Using Brexanolone for Postpartum Depression Must Account for Lactation.

On March 19, 2019, Brexanolone (Zulresso ™) was released as the first-ever FDA-approved medication specifically for the treatment of postpartum depression by Sage Therapeutics, Inc. Unfortunately, its use in breastfeeding mothers was not evaluated and is being restricted. An efficacious drug for postpartum depression stands to benefit many families. However, the lack of guidance for breastfeeding patients, and the resultant restrictions on breastfeeding by insurance companies is deeply troubling. Conversely, withholding this medication from a lactating mother is ethically problematic. From a public health perspective, we aim to foster continuous breastfeeding among depressed women while they are being treated for depression. We therefore aim to address concerns about Brexanolone's effects on the breastfed child, as exposed through breastmilk, as well as the impact this medication may have on lactation.

Low-Level Prenatal Toxin Exposures and Breastfeeding Duration: A Prospective Cohort Study.

Introduction Maternal exposure to tobacco smoke is associated with shortened breastfeeding duration, but few studies have examined the effects on breastfeeding outcomes of low level exposures to other toxic chemicals. Moreover, it is unclear if passive smoking is associated with duration of breastfeeding. Our objective was therefore to examine the effect of low-level prenatal exposures to common environmental toxins (tobacco smoke, lead, and phthalates) on breastfeeding exclusivity and duration. Methods We conducted an analysis of data from the Health Outcomes and Measures of the Environment (HOME) Study. Serum and urine samples were collected at approximately 16 and 26 weeks gestation and at delivery from 373 women; 302 breastfed their infants. Maternal infant feeding interviews were conducted a maximum of eight times through 30 months postpartum. The main predictor variables for this study were gestational exposures to tobacco smoke (measured by serum cotinine), lead, and phthalates. Passive smoke exposure was defined as cotinine levels of 0.015-3.0 µg/mL. Primary outcomes were duration of any and exclusive breastfeeding. Results Serum cotinine concentrations were negatively associated with the duration of any breastfeeding (29.9 weeks unexposed vs. 24.9 weeks with passive exposure, p = 0.04; and 22.4 weeks with active exposure, p = 0.12; p = 0.03 for linear trend), but not duration of exclusive breastfeeding. Prenatal levels of blood lead and urinary phthalate metabolites were not significantly associated with duration of any or exclusive breastfeeding. Conclusions Passive exposure to tobacco smoke during pregnancy was associated with shortened duration of any breastfeeding.

Tongue-tie in the Neonatal Intensive Care Unit Compared to Healthy Newborns.

OBJECTIVE: We sought to characterize the prevalence of ankyloglossia in our neonatal intensive care unit (NICU) population and to determine characteristics of this cohort compared to infants in the birth center (BC). METHODS: Prospective data were collected using a standardized flow sheet. Breastfeeding infants undergoing evaluation for tongue-tie in the BC and NICU were included. Coryllos type, tip to frenulum length, tongue function, frequency of frenotomy, and breastfeeding outcomes were compared. RESULTS: Of 20,879 infants birthed at or admitted to the institution during the study period, there were fewer patients diagnosed with ankyloglossia in the BC compared to the NICU (3.3% BC vs. 5.4% NICU, p < 0.01). Of these, 163 underwent frenotomy: 86 in the BC and 77 in the NICU. For those undergoing frenotomy, gestational age (39.1 ± 1.3 BC, 34.4 ± 4.4 NICU, p < 0.01) and age at time of procedure (3.2 days BC, 29.2 NICU, p < 0.01) were the only demographic factors significantly different between the groups. There was no difference in Coryllos type or function score. In a subset of NICU infants with multiple assessments over time, function scores after frenotomy were significantly improved compared to pre-frenotomy (p < 0.01). CONCLUSION: Standard assessment tools appear to be appropriate for use in infants in the NICU, despite the higher rates of prematurity, low birth weights, and increased comorbidities. Assessment and intervention for tongue-tie can be one critical intervention to move these patients closer to oral feeding and discharge to home. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

The Rights of Physicians and Future Physicians Who Are Lactating, Breastfeeding, or Chestfeeding: An American Medical Women's Association Position Article.

