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1 La Trobe University

latrobe.edu.au

CRICOS Provider 00115M

Judith Lumley Centre

Under the pump: the Mothers and Infants

Lactation Cohort (MILC) study

Helene Johns, Della Forster, Lisa Amir, Helen McLachlan, Anita Moorhead, Rachael Ford, Kerri McEgan

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Background Increasing reports of women giving expressed breast milk (EBM) rather than directly feeding from breast

• Australia – rate of expressing almost doubled in

decade to 2002 (Binns et al 2006)

• US - 73% of women expressed at least once in first six

months (Geraghty et al 2005)

• Singapore – rate of exclusive expressing doubled to

18% in seven years to 2008 (Hornbeak et al 2010)

• Reasons for increase poorly understood → more

evidence needed (Geraghty et al 2005)

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What is known? Lack of evidence on the association between feeding EBM and breastfeeding duration Outcomes of breast milk expression are unknown:

• Maternal → mastitis? fatigue? stress? anxiety?

respite? freedom?

• Infant → bonding? self regulation? orofacial

development?

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Potential risks of not breastfeeding at the breast ↓ Vitamin content (Hanna 2004) ↓ Self-regulation of intake (Li 2010) ↑ Risk of childhood obesity (Li 2012) ↑ Dental caries (Harris 2004) ↑ Orthodontic problems associated with not breastfeeding (Emerich 2010) ↑ Adverse reactions related to pump use (Clemons 2010) Compromised milk quality and safety ( Boo 2001, Geraghty

2010)

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Study design Prospective cohort study (MILC – Mothers and Infants Lactation Cohort) Hypothesis: “Infants fed solely at the breast in the 24 to 48 hours after birth are more likely to be breastfeeding at six months than other infants”

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The Mothers and Infants Lactation Cohort (MILC) Study Aims To explore:

• the prevalence and outcomes of breast milk

expression

• whether feeding other than directly from the breast

prior to hospital discharge decreases the proportion of infants receiving any breast milk at six months

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Participants Women recruited from three Melbourne maternity hospitals 24-48 hours postpartum

• Mercy Hospital for Women
• Royal Women’s Hospital
• Frances Perry House

Eligibility criteria

• feeding some breast milk
• singleton infant born at term (≥37 weeks)
• English-speaking

Excluded if either the mother or infant very ill

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Outcome measures

Primary outcome:

• any breast milk feeding at six months

Secondary outcomes:

• exclusive breastfeeding duration
• breastfeeding at three months
• expressing outcomes (frequency,

duration, amount, method)

• maternal mental health
• breastfeeding confidence and satisfaction

Other descriptive data collected:

• background demographic data/maternal

BMI/maternal smoking/method of birth

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Data collection Data collected at three time points In hospital after the birth

• structured interview (demographic details, breastfeeding

intentions, current feeding details)

• obstetric data medical record

3 months postpartum – structured telephone interview (data not presented here) 6 months postpartum – structured telephone interview

• Some open-ended questions at each time point to allow for

extra comments by women

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Sample size Used Victoria’s 2009 state average of ‘any’ breastfeeding at 6 months postpartum: 46% To detect a 10% difference in either direction (i.e. 46%→56% or 36%)

→needed a total of 822 women

→ to allow for loss to follow up planned to

recruit 1000 women

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Study participation

Recruitment July 2009 – April 2011 499 Primipara / 504 Multipara Total = 1003 3 month interview (telephone) 560/888 (63%) 6 month interview (telephone) 924/1003 (92%)

Discontinued April 2011

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Snapshot of findings Study participant characteristics Infant feeding at recruitment and six months Expressing patterns and breast pump usage

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The Mothers and Infants Lactation Cohort (MILC) Study Main study outcomes

• Only 36% of healthy term infants of primiparous

women and 61% of those born to multipara were exclusively breastfed at the breast in the first 24-48 hours (Johns et al Acta Paediatrica 2013)

• Women feeding only directly at the breast in the first

24-48 hours (compared with any other feeding combination) were more likely to be continuing to be breast milk feeding at 6 months (Forster et al BMC Pregnancy

& Childbirth 2015)

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Participant characteristics

Characteristic (n = 1003)

