ABM Clinical Protocol #5: Peripartum breastfeeding management for the healthy mother and infant at term, revision 2013

Having Enough Milk to Sustain a Lactation Journey: A Call to Action

The rates of human milk feeding are suboptimal worldwide. Recommendations for healthy, term mother-infant dyads include early breastfeeding initiation, frequent skin-to-skin contact, and frequent breastfeeding. The normal physiology of lactation can be affected by prenatal factors such as diabetes, obesity, and excessive gestational weight gain. Furthermore, birth-related factors such as early-term gestation, stressful labor, unscheduled cesarean birth, and postpartum hemorrhage can additionally disrupt recommended practices such as early initiation of breastfeeding and skin-to-skin contact. Given that the first 2 to 3 days postpartum are critical to achieving timely secretory activation and establishing an adequate volume of milk, a proactive approach to care can include building awareness of risk factors and development of protocols for the effective early initiation of lactation.

Changes in maternity care policies and practices that support breastfeeding as measured by the Ten Steps to Successful Breastfeeding - United States, 2018-2022

BACKGROUND

Experiences during the birth hospitalization affect a family's ability to establish and maintain breastfeeding. The Ten Steps to Successful Breastfeeding (Ten Steps) describe evidence-based hospital policies and practices shown to improve breastfeeding outcomes. We aim to describe hospitals' implementation of the Ten Steps, changes over time, and hospitals' implementation of a majority (≥ 6) of the Ten Steps by hospital characteristics and state.

METHODS

The biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey assesses all hospitals in the United States (including the District of Columbia and territories) that routinely provide maternity care services. We analyzed data from 2018, 2020, and 2022 survey cycles to describe trends in the prevalence of hospitals implementing maternity care policies and practices that are consistent with the Ten Steps. Differences were calculated using the absolute difference in percentage-points between 2018 and 2022.

RESULTS

Between 2018 and 2022, the percentage of hospitals that implemented Step 2: Staff Competency and Step 5: Support Mothers with Breastfeeding increased 12 and 8 percentage points, respectively. The percentage of hospitals that implemented Step 6: Exclusive Breastfeeding Among Breastfed Infants was 7 percentage points lower in 2022 than 2018. Implementation of the remaining seven steps did not change by more than 5 percentage points in either direction between 2018 and 2022. Nationally, the percentage of hospitals that implemented ≥ 6 of the Ten Steps increased from 44.0% in 2018 to 51.1% in 2022. Differences were seen when comparing implementation of ≥ 6 of the Ten Steps by hospital characteristics including state, hospital size, and highest level of neonatal care offered.

CONCLUSIONS

Nationally, maternity care policies and practices supportive of breastfeeding continued to improve; however, certain practices lost progress. Differences in implementation of the Ten Steps were observed across states and by certain hospital characteristics, suggesting more work is needed to ensure all people receive optimal breastfeeding support during their delivery hospitalization.

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.

Comparison of Breastfeeding Practices in Mothers With Chronic Kidney Disease With or Without Kidney Transplantation

Introduction: Existing literature on pregnant patients with chronic kidney disease (CKD) with or without kidney transplantation focuses mainly on their pregnancy outcomes, but there are scant data on their lactation outcomes. Our objective was to characterize the lactation outcomes of patients with CKD with or without kidney transplantation. Methods: This is a single-institution retrospective cohort study of female-identifying patients with CKD with or without kidney transplantation who had a birth hospitalization at a tertiary health system between 2010 and 2020. Maternal and pediatric data on medical history, pregnancy, delivery, neonatal, and lactation outcomes, medications, and care team involved were collected. Primary outcome measures were breastfeeding initiation within 24-hour postpartum, breastfeeding 8 or more times per day during hospitalization, and any breastfeeding beyond 1 month. Health professionals' comments related to lactation and medications were extracted for qualitative data analysis. Results: Patients with and without kidney transplantation had similar comorbidities, pregnancy, delivery, and neonatal outcomes, and hospital length of stay (p > 0.05). Patients without kidney transplantation were more likely to initiate breastfeeding in the first 24 hours (p = 0.03) after delivery and continue breastfeeding beyond 1 month postpartum. There was a lack of consistency between specialties regarding medication compatibility with lactation. Patients on immunosuppression were more likely to exclusively formula feed (p = 0.02) or to initiate breastfeeding and then switch to formula (p = 0.0004) because of their immunosuppressive medications versus patients on any other medication. Conclusion: Patients with CKD but without a kidney transplantation were more likely to initiate breastfeeding or provide breast milk to their infant within 24 hours of delivery, breastfeed >8 times per day during their hospital stay, and breastfeed beyond a month postpartum than those with a transplanted kidney. Lactation support and pharmacology should be incorporated into graduate medical education.

