Fatty Acid Transfer from Blood to Milk Is Disrupted in Mothers with Low Milk Production, Obesity, and Inflammation.

BACKGROUND: Obesity is associated with chronic inflammation and is a risk factor for insufficient milk production. Inflammation-mediated suppression of LPL could inhibit mammary uptake of long-chain fatty acids (LCFAs; >16 carbons). OBJECTIVES: In an ancillary case-control analysis, we investigated whether women with low milk production despite regular breast emptying have elevated inflammation and disrupted transfer of LCFAs from plasma into milk. METHODS: Data and specimens from a low milk supply study and an exclusively breastfeeding control group were analyzed, with milk production measured by 24-h test-weighing at 2-10 wk postpartum. Low milk supply groups were defined as very low (VL; <300 mL/d; n = 23) or moderate (MOD; ≥300 mL/d; n = 20) milk production, and compared with controls (≥699 mL/d; n = 18). Serum and milk fatty acids (weight% of total) were measured by GC, serum and milk TNF-α by ELISA, and serum high-sensitivity C-reactive protein (hsCRP) by clinical analyzer. Group differences were assessed by linear regression models, chi-square exact tests, and Kruskal-Wallis nonparametric tests. RESULTS: VL cases, as compared with MOD cases and controls, had higher prevalence of elevated serum hsCRP (>5 mg/L; 57%, 15%, and 22%, respectively; P = 0.004), detectable milk TNF-α (67%, 32%, and 33%, respectively; P = 0.04), and obesity (78%, 40%, and 22%, respectively; P = 0.003). VL cases had lower mean ± SD LCFAs in milk (60% ± 3%) than MOD cases (65% ± 4%) and controls (66% ± 5%) (P < 0.001). Milk and serum LCFAs were strongly correlated in controls (r = 0.82, P < 0.001), but not in the MOD (r = 0.25, P = 0.30) or VL (r = 0.20, P = 0.41) groups (Pint < 0.001). CONCLUSIONS: Mothers with very low milk production have significantly higher obesity and inflammatory biomarkers, lower LCFAs in milk, and disrupted association between plasma and milk LCFAs. These data support the hypothesis that inflammation disrupts normal mammary gland fatty acid uptake. Further research should address impacts of inflammation and obesity on mammary fatty acid uptake for milk production.

DHA Supplementation Attenuates Inflammation-Associated Gene Expression in the Mammary Gland of Lactating Mothers Who Deliver Preterm.

BACKGROUND: In a randomized trial of DHA supplementation to lactating mothers who delivered preterm, there were significant increases in DHA status in the mother and her infant. OBJECTIVES: Our objective here was to characterize the mammary gland transcriptomes from the above study. We hypothesized that proinflammatory gene expression would be attenuated in the increased DHA group compared with the standard DHA group. METHODS: In the original trial, mothers delivering at <29 wk gestation at the University of Cincinnati Medical Center and intending to express their milk were randomly assigned to supplementation with 200 mg/d DHA (standard group: STD) or 1000 mg/d DHA (experimental group: EXP) within 7 d of delivery. Here, we conducted RNA-seq transcriptome analysis of n = 5 EXP and n = 4 STD extracellular mammary mRNA samples extracted from the fat layer of milk samples obtained 4 wk postenrollment. Transcripts were assessed for differential expression (false discovery rate adjusted P value <0.05) and clustering between EXP compared with STD groups. Ontological analysis of all differentially expressed genes (DEGs) was performed with Toppcluster. RESULTS: There were 409 DEGs. We observed 5 main groups of biological processes that were upregulated, including those associated with improved immune regulation and management of oxidative stress; and 3 main groups of biological processes that were downregulated, including 1 associated with immune dysregulation. For example, we observed upregulation of inflammation-inhibiting genes including NFKB inhibitor alpha (NFKBIA; fold-change (FC), adjusted P value: FC = 1.70, P = 0.007) and interleukin-18 binding protein (IL18BP: FC = 2.2, adjusted P = 0.02); and downregulation of proinflammatory genes including interleukin 7 receptor (IL7R: FC = -1.9, adjusted P = 0.02) and interleukin 1 receptor like 1 (IL1RL1: FC = -13.0, adjusted P = 0.02). CONCLUSIONS: Increased DHA supplementation during lactation can modulate the expression of inflammation-related genes within the mammary gland. This might translate to milk composition with a more optimal inflammasome profile. Future research with a larger clinical trial and greater interrogation of clinical outcomes is warranted.

