Early acquisition of cytomegalovirus infection.

Two hundred and fifty three infants were screened for cytomegalovirus (CMV) in the urine at birth and were followed up at regular intervals for one year. Twelve per cent (of 249) were excreting virus at 3 months, and 20% (of 234) at 12 months. In all cases infection was subclinical. The major factors determining risk of acquiring infection were the mother''s serological state and whether the infant was breast fed. There was no association with social class, mother''s age, or whether the child had been in a special care baby unit or a postnatal ward. By one year 33% (of 123) of infants of seropositive mothers had acquired CMV infection compared with 4% (of 123) born to seronegative mothers. Twenty per cent (17) of seropositive women who breast fed had virus isolated from their breast milk on at least one occasion, and 76% (13) of their infants became infected. In four mother-infant pairs comparison of CMV isolates from the mother''s milk and the child''s urine was made by restriction endonuclease digestion; in each pair infection had apparently occurred with the same strain of virus. All 13 infected infants followed up for three years were still shedding virus. Infection with CMV is common in infancy, and virus shedding persists for years. Congenital infection cannot be distinguished from acquired infection unless the presence of CMV in the urine is identified within three or four weeks after birth, even when clinical problems suggestive of congenital infection are present.     

“Breastfeeding” without baby: A longitudinal,qualitative investigation of how mothers perceive,feel about,and practice human milk expression

Most American mothers who produce human milk (HM) now pump in place of some or all feeding at the breast, and most American infants are now fed pumped HM. We aimed to investigate mothers' perceptions of, attitudes toward, and practices for pumping and providing pumped HM. Results related to pumping are reported here. We conducted in‐depth, semi‐structured interviews among a diverse sample of 20 mothers who pumped, following each from pregnancy through infant HM‐feeding cessation up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Mothers' reasons for pumping changed over time and reflected their needs and desires (e.g., latch difficulty, return to work, and increasing their milk supply). Mothers reported that pump type and quality were important to pumping success and that pumping was time‐consuming, costly, and unpleasant compared to feeding at the breast. Regardless of how often mothers pumped, most felt pumping was necessary to meet their infant HM‐feeding goals and was a welcome means of sharing with other caregivers the bonding opportunity and tasks they associated with feeding infants. Mothers interpreted output from pumping sessions to understand their ability to provide enough milk to meet their infants' needs. Mothers' reasons for pumping may signal constraints to infant HM feeding that may be addressed with policy changes. Mothers' attitudes and perceptions toward pumping indicate that, although pumping fills important and welcome roles for many mothers, the reality of its practice may make it an unacceptable or infeasible substitute for some.     

“Breastfeeding” but not at the breast: Mothers' descriptions of providing pumped human milk to their infants via other containers and caregivers

As pumping has become more prevalent among American women, pumped human milk (HM) is on the rise in their infants' diets in place of some or all feeding at the breast. We aimed to fill a gap in knowledge about mothers' motivations, practices and perceptions related to pumping, and about mothers' and other caregivers' motivations, practices, and perceptions related to feeding pumped HM. Results related to providing pumped HM are reported here, and results related to pumping are reported elsewhere. We conducted in‐depth, semi‐structured interviews among a diverse sample of mothers whose infants were fed pumped HM (n = 20), following each up to 1 year postpartum. Data were analyzed using thematic analysis with Atlas.ti. Nearly all mothers felt bottles were necessary to meet infant HM‐feeding goals. Nearly all pumped HM was fed by other caregivers because mothers typically preferred and prioritized feeding at the breast for convenience and maintaining their milk supply. Infants were bottle‐fed HM for several reasons that changed over time, such as mother's absence, latch difficulty, or desire to share the burden and bonding of feeding. Feeding practices differed between feeds from bottles versus at the breast; some infants were bottle‐fed on schedules but fed at the breast on demand. Mothers' methods for storing, transporting, and preparing HM varied substantially and included practices associated with loss of nutrients and microbial contamination. Mothers' reasons for bottle‐feeding HM may affect how much their infants are bottle‐fed. Consumption of pumped HM may not provide the same benefits to infants as feeding at the breast. These findings highlight important avenues for future research into the relationships between bottle‐feeding HM and infant health, growth, and developmental outcomes.     

