Physiology of Human Lactation and Strategies to Support Milk Supply for Breastfeeding.

Despite advances across the globe in breastfeeding initiation rates, many families continue to report they are not meeting their breastfeeding goals. Concerns about milk supply, infant nutritional intake, and infant weight gain are among the most commonly cited reasons for early breastfeeding cessation. Nurses working with individuals during the perinatal period are uniquely positioned to educate families and offer evidence-based interventions to promote optimal milk supply, infant growth, and maternal mental and physical health. Such interventions include early and frequent skin-to-skin care, emptying of the breast, and professional lactation support. By implementing such evidence-based practices in the first hours after birth and connecting families to lactation support in the first 14 days, nurses can begin to help families achieve their breastfeeding goals.

Evaluating milk flow patterns using the high flow rate period during breast pumping.

PROBLEM: Breast pumping practices have scope for improvement. BACKGROUND: Breast milk weight measurement can be used to evaluate milk flow pattern dynamics during breast pumping. AIM: To determine inter-individual differences in milk flow patterns and their practical implications based on high milk flow rate period (HFP) data among Japanese women expressing breast milk using an electric pump. METHODS: This cross-sectional, observational study analysed data from 19 women (33.0 ± 3.9 years) nursing 1-6-month-old infants and with previous breast milk expression experience. Breast milk was weighed continuously during a 15-min single-breast electric pumping session. The HFP features and flow rate time (≥0.1 g/s) were analysed to determine each individual's milk flow pattern. FINDINGS: The total expressed breast milk was 69.8 ± 42.5 g with a maximum individual flow rate of 0.5 ± 0.2 g/s. The breast milk yielded during the HFPs was 43.1 (34.4-81.3) g, accounting for 82.5 % (69.9-89.5 %) of the total expressed breast milk. HFP occurred 0-3 times during the 15-min session. Multiple discrete and continuous milk flow patterns were observed. Among those with discrete HFP, the HFP interval was 221 (68-371) s. Breast milk fat content changes and subjective residual milk measurements implied sufficient milk removal. A strong positive correlation was noted between HFP length and total breast milk expression volume. DISCUSSION: Individual differences in milk flow patterns were observed among the women using HFP. Milk flow patterns were consistent with previous reports. CONCLUSION: Milk flow pattern data can be used to guide individualised lactation support.

Effect of brewer's yeast or beta-glucan on breast milk supply following preterm birth: the BLOOM study - protocol for a multicentre randomised controlled trial.

BACKGROUND: Many individuals who experience preterm birth struggle with early breast milk supply, which can translate into suboptimal longer-term breastfeeding outcomes. Further investigations into the potential role of early non-pharmacological and pharmacological interventions in improving breast milk production soon after birth is growing. While natural galactagogues, such as brewer's yeast, are widely perceived by women to be safer than pharmaceutical galactagogues and are taken by many women, evidence to support their efficacy is largely absent. The BLOOM study has been designed to determine the efficacy and safety of brewer's yeast and beta-glucans, derived from Saccharomyces cerevisiae, when administered soon after birth for increasing early breast milk supply in mothers who have delivered preterm. METHODS: The BLOOM study is a multicentre, double-blinded, randomised controlled trial that will assess if brewer's yeast or beta-glucan can increase early breast milk production following preterm birth. Target population are mothers of preterm infants born at less than 34 weeks' gestation who intend to provide breast milk for their infant, are less than 72 h following birth and able to give informed consent. Participants will be randomly allocated into three parallel groups at 1:1:1 ratio (n = 33 per group) to receive either brewer's yeast, beta-glucan or placebo capsules for seven days. The primary outcome is total expressed breast milk volume over a 24-hour period on day 7 of intervention. Participants and their infants will be followed until the infant reaches term corrected age or is discharged home from the neonatal unit (whichever occurs first). DISCUSSION: The use of brewer's yeast as a galactagogue to enhance milk production is extremely common amongst breastfeeding mothers, however, there are no trials evaluating its efficacy and safety. This will be the first randomised controlled trial to evaluate the efficacy and safety of two commonly used galactagogues, brewer's yeast and beta-glucan, compared with placebo in improving maternal breast milk supply following preterm birth. The trial will also evaluate whether early intervention with galactagogues soon after a preterm birth improves longer-term breastfeeding outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12622000968774 (registered on 8 July 2022) and UTN U1111-1278-8827.

