Journal of Human Lactation

Background: Strong evidence-based advocacy efforts have now translated into high level political support and concrete goals for improving breastfeeding outcomes among women in the United States. In spite of this, major challenge remain for promoting, supporting and especially for protecting breastfeeding in the country.

Objectives: The goals of this commentary are to argue in favor of: A) Changes in the default social and environmental systems, that would allow women to implement their right to breastfeed their infants, B) A multi-level and comprehensive monitoring system to measure process and outcomes indicators in the country.

Methods: Evidence-based commentary.

Results: Breastfeeding rates in the United States can improve based on a well coordinated social marketing framework. This approach calls for innovative promotion through mass media, appropriate facility based and community based support (e.g., Baby Friendly Hospital Initiative, WIC-coordinated community based peer counseling), and adequate protection for working women (e.g., longer paid maternity leave, breastfeeding or breast milk extraction breaks during the working day) and women at large by adhering and enforcing the WHO ethics Code for the Marketing of Breast Milk Substitutes. Sound infant feeding practices monitoring systems, which include WIC administrative food package data, are needed.

Conclusions: Given the current high level of political support to improve breastfeeding in the United States, a window of opportunity has been opened. Establishing breastfeeding as the social norm in the USA will take time, but the global experience indicates that it can be done.

Research has documented health benefits associated with donor human milk (DHM). Offering DHM to people of the Muslim faith raises important religious concerns for these families. Knowledge of these beliefs and an understanding of the rationale for these beliefs enable the health care team to establish rapport and build a foundation of trust with patients and their families, thereby paving the way to developing a treatment plan that is in the best interest of the patients without compromising care. This article describes the issues and a rationale for them and provides physicians caring for preterm infants of Muslim families with information to facilitate advocating DHM to those families.

Initiating a pasteurized human donor milk (PDM) program in a level III neonatal intensive care unit (NICU) can be a difficult process that requires commitment by a multidisciplinary team, education, sufficient funding, and “buy-in” from NICU staff, families, and hospital administration. We began planning for our program in February 2011 and started using PDM in June 2011. This paper describes the steps taken and the obstacles overcome to initiate a PDM program for our hospital’s tiniest, sickest, and most vulnerable patients.

Background: Multiple datasets collect breastfeeding data in the United States (US), but a coordinated monitoring and surveillance system does not currently exist. The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) reaches over 50% of all infants in the US and provides a potential wealth of administrative data about the breastfeeding practices of low-income women.

Objective: The objective of this research was to assess whether WIC administrative data are a valid source of information about breastfeeding practices.

Methods: A phone survey of 2015 postpartum WIC mothers in Southern California was conducted to assess the feeding practices of mothers with infants 2-12 months old. Survey data were linked with WIC administrative records from the same month in order to assess the percent agreement between feeding behavior as reported by survey methods and as documented in WIC administrative records.

Results: The unweighted κ test statistic was used to test the agreement between survey responses and WIC administrative data. Substantial to almost perfect agreement was found between the two measures.

Conclusions: WIC administrative data are a valid source of information about breastfeeding. With appropriate funding support, WIC administrative data should be considered for use in nationwide breastfeeding surveillance and monitoring systems.

Background: Accurate hospital exclusive breastfeeding (EBF) rates, a core indicator of hospital performance, are important.

Objective: The aim of this study was to assess the accuracy of hospital infant feeding data by comparing EBF rates obtained from standard charts in which once-daily observations are recorded with new infant feeding charts in which every feed was documented.

Methods: In this cross-sectional study, 157 healthy mother-infant pairs were enrolled at the University Hospital of Split, Croatia, between February and May 2008. Infant feeding data were gathered from 4 sources: (1) standard once-daily observations recorded by pediatricians; (2) new, every-feed observations recorded by nursing staff; (3) interview with the mother before discharge; and (4) Newborn Examination Form, completed on discharge by the pediatrician. WHO definitions were used to determine EBF during the first 48 hours and from birth until discharge.