Serum Vitamin D Status and Breast Cancer Risk by Receptor Status: A Systematic Review.

BACKGROUND: The association between vitamin D status and breast cancer risk is equivocal. No systematic reviews or meta-analyses have examined this association stratified by receptor status. Our objective is to conduct a systematic review to answer the question, "Is there a relationship between lower serum/plasma vitamin D levels and increased risk of triple negative breast cancer (TNBC) specifically?" METHODS: We systematically searched Embase and PubMed databases for published original research studies examining the risk of a breast cancer diagnosis according to vitamin D status. We excluded studies that did not provide risk estimates stratified by receptor status. RESULTS: Fourteen studies met our criteria, including case-control, nested case-control, and case-series studies, reflecting the cumulative results of 13,135 breast cancer cases. When grouped by relevancy to TNBC, the proportion of analyses across all study types showing a significant association between vitamin D status and breast cancer diagnosis was 37% for non-TNBC analyses, 48% for analyses that included some TNBC cases, and 88% for TNBC analyses. CONCLUSIONS: Our results suggest that low vitamin D status may particularly increase the risk of TNBC, although more research is needed to determine if this association is causative. Women should be routinely screened for 25(OH)D deficiency.

The Relation between Breast Milk Sodium to Potassium Ratio and Maternal Report of a Milk Supply Concern.

We report that, among exclusively breastfeeding mothers at day 7 postpartum, those with milk supply concerns were significantly more likely to exhibit biochemical evidence of less progress toward mature lactation (elevated ratio of breast milk sodium to potassium concentration). Furthermore, an elevated ratio of breast milk sodium to potassium concentration was predictive of early weaning.

Low milk supply and the pediatrician.

PURPOSE OF REVIEW: Human milk is the optimal food for human infants, and provides many diverse and well described benefits for both mother and infant. Low milk supply, whether perceived or actual, is one of the most common reasons why mothers stop breastfeeding. Breastfeeding mothers often seek out the guidance and support of their pediatrician in evaluating and resolving milk production concerns. RECENT FINDINGS: Recent evidence supports the importance of breastfeeding for maternal and child health in both developing and developed countries. Lack of knowledge regarding optimal breastfeeding management accounts for the large majority of low milk supply concerns, but there is emerging evidence that impaired glucose tolerance may contribute to intrinsic low milk supply. SUMMARY: Breastfeeding mother-infant dyads should be followed closely until lactation is well established and the infant is gaining well. Further research is needed to understand the physiologic contributors to low milk supply and to guide evidence-based interventions to optimize maternal success in reaching breastfeeding goals, particularly for women of poorer metabolic health.

In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed.

OBJECTIVE: To evaluate in-hospital formula supplementation among first-time mothers who intended to exclusively breastfeed and determined if in-hospital formula supplementation shortens breastfeeding duration after adjusting for breastfeeding intention. STUDY DESIGN: We assessed strength of breastfeeding intentions prenatally in a diverse cohort of expectant primiparae and followed infant feeding practices through day 60. Among mothers planning to exclusively breastfeed their healthy term infants for ≥1 week, we determined predictors, reasons, and characteristics of in-hospital formula supplementation, and calculated the intention-adjusted relative risk (ARR) of not fully breastfeeding days 30-60 and breastfeeding cessation by day 60 with in-hospital formula supplementation (n = 393). RESULTS: Two hundred ten (53%) infants were exclusively breastfed during the maternity stay and 183 (47%) received in-hospital formula supplementation. The most prevalent reasons mothers cited for in-hospital formula supplementation were: perceived insufficient milk supply (18%), signs of inadequate intake (16%), and poor latch or breastfeeding (14%). Prevalence of not fully breastfeeding days 30-60 was 67.8% vs. 36.7%, ARR 1.8 (95% CI, 1.4-2.3), in-hospital formula supplementation vs exclusively breastfed groups, respectively, and breastfeeding cessation by day 60 was 32.8% vs. 10.5%, ARR 2.7 (95% CI, 1.7-4.5). Odds of both adverse outcomes increased with more in-hospital formula supplementation feeds (not fully breastfeeding days 30-60, P = .003 and breastfeeding cessation, P = .011). CONCLUSIONS: Among women intending to exclusively breastfeed, in-hospital formula supplementation was associated with a nearly 2-fold greater risk of not fully breastfeeding days 30-60 and a nearly 3-fold risk of breastfeeding cessation by day 60, even after adjusting for strength of breastfeeding intentions. Strategies should be sought to avoid unnecessary in-hospital formula supplementation and to support breastfeeding when in-hospital formula supplementation is unavoidable.

