Platform presentations

1. Hydroxyurea Exposure in Lactation - A Pharmacokinetics Study (HELPS)

Julie Ware, Anu Marahatta, Kathryn McElhinney, Min Dong, Alexander Vinks, Russell Ware
Category: Research
Background: Hydroxyurea is a potent and safe disease-modifying therapy for both children and adults with sickle cell anemia (SCA). Substantial research data have documented clinical efficacy characterized by fewer acute complications, improved organ function, and reduced mortality. Relatively sparse data exist, however, regarding the risks and benefits of hydroxyurea for mothers with SCA during pregnancy and lactation. Mothers with SCA who wish to breastfeed their babies are discouraged from taking hydroxyurea, due to mostly theoretical concerns about transfer of the drug into breastmilk. Determination of the pharmacokinetics (PK) of hydroxyurea in breastmilk, along with accurate measurement of the amounts transferred to infants during lactation, are warranted since hydroxyurea is now commonly prescribed to women of child-bearing years.
Objective(s): To determine 1) the pharmacokinetics (PK) profile of hydroxyurea in blood and breastmilk; 2) the distribution of hydroxyurea between plasma and milk compartments; 3) the amount of hydroxyurea excreted into the milk and urine; and 4) population PK profiles to estimate infant drug use.
Materials/Methods: Lactating women were recruited to receive a single oral dose of hydroxyurea (two 500mg capsules). Breastmilk, blood, and urine were collected before the dose and then at scheduled timepoints, including 15, 30, 60, 120, 180, 240, 360, 480, 720, and 1440 minutes. Hydroxyurea concentrations were measured using a validated HPLC assay.
Results: A total of 16 women (14 healthy volunteers and 2 with SCA; 11 white and 5 black) were recruited into HELPS; the median age was 31 years (range 26-38 years) and the median weight was 76.3 kg (range 48.8-115.9 kg). All women were currently lactating and breastfeeding their infants for a median duration of 6 months (range 2-22 months). After the 1000mg dose, peak plasma hydroxyurea concentrations ranged from 10-40 µg/mL, typically at 60-120 minutes after dosing although absorption varied among participants. Hydroxyurea was measured in breastmilk at ~80% of the plasma concentration, with both compartments having a similar pharmacokinetics profile for each participant, from absorption through distribution and clearance. No hydroxyurea was detected in either plasma or breastmilk 24 hours after the dose. With this frequent collection schedule, an average of 2.2 ± 1.0 mg of hydroxyurea transferred into breastmilk over the 24-hour timeframe, with the majority transferred in the first 3-6 hours. Most of the drug was excreted into the urine, with an average of 542 ± 178 mg (range 295 – 876 mg) measured over the 24-hour timeframe; over 90% of urinary excretion occurred in the first 9 hours after the dose. The collection schedule was then modified to assess drug accumulation and equilibrium in more physiologically relevant 3-hour intervals, which reduced the average amount of hydroxyurea transfer to 1.1 mg; this 50% reduction in drug transfer indicated a rapid equilibrium between milk and plasma compartments. Two lactating women with SCA had similar hydroxyurea PK curves for plasma and milk to the 14 healthy volunteers. PK analysis based on the frequent milk collection schedule and a standard 150 mL/kg intake per 24 hours concluded that 0.41 ± 0.14 mg hydroxyurea will transfer per kg of infant weight per day. Using the World Health Organization definition of Relative Infant Dosage (RID), defined as the infant dose (mg/kg/day) compared to the maternal dose (mg/kg/day), this infant hydroxyurea exposure is 3.1%, where  < 5 % is generally considered safe and acceptable. However, since 48% of the drug transfers in the first 3 hours, the RID would be 1.6% if the mother fed her baby before the dose and waited 3 hours before the next feeding, or  < 1 % when using a single “pump and dump” process.
Conclusions: The HELPS trial provides definitive measurements and PK data regarding hydroxyurea in human breast milk, confirming that drug does transfer but has a rapid equilibrium between plasma and milk. Breastfeeding mothers will transfer only a small amount of hydroxyurea to their infants, so lactation during hydroxyurea therapy should not be contraindicated. These data are relevant for expanded access to hydroxyurea as a disease-modifying therapy to lactating women around the world.

