H3022- Section on Breastfeeding Program

Challenges in Breastfeeding

Topic: Breast Feeding

Sponsors: Section on Breastfeeding (SOBr)

Monday, October 24
8:00AM - 12:00PM
Moscone West, 2005/2007

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This program is designed for all conference attendees and will address current controversies, challenges, and evidence in breastfeeding. The program will provide an opportunity for networking among section members and guests. Attendees will be updated on the latest research and key literature published in the past year. Time will be allowed for review of posters, presentation of original research and breastfeeding advocacy projects, and audience discussion.

8:00AM Welcome
Moderator: Natasha Sriraman, MD, MPH, FAAP
8:05AM Milk and Marijuana: Do No Harm
Lisa Stellwagen, MD, FAAP
8:30AM Food Intolerance Syndromes During the First Year
David Brumbaugh, MD, MSCI, FAAP
9:15AM Hand Expression
Jane Morton, MD, FAAP
10:00AM Poster Presentation
10:30AM Oral Podium Presentation
11:30AM Section Abstract Award Presentation
11:35AM Question & Answer Session
12:00PM Adjourn

Abstracts

10:00AM - 10:30AM
10:00AM - 10:30AM

David Brumbaugh, MD, MSCI, FAAP

Assistant Professor of Pediatrics, Division of Pediatric Gastroenterology, Hepatology, and Nutrition
University of Colorado School of Medicine
Aurora, Colorado

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Jane Morton, MD, FAAP

Adj. Cl. Professor of Pediatrics, Emerita
Stanford University
Portola Valley, California

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Lisa Stellwagen, MD

Medical Director, Newborn Service
UC San Diego Pediatrics
San Diego, CA

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Handout

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Faculty

Jane Morton, MD, FAAP

Adj. Cl. Professor of Pediatrics, Emerita
Stanford University
Portola Valley, California

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1- Maternal Vitamin D Supplementation Among Lactating Mothers in the Prevention of Vitamin D Deficiency Among Breastfed Term Infants: A Meta Analysis

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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BACKGROUND: Exclusively breastfed infants, pregnant and lactating mothers have been identified as a population in need of special requirements of vitamin D. While breast milk is a nutritionally complete food, studies reporting that it is low in vitamin D may place exclusively breastfed infants at risk for vitamin D deficiency.

OBJECTIVE: To determine the optimal dose of maternal vitamin D supplementation to lactating mothers to achieve maternal vitamin D adequacy and to prevent vitamin D deficiency in exclusively breastfed term infants.

METHODOLOGY: An electronic search of literature to identify all prospective randomized controlled trials that evaluated the vitamin D level of exclusively breastfed infants supplemented through their mothers via milk transfer published in PubMed, Cochrane Collaboration, Science Direct and Google Scholar from 1999 to 2014 was done.

DATA ANALYSIS: Review Manager version 5.3 was utilized to determine the risk ratio for dichotomous data, and weighted mean differences for continuous data. Heterogeneity and overall effect were analyzed. The corresponding 95% CI for both outcomes were determined.

RESULTS: Three studies were included where a total of 170 participants were enrolled, but only 83 were included in the results. They were supplemented with vitamin D as follows: 12 participants with 2,000 IU/day vs 13 participants with 4,000 IU/day for 3 months (Basile et al 2006); 9 participants with 2,000 IU/day vs 9 participants with 4,000 IU/day for 3 months (Hollis and Wagner 2004); and 20 participants with 150,000IU once vs 20 participants with 5000 IU/day for 28 days (Oberhelman et al 2013). The three studies’ results favored supplementation with 2,000IU of vitamin D daily and 150,000IU of vitamin D single dose supplementation for better improvement of the vitamin levels in the maternal blood. The overall effect of the 2,000IU and 150,000IU supplementation is statistically significant at 0.0003. The meta-analysis performed on the infant levels of vitamin D after maternal supplementation showed that the two dosages do not have any significant differences (computed overall effect=0.071). The p-value for heterogeneity was above 0.045 indicating the studies were statistically similar.

CONCLUSION: A maternal vitamin D supplementation of 2,000 IU daily and a single dose of 150,000 IU can improve maternal vitamin D levels. These doses had an effect on infant vitamin D level, however, this failed to demonstrate a significant difference to favor one dose over another. Supplementing infants with vitamin D via milk transfer shows potential but further studies in the form of randomized controlled trials are required to determine the optimal doses of vitamin D supplementation during lactation for maintaining vitamin D adequacy in breastfed infants.

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2- The Effect of Exclusive/non-exclusive Breastfeeding on Asthma Risk in Children Aged 3-5 Years: A Study Based on the National Survey of Children’s Health 2011-2012

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Purpose: The prevalence of childhood asthma in the U.S. has increased drastically. The potential protective effect that breastfeeding can have against asthma in the context of adverse childhood experiences (ACEs) is of great interest. Previous research that has examined the association between breastfeeding and asthma has not considered the mediating role that psychosocial stressors such as ACEs may have in asthma onset, exacerbations, and inadequate control.The purpose of this study was to determine whether duration and exclusive breastfeeding was associated with a lower asthma risk in children ages 3 to 5 years, and investigate whether ACEs early in life influence the relationship between breastfeeding and asthma.

Methods: A secondary analysis of the National Survey of Children’s Health (2012), a nationally representative survey of U.S. children ages 0-17 years was conducted providing a nationally representative sample of children ages 3 to 5. Latent Class Analysis (LCA) was used to group children into three distinct latent classes distinguished by type and severity of exposure to ACEs: low (class1), intermediate (class2) and severe (class3) adversity. Modified Poisson regression was used to examine the association between breastfeeding (never breastfed, exclusive breastfeeding for up to 6 months, non-exclusive breastfeeding for up to 6 months, non-exclusive breastfeeding for 6-12 months, and non-exclusive breastfeeding for more than 12 months) and lifetime and current asthma, adjusting for LCA classes and other study covariates.

