Barriers to Human Milk Feeding at Discharge of Very Low-Birthweight Infants: Evaluation of Neighborhood Structural Factors

Need for Gastrostomy Tube in Periviable Infants

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

The Effects of Health Disparities on Neonatal Outcomes

The history of racism in the United States was established with slavery, and the carry-over effect continues to impact health care through structural and institutional racism. Racial segregation and redlining have impacted access to quality health care, thereby impacting prematurity and infant mortality rates. Health disparities also impact neonatal morbidities such as intraventricular hemorrhage and necrotizing enterocolitis and the family care experience including the establishment of breastfeeding and health care provider interactions.

Examining the Role of Women, Infant, and Children in Black Women Breastfeeding Duration and Exclusivity: A Systematic Review

Background: African American women continue to experience low rates of breastfeeding initiation as well as low rates of exclusive breastfeeding for 6 months. Research has indicated that there are several social determinants that impact breastfeeding rates, but there is a dearth of literature that allows African American women to give voice to their experiences. In addition, research has shown women, infant, and children (WIC) participants to have lower breastfeeding rates than non-WIC eligible women. Research Aim/Question: The aim of this systematic review was to examine the relationship between WIC program participation and breastfeeding initiation and duration among non-Hispanic African American/Black women. Methods: The approach for this review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Four online databases, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, MEDLINE, and SCOPUS, were used to search for peer-reviewed articles and grey literature. Results: Two hundred eighteen articles were retrieved through the database search and underwent initial screening, yielding 59 potential eligible articles. Full-text articles were further reviewed and 11 met the inclusion criteria and were included in this systematic review. Conclusions: Included studies show mixed results regarding the association between WIC participation and breastfeeding initiation, but there is a general negative association between WIC participation and breastfeeding duration, especially among Black women.

Understanding the Domains of Experiences of Black Mothers with Preterm Infants in the United States: A Systematic Literature Review

OBJECTIVE

To report the domains of Black mothers' experiences with preterm infants in the neonatal intensive care unit (NICU) and to determine the frameworks used.

METHODS

A systematic review of the literature using the PRISMA guideline was performed. An electronic database search of published literature between 2000 and 2022 was conducted based on predetermined search terms and parameters.

RESULTS

Twenty-seven articles met the inclusion and exclusion criteria. Eleven articles focused on feeding practices, ten reported on nursing/maternal care experiences, five reported mental health/social support, and only one focused on mother-infant relationships. Only five papers reported using any frameworks, comprising grounded theory framework (n = 2), theory of planned behavior (n = 1), research justice framework (n = 1), and the patient and public engagement protocol (n = 1).

DISCUSSION

A holistic approach to understanding the multifactorial experiences of Black mothers with preterm infants needs to be socio-culturally competent to ensure their diverse intersections and identities are accurately represented and understood. Rigorous research at the intersection of Black maternal health and the NICU hold promises for advancing maternal health equity in the United States.

Recognizing Our Biases, Understanding the Evidence, and Responding Equitably: Application of the Socioecological Model to Reduce Racial Disparities in the NICU

BACKGROUND

Implicit bias permeates beliefs and actions both personally and professionally and results in negative health outcomes for people of color-even in the neonatal intensive care unit (NICU). NICU clinicians may naïvely and incorrectly assume that NICU families receive unbiased care. Existing evidence establishing associations between sex, race, and neonatal outcomes may perpetuate the tendency to deny racial bias in NICU practice.

EVIDENCE ACQUISITION

Using the socioecological model as a framework, this article outlines evidence for racial health disparities in the NICU on multiple levels-societal, community, institutional, interpersonal, and individual. Using current evidence and recommendations from the National Association of Neonatal Nurses Position Statement on "Racial Bias in the NICU," appropriate interventions and equitable responses of the NICU clinician are explored.

RESULTS

Based on current evidence, clinicians should reject the notion that the social construct of race is the root cause for certain neonatal morbidities. Instead, clinicians should focus on the confluence of medical and social factors contributing to each individual infant's progress. This critical distinction is not only important for clinicians employing life-saving interventions, but also for those who provide routine care, developmental care, and family education-as these biases can and do shape clinical interactions.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Healthcare practitioners have an ethical and moral responsibility to maintain up-to-date knowledge of new evidence that impacts our clinical practice. The evidence demonstrates the importance of recognizing the enduring role of racism in the health and well-being of people of color and the need to adjust care accordingly.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

IMPLICATIONS FOR PRACTICE

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

IMPLICATIONS FOR RESEARCH

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

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

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

Racial Disparities in Donor Human Milk Feedings: A Study Using Electronic Medical Records

INTRODUCTION

The aim of this study was to evaluate differences in the use of pasteurized donor human milk (PDHM) by maternal race-ethnicity during postpartum hospitalization using electronic medical records (EMRs).

