sectional, multicentre, descriptive epidemiological study based on the general population. A total of 1164 children were studied, corresponding to a questionnaire response rate of 71%. The questionnaire of the Estudio Internacional de Sibilancias en Lactantes (EISL) was used. Multiple logistic regression analysis was used to estimate the probability of developing recurrent wheezing and to quantify the contribution of each individual variable in the presence of the rest.

RESULTS

Infants presenting eczema and attending nursery school, with a mother who has asthma, smoked during the third trimester of pregnancy, and did not consume a Mediterranean diet during pregnancy were found to have a probability of 79.7% of developing recurrent wheezing in the first year of life. In contrast, infants with none of these factors were seen to have a probability of only 4.1% of developing recurrent wheezing in the first year of life. These results in turn varied according to modifications in the risk or protective factors.

CONCLUSIONS

The mathematical model estimated the probability of developing recurrent wheezing in infants under one year of age in the province of Salamanca (Spain), according to the risk or protective factors associated to recurrent wheezing to which the infants are or have been exposed.

Feeding at the Breast and Expressed Milk Feeding: Associations with Otitis Media and Diarrhea in Infants

OBJECTIVE

To examine the associations of substance fed and mode of breast milk delivery with occurrence of otitis media and diarrhea in the first year of life.

STUDY DESIGN

At 12 months postpartum, women (n = 813; 62% response) completed a questionnaire that assessed sociodemographics, infant occurrence of otitis media and diarrhea, and the timing of starting/stopping feeding at the breast, expressed milk, and formula. Women who intended to "bottle feed" exclusively were not recruited. Logistic and negative binomial regressions were conducted in the full sample (n = 491) and no-formula (n = 106) and bottle-only (n = 49) subsamples.

RESULTS

Longer duration of expressed milk feeding was associated with increased odds of experiencing otitis media (6-month OR [OR6-month] 2.15, 95% CI 1.01-4.55) in the no-formula subsample. Longer durations of breast milk feeding (OR6-month 0.70, 95% CI 0.54-0.92; 6-month incidence rate ratio [IRR6-month] 0.74, 95% CI 0.63-0.91), and feeding at the breast (OR6-month 0.70, 95% CI 0.54-0.89; IRR6-month 0.74, 95% CI 0.63-0.88) were associated with less diarrhea, and longer formula feeding duration was associated with increased risk of diarrhea (IRR6-month 1.34, 95% CI 1.13-1.54) in the full sample.

CONCLUSION

Substance fed and mode of breast milk delivery have different contributions to infant health depending on the health outcome of interest. Feeding at the breast may be advantageous compared with expressed milk feeding for reducing the risk of otitis media, and breast milk feeding compared with formula may reduce the risk of diarrhea.

Evaluating the efficacy of breastfeeding guidelines on long-term outcomes for allergic disease

BACKGROUND

WHO guidelines advocate breastfeeding for 6 months, and EAACI guideline recommends exclusive breastfeeding for 4-6 months. However, evidence for breastfeeding to prevent asthma and allergic disease is conflicting. We examined whether following recommended breastfeeding guidelines alters the long-term risks of asthma, eczema, rhinitis or atopy.

METHODS

The effect of nonexclusive (0, >0-6, >6 months) and exclusive breastfeeding (0, >0-4, >4 months) on repeated measures of asthma (10, 18 years), eczema, rhinitis, and atopy (1-or-2, 4, 10, 18 years) risks was estimated in the IoW cohort (n = 1456) using log-linear models with generalized estimating equations. The Food Allergy and Intolerance Research (FAIR) cohort (n = 988), also from the IoW, was examined to replicate results.

RESULTS

Breastfeeding (any or exclusive) had no effect on asthma and allergic disease in the IoW cohort. In the FAIR cohort, any breastfeeding for >0-6 months protected against asthma at 10 years (RR = 0.50, 95% CI = 0.32-0.79, P = 0.003), but not other outcomes, whilst exclusive breastfeeding for >4 months protected against repeated rhinitis (RR = 0.36, 95% CI = 0.18-0.71, P = 0.003). Longer breastfeeding was protective against late-onset wheeze in the IoW cohort.

CONCLUSION

The protective effects of nonexclusive and exclusive breastfeeding against long-term allergic outcomes were inconsistent between these colocated cohorts, agreeing with previous observations of heterogeneous effects. Although breastfeeding should be recommended for other health benefits, following breastfeeding guidelines did not appear to afford a consistent protection against long-term asthma, eczema, rhinitis or atopy. Further research is needed into the long-term effects of breastfeeding on allergic disease.

