Racial and socioeconomic disparities in breast milk feedings in US neonatal intensive care units

Early postpartum pumping behaviors, pumped milk volume, and achievement of secretory activation in breast pump-dependent mothers of preterm infants

OBJECTIVE

Pumping studies in mothers of preterm infants are limited by self-reported pumping behaviors and non-objective measures of pumped milk volume and secretory activation (SA).

METHODS

Non-randomized observational study of first 14 days postpartum in 29 mothers of preterm infants. Smart pumps measured and stored pumping behaviors and pumped milk volume. Selective ion electrodes measured sodium and sodium:potassium ratio to determine SA. Generalized estimating equations, cluster analyses and multivariate regression were used.

RESULTS

SA was delayed (median 5.8 days) and impermanent. Each additional daily pumping increased odds of SA within 2 days by 48% (p = 0.01). High-intensity pumping mothers (N = 17) had greater daily and cumulative pumped milk volume than low-intensity pumping mothers (N = 12). Pumping variables showed daily changes in the first week, then plateaued.

CONCLUSION

The first week postpartum is critical for optimizing pumping behaviors. Accurate, objective measures of pumping behaviors, pumped milk volume and SA are a research priority.

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity

OBJECTIVE

 This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants.

STUDY DESIGN

 This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races.

RESULTS

 The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model.

CONCLUSION

This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709).

KEY POINTS

· Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

Lactation support in neonatal intensive care units in Germany from the mothers' perspective - a mixed-method study of the current status and needs

BACKGROUND

Establishing successful lactation in mothers of very low birth weight (VLBW, <1500g) infants requires structured lactation support. Little is known about mothers' perspectives on lactation support in German neonatal intensive care units (NICUs).

METHODS

This paper features a convergent mixed-method approach that includes a retrospective, cross-sectional questionnaire and interview data to showcase mothers' perceptions of lactation support in NICUs. Content analysis of the interviews (n = 12) and a descriptive analysis of quantitative data (n = 533) were performed to illustrate the current status and need for lactation support in German NICUs.

RESULTS

The results show that lactation support in German NICUs is often inadequate and does not comply with recommendations based on the existing literature to encourage pumping and breastfeeding in mothers. The data imply that even if lactation is successfully initiated in most cases, it is often not maintained over time, which may be due to a lack of personal support and consistent information.

CONCLUSION

The overall structures and institutional guidelines for lactation support should be encouraged to promote nutrition with mother´s own milk in German NICUs.

Need for Gastrostomy Tube in Periviable Infants

OBJECTIVE

 We sought to identify clinical and demographic factors associated with gastrostomy tube (g-tube) placement in periviable infants.

STUDY DESIGN

 We conducted a single-center retrospective cohort study of live-born infants between 22 and 25 weeks' gestation. Infants not actively resuscitated and those with congenital anomalies were excluded from analysis.

RESULTS

 Of the 243 infants included, 158 survived until discharge. Of those that survived to discharge, 35 required g-tube prior to discharge. Maternal race/ethnicity (p = 0.006), intraventricular hemorrhage (p = 0.013), periventricular leukomalacia (p = 0.003), bronchopulmonary dysplasia (BPD; p ≤ 0.001), and singleton gestation (p = 0.009) were associated with need for gastrostomy. In a multivariable logistic regression, maternal Black race (Odds Ratio [OR] 2.88; 95% confidence interval [CI] 1.11-7.47; p = 0.029), singleton gestation (OR 3.99; 95% CI 1.28-12.4; p = 0.017) and BPD (zero g-tube placement in the no BPD arm; p ≤ 0.001) were associated with need for g-tube.

CONCLUSION

 A high percentage of periviable infants surviving until discharge require g-tube at our institution. In this single-center retrospective study, we noted that maternal Black race, singleton gestation, and BPD were associated with increased risk for g-tube placement in infants born between 22 and 25 weeks' gestation. The finding of increased risk with maternal Black race is consistent with previous reports of racial/ethnic disparities in preterm morbidities. Additional studies examining factors associated with successful achievement of oral feedings in preterm infants are necessary and will inform future efforts to advance equity in newborn health.

KEY POINTS

· BPD, singleton birth, and Black race are associated with need for g-tube in periviable infants.. · Severe intraventricular hemorrhage is associated with increased mortality or g-tube placement in periviable infants.. · Further investigation into the relationship between maternal race and g-tube placement is warranted..

No change in mother's own milk provision and breastfeeding rates in preterm infants during the COVID-19 pandemic

AIM

The aim of the study was to evaluate the duration of mother's own milk (MOM) provision to preterm very low-birth weight (VLBW, <1500 g) infants during the COVID-19 pandemic. We hypothesised that COVID-19 restrictions would reduce the duration of MOM provision.

METHODS

This retrospective study compared VLBW infants born at the Berlin university hospital during the pandemic (15 March 2020 to 14 March 2021, n = 108) with infants born in the pre-pandemic year (01 January 2019 to 31 January 2019, n = 121). We calculated the duration of MOM provision and analysed factors associated with its early cessation.