2. Establishing Gestational Age Specific, Longitudinal Growth Curves for Infants on Exclusive Fortified Human Milk Diet

Yuanyi Murray, Boriana Parvez, Amanda Rhaman, Alpan Gad
Category: Research
Background: Optimal postnatal growth of preterm infants is currently defined as equivalent to the growth of ‘the reference fetus’ and extrauterine growth restriction (EUGR) in the past has been associated with poor neurodevelopmental (ND) outcomes. The most commonly used growth curve (Fenton 2013) is constructed based on cross-sectional data reflecting both intrauterine and postnatal growth without taking into account postnatal diet. Exclusive human milk diet (EHM) with mother’s own or donor breast milk fortified with human milk derived fortifier may lead to slower weight gain and increasing the risk of being classified as EUGR. The correlations between EHM, EUGR as currently defined, and ND have not been assessed.
Objective(s): We sought to develop a longitudinal-based, extrauterine growth curve for weight, length and head circumference in ELBW infants feeding EHM.
Materials/Methods: We obtained serial longitudinal anthropometric data as well as demographic and medical information for all infants born at 23-28 wks GA, between February 2015 – May 2018 who were fed EHM. We excluded those with diagnosis of hydrops, HIE, congenital malformation or those who died within 5 days of life or died before reaching full feeds. Weekly measurements of weight, head circumference and length for each gestational week between 23 and 28 were collected from birth until discharge or 40 weeks postmenstrual age (PMA). Separate longitudinal growth charts for each gestational age were constructed using the Least Mean Square (LMS) Algorithm. We defined EUGR for each GA cohort as weight EUGR rates using the Fenton 2013 curve were also assessed.
Results: 193 ELBW infants met inclusion criteria: BW 839 ± 197g (Mean ± SD). Rates of EUGR on Fenton vs. our growth charts were compared for each gestational week.  Using the new growth chart for each gestational age, the incidence of EUGR at discharge is significantly reduced.  Overall combined rate of EUGR was 26% vs. 6%. GA specific EUGR rates (%) were: 40 vs. 4, 31 vs. 3, 11 vs. 3, 26 vs. 6, 26 vs. 10, 32 vs. 6 for each GA week from 23 to 28 respectively. Length and Head circumference for each gestational age were also plotted and compared.
Conclusions: We have generated longitudinal, postnatal, gestational age specific growth charts for ELBW infants on exclusive human milk diet. Rates of EUGR for each GA on our growth charts were lower than the rates on the Fenton Chart. Whether EUGR defined by diet specific longitudinal growth curve will lead to different neurodevelopment outcome remains to be determined.

