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

An exploration of prenatal breastfeeding self-efficacy: a scoping review

BACKGROUND

Breastfeeding self-efficacy is a woman's self-belief and confidence in her perceived ability to breastfeed. This modifiable determinant is strongly associated with breastfeeding initiation, exclusivity, and duration. It is unclear how important the timing of breastfeeding self-efficacy measurement and interventions are. The prenatal period appears underexplored in the literature and yet a prenatal focus provides increased opportunity for breastfeeding self-efficacy enhancement and further potential improvement in breastfeeding outcomes. This scoping review aims to synthesise the evidence on prenatal breastfeeding self-efficacy, describing for the first time the theoretical frameworks, measurement tools, and interventions used in the prenatal period.

METHODS

8 databases were searched using the PCC framework (Problem: breastfeeding, Concept: self-efficacy, Context: prenatal period). From 4,667 citations and 156 additional sources identified through grey literature and snowballing, data were extracted from 184 studies and 2 guidance documents. All were summarised descriptively and narratively.

RESULTS

Just over half (57%) of included studies stated their theoretical underpinning, with Bandura's Self-Efficacy Theory / Dennis' Breastfeeding Self-Efficacy Framework predominant. Only half of intervention studies incorporated theory in their design. More intervention studies were undertaken in the past decade than previously, but the level of theoretical underpinning has not improved. Prenatal interventions incorporating theory-led design and using components addressing the breadth of theory, more frequently reported improving breastfeeding self-efficacy and breastfeeding outcomes than those not theory-led. Intervention components used less frequently were vicarious or kinaesthetic learning (52.5%) and involvement of social circle support (26%). The Breastfeeding Self-Efficacy Scales were the most common measurement tool, despite being designed for postpartum use. Overall, issues were identified with the late prenatal timing of breastfeeding self-efficacy investigation and the design, content and phraseology of measurements and interventions used in the prenatal period.

CONCLUSION

This review provides novel insights for consideration in the design and conduct of breastfeeding self-efficacy studies in the prenatal period. Future research should aim to be theory-led, commence earlier in pregnancy, and embed the breadth of self-efficacy theory into the design of interventions and measurement tools. This would provide more robust data on prenatal breastfeeding self-efficacy's role in impacting breastfeeding outcomes.

Goliath Just Slayed David in Georgia

Challengers to IBCLC licensure filed a private lawsuit to dismantle the Georgia Act arguing equivalence in competencies between the IBCLC and the CLC and asserting ideological claims that economic liberty is promoted by the dismantling of occupational licensing. This Commentary reveals who is behind the private lawsuit in Georgia and explores how it threatens the multiple measures of increased access to clinical lactation care for Georgia’s breastfeeding families which occurred following passage of the Georgia Act.

Maternal Evaluation of a Team-Based Maternity Care Model for Women of Low Obstetric Risk

In response to the need for affordable and comprehensive maternity care, a multidisciplinary team-based maternity care service led by general practitioners with obstetric training (GPOs) and midwives was established for women of low obstetric risk. We evaluated maternal satisfaction with this model of care. All women that attended the service and gave birth in 2020 were approached. Participants used an online survey to rate their satisfaction with aspects of their pregnancy, hospital stay and postpartum care and were invited to provide additional written feedback. Fifty percent (81/162) of women (33 ± 3.9 years) responded, with 59% primiparous. Proportions of participants that were very satisfied with their overall pregnancy, hospital stay, and postpartum care were 91%, <50%, and 85%, respectively. Both survey and qualitative data identified high satisfaction with emotional care and time afforded to discuss concerns during appointments. High levels of satisfaction can be achieved in women of low obstetric risk through the provision of GPO-midwife led multidisciplinary care throughout the maternity journey.

ABM Clinical Protocol #14: Breastfeeding-Friendly Physician's Office-Optimizing Care for Infants and Children

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 is Possible: A Systematic Review on the Feasibility and Challenges of Breastfeeding Among Breast Cancer Survivors of Reproductive Age

BACKGROUND

Breastfeeding is the biologically normative mode of feeding human infants, and reduces the risk of breast cancer for mothers. This systematic review assesses engagement in breastfeeding and the factors associated with breastfeeding among breast cancer survivors.

METHODS

An online literature search was performed using the PubMed, Embase, CINAHL, PsychInfo, and Web of Science databases. Inclusion criteria were original research articles written in English, published in peer-reviewed journals from 1 January 1990 to 25 November 2019, and included data on breast cancer survivors who attempted breastfeeding.

