Journal of Human Lactation

Accurate measurement of exclusive breastfeeding is important in maternal and child health research. Exclusive breastfeeding is often measured using the 24-hour recall or the since birth method for the first 6 months. These methods can produce different estimates, introducing problems in interpreting breastfeeding behavior and making accurate comparisons across settings or countries.

Our aim was to compare the exclusive breastfeeding rates between the 24-hour recall and since birth methods among a diverse cohort of birthing people using the ecological momentary assessments method. In addition, we compared the exclusive breastfeeding rates between the two methods across race and other maternal characteristics.

This study is a secondary analysis using data from the Postpartum Mothers Mobile Study (PMOMS), a prospective longitudinal study which recruited participants during pregnancy and followed them for 12 months after delivery. Participants completed surveys in real-time via ecological momentary assessment. Individual exclusive breastfeeding rates from months 1–6 were computed using 24-hour recall and since birth methods for 284 participants. We calculated the percentage point difference between the two methods across child age and maternal characteristics. We used a two-sample test of proportions to determine if the differences observed in the proportions were significant.

Exclusive breastfeeding rates from the 24-hour recall were higher than the since birth rates across all ages and maternal characteristics. The difference between the two methods at 3 months was 25.7 percentage points and at 6 months was a 17.2 percentage points. Irrespective of the method used to measure exclusive breastfeeding, White participants had higher exclusive breastfeeding rates than Black participants.

The 24-hour recall and the since birth methods of assessing exclusive breastfeeding provided substantially different estimates. These findings highlight the importance of specificity in measuring and reporting exclusive breastfeeding.

Breastfeeding self-efficacy has been proven to play a predictive role in enhancing breastfeeding initiation and continuation. Breastfeeding self-efficacy measurement tools have facilitated healthcare professionals’ early identification and support of women at higher risk of early discontinuation of breastfeeding.

The aim of this study was to assess the psychometric properties of breastfeeding self-efficacy measurement tools.

A systematic review was carried out in three phases. Phase One comprised a systematic literature review performed in PubMed, SCOPUS, Web of Science, and Cochrane Database of Systematic Reviews from February 2021 to January 2023, including 36 studies for final analysis. Phase Two provided a quality appraisal of the psychometric properties of each of the seven breastfeeding self-efficacy measurement tools, according to COnsensus-based Standards for the selection of health Measurement Instrument checklist (COSMIN) guidelines. Phase Three summarized and graded the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) modified approach.

The included articles comprised 9,225 participants and seven breastfeeding self-efficacy measurement tools. The Breastfeeding Self-Efficacy Scale, Breastfeeding Self-Efficacy Scale – Short Form (BSES-SF), and Prenatal Breastfeeding Self-Efficacy Scale were supported by Grade A evidence sustaining their validity and reliability to assess breastfeeding self-efficacy in the continuum of maternity care. The BSES-SF is the most feasible tool in clinical practice and the most utilized internationally, available in 15 languages.

This systematic review provided a Grade A recommendation on breastfeeding measurement tools that will be helpful both for clinical and research purposes.

Registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42021238450)

There are well-documented disparities in rates of continued breastfeeding. Existing research regarding breastfeeding during COVID-19 has raised concerns that the pandemic may have exacerbated these disparities.

The aim of this research was first to quantify disparities in any breastfeeding associated with the maternal factors of race/ethnicity, age, insurance payor, and zip code rates of education in North Carolina. Second, we aimed to investigate any changes in these disparities before and during the COVID-19 pandemic.

This was an observational study, with a retrospective, longitudinal design. Participants included infants who were born in one of eight medical centers across North Carolina from either September 1, 2019 to October 31, 2019 (pre-COVID: n = 1,104) or from April 1, 2020 to May 31, 2020, (during COVID: n = 1,157), and whose caregivers reported whether they were breastfeeding at either a 3-month or 6-month postnatal follow-up (N = 2,261). Mixed effects logistic models, including random effects of zip code, assessed predictors associated with probability of breastfeeding cessation at 3- and 6-month child well-check.

