Resources on Medications in Human Milk

Lactation consultants are often asked about the safety of various maternal medications during lactation, which is but one aspect of education and training for the International Board Certified Lactation Consultant (IBCLC).  Since the early 1990s, our profession has often referred to the invaluable text, Hale's Medications and Mothers' Milk by Thomas W. Hale RPh PhD, and on May 28th, the 19th edition of this important volume will be released.  Dr. Hale also founded the InfantRisk Center, which addresses maternal medications during lactation and more about infant health and wellbeing. 

Dr. Frank J. Nice offers the text, Nonprescription Drugs for the Breastfeeding Mother, now in its 2nd edition. 

The U.S. National Institutes of Health's Toxicology Database offers LactMed to professionals as well as the general public, and is another invaluable resource on drugs in human milk.  Most medications are compatible with breastfeeding, and in instances of a medication that is not compatible, an alternative medication is often safely prescribed.    

The website for the online version of Hale's Medications and Mothers' Milk by Dr. Thomas W. Hale RPh, PhD: https://www.medsmilk.com/

Kelly Bonyata's interview with Dr. Hale on her well-known website, KellyMom.com:   https://kellymom.com/bf/can-i-breastfeed/meds/interview-dr-hale/

Dr. Hale's website, the InfantRisk Center at Texas Tech University Health Sciences Center:   https://www.infantrisk.com/

Dr. Frank Nice's website:  https://nicebreastfeeding.com/

LactMed's website, part of the U.S. National Institutes of Health Toxicology Data Network:  https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

New Study on Escitalopram (Lexapro) in Human Milk

A new study from Canada:  

Title:  Predicting Escitalopram Exposure to Breastfeeding Infants: Integrating Analytical and In Silico Techniques.

Journal:  Clinical Pharmacokinetics

Authors:  Sarah R. Delaney, Paul R. V. Malik, Cristiana Stefan, Andrea N. Edginton, David A. Colantonio, Shinya Ito

Abstract: 
"Background: Escitalopram is used for post-partum depression; however, there are limited pharmacokinetic data of escitalopram in milk and plasma of infants breastfed by women taking the drug."

"Objective: The objective of this study was to apply physiologically-based pharmacokinetic (PBPK) modelling to predict infant drug exposure (plasma area under the curve from time zero to infinity [AUC∞]) based on drug monitoring data of escitalopram in breast milk."

"Methods: Using a newly developed liquid chromatography-tandem mass spectrometry (LC-MS/MS) method, we quantified escitalopram concentrations in milk samples of 18 breastfeeding women with escitalopram therapy at steady state, collected at three to five time points. The escitalopram concentrations in breast milk were used with infant feeding parameters from the literature to simulate infant daily dose. We used PK-Sim® to develop an adult PBPK model for escitalopram and extrapolated it to a population of 1600 infants up to 12 months of age. An integration of the simulated infant daily dose and the virtual infants with variable physiological–pharmacological parameters was used to predict drug exposure (plasma AUC∞) distribution in the population of infants breastfed by women receiving escitalopram 20 mg/day." 

"Results: Escitalopram concentrations in milk were 50 ± 17 ng/mL (mean ± standard deviation). The simulated infant plasma AUC∞ following escitalopram exposure through breast milk was low, with a median of 1.7% (range 0.5–5.9%) of the corresponding maternal plasma AUC∞, indicating no substantial exposure." 

"Conclusions: Infant exposure levels to escitalopram in breast milk are low. A PBPK modeling approach can be used to translate data on drug monitoring in milk into a population distribution of infant plasma levels for drug safety assessment." 

https://link.springer.com/article/10.1007%2Fs40262-018-0657-2

New Study on Trajectories in Maternal Depression and Children's Behavior

Developmental cognitive neuroscientist Adele Diamond is one of the authors of this new study from the University of British Columbia.  Diamond is a leader in the field of developmental cognitive neuroscience.  

Title:  Maternal depression trajectories from pregnancy to 3 years postpartum are associated with children’s behavior and executive functions at 3 and 6 years.

Journal:  Archives of Women's Health

Authors:  Mina Park, Ursula Brain, Ruth E. Grunau, Adele Diamond, Tim F. Oberlander

Abstract:  "The objective of this study was to investigate how patterns of maternal depressive symptoms from mid-pregnancy to 3 years postpartum are associated with children’s behavior at age 3 years and executive functions. Maternal depressive symptoms were measured from mid-pregnancy to 3 years postpartum. Growth mixture modeling was used on standardized maternal depression scores (n = 147) to identify trajectories. Children’s behavioral problems and mental health symptomatology (internalizing, externalizing, and attention deficit hyperactivity disorder) were obtained at 3 and 6 years. EFs were assessed by a laboratory-based computerized task and maternal-report at 6 years. Multivariable linear regressions of children’s outcomes against maternal depressive symptom trajectories were conducted (n = 103). Three distinct patterns of maternal depressive symptom trajectories were identified: low (n = 105), increasing (n = 27), and decreasing (n = 15). Children of mothers whose depressive symptoms increased reported more problem behaviors at 3 years and poorer EFs at 6 years as assessed by both instruments, but no significant differences in mental health symptomatology at 6 years, relative to those whose mothers had consistently low depressive symptoms. Children whose mothers became less depressed over time had comparable levels of behavioral problems at age 3, executive functions, and internalizing and externalizing scores at age 6; and fewer reported ADHD behaviors at age 6, than those whose mothers remained less depressed over time. If mothers’ depressive symptoms improve over the first 3 years postpartum, their children’s outlook may be comparable to those whose mothers had consistently low depressive symptoms."

http://www.devcogneuro.com/Publications/Park(2018)_maternal_depression.pdf

Dr. Diamond's developmental cognitive neuroscience website:  http://www.devcogneuro.com/

New Study on Mirror Neurons

When we provide print literature to parents as well as video teaching materials, and when we use dolls in prenatal breastfeeding classes to demonstrate various infant feeding positions, mirror neurons must be very busy.  I suspect mirror neurons are even more highly activated when observing infant feeding in real time.