'She was hungry'-Croatian mothers' reasons for supplementing their healthy, term babies with formula during the birth hospitalisation

AIM

To explore why Croatian mothers request formula for their healthy, term newborn infants during the postnatal hospital stay.

METHODS

Four focus groups discussions were conducted with a total of 25 women who gave birth to healthy newborn infants, between May and June 2021 in Split, Croatia. A homogenous, non-random purposive sampling technique was used. The semi-structured interview schedule contained 15 open-ended questions. Reflexive thematic analysis was applied.

RESULTS

Three themes were generated. The first theme fear of hunger referred to the mothers' fears arising from difficulties in interpreting newborn infant behaviour and finding solace in giving formula. The second theme too little support-too late reflected participants' unrealised expectations of hospital staff. The third theme non-supportive communication addressed mother's need for empathy during the postpartum hospital stay.

CONCLUSION

Croatian mothers want to breastfeed, but often feel unsupported in doing so in the maternity hospital setting. Antenatal education of expectant mothers and training of maternity staff in breastfeeding counselling, with a strong emphasis on communication skills, as well as employment of International Board Certified Lactation Consultants and/or volunteer breastfeeding counsellors, were perceived by participants as a way to decrease mothers' requests for formula for their healthy, newborn infants.

Effectiveness of a community-based support programme to reduce social inequality in exclusive breastfeeding: study protocol for a cluster-randomised trial

BACKGROUND

Breastmilk is the ideal nutrition for infants, and breastfeeding protects infants and mothers from a range of adverse health outcomes. In Denmark, most mothers initiate breastfeeding but many cease within the first months resulting in just 14% reaching the World Health Organization recommendation of six months of exclusive breastfeeding. Furthermore, the low breastfeeding proportion at six months is characterised by a marked social inequality. A previous intervention tested in a hospital setting succeeded in increasing the proportion of mothers breastfeeding exclusively at six months. However, most breastfeeding support is provided within the Danish municipality-based health visiting programme. Therefore, the intervention was adapted to fit the health visiting programme and implemented in 21 Danish municipalities. This article reports the study protocol, which will be used to evaluate the adapted intervention.

METHODS

The intervention is tested in a cluster-randomised trial at the municipal level. A comprehensive evaluation approach is taken. The effectiveness of the intervention will be evaluated using survey and register data. Primary outcomes are the proportion of women who breastfeed exclusively at four months postpartum and duration of exclusive breastfeeding measured as a continuous outcome. A process evaluation will be completed to evaluate the implementation of the intervention; a realist evaluation will provide an understanding of the mechanisms of change characterising the intervention. Finally, a health economic evaluation will assess the cost-effectiveness and cost-utility of this complex intervention.

DISCUSSION

This study protocol reports on the design and evaluation of the Breastfeeding Trial - a cluster-randomised trial implemented within the Danish Municipal Health Visiting Programme from April 2022 to October 2023. The purpose of the programme is to streamline breastfeeding support provided across healthcare sectors. The evaluation approach is comprehensive using a multitude of data to analyse the effect of the intervention and inform future efforts to improve breastfeeding for all.

TRIAL REGISTRATION

Prospectively registered with Clinical Trials NCT05311631 https://clinicaltrials.gov/ct2/show/NCT05311631.

Implementing the Role of Neonatal Assessment Nurse to Improve Skin-to-Skin Care and Breastfeeding Exclusivity

OBJECTIVE

To improve rates of exclusive breastfeeding during the postpartum hospital stay by implementing a new role of dedicated neonatal assessment nurse (NAN), whose primary function was neonatal care beginning immediately after birth.

DESIGN

Quality improvement project with plan-do-study-act using evidence-based guidelines for implementing the NAN role.

SETTING/LOCAL PROBLEM

Labor and delivery department of a tertiary care teaching hospital in the southeastern United States; breastfeeding exclusivity rates at this hospital were in the range of 50%.

PARTICIPANTS

Registered nurses employed in the labor-delivery-recovery unit, mother-baby unit, and NICU.