RESULTS

During the pandemic, the rate of primiparous mothers increased from 29% to 44% while the distribution of all other parental and infants' characteristics remained similar. There were no differences in the median duration of MOM provision (47 vs. 51 days), feeding type (MOM 67% vs. 65%) and breastfeeding rates at discharge (exclusive, 8% vs. 13%; partial 69% vs. 60%). Cox proportional hazard analysis revealed smoking during pregnancy and parental school education consistently as independent risk factors for early cessation of MOM provision.

CONCLUSION

Supply of MOM for VLBW infants can be upheld also during pandemic restrictions.

Human Milk Cessation in the NICU in Infants with Bronchopulmonary Dysplasia

OBJECTIVE

 The objective of this study was to identify factors associated with the cessation of human milk prior to neonatal intensive care unit (NICU) discharge for infants diagnosed with bronchopulmonary dysplasia (BPD).

STUDY DESIGN

 Participants were recruited from the Johns Hopkins BPD Clinic between January 2016 and October 2018. Clinical and demographic characteristics were analyzed based on whether participants stopped human milk before or after NICU discharge.

RESULTS

 Of the 224 infants included, 109 (48.7%) infants stopped human milk prior to discharge. The median duration of human milk intake was less for infants who stopped human milk prior to discharge compared with those who continued after discharge (2 vs. 8 months, p < 0.001). In multivariate regression analysis, pulmonary hypertension (odds ratio [OR]: 2.90; p = 0.016), public insurance (OR: 2.86; p < 0.001), and length of NICU admission (OR: 1.26 per additional month; p = 0.002) were associated with human milk cessation prior to NICU discharge.

CONCLUSION

 Infants with BPD who have severe medical comorbidities and markers of lower socioeconomic status may be at higher risk for earlier human milk discontinuation.

KEY POINTS

· Half of infants in our study with BPD who received human milk stopped human milk prior to NICU discharge.. · For infants on human milk after discharge, the duration of human milk intake was 8.6 months.. · Infants with pulmonary hypertension, tracheostomies, and ventilation stopped human milk earlier.. · Non-White race, lower income, and public insurance were predictors of early human milk cessation..

Where does the time go? Temporal patterns of pumping behaviors in mothers of very preterm infants vary by sociodemographic and clinical factors

Background

Mothers of very preterm (<32 weeks gestational age [GA]) infants are breast pump dependent and have shorter duration of milk provision than mothers of term infants. The opportunity (i.e., time) cost of pumping and transporting mother's own milk (MOM) from home to the NICU may be a barrier. There is a paucity of data regarding how much time mothers actually spend pumping.

Objective

To investigate the variation in pumping behavior by postpartum week, maternal characteristics, and infant GA.

Methods

Prospectively collected pump log data from mothers enrolled in ReDiMOM (Reducing Disparity in Mother's Own Milk) randomized, controlled trial included pumping date and start time and end time of each pumping session for the first 10 weeks postpartum or until the infant was discharged from the NICU, whichever occurred first. Outcomes included number of daily pumping sessions, number of minutes spent pumping per day, and pumping behaviors during 24-h periods, aggregated to the postpartum week. Medians (interquartile ranges) were used to describe outcomes overall, and by maternal characteristics and infant GA.

Results

Data included 13,994 pump sessions from 75 mothers. Maternal characteristics included 55% Black, 35% Hispanic, and 11% White and 44% <30 years old. The majority (56%) of infants were born at GA 28-31 weeks. Mothers pumped an average of less than 4 times per day, peaking in postpartum week 2. After accounting for mothers who stopped pumping, there was a gradual decrease in daily pumping minutes between postpartum weeks 2 (89 min) and 10 (46 min). Black mothers pumped fewer times daily than non-Black mothers after the first 2 weeks postpartum.

Conclusion

On average mothers pumped less intensively than the minimum recommendation of 8 times and 100 min per day. However, these pumping behaviors represent significant maternal opportunity costs that should be valued by the institution and society at large.

Milk Biomarkers of Secretory Activation in Breast Pump-Dependent Mothers of Preterm Infants: An Integrative Review

Background: Lack of mother's own milk (MOM) at discharge from the neonatal intensive care unit (NICU) is a global problem and is often attributable to inadequate MOM volume. Evidence suggests that the origins of this problem are during the first 14 days postpartum, a time period that includes secretory activation (SA; lactogenesis II, milk coming in). Objectives: To describe and summarize evidence regarding use of MOM biomarkers (MBMs) as a measure of SA in pump-dependent mothers of preterm infants in the NICU and to identify knowledge gaps requiring further investigation. Methods: An integrative review was conducted using Whittemore and Knafl methodology incorporating the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. A search using electronic databases MEDLINE (through PubMed) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) and reference lists of included articles was conducted. Results: Of the 40 articles retrieved, 6 met the criteria for inclusion. Results revealed the following five findings: (1) Achievement of SA defined by MBMs is delayed and/or impaired in mothers of preterm infants. (2) MBMs are associated with pumped MOM volume. (3) Achievement of SA defined by MBMs is associated with pumping frequency. (4) Delayed and/or impaired achievement of SA defined by MBMs may be exacerbated by maternal comorbidities. (5) There is a lack of consensus as to which MBM(s) and analysis techniques should be used in research and practice. Conclusions: MBMs hold tremendous potential to document and monitor achievement of SA in mothers of preterm infants, with multiple implications for research and clinical practice.

