Safety of COVID-19 Vaccination During Pregnancy and Lactation: A VigiBase Analysis.

BACKGROUND: There is limited evidence on the safety of coronavirus disease 2019 (COVID-19) vaccination during pregnancy and lactation. Thus, we aimed to evaluate the association between COVID-19 vaccination during pregnancy and lactation and reporting risk of adverse pregnancy or lactation outcomes. METHODS: Using VigiBase, we performed a disproportionality analysis with case/non case design. Cases were defined based on the Standardized MedDRA Queries (SMQs) of "pregnancy and neonatal topics" and non-cases were defined as all other adverse events. We included all reports with COVID-19 vaccines as the suspected cause. Using the full database as the comparators, reporting odds ratios (RORs) with 95% confidence intervals (CIs) were estimated by logistic regression while adjusting for maternal age. Infants' age and sex were additionally adjusted in analyzing the risk of COVID-19 vaccination during lactation. RESULTS: We identified 10,266 and 6,474 reports with the SMQ of "pregnancy and neonatal topics" associated with COVID-19 vaccines during pregnancy and lactation, respectively. No significant RORs of adverse pregnancy outcomes associated with COVID-19 vaccines during pregnancy were observed; however, "functional lactation disorders" showed significant disproportionality during lactation with adjusted ROR of 1.48 (95% CI, 1.21-1.79). Further analysis that analyzed "functional lactation disorders" at a preferred term level, showed higher ROR in mastitis (2.76 [95% CI, 1.45-5.27]). CONCLUSION: Overall, we did not observe a positive association between COVID-19 vaccination during pregnancy and risk of reporting adverse pregnancy outcomes. However, we found a significant disproportionate reporting association between COVID-19 vaccination during lactation and "functional lactation disorders", specifically mastitis. Continuous surveillance is warranted to confirm the safety of COVID-19 vaccine during pregnancy and lactation.

Randomised Controlled Trial on Prophylaxis of Mastitis-Metritis-Agalactia Syndrome in Swine using Caulophyllum Logoplex and Lachesis Logoplex.

BACKGROUND: Mastitis-metritis-agalactia (MMA) syndrome occurs in the first days post-partum and causes piglet losses mainly due to malnutrition. One possibility for prophylaxis of MMA is via homeopathy. In this veterinary study, the effectiveness of a prophylactic administration of homeopathic remedies for the prevention of the occurrence of MMA in swine was evaluated. METHODS: In a randomised and blinded study, 60 sows were examined. Sows were randomly distributed in two groups: the experimental group (CL/LL) received a prophylactic administration of the complex homeopathic remedies Caulophyllum Logoplex and Lachesis Logoplex, and the placebo group was administered a sodium chloride (NaCl) solution in the same injection scheme as the experimental group. Clinical signs of MMA, behavioural changes, as well as production parameters, were recorded beginning with the day of farrowing until 5 days post-partum. RESULTS: The treatment group showed no significant effect on the occurrence of MMA in sows (CL/LL: 56.67% MMA positive sows; NaCl: 53.53% MMA positive sows). Treatment group had also no significant effect on health parameters (vaginal discharge, raised rectal temperature, shortage of milk) or behavioural parameters (impaired feeding behaviour and impaired general condition). For the production parameter average weight gain, statistically significant effects in the treatment group were detected. CONCLUSIONS: Prophylaxis with the homeopathic remedies Caulophyllum Logoplex and Lachesis Logoplex showed neither an improvement in MMA prevention nor an improvement in health parameters or behavioural traits in the present herd of sows.

Physical therapy intervention for breast symptoms in lactating women: a randomized controlled trial.

BACKGROUND: Therapeutic ultrasound, education, and massage are the most common physical therapy interventions provided to mothers with breast symptoms. However, there is insufficient evidence on the effectiveness of the combination of these interventions. This study aimed to explore the effects of the combination of therapeutic ultrasound, education, and massage on breast symptoms in lactating women. METHODS: This study was a single-blind randomized controlled trial. Postpartum lactating women aged from 21 to 45 with breast symptoms were recruited and randomly allocated to one of three groups (ultrasound group, sham group, and usual care group). The severity of breast symptoms (pain, redness, lump, general malaise), breast engorgement, breast hardness, body temperature, breast temperature, and milk volume were assessed at baseline (T1), immediately post-intervention (T2), and at 3 months following baseline (T3). RESULTS: A total of 37 participants were included in the study (ultrasound group n = 12; sham group n = 12; usual care n = 13). The severity of breast symptoms (i.e., pain, lump, and general malaise) as well as breast engorgement, were significantly improved in the ultrasound group at T2 when compared to T1, and these improvements were sustained at T3. The severity of breast engorgement was significantly lower in the ultrasound group when compared to the usual care group at T2. However, no statistically significant differences were found between the ultrasound and sham groups for all outcomes at any assessment time points. CONCLUSIONS: Physical therapy interventions may be beneficial in relieving breast symptoms in lactating women. Larger randomized controlled trials are needed to confirm the findings of this study. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04569136); Date of registration: 29/09/2020.

