Association of Breastfeeding Duration with Neurodevelopmental Outcomes in an Enriched Familial Likelihood Cohort for Autism Spectrum Disorder.

This study aimed to compare the breastfeeding (BF) duration of the younger siblings of children with ASD in an enriched-likelihood cohort for autism spectrum disorder (ASD), and to determine whether longer BF duration was associated with differences in neurodevelopmental outcomes in this cohort. Information on BF practices was collected via surveys in the MARBLES (Markers of Autism Risk in Babies-Learning Early Signs) study. Developmental evaluations, including the Mullen Scales of Early Learning and the Autism Diagnostic Observation Schedule, were conducted by expert clinicians. Participants' neurodevelopmental outcome was classified by an algorithm into three groups: typical development, ASD, and non-typical development. The median duration of BF was 10.70 months (interquartile range of 12.07 months). There were no significant differences in the distribution of duration of BF among the three neurodevelopmental outcome categories. Children in this enriched-likelihood cohort who were breastfed for > 12 months had significantly higher scores on cognitive testing compared to those who were breastfed for 0-3 months. There was no significant difference in ASD symptomatology or ASD risk based on BF duration.

Prenatal Counseling on the Maternal Health Benefits of Lactation: A Randomized Trial.

Objective: To assess the effects of prenatal counseling about the maternal health benefits of lactation on postpartum knowledge, breastfeeding intentions, and infant feeding behaviors. Materials and Methods: We conducted a randomized trial with 411 nulliparous U.S.-born women carrying a singleton gestation. Participants were recruited online; after completing a baseline survey that assessed breastfeeding knowledge and intentions, participants were randomized to receive a 10-minute virtual counseling session about the benefits of breastfeeding or attention-control counseling about smoke-free homes. We collected data on breastfeeding knowledge, intentions, and infant feeding behaviors through 12 months postpartum and conducted an intention-to-treat analysis. Results: On enrollment, awareness of the maternal health benefits of lactation was similarly low in both study groups. Postpartum, participants who received this prenatal counseling intervention had significantly greater awareness that breastfeeding decreases maternal risk of breast cancer, ovarian cancer, diabetes, heart disease, and rheumatoid arthritis (p < 0.001 for all). On enrollment, intended duration of breastfeeding was similar between groups (10.1 months versus 9.7 months, p = 0.41). At 1-month postpartum, intended duration of breastfeeding had increased from baseline among those who received this counseling (+0.7 months versus -0.7 months among controls, p = 0.004); among intervention participants intended duration of breastfeeding decreased less at 3 (-0.8 versus -1.6, p = 0.18), 6 (-2.0 versus -3.0, p = 0.06), 9 (-2.8 versus -4.2, p = 0.03), and 12 months postpartum (-4.8 versus -6.2, p = 0.09). Rates of exclusive breastfeeding and any breastfeeding were similar between groups. Conclusion: Prenatal counseling on the maternal health benefits of lactation increases awareness of these maternal health benefits and extends intended duration of breastfeeding. ClinicalTrials.gov Identifier: NCT04601987.

Physician personal breastfeeding experience and clinical care of the breastfeeding dyad.

BACKGROUND: Prior research suggests that physicians' personal experience with breastfeeding may influence their attitudes toward breastfeeding. This phenomenon has not been explored in well-newborn care physician leaders, whose administrative responsibilities often include drafting and approval of hospital breastfeeding and formula supplementation policies. METHODS: We conducted a mixed-methods study, surveying physicians in the Better Outcomes through Research for Newborns (BORN) network. We examined physician attitudes toward recommending breastfeeding and their breastfeeding experience. Qualitative analysis was conducted on responses to the question: "How do you think your breastfeeding experience influences your clinical practice?" RESULTS: Of 71 participants, most (92%) had a very positive attitude toward breastfeeding with 75% of respondents reporting personal experience with breastfeeding. Of these, 68% had a very positive experience, 25% had a somewhat positive experience, and 6% had a neutral experience. Four themes emerged with respect to the effect of breastfeeding experience on practice: (1) empathy with breastfeeding struggles, (2) increased knowledge and skills, (3) passion for breastfeeding benefits, and (4) application of personal experience in lieu of evidence-based medicine, particularly among those who struggled with breastfeeding. CONCLUSIONS: Well-newborn care physician leaders reported positive attitudes about breastfeeding, increased support toward breastfeeding persons, and a perception of improved clinical lactation skills. Those who struggled with breastfeeding reported increased comfort with recommending formula supplementation to their own patients. Medical education about evidence-based breastfeeding support practices and provision of lactation support to physicians has the potential to affect public health through improved care for the patients they serve.