Parent Perspectives: Part 1-Considerations for Changing the NICU Culture

While publications that aim to reflect the parent perspective are increasingly common in the medical literature, few are authored by parents in their own words. As mothers with lived and professional experience in the Neonatal Intensive Care Unit (NICU), we believe this perspective is vital to improving health outcomes. We are writing from a life course health development framework that regards health as an active process that develops over time with the integration of physical, social, emotional, and relational components. Health development trajectories are shaped by the family and community ecosystems that surround each child. This means that the child's ability to thrive is strongly linked to the family's health and well-being. These links are not being given sufficient attention in clinical practice. Psychological distress, trauma, and grief are common family experiences in the NICU. Left unaddressed, they can negatively impact parent-child bonding. Drawing on life course principles, we make a series of recommendations for changes to practice to enable NICUs to better serve children and families, and better prepare families for the post-NICU experience. These include setting a positive tone in the NICU, creating a nurturing, personalized environment; addressing the social determinants of health; supporting families to develop a 'growth' mindset; and communicating in an optimistic, positive manner. Building trust is key to ensuring families feel supported and can be promoted through establishing equitable collaborative models of care. Peer support, doulas, and community health worker engagement can facilitate early interactions crucial to the child's developmental progress and family healing.

Wayfinding through the "ocean of the great unknown": how lactating parents establish a direct breastfeeding relationship with an infant with critical CHD

INTRODUCTION

Lactating parents of infants hospitalised for critical congenital heart disease (CHD) face significant barriers to direct breastfeeding. While experiences of directly breastfeeding other hospitalised neonates have been described, studies including infants with critical CHD are scarce. There is no evidence-based standard of direct breastfeeding care for these infants, and substantial practice variation exists.

AIM

To explain how direct breastfeeding is established with an infant hospitalised for critical CHD, from lactating parents' perspectives.

MATERIALS & METHODS

This study is a qualitative grounded dimensional analysis of interviews with 30 lactating parents of infants with critical CHD who directly breastfed within 3 years. Infants received care from 26 United States cardiac centres; 57% had single ventricle physiology. Analysis included open, axial, and selective coding; memoing; member checking; and explanatory matrices.

RESULTS

Findings were represented by a conceptual model, "Wayfinding through the 'ocean of the great unknown'." The core process of Wayfinding involved a nonlinear trajectory requiring immense persistence in navigating obstacles, occurring in a context of life-and-death consequences for the infant. Wayfinding was characterised by three subprocesses: navigating the relationship with the healthcare team; protecting the direct breastfeeding relationship; and doing the long, hard work. Primary influencing conditions included relentless concern about weight gain, the infant's clinical course, and the parent's previous direct breastfeeding experience.

CONCLUSIONS

For parents, engaging in the Wayfinding process to establish direct breastfeeding was feasible and meaningful - though challenging. The conceptual model of Wayfinding explains how direct breastfeeding can be established and provides a framework for research and practice.

Predictors of Human Milk Feeding and Direct Breastfeeding for Infants with Single Ventricle Congenital Heart Disease: Machine Learning Analysis of the National Pediatric Cardiology Quality Improvement Collaborative Registry

OBJECTIVE

To identify factors that support or limit human milk (HM) feeding and direct breastfeeding (BF) for infants with single ventricle congenital heart disease at neonatal stage 1 palliation (S1P) discharge and at stage 2 palliation (S2P) (∼4-6 months old).

STUDY DESIGN

Analysis of the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry (2016-2021; 67 sites). Primary outcomes were any HM, exclusive HM, and any direct BF at S1P discharge and at S2P. The main analysis involved multiple phases of elastic net logistic regression on imputed data to identify important predictors.

RESULTS

For 1944 infants, the strongest predictor domain areas included preoperative feeding, demographics/social determinants of health, feeding route, clinical course, and site. Significant findings included: preoperative BF was associated with any HM at S1P discharge (OR = 2.02, 95% CI = 1.74-3.44) and any BF at S2P (OR = 2.29, 95% CI = 1.38-3.80); private/self-insurance was associated with any HM at S1P discharge (OR = 1.91, 95% CI = 1.58-2.47); and Black/African-American infants had lower odds of any HM at S1P discharge (OR = 0.54, 95% CI = 0.38-0.65) and at S2P (0.57, 0.30-0.86). Adjusted odds of HM/BF practices varied among NPC-QIC sites.

CONCLUSIONS

Preoperative feeding practices predict later HM and BF for infants with single ventricle congenital heart disease; therefore, family-centered interventions focused on HM/BF during the S1P preoperative time are needed. These interventions should include evidence-based strategies to address implicit bias and seek to minimize disparities related to social determinants of health. Future research is needed to identify supportive practices common to high-performing NPC-QIC sites.