An evaluation of patient comfort levels during expression with a modified pumping program: a prospective proof of concept study.

Introduction: This study aimed to assess if the implementation of a gentle transition of vacuum mode into a breast pump suction pattern commonly used to initiate milk production would improve user comfort while expressing during the first four days postpartum. Methods: This prospective study was conducted at OLVG hospital in the Netherlands in two sequential phases. Breastfeeding patients delivering >36 weeks gestation with an infant aged ≤96 h old and a clinical indication to express milk with a breast pump were recruited. Intervention group 1 (n = 40) used a hospital-grade electric breast pump with a standard breast pump suction pattern. Intervention group 2 used a hospital-grade electric breast pump with a modified breast pump suction pattern (n = 40). The primary outcome was an objective assessment of comfort as measured by participants' need to reduce vacuum level during the 20 min test session. Secondary outcomes included the total expression volume (ml) in 20 min pumping. Results: The study found that the primary outcome of comfort was significantly improved with the modified breast pump suction pattern compared to the standard pattern (OR 1.29, 95% CI 1.08 to 1.6) with 86% vs. 67% of participants not needing to reduce applied vacuum levels. The amount of milk expressed did not differ significantly between phases (group 1: 7.6 ml (2.7-25.5 ml), group 2: 12.0 ml (1.2-31.5 ml), p = 0.43). Discussion: This study is the first to demonstrate an improvement in user comfort driven by the implementation of gentle transitions in vacuum modes in a commonly used breast pump suction pattern. Research into this novel population combining both pumping and breastfeeding in the first days after birth offers new unique insights on the requirements of breast pump suction patterns. Trial registration: Registered on clinical trials.gov NCT04619212. Date of registration November 6, 2020.

The Effects of Different Storage Conditions on Leukocytes in Human Breast Milk.

Objectives: Breast milk is the best baby food because it contains various nutrients and important factors for the baby's immune system, including leukocytes. This study aimed to determine the effects on morphology, number of cells and breast milk leukocytes count of various ways of storing breast milk based on different temperatures and storage durations. Methods: This study was conducted at the Biochemistry Laboratory, Integrated Laboratory and the Histology Laboratory, Universitas Indonesia, Jakarta, Indonesia from September 2022 to February 2023. Transitional breast milk samples from 7 breastfeeding mothers were utilised in the study. A total of 50 mL was divided into 4 tubes of 12.5 mL each and treated based on temperature, storage time and method of thawing frozen breast milk based on the Centers for Disease Control and Prevention's (CDC) recommendations for breast milk storage. The breast milk cells were isolated to calculate the cell number and leukocyte population. Subsequently, the breast milk cells were stained with haematoxylin and eosin to analyse the number and morphology of leukocytes. Results: The findings showed a significant decrease in the breast milk's total number and population and changes in the morphology of breast milk leukocytes after storage. Conclusion: This study indicates that CDC storage recommendations do not affect the quantity of the CD45+ leukocyte population; however, there is a decrease in the total number of leukocytes and alterations in their microscopic morphology. Thus, additional research is recommended to determine whether these modifications influence the function of the breast milk cells.

Comparison of the Effect of Direct Breastfeeding, Expressed Human Milk, and Infant Formula Feeding on Infant Weight Trajectories: A Systematic Review.