Understanding of Lactational Amenorrhea As a Contraceptive Method Among U.S. Pregnant Women.

Introduction: The lactational amenorrhea method (LAM) of postpartum contraception is more effective than typical use of condoms or birth control pills. However, LAM may be underutilized due to incomplete perinatal counseling. Methods: We compared perceptions of the effectiveness of postpartum contraceptives including LAM among U.S.-born nulliparous pregnant women recruited using social media for a trial (NCT04601987). We used descriptive statistics to summarize data. Results: Of 760 individuals screened, 627 were invited to participate, and 451 (72%) were enrolled. Most (81%) had a college degree; 79% intended to breastfeed for at least 1 month. Only 8% believed exclusive breastfeeding reduces the chance of pregnancy "a lot" within 6 months of delivery and 2% indicated that exclusive breastfeeding is typically more effective than birth control pills or condoms. Compared with those planning to use other postpartum contraceptives, the 17% of respondents who planned to use LAM were more likely to know that breastfeeding delays return of menses (84% versus 44%, p ≤ 0.0001) and provides protection from pregnancy until menses return (54% versus 22%, p ≤ 0.0001). Although 25% of those planning to use LAM believed exclusive breastfeeding reduces pregnancy risk by "a lot," only 5% thought LAM is more effective than birth control pills and only 9% thought that it is more effective than condoms. Conclusions/Implications: First-time U.S. mothers are often unaware of breastfeeding's effects on menses and fertility. Clinicians providing counseling about postpartum contraceptive options should include more information on LAM.

Vaccination and treatment options for SARS-CoV2 infection affecting lactation and breastfeeding.

The COVID-19 pandemic has posed considerable challenges to the health of lactating individuals. Vaccination remains one of the most important strategies for prevention of moderate to severe COVID-19 infection and is associated with protective benefits for lactating individuals and their breastfed infants with overall mild side effects. The current recommendations for COVID-19 treatment in lactating individuals includes remdesivir and dexamethasone for hospitalized patients and Paxlovid® (nirmatrelavir + ritonavir) as outpatient treatment in those with mild disease. As the pandemic continues to evolve with new COVID-19 variants, alternative therapeutic options are potentially needed, and it is critical to include lactating individuals in research to evaluate the safety and efficacy of COVID-19 treatment options in this population.

Providing Low-Income Women With a Manual Pump: A Pilot Study.

OBJECTIVES: Low-income, first-time mothers generally breastfeed exclusively and, overall, for a shorter average duration than high-income, multiparous mothers. A potential barrier to breastfeeding success is access to a breast pump for home use. In this pilot study, we estimated the effect of providing a manual breast pump during birth hospitalization for home use on any/exclusive breastfeeding and investigated participant attitudes about manual pumps and their breastfeeding experiences. METHODS: Sixty low-income, first-time mothers were enrolled in a pilot randomized controlled trial. One-half received a manual breast pump and the other half received an attention control. Breastfeeding exclusivity, duration, and use of the manual pump were assessed at 6 and 12 weeks. Qualitative interviews regarding the breastfeeding experience were completed. Thirty-one women answered 13 questions that were then transcribed, coded, and grouped into themes. RESULTS: Participants who were randomized to manual breast pump receipt during birth hospitalization had increased manual pump use at 6 weeks (13/19 [68%] versus controls 5/17 [29%]), there was no effect of pump receipt on any nor exclusive breastfeeding at 12 weeks. In qualitative analysis of the overall breastfeeding experience, participants expressed a need for additional support and had conflicting attitudes regarding breastfeeding and the pumping experience. CONCLUSIONS: Manual breast pump receipt in hospital among low-income, first-time mothers did not affect breastfeeding exclusivity or duration. Participants reported that early and ongoing lactation support is essential. Strategies to improve breastfeeding outcomes low-income, first-time mothers are needed.

Protecting Breastfeeding during the COVID-19 Pandemic.

