Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
On September 10, I had the pleasure of interviewing my friend and colleague David Lawson Clark, the legal advisor for infant and young child nutrition and expert on the International Code of Marketing of Breast-milk Substitutes at UNICEF. A native of Scotland, David began his career as an attorney with the Scottish Development Agency and subsequently worked for the United Nations Interregional Crime and Justice Research Institute in Rome, Italy. Since 1995, David has assisted more than 60 countries in drafting legislation to implement the International Code of Marketing of Breastmilk Substitutes and has been instrumental in bringing a human rights-based approach to the protection, promotion, and support of breastfeeding. He has contributed to the development of international policy guidelines in the area of HIV and infant feeding and infant feeding in emergencies, and has provided guidance on issues around international trade agreements and intellectual property rights. David has written and contributed to many articles and publications on health and nutrition policy, developed courses and training materials on the implementation of the International Code and maternity protection, and has facilitated numerous workshops on the issue. (LGS refers to Dr. Laurence Grummer-Strawn and DC are the verbatim responses of David Clark)

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Human milk oligosaccharides (HMO) have been recognized for the protective effects they may elicit among high risk infants. One HMO, disialyllacto-N-tetraose (DSLNT), has been shown to reduce the risk for developing necrotizing enterocolitis in preterm infants.Research aims:To measure DSLNT content in the human milk from mothers of preterm infants, and (1) assess variability; (2) establish correlations between maternal factors and/or an infant’s risk for developing necrotizing enterocolitis; and (3) determine the effect of pasteurization.Methods:DSLNT was measured in 84 samples of preterm milk, in human donor milk, and in Holder and flash pasteurized samples. Preterm infant outcomes were assessed by medical record review.Results:DSLNT content of mother’s own milk was highly variable and decreased significantly with increasing postnatal age. Four preterm infants (6.7%) developed necrotizing enterocolitis (Bell stage II or greater), 4 (6.7%) developed spontaneous intestinal perforation, and 1 developed both. DSLNT z-score was below the age-specific M within 8 (89%) of the 9 milk samples from mothers whose babies developed necrotizing enterocolitis (p = 0.039), but the DSLNT content did not differ between infants with necrotizing enterocolitis, spontaneous intestinal perforation, or neither condition (p > 0.1). DSLNT levels were significantly reduced in samples of donor milk compared to mothers’ own milk (p = 0.0051). Pasteurization did not significantly reduce DSLNT content.Conclusions:DSLNT content of human milk is variable and may be lower in milk from mothers whose infants developed necrotizing enterocolitis. DSLNT content is unaffected by flash or Holder pasteurization.

Journal of Human Lactation, Ahead of Print.
Background:Little research has focused on breastfeeding and diet quality, particularly in low-income populations at risk for shorter breastfeeding duration and poorer diet quality.Research Aim:The aim of this study was to examine the association between breastfeeding duration and later diet quality in a low-income population.Methods:For this longitudinal prospective cohort study we conducted a secondary analysis of data from the Infant and Toddler Feeding Practices Study-2, a national study of infant feeding practices and child outcomes. Study infants were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children by 2.5 months of age and followed until 36 months (N = 1,223). We examined the association between breastfeeding duration until 13 months of age, and child diet quality derived from a 24-hour dietary recall with a usual intake adjustment at child age 36 months. Multiple regression analyses were used to examine the association of breastfeeding duration with overall diet quality, as measured by the Heathy Eating Index 2015, and with consumption of specific food groups.Results:Longer breastfeeding duration during infancy was associated with better diet quality at child age 36 months after controlling for key socio-demographic variables. In follow-up analyses, the origin of the association was narrowed to greater consumption of mature/dried beans and peas.Conclusions:Longer breastfeeding duration in infancy was associated with better diet quality at 36 months, in a population at risk for shorter breastfeeding duration and poorer diet quality. Breastfeeding was particularly associated with children’s consumption of mature/dried beans and peas.Clinical Trial Registration:This study is registered at clinicaltrials.gov as Feeding My Baby—A National WIC Study, NCT02031978

