Journal of Human Lactation - online first articles

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:Few studies have examined the role of maternal emotions in breastfeeding outcomes.Research aim:We aimed to determine the extent to which positive maternal emotions during human milk feeding at 2 months were associated with time to any and exclusive human milk feeding cessation and overall breastfeeding experience.Methods:A sample of 192 women intending to breastfeed for at least 2 months was followed from the third trimester until 12 months postpartum. Positive emotions during infant feeding at 2 months were measured using the modified Differential Emotions Scale. Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) for time to any and exclusive human milk feeding cessation associated with a 1-point increase in positive emotions. Linear regression was used to estimate the association between positive emotions and maternal breastfeeding experience reported at 12 months.Results:Among those human milk feeding at 2 months, positive emotions during feeding were not associated with human milk feeding cessation by 12 months (aHR = 0.94, 95% CI [0.64, 1.31]). However, among women exclusively human milk feeding at 2 months, a 1-point increase in positive emotions was associated with a 35% lower hazard of introducing formula or solid foods by 6 months (aHR = 0.65, 95% CI [0.46, 0.92]). Positive emotions were associated with a significantly more favorable maternal report of breastfeeding experience at 12 months. Results were similar in sensitivity analyses using maternal feelings about breastfeeding in the first week as the exposure.Conclusions:A positive maternal emotional experience of feeding is associated with breastfeeding outcomes.

Journal of Human Lactation, Ahead of Print.
Background:Few studies have examined the role of maternal emotions in breastfeeding outcomes.Research aim:We aimed to determine the extent to which positive maternal emotions during human milk feeding at 2 months were associated with time to any and exclusive human milk feeding cessation and overall breastfeeding experience.Methods:A sample of 192 women intending to breastfeed for at least 2 months was followed from the third trimester until 12 months postpartum. Positive emotions during infant feeding at 2 months were measured using the modified Differential Emotions Scale. Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHR) for time to any and exclusive human milk feeding cessation associated with a 1-point increase in positive emotions. Linear regression was used to estimate the association between positive emotions and maternal breastfeeding experience reported at 12 months.Results:Among those human milk feeding at 2 months, positive emotions during feeding were not associated with human milk feeding cessation by 12 months (aHR = 0.94, 95% CI [0.64, 1.31]). However, among women exclusively human milk feeding at 2 months, a 1-point increase in positive emotions was associated with a 35% lower hazard of introducing formula or solid foods by 6 months (aHR = 0.65, 95% CI [0.46, 0.92]). Positive emotions were associated with a significantly more favorable maternal report of breastfeeding experience at 12 months. Results were similar in sensitivity analyses using maternal feelings about breastfeeding in the first week as the exposure.Conclusions:A positive maternal emotional experience of feeding is associated with breastfeeding outcomes.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Human milk is known to be protective against necrotizing enterocolitis, a devastating intestinal inflammatory disease affecting the preterm population. Although the pathogenesis of necrotizing enterocolitis is yet to be solidified, intestinal integrity dysfunction, bacterial invasion and/or translocation, and inflammation may play important roles. Glycosaminoglycans, compounds naturally prevalent in both human milk and the intestine, are thought to be anti-inflammatory and capable of altering bacterial interactions within the gut.Research aim:In this study, we aimed to evaluate the potential of chondroitin sulfate, the most prominent class of glycosaminoglycans in human milk, to protect against bacterial infection in an intestinal in vitro model.Methods:T84 cell monolayers were treated with chondroitin sulfate and cell viability was assessed across a number of doses. Monolayers were then pretreated with chondroitin sulfate and subsequently challenged with E. coli invasion and translocation to evaluate any protective role of the compound against infection. Tight junction barrier function was assessed by transepithelial electrical resistance, and cytokine levels were evaluated.Results:Chondroitin sulfate at any dose up to 750 μg/ml was not associated with any statistically significant decrease in cell viability. Additionally, chondroitin sulfate at 750 μg/ml was associated with a 75% decrease in both bacterial invasion and translocation compared to control.Conclusions:These data suggest chondroitin sulfate may protect against bacterial infection through a reduction in both invasion and translocation, importantly without attendant reduction in cell viability.

