General practitioners' management of mastitis in breastfeeding women: a mixed method study in Australia

BACKGROUND

Mastitis is a common reason new mothers visit their general practitioner (GP). In Australia, the Therapeutic Guidelines: Antibiotic provides practical advice to GPs managing a range of infections, including mastitis. It is not known if Australian GPs prescribe antibiotics and order investigations as recommended for the management of mastitis.

METHODS

A convergent mixed methods design integrated quantitative analysis of a general practice dataset with analysis of interviews with GPs. Using the large-scale primary care dataset, MedicineInsight, (2021-2022), antibiotics prescribed and investigations ordered for mastitis encounters were extracted. Mastitis encounters were identified by searching 'Encounter reason', 'Test reason' and 'Prescription reason' free text field for the term 'mastitis'; 'granulomatous mastitis' was excluded. Clinical encounters for mastitis occurring within 14 days of a previous mastitis encounter were defined as belonging to the same treatment episode. Semi-structured interviews were conducted with 14 Australian GPs using Zoom or telephone in 2021-2022, and analysed thematically. The Pillar Integration Process was used to develop a joint display table; qualitative codes and themes were matched with the quantitative items to illustrate similarities/contrasts in findings.

RESULTS

During an encounter for mastitis, 3122 (91.7%) women received a prescription for an oral antibiotic; most commonly di/flucloxacillin ([59.4%]) or cefalexin (937 [27.5%]). Investigations recorded ultrasound in 303 (8.9%), blood tests (full blood examination [FBE]: 170 [5.0%]; C-reactive protein [CRP]: 71 [2.1%]; erythrocyte sedimentation rate [ESR]: 34 [1.0%]) and breast milk or nipple swab cultures in approximately 1% of encounters. Analysis using pillar integration showed consistency between quantitative and qualitative data regarding mastitis management. The following themes were identified: - GPs support continued breastfeeding. - Antibiotics are central to GPs' management. - Antibiotics are mostly prescribed according to Therapeutic Guidelines. - Analgesia is a gap in the Therapeutic Guidelines. - Low use of breast milk culture.

CONCLUSIONS

Prescribing antibiotics for mastitis remains central to Australian GPs' management of mastitis. Interview data clarified that GPs were aware that antibiotics might not be needed in all cases of mastitis and that delayed prescribing was not uncommon. Overall, GPs followed principles of antibiotic stewardship, however there is a need to train GPs about when to consider ordering investigations.

Parents' Views on Prolonged Maternal Hospital Stay With Sick Newborn Infants in a Tertiary Neonatal Unit in Sri Lanka

BACKGROUND

Mothers of infants in most Sri Lankan neonatal units are required to be "inpatients" during the entirety of their infant's stay. This traditional practice is closely aligned to the relatively newer model of family-integrated care.

PURPOSE

Exploration of parent's views regarding the expectation for mothers to remain in hospital for the entire duration of their infant's neonatal unit stay.

METHODS

Cross-sectional study of parents of infants admitted to the University neonatal unit of Colombo North Teaching Hospital, Ragama, Sri Lanka, using self-administered questionnaires in 2017.

RESULTS

We found that 40% (19/48) of mothers and 43% (16/37) of fathers preferred that mothers traveled from home, rather than being inpatients continuously, in order to care for older children, receive psychological support from family, and also due to other practical inconveniences of living in the hospital. The main barriers to women being able to travel from home were the need to safely provide expressed human milk for their hospitalized infants and current hospital administrative and societal attitudes.

IMPLICATIONS FOR PRACTICE AND RESEARCH

We found that a considerable number of parents with infants in the neonatal intensive care unit in Sri Lanka would like the option of the mother being able travel from home, rather than being confined to hospital. To facilitate this option, changes in hospital protocols and further research into storage and transportation of expressed mother's milk will be required. Improving facilities in hospital and providing more opportunities for families to interact with infants in neonatal intensive care unit will encourage mothers to remain in hospital continuously.

Breast hypoplasia markers among women who report insufficient milk production: A retrospective online survey

OBJECTIVES

To estimate the proportions of anatomical breast characteristics suggestive of breast hypoplasia among breastfeeding women self-reporting low milk supply. We also explored breast hypoplasia risk factors.

DESIGN

Online survey conducted between October 2021 and January 2022.

SETTING

Five low milk supply Facebook groups.

PARTICIPANTS

487 women reporting low milk supply with their first child born ≥ 37 weeks gestation within 5 years of participation in this study, and residing in the USA, Australia or the UK. We present data on the primary outcome ('breast type') for 399 women. Women were excluded if the dyad was separated for more than 24 hours during the hospital stay, or if the mother reported removing milk less than 6 times per day from each breast on most days before being aware of having insufficient milk production.

PRIMARY AND SECONDARY OUTCOME MEASURES

The proportions of proposed breast hypoplasia markers including atypical breast type, widely spaced breasts, breast asymmetry, stretch marks on the breast and lack of pregnancy breast growth. We also estimated the odds of having breast hypoplasia markers in at-risk groups compared to reference groups, adjusting for covariates.

RESULTS

Approximately 68% reported at least one atypical breast (270/399; 95% CI: 62.9%, 72.1%). Around 47% reported widely spaced breasts (212/449; 95% CI: 42.7%, 52.7%), 72% a lack of pregnancy breast growth (322/449; 95% CI: 68.3%, 77.4%), and 76% stretch marks on the breast (191/250; 95% CI: 70.7%, 81.3%). Multiple logistic regression analyses identified being overweight during pubertal years as a risk factor for atypical breast type and lack of pregnancy breast growth.

CONCLUSIONS

Participants in low milk supply Facebook groups reported high rates of breast hypoplasia markers. Being overweight during adolescence was a risk factor for breast hypoplasia markers. These findings should be confirmed in well-conducted large cohort studies to determine the strongest combination of hypoplasia markers in predicting low supply.

"I didn't want to let go of the dream": Exploring women's personal stories of how their low milk supply was discovered

PROBLEM

Low milk supply is the most common reason women give for stopping breastfeeding early and yet there is a lack of understanding about these women's experiences.

BACKGROUND

Most women plan to breastfeed but many experience challenges such as low milk production, leading them to seek help and support.

AIM

To explore women's personal stories of how their low supply was discovered.

METHODS

Inductive template analysis was used to analyse free-text online survey responses of women from the United States of America, Australia and the United Kingdom.

FINDINGS

384 women responded to the open-ended survey item between October 2021 and January 2022. We identified three themes: (i) Events and observations: From 'risk factors' to 'failure of breast changes' to 'my baby was so unhappy', (ii) Seeking support and taking action: 'I tried everything' and (iii) A rollercoaster of emotion: 'I didn't want to let go of the dream'.

DISCUSSION

Our findings emphasise women's need to feel heard and understood and their quest to find answers. The rollercoaster of emotions they experienced largely stemmed from a gap between the expectations and reality of breastfeeding. Some participants described accepting a different feeding journey.

CONCLUSION

Findings underscore the need for quality and accessible psychosocial support for women experiencing low milk supply, in addition to the provision of evidence-based advice.

'I don't want to be a guinea pig' - Swedish women's experiences of breast abscess treatment

BACKGROUND

It is well known that breastfeeding plays an important role in the health of women and children. However, women are not always given optimal support and most do not reach their breastfeeding goals. About one in five, breastfeeding women report mastitis and a small proportion of these develop a breast abscess. Our aim was to describe the experiences of a group of Swedish breastfeeding women who developed a breast abscess.

