Breastfeeding: crucially important, but increasingly challenged in a market-driven world.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

The effects of 16-weeks of prebiotic supplementation and aerobic exercise training on inflammatory markers, oxidative stress, uremic toxins, and the microbiota in pre-dialysis kidney patients: a randomized controlled trial-protocol paper.

BACKGROUND: Chronic kidney disease (CKD) is characterized by dysbiosis, elevated levels of uremic toxins, systemic inflammation, and increased markers of oxidative stress. These factors lead to an increased risk of cardiovascular disease (CVD) which is common among CKD patients. Supplementation with high amylose maize resistant starch type 2 (RS-2) can change the composition of the gut microbiota, and reduce markers of inflammation and oxidative stress in patients with end-stage renal disease. However, the impact of RS-2 supplementation has not been extensively studied in CKD patients not on dialysis. Aerobic exercise training lowers certain markers of inflammation in CKD patients. Whether combining aerobic training along with RS-2 supplementation has an additive effect on the aforementioned biomarkers in predialysis CKD patients has not been previously investigated. METHODS: The study is being conducted as a 16-week, double-blind, placebo controlled, parallel arm, randomized controlled trial. Sixty stage 3-4 CKD patients (ages of 30-75 years) are being randomized to one of four groups: RS-2 & usual care, RS-2 & aerobic exercise, placebo (cornstarch) & usual care and placebo & exercise. Patients attend four testing sessions: Two baseline (BL) sessions with follow up visits 8 (wk8) and 16 weeks (wk16) later. Fasting blood samples, resting brachial and central blood pressures, and arterial stiffness are collected at BL, wk8 and wk16. A stool sample is collected for analysis of microbial composition and peak oxygen uptake is assessed at BL and wk16. Blood samples will be assayed for p-cresyl sulphate and indoxyl sulphate, c-reactive protein, tumor necrosis factor α, interleukin 6, interleukin 10, monocyte chemoattractant protein 1, malondialdehyde, 8-isoprostanes F2a, endothelin-1 and nitrate/nitrite. Following BL, subjects are randomized to their group. Individuals randomized to conditions involving exercise will attend three supervised moderate intensity (55-65% peak oxygen uptake) aerobic training sessions (treadmills, bikes or elliptical machine) per week for 16 weeks. DISCUSSION: This study has the potential to yield information about the effect of RS-2 supplementation on key biomarkers believed to impact upon the development of CVD in patients with CKD. We are examining whether there is an additive effect of exercise training and RS-2 supplementation on these key variables. TRIAL REGISTRATION: Clinicaltrials.gov Trial registration# NCT03689569 . 9/28/2018, retrospectively registered.

Acculturative type is associated with breastfeeding duration among low-income Latinas.

We sought to assess the relationship between acculturative type and breastfeeding outcomes among low-income Latinas, utilising a multidimensional assessment of acculturation. We analysed data derived from a breastfeeding peer counselling randomised trial. Acculturation was assessed during pregnancy using a modified Acculturation Rating Scale for Mexican Americans scale. Analyses were restricted to Latinas who completed the acculturation scale and had post-partum breastfeeding data (n = 114). Cox survival analyses were conducted to evaluate differences in breastfeeding continuation and exclusivity by acculturative type. Participants were classified as integrated-high (23.7%, n = 27), traditional Hispanic (36.8%, n = 42), integrated-low (12.3%, n = 14) and assimilated (27.2%, n = 31). The integrated-low group was significantly more likely to continue breastfeeding than the traditional Hispanic, assimilated, and integrated-high groups (P < 0.05, P < 0.05, and P < 0.01, respectively). The traditional Hispanic group was marginally more likely to continue breastfeeding than the integrated-high group (P = 0.06). Breastfeeding continuation rates vary significantly between acculturative types in this multinational, low-income Latina sample. Multidimensional assessments of acculturation may prove useful in better tailoring future breastfeeding promotion interventions.

US national breastfeeding monitoring and surveillance: current status and recommendations.