Breast hypoplasia markers among women who report insufficient milk production: A retrospective online survey.

OBJECTIVES: To estimate the proportions of anatomical breast characteristics suggestive of breast hypoplasia among breastfeeding women self-reporting low milk supply. We also explored breast hypoplasia risk factors. DESIGN: Online survey conducted between October 2021 and January 2022. SETTING: Five low milk supply Facebook groups. PARTICIPANTS: 487 women reporting low milk supply with their first child born ≥ 37 weeks gestation within 5 years of participation in this study, and residing in the USA, Australia or the UK. We present data on the primary outcome ('breast type') for 399 women. Women were excluded if the dyad was separated for more than 24 hours during the hospital stay, or if the mother reported removing milk less than 6 times per day from each breast on most days before being aware of having insufficient milk production. PRIMARY AND SECONDARY OUTCOME MEASURES: The proportions of proposed breast hypoplasia markers including atypical breast type, widely spaced breasts, breast asymmetry, stretch marks on the breast and lack of pregnancy breast growth. We also estimated the odds of having breast hypoplasia markers in at-risk groups compared to reference groups, adjusting for covariates. RESULTS: Approximately 68% reported at least one atypical breast (270/399; 95% CI: 62.9%, 72.1%). Around 47% reported widely spaced breasts (212/449; 95% CI: 42.7%, 52.7%), 72% a lack of pregnancy breast growth (322/449; 95% CI: 68.3%, 77.4%), and 76% stretch marks on the breast (191/250; 95% CI: 70.7%, 81.3%). Multiple logistic regression analyses identified being overweight during pubertal years as a risk factor for atypical breast type and lack of pregnancy breast growth. CONCLUSIONS: Participants in low milk supply Facebook groups reported high rates of breast hypoplasia markers. Being overweight during adolescence was a risk factor for breast hypoplasia markers. These findings should be confirmed in well-conducted large cohort studies to determine the strongest combination of hypoplasia markers in predicting low supply.

Lactation and neonatal nutrition: defining and refining the critical questions.

This paper resulted from a conference entitled "Lactation and Milk: Defining and refining the critical questions" held at the University of Colorado School of Medicine from January 18-20, 2012. The mission of the conference was to identify unresolved questions and set future goals for research into human milk composition, mammary development and lactation. We first outline the unanswered questions regarding the composition of human milk (Section I) and the mechanisms by which milk components affect neonatal development, growth and health and recommend models for future research. Emerging questions about how milk components affect cognitive development and behavioral phenotype of the offspring are presented in Section II. In Section III we outline the important unanswered questions about regulation of mammary gland development, the heritability of defects, the effects of maternal nutrition, disease, metabolic status, and therapeutic drugs upon the subsequent lactation. Questions surrounding breastfeeding practice are also highlighted. In Section IV we describe the specific nutritional challenges faced by three different populations, namely preterm infants, infants born to obese mothers who may or may not have gestational diabetes, and infants born to undernourished mothers. The recognition that multidisciplinary training is critical to advancing the field led us to formulate specific training recommendations in Section V. Our recommendations for research emphasis are summarized in Section VI. In sum, we present a roadmap for multidisciplinary research into all aspects of human lactation, milk and its role in infant nutrition for the next decade and beyond.

Measures of Maternal Metabolic Health as Predictors of Severely Low Milk Production.

