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

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.

Is Maternal Body Weight or Composition Associated with Onset of Lactogenesis II, Human Milk Production, or Infant Consumption of Mother's Own Milk? A Systematic Review and Meta-Analysis

Maternal adiposity impacts lactation performance, but the pathways are unclear. We conducted a systematic review to understand whether maternal adiposity (body mass index [BMI] or percentage fat mass) is associated with onset of lactogenesis II (copious milk; hours), human milk production (expressed volume/24 h), and infant consumption of mother's own milk (volume/24 h). We used random-effects standard meta-analyses to compare the relative risk (RR) of delayed lactogenesis II (>72 h) between mothers classified as underweight (BMI <18.5 kg/m2), healthy weight (BMI, 18.5-24.9 kg/m2), and overweight/obese (BMI ≥25 kg/m2) and random-effects meta-regressions to examine associations with hours to lactogenesis II and infant milk consumption. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. We included 122 articles. Mothers with underweight (RR: 0.64; 95% CI: 0.49, 0.83; I2 = 39.48%; 8 articles/data points) or healthy weight status (RR: 0.67; 95% CI: 0.57, 0.79; I2 = 70.91%; 15 articles/data points) were less likely to experience delayed lactogenesis II than mothers with overweight/obesity. We found no association between maternal BMI and time to onset of lactogenesis II (β: 1.45 h; 95% CI: -3.19, 6.09 h; P = 0.52, I2 = 0.00%; 8 articles, 17 data points). Due to limited data, we narratively reviewed articles examining BMI or percentage fat mass and milk production (n = 6); half reported an inverse association and half no association. We found no association between maternal BMI (β: 6.23 mL; 95% CI: -11.26, 23.72 mL; P = 0.48, I2 = 47.23%; 58 articles, 75 data points) or percentage fat mass (β: 7.82 mL; 95% CI: -1.66, 17.29 mL; P = 0.10, I2 = 28.55%; 30 articles, 41 data points) and infant milk consumption. The certainty of evidence for all outcomes was very low. In conclusion, mothers with overweight/obesity may be at risk of delayed lactogenesis II. The available data do not support an association with infant milk consumption, but the included studies do not adequately represent mothers with obesity. This study was registered in PROSPERO as 285344.

Current hospital policies on breastfeeding: a survey from Italy

BACKGROUND

The availability of an appropriate newborn feeding policy is an essential component of the promotion of breastfeeding in health facilities. The Italian Society of Neonatology (SIN) and the Italian Society of Paediatrics (SIP) have run an online survey among Maternity Hospitals to explore the existing breastfeeding policies and their characteristics.

METHODS

Between February and April 2023, an online survey was carried out among 110 Italian maternity hospitals with a Neonatal Intensive Care Unit (NICU).

RESULTS

Forty-nine Maternity Hospitals completed the online questionnaire. Twenty out of 49 (40.8%) reported to have a breastfeeding policy. When a policy is available, its quality appears to be suboptimal because of lack of inclusion of a family representative in the policy working group, limited options for translating breastfeeding policy into minority languages, lack of periodic assessment of their implementation.

CONCLUSION

Currently, only a limited number of Italian Maternity Hospitals have developed a breastfeeding policy. Additional efforts are needed for their improvement as well as implementation.

Introduction of Breast Milk Substitutes During the First 3 Days of Life: Results of the Mexican National Survey of Demographic Dynamics, 2018

Background: The introduction of foods or fluids other than breast milk in the first few days after birth interferes with the establishment of breastfeeding. This study aimed to investigate the association of formula introduction during the first 3 days of life with maternal sociodemographic characteristics, hospital practices, and breastfeeding duration. Materials and Methods: Information from the National Survey of Demographic Dynamics, 2018, which includes 17,686 mother-baby pairs was analyzed. Mother-baby pairs were classified into categories according to breastfeeding duration: <5 months and ≥5 months. Statistical methods and a machine learning algorithm (Bayesian network, BN) were used to analyze the data. Results: In general, 3,720 (21%) mothers reported introducing formula during the first 3 days of life. A lower education level, lower sociodemographic stratum, living in a rural area, and considering oneself indigenous were factors associated with not introducing formula during the first 3 days of life. A total of 5,168 (29.2%) mother-baby pairs practiced breastfeeding for <5 months, and 12,518 (70.8%) for ≥5 months. Almost twice as many mothers who practiced breastfeeding for <5 months introduced formula during the first 3 days of life (31.7%) compared with those who practiced breastfeeding for ≥5 months (16.6%). The BN model can sufficiently predict cases with a breastfeeding duration ≥5 months (precision-recall curve area = 0.792). Discussion: Introducing formula during the first 3 days of life was associated with a shorter breastfeeding duration. BN analysis showed a probabilistic dependency between the type of delivery and variables associated with the establishment of breastfeeding.

