Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
Background:Subclinical mastitis is an asymptomatic inflammatory condition of the lactating mammary glands possibly associated with premature interruption of breastfeeding and poor weight gain in infants. However, data on human milk composition in mothers with subclinical mastitis are limited and inconsistent. Although human milk from donors with subclinical mastitis may be used after pasteurization if it meets the criteria, whether the composition is suitable for donor human milk remains unknown.Research Aims:This study assessed the human milk composition of participants with subclinical mastitis and verified the safety of donor human milk, including that from mothers with subclinical mastitis.Methods:This cross-sectional survey included 106 milk samples collected between March 2022 and January 2023. Subclinical mastitis status was assessed using the sodium-potassium ratio, which was measured using an ion-selective electrode. The concentrations of lactoferrin and secretory Immunoglobulin A were analyzed using an enzyme-linked immunosorbent assay. True protein, fat, carbohydrate, and energy levels were analyzed using a mid-infrared transmission spectroscopy.Results:In human milk from the subclinical mastitis group, lactoferrin and true protein concentrations were significantly increased compared to those without subclinical mastitis. A positive correlation was observed between lactoferrin and secretory Immunoglobulin A levels.Conclusions:Increased immunological substances and protein concentrations in human milk are similar to those observed in clinical mastitis, indicating an inflammatory response in the body, even in asymptomatic individuals. Immunological substances and proteins are beneficial for preterm infants. Therefore, human milk from mothers with subclinical mastitis is suitable for use by milk banks.

Journal of Human Lactation, Ahead of Print.
Exclusive breastfeeding, as recommended by the World Health Organization (WHO) for the first 6 months of life, is a critical metric for evaluating maternal and infant feeding practices and health outcomes. Despite its importance, inconsistencies in defining and measuring breastfeeding exclusivity present challenges for research comparability and interpretation. Equally, research design, outcomes of interest, and study resources are necessary considerations when collecting and analyzing exclusive breastfeeding data, and may require the adaption of standardized questions and techniques to individual situations. This paper explores key considerations for researchers when operationalizing and measuring exclusive breastfeeding. We address the nuances of point prevalence and since-birth measures, highlighting their influence on study outcomes and data interpretation. Statistical approaches for analyzing exclusivity data, including logistic regression, survival analysis, and Kaplan-Meier methods, are also discussed. By outlining best practices for precise definitions, tailored data collection, and transparent reporting, this paper aims to provide an overview for precise definition, effective data collection, and clear interpretation.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
National staffing guidelines for hospital lactation services do not account for the lactation acuity of breastfeeding patients. Higher acuity breastfeeding couplets require a higher level of knowledge and skill from lactation care providers. In these cases, a referral to an International Board Certified Lactation Consultant (IBCLC) is recommended for appropriate management. Use of a lactation acuity classification system as a clinical practice innovation was implemented at Oklahoma University Medical Center to improve the distribution of staff resources for optimal care of breastfeeding patients. Lactation service reports from this facility, a tertiary care teaching hospital, were reviewed to evaluate staffing, number of lactation consults, reason for and acuity of consults, and time spent. The review included over 10,000 lactation consults completed over a 1-year period. Once the lactation acuity system for IBCLC staff was in place, there was an increased mean direct consult time and acuity level with 85% of IBCLC time allocated to high acuity consults. Trained bedside nurses handled most low-acuity patients. The percentage of patients needing a lactation consult who received one increased along with the number of consults per patient. Data on time spent per consult were stratified by acuity, location, and reason for consult, including details on priority consults for neonatal intensive care unit patients. The productivity of the lactation team was higher with the use of a lactation acuity system compared to without it. The data reported support the use of lactation acuity in making recommendations for staffing of hospital lactation services.