INTERVENTION/MEASUREMENTS

The NAN role was implemented to promote immediate skin-to-skin care (SSC) for stable newborns after vaginal and cesarean birth. Each NAN's competency was evaluated at the beginning and end of the education session through a pretest/posttest, and a skills validation was used to affirm their readiness for the new role. The outcome measure was breastfeeding exclusivity at the time of discharge from the hospital. SSC initiation and duration immediately after birth were the process measures.

RESULTS

Twenty-five bedside registered nurses participated in this quality improvement project. There was a statistically significant difference between the pretest and posttest scores (p < .001), indicating a knowledge increase. All nurses met the skills validation criteria. The rate of SSC immediately after vaginal birth increased from 49% to 82% and after cesarean birth from 33% to 63%. Breastfeeding exclusivity rate at the time of discharge from the hospital increased from 50% to 86%.

CONCLUSION

The NAN role provided transitional care at the bedside without the separation of mothers and newborns. This was an innovative role, without the need to hire new staff, that provided evidence-based care, resulting in improved SSC and exclusivity of breastfeeding before discharge.

Development of SARS-CoV-2 specific IgG and IgA antibodies in serum and milk with different SARS-COV-2 vaccines in lactating women

BACKGROUND

Our main objective was to determine the evolution of IgG and IgA antibodies directed against SARS-CoV-2 protein S in the blood of lactating women and in breast milk.

METHODS

A cohort of 110 uninfected and vaccinated breastfeeding women was followed-up for 6 months at the Marqués de Valdecilla University Hospital, Spain, in 2020. An additional group of 23 breastfeeding mothers who had no previously documented infection and had not been vaccinated against SARS-CoV-2 were included as a control group. The antibodies in blood and breast milk and their evolution at 6 months post-vaccination were analysed.

RESULTS

One hundred ten breastfeeding mothers were included; 70 women (63.6%) were vaccinated with two doses of BNT162b2, 20 women (18.2%) received two doses of mRNA-1273, and 20 women (18.2%) received a single dose of ChAdOx1-S. No evidence of differences between concentrations of antibodies was found according to the type of vaccine, with the exception of serum IgA antibodies, which was higher in women vaccinated with mRNA-1273: mean [95%CI]: 0.05 AU/mL [0.03,0.06] with mRNA-1273, 0.02 AU/mL [0.01,0.03] with BNT162b2 and 0.01 AU/mL [0.00,0.03] with ChAdOx1-S, ANOVA p value = 0.03. The lack of difference between vaccines was also found when anti-S1 specific IgG in serum and breast milk were measured.

CONCLUSIONS

In lactating women vaccinated against COVID-19, anti-SARS-CoV-2 antibodies can be detected in both serum and breastmilk 6 months after receiving the second dose, although their concentrations decreased when compared with concentrations reached immediately after vaccination.

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.

Updating Clinical Practices to Promote and Protect Human Milk and Breastfeeding in a COVID-19 Era

The COVID-19 pandemic has impacted breastfeeding and lactation globally, with clinical practices implemented early in the pandemic being mostly anti-breastfeeding, e.g., separation of mothers from their infants, and not evidence based. As the pandemic has progressed, evidence has emerged reconfirming the value of human milk and the importance of protecting and supporting breastfeeding, especially the initiation of lactation. However, it is clear that COVID-19 has changed the clinical care paradigm around breastfeeding and lactation support and, as such, it is imperative that practices adapt and evolve to maintain the emphasis on lactation support. We participated in a round table conference aiming to rescue and develop protocols and practices that support breastfeeding during the COVID-19 pandemic. One key area to target will be to maximize the use of the antenatal period. The early identification of lactation risk factors together with the development of person-centered methods to deliver breastfeeding information and education to parents-to-be will be critical. In addition, the establishment of a hospital culture that values breastfeeding and prioritizes the use of human milk will be integral for the motivation of health care professionals. That culture will also support active management of the initiation of lactation and the development of a 'back-up plan' toolkit to support the mother experiencing lactation difficulties. Post-discharge support will also be crucial with the development of both in-person and virtual lactation support programs, in particular for the immediate post-discharge period to benefit mothers who experience an early discharge process. These measures will allow for a new, adapted framework of practice that acknowledges the current COVID-19 paradigm and maintains the emphasis on the need to protect and support breastfeeding and the use of human milk.