This new study from the Journal of Neuroscience is on the role of mirror neurons in learning, and is yet another example of the heavily studied area of prehension (the manual reach and grasp). 

Title:  Mirror neuron populations represent sequences of behavioral epochs during both execution and observation.

Authors: Kevin A. Mazurek, Adam G. Rouse and Marc H. Schieber, all with the University of Rochester in Rochester, New York

Abstract:  "Mirror neurons (MNs) have the distinguishing characteristic of modulating during both execution and observation of an action. Although most studies of MNs have focused on various features of the observed movement, mirror neurons also may monitor the behavioral circumstances in which the movement is embedded, including time periods preceding and following the observed movement. Here, we recorded multiple MNs simultaneously from implanted electrode arrays as two male monkeys executed and observed a reach, grasp, and manipulate task involving different target objects. MNs were recorded from premotor cortex (PM-MNs) and primary motor cortex (M1-MNs). During execution trials, Hidden Markov Models (HMMs) applied to the activity of either PM- or M1-MN populations most often detected sequences of 4 hidden states, which we named according to the behavioral epoch during which each state began: initial, reaction, movement, and final. The hidden states of MN populations thus reflected not only the movement, but also three behavioral epochs during which no movement occurred. HMMs trained on execution trials could decode similar sequences of hidden states in observation trials, with complete hidden state sequences decoded more frequently from PM-MN populations than from M1-MN populations. Moreover, population trajectories projected in a 2-dimensional plane defined by execution trials were preserved in observation trials more for PM- than for M1-MN populations. These results suggest that MN populations represent entire behavioral sequences, including both movement and non-movement. PM-MN populations showed greater similarity than M1-MN populations in their representation of behavioral sequences during execution versus observation."

Significance Statement:

"Mirror neurons (MNs) are thought to provide a neural mechanism for understanding the actions of others. But for an action to be understood, both the movement per se and the non-movement context before and after the movement need to be represented. We found that simultaneously recorded MN populations encoded sequential hidden neural states corresponding approximately to sequential behavioral epochs of a reach, grasp, and manipulate task. During observation trials, hidden state sequences were similar to those identified in execution trials. Hidden state similarity was stronger for MN populations in premotor cortex than for those in primary motor cortex. Execution/observation similarity of hidden state sequences may contribute to understanding the actions of others without actually performing the action oneself."
 

Motor Learning Term of the Day

Inhibition of Return (IOR): the delay in responding to the previously cued (or orienting) stimulus/stimuli.  

In the field of infant feeding, infants are often observed to inhibit the reflexive lunge toward the breast following a learning experience with an artificial nipple, regardless of whether the artificial nipple is a pacifier (soother or dummy) or a bottle nipple. 

In many infants, this inhibition is displayed as slower speed and less accuracy as the infant moves toward the nipple-areolar complex for the oral grasp/latch, and this can be studied and measured in milliseconds as a prolonged movement time [MT] for the oral grasp.  Other infants can achieve and sustain the oral grasp at the breast after a learning experience with an artificial nipple, but display an inhibition of the reflexive wide oral gape in order to learn the shallow oral grasp of an artificial nipple, and the shallow latch is a well-known risk factor for maternal nipple pain and nipple trauma.  In yet other infants who have been given a learning experience with an artificial nipple, there are observable displays of ineffective suckling which can result in inadequate transfer of milk.  An infant may display such learning difficulties (task-switching difficulties with subsequent switch costs of decreased speed and accuracy) in one of these areas, while other infants will display feeding difficulties in some or all of these areas. 

When infants are given a learning experience with an artificial nipple and are subsequently returned to the breast, some infants no longer move toward the nipple-areolar complex at all, as if waiting for other, more recently learned feeding stimuli to be offered.  

Lactation consultants are often consulted to assist the infant in returning to the breast when such difficulties occur, particularly in non-Baby Friendly childbearing facilities.  Clinicians often provide manual guidance to the mother in positioning the infant at the breast for the infant's correct trajectory toward the nipple-areolar complex, as well as manual guidance for the necessary speed in moving toward the nipple-areolar complex while the infant's mouth is reflexively open for the oral grasp, and also while the infant's tongue is reflexively extended over the lower alveolar ridge for the oral grasp.  Less tongue extension is needed for bottle-feeding skills, and during task-switching difficulties between breast and artificial nipple and back to the breast again, even the baby's reflexive tongue extension for the oral grasp can be inhibited for the oral grasp of the nipple-areolar complex.   

When a breastfeeding mother bottle-feeds her infant and subsequently returns her infant to the breast, the mother has often positioned her baby at the breast but in a bottle-feeding position, i.e., the baby is often cradled in one arm and reclining in a supine position.  With verbal and manual guidance from the clinician, the mother can quickly relearn how to position her infant at the breast, but the infant's primitive survival reflexes are often more heavily weighted toward the more recently learned feeding method, rather than equally weighted for all infant milk-feeding methods all the time.  Even the novice clinician is undertaking her own motor learning toward increasingly greater motor control.  The clinician often provides verbal and manual guidance to the mother in learning how to position her infant at the breast, and also in learning how to guide her infant in learning the oral grasp and/or effective suckling. 

