In-hospital formula supplementation of breastfed babies: a population-based survey

Investigating short-stay admission to a neonatal intensive care unit as a risk factor for reduced breast feeding at discharge in infants ≥36 weeks' gestation: a retrospective cohort study

OBJECTIVE

This study aims to determine the effect of infant-mother separation following a short-stay (≤72 hours) admission to a Level 5 neonatal unit versus no admission on infant-feeding outcomes at hospital discharge.

DESIGN

Retrospective cohort study.

SETTING

An Australian Level 5 neonatal unit within a tertiary referral hospital.

PARTICIPANTS

Mothers and their infants born between 1 January 2018 and 31 December 2020 had a short-stay admission to the neonatal unit or no admission. All participants met admission criteria to the postnatal ward and were discharged home at ≤72 hours (n=12 540). Postnatal ward admission criteria included ≥36 weeks' gestation and birth weight ≥2.2 kg.

MAIN OUTCOME MEASURES

Infant feeding at discharge from hospital. Multivariate logistic regression analysis was conducted, adjusting for confounders associated with known breastfeeding issues. These included age, ethnicity, parity, obesity, socioeconomic score, hypertensive disorders of pregnancy, diabetes, infant gestation and birthweight centile, caesarean section birth, postpartum haemorrhage and skin-to-skin contact.

RESULTS

Of the 12 540 live births meeting inclusion criteria, 1000 (8%) infants were admitted to the neonatal unit. The primary reasons for admission were suspicion of sepsis (24%), maternal diabetes (19%) and jaundice (16%). We found a reduction in full breast feeding at hospital discharge in cases of a short admission to the neonatal unit compared with no admission (aOR 0.40; 95% CI 0.34 to 0.47; p<0.001). We identified that women of different ethnicities had differing levels of risk for formula supplementation at hospital discharge. The ethnic grouping least likely to be fully breast feeding at discharge was Southeast Asian women (aOR 0.47; 95% CI 0.39 to 0.57; p<0.001).

CONCLUSIONS

Identifying mother-infant dyads at risk of non-exclusive breast feeding at hospital discharge will help target resources for practice improvement.

Non-medical formula use in newborn infants still common at two Swedish hospitals after a breastfeeding support program

AIM

To evaluate the effectiveness of a breastfeeding support programme on reducing infant formula use and to investigate indications for formula in newborn infants in Sweden.

METHODS

A quasi-experimental study design was carried out. It included 255 mother-infant pairs in a control group, who received standard care and 254 pairs in an intervention group, who took part in a breastfeeding support programme. Data were collected by reviewing patient records from two regional hospitals in Uppsala and Gotland and recruitment took place between 2017 and 2019.

RESULTS

Median age of mothers were 31 years (range 20-49) and median gestational age of infants were 39 + 6 weeks/days (range 37 + 0 to 42 + 4). The intervention did not reduce infant formula use. In total, 87/507 (17%) of the infants received formula. Among children receiving formula 30/87 (34%) had a medical indication, whereas 57/87 (66%) had no medical indication. Main reasons for medically indicated formula use were hypoglycaemia, 13/30 (43%), and weight loss, 13/30 (43%). Main reasons for non-medical use were mothers'/parents' wishes, 25/57 (44%) and infants' dissatisfaction, 11/57 (19%).

CONCLUSION

Continued efforts are needed to develop effective breastfeeding interventions with increased focus on infant formula reduction.

Neonates at high risk of hypoglycaemia: Is admission necessary?

AIM

To evaluate the practice of routine admission of infants at high risk of hypoglycaemia by determining the incidence of hypoglycaemia, factors that predict necessary admission and breastfeeding outcomes.

METHODS

A retrospective cohort study of neonates admitted to a tertiary neonatal unit for high risk of hypoglycaemia. Clinical data, including blood glucose concentrations, body fat percentage and time to initiation of feeding, were collected for 122 infant-maternal dyads for a 3-year period from April 2016 to May 2019. Descriptive statistical analysis and binary logistic regression analysis were undertaken.

RESULTS

Hypoglycaemia developed in 39.3% of the neonates identified as high risk. Overall, 69 out of 122 admissions were potentially avoidable. Initial blood glucose was the most significant predictive factor for necessary admission with odds ratio of 3.26 (95% confidence interval (CI) 1.04-10.17) for an initial glucose of 1.6-2.0 and 27.05 (95% CI 5.06-144.42) for initial glucose ≤1.5. Exclusive breastfeeding rates at discharge were lower in admitted infants (59%) compared to the overall hospital rate (75.6%).

CONCLUSIONS

Neonates at high risk of hypoglycaemia should be monitored with their mothers as most infants needing admission are detected by initial blood glucose concentration. This would reduce infant-maternal separation and potentially improve breastfeeding rates.

Exact Gestational Age, Term Versus Early Term, Is Associated with Different Breastfeeding Success Rates in Mothers Delivered by Elective Cesarean Section

Objectives: The study was intended to verify the association between the gestational age of newborns classified as term and the success of breastfeeding in babies born by elective cesarean section. Also, to analyze how the variability of gestational age within the term influences breastfeeding. Materials and Methods: Retrospective study of a cohort, which included full-term newborns and their mothers, whose deliveries occurred by elective cesarean section. Among the inclusion criteria are delivery due to elective cesarean section and minimum gestational age of 37 weeks. The database consisted of medical birth information and interviews with mothers. Results: This study included 954 full-term newborns born by elective cesarean section. Exclusive breastfeeding at 3 months and being breastfed at 6 months showed a statistically significant association in the correlation with the variability of gestational age. There was a statistically significant association between exclusive breastfeeding at 3 months and breastfeeding at 6 months in the correlation between early term and full term. The trend test showed a significant progressive in the breastfeeding curve versus gestational age. Conclusion: Full-term newborns show better results of exclusive breastfeeding at 3 months and continued breastfeeding at 6 months, compared with those born at early term. Gestational age, even in term, has an influence on the success of breastfeeding in newborns undergoing elective cesarean delivery.

Factors associated with infant formula supplementation in Brazilian hospitals: a cross-sectional study

OBJECTIVE

To analyze the factors associated with infant formula supplementation in newborns referred to rooming-in in Brazilian hospitals.

METHOD

Cross-sectional study with data from 14,531 postpartum women and newborns obtained from the "Birth in Brazil" survey, conducted in 2011-2012. The analysis used a logistic regression model with a hierarchical approach.

