Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT

Do various types of prelacteal feeding (PLF) have different associations with breastfeeding duration in Indonesia? A cross-sectional study using Indonesia Demographic and Health Survey datasets

INTRODUCTION

Prelacteal feeding (PLF) is anything other than breastmilk given to newborns in the first few days of birth and/or before breastfeeding is established. PLF comes in many forms and is known as a challenge to optimal breastfeeding. Interestingly, both breastfeeding and PLF are common in Indonesia. This study investigated the association between PLF (any PLF, formula, honey, water and other milk) and breastfeeding duration.

METHODS

This study used Indonesia Demographic and Health Surveys data from 2002, 2007 and 2017. Sample sizes were 5558 (2007), 6268 (2007) and 6227 (2017) mothers whose last child was aged 0-23 months. We used Cox regression survival analysis to assess the association between PLF and breastfeeding duration, estimating hazard ratios (HR) for stopping earlier.

RESULTS

Overall PLF was prevalent (59%, 67% and 45% in 2002, 2007 and 2017, respectively), with formula being the most common (38%, 50% and 25%). No association between any PLF and breastfeeding duration in 2002 (HR 0.90 (95% CI 0.70 to 1.16)), but in 2007 and 2017, mothers who gave any PLF were more likely to stop breastfeeding earlier than those who did not (HR 1.33 (95% CI 1.11 to 1.61) and 1.47 (95% CI 1.28 to 1.69), respectively), especially in the first 6 months (HR 2.13 (95% CI 1.55 to 2.92) and 2.07 (95% CI 1.74 to 2.47), respectively). This association was more consistent for milk-based PLF. For example, HR in 2017 was 2.13 (95% CI 1.78 to 2.53) for prelacteal formula and 1.73 (95% CI 1.39 to 2.15) for other milk. The associations were inconsistent for the other PLF types. Prelacteal water showed no association while prelacteal honey showed some association with a longer breastfeeding duration in 2002 and 2007.

CONCLUSION

The impact of PLF on breastfeeding duration varied by type. While this study supports current recommendations to avoid PLF unless medically indicated, the potential consequences of different PLF types on breastfeeding outcomes should be clearly communicated to healthcare providers and mothers. Further research should explore the reasons for the high PLF prevalence in this setting.

'Breastfeeding exclusivity, difficulties, and support in the first days after hospital discharge: A correlational study'

OBJECTIVE

Global breastfeeding rates are not optimal, and the early postpartum period represents a critical time for breastfeeding initiation. The Baby-Friendly Hospital Initiative endeavours to provide mothers with evidence-based breastfeeding support in birth hospitals. This study examined factors associated with breastfeeding exclusivity and breastfeeding difficulties in the first days after being discharged from Baby-Friendly designated hospital. The adequacy of breastfeeding support and maternal preferences for optimal support were also reported.

STUDY DESIGN

A non-experimental correlational study was conducted between May 2021 and October 2022. A total of n = 80 breastfeeding mothers completed a semi-structured questionnaire within two weeks of discharge from Baby-Friendly hospital in Finland. The questionnaire included demographic and obstetric background information and six questions on breastfeeding exclusivity, breastfeeding difficulties, and breastfeeding support. Descriptive statistical analysis and multivariate binary logistic regression analysis were performed.

RESULTS

The mean age of the mothers was 30.6 years (SD 5.4), and half of the mothers were primiparas (49 %). Most mothers gave birth vaginally (85 %) to a full-term infant (84 %). Most (85 %) had made some prenatal plans for breastfeeding, and the median planned duration of breastfeeding was 12 months. Half of the infants (53 %) received supplemental milk while in the hospital. Most mothers (81 %) were exclusively breastfeeding after hospital discharge. Mothers whose infants received supplemental milk in the hospital had an increased odds of non-exclusive breastfeeding (aOR 16.5 [CI 95 % 1.7-156.7], p 0.015). Approximately one-third of the mothers (39 %) experienced breastfeeding difficulties. Primiparous mothers had increased odds of experiencing breastfeeding difficulties (aOR 3.41 [CI 95 % 1.2-9.8], p 0.023). Mothers who received adequate postnatal breastfeeding support in birth hospital had decreased odds of experiencing breastfeeding difficulties (aOR 0.16 [CI 95 % 0.03-0.8], p 0.026). Mothers were mainly satisfied with breastfeeding support, although timelier access to support was preferred after hospital discharge.

