Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
In this issue’s Lactation Newsmakers: Documenting our History, we are featuring Elizabeth Hormann, who has been a force in breastfeeding advocacy globally for over a half century of counselling, teaching, and writing to create a better experience for breastfeeding mothers. Elizabeth Hormann was born and raised in the United States. She has a bachelor’s degree from Boston College (1967) and a master’s degree from Harvard University’s Graduate School of Education (1976). In 1972, she started training and lecturing at conferences, while raising her five breastfed children. Just after receiving her IBCLC in 1986, she changed continents moving to live and work in Germany. She was a role model, influencing the development of the IBCLC accreditation in Europe. Elizabeth Hormann was a pioneer in lecturing and sharing expertise during the 1980s, when there was a renewed interest in breastfeeding and a huge demand on breastfeeding education for health professionals. She helped to advance the Baby-Friendly Hospital Initiative (BFHI) in many countries, as a trainer and as an assessor. Over the years, she shared her expertise about relactation breastfeeding and infant feeding during emergencies. As the author and a translator of a number of breastfeeding books, her influence has been felt across Europe and Africa.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
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.

Journal of Human Lactation, Ahead of Print.
Background:Puerperal mastitis, as well as breast abscess, are common complications that can arise during the breastfeeding period. Acute-onset quadriplegia has been described as a complication of bacterial or viral infections. Here we report a case of puerperal breast abscess with transient acute-onset staphylococcal mediated quadriplegia.Main Issue:A 28-year-old lactating Caucasian woman presented at our tertiary perinatal center 31 days postpartum with weakness of all four limbs, the signs and symptoms of mastitis in her left breast and a possible breast abscess with redness, a painful breast lump, and fever. A few hours after admission, the participant developed a proximal quadriplegia.Management:The participant was admitted to the intensive care unit for monitoring. The neurologists treated her as a possible case of Guillain-Barré syndrome and administered intravenous immunoglobulin therapy for 5 days. The breast abscess was diagnosed via ultrasound and treated by regular aspiration of pus and intravenous antibiotic therapy with ampicillin and sulbactam as Staphylococcus aureus was isolated from breast abscess fluid. Fifteen days after the first symptoms the participant recovered completely and could breastfeed her son exclusively, even though she developed a galactocele on the affected side.Conclusion:We report a possible association between mastitis and abscess formation, common breastfeeding issues, and transient acute onset staphylococcal mediated quadriplegia. To the best of our knowledge this is the only case in the medical literature. Independent of the systemic complications, antibiotic treatment and regular abscess aspirations have proven to be a key strategy to the resolution of puerperal mastitis and breast abscess.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:There is limited evidence about the influence of human milk feeding on short-term outcomes in a large preterm infant population.Research Aims:To explore the influences of human milk feeding on the primary outcome of necrotizing enterocolitis and secondarily sepsis, bronchial pulmonary dysplasia, severe retinopathy of prematurity, death, and the time to achieve full enteral feeding at discharge in very/extremely low-birth-weight infants.Methods:This study was a retrospective, longitudinal, observational two-group comparison cohort study. A total of 4470 very/extremely low-birth-weight infants from 25 neonatal intensive care units in China, between April 2015 and May 2018, were enrolled in this study. Exclusive human milk-fed and formula-fed participants were matched using propensity scores. After matching, human milk-fed participants (n = 1379) and formula-fed participants (n = 1378) were included in the analyses. The likelihood of necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, severe retinopathy of prematurity, death, and the time to achieve full enteral feeding were compared between the two groups.Results:Exclusive human milk feeding was associated with lower odds of necrotizing enterocolitis (2.90% vs. 8.42%, OR 0.33, 95% CI [0.22, 0.47]), bronchopulmonary dysplasia (15.74% vs. 20.26%, OR 0.69, 95% CI [0.56, 0.86]), severe retinopathy of prematurity (1.45% vs. 2.39%, OR 0.50, 95% CI [0.27, 0.93]), and death (6.02% vs. 10.38%, OR 0.44, 95% CI [0.32, 0.61]) compared with formula feeding. No significant differences in the time to achieve full enteral feeding or the odds of sepsis were found between the two groups.Conclusion:Exclusive human milk feeding is associated with a reduction in necrotizing enterocolitis, bronchopulmonary dysplasia, severe retinopathy of prematurity, and mortality among very/extremely low-birth-weight infants.Trial registration:Clinicaltrials.gov on November 9, 2015 (NCT02600195).