MATERIALS AND METHODS

A retrospective cohort study of all live-born infants at our academic research institution from July 1, 2014, to June 30, 2016, was conducted. EMR data were used to determine whether each infant received mother's own milk (MOM), PDHM, or formula. These data were stratified based on whether the infant received treatment in the Neonatal Critical Care Center. Generalized estimating equation models were used to calculate the odds of receiving PDHM by maternal race-ethnicity, adjusting for gestational age, birth weight, insurance, preferred language, nulliparity, and mode of delivery.

RESULTS

Infant feeding data were available for 7097 infants, of whom 49% were fed only MOM during their postpartum hospitalization. Among the 15.9% of infants admitted to neonatal critical care, infants of non-Hispanic Black (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.31-0.72), Hispanic (OR 0.65, 95% CI 0.36-1019), and Other (OR 0.63, 95% CI 0.32-1.26) mothers had lower rates of PDHM feedings than infants of non-Hispanic White mothers in the adjusted models. Among well infants, the use of PDHM was lower among non-Hispanic Black and Hispanic mothers (OR 0.25, 95% CI 0.18-0.36, and OR 0.38, 95% CI 0.26-0.56) compared with non-Hispanic White mothers.

CONCLUSIONS

Inequities in exclusive human milk feeding and use of PDHM by maternal race-ethnicity were identified. Antiracist interventions are needed to promote equitable access to skilled lactation support and counseling for PDHM use.

Breastfeeding rates at discharge for very low birthweight neonates and their determinants: An observational study from a tertiary care neonatal intensive care unit in India

BACKGROUND

Mother's milk is the best milk for neonates. Preterm very low birthweight (VLBW) neonates face many challenges leading to low rates of breastfeeding at discharge.

AIMS

(i) To determine the proportion of <32 weeks preterm VLBW neonates who are exclusively breastfed (EB) at discharge and (ii) determinants of exclusive breastfeeding (EBF) at discharge.

METHODS

An observational study was conducted for a duration of 1 year, from May 2019 to April 2020 in a tertiary care neonatal intensive care unit (NICU) in North India. Consecutive <32 weeks preterm VLBW neonates admitted within 72 h of birth and on full enteral feeds (FEF) within 10 days of birth were included in this study and followed up till discharge.

RESULTS

Forty-four of 97 (45.4%) preterm VLBW neonates were exclusively breastfed and 31/97 (32%) received more than 80% mother's own milk (MOM) at discharge. Male sex (P = 0.03), those whose first feed had any amount of MOM (P = 0.038) or exclusive MOM in their first feed or when initiated on first FEF (P = 0.002), and neonates with longer duration of hospital stay (P = 0.035) had an increased chance of being exclusively breastfed at discharge.

CONCLUSION

Preterm VLBW neonates who receive any amount of MOM in their first feed or first FEF, male infants and those who stay longer in hospital are more likely to be exclusively breastfed at discharge.

Evaluating Care in Safety Net Hospitals: Clinical Outcomes and Neonatal Intensive Care Unit Quality of Care in California

OBJECTIVES

To examine the characteristics of safety net (sn) and non-sn neonatal intensive care units (NICUs) in California and evaluate whether the site of care is associated with clinical outcomes.

STUDY DESIGN

This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22 081 infants born between 2014 and 2018 with a birth weight of 401-1500 g or gestational age of 22-29 weeks. Quality of care as measured by the Baby-MONITOR score and rates of survival without major morbidity were compared between snNICUs and non-snNICUs.

RESULTS

Black and Hispanic infants were cared for disproportionately in snNICUs, where care and outcomes varied widely. We found no significant differences in Baby-Measure Of Neonatal InTensive care Outcomes Research (MONITOR) scores (z-score [SD]: snNICUs, -0.31 [1.3]; non-snNICUs, 0.03 [1.1]; P = .1). Among individual components, infants in snNICUs exhibited lower rates of human milk nutrition at discharge (-0.64 [1.0] vs 0.27 [0.9]), lower rates of no health care-associated infection (-0.27 [1.1] vs 0.14 [0.9]), and higher rates of no hypothermia on admission (0.39 [0.7] vs -0.25 [1.1]). We found small but significant differences in survival without major morbidity (adjusted rate, 65.9% [95% CI, 63.9%-67.9%] for snNICUs vs 68.3% [95% CI, 67.0%-69.6%] for non-snNICUs; P = .02) and in some of its components; snNICUs had higher rates of necrotizing enterocolitis (3.8% [3.4%-4.3%] vs 3.1% [95% CI, 2.8%-3.4%]) and mortality (95% CI, 7.1% [6.5%-7.7%] vs 6.6% [6.2%-7.0%]).

CONCLUSIONS

snNICUs achieved similar performance as non-snNICUs in quality of care except for small but significant differences in any human milk at discharge, infection, hypothermia, necrotizing enterocolitis, and mortality.

Study protocol for reducing disparity in receipt of mother's own milk in very low birth weight infants (ReDiMOM): a randomized trial to improve adherence to sustained maternal breast pump use

BACKGROUND

Black very low birth weight (VLBW; < 1500 g birth weight) and very preterm (VP, < 32 weeks gestational age, inclusive of extremely preterm, < 28 weeks gestational age) infants are significantly less likely than other VLBW and VP infants to receive mother's own milk (MOM) through to discharge from the neonatal intensive care unit (NICU). The costs associated with adhering to pumping maternal breast milk are borne by mothers and contribute to this disparity. This randomized controlled trial tests the effectiveness and cost-effectiveness of an intervention to offset maternal costs associated with pumping.

METHODS

This randomized control trial will enroll 284 mothers and their VP infants to test an intervention (NICU acquires MOM) developed to facilitate maternal adherence to breast pump use by offsetting maternal costs that serve as barriers to sustaining MOM feedings and the receipt of MOM at NICU discharge. Compared to current standard of care (mother provides MOM), the intervention bundle includes three components: a) free hospital-grade electric breast pump, b) pickup of MOM, and c) payment for opportunity costs. The primary outcome is infant receipt of MOM at the time of NICU discharge, and secondary outcomes include infant receipt of any MOM during the NICU hospitalization, duration of MOM feedings (days), and cumulative dose of MOM feedings (total mL/kg of MOM) received by the infant during the NICU hospitalization; maternal duration of MOM pumping (days) and volume of MOM pumped (mLs); and total cost of NICU care. Additionally, we will compare the cost of the NICU acquiring MOM versus NICU acquiring donor human milk if MOM is not available and the cost-effectiveness of the intervention (NICU acquires MOM) versus standard of care (mother provides MOM).

DISCUSSION

This trial will determine the effectiveness of an economic intervention that transfers the costs of feeding VLBWand VP infants from mothers to the NICU to address the disparity in the receipt of MOM feedings at NICU discharge by Black infants. The cost-effectiveness analysis will provide data that inform the adoption and scalability of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04540575 , registered September 7, 2020.

Barriers to optimal breast milk provision in the neonatal intensive care unit

OBJECTIVE

This study examines comprehensive patient and process factors that influence breast milk use in the NICU setting.

STUDY DESIGN

We examined the association of maternal, neonatal, and family factors and lactation support systems to identify gaps in breast milk use in a retrospective study of 865 infants born in 23-41 weeks gestation admitted to the NICU.

RESULTS

Breast milk at discharge for all infants was 89.3%, for extremely preterm 82.3%, moderately preterm 91.4%, late preterm 86.5%, and term 92.7%. Prematurity (OR 0.31 [0.17-0.56]), low birth weight, morbidities, Black maternal race (OR 0.20 [0.07-0.57]) and public insurance (OR 0.54 [0.34-0.85]) were associated with decreased breast milk use. Early initiation of feeds was associated with increased breast milk use.

CONCLUSIONS

There is a need to increase social as well as hospital support systems to address gaps in breast milk use in the NICU.

A Mixed-Methods Examination of Inpatient Breastfeeding Education Using a Human Factors Perspective

Objective: The objective of this study was to examine postpartum, inpatient mother-lactation educator (LE) breastfeeding education, resulting perceptions, and patient-reported worries and outcomes. In the breastfeeding literature, there is inadequate insight into the mother-LE relationship, and specifically, the extent to which contextual factors are elicited and information is tailored accordingly. In this study, we were specifically interested in maternal contextual factors. Materials and Methods: Using a mixed methods approach, we (1) captured 20 postpartum, inpatient mother-LE breastfeeding education sessions and analyzed them for the presence of maternal contextual factors, (2) administered separate perception questions to mothers and LEs, and (3) conducted 13 follow-up interviews with mothers after being discharged from the hospital. Results: Inpatient breastfeeding education is delivered in dynamic and busy clinical settings, characterized by potential distractions such as delivery of medical care. Maternal contextual factors are infrequently elicited during the education. Although both LEs and mothers rate the sessions positively, potential gaps remain as highlighted by the analyses of semistructured interviews with mothers. Conclusion: Human factors perspective, theories, and methods are relevant to the characterization of facilitators and barriers of current breastfeeding education, as well as to the development of interventions to support the delivery of human-centered, effective, and timely breastfeeding education.