Breastfeeding is a fundamental and biologically normal function with well-established benefits for both lactating parents and infants. Despite these benefits, physicians, particularly those in training, often face significant obstacles when attempting to meet their breastfeeding and pumping goals. In response to these challenges, the American Medical Women's Association (AMWA) and a diverse group of health care professionals have come together to advocate for comprehensive lactation support policies in medical learning environments and workplaces. This position article highlights the ethical necessity of comprehensive lactation support in medical educational and workplace settings, emphasizing the importance of not only providing physical accommodations but also fostering a cultural shift, educational initiatives, and policy reforms to empower lactating parents. It offers an examination of the difficulties encountered by lactating parents within medical environments and proposes guidelines for the formulation and enhancement of supportive policies. The position article envisions a future where medical professionals can thrive in both their careers and parenthood through collaborative efforts and a commitment to the key elements of Effective Lactation Support Programs in medical workplaces based on the following: (1) well-equipped lactation facilities, (2) customized work schedules, (3) mentorship and support networks, (4) lactation support in clinical settings, and (5) research and advocacy.

Academy of Breastfeeding Medicine Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Period (Revised 2024).

Background: The Academy of Breastfeeding Medicine revised the 2015 version of this clinical protocol to review the evidence and provide recommendations related to breastfeeding promotion in the prenatal period. Key Information: Promoting and normalizing breastfeeding in the prenatal period can improve breastfeeding outcomes including initiation and duration of breastfeeding. Ideally, prenatal interventions should be a part of a comprehensive longitudinal breastfeeding support program. Recommendations: Clinicians or other health workers should discuss breastfeeding at each prenatal visit. Counseling topics should include the health benefits of breastfeeding versus not breastfeeding, the basics of breastfeeding (e.g., physiology, positioning), what to expect of hospital-based and immediate postpartum breastfeeding support (i.e., Baby-Friendly Ten Steps), and the risks of unnecessary supplementation. Medical, anatomical, and other risk factors for breastfeeding challenges should be identified, and targeted anticipatory guidance should be given. Prenatal counseling should include distribution of structured breastfeeding education at low literacy levels and in the parent's preferred language. Counseling should be culturally sensitive and patient-centered, including family members when appropriate. Prenatal support may integrate various health workers (e.g., medical doctors, midwives, community health workers, lactation consultants, among others) and include various modalities including telecommunication. Enhancing breastfeeding education for prenatal care providers is also imperative. Additional themes related to implementation of recommendations for specific populations are also reviewed.

Association between maternal stress and premature milk cortisol, milk IgA, and infant health: a cohort study.

Background: Maternal stress is pervasive in the neonatal intensive care unit (NICU). Maternal stress is associated with changes in human milk (HM) immunomodulatory agents, which may impact neonatal health. We sought to determine the association between maternal stress, HM immunoglobulin A (IgA) and cortisol, and to assess how these milk components correlate with infant immune and neurodevelopmental outcomes. We then compared how these associations persist over time. Methods: The study design involved a cohort study of exclusively breastfeeding mothers and their singleton moderately preterm (28-34 weeks) infants admitted to the NICU. We collected maternal serum, maternal saliva, and first-morning whole milk samples, and administered maternal stress questionnaires at 1 and 5 weeks postpartum. We analyzed the samples for HM IgA (using a customized immunoassay in skim milk) and for HM and salivary cortisol (using a chemiluminescent immunoassay). Infant illness was assessed using the Score for Neonatal Acute Physiology II (SNAP II) and SNAP II with Perinatal Extension (SNAPPE II), and infant neurodevelopment were assessed using the Test of Infant Motor Performance. We analyzed changes in HM IgA and cortisol over time using paired t-tests. Furthermore, we performed correlation and regression analyses after adjusting for gestational age (GA), corrected GA, and infant days of life. Results: In our study, we enrolled 26 dyads, with a mean maternal age of 28.1 years, consisting of 69% white, 19% Black, and 8% Hispanic. Cortisol: Salivary and HM cortisol were closely associated in week 1 but not in week 5. Though mean salivary cortisol remained stable over time [2.41 ng/mL (SD 2.43) to 2.32 (SD 1.77), p = 0.17], mean HM cortisol increased [1.96 ng/mL (SD 1.93) to 5.93 ng/mL (SD 3.83), p < 0.001]. Stress measures were inversely associated with HM cortisol at week 1 but not at week 5. IgA: HM IgA decreased over time (mean = -0.14 mg/mL, SD 0.53, p < 0.0001). High maternal stress, as measured by the Parental Stressor Scale: neonatal intensive care unit (PSS:NICU), was positively associated with HM IgA at week 5 (r = 0.79, P ≤ 0.001). Higher IgA was associated with a lower (better) SNAP II score at week 1 (r = -0.74, p = 0.05). No associations were found between maternal stress, salivary cortisol, HM cortisol, or HM IgA and neurodevelopment at discharge (as assessed using the TIMP score). Furthermore, these relationships did not differ by infant sex. Conclusion: Maternal stress showed associations with HM cortisol and HM IgA. In turn, HM IgA was associated with lower measures of infant illness.