Twenty Years Baby-Friendly: Personal Reflections on Change

Background: Boston Medical Center (BMC) is an inner-city hospital located in Boston, Massachusetts. In 1995, like many maternity hospitals in the United States, BMC had policies that routinely separated mothers from their babies, limited breastfeeding education for staff, provided no hospital-funded lactation consultants, and did not initiate any limitations on the presence of the formula industry in the hospital. This all changed in 1999 when BMC became the first Baby-Friendly designated hospital in Massachusetts and the 22^nd in the nation. Objective: Describe challenges encountered on the hospital's journey to Baby-Friendly and subsequent re-designations and share strategies used to overcome them. Materials and Methods: Policy changes and new programs instituted over the twenty-year period are described as well as personal reflections on change by the author. Results: Over the time period chronicled, improvements in breastfeeding initiation and exclusivity rates were observed. From 1997 to 2019, the breastfeeding initiation rate increased from 53% to 90% and the exclusive breastfeeding rate increased from 6% to 50-60%. Delivery volume at the hospital increased from 1600 to 2850 births per year in the same time period. Following the Ten Steps is an important way to decrease racial disparity gaps. Conclusions: Change is possible in the hospital setting. Achieving and maintaining Baby-Friendly designation is a successful strategy to increase maternity unit breastfeeding rates.

Declared Reasons for Cessation of Breastfeeding during the First Year of Life: An Analysis Based on a Cohort Study in Northern Spain

BACKGROUND

Breastfeeding is the gold standard of infant feeding due to the many advantages it offers to both the child and the mother.

OBJECTIVE

To identity the main reasons for cessation of breastfeeding reported by mothers during the first year of life.

DESIGN

A prospective cohort study was conducted, recruiting 970 infants from a university hospital in Spain. The main maternal variables studied were maternal age, parity, educational level, work occupation, smoking habit, weeks of gestation at birth, birth weight, feeding type, and duration of breastfeeding. All participants were followed for one year to determinate the duration of breastfeeding and to gather reasons for abandoning breastfeeding.

RESULTS

At six months, the percentage of breastfeeding experienced a decline of 50%, and only 24.5% of these mothers maintained breastfeeding. Up to 15.8% of the mothers decided to give up exclusive breastfeeding by their own choice, whereas 15.4% did so because they suspected low milk production. Work-related causes represent the third reason of abandonment.

CONCLUSIONS

Our results highlight the need to improve the health policies for the promotion, protection, and support for the initiation and maintenance of breastfeeding. In particular, our results highlight the importance of researching women's low milk production and work-related factors, with particular emphasis on improving conciliation measures.

Determinants of Neonatal Readmission in Healthy Term Infants: Results from a Nested Case-Control Study

OBJECTIVE

The aim of this study was to estimate the incidence and identify the factors associated with neonatal readmission among healthy term infants.

STUDY DESIGN

A nested case-control study with matching was conducted at a large level III perinatal hospital with approximately 8,700 deliveries each year. Each case infant (n = 130) was matched to two control infants (n = 260) on the case infant's date of birth (±7 days) and the mother's maternal age (<20 years, 20-29, 30-39, and >39 years). All infants were selected from a cohort of eligible term, healthy, in-state infants admitted to the newborn unit postdelivery from January 1, 2016 to May 8, 2017. Data were analyzed using hierarchical conditional logistic regression.

RESULTS

The incidence of neonatal readmission was 2.2%, and all readmissions occurred within 8.6 days of birth. Earlier gestational age (37 weeks; odds ratio [OR]: 4.11, 95% confidence interval [CI]: 1.79-9.45; 38 weeks OR: 1.29, CI 0.60-2.75; [ref] 39 weeks), jaundice on day two of life (OR: 2.45; CI: 1.40-4.30), maternal group B streptococcus chemoprophylaxis (OR: 2.55; CI: 1.23-5.28 [Ref N/A]) were associated with readmission. Delivery by cesarean section (OR: 0.31, CI: 0.12-0.79) and each milliliter of formula [first three days] (OR: 0.96; CI: 0.993-0.999) were protective.

CONCLUSION

Neonatal readmission in healthy term infants may potentially be reduced with identification of modifiable determinants of readmission prior to discharge. Policies to capture the true incidence of neonatal readmissions should include admissions to hospitals other than the birth hospital.

Retrospective Analysis of a Nationwide Telelactation Program

Background

Telelactation is a modality for delivering remote clinical lactation care using telecommunications technology. Sonder Health, in partnership with Amwell, began offering synchronous video telelactation services to health plans and employer groups in 2016.