Results: Exclusive breastfeeding for up to 6 months was associated with a reduction in lifetime asthma (IRR, 0.66; 95% CI: .47-.91) controlling for adverse childhood experiences and study covariates. Prolonged non-exclusive breastfeeding (≥12 months) was also protective against lifetime (IRR, 0.66; 95%CI: .45-.96) and current asthma (IRR, 0.59; 95% CI: .40-.87). Children classified in the intermediate adversity class experienced a higher risk of asthma than children in the low adversity class (Lifetime asthma: IRR, 1.51; 95% CI: 1.20-1.90). The combined intermediate/severe ACE latent class partially mediated the protective effect of breastfeeding for ˃ 6 months on the development of lifetime and current asthma in children aged 3 to 5 years (Lifetime asthma: β=-.016; 95% CI:-.024,-.012; Current asthma: β=-.014; 95% CI: -.020,-.009).

Conclusion: This study confirmed the protective effects of exclusive breastfeeding for lifetime asthma and prolonged non-exclusive breastfeeding for lifetime and current asthma, controlling for the co-occurrence of early adverse childhood experiences. The results of this study add to the body of evidence that bioactive components of breast milk may play a role in early immune development. Further investigation is warranted to explore the complex co-occurrence of risk and protective factors associated with asthma in young children.

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3- Cultural Adaptation of Breastfeeding Assessment Tool to the Portuguese Language: 'Latch'

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Introduction: Despite advances in breastfeeding rates in Brazil, the situation is still far from recommended by The World Health Organization. To evaluate the effectiveness of breastfeeding, there are several tools available, but not always translated and validated for the Portuguese. Objective: Adapting the LATCH scale into Portuguese and verify the psychometric properties of the instrument. Method: This is a methodological research with a quantitative approach, developed in five stages: 1 - Translation of the original version into Portuguese by two independent translators, obtaining two translations of the native language of the instrument to the target language; 2 Retro-translation (Back-translation), in that the initial translation was again translated back into the original language by two other translators who did not participate in the first stage and that worked independently; 3 - Multidisciplinary Judges Committee, which had as assignments compare the original version with the translated versions, and establish the final version of the instrument for pre-test; 4 Pre-test together with 30 expert nurses, who assessed the instrument translated in order to detect errors; 5. Validation of the instrument, which was applied in two specialist nurses simultaneously in the evaluation of 160 feeds in order to validate the reliability of the instrument. Results: The analysis of the original version of the translation and back translation of the original instrument and evaluated by the judges showed that most of the sentences presented content validity index (CVI-s) greater than 0.90 (60%) and general CVI 0, 91. In the areas studied, the cultural dimension showed the highest percentage of responses of equivalences (96.6%). The agreement between the evaluations of judges was excellent, according to the concordance coefficient AC 2 Gwett, which was 0.93 (95% CI from 0.91 to 0.96). In the pre-test, most of the nurses said understood perfectly and have no doubt, and the CVI-S each item (CVI-I) were high (greater than or equal to 0.93) and the overall CVI (0.95) indicating excellent content validity. The instrument validation step, the assessment was similar for both nurses in almost all 160 feeds. As for the agreement between the evaluations, considering the total scores of LATCH, the intraclass correlation coefficient between observers was 0.96, indicating excellent agreement. As for the agreement between observers in each of the scale items, all coefficients show that was excellent, with 95% confidence. Conclusion: The study met the objective of adapting to the Portuguese language and verify the psychometric properties of breastfeeding assessment tool LATCH. The validity of the LATCH measuring instrument which is designed to measure, applied in clinical practice.

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4- Impact of the Knowledge and Attitudes of a Support Person on Maternal Feeding Choice

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Breastfeeding rates among urban, low-income populations are lower than the national average, creating a health disparity that greatly impacts mothers and children. Social support can affect breastfeeding initiation and duration both positively and negatively. This study aimed to determine the impact of the presence of a support person, as well as the breastfeeding knowledge and attitudes of that support person, on both a mother’s feeding choice and her perceived level of support for that feeding choice. A questionnaire was administered to 192 mothers receiving care for their infant in the Pediatric Practice at University Hospitals Rainbow Babies and Children’s Hospital in Cleveland, Ohio. We also surveyed 74 adults who accompanied these mothers. Data on demographics, feeding characteristics, and knowledge and attitudes regarding breastfeeding were collected. Analysis of the entire population of mothers categorized by feeding choice found that mothers’ intention to breastfeed (OR 8.09, 95% CI 4.03-16.26) and breastfeeding-supportive knowledge and attitudes (OR 1.89, 95% CI 1.38-2.61) were independent predictors of choosing to exclusively breastfeed. Intending to breastfeed (OR 21.4, 95% CI 8.53-53.9) and breastfeeding-supportive knowledge and attitudes (OR 2.28, 95% CI 1.62-3.21) were also independent predictors for mothers who were doing any breastfeeding. The presence of an accompanying adult was not significantly related to feeding choice. Further analysis of the subgroup of mothers with an accompanying adult who completed a survey found that independent predictors of any breastfeeding included maternal intention to breastfeed (OR 23.68, 95% CI 1.48-377.6) and breastfeeding supportive knowledge and attitudes (OR 2.71, 95% CI 1.36-5.40). In addition, breastfeeding-supportive knowledge and attitudes of the accompanying adult was also an independent predictor of any breastfeeding (OR 2.78, 95% CI 1.17-6.60). Among mothers exclusively breastfeeding, only maternal intention to breastfeed was predictive (OR 7.64, 95% CI 2.22-26.3). The overwhelming majority of mothers (91%) felt supported in their feeding choice, regardless of presence or absence of an accompanying adult. These findings emphasize the importance of educating not only mothers but also their support system.

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5- Iron Status Among Children Aged 12-23 Months by Infant Feeding Method, Nhanes 2003-2010

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Background: Iron deficiency (ID) places children at risk for neurocognitive deficiencies as well as anemia. In the United States, ID is estimated to be 13% among children aged 12-23 months; no national estimates exist for iron deficiency anemia (IDA) among children of this age. It is unclear whether ID among children 12-23 months differs by infant feeding method given that breast milk has a low iron concentration. Thus, we sought to answer whether children aged 12-23 months who were breastfed >6 months were more likely to be ID, anemic, or have IDA compared to infants who breastfed for shorter durations or never breastfed.

