Sheela R. Geraghty

Microbial Contamination of Human Milk Purchased Via the Internet

OBJECTIVE: To quantify microbial contamination of human milk purchased via the Internet as an indicator of disease risk to recipient infants. METHODS: Cross-sectional sample of human milk purchased via a popular US milk-sharing Web site (2012). Individuals advertising milk were contacted to arrange purchase, and milk was shipped to a rented mailbox in Ohio. The Internet milk samples (n = 101) were compared with unpasteurized samples of milk donated to a milk bank (n = 20). RESULTS: Most (74%) Internet milk samples were colonized with Gram-negative bacteria or had >104 colony-forming units/mL total aerobic count. They exhibited higher mean total aerobic, total Gram-negative, coliform, and Staphylococcus sp counts than milk bank samples. Growth of most species was positively associated with days in transit (total aerobic count [log10 colony-forming units/mL] β = 0.71 [95% confidence interval: 0.38–1.05]), and negatively associated with number of months since the milk was expressed (β = −0.36 [95% confidence interval: −0.55 to −0.16]), per simple linear regression. No samples were HIV type 1 RNA-positive; 21% of Internet samples were cytomegalovirus DNA-positive. CONCLUSIONS: Human milk purchased via the Internet exhibited high overall bacterial growth and frequent contamination with pathogenic bacteria, reflecting poor collection, storage, or shipping practices. Infants consuming this milk are at risk for negative outcomes, particularly if born preterm or are medically compromised. Increased use of lactation support services may begin to address the milk supply gap for women who want to feed their child human milk but cannot meet his or her needs.

The quiet revolution: breastfeeding transformed with the use of breast pumps.

A quiet revolution has been taking place in the feeding of US infants in the form of women using electric breast pumps. This revolution in milk expression may be a boon for both mothers and infants if more infants are fed human milk or if they receive human milk for a longer period. Milk expression may also be problematic for mothers, and it may be particularly problematic for infants if they are fed too much, fed milk of an inappropriate composition, or fed milk that is contaminated. As a result, the time has come to determine the prevalence of exclusive and periodic breast milk expression and the consequences of these behaviors for the health of mothers and their infants.

Evaluation of resident communication skills and professionalism: a matter of perspective?

OBJECTIVE. Evaluation procedures that rely solely on attending physician ratings may not identify residents who display poor communication skills or unprofessional behavior. Inclusion of non-physician evaluators should capture a more complete account of resident competency. No published reports have examined the relationship between resident evaluations obtained from different sources in pediatric settings. The objective of this study was to determine whether parent and nurse ratings of specific resident behaviors significantly differ from those of attending physicians. METHODS. Thirty-six pediatric residents were evaluated by parents, nurses, and attending physicians during their first year of training. For analysis, the percentage of responses in the highest response category was calculated for each resident on each item. Differences between attending physician ratings and those of parents and nurses were compared using the signed rank test. RESULTS. Parent and attending physician ratings were similar on most items, but attending physicians indicated that they frequently were unable to observe the behaviors of interest. Nurses rated residents lower than did attending physicians on items that related to respecting staff (69% vs 97%), accepting suggestions (56% vs 82%), teamwork (63% vs 88%), being sensitive and empathetic (62% vs 85%), respecting confidentiality (73% vs 97%), demonstrating integrity (75% vs 92%), and demonstrating accountability (67% vs 83%). Nurse responses were higher than attending physicians on anticipating postdischarge needs (46% vs 25%) and effectively planning care (52% vs 33%). CONCLUSIONS. Expanding resident evaluation procedures to include parents and nurses does enhance information that is gathered on resident communication skills and professionalism and may help to target specific behaviors for improvement. Additional research is needed to determine whether receiving feedback on parent and nurse evaluations will have a positive impact on resident competency.

Human Milk Pumping Rates of Mothers of Singletons and Mothers of Multiples

Rates of breastfeeding are increasing, but the methods by which human milk is fed to infants is not well described. Using a retrospective survey design, the authors collected information about infant feeding from mothers of term, preterm, singleton, and multiple-gestation infants (n = 346). Human milk feeding methods were characterized as solely at the breast, pumped only, or a combination. Sixty-eight percent of mothers in the study fed their infants at least some human milk; 77% of these mothers reported pumping milk. There was no difference in the percentage of pumping based on multiple gestation or length of pregnancy. Feeding human milk solely at the breast at early postpartum time points was associated with longer durations of human milk feeding overall. More research is needed to better understand why mothers choose pumping over direct human milk feedings and to evaluate the health outcomes associated with this practice. J Hum Lact. 21(4):413-420.

Redefining "breastfeeding" initiation and duration in the age of breastmilk pumping.