Low frequency of CD4+, but not CD8+, T cells expressing interferon‐γ is related to cow's milk allergy in infancy

Low interferon‐γ (IFN‐γ) and tumor necrosis factor‐α (TNF‐α) production in peripheral blood mononuclear cells (PBMC) from patients with atopic dermatitis and food allergy have been reported previously. However, it remains unclear whether the weak cytokine production is caused by the imbalance of specific T‐cell subsets or by dysregulation of T‐cell function. In the present study we investigated the intracellular expression of these cytokines at a single‐cell level to clarify the background of the disruption. Twelve of 27 breast‐fed infants (0.1–8.8 months of age) had challenge‐proven cow's milk allergy (CMA), and 15 infants were studied as a healthy control group. PBMC were stimulated with phorbol 12‐myristate 13‐acetate (PMA) and ionomycin. The frequencies of the cells expressing intracellular IL‐4, IFN‐γ, and TNF‐α were assessed using flow cytometry. In addition, at this time‐point leucocyte subsets from the milk of mothers of these infants were evaluated using light microscopy. A lower number of CD8⁺ T cells and the defective capability of CD4⁺ T cells to express IFN‐γ in infant's peripheral blood co‐existed with a lower number of macrophages in their mother's milk.     

Randomised, double blind trial of oxytocin nasal spray in mothers expressing breast milk for preterm infants

BACKGROUND: Human milk has considerable short and long term benefits for preterm infants, but mothers may experience difficulties in expressing breast milk for infants too immature or sick to breast feed. Oxytocin has been used to assist breast feeding and milk expression, but few data are available to support this intervention in the neonatal unit setting. AIM: To test the hypothesis that oxytocin nasal spray increases early milk output in mothers expressing milk for preterm infants. METHODS: A randomised, double blind trial of oxytocin nasal spray (100 microl per dose) versus placebo was conducted in mothers delivering infants <35 weeks gestation. Sprays were used before expression of milk using an electric pump up to day 5. Main outcome: Total weight of milk expressed while using spray (study powered to detect >1SD difference between groups). Secondary outcomes: Pattern of milk production; number of pumping sessions; weight/fat content of milk expressed during a fixed 20 minute period on day 5 ("physiological study"); mother's opinion of expressing and spray assessed by questionnaire. RESULTS: Fifty one mothers were randomised (27 oxytocin, 24 placebo). Total milk production did not differ between groups. Repeated measures analysis of variance suggested significantly (p = 0.001) different patterns of milk production, with initial faster production in the oxytocin group then convergence between groups. Parity did not influence the response to the intervention. No significant differences were seen in milk weight or fat content in the physiological study nor in mothers' opinions of milk expression and treatment. CONCLUSIONS: Despite marginal differences in the pattern of early milk production, the use of oxytocin nasal spray did not significantly improve outcome. Most mothers believed they were receiving the active spray, suggesting a significant placebo effect (supported by limited data from historical controls) and benefits from the extra breast feeding support available during the study.     

Studies on Perceived Breast Milk Insufficiency: III. Consequences for Breast Milk Consumption and Growth

ABSTRACT. Fifty-one mother–infant pairs were followed prospectively during the period 3 days to 18 months after delivery. In total 54.9% of the mothers experienced transient lactation crises, emanating mostly from a perception of breast milk insufficiency. Within the crisis group no significant difference in the infants' intake of breast milk during the crises compared with control measurements 1 week later was found. Nor had the crises any immediate impact on growth of the infants. A comparison between the crisis and the non-crisis group, revealed that the breast milk consumption in the crisis group was throughout lower with significant differences at 3 and 5 months. The infants in the crisis group also had a significantly lower weight at 2, 3, 4 and 9 months and were significantly thinner for their height at 1–6 months and at 9 months, although both groups were above the NCHS mean. We conclude that even if the infants in the crisis group had a lower consumption and a slower growth development, the differences were comparatively small. Furthermore, evidence was provided that the breast milk insufficiency occasionally perceived as acute by the mothers was in most cases not real.     