Motor learning is complex, and this also applies to the mother who is also learning how to comfortably hold her infant in nursing positions, while also learning how to provide manual guidance to her infant in helping the little one to learn the oral grasp.  The mother's advantage is that she has spent a lifetime in learning her own feeding skills and other many other skills with the repetition of task-specific practice.  Nature provides remarkable assistance to the newborn mammal by endowing preadapted feeding movements that are further adapted in response to feeding stimuli.  However, these preadapted feeding movements, i.e., the primitive survival reflexes, are often more heavily weighted toward the more recently learning feeding method, an elegant and efficient approach by nature in support of the newborn's survival.  Particularly during early learning when early motor memories are most fragile, task-switching from breast to artificial nipple and back to breast is often challenging for the healthy term infant, and the challenges may be mild, moderate, or pronounced and prolonged.    

Without the presence of the infant's primitive survival reflexes, motor learning for milk-feeding skills would occur too slowly for the newborn's survival.  Consider the weeks of practice needed by the 6-month-old who is learning how to transfer liquid from a sippee-cup, and the difficulties displayed by the older baby when a different style of sippee-cup is offered.  The frequent response by many babies is a clear refusal of the novel sippee-cup, particularly during early learning.  Similarly, bottle-fed infants often display a preference for one style of artificial nipple, struggling with and often refusing a novel artificial nipple.  

When infants are exclusively bottle-fed, regardless of whether the milk is mother's milk, human donor milk, or artificial infant milk, it is also important to observe and study how infants learn to inhibit the reflexive lunge toward the bottle nipple.  In bottle-feeding, the reflexive lunge toward the bottle can be observed during earliest practice sessions in bottle-feeding, but as more practice sessions in bottle-feeding take place, newborns learn to inhibit this reflexive lunge toward the bottle very quickly, an example of the exuberant learning of infancy.   

This is a dramatic and profound display of infants learning very soon after birth to inhibit a reflexive movement when this reflexive movement is not at all needed for bottle-feeding.  The reflexive movement/lunge toward the breast is genetically designed for infant mammals to be a forward movement toward the nipple-areolar complex, but this reflexive lunge is highly adaptable in the manner of a heavier weighting toward the more recently learned milk-feeding method.  Bottles are consistently moved by the parent or other caregiver toward the baby for feeding, rather than the inefficient movement by the parent of moving the baby toward the bottle.  As the parent or other caregiver quickly learns to be efficient in their bottle-feeding movements, newborns also become quickly efficient in inhibiting the reflexive lunge that is needed for the oral grasp at the breast, but not at all needed for bottle-feeding. 

Learning is most rapid in infancy, but the cognitive demands of task-switching are greatest during infancy.  Across the lifespan, cognitive flexibility is most limited in the young.  

On Consolidating Memories During Sleep

Sleep helps us to build memory toward a robust state termed consolidation. Very soon after birth, the healthy term newborn soon enters an alert cycle that may last 1 to 5 hours (2 to 2 1/2 hours is average), and this early alert cycle is an ideal time for the youngest newborn to practice learning milk-feeding skills at the breast. Following this earliest feeding session, newborns enter a sleepy cycle of satiety and in recovery from birth. When a newborn has learned the oral grasp (or latch) in the initial alert cycle after birth, then awakens after a period of sleep, the infant's subsequent feeding movements for the oral grasp are expected to becoming increasingly more smooth and accurate (and therefore faster) at subsequent feedings when practice is specific to the task.  (An exception to the infant's display of increasing speed and accuracy for the oral grasp at the breast is during pronounced breast engorgement, which can serve as a temporary learning constraint for the infant.)  

Newborns must feed often in order to thrive, and with more task-specific feeding practice, motor memory for feeding becomes even more robust. This strengthened motor memory is reflected in the baby's increasingly greater performance of the oral grasp (the young novice soon becomes The Insta-Latch Baby), and the infant also becomes more skilled in milk transfer, so that greater volumes of milk can be transferred over increasingly shorter periods of time. Interestingly, as newborns become gradually more skilled in a milk-feeding method, gradually less sleep is required. 
                                                                                                                                          However, early memories are often fragile. Consider the fragile memory for a new computer password or a new telephone number, where the repetition of practice is necessary for building robust memory for that information.

In motor learning, such fragility can be frequently observed during the formation of early motor memories for infant feeding when a breastfed infant is given a learning experience with an artificial nipple, and particularly (but not only) if the introduction to an artificial nipple occurs during early skill acquisition at the breast, i.e., during early motor learning toward motor control.  If the infant's learning experience at the breast is followed by a learning experience with an artificial nipple, the infant's subsequent return to the nipple-areolar complex is often observed as decreased speed and accuracy (skill decay) for the oral grasp.

Following a learning experience with an artificial nipple, there are often many pronounced observations of a delayed and/or prolonged reaction time (RT) for the infant's oral grasp of the nipple-areolar complex (delayed onset of rooting and/or prolonged rooting for sensory processing, which includes but is not limited to texture and shape discrimination as well as target identification, followed by action planning); as well as a prolonged movement time (MT) for the oral grasp and/or effective suckling, resulting in a prolonged response time.  A significant inhibition of return (IOR) is also frequently observed -- the delay in responding to the previously cued (or orienting) stimulus. Although a wealth of longitudinal studies have correlated artificial infant feeding methods and artificial infant milks with both shorter duration of exclusive breastfeeding as well as early termination of the entire breastfeeding course, the universal phenomenon of infant breastfeeding difficulties that often follow the use of an artificial nipple can also be formally studied by using these real-time measurement parameters toward greater understanding of the infant’s skill acquisition for milk-feeding skills.

