The new mandate from the joint commission on the perinatal care core measure of exclusive breast milk feeding: implications for practice and implementation in the United States

Differences in Exclusive Breastfeeding Rates in US Hospitals According to Baby-Friendly Hospital Initiative Designation and Area Deprivation Index Category

Background: Disparities in breastfeeding persist placing a greater burden of disease on non-Hispanic black and Hispanic women and infants. Targeted implementation of the Baby-Friendly Hospital Initiative (BFHI) in areas at risk for poor breastfeeding outcomes has been shown to improve disparities in breastfeeding. The area deprivation index (ADI), a measure of the relative socioeconomic disadvantage of a neighborhood, may be useful in exploring the accessibility of BFHI hospitals in highly deprived areas and the differences in exclusive breastfeeding (EBF) rates in hospitals with and without the BFHI designation across deprivation categories. Objective: To evaluate the geographical distribution of BFHI and non-BFHI hospitals across ADI categories and explore the differences in EBF rates in BFHI and non-BFHI hospitals across ADI categories. Methods: Hospital EBF rates obtained from the Joint Commission included 414 BFHI and 1,532 non-BFHI hospitals. State ADI rank scores were determined for each hospital's census block group. Descriptive statistics were used to describe the geographic distribution of BFHI hospitals across three ADI categories (low, medium, and high). EBF rates across ADI categories and BFHI designations were compared using multiway analysis of variance. Results: The distribution of BFHI was similar across all ADI categories, ranging from 18% to 24%. EBF rates were 4.9% lower in highly deprived areas compared to areas with lower deprivation (p < 0.01). BFHI was associated with significantly higher EBF rates across all ADI categories (6.9%-11.2%, p < 0.01). Conclusion: ADI may be a useful tool for targeting the implementation of BFHI in hospitals in highly deprived areas to reduce breastfeeding disparities.

The Effect of Circumcision on Exclusive Breastfeeding, Phototherapy, and Hospital Length of Stay in Term Breastfed Newborns

BACKGROUND AND OBJECTIVES

Little is known about the effect of circumcision on breastfeeding in the hours and days after the procedure. Factors with the potential to negatively impact breastfeeding success in the newborn period may result in higher rates of jaundice requiring phototherapy and formula supplementation, both of which can potentially extend the length of initial hospitalization. Our objective was to determine the impact of circumcision on rates of exclusive breastfeeding, neonatal jaundice requiring phototherapy, and length of stay at hospital discharge immediately after birth.

METHODS

Term male newborn infants whose mothers intended to exclusively breastfeed were included in this retrospective cohort. Bivariate analysis and multivariate logistic regression modeling were used to evaluate target behaviors, comparing infant boys who were circumcised with those who were uncircumcised.

RESULTS

Of the 1109 breastfed male newborns included, 846 (76.6%) were circumcised. There was no significant effect of circumcision status or circumcision timing on the rate of in-hospital formula supplementation. There were no differences in peak bilirubin levels, phototherapy requirement, or length of hospital stay for male newborns based on circumcision status.

CONCLUSIONS

Circumcision did not affect the rate of exclusive breastfeeding, neonatal jaundice, phototherapy requirement, or length of hospital stay in this retrospective analysis of breastfed male newborns.

Breastfeeding as a Quality Measure: Demonstrating Levers of the National Quality Strategy

The purpose of this study is to explore the National Quality Strategy (NQS) levers (measurement and feedback, public reporting, learning and technical assistance, and certification) on state and national breastfeeding performance. The research evaluates the NQS levers of measurement and feedback and public reporting using secondary data analysis of publicly reported data from the National Immunization Survey and the Centers for Disease Control and Prevention Breastfeeding Report Cards between 2008 and 2018, the latest years available. Linear regression explores the association between the prevalence of state-level Baby-Friendly hospitals and state-level breastfeeding rates. Subsequent analyses use event study to test whether state-level Baby-Friendly hospital adoption is associated with higher breastfeeding rates. A 10% increase in Baby-Friendly hospitals at the state level is associated with increased population breastfeeding rates by nearly 5% and a decrease in early formula use (before 2 days of life) by 2% to 9%. Breastfeeding increased by 2% to 5% in the first 2 years following state-level Baby-Friendly initiatives, with subsequent increases up to 10% in the next 4 years. The National Quality Strategy levers of measurement and public reporting combined with certification and learning and technical assistance are associated with increases in exclusive breastfeeding, a national quality metric.

