Nipple thrush in lactating patients is characterized by nipple-areolar complex (NAC) pain, itch, and burning with breast pain. Expert opinion and single clinic chart reviews suggest that most cases of nipple thrush are actually contact or irritant dermatitis, nipple vasospasm, or subclinical mastitis often in the setting of improper breast pump use. The relationship between breast pump use, symptoms of nipple thrush, and thrush diagnosis has not been examined at the level of a health care system.

We endeavored to determine which elements of a lactating patient’s clinical presentation, including breast pump use and symptoms, were associated with a diagnosis of nipple thrush. We used data from the largest-to-date retrospective cohort study at a tertiary health care system where all NAC complaints of reproductive-age female-identifying patients between 2015 and 2019 were reviewed. Following approval by the institutional review board, data about symptoms, diagnosis, specialty providing care, diagnostic considerations, and treatments were collected. Read the full, open access research article here.

PhD Dissertation Overview (NIH NICHD F30 Award): In my PhD dissertation work, I first sought to define the effect of a synthetic glucocorticoid (dexamethasone) on milk yield and composition alongside changes in mammary gene expression in dairy cows. I demonstrated that a single, high dose of dexamethasone administered to lactating dairy cows transiently suppressed milk volume, milk lactose content, milk LALBA content, and LALBA gene expression.

Then, I wanted to determine the reliability and replicability of the murine mammary explant system for the study of glucocorticoid-mediated regulation of Lalba expression. I defined doses of corticosterone and dexamethasone and time intervals at which Lalba expression could be maximally upregulated, inhibited, or suppressed following initial stimulation. I demonstrated for the first time that Lalba expression in mammary explants from midpregnant mice can be suppressed by over 50% in response to high dose of CORT after initial 48 h of stimulation by a low dose of CORT.

Milk production by dairy cows is sensitive to increased levels of stress hormones such as glucocorticoids (GC) that also regulate the transcription of several genes required for milk synthesis. Whereas previous studies identified that an exogenous GC such as dexamethasone (DEX) transiently suppresses milk yield in several species without any pronounced effect on milk protein or fat percentage, the mechanism underlying this effect has not been established. In this study we sought to establish changes within the mammary glands of non-pregnant dairy cows in their second lactation (n = 3-4; 648-838 kg) following a single dose of exogenous DEX. Changes in the udder were monitored by serial biopsy of alternating quarters, concurrent with quarter-level monitoring of milk yield and composition. Read the full open access research article here.

Background: The United States Surgeon General, World Health Organization, and professional physician and nursing organizations strongly recommend health professional training in clinical lactation. Current educational methods for hospital staff or nursing students lead to small or insignificant improvements in breastfeeding outcomes. Likewise, existing antenatal breastfeeding educational strategies for parents do not result in improved breastfeeding outcomes. There is an urgency to develop education solutions for health professionals and families that result in an improvement in breastfeeding initiation and duration rates.

Health professionals receive inadequate training in clinical lactation largely because existing lecture-based teaching modalities are not effective and breast and newborn simulators are not realistic in look, feel, or functionality. Health professionals commonly cite a lack of confidence or ability to support lactating families. Live simulation-based learning with a Standardized Patient (SP) wearing a realistic breast model and holding a realistic newborn simulator is the ideal method for teaching breastfeeding and lactation skills to healthcare professional learners. It is well-established that simulation-based learning in other fields, like CPR training, results in the translation of those skills to patient care, improved patient outcomes, and decreased medical errors. Simulation-based training in clinical lactation has yet to be developed and tested.

Overview of LiquidGoldConcept’s contribution to the field: The product of LiquidGoldConcept’s NIH SBIR Phase I project was a Newborn Oral Assessment and Latch Simulator (NORALSim) that had structural and functional fidelity, whereby it looked, felt, and moved like a term newborn that could open and close its mouth via a cable-foot pedal mechanism when paired with LiquidGoldConcept’s commercialized Lactation Simulation Model (LSM). The LSMs were wearable breast models that lactate, engorge, and simulate common breastfeeding scenarios. NORALSim and LSM were used by lactation educators for parent education in in-person and virtual settings, by clinical instructors in hospitals, academic training programs, and community clinics for health professional education, and by standardized patients portraying pregnant and breastfeeding women in LiquidGoldConcept’s On-Demand Telesimulation program. Telesimulations were only training solution that enabled health professionals to engage in live, clinical practice with a standardized patient over video call to build clinical competence in lactation support and maternal-newborn care. Learn more about the work that LiquidGoldConcept accomplished, and our legacy here.

Introduction: Breast and skin assessment are both required clinical skills across health professional training programs. The breast is an ideal "canvas" for the development of a simulation exercise focused on the identification and diagnosis of skin conditions that could present anywhere on the body alongside unique conditions specific to the breast and nipple-areolar complex. A skin assessment simulation on a breast model has not been described.

Methods: Investigators developed 20 clinical vignettes for breast and skin conditions (ie, features) depicted on a set of 10 single silicone breast models in 4 skin tones. A modified Delphi approach was used to evaluate the appropriateness of the clinical vignettes and realism of features. A convenience sample of 136 licensed physicians was recruited online. In round 1, participants rated the realism of features and suggested descriptors for each feature. In round 2, participants rated their agreement with descriptors from round 1, selected a diagnosis based on clinical vignettes, and assessed the utility of the Breast Health Training Tool for health professionals.

