Abstracts from the 19th International Society for

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talk will use several examples of different guidelines regarding breastfeeding to ..... Co-Authors: Michelle K. McGuire, Avery Lane, Kimberly Lackey,. Abhishek ...
BREASTFEEDING MEDICINE Volume 13, Number 7, 2018 ª Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2018.29100.abstracts

Abstracts 19th International Society for Research in Human Milk and Lactation (ISRHML) Conference

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October 7–11, 2018 Kanagawa, Japan

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Abstracts from the 19th International Society for Research in Human Milk and Lactation Conference Workshops reviewed and updated as necessary every 5 years. A description of the process of development of a recent protocol will be highlighted.

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W-1. CASE STUDIES OF DEVELOPING BREASTFEEDING GUIDELINES AT CDC Presenting Author: Cria G. Perrine, Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity and Obesity

The U.S. Centers for Disease Control and Prevention (CDC) is the country’s lead health protection agency and is recognized for using the highest quality scientific information available as part of making public health decisions. Because of the breadth of public health topics and different settings and audiences that guidance may apply to, CDC does not use a single approach for developing guidelines. Instead, general standards exist, and a number of factors are then considered for each context. This talk will use several examples of different guidelines regarding breastfeeding to consider factors such as when guidance is necessary, consistency with other Federal and global agencies, decision making when evidence may be limited, the importance of getting feedback from key partners and stakeholders, and considerations for potential revisions or clarifications of the guidelines as needed after release. W-2. DEVELOPMENT OF CLINICAL PROTOCOLS AT THE ACADEMY OF BREASTFEEDING MEDICINE: A CASE-STUDY Presenting Author: Tomoko Seo, Protocol Committee, The Academy of Breastfeeding Medicine

A central goal of The Academy of Breastfeeding Medicine (ABM) is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. The Protocol Committee defines a need for a protocol to be developed and appoints the Authors/Expert Panel. Then a summary of the purpose of the protocol and an annotated bibliography is submitted by the Expert Panel. The draft protocol is peer-reviewed by international reviewers. After all revisions are evaluated and necessary changes made, the final protocol is submitted to the Board of Directors of the ABM for approval. ABM aims for clinical protocols to be practical, evidence-based, and applicable across the globe. Sometimes insufficient evidence, variation in medical systems, and cultural diversity can make the process of developing and implementing clinical protocols difficult hard. Protocols and annotated bibliographies are

W-3. DEVELOPMENT OF EVIDENCE-BASED GUIDELINES AT THE WORLD HEALTH ORGANIZATION: A CASE-STUDY OF THE TEN STEPS TO SUCCESSFUL BREASTFEEDING Presenting Author: Laurence M. Grummer-Strawn, World Health Organization, Department of Nutrition for Health and Development

WHO has adopted internationally recognized methods and standards for guideline development to ensure that its guidelines are of the highest quality. WHO recommendations must be based on a systematic and comprehensive assessment of the balance of a policy’s or intervention’s potential benefits and harms and explicit consideration of other relevant factors. The process is multidisciplinary, aiming to minimize any risk of bias in the recommendations. The Ten Steps to Successful Breastfeeding were first published in 1989, long before the current WHO guideline development process was codified. As such, the development of recommendations on the appropriate policies and procedures for facility care of early infant feeding was treated as a new guideline. The WHO Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services was published in November 2017 and an updated list of the Ten Steps to Successful Breastfeeding was published in April 2018. This presentation will discuss the advantages and disadvantages of systematic reviews in developing guidelines, the use of different kinds of evidence (RCTs, observational studies on humans, animal studies, biologic mechanisms, and qualitative research), involvement of expert groups vs. objective panels to review evidence, management of conflicts of interest, and peer review and public comment processes. Examples of how these issues were handled in developing the Ten Steps will be offered. W-4. U.S. FEDERAL EFFORTS TO ADVANCE KNOWLEDGE ON HUMAN MILK COMPOSITION Presenting Author: Kellie Casavale, U.S. Department of Health and Human Services (HHS), Office of Disease Prevention and Health Promotion (ODPHP)

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Co-Authors: Richard Olson, Julia Quam (ODPHP, HHS); Christopher Lynch (National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health); Pamela Pehrsson, Jaspreet Ahuja, Xianli Wu, Ying Li (Agricultural Research Service, U.S. Department of Agriculture)

