2022 PLATFORM PRESENTATIONS 

Platform presentations are abstract submissions chosen by the abstract review committee to orally present their research.  

The Effects of Oral Feeding on the Preterm Infants’ Microbiome and Metabolome 
Keriann Schulkers Escalante, DO, MPH, Shiyu Bai-Tong, MD, Megan Thoemmes, PhD, Kelly Weldon, BS, Diba Mortazavi, BS, Jessica Kitsen, BS, Se Jin Song, PhD, Jack Gilbert, PhD, Sandra Leibel, Sydney Leibel, MD, MPH 
Category: Research 
Background: Breast milk provides numerous benefits to preterm infants including decreasing the risk of necrotizing enterocolitis and sepsis. While direct breastfeeding is ideal for establishing a healthy microbiota, the majority of preterm infants initially receive maternal breast milk through an orogastric/nasogastric (OG/NG) tube. Previous studies have shown that enteral feeding tubes can be colonized with high-risk bacteria, thus increasing their risk for adverse events. How the method of enteral feeding affects the preterm infants’ oral and gut microbiome and the relationship to the breast milk microbiome and human milk oligosaccharide (HMO) diversity is unknown. We aim to elucidate the relationship of the maternal milk microbiome and the preterm oral and gut microbiome and metabolome after the initiation of oral feeds by analyzing stool, saliva and milk samples collected from a cohort of preterm infants from the study: “The Association Between Milk Feedings, the Microbiome and Risk of Atopic Disease in the Preterm Population (MAP) Study” (NCT04835935). This study recruited 46 babies <34 weeks gestational age. Clinical data was collected as well as weekly samples of their milk feeds, saliva and stool until discharge. 
Materials/Methods: Metabolites will be analyzed by untargeted gas chromatography-mass spectrometry. Bacterial compositions will be analyzed by shotgun metogenomic. Differences in bacterial community composition will be compared using a permutational multivariate analysis of variance. HMO analysis will be performed by high performance liquid chromatography. 
Results: Analysis of a cohort of 54 infant stool samples showed a strong differentiation in bacterial community composition after the initiation of bottle (p = 0.014) & breast feeding (p = 0.014). This indicated changes to the stool microbiome at the onset of oral feeding following tube feeds. Further analysis of infant stool, saliva and maternal milk is pending. 
Conclusions: While stool analysis revealed changes in community composition after the initiation of oral feeds, we aim to analyze additional samples for distinct microbiome, metabolome & HMO signatures. We hypothesize that the diversity of breast milk microbiome and HMOs change after oral feeds are initiated, which alters the infant’s microbiome and metabolome. 


The role of breastfeeding in racial and ethnic disparities in Sudden Unexpected Infant Death: A population-based study of 13 million infants from the United States 
Melissa Bartick, MD, MS, Alexis Woods Barr, PhD, CPH, MS, Lori Feldman-Winter, MD, MPH, Monica Guxens, MD, MPH, PhD, Henning Tiemeier, MD,PhD 
Category: Research  
Background: Sudden Unexpected Infant Death (SUID) disproportionately affects non-Hispanic Black (NHB) and American Indian/Alaskan Native (AI/AN) infants, who have lower rates of breastfeeding than other groups. No existing literature investigates if breastfeeding explains disparities in SUID rates. 
Materials/Methods: Using 13,077,880 live birth certificates and 11,942 linked SUID death certificates from 2015-2018, we calculated odds ratios and adjusted risk differences of SUID by not-breastfeeding across 5 racial/ethnic strata in the United States, adjusting for 12 covariates. We analyzed mediation by not-breastfeeding in the race/ethnicity-SUID association, adjusting for 12 covariates. 
Results: The overall SUID rate was 0.91/1,000 live births. NHB and AI/AN infants had the highest disparity in SUID relative to non-Hispanic White (NHW) infants. Overall not-breastfeeding was associated with SUID, adjusted Odds Ratio (aOR) 1.14 (95% Confidence Interval [CI]: 1.10, 1.19), the adjusted risk difference (AdjRD) was 0.12/1,000 live births. The aOR of not-breastfeeding for SUID was 1.07 (95% CI: 1.00, 1.14) in NHB infants, and 1.29 (95% CI: 1.14, 1.46) in Hispanic infants. Breastfeeding minimally explained the higher SUID risk in NHB infants (2.3% mediated) and the lower SUID risk in Hispanic infants (2.1% mediated) relative to NHW infants. When adjusted for background risks, AI/AN mothers were more likely to initiate breastfeeding than similar NHW mothers, resulting in a negative mediation effect (-0.9% mediated) relative to NHW infants. Asian mothers were less likely to initiate breastfeeding than similar NHW mothers.  
Conclusions: Competing risks likely explain the lower aOR seen in NHB infants of not-breastfeeding on SUID, suggesting that social/structural determinants must be addressed to reduce racial disparities in SUID. Reducing the rates of SUID of NHB and AI/AN infants will likely depend on confronting larger social and structural determinants of health through political solutions. 

