Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
Background:Although exclusive breastfeeding of infants has several benefits, in Ghana only 52% of children under 6 months old are breastfed exclusively. However, researchers have not conducted longitudinal observational studies to examine exclusive breastfeeding discontinuation and determine risk factors.Research aims:(1) To determine exclusive breastfeeding discontinuation, and (2) to examine those factors linked to discontinued exclusive breastfeeding.Methods:A longitudinal, one-group observational study was conducted. A total of 322 mothers who had normal and full-term delivery at a district level referral hospital from January to December 2017 were recruited, followed-up every month, and subsequently interviewed after 6 months postpartum. Data were collected using validated questionnaires. Binary and multivariable Poisson regression analyses were the statistical analytical methods used.Results:Respondents’ mean age was 29.78 years (SD = 5.20). Among the 322 mothers who initiated breastfeeding with human milk at birth, 108 (34%) discontinued exclusive breastfeeding before 6 months postpartum. After controlling for possible covariates, attending antenatal care 4 or less times during pregnancy (aRR = 6.54; 95% CI [1.77–24.22]; p = .005); lack of support from family to breastfeed exclusively (aRR = 2.41; 95% CI [1.23–4.71]; p = .010), outside pressure to provide other food to the baby < 6 months postpartum (aRR = 1.87; 95% CI [1.01–3.46]; p = .045), and living in an urban area (aRR = 2.10; 95% CI [1.17-3.75]; p = .013) significantly increased the risks of discontinuing exclusive breastfeeding.Conclusion:Universal exclusive breastfeeding may not be achieved without tackling the key determinants of discontinuation of exclusive breastfeeding. Health facility and community-based exclusive breastfeeding promotion interventions are therefore needed.

Journal of Human Lactation, Ahead of Print.
Background:A professional association journal should reflect the needs of its organization, its readers, and the field it represents. Evaluating the needs that the Journal of Human Lactation has met, and those it has not, is essential if it is to remain relevant to its readers.Aims:(1) Describe the characteristics of articles published from 1985 through 2018. (2) Describe content intended to educate lactation support providers and clinicians. (3) Explore the ways the content has illustrated the growth and development of lactation knowledge, and (4) identify the reoccurring content threads consistent throughout the 34 years.Methods:A prospective mixed methods approach incorporating a quantitative content analysis and a qualitative thematic analysis was used. Frequency distributions were done on all the variables extracted from published articles (N = 1586). The second level of analysis identified themes using an iterative and consensus approach.Results:Mirroring the growth in the lactation field, the volume of research articles published each year has increased along with the percent of research articles per issue. Research methods have become more diverse. The international scope and relevance, while always present, has been steadily increasing. Threads identified were; striving for international scope, advancing lactation education, developing a body of knowledge that informs clinical practice in lactation, and creating a centralized place for multidisciplinary research about lactation.Conclusion:The body of work published in the Journal of Human Lactation parallels the development of the lactation specialty. We have highlighted areas for improvement and possible further study.

Journal of Human Lactation, Ahead of Print.
Background:The Neonatal Eating Assessment Tool—Breastfeeding is a valid and reliable 62-item parent-report assessment of symptoms of problematic breastfeeding behavior intended for infants less than 7 months old.Research aim:The aim of this study was to describe the Neonatal Eating Assessment Tool—Breastfeeding total score and subscale scores within a sample of full-term, healthy, typically-developing infants under 7 months old.Methods:Parents of healthy, full-term breastfeeding infants (N = 475) less than 7 months old completed the Neonatal Eating Assessment Tool – Breastfeeding through an online survey. Descriptive statistics were calculated for the total score and seven subscale scores within each age group: 0–2, 2–4, 4–6, and 6–7 months.Results:Neonatal Eating Assessment Tool—Breastfeeding total scores were highest (i.e., more problematic symptoms) at 0–2 months and decreased in older infant age groups. All subscale scores also had a downward trajectory in symptoms of problematic breastfeeding except the subscale Compelling Symptoms of Problematic Feeding, which was very low across age groups. Scores on the Infant Regulation subscale remained elevated for the first 6 months of life, then declined markedly in the 6–7 month age group.Conclusion:The Neonatal Eating Assessment Tool—Breastfeeding now has reference values to facilitate interpretation of scores and guide decision-making, personalization of interventions, and assessment of response to interventions. For research, the Neonatal Eating Assessment Tool—Breastfeeding can be used to follow longitudinal development of breastfeeding as well as to test efficacy of breastfeeding interventions.

