An Integrative Review: The Role of the Doula in Breastfeeding Initiation and Duration

The objective of this integrative review was to assess birth and postpartum doulas' roles in supporting breastfeeding initiation and duration. The electronic databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PubMed, and Scopus were searched using the key terms doula and breastfeeding. Fourteen articles met inclusion criteria. Six key themes were identified. Doulas may acquire only modest amounts of lactation-specific education; however, doula care still enhances the breastfeeding care provided by health-care professionals. Doulas offer prenatal and intrapartum support that encourages breastfeeding initiation in the hospital, as well as providing breastfeeding support in the community and home settings. This reinforces the unique role of the doula in bolstering maternal-infant health. The effect of doulas on breastfeeding duration is less clear.

When Your Breasts Might Not Work: Anticipatory Guidance for Health-Care Professionals

There are many factors that can negatively impact a mother developing a copious milk supply and being able to exclusively breastfeed her infant. In this article, we present two case exemplars (glandular hypoplasia and breast reduction surgery) to illustrate that not all mothers may be able to develop a full milk supply, and that families should receive appropriate prenatal anticipatory education and guidance from childbirth educators and all health-care providers. Important considerations include the value of every drop of milk that the mother is able to produce, treating the milk as an important medical intervention, and developing a plan with the family for supplementation so the infant can receive adequate intake for growth.

Lactation Outcomes Among Dyads Following Participation in a Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies

Introduction: MamaCare is an adaptation of the CenteringPregnancy group prenatal care model designed to support women when the pregnancy has been complicated by the presence of known congenital anomalies. The lactation-related outcomes of participants were unknown. Materials and Methods: This is a retrospective descriptive cohort study describing the lactation-related outcomes of participants of MamaCare over 43 months. Data collection included abstraction of maternal demographic data, maternal group prenatal care session participation data, maternal pregnancy and delivery data, as well as documented lactation and breastfeeding data. Results: The total cohort consisted of 92 dyads. Of the 81 women who received an individualized prenatal nutrition consultation, 65 (80.2%) voiced a prenatal feeding goal of human milk and breastfeeding only, while the remaining 16 (19.8%) expressed goals of combination feeding (human milk and infant formula). For the surviving 85 infants, 91.8% of the mothers initiated lactation on the delivery day and the remaining 7 women initiated lactation on postpartum day 1. Also at the time of discharge from the initial intensive care unit stay, 87.1% of infants were receiving maternal human milk. Discussion: For families who participate in MamaCare, not only do they form a sense of community and learn about human milk and breastfeeding before delivery, the MamaCare facilitators and presenters normalize their experience to help MamaCare participants best meet their personal breastfeeding goals as well.

Improving Human Milk and Breastfeeding Rates in a Perinatal Hospital in Japan: A Quality Improvement Project

The leadership team at the Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University in Tokyo, Japan sought to improve our human milk (HM) and breastfeeding rates for vulnerable infants. This article describes the quality improvement (QI) initiative, which involved the implementation of the first three steps of the Spatz 10-step model for HM and breastfeeding in vulnerable infants. Our main objectives were to ensure that: (1) families were making informed feeding decisions about HM and breastfeeding as a medical intervention; (2) mothers were pumping early and often; (3) the staff implemented HM management; and (4) the proportion of infants who received HM at 1 month of life increased. Using a QI approach led by a nursing team, we were able to achieve all our goals. Our prenatal education was effective at having more families choose HM and breastfeeding versus formula. Our time to first milk expression improved as did the mothers' adherence with pumping early and often. We purchased physical resources to ensure that all milk was efficiently delivered to the infant in appropriate storage containers. At the initiation of this QI project, exclusive HM rates at discharge were only 15%. In only a 4 months time frame, the HM rate at discharge increased threefold to 47%. During the entire year, the portion of mothers selecting formula continued to decrease and HM rates continued to rise.

Informal Milk Sharing for the Hospitalized at-Risk Infant in the Ultra-Orthodox-Haredi Jewish Community in the United States

The process of human milk donation and sharing for the promotion of infant health is a phenomenon of interest as it directly affects children's health and well-being. Although its prevalence is currently unknown, informal sharing of human milk is occurring across the United States. The U.S. Food and Drug Administration recommends against informal sharing of human milk. However, the Ultra-Orthodox (Haredi) Orthodox Jewish population, who strictly observes Jewish laws and often consults with rabbis before making medical decisions, is known to donate and obtain milk through informal sharing. The objective of this study was to explore the lived experience of informal donation from the perspective of Ultra-Orthodox mothers from the Northeastern region of the United States who engaged in milk sharing to support hospitalized at-risk infants. Women were interviewed by an Orthodox Jewish member of the team, using a semistructured interview guide. Informal milk sharing was regarded as a positive empowering experience. Themes which illuminate the phenomena of milk sharing include faith, mistrust of the medical establishment, a strong reliance on social connectedness, and importance of sacred cultural traditions. Health care providers need to be aware of these specific needs to provide culturally sensitive care for safer milk sharing practices in cloistered and faith-based communities.

Historical Antecedents of Breastfeeding for African American Women: from the Pre-Colonial Period to the Mid-Twentieth Century

INTRODUCTION

African American women have much lower breastfeeding rates than other racial and ethnic groups in the USA. While researchers are beginning to explore contemporary factors contributing to this inequality, much less research has been devoted to the historical conditions that have contributed to these disparities.

