ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017

Guidelines for Primary Pediatric Care Professionals to Help Patients Establish and Protect Milk Supply

ABSTRACT

The first well-child encounter for healthy, full-term newborns occurs within the critical window for the establishment of the milk supply. Frequent, effective removal of human milk from the breast is essential to achieving a robust milk supply. Nurses in primary care settings are crucial in providing quality and timely lactation care to ensure the parent is experiencing effective milk removal. Identification of risk factors and barriers to achieving a milk supply requires adept assessment and knowledge of lactation physiology. Not all nurses receive formal education on human milk and lactation. This resource can be used by primary care nurses to prioritize establishing and protecting the milk supply among families with a desire to breastfeed.

Clinical evaluation of Ayush-SS granules in exclusively breastfeeding mothers with insufficient lactation: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Breast milk is essential for infant growth and development, with exclusive breastfeeding (EBF) recommended for the first six months. Many mothers experience insufficient milk production, leading to early supplementation or cessation of breastfeeding. Ayurvedic formulations, such as Ayush-SS granules, have been proposed to enhance lactation. This study evaluated Ayush-SS granules as a galactagogue, with EBF at six months as the primary outcome. Secondary outcomes included infant weight gain over 90 days and maternal perceptions of lactation sufficiency.

METHODS

A double-blind, randomized, placebo-controlled trial was conducted between 1 February 2021 and 31 January 2023 at Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India. A total of 210 lactating mothers (aged 20-40 years) with full-term singleton infants (≥ 37 weeks, ≥ 2.5 kg) experiencing insufficient lactation were enrolled. Infants who had not regained birth weight by day 14 or gained < 20 g/day after day 15 were included. Participants were randomized (1:1) to receive 6 g of Ayush-SS granules or placebo twice daily for 12 weeks. All participants received standardized breastfeeding counseling. Safety monitoring was conducted, and an intention-to-treat analysis was performed.

RESULTS

At six months, 74 of 106 (69.8%) infants in the Ayush-SS group were exclusively breastfed, compared to 47 of 105 (44.8%) in the placebo group (p < 0.001). After 90 days, 81 of 106 infants (76.5%) in the Ayush-SS group gained ≥ 20 g/day compared to 44 of 105 (41.8%) in the placebo group (p < 0.001). Maternal perceptions of insufficient lactation were significantly lower in the Ayush-SS group (15.3% vs. 58.2%). No severe adverse events related to the intervention were observed.

CONCLUSION

Ayush-SS granules significantly improved EBF rates at six months, maternal perceptions of lactation sufficiency, and infant weight gain. These findings suggest their potential as a galactagogue for mothers with insufficient milk production. Further research is needed to explore long-term effects and maternal dietary influences.

CLINICAL TRIAL REGISTRATION

CTRI/2019/08/020579 [Registered on: 06/08/2019].

Evaluating Nutritional Selection and Outcomes in Neonatal Abstinence Syndrome: A Retrospective Review

The rising incidence of neonatal abstinence syndrome (NAS) has amplified the importance of nonpharmacological interventions in its management, which include the selection of feedings. With the goal of obtaining an accurate assessment of the effects of current feeding practices in NAS infants in our neonatal intensive care unit, we conducted a retrospective review of NAS infants at our hospital over a 3-year period to determine their nutritional selections and evaluate their length of stay (LOS), length of treatment (LOT), and growth outcomes.Retrospective chart review of term infants (≥37 weeks of gestation) with NAS. Maternal and infant demographics and characteristics were recorded. Infants were grouped based on majority (>50% of total feeding) nutritional selections and LOS, LOT, and growth parameters were evaluated. Linear regression was used to compare group outcomes. Significance was set at a p-value <0.05.A total of 70 infants were included and grouped based on majority feeds into maternal breast milk (MBM), standard term formula (STF), low lactose formula (LLF), and extensively hydrolyzed formula (EHF) groups. Feeding selections were provider-dependent and infants were placed on MBM or STF as an initial selection. In all infants included in our review, LLF was selected as the first choice following MBM or STF for increased gastrointestinal (GI) disturbance-related Finnegan Neonatal Abstinence Scoring scores and changed to EHF if LLF failed to improve the GI-related symptoms. The STF-fed infants had the shortest LOS, and none of these infants required pharmacological treatment. The LOT and LOS were similar in the MBM- and LLF-fed groups. Infants who were EHF fed had the longest LOT and LOS. All feeding groups demonstrated appropriate growth.Nutritional selections in our NAS infants were modified for the severity of their withdrawal symptoms. All nutritional modifications driven by severity of withdrawal symptoms supported favorable growth outcomes in the infants. · Our NAS infants were fed with multiple types of nutrition.. · Infants with severe NAS required more elemental feeds.. · All formula selections supported favorable growth..

Development of a Breastfeeding and Lactation Medicine Division Over a Seven-Year Period: An Homage to Dr Ruth A. Lawrence

Background: Breastfeeding and Lactation Medicine (BFLM) programs at academic medical centers are uncommon but expanding. Our academic medical center, with a long legacy of leadership in BFLM, established a BFLM program in 2016 and launched a dedicated division in 2022. Objectives: To describe the strategy, services, measures, and challenges facing our multidisciplinary academic BFLM program in its first 8 years. Methods: To support the development of the Division, we proved clinical need, built capacity, and determined key outcomes. We organized partnerships across clinical and research programs and developed leadership and reporting structures. These services and programs coalesced to form the first Division of Breastfeeding and Lactation Medicine in 2022, including multiple specialties (pediatrics, obstetrics, family medicine, nutrition research, toxicology, public health, dentistry) and provider types (nursing, lactation consultants, physicians, midwife, nurse practitioner, PhD, dentist). Challenges included variable buy-in, staff training, reimbursement, medical record infrastructure, and data reports. Challenges to research included funding and clinical integration. Conclusion: A multidisciplinary BFLM Division at a large academic medical center was formed, spanning our clinical, research, and educational missions. Integration into traditional academic structures brings essential resources, enables participation in medical center leadership, and promotes the sustainability of divisional activities.

