Maternal Reports of Preterm and Sick Term Infants' Settling, Sleeping and Feeding in the 9 Months after Discharge from Neonatal Nursery: An Observational Study.

The effects of preterm birth, neonatal morbidities and environmental influences on infant sleep development is an important yet under-researched topic, with little known about normative sleep for infants born sick or preterm. The aim of this prospective, observational longitudinal study was to evaluate maternal perceptions and degree of bother with infant sleep behaviours and feeding outcomes across the first 9 months after discharge for sick/preterm infants cared for in the neonatal intensive care unit (NICU) and for healthy term-born infants. This paper reports outcomes for the sick/preterm cohort (I = 94) that were recruited from two NICUs in Perth, Western Australia. Total bother scores were on average 20.2% higher at 9 months than at two weeks post-discharge (p < 0.001). Increased night waking frequency, evening settling duration and crying duration were all positively associated with total bother scores. Maternal confidence scores were negatively associated with maternal bother scores; with each unit increase in confidence, maternal bother decreased by 8.5% (p < 0.001). Covariates such as birth gestation, breastfeeding status and multiple births were not associated with maternal bother. Families may benefit from additional support when experiencing increased night waking frequency and crying and settling durations in the first 9 months after discharge from NICU.

Australian Women's Experiences of Establishing Breastfeeding after Caesarean Birth.

Breastfeeding exclusivity and duration rates are lower after caesarean birth, yet the factors contributing to these are not well understood. This mixed-methods study used an anonymous online questionnaire to examine the facilitators and barriers to establishing breastfeeding as identified by Australian women after a caesarean birth. Quantitative data were reported using descriptive statistics, and multivariable models were used to determine the factors associated with breastfeeding outcomes including the timing of breastfeeding initiation, birth experience, and commercial infant formula use. Qualitative data were analysed using an inductive thematic analysis. Data were obtained for N = 961 women, of which <50% reported skin-to-skin contact during breastfeeding initiation. The barriers to breastfeeding included aspects of clinical care and reduced mobility, while unrushed care, partner support, and physical help with picking up the baby were helpful. Following a non-elective caesarean birth, women had half the odds of early breastfeeding initiation (OR = 0.50; 95% CI: 0.36, 0.68; p ≤ 0.001) and 10 times the odds to report a negative birth experience (OR = 10.2; 95% CI: 6.88, 15.43; p < 0.001). Commercial milk formula use was higher in primiparous women (OR = 2.16; 95% CI: 1.60, 2.91; p < 0.001) and in those that birthed in a private hospital (OR = 1.67; 95% CI: 1.25, 2.32; p = 0.001). Pain and reduced mobility, as well as conflicting and rushed care, negatively impacted breastfeeding after a caesarean birth, while delayed breastfeeding initiation, higher pain ratings, and negative birth experiences were more common for women that birthed by non-elective caesarean. This study adds valuable insights into the physical, emotional, and clinical care needs of women in establishing breastfeeding after a surgical birth. Clinical staffing and care should be modified to include full access to partner support to meet the specific needs of breastfeeding women after a caesarean birth.

Sampling Procedures for Estimating the Infant Intake of Human Milk Leptin, Adiponectin, Insulin, Glucose, and Total Lipid.

Limited attention is given to the efficacy of protocols for the estimation of infant intake of milk components when investigating their impact on infant outcomes. We compared the actual measured intake of human milk components with estimations derived from 15 protocols to determine the most reliable approach for estimating intake of HM leptin, adiponectin, insulin, glucose, and total lipid. Twenty mothers who were 3-5 months postpartum completed a 24 h milk profile study with pre-/post-feed milk samples collection. The true infant intake (control group) based on 24 h milk intake (MI) was compared to estimated infant intakes using concentrations from five sampling protocols that were multiplied by one of true infant MI, considered mean MI (800 mL), or global mean MI (766 mL). The mean measured concentrations of six samples (three sets of pre- and post-feed samples, from morning (06:00-09:00), afternoon (13:00-16:00), and evening (19:00-22:00)) multiplied by the true infant MI, mean considered MI, and global mean MI produced the most accurate estimates of infant intake of these components. Therefore, in the absence of 24 h measurements and sampling, a sampling protocol comprising three sets of pre-/post-feed samples provides the most reliable infant intake estimates of HM leptin, adiponectin, insulin, glucose, and total lipid.