Promotion, Protection, and Support of Breastfeeding as a Human Right: A Narrative Review

Background: Despite the benefits of breastfeeding, there are significant disparities in rates among various racial, social, and economic groups. Society poses various barriers to breastfeeding, threatening the child's access to a basic human right. Exploring and understanding these issues can ensure that effective interventions are implemented. Objective: To present situations in which the mother's and child's basic human right to breastfeeding is threatened and to highlight opportunities to uphold their rights within social and health care systems. Methods: A literature search of relevant articles was performed via PubMed regarding (1) rights to optimal protections for breastfeeding, (2) situations in which the rights of breastfeeding parents are threatened, and (3) challenges in providing inclusive and equitable breastfeeding care along with strategies to uphold the human right to breastfeed. Results: Maternity leave of at least 12 weeks was associated with higher breastfeeding rates, whereas mandated breaks in the workplace resulted in either positive or inconclusive effects. Peer counseling, institutional initiatives, and mass media campaigns were among the most effective interventions; however, effects on breastfeeding varied among different racial groups. Conclusions: There are clear benefits of breastfeeding for mothers and infants, which highlight the importance of prioritizing breastfeeding as a basic human right. Regardless, there are numerous societal barriers to providing equitable breastfeeding care. Although there are interventions that have proven to be helpful in breastfeeding promotion, protection, and support, further standardized research will be beneficial in identifying effective and inclusive interventions.

Early pumping frequency and coming to volume for mother's own milk feeding in hospitalized infants

OBJECTIVE

To identify daily pumping frequencies associated with coming to volume (CTV: producing > 500 milliliters of milk per day by postnatal day 14) for mothers of infants in the neonatal intensive care unit (NICU).

STUDY DESIGN

We compared demographics and daily pumping frequencies for mothers who did and did not experience CTV.

RESULTS

Of 427 mothers who produced milk, 201 (50.1%) experienced CTV. Race, insurance, delivery type and birthweight were associated with CTV. For mothers who experienced CTV, average pumping episodes increased daily, stabilizing at 5 pumping episodes per day by postnatal day 5 (5 × 5). Women who experienced CTV were also more likely to have pumped between 0100 and 0500 (AM pumping). In multivariable analysis birthweight, 5 × 5 and AM pumping were each independently associated with CTV.

CONCLUSION

Supporting mothers of NICU infants to achieve 5 or more daily pumping sessions by postnatal day 5 could improve likelihood of achieving CTV.

Racial Disparities in Breastmilk Receipt and Extremely Low Gestational Age Neonatal Morbidities in an Asian Pacific Islander Population

BACKGROUND

Racial disparities in breastmilk provision and neonatal morbidities of extreme prematurity have been documented in previous studies but are not as well-documented in Asian and Pacific Islander (API) infants. The objectives of this study were to evaluate a predominantly API neonatal intensive care unit (NICU) population for racial disparities in (1) the receipt of breastmilk within 24 h of admission and at discharge and (2) neonatal morbidities among infants ≤ 28 weeks gestational age.

METHODS

A retrospective chart review of 2528 infants from 2018 to 2020 born at the largest level 3 NICU in Honolulu, Hawai'i, was conducted. Multivariable logistic regression analysis was performed on NICU outcomes to calculate adjusted odds ratios (aOR) and confidence intervals (CI).

RESULTS

Native Hawaiian (NH) (aOR 0.73 [0.54, 0.98]), Pacific Islander (PI) (aOR 0.57 [0.41, 0.79]), and Filipino infants (aOR 0.66 [0.49, 0.89]) were less likely to receive breastmilk at discharge compared to Asian infants. PI infants were also more likely to experience necrotizing enterocolitis (aOR 7.89 [1.07, 58.10]) and intraventricular hemorrhage (aOR 3.86 [1.15, 13.02]) compared to Asian infants.

CONCLUSION

In a predominantly API population, disparities in breastmilk receipt and neonatal morbidities exist among NH, PI, and Filipino infants in the NICU. Our findings call for better understanding of the underlying inequities to guide directed efforts, including standardization of care through staff trainings on implicit biases and trauma-informed care, as well as provision of culturally sensitive education and lactation support for these patients.

Sociodemographic factors associated with tracheostomy and mortality in bronchopulmonary dysplasia

OBJECTIVES

We sought to investigate how race, ethnicity, and socioeconomic status relate to tracheostomy insertion and post-tracheostomy mortality among infants with bronchopulmonary dysplasia (BPD).

METHODS

The Vizient Clinical Database/Resource Manager was queried to identify infants born ≤32 weeks with BPD admitted to US hospitals from January 2012 to December 2020. Markers of socioeconomic status were linked to patient records from the Agency for Healthcare Research and Quality's Social Determinants of Health Database. Regression models were used to assess trends in annual tracheostomy insertion rate and odds of tracheostomy insertion and post-tracheostomy mortality, adjusting for sociodemographic and clinical factors.

RESULTS

There were 40,021 ex-premature infants included in the study, 1614 (4.0%) of whom received a tracheostomy. Tracheostomy insertion increased from 2012 to 2017 (3.1%-4.1%), but decreased from 2018 to 2020 (3.3%-1.6%). Non-Hispanic Black infants demonstrated a 25% higher odds (aOR 1.25, 1.09-1.43) and Hispanic infants demonstrated a 20% lower odds (aOR 0.80, 0.65-0.96) of tracheostomy insertion compared with non-Hispanic White infants. Patients receiving public insurance had increased odds of tracheostomy insertion (aOR 1.15, 1.03-1.30), but there was no relation between other metrics of socioeconomic status and tracheostomy insertion within our cohort. In-hospital mortality among the tracheostomy-dependent was 14.1% and was not associated with sociodemographic factors.