Background: A comprehensive approach to breastfeeding support requires elucidation of how metabolic health influences milk production. Objective: We compared metabolic health indicators in women with severely low milk output versus those with moderate/normal milk output using a case-control study design, with nested and external control groups. Design: Cases and nested controls were derived from women screened for a low milk supply trial, with cases defined as severely low milk output (<300 mL/24 hours), and nested controls defined as moderate/normal milk output (>300 mL/24 hours). In addition, we included an external control group of exclusively breastfeeding women. All were enrolled at 2-10 weeks postdelivery of a healthy term infant. Milk output and breast emptying frequency were recorded through test-weigh. Metabolic health variables included all components of the metabolic syndrome, homeostatic model assessment of insulin resistance (HOMA-IR), and diagnosis of gestational diabetes mellitus (GDM). Results: Maximum milk output, mL/24 hours, ranged as follows: 30-281 in cases (n = 18), 372-801 in nested controls (n = 12), and 661-915 in external controls (n = 12). Mean breast emptying frequency in cases was not significantly different from nested or external controls. All metabolic syndrome components and HOMA-IR were significantly worse in cases as compared with both nested and external control groups (p < 0.05). There was no significant difference between the nested and external control groups for these variables. GDM prevalence was 39%, 0%, and 8%, across cases, nested control, and external control groups, respectively (chi-square p-value = 0.02). Conclusion: Results from this small case-control study identify class 2+ obesity and poor metabolic health as strong risk factors for severely low milk production. These findings should be further validated in larger prospective cohort studies designed to identify individuals at risk for metabolically driven low milk supply. In addition, clinical and qualitative research studies aimed at improving patient-centered approaches to the management of persistent low milk supply are needed.

First-Day Use of the Newborn Weight Loss Tool to Predict Excess Weight Loss in Breastfeeding Newborns.

Background and Objectives: Exclusive breastfeeding is recommended for most newborns. However, exclusively breastfed newborns sometimes experience excess weight loss (EWL, loss ≥10% of birth weight) while lactation is being established. Our primary objective was to evaluate the sensitivity and specificity of the Newborn Weight Loss Tool (NEWT) in early identification of exclusively breastfed newborns who develop EWL; and secondarily, identify breastfeeding variables associated with an at-risk NEWT trajectory. Materials and Methods: We conducted a secondary analysis of prospective data from mother-infant dyads screened for inclusion in the U.S. site of the WHO Growth Reference Study. We excluded records if: NEWT-specific criteria not met, missing key data, or >60 mL formula consumed. We defined NEWT "test-positive" based on an in-hospital weight at about 24 hours falling within the NEWT trajectory consistent with eventual EWL. We defined cases as true EWL based on weight measured at home on day of life 4 (DoL4). Results: Of 280 original records, 60 were excluded (n = 27, NEWT-specific exclusion; n = 15, missing data; n = 18, >60 mL formula), resulting in 220 paired newborn weights measured in-hospital (17 ± 8 hours), and at DoL4 (84 ± 8 hours). NEWT status correctly identified 6/28 EWL cases (21% sensitivity [95% confidence interval, CI, 8-34%]), and 158/192 noncases (82% specificity [95% CI, 75-89%]). NEWT test-positive status was associated with greater weight loss, lower perceived breastfeeding support, and infant less often showing feeding cues on DoL4 (p < 0.05). Conclusion: Sensitivity in predicting EWL is low when applying NEWT at about 24 hours of life; however, early test-positive status is associated with indicators of breastfeeding difficulties on DoL4.

Breastfeeding Disparities and Their Mediators in an Urban Birth Cohort of Black and White Mothers.

Background: Black mothers in the United States have shorter breastfeeding (BF) durations and less exclusive breastfeeding (EBF) than others. The factors underlying these disparities require investigation. Methods: Using longitudinal data from a CDC-sponsored birth cohort in Cincinnati, Ohio, we analyzed the factors mediating racial disparity in BF outcomes. Study mothers were enrolled in prenatal clinics associated with two large birth hospitals. Analysis was restricted to racial groups with sufficient numbers in the cohort, non-Hispanic Black (n = 92) and White (n = 113) mothers, followed to at least 6 months postpartum. Results: Black mothers were 25 times more likely to reside in socioeconomically deprived neighborhoods and 20 times more likely to have an annual household income <$50,000/year than White mothers (p < 0.001). The gap in EBF for 6 weeks was 45 percentage points by racial group (13%-Black mothers versus 58%-White mothers, p < 0.001); in any BF at 6 months was 37 percentage points (28%-Black mothers versus 65%-White mothers, p < 0.001); and in mothers meeting their own intention to BF at least 6 months was 51 percentage points (29%-Black mothers versus 80%-White mothers, p < 0.001). Racial disparity in EBF at 6 weeks was mediated in logistic regression models by inequities in socioeconomic position, maternal hypertension, and BF intention. Racial disparities in BF at 6 months or meeting 6-month BF intention were mediated by inequities in socioeconomic position, maternal obesity, and EBF at 6 weeks. Not all BF disparities could be explained by models used in these analyses. Conclusions: Efforts to lessen BF disparities should address the underlying structural inequities that disproportionately affect Black mothers and children, should incorporate maternal health, and focus on breastfeeding exclusivity and duration. Few Black mothers achieved EBF at 6 weeks, which contributed to disparity in BF duration. Greater attention to Black mother-infant pairs is a public health priority.