Milk microbiome transplantation: recolonizing donor milk with mother's own milk microbiota.

Donor human milk (DHM) provides myriad nutritional and immunological benefits for preterm and low birthweight infants. However, pasteurization leaves DHM devoid of potentially beneficial milk microbiota. In the present study, we performed milk microbiome transplantation from freshly collected mother's own milk (MOM) into pasteurized DHM. Small volumes of MOM (5%, 10%, or 30% v/v) were inoculated into pasteurized DHM and incubated at 37 °C for up to 8 h. Further, we compared microbiome recolonization in UV-C-treated and Holder-pasteurized DHM, as UV-C treatment has been shown to conserve important biochemical components of DHM that are lost during Holder pasteurization. Bacterial culture and viability-coupled metataxonomic sequencing were employed to assess the effectiveness of milk microbiome transplantation. Growth of transplanted MOM bacteria occurred rapidly in recolonized DHM samples; however, a greater level of growth was observed in Holder-pasteurized DHM compared to UV-C-treated DHM, potentially due to the conserved antimicrobial properties in UV-C-treated DHM. Viability-coupled metataxonomic analysis demonstrated similarity between recolonized DHM samples and fresh MOM samples, suggesting that the milk microbiome can be successfully transplanted into pasteurized DHM. These results highlight the potential of MOM microbiota transplantation to restore the microbial composition of UV-C-treated and Holder-pasteurized DHM and enhance the nutritional and immunological benefits of DHM for preterm and vulnerable infants. KEY POINTS: • Mother's own milk microbiome can be successfully transplanted into donor human milk. • Recolonization is equally successful in UV-C-treated and Holder-pasteurized milk. • Recolonization time should be restricted due to rapid bacterial growth.

Causes of Low Milk Supply: The Roles of Estrogens, Progesterone, and Related External Factors.

Low milk supply (LMS) poses a significant challenge to exclusive and continued breastfeeding, affecting ∼10% to 15% of mothers. Milk production is intricately regulated by both endocrine and autocrine control mechanisms, with estrogens and progesterone playing pivotal roles in this process. In addition to endogenously produced hormones, external substances capable of interfering with normal hormonal actions, including phytoestrogens, mycoestrogens, synthetic estrogens, and hormonal contraceptives, can influence milk production. The effects of these extrinsic hormones on milk production may vary based on maternal body mass index. This comprehensive review examines the multifaceted causes of LMS, focusing on the involvement of estrogens, progesterone, and related external factors in milk production. Furthermore, it investigates the interplay between hormonal factors and obesity, aiming to elucidate the endocrine mechanisms underlying obesity-associated LMS. Insights from this review provide valuable perspectives for developing interventions to improve milk production and address the challenges associated with LMS.

Circadian Variation in Human Milk Hormones and Macronutrients.

There is an inadequate understanding of the daily variations in hormones and macronutrients in human milk (HM), and sample collection protocols vary considerably from study to study. To investigate changes in these milk components across 24 h, 22 lactating women collected small milk samples before and after each breastfeed or expression from each breast. Test weighing was used to determine the volume of HM consumed in each feed. The concentrations of leptin, adiponectin, insulin, fat, and glucose were measured, and the intakes were calculated. A linear mixed model was fitted to assess within-feed and circadian variation in HM feed volume and concentration, and intakes of several components. The average infant intake of HM was 879 g/24 h. Significantly higher pre-feed concentrations were found for adiponectin and glucose and lower post-feed concentrations were found for insulin and fat. Significant circadian rhythms were displayed for leptin, adiponectin, insulin, glucose (both concentration and intake), fat concentration, and milk volume. These findings demonstrate the necessity for setting up standardised and rigorous sampling procedures that consider both within-feed and circadian variations in HM components to gain a more precise understanding of the impacts of these components on infant health, growth and development.

Relationships between the Intakes of Human Milk Components and Body Composition of Breastfed Infants: A Systematic Review.

