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Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Identifying those at risk for suboptimal breastfeeding outcomes remains critical for improving maternal and child health. Prenatal breastfeeding motivation may be a key predictor useful for identifying those who would benefit from additional breastfeeding support.Research Aims:To (1) validate a breastfeeding-specific adaptation of the Treatment Self-Regulation Questionnaire (TSRQ-BF); and (2) determine if breastfeeding motivation predicts prenatal breastfeeding intentions and early breastfeeding outcomes.Methods:Participants in their third trimester of pregnancy (N = 150) completed several instruments, including the TSRQ-BF and infant feeding intention, and could opt to participate in an assessment of early breastfeeding outcomes (by medical record review). TSRQ-BF subscales were derived from factor analysis, and multivariable regression was used to evaluate the association between TSRQ-BF subscale scores and breastfeeding intention and outcomes during the birth hospitalization.Results:Autonomous (related to personal values/beliefs regarding self) and Autonomous-Baby (values/benefits for the infant) subscale scores were positively associated with intended exclusivity (aOR [95% CI]: 2.22 [1.57, 3.30], 4.94 [2.49, 11.07], respectively) while higher scores on these subscales predicted longer time to planned cessation (aHR [95% CI]: 0.72 [0.61, 0.84],0.52 [0.34, 0.81]). Higher Amotivation (lack of motivation) scores were negatively associated with intended exclusivity (0.45 [0.26, 0.74]). Higher scores on Autonomous, Autonomous-Baby, and Controlled (avoidance of negative feelings/punishment or gaining reward) subscales were associated with greater odds of hospital exclusivity (aOR [95% CI]: 3.39 [1.75, 8.00], 3.44 [1.66, 9.04] and 6.05 [1.88, 29.04]) and lower odds of 2-day formula supplementation (aOR [95% CI]: 0.31 [0.14, 0.59],0.28 [0.11, 0.59], 0.19 [0.04, 0.62]).Conclusions:The TSRQ-BF predicted breastfeeding intent and outcomes, and may be helpful for identifying patients at risk for suboptimal breastfeeding outcomes before delivery.

Journal of Human Lactation, Ahead of Print.
Introduction:Many mothers have the goal to breastfeed. However, more than 50% will have breastfeeding difficulty by the 3rd day of life. Mothers who are unable to meet their breastfeeding goals are at higher risk for anxiety, depression, embarrassment, and guilt. Those who stop breastfeeding need support and help resolving these feelings. This case study aims to describe one woman’s difficulty with mental health surrounding breastfeeding, her decision to bottle feed, and her successful transition back to direct breastfeeding.Main Issue:Barriers to the participant’s success with breastfeeding were pre-existing history of depression/anxiety, forceps delivery, uncontrolled perineal pain, infant physical trauma, and nipple/flow confusion. The decision to discontinue direct breastfeeding and start bottle feeding came after 2 months of anxiety, frustration, and persistence.Management:The participant followed her healthcare team’s recommendations of triple feeding, lactation support groups, pediatric chiropractic adjustments, and prescribed galactagogues. After 2 months of exhaustion and deliberation, she made the difficult decision to stop breastfeeding for nutritional benefits and switched to breastfeeding only for her infant’s pleasure and comfort. Lowered expectations allowed the dyad to heal and her son to transition to nearly exclusive breastfeeding at 4 months of life.Conclusion:Clinicians must be aware of the delicate balance between promoting breastfeeding for its nutritional value and health benefits and supporting a struggling mother with mental health needs.