Nationally representative data from mother-child dyads that capture human milk composition, factors influencing it, and subsequent health effects are crucial to advancing the science base used to inform Federal nutrition and health programs, policies, and consumer information across agencies in the U.S. and Canada and in non-government sectors. U.S. food composition data for human milk (also used in Canada) are outdated; published literature is not adequate to update them. In response, Federal agencies have begun collaborative efforts to establish an initiative on human milk composition. The NIH sponsored a workshop in 2017 with ODPHP and ARS to gather information on data needs; factors affecting human milk composition; methodological challenges in human milk collection, storage, and analysis; and visions for a research program to develop a human milk composition database. Key applications of these data include updating human milk food composition profile(s); informing Dietary Reference Intakes, dietary guidelines, and Codex Alimentarius; monitoring nutrient and other exposures; and advancing research on human milk exposure related to short- and long-term health. In addition to the workshop, initial activities of this initiative include 1) prioritizing human milk components and related data based on public health importance (e.g., potential to inform dietand/or nutrient-based guidance or clinical practice guidelines) and 2) identifying and/or developing standard protocols and validated measures to collect these data. Efforts aim to establish public-use data repositories with substantive, nationally representative metadata. W-5. WHAT’S NORMAL FOR HUMAN MILK COMPOSITION: LESSONS LEARNED FROM THE INSPIRE PROJECT Presenting Author: Michelle K. McGuire, Washington State University (WSU) Co-Authors: Courtney Meehan (WSU), Mark A. McGuire (University of Idaho), Janet Williams (University of Idaho), and the INSPIRE Consortium

The primary focus of the INSPIRE project was to characterize the human milk microbiome in selected locations around the globe and begin understanding biological, environmental, and behavioral factors related to its variation. In all, data and biological samples were collected from 412 mother-infant dyads in 11 locations. This project represented the first large-scale multinational human milk study for several members of the core investigative group. As such, there have been many lessons learned. For example, standardizing, assembling, and providing all collection supplies was fundamental to both successful sample collection and establishing confidence that differences among cohorts were genuine. The early compilation of an operations manual that included not only detailed sample collection methods but

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also other important information such as publication ‘‘rules of the road’’ and shipping instructions both codified approaches and helped collaborators quickly answer questions as they arose. Social media and frequent communication helped create momentum, community, and enthusiasm as the project progressed. Some unexpected difficulties included the fact that we underestimated the need for a secure, inexpensive, user-friendly data management and distribution plan and dedicated personnel to administer it. We also encountered some unexpected difficulties garnering ethics approvals in some locations; shipping milk collection supplies to another; and securing dry ice for shipping the samples to the US. Although the INSPIRE team enjoyed an allhands retreat after the samples and data were collected and most of the analyses completed, an addition meeting earlier in the project would have been beneficial. These issues and others will be discussed by members of the INSPIRE Consortium. Funding: National Science Foundation.

W-6. THE MOTHERS, INFANTS AND LACTATION QUALITY (MILQ) PROJECT Presenting Author: Lindsay H. Allen, USDA-ARS Western Human Nutrition Research Center (WHNRC), Davis, California

Reported values for nutrient concentrations in human milk are needed to set infant and maternal recommended intakes. However, there are no valid Reference Values (RVs) for nutrients in milk. Existing data have many limitations. There relatively few studies of milk composition and concentrations of many nutrients are affected by maternal status and/or intake, consumption of supplements during pregnancy and/or lactation, and food fortification. Moreover, concentrations of most nutrients in milk change during the first year postpartum, and some vary during a feed and during the day. Analytical methods that measure nutrients in milk usually need to be different from those used for serum and some older methods are invalid. The ongoing Mothers, Infants and Lactation Quality (MILQ) study aims to develop valid RVs for milk. Research sites are Copenhagen (Denmark), Dhaka (Bangladesh), Bakoteh (The Gambia) and Rio de Janeiro (Brazil). Inclusion and exclusion criteria are designed to recruit well-nourished, healthy mothers not consuming supplements other than iron, folic acid and calcium (these supplements do not affect the milk nutrient concentration) or heavily fortified foods. Mothers are recruited during pregnancy and within 2-3 days of birth colostrum is collected. Additional milk and blood samples are collected from 250 mothers and infants per site between 1 and 3.49 mo, 3.5 and 5.99 mo, and 6 and 8.49 mo. Exclusive breastfeeding is required through 3.49 mo. The volume of milk consumed by infants is measured with deuterated water at each time point to determine actual infant nutrient intakes. The RVs will be constructed as percentile reference curves so that samples from other surveys and studies can be readily compared. The nutrients will be measured at the WHNRC with 5 analytical platforms including mass spectrometry. Funding: USDA, ARS and the Bill & Melinda Gates Foundation.