AIM

The aim of this paper was to describe the social, economic, and political factors that have influenced African American breastfeeding behavior in the USA from the colonial era through the mid-twentieth century.

METHODS

A thematic analysis was conducted across multiple databases and sources. A social history framework, which focuses on the experiences of ordinary people and events, was used to identify and integrate themes found within the reviewed literature.

RESULTS

Three themes emerged: (1) Labor forces and other socio-cultural factors affected feeding practices and communal caregiving; (2) history of supplementation; and (3) influence of medicalization of birth and mobility on infant feeding in the twentieth century. These themes illustrate how African American women's ability to breastfeed has been significantly constrained throughout the U.S.

HISTORY

Supplementation with non-human milk substitutes and communal caregiving helped African American women navigate infant rearing under adverse socioeconomic circumstances.

CONCLUSIONS

Social, political, and economic factors have contributed significantly to African American women's ability to breastfeed throughout the U.S.

HISTORY

Understanding the influences of historical antecedents on breastfeeding decisions over time may be key to finding effective interventions that might increase breastfeeding rates within this population.

Breastfeeding experiences of same-sex mothers

BACKGROUND

Family structures are diversifying in the United States, and more same-sex female couples are building families. For two-mother families, complexity exists for breastfeeding as more than one mother can provide human milk. The purpose of this study was to explore the lactation experience and level of lactation support of birth mothers in a same-sex (two female) relationship.

METHODS

This study consists of a mixed methods design using an online survey to identify the demographic of same-sex mothers and qualitative interviews to provide an in-depth understanding of the mothers' experiences. Qualitative content analysis is applied to develop themes from the interviews.

RESULTS

Sixty-eight participants completed the online survey. Thirty-seven mothers (59%) reported breastfeeding for more than one year. Fourteen (21%) respondents reported accessing induced lactation information for the nongestational parent from their health care practitioner. Forty-three (63%) respondents reported receiving breastfeeding and induced lactation information from other sources. Only nine (13%) nongestational parents underwent induced lactation. Eighteen gestational mothers participated in qualitative interviews. Five themes emerged from the qualitative data: (a) committed to a year, (b) deciding "how to do it," (c) sources of information, (d) involvement of partner, and (e) need for inclusive and educated health care practitioners.

CONCLUSIONS

Same-sex mothers have strong intentions to breastfeed and are resourceful in educating themselves for induced lactation and conursing. Nongestational parents are essential support partners and equivalent in motherhood. Providers need to better equip themselves and incorporate inclusive language in breastfeeding policy statements to support lactation outcomes.

Maintaining Breastfeeding During Severe Infant and Maternal HSV-1 Infection: A Case Report

INTRODUCTION

Childbearing women with primary or secondary Herpes Simplex Virus type 1 infection are at risk of transmitting neonatal herpes infection to their infants; a medical emergency that is associated with high mortality and morbidity. Neonatal herpes infection has been commonly associated with Herpes Simplex Virus type 2, or genital herpes, but can be caused by either subtype and the presentations are indistinguishable. This case describes the course of diagnosis, treatment, and recovery for a mother and infant during a severe maternal and neonatal herpes infection, and how lactation was maintained and breastfeeding re-established. Our children's hospital coordinated its efforts to assist and monitor this breastfeeding family, and they were able to resume breastfeeding soon after discharge. It is our opinion that it is imperative that mothers receive evidence-based lactation care to maintain their breastfeeding relationship during extended hospital stays.

MAIN ISSUE

An acutely ill infant was admitted to our urban children's hospital with severe neonatal herpes infection for a total of 3 weeks. His mother was severely affected on her breasts and she required a brief hospitalization. The mother's breasts were covered with draining herpetic lesions that required daily dressing changes. However, her lesions were slow to heal, and a wound care consultation was facilitated and her treatment plan was adjusted. We were surprised that she experienced minimal discomfort with pumping and dressing changes. The mother maintained a positive outlook, complied with the plan to express frequently to maintain milk production, and was able to breastfeed again when they both recovered.

MANAGEMENT

This mother received immediate support and appropriate pumping equipment from our hospital personnel and was subsequently able to establish and maintain her milk supply. The difficulty in this case was the management of the mother's extensive herpetic wounds that were slow to heal. A certified wound care specialist was required. Both mother and child recovered from their infections and were able to restart breastfeeding; eventually reaching their goal of breastfeeding for 2 years.

CONCLUSIONS

Neonatal herpes infection is a potentially fatal disease and maternal child health professionals should have a high suspicion for any ill-appearing newborn with or without a rash. When a breastfeeding infant and mother become infected with Herpes Simplex Virus type 1, it is the responsibility of the healthcare institution to support lactation and the return to breastfeeding rather than recommend cessation of lactation, which is rarely necessary. A multi-disciplinary evidence-based approach to lactation care is essential to preserve lactation during infant hospitalization.