Development and Validation of a Decision Support Tool for Baby Formula Prescription

INTRODUCTION

Although there are acceptable medical reasons for the use of food supplements, most prescriptions for newborns do not comply with current recommendations, putting continued breastfeeding at risk. This study aimed to create and validate a flowchart for newborn supplement prescription.

METHODS

The flowchart was created and submitted to two rounds of assessments by a panel of judges, who calculated the content validity index (CVI) (acceptable > 0.80). Flowchart use in clinical practice (applicability) was validated by professional prescribers through the resolution of 3 clinical cases. Data were analyzed using Pearson`s chi-squared test (p < 0.05).

RESULTS

The flowchart was assessed by 17 judges and validated regarding its content (CVI = 0.84). Took part in validating the applicability of this study 169 doctors and nutritionists who work in maternal and child health. There was a statistical association between correct case resolution and flowchart utilization in two of the three clinical cases (p < 0.05). In situation 1, the use of a validated flowchart increased the likelihood of correct answers 7.76 times.

DISCUSSION

Prescribing baby formula is complex and requires careful assessment of several factors. Thus, knowledge translation is an effective intervention to eliminate the gaps between knowledge and clinical practice. The validated flowchart allows more assertive conduct regarding breastfeeding management and food supplement prescription for newborns.

The impact of implementation of oral dextrose gel on the incidence of multiple hypoglycemia events in the well newborn nursery

OBJECTIVE

Evaluate the impact of 40% oral dextrose gel (DG) for management of neonatal hypoglycemia (NH) on the incidence of multiple hypoglycemic events in the well-baby nursery.

STUDY DESIGN

A retrospective chart review of 738 at-risk infants in 2 cohorts before (Cohort 1) and after (Cohort 2) DG implementation. Primary outcome was the incidence of ≥2 hypoglycemic episodes. Secondary outcomes were number of lowest median glucose level, and incidence of NICU admission.

RESULTS

There were 384 and 354 at-risk newborns in Cohorts 1 & 2. The incidence of developing ≥2 hypoglycemia episodes significantly decreased following DG implementation [62(42.5%) vs 29(25.9%), p = 0.0058]. There were no differences in lowest glucose level [37 (14-45) vs 37 (10-45), p = 0.31], and NICU admission rate [31 (21.2%) vs 21 (18.8%), p = 0.62].

CONCLUSIONS

Implementation of DG lowers the incidence of subsequent hypoglycemia episodes.

Close Relations, Practitioners or Social Networks: What Affects the Selection of Infant Formula Products?

This study examines which factors influence the preferences of mothers seeking advice on the use of infant formula in feeding practices. The effects of their close social circle, medical professionals and social network forums on feeding choices were evaluated. Data were collected from 638 questionnaires from mothers and were statistically analyzed. Our findings suggest that age may influence the preference to seek advice from a close social circle over consulting with medical professionals (p-value = 0.019 < 0.05). The educational level and the number of children impact the preferences of using infant formula over combining it with breastfeeding (p-value = 0.000 < 0.05 and p-value = 0.004 < 0.05, respectively). The research contributes to the understanding of the complex interplay between various demographic and socioeconomic factors and the decision-making process of mothers based on multiple social and digital sources of influence. The research presents valuable insights for healthcare policymakers and professionals in supporting mothers and providing them with up-to-date information. Feeding information can be distributed through all the communication channels that were examined in this study to benefit different socio-economic groups and to contribute to the well-being of infants in the long-run.

Management and Clinical Outcomes of Neonatal Hypothermia in the Newborn Nursery

OBJECTIVES

Neonatal hypothermia has been shown to be commonly detected among late preterm and term infants. In preterm and very low birth weight infants, hypothermia is associated with increased morbidity and mortality. Little is known about the clinical interventions and outcomes in hypothermic late preterm and term infants. This study fills this gap in the evidence.

METHODS

Single-center retrospective cohort study using electronic health record data on infants ≥35 weeks' gestation admitted to a newborn nursery from 2015 to 2021. Hypothermia was categorized by severity: none, mild (single episode, 36.0-36.4°C), and moderate or recurrent (<36.0°C and/or 2+ episodes lasting at least 2 hours). Bivariable and multivariable logistic regression examined associations between hypothermia and interventions or outcomes. Stratified analyses by effect modifiers were conducted when appropriate.

RESULTS

Among 24 009 infants, 1111 had moderate or recurrent hypothermia. These hypothermic infants had higher odds of NICU transfer (adjusted odds ratio [aOR] 2.10, 95% confidence interval [CI] 1.68-2.60), sepsis evaluation (aOR 2.23, 95% CI 1.73-2.84), and antibiotic use (aOR 1.73, 95% CI 1.15-2.50) than infants without hypothermia. No infants with hypothermia had culture-positive sepsis, and receipt of antibiotics ≥72 hours (surrogate for culture-negative sepsis and/or higher severity of illness) was not more common in hypothermic infants. Hypothermic infants also had higher odds of blood glucose measurement and hypoglycemia, slightly higher percent weight loss, and longer lengths of stay.

CONCLUSIONS

Late preterm and term infants with hypothermia in the nursery have potentially unnecessary increased resource utilization. Evidence-based and value-driven approaches to hypothermia in this population are needed.

Branching Path Simulation for Pediatric Nurse Practitioner Students to Promote Critical Thinking: A Quasi-Experimental Study

INTRODUCTION

Branching path simulation (BPS) is an active learning pedagogy incorporating gaming principles in a low-stakes, safe environment. No study has explored the use of BPS in advanced practice nursing education. This study measured pediatric nurse practitioner students' perception of the integration of BPS in one graduate-level course.

METHOD

This study used a one group, post-test only quasi-experimental design with a convenience sample of 22 pediatric nurse practitioner students over 2 years enrolled in a university in the Pacific Northwest United States.

