Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
BackgroundThere is growing recognition that current food systems and policies are environmentally unsustainable. There is an identified need to integrate sustainability objectives into national food policy and dietary recommendations.Research AimsTo (1) describe exploratory estimates of greenhouse gas emission factors for all infant and young child milk formula products and (2) estimate national greenhouse gas emission association with commercial milk formulas sold in selected countries in the Asia Pacific region.MethodWe used a secondary data analysis descriptive design incorporating a Life Cycle Assessment (LCA) concepts and methodology to estimate kg CO2 eq. emissions per kg of milk formula, using greenhouse gas emission factors for milk powder, vegetable oils, and sugars identified from a literature review. Proportions of ingredients were calculated using FAO Codex Alimentarius guidance on milk formula products. Estimates were calculated for production and processing of individual ingredients from cradle to factory gate. Annual retail sales data for 2012–2017 was sourced from Euromonitor International for six purposively selected countries; Australia, South Korea, China, Malaysia, India, Philippines.ResultsAnnual emissions for milk formula products ranged from 3.95–4.04 kg CO2 eq. Milk formula sold in the six countries in 2012 contributed 2,893,030 tons CO2 eq. to global greenhouse gas emissions. Aggregate emissions were highest for products (e.g., toddler formula), which dominated sales growth. Projected 2017 emissions for milk formula retailed in China alone were 4,219,052 tons CO2 eq.ConclusionsPolicies, programs and investments to shift infant and young child diets towards less manufactured milk formula and more breastfeeding are “Triple Duty Actions” that help improve dietary quality and population health and improve the sustainability of the global food system.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
BackgroundMother’s milk improves outcomes. Referral neonatal intensive care units face unique lactation challenges with maternal–infant separation and maternal pump dependency. Little is known about lactation resource allocation in this high-risk population.Research AimsTo determine differences in human milk outcomes, (1) the proportion of infants fed exclusive or any mother’s milk and (2) recorded number and volume of pumped mothers’ milk bottles, between two models of lactation care in a referral neonatal intensive care unit.MethodsThis retrospective, longitudinal, two-group comparison study utilized medical record individual feeding data for infants admitted at ≤ Day 7 of age and milk room storage records from reactive and proactive care model time periods (April, 2017–March, 2018; May, 2018–April, 2019). The reactive care model (n = 509 infants, 58% male, median birth weight and gestational age of 37 weeks,) involved International Board Certified Lactation Consultant referral for identified lactation problems; whereas, the proactive model (n = 472 infants, 56% male, median birth weight and gestational age 37 weeks) increased International Board Certified Lactation Consultant staffing, who then saw all admissions. Comparisons were performed using chi square, Mann Whitney, and t-tests.ResultsA proactive lactation approach was associated with an increase in the receipt of any mother’s milk from 74.3% to 80.2% (p = .03) among participants in the proactive model group. Additionally, their milk room mean monthly bottle storage increased from 5153 (SD 788) to 6620 (SD 1314) bottles (p < .01).ConclusionsIn this retrospective study at a tertiary referral neonatal intensive care unit, significant improvement inhuman milk outcomes suggests that increased resources for proactive lactation care may improve mother’s milk provision for a high-risk population.

Journal of Human Lactation, Ahead of Print.
BackgroundLittle is known about breastfeeding initiation and duration in the context of postpartum marijuana use and safety beliefs.Research Aims(1) To describe characteristics of women who used marijuana postpartum; (2) to evaluate the relationship between postpartum marijuana use and breastfeeding behaviors; and 3) to assess, among women who used marijuana postpartum, how safety perceptions are associated with breastfeeding behaviors.MethodsData from the cross-sectional Pregnancy Risk Assessment Monitoring System, a United States national governmental survey, 2017, were analyzed for participants with infants aged ≥ 12 weeks (seven states, unweighted N = 4604). Chi-square tests were used to compare characteristics and counseling for postpartum marijuana use. For participants with postpartum use, adjusted prevalence ratios (aPR) were calculated to evaluate relationships between safety perceptions and breastfeeding initiation and duration.ResultsOverall, 5.5% (95% CI [4.6, 6.6]) of participants reported postpartum marijuana use; among these women, 47.2% (CI [37.6, 56.9]) were breastfeeding at the time of the survey. Overall, 25.7% of participants indicated that they had been advised, by their prenatal care provider, against marijuana use while breastfeeding. Breastfeeding initiation or duration did not differ by postpartum marijuana use. Among participants with postpartum use, those who perceived marijuana was safe for breastfeeding women to use were more likely to have breastfed (aPR = 1.22, CI [1.04, 1.43]) and have a breastfeeding duration > 12 weeks (aPR = 1.57, CI [1.08, 2.27]) compared to those who perceived it to be unsafe.ConclusionsUnderstanding maternal safety beliefs and provider education about the latest evidence and guidance related to postpartum marijuana use may improve clinical care.