Risk factors for early lactation problems among Peruvian primiparous mothers.

The aim of this study was to determine the incidence and risk factors for early lactation problems [suboptimal infant breastfeeding behaviour (SIBB), delayed onset of lactogenesis (OL) and excessive neonatal weight loss] among mother-infant pairs in Lima, Peru. All primiparous mothers who gave birth to a healthy, single, term infant at a government hospital in a peri-urban area of Lima during the 8-month recruitment period were invited to participate in the study. Data were collected at the hospital (day 0) and during a home visit (day 3). Infant breastfeeding behaviour was evaluated using the Infant Breastfeeding Assessment Tool; SIBB was defined as < or = 10 score. OL was determined by maternal report of breast fullness changes; delayed OL was defined as perceived after 72 h. Excessive neonatal weight loss was defined as > or = 10% of birthweight by day 3. One hundred seventy-one mother-infant pairs participated in the study. SIBB prevalence was 52% on day 0 and 21% on day 3; it was associated with male infant gender (day 0), < 8 breastfeeds during the first 24 h (days 0 and 3), and gestational age < 39 weeks (day 3). Delayed OL incidence was 17% and was associated with infant Apgar score < 8. Excessive neonatal weight loss occurred in 10% of neonates and was associated with maternal overweight and Caesarean-section delivery. Early lactation problems may be influenced by modifiable factors such as delivery mode and breastfeeding frequency. Infant status at birth and maternal characteristics could indicate when breastfeeding dyads need extra support.

The Infant Feeding Intentions scale demonstrates construct validity and comparability in quantifying maternal breastfeeding intentions across multiple ethnic groups.

Research tools that are comparable across ethnic groups are needed in order to understand sociodemographic disparities in breastfeeding rates. The Infant Feeding Intentions (IFI) scale provides a quantitative measure of maternal breastfeeding intentions. IFI score ranges from 0 (no intention to breastfeed) to 16 (very strong intentions to fully breastfeed for 6 months). The objective of this study was to examine intra- and inter-ethnic validity of the IFI scale. The IFI scale was administered to 218 white non-Hispanic, 75 African-American, 80 English-speaking Hispanic, 62 Spanish-speaking Hispanic and 64 Asian expectant primiparae. Participants were asked their planned duration of providing breast milk as the sole source of milk (full breastfeeding). The IFI scale was examined for intra-ethnic internal consistency and construct validity and for inter-ethnic comparability. For all five ethnic categories, principal component analysis separated the scale into the same two factors: intention to initiate breastfeeding and intention to continue full breastfeeding. Across ethnic categories, the range in Cronbach's alpha was 0.70-0.85 for the initiation factor and 0.90-0.93 for the continuation factor. Within each ethnic category, IFI score increased as planned duration of full breastfeeding increased (P < 0.0001 for all). Within the planned duration categories of <1, 1-3, 3-6 and ≥6 months, the median IFI score by ethnic category ranged from (low-high) 5-8, 9-10, 12-14 and 16-16, respectively. The IFI scale provides a valid measure of breastfeeding intentions in diverse populations of English- and Spanish-speaking primiparae, and may be a useful tool when researching disparities in breastfeeding practices.

Validity of a 3-Hour Breast Milk Expression Protocol in Estimating Current Maternal Milk Production Capacity and Infant Breast Milk Intake in Exclusively Breastfeeding Dyads.