Journal of Human Lactation, Ahead of Print.
Background:The retention of human milk nutrients in gastric tubes used to feed premature infants is a challenge to be overcome.Research Aims:To evaluate (1) the performance of six homogenizers (mixing processor, piston valve, ultrasonic bath, ultraturrax, stirring mixer, and ultrasound probe) for the fat retention reduction in gastric tubes; (2) the influence of the best homogenization conditions on the fatty acid and protein profiles of human milk; and (3) the cost/benefit ratio for the inclusion of homogenization as a new step in human milk processing.Methods:The influence of different levels and times of homogenization on reducing fat retention of human milk in probes was evaluated in this comparative prospective cross-sectional study. After homogenization, human milk flowed through a gavage and infusion pump apparatus used for feeding. Fat content was quantified before and after feeding. The techniques that reduced fat globule sizes and/or promoted a lower percentage of fat holding were evaluated for efficiency, variations in the fatty acid and protein profiles, and energy density and operating costs.Results:Homogenization led to a reduction in fat retention in feeding probes. The mixer processor and the ultrasound probe reduced fat retention by 99.23% (SD = 0.07) and 99.95% (SD = 0.02), respectively, and did not negatively influence fatty acid and protein profiles. The mixer processor demonstrated low energy density and low cost for human milk processing.Conclusion:Homogenization promoted reduced fat retention in the feed probe and could help maintain fat nutrients of human milk during enteral feeding.

Journal of Human Lactation, Ahead of Print.
Background:Human milk contains antibodies against Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) following Coronavirus Disease 2019 (COVID-19). These antibodies may serve as protection against COVID-19 in infants. However, the evolution of these human milk antibodies over time is unclear.Research Aim:To elucidate the evolution of immunoglobulin A (IgA) against SARS-CoV-2 in human milk after a SARS-CoV-2 infection.Methods:This longitudinal follow-up study included lactating mothers (N = 24) who had participated in the COVID MILK study. To assess the evolution of SARS-CoV-2 antibodies, serum and human milk samples were collected 14–143 days after the onset of clinical symptoms related to COVID-19. Enzyme-Linked ImmunoSorbent Assay was used to detect antibodies against the ectodomain of the SARS-CoV-2 spike protein.Results:SARS-CoV-2 antibodies remain present up to 5 months (143 days) in human milk after onset of COVID-19 symptoms. Overall, SARS-CoV-2 IgA in human milk seems to gradually decrease over time.Conclusion:Human milk from SARS-CoV-2 convalescent lactating mothers contains specific IgA antibodies against SARS-CoV-2 spike protein up to at least 5 months post-infection. Passive viral immunity can be transferred via human milk and may serve as protection for infants against COVID-19. Dutch Trial Register on May 1st, 2020, number: NL 8575, URL: https://www.trialregister.nl/trial/8575.

Sunday 1 August through Saturday 7 August is World Breastfeeding Week! Show your support by changing your profile frame on Facebook. How to Add a Profile Frame on Desktop  UPDATE: Skip the steps below and add the frame easily by clicking this link: https://www.facebook.com/profilepicframes/?selected_overlay_id=520314699052088 Navigate to your profile page by clicking your name on top […]

Journal of Human Lactation, Ahead of Print.
BackgroundThe Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic has infected over 127 million people worldwide, with almost 2.8 million deaths at the time of writing. Since no lactating individuals were included in initial trials of vaccine safety and efficacy, research on SARS-CoV-2 vaccination in lactating women and the potential transmission of passive immunity to the infant through mother’s milk is needed to guide patients, clinicians, and policy makers on whether to recommend immunization during the worldwide effort to curb the spread of this virus.Research Aims(1) To determine whether SARS-CoV-2 specific immunoglobins are found in human milk after vaccination, and (2) to characterize the time course and types of immunoglobulins present.MethodsA longitudinal cohort study of lactating women (N = 7) who planned to receive both doses of the Pfizer-BioNTech or Moderna SARS-CoV-2 vaccine between December 2020 and January 2021 provided milk samples. These were collected pre-vaccination and at 11 additional timepoints, with the last sample at 14 days after the second dose of vaccine. Samples were analyzed for levels of SARS-CoV-2 specific immunoglobulins A and G (IgA and IgG).ResultsWe observed significantly elevated levels of SARS-CoV-2 specific IgG and IgA antibodies in human milk beginning approximately 7 days after the initial vaccine dose, with an IgG-dominant response.ConclusionsMaternal vaccination results in SARS-CoV-2 specific immunoglobulins in human milk that may be protective for infants.

