Journal of Human Lactation - online first articles

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.

Journal of Human Lactation, Ahead of Print.
BackgroundThe mothers of very low birth weight infants face many challenges to achieve breastfeeding at hospital discharge, especially during long stays.Research aimThe aim of this study was to describe the incidence and factors associated with breastfeeding rates (exclusive or with formula) at discharge, for very low birth weight infants, in a private Neonatal Intensive Care Unit in southern Brazil.MethodsWe conducted a prospective longitudinal cohort study of infants (N = 335) with very low birth weight and/or less than 30 weeks gestational age, who survived to discharge and had no contraindication to mother’s own milk. Participants were initially divided into three groups (exclusive breastfeeding, some breastfeeding, and no breastfeeding) based on their feedings at discharge; however, later, two groups were analyzed (any breastfeeding, no breastfeeding).ResultsMost (93.4%; n = 313) were breastfeeding directly at least once daily at discharge, of which 16.1% (n = 54) were receiving exclusive mother’s milk and 77.3% (n = 259) mixed feeding (mother’s milk and formula). Breastfeeding at discharge was associated with gestational age ≥ 28 weeks, higher birth weight, not developing neonatal sepsis or bronchopulmonary dysplasia during the hospital stay, shorter lengths of stay, and lower weight at discharge. After Poisson regression, breastfeeding at discharge was associated only with a shorter length of stay (RR 0.98; CI 95% [0.95, 0.99], p < .05).ConclusionsIn our single unit experience in Brazil, most infants were breastfeeding at discharge. NICU staff might address mothers of infants who have prolonged hospitalization with specific strategies. Mothers and infants at risk can be identified early and personalized interventions can be developed for improving breastfeeding rates at discharge.

Journal of Human Lactation, Ahead of Print.
BackgroundDefinitive criteria for microbial screening of pasteurized donor human milk are not well established and international recommendations vary.Aims(1) To review pasteurized donor human milk batch discard due to failed microbial screening criteria at our milk bank (following United Kingdom National Institute of Clinical Excellence guidelines), and (2) to compare our known milk discard proportion with estimated milk discard proportions that would be required by other international milk bank guidelines.MethodsWe reviewed our microbial screening results (N = 783) over 18-months (July 2018-December 2019) and compared our known milk discard proportion with estimated milk discard proportions using other international milk bank guidelines.ResultsOf samples, n = 50 (6.4%) failed pre-pasteurization screening, most commonly due to the presence of >104 CFU/mL Enterobacterales in the pre-pasteurization sample (n = 30; 3.8%). Two (0.3%) samples failed post-pasteurization screening, with Bacillus cereus identified in both cases, resulting in total discard proportion of 6.7% (n = 52) of batches. Applying European Milk Bank Association recommended bacterial screening criteria, approximately 23.3% (n = 183) of milk batches would have been discarded.ConclusionsFurther research is required to justify the stringent European Milk Bank Association recommendations for pre-pasteurization discard criteria, although we believe that a post-pasteurization acceptance criterion of <1 CFU/mL is appropriate and aligns with international guidance. Further work is needed to understand pasteurized donor human milk microbiological safety risks, to better integrate screening criteria within current food standards regulation, and to consider risk-based assessment including the impact on availability and affordability.

Journal of Human Lactation, Ahead of Print.
BackgroundHuman milk is recommended as the only nutritional source during the first 6 months of life. For preterm infants, the benefits of human milk are even more important and can alleviate the negative influences of preterm birth.Research aimTo describe how Swedish human milk donors experienced the donation process.MethodA prospective mixed methods mail survey was designed. It was sent to human milk donors (N = 72) at two Swedish hospitals. Quantitative data are presented with descriptive statistics and qualitative data were analyzed using qualitative content analysis.ResultsThe infants were between newborn and 17 weeks of age when the participants started their human milk donations, and the duration of the donation period lasted 1–24 weeks. The overall theme identified was the participants’ strong desire to help infants, often expressed as being involved in saving infants’ lives. Many participants experienced difficulties getting the information needed to become human milk donors; for others, expressing milk required both time and energy that they could otherwise spend with their own newborn infants.ConclusionDonating human milk can be experienced as a demanding and strenuous task. Therefore, it is important that women who donate human milk receive the practical help from health care staff that they feel they need. Furthermore, information and knowledge about the possibility of donating human milk, and how important human milk is for preterm and/or sick infants, are important in order to increase the number of women willing to donate human milk.

Journal of Human Lactation, Ahead of Print.
BackgroundMore than 550,000 late preterm infants are born each year in Indonesia. These infants, born between 340/7–366/7 weeks, have more complications than term infants. Breastfeeding is considered the most optimal nutrition for newborn infants. Two groups of factors are important for successful breastfeeding: infant and maternal factors. The infant factors can be evaluated using the Infant Breastfeeding Assessment Tool and the maternal aspects with the Breastfeeding Self-Efficacy Scale–Short Form.AimTo determine whether the Infant Breastfeeding Assessment Tool or the Breastfeeding Self-Efficacy Scale–Short Form was more predictive of successful breastfeeding among late preterm infants.MethodsThis study was conducted in the Academic Teaching Hospital in Surabaya, Indonesia in March–July 2017. Mothers who delivered their infant between a gestational age of 340/7 and 366/7 weeks were included.ResultsFifty-four single born participant mother–infant pairs were included. The mean total Breastfeeding Self-Efficacy Scale–Short Form score was 57.8 (SD = 8.9). The mean Infant Breastfeeding Assessment Tool score was 8.3 (SD = 1.8). There was a significant correlation between the total Breastfeeding Self-Efficacy Scale–Short Form score and the Infant Breastfeeding Assessment Tool score (p = .020, r = 0.316). The Breastfeeding Self-Efficacy Scale–Short Form was significantly higher in the participant (mothers) of the infants breastfed ≥ 4 months, compared to < 4 months, 61.59 (SD = 5.78) versus 51.78 (SD = 11.64; p = .001). No correlation was found between the duration of breastfeeding and Infant Breastfeeding Assessment Tool score (p = .087)ConclusionMaternal factors were more important for successful breastfeeding in these late preterm infants than infant factors in our sample.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
IntroductionWith the prevalence of infertility increasing worldwide, many are seeking adoption to fulfill the need to start or expand their family. However, one of the challenges mothers face is the lack of the early maternal bond with the adopted infant, which typically starts during pregnancy, and then continues after birth, while providing care and nourishment to the infant. Breastfeeding is proven to strengthen the maternal–infant bond and provides numerous benefits to the dyad. Reports of induced lactation in non-biological mothers are uncommon, they are even more uncommon to find in women with a history of breast cancer.Main issueThe induction of lactation in a Muslim adoptive mother who had a history of breast cancer.ManagementPharmacologic methods, which included galactagogues Domperidone and fenugreek, in addition to non-pharmacologic methods that included breast stimulation by using a breast pump. The participant was able to provide her own milk for her adopted infant.ConclusionWhen provided with proper support, an adopting mother with a history of breast radiation was able to breastfeed. The participant’s need to provide her own expressed milk was met; although, she was counseled on the possibility that her milk production will most likely not be sufficient to entirely meet the infant’s needs. Determination and support definitely have a role in cases where the influence of past treatment on human milk production is not known.

Journal of Human Lactation, Ahead of Print.
IntroductionPuerperal mastitis, a complication occurring during the breastfeeding period, is often caused by Staphylococcus aureus. Here we report on severe streptococcal mastitis in a lactating breast, with subsequent invasive disease and wound healing problems.Main issueThe 41-year-old woman (G2, P2) presented at 2 weeks postpartum to our hospital with painful swelling and reddening of the left breast, in addition to fever and malaise, and complained about a nipple fissure on the left breast. Previously, her 4-year-old son was treated for an acute otitis media and her husband experienced flu-like symptoms.ManagementDue to the severity of the symptoms, Clindamycin antibiotic treatment was initiated intravenously. Streptococcus pyogenes was isolated in the milk. This strain is commonly known to cause infections of the upper respiratory tract, skin, and soft tissue, but rarely mastitis. Furthermore, the participant developed invasive disease with abscess formation and skin erosion with a milk fistula. Special dressing was applied to promote wound healing. The participant continued breastfeeding well into the child’s 2nd year of life.ConclusionThis rare form of complicated mastitis with invasive disease caused by Streptococcus pyogenes called for an interdisciplinary approach. We want to draw attention to other pathogens causing mastitis and to alert health care workers to promote hygiene in lactating women to prevent transmission.

Journal of Human Lactation, Ahead of Print.
BackgroundThis case presents a mother’s feeding experience of an infant born with a complete unilateral cleft lip and palate from birth until both were repaired. She fed him directly at the breast with assistance, controlling the delivery of the mother’s own milk. The infant received only his mother’s own milk, no bottles, and the excess expressed milk was donated to a milk bank.Main issueThe Cleft Team supported the mother’s wish to breastfeed but expressed realism that cleft lip and palate infants could not create suction. Success had never been observed in the unit. Instead, the team suggested expressing to deliver as much of the mother’s own milk. The mother had previously breastfed her three children and was keen on finding innovative ways to breastfeed.ManagementSeveral techniques were trialed with the help of an International Board Certified Lactation Consultant. The most sustainable and successful was the use of a nipple shield applied to the maternal nipple areola complex to cover the lip palate. Underneath, a nasogastric tube connected to a syringe delivered the mother’s own milk. Exclusive expressing protected maternal supply, the infant’s nutrition and growth were monitored carefully and this technique reinforced mother–infant bonding.ConclusionFeeding with the modifications was challenging at times. However, maternal satisfaction was high because the mother had achieved her goal of breastfeeding without assistance post cheiloplasty and palatoplasty. This case adds to the limited body of research about feeding infants with cleft lips and palates directly at the breast.

Journal of Human Lactation, Ahead of Print.
BackgroundThe human milk donor pool in South Africa is severely limited due to the low rate of continued breastfeeding and the HIV pandemic. It was crucial to determine why willing donors did not donate to determine if infrastructure could be implemented to prevent this loss.Research aimTo determine why mothers who had committed to donating to a human milk bank in South Africa did not donate their milk.MethodsParticipants (N = 37) were interviewed using a telephone administered questionnaire. Variables measured were initiation and continuation of breastfeeding, reasons for discontinuation, age of introduction of solids and type, and reasons for not donating. Data were interpreted using descriptive statistics and Pearson’s chi-square test.ResultsParticipants were mainly unemployed (70.2%, n = 26), single (73%, n = 27), black African (83.7%, n = 31), Christian (62.2%, n = 23) women with a M age of 25.7 (5.2) years, and a secondary or higher education level (81.1%, n = 30). Most lived in urban areas (70.2%, n = 26), with piped water (100%, n = 37), electricity (100%, n = 37), and refrigerators (100%, n = 37). Only 29.7% (n = 11) owned a vehicle. The major barrier was infrastructure related, as 62.2% (n = 23) were unaware of the process after discharge. This was followed by practical issues including no transport (21.6%, n = 8), no freezer for milk storage (18.9%, n = 7), or working (5.4%, n = 2).ConclusionThe major barrier was ignorance of the post discharge process and lack of support from clinic staff. No transportation challenged the maintenance of the cold chain. A potential solution is mothers donating only at clinic immunization visits.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
BackgroundOptic neuritis is a rare condition that can lead to sudden blindness and also could be a precursor to multiple sclerosis. When it occurs postpartum during lactation, it is called lactation optic neuritis.Main issueWe present four cases of optic neuritis in lactating mothers, two of which had additional features of demyelinating disease upon neurological imaging.ManagementAll participants were treated with high dose intravenous steroids followed by 11 days of oral steroids, per the optic neuritis treatment trial, which led to complete recovery of vision. Two participants with demyelinating disease on magnetic resonance imaging scans were advised to wean, because of a need for immunosuppressive therapy later.ConclusionOptic neuritis during lactation should be suspected following acute loss of vision. Prompt referral to an ophthalmologist is mandated for early diagnosis and treatment to prevent long-term co-morbidities.

Journal of Human Lactation, Ahead of Print.
BackgroundBreastfeeding mothers have been avoiding foods in their diet based on ancient beliefs that it can prevent/reduce unsettled infant crying–fussing behavior.Research aimsThis study aimed to explore (1) the prevalence of maternal dietary changes during the postpartum period; (2) the demographic and infant feeding differences between women who made dietary changes and those who did not; (3) the reasons for dietary change; and (4) what specific foods were avoided.MethodsA prospective, cross-sectional 2-group comparison using an online survey mixed-methods design was advertised via social media and Australian websites. Anonymous volunteers who were presently breastfeeding or had breastfed for any length of time in the past were eligible.ResultsOf 1,262 participants, 966 (77%) avoided foods/beverages in their diet. The most commonly avoided beverages were alcohol (79%) and coffee (44%), and the most commonly avoided foods were chili (22%), milk-chocolate (22%), cabbage (20%), onion (20%), and garlic (16%). Reasons for dietary avoidance related to baby being unsettled (31%), baby having wind/gas (29%), colic (11%), and crying (10%). Of 245 participants who removed dairy, 80 (33%) did not substitute with calcium-rich alternatives. Food and beverage avoidance commenced as early as 1 week postpartum and continued until mean (SD) infant age of 9 (5) months.ConclusionsIt is commonplace for breastfeeding mothers to avoid foods and beverages for reasons associated with infantile colic. Of major concern is the duration of food avoidance during a time of increased nutritional requirements. This information may assist in improving the nutritional support given to breastfeeding mothers.

Journal of Human Lactation, Ahead of Print.