Methods: We analyzed National Health and Nutrition Examination Survey (NHANES) 2003-2010 data for children 12-23 months. Serum ferritin and transferrin were used to calculate total body iron. ID was defined as total body iron less than 0, anemia as hemoglobin < 110 g/L, and IDA as being ID and having anemia. Infant feeding method was based on maternal recall of breastfeeding duration and categorized as: 1) breast milk for ≥6 months; 2) breast milk for >0– < 6 months; or 3) only infant formula. All analyses were weighted and accounted for complex survey design. We used chi-square tests to assess whether ID, anemia, or IDA varied by infant feeding method. Logistic regression was used to examine ID by infant feeding method controlling for demographic variables.

Results: There were 611 children aged 12-23 months with complete data; of which, 49% were male, 51% non-Hispanic white, and 51% low-income. Twenty-seven percent of children were breastfed for >6 months, 41% ever breastfed for < 6 months, and 31% were formula-fed only. There were no statistical differences among children breastfed >6 months, those breastfed for < 6 months, and those only formula-fed with respect to the prevalence of ID (14.3%, 13.1%, 16.7%, respectively, p=0.8). Prevalence estimates for anemia and IDA were unreliable with relative standard errors >30%. Logistic regression results for ID and infant feeding method were not significant.

Conclusion: Children breastfed for >6 months duration did not have a significantly higher prevalence of ID at 12-23 months of age compared to children never breastfed or breastfed for < 6 months. The small number of children aged 12-23 months in the NHANES data limited the ability to assess anemia and IDA by feeding method. Further, data on these biochemical indicators were not available for children < 12 months, so we were unable to assess how breastfeeding may be associated with iron status or anemia in the first year of life.

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6- Relationship Between Circumcision and Supplementation Risk in Term Breast Fed Infants

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Background: The Joint Commission established Perinatal Core Measure PC-05: exclusive breast milk feeding. Exclusive breast feeding rates are < 50% at most institutions. Compromised feeding after circumcision, leading to formula supplementation, is a perceived barrier to improved exclusive breastfeeding rate. The effect of circumcision on formula supplementation rate during the first days of life has not been well characterized.

Objective: Study the relationship between circumcision and formula supplementation rate within the first days of life.

Design/Methods: A single center retrospective study of term (≥37 weeks gestation) breastfed newborns born May 29, 2012-November 29, 2014 explored rates of supplementation (non-human formula fed in addition to breast milk), among infants with and without circumcision. Univariate analysis and a multivariate logistic regression model were used to explore factors that predicted supplementation.

Results: The large sample of 2111 infants comprised of 1059 males (811 received circumcision) and 1052 females. There were no differences in rates of supplementation for males (381/1059) and females (375/1052). In adjusted analyses, supplementation was significantly associated with black race, multiple-births, and mode of delivery but not with circumcision (table). Further evaluation of circumcision timing revealed that infants requiring supplementation were circumcised at a significantly later time (supplemented circumcised at 56.7 ± 28 hr. vs unsupplemented circumcised at 47.5 ± 16 hr.; p < 0.0001).

Conclusions: Circumcision did not increase the rate of supplementation in term breastfed male newborns; however, infants receiving supplementation were circumcised at a significantly later time. The relationship between circumcision timing and supplementation among infants should be further explored at multiple centers. Better understanding of this relationship could lead to the development of guidelines designed to increase adherence to Core Measure PC-05.

Comparison of circumcision status and other variables

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7- Provision of Breast Milk to Vlbw Infants in the Nicu by African-american Mothers

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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BACKGROUND: Maternal breast milk (MBM) provides significant health benefits and improved neurodevelopment for very low birth weight (VLBW) infants. However, 60% of African-American women initiate breastfeeding and < 35% provide MBM past six months. Previous research cites lack of knowledge about benefits, preference to formula feed, and low milk supply as explanations for non-initiation or discontinuation of MBM. However, data are not specific to African-American mothers.
OBJECTIVE: To enhance understanding of motivations, supports, and challenges of provision of MBM by African-American mothers of VLBW infants in an urban Level IV NICU.
METHODS: In this qualitative, descriptive study, we are conducting semi-structured interviews with African-American NICU mothers who have provided MBM for their VLBW infant. The interview was developed after literature review, with input from an interdisciplinary team of providers. The interview was piloted prior to utilization. Mothers with contraindications to breastfeeding or failed lactation are excluded. Purposive sampling is utilized to identify a heterogeneous study sample. Mothers are recruited when their infant is clinically stable, and informed consent is obtained. Researchers transcribe and manually code audio-recorded interviews. Infant charts are reviewed for demographics and notes pertaining to MBM feeding to increase validity. Interview coding and data extrapolation occur concurrently with recruitment; discrepancies are resolved through repeated discussions. Emerging categories are used to refine interview questions. Preliminary themes have been generated after analysis of 7 interviews and chart review. As theoretical saturation of themes (a qualitative method used to avoid repetitive data collection) has not been achieved, recruitment is ongoing and will cease theoretical saturation is reached. Member checks will be conducted after final themes are generated to verify and refine interpretation of data.
RESULTS: 25 mothers were approached, and 7 consented to participate. The primary reason for declining participation is an unwillingness to discuss the topic. The length of interviews varied slightly (~ 37 minutes). Emerging themes related to motivation for provision of MBM include understanding benefits for infants and encouragement from providers. Emerging themes related to maternal support include use of technology as a resource and education and training by healthcare providers. Emerging themes related to maternal challenges include difficulty with pumping and lack of close contacts with breastfeeding experience.
IMPLICATIONS: Despite strong evidence of benefits, provision of MBM for VLBW NICU infants remains inconsistent among African-American mothers. Preliminary data indicates that providers and technological resources are as supports of breast-feeding. Long -term pumping and lack of community backing are barriers. We speculate that low recruitment rates may be secondary to maternal discomfort discussing breastfeeding after pumping has ceased. In addition to guiding future research, we anticipate that final results will provide insight into initiatives targeted to improve the provision of MBM for VLBW infants of African-American mothers.

