Elizabeth A. Brownell

Delayed Onset Lactogenesis II Predicts the Cessation of Any or Exclusive Breastfeeding

OBJECTIVE To evaluate the association between delayed lactogenesis II (>3 days postpartum; delayed onset lactogenesis II [DLII]) and the cessation of any and exclusive breastfeeding at 4-weeks postpartum. STUDY DESIGN We constructed multivariable logistic regression models using data from 2491 mothers enrolled in the prospective Infant Feeding Practice Study II cohort. Models included DLII, known risk factors for breastfeeding cessation (age, education, race, parity/previous breastfeeding, and exclusive breastfeeding plan), and potential confounders identified in bivariate analyses (P ≤ .1). Backward selection processes (P ≤ .1) determined risk factor retention in the final model. RESULTS DLII was associated with cessation of any and exclusive breastfeeding at 4-weeks postpartum (OR 1.62; CI 1.14-2.31; OR 1.62; CI 1.18-2.22, respectively); numerous independent risk factors qualified for inclusion in the multivariable model(s) and were associated with the outcome(s) of interest (eg, supplemental nutrition program for women, infants, and children enrollment, onset of prenatal care, feeding on-demand, time initiated first breastfeed, hospital rooming-in, obstetric provider preference for exclusive breastfeeding, and maternal tobacco use). CONCLUSIONS Women experiencing DLII may be less able to sustain any and/or exclusive breastfeeding in the early postpartum period. Routine assessment of DLII in postpartum breastfeeding follow-up is warranted. Women with DLII may benefit from additional early postpartum interventions to support favorable breastfeeding outcomes.

End-of-life care in the neonatal intensive care unit: experiences of staff and parents.

OBJECTIVE The aim of the study is to determine the perceptions of end-of-life care practices and experience with infants who have died in the NICU among neonatologists, advanced practitioners, nurses, and parents, and also to determine perceived areas for improvement and the perceived value of a palliative care team. STUDY DESIGN This descriptive, exploratory cross-sectional study using surveys consisting of 7-point Likert scales and free response comments was sent to all neonatologists (n = 14), advanced practitioners (n = 40), and nurses (n = 184) at Connecticut Childrens Medical Centers neonatal intensive care units (NICUs) in April 2013 and to all parents whose infants died in these NICUs from July 1, 2011, to December 31, 2012 (n = 28). RESULTS The response rates were 64.3% for physicians; 50.0% for practitioners; 40.8% for nurses; and 30.4% for parents. Most providers reported they feel comfortable delivering end-of-life care. Bereavement support, debriefing/closure conferences, and education did not occur routinely. Families stressed the importance of memory making and bereavement/follow-up. Consistent themes of free responses include modalities for improving end-of-life care, inconsistency of care delivery among providers, and the importance of memory making and follow-up. CONCLUSION End-of-life experiences in the NICU were perceived as variable and end-of-life practices were, at times, perceived as inconsistent among providers. There are areas for improvement, and participants reported that a formalized palliative care team could help. Families desire memory making, follow-up, and bereavement support.

Trends and variation in management and outcomes of very low-birth-weight infants with patent ductus arteriosus

Background:We examined recent trends and interhospital variation in use of indomethacin, ibuprofen, and surgical ligation for patent ductus arteriosus (PDA) in very-low-birth-weight (VLBW) infants.Methods:Included in this retrospective study of the Pediatric Hospital Information System database were 13,853 VLBW infants from 19 US children’s hospitals, admitted at age < 3 d between 1 January 2005 and 31 December 2014. PDA management and in-hospital outcomes were examined for trends and variation.Results:PDA was diagnosed in 5,719 (42%) VLBW infants. Cyclooxygenase inhibitors and/or ligation were used in 74% of infants with PDA overall, however studied hospitals varied greatly in PDA management. Odds of any cyclooxygenase inhibitor or surgical treatment for PDA decreased 11% per year during the study period. This was temporally associated with improved survival but also with increasing bronchopulmonary dysplasia, periventricular leukomalacia, retinopathy of prematurity, and acute renal failure in unadjusted analyses. There was no detectable correlation between hospital-specific changes in PDA management and hospital-specific changes in outcomes of preterm birth during the study period.Conclusion:Use of cyclooxygenase inhibitors and ligation for PDA in VLBW infants decreased over a 10-y period at the studied hospitals. Further evidence is needed to assess the impact of this change in PDA management.

