CASE STUDIES OF DEVELOPING BREASTFEEDING GUIDELINES AT CDC
Presenting Author: Cria G. Perrine, Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity and Obesity
The U.S. Centers for Disease Control and Prevention (CDC) is the country's lead health protection agency and is recognized for using the highest quality scientific information available as part of making public health decisions. Because of the breadth of public health topics and different settings and audiences that guidance may apply to, CDC does not use a single approach for developing guidelines. Instead, general standards exist, and a number of factors are then considered for each context. This talk will use several examples of different guidelines regarding breastfeeding to consider factors such as when guidance is necessary, consistency with other Federal and global agencies, decision making when evidence may be limited, the importance of getting feedback from key partners and stakeholders, and considerations for potential revisions or clarifications of the guidelines as needed after release.
DEVELOPMENT OF CLINICAL PROTOCOLS AT THE ACADEMY OF BREASTFEEDING MEDICINE: A CASE-STUDY
Presenting Author: Tomoko Seo, Protocol Committee, The Academy of Breastfeeding Medicine
A central goal of The Academy of Breastfeeding Medicine (ABM) is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. The Protocol Committee defines a need for a protocol to be developed and appoints the Authors/Expert Panel. Then a summary of the purpose of the protocol and an annotated bibliography is submitted by the Expert Panel. The draft protocol is peer-reviewed by international reviewers. After all revisions are evaluated and necessary changes made, the final protocol is submitted to the Board of Directors of the ABM for approval. ABM aims for clinical protocols to be practical, evidence-based, and applicable across the globe. Sometimes insufficient evidence, variation in medical systems, and cultural diversity can make the process of developing and implementing clinical protocols difficult hard. Protocols and annotated bibliographies are reviewed and updated as necessary every 5 years. A description of the process of development of a recent protocol will be highlighted.
DEVELOPMENT OF EVIDENCE-BASED GUIDELINES AT THE WORLD HEALTH ORGANIZATION: A CASE-STUDY OF THE TEN STEPS TO SUCCESSFUL BREASTFEEDING
Presenting Author: Laurence M. Grummer-Strawn, World Health Organization, Department of Nutrition for Health and Development
WHO has adopted internationally recognized methods and standards for guideline development to ensure that its guidelines are of the highest quality. WHO recommendations must be based on a systematic and comprehensive assessment of the balance of a policy's or intervention's potential benefits and harms and explicit consideration of other relevant factors. The process is multidisciplinary, aiming to minimize any risk of bias in the recommendations. The Ten Steps to Successful Breastfeeding were first published in 1989, long before the current WHO guideline development process was codified. As such, the development of recommendations on the appropriate policies and procedures for facility care of early infant feeding was treated as a new guideline. The WHO Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services was published in November 2017 and an updated list of the Ten Steps to Successful Breastfeeding was published in April 2018. This presentation will discuss the advantages and disadvantages of systematic reviews in developing guidelines, the use of different kinds of evidence (RCTs, observational studies on humans, animal studies, biologic mechanisms, and qualitative research), involvement of expert groups vs. objective panels to review evidence, management of conflicts of interest, and peer review and public comment processes. Examples of how these issues were handled in developing the Ten Steps will be offered.
U.S. FEDERAL EFFORTS TO ADVANCE KNOWLEDGE ON HUMAN MILK COMPOSITION
Presenting Author: Kellie Casavale, U.S. Department of Health and Human Services (HHS), Office of Disease Prevention and Health Promotion (ODPHP)
Co-Authors: Richard Olson, Julia Quam (ODPHP, HHS); Christopher Lynch (National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health); Pamela Pehrsson, Jaspreet Ahuja, Xianli Wu, Ying Li (Agricultural Research Service, U.S. Department of Agriculture)
Nationally representative data from mother-child dyads that capture human milk composition, factors influencing it, and subsequent health effects are crucial to advancing the science base used to inform Federal nutrition and health programs, policies, and consumer information across agencies in the U.S. and Canada and in non-government sectors. U.S. food composition data for human milk (also used in Canada) are outdated; published literature is not adequate to update them. In response, Federal agencies have begun collaborative efforts to establish an initiative on human milk composition. The NIH sponsored a workshop in 2017 with ODPHP and ARS to gather information on data needs; factors affecting human milk composition; methodological challenges in human milk collection, storage, and analysis; and visions for a research program to develop a human milk composition database. Key applications of these data include updating human milk food composition profile(s); informing Dietary Reference Intakes, dietary guidelines, and Codex Alimentarius; monitoring nutrient and other exposures; and advancing research on human milk exposure related to short- and long-term health. In addition to the workshop, initial activities of this initiative include 1) prioritizing human milk components and related data based on public health importance (e.g., potential to inform diet- and/or nutrient-based guidance or clinical practice guidelines) and 2) identifying and/or developing standard protocols and validated measures to collect these data. Efforts aim to establish public-use data repositories with substantive, nationally representative metadata.
WHAT'S NORMAL FOR HUMAN MILK COMPOSITION: LESSONS LEARNED FROM THE INSPIRE PROJECT
Presenting Author: Michelle K. McGuire, Washington State University (WSU)
Co-Authors: Courtney Meehan (WSU), Mark A. McGuire (University of Idaho), Janet Williams (University of Idaho), and the INSPIRE Consortium
The primary focus of the INSPIRE project was to characterize the human milk microbiome in selected locations around the globe and begin understanding biological, environmental, and behavioral factors related to its variation. In all, data and biological samples were collected from 412 mother-infant dyads in 11 locations. This project represented the first large-scale multinational human milk study for several members of the core investigative group. As such, there have been many lessons learned. For example, standardizing, assembling, and providing all collection supplies was fundamental to both successful sample collection and establishing confidence that differences among cohorts were genuine. The early compilation of an operations manual that included not only detailed sample collection methods but also other important information such as publication “rules of the road” and shipping instructions both codified approaches and helped collaborators quickly answer questions as they arose. Social media and frequent communication helped create momentum, community, and enthusiasm as the project progressed. Some unexpected difficulties included the fact that we underestimated the need for a secure, inexpensive, user-friendly data management and distribution plan and dedicated personnel to administer it. We also encountered some unexpected difficulties garnering ethics approvals in some locations; shipping milk collection supplies to another; and securing dry ice for shipping the samples to the US. Although the INSPIRE team enjoyed an all-hands retreat after the samples and data were collected and most of the analyses completed, an addition meeting earlier in the project would have been beneficial. These issues and others will be discussed by members of the INSPIRE Consortium.
Funding: National Science Foundation.
THE MOTHERS, INFANTS AND LACTATION QUALITY (MILQ) PROJECT
Presenting Author: Lindsay H. Allen, USDA-ARS Western Human Nutrition Research Center (WHNRC), Davis, California
Reported values for nutrient concentrations in human milk are needed to set infant and maternal recommended intakes. However, there are no valid Reference Values (RVs) for nutrients in milk. Existing data have many limitations. There relatively few studies of milk composition and concentrations of many nutrients are affected by maternal status and/or intake, consumption of supplements during pregnancy and/or lactation, and food fortification. Moreover, concentrations of most nutrients in milk change during the first year postpartum, and some vary during a feed and during the day. Analytical methods that measure nutrients in milk usually need to be different from those used for serum and some older methods are invalid. The ongoing Mothers, Infants and Lactation Quality (MILQ) study aims to develop valid RVs for milk. Research sites are Copenhagen (Denmark), Dhaka (Bangladesh), Bakoteh (The Gambia) and Rio de Janeiro (Brazil). Inclusion and exclusion criteria are designed to recruit well-nourished, healthy mothers not consuming supplements other than iron, folic acid and calcium (these supplements do not affect the milk nutrient concentration) or heavily fortified foods. Mothers are recruited during pregnancy and within 2-3 days of birth colostrum is collected. Additional milk and blood samples are collected from 250 mothers and infants per site between 1 and 3.49 mo, 3.5 and 5.99 mo, and 6 and 8.49 mo. Exclusive breastfeeding is required through 3.49 mo. The volume of milk consumed by infants is measured with deuterated water at each time point to determine actual infant nutrient intakes. The RVs will be constructed as percentile reference curves so that samples from other surveys and studies can be readily compared. The nutrients will be measured at the WHNRC with 5 analytical platforms including mass spectrometry.
Funding: USDA, ARS and the Bill & Melinda Gates Foundation.
GLOBAL EXPLORATION OF HUMAN MILK (GEHM): A LONGITUDINAL STUDY OF HUMAN MILK COMPOSITION IN URBAN POPULATIONS OF MEXICO, CHINA, AND THE UNITED STATES
Presenting Author: Ardythe Morrow, University of Cincinnati, Cincinnati, OH
Co-Authors: Allison Cline (University of Cincinnati); Sarah Maria, Robert J. McMahon, Shay Phillips (Mead Johnson Nutrition, Evansville, IN); Christina Valentine (University of Cincinnati and Mead Johnson Nutrition, Evansville, IN)
Knowledge of human milk composition is critical for establishing dietary guidelines and the nutritional standards for breast milk substitutes. While human milk composition has been studied over many decades, it has nevertheless not been well defined. Lack of robust characterization of human milk components has been due to several limitations: the number of components to be analyzed; limitations in milk and data collection methods; and the lack of standardized, comparative studies in recent years. Human milk is known to be highly variable, influenced by stage of lactation, time of day, genetics, maternal diet, and environment. Nevertheless, the role of each of these influences has not been well defined for the many components of human milk. And it is not clear how variable or consistent the composition of human milk is across populations.
Funding: NICHD P01 13021; CTSA grant; Mead Johnson Nutrition.
Oral Presentations
CAN DIGITAL TOOLS PROMOTE COMPETENCE AND SUCCESS OF BREASTFEEDING PROMOTION?
Presenting Author: Sunhea Choi, University of Southampton, UK, Human Development & Health Academic Unit
Reviews of breastfeeding intervention studies have shown that breastfeeding education and support, given during prenatal and postpartum periods with routine care by health professionals or non-health professionals, significantly increase exclusive breastfeeding and initiation of breastfeeding. Despite education and other interventions proven to be effective, the UNICEF reports that the progress to improve exclusive breastfeeding has stagnated over the past 15 years, with early initiation of breastfeeding <1hour being 45%, exclusive breastfeeding for the first 6 months 40% in 2017. The availability and use of digital technologies have rapidly increased globally. In 2015, the World Bank reported that 46% of individuals (3.15 billions) used Internet. This has increased to 51% (3.58 billions) in 2017 and 53% (4.02 billions) in 2018. Among these, 80% (3.20 billions) use social media. Digital technologies bring the opportunity to educate and influence mothers, health professionals and the wider community. Although this is a relatively new field, examples of creative approaches, using a mixture of social media, apps and/or education, to breastfeeding promotion are emerging, i.e. 2015 Twitter campaign in Saudi Arabia, UNICEF China (micro)blogs and forum using Weibo and Notsorrymums campaign in Northern Ireland. Digital technologies can innovate the promotion and education of breastfeeding, deliver education cost-effectively and/or increase its accessibility. The question is “how”. The key for success found from other areas is embedding a technology-enabled/enhanced intervention within the existing healthcare and support contexts. The World Development Report 2016 considers this as understanding “problems” for which technological “solutions” are employed. From looking at previous interventions, we will identify key elements to consider (i.e. target audience, objectives, styles/types of intervention) when implementing digital interventions.
HIGHLIGHTS OF HUMAN MILK AND LACTATION RESEARCH IN JAPAN
Presenting Author: Katsumi Mizuno, Showa University of Medicine, Department of Pediatrics
With recent changes to the nutritional strategies for preterm infants, early initiation of enteral nutrition is becoming a standard practice. For Japan, this all started about 20 years ago with a multicenter prospective study on early enteral feeding (within 24 hours of birth). The results were excellent: infants on early enteral feeding had lowered risks for chronic lung disease, necrotizing enterocolitis and cholestasis; they also showed better weight gain and cognitive development at 6 years of age. Initiating enteral feeding within 24 hours of birth was not difficult in those days as it was common practice to use another mother's unpasteurized milk. With increasing awareness of disease transmission via unpasteurized breast milk, the practice of early enteral feeding was abolished. Enter 2017 and the Japanese Human Milk Bank Association (JHMBA) was formed. Donor human milk is now available at all NICUs in Japan. A new multicenter prospective study is currently under way to inform on the standardization of enteral nutrition using donor human milk (DHM) for very preterm infants. The other current challenge on infant nutrition is how to move toward an exclusive human milk diet. We have had instances where infants suffered milk allergy or ileus due to fatty acid calcium stone with the use of bovine milk-based fortifier. To this end, JHMBA has been conducting research on the use of lyophilized mother's own milk (MOM). We have been successful in lyophilizing MOM with no detectable contamination. The increase in osmolarity when using lyophilized MOM is still of concern, but as long as less than 20% lyophilized MOM is used as supplement the osmolarity does not exceed 400mOsm/l. In this presentation, I will discuss the past, present, and future of JHMBA with a focus on its research activities.
BREASTFEEDING IN MALAYSIA: PREVALENCE, BARRIERS AND MOTIVATORS
Presenting Author: Bee Koon Poh, Universiti Kebangsaan Malaysia, Nutritional Sciences Programme & Centre for Community Health, Faculty of Health Sciences
Co-Authors: Sameeha Mohd Jamil (Universiti Kebangsaan Malaysia – Faculty of Health Sciences); Nur Shafawati Mohd Ghazali (Ministry of Health Malaysia – Nutrition Division)
Worldwide prevalence of exclusive breastfeeding has improved over the past decades. Although a similar rise has been observed in Malaysia, the practice is still not widespread. This presentation aims to examine breastfeeding rates in Malaysia and to explore barriers and motivators towards exclusive breastfeeding. Findings from periodical National Health and Morbidity Surveys (NHMS) have reported increasing rates over the past two decades in ever-breastfeeding (1996 at 88.6%; 2006 at 94.7%; 2016 at 98.1%); exclusive breastfeeding for up to 6 months (2006 at 14.5%; 2016 at 47.1%); and continued breastfeeding for up to 2 years (1996 at 11.7%; 2006 at 37.4%; 2016 at 39.4%). Exclusive breastfeeding was more common among Malay mothers, housewives, and mothers with lower educational levels; while mothers from rural areas tend to breastfeed longer than their urban counterparts. NHMS 2016 also reported that majority of mothers (93.2%) made the decision themselves to stop breastfeeding; and that major barriers were inadequate breast milk (59.0%), tiredness due to work (16.4%), and latching/suckling problems (8.6%). A qualitative study on successful exclusive breastfeeding pratices among mothers found that motivating factors include psychosocial, emotional, economic, adequate information on breastfeeding, and religion; whereas hindering factors were biophysical (perceived insufficient supply), physiological changes, inconvenience, returning to work, and lack of facilities. In conclusion, although prevalence of breastfeeding in Malaysia is increasing, there are still large proportions of infants who are not breastfed. Considerations that may aid in successful exclusive breastfeeding include social support and access to lactation consultant early on during the breastfeeding period.
Funding: None.
LEAD THE TREND: The FIRST EVIDENCE-BASED GUIDELINES FOR BREASTFEEDING PROMOTION IN CHINA
Presenting Author: Meng Mao, West China Second University Hospital, Sichuan University, Department of Pediatrics
Background: Breastfeeding supports early and long-term development and can reduce disease-related morbidity. However, in 2012–2014, the EBF rate in China was 28%, without any increase in 3 years. The General Office of the State Council of China issued the “National Nutrition Plan” on June 30, 2017, which proposes that EBF rate reach >50% in infants aged 0–6 months by 2020 and further increases by 10% by 2030.
Objective/Hypothesis: To develop specific guidelines and recommendations for breastfeeding promotion in China.
Methods: A multidisciplinary working group developed evidence-based, practical guidelines targeting mothers, healthy infants, and infants with specific needs. Guidelines referenced existing domestic and international practices, while considering the current situation in contemporary China.
Results: Guidelines were targeted 3 stages. In obstetrics, preparations for pregnancy and lactation, depression in pregnancy/lactation, insufficient milk secretion, crater nipple and mammary duct obstruction and mastitis, etc were addressed. In neonatology, the guideline includes intervention measures to promote early breastfeeding and early milk secretion, skin contact etc. In pediatrics, the guideline addresses assessment of breastfeeding efficacy, applications of growth curves, use of the Human Breastfeeding Assessment Scale and insufficient milk secretion, cow's milk protein allergy and poor growth, etc.
Conclusions: The guidelines provide scientific support for the actions promoted by the Ministry of Health and should play an important role in breastfeeding promotion in China.
Funding: Chinese Journal of Pediatrics.
EXCLUSIVE BREASTFEEDING POSSIBLY REDUCES THE ADVERSE EFFECT OF LATE PRETERM BIRTH ON GASTROINTESTINAL INFECTION
Presenting Author: Kazue Nakamura, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Department of Epidemiology
Co-Authors: Takashi Yorifuji (Okayama University Graduate School of Environmental and Life Science – Department of Human Ecology); Hiroyuki Doi (Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences – Department of Epidemiology)
Background: Late preterm infants (LPIs) are at greater risk of short- and long-term morbidity than are term infants (TIs). However, whether breastfeeding can reduce the adverse effect of late preterm birth on various diseases remains unclear.
Hypothesis: Breastfeeding can modify the adverse effects of late preterm birth on hospitalization for respiratory and gastrointestinal infection from 6 to 18 months of age.
Methods: Data were extracted from a nationwide longitudinal survey of Japanese children. We restricted the analysis to TIs and LPIs with information on history of hospitalization (n = 31,578). Multivariate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated to evaluate the association between late preterm birth and hospitalization using term birth as the reference. We next stratified the infants by breastfeeding status (exclusively breastfeeding vs. partially breastfeeding and formula-feeding) and evaluated the association between late preterm birth and hospitalization.
Results: LPIs were more likely to be hospitalized for respiratory and gastrointestinal infection (aOR, 1.52; 95% CI, 1.21–1.92 and aOR, 1.73; 95% CI, 1.14–2.62, respectively). Stratification by breastfeeding status showed that LPIs had a higher risk of hospitalization for respiratory infection in both strata. Conversely, a higher risk of hospitalization for gastrointestinal infection was observed only in the partially breastfeeding and formula-feeding stratum.
Conclusions: The higher morbidity risk in LPIs than TIs was modified by breastfeeding practices. Exclusive breastfeeding seems to reduce the adverse effect of late preterm birth on gastrointestinal infection.
WHAT'S NORMAL? GLOBAL VARIATION IN HUMAN MILK MICROBIOME AND OTHER RELATED FACTORS
Presenting Author: Janet Williams, University of Idaho
The human milk microbiome consists of myriad types of bacteria, the presence and composition of which have varied across cohorts and studies. Variation has been associated with factors such as stage of lactation, maternal BMI, delivery mode, and maternal diet. Another major consideration in understanding this variation is understanding and controlling for potential effects of sampling and methodological differences on the results obtained. To better understand biological, behavioral, and environmental factors contributing to the variation seen in the milk microbiome, the INSPIRE study was conducted. Milk, maternal saliva, and infant feces were collected using standardized protocols and supplies, and detailed information regarding maternal dietary intake, social and behavioral patterns, and family structure was collected in 11 different locations around the world. Milk from each location was shipped to two laboratories (Spain and USA), where DNA from the milk samples were extracted using similar protocols, amplified using PCR primers targeting hypervariable regions of the 16S rRNA gene, sequenced, and data analyzed to characterize the milk samples' bacterial compositions. Results from both laboratories suggest that Staphylococcus and Streptococcus were present in almost all milk samples, but more extensive sets of core bacteria were present in some of the cohorts. Importantly, substantial intra- and inter-cohort variability existed in bacterial community membership within and among cohorts. Variation in the milk bacterial community was also associated with many factors, including the intake of various foods; for instance, relative abundance of Proteobacteria was higher in milk produced by women who consumed meat than those that did not. By minimizing the differences in collection and sample processing, similarities/dissimilarities in milk bacterial compositions among locations and other factors that are associated with this variation can be better identified.
HUMAN MILK OLIGOSACCHARIDES: MATERNAL MODIFIERS AND INFANT OUTCOMES
Presenting Author: Lars Bode, University of California, San Diego, Department of Pediatrics and Larsson-Rosenquist Foundation Mother-Milk-Infant Center of Research Excellence, La Jolla, California, USA
The past decade has experienced an immense increase in research on human milk oligosaccharides (HMOs), a group of over 150 unconjugated complex glycans that, together, represent the third most abundant solid component of human milk. Our continuously evolving analytical platform allows us to generate reliable HMO composition data from less than a drop of milk – and from several hundred milk samples per week. This high-throughput approach has enabled us, together with our collaborators from around the world, to investigate which maternal genetic and environmental factors influence HMO composition as well as how HMO composition impacts health and development of infants and mothers. In parallel to our analytical platform that enables HMO analyses for hypotheses-generating cohort studies, we developed a preparative platform to extract HMOs from pooled donor human milk for efficacy testing in suitable in vitro and in vivo models. We carefully ensure that our HMO preparations are very low in lactose, salt, and endotoxin contaminations, which might otherwise compromise research results. After initial efficacy testing of pooled HMOs, we apply a multi-dimensional chromatography approach for the stepwise fractionation of HMOs to determine structure-function relationships. So far, this approach of combining association data from human cohort studies with efficacy data from in vitro and in vivo testing has taught us that sometimes specific HMOs are required to exert an effect that is highly structure-specific, dose-dependent, and likely receptor-mediated. Other times, specific HMO composition profiles (mixtures of HMOs in specific ratios) are required, and the effect is likely mediated through shaping microbial communities and/or intricate host immune responses.
IMPACT OF DIET ON THE INFANT METABOLOME, MICROBIOME AND IMMUNE DEVELOPMENT
Presenting Author: Carolyn M. Slupsky, University of California, Davis, Department of Nutrition and Department of Food Science and Technology
The link between food and health is complex, particularly for the developing neonate, as the period after birth is the time when long term programming is occurring in the neurologic, immune and metabolic regulatory systems. Breastfeeding is known to have short- and long-term benefits, and we have previously reported profound differences between breast-fed and formula-fed infants with respect to growth trajectory, immunological development, succession of the gut microbiome and metabolism that indicate development of unique metabolic phenotypes as a consequence of diet. While the world health organization (WHO) advises that no other food other than human milk be introduced before 6 months of age, many infants are supplemented with formula or encouraged to consume complementary foods even before 4 months of age. To date, not much is known about the impact of other foods introduced during the first 6 months on the microbiome and metabolism. To investigate how complementary feeding affects the gut microbiome and overall host metabolism, fecal microbial ecology combined with comprehensive metabolic profiling of serum and feces were analyzed in breast- and formula- fed infants. Our results highlight the need for a greater understanding of how the introduction of complementary foods shape immunity and metabolism in the developing neonate.
IMMUNE COMPONENTS IN HUMAN MILK ARE ASSOCIATED WITH EARLY INFANT IMMUNOLOGICAL HEALTH OUTCOMES: A PROSPECTIVE THREE-COUNTRY ANALYSIS
Presenting Author: Donna Geddes, University of Western Australia, School of Molecular Sciences
Co-Authors: Daniel Munblit, Robert Boyle, John Warner (Imperial College London - Department of Paediatrics); Marina Treneva, Alexander Pampura (Veltischev Clinical Pediatric Research Institute of Pirogov Russian National Research - Allergy Department); Diego G. Peroni (University of Pisa - Department of Paediatrics); Silvia Colicino, (Imperial College London - National Heart and Lung Institute); Li Yan Chow (Imperial College London - Department of Paediatrics); Shobana Dissanayeke (Royal Holloway University of London School of Biological Sciences - Biomedical Sciences); Attilio L. Boner (University of Verona – Department of Paediatrics)
Background: Evidence of the mechanisms by which breastfeeding may improve allergic outcomes in early childhood has not been elucidated. Immune mediators in human milk (HM) may contribute to infant immune maturation as well as protection against atopy/allergy.
Objective: The aim of this study was to investigate relationships between levels of immune mediators in colostrum and mature milk and infant outcomes in the first year of life.
Methods: 398 pregnant/lactating women in the United Kingdom, Russia and Italy were recruited and provide samples of colostrum and mature human milk (HM). Samples were analysed for immune components.
Results: HM interleukin (IL) 13 was associated with less eczema and colostral IL13 was linked to less food allergy. Hepatocyte growth factor was protective for common cold incidence at 12 months. Whereas transforming growth factor 2 was associated with a higher risk of eczema.
Conclusions: Data from this study suggests that differences in the individual immune composition of HM may have an influence on early life infant health outcomes.
Funding: DG receives a salary from an unrestricted research grant (Medela AG, Switzerland).
MULTI-COMPONENT CHARACTERIZATION OF BREAST MILK “GLYCOTYPES” IN POPULATIONS AT HIGH- OR LOW-RISK FOR ALLERGIC DISEASES
Presenting Author: Kirsi Jarvinen-Seppo, University of Rochester School of Medicine
Co-Authors: Antti Seppo, Sade Fridy, Puja Sood Rajani, Juilee Thakar, R. John Looney (University of Rochester School of Medicine); Chloe Yonemitsu, Lars Bode (University of California San Diego)
Background: Our prior studies have shown that the Old Order Mennonite (OOM) population has a lower prevalence of allergic diseases and asthma than the general U.S. population.
Objective: To determine if there is variation in breast milk immune composition between OOM, a low allergy risk population with long breastfeeding duration, and a control group from urban Rochester (ROC).
Methods: Breast milk samples from a cohort of OOM (n = 60) and ROC (n = 31) mothers at 1–2 months of lactation were assayed for 39 cytokines by Luminex, 19 human milk oligosaccharides (HMOs) by HPLC and IgA1 and IgA2 to food (n = 4), inhalant antigens (n = ) and whole bacteria (n = 7) by Luminex. Levels were compared between groups and across components using parametric and non-parametric methods to analyze the impact of various maternal exposures on milk composition. Additionally, clustering analysis was performed to identify clusters of cytokines, HMOs and specific IgA.
Results: Compared to ROC milk, OOM milk had significantly higher levels of TGFbeta2, IL10, and IL6. OOM milk also had significantly higher levels of IgA specific for L. reuteri and several inhalant and food antigens and lower levels of IgA specific to E. cloacae. Among HMOs, OOM had significantly higher LNnT and lower LNFPIII. Cytokine clustering showed grouping of BAFF, TSLP, sTNF-R2 with TWEAK and TGFbeta2 with IL6. Several bacteria-specific IgAs clustered together (E. coli, M. morganii, L. reuteri, S. aureus, E. cloacae), as do IgA against dust mite, mold, mouse, rat, birch, dog and cat.
Conclusion: To our knowledge this is the first multi-component characterization of breast milk between mothers with different lifestyles. OOM milk is richer in many immune components, which together with longer breastfeeding duration may provide protection against allergic diseases.
Funding: University of Rochester Clinical and Translational Science Institute.
NUTRIENTS OR NURSING? UNDERSTANDING HOW BREAST MILK FEEDING AFFECTS CHILD COGNITION
Presenting Author: Wei Wei Pang, National University of Singapore (NUS)
Co-Authors: PT Tan (NUS); S Cai (Singapore Institute for Clinical Sciences); D Fok (NUS); MC Chua, SB Lim (KK Women's and Children's Hospital); LP Shek (NUS and Singapore Institute for Clinical Sciences); KH Tan, F Yap (KK Women's and Children's Hospital), PD Gluckman (Liggins Institute); KM Godfrey (University of Southampton); MJ Meaney (McGill University); R van Dam (NUS); BFP Broekman (VU University Medical Center); MS Kramer (NUS and McGill University); YS Chong (NUS and Singapore Institute for Clinical Sciences); A Rifkin-Graboi (National Institute of Education, Singapore)
Background: It is unknown whether breastfeeding benefits child cognition through breast milk nutrients alone, the physical/emotional contact during breastfeeding, or a combination of both.
Objective/Hypothesis: We explored the associations between mode of breast milk feeding (the “nursing”) and type of milk feeding (the “nutrients”) with child cognition.
Methods: Healthy children from the GUSTO cohort participated in repeated neurodevelopmental assessments between 6 and 54 months. For content, we compared children exclusively bottle-fed according to type of milk received: formula only vs some/all breast milk. For mode, we included only children who were fully fed breast milk, comparing those fed directly at the breast vs those fed partially/completely by bottle.
Results: Compared to children fed formula only, those who were bottle-fed breast milk demonstrated significantly better cognitive performance on both the Bayley Scales of Infant and Toddler Development-III and Kaufman Brief Intelligence Test-2 at 24 (adjusted mean differences; 95% CI: 1.36; 0.32, 2.40) and 54 (7.59; 1.20, 13.99) months, respectively. Children fed directly at the breast performed better at the deferred imitation task at 6 months (0.67; 0.02, 1.32) and relational binding tasks at 6 (0.41; 0.07, 0.74), 41 (0.67; 0.04, 1.29) and 54 (0.12; 0.01, 0.22) months vs children bottle-fed breast milk.
Conclusions: These modest significant associations suggest that the nutritional content of breast milk may improve general child cognition, while feeding infants directly at the breast may benefit memory.
Funding: NMRC/TCR/004-NUS/2008; NMRC/TCR/012-NUHS/2014, and the Singapore Institute for Clinical Sciences, Agency for Science Technology and Research (A*STAR).
ENVIRONMENTAL, SOCIAL, AND BEHAVIORAL CHARACTERISTICS AND THE HUMAN MILK MICROBIOME
Presenting Author: Courtney L. Meehan, Washington State University – Department of Anthropology
Co-Authors: Michelle K. McGuire, Avery Lane, Kimberly Lackey, Abhishek Kaul (Washington State University); Mark A. McGuire, Janet Williams, William Price (University of Idaho); Debela Gindola (Hawassa University); the INSPIRE Consortium
Background: Human milk, which harbors a diverse microbiome, is an early and consistent source of bacteria to infants. However, there are no data or inconsistent results on whether or how the human milk microbiome (HMM) is related to maternal characteristics (age, parity, time postpartum, birth mode), household environments (household composition, animal exposure), and social and behavioral patterns (diversity of caregivers, intensity of maternal-infant interactions, and breastfeeding).
Objective: We examined the relationships between women's (n = 348) HMM diversity and community composition and maternal characteristics, household environments, and caregiving behaviors in 10 populations across Africa, Europe, and the Americas (the INSPIRE study).
Methods: Human milk samples, demographic, and survey data were collected via standardized procedures. HMM community structure was determined by amplifying, sequencing, and classifying (to the genus level) the V1–V3 region of the bacterial 16S rRNA gene.
Results: HMM alpha diversity and the relative abundance of specific genera (e.g., Dyella, Rhizobium, Achromobacter, Kocuria) were significantly associated to a host of maternal and household characteristics and social/behavioral patterns.
Conclusion: Our results identify multiple external influences on HMM diversity and community composition and provide initial evidence suggesting that HMM diversity and composition may reflect short- and long-term environmental exposures, possibly priming infants for the worlds in which they are reared.
Funding: National Science Foundation.
HUMAN MILK OLIGOSACCHARIDES (HMOs) AND EXCESSIVE WEIGHT GAIN IN EXCLUSIVELY BREASTFED INFANTS
Presenting Author: Melanie W. Larsson, University of Copenhagen and University College Copenhagen, Denmark
Co-Authors: Anni Larnkjær, Mads Lind, Christian Mølgaard (University of Copenhagen); Chloe Yonemitsu (University of California, San Diego); Kim Michaelsen (University of Copenhagen); Lars Bode (University of California, San Diego)
Background: Some infants have excessive weight gain during the first months of exclusive breastfeeding. HMO composition has been shown to be associated with infant growth and body composition.
Objective/Hypothesis: To investigate the associations between HMOs and growth in infants with excessive or normal weight gain.
Methods: HMOs were analyzed by HPCL in milk samples from mothers of 11 infants with excessive weight gain (mean increase in weight-for-age SDS from birth to 5 mo: 1.6, HW group) during exclusive breastfeeding (≥4 mo) and compared to a control group of 15 infants with normal weight gain (NW group). Infant body composition (bioimpedance at 5 mo), and infant weight and length (5 and 9 mo) and maternal BMI were measured.
Results: All infants were included in the initial analysis. Three mothers of HW and two mothers of NW infants were non-secretors. At 5 mo LSTc, LNnT, diversity, and evenness were lower in the HW group with no difference between the groups at 9 mo. In an analysis of the combined HW and NW groups at 5 mo LNnT, LNFP-I and LSTc were negatively associated with length-for-age SDS. Furthermore, percentage fat mass was negatively associated with diversity, evenness and LNH. Maternal BMI was negatively associated with 6′SL, LNT, LSTb, and DSLNT and positively associated with total HMOs and HMO-bound fucose.
Conclusions: These data support that HMO composition is related to both infant growth and body composition. Furthermore, they suggest that maternal BMI has an effect on HMO composition with potential impact on infant health and disease.
Funding: University College Copenhagen, University of Copenhagen and Family Larsson-Rosenquist Foundation.
WITHDRAWN
THE IMPACT OF MATERNAL VITAMIN DEFICIENCIES AND SUPPLEMENTATION ON BREAST MILK LEVELS AND INFANT VITAMIN STATUS
Presenting Author: Lindsay H. Allen, USDA-ARS Western Human Nutrition Research Center (WHNRC), Davis, California
It has been known for several decades that maternal vitamin deficiencies can lead to low vitamin concentrations in milk. In 1994, we suggested that in lactation micronutrients can be categorized into two groups. Group I micronutrients include all the B vitamins except folate, all the fat soluble vitamins, iodine, selenium, and probably choline. The concentration of these nutrients in milk is correlated with maternal status, and maternal deficiency can lead to infant depletion. Conversely, maternal supplementation can increase their concentration in milk. There are fewer Type II micronutrients; folate, iron, minerals such as iron, copper and zinc, and calcium. Status or intake of the mother, including supplementation, does not affect levels of these nutrients in milk, so the mother may become more depleted during lactation while her infant is protected. There are still many questions around this general classification scheme, however. How deficient does the mother have to be before milk concentrations fall low enough to adversely affect infant status? There are few data on this question for several reasons; reluctance to question the nutritional quality of milk, difficulties related to milk sampling and analysis protocols, and lack of reference values for milk micronutrients and infant status. Similarly, data are sparse concerning the effects of maternal supplementation on milk micronutrients and infant status. For some vitamins, maternal supplementation during pregnancy may be most important so that the infant accumulates adequate stores in utero. For others, milk concentrations are responsive if the mother is supplemented during lactation, with the amount of response differing among vitamins. In general <5% of a supplement taken by a lactating mother appears in milk but this can improve infant intake substantially. In this presentation we will share data on milk composition of women in many countries, some of whom were participants in maternal supplementation or food fortification studies.
Funding: USDA, ARS and the Bill & Melinda Gates Foundation.
EFFECTS OF MATERNAL SUPPLEMENTATION WITH SMALL-QUANTITY LIPID-BASED NUTRIENT SUPPLEMENTS ON BREAST MILK COMPOSITION AND INFANT OUTCOMES
Presenting Author: Kathryn Dewey, University of California, Davis – Department of Nutrition
The potential effects of maternal nutrient supplementation on human milk lipids, proteins and oligosaccharides (HMOs) are poorly understood. In the International Lipid-based Nutrient Supplements (iLiNS) Project, we conducted two randomized controlled trials in Ghana (n = 1320) and Malawi (n = 1391) to evaluate the impact of lipid-based nutrient supplements (LNS) provided during pregnancy and the first 6 months postpartum, and to the infant from 6 to 18 months, on maternal and child outcomes. Women were randomly assigned to receive daily either: 1) iron-folic acid (pregnancy); 2) multiple micronutrients (pregnancy and lactation); or 3) LNS (pregnancy and lactation). Breast milk samples were collected at 6 months postpartum and analyzed for milk fatty acids (Oaks et al. Prostaglandins Leukot Essent Fatty Acids. 2017); in Malawi they were also analyzed for several bioactive proteins (lactoferrin, lactalbumin, lysozymes, antitrypsin, immunoglobulin A, and osteopontin) and numerous HMOs (Jorgensen et al. J Nutr 2017). LNS increased breast milk alpha-linolenic acid levels in Ghana, but not Malawi. There was no effect in either site on other milk fatty acids including DHA. Milk DHA levels were 2–3 times higher than the worldwide average, likely due to frequent fish consumption. In Malawi, there was no effect of LNS on milk bioactive proteins or HMOs. This presentation will discuss other factors related to levels of these milk constituents, and their association with infant growth and inflammation.
MORE MILK FOR DAUGHTERS? SEX-DIFFERENTIATED BREASTFEEDING IN TWO BIRTH COHORTS
Presenting authors: Meghan Azad, University of Manitoba, Department of Pediatrics and Katie Hinde, Arizona State University, Center for Evolution and Medicine
Co-Authors: N.J. Timpson (ALSPAC Cohort); S. Moossavi, A.B. Becker, P. Mandhane, S.E. Turvey, T.J. Moraes, D. Lefebvre, P. Subbarao, M.R. Sears (CHILD cohort)
Background: Among diverse mammalian species, maternal milk synthesis and nursing behavior can differ between male and female offspring. This has rarely been studied in humans.
Objective: To assess whether breastfeeding differed by infant sex in two large prospective birth cohorts.
Methods: Breastfeeding initiation, exclusivity and duration were prospectively reported by mothers in the 2009–12 CHILD cohort (n = 3,157; Canada) and the 1991–92 ALSPAC cohort (n = 12,092; UK). Sex differences were evaluated by two-sided t-test and multivariable regression.
Results: Breastfeeding initiation rates were 97.8% in CHILD (mean 3.8 ± 2.2 months exclusive and 11.1 ± 6.5 months any breastfeeding) and 74.9% in ALSPAC (2.0 ± 1.5 months exclusive, 5.3 ± 4.6 months any). Breastfeeding initiation did not differ between mothers of daughters versus sons. However, among breastfed infants in both cohorts, exclusive breastfeeding duration was significantly longer for daughters (mean difference in CHILD: +9.8 days, 95%CI 4.8-14.8, p = 0.0001; ALSPAC: +3.4 days, 95%CI 1.5–5.4, p = 0.0005). The duration of any breastfeeding was also longer for daughters (CHILD: +11.5 days, 95%CI −2.7–25.7, p = 0.11; ALSPAC: +9.6 days, 95%CI 3.8–15.3, p = 0.001). These sex differences persisted in multivariable models, and were similar in magnitude to the effect estimates for established predictors of breastfeeding, such as parity, maternal overweight, post-secondary education, and method of delivery.
Conclusions: Results from two distinct human cohorts suggest that mothers sustain lactation longer for daughters than for sons, consistent with evidence from other mammalian species. Further research is needed to explore the biological and social factors underlying these sex differences. Meanwhile, it is important to consider infant sex in human milk and lactation research.
Funding: CIHR, AllerGen NCE.
THE INFLUENCE OF RELAXATION THERAPY ON BREAST MILK HORMONES AND MACRONUTRIENT CONTENT: A RANDOMIZED CONTROLLED TRIAL
Presenting Author: Nurul Husna M. Shukri, Universiti Putra Malaysia, Department of Nutrition & Dietetics
Co-Authors: Mary Fewtrell, Jonathan Wells (GOS Institute of Child Health UCL, UK)
Background: Breastfeeding involves complex biological and behavioral signaling between mothers and infants. In a randomized controlled trial we found that the use of relaxation therapy by breastfeeding mothers led to reduced maternal stress and increased infant sleep duration, with more optimal infant weight gain.
Objective/Hypothesis: To test the hypothesis that the relaxation intervention influenced infant outcomes via alterations in certain signaling components in breast milk, we investigated effects of the intervention on breast milk hormones and macronutrient content.
Methods: Primiparous breastfeeding mothers and full-term infants were randomized to intervention (IG, n = 33) and control groups (CG, n = 31) at 2 weeks post-partum. Home visits (HV) were performed at 2–3(HV1), 6-8(HV2) and 12–14(HV3) weeks to measure maternal stress, breast milk composition and infant behavior and growth. IG mothers were asked to listen daily to a relaxation tape for at least 2-weeks post-HV, including during a breastfeeding session at each HV. Cortisol, leptin, ghrelin and macronutrient content were measured in fore- and hindmilk samples.
Results: IG mothers had a greater reduction in milk cortisol concentration within a feed at HV1 than CG (Δ34s%; p = 0.02, CI: −63s%, −5s%). Milk leptin concentration reduced within a feed in the CG, and increased in the RG (p = 0.02, CI: 11.5s%, 157.3s%), whereas foremilk ghrelin was significantly lower in CG than RG (Δ16.5s%; p = 0.002, CI: −26.7s%, −6.3s%) at HV2. Foremilk carbohydrate was significantly higher in the RG than CG (Δ HV3 = 0.29, p = 0.03, CI: −0.55, −0.03). There were consistent non-significant trends for higher hindmilk fat (HV1–3) and foremilk carbohydrate (HV2–3) in the IG.
Conclusions: The relaxation intervention had effects on milk ghrelin, leptin and carbohydrate, raising the hypothesis that these may be biological signals mediating the observed intervention effects on infant behaviour and growth. These results from an experimental study provide evidence on potential mother-infant signaling mechanisms for investigation in future studies.