Journal of Human Lactation, Ahead of Print.
Background:Previous low human milk feeding rates in Chinese neonatal intensive care units of preterm infants were reported. There are no nationwide data on these.Research Aims:To investigate the current status of human milk feeding for preterm infants in Chinese units and provide baseline data for future research.Methods:A secondary data analysis was conducted from a previously established clinical database including 25 Chinese neonatal intensive care units. All infants born <34 weeks gestation and admitted to participating units from May 2015 to April 2018 were enrolled. Variables analyzed were infant data collected and the human milk feeding practices at participating units were surveyed.Results:A total of 24,113 infants were included. The overall and exclusive human milk feeding rates were 58.2% and 18.8%, respectively, which increased significantly during study years. We found that rates of human milk feeding decreased with increase in gestational age and birth weight. There was significant variation in human milk feeding rates among units. Most participating Chinese neonatal intensive care units have taken measures to improve the rates of human milk feeding.Conclusions:The human milk feeding rates in Chinese neonatal intensive care units have continued to increase in the past 3 years, but there was significant variation among them. More efforts are needed to further increase the human milk feeding rates in China.Trial registration:This study was registered NCT02600195 with clinicaltrials.gov on November 9, 2015.

Journal of Human Lactation, Ahead of Print.
Background:Infants, young children, and their mothers are vulnerable in humanitarian emergencies. The health benefits of optimal breastfeeding practices in emergency settings have been demonstrated by many researchers. Infant and Young Children Feeding in Emergency guidelines illustrate a series of interventions to protect, promote, and support breastfeeding, but unfortunately, these recommendations are still scarcely applied.Research Aims:(1) To review the literature describing the effectiveness of breastfeeding protection, promotion, and support interventions in humanitarian emergency contexts; (2) to describe the influence of interventions on breastfeeding initiation, exclusivity, and duration; and (3) to evaluate relevant mother and infant/child outcomes available in the literature.Methods:PubMed, CINAHL, Cochrane Library, Psychology Database, JSTOR, Web of Science, EMBASE, and Ovid were searched for articles that examined breastfeeding protection, promotion, or support interventions and the resulting outcomes without any time limits (N = 10). Articles that did not include the interventions and related outcomes were excluded (n = 1,391).Results:Improved breastfeeding outcomes were reported in four (40%) papers, and three (30%) highlighted a behavioral change in infant and young child feeding practices following the implementation of the interventions. Increased knowledge about appropriate infant and young child feeding practices among mothers and humanitarian/health staff was reported in eight (80%) papers. However, outcomes were sometimes only generically reported, and some of the included papers had a low strength of evidence.Conclusion:In the literature, there is a great dearth of studies evaluating the influence of interventions aimed at improving breastfeeding in emergency settings. More evidence is urgently needed to encourage and implement optimal breastfeeding practices.

Journal of Human Lactation, Ahead of Print.
Background:Establishing a human milk bank for the benefit of premature newborns who are unable to receive their mothers’ milk for various reasons is a common initiative. To date, 19 human milk banks have been established in China; however, data associated with human milk banks are lacking, including information on the operational costs, guidelines, and regulatory systems for human milk banks in China.Research Aim:Our study aim was to conduct a cost analysis for the human milk bank at Shanghai Children’s Hospital.Methods:A management accounting approach, based on the activity-based costing method, was used to develop a cost model for donor human milk. The data were collected retrospectively and included budget plans, financial and expenditure reports, databases, and interviews with the staff and managers at the Shanghai Children’s Hospital Human Milk Bank in 2017.Results:In 2017, the total volume of qualified donor human milk was 933.70 L, of which 842.71 L (90%) was frozen and 90.99 L (10%) was freshly donated on site. The total annual cost to provide milk for 212 high-risk infants in 2017 was US$156,923, and the unit cost was US$168/L.Conclusions:The operating costs of human milk banks in China are similar to those in other countries internationally, but these costs are so large that they require government and society support for funding and milk donation. Therefore, ongoing breastfeeding support for mothers and measures to reduce the operating costs of human milk banks should be advocated.