Among exclusively bottle-fed populations, routine task-switching between different styles of artificial nipples is never the norm in hospital settings or among families, although such task-switching of various styles of artificial nipples and subsequent switch costs of decreased speed and accuracy for the oral grasp and/or effective sucking can be studied in bottle-feeding infants as well. Skill acquisition in bottle-feeding populations can also be studied when bottle-fed infants learn their feeding skills unimpeded by task-switching to different styles of artificial nipples. The impact of sleep can also be studied among exclusively bottle-fed infants during their acquisition of bottle-feeding skills, regardless of whether the bottled milk is mother's milk, human donor milk, and/or artificial infant milk.

Motor learning is a complex process, and the presence of the primitive survival reflexes hastens the newborn's acquisition of milk-feeding skills in dramatic support of the newborn's survival. However, the newborn's reflexive movements are often more heavily weighted toward the more recently learned milk-feeding method (a recency effect), rather than equally weighted reflexive feeding movements for all infant milk-feeding methods all the time. 
                                                                                                                                        When the repetition of practice is specific to the task, the infant has the opportunity to build increasingly greater motor control during the process of motor learning for milk-feeding skills. The brain continues to process and strengthen motor memories between practice sessions, and this critical processing also takes place during sleep.

As the spring semester winds down on college campuses, parents are likely to advise their college-aged students not to stay up all night cramming for final exams, but to study as much as possible throughout the semester and to get adequate sleep, including during the week of final exams. When the repetition of frequent studying (in-session learning) is followed by regular study breaks and adequate sleep (between-session learning), this academic routine is expected to result in more robust memory for students everywhere. In studies on the impact of sleep in the aging population, adequate sleep is one of many important factors in supporting and optimizing cognitive function.

A new review article on daytime napping in infants and children from the journal, Nature and Science of Sleep:  https://www.ncbi.nlm.nih.gov/pubmed/22430027

New Study on Genetic Aspects of Rapid Involution and Aggressive Breast Cancer

Infant feeding and lactation specialists often provide patient and client teaching on the many health aspects of breastfeeding and human milk.  One of these aspects is the lesser incidence of inflammatory and triple-negative breast cancers among women who breastfeed their children with greater frequency and longer duration.  This new peer-reviewed, open access study from the University of Texas looked at the genetic changes in rapid "forced" weaning and breast involution, finding an association between these genetic changes and aggressive breast cancers.   

Title:  Gene set analysis of post-lactational mammary gland involution gene signatures in inflammatory and triple-negative breast cancer.

Study authors: Arvind Bambhroliya, Renae D. Van Wyhe, Swaminathan Kumar, Bisrat G. Debeb, Jay P. Reddy, Steve Van Laere, Randa El-Zein, Arvind Rao, Wendy A. Woodward

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0192689

From the abstract:

“Background: Epidemiological studies have found that triple-negative breast cancer (TNBC) and TN inflammatory breast cancer (IBC) are associated with lower frequency and duration of breast-feeding compared to non-TNBC and non-TN IBC, respectively. Limited breast-feeding could reflect abrupt or premature involution and contribute to a “primed” stroma that is permissive to the migration of cancer cells typical of IBC. We hypothesized that gene expression related to abrupt mammary gland involution after forced weaning may be enriched in the tissues of IBC patients and, if so, provide a potential correlation between limited breast-feeding and the development of aggressive breast cancer.”

“Results: Examining the combined data, we identified 10 involution gene clusters (Inv1-10) that share time-dependent regulation after forced weaning. Inv5 was the only cluster significantly enriched in IBC in the training and validation set (nominal p-values <0.05) and only by unadjusted p-values (FDR q-values 0.26 and 0.46 respectively). Eight genes in Inv5 are upregulated in both the training and validation sets in IBC. Combining the training and validation sets, both Inv5 and Inv6 have nominal p-values <0.05 and q-values 0.39 and 0.20, respectively. The time course for both clusters includes genes that change within 12 hours after forced weaning.”

On Practice

In order to build robust motor memory, the repetition of effective practice must take place during sensory-perceptual-motor learning, or more simply, motor learning. The Specificity Principle refers to practice specificity and learning specificity, in that practice must be specific to the task in order for learning to be effective.  When practice is indeed task-specific, and with the repetition of this specificity of practice, we can expect our performance to improve in the acquisition of all feeding skills and so many other skills across the lifespan.

The Specificity Principle is reflected in the Ten Steps to Successful Breastfeeding, a set of recommendations from the World Health Organization (WHO) and the United Nations International Children's Emergency Fund (UNICEF).  Step 9 of the Ten Steps advises, "Give no pacifiers or artificial nipples to breastfeeding infants."  The Baby-Friendly Hospital Initiative (BFHI) has long supported the Ten Steps to Successful Breastfeeding, and in childbearing facilities where the Ten Steps are followed, longer rates of breastfeeding duration result (see Appendices I - VI in the Resources section of this website).  

Here in the U.S., college basketball is nearing the end of its season, and the final men's game will take place on Monday night between Villanova and Michigan.  As the daughter of a high school coach in boys' basketball and baseball, I have so many positive memories of watching my late father, Wlbur Swank, coach athletes in his highly positive, high-energy style.  With these happy memories in mind, here are some favorite quotes about the importance of practice.  