Journal of Human Lactation, Ahead of Print.
Background:Pumping is a common practice in the United States, but it can be uncomfortable and lead to concerns about milk supply. The fit of the flange, or breast shield, used while pumping can contribute to or alleviate these problems. Flanges are available in a wide variety of sizes, and there are inconsistencies in guidance provided by healthcare providers and pump manufacturers for parents choosing a size. There have been no studies comparing different methods of sizing in terms of comfort and milk output.Research Aims:The aim of this research was to examine differences in milk output and comfort using two methods of flange sizing.Method:A within-subject cross-over design with a convenience sample of parents exclusively feeding their own human milk was used to compare comfort and milk yield between using smaller-fit and standard-fit flanges. Participants pumped for 1 week with each set of flanges and recorded milk output and comfort outcome measures. Data were collected on participant demographics, nipple measurements, and flange sizes used.Results:When compared to the newer small-size fitting, participants using the standard fit flanges had significantly less milk output (mean difference = −15.0 g, 95% CI [−25.0, −5.0], d = −0.51, p = 0.004) and less comfort (mean difference = −1.2, 95% CI [−1.6, −0.91], d = −1.23, p < 0.001).Conclusion:Flange fitting is a process that should be individualized to the patient and may require a trial of one or more sizes during a pumping session. Smaller sizes determined using this individualized process and starting with nipple tip measurement may be used without compromising milk output or comfort.

Journal of Human Lactation, Ahead of Print.
Background:Medical students should have adequate knowledge and positive attitudes toward breastfeeding to support breastfeeding dyads. No studies in Croatia have explored breastfeeding knowledge, attitudes or intentions among medical students.Research Aim:To investigate breastfeeding knowledge, attitudes and intentions among medical students at the University of Split School of Medicine.Methods:A cross-sectional study was conducted from March to April 2023, using online and written questionnaires. All medical students without children were eligible to participate. The validated Breastfeeding Intentions, Attitudes, and Knowledge Questionnaire (BIAKQ) was used. Sociodemographic data were collected. Analysis was conducted using descriptive statistics, t tests, and Mann-Whitney U test.Results:A total of 357 medical students participated (response rate 64.1%). There was no significant difference between preclinical and clinical students. Students who attended the elective “Breastfeeding Medicine” demonstrated significantly more positive attitudes toward breastfeeding (Mean Rank = 215.62) than those who did not attend (Mean Rank = 173.58; U= 5468.50, p = 0.010); however, no significant difference was found in knowledge or intentions. Female students had significantly more positive attitudes compared to male students (Mean Rank = 189.47 vs. Mean Rank = 150.55, U = 9796.50, p = 0.001), whereas male students expressed significantly more positive intentions (M = 36.97, SD = 5.26 vs. M = 34.44, SD = 5.86, t = −3.69, p = 0.002). The mean knowledge score was 11.92 (SD = 1.43) out of 13 points. Negative attitudes towards breastfeeding beyond 1 year and breastfeeding in public were found.Conclusion:Despite adequate breastfeeding knowledge, some medical students demonstrated negative attitudes and intentions toward breastfeeding. Including breastfeeding education into core medical subjects focusing on the importance of breastfeeding for maternal and infant health and the risks of formula feeding could help improve attitudes, especially during the clinical years. It would also be important to address prevailing prejudices.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
The importance of a child receiving their mother’s own milk (MOM) in the care and treatment of preterm infants is undisputed in the literature. Despite this, lactation support in the Neonatal Intensive Care Unit is often fragmented. Gaps in adequate lactation care for infants receiving MOM, and barriers to that lactation care, can contribute to healthcare disparities and outcome inequalities. Here, I outline a comprehensive lactation care manager model based on the concepts of continuity of care and care management. This is a starting point for discussion that may be helpful in informing future research and adequate lactation care options.

Journal of Human Lactation, Ahead of Print.
Background:Globally, rising trends in gestational diabetes and body mass index contribute to maternal and neonatal morbidity and mortality. Lifestyle modifications and breastfeeding may reverse this effect, although few studies combine these into one intervention.Research Aims:To measure postpartum weight retention, breastfeeding duration, hemoglobin A1C, and mean arterial blood pressure at 6 months postpartum among women with elevated pre-pregnancy body mass index.Methods:The electronic Monitoring of Mom’s Schedule study (eMOMS™) was a feasibility, three-arm, randomized controlled trial modeled after a Diabetes Prevention Program and breastfeeding support. A health coach delivered a 12-month virtual intervention. Study arm results were compared using Wilcoxon signed-ranks exact test reporting from a two-sided test and bootstrapped samples with 95% confidence intervals.Results:Between September 2019 and May 2021, 100 individuals were screened, and 35 were randomized: nine to Group 1, 14 to Group 2, and 12 to Group 3. At baseline, participants averaged 13.0 (SD = 2.5) weeks gestation, with a mean pre-pregnancy body mass index of 29.7 (SD = 3.0). With 5,000 bootstrapped samples, mean weight retention from baseline to 6 months postpartum was: 4.0 kg, 95% CI [1.6, 6.2] for Group 1; 3.7 kg, CI [-1.8, 9.8] for Group 2; and 7.5 kg, CI [4.1, 11.6] for Group 3. Mean (exclusive) breastfeeding duration was 9.3 weeks, 95% CI [0.43, 26.1]; 9.6 weeks, CI [4.4, 15.7]; and 15.1 weeks, CI [6.5, 23.3] for each group, respectively.Conclusion:Our intervention was positively associated with postpartum weight retention and breastfeeding duration. Future research is needed to assess intervention components.