Journal of Human Lactation, Ahead of Print.
IntroductionDuring the Coronavirus Disease 2019 global pandemic, maternal and newborn wellbeing has received much attention. Detailed reports of infected women breastfeeding their infants are uncommon. Due to incomplete information available, full data about those infants’ outcomes are lacking, and evidence of infectivity through breastfeeding has not been documented.Main IssueHere, we report about a mother who breastfed her infant until she was confirmed with the SARS-Cov-2 infection. After follow-up, we have confirmed that the infant, who was breastfed by the infected mother, was not infected.MethodsA 33-year-old woman gave birth to a full-term male infant on November 8, 2019. Since birth, she had been exclusively breastfeeding the baby until she was confirmed with the SARS-Cov-2 infection on February 8, 2020. She was hospitalized, isolated from her baby, and stopped breastfeeding. Even though she remained asymptomatic, her milk was expressed using a breast pump and discarded. The mother’s milk sample was collected on February 9, 2020, and the result of the nucleic acid test for COVID-19 was negative. Her infant was asymptomatic and remained virus negative. Her laboratory findings and chest Computed Tomography imaging was normal. She was treated according to the national protocol with aerosolized interferon α2β, lopinavir/ritonavir and ribavirin. Her serum SARS-CoV-2 specific antibodies(IgG and IgM) tested positive when discharged. She returned to breastfeeding after discharge.ConclusionOur findings suggest that breastfeeding may be less of a risk than anticipated. Additional research is needed to explore this possibility.

Journal of Human Lactation, Ahead of Print.
BackgroundBreast 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 aimsTo 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.MethodsThis 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.ResultsExcellent 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.ConclusionThe 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.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
BackgroundExclusive breastfeeding has a wide range of benefits for maternal health. However, the benefit of exclusive breastfeeding for maternal mental health needs to be further explored.Research AimTo determine the moderating role of exclusive breastfeeding at 3 months on the association between prenatal and postpartum depression.MethodsThis study had a prospective, longitudinal, and comparative design with two groups and three assessment waves. The sample comprised 334 participants (70 depressed and 264 non-depressed) recruited at public health services in northern Portugal. Participants completed a measure of depression symptoms between the second and the third trimester of pregnancy and between 3 and 6 months, and a measure of breastfeeding status at 3 months.ResultsExclusive breastfeeding at 3 months moderated the association between prenatal and postpartum depression. Participants with prenatal depression who were exclusively breastfeeding at 3 months showed fewer symptoms of depression and lower rates of depression between 3 and 6 months postpartum, compared to participants with prenatal depression who were not exclusively breastfeeding. Participants without prenatal depression who were exclusively breastfeeding at 3 months showed similar depression symptoms and similar rates of depression between 3 and 6 months postpartum, compared to participants without prenatal depression who were not exclusively breastfeeding.ConclusionExclusive breastfeeding has a potential protective influence on postpartum depression among women with prenatal depression. Public health policies targeting women with prenatal depression should be implemented and include practices to promote and support exclusive breastfeeding in order to enhance women’s exclusive breastfeeding and mental health.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
BackgroundThe continuity of maternal depressive symptoms throughout the perinatal period and breastfeeding problems have adverse influences on breastfeeding.Research aimTo compare the feeding patterns and breastfeeding experiences, maternal health and mental health, and breastfeeding self-efficacy between women with depressive symptoms who participated in a prenatal individualized mixed management intervention and those who received usual care.MethodsChinese primigravida (N = 182) with an Edinburgh Postnatal Depression Scale score ≥ 9 in late pregnancy (≥ 28 weeks and < 35 weeks) were randomly assigned to the intervention group (n = 84) or the control group (n = 84). Intervention group participants received four sessions of individualized mixed management combining psycho-education and breastfeeding education. Breastfeeding self-efficacy, feeding patterns, maternal depression, and health status were evaluated in both groups.ResultsSignificant differences were noted between the groups in breastfeeding self-efficacy at 42 days postpartum (p < .05) and feeding patterns at 3 months and 6 months postpartum (p < .05). Repeated measures analysis of variance showed significant differences in the EPDS scores between groups at three postpartum time points (p < .05). The intervention group had significantly lower postpartum depression as diagnosed by the MINI (p < .05).ConclusionsA prenatal individualized mixed management intervention holds promise as an effective prevention and health promotion program addressing breastfeeding outcomes and maternal mental health.This RCT was registered (ChiCTR-IOR-17013761) with Chinese Clinical Trial Registry, http://www.chictr.org.cn/enIndex.aspx on 12/7/2017.