Human milk banking; current evidence and future challenges

Human milk banks systematically collect, pasteurize, store, and distribute donated breast milk. In situations when a mother's own milk is insufficient or unavailable donor milk may be used as an alternative. There are a number of clinical groups who may benefit from donor milk; due to limitations in supply and evidence of benefit in term infants, most commonly donor milk is administered to preterm infants. Guidelines regarding the management of milk banks recommend potential donors are screened and tested and that milk is heat treated to minimize risk of transmission of infectious agents. Although essential to safety, pasteurization alters bioactive and nutritional properties of human milk. Pasteurized donor milk is lower in protein, calories and bioactive molecules compared with mother's own preterm milk produced in the first few weeks after delivery.Current evidence suggests that there are some health advantages for preterm infants to being fed pasteurized donor milk over preterm formula. There are challenges with regard to providing adequate nutrition with donor milk as well as logistical and ethical concerns. Formation of a national milk-bank network within the UK combined with standardized data collection would assist in the distribution and further evaluation of the potential benefits of this precious resource.     

Transmission of cytomegalovirus to extremely preterm infants through breast milk

AIM: To evaluate the rate and clinical expression of postnatal cytomegalovirus (CMV) infection transmitted through breast milk in extremely preterm infants. METHODS: Ten extremely preterm infants and their six mothers were included. Maternal CMV serology was determined. Breast milk samples and urine samples from the infants were screened for CMV. Symptoms and laboratory findings of CMV infected infants were documented. All infants received partly fresh and/or defrosted breast milk. RESULTS: CMV-DNA was found in breast milk in four of five CMV-seropositive mothers. Two infants were infected by CMV. They were the only infants fed with breast milk positive for viral culture. One infant developed hepatic affection concurrent with viral excretion in urine. This infant was later diagnosed with cystic fibrosis. CONCLUSION: This study supports that CMV transmission through breast milk can aggravate the clinical course in extremely preterm infants with preexisting hepatic conditions.     

Mother–infant interactions and infant intake during breastfeeding versus bottle‐feeding expressed breast milk

Bottle‐fed infants are at higher risk for rapid weight gain compared with breastfed infants. Few studies have attempted to disentangle effects of feeding mode, milk composition and relevant covariates on feeding interactions and outcomes. The objective of the present study was to compare effects of breastfeeding directly at the breast versus bottle‐feeding expressed breast milk on feeding interactions. Mothers with <6‐month‐old infants (n = 47) participated in two counterbalanced, feeding observations. Mothers breastfed their infants directly from the breast during one visit (breast condition) and bottle‐fed their infants expressed breast milk during the other (bottle condition). Masked raters later coded videos using the Nursing Child Assessment Parent–Child Interaction Feeding Scale. Infant intake was assessed. Mothers self‐reported sociodemographic characteristics, infant feeding patterns (i.e. percentage of daily feedings from bottles) and level of pressuring feeding style. Mother and infant behaviours were similar during breast and bottle conditions. Percent bottle‐feeding moderated effects of condition on intake (P = 0.032): greater percent bottle‐feeding predicted greater intake during the bottle compared with breast condition. Effects of feeding mode were not moderated by parity or pressuring feeding style, but, regardless of condition, multiparous mothers fed their infants more than primiparous mothers (P = 0.028), and pressuring feeding style was positively associated with infant intake (P = 0.045). Findings from the present study do not support the hypothesis that feeding mode directly impacts dyadic interaction for predominantly breastfeeding mothers and infants, but rather suggest between‐subject differences in feeding experiences and styles predict feeding outcomes for this population.     

A new breast milk supplement for preterm infants

Objective : To assess the effect of a new formula (Prenan), which contains n-3 and n-6 long-chain polyunsaturated fatty acids (LC PUFA) on the fatty acid profile of preterm infants.
Methodology : Plasma fatty acids were measured in 61 preterm infants at term by gas liquid chromatography. In 20 of these infants, paired samples were collected and changes in fatty acids with time analysed.
Results : Plasma docosahexaenoic acid (DHA) levels were higher in those who had been fed expressed breast milk (EBM) ±/or Prenan compared with those fed standard formula ± EBM, P <0.05. The plasma arachidonic acid (AA) levels of infants fed Prenan were not different to those fed EBM, both groups achieving higher levels than infants fed standard formula, P <0.05. Further, paired analysis demonstrated that DHA levels increased in infants changed from standard formula to Prenan to levels equal or higher than those of fully breast-fed infants ( P <0.01), whereas DHA levels remained unchanged with time in all other groups.
Conclusions : The fatty acid composition of Prenan enables preterm infants fed formula to have plasma DHA and AA levels similar to those of infants fed breast milk and consequently different to those of infants fed standard formula. Prenan is an appropriate supplement to breast milk for preterm infants in that it provides LC PUFA as well as additional phosphorus and protein without exposing the infant to intact cows milk protein.     