Journal of Human Lactation, Ahead of Print.
Background:Web-based prenatal education is increasingly employed, but its association with increased breastfeeding and predictors of breastfeeding success is uncertain.Research Aims:Our primary aim was to evaluate our live, online intervention’s association with exclusive breastfeeding at hospital discharge. Secondarily, we aimed to describe participants’ reports of the intervention on predictors of breastfeeding success.Method:We used a retrospective quasi-experimental cohort design to assess the association between our intervention and exclusive breastfeeding at discharge. The intervention consisted of an evidence-based live, online, 2-hour class open to all prenatal patients and supporters at our urban community medical center from June 2020 through April 2022. Patient characteristics and breastfeeding rates were extracted from the electronic medical record. Samples were drawn using stratified random sampling. Three logistic regression models were conducted to assess the associations between the intervention and exclusive breastfeeding. Two surveys assessed the participant reports of the intervention.Results:Samples of the first model, comprised of 160 participants and 160 non-participants, were similar in important characteristics. Participants were 2.12 times (95% CI [1.12, 3.69]) more likely to exclusively breastfeed. Participants reported positively on the impacts of the intervention on breastfeeding predictors.Conclusions:Our live, online intervention was significantly associated with an increased likelihood of exclusive breastfeeding at hospital discharge. A randomized, prospective examination of the intervention’s association with breastfeeding duration would further define its impact.

Journal of Human Lactation, Ahead of Print.
Anwar Fazal has been a driving force in the founding of several civil society organizations in the areas of health, human rights, environment, and peace, that have been at the forefront of activism locally, nationally, and globally. In this interview, he shares his journey of 6 decades, involving a multiverse of public interest issues, which led him into the breastfeeding movement. It began with the setting up of the International Baby Food Action Network (IBFAN), a pioneering action that triggered the formation of Health Action International (HAI), Pesticide Action Network (PAN), and the World Alliance for Breastfeeding Action (WABA). Each of these resulted in several unique frameworks and codes relating to the marketing of infant foods, pharmaceuticals, and pesticides. They also led to the formation of World Breastfeeding Week, now being celebrated globally. Anwar studied Economics at the University of Malaya and did his postgraduate studies in Education. Anwar has served as a visiting professor at the University of Science Malaysia and the International Islamic University Malaysia (IIUM). He is the recipient of the Right Livelihood Award, popularly known as the “Alternative Nobel Prize,” for his work on breastfeeding and infant nutrition and other health, environmental, and consumer issues. La Leche League International (LLLI) and the United Nations Development Programme (UNDP) have honored him with the International Health Award and the Millennium Development Goals Award. He has written extensively on breastfeeding. He is currently Chairperson Emeritus of the World Alliance for Breastfeeding Action (WABA) and continues to speak out actively on protecting, promoting, and supporting breastfeeding.

Journal of Human Lactation, Ahead of Print.
Introduction:Favipiravir is a known anti-influenza agent that has been used globally, especially during the coronavirus disease 2019 (COVID-19) pandemic. This drug has been important for treating influenza and other emerging infectious diseases, although it was ultimately proven to be ineffective for COVID-19. Currently, no studies have reported the human-milk transfer of favipiravir at doses of 1,600–3,600 mg/day in the treatment of diseases, including COVID-19.Main Issue:A 38-year-old mother gave birth at 38 gestational weeks because of severe respiratory distress caused by COVID-19. Considering her illness and the inadequate information available on the safety of favipiravir in breastfeeding, she chose formula feeding for her infant. However, she still provided human milk and blood samples for the analysis of drug concentrations.Management:Five concentrations of favipiravir in the mother’s milk and four in maternal blood were measured (3.0–80.9 and 3.5–78.4 μg/ml, respectively). Metabolites of favipiravir were not measured. The relative infant dose was 15.2%. The favipiravir concentration in human milk was as high as 80.9 μg/ml at 1.3 hours after the medication was given, when maternal blood levels are considered to be at their highest; however, favipiravir concentration was low in human milk immediately before medication administration (5.9–9.7 μg/ml).Conclusion:Breastfeeding is not contraindicated in mothers undergoing favipiravir therapy and would be safer immediately before medication. Avoiding feeding at the peak time (1.3 hours after medication) minimizes infant exposure.