Overall, younger maternal age, being non-Hispanic Black, not having commercial insurance, and residing in a zip code with lower rates of higher education, were all independently associated with earlier breastfeeding cessation across both cohorts. Disparities did not significantly change during the COVID-19 pandemic.

We did not find support for the hypothesis that the COVID-19 pandemic might have exacerbated breastfeeding disparities. Nevertheless, there is a continued need to eliminate existing disparities.

The SARS-CoV-2 pandemic and its influence on peripartum processes worldwide led to issues in breastfeeding support.

The aim of this study was to describe breastfeeding behavior and peripartum in-hospital management during the pandemic in Germany and Austria.

This study was a descriptive study using a combination of secondary longitudinal data and a cross-sectional online survey. Registry data from the prospective multicenter COVID-19 Related Obstetric and Neonatal Outcome Study (CRONOS) cohort study (longitudinal, medical records of 1,815 parent-neonate pairs with confirmed SARS-CoV-2 infection during pregnancy) and a cross-sectional online survey of CRONOS hospitals’ physicians (N = 67) were used for a descriptive comparison of feeding outcomes and postpartum management.

In 93.7% (n = 1700) of the cases in which information on the neonate's diet was provided, feeding was with the mother’s own milk. Among neonates not receiving their mother’s own milk, 24.3% (n = 26) reported SARS-CoV-2 infection as the reason. Peripartum maternal SARS-CoV-2 infection, severe maternal COVID-19 including the need for intensive care unit (ICU) treatment or invasive ventilation, preterm birth, mandatory delivery due to COVID-19, and neonatal ICU admission were associated with lower rates of breastfeeding. Rooming-in positively influenced breastfeeding without affecting neonatal SARS-CoV-2 frequency (4.2% vs. 5.6%). CRONOS hospitals reported that feeding an infant their mother’s own milk continued to be supported during the pandemic. In cases of severe COVID-19, four of five hospitals encouraged breastfeeding.

Maintaining rooming-in and breastfeeding support services in the CRONOS hospitals during the pandemic resulted in high breastfeeding rates.

Wet nursing and human milk banks are vital sources of human milk for infants unable to breastfeed.

This study aims to determine the knowledge and opinions of neonatal intensive care unit nurses regarding wet-nursing and human milk banks in Türkiye.

This descriptive cross-sectional study was conducted with 219 neonatal intensive care unit nurses using an online survey comprising 20 questions. The data were collected between August and September 2021.

Among the participants, 64.4% (n = 141) expressed that they would be a wet-nurse and 59.8% (n = 131) would search for a wet-nurse if necessary. Some, 47.0% (n = 103) of participants did not know if there were any human milk banks in Türkiye, 53.9% (n = 118) would like to be a donor if human milk banks were established, and 71.7% (n = 157) stated that the establishment of human milk banks should be supported. Religious concerns were the basis for reluctance to donate milk to human milk banks for 60% (n = 51) of the participants. Knowledge was greater and opinions about wet-nursing and human milk banks were more positive for participants with higher education, more time in the neonatal intensive care unit, or work at a tertiary care center.

The approaches of neonatal intensive care unit nurses towards personally being wet-nurses and milk sharing were generally positive, although more information about human milk banks is needed. Religious beliefs are an important consideration when providing information about milk sharing.

With improvement in a population’s welfare, its food consumption patterns may change, including those of nursing mothers. This, in turn, could influence their human milk composition.

To investigate the secular trend in macronutrient composition of mature human milk from mothers of healthy, full-term infants in urban populations in Indonesia from 1974 and 2019.

We compared the macronutrient composition of mature human milk of healthy full-term infants from 1974 and 2019. The data from 2019 used the Human Milk Analyzer MIRIS to quantify the milk’s carbohydrate, fat, and protein content, while the historical data used methods available at that time, that is, methods described by Benedict, Gerber and Kjeldahl, respectively.