Objective: An efficient method for measuring maternal milk production is needed. Our objectives were to: (1) validate a milk production rate (MPR) protocol in exclusively breastfeeding mothers; (2) determine MPR change following 48 hours of increased breast emptying; (3) assess agreement between MPR and infant test-weighing; and (4) characterize MPR in early postpartum exclusively breastfeeding mothers. Materials and Methods:N = 23 mothers emptied both breasts hourly over 3 hours (h0, h1, h2, and h3). We estimated steady-state MPR as mean (h2 and h3). Subset A mothers (n = 5) also completed MPR measurements after 48 hours of increased breast emptying. Subset B mothers (n = 16) also test-weighed for 48 hours. We used paired t-test to examine within-participant change in hourly milk yield and MPR; and we used Bland-Altman analysis to compare 24-hour milk production (g/24 hours) measured using test-weight versus MPR. Results are reported as mean ± standard deviation or (±95% limits of agreement). Results: Mothers were 54 ± 14 days postpartum. Paired difference in h3-h2 hourly milk yield was not significantly different (p > 0.05, 3 ± 10 g/hour). In Subset A (n = 5), MPR declined from 50 ± 13 to 43 ± 16 g/hour (p = 0.003) following 48 hours of increased breast emptying. In Study B (n = 16), mean infant test-weighed intake (TW) was 717 ± 119 g/24 hours, and mean MPR was 1,085 ± 300 g/24 hours. Mean difference (MPR-test-weigh) and mean ratio (MPR/test-weigh) significantly increased as MPR increased (p < 0.05). For infants with adequate weight gain (>20 g/24 hours, n = 12), mean MPR = 48 ± 12 g/hour (range, 35-78 g/hour). Conclusion: MPR is a valid measure of current maternal milk production capacity, but is not accurate for evaluating infant intake in exclusively breastfeeding dyads.

Development and validation of the infant feeding intentions scale.

OBJECTIVES: There is a need in breastfeeding behavior studies for a quantitative measure of maternal breastfeeding intentions. The Infant Feeding Intentions (IFI) scale was developed to fill this need. METHODS: Two items probe strength of intentions to initiate breastfeeding and subsequent items assess strength of intentions to be breastfeeding exclusively (EBF) at 1, 3, or 6 months. Total score ranges from 0 to 16. Content validity was established among women in their third trimester of pregnancy (n = 88). Subsequently, construct validity was assessed in a low-income, multi-ethnic cohort of primiparae (n = 170) interviewed at 25 +/- 15 h postpartum and followed to 6 months. RESULTS: Cronbach's coefficient alpha was 0.90 for both the content and construct validity samples. Construct validity was demonstrated by a significant association between IFI score and both planned and actual EBF duration: mean (+standard deviation) IFI scores were 4.6 +/- 2.9, 7.5 +/- 3.2, 10.3 +/- 2.7, 12.0 +/- 1.8, and 13.8 +/- 2.7 for planned duration of EBF of 'Never', up to 1 month, 1 to <3 months, 3 to <6 months, and > or =6 months, respectively; ANOVA, P < 0.0001; and each 1-point increase in IFI score decreased the hazard of not EBF by 23.4% at day 0 and 13.7% at day 30 (Cox proportional hazards model chi-square = 92.5, P < 0.0001). CONCLUSIONS: In a multi-ethnic U.S. sample of low-income primiparae, the IFI scale was shown to be a valid, simple tool for quantitatively assessing the strength of intentions to initiate and sustain EBF.

Contribution of Maternal Obesity to Medically Indicated and Elective Formula Supplementation in a Baby-Friendly Hospital.

Objective: Determine if maternal obesity increases use of medically indicated or elective formula in the context of a Baby-Friendly Hospital with high prevalence of obesity. Study Design: We conducted a secondary analysis of mothers who initiated breastfeeding of their term, singleton infant born at a Baby-Friendly community hospital in 2016. We defined medically indicated as formula given per physician order; and elective as formula given per maternal request. We used multinomial logistic regression to determine the odds ratio (OR) and 95% confidence interval (95% CI) for medically indicated and elective formula (each versus exclusive breastfeeding) by obesity status. We adjusted for available covariates and mediating conditions that may be exacerbated by obesity. Results: A total of 1,245 mothers met inclusion criteria, of which 41% were obese. Exclusive breastfeeding, medically indicated formula, and elective formula were 84% versus 70%, 5% versus 12%, and 11% versus 18%, in nonobese versus obese women, respectively. After adjusting for covariates, obesity significantly increased the risk for medically indicated (OR 2.6 [95% CI 1.7-4.1]) and elective (OR 2.0 [95% CI 1.5-2.8]) formula. After additionally adjusting for conditions exacerbated by obesity, the risk of medically indicated formula was attenuated by 48% (OR 1.7 [95% CI 1.02-2.7]), and there was little attenuation of the risk of elective formula (OR 1.8 [95% CI 1.3-2.6]). Conclusions: In a setting with high obesity prevalence and strong support for exclusive breastfeeding, obesity accounted for 36% of medically indicated formula and 21% of elective formula use. In this era of globally increasing maternal obesity prevalence, there is an urgent need to develop successful strategies for supporting breastfeeding that goes above and beyond standard Baby-Friendly approaches.

