Journal of Human Lactation - online first articles

Journal of Human Lactation, Ahead of Print.
Background:Women during the postpartum period undergo significant changes which affect body image, eating behaviors, and, potentially, breastfeeding. There is limited research about relationships among these variables, particularly related to breastfeeding experiences and self-efficacy.Research Aims:To determine: (1) the associations between eating disorder symptoms and body image, breastfeeding self-efficacy, and breastfeeding experiences; and (2) the differences in body image, breastfeeding self-efficacy, breastfeeding experiences, and breastfeeding status of postpartum women with and without clinically significant eating disorder symptoms.Methods:A secondary data analysis using a 2-group correlational, cross-sectional online survey design was used. Participants with infants 2–6 months old who had breastfed their infant at least once (N = 204) were recruited nationally to complete a cross-sectional survey assessing breastfeeding and postpartum physical and mental health using validated measures. Linear and logistic regression evaluated differences between participants with and without eating disorder symptoms regarding their body image, breastfeeding experience and self-efficacy, and breastfeeding status (continued vs. discontinued) at 2 months postpartum.Results:Clinical eating disorder symptoms were reported by 9.8% (n = 20). Participants with clinical eating disorder symptoms reported lower appearance evaluations (B = -0.53, 95% CI [-0.93, -0.14]) and body image satisfaction (B = -0.55, 95% CI [-0.87, -0.23]); reduced odds of breastfeeding at 2 months postpartum (AOR = 0.15, 95% CI [0.04, 0.56]); and lower breastfeeding self-efficacy (B = -7.70, 95% CI [-14.82, -0.58] relative to participants without clinical symptoms. No differences between groups were observed for breastfeeding experiences.Conclusions:Participants with clinically significant eating disorder symptoms are at risk for early breastfeeding discontinuation and lower breastfeeding self-efficacy. Our findings have implications for future research and clinical care practices, including screening for body image concerns and eating disorder symptoms and supporting breastfeeding self-efficacy.

Journal of Human Lactation, Ahead of Print.
Background:No consensus on the definitions of nipple trauma has been reported. Thus, different individuals assess identical events inconsistently.Research Aims:To establish clear definitions for the seven signs of nipple trauma related to breastfeeding—erythema, swelling, scabbing, blistering, fissure, purpura, and peeling—and to reach consensus among multiple specialists.Methods:We implemented a longitudinal, prospective survey design using a 3-step Delphi method. In the first survey we targeted specialists in breastfeeding, dermatology, and cosmetics, and we presented images as representative cases during a set of semi-structured interviews. In the second and third surveys, we questioned midwives who were certified as “advanced midwives” through mail, using a questionnaire prepared based on the results of the first survey. The agreement criteria of this study were as follows: (1) a median of 2.0 or below; (2) an interquartile range of 1.0 or below; and (3) at least 51% showing responses of either “strongly agree” or “agree.”Results:Based on the responses of the 42 experts, we reached a consensus on 48 items: eight related to erythema, 10 to swelling, nine to scabbing, seven to blistering, seven to fissure, four to purpura, and three to peeling. We then classified these items based on the condition or possible mechanism of the wound. Finally, we developed an observation tool: “seven signs of nipple trauma associated with breastfeeding,” along with images.Conclusions:Application of this tool for breastfeeding support could improve objectivity in observing and evaluating nipple trauma.