3. Disparities in Donor Human Milk Supplementation among Well Newborns

Laura Kair, Nichole Nidey, Jessie Marks, Lorraine Femino, Kirsten Hanrahan, Kelli Ryckman, Kelly Wood
Category: Research
Background: Use of donor human milk as a supplementation option for healthy, breastfed term and late preterm newborns has increased in the United States over the last decade. Racial disparities in donor human milk supplementation in the neonatal intensive care unit setting have been described, but such disparities in the well newborn setting have yet to be examined.
Objective(s): To identify maternal demographic characteristics associated with donor human milk versus formula supplementation in the mother-baby/well newborn care unit.
Materials/Methods: This retrospective cohort study includes 653 dyads of well newborns and their mothers admitted to an academic medical center in the Midwestern United States in 2014. Mothers were included if they breastfed and supplemented with formula or donor human milk during the birth hospitalization. Maternal demographic characteristics and infant feeding type were extracted from medical records. Chi-square tests and logistic regression were used to examine associations between demographic characteristics and donor human milk use. All analyses were conducted in SAS 9.4.
Results: Among our study population of breastfeeding dyads, 361 supplemented with formula and 292 supplemented with donor human milk. Overall, non-White mothers were less likely to use donor milk compared to formula. The largest disparity was observed among Hispanic mothers, as they were 80% less likely to use donor milk when compared to non-Hispanic White mothers (OR 0.20, 95% CI 0.09, 0.43, p < 0 .0001). Non-Hispanic Black (OR: 0.32, 95% CI 0.14, 0.69, p=0.0037) and Asian mothers (OR: 0.40, 95% CI: 0.19, 0.83, p=0.0145) were also less likely to use donor milk when compared to non-Hispanic White mothers, as were non-English-speaking mothers versus English-speaking mothers (OR: 0.11, 95% CI: 0.04, 0.33, p < 0 .0001). Mothers who were publicly-insured (a marker of lower socioeconomic status) had lower odds of donor milk supplementation than privately-insured mothers (OR: 0.42, 95% CI: 0.26, 0.69, p=0.0006). Additionally, mode of delivery and gestational age of the newborn were associated with donor milk use.  Mothers with Cesarean delivery had increased odds of using donor milk than those with vaginal delivery (OR: 1.64, 95% CI: 1.12, 2.40, p=0.0115). Mothers of late preterm infants were more likely to use donor milk than mothers of term infants (OR: 2.69, 95% CI: 1.30, 5.56, p=0.0075).
Conclusions: Mothers of color, those who do not speak English, and those without private insurance were more likely to supplement with formula rather than donor human milk. Implementation of a donor human milk program in the well newborn setting without focused efforts toward these groups has the potential to widen health disparities while seeking to improve public health through breastfeeding promotion. Efforts should be made to determine the underlying reasons for these disparities and to provide focused, patient-centered intervention to address the needs of low-income women, non-English speakers, and mothers of color.

4. What Breast Milk Expression Volume Targets are Required for Mothers of Preterm Babies?

Ilana Levene, Gillian Denton, Frances O'Brien
Category: Research
Background: Mother's own milk protects premature infants from necrotising enterocolitis, a serious gut infection, and is associated with decreased late-onset sepsis, retinopathy of prematurity (which can cause blindness), hospital admissions in the first 3 years of life and improved neurodevelopmental outcomes. However mothers of premature infants are at high risk for early cessation of human milk feeding and poor milk supply. Very preterm babies do not feed orally for weeks to months after birth. A very preterm baby needs around 100-200ml of expressed milk each day in the first weeks of life (via a tube directly into the stomach), and likely around 400ml each day by discharge from hospital. The Unicef Baby Friendly Initiative (BFI) recommends that mothers of premature infants express 750-900ml breast milk in 24 hours by day 10 of their baby’s life, to establish a full milk supply for long term exclusive breastfeeding. This is extremely challenging to many and can cause stress for mothers already in a very stressful situation - is it necessary, and at what timepoint?
Objective(s): 1) To test whether the Unicef BFI recommendation of expressing 750ml or more by day 14 is associated with long term breastfeeding outcomes and 2) To test whether the Unicef BFI recommendation of expressing 750ml or more by a later time point is associated with long term breastfeeding outcomes
Materials/Methods: A retrospective two-centre study was conducted in the regional tertiary neonatal unit (John Radcliffe Hospital, Oxford) and a local neonatal unit in the same network (Royal Berkshire Hospital, Reading). Interviews were conducted with a convenience sample of mothers present on the unit on three separate days, separated by several months, who were expressing milk at 3 weeks of age or later. Interviews were conducted between October 2017 and January 2018. Mothers were asked about their 24-hour yield at several timepoints, among other questions. Mothers at the tertiary centre were asked for permission to contact them by email or telephone at 1 month corrected age (1 month after their estimated date of delivery). The project was classified as audit and did not require ethical permission. Fisher’s and Mann-Whitney tests were used for analysis.
Results: 32 mothers were interviewed, with 41 infants. Mean gestation at birth was 29+1 weeks (range 23+5 to 33+3). Mean birthweight was 1312g (range 570-2500g). Mean age at the final timepoint (named ?3 weeks) was 38 days (range 21-100 days)
Conclusions: The study is limited by its partially retrospective nature and small sample size. The expressing target of ?750ml in 24 hours for mothers of preterm babies is supported by this data, to maximise the chance of long term exclusive breast milk feeding. However the data suggest that the time point for this target could be 3 weeks of life or later, rather than day 10-14. This would place less stress on mothers.