Transfer of Injected Triamcinolone into Human Milk of a Lactating Patient Suffering from Idiopathic Granulomatous Mastitis.

Background: Idiopathic granulomatous mastitis (IGM) is a chronic inflammatory condition of the mammary gland that presents as a painful mass, and it must be distinguished from both infectious mastitis and breast cancer. When diagnosed during lactation, it can result in significant distress and early weaning. Injection of triamcinolone has been used as a successful treatment method, but safety in breastfed infants has not been established. Methods: We present a case of a lactating patient who received a direct injection of triamcinolone (dosage 40 mg) in her breast to treat IGM after failure of oral corticosteroids. Breastmilk samples were expressed by the patient 0, 1, 4, and 24 hours after the procedure, and then daily for 1 week. All the samples were analyzed using liquid chromatography mass spectrometry. The patient was supported by a breastfeeding and lactation medicine clinic. Results: After injection of triamcinolone into the granulomatous mass, breast milk samples were collected and analyzed. No samples were found to contain triamcinolone. A temporary but significant decrease in milk production was noted after injection, though only a slight decrease had been noted with 6 weeks of systemic corticosteroids. With support, the patient rebuilt milk production and continued to breastfeed from both breasts. Conclusion: Triamcinolone was not found in any milk samples (≥0.78 ng/mL) following therapeutic injection of the affected breast. The patient was able to continue breastfeeding from the affected breast with intermittent symptoms.

Recommended Core Competencies for Specialists Practicing Breastfeeding and Lactation Medicine.

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using genderinclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Prenatal Provider Breastfeeding Toolkit: Results of a Pilot to Increase Women's Prenatal Breastfeeding Support, Intentions, and Outcomes.

BACKGROUND: Breastfeeding rates for United States women with lower incomes fall below the government's Healthy People 2020 Goals. Breastfeeding recommendations combined with support from providers and peer counselors help women decide to begin and sustain breastfeeding, but peer counselor uptake is low. RESEARCH AIM: To evaluate changes in referrals to Women, Infants, and Children's Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention. METHOD: In this pre-post intervention study (2015-2016; upstate New York), providers implemented a Toolkit to discuss infant feeding recommendations and initiate peer counselor referral. We surveyed women pre- and post-implementation (after delivery; 1 month postpartum) about prenatal breastfeeding intentions, provider support, and breastfeeding outcomes. Analyses controlled for secular trends. RESULTS: Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding support. CONCLUSIONS: Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants' breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

Association of Human Milk Antibody Induction, Persistence, and Neutralizing Capacity With SARS-CoV-2 Infection vs mRNA Vaccination.