RESULTS

Responses to BPS were positive: design (M = 4.8; SD ± 0.4), usability (M = 4.3; SD ± 1.0), self-confidence (M = 4.2; SD ± 0.8) and satisfaction (M = 4.8; SD ± 0.4).

DISCUSSION

BPS was well received by learners. It not only provides immediate feedback and encourages students to identify their clinical management weaknesses and strengths but it also can be customized to needs in a course at a significant cost saving.

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

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

Physiology of Human Lactation and Strategies to Support Milk Supply for Breastfeeding

Despite advances across the globe in breastfeeding initiation rates, many families continue to report they are not meeting their breastfeeding goals. Concerns about milk supply, infant nutritional intake, and infant weight gain are among the most commonly cited reasons for early breastfeeding cessation. Nurses working with individuals during the perinatal period are uniquely positioned to educate families and offer evidence-based interventions to promote optimal milk supply, infant growth, and maternal mental and physical health. Such interventions include early and frequent skin-to-skin care, emptying of the breast, and professional lactation support. By implementing such evidence-based practices in the first hours after birth and connecting families to lactation support in the first 14 days, nurses can begin to help families achieve their breastfeeding goals.

Early and Higher Volumes of Formula Supplementation after Birth Impact Breastfeeding Rates at Discharge in Well-Baby Nursery: A Retrospective Cohort Study

OBJECTIVE

 Physiologic breast milk production in the first 24 hours is estimated to be between 2 and 10 mL per feed. Many mothers intending to breastfeed use formula supplementation (FS) early on, which can affect successful breastfeeding. Whether the volume and timing of FS introduced in the first 24 hours of life (24 HOL) impacts the rate of "breastfeeding at discharge" (BFAD) is not well-studied and was investigated herein.

STUDY DESIGN

 Single-center, retrospective, chart review of breastfeeding infants born at ≥35 weeks who received supplementation in the first 24 HOL. Comprehensive demographic data pertaining to maternal and infant characteristics, along with infant feeding data, were collected. Four supplementation characteristics, (timing, rate, volume [mL/kg per feed], and type [expressed breast milk (EBM) or formula]) were correlated with BFAD.

RESULTS

 Among 3,102 supplemented infants in whom mothers intended to breastfeed, 1,031 (33.2%) infants were BFAD. At baseline, African American, Medicaid-insured, and single mothers had lower odds of BFAD. The overall maximum volume of FS per feed was 11.0 mL/kg (interquartile range 8.0-14.4). With each hour of delay in first supplementation, the odds of BFAD increased by 2.8% (95% confidence interval [CI] 0.022, 0.035). With every 1 mL/kg increase in the first formula volume, subsequent supplementation frequency increased by 4.5%. A positive association was observed between BFAD and a lower rate of supplementation (cutoff value ≤35.1%). However, among infants with these lower rates of supplementation, each unit increase in maximum FS, from 2 to 15 mL/kg, decreased the probability of BFAD by 4.2% (3.6-4.7%). Additionally, we observed that infants who were given at least one EBM supplementation (n = 223; 7.2%) had substantially increased rates of BFAD (odds ratio [OR] = 9.8, 95% CI 7.2-13.3).

CONCLUSION

 Early and higher volumes of FS negatively impacted BFAD. Birthweight-based FS of feeding with physiological volumes may increase breastfeeding rates at discharge.

KEY POINTS

· Higher volumes of first supplementation increases subsequent supplementation frequency.. · For each unit increase in maximum supplementation, BFAD probability decreases by 4.2%.. · Even one EBM supplementation increases rates of BFAD..

Physician personal breastfeeding experience and clinical care of the breastfeeding dyad

BACKGROUND

Prior research suggests that physicians' personal experience with breastfeeding may influence their attitudes toward breastfeeding. This phenomenon has not been explored in well-newborn care physician leaders, whose administrative responsibilities often include drafting and approval of hospital breastfeeding and formula supplementation policies.

METHODS

We conducted a mixed-methods study, surveying physicians in the Better Outcomes through Research for Newborns (BORN) network. We examined physician attitudes toward recommending breastfeeding and their breastfeeding experience. Qualitative analysis was conducted on responses to the question: "How do you think your breastfeeding experience influences your clinical practice?"

RESULTS

Of 71 participants, most (92%) had a very positive attitude toward breastfeeding with 75% of respondents reporting personal experience with breastfeeding. Of these, 68% had a very positive experience, 25% had a somewhat positive experience, and 6% had a neutral experience. Four themes emerged with respect to the effect of breastfeeding experience on practice: (1) empathy with breastfeeding struggles, (2) increased knowledge and skills, (3) passion for breastfeeding benefits, and (4) application of personal experience in lieu of evidence-based medicine, particularly among those who struggled with breastfeeding.

CONCLUSIONS

Well-newborn care physician leaders reported positive attitudes about breastfeeding, increased support toward breastfeeding persons, and a perception of improved clinical lactation skills. Those who struggled with breastfeeding reported increased comfort with recommending formula supplementation to their own patients. Medical education about evidence-based breastfeeding support practices and provision of lactation support to physicians has the potential to affect public health through improved care for the patients they serve.

90 versus 60 min of early skin-to-skin contact on exclusive breastfeeding rate in healthy infants' ≥35 weeks: A randomised controlled trial

AIM

To compare the effect of 90 versus 60 min of early skin-to-skin contact (SSC) among vaginally born healthy infants ≥35 weeks of gestation on their exclusive breastfeeding rates and breastfeeding behaviour.

METHODS

This parallel-group, open-label, randomised controlled trial enrolled healthy term and late preterm infants born vaginally. Infants in the intervention group received early SSC for 90 min compared to 60 min in the control group. The primary outcome was the proportion of infants on exclusive breastfeeding at 60 ± 12 h.