RESULTS

In total, 21.2% newborns received infant formula during hospital stay. After adjustment, the following factors were associated with the use of infant formula: maternal age ≥ 35 years (OR = 1.51; IC95%:1.30-1.75), prenatal care in a private service (OR = 2,22; IC:1.72-2.85)/public and private service (OR = 1.67; IC:1.24-2.23), cesarean delivery (OR = 1.83; IC:1.41-2.38), multiple pregnancy (OR = 3.786; IC:2.02-7.06), non-breastfeeding in the delivery room (OR = 1.780; IC:1.43-2.21), birth in a private hospital (OR = 1.695; IC:1.02-2.79), prematurity (OR = 1.656; IC:1.32-2.06) and extremes of birth weight (< 2.500 g: OR = 2.084; IC: 1.585-2.741/ ≥4,000g: OR = 1.672; IC:1.31-2.11). Teenage age (OR = 0.651; IC:0.55-0.76), low maternal education (OR = 0.579; IC:0.43-0.77), multiparity (OR = 0.588; IC:0.510-0.678), and lower economic class (OR = 0.565; IC:0.41-0.76) significantly reduced the probability of using infant formula.

CONCLUSIONS

Of the associated factors, the authors highlight cesarean delivery and non-breastfeeding in the delivery room, showing that it is necessary to strengthen policies that encourage good practices during childbirth care in order to promote exclusive breastfeeding and protect mothers and newborns from all social classes against the misuse of infant formula.

Breastfeeding practices in an Australian tertiary care hospital: A retrospective study

BACKGROUND

The World Health Organization recommend that infants be exclusively breastfed until six months of age. The Baby Friendly Health Initiative (BFHI) was developed for protecting, promoting, and supporting breastfeeding. The BFHI global criteria guides hospital practice for supporting infant feeding and reducing disparities in breastfeeding outcomes.

AIM

The aim of this study was to analyse 2019 data to identify factors that predict exclusive breastfeeding vs non-exclusive breastfeeding on discharge to determine areas for intervention in relation to BFHI guidelines.

MATERIAL AND METHODS

A retrospective chart review of 5836 neonates born at an Australian tertiary hospital in 2019 was conducted. Descriptive statistics were used to report exclusive breastfeeding rates. Univariate and logistic regression analyses were conducted to determine factors associated with exclusive breastfeeding and non-exclusive breastfeeding on discharge.

RESULTS

A total of 69% of neonates were exclusively breastfed on discharge in 2019. When excluding admissions to Newborn Services, 75% of neonates were exclusively breastfed on discharge, achieving the BFHI benchmark. Predictors which significantly reduced the odds of exclusive breastfeeding on discharge were maternal country of birth (Vietnam, p < 0.001, Sudan p < 0.001, Samoa p < 0.01, Philippines p < 0.05), main language (Other, p < 0.05), birth type (caesarean or assisted vaginal birth p < 0.001), first-feed type (mixed feeding or formula p < 0.001), and Newborn Services admission (p < 0.001).

CONCLUSIONS

Examining breastfeeding outcomes is an important quality assurance process for health services. Understanding groups of mothers who commence breastfeeding but do not exclusively breastfeed upon discharge enables identification of areas for intervention to achieve BFHI targets and reduce breastfeeding disparities.

Mixed milk feeding: a systematic review and meta-analysis of its prevalence and drivers

CONTEXT

Extensive literature is available on exclusive breastfeeding and formula-feeding practices and health effects. In contrast, limited and unstructured literature exists on mixed milk feeding (MMF), here defined as the combination of breastfeeding and formula feeding during the same period in term infants > 72 hours old (inclusion criterion).

OBJECTIVE

A systematic review and meta-analysis were performed, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, on the global prevalence of MMF (primary outcome) and related drivers and practices (secondary outcomes).

DATA SOURCES

The search of MMF in generally healthy populations was conducted across 6 databases, restricted to publications from January 2000 to August 2018 in English, Spanish, French, and Mandarin.

DATA EXTRACTION

Two reviewers independently performed screenings and data extraction according to a priori inclusion and exclusion criteria.

DATA ANALYSIS

Of the 2931 abstracts identified, 151 full-text publications were included for data extraction and 96 of those were included for data synthesis (the majority of those were cross-sectional and cohort studies). The authors summarized data across 5 different categories (feeding intention prenatally, and 4 age intervals between > 72 hours and > 6-23 months) and 5 regional subgroups. The overall prevalence of MMF across different age intervals and regions varied between 23% and 32%; the highest rate was found for the age group 4-6 months (32%; 95% confidence interval, 27%-38%); regional comparisons indicated highest MMF rates in Asia (34%), North and South America (33%), and Middle East and Africa together (36%), using a random effects meta-analysis model for proportions. Some drivers and practices for MMF were identified.

CONCLUSION

MMF is a widespread feeding reality. A shared and aligned definition of MMF will help shed light on this feeding practice and evaluate its influence on the duration of total breastfeeding, as well as on infants' nutrition status, growth, development, and health status in the short and long terms. PROSPERO registration number CRD42018105337.

Maternal Body Mass Index and Breastfeeding Non-Initiation and Cessation: A Quantitative Review of the Literature

This study aims to investigate which maternal body mass index (BMI) categories are associated with the non-initiation or cessation of breastfeeding (BF) based on a quantitative review of the literature. We searched Ovid MEDLINE and EBSCO CINAHL for peer-reviewed articles published between 1946 (MEDLINE) or 1981 (CINAHL), and 2019. Selected studies were either cross-sectional or cohort studies, of healthy mothers and infants, that reported nutrition method (exclusive/full or any) and period (initiation/duration/cessation) of breastfeeding according to maternal BMI levels. Pairwise meta-analyses of 57 studies demonstrated that the pooled odds risks (OR) of not initiating BF among overweight and obese mothers compared to normal weight mothers were significant across 29 (OR 1.33, 95% confidence interval (CI), 1.15–1.54, I² = 98%) and 26 studies (OR 1.61, 95% CI, 1.33–1.95, I² = 99%), respectively; the pooled risks for BF cessation were inconsistent in overweight and obese mothers with substantial heterogeneity. However, we found that overweight mothers (n = 10, hazard ratio (HR) 1.16, 95% CI, 1.07–1.25; I² = 23%) and obese mothers (n = 7, HR 1.45, 95% CI: 1.27–1.65; I² = 44%) were both associated with an increased risk of not continuing any BF and exclusive BF, respectively. Overweight and obese mothers may be at increased risk of not initiating or the cessation of breastfeeding.