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8- Using Quality Improvement Methods to Increase Duration of Breastfeeding in an Urban Primary Care Clinic

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Background: The American Academy of Pediatrics recommends that infants breastfeed exclusively for 6 months and then up to at least one year of age with supplementary foods. National breastfeeding initiation rates have increased, however weaning continues to be very early in many high risk populations. Breastfeeding rates had not been tracked and no targeted interventions had taken place in this clinic prior to our project.
Specific Aim: Increase the percent of infants continuing to receive human milk at the second visit in the Pediatric Primary Care Center from 63% to 80% by June 1st, 2015.

Design/Methods: The project took place in a large academic urban pediatric primary care clinic seeing approximately 150 newborns per month. We initially collected data from the electronic medical record to capture baseline feeding information at the newborn visit and at the 2nd visit to the clinic. We used the Model for Improvement and tested interventions through Plan-Do-Study-Act (PDSA) cycles. A multidisciplinary team of registered nurses, physician lactation specialists, a dietitian and a nurse lactation consultant evaluated the current process of breastfeeding support and designed interventions targeted at providing support for breastfeeding. These included: 1) trialing a breastfeeding education tool at the newborn visit, 2) designing a system of breastfeeding outreach calls to high risk infants after the first visit, and 3) streamlining visits to a Breastfeeding Medicine Clinic if needed.
The percentage of infants receiving human milk at their second visit to the primary care clinic was plotted on a run chart using standard techniques.
Results: Baseline median percentage of infants receiving any human milk at 2nd visit (which could occur anytime in 1st 8 weeks of life) was 63%. Median increased to 80% during the first phase of project (date of shift 9/21/15). The aim was achieved, but not in the initially proposed timeline. Challenges encountered included large volume clinic with many providers and staff, long lag time of measure and limited resources.
Next Steps: Upcoming interventions include: increasing standardization, collaboration with WIC office lactation consultant, targeted referral for further breastfeeding support based on formula use and tests of different forms of resource lists.

Run Chart of Breastfeeding Duration at 2nd Visit
Percent of infants still breastfeeding at 2nd visit to Pediatric Primary Care Center

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9- Investigating Community Gaps in Breastfeeding Support

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Introduction. Memphis, Tennessee, has some of the lowest breastfeeding rates in the country. Breastfeeding continuation depends on early identification of problems, especially at the AAP recommended 3-5 day visit. Preliminary data indicate a gap in care at the 3-5 day visit, with many newborns from underserved populations having their first visit after 2 weeks of life. By this time, even if breastfeeding was initiated, many mothers have already switched their infants to formula feedings.
Study Objective. To understand breastfeeding-related practices and identify barriers to the 3-5 day visit among medical practices providing newborn care in the Memphis region, particularly those caring for underserved children.

Methods. Qualitative and quantitative analysis was performed on data collected from physician practices via a standardized questionnaire. Practices that include Medicaid populations were specifically targeted. Outcome measures included the frequency of completed 3-5 day visits by type of insurance, reasons for not being seen at the 3-5 day visit post-discharge, and gaps in lactation care beyond the 3-5 day visit. Funding was provided by an AAP CATCH grant to JW.

Results. A total of 67 surveys were hand-delivered to pediatric and family physician offices by study personnel with 20 returned (30%). Completion of the 3-5 day visit was higher for mothers with private insurance (52%) than public insurance (30%). Missed or “no show” appointments were the primary reason for missing the 3-5 day appointment (82%), followed by unavailable appointments (9%) and not providing an appointment (9%). Regarding gaps and suggestions, 70% of practices were not interested in a community-based clinic that could provide a 3-5 day visit for routine newborn and breastfeeding care together, but 65% would like a community breastfeeding clinic to refer patients for breastfeeding concerns. The majority of practices (80%) assessed breastfeeding at all office visits, but used general breastfeeding knowledge and not specific tools. Most practices (55%) were not referring patients to the available Tennessee Breastfeeding Hotline for advice, while 52% wanted more information for their practice to help mothers and babies breastfeed, and 50% did not use recommended resources to determine safety of maternal medications while breastfeeding (LactMed, Medications and Mother’s Milk).

Discussion. These preliminary survey data identify a substantial difference in the critical 3-5 day visit completion rate, between mothers with private versus public insurance. The predominant reason for not completing the visit was patient “no show” revealing a potential opportunity for improvement by stressing the importance of this early visit at the time of newborn discharge. Other opportunities to improve education of practices includes providing specific tools to assess breastfeeding, identifying existing community resources, using the breastfeeding hotline, and sharing existing tools to support mothers on medications while breastfeeding. Development of a community breastfeeding referral clinic should be considered.

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10- Early Initiation of Colostrum and Skin to Skin to Establish Successful Breast Milk Feeding in Very Preterm Infants

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Introduction:
Early colostrum feeds and skin to skin have shown to increase duration of breast milk feeds in newborns. Despite the known benefits of breast milk feeds for high risk preterm infants, many barriers still remain for the preterm infants to receive mother’s own breast milk. We initiated a quality improvement project to support NICU mothers to improve the duration of breast milk feeding in their preterm infants.

Methods:
Infants with birth weight ≤1500g born and admitted to Santa Clara Valley Medical Center NICU from January 2013 to December 2015 who were discharged home and eligible to breastfeed were included in this study. An ongoing family centered, multi-disciplinary approach was used to improve mother’s own breast milk feeds in all eligible infants. This included education to nursing staff on the science of human milk, lactation, and breastfeeding; 5 day lactation educator certification course offered to all maternal child health staff including nurses and providers; comfortable reclining chairs for NICU mothers to hold their infant skin to skin; and optimal clinical documentation of skin to skin practice in the infant’s electronic health record. The primary outcome was any breast milk feeding at discharge and the process measures were timing of initiation of colostrum, skin to skin, and breastfeeding. Data was collected by chart review. We compared the primary outcome using logistic regression and the gestational age, birth weight, and process measures using non-parametric Kruskal-Wallis test.