The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has impacted all patient populations including pregnant mothers. There is an incomplete understanding of SARS-CoV-2 pathogenesis and transmission potential at this time and the resultant anxiety has led to variable breastfeeding recommendations for suspected or confirmed mothers with novel coronavirus disease 2019 (COVID-19). Due to the potential concern for transmission of infection from maternal respiratory secretions to the newborn, temporary separation of the maternal-baby dyad, allowing for expressed breast milk to be fed to the infant, was initially recommended but later revised to include breastfeeding by the American Academy of Pediatrics in contrast to international societies, which recommend direct breastfeeding. This separation can have negative health and emotional implications for both mother and baby. Only two publications have reported SARS-CoV-2 in human breast milk but the role of breast milk as a vehicle of transmission of COVID-19 to the newborns still remains unclear and may indeed be providing protective antibodies against SARS-CoV-2 infection even in infected neonates. Other modes of transmission of infection to neonates from infected mothers or any care providers cannot be overemphasized. Symptomatic mothers on hydroxychloroquine can safely breastfeed and no adverse effects were reported in a baby treated with remdesivir in another drug trial. The excretion of sarilumab in human breast milk is unknown at this time. Hence, given the overall safety of breast milk and both short-term and long-term nutritional, immunological, and developmental advantages of breast milk to newborn, breast milk should not be withheld from baby. The setting of maternal care, severity of maternal infection and availability of resources can impact the decision of breastfeeding, the role of shared decision making on breastfeeding between mother and physician needs to be emphasized. We strongly recommend direct breastfeeding with appropriate hygiene precautions unless the maternal or neonatal health condition warrants separation of this dyad. KEY POINTS: · Breastmilk does not appear to play a significant role in transmission of SARS-CoV-2.. · Mother-baby separation has negative health and emotional consequences.. · Mothers with suspected or confirmed COVID-19 can directly breastfeed with appropriate precautions..

Racial Inequities in Breastfeeding Counseling Among Pregnant People Who Use Cannabis.

We examined how breastfeeding advice in the context of cannabis use differed by race and ethnicity. Data from the 2017-2018 PRAMS (Pregnancy Risk Assessment Monitoring System) survey were used to assess differences in breastfeeding guidance related to cannabis use among 1,213 individuals who self-reported cannabis use 3 months before or during pregnancy. A multivariable logistic regression model was specified to examine the extent to which the odds of receiving prenatal advice against breastfeeding if using cannabis differed by self-reported race and ethnicity. We found that non-Hispanic Black people were four times more likely than non-Hispanic White people to be advised against breastfeeding if using cannabis (adjusted odds ratio 4.1, 95% CI 2.1-8.2). Pregnant non-Hispanic Black people were disproportionately advised not to breastfeed if using cannabis.

History of Breastfeeding and Stroke Prevalence Among Parous Females: Findings from the National Health and Nutrition Examination Survey, 1999-2012.

Introduction: Given the known relationships between breastfeeding and hypertension, and between hypertension and stroke, we examined the association between breastfeeding a child and stroke later in life. We hypothesized a history of breastfeeding is associated with lower prevalence of stroke. Methods: Our study population included parous females 20 years and older. Potential confounders included family income-to-poverty ratio, education, smoking status, parity, and age at first live birth. Potential effect measure modifiers included race/ethnicity and age at survey. Multivariable logistic regression models were used to estimate crude and adjusted prevalence odds ratios (ORs) and 95% confidence intervals (CIs) for the association between breastfeeding and stroke. Results: The odds of stroke among those who ever breastfed were lower than those who never breastfed (OR = 0.68, 95% CI: 0.55-0.86; p < 0.01). Adjusting for education decreased the strength of the association (OR = 0.80, 95% CI: 0.63-1.01; p = 0.06). In analyses stratified by age, the inverse association between breastfeeding status was significant among those ages 20-64 years (OR = 0.69, 95% CI: 0.47-1.00) but not among those 65 years and older (OR = 0.99, 95% CI: 0.73-1.34). Conclusions: Ever breastfeeding a child was associated with lower prevalence of stroke in a nationally representative U.S. sample of parous females 20 years and older. Results were strongest among those <65 years old.

Hospital Readmission Among Late Preterm Infants: New Insights and Remaining Questions.

Late preterm infants (LPIs), those born at 34 to 36 6/7 weeks' gestation, account for the majority of preterm births (73%).1 Given their physiologic immaturity, LPIs are at increased risk of respiratory distress, hyperbilirubinemia, hypoglycemia, and other complications in the neonatal period, and are at increased risk of hospital readmission in the first month of life.2 As Amsalu and colleagues describe in this month's issue of Hospital Pediatrics,3 identification of a predictive model to differentiate LPI at higher risk of complications would help inform tailored discharge plans and prevent readmissions.

Bonding, Relaxation, Separation, and Connection: Expressing Human Milk While Videoconferencing with the Hospitalized Premature Infant.