Exposure to baby-friendly hospital practices and mothers' achievement of their planned duration of breastfeeding

BACKGROUND

Both breastfeeding intentions and exposure to baby-friendly hospital practices were found to be associated with a longer duration of breastfeeding. This study aims to examine the effect of exposure to baby-friendly hospital practices on mothers' achievement of their planned duration of breastfeeding.

METHODS

A total of 1011 mother-newborn pairs from the postnatal units of four public hospitals in Hong Kong were recruited. Sociodemographic data and breastfeeding intention data were collected via self-report questionnaires during the postnatal hospitalization and exposure to Baby-Friendly hospital practices were assessed through hospital records and maternal self-report. Breastfeeding status after hospital discharge was assessed through telephone follow-up for up to 12 months postnatal, or until participants were no longer breastfeeding.

RESULTS

Only 55% (n = 552) of study participants achieved their intended duration of breastfeeding. Participants with higher socioeconomic status, previous breastfeeding experience, and those who had lived in Hong Kong for less than 5 years, were more likely to achieve their planned duration of breastfeeding. Among baby-friendly hospital practices, feeding only breast milk during the hospitalization and providing information about breastfeeding support on discharge were associated with participants' achieving their individual breastfeeding intentions. After adjustment, when compared with women who experienced onebaby-friendly practice, participants who experienced six baby-friendly hospital practices were significantly more likely to achieve their planned duration of breastfeeding (adjusted odds ratio = 8.45, 95% confidence interval 3.03-23.6).

CONCLUSIONS

Nearly half of participants did not achieve their planned breastfeeding duration. Exposure to baby-friendly hospital practices, especially in-hospital exclusive breastfeeding and providing breastfeeding support information upon hospital discharge may help more mothers to achieve their individual breastfeeding goals.

Birth mode, breastfeeding and childhood infectious morbidity in the Yucatec Maya

OBJECTIVES

Cesarean delivery is linked to breastfeeding complications and child morbidity. These outcomes may disproportionately affect Latin American indigenous populations that are experiencing rising cesarean delivery rates, but often inhabit environments that exacerbate postnatal morbidity risks. We therefore assess relationships between birth mode, infant feeding practices, and childhood infectious morbidity in a modernizing Yucatec Maya community, where prolonged breastfeeding is the norm. We predicted that under these conditions, cesarean delivery would increase risk of childhood infectious morbidity, but prolonged breastfeeding postcesarean would mitigate morbidity risk.

METHODS

Using a longitudinal child health dataset (n = 88 children aged 0-60 months, 24% cesarean-delivered, 2290 observations total), we compare gastrointestinal infectious (GI) and respiratory infectious (RI) morbidity rates by birth mode. We model associations between cesarean delivery and breastfeeding duration, formula feeding and child nutritional status, then model GI and RI as a function of birth mode, child age, and feeding practices.

RESULTS

Cesarean delivery was associated with longer breastfeeding durations and higher child weight-for-age, but not with formula feeding, GI, or RI. Adolescent motherhood and RI were risk factors for GI; formula feeding and GI were risk factors for RI. Regional housing materials protected against GI; breastfeeding protected against RI and mitigated the effect of formula feeding.

CONCLUSIONS

We find no direct link between birth mode and child infectious morbidity. Yucatec Maya mothers practice prolonged breastfeeding, especially postcesarean, and in conjunction with formula feeding. This practice protects against childhood RI, but not GI, perhaps because GI is more susceptible to maternal and household factors.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Formula supplementation in hospital and subsequent feeding at discharge among women who intended to exclusively breastfeed: An administrative data retrospective cohort study

BACKGROUND

Among women who intend to exclusively breastfeed, it is important to identify mothers and their infants who have a greater risk of formula supplementation in hospital, and are unlikely to recover exclusive breastfeeding at discharge. We investigated factors associated with in-hospital formula feeding among healthy term infants born to women who intended to exclusively breastfeed, and among this group, predictors of infant feeding at discharge.

METHODS

Retrospective cohort study utilizing routinely collected clinical data for women who intended to exclusively breastfeed and gave birth to healthy term infants in five hospitals in New South Wales, Australia, 2010-2013. Robust Poisson regression was used to obtain adjusted relative risks (aRR) for the associations between formula feeding in hospital, feeding at discharge, and associated factors.

RESULTS

Of 24 713 mother-infant dyads in the study population, 16.5% received formula in hospital. After adjustment, the strongest predictors of formula supplementation were breastfeeding difficulties (aRR 2.90 [95% confidence interval {CI} 2.74-3.07]), Asian born mother (aRR 2.07 [95% CI 1.92-2.23]), and neonatal conditions (aRR 2.00 [95% CI 1.89-2.13]). Among infants who received formula (n=3998), 49.3% were fully breastfeeding at discharge, 33.1% partially breastfeeding, and 17.5% formula-only feeding. Compared with formula-only feeding, special care nursery admission (aRR 1.23 [95% CI 1.17-1.30]) and ≥1 neonatal conditions (compared with none) were most strongly associated with fully breastfeeding at discharge (aRR 1.21 [95% CI 1.16-2.16]).

CONCLUSION

Women and their infants who receive formula in hospital need additional support to attain exclusive breastfeeding by hospital discharge. Such support is especially needed for younger women, smokers, and women with breastfeeding difficulties.

Predictors of breastfeeding exclusivity and duration in a hospital without Baby Friendly Hospital Initiative accreditation: A prospective cohort study

AIM

The aim of this study was to investigate the maternity care factors associated with exclusive breastfeeding duration at three months and six months postpartum in a setting without BFHI accrediation.

METHODS

A prospective cohort design. Participants from one tertiary maternity hospital were eligible if they intended to exclusively breastfeed, had birthed a live, term baby; were breastfeeding at recruitment; were rooming-in with their baby; were healthy and well; and understood English. Participants completed an infant feeding survey using 24-h recall questions at three time-points. Data were analysed using descriptive statistics, bivariate analysis and regression modelling.

