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 Assessing breastfeeding adequacy by monitoring urine output, stooling and timing of onset of lactation. Monitoring by mothers of their babies’ urine output and stooling, as a method of assessing their own breastfeeding adequacy, has been traditionally suggested, although the evidence base is limited. A study was carried out in an area of California with traditionally high exclusive breastfeeding rates to test this. The authors argued the need for a validated method for mothers to assess their own breastfeeding, given the increasing success of breastfeeding promotion campaigns and numbers of mothers leaving hospital breastfeeding exclusively.
All mothers (n=242) received a standard package of support from a lactation consultant with additional telephone support if needed. Mothers were interviewed and data collected on days 1, 4 (72-96 hours), 6, 8 and 14. Mothers were asked to report the frequency of wet and soiled nappies and to rate their level of breast fullness on a scale of 1- 5 (1 = no change, 5 = uncomfortably full). Onset of lactation (stage II lactogenesis) was defined as level 3, i.e. noticeably fuller. On average infants lost 5.5% of birth weight on day 4; however, 30 lost in excess of 10% and were classified as “breastfeeding inadequacy” (BI). Elimination was shown to increase steadily over the first week of life; however, there was a wide variation and difficulty was encountered in defining a frequency which was both sensitive (i.e. identified all cases of BI) and specific enough (i.e. did not identify cases of non-BI).
The most efficient predictor of breastfeeding inadequacy on day 4 was 3 or fewer soiled nappies. Sensitivity improved when used together with delayed onset of lactation (72 hours or longer), however low specificity is likely to result in false positive results. Urine output was less meaningful as mothers recall was less accurate. The authors conclude that fewer than 4 soiled nappies on day 4 and delay of lactogenesis stage II for 72 hours or longer is suggestive of difficulties in establishing breastfeeding. However, although it is useful for mothers to have a general idea of what newborn elimination patterns are, it is also important that they understand that there is a wide range of normal.
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 Impact of kangaroo care on breastfeeding for preterm babies. A randomised controlled trial was conducted to assess the impact of kangaroo care (KC) on a sample of mothers and preterm infants (n=66) of 32-36 weeks’ gestation who intended to breastfeed. In the KC group, unlimited KC was encouraged, whereas the control group received standard nursery care. The mean average time spent in KC was in 4.47 hours per day. Breastfeeding at hospital discharge and at 1.5, 3, 6, 12, and 18 months was recorded. The results demonstrated that KC dyads, compared with control dyads, breastfed for significantly longer (5.08 months vs 2.05 months). Breastfeeding was also significantly more likely to be exclusive at each data collection point.
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 Impact of frenulotomy on breastfeeding. A group of 24 mother-baby dyads with persistent breastfeeding difficulties despite receiving professional advice were assessed using ultrasound. The researchers were investigating whether frenulotomy was an effective method of treating ankyloglossia (tongue-tie) in babies where breastfeeding difficulties such as ineffective attachment, suboptimal weight gain and maternal nipple pain were experienced. The aim of the study was to measure changes in milk transfer and tongue movement during breastfeeding before and after frenulotomy. Assessment of breastfeeding, including ultrasound scans of the oral cavity, were performed before frenulotomy and again at around 7 days post-procedure. On ultrasound scan, two groups of infants were identified – one in which the infant’s tongue action compressed the tip of the nipple and the other in which the base of the nipple was compressed. In addition, milk transfer was assessed and milk intake measured using the test-weighing method. Maternal pain was recorded and an assessment made of the attachment (LATCH score - latch, audible swallowing, type of nipple, comfort, and hold). The researchers found that in all cases the above measures improved significantly. They recommend that an assessment for ankyloglossia should be made in all cases of breastfeeding difficulties. Geddes DT, Langton DB, Gollow I et al (2008) Frenulotomy for Breastfeeding Infants With Ankyloglossia: Effect on Milk Removal and Sucking Mechanism as Imaged by Ultrasound Pediatrics;122 :e188-e194 (doi:10.1542/peds.2007-2553)