Background: Formula and breastfeeding are known factors associated with infant weight trajectories. Evidence exploring the effect of expressed human milk feeding on infant weight in the community setting has not been well synthesized. Objectives: This systematic review examined (1) weight changes among infants fed expressed human milk and (2) differences in weight change between infants fed expressed human milk and infants fed at the breast or infant formula via bottle. Methods: A comprehensive search of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of each study was appraised using the Joanna Briggs Critical Appraisal Tools. Results: A total of six studies met the eligibility criteria and included a total of 5,152 infants. The within-subject analysis identified only 31 infants strictly or predominantly fed expressed human milk. The between-subject analysis comparing expressed human milk feeding to the available comparison groups (formula-fed or direct at the breastfed) revealed that higher weight gains were observed in the weight trajectories among infants in the bottle or formula-fed conditions in four of the six included studies. Conclusions: Findings from the few studies included in this review found a difference in the infant weight gain patterns among expressed human milk-fed infants when compared with their respective feeding groups (directly breastfed or formula-fed). Further research is needed to corroborate these findings and elucidate the clinical significance of the differences in weight gain patterns observed across infant feeding groups.

ABM Position Statement: Paid Maternity Leave-Importance to Society, Breastfeeding, and Sustainable Development.

Background: Paid maternity leave benefits all of society, reducing infant mortality and providing economic gains. It is endorsed by international treaties. Paid maternity leave is important for breastfeeding, bonding, and recovery from childbirth. Not all mothers have access to adequate paid maternity leave. Key Information: Paid leave helps meet several of the 17 United Nations' Sustainable Development Goals (2, 3, 4, 5, 8, and 10), including fostering economic growth. A family's expenses will rise with the arrival of an infant. Paid leave is often granted with partial pay. Many low-wage workers earn barely enough to meet their needs and are unable to take advantage of paid leave. Undocumented immigrants and self-employed persons, including those engaging in informal work, are often omitted from maternity leave programs. Recommendations: Six months of paid leave at 100% pay, or cash equivalent, should be available to mothers regardless of income, employment, or immigration status. At the very minimum, 18 weeks of fully paid leave should be granted. Partial pay for low-wage workers is insufficient. Leave and work arrangements should be flexible whenever possible. Longer flexible leave for parents of sick and preterm infants is essential. Providing adequate paid leave for partners has multiple benefits. Increasing minimum wages can help more families utilize paid leave. Cash benefits per birth can help informal workers and undocumented mothers afford to take leave. Equitable paid maternity leave must be primarily provided by governments and cannot be accomplished by employers alone.

Mothers' experiences of breast milk expression during separation from their hospitalized infants: a systematic review of qualitative evidence.

BACKGROUND: Mother-infant separation, which is occurring with an increasing incidence, is a barrier to direct breastfeeding. Owing to the importance of breast milk to hospitalized infants, mothers are actively encouraged to express milk during their infants' neonatal intensive care unit (NICU) stay. However, mothers are often faced with a number of challenges in this process. There is a need to understand such mothers' real-life experiences of breast milk expression to develop supportive strategies to reduce the burden on mothers and increase breastfeeding rates. METHODS: A comprehensive search of 12 databases was conducted for relevant studies published from database construction to December 2022. All qualitative and mixed-method studies published in English and Chinese that reported on mothers' experiences of human milk expression during separation from their hospitalized infants were included. Two reviewers independently conducted screening, data extraction, and quality appraisal, with disagreements resolved by a third reviewer. The process of searching followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The JBI Qualitative Assessment and Review Instrument was used to assess study quality and the credibility of study findings. Meta-aggregation was performed to integrate the results. RESULTS: This systematic review aggregated mothers' experiences of milk expression during separation from their hospitalized infants. Database search yielded 600 records, of which 19 full-text documents were screened. Finally, 13 studies of good quality were included with data from 332 mothers across seven countries. A total of 61 primary findings with illustrations were extracted from the 13 eligible studies, the findings were generalized into 16 categories, and further were concluded as four synthesized findings: purpose and motivation, physical and emotional experiences, barrier factors, and coping styles. CONCLUSION: Mothers were driven by extrinsic motivation in their decision to express breast milk. They experienced physical exhaustion and many negative emotional feelings while expressing. This process was affected by numerous barriers. Social support was essential to the initiation and maintenance of milk expression. Medical staff and families should pay more attention to the mental health of mothers with infants in the NICU. Future research should incorporate strategies to cope with emotional responses and offer practical strategies for managing milk expression. SYSTEMATIC REVIEW REGISTRATION: [ www.crd.york.ac.uk ], identifier [PROSPERO 2022 CRD42022383080].