FINDINGS

We recruited 424 participants of whom 84% (n=355) responded to the survey at 3-months and 79% (n=335) at 6-months. Women who avoided exposure to intrapartum opioid analgesia (e.g. intramuscular, intraveous or epidural) were more likely to be exclusively breastfeeding at 3-months postpartum (adjusted odds ratio (aOR) 2.09, 95% confidence interval (CI) 1.15-3.80, probability value (p) 0.016). The only other modifiable predictor of exclusive breastfeeding at 3-months was non-exposure to artificial formula on the postnatal ward (aOR 2.44, 95% CI 1.43-4.18, p<0.001). At 6-months postpartum, the rate of exclusive breastfeeding had reduced to 5% (n=16) which rendered regression modelling untenable.

DISCUSSION

Strategies to decrease exposure to opioid analgesia in birth settings and the use of infant formula on the postnatal ward may improve exclusive breastfeeding at three months.

CONCLUSION

Results suggest that both intrapartum and postpartum maternity care practices can predict long-term breastfeeding success.

Predictors of supplementation for breastfed babies in a Baby-Friendly hospital

PROBLEM

Supplementation of breastfed babies is common during the hospital stay.

BACKGROUND

The Baby Friendly Hospital Initiative (BFHI) optimises practices to support exclusive breastfeeding, yet supplementation is still prevalent.

OBJECTIVE

To determine predictors for supplementation in a cohort of breastfed babies in a Baby-Friendly hospital.

METHODS

Electronic hospital records of 1530 healthy term or near term singleton infants and their mothers were examined retrospectively and analysed to identify factors associated with in-hospital supplementation using Poisson regression (unadjusted and adjusted).

FINDINGS

Fifteen percent of breastfed infants were supplemented during their hospital stay. Analysis by multivariable Poisson regression found that supplementation was independently associated with overweight (reference normal weight) (aRR [adjusted relative risk]=1.46; 95% CI: 1.11-1.93); primiparity (aRR=1.40; 95% CI: 1.09-1.80); early term gestation (37-37⁶ weeks, aRR=2.79; 95% CI: 1.88-4.15; 38-38⁶ weeks, aRR=2.03, 95%CI: 1.46-2.82); birthweight less than 2500 grams (reference 3000-3499 grams) (aRR=3.60; 95% CI: 2.32-5.60) and use of postpartum uterotonic (aRR=2.47; 95% CI: 1.09-5.55). Greater than 65 minutes of skin-to-skin contact at birth reduced the risk of supplementation (aRR=0.66; 95% CI; 0.48-0.92).

CONCLUSION

These identified predictors for supplementation, can inform the development of interventions for mother-infant pairs antenatally or in the early postpartum period around increased breastfeeding education and support to reduce supplementation. It may also be possible to reduce supplementation through judicious use of postpartum uterotonics and facilitation of mother-infant skin-to-skin contact at birth for greater than one hour duration.

Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals

OBJECTIVES

We examined the variation between 126 New York hospitals in formula supplementation among breastfed infants after adjusting for socioeconomic, maternal, and infant factors and stratifying by level of perinatal care.

METHODS

We used 2014 birth certificate data for 160 911 breastfed infants to calculate hospital-specific formula supplementation percentages by using multivariable hierarchical logistic regression models.

RESULTS

Formula supplementation percentages varied widely among hospitals, from 2.3% to 98.3%, and was lower among level 1 hospitals (18.2%) than higher-level hospitals (50.6%-57.0%). Significant disparities in supplementation were noted for race and ethnicity (adjusted odds ratios [aORs] were 1.54-2.05 for African Americans, 1.85-2.74 for Asian Americans, and 1.25-2.16 for Hispanics, compared with whites), maternal education (aORs were 2.01-2.95 for ≤12th grade, 1.74-1.85 for high school or general education development, and 1.18-1.28 for some college or a college degree, compared with a Master's degree), and insurance coverage (aOR was 1.27-1.60 for Medicaid insurance versus other). Formula supplementation was higher among mothers who smoked, had a cesarean delivery, or diabetes. At all 4 levels of perinatal care, there were exemplar hospitals that met the HealthyPeople 2020 supplementation goal of ≤14.2%. After adjusting for individual risk factors, the hospital-specific, risk-adjusted supplemental formula percentages still revealed a wide variation.

CONCLUSIONS

A better understanding of the exemplar hospitals could inform future efforts to improve maternity care practices and breastfeeding support to reduce unnecessary formula supplementation, reduce disparities, increase exclusive breastfeeding and breastfeeding duration, and improve maternal and child health outcomes.

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

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.

Infant Formula Feeding at Birth Is Common and Inversely Associated with Subsequent Breastfeeding Behavior in Vietnam

BACKGROUND

The association between infant formula feeding at birth and subsequent feeding patterns in a low- or middle-income context is not clear.

OBJECTIVE

We examined the association of infant formula feeding during the first 3 d after birth with subsequent infant formula feeding and early breastfeeding cessation in Vietnam.

METHODS

In a cross-sectional survey, we interviewed 10,681 mothers with children aged 0-23 mo (mean age: 8.2 mo; 52% boys) about their feeding practices during the first 3 d after birth and on the previous day. We used stratified analysis, multiple logistic regression, propensity score-matching analysis, and structural equation modeling to minimize the limitation of the cross-sectional design and to ensure the consistency of the findings.

RESULTS

Infant formula feeding during the first 3 d after birth (50%) was associated with a higher prevalence of subsequent infant formula feeding [stratified analysis: 7-28% higher (nonoverlapping 95% CIs for most comparisons); propensity score-matching analysis: 13% higher (P < 0.001); multiple logistic regression: OR: 1.47 (95% CI: 1.30, 1.67)]. This practice was also associated with a higher prevalence of early breastfeeding cessation (e.g., <24 mo) [propensity score-matching analysis: 2% (P = 0.08); OR: 1.33 (95% CI: 1.12, 1.59)]. Structural equation modeling showed that infant formula feeding during the first 3 d after birth was associated with a higher prevalence of subsequent infant formula feeding (β: 0.244; P < 0.001), which in turn was linked to early breastfeeding cessation (β: 0.285; P < 0.001).

CONCLUSIONS

Infant formula feeding during the first 3 d after birth was associated with increased subsequent infant formula feeding and the early cessation of breastfeeding, which underscores the need to make early, exclusive breastfeeding normative and to create environments that support it.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Health organisations recommend exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries. Recently, research has suggested that introducing solid food at around four months of age while the baby continues to breastfeed is more protective against developing food allergies compared to exclusive breastfeeding for six months. Other studies have shown that the risks associated with non-exclusive breastfeeding are dependent on the type of additional food or fluid given. Given this background we felt it was important to update the previous version of this review to incorporate the latest findings from studies examining exclusive compared to non-exclusive breastfeeding.

