Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
Background:Women with high body mass indices are at risk of lower breastfeeding rates but the drivers of successful breastfeeding in this population are unclear.Research Aim:We aimed to (a) explore the barriers and enablers to breastfeeding among women with high body mass indices and (b) map specific behaviors suitable for intervention across the antenatal to postpartum periods.Methods:This was a prospective, cross-sectional qualitative study. We conducted semi-structured interviews with women with high body mass indices who successfully breastfed for 6 months or more (n =20), partners (n = 22), and healthcare professionals (n =19) in Ireland during 2018. Interviews were audio recorded, and transcribed verbatim. Data were inductively coded using reflexive thematic analysis and deductively mapped within the Capability, Opportunity, Motivation–Behavior model.Results:The three themes developed were knowledge, support, and self-efficacy. Knowledge supported a participant’s psychological and physical capability to engage in breastfeeding. Support was related to the social and physical opportunity to enable performance of breastfeeding behaviors. Self-efficacy influenced reflective and automatic motivation to perform breastfeeding behaviors. A multifactorial intervention design is needed to support successful breastfeeding.Conclusion:The barriers and enablers identified for participants with high body mass indices were similar to those for the broader population; however, the physicality and associated social bias of high body mass indices mean that additional support is warranted. Antenatal and postpartum breastfeeding services need a multifaceted, inclusive, and high-quality program to provide the necessary support to women with higher body mass indices.

Journal of Human Lactation, Ahead of Print.
Background:Physical distancing associated with the COVID-19 pandemic may lead to suboptimal maternal mental health, social support after birth, and infant feeding practices.Research Aims:To compare breastfeeding prevalence in participants who were pregnant at a time when strict physical distancing measures were imposed in Fortaleza, the capital of Ceará state, Brazil, with the pre-pandemic breastfeeding levels, and to assess the association of breastfeeding prevalence with maternal common mental disorders, and sociodemographic and health predictors.Method:A cross-sectional prospective two-group comparison design using two population-based surveys was carried out in Fortaleza before and after the pandemic. Participants (n = 351) who had a live birth in Fortaleza in July or August 2020, and participants (n = 222) who had a child younger than 12 months in 2017 were surveyed. Crude and adjusted multinomial logistic regressions with robust variance were used to estimate risk ratios and 95% confidence intervals (CI).Results:Similar prevalence of exclusive breastfeeding were observed in 2021 (8.1%) and 2017 (8.5%; p = .790). An increase in predominant (2.2% vs. 13.4%; p < .001) and a decrease in complementary breastfeeding (64.0% vs. 48.4%; p = .037) was observed in 2021, compared to 2017. The prevalence of maternal common mental disorders also increased in 2021 (17.6% vs. 32.5%, p < .001). No statistically significant associations were found between breastfeeding patterns, maternal common mental disorders, and other predictors in 2017 or 2021.Conclusions:Participants who delivered during the COVID-19 pandemic delayed solid foods introduction and breastfed predominantly longer than participants during the pre-pandemic period. While common mental disorders significantly increased, they were not associated with differences in breastfeeding.

Journal of Human Lactation, Ahead of Print.
Background:The World Health Organization recommends lactation support to enhance the rates of exclusive breastfeeding. Access to in person lactation support may be limited due to scarcity of resources (e.g., healthcare professionals) and geography. Advances in technology have allowed lactation supports to be offered virtually through information and communication technologies (i.e., telephone, internet, and social media).Research Aims:To (1) critically review and (2) statistically analyze the effectiveness of virtual lactation support for postpartum mothers’ exclusive breastfeeding for up to 6 months.Methods:A systematic review and meta-analysis were conducted using PRISMA guidelines. Studies were included if they were (a) randomized controlled trials, (b) with a virtual lactation support intervention during the postpartum period, (c) reported on exclusive breastfeeding outcomes. Two reviewers independently assessed the risk of bias and extracted data. The prevalence of exclusive breastfeeding in each group and the total number of participants randomized for each group were entered into random-effects meta-analyses to calculate a pooled relative risk (RR) at three different time points (1, 4, and 6 months). The sample size was 19 randomized control trials.Results:Of the 19 studies, 16 (84.2%) were included in the meta-analysis (n = 5,254). Virtual lactation support was found to be effective at increasing exclusive breastfeeding at 1 month (RR, 1.21; 95% CI [1.09, 1.35]; p < .001) and 6 months (RR, 1.87; 95% CI [1.30, 2.68]; p < .001).Conclusion:In this meta-analysis of randomized controlled trials comparing virtual lactation support with other postnatal maternity care, virtual lactation support was associated with increasing exclusive breastfeeding rates at 1 month and 6 months postpartum.The study protocol was registered (CRD42021256433) with PROSPERO

