Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
Introduction:Medicalized Ketogenic Therapy is commonly used to treat refractory epilepsy. Patients have varying degrees of seizure or symptom relief, responding at individual levels of ketone production. Typically, initiating the therapy necessitates the discontinuation of breastfeeding. Our case study mother was keen to continue breastfeeding if possible. We were able to achieve this by placing the healthy mother on a ketogenic diet and altering the composition of the mother’s own milk.Main Lactation Issue:Pediatric Medicalized Ketogenic Therapy is delivered through a ketogenic diet consisting of up to 90% fat, measuring of ingredients to 0.1 g matching a food prescription of fat, protein, and carbohydrate. We placed the mother on a less stringent ketogenic diet achieving 61% fat and measured both infant and mother’s blood sugar levels and ketones. The hypothesis was that changes would occur in the mother’s own milk fat content, and/or ketones would be passed directly to the infant. If therapeutic levels of ketones were reached in the infant and a reduction in seizures observed, breastfeeding could continue.Management Overview:Over 3 months we achieved a calorific increase of the mother’s mature milk by an additional 134%. The infant was successfully put into nutritional ketosis and visible seizures eliminated.Conclusion:Medicalized Ketogenic Therapy can be safely used to treat seizures of breastfeeding infants diagnosed with epilepsy, through management of the mother on a ketogenic diet. Significantly increasing the mature mothers own milk fat component could have implications for other areas, including faltering growth.

Journal of Human Lactation, Ahead of Print.
Background:The COVID-19 pandemic presents unique challenges to maternity settings. Its effect on providing in-hospital lactation support has not been well described.Research Aim:To describe the experiences of healthcare workers as they provided in-hospital lactation support during the pandemic.Methods:A prospective, cross-sectional, online survey evaluated healthcare providers working with postpartum women and newborns affected by COVID-19 at an academic center during March–June 2020. Providers were queried regarding the influence of COVID-19 and COVID-19-specific policies on providing lactation support. Questions assessed guidance received, perceived stress, difficulty providing care, and solicited qualitative responses. The constant comparative method was used to analyze qualitative data.Results:Of 108 providers, 70 (65%) completed the survey. Of 57 providing direct lactation support to women affected by COVID-19, most (n = 39, 67%) reported increased stress. Participants reported lower stress scores when receiving guidance through shift meetings or email compared to those not receiving this guidance [stress score with shift meeting guidance (M [SD]): 3.10 (0.88); score without guidance: 3.83 (0.66); n = 39, p = .009; score with email guidance: 3.79 (0.58); score without guidance: 4.50 (0.58); n = 18, p = .045). Qualitative responses (n = 67; 96%) identified three themes: visitor restrictions allowed less distraction during lactation support; physical separation disrupted maternal/infant bonding; workflow challenges resulted from policy changes and supply access.Conclusions:Most participating staff providing lactation support to women affected by COVID-19 reported increased stress. Ensuring written or verbal guidance may reduce staff’s experiences of stress. Efforts to optimize lactation support during COVID-19 should consider reducing distractions, physical separation, and logistic challenges.

Journal of Human Lactation, Ahead of Print.
Background:The composition of the human milk microbiome is highly variable and multifactorial. Milk microbiota from various countries show striking differences. There is a paucity of data from healthy lactating Indian mothers.Research Aim:To describe the milk microbiota of healthy North Indian women, using a culture-independent, targeted metagenomic approach.Methods:We recruited exclusively breastfeeding mothers (N = 22) who had vaginally delivered full-term singleton infants in a tertiary care hospital less than 1 week previously and had not recently consumed systemic antibiotics. Milk samples (5 ml) were collected aseptically, and microbial deoxyribonucleic acid was extracted. Microbial composition and diversity were determined using a 454-pyrosequencing platform. Core genera were identified, and their relative abundances ranked. Heatmaps showing the variation of the ranked abundances and Shannon index were obtained using R.Results:Participants (all exclusively vegetarian) had a mean (SD) age of 27.2 (3.4) years, postnatal age of 3.9 (1.6) days and gestation 38 (1.2) weeks. The dominant phylum was Proteobacterium (relative abundance 84%) and dominant genus Pseudomonas (relative abundance 61.78%). Eleven species of Pseudomonas were identified, all generally considered nonpathogenic. Based on abundance patterns of the core genera, the milk samples could be grouped: (a) dominated by Pseudomonas with low diversity; (b) less Pseudomonas and high diversity; and (c) dominated by Pseudomonas but high diversity. All neonates were healthy and gaining weight well at 1 month of age.Conclusions:Healthy, lactating, vegetarian, North Indian women who deliver at term gestation and have no recent exposure to antibiotics, have a unique milk microbiome dominated by Pseudomonas.