Journal of Human Lactation, Ahead of Print.
Background:Developing a simple quantitative tool for mastitis diagnosis is essential. The Ion-Selective Electrode for sodium has been reported to reliably measure sodium concentrations in human milk.Research Aim:To determine whether an Ion-Selective Electrode measurement of sodium:potassium ratios could serve as a diagnostic tool for mastitis and, if so, to determine the diagnostic cut-off value.Methods:A total of 107 milk samples, including 55 from milk bank donors and 52 from participants with mastitis, were studied. The sodium:potassium ratios were determined in 33 samples (without mastitis n = 15; with mastitis n = 18) by the Ion-Selective Electrode and ion chromatography. The remaining 74 samples (donor milk n = 40; participants with mastitis n = 34) were analyzed by Ion-Selective Electrode only. Values were averaged over three measurements for each method.Results:The median postpartum months of donors and participants with mastitis were 2 and 3 months, respectively. The mean (SD) sodium:potassium ratios without and with mastitis were 0.5 (0.1) and 1.7 (1.2), respectively. A positive correlation existed between sodium:potassium ratios obtained from the two methods (r = 0.98). Area under the curve values were 0.951 (95% CI [0.904, 0.986]) for the Ion-Selective Electrode (N = 107) and 0.978 (95% CI [0.926, 1.000]) for the ion chromatography (n = 33) methods. The optimal cut-off value for the Ion-Selective Electrode method was 0.60, with 86.5% sensitivity and 92.7% specificity.Conclusions:The Ion-Selective Electrode was sufficiently accurate for the diagnosis of mastitis. Cohort studies are needed to explore the relationship between sodium:potassium ratios and clinical outcomes.

Journal of Human Lactation, Ahead of Print.
Background:Breastfeeding offers the best nutrition during the first months of life. Scholars have identified a dose-response association between breastfeeding duration and reduced risk for child morbidity and mortality. In upper-middle-income countries, including Mexico, maternal employment has been negatively associated with breastfeeding duration. Despite increasing numbers of women entering the workforce and disproportionately participating in the informal sector, where they are un-entitled to paid maternity leave, little is known about how these factors may affect breastfeeding practices.Research Aim:To determine whether household income moderated the association between maternal employment status (defined as unemployed, formal, and informal full- and part-time employed) and any breastfeeding for ≥ 6 months.Methods:We conducted a cross-sectional study using retrospective secondary data from the 2018–2019 Mexican Health and Nutrition Survey. The analytic sample included data about 2,156 children aged 6–36 months. We computed logistic regression models stratified by household income.Results:The association between maternal employment and breastfeeding duration varied by household income. Compared to unemployed women, among lower-income households, children were less likely to be breastfed for ≥ 6 months when the participants was part-time informally employed (AOR = 0.30, 95% CI [0.13, 0.69]). Among higher-income households, children were less likely to be breastfed for ≥ 6 months when the participants was full-time formally employed (AOR = 0.52, 95% CI [0.30, 0.88]).Conclusions:To increase breastfeeding duration, stakeholders need to continue strengthening and enforcing policies among formally employed women, and strategies are urgently needed to support women in the informal sector, particularly those in lower-income households.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Only 61% of Malawian women exclusively breastfeed to the recommended 6 months. Paternal support is predictive of exclusive breastfeeding, and significantly related to paternal breastfeeding self-efficacy, defined as fathers’ confidence in their ability to assist mothers with breastfeeding.Research Aims:To (1) examine the psychometric properties of the Paternal Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) in Malawian fathers, including internal consistency reliability, test-retest reliability, construct validity using Confirmatory Factor Analysis (CFA), and convergent validity; and (2) assess the relationship between the BSES-SF and paternal demographic and health factors.Methods:A cross-sectional study was conducted at a maternity hospital in Lilongwe, Malawi, and 180 fathers whose partners had delivered a singleton infant were included. Participants completed the Breastfeeding Self-Efficacy Scale and Quality of Life with confirmatory factor analysis performed to assess the construct validity. The internal consistency reliability and test-retest reliability were evaluated using Cronbach’s alpha coefficient and intra-class correlations. Convergent validity was also assessed.Results:A unidimensional factorial structure of the Malawian Paternal BSES-SF was identified using confirmatory factor analysis. The scale had an excellent Cronbach’s alpha of .90 and a test-retest reliability of .93. Participants’ breastfeeding self-efficacy was significantly correlated with the Quality of Life domains of psychological health (r = .23; p < .01), social relationships (r = .28; p < .001), and environmental health (r = .30; p < .001). Participants who were older, married, and with ≥ two children had significantly higher breastfeeding self-efficacy and were more confident in their ability to support their partner’s breastfeeding.Conclusion:The Paternal Breastfeeding Self-Efficacy Scale-Short Form was a valid and reliable measure to assess fathers’ confidence in their ability to assist mothers with breastfeeding in Malawi.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:Previous research examined effects of human milk on the infant gut microbiota, but little attention has been given to the microbiota of lactating women.Research Aim:To determine associations between exclusive human milk feeding and gut microbiota characteristics in mothers and infants at 6-weeks postpartum.Methods:A sample of mother–infant dyads (N = 24) provided fecal samples and questionnaire responses at 6-weeks postpartum as part of the Pregnancy, EAting & POstpartum Diapers study. Deoxyribonucleic acid was extracted from stool samples, followed by (V4) 16S ribosomal ribonucleic acid gene amplicon sequencing. Alpha and beta diversity, in addition to taxa differences, were compared by human milk exposure status, exclusive versus non-exclusive. A subset of dyads (those exclusively fed human milk; n = 14) was analyzed for shared bifidobacterial species using polymerase chain reaction.Results:Alpha diversity was significantly lower in exclusively human milk-fed infants. Maternal lactation status (exclusive vs. partial) and Shannon diversity were associated in univariate analysis but were no longer associated in multivariable regression including body mass index category in the model. Beta diversity (Sorensen dissimilarity) of fecal samples from women and infants was significantly associated with human milk feeding. Of six infants with Bifidobacterium longum subspecies longum in their fecal samples, all their mothers shared the same species.Conclusion:Maternal gut microbiotas differ by lactation status, a relationship potentially confounded by body mass index category. Further research is needed to identify whether lactation directly influences the maternal gut microbiota, which may be another mechanism by which lactation influences health.

