Domperidone for increasing breast milk volume in mothers expressing breast milk for their preterm infants: a systematic review and meta-analysis.

BACKGROUND: Mothers of preterm infants often struggle to produce enough breast milk to meet the nutritional needs of their infant. Galactagogues such as domperidone are often prescribed to increase breast milk supply but evidence supporting their role in clinical practice is uncertain. OBJECTIVE: To evaluate the efficacy and safety of domperidone for increasing breast milk volume in mothers expressing breast milk for their preterm infants. SEARCH STRATEGY: MEDLINE, Embase and Web of Science were searched without language restrictions from first publication until January 2017. Bibliographies of articles and reviews were hand-searched for additional reports. SELECTION CRITERIA: Randomised controlled trials that compared domperidone with placebo in mothers of preterm infants (<37 weeks' gestation) experiencing insufficient milk supply. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data and evaluated study quality. Differences in breast milk volume and adverse events were combined using fixed effects meta-analysis. MAIN RESULTS: The pooled analysis of five trials consisting of 194 women demonstrated a moderate increase in daily breast milk volume of 88.3 ml/day (95% CI 56.8-119.8) with the use of domperidone compared with placebo. No difference was evident with respect to maternal adverse events (odds ratio 1.05, 95% CI 0.65-1.71), with no reported cases of prolonged QTc syndrome or sudden cardiac death. Sensitivity analyses showed no important differences in the estimates of effects. CONCLUSIONS: Domperidone is well tolerated and results in a moderate short-term increase in expressed breast milk volume among mothers of preterm infants previously identified as having insufficient breast milk supply. TWEETABLE ABSTRACT: Domperidone leads to short-term improvements in breast milk volume in mothers of preterm infants.

Physical health, breastfeeding problems and maternal mood in the early postpartum: a prospective cohort study.

This study aimed to investigate prospectively the contribution of maternal physical health and/or breastfeeding problems to maternal mood (depression, anxiety, fatigue, irritability, confusion, vigor) at 8-weeks postpartum. A prospective study was conducted. Participants were recruited antenatally from a public and a private maternity hospital in Melbourne, Australia. Nulliparous pregnant women (N = 229), ≥ 18 years of age, ≥ 36-week gestation, singleton pregnancy and with sufficient English were eligible. Data were collected by self-report questionnaire (pregnancy, weeks 1-4 postpartum) and telephone interview (week 8 postpartum). A high burden of physical problems was classified as ≥ 3 problems (caesarean/perineal pain; back pain; constipation; haemorrhoids; urinary and bowel incontinence) for ≥ 2 time points. A high burden of breastfeeding problems was having ≥ 2 problems (mastitis; nipple pain; frequent expressing; over- or under-supply of milk) for ≥ 2 time points. Multivariate linear regression was used to investigate the relationship between maternal mood, assessed using Profile of Mood States (8-week postpartum), and a high burden of breastfeeding and/or physical health problems. Forty-six women (20.1%) had a high burden of physical symptoms, 44 (19.2%) a high burden of breastfeeding problems only and 25 women (11.0%) had both. A high burden of breastfeeding problems alone (ß = 10.6, p = 0.01) or with co-morbid physical problems (ß = 15.35, p = 0.002) was significantly associated with poorer maternal mood at 8 weeks. Early, effective postnatal treatment of maternal health and breastfeeding problems could reduce women's risk for poor mental health.

Is onset of lactation delayed in women with diabetes in pregnancy? A systematic review.

AIM: To determine if women with diabetes in pregnancy have a delayed onset of lactation through a systematic review of the literature. METHODS: We searched databases including MEDLINE, Web of Science, PubMed, CINAHL Plus and PsychINFO for articles assessing diabetes in pregnancy and lactogenesis. Thirty-one articles were screened and 10 articles were included in the systematic review. We extracted data on diabetes in pregnancy and onset of lactation (secretory activation or lactogenesis II). RESULTS: The 10 studies examining the association between women with diabetes in pregnancy and delayed onset of lactation reported a significant delay in women with diabetes compared with women without diabetes. Two studies assessed the impact of metabolic control on lactogenesis, and found an association between poorer metabolic control and delayed onset of lactation. CONCLUSIONS: Although this review has found evidence of an association between women experiencing diabetes during pregnancy and delayed onset of lactation, the presence of many potential confounding factors need to be acknowledged.

Infant feeding practices in the first 24-48 h of life in healthy term infants.