Early diet in preterm babies and developmental status in infancy.

Few data from randomised prospective studies address whether early diet influences later neurodevelopment in man. As part of a larger multicentre trial, 502 low birthweight infants were assigned randomly, for a median of 30 days, to receive a preterm formula or unfortified donor breast milk as sole diets or as supplements to their mothers'' expressed milk. Surviving infants were assessed at nine months after their expected date of delivery without knowledge of their feeding regimen. The mean developmental quotient was 0.25 standard deviations lower in those fed donor breast milk rather than preterm formula. In infants fed their mother''s expressed milk, however, the disadvantage of receiving banked milk compared with preterm formula as a supplement, was greater when the supplement was over half the total intake, and approached five points, representing 0.5 standard deviations for developmental quotient. Infants fed donor breast milk were at particular disadvantage following fetal growth retardation, with developmental quotients 5.3 points lower. We suggest that the diet used for low birthweight babies over a brief, but perhaps critical, postnatal period has developmental consequences that persist into infancy; infants who are small for gestational age are especially vulnerable to suboptimal postnatal nutrition.     

Causes of perception of insufficient milk supply in Western Australian mothers

A perception of insufficient milk supply (PIMS) is associated with early discontinuation of breastfeeding. Ideally, an objective measure of milk supply would either dispel or confirm this perception and provide reassurance or guide professional advice. Clinical signs of sufficient milk intake (steady growth, sufficient elimination, infant alertness and breasts feeling full before breastfeeds and soft after breastfeeds) should provide confidence in milk supply. We surveyed 423 mothers in early lactation who had breastfeeding problems to determine the proportion that had PIMS and to determine if the mothers with PIMS relied on these clinical signs or other perceptions of their infants' behaviour as indications of insufficient milk supply. By 3 weeks after birth, we found that the rate of PIMS among mothers with breastfeeding problems was 44%. Supplementary infant formula was being given to 66% of the infants, so the clinical indications were that milk intake was sufficient, but 74% of the mothers with PIMS cited concerns that their infants did not appear satisfied after breastfeeds. After targeted advice from lactation consultants, mothers with PIMS showed positive changes in their perceptions of their milk supply, underlining the value of professional guidance soon after birth. We conclude that an appearance of infant dissatisfaction is the major cause of PIMS in Western Australia.     

Serum Thiamin, Pyridoxal, Cobalamin and Folate Concentrations in Young Infants

ABSTRACT. Blood samples were obtained from 509 apparently healthy infants between the age of 3 and 54 weeks attending for routine checks at infant health centres. Serum was assayed for thiamin, pyridoxal, cobalamin and folate. Three hundred and five infants were being breast fed and results from these were used to construct a reference range–thiamin 2-17 μg/1, pyridoxal 8-39 ng/1, cobalamin 120-800 μg/1 and folate 7-47 ng/1 (95 percentile ranges). One hundred and thirty-four infants were being fed a manufactured milk formulation and the serum concentrations of thiamin, pyridoxal and cobalamin were significantly higher than those found in breast fed infants. Thirteen infants were receiving pasteurised cow's milk. This milk was found to have more than 3 times the folate content of human breast milk yet these infants had a significantly reduced serum level of folate.     

