Failure to initiate breastfeeding among high risk obstetrical patients who intended to breastfeed

Explaining the perception and experiences of breastfeeding in mothers who have a high risk pregnancy: a protocol study

INTRODUCTION

Enhancing breastfeeding practices, even in affluent nations, significantly reduces child mortality rates. Nevertheless, three out of five newborns do not receive breastfeeding within the first hour of birth. Research indicates that under high-risk pregnancy circumstances, there may be challenges in initiating and sustaining breastfeeding. Infants born from high-risk pregnancies are particularly vulnerable to illnesses and mortality. Although breastfeeding serves as a protective measure against various infant and post-infancy ailments, many mothers encounter difficulties in commencing or maintaining breastfeeding due to complications associated with their conditions. The present study aims to illuminate the understanding and experience of breastfeeding in mothers with high-risk pregnancies, considering the cultural and social context of Iran.

METHOD

This study is a qualitative research utilizing a conventional content analysis approach. In this qualitative study, mothers who have undergone a high-risk pregnancy and currently have infants under 6 months old will be chosen through purposeful and snowball sampling. Their breastfeeding experiences will be gathered through individual, semi-structured, and face-to-face interviews. In addition to interviews, observation and focus groups will also be used to collect data. Data analysis was performed using Graneheim and Lundman's method with MAXQDA software version 10, VERBI Software GmbH, Berlin. The study will utilize the criteria of Lincoln and Guba (1985) for validity and reliability.

DISCUSSION

This qualitative study aims to investigate the experiences and challenges of breastfeeding in mothers with high-risk pregnancies to pinpoint breastfeeding barriers in this demographic and develop essential interventions and strategies to address these obstacles.

Factors associated with high exclusive breastfeeding rates among preterm infants under 34 weeks of gestation in Da Nang, Vietnam: A retrospective cohort study

Background

Preterm infants have higher mortality than full-term infants. While breastfeeding dramatically reduces preterm death, it is limited by biological and practice barriers, particularly for babies born before 34 weeks gestational age. Da Nang Hospital for Women and Children developed a quality improvement approach to improve breastfeeding of preterm infants by strengthening feeding support, non-separation, and kangaroo mother care (KMC).

Methods

To determine breastfeeding outcomes following discharge and explore factors associated with improved feeding, mothers of infants under 34 weeks gestational age born October 2021 to March 2022 and discharged alive were interviewed at six months and their medical records were reviewed.

Results

Out of 104 preterm infants included, all were exclusively breastfed at discharge and one month, 86.5% at three months, and 63.5% at six months; 47.1% received immediate skin-to-skin contact, 31.7% immediate and continuous KMC, and the remaining 68.3% continuous KMC beginning at a median of three days. Exclusive breastfeeding at six months was associated with the mother antenatally seeking breastfeeding information (odds ratio (OR) = 14.5; 95% confidence interval (CI) = 1.2-173.6), avoiding bottle-feeding at home (OR = 7.7; 95% CI = 1.7-33.7) and reduced with each day delay between birth and full breastfeeding (OR = 0.8; 95% CI = 0.6-0.9).

Conclusions

Hospital environments that limit mother-baby separations and feeding delays, including rooming-in of mothers and infants, KMC, and breastfeeding support from birth, enabled 100% of preterm infants born before 34 weeks gestational age to breastfeed exclusively with continued rates higher than previously reported. Addressing antenatal and post-natal factors limiting practice can further improve longer-term breastfeeding outcomes. The approach can be adapted to achieve high exclusive breastfeeding rates, regardless of gestational age.

Breastfeeding practices and associations with pregnancy, maternal and infant characteristics in Australia: a cross-sectional study

BACKGROUND

Exclusive breastfeeding to six months of age is a major global public health priority. Several characteristics are known to be associated with early cessation of breastfeeding, however, limited evidence exists regarding whether women's reported reasons for cessation are associated with maternal, pregnancy and infant characteristics. The aims of this study were to: i) describe women's reported intention to breastfeed and their subsequent breastfeeding practices; ii) describe women's reported reasons for breastfeeding cessation prior to the infant being five months of age; and iii) examine associations between these factors and maternal, pregnancy and infant characteristics.