(unless otherwise stated)

n % Primiparous 499 49.8 Married/Living with partner 971 96.8 Education (diploma/degree) 727 72.5 Public hospital care 667 66.5 Smoking prior to pregnancy 127 12.7 Plan to breastfeed ≥ 6 months

(n=954)

817 85.6 English first language 692 69.0 Australian-born (n=1002) 674 67.3

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Reasons for not feeding at the breast (in hospital)

Reason

(* able to give more than one response)

n (n=518) %* Advice from doctor/midwife 216 41.7 Attaching/sucking difficulties 180 34.8 Baby sleepy 82 15.8 Not enough milk 62 12.0 Nipple pain/trauma 33 6.4 Low baby blood sugar levels 24 4.6 Staff concern about infant weight loss 20 3.9 Mother unwell 18 3.5 Breasts too full 10 1.9 Personal preference 1 0.2 Baby premature 1 0.2 Not enough help breastfeeding 1 0.2

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Feeding in the first 24-48 hours

Feeding

(EBM = expressed breast milk)

Primipara (n=499) Multipara (n=504) All (n=1003) n % n % n % Feeding only at breast 177 35.5 308 61.1 485 48.4 Breast + EBM 187 37.5 105 20.8 292 29.1 Breast, EBM + formula 104 20.8 57 11.3 161 16.1 Breast + formula 21 4.2 32 6.4 53 5.3 EBM only 5 1.0 1 0.2 6 0.6 EBM + formula 4 0.8 1 0.2 5 0.5 Fully formula feeding 1 0.2 0 0 1 0.1

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Summary: at 24 - 48 hours of age: 48% fully breastfeeding at the breast since birth

• primipara and those not confident with breastfeeding less likely
• women confident about supply and those intending to breastfeed six

months or more – more likely

• 47% had received some expressed breast milk
• 23% had received some artificial formula
• 16% considered their milk supply inadequate
• 30% reported problems with feeding

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Feeding any breast milk at 6 months

Time since birth Primipara Multipara All n % n % n % Six months 298/456 65.4 316/456 69.3 615/913 67.4

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Relationship between feeding method in hospital and giving any breast milk at 6 months

Feeding in hospital first 24 -48 hours Primipara (n=457) Multipara (n=457) All (n=914) n % n % n (%) % Directly at breast

• nly

123/161 76.4 215/283 76.0 338/444 76.1 Had some EBM 167/276 60.5 88/145 60.7 255/421 60.6 Had at least some EBM and formula 47/95 49.5 34/49 69.4 81/144 56.3 Had some formula 55/114 48.3 47/77 61.0 102/191 53.4

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Feeding from the breast directly in hospital compared with any other type of feeding: …association with any breast milk at 6 months

Any breast milk Direct only Any other feeding AjOR (95% CI)* n % n % Any breast milk 6 mths 338/444 76.1 276/468 59.0 1.8 (1.28, 2.51)

* adjusted for parity, type of birth, breastfeeding intention, perceived breastfeeding problems at recruitment, public private status and education

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Summary: feeding outcomes Feeding other than directly at the breast in hospital associated with decreased breast milk feeding at 6 months Infants receiving any formula in hospital least likely to receive any breast milk at 6 months

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Breast pump ownership at birth (all women)

Primipara (n=457) Multipara (n=457) All (n=914) n % n % n % 224 49.0 334 73.1 558 61.0

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Who suggested pump (primiparous women only)

Suggested pump n (n=239) % * Self 107 44.8 Friends / partner / family 103 43.1 Gift 40 16.8 Midwife / Lactation Consultant 20 8.4 Other 4 1.7

*Women could give more than one answer

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Source of breast pump at recruitment* (primiparous women only)

Source n (n=232) % Bought 103 44.4 Borrowed 77 33.2 Gift 54 23.3 Other 4 1.7 Hired 3 1.3

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Reasons for having a pump at recruitment (primiparous women only)

Reason n (n=239) % * So others can feed baby 83 34.7 “In case” of breastfeeding difficulties 66 27.6 Returning to workforce 30 12.6 To increase milk supply 14 5.9 Baby can’t attach 9 3.8 Full breasts 5 2.1 Sore nipples 2 1.0 Unsure 1 0.4