CONCLUSION

Adequate in-hospital postnatal breastfeeding support, including avoidance of non-medical supplementation, contributes to successful breastfeeding after hospital discharge in terms of more exclusive breastfeeding and fewer breastfeeding difficulties. Primiparous mothers need emphasized support to mitigate breastfeeding difficulties. Timelier access to breastfeeding support after discharge is needed.

Perspective: Supporting Maternal Efforts to Provide Optimal Infant Nutrition in the Post-Partum Setting

Supporting optimal newborn nutrition and the positive maternal-infant relationship while encouraging safe sleep practices are essential components of maternal and newborn care in the hospital setting following birth. Breastfeeding is widely recognized as the best practice to support the nutritional needs and well-being of the infant, and recommendations have been developed by the WHO, the American Academy of Pediatrics (AAP), and the United States Centers for Disease Control to encourage and successfully support breastfeeding efforts before hospital discharge. The 10 Steps to Successful Breastfeeding, developed and promoted by the WHO, form the basis of the Baby-Friendly Hospital Initiative (BFHI) and have become the international framework for public health initiatives to promote breastfeeding. An evaluation of hospital performance implementing the 10 steps through the process of "Baby-Friendly Designation" (BFD) has been suggested by many breastfeeding advocates as the optimal pathway to attain the goals of the BFHI. However, the WHO has recognized that BFD may not be an appropriate goal in all settings, and indicated, as part of their updated 2018 guidance, that "facilities may make changes in their policies and procedures to obtain the designation, but these changes are not always sustainable, especially when there are no regular monitoring systems in place." In addition, unintended associated issues regarding newborn safety and maternal dissatisfaction with some of the 10 steps have emerged. This perspective discusses the challenges faced by hospitals attempting to implement the BFHI 10 steps and suggests potential solutions to make progress in those efforts with or without BFD and also the efforts needed to support formula feedings when appropriate.

Breastfeeding and Once-Daily Small-Volume Formula Supplementation to Prevent Infant Growth Impairment

BACKGROUND

Randomized controlled trials in Guinea-Bissau and Uganda have revealed that the intensive promotion of exclusive breastfeeding (EBF) impairs growth in early infancy. When newborn growth is impaired, small amounts of formula may be combined with breastfeeding to promote growth.

METHODS

To determine if breastfeeding combined with once-daily formula supplementation improves growth among at-risk newborns, we conducted a pilot randomized controlled trial in Bissau, Guinea-Bissau and Kampala, Uganda. We randomly assigned 324 healthy breastfeeding newborns who weighed 2000 g to 2499 g at birth or <2600 g at 4 days old to once-daily formula feeding through 30 days as a supplement to frequent breastfeeding followed by EBF from 31 days through 6 months, or to EBF through 6 months. The primary outcome was weight-for-age z score (WAZ) at 30 days. Other outcomes included weight-for-length z score (WLZ), length-for-age z score (LAZ), breastfeeding cessation, adverse events, and serious adverse events through 180 days.

RESULTS

Daily formula consumption in the intervention group was 31.9 ± 11.8 mL. The random assignment did not impact WAZ, WLZ, LAZ, breastfeeding cessation, adverse events, or serious adverse events through 180 days. In the intervention and control groups, 19 (12%) and 35 (21%) infants, respectively, reported nonformula supplementation in the first 30 days (P = .02).

CONCLUSIONS

Once-daily formula supplementation for 30 days was well-tolerated, but the small volume consumed did not alter growth through 180 days of age. Further research would be required to determine if larger formula volumes, longer duration of treatment, or more frequent feeding are effective at increasing growth for this at-risk population.

In-Hospital Formula Feeding Hindered Exclusive Breastfeeding: Breastfeeding Self-Efficacy as a Mediating Factor

Breastfeeding self-efficacy (BSE), defined as a mother's confidence in her ability to breastfeed, has been confirmed to predict the uptake of exclusive breastfeeding (EBF). Early experiences during the birth hospital stay, especially in-hospital formula feeding (IHFF), can impact both EBF and maternal breastfeeding confidence. Therefore, our objective was to examine the association between IHFF and EBF outcomes and investigate whether this association is influenced by BSE. The study included 778 infants from a larger cohort study conducted in 2021, with a one-year follow-up in rural areas of Sichuan Province, China. We used a causal mediation analysis to estimate the total effect (TE), natural direct (NDE), and nature indirect effects (NIE) using the paramed command in Stata. Causal mediation analyses revealed that IHFF was negatively associated with EBF (TE odds ratio = 0.47; 95% CI, 0.29 to 0.76); 28% of this association was mediated by BSE. In the subgroup analysis, there were no significant differences in the effects between parity subgroups, as well as between infant delivery subgroups. Our study found that IHFF hindered later EBF and that BSE mediated this association. Limiting the occurrence of in-hospital formula feeding or improving maternal breastfeeding self-efficacy is likely to improve exclusive breastfeeding outcomes.

