Predictors of supplementation for breastfed babies in a Baby-Friendly hospital

Reported Adherence to the 10 Steps to Successful Breastfeeding Is Higher Among Baby-Friendly Hospitals

OBJECTIVE

Quantify and compare reported breastfeeding support practices in the Baby-Friendly Hospital Initiative (BFHI) and non-BFHI facilities.

DESIGN

Cross-sectional survey.

SETTING

Regions across the US.

PARTICIPANTS

Two hundred and eighty-six facilities (110 BFHI and 176 non-BFHI) selected by a stratified (by hospital size) random sample of 50% BFHI and 50% non-BFHI facilities.

INTERVENTION

Emailed survey Fall 2019 through Spring 2020.

MAIN OUTCOME MEASURE

Reported adherence to the 10 Steps to Successful Breastfeeding.

ANALYSIS

Wilcoxon rank sum test with continuity correction, Pearson chi-square test of independence, and Fisher's exact test.

RESULTS

Baby-Friendly Hospital Initiative facilities were more likely to report adherence to the 10 Steps to Successful Breastfeeding. Only 2 of the reported steps were not significantly different: immediate postnatal care and responsive feeding.

CONCLUSIONS AND IMPLICATIONS

This research supports breastfeeding support interventions within hospitals as both BFHI and non-BFHI facilities have room for improvement. Interventions targeting non-BFHI facilities are an opportunity to close the disparity in breastfeeding care.

Implementing the practice of early skin-to-skin contact among infants ≥35 weeks gestation born vaginally: a quality improvement study

BACKGROUND

Early skin-to-skin contact (SSC) at birth has been shown to improve neonatal outcomes due to enhanced cardiorespiratory stability, thermoregulation and breastfeeding success.

LOCAL PROBLEM

The practice of early SSC was virtually non-existent in our delivery room (DR).

METHODS AND INTERVENTIONS

The study was conducted in a newly established tertiary care teaching hospital in Western Rajasthan, India. We aimed to improve the median duration of early SSC from 0 min to at least 60 min over 24 weeks in our DR. A quality improvement (QI) team was formed, and all inborn infants ≥35 weeks born vaginally from 9 March 2017 were included. Using the tools of point-of-care QI, we found the lack of standard operating procedure, lack of knowledge among nursing staff regarding early SSC, routine shifting of all infants to radiant warmer, the practice of prioritising birthweight documentation and vitamin K administration as the major hindrances to early SSC. Various change ideas were implemented and tested sequentially through multiple plan-do-study-act (PDSA) cycles to improve the duration of early SSC. Interventions included framing a written policy for SSC, sensitising the nursing staff and resident doctors, actively delaying the alternate priorities, making early SSC a shared responsibility among paediatricians, obstetricians, nursing staff and family members, and continuing SSC in the recovery area of the DR complex.

RESULTS

The duration of early SSC increased from 0 to 67 min without any additional resources. The practice of SSC got well established in the system as reflected by a sustained improvement of 63 min and 72 min, respectively, at the end of 2 months and 4 years after study completion.

CONCLUSION

Using the QI approach, we established and sustained the practice of early SSC for more than 60 min in our unit by using system analysis and testing change ideas in sequential PDSA cycles.

90 versus 60 min of early skin-to-skin contact on exclusive breastfeeding rate in healthy infants' ≥35 weeks: A randomised controlled trial

AIM

To compare the effect of 90 versus 60 min of early skin-to-skin contact (SSC) among vaginally born healthy infants ≥35 weeks of gestation on their exclusive breastfeeding rates and breastfeeding behaviour.

METHODS

This parallel-group, open-label, randomised controlled trial enrolled healthy term and late preterm infants born vaginally. Infants in the intervention group received early SSC for 90 min compared to 60 min in the control group. The primary outcome was the proportion of infants on exclusive breastfeeding at 60 ± 12 h.

RESULTS

One hundred ninety-eight mother-infant dyads were randomised (99 in each group). The infants in the 90-min SSC group were more likely to be exclusively breastfed at 60 ± 12 h as compared to the 60-min SSC group (RR, 95% CI-1.44, [1.15-1.79], p < 0.01). The modified infant breastfeeding assessment tool score at 60 ± 12 h was significantly higher in the 90-min SSC group (median [IQR]-9, [8, 10] versus 8 [7, 10], p = 0.03]. The proportion of infants on exclusive breastfeeding at 6, 10, and 14 weeks of age was also significantly higher in the 90-min SSC group (RR, 95% CI-1.39 [1.11-1.74], 1.36 [1.08-1.07], and 1.38 [1.08-1.75], respectively).

