Abstract
The first 2–4 weeks postpartum is a high-risk period for unplanned cessation of lactation in both healthy term dyads and in breast pump-dependent mothers with infants in the neonatal intensive care unit (NICU). The vast majority of studies and practices that target this short but critical interval recommend additional “support” but fall short of delineating specific assessments, interventions, and evaluations that comprise “support.” We undertook this special issue to highlight the biology of this early postpartum period, which is extraordinarily complex, distinct from later lactation phases, and often overlooked by researchers and clinicians. Similarly, economic barriers specific to this early time interval have not been evaluated, despite the vast amount of maternal time and family resources invested in the achievements of secretory activation (SA) and establishing a threshold volume of mothers’ own milk (MOM) to nourish the infant.
The authors of articles in this issue compose an invited work group conceptualized by senior mentors Drs. Meier, Parker, Johnson, and Hoban. This multidisciplinary group met in June, 2024, with the goals of delineating barriers to the achievement of optimal lactation outcomes during the first 2–4 weeks postpartum and to conceptualize research and clinical priorities in this area. Our work is summarized in this special issue and includes: a framework for the study and practice of early, unplanned cessation of lactation; an integrative review of point-of-care (POC) techniques that can be leveraged to address this problem; five original research articles; and a commentary that translates these concepts and principles into actionable practices for breastfeeding medicine practitioners.
Bookhart et al. propose a novel framework for the comprehensive study and practice of early, unplanned lactation cessation incorporating biological, behavioral, and economic factors that influence the initiation and maintenance of early lactation. This article summarizes the multiple emerging maternal biological risk factors that compromise the achievement of SA and early MOM volume and addresses often overlooked economic barriers that impact this early postpartum period. In the second article, Bookhart et al. present an integrative review of point of care (POC) techniques that hold promise for addressing early unplanned lactation cessation in term dyads. These techniques, with origins in the dairy industry and human milk field studies, include serial infant weight measures, MOM transfer or test-weighing, and MOM sodium measures to assess achievement of SA and maintenance of paracellular pathway closure thereafter.
The five original research articles that follow enrolled both term healthy dyads and NICU mothers with preterm infants and used one or more of the POC measures outlined in the integrative review. As a group, these manuscripts report delayed and/or impaired SA achievement in most NICU mothers and in a subset of healthy dyads. Similarly, reopening of paracellular pathways following achievement of SA, which impacts MOM volume, occurred in over half of NICU mothers and in a subset of healthy dyads. Kivlighan et al. report a pilot study in healthy term dyads that informs the feasibility and utility of POC measures outlined in the integrative review, including in-home MOM sample collection for sodium measurement. In a study of breast pump-dependent mothers of preterm infants, Medina-Poeliniz et al. report that each additional hour spent pumping during the first five postpartum days increased the odds of SA achievement by 2.8 and yielded an additional 1278 mLs cumulative MOM on day seven postpartum. Johnson et al. report both the pumping trajectories and maternal time costs involved in achieving SA, maintaining paracellular closure after SA, and achieving coming to volume (CTV; ≥ 500 mLs MOM per day by day 14 postpartum) in breast pump-dependent mothers of preterm infants hospitalized in the NICU. In the largest sample to date, Hoban et al. report the impact of maternal metabolic and inflammatory health conditions on the achievement of early lactation outcomes in breast pump-dependent mothers of preterm infants hospitalized in the NICU. Bendixen et al. examine methodological issues relevant to the collection of MOM samples for POC measurement of SA achievement. Finally, Eglash provides a commentary from the perspective of a breastfeeding medicine physician, emphasizing the need for additional evidence-based provider education and practice algorithms to address early, unplanned cessation of lactation.
We have chosen to use the terms “mothers” and “breastfeeding” throughout this issue in accordance with the cited publications’ original nomenclature and for clarity and consistency. Important concepts relevant to social determinants of health are integrated throughout these articles rather than summarized in a separate article. Finally, we acknowledge the receipt of a unrestricted educational grant from Medela (McHenry, IL) to the University of Florida that permitted the abovementioned June 2024 meeting of our original workgroup.