CONCLUSIONS

Disparities in tracheostomy insertion are not accounted for by differences in socioeconomic status or the presence of additional neonatal morbidities. Post-tracheostomy mortality does not demonstrate the same relationships. Further investigation is needed to explore the source and potential mitigators of the identified disparities.

Health Care Disparities in High-Risk Neonates

Long-standing health disparities in maternal reproductive health, infant morbidity and mortality, and long-term developmental outcomes are rooted in a foundation of structural racism. Social determinants of health profoundly affect reproductive health outcomes of Black and Hispanic women disproportionately; they have higher rates of death during pregnancy and preterm birth. Their infants are also more likely to be cared for in poorer quality neonatal intensive care units (NICUs), receive poorer quality of NICU care, and are less likely to be referred to an appropriate high-risk NICU follow-up program. Interventions that mitigate the impact of racism will help to eliminate health disparities.

Beyond income: material hardship and the health and healthcare of premature children

OBJECTIVES

To estimate national prevalence of household hardships (food insufficiency, financial hardship, and difficulty paying medical bills) among children born term and preterm; and examine associations of household hardships with preterm children's outcomes (health status, emergency room visits, and unmet healthcare needs).

METHODS

We studied 24,026 children aged 0-3 years born term, preterm with moderately low birth weight (1501-2499 grams) and preterm with very low birth weight (VLBW; ≤1500 grams). Using propensity score matching to control for correlates of poverty, we examined associations of hardships and child outcomes.

RESULTS

Compared with term, households with preterm VLBW children had >2-fold higher odds of financial hardship (aOR:2.63; 95% CI: 1.26-5.46) and >5-fold higher odds of difficulty paying bills (aOR:5.60; 95% CI: 2.35-10.35). Matching for sociodemographics, special healthcare needs, income and receipt of public benefits, hardships were independently associated with adverse preterm children's outcomes.

CONCLUSIONS

Addressing household hardships is needed to optimize preterm child outcomes.

The Role of Work as a Social Determinant of Health in Mother's Own Milk Feeding Decisions for Preterm Infants: A State of the Science Review

In the United States, 10% of infants are born preterm (PT; <37 weeks gestational age) each year and are at higher risk of complications compared to full term infants. The burden of PT birth is borne disproportionately by Black versus non-Black families, with Black mothers significantly more likely to give birth to a PT infant. One proven strategy to improve short- and long-term health outcomes in PT infants is to feed mother's own milk (MOM; breast milk from the mother). However, mothers must make decisions about work and MOM provision following PT birth, and more time spent in paid work may reduce time spent in unpaid activities, including MOM provision. Non-Black PT infants are substantially more likely than Black PT infants to receive MOM during the birth hospitalization, and this disparity is likely to be influenced by the complex decisions mothers of PT infants make about allocating their time between paid and unpaid work. Work is a social determinant of health that provides a source of income and health insurance coverage, and at the same time, has been shown to create disparities through poorer job quality, lower earnings, and more precarious employment in racial and ethnic minority populations. However, little is known about the relationship between work and disparities in MOM provision by mothers of PT infants. This State of the Science review synthesizes the literature on paid and unpaid work and MOM provision, including: (1) the complex decisions that mothers of PT infants make about returning to work, (2) racial and ethnic disparities in paid and unpaid workloads of mothers, and (3) the relationship between components of job quality and duration of MOM provision. Important gaps in the literature and opportunities for future research are summarized, including the generalizability of findings to other countries.

Factors Which May Contribute to the Success or Failure of the Use of Mother's Own Milk in a Level IV Neonatal Intensive Care Unit

BACKGROUND

Benefits of mother's own milk (MOM) for infants in neonatal intensive care units (NICUs) are well known. Many mothers provide for their infant's feedings during their entire hospitalization while others are unable. Knowledge is limited about which infant and maternal factors may contribute most to cessation of MOM feedings.

PURPOSE

Study aims were to (1) identify which maternal and infant risk factors or combination of factors are associated with cessation of provision of MOM during hospitalization, (2) develop a lactation risk tool to identify neonatal intensive care unit infants at higher risk of not receiving MOM during hospitalization, and (3) identify when infants stop receiving MOM during hospitalization.

METHODS

A data set of 797 infants admitted into a level IV neonatal intensive care unit before 7 days of age, whose mothers chose to provide MOM, was created from analysis of data from the Children's Hospital Neonatal Database. Maternal and infant factors of 701 dyads who received MOM at discharge were compared with 87 dyads who discontinued use of MOM by discharge using χ 2 , t tests, and Wilcoxon rank tests. Logistic regression was used to build a risk-scoring model.

RESULTS

The probability of cessation of MOM increased significantly with the number of maternal-infant risk factors. A Risk Calculator was developed to identify dyads at higher risk for cessation of MOM by discharge.

IMPLICATIONS FOR PRACTICE

Identifying mothers at risk for cessation of MOM can enable the healthcare team to provide optimal lactation management and outcomes.

IMPLICATIONS FOR RESEARCH

Although the Risk Calculator has potential to identify dyads at risk of early MOM cessation, further research is needed to validate these results.