First-Day Use of the Newborn Weight Loss Tool to Predict Excess Weight Loss in Breastfeeding Newborns

Background and Objectives: Exclusive breastfeeding is recommended for most newborns. However, exclusively breastfed newborns sometimes experience excess weight loss (EWL, loss ≥10% of birth weight) while lactation is being established. Our primary objective was to evaluate the sensitivity and specificity of the Newborn Weight Loss Tool (NEWT) in early identification of exclusively breastfed newborns who develop EWL; and secondarily, identify breastfeeding variables associated with an at-risk NEWT trajectory. Materials and Methods: We conducted a secondary analysis of prospective data from mother-infant dyads screened for inclusion in the U.S. site of the WHO Growth Reference Study. We excluded records if: NEWT-specific criteria not met, missing key data, or >60 mL formula consumed. We defined NEWT "test-positive" based on an in-hospital weight at about 24 hours falling within the NEWT trajectory consistent with eventual EWL. We defined cases as true EWL based on weight measured at home on day of life 4 (DoL4). Results: Of 280 original records, 60 were excluded (n = 27, NEWT-specific exclusion; n = 15, missing data; n = 18, >60 mL formula), resulting in 220 paired newborn weights measured in-hospital (17 ± 8 hours), and at DoL4 (84 ± 8 hours). NEWT status correctly identified 6/28 EWL cases (21% sensitivity [95% confidence interval, CI, 8-34%]), and 158/192 noncases (82% specificity [95% CI, 75-89%]). NEWT test-positive status was associated with greater weight loss, lower perceived breastfeeding support, and infant less often showing feeding cues on DoL4 (p < 0.05). Conclusion: Sensitivity in predicting EWL is low when applying NEWT at about 24 hours of life; however, early test-positive status is associated with indicators of breastfeeding difficulties on DoL4.

Breastfeeding initiation among women with preeclampsia with and without severe features

BACKGROUND

Timely delivery and magnesium sulfate (MgSO4) are mainstay in the treatment of preeclampsia with severe features (PWSF). Premature delivery, severity of illness and mother-infant separation may increase the risk for breastfeeding (BF) initiation failure.

OBJECTIVE

To compare BF initiation among women with late-onset PWSF treated with MgSO4 to women with late-onset preeclampsia without severe features (WOSF) who did not receive MgSO4.

METHODS

Retrospective study of 158 women with PWSF and 104 with WOSF who delivered at ≥34 weeks. Intention to BF, formula feed (FF) or partially BF was declared prenatally. At discharge, exclusive BF included direct BF or direct BF with expressed breast milk (EBM).

RESULTS

PWSF and WOSF groups were similar in age, race, and obstetric history. PWSF and WSOF differed in primiparity (65 & 51%), late preterm births (73 vs 15%), admission to NICU (44 &17%) and mother (5 & 4d) and infant (6 & 3d) hospital stay. Both groups were similar in intention to BF (80 & 84%), to FF (16 & 13%) and to partially BF (5 & 5%). At discharge, exclusive BF (37 & 39%), partial BF (33 & 31%) and FF (30 & 30%) were similar. Exclusive BF in the PWSF group was 43% direct BF, 28% direct BF and EBM and 29% EBM alone whereas in the WOSF group exclusive BF was 93% direct BF and 7% direct BF and EBM.

CONCLUSION

BF initiation rates for women with PWSF and WOSF were similar. EBM alone or with direct BF enabled infants in the PWSF group to exclusively BF at discharge.

The impact on the exclusive breastfeeding rate at 6 months of life of introducing supplementary donor milk into the level 1 newborn nursery

OBJECTIVES

This study explored whether donor-milk supplementation increases breastfeeding exclusivity at 6 months of life. In 10/2015, we implemented donor milk for breastfed newborns who needed nutritional supplements for hypoglycemia, hyperbilirubinemia, and >8% weight loss at 40 h of life.

STUDY DESIGN

We conducted a retrospective chart review on 122 qualified neonates admitted to newborn nursery at University of Florida Jacksonville 4 months before donor-milk implementation and 6 months after.