AIM: To examine in-hospital infant feeding practices, focusing on initiation and prevalence of breastmilk expression and to describe the proportion of women having a breast pump immediately after birth. METHODS: Postpartum women were recruited from three hospitals in Melbourne, Australia, between 2009 and 2011. INCLUSION CRITERIA: having had a healthy singleton term infant, intending to breastfeed and fluency in English. Data were collected using a structured questionnaire. RESULTS: Just over 1000 women were recruited at 24-48 h postpartum; 50% were primiparous. Forty-seven per cent of infants had been fully breastfeeding at the breast from birth, and another 47% had received at least some expressed breastmilk. Forty per cent of first-time mothers reported having had a problem breastfeeding, and 46% already had a breast pump prior to the birth of their infant. CONCLUSIONS: Early breastfeeding problems were common, and less than half the infants had fed only at the breast in the first days of life. Given the normalization of breastmilk expression, more evidence is needed regarding the impact of expressing on duration of breastmilk feeding and maternal health outcomes.

Maternal smoking and reduced duration of breastfeeding: a review of possible mechanisms.

AIM: To systematically review the possible mechanisms by which maternal smoking affects lactation. METHODS: Databases (Medline, CINAHL, Current Contents, Psychinfo, Sociological Abstracts and the Cochrane Library) were searched for smoking and breastfeeding or infant feeding. The Journal of Human Lactation and Birth were hand-searched, searches were also conducted at NMAA's Lactation Resource Centre and references cited were located where appropriate. Articles were divided into the various ways that smoking could affect breastfeeding and were tabulated. RESULTS: Most studies were conducted on small samples of animals or humans; the majority were prior to 1985. Most animal studies exposed the animals to much greater levels of nicotine than those to which humans are exposed. Most studies did not examine if breastfeeding behaviour was similar in smokers and non-smokers, and did not consider that any physiological difference found could be the result of poor lactation practices, rather than the cause of poor lactation in smokers. The definition of breastfeeding infants was also problematic in many studies. The effect of smoking on oxytocin in women was only examined in one study, and no effect was found, yet a negative effect of smoking on oxytocin release is reported in the breastfeeding literature. CONCLUSION: Although there is consistent evidence that women who smoke breastfeed their infants for a shorter duration than non-smokers, the evidence for a physiological mechanism is not strong.

Psychological aspects of nipple pain in lactating women.

The aim of the study was to assess the psychological impact of nipple pain in lactating women. Forty-eight lactating women with nipple pain completed mood scales at their first visit and following resolution of their pain, and 65 lactating women without nipple pain completed one set of mood scales. At the first visit, the mean score on the Edinburgh Postnatal Depression Scale (EPDS) in the nipple pain group was 12.4 and the control group was 7.6 (p < 0.0001). Eighteen women (38%) scored above the threshold for depression (> 12), compared to nine in the control group (14%): p < 0.01. Following pain resolution, the mean score on the EPDS decreased to 7.3 (p < 0.001); and six women (16%) scored 13 or over on the EPDS, significantly less than initially (p < 0.05). Similarly, on the Profile of Mood States (POMS), the nipple pain group scored significantly higher than control group on all mood factors (Tension, Depression, Fatigue, Confusion, Vigor [lower]), except Anger which did not reach a level of significance. After pain resolution, POMS scores returned to similar levels as the control group. In conclusion, both the EPDS and POMS indicated women with nipple pain were experiencing high levels of emotional distress. However, once the pain had resolved their distress also resolved.

Candida and the lactating breast: predisposing factors.

Candida albicans infection of the nipples and breast ducts is a cause of sore nipples and "shooting" breast pain during lactation. A questionnaire which sought to identify predisposing factors was given to 51 women with candidiasis of the lactating breast, 18 women with other breastfeeding difficulties, and 29 women breastfeeding without any difficulties. Nipple damage in early lactation, mastitis, recent use of antibiotics postpartum, long-term use prior to pregnancy, and history of vaginal thrush were positively associated with candidiasis of the lactating breast. Thrush, especially oral thrush, was more common in babies of mothers in the candida group. However, some mothers with symptomatic candida infection reported none of these predisposing factors.

An audit of mastitis in the emergency department.

A medical audit was conducted in 1997 of hospital records of women attending the emergency department of the Royal Women's Hospital in Melbourne, Australia, in 1996 with a diagnosis of "mastitis." One hundred and seven women were diagnosed with mastitis; approximately half were primiparous (53%) and the median age of the baby was 14 days. Most women (69%) attended the emergency department after normal working hours. Thirty-nine percent of the women were afebrile, and only 27% had a temperature of 38.5C or higher. The majority of women were prescribed flucloxacillin. Milk culture was obtained in only 15 cases, and Staphylococcus aureus was the most common pathogen.