Journal of Human Lactation, Ahead of Print.
Background:Social norms and public perception of breastfeeding are well-established predictors of breastfeeding outcomes; however, little is known about perceptions of breastfeeding beyond infancy or public breastfeeding among the public in Nova Scotia, Canada.Research Aim:To explore public opinion about breastfeeding beyond infancy and public breastfeeding.Methods:In this cross-sectional study participants were recruited from public spaces in Nova Scotia, Canada. Using photo elicitation methods, participants (N = 229) viewed six photographs of breastfeeding children aged 2 weeks, 13 months, and 2.5 years, one photograph captured at home, and the other in a public space (a café, a store, or outdoors). Participants were asked to score their self-rated comfort with each photograph on a 10.0 cm visual analog scale and asked to share their feelings about each photograph (open-ended responses).Results:Mean (SD) visual analog scale comfort scores for photographs differed by location (private, 7.9 [2.2]; public, 7.3 [2.6]; p < .05) and child age (2 weeks, 8.5 [2.0]; 13 months, 7.5 [2.6]; 2.5 years, 6.9 [3.0]; p < .05). Participants who identified as women and parents self-reported significantly higher comfort with all photographs, while younger participants and urban dwellers were generally less comfortable. Open-ended responses varied considerably, but a higher proportion of negative comments were reported for older children feeding in public spaces (e.g., 2.5-year-old in public: “Inappropriate. Indecent. Abnormal.”).Conclusion:Given the importance of social norms in supporting breastfeeding, future public health campaigns should strive to normalize breastfeeding beyond infancy, and in public spaces.

Journal of Human Lactation, Ahead of Print.
Background:A donor milk bank provides an alternative source of human milk for mothers who cannot breastfeed or provide their own milk. Although wet-nursing is a common practice, there is currently no donor milk bank in Turkey.Research Aims:The aims of our study were (1) to determine the knowledge and opinions of Turkish women in regard to donor milk banking; and (2) to raise awareness of donor milk banking.Methods:This was a prospective cross-sectional descriptive study, in which the data were collected with an online survey consisting of 22 questions. The link to the online survey was distributed through the social media accounts of the researchers, with a statement inviting women aged 18–64, who were literate and actively using social media, to participate in the survey. There were 648 female participants.Results:Of those who responded to the questionnaire, 54.1% had not previously given birth, and 54.2% had heard about donor milk banks before. The implementation of donor milk banks in Turkey was desired by 56.4% of the participants, and 50.8% of the participants considered donating their milk. It was determined that the reasons why the women did not want to benefit from donor milk banks were the risk of disease transmission to the baby and the possibility of their child marrying his or her milk sibling in the future.Conclusion:It appears that Turkish women lack information about donor milk banking. We recommend public awareness activities to be organized concerning donor milk banking.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
BackgroundThe COVID-19 pandemic has hugely impacted upon people’s psychological and physical wellbeing; however, the effects of the COVID-19 lockdown on mothers of young children, with particular regard to breastfeeding, are unknown.Research AimsTo explore: (1) Sources of advice and support available to breastfeeding mothers during and prior to the COVID-19 lockdown; (2) Mothers’ opinions on statements and recommendations made by the World Health Organization on the importance of breastfeeding and breastfeeding during the COVID-19 pandemic; (3) Maternal emotional states (i.e., anxiety and depression symptoms) experienced by breastfeeding mothers during the COVID-19 lockdown; and (4) influence of breastfeeding duration and number of children on breastfeeding opinions and emotional states.MethodsMothers of children aged 0–36 months (N = 4018) took part in an online survey. The survey included demographic questions, as well as the Generalised Anxiety Disorder Questionnaire and the Patient Health Questionnaire. Mothers were further probed on opinions regarding breastfeeding practices during the COVID-19 pandemic.ResultsParticipants strongly agreed with the importance of breastfeeding, even if a mother showed symptoms of COVID-19. Differences in opinions on breastfeeding practices (e.g., the use of donor human milk and relactation), were found between participants in relation to breastfeeding duration and number of children. Participants with more than one child showed higher negative emotional states, namely anxiety symptoms. Except for Internet usage, participants indicated a decline in all sources of advice and support for breastfeeding during the COVID-19 lockdown.ConclusionsHealth bodies and professionals should consider maternal viewpoints and opinions regarding breastfeeding during the COVID-19 pandemic. Interventions are urgently needed in order to support breastfeeding mothers and prevent the development of mental health issues.

Journal of Human Lactation, Ahead of Print.
Background:Quantification of viral antigens and viral loads in human milk samples from mothers infected with hepatitis B virus is largely unknown.Research Aim:The aim of the study was to quantitatively measure the levels of viral antigens and deoxyribonucleic acid of hepatitis B virus in human milk from mothers infected with hepatitis B virus.Methods:Fifty-five pairs of milk and serum samples from mothers with positive hepatitis B surface antigen, including 11 hepatitis B e antigen positive, were quantitatively tested to measure viral antigens by microparticle enzyme immunoassay and viral loads by real-time polymerase chain reaction assay.Results:The median level of hepatitis B surface antigen in the human milk samples of mothers with positive or negative hepatitis B e antigen was each lower than that in the sera, respectively (1.10 vs. 4.32 log10 IU/ml, t = 10.693, p < .001; -0.77 vs. 2.53 log10 IU/ml, t = -25.135, p < .001). The titers of hepatitis B surface antigen or hepatitis B e antigen in the human milk samples were each correlated with that in maternal serum. The detectable level of deoxyribonucleic acid of hepatitis B virus in human milk ranged from 1.42–5.27 log10 IU/ml, whereas that in maternal sera was 1.44–8.66 log10 IU/ml. The viral level in human milk was not correlated with that in maternal circulation.Conclusion:The present study data illustrate the relatively low titers of viral markers in the milk of mothers with positive hepatitis B surface antigen.

Journal of Human Lactation, Ahead of Print.
Introduction:Transgender and gender diverse individuals may choose to provide their infants with human milk. Lactating transgender men may experience gender dysphoria and desire to initiate or reinitiate gender-affirming testosterone therapy. However, there is limited safety data regarding use of testosterone during lactation.Main Issue:A 30-year-old G2P2 transgender man with gender dysphoria sought to initiate gender-affirming testosterone therapy while lactating.Management:Subcutaneous testosterone was self-administered beginning at 13 months post-partum. We prospectively collected data on circulating testosterone concentrations in parent serum, milk, and infant serum over 5 months until the infant self-weaned. The infant was monitored for growth and development at routine pediatric outpatient appointments. Parent serum testosterone concentrations rose with the initiation of testosterone therapy, reaching therapeutic concentrations by Day 14. Milk testosterone concentrations also increased with a maximum concentration of 35.9 ng/dl when the lactating parent was on a dose of 80 mg subcutaneous testosterone cypionate weekly. The calculated milk/plasma ratio remained under 1.0 and the calculated relative infant dose remained under 1%. The infant had no observable side effects, and his serum testosterone concentrations remained undetectable throughout the study period.Conclusion:This is the first study with data regarding human milk and infant serum testosterone concentrations during the initiation of gender-affirming testosterone therapy in a lactating individual. This evidence can help families and clinicians with decisions regarding lactation and testosterone use.

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.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Adherence to the Ten Steps of the Baby-Friendly Hospital Initiative has been shown to have a protective role for the initiation and maintenance of breastfeeding.Research Aims:(1) To determine the breastfeeding rate during the first 6 months of life in children of mothers diagnosed with COVID-19 infection at the time of birth; and (2) to assess the possible influence of being born in a center with Baby-Friendly Hospital Initiative accreditation.Methods:This was a two-group comparative longitudinal observational study of infants born to mothers with COVID-19 at the time of birth, between March 13–May 31, 2020 (the first wave of the pandemic) in Spain. Fourteen Spanish hospitals participated, five (35.7%) were Baby-Friendly Hospital Initiative accredited. Type of feeding was assessed prospectively at discharge, 1, 3, and 6 months of age. A total of 248 newborns were included in the study.Results:A total of 117 (47.3%) newborns were born in Baby-Friendly Hospital Initiative (BFHI) accredited centers. These centers applied skin-to-skin contact with greater probability (OR = 1.9; 95% CI [1.18, 3.29]) and separated the newborns from their mothers less frequently (OR = 0.46; 95% CI [0.26, 0.81]) than non-accredited centers. No differences were observed in relation to the presence of a companion at the time of birth. At discharge, 49.1% (n = 57) of newborns born in BFHI-accredited centers received exclusive breastfeeding versus 35.3% (n = 46) in non-accredited centers (p = .03). No differences were observed in breastfeeding rates throughout follow-up.Conclusions:The exclusive breastfeeding rate at discharge in children of mothers with COVID-19 infection at birth was higher in Baby-Friendly Hospital Initiative accredited centers, which most frequently applied skin-to-skin contact at birth as well as rooming-in.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.