RESULTS

73 (60%) of the neonates received formula and 49 (40%) received donor milk. 39 (54%) in the formula group and 33 (46%) in the donor-milk group were surveyed after 6 months of life. Multivariate logistic regression showed that newborns who received donor milk had five times greater odds of being exclusively breastfed at 6 months of life.

CONCLUSIONS

Donor milk as feeding supplementation for newborns is associated with increased exclusive breastfeeding at 6 months of life.

Prescribing Video-Based Patient Education in the Hospital Setting: Can Bedside Breastfeeding Videos Affect Exclusive Breastfeeding at Postpartum Discharge?

BACKGROUND AND OBJECTIVES

Evaluate the impact of a standardized bundle of educational videos delivered via the bedside television to postpartum mothers on exclusive breastfeeding rates. Despite the growing use of videos for hospital discharge education, there is a paucity of literature evaluating their effectiveness.

METHODS

In November 2015, we began ordering 4 externally produced, peer-reviewed breastfeeding education videos for all postpartum mothers to view via their bedside televisions. Mothers could choose whether to watch the videos, and if they did, this was automatically documented in the electronic health record. We then performed a retrospective chart review generating a data set focusing on newborns who were healthy, term, and appropriate for gestational age, born in the year pre- and postintervention, and compared exclusive breastfeeding rates at the time of discharge among both groups.

RESULTS

Our data set included 3115 newborns (1467 pre- and 1648 postintervention). In the postintervention year, the exclusive breastfeeding rate at discharge was 69.5% vs 68.4% preintervention (P value: .80). Most mothers (81.3%; 1339) watched all 4 videos, and 308 mothers (18.7%) watched none. The mothers who watched all 4 videos were more likely to breastfeed exclusively (72.7% vs 55.3%) and less likely to exclusively formula feed than the mothers who watched none (1.1% vs 19.8%; P < .0001).

CONCLUSIONS

There was no change in exclusive breastfeeding rates pre- versus post-video education intervention. However, most mothers watched all 4 videos, and those who did were significantly more likely to engage in any breastfeeding (98.9%) compared with those who watched none (80.2%) during the postpartum hospitalization.

Contribution of Maternal Obesity to Medically Indicated and Elective Formula Supplementation in a Baby-Friendly Hospital

Objective: Determine if maternal obesity increases use of medically indicated or elective formula in the context of a Baby-Friendly Hospital with high prevalence of obesity. Study Design: We conducted a secondary analysis of mothers who initiated breastfeeding of their term, singleton infant born at a Baby-Friendly community hospital in 2016. We defined medically indicated as formula given per physician order; and elective as formula given per maternal request. We used multinomial logistic regression to determine the odds ratio (OR) and 95% confidence interval (95% CI) for medically indicated and elective formula (each versus exclusive breastfeeding) by obesity status. We adjusted for available covariates and mediating conditions that may be exacerbated by obesity. Results: A total of 1,245 mothers met inclusion criteria, of which 41% were obese. Exclusive breastfeeding, medically indicated formula, and elective formula were 84% versus 70%, 5% versus 12%, and 11% versus 18%, in nonobese versus obese women, respectively. After adjusting for covariates, obesity significantly increased the risk for medically indicated (OR 2.6 [95% CI 1.7-4.1]) and elective (OR 2.0 [95% CI 1.5-2.8]) formula. After additionally adjusting for conditions exacerbated by obesity, the risk of medically indicated formula was attenuated by 48% (OR 1.7 [95% CI 1.02-2.7]), and there was little attenuation of the risk of elective formula (OR 1.8 [95% CI 1.3-2.6]). Conclusions: In a setting with high obesity prevalence and strong support for exclusive breastfeeding, obesity accounted for 36% of medically indicated formula and 21% of elective formula use. In this era of globally increasing maternal obesity prevalence, there is an urgent need to develop successful strategies for supporting breastfeeding that goes above and beyond standard Baby-Friendly approaches.