Journal of Human Lactation, Ahead of Print.
Background:The Neonatal Eating Assessment Tool—Breastfeeding is a valid and reliable 62-item parent-report assessment of symptoms of problematic breastfeeding behavior intended for infants less than 7 months old.Research aim:The aim of this study was to describe the Neonatal Eating Assessment Tool—Breastfeeding total score and subscale scores within a sample of full-term, healthy, typically-developing infants under 7 months old.Methods:Parents of healthy, full-term breastfeeding infants (N = 475) less than 7 months old completed the Neonatal Eating Assessment Tool – Breastfeeding through an online survey. Descriptive statistics were calculated for the total score and seven subscale scores within each age group: 0–2, 2–4, 4–6, and 6–7 months.Results:Neonatal Eating Assessment Tool—Breastfeeding total scores were highest (i.e., more problematic symptoms) at 0–2 months and decreased in older infant age groups. All subscale scores also had a downward trajectory in symptoms of problematic breastfeeding except the subscale Compelling Symptoms of Problematic Feeding, which was very low across age groups. Scores on the Infant Regulation subscale remained elevated for the first 6 months of life, then declined markedly in the 6–7 month age group.Conclusion:The Neonatal Eating Assessment Tool—Breastfeeding now has reference values to facilitate interpretation of scores and guide decision-making, personalization of interventions, and assessment of response to interventions. For research, the Neonatal Eating Assessment Tool—Breastfeeding can be used to follow longitudinal development of breastfeeding as well as to test efficacy of breastfeeding interventions.

Journal of Human Lactation, Ahead of Print.
Research about lactation and breastfeeding has exploded since the Journal of Human Lactation (JHL) began publishing in 1985. To discuss the 3-decade-long role of the Journal in promoting, supporting, and disseminating lactation research, editors convened a multidisciplinary group of lactation researchers and providers which comprised three senior researchers and one clinical practitioner, all of whom have a long history of lactation advocacy. Their discussion took place on July 1, 2019. Dr Aimee Eden is a medical anthropologist who leads the qualitative research efforts in a small research department. Her dissertation research focused on the maternal and child healthcare workforce, and the professionalization of breastfeeding support. She served on the Board of Directors of the International Board of Lactation Examiners (2010–2016) and currently serves on the board of the Monetary Investment for Lactation Consultant Certification. Dr Karleen Gribble has been conducting research for 15 years about infant and young child feeding in emergencies, long-term breastfeeding, milk sharing, early childhood trauma, adoption, and fostering. She is an Australian Breastfeeding Association community educator and breastfeeding counselor and a member of the Infant and Young Child Feeding in Emergencies Core Group. Elien Rouw is a practicing physician in Germany specialized in healthy infant care, with a long-standing specialization in breastfeeding medicine. She serves on the Board of Directors of the Academy of Breastfeeding Medicine, is a member of the German National Breastfeeding Committee and their delegate to the World Alliance for Breastfeeding Action. Dr Jackie Wolf is an historian of medicine, whose research focuses on the history of childbirth and breastfeeding practices in the United States and how those practices have shaped women’s and children’s health, as well as public health, over time. Her latest book, published by Johns Hopkins University Press and funded by a 3 year grant from the National Institutes of Health, is Cesarean Section: An American History of Risk, Technology, and Consequence. Dr Sara Gill moderated the discussion. She was a member of the Board of Directors of the International Lactation Consultant Association for 5 years, and has been an Associate Editor of the Journal of Human Lactation for the past 4 years. Her research has focused on breastfeeding among vulnerable populations. (Participants’ comments are noted as AE = Aimee Eden; SG = Sara Gill; KG = Karleen Gribble; ER = Elien Rouw; JW = Jacqueline Wolf).