Eleven federally funded datasets assessing breastfeeding behaviors in the United States (Early Childhood Longitudinal Survey, Infant Feeding Practices Survey II, National Health and Nutrition Examination Survey, National Immunization Survey, National Survey of Children's Health, National Survey of Early Childhood Health, National Survey of Family Growth, Pediatric Nutrition Surveillance System, Pregnancy Nutrition Surveillance System, Pregnancy Risk Assessment Monitoring Survey, and WIC Participant and Program Characteristics) were reviewed to evaluate breastfeeding variables (initiation, duration and exclusivity) and determine whether relevant breastfeeding determinants were collected to evaluate breastfeeding practices from a health disparities perspective. The datasets used inconsistent breastfeeding definitions, limited ethnic descriptors, and varied regarding availability of relevant determinants. Multiple datasets collect breastfeeding data, but a coordinated US breastfeeding monitoring and surveillance system does not exist. Suggestions to improve this system include: standardizing breastfeeding definitions, expanding ethnic/racial descriptors, collecting additional relevant variables, and reducing recall periods.

Qualitative Analysis of Registered Nurses' Perceptions of Lactation Assessment Tools: Why and How They Are Completed.

BACKGROUND: Although lactation assessment tools are consistently used in clinical practice, there is no evidence describing registered nurses' perspectives regarding the purpose and thought processes involved when conducting a breastfeeding assessment. Research aim: This study aimed to explore registered nurses' perceptions on the purpose of lactation assessment tools and the thought processes involved in completing one. METHODS: Seven focus groups were held from April 2015 through July 2015, in coordination with regional and international lactation and perinatal conferences. Participants included 28 hospital-based registered nurses who routinely used a lactation assessment tool to assess postpartum mothers with healthy breastfeeding newborns. Focus groups were audiotaped, transcribed verbatim, and content analyzed by two lactation researchers to identify relevant themes and subthemes. RESULTS: The analyses identified four different purposes of breastfeeding assessment tools (Teaching and Assessing Simultaneously, Infant Safety, Standardized Practice, and "It's Your Job!") and four themes related to the thought processes used in completing the tool (Novice vs. Expert, Real-Time vs. Recalled Documentation, Observation or Not, and "Fudging the Score"). CONCLUSION: Registered nurses found lactation assessment tool completion to be an essential part of their job and that it ensured infant safety, standardized care, maternal instruction, and lactation assessment. Differences in the lactation assessment tool completion process were described, based on staff expertise, workload, hospital policies, and varying degrees of compliance with established protocols. These findings provide critical insight for the development of future breastfeeding assessment tools.

Lactation Assessment Tools: A Qualitative Analysis of Registered Nurses' Perceptions of Tool Limitations and Suggested Improvements.

Background Several lactation assessment tools are available for in-hospital assessment of breastfeeding dyads, and their components vary widely. To date, no research has evaluated the perceptions of registered nurses (RNs) regarding the limitations and future improvements of these tools. Research Aim The aim was to describe RNs' perceptions of the limitations of currently used lactation assessment tools and how these tools could be enhanced. Methods Focus groups ( n = 7) were conducted with RNs ( N = 28) whose current responsibilities included in-hospital breastfeeding assessment. Recruitment occurred from April through July 2015 at regional and international lactation conferences. Focus groups were audiotaped and transcribed verbatim. Two lactation researchers analyzed the transcripts to identify emerging themes and subthemes. Results RNs identified three key limitations of the tools included being too subjective and time-consuming, difficulty in assessing audible swallows, and missing the big picture (e.g., overemphasizing numbers, being a snapshot in time). Suggested improvements focused on maternal characteristics (evolving breasts and nipples, holding it together, "got milk?," risk factors, embracing the role), infant characteristics (day of life, latch/suck/swallow, baby's "driving the bus," risk factors for supplemental feeding), their interaction (two to tango, positioning, better qualitative descriptors), and tool organization (formatting and multiple versions). Conclusions RNs suggested novel components for consideration when developing future lactation assessment scales, including removing audible swallowing, adding mother/infant interactions, infant output, and expressible colostrum, and developing criteria specific to infant age. Future research should translate these suggestions into evidence-based indicators and evaluate the resulting proposed tools for reliability and validity.