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 Does breastfeeding impact on maternal blood pressure? It is suggested that breastfeeding has positive health benefits for mothers as well as for their infants and one area of interest is whether breastfeeding can reduce maternal blood pressure. A study in Sweden aimed to investigate this by measuring maternal blood pressure before, during and after a breastfeed, initially at 2 days postpartum and then during the following 25-week breastfeeding period. Sixty-six primiparae who had had a normal birth had their blood pressure measured 5 minutes before breastfeeding and 10, 30, and 60 minutes after a morning breastfeed. Thirty-three women continued to measure their blood pressure before and after breastfeeding for 25 weeks. The researchers found that blood pressure fell significantly in response to breastfeeding 2 days after birth. The fall in systolic and diastolic blood pressure amounted to an average of 8.8 mm Hg and 7.7 mm Hg respectively. During the 25-week follow-up period a significant fall in blood pressure was also observed with the overall fall in systolic and diastolic blood pressure amounting to a mean of 15 mm Hg and 10 mm Hg, respectively. Although the numbers were relatively small, the authors were able to conclude that, in a homelike environment, breastfeeding has a significant positive impact on both systolic and diastolic blood pressures of mothers.  18563998Jonas W, Nissen E, Ransjo-Arvidson AB, et al (2008) Short- and long-term decrease of blood pressure in women during breastfeeding. Breastfeed Med; 3: 103-9.
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 21 October 2008 Research update
Two papers from the USA highlight importance of Baby Friendly practices-As part of a wider study (1), researchers reviewed the impact of a number of factors including six “Baby-Friendly” practices (breastfeeding initiation within one hour of birth, giving only breastmilk, rooming-in, breastfeeding on demand, no pacifiers, fostering breastfeeding support groups) on a sample of 1907 mothers who planned to breastfeed for more than two months. The main outcome measure was breastfeeding cessation before six weeks. Only 8% of the mothers experienced all of the above practices. The practices most consistently associated with sustained breastfeeding beyond six weeks were initiation of breastfeeding within one hour of birth, giving only breastmilk, and not using pacifiers. Mothers who experienced none of the above practices were 13 times more likely to cease breastfeeding than those who experienced them all.
A second paper (2), using findings from the same study, analysed data collected by questionnaire from 1323 mothers at around 2, 3, 4, 5, 6, 7, 9, 10.5 and 12 months following the birth. At each time point mothers were asked to rate the importance of a potential total of 32 reasons for their decision to stop breastfeeding. The researchers found that one of the most common reasons (consistently in the top three) for breastfeeding cessation, regardless of the age of the baby, was the perception that their infant was not satisfied by breastmilk alone. This was particularly notable amongst mothers from low income groups. They suggest that this knowledge should be helpful to health-care professionals in helping mothers to overcome barriers to breastfeeding.
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 Systematic review of interventions to support breastfeeding in neonatal units-A review was carried out to identify interventions which support breastfeeding or breastmilk feeding for infants in neonatal units. 86 studies were identified of which 27 fulfilled the inclusion criteria and were culturally applicable in the UK. The authors found that variations in the type of study and outcomes measured resulted in a lack of clarity about what would be likely to work best. However they were able to conclude that skin-to-skin contact and additional postnatal support seemed to be most effective in supporting breastfeeding outcomes. It was noted that use of galactogogues in mothers who are unable to produce sufficient milk for their baby may help to increase milk supply. The researchers were unable to identify a significant effect from other practices, such as cup-feeding, on breastfeeding mainly because of a lack of research but also because few studies followed up the population beyond discharge from the unit. They conclude that further research is needed to explore the barriers to breastfeeding in this group of babies, and to identify which interventions are most likely to lead to an improvement in breastfeeding outcomes. 18811790McInnes RJ, Chambers J (2008) Infants admitted to neonatal units--interventions to improve breastfeeding outcomes: a systematic review 1990-2007. Matern Child Nutr; 4: 235.


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