There were no significant differences in carbohydrate, protein and fat content across categories of maternal nutritional status in the respective periods. However, the fat content of human milk from 2019 was significantly higher than that of 1974 (4.7 g/dl, SD = 1.7 g/dl vs. 3.3 g/dl, SD = 1.1 g/dl; p < 0.001), while its carbohydrate content was significantly lower (6.2 g/dl, SD = 2.1 g/dl vs. 7.1 g/dl, SD = 0.2 g/dl; p < 0.001). There was no difference in the protein content between the two periods (1.4 g/dl, SD = 0.5 g/dl vs. 1.6 g/dl, SD = 0.3 g/dl; p = 0.491).

The mature human milk from 2019 has a higher fat and total energy content but lower carbohydrate content than those observed 4 decades ago. The protein content remained the same.

Mother’s breastmilk is the gold standard for feeding preterm infants. Preterm delivery may be precipitated by inflammatory maternal states, but little is known about milk cytokine profiles and how they correlate with markers of infant gut inflammation (i.e., stool calprotectin) in this vulnerable population.

To assess cytokines and inflammatory markers in milk from parents of very preterm infants over time as well as correlations between milk and infant’s stool calprotectin.

This is a secondary analysis of milk samples collected during OptiMoM, a triple-blind randomized clinical trial of infants born < 1250 g (NCT02137473). Longitudinally collected samples were analyzed for cytokines, choline, and inflammatory markers (C-reactive protein [CRP], IFN-γ, IL-10, IL-1β, IL-1ra, IL-6, IL-8, TNF-α). Infant stools were collected for longitudinal calprotectin analysis. Generalized estimating equations quantified longitudinal profiles of milk markers and stool calprotectin, their associations, and the correlation between free choline and C-reactive protein over follow-up.

Participants included 92 parents and infants (median weeks of gestation 27.3, median birth weight 845 g, and prevalence of male infants 45%). In all, 212 milk samples and 94 corresponding stool calprotectin levels were collected 1–11 weeks postpartum. C-reactive protein was present in much higher concentrations than other markers, and was highest in Week 1 postpartum. It decreased over time. IL-8 and free choline also changed over time while other markers did not. There was no correlation between any milk markers and stool calprotectin.

Milk from mothers of very preterm infants has detectable inflammatory markers, some of which change over time. Research is needed to determine if infant outcomes are associated with these markers.

Although WhatsApp can be used to provide continuous lactation support, there are few studies on this subject.

To determine the influence of lactation support provided through WhatsApp on the duration and exclusivity of breastfeeding, initiation of complementary feeding, breastfeeding problems, breastfeeding difficulties score, and the use of bottles and pacifiers.

We conducted a randomized controlled trial assessing the efficacy of education and support provided through the cell phone based WhatsApp application. There were 129 primiparous participants recruited while attending a Baby-Friendly Hospital in Istanbul, Turkey. Participants were randomized to intervention (n = 64) and control (n = 65) groups. All participants received the same routine postpartum breastfeeding education in the hospital, and the intervention group received additional continuous breastfeeding education for 6 months. For both groups, data was collected by telephone interview on Days 7 and 15, and Months 1, 2, 4, and 6 months. T-tests were used to assess inter-group differences in duration of exclusivity of breastfeeding. Mixed-model ANOVA was used to compare breastfeeding difficulties scores. Chi-square tests were used to compare breastfeeding problems, feeding practices, and the proportion of the use of bottles and pacifiers.

The mean duration of exclusive breastfeeding for groups receiving breastfeeding support was higher (4.75, SD = 1.72) than that of the control group (2.21, SD = 1.98; p = 0.001). The change in the mean breastfeeding difficulties severity score between the initial and final measurements (17.03, SD = 8.66) was more in the intervention group than the control group (11.42, SD = 10.34, F = 4.081, p = 0.001). The proportion of exclusive breastfeeding in the 6th month was higher in the intervention group (62.5%) than in the control group (10.8%; p = 0.001).

The use of cellphone applications are accessible to both patients and health workers and offer a low-cost alternative for providing uninterrupted breastfeeding support.

Breastfeeding confers significant maternal and infant benefits; however, breastfeeding rates remain suboptimal in the United States. A parent’s decision to breastfeed is influenced by non-modifiable and modifiable factors, including breastfeeding knowledge and self-efficacy. There is a positive correlation between high maternal self-efficacy and breastfeeding duration. Parents increasingly rely on technology for health information.