Journal of Human Lactation, Ahead of Print.
One of the distinguishing and unique features of being an International Board Certified Lactation Consultant is successful completion of the International Board of Lactation Consultant Examiners examination, necessary for initial and ongoing certification. First offered in 1985, the exam content and scoring criteria have been developed using rigorous psychometric principles. While conducting my dissertation research about the professionalization of breastfeeding support (Eden, 2017), I interviewed Leon Gross, PhD, the psychometrician who oversaw the development of the first exam offered in 1985. He continued in this role through 2013. The interview excerpts below are from a taped interview conducted on March 27, 2011 in Rosslyn, Virginia (AE = Aimee Eden; LG = Leon Gross).

Journal of Human Lactation, Ahead of Print.
Introduction:Although lactation dysfunction and breastfeeding difficulties after spinal cord injury have been previously reported, there is still a lack of research on the specific challenges and aspects that require more support. This unique case of a mother with C6 tetraplegia details her breastfeeding experience before and after spinal cord injury.Main Issue:A 23-year-old woman with a 20-month-old daughter sustained a motor and sensory complete traumatic spinal cord injury in a motor-vehicle crash while she was 6 months pregnant with her second child. This resulted in complete absence of sensory function below the level of injury (including the breast) and limited hand function. In comparison with her breastfeeding experience before injury, after injury she experienced decreased milk production, absence of the milk ejection reflex, and impaired ability to pick up, hold, and position her infant.Management:Care aides and family members assisted this mother with picking up, positioning, and latching her infant. She also utilized alternative breastfeeding positions, nursing pillows, and wedges. Domperidone was suggested by her physiatrist to increase milk production but ultimately was not used as there were no concerns with her infant’s growth or development.Conclusion:Breastfeeding as a recently injured mother while undergoing intensive post-injury rehabilitation was challenging. Her second child developed well and was breastfed for 3 months compared to her first child (9 months). Breastfeeding was possible for this mother after spinal cord injury, in part due to previous experience successfully breastfeeding her first child, assistance from care personnel, and nursing aids.

Journal of Human Lactation, Ahead of Print.
Background:Exclusive breastfeeding is recommended for the first 6 months of life and has significant benefits for both mother and child. Pregnancy-specific anxiety is a distinct and definable syndrome that has been identified as a robust predictor of pregnancy outcomes, but whether it is associated with exclusive breastfeeding status has not been determined.Research aims:To examine the association between pregnancy-specific anxiety in each trimester of pregnancy and exclusive breastfeeding status early in the postpartum period.Methods:Data were available from 412 women who participated in a longitudinal pregnancy cohort study. Pregnancy-specific anxiety and exclusive breastfeeding status were assessed using an online self-report questionnaire.Results:Logistic regression analyses showed that a one-unit increase in pregnancy-specific anxiety in the first (OR = 0.94, 95% CI [0.90, 0.98]) and third (OR = 0.95, 95% CI [0.91, 0.99]) trimester of pregnancy was associated with a 5–6% decrease in the odds of exclusive breastfeeding at 6–8 weeks postpartum.Conclusions:Pregnancy-specific anxiety was associated with lower odds of exclusive breastfeeding at 6–8 weeks postpartum. Prenatal interventions designed to increase exclusive breastfeeding duration may benefit from the incorporation of strategies that help reduce worries and concerns unique to the pregnancy experience.