Breastfeeding and human milk in the NICU: From birth to discharge

It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Factors Associated with In-Hospital Exclusive Breastfeeding Among a Racially and Ethnically Diverse Patient Population

Objective: The aim of this study is to examine in-hospital exclusive breastfeeding (EBF) and its association with sociodemographic factors, medical factors, breastfeeding intentions, and health care system breastfeeding support. Materials and Methods: We conducted a retrospective cross-sectional study using medical records from 2015 to 2019 of healthy term infants without breastfeeding contraindications at a public teaching hospital serving a racially and ethnically diverse patient population. Using multivariable regression analysis, we examined the associations between in-hospital EBF and sociodemographic factors, medical factors, breastfeeding intentions, and health care system breastfeeding support (in-hospital breastfeeding education and lactation support). Results: The prevalence of in-hospital EBF was 29.0%. The statistically significant findings from our fully adjusted regression analysis include that there was a higher prevalence of in-hospital EBF among adult mothers (prevalence ratio [PR]: range 1.78-1.96), married mothers (PR: 1.35, 95% confidence interval [CI]: 1.23-1.44), and mothers who were White (PR: 1.41, 95% CI: 1.20-1.66, compared with Black). Factors associated with a lower prevalence of in-hospital EBF were maternal diabetes (PR: 0.82, 95% CI: 0.70-0.95), pre-eclampsia/eclampsia (PR: 0.82, 95% CI: 0.71-0.95), cesarean delivery (PR: 0.84, 95% CI: 0.77-0.92), neonatal hypoglycemia (PR: 0.46, 95% CI: 0.36-0.59), and intention in the prenatal period to formula feed only (PR: 0.15, 95% CI: 0.10-0.22). In-hospital lactation support was associated with higher prevalence of in-hospital EBF (PR: 1.24, 95% CI: 1.16-1.33). Conclusions: Prioritizing lactation support for Black mothers, adolescent mothers, those intending in the prenatal period to formula feed only, and mother-infant dyads with certain medical factors could improve in-hospital EBF.

Controversies and Conundrums in Newborn Feeding

Breastfeeding is the biologic norm for newborn feeding, and exclusive breastfeeding for the first 6 months of life is universally endorsed by leading global and national organizations. Despite these recommendations, many people do not meet their breastfeeding goals and controversies surrounding breastfeeding problems exist. Medical issues can present challenges for the clinician and parents to successfully meet desired feeding outcomes. There are studies evaluating these common controversies and medical conundrums, and clinicians should provide evidence-based recommendations when counseling families about newborn feeding.

Comparison of Effects of Storage at Different Temperatures in a Refrigerator, Upright Freezer on Top of Refrigerator, and Deep Freezer on the Immunoglobulin A Concentration and Lysozyme Activity of Human Milk

This study aimed to investigate the effects of storing expressed human milk (HM) at different domestic storage temperatures on the secretory immunoglobulin A (SIgA) concentration and lysozyme activity. Forty mothers of full-term infants aged one to six months provided milk samples. The fresh samples were examined within 24 h of expression, and the other samples were stored in a refrigerator for four days or in two types of freezers for six months. The SIgA concentrations and lysozyme activity in the milk samples were studied using enzyme-linked immunosorbent assay (ELISA) kits and fluorometric lysozyme activity assay kits, respectively. The pairwise comparisons of the SIgA concentration and lysozyme activity were carried out using one-way analysis of variance with Dunnett T3 or Kruskal-Wallis tests with Bonferroni correction, depending on the data distribution. The mean temperatures of the refrigerator, upright freezer on top of the refrigerator, and deep freezer (chest freezer) were 2.0, -16.7, and -22.3 °C, respectively. Our study results highlight that the SIgA concentration and lysozyme activity of HM stored in the refrigerator for four days and in freezers for six months were significantly lower than those of fresh HM (p < 0.001). During the first six months of storage in both types of freezers, the SIgA levels were stable, whereas the lysozyme activity significantly decreased (p < 0.001). HM stored in the deep freezer had a higher SIgA concentration and lysozyme activity than HM stored in the upright freezer on top of the refrigerator. Our data support the superiority of fresh human milk over stored HM. If HM is to be stored, then storage in a deep freezer is potentially a more effective method for the preservation of SIgA concentrations and lysozyme activity than storage by refrigeration for four days or in an upright freezer on top of a refrigerator for six months.