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W-7. GLOBAL EXPLORATION OF HUMAN MILK (GEHM): A LONGITUDINAL STUDY OF HUMAN MILK COMPOSITION IN URBAN POPULATIONS OF MEXICO, CHINA, AND THE UNITED STATES Presenting Author: Ardythe Morrow, University of Cincinnati, Cincinnati, OH Co-Authors: Allison Cline (University of Cincinnati); Sarah Maria, Robert J. McMahon, Shay Phillips (Mead Johnson Nutrition, Evansville, IN); Christina Valentine (University of Cincinnati and Mead Johnson Nutrition, Evansville, IN)

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Knowledge of human milk composition is critical for establishing dietary guidelines and the nutritional standards for

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breast milk substitutes. While human milk composition has been studied over many decades, it has nevertheless not been well defined. Lack of robust characterization of human milk components has been due to several limitations: the number of components to be analyzed; limitations in milk and data collection methods; and the lack of standardized, comparative studies in recent years. Human milk is known to be highly variable, influenced by stage of lactation, time of day, genetics, maternal diet, and environment. Nevertheless, the role of each of these influences has not been well defined for the many components of human milk. And it is not clear how variable or consistent the composition of human milk is across populations. Funding: NICHD P01 13021; CTSA grant; Mead Johnson Nutrition.

Oral Presentations O-1. CAN DIGITAL TOOLS PROMOTE COMPETENCE AND SUCCESS OF BREASTFEEDING PROMOTION?

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Presenting Author: Sunhea Choi, University of Southampton, UK, Human Development & Health Academic Unit

Reviews of breastfeeding intervention studies have shown that breastfeeding education and support, given during prenatal and postpartum periods with routine care by health professionals or non-health professionals, significantly increase exclusive breastfeeding and initiation of breastfeeding. Despite education and other interventions proven to be effective, the UNICEF reports that the progress to improve exclusive breastfeeding has stagnated over the past 15 years, with early initiation of breastfeeding 50% in infants aged 0–6 months by 2020 and further increases by 10% by 2030. Objective/Hypothesis: To develop specific guidelines and recommendations for breastfeeding promotion in China. Methods: A multidisciplinary working group developed evidence-based, practical guidelines targeting mothers, healthy infants, and infants with specific needs. Guidelines referenced existing domestic and international practices, while considering the current situation in contemporary China. Results: Guidelines were targeted 3 stages. In obstetrics, preparations for pregnancy and lactation, depression in pregnancy/lactation, insufficient milk secretion, crater nipple and mammary duct obstruction and mastitis, etc were addressed. In neonatology, the guideline includes intervention measures to promote early breastfeeding and early milk secretion, skin contact etc. In pediatrics, the guideline addresses assessment of breastfeeding efficacy, applications of growth curves, use of the Human Breastfeeding Assessment Scale and insufficient milk secretion, cow’s milk protein allergy and poor growth, etc. Conclusions: The guidelines provide scientific support for the actions promoted by the Ministry of Health and should play an important role in breastfeeding promotion in China. Funding: Chinese Journal of Pediatrics.

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O-5. EXCLUSIVE BREASTFEEDING POSSIBLY REDUCES THE ADVERSE EFFECT OF LATE PRETERM BIRTH ON GASTROINTESTINAL INFECTION Presenting Author: Kazue Nakamura, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Department of Epidemiology Co-Authors: Takashi Yorifuji (Okayama University Graduate School of Environmental and Life Science – Department of Human Ecology); Hiroyuki Doi (Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences – Department of Epidemiology)

Background: Late preterm infants (LPIs) are at greater risk of short- and long-term morbidity than are term infants (TIs). However, whether breastfeeding can reduce the adverse effect of late preterm birth on various diseases remains unclear. Hypothesis: Breastfeeding can modify the adverse effects of late preterm birth on hospitalization for respiratory and gastrointestinal infection from 6 to 18 months of age. Methods: Data were extracted from a nationwide longitudinal survey of Japanese children. We restricted the analysis to TIs and LPIs with information on history of hospitalization (n = 31,578). Multivariate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated to evaluate the association between late preterm birth and hospitalization using term birth as the reference. We next stratified the infants by breastfeeding status (exclusively breastfeeding vs. partially breastfeeding and formula-feeding) and evaluated the association between late preterm birth and hospitalization. Results: LPIs were more likely to be hospitalized for respiratory and gastrointestinal infection (aOR, 1.52; 95% CI, 1.21–1.92 and aOR, 1.73; 95% CI, 1.14–2.62, respectively). Stratification by breastfeeding status showed that LPIs had a higher risk of hospitalization for respiratory infection in both strata. Conversely, a higher risk of hospitalization for gastrointestinal infection was observed only in the partially breastfeeding and formula-feeding stratum. Conclusions: The higher morbidity risk in LPIs than TIs was modified by breastfeeding practices. Exclusive breastfeeding seems to reduce the adverse effect of late preterm birth on gastrointestinal infection. O-6. WHAT’S NORMAL? GLOBAL VARIATION IN HUMAN MILK MICROBIOME AND OTHER RELATED FACTORS Presenting Author: Janet Williams, University of Idaho

The human milk microbiome consists of myriad types of bacteria, the presence and composition of which have varied across cohorts and studies. Variation has been associated with factors such as stage of lactation, maternal BMI, delivery mode, and maternal diet. Another major consideration in understanding this variation is understanding and controlling for potential effects of sampling and methodological differences on the results obtained. To better understand biological, behavioral, and environmental factors contributing to the variation seen in the milk microbiome, the INSPIRE