Funding: Ministry of Higher Education Malaysia & Universiti Putra Malaysia for funding the Ph.D study, and GOS Institute of Child Health UCL, U.K., for funding the research study.
MATERNAL VITAMIN D (VITD) STATUS AFFECTS HEPATITIS B VACCINE (HBV) RESPONSE IN BREASTFEEDING INFANTS
Presenting Author: Carol Wagner, Medical University of South Carolina (MUSC), Department of Pediatrics, Charleston, South Carolina
Co-Authors: Danforth A. Newton, John E. Baatz
Background/Hypothesis: Vit D affects immune function across the lifespan, which includes pregnancy and lactation. We hypothesized that the response of fully breastfeeding infants to HBV would differ as a function of both maternal and infant's vit D status as measured by circulating 25(OH)D concentration.
Methods: Circulating 25(OH)D concentration and HBV titers were measured in a subset of mothers and infants (n = 20) participating in a lactation vit D supplementation clinical trial. Mothers were randomized to receive either 400 vs. 6400 IU vitamin D3/day and infants 400 IU/day or placebo (if mother was in 6400 IU group). 25(OH)D concentration (RIA) and infant anti-HBV IgG titers (ELISA) at 4 and 7 months of age (n = 20 each) were measured. The association between maternal vit D treatment group, circulating 25(OH)D, and HBV IgG titers was explored using Spearman's correlation and ANOVA.
Results: Infants of mothers in 6400 IU group had similar titers compared to 400 IU control infants at 4-months of age, but titers decreased significantly by 7-months (p < 0.001). Group A, infants directly-supplemented 400 IU vitamin D/day (mothers supplemented with 400 IU vitamin D/d); Group B, mothers only supplemented 6400 IU vitamin D/d (n = 20/group).
Conclusions: HBV titers of fully breastfeeding infants differed at 7 months of age by maternal vi tD treatment and not on the basis of infant vit D status. These findings suggest that the regulation of infant immune response to maternal signals differentially through her breast milk on the basis of maternal vit D status.
Funding: NICHD, SCTR/NIH.
LACTATING MOTHERS AND INFANTS RESIDING IN AN AREA WITH EFFECTIVE SALT IODIZATION PROGRAM HAVE NO NEED FOR IODINE SUPPLEMENTS: RESULTS FROM A DOUBLE-BLIND, PLACEBO-CONTROLLED, RANDOMIZED CLINICAL TRIAL
Presenting Author: Pantea Nazeri, Tehran University of Medical Sciences, Tehran, Iran- Breastfeeding Research Center; Shahid Beheshti University of Medical Sciences, Tehran, Iran- Research Institute for Endocrine Sciences
Co-Authors: Zhale Tahmasebinejad, Yadollah Mehrabi, Mehdi Hedayati, Parvin Mirmiran, Fereidoun Azizi (Shahid Beheshti University of Medical Sciences, Research Institute for Endocrine Sciences; Shahid Beheshti University of Medical Sciences - School of Public Health, Tehran, Iran)
Background: The necessity of iodine supplementation in lactating mothers residing in countries with sustained salt iodization programs for iodine-sufficiency of breastfed infants remains unclear.
Objective: The aim of the study was to investigate the effect of iodine supplementation on iodine status and growth parameters of lactating mothers and breastfed infants during the first year of infancy.
Methods: In this multi-center, double-blinded, randomized clinical trial conducted in four healthcare centers in Tehran (Iran), healthy lactating mothers and their term newborns aged 3–5 days were randomly assigned to treatment groups: placebo, 150 μg/d iodine, or 300 μg/d iodine, and followed-up for 12 months. The primary outcomes were maternal and infant urinary iodine concentrations (UICs), breast milk iodine concentrations (BMICs), and infant growth parameters, measured at 1, 2, 4, 6, 9, and 12 months during routine health visits.
Results: One hundred and eighty mother-newborn pairs participated between October 2014 and January 2016. Median baseline UICs (interquartile range) were in mothers 84 (41–143) μg/L and infants 208 (91–310) μg/L. The 300 μg iodine/d group showed significantly higher UICs and BMICs than did the 150 μg iodine/d or placebo groups. Infants in all groups showed iodine sufficiency (median UIC ≥100 μg/L) throughout the study period. Infant anthropometric measurements were similar between three arms of treatment group over the study period.
Conclusions: Supplementation of breastfeeding mothers with either 300 or 150 μg iodine/d improved their iodine status; however, the iodine status of infants in all groups studied indicated iodine sufficiency during the first year of infancy.
Funding: Grant from the Research Institute of Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
BREASTFEEDING AND MATERNAL HEALTH OUTCOMES
Presenting Author: Ranadip Chowdhury, Society for Applied Studies, New Delhi, India
Co-Authors: Bireshwar Sinha, Sunita Taneja, Nita Bhandari, (Society for Applied Studies, New Delhi, India); Mari Jeeva Sankar (Newborn Health Knowledge Centre, ICMR Centre for Advanced Research in Newborn Health, Department of Paediatrics, All India Institute of Medical Sciences, New Delhi, India); Nigel Rollins, Rajiv Bahl (World Health Organization - Department of Maternal, Newborn, Child and Adolescent Health, Geneva, Switzerland); Jose Martines (Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway)
Objectives: To evaluate the effect of breastfeeding on long-term (breast carcinoma, ovarian carcinoma, osteoporosis and type 2 diabetes mellitus) and short-term (lactational amenorrhoea, postpartum depression, postpartum weight change) maternal health outcomes.
Methods: A systematic literature search was conducted in PubMed, Cochrane Library and CABI databases. Outcome estimates of odds ratios or relative risks or standardized mean differences were pooled. In cases of heterogeneity, subgroup analysis and meta-regression were explored.
Results: Breastfeeding >12 months was associated with reduced risk of breast and ovarian carcinoma by 26% and 37%, respectively. No conclusive evidence of an association between breastfeeding and bone mineral density was found. Breastfeeding was associated with 32% lower risk of type 2 diabetes. Exclusive breastfeeding and predominant breastfeeding were associated with longer duration of amenorrhoea. Shorter duration of breastfeeding was associated with higher risk of postpartum depression. Evidence suggesting an association of breastfeeding with postpartum weight change was lacking.
Conclusion: This review supports the hypothesis that breastfeeding is protective against breast and ovarian carcinoma, and exclusive breastfeeding and predominant breastfeeding increase the duration of lactational amenorrhoea. There is evidence that breastfeeding reduces the risk of type 2 diabetes. However, an association between breastfeeding and bone mineral density or maternal depression or postpartum weight change was not evident.
THE BURDEN OF SUBOPTIMAL BREASTFEEDING IN MEXICO: MATERNAL HEALTH OUTCOMES AND COSTS
Presenting Author: Teresita González de Cosío, Universidad Iberoamericana, Mexico, Health Department
Co-Authors: Mishel Unar-Munguía, Dalia Stern, M. Arantxa Colchero (National Institute of Public Health, Mexico)
Background: Longer duration of breastfeeding has been associated with a lower risk of diabetes, breast and ovarian cancer, myocardial infarction and hypertension in women. Mexico has one of the lowest breastfeeding rates worldwide, therefore estimating the disease and economic burden of such rates is needed to influence public policy.
Objective: Quantify the lifetime excess cases of maternal health outcomes, premature death, DALYs, direct costs and indirect costs attributable to suboptimal breastfeeding practices, using rates in Mexico in 2012.
Methods: Static microsimulation model for a hypothetical cohort of 100,000 Mexican women were used to estimate the lifetime economic cost and disease burden in mothers, due to suboptimal breastfeeding under 2012 breastfeeding rates, compared to an optimal scenario of 95% of parous women breastfeeding for 24 months.
Results: The 2012 suboptimal scenario was associated with 5,344 more cases of ALL diseases, 1,681 additional premature deaths and 66,873 DALYs as well as 561.94 million USD for direct and indirect costs over the lifetime of a cohort of 1,116 million Mexican women aged 15 in 2012, if 95% of parous women breastfed for 24 months per child.
Conclusions: Findings suggest that investments in strategies to enable more women to optimally breastfeed could result in important health and cost savings.
Funding: Promotora Social México and Universidad Iberoamericana.
BREASTFEEDING AND GYNAECOLOGICAL CANCER
Presenting Author: Susan Jordan, QIMR Berghofer Medical Research Institute, Population Health Department, Brisbane Australia
Breastfeeding has marked effects on maternal reproductive hormone levels and consistent evidence indicates that it reduces maternal risk of breast cancer. However, its association with other hormonally-related cancers such as endometrial and ovarian cancers is much less clear. Indeed, in its Continuous Update Project, the World Cancer Research Fund found there was insufficient evidence to evaluate whether there was an association with endometrial cancer (2013) and that evidence for an association with ovarian cancer was limited but suggestive of a decrease in risk (2014).1
We have conducted case-control analyses and pooled analyses of case-control and cohort studies to examine these relationships. Using our results and those from the literature we have also calculated the proportions of ovarian and endometrial cancers that may be attributed to a lack of breastfeeding.
Notwithstanding some heterogeneity of findings across studies, our pooled analysis of endometrial cancer (8981 women diagnosed in the United States, Europe, Asia and Australia) suggested ever breastfeeding reduced the risk of endometrial cancer by ∼10%, with greater reductions for longer durations of breastfeeding. Our ovarian cancer studies showed similarly protective associations with breastfeeding, results consistent with most, although not all, recent findings. Assuming that the observed associations are causal, our estimates suggest that as many as 4–9% of these gynaecological cancers might be attributable to no or limited breastfeeding, equating to >35,000 cancers worldwide each year.
Our results therefore suggest that in addition to established benefits for babies, supporting women to commence and continue breastfeeding for recommended periods could also contribute to the prevention of these increasingly common cancers.
Funding: While conducting this work, SJ was supported by fellowships from the National Health and Medical Research Council of Australia.
MATERNAL TIME AND NURTURING CARE; ASSOCIATIONS BETWEEN BREASTFEEDING PRACTICE, TIME SPENT INTERACTING WITH BABY, AND SLEEP
Presenting Author: Julie P. Smith, Australian National University - Research School of Population Health
Co-Author: Robert Forrester (Australian National University, Statistical Consulting Unit)
Background: Breastfeeding supports child development through complex mechanisms that are not well understood. Numerous studies have compared how well breastfeeding and non-breastfeeding mothers interact with their child, but few examine how much interaction occurs.
Objective/Hypothesis: Our study investigated whether lactating mothers spend more time providing emotional support or cognitive stimulation of their infants than non-breastfeeding mothers, and whether the amount of such interactive time is associated with breastfeeding intensity. Maternal sleep hours may be associated with nurturing care time.
Methods: The study collected weekly time use data from 156 mothers of infants aged 3–9 months recruited via mother's and baby groups, infant health clinics, and childcare services. Participants used an electronic device to record their 24-hour time use for 7 days. Sociodemographic and feeding status data were collected by questionnaire. Statistical analysis used linear mixed modeling and residual maximum likelihood analysis.
Results: Breastfeeding and non-breastfeeding mothers had broadly similar socioeconomic and demographic characteristics. Breastfeeding was associated with more mother–child interaction time, a difference only partially explained by maternal employment hours or other interactive care activities. Older age of infant was associated with reduced maternal sleep hours.
Conclusions: This study presents data suggesting that lactating mothers spent significantly more hours weekly on milk feeding and on carrying, holding, or soothing their infant than non-lactating mothers; and on providing childcare. Understanding mechanisms by which child mental health and development benefits from breastfeeding and nurturing care may have important implications for policies and intervention strategies. Time pressures on mothers of older infants may have implications for maternal sleep, health and wellbeing.
Funding: The Australian Research Council (ARC) contributed funding for conduct of the Time Use Survey of New Mothers (TUSNM) alongside an Australian Postdoctoral Fellowship (DP0451117). JPS is currently funded by an ARC Future Fellowship (FT140101260).
CHARACTERIZATION OF HUMAN MILK MICRORNAS IN MATERNAL METABOLIC DISEASE
Presenting Author: Lindsay Ellsworth, University of Michigan – Division of Neonatal-Perinatal Medicine
Co-Authors: Emma Harman, Brigid Gregg (University of Michigan – Division of Pediatric Endocrinology)
Background: Maternal metabolic diseases during pregnancy influence breast milk composition of nutrients and bioactive factors. Lactational metabolic programming from altered breast milk composition is hypothesized to contribute to the risk of childhood obesity. Milk microRNA profile alterations may mediate regulation of early infant metabolism.
Objective: Determine the human breast milk microRNA profiles and differential expression of microRNAs in mothers with obesity (OB), gestational diabetes (GDM), and polycystic ovary syndrome (PCOS) compared to healthy normal weight mothers.
Methods: Breast milk samples were collected at 2 weeks postpartum from a total of 36 mothers with maternal obesity (5), gestational diabetes (5), polycystic ovary syndrome (5), and healthy controls (21) through a prospective observational cohort study of mother-baby dyads at the University of Michigan. Breast milk microRNA expression profiles in the extracted lipid fraction were analyzed using OpenArray real-time PCR through the Sequencing Core at the University of Michigan.
Results: A total of 381 microRNAs were identified in the 36 milk samples. 19 miRNAs were differentially expressed in maternal metabolic disease compared to healthy mothers' milk (p = <0.1). The significant differential expression (p < 0.05) in maternal metabolic disease groups compared to healthy mothers included over-expression in obese mothers of miR-199a-3p, miR-521; over-expression in PCOS mothers of miR-518b, miR-1227; under-expression in GDM mothers of miR-155. Potential actions of these microRNAs include regulation of adipocyte proliferation, fatty acid synthesis, glucose uptake, and potential biomarkers for childhood obesity based on current microRNA literature.
Conclusions: The microRNA profile in human milk is influenced by maternal metabolic disease. Additional infant cohort outcome data is needed to determine potential clinical significance of microRNAs in metabolic programming.
Funding: 5T32DK071212-13.
IS MATERNAL POSTNATAL PSYCHOSOCIAL DISTRESS RELATED TO MILK CORTISOL AND IMMUNE COMPONENTS IN BREAST MILK?
Presenting Author: Marina Aparicio, Complutense University of Madrid (UCM), Spain – Department of Nutrition and Food Science
Co-Authors: Pamela D. Browne (Radboud University, The Netherlands - Developmental Psychology, Behavioural Science Institute); Leonides Fernández (UCM); Christine Hechler (Radboud University); Roseriet Beijers (Radboud University); Juan M. Rodríguez (UCM); Carolina de Weerth (Radboud University)
Background: Breast milk provides nutrients, immune factors and other bioactive compounds, including cortisol, for the adequate growth and development of the infant. Environmental and maternal factors modify the composition of this complex and dynamic biological fluid.
Objective: To characterize the immunological profile and cortisol concentration in breast milk, and to assess its potential relationship with maternal postnatal psychosocial distress during the first months postpartum.
Methods: Fifty-nine mothers collected breast milk samples at 2, 6 and 12 weeks postpartum and filled in mood questionnaires on experienced stress, anxiety and depression at 6 weeks postpartum. Immune factors were quantified by magnetic beads-based multiplex immunoassays, and cortisol levels by liquid chromatography-tandem mass spectrometry.
Results: The concentration of most immunological factors decreased over time, especially between week 2 and 6 postpartum, while that of cortisol increased. There were no relevant correlations between immune factors and cortisol concentrations in milk. Psychosocial distress did not correlate with any immune compound found in milk but it was positively related to milk cortisol concentration.
Conclusions: Globally, the content of most immune components in breast milk decreases during lactation and they are not related to maternal psychosocial distress. In contrast, high maternal psychosocial distress experienced during breastfeeding is associated to high milk cortisol concentration.
Funding: AGL2013-41980P and AGL2016-75476R projects (MINECO, Spain) and Radboud University (The Netherlands).
FACTORS AFFECTING MILK PRODUCTION AND COMPOSITION BY MOTHERS DELIVERING PRETERM
Presenting Author: Rebecca Hoban, University of Toronto/Sick Kids Hospital
Mother's own milk (MOM) reduces the risk of complications of prematurity during and after neonatal hospitalization. However, mothers of premature, very low birthweight infants produce lower MOM volumes than mothers who breastfeed healthy term infants. Etiologies of this disparity include biological and behavioral components. Lactation in premature delivery, occurring before full pregnancy-induced mammary gland development, is often also complicated by co-existing maternal risk factors like pre-eclampsia, cesarean delivery, and overweight/obesity that have been associated with lactation problems in healthy populations, and is further compromised by the stress of having an ill infant. In addition, potentially most importantly, mothers of very preterm infants are breast pump-dependent for lactation initiation, a critical window when the breast is programmed for long-term MOM synthesis. Studies demonstrate the importance of early and intensive use of hospital-grade pumps in the first hours and days post-partum, with early pumping behaviors predicting mammary gland tight junction closure, early MOM volumes and coming to volume (pumped MOM volume ≥500 mLs/day by day 14), which is associated with long term MOM provision. However, optimal pumping behaviors are challenging when mothers of sick infants are still ill themselves in the post-partum period. In this preterm population, it is well known that macronutrient composition, especially protein levels in early MOM, differs from term mothers, but seems relatively unaffected by maternal nutritional status or diet. However, new research suggests maternal diet and factors such as obesity may significantly affect other aspects of MOM, from fatty acid, hormone, and cytokine profiles to human milk oligosaccharides that may affect long-term infant health. However, preterm-specific data is lacking, making the study of maternal influence on MOM composition in this vulnerable population a research priority.
MOTHER'S OWN MILK AND DONOR HUMAN MILK: HEALTH OUTCOMES AND COSTS ARE DIFFERENT IN VERY LOW BIRTHWEIGHT (VLBW; <1500 G) INFANTS
Presenting Author: Paula Meier, Rush University Medical Center, Chicago, IL
Co-Authors: Aloka L. Patel, Tricia J. Johnson, Anita Esquerra-Zwiers
Mother's own milk (MOM) reduces the risk of potentially preventable complications of prematurity and their associated costs in VLBW infants, including necrotizing enterocolitis (NEC), late onset sepsis (sepsis), bronchopulmonary dysplasia (BPD), neurodevelopmental problems and rehospitalization. This protection is provided by myriad components that function synergistically via anti-inflammatory, antioxidant, immunomodulatory, growth-promoting, neuroprotective and gut-colonizing mechanisms. Many components are concentrated most highly in early lactation MOM and in MOM produced by the immature mammary gland following premature birth. When MOM is unavailable, donor human milk (DHM) is the recommended global alternative, in part because bovine formulas upregulate inflammation and oxidative stress and contribute to gut dysbiosis. However, DHM does not reduce sepsis, BPD or NICU costs, despite significantly reducing the incidence and severity of NEC. Compared to preterm formula, DHM does not improve neurodevelopment and results in slower NICU growth unless “super-fortified,” frequently with bovine products. However, a limitation common to nearly all studies comparing MOM, DHM and preterm formula is the inability to randomize MOM feedings, so both DHM and formula groups typically receive some MOM. This presentation highlights the differences between MOM and DHM that are not related to pasteurization processes, including: the “lack of fit” between DHM and the biology of the VLBW infant; the costs and ethics of acquiring MOM versus DHM in the NICU; the impact of bovine fortifiers not studied for DHM feedings; and the misleading use of the variable “human milk feedings” that combine MOM and DHM into a single group for research and quality improvement initiatives,
Funding: NIH grant NR010009 and internal RUMC research awards.
HUMAN MILK FORTIFIERS: WHAT MILK IS BEING FORTIFIED, WHEN AND WITH WHAT?
Presenting Author: Deborah L. O'Connor, University of Toronto, Toronto – Department of Nutritional Sciences
Mother's milk is the optimal way to feed all infants, including those born of very low birth weight (<1500 grams). Hospitalized infants with elevated nutritional requirements or fluid restriction, may require their mother's milk to be nutrient-enriched. In this talk, the evidence for routine nutrient fortification of mother's milk on short and long term health outcomes will be discussed and gaps in knowledge identified. The challenges associated with human milk nutrient fortification including variability in mother's milk and donor milk composition, variability in the nutritional requirements of hospitalized infants and adherence of fat to feeding tubes will be discussed as will potential solutions. Finally the evidence in support of the use of hydrolyzed bovine-based, human milk-based fortifiers over intact bovine-protein fortifiers will presented. Findings from our recently completed triple-blind randomized clinical trial (OptiMoM, NCT02137473) that assessed, in the absence of formula feeding, whether addition of a human milk-based versus bovine milk-based nutrient fortifiers improves feeding intolerance for infants born <1250 grams will be presented. Secondary outcomes from the trial including a dichotomous mortality and morbidity index, fecal calprotectin (e.g. gut inflammation) and growth will also be reviewed.
Funding: Canadian Institutes of Health Research (#FHG129919; #FDN143233).
EQUITABLE ACCESS TO HUMAN MILK BY ALIGNING GLOBAL POLICIES AND STANDARDS FOR SAFE DONOR HUMAN MILK
Presenting Author: Kiersten Israel-Ballard, PATH, Seattle, Washington USA – Maternal, Newborn, Child Health and Nutrition Global Program and University of Washington, School of Public Health - Department of Global Health
For sick and vulnerable newborns, evidence shows that those that receive human milk early and exclusively, are more likely to survive. Recognizing the benefits of using donor human milk (DHM) over formula, the WHO recommends the scale-up of human milk banks (HMB) to improve newborn health and survival. Currently, over 35 countries have established systems to provide DHM through HMB, including a number in low- and middle-income countries such as Brazil and Vietnam. However, most WHO Member States have yet to establish national policies and programs that support the provision of DHM to infants in need. The following are actions that policy makers can take to strengthen systems to increase access to and intake of human milk for sick and vulnerable newborns: 1) Commit to developing, improving, and enforcing policies and legislation that protect, promote, and support the use of human milk for all newborns; 2) Invest in capacity-building in the optimal feeding of premature, sick and vulnerable newborns; 3) Integrate the provision of DHM from HMB into national strategies and policies as part of a comprehensive approach for newborn care; 4) Establish culturally appropriate national standards for establishing HMB, monitoring distribution and quality control of DHM, and ensuring equitable access to donor human milk; and 5) Ensure that policies and programs to increase access to and intake of DHM do not undermine breastfeeding.
Presenting Author: Sarah N. Taylor, Yale University School of Medicine, Department of Pediatrics
Co-Authors: Carol L. Wagner, James Roberts, Martina Mueller (Medical University of South Carolina)
Background: Preterm birth presents a barrier to breastfeeding and often requires long-term maternal breast pumping and complicated regimens. A post-hospital discharge (HD) intervention of home hospital grade breast pump, baby weigh scale and pediatric clinic lactation counseling was developed to support mother's goal to sustain milk post-HD.
Objective/Hypothesis: By randomized, controlled trial, determine whether the Promoting Lactation Education, Access, and Support Efforts for Preterm Infants (PLEASE for Preterm Infants) intervention is associated with increased mother's milk (MM) intake post-HD and identify barriers and facilitators to continuing MM feeds.
Methods: Fourteen pediatric clinics in 5 counties in South Carolina were randomized to provide lactation support or serve as control. Mother-infant dyads were recruited if infant born <35 weeks' gestation and mother planned to provide milk for at least 6 months. Results were analyzed by quantitative and qualitative methods.
Results: Of 59 infants (41% black, 78% lower socioeconomic status), 47 mother's completed 4-month post-HD survey. Groups (control and intervention) did not differ significantly in receiving MM [52% and 54%, relative risk (RR) (95% CI) 0.97 (0.6, 1.7)] or sustaining breastfeeding [50% and 57%, RR (95% CI) 0.9 (0.5, 1.6)]. Primary reasons for lactation cessation included low milk supply (57%), return to work (17%), inconvenient (11%), overwhelmed (9%), other reason (6%).
Conclusions: In this effectiveness study, both study groups at 6 months of age, demonstrated lactation rates greater than the 2016 CDC breastfeeding report card 6-month rate for SC rate of 44%. Further analysis will evaluate the effect of the intervention components as well as maternal self-efficacy and attitudes regarding support.
Funding: National Institutes of Health R01-HD076959.
BABY OR PUMP: A QUALITY IMPROVEMENT (QI) PROJECT TO DECREASE TIME TO PUMPING INITIATION IN MOTHERS OF VLBW INFANTS
Presenting Author: Patoula G. Panagos, Rush University Medical Center, Chicago, IL
Co-Authors: Miriam Garza, Kristine Glaviano, LaJeune Vaughn, Melissa Holland, Denise Banton, Katherine McGee, Judy Janes, Paula Meier, Aloka L. Patel
Background: Early initiation of milk expression within one hour following delivery has been shown to increase milk production in mothers of very low birth weight (VLBW) infants.
Objective: The aim of this QI project is to decrease the mean timing to first pumping for mothers of VLBW infants from 12 hours to 2 hours by standardizing the postpartum workflow by July 2018.
Methods: An interdisciplinary obstetric-neonatal team used QI tools to identify barriers to early pumping initiation and develop a key driver diagram underscoring the following interventions. Prior to delivery: centralizing supplies for pumping, educating mothers (Neonatology consults and a video), and scripting nursing support. Intrapartum: assigned clinician roles to initiate pumping immediately after delivery, excluding mothers that receive general anesthesia. Postpartum: an electronic medical record field was created for easy charting of pumping initiation. Measures included: outcome- time to first pump, process- charting compliance, and balancing- postpartum event. Short interval Plan-Do-Study-Act (PDSA) cycles were performed to learn from interventions and enable measurable change.
Results: The xmr chart shows that the mean time to pumping initiation decreased from 12 hours to 2.9 hours. The pre versus post implementation medians were 3.75 hours versus 1.38 hours. Further examination of the post-intervention phase demonstrated a significant difference by mode of delivery with median time to pumping initiation of 2 hours for cesarean versus 1 hour for vaginal delivery (p = 0.011).
Conclusions: QI methods significantly improved timing of pumping initiation. Ongoing data collection will evaluate impact on milk volume and donor milk usage.
Funding: None.
UNDERSTANDING HUMAN MAMMARY GLAND MATURATION AND MILK PRODUCTION ON A SINGLE CELL LEVEL
Presenting Author: Alecia-Jane Twigger, Helmholtz Zentrum München- Institute for Stem Cell Research
Co-Authors: Lisa K. Meixner, Susanne Herber-Jonat, Christina H. Scheel, Andreas W. Flemmer (Klinikum der Universität München, Neonatologie am Perinatalzentrum München-Großhadern),
Background: Human mammary epithelial cells undergo major changes within the adult gland during key stages of development including pregnancy, lactation and subsequent involution. Previously, the plasticity of single resting (non-pregnancy, non-lactating) human mammary epithelial cells (isolated from esthetic breast mammoplasties) was interrogated by the use of a mammary organoid assay. Mammary epithelial cells cultured under floating collagen gel conditions yield complex three-dimensional mammary organoids that resemble the morphological and cellular organization of the resting mammary gland (Linnemann et al. Development 2015). Whilst this assay gives us great insight into the plasticity of the mammary cells taken from the resting condition, it does not inform our understanding of the cellular identity and signaling pathways that drive breast maturation during pregnancy and milk production in lactation.
Objectives/Hypothesis: To understand mechanisms governing lactation, we sought to comprehensively characterize human milk cells and compare them to resting mammary epithelial cells.
Methods: Human milk cells were firstly molecularly analysed using single-cell RNA-sequencing and fluorescence-activated cell sorting and secondly functionally examined in 2-dimensional and floating collagen gel culture.
Results: Using single-cell RNA-sequencing and fluorescence-activated cell sorting, we find that human milk contains a viable largely luminal milk-producing cell population that display different gene-expression profiles to cells from the resting breast. When milk cells are cultured in floating collagen gels, they are also able to form mammary organoids that resemble the morphology of those formed by the resting breast, albeit at a lower frequency. Preliminary data suggests that this frequency of occurrence can be enhanced with initial 2D culture of milk cells.
Conclusions: In the future, comparing data from many milk and resting cells will enable us to determine the cell types and signaling pathways leading to breast maturation and milk production.
Funding: Trainee Bridge Fund from the Family Larsson Rosenquist Foundation and ISRHML Trainee Enhancement Program, Helmholtz Postdoctoral Fellowship Program (PFP).
EVALUATION OF THE BREASTFEED4GHANA SOCIAL MEDIA CAMPAIGN
Presenter: Kassandra Harding, Yale University, School of Public Health
Co-Authors: Richmond Aryeetey, (University of Ghana - School of Public Health, Legon, Accra, Ghana); Rafael Pérez-Escamilla, Grace Carroll (Yale); Opeyemi Lasisi (University of Ghana); Amber Hromi-Fiedler (Yale)
Background: There is a gap in research regarding breastfeeding dissemination through social media, an approach that has the potential to be more cost-effective than traditional social marketing campaigns.
Objective: To assess knowledge regarding breastfeeding among Ghanaian social media users before the April 2018 Breastfeed4Ghana campaign was launch, and determine qualities associated with social media performance of campaign materials.
Methods: An online baseline survey assessed breastfeeding knowledge among Ghanaian adults. Facebook and Twitter performance indicators are being monitored throughout the campaign, and monthly online surveys are conducted to evaluate campaign materials of top, middle and bottom performance. Using Fisher's Exact test, differences in respondent perceptions of material image and message across material performance level was determined.
Results: Among baseline survey respondents (n = 153), 31% had seen breastfeeding resources online prior to the campaign; and 33% and 22% did not know the appropriate age for introducing water and semi-solid foods, respectively. When launched, Breastfeed4Ghana had 3131 followers. To date, campaign materials (n = 20) have received an average (±SD) applause rate (i.e. likes) of 1.99 (±1.27) and 2.55 (±3.03) per 100 followers on Facebook and Twitter. Corresponding amplification rates (i.e. shares) are 0.25 (±0.18) and 1.13 (±1.77). Performance ranking was associated (p < 0.05) with the perception that the image promotes breastfeeding, is informative, is liked and is overall good. Message perceptions were not significantly associated with performance.
Conclusions: Breastfeed4Ghana has more Facebook followers, however Twitter followers have interacted at a higher rate with campaign materials thus far. Preliminary findings suggest the material image is important for material applause and amplification.
Funding: Trainee Bridge Fund from the Family Larsson Rosenquist Foundation and ISRHML Trainee Enhancement Program.
CHARACTERIZING THE BREAST MILK MICROBIOME WITH CULTURE-ENRICHED MOLECULAR PROFILING
Presenting Author: James Butcher, University of Ottawa – Ottawa Institute of Systems Biology
Co-Authors: Sharon Unger, Alain Stintzi, Deborah L. O'Connor (University of Toronto – Departments of Nutritional Sciences & Pediatrics; University of Ottawa – Ottawa Institute of Systems Biology)
Human milk contains limited amounts of iron and the little iron that is present should be sequestered from potential pathogens, as it is a key limiting micronutrient for microbial growth. Iron-sequestration is accomplished by several host iron-binding proteins, such as lactoferrin. However, human breast milk is now known to be home to a complex community of microbes that are not pathogenic and may in fact promote optimal gut colonization and health in infants. How do the commensal bacteria that co-exist in breast milk acquire sufficient iron for their metabolic needs? The answer is currently unknown and perhaps unappreciated by many in the field. Commensal bacteria have likely evolved sophisticated mechanisms to acquire iron from the human milk milieu that are distinct from pathogenic bacteria. The presence/absence of different iron sources in the environment will cause commensal bacteria to alter the expression of key genes/pathways, with unknown and potentially deleterious consequences for host/microbe interactions. In particular, human milk is often mixed with formula and or bovine-based fortifiers, both of which will contain supplemental iron. It is important to understand these functional alterations in order to assess the impact of interventions that alter the bioavailability of iron whether endogenous or added as a fortificant within human milk. We will be answering these questions by first developing a human milk-centric culture-enriched molecular profiling protocol and subsequently by characterizing the changes in microbial compositional related to the presence of various iron sources.
Funding: Trainee Bridge Fund from the Family Larsson Rosenquist Foundation and ISRHML Trainee Enhancement Program.
SCALING UP BREASTFEEDING PROGRAMS IN A COMPLEX ADAPTIVE WORLD: THE BECOMING BREASTFEEDING FRIENDLY INITIATIVE
Presenting Author: Rafael Pérez-Escamilla, Yale University - School of Public Health, New Haven, CT
Co-Authors: Amber Hromi-Fiedler (Yale); Muriel B Gubert (University of Brasilia); Katherine Doucet, Gabriela Buccini (Yale)
Background: Becoming Breastfeeding Friendly (BBF) is designed to assess countries readiness and develop an effective action plan to scale up of breastfeeding protection, promotion and support programs.
Objective: To describe the development, pre-testing and dissemination of BBF across low-, middle- and high- income countries (LMHICs).
Methods: BBF was developed based on the complex adaptive systems (CAS) Breastfeeding Gear Model with input from a global Technical Advisory Group. It was rigorously pretested in Mexico and Ghana and disseminated to diverse LMHICs thereafter.
Results: BBF includes a toolbox containing: a) a 54 benchmark index assessing country readiness; b) real-world case studies which guide countries on developing recommendations and effective scaling up plans; and c) a 5-meeting process to apply the index and utilize the case studies to make policy recommendations. BBF in Mexico and Ghana yielded key policy recommendations for workforce training, maternity leave extension and BFHI improvements. Process feedback resulted in improvements to the BBF toolbox. BBF has now also been launched in Germany, England, Scotland, Wales, Myanmar, and Samoa. BBF has led to costing maternity leave benefits for women employed in the informal economy in Mexico and to a social media breastfeeding campaign in Ghana.
Conclusions: BBF is a dynamic evidence-based initiative that is being implemented across world for effective scaling up of breastfeeding programs. Lessons learned are relevant for scaling up other maternal-child health and nutrition initiatives.
Funding: Family Larsson-Rosenquist Foundation.
SCALING UP DOWN SOUTH: MOVING MISSISSIPPI ALONG THE BABY-FRIENDLY PATHWAY
Presenting Author: Anne Merewood, Boston University School of Medicine – Pediatrics, Boston University School of Public Health, Center for Health Equity, Education, and Research
Geography and race are major predictors of breastfeeding rates in the US, and rates are lowest among African Americans in the southern states. This presentation describes the wave of Baby-Friendly and related breastfeeding-friendly activity, especially in Mississippi, since 2014, and outcomes around breastfeeding and race. Based on 2013 birth data, Mississippi had the lowest breastfeeding rate in the US, and breastfeeding initiation rates between black and white infants differed by 25 percentage points. Communities and Hospitals Advancing Maternity Practices (CHAMPS) launched in 2014, with goals of increasing compliance with the Ten Steps to Successful Breastfeeding and increasing breastfeeding rates. Hospitals received an intensive quality improvement and technical assistance intervention to assist them in meeting some or all of the Ten Steps. Across the 33 hospitals enrolled, 18 were in Mississippi. Breastfeeding rates in Mississippi CHAMPS hospitals increased from 49% to 67%, and exclusivity, from 18% to 33%. In 2014, there were no Baby-Friendly hospitals in Mississippi. Between 2014 and 2017, 18 Mississippi hospitals enrolled into the initial CHAMPS initiative, 100% of which enrolled on Baby-Friendly USA's 4D pathway with a goal of Baby-Friendly designation. Due to success in Mississippi particularly, CHAMPS was refunded for 3 more years. Currently, in 2018, 36 of Mississippi's 42 birthing hospitals are enrolled in CHAMPS, and 90% of all Mississippi hospitals are on Baby pathway; as of April 2018, 3 have become Baby-Friendly designated. In collaboration with CHAMPS, Blue Cross Blue Shield of Mississippi made Baby-Friendly designation a quality-improvement requirement of its Network Hospitals, and Reaching Our Sisters Everywhere, which supports breastfeeding at the community level with a focus on African Americans, trained 126 community transformers and supported 54 breastfeeding clubs. CHAMPS also opened the first Baby Cafés in Mississippi.
APPLICATION OF A STAKEHOLDER MAPPING TOOL TO IMPROVE THE INFANT AND YOUNG CHILD FEEDING (IYCF) POLICY ENVIRONMENT
Presenting Author: Cara Safon, Yale University School of Public Health
Co-Authors: Gabriela Buccini, Kassandra Harding, Rafael Pérez-Escamilla
Background: Stakeholder mapping and analysis are critical components of effective research and program implementation. NetMap is a governance analysis tool consisting of a participatory interview-based mapping technique used to identify stakeholders and assess how they are linked, their influence, and their goals with respect to public health programming. The NetMap approach has been used globally by researchers, program implementers and others to monitor interventions, facilitate community-based projects, and understand and improve influence networks and policy outcomes.
Objective: To document how NetMap has been applied to Infant and Young Child Feeding (IYCF) programming in diverse settings.
Methods: A review of the literature was conducted. The NetMap approach was applied to Becoming Breastfeeding Friendly, an initiative designed to help countries assess their readiness to scale up national breastfeeding programs and implement policy recommendations.
Results: Utilized with individuals or groups and employed using qualitative and/or quantitative data collection and analysis methods, NetMap has been applied across local, national, and regional IYCF policy environments to achieve various objectives, including: identifying key actors and policy documents; identifying barriers and facilitators to successful IYCF program implementation; and identifying opportunities for improvement to bolster institutional support for IYCF practices, service delivery mechanisms, and capacity building among health personnel.
Conclusions: NetMap is a low-cost, low-technology tool that can easily be applied and adapted to align IYCF goals as well as strengthen research, organizational development, strategic planning, and advocacy efforts.
Funding: An unrestricted grant from the Family Larsson-Rosenquist Foundation to Yale University (PI Rafael Pérez-Escamilla) for its Becoming Breastfeeding Friendly initiative.
STAKEHOLDER NETWORK AND INFLUENCE MAPPING OF BREASTFEEDING IN GHANA
Presenting Author: Richmond Aryeetey, University of Ghana - School of Public Health, Legon, Accra, Ghana
Co-Authors: Kassandra Harding (Yale University - School of Public Health, New Haven, CT); Opeyemi Lasisi (University of Ghana); Amber Hromi-Fiedler (Yale); Helena Bentil (University of Ghana); Rafael Pérez-Escamilla (Yale)
Introduction: In 2017, the Becoming Breastfeeding Friendly toolbox was used to assess the national breastfeeding programs in Ghana. This process yielded a prioritized list of recommendations to guide scale-up efforts. The process of translating these recommendations into action requires understanding of the complex landscape of actors working on different components of breastfeeding promotion and support at national level.
Objective: To identify and describe key stakeholder individuals and institutions who are active in the breastfeeding landscape in Ghana regarding their roles, linkages, and influence.
Methods: Between December 2017 and January 2018, 10 key informants from government and non-government institutions participated in a Net-Map exercise. Each participant engaged in a participatory interview which combined actor mapping, linking actor networks, and power mapping. Picture and audio records were taken of each session. Network analysis of maps was conducted in Gephi 0.9.2 and graphed using the Yifan Hu algorithm.
Findings: Of 58 actors identified, 40% were Government agencies and 25% were Civil Society Organizations (CSO). Half of stakeholders were cited once (41%) or twice (9%). There were 378 links between actors; 185 were unique links connected across 47 actors. The most commonly reported links were technical assistance (29%), dissemination (28%), and funding support (17%). The most important links were technical assistance and funding flow from United Nations agencies to Government health agencies.
Conclusions: Government and CSO's together are primary actors influencing breastfeeding action in Ghana, and are linked mostly by technical assistance, dissemination, and funding.
Funding: Family Larsson-Rosenquist through Yale University (PI: Rafael Pérez-Escamilla).
STAKEHOLDERS ON INFANT AND YOUNG CHILD FEEDING (IYCF) PROGRAMMES IN SRI LANKA
Presenting Author: Upul Senarath, Faculty of Medicine, University of Colombo and South Asia Infant Feeding Research Network
Co-Authors: Sanjeeva S.P. Godakandage, Hiranya Jayawickrama (Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka); Indika Siriwardena (National Authority for Protection of Victims of Crime and Witnesses, Sri Lanka), Aravinda Wickramasinghe, Prasantha Arumapperuma (Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka); Claudio Umesh (South Asia Infant Feeding Research Network), Shahadata Uddin, Michael Dibley (University of Sydney)
Background: Even though Sri Lanka has good policy and programme support in essential areas for the improvement of IYCF, there are some identified gaps.
Objective/hypothesis: To assess the role of stakeholders in policy making in Sri Lanka, in order to identify opportunities to strengthen the policy environment to better support appropriate IYCF.
Methods: We conducted an analysis of technical and funding links of stakeholders who shape IYCF policies and programmes in Sri Lanka using the Net-Map technique. A total of 35 experts on IYCF programmes were purposively selected and interviewed individually. Network dynamics were mapped and assessed.
Results: Participants identified 56 actors involved in shaping IYCF policies and programmes through technical support, and 36 through funding support. The Government Health Sector was the most connected as well as influential, followed by development partners. Almost all actors in the networks were supportive for IYCF policies and programmes.