Methods

We completed a retrospective data analysis on a randomized selection of 1,087 telelactation visits covered by a health plan or employee-sponsored health plan conducted between 2016–2019. Our aim is to describe a telelactation model and review selected visits for technical modalities utilized, clinical workflow, top self-reported chief conditions, patient satisfaction, visit duration, acuity levels, alternative care options, peak visit time, visits conducted during or after business hours, and days visits took place, and discuss the potential for telelactation to bridge the gaps in timely access to IBCLC-level breastfeeding support.

Results

Using a 5-star rating system, 95% of patients gave a 5-star rating; 52% of visits occurred outside normal business hours. Top three conditions identified: latching (31%), supply (24%), and nipple/breast pain (15%). Without access to the service, 59% reported they would have accessed an urgent care, emergency department, retail health clinic, or other office appointment; 41% reported they would have sought care “nowhere.”

Conclusions

This telelactation program provided access to skilled, comprehensive clinical lactation care and documents a strong use case for telelactation services.

Factors Associated with Early Breastfeeding Initiation among Women Who Underwent Cesarean Delivery at Tertiary Hospitals in Kelantan, Malaysia

Background

Cesarean delivery is linked with lower rates of early breastfeeding initiation. This study aimed to determine the prevalence and associated factors of early initiation of breastfeeding among women admitted for elective cesarean delivery in Kelantan, Malaysia.

Methods

A total of 171 women admitted for elective cesarean delivery at two tertiary hospitals in Kelantan, Malaysia, participated in this study. On day two after cesarean delivery, face-to-face interviews were conducted with the mothers to get information on feeding practice. Descriptive statistics, including simple and multiple logistic regressions, were used for data analysis.

Results

Seventy-three percent of mothers initiated breastfeeding within 1 hour of birth. Approximately 15.8% and 10.5% of mothers initiated breastfeeding within 24 hours and ≥24 hours, respectively. Skin-to-skin contact between mothers and their infants occurred in 77.8% of cases after cesarean delivery. Breastfeeding initiation was significantly associated with skin-to-skin contact (odds ratio [OR], 14.42; 95% confidence interval [CI], 3.58–58.06), mothers who exclusively breastfed during hospitalization (OR, 36.37; 95% CI, 5.60–236.24), and infants who were not sleepy during attempts at breastfeeding (OR, 5.17; 95% CI, 1.32–20.21).

Conclusion

Based on our results, it is possible to increase the proportion of mothers initiating breastfeeding within 1 hour among women who undergo elective cesarean delivery. Therefore, it is important that health practitioners educate women beginning in the antenatal period who plan to undergo cesarean delivery by emphasizing the importance of early initiation of breastfeeding.

ABM Clinical Protocol #33: Lactation Care for Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Plus Patients

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Attitudes, Perceptions, and Knowledge of Breastfeeding Among Professional Caregivers in a Community Hospital

OBJECTIVE

To explore the knowledge, attitudes, and perceptions of exclusive breastfeeding among professional caregivers in a suburban community hospital who typically provide, or influence, the care of parturient women.

DESIGN

Cross-sectional quantitative study.

SETTING

Acute care community hospital in suburban New Jersey with 3,500 births per year.

PARTICIPANTS

Obstetricians, midwives, neonatologists, pediatricians, and registered nurses.

INTERVENTIONS/MEASUREMENTS

We designed a survey using two instruments-the Iowa Infant Feeding Attitudes Scale and the Breastfeeding Attitudes Scale-to explore concepts of breastfeeding knowledge, attitudes, and perceptions. Data were analyzed by using descriptive and inferential statistics with SPSS (Version 19). Independent sample t tests, Pearson's correlation coefficient, and Pearson's chi-square test (×2) were used to assess differences between the groups.

RESULTS

When the physician scores were separated out by specialty, statistically significant differences in mean scores were found (p = .002). Pediatricians had lower scores on attitude toward breastfeeding. In contrast, mean scores for perceptions and knowledge of breastfeeding were positive for physicians and nurses, regardless of area of specialization, with no statistically significant differences found.

CONCLUSION

Although pediatricians' attitudes, perceptions, and knowledge of breastfeeding cannot be deemed the sole cause for our organization's low rates of sustained exclusive breastfeeding in the postpartum period, this study provided an avenue for exploration that we did not immediately consider as we dissected our performance metrics related to exclusive breastfeeding. We encourage teams at other organizations to replicate and build on this work to explore influences surrounding low rates of exclusive breastfeeding.

