BACKGROUND: The Hospital to Home Outcomes (H2O) trial was a 2-arm, randomized controlled trial that assessed the effects of a nurse home visit after a pediatric hospital discharge. Children randomized to the intervention had higher 30-day postdischarge reutilization rates compared with those with standard discharge. We sought to understand perspectives on why postdischarge home nurse visits resulted in higher reutilization rates and to elicit suggestions on how to improve future interventions. METHODS: We sought qualitative input using focus groups and interviews from stakeholder groups: parents, primary care physicians (PCP), hospital medicine physicians, and home care registered nurses (RNs). A multidisciplinary team coded and analyzed transcripts using an inductive, iterative approach. RESULTS: Thirty-three parents participated in interviews. Three focus groups were completed with PCPs (n = 7), 2 with hospital medicine physicians (n = 12), and 2 with RNs (n = 10). Major themes in the explanation of increased reutilization included: appropriateness of patient reutilization; impact of red flags/warning sign instructions on family’s reutilization decisions; hospital-affiliated RNs “directing traffic” back to hospital; and home visit RNs had a low threshold for escalating care. Major themes for improving design of the intervention included: need for improved postdischarge communication; individualizing home visits—one size does not fit all; and providing context and framing of red flags. CONCLUSION: Stakeholders questioned whether hospital reutilization was appropriate and whether the intervention unintentionally directed patients back to the hospital. Future interventions could individualize the visit to specific needs or diagnoses, enhance postdischarge communication, and better connect patients and home nurses to primary care.

Women diagnosed with low milk supply were significantly more likely to have had diabetes in pregnancy compared with women with latch or nipple problems and, more generally, compared with women with any other lactation difficulty. Further research is needed to elucidate how maternal glucose intolerance may impede lactation.

Background: Metformin improves insulin action, but feasibility in treating low milk supply is unknown. Research aim: To determine the feasibility of a metformin-versus-placebo definitive randomized clinical trial in women with low milk production and signs of insulin resistance. Methods: Pilot trial criteria included: Mother 1–8 weeks postpartum (ideally 1–2 weeks), low milk production, and ≥1 insulin resistance sign; and singleton, healthy, term infant. Eligible mothers were randomly assigned 2:1 (metformin:placebo) and instructed in frequent milk removal for 28 days with option to stop at 14 days. Results: From 02/2015 through 06/2016, we screened 114 women, completed baseline assessments on 46, and trialed 15 (median, 36 days postpartum). Comparing metformin-assigned (n = 10) to placebo (n = 5), 70% versus 80% continued to day 28; peak median change in milk output was +8 versus –58 mL/24 hr (p = .31) and 80% peaked at Day 14 for both groups; 0% versus 20% desired to continue assigned drug after study completion; 44% versus 0% reported nausea/vomiting. Post-hoc, median peak change in milk output was +22 (metformin completers, n = 8) versus –58 mL/24 hr (placebo + non-completers, n = 7, p = .07). At baseline assessment, median milk production was significantly lower in those with (n = 31), versus those without (n = 15) signs of insulin resistance (p = .002). Conclusions: Although results trend toward hypothesized direction, trial feasibility concerns include late enrollment and only 20% of metformin-assigned participants sustaining improved milk output to Day 28, with none perceiving metformin worthwhile. Better tools are needed to identify and treat metabolically-driven low milk production. Registered at ClinicalTrials.gov (NCT02179788) on 02/JUL/2014.

An estimated 70% of mothers in the United States initiate breastfeeding annually. Mothers often discuss breastfeeding problems with their infant's pediatrician. Pediatricians may feel unsure about their role when assisting the nonpatient, breastfeeding mother. By having practical solutions and support systems in place to anticipate and tend to breastfeeding mothers' needs, pediatricians can be instrumental in preventing early weaning. The purpose of this article is to provide practical suggestions to outpatient-based pediatric health care providers when assisting the breastfeeding dyad.