To determine if a smartphone application affected maternal self-efficacy and breastfeeding exclusivity rates.

This study was a randomized, controlled pilot study examining the effect of an educational program, included in a smartphone application, on breastfeeding self-efficacy (assessed in postpartum Week 1 and Weeks 4–6) and breastfeeding rates (assessed in postpartum Weeks 4–6). Forty participants were recruited using block randomization to intervention (17 of 20 completed the study) and usual care (19 of 20 completed the study) groups. To examine the pre-test/post-test difference in the Breastfeeding Self-Efficacy Scale – Short Form total scores, a change in score (post-intervention minus pre-intervention) was calculated for each parent.

The intervention group (phone application and usual care) showed greater change in self-efficacy scores (M = 7.6, SD = 7.8) compared to the control group (usual care; M = 1.2, SD = 3.7, p = .001). The rate of exclusive breastfeeding was nearly twice as high in the intervention group as in the control group, but did not reach statistical significance (p = .093).

The investigators found enhanced breastfeeding self-efficacy and breastfeeding rates among postpartum women receiving a smartphone educational program in the first 6 weeks postpartum. Further studies on smartphone interventions will develop our understanding of this technology in improving breastfeeding rates.

Evidence is lacking on the phenomenon of peer-to-peer human milk-sharing in the Middle East, specifically, in Israel.

This study aimed to uncover peer-to-peer human milk-sharing in Israel, learn about how and whether donors engage in safe milk handling and storage practices, and assess knowledge about human milk and breastfeeding among this milk-sharing population. We also aimed to investigate donors’ selectiveness in their decisions about to whom they donate their milk and their perceptions about the sale and purchase of human milk.

We conducted a semi-structured online survey, including both closed- and open-ended questions and used mixed methods to analyze responses descriptively. We used non-probability sampling to obtain a broad sample of human milk donors.

Out of 250 completed surveys, most participants (87.2%, n = 218) reported engaging in safe milk-sharing practices and were generally knowledgeable about the health risks associated with milk-sharing. Participant religiosity was associated with somewhat lower hygiene practices (r = −0.15, p ≤ .05). Most of the participants (81.7%, n = 190) were against the sale of human milk. Participants generally expressed no preference about the recipient of their milk, with some exceptions.

The milk-handling and storage practices of the participants in this study suggest a need to improve knowledge and awareness of safe milk storage temperature and the importance of washing hands before pumping milk, particularly within the religious sector. We propose that guidelines about safe milk-sharing practices be written and adopted by the Israeli Ministry of Health, and communicated through pediatricians, family doctors, nurses in Mother and Child Clinics (In Hebrew: Tipat Halav), and social media.

With the advancement of antiretroviral therapy scale-up, it is possible for women living with HIV to breastfeed safely. However, this practice has not been adopted in Malaysia. Instead, infants are provided with subsidized human milk substitutes for their first 2 years of life.

This study describes the infant feeding experiences of women living with HIV in Malaysia.

From August to October 2021, a nationwide, community-based qualitative study was conducted among women living with HIV and who received care from the Malaysian Ministry of Health. Using purposive sampling, participants who met the inclusion criteria were recruited. Interview and focus group transcripts were coded based on a secondary thematic analysis.

Six in-depth interviews and five focus group discussions were conducted among 32 participants. Study participants were mostly Malay secondary school graduates in their 30s and 40s. Due to the fear of vertical transmission, which was explained by healthcare providers to the participants, none of the women breastfed their infants. The three primary themes that emerged from analyzing the women’s infant feeding experiences were (1) a human milk substitute was the only option and was encouraged; (2) feeding infants with a human milk substitute made the women feel incomplete as mothers; and (3) the women encountered difficulties in obtaining the subsidized human milk substitute.

Women living with HIV in Malaysia have been advised to provide human milk substitutes to their infants in fear of HIV transmission.

Parents who express milk by pumping often feel this is judged as inferior to direct breastfeeding by healthcare providers, leaving parents feeling unsupported. Healthcare provider attitudes can influence decisions about human milk feeding directly at the chest. Yet, there is a gap in knowledge regarding lactation care provider attitudes about pumping.