RESULTS

One hundred ninety-eight mother-infant dyads were randomised (99 in each group). The infants in the 90-min SSC group were more likely to be exclusively breastfed at 60 ± 12 h as compared to the 60-min SSC group (RR, 95% CI-1.44, [1.15-1.79], p < 0.01). The modified infant breastfeeding assessment tool score at 60 ± 12 h was significantly higher in the 90-min SSC group (median [IQR]-9, [8, 10] versus 8 [7, 10], p = 0.03]. The proportion of infants on exclusive breastfeeding at 6, 10, and 14 weeks of age was also significantly higher in the 90-min SSC group (RR, 95% CI-1.39 [1.11-1.74], 1.36 [1.08-1.07], and 1.38 [1.08-1.75], respectively).

CONCLUSION

Increasing the duration of early SSC showed a dose-response benefit on exclusive breastfeeding rates and breastfeeding behaviour.

TRIAL REGISTRATION

CTRI/2018/09/015632, registered on 06/09/2018.

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.

A dose-response relationship found between the Ten Steps to Successful Breastfeeding indicators and in-hospital exclusive breastfeeding in US hospitals

BACKGROUND

In-hospital exclusive breastfeeding (EBF) is associated with longer breastfeeding durations, yet only 64% of US newborns are EBF for 7 days. The Ten Steps to Successful Breastfeeding (Ten Steps) are a set of evidenced-based maternity practices shown to improve breastfeeding outcomes; these were updated in 2018.

METHODS

Using hospital-level data from the 2018 Maternity Practices in Infant Nutrition and Care Survey (n = 2045 hospitals), we examined the prevalence of implementation of Ten Steps indicators (each step and total number of steps implemented). Using linear regression, we also examined the association between the steps and EBF prevalence adjusted for hospital characteristics and all other steps. Discharge support was not included in the models since it primarily occurs after hospital discharge.

RESULTS

The most frequently implemented step was the provision of prenatal breastfeeding education (95.6%). Steps with low implementation included rooming-in (18.9%), facility policies supportive of breastfeeding (23.4%), and limited formula supplementation (28.2%). After adjusting for hospital characteristics and all other steps, limited formula supplementation (difference = 14.4: 95% confidence interval [CI]: 12.6, 16.1), prenatal breastfeeding education (difference = 7.0; 95% CI: 3.3, 10.8), responsive feeding (difference = 6.3; 95% CI: 3.7, 9.0), care right after birth (skin-to-skin; difference = 5.8; 95% CI: 4.2, 7.4), and rooming-in (difference = 2.4; 95% CI: 0.4, 4.6) were associated with higher in-hospital EBF prevalence. We found a dose-response relationship between the number of steps implemented and in-hospital EBF prevalence.

CONCLUSION

Increased implementation of the updated Ten Steps may improve EBF and infant and maternal health outcomes.

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.

Impact of feeding volumes in the first 24 h of life on neonatal feeding intolerance

Objective

This study investigates whether volumes of intake in the first 24 h of life (24 HOL), in relation to birth weight (BW) and gestational age (GA), impact neonatal feeding intolerance (FI).

Methods

This study employed a retrospective chart review of 6,650 infants born at ≥35 weeks. The volumes of each formula feed per kg BW in the first 24 HOL were assessed. FI was defined as evidenced by chart documentation of emesis, abdominal distension, abdominal x-ray, and/or switching to a sensitive formula.

Results

Overall, the maximum volume of formula intake per feed was inversely correlated with GA and was higher in infants with FI (β = -1.39, p < 0.001) compared with infants without FI (β = -1.28, p < 0.001). The odds of emesis in late preterm infants with first feeding of >8 ml/kg [adjusted odds ratio (AOR) = 2.5, 95% confidence interval (CI): 1.4-4.6] and formula switching in the exclusively formula-fed group with volumes >10.5 ml/kg [AOR =  2.2, 95% CI (1.8-2.6)] were high. In the breastfeeding group, the odds of FI increased by 2.8-, 4.6-, and 5.2-fold with 5-10, 10-15, and >15 ml/kg of supplementations, respectively.

Conclusion

A higher volume of intake in relation to BW often exceeds the physiological stomach capacity of newborns and is associated with early FI. Optimizing early feeding volumes based on infant BW and GA may decrease FI, which may be an issue of volume intolerance.

Supporting Families Facing Lactation Anaphylaxis: A Case Report

Lactation anaphylaxis is a rare condition that may occur consequent to breastfeeding. Early identification and management of symptoms is paramount to the physical well-being of the birthing person. Supporting newborn feeding goals is also a key component of care. In cases in which the birthing person wants to exclusively feed human milk, planning should include streamlined access to donor milk. Clear communication between health care providers and developing systems to access donor milk for parental indications may help address barriers.

The effect of perceived insufficient milk on transition to supplementary food and factors affecting it during the first six months postpartum in Turkey: A cross-sectional study

The researchers' aims were to determine the effect of perceived insufficient milk supply on the transition to supplementary food and the factors affecting it. This is a cross-sectional design study, we were conducted between April and August 2019 and included 335 mothers and their babies in a baby-friendly hospital in Turkey. It was shown that mothers with perceived insufficient milk switched to supplementary food 6.538 times more frequently (p < 0.05). It was shown that some maternal, lactational, and infant (baby's age) factors affected the perception of insufficient milk (p < 0.05). The perception of insufficient milk is an important factor contributing to the transition to supplementary food.

In-hospital supplementation and subsequent breastfeeding practices in Finland: A cross-sectional population-level study

BACKGROUND

The Baby-Friendly Hospital Initiative suggests that in-hospital supplementation should be avoided unless medically indicated. The supporting evidence is contradictory, as nonexperimental studies have shown an association between supplementation and decreased breastfeeding rates, whereas trials have failed to do so. The aim of this study was to investigate whether in-hospital supplementation is associated with exclusive breastfeeding to the age of 5 months and any breastfeeding to the age of 12 months in full-term, normal-weight singleton infants.