Predictors of the Provision of Mother's Milk Feedings in Newborns Admitted to the Neonatal Intensive Care Unit

Background: Breast milk reduces morbidity and mortality in infants admitted to neonatal intensive care unit (NICU). Objectives: We determined predictors of procuring mother's own milk (MOM) among NICU-admitted newborn-mother dyads: (1) initiation of any milk expression; (2) initiation of milk expression within 6 hours of birth; (3) MOM as the first enteral feeding; (4) colostrum for oral care within 36 hours of birth if not yet orally fed; and (5) provision of MOM at 21 days of life or discharge, whichever occurred first. Methods: We performed a retrospective chart review of NICU-admitted newborn-mother dyads at an urban medical center from June 1, 2018-May 31, 2019. We excluded infants not directly admitted to the NICU, those never enterally fed, multiple gestations if not the first to be discharged, and infants discharged to a nonbiological caregiver. We used chi-square analysis to examine unadjusted associations between independent variables and MOM outcomes and then used logistic regression to determine the adjusted odds ratio and 95% confidence interval (AOR [95% CI]) for predictors of MOM outcomes. Results: There were 341 mother-infant dyads who met inclusion criteria and 71% of these mothers initiated milk expression. Smoking, multiparity, gestational diabetes, and Hepatitis C lowered the odds for at least one MOM outcome; whereas mothers who delivered at 28-32 weeks versus ≥33 weeks, and infants with birthweight <1,500 g versus 1,500-2,500 g had higher odds for at least one MOM outcome. Conclusion: Maternal/infant dyad characteristics may predict some, but not all NICU breastfeeding outcomes. This suggests that hospital practices may influence these outcomes and can inform future interventions.

Black/African American Breastfeeding Experience: Cultural, Sociological, and Health Dimensions Through an Equity Lens

Background: Disparities in breastfeeding (BF) continue to be a public health challenge, as currently only 42% of infants in the world and 25.6% of infants in the United States are exclusively breastfed for the first 6 months of life. In 2019, the infants least likely to be exclusively breastfed at 6 months are African Americans (AA) (17.2%). Materials and Methods: A scoping review of the literature was undertaken by using Arksey and O'Malley's six-stage framework to determine key themes of AA women's experience BF through an equity lens. Electronic databases of CINAHL and PubMed were searched for peer-reviewed, full-text articles written in the English language within the past 5 years by using the terms BF, AA, Black, sociological, cultural, equity, health, attitude, exposure, initiation, continuation, barriers, and facilitators. Results: Initially, 497 articles were identified, and 26 peer-reviewed articles met the eligibility criteria. Through an equity lens, three main themes emerged, which summarized AA women's BF experience: cultural (family, peers and community support; misconceptions; personal factors), sociological (prejudices, racism, home environment; financial status; sexuality issues; BF role models; employment policies), and health dimensions (family involvement; timely and honest information from staff; baby-friendly hospital initiatives; postnatal follow-up; special supplemental nutrition program for women, infants, and children). Conclusion: For AA women, exclusively BF is beset with diverse cultural, health, and sociological challenges. Multifaceted approaches are needed for successful resolution of BF challenges to bridge the racial gap in BF in the United States. Future studies may explore interventions targeted to modifiable barriers to improve BF outcomes.

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

Very low birth weight (VLBW; <1500 g birth weight) infants are substantially more likely to be born to black than to non-black mothers, predisposing them to potentially preventable morbidities that increase the risk for costly lifelong health problems. Mothers' own milk (MOM) may be considered the ultimate "personalized medicine" since milk composition and bioactive components vary among mothers and multiple milk constituents provide specific protection based on shared exposures between mother and infant. MOM feedings reduce the risks and associated costs of prematurity-associated morbidities, with the greatest reduction afforded by MOM through to NICU discharge. Although black and non-black mothers have similar lactation goals and initiation rates, black VLBW infants are half as likely to receive MOM at NICU discharge in the United States. Black mothers are significantly more likely to be low-income, single heads of household and have more children in the home, increasing the burden of MOM provision. Although rarely considered, the out-of-pocket and opportunity costs associated with providing MOM for VLBW infants are especially onerous for black mothers. When MOM is not available, the NICU assumes the costs of inferior substitutes for MOM, contributing further to disparate outcomes. Novel strategies to mitigate these disparities are urgently needed. IMPACT: Mother's own milk exemplifies personalized medicine through its unique biologic activity. Hospital factors and social determinants of health are associated with mother's own milk feedings for very low-birth-weight infants in the neonatal intensive care unit. Notably, out-of-pocket and opportunity costs associated with providing mother's own milk are borne by mothers. Conceptualizing mother's own milk feedings as an integral part of NICU care requires consideration of who bears the costs of MOM provision-the mother or the NICU?

Racial/ethnic disparities and human milk use in necrotizing enterocolitis

BACKGROUND

The impact of human milk use on racial/ethnic disparities in necrotizing enterocolitis (NEC) incidence is unknown.

METHODS

Trends in NEC incidence and human milk use at discharge were evaluated by race/ethnicity among 47,112 very low birth weight infants born in California from 2008 to 2017. We interrogated the association between race/ethnicity and NEC using multilevel regression analysis, and evaluated the effect of human milk use at discharge on the relationship between race/ethnicity and NEC using mediation analysis.

RESULTS

Annual NEC incidence declined across all racial/ethnic groups from an aggregate average of 4.8% in 2008 to 2.6% in 2017. Human milk use at discharge increased over the time period across all racial groups, and non-Hispanic (NH) black infants received the least human milk each year. In multivariable analyses, Hispanic ethnicity (odds ratio (OR) 1.27, 95% confidence interval (CI) 1.02-1.57) and Asian or Pacific Islander race (OR 1.35, 95% CI 1.01-1.80) were each associated with higher odds of NEC, while the association of NH black race with NEC was attenuated after adding human milk use at discharge to the model. Mediation analysis revealed that human milk use at discharge accounted for 22% of the total risk of NEC in non-white vs. white infants, and 44% in black vs. white infants.

CONCLUSIONS

Although NEC incidence has declined substantially over the past decade, a sizable racial/ethnic disparity persists. Quality improvement initiatives augmenting human milk use may further reduce the incidence of NEC in vulnerable populations.

Prevalence and predictors of donor milk programs among U.S. advanced neonatal care facilities

OBJECTIVE

(1) Determine national prevalence and predictors of donor milk programs among levels 2-4 advanced neonatal care facilities; (2) describe characteristics of donor milk programs.

STUDY DESIGN

We randomly selected 120 U.S. hospitals with levels 2-4 advanced neonatal care facilities among each of four U.S. regions and surveyed the medical directors from July 2017 to November 2017 regarding donor milk use. We weighted responses according to the number of birthing hospitals in each region.

RESULTS

Response rate was 213/480 (44%). Twenty-eight percent of level 2 and 88% of levels 3 and 4 neonatal care facilities had donor milk programs. Donor milk programs occurred more often in the South vs. Northeast (aOR 3.7 [1.1, 12.5] and less often in safety-net hospitals (≥75% Medicaid patients) vs. nonsafety-net hospitals (aOR 0.3 [0.1, 0.8]).

CONCLUSION

In 2017, the vast majority of levels 3 and 4 neonatal care facilities had donor milk programs but disparities existed according to the safety-net hospital status and region.

Racial and Ethnic Disparities in Human Milk Intake at Neonatal Intensive Care Unit Discharge among Very Low Birth Weight Infants in California

OBJECTIVES

To examine how infant and maternal factors, hospital factors, and neighborhood-level factors impact or modify racial/ethnic disparities in human milk intake at hospital discharge among very low birth weight infants.

STUDY DESIGN

We studied 14 422 infants from 119 California Perinatal Quality Care Collaborative neonatal intensive care units born from 2008 to 2011. Maternal addresses were linked to 2010 census tract data, representing neighborhoods. We tested for associations with receiving no human milk at discharge, using multilevel cross-classified models.

RESULTS

Compared with non-Hispanic whites, the adjusted odds of no human milk at discharge was higher among non-Hispanic blacks (aOR 1.33 [1.16-1.53]) and lower among Hispanics (aOR 0.83 [0.74-0.93]). Compared with infants of more educated white mothers, infants of less educated white, black, and Asian mothers had higher odds of no human milk at discharge, and infants of Hispanic mothers of all educational levels had similar odds as infants of more educated white mothers. Country of birth and neighborhood socioeconomic was also associated with disparities in human milk intake at discharge.

CONCLUSIONS

Non-Hispanic blacks had the highest and Hispanic infants the lowest odds of no human milk at discharge. Maternal education and country of birth were the biggest drivers of disparities in human milk intake, suggesting the need for targeted approaches of breastfeeding support.

A Spatial Analysis of Breastfeeding and Breastfeeding Support in the United States: The Leaders and Laggards Landscape

BACKGROUND

To better track progress in achieving the Healthy People 2020 goals, the Centers for Disease Control and Prevention (CDC) publishes an annual Breastfeeding Report Card (BRC) that represents a compilation of data on breastfeeding practices in all states. With data drawn from the CDC National Immunization Survey, the BRC provides an especially valuable source of information about geographic trends in breastfeeding and related support activities.

RESEARCH AIM

This study aimed to identify important geographic trends in both breastfeeding practices and support structures in the United States, highlighting their spatial disparities.

METHODS

Exploratory spatial data analysis, including local indicators of spatial association, is combined with spatial regression models to highlight geographic variations in breastfeeding practices and support.

RESULTS

Geographic variation in both breastfeeding practices and allied support exists within the United States. Geographic hot spots of breastfeeding are found in the western and northeastern sections of the United States, and cool spots are located primarily in the Southeast. Regression results suggested that unemployment and demographic diversity are negatively associated with breastfeeding rates, whereas higher education and the presence of International Board Certified Lactation Consultants® (IBCLCs®) are positively connected to persistent breastfeeding practices. Further, although the availability of professional support (IBCLC) strengthened nationwide between 2011 and 2016, the availability of mother-to-mother support (La Leche League) softened.

CONCLUSION

Although breastfeeding initiation rates continue to increase in the United States, rates of exclusive breastfeeding at 3 and 6 months remain low, displaying significant geographic variation. The ability to pinpoint lagging regions can help to efficiently allocate additional breastfeeding support resources and interventions.

National Trends in the Provision of Human Milk at Hospital Discharge Among Very Low-Birth-Weight Infants

IMPORTANCE

Human milk confers important health benefits to very low-birth-weight (VLBW) infants (≤1500 g). The extent to which the use of human milk has changed over time and the factors associated with human milk use nationally in this population are poorly understood.

OBJECTIVES

To describe US trends in the provision of human milk at hospital discharge for VLBW infants during the past decade according to census region and maternal race/ethnicity, quantify associations of census region and maternal race/ethnicity with the provision of human milk at hospital discharge, and examine regional and state variations in any provision of human milk at hospital discharge among racial/ethnic groups.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study was conducted of 346 248 infants, born at 23 to 29 weeks' gestation or with a birth weight of 401 to 1500 g, who were cared for at 802 US hospitals in the Vermont Oxford Network from January 1, 2008, to December 31, 2017. The US census region was categorized as West, Midwest, Northeast, and South (reference). Maternal race/ethnicity was categorized as non-Hispanic white (reference), non-Hispanic black, Hispanic, Asian and Pacific Islanders, and Native American.

MAIN OUTCOMES AND MEASURES

Any provision of human milk at hospital discharge, defined as the use of human milk as the only enteral feeding or the use of human milk in combination with fortifier or formula.

RESULTS

Of the 346 248 infants in the study (172 538 boys and 173 710 girls), 46.2% were non-Hispanic white, 30.1% were non-Hispanic black, 18.3% were Hispanic of any race, 4.7% were Asian and Pacific Islanders, and 0.8% were Native American. Any provision of human milk at hospital discharge increased steadily among all infants, from 44% in 2008 to 52% in 2017. There were increases across all US census regions and racial/ethnic groups. Any provision of human milk at hospital discharge was higher in the West (among singleton births: adjusted prevalence ratio, 1.32; 95% CI, 1.25-1.39; among multiple births: adjusted prevalence ratio, 1.28; 95% CI, 1.21-1.35) and Northeast (among singleton births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19; among multiple births: adjusted prevalence ratio, 1.11; 95% CI, 1.04-1.19), compared with the South, and was higher among Asian mothers (among singleton births: adjusted prevalence ratio, 1.21; 95% CI, 1.18-1.25; among multiple births: adjusted prevalence ratio, 1.12; 95% CI, 1.09-1.15) and lower among Hispanic (among singleton births: adjusted prevalence ratio, 0.98; 95% CI, 0.96-1.01; among multiple births: adjusted prevalence ratio, 0.88; 95% CI, 0.86-0.91), Native American (among singleton births: adjusted prevalence ratio, 0.64; 95% CI, 0.59-0.70; among multiple births: adjusted prevalence ratio, 0.59; 95% CI, 0.50-0.69), and non-Hispanic black mothers (among singleton births: adjusted prevalence ratio, 0.67; 95% CI, 0.65-0.70; among multiple births: adjusted prevalence ratio, 0.57; 95% CI, 0.54-0.60), compared with non-Hispanic white mothers. These results were robust to adjustment for birth year and infant characteristics. Wide regional and state variations were found in any provision of human milk at hospital discharge.

CONCLUSIONS AND RELEVANCE

Overall prevalence of any provision of human milk at hospital discharge among VLBW infants has steadily increased during the past decade. Disparities by US region and race/ethnicity in the provision of human milk exist and have not diminished over time.

Current Trends in Research on Human Milk Exchange for Infant Feeding

Breastfeeding is critical for the healthy growth and development of infants. A diverse range of infant-feeding methods are used around the world today. Many methods involve feeding infants with expressed human milk obtained through human milk exchange. Human milk exchange includes human milk banking, human milk sharing, and markets in which human milk may be purchased or sold by individuals or commercial entities. In this review, we examine peer-reviewed scholarly literature pertaining to human milk exchange in the social sciences and basic human milk sciences. We also examine current position and policy statements for human milk sharing. Our review highlights areas in need of future research. This review is a valuable resource for healthcare professionals and others who provide evidence-based care to families about infant feeding.

Racial/Ethnic Disparities in Neonatal Intensive Care: A Systematic Review

CONTEXT

Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear.

OBJECTIVE

To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting.

DATA SOURCES

Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care."

STUDY SELECTION

English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected.

DATA EXTRACTION

Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities.

RESULTS

Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included.

LIMITATIONS

Quantitative meta-analysis was not possible because of study heterogeneity.

CONCLUSIONS

Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.

Mediators of racial and ethnic disparity in mother's own milk feeding in very low birth weight infants

BACKGROUND

Despite high initiation rates for mother's own milk (MOM) provision, MOM feeding at discharge from the neonatal intensive care unit (NICU) drops precipitously and reveals a racial/ethnic disparity. This study sought to identify factors that (1) predict MOM feeding at NICU discharge, and (2) mediate racial/ethnic disparity in MOM feeding at discharge.

METHODS

Secondary analysis of prospective cohort study of 415 mothers and their very low birth weight infants. Variables were grouped into five categories (demographics, neighborhood structural, social, maternal health, and MOM pumping). Significant predictors from each category were entered into a multivariable logistic regression model.

RESULTS

Although 97.6% of infants received MOM feedings, black infants were significantly less likely to receive MOM feeding at discharge. Positive predictors were daily pumping frequency, reaching pumped MOM volume ≥500 mL/day by 14 days, and maternal age. Negative predictors were low socioeconomic status (SES) and perceived breastfeeding support from the infant's maternal grandmother. Low SES, maternal age, and daily pumping frequency mediated the racial/ethnic differences.

CONCLUSIONS

Multiple potentially modifiable factors predict MOM feeding at NICU discharge. Importantly, low SES, pumping frequency, and maternal age were identified as the mediators of racial and ethnic disparity. Strategies to mitigate the effects of modifiable factors should be developed and evaluated in future research.

Racial and Ethnic Disparities in the Use of Mother's Milk Feeding for Very Low Birth Weight Infants in Massachusetts

OBJECTIVE

To examine the extent to which maternal race/ethnicity is associated with mother's milk use among hospitalized very low birth weight (VLBW) infants and maternal receipt of hospital breastfeeding support practices (human milk prenatal education, first milk expression <6 hours after delivery, lactation consultation <24 hours, any skin-to-skin care <1 month).

STUDY DESIGN

We studied 1318 mother-VLBW infant pairs in 9 Massachusetts level 3 neonatal intensive care units (NICUs) between January 2015 and November 2017. We estimated associations of maternal race/ethnicity with any and exclusive mother's milk on day 7, on day 28, and at discharge/transfer and hospital practices. We estimated HRs comparing the probability of continued milk use over the hospitalization by race/ethnicity and tested mediation by hospital practices, adjusting for birth weight and gestational age and including hospital and plurality as random effects.

RESULTS

Mothers were 48% non-Hispanic white, 21% non-Hispanic black, and 20% Hispanic. Initiation of mother's milk was similar across groups, but infants of Hispanic mothers (hazard ratio [HR], 2.71; 95% CI, 2.05-3.59) and non-Hispanic black mothers (HR, 1.55; 95% CI, 1.17-2.07) stopped receiving milk earlier in the hospitalization compared with infants of non-Hispanic white mothers. Hispanic mothers had lower odds of providing skin-to-skin care at <1 month (OR, 0.61; 95% CI, 0.43-0.87) compared with non-Hispanic whites.

CONCLUSIONS

Hispanic and non-Hispanic black mothers were less likely than non-Hispanic white mothers to continue providing milk for their VLBW infants throughout the NICU stay.

Predictors of Prolonged Breast Milk Provision to Very Low Birth Weight Infants

OBJECTIVE

To identify factors associated with prolonged maternal breast milk (BM) provision in very low birth weight (VLBW) infants.

STUDY DESIGN

This was a cohort study of VLBW infants who initially received maternal BM and were born at one of 197 neonatal intensive care units managed by the Pediatrix Medical Group from 2010 to 2012. We used multivariable logistic regression to identify demographic, clinical, and maternal factors associated with provision of maternal BM on day of life (DOL) 30 and at discharge.

RESULTS

Median gestational age for all infants was 28 weeks (25th, 75th percentiles: 26, 30), and median maternal age was 28 years (23, 33). Of 8806 infants, 6261 (71%) received maternal BM on DOL 30, and 4003 of 8097 (49%) received maternal BM at discharge to home. Predictors of maternal BM provision at DOL 30 included increased maternal age, white maternal race, absence of history of necrotizing enterocolitis or late-onset sepsis, higher household income, lower education level, lack of donor BM exposure, and lower gestational age.

CONCLUSIONS

Our results suggest that maternal-infant demographic and clinical factors and household neighborhood socioeconomic characteristics were associated with provision of maternal BM at 30 postnatal days to VLBW infants. Identification of these factors allows providers to anticipate mothers' needs and develop tailored interventions designed to improve rates of prolonged maternal BM provision and infant outcomes.

Breastfeeding Trends Among Very Low Birth Weight, Low Birth Weight, and Normal Birth Weight Infants

OBJECTIVE

To examine the change in breastfeeding behaviors over time, among low birth weight (LBW), very low birth weight (VLBW), and normal birth weight (NBW) infants using nationally representative US data.

STUDY DESIGN

Univariate statistics and bivariate logistic models were examined using the Early Child Longitudinal Study-Birth Cohort (2001) and National Study of Children's Health (2007 and 2011/2012).

RESULTS

Breastfeeding behaviors improved for infants of all birth weights from 2007 to 2011/2012. In 2011/2012, a higher percentage of VLBW infants were ever breastfed compared with LBW and NBW infants. In 2011/2012, LBW infants had a 28% lower odds (95% CI, 0.57-0.92) of ever breastfeeding and a 52% lower odds (95% CI, 0.38-0.61) of breastfeeding for ≥6 months compared with NBW infants. Among black infants, a larger percentage of VLBW infants were breastfed for ≥6 months (26.2%) compared with LBW infants (14.9%).

CONCLUSIONS

Breastfeeding rates for VLBW and NBW infants have improved over time. Both VLBW and NBW infants are close to meeting the Healthy People 2020 ever breastfeeding goal of 81.9%. LBW infants are farther from this goal than VLBW infants. The results suggest a need for policies that encourage breastfeeding specifically among LBW infants.

Postdischarge Feeding of Very-low-birth-weight Infants: Adherence to Nutrition Guidelines

OBJECTIVES

Infant feeding guidelines are important public health strategies to promote optimal growth, development, and chronic disease prevention, but their effectiveness is contingent upon families' ability to adhere to them. Little is known of adherence to guidelines among nutritionally vulnerable infants, specifically those born very-low-birth-weight (VLBW) (<1500 g). This study investigated whether postdischarge feeding practices for VLBW infants align with current recommendations and explored parental and infant baseline sociodemographics related to these practices.

METHODS

Prospectively collected data from families of 300 VLBW infants participating in a randomized clinical trial (ISRCTN35317141) were used. Baseline demographics were obtained at enrollment and postdischarge feeding practices via monthly telephone questionnaires to 6 months corrected age (CA).

RESULTS

At discharge, 4 and 6 months CA, 72%, 39%, and 29% of infants received any amount of mother's milk, respectively; exclusive breast-feeding rates were 49%, 20%, and 6%, respectively. Among infants receiving mother's milk, rates of vitamin D supplementation were ≥83%. Recommendations for introducing solids between 4 and 6 months CA were followed by 71% of the cohort and for iron supplementation by 58%. Overall, 12% of infants adhered to all aforementioned recommendations. Mothers with university degrees were more likely to provide mother's milk, whereas mothers of Middle Eastern/South Asian ethnicity were less likely to provide mother's milk.

CONCLUSIONS

Low rates of partial and exclusive breast-feeding of VLBW infants to 6 months CA were reported. Overall adherence to iron supplementation was low. Strategies to provide increased support for mothers identified as at-risk should be developed.

Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mother's HM.

Barriers to Human Milk Feeding at Discharge of Very-Low-Birth-Weight Infants: Maternal Goal Setting as a Key Social Factor

BACKGROUND

While black mothers initiate human milk (HM) provision at lower rates than non-black mothers in the United States, some neonatal intensive care units (NICUs) report similar initiation rates regardless of race/ethnicity for mothers of very-low-birth-weight (VLBW) infants. However, racial disparity frequently becomes evident in the proportion of black infants who continue to receive HM feedings at NICU discharge. Since social factors have been associated with differences in HM provision for term infants, we sought to identify differences in social factors associated with HM feeding at discharge based on race/ethnicity.

MATERIALS AND METHODS

A prospective cohort study of racially diverse mothers of VLBW infants measured social factors including maternal education, breastfeeding support, return to work/school, HM feeding goal, previous breastfeeding, or formula experience. Multivariate logistic regression modeling was applied to social factors to predict HM feeding at discharge. Additional regression models were created for racial/ethnic subgroups to identify differences.

RESULTS

For all 362 mothers, WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) eligibility and maternal goal near time of discharge of providing any HM negatively and positively predicted HM feeding at discharge, respectively. Perceived breastfeeding support from the infant's maternal grandmother negatively predicted HM feeding at discharge for black mothers.

CONCLUSIONS

Future interventions to increase duration of HM provision in VLBW infants should focus on the establishment and maintenance of maternal HM feeding goals. Further studies of the familial support system of black mothers are warranted to determine multigenerational impact and potential interventions.