 
Passing on Protection: Frequency of Breastfeeding and Protection Against COVID-19 in Young Children of Vaccinated Mothers 
April Castillo, MD  
Category: Research 
Background: Many lactating parents extended breastfeeding relationships longer than initially planned during the COVID-19 pandemic to provide their children some immunity. It is unknown how much protection is conferred, and whether there is a dose-response relationship or minimum threshold for protection. Additional booster recommendations raised further questions. This study aims to elucidate a minimum number of feeds needed for some observable passive immunity, and whether maternal boosters provide increased protection to breastfed children. 
Materials/Methods: This is a non-blinded observational prospective cohort study of women physicians and their breastfed children assessing maternal COVID-19 mRNA vaccination effects. One-year self-reported outcome surveys were used for this analysis. Pearson chi square, Cochran-Mantel-Haenszel tests were used; logistic regression was used to model factors affecting likelihood of COVID-19 symptoms and diagnosis to estimate odds ratios, with adjusted odds ratios after controlling for high-risk exposures of children. Study sample n=534 
Results: Weaning (<2 breastfeeds/day) is associated with increased risk of COVID diagnosis (AOR 2.168, p=.024), while maternal booster is protective (AOR 0.204, p=.002). Continued breastfeeding (≥2 times/ day) is associated with a decreased risk of needing medical if symptoms develop (AOR 0.348, p=0.001) No frequency of breastfeeding reached significance for protection against development of any COVID-like symptoms over the one-year study period, however maternal booster decreased risk of developing symptoms (AOR 0.290, p=0.002). 
Conclusions: Continued breastfeeding by mothers receiving COVID-19 with mRNA vaccines reduces breastfed children’s risks of both  COVID-19 diagnosis and needing medical attention when compared to children who have weaned to <2 breastfeeds per day, controlling for children’s age and high-risk exposures. Lactating parents receiving a booster dose is associated with children’s decreased risk of COVID symptoms and diagnosis. Lactating parents vaccinated against COVID-19 may optimize protection for their young children by continuing breastfeeding relationships with at least two feeds per day and getting the booster dose when recommended. 


The Influence of Family Support on Exclusive Breastfeeding Practice of Mothers attending the National Hospital, Abuja, Nigeria 
Opeyemi Oshodi, FWACP 
Category: Research
Background: Exclusive breastfeeding practice has remained suboptimal despite global efforts to promote it. Unfortunately, most breastfeeding interventions target mothers, with no corresponding understanding of the role of the family. A focus on family support is imperative, as evidence suggests that the family is probably more influential than health professionals in breastfeeding-related matters. 
Materials/Methods: A cross-sectional study using a systematic sampling technique was conducted among 393 mothers of infants under six months in a tertiary Hospital in Abuja, Nigeria. Data for variables on exclusive breastfeeding practice and family support were collected using validated tools. Factors associated with exclusive breastfeeding practice were analysed using logistic regression. A p-value of 0.05 was considered as statistically significant. 
Results: High emotional support for exclusive breastfeeding from husbands (OR: 2.97; 95% CI: 1.28-5.02) and high informational support for exclusive breastfeeding from husbands (OR: 3.72; CI: 1.91-7.25) were significantly associated with the practice of exclusive breastfeeding among the mothers. Practical support from husbands as well as all dimensions of support from other family members were not associated with exclusive breastfeeding practice.  
Conclusions: Emotional and informational support specific for exclusive breastfeeding from husbands, is crucial in enabling mothers practice exclusive breastfeeding. As such, breastfeeding interventions should also be targeted towards these family members for maximum effectiveness. 