Systematic Review of the Human Milk Microbiota

Human milk–associated microbes are among the first to colonize the infant gut and may help to shape both short- and long-term infant health outcomes. We performed a systematic review to characterize the microbiota of human milk. Relevant primary studies were identified through a comprehensive search of PubMed (January 1, 1964, to June 31, 2015). Included studies were conducted among healthy mothers, were written in English, identified bacteria in human milk, used culture-independent methods, and reported primary results at the genus level. Twelve studies satisfied inclusion criteria. All varied in geographic location and human milk collection/storage/analytic methods. Streptococcus was identified in human milk samples in 11 studies (91.6%) and Staphylococcus in 10 (83.3%); both were predominant genera in 6 (50%). Eight of the 12 studies used conventional ribosomal RNA (rRNA) polymerase chain reaction (PCR), of which 7 (87.5%) identified Streptococcus and 6 (80%) identified Staphylococcus as present. Of these 8 studies, 2 (25%) identified Streptococcus and Staphylococcus as predominant genera. Four of the 12 studies used next-generation sequencing (NGS), all of which identified Streptococcus and Staphylococcus as present and predominant genera. Relative to conventional rRNA PCR, NGS is a more sensitive method to identify/quantify bacterial genera in human milk, suggesting the predominance of Streptococcus and Staphylococcus may be underestimated in studies using older methods. These genera, Streptococcus and Staphylococcus, may be universally predominant in human milk, regardless of differences in geographic location or analytic methods. Primary studies designed to evaluate the effect of these 2 genera on short- and long-term infant outcomes are warranted.

The Effect of a Donor Milk Policy on the Diet of Very Low Birth Weight Infants.

Background: Use of donor milk (DM) to supplement mother’s own milk (MOM) in the neonatal intensive care unit (NICU) is steadily increasing based on health and developmental benefits to premature infants. A paucity of data exists documenting the effect of DM use on the diet of very low birth weight (VLBW) infants related to the implementation of a DM policy. Objective: This study aimed to compare VLBW enteral intake type in the first 28 days of life before versus after establishing a DM policy. Methods: This single-center pre–post prospective cohort study included all inborn infants ≤ 1500 grams in a level 4 NICU remaining hospitalized at 28 days and admitted either before (pre-DM period, October 2009–March 2010) or after (DM period, October 2010–September 2012) implementing a DM policy. The feeding protocol was unchanged in both periods. Collected data included maternal/infant demographics, infant clinical data, and daily volume of enteral intake as MOM, DM, and formula. The proportion of enteral feeds from these sources during the first 28 days of life was compared pre-DM versus DM. Results: Compared to pre-DM baseline, formula exposure was significantly decreased, and human milk exposure and proportion of diet as human milk increased. The proportion of infants fed exclusively human milk increased. Exposure to and proportion of diet as MOM was unchanged. Infants were fed earlier in the DM period. Conclusion: Establishment of a DM policy was associated with reduced exposure to formula, promoting an exclusively human milk diet, with earlier initiation of feeds and no decrease in use of MOM.

Influence of Feeding Type on Gut Microbiome Development in Hospitalized Preterm Infants

Background Premature infants have a high risk for dysbiosis of the gut microbiome. Mother’s own milk (MOM) has been found to favorably alter gut microbiome composition in infants born at term. Evidence about the influence of feeding type on gut microbial colonization of preterm infants is limited. Objective The purpose of this study was to explore the effect of feeding types on gut microbial colonization of preterm infants in the neonatal intensive care unit. Methods Thirty-three stable preterm infants were recruited at birth and followed up for the first 30 days of life. Daily feeding information was used to classify infants into six groups (MOM, human donor milk [HDM], Formula, MOM + HDM, MOM + Formula, and HDM + Formula) during postnatal days 0–10, 11–20, and 21–30. Stool samples were collected daily. DNA extracted from stool was used to sequence the 16S rRNA gene. Exploratory data analysis was conducted with a focus on temporal changes of microbial patterns and diversities among infants from different feeding cohorts. Prediction of gut microbial diversity from feeding type was estimated using linear mixed models. Results Preterm infants fed MOM (at least 70% of the total diet) had highest abundance of Clostridiales, Lactobacillales, and Bacillales compared to infants in other feeding groups, whereas infants fed primarily HDM or formula had a high abundance of Enterobacteriales compared to infants fed MOM. After controlling for gender, postnatal age, weight, and birth gestational age, the diversity of gut microbiome increased over time and was constantly higher in infants fed MOM relative to infants with other feeding types (p < .01). Discussion MOM benefits gut microbiome development of preterm infants, including balanced microbial community pattern and increased microbial diversity in early life.

Donor Human Milk Bank Data Collection in North America An Assessment of Current Status and Future Needs

Background: The Human Milk Banking Association of North America (HMBANA) is a nonprofit association that standardizes and facilitates the establishment and operation of donor human milk (DHM) banks in North America. Each HMBANA milk bank in the network collects data on the DHM it receives and distributes, but a centralized data repository does not yet exist. In 2010, the Food and Drug Administration recognized the need to collect and disseminate systematic, standardized DHM bank data and suggested that HMBANA develop a DHM data repository. Objectives: This study aimed to describe data currently collected by HMBANA DHM banks and evaluate feasibility and interest in participating in a centralized data repository. Methods: We conducted phone interviews with individuals in different HMBANA milk banks and summarized descriptive statistics. Results: Eight of 13 (61.5%) sites consented to participate. All respondents collected donor demographics, and half (50%; n = 4) rescreened donors after 6 months of continued donation. The definition of preterm milk varied between DHM banks (≤ 32 to ≤ 40 weeks). The specific computer program used to house the data also differed. Half (50%; n = 4) indicated that they would consider participation in a centralized repository. Conclusions: Without standardized data across all HMBANA sites, the creation of a centralized data repository is not yet feasible. Lack of standardization and transparency may deter implementation of donor milk programs in the neonatal intensive care unit setting and hinder benchmarking, research, and quality improvement initiatives.