Lactation Experience of Mothers and Feeding Outcomes of Infants with Congenital Diaphragmatic Hernia

Objective: This study explores the congenital diaphragmatic hernia (CDH) infant-mother dyad with regard to maternal lactation outcomes and infant exposure to a human milk diet. Study Design: This was a retrospective descriptive cohort study conducted at Children's Hospital of Philadelphia. A total of 149 infants born with CDH and admitted to the Newborn/Infant Intensive Care Unit (N/IICU) were included in the study. Results: Of 149 mothers, 141 (95%) initiated pumping for their CDH infants. At discharge from the N/IICU, 79% (n = 118) of infants were being fed human milk. Among those discharged on human milk, 55% (n = 65) were discharged being fed unfortified human milk with 9% (n = 11) being fed unfortified maternal hind milk. Conclusion: This research demonstrates that mothers of CDH infants can effectively establish and maintain a complete milk supply and that the majority of infants with CDH can receive a human milk diet for the entire hospital stay.

An Exploration of Lactation Facilities and Planning in U.S. Higher Education Campuses

BACKGROUND

Women in academia face challenges in continuing breastfeeding. Higher education campuses are investing in lactation support, but little is known about their approaches. This study explores the planning and design of lactation spaces on college and university campuses from the perspectives of campus planners and facility professionals, administrators, and other decision-makers.

MATERIALS AND METHODS

We conducted an online survey with a convenience sample of members of the Society for College and University Planning (SCUP). Representatives from each U.S. member campus were invited to participate in an online survey.

RESULTS

One hundred five individuals responded, representing their institutions; 94% reported at least one dedicated lactation space (range 0-50). Sixty-eight percent reported having a policy for creating/identifying lactation spaces; 28% reported that the lactation space was included in campus construction standards. Over 80% of spaces were structurally enclosed, lockable, Americans with Disabilities Act (ADA) compliant, and had open electrical outlets and in-room light control. Campus/facility planning was involved in lactation space planning at 77% of institutions and in funding for creation and maintenance at 59%.

CONCLUSIONS

Many campuses are building lactation infrastructure, but there is considerable variability in approaches and accommodations for lactation at higher education institutions. While local conditions, constraints, and demands will inform program development, decision-makers can leverage campus resources, recommendations, and design best practices to improve lactation experiences of women.

Helping Mothers Reach Personal Breastfeeding Goals

Professional organizations worldwide recommend exclusive human milk/breastfeeding for the first 6 months of life, and continued breastfeeding with appropriate complementary foods for 1 year or more. This article focuses on the importance of prenatal messaging and goal setting to ensure that mothers are able to optimize their milk supply during the critical window of opportunity in first 2 weeks after delivery. Research data in the United States indicate that the largest categories of why women stopped breastfeeding were for reasons related to milk supply or concerns that the infant was not getting enough nutrition or gaining enough weight.

Lactation Space Experiences and Preferences Among Health Care Workers in an Academic Medical Center

BACKGROUND

Comprehensive workplace lactation support programs can reduce the risk for early breastfeeding discontinuation; however, scant evidence is available to inform user-centered design of employee lactation spaces. This study describes health care workers' preferences for lactation space.

MATERIALS AND METHODS

In 2016-2017, a convenience sample of 151 women who pumped at work at an academic medical center reported on demographics, lactation experiences, and room and equipment preferences through an online survey.

RESULTS

Respondents worked in research and administration (32%), were nurses (30%), physicians and medical students (19%), or allied health or clinical support staff (19%). Seventy percent had ever used one of the hospital's dedicated lactation spaces. Forty-nine percent ranked hospital-grade pumps the most important piece of lactation room equipment; 83% preferred multiple occupancy lactation suites; and the average maximum acceptable distance to lactation space was 5.6 minutes.

CONCLUSIONS

Optimal lactation infrastructure supports the immediate and long-term health of female workers and their children. User needs and preferences can guide design of lactation space to ensure a minimum standard for design, equipment, and distance. Workers may have different preferences depending on roles and experiences; thus, a variety of solutions may be most effective.

Status of Legislative Efforts to Promote and Protect Breastfeeding and the Provision of Human Milk for Women Returning to Work in the First Postpartum Year

INTRODUCTION

Women account for over 50% of the workforce in the United States with many working women being of childbearing age. The United States does not provide long paid parental leave, thus mothers who choose to breastfeed are confronted with the reality of combining breastfeeding and returning to work. Return to work is reported to negatively impact breastfeeding exclusivity and duration. While the existing federal law protects some women, not all women have legal support to breastfeed or express milk at work. Exemptions to the federal law include limitations related to the employee's status, classification of employer, total number of employees and the employer's annual revenue. This study aimed to examine existing city-level legislation protecting the rights of women to breastfeed or express milk at their place of employment during the postpartum period.

MATERIALS AND METHODS

Prospective descriptive study with survey. The national sample includes the three largest cities of each state and the capital city of the United States (Washington, DC) for a total of 151 cities. The data were collected in a tiered approach with three phases: (1) assessment of city website, (2) e-mail to city mayor's office, and (3) telephone follow-up with the city's office.

RESULTS

Only 2/151 (1.3%) of cities had specific legislation outlining the protections for all breastfeeding women in the workplace.

CONCLUSIONS

This research demonstrates a clear need for political action to increase the number of women who have workplace regulations to protect breastfeeding.

Factors That Influence Breastfeeding Initiation Among African American Women

OBJECTIVE

To examine cultural and socioenvironmental factors that affect breastfeeding initiation among African American women.

DESIGN

Qualitative descriptive design and conventional content analysis.

SETTING

A large, inner-city, primary care center affiliated with a 500-bed children's hospital within a large, Northeastern U.S. city.