Peer-to-Peer Milk Sharing Network among OBGYN Co-workers in an Academic Institution  
Abigail Liberty, MD, MSPH, Kimberley Bullard, MD, MPH, Katherine Au, MD, IBCLC  
Category: Research 
Background: Less than one third of physicians reach their personal breastfeeding goals and approximately one third are breastfeeding at 12 months. The World Health Organization recommends the use of human donor milk before the use of artificial supplementation to achieve optimal infant nutrition. The use of formal and informal milk sharing among physician parents has not been previously described. 
Materials/Methods: A retrospective database of individuals known to have shared milk within a single OB/Gyn department was created. A network map was generated spanning 7 years of sharing events. The network was plotted chronologically by the birth month and year of the donor or recipient. Informal milk sharing outside of the OB/Gyn Department was excluded. Formal sharing with through an accredited HMBANA Milk Bank was included. 
Results: Informal milk sharing occurred between 18 dyads which included 7 donors and 12 recipients over a span of 7 years. Two individuals acted as both recipients and donors. Three recipients received milk from more than one donor. Two donors participated in both informal and formal milk donation. Milk sharing crossed traditional hierarchical boundaries with trainees sharing milk with supervisors and vice versa. Milk sharing was also noted between physician and nurse colleagues.  
Conclusions: This is the first ever description of a peer-to-peer informal milk sharing network among physician co-workers, a group at high risk of not meeting their personal breastfeeding goals. This network highlights several key areas for future research including survey of recipient and donor experiences, the role of milk sharing in achieving personal breastfeeding goals, the role of workplace support on milk sharing, and the impact of personal experience with milk sharing on patient counseling. 


History of Breastfeeding and Stroke Prevalence among Parous Females: Findings from the National Health and Nutrition Examination Survey (NHANES), 1999-2012  
Gina Richardson, BA, Emily Mitchell, MD, MPH Student, Kalera Stratton, MS, MPH, Laura Kair, MD, MAS, FABM, Lynn Marshall, Sc.D. 
Category: Research  
Background: Stroke is the third leading cause of death for women in the United States, resulting in twice as many deaths as breast cancer. There is a known relationship between hypertension and stroke, as well as breastfeeding a child and hypertension.  However, there has been little research connecting these associations to evaluate whether breastfeeding a child may be associated with stroke risk later in life. 
Materials/Methods: Multivariable logistic regression models were used to estimate crude and adjusted prevalence odds ratios for the association between breastfeeding and stroke.  
Results: There is an inverse association between ever breastfeeding a child and prevalence of stroke that was significant in 20–64-year-olds (OR = 0.69, 95% CI: 0.47, 1.00).  
Conclusions: Ever breastfeeding a child was associated with lower prevalence of stroke in a nationally representative US sample of parous females 20 years and older. The inverse association was significant among those ages 20-64 years but not among those 65 years and older. 

 
Racial Inequities in Breastfeeding Counseling among Pregnant People who use Cannabis 
Laura Kair, MD, MAS, FABM, Adrienne Hoyt-Austin, DO, MAS, IBCLC, Melissa Chen, MD, MPH, Brandie Bentley, MSW, Karen Tabb, PhD, MSW, Mishka Terplan, MD, MPH, Jennifer McAllister, MD, IBCLC, Scott Wexelblatt, MD, Aaron Murnan, PhD, Chidiogo Anyigbo, MD, MPH, Christine Wilder, MD, Nichole Nidey, PhD 
Category: Research  
Background: Cannabis use has increased in the US among pregnant and postpartum people. Disparities in breastfeeding rates persist across racial/ethnic groups in the US with Black dyads experiencing the lowest breastfeeding initiation and continuation rates. Although professional societies advise against using cannabis while breastfeeding, the extent to which breastfeeding guidance given by healthcare providers to pregnant patients who use cannabis varies by maternal race/ethnicity is unknown. 
Materials/Methods: We analyzed data from the population-representative 2017-18 CDC Pregnancy Risk Assessment Monitoring System (PRAMS) survey from 9 US states (AK,IL,ME,ND,NJ,NM,NY,PA,WV) with data on prenatal breastfeeding advice and cannabis use using weighted logistic regression models, unadjusted and adjusted for insurance type, year of delivery, prenatal smoking, education, age, and state. 
Results: 9.5% of respondents reported cannabis use during pregnancy or the 3 months prior. Of these respondents (weighted N=51,793), 36.2% reported receiving advice from a prenatal care provider not to breastfeed if using cannabis. Receipt of this advice was associated with decreased odds of initiating breastfeeding (OR 0.6, 95%CI 0.3,0.99). Non-Hispanic Black people were disproportionately advised not to breastfeed if using cannabis and had 4 times the odds of receiving this advice when compared with non-Hispanic white birthing people (aOR 4.1, 95%CI 2.1,8.2). 
Conclusions: In this study of birthing people who used cannabis prior to and/or during pregnancy, over one third of respondents reported being advised to avoid breastfeeding if using cannabis. Advice not to breastfeed was associated with lower odds of initiating breastfeeding, and non-Hispanic Black birthing people were 4 times as likely as non-Hispanic white birthing people to be advised not to breastfeed if using cannabis. As cannabis use continues to increase, practice guidelines and provider education are critical. To achieve equitable maternal-child health outcomes, interventions aimed at increasing breastfeeding initiation need to prioritize addressing structural and interpersonal racism in the context of maternal-child health care. 