Human milk provides all of the elements necessary for infant growth and development. Previous studies have reported associations between breastfeeding and a reduced risk of developing obesity and late-onset metabolic disorders; however, the underlying mechanisms are poorly understood. Recently, intakes of human milk components have been associated with infant body composition, which is likely partially implicated in the reduced risk of developing childhood obesity among breastfed infants. In this systematic review, we searched electronic bibliographic databases for studies that explored relationships between the 24 h intakes of human milk macronutrients and bioactive components and infant body composition and/or growth parameters. Of 13 eligible studies, 10 assessed relationships of infant body composition and growth outcomes with human milk macronutrients, while 8 studies assessed relationships with human milk bioactive components. Significant time-dependent relationships with infant anthropometrics and body composition were found for intakes and no relationships for concentrations of several human milk components, such as lactose, total protein, and human milk oligosaccharides, suggesting that measuring concentrations of human milk components without quantifying the intake by the infant may provide a limited understanding. Future studies investigating the effect of human milk components on infant growth and body composition outcomes should consider measuring the actual intake of components and employ standardised methods for measuring milk intake.

Oestrogens and progesterone in human milk and their effects on infant health outcomes: A narrative review.

Human milk (HM) is a complex biological system that contains a wide range of bioactive components including oestrogens and progesterone. Whilst maternal oestrogens and progesterone concentrations drop rapidly after birth, they remain detectable in HM across lactation. Phytoestrogens and mycoestrogens, which are produced by plants and fungi, are also present in HM and can interact with oestrogen receptors to interfere with normal hormone functions. Despite the potential impact of HM oestrogens and progesterone on the infant, limited research has addressed their impact on the growth and health of breastfed infants. Furthermore, it is important to comprehensively understand the factors that contribute to these hormone levels in HM, in order to establish effective intervention strategies. In this review, we have summarized the concentrations of naturally occurring oestrogens and progesterone in HM from both endogenous and exogenous sources and discussed both maternal factors impacting HM levels and relationships with infant growth.

Human Milk Sodium and Potassium as Markers of Mastitis in Mothers of Preterm Infants.

Introduction: This prospective longitudinal study examined changes in milk sodium concentration (Na) and sodium:potassium ratio (Na:K), microbiological culture, milk production, and breast health in relation to mastitis after preterm birth. Methods: We studied women who gave birth at 29-34 weeks of gestation in a tertiary obstetric hospital in Perth, Western Australia. Milk samples, 24-hour milk production, and breast health data were collected every second day to day 10 postpartum, then every third day until infant discharge from the neonatal unit. Milk Na and K were measured at point of care (POC) using handheld ion selective meters, and Na:K calculated. Cultures were performed on postnatal days 8, 13, and every 6 days thereafter. For episodes of mastitis, milk was cultured at onset, and Na and Na:K measured daily until resolution. Women were followed up at 4 and 8 weeks postpartum. Results: In a sample of 44 women, 4 mastitis cases were detected in 3 women during their infants' neonatal stay; all had elevated milk Na and Na:K that resolved within 48 hours; 2/4 experienced reduced milk production and 1/4 had heavy growth of Staphylococcus epidermidis. A further 2 mastitis cases were reported in 39 women followed up to 8 weeks postpartum. Four women had elevated milk Na and Na:K without clinical signs of mastitis; three also had reduced milk production. Conclusions: POC testing of milk Na and/or Na:K may offer a useful indicator of breast health. Mastitis may cause an acute reduction in milk production regardless of the presence of culture-positive infection.

Breastfeeding and Maternal Perceptions of Infant Sleep, Settle and Cry Patterns in the First 9 Months.

This study evaluated relationships between maternal perceptions of infant sleep, settling and crying patterns and breastfeeding. A prospective observational study of 91 mothers of healthy, term infants was conducted with follow ups over 9 months after discharge from a Western Australian maternity hospital. Feeding information, sleep, settle and cry behaviours, maternal bother at infant behaviours and confidence were measured using the Sleep and Settle Questionnaire. Breastfeeding confidence was measured using the Breastfeeding Self-Efficacy Scale-Short Form. Questionnaires were administered at 2 and 6 weeks, 3, 6 and 9 months. Linear mixed models were used to assess associations between maternal bother, feeding method and infant characteristics. The feeding method was not associated with maternal bother, and cessation of breastfeeding did not result in a change in bother scores (p = 0.34). Duration of infant crying in the day, evening and night, frequency of night waking and duration of settling to sleep in the day were associated with increased bother scores. Higher breastfeeding self-efficacy and maternal confidence were associated with lower bother scores (both p < 0.01). Maternal bother is associated with infant behaviours that require parental input, but not breastfeeding status. Resources that address parental expectations regarding infant sleep while providing strategies to support maternal wellbeing and breastfeeding are needed.