Background: Breast milk feeding is an essential component of safe and effective care of the hospitalized premature infant. There are numerous barriers that impact breast milk expression during a preterm infant's hospitalization. We aimed to explore the experience of using videoconferencing with one's hospitalized premature infant while expressing breast milk. Materials and Methods: We conducted a qualitative study using purposive sampling to recruit lactating parents of premature (<34 weeks) hospitalized infants. We conducted semistructured interviews using an interview guide with 14 open-ended questions regarding the breast milk expression experience. Data collection and analysis were performed iteratively and were analyzed using inductive thematic analysis with a constant comparative approach. Data were organized into themes. Interview recruitment was discontinued when thematic saturation was reached. Results: Seventeen participants completed the interviews and four themes were identified: (1) videoconferencing promotes bonding and connection with the hospitalized infant, (2) videoconferencing provides motivation to pump, (3) videoconferencing reminds participants of the realities of separation from their infant, and (4) videoconferencing connects the whole family to the hospitalized infant. Conclusions: Users of videoconferencing with their hospitalized neonate reported an improved pumping experience while expressing milk for their premature infant. Videoconferencing is also a tool that can connect the whole family to the infant. This study was registered at clinicaltrials.gov (clinicaltrials.gov Identifier: NCT03957941) under the title "FamilyLink and Breastfeeding."

Future Pregnancy Considerations after Premature Birth of an Infant Requiring Intensive Care: A Qualitative Study.

BACKGROUND: Postpartum contraception counseling and method use vary widely among patients who had a preterm birth. We performed this study to explore what issues and concerns individuals with preterm infants requiring intensive care describe as influencing their postpartum contraceptive choices. METHODS: We conducted a qualitative study using semi-structured interviews with participants who gave birth to a singleton preterm infant admitted to the neonatal intensive care unit (NICU). We explored pregnancy, childbirth, postpartum care, and NICU experiences, as well as future reproductive plans and postpartum contraceptive choices. Two coders used a constant-comparative approach to code transcripts and identify themes. RESULTS: We interviewed 26 participants: 4 (15%) gave birth at less than 26, 6 (23%) at 26 to 27 6/7, 8 (31%) at 28 to 31 6/7, and 8 (31%) at 32 to 36 6/7 weeks of gestation. We identified three main themes related to future pregnancy plans and contraception choice. First, participants frequently described their preterm birth and their infants' NICU hospitalization as traumatic experiences that affected plans for future pregnancies. The loss of control in predicting or preventing a future preterm birth and uncertainty about their premature child's future medical needs resulted in participants wanting to avoid going through the same experience with another child. Second, participants chose contraception based on previous personal experiences, desired method features, and advice from others. Last, having a preterm birth did not result in any ambivalence among those who desired permanent contraception. CONCLUSIONS: Preterm birth influences future pregnancy plans. When discussing reproductive goals with patients, clinicians should be aware of potential trauma associated with a premature birth, assess for whether patients want to discuss contraception, and center the conversation around individual needs if patients do desire contraceptive counseling.

Breastfeeding Initiation and Continuation Among Women with Substance and Tobacco Use During Pregnancy: Findings from the Pregnancy Risk Assessment Monitoring System 2016-2018.

Background and Aims: Substance and tobacco use is associated with poor maternal and child health outcomes. Although these have each been linked to lower breastfeeding rates when examined separately, studies have yet to examine how the combination of tobacco and other substance use influences breastfeeding initiation and continuation. The aim of this study was to examine how the combination of smoking tobacco and use of illicit substances influences the odds of breastfeeding initiation and continuation. Materials and Methods: This retrospective cohort study (n = 15,634) used survey data from the 2016-2018 Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System from eight US states to examine the association of tobacco and illicit substance use with breastfeeding initiation and continuation (≥6 weeks). The odds of breastfeeding initiation and continuation for individuals with and without prenatal tobacco and illicit substance use, adjusting for maternal and infant characteristics, were estimated using weighted, multivariable logistic regression models. Results: The combination of prenatal tobacco and illicit substance use was associated with a 42% reduction in the odds of initiating breastfeeding (adjusted odds ratio [aOR] 0.58 [95% confidence interval, CI 0.39-0.87]) and a 39% reduction in the odds of breastfeeding for at least 6 weeks (aOR 0.61 [95% CI 0.41-0.92]) when compared with those without tobacco and substance use. Conclusion: The odds of breastfeeding initiation and continuation are significantly lower among individuals with both prenatal tobacco and illicit substance use. Future studies are needed to identify barriers to breastfeeding within this population, to inform patient-centered interventions aimed at overcoming these barriers.

Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads, Revised 2022.

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 gender-inclusive 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.

Substance Use and Utilization of Prenatal and Postpartum Care.

