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1.  Employee Perception of Breastfeeding-Friendly Support and Benefits of Breastfeeding as a Predictor of Intention to Use Breast-Pumping Breaks After Returning to Work Among Employed Mothers 
Breastfeeding Medicine  2014;9(1):16-23.
Background: Although increasing numbers of large companies are complying with demands for a breastfeeding-friendly workplace by providing lactation rooms and breast-pumping breaks, the effectiveness for intention to use breast-pumping breaks to express breast milk among employed mothers is uncertain. To explore the impact of employees' perceived breastfeeding support from the workplace and the benefits of breastfeeding on a woman's intention to use breast-pumping breaks after returning to work, 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, and breastfeeding behavior after returning to work, as well as employees' perception of breastfeeding-friendly support and awareness of the benefits of breastfeeding when raising their most recently born child.
Results: Higher education (odds ratio [OR] 2.33), non–clean room worksite (OR 1.51), awareness of breast-pumping breaks (OR 4.70), encouragement by colleagues to use breast-pumping breaks (OR 1.76), and greater awareness of the benefits of breastfeeding (OR 1.08) were significant predictors of the use of breast-pumping breaks after returning to work, whereas the perception of inefficiency when using breast-pumping breaks reduced an employed mother's intention to use breast-pumping breaks (OR 0.55).
Conclusions: This study finds an association between an appreciation of the benefits provided by the employer and the likelihood of increased usage of breastfeeding breaks. Workplaces and employers can help employed mothers to understand the benefits of breastfeeding, which may increase the intention of the mother to take breast-pumping breaks after returning to work.
PMCID: PMC3903328  PMID: 24304034
2.  ABM Clinical Protocol #2: Guidelines for Hospital Discharge of the Breastfeeding Term Newborn and Mother: “The Going Home Protocol,” Revised 2014 
Breastfeeding Medicine  2014;9(1):3-8.
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
PMCID: PMC3903163  PMID: 24456024
3.  Women's Perceptions of Breastfeeding Barriers in Early Postpartum Period: A Qualitative Analysis Nested in Two Randomized Controlled Trials 
Breastfeeding Medicine  2014;9(1):9-15.
Objectives: This study examined women's perceptions of early infant feeding experiences and identified early postpartum barriers to successful breastfeeding.
Subjects and Methods: We conducted semistructured exit interviews at 6 months postpartum with a subsample of participants (n=67) enrolled in two randomized controlled trials of breastfeeding promotion. Study arms included (1) routine pre- and postnatal visits with an International Board Certified Lactation Consultant (IBCLC) (LC group), (2) electronically prompted guidance from prenatal care providers (EP group), (3) EP+LC combined, and (4) standard of care (control group). Interview transcripts were coded using grounded theory and analyzed in MAXqda. Code matrices were used to identify early postpartum breastfeeding barriers and were further examined in relation to treatment group using a mixed methods analysis.
Results: The majority of the participants reported experiencing at least one barrier to breastfeeding. Barriers to breastfeeding were more commonly reported in the early postpartum than late postpartum period. The most common barrier during the early postpartum period was the perception of inadequate milk supply (“lactational”) (n=18), followed by problems with latch, medical problems that were perceived as precluding breastfeeding, and medical staff and hospital practices. Participants frequently reported that the IBCLCs assisted them in anticipating, managing, and overcoming these barriers.
Conclusions: Our findings underscore the importance of integrating IBCLCs into routine pre- and postpartum care because they provide critical support that effectively addresses early postpartum barriers to breastfeeding.
PMCID: PMC3903167  PMID: 24304033
4.  A Case Control Study of Bacterial Species and Colony Count in Milk of Breastfeeding Women with Chronic Pain 
Breastfeeding Medicine  2014;9(1):29-34.
Background: An infectious etiology for chronic breast pain in breastfeeding women continues to be debated. Although recent data suggest that Staphylococcus aureus and coagulase-negative Staphylococcus (CNS) may cause chronic breast pain, no studies have used quantitative cultures to address this question. In this study we compared bacterial species and colony counts between breastfeeding women with (cases) and without (controls) chronic pain.
Subjects and Methods: We enrolled 114 breastfeeding women in a prospective cohort study. Cases (n=61), breastfeeding women with breast pain for >1 week and no signs of acute infection, were matched with controls (n=53) by weeks postpartum and parity.