5. Breastfeeding Interventions are not Associated with Increased Risk of Infant Death: Using Data to Refute Sensationalistic Claims in the Literature

Melissa Bartick, Mary Ellen Boisvert, Barbara Philipp
Category: Research
Background: Two recent publications have asserted that hospital-based breastfeeding initiatives are associated with an increase in Sudden Unexpected Infant Deaths (SUID) in Massachusetts and in the United States. A 2016 publication highlighting Massachusetts data from 2004-14 gained considerable media attention, including a feature on a Time magazine cover story. This was followed by a 2018 publication by the same authors using national data, which also concluded that breastfeeding initiatives caused an increase in Sudden Unexpected Post-Natal Collapse (SUPC). However, the authors did not track breastfeeding initiatives by year in either publication, nor did they report deaths by year in Massachusetts, making such a trending correlation impossible to determine. Because SUPC has no ICD-10 Code, it cannot be tracked readily. The publications caused public backlash against evidence-based hospital care supporting breastfeeding, such as the Baby-friendly Hospital Initiative.
Objective(s): We sought to use objective data to examine if breastfeeding initiatives were associated with an increase in breastfeeding rates and were associated with increased SUID in infants under 6 months of age or under 1 year.
Materials/Methods: Using data from the Massachusetts Baby-friendly Collaborative, the Massachusetts Department of Public Health, the Centers for Disease Control and Prevention (CDC) and the CDC WONDER database, and the CDC Breastfeeding Report Card, breastfeeding initiatives, breastfeeding rates, and SUID deaths were tracked by year from 2006-2016. SUID was also used as the best proxy for cases of SUPC that resulted in death
Results: In Massachusetts, the Baby-friendly Collaborative began in 2008 with 4 facilities, growing to 30 facilities of 47 to 48 in 2013, and made available records of implementation of breastfeeding interventions throughout its hospitals. The percentage of births in Baby-friendly facilities grew from 3.4% to 13.6% in 2015. Breastfeeding rates increased from 77.5% initiation with 37.6% exclusive at 3 months, to 89.2% initiation, with 46.9% exclusive 3 at months in 2015. SUID rates in infants under 6 days of age during 2004-2009 decreased compared to 2010-2016 (OR 3.09, 95% Confidence Interval [CI] 1.22-7.84). The overall numbers of Massachusetts SUID deaths at 6 days of age over this 13-year period (of which SIDS is a subset), 22, is very small. Massachusetts SUID deaths at one year of age remained unchanged, comparing 2004-09 to 2010-16 (OR 1.14, 95% CI 0.96-1.35). Massachusetts SIDS deaths at one year of age fell over 60% over this period, to a number too low be considered reliably precise. Nationally, SUID rates at 6 days of age remained stable at 0.03 per 1000, and were stable at 1 month and 1 year as well, as Sudden Infant Death Syndrome rates fell at 1 year of age from 0.55 per 1000 live births in 2004 to 0.39 in 2016 along a steadily decreasing pattern. The percentage of births in Baby-friendly hospitals rose from 1.8% to 18.3%, and breastfeeding rates increased, but somewhat more modestly than in Massachusetts.
Conclusions: Breastfeeding initiatives are associated with increased breastfeeding rates and are not associated with increased SUID, and are associated with decreased rates SIDS, although other factors may be playing a role in the decrease in SIDS. Breastfeeding and interventions which promote it are generally associated with decreased infant mortality. Thus, when publications reported in the media claim that breastfeeding interventions are associated with increased infant mortality, it is important to publish actual data that such publications omitted. Such publications should carefully be examined for methodologic flaws, such as aggregating multiple years’ worth of data and presenting it as a trend.