Rates of breastfeeding in Australia by state and socioeconomic status: evidence from the 1995 National Health Survey.

OBJECTIVE: To estimate rates of breastfeeding in the first year of life in Australia, according to state and socioeconomic status. METHODOLOGY: Analysis of data from the 1995 Australian National Health Survey. RESULTS: Estimated breastfeeding rates are 81.8% on discharge from hospital, 57.1% fully breastfed at three months and 62.6% fully or partially breastfed at three months. At six months, it is estimated that 18.6% of babies are fully breastfed and 46.2% fully or partially breastfed. At one year, 21.2% of infants are receiving some breastmilk. Comparison between states demonstrates that there is considerable variation in breastfeeding practice within Australia. Rates of breastfeeding also vary according to the socioeconomic status of the geographic area in which the child is living, with a strong inverse relationship between rates of breastfeeding and socioeconomic status. CONCLUSION: Australia's target for breastfeeding in the year 2000 is to have 80% of babies at least partially breastfed for the first six months of life. Although Australia has good rates of initiation of breastfeeding these levels are not maintained over time, and it seems unlikely that we will reach the year 2000 targets.

Does maternal obesity adversely affect breastfeeding initiation and duration?

OBJECTIVE: To examine the relationship between maternal obesity and the initiation and duration of breastfeeding. METHODS: Analysis was made of the 1995 National Health Survey, in which personal interviews were conducted on a multistage area sample of private dwellings and a list sample of non-private dwellings in all States and Territories of Australia. Mothers between the ages of 17 and 50 years (n = 1991) with children under the age of four years in 1995 participated in the study. RESULTS: Of the group of mothers with a body mass index (BMI) of 20-25, 89.2% (95% confidence interval (CI) 87.4-91.0) initiated breastfeeding, compared with 82.3% (95% CI 77.6-87.0) of mothers with a BMI of 30 or more. There was also a significant difference between the mean and median duration of breastfeeding of obese and non-obese mothers (BMI 30 and over, < 25, respectively). These differences remained significant when maternal smoking, age and other sociodemographic factors were taken into consideration. CONCLUSIONS: Health professionals should be aware that obese women may be at increased risk of not breastfeeding or stopping breastfeeding prematurely.

Effect of gestation on initiation and duration of breastfeeding.

OBJECTIVE: The aim of this study was to investigate the effect of gestation on initiation and duration of breastfeeding in Australian infants. METHODS: The Longitudinal Study of Australian Children recruited a national sample of children born between March 2003 and February 2004 (n = 3600 in this multivariate sample). RESULTS: Breastfeeding initiation was lower for infants of 35-36 weeks' gestation (88.2%) than 37-39 weeks' gestation (92.0%) and > or =40 weeks' gestation (93.9%). At 6 months, 41.2% of infants 35-36 weeks' gestation were breastfeeding compared with 54.5% of 37-39 weeks' gestation infants and 60.5% of infants born > or =40 weeks. Compared with infants born > or =40 weeks, infants born at 35-36 weeks had an adjusted odds ratio (OR) of 0.51 (95% CI 0.34 to 0.76) and infants born at 37-39 weeks had an adjusted OR of 0.80 (95% CI 0.69 to 0.93) of breastfeeding at 6 months. CONCLUSION: Infants born before 40 weeks are at greater risk of being artificially fed than infants born > or =40 weeks.

Nipple pain, mastalgia and candidiasis in the lactating breast.

During lactation, persistently sore nipples or shooting breast pain in the absence of local or systemic signs may be symptoms of C. albicans infection of the nipples and/or breast ducts. The nipple may be erythematous or fissured, but the appearance does not resemble oral or vaginal candidiasis. Case 1 is a woman with sore nipples following a course of antibiotics. Case 2 is a woman with severe shooting breast pain which was worsened by antibiotic treatment. Treatment included topical and oral antifungal treatment for the mother in conjunction with an 'anti-candida' diet. The infant's mouth was also treated to prevent reinfection.

Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study.