OBJECTIVES

To assess the benefits and harms of additional food or fluid for full-term healthy breastfeeding infants and to examine the timing and type of additional food or fluid.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2016) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 trials (2542 randomised infants/mothers). Nine trials (2226 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one primary (breastfeeding duration) and one secondary (weight change) outcome. None of the trials reported on physiological jaundice. Infant mortality was only reported in one trial.For the majority of older trials, the description of study methods was inadequate to assess the risk of bias. Most studies that we could assess showed a high risk of other biases and over half were at high risk of selection bias.Providing breastfeeding infants with artifical milk, compared to exclusive breastfeeding, did not affect rates of breastfeeding at hospital discharge (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.97 to 1.08; one trial, 100 infants; low-quality evidence). At three months, breastfeeding infants who were provided with artificial milk had higher rates of any breastfeeding compared to exclusively breastfeeding infants (RR 1.21, 95% CI 1.05 to 1.41; two trials, 137 infants; low-quality evidence). Infants who were given artifical milk in the first few days after birth before breastfeeding, had less "obvious or probable symptoms" of allergy compared to exclusively breastfeeding infants (RR 0.56, 95% CI 0.35 to 0.91; one trial, 207 infants; very low-quality evidence). No difference was found in maternal confidence when comparing non-exclusive breastfeeding infants who were provided with artificial milk with exclusive breastfeeding infants (mean difference (MD) 0.10, 95% CI -0.34 to 0.54; one study, 39 infants; low-quality evidence). Rates of breastfeeding were lower in the non-exclusive breastfeeding group compared to the exclusive breastfeeding group at four, eight, 12 (RR 0.68, 95% CI 0.53 to 0.87; one trial, 170 infants; low-quality evidence), 16 and 20 weeks.The addition of glucose water resulted in fewer episodes of hypoglycaemia (below 2.2 mmol/L) compared to the exclusive breastfeeding group, reported at 12 hours (RR 0.07, 95% CI 0.00 to 1.20; one trial, 170 infants; very low-quality evidence), but no significant difference at 24 hours (RR 1.57, 95% CI 0.27 to 9.17; one trial, 170 infants; very low-quality evidence). Weight loss was lower for infants who received additional glucose water (one trial, 170 infants) at six, 12, 24 and 48 hours of life (MD -32.50 g, 95% CI -52.09 to -12.91; low-quality evidence) compared to the exclusively breastfeeding infants but no difference between groups was observed at 72 hours of life (MD 3.00 g, 95% CI -20.83 to 26.83; very low-quality evidence). In another trial with the water and glucose water arms combined (one trial, 47 infants), we found no significant difference in weight loss between the additional fluid group and the exclusively breastfeeding group on either day three or day five (MD -1.03%, 95% CI -2.24 to 0.18; very low-quality evidence) and (MD -0.20%, 95% CI -0.86 to 0.46; very low-quality evidence).Infant mortality was reported in one trial with no deaths occurring in either group (1162 infants). The early introduction of potentially allergenic foods, compared to exclusively breastfeeding, did not reduce the risk of "food allergy" to one or more of these foods between one to three years of age (RR 0.80, 95% CI 0.51 to 1.25; 1162 children), visible eczema at 12 months stratified by visible eczema at enrolment (RR 0.86, 95% CI 0.51 to 1.44; 284 children), or food protein-induced enterocolitis syndrome reactions (RR 2.00, 95% CI 0.18 to 22.04; 1303 children) (all moderate-quality evidence). Breastfeeding infants receiving additional foods from four months showed no difference in infant weight gain (g) from 16 to 26 weeks compared to exclusive breastfeeding to six months (MD -39.48, 95% CI -128.43 to 49.48; two trials, 260 children; low-quality evidence) or weight z-scores (MD -0.01, 95% CI -0.15 to 0.13; one trial, 100 children; moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found no evidence of benefit to newborn infants on the duration of breastfeeding from the brief use of additional water or glucose water. The quality of the evidence on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. The majority of studies showed high risk of other bias and most outcomes were based on low-quality evidence which meant that we were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence to disagree with the current international recommendation that healthy infants exclusively breastfeed for the first six months.

Effect on Baby-Friendly Hospital Steps When Hospitals Implement a Policy to Pay for Infant Formula

BACKGROUND

The Baby-Friendly Hospital Initiative requires hospitals to pay market price for infant formula. No studies have specifically examined the effect of hospitals paying for infant formula on breastfeeding mothers' exposure to Baby-Friendly steps.

OBJECTIVES

To investigate the effect of hospitals implementing a policy of paying for infant formula on new mothers' exposure to Baby-Friendly steps and examine the effect of exposure to Baby-Friendly steps on breastfeeding rates.

METHODS

We used a repeated prospective cohort study design. We recruited 2 cohorts of breastfeeding mother-infant pairs (n = 2470) in the immediate postnatal period from 4 Hong Kong public hospitals and followed them by telephone up to 12 months postpartum. We assessed participants' exposure to 6 Baby-Friendly steps by extracting data from the medical record and by maternal self-report.

RESULTS

After hospitals began paying for infant formula, new mothers were more likely to experience 4 out of 6 Baby-Friendly steps. Breastfeeding initiation within the first hour increased from 28.7% to 45%, and in-hospital exclusive breastfeeding rates increased from 17.9% to 41.4%. The proportion of mothers who experienced all 6 Baby-Friendly steps increased from 4.8% to 20.5%. The risk of weaning was progressively higher among participants experiencing fewer Baby-Friendly steps. Each additional step experienced by new mothers decreased the risk of breastfeeding cessation by 8% (hazard ratio = 0.92; 95% CI, 0.89-0.95).

CONCLUSION

After implementing a policy of paying for infant formula, breastfeeding mothers were exposed to more Baby-Friendly steps, and exposure to more steps was significantly associated with a lower risk of breastfeeding cessation.

Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS): a mixed-methods study to inform trial design

BACKGROUND

Smoking in pregnancy and/or not breastfeeding have considerable negative health outcomes for mother and baby.

AIM

To understand incentive mechanisms of action for smoking cessation in pregnancy and breastfeeding, develop a taxonomy and identify promising, acceptable and feasible interventions to inform trial design.

DESIGN

Evidence syntheses, primary qualitative survey, and discrete choice experiment (DCE) research using multidisciplinary, mixed methods. Two mother-and-baby groups in disadvantaged areas collaborated throughout.

SETTING

UK.

PARTICIPANTS

The qualitative study included 88 pregnant women/recent mothers/partners, 53 service providers, 24 experts/decision-makers and 63 conference attendees. The surveys included 1144 members of the general public and 497 health professionals. The DCE study included 320 women with a history of smoking.

METHODS

(1) Evidence syntheses: incentive effectiveness (including meta-analysis and effect size estimates), delivery processes, barriers to and facilitators of smoking cessation in pregnancy and/or breastfeeding, scoping review of incentives for lifestyle behaviours; (2) qualitative research: grounded theory to understand incentive mechanisms of action and a framework approach for trial design; (3) survey: multivariable ordered logit models; (4) DCE: conditional logit regression and the log-likelihood ratio test.

RESULTS

Out of 1469 smoking cessation and 5408 breastfeeding multicomponent studies identified, 23 smoking cessation and 19 breastfeeding studies were included in the review. Vouchers contingent on biochemically proven smoking cessation in pregnancy were effective, with a relative risk of 2.58 (95% confidence interval 1.63 to 4.07) compared with non-contingent incentives for participation (four studies, 344 participants). Effects continued until 3 months post partum. Inconclusive effects were found for breastfeeding incentives compared with no/smaller incentives (13 studies) but provider commitment contracts for breastfeeding show promise. Intervention intensity is a possible confounder. The acceptability of seven promising incentives was mixed. Women (for vouchers) and those with a lower level of education (except for breastfeeding incentives) were more likely to disagree. Those aged ≤ 44 years and ethnic minority groups were more likely to agree. Agreement was greatest for a free breast pump and least for vouchers for breastfeeding. Universal incentives were preferred to those targeting low-income women. Initial daily text/telephone support, a quitting pal, vouchers for > £20.00 per month and values up to £80.00 increase the likelihood of smoking cessation. Doctors disagreed with provider incentives. A 'ladder' logic model emerged through data synthesis and had face validity with service users. It combined an incentive typology and behaviour change taxonomy. Autonomy and well-being matter. Personal difficulties, emotions, socialising and attitudes of others are challenges to climbing a metaphorical 'ladder' towards smoking cessation and breastfeeding. Incentive interventions provide opportunity 'rungs' to help, including regular skilled flexible support, a pal, setting goals, monitoring and outcome verification. Individually tailored and non-judgemental continuity of care can bolster women's capabilities to succeed. Rigid, prescriptive interventions placing the onus on women to behave 'healthily' risk them feeling pressurised and failing. To avoid 'losing face', women may disengage.

LIMITATIONS

Included studies were heterogeneous and of variable quality, limiting the assessment of incentive effectiveness. No cost-effectiveness data were reported. In surveys, selection bias and confounding are possible. The validity and utility of the ladder logic model requires evaluation with more diverse samples of the target population.

CONCLUSIONS

Incentives provided with other tailored components show promise but reach is a concern. Formal evaluation is recommended. Collaborative service-user involvement is important.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012001980.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Evaluation of the impact of breast milk expression in early postpartum period on breastfeeding duration: a prospective cohort study

Background

Breast milk expression (breast pumping) has become prevalent as an important dimension of breastfeeding behavior. It is, however, not clear whether increasing breast milk expression contributes to extend the duration of breastfeeding. The objective of the present study was to evaluate the impact of breast milk expression in early postpartum period on breastfeeding duration amongst mothers of healthy term infants.

Methods

A prospective cohort study had been conducted from March to June 2010. Mothers who gave birth to healthy, full-term and singleton babies were enrolled at discharge. These women were interviewed at 6 weeks postpartum about their breastfeeding behaviors. According to expressing patterns at 6 week postpartum, women were divided into three groups: direct breastfeeding (group 1), combining direct breastfeeding with expressing (group 2), exclusive expressing (group 3). The investigators followed up the women by telephone thereafter at a bimonthly basis and documented breastfeeding duration. Survival analysis was conducted to explore the association between expressing patterns at 6 weeks postpartum and breastfeeding duration. Associated factors of exclusive expressing at 6 weeks postpartum were characterized by logistic regression analysis.

Results

Four hundred one eligible women were enrolled at discharge. Among the 389 women who attended the face-to-face interview at 6 weeks postpartum, 345 women continued breastfeeding. They were divided into 3 groups by their expressing patterns. According to survival analysis, women who exclusively expressed breast milk at 6 months postpartum (group 3) were 1.77 times as likely to stop breastfeeding as those who did not (group 1 and 2) (95 % confidence interval: 1.25–2.48; P <0.001). There is, however, no significant difference of breastfeeding duration between group 1 and group 2. Subgroup analysis showed that exclusive expressing women who were exclusively breastfeeding at 6 weeks postpartum had the shortest breastfeeding duration. Mother’s high education level, short maternity leave, breast milk expression in hospital and bottle-feeding in hospital were associated factors to exclusive expressing at 6 weeks postpartum.

Conclusions

Exclusive expressing in the early postpartum period may not help women to achieve long-term breastfeeding duration, especially in women who were exclusively breastfeeding.

An Institutional Ethnography of Nurses' Support of Breastfeeding on the Night Shift

OBJECTIVE

To describe nurses' support of breastfeeding on the night shift and to identify the interpersonal interactions and institutional structures that affect this support.

DESIGN

Institutional ethnography.

SETTING

The mother/baby unit of a tertiary care hospital with 4200 births per year.

PARTICIPANTS

Registered nurses (N = 16) who provided care on the night shift to mother/infant dyads in the immediate postpartum period.

METHODS

Data were collected using focus groups, individual and group interviews, and mother/baby unit observations. The focus groups were held before the night shift and had five participants. The nine individual and group interviews were conducted between 0100 and 0230 on the mother/baby unit. Three unit observations were conducted. Interviews were recorded, professionally transcribed, and analyzed using a content analysis method.

RESULTS

Data analysis yielded three themes that described these nurses' support of breastfeeding on the night shift: competing priorities, incongruent expectations, and influential institutional structures. The need of visitors to see their new family members competed with the needs of mothers to rest and breastfeed their newborns. Helping breastfeeding dyads who experienced difficulties competed with providing care to other patients. Parents' expectations regarding newborn behavior were incongruent with the reality of newborn feeding and sleeping patterns. Institutional structures that affected the provision of breastfeeding support by nurses included hospital breastfeeding practices, staffing, and policies.