Community Practices, Published Guidelines, and Evidence Base Surrounding Breast Milk Handling and Storage: A Qualitative Study.

Background: Expressed breast milk (EBM) is the best alternative to direct breastfeeding. However, expressing breast milk requires good milk handling and storage practices to preserve EBM safety and integrity. Mothers require handling and storage guidance, and many seek this from the internet and online support groups. Aim: This study aimed at exploring EBM handling and storage practices within an online exclusively expressing community and comparing these with both internet resources and evidence-based research. Methods: A naturalistic observational design was used. Content analysis was undertaken on 10,000 posts from an Australian Facebook peer-support community for women who exclusively express breast milk. Women's questions, reported practices, and advice for EBM handling and storage were analyzed thematically and compared with both guidelines and evidence-based research. Findings: There were 460 posts on EBM handling and storage. Three key themes emerged: "How should I store my EBM?," "How long can I store my EBM?," and "How do I use my EBM?" The greatest consistency and agreement between recommendations and community practices were found for storage methods, whereas the least was found for storage times. EBM handling and storage practices were influenced by factors such as EBM value, convenience, and cost, leading to occasional deviations from consistent practice recommendations. Conclusion: To facilitate safe EBM handling and continuation of expression, guidelines should be updated so they are consistent, align with current evidence, and cater to mothers' cost, convenience, and milk wastage concerns. Health care providers can partner with women to evaluate online information to empower mothers in their decision making.

Milk Biomarkers of Secretory Activation in Breast Pump-Dependent Mothers of Preterm Infants: An Integrative Review.

Background: Lack of mother's own milk (MOM) at discharge from the neonatal intensive care unit (NICU) is a global problem and is often attributable to inadequate MOM volume. Evidence suggests that the origins of this problem are during the first 14 days postpartum, a time period that includes secretory activation (SA; lactogenesis II, milk coming in). Objectives: To describe and summarize evidence regarding use of MOM biomarkers (MBMs) as a measure of SA in pump-dependent mothers of preterm infants in the NICU and to identify knowledge gaps requiring further investigation. Methods: An integrative review was conducted using Whittemore and Knafl methodology incorporating the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. A search using electronic databases MEDLINE (through PubMed) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) and reference lists of included articles was conducted. Results: Of the 40 articles retrieved, 6 met the criteria for inclusion. Results revealed the following five findings: (1) Achievement of SA defined by MBMs is delayed and/or impaired in mothers of preterm infants. (2) MBMs are associated with pumped MOM volume. (3) Achievement of SA defined by MBMs is associated with pumping frequency. (4) Delayed and/or impaired achievement of SA defined by MBMs may be exacerbated by maternal comorbidities. (5) There is a lack of consensus as to which MBM(s) and analysis techniques should be used in research and practice. Conclusions: MBMs hold tremendous potential to document and monitor achievement of SA in mothers of preterm infants, with multiple implications for research and clinical practice.

Electroencephalographic activity during direct breastfeeding and breast milk expression in primiparous mothers.