Dear Editor: Breastfeeding rates have been chronicled in the United States throughout the past 50 years. The general purpose of these descriptive data collections has been to provide public health surveillance of infant feeding. The results have been used to identify demographic characteristics and the geographic locations of women who may need breastfeeding support and assistance. These statistics have helped create policy, set goals for the country, and provide benchmark measures from which to increase the proportion of children receiving breastmilk. Although investigators have used distinct methods of data collection in past studies, the definition of how “breastfeeding” was characterized has been relatively constant. If an infant was fed breastmilk even once, the mother was said to have initiated breastfeeding. For the period that a child was fed breastmilk, the mother was considered to be concurrently providing that breastmilk. If a child was fed breastmilk exclusively, predominantly, or nominally at any time, then the mother was categorized, respectively, as exclusively, predominantly, or nominally “breastfeeding” for that same period. The collection of breastfeeding statistics has always assumed the behavior between the mother and child to be a synchronized, simultaneous event, with both participating equally. This presumption in “breastfeeding” data collection is no longer uniformly true for mothers and their children in the United States, however. Approximately 70% of American women initiate breastmilk feeding in the postpartum period,1 while approximately 70% of women with children under the age of 18 years work outside the home.2 If women are going to maintain their milk supply when separated from their infant, they must extract their milk regularly. Thus, in addition to feeding their children directly “at the breast,” women in the United States now commonly extract milk from their breasts by mechanical means. A woman with a double-sided electric breast pump can easily and painlessly extract the contents of both breasts in a short period. This pumped milk may be fed to the infant immediately, left at ambient temperature, or stored in the mothers own refrigerator or freezer for variable lengths of time. In the Infant Feeding Practices Study II, the largest study on pumping by American mothers, 85% of 1,564 breastfeeding mothers of healthy, singleton infants 1.5–4.5 months old expressed milk from their breasts.3 Among the 1,493 of these mothers with complete data, only 32% had not expressed milk in the previous 2-week period, 43% had expressed milk occasionally, and 25% expressed milk on a regular schedule. Among the 820 mothers who continued to breastfeed through 7 months postpartum, 92% had expressed breastmilk at some time.3 The behavior of pumping clearly raises the question: What is “breastfeeding?” Is a child fed at the mothers breast and also fed bottled pumped milk by another caregiver “exclusively” breastfed? Is a premature infant fed a combination of his or her mothers own pumped breast milk and donor human milk also “exclusively” breastfed? Is a mother pumping two or three times a day while at work and feeding her baby at the breast when she gets home “exclusively” breastfeeding? What if a mother stops lactating completely, and the child continues to receive her stored milk until the supply is gone for a period that could be weeks? Traditional definitions of breastfeeding classify a mother as still “breastfeeding” for the duration that her child is receiving breastmilk regardless of whether she has ceased lactating. We suggest that descriptive studies of breastmilk feeding rates now include questions that (1) separate the mothers breastmilk extraction from the childs breastmilk consumption, (2) distinguish between breastmilk fed at the breast or hand-expressed/pumped, and (3) establish the time when breastmilk substitutes are introduced (Table 1). Along with these categories of breastmilk feeding initiation and cessation, there also should be a way to note the time period of feeding “another mothers milk” as may occur in the cases of donor milk or milk sharing. Table 1. Suggested Questions to More Accurately Define Breastmilk Feeding Initiation and Cessation The reason that it is important to distinguish between feeding directly at the breast and feeding pumped milk because these behaviors may have different effects on the health of mothers and children. The seminal studies that established the benefits of “breastfeeding” compared outcomes for children who were fed breastmilk directly at the breast with those who were fed a breastmilk substitute from a bottle or cup. Pumping, however, creates the combination of these two once-distinct feeding behaviors: the mothers breastmilk is now in a bottle or cup. There is much that we do not know about how at-the-breast feeding compares with pumped-milk feeding. Using more detailed questions, such as those suggested here, will still permit the use of current designations of “breastfeeding”: ever breastfed or fed breastmilk, age of child when no longer fed breastmilk, age of child when fed formula, and age of child when fed any other food. Further delineation of these descriptive statistics, however, will lead to a more accurate representation of this complicated behavior and, thus, to more clinically relevant results to important research questions.