Practice does not make perfect. Only perfect practice makes perfect. - Vince Lombardi

Practice doesn't make perfect. Practice reduces the imperfection. - Toba Beta

Everything is practice. - Pele

The way anything is developed is through practice practice practice practice practice practice practice practice practice and more practice. - Joyce Meyer

I used to practice at the hockey ground on synthetic surface while I was in the sports hostel, so Test cricket is certainly going to be a challenge for me. - Suresh Raina

Failure happens all the time. It happens every day in practice. What makes you better is how you react to it. - Mia Hamm

Champions keep playing until they get it right. - Billie Jean King

I've always really just liked football, and I've always devoted a lot of time to it. When I was a kid, my friends would call me to go out with them, but I would stay home because I had practice the next day. - Lionel Messi

Do it again. Play it again. Sing it again. Read it again. Write it again. Sketch it again. Rehearse it again. Run it again. Try it again. Because again is practice, and practice is improvement, and improvement only leads to perfection. - Richelle E. Goodrich

The same way that I practiced the violin, the same way that I practiced my dance moves, I decided that I was going to practice being positive and practice loving myself. - Lindsey Stirling

If I don't practice one day, I know it; two days, the critics know it; three days, the public knows it. - Jascha Heifetz

If you don't practice, you don't deserve to win. - Andre Agassi

Why should I practice running slow? I already know how to run slow. I want to learn to run fast. - Emil Zatopek

We learn by practice. Whether it means to learn to dance by practicing dancing or to learn to live by practicing living, the principles are the same. One becomes in some area an athlete of God. - Martha Graham

There is something comforting about going into a practice room, putting your sheet music on a stand and playing Bach over and over again. - Andrew Bird

First you study photography, then you practice photography, then you serve photography, and finally one becomes photography. - Ralph Gibson

Pastry school is great for a foundation and introducing you to basic techniques, but it is really up to the chefs to practice, practice, practice and refine their techniques. - Johnny Iuzzini

I'm a person who gets better with practice. Getting older is awesome - because you get more practice. - Zooey Deschanel

In the end, it's about the teaching, and what I always loved about coaching was the practices. Not the games, not the tournaments, not the alumni stuff. But teaching the players during practice was what coaching was all about to me. - John Wooden

Bradley is one of the few basketball players who have ever been appreciatively cheered by a disinterested away-from-home crowd while warming up. This curious event occurred last March, just before Princeton eliminated the Virginia Military Institute, the year's Southern Conference champion, from the NCAA championships. The game was played in Philadelphia and was the last of a tripleheader. The people there were worn out, because most of them were emotionally committed to either Villanova or Temple - two local teams that had just been involved in enervating battles with Providence and Connecticut, respectively, scrambling for a chance at the rest of the country. A group of Princeton players shooting basketballs miscellaneously in preparation for still another game hardly promised to be a high point of the evening, but Bradley, whose routine in the warmup time is a gradual crescendo of activity, is more interesting to watch before a game than most players are in play. In Philadelphia that night, what he did was, for him, anything but unusual. As he does before all games, he began by shooting set shots close to the basket, gradually moving back until he was shooting long sets from 20 feet out, and nearly all of them dropped into the net with an almost mechanical rhythm of accuracy. Then he began a series of expandingly difficult jump shots, and one jumper after another went cleanly through the basket with so few exceptions that the crowd began to murmur. Then he started to perform whirling reverse moves before another cadence of almost steadily accurate jump shots, and the murmur increased. Then he began to sweep hook shots into the air. He moved in a semicircle around the court. First with his right hand, then with his left, he tried seven of these long, graceful shots - the most difficult ones in the orthodoxy of basketball - and ambidextrously made them all. The game had not even begun, but the presumably unimpressible Philadelphians were applauding like an audience at an opera.            - John McPhee, A Sense of Where You Are:  Bill Bradley at Princeton

Quote of the Day

It always seems impossible until it's done. 

- Nelson Mandela (1918 - 2013) 

Noggin Bloggin

A link follows to Noggin Bloggin, a new favorite blog on "building networks in the community through neuroscience education and art".   Their most recent blog post,  "Why Art? Noggins Go To Washington", contains photos of many beautiful pieces of art on display during the recent Society for Neuroscience Conference held in D.C.  Of course the elegant drawings of neurons and synapses by neuroscientist and pathologist, Santiago Ramon y Cajal (1852 - 1934), were included in the exhibit.  The Noggins team also visited Sidwell Friends School in D.C. and Turner Elementary in Anacostia, where lucky students had the opportunity to make art, inspired by the inner workings of the brain.

http://nwnoggin.org/2017/12/23/why-art-noggins-go-to-washington/

An Untested Hypothesis

The learning of all feeding and drinking skills across the lifespan are forms of reward-based learning and reinforcement learning, both of which have been studied in the cognitive sciences for many decades. 

There are indeed some babies who display little difficulty in task-switching between breastfeeding and bottle-feeding, and the minimal difficulty is often displayed as minimal but nevertheless prolonged rooting (sensory processing in identifying the stimulus/stimuli, followed by action planning) prior to achieving the oral grasp for either or both feeding methods. This can be measured in milliseconds as response time, which is comprised of both reaction time and movement time for achieving the task, as in achieving and sustaining the oral grasp for milk-feeding. 

Task-switching has long been studied in the cognitive sciences, and today's PubMed search using the term task switching has yielded 2,888 results.  However, if using the term with a hyphen as task-switching, the search yielded only 1,321 results.  Switch costs of task-switching are measured as decreased speed and accuracy for the task, measured in milliseconds.  Infant feeding specialists, such as IBCLCs and others, are often called upon to provide manual guidance to the infant toward re-learning the oral grasp and/or effective suckling after a learning experience with an artificial nipple.  