Effect of cold cabbage leaf application on breast engorgement and pain in the postpartum period: A systematic review and meta-analysis.

The researchers' aims are to determine the effect of cold cabbage leaf application on breast engorgement and pain during the postpartum period through a systematic review and meta-analysis. Between June and September 2021, researchers systematically searched Turkish and English databases using a combination of keywords. We calculated individual and general effect sizes of the studies to evaluate effect sizes. We obtained 25,996 results with the databases search and we included a total of eight studies for analysis. According to the pooled results, we determined that cold cabbage leaf application caused a significant reduction in breast pain, though no significant reduction was seen in breast engorgement. In this systematic review and meta-analysis, we found that cold cabbage leaf application was effective in reducing breast pain, but that more experimental studies are needed to determine its effect on breast engorgement.CALLOUTSBreast engorgement is a common physiological problem for lactating mothers.Researchers state that the results of the eight studies included in the analysis suggested that cold cabbage leaf application was effective in reducing breast pain.More studies are needed to evaluate the effect of cold cabbage application on reducing breast engorgement.

Mycoplasma agalactiae ST35: a new sequence type with a minimal accessory genome primarily affecting goats.

BACKGROUND: Mycoplasma agalactiae, causing agent of contagious agalactia, infects domestic small ruminants such as sheep and goats but also wild Caprinae. M. agalactiae is highly contagious and transmitted through oral, respiratory, and mammary routes spreading rapidly in an infected herd. RESULTS: In an outbreak of contagious agalactia in a mixed herd of sheep and goats, 80% of the goats were affected displaying swollen udders and loss of milk production but no other symptom such as kerato-conjunctivitis, arthritis or pulmonary distress commonly associated to contagious agalactia. Surprisingly, none of the sheep grazing on a common pasture and belonging to the same farm as the goats were affected. Whole genome sequencing and analysis of M. agalactiae strain GrTh01 isolated from the outbreak, revealed a previously unknown sequence type, ST35, and a particularly small, genome size of 841'635 bp when compared to others available in public databases. Overall, GrTh01 displayed a reduced accessory genome, with repertoires of gene families encoding variable surface proteins involved in host-adhesion and variable antigenicity being scaled down. GrTh01 was also deprived of Integrative Conjugative Element or prophage, and had a single IS element, suggesting that GrTh01 has a limited capacity to adapt and evolve. CONCLUSIONS: The lack of most of the variable antigens and the Integrative Conjugative Element, both major virulence- and host specificity factors of a M. agalactiae strain isolated from an outbreak affecting particularly goats, indicates the implication of these factors in host specificity. Whole genome sequencing and full assembly of bacterial pathogens provides a most valuable tool for epidemiological and virulence studies of M. agalactiae without experimental infections.

Trpc5 deficiency causes hypoprolactinemia and altered function of oscillatory dopamine neurons in the arcuate nucleus.

Dopamine neurons of the hypothalamic arcuate nucleus (ARC) tonically inhibit the release of the protein hormone prolactin from lactotropic cells in the anterior pituitary gland and thus play a central role in prolactin homeostasis of the body. Prolactin, in turn, orchestrates numerous important biological functions such as maternal behavior, reproduction, and sexual arousal. Here, we identify the canonical transient receptor potential channel Trpc5 as an essential requirement for normal function of dopamine ARC neurons and prolactin homeostasis. By analyzing female mice carrying targeted mutations in the Trpc5 gene including a conditional Trpc5 deletion, we show that Trpc5 is required for maintaining highly stereotyped infraslow membrane potential oscillations of dopamine ARC neurons. Trpc5 is also required for eliciting prolactin-evoked tonic plateau potentials in these neurons that are part of a regulatory feedback circuit. Trpc5 mutant females show severe prolactin deficiency or hypoprolactinemia that is associated with irregular reproductive cyclicity, gonadotropin imbalance, and impaired reproductive capabilities. These results reveal a previously unknown role for the cation channel Trpc5 in prolactin homeostasis of female mice and provide strategies to explore the genetic basis of reproductive disorders and other malfunctions associated with defective prolactin regulation in humans.

