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Fulltext Study protocol: An investigation of mother-infant signalling during breastfeeding using a randomised trial to test the effectiveness of breastfeeding relaxation therapy on maternal psychological state, breast milk production and infant behaviour and growth

Shukri NHM, Wells J, Mukhtar F, Lee MHS, Fewtrell M

Int Breastfeed J, 2017;12:33.
PMID: 28725257 DOI: 10.1186/s13006-017-0124-y

BACKGROUND: The physiological and psychological signalling between mother and infant during lactation is one of the prominent mother-infant factors that may influence breastfeeding outcomes. The infant can 'signal' his needs through vocalisation, and the mother can respond by allowing or restricting nipple access, which might alter the breast milk composition or volume. This may lead to parent-offspring conflict during the lactation period. Challenging infant behaviour has also been associated with maternal psychological distress, which might affect breastfeeding performance. Most attempts to improve breastfeeding rates focus on providing additional support, yet many aspects of the breastfeeding process are poorly understood. Thus, our objective is to investigate mother-infant signalling during breastfeeding by manipulating maternal psychological state using a relaxation therapy intervention. The study will test the hypothesis that mothers who listen to the therapy will be more relaxed/less stressed and this will favourably alter breast milk composition and/or affect milk volume and hence influence infant outcomes.
METHODS: A randomised controlled trial will be conducted in first-time breastfeeding mothers and their new-born infants. Pregnant mothers will be recruited at antenatal clinics in Selangor, Malaysia, and four home visits will be carried out at 2, 6, 12 and 14 weeks postnatally. Participants will be randomised into a control and an intervention group in the early post-partum period. Mothers from the intervention group will be asked to listen daily to an audio recording with relaxation therapy during breastfeeding. Maternal psychological state, breastfeeding practices and infant behaviour will be assessed using validated questionnaires. Milk volume will be measured using stable isotopes. Breast milk samples will be collected to measure macronutrient content and hormone levels. Anthropometric measurements (weight, length and head circumference) will be performed during all home visits, including body composition at week 14.
DISCUSSION: The main outcomes will be the effect of the intervention on maternal psychological state, milk production, cortisol levels, and infant behaviour and growth. Secondary outcomes will be associations between breast milk composition and infant appetite and growth. This study aims to provide a greater understanding of maternal-infant factors which influence breastfeeding outcomes and which may be useful targets for future interventions.
TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01971216.
COVID-19 Restrictions and Maternal Experience and Infant Feeding

Shukri NHM, Ying GW, Zalbahar N, Tusimin M, Nasri NM

Nurs Res, 2021 Nov 23.
PMID: 34818264 DOI: 10.1097/NNR.0000000000000568

BACKGROUND: The Movement Control Order (MCO), also known as the partial lockdown, was introduced in Malaysia in March 2020 to combat the COVID-19 pandemic, changing many public-sector protocols and regulations. This may have implications for neonatal and maternity care and services, especially among new mothers.
OBJECTIVE: To compare the postnatal experiences and feeding practices between mothers who gave birth before MCO (B-MCO) and during MCO (D-MCO).
METHOD: 1,051 mothers with an infant under 18 months in Malaysia completed an online survey between July 2020 and October 2020. The survey advertisement was disseminated online via various social media platforms.
RESULTS: More D-MCO mothers faced a significant effect on the ability to pay rent/mortgage, with their spouses facing a higher impact on employment. D-MCO mothers were more likely to have changed their birth plans, perceived insufficient breastfeeding support, and experienced changes in postnatal services since MCO. In contrast, more B-MCO mothers had stopped breastfeeding during the MCO and started complementary feeding earlier than planned. Many mothers reported feeling down, lonely, and having sleeping trouble and a poor appetite. D-MCO mothers had more time to focus on their health, whereas B-MCO mothers spent more time outdoors.
DISCUSSION: MCO affected mothers' livelihood and postnatal experiences, potentially causing emotional distress. Hence, improved breastfeeding support, particularly at birth, is recommended, as is routine mental health screening during the postnatal check-up. Furthermore, since online contact was readily accessible during the pandemic, the efficacy of online breastfeeding support should be evaluated.
Fulltext Maternal melatonin levels and temporal dietary intake: results from MY-CARE cohort study

Teoh AN, Kaur S, Shafie SR, Shukri NHM, Bustami NA, Takahashi M, et al.

BMC Pregnancy Childbirth, 2023 Jul 04;23(1):491.
PMID: 37403031 DOI: 10.1186/s12884-023-05796-y