Results: More cases had a history of mastitis (14% vs. 2%, p=0.036), cracked nipples (64% vs. 17%, p=0.001), and other breastfeeding difficulties. Enterobacter species growth was less likely in cases (0% vs. 7.5%, p=0.029). Cases had a significantly higher growth of S. aureus (19.7% vs. 1.9%, p=0.003). CNS frequency was similar between groups (75% vs. 79%, p=0.626), but median colony count growth was significantly lower in cases (900 colony-forming units/mL vs. 5,000 colony-forming units/ml, p=0.003). Growth of CNS and S. aureus was negatively correlated (r=–0.265, p=0.004).
Conclusions: Higher S. aureus growth in cases supports a pathogenic role for S. aureus and reinforces the need for future antibiotic treatment studies in breastfeeding women with chronic pain. In contrast, similar CNS frequency between groups, lower CNS colony counts in cases, and a negative correlation between S. aureus and CNS growth suggest that neither CNS, nor its overgrowth, causes chronic breast pain.
PMCID: PMC3903327  PMID: 23789831
5.  Early Administration of Oropharyngeal Colostrum to Extremely Low Birth Weight Infants 
Breastfeeding Medicine  2013;8(6):491-495.
Background: Human milk reduces morbidities in extremely low birth weight (ELBW) infants. However, clinical instability often precludes ELBW infants from receiving early enteral feeds. This study compared clinical outcomes before and after implementing an oropharyngeal colostrum (COL) protocol in a cohort of inborn (born at our facility) ELBW infants.
Study Design: This is a retrospective cohort study of inborn ELBW infants admitted to the Duke Intensive Care Nursery from January 2007 to September 2011. In November 2010, we initiated a COL protocol for infants not enterally fed whose mothers were providing breastmilk. Infants received 0.1 mL of fresh COL to each cheek every 4 hours for 5 days beginning in the first 48 postnatal hours. We assessed demographics, diagnoses, feeding history, and mortality and for the presence of medical necrotizing enterocolitis (NEC), surgical NEC, and spontaneous perforation. Between-group comparisons were made using Fisher's exact test or Wilcoxon rank sum testing where appropriate.
Results: Of the 369 infants included, 280 (76%) were born prior to the COL protocol (Pre-COL Cohort [PCC]), and 89 (24%) were born after (COL Cohort [CC]). Mortality and the percentage of infants with surgical NEC and spontaneous perforations were statistically similar between the groups. The CC weighed an average (interquartile range) of 1,666 (1,399, 1,940) g at 36 weeks versus 1,380 (1,190, 1,650) g for the PCC (p<0.001). In a multivariable analysis with birth weight as a covariable, weight at 36 weeks was significantly greater (37 g; p<0.01).
Conclusions: Initiating oropharyngeal COL in ELBW infants in the first 2 postnatal days appears feasible and safe and may be nutritionally beneficial. Further research is needed to determine if early COL administration reduces neonatal morbidity and mortality.
PMCID: PMC3868273  PMID: 23805944
6.  Increased Breastfeeding Rates in Black Women After a Treatment Intervention 
Breastfeeding Medicine  2013;8(6):479-484.
There has been a considerable increase in rates of breastfeeding in the United States. Despite these trends, black women continue to fall below medical recommendations. Impoverished and poorly educated women also have a comparatively lower rate of breastfeeding. Provider encouragement and supportive interventions increase breastfeeding initiation among women of all backgrounds. The data presented come from a three-site randomized controlled bilingual depression treatment trial from 2005 to 2011 that examined the comparative effectiveness of interpersonal psychotherapy and a parenting education program. Breastfeeding education and support were provided for the majority of participants in each intervention. Breastfeeding status was queried at postpartum week 4. We found higher rates of breastfeeding in black women compared with those reported in national surveys. The black breastfeeding rate did not significantly differ from that of white or Hispanic women. American-born black women were just as likely to breastfeed as American-born white women, both at significantly greater rates than American-born Hispanic women. We also found no differences in breastfeeding rate in poorly educated and impoverished women. These data must be seen against the backdrop of a significant intervention to treat depression. Because breastfeeding interventions have been shown to increase breastfeeding rates, the support provided in our study likely increased rates in groups that lag behind.