I have an untested two-part hypothesis in regard to why a number of babies are able to successfully switch back and forth from breast to bottle and back to breast again, given that so very many infants display challenges ranging from mild to moderate to pronounced difficulties in correctly performing such task-switching skills, particularly during early learning, but not only during early learning.  This hypothesis applies to conditions of learning in the absence of learning constraints, such as complete cleft of the lip and palate; non-protractile nipple anatomy; and pronounced breast engorgement, however transient.  

Part 1 of the hypothesis: By following Step 9 of the Ten Steps and thereby building motor memory for the oral grasp and effective suckling at the breast, babies are able to strengthen motor memories for latch and suckling at the breast to a more robust state of motor memory.  Step 9 of the Ten Steps to Successful Breastfeeding encourages this accommodation for infants who are just beginning to learn, by advising, "Give no pacifiers or artificial nipples to breastfeeding infants."

Consolidation is the building and strengthening of memory into a robust state, and this includes the consolidation of motor memory. Early memories are fragile, and require the repetition of practice as well as sleep in building robust memory. Aside from the fragility of early motor memories, consider the fragility of other early memories, such as the difficulty in remembering a new computer password until more frequent use (the repetition of task-specific practice) builds increasingly robust memory for that new password. 

The second part of my untested hypothesis follows in regard to why some babies are able to switch back and forth between breast and bottle with only minimal delays in achieving the oral grasp following a moment or two of prolonged rooting. 

When babies are able to both breast and bottle-feed with no greater difficulty during task-switching other than minimal rooting prior to achieving and sustaining the oral grasp, I suspect and hypothesize that these babies are at a particular breast (and brain!) that is being stimulated for a far more rapid onset of the initial MER than average, which is a rapid reward to the infant in reinforcing what is being learned (rapid onset of the initial MER is not to be confused with an overactive MER that lasts throughout most or much of a feed).  This hypothesis is not a new lightning bolt of realization, but an integration of precepts from breastfeeding science and the cognitive sciences.  Clinicians have long discussed flow confusion and flow preferences, in addition to nipple confusion, nipple preference, suck confusion, and suck preference.       

When babies learn how to bottle-feed, regardless of whether the bottled milk is their own mother's milk, human donor milk, or artificial infant milk, the positive reinforcement to the infant of learning how to use correct bottle-feeding movements is the infant's ability to obtain milk with the very first suck via gravity flow, even when paced bottle-feeding is ideally used for a bottled feed.  The Milk Ejection Reflex (MER) is not stimulated by gravity, which is ideal from the milk-giver's point of view.  While lactating, who would wish to constantly release milk via gravity, except when adopting a supine position ?      

When we’re no longer at the breast and have transitioned to meals at the family table, the acquisition of all other feeding and drinking skills involves the reward and reinforcement of food or liquid with the very first correct eating and drinking movements, in spite of the awkward nature of feeding and drinking movements during earliest skill acquisition.  How we move, and the sensory consequences of our movements, inform us of so much.

New Study on Inhibition

Following the motor learning experience with an artificial nipple, the speed and accuracy of the infant's reflexive lunge toward the breast often becomes inhibited, particularly during early learning but not only during early learning. When an infant learns to bottle-feed, the opposite movement is learned, in that the bottle is moved toward the baby, rather than the baby being moved toward the bottle.  When an infant is subsequently returned to the breast, decreased speed and accuracy are often observed for the infant's latch, and such difficulties may be mild, moderate, or profound.  In many such instances, there are also observable decreases in speed and accuracy for organized, effective suckling.  The term skill decay is defined as decreased speed and accuracy for the task.  

Following a learning experience with an artificial nipple, the infant's reflexive oral gape is often inhibited to a more shallow gape as well (a "shallow latch"), even when an infant is able to achieve and sustain the oral grasp at the breast.  

Inhibition has been heavily studied in the cognitive sciences for decades. Today's PubMed search using the term "cognitive inhibition" yielded 11,580 search results, with newest studies published this month.

How has inhibition been traditionally studied in the cognitive sciences?

Researchers often compare reaction time, movement time, response time, and inhibition of return - - parameters that are measured in milliseconds. Inhibition of return (IOR), the delay in a previously orienting response, is considered significant when the delay is at least 200 to 500 milliseconds in duration. Although the comparison of these measurement parameters is not yet an area of formal study in the field of infant feeding for lactation consultants, the clinician often observes dramatic changes in these parameters over the course of a career, particularly in non-Baby Friendly hospital settings.  IBCLCs are educated and trained in many aspects of human lactation and infant feeding, and much of the clinician's workday is spent providing skilled guidance to both members of the dyad for the infant's oral grasp and/or effective suckling.  Varying levels of manual guidance are often needed by the infant in the acquisition and re-acquisition of infant milk-feeding skills, particularly when interference takes place during a baby's learning.  Neifert, Lawrence, and Seacat (1995) cited interference in their discussion on the first formal definition of the phenomenon of nipple confusion.  

In their new study published on December 4, 2017, Johns Hopkins researchers K.Z. Xu and colleagues used fMRI (functional magnetic resonance imaging) to study response inhibition.  Prior to this study, inhibition of planned behavior was thought to be governed by a single brain system.  In their current study, Xu and colleagues concluded that inhibition of a planned behavior "depends on two distinct neural processes involving different sub-regions of the rVLPFC [right ventrolateral prefrontal cortex] and their interactions with other motor-related brain regions." 

Title: Neural Basis of Cognitive Control over Movement Inhibition: Human fMRI and Primate Electrophysiology Evidence.

In: Neuron 2017 Dec 4. pii: S0896-6273(17)31063-2. doi: 10.1016/j.neuron.2017.11.010. [Epub ahead of print]   https://www.ncbi.nlm.nih.gov/pubmed/2922472

 Authors: Xu KZ, Anderson BA, Emeric EE, Sali AW, Stuphorn V, Yantis S, Courtney SM.  