Racial and ethnic disparities in outcomes after NICU discharge: An equity-focused model

Significant racial and ethnic disparities exist in birth outcomes and complications related to prematurity. However, little is known about racial and ethnic variations in health outcomes after premature infants are discharged from the neonatal intensive care unit (NICU). We propose a novel, equity-focused conceptual model to guide future evaluations of post-discharge outcomes that centers on a multi-dimensional, comprehensive view of health, which we call thriving. We then apply this model to existing literature on post-discharge inequities, revealing a need for rigorous analysis of drivers and strength-based, longitudinal outcomes.

Racial disparities in the development of comorbid conditions after preterm birth: A narrative review

Despite recognition and attempts to reduce racial disparities in perinatal outcomes, Black infants are still disproportionately represented among those who are born preterm. Postnatal investigations of racial disparities in comorbidities and outcomes after preterm birth are increasing, although their results and interpretations are conflicting. In the present review, we 1.) identify important methodological limitations of that literature 2.) summarize the conflicting literature investigating racial disparities, specifically Black-white differences, in postnatal comorbidities and outcomes after preterm birth 3.) describe mechanisms by which racism operates to contextualize our understanding to inform future work to actively reduce disparities in preterm birth and subsequently, its complications.

Clinical decision support in the neonatal ICU

Clinical Decision Support (CDS) tools help the healthcare team diagnose, monitor, and treat patients more efficiently and consistently by executing clinical practice guidelines and recommendations. As a result, CDS has a direct impact on the delivery and healthcare outcomes. This review covers the fundamental concepts, as well as the infrastructure needed to create a CDS tool and examples of its use in the neonatal setting. This article also serves as a primer on what to think about when proposing the development of a new CDS tool, or when upgrading an existing one. We also highlight important elements that influence CDS development, such as informatics methodologies, data and device interoperability, and regulation.

Association of Racial Disparities With In-Hospital Outcomes in Severe Bronchopulmonary Dysplasia

IMPORTANCE

Bronchopulmonary dysplasia (BPD) is the most common serious morbidity of preterm birth. Short-term respiratory outcomes for infants with the most severe forms of BPD are highly variable. The mechanisms that explain this variability remain unknown and may be mediated by racial disparities.

OBJECTIVE

To determine the association of maternal race with death and length of hospital stay in a multicenter cohort of infants with severe BPD.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study included preterm infants enrolled in the BPD Collaborative registry from January 1, 2015, to July 19, 2021, involving 8 BPD Collaborative centers located in the US. Included patients were born at less than 32 weeks' gestation, had a diagnosis of severe BPD as defined by the 2001 National Institutes of Health Consensus Criteria, and were born to Black or White mothers.

EXPOSURES

Maternal race: Black vs White.

MAIN OUTCOMES AND MEASURES

Death and length of hospital stay.

RESULTS

Among 834 registry infants (median [IQR] gestational age, 25 [24-27] weeks; 492 male infants [59%]) meeting inclusion criteria, the majority were born to White mothers (558 [67%]). Death was observed infrequently in the study cohort (32 [4%]), but Black maternal race was associated with an increased odds of death (adjusted odds ratio, 2.1; 95% CI, 1.2-3.5) after adjusting for center. Black maternal race was also significantly associated with length of hospital stay (adjusted between-group difference, 10 days; 95% CI, 3-17 days).

CONCLUSIONS AND RELEVANCE

In a multicenter severe BPD cohort, study results suggest that infants born to Black mothers had increased likelihood of death and increased length of hospital stay compared with infants born to White mothers. Prospective studies are needed to define the sociodemographic mechanisms underlying disparate health outcomes for Black infants with severe BPD.

Profiling of mature-stage human breast milk cells identifies six unique lactocyte subpopulations

Breast milk is chock-full of nutrients, immunological factors, and cells that aid infant development. Maternal cells are the least studied breast milk component, and their unique properties are difficult to identify using traditional techniques. Here, we characterized the cells in mature-stage breast milk from healthy donors at the protein, gene, and transcriptome levels. Holistic analysis of flow cytometry, quantitative polymerase chain reaction, and single-cell RNA sequencing data identified the predominant cell population as epithelial with smaller populations of macrophages and T cells. Two percent of epithelial cells expressed four stem cell markers: SOX2, TRA-1-60, NANOG, and SSEA4. Furthermore, milk contained six distinct epithelial lactocyte subpopulations, including three previously unidentified subpopulations programmed toward mucosal defense and intestinal development. Pseudotime analysis delineated the differentiation pathways of epithelial progenitors. Together, these data define healthy human maternal breast milk cells and provide a basis for their application in maternal and infant medicine.

Exclusive breastfeeding in African American women: A concept analysis

AIM

To report an analysis of the concept of exclusive breastfeeding (EBF) in African American women.

BACKGROUND

EBF is the gold standard for infant nutrition from birth until 6 months. The rate of EBF in United States is low-26%, with African American women having the lowest rates. The low rates of EBF in this population are strongly attributed to bias, racism and generational trauma. Therefore, clarifying the concept of EBF with respect to these factors is important for promoting EBF rates of this population.

DESIGN

Concept analysis.