Breastfeeding is recognized worldwide as the best option for infant feeding. Expressing breast milk is an alternative for mothers to provide their infants all the benefits of maternal milk. During breast milk expression, mothers receive a distinct kind of sensory stimulation, because there is no direct bodily or affective interaction with their infants, many women report feeling isolated, generating a love-hate relation with pumping, and even low levels of satisfaction while expressing breast milk. While it is well known that the prefrontal, parietal, and temporal cortices play important roles in the emotional and cognitive processing of maternal stimuli, knowledge about how these cortical areas function during breastfeeding is lacking. This study was designed to characterize EEG activity in the prefrontal and parietal cortices and the affective scores of primiparous breastfeeding mothers during two conditions of milk expression: breast milk expression and direct breastfeeding. Participants reported higher valence and arousal and a pleasant state during direct breastfeeding. In the direct breastfeeding condition, both prefrontal areas showed a higher absolute power (AP) of the slow bands, with a lower AP of the alpha band in the parietal cortex. A lower correlation between frontopolar and dorsolateral areas with a higher correlation between prefrontal and parietal cortices was obtained mainly in the right hemisphere. This EEG activity could be linked to an internal state of focused attention and, simultaneously, open monitoring of the environment that suggests an integration of the motive-emotional and cognitive processes necessary for adequate mother-baby interaction during direct breastfeeding.

Expressed breast milk and maternal expression of breast milk for the prevention and treatment of neonatal hypoglycemia: a systematic review and meta-analysis.

BACKGROUND: Worldwide, many guidelines recommend the use of expressed breast milk (EBM) and maternal expression of breast milk for the prevention and treatment of neonatal hypoglycemia. However, the impact of both practices on neonatal hypoglycemia is unclear. This study aims to determine the effectiveness of EBM and maternal expression of breast milk in preventing and treating neonatal hypoglycemia. METHODS: We registered our review in PROSPERO (CRD42022328072). We systematically reviewed five databases and four clinical trial registries to identify randomized controlled trials (RCT), non-randomized studies of intervention (NRSI), and cohort studies that compared infants who received EBM to infants who did not, and similar study designs that compared infants whose mothers expressed breast milk to infants whose mothers did not. Two independent reviewers carried out screening, data extraction, and quality assessment. The quality of included RCT, NRSI, and cohort studies were respectively assessed with the Cochrane Risk of Bias 2, Risk Of Bias In Non-randomised Studies-of Interventions, and the Newcastle-Ottawa Scale tools. Results from studies on EBM were synthesized separately from those on maternal expression of breast milk. Meta-analysis was undertaken using Revman 5.4. and fixed-effect models. RESULTS: None of the ten included studies was specifically designed to determine the effect of EBM or maternal expression of breast milk on neonatal hypoglycemia. The effect of EBM on neonatal hypoglycemia was not estimable. There was no difference in the risk of hypoglycaemia among neonates whose mothers expressed breast milk compared to those whose mothers did not [RR (95%CI); one RCT: 0.92 (0.77, 1.10), high-certainty evidence; one cohort: 1.10 (0.74, 1.39), poor quality study]. CONCLUSIONS: There is insufficient evidence to determine the effectiveness of EBM for preventing or treating neonatal hypoglycemia. Limited data suggests maternal breast milk expression may not alter the risk of neonatal hypoglycemia. High-quality randomized controlled trials are needed to determine the effectiveness of EBM and maternal expression of breast milk for the prevention and treatment of neonatal hypoglycemia.

Effect of antenatal milk expression education on lactation outcomes in birthing people with pre-pregnancy body mass index ≥25: protocol for a randomized, controlled trial.