Mothers with diabetes are less likely to achieve successful breastfeeding. Antenatal breastmilk expression (ABE) may facilitate earlier breastfeeding, but feasibility of introducing ABE and its acceptance amon...

The probability of not breastfeeding within the first hour after delivery (timely initiation of breastfeeding) is particularly pronounced in sub-Saharan Africa. In this study, we examined the maternal and chil...

The Iowa Infant Feeding Attitude Scale (IIFAS) is a widely used tool to assess attitudes towards infant feeding. Attitudes towards breastfeeding are one of the main influencing factors of feeding choice and br...

As a lactation professional, you know that successful breastfeeding or chestfeeding rarely happens in isolation. Parents providing human milk to their babies need the support of healthcare providers, partners and extended families, employers, and wider communities to thrive.  Every person a parent contacts forms a link in the chain. The more solid the links, the […]

Early breastfeeding cessation is a societal concern given its importance to the health of mother and child. More effective interventions are needed to increase breastfeeding duration. Prior to developing such ...

The prevalence of early initiation of breastfeeding and exclusive breastfeeding (EBF) at 6 months remain low in the Philippines. To help meet the 90% early initiation of breastfeeding target and to improve inf...

Data indicates that as many as 10 to 15 percent of lactating parents use some kind of cannabis product while they are breastfeeding or chestfeeding. Chances are, this includes some of the parents you care for. When it comes to the safety of cannabis use during lactation, what do we really know for sure? At […]

Journal of Human Lactation, Ahead of Print.
BackgroundBreast engorgement and breast pain are the most common reasons for the early cessation of exclusive breastfeeding by mothers.Research Aims(1) To examine the influence of breastfeeding educational interventions on breast engorgement, breast pain, and exclusive breastfeeding; and (2) to identify effective components for implementing breastfeeding programs.MethodsRandomized controlled trials of breastfeeding educational interventions were searched using five English and five Chinese databases. Eligible studies were independently evaluated for methodological quality, and data were extracted by two investigators. In total, 22 trials were identified, and 3,681 participants were included. A random-effects model was used to pool the results, and a subgroup analysis and meta-regression analysis were conducted.ResultsBreastfeeding education had a significant influence on reducing breast engorgement at postpartum 3 days (odds ratio [OR]: 0.27, 95% CI [0.15, 0.48] p < .001), 4 days (OR: 0.16, 95% CI [0.11, 0.22], p < .001), and 5–7 days (OR: 0.24, 95% CI [0.08, 0.74], p = .013) and breast pain (standardized mean difference: −1.33, 95% CI [−2.26, −0.40]) at postpartum 4–14 days. Participants who received interventions had higher odds of exclusive breastfeeding. Breastfeeding educational interventions provided through lecture combined with skills practical effectively reduced breast engorgement (OR: 0.21; 95% CI [0.15, 0.28]; p = .001) and improved exclusive breastfeeding at postpartum 1–6 weeks (OR: 2.16; 95% CI [1.65, 2.83]; p = .001).ConclusionsBreastfeeding educational interventions have been effective in reducing breast engorgement, breast pain, and improved exclusive breastfeeding. A combination of knowledge and skill-based education has been beneficial for sustaining exclusive breastfeeding by mothers.

Timely initiation of breastfeeding is feeding of breast milk within one hour of birth, however, three in five babies were not breastfed in the first hour of birth globally. There is evidence that cesarean sect...

France has one of the lowest rates in the world regarding breastfeeding initiation and duration. Few studies have explored breastfeeding practices in France since the middle of the twentieth century, or follow...