Quote of the Day

I discovered what I could not do today, I could do tomorrow.   It's very important to know that what you cannot do today, you will do it tomorrow . . . . Each one of us is unique. 

                                     - Francois Rabbath, double bassist and composer,                                          speaking to students on learning to play the instrument

On Credentials: Discerning and Differentiating Between Those That Are Similar Yet Different

From a cognitive science point of view, discerning and differentiating between things that are similar yet different is cognitively demanding, and these cognitive demands range from mild to moderate to pronounced. 

We can quickly relate to this in our field of infant feeding when we observe the common difficulties that so many infants display when task-switching between the breast and a learning experience with an artificial nipple, particularly during early learning but not only during early learning. Similarly, families as well as hospital nursery staff often report that bottle-fed babies frequently "do better" with one style of artificial nipple versus another, and such observations are also made when infants are given different styles of soothers/pacifiers. We can expect the older baby as well as the toddler to reject one style of sippee-cup in favor of another, rather than task-switching between the two different styles with ease.   

In addition to the cognitive demands in learning motor skills, other forms of learning are often cognitively demanding from a task-switching perspective, including language. In our field of infant learning for milk-feeding skills, we are rightly concerned that the general public will have cognitive demands in discerning and differentiating between similar but different credentials of the infant feeding specialist. In these examples of job titles from our own field as well as other fields, consider the cognitive demands in learning how to accurately differentiate these professional titles, either with little difficulty, moderate difficulty, or marked difficulty: 

Teacher versus Teacher's Aide

Manager vs. Assistant Manager

Nurse vs. Nursing Assistant

Licensed Practical Nurse (LPN) vs. Registered Nurse (RN) vs. Nurse Practitioner (NP) 

Doctor/physician vs. Physician's Assistant

Optician vs. Optometrist vs. Ophthalmologist

International Board Certified Lactation Consultant vs. Certified Lactation Specialist vs. Certified Breastfeeding Specialist vs. Certified Lactation Counselor vs. Certified Lactation Educator Counselor vs. Breastfeeding Counselor vs. Breastfeeding Peer Counselor vs. Lactation Educator vs. Certified Lactation Educator vs. Community Breastfeeding Educator vs. Certified Clinical Lactationist, and so on.   

We clinicians are often asked by new parents about the differences between breastpumps, and we are educated and trained to teach these differences in pump technology, in order that parents may be best educated to discern which pump will meet their needs. In the U.S., prenatal breastfeeding classes typically include a segment on various pumps, with detailed instruction in how one type of pump varies from another, and such teaching is also provided at the hospital bedside and in home settings.

The eminent psychologist, William James (1842 - 1910), discussed the cognitive challenges in discernment and differentiation, using the examples of discerning between different red wines, and differentiating one twin from another. The cognitive demands of task-switching (and the subsequent switch costs of decreased speed and accuracy for the task) have been heavily studied in the cognitive sciences for decades, and these areas continue to be heavily studied. Today's PubMed search using the term "task switching" yielded 2,873 results. 

The extraordinary growth of the lactation consulting profession has been nurtured and supported by the credentialing body, the International Board of Lactation Consultant Examiners (IBLCE).  For decades, this credentialing body has promoted the International Board Certified Lactation Consultant (IBCLC) as "The Gold Standard" in specialized knowledge and clinical expertise in breastfeeding and human lactation. 

IBLCE offered the first board certification exam in 1986, and since that time, the lactation consulting profession has grown to over 28,000 IBCLCs from 105 countries, with over 15,000 IBCLCs in the United States alone.  In the short timespan of the profession's 31-year history, the dramatic growth in the number of IBCLCs is a remarkable testament to the care of the dyad by skilled clinicians.  The growth of our profession is also a testament to the decades of support from the IBLCE in promoting the education and training of the IBCLC as "The Gold Standard" in caring for the dyad. 

Parents who seek skilled infant feeding and lactation care are best served by appropriately credentialed clinicians. As parents seek information about various credentials for lactation and infant feeding specialists, this search should not be so cognitively demanding as to require the expenditure of hours by sleep-deprived new parents.  When parents can readily access concise information about the credentialing of lactation clinicians, parents should then be able to accurately discern and differentiate one credential from another, in order to meet their own health care needs and the health care needs of their infant.

At Least 2.33 Million Reasons

The skilled support of the IBCLC is critical in the health of the dyad, and there are at least 2.33 million reasons why.  

A 2017 study looked at expanding Medicaid coverage for lactation services, breastfeeding duration rates, and cost-effectiveness of IBCLC support.  This study was conducted in North Carolina, finding that when breastfeeding support resources are available state-wide, such high-density IBCLC support is associated with increased breastfeeding by low-income mothers.  Furthermore, this study found that such high-density IBCLC services are cost-effective:  Medicaid reimbursement of IBCLCs showed an estimated annual cost savings of $2.33 million.    https://www.ncbi.nlm.nih.gov/pubmed/27535132

New Study: The Significance of Breastfeeding Duration on Maternal Cardiovascular Disease

This new prospective study of 300,000 Chinese women found that breastfeeding reduced the risk of maternal CVD (cardiovascular disease) later in life, particularly with greater duration of breastfeeding.  Of note is the decreased risk of maternal heart attack and stroke with greater breastfeeding duration.                                                                                                                                                                                                                                                            The press release:  https://www.medpagetoday.com/cardiology/strokes/66168

The open access article:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5669201/pdf/JAH3-6-e006081.pdf

Quote of the Day

It's all connected,

because the way babies move determines what they see,

and what they see determines what they learn.  