OBJECTIVES: Prenatal and postpartum care for women with substance use is important due to increased risk of poor health outcomes. The influence of substance use on perinatal care utilization is not well characterized, especially postpartum care. The objective of this study was to examine the effect of substance use during pregnancy on prenatal and postpartum care utilization in a nationally representative sample and to identify maternal characteristics associated with inadequate prenatal and postpartum care among women with substance use. METHODS: Pregnancy Risk Assessment Monitoring System data (2016-2018) from 8 states were used for this study. Logistic regression models adjusted for complex survey weights and confounder variables were used to estimate the odds of not receiving adequate prenatal care and postpartum care. Weighted Rao-Scott chi-square tests were used to examine maternal characteristics associated with care utilization among women who reported substance use during pregnancy. RESULTS: The study included 15,131 women, with 5.3% who reported illicit substance use during pregnancy. In multivariable models, substance use was associated with an increase in the odds of not receiving adequate prenatal care (OR 1.69, CI 1.32, 2.17) and not receiving postpartum care (OR: 1.47, CI 1.10, 1.95). Among women who reported substance use, depression and smoking status were associated with not receiving adequate prenatal or postpartum care. CONCLUSIONS: Substance use during pregnancy is independently associated with disparities in prenatal and postpartum care access. Future studies are needed to identify how barriers lead to care inequalities and importantly, to identify strategies to improve care utilization.

Parent and Physician Qualitative Perspectives on Reasons for Pediatric Hospital Readmissions.

OBJECTIVES: One in 5 parents report a problem in their child's hospital-to-home transition, leading to adverse events, dissatisfaction, and readmissions. Although researchers in several studies have explored parent insights into discharge needs, few have explored perceptions of causes for pediatric readmissions. We sought to investigate factors contributing to pediatric readmissions, from both parent and physician perspectives. METHODS: We conducted a qualitative study using semistructured interviews with parents, discharging and readmitting physicians, and subspecialist consultants of children readmitted within 30 days of initial discharge from the pediatric ward at an urban nonfreestanding children's hospital. Participants were interviewed during the readmission and asked about care transition experiences during the initial admission and potential causes and preventability of readmission. Data were analyzed iteratively by using a constant-comparative approach. We identified major themes, solicited feedback, and inferred relationships between themes to develop a conceptual model for preventing readmissions. RESULTS: We conducted 53 interviews from 20 patient readmissions, including 20 parents, 20 readmitting physicians, 11 discharging physicians, and 3 consulting subspecialists. Major themes included the following: (1) unclear roles cause lack of ownership in patient care tasks, (2) lack of collaborative communication leads to discordant understanding of care plans, and (3) incomplete hospital-to-home transitions result in ongoing reliance on the hospital. CONCLUSIONS: Clear definition of team member roles, improved communication among care team members and between care teams and families, and enhanced care coordination to facilitate the hospital-to-home transition were perceived as potential interventions that may help prevent readmissions.

Management and Early Outcomes of Neonates Born to Women with SARS-CoV-2 in 16 U.S. Hospitals.

OBJECTIVE: There is a paucity of evidence to guide the clinical care of late preterm and term neonates born to women with perinatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The objective of this case series is to describe early neonatal outcomes and inpatient management in U.S. hospitals. STUDY DESIGN: We solicited cases of mother-infant dyads affected by novel coronavirus disease 2019 (COVID-19) from the Better Outcomes through Research for Newborns (BORN) Network members. Using a structured case template, participating sites contributed deidentified, retrospective birth hospitalization data for neonates ≥35 weeks of gestation at birth with mothers who tested positive for SARS-CoV-2 before delivery. We describe demographic and clinical characteristics, clinical management, and neonatal outcomes. RESULTS: Sixteen U.S. hospitals contributed 70 cases. Birth hospitalizations were uncomplicated for 66 (94%) neonates in which 4 (6%) required admission to a neonatal intensive care unit. None required evaluation or treatment for infection, and all who were tested for SARS-CoV-2 were negative (n = 57). Half of the dyads were colocated (n = 34) and 40% directly breastfed (n = 28). Outpatient follow-up data were available for 13 neonates, all of whom remained asymptomatic. CONCLUSION: In this multisite case series of 70 neonates born to women with SARS-CoV-2 infection, clinical outcomes were overall good, and there were no documented neonatal SARS-CoV-2 infections. Clinical management was largely inconsistent with contemporaneous U.S. COVID-19 guidelines for nursery care, suggesting concerns about the acceptability and feasibility of those recommendations. Longitudinal studies are urgently needed to assess the benefits and harms of current practices to inform evidence-based clinical care and aid shared decision-making. KEY POINTS: · Birth hospitalizations were uncomplicated for late preterm and term infants with maternal COVID-19.. · Nursery management of dyads affected by COVID-19 varied between hospitals.. · Adherence to contemporaneous U.S. clinical guidelines for nursery care was low.. · Breastfeeding rates were lower for dyads roomed separately than those who were colocated..