METHODS

This is a secondary analysis of national-level, cross-sectional survey data. The data were collected in child health clinics in Finland. Families attending a regular health examination with a child aged 2 weeks to 12 months were eligible to participate. Full-term, normal-weight, singleton infants (n = 3025) were included in this study. Multivariate logistic regression was performed using in-hospital supplementation and socioeconomic characteristics as covariates and exclusive and any breastfeeding as outcomes.

RESULTS

In total, 55.3% (n = 1631) of the infants received in-hospital supplementation. After controlling for socioeconomic factors, in-hospital supplementation was associated with decreased exclusive breastfeeding to the age of 5 months and with a decrease in any breastfeeding to the age of 7 months.

CONCLUSIONS

Our findings suggest that noncontrolled supplementation, without a trial's rigorous procedures of care, is associated with decreased breastfeeding postdischarge. Both donor milk and infant formula use were associated with lower breastfeeding rates, although the association was stronger with formula use. In clinical settings, liberal, nonmedically indicated supplementation should be avoided.

Development and Interrater Reliability of the Lactation Assessment Care Tool

BACKGROUND

There have been no comprehensive predictive measurement instruments published that account for the dynamic interaction between maternal, infant, and functional factors related to breastfeeding difficulty. The Lactation Care Assessment Tool (LACT) was developed by the authors as a predictive measure of lactation acuity to identify families at risk for breastfeeding difficulty and facilitate access to the most effective level of care.

RESEARCH AIM

To describe the development, content validation, and interrater reliability of the LACT.

METHODS

This study was a cross-sectional, online survey. Upon reading a standardized case scenario reflective of common experiences among families with goals to breastfeed, participants (N = 82) anonymously completed the LACT, which consisted of 16 measures based upon research relevant to maternal, infant, and functional factors affecting breastfeeding success. Descriptive statistics were used to summarize and describe the characteristics of the study sample. Interrater reliability was evaluated using Krippendorff's alpha.

RESULTS

An acceptable degree of interrater reliability (α = 0.70) among participants was detected for the 16 measures included in the instrument.

CONCLUSION

This instrument supports Baby-Friendly Hospital Initiative Step 10 to facilitate more precise and timely continuity of care after discharge from the hospital by identifying families in need of referral to a level of care consistent with their lactation acuity. Future research is necessary to determine appropriate levels of care and support based on the instrument scores in diverse breastfeeding dyads during early lactation and through the duration of breastfeeding.

Initiating and Supporting Breastfeeding: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Exclusive breastfeeding is recommended for children for the first 4 to 6 months of life, with complementary foods added thereafter. It is the most ecological way of protecting the child's and mother's health. Training of health professionals is required to avoid transmitting inconsistent information in 3 areas: 1) implementing these 3 predictors: safe skin-to-skin, first breastfeed, and rooming-in 24/7; 2) teaching and monitoring: i) early signs of waking and feeding rhythms, ii) positioning and latching, and iii) signs of effective transfer; and 3) referring women to specialized support services if difficulties arise (eg, inadequate milk production, pain, cracked nipples, engorgement). Breastfeeding should continue during mastitis or an abscess. Ultrasound-guided needle aspiration is beneficial in treating an abscess. Précis: Information is provided to enable health professionals to better support breastfeeding and help women with the most common difficulties, thus promoting breastfeeding initiation and duration.

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.

Fatal Hypernatremic Dehydration in a Term Exclusively Breastfed Newborn

Hypernatremic dehydration in term newborns has steadily increased in incidence with increasing efforts to promote exclusive breastfeeding before hospital discharge, a key metric of the Baby-Friendly Hospital Initiative. The following report details a case of a term newborn infant who had evidence of poor intake while exclusively breastfeeding during his hospital stay that may not have been recognized by health care providers. The infant was discharged home and was subsequently found by the parents in cardiac arrest 12 h after discharge and was found to have hypernatremic dehydration. Although return of spontaneous circulation was achieved after fluid resuscitation, the infant sustained extensive hypoxic-ischemic brain injury due to cardiovascular collapse. Due to the infant’s extremely poor prognosis, life support was withdrawn at 19 days of age and the infant expired. This sentinel case demonstrates multiple pitfalls of current perceptions of normal vs. abnormal newborn feeding behavior, weight loss percentages, elimination patterns, and acceptable clinical thresholds believed to be safe for neonates. Newer data have shown that hypernatremia occurs commonly in healthy, term breastfed newborns at weight loss percentages previously deemed normal by most health professionals and hospital protocols. In-hospital strategies to prevent excessive weight loss and screening for hypernatremia in response to signs of inadequate feeding have the potential to prevent tens of thousands of readmissions for feeding complications a year, as well as hundreds of millions in health care costs.

Breastfeeding challenges and support in a high initiation population

BACKGROUND

The breastfeeding initiation rate in Israel is approximately 90%, yet exclusive breastfeeding drops sharply in the early postnatal period. The study objective was to assess early postpartum professional breastfeeding support, its association with breastfeeding success and identification of risk factors for early breastfeeding discontinuation.

METHODS

As part of a post-discharge newborn follow-up study, a convenience sample of 868 mothers attending Maternal and Child Health Centers (MCHCs) up to three months post-partum were interviewed using a 26-item questionnaire. Breastfeeding-related questions covered demographic variables, pregnancy and birth details; breastfeeding duration, lactation support in hospital and post-discharge; and problems experienced.

RESULTS

Most mothers, 797 (91.8%), initiated breastfeeding in hospital. All women who initiated breastfeeding in the hospital reported exclusive breastfeeding; by two weeks postpartum, 70 women (13.2%) were supplementing with formula (partial breastfeeding). Kaplan-Meier Survival Analysis revealed an estimated mean duration of exclusive breastfeeding in the sample population of 66.8 ± 1.5 days. This duration was shorter for women with preterm births, low birthweight infants (LBW), cesarean births, and hospitalizations in neonatal intensive care units (NICU). A total of 472 (59.3%) breastfeeding mothers reported receiving in-hospital guidance. Of these, 290 (61.3%) were observed breastfeeding. Of all women who initiated breastfeeding, 280 (35.1%) attended MCHC follow-up within 72 h of hospital discharge. A higher proportion of women experiencing breastfeeding difficulties attended an MCHC within 72 h (131/297, 44.1%) compared to women not experiencing difficulties (148/499, 29.7%). The most frequently reported problems were mechanical (55.2%) or milk supply concerns (18.5%). First-time mothers were more likely to report problems, as were Jewish (vs Arab) mothers.

CONCLUSIONS

Even in a population with high initiation rates of breastfeeding, breastfeeding duration, both exclusive and partial, is less than recommended. As much of this drop-off occurs during maternity leave, it is likely related to breastfeeding challenges other than employment. Breastfeeding support needs of women are currently not adequately met; staffing and time for both in-hospital and community-based counseling needs to be funded as well as mandated. Counseling hours should be tailored to assure adequate coverage of high-risk groups such as women after cesarean delivery and newborns requiring intensive care.

Maintaining Breastfeeding During the Treatment of Breast Abscesses Is Not Contraindicated

Background: World Health Organization guidelines recommend maintaining breastfeeding if a woman develops breast abscess, because of benefits to her recovery and the infant's health. However, clinical staff recommend weaning to promote faster recovery from the abscess. The purpose of this study was to determine whether maintaining breastfeeding after development of a breast abscess has any influence on the resolution of the breast abscess. Methods: The records of 212 patients who were breastfeeding and developed breast abscess treated at Guangzhou Women and Children's Medical Center from January 2018 to December 2019 were retrospectively reviewed. Patients were divided into two groups: those who maintained breastfeeding (study group) and those who stopped breastfeeding (control group). Results: There were 139 patients in study group and 73 patients in the control group. Baseline characteristics were similar between the two groups. The time to cure in the study group and in the control group was 7.20 ± 2.21 days and 7.01 ± 2.39 days, respectively (t = 0.579, p = 0.563). Common complications were milk fistula and galactocele, and the frequency of both was similar between the two groups (milk fistula: 7.9% versus 8.2%, respectively; χ² = 0.006, p = 0.938; galactocele: 8.6% versus 9.6%, respectively; χ² = 0.054, p = 0.817). There was no significant difference in the recurrence rates between the two groups (5.0% versus 2.7%; χ² = 0.184, p = 0.668). Conclusion: Maintaining breastfeeding during treatment of breast abscess does not affect the outcome of treatment provided, on condition that the abscess is treated appropriately.

The Relationship Between Maternal Fluid Intake During Labor and Neonatal Weight Loss: A Review of the Literature

Introduction

Though in-hospital supplementation of the newborn is associated with decreased breastfeeding success, excessive neonatal weight loss is a medical indication for supplementation. Studies have theorized that maternal fluid intake during labor may impact neonatal weight loss, resulting in unnecessary supplementation. The purpose of this review was to synthesize evidence regarding the relationship between maternal fluid intake during labor and neonatal weight loss.

Methods

Literature searches were conducted in relevant databases using controlled vocabulary. The main findings and outcomes were compared across studies and calculations conducted to report the proportion of studies reporting significant findings.

Results

11 studies were included in the review. Overall, 7 studies (64%) identified a significant relationship between maternal fluid intake during labor and neonatal weight loss.

Conclusions

Given the risk to the newborn associated with excessive weight loss, it is not prudent to incorporate maternal fluid intake into supplementation guidelines based on existing evidence. Further research is needed before practice recommendations can be made.

Structured antenatal milk expression education for nulliparous pregnant people: results of a pilot, randomized controlled trial in the United States

BACKGROUND

Hand-expression, collection, and storage of breast milk during pregnancy (i.e., antenatal milk expression or AME) is a safe, potentially effective practice to reduce early, undesired infant formula supplementation among women with diabetes. The feasibility and potential impact of AME on lactation outcomes in the United States (U.S.) and among non-diabetic birthing people is unknown.

METHODS

The purpose of this study was to examine the feasibility of a structured AME intervention among nulliparous birthing people in the United States. We recruited 45 low-risk, nulliparous individuals at 34-36^6/7 weeks of gestation from a hospital-based midwife practice. Participants were randomized to AME or a control group receiving lactation education handouts. Interventions were delivered at weekly visits at 37-40 weeks of pregnancy. The AME intervention involved technique demonstration and feedback from a lactation consultant and daily independent practice. Lactation outcomes were assessed during the postpartum hospitalization, 1-2 weeks postpartum, and 3-4 months postpartum.

RESULTS

Between December 2016 and February 2018, 63 individuals were approached and screened for eligibility, and 45 enrolled into the study (71%). Of 22 participants assigned to AME, 18 completed at least one AME study visit. Participants reported practicing AME on at least 60% of days prior to their infant's birth. Most were able to express milk antenatally (15/18), more than half collected and froze antenatal milk (11/18), and 39% (7/18) supplemented their infants with antenatal milk after birth. No major problems were reported with AME. Perinatal and lactation outcomes, including infant gestational age at birth, neonatal intensive care unit admissions, delayed onset of lactogenesis II, and use of infant formula were similar between AME and control groups. Among participants in both groups who were feeding any breast milk at each assessment, breastfeeding self-efficacy increased and perceptions of insufficient milk decreased over the postpartum course.

CONCLUSIONS

In a small group of nulliparous birthing people in the U.S., AME education and independent practice beginning at 37 weeks of pregnancy was feasible. In some cases, AME provided a back-up supply of milk when supplementation was indicated or desired. The relationship between AME and lactation outcomes requires further study with adequately powered samples.

TRIAL REGISTRATION

This trial was retrospectively registered at ClinicalTrials.gov on May 11, 2021 under the following registration ID: NCT04929301. https://clinicaltrials.gov/ct2/show/NCT04929301 .