Only one-third of Canadian infants are exclusively breastfed for the first 6 months of life as recommended. Skilled lactation support in the early postpartum period is one strategy for improving breastfeeding ...

Preeclampsia is a global health problem and it is the main cause of maternal and perinatal morbidity and mortality. Breastfeeding has been reported to be associated with lower postpartum blood pressure in wome...

to reduce spitTING up, keep baby upright for 20-30 min. after feeds

Spitting up can trigger a host of worries in new parents, some related to their role in this behavior and others to do with baby’s growth and health.

• Was it something I did?

• Was it something I ate?

• Will my baby’s weight gain suffer with the loss of so much milk?

• Does my baby have reflux disease?

Along with these concerns, parents often ask themselves “What should I do next?” Here are the answers to these and other questions. 

Is Spitting Up Ever Normal?

Yes, because most young babies (between 50% and 70%) spit up at least some of the time.1 Why? In the early months, the sphincter muscle that keeps the milk in the baby’s stomach has low tone and relaxes often. On average, several times each day a baby’s stomach contents wash back into her esophagus. Known as reflux, this is normal in both children and adults.  

Normal reflux becomes spitting up when the baby’s stomach contents make it all the way up her esophagus and out of her mouth. Spitting up peaks between 3 and 5 months, occurring less and less often as the digestive system matures and baby spends more time upright. By 12 months, only 4% to 10% of babies spit up.2  

Vomiting and spitting up are not the same. Usually, babies vomit when they are ill and spit up (or “spill”) when they’re not. Often, spitting up happens after feeding. Sometimes babies bring up a little milk and sometimes a lot. Even if it looks like much milk is lost, spitting up is not a cause for concern when the baby is gaining weight as expected and feeding well. Sometimes called “happy spitters,” think of spitting up in these babies as a temporary inconvenience that will resolve on its own over time. Some refer to this as a laundry problem, not a medical problem. See the later “Strategies” section for tips to minimize spitting up. 

Can Overfeeding Cause Spitting Up?

Sometimes yes. Babies who directly nurse are less likely to overfeed than babies who are bottle-fed, no matter what’s in the bottle.3 But overfeeding can happen with direct nursing, too, when parents produce much more milk than the baby takes (oversupply, aka hyperlactation) and especially when they regularly coax their babies to keep nursing after they are done.4 Babies who are fast nursers can sometimes take all they need in just 5 minutes. 

Nursing babies are less likely to overfeed and spit up in part because on average they consume less milk per feed than they do during a bottle-feeding. Why? During nursing, milk flow is fast during milk ejections (parents average five per feed, even though most don’t feel them all) and slower in between. These periods of slower milk flow between milk ejections gives babies time to realize they’re full and stop nursing before they overfeed.  

Unless paced bottle-feeding is used (described HERE), which makes bottle-feeding more like nursing, during bottle-feeding, milk flow from the bottle is consistently fast. When babies eat too fast (just like adults), they are more likely to overeat. Regular overfeeding doesn’t just trigger more spitting up, it also increases risk of child overweight and obesity.3 See the later “Strategies” section for tips to prevent overfeeding. 

Can Something I Ate Cause My Baby to Spit Up?

Many parents worry about this, but although it is possible, it is unlikely. An allergy or hypersensitivity to something in the nursing parent’s diet that passes into the milk occurs in only about 1% to 5% of exclusively nursing babies. 5,6 When it happens, the most common culprit is dairy, and in addition to spitting up, there are almost always other physical symptoms, such as a skin rash, congestion, or frothy, bloody, or mucusy stools. An allergy or sensitivity sometimes mimics symptoms of GERD (next section), as it may also cause irritation of the esophagus.7  

An exclusively nursing parent can rule in or out allergy to cow’s milk by avoiding all forms of dairy, including milk, yogurt, ice cream, cheese, and butter, plus anything containing casein and whey.8 It may take up to 4 weeks to see a significant improvement in the baby’s symptoms,7 but there is often some improvement within a few days. If the baby is also receiving formula (most are cow-milk based), use a hypoallergenic type until allergy is ruled out. 