PMCID: PMC3868278  PMID: 23971683
7.  ABM Clinical Protocol #5: Peripartum Breastfeeding Management for the Healthy Mother and Infant at Term, Revision 2013 
Breastfeeding Medicine  2013;8(6):469-473.
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
PMCID: PMC3868283  PMID: 24320091
8.  TGF-β2, a Protective Intestinal Cytokine, Is Abundant in Maternal Human Milk and Human-Derived Fortifiers but Not in Donor Human Milk 
Breastfeeding Medicine  2013;8(6):496-502.
Objective: This study compared cytokines (in particular transforming growth factor [TGF]-β2) and lactoferrin in maternal human milk (MHM), human-derived milk fortifier (HDMF), and donor human milk (DHM).
Materials and Methods: MHM was randomly collected from breastfeeding mothers who had no infectious illness at the time of milk expression. HDMF and DHM were products derived from human milk processed by Holder pasteurization. MHM samples were collected at different times (early/late) and gestations (preterm/term). Lactoferrin was analyzed by western blotting, and cytokines were quantified using commercial enzyme-linked immunosorbent assays. Significance was determined using analysis of variance.
Results: In the 164 samples analyzed, TGF-β2 concentrations in HDMF and preterm MHM (at all collection times) were fivefold higher than in DHM (p<0.05). Early preterm MHM had levels of interleukin (IL)-10 and IL-18, 11-fold higher than DHM (p<0.05). IL-6 in DHM was 0.3% of the content found in MHM. IL-18 was fourfold higher in early MHM versus late MHM regardless of gestational age (p<0.05). Lactoferrin concentration in DHM was 6% of that found in MHM.
Conclusions: Pasteurization decreases concentrations of most cytokines and lactoferrin in DHM. TGF-β2, a protective intestinal cytokine, has comparable concentrations in HDMF to MHM despite pasteurization.
PMCID: PMC3919475  PMID: 23869537
9.  Buying Human Milk via the Internet: Just a Click Away 
Breastfeeding Medicine  2013;8(6):474-478.
Background: For past centuries, infants have been fed the milk of mothers who are not their own by latching to another woman's breast. Today, the majority of lactating women use electric pumps to extract milk from their breasts; thus, an infant now may be fed another woman's milk via a bottle or cup. The Internet is an emerging avenue to acquire pumped human milk. The purpose of our study was to participate in and describe the process of buying milk via the Internet. Our goal is to help those involved with the clinical care, research, and public health policy of mothers and infants better understand that families may be buying milk in this way.
Subjects and Methods: We anonymously bought 102 human milk samples via the Internet. We characterized the outside box, packing materials, milk container, temperature and condition of the milk, and cost.
Results: We bought 2,131 ounces of milk at a total cost of $8,306. Eighty-nine percent of the milk arrived above the recommended frozen temperature of −20°C; 45% of it was even above the recommended refrigerator temperature (4°C). The mean surface temperature of the milk samples in each shipment was correlated with the cost of shipping, time in transit, and condition of the milk containers.
Conclusions: The prevalence and potential risks of this practice currently are unknown. Research related to milk quality and infant outcomes related to milk buying via the Internet is urgently needed.
PMCID: PMC4046749  PMID: 23971685
10.  Airports in the United States: Are They Really Breastfeeding Friendly? 
Breastfeeding Medicine  2014;9(10):515-519.
Introduction: State and federal laws have been enacted to protect the mother's right to breastfeed and provide breastmilk to her infant. The Patient Protection and Affordable Care Act requires employers to provide hourly waged nursing mothers a private place other than a bathroom, shielded from view, free from intrusion. Minimum requirement for a lactation room would be providing a private space other than a bathroom. Workplace lactation accommodation laws are in place in 24 states, Puerto Rico, and the District of Columbia. These requirements benefit the breast-pumping mother in an office, but what about the breast-pumping mother who travels? Of women with a child under a year, 55.8% are in the workforce. A significant barrier for working mothers to maintain breastfeeding is traveling, and they will need support from the workplace and the community. This study aimed to determine which airports offer the minimum requirements for a breast-pumping mother: private space other than a bathroom, with chair, table, and electrical outlet.