Assessing Barriers to Implement Birth Kangaroo Care in Kentucky Birthing Hospitals

Introduction

Kentucky continues to have one of the lowest state breastfeeding rates in the country. In 2014, the majority of the birthing hospitals in Kentucky implemented a practice change to the healthcare model known as Birth Kangaroo Care (BKC) as an effort to increase breastfeeding initiation. The goal of this study was to identify current practices and barriers to implementing BKC.

Methods

An evaluation/surveillance study that incorporated an Internet survey to collect information about the practices and policies of BKC in birthing hospitals in Kentucky was completed.

Findings

The response rate was 54% (n = 25). The birthing hospitals responders to the survey (84%) reported that a BKC policy was established after the educational intervention. Data identified two perceived barriers regarding uninterrupted BKC. One barrier was the interruption by family members to hold the newborn, and the second was a delay in BKC for medical evaluations of the baby by staff members.

Conclusion

Breastfeeding rates after implementation of the BKC policy in Kentucky birthing hospitals showed a statistically significant (p = .02) improvement of "ever breastfed" infants.

Impact of Maternal Smoking on the Onset of Breastfeeding versus Formula Feeding: A Cross-Sectional Study

This study sought to estimate the prevalence of maternal smoking and its association with exclusive breastfeeding vs. formula feeding. A cross-sectional study was performed on postpartum women at a public hospital in Spain, between January and August 2018. The main variables studied were their age, level of study, smoking habits, and chosen mode of infant feeding. In total, 948 postpartum women were included. Of these, 12.45% were smokers who smoked a mean of 7.23 cigarettes/day. Among the group of smokers, the probability of feeding the newborns with formula milk was multiplied by 2.32 ([95%CI 1.50-3.58] p < 0.001). When stratifying tobacco use into mild, moderate and severe, we found a statistically significant dose-response pattern. These associations and their statistical significance were maintained when adjusting by age and level of study. In conclusion, in the group of postpartum mothers who smoked, the probability of feeding the newborns with formula milk doubled. Our data highlight the need to improve health education programs in women of childbearing age, especially during pregnancy.

Effects of Skin-to-Skin Care During Cesareans: A Quasiexperimental Feasibility/Pilot Study

Introduction: Our aim was to describe feasibility and outcomes of skin-to-skin care (SSC) that began during cesarean surgery and continued, uninterrupted, for about 5 hours. We described maternal/newborn measures of physiologic stability and stress; maternal measures of comfort; maternal satisfaction with surgery and SSC; and exclusive breast milk feeding at discharge. Materials and Methods: We used a quasiexperimental, time-interrupted design and randomly assigned women to receive SSC that began during surgery (Group 1, intervention; n = 20) or after surgery, before transfer to recovery (Group 2, standard care; n = 20). We analyzed differences across time and for five observations: before transfer to the operating room (OR); in the OR, about 20 minutes after birth; in the recovery room, about 1 hour after admission; in the New Family Center (NFC), about 1 hour after admission; and in the NFC, about 2 hours after admission. Results: Group 1 began SSC an average of 0.89 minutes after birth and continued an average of 300 minutes and Group 2 began an average of 46 minutes after birth and continued an average of 126 minutes. Women who began SSC during surgery were more satisfied with the experience (p = 0.015) and had lower levels of salivary cortisol across time (p = 0.003). We found no negative effects on maternal or newborn measures of physiologic stability and no difference in exclusive breast milk feeding rates at discharge. Conclusion: Immediate and uninterrupted SSC during medically uncomplicated cesarean surgery is a feasible, low-cost intervention that can safely begin during surgery and continue, uninterrupted, for extended durations.

Healthy Birth Practice #6: Keep Mother and Newborn Together-It's Best for Mother, Newborn, and Breastfeeding

Mothers and newborns have an emotional and physiological need to be together at the moment of birth and during the hours and days that follow. Keeping mothers and newborns together is a safe and healthy birth practice. Evidence supports immediate, undisturbed skin-to-skin care after vaginal birth and during and after cesarean surgery for all medically stable mothers and newborns, regardless of feeding preference; and, no routine separation during the days after birth. Childbirth educators and other health-care professionals have an ethical responsibility to support this essential healthy birth practice through education, advocacy, and implementation of evidence-based maternity practices.