Journal of Human Lactation, Ahead of Print.
Background:Data are limited on the association between the use of donor human milk and improvements in feeding tolerance.Objective:To determine the influence of the duration of parenteral nutrition on the growth and morbidity of the breastfed newborn when using donated human milk in the absence of mother’s own milk.Methods:We conducted a retrospective study before and after the intervention that compared two groups of newborns (N = 284; each group n = 142). We used a convenience sample of all newborns ≤32 weeks gestation consecutively admitted in a single unit before (Group 1 between December 2012 and May 2014) or after (Group 2 between October 2014 and December 2016) the availability of donor human milk. In Group 2, donor human milk was administered at least 3 to 4 weeks or until the baby weighed 1,500 g. Weight was recorded daily and length and head circumference weekly. Parenteral nutrition was continued until enteral feeding volume reached 120 ml/kg/day. Additional variables measured were the number of days with a central venous catheter, age that the enteral feeding volume reached 150 ml/kg/day, and duration of stay.Results:The duration of parenteral feeding was the same before and after: 12 (8.23) and 11 (7.19) days (p = .822). The z scores for weight and height of newborns was lower in Group 2 = −1.8 (1.0) and −2.3 (1.1) and Group 1 = −1.2 (1.1) (p < .001) and −1.8 (1.4) (p = .005).Conclusion:We did not find an association between the administration of donor human milk as a supplement to mother’s own milk and reduced number of days of parenteral nutrition.Back translation by Laurence Grummer-Strawn

Journal of Human Lactation, Ahead of Print.
Background:Increasing breastfeeding duration may help physician mothers better counsel their patients. To improve the breastfeeding duration of physician mothers, the factors that may influence their breastfeeding duration should be known.Research Aim:To investigate the breastfeeding behavior and duration among physician mothers and to determine the factors that influence breastfeeding practices.Methods:This was an online prospective cross-sectional self-report survey. A 26-item author-created data-collecting tool inquiring sociodemographic and work characteristics, medical history of delivery, and breastfeeding history was sent to female physicians who had infants between 12 and 60 months of age via an online social group, “Physician Mothers,” with 11,632 members. Participants (N = 615) responded, and descriptive statistics were analyzed.Results:Participants’ mean duration of exclusive breastfeeding was 4.8 months (SD = 1.9). The total breastfeeding length was a mean 15.8 months (SD = 7.6). The rate of breastfeeding duration for at least 24 months was 17.8% (n = 75). The most common reason for weaning from breastfeeding was workplace-related conditions (23.6%, n = 145). Participants reported that the mean time of resuming night shifts after delivery was 8.6 months (SD = 4.7). The rate of participants who were unable to use their breastfeeding leave rights partially or completely was 43.6% (n = 268).Conclusion:Although legislation is in place to allow working mothers to breastfeed their infants, these legal rights were not used properly. Physician mothers should be fully supported in using their breastfeeding leave rights, and workplace conditions should be improved to enable physician mothers to breastfeed their infants for extended periods.

Journal of Human Lactation, Ahead of Print.
Introduction:Breastfeeding offers the optimal feeding option for newborns in terms of nutritional content and reinforces mother-infant bonding. As a physiological process intrinsically linked to parturition, breastfeeding is no longer reserved for puerperal mothers. Progress in understanding the intricacies of lactogenesis and breastfeeding has further paved the way for artificially induced lactation in recent years.Main issues:We describe the case of a mother through surrogacy with XY karyotype and complete androgen insensitivity syndrome who wished to breastfeed her child.Management:Through a combination of estrogen therapy, galactagogues, and mechanical breast stimulation she was able to partially breastfeed her child for one month.Conclusion:This case further shifts the concept that breastfeeding is a physiological process confined to only puerperal mothers and offers an opportunity to a wider group of nontraditional mothers to take part in the unique experience of breastfeeding.