* Women could give more than one response

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Methods of expressing*

Primiparas n=417 Multiparas n=355 All n=772 n % n % n % Hand 241 57.8 168 47.3 409 56.4 Electric 306 73.4 195 54.7 501 64.9 Manual 219 52.5 191 53.8 410 53.1 Battery 27 6.5 18 5.1 45 5.8

*Women could report more than one method

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Main reason for expressing - asked at 6 months (1)

Reason n (n=704) % To be able to go out and leave the baby 161 22.9 Not enough milk 117 16.6 Attachment problems 60 8.5 Too much milk 60 8.5 To return to work 60 8.5 Nipple pain 43 6.1 Feed to be given by someone else 33 4.7 Father wanted to feed baby 22 3.1

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Main reason for expressing - asked at 6 months (2)

Reason n (n=703) % Wanted to measure milk 15 2.1 To store extra milk 14 2.0 Mastitis 12 1.7 Advised to express 12 1.7 Just to try it out 10 1.4 To use on cereal 10 1.4 Embarrassed about breastfeeding in public 10 1.4 Baby not drinking properly 10 1.4

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Main reason for expressing - asked at 6 months (3)

Reason n (n=703) % Baby sick 8 1.1 Inconvenient 7 1.0 Breast refusal 6 0.9 Maternal medication 4 0.6 To allow mother to drink alcohol 3 0.4 Maternal illness 2 0.3 Preferred method of feeding baby 2 0.3 Other 22 3.0

37 La Trobe University 5 10 15 20 25 30 35 40 45 50 0-2 wks 3-4 wks 5-8 wks 9-12 wks 3-4 mths 4-5 mths 5-6 mths ≥ 7mths

Percentage Expressing 'Several times a day' by time period

Primi Multi All

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Click here to enter Title Click here to enter Text Click here to enter Text Click here to enter Text Click here to enter Text

Adverse reactions to pumps

n (n = 755) % * At least one adverse reaction 105 14.0 Pain 54 7.2 Nipple damage 35 4.6 Bruising 18 2.4 Rash 6 0.1 Other 18 2.4

*Women could give more than one response

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Importance of breastfeeding well documented Increasing prevalence of breast milk expressing Pretty pumps

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Early Breast pumps

Guttus (Hellenistic era)

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Early Breast pumps (continued)

Sucking glass (16th century Italian) Tire-lait (18th Century French)

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Early Breast pumps (continued)

English breast pump (1870-1901)

English breast pump (1870-1901)

Goodyear’s patent breast pump (1844)

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Early Breast pumps (continued)

Breast exhauster (1892) Breast reliever (1947) Ameda Egnell Breast Pump (1956)

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Accessories of breastfeeding

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Accessories of breastfeeding

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And still more accessories?

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Summary 61% of women had a pump ready and waiting before the baby had arrived, alongside the cot and the pram More than half of the women interviewed had expressed their breasts in hospital before they went home, usually in addition to breastfeeding in the traditional manner Of the first time mothers just one third had fed directly at the breast only

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Conclusion

Breast pumps have become almost ubiquitous. Do they symbolise the position of mothers in our society; juggling competing roles and surrounded by ‘convenience’ retail solutions? Is reaching for a breast pump likely to provide a short term solution that might leave our mothers and babies lost along the way?

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Acknowledgments

Thanks to:

• The women who participated
• The midwives and other

hospital staff who facilitated recruitment

• The research midwives and

assistants

• La Trobe University Faculty of

Health Sciences

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Thank you

latrobe.edu.au

CRICOS Provider 00115M

Judith Lumley Centre h.johns@latrobe.edu.au

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Publications

Johns HM, Forster DA, Amir LH, Moorhead AM, McEgan KM, McLachlan HL. Infant feeding practices in the first 24–48 h of life in healthy term infants. Acta Paediatrica 2013;102(7): e315-e20. Johns HM, Forster DA, Amir LH, McLachlan HL. Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic

• review. BMC Pregnancy Childbirth 2013; 13: 212.

Forster DA, Johns HM, McLachlan HL, Moorhead AM, McEgan KM, Amir LH. Is feeding infants directly at the breast during the postpartum hospital stay associated with increased breastfeeding at 6 months postpartum? A prospective cohort study. BMJ Open 2015 (5): e007512. Further papers in preparation.