Results:
In the 100 infants included in this study, the time to first skin to skin improved significantly from our baseline of 6.4 days in 2013 to 2.7 days in 2015 (Table 1). The median birth weight of infants in 2013 (990g) was significantly lower than those in 2015 (1280g). In a sub-group analysis for babies with birth weight < 1000g and >1000g, we saw a similar trend towards improvement of time to first skin to skin, although not statistically significant.

Conclusions:
With our family centered, multi-disciplinary approach, we were able to improve our skin to skin practice. Our future goals include initiating colostrum within 1 hour after birth to improve milk volume production. We will also be introducing earlier initiation of breastfeeding with the goal at 32 weeks so that the first feed should be at breast.

Table 1

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11- The Impact of Maternal Attitudes, Experiences, and Support on Breastfeeding Discontinuation in the First Four Months

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Purpose: The AAP recommends exclusive breastfeeding for the first six months of an infant's life. However, in the U.S., only a minority of women accomplish this goal. According to the CDC, 4 of every 5 U.S. infants initiate breastfeeding, but only 1 of every 5 are exclusively breastfed through 6 months of age. Maternal age, education level, marital status, race/ethnicity, income, and previous breastfeeding experience have all been well-associated with breastfeeding duration. Our goal was to identify maternal attitudes, experiences, and support associated with breastfeeding duration in the first 4 months.
Methods: Mothers were recruited from an academic general pediatrics clinic upon bringing their infant for a 2-week, 2-month, or 4-month well child visit. Participants completed a questionnaire about socio-demographic, medical, and psycho-social factors including social support, media exposure, attitudes and feelings while breastfeeding. Bivariate analysis was done using chi-square and independent sample t-test. Further analysis was then done using logistic regressions.
Results: Of the 158 mothers recruited, 149 provided data for analysis. The sample had strong representation of groups known to have lower breastfeeding rates. 77.9% were uninsured or had public insurance, 52.3% had a high school education or less, 41.8% described themselves as black or African American, and 57.7% did not report a spouse living with them. Just over half of the respondents were still breastfeeding (55%), 27.5% had discontinued, and 16.8% never started. The time to discontinuation averaged 21.9 ± 16.2 days. Factors associated with continued breastfeeding include having family members (p=0.042), especially a mother (p < 0.001), who has breastfed or a close friend or relative that is supportive of breastfeeding (p=0.011). Mothers who were still breastfeeding were more likely to feel fulfilled (p=0.004), relaxed (p < 0.001), and confident (p=0.009) while nursing and less likely to feel pain (p=0.041). Logistic regressions found that feeling relaxed while breastfeeding decreased the odds of discontinued breastfeeding when controlling for maternal age, race, education, insurance, and marital status (p=0.005, Odds Ratio=0.057). Meanwhile, mothers who thought breastfeeding would be easy were more likely to have discontinued breastfeeding (p=0.033). Most (82.3%) of mothers reported exposure to breastfeeding material on social media, but it was more strongly associated with mothers who discontinued (p=0.062). No other types of media exposure were associated with breastfeeding cessation.
Conclusion: Positive maternal experiences while breastfeeding is associated with breastfeeding continuation. More research is needed to explore the effects of maternal experience and the role of social media exposure on breastfeeding, considering the pervasive use of such media in this age group. Support from significant others and close friends or relatives may be protective against obstacles many women face while breastfeeding. Identifying and assuring a personal breastfeeding ally for mothers may help increase breastfeeding duration in vulnerable populations.

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12- Productive Pumping! Helping Trainees Increase Clinical Time

Monday, October 24
10:00AM - 10:30AM
Moscone West, 2005/2007

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Background: Many residents and medical students choose to start families during training. Much is known about the benefits of breastfeeding, and many trainees desire to exclusively breastfeed. However, continuing lactation at work while balancing service and educational demands can be challenging. While literature exists on improving the efficiency of lactation using higher frequency cycles and two phase expression in lactating women, no studies have specifically examined trainee lactation and compared methods of milk extraction.
Objective: Our goal is to measure and improve the efficiency of lactation by providing trainees with a quiet, hospital grade pump (HGP) compared to a portable double-electric pump (PP).
Design/Methods: A quiet, HGP was purchased for trainee use only and stored in a designated room with computer, phone, and dictation system. Lactating trainees compared pumping time as well as production using their own PP and the HGP. Mothers were asked to provide the time to complete pumping and ounces produced based upon the first pump of the morning averaged over the first month back from maternity leave. Data was reported and analyzed with a paired t test.
Results: A total of six trainees provided data. Lactation time with PP averaged 24 minutes (range 15 to 40 minutes). Lactation time with HGP averaged 15.5 minutes (range 10-32 minutes), resulting in an average reducing total lactation time by 8.5 minutes (p=0.045 95% 3.8-12.2). Production volume also increased from 6.0 ounces (range 3.5-8.5 ounces) with PP to 8.8 ounces (range 8-11 ounces) with HGP, averaging 2.8 ounces (p=0.06 95% 1.2-4.3) despite decreased lactation time. Trainees also commented that the noise was reduced allowing them to return pages, dictate, and even listen to lectures.
Conclusions: Purchasing a HGP for trainee use significantly decreased time to complete lactation while increasing milk supply. In addition to having more time for clinical tasks, the quietness of the pump increased the amount of clinical and educational tasks that could be accomplished while pumping. Providing a HGP may be one way training programs can help residents sustain breastfeeding and decrease the burden of lactation on patient care and education tasks.