Journal of Human Lactation, Ahead of Print.
BackgroundIt is known that breastfeeding protects the infant from enteric and respiratory infections; however, the antiviral properties of human milk against enteric and respiratory viruses are largely unexplored.Research aimsTo explore the antiviral activity of human preterm colostrum against rotavirus and respiratory syncytial virus and to assess whether the derived extracellular vesicle contribute to this activity.MethodsWe used a cross-sectional, prospective two-group non-experimental design. Colostra were collected from mothers of preterm newborns (N = 10) and extracellular vesicles were purified and characterized. The antiviral activity of colostra and derived extracellular vesicles were tested in vitro against rotavirus and respiratory syncytial virus and the step of viral replication inhibited by extracellular vesicles was investigated.ResultsEach sample of colostrum and colostrum-derived extracellular vesicles had significant antiviral activity with a wide interpersonal variability. Mechanism of action studies demonstrated that extracellular vesicles acted by interfering with the early steps of the viral replicative cycle.ConclusionWe demonstrated the intrinsic antiviral activity of human colostrum against rotavirus and respiratory syncytial virus and we showed that extracellular vesicles substantially contribute to the overall protective effect. Our results contribute to unravelling novel mechanisms underlying the functional role of human milk as a protective and therapeutic agent in preterm infants.

Journal of Human Lactation, Ahead of Print.
Since 1980, alongside IBFAN partners, Patti Rundall has worked to build collaborative networks that help countries bring in legally binding controls based on the International Code of Marketing of Breastmilk Substitutes and the United Nations World Health Assembly (WHA) Resolutions. Conflicts of interest and their impact on policymaking, research, education, and health systems has been a cross-cutting theme of her work, which has focused on the adoption and strengthening of the European Union’s baby food legislation and the improvement of Codex Global Trading Standards. With IBFAN, she helped countries adop many resolutions including WHA Resolution 49.15 https://www.who.int/nutrition/topics/WHA49.15_iycn_en.pdf?ua=1 (1996) about conflicts of interest; she helped found and launch the Conflicts of Interest Coalition at the UN General Assembly. Patti is a founder of Baby Feeding Law Group (the alliance of 23 United Kingdom health professional and mother-support organizations), a member of the Infant Feeding in Emergencies core group and a leader in company campaigns (e.g., the Nestlé Boycott). She represented IBFAN on the European Commission’s Platform for Action on Diet and Physical Activity from 2007 until 2019. In the year 2000 she was awarded the title Officer of the British Empire (OBE) for her service to infant nutrition. (This is a verbatim interview: MA = Maryse Arendt; PR = Patti Rundall.)

Journal of Human Lactation, Ahead of Print.
BackgroundEarly breastfeeding practices are important determinants of later breastfeeding behaviors and can be influenced by multiple factors. Despite the Baby-Friendly Hospital Initiative reported positive influence on breastfeeding initiation, its influence on the association between maternal country of birth and first day in-hospital breastfeeding has not been examined.Research aimsTo determine (1) if association between maternal country of birth and first day in-hospital exclusive breastfeeding exists in Portugal and (2) if any association is affected by giving birth in a Baby-Friendly Hospital.MethodsData were drawn from baMBINO—a longitudinal, 2017–2019 nationwide study designed to assess the perinatal health and healthcare experiences of migrant and native Portuguese women. Data from participants (N = 5,340) were collected during their hospital stay from 32 maternity units. Missing data were handled through multiple imputation. After stratifying by Baby-Friendly Hospital Initiative accreditation, a multivariate logistic regression was performed.ResultsFirst day in-hospital exclusive breastfeeding rates were high among both migrant and native participants (89.2% vs. 87.4%). Migrants were more likely to exclusively breastfeed when compared to natives (OR = 1.19, 95% CI [1.00, 1.41]). In non-Baby-Friendly Hospitals, a positive association was found between participants from Eastern European countries (aOR = 2.46, 95% CI [1.27, 4.78]) and first day in-hospital exclusive breastfeeding. In accredited hospitals, maternal country of birth did not influence exclusive breastfeeding during the first 24 hr.ConclusionsThe Baby-Friendly Hospital Initiative attenuates differences between migrant and native participants, promoting optimal breastfeeding practices among natives.