Journal of Human Lactation, Ahead of Print.
Background:Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding. However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction domains.Research aim:We aimed to examine the influence of telephone-based peer support on the following three domains of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle compatibility with breastfeeding.Methods:Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants (N = 114), those in the intervention group (n = 60) received telephone-based peer support until 4 months postpartum, and participants in the control group (n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were used to examine the influence of the intervention.Results:On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard deviations among participants with low and mid-level scores at baseline.Conclusion:Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of peer support.

Journal of Human Lactation, Ahead of Print.
Background:Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding. However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction domains.Research aim:We aimed to examine the influence of telephone-based peer support on the following three domains of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle compatibility with breastfeeding.Methods:Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants (N = 114), those in the intervention group (n = 60) received telephone-based peer support until 4 months postpartum, and participants in the control group (n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were used to examine the influence of the intervention.Results:On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard deviations among participants with low and mid-level scores at baseline.Conclusion:Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of peer support.

Journal of Human Lactation, Ahead of Print.
Background:Although the reasons for discontinued breastfeeding are multifactorial, an unsupportive work environment is consistently reported as a barrier to continued breastfeeding. In the United States, several state breastfeeding advocates have taken a distinctive approach to promote worksite lactation support by developing statewide recognition initiatives aimed at incentivizing employers to support breastfeeding employees by offering public recognition for the worksites’ efforts.Research aim:To identify and describe statewide worksite lactation support recognition initiatives in the United States.Methods:Between May 2016 and June 2017, semi-structured phone interviews were conducted with breastfeeding experts in each U.S. state (N = 60 participants) for this cross-sectional study. Experts in states with a recognition initiative were asked about the background, structure, and requirements of the initiative.Results:Twenty-six states had a current initiative, and some had requirements for providing a private space (n = 19; 73%) and time (n = 18; 69%) for employees to express human milk, as well as a written worksite lactation support policy (n = 10; 38%).Conclusions:This was the first study in which researchers systematically identified ongoing worksite lactation support recognition initiatives in the United States. The results of this work also served to highlight both the similarities and the variety between initiatives. Future researchers should aim to determine the components of an initiative that increase employer support and, in turn, breastfeeding rates.

Journal of Human Lactation, Ahead of Print.
Background:Although the reasons for discontinued breastfeeding are multifactorial, an unsupportive work environment is consistently reported as a barrier to continued breastfeeding. In the United States, several state breastfeeding advocates have taken a distinctive approach to promote worksite lactation support by developing statewide recognition initiatives aimed at incentivizing employers to support breastfeeding employees by offering public recognition for the worksites’ efforts.Research aim:To identify and describe statewide worksite lactation support recognition initiatives in the United States.Methods:Between May 2016 and June 2017, semi-structured phone interviews were conducted with breastfeeding experts in each U.S. state (N = 60 participants) for this cross-sectional study. Experts in states with a recognition initiative were asked about the background, structure, and requirements of the initiative.Results:Twenty-six states had a current initiative, and some had requirements for providing a private space (n = 19; 73%) and time (n = 18; 69%) for employees to express human milk, as well as a written worksite lactation support policy (n = 10; 38%).Conclusions:This was the first study in which researchers systematically identified ongoing worksite lactation support recognition initiatives in the United States. The results of this work also served to highlight both the similarities and the variety between initiatives. Future researchers should aim to determine the components of an initiative that increase employer support and, in turn, breastfeeding rates.