Conclusions: The stakeholder analysis demonstrated that the policies are supported by an influential Government Health Sector. The strategic involvement of stakeholders in other sectors would help to strengthen IYCF policy process in Sri Lanka.
Funding: Department of Foreign Affairs and Trade, Australia.
Poster Presentations
*Poster of Distinction (top 15%)
WITHDRAWN
VITAMIN B12 IN BREAST MILK FROM MOTHERS IN RURAL INDONESIA
Presenting Author: Larisse Melo, University of British Columbia - Food, Nutrition and Health Program
Co-Authors: Aly Diana, Lisa Houghton (University of Otago); Sofa Rahmania (Universitas Padjadjaran); Setareh Shahab-Ferdows, Daniela Hampel, Lindsay H. Allen (USDA, ARS Western Human Nutrition Research Center, Davis, CA); Yvonne Lamers (University of British Columbia)
Background: Vitamin B12 (B12) concentrations in human milk are likely lower in women living in resource-poor settings. Adequate B12 status in early life however is crucial for optimal infant growth and cognitive development.
Objective: To assess breast milk B12 concentration, sociodemographic characteristics, dietary B12 intake, and functional B12 status (dried blood spot methylmalonic acid - DBS MMA) in Indonesian mothers of infants aged 2–5.9mo.
Methods: In this cross-sectional study with 120 apparently healthy, unsupplemented mothers from West Java, Indonesia, full-breast milk aliquots were analyzed for B12 using a competitive chemiluminescent enzyme assay. Breast milk B12 concentrations ≥380pmol/L were considered adequate assuming an average milk intake of 780mL/day and with the Adequate Intake being 0.4μg/day. Maternal dietary intake was assessed using 3-day in-home weighed food records.
Results: Median (IQR) breast milk B12 concentration was 197 (173;242) pmol/L, with 89% having inadequate levels. Fifty-seven percent of mothers did not meet their dietary B12 requirements. Maternal dietary B12 intake and DBS MMA concentration did not predict breast milk B12 concentrations. Having multiple children <5y in the household, compared to one child only, was associated with a 22% lower B12 concentration in breast milk, after adjusting for potential confounders.
Conclusions: Most mothers had inadequate breast milk B12 concentrations. Assuming an average milk intake of 780mL/day, this would translate into infants receiving 0.2μg B12/day, i.e., half of the Adequate Intake. These infants may be at risk for B12 deficiency symptoms and poor developmental outcomes.
Funding: Trainee Travel Fund from the Family Larsson Rosenquist Foundation and ISRHML Trainee Enhancement Program (L. Melo, PI).
WHAT'S NORMAL? HUMAN MILK AND INFANT FECAL MICROBIOMES VARY GEOGRAPHICALLY AND ARE RELATED TO EACH OTHER
Presenting Author: Kimberly Lackey, Washington State University
Co-Authors: Michelle K. McGuire, Courtney Meehan (WSU); Mark A. McGuire, Janet Williams, William Price (University of Idaho); the INSPIRE Consortium
Background: Substantial variation exists in human milk and infant fecal microbiomes, but few studies have compared these complex communities across cultures and explored whether variation in one is related to variation in the other.
Objective: The primary purpose of this study was to describe and compare the microbiome of milk produced by relatively healthy women and the microbiome of the feces of their breastfed infants living in Ethiopia, Kenya, Ghana, the Gambia, Spain, Sweden, Peru, and the United States (the INSPIRE study).
Methods: Milk (n = 396) and infant feces (n = 377) were collected from relatively healthy mother/infant dyads. DNA was extracted, the V1–V3 region of the16S rRNA gene sequenced, and microbial communities characterized and compared within and among cohorts.
Results:Streptococcus, Escherichia/Shigella, and Veillonella were identified as core genera in infant feces, and Streptococcus and Staphylococcus were core genera in milk. Inter- and intra-cohort variability existed for both sample types; bacterial diversity also varied across cohorts. Correlations between relative abundances of some genera in milk and feces were noted; for example, between milk Achromobacter and infant fecal Lactococcus and Leuconostoc. Moreover, ecological analyses suggest strong associations between complex bacterial communities in milk and infant feces.
Conclusions: These data provide evidence of within- and among-population differences in milk and infant fecal microbiomes across cultures and locations. Importantly, variation in the milk microbiome was found to be related to variation in the breastfed infant's fecal microbiome. Additional work is needed to understand what drives this variation and its significance for both maternal and infant health.
Funding: National Science Foundation.
BREAST MILK CALCIUM AND PHOSPHORUS CONCENTRATIONS IN HIV-POSITIVE UGANDAN MOTHERS ON ANTIRETROVIRAL THERAPY
Background: Calcium (Ca) and phosphorus (P) are the primary bone-forming minerals. Predominantly breastfed infants depend on Ca and P in breast milk for bone mineral accretion and growth. We recently reported greater mobilization of bone mineral, hyperparathyroidism, and disruptions in Ca and P phosphate metabolism at 14 weeks postpartum in HIV-positive Ugandan mothers on antiretroviral therapy (ART) compared to HIV-negative counterparts.
Objective: To compare breast milk Ca and P concentrations between HIV-positive on ART and HIV-negative Ugandan mothers at 2 and 14 weeks postpartum (PP2 and PP14).
Methods: 84 HIV-positive and 78 HIV-negative mothers hand expressed breast milk into 5ml plain blood tubes. Breast milk Ca and P were assayed on a Konelab analyser (Thermo Fischer Scientific, Vantaa, Finland) using the semi-automated micro method (Laskey et al. 1991). We also quantified breast milk Na and K by flame photometry.
Results: Mean breast milk Ca was 5.68 ± 1.08 and 4.62 ± 0.97 mmol/L at PP2 and PP14 respectively; and not significantly different between the groups. Mean breast milk P was 4.64 ± 1.10 and 4.51 ± 1.01 mmol/L at PP2 and PP14, respectively. However, HIV-positive mothers had significantly higher breast milk P at PP2 (+9.7 ± 3.8%, p = 0.01) and PP14 (+9.6 ± 3.5 %, p = 0.007), and lower Ca/P ratio at PP2. Mean Na, K concentrations and Na/K ratio decreased in both groups. However, HIV+ mothers had a smaller decrease in breast milk Na (−44.3 ± 8.9% vs −72.6 ± 9.0%, p = 0.03) and a trend towards a smaller reduction in Na/K ratio (−22.2 ± 9.3% vs −46.6.6 ± 9.5%, p = 0.07).
Conclusions: Compared to HIV negative, HIV-positive mothers had ∼10% higher breast milk P, suggesting early disruptions in breast milk mineral metabolism. More studies are needed to investigate the mechanisms and longer-term implications for bone health in the babies.
Funding: This research is jointly funded by the Medical Research Council (MRC) (programme code U105960371) and the Department for International Development (DFID) under the MRC/DFID Concordat agreement.
HUMAN MILK OLIGOSACCHARIDES AND THEIR ASSOCIATION WITH LATE-ONSET NEONATAL SEPSIS IN PERUVIAN WOMEN WITH VERY LOW BIRTH WEIGHT INFANTS
Presenting Author: Victor Torres-Roldan, Universidad Peruana Cayetano Heredia (UPCH), Facultad de Medicina Alberto Hurtado, Lima, Peru
Co-Authors: Lourdes M. Urtecho (UPCH); Cesar P. Cárcamo (UPCH); Lars Bode (UC San Diego – Dept Pediatrics); Theresa J. Ochoa (UPCH, Instituto de Medicina Tropical, UTHSC - Center for Infectious Diseases, Houston, TX)
Background: Oligosaccharides are one of the most abundant components in human milk. They have proven prebiotic, antimicrobial and antiadhesive effects, and are a potential protective agents against neonatal infections, including late onset sepsis.
Objectives: This study aims to describe the composition and characteristics of human milk oligosaccharides (HMO) in Peruvian mothers of very low birth weight infants and identify a possible association with late onset sepsis.
Design: This was a secondary data analysis from a randomized clinical trial. We conducted a retrospective cohort, where participants were neonates with very low birth weight (<1500 gr) who had at least one milk sample and a follow-up for at least 30 days. The oligosaccharides were measured by high-performance liquid chromatography. The outcomes were evaluated through survival analysis using factor analysis to summarize variables.
Results: We included 153 mother-infant pairs and their 208 milk samples. The most abundant oligosaccharides were 2’ -fucosyllactose, lacto-N-fucopentaose and lacto-N-tetraose. The frequency of Secretor phenotype was 93%. Secretor phenotype had higher amounts of total oligosaccharides than Non Secretors (11.45 vs 7.78 gr/L). One of the factors, which was tightly correlated to the oligosaccharide fucosyl-disialyl-lacto-N-hexaose (FDSLNH), showed a protective effect against late onset sepsis.
Conclusions: We found a possible association between FDSLNH and a lower risk of late onset neonatal sepsis that needs to be confirmed in future research.
Funding: Funded by the National Institute of Child Health & Human Development (NICHD), Grant number: R01-HD067694.
TRACE METALS IN TERM AND PRETERM MOTHERS' MILK IN WESTERN AUSTRALIA
Presenting Author: Ching Tat Lai, The University of Western Australia (UWA) - School of Molecular Sciences
Co-Authors: Hazel Gardner, Donna Geddes
Background: Trace metals are transferred into milk via the maternal bloodstream during lactation. These components have the potential to greatly influence the growth and development of infants.
Objective/Hypothesis: To determine the levels of trace metals in milk samples collected from term and preterm mothers in Western Australia (WA).
Methods: Milk age matched samples from 17 preterm and 15 term mothers were digested with Nitric Acid (65%) at 110°C for 1 hour. The digested samples were analysed with inductively coupled plasma optical emission spectrometry (ICP-OES) to determine the concentrations of aluminium (Al), calcium (Ca), copper (Cu), iron (Fe), potassium (K), magnesium (Mg), sodium (Na), phosphate (P) and zinc (Zn).
Results: The concentrations of Cu, K, Na, P and Zn were higher in the first 20 days postpartum (p < 0.05). There was no difference in their concentrations between 30-60 days postpartum (p > 0.05). Most elements were not different between term and preterm milk at around the 2nd month of lactation. Mg and P were higher in preterm milk than in term milk (p = 0.006 and 0.018, respectively).
Conclusion: In WA, both preterm and term mothers' milk provide similar concentrations of these trace elements to their infant by 2nd month of lactation.
Funding: Unrestricted research grant (Medela AG, Switzerland).
WHAT'S NORMAL? CHARACTERIZING IMMUNOGLOBULIN SPECIFICITY IN MILK PRODUCED BY WOMEN IN DIVERSE LOCATIONS
Presenting Author: Michelle K. McGuire, Washington State University (WSU)
Co-Authors: Courtney Meehan (WSU); Mark A. McGuire, Janet Williams (University of Idaho); Joseph Campo, Arlo Randall (Antigen Discovery Incorporated); Antti Seppo, Kirsi Jarvinen-Seppo (University of Rochester); the INSPIRE Consortium
Background: Breastfeeding protects against infection and many chronic conditions, but the mechanisms are largely unknown.
Objective: We characterized IgA and IgG specificity to selected pathogens in milk from 404 women in 11 populations (the INSPIRE study).
Methods: Proteome microarrays were used to characterize immunoglobulin specificity to ∼80 proteins each from enteroaggregative Escherichia coli, enteropathogenic E. coli (EPEC), enterotoxigenic E. coli, Staphylococcus aureus, Salmonella enterica serovar Typhi, Shigella spp., Streptococcus pneumoniae, and Mycobacterium tuberculosis.
Results: IgA reactivities to EPEC and Shigella were highest in Africa and Peru and lowest in Spain, Sweden, and US-Washington. For S. pneumoniae and S. aureus, IgA levels to the most differentially-reactive proteins were highest in Europe, US, and Peru. The Gambia, Ghana and Kenya cohorts clustered with low IgA reactivity to M. tuberculosis. IgG reactivity was generally lower than IgA reactivity but with highest immunoreactivities for Shigella, S. aureus and S. pneumoniae. IgG reactivity to the most differentially-reactive proteins for S. pneumoniae and S. aureus were highest in Africa and Peru; trends for Salmonella were similar.
Conclusion: This approach provides a promising means whereby we can understand how human milk protects infants from locally-relevant pathogens and might lead to interventions boosting population-specific immunity in at-risk breastfeeding infants.
Funding: National Science Foundation and the Bill & Melinda Gates Foundation.
HOW DOES ‘BECOMING BREASTFEEDING FRIENDLY’ WORK? A PROGRAM IMPACT PATHWAYS ANALYSIS
Presenting Author: Gabriela Buccini, Yale University, School of Public Health
Co-Authors: Kassandra Harding, Amber Hromi-Fiedler, Rafael Pérez-Escamilla
Background: Becoming Breastfeeding Friendly (BBF) is an initiative designed to track country progress and readiness to effective scaling up of breastfeeding programs. Mapping pathways of how BBF is implemented and utilized enables contextually grounded interpretation of its results and identifies factors that might influence the global impact.
Objective: Identify and document pathways, indicators and critical quality control points (CCPs) by which BBF can enable changes in policy, legislation, and implementation of breastfeeding protection, promotion, and support programs.
Methods: A BBF Program Impact Pathway (PIP) analysis was developed through an iterative process with the program implementation team and extensive literature review; the PIP then guided the identification of key indicators and CCPs. Ghana and Mexico BBF Directors participated in in-depth interviews and a qualitative confirmatory analysis of PIP indicators and CCPs was conducted. An implementation science research framework was designed to investigate the impact of BBF in enabling breastfeeding at the country level.
Results: The PIP identified seventeen key indicators and seven CCPs that facilitate or attenuate BBF impact. These factors were mapped into complex adaptive systems (CAS) framework domains (i.e., path dependence, feedback loops, scale-free networks, emergent behavior and phase transition). A stakeholder analysis, media survey, policy review, motivational interview with decision makers, costs to implement breastfeeding programs are being conducted to further understand BBF impact.
Conclusions: The combination of PIP analysis and implementation science research framework is a theory-driven approach that is being tested in Ghana and Mexico to find out if and how BBF enables breastfeeding environments.
Funding: Family Larsson-Rosenquist Foundation through Yale University (PI: Rafael Pérez-Escamilla).
COSTING THE BREASTFEED4GHANA SOCIAL MEDIA CAMPAIGN
Presenting Author: Grace Carroll, Yale University, School of Public Health – Social and Behavioral Science
Co-Authors: Richmond Aryeeey, Opeyemi Lasisi (University of Ghana – School of Public Health); Rafael Perez-Escamilla, Kassandra Harding (Yale)
Background: To strengthen the breastfeeding environment in Ghana, a breastfeeding social media-based campaign was implemented. Costing frameworks for social media campaigns have the potential to strengthen advocacy and financial commitments to scale-up and maintain breastfeeding programs.
Objective: To estimate the costs of developing and implementing a six-month breastfeeding social media-based campaign in Ghana.
Methods: Using an organizational perspective, costs were categorized by program (i.e., promotion, materials, website), evaluation, personnel and overhead costs for the six-month start-up phase and six-month campaign implementation phase. Full-time equivalent (FTE) was used to estimate the personnel costs. Program, evaluation, and personnel costs were sub-totalled and 10% was added for overhead costs. Start-up costs were divided by the absolute number of followers at the time of the campaign launch to evaluate costs invested to acquire a follower base (i.e., cost per follower). Alternative scenarios for this campaign will be explored through sensitivity analysis.
Results: Preliminary findings indicate the total cost for developing and implementing this campaign was US $89,025.64, where 39% were start-up and 61% were campaign implementation costs. For the start-up phase, 1.6 FTE was needed and 2.6FTE was needed during the campaign phase. Of the estimated start-up costs, 7% were program, 4% evaluation, 80% personnel, and 9% were overhead costs. Of the estimated campaign implementation costs, 13% were program, 3% evaluation, 75% personnel, and 9% were overhead costs. Cost per follower at the start of the campaign was US$11.13.
Conclusions: Preliminary conclusions are: a) personnel to carry out campaign activities is the greatest cost; and b) costs for social media-based campaigns can vary depending on the type and level of implementation.
Funding: Trainee Bridge Fund from the Family Larsson Rosenquist Foundation and ISRHML Trainee Enhancement Program (K. Harding, PI).
BREASTFEEDING RATES AND NATIONAL PROGRAMS IN EUROPE: SURVEY OF 11 NATIONAL BREASTFEEDING COMMITTEE REPRESENTATIVES
Presenting Author: Melissa Theurich, Dr. von Hauner Children's Hospital, LMU-Ludwig-Maximilians-Universität Munich, Germany
Co-Authors: Riccardo Davanzo (IRCCS Burlo Garofolo, Trieste, Italy); Marianne Busck-Rasmussen (Danish Comm. Health Education, Copenhagen, Denmark); N. Marta Díaz-Gómez (University La Laguna Tenerife, Spain); Christine Brennan (Breastfeeding Promotion Foundation, Bern, Switzerland); Elisabeth Kylberg (University of Skövde, Sweden); Anne Bærug (Norwegian National Advisory Unit on Breastfeeding, Oslo, Norway); Cornelia Weikert, Klaus Abraham (German Federal Institute for Risk Assessment, Berlin, Germany); Berthold Koletzko (LMU-University of Munich, Germany)
Background: The European Region has the lowest global rates of exclusive breastfeeding for 6 months rates.
Objectives: To compare national breastfeeding data, monitoring systems and programs in Europe.
Methods: National representatives of breastfeeding committees in 11 countries (Belgium, Croatia, Denmark, Germany, Ireland, Italy, The Netherlands, Norway, Spain, Sweden, Switzerland) participated in a standardized survey. Mechanisms for the support, protection and promotion of breastfeeding, and national program implementation are presented in a narrative review.
Results: Large variation in breastfeeding rates, data collection methodology, and mechanisms for support, protection and promotion of breastfeeding exist. Six of 11 countries have national plans for breastfeeding promotion, protection and support. After birth 56–98% of infants received breast milk. At 6 months 35–65% of infants received breast milk and 13.0–39.0% were exclusively breastfed.
Conclusions: European governments should implement evidence-based monitoring and promotion activities, financial and political support. Renewed efforts for inter-country collaboration are needed.
Funding: The German Federal Ministry of Food and Agriculture (BMEL) supported the meeting in Berlin and the survey.
THE BECOMING BREASTFEEDING FRIENDLY INDEX: DEVELOPMENT AND PRETESTING
Presenting Author: Amber J. Hromi-Fiedler (Yale School of Public Health)
Co-Authors: Muriel Bauermann Gubert (University of Brasilia); Gabriela Buccini, Katie Doucet, Rafael Pérez-Escamilla (Yale School of Public Health)
Background: There is a lack of tools to guide governments with effective scaling up of breastfeeding programs globally. The Becoming Breastfeeding Friendly Index (BBFI) was developed to assess a country's readiness for progress with scaling up breastfeeding programs.
Objective: Describe the development and pretesting of the Becoming Breastfeeding Friendly Index (BBFI).
Methods: The BBFI is based on the Breastfeeding Gear Model, which stipulates that eight gears (Advocacy; Political Will; Legislation & Policies; Funding & Resources; Training & Program delivery; Promotion, Research & Evaluation; Coordination, Goals & Monitoring) must work in harmony to drive breastfeeding program scale up. BBFI development began with a rigorous review of maternal and child health and nutrition scaling up initiatives to identify potential benchmarks. The Delphi Method of decision-making was followed to elicit consensus from a 14-member expert international Technical Advisory Group. This iterative consensus process over a period of 6 months involved two survey rounds plus in-person discussion to finalize the BBFI. An operational manual was developed to provide step-by-step guidance on applying the BBFI. The BBFI and operational manual were pretested in Mexico and Ghana in 2015–2016 and extensive feedback informed changes.
Results: The final BBFI includes 54 benchmarks across eight gears. Mexico and Ghana successfully conducted their baseline BBFI assessments and found BBFI useful to inform policy making. Their collective feedback led to revisions to clarify descriptions, modify data sources, and/or modify scoring of 37 benchmarks.
Conclusions: The BBFI is a robust, evidence-based index that empowers countries to assess and identify gaps in their breastfeeding environments.
Funding: Family Larsson-Rosenquist Foundation through Yale University (PI Rafael Pérez-Escamilla).
EVALUATION OF A DATA INFRASTRUCTURE FOR CAPTURING TOTAL-POPULATION INFANT FEEDING DATA: THE MANITOBA INFANT FEEDING DATABASE
Presenting Author: Nathan Nickel, University of Manitoba, Department of Community Health Sciences
Co-Authors: Julia Paul (Public Health Agency of Canada); Joanne Chateau (University of Manitoba - Department of Community Health Sciences)
Background: Few linkable databases capture infant feeding data beyond hospital discharge. The Manitoba Infant Feeding Database (MIFD), developed in 2015, records infant feeding practices at vaccination visits and is linkable, at the individual- and dyad-level, with total-population data capturing information from all contacts with the health and social services systems in Manitoba.
Objective: To evaluate the data quality and staff experiences with implementing the MIFD.
Methods: The MIFD records information on breastfeeding initiation, duration, and exclusivity. Personal Health Identification Numbers (PHINs), birthdate, and postal code are used to link infant feeding information with administrative health and social data. Data are automatically transcribed during data transmission via fax. Two authors independently reviewed the proportion of complete data fields and data fields with potential transcription errors. A survey assessed healthcare workers' experiences with the MIFD.
Results: 950 (out of 2500) records were randomly selected and reviewed, equating to 13,258 data fields. Data were 98.5% complete (n = 13,064/13,258). Identifying information, used for data linkage, were 95.4% complete. Transcription had to be verified in 13.5% of MIFD data. Nearly all (96.6%) healthcare workers felt that the MIFD data collection tool was easy to use (Response Rate 79.8%). Most (93.1%) were happy to continue with the MIFD. A 0.7 FTE is required to maintain the MIFD (N = 15,000 births annually).
Conclusions: The MIFD is a sustainable system for collecting and storing infant feeding information, which can be linked with administrative health and social data. These data can be used in future intervention research.
Funding: Research Manitoba.
THE REVITALIZATION AND SCALE-UP OF THE BABY-FRIENDLY HOSPITAL INITIATIVE IN MALAWI
Presenting Author: Patricia R. Welch, Maternal and Child Survival Program (MCSP)/PATH, Washington, DC
Co-Authors: Justine A. Kavle, Sarah Straubinger (MCSP/PATH); Florence Bwanali, Kanji Nyambo, (MCSP/PATH Malawi); Janet Guta (Malawi Ministry of Health); Susan Kambale (WHO-AFRO)
Background: In 1993, Malawi faced a low exclusive breastfeeding (EBF) rate of 3%, which provided the impetus for launching the Baby-Friendly Hospital Initiative (BFHI). From 1993–2004, 26 hospitals were designated Baby-Friendly, and the EBF rate increased to 71% by 2010. Yet, due to funding losses, BFHI languished and by 2015/16, the EBF rate had decreased to 61%. In response, the USAID-funded MCSP and the Malawi Ministry of Health revitalized BFHI from January 2016–March 2018.
Objectives: 1) Discuss the revitalization and scale-up process of BFHI within Malawi's health system, 2) Describe successes, challenges, and lessons learned from implementation, 3) Describe next steps and the future of BFHI in Malawi.
Methods: Process documentation and routine monitoring of the following indicators were carried out: early initiation of breastfeeding <1 hour, number of mothers counseled on EBF prior to discharge following childbirth.
Results: Across Malawi's 28 districts, staff from 54 health facilities were trained on BFHI, three of which received Baby-Friendly designation. This resulted in over 80,000 mothers receiving counseling on EBF prior to discharge from the facility after childbirth. Increased rates of early initiation of breastfeeding were shown in two of the three regions in Malawi: by 6% in the Southern region and 2% in the Central region. Additionally, linkages from the facility to community levels were strengthened, helping to improve breastfeeding support to mothers following discharge from the facility.
Conclusions: BFHI, when sustainably integrated into a national health system, can be an effective approach for improving breastfeeding outcomes.
Funding: United States Agency for International Development (USAID).
FROM NATIONAL GUIDELINES TO IMPLEMENTATION: OPPORTUNITIES AND CHALLENGES FOR SCALE-UP OF BABY- FRIENDLY COMMUNITY INITIATIVE (BFCI) IN KENYA
Presenting Author: Justine A. Kavle, PhD, MPH, Maternal and Child Survival Program (MCSP)/PATH, Washington DC, USA
Co-Authors: Brenda Ahoya (MCSP/PATH Kenya); Laura Kiige (UNICEF Kenya); Rael Mwando (MOH Kisumu, Kenya); Florence Olwenyi (MOH Migori, Kenya)
Background: Kenya made significant gains in exclusive breastfeeding (EBF) practices, from 15% in 1998 to 61% in 2014, largely due to national commitments to support breastfeeding, including free maternity services, regulations on breast milk substitutes, and community support for breastfeeding. The Ministry of Health (MOH), Kenya prioritized the Baby Friendly Community Initiative (BFCI), which protects and promotes EBF through community support groups (CSGs) and mother-to-mother support groups. BFCI was implemented through the USAID-funded Maternal and Child Survival Program (MCSP) and MOH.
Objectives: 1)To describe BFCI implementation within the health system 2) To discuss successes, challenges, and lessons learnt around BFCI and implications for scale-up of infant and young child feeding (IYCF) programming
Methods: The National BFCI Implementation package guided BFCI roll-out in Migori and Kisumu counties, Kenya. Process documentation and routine monitoring of IYCF practices were carried out: early initiation of breastfeeding, introduction of prelacteal feeding, early introduction of foods/liquids, and EBF from October 2016–December 2017.
Results: BFCI provided health education to mothers through health facilities, home visits by CSGs and community health volunteers, ‘safe spaces’ for breastfeeding at health facilities and communities, as well as continuous medical education sessions for health workers and community volunteers. Improvements in IYCF practices were marked (i.e.75 to 92% - Migori for EBF).
Conclusions: Multiple channels are required to scale up IYCF programming at community and health facility level. Future integration of BFCI indicators into DHIS2 and linkages between BFHI and BFCI are needed.
Funding: United States Agency for International Development (USAID).
CHAMPS: COMMUNITIES AND HOSPITALS ADVANCING MATERNITY PRACTICES TO DECREASE BREASTFEEDING INEQUITIES IN THE SOUTHERN USA
Presenting Author: Anne Merewood, Boston University School of Medicine – Pediatrics, Boston University School of Public Health, Center for Health Equity, Education, and Research
Co-Authors: Laura Burnham (Boston Medical Center – Div, General Pediatrics); Kimarie Bugg (Reaching Our Sisters Everywhere, Inc., Lithonia, GA); Kirsten Krane (Boston University – Div. General Pediatrics); Nathan Nickel (University of Manitoba College of Medicine); Sarah Broom (Blue Cross & Blue Shield of Mississippi); Cathy Carothers (Every Mother, Inc., Greenville, MS); Roger Edwards (MGH Institute of Health Professions - Center of Interprofessional Studies and Innovation); Lori Feldman-Winter (Children's Regional Hospital at Cooper - Cooper Medical School of Rowan University, Dept. Pediatrics, Camden, NJ)
Background: Race is a major predictor of breastfeeding rates in the US, and rates are lowest among African Americans. Few studies have assessed changes in breastfeeding rates by race after implementing the Ten Steps to Successful Breastfeeding, and none have assessed the association between implementation and changes in racial disparities in breastfeeding rates.
Objective: To determine whether a hospital and community-based initiative in the southern US, focused on increasing compliance with the Ten Steps to Successful Breastfeeding, would decrease racial disparities in breastfeeding rates by race/ethnicity, and to determine whether specific Steps were associated with changes in breastfeeding rates by race/ethnicity.
Methods: Birthing hospitals in Mississippi, New Orleans, Southern Tennessee and Texas enrolled into the CHAMPS initiative between 2014 and 2017, and received an intensive quality improvement and technical assistance intervention to assist them in meeting some or all of the Ten Steps. Community partners and statewide organizations provided support in synchronization with CHAMPS. The median percentage of births to black mothers was 34%, and 54% were to a mother of a racial/ethnic minority.
Results: Thirty one of 33 enrolled hospitals submitted data. The disparity in breastfeeding initiation between black and white infants decreased by 9.6 percentage points [95% CI 1.6, 19.5] over 31 months. Breastfeeding initiation and exclusivity among black infants increased from 46% to 63% (p < 0.05) and from 19% to 31% (p < 0.05) respectively. Skin-to-skin care post cesarean was significantly associated with increased breastfeeding initiation and exclusivity in all races; rooming-in was significantly associated with increased exclusive breastfeeding in black infants only.
Conclusion: Implementation of practice changes based on the Ten Steps to Successful Breastfeeding was associated with a decrease in racial disparities in breastfeeding in the US South.
Funding: The W. K. Kellogg Foundation.
WIDE VARIATION IN EARLY BREASTFEEDING BEHAVIOR: INSIGHTS FROM RURAL ETHIOPIA
Presenting Author: Alessandra Bazzano, Tulane University School of Public Health and Tropical Medicine – Department of Global Community Health and Behavioral Sciences (TUSPHTM/GCHB)
Co-Authors: Kaitlin S. Potts, Megumi Asaba
Background: Recent decades have seen large reductions in undernutrition in Ethiopia, but key breastfeeding behaviors require targeted attention. Exclusive breastfeeding is 58%, and prompt initiation 73%, per the Demographic and Health Survey 2016.
Objective/Hypothesis: The research sought to identify variations in early breastfeeding for targeting and design of nutrition services, with the hypothesis that patterns would be apparent by geographic zone and region.
Methods: Data came from a cross-sectional survey using multistage probability sampling in 8 geographic zones during 2015-2016. Information was collected on breastfeeding (early initiation, provision of colostrum, prelacteal feeding) and differences assessed by zone, education, religion, livelihood, and skilled birth assistance.
Results: The prevalence of all recommended practices across the country differed significantly by education level, while initiation and prelacteal feeding differed more by livelihood type and religion. Prevalence of prelacteal feeding across sites was 4% among Ethiopian Orthodox, 38% among Muslim respondents; 10% among agriculturalists, and 68% among pastoralists. Women who had assistance at birth by a skilled attendant reported prelacteal feeding less often than those supported by an untrained attendant (4% vs 75%). Geographic variation was also evident by location: in North Western Tigray no respondents reported prelacteal feeding, compared to 75% of respondents from Afar Zone 4. The prevalence of early initiation of breastfeeding differed from 19% in Afar Zone 1 to 93% in Eastern Tigray, with less variation country-wide in reported provision of colostrum.
Conclusions: Given large variations in behavior across Ethiopia, formative or design-based research should be used for locally appropriate strategies to support early breastfeeding practices among diverse populations within the country.
Funding: UNICEF, DFID.
MATERNAL RELIGIOUS AFFILIATION AND INFANT FEEDING PRACTICE IN PROJECT VIVA
Presenting Author: Jonathan Y Bernard, Inserm, Villejuif, France – Centre of Research in Epidemiology and Statistics Sorbonne Paris Cité (CRES)
Co-Authors: Sheryl L Rifas-Shiman (Harvard Medical School and Harvard Pilgrim Health Care Institute – Dept Population Medicine), Emmanuel Cohen (CNRS – UMI 3189 Environnement, Santé, Société, and University of the Witwatersrand - Dept Paediatrics), Sandrine Lioret (CRES), Blandine de Lauzon-Guillain (I CRES), Marie-Aline Charles (CRES), Janet W Rich-Edwards (Brigham and Women's Hospital – Dept Medicine), Michael S Kramer (McGill University Faculty of Medicine – Departs of Pediatrics and of Epidemiology and Biostatistics, and National University of Singapore, Department of Obstetrics & Gynaecology), Emily Oken (Harvard Medical School and Harvard Pilgrim Health Care Institute – Department of Population Medicine).
Background: Religion has rarely been studied as a determinant of infant feeding practices. We recently reported an ecological study from Western countries and observed that the national/regional proportion of Catholics vs Protestants was negatively correlated with breastfeeding initiation.
Objective/Hypothesis: To examine individual-level associations of maternal religious affiliation with breastfeeding intention and practice among U.S. women participating in the US Project Viva cohort.
Methods: We recruited 2,128 pregnant Boston-area women between 1999 and 2002 at their first prenatal visit. During pregnancy, women reported their religious affiliation, their intention to breastfeed their baby and sociodemographic characteristics. During their post-delivery maternity stay, they reported whether they were feeding their infant breast milk, formula, or both. We examined associations of religious affiliation with breastfeeding intention and practice [exclusive breastfeeding (reference group), partial breastfeeding (PBF), exclusive formula feeding (EFF)] using multinomial logistic regression adjusted for known confounders, including race/ethnicity, birth place, age, education and socioeconomic status.
Results: Of the 1,643 women with available data, 51.7% reported being Catholic, 29.5% Protestant, 8.2% other religions, and 10.6% unaffiliated. Rates of EFF intention and EFF initiation were 8.5% and 14.0%, respectively. Compared to Catholic women, Protestant (OR [95%]: 0.44 [0.23, 0.81] and unaffiliated (0.11 [0.02, 0.55]) women were less likely to intend EFF, and to initiate EFF (0.64 [0.42, 0.98] and 0.38 [0.18, 0.81], respectively). Odds to intend PBF and to initiate PBF did not differ by religious affiliation.
Conclusions: Protestant and unaffiliated women are less likely to intend or initiate EFF than Catholic women. Breastfeeding promotion policies should take account of religious affiliation.
Funding: Project Viva is supported by grants from the US National Institutes of Health (R01 HD 34568, UG3 OD023286).
EXCLUSIVE BREASTFEEDING AND MATERNITY LEAVE: A POOLED ANALYSIS FROM TWO SURVEYS FROM THE FEDERAL DISTRICT OF BRAZIL
Presenting Author: Teresa H M da Costa, University of Brasilia, Brazil – Department of Nutrition
Co-Authors: Fernanda Monteiro (Ministry of Health); Gabriela Buccini (Yale University, University of São Paulo); Sonia Venancio (São Paulo Health Institute)
Background: Initiatives to support breastfeeding for working women is of upmost interest. In Brazil, maternity leave (ML) paid in full for 16 weeks has been available since 1988. However, few studies have analyzed the impacts of ML on breastfeeding using population-based indicators.
Objective: To analyze the association between ML and exclusive breastfeeding (EBF) in children under 4 months residing in the Federal District (FD) Brazil, in 2008 and 2014.
Methods: Data from two surveys were used: Second National Survey on Prevalence of Breastfeeding - 2008 and Monitoring of Infant Feeding Practices - 2014. The analytical sample included 1,742 mothers with children under 4 months residing in the FD and users of the Public Unified Health System. Multiple analysis was performed to test the association between ML and the risk of discontinuing EBF in the pooled sample and in each survey separately adjusting for socioeconomic, demographic, and biomedical characteristics.
Results: In the pooled sample, 72.2% of the women who reported being in ML practiced EBF. Between 2008 and 2014, both the prevalence of exclusive breastfeeding (from 60% to 71.4%) and ML (from 27% to 41%) increased. The lack of ML was strongly associated with exclusive breastfeeding interruption in the pooled sample (Prevalence Ratio 2.19; IC95% 1.44 −3.34) after adjusting for confounding variables.
Conclusion: ML was strongly associated with EBF practices in children under 4 months among employed women residing in the FD.
Funding: No direct funding.
TIMING OF SWALLOWING IN RELATION TO BREATHING AND SUCKING IN TERM BREASTFEEDING INFANTS
Presenting Author: Anna Cannon, University of Western Australia (UWA) – School of Molecular Sciences
Co-Authors: Vanessa S. Sakalidis (Medela AG, Baar, Switzerland); Sharon Perrella (UWA – School of Molecular Sciences); Alethea Rea (UWA – Centre for Applied Statistics); Kevin Murray (UWA – School of Population and Global Health); Ching Tat Lai, Donna Geddes (UWA – School of Molecular Sciences)
Background: When breastfeeding, infant swallowing must be coordinated during the application and release of intra-oral vacuum (vacuum phases) and inspiratory/expiratory phases of respiration to prevent aspiration. Swallowing may occur at one of four respiratory-phase patterns: expiration-swallow-expiration (EE), expiration-swallow-inspiration (EI), inspiration-swallow-inspiration (II) and inspiration-swallow-expiration (IE), with swallowing followed by expiration considered safe. During breastfeeding it occurs at one of four vacuum phases: vacuum-application, peak-vacuum, vacuum-release and baseline-vacuum.
Objective: To determine the timing of swallowing with respect to respiration and vacuum phases during the highest expected milk flow rates of breastfeeding: first and next 2 min of nutritive sucking (NS).
Methods: Infants (n = 21) were monitored during a breastfeed. Continuous recording of intra-oral vacuum and respiration was made. The first and next 2 mins of NS were analyzed to determine the timing of swallowing with respect to the respiration and vacuum phases.
Results: The majority of swallows occurred during EE (33%) and EI (34%). Swallowing occurred at all phases of vacuum with the majority at: vacuum-application (35%) and baseline-vacuum (31%),
Conclusions: Healthy breastfed infants are able to coordinate safe swallowing across all respiratory and vacuum phases.
Funding: Unrestricted research grant from Medela AG, Switzerland.
BREASTFEEDING SELF-EFFICACY AND THE DURATION OF EXCLUSIVE BREASTFEEDING IN HIV-INFECTED AND UNINFECTED MOTHERS
Presenting Author: Abigail Courtenay, University of Stellenbosch -Division of Human Nutrition.
Co-Authors: Evette van Niekerk (University of Stellenbosch-Division of Human Nutrition); Caida MacDougall RD, Sefako Makgatho (Health Sciences University- Department of Human Nutrition and Dietetics)
Background: The overwhelming benefits of exclusive breastfeeding are well documented, and current recommendations advocate exclusive breastfeeding for the first six months of life, regardless of HIV status. Breastfeeding self-efficacy, measured using the Breastfeeding Self-Efficacy Scale Short-Form (BSES-SF), is a modifiable risk factor for breastfeeding outcomes.
Objectives: To determine if a relationship exists between breastfeeding self-efficacy and the duration of exclusive of breastfeeding in HIV-infected and uninfected mothers. In addition to this the difference in exclusive breastfeeding between HIV-infected and uninfected will be assessed, together with additional factors that could affect a mother's breastfeeding self-efficacy.
Methods: A descriptive analytical cohort study was conducted, with the primary outcome being the duration of exclusive breastfeeding up to six months postpartum. The study sample comprised 329 women who were interviewed during their postpartum hospital stay using self-formulated questionnaires including the BSES-SF. Post hospital follow-up was done telephonically.
Results: The BSES-SF scores were a positive predictor of the duration of exclusive breastfeeding in both HIV-infected and uninfected mothers. The BSES-SF scores were found to be an independent predictor of an increased duration of exclusive breastfeeding. Other independent predictors of breastfeeding included; method of feeding in hospital, prenatal intention to breastfeed and race.
Conclusion: The BSES-SF has been confirmed by our study as a valuable instrument for identifying women at risk of early cessation of exclusive breastfeeding. Together with other demographic, medical and breastfeeding factors, this instrument could be useful in directing limited resources to those most in need of breastfeeding support.
Funding: Fund for Innovation and Research in Rural Health (FIRRH), administered by the University of Stellenbosch.
ASSOCIATIONS OF PATERNAL INFANT FEEDING PERCEPTIONS AND BREASTFEEDING SUPPORT WITH EXCLUSIVE BREASTFEEDING DURATION AMONG MOTHER-FATHER DYAD IN KUALA LUMPUR, MALAYSIA
Presenting Author: Nurul Husna M. Shukri, Universiti Putra Malaysia - Department of Nutrition and Dietetics, Malaysia
Co-Authors: Phua H. Wen
Background: Exclusive breastfeeding (EBF) is the gold standard to feed an infant in early life, yet the breastfeeding rate was still low in many countries, including Malaysia. Husband/spouse plays an important role in supporting breastfeeding but their perception and understanding of breastfeeding are less explored.
Objective/Hypothesis: To determine the associations of paternal infant feeding perceptions and breastfeeding support with EBF duration among first-time parents in Kuala Lumpur, Malaysia.
Methods: This was a cross-sectional study involved 104 parents with infants aged 6–12 months in three randomly selected antenatal clinics in Kuala Lumpur. Paternal infant feeding perception was assessed using Iowa Infant Feeding Attitude Scale (IIFAS) whereas father's breastfeeding support was measured using Paternal Breastfeeding Influence Scale (PBIS), assessing the subjective norms surrounding paternal involvement in breastfeeding practice, breastfeeding savvy, helping, appreciation, presence, and responsiveness. Breastfeeding practice was collected using adapted questionnaire from Malaysia Health Morbidity Survey 2016. Data were analyzed using SPSS version 22.
Results: The prevalence of EBF for 6 months was 27.9%. Paternal IIFAS mean score was 61.09 ± 6.3, indicating positive perception towards breastfeeding. The average subjective norm score was 4.32 ± 0.6 while PBIS mean score was 4.06 ± 0.56, indicating fathers were frequently engaging in breastfeeding process. There was a positive correlation between paternal attitude and EBF duration (r = 0.212, p = 0.039). However, subjective norm surrounding paternal involvement in breastfeeding (r = 0.10, p = 0.334) and breastfeeding support (r = 0.001, p = 0.988) were not correlated with EBF duration. Paternal employment status was associated with EBF practice (χ2 = 12.43, p = 0.002).