CONCLUSION

Increasing the duration of early SSC showed a dose-response benefit on exclusive breastfeeding rates and breastfeeding behaviour.

TRIAL REGISTRATION

CTRI/2018/09/015632, registered on 06/09/2018.

A dose-response relationship found between the Ten Steps to Successful Breastfeeding indicators and in-hospital exclusive breastfeeding in US hospitals

BACKGROUND

In-hospital exclusive breastfeeding (EBF) is associated with longer breastfeeding durations, yet only 64% of US newborns are EBF for 7 days. The Ten Steps to Successful Breastfeeding (Ten Steps) are a set of evidenced-based maternity practices shown to improve breastfeeding outcomes; these were updated in 2018.

METHODS

Using hospital-level data from the 2018 Maternity Practices in Infant Nutrition and Care Survey (n = 2045 hospitals), we examined the prevalence of implementation of Ten Steps indicators (each step and total number of steps implemented). Using linear regression, we also examined the association between the steps and EBF prevalence adjusted for hospital characteristics and all other steps. Discharge support was not included in the models since it primarily occurs after hospital discharge.

RESULTS

The most frequently implemented step was the provision of prenatal breastfeeding education (95.6%). Steps with low implementation included rooming-in (18.9%), facility policies supportive of breastfeeding (23.4%), and limited formula supplementation (28.2%). After adjusting for hospital characteristics and all other steps, limited formula supplementation (difference = 14.4: 95% confidence interval [CI]: 12.6, 16.1), prenatal breastfeeding education (difference = 7.0; 95% CI: 3.3, 10.8), responsive feeding (difference = 6.3; 95% CI: 3.7, 9.0), care right after birth (skin-to-skin; difference = 5.8; 95% CI: 4.2, 7.4), and rooming-in (difference = 2.4; 95% CI: 0.4, 4.6) were associated with higher in-hospital EBF prevalence. We found a dose-response relationship between the number of steps implemented and in-hospital EBF prevalence.

CONCLUSION

Increased implementation of the updated Ten Steps may improve EBF and infant and maternal health outcomes.

Exact Gestational Age, Term Versus Early Term, Is Associated with Different Breastfeeding Success Rates in Mothers Delivered by Elective Cesarean Section

Objectives: The study was intended to verify the association between the gestational age of newborns classified as term and the success of breastfeeding in babies born by elective cesarean section. Also, to analyze how the variability of gestational age within the term influences breastfeeding. Materials and Methods: Retrospective study of a cohort, which included full-term newborns and their mothers, whose deliveries occurred by elective cesarean section. Among the inclusion criteria are delivery due to elective cesarean section and minimum gestational age of 37 weeks. The database consisted of medical birth information and interviews with mothers. Results: This study included 954 full-term newborns born by elective cesarean section. Exclusive breastfeeding at 3 months and being breastfed at 6 months showed a statistically significant association in the correlation with the variability of gestational age. There was a statistically significant association between exclusive breastfeeding at 3 months and breastfeeding at 6 months in the correlation between early term and full term. The trend test showed a significant progressive in the breastfeeding curve versus gestational age. Conclusion: Full-term newborns show better results of exclusive breastfeeding at 3 months and continued breastfeeding at 6 months, compared with those born at early term. Gestational age, even in term, has an influence on the success of breastfeeding in newborns undergoing elective cesarean delivery.

A nation‐wide study on the common reasons for infant formula supplementation among healthy, term, breastfed infants in US hospitals

In‐hospital infant formula supplementation of breastfed infants reduces breastfeeding duration, yet little is known about common reasons for infant formula supplementation. We examined the three most common reasons for in‐hospital infant formula supplementation of healthy, term, breastfed infants in the US reported by hospital staff. Hospital data were obtained from the 2018 Maternity Practices in Infant Nutrition and Care survey (n = 2045), which is completed by hospital staff. An open‐ended question on the top three reasons for in‐hospital infant formula supplementation was analyzed using thematic qualitative analysis and the frequencies for each reason were reported. The top three most common reasons for in‐hospital infant formula supplementation reported by hospital staff included medical indications (70.0%); maternal request/preference/feelings (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%) and medical staff/institutional practices (4.7%). These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation. Lactation management support delivered in a timely and culturally sensitive manner and targeted to mother‐infant dyads with potential medical and physical indications may reduce unnecessary in‐hospital infant formula supplementation.

The three most commonly reported reasons by hospital staff for infant formula supplementation were found to be related to medical indications (70.0%); maternal request/preference/feelings about breastfeeding such as frustration or lack of confidence (55.9%); lactation management‐related issues (51.3%); physical but non‐medically indicated reasons (36.1%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%); and medical staff/institutional practices (4.7%).

