April Fogleman

The Nutritive and Immunoprotective Quality of Human Milk beyond 1 Year Postpartum Are Lactation-Duration-Based Donor Exclusions Justified?

Donor human milk is critical for the fragile preterm infant who does not have access to his or her mother’s milk, improving survival rates and quality of survival and decreasing hospital stay. Despite the opening of donor milk banks around the world, shortages continue as demand for donor milk exceeds supply. One potential means of increasing supply is by reducing exclusion criteria that prohibit mothers from donating milk based on duration of lactation. Minimal research has been done on the composition of human milk during the second year of lactation, with most research focusing on the nutritive compounds and not the immunoprotective compounds. Several immunoprotective compounds, including lysozyme, lactoferrin, secretory immunoglobulin A, and oligosaccharides, are abundant in human milk compared to bovine-based infant formula and are partially or fully retained during Holder pasteurization, making them an important differentiating feature of donor milk. A PubMed search was conducted to review studies in human milk composition during the second year of lactation. Limitations of existing research include sample collection protocols, small study sizes, and use of populations that may have been at risk for nutritional deficiencies. Stable concentrations of several components were reported including protein, lactose, iron, copper, lactoferrin, and secretory immunoglobulin A. Lysozyme concentration increased during extended lactation, while zinc and calcium concentrations declined into the second year. Conflicting findings were reported on fat content, and no information was available regarding oligosaccharide content. More research is needed to create evidence-based guidelines regarding the nutritive and immunoprotective value of donor milk throughout the course of lactation.

A longitudinal study of human milk composition in the second year postpartum: implications for human milk banking.

While the composition of human milk has been studied extensively in the first year of lactation, there is a paucity of data regarding human milk composition beyond one year postpartum. Policies vary at milk banks around the world regarding how long lactating women are eligible to donate their milk. The primary purpose of this study is to describe longitudinal changes in human milk composition in the second year postpartum to support the development of evidence based guidelines regarding how long lactating women can donate human milk to a milk bank. Nineteen lactating women in North Carolina provided monthly milk samples from 11 months to 17 months postpartum (N = 131), and two non-profit milk banks provided (N = 33) pooled, unpasteurized milk samples from 51 approved donors less than one year postpartum. There was a significant increase (P < 0.05) in the concentration of total protein, lactoferrin, lysozyme, Immunoglobulin A, oligosaccharides and sodium in longitudinal samples of mothers milk between 11 and 17 months postpartum, while zinc and calcium concentrations declined, and no changes were observed in lactose, fat, iron and potassium. Human milk in the second year postpartum contained significantly higher concentrations of total protein, lactoferrin, lysozyme and Immunoglobulin A, than milk bank samples, and significantly lower concentrations of zinc, calcium, iron and oligosaccharides. Accepting milk bank donations beyond one year postpartum is a potential strategy for increasing the supply of donor milk, but may require mineral fortification.

The intricacies of induced lactation for same-sex mothers of an adopted child.

The definition of a modern family is changing. In this case study, we describe the breastfeeding experience of a child receiving human milk from all 3 of his mothers: his 2 adoptive mothers, who induced lactation to nurse him, and his birth mother, who shared in his early feeding during the open adoption process and continued to pump and send milk to him for several months. We review the lactation protocol used by his adoptive mothers and the unique difficulties inherent in this multi-mother family dynamic. Both adoptive mothers successfully induced moderate milk production using a combination of hormonal birth control, domperidone, herbal supplements, and a schedule of breast pumping. However, because of the increased complexity of the immediate postpartum period and concerns with defining parental roles in a same-sex marriage, maintenance of milk production was difficult.

Expanding the Supply of Pasteurized Donor Milk: Understanding Why Peer-to-Peer Milk Sharers in the United States Do Not Donate to Milk Banks.