RESULTS

Thirteen studies were included in the systematic review. Between 7.7 and 90.9% of women attempted breastfeeding. Breastfeeding among participants varied from a few weeks to approximately 2 years. Common factors leading to breastfeeding were use of the contralateral breast, support from others, lactation counseling and advice from an International Board-Certified Lactation Consultant, being motivated to breastfeed, frequent feedings, and use of galactagogues. Common barriers were medical counseling against breastfeeding, insufficient milk production, lack of support, refusal of the infant to breastfeed from the treated breast, and being tired from relying on one breast.

CONCLUSIONS

Breastfeeding from the unaffected breast is feasible for some breast cancer survivors. Successful breastfeeding may require multilevel support and expert advice.

Enabling Breastfeeding to Support Lifelong Health for Mother and Child

The health benefits of breastfeeding are well documented, and more than 80% of US women initiate breastfeeding; however, mothers in the United States face substantial challenges in meeting their personal breastfeeding goals, with approximately 60% weaning earlier than they had intended. In addition, there are significant racial/ethnic inequities in infant-feeding behaviors, and these inequities are a major public health concern. Enabling women to meet their breastfeeding goals is a public health priority. Infant feeding should be addressed as a modifiable health behavior, rather than a lifestyle choice.

In-Hospital Formula Feeding and Breastfeeding Duration

BACKGROUND

In-hospital formula feeding (IHFF) of breastfed infants is associated with shorter duration of breastfeeding. Despite evidence-based guidelines on when IHFF is appropriate, many infants are given formula unnecessarily during the postpartum hospital stay. To account for selection bias inherent in observational data, in this study, we estimate liberal and conservative bounds for the association between hospital formula feeding and duration of breastfeeding.

METHODS

Infants enrolled in the Minnesota Special Supplemental Nutrition Program for Women, Infants, and Children were selected. Breastfed infants given formula were matched with infants exclusively breastfed (n = 5310) by using propensity scoring methods to adjust for potential confounders. Cox regression of the matched sample was stratified on feeding status. A second, more conservative analysis (n = 4836) was adjusted for medical indications for supplementation.

RESULTS

Hazard ratios (HR) for weaning increased across time. In the first analysis, the HR across the first year was 6.1 (95% confidence interval [CI] 4.9-7.5), with HRs increasing with age (first month: HR = 4.1 [95% CI 3.5-4.7]; 1-6 months: HR = 8.2 [95% CI 5.6-12.1]; >6 months: HR = 14.6 [95% CI 8.9-24.0]). The second, more conservative analysis revealed that infants exposed to IHFF had 2.5 times the hazard of weaning compared with infants who were exclusively breastfed (HR = 2.5; 95% CI 1.9-3.4).

CONCLUSIONS

IHFF was associated with earlier weaning, with infants exposed to IHFF at 2.5 to 6 times higher risk in the first year than infants exclusively breastfed. Strategies to reduce IHFF include prenatal education, peer counseling, hospital staff and physician education, and skin-to-skin contact.

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.

Prenatal Provider Support for Breastfeeding: Changes in Attitudes, Practices and Recommendations Over 22 Years

BACKGROUND

Prenatal care providers play a central role in breastfeeding outcomes. A survey on obstetricians' support of breastfeeding was conducted in 1993 in Monroe County, NY. Since the landscape of prenatal care and breastfeeding support has changed significantly in the past 2 decades, we repeated and extended this survey in 2015.

RESEARCH AIM

To determine changes in breastfeeding support by prenatal care providers over a 20 year period.

METHODS

We sent a 46-item on-line or paper questionnaire to all categories of prenatal care providers identified by an online search. A breastfeeding support score was created based on the prior survey, with a maximum score of 3. One point was awarded for: (1) personally discussing breastfeeding; (2) generally suggesting breastfeeding; and (3) commonly receiving questions from patients. Data were analyzed using Chi-square.

RESULTS

We had 164 participants (response rate 80%). More current participants, compared to 1993, reported discussing (97% vs. 86%, p < .001) and recommending (93% vs. 80%, p = .001) breastfeeding. Only 10% of 2015 participants gave infant formula samples, compared with 34% in 1993 (p < .0001). Improvement in the support score was seen, with 98% of current participants having high scores compared to 87% in 1993 (p < .001). Similar numbers reported receiving breastfeeding education, though more reported that the education was inadequate (54% vs. 19%, p < .0001).