EARLY PROGNOSIS OF HYPOGALACTIA IN BREASTFEEDING MOTHERS: NEW OPPORTUNITIES FOR PRIMARY PREVENTION.

An increase in the hypogalactia frequency diagnosis in breastfeeding mothers is one of the world-spread medical and social problems and is especially high in women with risk factors of lactation disorders. Early estimation of risk factors creates opportunities for physicians to diagnose the lactation problem that mothers face and solve it. Aim - to identify and calculate prognostic criteria for determining the risk of hypogalactia in breastfeeding mothers and strategies to help women overcome them. Twenty-two factors that cause the most significant impact on the development of hypogalactia were selected, and their frequency was determined in 208 mothers with hypogalactia (group 1) and 388 mothers with normal lactation (group 2). The sequential Wald analysis, which compares the frequencies of distribution of traits in the study groups and determines their informativeness by calculating prognostic coefficients (PK) for different risk factors and estimating the individual risk of hypogalactia was used. The elder age of the breastfeeding mother (36-40 years and elder) and its lower educational level promoted hypogalactia. Low security of the mother was associated with hypogalactia (PC -1,4). It was also found that mothers engaged in heavy physical labor suffer from hypogalactia more often than employees. Mothers' return to work, have been reported as factors that influence breastfeeding. Occupational hazards (noise, dyes, vibration, lead soldering, dust factors) and bad habits caused hypogalactia (PC -5,4). Prenatal breastfeeding education has been shown to prevent hypogalactia. A burdensome obstetric history (PC -3,9), habitual miscarriage (PC-1,4), and female genital diseases worsen the prognosis of lactation. Extragenital pathology was characterized by negative PC of hypogalactia, especially rheumatic fever, compensated heart defect (PC -3,2), chronic cardiovascular insufficiency (PC -11,4), congenital heart disease (PC -11,4), obesity (PC -4,8), diabetes mellitus (PC -5,8). The time of the first application to the breast affected the mothers' milk production. The mathematical model of the individual prognosis of lactation in mothers contributes to the early detection of hypogalactia and the corresponding correction.

Variant Prolactin Receptor in Agalactia and Hyperprolactinemia.

A loss-of-function variant in the gene encoding the prolactin receptor ( PRLR) was reported previously in a woman with persistent postpartum galactorrhea; however, this paradoxical phenotype is not completely understood. Here we describe a 35-year-old woman who presented with idiopathic hyperprolactinemia that was associated with a complete lack of lactation after each of her two deliveries. She is a compound heterozygote for loss-of-function variants of PRLR. Her unaffected parents are heterozygotes. These findings are consistent with previous work showing that mice deficient in functional Prlr do not lactate.

Hypogalactia in mammary quarters adjacent to lipopolysaccharide-infused quarters is associated with transcriptional changes in immune genes.

Infusion of lipopolysaccharides (LPS) into a mammary gland can provoke inflammatory responses and impair lactation in both the infused gland and neighboring glands. To gain insight into the mechanisms controlling the spatiotemporal response to localized mastitis in lactating dairy cows, we performed RNA sequencing on mammary tissue from quarters infused with LPS, neighboring quarters in the same animals, and control quarters from untreated animals at 3 and 12 h postinfusion. Differences in gene expression were annotated to Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Comparing mammary transcriptomes from all 3 treatments revealed 3,088 and 1,644 differentially expressed (DE) genes at 3 and 12 h, respectively. Of these genes, >95% were DE only in LPS-infused quarters and represented classical responses to LPS: inflammation, apoptosis, tissue remodeling, and altered cell signaling and metabolism. Although relatively few genes were DE in neighboring quarters (56 at 3 h; 74 at 12 h), these represented several common pathways. At 3 h, tumor necrosis factor (TNF), nuclear factor-κB, and nucleotide-binding and oligomerization domain (NOD)-like receptor signaling pathways were identified by the upregulation of anti-inflammatory (NFKBIA, TNFAIP3) and cell adhesion molecule (VCAM1, ICAM1) genes in neighboring glands. Additionally, at 12 h, several genes linked to 1-carbon and serine metabolism were upregulated. Some responses were also regulated over time. The proinflammatory response in LPS-infused glands diminished between 3 and 12 h, indicating tight control over transcription to re-establish homeostasis. In contrast, 2 glucocorticoid-responsive genes, FKBP5 and ZBTB16, were among the top DE genes upregulated in neighboring quarters at both time points, indicating potential regulation by glucocorticoids. We conclude that a transient, systemic immune response was sufficient to disrupt lactation in neighboring glands. This response may be mediated directly by proinflammatory factors from the LPS-infused gland or indirectly by secondary factors released in response to systemic inflammatory signals.