Conclusion: Paternal attitude and employment status were significantly associated with exclusive breastfeeding duration. Recall bias was a concern since data were self-reported. Future intervention or educational materials regarding infant feeding should include husband's/father's role in supporting and promoting mothers to exclusive breastfeeding.
Funding: None.
WITHDRAWN
DETECTION OF MILK EJECTION USING BIOIMPEDANCE
Presenting Author: Hazel Gardner, University of Western Australia (UWA), School of Molecular Sciences
Co-Authors: Ching-Tat Lai, Donna Geddes (UWA, School of Molecular Sciences); Leigh Ward (University of Queensland, School of Chemistry and Molecular Biosciences)
Background: Milk ejection is essential for effective milk removal during breastfeeding and pumping. Many women are unable to accurately sense milk ejection to determine whether their infant is receiving milk or, when pumping, to switch the pump into a more effective expression pattern.
Objective: To determine if changes in bioimpedance parameters (BP) occur in association with milk ejection in the lactating breast during pumping.
Methods: 30 lactating women participated in 2 pumping sessions where the breasts were monitored with bioimpedance spectroscopy and milk flow rate and volume was measured.
Results: Changes in BP were greater at the first milk ejection (median (IQR): R zero: −7% (−17, −4,) (n = 30); R infinity: −8% (−20, −2) (n = 29); membrane capacitance: −24% (−59, −7). Changes were less at the first milk ejection when monitored on the contralateral breast (R zero: −3% (−8, −2) (n = 25); R infinity: −5% (−8, −2) (n = 23); membrane capacitance: −9% (−17, 15). While decreases in the BP were detected in association with the second milk ejection, these were smaller and less consistent.
Conclusion: BP consistently showed a stronger decrease associated with the first milk ejection when electrodes were placed on the pumped breast. Smaller decreases were observed at the second milk ejection, and also when electrodes were placed on the contralateral breast.
Funding: Unrestricted research grant, Medela AG, Switzerland.
CAUSES OF PERCEPTION OF INSUFFICIENT MILK SUPPLY
Presenting Author: Jacqueline Kent, University of Western Australia (UWA)
Co-Authors: Donna Geddes (UWA), Elizabeth Ashton, Catherine Hardwick (Breastfeeding Centre of WA, King Edward Memorial Hospital)
Background: The most common reason given for early discontinuation of exclusive breastfeeding is perceived insufficient milk supply (PIMS). However, there is no published information on which aspects of infant behaviour contribute to this perception.
Objectives: To: 1) Determine reasons for PIMS, and 2) record changes in perceptions of milk supply after receiving professional advice
Methods: Participants attended the Breastfeeding Centre and completed a survey on their perception of milk supply. A subset of the participants completed a second survey 2–4 weeks after receiving targeted care provided by the lactation consultants.
Results: We recruited 415 participants. For participants who reported PIMS (n = 181) 153 were expressing, and 144 thought their infant needed supplementary infant formula, and by 3 weeks after birth 115 of these infants were receiving formula. Concerns of participants with PIMS included infants' attachment (148), sucking (121) and satisfaction after breastfeeds (131). At follow-up of 61 PIMS participants, 29 were satisfied they had sufficient milk supply (although 8 of these thought formula was still needed) and 31–41 were satisfied with their infant's attachment, sucking, and satisfaction after breastfeeds.
Conclusions: Perception of insufficient milk supply is often associated with concerns about infant attachment and sucking, and a perception that the infant is not satisfied after breastfeeding. The data underline the importance of professional guidance on positioning and attachment soon after birth.
Funding: Unrestricted research grant from Medela AG.
MEDIAN BREASTFEEDING DURATION AND EXCLUSIVITY: GLOBAL CONTEXT AND ESTIMATES FROM THE UNITED STATES NATIONAL IMMUNIZATION SURVEY 2011–2016
Presenter: Ann Dozier, University of Rochester Public Health Sciences, New York
Co-Author: Hayley Martin
Background: WBTi (World Breastfeeding Trends Initiative) established in 2004 to monitor breastfeeding outcomes, policies and programs, uses median breastfeeding duration as a core outcome metric. This direct estimate differs from US breastfeeding statistics reporting the proportion of women maintaining any breastfeeding (BF) and exclusive breastfeeding (eBF) as laid out in the HealthyPeople 2020 objectives.
Objective: To demonstrate the utility of the metric, we report median BF and eBF duration over time and provide estimates from all WBTi participating countries with available data.
Methods: Utilizing data from the CDC's National Immunization Survey we calculated the population-weighted median duration of BF and eBF at the national, state and regional level (2011–2016) for the US. In addition to individual country-specific estimates, regional averages were calculated using estimates from all countries with WBTi County Report data (N = 83)(1998–2016) to provide a crude summary of regional trends.
Results: Median US eBF duration in 2016 was 4 months (IQR (interquartile range): 1.35–5.97), increased from 2 months (IQR: 0.03–4.97) in 2011. Median duration of BF was 6 months (IQR: 3.00–12.00) in 2011 and increased to 8 months (IQR: 3.00–12.00) in 2016. On average, countries in South Asia had the longest median breastfeeding duration (26.1 months), followed by African countries (19.2 months), and Latin American countries (15.7 months) while European countries had the shortest average median duration of breastfeeding (8.76 months).
Conclusions: Median duration is a valuable metric that the US should routinely include as it allows for additional evaluation of breastfeeding outcomes over time, and comparisons with countries/regions around the world.
Funding: NIH R01-HD055191.
MOTHER'S MILK AND MAMMALS: A PILOT STUDY OF TARGETED BREAST MILK EDUCATION IN MINORITY 4TH AND 5TH GRADE STUDENTS
Presenting Author: Aloka L. Patel (Rush University Medical Center, Chicago, IL)
Co-Authors: George Ziegler, Michael Schoeny, Sharon Gates
Background: Despite the many benefits associated with breast milk (BM) feedings and initiatives to increase breastfeeding (BF) rates, African American (AA) mothers BF their infants significantly less frequently and for a shorter duration than non-AA mothers in the US. This discrepancy may be attributed to differences in cultural acceptance of BF.
Objective: To evaluate the impact of a BF education session, as a component of mammalian science, on 4th–5th grade students' BF knowledge and attitudes.
Methods: Pilot study of primarily minority 4th–5th grade students from Chicago public schools who underwent a 30-minute education session on BM science. Questionnaires evaluating knowledge of animal BF, components of BM, human BF, and BF attitudes were completed prior to and immediately following the education session and 1 month later. Written informed consent was obtained from parents/guardians. Data was analyzed with paired McNemar's change tests and repeated measures ANOVA.
Results: Subject characteristics (n 43): male (40%), AA (60%), Hispanic (26%). Following the education session, subjects showed statistically significant improvement in mammalian BF knowledge that was sustained after 1 month. BF attitude questions demonstrated improvement immediately post-session but were not sustained at 1 month. No effect of subjects' sex or previous BF exposure was detected. Students reported interest in learning about BF in general and at school.
Conclusions: This pilot study demonstrates that BF education is feasible in elementary school children and results in sustained improvement in BF knowledge. Pre-pubertal children may be an ideal population to receive BM education to enable BF to become the cultural norm as one potential strategy to address racial disparities in BF.
Funding: Rush Pediatrics grant.
IDENTIFICATION OF THE MOST EFFECTIVE RELAXATION TOOL FOR USE IN A TRIAL TO IMPROVE BREASTFEEDING OUTCOMES IN MOTHERS OF LATE PRETERM INFANTS
Presenting Author:Sarah Dib, UCL-Institute of Child Health
Co-Authors: Jonathan Wells, Mary Fewtrell
Background: Late preterm infants (LPI) (34–37 weeks) have significantly higher morbidity and mortality and poorer breastfeeding initiation and duration than term infants. Their mothers also experience higher stress. The combination of poor signalling skills due to neurodevelopmental immaturity and lower maternal energy investment due to psychological distress may contribute to suboptimal breastfeeding and developmental outcomes.
Objective/Hypothesis: The objective of this pilot study was to determine the most effective relaxation therapy for use in a trial for breastfeeding mothers of LPI. We hypothesize that its use to ease mother-infant tension will result in diversion of energy from stress to investment in the infant, with improved breastfeeding outcomes.
Methods: A within-subject study was conducted in 17 women of reproductive age comparing five different relaxation interventions (guided-imagery relaxation tape (RT), music, relaxing lighting (RL), RT+RL, music+RL) with control (silence/sitting), assigned in randomised order over a 3–6 week period, on changes in subjective feelings of relaxation (10-point scale), heart rate (HR), blood pressure (BP), and fingertip temperature (FT).
Results: The majority (76.5%) of participants experienced moderate stress (Perceived Stress Scale) at baseline. HR (bpm) significantly decreased with RT and music+RL (mean 2.01 and 1.13, respectively, vs control 1.69 increase, p < 0.01). FT increased significantly following music vs control (3.07 vs 1.14°C, p < 0.05). Perceived relaxation increased significantly following RT (2.6 points), music (2.3), RT+RL (2.2), and music+RL (2.0). RT+RL followed by RT and music+RL were the most preferred interventions.
Conclusions: Based on preference, effectiveness and simplicity, RT was identified as the most appropriate intervention for use in the planned trial in breastfeeding mothers of LPI.
Funding: UCL GOS Institute of Child Health.
INTELLIBRA: A WEARABLE DEVICE FOR MEASUREMENT OF MILK PRODUCTION AND OUTPUT
Presenting Author: Abhishek Gannarapu, Washington State University (WSU)
Co-Authors: Kimberly Lackey, Michelle K. McGuire, Arda Gozen (WSU)
Background: Demand exists for a simple, accurate method to measure milk production and output during breastfeeding. Conventional stable isotope and/or 24-hour infant weigh-back techniques are not suitable for measurements in-home. A more user-friendly technology which provides mothers with precise milk production and infant consumption information may help in reaching breastfeeding goals.
Objective/Hypothesis: We developed a wearable device, the “IntelliBra”, that is capable of quantifying milk production and infant milk consumption during breastfeeding in real-time, with no interference to the breastfeeding experience.
Methods: The IntelliBra uses sensors that can be fitted to a commercially available bra, to conform to the breast and its volumetric changes induced by the milk production and removal. Consequently, the signal varies proportionally with the breast volume and can be calibrated to monitor changes in the amount of milk; this information can be provided to the wearer in real-time via a smart device. The performance of the first IntelliBra prototype was evaluated in vitro on a mock-mother hosting silicone breast replicas infused with controlled volumes of water.
Results: Our preliminary evidence suggests that the IntelliBra prototype can measure the infused water volume with <5 mL accuracy, provided temperature is monitored and incorporated in the signal-processing algorithm. The transient sensor signal is also responsive to small deformations that might occur due to suckling.
Conclusions: The IntelliBra, when fully developed, will likely provide real-time, quantitative milk production and infant milk consumption information to breastfeeding mothers in a convenient fashion. It may also detect suckling behaviors alongside alerting a woman to increased risk of mastitis by monitoring temperatures.
Funding: WSU Office of Research commercialization gap fund.
IMPROVING THE CULTURE OF BREASTFEEDING SUPPORT IN PRIMARY CARE PRACTICES: A PILOT OF THE OUTPATIENT BREASTFEEDING CHAMPION PROGRAM
Presenting Author: Julie A. Patterson, University of Wisconsin-Madison, Department of Nutritional Sciences
Co-Authors: Beth H. Olson (University of Wisconsin-Madison- Dept of Nutritional Sciences) and Nicholas S. Keuler (University of Wisconsin-Madison – Dept of Statistics)
Background: Breastfeeding support offered by trained professionals can increase breastfeeding success. The Outpatient Breastfeeding (OBF) Champion program provides education to a “breastfeeding champion” in primary care practices.
Objective/Hypothesis: To evaluate mothers' perceptions of breastfeeding support and health care professionals' attitudes and confidence in providing breastfeeding care before and after implementation of the OBF program.
Methods: The OBF program was implemented in 12 medical offices within a health care system. Clinic physicians, nurses trained as champions and two groups of mothers were surveyed before and after program implementation. Non-parametric tests and generalized linear models were used to test statistical differences and relationships.
Results: Mothers who responded before (N = 117) and after (N = 131) the OBF program were predominantly white, well educated women who experienced physical difficulties with breastfeeding (60%), which was a negative predictor of exclusive breastfeeding at 6 weeks (p < 0.05) and 4 months (p < 0.05). Perception of technical support was significantly higher in women reporting physical difficulties (p < 0.05). Mothers' attainment of breastfeeding goals was higher post-program (p = 0.06). Nurses (N = 9) reported higher self-confidence in managing breastfeeding position and attachment (p = 0.09) and their attitude towards breastfeeding was higher (p = 0.05) in the post program assessment. Providers (N = 24) confidence in nurses' ability to provide breastfeeding care was significantly higher (p < 0.05) post-program.
Conclusions: This study suggests the potential to positively influence achievement of mothers' breastfeeding goals, and nurses' attitudes and confidence in providing breastfeeding support. Further research needs to be done to determine OBF program effectiveness in improving breastfeeding rates.
Funding: University of Wisconsin- Madison College of Agricultural and Life Sciences, Department of Nutritional Sciences and the Wisconsin Alumni Research Foundation.
LACTAMAP: A NEW APPROACH TO LACTATION CARE
Presenting Author: Melinda Boss, University of Western Australia (UWA) -Faculty of Health and Medical Sciences.
Co-Authors: Douglas Pritchard, Rhonda Clifford (UWA-Faculty of Health and Medical Sciences); Peter Hartmann (UWA - Faculty of Science)
Background: Doctors report insufficient training for the skills expected of them when treating patients with lactation difficulties. To address this, researchers developed LactaMap, a novel lactation care support system.
Objective: To develop an evidence-informed online lactation care support system designed for use during a medical consult.
Methods: A multidisciplinary expert group met weekly to conceptualise content and scope. The need for an evidence-informed description of normal function was identified. From this, a care pathway to screen for lactation outside normality was developed. Clinical practice guideline topics were identified and grouped into subject areas defined by the care pathway. A literature search using relevant search terms and criteria for each guideline topic was completed. Each guideline required group consensus prior to finalisation. An expert, senior researcher moderated when required.
Results: The normal function description identified 4 domains for consideration when screening for lactation dysfunction: pain, milk transfer, infant health and maternal health. Evidence-informed guidelines for 112 conditions affecting lactation were developed and grouped under the domains in an overarching care pathway. Literature searches highlighted varying terminology and definitions. A glossary of 564 lactation terms was developed to standardise language.
Conclusions: The successful development of LactaMap took 10 years to complete. The next phase involving piloting with doctors has commenced.
Funding: The Family Larsson-Rosenquist Foundation.
EFFICACY OF A NOVEL DEVICE TO MEASURE FLUCTUATIONS IN ORAL PRESSURE DURING DIRECT BREASTFEEDING IN THE HOME
Presenting authors: Ruth Lucas (University of Connecticut – School of Nursing) and Jimi Francis (University of Texas at Tyler – Department of Health and Kinesiology)
Background: Knowledge of the individual infant differences in the mechanics of human milk transfer is limited. For this study, direct breastfeeding is identified as the infant transferring milk directly from the breast. Establishing normative ranges of mechanics for direct breastfeeding is problematic due to a lack of instrumentation to collect data outside laboratory settings.
Objective: Determine feasibility of measuring parameters of neonatal fluctuations in oral pressure during direct breastfeeding in home and clinical settings.
Methods: A novel prototype device, the Breastfeeding Diagnostic Device (BDD) was used to measure 2 groups of neonates' (<15 days of age, n = 5; >15 days of age, n = 10) number of pressure fluctuations (sucks) per minute, per fluctuation burst, number of bursts per feeding, and intra-oral pressure during milk transfer. The location of data collection was based on maternal choice.
Results: Fifteen mother/infant dyads participated in 52 measurements. Measurements were grouped by chronological age with no significant differences between groups. The mean values were; number of pressure fluctuations per feeding = 80 (SD = 81), per minute = 55 (SD = 38), per burst = 9 (SD = 6), number of bursts per feeding = 12 (SD = 13), and intra-oral pressure = 71 (SD = 32).
Conclusions: The use of the BDD was tolerated by the mother/infant dyads in both home and clinical settings. Preliminary data were consistent to that reported in the literature. Additional analysis is needed to further explore the variance in each feeding session.
The authors have no conflict of interest.
Funding sources: Internal grant funding from the Institute for Integrated Healthcare at UT Tyler, the College of Nursing and Health Sciences at UT Tyler, Accelerate UConn, and Connecticut Bioscience Pipeline Grant.
INTEGRATION OF A HUMAN MILK EDUCATION PROGRAM AND ITS TRANSLATIONAL USE TO CRITICALLY ILL NEONATES IN A LOW RESOURCE MILITARY ENVIRONMENT
Presenting Author: Elizabeth V. Schulz, US Naval Hospital Okinawa – Department of Neonatology
Co-Authors: Heidi Engel (US Naval Hospital Okinawa – Department of Neonatology); Alexis Wadas (US Naval Hospital Okinawa – Department of Obstetrics and Gynecology); Ruben Castro, Mariela Rodriguez (US Naval Hospital Okinawa – Department of Neonatology)
Background: Innately high turnover rates of staff within United States military treatment facilities (MTF) serves to hinder the institutional utility of human milk to critically ill neonates in this population.
Objective/Hypothesis: We aimed to improve staff education of human milk, increase primary maternal pump session within first six postpartum hours to ≥50% in PDSA cycle 1 and provide colostrum within infant's first 24 hours of life (HOL) by instituting a multi-disciplinary human milk education/utilization program in a low-resource MTF.
Methods: Process mapping of institutional couplet care revealed a key driver diagram, with primary drivers: education, equipment, time, and leadership. Sequential PDSA cycles initiated, including creation of a multidisciplinary team, staff education, and a comprehensive audit.
Results: Mean pre-education staff survey scores of 83% improved to 93% following training. 36 charts meeting inclusion criteria were audited. Achievement of initial pump ≤6 hours postpartum increased from 43% to 57% in cycle 1 of an ongoing quality improvement initiative. 88% of infants in cycle 1 received colostrum by 24HOL.
Conclusions: Preliminary data suggests the ability to successfully institute a multi-departmental human milk education program to improve staff education, initial maternal pump, and time to first colostrum feed to critically ill neonates in low resource environments with high staff turnover.
Funding: None.
INVESTIGATING MATERNAL PERSPECTIVES ON MILK MAN, A BREASTFEEDING MOBILE APP TARGETING FATHERS
Presenting Author: Jane Scott, Curtin University, Perth - School of Public Health
Background: The support of her partner is one of the most important factors influencing a mother's breastfeeding success, and an increasing number of breastfeeding interventions target fathers. This approach is potentially problematic, and few father-focused studies report on maternal perspectives.
Objective: To explore mothers' perspectives of their partner's use of Milk Man, a father-focused breastfeeding mobile app.
Methods: Questionnaire data collected at six weeks postpartum from 459 mothers were used to determine their knowledge of the app, and whether it had generated discussion with their partner. In addition, a sentiment analysis was carried out on answers to open-ended questions asking their thoughts on the app. Data were initially coded in NVivo to a top-level sentiment node of positive, negative or neutral and then to a number of sub-nodes.
Results: Just over a quarter of mothers (28%, 116/418) said their partner had shown them something from the app and 37% (155/416) said they had had a discussion about something from Milk Man. Sentiment analysis was carried out on the 162 open responses regarding mothers' thoughts on the app. Of these, 33 responses were coded as not applicable and excluded. Of the remaining 129 responses, which could include multiple comments, most comments were coded as positive (73%, n = 94), with a similar proportion of negative (19%, n = 25) or neutral (16%, n = 21) comments. None of the negative comments referred to the intent of the app or the appropriateness of targeting fathers.
Conclusions: Mothers had differing levels of involvement and knowledge of Milk Man. The qualitative analysis showed an overall positive sentiment towards the app.
Funding: Healthway, Perth.
HIGH CONFIDENCE, YET POOR KNOWLEDGE OF INFANT FEEDING RECOMMENDATIONS AMONG ADULTS IN NOVA SCOTIA, CANADA
Presenting Author: Kyly C. Whitfield, Mount Saint Vincent University – Department of Applied Human Nutrition
Co-Author: Kathleen Chan
Background: In Canada the Nutrition for Healthy Term Infants (NHTI) recommendations guide infant and young child feeding (IYCF; 0–24 months), however adherence to these guidelines is suboptimal. While maternal knowledge of IYCF is commonly assessed, that of the general public has rarely been explored.
Objective: To assess knowledge of, and confidence in answers to, NHTI recommendations among a diverse sample of adults in Nova Scotia, Canada.
Methods: In March 2018, a self-administered questionnaire examining IYCF knowledge, self-rated confidence, and sociodemographic information was conducted among Nova Scotians (>19 years) in public locations.
Results: We surveyed 212 adults (59% women, 40% men); 73% self-identified as white, and 79% were born in Canada. Mean (95%CI) age was 44 (42–47; range 19–95) years. Most (67%) were parents with 2.4 (2.1–2.6) children, 67% of whom breastfed. Knowledge deficits were: age to terminate breastfeeding (17 (16–19) months), age to introduce solids (9.3 (8–10) months), vitamin D supplementation (7% correct), and optimal complementary foods (36% indicated iron-rich foods). More men were incorrect with regards to age to introduce solids (p < 0.001), and optimal complementary foods (p = 0.012). Mean self-rated confidence (/10) was high (7.5 (6.7–8.4)), and not different (p > 0.05) between correct and incorrect responses, except for age to introduce solids (p = 0.002) and optimal complementary foods (p = 0.001).
Conclusions: Knowledge of IYCF recommendations is low among adults in Nova Scotia, however self-rated confidence of IYCF knowledge is high regardless of alignment with NHTI recommendations. Knowledge deficits may contribute to an unsupportive culture around IYCF practices and low adherence to NHTI recommendations.
Funding: Mount Saint Vincent University New Scholars Grant.
BREASTFEEDING PRACTICES: FOCUS OF NUTRITION-SPECIFIC AND NUTRITION-SENSITIVE PROGRAMMING IN AFRICA AND ASIA
Presenting Author: Daniel Sellen, University of Toronto, Dalla Lana School of Public Health (DLSPH) and Departments of Nutritional Sciences and Anthropology
Co-Authors: Aatekah Owais, Khadija Begum (University of Toronto, DLSPH)
Background: Optimal breastfeeding (BF) in the first two years of life is one of the major pathways to prevent childhood malnutrition.
Objective/Hypothesis: We assessed the prevalence of BF practices among mothers of children 0–23.9 months in Bangladesh, Pakistan, Kenya and Tanzania.
Methods: We used baseline data from four large cross-sectional household surveys conducted as part of impact evaluation of ENRICH (Enhancing Nutrition Services to Improve Maternal and Child Health in Africa and Asia).
Results: Initiation of BF within the first hour of birth among children aged 0–23.9 months was less prevalent in the Pakistan and Kenya program areas (∼35%) in comparison to Bangladesh (62%) and Tanzania (69%). Among children aged 0–5.9 months exclusive BF prevalence was 71%, 63%, 43%, and 73% respectively in Bangladesh, Pakistan, Kenya and Tanzania. Although ever BF rates among children aged 0–23.9 months were almost universal across all four countries, rates of continued BF at 2 years among children aged 20–23.9 months declined in Pakistan (69%), Kenya (50%), and Tanzania (37%). There were no significant binary sex differences in BF practices at any site.
Conclusions: Suboptimal BF practices are common in all four ENRICH countries, equally affect girls and boys of similar age and settings, highlighting existing gaps between achieved and recommended BF practices, and suggesting likely potential benefits of interventions to support healthier BF practices integrated into nutrition-specific and nutrition-sensitive programming to prevent childhood malnutrition. Further analysis of the nutrition-sensitive determinants of BF practices to strengthen ongoing ENRICH interventions is needed.
Acknowledgments: James P. Grant School of Public Health, Bangladesh; Aga Khan University, Pakistan; Egerton University, Kenya; Enhance Tanzania Foundation, Tanzania; World Vision Canada, Canada.
Funding: Global Affairs Canada through World Vision Canada.
DNA- AND RNA-BASED BACTERIOLOGICAL ANALYSIS OF BREAST MILK DURING LACTATIONAL MASTITIS
Presenting Author: Alba Boix-Amorós, Institute of Agrochemistry and Food Technology (IATA-CSIC) and Dr. Peset Hospital, Valencia, Spain
Co-Authors: Maria Teresa Hernández (Fundación FISABIO, Valencia, Spain); Maria Carmen Collado (Institute of Agrochemistry and Food Technology (IATA-CSIC), Valencia, Spain); and Alex Mira (Dr. Peset Hospital, Valencia, Spain)
Background: In addition to nutritional components, breast milk harbors commensal bacteria. Imbalances in the ecosystem may give rise to an overgrowth of opportunistic pathogens, leading to an increased risk of mammary infections, such as lactational mastitis. Sub-acute mastitis is a less acute state of the disease, but extremely prevalent among lactating women, causing considerable pain and being one of the main reasons for early weaning. Although the etiology and diagnose of acute mastitis is well established, very little is known about bacteria causing the sub-acute state, and no biomarkers are available for diagnosis.
Objective/Hypothesis: We aimed to define the bacterial composition and quantity of breast milk during sub-acute mastitis as compared to healthy controls, in order to identify potential biomarkers of the disease.
Methods: Bacterial DNA and RNA from healthy and mastitis-suffering mothers' milk was extracted at two time-points (during mastitis and when symptoms disappeared). Total (DNA-based) and active (RNA-based) bacterial composition were analyzed by 16S rRNA sequencing (n = 80) and bacterial load was estimated by qPCR.
Results: Bacterial load was significantly higher in mastitis compared to healthy mothers, and decreased after the symptoms disappeared. Bacterial diversity significantly decreased in mastitis samples. Significant differences in bacterial composition and activity were found in milk from healthy and mastitis mothers, but the composition was highly heterogeneous, suggesting a polymicrobial and varying etiology.
Conclusions: Our work shows variable bacterial communities associated with sub-acute mastitis, with increased loads and reduced diversity. Potential bacterial biomarkers of the disease were detected, which could provide novel tools to diagnose, prevent and treat human mastitis.
Funding: ERC Starting Grant, project 639226.
POLYMORPHISMS IN AND EVIDENCE FOR SELECTION OF GENES RELATED TO HUMAN MILK COMPOSITION
Presenting Author: Sarah Brooker, University of Idaho (UI), Moscow, ID
Co-Authors: Michelle K. McGuire, Courtney Meehan (Washington State University); Janet Williams, Mark A. McGuire, Brenda Murdoch (UI); the INSPIRE Consortium
Background: Despite extensive knowledge about the genetic regulation of bovine milk composition, little is known about genetic regulation of human milk composition.
Objective: The purpose of this study was to characterize and compare variation in 6 genes (ST6GALNAC5, SPP1, DGAT1, LALBA, FUT2, FUT3) associated with macronutrient synthesis in milk among 412 women living on 4 continents (INSPIRE study). We also explored the likelihood that evolutionary selection has driven some of this variation.
Methods: High-throughput sequencing was used to characterize exonic regions of the selected genes. Gene variants were determined by aligning reads to the human reference. Population-level evolutionary statistics [e.g., fixation index (FST) and Tajima's D, which characterize genetic diversity among populations] were calculated.
Results: Our data provide evidence of global diversity in both frequency and locations of polymorphisms in these genes. For instance, there were ∼120 unique polymorphisms in FUT2, of which ∼80 were identified within a population and ∼40 shared among populations. An example polymorphism showing variation among populations is rs602662, which has a higher-than-average FST, and a positive Tajima's D range, both providing evidence for selection at this genomic location.
Conclusions: Substantial variation exists among globally-diverse populations in terms of genetic variants associated with human milk composition, and at least some of this may have been driven by selective evolution. Importantly, optimal human milk composition may vary by location and/or culture.
Funding: National Science Foundation, BEACON Center for Evolution in Action.
LIPIDOMICS OF HUMAN MILK AND PLASMA FROM EXCLUSIVELY BREASTFED INFANTS WITH EXCESSIVE WEIGHT GAIN
Presenting Author: Sophie Christensen, University of Copenhagen, Denmark
Co-Authors: Samuel Furse (University of Cambridge); Melanie E. Larsson, Kamilla G. Eriksen, Mads Lind, Kim Michaelsen (University of Copenhagen); Albert Koulman (University of Cambridge)
Background: Breastfeeding is suggested to have a protective effect on later risk of obesity. The total fat content of human milk (HM) is found to be associated with a slower rate of infant growth. Lipid profiling of HM is a research area with sparse evidence. However, a recent study found significant differences in the plasma lipid profile (LP) of exclusively breastfed infants compared to formula-fed and found the LP associated with weight, suggesting an effect of the HM LP on infant growth.
Objective: To investigate whether excessive weight gain in exclusively breastfed infants is associated with distinct lipid profile.
Methods: Breastfed infants with excessive weight gain (HW group, n = 13) and infants with normal weight gain (NW group, n = 17) were examined at 5mo. Lipid fractions of HM and infant plasma were profiled by mass spectrometry (+ve ion mode) before applying Partial Least Squares-Discriminant Analyses (PLS-DAs).
Results: The PLS-DAs showed that the plasma lipid and triglyceride fractions were more homogenous in the HW group than in the NW group with clear differences between groups. Further, the milk lipid/triglyceride fractions of infants of obese mothers (BMI ≥30) were more homogeneous than infants from mothers with BMI ≤23, despite there were no differences in BMI between the groups.
Conclusion: The lipid and triglyceride fractions in milk from groups of obese mothers and in groups of infants with excessive weight gain both followed a homogeneous pattern. This suggests that the metabolic pattern driving the phenotypes observed follow a similar pattern and raises questions about whether maternal obesity and high weight gain in breastfed infants are related.
Funding: University of Copenhagen.
ENDOCANNABINOID METABOLOME OF HUMAN BREAST MILK
Presenting Author: Adriana Gaitán, Louisiana State University, Baton Rouge – School of Nutrition and Food Sciences
Co-Authors: Jodi Wood, Lipin Ji, Yingpeng Liu, Spyros Nikas, Alexandros Makriyannis (Northeastern University, Boston – Center for Drug Discovery); Carol Lammi-Keefe (Louisiana State University – School of Nutrition and Food Sciences and Pennington Biomedical Research Center, Baton Rouge)
Background: Breast milk (BM) has a unique composition that meets infants' needs throughout development. Endocannabinoids (EC) and endocannabinoid-like compounds (endocannabinoid metabolome, ECM) are endogenous lipid mediators derived from long-chain polyunsaturated fatty acids (LCPUFAs) that have been identified in BM. One EC in particular, 2-arachidonoylglycerol plays a role in establishing the infant's suckling response during lactation by activating the cannabinoid receptor type-1 in the infant's brain. The mechanisms of action and the role of the ECM in BM are not fully understood.
Objective/Hypothesis: To characterize and quantitate the ECM in transitional and mature milk and to assess maternal dietary LCPUFAs.
Methods: BM (n = 24) was collected at two and four weeks postpartum and analyzed by liquid chromatography-mass spectrometry. Dietary intake was assessed with three 24-hour dietary recalls using the Nutrition Data System for Research.
Results: Identified members of the ECM were: arachidonoylethanolamine, palmitoylethanolamine, oleoylethanolamine, docosahexaenoylethanolamine, eicoapentaenoylethanolamine, eicosenoy-lethanolamine, arachidonoylglycerol, palmitoyglycerol, oleoylglycerol, docosahexaenoylglycerol, eicosapentaenoylglycerol, eiconenooylglycerol, arachidonic acid (ARA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA). The glycerols were present in higher concentrations than those of the ethanolamides. On average, maternal intake was [±(SD)] 98(162) DHA, 49(91) EPA, and 155(73) ARA mg/day.
Conclusions: Our findings support the importance of the LCPUFAs for infant growth and development. The presence of the ECM in BM warrants further exploration with regards to the mechanisms of action and its role in infant health and development. Hypotheses for future studies can be developed based on this study's data.
Funding: Supported in part by LSU College of Agriculture and LSU Agricultural Center.
HUMAN MILK LIPIDOME ANALYSIS USING LIQUID CHROMATOGRAPHY-ION MOBILITY SPECTROSCOPY-MASS SPECTROMETRY
Presenting Author: Alexandra George, University of Western Australia (UWA) - School of Molecular Sciences (SMS)
Co-Authors: Melvin Gay (UWA-SMS), Kevin Murray (UWA-School of Population Health), Rob Trengove (Murdoch University-Separation Science and Metabolomics Laboratory), Donna Geddes (UWA-SMS)
Background: Lipids are vital to the infant, although the most variable component of human milk (HM), contributing to immune cell metabolism and activation, neural and retinal development and providing the energy for infant growth. Basic methods have been employed in HM lipid investigation over the years, but technological advancements provide new potential in ‘omics analysis. While Liquid Chromatography-Mass Spectrometry (LC-MS) offers lipid separation by chemistry and identification using mass/charge ratio, Ion-Mobility Spectroscopy (IMS) gives a third-dimension with complementary information relating to size and shape. LC-IMS-MS has not been previously used in HM lipid characterisation.
Objective: To prove that LC-IMS-MS is invaluable for HM characterisation and will confirm and add to the existing HM lipidome knowledge.
Methods: HM samples were collected as part of a longitudinal study from exclusively breastfeeding mothers in Western Australia during month three of lactation. An LC-IMS-MS method in positive ionisation mode was optimised for HM analysis and untargeted lipidomics was carried out on HM samples.
Results: Preliminary analyses have identified hundreds of lipid compounds in HM based on compound retention time, mass and structure. The HM lipid profile contained many lipids of interest, including C59H98O6 which is a DHA-containing triglyceride, and showed significant inter- and intra-individual differences in lipid composition.
Conclusions: This method has shown that additional orthogonal separation using LC-IMS-MS can more accurately profile HM lipids, providing an opportunity to fully characterise the HM lipidome.
Funding: Australian Graduate Research Training Program, Unrestricted Research Grant Medela AG.
HUMAN MILK EXOSOMES ALTER CYTOKINE RELEASE IN CACO-2 INTESTINAL EPITHELIAL CELLS
Presenting Author: Jaime D. Kraft, Biochemistry, Microbiology and Immunology, University of Ottawa, Canada
Co-Authors: E. Ferretti (Pediatrics, The Ottawa Hospital/Children's Hospital of Eastern Ontario, Canada) E. Tremblay, J.F. Beaulieu (Anatomy and Cell Biology, Université de Sherbrooke, Canada) & I. Altosaar (Biochemistry, Microbiology and Immunology, University of Ottawa)
Background: Human milk (HM) contains multiple bioactive components that provide protection against inflammatory gastrointestinal diseases. HM exosomes can withstand simulated digestion and may remain biologically active upon ingestion, thus reaching the gastrointestinal tract of newborns. HM exosomes have immunomodulatory features that may provide protection to the gut of a newborn by promoting immune tolerance.
Hypothesis: HM exosomes alter inflammatory cytokine expression in intestinal epithelial cells.
Methods: From milk of mothers who gave birth to term and preterm infants, exosomes were isolated and fully characterized. Post-confluent Caco-2/15 cells were incubated with either culture medium containing HM exosomes or culture medium and PBS (24 h). An inflammatory response was induced by incubating the Caco-2/15 cells with heat-killed bacteria. Expression of pro-inflammatory markers, IL-8, IL-6, CXCL10, TNF-α, CCL2 and IL-1b, and anti-inflammatory IL-10 was measured with RT-qPCR.
Results: Pro-inflammatory cytokine expression was significantly (p < 0.05) decreased in cells pretreated with HM exosomes compared to controls. Anti-inflammatory cytokine expression was upregulated in cells pretreated with milk exosomes.
Conclusions: HM exosome exposure to intestinal cells led to a decreased expression of pro-inflammatory cytokines, suggesting that exosomes may play a role in promoting immune tolerance in the gut of newborns. This finding is significant as preterm infants have an increased risk of developing gastrointestinal diseases and inflammation. Thus, promotion of immune tolerance is necessary in this newborn population.
GENOME-WIDE ASSOCIATION ANALYSIS OF 2'-FUCOSYLLACTOSE CONCENTRATION IN HUMAN MILK
Presenting Author: Kelcey McBride, Washington State University
Co-Authors: Michelle K. McGuire, Holly Neibergs, Jennifer Kiser, Courtney Meehan (WSU); Janet Williams, Mark A. McGuire, Brenda Murdoch (University of Idaho); Lars Bode, Bianca Robertson (University of California, San Diego); the INSPIRE Consortium
Background: 2'-fucosyllactose (2’FL) is a potentially beneficial human milk oligosaccharide whose synthesis requires alpha-(1,2)fucosyltransferase 2, an enzyme encoded by the FUT2 gene. Although functionality of the FUT2 enzyme has been associated with variation in 2’FL concentration, the relationships between FUT2 variants and milk-borne 2’FL concentration across continents have not been rigorously explored.
Objective: We sought to identify single nucleotide polymorphisms (SNP) associated with variation in 2’FL concentration in human milk across continents.
Methods: DNA was extracted from saliva samples using the Gentra Puregene Blood Kit. The Illumina Multi-Ethnic Global-8 v1.0 array was used to genotype 396 women living in Ethiopia, The Gambia, Kenya, Ghana, Spain, Sweden, Peru, and the United States (INSPIRE study). After data filtering, PLINK (version 1.07) was used to perform a genome-wide association analysis.
Results: 14 SNP located within the FUT2 gene (chromosome 19) were associated with variation in 2’FL concentration at P < 10−40. Examples included rs681343 (a stop-gain mutation), rs492602 (a coding-synonymous mutation), and intronic mutations rs679574, rs516316, and rs516246.
Conclusion: These data support the widely held belief that variation in FUT2 is the primary driver of 2’FL concentration in human milk, and provide novel insight as to which polymorphisms are likely important in independently and perhaps interactively regulating its synthesis.
Funding: National Science Foundation and Washington State University Office of Research nutritional genomics grand challenge initiative.
EXPLORING HUMAN BREAST MILK METABOLOMIC PROFILE ACROSS DIFFERENT GEOGRAPHICAL LOCATIONS AND ITS ASSOCIATION WITH MICROBIOTA
Presenting Author: Carlos Gómez-Gallego, University of Turku (UT), Functional Foods Forum, Finland
Co-Authors: Jose Manuel Morales, Daniel Monleon (Laboratory of Metabolomics, Institute of Health Research-INCLIVA, Spain); Elloise du Toit (Department of Pathology, University of Cape Town, South Africa); Kaisa M. Linderborg (UT- Food Chemistry and Food Development, Department of Biochemistry); Yumei Zhang (Department of Nutrition and Food Hygiene, Peking University, China); Baoru Yang (UT- Food Chemistry and Food Development, Department of Biochemistry); Erika Isolauri (Department of Paediatrics, University of Turku and Turku University Hospital); Seppo Salminen (UT- Functional Foods Forum,), Maria Carmen Collado (UT - Functional Foods Forum; Institute of Agrochemistry and Food Technology, IATA-CSIC, Spain)
Background: Composition of breast milk is highly variable among individuals and can be influenced by genetics, diet, lifestyle and other environmental factors.
Objective: This study is aimed to identify the association of geographical location in the NMR-metabolic profile of breast milk and its relationship with milk microbiome.
Methods: Human milk metabolic and microbiome profiles were determined by nuclear magnetic resonance spectroscopy (NMR) and 16S rRNA gene sequencing, respectively, in 79 healthy women from Finland, Spain, South Africa and China.
Results: Up to 68 metabolites including amino acids, oligosaccharides and fatty acid-associated metabolites were identified in the human milk NMR-spectra. Metabolite profiles showed significant differences among geographical locations. The PLSDA analysis shows different distribution of the samples according to geographical location. Proteobacteria, Actinobacteria and Bacilli were the bacterial class most significantly correlated with milk metabolites, being positive or negative correlated depending on the metabolite. Specific interrelations between human milk metabolites and microbiota were identified.
Conclusions: Results demonstrate associations between differences in milk metabolome and geographical location and identify correlations between milk composition and bacterial groups. Future studies are needed to validate these findings and implications for infant health.
INTEGRATED ANALYSIS OF HUMAN MILK MICROBIOTA, OLIGOSACCHARIDES AND FATTY ACIDS IN THE CHILD COHORT
Presenting Author: Shirin Moossavi, University of Manitoba, Department of Medical Microbiology
Co-Authors: S. Sepehri, B. Robertson, L. Bode, S. Goruk, C.J. Field, A.B. Becker, P. Mandhane, S.E. Turvey, T. Moraes, P. Subbarao, D. Lefebvre, M.R. Sears, E. Khafipour, M.B. Azad
Background: Human milk contains many bioactive components that are rarely studied in combination.
Methods: We analyzed the composition of human milk collected at 3-4 months postpartum from 395 mothers in the CHILD cohort. Microbiota were analysed by Illumina 16S rRNA V4 sequencing, human milk oligosaccharides (HMO) by rapid high-throughput HPLC and milk fatty acids (MFA) by gas chromatography. Dimension reduction was performed with principal component analysis for HMO and MFA. Centre log-ratio transformation and hierarchical clustering were applied to microbiota. Associations between components were assessed using Spearman correlation, network visualization, multivariable linear regression, and redundancy analysis. P-values were adjusted for multiple comparisons.
Results: Total HMO concentration was associated with microbiota clustering patterns (p = 0.04). HMO-PC1 was marginally associated with microbiota α diversity (inverse Simpson, p < 0.1), independent of infant sex, parity, mode of breastfeeding, and birth mode. In redundancy analyses, HMO composition accounted for 5% of variation in the microbiota composition (p < 0.1); after controlling for parity and mode of breastfeeding, this association was significant only among mothers of daughters (p = 0.02). Firmicutes, Proteobacteria and Veillonellaceae were significantly correlated with the HMO DFLac, while Fusobacteria was correlated with DSLNT. Multiple significant yet weak correlations were identified between milk microbiota and individual fatty acids including Fusobacteria with C12:0, t18:1n7, 22:5n3, and 16:1n9, and Firmicutes and Proteobacteria with 16:1n9 and 20:4n6.
Conclusion: Using multiple approaches to integrate and analyse milk microbiota, HMO, and MFA, we observed novel and sometimes sex-specific associations. Further research is needed to characterize these associations and determine their clinical significance.
Funding: CIHR, AllerGen NCE, Canadian Lung Association, Research Manitoba, Manitoba Medical Services Foundation.
HUMAN PRE-COLOSTRUM: POTENTIAL ROLE AS A SOURCE OF BACTERIA TO THE INFANT MOUTH
Presenting Author: Juan M. Rodríguez, Complutense University of Madrid (UCM), Department of Nutrition and Food Science, Spain
Co-Authors: Lorena Ruiz (IPLA-CSIC, Institute of Dairy Products of Asturias, Villaviciosa, Spain; UCM - Department of Nutrition and Food Science, Madrid Spain); Alba Boix-Amorós (Fundación FISABIO, Valencia, Spain); Cristina García-Carral (UCM; Probisearch S.L., Tres Cantos, Spain); Rodrigo Bacigalupe (Fundación FISABIO); Héctor Argüello (Departamento de Genética, Universidad de Córdoba, Córdoba, Spain); Camilla Beatriz (UCM); María A. Checa (Centro de Salud Arrabal, Zaragoza, Spain); Alex Mira (Fundación FISABIO)
Background: Oral bacteria in human milk are usually considered a contamination from the infant oral cavity during breastfeeding but the influence of milk on initial acquisition of oral microbiota has not been investigated.
Objective: To investigate the composition of the microbiota of maternal pre-colostrum produced before birth and to study its potential as a source of bacteria to the infant mouth.
Methods: Pre-colostrum and infant saliva were collected from 19 mother-infant pairs. Microbiomes were analyzed (V3-V4 regions of 16S rDNA) in an Illumina platform. Bacteria were isolated and identified by MALDI-TOF. Whole-genome sequencing was performed on those isolates that seemed to be shared in both samples from the same mother-infant pair.
Results: Certain bacterial groups (mainly Streptococcus and Staphylococcus) were shared between pre-colostrum and infant salivary samples. In 13 pairs, at least one isolate from the same species was recovered from pre-colostrum and salivary samples. Globally, 8 out of 10 fully sequenced strain pairs were >99.9% identical at the nucleotide level.
Conclusions: The presence of oral bacteria in colostrum before contact with the newborn indicates that they are not a contamination from the infant and suggests that at least some oral bacteria colonize the infant's oral cavity through transmission through human milk.
Funding: Grants 624773 (European Commission) and AGL2016-75476R (MINECO, Spain).
GENOME-WIDE ASSOCIATION ANALYSIS OF LACTOSE AND PROTEIN CONCENTRATIONS IN HUMAN MILK
Presenting Author: Janet Williams, University of Idaho
Co-Authors: Brenda Murdoch, Mark A. McGuire, Sarah Brooker (University of Idaho); Michelle K. McGuire, Holly Neibergs, Jennifer Kiser, Kelcey McBride, Courtney Meehan (Washington State University); the INSPIRE Consortium
Background: The complexity of human milk is influenced by many factors including diet, stage of lactation, environmental factors, and social networks; but little is known about the extent to which maternal genetics contributes to variation in milk composition. Although extensively used to understand variation in bovine milk composition, genome-wide association studies have not been used to investigate the genetic contribution to variation in human milk composition.
Objective: Our objective was to utilize a genome-wide association approach to test if genetic variants are associated with variation in human milk lactose and protein concentrations.
Methods: Milk and saliva samples were collected from lactating women living in 11 locations around the world (the INSPIRE study). Protein and lactose concentrations were determined using colorimetric assays. DNA was extracted from the saliva, and maternal genotypes ascertained using the Illumina Multi-Ethnic Global-8 v1.0 array. Genome-wide association tests were conducted using linear mixed models.
Results: Significant SNPs were associated with variation in lactose concentration (e.g., long non-coding RNA LOC107986400; P = 9.72 × 10−9). Additional SNPs were identified as being associated with variation in protein concentration.
Conclusions: Our results provide evidence that maternal genetics contributes to variation in milk nutrient composition which may, ultimately, affect infant health and development.
Funding: National Science Foundation, Washington State University Office of Research grand challenges nutritional genomics initiative, Idaho Agricultural Experiment Station.
SEROPREVALENCE OF CYTOMEGALOVIRUS AMONG MOTHERS OF HIGH-RISK INFANTS: A TWELVE-YEAR REVIEW IN A SINGLE JAPANESE PERINATAL CENTER
Presenting Author: Mari Hayata, Kawaguchi Municipal Medical Center, Japan – Department of Neonatal Intensive Care Unit
Background: Cytomegalovirus (CMV) is one of the viruses transmitted through breast milk and could cause symptomatic infection in preterm infants. It is reported that rate of infection through raw breast milk from seropositive mother is 5–60%.
Objective: To determine the CMV seroepidemiology and to estimate the risk of CMV infection in NICU infants.
Methods: Maternal CMV seroscreening data, age and parity were obtained from medical record of 2814 infants who were hospitalized in our NICU between 2006/1 and 2017/12.
Results: 2495 data points were obtained. Maternal age was 16–49 years old (median 32), and primiparous rate was 51.3%. The overall seroprevalence of CMV-IgG and -IgM was 70.4% and 8.6%, respectively. CMV-IgG seronegative mothers were 16–45 years old (median 31) and primiparous rate was 55.6%. CMV-IgG seroprevalence in teenagers was 56.9% and increased with age and with parity. CMV-IgM seropositive mothers were 19–45 years old (median 32) and primiparous rate was 47.9%. CMV-IgM seropositive rate increased over the years.
Conclusions: Maternal CMV-IgM seropositive rate increased in 12 years. Raw breast milk should be given to preterm infants in NICU under careful conditions. Further study is needed to determine the risk of CMV infection through breast milk due to the increasing CMV-IgM seropositive rate.
GESTATIONAL DIABETES REDUCES BREASTFEEDING DURATION: A PROSPECTIVE COHORT STUDY IN VIETNAM
Presenting Author: Phung Thi Hoang Nguyen, Curtin University, Perth - School of Public Health
Co-Authors: Colin Binns, Andy Lee
Background: Gestational diabetes mellitus (GDM) and its complications are major concerns due to its negative effects during antenatal period and on the future health of mothers and infants. Breastfeeding is beneficial for GDM mothers and their babies to reduce future health risks. Little is known about whether the effect of GDM on “any breastfeeding” duration.
Objective: To determine the effects of GDM on “any breastfeeding” duration for Vietnamese women.
Methods: A prospective cohort study of 2,030 pregnant women, recruited from 24 to 28 weeks gestation to examine GDM status using 75g oral glucose tolerance test, then were followed up the any breastfeeding duration from discharge and until twelve month postpartum. Cox's regression model was used to examine the association of GDM and breastfeeding duration.
Results: 94.4% of all women reported “any breastfeeding” at discharge, and 72.9% of women were still breastfeeding at twelve months. There were no significant difference in breastfeeding outcomes at discharge (early initiation, prelacteal feeding, and any breastfeeding rate) between GDM and non GDM mothers. However, breastfeeding duration (weeks) was found to decrease in GDM women compared to other mothers after adjustment (HR 1.38, 95% CI 1.12–1.70, p = 0.002).
Conclusion: GDM can result in lower breastfeeding duration during twelve months postpartum. Women with GDM require ongoing support after hospital discharge to maintain “any breastfeeding” duration.
Funding: This work was partially supported by the School of Public Health, Curtin University, Western Australia.
BREASTFEEDING EXPERIENCE, CHALLENGES AND SERVICE DEMANDS AMONG CHINESE MOTHERS: A QUALITATIVE STUDY IN TWO CITIES
Presenting Author: Yan Zhang, Fudan University, School of Public Health, Shanghai, China
Co-Authors: Yi Jin (Danone Nutricia Early Life Nutrition, Shanghai, China); Carel Vereijken, Bernd Stahl (Danone Nutricia Research, Utrecht, The Netherlands); Hong Jiang (Fudan University, School of Public Health)
Background: Breastfeeding rates remain low and breastfeeding practices remain unclear in China.
Objective: To explore mothers' experiences throughout the breastfeeding period and to understand their challenges and service needs at each stage.
Methods: Qualitative research methods were used. A total of 32 individual in-depth interviews and 10 focus group discussions regarding BF practices were carried out with stakeholders, including, mothers, service providers, researchers, and policymakers, etc.
Results: During pregnancy, women had high intention towards breastfeeding, but had inadequate knowledge and skills preparation. During the hospitalization for childbirth, mothers received inadequate support from hospital professionals due to the short hospital stay. After being discharged from the hospital, mothers mostly relied on support from non-professionals. Between 4–6 months postpartum, most mothers returned to work and stopped exclusively breastfeeding due to the lack of a supportive workplace environment. Between 6–12 months, most mothers stopped breastfeeding and switched to formula because of returning to work, perceived non-nutritious value of breast milk after six months, and desiring returning to former lifestyle.
Conclusion: Tailored support should be provided to mothers with different problems and specific service needs at different periods of breastfeeding.
Funding: Danone Nutricia Research, Utrecht and Danone Nutricia Early Life Nutrition, China.
UTILIZATION OF DONOR MILK AMONGST MUSLIMS IN A TERTIARY HOSPITAL IN SINGAPORE
Presenting Author: Mei Chien Chua, KK Women's and Children's Hospital–Department of Neonatology and KK Human Milk Bank
Co-Authors: Pooja A. Jayagobi, Anng Anng Wong, Cynthia Pang, Siew Tin Ang (KKH Human Milk Bank)
Background: Singapore is a multi-ethnic society. 14.3% of the population are Muslims. The religious concept of milk kinship in Islam presents as a potential obstacle to the use of pasteurised donor human milk (PDHM) in hospitalized premature Muslim infants.
Objective/ Hypothesis: Seeking guidance from the Islamic Religious Council of Singapore (MUIS) may result in acceptance of the use PDHM amongst the Muslim population.
Methods: Scientific evidence on benefits of donor milk and controversies regarding milk kinship were discussed with MUIS. A fatwā—a ruling on a point of Islamic law—was released. It stated that using PDHM from the milk bank for purposes of preserving the well-being of the infant, is in line with the objectives of Sharī'a (Muslim Rule of Law) which emphasize the need for the preservation of human life, is acceptable and does not establish kinship.
Results: Since its launch in August 2017, KK Human Milk Bank recruited 305 donors and 4% (n = 11) were Muslims. 28% (n = 82) of the recipients were premature Muslim infants. They consumed 35% of the 948 liters PDHM dispensed to 291 recipients.
Conclusions: Guidance from the relevant religious authority was key to acceptance of donor milk amongst Muslims in a culturally diverse society.
Funding: Temasek Foundation Cares.
BRAINSTEM MATURATION AMONG PRETERM INFANTS AS AFFECTED BY BREASTFEEDING DURING A NICU STAY
Presenting Author: Hajime Yasuhara, Nara Prefecture General Medical Center, Nara- Department of Neonatal Intensive Care Unit
Objective: To assess the relationship between breastfeeding during a NICU stay and brainstem maturation in preterm infants as measured by latencies of the Auditory Brainstem Response (ABR).
Methods: The present study was performed on infants born at our medical center between April 2013 and March 2016. Study subjects comprised 153 preterm infants who were appropriate for gestational age and born before 35 gestational weeks. Subjects were allocated into three treatment groups according to the percentage of breast milk in the total nutrition: formula dominant group (percentage of breast milk <50%), breast milk dominant group (percentage of breast milk 50–90%), and almost exclusively breast milk (percentage of breast milk ≧90%). ABR measurements were performed before discharge from the NICU. Absolute latencies for waves I, III, and V and interpeak latencies I–III, III–V, and I–V were recorded. Correlations between absolute latencies and postconceptional age of the 3 groups were analyzed by linear regression.
Results: The formula dominant, breast milk dominant, and almost exclusively breast milk groups comprised 43, 71, and 39 infants, respectively. From 36 to 40 weeks, absolute latencies for V, I–III, and I–V intervals in the breast milk dominant group were shortened by 0.112, 0.096, and 0.139 msec/week, respectively, and absolute latencies for III, V, I–III, and I–V intervals in the almost exclusively breast milk group were shortened by 0.17, 0.147, 0.155 and 0.134 msec/week, respectively, as revealed by regression analysis. The formula dominant group showed no shortening of absolute latencies.
Conclusion: Preterm infants fed more breast milk than formula exhibit faster brainstem maturation as measured by ABR.
THE DIETARY INTAKE OF TWO GROUPS OF LACTATING WOMEN IN SHANGHAI DURING THE CONFINEMENT PERIOD
Presenting Author: Rui Hu, Jing Li, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine
Co-Authors: Janet Warren (FirstStop Nutrition Ltd, c/o INCA Accounting, UK); Bernd Stahl (Danone Nutricia Research, The Netherlands); Yi Jin (Danone Nutricia Early Life Nutrition, China); Zhixu Wang (Nanjing Medical University - Dept Maternal, Child and Adolescent Health, School of Public Health, China)
Background: Lactation is a time of increased nutritional requirements for mothers; there are limited data on the dietary intake of lactating Chinese mothers during the confinement period (one month after delivery).
Objective: To investigate the dietary intake of two groups of lactating women in Shanghai during the traditional confinement period.
Methods: Two groups of women: (1) a community dwelling sample (n = 92); (2) residents in a Maternity Care Centre (MCC) (n = 30), kept a prospective dietary and photographic record of intake. Intakes were recorded for a single day on three occasions for the community group, and for three days on five occasions in the MCC group. Mean nutrient intakes of the two groups were compared to China's dietary reference intakes (2013), and food intake compared to food-based guidelines of China (2016).
Results: Fruit, vegetable, bean, tuber and milk intakes were lower than recommendations. An excessive proportion of calories came from fat (34% of total energy). Intakes of sodium were higher than recommendations. Over 70% of all women failed to meet the EAR for calcium and dietary intake gaps were seen for vitamin C, thiamin and riboflavin. Mean dietary fiber intakes were less than 50% of the AI. Overall, multiple micronutrient intakes for community group are poorer than MCC group.
Conclusions: This dietary intake study indicates potential nutritional intake concerns among lactating women in Shanghai, particularly for community dwelling women.
Funding: Danone Nutricia Early Life Nutrition, China.
CONCENTRATION OF CAFFEINE IN BREAST MILK OF JAPANESE BREASTFEEDING MOTHERS
Presenting Author: Ikuko Kato, Kagawa University, Department of Pediatrics, Kagawa, Japan
Co-Authors: Shoko Kozai (Yashima General Hospital, Department of Pharmacy), Yinmon Htun, Hitoshi Okada, Takashi Kusaka (Kagawa University, Department of Pediatrics)
Background: It is well known that excessive caffeine intake is bad for health. Some infants can be sensitive to caffeine and display increased irritability and sleep disturbances when exposed to caffeine in breast milk. The half-life of caffeine in infants is longer than that of adults, thus, it stays in the body much longer before excretion. Information about the adverse effects of caffeine in infants is available, making some mothers nervous. The main contributors of caffeine intake are Japanese tea and coffee. Most of the Japanese breastfeeding mothers avoid caffeine to an unnecessary extent. So far, there have been few studies about the concentration of breast milk caffeine of mothers who regularly take Japanese tea and coffee while breastfeeding their infants.
Objective: To reveal the concentration of breast milk caffeine of Japanese breastfeeding mothers.
Methods: Breast milk was collected from Japanese breastfeeding mothers who visited Kagawa University Hospital for the 1-month postpartum checkup of their infants. Caffeine intake was assessed using a dietary questionnaire and the concentration of breast milk caffeine was measured by HPLC.
Results: 13 breastfeeding mothers were recruited. Most of the mothers (11/13, 85%) restricted caffeine, and more than half of them never consumed caffeine during pregnancy. 9 mothers out of 13 mothers (69%) showed undetectable breast milk caffeine concentrations and for the detectable ones, the values were between 0.24∼1.70 μg/ml.
Conclusions: In most mothers, caffeine in breast milk was not detected. Most of them also avoided caffeine intake. The concentration of caffeine breast milk was very low in the mothers who took caffeine regularly.
ESTIMATION OF MILK INTAKE BY STABLE ISOTOPE ANALYSIS IN CAPTIVE ORANGUTANS
Presenting Author: Noko Kuze, The National Museum of Nature and Science, Tokyo
Co-Authors: Takumi Tsutaya (Japan Agency for Marine-Earth Science and Technology)
Background: Lactation is important for the healthy development of infants and for its effect on reproduction (suppression and restart of ovulation) among mammals, including humans. The estimation of milk intake in great apes (non-human Hominidae species) is difficult because interviews cannot be applied. Recently, however, stable isotope analysis has been used to estimate milk intake in humans.
Hypothesis: Stable isotope analysis can be used to estimate milk intake in great apes and humans.
Methods: Hair samples and behavioral data (e.g. nipple contact) from 3 mother-offspring pairs of captive orangutans were collected for >3 years. The carbon and nitrogen stable isotope ratios of the hair were measured using an elemental analyser-to-isotopic ratio mass spectrometer.
Results: Infants aged <1 year have elevated nitrogen isotope ratios than their mothers, which is consistent with previous results in humans. The elevated values abruptly decrease after 1.5 years, but the offspring still show slightly higher values than the mothers until 4 years old. These isotopic patterns are consistent with behavioral data.
Conclusions: Stable isotope analysis is a useful method to estimate milk intake in non-human great apes. Combination of isotope analysis, behavioural observation, and urinary sex hormone analysis would contribute in assessing the relationship between lactation and reproduction (restart of ovulation).
Funding: Grant-in-Aid for JSPS Research Fellow.
A Multicenter Survey on Management of Breast milk and Formula Feeding in NICUs in China
Presenting Author: Linlin Li, Peking Union Medical College Hospital - Pediatrics
Co-Authors: Dongmei Lian, Jing Sun
Background: There are no specific guidelines for the management of breast milk and formula in China. NICUs and current practices in hospitals at different locations is unknown.
Objective: To investigate the current management policies and practices for breast milk and formula in NICUs in China.
Methods: NICUs from 53 hospitals were recruited by convenience sampling to complete a 48-item survey containing questions on how formulas are selected, systems for managing breast milk and formula, quality control measures, and education for parents on infant feeding. The questionnaire was tested by 6 neonatologists. The content validity index was 0.97, while the Cronbach's αwas 0.832.
Results Among the 53 NICUs surveyed, 66% did not have a breastfeeding room, 75.5% were not completely open to the parents, 15.1% did not accept breast milk from the mother, 48.9% did not have facilities for storing breast milk, and 16.3% reheated breast milk in non-recommended ways. In addition, management of breast milk and formula were not standardized; 18.9% and 6.7% of the NICUs did not maintain records of breast milk and formula, respectively. The quality control measures were not well documented. The content of education was not comprehensive, and breastfeeding-related education was not standardized in 32.1% of the NICUs.
Conclusion: While breastfeeding rates have improved in China, most of the NICUs surveyed had substantial breastfeeding/formula management problems.
Funding: Self-raised funds.
ASSOCIATION BETWEEN MATERNAL DIET AND HUMAN MILK COMPOSITION IN A CHINESE POPULATION
Presenting Author: Bianca Papi, Danone Nutricia Research
Co-Authors: Sophie Swinkels (Danone Nutricia Research); Yi Jin (Danone Nutricia Early Life Nutrition, China); Zhixu Wang (Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University); Jing Li (Shanghai Children's Medical Center); Marko Mank (Danone Nutricia Research); Bernd Stahl (Danone Nutricia Research)
Background: The impact of maternal diet during lactation and the composition of Human Milk (HM) is difficult to evaluate. Most studies consider only pairwise associations between diet and HM using simple correlation coefficients, which does not capture the multidimensionality of the data.
Objective: We aim to elucidate associations between maternal diet and HM composition using multivariate statistical techniques that can deal with the high intra-correlations within multiple dietary ingredients during lactation.
Methods: A two-step multivariate approach was used to detect the association between dietary intake during lactation and HM composition (separately for colostrum and mature milk) of 122 healthy Chinese lactating mothers at Shanghai Children's Medical Centre. Dietary intake was collected via dietary record at different visits, at the same visits HM samples were analyzed via MIRIS.
Results: Four dietary profiles were detected with a strong signal of association with HM composition. Diet intake of relative more milk/diary and of relatively less grain was found to be associated with a higher relative concentration of Fat and Carbohydrate, and a relatively lower concentration of Protein in colostrum. The same association was found for mature milk but the association with the relative concentration of HM Fat was no longer significant.
Conclusions: To our knowledge, this is the first study that has provided a quantitative evidence of association between maternal diet and human milk composition by studying all possible correlations at the same time.
Funding: Danone Nutricia ELN, China.
EFFECTIVENESS AND SAFETY OF DOMPERIDON FOR INCREASING MILK SECRETION IN JAPANESE MOTHERS WITH LACTATION FAILURE WHO'S BABIES WERE IN THE NICU
Presenting Author: Yuka Wada, National Center for Child Health and Development (NCCHD)
Background: When mothers are unable to breastfeed directly, as when their baby is in the NICU, lactation tends to fail despite adequate support. Domperidone has been shown to be effective for increasing milk secretion; however, there is little data about its effectiveness and safety for Japanese mothers and babies.
Objective: To investigate the effectiveness of domperidone and safety for Japanese mothers and babies.
Methods: Subjects were ten mothers and their babies in the NICU. Mothers were treated with domperidone 30 mg/day for 14 days. Milk amounts were measured and blood tests were performed before administration and on days 7 and 14 after administration. Physical condition and concentration of domperidone in blood were checked for the babies.
Results: Milk secretion on day 14 after administration of domperidone increased by 1.5 times or more in seven subjects compared to before administration. Abdominal pain (one mother) and headache (one mother) were noted. There were no observed changes in babies. The RID was 0.1%.
Conclusions: Domperidone was effective for increasing milk secretion Japanese mothers in our study sample. There were no serious adverse events and it could be safely used.
Funding: Child Health and Development Research and Development for expenses.
THE SN-2 FATTY ACID COMPOSITION OF MATURE HUMAN MILK IN CHINESE POPULATION
Presenting Author: Shan Jiang, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing 100050, PR China
Co-Authors: Zhenyu Yang, Jie Wang, Yifan Duan, Xuehong Pang, Ye Bi, Huanmei Zhang, Jianqiang Lai, Shian Yin
Objective: To investigate the sn-2 fatty acid composition of mature human milk in 11 provinces of China.
Methods: A large cross-sectional study was conducted and lactating women (n = 6481) within 0–330 days postpartum were recruited in China between 2011 and 2013. Mature human milk samples (n = 3387) were collected in the original study, from which 561 samples were randomly selected. Triglycerides were hydrolyzed and fatty acids at sn-2 position methyl esters were analyzed using gas chromatography.
Results: About 56.1% of total sn-2 fatty acids was palmitic acid in mature human milk of China. Saturated fatty acids, monounsaturated fatty acids and polyunsaturated fatty acids accounted for 73.7%, 13.4% and 12.9% of total fatty acids at the sn-2 position, respectively. The percentage of linoleic acid and arachidonic acid at the sn-2 position were 10.2% and 0.37%, respectively. The percentage of eicosapentaenoic acid (EPA) and docosahexenic acid (DHA) at the sn-2 position were 0.07% and 0.16%, respectively. The percentage of fatty acids at the sn-2 position in mature human milk differed significantly among various regions (Palmitic acid: Guangxi (67.1%) vs. Gansu (49.4%); DHA: Beijing and Shandong (0.13%) vs. Xinjiang (0.03%)) and nationalities (Palmitic acid: Zhuang (66.5%) vs. Hui (47.1%); DHA: Han (0.11%) vs. Bai and Zhuang (0.04%)).
Conclusions: Palmitic acid is the most abundant fatty acids at the sn-2 position in mature human milk. The fatty acid concentrations at the sn-2 position vary among different regions and nationalities in China.
CONCENTRATION OF ALPHA-LACTALBUMIN IN HUMAN MILK IN CHINESE POPULATIONS
Presenting Author: Jie Wang, National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, PR China
Co-Authors: Zhenyu Yang; Qi Chen (Zhejiang Center for Disease Control and Prevention); Yifan Duan; Xuehong Pang; Shan Jiang; Ye Bi; Huanmei Zhang; Jianqiang Lai; Shian Yin
Background: Alpha-lactalbumin (ALB) is a key protein in human milk. ALB provides essential amino acids for infants, carries minerals, and enhances immune function.
Objectives: To examine the dynamic change of ALB concentration throughout the whole course of lactation and to explore factors associated with ALB concentrations in Chinese populations.
Methods: A cross-sectional study was conducted in 11 provinces across China between 2011 and 2013. Lactating women (n = 6481) within 0–330 days postpartum and their babies were enrolled in the original study. A full-term milk sample of 782 was randomly selected from the original study, and the ALB concentration was determined by UPLC/MS.
Results: The median ALB concentration was 2.67 g/L, 2.77 g/L, and 2.08 g/L in colostrum, transitional milk and mature milk, respectively. The ALB concentration in mature milk was lower than in colostrum and in transitional milk (both P < 0.01). Age, the mode of delivery, partition, and the serum albumin level were not associated with ALB concentration. However, mothers with BMI <18.5kg/m2 has lower ALB concentration (2.06 g/L) than mothers with normal BMI (2.34 g/L, P < 0.01) or higher BMI (2.58g/L, P < 0.01). Living areas and ethnicity of the mother were also associated with ALB concentration (urban vs rural, 2.62 g/L vs 2.36 g/L, P < 0.01; Han vs Minority, 2.59 g/L vs 2.30 g/L, P < 0.01).
Conclusions: The ALB concentration dynamically changes throughout lactation. BMI, living area and ethnicity are associated with ALB concentration.
PRELACTEAL FEEDS AND EXCLUSIVE BREASTFEEDING IN ASIA
Presenting Author: Colin Binns, Curtin University, Australia, School of Public Health
Co-Authors: Andy Lee, Mi Kyung Lee, Murdoch University,
Background: In many Asian cultures prelacteal feeds are often given to infants. Traditionally foods such as tea, herbal infusions, goat milk etc. were used. Colostrum was commonly discarded as unhealthy for infants. A number of different definitions of exclusive breastfeeding are in common use and data is reported as period prevalence and point prevalence.
Hypothesis: Prelacteal feeds are common in Asia and distort exclusive breastfeeding statistics.
Methods: Fifteen cohort studies have been undertaken in seven countries across Asia by universities and our research group using the same methodology. Mothers (n = 11500) were interviewed while in hospital and at regular intervals until 6 months postpartum using a standardised questionnaire. Approval was given by Curtin Ethics Committee, National Ministries of Health and Universities
Results: The rates of prelacteal feeding varied from a high of 93% in Sichuan Province, China to 9% in Sabah Malaysia and Central Nepal. In many places the traditional prelacteal foods have been replaced with the use of infant formula. At 6 months post-partum exclusive breastfeeding (nothing but breast milk since birth) ranged from 0 to 9%. Predominant breastfeeding rates were as high as 36–39% in the Maldives, Nepal and Sabah.
Conclusions: The results bear little resemblance to published figures suggesting that definitions and methods of data collection need to be standardised and very few countries follow Baby Friendly practices.
Funding: Local university resources, Curtin University.
POLICIES ON BREASTFEEDING PROMOTION IN SRI LANKA
Presenting author - Sanjeeva S.P. Godakandage, Ministry of Health, Sri Lanka
Co-Authors - Upul Senarath (University of Colombo); Hiranya Jayawickrama (Ministry of Health); Indika Siriwardena (National Authority for Protection of Victims of Crime and Witnesses, Sri Lanka); Aravinda Wickramasinghe, Prasantha Arumapperuma (Ministry of Health); Claudio Umesh (University of Colombo); Annemarie Thow, Michael Dibley (University of Sydney)
Background: Favourable policies are a pre-requisite to design effective interventions to improve breastfeeding practices.
Objective: To assess national level policies on breastfeeding promotion in Sri Lanka, with a view to identifying gaps to facilitate improving them.
Methods: Sri Lankan policy documents on breastfeeding promotion were collected systematically through search of websites, contacting key informants and from repositories. Mind mapping and causal analysis were used to identify relevant policy sectors and types. Data were analysed using a narrative synthesis approach, with a matrix under the four domains of general policy support, communication of evidence-based information, staff training and engaging mothers/caregivers.
Results: Nineteen policy documents related to global breastfeeding recommendations, International Code on Breast Milk Substitutes, maternity benefits, behaviour change communication, supplementation, capacity building and strengthening health and non-health systems and inter-sectoral collaboration were identified. Fifteen policy documents belonged to the health sector. However there is no written, exclusive Sri Lankan policy document on breastfeeding.
Conclusions: The policy environment in Sri Lanka for breastfeeding promotion is highly favourable, yet further improvements through a separate written policy and better involvement of non-health sectors need to be explored.
Funding: Department of Foreign Affairs and Trade, Australia.
BREASTFEEDING WITHOUT NURSING: REASONS FOR INITIATION AND CESSATION OF EXCLUSIVELY PUMPING HUMAN MILK
Presenting Author: Fiona Jardine, University of Maryland, College of Library and Information Studies.
Background: The rates of exclusive milk expression or pumping (EPing) are increasing. However, little is known about the reasons for EPing initiation and cessation, or the durations achieved by those who breastfeed without nursing.
Objectives: Describe the reasons given by EPers for initiating and ceasing EPing and explore the durations of EPing achieved.
Methods: A cross-sectional, self-report, mixed-methods survey was administered online to a convenience sample of current and/or former EPers (N = 2,007). To identify trends, data were analyzed using descriptive statistics. Respondents could select multiple responses to most questions.
Results: 69% (1,394) of respondents reported latch problems as a reason for EPing; 25% (496) reported their infant did not transfer milk well while nursing; 23% (463) had a NICU infant; and 8% (157) “just wanted to.” The health benefits of breastfeeding to their child (98%; 1964) and themselves (43%; 859), as well as the cost of formula (57%; 1,138), were cited as reasons not to exclusively formula feed. Out of 696 (35%) former EPers, reasons for cessation included: reaching their goal (37%; 257); supply issues (low/”drying up”) (35%; 242); logistical difficulties (caring for child/time to pump) (32%; 222); and infant(s) successfully latching (7%, 48). Excluding those who ceased EPing because of latching, mean EPing duration was approximately 8.6 months (SD = 5.18; median = 8; range = >1 week–54 months).
Conclusions: Among respondents predominantly recruited from online EPing support groups, EPing was often necessitated by latch problems; few spontaneously chose to EP. The duration of EPing achieved, while greatly varied, provides evidence that EPing is a sustainable long-term breastfeeding option.
Funding: None.
CHANGES IN NIPPLE TEMPERATURE ASSOCIATED WITH BREASTFEEDING AND PUMPING
Presenting Author: Hazel Gardner, University of Western Australia, School of Molecular Sciences
Co-Authors: Ching-Tat Lai, Donna Geddes
Background: Changes in skin temperature during breastfeeding are partly due to changes in peripheral blood circulation associated with the cyclical release of oxytocin. The nipple has a critical role in successful breastfeeding, and damage to the nipple will negatively impact milk removal and breastfeeding duration. Changes in nipple temperature associated with breastfeeding and pumping have not previously been reported in the same participants.
Objective: To examine changes in nipple temperature during breastfeeding and pumping.
Methods: 30 lactating women participated in two pumping and one breastfeeding session. 24-hour milk productions were completed. Nipple temperature was recorded for 2 minutes before and after each session. In addition the opposite breast was monitored throughout each session.
Results: The mean change in nipple temperature after milk expression was 1.57 ± 1.62°C (range −0.9–6.1, p < 0.001). The mean change in nipple temperature after breastfeeding was 0.86 ± 1.5 °C (range −3.2–3.2, p = 0.04). Temperature changes were similar between the 2 pumping sessions (p = 0.63) but both were significantly different from the breastfeeding session (p = 0.04 & p = 0.02).
Conclusions: Nipple temperature is variable between individuals and changes significantly during both pumping and breastfeeding. Extreme changes in nipple temperature may indicate reduced blood flow due to poor fitting breast shields, extended duration of pumping, or possibly infection.
Funding: Unrestricted research grant, Medela AG, Switzerland.
MEASURING PUMPED MOTHER'S OWN MILK (MOM) VOLUME AS A DEPENDENT VARIABLE IN LACTATION RESEARCH
Presenting Author: Harold Bigger, Rush University Medical Center
Co-Authors: Rebecca Hoban (Toronto Sick Children's Hospital and Rush University Medical Center); Judy Janes, Aloka Patel, Fabiola Loara-Garcia, Clarisa Medina Poeliniz, Paula Meier
Background: The volume of pumped MOM is a common dependent variable in clinical studies of breast pump-dependent mothers with infants hospitalized in the neonatal intensive care unit. Two common measurement methods are mother-maintained pumping logs and staff-measured MOM weights.
Objective: This study examined differences between these two methods of measuring pumped MOM volume.
Methods: This study is part of a non-randomized study focused on MOM biomarkers of secretory activation that enrolled 40 breast pump-dependent mothers of premature infants (<33 weeks). Pumped MOM volume was measured both by maternal pumping logs (mLs) and staff weights (g) for each pumping session during the first 14 days post-delivery. Staff and mothers were blinded to the others' measures.
Results: Results reveal 1063 mother-recorded and 1986 staff-recorded pumping sessions. Of the 838 pumping sessions recorded by both mothers and staff, 64 were eliminated due to obvious data entry errors, leaving 774 sessions for analysis. The mean, minimum and maximum recorded values for mothers were 63.8 mLs, 1 mLs and 375 mLs, respectively. The mean, minimum and maximum recorded values for staff were: 65.3 g, 1.3 g and 379.7 g, respectively. Lin's Concordance Correlation Coefficient was 0.995, Pearson's Correlation Coefficient was 0.996.
Conclusions: While the paired values were highly correlated and agreed statistically, there remains substantial differences between staff vs mother's measures of MOM production which may impact clinical trial results.
Funding: Rush Pediatrics internal grant, Medela, Inc.
ANALYSIS OF THE LACTATING BREAST AFTER MILK TRANSFER: BREASTFEEDING VS ELECTRIC PUMPS
Presenting Author: Jimi Francis (University of Texas at Tyler – Department of Health and Kinesiology)
Co-author: Darby Dickton (UC-Davis Medical Center)
Background: Many women are using electronic devices to transfer milk out of the breast. Little research has been reported on the physical effects of vacuum-based pumping systems on the breast compared to the infant at the breast when transferring milk out of the breast. There is a knowledge gap regarding the physical response of the breast and nipple tissue to the use of breast pumps.
Objective: To quantify any nipple changes after milk transfer via breastfeeding and using different types of electric breast pumps.
Methods: Women were recruited from a local lactation center. Three breast pumps with different vacuum and cycle profiles were used. Digital calipers were used for all nipple diameter and length measurements. A slightly modified Wong-Baker FACES pain Scale was used to assess comfort level during each milk transfer session. Physical changes in nipple length, diameter, and the appearance of breast tissue were documented and compared to baseline as a measure of breast tissue change.
Results: 26 participants were observed during breastfeeding and using 3 different pumping devices. Erythema and swelling were observed and documented. Statistically significant differences were evident between the milk transfer methods. Increased nipple diameter and length was commonly accompanied by some level of pain felt by the user of the pumping device.
Conclusions: It is critical for professionals advising women about milk expression to have good understanding of the effects of pumping on breast tissue and how that contrasts to at-the-breast feedings. Increased knowledge is a crucial component for the health care provider assisting women to meet their breastfeeding goals and assist them with milk transfer techniques. The authors have no conflict of interest.
Funding: A grant from the Foundation for Maternal, Infant, and Lactation Knowledge.
HUMAN MILK BIOMARKERS AND MILK VOLUME IN PUMP-DEPENDENT MOTHERS OF PREMATURE INFANTS
Presenting Author: Rebecca Hoban, University of Toronto
Co-Authors: Aloka L. Patel (Rush University); Ching Tat Lai (University of Western Australia), Clarisa Medina Poeliniz, Judy Janes (Rush University); Donna Geddes (University of Western Australia); Paula P. Meier (Rush University)
Background: Coming to volume (CTV; ≥500mL/day mother's own milk [MOM] by postpartum day 14) predicts continued MOM provision at NICU discharge in pump-dependent mothers of premature infants. MOM biomarker concentrations reflect mammary epithelium secretory activation, but are little studied in premature populations.
Objective: To determine relationships between MOM biomarkers (sodium, protein, lactose, citrate) and CTV in pump-dependent mothers of premature infants.
Methods: Observational study collected serial MOM samples and pumped volume measures for 14 days postpartum in 39 mothers who delivered <33 weeks. MOM biomarkers were considered normal if ±3SD from published values for full-term lactating women. Analyses included chi square, t-tests, and Wilcoxon testing.
Results: The cohort was high risk (mothers: 69% low socioeconomic status, 54% black, 67% overweight/obese, 41% cesarean delivery; infants: birthweight 1259 ± 485g, gestation 28.8 ± 2.7 weeks). Only 46% of mothers had all 4 biomarkers in normal range (median day 5, IQR4,9). Sodium and citrate normalized first. Mothers who experienced CTV (36%) normalized ≥1 MOM biomarker(s) earlier (3 vs 4 days, p < 0.001) and trended towards having 4 normal biomarkers (64% vs not CTV 36%, p = 0.09). They had normal sodium (>16 mmol) more frequently (79% vs not CTV 40%, p = 0.02) and earlier (3 vs 5 days, p < 0.001), and combination of normal sodium and citrate more frequently (57% vs not CTV 20%, p = 0.02) and earlier (3 vs 4 days, p < 0.001).
Conclusions: Mothers frequently experienced compromised lactation. Delays in normal MOM sodium and citrate predicted not CTV, suggesting clinical utility as indicators of compromised lactation and objective outcome measures of lactation interventions.
Funding: Rush, ISRHML, Family Larsson-Rosenquist Foundation, Medela.
EFFECTIVENESS OF MILK TRANSFER DOES NOT IMPROVE IN BREASTFED TONGUE-TIED INFANTS FOLLOWING FRENOTOMY
Presenting Author: Donna Geddes, University of Western Australia – School of Molecular Sciences (UWA-SMS)
Co-Authors: Anna Cannon, Sharon Perrella (UWA-SMS), Elizabeth Whan (Department of General Surgery, Princess Margaret Hospital), Alethea Rea, Kevin Murray (UWA – Centre for Applied Statistics)
Background: Ankyloglossia (tongue tie) is defined as the restriction of tongue movement due to tethering of the tongue by a short and/or fibrous lingual frenulum and is often associated with breastfeeding problems for which frenotomy may be recommended. Frenotomy has not resulted in increased duration of breastfeeding.
Objective: The aim of this study was to measure infant milk transfer and maternal milk production before and after frenotomy.
Methods: Infant milk transfer and milk production was measured over 24 hours with test weighing.
Results: 25 breastfeeding infants diagnosed with tongue tie underwent frenotomy. Pre frenotomy 24hr infant milk intake from the breast did not change after frenotomy (498 ± 266mL vs 542 ± 275mL; p = 0.114) nor did milk production (595 ± 252mL vs 599 ± 263L; p = 0.84).
Conclusions: Prior to frenotomy the majority of mothers had a clinically low milk production. Despite maternal pain reduction after frenotomy, infant milk transfer or milk production did not increase significantly. These results suggest that milk transfer be measured prior to consideration for frenotomy.
Funding: Unrestricted research grant from Medela AG.
PROMOTING SELF-MANAGEMENT OF BREAST AND NIPPLE PAIN IN BREASTFEEDING WOMEN
Presenting Author: Ruth Lucas, University of Connecticut, School of Nursing
Co-Authors: Angela Starkweather (University of Connecticut, School of Nursing); Heather Evans, (Manchester Memorial Hospital)
Background: During the first week of breastfeeding, 90% of women report breast and nipple pain. Approximately 30% will develop persistent pain (>10 days in duration). Self-management (SM) interventions that incorporate knowledge, skills and support for managing pain are effective in individuals experiencing chronic pain and managing pain during labor, however, these interventions have not been applied in managing pain during breastfeeding.
Objective/Hypothesis: To evaluate the effect of a tailored breastfeeding SM intervention on breast, nipple and generalized pain, and breastfeeding duration in breastfeeding women of full-term infants.
Methods: A randomized controlled pilot study was conducted among 60 (30 intervention and 30 attention control) breastfeeding women. Both groups received online interactive modules to address knowledge and skills and were asked to complete a breastfeeding log. The intervention group also received nurse consultations via phone and supportive texts to address instrumental and emotional support. Participants completed study questionnaires, including the brief pain inventory (BPI), at delivery, 1-, 2-, and 6-weeks.
Results: Women in the intervention compared to attention control group reported significantly less breast and nipple pain at 1-week (M = 32.54; 46.97, p = 0.01), 2-weeks (M = 22.69; 39.97, p = 0.01), 6-weeks (M = 11.46; 15.53; p = 0.08), and generalized pain intensity at 2-weeks (M = 1.70; 2.28, p = 0.028). There was no significant difference in breastfeeding duration between groups.
Conclusions: The SM intervention significantly lowered breast, nipple and general pain. The acquisition of knowledge and skills for breastfeeding SM through an online platform may be sufficient to influence breastfeeding duration, which was higher than the national average in this study. Additional analysis will examine genetic and sensory testing in relation to breastfeeding pain, and maternal mood over time.
OPTIMIZATION OF BREASTSHIELD DESIGN IMPROVES MILK FLOW RATE DURING EXPRESSION
Co-Authors: S. Höner, A. Zimmerman, L. Ivarsson, N.G. Schärer-Hernández, V.S. Sakalidis, L.R. Mitoulas
Background: The role of breastshield design on milk removal is poorly understood. A recent study (NCT03091985) demonstrated that the opening angle of a breastshield impacts milk removal, with a 105° angle providing significantly more milk and higher flow rates than a 90° angle.
Objective/Hypothesis: Optimization of the interaction between the breastshield and the breast anatomy is hypothesized to be a driver for the improved milk removal characteristics. Comparing 3D breast scans with the 105°/90° breastshields will identify the mechanisms driving these improvements.
Methods: 3D upper-body scans (Arctec3D Eva) were performed on a subset of subjects from the study (n = 10/49). A validated method was used to place virtual breastshields (105°/90°) onto 3D models of the breasts. The distance between the tunnel-flange junction and the contact points on the superior and inferior breast portions, and nipple tip were determined. The internal area between the breastshield and breast surface was also measured (UniversalDesktopRuler v3.6.3841). Each measurement was compared between the 105°/90° for peak milk flow rate and breast drainage.
Results: All measurements between the 105° and 90° breastshields were different (p < 0.001). Less area between the breast and breastshield (105°<90°) was associated a stronger peak milk flow rate (p = 0.03). A shorter distance for the inferior contact point (105°<90°) was associated with an improvement in breast drainage at 5 (p = 0.04), 10 (p = 0.02) and 15 (p = 0.03) minutes.
Conclusions: Improved milk removal with the 105° breastshield is driven by the optimization of the breastshield's inferior contact point, which reduces the amount of tissue deformation allowing for the maintenance of maximum milk duct diameters and increased peak milk flow rates.
Funding: Medela AG, Switzerland.
EFFECT OF NIPPLE SHIELD USE ON MILK REMOVAL IN MOTHERS EXPERIENCING NIPPLE PAIN: PRELIMINARY FINDINGS OF A MECHANISTIC STUDY
Presenting Author: Viviane Coentro, University of Western Australia, Perth – School of Molecular Sciences
Co-Authors: Sharon Perrella, Ching Tat Lai, Donna Geddes (University of Western Australia – School of Molecular Sciences)
Background: Nipple shields (NS) are used to improve breastfeeding comfort but may inhibit milk removal. Assessment of the effect of NS use on milk removal can be confounded by the infant's sucking characteristics. We designed a mechanistic study to determine the effect of NS use on milk removal during use of an electric breast pump, enabling the control and replication of vacuum strength, pattern and duration across multiple study sessions.
Objective: To determine whether NS use and size impact milk removal during pumping.
Methods: Control Group (CG) mothers without feeding difficulties; Pain Group (PG) mothers using a NS for pain. 3 randomized visits: pumping without a NS; pumping with 2 different NS sizes. Mothers expressed for 15 min. 24hr milk production, milk samples, expressed milk volumes and PAMRs were measured.
Results: 24hr milk production volumes were similar between CG (n = 19): 770 ± 190mL (584 to 1122mL) and PG (n = 7): 768 ± 279mL (244 to 1147mL, p = 0.84). Fitted and small NS were associated with reductions in volume of 35mL and 43mL, and PAMR 29% and 30% respectively for CG only (p = 0.01 and p = 0.004; p = 0.002 and p = 0.003 respectively).
Conclusions: NS use in mothers without pain may reduce milk removal. Accurate NS sizing is imperative.
Funding: Medela AG and Science Without Borders Program.
RHEOLOGICAL BEHAVIOR OF HUMAN MILK
Presenting Author: Diana Alatalo, The University of Texas at Dallas – Department of Mechanical Engineering
Co-Authors: Fatemeh Hassanipour
Background: This study investigates the flow properties of human milk from an engineering point of view. Recent studies of human milk flow within the breast ductal system assumed Newtonian behavior meaning the viscosity (response to shear stress) of milk is constant under environmental conditions. However, milk experiences large variations of shear rates (7–90,000+ s−1) in the breast ductal system.
Objective/Hypothesis: Milk is derived from blood, and therefore it should exhibit the same flow behavior as blood which is shear-thinning with a yield and flow point. This study aims to determine the flow behavior (rheological properties) of raw human milk.
Methods: Fifteen milk samples from 8 lactating women were tested for viscosity at 37°C using rotational shear sweep (0.01–100 s−1). Six samples were tested for complex shear modulus using oscillatory shear strain logarithmic ramp from 0.01–1000% at constant angular frequency 5 s−1.
Results: Viscosity is inversely related to shear rate which confirms milk, like blood, is shear-thinning. The complex shear modulus defines milk as a viscoelastic solid with both yield and flow points similar to blood.
Conclusions: Raising the shear rate in breast ducts, as occurs during suckling, positively impacts flow by decreasing viscosity. Further study is planned.
Funding: National Science Foundation Graduate Research Fellowship Program under Grant No. 1746053, National Science Foundation under Grant No. 1454334 and 1707063, and Eugene McDermott Graduate Fellowship.
EX-VIVO PLACENTAL TRANSFER OF 2-FUCOSYLLACTOSE
Presenting Author: Evelyn Jantscher-Krenn, Medical University Graz – Department of Obstetrics and Gynecology
Co-Authors: Birgit Hirschmugl, Christian Wadsack (Medical University Graz – Department of Obstetrics and Gynecology)
Background: Recently, we found that Human Milk Oligosaccharides (HMOs) are not only present in maternal serum during pregnancy, but also in cord blood. Maternal concentrations of Secretor status dependent HMOs, such as 2’Fucosyllactose (2’FL) increase during pregnancy and are correlated with concentrations in cord blood, suggesting maternal origin and transfer of HMOs across the placental barrier.
Objective/Hypothesis: This study aimed to investigate maternal to fetal 2’FL transport across the human placenta using an ex-vivo placental perfusion method.
Methods: As a pilot study, placentas were obtained from C-sections of uncomplicated term pregnancies (n = 2). After a washout phase (1h), isolated cotyledons were perfused with 2’FL (5μg/ml) in the maternal reservoir in a double closed setting for 180 mins. Samples were taken from the maternal and fetal circulation at 15 mins, 30 min, followed by 30 min steps. 2’FL concentrations were determined in maternal and fetal samples by HPLC with fluorescence detection.
Results: Time dependent 2’FL transfer from maternal to fetal circulation was observed. 2’FL was already detectable in fetal vein within 15 min of perfusion, and mean concentration increased from 0.37 μg/ml to 1.1 μg/ml (7 % and 22 % of the offered 2’FL concentration, respectively) without reaching equilibrium after 180 min. 2’FL was not detectable in samples taken after the initial washout phase as well as from the fetal reservoir at the start of perfusion.
Conclusions: Our results suggest that the placenta transfers 2’FL from the maternal to the fetal circuit. Future studies will investigate potential differences in the transfer of individual HMOs and whether this transport might be altered in pregnancy disorders implicating placental or fetal development.
Funding: This project was supported by OeNB (#16927) and BioTechMed-Graz, Graz, Austria.
HUMAN MILK OLIGOSACCHARIDE ISOMERS DIFFERENTIALLY INFLUENCE BIFIDOBACTERIAL PHYSIOLOGY WITHIN A MODELED INFANT GUT MICROBIOME
Presenting Author: Ezgi ൡzcan, University of Massachusetts Amherst – Department of Food Science
Co-Author: David A. Sela, University of Massachusetts Amherst – Department of Food Science, Department of Microbiology, University of Massachusetts Medical School – Department of Microbiology & Physiological Systems.
Background:Bifidobacterium infantis colonizes the infant gut microbiome as it evolved to metabolize human milk oligosaccharides (HMOs) and secrete metabolites to benefit its host. Lacto-N-tetraose (LNT) and lacto-N-neotetraose (LNnT) are abundant HMO tetrasaccharide isomers that vary by a single glycosidic link with unknown impacts to B. infantis physiology, the emergent properties of the microbiome, and ultimately infant health and nutrition.
Objective/Hypothesis: We hypothesize that B. infantis differentially metabolizes LNT and LNnT to secrete formate during inefficient metabolism as informed by our previous research. Increased formate in the infant gut microbiome is predicted to increase acetogenic bacteria and attendant metabolic networks.
Methods:B. infantis metabolite production and gene expression was profiled while utilizing purified LNT and LNnT. In addition, a bioreactor model of the infant gut microbiome was employed to investigate the emergent properties of this community. Secreted metabolites, microbiome community structure, and global gene expression (i.e. transcriptomics) were characterized while consuming HMO species.
Results: Structural variation in HMO isomers resulted in inefficient utilization of LNnT to induce formate production concurrent with differential gene expression. This includes biochemical pathways involved in ATP generation and cofactor recycling to limit lactate production and increase formate secretion. Furthermore, a modeled infant gut microbiome was developed and exhibited changes in composition and function dependent on the human milk carbohydrate source.
Conclusions: This study provides in vitro evidence for human milk to influence the specific organic acids produced by bacteria within the infant gut microbiome. As a consequence, the potential impact to infant health is currently being tested in vivo.
Funding: Funded in part through grants from Ocean Spray, Inc. and the U.S. Department of Agriculture (2016-67017-24425).
HUMAN MILK AND INFANT FECAL MICROBIOMES, AND SIBLING PRESENCE
Presenting Author: Avery Lane, Washington State University
Co-Authors: Courtney Meehan, Michelle K. McGuire, Kimberly Lackey, Abhishek Kaul, Edward Hagen (WSU); Janet Williams, Mark A. McGuire (University of Idaho); the INSPIRE Consortium
Background: There are only a few studies, with inconsistent results, which explore the role of human sociality and family structure on the human milk microbiome (HMM) and infant fecal microbiome (IFM). Here we consider the relationship between the presence or absence of siblings on HMM and IFM diversity and community composition.
Objective: We examined the relationship between sibling presence and the HMM and IFM of 364 breastfeeding mother-infant dyads from 10 global populations, with respect to alpha diversity and taxonomic composition.
Methods: HMM and IFM community structures were determined by amplifying, sequencing, and classifying (to the genus level) the V1–V3 region of the bacterial 16S rRNA gene. Demographic surveys identified household composition.
Results: Sibling presence was not a strong predictor of HMM or IFM alpha diversity, yet sibling presence was associated with differential relative abundances of Achromobacter and Psychrobacter in the HMM, and Lactobacillus in the IFM.
Conclusion: Our study helps to resolve conflicting results in the literature regarding sibling influence on alpha diversity of the IFM, and is one of the first to examine siblings relationship with the HMM. These results indicate that household composition may not fully represent the mother-infant dyad's social network, and adds to discussions on the old friends hypothesis.
Funding: National Science Foundation.
BIFIDOBACTERIAL UREASE ENABLES THE INFANT GUT MICROBIOME TO UTILIZE HUMAN MILK UREA
Presenting Author: Yang Lyu, University of Massachusetts, Amherst (UMA), Department of Food Science
Co-Authors: Xiaomeng You (UMA- Department of Food Science), Korin Albert (UMA - Department of Food Science, Molecular and Cellular Biology Graduate Program), David A. Sela (UMA - Department of Food Science, Department of Microbiology, UMA Medical School - Department of Microbiology and Physiological Systems)
Background: Urea accounts for ∼15% of the total nitrogen in human milk. As urea is typically excreted to maintain nitrogen metabolism, the potential function of human milk urea is currently unknown. Infants are rapidly colonized following birth, often by bacteria (i.e. the gut microbiome) including bifidobacteria. Previous work on this host-microbial interaction has demonstrated bifidobacteria are capable of utilizing human milk carbohydrates that are not digested by the infant.
Objectives/Hypothesis: We hypothesize that bifidobacteria that possess urease activity utilize urea as a primary nitrogen source. As a consequence, these bifidobacteria produce molecules that benefit the infant to enable a nitrogen recycling mechanism within the infant gut.
Methods: Urease-positive bifidobacteria were characterized in their ability to utilize urea both physiologically and through transcriptomics. A urease-positive bifidobacterial strain was mutagenized by chemical means to knockout urease activity and thus the ability to utilize urea as a nitrogen source. Finally, the mutated urease was heterologously expressed, purified, and characterized further.
Results: Urease-positive bifidobacteria are capable of utilizing human milk urea as a primary nitrogen source, characterized by an increase in the biosynthesis of essential amino acids. Conversely, urease-deficient mutants cannot utilize urea. A single mutation in the ureC gene diminished the ability of the urease subunit to bind its nickel cofactor. Finally, complementing the mutation with the wildtype subunit restored urease activity.
Conclusions: Bifidobacterial urease function and access to nickel enables urea nitrogen utilization, to potentially recycle urea within the infant gut. This further links human milk composition to microbiome function within the nursing infant microbiome.
Funding: Funded in part through a grant from the U.S. Department of Agriculture (2016-67017-24425).
INFLUENCE OF MATERNAL POSTNATAL PSYCHOSOCIAL DISTRESS IN HUMAN MILK MICROBIOTA
Presenting Author: Leonides Fernández, Complutense University of Madrid (UMC), Spain – Department of Food Technology
Co-Authors: Marina Aparicio (UMC - Department of Nutrition, Food Science and Food Technology); Pamela D. Browne (Radboud University, The Netherlands - Developmental Psychology, Behavioural Science Institut); Christine Hechler, Roseriet Beijers (Radboud University); Juan M. Rodríguez (UMC); Carolina de Weerth (Radboud University)
Background: Breast milk contains a diverse population of bacteria that play an essential role in the infant gut colonization. Milk bacterial composition depends on maternal factors, such as health status.
Objective: This study explored the evolution of milk microbiome during the first three months postpartum and the relationship between maternal psychosocial distress and milk bacterial composition and diversity.
Methods: Fifty-nine mothers collected breast milk samples at 2, 6 and 12 weeks postpartum and filled in mood questionnaires on experienced stress, anxiety and depression at 6 weeks postpartum. A metataxonomic (16S rRNA gene sequencing (region V3 and V4) using Illumina MiSeq technology) approach was used to assess bacterial diversity and abundance.
Results:Firmicutes was the most frequent and abundant phylum, followed by Proteobacteria and Actinobacteria, but its proportion decreased progressively with time. Parallel, an increase in Proteobacteria and other less abundant phyla was observed. At the genus level, Staphylococcus was detected in all samples but its relative abundance decreased at week 12. Bacterial diversity (Shannon diversity index) was higher at week 12 in women with low psychosocial distress (p = 0.011).
Conclusions: Bacterial composition of milk changed during the first three months postpartum, showing a progressive decrease of Firmicutes, the most abundant phylum present in milk samples. Lower bacterial diversity in milk at 12 weeks was related to high maternal psychosocial distress.
Funding: AGL2013-41980P and AGL2016-75476R projects (MINECO, Spain) and Radboud University (The Netherlands).
HUMAN MILK MICROBIOTA IN BREASTFEEDING AND MIXED-FEEDING MOTHERS
Presenting Author: Erin C. Davis, University of Illinois, Urbana–Nutritional Sciences
Co-Authors: Mei Wang, Sharon M. Donovan (University of Illinois, Urbana–Food Science and Human Nutrition)
Background: Breastfeeding exclusivity is associated with infant gut microbiota composition over the first year of life. While mixed-feeding (MF) infants, receiving human milk (HM) and formula, have differences in Bifidobacterium and Lactobacillus, relative to exclusively breastfeeding (EBF) infants, results are inconsistent across studies. The HM microbiota is hypothesized to influence the gut microbiota composition of infants receiving HM. However, how this community differs between EBF and MF mothers and whether this may, in part, contribute differences in the gut microbiota of EBF and MF infants in unknown.
Objective: To examine quantities of Bifidobacterium and Lactobacillus in mature HM of EBF and MF mothers.
Methods: HM samples were collected via manual expression at 6 weeks postpartum from 33 mothers (EBF = 20; MF = 13). DNA was extracted from 0.5–3 mL of HM, and quantities of Bifidobacteria and Lactobacillus were measured by qPCR.
Results:Bifidobacterium and Lactobacillus were detected in 13 and 15 samples respectively. Genera were simultaneously detected in 8 mothers with no correlation between bacterial abundance (p = 0.65). Bifidobacterium was more frequently detected in MF mothers (p = 0.03); however, Lactobacillus frequency did not differ between groups (p = 0.17). Comparing only samples in which the bacteria were detected, there were no differences in abundance (mL−1) of Bifidobacterium (p = 0.24) or Lactobacillus (p = 0.35) between groups.
Conclusions: Mature HM is a source of Bifidobacterium and Lactobacillus. Both genera are detectable, at similar levels, in HM of EBF and MF mothers; however, differences in prevalence may explain inconsistent results on the gut microbiota of EBF and MF infants.
Funding: National Dairy Council, Gerber Foundation, Doris Kelley Christopher Foundation, and USDA Hatch funds.
CHARACTERIZATION OF THE HUMAN MILK MICROBIOME FROM MOTHERS WHO DELIVERED INFANTS AT DIFFERENT GESTATIONAL AGES
Presenting Author: Ali Sadiq Cheema, The University of Western Australia (UWA) – School of Molecular Sciences (SMS).
Co-Authors: Megan Lloyd (UWA- School of Pathology and Laboratory Medicine), Richard Allcock (UWA- School of Biomedical Sciences), Ching Tat Lai (UWA - SMS), Matthew Payne (UWA- Medical School), Donna Geddes (UWA- SMS), Karen Simmer (UWA- Medical School)
Background: Human milk (HM) is an optimal food for the growth and development of rapidly-growing infants.
Objective/Hypothesis: To characterize the bacterial diversity in HM collected in the first month postpartum from mothers who delivered between 22–42 gestational weeks.
Methods: DNA was extracted using the QIAamp DNA Mini Kit and quantified on a Qubit fluorometer. The V4 region of 16S rRNA gene was amplified and sequenced on an Ion Torrent PGM. Reads were analysed using the Greenfield Hybrid Analysis Pipeline v2.1, which incorporates USEARCH and the Ribosomal Database Project sequence database.
Results: The Firmicutes phyla (40.9%) had the greatest numbers of reads followed by the Proteobacteria (38.9%), Bacteroidetes (1.5%) and Actinobacteria (1.1%) phyla. For reads that were able to be mapped to the genus level, the greatest numbers were associated with Staphylococcus spp. (30.2%), Acinetobacter spp. (17.4%), Pseudomonas spp. (13.1%), Streptococcus spp. (8.7%) and Aeromonas spp. (2.4%). A greater abundance of bacterial sequences was found in samples from mothers who gave birth to term infants (37–42 weeks' gestation). In addition, the lowest number of bacterial sequences were detected in colostrum compared with both transitional and mature milk.
Conclusions: The major bacterial phyla present in HM appear to be consistent across samples. There is temporal variation at the genus level found within and between individuals' colostrum, transitional and mature milk.
Funding: Scholarship for International Research Fees, UWA; Unrestricted Research Grant Medela AG, Switzerland.
CITRATE QUANTIFICATION IN HUMAN MILK: A NUCLEAR MAGNETIC RESONANCE (NMR) SPECTROSCOPY AND ENZYMATIC ASSAY METHOD ANALYSIS
Presenting Author: Ophelia Schilizzi, The University of Western Australia - School of Molecular Sciences
Co-Authors: Ching Tat Lai, Melvin Gay, Gareth Nealon, Donna Geddes
Background: Citrate is an important biomarker prior to and during lactation. It plays an indirect, but important role in fatty acid synthesis.
Objective: To investigate whether filtration and/or NMR methods are a viable and precise alternative to the enzymatic assay for high-throughput human milk (HM) citrate analysis.
Methods: HM citrate levels (n = 45) were measured using combinations of different extraction and quantification methods. Extraction methods included standard acid/base deproteinisation and filtration with a 3kDa cut off filter. Quantification methods included an enzymatic assay and NMR spectroscopy.
Results: There was no significant difference between extraction methods for the same quantification method (p = 1.0), however there was a significant difference between the citrate concentrations of deproteinisation and filtration using the enzymatic assay and the citrate concentrations of deproteinisation and filtration using NMR (p < 0.0001). NMR levels were lower than the enzymatic assay.
Conclusions: Citrate levels determined by NMR and enzymatic assay did not differ regardless of extraction method. It is possible the endogenous molecule, oxaloacetate, affects the quantified citrate by participating in the enzymatic reaction. Confirmation is required for prior to considering NMR as an alternative to the citrate assay for quantifying citrate in HM.
Funding: Unrestricted research grant (Medela AG, Switzerland).
SUBCLINICAL MASTITIS MODIFIES HUMAN MILK COMPOSITION: NEW INSIGHTS FROM A EUROPEAN COHORT
Presenting Author: Tinu Mary Samuel, Nestle Research Center (NRC), Lausanne
Co-Authors: C.A. De Castro (NRC-Singapore); S. Dubascoux, M. Affolter, F. Giuffrida, A. Binia, E. Castañeda-Gutiérrez, S.K. Thakkar (NRC-Lausanne); I. Silva-Zolezzi (NRC-Singapore); on behalf of Atlas Study Team
Background: Subclinical mastitis (SCM) is associated with risk of lactation failure and its effects on HM composition remain under-researched.
Objective: Examine SCM prevalence and its effects on HM composition in a mother-infant cohort from 7 European countries.
Method: HM samples (single full breast collection) were obtained from 290 women at 2, 17 & 30 days post-partum. HM minerals were measured by ICP-MS and total proteins by BCA. SCM status was assessed using HM sodium potassium ratios (Na/K). Women with Na/K > 0.6 at either 2, 17 or 30d comprised the SCM group, while those with Na/K ≤ 0.6 at all time points comprised the normal (N).
Results: SCM prevalence in the 1st month of lactation was 35.9%. The mean gestational age (GA) at birth was lower and birth by C-section higher in SCM vs N (p ≤ 0.001). At 2 days, HM lactose concentration was lower, while total protein and some minerals (Se, Cu, Zn) levels were higher in SCM vs N (p < 0.05), adjusted for country, delivery mode, GA, parity, pre-pregnancy BMI.
Conclusion: The observed alterations on HM composition in SCM may be due to the increased permeability of the breast acting potentially as a mechanism to combat inflammation.
Funding: Nestec, S.A.
CAN WE DEFINE STANDARD CONCENTRATIONS OF OLIGOSACCHARIDES IN HUMAN MILK?
Presenting Author: Bernd Stahl, Danone Nutricia Research, Department of Human Milk Research, Utrecht, Netherlands
Co-Author: Stephan Thurl, Fulda University of Applied Sciences, Food Technology, Fulda, Germany
Background: Human milk oligo-saccharides (HMOS) consist of several hundred different structures with beneficial functions in infants, including prebiotic-, immune- and anti-infective effects.
Objectives: The aim of this literature review was to identify the main factors that affect the concentrations of HMOS and to determine whether it is possible to indicate representative standard concentrations.
Method: A comprehensive literature search (until August 2015) on HMOS has been performed in 6 electronic databases. The application of strict inclusion criteria resulted in 21 studies selected. The screening of very recent articles (until November 2017) yielded two further studies meeting the above-mentioned inclusion criteria.
Results: Mean concentrations, including confidence limits (CL), of 33 neutral and acidic oligosaccharides reported could be calculated (Thurl S, et al. 2017. Nutrition Reviews 75:920–933). Concentrations of HMOS showed variations that are dependent on both the secretor type of the mother and the lactation period as examined by analyses of variance exhibiting a large interlaboratory variations in the data. Recent studies (Sprenger N, et al. 2017. PLoS One 12:e0171814; McGuire MK, et al. 2017. Am J Clin Nutr 105:1086–1100) showed deviation of some mean values compared to the CL calculated in the review article.
Conclusion: Data on the largely variable concentrations of HMOS are a prerequisite for understanding the biological functions. It is necessary for future studies to exactly report the relevant parameters of milk sampling and the quantification method used. Therefore, worldwide interlaboratory analyses of identical milk samples are required to identify the most reliable methods of determining concentrations of HMOS.
COMPARISON OF HUMAN MILK IMMUNOGLOBULIN SURVIVAL DURING GASTRIC DIGESTION BETWEEN PRETERM AND TERM INFANTS
Presenting Author: Veronique Demers-Mathieu, Oregon State University, Nutrition
Co-Authors: Mark A. Underwood (University of California, Davis - Pediatrics); Robert L. Beverly, David C. Dallas (Oregon State University - Nutrition)
Background: Preterm infants produce less antibodies in their gut and are at higher risk for bacterial and viral infections compared with term infants. The presence of immunoglobulins (Igs) in preterm milk may be even more important to their health outcomes. In order to function in immunoprotection, Igs must remain intact in the infant gut. Our work previously demonstrated that preterm infants have lower gastric digestion capacity for human milk proteins than term infants. Whether differences in preterm and term infant gastric digestion result in differences in Ig survival remain unknown.
Objective/Hypothesis: The aim of the present study was to determine whether Ig survival in the stomach is higher in preterm infants than in term infants.
Methods: Human milk, and infant gastric samples at 2 h post-ingestion were collected from 15 preterm (23–32 wk gestational age (GA)) mother-infant pairs and from 8 term (38–40 wk of GA) mother-infant pairs within 7–98 days postnatal age. Samples were analyzed via ELISA for concentration of total IgA (secretory IgA (SIgA)/IgA), total secretory component (SC/SIgA/SIgM), total IgM (SIgM/IgM) and IgG as well as peptidomics.
Results: Total IgA concentration decreased 60% from human milk to the preterm infant stomach and decreased 48% in the term infant stomach. Total IgM and IgG concentrations decreased by 33% and 77%, respectively, from human milk to the term infant stomach but were stable in the preterm infant stomach. Release of peptides from all Ig isotypes in the term infant stomach was higher than in the preterm stomach.
Conclusions: Overall, the stability of human milk Igs during gastric digestion is higher in preterm infant than in term infants, which could be beneficial for assisting the preterm infants' immature immune system.
Funding: K99/R00 Pathway to Independence Career Award, Eunice Kennedy Shriver Institute of Child Health & Development of the National Institutes of Health (R00HD079561) and The Gerber Foundation.
SOURCES OF BACTERIAL CONTAMINATION IN HOME-EXPRESSED HUMAN MILK
Presenting Author: S.M. Reyes, Cornell University - Division of Nutritional Sciences
Co-Authors: D.L. Allen (Cornell University); J. Williams, M.A. McGuire (University of Idaho); M.K. McGuire (Washington State University); A.G. Hay (Cornell University – Department of Microbiology); K.M. Rasmussen (Cornell University)
Background and Objective: Milk collected at home with women's own supplies is contaminated more often than when collected aseptically. Our objective was to identify the sources of and behavioral factors associated with contamination with bacteria.
Methods: In this observational study of 52 women, we determined the bacterial composition of home-expressed milk by aerobic culturing (milk only) and high-throughput sequencing of the V1–V3 region of the 16S rRNA gene (milk and other sources). Using SourceTracker2, we estimated the contribution of bacteria from swabs of women's hands, breasts, milk collection kit, pumps, and infants' mouths to bacteria in milk. Women self-reported their collection kits as being “home-washed” (hand-washed or –rinsed) or “home-sterilized” (washed in the dishwasher or steam-sterilized in the microwave). We evaluated the associations between women's method of cleaning their collection kits and the odds of excessive bacterial growth (≥104 cfu/mL) and of the presence of gram-negative bacteria in milk.
Results: Compared to milk collected with home-sterilized kits, milk collected with home-washed kits contained an 8.5-times (p = 0.001) higher proportion of bacteria from collection kits and a 1.9-times (p = 0.003) and 2.5-times ( = 0.004) lower proportion of bacteria. Compared to milk collected with home-sterilized kits, milk collected with home-washed kits was associated with higher odds (OR 5.8, 95% CI 1.13, 29.6) of excessive bacterial growth and higher odds (OR 4.8, 95% CI 1.13, 20.2) of gram-negative bacterial growth.
Conclusions: Home sterilization of milk collection kits may reduce the transfer of bacteria, including gram-negative bacteria, to expressed human milk associated with home-washing or -rinsing of these kits.
Funding: Funded in part by NIH (T32 DK007158 and P30 GM103324), USDA/Hatch (NYC-399346), in-kind contributions from Medela, Family Larsson-Rosenquist Foundation, McNair Scholars Program, Idaho Agricultural Experiment Station.
MILK SHARING: A CASE OF COMPARATIVE RISKS
Presenting Author: Jennifer A. Peregoy, Division of Nutritional Sciences, Cornell University
Co-Authors: Kathleen M. Rasmussen, Giovana Pinheiro
Background: The recent emergence of peer-to-peer human milk sharing (PHMS) is controversial because of the potential risks, including infectious disease transmission and microbial contamination from suboptimal milk expression and storage practices. Despite these potential risks and warnings from public health and medical authorities, interest in PHMS is increasing. Little is known about the risk perceptions and risk-mitigation strategies of recipients of peer-shared human milk.
Objective: To elicit and critically analyze milk-sharing narratives to understand how risk is perceived, analyzed, and mitigated among PHMS recipients.
Methods: In-depth, semi-structured interviews were conducted with 30 mothers who recently received peer-shared milk. Interviews were transcribed and qualitatively analyzed using Atlas.ti v8 software.
Results: Multiple themes were identified, including: 1) use of donor milk is preferred over infant formula because of the known risks of formula feeding, 2) mothers acknowledged and considered the potential risks of PHMS but these were outweighed by the benefits of HM-feeding, 3) home pasteurization of donor milk is perceived as undesirable because it destroys beneficial HM components, and 4) PHMS depends heavily on trust engendered by the mother-to-mother bond.
Conclusions: The risk analysis process of parents who engage in PHMS is highly personalized, informed by each parent's knowledge, values, and perceptions, and often includes comparing the perceived relative risks of each potential infant feeding option, as all infant feeding practices have inherent risks. The absolute risks of PHMS remain unknown. Further research is needed to quantify these risks to assist parents in making informed infant feeding decisions.
Funding: NIH Training Grant (T32 HD087137).
PATTERNING OF LACTATION AND INFANT FEEDING DEVELOPMENT IN WILD CHIMPANZEES: LACTATION EFFORT PLATEAUS WHILE INFANTS ATTAIN INDEPENDENT FEEDING ABILITIES
Presenting Author: Iulia Bădescu, University of Montréal, Montréal – Department of Anthropology
Co-Authors: Anne Katzenberg (University of Calgary – Anthropology and Archaeology), David Watts (Yale University –Anthropology), Daniel Sellen (University of Toronto – Anthropology)
Background: Female mammals balance the metabolic requirements of milk synthesis for current offspring (i.e. lactation effort) against their own health and future reproduction.
Objective/Hypothesis: We investigated whether lactation effort in chimpanzees decreases, increases, or plateaus as infants attain independent feeding abilities in a cross-sectional sample at Ngogo, Uganda.
Methods: We compared rates and durations of infant nursing and foraging at different ages (N = 45 infants) with estimates of the relative reliance of infants on milk versus solid food from fecal stable carbon and nitrogen isotopes (N = 48 infants, 560 samples from offspring and mothers).
Results: Nursing rates and durations were highest for infants ≤6 months, which suggests lactation effort was greatest soon after birth. Combined stable isotope and behavioral data indicated lactation effort was similar for mothers with infants ranging in age from 6 months to 4 years, which suggests mothers provided a steady milk supply while infants increasingly supplemented their growing energy needs with foraged food. Mothers terminated lactation effort by the time infants were 4 years old, which is when weaning occurred.
Conclusions: Lactation effort remains constant over several years while offspring build independent feeding abilities. Plateauing lactation may allow hominoid infants time to attain the physiology and skills necessary for independent feeding, while providing them with a steady dietary base on which they could rely consistently through infancy, and enabling mothers to maintain a predictable level of lactation effort.
Funding: NSERC, Leakey Foundation, U of Toronto, Explorers Club, CAPA, IPS, OGS.
MATERNAL NUTRITIONAL STATUS INFLUENCES THE SECRETION OF OBESTATIN AND IGF1 IN BREAST MILK
Presenting Author: Pilar Amellali Badillo-Suárez, Department of Medical Research in Nutrition, IMSS; PCB UNAM
Co-Authors: María del Rosario Ruiz-León, Guillermo Iglesias-Rodríguez, Judith Villa-Morales, Maricela Rodríguez-Cruz. (IMSS - Department of Medical Research in Nutrition)
Background: Breast milk contains compounds that influence the metabolism of the infant, as obestatin and IGF-1 that could be involved in nutrition programming.
Objective: Determine the influence of maternal body fat (BF) percentage on obestatin and IGF-1 concentration in breast milk.
Methods: Obestatin and IGF-1 were measured by ELISA in breast milk from lactating non-obese (n = 28) and obese (n = 30) women according their %BF, enrolled at 5 and 30 post-partum days.
Results: Obestatin levels were higher (P < 0.001) in non-obese (566.21 (504.76, 577.25pg/mL)) than obese women 516.76 (498.65, 582.02pg/mL); IGF-1 levels were lower (P = 0.010) in non-obese (10.56 (0.30, 74.85ng/mL)) in comparison with obese (24.81 (1.16, 96.43 ng/mL)) women at first month of lactation. Obestatin decrease in non-obese and obese women, and, it was more evident in the obese group; while IGF-1 concentration not changed during the first month of lactation in both groups in comparison with 5 days post-partum. A negative correlation was found between obestatin and % BF (P < 0.001, R = -0.733) while IGF-1 concentration showed a positive correlation with % of BF (P = 0.002, R = 0.460) at 30 post-partum days.
Conclusion: Our findings demonstrate that breast milk from obese mothers provides higher amount of IGF-1 and a lower concentration of obestatin.
Funding: IMSS R-2015-785-045.
MATERNAL DIET AND THE HUMAN MILK MICROBIOME
Presenting Author: Sarah Boothman, Washington State University
Co-Authors: Michelle K. McGuire, Kimberly Lackey, Courtney Meehan (WSU); Mark A. McGuire, Janet Williams, William Price (University of Idaho); the INSPIRE Consortium
Background: Substantial variation between women and among populations exists in the diversity and composition of the human milk microbiome, but little is known about the factors influencing this variation.
Objective: We explored relationships between maternal diet and microbiomes of milk produced by women in 11 global locations (the INSPIRE study).
Methods: Milk was collected from and dietary surveys administered to 395 relatively healthy women. The V1–V3 region of the16S rRNA gene was sequenced, and microbial communities characterized. Women reported if they consumed 22 food categories within the last 24 hours, and independent and interactive effects of cohort and diet on milk taxa were evaluated using two-way ANOVA.
Results: There were both main effects of and interactions between diet and location on the milk microbiome. For example, milk produced by women consuming milk in the last day had lower relative abundance of Firmicutes than milk produced by those who did not consume milk (55.7 ± 1.8 and 64.1 ± 3.5%; P = 0.04). Relative abundance of Proteobacteria was higher in milk produced by women who consumed meat than in milk produced by those who did not (24.5 ± 1.8 and 18.5 ± 1.9%; P = 0.02). There were also several interactions between intake of various carbohydrate-rich foods (e.g., legumes, tubers) and cohort on selected taxa.
Conclusions: Our findings provide additional evidence that diet may influence the human milk microbiome. Future work will examine the implications of these associations for health.
Funding: National Science Foundation.
INFANT ANTHROPOMETRY AT FOUR MONTHS OF AGE IS STRONGLY ASSOCIATED TO CONCURRENT OLEOYLETHANOLAMIDE (OEA), STEAROYLETHANOLAMIDE (SEA), AND PALMITOYLETHANOLAMIDE (PEA) CONTENT IN MOTHER'S MILK
Co-Authors: Sandra Gouveia-Figueira, Magnus Domellöf (University Hospital of Umeå, Sweden); Steffen Husby (Hans Christian Andersen Children's Hospital, Denmark); Lotte Neergaard Jacobsen (Arla Foods Ingredients, Denmark); Kim F. Michaelsen (University of Copenhagen, Denmark); Christopher J. Fowler (Umeå University, Sweden); Gitte Zachariassen (University Hospital of Umeå, Sweden)
Background: OEA is an N-acylethanolamine involved in appetite regulation. Both endogenous and oral administered OEA acts peripherally causing a state of satiety accompanied by prolonged inter-meal intervals, delayed gastric emptying, and intestinal transit, resulting in improved energy expenditure. In animal models, related N-acylethanolamines have also shown appetite-reducing effects.
Objective: We aimed to investigate associations between the content of three different N-acylethanolamines in mother's milk collected at four months of age and concurrent infant anthropometry.
Methods: From Odense Child Cohort, milk samples from mothers to 50 infants with lower and 50 infants with higher weight-for-age Z-score (WAZ) were selected. OEA, SEA, and PEA were quantified by ultra-high performance liquid chromatography coupled with mass spectrometry. Due to non-normality of residuals, results were log10 transformed. Associations were tested by linear and logistic regression analyses.
Results: The content of satiety factors OEA, SEA, and PEA were significantly lower in the high WAZ group compared to the low WAZ group. The observed associations were recovered for SEA and PEA in the logistic and linear regression analyses, also after adjustment for relevant confounders.
Conclusions: We observed significant inverse associations between content of satiety factors SEA and PEA, but not OEA, in mother's milk and infant anthropometry at four months of age – even after adjustment for birth weight, maternal pre-pregnancy BMI, and early supplementation with infant formula.
Funding: Arla Foods Ingredients Group P/S and Innovation Fund Denmark.
HUMAN MILK HORMONES AND BODY COMPOSITION AT AGE 3 IN THE CHILD COHORT
Presenting Author: Deborah Chan, Department of Pediatrics, University of Manitoba
Co-Authors: Susan Goruk, Allan B. Becker, Theo Moraes, Piushkumar Mandhane, Stuart Turvey, Padmaja Subbarao, Diana Lefebvre, Malcolm Sears, The CHILD Study Investigators, Catherine Field and Meghan B. Azad
Background: Breastfeeding may protect against childhood obesity, but the underlying mechanism is unclear. Previously, we found that human milk leptin, insulin and adiponectin concentrations were associated with infant body mass index (BMI) at 3 months and 1 year of age in the CHILD cohort.
Objective: To determine if associations between milk hormones and body composition persist to 3 years.
Methods: We studied a representative subset of 430 breastfed infants from the CHILD birth cohort. Milk was collected at 3-4 months postpartum. Milk leptin, insulin and adiponectin were measured using the MesoScale Discovery System and classified into quintiles. Child anthropometrics were measured at 3 years. BMI z-scores were calculated according to the WHO reference and those >85th percentile were considered at risk for overweight. Analyses controlled for maternal pre-pregnancy BMI, diabetes, smoking, lactation stage, and child diet and inactivity at 3 years.
Results: The mean (SD) BMI z-score at 3 years was 0.54 (0.93), and 28.1% were at risk of overweight. Milk hormone concentrations were not consistently associated with continuous BMI z-scores. However, high milk leptin concentrations were associated with a lower risk of overweight (adjusted OR 0.29; 95%CI 0.08–0.95 for uppermost vs. lowermost leptin quintile). There was no strong evidence of association for high milk adiponectin (0.62; 0.27–1.42) or insulin (1.45; 0.58–3.72).
Conclusion: Associations between human milk hormones and infant body composition appear to diminish after infancy, although high leptin concentrations may have a persistent protective effect against early childhood overweight.
Funding: Manitoba Medical Services Foundation, CIHR, AllerGen NCE.
RELATIONSHIPS OF GLUCOCORTICOIDS LEVELS IN HUMAN MILK AND MATERNAL AND INFANT CHARACTERISTICS OVER THE FIRST YEAR OF LIFE
Presenting Author: Shikha Pundir, University of Auckland, New Zealand - Liggins Institute
Co-Authors: Zoya Gridneva (University of Western Australia -School of Molecular Sciences), Eric B Thorstensen (University of Auckland- Liggins Institute), Clare R Wall (University of Auckland, New Zealand- Faculty of Medical and Health Science), Donna T Geddes (University of Western Australia -School of Molecular Sciences), David Cameron-Smith (University of Auckland - Liggins Institute)
Background: Human milk (HM) is a complex and dynamic biological fluid, which is adaptively altered throughout lactation to tailor the individual and unique needs of a developing infant. In addition to providing nutrients, HM contains a wide array of non-nutritive bioactive elements, including the complex array of hormones such as glucocorticoids. Cortisol and cortisone are typically the predominant glucocorticoids found in HM, known to play a critical role in shaping infants behaviour, physiology and metabolic programming.
Objective: To investigate the influence of lactation period on the glucocorticoid composition and its impact on infant development.
Subjects/Methods: Breast milk was collected using a standardised protocol from eighteen lactating mothers collected milk, prior to and after each breastfeeding session at 2, 5, 9 and 12 months of lactation. HM cortisol and cortisone levels were measured using high pressure liquid chromatography mass spectroscopy.
Results: Cortisol (p = 0.10) and cortisone (p = 0.06) concentrations remained constant throughout the first 12 months of lactation. Infant percentage fat mass (%FM) and head circumference was significantly correlated with HM cortisol and cortisone. No significant sex difference was found in the HM glucocorticoids. Further, a significant correlation was found between maternal body mass index and HM cortisol. This study demonstrated that HM glucocorticoids levels remain constant over the 12 months of lactation and that infant adiposity and cranial growth are related to HM glucocorticoids.
Conclusion: Concentration of HM glucocorticoids remained constant throughout the first year of lactation. Furthermore, higher concentrations of HM cortisol and cortisone were related with greater infant adiposity (%FM) and head circumference, indicating the potential role of milk-borne glucocorticoids in infant development.
Funding: Liggins Institute Philanthropic trust (The University of Auckland), Gravida (The National Centre for Growth and Development).
HOW DOES NUTRITIONAL INTAKES AFFECT THE BODY COMPOSITION OF HIV-EXPOSED AND HIV-UNEXPOSED PRETERM, VERY-AND EXTREMELY-LOW BIRTH WEIGHT INFANTS?
Presenting Author: K Strydom, Stellenbosch University–Division of Human Nutrition
Co-Authors: DG Nel, MA Dhansay, E Van Niekerk
Background: Human breast milk (HBM) is considered inadequate in meeting protein requirements, especially for very low birth weight (VLBW) infants, which could affect the body composition.
Objectives: Determining the effect of HBM on body composition of HIV-exposed and -unexposed preterm VLBW and extremely low birth weight (ELBW) infants. Furthermore the effect of breast milk fortification, and days nil per os (NPO) has on body composition.
Methods: A descriptive cross-sectional study was conducted. Preterm infants with a birth weight of ≤1200g were included. Infant nutritional intakes and body composition measurements were recorded during the 28-day follow-up period.
Results: 110 of 113 preterm infants received HBM and 91 infants received fortified HBM. HIV-exposed and unexposed infants receiving fortified HBM displayed differences in fat mass % (FM%) (0.88 vs. 1.36; p = 0.01) and (0.97 vs.1.49; p = 0.03) and fat free mass % (FFM%) (98.98 vs. 98.68 p = 0.03) and (99.02 vs. 98.49; p = 0.02), on day 21 and 28, respectively. Infants kept NPO displayed differences in FM% on day 7, 21 and 28 (0.9 vs 1.3; p = 0.03), (0.99 vs 1.4; p = 0.02) and (0.9 vs 1.6 p = 0.0004) as well as differences in FFM% (99.1 vs 98.4 p = 0.0005) on day 28 of life.
Conclusion: There were no significant differences in the body composition of infants who received HBM vs. fortified HBM. However, significant differences in body composition were between HIV exposure groups for infants who received fortified HBM. Infants who were kept NPO were generally smaller, shorter, and had lower FM% and more FFM%.
Funding: The Early Career Development Fund, Stellenbosch University and the Harry Crossley Foundation supported this study.
GROWTH IN INFANTS RECEIVING MODIFIED FAT MOTHER'S MILK FOR TREATMENT OF POST-CARDIOTHORACIC SURGERY CHYLOTHORAX
Presenting Author: Sara DiLauro, Hospital for Sick Children, Toronto
Co-Authors: Jennifer Russell, Sarah Kocel, Brian McCrindle, Christopher Tomlinson, Sharon Unger, Deborah O'Connor (Hospital for Sick Children & University of Toronto - Departments of Pediatrics and Nutritional Sciences, Toronto)
Background: Lacto-engineering may be a promising strategy to facilitate human milk use among infants with conditions/disorders traditionally treated with specialty formulas. We have shown use of modified fat breast milk (MFBM) can facilitate resolution of post-cardiothoracic surgery chylothorax in infants no differently than high medium chain triglyceride formula (MCT-formula), however weight-for-age (WAZ) and length-for-age z-scores (LAZ) declined over the ≥6-week treatment period.
Objective: To assess two proactive MFBM feeding protocols in promoting growth in cardiac infants with chylothorax.
Methods: In this open-label trial, mothers milk-fed infants were randomized to either: Target Fortification, where protein content of defatted milk was measured weekly prior to individualized multi-nutrient fortification to provide 3.5g/kg/day of protein (n = 8); or Higher Initial Concentration, where defatted milk was fortified to a higher initial energy/nutrient level (80kcal/dL; 2.2g/dL/protein) (n = 8). A third unrandomized group received MCT-formula (68kcal/dL; 2.3g/dL/protein) (n = 8). Interventions lasted 6 weeks after chest tube(s) removal and continued after discharge. Weight, length and head circumference (HC) were measured weekly. Repeated measures regression models were used to determine anthropometric differences among groups over time.
Results: There were no differences in mean WAZ (−1.6 ± 0.9, n = 24), LAZ (−1.3 ± 0.8), or HC-for-age (HCZ) (−0.9 ± 1.0) at enrollment. One Target Fortification infant withdrew at discharge. Changes in mean WAZ (−0.3 ± 0.9, n = 23), LAZ (0.1 ± 0.6) and HCZ (0.2 ± 0.6) did not differ among groups over time. There was no difference in chest tube drainage among groups.
Conclusions: Use of lacto-engineered MFBM and proactive feeding protocols facilitate resolution of chylothorax and support growth in cardiac infants.
Funding: SickKids, CHIR(143233).
HUMAN MILK CASEIN AND BODY COMPOSITION OF BREASTFEEDING DYAD OVER THE FIRST YEAR OF LACTATION
Presenting Author: Donna Geddes, The University of Western Australia (UWA) - School of Molecular Sciences
Co-Authors: Zoya Gridneva, Wan Jun Tie, Ching Tat Lai, Peter Hartmann (UWA - School of Molecular Sciences); Alethea Rea, Kevin Murray (UWA - Centre for Applied Statistics); Leigh Ward (University of Queensland - School of Chemistry and Molecular Biosciences)
Background: Human milk (HM) influences infant feeding patterns and body composition (BC).
Objective/Hypothesis: To investigate relationships between infant/maternal BC and HM casein/whey/total protein during the first 12 months of lactation.
Methods: BC of breastfeeding dyads (n = 20) was measured at 2, 5, 9 and/or 12 months postpartum (ultrasound skinfolds (infants); bioimpedance spectroscopy (infants/mothers)). Protein concentrations and 24-h milk intake were measured and calculated daily intakes (CDI) determined.
Results: There were no associations between maternal/infant BC and concentrations of proteins, and between infant BC and CDI of whey and total protein. Higher CDI of casein was associated with lower infant fat-free mass (p = 0.003) and fat-free mass index (p = 0.001) and higher fat mass (p < 0.001), fat mass index (p = 0.001) and percentage fat mass (p < 0.001) measured with ultrasound skinfolds.
Conclusions: These results show a differential effect of HM casein on development of infant BC during the first year of life, which is a critical window for infant developmental programming that has the potential for intervention to improve outcomes for the infant.
Funding: Australian Postgraduate Award (UWA); unrestricted research grant (Medela AG, Switzerland).
ALCOHOL AND BREASTFEEDING. DO THE CARERS CARE?
Presenting Author: Roslyn Giglia, Telethon Kids Institute - Team Lead, Alcohol, Pregnancy & FASD Research
Background: The 2009 Australian Guidelines to Reduce Health Risks from Drinking evidence-based alcohol and breastfeeding guideline (Guideline 4B) has been translated into a hard copy education resource (2009) and online interactive app (2014) for breastfeeding women. Despite the translation of evidence into national policy and applied education resources, little is known about the role of maternal health practitioners in discussing alcohol and breastfeeding with maternal consumers.
Objective: To determine the degree to which maternal health practitioners adopted an Australian national policy guideline (Guideline 4B) on alcohol and breastfeeding into their everyday health practice and the factors associated with adoption.
Methods: An integrated model of knowledge translation was used to investigate the pathway of evidence to practice for this policy directive. A mixed methods model of enquiry using online surveys and phone interviews provided data from maternal health practitioners. Investigative survey questions have been based on the Nursing Practice Questionnaire (NPQ) with input from key stakeholders to elicit measures of knowledge, awareness and practice implementation.
Results: In total, 240 maternal health practitioners completed the online survey. All statistical analyses clearly indicated a higher adoption of Guideline 4B by the child health nurses, midwives and GPs than was the case for pediatricians and obstetricians. A mean adoption score (range 0–4) indicative of ‘some’ practice implementation of 3.13, 3.04 and 2.73 was obtained by child health nurses, midwives and GPs, respectively. Obstetricians and pediatricians scored a mean of 2.0, indicating they remain to be ‘persuaded about the practice’ of incorporating discussions around alcohol and breastfeeding into their practice.
Conclusion: Despite the existence of a national alcohol guideline for breastfeeding women maternal health practitioners are not incorporating this advice into their everyday practice with lactating women. Opportunities exist along the reproductive continuum for all practitioners to deliver a harm minimization message.
Funding: At the time of conducting this research Dr. Roslyn Giglia was in receipt of a NHMRC Translating Research Into Practice (TRIP) Fellowship (GNT1090122).
IMPLICATIONS OF MATERNAL OVERWEIGHT OR OBESITY ON PRETERM HUMAN MILK COMPOSITION
Presenting Author: Daniel Robinson, Northwestern University, Department of Pediatrics
Co-Authors: Jami Josefson, Linda Van Horn; Northwestern University, Departments of Pediatrics and Preventive Medicine
Background: Preterm human milk (PHM) reduces morbidity risk in preterm infants, yet its composition is highly variable. Pre-pregnancy overweight or obesity (OW/OB), a circumstance of malnutrition resulting from overnutrition, can increase the risk of morbidity in preterm infants. Detecting variations in PHM composition attributable to OW/OB may facilitate the understanding of maternal malnutrition-related morbidity in human milk-fed preterm infants.
Objective: To measure associations between maternal OW/OB status and PHM lipidome and metabolome constituents.
Hypothesis: Lipidomic and metabolomic analyses will differ in PHM expressed by women with OW/OB as compared to milk from normal weight women.
Methods: PHM was prospectively collected from normal weight, OW, and OB women (N = 5 from each group) who delivered <32 weeks of gestation, at lactation weeks 1 and 4. Mass spectroscopy will measure lipidomic and metabolomic profiles. Select analytes, potential effectors of preterm infant morbidity and body composition, will be reported (e.g. milk fat globule membrane lipids, branched chain amino acids). Non-parametric methods will assess analyte distributions and compare week 1 concentrations between the three weight groups. Secondary paired comparisons will assess changes from week 1 to week 4. Regression models will measure associations between maternal body mass index (BMI) and analyte concentrations.
Results: Participating women were a median (IQR) age of 31 (29.5,34.5) years and delivered at 28 (26.8,30) weeks. Pre-pregnancy BMI ranged 19.8–36.3 kg/m2. Infants were born weighing 1125 (945,1249) grams.
Conclusions: Profiling PHM by OW/OB status will elucidate compositional changes attributable to maternal OW/OB and associated malnutrition. These data may suggest future directions for study to improve the health of human milk-fed preterm infants born to women with OW/OB.
Funding: Northwestern Developmental Sciences Institute for Pilot Research Initiatives; Northwestern University Clinical and Translational Sciences Tier 2 Pilot Grants (UL1TR001422).
EFFECT OF MATERNAL VITAMIN D (VITD) STATUS AND BMI ON MILK FAT GLOBULE MEMBRANE (MFGM) SPHINGOLIPID COMPOSITION
Presenting Author: Carol L. Wagner, Medical University of SC (MUSC), Pediatrics
Co-Authors: John E. Baatz (MUSC), Danforth A. Newton (MUSC), and Sarbattama Sen (Brigham & Women's Hospital, Boston, MA)
Background: Signaling proteins are associated with sphingolipid-rich microdomains on membranes, and both the proteins and sphingolipids and/or metabolites are involved in immunity, inflammation, cell differentiation and several other protective signaling cascades. Previous studies have shown that diet affects the sphingolipid composition in milk fat globule membranes (MFGM).
Objective/Hypothesis: Since sphingolipid (sphingomyelin [SM] and ceramide [Cer]) composition in MFGM has been shown to be affected by diet and BMI, we tested the hypothesis that SM and Cer composition is also dependent upon maternal VitD status (as measured by maternal blood 25OHD) and varies by BMI.
Methods: Fully lactating mothers participated in this pilot study (n = 13). Following informed consent, blood and whole breast milk samples were obtained 1–4 months postpartum from mothers who had delivered at term gestation. Pre-pregnancy BMI was collected on each mother, and total circulating 25OHD concentration was measured by RIA. Milk samples were processed for MFGM isolation as previously described. LC-MS was used to analyze long chain (C14–C18) and very long chain (VLC, C20–C26) acyl SM species of the MFGM normalized to total milk lipid inorganic phosphate. Data were analyzed by SAS 9.4 software (Cary, NC).
Results: Analysis of LC-MS data revealed that concentrations of VLC sphingomyelin species (C22-SM, C24-SM and C24:1-SM) increased dramatically with increasing maternal 25OHD, with other species (C14 and C20-SM) being in very low concentrations independent of 25OHD concentration. Similar results were found for C22-Cer and C24-Cer (data not shown). In accordance with an observed inverse correlation to 25OHD concentrations, lower BMI correlated with higher abundance of long chain SM species.
Conclusions: The findings are consistent with previous reports in other cells and organs that vitamin D regulates sphingolipid synthesis via VDR-responsive genes affecting MFGM sphingolipid composition, specifically with regard to sphingomyelin and ceramide profiles.
Funding: SCTR, MUSC.
ARE MATERNALLY ADMINISTERED PROBIOTIC STRAINS TRANSFERRED TO BREAST MILK: A SYSTEMATIC REVIEW OF HUMAN STUDIES
Presenting Author: Dawn Whitten, University of Tasmania, Hobart, Australia, College of Health & Medicine
Co-Author: Jason Hawrelak (University of Tasmania, Hobart, Australia, College of Health & Medicine)
Background: An entero-mammary pathway enabling transfer of bacteria has been hypothesized and is supported by preliminary animal and human data. Based on this premise, the breastfeeding infant may have the potential to be exposed to maternally-administered probiotics.
Objective/Hypothesis: To assess the evidence for breast milk transfer of maternally-administered probiotic strains. To test the hypothesis: Capacity to transfer to the breast milk is a strain-specific trait.
Methods: A computer-based search of MEDLINE, EMBASE and SPORTS DISCUSS was conducted in May 2018. A hand-search of bibliographies of relevant studies and of the author's personal library was undertaken. Studies were included if they investigated the presence of maternally-supplemented probiotics in breast milk and/or infant stool. Non-English language Studies were excluded due to resource limitations.
Results: Eight studies were identified that met the eligibility criteria. These studies included data on 9 specific probiotic strains. Studies used a variety of analytical techniques. The strains reported to be identified in breast milk following maternal probiotic treatment included Lactobacillus fermentum CECT5716, L. salivarius CECT5713, L. gasseri CECT5714, L. reuteri DSM 17938. One study identified L. rhamnosus GG in infant stool and absence in the majority of breast milk samples. L. acidophilus LA-5 and Bifidobacterium animalis ssp. lactis Bb-12 were largely undetected in stool or breast milk. No meta-analysis was preformed due to the heterogeneous nature of the data.
Conclusions: Preliminary data suggests that some probiotic bacteria strains have the potential to be transferred to breast milk following maternal administration. More data is needed to confirm this and to determine whether transfer to breast milk is a strain-specific trait.
Funding: None.
PROGRAMMING OF OFFSPRING ADIPOSITY AND INSULIN RESISTANCE BY MATERNAL HIGH FAT DIET DURING LACTATION
Presenting Author: Brigid Gregg (University of Michigan, Pediatric Endocrinology)
Co-Authors: Hannah Hafner, Eric Chang, Allen Zhu, Zachary Carlson, Cecilia Rivet, Emma Harman, Kanakadurga Singer (University of Michigan, Pediatric Endocrinology and Neonatal-Perinatal Medicine)
Background: Offspring of obese mothers have been shown to have an increased risk of metabolic disease. The independent contribution of the early postnatal lactation period to this risk is not well understood.
Hypothesis: We hypothesized that high fat diet exposure during the lactation period would alter the milk composition leading to programming of still developing metabolic tissues in the offspring, using a mouse model.
Methods: Adult female C57Bl6/J mice were fed standard chow through pregnancy. At birth, a group of mothers were fed 60% HFD for 21 days, generating high fat in lactation offspring (HFD-PN). Control mothers remained on standard chow generating control in lactation offspring (CTRL-PN). Offspring were weighed weekly and insulin tolerance measures were performed. At necropsy body composition was assessed. Milk composition was also determined by mass spectrometry.
Results: Male offspring of the HFD-PN group had increased visceral fat pad weights at postnatal day 16. HOMA-IR was increased in the HFD-PN group at 8 weeks of age. On insulin tolerance testing HFD-PN animals had decreased insulin sensitivity. At necropsy HFD-PN males had increased whole-body adiposity (p < 0.05) and visceral and subcutaneous fat pad weights compared to controls. When milk was analyzed free amino acid and long chain polyunsaturated fatty acid profiles differed between the groups.
Conclusions: Findings from this study indicate that maternal HFD during lactation period has an impact on milk composition and long-term offspring programming of adiposity and insulin resistance. Future studies will examine interventions to reverse this programming.
Funding: NIH K08-DK102526, Amendt-Heller Award for Newborn Research.
THE IMPACT OF GESTATIONAL DIABETES MELLITUS ON HUMAN MILK COMPOSITION
Author: Anna Kotlińska, PhD candidate, Jagiellonian University, Kraków, Poland
Background: The impact of gestational diabetes mellitus (GDM) on maternal and neonatal outcomes is well documented. However, almost nothing is known about the influence of glucose intolerance during pregnancy on human milk (HM) composition.
Objective/ Hypothesis: The purpose of this study was to determine the impact of GDM on HM macronutrient composition in first month of lactation.
Methods: A total 130 breastfeeding women (65 GDM and non-GDM during pregnancy) were recruited from the Clinical Hospital in Krakow, Poland, between November 2016 and May 2018. All mothers were recruited by day 3 postpartum and instructions on hand expression of HM was given. Five milk samples were collected on days 3, 7, 14, 21 and 28 days of lactation. Macronutrient composition was analyzed using the MIRIS Human Milk Analyzer (Uppsala, Sweden).
Results: GDM had no effect on birth weight, however, in the full sample (n = 130), male newborns were heavier than females. There was no significant effect of GDM on HM macronutrient content. A positive correlation was found between male offspring and protein and carbohydrate content of colostrum, but not later milk samples.
Conclusion: There is no significant correlation between GDM and changes in HM macronutrient content in first month of lactation.
Funding: Jagiellonian University.
PREGNANCY WEIGHT-GAIN AND RISK OF BREASTFEEDING CESSATION
Presenting Author: Hayley Martin, University of Rochester Department of Public Health Sciences (PHS)
Co-Authors: Kelly Thevenet-Morrison, Ann Dozier
Background: It has been well-established that mothers with above-normal pre-pregnancy body mass index (BMI) are at increased risk of breastfeeding cessation, however the relationship with pregnancy weight-gain (PWG) has been understudied. Excess PWG may alter the hormonal preparation of breast tissue for lactation, increase the risk of complications that negatively impact breastfeeding (eg. C-section, gestational diabetes), and may make effective positioning and latch more difficult to achieve.
Hypothesis: Women with greater than recommended PWG will have increased risk of breastfeeding cessation compared with women who gained within the Institute of Medicine's 2009 recommendations.
Methods: A survey-weighted cox proportional hazards model was utilized to estimate the instantaneous hazard of breastfeeding cessation among women who initiated breastfeeding in a New York county (N = 1184[9780weighted]). Confounders of the relationship of interest were evaluated using directed acyclic graphs and bivariate analyses; variables not on the proposed causal pathway and associated with the exposure (PWG category: less than, greater than, or within recommendations) and outcome (time-to-breastfeeding cessation) were included in the model.
Results: Women with greater-than-recommended PWG had 1.28 (95%CI:1.01–1.61) times the risk of breastfeeding cessation within the first 3 months postpartum compared to women who fell within PWG recommendations (controlling for parity, pre-pregnancy BMI, and maternal demographics [age, education, smoking, income, race/ethnicity, marital status]). No association was found between less-than-recommended PWG and time-to-breastfeeding cessation (HR = 1.15, 95%CI:0.86–1.55).
Conclusions: Greater-than-recommended PWG may be an additional modifiable risk factor for early breastfeeding cessation. Understanding the mechanism behind this risk should be ascertained by additional studies aimed at understanding the hormonal, social, logistical (positioning) and other issues resulting from excess PWG that may lead to early breastfeeding cessation.
Funding: NIH R01-HD055191.
JUST ONE FEED? BREASTFEEDING AND BLOOD PRESSURE IN THE CHILD STUDY
Presenting Author: Kozeta Miliku, University of Manitoba – Department of Pediatrics
Co-Authors: A.B. Becker, P. Subbarao, P. Mandhane, S.E. Turvey, T.J. Moraes, D. Lefebvre, M.R. Sears and M.B. Azad (The CHILD Study)
Background: Breastfeeding in infancy is associated with lower cardiovascular disease risk in adulthood, but the minimum duration required is unknown.
Objective: We investigated the association of breastfeeding and blood pressure at 3 years of age.
Methods: In the CHILD pregnancy cohort (n = 2,382), infant feeding was reported prospectively and documented from hospital records. Blood pressure and body mass index (BMI) were measured at 3 years of age. Associations were examined using regression models with adjustment for potential confounders.
Results: Nearly all children (97.9%) were breastfed, of which 98 (4.2%) briefly received breast milk only in hospital. At the age of 3 years, blood pressure was significantly higher in children who were never breastfed (mean systolic/diastolic 103/60 mmHg) compared to those who were ever breastfed (99/58 mmHg), including those who briefly received breast milk in hospital only (99/57 mmHg). These associations were independent of maternal age, education, ethnicity, pre-pregnancy BMI, pre-eclampsia and infant sex, gestational age, birth weight, and current BMI. Adjusted estimates for systolic blood pressure were −4.47 mmHg (95%CI −7.95, −1.00) for breastfeeding limited to the hospital stay, and −3.64 mmHg (95%CI −6.58, −0.71) for sustained breastfeeding after hospital discharge, compared to infants who were never breastfed. Similar patterns were observed for diastolic blood pressure. Among breastfed children, the duration and exclusivity of breastfeeding was not associated with blood pressure.
Conclusions: Any breastfeeding, regardless of duration or exclusivity, was associated with lower blood pressure at the age of 3 years. Ongoing research in the CHILD study will examine the possible mechanisms and bioactive milk components underlying this association.
Funding: Research Manitoba, CIHR, AllerGen NCE.
PRE-PREGNANCY BMI IS ASSOCIATED WITH PUMPED HUMAN MILK VOLUME DURING THE FIRST 14 DAYS AFTER BIRTH IN PUMP-DEPENDENT MOTHERS OF PRETERM INFANTS
Presenting Author: Clarisa Medina Poeliniz, Rush University Medical Center
Co-Authors: Rebecca Hoban (University of Toronto); Aloka Patel, Judy Janes, Janet Engstrom, Paula Meier (Rush University Medical Center)
Background: Overweight and obese mothers of term infants are at greater risk for impaired secretory activation (SA) and suboptimal long-term lactation outcomes. However, little is known about the relationship between maternal BMI and impaired SA in pump-dependent mothers of premature infants.
Objective: To examine the relationship between pre-pregnancy BMI and mean daily milk volume in pump-dependent mothers of premature infants during the first 14 days after birth.
Methods: All pumped milk volume was measured using an electronic balance (nearest 0.1g) through the first 14 days after birth for 39 mothers of premature infants (<33 weeks' gestation). Pre-pregnancy BMI was collected from the maternal health record.
Results: Mean maternal pre-pregnancy BMI was 30.1 (SD = 9.0) and 33.3% were under/normal weight, 23.1% were overweight, and 43.6% were obese. There was a moderate negative correlation between BMI and mean daily (rs = −.48, p = .002) and cumulative (rs. = −.47, p = .003) milk volume. BMI accounted for 25.1 % of the variance of the mean daily milk volume and 25.0% of the cumulative milk volume. A one-way ANOVA revealed statistically significant differences in mean daily milk volume (338, 232, 172 mL; p = .030) and total cumulative volume (4024, 3171, 2077 mL; p = .042) among the under/normal weight, overweight, and obese women, respectively.
Conclusion: There was an inverse relationship between maternal pre-pregnancy BMI and milk volume, and obese women were significantly more likely to have lower milk volumes.
Funding: Family Larsson-Rosenquist Foundation, Heal the Children Research Grants, Department of Pediatrics, Rush University.
INFANT FEEDING AFTER DIFFICULT BIRTH: COMMUNION AND AGENCY IN NARRATIVES OF REDEMPTIVE FEEDING EXPERIENCES
Presenting Author: Hannah Tello, University of Massachusetts, Lowell – Department of Psychology
Co-Authors: Joseph E. Gonzales
Background: Traumatic birth experiences represent 34% of all birth experiences in the US. Most of these are due to undermined agency and a lack of communion with caregivers during labor and delivery. Infant feeding during the post-partum period may enable reclamation of autonomy and agency, promoting maternal psychological well-being.
Objective/Hypothesis: To identify infant feeding experiences that resolve maternal psychological harm caused by traumatic birth experience.
Methods: We analyzed birth and infant feeding narratives of 20 mothers using a phenomenological narrative analysis to map pathways of positive post-natal infant feeding experiences via acts of agency and communion.
Results: Positive infant feeding experiences were identified as critical for maternal-infant bonding and for restoring mothers' psychological well-being. Positive infant feeding experiences included exclusive or predominant breastfeeding, and were characterized by pride in the functioning of one's maternal body, establishing closeness with their baby, positive interactions with caregiving authorities, and engagement with infant feeding communities.
Conclusions: Positive infant feeding experiences are critical for promoting psychological well-being following traumatic birth experiences. Optimized infant feeding experiences allow mothers to feel autonomy over their bodies and their infant feeding decisions, as well as create positive, supportive encounters with caregiving authorities. Caregiving authorities should prioritize empowered decision-making in efforts to support redemptive experiences in the post-partum period via infant feeding.
Funding: The College of Fine Arts, Humanities and Social Sciences and the Office of the Vice Chancellor for Research and Innovation: University of Massachusetts, Lowell (R50180000038539).
FATTY ACIDS IN HUMAN MILK: MATERNAL DETERMINANTS AND ASSOCIATIONS WITH INFANT GROWTH
Presenting Author: Rachel Criswell, Maine-Dartmouth Family Medicine Residency
Co-Authors: Virissa Lenters (Norwegian Institute of Public Health [NIPH] – Department of Environmental Exposure and Epidemiology), Hans Demmelmair (Dr. von Hauner Children's Hospital – Department of Metabolism and Nutrition; Nina Iszatt (NIPH); Berthold Koletzko (Dr. von Hauner Children's Hospital); Merete Eggesbø (NIPH)
Background: Lipids make up half the energy content of human milk, the majority of which are triglyceride-bound fatty acids (TGFAs).
Objective/Hypothesis: We described concentrations of 32 TGFAs in human milk, identified predictors of TGFA composition, and investigated associations between TGFAs and infant growth.
Methods: We used data from the Norwegian HUMIS-NoMIC birth cohort. Mothers provided milk samples and completed questionnaires during the child's first 2 years. In a subset of 789 mothers oversampled for overweight, we analyzed milk concentrations of TGFAs. We studied the relations between percent composition of TGFAs and body mass index, pregnancy weight gain, parity, smoking, delivery mode, gestational age, fish and cod liver oil intake. We also studied the relations between TGFAs and infant growth from 0–6 months.
Results: Gestational age was inversely associated with myristic acid. Excess pregnancy weight gain was associated with palmitoleate and cis-vaccenic acid and inversely associated with stearic acid; multiparity showed opposite associations. Fatty fish and cod liver oil intake were associated with eicosapentaenoic and docosahexaenoic acids; obesity and multiparity showed opposite associations. Lauric and myristic acids had inverse associations with infant growth although not with failure to thrive. Palmitoleate, oleic, and cis-vaccenic acids were associated with increased odds of rapid growth.
Conclusions: Early life exposure to medium-chain saturated fatty acids may be associated with reduced growth whereas monounsaturated fatty acids may be associated with rapid growth.
Funding: The European Union's “Early Nutrition,” project, grant agreement no. 289346 and the Norwegian Research Council's MILPAAHEL program, project No. 213148.F20.
ASSOCIATION BETWEEN POSTPARTUM DEPRESSION SYMPTOMS AND WOMEN'S SATISFACTION WITH BREASTFEEDING
Presenting Author: Elsa Giugliani, Universidade Federal do Rio Grande do Sul, Brazil – Department of Pediatrics
Co-Authors: Juliana Lago, Camila Giugliani, Agnes Bizon, Andrea Senna, Ana Cláudia Martins (Universidade Federal do Rio Grande do Sul)
Background: Postpartum depression and woman's satisfaction with breastfeeding are risk factors for breastfeeding initiation and maintenance. Nevertheless, there are no studies that have explored the association between them.
Objective: To estimate the association between postpartum depression symptoms and women's satisfaction with breastfeeding.
Methods: Cross-sectional study conducted in Porto Alegre, Brazil, with 287 postpartum women selected in two maternity hospitals. They were interviewed 30 days postpartum at home. Maternal Breastfeeding Evaluation Scale - adapted and validated for use in Brazil - and Edinburgh Postnatal Depression Scale were used to evaluate maternal satisfaction with breastfeeding and postpartum depression symptoms, respectively. The association between greater satisfaction with breastfeeding and negative screening for postpartum depression was tested using the Poisson Regression.
Results: The prevalence of having greater satisfaction (above the median) was 47% higher among women with negative screening for postpartum depression (PR 1.47; CI 95% 1.01–2.16), after adjustment for maternal age, skin color, cohabitation with the child's father, pregnancy planning, type of delivery, and exclusive breastfeeding practice.
Conclusion: This study confirmed the association between symptoms of postpartum depression and maternal satisfaction with breastfeeding, pointing to the importance of addressing the woman's mental health during pregnancy and lactation as well as her satisfaction level with breastfeeding.
Funding: CNPq.
STAPHYLOCOCCUS AUREUS ENTEROTOXIN PRODUCTION IN RAW AND PASTEURIZED HUMAN MILK
Presenting Author: Yahya Almutawif, Taibah University, Saudi Arabia-School of Applied Medical Sciences and The University of Western Australia (UWA)-School of BioMedical Sciences
Co-Authors: Megan Lloyd (UWA-School of BioMedical Sciences and Edith Cowan University-School of Medical and Health Sciences), Benjamin Hartmann (UWA- School of Pediatrics and Child Health and King Edward Memorial Hospital- Perron Rotary Express Milk Bank), Alethea Rea (UWA-Centre for Applied Statistics), Ching Tat Lai and Donna Geddes (UWA-School of Molecular Sciences)
Background:S. aureus is one of the most prevalent potential pathogenic bacteria found in donated human milk (DHM). Some strains produce heat-stable enterotoxins that are able to survive pasteurization.
Objectives/hypothesis: To determine S. aureus growth and enterotoxin production in raw and Holder pasteurized DHM (HP-DHM) at different storage temperatures.
Methods: Four individual milk samples were aliquots into raw and HP-DHM then inoculated with enterotoxin A and B producing S. aureus. Samples incubated at 4°C (10 days), 21°C and 37°C (18 hours). Bacterial growth and enterotoxin A and B were quantified.
Results:S. aureus count increased in pasteurized HM similar to the LB broth control. In contrast, bacterial count decreased in the raw milk. Enterotoxin A and B were only detected in pasteurized HM at 37°C from 9 hours onward, showing a positive relationship between the production of enterotoxin and number of bacteria over time.
Conclusion: This study showed that raw milk is capable of suppressing S. aureus growth compared to HP-DHM. It also provides a measure of assurance of the safety of raw and HP-DHM when refrigerated or left at room temperature for few hours.
Funding: PhD/scholarship (Taibah University, Saudi Arabia). Unrestricted grant (Medela AG, Switzerland).
CHARACTERIZING THE MICROBIAL COMPOSITION OF MILK FROM MOTHERS WITH INFANTS BORN <1250 GRAMS
Presenting Author: Michelle Asbury, University of Toronto, Toronto – Department of Nutritional Sciences
Co-Authors: James Butcher, Sharon Unger, Julia Copeland, Alex Kiss, Philip Sherman, Alain Stintzi, Christopher Tomlinson, Pauline Wang, Deborah L. O'Connor, on behalf of the OptiMoM Fortifier Study (University of Toronto – Departments of Nutritional Sciences, Pediatrics, Centre for Analysis of Genome Evolution and Function, and Institute of Health Policy, Management and Evaluation; University of Ottawa – Ottawa Institute of Systems Biology)
Background: Term mother's milk contains complex microbial communities thought to colonize her infant's GI tract; however, little is known about the preterm mother's milk microbiota.
Objective: To characterize the microbial composition of milk from mothers of hospitalized infants born <1250 g across the first 8 weeks postpartum.
Methods: Weekly milk samples (n = 245) from mothers (n = 30) of infants in the OptiMoM Fortifier RCT (NCT02137473) were prospectively collected. Microbial composition was determined using V4-16S rRNA gene sequencing. Longitudinal relationships between maternal factors (mode of delivery, pre-pregnancy BMI, antibiotic use) and microbial composition were assessed using linear and Poisson regressions.
Results: Each mother had a unique microbial profile in her milk, with the five most predominant genera being Staphylococcus (mean[SD]: 50.1[27.1]%), Pseudomonas (17.6[14.8]%), Acinetobacter (10.6[19.1]%), Corynebacterium (4.7[7.0]%), and Streptococcus (2.9[9.7]%). No associations between richness (Chao1) and maternal characteristics were found; however, healthy-weight mothers showed increased evenness (Shannon index) in their milk over time, compared to overweight/obese mothers (0.13 vs −0.07 per week; p = 0.0002). Antibiotic use was also associated with a higher abundance of Corynebacterium (incidence rate ratio[95%CI]: 2.52[1.35–4.70], p = 0.004) in mother's milk.
Conclusions: Microbiota evenness and composition in preterm mother's milk are associated with maternal characteristics during initial hospitalization. The impact of these observations on GI colonization is worthy of future investigation.
Funding: CIHR (#FHG129919; #FDN143233).
NEWLY ESTABLISHED DONOR MILK COMPOSITION VALUES ACCURATELY ESTIMATE NUTRIENT INTAKES OF INFANTS BORN <1250G
Presenting Author: Sara Shama, University of Toronto, Toronto – Department of Nutritional Sciences
Co-Authors: Sharon Unger, Michelle Asbury, Nicole Bando, Alex Kiss, Deborah L. O'Connor (University of Toronto – Departments of Nutritional Sciences, Pediatrics, and Institute of Health Policy, Management and Evaluation)
Background: Although donor milk (DM) undergoes several processing steps known to affect its macronutrient content, it is still fortified primarily using mother's milk composition values; this practice may overestimate nutrient intakes of DM-fed preterm infants.
Objectives: (1) To establish new macronutrient composition values for pooled, pasteurized DM dispensed by the Rogers Hixon Ontario Human Milk Bank (RHOHMB) and (2) to determine mean differences in nutrient intakes calculated using direct assessment of DM, our newly established macronutrient values, and the current practice DM reference values.
Methods: DM-fed infants (n = 22) from the OptiMoM Fortifier Study (NCT02137473) were included. Daily feeding data and all DM batches fed (n = 311) were prospectively collected for 8 weeks or until discharge. DM batches were analyzed by mid-infrared human milk analyzer and confirmed by wet chemistry. Nutrient intakes were calculated using directly-assessed DM values, our newly established composition values, and current practice reference values.
Results: Newly established reference values for protein, lipid, carbohydrate, and energy were 0.8g/dL, 3.4g/dL, 6.9g/dL, and 62kcal/dL, respectively. Compared to direct assessment, nutrient intakes calculated using current practice reference values were overestimated (mean difference[95%CI]: protein 0.12[0.06–0.18]g/kg/d, p = 0.0006; lipid 0.50[0.37–0.63]g/kg/d, p < 0.0001; carbohydrate 0.19[0.01–0.37]g/kg/d, p = 0.0468; energy 3.88[2.07–5.68] kcal/kg/d, p = 0.0001). No significant differences were found for intakes calculated using our newly established composition values.
Conclusions: Current practice reference values overestimated nutrient intakes of infants born <1250g. Our newly established DM composition values for the RHOHMB should improve fortification practices to better support the growth of DM-fed preterm infants in Ontario.
Funding: CIHR (#FHG129919).
PROFILING GUT MICROBIOME DEVELOPMENT IN VERY LOW BIRTH-WEIGHT INFANTS RECEIVING SUPPLEMENTS OF PASTEURIZED DONOR MILK OR FORMULA
Presenting Author: James Butcher, University of Ottawa – Ottawa Institute of Systems Biology
Co-Authors: Sharon Unger, Jennifer Li, Nicole Bando, Deborah L. O'Connor, Alain Stintzi (University of Toronto – Departments of Nutritional Sciences & Pediatrics; University of Ottawa – Ottawa Institute of Systems Biology)
Background: Human milk is of critical importance for very low birth-weight (VLBW, <1500g) infants. Unfortunately, many VLBW infants require pasteurized donor milk (PDM) or formula supplements and how these supplements impact gut microbiome development is unknown.
Objective: To characterize the gut microbiomes of VLBW infants receiving PDM/formula supplementation.
Methods: In this prospective cohort, VLBW infants (n = 147) were recruited from those admitted to Mount Sinai Hospital. Infants always received mother's milk when available and PDM or formula was provided as a supplement. Nutrient fortification was achieved with bovine-based fortifiers. Weekly stool samples were collected (n = 688) and profiled using V6-16S-rRNA gene sequencing. We also profiled 28 infant microbiotas at ∼30 weeks gestational age using shotgun-metagenomic sequencing (9 exclusively human milk-fed, 9 PDM, 10 formula).
Results: The PDM/formula groups each had high rates of human milk feeding (median days receiving human milk >77%). They also showed increasing Shannon diversity and Clostridia class bacteria as we have previously reported for exclusively human milk-fed VLBW infants. Surprisingly, levels of fortifier intake appear to be an important factor impacting VLBW microbiota development. Shotgun sequencing revealed that the PDM infants were enriched for various Clostridium genera ∼30 weeks gestational age.
Conclusions: In a high mother's milk setting, PDM/formula supplementation appears to have minor impacts on the global development of VLBW infant gut microbiomes; exploration of the fortifier dose provided and its impact on the microbiome is worthy of future investigation.
ECONOMIC IMPACT OF DONOR MILK IN THE NEONATAL INTENSIVE CARE UNIT
Presenting Author: Tricia Johnson, Rush University – Department of Health Systems Management
Co-Authors: Kelly Sulo, Paula Meier, Aloka Patel (Rush University– Department of Pediatrics)
Background: Pasteurized donor human milk (DM) is the recommended alternative when mother's own milk (MOM) is not available for very low birth weight (VLBW, birth weight <1500g) infants. DM may reduce the risk of necrotizing enterocolitis (NEC) relative to formula. Little is known about NICU hospitalization costs associated with MOM diets supplemented with DM versus MOM diets supplemented with formula.
Objective: To assess the impact of MOM supplemented with DM versus MOM supplemented with formula on NICU hospitalization costs for VLBW infants.
Methods: Retrospective study of 338 infants born before (January 2011–December 2012, MOM+formula) and after a DM program (April 2013–March 2015, MOM+DM) was implemented at Rush University NICU. Data were retrieved from a prospectively-collected research database, the electronic medical record, and the hospital's cost accounting system.
Results: Comparing the MOM+formula versus MOM+DM, the mean proportion of MOM for the NICU stay was 45.2% vs. 47.1% (p = 0.683), and NEC (stage ≥2) incidence was 3.7% vs. 1.3% (p = 0.117), respectively. Total hospital cost (2016 USD) was $174,524 and NICU length of stay was 78 days for MOM+formula, and $191,641 and 85 days for MOM+DM.
Conclusions: We found no evidence of a reduction in the cumulative dose of MOM for infants in the MOM+DM group compared to infants in the MOM+formula group. While there was a reduction in NEC, we found no significant difference in hospital costs between groups. We speculate that the costs associated with NEC were offset by the costs associated with DM purchase.
Funding: NIH NR010009, Rush University grants.
IMPACT OF ESTABLISHING ‘COMPREHENSIVE LACTATION MANAGEMENT CENTRE’ ON INTAKE OF ‘MOTHER's OWN MILK’ IN A NEONATAL UNIT
Presenting Author: Sushma Nangia, Neonatology and CLMC, Lady Hardinge Medical College, New Delhi, India
Background: Human milk is undisputed gold standard for neonatal nutrition with Mother's Own Milk (MOM) faring better than Pasteurised Donor Human Milk (PDHM). With increasing milk bank establishments, focus should be increased provision of MOM for the biologic baby, rather than PDHM substituting its inconsistent availability.
Objective: To evaluate Impact of establishing Comprehensive Lactation Management Centre (CLMC) in augmenting MOM usage in Public health tertiary care NICU.
Methods: This prospective study was conducted after operationalization and running of CLMC for 6 months. CLMC functioning included a) rigorous counselling and motivation of mothers of neonates in NICU along with b) pumping support as required for stimulation or expression of milk and c) establishment of milk kitchen in NICU for PDHM disbursement. The consumption pattern of formula, MOM and PDHM among NICU neonates was tracked over 8 weeks from March 5, to April 29, 2018.
Results: Eighty bedded neonatal unit's daily consumption of milk is 14–15 litres. Before establishment of CLMC, EBM utilization was 45% and formula 55%. After active intervention, unit has shown steady increase of MOM availability and utilization by 25% (45% to 70%). Formula usage has declined by 30% (55 to 25%). PDHM is used for neonates <34 weeks during first 2 weeks if MOM is unavailable and has averaged at 5%. Formula use in <34 weeks during first two weeks has been virtually eliminated.
Conclusions: This study shows that if milk banks are established with primary goal of augmenting MOM, they can play a significant role in both augmenting MOM and providing PDHM.
Funding: None.
IMPACT OF DONOR HUMAN MILK ON PRETERM GUT MICROBIOME AND URINARY METABOLOME
Presenting Author: Anna Parra-Llorca, Instituto de Investigación Sanitaria La Fe, Valencia, España
Co-Authors: Cristina Alcántara (Instituto de Agroquímica y Tecnología de Alimentos (IATA-CSIC) Paterna, España); José David Piñeiro-Ramos (Instituto de Investigación Sanitaria La Fe); María Gormaz, Maria Cernada, Antonio Núñez-Ramiro (Hospital Universitario y Politécnico La Fe, Valencia, España); Julia Kuligowski (Instituto de Investigación Sanitaria La Fe); Maria Carmen Collado (IATA-CSIC)2, Máximo Vento (Hospital Universitario y Politécnico La Fe)
Background: Breast milk (BM) is a complex, dynamic and live fluid that directly influences microbiota colonization and immune system maturation. BM is optimal for preterm infant nutrition as it has been demonstrated to improve growth, cognitive and health outcomes (i.e. reduced risk of necrotizing enterocolitis and sepsis). When maternal milk is not available, pasteurized donor human milk (DHM) has become the best alternative, but its impact on preterm microbiota and metabolism are not well understood.
Objective: This study aims at the characterization of the impact of DHM vs. BM on the gut microbiome and urinary metabolome in preterm neonates admitted to a neonatal intensive care unit (NICU).
Methods: A prospective observational cohort study of 69 neonates in a NICU with <32 weeks of gestation and ≤1.500 g birth weight was conducted. Preterm infants were classified in 3 groups according nutrition type (OMM, DHM or formula). Preterm gut microbiome and urinary metabolic fingerprints were determined by 16S rRNA gene sequencing and liquid chromatography coupled to high resolution time-of-flight mass spectrometry, respectively.
Results: Preterm microbiota composition and urinary metabolic fingerprints were influenced by nutrition. Preterm neonates fed with BM showed a higher abundance of Bifidobacterium and lower of Staphylococcocus spp compared to the DHM group. A total of 34 altered features were found be associated to microbial activity. From them, 21 were higher in BM preterm infants (e.g. 3-methyldioxyindole, methylgallic acid) while other 13 were higher in DHM (e.g. vanilloylglycine, hippuric acid).
Conclusions: Nutrition has a key impact on microbiota which is mirrored in metabolic fingerprints. The integration of microbiome and metabolome data allowed to gain new insights on the role of nutrition in preterm infants' health from a systems biology perspective.
BREAST MILK FROM REMUNERATED DONORS APPEARS TO BE AS SAFE AS THAT FROM UNREMUNERATED DONORS
Presenting Author: David J Rechtman, Prolacta Bioscience Duarte CA, USA
Co-Authors: Martin L Lee, Aaron Chestnut and Scott Eaker (Prolacta Bioscience, Duarte, CA; USA, MLL School of Public Health UCLA)
Background: The question of altering remuneration to breast milk donors has been debated for decades. In much of Europe, remuneration of breast milk donors is not permitted. In parts of Scandinavia, remunerated breast milk donation is considered de rigueur. In North America, some milk banks do not remunerate their donors while others do. Moreover, regardless of whether or not milk banks in North America are willing to remunerate their donors there is a robust and unregulated market for the sale of breast milk online. In 2014, in response to the burgeoning unsafe online breast milk market, Prolacta Bioscience established a process to give mothers the option of receiving the same level of remuneration as would have resulted if that same donation would have been made to one of the charitable milk banks, if she so chose. This process was initiated with a pilot study and based on those initial data became available to all Prolacta donors. We have reviewed our experience with both remunerated and un-remunerated donors from the initiation of remuneration until now.
Objective: Determine if there is a difference between remunerated and unremunerated donors.
Methods: All Donors to Prolacta Bioscience regardless of whether or not they are remunerated are required to complete a medical and social history questionnaire. Those who are not eliminated based on the questionnaire answers undergo blood testing for HAV, HBV, HCV, HIV 1 & 2 HTLV I & II and syphilis. Each donation of their milk is tested for common drugs of abuse including nicotine as well as some prescription medications, common adulterants and dilution. We compiled the records of all donors who have donated since the start of remuneration regardless of their remuneration status and compared those who were to those who were not remunerated in each testing category.
Results: As of this review there was no statistically significant difference in the percentage of donors to either the remunerated or non-remunerated milk banks who were disqualified due to positive results on blood testing for infectious diseases. Similarly, there did not appear to be a difference between groups with regard to drug testing except for cotinine which was significantly less likely to be seen in the milk of remunerated donors then in that of volunteers. (0.29% versus 1.03% P = 0.0016)
Conclusion: it has long been hypothesized that remunerated in breast milk donors would result in increased risk of infectious agents or other forms of adulteration in the milk supply. Our results indicate that appears not to be the case.
Funding: Prolacta Bioscience.
UNCHANGED BIOCHEMISTRY OF LIPIDS IN DONOR PASCALIZED HUMAN MILK
Presenting Author: Aleksandra Wesolowska, Medical University of Warsaw (MUW), Department of Neonatology, Poland
Co-Authors: J. Brys (Warsaw University of Life Sciences, Faculty of Food Sciences); E. Sinkiewicz-Darol, O. Barbarska (MUW - Department of Neonatology); K. Strom (MUW- Department of Medical Biology); J. Szymanska (MUW- Department of Biochemistry); D. Martysiak-Zurowska, M. Puta (Gdansk University of Technology - Department of Chemistry); K. Karzel (Warsaw University, Faculty of Psychology); E. Pawlikowska, S. Rzoska (Polish Academy of Science - High Pressure Physics); G. Olędzka (MUW- Department of Medical Biology); M.K. Borszewska-Kornacka (MUW- Neonatal and Intensive Care Department)
Background: Preservation of unique composition of lipids in donor human milk (DHM) is needed.
Objective/Hypothesis: The aim of the study was to compare the effects of pascalization (HPP) and holder pasteurization (HoP) on lipids and BSSL activity in DHM.
Methods: DHM was processed respectively: HoP (62,5°C;30min) and the HPP variants: 1) 600MPa; 2) 200 + 400MPa; 3) 100 + 600MPa; 4) 200 + 600MPa; and 5) 450MPa. Lipase activity was estimated by QuantiChrom™ ELISA kit. Folch lipids extraction was used. Fatty acids (FA) composition was characterized with GC technique, free FA content by titration with 0.1M KOH. The positional distribution of FA of TGAs was based on the ability to selectively hydrolyze ester bonds in the sn-1,3 positions. The oxidative induction time (IT) was obtained from the PDSC (Pressure Differential Scanning Calorimetry).
Results: BSSL activity was completely destroyed HoP, decreased significantly in HPP variants with 600MPa and remained intact by 200 + 400MPa; 450MPa. FA composition and structure of TGAs of DHM fat were unchanged. The lipids of HoP - DHM had lowest content of FFA and the shortest IT compared to HPP - DHM.
Conclusions: HPP minimizes any changes in the lipids of DHM.
Funding: Regional Development Funds, Smart Growth Operational Program 2014–2020.
MILK BANKING AND THE UNCERTAIN INTERACTION BETWEEN MATERNAL MILK AND ETHANOL (MUIMME)
Presenting Author: Tanya Cassidy, Dublin City University (DCU), School of Nursing and Health Sciences.
Co-Authors: Bernard Mahon (Maynooth University (MU), Biology Department), Fiona Dykes (University of Central Lancashire (UCLan), School of Community Health and Midwifery)
Background: The MUIMME (Milk Banking and the Uncertain Interaction between Maternal Milk) project discusses UK women's health and lifestyle policies as part of an interdisciplinary ethnographic study of the four of the largest donor human milk banks.
Objective: Using ethnographic methods, we investigate socio-cultural issues of trust and translation regarding donor human milk banking and lifestyle choices - especially alcohol related issues.
Methods: Triangulated qualitative data collection (observational field work, narrative interviews and archival/document data collection by a senior social scientist) was conducted between February 2016 and February 2017. Human milk alcohol testing strips tested eight samples of donor milk per month per bank.
Results: No samples showed high alcohol levels. Over twelve months, only four samples slightly changed colour, indicating a possible positive test. In three of these cases the samples failed other bacteriological checks and would not have been used clinically. Only one sample would not have been detected through other checks.
Conclusions: National Institute of Clinical Excellence (NICE) guidelines for milk bank operating procedures states that women drinking more than 1 or 2 units of alcohol more than once or twice a week are ineligible to become donors. The World Health Organization recently identified “harmful alcohol use” as one of four behavioural “health priorities as risk factors for noncommunicable diseases in maternal populations” (Washio and Humphreys, 2018). Our research indicates this population does not donate human milk, and that current donors follow guidelines regarding alcohol and donation.
Funding: EU Horizon 2020 Marie Sklodowska Curie Award (H2020-MSCA-IF-2014, reference number 654495).
RETROSPECTIVE STUDY OF GASTROSCHISIS: EFFECTS OF BREAST MILK ON CLINICAL OUTCOMES
Presenting Author: Aloka L. Patel (Rush University Medical Center)
Co-Authors: Andrew Storm, Rakhee Bowker, Samuel Klonoski, Stephanie Iantorno, Srikumar Pillai, Ami Shah (Rush University)
Background: Infants with gastroschisis, a congenital defect of the anterior abdominal wall, commonly require parenteral nutrition (PN) due to prolonged ileus and intestinal dysmotility, which impact enteral feeding tolerance. The optimal postoperative feeding regimen for infants with gastroschisis is unknown, with few studies investigating the effect of breast milk (BM) feedings on outcomes.
Objective: To determine the impact of BM dose on a) time to full feedings, b) duration of PN, and c) NICU length of stay (LOS) for infants with gastroschisis.
Methods: Retrospective study of a convenience sample of 44 infants with gastroschisis born in 2005–2016. Birth gestational age (GA), gastroschisis type (complex associated with ischemia/atresia), daily volume of BM/formula, PN days, and ages at surgical closure and full feedings were abstracted. BM dose was defined as percentage of total enteral nutrition. Data were analyzed using Pearson correlation and multivariate linear regression.
Results: Infant characteristics included as covariates: GA (35.9 ± 2.0wk), male (52%), complex gastroschisis (11%). BM dose was significantly correlated with PN days (r = −.43, p = .003) and LOS (r = −.30, p = .046). Multivariate linear regression demonstrated every 10% increase in BM dose was significantly associated with a decrease of 3.2 PN days (β −3.2, 95% CI [−5.3, −1.1], p = .003). BM was not associated with time to full feedings or LOS after adjusting for covariates.
Conclusions: Dose of BM was associated with fewer PN days but did not affect LOS in infants with gastroschisis. These preliminary findings are provocative and suggest that further study of the role for donor milk when BM is unavailable for infants with gastroschisis may be indicated.
Funding: Rush Dean's Office Summer Research Fellowship.
EARLY FEEDING PATTERNS OF INFANTS WITH MYELOMENINGOCELE
Presenting Author: Diane L. Spatz, The University of Pennsylvania School of Nursing & The Children's Hospital of Philadelphia (CHOP)
Co-Authors: Elizabeth B. Froh (CHOP)
Background: At CHOP, in-utero repair of myelomeningocele (MMC) is the standard of care for this diagnosis. After fetal surgery the goal is for the mother to carry the infant until 37 weeks gestation. Therefore, these infants are “healthier” infants in the hospital's Neonatal/Infant Intensive Care Unit (N/IICU) and are often able to orally feed at birth or soon thereafter.
Objectives: In December 2014, a newborn feeding guideline protocol for breastfeeding and the provision of human milk for the “healthier” infant in the N/IICU was implemented. This research examined early feeding patterns of infants born with MMC for two years prior to the guideline (2013, 2014) and two years post implementation of the guideline (2015, 2016).
Methods: Through the hospital's lactation pumping initiation database and N/IICU admission database, infants admitted with the diagnosis of MMC were identified (n = 181). The electronic patient record was utilized to abstract maternal and infant demographics, as well as the infants' enteral and parental feeding patterns from birth through discharge.
Results: The majority of infants were exposed to human milk both before and after implementation of the feeding protocol (90% and 93%, respectively). During the 2013/2014 period, 60% of infants were exposed to infant formula which decreased to an average of 47% in the 2015/2016 time period.
Conclusions: MMC infants had high rates of human milk and breastfeeding, despite some infants being exposed to infant formula during the N/IICU stay. This has led us to change practice and consent mothers prior to delivery for the use of pasteurized donor human milk as a bridge to mother's own milk to further minimize formula exposure.
Funding: None.
THE EFFECT OF AN EXCLUSIVE HUMAN MILK DIET (EHMD) ON THE INCIDENCE OF NECROTIZING ENTEROCOLITIS (NEC) IN THE US: AN UPDATED EPIDEMIOLOGICAL EVALUATION
Presenting Author: Martin L Lee, Prolacta Bioscience and UCLA-Fielding School of Public Health
Co-Authors: David J. Rechtman (Prolacta Bioscience), Alan Lucas (Child Nutrition Research Centre)
Background: Clinical trials investigating an exclusively human milk based diet (EHMD) in premature infants born at less than 1,250g demonstrated a two-thirds lower incidence of NEC. Consequently, many hospitals in the US have instituted this protocol. The repeatability of this effect in routine practice remained an open question.
Objective/Hypothesis: An exclusive human milk diet results in a consistently beneficial effect on the incidence of NEC in extremely premature infants.
Method: Several NICUs reported data on the incidence of NEC both pre and post the introduction of the EHMD. We investigated whether any reduction in NEC can be attributed to a general population decline rather than the nutritional intervention.
Results: In the published randomized controlled trials, overall NEC rates were reduced from 17.4% to 6%; surgical NEC was reduced from 12% to 1.2%. Seven independent cohort studies (N = 2,194) have shown similar relative reductions. The weighted average of the percent reduction in overall NEC was ∼73.3%. The likelihood of these results being due to chance is approximately 0.0001. An evaluation of NEC rates from the VON database from 2008–2014 for infants born under 1,250g bodyweight N ∼ 264,000) indicated that overall NEC rates fell from 8.9% to 6.9%, about a 22% decline. However, across the shorter timeframe of the evaluated studies, this decline is closer to 15%.
Conclusion: The effect of an EHMD on NEC rates far exceeds the population incidence decline, and is overwhelmingly associated with this diet. The widespread introduction of EHMD may be responsible for part of this decline.
Funding: Prolacta Bioscience, Inc.
GENDER-SPECIFIC EFFECT OF BREASTFEEDING ON ACUTE DIARRHEA
Presenting Author: Allison Cline, University of Cincinnati
Co-Authors: Ardythe Morrow, PhD (U. Cincinnati) and CDC New Vaccine Surveillance Network (NVSN) investigators
Background: Not breastfeeding (NBF) increases the odds of infectious disease in infancy. However, NBF has been reported to increase the odds of acute respiratory illness more in female than male infants (Libster, 2009). The gender specific odds of acute diarrhea associated with NBF has not been studied.
Objective: We tested the effect of gender on the odds of acute diarrhea associated with NBF.
Methods: Between 12/2011–11/2012, the NVSN enrolled 1641 infants (0-1 year) in 6 U.S. medical centers. Enrollment included 1021 acute diarrhea cases admitted to emergency departments or hospitals and 620 healthy controls seen in outpatient clinics. Parents reported breastfeeding status at the time of visit.
Results: Of the 1021 AGE cases, 18% were breastfed, 54% male, 17% privately insured, with median age of 6.6 months. Of the 620 controls, 31% were breastfed, 50% male, 27% privately insured; median age was 6.0 months. In multiple logistic regression models including all of these factors, AGE cases were 2-fold more likely to be NBF (odds ratio [OR] = 2.0, 95%CI = 1.5–2.6, p < 0.001); infant gender was not a significant risk factor but the interaction term for NBF and gender was significant. In males, acute diarrhea cases were 2.9-fold more likely to be NBF (95% CI 2.0, 4.1; p < 0.001), whereas in females, acute diarrhea cases were only 1.3-fold more likely to be NBF (95% CI 0.9, 1.9; p = 0.192).
Conclusions: NBF in infancy was associated with a 2-fold increased risk of emergency room use/hospitalization with acute diarrhea. But, NBF was a stronger risk factor for male than female infants, reverse of the gender association previously reported for NBF and acute respiratory illness.
Funding: NIEHS T32-ES010957.
HEMOGLOBIN CONCENTRATION IN PRETERM INFANTS VARIES ACCORDING TO BIRTHWEIGHT, GESTATIONAL AGE AND FEEDING TYPE
Presenting Author: Miriam Aguilar Lopez, University of Illinois, Urbana – Nutritional Sciences
Co-Authors: Thao Ho (University of South Florida –Pediatrics), Sharon M. Donovan (University of Illinois –Food Science and Human Nutrition)
Introduction: In the U.S., 10% of infants are born prematurely. Preterm infants (PT) are at risk for anemia of prematurity (AOP) due to delivery before placental iron transport and fetal erythropoiesis are complete, phlebotomy blood losses and low plasma erythropoietin. AOP is associated with slower growth rate, gastrointestinal complication, thyroid dysfunctions, immune dysregulation, and temperature instability. Thus, it is important to examine factors affecting hemoglobin (Hb) concentrations of PT.
Objective: To evaluate weekly Hb concentrations of PT. We hypothesized that Hb concentrations would vary in relation to birthweight (BW), age and type of enteral nutrition.
Methods: PT (n = 97) were followed from birth until 37 weeks corrected gestational age (GA) or discharge. Medical records and weekly Hb levels were collected. Three feeding types were provided based on birth GA: mother's own milk (MOM) or donor human milk (DHM) + human milk-based fortifier (HMF) (<28 weeks), MOM/DHM + bovine milk based fortifier (BMF) (28-34 weeks), or MOM+BMF/Formula (>34 weeks).
Results: Hb levels declined in all PT over time (p < 0.001). However, infants born ≤1250 g had lower Hb concentrations at birth and over time (p < 0.001) than those BW >1250 g. Hb was also lower in infants fed MOM+BMF/Formula compared to infants fed with the other two feeding combinations.
Conclusion: Hb concentrations in PT are affected by GA, BW and feeding type. Infants had higher Hb if they were born at higher GA, heavier, and received MOM or DBM. These factors should be considered in the prevention and treatment of AOP.
Funding: University of Illinois - Carle Hospital Seed Grant, CONACYT Graduate Fellowship.
HUMAN MILK PROTEIN MEDIATORS FOLLOWING IN VITRO DIGESTION
Presenting Author: Yimin Chen, University of Illinois at Chicago (UIC) - Department of Kinesiology and Nutrition
Co-Authors: Kelly Tappenden (UIC); Paula Meier, Aloka Patel, Giamila Fantuzzi (Rush University Medical Center – Department of Pediatrics)
Background: A variety of immunomodulatory proteins have been identified in human milk (HM) and shown to alter inflammatory response. We previously showed that pretreating intestinal epithelial cells with digested HM suppressed inflammation and cytotoxicity. However, we observed wide variability in suppression among HM samples from different mothers.
Hypothesis: The concentrations of select HM protein mediators in the previously used HM samples are correlated with inflammation and cytotoxicity suppression.
Methods:Samples. Ten digested HM samples (from previous study), one mature HM and one colostrum samples (digested, digested skim, undigested, and undigested skim). Measurements. IL-8, TNF, LPS binding protein (LBP), sCD14, TNF receptors I and II were measured using ELISA.
Results: All mediators were within measurable concentrations in undigested samples; skimming of HM did not significantly alter concentrations. Following in vitro digestion, all mediators except LBP fell below detection limits. LBP concentration was negatively correlated with LPS-induced cytotoxicity (p = .037).
Conclusions: Following full digestion simulating the premature infant's GI tract, we demonstrated that majority of immunomodulatory mediators are not present in detectable concentrations. We conclude that previously identified HM immunomodulatory protein mediators, except LBP, may not explain all the benefits seen in infants.
Funding: Rush University Pilot Grant; Academy of Nutrition and Dietetics Foundation Research Grant.
PRETERM INFANT GROWTH AND HUMAN MILK EXPOSURE IN THE NICU
Presenting Author: Lindsay Schehr, University of Wisconsin, Milwaukee – College of Nursing
Co-Author: Teresa S. Johnson
Background: Intrauterine growth is the standard for extrauterine growth for preterm infants (Fenton & Kim, 2013). Human milk is the preferred feeding for preterm infants (Menon & Williams, 2013). Preterm infants are commonly supplemented with bovine milk based fortifier and/or formula to maximize growth acceleration (Menon & Williams, 2013). There is not sufficient research to determine optimal growth for individual preterm infants (Embleton et al., 2017). Guidelines for feeding preterm infants that include fortification and lacto-engineering are a source of controversy among health care providers (Menon & Williams, 2013).
Objective/Hypothesis: The objective of this study is to examine how feeding practices impact growth in infants less than 1500 grams from birth until reaching full enteral feedings.
Methods: A retrospective descriptive correlational study was conducted that compared growth of hospitalized preterm infants.
Results: 82 preterm infants with a mean gestational age 29.30 (SD 3.11) weeks and mean birthweight of 1108.84 (SD 272.77) g were included. In infants that received fortified human milk (53.7%), the mean growth velocity was 5.66 (SD 17.20) g/kg/day and mean volume of enteral intake was 132.60 (SD 28.29) mL/kg/day at the time of fortification initiation. At the time infants reached full enteral feedings, mean growth velocity was 1.71 (SD 10.67) g/kg/day.
Conclusions: Initiation of human milk fortification or lactoengineering earlier may have prevented growth failure that was evident by growth velocity less than 15 g/kg/day when reaching full enteral feedings.
Funding: Ms. Schehr received no funding for this work. Dr. Johnson is supported as a Research Nurse Consultant at Ascension-All Saints, Racine, WI.
NEONATAL FECAL CALPROTECTIN: ASSOCIATION WITH MATERNAL INFLAMMATION
Presenting Author: Rebecca Hoban, University of Toronto
Background: Calprotectin, released by neutrophils after intestinal damage, is increased in stool of infants with necrotizing enterocolitis (NEC). Research suggests associations with NEC and maternal inflammatory states like obesity. It is unknown whether maternal inflammation in-utero or during lactation has associations with infant fecal calprotectin (FC).
Objective: To study relationships between preterm infant FC during full feedings (mother's [MOM] or donor milk) and common maternal inflammatory diagnoses.
Methods: Infants born <1250g enrolled in the OptiMoM fortification trial had FC measured before (n = 68, median day of life [DOL] 11) and after (n = 102, median DOL 21) fortification. A secondary analysis of prospectively collected data utilized Mann Whitney testing and Pearson correlation of infant factors (exclusive MOM [EMOM], birth gestational age [GA], DOL) and maternal inflammatory diagnoses (BMI, chorioamnionitis, cesarean delivery [CS]). Regression analyses are ongoing.
Results: Cohort with median GA 27.8 (IQR 25.4,29.6) weeks, birthweight 860g (740,1050), 46% EMOM, 36% chorioamnionitis, 63% CS, 47% overweight/obese had similar FC pre- vs post-fortification (110μg/g[30,262] vs 120μg/g[74,178], p = 0.4).
Pre-fortification, mothers with chorioamnionitis had lower median FC (70.3μg/g [23.9,176.1] vs 157.0μg/g [63.9,455.1], p = 0.05). CS trended towards higher FC (118.8μg/g [50.4,290.3] vs 63.0μg/g [20.2,207.3], p = 0.08); obese/overweight (p = 0.79) and EMOM (p = 0.96) were non-significant. Pre-fortification FC was not correlated with GA (0.11) nor DOL (−0.19). Post-fortification, no variables significantly predicted FC in univariate testing.
Conclusions: Surprisingly, chorioamnionitis was negatively associated with pre-fortification FC, potentially signaling lack of normal neutrophil defense in sick infants. In keeping with our hypothesis, CS was positively associated; BMI was not significant. Post-fortification showed no obvious maternal impact. Regression models will further study how maternal factors affect preterm infant gut health in early life.
Funding: CHIR #FHG129919 (O'Connor, PI).
TEMPORAL PROGRESSION OF FATTY ACIDS IN PRE-TERM AND TERM HUMAN MILK
Presenting Author:Sagar K. Thakkar, Nestlé Research Center, Lausanne, Switzerland
Co-authors:, C.A. De Castro, M. Affolter, C.L. Garcia-Rodenas, L. Beauport, J.F. Tolsa, C.J. Fischer-Fumeaux, F. Giuffrida
Background: Fatty acids (FA) in human milk (HM) support the growth & development of breast-fed infants.
Objective: To longitudinally quantify and compare FA from HM of mothers delivering preterm (PT) and term (T) infants.
Methods: HM (single full breast expression) from mothers who delivered PT (28 0/7–32 6/7 weeks gestation) and at T (37 0/7–41 6/7 weeks gestation) was collected for 4 months postpartum at 12 time points for PT HM (280 samples) and for 2 months postpartum at 8 time points for T HM (220 samples). FA were analysed by gas-chromatography coupled with flame ionization detector.
Results: Sum of SFA and MUFA significantly increased and decreased, respectively, from colostrum to mature milk. Significant differences (p < 0.05) for oleic acid and palmitic acid were observed between colostrum and mature milk. The relative content of short (8:0), medium chain FA (10:0 and 12:0) and alpha-linolenic acid were significantly higher in PT colostrum than in T group.
Conclusions: This study provides quantitative data on longitudinal changes of FA in PT HM. Further investigations are warranted on how to optimize fortification of mothers' own milk along stages of lactation or that of donor human milk.
Funding: Nestec Ltd.
THE MICROBIOME OF LATE PRETERM INFANTS SHOWS RAPID NICHE DIFFERENTIATION WITHIN THE FIRST WEEK OF LIFE
Presenting Author: Stephanie B. Orchanian, UC San Diego-Center for Microbiome Innovation
Co-Authors: Megan Doty, Kristina Stillwell, Jae H. Kim, Austin D. Swafford, Rob Knight (UC San Diego-Department of Pediatrics)
Background: Studies have demonstrated that skin, oral, and gut microbiomes are well-differentiated in adults, with specialized bacteria colonizing each niche. While time-series of infant gut microbiomes have examined their development toward the adult state, no study has examined the differentiation of the gut microbiome from the other host organs in infants and the impact of environmental factors on this progression.
Objective/Hypothesis: Examine evidence of niche differentiation in the microbiomes of preterm infants and the effects of related environmental factors.
Methods: Swabs were collected daily for one week from preterm infants (34–36 weeks of gestation) admitted to the UCSD neonatal intensive care unit and processed for 16S sequencing and subsequent analysis in Qiime2. Randomized subjects received mother's breast milk with either supplemental formula or donor breast milk.
Results: Oral, gut, and skin microbiomes of preterm infants began to differentiate from each other within the first week of life. Although skin and oral microbiomes initially differed by delivery mode, this effect diminished for our cohort. While the microbiomes of C-section-delivered infants significantly changed from their original composition, only oral and skin microbiomes of vaginally-delivered infants significantly changed from their initial composition within their first week. The impacts of antibiotic exposure were inconsistent across delivery modes, with oral microbiomes of vaginally-delivered infants and gut microbiome only of C-section-delivered infants showing changes. No impact of supplemental feeding was observed.
Conclusions: Rapid niche differentiation occurs within the first week of life in preterm infants regardless of environmental factors.
Funding: UCSD-CMI Seed Grant.
OPTIMAL TIME TO INITIATE BREAST MILK EXPRESSION IN MOTHERS DELIVERING EXTREMELY PREMATURE INFANTS
Presenting Author: Leslie Parker, University of Florida
Co-Authors: Sandra Sullivan, Charlene Kruger, Martina Mueller (University of Florida; Medical University of South Carolina)
Background: Feeding mother's own milk to premature infants decreases morbidity but is often limited owing to an insufficient breast milk supply and delayed secretory activation. Early initiation of breast milk expression following delivery has been shown to increase breast milk production in mothers of very low-birth-weight (VLBW) infants. However, no adequately powered randomized controlled trials (RCT) have been conducted to determine the optimal time to initiation of breast milk expression in mothers who deliver extremely premature infants.
Objective: To determine the optimal time to initiate breast milk expression in mothers of VLBW infants.
Methods: 180 women were stratified according to their infant's gestational age and were randomized to initiate breast milk expression within 60 min (group 1), 60–179 min (Group 2) or 180–360 min (group 3) following delivery. Breast milk volume and timing of secretory activation was compared between groups using Wilcoxon's rank sum tests. Breast milk volume was measured daily for the first 7 days and weekly for the first 6 weeks. Timing of secretory activation was determined through mothers' perceptions of sudden breast fullness.
Results: Although not statistically significant, mothers who initiated BM expression 1–3 hours following delivery were more likely to be lactating at discharge (51.7%) compared to those who initiated BM expression within 1 hour (42.3%) or 3–6 hours (45.4%) after delivery. The onset of secretory activation was also earlier in mothers who began expression 1–3 hours following delivery (83.1 hours versus 97.9 and 97.7 respectively. Mean time to secretory activation in all group was significantly longer than previously reported in mothers of term infants.
Conclusion: Initiation of breast milk expression 1–3 h following delivery may increase duration of lactation and decrease time to secretory activation in mothers of VLBW infants. Secretory activation is delayed in mothers delivering extremely premature infants
Funding: National Institutes of Nursing Research.
EXPERIENCES OF BREASTFEEDING SUPPORT IN MOTHERS OF PRETERM INFANTS
Presenting Author: Jenny Ericson, Dalarna University, School of Education, Health and Social Studies
Co-Author: Lina Palmér (University of Borås, Faculty of Caring Science, Work Life and Social Welfare)
Background: How mothers of preterm infants (<37 gestational weeks) experience breastfeeding support during the first year is less clear.
Objective: The aim was to describe experiences of breastfeeding support in mothers of preterm infants during the first 12 months postpartum.
Methods: Overall, 151 mothers contributed data to this qualitative study. The data were analyzed using a thematic network analysis.
Results: The results exposed two organizing themes and one global theme. In the organizing theme “genuine presence strengthens”, the mothers described how they were strengthened by being listened to and by being met with respect, understanding and knowledge. The support was individually adapted and included both practical and emotional support. In the organizing theme “authoritative presence diminishes”, the mothers described how health professionals who were controlling and intrusive diminished them and how the needed support was not provided or was inappropriate. Thus, the global theme “being thrown into a lottery – not being able to choose” emerged, meaning that the support was random in terms of knowledge, support style and approach, depending on the individual health professionals who were available.
Conclusion: This findings implies challenges for health care, which should make breastfeeding support more person-centered, equal and supportive in accordance with each mother's individual needs.
Funding: The Centre for Clinical Research Dalarna and the Uppsala-ൡrebro Regional Research Council, the Birth and the Gillbergska Foundation.
RECRUITING, RETAINING AND MINIMIZING MISSING DATA FOR BREAST-PUMP DEPENDENT MOTHERS OF PREMATURE INFANTS IN BIOMEDICAL HUMAN MILK RESEARCH
Presenting Author: Judy Janes, Rush University Medical Center
Co-Authors: Esmeralda Covarrubias, Aloka L Patel, Beverly Rossman, Paula Meier, Rebecca Hoban (University of Toronto)
Background: Studies suggest that mothers who deliver prematurely have pre-pregnancy, pregnancy, delivery and milk expression risk factors that affect lactation processes and thus, the quantity and quality of human milk (HM) available for infant feeding. However, nearly all of these studies have relied on subjective and imprecise outcome measures.
Objective: The objective of this research is to detail the processes of recruitment, retention, and minimization of missing data by a clinically based, multidisciplinary research team in a recent prospective study of 40 mothers of premature infants that measured secretory activation.
Results: From October, 2016 through March, 2017, a total of 55 mothers who met inclusion criteria were approached for enrollment. Forty (73%) were enrolled and no mothers withdrew. Thirty-nine mothers provided 755 samples for biologic measures of secretory activation and 2537 pumped HM containers for which measured weights were recorded by a team of neonatal intensive care nurses who were trained in this technique. The mothers reported that participation incentives were not important to their participation, and that the key to their “success” with completing all study procedures was the repeated information and reminders about study procedures from the clinical research staff.
Conclusions: The findings from this study can inform subsequent research with respect to the effectiveness, efficiency and value of a NICU-based, interdisciplinary, clinical HM research team for recruitment, retention and the minimization of missing data in this vulnerable NICU population.
Funding: Rush University Children's Hospital Heal the Children and the Center for Clinical Research and Scholarship at Rush University Medical Center.
RE-EXAMNING BREASTFEEDING INTENTION AND OUTCOMES
Presenting Author: Ann Dozier, University of Rochester –Public Health Sciences (PHS)
Co-Authors: Hayley Martin, Kelly Thevenet-Morrison, Holly Widanka, Christopher Seplaki (University of Rochester–PHS)
Background: Prenatal breastfeeding intent [PBI] (typically established by early pregnancy) is correlated with many breastfeeding outcome predictors, resulting in biased estimates if predictors are not controlled for, a common limitation in previous studies.
Objective: Estimating the relative odds of exclusive breastfeeding (eBF) and combination-feeding versus cessation at 1 and 3 months (outcomes) associated with PBI (exposure) controlling for key confounders.
Methods: We used survey-weighted multinomial logistic regression models to estimate the odds of eBF and combination-feeding relative to breastfeeding cessation based on PBI-status among initiators from one US county (N = 1203[9903weighted]). Confounder evaluation used directed acyclic graphs and bivariate analyses. Variables included in models were associated with the outcome and exposure (p < 0.15) and not on the proposed causal pathway.
Results: The odds of eBF (1-month postpartum) relative to cessation was 4.32 times higher among women with PBI relative to women without clear PBI (95%CI:2.76–6.73). The association between PBI and combination-feeding (relative to cessation) was not significant (OR 0.98, 95%CI:0.61–1.58) after accounting for parity, demographics(age/education/race/ethnicity/marital status/income) smoking, pregnancy intent, prenatal care initiation, and stress (partner/financial/emotional/traumatic). The odds of 3-month eBF relative to cessation was 8.14 (95% CI:3.92–16.92) times higher among women with PBI relative to women without clear PBI, and the odds of combination-feeding relative to cessation was 1.79 times (95%CI:1.23–2.60) higher among those with PBI compared to those without clear PBI.
Conclusions: Controlling for important confounders, PBI was a significant predictor of eBF at 1 and 3 months postpartum, and predicted maintenance of combination feeding at 3 months. Efforts to strengthen PBI should not be undervalued as they may improve exclusivity and duration.
Funding: NIH R01-HD055191.
THE ROLE OF MATERNAL TLR2 DURING BREASTFEEDING ON ORAL TOLERANCE DEVELOPMENT
Presenting Author: Bassel Dawod, Dalhousie University (DU) - Department of Pathology, Halifax, NS
Co-Authors: Alexander Edgar, Matthew C. Tunis (DU - Department of Microbiology & Immunology); Jean S. Marshall (DU - Department of Pathology and Department of Microbiology & Immunology)
Background: Breastfeeding has beneficial effects on the development of oral tolerance towards food allergens. Multiple factors in breast milk help shape the immune system, including cytokines, growth factors, and beneficial bacteria. Toll-like receptor-2 (TLR2) activation by pathogen products can lead to tolerance disruption. Human milk also contains Soluble TLR2 (sTLR2) that acts as a decoy receptor, but its role in oral tolerance is unknown.
Hypothesis: We hypothesized that either a TLR2 deficient maternal in utero environment or breast milk from mothers deficient in TLR2 does not support the normal development of oral tolerance.
Methods: A murine cross-fostering model was designed to evaluate the impact of maternal TLR2 and breast milk-associated factors on tolerance development. Pups from crosses of male TLR2-/- with female TLR2+/+ and male TLR2+/+ crossed with female TLR2-/- were divided into two groups, such that half of each litter remained with its biological mother while the other half was cross fostered by a mother of the alternate genotype. The pups were exposed to 20μg/ml ovalbumin daily during lactation (day 10–17) to induce tolerance, which was assessed by measuring serum anti-OVA IgE responses following i.p. OVA immunization and levels of T-regulatory cells (Tregs) in the intestine of the pups after weaning.
Results: The most effective oral tolerance generation, marked by low anti-OVA IgE (P = 0.0065) in serum and higher intestinal Tregs (P = 0.0477), occurred in the animal nursed by TLR+/+ mothers regardless of their in utero exposure to maternal TLR2.
Conclusions: Our results confirm an important role for TLR2 in the development of oral tolerance, by a breast milk dependent mechanism.
Funding: CIHR and Allergen-NCE.
A ROLE FOR EARLY ORAL EXPOSURE TO HOUSE DUST MITE PROTEASES IN FOOD ALLERGY SUSCEPTIBILITY
Presenting Author: A. Rekima, University of Western Australia – Australia
Co-Authors: C. Bonnart, J. Metcalfe, M.K. Tulic, N. Halloin, P. Macchiaverni, J. Genuneit, S. Zanelli, S. Medeiros, D. J. Palmer, S. Prescott, V. Verhasselt
Background: We recently demonstrated that allergens from house dust mite (HDM) are present in human milk and thereby could potentially affect gut mucosal immunity in offspring.
Objective: Investigate if the presence of HDM in breast milk could affect the gut mucosal immune ontogeny and disturb the long-term gut immune homeostasis to food antigens.
Methods: In 2 week-old mice orally exposed to HDM through breast milk, we assessed gut mucosal immunity and the impact on oral tolerance induction. In a birth cohort of 100 infants we evaluated if data obtained in the mice could be translated to the human.
Results: Mice exposed to HDM through breast milk showed pro-inflammatory epithelium, ILC2 activation and Th2 cell differentiation in the small intestine. This pro-Th2 gut mucosal environment hindered the induction of antigen-specific FoxP3 regulatory T cells upon oral exposure to egg-antigen (OVA) through breast milk. In the long term, the HDM-induced imbalance in gut mucosal immunity abolished the possibility to prevent food allergy by OVA exposure through breast milk. Neutralization of HDM protease activity indicated that this enzymatic activity was necessary for HDM-induced gut mucosal immune dysregulation and increased food allergy susceptibility. In a birth cohort, IgE-mediated egg allergy prevalence at one year was 4.7 times higher in infants exposed to HDM compared to infant exposed to OVA through breast milk.
Conclusions: The proteases from HDM could affect gut immune ontogeny and the risk for food allergy.
Funding: ITMO IHP-CMN (Institut National de la Santé et Recherche Médicale), Université Nice Sophia-Antipolis, Recherche en Santé Respiratoire, Société Française d'Allergologie, CAPES-COFECUB, Larsson-Rosenquist Foundation.