6. Maternal DNA Methylation Changes Associated with Lactation

Adetola Louis-Jacques, Thomas Keller, Monica Uddin, Ronald Madness, Charles Lockwood, Maureen Groer
Category: Research
Background: Breastfeeding has been associated with decreased risks of type 2 diabetes, breast cancer, ovarian cancer, and cardiovascular diseases, in particular hypertension. These non-communicable diseases are among the leading causes of death in women worldwide. Yet, we know very little about the molecular basis of the long-term benefits of lactation in mothers. We hypothesize that women who breastfeed will display differences in DNA methylation when compared to women who formula feed.
Objective(s): To determine the influence of lactational status on DNA methylation patterns in peripheral blood mononuclear cells (PBMCs).
Materials/Methods: This study was nested within a prospective study of healthy women during pregnancy and followed up to 12 months postpartum. Demographics, medical data and detailed lactation histories were obtained. The lactation group included mothers who were exclusive or high partial breastfeeders for at least 4 months postpartum (n=15) and the control group were formula feeding women (n=9). Blood samples were obtained mid-pregnancy, 1 week postpartum and then monthly up to 12 months postpartum. DNA was extracted from preserved PBMCs. Illumina Human MethylationEpic Array was used to interrogate over 850,000 methylation sites. Differential methylation analyses were performed using a region-based gene enrichment analysis (McSEA test). The final model adjusted for age, race, parity, white blood cell estimates, and time point. GO enrichment analysis was used to determine DMR-associated pathways.
Results: A total of 24 participants were included yielding 127 PBMC samples longitudinally (up to 9 samples per participant). 977 differentially methylated regions (DMRs) were associated with lactation (FDR < 0 .05) and 4777 DMRs were associated with changes over time in the postpartum period. A total of 315 DMRs overlapped between these two analyses. The top DMR-associated pathways were related to immune response; regulation of cell cycle, RNA catabolic processes and execution phase of apoptosis were additional implicated DMR-associated pathways.
Conclusions: Maternal breastfeeding status is associated with differential methylated gene regions that are relevant to diseases for which lactation is protective such as breast and ovarian cancer. Analysis revealed predominantly immune-related pathways. Differential DNA methylation may serve as a marker of the long term benefit of lactation. Next steps include in depth longitudinal analysis of DMRs, validation and replication of DMRs, and transcriptomics.

7. Why is it Worth to Breastfeed Over One Year? A Study from Human Milk Bank in Torun, Poland

Elena Sinkieqicz-Darol, Urszula Berntaowicz-Łojko, Dorota Martysiak-Żurowska, Katarzyna Kaczmarek, Małgorzata Puta, Aleksandra Wesołowska