The effect of pegbovigrastim on early-lactation disease, production, and reproduction in dairy cows.

The objective of this randomized, double-blind, controlled trial was to evaluate the effect of pegbovigrastim (pegylated recombinant bovine granulocyte colony-stimulating factor) on early-lactation disease, milk yield, and reproduction on commercial dairy farms. A total of 1,607 Holstein cows from 6 farms in Ontario and Québec, Canada, were randomly assigned to receive two 2.7-mL subcutaneous injections of either 15 mg of pegbovigrastim (n = 798; Imrestor, Elanco) or sterile physiological saline (placebo; n = 809). The first injection was administered by investigators 1 wk before expected calving, and the second by farm personnel within 24 h after calving, according to the product label. Producers inspected cows daily and using standardized disease definitions, recorded cases of retained placenta, metritis, displaced abomasum, and clinical mastitis until 63 d in milk. Progesterone concentration was measured in serum at wk 3, 5, 7, and 9 postpartum. Cows were examined for purulent vaginal discharge using the Metricheck (Simcro) device and endometritis using the cytobrush method at wk 5 postpartum. Milk production and reproduction data were obtained from farm management software and the national milk recording database. Disease and culling outcomes were assessed with logistic regression, milk production with linear regression, and time-to-event outcomes with proportional hazards regression. All analyses considered parity and pre-treatment body condition score and their interaction with treatment, and accounted for clustering of cows within farm. In a subset of 246 cows, the effect of treatment on metabolic markers (serum concentrations of glucose, ß-hydroxybutyrate, nonesterified fatty acids, cholesterol, haptoglobin, albumin, and calcium) was assessed in wk 1 and 2 postpartum. Pegbovigrastim had no significant effects on the incidence of retained placenta, metritis, displaced abomasum, clinical or subclinical mastitis, purulent vaginal discharge, or endometritis. Treatment reduced the serum concentration of glucose, slightly reduced the concentration of albumin, and slightly increased concentrations of ß-hydroxybutyrate and nonesterified fatty acids, with no effect on the other markers. There were no differences between treatments in culling risk, time to first insemination, pregnancy at first insemination, or time to pregnancy. Milk yield over the first 3 test days of lactation was 1.0 kg per day lower in the pegbovigrastim group, although a mechanism for that effect could not be explained through analysis of our data.

Influence of mastitis metritis agalactia (MMA) on bone and fat metabolism.

Mastitis metritis agalactia (MMA) is a common disease in post-partum sows and has a negative effect on sows' longevity as well as on sows' and piglets' health. MMA leads to an inflammatory state. The aim was to investigate the impact of MMA on bone and fat metabolism. The hypothesis was that it is possible to predict MMA by measuring ketone bodies and bone markers. Blood samples from 175 sows were taken within 72 hr after farrowing. Serum was analysed for 25-hydroxyvitamin D (25-(OH)-D), serum crosslaps (CTX-I), osteocalcin (OC), alkaline phosphatase (ALP), calcium (Ca), magnesium (Mg), phosphorus (P), parathyroid hormone (PTH), triglycerides (TG), beta-hydroxybutyric acid (BHB), tumour necrosis factor-alpha (TNF-α) and haptoglobin. Spontaneous urine was collected, and pH value was measured in addition to Ca and P. A proximate analysis of the sows' diets was performed. Age, litter size, body condition score (BCS) and clinical signs of MMA were recorded for each sow. A multivariable logistic regression was undertaken with disease status (MMA or healthy) as the dependent variable. Significance was accepted at p < .05. MMA sows had a poorer BCS (p < .001) in relation to healthy sows. Age and number of piglets did not differ. MMA sows showed increased serum CTX-I (p = .004) and decreased serum OC (p < .001). Concentrations of P (p = .007), activity of ALP (p = .002) and BHB (p = .019) as well as TNF-α (p < .001) and haptoglobin (p = .048) concentrations were increased in MMA sows. No difference in urinary pH value between MMA and healthy sows was found. Our results are in accordance with the known fact that sows are in an extreme catabolic state peripartum. Bone metabolism in MMA sows is much more negatively affected than in healthy sows post-partum, due to inflammatory processes shown by higher concentrations of pro-inflammatory cytokines.