Influence of skin-to-skin contact on breastfeeding: results of the Mexican National Survey of Demographic Dynamics, 2018

Background

Skin-to-skin contact and breastfeeding initiation within the first hour after birth are key recommendations to promote breastfeeding. In Mexico, the National Survey of Demographic Dynamics 2018, known by its Spanish acronym ENADID, collected information about breastfeeding practices. The ENADID survey is probabilistic and allows results to be generalized to the entire population in Mexico.

Methods

Information from a public database featuring 26,587 mother-baby pairs was analyzed by proportions, means and associations, as well as machine learning methods, to conduct a comparison among the pairs according to immediate skin-to-skin contact after delivery status.

Results

Skin-to-skin contact was described by 78.7% of the mothers and was associated with receiving an explanation regarding how to give breastmilk or the breast to the baby immediately following birth [Odds ratio (OR) 6.46; 95% Confidence Interval (CI) 6.02, 6.97], initiating breastfeeding in the first hour of life (OR 2.01; 95% CI (1.84, 2.18) and a breastfeeding duration of ≥ 6 months (OR 1.16; 95% CI 1.08, 1.25). The breastfeeding duration, in days, was greater in the group with skin-to-skin contact than in the group without skin contact.

Conclusions

In Mexico, immediate and uninterrupted skin-to-skin contact between newborns and their mothers should be facilitated. Support should be provided to mothers to favor skin-to-skin contact and breasting initiation during the first hour of life, ideally through an empathic explanation by trained health personnel. Future research should focus on the evaluation of strategies to modify maternity services to facilitate immediate skin-to-skin contact after delivery and develop training programs for health personnel to support the initiation of breastfeeding during the first hour of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00489-2.

Providing Equitable Postpartum Breastfeeding Support at an Urban Academic Hospital

OBJECTIVE

To equitably increase exclusive breastfeeding at hospital discharge among obstetrician/gynecologist resident service clients by 20% over 8 weeks.

DESIGN

This quality improvement project used a plan-do-study-act format to implement interventions with patients and staff based on the Baby-Friendly Hospital Initiative. Run charts were used to evaluate intervention effects over time according to Institute for Healthcare Improvement criteria, and outcome data informed tests of change for subsequent cycles.

SETTING/LOCAL PROBLEM

Postpartum clients of an obstetrician/gynecologist resident service were found to be less likely to exclusively breastfeed compared to the hospital average (7% vs. 34%) at baseline. A baseline resident client survey (n = 20) showed that 75% believed it best to give human milk plus formula.

PARTICIPANTS

Of 186 postpartum participants, 65% identified as breastfeeding at the time of birth (53% of Hispanic participants [n = 99], 52% of non-Hispanic Black participants [n = 44], and 73% of non-Hispanic White participants [n = 33]).

INTERVENTIONS/MEASURES

The World Health Organization's revised Implementation Guidance for the Baby-Friendly Hospital Initiative provided the basis for all interventions, which included a prenatal infant feeding plan, postpartum educational video with teach-back, cue-based feeding log, breastfeeding education guidelines for postpartum nurses, and team engagement via huddles. Measures assessed whether each intervention met the intended goals.

RESULTS

Rates of exclusive breastfeeding at hospital discharge were 7% at baseline and 13% after implementation. Rates of exclusive breastfeeding among Black clients were 0% at baseline and 16% after implementation. Clients demonstrated Baby-Friendly knowledge (teach-back average, 89%) but continued to supplement with formula, most often related to supply concerns (65%).

