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1.  Greater Mortality and Morbidity in Extremely Preterm Infants Fed a Diet Containing Cow Milk Protein Products 
Breastfeeding Medicine  2014;9(6):281-285.
Abstract
Background: Provision of human milk has important implications for the health and outcomes of extremely preterm (EP) infants. This study evaluated the effects of an exclusive human milk diet on the health of EP infants during their stay in the neonatal intensive care unit.
Subjects and Methods: EP infants <1,250 g birth weight received a diet consisting of either human milk fortified with a human milk protein-based fortifier (HM) (n=167) or a diet containing variable amounts of milk containing cow milk-based protein (CM) (n=93). Principal outcomes were mortality, necrotizing enterocolitis (NEC), growth, and duration of parenteral nutrition (PN).
Results: Mortality (2% versus 8%, p=0.004) and NEC (5% versus 17%, p=0.002) differed significantly between the HM and CM groups, respectively. For every 10% increase in the volume of milk containing CM, the risk of sepsis increased by 17.9% (p<0.001). Growth rates were similar between groups. The duration of PN was 8 days less in the subgroup of infants receiving a diet containing <10% CM versus ≥10% CM (p<0.02).
Conclusions: An exclusive human milk diet, devoid of CM-containing products, was associated with lower mortality and morbidity in EP infants without compromising growth and should be considered as an approach to nutritional care of these infants.
doi:10.1089/bfm.2014.0024
PMCID: PMC4074755  PMID: 24867268
2.  The Utility of Breastmilk for Genetic or Genomic Studies: A Systematic Review 
Breastfeeding Medicine  2013;8(3):249-256.
Abstract
This study synthesized scientific literature that applies genetic or genomic approaches to breastmilk. A literature search of PubMed was conducted in March 2012 using the key words "breast milk," "lactation," "genetic," "gene expression," and "epigenetic." Additional articles were identified/selected for evaluation with MeSH term searches, and a review of article reference lists was obtained from the search. The initial 657 abstracts retrieved from the literature search were reviewed, and 16 studies were selected for evaluation. Studies that examined the transmission of viruses/bacteria into breastmilk and/or measured concentration of specific proteins without examination of genetic material from milk were excluded. Data related to subjects, tissue, purpose, setting, gene/protein, approach (candidate versus genome-wide), platform, statistical analysis, and results were extracted. Gene expression and epigenetic/epigenomic study designs have been successfully implemented using breastmilk. A major weakness of both gene expression studies and epigenetic studies that examine breastmilk is the omission of maternal information known to influence milk composition. This review article is the first to synthesize evidence related to the application of breastmilk to evaluate RNA and epigenetic modifications. Additional research is needed that applies epigenetic analyses to human breastmilk samples. Findings from this review can be used for future research designs that use breastmilk for genetic analyses.
doi:10.1089/bfm.2012.0054
PMCID: PMC3663450  PMID: 23259645
3.  Effect of Breastfeeding on Head Circumference of Children from Impoverished Communities 
Breastfeeding Medicine  2013;8(3):294-301.
Abstract
Objective
This study investigated the effect of exclusive breastfeeding on head circumference (HC) among children living in impoverished communities.
Subjects and Methods
A cross-sectional study was conducted among children 12–60 months old from the 39 quilombos located in the State of Alagoas, Brazil. HC deficit was defined by a z-score of less than −2 from the median (based on the 2006 World Health Organization growth standards). Prevalence ratio and 95% confidence interval (95% CI) were estimated using Poisson regression with robust adjustment of the variance, and estimates were adjusted for possible confounders (anthropometric, socioeconomic, demographic, and health-related variables).
Results
We evaluated 725 children (365 boys and 360 girls). The prevalence of HC deficit was 13.3% among those children who were exclusively breastfed for less than 30 days, 10.6% among those exclusively breastfed for 30–119 days, and 5.8% among those who were exclusively breastfed for 120 days or more. Even after controlling for possible confounding variables, exclusive breastfeeding for ≥4 months decreased the risk of HC deficit (prevalence ratio, 0.48; 95% CI 0.24, 0.99).
Conclusions
Exclusive breastfeeding for ≥4 months was associated with a larger HC in children exposed to great social vulnerability in impoverished communities.
doi:10.1089/bfm.2012.0105
PMCID: PMC3663451  PMID: 23414229
4.  The Cost of Using Donor Human Milk in the NICU to Achieve Exclusively Human Milk Feeding Through 32 Weeks Postmenstrual Age 
Breastfeeding Medicine  2013;8(3):286-290.
Abstract
Objectives
Donor human milk (DHM) is increasingly being used in neonatal intensive care units (NICUs) to achieve exclusive human milk (EHM) feedings in preterm infants. The aim of the study was to determine the cost of DHM to achieve EHM feeding for very preterm infants. The hypothesis was that the cost of DHM per infant is modulated by the availability of mother's own milk (MOM).