PARTICIPANTS

Participants were 34 U.S.-born African American mothers of healthy term infants 0 to 3 months of age.

METHODS

Six focus groups were conducted using a 16-question, scripted interview guide.

RESULTS

A number of complex factors that influenced breastfeeding initiation included certain cultural beliefs about sexuality, the influence of family and peer networks, information sources, intentions, and a variety of other barriers and facilitators.

CONCLUSION

Our findings suggest that the decision to initiate breastfeeding is not solely determined by the woman within the African American community. Because this decision is contingent on multiple factors external to the woman, it is important to recognize the role that partners, grandmothers, communities, information sources, and health care providers/organizations play in women's decisions. Implementation of multilevel strategies is critical to increase breastfeeding initiation among African American mothers.

Experiences of Women Who Donated Human Milk

OBJECTIVE

To examine the experiences of women who donated breast milk to a hospital-based milk bank regulated under the policies and procedures set forth by the Human Milk Banking Association of North America (HMBANA).

DESIGN

Qualitative, phenomenological design.

SETTING

The Mothers' Milk Bank in a children's hospital in the Northeastern region of the United States.

PARTICIPANTS

Twelve HMBANA-approved milk donors older than 21 years with infants hospitalized in the NICU.

METHODS

Edmund Husserl's design of interpretive phenomenology and Colaizzi's method of data analysis were used for this study. Participants were interviewed using a face-to-face, semistructured interview format.

RESULTS

Four themes represented the experience of donating breast milk: Ripple of Hope and Help, Dynamic Interplay of Nurturance, Standing on the Shoulders of Others, and Sharing Their Stories. Donors felt proud and accomplished to provide hope for other infants and families. Nurses were crucial in facilitating and motivating donors and making donation achievable in a supportive environment. Donors felt compelled to share their experiences to teach and motivate others to donate.

CONCLUSION

For our participants, donation of human milk was a positive, valuable, and nurturing experience. Donors reported feelings of increased self-esteem during donation that motivated them to "give back" and continue. The support of a well-trained nursing staff is essential for donors to meet their personal goals.

Best Practices to Limit Contamination of Donor Milk in a Milk Bank

Human milk donated to a milk bank can become contaminated in a number of ways, but processes exist to eradicate pathogenic bacterial growth. Donor human milk may be cultured before or after pasteurization or both. The purpose of this article is to describe standard operations of the Mothers' Milk Bank of the Children's Hospital of Philadelphia, best practices to limit the bacterial contamination of donor human milk, and implications for future research.

Obesity as a Predictor of Delayed Lactogenesis II

BACKGROUND

Lactogenesis II is the onset of copious milk production. A delay in this has been associated with an increased risk of formula supplementation and early cessation of breastfeeding. Prepregnancy obesity has also been associated with decreased breastfeeding rates and early cessation. Research aim: This study aimed to evaluate the effect of prepregnancy obesity on self-reported delayed lactogenesis II.

METHODS

We conducted a prospective observational cohort study of 216 women with a singleton pregnancy and who planned to breastfeed. We compared the onset of lactogenesis II between women with a body mass index (BMI) < 30 kg/m² and women with a BMI ≥ 30 kg/m². Using multivariate logistic regression analyses, we assessed the relationship between maternal BMI and delay of lactogenesis II.

RESULTS

The prevalence of delayed lactogenesis II among women with prepregnancy BMI < 30 kg/m² and BMI ≥ 30 kg/m² was 46.4% and 57.9%, respectively. Delayed lactogenesis II occurred more frequently among women who were obese at the time of delivery ( p < .05). After controlling for the covariates, age, prepregnancy BMI, and gestational weight gain were positively associated with delayed lactogenesis II.

CONCLUSION

Prepregnancy obesity and excessive gestational weight gain are associated with an increased risk of delayed lactogenesis II. Women who are at risk for delay in lactogenesis II and early breastfeeding cessation will need targeted interventions and support for them to achieve their personal breastfeeding goals.

Mothers of Infants With Congenital Diaphragmatic Hernia Describe "Breastfeeding" in the Neonatal Intensive Care Unit: "As Long as It's My Milk, I'm Happy"

BACKGROUND

Very little is known about the breastfeeding experience of mothers of infants born with congenital anomalies and cared for in the neonatal intensive care unit (NICU). Often, studies related to breastfeeding and lactation in the NICU setting are focused on the mothers of late preterm, preterm, low-birth-weight, and very-low-birth-weight infants. Congenital diaphragmatic hernia (CDH) is an anatomic malformation of the diaphragm and affects 1 in every 2,000 to 4,000 live births. Currently, there are no studies examining the health outcomes of infants with CDH and the effect of human milk. Research aim: This study aimed to describe the breastfeeding experience of mothers of infants with CDH cared for in the NICU.

METHODS

A prospective, longitudinal qualitative descriptive design was used. Phased interviews were conducted with a purposive sample of 11 CDH infant-mother dyads from a level 3 NICU in a children's hospital.

RESULTS

Six themes emerged from the data: (a) hopeful for breastfeeding, (b) latching on . . . to the pump, (c) we've already worked so hard, (d) getting the hang of it-it's getting easier, (e) a good safety net, and (f) finding a way that works for us.