BACKGROUND: Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m2, particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population. METHODS: This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m2. The assigned study treatment is delivered via four weekly online video consultations between gestational weeks 37-40. Participants assigned to AME meet with study personnel and a lactation consultant to learn and practice AME. Instructions are provided for home practice of AME between study visits. Control group participants view videos on infant care/development at study visits. Participants complete emailed surveys at enrollment (340/7-366/7 gestational weeks) and 2 weeks, 6 weeks, 12 weeks, 6 months, and 12 months postpartum. Surveys assess lactation and infant feeding practices; breastfeeding self-efficacy, attitudes, and satisfaction; perception of insufficient milk; onset of lactogenesis-II; lactation support and problems; and reasons for breastfeeding cessation. Surveys also assess factors associated with lactation outcomes, including demographic characteristics, health problems, birth trauma, racial discrimination, and weight stigma. Health information and infant feeding data are abstracted from the pregnancy and birth center electronic health record. Milk samples are collected from the intervention group at each study visit and from both groups at each postpartum follow-up for future analyses. Qualitative interviews are conducted at 6 weeks postpartum to understand AME experiences. Primary outcomes of interest are breastfeeding exclusivity and breastfeeding self-efficacy scores at 2 weeks postpartum. Outcomes will be examined longitudinally with generalized linear mixed-effects modeling. DISCUSSION: This is the first adequately powered trial evaluating the effectiveness of AME among U.S. birthing people and within a non-diabetic population with pre-pregnancy BMI ≥ 25 kg/m2. This study will also provide the first evidence of acceptability and effectiveness of telelactation-delivered AME. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04258709.

Human milk expression in the first year postpartum among persons with low incomes.

BACKGROUND: Expressing milk (i.e., human milk) is common in the USA, but practices are unknown among families in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). This study of a WIC population explores the practice of and reasons for expressing milk in the first year postpartum. METHODS: We analysed data from a longitudinal study to examine milk expression at 1, 3, 5, 7, 9, 11, and 13 months postpartum among breastfeeding persons enrolled in WIC with term singletons. We cross-sectionally analysed the weighted prevalence of milk expression at each survey month and report reasons for milk expression in the first 7 months. RESULTS: Among the study participants who reported feeding human milk at Month 1, 70.4% expressed milk in the first 13 months postpartum. The prevalence of milk expression was 56.8% at Month 1 and decreased to 13.9% at Month 13 among those feeding any human milk that month. Reasons for expressing milk changed over time; in the first month, increasing milk supply, relieving engorgement, and having an emergency supply of milk were common. In later months, having a supply of milk available so that someone else could feed their infant was common. CONCLUSIONS: Clinicians, health educators, WIC staff, and others working with WIC families can promote optimal expressed milk feeding and storage practices. Extra attention and support may be especially important in the first months postpartum when milk expression is common. Support for persons who are expressing milk can be tailored for reasons of milk expression.

Factors Associated with an Inadequate Volume of Expressed Milk Among Mothers of Preterm and Low Birth Weight Neonates Admitted to Neonatal Intensive Care Units of Government Hospitals in Addis Ababa, Ethiopia.

Background: Around 15 million live newborns are born prematurely each year around the world before 37 weeks. One cause of inadequate nursing is prematurity. The goal of this study was to find parameters linked to an insufficient volume of expressed milk among mothers of preterm and low birth weight neonates at government hospitals in Addis Ababa, Ethiopia. Methods: An nstitution-based cross-sectional study was conducted on a total of 124 mothers who were available in neonatal intensive care units during the study period in government hospitals that provided such units. Results: One-third of the responders (33.9%) were unable to express the necessary amount of milk. An inadequate volume of expressed breast milk was significantly associated with a baby's stable health status (AOR=0.24; CI=0.07-0.86), the fair (subcritical) health status of the baby (AOR=0.178; CI=0.04-0.76), worry about the volume of milk (AOR=7.50; CI=3.32-16.95), and worry about the baby's health status (AOR=4.63; CI=2.21-9.70). Conclusion: According to our findings, 33.9% of mothers were unable to express sufficient amounts of milk. To produce an adequate volume of expressed breast milk, health care workers must address mothers' psychological issues in the neonatal intensive care units and give all necessary care to prevent neonatal deterioration.

Benefits and issues of education program for nurse-midwives on milk expression care for preterm mothers in postpartum period.