Differential response to an exclusive breastfeeding peer counseling intervention: the role of ethnicity.

The authors analyzed data from a trial assessing the efficacy of breastfeeding peer counseling (PC) for increasing exclusive breastfeeding (EBF) to (1) examine whether different ethnic groups responded differently to the intervention and (2) document the determinants of EBF. At 2 months postpartum, the prevalence of EBF in the intervention group was 11.4% among Puerto Ricans compared to 44.4% among non-Puerto Ricans (P = .008). Multivariate logistic regression analyses showed that women who had the intention prenatally to engage in EBF were more likely to do so and those whose mothers lived in the United States were less likely to engage in EBF at hospital discharge. At 2 months postpartum, mothers who were breastfed as children were more likely to engage in EBF, whereas non-Puerto Ricans had a significantly greater response to the intervention than Puerto Ricans (odds ratio, 6.40; 95% confidence interval, 1.45-28.33). There is a need for further studies to determine why different ethnic groups respond differently to EBF promotion interventions.

Incentive-based Intervention to Maintain Breastfeeding Among Low-income Puerto Rican Mothers.

BACKGROUND AND OBJECTIVE: Despite maternal and child health benefits, breastfeeding rates are relatively low among low-income Puerto Rican mothers. This study examined the hypothesis that monthly financial incentives would significantly increase the proportion of breastfeeding mothers at 6 months postpartum compared with Supplemental Nutrition Program for Women, Infants, and Children (WIC) services only among Puerto Rican mothers. METHODS: A randomized, 2-arm parallel-group design, from February 2015 through February 2016. Half of the randomized participants received monthly financial incentives contingent on observed breastfeeding for 6 months (Incentive), and the other half received usual WIC services only (Control). Thirty-six self-identified Puerto Rican women who initiated breastfeeding were enrolled. Monthly cash incentives were contingent on observed breastfeeding increasing the amount given at each month from $20 to $70 for a total possible of $270. RESULTS: The intent-to-treat analysis showed significantly higher percentages of breastfeeding mothers in the incentive group at each time point compared with those in the control group (89% vs 44%, P = .01 at 1 month; 89% vs 17%, P < .001 at 3 months; 72% vs 0%, P < .001 at 6 months). No significant differences were detected at any time point between study groups for self-reported exclusive breastfeeding rate and infant outcomes (ie, weight, emergency department visits). CONCLUSIONS: Contingent cash incentives significantly increased breastfeeding through 6-month postpartum among WIC-enrolled Puerto Rican mothers; however, no significant differences between the study groups were observed on exclusive breastfeeding rate and infant outcomes. Larger-scale studies are warranted to examine efficacy, implementation potential, and cost-effectiveness.

Prepregnancy Obesity Class Is a Risk Factor for Failure to Exclusively Breastfeed at Hospital Discharge among Latinas.

BACKGROUND: Suboptimal infant feeding practices, including the failure to exclusively breastfeed, are modifiable risk factors that affect multiple maternal and child health outcomes. Women who are overweight or obese prenatally are more likely to fail to exclusively breastfeed. In the United States, Latinas represent a high-risk population with respect to overweight, obesity, and suboptimal infant feeding practices. OBJECTIVES: Examine whether exclusive breastfeeding status at hospital discharge among overweight and obese Latinas was associated with (1) prepregnancy body mass index (BMI) and gestational weight gain and (2) sociodemographic, psychosocial, and maternal/infant biomedical factors. METHODS: An electronic medical records review was conducted to determine exclusive breastfeeding status at hospital discharge among Latinas who gave birth at Hartford Hospital, Hartford, Connecticut, USA (N = 480). Eligible participants were ≥ 16 years, Latina, overweight or obese (BMI ≥ 25.0 kg/m(2)) and delivered a healthy full-term (≥ 37 weeks) singleton. RESULTS: In the multivariable model, obese class II (BMI, 35.0-39.9 kg/m(2)) women had increased odds of failing to exclusively breastfeed at hospital discharge compared with overweight women. Planned formula use/partial breastfeeding was the single strongest predictor of nonexclusive breastfeeding status. Other risk factors included Puerto Rican ethnicity and parity. CONCLUSION: Maternal prepregnancy obesity class is an important predictor of exclusive breastfeeding status at hospital discharge among overweight and obese Latinas. Future research should examine why in-hospital exclusive breastfeeding behaviors differ by obesity class to subsequently inform the design of breastfeeding promotion and support interventions tailored to the needs of Latinas by obesity class. Culturally appropriate prenatal breastfeeding promotion interventions emphasizing action and coping planning should be considered.