CONCLUSION

For this population of CDH infant-mother dyads, the term breastfeeding is not exclusive to direct feeding at the breast and the mothers emphasized the significance of providing their own mother's milk through a combination of feeding mechanisms to their infants with CDH.

Experiences of Parish Nurses in Providing Diabetes Education and Preconception Counseling to Women With Diabetes

OBJECTIVE

To explore the role and experiences of the parish nurse in providing diabetes education and preconception counseling to women with diabetes.

DESIGN

Mixed-methods concurrent embedded design.

SETTING

Focus groups of community-based parish nurses accessed from a regional database (Pennsylvania, Florida, Ohio, New York, Arizona, and Minnesota).

PARTICIPANTS

Forty-eight parish nurses recruited from the Parish Nurse and Health Ministry Program database in Western Pennsylvania.

METHODS

The primary method was focus groups using face-to-face, teleconference, and videoconferencing formats. A secondary method used a quantitative descriptive design with three self-report measures (demographic, preconception counseling self-efficacy, and preconception counseling knowledge). Qualitative content analysis techniques were conducted and combined with descriptive analysis.

RESULTS

Forty-eight parish nurses participated in 1 of 11 focus groups. Eight qualitative themes emerged: Awareness, Experience, Formal Training, Usefulness, Willingness, Confidence, "Wise Women," and Preconception Counseling Tool for Patients. Participants provided recommendations for training and resources to increase their knowledge and skills. Parish nurses' knowledge scores were low (mean = 66%, range = 40%-100%) with only moderate levels of self-efficacy (mean = 99, range = 27-164). Self-efficacy had a significantly positive association with knowledge (r = .29, p = .05).

CONCLUSION

Quantitative results were consistent with participants' qualitative statements. Parish nurses were unaware of preconception counseling and lacked knowledge and teaching self-efficacy as it related to preconception counseling and diabetes education. Understanding parish nurses' experiences with women with diabetes and identifying their needs to provide education and preconception counseling will help tailor training interventions that could affect maternal and fetal outcomes.

Maternal Interleukin Genotypes Are Associated With NICU Outcomes Among Low-Birth-Weight Infants

BACKGROUND

Maternal interleukin (IL) single nucleotide polymorphisms (SNPs) are associated with obstetrical outcomes. Conversely, infant SNPs are associated with subsequent neonatal intensive care unit (NICU) outcomes. Little is known about relationships between maternal SNPs and neonatal outcomes.

PURPOSE

To examine the relationships between maternal IL genotypes and neonatal outcomes.

METHODS

An ancillary study was conducted among mothers ( N = 63) who delivered very low-birth-weight infants ( N = 74). Maternal DNA was extracted from breast milk and genotyped. Outcomes included fecal calprotectin, length of stay, scores for neonatal acute physiology with perinatal extension (SNAPPE-II), weight gain, oxygen needs, necrotizing enterocolitis, intraventricular hemorrhage, sepsis, retinopathy of prematurity, blood transfusions, and feeding intolerance. Multivariate analyses examined the relationships between maternal IL SNPs and outcomes, controlling for gestational age and the ratio of maternal milk to total milk.

RESULTS

Absence of a minor allele in 2 IL6 SNPs was associated with fecal calprotectin ( p = .0222, p = .0429), length of stay ( p = .0158), SNAPPE-II ( p = .0497), weight gain ( p = .0272), and days on oxygen ( p = .0316). IL6 genotype GG (rs1800795) was associated with length of stay ( p = .0034) and calprotectin ( p = .0213). Minor-allele absence in 2 IL10 SNPs was associated with days on oxygen ( p = .0320). There were associations between IL10 genotype TT (rs1800871) and calprotectin ( p = .0270) and between IL10 genotypes AA (rs1800872 and rs1800896) and calprotectin ( p = .0158, p = .0045).

CONCLUSION

Maternal IL SNPs are associated with NICU outcomes. A potential clinical application includes an antenatal risk profile to identify neonatal needs.

Navigating Return to Work and Breastfeeding in a Hospital with a Comprehensive Employee Lactation Program

BACKGROUND

The Surgeon General's Call to Action to Support Breastfeeding details the need for comprehensive employer lactation support programs. Our institution has an extensive employee lactation program, and our breastfeeding initiation and continuation rates are statistically significantly higher than state and national data, with more than 20% of our employees breastfeeding for more than 1 year.

OBJECTIVE

The objective of this research was complete secondary data analysis of qualitative data collected as part of a larger study on breastfeeding outcomes. In the larger study, 545 women who returned to work full or part time completed an online survey with the ability to provide free text qualitative data and feedback regarding their experiences with breastfeeding after return to work.

METHODS

Qualitative data were pulled from the online survey platform. The responses to these questions were analyzed using conventional content analysis by the research team (2 PhD-prepared nurse researchers trained and experienced in qualitative methodologies and 1 research assistant) in order to complete a thematic analysis of the survey data.

RESULTS

Analysis of the data yielded 5 major themes: (1) positive reflections, (2) nonsupportive environment/work culture, (3) supportive environment/work culture, (4) accessibility of resources, and (5) internal barriers. The themes that emerged from this research clearly indicate that even in a hospital with an extensive employee lactation program, women have varied experiences-some more positive than others.

CONCLUSION

Returning to work while breastfeeding requires time and commitment of the mother, and a supportive employee lactation program may ease that transition of return to work.