CONCLUSION

Intentionally equitable implementation of the Baby-Friendly steps may ameliorate racial disparities in breastfeeding during the early postpartum period. Preparing families to exclusively breastfeed should begin prenatally.

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.

Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads, Revised 2022

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. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

[Review of new evidence about the possible vertical transmission of coronavirus disease-2019]

OBJECTIVE

To conduct a systematic review of original peer-reviewed studies, containing data on the identification of SARS-CoV-2 in clinical samples of amniotic fluid, placenta or membranes, umbilical cord blood, and human milk, from women with a clinically or confirmed diagnosis of COVID-19. These studies should have been published after the guide for the management of patients with COVID-19 from World Health Organization guide (available in March 13, 2020).

RESULTS

Seventeen studies were included, in which 143 clinical samples were identified (38 of amniotic fluid; 34 of placentas or membranes; 39 from umbilical cord blood and 32 from human milk). Among the 143 samples, nine were positive for SARS-CoV-2 RNA (one amniotic fluid sample obtained before rupturing the membranes; six samples of placenta or membranes, although authors indicate the possibility of contamination by maternal blood in three of these, and two samples of human milk).

CONCLUSIONS

Following our search criteria, we found no studies that demonstrate the detection of SARS-CoV-2, in conjunction with viral isolation and the evaluation of the infective capacity of viral particles, in clinical samples of amniotic fluid, placenta or membranes, umbilical cord blood and human milk, from women with a confirmed or clinical diagnosis of COVID-19. However, vertical transmission cannot be ruled out, larger studies are required that ideally locate in situ RNA and protein of SARS-CoV-2, as well as isolation that demonstrate the infective capacity of the viral particles.

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.

ABM Clinical Protocol #35: Supporting Breastfeeding During Maternal or Child Hospitalization

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. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as female. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Good practices in perinatal care and breastfeeding protection during the first wave of the COVID-19 pandemic: a national situation analysis among BFHI maternity hospitals in Spain

BACKGROUND

Although the positive effects of good clinical quality standards in perinatal care and breastfeeding support for women, newborns and families have been already demonstrated, many of these practices were disrupted during the COVID-19 pandemic. The objective of this study was to analyse the impact of the COVID-19 pandemic on perinatal care and breastfeeding support practices offered by the Spanish maternity hospitals committed to the UNICEF Baby-friendly Hospital Initiative (BFHI), to women with and without COVID-19.

METHODS

Implementation of perinatal practices was assessed by a cross-sectional survey conducted in May 2020 using an online questionnaire. Comparison with pre-pandemic situation and level of commitment to BFHI practices was performed.

RESULTS

Response rate was 50% (58/116). Mothers with COVID-19 suffered greater restrictions in the practices compared to women without COVID-19, with lower rates of companion of choice during labour (84% vs 100%; p = 0.003), skin-to-skin contact (32% vs 52%; p = 0.04), rooming-in (74% vs 98%; p <  0.001), companion of choice during hospital stay (68% vs 90%; p = 0.006), and breastfeeding support (78% vs 94%; p = 0.02). Practices were significantly less prevalent in COVID-19 mothers compared to pre-pandemic situation. A lower accompaniment rate was observed in non-COVID-19 group during delivery (24% vs 47.9%; p <  0.01). Hospitals with higher commitment to BFHI practices reported higher rates of skin-to-skin contact (45.2% vs 10.5%; p = 0.01) and rooming-in (83.9% vs 57.9%; p <  0.05) in COVID mothers. Fewer restrictions were observed in hospitals located in the regions where the pandemic hit harder. In these regions there was a significantly higher level of BFHI commitment of the hospitals, but no significant differences were observed in the average size of the hospital. All the practices suffered even more restrictions during the first weeks of the pandemic.

CONCLUSION

All mothers suffered restrictions in perinatal care during the COVID-19 pandemic. Women with COVID-19 infection suffered more restrictions in perinatal practices than women without infection. The degree of commitment to WHO-UNICEF perinatal quality standards, integrated into the BFHI, was associated with maintenance of good clinical practices.