Breast Pathology That Contributes to Dysfunction of Human Lactation: a Spotlight on Nipple Blebs.

Nipple blebs are blister-like fibrinous lesions that form on the surface of the nipple during lactation, and can result in orifice obstruction and mastitis. They likely result from superficial extension of underlying ductal plugging, and can present concurrently with hyperlactation and mammary dysbiosis. Despite their prevalence, few formal reports on nipple blebs exist. In this perspective, we review the experience of a breastfeeding medicine practice that receives referrals for patients with nipple blebs, and provide preliminary insight into etiology, management, and outcomes of these lesions.

Vivax malaria in pregnancy and lactation: a long way to health equity.

BACKGROUND: The Sustainable Development Goals (SDG) call for increased gender equity and reduction in malaria-related mortality and morbidity. Plasmodium vivax infections in pregnancy are associated with maternal anaemia and increased adverse perinatal outcomes. Providing radical cure for women with 8-aminoquinolines (e.g., primaquine) is hindered by gender-specific complexities. CASE PRESENTATION: A symptomatic episode of vivax malaria at 18 weeks of gestation in a primigravid woman was associated with maternal anaemia, a recurrent asymptomatic P. vivax episode, severe intra-uterine growth restriction with no other identifiable cause and induction to reduce the risk of stillbirth. At 5 months postpartum a qualitative glucose-6-phosphate dehydrogenase (G6PD) point-of-care test was normal and radical cure with primaquine was prescribed to the mother. A 33% fractional decrease in haematocrit on day 7 of primaquine led to further testing which showed intermediate phenotypic G6PD activity; the G6PD genotype could not be identified. Her infant daughter was well throughout maternal treatment and found to be heterozygous for Mahidol variant. CONCLUSION: Adverse effects of vivax malaria in pregnancy, ineligibility of radical cure for pregnant and postpartum women, and difficulties in diagnosing intermediate levels of G6PD activity multiplied morbidity in this woman. Steps towards meeting the SDG include prevention of malaria in pregnancy, reducing unnecessary exclusion of women from radical cure, and accessible quantitative G6PD screening in P. vivax-endemic settings.

Treatments for breast engorgement during lactation.

BACKGROUND: Engorgement is the overfilling of breasts with milk, often occurring in the early days postpartum. It results in swollen, hard, painful breasts and may lead to premature cessation of breastfeeding, decreased milk production, cracked nipples and mastitis. Various treatments have been studied but little consistent evidence has been found on effective interventions. OBJECTIVES: To determine the effectiveness and safety of different treatments for engorgement in breastfeeding women. SEARCH METHODS: On 2 October 2019, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. SELECTION CRITERIA: All types of randomised controlled trials and all forms of treatment for breast engorgement were eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for eligibility, extracted data, conducted 'Risk of bias' assessment and assessed the certainty of evidence using GRADE. MAIN RESULTS: For this udpate, we included 21 studies (2170 women randomised) conducted in a variety of settings. Six studies used individual breasts as the unit of analysis. Trials examined a range of interventions: cabbage leaves, various herbal compresses (ginger, cactus and aloe, hollyhock), massage (manual, electromechanical, Oketani), acupuncture, ultrasound, acupressure, scraping therapy, cold packs, and medical treatments (serrapeptase, protease, oxytocin). Due to heterogeneity, meta-analysis was not possible and data were reported from single trials. Certainty of evidence was downgraded for limitations in study design, imprecision and for inconsistency of effects. We report here findings from key comparisons. Cabbage leaf treatments compared to control For breast pain, cold cabbage leaves may be more effective than routine care (mean difference (MD) -1.03 points on 0-10 visual analogue scale (VAS), 95% confidence intervals (CI) -1.53 to -0.53; 152 women; very low-certainty evidence) or cold gel packs (-0.63 VAS points, 95% CI -1.09 to -0.17; 152 women; very low-certainty evidence), although the evidence is very uncertain. We are uncertain about cold cabbage leaves compared to room temperature cabbage leaves, room temperature cabbage leaves compared to hot water bag, and cabbage leaf extract cream compared to placebo cream because the CIs were wide and included no effect. For breast hardness, cold cabbage leaves may be more effective than routine care (MD -0.58 VAS points, 95% CI -0.82 to -0.34; 152 women; low-certainty evidence). We are uncertain about cold cabbage leaves compared to cold gel packs because the CIs were wide and included no effect. For breast engorgement, room temperature cabbage leaves may be more effective than a hot water bag (MD -1.16 points on 1-6 scale, 95% CI -1.36 to -0.96; 63 women; very low-certainty evidence). We are uncertain about cabbage leaf extract cream compared to placebo cream because the CIs were wide and included no effect. More women were satisfied with cold cabbage leaves than with routine care (risk ratio (RR) 1.42, 95% CI 1.22 to 1.64; 152 women; low certainty), or with cold gel packs (RR 1.23, 95% CI 1.10 to 1.38; 152 women; low-certainty evidence). We are uncertain if women breastfeed longer following treatment with cold cabbage leaves than routine care because CIs were wide and included no effect. Breast swelling and adverse events were not reported. Compress treatments compared to control For breast pain, herbal compress may be more effective than hot compress (MD -1.80 VAS points, 95% CI -2.07 to -1.53; 500 women; low-certainty evidence). Massage therapy plus cactus and aloe compress may be more effective than massage therapy alone (MD -1.27 VAS points, 95% CI -1.75 to -0.79; 100 women; low-certainty evidence). In a comparison of cactus and aloe compress to massage therapy, the CIs were wide and included no effect. For breast hardness, cactus and aloe cold compress may be more effective than massage (RR 0.66, 95% CI 0.51 to 0.87; 102 women; low-certainty evidence). Massage plus cactus and aloe cold compress may reduce the risk of breast hardness compared to massage alone (RR 0.38, 95% CI 0.25 to 0.58; 100 women; low-certainty evidence). We are uncertain about the effects of compress treatments on breast engorgement and cessation of breastfeeding because the certainty of evidence was very low. Among women receiving herbal compress treatment, 2/250 experienced skin irritation compared to 0/250 in the hot compress group (moderate-certainty evidence). Breast swelling and women's opinion of treatment were not reported. Medical treatments compared to placebo Protease may reduce breast pain (RR 0.17, 95% CI 0.04, 0.74; low-certainty evidence; 59 women) and breast swelling (RR 0.34, 95% CI 0.15 to 0.79; 59 women; low-certainty evidence), whereas serrapeptase may reduce the risk of engorgement compared to placebo (RR 0.36, 95% CI 0.14 to 0.88; 59 women; low-certainty evidence). We are uncertain if serrapeptase reduces breast pain or swelling, or if oxytocin reduces breast engorgement compared to placebo, because the CIs were wide and included no effect. No women experienced adverse events in any of the groups receiving serrapeptase, protease or placebo (low-certainty evidence). Breast induration/hardness, women's opinion of treatment and breastfeeding cessation were not reported. Cold gel packs compared to control For breast pain, we are uncertain about the effectiveness of cold gel packs compared to control treatments because the certainty of evidence was very low. For breast hardness, cold gel packs may be more effective than routine care (MD -0.34 points on 1-6 scale, 95% CI -0.60 to -0.08; 151 women; low-certainty evidence). It is uncertain if women breastfeed longer following cold gel pack treatment compared to routine care because the CIs were wide and included no effect. There may be little difference in women's satisfaction with cold gel packs compared to routine care (RR 1.17, 95% CI 0.97 to 1.40; 151 women; low-certainty evidence). Breast swelling, engorgement and adverse events were not reported. AUTHORS' CONCLUSIONS: Although some interventions may be promising for the treatment of breast engorgement, such as cabbage leaves, cold gel packs, herbal compresses, and massage, the certainty of evidence is low and we cannot draw robust conclusions about their true effects. Future trials should aim to include larger sample sizes, using women - not individual breasts - as units of analysis.

Lactational phlegmon: A distinct clinical entity affecting breastfeeding women within the mastitis-abscess spectrum.

We aimed to describe the presentation and treatment of lactational phlegmon, a unique complication of mastitis in breastfeeding women that may require surgical management. We retrospectively analyzed medical charts of breastfeeding women treated by a single breast surgeon for lactational phlegmon or the related conditions of abscess or uncomplicated mastitis (UM) from July 2016 to October 2018. Demographic variables and treatment details were analyzed using ANOVA and Pearson's Chi-square test. Ten women with lactational phlegmon (19.2%), 15 women with abscess (28.8%), and 27 women with UM (51.9%) were identified. Phlegmon presented as a tender, erythematous, and nonfluctuant mass in a ductal distribution. Ultrasonography demonstrated an ill-defined, complex fluid collection. Epidemiologically, women with phlegmon were similar to patients with abscess and UM. Women with phlegmon reported more intense deep breast massage than patients in the other two groups, but significantly lower rates of breast pump use than women with abscess (30.0% vs 80.0%, P < .05). Relative to women with UM, patients with complicated mastitis (CM, defined as phlegmon or abscess) reported greater utilization of nipple shields (36.0% vs 11.1%, P < .05). Treatment of phlegmon entailed effective milk removal, antibiotics (range 10-30 days), and close follow-up until both clinical and radiographic resolution (range 8 days to >3 months), with biopsy of persistent masses. Antibiotic duration was significantly longer for patients with phlegmon compared to those with UM (mean 15.0 days vs 9.7 days, P < .05). Two phlegmons coalesced into abscesses within 1 week of diagnosis. Lactational phlegmon is a complication of mastitis in breastfeeding women that is distinct from abscess and UM. Optimal treatment consists of an extended course of antibiotics and close follow-up to monitor for coalescence into a drainable fluid collection and/or persistence of mass requiring biopsy.

An endocrine hypothesis to explain obesity-related lactation insufficiency in breastfeeding mothers.

In this Research Reflection I shall develop and validate the hypothesis that lactation insufficiency in obese breastfeeding mothers has an endocrine explanation. I shall not present data, but I shall review pertinent literature to show that obesity is associated with a partial or sometimes complete failure to initiate and maintain lactation, and critically examine the belief that this is due to psychosocial factors, a failure of prolactin secretion or both. Since progesterone is inhibitory to lactogenesis and oestrogens are inhibitory to milk secretion, I shall then explore the possibility that these steroids are linked to lactation failure, through sequestration of progesterone and aromatization of oestrogen in mammary adipose tissue. I shall conclude by describing experimental approaches in animal models that could be used to test this hypothesis.

Breastfeeding a small for gestational age infant, complicated by maternal gestational diabetes: a case report.

BACKGROUND: Small for gestational age (SGA) infants are those born small for their gestational age, with weight below the 10th percentile. Not only do SGA infants suffer growth issues after birth, they have elevated risk for the development of metabolic and cardiovascular diseases later in life. Current research has suggested that in cases of SGA infants, maternal milk and breastfeeding are not affected. The mother of an SGA infant was diagnosed with placental insufficiency and Gestational Diabetes Mellitus (GDM) during her pregnancy. The infant was born term, at 38 weeks 3 days, and SGA. The mother had a low milk supply and her milk composition differed from reference values such that the daily infant intake provided less than 50% of the required energy intake at 3 months. CONCLUSION: In cases of SGA and/or GDM, maternal milk quality and quantity may be compromised. This requires follow-up in order to reduce the disease risk for SGA infants and the corresponding public health implications.

Preeclampsia-Like Features and Partial Lactation Failure in Mice Lacking Cystathionine γ-Lyase-An Animal Model of Cystathioninuria.

Elevated plasma homocysteine levels are considered as a risk factor for cardiovascular diseases as well as preeclampsia-a pregnancy disorder characterized by hypertension and proteinuria. We previously generated mice lacking cystathionine γ-lyase (Cth) as cystathioninuria models and found them to be with cystathioninemia/homocysteinemia. We investigated whether Cth-deficient (Cth-/-) pregnant mice display any features of preeclampsia. Cth-/- females developed normally but showed mild hypertension (~10 mmHg systolic blood pressure elevation) in late pregnancy and mild proteinuria throughout development/pregnancy. Cth-/- dams had normal numbers of pups and exhibited normal maternal behavior except slightly lower breastfeeding activity. However, half of them could not raise their pups owing to defective lactation; they could produce/store the first milk in their mammary glands but not often provide milk to their pups after the first ejection. The serum oxytocin levels and oxytocin receptor expression in the mammary glands were comparable between wild-type and Cth-/- dams, but the contraction responses of mammary gland myoepithelial cells to oxytocin were significantly lower in Cth-/- dams. The contraction responses to oxytocin were lower in uteruses isolated from Cth-/- mice. Our results suggest that elevated homocysteine or other unknown factors in preeclampsia-like Cth-/- dams interfere with oxytocin that regulates milk ejection reflex.

The prevalence of Coxiella burnetii shedding in dairy goats at the time of parturition in an endemically infected enterprise and associated milk yield losses.

BACKGROUND: This was a panel study of the prevalence of C. burnetii infection in does in an endemic dairy goat enterprise in Victoria, Australia. Our first objective was to determine the prevalence of does shedding C. burnetii at the time of parturition and to quantify the concentration of genome equivalents (GE) present in each C. burnetii positive sample. Our second objective was to determine the proportion of positive does that were persistent shedders. Our final objective was to quantify the association between C. burnetii qPCR status at the time of kidding and daily milk volumes produced during the subsequent lactation. RESULTS: Vaginal swabs (n= 490) were collected from does at the time of kidding and analysed using a quantitative polymerase chain reaction (qPCR) assay. Shedding of C. burnetii was detected in 15% (95% CI: 12% to 18%) of the sampled does. Does were classified as qPCR-negative, qPCR-positive low and qPCR-positive high based on the estimated concentration of GE from the qPCR. Persistent shedding at relatively low concentrations was detected in 20% (95% CI: 10% to35%) of shedding does sampled again at their subsequent parturition. After controlling for possible confounders and adjusting for variation in daily milk yields at the individual doe level, daily milk yields for qPCR-positive high does were reduced by 17% (95% CI: 3% to 32%) compared to qPCR-negative does (p= 0.02). CONCLUSIONS: Shedding concentrations of C. burnetii were highly skewed, with a relatively small group of does shedding relatively high quantities of C. burnetii. Further, high shedding does had reduced milk yields compared to qPCR-negative does. Early detection and culling of high shedding does would result in increased farm profitability and reduce the risk of Q fever transmission.

Hormonal and metabolic indicators before and after farrowing in sows affected with postpartum dysgalactia syndrome.

BACKGROUND: Postpartum dysgalactia syndrome (PDS) in sows is difficult to diagnose and the pathogenesis is obscure. Hormonal changes related to the disease are often difficult to distinguish from those found in the normal transition period from gestation to lactation. The study aimed to investigate metabolic and hormonal changes related to PDS with the goal of identifying potential biomarkers in sows suffering from PDS (PDS+). Selected biomarkers were examined by comparing 38 PDS+ sows with 38 PDS negative (PDS-) sows. The sows were sampled every 24 h from 60 h ante partum (a.p.) to 36 h post partum (p.p.). RESULTS: Compared to the baseline (60 to 36 h a.p.), cortisol in serum and saliva and fasting blood glucose concentrations increased in PDS+ as well as PDS- sows. C-peptide decreased relative to the baseline in PDS+ sows, and prolactin and 8-epi prostaglandin F2 alpha (8-epi-PGF2α) decreased in PDS- sows. Concentrations of cortisol in serum and saliva, salivary chromogranin A (CgA), fasting blood glucose, C-peptide, and 8-epi-PGF2α differed significantly between PDS+ and PDS- sows, with levels of cortisol in serum and saliva, salivary CgA, and 8-epi-PGF2α in serum being different in the two groups already before parturition. Concentrations of salivary CgA were significantly lower in PDS- sows than in PDS+ sows during the entire study period. CONCLUSIONS: The results suggest that salivary CgA, cortisol and serum 8-epi-PGF2α may potentially serve as early diagnostic indicators for PDS. The consistently higher salivary CgA concentration in PDS+ sows compared to PDS- sows may indicate that homeostatic disturbances are present between 36 to 60 h before parturition in sows developing PDS. The higher serum and saliva cortisol concentration in PDS+ sows compared to PDS- sows could reflect an early sign of inflammation or stress. The significantly lower C-peptide in PDS+ sows compared to PDS- sows may reflect a lower food intake. Our results contribute to the understanding of the pathogenesis of PDS, and the homeostatic disturbances detected before parturition warrants further investigation. The diagnostic potential of the markers identified in this study should be investigated further in a larger population of sows.