Does Spitting Up Mean My Baby Has GERD?

When the normal reflux described in the second paragraph causes damage to the lining of the esophagus, this is called gastroesophageal reflux disease (GERD). A baby with GERD may or may not spit up, because damage to the esophagus can occur even if the stomach contents don’t make it all the way to the baby’s mouth (called “silent reflux”).  

Nursing with baby’s head higher than bottom can help

GERD can cause congestion, coughing, and other respiratory problems. The baby’s irritated esophagus may make feeding painful.9 Some upsetting behaviors linked to GERD include irritability, poor weight gain, back arching and head turning, and feeding distress.9  

GERD symptoms are sometimes attributed to “colic,”10 a term used to describe regular and unexplained periods of crying in babies younger than 3 to 4 months. If GERD is suspected, it’s time for baby to see her healthcare provider. 

 A treatment sometimes suggested for formula-fed babies with GERD is adding cereal or starch to formula to thicken it as a way to reduce the number of reflux episodes.1 Also, pre-thickened formulas are sold for babies with GERD.  

But thickening milk and giving solids before 6 months are not recommended for nursing babies with GERD. No evidence supports thickening milk for nursing babies11 and the American Academy of Pediatrics does not recommend it.1 See the next-to-last section “Will Switching to Formula Help” for research comparing the effects of direct nursing, formula-feeding, and solids on reflux, spitting up, and GERD. 

Are There Other Physical Causes of Spitting Up?

Some speculate that tongue-tie contributes to spitting up, but research does not yet confirm or refute this possibility.  

If spitting up happens more and more often and becomes projectile (milk shooting a distance from baby), it’s time for baby to be evaluated by her healthcare provider. Some babies with these symptoms have a condition called pyloric stenosis that can hinder baby’s weight gain and growth and needs immediate treatment.  

Strategies That Minimize Spitting Up

If baby is spitting up for any reason, these basic strategies may help. A 2013 study of babies with GERD12 found they improved symptoms by 50%.

When wiping baby, roll her on her left side rather than lifting her legs

• Positional therapy means keeping baby’s head above bottom as much as possible. Nurse with baby’s head higher than her bottom. After feeds, keep baby upright for 20 to 30 minutes in arms or in an upright baby carrier.

• When baby is awake and horizontal, lay her on her left side or tummy. The baby’s esophagus connects to the stomach near her back, and lying tummy down triggers less reflux than back-lying. 

• Offer smaller, more frequent feeds. A nursing baby between 1 and 6 months needs on average about 25 oz. (750 mL) every 24 hours to grow and thrive. Taking less milk more often means less milk in the stomach to wash back into the esophagus and less time with an empty high-acid-content stomach. If oversupply is an issue, avoid prolonging feeds if baby seems done. If baby is bottle-feeding, pace them as described in THIS free handout.

• Avoid putting baby in a car seat when not in a moving car, as this position increases reflux episodes.13

If the baby who spits up also has a rash, congestion, or unusual stools, to rule out allergy, try eliminating dairy for a few weeks to see if that makes a difference. 

Will Switching to Formula Help?

Some parents wonder if nursing is the cause of their baby’s spitting up. Some healthcare providers suggest weaning babies with GERD to formula under the mistaken assumption that it will help.  

avoid car seats unless baby is in a moving car

Unfortunately, giving formula is linked to more reflux episodes, more spitting up and can make GERD symptoms worse. Direct nursing, on the other hand, reduces reflux episodes. In 2017, a U.S. study using data from more than 2,800 babies14 compared how feeding method affected reflux episodes. Some babies directly nursed, some were formula-fed, some did both, and some ate solids. They concluded that feeding solids did not reduce reflux in nursing babies and that formula- and bottle-feeding increased the episodes of reflux.  