Compliance With the "Baby-Friendly Hospital Initiative for Neonatal Wards" in Russian Hospitals

BACKGROUND

The expansion of the Baby-Friendly Hospital Initiative to neonatal wards, known as the Neo-BFHI, provides recommendations to support breastfeeding, as outlined in the Three Guiding Principles, the expanded Ten Steps, and the International Code for Marketing of Breast-Milk Substitutes. In 2017, Russia participated in an international survey about compliance with the Neo-BFHI.

RESEARCH AIM

To assess breastfeeding support policies and practices in Russian neonatal wards at the country and federal district level in accordance with the Neo-BFHI recommendations.

METHODS

This study was a prospective cross-sectional survey. We used the Neo-BFHI Self-Assessment questionnaire to collect data from neonatal wards that had all levels of care. A total of N = 60 Russian neonatal wards in hospitals that have ever been designated Baby-Friendly or planned to do so participated in the survey.

RESULTS

Compliance scores at the federal district and country level ranging from 0-100 were used to summarize results. The median country overall score was 90 (IQR = 83 - 93). Respect for mothers, continuity of care, having a breastfeeding policy, and rooming-in had the highest median scores. Family-centered care, antenatal informing, skin-to-skin contact, and human milk use had the lowest median scores. Neonatal wards in the hospitals that were ever designated as Baby-Friendly had significantly higher scores than those that were never designated. Most respondents (n = 48, 80%) expressed a desire to obtain Neo-BFHI designation in their neonatal wards.

CONCLUSION

Neo-BFHI recommendations can be successfully implemented in Russian neonatal wards at hospitals designated Baby-Friendly or planning to be designated.

Measuring health professionals' beliefs about skin-to-skin care during a cesarean

Women and their newborns are at risk of delayed or withheld skin‐to‐skin care (SSC) during a caesarean, which is about one‐third of births, worldwide. To date, no instrument exists to assess health professionals' (HPs) beliefs, and potential barriers and strategies for implementing SSC during a cesarean. The study aims were to (1) develop an instrument, Health Professionals' Beliefs about Skin‐to‐Skin Care During a Cesarean (SSC_B), (2) establish its validity and reliability and (3) describe HPs' beliefs about SSC during a caesarean. Quantitative and qualitative analyses were used to test the SSC_B and describe HPs' beliefs. SSC_B analysis yielded a content validity of 0.83 and reliability of α = 0.9. We grouped all practice roles as either nurses or physicians. The mean rank score for nurses (n = 120, M = 90) was significantly higher (p = 0.001) than physicians (n = 46, M = 79). Despite this difference, scores for both roles reflected support for SSC. Participants identified hospital readiness to implement SSC and maintaining maternal and newborn safety as major issues. SSC_B is a valid, reliable instrument to measure HPs' beliefs about SSC during a caesarean birth. HPs can use the SSC_B during quality improvement initiatives to improve access to immediate SSC for women who have a caesarean birth. Improved access can enhance breastfeeding outcomes and promote optimal maternal and child health.

[Prospective study on influence of perinatal factors on the development of early neonatal hypoglycemia in late-preterm and term infants]

INTRODUCTION AND OBJECTIVE

Neonatal hypoglycemia offers multiple controversies. The study aims to assess the main factors involved in the development of early hypoglycemia in term and late preterm infants, and the implication of different environmental circumstances.

METHODS

A prospective cohort study, in infants born between 34 0/7 weeks and 36 6/7 weeks of gestation. Three capillary blood glucose determinations were performed during the eight first hours after birth.

SAMPLE SIZE

207; 59 neonates developed hypoglycemia.

RESULTS

Prenatal risk factors include gestational diabetes with poor glycemic control, twin pregnancy and gestational age. The presence of meconium amniotic fluid and planned cesarean delivery are associated with a higher probability of hypoglycemia. After birth, skin to skin contact, breastfeeding, soft lightening, and normothermia are described as protective factors. The predictive model that combines the type of lightening, body temperature and the excess of bases level, correctly classifies 98% of the severe hypoglycemia cases, with a high Nagelkerke R2 value (0.645) and specificity of 99.5%.

CONCLUSIONS

Postnatal environmental factors seem to be directly related to early hypoglycemia development, so it is essential to support the maternal-child union and breastfeeding. Our results allow better identification of neonates who are not subsidiary to performing blood glucose determinations because they have little risk of developing it.