Journal of Human Lactation, Ahead of Print.
Background:Breastfeeding provides perfect nutrition for infants. The inverted nipples in mothers make breastfeeding more challenging. Besides surgical approaches, non-pharmacological interventions are also gaining importance.Research Aim:To evaluate the effectiveness of Hoffman’s exercise on breastfeeding among postnatal mothers with grade I inverted nipples.Method:A quantitative approach with a parallel arm randomized controlled trial was used in the study. Postnatal mothers were screened for inverted nipples using a pinch test. Participants with at least one inverted nipple (Grade 1) were randomly allocated into two groups: the experimental group (supported with Hoffman’s exercise; n = 28, 50.9% ) and the control group (without Hoffman’s exercise; n = 27, 49.1%). The pre-test data, including demographics, nipple length, and breastfeeding assessment, were collected. Breastfeeding assessment was evaluated using the Bristol Breastfeeding Assessment Tool (BBAT). On the 3rd day, the post-test data, including nipple length and Breastfeeding Assessment, were collected among the groups.Results:The BBAT assessment was significantly higher in the post-test compared to that of the pre-test in the participants provided with Hoffman’s exercise. The nipple length was found to be higher in participants provided with Hoffman’s exercise. Furthermore, the variables—including age, gravida, nipple problems, and delivery type—were not found to have any significant effect with either pre-test or post-test levels of breastfeeding.Conclusions:Hoffman’s exercise was found to be an effective method to improve breastfeeding in Grade 1 nipple-inverted among post-natal mothers. This nipple exercise is inexpensive, easy to follow, and results in the successful initiation of breastfeeding.Clinical Trial Registry and Registration Number:CTRI/2019/05/019279, May 23, 2019 (retrospectively registered)

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.
Leah Margulies was Director of the Infant Formula Program at the Interfaith Center on Corporate Responsibility in NYC from 1975 to 1985. She is a founder of the International Nestlé Boycott, Corporate Accountability (formerly INFACT), and one of the founders of the International Baby Food Action Network (IBFAN). She was hired at UNICEF in 1982 to set up the legal office for implementation of the International Code of Marketing Breast-Milk Substitutes, as part of the Baby Friendly Hospital Initiative. Previously, she was legal advisor to the Environment Unit of the United Nations Centre on Transnational Corporations. From 2006 to 2016, she was Project Director of LawHelpNY at the NYC Bar Association. Currently, she works for a legal non-profit, representing low-income Brooklynites, defending them against eviction. She is a lawyer, a second Wave Feminist, and a member of Veteran Feminists of America. She is also a musician and founding member of a pioneering women’s rock band that played at the first national women’s march for abortion rights in Washington, DC, 1972.