Results: Only 3% of infants were EBF throughout the hospital stay when calculated with the every-feed method, as opposed to 56% and 82%, with the once-daily and newborn examination methods, respectively (P < .001). Maternal report confirmed the finding that 97% of infants were supplemented with formula, indicating that most formula supplements are not recorded in the standard once-daily charts.

Conclusions: Accurate documentation of infant feeding practices is essential for obtaining reliable EBF rates. This study shows that once-daily recordings of infant feeding practices grossly underestimate the prevalence of formula supplementation in breastfed infants, resulting in significantly higher, erroneous EBF rates.

Background: Despite the increased metabolic activity of the lactating breast, no studies have been carried out to determine mammary blood flow (MBF) parameters or the relationship between MBF and milk production in women. The aim of this study was to measure the MBF in the internal mammary artery (IMA) and lateral thoracic artery (LTA) of lactating women and determine if these were related to milk production.

Methods: Blood flow in the IMA and LTA was measured with color Doppler ultrasound in 55 lactating women. Twenty-four-hour milk production was determined with the test-weigh method.

Results: IMA contributed the greater proportion of blood flow to the lactating breast (70%). MBF was highly variable between women but consistent between the left (126 L/24 h; interquartile range, 76-169) and right (110 L/24 h) breasts. No relationship between MBF and milk production was demonstrated. For 3 women, MBF was markedly reduced in 1 breast that was synthesizing almost no milk compared to the other that was producing a normal volume of milk.

Discussion: Although no relationship between MBF and milk production was found, the substantial reduction in blood flow in the breasts of lactating women producing almost no milk suggests a threshold below which milk production is compromised.

Conclusion: Doppler ultrasound did not demonstrate a relationship between MBF and milk production in lactating women. Further investigation is required to fully understand the role of blood flow in milk synthesis.

Background: Rates of exclusive breastfeeding during the postpartum hospital stay are a key measure of quality maternity care. Often, however, concern for excessive in-hospital weight loss leads to formula supplementation of breastfed infants. The American Academy of Pediatrics defines 7% weight loss as acceptable for breastfed newborns regardless of mode of delivery. Typical weight loss in exclusively breastfed infants delivered by cesarean birth has not been studied nor have possible correlates of greater weight loss in this population.

Objectives: To determine average weight loss in a cohort of exclusively breastfed infants delivered by cesarean birth and to identify correlates of greater than expected weight loss.

Methods: We performed a retrospective chart review of exclusively breastfed infants delivered via cesarean birth at a Baby-Friendly hospital between 2005 and 2007. Average weight loss was calculated, and multivariate regression analysis was performed.

Results: Average weight loss during the hospital stay in our cohort of 200 infants was 7.2% ± 2.1% of birth weight, slightly greater than the American Academy of Pediatrics guideline of 7%.Absence of labor prior to delivery was significantly associated with a greater percentage of weight loss (P = .0004), as were lower gestational age (P = .0004) and higher birth weight (P < .0001). Maternal age, gravity, parity, infant sex, Apgar scores, and prior cesarean birth were not significantly associated.

Conclusions: We conclude that for exclusively breastfed infants delivered by cesarean birth in a Baby-Friendly hospital, absence of labor prior to cesarean birth may be a previously unreported risk factor for greater than expected weight loss.

Background: Concerns over vitamin D deficiency in infants and children recently prompted the American Academy of Pediatrics to recommend increased supplementation. Few studies have examined vitamin D status in the same infants over time. Also, while many researchers label “breastfeeding” as a risk factor for vitamin D deficiency, few differentiate between any breastfeeding, exclusive breastfeeding, and supplemented or unsupplemented breastfeeders.

Objective: To determine predictors of 25(OH)D deficiency at 4 months in a group of children previously tested at birth.

Methods: We enrolled newborns from 2005 to 2007 at an urban Boston hospital. Maternal and infant blood samples were collected within 72 hours of birth. At 4 months, we obtained a second infant blood sample.