Breastfeeding During Military Service: Different Countries, Different Possibilities

INTRODUCTION

Breastfeeding is a human biological norm that is widely acknowledged as the ideal form of nutrition for all infants. Human milk saves lives, improves long-term health for the both mother and infant, and significantly reduces health care-related costs. The American Academy of Pediatrics recommends exclusive breastfeeding for at least 6 months and thereafter to continue with breastfeeding, in addition to complimentary foods for at least 1 year or longer. The World Health Organization extends this recommendation to at least 2 years or beyond this age.

MATERIALS AND METHODS

Multiple complex policies and directives would not be necessary if a federal law would entitle all new mothers to an adequate length of paid maternity leave and would protect parents during the time they personally care for their infants. Although a nationally mandated maternity leave is not available, the DoD should create a coherent global policy applicable to all active duty personnel across all branches of the U.S. Military. A global policy would govern positive change across all military branches and create consistent work conditions conducive for mothers to achieve their personal breastfeeding goals. In addition, a global policy would improve the military employees' health as well as maintain retention of military personnel.

RESULTS

A comparison of the U.S. Armed Forces to the Czech Armed Forces shows that the individual breastfeeding policies and directives of the U.S. Military branches are certainly steps in the right direction to support breastfeeding military members.

CONCLUSION

The well-documented evidence of long-term breastfeeding health benefits in addition to the economic benefits justifies such global military policy and would be a foundation to a national maternity leave policy, given that the USA is the only developed country without nationally mandated statutory entitlement to paid maternity leave.

Prevalence of Nipple Soreness at 48 Hours Postpartum

Background: Although most women start breastfeeding after delivery, difficulties often arise. One of the main reasons is nipple soreness, which contributes greatly to early cessation of breastfeeding. A soreness evaluation through validated scales, performed by health care professionals during the first few days, can contribute to improve breastfeeding and support for the mothers. Research Aim: Knowing the prevalence of nipple soreness during breastfeeding at 48 hours postpartum at the Infanta Cristina University Hospital (Madrid, Spain) through a cross-sectional descriptive study. Materials and Methods: The study took place between February and March 2019. A survey of 58 postpartum second day mothers was conducted including the Visual Analogue Scale (VAS) and Lactation Assessment Scale (LATCH) score for breastfeeding assessment. A descriptive analysis of secondary variables and subsequent bivariate inferential was performed for 95% confidence interval (CI). Results: The prevalence of nipple soreness observed is 97% (95% CI = 92-100%). It was found, significantly (p = 0.001), that the higher the score on LATCH, the lower the score on VAS and therefore the less pain. We found a relationship between women who were in skin-to-skin contact with their babies for 2 hours without interruption after birth and a higher pain score (p = 0.046). No other associations were found between VAS and other variables such as parity, type of birth, artificial milk supplements for the newborn, or using a pacifier. Conclusions: The high percentage of nipple soreness detected highlights that breastfeeding can be unpleasant in the first days after delivery. It is important to include in clinical practice the assessment of nipple soreness and the effectiveness of breastfeeding using validated scales.

Moving Beyond Breastfeeding Initiation: A Qualitative Study Unpacking Factors That Influence Infant Feeding at Hospital Discharge Among Urban, Socioeconomically Disadvantaged Women

BACKGROUND

Factors that influence breastfeeding initiation and duration have been well established; however, there is limited understanding of in-hospital exclusive breastfeeding (EBF), which is critical for establishing breastfeeding. Grady Memorial Hospital, which serves a high proportion of participants receiving Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and racial/ethnic minorities, had an in-hospital EBF rate in 2018 by the Joint Commission's definition of 29% and sought contextualized evidence on how to best support breastfeeding mothers.

OBJECTIVE

The objectives were to (1) identify facilitators and barriers to in-hospital EBF and (2) explore breastfeeding support available from key stakeholders across the social-ecological model.

DESIGN

In-depth, semistructured interviews were conducted and analyzed using thematic analysis.

PARTICIPANTS

The sample included a total of 38 purposively sampled participants from Grady Memorial Hospital (10 EBF mothers, 10 non-EBF, and 18 key stakeholders such as clinicians, community organizations' staff, and administrators).