Subjects and Methods
Preterm infants (<1,500 g at birth weight or <33 weeks in gestational age) were retrospectively evaluated for a 1-year interval. MOM, DHM, and formula feeding categories were determined. A DHM feeding log was retrospectively analyzed for feeding volumes (in milliliters) and duration (in days). Four categories were created, based on maternal ability to provide sufficient breastmilk volumes and her intention to breastfeed. The volume, duration, and cost of DHM were calculated for each category.
Results
Forty-six of the 64 (72%) infants admitted to the NICU who were <33 weeks in gestational age received DHM. Four categories of DHM use were observed. The mean costs of DHM were $27 for infants of mothers who provided sufficient breastmilk through to discharge, $154 for infants of mothers who had insufficient milk supply during admission, $281 for infants of mothers who went home on formula but received any volume of MOM during admission, and $590 for infants who received no MOM during admission.
Conclusions
Most NICU mothers (72%) of very preterm infants were unable to provide all of the milk necessary for an EHM diet. Few infants (15%) received exclusively DHM. The cost of DHM per NICU infant ranged from $27 to $590 and was influenced by the mother's willingness or ability to provide human milk.
doi:10.1089/bfm.2012.0068
PMCID: PMC3663453  PMID: 23323965
5.  Prevalence and Predictors of Early Breastfeeding Among Late Preterm Mother–Infant Dyads 
Breastfeeding Medicine  2013;8(3):277-285.
Abstract
Background
Although late preterm infants (LPIs), at 340/7–366/7 weeks of gestation, are reported to have suboptimal rates of breastfeeding, there is a lack of quantitative evidence describing this trend. This study examined the prevalence of breastfeeding initiation and factors associated with breastfeeding non-initiation within a Pennsylvania population-based cohort of late preterm mother–infant dyads.
Subjects and Methods
Descriptive statistics and odds ratios were used to assess and compare breastfeeding initiation rates in 2003–2009 among LPI mothers (n=62,451) and their infants (n=68,886) with moderately preterm (n=17,325) and term (n=870,034) infants. Binary logistic regression was used to determine the association of system/provider, sociodemographic, and medical factors with breastfeeding non-initiation in late preterm mother–infant dyads for the year 2009 (n=7,012).
Results
Although LPI breastfeeding initiation in Pennsylvania increased significantly from 2003 (54%) to 2009 (61.8%) (p<0.001), the 2009 prevalence remained well below rates in term infant populations and national standards. The regression model indicated that interactions involving sociodemographic variables, including marital status, age, race/ethnicity, education, parity, Women, Infants and Children Program participation, and smoking status were among the most significant factors associated with LPI breastfeeding non-initiation (p<0.05). The univariate results were similar to those reported in preterm and term populations.
Conclusions
Our data suggest that certain, unexpected demographic groups in the late preterm population be prioritized for further analysis and possibly greater breastfeeding support. More research is indicated to understand the effect of modifiable psychosocial factors on LPI breastfeeding initiation.
doi:10.1089/bfm.2012.0075
PMCID: PMC3663454  PMID: 23199304
6.  An Exclusively Human Milk Diet Reduces Necrotizing Enterocolitis 
Breastfeeding Medicine  2014;9(4):184-190.
Abstract
Objective: This study tested the hypothesis that feeding an exclusively human milk (EHM) diet to premature infants reduces the incidence of necrotizing enterocolitis (NEC) associated with enteral feeding.
Study Design: An observational study for infants born at less than 33 weeks of gestational age was performed in a single neonatal intensive care unit. An EHM diet prospectively eliminated bovine-based artificial milk, including bovine-based fortifier, through 33 weeks postmenstrual age (PMA). The clinical data from a 2.5-year interval of the EHM diet were compared with data from the previous 6.5 years for similar infants who received bovine-based milk products before 33 weeks PMA.
Results: In the EHM diet cohort, 148 of 162 infants (91%) received EHM through 33 weeks PMA. In order to achieve an EHM diet, 140 of 162 infants (86%) received their own mother's milk, and 98 of 162 infants (60%) received donor human milk. The EHM cohort was also fed a human milk-based fortifier to truly eliminate bovine products. The distribution of NEC onset in the EHM cohort was significantly different from that in the control cohort for the day of onset (p=0.042) and the PMA at onset (p=0.011). In the control cohort, NEC onset after Day 7 of life occurred in 15 of 443 infants (3.4%), significantly more than in the EHM cohort where NEC occurred in two of 199 infants (1%) (p=0.009).
Conclusions: Changing to an EHM milk diet through 33 weeks PMA reduced the incidence of NEC associated with enteral feeding.
doi:10.1089/bfm.2013.0121
PMCID: PMC4025624  PMID: 24588561
7.  New Insight into Onset of Lactation: Mediating the Negative Effect of Multiple Perinatal Biopsychosocial Stress on Breastfeeding Duration 
Breastfeeding Medicine  2013;8(2):151-158.