Reliability of Lactation Assessment Tools Applied to Overweight and Obese Women.

BACKGROUND: The interrater reliability of lactation assessment tools has not been evaluated in overweight/obese women. OBJECTIVE: This study aimed to compare the interrater reliability of 4 lactation assessment tools in this population. METHODS: A convenience sample of 45 women (body mass index > 27.0) was videotaped while breastfeeding (twice daily on days 2, 4, and 7 postpartum). Three International Board Certified Lactation Consultants independently rated each videotaped session using 4 tools (Infant Breastfeeding Assessment Tool [IBFAT], modified LATCH [mLATCH], modified Via Christi [mVC], and Riordan's Tool [RT]). For each day and tool, we evaluated interrater reliability with 1-way repeated-measures analyses of variance, intraclass correlation coefficients (ICCs), and percentage absolute agreement between raters. RESULTS: Analyses of variance showed significant differences between raters' scores on day 2 (all scales) and day 7 (RT). Intraclass correlation coefficient values reflected good (mLATCH) to excellent reliability (IBFAT, mVC, and RT) on days 2 and 7. All day 4 ICCs reflected good reliability. The ICC for mLATCH was significantly lower than all others on day 2 and was significantly lower than IBFAT (day 7). Percentage absolute interrater agreement for scale components ranged from 31% (day 2: observable swallowing, RT) to 92% (day 7: IBFAT, fixing; and mVC, latch time). Swallowing scores on all scales had the lowest levels of interrater agreement (31%-64%). CONCLUSION: We demonstrated differences in the interrater reliability of 4 lactation assessment tools when applied to overweight/obese women, with the lowest values observed on day 4. Swallowing assessment was particularly unreliable. Researchers and clinicians using these scales should be aware of the differences in their psychometric behavior.

A randomized trial assessing the efficacy of peer counseling on exclusive breastfeeding in a predominantly Latina low-income community.

OBJECTIVE: To assess the efficacy of peer counseling to promote exclusive breastfeeding (EBF) among low-income inner-city women in Hartford, Conn. DESIGN: Participants recruited prenatally were randomly assigned to either receive support for EBF from a peer counselor plus conventional breastfeeding support (peer counseling group [PC]) or only conventional breastfeeding support (control group [CG]) and followed through 3 months post partum. SETTING: Low-income predominantly Latina community. PARTICIPANTS: Expectant mothers, less than 32 weeks gestation and considering breastfeeding (N = 162). Intervention Exclusive breastfeeding peer counseling support offering 3 prenatal home visits, daily perinatal visits, 9 postpartum home visits, and telephone counseling as needed. MAIN OUTCOME MEASURES: Exclusive breastfeeding rates at hospital discharge, 1, 2, and 3 months post partum (n = 135). RESULTS: At hospital discharge, 24% in the CG compared with 9% in the PC had not initiated breastfeeding, with 56% and 41%, respectively, nonexclusively breastfeeding. At 3 months, 97% in the CG and 73% in the PC had not exclusively breastfed (relative risk [RR] = 1.33; 95% CI, 1.14-1.56) during the previous 24 hours. The likelihood of nonexclusive breastfeeding throughout the first 3 months was significantly higher for the CG than the PC (99% vs 79%; RR = 1.24; 95% CI, 1.09-1.41). Mothers in the CG were less likely than their PC counterparts to remain amenorrheic at 3 months (33% vs 52%; RR = 0.64; 95% CI, 0.43-0.95). The likelihood of having 1 or more diarrheal episode in infants was cut in half in the PC (18% vs 38%; RR = 2.15; 95% CI, 1.16-3.97). CONCLUSION: Well-structured, intensive breastfeeding support provided by hospital and community-based peer counselors is effective in improving exclusive breastfeeding rates among low-income, inner-city women in the United States.

Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina population: a randomized controlled trial.

BACKGROUND: Breastfeeding peer counseling has improved breastfeeding rates in developing countries; however, its impact in this country has not been adequately evaluated. OBJECTIVE: To evaluate the effectiveness of an existing, breastfeeding peer counseling program within the United States. DESIGN: Randomized, prospective, controlled trial in which participants were recruited prenatally and randomly assigned to receive either routine breastfeeding education or routine breastfeeding education plus peer counseling. SETTING: An urban hospital serving a large population of low-income Latinas. PARTICIPANTS: Pregnant women (< or =26 weeks' gestation) were recruited from the hospital's prenatal clinic. Inclusion criteria specified that participants be low income, be considering breastfeeding, have delivered a healthy, full-term singleton, and have access to a telephone. Intervention Breastfeeding peer counseling services included 1 prenatal home visit, daily perinatal visits, 3 postpartum home visits, and telephone contact as needed. MAIN OUTCOME MEASURES: Breastfeeding rates at birth and 1, 3, and 6 months postpartum. RESULTS: The proportion not initiating breastfeeding was significantly lower in the intervention group than among controls (8/90 [9%] vs 17/75 [23%]; relative risk, 0.39; 95% confidence interval, 0.18-0.86). The probability of stopping breastfeeding also tended to be lower in the intervention group at both 1 month (36% vs 49%; relative risk, 0.72; 95% confidence interval, 0.50-1.05) and 3 months (56% vs 71%; relative risk, 0.78; 95% confidence interval, 0.61-1.00). CONCLUSION: These findings demonstrate that, in the United States, peer counselors can significantly improve breastfeeding initiation rates and have an impact on breastfeeding rates at 1 and 3 months post partum.

Differential response to breastfeeding peer counseling within a low-income, predominantly Latina population.

This study aims to identify those most responsive to breastfeeding peer counseling (PC) using data from a US-based randomized trial. The authors ran a series of logistic regression models to identify differential responses to PC, using breastfeeding status at 0, 1, 3, and 6 months postpartum as the dependent variables. Three subgroups were found to be most responsive to breastfeeding PC. Multiparae receiving PC were 6 times more likely to initiate breastfeeding than were multiparous controls (odds ratio [OR] = 6.4; 95% confidence interval [CI] = 1.9-20.8). Similarly, those with uncertain prenatal breastfeeding intentions in the PC group were 7 times (OR = 7.4; 95% CI = 1.5-37.0) more likely to initiate breastfeeding than their control group counterparts. Among subjects partially breastfeeding on day 1 postpartum, those receiving PC were 12 times (OR = 11.9; 95% CI = 1.2-111.1) more likely to breastfeed through 3 months postpartum than were controls. These findings have important implications to the Supplemental Food Program for Women, Infants and Children.

Breastfeeding education and support trial for overweight and obese women: a randomized trial.