Importance: Long-term effect of parental COVID-19 infection vs vaccination on human milk antibody composition and functional activity remains unclear. Objective: To compare temporal IgA and IgG response in human milk and microneutralization activity against SARS-CoV-2 between lactating parents with infection and vaccinated lactating parents out to 90 days after infection or vaccination. Design, Setting, and Participants: Convenience sampling observational cohort (recruited July to December 2020) of lactating parents with infection with human milk samples collected at days 0 (within 14 days of diagnosis), 3, 7, 10, 28, and 90. The observational cohort included vaccinated lactating parents with human milk collected prevaccination, 18 days after the first dose, and 18 and 90 days after the second dose. Exposures: COVID-19 infection diagnosed by polymerase chain reaction within 14 days of consent or receipt of messenger RNA (mRNA) COVID-19 vaccine (BNT162b2 or mRNA-1273). Main Outcomes and Measures: Human milk anti-SARS-CoV-2 receptor-binding domain IgA and IgG and microneutralization activity against live SARS-CoV-2 virus. Results: Of 77 individuals, 47 (61.0%) were in the infection group (mean [SD] age, 29.9 [4.4] years), and 30 (39.0%) were in the vaccinated group (mean [SD] age, 33.0 [3.4] years; P = .002). The mean (SD) age of infants in the infection and vaccinated group were 3.1 (2.2) months and 7.5 (5.2) months, respectively (P < .001). Infection was associated with a variable human milk IgA and IgG receptor-binding domain-specific antibody response over time that was classified into different temporal patterns: upward trend and level trend (33 of 45 participants [73%]) and low/no response (12 of 45 participants [27%]). Infection was associated with a robust and quick IgA response in human milk that was stable out to 90 days after diagnosis. Vaccination was associated with a more uniform IgG-dominant response with concentrations increasing after each vaccine dose and beginning to decline by 90 days after the second dose. Vaccination was associated with increased human milk IgA after the first dose only (mean [SD] increase, 31.5 [32.6] antibody units). Human milk collected after infection and vaccination exhibited microneutralization activity. Microneutralization activity increased throughout time in the vaccine group only (median [IQR], 2.2 [0] before vaccine vs 10 [4.0] after the first dose; P = .003) but was higher in the infection group (median [IQR], 20 [67] at day 28) vs the vaccination group after the first-dose human milk samples (P = .002). Both IgA and non-IgA (IgG-containing) fractions of human milk from both participants with infection and those who were vaccinated exhibited microneutralization activity against SARS-CoV-2. Conclusions and Relevance: In this cohort study of a convenience sample of lactating parents, the pattern of IgA and IgG antibodies in human milk differed between COVID-19 infection vs mRNA vaccination out to 90 days. While infection was associated with a highly variable IgA-dominant response and vaccination was associated with an IgG-dominant response, both were associated with having human milk that exhibited neutralization activity against live SARS-CoV-2 virus.

Upper Lip Tie: Anatomy, Effect on Breastfeeding, and Correlation With Ankyloglossia.

OBJECTIVES: There is debate among otolaryngologists and other practitioners about whether upper lip tie contributes to difficulty with breastfeeding and whether upper lip tie and ankyloglossia are linked. Our objectives were to evaluate the anatomy of the upper lip (maxillary) frenulum, to determine if the visual anatomy of the upper lip has an effect on breastfeeding, and to determine whether the occurrence of lip tie and tongue tie are correlated. METHODS: A prospective cohort study of 100 healthy newborns was examined between day of life 3-7. Surveys were completed by the mother at the time of the initial exam and 2 weeks later. The maxillary frenulum was graded based on the Stanford and Kotlow classifications by two independent reviewers. Inter-rater reliability and relationships between tongue tie, lip tie, and the infant breastfeeding assessment tool (IBFAT) were calculated. RESULTS: Inter-rater reliability showed fair agreement (κ = 0.302) using the Kotlow scale and better agreement using the Stanford classification (κ = 0.458). There was no correlation between the upper lip tie classification and breastfeeding success score. Lastly, there was a modest inverse correlation in the degree of tethering for the tongue and lip. CONCLUSIONS: There was no correlation between maxillary frenulum grade and comfort with breastfeeding, pain scores, or latch. There was also no relationship between tip to frenulum length (tongue tie) and visualized lip anatomy, suggesting that tongue tie and lip tie may not cluster together in infants. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:E1701-E1706, 2021.

Who Makes the Choice: Ethical Considerations Regarding Instituting Breastfeeding in a Mother Who Has Compromised Mental Capacity.

This case reports an ethical dilemma in which a mother who had recently delivered a baby through cesarean section after sustaining life-threatening injuries in a car accident did not have documented wishes whether she wanted to breastfeed. Her medical condition rendered her temporarily mentally incapacitated and critically ill, and the lactation medicine team was consulted about whether lactation choice should be preserved by pumping. Complicating considerations in this case were (1) lack of family or designated decision-makers available at the time of injury and emergent delivery, (2) lack of prenatal care, and (3) complex social situation, including prior history of illicit substance use, and state removal of other children into foster care. This case raises important ethical considerations regarding breastfeeding decision-making when a mother is incapable of making the decision, and if there is an intrinsic right for an infant to be breastfed in situations where maternal choice to lactate or to formula feed is unknown. Ultimately, the mother chose to discontinue breastfeeding once she was able to voice her own opinion. The issues discussed in this study may be relevant for future cases when providing guidance on the ethical argument to preserve maternal choice when a mother is critically ill and mentally incapacitated.