Journal of Human Lactation, Ahead of Print.
Background:Maternal milk production requires the neuropeptide oxytocin. Individual variation in oxytocin function is a compelling target for understanding low milk production, a leading cause of breastfeeding attrition. Complicating the understanding of oxytocin pathways is that vasopressin may interact with oxytocin receptors, yet little is known about the role of vasopressin in lactation.Research aims:The aims of this study were (1) to describe maternal plasma oxytocin, vasopressin, and prolactin patterns during breastfeeding following low-risk spontaneous labor and birth in healthy first-time mothers and (2) to relate hormone patterns to maternal characteristics and breastfeeding measures.Methods:Eligible women were recruited before hospital discharge. Forty-six participants enrolled and 35 attended the study visit. Participants kept a journal of breastfeeding frequency, symptoms of lactogenesis, and infant weight. Plasma samples were obtained at breastfeeding onset on Day 4–5 postpartum, and repeated after 20 min. Hormones were measured with immunoassays. Infant weight change, milk transfer, and onset of lactogenesis were also measured.Results:Baseline oxytocin and vasopressin were inversely related to one another. Oxytocin and prolactin increased significantly across the 20-min sampling period while vasopressin decreased. Higher oxytocin was associated with higher maternal age, lower BMI, shorter active labor, physiologic labor progression, and less weight loss in the newborn. Higher vasopressin correlated with younger maternal age, higher BMI, and greater newborn weight loss.Conclusions:Oxytocin and vasopressin have contrasting relationships with maternal clinical characteristics and newborn weight gain in early breastfeeding infants. Further study is needed to understand how oxytocin and vasopressin influence lactation outcomes.

Journal of Human Lactation, Ahead of Print.
Background:Maternal milk production requires the neuropeptide oxytocin. Individual variation in oxytocin function is a compelling target for understanding low milk production, a leading cause of breastfeeding attrition. Complicating the understanding of oxytocin pathways is that vasopressin may interact with oxytocin receptors, yet little is known about the role of vasopressin in lactation.Research aims:The aims of this study were (1) to describe maternal plasma oxytocin, vasopressin, and prolactin patterns during breastfeeding following low-risk spontaneous labor and birth in healthy first-time mothers and (2) to relate hormone patterns to maternal characteristics and breastfeeding measures.Methods:Eligible women were recruited before hospital discharge. Forty-six participants enrolled and 35 attended the study visit. Participants kept a journal of breastfeeding frequency, symptoms of lactogenesis, and infant weight. Plasma samples were obtained at breastfeeding onset on Day 4–5 postpartum, and repeated after 20 min. Hormones were measured with immunoassays. Infant weight change, milk transfer, and onset of lactogenesis were also measured.Results:Baseline oxytocin and vasopressin were inversely related to one another. Oxytocin and prolactin increased significantly across the 20-min sampling period while vasopressin decreased. Higher oxytocin was associated with higher maternal age, lower BMI, shorter active labor, physiologic labor progression, and less weight loss in the newborn. Higher vasopressin correlated with younger maternal age, higher BMI, and greater newborn weight loss.Conclusions:Oxytocin and vasopressin have contrasting relationships with maternal clinical characteristics and newborn weight gain in early breastfeeding infants. Further study is needed to understand how oxytocin and vasopressin influence lactation outcomes.

Journal of Human Lactation, Ahead of Print.
Background:Human milk is known to be rich in cellular components, including stem cells and immune cells. However, the dynamics of these cellular components at different lactation stages, and the differences between milk for preterm and term infants, are poorly understood.Research aim:To identify changes in the cellular components of human milk at different lactation stages, and to explore the associations of these changes with maternal and infant characteristics.Methods:Forty mothers of newborns of different gestational ages were enrolled. Colostrum, transitional, and mature milk samples were collected. Stem cell and immune cell molecule markers were detected using flow cytometry. Pluripotent genes (SOX2, NANOG, OCT4, and KLF4) were detected via quantitative real-time PCR.Results:Human milk contained some stem cells but more immune cells. The percentages of hemopoietic stem cells were significantly higher in mature milk than in colostrum, and the percentages of total immune cells were lower in mature milk than in colostrum. The percentages of hemopoietic stem cells in colostrum and transitional milk were influenced by gestational age. Some minor differences in the cell composition of human milk could be explained by maternal body mass index, the mode of delivery, and parity.Conclusion:Our results again confirmed that human milk contains stem cells. Additionally, the percentages of hemopoietic stem cells and major immune cells changed dynamically at different lactation stages and were associated with gestational age at delivery.