AIM: To report the relationship between maternal prenatal intention to breastfeed and the actual initiation and duration of breastfeeding. METHODS: Pregnant women resident within Avon, UK, expected to give birth between 1 April 1991 and 31 December 1992 were recruited in a longitudinal cohort study. Main outcome measures included maternal infant feeding intention (breastfeed, breast and bottle feed, bottle feed, or uncertain) at 32 wk of pregnancy: intention in the first week, intention for the rest of the first month and intention in months 2 to 4; initiation and duration of breastfeeding up to six months. RESULTS: Data were available on 10,548 women. Prenatal intention to breastfeed had an influence on both initiation and duration of breastfeeding. Of the women intending to bottle feed from birth, only 3.4% initiated breastfeeding compared with 96.6% of women planning to breastfeed for at least four months. At six months postpartum, the mean duration of breastfeeding for women intending to breastfeed for at least five months was 4.4 mo (95% CI 4.3, 4.4), compared with 2.5 mo (95% CI 2.4, 2.6) for women with a prenatal intention to breastfeed for only one month. Logistic regression, using intended duration as the only explanatory variable, correctly predicted 91.4% of breastfeeding initiation and 72.2% of infant feeding at six months. CONCLUSIONS: This large population-based study confirms the strength of the relationship between maternal prenatal intention to breastfeed and both breastfeeding initiation and duration. Maternal intention was a stronger predictor than the standard demographic factors combined. This should be taken into account in future research, and trials should be undertaken to establish whether interventions could alter maternal intention and thereby increase rates of breastfeeding initiation and duration.

The relationship between maternal smoking and breastfeeding duration after adjustment for maternal infant feeding intention.

AIM: To investigate whether maternal smoking remains associated with decreased breastfeeding duration after adjustment for the mother's infant feeding intention. METHOD: Pregnant women resident within Avon, UK, expected to give birth between 1 April 1991 and 31 December 1992 were recruited in a longitudinal cohort study. Main outcome measures included maternal infant feeding intention at 32 wk of pregnancy: intention for the first week, intention for the rest of the first month and intention in months 2 to 4. Maternal smoking was defined as any smoking reported at any time during pregnancy. Data on initiation and duration of breastfeeding were based on the questionnaire at 6 mo postpartum, supplemented by data from the 15-mo questionnaire if necessary. RESULTS: Women who smoked during pregnancy had an adjusted odds ratio of 1.5 (95% CI: 1.3-1.7) of not breastfeeding at 6 mo compared to non-smokers (adjusting for maternal age, education and intention). Survival analysis of duration of breastfeeding in the first 6 mo postpartum found that women who intended to breastfeed for less than 1 mo were 78% more likely to stop at any given time than women planning to breastfeed for at least 4 mo, while smokers were 17% more likely to stop breastfeeding than non-smokers. CONCLUSION: Although women who smoke are less likely to breastfeed their infants than are non-smoking women, it appears that this is largely due to lower motivation to breastfeed rather than a physiological effect of smoking on their milk supply.

Does maternal obesity adversely affect breastfeeding initiation and duration?

OBJECTIVE: To examine the relationship between maternal obesity and the initiation and duration of breastfeeding. METHODS: Analysis was made of the 1995 National Health Survey, in which personal interviews were conducted on a multistage area sample of private dwellings and a list sample of non-private dwellings in all states and territories of Australia. Mothers between the ages of 17 and 50 years (n = 1991) with children under the age of 4 years in 1995 participated in the study. RESULTS: Of the group of mothers with a body mass index (BMI) of 20-25, 89.2% (95% confidence interval (CI) 87.4-91.0) initiated breastfeeding, compared with 82.3% (95% CI 77.6-87.0) of mothers with a BMI of 30 or more. There was also a significant difference between the mean and median duration of breastfeeding of obese and non-obese mothers (BMI 30 and over, < 25, respectively). These differences remained significant when maternal smoking, age and other sociodemographic factors were taken into consideration. CONCLUSIONS: Health professionals should be aware that obese women may be at increased risk of not breastfeeding or stopping breastfeeding prematurely.

Candida albicans: is it associated with nipple pain in lactating women?

Persistent nipple pain in lactating women, burning in nature, and associated with radiating breast pain, has been claimed by some authorities to be due to 'thrush' (candida) infection. Yet, scientific proof has been lacking. This study compared microbiological assessment of 61 women with nipple pain, 64 women without nipple pain, and 31 non-lactating women. Swabs of the nipple and baby's mouth, and expressed breast milk were collected for culture. Growth of Candida albicans (nipple and milk) was found more often in the women with nipple pain (19%) than in the control group (3%, p < 0.01). In addition, Staphylococcus aureus was also associated with nipple pain (p < 0.0001), and independently associated with nipple fissures (p < 0.0001). Neither C. albicans nor S. aureus was found on the nipples of the non-lactating group.