Background and aims: Breastfeeding is important for preterm mothers and infants. However, evidence-based practice and standardized education remain inadequate. To implement evidence-based practice, continuous education is mandatory for nurse-midwives. We previously implemented our developed education program on early essential milk expression care for preterm mothers among Japanese nurse-midwives. Herein, we aimed to assess the effects of our education program on nurse-midwives' knowledge of milk expression care for preterm mothers in terms of changes in their correct answer rates for 20 specific knowledge items before and after the education program implementation. We also aimed to identify program-related issues from nurse-midwives' comments to improve the program. Methods: We conducted a secondary analysis of our previous data and surveyed the knowledge of 36 nurse-midwives who received a similar face-to-face education program on milk expression care for mothers three months before (Pre-1), just before (Pre-2), just after (Post-1), and three months after (Post-2) the program. We obtained their comments at Post-2 and identified issues for program improvement. Results: The knowledge items, in which the correct answer rates of Post-1 were significantly higher than those of Pre-2, were Verification of the motivation and intent, Benefits of breastfeeding for mothers and infants, Milk volume on the fourth day and at around the second week after birth, Lactogenesis stage 3, Autocrine control, Time between birth and the initiation of milk expression, Early initiation of milk expression, Frequent milk expression, and Duration of pumping. The issues identified were practical training, knowledge retention, and misunderstanding knowledge. Conclusions: Nurse-midwives' unacquired knowledge of milk expression care for preterm mothers was effectively supplemented by the education program. Pre-education knowledge items with low correct answer rates must be strengthened during in-service education. Practical training, knowledge retention, and misunderstanding knowledge can be improved.

Breast Pumps and Mastitis in Breastfeeding Women: Clarifying the Relationship.

Mastitis is a debilitating condition that can impact around 20% of mothers and is characterized by fever, flu-like symptoms and tender, swollen areas of the breasts. Despite the emerging evidence that breast milk dysbiosis is an underlying cause of mastitis, breast pumps have been implicated as a predisposing risk factor in the pathophysiology of mastitis in breastfeeding mothers. Previous studies have suggested that the use of a breast pump increases a mother's risk for developing mastitis, however, incidence rates of mastitis over the stages of lactation do not match breast pump usage rates. Furthermore, breast pumps, even when used at low vacuum, still promote some breast drainage, thus avoiding milk stasis, which is considered a key factor in the development of mastitis. As a consequence, these data suggest that the literature association of breast pumps with mastitis is more a case of reverse causation and not direct association. Moreover, it is important to note that breast pumps are actually a part of the conservative management of mastitis. In combination, these data show that the breast pump should not be considered a driver in the pathophysiology of mastitis in women.

Breast milk expression as a challenge for mothers of premature infants.

The aim of this study was to examine the psychometric properties of the 11-item Breast Milk Expression Experience Scale and determine the level of breast milk expression experience of mothers after preterm delivery in Turkey. 165 mothers who agreed to participate between February 2019 and March 2020 used the Breast Milk Expression Experience Scale (BMEE-S). The general Cronbach alpha coefficient was 0.82 for the BMEE-S. The fit indices calculated by confirmatory factor analysis were χ2 (41) = 87.95, p = .00003, χ2/sd = 2.15, GFI = 0.91, NNFI = 0.93, CFI = 0.95, RMSEA = 0.08 and SRMR = 0.078. The BMEE-S three-factor structure was verified by the confirmatory factor analysis. The BMEE-S was a valid and reliable instrument for mothers of preterm infants. Multiparity and high-risk pregnancy history negatively affected the milk expression experience, whereas spousal support positively affected it.Impact statementWhat is already known on this subject? The risk of infectious diseases, obesity, diabetes, and impaired intellectual development increases in children who do not breast milk (Verduci et al. 2014). International breastfeeding guidelines recommend supporting all mothers to start breastfeeding within one hour of birth, and counselling mothers who are separated from their babies about expressing milk.What the results of this study add? The breast milk expression experience scale is a valid and reliable tool for women who give preterm birth and express milk. The experience of expressing breast milk can affect the amount of milk that passes from mother to baby. Multiparity and high risk pregnancy history of mothers negatively affects the milk expression experience while husband support positively affects the milk expression experience.What the implications are of these findings for clinical practice and/or further research? Our study provides a quantitative examination of the experiences of mothers who are separated from their babies. The BMEE-S should be adapted to different cultures and the experiences of mothers in this process should be determined.