Results: At 4 months, 11.9% of the 177 infants were vitamin D deficient compared to 37.5% at birth (25(OH)D <20 ng/mL). Median 25(OH)D was 35.2 ng/mL (range, 5-100.8; 95% confidence interval [CI], 32.8-37.6). At 4 months, 40% of unsupplemented infants were deficient. Lack of supplementation was significantly associated with increased risk of deficiency (adjusted odds ratio [AOR], 19.3; 95% CI, 4.80-77.2). Being outside at least 10 minutes a day, once per week, was protective (AOR, 0.12; 95% CI, 0.02-0.66), as was increasing gestational age (AOR, 0.36; 95% CI, 0.19-0.69). In 48.4% of patients, physicians failed to prescribe vitamin D at 2 months.

Conclusions: Despite inconsistent supplementation, a smaller proportion of infants were vitamin D deficient at 4 months than at birth. While supplemented breastfed infants were not at risk of deficiency, unsupplemented exclusively breastfed infants were at high risk of severe deficiency.

Background: Breastfeeding rates are typically higher among Hispanic women; however, they vary by acculturation status in that those more acculturated are less likely to breastfeed than those who are less acculturated. This study examined the association between acculturation and breastfeeding behaviors using population-based data.

Methods: Data (N = 8942) from the Pregnancy Risk Assessment Monitoring System (PRAMS) were used for analysis. Acculturation status was determined using self-reported Hispanic ethnicity and the language in which the women responded to the PRAMS survey, either English or Spanish. Hispanic women who responded to the survey in Spanish were categorized as less acculturated than those who responded in English. Breastfeeding indicators used were: initiation, duration to ≥ 10 weeks, and exclusive breastfeeding to ≥ 10 weeks.

Results: The prevalence rates of breastfeeding initiation, duration, and exclusive breastfeeding to ≥ 10 weeks were significantly higher among less acculturated than among highly acculturated. More acculturated were less likely to initiate breastfeeding (prevalence ratio [PR] = 0.88; 95% CI, 0.86-0.90), less likely to breastfeed ≥ 10 weeks (PR = 0.77; 95% CI, 0.72-0.82), and less likely to report exclusive breastfeeding to ≥ 10 weeks (PR =,0.70; 95% CI, 0.58-0.85). The relationship between breastfeeding continuation and acculturation persisted after adjusting for covariates in that more acculturated were less likely to breastfeed to ≥ 10 weeks (adjusted prevalence ratio [APR] = 0.81; 95% CI, 0.75-0.87), as did the relationship between exclusivity and acculturation; more acculturated were less likely to report exclusive breastfeeding (APR = 0.69; 95% CI, 0.55-0.87).

Conclusions: Breastfeeding promotion efforts must include culturally/linguistically supportive services to assure that women are able to make optimal infant feeding decisions.

Background: Infant formula usage places children at risk for illness and death. Studies in the United States demonstrated high economic burden, health care costs, and absenteeism of caregivers associated with formula usage. Despite high formula usage in developing countries, no economic studies were found. This study examines the financial burden of purchasing infant formula and increased health care expenditure in the Philippines, a developing country with a per capita income of $3930. The average exchange rate of the peso to the US dollar for 2003 was $1 to P52, according to Bangko Sentral ng Pilipinas (BSP).

Methods: This is a secondary analysis of the 2003 Family Income and Expenditure Survey, a national cross-sectional multistage cluster survey of 42 094 households.

Results: Almost half of Philippine families with a young child and one-third of families living on less than $2 per day purchase formula. Nationally, $260 million was spent on infant formula in 2003. Formula-buying families with young children had spent an aggregate of $143.9 million on medical care compared to $56.6 million by non-formula-buying families. After adjusting for income and nonmilk family expenditures, the average formula-purchasing Philippine family spent an additional $0.30 (95% CI: 0.24 – 0.36; r² = 0.08) on medical expenditure for every $1 spent on formula.