Journal of Human Lactation, Ahead of Print.
BackgroundThe need for donor human milk has accelerated both locally and globally. To remain sustainable, human milk banks need to maintain effective recruitment including frequent donations of adequate volumes.Research aimsTo determine (1) which factors influenced mothers’ willingness to give or receive donor human milk, and the influence of (2) socio-demographics, (3) pregnancy, (4) breastfeeding history, (5) prior knowledge of human milk banks, and (6) general factors on milk donations.MethodsThis was a cross-sectional, prospective, descriptive study. Interviewer administered questionnaires were used (N = 148). Independent sample t-tests and one-sample t-tests were used to determining differences in variables.ResultsThe sample population consisted of mainly single (n = 104, 70.3%) Black African mothers (n = 127, 85.8%) who identified as Christian (n = 97, 65.6%) with a mean age of 24.8 (SD = 5.63) years. The majority (n = 120, 81.1%) had no prior knowledge of human milk banks; however, most (n = 78, 52.7%) were significantly likely to donate. The main factors that influenced the participants’ willingness to donate were altruism (n = 99, 66.9%), information provided by staff at hospitals/clinics (n = 92, 62.2%), amount of milk produced (n = 69, 46.4%), fear of not having enough milk for their own infant (n = 68, 45.9%), and support from family/friends/partner (n = 67, 45.3%).ConclusionThere is a strong need to increase visibility and information sharing with potential donor mothers to ensure a sustainable supply and system of human milk banks.

Journal of Human Lactation, Ahead of Print.
BackgroundBreastfeeding is a fundamental component of health care, and health professionals need to be adequately prepared. As part of the system, health care professionals have the ability to influence the establishment and maintenance of breastfeeding. The global literature regarding the curricular approach or established best practices for health professional education in lactation is inconclusive and lacking in rigor.Research aimTo explore the literature for the educational resources, methods, and curriculum used in the education of undergraduate health students related to lactation.MethodsA scoping review examining the curricular programs of health professional students in lactation was undertaken exploring and summarizing evidence from peer reviewed and grey literature. A scoping review with a five-stage review process was followed. The database search between 1982–2018 generated 625 results, 79 full-text articles were reviewed, and 29 articles published in English met the inclusion criteria.ResultsIn general, educational resources, methods, curricular approaches, and foundational topics were based on best practice standards. Some authors incorporated a variety of learning methods and provided experiential learning, with evidence of translation of knowledge into clinical practice. In the studies examined, researchers reported that students had improved their: knowledge and attitudes (59%); breastfeeding support skills (45%); and confidence (10%). However, even in programs that focused on developing students’ breastfeeding support skills, authors reported a lack of change in students’ confidence.ConclusionsAlthough only English articles met the inclusion criteria, this review was unique in its search of multidisciplinary, multilingual, and international studies. Consistency in teaching across disciplines is key and not evident in the studies reviewed.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
BackgroundStudents returning to school who are breastfeeding face unique challenges. There is limited literature on breastfeeding university students. Several researchers have studied breastfeeding employees in the workplace. Institutions of higher education closely mimic the employment environment. Breastfeeding college students who express their milk while at school share similar challenges to employed mothers. A baccalaureate nursing program is rigorous and little is known about the challenges facing breastfeeding student nurses returning to classes.Research aimTo explore the breastfeeding experience of baccalaureate nursing students.MethodsOur study was a cross-sectional descriptive qualitative design. Purposive sampling was used to enroll participants (N = 12). In depth, semi-structured interviews were conducted. Qualitative thematic analysis was used to analyze the data both manually and using Dedoose QDA software.ResultsAn overarching theme of pervasive conflict between the role of the breastfeeding mother and the role of the student nurse surfaced. Three interrelated organizing themes also emerged; challenging, vulnerability, and resilience. Time constraints, self-care versus role demands, and structural accommodations contributed to the challenges. Only one participant indicated a knowledge of her breastfeeding rights. All of the participants expressed gratitude for faculty and community support, regardless of conflicts.ConclusionBreastfeeding participants were both vulnerable and resilient. Faculty may improve experiences through providing specific areas of support. A breastfeeding support policy outlining student rights and faculty responsibilities is needed to educate, guide, and enforce protections. Health care providers may enhance breastfeeding students’ experiences through anticipatory guidance, education, and continued support.