Associations between high prepregnancy body mass index, breast-milk expression, and breast-milk production and feeding

BACKGROUND Breast-milk expression is widely practiced by American mothers, but little is known about who expresses milk, how expression affects breastfeeding, or whether overweight or obese women, who have less breastfeeding success than do normal-weight women, express milk differently. OBJECTIVES We investigated 1) whether breast-milk expression behavior differed by body mass index (BMI; in kg/m(2)) category and 2) whether the different breastfeeding behaviors of overweight (BMI: ≥25 and <30) and obese (BMI: ≥30) women resulted in different breastfeeding outcomes. DESIGN The subjects (n = 2288) provided information on BMI and breast-milk production, feeding, and expression in mail-in questionnaires as part of the Infant Feeding Practices Study II. Longitudinal and cross-sectional data were analyzed by using regression procedures adjusted for confounding. RESULTS Women of different BMI categories overall did not differ in whether, when, or why they expressed breast milk. Before 2 mo postpartum, however, obese women were more likely (P = 0.04, unadjusted) to try milk expression and were less likely (P = 0.01, unadjusted) to express milk successfully. In addition, overweight or obesity was associated (P < 0.03, unadjusted) with a shorter duration of breast-milk production only in women who never expressed milk. In overweight or obese women, those who ever expressed milk had longer durations of breastfeeding (P < 0.003, unadjusted) than did those who never expressed milk. CONCLUSIONS Breast-milk expression behaviors may differ by maternal BMI category only in the early postpartum period. In addition, breast-milk expression may reduce differences between BMI categories in the duration of breastfeeding and support longer durations of breastfeeding.

Got Milk? Sharing Human Milk Via the Internet

Division of Nutritional Sciences, Cornell University, Ithaca, NYAddress correspondence to: Sheela R. Geraghty, MD, MS, IBCLC, Cincinnati Children’s Hospital Medical Center, Center for Breastfeeding Medicine, 3333 Burnet Ave., MLC 7035, Location S, 9-242, Cincinnati, OH 45229; tel. 513-636-2526; fax 513-636-4402; e-mail . ©2011 Association of Schools of Public Health

Cow’s Milk Contamination of Human Milk Purchased via the Internet

BACKGROUND: The US Food and Drug Administration recommends against feeding infants human milk from unscreened donors, but sharing milk via the Internet is growing in popularity. Recipient infants risk the possibility of consuming contaminated or adulterated milk. Our objective was to test milk advertised for sale online as human milk to verify its human origin and to rule out contamination with cow’s milk. METHODS: We anonymously purchased 102 samples advertised as human milk online. DNA was extracted from 200 μL of each sample. The presence of human or bovine mitochondrial DNA was assessed with a species-specific real-time polymerase chain reaction assay targeting the nicotinamide adenine dinucleotide (NADH) dehydrogenase subunit 5 gene. Four laboratory-created mixtures representing various dilutions of human milk with fluid cow’s milk or reconstituted infant formula were compared with the Internet samples to semiquantitate the extent of contamination with cow’s milk. RESULTS: All Internet samples amplified human DNA. After 2 rounds of testing, 11 samples also contained bovine DNA. Ten of these samples had a level of bovine DNA consistent with human milk mixed with at least 10% fluid cow’s milk. CONCLUSIONS: Ten Internet samples had bovine DNA concentrations high enough to rule out minor contamination, suggesting a cow’s milk product was added. Cow’s milk can be problematic for infants with allergy or intolerance. Because buyers cannot verify the composition of milk they purchase, all should be aware that it might be adulterated with cow’s milk. Pediatricians should be aware of the online market for human milk and the potential risks.

Trends in breastfeeding: it is not only at the breast anymore

The past characterisations of breastfeeding as being only at the breast of the mother may no longer be applicable in the United States as mothers now frequently express their milk. We conducted a retrospective cohort study with women who visited the Cincinnati Childrens Breastfeeding Medicine Clinic to understand breast milk feeding behaviours of healthy mothers and infants, which included questions specifically about breast milk expression. All 40 mothers in the cohort expressed their milk and all 40 infants were fed expressed milk. One infant was fed another mothers milk for 30 days. Two-thirds (13/40) of infants received their mothers expressed milk at least a week after it was first expressed and 25% (10/40) of infants continued to be fed expressed breast milk after mothers had stopped expressing milk. There were 14 sequences of breast milk production by the mothers and 16 sequences of consumption by the infants. Early in the post-partum period, mothers started expressing milk even though their infants were consuming all of the breast milk that they needed at the breast. As a result of breast milk expression by all mothers in this cohort, we observed highly variable patterns of maternal breast milk production and infant breast milk consumption, which were not necessarily synchronous within a dyad. It is now time to develop appropriate ways to characterise the production and consumption of breast milk more accurately and investigate whether these behaviours have consequences for the health of mothers and infants.

The development of a research human milk bank.

Although there are well-established clinical human milk banks in the United States, there are no milk banks specifically intended to foster research on human milk. The authors’goalwas to establish a milk bank with a core data set to support exploratory and hypothesis-driven studies on human milk. Donations to the Cincinnati Children’s Research Human Milk Bank are accepted within the context of ongoing, hypothesis-driven research or on an ad hoc basis. Donors must give informed consent, and scientists wishing to use the samples must have Institutional review board approval for their use. Development of more research human milk banks can potentially provide resources for multidisciplinary collaboration and advance the study of human milk and lactation.