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study was conducted. Milk, maternal saliva, and infant feces were collected using standardized protocols and supplies, and detailed information regarding maternal dietary intake, social and behavioral patterns, and family structure was collected in 11 different locations around the world. Milk from each location was shipped to two laboratories (Spain and USA), where DNA from the milk samples were extracted using similar protocols, amplified using PCR primers targeting hypervariable regions of the 16S rRNA gene, sequenced, and data analyzed to characterize the milk samples’ bacterial compositions. Results from both laboratories suggest that Staphylococcus and Streptococcus were present in almost all milk samples, but more extensive sets of core bacteria were present in some of the cohorts. Importantly, substantial intraand inter-cohort variability existed in bacterial community membership within and among cohorts. Variation in the milk bacterial community was also associated with many factors, including the intake of various foods; for instance, relative abundance of Proteobacteria was higher in milk produced by women who consumed meat than those that did not. By minimizing the differences in collection and sample processing, similarities/dissimilarities in milk bacterial compositions among locations and other factors that are associated with this variation can be better identified.

O-7. HUMAN MILK OLIGOSACCHARIDES: MATERNAL MODIFIERS AND INFANT OUTCOMES Presenting Author: Lars Bode, University of California, San Diego, Department of Pediatrics and Larsson-Rosenquist Foundation Mother-Milk-Infant Center of Research Excellence, La Jolla, California, USA

The past decade has experienced an immense increase in research on human milk oligosaccharides (HMOs), a group of over 150 unconjugated complex glycans that, together, represent the third most abundant solid component of human milk. Our continuously evolving analytical platform allows us to generate reliable HMO composition data from less than a drop of milk – and from several hundred milk samples per week. This high-throughput approach has enabled us, together with our collaborators from around the world, to investigate which maternal genetic and environmental factors influence HMO composition as well as how HMO composition impacts health and development of infants and mothers. In parallel to our analytical platform that enables HMO analyses for hypothesesgenerating cohort studies, we developed a preparative platform to extract HMOs from pooled donor human milk for efficacy testing in suitable in vitro and in vivo models. We carefully ensure that our HMO preparations are very low in lactose, salt, and endotoxin contaminations, which might otherwise compromise research results. After initial efficacy testing of pooled HMOs, we apply a multi-dimensional chromatography approach for the stepwise fractionation of HMOs to determine structure-function relationships. So far, this approach of combining association data from human cohort studies with efficacy data from in vitro and in vivo testing has taught us that sometimes specific HMOs are required to exert an effect that is highly structure-specific, dose-dependent, and likely receptormediated. Other times, specific HMO composition profiles (mixtures of HMOs in specific ratios) are required, and the

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effect is likely mediated through shaping microbial communities and/or intricate host immune responses.

O-8. IMPACT OF DIET ON THE INFANT METABOLOME, MICROBIOME AND IMMUNE DEVELOPMENT Presenting Author: Carolyn M. Slupsky, University of California, Davis, Department of Nutrition and Department of Food Science and Technology

The link between food and health is complex, particularly for the developing neonate, as the period after birth is the time when long term programming is occurring in the neurologic, immune and metabolic regulatory systems. Breastfeeding is known to have short- and long-term benefits, and we have previously reported profound differences between breast-fed and formula-fed infants with respect to growth trajectory, immunological development, succession of the gut microbiome and metabolism that indicate development of unique metabolic phenotypes as a consequence of diet. While the world health organization (WHO) advises that no other food other than human milk be introduced before 6 months of age, many infants are supplemented with formula or encouraged to consume complementary foods even before 4 months of age. To date, not much is known about the impact of other foods introduced during the first 6 months on the microbiome and metabolism. To investigate how complementary feeding affects the gut microbiome and overall host metabolism, fecal microbial ecology combined with comprehensive metabolic profiling of serum and feces were analyzed in breast- and formula- fed infants. Our results highlight the need for a greater understanding of how the introduction of complementary foods shape immunity and metabolism in the developing neonate. O-9. IMMUNE COMPONENTS IN HUMAN MILK ARE ASSOCIATED WITH EARLY INFANT IMMUNOLOGICAL HEALTH OUTCOMES: A PROSPECTIVE THREE-COUNTRY ANALYSIS Presenting Author: Donna Geddes, University of Western Australia, School of Molecular Sciences Co-Authors: Daniel Munblit, Robert Boyle, John Warner (Imperial College London - Department of Paediatrics); Marina Treneva, Alexander Pampura (Veltischev Clinical Pediatric Research Institute of Pirogov Russian National Research - Allergy Department); Diego G. Peroni (University of Pisa - Department of Paediatrics); Silvia Colicino, (Imperial College London - National Heart and Lung Institute); Li Yan Chow (Imperial College London - Department of Paediatrics); Shobana Dissanayeke (Royal Holloway University of London School of Biological Sciences Biomedical Sciences); Attilio L. Boner (University of Verona – Department of Paediatrics)

Background: Evidence of the mechanisms by which breastfeeding may improve allergic outcomes in early childhood has not been elucidated. Immune mediators in human milk (HM) may contribute to infant immune maturation as well as protection against atopy/allergy.