Abstract
Background
Many perinatal stressors, including high prepregnancy body mass index, preterm birth, and cesarean section, increase the risk for short breastfeeding duration. Few studies, however, have investigated the mechanism in the relationship between perinatal determinants and breastfeeding duration. This study aimed to test the hypothesis that delayed onset of lactation (OL) could mediate the negative effect of perinatal biopsychosocial stress on breastfeeding duration and to evaluate the impact of new perinatal factors with potentially hazardous effects.
Subjects and Methods
Maternal demographic characteristics, health status, and psychological stress during pregnancy were assessed by structured questionnaires and medical records. The information of lactation was collected in the hospital within 1–3 days after delivery. Data on breastfeeding behaviors were obtained through the telephone interview at 2 months after delivery.
Results
The risk of delayed OL increased in women who had experienced severe life event stress in the first trimester of pregnancy (adjusted risk ratio [RR] 2.59, 95% confidence interval [CI] 1.52, 4.40), had undergone cesarean section (adjusted RR 2.11, 95% CI 1.46, 3.05), whose gestational body mass index gain were not less than 7.62 (adjusted RR 1.90, 95% CI 1.27, 2.86), and whose breastfeeding frequency was less than three times in the first day after childbirth (adjusted RR 2.14, 95% CI 1.57, 2.91). The final model of structural equation modeling indicated that women with cesarean section, preterm birth, greater gestational body mass index gain, higher scores of stressful life events in the first trimester, and less breastfeeding frequency in the first day after delivery were more likely to experience delayed OL, which could result in an earlier breastfeeding termination.
Conclusions
Delayed OL, as a negative biological event resulted from the perinatal biopsychosocial stress, is a key mediator linking perinatal factors to breastfeeding duration. More attention should to be paid to underweight before pregnancy and severe life events during pregnancy, which are regarded as novel and remarkable risk factors of delayed OL and short breastfeeding duration.
doi:10.1089/bfm.2012.0010
PMCID: PMC3616404  PMID: 23057642
8.  Perspectives on Promoting Breastmilk Feedings for Premature Infants During a Quality Improvement Project 
Breastfeeding Medicine  2013;8(2):176-180.
Abstract
Objective
This study investigated clinicians' perspectives during a quality improvement project to promote breastmilk feedings in premature infants.
Study Design
From 2009 to 2010, 11 hospitals in the California Perinatal Quality Care Collaborative participated in a project to promote breastmilk feedings in premature infants. Audio recordings of monthly meetings held to encourage sharing of ideas were analyzed using qualitative methods to identify common themes related to barriers and solutions to breastmilk feeding promotion.
Results
Two broad categories were noted: communication and team composition. Communication subthemes included (1) communication among hospital staff, including consistent documentation, (2) communication with family, and (3) communication between transfer hospitals. Team composition subthemes included (4) importance of physician buy-in and (5) integrated teams designed to empower leaders.
Conclusions
Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.
doi:10.1089/bfm.2012.0056
PMCID: PMC3616405  PMID: 23186387
9.  Impact of a Breastfeeding-Friendly Workplace on an Employed Mother's Intention to Continue Breastfeeding After Returning to Work 
Breastfeeding Medicine  2013;8(2):210-216.
Abstract
Background
Ever-increasing populations of women in their childbearing years are choosing to become employed. Breastfeeding provides unique health advantages to both the infant and mother. A breastfeeding-friendly workplace might be an important factor for predicting breastfeeding rates among working women. To explore the impact of breastfeeding-friendly support on the intention of working mothers to continue breastfeeding, we conducted a survey at a female labor-intensive electronics manufacturer in Taiwan.
Subjects and Methods
A structured questionnaire survey was administered to 715 working mothers employed in an electronics manufacturing plant in Tainan Science Park in Southern Taiwan. Questionnaire content included female employee demographics, employment characteristics, continued breastfeeding behavior after returning to work, access to lactation rooms, and employee perception of the breastfeeding policy and support when raising their most recently born child.
Results
A higher education level (odds ratio [OR]=2.66), lower work load (8 work hours/day) (OR=2.66), lactation room with dedicated space (OR=2.38), use of breast pumping breaks (OR=61.6), and encouragement from colleagues (OR=2.78) and supervisors (OR=2.44) to use breast pumping breaks were significant predictors of continued breastfeeding for more than 6 months after returning to work.
Conclusions
The findings of the present study suggest that to encourage and increase the rate of continued breastfeeding, workplaces should establish dedicated breastfeeding rooms and maintain a comfortable and clean environment. Furthermore, employers should provide encouragement and support for working mothers to continue breastfeeding after returning to work.
doi:10.1089/bfm.2012.0119
PMCID: PMC3616406  PMID: 23390987
10.  A Controlled Study on Baby-Friendly Communities in Italy: Methods and Baseline Data 
Breastfeeding Medicine  2013;8(2):198-204.