Characterization of SARS-CoV-2 RNA, Antibodies, and Neutralizing Capacity in Milk Produced by Women with COVID-19.

Whether mother-to-infant SARS-CoV-2 transmission can occur during breastfeeding and, if so, whether the benefits of breastfeeding outweigh this risk during maternal COVID-19 illness remain important questions. Using RT-qPCR, we did not detect SARS-CoV-2 RNA in any milk sample (n = 37) collected from 18 women following COVID-19 diagnosis. Although we detected evidence of viral RNA on 8 out of 70 breast skin swabs, only one was considered a conclusive positive result. In contrast, 76% of the milk samples collected from women with COVID-19 contained SARS-CoV-2-specific IgA, and 80% had SARS-CoV-2-specific IgG. In addition, 62% of the milk samples were able to neutralize SARS-CoV-2 infectivity in vitro, whereas milk samples collected prior to the COVID-19 pandemic were unable to do so. Taken together, our data do not support mother-to-infant transmission of SARS-CoV-2 via milk. Importantly, milk produced by infected mothers is a beneficial source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness.IMPORTANCE Results from prior studies assaying human milk for the presence of SARS-CoV-2, the causative virus of COVID-19, have suggested milk may act as a potential vehicle for mother-to-child transmission. Most previous studies are limited because they followed only a few participants, were cross-sectional, and/or failed to report how milk was collected and/or analyzed. As such, considerable uncertainty remains regarding whether human milk is capable of transmitting SARS-CoV-2 from mother to child. Here, we report that repeated milk samples collected from 18 women following COVID-19 diagnosis did not contain SARS-CoV-2 RNA; however, risk of transmission via breast skin should be further evaluated. Importantly, we found that milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness as milk likely provides specific immunologic benefits to infants.

Milk From Women Diagnosed With COVID-19 Does Not Contain SARS-CoV-2 RNA but Has Persistent Levels of SARS-CoV-2-Specific IgA Antibodies.

Background: Limited data are available regarding the balance of risks and benefits from human milk and/or breastfeeding during and following maternal infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Objective: To investigate whether SARS-CoV-2 can be detected in milk and on the breast after maternal coronavirus disease 2019 (COVID-19) diagnosis; and characterize concentrations of milk immunoglobulin (Ig) A specific to the SARS-CoV-2 spike glycoprotein receptor binding domain (RBD) during the 2 months after onset of symptoms or positive diagnostic test. Methods: Using a longitudinal study design, we collected milk and breast skin swabs one to seven times from 64 lactating women with COVID-19 over a 2-month period, beginning as early as the week of diagnosis. Milk and breast swabs were analyzed for SARS-CoV-2 RNA, and milk was tested for anti-RBD IgA. Results: SARS-CoV-2 was not detected in any milk sample or on 71% of breast swabs. Twenty-seven out of 29 (93%) breast swabs collected after breast washing tested negative for SARS-CoV-2. Detection of SARS-CoV-2 on the breast was associated with maternal coughing and other household COVID-19. Most (75%; 95% CI, 70-79%; n=316) milk samples contained anti-RBD IgA, and concentrations increased (P=.02) during the first two weeks following onset of COVID-19 symptoms or positive test. Milk-borne anti-RBD IgA persisted for at least two months in 77% of women. Conclusion: Milk produced by women with COVID-19 does not contain SARS-CoV-2 and is likely a lasting source of passive immunity via anti-RBD IgA. These results support recommendations encouraging lactating women to continue breastfeeding during and after COVID-19 illness.

Prenatal Provider Support for Breastfeeding: Changes in Attitudes, Practices and Recommendations Over 22 Years.