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Objective: The aim of this study was to investigate relationships between levels of immune mediators in colostrum and mature milk and infant outcomes in the first year of life. Methods: 398 pregnant/lactating women in the United Kingdom, Russia and Italy were recruited and provide samples of colostrum and mature human milk (HM). Samples were analysed for immune components. Results: HM interleukin (IL) 13 was associated with less eczema and colostral IL13 was linked to less food allergy. Hepatocyte growth factor was protective for common cold incidence at 12 months. Whereas transforming growth factor 2 was associated with a higher risk of eczema. Conclusions: Data from this study suggests that differences in the individual immune composition of HM may have an influence on early life infant health outcomes. Funding: DG receives a salary from an unrestricted research grant (Medela AG, Switzerland).

O-10. MULTI-COMPONENT CHARACTERIZATION OF BREAST MILK ‘‘GLYCOTYPES’’ IN POPULATIONS AT HIGH- OR LOW-RISK FOR ALLERGIC DISEASES Presenting Author: Kirsi Jarvinen-Seppo, University of Rochester School of Medicine Co-Authors: Antti Seppo, Sade Fridy, Puja Sood Rajani, Juilee Thakar, R. John Looney (University of Rochester School of Medicine); Chloe Yonemitsu, Lars Bode (University of California San Diego)

Background: Our prior studies have shown that the Old Order Mennonite (OOM) population has a lower prevalence of allergic diseases and asthma than the general U.S. population. Objective: To determine if there is variation in breast milk immune composition between OOM, a low allergy risk population with long breastfeeding duration, and a control group from urban Rochester (ROC). Methods: Breast milk samples from a cohort of OOM (n = 60) and ROC (n = 31) mothers at 1–2 months of lactation were assayed for 39 cytokines by Luminex, 19 human milk oligosaccharides (HMOs) by HPLC and IgA1 and IgA2 to food (n = 4), inhalant antigens (n = ) and whole bacteria (n = 7) by Luminex. Levels were compared between groups and across components using parametric and non-parametric methods to analyze the impact of various maternal exposures on milk composition. Additionally, clustering analysis was performed to identify clusters of cytokines, HMOs and specific IgA. Results: Compared to ROC milk, OOM milk had significantly higher levels of TGFbeta2, IL10, and IL6. OOM milk also had significantly higher levels of IgA specific for L. reuteri and several inhalant and food antigens and lower levels of IgA specific to E. cloacae. Among HMOs, OOM had significantly higher LNnT and lower LNFPIII. Cytokine clustering showed grouping of BAFF, TSLP, sTNF-R2 with TWEAK and TGFbeta2 with IL6. Several bacteria-specific IgAs clustered together (E. coli, M. morganii, L. reuteri, S. aureus, E. cloacae), as do IgA against dust mite, mold, mouse, rat, birch, dog and cat.

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Conclusion: To our knowledge this is the first multicomponent characterization of breast milk between mothers with different lifestyles. OOM milk is richer in many immune components, which together with longer breastfeeding duration may provide protection against allergic diseases. Funding: University of Rochester Clinical and Translational Science Institute. O-11. NUTRIENTS OR NURSING? UNDERSTANDING HOW BREAST MILK FEEDING AFFECTS CHILD COGNITION Presenting Author: Wei Wei Pang, National University of Singapore (NUS) Co-Authors: PT Tan (NUS); S Cai (Singapore Institute for Clinical Sciences); D Fok (NUS); MC Chua, SB Lim (KK Women’s and Children’s Hospital); LP Shek (NUS and Singapore Institute for Clinical Sciences); KH Tan, F Yap (KK Women’s and Children’s Hospital), PD Gluckman (Liggins Institute); KM Godfrey (University of Southampton); MJ Meaney (McGill University); R van Dam (NUS); BFP Broekman (VU University Medical Center); MS Kramer (NUS and McGill University); YS Chong (NUS and Singapore Institute for Clinical Sciences); A Rifkin-Graboi (National Institute of Education, Singapore)