Abstract
Aim
This study reports the research methods and baseline data of a project aimed at assessing the effect of an intervention based on the 7 Steps of the Baby Friendly Community Initiative (BFCI) on the rate of exclusive breastfeeding at 6 months in Italy.
Subjects and Methods
In this controlled, nonrandomized study, nine Local Health Authorities were assigned to an early and nine to a late intervention group. Data on breastfeeding in infants followed up from birth to 12 months were gathered at baseline and in two subsequent rounds, after the 7 Steps were implemented in the early and late intervention groups, respectively. Step-down logistic regression analysis, corrected for the cluster effect, was used to compare breastfeeding rates between groups.
Results
At baseline, there were no significant differences in breastfeeding rates at birth (n=1,781) and at 3 (n=1,854), 6 (n=1,601), and 12 (n=1,510; loss to follow-up, 15.2%) months between groups. At birth, 96% of mothers initiated breastfeeding, 72% exclusively (recall from birth). At 3 months, 77% of infants were breastfed, 54% exclusively with 24-hour and 46% with 7-day recall. At 6 months, the rate of any breastfeeding was 62%, with 10% and 7% exclusive breastfeeding with 24-hour and 7-day recall, respectively. At 12 months, 31% of the children continued to breastfeed.
Conclusions
The project is ongoing and will allow estimation of the effect of the BFCI.
doi:10.1089/bfm.2012.0130
PMCID: PMC3616411  PMID: 23398142
11.  Nipple Pain, Damage, and Vasospasm in the First 8 Weeks Postpartum 
Breastfeeding Medicine  2014;9(2):56-62.
Abstract
Background: Nipple pain and damage are common in the early postpartum period and are associated with early cessation of breastfeeding and comorbidities such as depression, anxiety, and mastitis. The incidence of nipple vasospasm has not been reported previously. This article describes nipple pain and damage prospectively in first-time mothers and explores the relationship between method of birth and nipple pain and/or damage.
Subjects and Methods: A prospective cohort of 360 primiparous women was recruited in Melbourne, Australia, in the interval 2009–2011, and after birth participants were followed up six times. The women completed a questionnaire about breastfeeding practices and problems at each time point. Pain scores were graphically represented using spaghetti plots to display each woman's experience of pain over the 8 weeks of the study.
Results: After birth, before they were discharged home from hospital, 79% (250/317) of the women in this study reported nipple pain. Over the 8 weeks of the study 58% (198/336) of women reported nipple damage, and 23% (73/323) reported vasospasm. At 8 weeks postpartum 8% (27/340) of women continued to report nipple damage, and 20% (68/340) were still experiencing nipple pain. Ninety-four percent (320/340) of the women were breastfeeding at the end of the study, and there was no correlation between method of birth and nipple pain and/or damage.
Conclusions: Nipple pain is a common problem for new mothers in Australia and often persists for several weeks. Further studies are needed to establish the most effective means of preventing and treating breastfeeding problems in the postnatal period.
doi:10.1089/bfm.2013.0106
PMCID: PMC3934541  PMID: 24380583
12.  Randomized Controlled Trial of Docosahexaenoic Acid Supplementation in Midwestern U.S. Human Milk Donors 
Breastfeeding Medicine  2013;8(1):86-91.
Abstract
Background
Docosahexaenoic acid (DHA) is a long-chain polyunsaturated fatty acid important for neonatal neurodevelopment and immune homeostasis. Preterm infants fed donor milk from a Midwestern source receive only 20% of the intrauterine accretion of DHA. We tested the hypothesis that DHA supplementation of donor mothers would provide preterm infants with DHA intake equivalent to fetal accretion.
Subjects and Methods
After Institutional Review Board approval and informed consent, human milk donors to the Mother's Milk Bank of Ohio were randomized to receive 1 g of DHA (Martek® [now DSM Nutritional Lipids, Columbia, MD]) or placebo soy oil. Dietary intake data were collected and analyzed by a registered dietitian. Fatty acids were measured by gas chromatography/flame ionization detection. Statistical analysis used linear mixed models.
Results
Twenty-one mothers were randomly assigned to either the DHA group (n=10) or the placebo group (n=11). Donor age was a median of 31 years in both groups with a mean lactational stage of 19 weeks. Dietary intake of DHA at baseline in both groups was a median of 23 mg/day (range, 0–194 mg), significantly (p<0.0001) less than the minimum recommended intake of 200 mg/day. The DHA content of milk increased in the DHA-supplemented group (p<0.05).
Conclusions
The women enrolled in this study had low dietary DHA intake. Supplementation with preformed DHA at 1 g/day resulted in increased DHA concentrations in the donor milk with no adverse outcomes. Infants fed donor milk from supplemented women receive dietary DHA levels that closely mimic normal intrauterine accretion during the third trimester.
doi:10.1089/bfm.2011.0126
PMCID: PMC3566653  PMID: 22568471
13.  Improving Hospital Breastfeeding Policies in New York State: Development of the Model Hospital Breastfeeding Policy 
Breastfeeding Medicine  2013;8(1):3-7.