Why do mothers mix milk feed their infants? Results from a systematic review

CONTEXT

Combining or supplementing breastfeeding with formula feeding, also called mixed milk feeding (MMF), is a common infant feeding practice. However, there is no well-established MMF evidence-base for informing and guiding parents. A better understanding of the reasons why mothers practice MMF may facilitate identification of efficient strategies for supporting exclusive breastfeeding, and/or opportunities to prolong breastfeeding, at least partially.

OBJECTIVE

An updated systematic literature review was undertaken with the primary aim of gaining a deeper understanding of the reasons why mothers choose MMF.

DATA SOURCES

Six databases were searched for relevant articles published in English from January 2012 to January 2022.

DATA EXTRACTION

Two reviewers independently performed the screenings and data extraction, and any differences were resolved by a third reviewer. Data from 138 articles were included, 90 of which contained data on MMF reasons/drivers, and 60 contained data on infant age and/or maternal demographic factors associated with MMF.

DATA ANALYSIS

A total of 13 different unique MMF drivers/reasons were identified and categorized according to whether the drivers/reasons related to perceived choice, necessity, or pressure. Risk of bias was evaluated using the Quality Assessment Tool of Diverse Studies and the JBI Systematic Reviews tool. Several different terms were used to describe and classify MMF across the studies. The most commonly reported reasons for MMF were related to a perception of necessity (39% of drivers, eg, concerns about infant's hunger/perceived breast milk insufficiency or breastfeeding difficulties), followed by drivers associated with perceived choice (34%; eg, having more flexibility) and perceived pressure (25%; eg, returning to work or healthcare professionals' advice). This was particularly true for infants aged 3 months or younger.

CONCLUSION

The key global drivers for MMF and their distribution across infant age and regions were identified and described, providing opportunities for the provision of optimal breastfeeding support. A unified definition of MMF is needed in order to enable more comparable and standardized research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022304253.

Controversies and Conundrums in Newborn Feeding

Breastfeeding is the biologic norm for newborn feeding, and exclusive breastfeeding for the first 6 months of life is universally endorsed by leading global and national organizations. Despite these recommendations, many people do not meet their breastfeeding goals and controversies surrounding breastfeeding problems exist. Medical issues can present challenges for the clinician and parents to successfully meet desired feeding outcomes. There are studies evaluating these common controversies and medical conundrums, and clinicians should provide evidence-based recommendations when counseling families about newborn feeding.

Self-Efficacy and Outcomes in Women with Diabetes: A Prospective Comparative Study

Background: Breastfeeding is especially beneficial to women with diabetes and their infants, yet diabetic mothers frequently experience less favorable breastfeeding outcomes. Objectives: To identify facilitators and barriers to breastfeeding for women with diabetes by comparing cognitive and social factors, health and hospital-related factors, and breastfeeding outcomes between women with and without diabetes. Design/Methods: Women with any type of diabetes (n = 28) and without diabetes (n = 29) were recruited during pregnancy. Data were collected from the electronic medical record and maternal surveys at 24-37 weeks' gestation, birth hospitalization, and 4 weeks' postbirth. We compared differences in mother's regard for breastfeeding, breastfeeding intention, and birth hospital experience by diabetes status, and estimated odds ratios for exclusive breastfeeding (EBF) and unmet intention to breastfeed. Results: Women with and without diabetes had similar breastfeeding intentions, attitudes, and self-efficacy. Women with diabetes were less likely to EBF, and more likely to have unmet intentions to EBF at hospital discharge, compared to women without diabetes. At 4 weeks' postpartum, there was no difference in breastfeeding by diabetes status, although EBF at hospital discharge was strongly associated with EBF at 4 weeks. Infant neonatal intensive care unit (NICU) admission and hypoglycemia were significantly associated with diabetes status, reduced EBF rates, and unmet breastfeeding intentions. Conclusions: Despite having a strong intent to breastfeed, women with diabetes experienced less favorable early breastfeeding outcomes and were less likely to meet their own breastfeeding goals. These differences may be driven by neonatal complications, such as infant hypoglycemia and NICU admissions, rather than maternal cognitive and social factors.