Intent to Breastfeed and Evaluation of Culturally Sensitive Education in a Migrant Pacific Islander Population

Background

The Marshallese, a Pacific Islander population, are a growing migrant population in the United States. Breastfeeding is the preferred method of infant feeding, but many cultural barriers deter exclusive breastfeeding. A culturally sensitive education intervention was implemented to meet the needs of the Marshallese population in a postpartum setting.

Objective

This study aimed to evaluate the impact of an education intervention, in native language, on breastfeeding rates among Marshallese mothers during hospitalization.

Methods

This quasi-experimental study was a retrospective data analysis of a quality improvement project in a hospital seeking Baby-Friendly status. Randomized record reviews of Marshallese mothers receiving the culturally targeted education (N = 40) between the ages of 18 and 45, delivering between 37 and 42 weeks gestation, were compared with mothers prior to implementation of the education (N = 40).

Results

Birthweight, discharge weight, and delivery method were not statistically different. No statistical difference existed between feeding intent and discharge feeding behavior.

Conclusion

Exclusive breastfeeding rates among Marshallese mothers are lower than desired. Culturally appropriate breastfeeding education in a hospital setting may not affect feeding patterns, but clarification is needed on cultural definitions of exclusive breastfeeding. Further studies are needed.

Baby-Friendly Practices Minimize Newborn Infants Weight Loss

INTRODUCTION

It is accepted that newborns lose weight in the first few days of life. Baby-Friendly practices that support breastfeeding may affect newborn weight loss. The objective of this study were: 1) To determine whether Baby-Friendly practices are associated with term newborn weight loss day 0-2 in three feeding categories (exclusively breastfed, mixed formula fed and breastfed, and formula fed). 2) To determine whether Baby-Friendly practices increase exclusive breast feeding rates in different ethnic populations.

MATERIALS AND METHODS

This was a retrospective case-control study. Term newborn birth weight, neonatal weights days 0-2, feeding type, type of birth, and demographic information were collected for 1,000 births for the year before Baby-Friendly designation (2010) and 1,000 in 2013 (after designation). Ultimately 683 in the first group and 518 in the second met the inclusion criteria.

RESULTS

Mean weight loss decreased day 0-2 for infants in all feeding types after the initiation of Baby-Friendly practices. There was a statistically significant effect of Baby-Friendly designation on weight loss for day 0-2 in exclusively breastfed infants (p < 0.01) after controlling for birth weight. Exclusive breast feeding increased in all ethnic groups after Baby-Friendly practices were put in place.

CONCLUSION

There was a decrease in mean weight loss day 0-2 regardless of feeding type after Baby-Friendly designation. Exclusive breast feeding increased in the presence of Baby-Friendly practices.

Best Fed Beginnings: A Nationwide Quality Improvement Initiative to Increase Breastfeeding

BACKGROUND AND OBJECTIVE

In response to a low number of Baby-Friendly-designated hospitals in the United States, the Centers for Disease Control and Prevention funded the National Institute for Children's Health Quality to conduct a national quality improvement initiative between 2011 and 2015. The initiative was entitled Best Fed Beginnings and enrolled 90 hospitals in a nationwide initiative to increase breastfeeding and achieve Baby-Friendly designation.

METHODS

The intervention period lasted from July 2012 to August 2014. During that period, data on process indicators aligned with the Ten Steps to Successful Breastfeeding and outcome measures (overall and exclusively related to breastfeeding) were collected. In addition, data on the Baby-Friendly designation were collected after the end of the intervention through April 2016. Hospitals assembled multidisciplinary teams that included parent partners and community representatives. Three in-person learning sessions were interspersed with remote learning and tests of change, and a Web-based platform housed resources and data for widespread sharing.

RESULTS

By April 2016, a total of 72 (80%) of the 90 hospitals received the Baby-Friendly designation, nearly doubling the number of designated hospitals in the United States. Participation in the Best Fed Beginnings initiative had significantly high correlation with designation compared with hospital applicants not in the program (Pearson's r [235]: 0.80; P < .01). Overall breastfeeding increased from 79% to 83% (t = 1.93; P = .057), and exclusive breastfeeding increased from 39% to 61% (t = 9.72; P < .001).

CONCLUSIONS

A nationwide initiative of maternity care hospitals accomplished rapid transformative changes to achieve Baby-Friendly designation. These changes were accompanied by a significant increase in exclusive breastfeeding.