Journal of Human Lactation, Ahead of Print.
Background:The benefits of breastfeeding in promoting child survival are well recognized. As one of the nutritional interventions for children, exclusive breastfeeding protects babies from various diseases that contribute to infant morbidity and mortality. However, no systematic review and meta-analysis has examined the influence of breastfeeding promotion programs on exclusive breastfeeding rates in sub-Saharan Africa.Research Aim:We examined the influence of breastfeeding promotion programs on exclusive breastfeeding rates at < 1 month, and at 1–5 months of breastfeeding in sub-Saharan countries including Ghana, Burkina Faso, Uganda, South Africa, Guinea-Bissau, Kenya, Tanzania, and the Democratic Republic of Congo.Methods:A systematic review and meta-analyses study of randomized controlled trials and quasi-experimental studies was conducted by searching in electronic databases and articles’ reference lists. Two investigators independently evaluated and extracted the data. A total of 131 studies were identified using five databases. Of the 10 studies meeting the inclusion criteria for systematic review, seven studies were included in the meta-analysis. We used a random-effects model to pool studies together and performed a subgroup analysis.Results:Breastfeeding promotion programs resulted in significantly higher exclusive breastfeeding rates at < 1 month (OR = 1.60, 95% CI [1.36,1.86]). However, there was no significant effect observed for exclusive breastfeeding at 1–5 months. Combined interventions were more effective in improving exclusive breastfeeding rates than individual counseling or home-based counseling alone.Conclusion:Breastfeeding promotion programs in sub-Saharan Africa are effective in increasing exclusive breastfeeding rates at 6 months after birth.

Journal of Human Lactation, Ahead of Print.
Background:Glutamic acid, an amino acid that exhibits umami taste, is utilized in Japanese food and is abundant in human milk. We examined the influence of maternal habitual eating behavior on glutamic acid concentration in human milk.Research Aim:To determine the association between maternal dietary behaviors at the end of pregnancy and the 1st month postpartum and glutamic acid concentration in colostrum and mature milk.Method:This was a prospective, correlational, one-group longitudinal study. Women aged 20–30 years during the third trimester of pregnancy (N = 30) consented to participate and completed the data collection. Dietary history questionnaires were used to measure food intake. Glutamic acid levels in whey from colostrum and mature milk and in plasma during late pregnancy and the first month postpartum were measured. Data were considered significant at p < .05. Basic statistics, correlation coefficients analysis, unpaired t test, and one-way analysis of variance were performed.Results:Glutamic acid concentrations in human milk and plasma were found to be significantly associated with the consumption of several different foods. There was no association between glutamic acid concentrations in human milk and plasma or between glutamic acid concentrations in colostrum and mature milk. The glutamic acid content of mature milk differed by physical activity level (mild and moderate) during the first month postpartum (t [46] = 2.87, p < .01).Conclusion:There was no clear association between habitual dietary behavior and glutamic acid concentration in human milk. However, maternal factors other than diet may be important and require additional research.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Ten years ago, the U.S. Surgeon General’s Call to Action to Support Breastfeeding made recommendations for childcare settings, including: (1) accommodating and supporting breastfeeding families; and (2) adopting national guidelines on breastfeeding support in childcare settings.Research Aims:To (1) describe the existing breastfeeding friendly childcare designation programs in the United States; and (2) describe how states are accommodating breastfeeding families in childcare settings.Method:The study design was cross-sectional, prospective thematic description of existing publicly available documents. A search of state breastfeeding coalitions was conducted to assess the number of states with breastfeeding friendly childcare designation programs. A definitive yes-or-no answer regarding whether each state had a program was obtained from all 50 states. For states with programs, designation materials were analyzed using thematic analysis and the framework method to compare designation components.Results:Fifteen states had evidence of breastfeeding friendly childcare designation programs and similarities exist across designation program components. Four standards were common to all 15 programs: written policy on breastfeeding, suitable space within the center where mothers can breastfeed or express their milk, educational materials, and resources on breastfeeding available to parents. Most states required self-assessment to achieve designation status.Conclusion:Research is needed to enable evidence-based programs and decision-making regarding components and processes. Federal funding should support these programs’ mission, including funding research to assess how and in what circumstances these programs are improving breastfeeding-related outcomes and supporting breastfeeding families.