Background: It is unknown whether breastfeeding benefits child cognition through breast milk nutrients alone, the physical/emotional contact during breastfeeding, or a combination of both. Objective/Hypothesis: We explored the associations between mode of breast milk feeding (the ‘‘nursing’’) and type of milk feeding (the ‘‘nutrients’’) with child cognition. Methods: Healthy children from the GUSTO cohort participated in repeated neurodevelopmental assessments between 6 and 54 months. For content, we compared children exclusively bottle-fed according to type of milk received: formula only vs some/all breast milk. For mode, we included only children who were fully fed breast milk, comparing those fed directly at the breast vs those fed partially/completely by bottle. Results: Compared to children fed formula only, those who were bottle-fed breast milk demonstrated significantly better cognitive performance on both the Bayley Scales of Infant and Toddler Development-III and Kaufman Brief Intelligence Test-2 at 24 (adjusted mean differences; 95% CI: 1.36; 0.32, 2.40) and 54 (7.59; 1.20, 13.99) months, respectively. Children fed directly at the breast performed better at the deferred imitation task at 6 months (0.67; 0.02, 1.32) and relational binding tasks at 6 (0.41; 0.07, 0.74), 41 (0.67; 0.04, 1.29) and 54 (0.12; 0.01, 0.22) months vs children bottle-fed breast milk. Conclusions: These modest significant associations suggest that the nutritional content of breast milk may improve general child cognition, while feeding infants directly at the breast may benefit memory. Funding: NMRC/TCR/004-NUS/2008; NMRC/TCR/ 012-NUHS/2014, and the Singapore Institute for Clinical Sciences, Agency for Science Technology and Research (A*STAR).

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O-13. HUMAN MILK OLIGOSACCHARIDES (HMOS) AND EXCESSIVE WEIGHT GAIN IN EXCLUSIVELY BREASTFED INFANTS Presenting Author: Melanie W. Larsson, University of Copenhagen and University College Copenhagen, Denmark Co-Authors: Anni Larnkjær, Mads Lind, Christian Mølgaard (University of Copenhagen); Chloe Yonemitsu (University of California, San Diego); Kim Michaelsen (University of Copenhagen); Lars Bode (University of California, San Diego)

Background: Some infants have excessive weight gain during the first months of exclusive breastfeeding. HMO composition has been shown to be associated with infant growth and body composition. Objective/Hypothesis: To investigate the associations between HMOs and growth in infants with excessive or normal weight gain.

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Background: Human milk, which harbors a diverse microbiome, is an early and consistent source of bacteria to infants. However, there are no data or inconsistent results on whether or how the human milk microbiome (HMM) is related to maternal characteristics (age, parity, time postpartum, birth mode), household environments (household composition, animal exposure), and social and behavioral patterns (diversity of caregivers, intensity of maternal-infant interactions, and breastfeeding). Objective: We examined the relationships between women’s (n = 348) HMM diversity and community composition and maternal characteristics, household environments, and caregiving behaviors in 10 populations across Africa, Europe, and the Americas (the INSPIRE study). Methods: Human milk samples, demographic, and survey data were collected via standardized procedures. HMM community structure was determined by amplifying, sequencing, and classifying (to the genus level) the V1–V3 region of the bacterial 16S rRNA gene. Results: HMM alpha diversity and the relative abundance of specific genera (e.g., Dyella, Rhizobium, Achromobacter, Kocuria) were significantly associated to a host of maternal and household characteristics and social/behavioral patterns. Conclusion: Our results identify multiple external influences on HMM diversity and community composition and provide initial evidence suggesting that HMM diversity and composition may reflect short- and long-term environmental exposures, possibly priming infants for the worlds in which they are reared. Funding: National Science Foundation.

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Co-Authors: Michelle K. McGuire, Avery Lane, Kimberly Lackey, Abhishek Kaul (Washington State University); Mark A. McGuire, Janet Williams, William Price (University of Idaho); Debela Gindola (Hawassa University); the INSPIRE Consortium

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Presenting Author: Courtney L. Meehan, Washington State University – Department of Anthropology

Methods: HMOs were analyzed by HPCL in milk samples from mothers of 11 infants with excessive weight gain (mean increase in weight-for-age SDS from birth to 5 mo: 1.6, HW group) during exclusive breastfeeding (‡4 mo) and compared to a control group of 15 infants with normal weight gain (NW group). Infant body composition (bioimpedance at 5 mo), and infant weight and length (5 and 9 mo) and maternal BMI were measured. Results: All infants were included in the initial analysis. Three mothers of HW and two mothers of NW infants were non-secretors. At 5 mo LSTc, LNnT, diversity, and evenness were lower in the HW group with no difference between the groups at 9 mo. In an analysis of the combined HW and NW groups at 5 mo LNnT, LNFP-I and LSTc were negatively associated with length-for-age SDS. Furthermore, percentage fat mass was negatively associated with diversity, evenness and LNH. Maternal BMI was negatively associated with 6¢SL, LNT, LSTb, and DSLNT and positively associated with total HMOs and HMO-bound fucose. Conclusions: These data support that HMO composition is related to both infant growth and body composition. Furthermore, they suggest that maternal BMI has an effect on HMO composition with potential impact on infant health and disease. Funding: University College Copenhagen, University of Copenhagen and Family Larsson-Rosenquist Foundation.