METHODS

A qualitative cross-sectional study with 18 study participants was undertaken in Sweden in 2017-2018. Potential participants were identified through electronic medical records at a university hospital and invited to participate in audio-recorded telephone interviews. Women were between 2 and 24 months postpartum at the time of the interview, on average 8 months. We conducted a thematic analysis in six steps according to Braun and Clark.

RESULTS

Our analysis identified two themes: 1) Seeking care and receiving treatment was long and unpleasant, and 2) Importance of adequate professional care. Women who experienced a breast abscess were uncertain about where to ask for professional help. They often had a long wait for the right time to undergo the unpleasant and painful procedure of draining their breast abscess. The women felt it was important to receive professional care with respectful communication, continuity of care, and to receive adequate information, but they did not always receive this level of care.

CONCLUSIONS

Women with puerperal breast abscesses often fall between medical specialty areas. No longer under the care of obstetricians and maternity services, their problem is too complicated for general practitioners or emergency departments, but not regarded as serious by breast surgeons. Healthcare professionals urgently need adequate training in order to deal with breastfeeding problems and be able to offer women-centred care.

Breastfeeding outcomes at 3 months for women with diabetes in pregnancy: Findings from the Diabetes and Antenatal Milk Expressing randomized controlled trial

BACKGROUND

Women with diabetes in pregnancy have decreased exclusivity and duration of breastfeeding compared with women without diabetes, and their infants are at increased risk of hypoglycemia. Clinicians often suggest pregnant women with diabetes to express breastmilk, and studies have reported increased breastfeeding exclusivity in the early postnatal period for patients who have expressed. Little is known about longer term outcomes. We investigated whether advising low-risk women with diabetes in pregnancy to express beginning at 36 weeks of pregnancy increased exclusivity and maintenance of breastfeeding at 3 months.

METHODS

We conducted a multicenter, two-group, randomized controlled trial at six hospitals in Melbourne, Australia, between 2011 and 2015. Women were randomized to either standard maternity care or advised to hand express for 10 min twice daily, in addition to standard care. Women were telephoned at 12-13 weeks postpartum and asked a series of questions about feeding their baby, perceptions of their milk supply, and other health outcomes.

RESULTS

Of 631 women in the study, data for 570 (90%) were analyzed at 12-13 weeks. After adjustment, we found no evidence that women allocated to antenatal expressing were more likely to be giving only breastmilk (aRR 1.07 [95% CI 0.92-1.22]) or any breastmilk (aRR 0.99 [95% CI 0.92-1.06]) at 12-13 weeks postpartum compared with women in the standard care group.

CONCLUSION

While the practice of antenatal expression for low-risk women with diabetes during pregnancy is promising for increasing exclusivity of breastmilk feeding in hospital, at 12-13 weeks, there was no association with breastfeeding outcomes.

Is proactive telephone-based breastfeeding peer support a cost-effective intervention? A within-trial cost-effectiveness analysis of the 'Ringing Up about Breastfeeding earlY' (RUBY) randomised controlled trial

OBJECTIVE

The 'Ringing Up about Breastfeeding earlY' (RUBY) randomised controlled trial showed increased breastfeeding at 6 months in participants who received the proactive telephone-based peer support breastfeeding intervention compared with participants allocated to receive standard care and supports. The present study aimed to evaluate if the intervention was cost-effective.

DESIGN

A within-trial cost-effectiveness analysis.

SETTING

Three metropolitan maternity services in Melbourne, Victoria, Australia.

PARTICIPANTS

First time mothers intending to breastfeed their infant (1152) and peer volunteers (246).

INTERVENTION

The intervention comprised proactive telephone-based support from a peer volunteer from early postpartum up to 6 months. Participants were allocated to usual care (n=578) or the intervention (n=574).

MAIN OUTCOME MEASURES

Costs during a 6-month follow-up period including individual healthcare, breastfeeding support and intervention costs in all participants, and an incremental cost-effectiveness ratio.

RESULTS

Costs per mother supported were valued at $263.75 (or $90.33 excluding costs of donated volunteer time). There was no difference between the two arms in costs for infant and mothers in healthcare and breastfeeding support costs. These figures result in an incremental cost-effectiveness ratio of $4146 ($1393 if volunteer time excluded) per additional mother breast feeding at 6 months.

CONCLUSION

Considering the significant improvement in breastfeeding outcomes, this intervention is potentially cost-effective. These findings, along with the high value placed on the intervention by women and peer volunteers provides robust evidence to upscale the implementation of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12612001024831.

Women's experiences with using domperidone as a galactagogue to increase breast milk supply: an australian cross-sectional survey

BACKGROUND

Domperidone is one of the most commonly utilised pharmacological galactagogues, with evidence of increasing use in clinical practice. However, the use of domperidone as a galactagogue remains controversial, with mixed evidence on safety and efficacy, leading to variable clinical practice recommendations. We sought to evaluate contemporary patterns of domperidone use and examine maternal experiences related to perceived safety and effectiveness.

METHODS

In 2019, we conducted an online, cross-sectional survey of Australian breastfeeding women to examine individual experiences related to domperidone use, in addition to perceptions of safety and effectiveness.

RESULTS

Among 1876 survey responses, 19% (n = 355) reported using domperidone. Domperidone use was significantly higher in women who were primiparous, gave birth preterm, delivered by caesarean section, had self-perceived low milk supply, and saw a lactation consultant. Nearly 20% of women commenced domperidone use in the first week postpartum (19%, n = 67). The median duration of use was six weeks (interquartile range 3-16 weeks). Maximum reported doses of domperidone used ranged from 20 mg/day to 160 mg/day. Half (n = 178, 50%) of women reported using a dose of 30 mg/day or less, 44% (n = 155) reported using a dose between 31 and 60 mg/day, and 6% (n = 22) reported using a dose greater than 61 mg/day. Nearly half of the respondents reported domperidone as 'very' or 'extremely effective' (45%, n = 161), with only 8% (n = 27) reporting it was 'not at all effective'. Almost half (n = 172, 48%) of all women using domperidone reported side effects, including weight gain (25%), headaches (17%) and dry mouth (13%). Higher doses were associated with an increased likelihood of any side effects (≤ 30 mg/day, 38%; >31-≤60 mg/day, 48%, > 61 mg/day 73%; P < 0.004), with 31 (9%) stopping domperidone because of side effects.

CONCLUSION

We identified widespread variation in domperidone utilisation patterns, with domperidone broadly perceived to be effective in increasing breast milk supply. Side effects associated with domperidone treatment were common, appeared to be dose-related, and were frequently associated with treatment cessation. These findings highlight the importance of improved clinical practice recommendations and generation of evidence from additional high-quality clinical trials evaluating the efficacy and safety of domperidone. More conclusive clinical trials are needed to determine the efficacy, as well as optimal dose and duration, of domperidone use.