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Oral (Podium)

Improving Vitamin D Administration to Breastfeeding Newborns Using a Quality Improvement Model

Monday, October 24
10:30AM - 10:45AM
Moscone West, 2005/2007

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Introduction: In November 2008, the American Academy of Pediatrics (AAP) doubled the recommended daily intake of vitamin D for infants and children, from 200 IU/day (2003 recommendation) to 400 IU/day. Vitamin D should also be offered to any mother giving less than 500 mL of breast milk per day. Although breast milk is the best source of food for infants, it only contains 25 to 50 IU/L of vitamin D and, thus, is insufficient by itself. Vitamin D deficiency can cause nutritional rickets in severe cases but can also cause impaired growth, developmental delays, lethargy, and hypocalcemic seizures. Many pediatricians are unaware of the new recommendations for Vitamin D administration.

Purpose: The purpose of this project is to identify rates of vitamin D administration in our resident clinic and develop a strategy for optimizing these rates by utilizing a quality improvement model. All of the newborn infants seen at our clinic were born at Jersey Shore University Medical Center. We theorized that initiating vitamin D supplement administration in the Nursery Unit to any newborn receiving breast milk as per the AAP guidelines will improve rates of vitamin D administration in our outpatient resident clinic.

Method: Pre-intervention, a retrospective chart review of 60 outpatient clinic visits for 2-week-old newborns during October 2014 to November 2014 was performed. Documentation based on maternal report was recorded for all visits during this time period. In July 2015, we added Tri-vi-sol (vitamins A, C, and D) 1 mL orally once a day as an admission order set for newborn infants who will be fed breast milk. Tri-vi-sol contains 400 units of vitamin D, satisfying the current AAP recommendation. No intervention or change was made in the resident clinic regarding vitamin D administration. Post-intervention, another chart review of outpatient clinic visits for 2-week-old newborns was performed from August 2015 to October 2015.

Results: The pre-intervention results showed that exclusive breastfeeding mothers were offered vitamin D supplements 93% of the time. However, combination feeding (breast milk and infant formula) mothers reported being offered vitamin D only 30% of the time. All of the combination feeding newborns were consuming less than 500 mL of infant formula per day. The post-intervention chart review remained consistent in the exclusive breastfeeding mothers; 93% of them reported being offered vitamin D. However, there was a vast improvement among the combination feeding mothers. They reported being offered vitamin D 86% of the time within the first 2 weeks of life

Conclusion: Using our quality improvement model, we discovered that compared to exclusively breastfeeding mothers, giving a combination of breast milk and infant formula were 63% less likely to report being offered vitamin D. We were able to demonstrate improvement in reported vitamin D administration rates for combination feeding infants by 56%. This intervention could be utilized in other hospital settings to improve evidence-based breastfeeding care practices.

Pre and Post Intervention Statistics

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Oral (Podium)

Elimination of Ebola Virus and Marburg Virus in human Milk Through Holder Pasteurization

Monday, October 24
10:45AM - 11:00AM
Moscone West, 2005/2007

Take Evaluation

Purpose
Although there is no evidence of vertical transmission of the Ebola Virus (EBOV) from mother to baby via breastfeeding or breastmilk feeding, there is concern that transmission is possible. EBOV has been detected in the breastmilk of 2 Ebola Hemorrhagic Fever victims. EBOV was first detected in the United States in 2014. Subsequently, questions emerged about the safety of the pasteurized donor human milk supply related to the transmission of Filoviridae Viruses, EBOV and Marburg (MARV).
The serum of potential donors is screened for syphilis and 4 viral pathogens (HIV, HTLV, Hepatitis B, Hepatitis C) 4 by member banks of The Human Milk Banking Association of North America (HMBANA). Donor milk is then processed using the Holder method of pasteurization. Widespread serum screening for EBOV and MARV is not available. Although these two viruses have been eliminated through exposure to heat, the effects of the specific heat parameters of the Holder method of pasteurization are unknown.

Methods
Human breastmilk samples were inoculated with EBOV or MARV and processed by standard Holder pasteurization technique.
Viral stocks were prepared by infecting Vero cells with MARV (Angola strain) or EBOV (Zaire strain). Virus-containing tissue culture supernatants were collected 7 days post infection for MARV, and 10 days post infection for EBOV. Cell debris was then removed by centrifugation.
Expressed human donor milk was obtained in sterile containers from screened mothers donating to the Mother’s Milk Bank of North Texas. The raw milk was then frozen at -20°C. Milk samples from 2 donors were inoculated with viral stocks at concentrations of 10^5 PFU/mL to 10^3 PFU/mL. The samples were divided into two groups, and either maintained at 22.2°C (room temperature) for 30 minutes followed by freezing at -80°C or subjected to Holder pasteurization. For Holder pasteurization, samples were placed in a water bath maintained at 62.5°C for 30 minutes, then removed and stored at -80°C. Media without the addition of milk served as controls for both groups. All studies were performed in triplicate. Samples were thawed and plaque assays for EBOV and MARV were performed to detect virus.

Results
After Holder pasteurization of the milk samples, there were zero replicating EBOV (table 1) or MARV (table 2) virus particles detected by plaque assay. For milk samples that remained at room temperature, there was a decrease in the number of virus particles detected compared to the control media.


Conclusion
EBOV and MARV are eliminated from human milk by standard Holder pasteurization technique. Additional screening specifically for EBOV and MARV are unnecessary to ensure the safety of pasteurized milk.

Table 1.
Table 2.