Quantifying breast milk intake by term and preterm infants for input into paediatric physiologically based pharmacokinetic models

Despite the many benefits of breast milk, mothers taking medication are often uncertain about the risks of drug exposure to their infants and decide not to breastfeed. Physiologically based pharmacokinetic models can contribute to drug‐in‐milk safety assessments by predicting the infant exposure and subsequently, risk for toxic effects that would result from continuous breastfeeding. This review aimed to quantify breast milk intake feeding parameters in term and preterm infants using literature data for input into paediatric physiologically based pharmacokinetic models designed for drug‐in‐milk risk assessment. Ovid MEDLINE and Embase were searched up to July 2, 2019. Key study reference lists and grey literature were reviewed. Title, abstract and full text were screened in nonduplicate. Daily weight‐normalized human milk intake (WHMI) and feeding frequency by age were extracted. The review process retrieved 52 studies. A nonlinear regression equation was constructed to describe the WHMI of exclusively breastfed term infants from birth to 1 year of age. In all cases, preterm infants fed with similar feeding parameters to term infants on a weight‐normalized basis. Maximum WHMI was 152.6 ml/kg/day at 19.7 days, and weighted mean feeding frequency was 7.7 feeds/day. Existing methods for approximating breast milk intake were refined by using a comprehensive set of literature data to describe WHMI and feeding frequency. Milk feeding parameters were quantified for preterm infants, a vulnerable population at risk for high drug exposure and toxic effects. A high‐risk period of exposure at 2–4 weeks of age was identified and can inform future drug‐in‐milk risk assessments.     

Influence of two infant formulas and human milk on the development of the faecal flora in newborn infants

The establishment of the faecal flora of 39 full-term infants fed exclusively on breast milk (n = 20) or with two different modern adapted cow's milk formulas (n = 19) was studied during the first 3 months of life. One formula investigated was based on 100% bovine casein as the protein source whereas the other formula contained bovine milk proteins with a whey/casein ratio of 60:40. A faecal flora rich in bifidobacteria was found in all study groups; the growth of putrefactive bacteria (especially Bacteroides spp.), however, was limited. In formula-fed infants, significantly higher bacterial counts of enterococci and Clostridia were detected compared to breast milk-fed infants. Similarities and differences due to the feeding regimen were particularly reflected in the pattern of the anaerobic bacterial species. Bifidobacterium bifidum, B. infantis and B. breve constituted the majority of the bifidobacterial flora independent of the type of milk feeding. Other bifidobacterial species such as B. longum, B. adolescentis, B. parabifidum and B. pseudo-catenulatum were detected in high numbers and at low frequencies in breastfed infants. The latter three were observed in infants fed the whey/casein formula as well. It seems that infants fed a casein formula develop a faecal flora more like that of breastfed infants concerning Lactobacillus spp. (especially L. fermentum and L. brevis).     

Enteral feeding composition and necrotizing enterocolitis

Enteral feeding and composition play a chief role in the prevention and treatment of necrotizing enterocolitis (NEC). In the face of decades of research on this fatal disease, the exact mechanism of disease is still poorly understood. There is established evidence that providing mother's own breast milk and standardization of feeding regimens leads to a decreased risk for NEC. More recent studies have focused on the provision of donor human milk or an exclusive human milk diet in the endeavor to prevent NEC while still maintaining adequate nutrition to the premature infant. There is growing literature on the provision of specific human milk components and its effect on the incidence of NEC.     

Breast milk feeding in very low birthweight infants

ABSTRACT. The infant feeding practices of 77 very low birthweight (VLBW) survivors with birthweights under 1500 g were studied. 58 (75%) infants received fresh expressed breast milk (EBM) from their own mothers, of whom 42 were successfully breastfed at a medium postconceptual age of 36 weeks. Overall incidence of breastfeeding in the VLBW population was 44% at 3 months and 23% at 6 months. The postnatal ages at which breastfeeding stopped ranged from 2 months to 28 months (median 4 months). No significant differences in perinatal factors were found between the breast milk and milk formula groups. There were significantly more mothers in the breast milk group who were given advice and encouragement during their pregnancy on breastfeeding and who had planned in the antenatal period to breastfeed their infants. The most common reasons given for deciding against providing breast milk were related to extreme prematurity of the infant. Nursery weight gain of infants fed breast milk and milk formula were similar. Necrotizing enterocolitis occurred significantly less frequently in the breast milk group. The study suggested that the special attention and positve encouragement given to parents of VLBW infants had contributed to the successful establishment and continuation of a feeding regime utilizing fresh breast milk from the infant's own mother, which we believe has immunological, psychological and nutritional benefits in this high-risk infant population.     