Objective: An efficient method for measuring maternal milk production is needed. Our objectives were to: (1) validate a milk production rate (MPR) protocol in exclusively breastfeeding mothers; (2) determine MPR change following 48 hours of increased breast emptying; (3) assess agreement between MPR and infant testweighing; and (4) characterize MPR in early postpartum exclusively breastfeeding mothers. Materials and Methods: N = 23 mothers emptied both breasts hourly over 3 hours (h0, h1, h2, and h3). We estimated steady-state MPR as mean (h2 and h3). Subset A mothers (n = 5) also completed MPR measurements after 48 hours of increased breast emptying. Subset B mothers (n = 16) also test-weighed for 48 hours. We used paired t-test to examine within-participant change in hourly milk yield and MPR; and we used Bland-Altman analysis to compare 24-hour milk production (g/24 hours) measured using test-weight versus MPR. Results are reported as meanstandard deviation or (-95% limits of agreement). Results: Mothers were 54 -14 days postpartum. Paired difference in h3-h2 hourly milk yield was not significantly different ( p > 0.05, 3 -10 g/hour). In Subset A (n = 5), MPR declined from 50 -13 to 43 -16 g/hour ( p = 0.003) following 48 hours of increased breast emptying. In Study B (n = 16), mean infant test-weighed intake (TW) was 717 -119 g/24 hours, and mean MPR was 1,085 -300 g/24 hours. Mean difference (MPR-test-weigh) and mean ratio (MPR/test-weigh) significantly increased as MPR increased ( p < 0.05). For infants with adequate weight gain (>20 g/24 hours, n = 12), mean MPR = 48 -12 g/hour (range, 35-78 g/hour). Conclusion: MPR is a valid measure of current maternal milk production capacity, but is not accurate for evaluating infant intake in exclusively breastfeeding dyads.

Background Obesity is associated with chronic inflammation and is a risk factor for insufficient milk production. Inflammation-mediated suppression of lipoprotein lipase could inhibit mammary uptake of long-chain fatty acids (LCFAs, &gt;16C). Objectives In an ancillary case control analysis, we investigated whether women with low milk production despite regular breast emptying have elevated inflammation and disrupted transfer of LCFAs from plasma into milk. Methods Data and specimens from a low milk supply study and an exclusively breastfeeding control group were analyzed, with milk production measured by 24-hour test-weighing at 2–10 weeks postpartum. Low milk supply groups were defined as very low (VL, &lt;300 mL/d; n = 23) or moderate (MOD, ≥300 mL/d; n = 20) milk production, and compared to controls (≥699 mL/d; n = 18). Serum and milk fatty acids (weight% of total) were measured by gas chromatography, serum and milk TNF-α by ELISA, and serum high-sensitivity C-reactive protein (hsCRP) by clinical analyzer. Group differences were assessed by linear regression models, Chi-square exact tests, and Kruskal Wallis nonparametric tests. Results VL cases, as compared to MOD and controls, had higher prevalence of elevated serum hsCRP (&gt;5 mg/L, 57%, 15%, 22%, respectively, p = 0.004), detectable milk TNF-α (67%, 32%, 33%, respectively, p = 0.04), and obesity (78%, 40%, 22%, respectively, p = 0.003). VL cases had lower LCFAs in milk (Mean[±SD], 60[±3%]) compared to MOD (65[±4%]) and controls (66[±5%]; (p &lt; 0.001). Milk and serum LCFAs were strongly correlated in controls (r = 0.82, p &lt; 0.001), but not in MOD (r = 0.25, p = 0.30) or VL (r = 0.20, p = 0.41) groups (pint &lt; 0.001). Conclusions Mothers with very low milk production have significantly higher obesity and inflammatory biomarkers, lower LFCAs in milk, and disrupted association between plasma and milk LCFAs. These data support the hypothesis that inflammation disrupts normal mammary gland fatty acid uptake. Further research should address impacts of inflammation and obesity on mammary fatty acid uptake for milk production.

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Aim:To describe paediatric postdischarge concerns manifesting in the first 96 hr after hospital discharge.Design: Analysis of nursing documentation generated as part of a randomized controlled trial evaluating the effect of a nurse home visit on healthcare re-use. Methods:We analysed home visit records of 651 children (age <18) hospitalized at a large Midwestern children's hospital in 2015 and 2016 who were enrolled in the trial.Registered nurses documented concerns in structured fields and free-text notes in visit records. Descriptive statistics were used to summarize visit documentation. Free-text visit notes were reviewed and exemplars illustrative of quantitative findings were selected. Results:Overall, nurses documented at least one concern in 56% (N = 367) of visits. Most commonly, they documented concerns about medication safety (15% or 91 visits). Specifically, in 11% (N = 58) of visits nurses were concerned that caregivers lacked a full understanding of medications and in 8% (N = 49) of visits families did not have prescribed discharge medications. Pain was documented as present in 9% of all visits (N = 56). Nurses completed referrals to other providers/services in 12% of visits (N = 78), most frequently to primary care providers. In 13% of visits (N = 85) nurses documented concerns considered beyond the immediate scope of the visit related to social needs such as housing and transportation. Conclusion: Inpatient and community nurses and physicians should be prepared toreconcile and manage discharge medications, assess families' medication administration practices and anticipate social needs after paediatric discharge. Impact: Little empirical data are available describing concerns manifesting immediately after paediatric hospital discharge.Concerns about medication safety were most frequent followed by concerns related to housing and general safety. | 1395TUBBS-COOLEY ET aL. S U PP O RTI N G I N FO R M ATI O NAdditional supporting information may be found online in the Supporting Information section.