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Oral (Podium)

Assessment of Implementation of the Guideline for Supplementation of at Risk Infants with Vitamin D in New Zealand

Monday, October 24
11:00AM - 11:15AM
Moscone West, 2005/2007

Take Evaluation

Background:
In 2013 the New Zealand (NZ) Ministry of Health published a “Companion Statement on Vitamin D and Sun Exposure in pregnancy and Infancy in New Zealand”. This advises for all breastfed infants in described risk groups to be supplemented with vitamin D to prevent nutritional rickets. Anecdotal information suggests that most of these infants are not getting supplements, resulting in observed cases of rickets and hospital admissions for complications of hypocalcaemia (like seizures and cardiomyopathy).
There is no published literature on how many of the infants that fall in these defined categories in NZ are being offered and actually getting vitamin D supplementation.
Methods:
Using a national database (NHI), we identified all term babies born in NZ in 2014 who were breastfed. Data on ethnicity, date of birth and place of birth were extracted from the NHI database to identify babies at risk for vitamin D deficiency that were eligible for supplementation as per current guideline (dark skin, born in winter and born on South Island) and compared with data on prescriptions of Vitadol C in this cohort. As Vitadol C is fully funded when prescribed and it is the only available vitamin D supplement for infants in NZ, it was assumed few babies would be supplemented without having a script.
We conducted a nationwide online survey of general practitioners, midwives and Well Child (Plunket and Tamariki Ora) nurses assessing their awareness of and current practice around vitamin D supplementing as well as eliciting suggestions for discussion and change.
Results:
Seventy-three percent (39,131/54,066) of term babies that were born in 2014 in NZ were documented to be breastfed. The overall prescription rate of Vitadol C was 3.5%. Being dark skinned was the strongest predictor of being prescribed supplements, but the rate of prescription was a low 9-17%, depending on presence or absence of other risk factors. Being born in winter or on the South Island did not seem to be a strong indication for prescribing Vitadol C. (Figure 1)
Survey of health professionals elicited a poor awareness of the existence of the guideline (43%) and knowledge of risk groups was mainly limited to dark skin and reduced sun exposure (Figure 2). Suggestions for change included increasing education and awareness among health professionals and parents as well as clarifying the current guideline. In multidisciplinary focus groups an action plan was laid out to implement these changes.
Conclusion:
Knowledge and implementation of a national guideline for supplementing infants with vitamin D was poor. Suggestions for change and an action plan were formulated.

Figure 1
Figure 2

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Oral (Podium)

Modes of Infant Feeding and Childhood Asthma Development: Is There a Difference Between Direct Breastfeeding and Expressed Breast Milk?

Monday, October 24
11:15AM - 11:30AM
Moscone West, 2005/2007

Take Evaluation

BACKGROUND: Epidemiologic evidence suggests that breastfeeding may reduce the risk of childhood asthma; however, very few studies have distinguished how breast milk is delivered (i.e. direct suckling at the breast or indirect feeding of expressed breast milk). We aimed to determine whether different modes of infant feeding are associated with childhood asthma.

METHODS: The study included 2647 children in the CHILD (Canadian Healthy Infant Longitudinal Development) study, a general population based national birth cohort. The primary exposure was modes of infant feeding, categorized at 3 and 6 months as: direct breast milk (DBM), indirect breast milk (IBM, any expressed breast milk in the previous two weeks), formula (no breast milk), or mixed (DBM/IBM and formula). Feeding data were collected prospectively by standardized caregiver questionnaires. The primary outcome was asthma diagnosis at three years of age, based on a standardized history and physical examination. Logistic regression was used to explore the relationship between modes of infant feeding and asthma while adjusting for relevant covariates.

RESULTS: A total of 327 children were diagnosed with possible or probable asthma at 3 years of age (12% incidence). At 3 months, the distribution of feeding modes was 61% breast milk only (28% DBM, 33% any IBM), 14% formula only, 25% mixed. By 6 months, the distribution was 48% breast milk (27% DBM, 21% any IBM), 26% formula, 26% mixed. Compared to direct breastfeeding, any mode of infant feeding at 3 months that included IBM or formula was associated with an increased risk of asthma. These associations persisted after adjusting for infant sex, maternal diagnosis of asthma, ethnicity, method of birth, daycare attendance, gestational age, and introduction of solid food before 6 months (IBM: adjusted OR=1.67, CI: 1.15-2.46; mixed feeding: aOR=1.68, CI: 1.12-2.54; formula: aOR=2.09, CI: 1.32-3.32). Modes of infant feeding at 6 months were not significantly associated with asthma (IBM: aOR=1.18, CI: 0.79-1.77; mixed: aOR=1.03, CI: 0.69-1.54; formula: aOR= 1.41,
CI: 0.95-2.21).

CONCLUSION: Modes of infant feeding in the first 3 months are associated with asthma development. Direct breastfeeding is protective compared to formula feeding, while indirect breast milk and mixed feeding confer intermediate levels of protection.

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Send Email for Nancy Abarca

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Ana Creo, MD

Mayo Clinic Deparment of Pediatrics
Rochester, MN

Presentation(s):

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Cristiane Da Conceição, M.Nur.

Hospital Israelita Albert Einstein
São Paulo, Brazil

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Angelica Mae Hilario, Fellow, PediatricGastroenterology, HepatologyandNutrition

University of Santo Tomas Hospital Manila, Philippines
Taguig, Philippines

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Monica Huff, MD

University of Texas Medical Branch
University of Texas Medical Branch
Galveston, TX

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Suhagi Kadakia, MD

Jersey Shore University Medical Center K. Hovnanian Children’s Hospital, Department of Pediatrics
Ocean, NJ

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Alganesh Kifle, RNC, BSN, IBCLC

Lactation Coordinator
Santa Clara Valley Medical Center
San Jose, CA

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Annika Klopp, MD

Pediatric Resident
Department of Pediatrics and Child Health, University of Manitoba and Children's Hospital Research Institute of Manitoba
Winnipeg, MB, Canada

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Bianca LoVerde, DO

University of Maryland Medical Center
Baltimore, MD

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Jennifer Nelson, MD, MPH

Centers for Disease Control and Prevention
Atlanta, Georgia

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Judith Nitert

Paediatric registrar
Capital and Coast District Health Board
Wellington, New Zealand

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Cliff O'Callahan, MD, PhD

Faculty and Director Nurseries
Middlesex Hospital and University of Connecticut
Middletown, Connecticut

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Courtney Thomas, MD

Medical Student
Case Western Reserve University School of Medicine
Columbus, OH

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Julie Ware, MD, MPH, IBCLC

Pediatrician
CIncinnati Children's Hospital Medical Center
Cincinnati, OH

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Julie Ware, MD, MPH, IBCLC

Pediatrician
CIncinnati Children's Hospital Medical Center
Cincinnati, OH

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Andrea Zimmer, MD

General Pediatrician
Boys Town Pediatrics
Boys Town, NE

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Fabiane Almeida, D. Nur.

