Journal of Human Lactation - online first articles

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.

Journal of Human Lactation, Ahead of Print.
Background:Chemerin and dermcidin, which have antimicrobial properties, are molecules that are also related to insulin resistance and inflammation.Research aims:The aims were to determine the amounts of chemerin and dermcidin in the milk and blood of mothers with gestational diabetes, and to compare the amounts of chemerin and dermcidin in the milk and blood of mothers with and without diabetes.Methods:This was a two-group nonrandomized longitudinal study with a convenience sampling of mothers without gestational diabetes (n = 27) and mothers with gestational diabetes (n = 26). Human milk and blood samples were obtained from these mothers during colostrum, transitional, and mature milk periods. The amount of chemerin and dermcidin in these samples was measured by enzyme-linked immunosorbent assay.Results:The presence of chemerin and dermcidin was first detected in human milk. The amounts of chemerin and dermcidin in the blood of all the mothers were greater in the colostrum period and lowest in the mature period. The amount of chemerin and dermcidin in the milk of all the mothers was greater than that in the blood. The amounts of chemerin and dermcidin were significantly increased in both blood and human milk within the gestational age samples.Conclusions:Chemerin and dermcidin may contribute to the protection of infants from infections during infancy. Increased amounts of these molecules found within the gestational diabetes group may also prevent adverse maternal and fetal outcomes.

Journal of Human Lactation, Ahead of Print.
Background:Fathers’ involvement has been identified as a significant predictor in maternal breastfeeding outcomes. Its benefits have been well-documented, but limited studies have examined its influencing factors.Research aim:To investigate factors influencing fathers’ involvement in their partners’ breastfeeding.Methods:A descriptive correlational design was used. Data were collected from 151 fathers from four obstetrics wards of a public hospital in Singapore from October 2016 to December 2016. Self-administered questionnaires were used to examine factors such as fathers’ knowledge and involvement in breastfeeding, attitudes towards breastfeeding, and perceived improvements of knowledge and attitudes for fathers’ involvement in breastfeeding on the discharge day of their partners’ and 2 weeks post-birth. Data were analyzed using IBMSPSS24.0.Results:Fathers’ involvement in their partners’ breastfeeding yielded a moderate to high mean score. The multiple linear regression analysis showed that five independent factors significantly influenced fathers’ involvement in their partners’ breastfeeding: (1) perceived approval of family members and friends in fathers’ breastfeeding involvement; (2) knowledge regarding breastfeeding and their involvement; (3) perceived behavioral control for fathers’ breastfeeding involvement; (4)marital relationship; and (5) perceived improvements of knowledge and attitudes 2 weeks post-birth.Conclusions:The study provided evidence on the significant factors that influenced fathers’ involvement in their partners’ breastfeeding, which can be used to guide healthcare professionals when providing appropriate support to facilitate fathers’ involvement. Future studies should continue to evaluate fathers’ involvement in breastfeeding longitudinally so that relevant support can be rendered.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
BackgroundMetabolic and hormonal disturbances are associated with sleep disturbances and delayed onset of lactogenesis II.Research AimsThe aim of this study was to measure sleep using wrist actigraphy during gestation weeks 22 and 32 to determine if sleep characteristics were associated with blood glucose, body mass index, gestational related disease, delayed onset of lactogenesis II, or work schedule.MethodsDemographic data were collected at study intake from primiparous women who wore a wrist actigraph during gestation weeks 22 (n = 50) and 32 (n = 44). Start and end sleep time, total nighttime sleep, sleep efficiency, wake after sleep onset, and sleep fragmentation were measured. Night to night variability was assessed with the root mean square of successive difference. Blood glucose levels, body mass index, and gestational disease data were abstracted from medical charts. Timing of lactogenesis II was determined by survey.ResultsBetween gestation week 22 and 32, sleep efficiency decreased and fragmentation increased (p < .05). During gestation week 32, blood glucose was negatively correlated with sleep duration, and positively related to fragmentation (p < .05). Women who experienced delayed lactogenesis II had lower sleep efficiency and greater fragmentation (p < .05), and greater night-to-night variability in sleep start and end time, efficiency, and duration during gestation week 32 (p < .05).ConclusionWomen with better sleep efficiency and more stable nightly sleep time are less likely to experience delayed onset of lactogenesis II. Interventions to improve sleep may improve maternal health and breastfeeding adequacy.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Low milk supply is frequently reported as a reason for exclusive breastfeeding cessation.Research aims:To determine the occurrence of, and the risk factors associated with, delayed onset of lactogenesis II among primiparas seen at a Baby-Friendly Hospital in Brazil.Method:We conducted a prospective longitudinal observational cohort study of 224 primiparas who had a singleton delivery. Data were first collected at the hospital. We assessed the onset of lactogenesis on day four postpartum, based on maternal reports of changes in breast fullness. Breastfeeding practices and Edinburgh Postnatal Depression Scale were evaluated on day seven postpartum. Using Poisson regression, we assessed significant factors associated with delayed onset of lactogenesis II.Results:Delayed lactogenesis II occurred in 18.8% (n = 42) of participants and was significantly associated with alcohol drinking during pregnancy (IRR = 2.710, 95% CI [1.469, 4.996]); Edinburgh Postnatal Depression Scale scores ≥ 10 (IRR = 2.092, 95% CI [1.118, 3.916]), and the age of the mother (IRR: 1.081, 95% CI [1.039, 1.125]).Conclusion:Postpartum depression and alcohol ingestion during pregnancy may be associated with lactogenesis II delay, but more research is needed to elucidate the directionality of these relationships. Older mothers are at risk of delayed lactogenesis II onset. The frequency of delayed lactogenesis in this population is similar to the rates seen in previous Latin America studies and much lower than the ranges seen in North America, possibly because of the low proportion of obesity and severe gestational diabetes in this sample.

Journal of Human Lactation, Ahead of Print.
Background:Low milk supply is frequently reported as a reason for exclusive breastfeeding cessation.Research aims:To determine the occurrence of, and the risk factors associated with, delayed onset of lactogenesis II among primiparas seen at a Baby-Friendly Hospital in Brazil.Method:We conducted a prospective longitudinal observational cohort study of 224 primiparas who had a singleton delivery. Data were first collected at the hospital. We assessed the onset of lactogenesis on day four postpartum, based on maternal reports of changes in breast fullness. Breastfeeding practices and Edinburgh Postnatal Depression Scale were evaluated on day seven postpartum. Using Poisson regression, we assessed significant factors associated with delayed onset of lactogenesis II.Results:Delayed lactogenesis II occurred in 18.8% (n = 42) of participants and was significantly associated with alcohol drinking during pregnancy (IRR = 2.710, 95% CI [1.469, 4.996]); Edinburgh Postnatal Depression Scale scores ≥ 10 (IRR = 2.092, 95% CI [1.118, 3.916]), and the age of the mother (IRR: 1.081, 95% CI [1.039, 1.125]).Conclusion:Postpartum depression and alcohol ingestion during pregnancy may be associated with lactogenesis II delay, but more research is needed to elucidate the directionality of these relationships. Older mothers are at risk of delayed lactogenesis II onset. The frequency of delayed lactogenesis in this population is similar to the rates seen in previous Latin America studies and much lower than the ranges seen in North America, possibly because of the low proportion of obesity and severe gestational diabetes in this sample.

Journal of Human Lactation, Ahead of Print.