Journal of Human Lactation, Ahead of Print.

Journal of Human Lactation, Ahead of Print.
Background:The Baby-Friendly Hospital Initiative represents a global effort to support breastfeeding. Commitment to this program has been associated with the longer duration and exclusivity of breastfeeding and improvements in hospital practices. Further, healthcare professionals’ breastfeeding attitudes have been associated with the ability to provide professional support for breastfeeding.Research Aims:To determine healthcare professionals’ breastfeeding attitudes and hospital practices before and after the implementation of the Baby-Friendly Hospital Initiative.Methods:Using a quasi-experimental pretest–posttest study design, healthcare professionals (N = 131) from the single hospital labor and delivery, maternity care, and neonatal intensive care were recruited before and after the Baby-Friendly Hospital Initiative intervention during 2017 and 2019. Breastfeeding attitudes with the validated Breastfeeding Attitude Questionnaire, breastfeeding-related hospital practices, and background characteristics were collected.Results:The healthcare professionals’ breastfeeding attitude scores increased significantly after the implementation of the Baby-Friendly Hospital Initiative, difference = 0.16, (95% CI [0.13, 0.19]) and became breastfeeding favorable among all professional groups in each study unit. Positive changes in breastfeeding-supportive hospital practices were achieved. The infants had significantly more frequent immediate and uninterrupted skin-to-skin contact with their mothers. The rate of early breastfeeding, as well as the number of exclusively breastfed infants, increased.Conclusions:After the Baby-Friendly Hospital Initiative and Baby-Friendly Hospital Initiative for neonatal wards (Neo-BFHI) interventions were concluded, we found significant improvements in the breastfeeding attitudes of healthcare professionals and in breastfeeding-related care practices.This RCT was registered (0307-0041) with ClinicalTrials.gov on 03/03/2017.