Low milk supply and the pediatrician

PURPOSE OF REVIEW

Human milk is the optimal food for human infants, and provides many diverse and well described benefits for both mother and infant. Low milk supply, whether perceived or actual, is one of the most common reasons why mothers stop breastfeeding. Breastfeeding mothers often seek out the guidance and support of their pediatrician in evaluating and resolving milk production concerns.

RECENT FINDINGS

Recent evidence supports the importance of breastfeeding for maternal and child health in both developing and developed countries. Lack of knowledge regarding optimal breastfeeding management accounts for the large majority of low milk supply concerns, but there is emerging evidence that impaired glucose tolerance may contribute to intrinsic low milk supply.

SUMMARY

Breastfeeding mother-infant dyads should be followed closely until lactation is well established and the infant is gaining well. Further research is needed to understand the physiologic contributors to low milk supply and to guide evidence-based interventions to optimize maternal success in reaching breastfeeding goals, particularly for women of poorer metabolic health.

In-Hospital Formula Supplementation of Healthy Newborns: Practices, Reasons, and Their Medical Justification

INTRODUCTION

In-hospital formula supplementation is a common practice and has been shown to be a strong determinant of shorter exclusive and any breastfeeding.

OBJECTIVE

To investigate the reasons for and circumstances in which in-hospital formula supplementation occurs and whether the stated reasons are medically acceptable.

MATERIALS AND METHODS

This prospective cohort study was conducted among 342 mother-infant pairs from April to July 2011 at the Department of Obstetrics and Gynecology, University Hospital of Split, Croatia. Data were collected based on "every feed" charts and WHO/UNICEF "Questionnaire for Monitoring Baby-Friendly Hospitals". We used WHO/UNICEF Baby-Friendly Hospital Initiative and Academy of Breastfeeding Medicine documents on indications for supplemental feeding.

RESULTS

During the first 48 hours and entire hospital stay, 49.5% and 62.8% of infants, respectively, received supplements, given on average 16.68 ± 18.6 hours after delivery. In 94.1% of supplemented infants, healthy newborns were given artificial milk, of which 5.9% of mothers had not been notified. The most common maternal reasons for supplementing were "lack of milk" (49.8%), a "crying baby" (35.5%), "cesarean section" (11.5%), newborn weight loss (10.6%), and sore nipples (10.1%). Of all the given reasons, 24.6% were categorized as being medically acceptable. Primiparas were 1.3 times more likely to supplement in hospital, whereas multiparas were 1.3 times more likely to exclusively breastfeed.

CONCLUSION

In our study, most reasons for formula supplementation of healthy term newborns were not standard acceptable medical reasons, indicating a need for improved maternal support, revision of hospital policies, and training of hospital staff.

The Impact of a Prenatal Education Video on Rates of Breastfeeding Initiation and Exclusivity during the Newborn Hospital Stay in a Low-income Population

BACKGROUND

Guidelines recommend prenatal education to improve breastfeeding rates; however, effective educational interventions targeted at low-income, minority populations are needed as they remain less likely to breastfeed.

OBJECTIVE

To determine whether a low-cost prenatal education video improves hospital rates of breastfeeding initiation and exclusivity in a low-income population.

METHODS

A total of 522 low-income women were randomized during a prenatal care visit occurring in the third trimester to view an educational video on either breastfeeding or prenatal nutrition and exercise. Using multivariable analyses, breastfeeding initiation rates and exclusivity during the hospital stay were compared.

RESULTS

Exposure to the intervention did not affect breastfeeding initiation rates or duration during the hospital stay. The lack of an effect on breastfeeding initiation persisted even after controlling for partner, parent, or other living at home and infant complications (adjusted odds ratio [OR] = 1.05, 95% CI, 0.70-1.56). In addition, breastfeeding exclusivity rates during the hospital stay did not differ between the groups (P = .87).

CONCLUSION

This study suggests that an educational breastfeeding video alone is ineffective in improving the hospital breastfeeding practices of low-income women. Increasing breastfeeding rates in this at-risk population likely requires a multipronged effort begun early in pregnancy or preconception.

Important determinants of newborn health: postpartum depression, teen parenting, and breast-feeding

PURPOSE OF REVIEW

The present article addresses recent research related to three important determinants of newborn health: postpartum depression, teenage parents and their offspring, and breast-feeding.