Conclusions: The economic burden from infant formula purchase and out-of-pocket medical expenditure exceeded $400 million in 2003. This cost was aside from other costs, such as absenteeism and the risk of childhood death and illness. These expenses caused an unnecessary burden on Filipino families and could instead have been invested in education and other social services.

This prospective cohort study compares the breastfeeding outcomes of women exposed to selective serotonin reuptake inhibitor (SSRI) antidepressants at the time of delivery, those who discontinued use prior to delivery, and those not exposed. Participants include 466 pregnant women who enrolled in the California Teratogen Information Service Clinical Research Program (CTIS) over 10 years. In bivariate analyses, breastfeeding rates were significantly different across SSRI exposure groups, with unexposed women having the highest rates. We used logistic regression to examine the relationship between SSRI exposure and breastfeeding outcomes. After adjustment for potential confounders, those exposed to an SSRI both prior to delivery (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.20-0.94) and at the time of delivery (OR, 0.34; 95% CI, 0.16-0.72) were significantly less likely to initiate breastfeeding as compared to unexposed women. Women exposed to an SSRI during pregnancy appear to be at risk for poorer breastfeeding outcomes and may benefit from additional education and support.

The aim of the present study was to examine the association between depressive symptoms in pregnancy and the concentration of long-chain polyunsaturated fatty acids (LCPUFAs) in breast milk. Women (n = 287) enrolled in the Pregnancy, Infection, and Nutrition Study completed the Center for Epidemiologic Studies Depression Scale in pregnancy (< 20 and 24-29 weeks) and had LCPUFAs measured in breast milk (4 months postpartum). Multiple linear regression was used to examine associations between depressive symptoms and breast milk LCPUFAs. Increasing depressive symptoms at < 20 weeks were associated with lower docosahexaenoic acid concentrations (adjusted β = −1.15, 95% confidence interval = −2.12, −0.19). No similar associations were observed with other fatty acids nor between symptoms at 24-29 weeks and LCPUFAs. Depressive symptoms, even in the subclinical range, early in pregnancy are inversely associated with breast milk docosahexaenoic acid. This may have implications for the timing of screening and interventions for perinatal depression and the nutritional value of breast milk.

Background: Several studies in Palestine, including some performed in refugee camps, showed that breastfeeding is a common practice, however, exclusive breastfeeding was practiced less frequently. The social and cultural patterns in relation to different types of infant feeding were not studied.

Objectives: This study aimed to evaluate the association between mothers’ and infants’ sociodemographic factors and breastfeeding patterns during the first 6 months of infant life.

Methods: This cross-sectional study evaluated data of 690 clinic files from 3 refugee camps in Nablus, Palestine in 2007. Maternal age, age at marriage, parity, mother’s and father’s education, type of delivery and infant’s gender were studied in relation to 3 types of breastfeeding: exclusive breastfeeding, partial breastfeeding, and exclusive formula feeding in the first 6 months of life. Bivariate analysis and logistic regression were applied for data analysis.

Results: A total of 69.7% of infants aged 0–6 months were exclusively breastfed and only 14.3% were exclusively formula fed. Older mothers at marriage (risk ratio [RR], 0.13; 95% confidence interval [CI], 0.06–0.28), and cesarean birth (RR, 0.59; 95% CI, 0.41–0.81) were negatively associated with EBF.

Conclusion: Breastfeeding educational and health promotion program and policy for EBF implemented by UNRWA (United Nations Relief and Works Agency for Palestine Refugees in the Near East) should continue with special attention to older mothers at marriage, and to babies born by cesarean section.

Although a personally defined experience, successful breastfeeding is usually measured with regard to duration. This study investigated the determinants of maternal satisfaction with breastfeeding experience for 907 mothers enrolled in a prospective cohort study. Despite a median breastfeeding duration (18 weeks) that fell short of recommendations, 822 mothers (90.6%) rated their breastfeeding experience as very or fairly satisfactory. Anticipated breastfeeding duration was a determinant of satisfaction only for women who actually breastfeed < 2 months; in this subgroup of mothers, satisfaction rates ranged from 84.6% for those who anticipated breastfeeding < 2 months to 69.8% for those who anticipated breastfeeding > 4 months (P = .01). Smoking during pregnancy and experiencing breastfeeding difficulties after discharge were independently associated with decreased satisfaction. Eliciting the mother’s expectations regarding breastfeeding duration may help the lactation consultant in providing appropriate guidance. Future studies should assess maternal satisfaction using validated instruments.