Underlying many of the reported three most common reasons for infant formula supplementation is potentially lack of lactation management support that considers the social influences (e.g. from family and friends) and that is culturally relevant.

These findings suggest that a variety of factors should be considered to address unnecessary infant formula supplementation.

Comparison of the Effects of Different Skin-to-Skin Contact Onset Times on Breastfeeding Behavior

Objective: Skin-to-skin contact (SSC) between mother and child improves the rates of exclusive breastfeeding (EBF) in the neonatal period. This study evaluated the effects of two SSC onset times on breastfeeding behavior in the neonatal period. Materials and Methods: A multicenter clinical trial was conducted, with random allocation of participants to two different SSC onset times: immediate (at birth) and early (at 60 minutes of life). Low-risk neonates at birth were included. The researchers responsible for analyzing the data were blinded. The outcomes evaluated were early breastfeeding; EBF in the hospital, in the first week of life, and in the first month; and breastfeeding effectiveness in the neonatal period. Bivariate analyses were performed to evaluate the effect of the onset of SSC on breastfeeding indicators. The relative risk (RR) was reported as an effect measure. Results: A total of 297 neonates were included (immediate SSC, n = 148; and early SSC, n = 149). No differences were found in early breastfeeding (93.6% versus 90.6%; RR 1.6, 95% confidence interval 0.07-3.82), breastfeeding effectiveness, or EBF in the neonatal period. There was an earlier initiation of breastfeeding in the immediate SSC group (22 versus 27 minutes, p < 0.001). Conclusions: No differences in breastfeeding indicators in the neonatal period were observed between groups with different onset times of SSC (immediate versus early) in the neonatal sensitive period among low-risk neonates at birth. Clinical Trial Registration Number: NCT02687685.

What Does It Mean to Be Breastfed? A Concept Analysis in the Context of Healthcare Research, Clinical Practice, and the Parent Perspective

Over the past 3 decades, there have been attempts to define breastfeeding for scientific research. However, a lack of clarity remains, with concurrent ambiguity in clinical practice and insufficient inclusion of the parent perspective. Furthermore, previous concept analyses of "breastfeeding" may not fully represent what it means for an infant to be breastfed. Therefore, this concept analysis sought to define "breastfed" in the context of Western healthcare research, clinical practice, and the parent perspective. Informed by Rodgers' evolutionary method, a literature search resulted in 16 representative articles, with related terms, attributes, antecedents, and consequences identified. Analysis of the literature resulted in a theoretical definition of breastfed as a valuable process, experience, or characteristic that involves human milk consumption by an infant through a variety of delivery methods. To be breastfed relies on the existence of lactation, whether from a parent or another source, and depends upon the intentional decision of a birthing person, caregiver, or provider. It is recommended that healthcare providers and institutions adopt this inclusive definition, committing to a linguistic and conceptual distinction between a breastfed infant and direct breastfeeding. Increased clarity may improve comparability between studies, reporting to government agencies, provider communication, and supportive, family-centered care.

Worldwide prevalence of mother-infant skin-to-skin contact after vaginal birth: A systematic review

BACKGROUND

Despite the World Health Organization's (WHO) recommendation for immediate skin-to-skin contact (SSC) after birth, separation of mothers and infants seems to be common practice in many hospitals. It is unknown how common the practice of SSC is worldwide. Therefore, we aimed to determine the reported prevalence of SSC for healthy mothers and infants immediately after normal birth.

METHODS

We systematically searched CINAHL, Medline, ProQuest Central, PubMed and the Cochrane Library for articles published between January 2007 and October 2017 using the keywords "kangaroo care" or "skin to skin contact" or "breastfeeding initiation" or "breast crawl" or "maternal infant contact" or "maternal newborn contact" or "baby friendly hospital initiative" or "ten steps for successful breastfeeding".

RESULTS

After an initial screening of 5266 records, 84 full text articles were assessed for eligibility, and 35 of these met the inclusion criteria. The studies were from 28 countries representing all six WHO world regions. There was a wide range in the practice of SSC for mother-infant dyads around the world: from 1% to 98%. Only 15 studies clearly defined SSC. Most of the studies were from high-income countries, and these reported higher rates of SSC than studies from low and middle-income countries.

CONCLUSION

There was a great heterogeneity in the definition of SSC as well as study designs, which makes cross-county comparison difficult. National studies reporting SSC rates are lacking. Future studies and guidelines to enhance SSC practice should include a standardised set of indicators and measurement tools that document SSC starting time and duration of SSC.