Journal of Human Lactation, Ahead of Print.
Background:Numerous researchers have evaluated the influence of federal and workplace lactation policies on breastfeeding duration, however few have considered the experiences of breastfeeding people returning to school.Research aim:The aim of this study was to evaluate the availability, accessibility, acceptability, and quality of existing on-campus lactation spaces.Methods:In-depth interviews were conducted with student-parents (N = 18) who had expressed milk on campus. Data collection and thematic analysis were based on the availability, accessibility, acceptability, and quality framework for evaluating health services from the human rights literature and adapted for this study.Results:For most participants with proximal access to a designated lactation space, room availability was exceptional and quality was marginally adequate. The provision of breast pumps, in-room sinks, and study desks were important aspects of quality discussed by the participants. Not all participants made use of the university’s designated lactation spaces due to either physical or informational inaccessibility. If designated lactation spaces were not convenient, participants found closer alternatives (e.g., bathroom, staff offices, or during the academic session).Conclusion:Breastfeeding parents who return to school experience obstacles similar to those reported by employed parents who return to work. They require convenient access to appropriate spaces and sufficient privacy to express milk for their infants. In order to best support all learners, university leaders must consider the needs of this unique student population.

Journal of Human Lactation, Ahead of Print.
Background:Recommendations to avoid breastfeeding for women living with HIV in high income countries has resulted in a gap in the literature on how healthcare professionals can provide the highest standard of lactation counseling.Research aims:(1) Describe social and emotional experiences of infant feeding for women living with HIV in high income countries; (2) raise ethical considerations surrounding the clinical recommendation in high income countries to avoid breastfeeding.Methods:A systematic literature search was conducted between January 1, 2008 and June 20, 2019. A total of 900 papers were screened and six met the inclusion criteria: (a) the sample was drawn from a high-income country regardless of the nativity of participants; (b) some or all participants were women living with HIV. Metasynthesis, according to Noblit and Hare (1988), was used to synthesize the experiences of women living with HIV in high-income countries and their experiences in infant feeding decisions.Results:Participants in this sample suffered a substantial emotional burden associated with infant feeding experiences potentially leading to risk of internalized stigma, suggesting that infant feeding considerations may contribute to HIV stigma in unique ways. Four overarching themes were identified expressing the meaning of avoidance of breastfeeding: maternal self-worth, deculturalization, surveillance, and intersectionality.Conclusion:Women in high-income countries living with HIV deserve the highest standard of lactation care and counseling available. Healthcare professionals in high-income countries are ethically obligated to provide evidenced-based lactation care and counseling to women living with HIV.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Recommendations to avoid breastfeeding for women living with HIV in high income countries has resulted in a gap in the literature on how healthcare professionals can provide the highest standard of lactation counseling.Research aims:(1) Describe social and emotional experiences of infant feeding for women living with HIV in high income countries; (2) raise ethical considerations surrounding the clinical recommendation in high income countries to avoid breastfeeding.Methods:A systematic literature search was conducted between January 1, 2008 and June 20, 2019. A total of 900 papers were screened and six met the inclusion criteria: (a) the sample was drawn from a high-income country regardless of the nativity of participants; (b) some or all participants were women living with HIV. Metasynthesis, according to Noblit and Hare (1988), was used to synthesize the experiences of women living with HIV in high-income countries and their experiences in infant feeding decisions.Results:Participants in this sample suffered a substantial emotional burden associated with infant feeding experiences potentially leading to risk of internalized stigma, suggesting that infant feeding considerations may contribute to HIV stigma in unique ways. Four overarching themes were identified expressing the meaning of avoidance of breastfeeding: maternal self-worth, deculturalization, surveillance, and intersectionality.Conclusion:Women in high-income countries living with HIV deserve the highest standard of lactation care and counseling available. Healthcare professionals in high-income countries are ethically obligated to provide evidenced-based lactation care and counseling to women living with HIV.