Do American Colleges and Universities Support the Lactation Needs of Students?

BACKGROUND

Despite strong evidence for the health benefits of breastfeeding, many mothers cannot continue breastfeeding their infants upon their return to work or school. Students are especially affected by this transition because they do not have legal protection that requires designated lactation space or time to express milk to be provided by places of education. Furthermore, limited research has been completed that specifically addresses the return to school of mothers who are students.

MATERIALS AND METHODS

One hundred fifty-seven colleges and universities from across the United States were contacted through telephone and/or e-mail, and their websites were searched to assess the support they offer for lactating students. The presence of a formal policy for lactating students and designated lactation rooms, accessible to students, were the key measures.

RESULTS

Information was gathered from 88.53% (n = 139) of the colleges and universities. A mere 3.6% (n = 5) had an official policy for lactating students and/or had the lactation spaces mentioned in the student handbook. However, more than half of the colleges and universities (54.68%; n = 76) had designated lactation spaces accessible to their students.

CONCLUSION

The vast majority of the sample did not have a policy for lactating students, and almost half of the schools did not have designated space for milk expression accessible to students. Lactating students will likely encounter challenges in simultaneously sustaining breastfeeding and meeting their educational goals in these contexts. To meet the recommendation of the American Academy of Pediatrics of 6 months of exclusive breastfeeding and continued breastfeeding for 1 year or more, American colleges and universities must establish not only designated spaces for milk expression but also policies to support lactating students.

Effect of Promoter Polymorphisms on Cytokine Concentration in Preterm Breast Milk and Subsequent Infant Outcomes

BACKGROUND

Breast milk concentrations of immune components are variable between women and interleukin (IL) differences may be associated with infant outcomes. Molecular mechanisms for milk variability remain unknown.

OBJECTIVE

The aims were to (1) examine the relationship between maternal IL genotypes and milk concentrations of IL4, IL6, and IL10, (2) describe the trajectories of milk IL change, (3) examine whether maternal IL genotypes predict IL trajectories and/or average weekly IL concentration, and (4) examine if weekly IL levels and/or IL trajectories are associated with infant outcomes.

METHODS

Milk aliquots were collected from each feeding of mother's own milk and pooled weekly. DNA was extracted from 1 sample of each mother's breast milk whey (n = 64), and single nucleotide polymorphisms (SNPs) of IL genes were genotyped. Milk IL concentrations were measured and trajectory analysis examined IL milk change over time. Multivariate breast milk IL concentration analyses controlled for gestational age and prepregnancy body mass index. Multivariate infant outcome (n = 73) analyses controlled for gestational age and the ratio of human milk to total milk.

RESULTS

Trajectory analysis resulted in linear group shapes, with 2 distinct subgroups in IL6 and 3 subgroups in IL4 and IL10. Trajectory groups trended toward significance with calprotectin, intraventricular hemorrhage, and blood transfusions. Multivariate analyses resulted in trending associations between maternal SNPs and subsequent IL6 and IL10 milk levels. There was a trending relationship between IL milk levels and both fecal calprotectin and intraventricular hemorrhage.

CONCLUSION

Maternal IL SNPs may affect IL breast milk levels and IL milk levels may be associated with infant outcomes.

Pump Early, Pump Often: A Continuous Quality Improvement Project

Research demonstrates that although many mothers initiate pumping for their critically ill children, few women are successful at maintaining milk supply throughout their infants' entire hospital stay. At the Garbose Family Special Delivery Unit (SDU) at the Children's Hospital of Philadelphia, we care for mothers who have critically ill infants born with complex cardiac and congenital anomalies. Human milk is viewed as a medical intervention at our institution. Therefore, nurses on the SDU wanted to ensure best practice in terms of pumping initiation. This article describes a continuous quality improvement project that ensured mothers pumped early and often. Childbirth educators can play a key role in preparing mothers who are anticipating an infant who will require hospitalization immediately post-birth.

Factors associated with infant feeding of human milk at discharge from neonatal intensive care: Cross-sectional analysis of nurse survey and infant outcomes data

CONTEXT

Nurses are principal caregivers in the neonatal intensive care unit and support mothers to establish and sustain a supply of human milk for their infants. Whether an infant receives essential nutrition and immunological protection provided in human milk at discharge is an issue of health care quality in this setting.

OBJECTIVES

To examine the association of the neonatal intensive care unit work environment, staffing levels, level of nurse education, lactation consultant availability, and nurse-reported breastfeeding support with very low birth weight infant receipt of human milk at discharge.

DESIGN AND SETTING

Cross sectional analysis combining nurse survey data with infant discharge data.

PARTICIPANTS

A national sample of neonatal intensive care units (N=97), nurses (N=5614) and very low birth weight infants (N=6997).

METHODS

Sequential multivariate linear regression models were estimated at the unit level between the dependent variable (rate of very low birth weight infants discharged on "any human milk") and the independent variables (nurse work environment, nurse staffing, nursing staff education and experience, lactation consultant availability, and nurse-reported breastfeeding support).