Study Design: A phone survey was done with the customer service representative at 100 U.S. airports. Confirmatory follow-up was done via e-mail.
Results: Of the respondents, 37% (n=37) reported having designated lactation rooms, 25% (n=25) considered the unisex/family restroom a lactation room, 8% (n=8) offer a space other than a bathroom with an electrical outlet, table, and chair, and 62% (n=62) answered yes to being breastfeeding friendly.
Conclusions: Only 8% of the airports surveyed provided the minimum requirements for a lactation room. However 62% stated they were breastfeeding friendly. Airports need to be educated as to the minimum requirements for a lactation room.
PMCID: PMC4267407  PMID: 25313682
11.  ABM Clinical Protocol #18: Guidelines for Breastfeeding Infants with Cleft Lip, Cleft Palate, or Cleft Lip and Palate, Revised 2013 
Breastfeeding Medicine  2013;8(4):349-353.
A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
PMCID: PMC3725852  PMID: 23886478
12.  Breastfeeding Intentions Among Pregnant Adolescents and Young Adults and Their Partners 
Breastfeeding Medicine  2013;8(4):374-380.
Rates of breastfeeding remain disproportionately low among young mothers in the United States. Although breastfeeding behavior may be most directly related to breastfeeding intention, little is known about breastfeeding intentions among young women who are expecting a baby.
Subjects and Methods
Pregnant adolescents and young adults (14–21 years old) and their male partners were recruited for participation. Females were asked if they intended to breastfeed, and their partners were asked if they wanted their partners to breastfeed; participants indicated reasons for their responses. Logistic regression modeling was used to determine the associations between breastfeeding intentions and sociodemographic characteristics, relationship characteristics, and partner's intention to breastfeed.
Approximately 73% of females reported intending to breastfeed, and 80% of males reported wanting his partner to breastfeed, most commonly because it is “healthier for the baby” and “a more natural way to feed the baby.” Sociodemographic and relationship characteristics explained a small amount of variance of breastfeeding intention (15% and 4% among females, respectively, and 8% and 4% among males, respectively). Partner intention explained an additional 23% and 24% of the variance in individual intention for females and males, respectively. Females who had experienced intimate partner violence (IPV) from their current partner had lower odds of intending to breastfeed (odds ratio=0.37; 95% confidence interval=0.16, 0.84). Race/ethnicity modified associations among both genders.
These findings emphasize the importance of dyadic approaches and suggest strategies for improving breastfeeding intentions and behavior among young couples expecting a baby. These results are also among the first to document the relationship between IPV and breastfeeding intentions among young women.
PMCID: PMC3725794  PMID: 23611330
13.  Breastfeeding Initiation in the Context of a Home Intervention to Promote Better Birth Outcomes 
Breastfeeding Medicine  2013;8(4):381-387.
This secondary analysis examined breastfeeding initiation rates and factors related to initiation in a sample of multiparous women with a history of a prior preterm birth.
Subjects and Methods
Data for a subsample of women (n=130) were derived from a randomized clinical trial testing a home visit intervention to improve birth outcomes. The subsample included women who gave birth to an infant greater than 35 weeks of gestation. All participants received standard prenatal care. Intervention participants (n=73) also received home visits by certified nurse-midwives. Visits were guided by protocols to improve factors associated with poor birth outcomes and maternal and infant health. Descriptive and logistic regression analyses were used, controlling for factors previously associated with breastfeeding.
Although 85% of women reported an intention to breastfeed, only 65% reported initiating breastfeeding at 48 hours postpartum. After controlling for race, income, marital status, smoking, and age, higher maternal education and lower pregravid body mass index were associated with higher rates of initiation (odds ratio [OR]=1.30, p=0.010 and OR=0.94, p=0.007, respectively). Lower levels of depressive symptoms (OR=0.95, p=0.039) and higher levels of prenatal stress (OR=1.11, p=0.042) increased the likelihood of initiating breastfeeding. No difference between groups emerged, although women in the intervention group with more home visit time were more likely to report breastfeeding (p=0.007).
Modifiable risk factors were associated with rates of breastfeeding initiation. It may be possible to use protocols delivered via nurse-midwife home visits within a global intervention to increase breastfeeding initiation.
