Donna J. Chapman

Identification of Risk Factors for Delayed Onset of Lactation

OBJECTIVE To identify infant feeding, socioeconomic, demographic, and delivery-related factors that affect womens self-reported timing of the onset of lactation. DESIGN Longitudinal survey of women from day 1 postpartum until self-reported onset of lactation. Subjects were interviewed in person on day 1 postpartum, then surveyed daily by telephone regarding infant feeding method, breast symptoms, and perception of whether the onset of lactation had occurred. Medical records were reviewed. SUBJECTS/SETTING Data were collected from 192 women after they gave birth to a healthy, term singleton. STATISTICAL ANALYSES PERFORMED chi 2 Analyses were used to identify variables associated with delayed onset of lactation (onset of lactation > or = 72 hours postpartum). Multivariate logistic regression was used to identify the independent association of each significant variable with delayed onset of lactation. RESULTS Risk factors for delayed onset of lactation included white/Hispanic ethnicity, heavy/obese body build, delivery of offspring by unscheduled cesarean delivery, vaginal delivery with prolonged stage 2 labor, infant birth weight less than 8 lb, and exclusive formula-feeding before the onset of lactation. APPLICATIONS/CONCLUSIONS Women who are at risk for delayed onset of lactation need additional breast-feeding support during the first week postpartum. During their hospitalization, these women should be instructed about the normal lactation process and the possibility that onset of lactation may occur later than 72 hours postpartum. Frequent nursing should be recommended, as delayed onset of lactation was associated with the lack of infant suckling.

Breastfeeding Peer Counseling: From Efficacy through Scale-up

An increasing number of publications have evaluated various breastfeeding peer counseling models. This article describes a systematic review of (a) the randomized trials assessing the effectiveness of breastfeeding peer counseling in improving rates of breastfeeding initiation, duration, exclusivity, and maternal and child health outcomes and (b) scientific literature describing the scale-up of breastfeeding peer counseling programs. Twenty-six peer-reviewed publications were included in this review. The overwhelming majority of evidence from randomized controlled trials evaluating breastfeeding peer counseling indicates that peer counselors effectively improve rates of breastfeeding initiation, duration, and exclusivity. Peer counseling interventions were also shown to significantly decrease the incidence of infant diarrhea and significantly increase the duration of lactational amenorrhea. Breastfeeding peer counseling initiatives are effective and can be scaled up in both developed and developing countries as part of well-coordinated national breastfeeding promotion or maternal-child health programs. J Hum Lact. 26(3):314-326.

Does Delayed Perception of the Onset of Lactation Shorten Breastfeeding Duration

This longitudinal study evaluated the impact of the timing of maternal perception of the onset of lactation on breastfeeding duration. Breastfeeding mothers who delivered a fullterm infant were interviewed daily from day 1 postpartum until the onset of lactation. Women were recontacted to determine the duration of any breastfeeding at 6.7 months postpartum, and if necessary, at 16.2 months postpartum. Cox survival multivariate analyses indicated that among women planning to breastfeed for at least 6 months, those with onset of lactation <72 hours postpartum were likely to breastfeed longer than their counterparts with a delayed onset of lactation. Median breastfeeding durations were 11.7 months and 3.4 months, respectively (p<0.00001). Among women who intended to breastfeed for less than 6 months, the timing of the onset of lactation did not influence breastfeeding duration. All analyses controlled for body build, delivery method, employment status, education, parity, and maternal age. These findings suggest that a delayed onset of lactation is likely to be associated with a shorter breastfeeding duration. This relationship, however, was modified by the mothers intended breastfeeding duration.

Breastfeeding among minority women: moving from risk factors to interventions.

The gap between current breastfeeding practices and the Healthy People 2020 breastfeeding goals is widest for black women compared with all other ethnic groups. Also of concern, Hispanic and black women have the highest rates of formula supplementation of breast-fed infants before 2 d of life. These disparities must be addressed through the scale-up of effective interventions. The objective of this critical review is to identify and evaluate U.S.-based randomized trials evaluating breastfeeding interventions targeting minorities and highlight promising public health approaches for minimizing breastfeeding disparities. Through PubMed searches, we identified 22 relevant publications evaluating 18 interventions targeting minorities (peer counseling [n = 4], professional support [n = 4], a breastfeeding team [peer + professional support, n = 3], breastfeeding-specific clinic appointments [n = 2], group prenatal education [n = 3], and enhanced breastfeeding programs [n = 2]). Peer counseling interventions (alone or in combination with a health professional), breastfeeding-specific clinic appointments, group prenatal education, and hospital/Special Supplemental Nutrition Program for Women, Infants, and Children enhancements were all found to greatly improve breastfeeding initiation, duration, or exclusivity. Postpartum professional support delivered by nurses was found to be the least effective intervention type. Beyond improving breastfeeding outcomes, 6 interventions resulted in reductions in infant morbidity or health care use. Future research should include further evaluations of successful interventions, with an emphasis on determining the optimal timeframe for the provision of support, the effect of educating womens family members, and the impact on infant health care use and cost-effectiveness.