RESULTS

The majority of very low birth weight infants (52%) were discharged on formula only. Fewer infants (42%) received human milk mixed with fortifier or formula. Only 6% of infants were discharged on exclusive human milk. A 1 SD increase (0.25) in the Practice Environment Scale of the Nursing Work Index composite score was associated with a four percentage point increase in the fraction of infants discharged on human milk (p<0.05). A 1 SD increase (0.15) in the fraction of nurses with a bachelor's degree in nursing was associated with a three percentage point increase in the fraction infants discharged on human milk (p<0.05). The acuity-adjusted staffing ratio was marginally associated with the rate of human milk at discharge (p=.056). A 1 SD increase (7%) in the fraction of infants who received breastfeeding support was associated with an eight percentage point increase in the fraction of infants discharged on human milk (p<0.001).

CONCLUSIONS

Neonatal intensive care units with better work environments, better educated nurses, and more infants who receive breastfeeding support by nurses have higher rates of very low birth weight infants discharged home on human milk. Investments by nurse administrators to improve work environments and support educational preparation of nursing staff may ensure that the most vulnerable infants have the best nutrition at the point of discharge.

A Continuous Quality Improvement Project to Implement Infant-Driven Feeding as a Standard of Practice in the Newborn/Infant Intensive Care Unit

OBJECTIVE

To increase the number of neonates who were fed according to cues prior to discharge and potentially decrease length of stay.

DESIGN

Continuous quality improvement.

SETTING

Eighty-five bed level IV neonatal intensive care unit.

PATIENTS

Surgical and nonsurgical neonates of all gestational ages. Neonates younger than 32 weeks gestation, who required intubation, continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC), or did not have suck or gag reflexes were excluded as potential candidates for infant-driven feeding.

INTERVENTION/MEASUREMENTS

The project was conducted over a 13-month period using the following methods: (a) baseline data collection, (b) designation of Infant Driven Feeding (IDF) Champions, (c) creation of a multidisciplinary team, (d) creation of electronic health record documentation, (e) initial staff education, (f) monthly team meetings, (g) reeducation throughout the duration of the project, and (h) patient-family education.

RESULTS

Baseline data were collected on 20 neonates with a mean gestational age of 36 0/7(th) weeks and a mean total length of stay (LOS) of 43 days. Postimplementation data were collected on 150 neonates with a mean gestational age of 36 1/7(th) weeks and a mean total LOS of 36.4 days. A potential decrease in the mean total LOS of stay by 6.63 days was achieved during this continuous quality improvement (CQI) project.

CONCLUSIONS

Neonates who are fed according to cues can become successful oral feeders and can be safely discharged home regardless of gestational age or diagnosis.

The use of technologies to support human milk & breastfeeding

The application of lactation technologies is not limited to the NICU or the hospital setting. These technologies can be implemented within the home or hospital setting to promote the use of human milk and protect the breastfeeding relationship. Through the use of breast pumps, scales, and nipple shields, women can be supported to achieve their personal breastfeeding and lactation goals.

Postdischarge breastfeeding outcomes of infants with complex anomalies that require surgery

OBJECTIVE

To examine the duration and exclusivity of breastfeeding and provision of human milk among infants with complex anomalies that require surgery postdischarge from a neonatal intensive care unit (NICU).

DESIGN

Prospective cohort study.

SETTING

A tertiary care children's hospital with a fetal diagnostic and treatment center, special delivery unit, and NICU.

PARTICIPANTS

Mothers who had delivered infants with complex anomalies that require surgery between 2009 and 2012 (N = 165).

METHODS

Phone interviews were used for data collection and were analyzed using descriptive statistics methods.

RESULTS

The average duration of breastfeeding/provision of human milk was 8 months. The percentage of infants who received human milk at 6 months was 60.1% (n = 98/163,; p = .0063) and at 12 months was 34.5% (n = 57/165, p = .023). Of infants in this cohort, the percentage of those infants exclusively receiving human milk was 54.3% (n = 89/164, p = .0004) at 3 months of age and 35.6% (n = 58/163, p < .0001) at age 6 months. Another clinically important finding is that 30.7% of the cohort required gavage feeds postdischarge from the NICU.

CONCLUSION

Even for the most surgically complex infant/mother dyads, breastfeeding outcomes can improve significantly with a strong prenatal lactation program, nursing staff with specific breastfeeding education, and a hospital culture that values and supports breastfeeding and the provision of human milk. These findings support the use of hospital-grade electric breast pumps postdischarge for families of infants with complex anomalies that require surgery, as approximately one third of the cohort went home on tube feeds and their mothers continued to pump their breast milk at home.

Making meaning of pumping for mothers of infants with congenital diaphragmatic hernia

OBJECTIVE

To describe the process of initiation and maintenance of milk supply and potential transition to direct breastfeeding among mother/infant dyads with infants with congenital diaphragmatic hernia (CDH).

SETTING

A Level-III neonatal intensive care unit.

PARTICIPANTS

Eleven mother/infant dyads with infants with CDH.

METHODS

Prospective, longitudinal qualitative descriptive design. Semistructured interviews were conducted over the course of the NICU stay. Conventional content analysis was used.

RESULTS

Human milk oral care emerged from the interview data as a strong facilitating factor to encouraging mothers to continue pumping during hospitalization. Four main themes emerged regarding the importance and value of human milk oral care for the mothers in relation to pumping and maintenance of milk supply: (a) It motivates me; (b) I'm a part of my baby getting better; (c) We do it together, and (d) We're getting somewhere.