                                                   - Linda Smith PhD (2013)                                                                                                             

Smith is Distinguished Professor and Chancellor's Professor of Psychological and Brain Sciences at Indiana University.  http://www.indiana.edu/~cogdev/

Psy Talks Episode 1:  Movement and babies' learning development  https://www.youtube.com/watch?v=yMyn8j8sMjA

New Study: Examining Delivery Method and Infant Feeding Intentions Between Women and Traditional and Non-Traditional Prenatal Care

In this new study, researchers found that women who were enrolled in group prenatal care (CenteringPregnancy), in contrast to those receiving traditional prenatal care, had fewer planned cesarean section births and high rates of breastfeeding initiation. 

From the abstract:  "The purpose of the study is to evaluate delivery method and breastfeeding initiation in women enrolled in group prenatal care (CenteringPregnancy) and in traditional prenatal care.  Methods:  Data were obtained from medical records of a hospital-based midwifery practice in south central Connecticut that offered both types of prenatal care programs.  Medical information from 307 women enrolled in this practice was included in the analysis. Out of the 307, 80 were enrolled in group prenatal care. Socio-demographic, lifestyle, and previous and current obstetrical information from medical records formed the basis of comparison. Bivariate and logistic regression analyses were carried out.  Results: Women in Centering had fewer planned cesarean sections (1.3 vs. 12.8%) and had a higher breastfeeding initiation (88.7 vs. 80.0%).  However, Centering women were found to have a higher portion of unplanned cesarean sections (27.5 vs. 11.0%). Both the unadjusted and the adjusted odds ratios of having a cesarean planned delivery were lower in the group care. Women in Centering had 2.44 (95% CI 1.05, 5.66) times the odds of breastfeeding initiation compared to the odds for women in traditional prenatal care after adjusting for maternal age, smoking status, gestation, and race. Discussion: CenteringPregnancy can have a positive impact for the woman and baby. This program implementation saw lower rates of elective cesarean sections and increased breastfeeding compared to women in traditional care."    https://www.ncbi.nlm.nih.gov/pubmed/29124626

New Study: Associations Between Breastfeeding and Maltreatment in Childhood

In this new study in Breastfeeding Medicine, researchers Kremer & Kremer looked at whether breastfeeding practices impact childhood maltreatment in regard to neglect, inadequate supervision, physical abuse, and sexual abuse. After controlling for covariates, the study found that compared with adolescents who were never breastfed, adolescents who were breastfed 9 months or longer had REDUCED ODDS of having experienced neglect and sexual abuse. Study conclusions: "Breastfeeding duration is significantly and inversely associated with childhood neglect and sexual abuse."  https://www.ncbi.nlm.nih.gov/pubmed/?term=associations+between+breastfeeding+and+maltreatment+in+childhood

The Dynamic Study of Task-Switching, Switch Costs, and Inhibition

As a registered nurse and IBCLC (International Board Certified Lactation Consultant) specializing in infant feeding and human lactation, I love studying kinesiology and other cognitive sciences on task-switching, switch costs of decreased speed and accuracy, and inhibition. These areas have all been heavily studied for many decades, and three new studies (among many new studies in these areas) are shared below.    

From time to time, lactation consultants are asked about the use of cannabis during lactation, and we frequently utilize three well-known resources in the field:  Lactmed, part of the toxicology database at the National Institutes of Health; Dr. Thomas Hale's invaluable reference handbook, Medications and Mothers' Milk (2017); and the InfantRisk Center.  

The first of three new studies mentioned here looked at vigilant attention, inhibitory control, top-down attentional control, and cognitive flexibility (aspects of executive functioning) in cannabis users and non-cannabis users.  Researchers measured salivary cortisol to assess these areas, finding altered attentional control among cannabis users compared to non-cannabis users.  These results are relevant to parenting, in that responsible parenting requires prolonged periods of alert attentiveness.  The cannabis study citation:  

Nusbaum AT, Whitney P, Cuttler C, Hinson JM, McLaughlin RJ.  Altered attentional control strategies but spared executive functioning in chronic cannabis users.  Drug and Alcohol Dependence 2017 Oct 12;181:116-123.  DOI: 10.1016/j.drugalcdep.2017.09.019. [Epub ahead of print]

Another interesting task-switching study just out:  

H. Freyja Ólafsdóttir, Francis Carpenter, Caswell Barry. Task Demands Predict a Dynamic Switch in the Content of Awake Hippocampal Replay. Neuron 2017; DOI: 10.1016/j.neuron.2017.09.035

And the third new study on task-switching and switch costs, which is by no means the very last of new studies in this fascinating area: 

Swainson R, Martin D, Prosser L.  Task-switch costs subsequent to cue-only trials.  The Quarterly Journal of Experimental Psychology 2017 Aug;70(8):1453-1470.  DOI: 10.1080/17470218.2016.1188321  

Today's PubMed search results using the term "task-switching":  1,295

Today's PubMed search results using the term "cognitive flexibility":  4,144

Today's PubMed search results using the term "cognitive inhibition": 11,362

Infant cognition labs in graduate psychology programs often study cognitive flexibility and task-switching in infants and children, with Piaget's A-not-B Task as one of the seminal task-switching studies in the field of developmental psychology, the study of learning across the lifespan.  Going well beyond Piaget's work, the late Carolyn Rovee-Collier (1942 - 2014) was the founder of the field of infant long-term memory research.  Please see a listing of infant learning labs under the Resources section of this website.  These infant learning labs are just part of Rovee-Collier's legacy.