A Systematic Review of Early Postpartum Medroxyprogesterone Receipt and Early Breastfeeding Cessation: Evaluating the Methodological Rigor of the Evidence

BACKGROUND Breastfeeding has numerous maternal and infant benefits. Progesterone contraception after birth is frequently recommended, but because a decrease in progesterone is required to initiate lactation, early postpartum progesterone contraception use could inhibit lactation. The purpose of this article is to critically evaluate the scientific basis for conflicting clinical recommendations related to postpartum medroxyprogesterone use among breastfeeding women. METHODS Relevant peer-reviewed literature was identified through a comprehensive search of PubMed through December 2010. The search was restricted to clinical trials, randomized clinical trials, or comparative studies written in English and conducted among humans. The studies included in this review addressed the effect of medroxyprogesterone administration at <6 weeks postpartum on breastfeeding exclusivity and/or duration and measured breastfeeding outcomes at ≥ 6 weeks postpartum. RESULTS Of the 20 articles identified, only three studies satisfied the inclusion criteria. However, all three studies were of low-quality methodological rigor, and none accounted for potential confounders. CONCLUSION Current evidence is methodologically weak and provides an inadequate basis for inference about a possible causal relationship between early postpartum medroxyprogesterone use and poor breastfeeding outcomes. However, given the presence of a strong biological model describing the potential deleterious effect of postpartum medroxyprogesterone use on lactation, further research that improves on current literature is warranted. Meanwhile, we recommend that potential breastfeeding risks associated with early (<6 weeks) postpartum medroxyprogesterone use be disclosed to allow for a fully informed consent and decision-making process.

Establishing Breastfeeding with the Late Preterm Infant in the NICU

OBJECTIVE To describe challenges that late preterm infants (LPIs) face with breastfeeding and to provide an overview of current policy statements and practice guidelines that support breastfeeding for LPIs. In addition, we describe current breastfeeding research related to the LPI and combine this research with policies and practice guidelines to provide evidence-based recommendations to guide practice and future research in the NICU. DATA SOURCES Cumulative Index to Nursing and Allied Health Literature and PubMed databases. STUDY SELECTION Policies, guidelines, and research relevant to breastfeeding the LPI were selected if they were published between January 1, 2009 and March 1, 2014. All documents were published in English and related to breastfeeding management or breastfeeding outcomes for the LPI. DATA EXTRACTION Information from articles, policies, and guidelines were chosen for their relevance to breastfeeding the LPI. DATA SYNTHESIS Policy statements and practice guidelines were reviewed to provide an understanding of breastfeeding recommendations for the LPI. Additionally, recent research studies were reviewed and combined with the policy statements and practice guidelines to provide practice recommendations for NICU providers. CONCLUSIONS LPIs require a unique set of interventions for breastfeeding success; though they might be perceived as small, full-term infants, these infants often have greater challenges with breastfeeding than their term counterparts. Future research should be directed at identifying and testing specific strategies that will best support this at-risk population. Findings from this article are applicable for the LPI in the NICU as well as other care areas such as special care and transitional nurseries.

The Relationship between Life Stress and Breastfeeding Outcomes among Low-Income Mothers.

Stressful life events during pregnancy negatively affect maternal and infant outcomes including breastfeeding initiation. Their impact on breastfeeding duration is uncertain. Given breastfeedings important health benefits we analyzed stressful life event types and cessation of any and exclusive breastfeeding by 4 and 13 weeks. Methods. We collected self-administered survey data at 5–7 months postpartum from over 700 primarily urban low-income US mothers. Data covered prepregnancy, prenatal, and postpartum periods including 14 stressful life events (categorized into financial, emotional, partner-associated, traumatic). Analyses included only mothers initiating breastfeeding (n = 341). Logistic regressions controlled for maternal characteristics including a breastfeeding plan. Results. All four stress categories were associated with shorter duration of any and exclusive breastfeeding. In the adjusted models, statistically significant relationships remained for financial stress (4 weeks cessation of any breastfeeding duration) and traumatic stress (13 weeks exclusive breastfeeding cessation). Controlling for stress, a longer breastfeeding plan was significantly associated with a shorter breastfeeding duration (all models) as was depression during pregnancy and current smoking (several models). Conclusions. Among low-income women, impact of stressful life events on cessation of breastfeeding may differ by stress type and interfere with achievement of breastfeeding goal. Among these stressed mothers, breastfeeding may serve as a coping mechanism.