CONCLUSION

Nurses' support of breastfeeding on the night shift encompasses a complex interplay of interpersonal interactions with new families and visitors regarding priorities and expectations and negotiating institutional structures such as feeding policies and staffing.

Reasons for initial formula supplementation of healthy breastfeeding newborns

In a retrospective review of 302 hospital charts, 38 percent of newborns whose mothers planned to exclusively breastfeed received formula before hospital discharge. Those breastfeeding infants who did not receive formula were significantly younger at first breastfeeding than infants who received formula. Significantly more infants born by cesarean (51 percent) received supplementation than those born vaginally (31 percent). Birth between 9 p.m. and 10 a.m. and a hospital stay for more than 24 hours increased odds of supplementation. Nurses can explore barriers to exclusive breastfeeding unique to their hospitals to develop strategies that facilitate breastfeeding support and decrease formula supplementation.

Effect of a hospital policy of not accepting free infant formula on in-hospital formula supplementation rates and breast-feeding duration

Objective

To investigate the effect of public hospitals in Hong Kong not accepting free infant formula from manufacturers on in-hospital formula supplementation rates and breast-feeding duration.

Design

Prospective cohort study.

Setting

In-patient postnatal units of four public hospitals in Hong Kong.

Subjects

Two cohorts of breast-feeding mother–infant pairs (n 2560). Cohort 1 (n 1320) was recruited before implementation of the policy to stop accepting free infant formula and cohort 2 (n 1240) was recruited after policy implementation. Participants were followed prospectively for 12 months or until they stopped breast-feeding.

Results

The mean number of formula supplements given to infants in the first 24 h was 2·70 (sd 3·11) in cohort 1 and 1·17 (sd 1·94) in cohort 2 (P<0·001). The proportion of infants who were exclusively breast-fed during the hospital stay increased from 17·7 % in cohort 1 to 41·3 % in cohort 2 (P<0·001) and the risk of breast-feeding cessation was significantly lower in cohort 2 (hazard ratio=0·81; 95 % CI 0·73, 0·90). Participants who non-exclusively breast-fed during the hospital stay had a significantly higher risk of stopping any or exclusive breast-feeding. Higher levels of formula supplementation also increased the risk of breast-feeding cessation in a dose–response pattern.

Conclusions

After implementation of a hospital policy to pay market price for infant formula, rates of in-hospital formula supplementation were reduced and the rates of in-hospital exclusive breast-feeding and breast-feeding duration increased.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2014) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted data and assessed risk of bias.

MAIN RESULTS

We included eight trials (984 randomised infants/mothers). Six trials (n = 613 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one secondary outcome (weight change). The trials that provided outcome data compared exclusively breastfed infants with breastfed infants who were allowed additional nutrients in the form of artificial milk, glucose, water or solid foods.In relation to the majority of the older trials, the description of study methods was inadequate to assess the risk of bias. The two more recent trials, were found to be at low risk of bias for selection and detection bias. The overall quality of the evidence for the main comparison was low.In one trial (170 infants) comparing exclusively breastfeeding infants with infants who were allowed additional glucose water, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), with more infants in the exclusive breastfed group still exclusively breastfeeding. Conversely in one small trial (39 infants) comparing exclusive breastfed infants with non-exclusive breastfed infants who were provided with artificial milk, fewer infants in the exclusive breastfed group were exclusively breastfeeding at one week (RR 0.58, 95% CI 0.37 to 0.92) and at three months (RR 0.44, 95% CI 0.26 to 0.76) and there was no significant difference in the proportion of infants continuing any breastfeeding at three months between groups (RR 0.76, 95% CI 0.56 to 1.03).For infant morbidity (six trials), one newborn trial (170 infants) found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference (MD) 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24 mmol/L, 95% CI -0.51 to 0.03). Weight loss was also higher (grams) in infants at six, 12, 24 and 48 hours of life in the exclusively breastfed infants compared to those who received additional glucose water (MD 7.00 g, 95% CI 0.76 to 13.24; MD 11.50 g, 95% CI 1.71 to 21.29; MD 13.40 g, 95% CI 0.43 to 26.37; MD 32.50 g, 95% CI 12.91 to 52.09), but no difference between groups was observed at 72 hours of life. In another trial (47 infants analysed), we found no significant difference in weight loss between the exclusively breastfeeding group and the group allowed either water or glucose water on either day three or day five (MD 1.03%, 95% CI -0.18 to 2.24) and (MD 0.20%, 95% CI -1.18 to 1.58).Three trials with four- to six-month-old infants provided no evidence to support any benefit from the addition of complementary foods at four months versus exclusive breastfeeding to six months nor any risks related either morbidity or weight change (or both).None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence of benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water, and the quality of the evidence from a small pilot study on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer-term effects on infants and mothers, though randomising infants to receive supplements without medical need may be problematic.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

Factors associated with exclusive breastfeeding at hospital discharge in rural Western Australia

BACKGROUND

Breastfeeding is accepted as the best way of feeding infants, and health authorities recommend exclusive breastfeeding to around 6 months of age, but despite the evidence of its benefits, few mothers meet this goal. Infants who are exclusively breastfed in the early postpartum period are more likely to continue breastfeeding at 6 and 12 months, reinforcing the role that Baby-Friendly hospital practices play in supporting exclusive breastfeeding.

OBJECTIVES

This study aimed to determine the rate of breastfeeding initiation and identify the factors associated with exclusive breastfeeding at discharge from hospital for rural mothers.

METHODS

The prospective cohort study recruited 489 women from hospitals in regional Western Australia following the birth of their infant. Breastfeeding exclusivity at discharge was assessed based on mothers' self-reported infant feeding behavior during her hospital stay. The self-administered baseline questionnaire was completed by 427 mothers.

RESULTS

Breastfeeding was initiated by 97.7% of the mothers in this cohort, with 82.7% exclusively breastfeeding at hospital discharge. The odds of exclusive breastfeeding at discharge were more than 4 times higher for women whose infants did not require admission to the special care nursery (adjusted odds ratio [aOR] = 4.43; 95% confidence interval [CI], 1.98-9.99). Demand feeding (aOR = 3.33; 95% CI, 1.59-6.95) and 24-hour rooming-in (aOR = 2.31; 95% CI, 1.15-4.62) were also significant positive factors.