CONCLUSIONS

The findings of this study reflect the importance and value of human milk oral care as a driving factor to motivate mothers to maintain milk supply during the critical time when the infant with CDH is not able to take in enteral nutrition and throughout the hospital stay.

Human milk and breastfeeding outcomes in infants with congenital heart disease

BACKGROUND

Although human milk (HM) is the recommended form of infant nutrition, the provision of HM feeding among infants with congenital heart disease in the cardiac intensive care unit is unknown. Therefore the aim of the study was to understand the prevalence of pumping initiation, HM feeding, and breastfeeding patterns of mothers and their infants born with congenital heart disease.

SUBJECTS AND METHODS

This was a prospective cohort study conducted a large children's hospital with a cardiac referral program and unit. All women with infants with congenital heart disease were approached for enrollment in order to document HM prevalence.

RESULTS

The majority of women (89%) initiated lactation via pumping for their infants. On average, mothers pumped five to six times per day, and mothers were able to achieve a milk supply of over 500 mL/day. Once infants received enteral feeds, over 70% of the infant diet was HM. Very few (13%) infants fed via direct breastfeedings; rather, they received HM via gavage or bottle. There was a significant difference in pumping initiation based on where the infant was born, with mothers delivering in the hospital having a significantly higher pumping initiation rate (96% born in this hospital, 67% born in an outside hospital).

CONCLUSIONS

Mothers who have infants diagnosed with congenital heart disease should be encouraged to initiate pumping for their infants. Future research is warranted regarding the dose response of HM and specific health outcomes and the need for postdischarge services for these families.

Outcomes of a hospital-based employee lactation program

BACKGROUND

Little has been published about employee lactation support in hospitals and other healthcare facilities. The Children's Hospital of Philadelphia (CHOP), Philadelphia, PA, has a comprehensive employee lactation program. The objective of this study was to describe the breastfeeding practices of our employees and compare these results with national Centers for Disease Control and Prevention (CDC) data.

MATERIALS AND METHODS

The human resources department generated a list of all employees who filed for maternity leave between 2007 and 2011. These employees were contacted confidentially via e-mail to complete an electronic-based (SurveyMonkey.com) questionnaire. An initial message and three reminder messages were sent over a 3-month period during the last quarter of 2012, with 545 women completing the survey (response rate, 40%).

RESULTS

Women who responded to the survey had significantly higher breastfeeding initiation rates compared with national CDC data (94.5% vs. 76.9%; p<0.0001). At 6 months, significantly more CHOP employees were breastfeeding (78.6% vs. 47.2%; p<0.0001). At 12 months 32.4% of CHOP employees were still breastfeeding compared with CDC data of 25.5% (p=0.0003). Additionally, over 20% of CHOP employees breastfed their infants for over 12 months (no national data for comparison).

CONCLUSIONS

Within CHOP's comprehensive employee lactation program, women achieved breastfeeding milestones that well exceeded national data and the Healthy People 2020 targets for breastfeeding initiation and duration. CHOP's employee lactation program can serve as a model for other institutions.

Characteristics of the NICU work environment associated with breastfeeding support

PURPOSE

The provision of breastfeeding support in the neonatal intensive care unit (NICU) may assist a mother to develop a milk supply for the NICU infant. Human milk offers unique benefits and its provision unique challenges in this highly vulnerable population. The provision of breastfeeding support in this setting has not been studied in a large, multihospital study. We describe the frequency of breastfeeding support provided by nurses and examined relationships between NICU nursing characteristics, the availability of a lactation consultant (LC), and breastfeeding support.

SUBJECTS AND DESIGN

This was a secondary analysis of 2008 survey data from 6060 registered nurses in 104 NICUs nationally. Nurse managers provided data on LCs. These NICUs were members of the Vermont Oxford Network, a voluntary quality and safety collaborative.

METHODS

Nurses reported on the infants (n = 15,233) they cared for on their last shift, including whether breastfeeding support was provided to parents. Breastfeeding support was measured as a percentage of infants on the unit. The denominator was all infants assigned to all nurse respondents on that NICU. The numerator was the number of infants that nurses reported providing breastfeeding support. Nurses also completed the Practice Environment Scale of the Nursing Work Index (PES-NWI), a nationally endorsed nursing care performance measure. The NICU nursing characteristics include the percentages of nurses with a BSN or higher degree and with 5 or more years of NICU experience, an acuity-adjusted staffing ratio, and PES-NWI subscale scores. Lactation consultant availability was measured as any/none and in full-time equivalent positions per 10 beds.

RESULTS

The parents of 14% of infants received breastfeeding support from the nurse. Half of the NICUs had an LC. Multiple regression analysis showed a significant relationship between 2 measures of nurse staffing and breastfeeding support. A 1 SD higher acuity-adjusted staffing ratio was associated with a 2% increase in infants provided breastfeeding support. A 1 SD higher score on the Staffing and Resource Adequacy PES-NWI subscale was associated with a 2% increase in infants provided breastfeeding support. There was no association between other NICU nursing characteristics or LCs and nurse-provided breastfeeding support.

CONCLUSIONS

Nurses provide breastfeeding support around the clock. On a typical shift, about 1 in 7 NICU infants receives breastfeeding support from a nurse. Lactation consultants are not routinely available in NICUs, and their presence does not influence whether nurses provide breastfeeding support. Better nurse staffing fosters nurse provision of breastfeeding support.