Journal of Human Lactation, Ahead of Print.
Background:Numerous researchers have evaluated the influence of federal and workplace lactation policies on breastfeeding duration, however few have considered the experiences of breastfeeding people returning to school.Research aim:The aim of this study was to evaluate the availability, accessibility, acceptability, and quality of existing on-campus lactation spaces.Methods:In-depth interviews were conducted with student-parents (N = 18) who had expressed milk on campus. Data collection and thematic analysis were based on the availability, accessibility, acceptability, and quality framework for evaluating health services from the human rights literature and adapted for this study.Results:For most participants with proximal access to a designated lactation space, room availability was exceptional and quality was marginally adequate. The provision of breast pumps, in-room sinks, and study desks were important aspects of quality discussed by the participants. Not all participants made use of the university’s designated lactation spaces due to either physical or informational inaccessibility. If designated lactation spaces were not convenient, participants found closer alternatives (e.g., bathroom, staff offices, or during the academic session).Conclusion:Breastfeeding parents who return to school experience obstacles similar to those reported by employed parents who return to work. They require convenient access to appropriate spaces and sufficient privacy to express milk for their infants. In order to best support all learners, university leaders must consider the needs of this unique student population.

Journal of Human Lactation, Ahead of Print.
Background:Increasing breastfeeding duration may help physician mothers better counsel their patients. To improve the breastfeeding duration of physician mothers, the factors that may influence their breastfeeding duration should be known.Research Aim:To investigate the breastfeeding behavior and duration among physician mothers and to determine the factors that influence breastfeeding practices.Methods:This was an online prospective cross-sectional self-report survey. A 26-item author-created data-collecting tool inquiring sociodemographic and work characteristics, medical history of delivery, and breastfeeding history was sent to female physicians who had infants between 12 and 60 months of age via an online social group, “Physician Mothers,” with 11,632 members. Participants (N = 615) responded, and descriptive statistics were analyzed.Results:Participants’ mean duration of exclusive breastfeeding was 4.8 months (SD = 1.9). The total breastfeeding length was a mean 15.8 months (SD = 7.6). The rate of breastfeeding duration for at least 24 months was 17.8% (n = 75). The most common reason for weaning from breastfeeding was workplace-related conditions (23.6%, n = 145). Participants reported that the mean time of resuming night shifts after delivery was 8.6 months (SD = 4.7). The rate of participants who were unable to use their breastfeeding leave rights partially or completely was 43.6% (n = 268).Conclusion:Although legislation is in place to allow working mothers to breastfeed their infants, these legal rights were not used properly. Physician mothers should be fully supported in using their breastfeeding leave rights, and workplace conditions should be improved to enable physician mothers to breastfeed their infants for extended periods.

Journal of Human Lactation, Ahead of Print.
Introduction:Breastfeeding offers the optimal feeding option for newborns in terms of nutritional content and reinforces mother-infant bonding. As a physiological process intrinsically linked to parturition, breastfeeding is no longer reserved for puerperal mothers. Progress in understanding the intricacies of lactogenesis and breastfeeding has further paved the way for artificially induced lactation in recent years.Main issues:We describe the case of a mother through surrogacy with XY karyotype and complete androgen insensitivity syndrome who wished to breastfeed her child.Management:Through a combination of estrogen therapy, galactagogues, and mechanical breast stimulation she was able to partially breastfeed her child for one month.Conclusion:This case further shifts the concept that breastfeeding is a physiological process confined to only puerperal mothers and offers an opportunity to a wider group of nontraditional mothers to take part in the unique experience of breastfeeding.

Journal of Human Lactation, Ahead of Print.