Category: Human Milk Composition
Background: Little is known about the composition of breast milk beyond 12th month of lactation. The research carried out so far concerns small groups of respondents, often ethnically and culturally isolated. Methodology of research and selection of mothers for examined and control groups as well as obtaining material for research are also diverse. The report of the Lactation Science Centre "Is Poland a friendly country for a nursing mother and her child?"1 and research carried out in the Kuyavian-Pomeranian Voivodeship 2 showed that in Poland there is about 10% of women which are nursing more than a year. However, the lack of information regarding the composition of human milk over 12 months of lactation causes that mothers who breastfeed their children for a year or more often do not receive adequate lactation support, are criticized or even discouraged from further breastfeeding. In many cases, they meet with the statement that women's milk after a year is only "water" devoid of  nutritional value, and  breastfeeding such a large child does not bring any benefits. Research concentrating on the content of nutrients and bioactive compounds in human milk of nursing mothers which are breastfeeding more than one year is also of practical importance in the operation in human milk banks. The vast majority of donors to the milk bank are women who gave birth prematurely or at a term, whose lactation is stable and who still have surpluses of their milk. Most of the donors are women which are between 1-3 months of lactation. In some milk banks, one of the criteria in the donor's recruitment process is the period of lactation. Only a woman who gave birth not later than 3 months before recruitment process can become a donor and her cooperation with the bank can last until her baby reaches 6- and in some cases 12 - months of age. Such restrictions are to affect both the composition of human milk and the total volume of milk delivered.
1 Lukowska-Rubik M., Nehring-Gugulska M., 2016. "Is Poland a friendly country for a nursing mother and her child?"
2  Bernatowicz-Lojko, U., Wesolowska, A., Wililska M., 2012. Share of human’s own milk in feeding children under two in Poland, based on the examples of Kujawy and Pomerania.Standardy Medyczne Pediatria, 9, 100–107.
Objective(s): The aim of the study was the analysis of macronutrients, including total fat [g /100ml], crude and true protein [g/100ml], carbohydrates [g/100ml], and energy [kcal/100ml] as well as antioxidant properties of human milk, including TAC [mgTE/100 ml], glutathione peroxidase activity [nmol/min/ml], catalase activity [nmol/min / ml] and content of lysozyme [?g/ml], lactoferrin [g/ L] and vitamin C [mg / l] in milk samples from women who have been breastfeeding over a year. The above-mentioned components were also analysed in two groups: in milk samples obtained from women who gave birth prematurely and in milk samples from women who gave birth on time (3-6 weeks of lactation).
Materials/Methods: We analysed the macronutrients, including total fat [g /100ml], crude and true protein [g/100ml], carbohydrates [g/100ml], and energy [kcal/100ml] as well as antioxidant properties of human milk, including TAC [mgTE/100 ml], glutathione peroxidase activity [nmol/min/ml], catalase activity [nmol/min / ml] and content of lysozyme [?g/ml], lactoferrin [g/ L] and vitamin C [mg / l] in milk samples from women who have been breastfeeding over a year. The above-mentioned components were also analysed in two groups: in milk samples obtained from women who gave birth prematurely and in milk samples from women who gave birth on time (3-6 weeks of lactation).
Results: The obtained results showed that milk of mothers nursing for over the year has significantly more protein (including true protein) than milk of mothers of preterms or term infants. In addition, in milk samples of long-nursing mothers, there is also significantly more fat, which translates into a significantly higher content of dry matter and a higher energy in comparison to milk samples from the other two groups. In the case of immunomodulatory components and antioxidant properties of human milk, the results showed that in 3 out of 6 analysed milk components - TAC, catalase activity, activity of glutathione peroxidase their content in milk samples of women lactating over a year was significantly higher than in milk samples of mothers term infants. In the case of lysozyme, vitamin C and lactoferrin no statistically significant differences were found between the studied groups.
Conclusions: Our results clearly indicate that human milk after 12 months of lactation does not lose its value, both nutritional and immunomodulatory components. Knowledge about the composition of human after 12h month of lactation and the health benefits of the general breastfeeding period should be a premise to support women who decide to continue breastfeeding when their child turns one year old. In addition, due to the increasing demand for human milk for milk banks, it is reasonable to reconsider the existing criteria regarding the lactation age of the donor and its maximum period of cooperation with the milk bank.

8. Development, Implementation, and Evaluation of a Simulation Based Breastfeeding Education Course for Health Care Professionals