Pumping human milk in the early postpartum period: its impact on long-term practices for feeding at the breast and exclusively feeding human milk in a longitudinal survey cohort

BACKGROUND

Most American mothers who feed human milk (HM) now use pumps to produce some of the HM they feed. Pumping is nationally recommended, but associations between pumping and HM-feeding durations are unknown.

OBJECTIVES

We examined whether and how the pumping frequency and types of reasons for pumping between 1.5 and 4.5 mo postpartum are associated with HM-feeding durations. We classified pumping reasons as nonelective [e.g., because of a difficulty feeding at the breast (FAB)] or elective (e.g., to produce HM to mix with solids). We hypothesized that women who pumped more frequently or nonelectively would have shorter HM-feeding durations.

DESIGN

We used data from 1116 mothers in a longitudinal cohort who fed and pumped HM 1.5-4.5 mo postpartum. We used χ(2) and Cox proportional hazards regression models to examine the survival of any HM feeding, exclusive HM feeding, and FAB.

RESULTS

Compared with mothers who pumped for elective reasons, mothers who reported one nonelective reason had greater hazards of stopping feeding any HM (HR: 1.12; 95% CI: 1.05, 1.21) or exclusive HM (HR: 1.14; 95% CI: 1.09, 1.20) and of stopping FAB (HR: 2.07; 95% CI: 1.77, 2.42). Mothers who pumped most frequently had the highest mean hazards of stopping feeding any HM (HR: 1.82; 95% CI: 1.68, 1.93) and feeding exclusive HM (HR: 1.21; 95% CI: 1.14, 1.26). Hazards of stopping FAB varied across the year. Compared with the least-frequent pumpers, the most-frequent pumpers had a 2.6-fold higher hazard of stopping FAB at 3 mo postpartum and a 1.7-fold higher hazard at 6 mo postpartum.

CONCLUSIONS

Nonelective pumping reasons and higher pumping frequency were associated with shorter HM-feeding durations. Mothers who report that they use a breast pump for reasons related to either employment or FAB difficulty and their infants may be more vulnerable to risks associated with a shorter HM-feeding duration.

Effect of feeding pattern on infant illness in Chinese cities

OBJECTIVE

To investigate the effect of different feeding patterns on the occurrence of diseases among infants.

DESIGN

Data on socio-economic status, feeding patterns before 6 months (exclusive breast-feeding (EBF); mixed feeding with breast milk and formula (MBF); exclusive formula-feeding (EFF)) and illness of infants were collected via face-to-face interviews. The proportions of infants who had ever been ill or hospitalized and their potential influence factors were investigated.

SETTING

Eight large cities in China.

SUBJECTS

Infants (n 1654) aged 0-11·9 months were recruited from hospitals.

RESULTS

For infants aged 0-2·9 months, the percentage who had been ill was 19·2%, 24·1% and 26·3% among the EBF, MBF and EFF groups, respectively. For those aged 3-5·9 and 6-11·9 months, the corresponding percentages were 41·6%, 45·6% and 51·0%, and 67·0%, 73·4% and 67·7%. Respiratory disease was the most common reported illness and cause of hospitalization. The risks of having (total) illness, diarrhoea and respiratory disease increased significantly with age, but not allergic disease. Compared with EBF, MBF and EFF infants had significantly higher risks of having illnesses except for allergic disease, and feeding patterns were not related to hospitalization. Low birth weight, middle family income and low level of mother's education also increased the risk of illness.

CONCLUSIONS

A protective effect of EBF against total illness in urban Chinese infants was found. An increasing trend with age was observed among the percentages of infants who had been ill or had diarrhoea or respiratory disease, but not allergic disease.

Epigenomics and allergic disease

Allergic disease development is affected by both genes and the environment, and epigenetic mechanisms are hypothesized to mediate these environmental effects. In this article, we discuss the link between the environment, DNA methylation and allergic disease, as well as questions of causality inherent to analyses of DNA methylation. From the practical side, we describe characteristics of allergic phenotypes and contrast different epidemiologic study designs used in epigenetic research. We examine methodological considerations, how best to conduct preprocessing and analysis of DNA methylation data sets, and the latest methods, technologies and discoveries in this rapidly advancing field. DNA methylation and other epigenetic marks are firmly entwined with allergic disease, a link that may hold the basis for future allergic disease diagnosis and treatment.