Abstract
The public health importance of breastfeeding, especially exclusive breastfeeding, is gaining increased recognition. Despite a strong evidence base that key hospital maternity practices (Ten Steps to Successful Breastfeeding) impact breastfeeding initiation and exclusivity in the hospital and breastfeeding duration post-discharge, they are not widely implemented. In 2009, written hospital breastfeeding policies were collected from all New York State (NYS) hospitals providing maternity care services (n=139). A systematic assessment of the policies found that, on average, approximately half (19/32) the components required under NYS hospital regulations were included. Inclusion of each of the Ten Steps varied from 14% to 98%. An evidence-based Model Hospital Breastfeeding Policy was developed that included required components (based on NYS hospital regulations and legislation) and recommendations from expert groups such as the Academy of Breastfeeding Medicine, Baby Friendly USA, Inc., and the United States Breastfeeding Committee. Improved hospital breastfeeding policies are a critical first step in improving hospital maternity care to better promote, support, and protect breastfeeding. Additional efforts throughout health care, the workplace, and the broader community will be required to make breastfeeding the norm.
doi:10.1089/bfm.2012.0030
PMCID: PMC3568958  PMID: 23249136
14.  Mastitis Is Associated with Increased Free Fatty Acids, Somatic Cell Count, and Interleukin-8 Concentrations in Human Milk 
Breastfeeding Medicine  2013;8(1):105-110.
Abstract
Background
Research in bovine lactation has demonstrated that milk produced by a mammary gland displaying inflammation-based symptoms of mastitis has increased levels of free fatty acids (FFAs) compared with milk produced by a contralateral asymptomatic gland. However, the effects of mastitis on lipid classes in milk have not been investigated in humans.
Methods
The study described here compared milk collected from the symptomatic breast of women with mastitis (n=14) with that collected from the contralateral asymptomatic breast to determine if mastitis caused alterations in the quantity of total lipids, FFAs, and phospholipids (PLs), as well as the fatty acid profiles of these lipid classes. To assess their efficacy as biomarkers of mastitis, samples were also analyzed for selected markers of local inflammation: sodium, somatic cell count (SCC), and interleukin-8 (IL-8).
Results
FFAs were higher in milk from the mastitic breast compared with that from the healthy breast (1.31 vs. 1.07±0.10 g/100 g of lipid, p<0.05). Similarly, SCC and IL-8 were elevated roughly 10-fold in milk from mastitic breasts, compared with milk from healthy breasts, and sodium tended to be higher in milk from mastitic breasts (p<0.10). However, there were no differences in total lipid, PLs, or fatty acid profiles within each lipid class.
Conclusions
In summary, mastitis is associated with increased lipolysis in the human breast but not alterations in milk fat synthesis, as evidenced by a lack of alteration in total milk lipids. Additionally, these results indicate that SCC and IL-8 may be better indicators of mammary inflammation than sodium content.
doi:10.1089/bfm.2011.0141
PMCID: PMC3568962  PMID: 22283504
15.  Determination of Dornic Acidity as a Method to Select Donor Milk in a Milk Bank 
Breastfeeding Medicine  2013;8(1):99-104.
Abstract
Background
Dornic acidity may be an indirect measurement of milk's bacteria content and its quality. There are no uniform criteria among different human milk banks on milk acceptance criteria. The main aim of this study is to report the correlation between Dornic acidity and bacterial growth in donor milk in order to validate the Dornic acidity value as an adequate method to select milk prior to its pasteurization.
Materials and Methods
From 105 pools, 4-mL samples of human milk were collected. Dornic acidity measurement and culture in blood and McConkey's agar cultures were performed. Based on Dornic acidity degrees, we classified milk into three quality categories: top quality (acidity <4°D), intermediate (acidity between 4°D and 7°D), and milk unsuitable to be consumed (acidity ≥8°D). Spearman's correlation coefficient was used to perform statistical analysis.
Results
Seventy percent of the samples had Dornic acidity under 4°D, and 88% had a value under 8°D. A weak positive correlation was observed between the bacterial growth in milk and Dornic acidity. The overall discrimination performance of Dornic acidity was higher for predicting growth of Gram-negative organisms. In milk with Dornic acidity of ≥4°D, such a measurement has a sensitivity of 100% for detecting all the samples with bacterial growth with Gram-negative bacteria of over 105 colony-forming units/mL.
Conclusions
The correlation between Dornic acidity and bacterial growth in donor milk is weak but positive. The measurement of Dornic acidity could be considered as a simple and economical method to select milk to pasteurize in a human milk bank based in quality and safety criteria.
doi:10.1089/bfm.2011.0091
PMCID: PMC3568963  PMID: 23373435
16.  Personal Breastfeeding Behavior of Physician Mothers Is Associated with Their Clinical Breastfeeding Advocacy 
Breastfeeding Medicine  2013;8(1):31-37.
Abstract
Background
Despite excellent breastfeeding initiation rates, physician mothers as a group are at risk of premature breastfeeding cessation. The main obstacles and reasons for breastfeeding cessation among physician mothers are work-related. We conducted this study to further explore physician mothers' personal infant feeding decisions and behavior as well as their clinical breastfeeding advocacy.
Subjects and Methods
We interviewed 80 physician mothers, mainly affiliated with the University of Florida College of Medicine (Gainesville, FL), using a questionnaire. Descriptive statistics were calculated with SPSS software version 16 (SPSS, Chicago, IL).
Results
The 80 mothers had a total of 152 children and were able to successfully initiate breastfeeding for 97% of the infants. Although maternal goal for duration of breastfeeding had been 12 months or more for 57% of the infants, only 34% of the children were actually still breastfeeding at 12 months. In 43% of cases, physician mothers stated that breastfeeding cessation was due to demands of work. Furthermore, physician mothers who reported actively promoting breastfeeding among their female patients and housestaff had significantly longer personal breastfeeding duration compared with physician mothers who denied actively promoting breastfeeding.
Conclusions
Our findings not only emphasize the discrepancy between physician mothers' breastfeeding duration goal and their actual breastfeeding duration, but also highlight the association between their personal breastfeeding success and their own active breastfeeding advocacy. Whether this association is causal cannot be determined by the current study and can be examined further by prospective studies. Our results support developing and implementing workplace strategies and programs to promote breastfeeding duration among physician mothers returning to work.
doi:10.1089/bfm.2011.0148
PMCID: PMC3568966  PMID: 23373434
17.  Role of Body Mass Index and Gestational Weight Gain in Breastfeeding Outcomes 
Breastfeeding Medicine  2012;7(6):448-456.
Abstract
Objective
This study determined whether high maternal prepregnancy body mass index (BMI) and/or excess gestational weight gain (GWG) is associated with reduced breastfeeding duration and earlier formula supplementation.
Study Design
A prospective longitudinal cohort of postpartum women (n=718), who were a subset of a larger randomized trial, was followed for 6 months postdelivery. We evaluated the relationship between BMI or BMI/GWG groups and timing of breastfeeding cessation and introduction of formula using Kaplan–Meier curves and log-rank tests. Then, we used multivariable Cox proportional hazards models to evaluate the relationship between BMI and BMI/GWG on these breastfeeding outcomes after controlling for potential confounding variables.
Results
The expected relationships between high BMI and high BMI/GWG and poor breastfeeding outcomes were observed in Kaplan–Meier curves. However, after adjusting for relevant maternal and infant covariates in the Cox models, the differences became nonsignificant. Prepregnancy BMI category was not statistically associated with breastfeeding duration (p=0.06) or timing of formula introduction (p=0.15). Similarly, BMI and GWG in combination were not associated with duration (p=0.33) or timing of formula introduction (p=0.18). Mothers' intended breastfeeding duration and rating of the importance of breastfeeding remained the only significant modifiable predictors of breastfeeding outcomes in the final models.
Conclusions
Maternal BMI and GWG were not significantly associated with breastfeeding outcomes after adjusting for confounding variables. Mothers' plans for breastfeeding duration and the importance mothers assign to breastfeeding remain the optimal intervention points for lengthening breastfeeding duration and reducing formula supplementation.
doi:10.1089/bfm.2011.0127
PMCID: PMC3523243  PMID: 23215909
18.  Perceptions of Primary Care-Based Breastfeeding Promotion Interventions: Qualitative Analysis of Randomized Controlled Trial Participant Interviews 
Breastfeeding Medicine  2012;7(6):417-422.
Abstract
Objective
This study examined women's perceptions and reported effects of routine, primary care-based interventions to increase breastfeeding.
Subjects and Methods
A subsample (n=67) of participants in randomized controlled trials (RCTs) completed semistructured exit interviews at 6 months postpartum. RCT arms included the following: (a) routine pre-/postnatal lactation consultant (LC) support (LC group); (b) electronic prompts (EP) guiding providers to discuss breastfeeding during prenatal care visits (EP group); (c) a combined intervention (LC+EP group); and (d) controls. Interview transcripts were coded and analyzed in MAX.qda.
Results
Key findings included the following: (1) Brief, non-directive assessment of feeding via postpartum interviews focused attention upon feeding practices. When coupled with breastfeeding promotion interventions, interviews promoted breastfeeding. (2) The EP and LC interventions were complementary: EPs influenced initiation, while LCs helped overcome barriers and sustain breastfeeding. (3) Prenatal intent to feed both breastmilk and formula was associated with the greatest receptivity to study messages.
Conclusions
Findings underscore the need for interventions across the continuum of care. Trained LCs in prenatal/postpartum settings and prenatal care providers play important complementary roles that, when coupled with brief telephone feeding assessments, may improve breastfeeding rates.
doi:10.1089/bfm.2011.0151
PMCID: PMC3523239  PMID: 22621223
19.  Systematic Review of Breastfeeding and Herbs 
Breastfeeding Medicine  2012;7(6):489-503.
Abstract
Objectives
Despite popular and historical use, there has been little modern research conducted to determine the safety and efficacy of herb use during breastfeeding. The purpose of this study was to systematically review the clinical literature on herbal medicine and lactation.
Methods
The databases PubMed, CAB Abstracts, Cochrane Central Register of Controlled Trials, HealthSTAR, Cumulative Index to Nursing and Allied Health Literature, and Reprotox were systematically searched for human trials from 1970 until 2010. Reference lists from relevant articles were hand-searched.
Results
Thirty-two studies met the inclusion criteria. Clinical studies were divided into three categories: survey studies (n=11), safety studies (n=8), and efficacy studies (n=13). Six studies were randomized controlled trials. The most common herbs studied were St. John's wort (Hypericum perforatum L.) (n=3), garlic (Allium sativum L.) extract (n=2), and senna (Cassia senna L.) (n=2). Studies were very heterogeneous with regard to study design, herbal intervention, and outcome measures. Overall, poor methodological quality predominated among the studies.
Conclusions
Our review concludes that further research is needed to assess the prevalence, efficacy, and safety of commonly used herbs during breastfeeding.
doi:10.1089/bfm.2011.0122
PMCID: PMC3523241  PMID: 22686865
20.  Awareness of Breastfeeding Recommendations and Duration of Breastfeeding: Findings from the Healthy Beginnings Trial 
Breastfeeding Medicine  2012;7(4):223-229.
Abstract
Background
To date, there are no studies examining the role of awareness of the World Health Organization's breastfeeding recommendation in determining mothers' breastfeeding decisions and practice. This study sought to determine whether awareness of the recommendation to breastfeed exclusively to age 6 months and intention to meet this recommendation are translated into breastfeeding practice.
Methods
We analyzed longitudinal data from 201 first-time mothers who participated in the Healthy Beginnings Trial as a control group. The mothers' awareness of the breastfeeding recommendation and their intention to meet the recommendation were assessed at baseline antenatally, and breastfeeding duration was assessed at 6 and 12 months postpartum, through telephone and face-to-face interviews, respectively. Logistic regression and Cox regression analyses were conducted.
Results
Mothers who knew the recommendation were 26% more likely to initiate breastfeeding (adjusted risk ratio [ARR] 1.26, 95% confidence interval [CI] 1.14 to 1.37, p=0.001) and 34% less likely to have stopped breastfeeding (adjusted hazard ratio 0.66, 95% CI 0.46 to 0.95, p=0.03) at 12 months than those who did not. Having an intention to meet the recommendation was weakly positively associated with the initiation of breastfeeding only (ARR 1.09, 95% CI 1.03 to 1.20, p=0.07).
Conclusions
Awareness of the breastfeeding recommendation to breastfeed exclusively for 6 months is an independent positive predictor of breastfeeding initiation and duration. Improving mothers' awareness of the recommendation and strengthening their intention to breastfeed could lead to increased breastfeeding initiation and duration.
doi:10.1089/bfm.2011.0052
PMCID: PMC3411340  PMID: 22568472
21.  The Longitudinal Role of Breastfeeding in Mothers' and Fathers' Relationship Quality Trajectories 
Breastfeeding Medicine  2012;7(4):241-247.
Abstract
Background
Guided by a family systems perspective, this study investigated whether breastfeeding plays a role in the quality of the mother–father intimate relationship over the course of child development.
Methods
Using a prospective, longitudinal design, and data drawn from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (n=986 couples), the present study examined the predictive role of breastfeeding in the first 3 years of life (for up to 4 months and for 5 months or longer, relative to never breastfeeding) in maternal and paternal trajectories of intimate relationship quality. The outcome variable of interest was emotional intimacy, rated by mothers and fathers when children were 54 months of age, in Grades 1, 3, 5, and 6, and 15 years of age.
Results
Multivariate hierarchical linear modeling, which appropriately handled dyadic data and accounted for effects of demographic covariates and earlier relationship quality, indicated that breastfeeding uniquely predicted increases in mothers' (but not fathers') marital quality levels over time. There was no difference in the strength of the positive associations for shorter versus longer breastfeeding duration. The findings suggest that improved intimate relationship quality may be another psychosocial benefit experienced by breastfeeding mothers.
Conclusion
The findings underscore the importance of considering breastfeeding in the context of intimate relationships and may be of interest to women weighing the decision to breastfeed, their partners, and healthcare providers.
doi:10.1089/bfm.2011.0074
PMCID: PMC3411344  PMID: 22148926
22.  Effect of Freezing Time on Macronutrients and Energy Content of Breastmilk 
Breastfeeding Medicine  2012;7(4):295-301.