Breastfeeding Simulation With the Standardized Patient

Despite an emphasis on lactation and the availability of resources to support and sustain lactation, our community hospital's rates of exclusive breastfeeding remained less than the 50% to 70% benchmark recommended by The Joint Commission and the World Health Organization. Concluding that we had exhausted the majority of evidence-based best practices described in the literature, we sought to find a new way to provide an engaging, useful medium for nursing education and improvement of clinical nurses' skills related to breastfeeding. Here, we describe the simulation program we developed using the standardized patient model. Although our rates of exclusive breastfeeding remained unchanged after introducing the simulation program, the experience enabled us to identify inconsistent practices and knowledge gaps.

The effect of maternity practices on exclusive breastfeeding rates in U.S. hospitals

The Baby-friendly Hospital Initiative (BFHI) includes a set of 10 evidenced-based maternity practices that when used together have been shown to improve breastfeeding outcomes. In 2007, the Centers for Disease Control and Prevention launched the Maternity Practices in Infant Nutrition and Care (mPINC) survey to assess and monitor these and other evidenced-based maternity practices. The purpose of this study was to explore individual maternity practices measured in the 2013 mPINC survey, along with hospital demographic information, and their relationships with exclusive breastfeeding (EBF) rates, using a sample of United States (U.S.) hospitals. We obtained mPINC survey data from 69 BFHI hospitals and 654 non-BFHI hospitals in the U.S., and EBF rates from The Joint Commission, a leading hospital accreditation agency. On the basis of linear regression analysis, we found that most maternity practices studied were significantly associated with EBF rates (max adjusted R2  = 14.9%). We found a parsimonious model with an adjusted R2 of 47.3%. This study supports the need for a systematic approach in providing breastfeeding support as no one maternity care practice was able to explain the variability in EBF rates as well as a collection of maternity care practices.

ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Modeling the Influence of Early Skin-to-Skin Contact on Exclusive Breastfeeding in a Sample of Hispanic Immigrant Women

Using data from a longitudinal study of breastfeeding in Hispanics, this study evaluated the influence of early skin-to-skin contact (SSC) on initiation and sustained exclusive breastfeeding (EBF) at 1 month postpartum. Two-thirds of the women in the sample participated in early SSC. At discharge, over half of the women were EBF; this proportion decreased to one-third at 1 month postpartum. Controlling for demographic and clinical variables in the model, participation in early SSC was associated with a greater than sevenfold increase in the odds of EBF at discharge (p = .005) but was not predictive of EBF at 1 month post-discharge (p = .7). Younger maternal age and increased prenatal infant feeding intention were associated with an increased likelihood of EBF across both timepoints. Promoting early SSC may help with initiation of EBF, while further breastfeeding support may be needed to maintain EBF following discharge for this vulnerable population.

Multiple-Case Studies of Hand-on Breast Massage Techniques used by Breastfeeding Experts

PURPOSE

The aim of this study was to understand the hand-on breast massage techniques used by well-known experts in breastfeeding clinics.

METHODS

A qualitative multiple-case design was applied that involved a feasibility test. Four experts sampling qualitative data collected by observing participants and in individual interviews were analyzed by content analysis, linking data to the propositions, and cross-case pattern matching. This study explored differences within and between cases, and the possibilities of replicating findings across cases. Thirty-nine postpartum women participated voluntarily in the feasibility test, which investigated the usability of four massage techniques.

RESULTS

The four techniques showed considerable similarities in terms of the application of stimulation to the breast base and increased flexibility of the wired flexible body, which was the core mechanism underlying the techniques. The breast management strategies were consistent with existing practice guidelines with the exception of using cold cabbage to control engorgement pain. There was insufficient scientific evidence for supporting the massage techniques used by the experts. All of the techniques showed 100% education completeness, but application rates were higher for self-control-oriented techniques.

CONCLUSION

The massage techniques applied by experts in breastfeeding were based on hypotheses and self-control techniques are feasible to apply in practice.

Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals

OBJECTIVES

We examined the variation between 126 New York hospitals in formula supplementation among breastfed infants after adjusting for socioeconomic, maternal, and infant factors and stratifying by level of perinatal care.

METHODS

We used 2014 birth certificate data for 160 911 breastfed infants to calculate hospital-specific formula supplementation percentages by using multivariable hierarchical logistic regression models.

RESULTS

Formula supplementation percentages varied widely among hospitals, from 2.3% to 98.3%, and was lower among level 1 hospitals (18.2%) than higher-level hospitals (50.6%-57.0%). Significant disparities in supplementation were noted for race and ethnicity (adjusted odds ratios [aORs] were 1.54-2.05 for African Americans, 1.85-2.74 for Asian Americans, and 1.25-2.16 for Hispanics, compared with whites), maternal education (aORs were 2.01-2.95 for ≤12th grade, 1.74-1.85 for high school or general education development, and 1.18-1.28 for some college or a college degree, compared with a Master's degree), and insurance coverage (aOR was 1.27-1.60 for Medicaid insurance versus other). Formula supplementation was higher among mothers who smoked, had a cesarean delivery, or diabetes. At all 4 levels of perinatal care, there were exemplar hospitals that met the HealthyPeople 2020 supplementation goal of ≤14.2%. After adjusting for individual risk factors, the hospital-specific, risk-adjusted supplemental formula percentages still revealed a wide variation.

CONCLUSIONS

A better understanding of the exemplar hospitals could inform future efforts to improve maternity care practices and breastfeeding support to reduce unnecessary formula supplementation, reduce disparities, increase exclusive breastfeeding and breastfeeding duration, and improve maternal and child health outcomes.

ABM Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Setting, Revision 2015

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Breastfeeding-Friendly Erie County: Establishing the New York State Breastfeeding Friendly Practice Designation

BACKGROUND

Primary care providers play an important role in encouraging and counseling pregnant and postpartum women to successfully breastfeed.

OBJECTIVE

One objective of this 1-year grant was to establish the Breastfeeding Friendly Practice Designation criteria and process to identify and designate at least 5 primary care practices as New York State Breastfeeding Friendly Practices in a high-need, racially/ethnically diverse, urban county in New York with very low prevalence of breastfeeding initiation, exclusivity, and duration.

METHODS

A partnership between the New York State Department of Health and the P(2) Collaborative of Western New York and United Way of Buffalo & Erie County's Healthy Start Healthy Future for All Coalition facilitated the development of the New York State Ten Steps to a Breastfeeding Friendly Practice, accompanying implementation guide, designation criteria, and model office policies. Practice staff and providers received on-site training and materials and participated in a virtual learning network to share their experiences, celebrate successes, and overcome challenges in implementing system changes. Practice staff completed a self-assessment survey at baseline and after implementation of the Ten Steps and submitted their written office breastfeeding policy for review.

RESULTS

Fourteen practices met the criteria for designation and were recognized by the New York State Health Commissioner.

CONCLUSION

The number of practices designated as Breastfeeding Friendly far exceeded the grant objective. Future efforts are directed at expanding this initiative statewide and determining the impact of the designation on breastfeeding outcomes.

Effect of early-onset sepsis evaluations on in-hospital breastfeeding practices among asymptomatic term neonates

OBJECTIVE

To examine the effect of separation for early-onset sepsis (EOS) evaluations due to perinatal risk factors on breastfeeding practices among asymptomatic term newborns.

METHODS

This observational study included 692 nulliparous women with term, singleton uncomplicated pregnancies who intended to breastfeed and whose infants were well appearing at birth. We examined the rate of early breastfeeding initiation (within 2 hours of birth) and formula supplementation (in the first 24 hours) among this mother-infant cohort.

RESULTS

Asymptomatic infants separated for EOS evaluation within 2 hours of birth were more likely to have delayed initiation of breastfeeding (46.5% vs 12.5%; P<.001). This association remained significant when adjusted for potential confounders (adjusted odds ratio [aOR]: 5.5 [95% confidence interval (CI): 3.4-8.9]; P<.001). Among infants separated for EOS evaluation, mother-infant time together of ≤0.5 hour in the first 2 hours of life significantly delayed initiation (aOR: 8.9 [95% CI: 1.5-53.7]; P=.02) compared with infants spending >1.5 hours with their mothers. In bivariate analysis, both separation and initiation were associated with formula supplementation. After adjusting for confounders, only delayed initiation remained significantly associated with supplementation (aOR: 1.9 [95% CI: 1.1-3.5]; P=.03).

CONCLUSIONS

Early separation of asymptomatic infants from their mothers for EOS evaluation was significantly associated with delayed initiation of breastfeeding, which in turn was associated with increased formula supplementation in the first day of life. This unintended consequence of EOS evaluations among asymptomatic infants may be minimized by delaying early separation for performance of the evaluation, attempting breastfeeding initiation before separation, and/or applying more efficient criteria for identifying infants requiring evaluation.