RESULTS

Key themes included that maternal perception of inadequate milk supply was a barrier to in-hospital EBF at the intrapersonal level. At the interpersonal level, a personable and individualized approach to breastfeeding counseling may be most effective in supporting EBF. At the institutional level, key determinants of EBF were gaps in prenatal breastfeeding education, limited time to provide comprehensive prenatal education to high-risk patients, and practical help with latching and positioning. Community-level WIC services were perceived as a facilitator due to the additional benefits provided for EBF mothers; however, the distribution of WIC vouchers for formula to mothers while they are in the hospital undermines the promotion of EBF. Cultural norms and a diverse patient population were reported as barriers to providing support at the macrosystem level.

CONCLUSION

Multipronged approaches that span the social-ecological model may be required to support early EBF in hospital settings.

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.

Six-month breastfeeding maintenance after a self-efficacy promoting programme: an exploratory trial

BACKGROUND

Breastfeeding care plays a fundamental role in establishing breastfeeding and longer duration after discharge. Practices though vary among professionals involved and are often inconsistent with good practices recommended, being a threat to women's breastfeeding self-efficacy. Breastfeeding self-efficacy is considered a predictor for successful breastfeeding and a significant variable amenable to intervention for promoting lactation AIM: To evaluate the efficacy, feasibility and acceptability of a new breastfeeding self-efficacy promoting programme (SIALAC) on 6-month breastfeeding maintenance.

METHODS

In this exploratory multi-centre controlled trial, participants were allocated into control and intervention groups sequentially. Professionals in charge of the treatment groups were trained in between, with an especial focus on reducing practice variability. Control and intervention group women received usual care, and the intervention group received in addition SIALAC, a three-stage breastfeeding self-efficacy promoting programme. Primary outcome was breastfeeding maintenance up to 6 months analysed by Kaplan-Meier and Cox proportional hazard regression analysis. Student's t-test or chi-square tests were also used for continuous and categorical variables. Data on breastfeeding status and breastfeeding self-efficacy were collected at baseline, and 4, 8 and 24 weeks after birth.

RESULTS

From May 2014 through November 2015, participants were enrolled. The sample consisted of 112 women. No relevant socio-demographic or obstetric difference was found between groups. The intervention achieved a significant difference between groups in breastfeeding survival (X²  = 4.94, p = 0.026). Six-month breastfeeding maintenance was significantly higher in the intervention group (67% vs. 55%; X²  = 5.384, p = 0.020). Breastfeeding dropout in the control group was 3.3 (CI 1.1, 10.1) times higher than that of the intervention group at 6 months. Breastfeeding self-efficacy scores were higher in the intervention group although without significant statistical difference. The programme showed good acceptability.

CONCLUSION

Breastfeeding self-efficacy promoting programme SIALAC was beneficial in fostering 6-month breastfeeding survival. Full-scale trial should consider feasibility-related issues identified.

Lactation after infant death: an analysis of Australian healthcare agencies' online health information

Lactation is a potent signifier of maternal love and care commonly associated with early motherhood and infant survival. It is common, however, for bereaved mothers who have recently undergone miscarriage, stillbirth or infant death to produce breastmilk. Drawing on a critical feminist lens that seeks to understand how maternal subjectivities and lactation norms are constructed through public and reproductive health information, this article tests whether lactation management options after stillbirth and infant death are comprehensively covered in Australia's health organisations' online information. A qualitative directed content analysis was conducted to critique the information provided on 21 Australian websites. Information extracted from websites was compared to a 'best-practice' Lactation After Infant Death (AID) Framework developed by the research team for the review. We found a notable absence of comprehensive lactation management information targeted directly to bereaved mothers. Moreover, the most common lactation option presented for women without a living infant was lactation suppression. This dearth of appropriate and comprehensive lactation information curtails maternal subjectivies and diverse lactation practices and further isolates women dealing with the painful contradictions of lactation after loss.

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.

Turkish Neonatal Society guideline on nutrition of the healthy term newborn

Research shows strong evidence that breastfeeding offers many health benefits for infants and mothers, as well as potential economic and environmental benefits for communities. The World Health Organization recommends breastfeeding exclusively for up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond.