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Concept: Infant formula

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Mothers' own milk is the best source of nutrition for nearly all infants. Beyond somatic growth, breast milk as a biologic fluid has a variety of other benefits, including modulation of postnatal intestinal function, immune ontogeny, and brain development. Although breastfeeding is highly recommended, breastfeeding may not always be possible, suitable or solely adequate. Infant formula is an industrially produced substitute for infant consumption. Infant formula attempts to mimic the nutritional composition of breast milk as closely as possible, and is based on cow’s milk or soymilk. A number of alternatives to cow’s milk-based formula also exist. In this article, we review the nutritional information of breast milk and infant formulas for better understanding of the importance of breastfeeding and the uses of infant formula from birth to 12 months of age when a substitute form of nutrition is required.

Concepts: Childbirth, Infant, Nutrition, Milk, Breastfeeding, Baby bottle, Breast milk, Infant formula

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This study examines access to workplace accommodations for breastfeeding, as mandated by the Affordable Care Act, and its associations with breastfeeding initiation and duration. We hypothesize that women with access to reasonable break time and private space to express breast milk would be more likely to breastfeed exclusively at 6 months and to continue breastfeeding for a longer duration.

Concepts: Milk, Breastfeeding, Lactation, Breast milk, Colostrum, Male lactation, Infant formula

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Background, Objectives: The Ten Steps to Successful Breastfeeding are not, as yet, the norm in the United States. This study examined how noncompliance with each of the Steps, and combinations of 2 Steps, influence duration of breastfeeding at the breast.Methods: Data were from the national Infant Feeding Practices Study II. The outcome was duration of any breastfeeding at the breast. Propensity scores modeled the probability of exposure to lacking 1 or more of the Ten Steps. Inverse probability weights controlled for confounding. Survival analyses estimated the relationship between the lack of a Step and breastfeeding duration.Results: Lack of Step 6 (No human milk substitutes) was associated with shorter breastfeeding duration, compared with being exposed to Step 6 (10.5-wk decrease). Lack of both Steps 4 (Breastfeed within 1 hour after birth) and 9 (Pacifiers), together, was related to the greatest decrease in breastfeeding duration (11.8-wk decrease). The findings supported a dose-response relationship: being exposed to 6 Steps was related to the longest median duration (48.8 wk), followed by 4 or 5 Steps (39.8 wk), followed by 2 or 3 Steps (36.4 wk).Conclusions: Prevalent US maternity care practices do not, as yet, include all of the Ten Steps. This lack of care may be associated with poor establishment of the physiological feedback systems that support sustained breastfeeding. Breastfeeding at the breast is compromised when specific combinations of Steps are lacking. Efforts to increase implementation of specific Steps and combinations of Steps may be associated with increased duration of breastfeeding.

Concepts: Infant, Milk, Breastfeeding, Lactation, Pacifier, Breast milk, Infant formula, Human milk banking in North America

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U.S. breastfeeding rates have improved, but we need to do more to support this practice.

Concepts: Milk, Breastfeeding, Lactation, Breast, Breast milk, Colostrum, Male lactation, Infant formula

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The American Academy of Pediatrics recommends that infants be breastfed exclusively* for the first 6 months of life, and that mothers continue breastfeeding for at least 1 year (1). However, in 2011, only 19.3% of mothers aged ≤20 years in the United States exclusively breastfed their infants at 3 months, compared with 36.4% of women aged 20-29 years and 45.0% of women aged ≥30 years.(†) Hospitals play an essential role in providing care that helps mothers establish and continue breastfeeding. The U.S. Surgeon General and numerous health professional organizations recommend providing care aligned with the Baby-Friendly Hospital Initiative (BFHI), including adherence to the Ten Steps to Successful Breastfeeding (Ten Steps), as well as not providing gift packs containing infant formula (2,3). Implementing BFHI-aligned maternity care improves duration of any and exclusive breastfeeding among mothers (4,5); however, studies have not examined associations between BFHI-aligned maternity care and breastfeeding outcomes solely among adolescent mothers (for this report, adolescents refers to persons aged 12-19 years). Therefore, CDC analyzed 2009-2011 Pregnancy Risk Assessment Monitoring System (PRAMS) data and determined that among adolescent mothers who initiated breastfeeding, self-reported prevalence of experiencing any of the nine selected BFHI-aligned maternity care practices included in the PRAMS survey ranged from 29.2% to 95.4%. Among the five practices identified to be significantly associated with breastfeeding outcomes in this study, the more practices a mother experienced, the more likely she was to be breastfeeding (any amount or exclusively) at 4 weeks and 8 weeks postpartum. Given the substantial health advantages conferred to mothers and children through breastfeeding, and the particular vulnerability of adolescent mothers to lower breastfeeding rates, it is important for hospitals to provide evidence-based maternity practices related to breastfeeding as part of their routine care to all mothers, including adolescent mothers.