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.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Psychosocial predictors of breastfeeding and changes in those factors during pregnancy, along with the relationship of those changes with both breastfeeding and smoke use and exposure, are not well explored.Research Aim:The aim of this study was to identify distinct trajectories of psychosocial determinants of breastfeeding and smoking in pregnant women.Methods:We used a longitudinal study design and data from a randomized controlled trial conducted among smoke-exposed pregnant women and their infants. Participants were recruited early in pregnancy and were surveyed at ≤ 16 and 32 weeks gestation, delivery, 3 and 6 months postpartum for breastfeeding intentions, initiation, continuation, and smoke use and exposure. Psychosocial variables associated with breastfeeding were measured at baseline and 32 weeks gestation using the Mitra index, a structured questionnaire that assesses barriers and facilitators of breastfeeding intentions. Latent class growth analysis was performed using Mitra scores to identify distinct subgroups of participants with different trajectories. Sociodemographic characteristics, breastfeeding, and tobacco smoke use and exposure were compared across classes.Results:Three or four trajectories were identified for each of the six Mitra scores. Trajectories for all Mitra scores were associated with breastfeeding intention and initiation. Overall, Mitra, knowledge, self-efficacy, social support, and time barrier classes all differed by tobacco smoke use or exposure.Conclusion:Trajectories of breastfeeding knowledge, self-efficacy, social support, and time to breastfeed/social barriers are associated with tobacco smoke use and exposure during pregnancy. Encouragement to breastfeed and to cease and avoid tobacco smoke should start early in pregnancy, focusing on these determinants to improve health outcomes.

Journal of Human Lactation, Ahead of Print.
Breastfeeding offers significant health benefits for both mothers and infants, particularly preterm infants, where it serves as a therapeutic strategy to reduce mortality and morbidities. However, breastfeeding practices are threatened globally by societal norms and systemic barriers at both micro and macro levels. This paper explores the complex interplay of these barriers and facilitators, focusing on the Neonatal Intensive Care Unit (NICU) setting. Preterm infants face specific feeding challenges due to immature physiological functions, yet evidence supports that strategies like cue-based feeding and individualized care can enhance feeding success and health outcomes. For mothers, initiating and maintaining lactation after preterm birth is critical but challenging, with early lactation support and achieving sufficient milk volume being key predictors of success. Partner support significantly influences lactation outcomes, although more inclusive research is needed for diverse family structures. In the NICU, a multidisciplinary approach to lactation care is vital, emphasizing the need for experienced staff and family-centered practices. NICU design, policies promoting parental presence, and adherence to Baby-friendly Hospital Initiative guidelines further support breastfeeding. This paper aims to provide directives for local breastfeeding policies through an integrated approach, considering societal attitudes and healthcare practices. The findings advocate for improved lactation support in NICUs, inclusive language and policies, and further research into diverse familial and gender roles in breastfeeding.

Journal of Human Lactation, Ahead of Print.
Establishing lactation when mother and infant are separated, such as when the neonate is admitted to the neonatal intensive care unit (NICU), is challenging. The most common clinical advice is to express milk eight or more times per day, every 3 hours, around the clock. Sometimes, the first time that parents hear this is after the birth of their baby. This can be overwhelming and sometimes unachievable. A five-step paradigm shift is proposed that refocuses lactation care on providing evidence-based assistance and ongoing clinical education, and assessment beginning prenatally and extending past maternal discharge, to improve outcomes through curated support. Simple guidelines can begin with expressing milk at least five times a day by Day 5 of life (5 × 5), and expressing milk at least once between 0100 and 0500 (overnight pumping). With these measures, neonatal care in the NICU setting can provide personalized and achievable guidance on pumping schedules.