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Introduction:Breastfeeding is a recognized preferred method of infant feeding; however, for many women, difficulties in breastfeeding result in termination before the recommended period of time. Acupuncture is suggested to be a promising option to treat lactation insufficiency and enhance the production of maternal milk.Main Issue:We have reported the case of a woman with lactation insufficiency due to Caesarean section and congenital unilateral invaginated nipple. Milk production started on the 3rd day following delivery. The newborn was not provided with any food or fluids other than mother’s milk. At 5 days of life, the newborn required long feeding periods and lost 4% of his birth weight, with the participant reporting lactation insufficiency described by the perception of inadequate milk production.Management:Despite the implementation of conventional measures to improve lactation, the difficulties in breastfeeding persisted. Acupuncture was tried on Day 6 of life, and enhanced milk production was observed, which could be measured as the volume of residual milk extracted using the breast pump each time after the newborn achieved satiety. After acupuncture treatment there was an augmentation of maternal milk production from both breasts and successful lactation.Conclusion:This case study provides information that might be useful for prospective investigation of acupuncture’s efficacy in women with lactation insufficiency.

Journal of Human Lactation, Ahead of Print.
Introduction:Remdesivir was originally developed to treat Ebola hemorrhagic fever, and its efficacy in treating coronavirus disease 2019 was detected during a preliminary analysis of a randomized controlled trial. It is known that Severe Acute Respiratory Syndrome Coronavirus 2 is not transmitted through human milk, but data about the presence of remdesivir in human milk have been lacking.Main issue:In this case study, we determined the human milk-to-serum drug concentration ratio and the relative dose of Remdesivir in one participant.Management:The participant, a 28-year-old primipara, was found to have Coronavirus 2 infection in 2019, 2 days after delivery. She was given Remdesivir. The Remdesivir concentration in maternal serum and human milk was measured, and the milk-to-serum drug concentration ratio was found to be low (0.089), as was the relative infant dose (0.0070). The participant could not breastfeed her infant during her Coronavirus 2 infection treatment because in Japan anyone with COVID-19 was completely quarantined. However, she was able to resume breastfeeding after discharge and breastfed her infant for 6 months with supplements.Conclusion:Given the low amount of Remdesivir in the participant’s milk, the inclusion of antibodies to Severe Acute Respiratory Syndrome Coronavirus 2, which can be expected to protect the infant from infection, and various other benefits of human milk, suggests that breastfeeding is safe during treatment with Remdesivir.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Suboptimal breastfeeding can result in negative health consequences for mother and infant and economic consequences for families and communities. Breastfeeding outcomes improve when multifaceted interventions spanning the perinatal period are implemented. Incentives to increase participation in effective, existing community-based breastfeeding support programs have the potential to create behavioral change and improve breastfeeding outcomes but results to date are inconclusive.Research Aim:The aim of this pilot study was to investigate the effectiveness of offering a Young Men’s Christian Association membership as an incentive to increase attendance at an existing breastfeeding support program to improve breastfeeding duration and exclusivity.Method:This was a two-group, quasi-experimental study using demographic information and pre- and post-intervention participant surveys. Attendance at a breastfeeding support program was incentivized with an offer of a free family Young Men’s Christian Association membership. Surveys and demographic information were used to compare attendance, maternal interest, and perceived significant other and family support for attendance with a non-incentivized control group in an adjacent city.Results:The groups differed demographically and socioeconomically. Significantly more at-risk participants both attended the incentivized group and perceived support from their families to attend. There was a significant increase in the incentivized group’s attendance: 62% (n = 26) of participants in the incentivized group attended three or more times compared to 36% (n = 50) of participants in the control group (p = .03). Both groups exceeded national breastfeeding averages for exclusive breastfeeding at six months.Conclusion:Offering an incentive increased breastfeeding support group attendance by participants at risk for suboptimal breastfeeding and improved their breastfeeding outcomes, thus closing the breastfeeding disparity gap in this population.