CONCLUSION

Breastfeeding support improved significantly over time, even though breastfeeding education has not improved in quality or quantity. Improving education of prenatal care providers may help future providers be more prepared to support breastfeeding.

Promoting and Protecting the Gastrointestinal Newborn Microbiome Through Breastfeeding Practices

Since newborns are a vulnerable population that cannot protect their own microbiome, healthcare professionals can promote, advocate, and assist with breastfeeding promotion to protect the healthy development of the newborn gastrointestinal microbiome. The newborn gastrointestinal microbiome is a dynamic community of bacteria that influence health. Breastfeeding seeds and feeds the newborn gastrointestinal microbiome. A disruption in the balance of the gastrointestinal microbiome can result in adverse health outcomes. This clinical article makes an evidence-based connection between breastfeeding and the establishment of the newborn gastrointestinal microbiome through breastfeeding promotion strategies during the childbearing year. Suggestions for healthcare profession education and future research that will continue to inform the understanding of healthy development of the microbiome will be provided. By assisting with breastfeeding promotion, healthcare professionals can protect the newborn gastrointestinal microbiome and promote overall newborn, infant, and child health.

[ECoLaE: Validation of a questionnaire on breastfeeding knowledge and skills for Nursing]

Objetivo

Validar en enfermeras el cuestionario «Encuesta sobre conocimientos en lactancia» (ECoLa).

Diseño

Estudio de validación, con una adaptación lingüística previa, acorde a las competencias y formación de las enfermeras.

Emplazamiento

Cantabria.

Participantes

Enfermeras generalistas, especialistas en pediatría y matronas del Servicio Cántabro de Salud, con responsabilidad en el cuidado madre-hijo.

Mediciones principales

Se evaluaron las propiedades psicométricas de la versión para enfermería del ECoLa. Consistencia interna: mediante α-Cronbach para las preguntas de respuesta múltiple y para el global, y la fórmula de Kuder-Richardson (KR20) para las preguntas con respuestas dicotómicas. Concordancia interobservadores: mediante el coeficiente kappa en los ítems 18 y 21. Fiabilidad test-retest: con 11 sujetos mediante el coeficiente de correlación intraclase.

Resultados

La puntuación media del cuestionario fue de 21,15 ± 4,67 puntos. No hubo diferencias estadísticamente significativas con respecto al sexo, ni al número de hijos. Hubo asociación entre la puntuación obtenida en el cuestionario y la experiencia previa en lactancia y con el perfil profesional (matrona 24,23 puntos, enfermera especialista en pediatría 21,20 puntos, enfermera 20 puntos; p < 0,01). Consistencia interna: KR20 de 0,802. El α-Cronbach para preguntas de respuesta múltiple fue de 0,719, y para la totalidad fue de 0,866. Concordancia interobservadores: ítem 18 (kappa = 0,6), ítem 30 (kappa = 0,825), puntuación total (kappa = 0,856). Fiabilidad test-retest: puntuación global (CCI = 0,856; IC 95% 0,55-0,96), pregunta 30 (CCI = 0,93; IC 95% 0,75-0,98).

Conclusiones

La escala posee propiedades psicométricas que hacen válido y fiable su uso en la evaluación de la formación de los profesionales de enfermería.

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.

Evaluation of Ready, Set, BABY: A prenatal breastfeeding education and counseling approach

BACKGROUND

Comprehensive prenatal education on infant feeding is recommended by many United States health organizations because of the need to maximize maternal preparedness for managing lactation physiology. Ready, Set, BABY (RSB) is a curriculum developed for counseling women about breastfeeding benefits and management including education on optimal maternity care practices. We hypothesized that RSB would be acceptable to mothers and that mothers' strength of breastfeeding intentions would increase, and their comfort with the idea of formula feeding would decrease after educational counseling using the materials. We also hypothesized that mothers' knowledge of optimal maternity care practices would increase after participation.

METHODS

Materials were sent to a total of seven sites in the United States and Puerto Rico. Local health care practitioners completed training before counseling mothers with the curriculum. A pre- and postintervention questionnaire was administered to participants. Statistical analysis of results included paired t tests, Wilcoxon signed-rank tests, and McNemar's tests.

RESULTS

Four hundred and sixteen expectant women participated. In the pre- and postintervention comparison, maternal participation in RSB significantly improved Infant Feeding Intentions Scale scores (P < 0.001) and knowledge of Baby-Friendly recommended maternity care practices (P < 0.001), while significantly decreasing comfort with the idea of formula feeding (P < 0.001). The education materials were positively rated by participants.