Breastfeeding Education and Support Trial for Overweight and Obese Women: A Randomized Trial

OBJECTIVE: To evaluate a specialized breastfeeding peer counseling (SBFPC) intervention promoting exclusive breastfeeding (EBF) among overweight/obese, low-income women. METHODS: We recruited 206 pregnant, overweight/obese, low-income women and randomly assigned them to receive SBFPC or standard care (controls) at a Baby-Friendly hospital. SBFPC included 3 prenatal visits, daily in-hospital support, and up to 11 postpartum home visits promoting EBF and addressing potential obesity-related breastfeeding barriers. Standard care involved routine access to breastfeeding support from hospital personnel, including staff peer counselors. Data collection included an in-hospital interview, medical record review, and monthly telephone calls through 6 months postpartum to assess infant feeding practices, demographics, and health outcomes. Bivariate and logistic regression analyses were conducted. RESULTS: The intervention had no impact on EBF or breastfeeding continuation at 1, 3, or 6 months postpartum. In adjusted posthoc analyses, at 2 weeks postpartum the intervention group had significantly greater odds of continuing any breastfeeding (adjusted odds ratio [aOR]: 3.76 [95% confidence interval (CI): 1.07–13.22]), and giving at least 50% of feedings as breast milk (aOR: 4.47 [95% CI: 1.38–14.5]), compared with controls. Infants in the intervention group had significantly lower odds of hospitalization during the first 6 months after birth (aOR: 0.24 [95% CI: 0.07–0.86]). CONCLUSIONS: In a Baby-Friendly hospital setting, SBFPC targeting overweight/obese women did not impact EBF practices but was associated with increased rates of any breastfeeding and breastfeeding intensity at 2 weeks postpartum and decreased rates of infant hospitalization in the first 6 months after birth.

Differential response to breastfeeding peer counseling within a low-income, predominantly Latina population.

This study aims to identify those most responsive to breastfeeding peer counseling (PC) using data from a US-based randomized trial. The authors ran a series of logistic regression models to identify differential responses to PC, using breastfeeding status at 0, 1, 3, and 6 months postpartum as the dependent variables. Three subgroups were found to be most responsive to breastfeeding PC. Multiparae receiving PC were 6 times more likely to initiate breastfeeding than were multiparous controls (odds ratio [OR] = 6.4; 95% confidence interval [CI] = 1.9-20.8). Similarly, those with uncertain prenatal breastfeeding intentions in the PC group were 7 times (OR = 7.4; 95% CI = 1.5-37.0) more likely to initiate breastfeeding than their control group counterparts. Among subjects partially breastfeeding on day 1 postpartum, those receiving PC were 12 times (OR = 11.9; 95% CI = 1.2-111.1) more likely to breastfeed through 3 months postpartum than were controls. These findings have important implications to the Supplemental Food Program for Women, Infants and Children.

US National Breastfeeding Monitoring and Surveillance: Current Status and Recommendations

Eleven federally funded datasets assessing breastfeeding behaviors in the United States (Early Childhood Longitudinal Survey, Infant Feeding Practices Survey II, National Health and Nutrition Examination Survey, National Immunization Survey, National Survey of Childrens Health, National Survey of Early Childhood Health, National Survey of Family Growth, Pediatric Nutrition Surveillance System, Pregnancy Nutrition Surveillance System, Pregnancy Risk Assessment Monitoring Survey, and WIC Participant and Program Characteristics) were reviewed to evaluate breastfeeding variables (initiation, duration and exclusivity) and determine whether relevant breastfeeding determinants were collected to evaluate breastfeeding practices from a health disparities perspective. The datasets used inconsistent breastfeeding definitions, limited ethnic descriptors, and varied regarding availability of relevant determinants. Multiple datasets collect breastfeeding data, but a coordinated US breastfeeding monitoring and surveillance system does not exist. Suggestions to improve this system include: standardizing breastfeeding definitions, expanding ethnic/racial descriptors, collecting additional relevant variables, and reducing recall periods. J Hum Lact. 25(2):139-150.

Acculturative type is associated with breastfeeding duration among low-income Latinas.

We sought to assess the relationship between acculturative type and breastfeeding outcomes among low-income Latinas, utilising a multidimensional assessment of acculturation. We analysed data derived from a breastfeeding peer counselling randomised trial. Acculturation was assessed during pregnancy using a modified Acculturation Rating Scale for Mexican Americans scale. Analyses were restricted to Latinas who completed the acculturation scale and had post-partum breastfeeding data (n = 114). Cox survival analyses were conducted to evaluate differences in breastfeeding continuation and exclusivity by acculturative type. Participants were classified as integrated-high (23.7%, n = 27), traditional Hispanic (36.8%, n = 42), integrated-low (12.3%, n = 14) and assimilated (27.2%, n = 31). The integrated-low group was significantly more likely to continue breastfeeding than the traditional Hispanic, assimilated, and integrated-high groups (P < 0.05, P < 0.05, and P < 0.01, respectively). The traditional Hispanic group was marginally more likely to continue breastfeeding than the integrated-high group (P = 0.06). Breastfeeding continuation rates vary significantly between acculturative types in this multinational, low-income Latina sample. Multidimensional assessments of acculturation may prove useful in better tailoring future breastfeeding promotion interventions.

Breastfeeding Protection, Promotion, and Support in the United States A Time to Nudge, a Time to Measure

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.

Impact of Maternal Nutritional Status on Human Milk Quality and Infant Outcomes: An Update on Key Nutrients

The profound importance of human milk in optimizing neonatal health and improving child survival is becoming increasingly more apparent, both domestically (1–5) and internationally (6). Human milk is recommended as the sole source of nutrition for the first 6 mo of life (7–10) and is an important food source for the first 1 (7) to 2 y (11). Therefore, promoting and protecting human milk nutrient quality are of great public health concern. Until recently, it was widely believed that nutritional deficiencies in breast-fed infants were relatively rare. Routine supplementation of breast-fed infants is not recommended in the United States, with the exception of vitamin K in the newly delivered neonate (12) and—since 2005—vitamin D supplementation throughout infancy (13). However, WHO expert consultation on the optimal duration of exclusive breastfeeding (10) did acknowledge that data are insufficient to exclude the possibility of micronutrient deficiencies in some infants exclusively breastfed for 6 mo. Thus, there has been a renewed effort to better understand the relationship between maternal micronutrient status and human milk quality, particularly in regions of the world where diet quality is poor (14). However, even for women in resource-rich settings, modern trends in diet and lifestyle may compromise human milk nutrient levels. For example, it was previously believed that only strict vegans were at risk of vitamin B-12 deficiency. However, recent studies have revealed that even lacto-ovo vegetarians and individuals who consume low amounts of meat (15) are at greater risk of vitamin B-12 deficiency compared with those consuming larger amounts of meat. Furthermore, current public health recommendations advise pregnant and lactating women to limit their consumption of seafood with high methylmercury levels (16) and for all individuals to minimize sun exposure, practices that may compromise the levels of (n-3) fatty acids (17) and vitamin D (18) in human milk, respectively. These contemporary issues highlight the need to better understand the impact of maternal dietary intake on human milk nutrient levels and the resultant infant functional outcomes. For some nutrients, the answers to these relationships are relatively well established; however, important knowledge gaps remain in our understanding of these relationships for select nutrients. Our expert panel was invited to address the current evidence and summarize emerging research with regard to human milk quality, focusing on the B vitamins, vitamin D, and docosahexaenoic acid (DHA). Dr. Lindsay Allen (19) presents a global overview of B vitamin levels in human milk, how these levels are influenced by maternal diet and supplementation patterns, and the B vitamin status of infants breast-fed by mothers with inadequate B vitamin intake. Drs. Adekunle Dawodu and Reginald Tsang (20) provide an overview of the interplay between the vitamin D status of the mother, her milk, and her infant in a contemporary, cross-national context. Their paper also highlights intriguing recent research evaluating maternal vitamin D supplementation as a means to improve the vitamin D status of infants in settings with very low maternal vitamin D levels. Dr. Christina Valentine (21) presents a critical review of the literature addressing the relationship between maternal DHA intake and DHA levels in human milk, including the donor milk supply in the United States and the potential impact of human milk DHA content on functional outcomes in the preterm infant. Although each of these authors has focused on addressing suboptimal human milk levels of select nutrients, these symposium proceedings should not be interpreted as reasons to disregard current recommendations to provide human milk as the sole source of nutrition for the first 6 mo of life. On the contrary, all 4 authors acknowledge the vitally important nutritional and immunological advantages of exclusive breastfeeding. In the instances in which human milk nutrient levels have been shown to be suboptimal, each author has highlighted emerging research on interventions designed to address the problem, primarily by improving maternal intake. It would be misguided to “solve” the problem of a nutrient deficiency in human milk by recommending human milk substitutes because this ignores the importance of exclusive breastfeeding in maximizing protection from infectious disease and improving child survival. By tackling the issue of human milk quality for select nutrients, this symposium provides a road map for future research focused on protecting and promoting human milk quality. Clearly, more research is needed to determine the safety and effectiveness of approaches used to address this challenging public health issue.