PMCID: PMC3726024  PMID: 23484671
14.  Greater Mortality and Morbidity in Extremely Preterm Infants Fed a Diet Containing Cow Milk Protein Products 
Breastfeeding Medicine  2014;9(6):281-285.
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.
PMCID: PMC4074755  PMID: 24867268
15.  Effect of Breastfeeding on Head Circumference of Children from Impoverished Communities 
Breastfeeding Medicine  2013;8(3):294-301.
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).
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).
Exclusive breastfeeding for ≥4 months was associated with a larger HC in children exposed to great social vulnerability in impoverished communities.
PMCID: PMC3663451  PMID: 23414229
16.  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.
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.
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.
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.
PMCID: PMC3663453  PMID: 23323965
17.  Prevalence and Predictors of Early Breastfeeding Among Late Preterm Mother–Infant Dyads 
Breastfeeding Medicine  2013;8(3):277-285.
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).
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.
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.
PMCID: PMC3663454  PMID: 23199304
18.  An Exclusively Human Milk Diet Reduces Necrotizing Enterocolitis 
Breastfeeding Medicine  2014;9(4):184-190.
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.
PMCID: PMC4025624  PMID: 24588561
19.  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.
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.
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.
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.
PMCID: PMC3616404  PMID: 23057642
20.  Perspectives on Promoting Breastmilk Feedings for Premature Infants During a Quality Improvement Project 
Breastfeeding Medicine  2013;8(2):176-180.
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.
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.
Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.
PMCID: PMC3616405  PMID: 23186387
21.  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.
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.
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.
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.
PMCID: PMC3616406  PMID: 23390987
22.  A Controlled Study on Baby-Friendly Communities in Italy: Methods and Baseline Data 
Breastfeeding Medicine  2013;8(2):198-204.
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.
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.
The project is ongoing and will allow estimation of the effect of the BFCI.
PMCID: PMC3616411  PMID: 23398142
23.  The Influence of Mode of Delivery on Breastfeeding Initiation in Women with a Prior Cesarean Delivery: A Population-Based Study 
Breastfeeding Medicine  2013;8(2):181-186.
This study compared breastfeeding initiation following repeat cesarean delivery, successful vaginal birth after cesarean (VBAC), and unsuccessful trial of labor.
Subjects and Methods
We performed a population-based retrospective cohort study of Ohio births (2006–2007) with a previous cesarean delivery. The primary outcomes were breastfeeding initiation rates among women with a previous cesarean delivery. Breastfeeding initiation rates were compared among three different delivery types: repeat cesarean delivery, successful VBAC, and unsuccessful trial of labor. Sociodemographic factors, medical risk factors, and pregnancy-related risk factors were also compared to assess influence on breastfeeding initiation rates.
Women delivered by successful VBAC were 47% more likely to initiate breastfeeding than women delivered by scheduled repeat cesarean (adjusted relative risk 1.47; 95% confidence interval 1.35, 1.60). Women who ultimately delivered by cesarean section with unsuccessful trial of labor were also more likely to breastfeed than women with a scheduled repeat cesarean section (61% vs. 58.7%, respectively) (adjusted relative risk 1.17; 95% confidence interval 1.04, 1.33).
Patients who undergo a scheduled repeat cesarean delivery are less likely to initiate breastfeeding. Women who attempt and succeed in achieving vaginal birth after a previous cesarean section are more likely to breastfeed than are women who deliver by repeat cesarean section. Also, those women who ultimately deliver by cesarean section after an unsuccessful trial of labor were also more likely to breastfeed than those women with a scheduled repeat cesarean section. This suggests there are influences on patient choice for delivery that also may influence the patient's decision to breastfeed.
PMCID: PMC4209487  PMID: 23186385
24.  Nipple Pain, Damage, and Vasospasm in the First 8 Weeks Postpartum 
Breastfeeding Medicine  2014;9(2):56-62.
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.
PMCID: PMC3934541  PMID: 24380583
25.  Randomized Controlled Trial of Docosahexaenoic Acid Supplementation in Midwestern U.S. Human Milk Donors 
Breastfeeding Medicine  2013;8(1):86-91.
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.
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).
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.
PMCID: PMC3566653  PMID: 22568471

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