Chrononutrition emerges as a novel approach to promote circadian alignment and metabolic health by means of time-of-the-day dietary intake. However, the relationship between maternal circadian rhythm and temporal dietary intake during pregnancy remains understudied. This study aimed to determine the change in melatonin levels in pregnant women across gestation and its association with temporal energy and macronutrient intake. This was a prospective cohort involving 70 healthy primigravidas. During the second and third trimesters, pregnant women provided salivary samples collected at 9:00, 15:00, 21:00, and 3:00 h over a 24 h day for melatonin assay. Data on chrononutrition characteristics were collected using a 3-day food record. Parameters derived from melatonin measurements including mean, amplitude, maximal level, area under the curve with respect to increase (AUCI), and area under the curve with respect to ground (AUCG) were computed. A rhythmic melatonin secretion over the day that remained stable across trimesters was observed among the pregnant women. There was no significant elevation in salivary melatonin levels as pregnancy advanced. In the second trimester, higher energy intake during 12:00-15:59 h and 19:00-06:59 h predicted a steeper melatonin AUCI (β=-0.32, p = 0.034) and higher AUCG (β = 0.26, p = 0.042), respectively. Macronutrient intake within 12:00-15:59 h was negatively associated with mean melatonin (Fat: β=-0.28, p = 0.041) and AUCG (Carbohydrate: β=-0.37, p = 0.003; Protein: β=-0.27, p = 0.036; Fat: β=-0.32, p = 0.014). As pregnant women progressed from the second to the third trimester, a flatter AUCI was associated with a reduced carbohydrate intake during 12:00-15:59 h (β=-0.40, p = 0.026). No significant association was detected during the third trimester. Our findings show that higher energy and macronutrient intakes particularly during 12:00-15:59 h and 19:00-06:59 h are associated with the disparities in maternal melatonin levels. Findings suggest the potential of time-based dietary approaches to entrain circadian rhythm in pregnant women.
Fulltext Parental support and exclusive breastfeeding at 3 months in West Java, Indonesia: a mixed-methods approach

Sartika RAD, Wirawan F, Gunawan W, Putri PN, Shukri NHM

Clin Exp Pediatr, 2024 Jul;67(7):358-367.
PMID: 38902920 DOI: 10.3345/cep.2023.01375

BACKGROUND: The exclusive breastfeeding (EBF) rate in Indonesia is lower than expected. Among the key factors affecting breastfeeding practices, paternal support has been suggested.
PURPOSE: To explore the role of paternal support in EBF failure among 3-month-old infants.
METHODS: This sequential mixed-methods study, part of an ongoing cohort study in West Java in early 2022, included 225 infants. The parents of 3-month-old infants were interviewed. Paternal support was assessed using a 15-point validated questionnaire for a total score of 15-60 points. Multivariate binary regression was used to determine adjusted odds ratios (aORs). The qualitative exploration was based on in-depth interviews (IDIs) and forum group discussions (FGDs) following the quantitative survey.
RESULTS: Of the 225 infants, 52.2% were no longer EBF. High paternal support (greater than the mean score) of breastfeeding was determined in 52.9% of cases (mean± standard deviation, 38.7±6.7 for the overall population vs. 37.5±6.3 and 40.2±6.8 for infants who were and were not EBF at 3 months of age, respectively). Low paternal support was associated with an increased EBF failure rate (aOR, 2.84; 95% confidence interval [CI], 1.46-5.54). Other variables that remained as predictors in the final model were a low birth rate (aOR, 7.35; 95% CI, 1.73-31.20), negative maternal attitude (aOR, 3.31; 95% CI, 1.63-6.75), lower self-efficacy (aOR, 4.82; 95% CI, 2.43-9.57), and lower maternal education level (aOR, 2.87; 95% CI, 1.03- 8.03). The IDIs and FGD observed the importance of the father's support of the mother and EBF. The qualitative exploration revealed a lack of knowledge about EBF as a parental support barrier.
CONCLUSION: Paternal support is important for EBF. Paternal involvement in EBF planning encouraged themother to continue. Plans that include fathers in breastfeeding education may help increase paternal support.
Fulltext Circadian rhythm and its association with birth and infant outcomes: research protocol of a prospective cohort study

Kaur S, Teoh AN, Shukri NHM, Shafie SR, Bustami NA, Takahashi M, et al.

BMC Pregnancy Childbirth, 2020 Feb 11;20(1):96.
PMID: 32046676 DOI: 10.1186/s12884-020-2797-2

BACKGROUND: Circadian rhythm plays an important role as our internal body's clock that synchronizes behavior and physiology according to the external 24-h light-dark cycle. Past studies have associated disrupted circadian rhythm with higher risk of miscarriages, preterm birth and low birth weights. This paper described the protocol of a prospective cohort study which aims to determine the circadian rhythm in pregnant women, identify its association with maternal factors during pregnancy, gestational weight gain, birth and infant outcomes.
METHODS: Ten government maternal and child health clinics in Kuala Lumpur, Malaysia will be randomly selected. Sample size of 438 first-trimester pregnant women will be followed-up until the birth of their infant. Salivary melatonin and cortisol concentration among subsample will be determined using enzyme-linked immunosorbent assay. Data on sleep quality, psychological distress and morningness/eveningness chronotype of pregnant women will be collected using validated questionnaires. Pedometer will be used to measure 5-day physical activity data. Total gestational weight gain will be determined at the end of pregnancy. Utilization of 3-day food record is to capture meal timing and nutrient intake. All measurements will be done in 2nd and 3rd trimester. Birth outcomes will be collected through clinic records and Centers for Disease Control and Prevention (CDC) Neonatal questionnaire. Infants will be followed-up at 6 and 12 months old to obtain anthropometric measurements.
DISCUSSION: There is a growing recognition of the role of maternal circadian rhythm, which entrains fetal circadian rhythms that may subsequently have long-term health consequences. The present study will identify the effect of circadian rhythm on pregnancy outcomes and infant growth in the first year of life.