Background: Lactating women in the United States have several options for what they do with excess breast milk, including donating to milk banks that serve medically fragile infants, sharing directly with families seeking milk, and selling to individuals or for-profit entities. The World Health Organization and the US Surgeon General have issued calls to increase access to pasteurized donor milk for medically fragile infants. Objective: To explore how lactating women with a surplus of breast milk come to the decision to share their milk with a peer rather than donate to a milk bank. Methods: A qualitative design using a grounded theory approach was employed. Semistructured telephone interviews were conducted with 27 women who had shared milk with a peer but not with a milk bank. Results: Five dominant themes were identified: a strong belief in the value of breast milk, unexpected versus planned donation, sources of information regarding milk exchange, concerns and knowledge gaps about milk banks, and helping and connecting. Conclusions: This research offers insights into potential strategies for promoting milk bank donation among peer-to-peer milk sharers, including developing donor education campaigns focused on knowledge gaps regarding milk banks and developing health care professional referral programs that can reduce barriers associated with the convenience of milk bank donation.

Effect of added calcium, phosphorus, and infant formula on calcium and phosphorus dialyzability in preterm donor human milk.

Objectives: We studied the effect of preparing donor human milk (DHM) with commonly used nutritional additives on the dialyzability of calcium and phosphate. We hypothesized that the additives to DHM would decrease the dialyzability of calcium and phosphate when prepared according to hospital protocols. Methods: An in vitro system simulating premature infant digestion was developed to measure dialyzability of calcium and phosphate in DHM. Dialyzable calcium and phosphate were measured after in vitro digestion in DHM before and after preparation of DHM with the following additives according to hospital protocols: calcium glubionate, sodium potassium phosphate, calcium glubionate and sodium potassium phosphate added together, Similac human milk fortifier, Similac NeoSure, or Enfamil Enfacare. Results: The percentage of dialyzable calcium in DHM with added calcium and calcium and phosphate together was greater than the percentage of dialyzable calcium in DHM with added powdered infant formulas (P < 0.0001). Dialyzable calcium was greater in DHM with added calcium and with added calcium and phosphate than in all other treatment groups (P < 0.0001). Dialyzable calcium in DHM without additives was not different from dialyzable calcium in DHM with added phosphate or with added powdered infant formulas. Dialyzable phosphate did not differ between the treatment groups. Conclusions: The addition of calcium alone or calcium and phosphate together increased calcium dialyzability in DHM significantly, whereas the addition of powdered human milk fortifier or formulas did not. The addition of calcium or calcium with phosphate together to DHM may provide the most dialyzable calcium.

Stakeholder views of breastfeeding education in schools: a systematic mixed studies review of the literature

BackgroundBreastfeeding provides numerous health benefits for mothers and infants, but worldwide breastfeeding rates fall below recommendations. As part of efforts to increase breastfeeding initiation and duration, the World Health Organization and UNICEF UK recommend educational interventions to increase awareness and positive attitudes towards breastfeeding beginning during the school years. Breastfeeding education in the school setting offers the opportunity to improve the knowledge base, address misconceptions, and positively influence beliefs and attitudes for students from a wide range of socioeconomic and cultural backgrounds. The purpose of this paper is to present a comprehensive narrative review of the literature regarding student and teacher (stakeholder) views of breastfeeding and breastfeeding education programs in schools to inform future research in the area.MethodsArticles were located through a systematic search of online databases and journals using the following keywords in various combinations: (1) breastfeeding, lactation, breast-feeding, “bottle feeding”, “infant feeding” (2) student, educator, teacher, “school administrator” and (3) schools, “secondary education”, “primary education”, “K-12”, “high school”, “middle school”, “elementary school”, education, adolescents, curriculum, and a manual search of article references. Studies were screened for inclusion against specific criteria and included papers were assessed using the Mixed Methods Appraisal Tool (MMAT).ResultsThis review suggests that adolescents have a deficit in breastfeeding knowledge and express negative conceptions about breastfeeding. Breastfeeding is being discussed in some school environments, but the extent of lessons and the specific messages that teachers communicate have not been explored. Students appear to be interested in receiving more information about breastfeeding, especially if delivered by health professionals or breastfeeding mothers. The majority of teachers are supportive of incorporating breastfeeding education in family and consumer sciences, sexual education, and health classes; however, time constraints and limited knowledge of infant feeding recommendations may be barriers to implementation of appropriate lesson plans.ConclusionsStudents generally support and are receptive to breastfeeding education; however, research on educator attitudes, knowledge, and experiences are necessary for appropriate implementation of breastfeeding education in varying school settings around the world.