Anne Drover, Amanda Pendergast
Category: Medical Education
Background: Breastfeeding issues are very common. It is critically important that health care providers have adequate knowledge and skill to identify and assist in the management of these issues. The inability to manage breastfeeding issues can adversely affect breastfeeding duration. It is well documented that education in lactation is lacking in nursing and medical schools. Traditionally, clinical knowledge and technical skills were obtained by spending long hours observing and doing in a hospital setting. The philosophy was “learning by doing” in an apprenticeship model. In this new era of competency-based education, we recognize that time does not equal competence and that deliberate practice is required. How much deliberate practice is needed for a particular skill is still under investigation.   The International Board of Lactation Consultant Examiners (IBLCE) who license Lactation consultants around the world allow three Pathways to obtaining lactation specific clinical hours: with hours required ranging from 300 to 1000. The Liaison Committee on Medical Education states that no longer can we assume learners see and learn what we think they do just by simply being in the location of patient care. We now must set predetermined objectives and ensure the learning environment is appropriate. Learners must log encounters to ensure these encounters occur. It is not sufficient to rely on the possibility that every learner will be exposed to a wide variety of breastfeeding cases. It behooves lactation programs to find alternative ways for learners to gain knowledge, skill and leadership expertise to manage critical breastfeeding issues.  To overcome the barriers of limited clinical exposure and the inordinate numbers of hours required for licensing; educators have the responsibility to create structured, repeatable educational interventions for their learners. In most other areas of clinical education, educators are now relying on simulation to ensure a standardized curriculum. The use of Human Patient Simulation allows the learner to be exposed to repeatable, standardized scenarios that mimic real life but in a safe and controlled way. Simulation allows safety for the patient and emotional safety for the learner. There is a growing literature on the use of simulation as a teaching and assessment tool in medical education. Overall, there seems to be an increasing acknowledgement of the benefits of this type of teaching and it has been shown to be highly accepted by the learner. It has also been shown to be effective in aiding learning and recall, particularly in skill development and assessment.
Objective(s): 1) To develop a breastfeeding education day that is highly interactive and innovative using various forms of simulation. 2) To utilize the LiquidGoldConcept Lactation Simulation Model, Gynecologic Teaching Associates and Recruited mother/baby pairs to enhance learning.
Materials/Methods: The whole clinical day course was developed with adult education principles in mind. The course development committee consisted of a pediatrician, a family doctor, and five lactation consultants representing NICU, Obstetrics, Community and La Leche League. We endeavored to develop a course that was as interactive and hands-on as possible. An outline of the course is as follows: Workshop 1: Getting Started with Breastfeeding: Three Rotating Sessions: A: Breast/nipple assessment & exam using gynecologic teaching associates and 3D breast models. B: Ideal position and latch using real mother and newborn dyads. C: Breast and nipple issues using LiquidGold Concept Lactation simulation Model. Workshop 2: Overcoming Challenges in Breastfeeding: Three Rotating Sessions. A. Shallow Latch using two sets of mother infant pairs. B.  Painful Latch using two sets of mother infant pairs. C. Baby won’t maintain latch using various videos. Concurrent Workshop 3: Tongue Tie/Lip Tie: assessment, imitators and management extensive use of pictures and videos. Concurrent Workshop 4: Overcoming Challenges in Breastfeeding: use of LiquidGold Concept Lactation simulation Model and demonstration of various pumps, and alternative feeding methods.
The innovative aspects of the curriculum are as follows: the use of Gynecologic Teaching Associates who are women trained and paid to serve as standardized patients for medical students in pelvic exam. We were able to utilize these women in breast and nipple assessment. We also were able to 3D print various breast models out of silicone that had varied nipple shapes and issues. These were very useful for assessment and discussion. Next, using the LiquidGold Concept Lactation simulation Model and a standardised patient who wore it; we were able to role play various scenarios in breastfeeding management. Most importantly, we recruited and paid a large number of mother/infant pairs that had various breastfeeding issues and the Lactation consultants were able to demonstrate and have participants assess and manage these issues.
Participants completed evaluations of the course specifically with respect to interactivity and the opportunity to practice clinical skills. The participants also evaluated the usefulness of the LiquidGold Concept Lactation Simulation Model, the use of the 3D breast models, the use of the Gynecologic Teaching Associates and the use of the real mothers and babies in enhancing the learning.
Results: Approximately 80 participants took part in the Breastfeeding Clinical Day workshop. The response to the highly interactive and hands-on workshop was overwhelmingly positive. Respondents unanimously agreed that the LiquidGoldConcept Lactation Simulation Model, 3D breast models, Gynecologic Teaching Associates and Recruited mother/baby pairs greatly enhance learning. The participants appreciated the active nature of the workshop as that more accurately reflects the clinical setting rather than sitting in a lecture. The varied sessions and topics reinforced and complemented each breastfeeding issue. We were unable to evaluate knowledge and skill as this was the first offering for this workshop but that will be added to the next offering. 
Conclusions: Breastfeeding education is crucial in order to properly support mothers in their breastfeeding journey. Lack of knowledge and skill can be a detriment to success. It is critical to create effective and efficient methods of teaching breastfeeding management. All areas of clinical care are moving to a competency based curriculum model. Lactation education must make use of new technologies and methodologies in order to ensure practitioners have all the skills required to assist mothers in the clinical setting. This innovative workshop made use of simulation based medical education techniques to ensure a high level of interactivity and hands-on learning. Participants were overwhelmingly positive about the use of the LiquidGoldConcept Lactation Simulation Model, 3D breast models, Gynecologic Teaching Associates and Recruited mother/baby pairs to enhance learning. Next steps will be to use the simulation tools in assessment. This may allow for the development of more robust curriculum and assessment tools in the education of new lactation practitioners.