Abstract
Background
In neonatal units and human milk banks freezing breastmilk at less than –20°C is the choice for preserving it. Scientific evidence in relation to the loss of nutritional quality during freezing is rare. Our main aim in this study is to determine the effect of freezing time up to 3 months on the content of fat, total nitrogen, lactose, and energy. Our secondary aim is to assess whether ultrasonic homogenization of samples enables a more suitable reading of breastmilk macronutrients with a human milk analyzer (HMA) (MIRIS®, Uppsala, Sweden).
Methods
Refrigerated breastmilk samples were collected. Each sample was divided into six pairs of aliquots. One pair was analyzed on day 0, and the remaining pairs were frozen and analyzed, one each at 7, 15, 30, 60, and 90 days later. For each pair, one aliquot was homogenized by stirring, and the other by applying ultrasound. Samples were analyzed with the HMA.
Results
By 3 months from freezing with the two homogenization methods, we observed a relevant and significant decline in the concentration of fat and energy content. The modification of total nitrogen and lactose was not constant and of lower magnitude. The absolute concentration of all macronutrients and calories was greater with ultrasonic homogenization.
Conclusions
After 3 months from freezing at –20°C, an important decrease in fat and caloric content is observed. Correct homogenization is fundamental for correct nutritional analysis.
doi:10.1089/bfm.2011.0079
PMCID: PMC3411345  PMID: 22047109
23.  Quick Reference Breastfeeding Guide Available for Medical Students and Residents 
Breastfeeding Medicine  2012;7(4):320.
doi:10.1089/bfm.2012.0074
PMCID: PMC4046747  PMID: 22861484
24.  Clinician Perspectives on Barriers to and Opportunities for Skin-to-Skin Contact for Premature Infants in Neonatal Intensive Care Units 
Breastfeeding Medicine  2012;7(2):79-84.
Abstract
Objective
Our objective was to investigate key factors in promoting skin-to-skin contact (STSC) in the neonatal intensive care unit (NICU).
Methods
As part of a California Perinatal Quality Care Collaborative on improving nutrition and promoting breastmilk feeding of premature infants, a multidisciplinary group of representatives from 11 hospitals discussed the progress and barriers in pursuing the project. A key component of the collaborative project was promotion of STSC. Sessions were audio-recorded, transcribed, and assessed using qualitative research methods with the aid of Atlas Ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Two primary investigators studied the transcripts for themes related to STSC. Using an iterative approach, selected themes were explored, and representative quotes were selected.
Results
Barriers to promoting STSC fell into broad themes of implementation, institutional, and familial factors. The main challenge identified in implementation was defining a clinically stable eligible population of patients. Key institutional factors were education and motivation of staff. Familial factors involved facilitation and sustained motivation of mothers. In response to these barriers, opportunities for promoting STSC were enacted or suggested by the group, including defining clinical stability for eligibility, facilitating documentation, strategies to increase parent and staff education and motivation, and encouraging maternal visitation and comfort.
Conclusions
Our findings may be useful for institutions seeking to develop policies and strategies to increase STSC and breastmilk feeding in their NICUs.
doi:10.1089/bfm.2011.0004
PMCID: PMC3317520  PMID: 22011130
25.  A Process-Oriented Breastfeeding Training Program for Healthcare Professionals to Promote Breastfeeding: An Intervention Study 
Breastfeeding Medicine  2012;7(2):85-92.
Abstract
Aim
The aim of the study was to evaluate the effects of process-oriented training in supportive breastfeeding counseling for midwives and postnatal nurses on the time lapse between the initial breastfeeding session, introduction of breastmilk substitutes and solids, and the duration of breastfeeding.
Materials and Methods
Ten municipalities in Sweden were randomized to either the intervention or control groups. The intervention included a process-oriented training program for midwives and postnatal nurses in the intervention municipalities. Primiparas (n=540) living in either an intervention or control municipality were asked to participate in a longitudinal study to evaluate the care given. Data collection for control group A (CGA) (n=162) started before the intervention was initiated. Data for control group B (CGB) (n=172) were collected simultaneously with the intervention group (IG) (n=206). The mothers responded to questionnaires at 3 days, 3 months, and 9 months postpartum.
Results
As a result of the process-oriented training program for midwives and postnatal nurses, the IG mothers had a significantly longer duration of exclusive breastfeeding, even if the initial breastfeeding session did not occur within 2 hours after birth, than the corresponding group of CGA mothers (p=0.01). Fewer infants in the IG received breastmilk substitutes (in the first week of life) without medical reasons compared with the control groups (p=0.01). The IG infants were significantly older (3.8 months) when breastmilk substitutes were introduced (after discharge from the hospital) compared with the infants in the control groups (CGA, 2.3 months, p=0.01; CGB, 2.5 months, p=0.03).
Conclusion
A process-oriented training program for midwives and postnatal nurses was associated with a reduced number of infants being given breastmilk substitutes during the 1st week without medical reasons and delayed the introduction of breastmilk substitutes after discharge from the hospital.
doi:10.1089/bfm.2010.0084
PMCID: PMC3317786  PMID: 22168946

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