Infant milk-feeding practices and childhood leukemia: a systematic review.

BACKGROUND: During the Pregnancy and Birth to 24 Months Project, the US Departments of Agriculture and Health and Human Services initiated a review of evidence on diet and health in these populations. OBJECTIVES: The aim of these systematic reviews was to examine the relation of 1) never versus ever feeding human milk, 2) shorter versus longer durations of any human milk feeding, 3) shorter versus longer durations of exclusive human milk feeding, and 4) feeding a lower versus higher intensity of human milk to mixed-fed infants with acute childhood leukemia, generally, and acute lymphoblastic leukemia, specifically. METHODS: The Nutrition Evidence Systematic Review team conducted systematic reviews with external experts. We searched CINAHL, Cochrane, Embase, and PubMed for articles published January 1980 to March 2016, dual-screened the results using predetermined criteria, extracted data from and assessed risk of bias for each included study, qualitatively synthesized the evidence, developed conclusion statements, and graded the strength of the evidence. RESULTS: We included 24 articles from case-control or retrospective studies. Limited evidence suggests that never feeding human milk versus 1) ever feeding human milk and 2) feeding human milk for durations ≥6 mo are associated with a slightly higher risk of acute childhood leukemia, whereas evidence comparing never feeding human milk with feeding human milk for durations <6 mo is mixed. Limited evidence suggests that, among infants fed human milk, a shorter versus longer duration of human milk feeding is associated with a slightly higher risk of acute childhood leukemia. None of the included articles examined exclusive human milk feeding or the intensity of human milk fed to mixed-fed infants. CONCLUSIONS: Feeding human milk for short durations or not at all may be associated with slightly higher acute childhood leukemia risk. The evidence could be strengthened with access to broadly generalizable prospective samples; therefore, we recommend linking surveillance systems that collect infant feeding and childhood cancer data.

Infant milk-feeding practices and cardiovascular disease outcomes in offspring: a systematic review.

BACKGROUND: During the Pregnancy and Birth to 24 Months Project, the US Departments of Agriculture and Health and Human Services initiated a review of evidence on diet and health in these populations. OBJECTIVES: The aim of these systematic reviews was to examine the relation of 1) never versus ever feeding human milk, 2) shorter versus longer durations of any human milk feeding, 3) shorter versus longer durations of exclusive human milk feeding, and 4) lower versus higher intensities of human milk fed to mixed-fed infants with intermediate and endpoint cardiovascular disease (CVD) outcomes in offspring. METHODS: The Nutrition Evidence Systematic Review team conducted systematic reviews with external experts. We searched CINAHL, Cochrane, Embase, and PubMed for articles published January 1980-March 2016, dual-screened the results using predetermined criteria, extracted data from and assessed the risk of bias for each included study, qualitatively synthesized the evidence, developed conclusion statements, and graded the strength of the evidence. RESULTS: The 4 systematic reviews included 13, 24, 6, and 0 articles, respectively. The evidence was insufficient to draw conclusions about endpoint CVD outcomes across all 4 systematic reviews. Limited evidence suggests that never versus ever being fed human milk is associated with higher blood pressure within a normal range at 6-7 y of age. Moderate evidence suggests there is no association between the duration of any human milk feeding and childhood blood pressure. Limited evidence suggests there is no association between the duration of exclusive human milk feeding and blood pressure or metabolic syndrome in childhood. Additional evidence about intermediate outcomes for the 4 systematic reviews was scant or inconclusive. CONCLUSIONS: There is insufficient evidence to draw conclusions about the relationships between infant milk-feeding practices and endpoint CVD outcomes; however, some evidence suggests that feeding less or no human milk is not associated with childhood hypertension.