Journal of Human Lactation, Ahead of Print.
Background:The Beginning Breastfeeding Survey-Cumulative (BBSC) is an instrument that assesses the overall maternal perception of breastfeeding effectiveness during the early postpartum period.Research aims:The aims of this study were to adapt and validate a Spanish version of the BBSC and provide new evidence regarding its validity.Methods:A standard forward and back-translation process was used to obtain the Spanish version of the questionnaire (BBSC-E). A sample of 793 breastfeeding mothers was used. Data were obtained from clinical records and questionnaires self-administered at discharge and at 1–4 months postpartum. The factorial structure of the BBSC-E was examined with both an exploratory and confirmatory approach. Internal consistency, comparisons between known groups, and correlations with other variables were also assessed, and receiver operating characteristics (ROC) curves were used to determine its predictive validity.Results:Analysis revealed a two-dimensional structure, with infant and maternal subscales, and adequate fit statistics. The Root Mean Squared Error of Approximation (RMSEA) was .067. The Cronbach’s α of the overall scale was .91. There were statistically significant associations between the BBSC-E and (1) previous breastfeeding experience, early skin-to-skin contact, exclusive breastfeeding, breastfeeding difficulty and self-efficacy, and infant weight loss during hospitalization and (2) at 1–4 months postpartum, with the breastfeeding status, the intensity of breastfeeding problems, and satisfaction with breastfeeding. The total BBSC-E area under the ROC curve for any breastfeeding at 60 days postpartum was .73, and a score of 88 was the most discriminative cut-off point for maximum performance.Conclusion:The BBSC-E is a reliable and valid instrument for measuring breastfeeding effectiveness during early postpartum.

Journal of Human Lactation, Ahead of Print.
Introduction:Cyclobenzaprine is a skeletal muscle relaxant primarily used in the treatment of pain. Its use during lactation is a matter of concern as its level of exposure to infants through human milk is still unknown.Main issue:The aim of this study was to determine cyclobenzaprine concentrations in the milk samples collected from two lactating mothers.Management:The present study describes the analysis of cyclobenzaprine in human milk using liquid chromatography mass spectrometry, which determined the drug concentration-time profiles in human milk.Conclusion:This study shows low levels of concentrations of cyclobenzaprine in human milk with calculated relative infant dose of 0.5%. However, due to the sedative properties of cyclobenzaprine, regular clinical assessment of the infant is recommended to evaluate for long-term effects.

Journal of Human Lactation, Ahead of Print.
Background:When an exclusively breastfed infant develops hematochezia, the pediatrician may recommend elimination of dairy and soy products from a mother’s diet, but there is limited scientific evidence to indicate that altering the maternal diet will lead to resolution of the problem.Research aim:To estimate the likelihood that maternal dairy and soy avoidance will resolve rectal bleeding in an exclusively breastfed infant.Methods:This was a prospective, longitudinal, one-group pre/post study involving mothers of exclusively breastfed infants at least 2 weeks but less than 6 months of age with a positive stool guaiac test in the absence of an intestinal lesion or other explanation for the blood. Participants agreed to follow a dairy and soy elimination/rechallenge protocol, maintain a food diary, and have their infant re-tested at 3-week intervals to determine the outcome of the dietary changes. One participant was lost to follow-up, leaving a final sample size of N = 19.Results:All infants continued to test positive for blood in the stool after their mothers eliminated foods containing dairy or soy. Therefore, 0% (0/19) of infants responded to their mother’s restricted diet, 95% confidence interval (one-sided [0%, 15%]).Conclusion:Given these results, we must call into question the rationale for advising breastfeeding mothers to eliminate dairy and soy from their diet in response to their infant’s unexplained rectal bleeding.