Hospital Israelita Albert Einstein
São Paulo, Brazil

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Heather Anderson, MD

Mayo Clinic Deparment of Pediatrics
Rochester, Minnesota

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Alan Cabasso, MD, FAAP

Jersey Shore University Medical Center K. Hovnanian Children’s Hospital, Department of Pediatrics
Neptune, NJ

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Rebecca Castro, Chief of Section, Pediatric Gastroenterology, Hepatology and Nutrition UST Hospital

Chief of Section
University of Santo Tomas Hospital Manila, Philippines
Quezon City, Philippines

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Alison Falck, MD

Assistant Professor
University of Maryland Medical Center
Baltimore, Maryland

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Lydia Furman, MD

Department of Pediatrics, Rainbow Babies and Children's Hospital
Cleveland, Ohio

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Aris Garro, MD, MPH

Associate Professor of Emergency Medicine and Pediatrics
Warren Alpert Medical School of Brown University and Rhode Island Hospital
Providence, Rhode Island

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Priya Gupta, MPH

Centers for Disease Control and Prevention
Atlanta, GA

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Erin Hamilton-Spence, MD

Medical Director of Mothers’ Milk Bank of North Texas
Pediatrix Medical Group, Mothers’ Milk Bank of North Texas
Fort Worth, TX

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Marion Hare, MD, MS

Pediatrician
Le Bonheur Children's Hospital
Memphis, TN

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Aaftab Husain, MD

Neonatology, University of Connecticut Health Center
Hartford, CT

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Sudha Rani Narasimhan, MD, IBCLC

Neonatologist
Santa Clara Valley Medical Center
San Jose, California

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Arwa Nasir, MD, MBBS, MSc.MPH

Division Chief of General Pediatrics
University of Nebraska Medical Center
Omaha, NE

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Sarah Riddle, MD, IBCLC

Assistant Professor
Cincinnati Children's Hospital Medical Center
Cincinnati, OH

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Pat Tuohy

Chief Advisor - Child & Youth Health
Ministry of Health , New Zealand
Wellington, New Zealand

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Lorena Vehling, BSc

Department of Pediatrics and Child Health, University of Manitoba and Children's Hospital Research Institute of Manitoba
Winnipeg, MB, Canada

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Allan Becker, MD

Department of Pediatrics and Child Health, University of Manitoba and Children's Hospital Research Institute of Manitoba
Winnipeg, MB, Canada

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Lauren Fischer, RD

Cincinnati Children's Hospital Medical Center
Cincinnati, OH

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Jay Homme, MD

Mayo Clinic Department of Pediatrics
Rochester, MN

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Yongwen Jiang, PhD

Assistant Professor of the Practice in Epidemiology
Brown University School of Public Health and Rhode Island Department of Health
Providence, RI

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Fawaz Mzayek, MD, MPH, PhD

Associate Professor of Epidemiology, Biostatistics,and Environmental Health
University of Memphis School of Public Health
Memphis, TN

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Mary Ann O'Riordan

Department of Pediatrics, Rainbow Babies and Children's Hospital
Cleveland, OH

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Kelley Scanlon, PhD

Centers for Disease Control and Prevention
Atlanta, GA

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Karen Shattuck, MD

University of Texas Medical Branch
Galveston, TX

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Anita Siu, PharmD, BCPPS

Jersey Shore University Medical Center Department of Pharmacy, Ernest Mario School of Pharmacy, Rutgers University
Neptune, NJ

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David Taylor, Ph.D.c

Graduate assistant, MD/PHD Candidate
University of Nebraska Medical Center
Omaha, NE

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Silena Te, BS

Wesleyan University
Middletown, CT

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Robin Wu

Data Coordinator
Santa Clara Valley Medical Center
San Jose, CA

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Suzanne Higgins, B.S.

Medical Student
University of Nebraska Medical Center
Omaha, NE

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Angela Huang, RNC

Data Coordinator
Santa Clara Valley Medical Center
San Jose, California

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Deborah Pearlman, PhD

Associate Professor of Epidemiology Practive
Brown University School of Public Health
Providence, RI

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Cria Perrine, PhD

Centers for Disease Control and Prevention
Atlanta, Georgia

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Stephanie Rosener, MD

Faculty
Family Medicine, Middlesex Hospital
Middletown, CT

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Rose St. Fleur, MD, FAAP

K. Hovnanian Children's Hospital at Jersey Shore University Medical Center
Neptune City, NJ

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Padmaja Subbarao, MD

Department of Pediatrics, Hospital for Sick Children and University of Toronto
Toronto, ON, Canada

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Ann Thulin, RN

Cincinnati Children's Hospital Medical Center
Cincinnati, OH

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Nadezda Yun, MD

Galveston National Laboratory
Galveston, TX

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Elizabeth Brownell, PhD

Neonatology, University of Connecticut Health Center
Farmington, CT

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Piushkumar Mandhane, MD

Department of Pediatrics and University of Alberta
Edmonton, AB, Canada

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Matthew Nudelman, MD

Research Assistant
Santa Clara Valley Medical Center
San Jose, California

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Terri Rutz, RN, IBCLC

Cincinnati Children's Hospital Medical Center
Cincinnati, OH

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Amy Vickers, MSN, RN, IBCLC

Mothers’ Milk Bank of North Texas
Fort Worth, TX

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Naveed Hussain, MD

Neonatology, University of Connecticut Health Center
Farmington, Connecticut

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Slobodan Paessler, PhD, DVM

Galveston National Laboratory
Galveston, TX

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Stuart Turvey, MBBS DPhil

Department of Pediatrics, Child and Family Research Institute, BC Children's Hospital and University of British Columbia
Vancouver, BC, Canada

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Malcolm Sears, MD

Department of Medicine and McMaster University
Hamilton, ON, Canada

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Meghan Azad, PhD

Department of Pediatrics and Child Health, University of Manitoba and Children's Hospital Research Institute of Manitoba
Winnipeg, MB, Canada

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