Journal of Human Lactation, Ahead of Print.
Background:Efforts to provide accessible and effective infant feeding support are advancing to set up new families to meeting their goals. However, data continue to be limited for understanding how inpatient postpartum support and experiences contribute to exclusive breastfeeding during hospitalization.Research Aims:To explore postnatal unit experiences including skin-to-skin contact, overnight support, rooming-in, responsive clinicians, and understandable communication that correlate with early infant feeding outcomes among a sample of mothers who intended to breastfeed.Methods:This was a prospective cross-sectional survey study. Through secure online survey, participants submitted (N = 2,401) responses from November 2016 to May 2017 about their experiences with maternity healthcare and offered thoughts on the postnatal unit environment. Descriptive statistics were used to examine distributions of maternal characteristics, postpartum experience, and birthing facility characteristics.Results:Exclusive breastfeeding was positively correlated with the following postnatal unit experiences: mother did not ask that her infant be taken out of the postnatal unit room; infant staying in postnatal unit room except for treatment(s); mother got help from clinical staff when needed after pressing the call button; and nurse, midwife, and/or doctor always explained information to mother in ways that they understood.Conclusion:Postnatal unit experiences associated with exclusive breastfeeding during postpartum hospitalization were rooming in; parents who did not ask for their infant to be taken out of the unit room; whether mothers received timely help from clinical staff; and information was explained in a way they could understand.

Journal of Human Lactation, Ahead of Print.
Marina Ferreira Rea is a Brazilian medical doctor. She has a masters and a doctorate degree in public health from the University of São Paulo (USP). She specialized in breastfeeding at Wellstart International, and completed post-doctoral research at Columbia University, New York, USA, focusing on working women and breastfeeding. She was a researcher at the Health Institute at Columbia University in New York, the Center for Population and Family Health, and at the postgraduate studies, Nutrition in Public Health, University of São Paulo, where she advised many students and published many articles and books (a few selected below). She was a Coordinator of International Breastfeeding Actions at the World Health Organization (Geneva), in the early 1990s, when actions like the Baby-Friendly Hospital Initiative, breastfeeding counseling, and other courses were started. During this same period, the World Alliance for Breastfeeding Action (WABA) and World Breastfeeding Week were initiated. In 1981 she participated in the launching of the International Code of Marketing of Breastmilk Substitutes. Marina Rea is a member of the International Baby Food Action Network and its Latin American policy committee, and is the founder of the International Baby Food Action Network (IBFAN) Brazil group. Since 2017, she has been a member of the IBFAN Global Council. She is now retired but continues to volunteer as an IBFAN member. She has two daughters and four grandchildren. A more detailed curriculum vitae in Portuguese can be found here: http://lattes.cnpq.br/8193850878281835 (MR = Marina Rea; MA = Maryse Arendt)

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.

Journal of Human Lactation, Ahead of Print.
Background:Human milk is the optimal food for newborns. Choices to feed preterm infants in neonatal intensive care units are mother’s milk, donor milk, or formula. Preterm infants have better tolerance for human milk, but the lower caloric density of donor milk might not meet preterm infant growth needs. Preterm infants have higher protein and energy requirements with a limited stomach capacity. Therefore, there is a need for human milk with increased nutrient density.Research Aim:To concentrate donor milk to have a higher caloric and protein density while avoiding side effects of high osmolality by precipitating lactose at low temperatures.Methods:We investigated the results of volume reduction and lactose removal processes on the lactose, protein, osmolality, and viscosity of human milk. Donor milk was obtained from WakeMed Mothers’ Milk Bank. Homogenization and evaporative condensation were applied to samples (N = 36) before they were stored frozen overnight, followed by refrigerated centrifugation for lactose removal at 0 °C. Supernatants were separated and compared to the composition of controls.Results:A significant reduction of lactose (SW = -262, p < .0001) and osmolality (SW = -211.5 p < .01) was achieved in the concentrated milk without a significant protein loss from centrifugation (SW = -44.5, p = .49). A 30%–40% volume reduction is within the American Academy of Pediatrics recommended osmolality for infant feeding.Conclusion:Concentrating human milk in a milk bank setting for feeding preterm infants might be a simple and low-cost process to achieve a product with higher nutrient density and no non-human components.

Journal of Human Lactation, Ahead of Print.