OBJECTIVE: To evaluate a specialized breastfeeding peer counseling (SBFPC) intervention promoting exclusive breastfeeding (EBF) among overweight/obese, low-income women. METHODS: We recruited 206 pregnant, overweight/obese, low-income women and randomly assigned them to receive SBFPC or standard care (controls) at a Baby-Friendly hospital. SBFPC included 3 prenatal visits, daily in-hospital support, and up to 11 postpartum home visits promoting EBF and addressing potential obesity-related breastfeeding barriers. Standard care involved routine access to breastfeeding support from hospital personnel, including staff peer counselors. Data collection included an in-hospital interview, medical record review, and monthly telephone calls through 6 months postpartum to assess infant feeding practices, demographics, and health outcomes. Bivariate and logistic regression analyses were conducted. RESULTS: The intervention had no impact on EBF or breastfeeding continuation at 1, 3, or 6 months postpartum. In adjusted posthoc analyses, at 2 weeks postpartum the intervention group had significantly greater odds of continuing any breastfeeding (adjusted odds ratio [aOR]: 3.76 [95% confidence interval (CI): 1.07-13.22]), and giving at least 50% of feedings as breast milk (aOR: 4.47 [95% CI: 1.38-14.5]), compared with controls. Infants in the intervention group had significantly lower odds of hospitalization during the first 6 months after birth (aOR: 0.24 [95% CI: 0.07-0.86]). CONCLUSIONS: In a Baby-Friendly hospital setting, SBFPC targeting overweight/obese women did not impact EBF practices but was associated with increased rates of any breastfeeding and breastfeeding intensity at 2 weeks postpartum and decreased rates of infant hospitalization in the first 6 months after birth.

Breastfeeding among minority women: moving from risk factors to interventions.

The gap between current breastfeeding practices and the Healthy People 2020 breastfeeding goals is widest for black women compared with all other ethnic groups. Also of concern, Hispanic and black women have the highest rates of formula supplementation of breast-fed infants before 2 d of life. These disparities must be addressed through the scale-up of effective interventions. The objective of this critical review is to identify and evaluate U.S.-based randomized trials evaluating breastfeeding interventions targeting minorities and highlight promising public health approaches for minimizing breastfeeding disparities. Through PubMed searches, we identified 22 relevant publications evaluating 18 interventions targeting minorities (peer counseling [n = 4], professional support [n = 4], a breastfeeding team [peer + professional support, n = 3], breastfeeding-specific clinic appointments [n = 2], group prenatal education [n = 3], and enhanced breastfeeding programs [n = 2]). Peer counseling interventions (alone or in combination with a health professional), breastfeeding-specific clinic appointments, group prenatal education, and hospital/Special Supplemental Nutrition Program for Women, Infants, and Children enhancements were all found to greatly improve breastfeeding initiation, duration, or exclusivity. Postpartum professional support delivered by nurses was found to be the least effective intervention type. Beyond improving breastfeeding outcomes, 6 interventions resulted in reductions in infant morbidity or health care use. Future research should include further evaluations of successful interventions, with an emphasis on determining the optimal timeframe for the provision of support, the effect of educating women's family members, and the impact on infant health care use and cost-effectiveness.

Breastfeeding protection, promotion, and support in the United States: a time to nudge, a time to measure.

BACKGROUND: Strong evidence-based advocacy efforts have now translated into high level political support and concrete goals for improving breastfeeding outcomes among women in the United States. In spite of this, major challenge remain for promoting, supporting and especially for protecting breastfeeding in the country. OBJECTIVES: The goals of this commentary are to argue in favor of: A) Changes in the default social and environmental systems, that would allow women to implement their right to breastfeed their infants, B) A multi-level and comprehensive monitoring system to measure process and outcomes indicators in the country. METHODS: Evidence-based commentary. RESULTS: Breastfeeding rates in the United States can improve based on a well coordinated social marketing framework. This approach calls for innovative promotion through mass media, appropriate facility based and community based support (e.g., Baby Friendly Hospital Initiative, WIC-coordinated community based peer counseling), and adequate protection for working women (e.g., longer paid maternity leave, breastfeeding or breast milk extraction breaks during the working day) and women at large by adhering and enforcing the WHO ethics Code for the Marketing of Breast Milk Substitutes. Sound infant feeding practices monitoring systems, which include WIC administrative food package data, are needed. CONCLUSIONS: Given the current high level of political support to improve breastfeeding in the United States, a window of opportunity has been opened. Establishing breastfeeding as the social norm in the USA will take time, but the global experience indicates that it can be done.