Journal of Human Lactation, Ahead of Print.
Background:The World Health Organization (WHO) and the United Kingdom Committee for UNICEF recommend that secondary schools include infant feeding education in the curriculum. However, little attention has been given to the study of educators’ views and practices regarding infant feeding education.Aims:The aims of this research were to (1) explore North Carolina Family and Consumer Sciences teachers’ attitudes towards infant feeding education in secondary schools and (2) describe North Carolina Family and Consumer Sciences teachers’ infant feeding education practices.Methods:Researchers conducted interviews (N = 19) and a survey (N = 137) using a sequential mixed methods design. The constant comparative method was used to analyze interview transcripts. Subsequently, a 33-item survey was developed to assess teachers’ attitudes and practices, and this survey was tested for validity and reliability.Results:The majority of participants supported including infant feeding (n = 119, 86.9%) and breastfeeding (n = 116, 84.7%) education in high school. Approximately half of the participants supported including infant feeding (n = 71, 51.9%) and breastfeeding (n = 64, 46.7%) education in middle school. Participants reported that they taught infant feeding at both levels; topics taught included complementary foods, patterns of infant feeding, and the safe preparation of infant formula. Breastfeeding content was covered primarily in the high school Parenting and Child Development course.Conclusions:North Carolina Family and Consumer Sciences teachers have positive attitudes towards teaching about breastfeeding at the secondary school level. Content about infant nutrition and breastfeeding is currently included in courses that cover child development and human nutrition.

Journal of Human Lactation, Ahead of Print.
Background:The World Health Organization (WHO) and the United Kingdom Committee for UNICEF recommend that secondary schools include infant feeding education in the curriculum. However, little attention has been given to the study of educators’ views and practices regarding infant feeding education.Aims:The aims of this research were to (1) explore North Carolina Family and Consumer Sciences teachers’ attitudes towards infant feeding education in secondary schools and (2) describe North Carolina Family and Consumer Sciences teachers’ infant feeding education practices.Methods:Researchers conducted interviews (N = 19) and a survey (N = 137) using a sequential mixed methods design. The constant comparative method was used to analyze interview transcripts. Subsequently, a 33-item survey was developed to assess teachers’ attitudes and practices, and this survey was tested for validity and reliability.Results:The majority of participants supported including infant feeding (n = 119, 86.9%) and breastfeeding (n = 116, 84.7%) education in high school. Approximately half of the participants supported including infant feeding (n = 71, 51.9%) and breastfeeding (n = 64, 46.7%) education in middle school. Participants reported that they taught infant feeding at both levels; topics taught included complementary foods, patterns of infant feeding, and the safe preparation of infant formula. Breastfeeding content was covered primarily in the high school Parenting and Child Development course.Conclusions:North Carolina Family and Consumer Sciences teachers have positive attitudes towards teaching about breastfeeding at the secondary school level. Content about infant nutrition and breastfeeding is currently included in courses that cover child development and human nutrition.

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.
Introduction:Mammary dysbiosis, also known as subacute mastitis, may be associated with nipple blebs. These overlapping diagnoses represent a challenging clinical scenario during lactation. Little research has been published on etiology, management strategies, and outcomes of these concurrent diagnoses.Main issue:We document the treatment and outcome of a patient who presented with left-breast dysbiosis and nipple blebs and whose milk culture grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus. She was treated safely and effectively with intravenous daptomycin and dalbavancin. This has not been described previously in the lactation literature.Management:The 35-year-old lactating gravida 3, para 3 patient presented at 6 months postpartum to a breast surgery clinic with a 1-week history of worsening deep left-breast pain, blebs, and recurrent plugging. She was afebrile and she had no erythema or induration on her breast exam. A culture of her milk grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus, and she was referred to infectious disease for assistance with intravenous antibiotic therapy. She continued to feed expressed milk throughout treatment and demonstrated complete resolution of symptoms 8 weeks later.Conclusions:We report that in patients with a multi-drug-resistant, methicillin-resistant Staphylococcus aureus–positive human milk culture and a clinical presentation of mammary dysbiosis and nipple blebs, intravenous daptomycin and dalbavancin may be an effective treatment.

