TABLE 2.

Select examples in applying a translational research framework to address obesity-related insufficient milk production

Stage	Examples
T1 Discovery	Going back at least 40 y, and as described by the Breastmilk Ecology and the Genesis of Infant Nutrition (BEGIN) Working Group 1, rodent models and epidemiologic research have found associations between birthing parent adiposity and suppressed milk production at the discovery stage [101,102].
T2 Human health implications	As reviewed by BEGIN WG 3, 24-h test-weighing and deuterium dilution are well-established validated methods for measuring milk intake in breastfeeding infants [4,103]. However, these methods are not practical in a clinical setting, pointing to the need to develop clinically accessible methods for evaluating birthing parent milk production sufficiency as part of the breastfeeding management toolkit [104,105]. To treat insufficient milk supply, focused studies are needed to elucidate the causal mechanism and pilot potential interventions.
T3 Clinical and Public Health Implications	While there is abundant evidence to characterize average milk intake of exclusively human milk–fed infants, clinical management of insufficient milk production requires addressing gaps in knowledge regarding optimal milk volume tailored to individual infant characteristics [106]. Also at this stage, large-scale intervention studies informed by focused pilot studies may lead to effective treatments for insufficient milk production in lactating parents with obesity. Importantly, insufficient milk production can take an emotional toll on new parents, especially given the limited treatment options. Thus, there is a particular need for patient-centered outcomes research that serves those who are at high risk for, or currently diagnosed with, insufficient milk production [71,107].
T4 Implementation	Careful messaging is required in addressing physiologic low milk production without exacerbating perceived insufficient milk. Thus, community-engaged research is needed to develop context-specific strategies for dissemination of guidelines for assessing risk and communicating about insufficient milk production in vulnerable patients and implementation of shared decision-making strategies to mutually optimize infant feeding and well-being of the family in affected patients irrespective of how much milk the lactating parent produces [108].
T5 Impact	On a population level, there is a gap in research characterizing how broader domains of influence, such as public policy, the built environment, structural inequities, and the health care system impact the prevalence of insufficient milk, such as contributing to the obesity epidemic [109] and worsening metabolic health [[110], [111], [112]], weight stigma [113], xenobiotic exposure [114], and institutional barriers to optimal human milk feeding management and support [115]. Also, ongoing epidemiologic surveillance is needed to monitor the prevalence of insufficient milk and societal level disparities. These research needs will require authentic engagement with key stakeholders, especially parents, in addition to consideration of the other overarching principles described in Part II of this report.

WG, working group.