Fatal Hypernatremic Dehydration in a Term Exclusively Breastfed Newborn

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

Mixed Milk Feeding: A New Approach to Describe Feeding Patterns in the First Year of Life Based on Individual Participant Data from Two Randomised Controlled Trials

'Mixed Milk Feeding' (MMF), whereby infants are fed with both breastmilk and infant formula during the same period, is a common feeding practice. Despite its high prevalence, knowledge regarding MMF practices and their association with (health) outcomes is limited, potentially because MMF behaviours are highly variable and difficult to standardise longitudinally. In this paper, we applied a statistical clustering algorithm on individual infant feeding data collected over the first year of life from two clinical trials: 'TEMPO' (n = 855) and 'Venus' (n = 539); these studies were conducted in different years and world regions. In TEMPO, more than half of infants were MMF. Four distinct MMF clusters were identified: early exclusive formula feeding (32%), later exclusive formula feeding (25%), long-term MMF (21%), and mostly breastfeeding (22%). The same method applied to 'Venus' resulted in comparable clusters, building trust in the robustness of the cluster approach. These results demonstrate that distinct MMF patterns can be identified, which may be applicable to diverse populations. These insights could support the design of future research studying the impact of infant feeding patterns on health outcomes. To standardise this in future research, it is important to establish a unified definition of MMF.

Randomized controlled trial of early, small-volume formula supplementation among newborns: A study protocol

Childhood undernutrition is a major health burden worldwide that increases childhood morbidity and mortality and causes impairment in infant growth and developmental delays that can persist into adulthood. The first weeks and months after birth are critical to the establishment of healthy growth and development during childhood. The World Health Organization recommends immediate and exclusive breastfeeding (EBF). In infants for whom EBF may not meet nutritional and caloric demands, early, daily, small-volume formula supplementation along with breastfeeding may more effectively avoid underweight wasting and stunting in early infancy than breastfeeding alone. The primary objective of this randomized controlled trial is to evaluate the efficacy of formula for 30 days among low birth weight (LBW) infants <6 hours of age and those not LBW with weights <2600 grams at 4 days of age. We will compare breastfeeding and formula (up to 59 milliliters administered daily) through 30 days of infant age vs recommendations for frequent EBF without supplementation, and test the hypothesis that formula increases weight-for-age z-score at 30 days of infant age. The trial will enroll and randomize 324 mother-infant pairs in Guinea-Bissau and Uganda, and follow them for 6 months for outcomes including growth, intestinal microbiota, breastfeeding duration, infant dietary intake, and adverse events. Conservatively estimating 20% loss to follow up, this sample size provides ≥80% power per weight stratum for intervention group comparison to detect a difference of 0.20 with respect to the outcome of WAZ at day 30. This trial was approved by the University of California, San Francisco Institutional Review Board (19-29405); the Guinea-Bissau National Committee on Ethics in Health (Comite Nacional de Etica na Saude, 075/CNES/INASA/2020); the Higher Degrees, Research and Ethics Committee of Makerere University (871); and the Uganda National Council of Science and Technology (HS1226ES). We plan to disseminate study results in peer-reviewed journals and international conferences. Trial registration number: NCT04704076.

Maternal Psychological Distress and Lactation and Breastfeeding Outcomes: a Narrative Review

PURPOSE

Despite recommendations from the World Health Organization and the American Academy of Pediatrics to exclusively breastfeed infants for their first 6 months of life, 75% of women do not meet exclusive breastfeeding guidelines, and 60% do not meet their own breastfeeding goals. Numerous observational studies have linked maternal psychological distress (eg, perceived stress, anxiety, and depression) with nonoptimal breastfeeding outcomes, such as decreased proportion and duration of exclusive breastfeeding. The physiological mechanisms underlying these associations, however, remain unclear.

METHODS

For this narrative review, we evaluated the evidence of relationships between maternal psychological distress and lactation and breastfeeding outcomes in pregnancy and post partum and the possible physiological mechanisms that facilitate these relationships. We searched PubMed using the following terms: stress, anxiety, depression, breastfeeding, and lactation. Additional search by hand was conducted to ensure a thorough review of the literature.