CONCLUSION

The findings suggest that hospital practices are strong predictors of exclusive breastfeeding. Greater emphasis on Baby-Friendly hospital practices in the early postpartum period may help the establishment of exclusive breastfeeding, assisting rural mothers to reach established international breastfeeding recommendations.

Factors influencing the intention of perinatal nurses to adopt the baby-friendly hospital initiative in southeastern quebec, Canada: implications for practice

Nurses play a major role in promoting the baby-friendly hospital initiative (BFHI), yet the adoption of this initiative by nurses remains a challenge in many countries, despite evidences of its positive impacts on breastfeeding outcomes. The aim of this study was to identify the factors influencing perinatal nurses to adopt the BFHI in their practice. Methods. A sample of 159 perinatal nurses from six hospital-based maternity centers completed a survey based on the theory of planned behavior. Hierarchical multiple linear regression analyses were performed to assess the relationship between key independent variables and nurses' intention to adopt the BFHI in their practice. A discriminant analysis of nurses' beliefs helped identify the targets of actions to foster the adoption the BFHI among nurses. Results. The participants are mainly influenced by factors pertaining to their perceived capacity to overcome the strict criteria of the BFHI, the mothers' approval of a nursing practice based on the BFHI, and the antenatal preparation of the mothers. Conclusions. This study provides theory-based evidence for the development of effective interventions aimed at promoting the adoption of the BFHI in nurses' practice.

Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns

BACKGROUND

Although exclusive breastfeeding is recommended for the first 6 months, the use of breast milk substitutes is widespread around the world.

OBJECTIVES

To describe the patterns of infant formula supplementation among healthy breastfeeding newborns, to identify factors contributing to in-hospital formula supplementation, and to assess the dose-response relationship between the amount of in-hospital formula supplementation and the duration of any breastfeeding.

METHODS

A sample of 1246 breastfeeding mother-infant pairs was recruited from 4 public hospitals in Hong Kong and followed prospectively for 12 months or until weaned. Multiple logistic regression analysis was used to examine factors associated with in-hospital supplementation. Cox regression analysis was used to explore the impact of in-hospital supplementation on breastfeeding duration.

RESULTS

Of the total, 82.5% of newborns were supplemented in the hospital; one-half received formula within 5 hours of birth. Assisted vaginal delivery (odds ratio [OR] = 2.06, 95% confidence interval [CI] 1.03, 4.15), cesarean section (OR = 3.45, 95% CI 1.75, 6.80), and higher birth weight (OR = 1.56, 95% CI 1.12, 2.18) were positively associated with in-hospital formula supplementation, whereas initiating breastfeeding in the delivery room (OR = 0.55, 95% CI 0.33, 0.89) was associated with decreased likelihood of in-hospital supplementation. Any infant formula in the first 48 hours was associated with a shorter duration of breastfeeding (hazard ratio [HR] = 1.51, 95% CI 1.27, 1.80), but there was no dose-response effect.

CONCLUSION

In-hospital formula supplementation is common in Hong Kong hospitals and appears to be detrimental to breastfeeding duration. Continued efforts should be made to avoid the provision of infant formula to breastfeeding babies while in the hospital unless medically indicated.

Maternal accounts of their breast-feeding intent and early challenges after caesarean childbirth

BACKGROUND

breast-feeding outcomes are often worse after caesarean section compared to vaginal childbirth.

OBJECTIVES

this study characterises mothers' breast-feeding intentions and their infant feeding experiences after caesarean childbirth.

METHODS

data are from 115 mothers on a postnatal unit in Northeast England during February 2006-March 2009. Interviews were conducted an average of 1.5 days (range 1-6 days) after the women underwent unscheduled or scheduled caesarean.

RESULTS

thematic analysis of the data suggested was mostly considered the 'right thing to do,' preferable, natural, and 'supposedly healthier,' but tiring and painful. Advantages of supplementation involved more satiated infants, feeding ease, and longer sleep bouts. The need for 'thinking about yourself' was part of caesarean recovery. Infrequent feeding was concerning but also enabled maternal rest. Other breast-feeding obstacles were maternal mobility limitations, positioning difficulties, and frustration at the need for assistance. Participants were confused about nocturnal infant wakings, leading many to determine that they had insufficient milk. Mothers were surprised that sub-clinically poor infant condition was common following caesarean section. Some breast-feeding difficulty stemmed from 'mucus' expulsion that had to occur before the infants could be 'interested' in feeding. Women who cited motivations for breast feeding that included benefit to themselves were more likely to exclusively breast feed on the postnatal unit after their caesareans than those who reported infant-only motivations.

CONCLUSIONS

for the majority of mothers, breast feeding after a caesarean is affected by interrelated and compounding difficulties. Provision of more relational breast-feeding information may enable families to better anticipate early feeding experiences after caesarean section childbirth.

Relationship between intention to supplement with infant formula and breastfeeding duration

OBJECTIVES

According to Health Canada and the Canadian Paediatric Society, infants should be exclusively breastfed for the first six months with continued breastfeeding for two years and beyond. This study examined the relationship between a mother's intention to supplement with infant formula and the risk of discontinuing breastfeeding during the 12 months postpartum.

METHODS

Surveys were administered to a cohort of mothers at 6 weeks, 6 months and 12 months postpartum as part of York Region's Infant Feeding Survey. Those who initiated breastfeeding were included in the analysis (n=345). The relationship between a mother's prenatal intention to supplement with infant formula and breastfeeding duration was examined using Cox proportional hazards regression controlling for mother's age, prenatal education, immigration status, parity, household income, mother's ethnicity and education.

RESULTS

Nearly one third of mothers intended to supplement with infant formula. Of those mothers, 69% actually supplemented their baby with infant formula within 12 months postpartum. Intention to supplement was found to be associated with shorter breastfeeding duration (HR=2.64, 95% CI 1.83-3.81). First-time mothers experienced shorter breastfeeding duration compared to experienced mothers (HR=2.13, 95% CI 1.39-3.27). Mothers who identified as European experienced shorter breastfeeding duration compared to East, Southeast or South Asian mothers (HR=1.79, 95% CI 1.05-3.06).

CONCLUSIONS

Continued breastfeeding is not only beneficial for the infant, but it also has important benefits for the mother. The analysis indicates that a mother's prenatal intent to supplement may be associated with shorter breastfeeding duration. Further research is required to confirm these findings and to address the underlying assumptions and limitations.