DATA SOURCES

Search was conducted in four databases (CINAHL, PubMed, PsycINFO and Scopus) for articles published between 2001 and 2021. A total of 30 articles (20 quantitative, seven qualitative and three mixed methods) clarified the concept. Relevant literature emanated from diverse disciplines examining historical and present maternal and infant health.

METHODS

Concept analysis using Rodger's evolutionary method.

RESULTS

An operational definition of the concept of EBF in African American women was developed from the identified antecedents (modifiable and non-modifiable), defining attributes and consequences of the concept. Access to breastfeeding resources, maternal (prenatal intention to breastfeed, smoking status, attitude towards breastfeeding), infant (skin-to-skin care, successful latching and weight) and contextual factors (socioeconomic, occupational and cultural) predict EBF. The primary attributes of EBF were physiological, physical, psychological and relational. Consequences of EBF were positive health outcomes for, and increased bonding between, mother and infant.

CONCLUSION

This concept analysis is the first identifying modifiable and non-modifiable antecedents of EBF. The analysis provides an operational definition for EBF in African American women which is useful to promote understanding of breastfeeding. This new concept examines the historic societal trauma associated with wet nursing and reframes breastfeeding as a positive maternal and infant health behaviour.

The Impact of Human Milk on Outcomes for Infants with Congenital Heart Disease: A Systematic Review

Background: Infants with congenital heart disease (CHD) are at risk for feeding-related morbidity and mortality, with growth failure and oral feeding problems associated with poor outcomes. The benefits of human milk (HM) for preterm infants have been well documented, but evidence on HM for infants with CHD has recently begun to emerge. Objectives: Our primary aim was to examine the impact of HM feeding on outcomes for infants with CHD. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. The quality of each study was assessed using the Joanna Briggs Critical Appraisal Tools. A total of 16 studies were included. Results: There was evidence that an exclusive HM diet reduces the risk of necrotizing enterocolitis (NEC) for infants with CHD. Evidence with a higher risk for bias indicated that a well-managed HM diet may be associated with improved growth, shorter length of stay, and improved postoperative feeding and nutritional outcomes. Chylothorax outcomes were similar between modified HM and medium-chain triglyceride formula. The studies had significant limitations related to power, lack of control for covariates, and inconsistent delineation of feeding groups. Conclusions: Based on the reduced risk for NEC and given the conclusive benefits in other vulnerable populations, we recommend that clinicians and institutions prioritize programs to support HM feeding for infants with CHD. Large high-quality studies are needed to validate these results. Future work should clarify best practices in managing an HM diet to support optimal growth and development for these infants.

Maternal Milk Provision in the Neonatal Intensive Care Unit and Mother–Infant Emotional Connection for Preterm Infants

Maternal milk (MM) intake during neonatal intensive care unit (NICU) hospitalization is associated with improved neurodevelopment in preterm infants. Underlying mechanisms may include stronger mother–infant emotional connection. This paper examines associations between MM provision in the NICU with maternal connection to her infant using three factors validated in our sample: maternal sensitivity, emotional concern, and positive interaction/engagement. We studied 70 mothers of infants born <1500 g and/or <32 weeks’ gestation. Associations between MM provision and mother–infant connection were modeled using median regression adjusted for clustering. Mothers who provided exclusive MM (i.e., 100% MM, no other milk) reported higher levels of maternal sensitivity by a median score of 2 units (β = 2.00, 95% CI: 0.76, 3.24, p = 0.002) than the mixed group (i.e., MM < 100% days, other milk ≥1 days), as well as greater emotional concern (β = 3.00, 95% CI: −0.002, 6.00, p = 0.05). Among mothers of very preterm infants, greater milk provision was associated with greater maternal sensitivity, but also with greater emotional concern about meeting the infant’s needs. These findings highlight the importance of supporting MM provision and early infant care as an integrated part of lactation support. The findings may also provide insight into links between MM provision in the NICU and infant neurodevelopment.

US state policies for Medicaid coverage of donor human milk

Donor human milk is recommended by the American Academy of Pediatrics for high-risk infants when mother's own milk is absent or insufficient in quantity. Several factors may contribute to the inequitable use of or access to donor human milk, including a limited knowledge of its effects, cost, reimbursement, and regulatory barriers. The American Academy of Pediatrics and the United States Surgeon General have called for investigating barriers that prevent use of donor human milk for high-risk infants and for changes to public policy known to improve availability and affordability. We review the current legislative, regulatory, and economic landscape surrounding donor human milk use in the United States, as well as suggest state- and federal-level solutions to increase access to donor human milk.

Antiracism in the Field of Neonatology: A Foundation and Concrete Approaches

Neonatal patients and families from historically marginalized and discriminated communities have long been documented to have differential access to health care, disparate health care, and as a result, inequitable health outcomes. Fundamental to these processes is an understanding of what race and ethnicity represent for patients and how different levels of racism act as social determinants of health. The NICU presents a unique opportunity to intervene with regard to the detrimental ways in which structural, institutional, interpersonal, and internalized racism affect the health of newborn infants. The aim of this article is to provide neonatal clinicians with a foundational understanding of race, racism, and antiracism within medicine, as well as concrete ways in which health care professionals in the field of neonatology can contribute to antiracism and health equity in their professional careers.