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:Globally, 10% of all births are preterm. Access to human milk via manual breast expression is required to reduce the incidence of adverse outcomes related to prematurity. However, there is little evidence to recommend optimum timing to commence breast expression in mothers of preterm infants or the most effective method.Research Aims:(1) To test feasibility of recruitment and compliance to the protocol and (2) to determine influence of using hand expressing and breast massage on milk production, engorgement, mastitis, and breastfeeding status at 3 months.Methods:This study was an exploratory parallel two-group, pilot randomized controlled trial. Mothers of preterm infants at a metropolitan maternity hospital in Queensland Australia (N = 31) were randomized to receive either hand expressing and breast massage within the 1st hr of birth or standard care, hand expressing within 6 hr of birth, to determine the influence on milk production, engorgement, mastitis, and breastfeeding status at 3 months.Results:Feasibility targets were not met; however, valuable learning from this trial uncovered barriers facing midwives in the birth suite to commencing expressing in the 1st hr of birth. There was no difference in occurrence of secondary outcomes, although trends support future study.Conclusions:Overall, unpredictability of preterm birth influenced our ability to recruit participants. Important directions for future study design would benefit from incorporating expressing times up to 6 hr with a replicable breast massage.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:With strict public health measures implemented in March 2020 due to the COVID-19 pandemic, many breastfeeding parents, who are within an at-risk population, have experienced limited formal and/or informal breastfeeding social support. In the Canadian context, the experiences of these women is unknown.Research Aim:To explore the experiences of at-risk postpartum breastfeeding women in accessing formal and informal breastfeeding social support during the COVID-19 pandemic.Methods:This was a prospective, longitudinal interpretive description study using mixed methods. Data were gathered using an online survey and one 52–112-min semi-structured interview at 12-weeks postpartum. At-risk breastfeeding participants were those who lack social support and had at least one of the following: age < 25 years; experiencing or had experienced intimate partner violence; or of low income. We sought participants’ experiences of accessing breastfeeding social support during the first few months of the COVID-19 pandemic/lockdown. Seven participants completed the survey and the interview.Results:Participants identified that the COVID-19 pandemic created barriers to accessing formal and informal breastfeeding social support, which stemmed from public health restrictions and difficulties communicating online with families and healthcare providers. Additionally, participants identified that the COVID-19 pandemic/lockdowns facilitated feelings of connectedness, protection, and resiliency.Conclusion:We provide preliminary insight into the experiences of trying to access breastfeeding social support during the COVID-19 pandemic. Future researchers should seek to prioritize improved communication and resources in supporting breastfeeding during COVID-19 and future pandemics/lockdowns.

Journal of Human Lactation, Ahead of Print.
Background:Secretory activation is characterized biochemically in human milk by a fall in sodium concentration, an increase in potassium concentration, and a decreased sodium to potassium ratio. These markers can be used to identify a delay in secretory activation which can result from hormonal birth control.Research Aim:To evaluate if the insertion of the Etonogestrel implant early in the postpartum period would delay the time to secretory activation as measured by biochemical markers.Methods:We conducted a prospective, longitudinal, non-randomized, observational cohort study. Women with singleton pregnancies were identified as wanting either no birth control or the Etonogestrel implant in the postpartum period. Human milk samples were collected starting at 12 hours after delivery, and then in 12-hour increments. Samples were tested for sodium and potassium levels.Results:As in the unadjusted models, there was evidence of a difference in sodium levels at two days postpartum, with the sodium level higher by 32.29 mM (95% CI [7.39, 57.20], p = .013) in the implant group than in the no birth control method group. A difference at day 2 was observed in the ratio (sodium/potassium) levels, with a higher mean ratio in the implant group by 2.49 (95% CI [0.14, 4.85], p = .039). For potassium levels, the only difference was observed at day 4, with lower values in the implant group (p = .045).Conclusion:The transition from colostrum to copious milk secretion is delayed by the early insertion of the Etonogestrel device. This is evidenced by the delay in biochemical markers normally seen in secretory activation.