RECENT FINDINGS

Postpartum depression can impact the entire family unit, and fathers may be affected more than previously recognized. Teenage mothers and their infants are at risk of a number of poor physical and mental health outcomes. New research continues to support the benefits of breast-feeding infants, and hospitals have adopted policies to improve breast-feeding rates.

SUMMARY

Recognizing both maternal and paternal depression during outpatient visits is key to family well-being, as well as to infant development and attachment. Pediatric providers should address the unique emotional, socioeconomic, educational, and health needs of teen mothers. Hospital implementation of evidence-based policies may increase the number of mothers who are successful in establishing breast-feeding, and pediatric healthcare providers should be prepared to support mothers of breast-feeding infants.

Quality indicators for human milk use in very low-birthweight infants: are we measuring what we should be measuring?

OBJECTIVE

The objective of this study was to compare the currently used human milk (HM) quality indicators that measure whether very low-birthweight (VLBW; <1500 g birthweight) infants 'ever' received HM and whether they were still receiving HM at discharge from the neonatal intensive care unit (NICU) to the actual amount and timing of HM received.

STUDY DESIGN

This study used data from a large NIH-funded cohort study and calculated whether VLBW infants ever received HM (HM-Ever) and of these infants, the percentage who were still receiving HM at NICU discharge (HM-DC). Then, the HM-DC indicator (exclusive, partial and none) was compared with the amount and timing of HM feedings received by these same infants.

RESULT

Of the 291 VLBW infants who met inclusion criteria, 285 received some HM (HM-Ever=98%). At NICU discharge (HM-DC), 24.2, 15.1 and 60.7% were receiving exclusive, partial and no HM, respectively. Of the 60.7% infants with no HM-DC, some had received higher amounts of HM during the NICU hospitalization than infants categorized as exclusive and partial for HM-DC. Of the infants with no HM-DC, 76.8 and 59.7% had received exclusive HM during the days 1-14 and days 1-28 exposure periods, respectively.

CONCLUSION

The average daily dose (HM-DD; in ml kg(-1) d(-1)) and cumulative percentage (HM-PCT; as % of cumulative enteral intake) of HM feedings were sufficient to significantly reduce the risk of multiple morbidities, including late-onset sepsis, necrotizing enterocolitis, neurocognitive delay and rehospitalization, in the majority of the VLBW infants who were discharged with no HM-DC. Quality indicators that focus on the amount and timing of HM feedings in the NICU should be added to the HM-Ever and HM-DC measures.

Using benchmarking techniques and the 2011 maternity practices infant nutrition and care (mPINC) survey to improve performance among peer groups across the United States

BACKGROUND

A substantial proportion of US maternity care facilities engage in practices that are not evidence-based and that interfere with breastfeeding. The CDC Survey of Maternity Practices in Infant Nutrition and Care (mPINC) showed significant variation in maternity practices among US states.

OBJECTIVE

The purpose of this article is to use benchmarking techniques to identify states within relevant peer groups that were top performers on mPINC survey indicators related to breastfeeding support.

METHODS

We used 11 indicators of breastfeeding-related maternity care from the 2011 mPINC survey and benchmarking techniques to organize and compare hospital-based maternity practices across the 50 states and Washington, DC. We created peer categories for benchmarking first by region (grouping states by West, Midwest, South, and Northeast) and then by size (grouping states by the number of maternity facilities and dividing each region into approximately equal halves based on the number of facilities).

RESULTS

Thirty-four states had scores high enough to serve as benchmarks, and 32 states had scores low enough to reflect the lowest score gap from the benchmark on at least 1 indicator. No state served as the benchmark on more than 5 indicators and no state was furthest from the benchmark on more than 7 indicators. The small peer group benchmarks in the South, West, and Midwest were better than the large peer group benchmarks on 91%, 82%, and 36% of the indicators, respectively. In the West large, the Midwest large, the Midwest small, and the South large peer groups, 4-6 benchmarks showed that less than 50% of hospitals have ideal practice in all states.

CONCLUSION

The evaluation presents benchmarks for peer group state comparisons that provide potential and feasible targets for improvement.