Journal of Human Lactation, Ahead of Print.
Introduction:Mammary dysbiosis, also known as subacute mastitis, may be associated with nipple blebs. These overlapping diagnoses represent a challenging clinical scenario during lactation. Little research has been published on etiology, management strategies, and outcomes of these concurrent diagnoses.Main issue:We document the treatment and outcome of a patient who presented with left-breast dysbiosis and nipple blebs and whose milk culture grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus. She was treated safely and effectively with intravenous daptomycin and dalbavancin. This has not been described previously in the lactation literature.Management:The 35-year-old lactating gravida 3, para 3 patient presented at 6 months postpartum to a breast surgery clinic with a 1-week history of worsening deep left-breast pain, blebs, and recurrent plugging. She was afebrile and she had no erythema or induration on her breast exam. A culture of her milk grew multi-drug-resistant, methicillin-resistant Staphylococcus aureus, and she was referred to infectious disease for assistance with intravenous antibiotic therapy. She continued to feed expressed milk throughout treatment and demonstrated complete resolution of symptoms 8 weeks later.Conclusions:We report that in patients with a multi-drug-resistant, methicillin-resistant Staphylococcus aureus–positive human milk culture and a clinical presentation of mammary dysbiosis and nipple blebs, intravenous daptomycin and dalbavancin may be an effective treatment.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Induced lactation and relactation are the processes that enable breastfeeding in non-gestating mothers.Research aim:The aim of this study was to describe and interpret the challenges faced by mothers who undergo induced breastfeeding and relactation for adopted infants, infants born via surrogacy, and infants born to same-sex female partners.Methods:A qualitative study was performed using in-depth interviews conducted with Spanish women (N = 9) who had decided to undergo induced lactation or relactation. The data were collected between October 2014 and May 2017. The length of the study was due to the difficulty in locating and recruiting the sample. Interviews were transcribed and coded with the ATLAS.ti v.7.5.7 software. We performed a deductive thematic analysis, creating categories based on the interview questions, which we developed on the basis of previous literature about induced lactation and relactation.Results:Participants described the following challenges: the physical hardships of the process; breastfeeding problems; difficulty with accessing information about induced lactation or relactation; and lack of support from health professionals. Breastfeeding periods lasted from 1.5 months to 4 years. Participants reported that breastfeeding increased the closeness between the mother and child and that this feeling of closeness tended to decrease after breastfeeding cessation.Conclusion:We offer data and analysis that can improve our understanding of the lived experiences of women undergoing the process of relactation or induced lactation and may help guide intervention strategies to support women in this situation.

Journal of Human Lactation, Ahead of Print.
Background:Induced lactation and relactation are the processes that enable breastfeeding in non-gestating mothers.Research aim:The aim of this study was to describe and interpret the challenges faced by mothers who undergo induced breastfeeding and relactation for adopted infants, infants born via surrogacy, and infants born to same-sex female partners.Methods:A qualitative study was performed using in-depth interviews conducted with Spanish women (N = 9) who had decided to undergo induced lactation or relactation. The data were collected between October 2014 and May 2017. The length of the study was due to the difficulty in locating and recruiting the sample. Interviews were transcribed and coded with the ATLAS.ti v.7.5.7 software. We performed a deductive thematic analysis, creating categories based on the interview questions, which we developed on the basis of previous literature about induced lactation and relactation.Results:Participants described the following challenges: the physical hardships of the process; breastfeeding problems; difficulty with accessing information about induced lactation or relactation; and lack of support from health professionals. Breastfeeding periods lasted from 1.5 months to 4 years. Participants reported that breastfeeding increased the closeness between the mother and child and that this feeling of closeness tended to decrease after breastfeeding cessation.Conclusion:We offer data and analysis that can improve our understanding of the lived experiences of women undergoing the process of relactation or induced lactation and may help guide intervention strategies to support women in this situation.