Journal of Human Lactation, Ahead of Print.
Background:Women during the postpartum period undergo significant changes which affect body image, eating behaviors, and, potentially, breastfeeding. There is limited research about relationships among these variables, particularly related to breastfeeding experiences and self-efficacy.Research Aims:To determine: (1) the associations between eating disorder symptoms and body image, breastfeeding self-efficacy, and breastfeeding experiences; and (2) the differences in body image, breastfeeding self-efficacy, breastfeeding experiences, and breastfeeding status of postpartum women with and without clinically significant eating disorder symptoms.Methods:A secondary data analysis using a 2-group correlational, cross-sectional online survey design was used. Participants with infants 2–6 months old who had breastfed their infant at least once (N = 204) were recruited nationally to complete a cross-sectional survey assessing breastfeeding and postpartum physical and mental health using validated measures. Linear and logistic regression evaluated differences between participants with and without eating disorder symptoms regarding their body image, breastfeeding experience and self-efficacy, and breastfeeding status (continued vs. discontinued) at 2 months postpartum.Results:Clinical eating disorder symptoms were reported by 9.8% (n = 20). Participants with clinical eating disorder symptoms reported lower appearance evaluations (B = -0.53, 95% CI [-0.93, -0.14]) and body image satisfaction (B = -0.55, 95% CI [-0.87, -0.23]); reduced odds of breastfeeding at 2 months postpartum (AOR = 0.15, 95% CI [0.04, 0.56]); and lower breastfeeding self-efficacy (B = -7.70, 95% CI [-14.82, -0.58] relative to participants without clinical symptoms. No differences between groups were observed for breastfeeding experiences.Conclusions:Participants with clinically significant eating disorder symptoms are at risk for early breastfeeding discontinuation and lower breastfeeding self-efficacy. Our findings have implications for future research and clinical care practices, including screening for body image concerns and eating disorder symptoms and supporting breastfeeding self-efficacy.

Journal of Human Lactation, Ahead of Print.
Background:No consensus on the definitions of nipple trauma has been reported. Thus, different individuals assess identical events inconsistently.Research Aims:To establish clear definitions for the seven signs of nipple trauma related to breastfeeding—erythema, swelling, scabbing, blistering, fissure, purpura, and peeling—and to reach consensus among multiple specialists.Methods:We implemented a longitudinal, prospective survey design using a 3-step Delphi method. In the first survey we targeted specialists in breastfeeding, dermatology, and cosmetics, and we presented images as representative cases during a set of semi-structured interviews. In the second and third surveys, we questioned midwives who were certified as “advanced midwives” through mail, using a questionnaire prepared based on the results of the first survey. The agreement criteria of this study were as follows: (1) a median of 2.0 or below; (2) an interquartile range of 1.0 or below; and (3) at least 51% showing responses of either “strongly agree” or “agree.”Results:Based on the responses of the 42 experts, we reached a consensus on 48 items: eight related to erythema, 10 to swelling, nine to scabbing, seven to blistering, seven to fissure, four to purpura, and three to peeling. We then classified these items based on the condition or possible mechanism of the wound. Finally, we developed an observation tool: “seven signs of nipple trauma associated with breastfeeding,” along with images.Conclusions:Application of this tool for breastfeeding support could improve objectivity in observing and evaluating nipple trauma.

Journal of Human Lactation, Ahead of Print.
Background:Developing a simple quantitative tool for mastitis diagnosis is essential. The Ion-Selective Electrode for sodium has been reported to reliably measure sodium concentrations in human milk.Research Aim:To determine whether an Ion-Selective Electrode measurement of sodium:potassium ratios could serve as a diagnostic tool for mastitis and, if so, to determine the diagnostic cut-off value.Methods:A total of 107 milk samples, including 55 from milk bank donors and 52 from participants with mastitis, were studied. The sodium:potassium ratios were determined in 33 samples (without mastitis n = 15; with mastitis n = 18) by the Ion-Selective Electrode and ion chromatography. The remaining 74 samples (donor milk n = 40; participants with mastitis n = 34) were analyzed by Ion-Selective Electrode only. Values were averaged over three measurements for each method.Results:The median postpartum months of donors and participants with mastitis were 2 and 3 months, respectively. The mean (SD) sodium:potassium ratios without and with mastitis were 0.5 (0.1) and 1.7 (1.2), respectively. A positive correlation existed between sodium:potassium ratios obtained from the two methods (r = 0.98). Area under the curve values were 0.951 (95% CI [0.904, 0.986]) for the Ion-Selective Electrode (N = 107) and 0.978 (95% CI [0.926, 1.000]) for the ion chromatography (n = 33) methods. The optimal cut-off value for the Ion-Selective Electrode method was 0.60, with 86.5% sensitivity and 92.7% specificity.Conclusions:The Ion-Selective Electrode was sufficiently accurate for the diagnosis of mastitis. Cohort studies are needed to explore the relationship between sodium:potassium ratios and clinical outcomes.