Measures of Maternal Metabolic Health as Predictors of Severely Low Milk Production

Background: A comprehensive approach to breastfeeding support requires elucidation of how metabolic health influences milk production. Objective: We compared metabolic health indicators in women with severely low milk output versus those with moderate/normal milk output using a case-control study design, with nested and external control groups. Design: Cases and nested controls were derived from women screened for a low milk supply trial, with cases defined as severely low milk output (<300 mL/24 hours), and nested controls defined as moderate/normal milk output (>300 mL/24 hours). In addition, we included an external control group of exclusively breastfeeding women. All were enrolled at 2-10 weeks postdelivery of a healthy term infant. Milk output and breast emptying frequency were recorded through test-weigh. Metabolic health variables included all components of the metabolic syndrome, homeostatic model assessment of insulin resistance (HOMA-IR), and diagnosis of gestational diabetes mellitus (GDM). Results: Maximum milk output, mL/24 hours, ranged as follows: 30-281 in cases (n = 18), 372-801 in nested controls (n = 12), and 661-915 in external controls (n = 12). Mean breast emptying frequency in cases was not significantly different from nested or external controls. All metabolic syndrome components and HOMA-IR were significantly worse in cases as compared with both nested and external control groups (p < 0.05). There was no significant difference between the nested and external control groups for these variables. GDM prevalence was 39%, 0%, and 8%, across cases, nested control, and external control groups, respectively (chi-square p-value = 0.02). Conclusion: Results from this small case-control study identify class 2+ obesity and poor metabolic health as strong risk factors for severely low milk production. These findings should be further validated in larger prospective cohort studies designed to identify individuals at risk for metabolically driven low milk supply. In addition, clinical and qualitative research studies aimed at improving patient-centered approaches to the management of persistent low milk supply are needed.

The Association Between Type of Supplementation in the Newborn Nursery and Breastfeeding Outcomes at 2 and 6 Months of Age

BACKGROUND

Supplementation in the newborn nursery has been associated with shorter breastfeeding duration. However, supplementation may at times be necessary.

RESEARCH AIM

To determine the association between type of supplementation in the newborn nursery (mother's own milk, formula, donor human milk) and breastfeeding outcomes at 2 and 6 months of age.

METHODS

This was a prospective, longitudinal, observational multi-group cohort study. In total, 2,343 surveys were sent to parents who, prior to delivery, indicated intent to exclusively breastfeed. Participants were grouped by type of nursery supplementation. Surveys asked about breastfeeding outcomes when infants were 2 and 6 months old. Our final analytic sample included data from 1,111 healthy newborns ≥ 35 weeks. We used multiple logistic regression to compare future breastfeeding outcomes for infants who were exclusively directly breastfed or who received supplementation during their birth hospitalization.

RESULTS

Both the donor human milk and formula groups had decreased breastfeeding at 2 and 6 months compared to the exclusively directly breastfed group. Notably, for infants who received formula compared to donor human milk, the odds of breastfeeding at 2 and 6 months were 74% and 58% lower, respectively (OR = 0.26, 95% CI [0.12, 0.56] at 2 months; OR = 0.42, 95% CI [0.19, 0.94] at 6 months). The donor human milk group had lower odds of breastfeeding at both follow up times compared to the mother's own milk group.

CONCLUSION

Among those who intend to breastfeed, supplementation with donor human milk instead of formula in the newborn nursery may support longer breastfeeding.

Impact of Breastfeeding Support Services on Mothers' Breastfeeding Experiences When Provided by an MD/IBCLC in the Pediatric Medical Home

Addressing breastfeeding issues enables mothers to reach their breastfeeding goals. We embedded a breastfeeding consultation service run by a pediatrician/International Board Certified Lactation Consultant (MD/IBCLC) in a medical home. This mixed-methods study investigated breastfeeding preparedness and the service's perceived benefits. Mothers with breastfeeding issues/concerns identified at well-baby appointments were referred to the service. Telephone interviews and chart reviews were conducted with 28 participating mothers approximately 1 month after the visits. Breastfeeding Self-Efficacy Scale scores improved significantly from the time of the in-person appointment to 1 month later. Most mothers felt unprepared for breastfeeding despite prenatal efforts. Trust in the pediatrician's recommendation, easy access, and insurance coverage were key factors in seeking the service. Reassurance provided by the MD/IBCLC increased mothers' confidence to breastfeed. The COVID-19 pandemic heightened feelings of isolation and anxiety due to lack of hands-on support from friends and family during the birth hospitalization and when at home.

Clinical Decision Support for Newborn Weight Loss: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

The Newborn Weight Tool (NEWT) can inform newborn feeding decisions and might reduce health care utilization by preventing excess weight loss. Clinical decision support (CDS) displaying NEWT might facilitate its use. Our study's objective is to determine the effect of CDS displaying NEWT on feeding and health care utilization.

METHODS

At an hospital involved in NEWT development, we randomly assigned 2682 healthy infants born ≥36 weeks gestation in 2018-2019 either to CDS displaying NEWT with an electronic flag if most recent weight was ≥75th weight loss centile or to a control of usual care with NEWT accessed at clinician discretion. Our primary outcome was feeding type concordant with weight loss, defined as exclusive breastfeeding for those not flagged, exclusive breastfeeding or supplementation for those flagged once, and supplementation for those flagged more than once. Secondary outcomes included inpatient and outpatient utilization in the first 30 days. We used χ2 and Student's t tests to compare intervention infants with control and to compare trial infants with those born in 2017.

RESULTS

Feeding was concordant with for 1854 (74.5%) trial infants and did not differ between randomized groups (P = .65); concordant feeding was higher for all trial infants than for infants born in 2017 (64.4%; P < .0005). Readmission occurred for 51 (3.8%) CDS infants and 45 (3.4%) control infants (P = .56). Among the 60% of trial infants with outpatient records available, there were 3.5 ± 1.7 visits with no differences between randomized groups (P = .10).

CONCLUSIONS

At an hospital involved in NEWT development, CDS displaying NEWT did not alter either feeding or health care utilization compared with discretionary NEWT access.