Provision of mother's own milk for preterm infants during the COVID-19 pandemic: Differential effect of insurance

Mother-infant dyads faced many challenges during the COVID-19 pandemic; however, the impact was different depending on socio-economic determinants. This study aims to investigate the impact of the COVID-19 pandemic on maternal provision of mother's own milk (MOM) at neonatal intensive care unit (NICU) discharge among preterm infants. We hypothesized that fewer infants would be discharged home on any MOM during the pandemic period compared to a pre-pandemic period. This is a retrospective analysis of infants born <34 weeks' gestation admitted to the Women and Infant's Hospital NICU. Infants born pre-pandemic (1/1/2019 to 2/29/2020) were compared to infants born during the pandemic (3/1/2020 to 4/30/2021). Maternal and neonatal variables were analyzed by group. The primary outcome was provision of MOM (defined as feeding exclusively MOM, or a combination of MOM and formula) at NICU discharge. Analyses were performed for time periods, and multivariable regression analyses were run for the total cohort and by insurance type. Analysis included 268 infants born pre-pandemic and 262 infants born during the pandemic. Pandemic group mothers vs. pre-pandemic were less likely to be single (27%, 63/233 vs. 38%, 93/243; p = 0.01) and more likely to have a diagnosis of chorioamnionitis (16%, 38/236 vs. 7%, 17/243; p = 0.002). Rates of public insurance were similar (55% pre-pandemic and 50% pandemic). There was no significant change in provision of MOM between time periods. In multivariable analysis, public insurance decreased the odds of MOM at discharge for the entire study period (aOR 0.31, 95% CI: 0.19-0.50; p = 0.0001). On analysis by insurance type, rates of MOM increased from 77% pre-pandemic to 88% during the pandemic (p = 0.03) for mothers with private insurance and remained unchanged for mothers with public insurance (52% pre-pandemic and 53% pandemic; p = 0.86). Mothers with private insurance had twice the odds (aOR 2.02, 95% CI: 1.02-3.97; p = 0.04) of providing MOM during the pandemic vs. pre-pandemic. For those with public insurance, the odds for any MOM provision during the pandemic were unchanged (aOR 0.95, 95% CI: 0.5-1.7; p = 0.86). These differences may be related to health care disparities requiring additional exploration of risk factors and the need for equitable opportunities for all mother-infant dyads.

Contraception Utilization in Black Women via a Reproductive Justice Lens

Background: Over 100 million women make decisions about beginning or resuming contraception after childbirth annually. The burden of an unplanned pregnancy is not equally distributed among racial and ethnic groups in the United States based on the rates of unplanned pregnancies. Objective: This article discusses the disparity in the utilization of contraception among Black women through a reproductive justice lens. Results: The reasons for these differences include a lack of access to care, and differences in contraceptive failure rates among racial and ethnic groups, as well as less of an inclination to have an abortion. Barriers to contraception for breastfeeding persons include patient medical conditions and concerns, and resistance by other health care providers due to language and cultural differences, and knowledge asymmetry. Institutionalized racism, transphobia, and homophobia may compromise patient access to the full spectrum of contraceptive options available. Conclusions: Given the individual and public health benefits of breastfeeding and the impact those benefits can have in helping Black birthing persons and children achieve health equity, it is important for obstetric and pediatric health care providers to play their part in encouraging and supporting breastfeeding.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

The impact of the Covid-19 pandemic on North American milk banks

This study aims to understand the impact of the Covid‐19 pandemic on human milk banking services in North America, with a focus on the United States. We triangulated questionnaire data with interviews and text‐based website data. Of the 30 human milk bank services from which data were obtained, the majority faced substantial internal organization change in terms of staffing and protocols and experienced financial hardship in particular because of decreases in donor human milk orders. At the same time, most banks reported an increase in their numbers of donors and in the volume of milk collected. These results show that the pandemic significantly affected the way in which many North American milk banks operate, some lactating mothers donate their milk and, at least during the first few months of the crisis, certain hospitals' donor human milk ordering patterns changed. It suggests in particular that stay‐at‐home orders and the turn to remote work created the potential for a surge in human milk available for donation as a number of parents no longer needed their surplus for their own children. Legal and policy reform should focus on replicating the positive effects of the pandemic on breastfeeding by guaranteeing paid parental leave and flexible work conditions. Initiatives should also aim at counteracting its negative effects by mandating the insurance coverage of donor human milk, supporting milk banks financially and, more generally, integrating lactation and human milk banking services within the health system.

Unequal care: Racial/ethnic disparities in neonatal intensive care delivery

Advances in neonatal intensive care have improved outcomes for preterm newborns, but significant racial/ethnic disparities persist. Neonatal disparities have their origin in a complex set of factors that include systemic racism and structural disadvantages endured by minority families, but differential quality of care in the neonatal intensive care unit (NICU) remains an important and modifiable source of disparity. NICU care has been shown to be segregated and unequal: Black and Hispanic infants are more likely to be cared for in lower quality NICUs and may receive worse care within a NICU. To eliminate disparities in care and outcomes, it is important to identify and address the mechanisms that lead to lower quality care for minority preterm infants. In this review, we identify improvements in both technical (clinical) and relational (engaging and supporting families) processes of care as critical to better outcomes for minority infants and families.