METHODS

Telephone and online surveys were conducted between October 2019 and April 2020 with 536 women who had given birth in the previous eight to 21 weeks at four public maternity services in Australia.

RESULTS

The majority of women intended to (94%), and did, initiate (95%) breastfeeding. At the time the survey was conducted, 57% of women were exclusively breastfeeding. Women who: had less than University level education, had a pre-pregnancy BMI in the overweight or obese category, and who smoked tobacco at the time of the survey had lower odds of exclusively breastfeeding. The most common self-reported reasons for breastfeeding cessation were breastfeeding challenges (47%) and low milk supply (40%). Women aged 26-35 years and 36 + years had greater odds of reporting breastfeeding cessation due to low milk supply (OR = 2.92, 95% CI: 1.11, 7.66; OR = 5.57, 95% CI: 1.70, 18.29) compared to women aged 18-25 years. While women who had completed a TAFE certificate or diploma had lower odds of reporting this as a reason for breastfeeding cessation (OR = 0.28; 95% CI: 0.11, 0.73) compared to women who had University level education. There were no other significant associations found between characteristics and reasons for ceasing breastfeeding.

CONCLUSIONS

The most common reasons for breastfeeding cessation may be modifiable through the provision of breastfeeding support in the early postpartum period, with such support being tailored to women's age and level of education. Such support should aim to increase women's self-efficacy in breastfeeding, and be provided from the antenatal period and throughout the first six months postpartum.

Impact of excessive gestational weight gain on exclusive breastfeeding among women with Type 1 and Type 2 diabetes and obesity

BACKGROUND

Pregestational diabetes, obesity and gestational weight gain (GWG) are associated with adverse perinatal outcomes, however, the influence of excessive GWG on lactation at discharge is less known. Our aim is to evaluate the impact of excessive GWG using the LifeCycle project guidelines on exclusive breastfeeding (EBF) and any BF rates at discharge among 171 women with Type 1 and 294 Type 2 diabetes and obesity who intended to BF.

METHODS AND FINDINGS

Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). GWG was categorized as adequate, inadequate or excessive according to the 2019 LifeCycle Project guidelines. Women with Type 1 were younger (30 vs 33y), primiparous (51 vs 32%), delivered earlier (37 vs 38w) than women with Type 2 andwere different in grade 1 (40 vs 26%), grade 3 obesity (19 vs 49%) and median GWG (15 vs 11kg). Of all 465 women with Type 1 and Type 2 combined, 365 (78%) who had excessive GWG and 100 (22%) who had non-excessive GWG showed similar EBF (27 vs 25%) and any BF (72 vs 72%) rates. Regression analysis showed that after adjusting for potential confounders excessive GWG was not a predictor of EBF or any BF at discharge.

CONCLUSION

Type 1 and Type 2 diabetes, obesity and excessive GWG are associated with low EBF, however, excessive GWG is not an independent predictor of low EBF or any BF at discharge.

Exclusive breastfeeding among women with type 1 and type 2 diabetes mellitus

Objective

To compare exclusive breastfeeding (BF) and BF initiation among 185 women with Type 1 and 212 women with Type 2 pregestational diabetes who intended exclusive or partial BF and delivered at ≥34 weeks of gestation.

Methods

Retrospective cohort study. At discharge, exclusive BF is direct BF or BF complemented with expressed breast milk. BF initiation is defined by exclusive or partial BF.