Understanding Mothers' Experiences of Being Ineligible to Donate Their Milk to a Not-for-Profit Milk Bank

Background: Donor milk banks have strict donor screening criteria to ensure that donor milk is safe for premature or hospitalized babies. Yet little evidence is available to understand how potential donors, who are often breastfeeding their own infants, experience being ineligible ("deferred") to donate their milk to a milk bank. Materials and Methods: Interviews were conducted with 10 mothers who were permanently or temporarily deferred from donating to a large, not-for-profit milk bank in Australia. Interviews focused on becoming a donor and being deferred, meanings of deferral, impact of deferral on feeding own infant, and improving the deferral process. Results: Thematic analysis of interviews identified nine themes: (1) donation as a solution to wasting milk; (2) eligibility questions were acceptable and understandable; (3) more information early on allows self-deferral; (4) deferral is not always clear; (5) deferral is disappointing but does not prevent future donation; (6) deferral did not prevent feeding own infant; (7) early information enables preparation for donation; (8) slow communication disrupts perfect timing to donate; and (9) alternatives to wasting milk. Conclusions: Milk banks have a duty of care to both milk recipients and donors. While mothers who want to donate milk are disappointed by deferrals, clear communication protects their breastfeeding relationships with their own infants. Milk banks can improve their screening processes by providing information up-front and ensuring timely contact with mothers. Mothers can then make informed decisions about donating and not feel as if their milk and resources are "wasted."

Rural primary care workforce views on trauma-informed care for parents experiencing complex trauma: A descriptive study

BACKGROUND

An important service system for rural parents experiencing complex trauma is primary health care.

AIM

To investigate workforce knowledge, attitudes and practices, and barriers and enablers to trauma-informed care in rural primary health care.

MATERIAL & METHODS

This study used a descriptive, cross-sectional design. It involved an on-line survey conducted in 2021 in rural Victoria, Australia. Participants were the primary health care workforce. The main outcome measures were study-developed and included, a 21-item Knowledge, Attitudes and Practices tool, a 16-item Barriers and Enablers to Trauma-Informed Care Implementation tool, and three open-ended questions.

RESULTS

The 63 respondents were from community health (n = 40, 63%) and child and family services (n = 23, 37%). Many (n = 43, 78%) reported undertaking trauma-informed care training at some point in their career; with 32% (n = 20) during higher education. Respondents self-rated their knowledge, attitudes and practices positively. Perceived enablers were mainly positioned within the service (e.g. workforce motivation and organisational supports) and perceived barriers were largely external structural factors (e.g. availability of universal referral pathways, therapeutic-specific services). Open-ended comments were grouped into four themes: (1) Recognition and understanding; (2) Access factors; (3) Multidisciplinary and collaborative approaches; and (4) Strengths-based and outcome-focused approaches.

DISCUSSION & CONCLUSION

Primary health care is an important driver of population health and well-being and critical in rural contexts. Our findings suggest this sector needs a rural trauma-informed care implementation strategy to address structural barriers. This also requires policy and system development. Long-term investment in the rural workforce and primary care service settings is essential to integrate trauma-informed care.

Knowledge of Galactagogue Use During Breastfeeding in Australia: A Cross Sectional Online Survey

BACKGROUND

Galactagogues have been used for centuries to induce, maintain, or increase a mother's milk supply. Recently, there has been an apparent increase in utilization and promotion of galactagogues, largely in the absence of data regarding their efficacy and safety. However, there is limited contemporary evidence about knowledge of these substances in the community or how and where individuals seek information.

RESEARCH AIM

To evaluate knowledge about galactagogue use during breastfeeding among birth parents, including recognition of specific substances, perceptions of safety, and common information sources.

METHOD

An online, prospective, cross-sectional survey of Australian birthing parents (N = 2055) who were currently breastfeeding or had previously breastfed their infants was conducted from September to December 2019. The survey included questions about recognition of galactagogues, perceptions of safety, and information-seeking behaviors.

RESULTS

Among participants, 47% (n = 882) were primiparous and 65% (n = 1,219) were currently breastfeeding. The most recognized galactagogues included lactation cookies (89%; n = 1,828), brewer's yeast (79%; n = 1,629), fenugreek (74%; n = 1,519), and domperidone (69%; n = 1,420). Respondents cited the internet (52%; n = 1,066), lactation support providers (46%; n = 951), midwives (42%; n = 873), general practitioners (39%; n = 802), and social media (35%; n = 714) as common information sources. Lactation support providers and breastfeeding helplines were commonly rated as helpful; whereas, general practitioners and community pharmacists were often rated as unhelpful. While most participants perceived galactagogues to be safe, herbal or dietary galactagogues were perceived to be safer than pharmaceutical galactagogues.

CONCLUSIONS

Our Australian community survey of individuals with current or previous breastfeeding experience identified widespread recognition of galactagogue use, with participants reporting a broad range of information-seeking behaviors and generally perceiving galactagogues as being safe to use.

Nurturing children's development through healthy eating and active living: Time for policies to support effective interventions in the context of responsive emotional support and early learning

Fostering the growth, development, health, and wellbeing of children is a global priority. The early childhood period presents a critical window to influence lifelong trajectories, however urgent multisectoral action is needed to ensure that families are adequately supported to nurture their children's growth and development. With a shared vision to give every child the best start in life, thus helping them reach their full developmental potential, we have formed the International Healthy Eating Active Living Matters (HEALing Matters) Alliance. Together, we form a global network of academics and practitioners working across child health and development, and who are dedicated to improving health equity for children and their families. Our goal is to ensure that all families are free from structural inequality and oppression and are empowered to nurture their children's growth and development through healthy eating and physical activity within the context of responsive emotional support, safety and security, and opportunities for early learning. To date, there have been disparate approaches to promoting these objectives across the health, community service, and education sectors. The crucial importance of our collective work is to bring these priorities for early childhood together through multisectoral interventions, and in so doing tackle head on siloed approaches. In this Policy paper, we draw upon extensive research and call for collective action to promote equity and foster positive developmental trajectories for all children. We call for the delivery of evidence-based programs, policies, and services that are co-designed to meet the needs of all children and families and address structural and systemic inequalities. Moving beyond the "what" is needed to foster the best start to life for all children, we provide recommendations of "how" we can do this. Such collective impact will facilitate intergenerational progression that builds human capital in future generations.

Exclusive breastfeeding and women's psychological well-being during the first wave of COVID-19 pandemic in Italy

Background

At the onset of the COVID-19 pandemic, support for breastfeeding was disrupted in many countries. Italy was severely impacted by the pandemic and is known to have the lowest exclusive breastfeeding rate of all European countries. Considering the inverse association between anxiety and breastfeeding, maternal concerns about the COVID-19 emergency could reduce breastfeeding rates. The aim of the study is to explore the association between infant feeding practices and maternal COVID-19 concerns.

Methods

This paper is a secondary analysis of the cross-sectional study COVID-ASSESS conducted in Italy in 2020. The original survey was administered in two phases: during the first lockdown and during the reopening. The survey included five sections: socio-demographic, medical history, concerns about the COVID-19 pandemic, infant feeding practices and psychometric evaluation. Participants were considered eligible for the post-hoc analyses if they were exclusively breastfeeding or they were feeding with infant formula (either alone or with breastfeeding) at the time of the interview.

Results

Between phase 1 and phase 2 there was a decrease in anxiety and concerns about the danger of COVID-19 to general health, except for concerns about their baby's health. Women using formula were more concerned about all the health topics investigated. Moreover, they showed higher levels of stress, state anxiety, somatization and PTSD symptoms.

Conclusion

Breastfeeding during the first pandemic lockdown in Italy seems to have been an independent factor associated with lower anxiety about COVID-19, fewer psychopathological symptoms, and a positive experience of infant feeding.

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

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

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

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

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

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

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

Incidence, antibiotic treatment and outcomes of lactational mastitis: Findings from The Norwegian Mother, Father and Child Cohort Study (MoBa)

BACKGROUND

Mastitis is a common and distressing maternal postpartum condition, but the relationship between mastitis timing and antibiotic treatment and breastfeeding outcomes and postnatal mental health is unclear.

OBJECTIVES

To describe the incidence of mastitis and treatment with antibiotics in first 6 months postpartum, and to investigate the impact of mastitis timing and antibiotic treatment on breastfeeding practices and postnatal mental health.

METHODS

This study is based on 79,985 mother-infant dyads in the Norwegian Mother, Father and Child Cohort Study (MoBa). Women were classified according to self-reported mastitis within first month ('early') or 1-6 months ('later') postpartum and antibiotic treatment. Breastfeeding outcomes included predominant or any breastfeeding and abrupt breastfeeding cessation until 6 months postpartum. Maternal mental health was assessed by self-report at 6 months postpartum.

RESULTS

The incidence of mastitis was 18.8%, with 36.8% reporting treatment with antibiotics. Women reporting early mastitis were less likely to report predominant breastfeeding (adjustedd relative risk [aRR] 0.92, 95% confidence interval [CI] 0.86, 0.99) and any breastfeeding for 6 months (aRR 0.97, 95% CI 0.96, 0.98) than women who did not report mastitis, and more likely to report abrupt breastfeeding cessation (aRR 1.37, 95% CI 1.23, 1.53). Late-onset mastitis was not associated with poorer breastfeeding outcomes. Among women reporting mastitis, the risk of abrupt breastfeeding cessation was higher in those also reporting antibiotic use. Mastitis was associated with an increased risk of mental health problems postpartum which was highest among those reporting no antibiotic use (aRR 1.29, 95% CI 1.18, 1.41), in contrast to those also reporting antibiotic use (aRR 1.08, 95% CI 0.96, 1.22).

CONCLUSIONS

Lactational mastitis and its associated treatment with antibiotics are common. Early (<1 month postpartum) mastitis appears to be a modest risk factor for suboptimal breastfeeding outcomes. In addition, mastitis is associated with poorer mental health.

Perinatal antidepressant use and breastfeeding outcomes: Findings from the Norwegian Mother, Father and Child Cohort Study

INTRODUCTION

Antidepressant use is common in the perinatal period, but there are concerns that it can negatively impact on breastfeeding outcomes. The aim of this study was to examine the effects of perinatal antidepressant use on breastfeeding initiation and duration.

MATERIAL AND METHODS

This was a retrospective analysis of 80 882 mother-infant dyads in the Norwegian Mother, Father and Child Cohort Study (MoBa). Women were first classified according to self-reported mental disorders and timing of antidepressant use before and/or after gestational week 28 (i.e., early-mid-gestation and/or late-gestation use). We subsequently classified women according to self-reported mental disorders and antidepressant use postpartum and whether antidepressants were continued from late gestation or were new/restarted. Breastfeeding outcomes included breastfeeding initiation as well as predominant or any breastfeeding and abrupt breastfeeding discontinuation until 6 months.

RESULTS

Late-gestation antidepressant use was associated with a reduced likelihood of breastfeeding initiation (adjusted relative risk [aRR] 0.93; 95% confidence interval [CI] 0.90-0.97) but not predominant (aRR 0.96; 95% CI 0.67-1.39) or any (aRR 1.00; 95% CI 0.93-1.07) breastfeeding at 6 months compared with unexposed women with mental disorders. When examined according to postnatal antidepressant use, no differences in predominant (aRR 0.94; 95% CI 0.60-1.48) or any breastfeeding (aRR 0.99; 95% CI 0.91-1.07) at 6 months were evident among women who continued antidepressant use from late gestation into the postpartum period compared with unexposed women with mental disorders. In contrast, new/restarted antidepressant use postpartum was associated with a reduced likelihood of predominant (aRR 0.37; 95% CI 0.22-0.61) and any (aRR 0.49; 95% CI 0.42-0.56) breastfeeding at 6 months, as well as increased risk of abrupt breastfeeding discontinuation (aRR 2.64; 95% CI 2.07-3.37) compared with the unexposed women with mental disorders.

CONCLUSIONS

A complex relation exists between depression, antidepressant use, and breastfeeding outcomes. Antidepressant use in late pregnancy was associated with a reduced likelihood of breastfeeding initiation but not breastfeeding duration or exclusivity. In contrast, initiating or restarting antidepressants postpartum was associated with poorer breastfeeding outcomes. Overall, women taking antidepressants and women with a mental disorder may benefit from additional education and support to improve breastfeeding rates and promote maternal and infant health and wellbeing.

Random amplified polymorphic DNA analysis reveals no clear link between Staphylococcus epidermidis and acute mastitis

Mastitis is commonly experienced by breastfeeding women. While Staphylococcus aureus is usually implicated in infectious mastitis, coagulase‐negative staphylococci (CoNS) are a possible alternative pathogen. This case‐control study examined the role of CoNS in mastitis using isolates cultured from breast milk of 20 women with mastitis and 16 women without mastitis. Gene sequencing determined bacterial species, and random amplified polymorphic DNA (RAPD) analysis investigated strain‐level variation. The majority of CoNS isolates were Staphylococcus epidermidis (182/199; 91%). RAPD analysis identified 33 unique S. epidermidis profiles, with no specific profile associated with mastitis cases.

Women's experiences of infant feeding support: Findings from a cross-sectional survey in Victoria, Australia

OBJECTIVE

To evaluate new mothers' experiences of infant feeding support.

DESIGN

A postal survey developed for this study was sent to all new mothers in ten local government areas in Victoria, Australia when their baby was six months of age. Questions explored infant feeding methods, feeding support services, and experiences of infant feeding support. This survey made up one component of the Supporting breastfeeding In Local Communities (SILC) cluster randomised controlled trial.

FINDINGS

997/4127 women (24%) completed the survey between 15 April 2013 and 31 July 2013. Women received infant feeding support from multiple sources, including professionals, family members, and peers. Overall, 88% reported receiving adequate infant feeding support. Women who reported not receiving adequate infant feeding support were less likely to be giving any breast milk at six months compared to those reporting adequate support (OR = 0.59; 95% CI 0.40, 0.88). Adjusting for breastfeeding intention and parity did not alter the association (Adj. OR = 0.60; 95% CI 0.40, 0.90). Women were most satisfied when they received accessible, available, consistent professional infant feeding support provided in a non-judgemental and reassuring way. Women were dissatisfied when there were barriers restricting access to support, or when they received conflicting advice or support that made them feel guilty, pressured or judged.

KEY CONCLUSIONS

Regardless of infant feeding method, women wanted accessible, non-judgemental support. Given that receiving adequate support was associated with more breast milk feeding at six months, care providers should ensure accessible infant feeding support is available to all new mothers.

Is There an Association Between Breast Hypoplasia and Breastfeeding Outcomes? A Systematic Review

Introduction: Insufficient milk supply is the most common reason for premature breastfeeding cessation. Breast hypoplasia is one reason why women may be inherently unable to make a full milk supply. This review aimed to systematically explore the relationship between breast hypoplasia and breastfeeding duration, milk supply, and lactation onset. Materials and Methods: Medline, CINAHL, ProQuest Central, and the Cochrane Library databases were searched using the keywords "insufficient glandular tissue" or "mammary hypoplasia" or "breast hypoplasia" or "mammary gland hypoplasia" or "droopy breasts" or "snoopy deformity" or "tubular breast*" or "tuberous breast*" AND breastfeeding or "breast feeding" or breast-feeding or lactation. After initially screening 20 records, including reference lists, 9 full texts were assessed for eligibility; 2 were excluded as no breastfeeding outcomes were reported, leaving 7 studies (N = 42 women). Results: The studies in this review drew on results from the oldest included study and plastic surgery literature to define breast hypoplasia. Most women in this review (40/42) ceased exclusive breastfeeding before 1 month postpartum. One case study reported 24-hour milk production, which was 52 mL at 26 weeks postpartum. Conclusion: The relationship between breast hypoplasia and breastfeeding outcomes is underresearched. The co-occurring medical conditions (e.g., polycystic ovary syndrome) of some women provide avenues for future research into the possible pathogenesis of breast hypoplasia resulting in insufficient milk supply. Research is needed to evaluate the reliability of measuring and classifying markers of breast hypoplasia, and prospective studies can help determine the role of breast hypoplasia in milk production. PROSPERO registration number CRD42020191228.

Use and experiences of galactagogues while breastfeeding among Australian women

Background

Galactagogues are substances thought to increase breast milk production, however evidence to support their efficacy and safety remain limited. We undertook a survey among Australian women to examine patterns of use of galactagogues and perceptions regarding their safety and effectiveness.

Methods

An online, cross-sectional survey was distributed between September and December 2019 via national breastfeeding and preterm birth support organisations, and networks of several research institutions in Australia. Women were eligible to participate if they lived in Australia and were currently/previously breastfeeding. The survey included questions about galactagogue use (including duration and timing), side effects and perceived effectiveness (on a scale of 1 [Not at all effective] to 5 [Extremely effective]).

Results

Among 1876 respondents, 1120 (60%) reported using one or more galactagogues. Women were 31.5 ± 4.8 years (mean ± standard deviation) at their most recent birth. Sixty-five percent of women were currently breastfeeding at the time of the survey. The most commonly reported galactagogues included lactation cookies (47%), brewer’s yeast (32%), fenugreek (22%) and domperidone (19%). The mean duration of use for each galactagogue ranged from 2 to 20 weeks. Approximately 1 in 6 women reported commencing galactagogues within the first week postpartum. Most women reported receiving recommendations to use herbal/dietary galactagogues from the internet (38%) or friends (25%), whereas pharmaceutical galactagogues were most commonly prescribed by General Practitioners (72%). The perceived effectiveness varied greatly across galactagogues. Perceived effectiveness was highest for domperidone (mean rating of 3.3 compared with 2.0 to 3.0 among other galactagogues). Over 23% of domperidone users reported experiencing multiple side effects, compared to an average of 3% of women taking herbal galactagogues.

Conclusions

This survey demonstrates that galactagogues use is common in Australia. Further research is needed to generate robust evidence about galactagogues’ efficacy and safety to support evidence-based strategies and improve breastfeeding outcomes.

Breastfeeding Practices and Problems Among Obese Women Compared with Nonobese Women in a Brazilian Hospital

Background: Women who are obese have lower rates of breastfeeding initiation and duration and are less likely to breastfeed exclusively compared with women who are not obese. To develop programs to improve breastfeeding practices among this group of women, we investigated the association between maternal obesity and breastfeeding practices and problems in the first days postpartum. Methods: We analyzed medical records from postpartum women at a rooming-in maternity ward in State of São Paulo, Brazil, between 2016 and 2018. We included those who had intended to exclusively breastfeed, had given birth to a singleton and were admitted to rooming-in. We analyzed exclusive breastfeeding and nonexclusive breastfeeding each day of hospitalization and the presence of breastfeeding problems, comparing women in the obese category (body mass index [BMI] ≥30 kg/m2) to normal and overweight women (≥18.6 to ≤29.9 kg/m2). Results: Two hundred and twenty-four postpartum women participated, including 86 women in the obese category. More than 50% of women with obesity reported a breastfeeding problem in the first and second postpartum days (p = 0.026 and p = 0.017, respectively) compared with the 41% and 38% nonobese group. Children of obese women were 2.8 times more likely to have poor latch during breastfeeding (95% confidence interval [CI]: 1.29-6.10) compared with the nonobese group on the third day. Conclusion: Maternal obesity increased the probability of breastfeeding difficulties and nonexclusive breastfeeding at discharge. Professionals need to support breastfeeding techniques in the days immediate after delivery to improve breastfeeding outcomes for mothers with obesity.

The suitability and utility of the pain and movement reasoning model for physiotherapy: A qualitative study

Introduction: The Pain and Movement Reasoning Model is a tool to assist clinical reasoning. It was created for physiotherapists to use in musculoskeletal outpatient clinics but may be appropriate in other clinical contexts. The Model has also been used in physiotherapy education.Objective: To determine physiotherapists' perceptions of the appropriateness (suitability) and benefit (utility) of the Pain and Movement Reasoning Model across clinical contexts in hospital and community practice. Methods Physiotherapists from two health networks in Melbourne, Australia, received training in using the Model and over 4-6 weeks applied it in their clinical interactions. Drawing on a deductive phenomenological approach, transcripts from focus groups and interviews were analysed to determine the suitability and utility of the Model across clinical areas.Results: Twenty-nine physiotherapists from 12 different clinical areas participated. Two themes represented the participants' comments: Suitability for Practice and Utility in Practice. Participants reported the approach to clinical reasoning, promoted by the Model, aligned with existing physiotherapy practice. Enhancements to practice included more comprehensive assessment, selection of broader management techniques and increased confidence with reasoning and explaining the complexity of pain to patients. Participants described using the Model for developing junior staff and training postgraduate students. They also saw potential in adapting the Model for other disciplines and for other multifactorial conditions.Conclusion: Physiotherapists working in a range of clinical contexts considered the Pain and Movement Reasoning Model appropriate and beneficial in clinical practice and in teaching. Further evaluation of the Model in wider settings is warranted.

The risk-risk trade-offs: Understanding factors that influence women's decision to use substances to boost breast milk supply

Galactagogues are foods, herbs or medications thought to support or increase breast milk supply. The use of galactagogues during lactation is becoming increasingly common despite limited evidence regarding effectiveness and safety, and no definitive recommendations for use in clinical practice. The aim of this study is to explore factors influencing women's decisions to use galactagogues during lactation. Twenty-two semi-structured interviews were conducted in October and November 2019 (over the telephone or in person) with participants located in most Australian states and territories, including metro and regional areas. Interviews were audio-recorded, transcribed verbatim and thematically analysed using NVivo. Analysis revealed that following a concern about breast milk supply, the decision to use galactagogues was influenced by three core and interrelated domains: access to and quality of breastfeeding support, maternal agency and determination to provide breast milk. Women revealed many problematic experiences with health care professionals that left them feeling dismissed and confused due to provision of inconsistent and insufficient information that was sometimes at odds with their desire to provide breast milk. In this instance, some women turned to galactagogues to regain agency. A range of broader dimensions influencing decision-making also emerged. These were separated into categories that emphasise distinctions relating to breast milk supply, which included: maternal emotional wellbeing, social norms and pressures, concerns about infant development, maternal physical health and lactation history, as well as those relating specifically to galactagogue use, including: desire for a guaranteed/urgent response, risk-risk trade-off, acceptance and trust, and accessibility and cost. In understanding the complexity of decision-making concerning these substances, we identify opportunities to improve breastfeeding counselling and support. We recommend that support be individually tailored to manage conflicting information, adopt communication styles that encourage trust and processes that enable shared decision-making to enhance or restore maternal agency. There is also considerable need to address evidence gaps regarding the effectiveness and safety of commonly used galactagogues, so that women can be appropriately counselled about potential benefits and harms.

Reliability of Markers for Breast Hypoplasia in the Early Postpartum Period

BACKGROUND

Breast hypoplasia is one reason for insufficient milk supply. Case reports use wide intra-mammary width and certain breast appearances as markers of breast hypoplasia. However, the reliability of these variables has not been determined.

RESEARCH AIMS

To test the (i) interrater and intrarater reliability of intra-mammary width measurement and interrater reliability of categorizing women's breasts into breast types, and (ii) feasibility and acceptability of study procedures for the participants.

METHODS

This was a prospective, longitudinal, non-experimental design with survey and observational components of a convenience sample of early postpartum women (N = 31). Interrater and intrarater reliability were measured using intraclass correlation coefficient for agreement for intra-mammary width measurements. Interrater reliability was measured using weighted kappa for agreement for categorizing breast type. Feasibility and acceptability of study procedures were collected 1 month later.

RESULTS

Excellent intrarater and interrater reliability for the intra-mammary width measurement (ICC = 0.99, 95% CI [0.99, 0.997] and ICC = 0.88, 95% CI [0.74, 0.94], respectively) and fair interrater reliability for breast type categorization (k = 0.35, 95% CI [-0.05, 0.75]) with high level of agreement between raters (97%) were achieved. Proportions of participants agreeing to breast photography and acceptability of study procedures were 68% (21/31) and 100% (28/28) respectively.

CONCLUSION

The excellent reliability for the intra-mammary width measurement means it provides a useful measure for future research. Since the "fair" reliability of categorizing breast type was due to lack of breast shape range in our sample, future research could assess the breasts of women with different medical profiles.

Modern, exogenous exposures associated with altered mammary gland development: A systematic review

BACKGROUND

Many women report low milk supply as the reason for premature breastfeeding cessation. Altered mammary gland development may impact a woman's lactation ability.

OBJECTIVE

This review identifies modern exogenous exposures which alter mammary gland development during embryonic life, puberty and pregnancy.

METHODS

A systematic review was undertaken whereby Medline, CINAHL and Embase articles published from January 1, 2005 to November 20, 2020 were searched using the keywords puberty or embry* or fetal or foetal or foetus or fetus or pregnan* or gestation* AND "mammary gland development" or "breast development" or "mammary development" or "mammary gland function" or "mammary function" or "insufficient glandular tissue" or "mammary hypoplasia" or "breast hypoplasia" or "mammary gland hypoplasia" or "tubular breast*" or "tuberous breast*" or "glandular tissue" or "breast composition" or "mammary composition" or "mammary gland composition". After initial screening of 1207 records, 60 full texts were assessed for eligibility; 6 were excluded due to lack of information about exposure or outcome, leaving 54 studies.

RESULTS

The review included results from 52 animal (rats and mice, monkeys, rabbits, sheep, goats pigs and cows) and 2 human studies. Various endocrine disrupting chemicals and an obesogenic diet were found to be associated with altered mammary gland morphology during key development stages.

CONCLUSIONS

To improve lactation outcomes, future studies need to focus on lactation as the endpoint and be conducted in a standardised manner to allow for a more significant contribution to the literature that allows for better comparison across studies.

Bacterial Growth in Expressed Mother's Milk Stored and Transported Under Different Simulated Conditions in a Tropical Country

Background: Research on how storage and transport of expressed human milk in a tropical country affect the milk bacterial count is limited. Materials and Methods: A cross-sectional descriptive study of 50 mothers of infants in a Sri Lankan tertiary neonatal unit was performed. Expressed mother's milk was divided into three bottles and kept under varied environmental conditions to simulate different storage and transport methods. Initial bacterial culture of milk was performed <30 minutes after expression, with further cultures at predetermined times. Bottles A and B were stored at room temperature and in a cool bag for the first 6 hours, respectively, and then refrigerated; and bottle C was refrigerated for 24 hours, transported in a cool bag for 6 hours, and rerefrigerated until 72 hours. Total colony counts >10⁵ colony-forming units (CFU)/mL of viable microorganisms or >10⁴ CFU/mL of either Enterobacteriaceae or Staphylococcus aureus were considered positive. Results: Initial culture was positive in 30% (15/50) of samples; majority, 87% (13/15), of these were S. aureus. For bottle A, 26% (13/50), 36% (18/50), 34% (17/50), and 26% (13/50) of samples were positive at 4, 6, 24, and 72 hours, respectively. For bottle B, positive cultures were found in 26% (13/50) and 17% (8/47) of samples at 24 and 72 hours, respectively. For bottle C, results were similar to bottle B. Conclusions: Transportation of expressed mother's milk for 4 hours in a tropical climate using a low-cost cool bag, with refrigeration at other times, maintained acceptable bacterial counts for up to 72 hours after expression. Hygienic practices at collection are extremely important as most samples with significant bacterial growth were positive on initial culture.

Mothers' perceptions and experiences of skin-to-skin contact after vaginal birth in Saudi Arabia: A cross-sectional study

PROBLEM

The World Health Organization recommends immediate skin-to-skin contact after birth, however, worldwide, separation of mothers and infant is common.

BACKGROUND

In Saudi Arabia, there is a lack of research exploring mothers' experiences of skin-to-skin contact after birth.

AIM

To estimate the rate of skin-to-skin contact and describe mothers' perceptions and experiences of immediate skin-to-skin contact after vaginal birth in two largest hospitals in Jeddah, Saudi Arabia.

METHODS

A cross-sectional study conducted in 2017. A total of 254 mothers completed the survey on the postnatal ward (92 % response rate). The survey consisted of 36 closed and open-ended items. Data were described using summary statistics and free text comments were analysed using content analysis.

RESULTS

The rate of direct skin-to-skin contact was 15%. A further 54% of mothers had the baby placed on their chest/abdomen but with a sheet/gown between them. Mothers reported favourable perceptions towards skin-to-skin contact and reported the practice as acceptable (67%). Most mothers did not express concerns about feeling exposed (85%) or that skin-to-skin contact was inconsistent with norms of modesty or culture (87%). The free text comments indicated that most mothers felt positive about their experience of skin-to-skin contact, while some mothers felt overwhelmed and unprepared.

DISCUSSION AND CONCLUSIONS

Skin-to-skin contact was not routinely implemented after birth and the rate was low. Mothers held positive perceptions and wanted to practice skin-to-skin contact. Policy makers and clinicians should acknowledge mothers' needs and feelings by facilitating skin-to-skin contact to achieve optimal outcomes for mothers and infants.

Breastfeeding peer support by telephone in the RUBY randomised controlled trial: A qualitative exploration of volunteers' experiences

BACKGROUND

There is growing evidence that peer support programs may be effective in supporting breastfeeding mothers. A randomised controlled trial (RCT) (the RUBY study) that tested peer support in the Australian context found that infants of first-time mothers who received proactive telephone peer support were more likely to be receiving breastmilk at six months of age.

METHODS

This qualitative sub-study of the RUBY RCT explores the experiences and views of peer volunteers who delivered the intervention. Focus groups were conducted with 17 peers from the RUBY RCT between November 2015 and March 2016. All had provided peer support to at least one mother.

RESULTS

We found that volunteers identified strongly with the mothers' need for support when establishing breastfeeding. Key components of the support were strengthening the mothers' self-belief through affirmation and sharing experiential knowledge. Volunteers found the role rewarding and personally therapeutic although some women reported challenges initiating and maintaining contact with some mothers. Data were analysed using a hybrid approach to thematic analysis combining inductive and deductive techniques.

CONCLUSIONS

Breastfeeding peer support programs are reliant on recruitment of motivated volunteers who can provide empathetic mother-to-mother support. This study provides important information regarding volunteers' experiences that may support the upscaling of breastfeeding peer support for new mothers.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry, ACTRN 12612001024831.

Proactive Peer (Mother-to-Mother) Breastfeeding Support by Telephone (Ringing up About Breastfeeding Early [RUBY]): A Multicentre, Unblinded, Randomised Controlled Trial

BACKGROUND

Breastfeeding rates are suboptimal internationally, and many infants are not receiving any breast milk at all by six months of age. Few interventions increase breastfeeding duration, particularly where there is relatively high initiation. The effect of proactive peer (mother-to-mother) support has been found to increase breastfeeding in some contexts but not others, but if it is shown to be effective would be a potentially sustainable model in many settings. We aimed to determine whether proactive telephone-based peer support during the postnatal period increases the proportion of infants being breastfed at six months of age.

METHODS

RUBY (Ringing Up about Breastfeeding earlY) was a multicentre, two-arm un-blinded randomised controlled trial conducted in three hospitals in Victoria, Australia. First-time mothers intending to breastfeed were recruited after birth and prior to hospital discharge, and randomly assigned (1:1) to usual care or usual care plus proactive telephone-based breastfeeding support from a trained peer volunteer for up to six months postpartum. A computerised random number program generated block sizes of four or six distributed randomly, with stratification by site. Research midwives were masked to block size, but masking of allocation was not possible. The primary outcome was the proportion of infants receiving any breast milk at six months of age. Analyses were by intention to treat; data were collected and analysed masked to group. The trial is registered with ACTRN, number 12612001024831.

FINDINGS

Women were recruited between Feb 14, 2013 and Dec 15, 2015 and randomly assigned to peer support (n = 574) or usual care (n = 578). Five were not in the primary analysis [5 post-randomisation exclusions]. Infants of women allocated to telephone-based peer support were more likely than those allocated to usual care to be receiving breast milk at six months of age (intervention 75%, usual care 69%; Adj. RR 1·10; 95% CI 1·02, 1·18). There were no adverse events.

INTERPRETATION

Providing first time mothers with telephone-based support from a peer with at least six months personal breastfeeding experience is an effective intervention for increasing breastfeeding maintenance in settings with high breastfeeding initiation.

FUNDING

The Felton Bequest, Australia, philanthropic donation and La Trobe University grant.

Evaluation of a Breastfeeding App in Rural Australia: Prospective Cohort Study

BACKGROUND

New mothers often need support to establish and maintain breastfeeding, and rural women may find it difficult to access breastfeeding resources locally. There are many smartphone applications for breastfeeding mothers; however, very few have been developed by health professionals. We evaluated a smartphone application, Breastfeeding Solutions, developed by U.S. IBCLC Nancy Mohrbacher. Research aims: The aims were (a) to explore usability of the application among rural Australian breastfeeding women and (b) to describe participants' infant feeding outcomes compared with the general population.

METHODS

A prospective longitudinal self-report survey design was used. Data were collected via online questionnaires at baseline and at 3 and 6 months from a convenience sample of new mothers. The setting was southwest Victoria, Australia, from 2016 to 2017. Descriptive statistics were used to answer research aims.

RESULTS

Of the initial 46 participants who received the app, 63% ( n = 29) completed surveys at 3 and 6 months. Usability was assessed at 3 months: 93.5% of participants (29 of 31) rated the application favorably, whereas 96.8% (30 of 31) found the application helpful and 87.1% (27 of 31) would recommend it to other mothers. At the 6-month survey, 79% of participants ( n = 23) were breastfeeding; 10% ( n = 3) had stopped breastfeeding during the first 3 months. The local breastfeeding rate at 6 months was approximately 50% according to routinely collected data; however, we cannot infer that the application was responsible for the difference.

CONCLUSION

The smartphone application was acceptable to breastfeeding women in an Australian rural setting. Further evaluation using a user-centered design could improve rural postpartum women's access to reliable, evidence-based information.

Worldwide prevalence of mother-infant skin-to-skin contact after vaginal birth: A systematic review

BACKGROUND

Despite the World Health Organization's (WHO) recommendation for immediate skin-to-skin contact (SSC) after birth, separation of mothers and infants seems to be common practice in many hospitals. It is unknown how common the practice of SSC is worldwide. Therefore, we aimed to determine the reported prevalence of SSC for healthy mothers and infants immediately after normal birth.

METHODS

We systematically searched CINAHL, Medline, ProQuest Central, PubMed and the Cochrane Library for articles published between January 2007 and October 2017 using the keywords "kangaroo care" or "skin to skin contact" or "breastfeeding initiation" or "breast crawl" or "maternal infant contact" or "maternal newborn contact" or "baby friendly hospital initiative" or "ten steps for successful breastfeeding".

RESULTS

After an initial screening of 5266 records, 84 full text articles were assessed for eligibility, and 35 of these met the inclusion criteria. The studies were from 28 countries representing all six WHO world regions. There was a wide range in the practice of SSC for mother-infant dyads around the world: from 1% to 98%. Only 15 studies clearly defined SSC. Most of the studies were from high-income countries, and these reported higher rates of SSC than studies from low and middle-income countries.

CONCLUSION

There was a great heterogeneity in the definition of SSC as well as study designs, which makes cross-county comparison difficult. National studies reporting SSC rates are lacking. Future studies and guidelines to enhance SSC practice should include a standardised set of indicators and measurement tools that document SSC starting time and duration of SSC.

Routinely collected infant feeding data: Time for global action

The importance of breastfeeding is clear. However, global action to support breastfeeding is hindered by the lack of reliable standard data, which continues to impede progress. Routinely collected data can monitor the effectiveness of health policy, evaluate interventions, and enhance international research collaboration and comparisons. Use of routine data to support effective public health initiatives such as smoking cessation has been demonstrated. However, the data collected about infant feeding practices worldwide is inconsistent in timing, methods, definitions, detail, storage, and consistency. Improvements to the reach and quality of routinely collected data about infant feeding are needed to strengthen the global evidence and policy base. An international collaborative effort is called for to progress this.

Review of guidelines on expression, storage and transport of breast milk for infants in hospital, to guide formulation of such recommendations in Sri Lanka

BACKGROUND

Sick newborns in neonatal units who are unable to breastfeed are fed expressed breast milk. In Sri Lanka, most mothers stay in hospital throughout baby's stay to provide this milk freshly. In other countries mothers go home, express breast milk at home and bring it to hospital. There are concerns about the safety of transported expressed milk if used in a tropical middle-income country. The aim of this paper is to compare and contrast advice offered by different hospitals and organizations on how to express, store and transport breast milk safely.

METHODS

We assessed guidelines used by hospital staff of the four Level 3 neonatal units in Melbourne, Australia, National Health Service UK, guidelines and training manuals of the Human Milk Banking Association of North America, the World Health Organization and an information leaflet from Family Health Bureau, Sri Lanka. Information on breast milk expression, storage and transport provided by the guidelines were tabulated under seven topics: general information; container for milk collection; hand expression; using a pump for expression; storage; thawing / warming; and transport of expressed breast milk. The AGREE II tool was used to assess the guidelines written for hospital staff.

RESULTS

There was considerable agreement on most recommendations provided by these sources, but no single source covered all topics in full. Most recommend hand expression as the initial method for expressing of breast milk, followed by breast pump use, except the Sri Lankan recommendations which strongly discourages the use of breast pumps. Durations of storage under various conditions are generally similar in the different recommendations. Most guidelines recommend a 'cool box' or container with ice or freezer packs for transportation of milk.

CONCLUSION

A single document containing recommendations on all aspects of expressing, storing and transporting breast milk should be available for each unit, with the same basic information for mothers and the healthcare staff and further technical details for staff if required. The Sri Lankan recommendations need to be updated based on current worldwide practices and further studies are needed to establish a safe method of transport of expressed breast milk in Sri Lanka.

Longer-term breastfeeding outcomes associated with domperidone use for lactation differs according to maternal weight

PURPOSE

To examine differences in longer-term breastfeeding outcomes among mothers of preterm infants according to domperidone exposure status, as well as examine the potential for effect modification according to maternal weight.

METHODS

Retrospective cohort study of 198 mothers of very preterm infants (born ≤ 30 weeks' gestation) who initiated breastfeeding and whose infants survived until hospital discharge. Data on domperidone use were obtained from hospital pharmacy records, with the primary outcome defined as continuation of breastfeeding at infant discharge from the Neonatal Unit. The relationship between domperidone exposure and breastfeeding status was investigated using multivariable regression analysis, adjusting for potential confounders. Additional pre-determined analyses were undertaken following stratification according to maternal weight to investigate the presence of effect modification.

RESULTS

No overall difference was observed in the proportion of mothers continuing to breastfeed at the time of infant discharge from the Neonatal Unit according to whether or not they received domperidone (aRR 0.99; 0.86-1.13). Notably, effect modification was observed according to maternal weight, with use of domperidone associated with a reduced likelihood of breastfeeding at discharge among women ≥ 70 kg (aRR 0.72; 0.54-0.97), but not among those < 70 kg (aRR 1.16; 0.92-1.46).

CONCLUSIONS

Despite experiencing low milk supply, longer-term breastfeeding outcomes were similar between women who did and did not use domperidone. Differences in domperidone effectiveness according to maternal weight have important implications for clinical practice given the increasing prevalence of overweight/obesity in reproductive-age women and their higher risk of low milk supply, highlighting the importance of further research in this area.

Impact of serotonin reuptake inhibitor use on breast milk supply in mothers of preterm infants: a retrospective cohort study

AIMS

The aims of the present study were to examine the association between late pregnancy exposure to serotonin reuptake inhibitor (SRI) antidepressants and difficulties in achieving an adequate breast milk supply in women who have given birth to preterm infants, while accounting for the potential impacts of underlying maternal psychiatric illness.

METHODS

A retrospective cohort study was carried out of 3024 women delivering liveborn preterm infants (<37 weeks' gestation) between January 2004 and December 2008. The primary outcome was postnatal domperidone use, considered to be a valid proxy for the presence and pharmacological management of low milk supply. Relative risks adjusted for maternal sociodemographic characteristics and comorbidities (aRRs) were calculated for low milk supply, comparing women with late pregnancy exposure to SRI antidepressants (n = 86), women with a psychiatric illness but no antidepressant use (n = 126) and women with neither antenatal exposures (n = 2812).

RESULTS

Compared with non-exposed women, nonmedicated psychiatric illness [aRR 1.64; 95% confidence interval (CI) 1.16, 2.30] but not late pregnancy SRI use (aRR 1.00; 95% CI 0.59, 1.70) was associated with an increased risk of domperidone use, indicative of low milk supply.

CONCLUSIONS

These findings do not support the previously observed negative impacts of antidepressant use on breastfeeding, instead suggesting that women with an underlying psychiatric illness appear at greatest risk of experiencing low milk supply and could benefit from additional breastfeeding education and support.

Timing of return to work and women's breastfeeding practices in urban Malaysia: A qualitative study

Nearly half of the working population in Malaysia are women, and with only a short period of maternity leave, they may struggle to achieve the recommended 6 months of exclusive breastfeeding. The aim of this paper was to explore the relationship between the timing of return to work and beliefs and breastfeeding practices among women in urban Malaysia. A qualitative inquiry based on a phenomenological framework and multiple methods was used: face-to-face interview, participant diary and researcher field notes. Data collection took place in Penang and the Klang Valley, Malaysia, from March to September 2011. Eligible participants were purposely identified at randomly selected recruitment sites. A thematic analysis method was used to develop the typologies and categories of the findings. A total of 40 working women with a mean age of 32 years (SD 3.4) were interviewed and 15 participated in the diary writing. Most women (75%) returned to work between 2 and 3 months. Only 10% returned to work 4 months or later postpartum, and 15% had an early return to work (defined here as less than 2 months). The women fell into three groups: Passionate women with a strong determination to breastfeed, who exclusively breastfed for 6 months; Ambivalent women, who commenced breastfeeding but were unable to sustain this after returning to work; and Equivalent women, who perceived formula feeding as equally nutritious as breast milk. Although longer maternity leave was very important for Ambivalent women to maintain breastfeeding, it was not as important for the Equivalent or Passionate women. In conclusion, returning earlier was not an absolute barrier to continuing breastfeeding. Instead, a woman's beliefs and perceptions of breastfeeding were more important than the timing of her return to work in determining her ability to maintain breastfeeding or breast milk feeding.

Implementation and evaluation of community-based drop-in centres for breastfeeding support in Victoria, Australia

Background

While Australia has high breastfeeding initiation, there is a sharp decline in the first weeks postpartum and this continues throughout the first year. Supporting breastfeeding In Local Communities (SILC) was a three-arm cluster randomised controlled trial to determine whether early home-based breastfeeding support by a maternal and child health nurse (SILC-MCHN), with or without access to a community-based breastfeeding drop-in centre, increased the proportion of infants receiving any breast milk at three, four and six months. The trial was conducted in ten Local Government Areas (LGAs) in Victoria, Australia.

The primary aim of this paper is to describe the three drop-in centres established during the trial; and the profile of women who accessed them. The secondary aim is to explore the views and experiences of the drop-in centre staff, and the challenges faced in establishing and maintaining a breastfeeding drop-in centre in the community.

Methods

Evaluation of the three LGAs with drop-in centres was multifaceted and included observational visits and field notes; data collected from attendance log books from each drop-in centre; a written survey and focus groups with maternal and child health (MCH) nurses who ran the drop-in centres; and semi-structured interviews with MCH coordinators of the participating LGAs.

Results

The three LGAs developed and ran different models of breastfeeding drop-in centres. They reported challenges in finding convenient, accessible locations. Overall, attendance was lower than expected, with an average of only one attendee per session. Two global themes were identified regarding staff views: implementation challenges, encompassing finding accessible, available space, recruiting volunteers to provide peer support, and frustration when women did not attend; and the work of SILC-MCHNs, including themes of satisfying and rewarding work, juggling roles, and benefits to women, babies and the community.

Conclusion

Providing community-based breastfeeding support was satisfying for the drop-in centre staff but proved difficult to implement, reflected by the lower than anticipated attendances at all of the drop-in centres. Interventions to increase breastfeeding in complex community settings require sufficient time to build partnerships with the existing services and the target population; to understand when and how to offer interventions for optimum benefit.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12611000898954.