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O-12. ENVIRONMENTAL, SOCIAL, AND BEHAVIORAL CHARACTERISTICS AND THE HUMAN MILK MICROBIOME

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O-15. THE IMPACT OF MATERNAL VITAMIN DEFICIENCIES AND SUPPLEMENTATION ON BREAST MILK LEVELS AND INFANT VITAMIN STATUS

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Presenting Author: Lindsay H. Allen, USDA-ARS Western Human Nutrition Research Center (WHNRC), Davis, California

It has been known for several decades that maternal vitamin deficiencies can lead to low vitamin concentrations in milk. In 1994, we suggested that in lactation micronutrients can be categorized into two groups. Group I micronutrients include all the B vitamins except folate, all the fat soluble vitamins, iodine, selenium, and probably choline. The concentration of these nutrients in milk is correlated with maternal status, and maternal deficiency can lead to infant depletion. Conversely, maternal supplementation can increase their concentration in milk. There are fewer Type II micronutrients; folate, iron, minerals such as iron, copper and zinc, and calcium. Status or intake of the mother, including supplementation, does not affect levels of these nutrients in milk, so the mother may become more depleted during lactation while her infant is protected. There are still many questions around this general classification scheme, however. How deficient does the mother have to be before milk concentrations fall low enough to adversely affect infant status? There are few data on this question for several reasons; reluctance to question the nutritional quality of milk, difficulties related to milk sampling and analysis protocols, and lack of reference values for milk micronutrients and infant status. Similarly, data are sparse concerning the effects of maternal supplementation on milk micronutrients and infant status. For some vitamins, maternal supplementation during pregnancy may be most important so that the infant accumulates adequate stores in utero. For others, milk concentrations are responsive if the mother is supplemented during lactation, with the amount of response differing among vitamins. In general 12 months was associated with reduced risk of breast and ovarian carcinoma by 26% and 37%, respectively. No conclusive evidence of an association between breastfeeding and bone mineral density was found. Breastfeeding was associated with 32% lower risk of type 2 diabetes. Exclusive breastfeeding and predominant breastfeeding were associated with longer duration of amenorrhoea. Shorter duration of breastfeeding was associated with higher risk of postpartum depression. Evidence suggesting an association of breastfeeding with postpartum weight change was lacking. Conclusion: This review supports the hypothesis that breastfeeding is protective against breast and ovarian carcinoma, and exclusive breastfeeding and predominant breastfeeding increase the duration of lactational amenorrhoea. There is evidence that breastfeeding reduces the risk of type 2 diabetes. However, an association between breastfeeding and bone mineral density or maternal depression or postpartum weight change was not evident.

O-22. THE BURDEN OF SUBOPTIMAL BREASTFEEDING IN MEXICO: MATERNAL HEALTH OUTCOMES AND COSTS Presenting Author: Teresita Gonza´lez de Cosı´o, Universidad Iberoamericana, Mexico, Health Department Co-Authors: Mishel Unar-Munguı´a, Dalia Stern, M. Arantxa Colchero (National Institute of Public Health, Mexico)

Background: Longer duration of breastfeeding has been associated with a lower risk of diabetes, breast and ovarian cancer, myocardial infarction and hypertension in women. Mexico has one of the lowest breastfeeding rates worldwide, therefore estimating the disease and economic burden of such rates is needed to influence public policy. Objective: Quantify the lifetime excess cases of maternal health outcomes, premature death, DALYs, direct costs and indirect costs attributable to suboptimal breastfeeding practices, using rates in Mexico in 2012. Methods: Static microsimulation model for a hypothetical cohort of 100,000 Mexican women were used to estimate the lifetime economic cost and disease burden in mothers, due to suboptimal breastfeeding under 2012 breastfeeding rates, compared to an optimal scenario of 95% of parous women breastfeeding for 24 months. Results: The 2012 suboptimal scenario was associated with 5,344 more cases of ALL diseases, 1,681 additional premature deaths and 66,873 DALYs as well as 561.94 million USD for direct and indirect costs over the lifetime of a cohort of 1,116 million Mexican women aged 15 in 2012, if 95% of parous women breastfed for 24 months per child. Conclusions: Findings suggest that investments in strategies to enable more women to optimally breastfeed could result in important health and cost savings. Funding: Promotora Social Me´xico and Universidad Iberoamericana.