Concepts: Pregnancy, Childbirth, Infant, United States, Breastfeeding, Baby bottle, Infant formula, Baby Friendly Hospital Initiative

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We evaluated effects of infant formula supplemented with 2 human milk oligosaccharides (HMOs) on infant growth, tolerance and morbidity.

Concepts: Milk, Breastfeeding, Baby bottle, Breast milk, Infant formula

11

Three important infant feeding support problems are addressed: (1) mothers who use formula milk can feel undersupported and judged; (2) mothers can feel underprepared for problems with breastfeeding; and (3) many mothers who might benefit from breastfeeding support do not access help. Theory of constraints (TOC) is used to examine these problems in relation to ante-natal education and post-natal support. TOC suggests that long-standing unresolved problems or ‘undesirable effects’ in any system (in this case a system to provide education and support) are caused by conflicts, or dilemmas, within the system, which might not be explicitly acknowledged. Potential solutions are missed by failure to question assumptions which, when interrogated, often turn out to be invalid. Three core dilemmas relating to the three problems are identified, articulated and explored using TOC methodology. These are whether to: (1) promote feeding choice or to promote breastfeeding; (2) present breastfeeding positively, as straightforward and rewarding, or focus on preparing mothers for problems; and (3) offer support proactively or ensure that mothers themselves initiate requests for support. Assumptions are identified and interrogated, leading to clarified priorities for action relating to each problem. These are (1) shift the focus from initial decision-making towards support for mothers throughout their feeding journeys, enabling and protecting decisions to breastfeed as one aspect of ongoing support; (2) to promote the concept of an early-weeks investment and adjustment period during which breastfeeding is established; and (3) to develop more proactive mother-centred models of support for all forms of infant feeding.

Concepts: Infant, Breastfeeding, Baby bottle, Problem solving, Breast milk, Infant formula, Baby food, Theory of Constraints

10

Perfluorinated alkylate substances (PFASs) are widely used and have resulted in human exposures worldwide. PFASs occur in breast milk, and the duration of breastfeeding is associated with serum-PFAS concentrations in children. To determine the time-dependent impact of this exposure pathway, we examined the serum concentrations of five major PFASs in a Faroese birth cohort at birth, and at ages 11, 18, and 60 months. Information about the children’s breastfeeding history was obtained from the mothers. The trajectory of serum-PFAS concentrations during months with and without breastfeeding was examined by linear mixed models that accounted for the correlations of the PFAS measurements for each child. The models were adjusted for confounders such as body size. The duration of exclusive breastfeeding was associated with increases of most PFAS concentrations by up to 30% per month, with lower increases during partial breast-feeding. In contrast to this main pattern, perfluorohexanesulfonate was not affected by breast-feeding. After cessation of breastfeeding, all serum concentrations decreased. This finding supports the evidence of breastfeeding being an important exposure pathway to some PFASs in infants.

Concepts: Infant, Milk, Breastfeeding, Lactation, Baby bottle, Breast milk, Infant formula

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High protein intake during infancy may contribute to obesity later in life in infants who are not exclusively breastfed. Lowering the protein content of infant formula so it is closer to that of mature breast milk may reduce long-term risk of overweight or obesity in formula-fed infants.

Concepts: Infant, Nutrition, Milk, Breastfeeding, Baby bottle, Breast milk, Infant formula, Baby food

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Human milk (HM) contains a complex array of hormones, including members of the glucocorticoid family. The predominant glucocorticoids, cortisol and cortisone may influence the growth and behaviour of the breastfed infant. However, little is understood of the factors regulating the levels of these hormones within HM. The aim of the study was to examine HM cortisol and cortisone concentration, measured in samples collected at each feed during a 24 hour period. Twenty three exclusively breastfeeding mothers collected milk, prior to and after each breastfeeding session over 24 hour period at 3.2(1.60) months. HM cortisol and cortisone levels were measured using high pressure liquid chromatography mass spectroscopy. Cortisone was the predominant glucocorticoid (3.40 ng/ml), and cortisol was detected in all samples (1.62 ng/ml). A positive correlation was found between cortisone and cortisol (r = 0.61, y = 1.93 ± 0.24, p < 0.0001). Cortisol and cortisone concentrations were significantly higher in feeds in the morning (2.97 ng/ml and 4.88 ng/ml), compared to afternoon (1.20 ng/ml and 3.54 ng/ml), evening (0.69 ng/ml and 2.13 ng/ml) and night (1.59 and 3.27 ng/ml). No difference was found between glucocorticoids level of the milk expressed for collection either before or immediately after the breastfeed, or between milk collected from the left or right breast. This study shows that HM glucocorticoid concentrations exhibit a 24 hour pattern, with highest peak levels in the early morning, reflecting the circadian pattern as previously reported in plasma. Thus, HM glucocorticoid concentrations are likely to reflect those in the maternal circulation.

Concepts: Infant, Breastfeeding, Lactation, Glucocorticoid, Cortisol, Breast, Breast milk, Infant formula