Perceived insufficient milk among primiparous,fully breastfeeding women: Is infant crying important?

Breastfeeding mothers often report perceived insufficient milk (PIM) believing their infant is crying too much, which leads to introducing formula and the early abandonment of breastfeeding. We sought to determine if infant crying was associated with reported PIM (yes/no) and number of problems associated with lactation (lactation problem score [LPS] 6‐point Likert scale) before formula introduction. Primiparous breastfeeding mothers were recruited at birth and visited at 1, 2 and 4 weeks. Among those fully breastfeeding at 1 week (N = 230), infant crying variables based on maternal reports were not associated with PIM at 1 week, but LPS was. However, a mother''s expectation that her infant would cry more than other infants was associated with increased odds of reporting PIM at 2 and 4 weeks, as were delayed onset of lactation and previous LPS. At 1 week, crying variables (frequency, difficulty in soothing) were associated with LPS along with percent weight change. Delayed onset of lactation, infant care style, number of breastfeeds and previous LPS were longitudinally associated with change in LPS from 1 to 2 weeks and 2 to 4 weeks. Our data suggest that reported infant crying is associated with PIM and LPS in the first 4 weeks of life. Guidance on what to expect in crying behaviour and the impact of infant care style may be beneficial in reducing PIM and LPS in the first month.     

婴儿输血传播病毒感染途径的分子病毒学研究

目的　观察产妇和所生婴儿在分娩及母乳喂养 6个月后的输血传播病毒 (TTV)感染情况 ,探讨婴儿TTV感染途径。方法　应用套式PCR对 40 0对正常孕产妇分娩前的血清及其新生儿的脐血血清标本、产妇的乳汁配对进行TTV DNA检测 ,对TTV DNA阳性、坚持母乳喂养的母亲及其婴儿进行 6个月随访 ,克隆其中 13对配对阳性标本的TTV基因 ,通过DNA序列测定比较分析母婴TTV感染株之间的核苷酸序列同源性。结果　 6 2例孕母血清、4例新生儿脐血血清、2 0例母乳TTV DNA阳性 ,TTV阳性母亲的乳汁TTV DNA检出率32 2 % (2 0 / 6 2 )。经 6个月随访孕母血TTV DNA阳性的 42对母乳喂养的母婴 ,母血清TTV DNA阳性率2 1 3 % (9/ 42 ) ,婴儿血清TTV DNA阳性率 40 5 % (17/ 42 ) ,孕母血清TTV DNA阳性的婴儿血TTV DNA由阴转阳率 38 1% (16 / 42 )。配对比较母婴间TTV感染株序列同源性为 97 4%～ 99 8%。结论　孕产妇血清TTV阳性率较正常人高 ,乳腺可能是TT病毒的另一存在部位 ,母乳喂养及母婴间密切接触可能是母 儿间TTV的重要传播途径。     

WHO COLLABORATIVE BREAST FEEDING STUDY

ABSTRACT. Larsson, B., Slorach, S. A., Hagman, U. and Hofvander, Y. (Food Research Department, National Food Administration, Uppsala, and Department of Paediatrics, University Hospital, Uppsala, Sweden). WHO Collaborative Breast Feeding Study: II. Levels of lead and cadmium in Swedish human milk, 1978–1979. Acta Paediatr Scand, 70:281, 1981.–Individual samples of human milk collected in Uppsala at 3 months post partum (18 samples) and 6 months post partum (23 samples) from 21–35-year-old healthy mothers were analysed for lead and cadmium by flameless atomic absorption spectrometry. The median lead content in the 41 samples was 2 µg/kg fresh weight (range 0.5–9.0 µg/kg), and the median cadmium level was 0.1 µg/kg. There were no appreciable differences between the 3-month and 6-month samples as regards lead or cadmium levels. The calculated median weekly intakes of lead and cadmium by the 3-month-old infants (who received nothing else except breast milk) were approx. 2 µg and 0.1 µg/kg body-weight, respectively. There is no reason to believe that these low intakes of lead and cadmium constitute any risk to the health of the child. The intake of these metals by the breast-fed infant is likely to be the same as or somewhat lower than that of infants fed human milk substitutes and certainly less than that of children fed cereal-based infant foods.