To explore the attitudes and feelings of lactation care providers about pumping.

A qualitative descriptive design was utilized. Researchers conducted semi-structured interviews with a convenience sample of 15 lactation care providers in the United States, recruited via social media. Data were analyzed using thematic analysis.

Four themes emerged: (1) I Support You, (2) But It’s Not the Same, (3) Frustration with Social Media, and (4) Changing Perspectives. Participants held positive attitudes toward pumping as a tool to meet human milk feeding goals. They strived to provide judgement-free support but stressed the importance of setting realistic expectations and sharing the difference in benefits and work between direct breastfeeding and pumping. Providers held negative attitudes about the portrayal of pumping on social media. The participants’ perspectives were that, while there has been stigma surrounding pumping in the past, views are changing.

Lactation care providers strive to provide judgement-free support for pumping, but communicating challenges about pumping may be perceived negatively by parents. More research is needed on lactation care provider education on pumping, interventions to reduce bias, and how these affect providers’ pumping beliefs, attitudes, and provision of judgement-free delivery of care.

As breastfeeding rates in the United States increase, barriers persist for Black, Latine, and low-socioeconomic status household dyads when compared to White and high-socioeconomic status household dyads. Previous breastfeeding disparities research has almost exclusively considered the influence of race, ethnicity, and socioeconomic status separately, although these attributes are not randomly distributed across the population.

To identify breastfeeding duration patterns by race/ethnicity and educational attainment in a nationally representative U.S. National Immunization Survey sample.

We conducted a cross-sectional, secondary analysis of the U.S. Centers for Disease Control and Prevention’s 2020 National Immunization Survey–Child public-use data. To examine breastfeeding and exclusive breastfeeding durations at the intersection of race/ethnicity and educational attainment, we created a 12-item, cross-classified variable using three educational attainment groups and four race/ethnicity groups. We used linear regressions to test these associations.

In all, 83% of the sample breastfed. Mean durations of breastfeeding were 7.5 (SE = 1.95) months and exclusive breastfeeding duration was 4.9 (SE = 0.87) months. In adjusted models, multi-race/other high-educational attainment participants had the longest breastfeeding duration by almost 3 weeks (β: 19.53, 95% CI [5.27, 33.79]), and Black low-educational attainment participants exclusively breastfed for 1 month less than White high-educational attainment participants (β:−30.23, 95% CI [−40.87, −19.58]).

Examining race/ethnicity and educational attainment together provides an intersectional understanding of breastfeeding outcomes and can inform targeted, culturally appropriate interventions.

Breastfeeding continuation rates are low in Ireland. The Breastfeeding Observation and Assessment Tool (BOAT) was developed to assist public health nurses in assessing breastfeeding challenges; however, little is known of its actual usage, the level of training experienced or desired by public health nurses, or their level of confidence in the support they provide to breastfeeding mothers.

To identify the current practices and support needs of public health nurses who provide breastfeeding support in Ireland.

An online questionnaire was devised to collect respondents’ confidence with breastfeeding issues, caseload, and practices. It was distributed to public health nurses with a current child health caseload in one Community Healthcare Organization. Mann Whitney U tests were used to ascertain the relationship between public health nurses’ confidence level and those with qualifications in midwifery or as an International Board Certified Lactation Consultant (IBCLC).

The survey was completed by 66 public health nurses. Only 14 respondents (21.2%) indicated that they always used the BOAT. The most common reason for not doing so was a lack of education on its use (n = 17, 25.8%). Postholders also certified as IBCLCs were considered by participants to be the most appropriate professionals to resolve certain breastfeeding issues. Confidence levels to manage breastfeeding issues were highest among public health nurses with IBCLC credentialing (U = 12.5, p = .001) while no difference was seen when comparing those with a midwifery degree to those without (U = 184.0, p = .92). Face-to-face workshops and blended-learning approaches were ranked as the preferred formats for breastfeeding education (Median rank = 2).

Breastfeeding education incorporating a face-to-face component is needed to support public health nurses who work with breastfeeding mothers, as is prioritization of recruitment in the community of public health nurses with IBCLC credentials.