Journal of Human Lactation, Ahead of Print.
BackgroundInconsistent information exists regarding indicators of secretory activation in mothers delivering very low birth weight infants.Research aimsTo compare time to the onset of secretory activation using three separate indicators. A secondary aim examined the association between indicators of secretory activation and milk production.MethodsIndicators of secretory activation included maternal perception, volume attainment (production of ≥ 20 mL in two consecutive expression sessions) and biomarkers (sodium and lactose) obtained at volume attainment. Milk production was measured on Days 1–7 and then weekly for 6 weeks.ResultsIn 69 mothers of infants born ≤ 32 weeks’ gestation and < 1500 g, we found no correlation in time to secretory activation between indicators. Earlier volume attainment was associated with increased milk production on Days 1–7, 14, 21, and 28 (all p < .007). Participants who exhibited both normal lactose and sodium levels produced more milk on Days 28 and 42 (p = .028 and .011), those with only normal lactose levels produced more on Day 42 (p = .026) and those with only normal sodium levels on Day 28 (p = .036). Earlier secretory activation by volume attainment was associated with increased expression frequency during Days 2–5 (all p < .014) and participants with normal biomarkers expressed more frequently during Days 2–5 (all p < .020).ConclusionMothers of very low birth weight infants are at risk for delayed secretory activation, which may decrease their milk production. Frequent expression during the first 5 days postpartum may promote earlier secretory activation. Valid methods of determining secretory activation are necessary to develop interventions promoting earlier secretory activation.

Journal of Human Lactation, Ahead of Print.
BackgroundAiming to protect breastfeeding, the World Health Organization released the International Code of Marketing of Breastmilk Substitutes in 1981, which was adopted by the vast majority of the 118 member countries, including Brazil. The Brazilian Code regulates the marketing of infant formulas, baby bottles, teats, pacifiers, milk, and processed complementary food.Research aims(1) To determine if retail stores had violated the Brazilian Code and (2) to analyze factors associated with these violations.MethodsThis cross-sectional study included all drugstores, supermarkets, and department stores in the Southern Zone of Rio de Janeiro City, Brazil. Trained health professionals observed retail stores for marketed products and violations of the Brazilian Code and then interviewed their managers. Factors associated with the retail stores violating the Brazilian Code (outcome) were analyzed, employing a logistic regression model with 95% Confidence Interval.ResultsOf the retail stores (N = 349) evaluated, 62.8% violated the Brazilian Code, ranging from 1 to 37 violations per retail store. The most common promotion strategies were price discounts and special displays. Retail stores being part of a chain store (aOR = 4.59) and their manager receiving visits from industry business representatives (aOR = 2.14) were associated with the presence of violations.ConclusionsThe prevalence of Brazilian Code violations was high, especially in chain stores. The association between regular visits by industry representatives and violations suggests an indirect influence of manufacturers on the promotion of human milk substitutes. We recommend strengthening compliance with the Brazilian Code through calling on governmental surveillance agencies and civil society mobilization.

Journal of Human Lactation, Ahead of Print.
BackgroundMother’s own milk does not provide enough nutrients to feed a preterm baby born before 32 weeks’ gestation; therefore, human milk fortifiers are needed. However, human milk fortifiers increase the osmolality, and enteral administration of high osmolality fluids has been associated with gastrointestinal symptoms. For this reason, it is necessary for laboratories to have a validated system in order to measure human milk osmolality.Research aimThe aim of this study was to validate the OM-6050 Station System for measuring the osmolality of fortified mother’s milk samples.MethodsOsmolality was measured using the osmometer OM-6050 Station System. Milk samples from healthy mothers (N = 3) unfortified and with two fortifiers (Almirón Fortifier® or NAN FM85®), as well as a nutritional supplement (Duocal MCT®) were used in the validation study through precision and linearity analysis.ResultsIn the precision study the mean intra-assay coefficient of variation was 1.2% and 1.7% for mother’s milk and fortified mother’s milk, respectively. The mean inter-assay coefficient of variation was ≤ 1% in both cases. In the linearity study the regression analysis had a linear response to fortified mother’s milk osmolality between 294 mOsm/kg and 539 mOsm/kg.ConclusionThe osmometer OM-6050 Station was reliable for determining the osmolality of fortified and unfortified mother’s milk. It may be useful in the clinical practices within Neonatal Intensive Care Units.