Thursday, February 9, 2017

Pumping experiences survey - Post 1 of the Series



 
First off, a giant THANK YOU to all the mothers who participated in the online survey. Your assistance was amazing! Three blog posts will be dedicated to the survey – expect them on 2/10, 2/28, 3/15.  I also have to apologize for the day in getting this out – I have actually been overseas managing our other giant milk project.

We started the pumping experiences survey to see how mothers would respond to differences in pump output, based on their normal pumping experiences. We had predicted that mothers who had dramatic changes in output in the experiment – either randomized to much more or much less than they typically produced – would have strong reactions to the images and the responses would tell us a lot about how women perceive their milk supply.

The survey randomly assigned each mother to one of three images showing expressed breast milk– one photo showed 1 ounce of pumped milk, the second photo showed 6 ounces of milk, and the final photo showed 12+ ounces of milk. The volumes were classified as “low”, “intermediate”, and “high” volume.

The photos created an experimental condition where women might be mismatched to their normal pumping output – either more or less – or pump the same amount. For the purposes of this post, we’re just going to focus on the two groups – pumped less and pumped more.

An equal number of mothers were exposed to each photo and were then asked to rate if they pumped the same, more, or less than the mother typically pumped. Of the 899 mothers who completed the experimental condition, 412 reported the volume in the photo was more than they usually produced, 269 reported a reduction in volume, and 218 reported no change.

We will not talk about the group that were randomized to the photo that best matched their output (and overwhelmingly, this was the intermediate volume) in this post.

The most common response in the increased volume group: “Great!”, followed closely by “Awesome”, accounting for 30% of all responses in this group. But their increased outputs weren’t just great and awesome – mothers were ecstatic, thrilled, and amazed. Mothers also responded that they felt successful and accomplished. Happy tears and happy dances were also reported, as well as feeling like winning the lottery. Several mothers reported that they would feel like supermothers or milk goddesses.

Disappointment was the most common response in the decreased volume group, followed by stress. Several women reported frustration, and 2% of mothers believed that if such output continued, pumping would be a waste of time and viewed continued pumping as counterproductive to their own happiness. Several mothers voiced concerns about further decreases in supply or losing their supply. However, about 10% of mothers took a more pragmatic approach, stating that they must have been dehydrated while a similar number of mothers suggested that there may have been a problem with the pump suction or that they may have pumped too soon. A small group of women reported feeling devastated, with multiple women stating that (I) would feel like I had let my baby down.

For a group of mothers, perceptions of milk supply based on pumping output were linked with their identities as mothers.  Tomori (2014) and others have written on this perception, especially in the context of the United States, of breastfeeding and milk volume being socially identified as aspects of maternal identity. Knaak (2006) suggests that such associations may arise from perceptions of risk, as breastfeeding being viewed as a "scientifically valid" strategy for minimizing risk . Marshall et al., (2007) however, argue that perceptions of good mothering associated with breastfeeding and milk supply are much more dynamic and fluid, changing for individual women over the course of their motherhood. Women's' perceptions of good mothering, as partially defined by exclusive, extended breastfeeding, while frequently present in early lactation shifted as the infant aged, and good mothering became increasingly defined by whatever maternal actions resulted in a "healthy, happy baby" - with happy baby defined by the mother (Marshall et al., 2011).

Responses to the change in output were also consistent between groups. Mothers in the decreased group overwhelmingly planned to drink more water, and a significant portion also planned to nurse more. A few mothers were committed to oatmeal, brewer’s yeast, and herbal galactagogues. Mothers in the increased production group planned to review the day and figure out what I did so I can do it again, to paraphrase several mothers.  

Next post in this series: Breastfeeding and pumping practices in mothers

References

Knaak SJ. 2006. The problem with breastfeeding discourse. Can J Public Health 97(5):412-4.

Marshall JL, Godfrey M, Renfrew MJ. 2007. Being a 'good mother': managing breastfeeding and merging identities. Soc Sci Med. 65(10):2147-59.

Marshall JL. 2011. Motherhood, breastfeeding, and identity. The Practicing Midwife 14(2):16-8. 

Tomori, C. 2014. Nighttime Breastfeeding: An American Cultural Dilemma (Fertility, Reproduction and Sexuality). Berghahn Books.

Monday, October 31, 2016

Human milk – as a topical treatment?



Not too long ago, a participant in one of my research studies asked me if I had heard of using breast milk as a treatment for ear or eye infections and skin rashes. A friend had recommended treating a recent episode of conjunctivitis on the baby with human milk. About a year earlier, another participate had informed me that she was putting milk in her baby’s ear to treat an infection.  So here’s the question . . .does it actually work?

Figure 1: Much like Gus Portokalos found that Windex cured everything, is it possible that human milk can treat topical infections?