The Impact of Gestational Diabetes Mellitus on Human Milk Metabolic Hormones: A Systematic Review.

Gestational diabetes mellitus (GDM) is a common pregnancy complication with short- and long-term health consequences for the infant and mother. Breastfeeding is the recommended mode of feeding as it offers an opportunity to reduce the risk of GDM consequences, likely partially mediated through changes in human milk (HM) composition. This review systematically reviewed 12 identified studies that investigated the impact of GDM on concentrations of HM metabolic hormones. Meta-analysis was not possible due to significant heterogeneity in study designs and hormone measurement techniques. The risk of bias was assessed using the National Institute for Clinical Excellence (NICE) tool. The methodological qualities were medium in half of the studies, while 25% (3/12) of studies carried a high risk of bias. Significant relationships were reported between GDM and concentrations of HM ghrelin (3/3 studies), insulin (2/4), and adiponectin (2/6), which may play an integral role in infant growth and development. In conclusion, preliminary evidence suggests that GDM may alter HM metabolic hormone concentrations; however, these relationships may be limited to the early lactation stage.

Longitudinal changes in wellbeing amongst breastfeeding women in Australia and New Zealand during the COVID-19 pandemic.

The COVID-19 pandemic has impacted new mothers' wellbeing and breastfeeding experience. Women have experienced changes in birth and postnatal care and restricted access to their support network. It is unclear how these impacts may have changed over time with shifting rates of infection and policies restricting movement and access to services in Australia and New Zealand. This study investigated the longitudinal effect of the COVID-19 pandemic on breastfeeding and maternal wellbeing in Australia and New Zealand. Mothers (n = 246) completed an online survey every 4 weeks for 6 months that examined feeding methods, maternal mental wellbeing, worries, challenges, and positive experiences during the pandemic. Mothers maintained high full breastfeeding rates at 4 months (81%) which decreased to 37% at 6 months. Perceived low milk supply contributed to the earlier cessation of full breastfeeding. Poor infant sleep was associated with stress, perinatal anxiety, mental wellbeing, and breastfeeding status. Although mothers initially reported that lockdowns helped with family bonding and less pressure, prolonged lockdowns appeared to have adverse effects on access to social networks and extended family support.    Conclusion: The results highlight the changing dynamic of the pandemic and the need for adaptable perinatal services which allow mothers access to in-person services and their support network even in lockdowns. Similarly, access to continuous education and clinical care remains critical for women experiencing concerns about their milk supply, infant sleep, and their own wellbeing. What is Known: • The COVID-19 pandemic and lockdown restrictions have significantly affected perinatal mental health, disrupted maternal services, and subsequent breastfeeding. What is New: • In Australia and New Zealand, breastfeeding women experienced challenges to their mental wellbeing, sleep, and breastfeeding, which was likely exacerbated over time by the pandemic. Lockdowns, while initially beneficial for some families, became detrimental to maternal support and wellbeing.

Maternal Evaluation of a Team-Based Maternity Care Model for Women of Low Obstetric Risk.

In response to the need for affordable and comprehensive maternity care, a multidisciplinary team-based maternity care service led by general practitioners with obstetric training (GPOs) and midwives was established for women of low obstetric risk. We evaluated maternal satisfaction with this model of care. All women that attended the service and gave birth in 2020 were approached. Participants used an online survey to rate their satisfaction with aspects of their pregnancy, hospital stay and postpartum care and were invited to provide additional written feedback. Fifty percent (81/162) of women (33 ± 3.9 years) responded, with 59% primiparous. Proportions of participants that were very satisfied with their overall pregnancy, hospital stay, and postpartum care were 91%, <50%, and 85%, respectively. Both survey and qualitative data identified high satisfaction with emotional care and time afforded to discuss concerns during appointments. High levels of satisfaction can be achieved in women of low obstetric risk through the provision of GPO-midwife led multidisciplinary care throughout the maternity journey.

Delayed secretory activation and low milk production in women with gestational diabetes: a case series.