Results: In round 1, participants (n = 38) agreed (5.1/6) that the features were realistic. In round 2, participants (n = 24) agreed (4.6/6) with the descriptors. Most (>50%) participants agreed on a diagnosis for each feature. Participants (n = 27) agreed (5.3/6) that this tool is useful for health professional education.

Conclusions: This is the first evaluation of a simulation tool for teaching breast examination and identification of skin conditions on the nipple-areolar complex and breast tissue in multiple skin tones, simultaneously filling the gap in women's breast, lactation, and skin health education. Read the full research article here.

M.P.H./M.A. research and field experience: For my Human Nutrition M.P.H. professional field experience in 2014, I designed an internship and secured funding to understand the reason why there are over 250 human donor milk banks in Brazil and fewer than 25 in the US. I spent three months in over two dozen milk banks in the United States and Brazil. I hypothesized that the Brazilian national policies of milk donation promotion and vertical integration of milk banks into hospital systems is the reason for their success. When I started to delve deeper into milk banking history, I learned that the Brazilian integrated approach was not novel. At the turn of the 20th century in Europe, an innovative “Drop of Milk” program was established to decrease infant mortality by providing pasteurized cow’s milk to working mothers who could not breastfeed. To my surprise, the impact of this public health initiative in Russia, where infant mortality in 1890 was 50%, was not well-researched. For my Russian/Eastern European MA thesis for which I received a US Department of Education FLAS fellowship, I used the “Drop of Milk” model as a framework for comparing today’s milk banking policies and practices in the US and Brazil. I found that, unlike the milk banking policies and proposed legislation in the US, Brazilian and “Drop of Milk” programs emphasized breastfeeding education and promotion, not just the logistics of milk pasteurization or reimbursement.

ReplyAll Podcast “Milk Wanted” Episode: On March 9, 2016, I was interviewed on Gimlet Media’s ReplyAll podcast (Episode #57 “Milk Wanted”) about my master’s thesis work. This episode has been downloaded over 500,000 times.

Background: Low milk production is one of the main reasons for premature breastfeeding cessation. Smartphone apps have the potential to assist mothers with promoting, interpreting, tracking, or learning about milk production. It is not known whether breastfeeding apps contain high-quality, engaging, and diverse content and features that could be used by mothers to increase their breastfeeding self-efficacy and answer their questions about milk production.

Objective: The overarching objective of this study was to identify and evaluate features and content within breastfeeding apps that could be used by mothers to increase breastfeeding self-efficacy and answer their questions about milk production. The secondary objectives were to quantify the diversity of representation of breastfeeding experiences within breastfeeding apps and to define the type of organization that is most likely to create free apps and/or apps with high-quality, engaging, and diverse features and content related to milk production.

Methods: Breastfeeding apps were identified in the Apple App Store. All features that assist mothers with tracking, promoting, or interpreting milk production in the first 0-6 months postpartum were noted. Every screen containing educational information about milk production was identified and saved for review. Images of mothers and caretakers within the selected screenshots were assessed. Three scoresheets informed by Social Cognitive Theory were created to evaluate all identified features, educational content, and images representing the breastfeeding experience.

Results: Forty-one breastfeeding apps were reviewed. Only seven apps contained both features and educational content related to milk production. Thirteen apps that contained educational content related to milk production received a mean combined content and cultural diversity score of 15.3 of 78. Of the 48 photos reviewed in screenshots that contained educational content on milk production, 87.5% (n=42) were of white women and their infants. For-profit companies and large organizations were most likely to create free apps and apps that received high scores on the combined content and diversity or features scoresheet, respectively.

Conclusions: Features and educational content related to milk production and breastfeeding imagery within breastfeeding apps were evaluated using three novel scoresheets informed by Social Cognitive Theory. Few apps contained both features that promote breastfeeding self-efficacy and high-quality, engaging, educational content with images of diverse caretakers. Thus, it is likely that parents, especially those from minority or low-income groups, have limited options when selecting a breastfeeding app. App developers could use the scoresheets and findings in this review to develop breastfeeding apps that assist mothers with interpreting, tracking, or learning about milk production through high-quality and engaging features, content, and imagery.

Read full text here

Lactose is the primary carbohydrate in the milk of most mammals and is unique in that it is only synthesized by epithelial cells in the mammary glands. Lactose is also essential for the development and nutrition of infants. Across species, the concentration of lactose in milk holds a strong positive correlation with overall milk volume. Additionally, there is a range of examples where the onset of lactose synthesis as well as the content of lactose in milk varies between species and throughout a lactation. Despite this diversity, the precursors, genes, proteins and ions that regulate lactose synthesis have not received the depth of study they likely deserve relative to the significance of this simple and abundant molecule. Through this review, our objective is to highlight the requirements for lactose synthesis at the biochemical, cellular and temporal levels through a comparative approach. This overview also serves as the prelude to a companion review describing the dietary, hormonal, molecular, and genetic factors that regulate lactose synthesis. Read the full, open access research article here.

Milk is critical for the survival of all mammalian offspring, where its production by a mammary gland is also positively associated with its lactose concentration. A clearer understanding of the factors that regulate lactose synthesis stands to direct strategies for improving neonatal health while also highlighting opportunities to manipulate and improve milk production and composition. In this review we draw a cross-species comparison of the extra- and intramammary factors that regulate lactose synthesis, with a special focus on humans, dairy animals, and rodents. We outline the various factors known to influence lactose synthesis including diet, hormones, and substrate supply, as well as the intracellular molecular and genetic mechanisms. We also discuss the strengths and limitations of various in vivo and in vitro systems for the study of lactose synthesis, which remains an important research gap. Read the full, open access research article here.