Unseen, unheard: a qualitative analysis of women's experiences of exclusively expressing breast milk.

BACKGROUND: Breast milk feeding has numerous benefits for women and infants. Positive maternal experiences with breast milk feeding impacts exclusivity, duration, and maternal mental health. Most research focuses on women feeding directly at the breast. Some women elect to feed exclusively expressed milk to their healthy, term infants rather than feed directly at the breast. Little is known about what constitutes a positive experience among this population. Therefore, the aim of this study was to explore women's experiences of exclusive expression (EE). METHODS: Interviews were conducted via Microsoft Teams to collect qualitative data from a purposive sample of 21 women practicing EE. Interviews were analyzed for themes. RESULTS: Three themes: Unseen and Unheard, Doing it My Way, and Getting into the Groove, and 8 subthemes: Breast is Best, Missed Opportunities for Healthcare Provider Support, Fighting for it, What Works for Us, A Sense of Control, Preparation, Tricks of the Trade, and Making it Manageable were identified. Despite challenges, including a lack of support from healthcare providers and a lack of acknowledgement as breastfeeding mothers, exclusive expression offered participants a method to continue breast milk feeding in a way that they found to be satisfying. CONCLUSION: This study provides insight into experiences of exclusive expression that clinicians can use to improve their support of breast milk feeding during perinatal encounters. Societal pressure to feed from the breast may have negative emotional consequences for women electing to exclusively express. There is a need for more information and support for breast milk expression from healthcare providers along with a reframing of how breast milk feeding is discussed and promoted.

Breast Milk Production in Women Who Use Nipple Shields for Persistent Nipple Pain.

OBJECTIVE: To examine relationships between nipple pain scores and 24-hour milk production volumes, breastfeeding and pumping frequencies, and breastfeeding duration in women using nipple shields for persistent nipple pain. DESIGN: Secondary outcome analysis of a prospective cohort study. SETTING: Research laboratory and participants' homes. PARTICIPANTS: Twenty-five breastfeeding women (6 ± 4 weeks after birth) who used nipple shields for persistent nipple pain. METHODS: We conducted a randomized trial to investigate the primary outcome of milk transfer with and without nipple shields among participants with and without nipple pain. Here, we report secondary outcomes of associations between 24-hour milk production, breastfeeding and pumping frequencies, breastfeeding durations, and intake in participants using a nipple shield for nipple pain. Participants completed demographic, health and breastfeeding questionnaires and, at two monitored breastfeeding sessions, completed a pain visual analogue scale and Brief Pain Inventory-Short Form (BPI-SF; total and subscale scores for pain interference with General Activity, Mood, Sleep, and Breastfeeding). Milk production (milliliters per 24 hours), feed volumes, and percentage of available milk removed were calculated from data and milk samples obtained by participants over one 24-hour period and at study visits. Participants logged 24-hour data on a customized research website. We used descriptive statistics as well as simple and multiple linear regression for analyses. RESULTS: Milk production and feeding duration were not associated with nipple pain scores (visual analogue scale: p = .80, BPI-SF: p = .44). An increase in BPI-SF Breastfeeding subscale score of 1 unit, indicating pain interference with breastfeeding, was associated with a 0.28 decrease in 24-hour breastfeeding frequency (p = .02) and an 18.8-ml decrease in 24-hour breastfeeding intake (p = .04). CONCLUSION: Persistent nipple pain was associated with reduced breastfeeding frequency; therefore, continuing professional support is required to ensure adequate milk removal and pain management.