 
BABE: Breastfeeding and Antenatal Breastmilk Expression Randomized Control Trial  
Merai Estafanous, BA, Nicole Chong, B.S, MS 2 Class of 2024, Alexander Thomas, MD, Gabrielle Cook, Elaine Hart, MD  
Category: Research  
Background: The purpose of this investigator-initiated randomized control trial was to improve the exclusive breastfeeding rate at 6 months, improve the exclusive breastfeeding rate while hospitalized during the postpartum period per California State guidelines, and to bolster mothers’ self-confidence in breastfeeding ability. Subjects were randomized to either initiate antenatal breast milk expression at 37 weeks gestation combined with routine breastfeeding education, or routine education plus standard interventions. Specifically, the intervention group was instructed to pump 3x daily for 20 minutes starting at 37 weeks gestation. No other procedures were implemented. No investigational drugs or devices were used. No radiation was included in the protocol. There were no placebo or sham interventions. Subjects were pregnant female adults between 28 - 39 weeks gestational age. Subjects were nulliparous and multiparous pregnant women who have not successfully breastfed their prior infants greater than 6 months and were intending to breastfeed their babies. In total, subject participation lasted approximately 7 months. Subjects were recruited from the SACH clinic system and FMO within the LLUMC OBGYN Medical Group Practice. Patients were invited to participate in the study during a prenatal visit at or after 28-39 weeks gestation. Consent took place at the time of study enrollment during a patient’s prenatal visit and was done by an IRB approved researcher. Patients were checked in on by a researcher 1-2 times before and once after they delivered. Breastfeeding, or lack thereof, at 6 months was documented in both groups. 165 and 140 women were recruited into the experimental and control groups, respectively; of those women, 62 in the experimental group and 112 in the control group had viable data. In the experimental group, the amount of colostrum pumped ranged from 0.0 to 184.5 mL, with an average of 52.3 mL. No significant differences were observed between the intervention and control group regarding cervical exam on admission, gestational age at delivery, APGAR scores, neonatal weight change at discharge, or newborn intensive care unit (NICU) admissions.<br>While it is known that breastfeeding provides numerous benefits to both mothers and infants, exclusive breastfeeding rates in the United States are surprisingly low with only 49.4% of infants breastfed at six months in 2011 (HealthyPeople.gov, 2017). Successful breastfeeding requires investment from care providers and the community; however, education on its own has not been shown to be an effective intervention (Balogun, 2016; Fair, 2019; Jung, 2019). Interventions to meet the goal of exclusive breastfeeding during a hospital admission, such as donor breast milk, are expensive and difficult to access. This gap in patient care creates an opportunity for the implementation of antenatal breast milk expression (ABE). Antenatal breast milk expression was once recommended for preparation of areolar tissue prior to breastfeeding in the mid-20th century, but fell out of favor with increasing formula use (Chapman, 2013). Some studies have found that ABE may be beneficial in increasing breastfeeding success. Perhaps the biggest reported benefit of ABE in the literature is increased confidence and self-efficacy regarding breastfeeding success (Demirici, 2019; Fair, 2018). Bolstering a patient’s self-efficacy has been shown to be an important factor in successful breastfeeding interventions as it provides familiarity with one’s breasts and reassurance of milk production (Brockway, 2017; Brisbane, 2015). A small amount of research outside the US has outlined the mechanisms by which ABE could increase breastfeeding success, primarily earlier onset of stage II lactogenesis and the use of stored colostrum during the postpartum hospital admission. For example, a significantly larger proportion of mothers who underwent either vaginal or cesarean deliveries were noted to have sooner onset of lactation if they had expressed milk starting at 37 weeks gestation (Lamba, 2016; Singh, 2009). Early establishment of breastfeeding encourages continuation in the postpartum period. Antenatal breast milk expression is a promising intervention that obstetric providers could utilize to increase breastfeeding rates (Win, 2006). 
Materials/Methods: The ABE group was instructed to pump 3x daily for 20 minutes starting at 37 weeks gestation. Breastfeeding at 6 months was examined in both groups. 
Results: 32% of women in the Antenatal Breast Expression (ABE) group used formula supplementation, compared to 41% of women in the control group (p=0.2).  
Conclusions: Although not statistically significant, the study found that ABE decreased formula supplementation in the hospital suggesting that it may be an effective measure to help patients meet their goals and CMQCC benchmarks for exclusive breastfeeding.