Results

Type 1 and Type 2 groups were similar in prior BF experience (69 vs 67%) but were different in intention to BF exclusively (92 vs 78%) and partially (8 vs 22%). Women in the Type 1 group were younger (median age 30 vs 33y), likely to be primiparous (47 vs 25%), have a lower median BMI (32 vs 36 kg/m²) and deliver by primary cesarean (37 vs 26%). Infants born to Type 1 women were more likely to be admitted to the NICU (44 vs 18%) and to have hypoglycemia (59 vs 41%). At discharge, exclusive BF among Type 1 was higher (34 vs 23%), partial BF was similar (47 vs 46%) while FF (formula feeding) was lower (19 vs 31%) than in the Type 2 group. BF initiation occurred in 81% of Type 1 and 69% of Type 2 women.

Conclusion

Intention to BF exclusively was higher in Type 1 women compared to Type 2. At discharge, exclusive BF and BF initiation were lower and FF higher in the Type 2 group highlighting the need for different strategies if lactation in this special population is to be improved.

The impact of breast augmentation on breast feeding in primigravida women - A cohort study

OBJECTIVE

Breast augmentations are among the most common interventional cosmetic procedures performed nowadays, but scarcity of data exists on its effects on breastfeeding. Our aim was to evaluate whether breast augmentation adversely affects breastfeeding.

STUDY DESIGN

A retrospective cohort study using database of a 2.3-million-member state mandate health maintenance organization (HMO). We identified primigravida women with a singleton pregnancy who delivered between the years 1998-2016, at gestational age of >34 weeks of gestation. Study group included women with breast augmentation surgery, which compared to control group of women who did not undergo breast augmentation. The primary outcome was documentation of any breastfeeding during the first three months postpartum.

RESULTS

Overall, 14,919 women were included, of them, 3913 and 11,006 women with and without breast augmentation, respectively. Women with breasts augmentation were younger (29.8 ± 3.6 years vs. 30.9 ± 4.0 years, p < 0.001), had lower pre-pregnancy BMI (25.2 ± 5.0 vs. 26.36 ± 5.0 Kg/m², p < 0.001), belong to higher socioeconomic status level and less religious communities. Breastfeeding rates in the study group were lower as compared to controls (70.7% VS 85.1%; p < 0.0001), with an adjusted odds ratio of 0.42(95% CI: 0.38-0.461). Maternal diabetes mellitus and advanced maternal age were associated with a lower likelihood of breastfeeding (95% CI:0.45-0.78, p-value < 0.0001), while belonging to religious communities were associated with higher breastfeeding rates (95% CI: 1.34-1.99, p-value < 0.0001).

CONCLUSION

Women with breast augmentation tend to breastfeed less than women without breast augmentation, during the first three month of postpartum.

Prior breastfeeding experience and infant feeding at discharge among women with pregestational diabetes mellitus

OBJECTIVE

To compare multiparous women with pregestational diabetes mellitus (PGDM) with and without prior breastfeeding (BF) experience and to ascertain their infants' feeding type during hospitalization and at discharge.

METHODS

A retrospective cohort study of 304 women with PGDM who delivered at ≥34 weeks gestational age (GA). Prior BF experience and infant feeding preference was declared prenatally. At discharge, BF was defined as exclusive or partial.

RESULTS

BF experience and no experience groups were similar in diabetes type 1 and 2, race and number of pregnancies. Women with no experience had more spontaneous abortions (35 vs 27%), fewer term deliveries (51 vs 61%) and living children (median 1 vs 2). In the current pregnancy, mode of delivery: vaginal (36 & 37%), cesarean (64 & 63%), birthweight (3592 & 3515 g), GA (38 & 37 w), NICU admission (14 & 11%) and hypoglycemia (44 & 43%) were similar. Women with experience intended to BF (79 vs 46%), their infants' first feeding was BF (64 vs 36%) and had lactation consults (96 vs 63%) more often than those without experience. At discharge, women with BF experience were different in rate of exclusive BF (33 vs 11%), partial BF (48 vs 25%) and formula feeding (19 vs 64%).

CONCLUSION

Prior BF experience leads to better BF initiation rates while the absence of BF experience adds a risk for BF initiation failure. A detailed BF history could provide insight into obstacles that lead to unsuccessful BF experiences and may help define appropriate preventive or corrective strategies.

Breastfeeding in Women on Opioid Maintenance Therapy: A Review of Policy and Practice

INTRODUCTION

Opioid use is epidemic in the United States. Opioid use disorder (OUD) in pregnancy, as well as neonatal abstinence syndrome, has quadrupled in the last decade, and opioid maintenance therapy is recommended for pregnant women with OUD. Breastfeeding is an important means of improving outcomes for these vulnerable women and newborns. The purpose of this study was to review current policy on breastfeeding and opioid maintenance therapy, the rates of breastfeeding among women in this population, and facilitators and barriers to implementing policy recommendations.

METHODS

CINAHL, PubMed, the Cochrane Database of Systematic Reviews, Embase, and Web of Science were searched. Inclusion criteria included publication between 2013 and 2018, English language, human only, and original data (except for policy statements). Studies were excluded if they did not report original data and did not examine breastfeeding for women on opioid maintenance therapy.

RESULTS

Eight policy statements and 17 original research studies were identified that met the search criteria. All the policy statements support breastfeeding for women who are stable on opioid maintenance therapy and do not have HIV. Despite this, rates of breastfeeding among women receiving opioid maintenance therapy remain low compared with women in the general population. Results of qualitative research indicates that women on opioid maintenance therapy face numerous barriers to breastfeeding, including misinformation from health care professionals. Quantitative research has only begun to identify interventions to improve breastfeeding outcomes in this population. Research was conducted primarily with white women receiving care at urban health care centers.

DISCUSSION

Practice lags behind policy in terms of supporting breastfeeding in women receiving opioid maintenance therapy. There is a need for more research that includes African American and rural women on opioid maintenance therapy, as well as quantitative research that uses findings from qualitative research to identify the best possible interventions for improving breastfeeding outcomes for women on opioid maintenance therapy and their newborns. One significant need is for health care provider education regarding these policies as well as best practices for providing breastfeeding education and support to this population.

In-hospital formula supplementation and breastfeeding initiation in infants born to women with pregestational diabetes mellitus

OBJECTIVE

To ascertain the rate of in-hospital supplementation as it relates to early breastfeeding (BF) and early formula feeding (FF) and its effects on BF (exclusive and partial) at the time of discharge for infants born to women with pregestational diabetes mellitus (PGDM).

METHODS

Retrospective cohort investigation of 282 women with PGDM who intended to BF and their asymptomatic infants admitted to the newborn nursery for blood glucose monitoring and routine care. Early feeding was defined by the initial feeding if given within four hours of birth.

RESULTS

Of the 282 mother-infant dyads, for 134 (48%) early feeding was BF and for 148 (52%) early feeding was FF. Times from birth to BF and FF (median 1 hr, 0.3-6) were similar, while the time to first BF for those who FF and supplemented was longer (median 6 hr., 1-24). Ninety-seven infants (72%) who first BF also supplemented. Of these, 22 (23%) BF exclusively, 67 (69%) BF partially and 8 (8%) FF at discharge. One hundred seventeen (79%) who first FF also supplemented. Of these, 21 (18%) BF exclusively, 76 (65%) BF partially and 20 (17%) FF at discharge.

CONCLUSION

Regardless of the type of first feeding, the majority of infants born to women with PGDM require supplementation. Even when medically indicated, in-hospital supplementation is an obstacle, albeit not absolute, to exclusive BF at discharge. Parents should be reminded that occasional supplementation should not deter resumption and continuation of BF.

Decreasing NICU admissions of asymptomatic infants of women with pregestational diabetes mellitus improves breastfeeding initiation rates

BACKGROUND

Asymptomatic infants born to women with pregestational diabetes mellitus (PGDM) are usually admitted to the well baby nursery (WBN) while those who are symptomatic or in need of specialized care are admitted to the neonatal intensive care unit (NICU).

OBJECTIVE

To determine if changes in the NICU admission rate of asymptomatic infants born to women with PGDM during two different epochs affected breastfeeding (BF) initiation rates.