Relationship Between Maternal COVID-19 Infection and In-Hospital Exclusive Breastfeeding for Term Newborns

Objective

To evaluate the relationship between maternal COVID-19 infection and the odds of in-hospital exclusive breastfeeding for term newborns.

Design

Retrospective descriptive quantitative.

Setting

A large, urban hospital with more than 6,000 births annually.

Sample

Term newborns born between March 1, 2020, and March 31, 2021 (N = 6,151).

Methods

We retrospectively extracted data from electronic health records to evaluate the relationship of maternal COVID-19 infection with the odds of in-hospital exclusive breastfeeding using univariate analysis and logistic regression models. The covariates included insurance type, race/ethnicity, glucose gel administration, length of stay, newborn gestational age, newborn birth weight, and maternal COVID-19 infection.

Results

Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding (p = .138) after adjustment for covariates in the logistic regression model. However, when newborns who received pasteurized donor human milk supplementation were excluded from the logistic regression model, maternal COVID-19 infection significantly decreased the odds of in-hospital exclusive breastfeeding (p = .043).

Conclusion

Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding when newborns received donor human milk supplementation. Access to donor human milk for supplementation for term newborns may protect the odds of in-hospital exclusive breastfeeding.

Ethical Considerations for Hospital-Based Infant Feeding Support

I applied a systematic ethical decision-making approach to evaluate how health care professionals in hospital settings should provide infant feeding support after childbirth. Human milk is recommended as the optimal source of nutrition for infants because of the health benefits it provides for infants and their lactating parents. However, health consequences of insufficient oral intake in infants and psychological distress in the lactating parent may occur when infant feeding does not go according to plan. Infant feeding support should be provided in a way that is objective, sensitive, individualized, equitable, and supportive of autonomy and avoids harm. I provide recommendations for ethical infant feeding support that can be applied by individual health care professionals and on postpartum units in hospitals.

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.

Comparing Attained Weight and Weight Velocity during the First 6 Months in Predicting Child Undernutrition and Mortality

BACKGROUND

The first 6 mo of life are critical for subsequent risk of undernutrition and mortality. The predictive abilities of attained weight at the end of each month and monthly weight velocity for undernutrition and mortality need to be compared.

OBJECTIVES

This study aimed to examine the predictive abilities of different weight metrics during the first 6 mo of life in predicting undernutrition and mortality.

METHODS

This study used a cohort of infants in Tanzania. Weight and length were measured monthly from birth to 18 mo of age. Three weight metrics during the first 6 mo of life were considered as predictors, including attained weight-for-age z score (WAZ) at the end of each month, monthly change in WAZ, and monthly weight velocity z score (WVZ). Logistic models were used with undernutrition (at 6 or 12 mo) and mortality (over the first 18 mo) as outcomes. AUC values were compared across metrics.

RESULTS

For predicting wasting at 6 mo, WVZ (AUC: 0.80) had a greater predictive ability than attained WAZ (AUC: 0.76) and change in WAZ (AUC: 0.71) during the second month of life. After 2 mo, attained WAZ (AUC: 0.81-0.89) had greater predictive abilities than WVZ (AUC: 0.71-0.77) and change in WAZ (AUC: 0.65-0.67). For predicting stunting at 6 mo, attained WAZ (AUC: 0.75-0.79) had consistently greater predictive abilities than WVZ (AUC: 0.56-0.66) and change in WAZ (AUC: 0.50-0.57). The weight metrics had similar abilities in predicting mortality, with the AUC rarely reaching >0.65.

CONCLUSIONS

Attained weight at the end of each month had greater abilities than monthly weight velocity in the same month in predicting undernutrition. Attained weight remains a useful indicator for identifying infants at greater risk of undernutrition.

Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus

OBJECTIVE

To compare breastfeeding (BF) initiation among 317 women with chronic hypertension (CHTN) and 106 women with CHTN superimposed on pregestational diabetes (CHTN-DM) who intended exclusive or partial BF.

METHODS

Retrospective cohort study of women who delivered at≥34 weeks of gestation. At discharge, exclusive BF was defined by direct BF or BF complemented with expressed breast milk (EBM) while partial BF was defined by formula supplementation.

RESULTS

CHTN and CHTN-DM groups were similar in prior BF experience (42 vs 52%), intention to BF exclusively (89 vs 79%) and intention to partially BF (11 vs 21%). Women in the CHTN group were younger (31 vs 33y), more likely primiparous (44 vs 27%), and delivered vaginally (59 vs 36%) at term (85 vs 75%). Women in the CHTN-DM group had higher repeat cesarean rates (32 vs 18%), preterm birth (25 vs 15%), neonatal hypoglycemia (42 vs 14%) and NICU admission (38 vs 16%). At discharge, exclusive BF rates among CHTN was higher (48 vs 19%), while rates of partial BF (34 vs 44%) and FF (18 vs 37%) were lower than in the CHTN-DM group. BF initiation (exclusive plus partial BF) occurred in 82%of CHTN and in 63% of CHTN-DM.

CONCLUSION

Although intention to BF was similar, BF initiation rates were higher for the CHTN compared to the CHTN-DM group. Exclusive BF was low in the CHTN and even lower in the CHTN-DM group signaling the need for targeted interventions if BF initiation rates are to be improved.

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.

Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalizations for jaundice/hyperbilirubinemia, hypernatremia/dehydration, and hypoglycemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide. Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity. As that new intervention has become increasingly widespread, so too have researchers widely reported associated possible harms of the longer neonatal starvation/deprivation and later infant under-nutrition periods that it creates when breastfeeding is insufficient. Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder. Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers' milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.

[Impact of mode of delivery on the weight kinetics of the breastfed infant]

In various studies, the introduction of infant formulas during the stay in the maternity ward has been shown to increase the risk of breastfeeding failure and the development of cow's milk protein allergy. How can they be avoided when the infant loses weight in an "abnormal" way? A team from the Polyclinique Majorelle, in Nancy, studied the impact of the mode of delivery on the weight of the newborn in order to improve its accompaniment while respecting the real needs and rhythms of each child.