BACKGROUND: Prenatal care providers play a central role in breastfeeding outcomes. A survey on obstetricians' support of breastfeeding was conducted in 1993 in Monroe County, NY. Since the landscape of prenatal care and breastfeeding support has changed significantly in the past 2 decades, we repeated and extended this survey in 2015. RESEARCH AIM: To determine changes in breastfeeding support by prenatal care providers over a 20 year period. METHODS: We sent a 46-item on-line or paper questionnaire to all categories of prenatal care providers identified by an online search. A breastfeeding support score was created based on the prior survey, with a maximum score of 3. One point was awarded for: (1) personally discussing breastfeeding; (2) generally suggesting breastfeeding; and (3) commonly receiving questions from patients. Data were analyzed using Chi-square. RESULTS: We had 164 participants (response rate 80%). More current participants, compared to 1993, reported discussing (97% vs. 86%, p < .001) and recommending (93% vs. 80%, p = .001) breastfeeding. Only 10% of 2015 participants gave infant formula samples, compared with 34% in 1993 (p < .0001). Improvement in the support score was seen, with 98% of current participants having high scores compared to 87% in 1993 (p < .001). Similar numbers reported receiving breastfeeding education, though more reported that the education was inadequate (54% vs. 19%, p < .0001). CONCLUSION: Breastfeeding support improved significantly over time, even though breastfeeding education has not improved in quality or quantity. Improving education of prenatal care providers may help future providers be more prepared to support breastfeeding.

ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients.

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

COVID-19 and human milk: SARS-CoV-2, antibodies, and neutralizing capacity.

Background: It is not known whether SARS-CoV-2 can be transmitted from mother to infant during breastfeeding, and if so whether the benefits of breastfeeding outweigh this risk. This study was designed to evaluate 1) if SARS-CoV-2 RNA can be detected in milk and on the breast of infected women, 2) concentrations of milk-borne anti-SARS-CoV-2 antibodies, and 3) the capacity of milk to neutralize SARS-CoV-2 infectivity. Methods: We collected 37 milk samples and 70 breast swabs (before and after breast washing) from 18 women recently diagnosed with COVID-19. Samples were analyzed for SARS-CoV-2 RNA using RT-qPCR. Milk was also analyzed for IgA and IgG specific for the nucleocapsid protein, receptor binding domain (RBD), S2 subunit of the spike protein of SARS-CoV-2, as well as 2 seasonal coronaviruses using ELISA; and for its ability to neutralize SARS-CoV-2. Results: We did not detect SARS-CoV-2 RNA in any milk sample. In contrast, SARS-CoV-2 RNA was detected on several breast swabs, although only one was considered conclusive. All milk contained SARS-CoV-2-specific IgA and IgG, and levels of anti-RBD IgA correlated with SARS-CoV-2 neutralization. Strong correlations between levels of IgA and IgG to SARS-CoV-2 and seasonal coronaviruses were noted. Conclusions: Our data do not support maternal-to-child transmission of SARS-CoV-2 via milk; however, risk of transmission via breast skin should be further evaluated. Importantly, milk produced by infected mothers is a source of anti-SARS-CoV-2 IgA and IgG and neutralizes SARS-CoV-2 activity. These results support recommendations to continue breastfeeding during mild-to-moderate maternal COVID-19 illness.

Mothers' Concerns for Personal Safety and Privacy While Breastfeeding: An Unexplored Phenomenon.

BACKGROUND: Preliminary qualitative research in upstate NY shows new mothers are worried about safety while breastfeeding. Little is known regarding prevalence of these concerns and their effect on breastfeeding outcomes. OBJECTIVES: (1) Determine frequency of breastfeeding safety and privacy concerns; (2) Explore their association with breastfeeding outcomes. METHODS: Mothers were surveyed immediately and 1-month postpartum about breastfeeding goals; both surveys addressed privacy and safety concerns at home, work, and in public. Outcome data included breastfeeding intent, exclusivity, and duration. Breastfeeding/non-breastfeeding mothers were compared using Chi-square and multivariate analyses. RESULTS: A total of 279 women enrolled. Of these 82.8% initiated breastfeeding; at 1-month 72% provided any breast milk, and 44% were exclusively breastfeeding. About 99% felt safe breastfeeding at home; 25% reported privacy concerns; and 5% felt "vulnerable or unsafe" while breastfeeding. At 1-month, 49% agreed there was a safe place to breastfeed/express milk at work (20% unsure). Non-breastfeeding mothers expressed more safety concerns outside home/at work: 18% breastfeeding versus 28% non-breastfeeding outside home; 27% breastfeeding versus 40% non-breastfeeding at work. Nearly 54% who reported feeling vulnerable/unsafe with breastfeeding initiated breastfeeding, compared with 86% not reporting this concern (p = 0.008). Fewer women initiating breastfeeding reported vulnerability/safety (3% breastfeeding versus 14% non-breastfeeding, p = 0.008) or privacy (22% breastfeeding versus 40% non-breastfeeding, p = 0.19) concerns. Associations held after controlling for age, race, parity, insurance, geography, and marital-status. Significant associations between initiation, privacy, and safety concerns did not extend to duration or exclusivity. CONCLUSION: Many breastfeeding women reported safety and privacy concerns, especially outside the home and at work, which may influence breastfeeding initiation. Further study may identify methods to address these issues, potentially increasing breastfeeding rates.

Defining Tip-Frenulum Length for Ankyloglossia and Its Impact on Breastfeeding: A Prospective Cohort Study.

OBJECTIVE: The purpose of this study was to investigate the normal lingual frenulum anatomy in newborns and to evaluate tip-frenulum distance as an objective diagnostic tool for identifying newborns at risk for anterior and posterior tongue tie and breastfeeding difficulty. MATERIALS AND METHODS: The distance from the tongue tip to the insertion of the lingual frenulum was measured in a group of 100 healthy newborns to establish normative data. The presence of a visible or palpable cord was noted. Inter-rater reliability was assessed. Breastfeeding surveys including a maternal pain scale and Infant Breastfeeding Assessment Tool (IBFAT) were administered on days of life 2 and 14 to determine whether these findings predict breastfeeding difficulty. RESULTS: Mean tip-frenulum length was 9.07 mm. Intraclass correlation coefficient between observers for tip-frenulum length was 0.82. A visible cord was identified in 21 subjects (21%). A palpable cord was identified in 59 subjects (59%). Unweighted κ coefficients for inter-rater reliability of visible and palpable cords were 0.91 and 0.47, respectively. Visible cord and shorter tip-frenulum distance were independently predictive of higher maternal pain scores. A positive correlation was identified between tip-frenulum length and IBFAT scores for mothers with two or more previous breastfed children. CONCLUSIONS: Tongue tip-frenulum length correlated with maternal nipple pain, and was useful as an objective tool for identifying newborns at risk for ankyloglossia. Maternal breastfeeding experience appears to be an important factor in the link between tongue anatomy and breastfeeding difficulty. The presence of a palpable cord was variable across examiners, and should be interpreted with caution when evaluating newborns for posterior tongue tie.

Medical Directors of Breastfeeding Programs at Academic Medical Centers: Duties and Challenges.

INTRODUCTION: An emerging trend in Academic Medical Centers (AMCs) is to coordinate breastfeeding care, research, and trainee education through "medical director" positions. Little is known about their duties, supports, and challenges. OBJECTIVE: To determine the duties and challenges of directors of breastfeeding medicine in AMCs. METHODS: A survey was distributed four times over a 3-month period to three listservs with a total of 860 members. Physicians directing breastfeeding programs or services at AMCs were included. Participants were asked about details of their employment, time distribution of the position, their role in education, billing practices, and major hurdles. RESULTS: Thirty-two physicians responded to the survey: 25 from the United States, and seven international. Only 22% of respondents had formal job descriptions and only 31% reported being paid for their breastfeeding work. Most positions were created in the past 10 years (75%), were housed in Departments of Pediatrics (75%), and provided clinical services for breastfeeding in inpatient and outpatient settings. Ninety-one percent of respondents educated trainees and provided oversight of lactation consultants. Major hurdles included difficulties with billing for services, lack of protected time and personal reimbursement, lack of formal structure and job descriptions, and lack of buy-in at the institutional and sometimes governmental levels. CONCLUSIONS: Medical Directors of Breastfeeding Services may be increasingly prevalent in AMCs and are engaged in inpatient and outpatient clinical work, trainee education, and lactation consultant oversight. Both financial and structural hurdles were reported by those holding these positions.