DESIGN/METHODS

Retrospective cohort investigation of 386 women with PGDM and their infants who delivered in 2008-11 (epoch 1) and 457 who delivered in 2013-16 (epoch 2) at a single institution.

RESULTS

NICU admissions: Comparison between epoch 1 and epoch 2 showed a decrease in the number of admissions from 243 (63%) to 175 (38%) *(chi square *p < 0.05). Respiratory distress (39 and 43%) and prematurity (28 and 23%) as admission diagnoses remained unchanged. Admissions for prevention of hypoglycemia declined (32% to 21%)*. At discharge from the NICU, exclusive BF (12 to 19%)* and any BF increased (41 to 55%)* while formula feeding (FF) decreased (59 to 45%)*. Admission to the NICU remained a strong predictor of BF initiation failure (a OR 0.6, 95% , CI 0.4-0.9, p 0.005).WBN admissions: Comparison between epoch 1 and epoch 2 showed an increase in the number of admissions from 143 (37%) to 282 (62%)*. The incidence of hypoglycemia (31% and 38%) and its correction with oral feedings (76% and 71%) remained unchanged. At discharge from the WBN, exclusive BF (15 to 27%)* and any BF (52 to 62%)* increased while FF decreased (48 to 38%)*.

CONCLUSIONS

A decrease in the number of NICU admissions of asymptomatic infants born to women with PGDM is associated with improvements in BF initiation rates.

Early feeding, hypoglycemia and breastfeeding initiation in infants born to women with pregestational diabetes mellitus

OBJECTIVE

To examine the effects of early breastfeeding (eBF) or early formula feeding (eFF) on hypoglycemia and on BF initiation in infants born to women with pregestational diabetes mellitus (PGDM) who intended to BF.

METHODS

Retrospective cohort investigation of 554 women with PGDM and their infants (IDMs) who delivered during 2008-2016. The first feeding (BF or FF) was considered early if given within 4 hours from birth.

RESULTS

282 (51%) IDMs were admitted to the Well Baby Nursery. Of the 134 IDMs whose early feeding was BF, hypoglycemia affected 30% which was corrected with oral feedings in 78% of the cases. At discharge, 49% BF exclusively while 45% BF partially. Of the 148 IDMs whose early feeding was FF, hypoglycemia affected 40% which was corrected with oral feedings in 69% of the cases. At discharge, 14% BF exclusively while 48% BF partially. There were 272 (49%) IDMs admitted to the NICU. Their early feeding was BF (14%) and FF (86%). Hypoglycemia developed in 50% and 43% of these groups, respectively. Benefits of early feedings on hypoglycemia were masked by the routine use of IV dextrose infusions. At discharge, early BF led to exclusive BF in 45% and partial BF in 50% of the cases. Early FF led to exclusive BF in 17% and partial BF in 42% of the cases.

CONCLUSIONS

Early and continued feeding (BF preferably or FF if BF is not feasible) should be the first line of treatment for hypoglycemia. Early BF is paramount for BF initiation. Early FF is an obstacle, albeit not absolute, to BF initiation, thus it should not deter continued efforts to start or resume BF.

Breast-Feeding Friendly, but Not Formula Averse

Breast-feeding is the optimal source of newborn nutrition in term infants and is associated with multiple short- and long-term health benefits. Establishment of breast-feeding may be difficult in a small subset of mothers, which can lead to adverse consequences in the newborn. Some of the consequences of suboptimal nutritional provision to the newborn, such as severe hyperbilirubinemia and breast-feeding-associated hypernatremic dehydration, can have devastating and long-lasting sequelae. Timely identification of mothers and newborns at risk for developing these complications is necessary to avoid significant morbidity and mortality. In these cases, the judicious use of formula supplementation may be considered. However, more studies are necessary to develop comprehensive formula supplementation criteria and guidelines for pediatric medical providers. [Pediatr Ann. 2017;46(11):e402-e408.].