Background: Use of videoconferencing technology for healthcare intervention and support is an area of tremendous potential, especially in regard to application in rural or underserved communities. Potential for cost-savings, time-savings, and increased access to care are the ultimate driving force behind use of this technology, for both providers and recipients of healthcare services. Recently, the Federal Government has initiated rulings to support the increased use of computer technology in underserved areas. Therefore, exploring novel applications of the technology of videoconferencing is timely. Remote lactation consultation may be one such novel application.

Objectives: The primary objective of this pilot study was to describe the maternal experience of lactation consultation by means of videoconferencing, compared with standard face-to-face care, using grounded theory for model development.

Methods: Twelve mothers participated in both a videoconferencing and a face-to-face consultation during one visit to the study site. Using grounded theory methods, responses to an in-depth phone interview occurring 3 days post-consultation were analyzed for major themes and a theoretical model proposed.

Results: Three major themes emerged including maternal characteristics and interaction with technology, accuracy and trust determines acceptability for consultation type and, conditional acceptance of remote consultation use.

Conclusions: Emergent themes were grounded in existing literature, and potential scales were identified to assist with development of a future tool to test the theoretical model. Responses to the videoconferencing experience were positive, but preferred use of the technology was situational.

Despite the evidence that there are considerable benefits of breastfeeding, there are still gaps in understanding why many women have difficulties initiating and maintaining breastfeeding. In this prospective longitudinal study, the factors affecting the initiation and duration of breastfeeding were expanded to include attachment representations, which are known to influence health behaviors as well as one’s ability to cope with stressful situations. Participants (n = 460) completed attachment and depression questionnaires during a prenatal clinic appointment, and in the postpartum period, mothers reported on their mood and breastfeeding behaviors. Consistent with attachment theory and previous research, women with attachment approach orientations were more likely to breastfeed, breastfeed longer, and continue breastfeeding when they experienced initial difficulties. The results of this study demonstrate that it is important to look beyond demographics to understand breastfeeding initiation and duration and provide further evidence that attachment representations influence health decisions.

Breastfeeding has extensive health benefits for both infants and mothers. Despite these benefits, a significant number of women, disproportionately low-income women, do not initiate breastfeeding. Previous research has also demonstrated that breastfeeding prevalence varies by urbanicity level. The objective was to examine race/ethnicity and urbanicity trends in breastfeeding initiation among low-income women in North Carolina from 2003 to 2007. Breastfeeding initiation data from the North Carolina Pregnancy Nutrition Surveillance System were utilized, with responses from 240,054 women over the 5-year period. Overall, 65.4% of women in mixed-urban counties and 62.1% of women in urban counties initiated breastfeeding compared to only 49.8% of women in rural counties. The disparity between rural and urban counties widened over time, with urban and mixed-urban counties making significantly greater gains in breastfeeding initiation than rural counties. Hispanic and non-Hispanic white women had 6.17 (95% confidence interval [CI], 5.99-6.36) and 1.4 (95% CI, 1.46-1.53) times the odds of initiating breastfeeding as non-Hispanic blacks, respectively. Finally, stratified multivariate regression models identified that the association between race/ethnicity and breastfeeding varied by urbanicity level. The current study provides a clearer picture of rural and urban breastfeeding trends within North Carolina and has implications for states with similar racial/ethnic and urbanicity levels. The research determined that women in rural areas, particularly non-Hispanic blacks, are less likely to initiate breastfeeding. Increased emphasis should be placed on developing breastfeeding interventions for rural communities, particularly targeting the non-Hispanic black population.