Journal of Human Lactation, Ahead of Print.
Background:When an exclusively breastfed infant develops hematochezia, the pediatrician may recommend elimination of dairy and soy products from a mother’s diet, but there is limited scientific evidence to indicate that altering the maternal diet will lead to resolution of the problem.Research aim:To estimate the likelihood that maternal dairy and soy avoidance will resolve rectal bleeding in an exclusively breastfed infant.Methods:This was a prospective, longitudinal, one-group pre/post study involving mothers of exclusively breastfed infants at least 2 weeks but less than 6 months of age with a positive stool guaiac test in the absence of an intestinal lesion or other explanation for the blood. Participants agreed to follow a dairy and soy elimination/rechallenge protocol, maintain a food diary, and have their infant re-tested at 3-week intervals to determine the outcome of the dietary changes. One participant was lost to follow-up, leaving a final sample size of N = 19.Results:All infants continued to test positive for blood in the stool after their mothers eliminated foods containing dairy or soy. Therefore, 0% (0/19) of infants responded to their mother’s restricted diet, 95% confidence interval (one-sided [0%, 15%]).Conclusion:Given these results, we must call into question the rationale for advising breastfeeding mothers to eliminate dairy and soy from their diet in response to their infant’s unexplained rectal bleeding.

Journal of Human Lactation, Ahead of Print.
Background:Despite advances in prevention of mother-to-child HIV transmission, infants in Africa remain at risk of HIV acquisition from inappropriate feeding practices.Research aims:To assess maternal knowledge and predictors of appropriate infant feeding practices among HIV-infected mothers attending a tertiary facility in Kano, Nigeria.Method:A cross section of 203 HIV-positive mothers were interviewed using structured, pretested survey questionnaires. Knowledge scores and infant feeding practices were analyzed. Multivariate logistic regression was employed to ascertain independent correlates of infant feeding practices in the study sample.Results:Over a third (37.4%) of the participants were aware of the risk of HIV transmission through breastfeeding. The proportion of participants with good, fair, and poor knowledge of recommended feeding options for HIV-exposed infants was 4.4%, 73.4%, and 22.2%, respectively. About three in four participants (73.9%) breastfed their index infants exclusively for the first six months. Approximately 7.4% of respondents practiced mixed feeding (breastfeeding plus infant formula). Counseling on infant feeding (Adjusted Odds Ratio [AOR] = 2.16, 95% Confidence Interval [CI] = [1.58, 4.15]) and hospital delivery (AOR = 3.02, 95% CI = [2.67, 7.84]) predicted appropriate infant feeding practice.Conclusion:Appropriate infant feeding practices were significantly associated with prior infant feeding counseling and delivery in a hospital setting. HIV-infected mothers in this setting should receive counseling on infant feeding early in their pregnancy and be educated on the importance of hospital delivery.

Journal of Human Lactation, Ahead of Print.
Background:According to the Baby Friendly Hospital Initiative, when supplementary feeding occurs, mothers should be counseled on the use and risks of feeding bottles and teats. To help support this initiative it is important to understand the supplementation practices of Internationally Board Certified Lactation Consultants (IBCLC)®.Research aims:To determine (1) if the location of an IBCLC’s practice has any impact on supplemental feeding methods; (2) the preferred methods of and the main reasons for supplementation; (3) the level of an IBCLC’s confidence with supplemental feeding methods; (4) who is making supplemental feeding decisions; and (5) if there are geographical differences among supplementation choices and reasons for supplementation.Methods:An exploratory, descriptive, cross sectional survey of IBCLCs was conducted to generate data about their use of supplemental feeding methods. The survey was sent via email invitation through the International Board of Lactation Consultant’s Board of Examiners, with a response rate of 11.5% (N = 2,308).Results:There was no standard method of supplementation among participants. Participants indicated that they were confident advising mothers on alternative feeding methods. Only 17.6% (n = 406) of participants reported that the IBCLC was the caregiver who recommended the method of supplementation used. The majority of participants believed the Supplemental Feeding Tube Device SFTD) best preserves the breastfeeding relationship, and this was their preferred method of supplementation. However, the bottle was ranked as the number one method used in the United States, Australia, and Canada. The use of alternative feeding methods may be overwhelming to the mother.Conclusion:Supplementation by alternative feeding methods might help preserve the breastfeeding relationship and help reach the World Health Organization’s goal of increasing exclusive breastfeeding rates.