A Pilot Study on the Protein Composition of Induced Nonpuerperal Human Milk

Background: Our understanding of the components of human puerperal milk is extensive and increasing, yet the literature on nonpuerperal human milk has been limited to studies that measure the success of induced lactation. Objective: This study aimed to describe the composition of total protein and key bioactive proteins when lactation is induced in nonpuerperal women. Methods: Two women who induced lactation in the absence of pregnancy provided weekly milk samples over a 2-month period for analysis of total protein, secretory immunoglobulin A (sIgA), lysozyme, and lactoferrin. Composition was compared to the mature milk of 3 puerperal control subjects who were 11 months postpartum. Results: Median total protein for subject A was 2.30 g/dL (interquartile range [IQR] = 0.46) and showed a significant downward trend over time (P < .0001), whereas the median total protein for subject B was 2.21 g/dL (IQR = 0.18) and showed a nonsignificant decline (P = .232). Total protein in both nonpuerperal subjects was elevated compared to control subjects. Secretory IgA activity declined for both nonpuerperal subjects over time, whereas lysozyme concentrations increased over time. Both sIgA and lysozyme approached the levels seen in the puerperal controls. Lactoferrin levels remained stable for both nonpuerperal subjects and were elevated compared to puerperal milk samples. Conclusion: This pilot study suggests that nonpuerperal milk has similar or higher levels of total protein, sIgA, lactoferrin, and lysozyme compared to puerperal, mature milk at 11 months postpartum, which warrants more attention as adoptive mothers increasingly choose to induce lactation.

Managing the Human-Milk-Fed, Preterm, VLBW Infant at NICU Discharge A Simpler Algorithm?

Feeding prematurely born infants after their stay in the neonatal intensive care unit (NICU) remains problematic. Growth in the NICU is almost always well below the intrauterine rate, and extrauterine growth restriction is common. Breastfeeding is difficult in the NICU, and human milk alone may not always provide adequate protein or minerals for optimal growth. At the time of NICU discharge, a regimen is needed that is supportive of both ongoing lactation and optimal nutrition. However, there is no one regimen that suits all babies and families. We propose a simplified algorithm to help guide the clinical team in deciding what dietary regimen is best suited for their patients.

Bacteria and bioactivity in Holder pasteurized and shelf-stable human milk products

Abstract Background: Historically, Holder pasteurization has been used to pasteurize donor human milk available in a hospital setting. There is extensive research that provides an overview of the impact of Holder pasteurization on bioactive components of human milk. A shelf-stable (SS) human milk product, created using retort processing, recently became available; however, to our knowledge, little has been published about the effect of retort processing on human milk. Objective: We aimed to assess the ability of retort processing to eliminate bacteria and to quantify the difference in lysozyme and secretory immunoglobulin A (sIgA) activity between Holder pasteurized (HP) and SS human milk. Methods: Milk samples from 60 mothers were pooled. From this pool, 36 samples were taken: 12 samples were kept raw, 12 samples were HP, and 12 samples were retort processed to create an SS product. All samples were analyzed for total aerobic bacteria, coliform bacteria, Bacillus cereus, sIgA activity, and lysozyme activity. Raw samples served as the control. Results: One raw sample and 3 HP samples contained B. cereus at the time of culture. There were no detectable bacteria in SS samples at the time of culture. Raw samples had significantly greater lysozyme and sIgA activity than HP and SS samples (P < 0.0001). HP samples retained significantly more lysozyme and sIgA activity (54% and 87%, respectively) than SS samples (0% and 11%, respectively). Conclusions: Human milk processed using Holder pasteurization should continue to be screened for the presence of B. cereus. Clinicians should be aware of the differences in the retention of lysozyme and sIgA activity in HP and SS products when making feeding decisions for medically fragile or immunocompromised infants to ensure that patients are receiving the maximum immune protection.

Addition of Calcium and Phosphorus to Preterm Donor Human Milk and the Impact on Protein, Fat, and Calcium Digestibility In Vitro

Infants born prematurely are at risk for metabolic bone disease and may need increased minerals for normal bone mineralization. In these situations, supplementation of human milk with calcium and p...