Ear Infections
First off, there is good evidence that the act of breastfeeding reduces the risk of ear infections in infants. It is unclear if this benefit is related to the milk itself or to the actual act of suckling at the breast, as no studies have been conducted on infants receiving only pumped milk. Abraham and Labbock do hypothesize that the mechanical act of suckling, with its distinct pattern of suck, swallow, breathe and the may increase aeration of the eustachian tube, while the differences in pressure associated with bottle feeding may instead increase the risk of eustachian tube dysfunction from the negative pressure transmitted from the bottle (Brown and Magnuson 2000). Importantly, these pressure differences are only found in unventilated or partially ventilated bottles – fully ventilated bottles showed no such pressure changes. Human milk also contains numerous antibodies and immune factors that will serve to protect the infant from infection.
However, the use of breast milk as a topical treatment for ear infections has not been similarly studies. No one has ever published the results of a randomized control trial – or even an observational study – on the topical application of human milk as a treatment for ear infections. And there is a pretty good reason why:

Most ear infections clear up on their own without the need for further treatment.

In fact, the American Academy of Pediatrics recommends against using routine antibiotics in the case of milk to moderate ear infections, instead reserving them for severe or chronic infections. Further, the majority of ear infections are middle ear infections, on the inside of the ear drum. In this instance, the ear drum will block the milk from entering the ear and maintain a barrier between the milk and the infection.  The majority of personal accounts reporting breast milk as curing the ear infection? The mostly likely explanation is that the ear infections resolved from a combination of immunological support from the mother’s milk during normal breastfeeding practices and the infant’s immune system, not from the external application of the milk.  

Skin conditions: rashes, eczema
Okay, so what about breast milk as a treatment for other, topical conditions, such as skin rashes, eczema, or diaper rash? In these instances, the milk will be in direct contact with the infection, possibly allowing the immunological agents in the milk to work directly on the infection. And certainly, we know from studies exposing different pathogens to human milk that exposure is associated with increased pathogen death.
A recent study by Farahani, Ghobadzadeh, and Yousefi actually conducted a randomized clinical trial or hydrocortisone 1% ointment compared to freshly expressed human milk in study of 141 breastfeeding infants. All infants in the study were breastfeeding, and they were randomly assigned to one of the two treatment groups: freshly expressed human milk or topical application of the 1% hydrocortisone ointment. Treatment lasted for 7 days, with clinical assessment of the diaper rash at baseline, 3 and 7 days. There were no differences between the two groups with regards to severity scoring of the rash at recruitment and no difference in severity between the two groups at day 7. Most importantly, both groups had shown significant declines in severity from the baseline assessment.  So, for mild diaper rash, human milk applied a minimum of three times a day has been shown to reduce severity of diaper rash. 

Eye infections
The history of using human milk as a treatment for eye infections is a very old one, going back to some of the earliest known medical texts. However, not much is known about the effectiveness. A recent study by Baynham and colleagues (2013) looked at the effectiveness of fresh human milk against several species of bacteria that commonly cause eye infections in infants. The researchers tested milk against Escherichia coli, Haemophilus influenzae, Neisseria gonorrhoeae, Pseudomonas aeruginosa, Streptococcus pneumonia, Staphylococcus aureus, Moraxella catarrhalis, coagulase-negative Staphylococcus and viridans group Streptococcus. Of these bacteria, three were inhibited following exposure to human milk: three were significantly inhibited by human milk relative to the negative control: N. gonorrhoeae, M. catarrhalis and viridans group Streptococcus. Human milk was as effective as polymyxin B sulfate/trimethoprim ophthalmic solutions against N. gonorrhoeae; less so but still effective against M. catarrhalis and Streptococcus.  In the typical American infant, the common causes of conjunctivitis are H influenzae, Streptococcus pneumonia and M catarrhalis. However, this pattern is unique to developed countries – in developing countries the most common pathogen causing eye infections is N. gonorrhoeae.
So how does human milk stack up as a topical treatment? Pretty well based on the limited clinical evidence and there is certainly no data to suggest that using milk as a first line intervention will have any negative consequences. 

References

Abrahams, Sheryl W., and Miriam H. Labbok. “Breastfeeding and Otitis Media: A Review of Recent Evidence.” Current Allergy and Asthma Reports 11, no. 6 (August 11, 2011): 508. doi:10.1007/s11882-011-0218-3.

Baynham, Justin T. L., M. Allison Moorman, Catherine Donnellan, Vicky Cevallos, and Jeremy D. Keenan. “Antibacterial Effect of Human Milk for Common Causes of Paediatric Conjunctivitis.” The British Journal of Ophthalmology 97, no. 3 (March 2013): 377–79. doi:10.1136/bjophthalmol-2012-302833.

Brown, C. E., and B. Magnuson. “On the Physics of the Infant Feeding Bottle and Middle Ear Sequela: Ear Disease in Infants Can Be Associated with Bottle Feeding.” International Journal of Pediatric Otorhinolaryngology 54, no. 1 (August 11, 2000): 13–20.

Farahani, Leila Amiri, Maryam Ghobadzadeh, and Parsa Yousefi. “Comparison of the Effect of Human Milk and Topical Hydrocortisone 1% on Diaper Dermatitis.” Pediatric Dermatology 30, no. 6 (December 2013): 725–29. doi:10.1111/pde.12118.