BACKGROUND: Gestational diabetes mellitus (GDM) is major pregnancy complication that is associated with short- and long-term consequences for both mother and infant, including increased risk of diabetes later in life. A longer breastfeeding duration has been associated with a reduced risk of diabetes, however, women with GDM are less likely to exclusively breastfeed and have shorter breastfeeding duration. While the timing of breastfeeding initiation and milk removal frequency affects subsequent breastfeeding outcomes, little is known about early infant feeding practices and milk production in women with GDM. This case series offers detailed prospective breastfeeding initiation data, as well as the first report of objective measures of milk production in women with GDM. CASE PRESENTATION: In this case series, we present the early infant feeding practices of eight women with GDM that gave birth at term gestation. Women recorded the timing of initiation of breastfeeding and secretory activation, as well as their breastfeeding, expression and formula feeding frequencies on postpartum days 1, 7 and 21. Measurement of 24 h milk production volume was performed at 3 weeks postpartum using the test weight method. We observed a delayed first breastfeed (> 1 h) in 6 (75%) cases, formula use in hospital in 5 (63%) cases and delayed secretory activation in 3 (38%) cases. At 3 weeks postpartum, 2 cases had measured milk productions that were insufficient to sustain adequate infant weight gain. CONCLUSIONS: Our data suggest that despite early and frequent milk removal, women with GDM are at greater risk of delayed secretory activation and low milk supply. Cohort studies that consider co-morbidities such as obesity are needed to determine the lactation outcomes of women with GDM.

Human Milk Macronutrients and Bioactive Molecules and Development of Regional Fat Depots in Western Australian Infants during the First 12 Months of Lactation.

We investigated associations between intakes of human milk (HM) components (macronutrients and biologically active molecules) and regional fat depots development in healthy term infants (n = 20) across the first year of lactation. Infant limb (mid-arm and mid-thigh) lean and fat areas were assessed by ultrasound imaging at 2, 5, 9 and 12 months of age. Concentrations of HM total protein, whey protein, casein, adiponectin, leptin, lysozyme, lactoferrin, secretory IGA, total carbohydrates, lactose, HM oligosaccharides (total HMO, calculated) and infant 24-h milk intake were measured, and infant calculated daily intakes (CDI) of HM components were determined. This pilot study shows higher 24-h milk intake was associated with a larger mid-arm fat area (p = 0.024), higher breastfeeding frequency was associated with larger mid-arm (p = 0.008) and mid-thigh (p < 0.001) fat areas. Lysozyme (p = 0.001) and HMO CDI (p = 0.004) were time-dependently associated with the mid-arm fat area. Intakes of HM components and breastfeeding parameters may modulate infant limb fat depots development during the first year of age and potentially promote favorable developmental programming of infant body composition; however, further studies are needed to confirm these findings.

A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding: case series.

BACKGROUND: Lactation consultants frequently advise adjustments to fit and hold (or positioning and attachment) with the aim of optimising intra-oral nipple placement. However, approaches to fit and hold vary widely, with limited evidence of benefits, and effects of fit and hold on infant tongue movement have not been examined. The aim of this preliminary study was to investigate whether a gestalt breastfeeding intervention alters tongue movement, using measurements from ultrasound imaging to determine nipple placement and intra-oral nipple and breast tissue dimensions. METHODS: Ultrasound measurements were conducted in five breastfeeding dyads, infants aged 4-20 weeks, while feeding in their usual or 'standard' position and again after brief application of gestalt principles of fit and hold. Four of the mother-baby pairs, who had received comprehensive lactation support, reported persisting nipple pain. Three of these infants had difficulty latching and fussed at the breast; three had been diagnosed with oral ties. A fifth pair was breastfeeding successfully. RESULTS: Ultrasound demonstrated that the distance from nipple tip to junction of the hard and soft palate decreased, intra-oral nipple and breast tissue dimensions increased, and nipple slide decreased after a brief gestalt intervention. CONCLUSION: These preliminary findings suggest that changes in fit and hold impact on infant tongue movement and contour. Further research investigating short- and long-term outcomes of a gestalt breastfeeding intervention in larger cohorts is required.

Breastfeeding in a COVID-19 world.

PURPOSE OF REVIEW: The coronavirus disease 2019 (COVID-19) pandemic has changed the birthing and postnatal experience of women. This review highlights how policy changes have affected pregnant and breastfeeding women, the evidence for continued breastfeeding and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines, and how the pandemic's unexpected consequences have affected these women's wellbeing. Additionally, we postulate the future of lactation and perinatal support as the pandemic continues. RECENT FINDINGS: Women who have given birth during the pandemic have had restricted access to postnatal care. Although pregnant and breastfeeding women who contract SARS-CoV-2 are more vulnerable to poor health outcomes than their nonpregnant counterparts, they are also at higher risk of mental health difficulties, with limited access to support. Continued breastfeeding may be protective to the infant, offering passive immunity against SARS-CoV-2, and vaccination against COVID-19 is safe and effective for pregnant and lactating women. Innovative and adaptable lactation care, including holistic perinatal, mental health, and social support services, both digital and in-person, will help mothers continue breastfeeding during future outbreaks. SUMMARY: Continued breastfeeding and vaccination may confer protection to the infant against SARS-CoV-2 infection. New mothers should not be isolated in future pandemics. Prioritizing lactation and perinatal care, including in-person services, remains paramount to optimizing breastfeeding during COVID-19.

Breast Milk Production in Women Who Use Nipple Shields for Persistent Nipple Pain.

OBJECTIVE: To examine relationships between nipple pain scores and 24-hour milk production volumes, breastfeeding and pumping frequencies, and breastfeeding duration in women using nipple shields for persistent nipple pain. DESIGN: Secondary outcome analysis of a prospective cohort study. SETTING: Research laboratory and participants' homes. PARTICIPANTS: Twenty-five breastfeeding women (6 ± 4 weeks after birth) who used nipple shields for persistent nipple pain. METHODS: We conducted a randomized trial to investigate the primary outcome of milk transfer with and without nipple shields among participants with and without nipple pain. Here, we report secondary outcomes of associations between 24-hour milk production, breastfeeding and pumping frequencies, breastfeeding durations, and intake in participants using a nipple shield for nipple pain. Participants completed demographic, health and breastfeeding questionnaires and, at two monitored breastfeeding sessions, completed a pain visual analogue scale and Brief Pain Inventory-Short Form (BPI-SF; total and subscale scores for pain interference with General Activity, Mood, Sleep, and Breastfeeding). Milk production (milliliters per 24 hours), feed volumes, and percentage of available milk removed were calculated from data and milk samples obtained by participants over one 24-hour period and at study visits. Participants logged 24-hour data on a customized research website. We used descriptive statistics as well as simple and multiple linear regression for analyses. RESULTS: Milk production and feeding duration were not associated with nipple pain scores (visual analogue scale: p = .80, BPI-SF: p = .44). An increase in BPI-SF Breastfeeding subscale score of 1 unit, indicating pain interference with breastfeeding, was associated with a 0.28 decrease in 24-hour breastfeeding frequency (p = .02) and an 18.8-ml decrease in 24-hour breastfeeding intake (p = .04). CONCLUSION: Persistent nipple pain was associated with reduced breastfeeding frequency; therefore, continuing professional support is required to ensure adequate milk removal and pain management.

Longitudinal Follow-up of Preterm Breastfeeding to 12 Weeks Corrected Gestational Age.

BACKGROUND: Preterm infants have shorter breastfeeding duration than that of term infants. Details of postdischarge feeding methods and difficulties are needed to inform the care of preterm breastfeeding dyads. PURPOSE: To describe postdischarge breastfeeding characteristics of mother-preterm infant dyads up to 12 weeks corrected gestational age (CGA). METHODS: A prospective observational study of preterm dyads (birth 24-33 weeks' gestation) that fed their mother's own milk (MOM) at discharge from a neonatal unit in Perth, Western Australia. Feeding method and frequency, breastfeeding duration, difficulties, and nipple shield use were recorded at 2, 6, and 12 weeks CGA. RESULTS: Data were obtained for 49 mothers (singleton infant n = 39, twins n = 10). At 12 weeks CGA, 59% fed any MOM with 47% exclusively fed MOM and 31% fully breastfed. Nipple shield use reduced from 42% at 2 weeks CGA to 11% at 12 weeks CGA. Compared with mothers who exclusively fed MOM at discharge (n = 41) those who fed both MOM and infant formula (n = 8) were more likely to wean before 12 weeks CGA ( P < .001). Weaning occurred before 2 weeks CGA in 12/19 (63%), with low milk supply the most frequently cited reason. IMPLICATIONS FOR PRACTICE: Most mothers with a full milk supply at discharge successfully transition to predominant breastfeeding. Frequent milk removal needs to be prioritized throughout the preterm infant's hospital stay. IMPLICATIONS FOR RESEARCH: Examination of facilitators and barriers to early and continued frequent milk removal across the postpartum period is required to identify strategies to optimize lactation after preterm birth.

25 Years of Research in Human Lactation: From Discovery to Translation.

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.