In Belgium, researchers found that exclusively nursing babies spit up less than nursing babies who also received formula.2 After examining medical records, Italian pediatricians15 found that nursing babies stop spitting up earlier than babies fed formula.  

Takeaways

For the vast majority of babies who spit up, this is just a normal—if messy—part of infancy that will gradually stop as they mature. But whether a baby’s spitting up is normal or it is triggered by overfeeding, allergy, GERD, or other causes, try the basic strategies described earlier. Anything that reduces laundry loads and house cleaning for new families is a definite plus.

References

1  Lightdale, J. R., Gremse, D. A., Section on Gastroenterology, H., et al. (2013). Gastroesophageal reflux: Management guidance for the pediatrician. Pediatrics, 131(5), e1684-1695.  

2.  Hegar, B., Dewanti, N. R., Kadim, M., et al. (2009). Natural evolution of regurgitation in healthy infants. Acta Paediatrica, 98(7), 1189-1193.  

3  Azad, M. B., Vehling, L., Chan, D., et al. (2018). Infant feeding and weight gain: Separating breast milk from breastfeeding and formula from food. Pediatrics, 142(4). 

4  Johnson, H. M., Eglash, A., Mitchell, K. B., et al. (2020). ABM clinical protocol #32: Management of hyperlactation. Breastfeeding Medicine, 15(3), 129-134. 

5  Munblit, D., Perkin, M. R., Palmer, D. J., et al. (2020). Assessment of evidence about common infant symptoms and cow’s milk allergy. JAMA Pediatrics, 174(6):599-608. 

6  Kvenshagen, B., Halvorsen, R., & Jacobsen, M. (2008). Adverse reactions to milk in infants. Acta Paediatrica, 97(2), 196-200. 

7  Salvatore, S., & Vandenplas, Y. (2002). Gastroesophageal reflux and cow milk allergy: Is there a link? Pediatrics, 110(5), 972-984. 

8  Heine, R. G. (2008). Allergic gastrointestinal motility disorders in infancy and early childhood. Pediatric Allergy and Immunology, 19(5), 383-391. 

9  Semeniuk, J., & Kaczmarski, M. (2008). Acid gastroesophageal reflux and intensity of symptoms in children with gastroesophageal reflux disease. Comparison of primary gastroesophageal reflux and gastroesophageal reflux secondary to food allergy. Advances in Medical Sciences, 53(2), 293-299. 

10  Vandenplas, Y., Badriul, H., Verghote, M., et al. (2004). Oesophageal pH monitoring and reflux oesophagitis in irritable infants. European Journal of Pediatrics, 163(6), 300-304. 

11  Kwok, T. C., Ojha, S., & Dorling, J. (2017). Feed thickener for infants up to six months of age with gastro-oesophageal reflux. Cochrane Database of Systematic Reviews, 12, CD003211. doi:10.1002/14651858.CD003211.pub2. 

12  Hegar, B., Satari, D. H., Sjarif, D. R., et al. (2013). Regurgitation and gastroesophageal reflux disease in six to nine months old indonesian infants. Pediatric Gastroenterology, Hepatology & Nutrition, 16(4), 240-247.   

13  Carroll, A. E., Garrison, M. M., & Christakis, D. A. (2002). A systematic review of nonpharmacological and nonsurgical therapies for gastroesophageal reflux in infants. Archives of Pediatrics and Adolescent Medicine, 156(2), 109-113. 

14  Chen, P. L., Soto-Ramirez, N., Zhang, H., et al. (2017). Association between infant feeding modes and gastroesophageal reflux: A repeated measurement analysis of the Infant Feeding Practices Study II. Journal of Human Lactation, 33(2), 267- 277. 

15  Campanozzi, A., Boccia, G., Pensabene, L., et al. (2009). Prevalence and natural history of gastroesophageal reflux: Pediatric prospective survey. Pediatrics, 123(3), 779-783.