CONCLUSIONS

The findings indicate that the approach of using RSB in prenatal counseling group classes or individual sessions improves breastfeeding intentions. Future testing is needed to determine the effectiveness of the materials for impacting breastfeeding outcomes.

Predicting Maintenance of Any Breastfeeding from Exclusive Breastfeeding Duration: A Replication Study

OBJECTIVES

To predict the duration of any breastfeeding using the duration of exclusive breastfeeding in a socioeconomically heterogeneous sample of mothers using receiver operator characteristic (ROC) analysis.

STUDY DESIGN

The Mother Baby Health Survey, a birth certificate-linked cross-sectional survey was sent at 4-5 months postpartum to a stratified random sample of socioeconomically and racially diverse women in upstate New York; 797 mothers who initiated exclusive breastfeeding were included in this study. Split-sample validation was employed; eligible subjects were divided into training or test samples at random (80% and 20%, respectively). ROC curves were constructed using the training sample and optimal exclusive breastfeeding duration thresholds were tested using the remaining test sample. Logistic regression using the training sample provided estimates of the predictive ability (sensitivity, specificity, positive predictive value) of thresholds in both unadjusted and adjusted analyses (covariates: age, education, parity, marital status, and race).

RESULTS

The ROC analysis in this sample demonstrated that 9 weeks of exclusivity was required for maintenance of breastfeeding at 3 months, and 14.9 weeks of exclusivity was required for maintenance at 20 weeks. Unadjusted and adjusted models yielded similar results; women who exclusively breastfed for at least 9 weeks had 2.2 times the risk (95% CI 1.7-2.8) of maintaining any breastfeeding at 3 months.

CONCLUSIONS

These results are similar to our previous results, from a less diverse cohort, and support that these thresholds may be useful in clinical settings for helping mothers achieve breastfeeding duration goals.

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.

Buprenorphine in Neonatal Abstinence Syndrome

Infants exposed in utero to opioids will demonstrate a withdrawal syndrome known as neonatal abstinence syndrome (NAS). Buprenorphine is a long-acting opioid with therapeutic use in medication-assisted treatment of opioid dependency in adults and adolescents. Emerging data from clinical trials and treatment cohorts demonstrate the efficacy and safety of sublingual buprenorphine for those infants with NAS who require pharmacologic treatment. Pharmacometric modeling will assist in defining the exposure-response relationships and facilitate dose optimization.

Development and Evaluation of a Lactation Rotation for a Pediatric Residency Program

BACKGROUND

The American Academy of Pediatrics recommends that pediatricians promote and help manage breastfeeding. However, research has shown that they are not adequately prepared. To address this gap, a 2-week mandatory lactation rotation program was developed for first-year pediatric residents. Research aim: The aim of the study was to provide a lactation education program and to measure the residents' knowledge and perceived confidence regarding breastfeeding.

METHODS

This longitudinal self-report pretest/posttest study was conducted with a convenience sample of 45 first-year pediatric residents. Each resident spent a minimum of 50 hours with an International Board Certified Lactation Consultant. To measure breastfeeding knowledge and clinical confidence, the American Academy of Pediatrics' Breastfeeding Residency Curriculum pretest was used 4 times: first and last day of the rotation and at 6 and 12 months postrotation.

RESULTS

Test and confidence scores were evaluated. Statistically significant differences in knowledge were found between test 1 when compared with tests 2, 3, and 4 ( p < .001). No significant differences were found between tests 2, 3, and 4 ( p > .05). The abilities to "adequately address parents' questions" and to "completely manage common problems" were significant, with confidence increasing in tests 2, 3, and 4 ( p < .001).

CONCLUSION

As a result of an innovative, comprehensive educational lactation program, the pediatric residents' knowledge and perceived confidence related to breastfeeding significantly increased.

Management of Common Breastfeeding Problems

The U.S. Department of Health and Human Services Healthy People 2020 goal is to achieve a rate of breastfeeding at 12 months of age of 34.1%. Primary care providers are the first line in breastfeeding—from prenatal nipple evaluations to identifying and treating complications early. Breastfeeding conveys numerous benefits for both infant and mother. Currently, 77% of women attempt breastfeeding, but only 16% are still breastfeeding at 12 months of age. One of the top reasons for failure is lack of provider support when faced with breastfeeding problems. When the diagnosis is missed, complications can include hospitalization and cessation of breastfeeding. Understanding and being able to manage complications as well as having a team care approach involving an IBCLC and support group, such as La Leche League, are crucial in ensuring breastfeeding success.