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O-23. BREASTFEEDING AND GYNAECOLOGICAL CANCER

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Presenting Author: Susan Jordan, QIMR Berghofer Medical Research Institute, Population Health Department, Brisbane Australia

Breastfeeding has marked effects on maternal reproductive hormone levels and consistent evidence indicates that it reduces maternal risk of breast cancer. However, its association with other hormonally-related cancers such as endometrial and ovarian cancers is much less clear. Indeed, in its Continuous Update Project, the World Cancer Research Fund found there was insufficient evidence to evaluate whether there was an association with endometrial cancer (2013) and that evidence for an association with ovarian cancer was limited but suggestive of a decrease in risk (2014).1 We have conducted case-control analyses and pooled analyses of case-control and cohort studies to examine these relationships. Using our results and those from the literature we have also calculated the proportions of ovarian and endometrial cancers that may be attributed to a lack of breastfeeding. Notwithstanding some heterogeneity of findings across studies, our pooled analysis of endometrial cancer (8981 women diagnosed in the United States, Europe, Asia and Australia) suggested ever breastfeeding reduced the risk of endometrial cancer by *10%, with greater reductions for longer durations of breastfeeding. Our ovarian cancer studies showed similarly protective associations with breastfeeding, results consistent with most, although not all, recent findings. Assuming that the observed associations are causal, our estimates suggest that as many as 4–9% of these gynaecological cancers might be attributable to no or limited breastfeeding, equating to >35,000 cancers worldwide each year. Our results therefore suggest that in addition to established benefits for babies, supporting women to commence and continue breastfeeding for recommended periods could also contribute to the prevention of these increasingly common cancers. Funding: While conducting this work, SJ was supported by fellowships from the National Health and Medical Research Council of Australia. O-24. MATERNAL TIME AND NURTURING CARE; ASSOCIATIONS BETWEEN BREASTFEEDING PRACTICE, TIME SPENT INTERACTING WITH BABY, AND SLEEP Presenting Author: Julie P. Smith, Australian National University - Research School of Population Health Co-Author: Robert Forrester (Australian National University, Statistical Consulting Unit)

Background: Breastfeeding supports child development through complex mechanisms that are not well understood. Numerous studies have compared how well breastfeeding and non-breastfeeding mothers interact with their child, but few examine how much interaction occurs. Objective/Hypothesis: Our study investigated whether lactating mothers spend more time providing emotional support or cognitive stimulation of their infants than non-breastfeeding mothers, and whether the amount of such interactive time is

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associated with breastfeeding intensity. Maternal sleep hours may be associated with nurturing care time. Methods: The study collected weekly time use data from 156 mothers of infants aged 3–9 months recruited via mother’s and baby groups, infant health clinics, and childcare services. Participants used an electronic device to record their 24-hour time use for 7 days. Sociodemographic and feeding status data were collected by questionnaire. Statistical analysis used linear mixed modeling and residual maximum likelihood analysis. Results: Breastfeeding and non-breastfeeding mothers had broadly similar socioeconomic and demographic characteristics. Breastfeeding was associated with more mother–child interaction time, a difference only partially explained by maternal employment hours or other interactive care activities. Older age of infant was associated with reduced maternal sleep hours. Conclusions: This study presents data suggesting that lactating mothers spent significantly more hours weekly on milk feeding and on carrying, holding, or soothing their infant than non-lactating mothers; and on providing childcare. Understanding mechanisms by which child mental health and development benefits from breastfeeding and nurturing care may have important implications for policies and intervention strategies. Time pressures on mothers of older infants may have implications for maternal sleep, health and wellbeing. Funding: The Australian Research Council (ARC) contributed funding for conduct of the Time Use Survey of New Mothers (TUSNM) alongside an Australian Postdoctoral Fellowship (DP0451117). JPS is currently funded by an ARC Future Fellowship (FT140101260). O-25. CHARACTERIZATION OF HUMAN MILK MICRORNAS IN MATERNAL METABOLIC DISEASE Presenting Author: Lindsay Ellsworth, University of Michigan – Division of Neonatal-Perinatal Medicine Co-Authors: Emma Harman, Brigid Gregg (University of Michigan – Division of Pediatric Endocrinology)

Background: Maternal metabolic diseases during pregnancy influence breast milk composition of nutrients and bioactive factors. Lactational metabolic programming from altered breast milk composition is hypothesized to contribute to the risk of childhood obesity. Milk microRNA profile alterations may mediate regulation of early infant metabolism. Objective: Determine the human breast milk microRNA profiles and differential expression of microRNAs in mothers with obesity (OB), gestational diabetes (GDM), and polycystic ovary syndrome (PCOS) compared to healthy normal weight mothers. Methods: Breast milk samples were collected at 2 weeks postpartum from a total of 36 mothers with maternal obesity (5), gestational diabetes (5), polycystic ovary syndrome (5), and healthy controls (21) through a prospective observational cohort study of mother-baby dyads at the University of Michigan. Breast milk microRNA expression profiles in the extracted lipid fraction were analyzed using OpenArray real-time PCR through the Sequencing Core at the University of Michigan. Results: A total of 381 microRNAs were identified in the 36 milk samples. 19 miRNAs were differentially expressed in

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maternal metabolic disease compared to healthy mothers’ milk (p =