FINDINGS

Among the studies examined, methods used to assess maternal psychological distress were not uniform, with some studies examining perceived distress via a variety of validated tools and others measuring biological measures of distress, such as cortisol. Evidence supports a role for psychological distress in multiple breastfeeding outcomes, including delayed secretory activation and decreased duration of exclusive breastfeeding. One physiological mechanism proposed to explain these relationships is that psychological distress may impair the release of oxytocin, a hormone that plays a critical role in milk ejection during lactation. Continued impairment of milk ejection may lead to decreased milk production because of incomplete emptying of the breast during each feed. Maternal distress may also yield elevated levels of serum cortisol and decreased insulin sensitivity, which are associated with decreased milk production. The relationship between psychological distress and breastfeeding is likely to be bidirectional, however, in that breastfeeding appears to reduce maternal distress, again possibly via effects on the pleasure or reward pathway and calming effects of oxytocin on the mother. This finding suggests that interventions to support lactation and breastfeeding goals in women who score high on measures of psychological distress would be beneficial for both maternal and infant well-being.

IMPLICATIONS

Evidence to date suggests that maternal psychological distress may impair lactation and breastfeeding outcomes, but stronger study designs and rigorous assessment methods are needed. A better understanding of the physiological mechanisms leading to impaired lactation may assist in the development of early interventions for mothers experiencing distress. In addition, stress-reducing programs and policies should be investigated for their potential to improve breastfeeding outcomes.

Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

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

Human Milk for the Term Newborn

Human milk provides optimal nutrition for term newborns, but the prevalence of its use is below target, and risks have been identified. Infants of black mothers as well as term newborns admitted to the neonatal intensive care unit are at risk for not receiving human milk. To improve human milk intake, multiple individual-level interventions have been shown to be effective, but some popular system-level interventions are ineffective or harmful. Expressed milk and donor milk may be less beneficial than direct breastfeeding. Nuanced public policies can help support lactation while promoting individual choice and equity.

Correlates of infant feeding practices among HIV-positive mothers and controls in northeast Nigeria

BACKGROUND

Despite the global decline in pediatric HIV infections, infants in sub-Saharan Africa still acquire HIV infection through inappropriate feeding.

OBJECTIVE

The aim of the study was to compare knowledge and predictors of infant feeding behavior between mothers living with HIV and controls of unknown HIV status in Gombe, northeast Nigeria.

METHOD

A cross-section of clinic-based samples of 84 HIV-positive mothers and 170 controls of unknown status were interviewed using validated questionnaires. Knowledge scores and self-reported infant feeding practices were analyzed. Multivariate logistic regression models were employed to determine predictors for infant feeding practices.

RESULTS

Transmission risk perception (95.2% vs. 65.3%) (p<0.05) and adequate knowledge of infant feeding (77.4% vs. 51.2%) (p<0.05) were higher among HIV-positive mothers. Compared to mothers of unknown status (56.5%), a higher proportion of HIV-positive mothers (84.5%) reported breastfeeding the infant exclusively for 6 months (p<0.05). In contrast, mixed feeding was more prevalent among controls (19.4% vs. 4.8%) (p<0.05). Further, over a third (39.3%) of HIV-positive mothers and 27.6% of controls weaned their infants at ≥12 months (p>0.05). Antenatal attendance, hospital delivery, knowledge and positive attitude predicted infant feeding practices in both groups. The predictive roles of education and parity were limited to HIV-positive mothers, while the effects of maternal age and infant death were restricted to controls.

CONCLUSION

Risk perception, knowledge, and exclusive breastfeeding rates were higher among mothers living with HIV. Antenatal care, hospital delivery, knowledge, and attitude predicted infant feeding practices in both groups. Girl child education, antenatal care, hospital delivery, and sustained promotion of exclusive breastfeeding with antiretroviral therapy are key to HIV-free infant survival.

Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review

(1) Introduction: Current evidence on managing infants under six months with growth failure or other nutrition-related risk is sparse and low quality. This review aims to inform research priorities to fill this evidence gap, focusing on breastfeeding practices. (2) Methods: We searched PubMed, CINAHL Plus, and Cochrane Library for studies on feeding interventions that aim to restore or improve the volume or quality of breastmilk and breastfeeding when breastfeeding practices are sub-optimal or prematurely stopped. We included studies from both low- and middle-income countries and high-income countries. (3) Results: Forty-seven studies met the inclusion criteria. Most were from high-income countries (n = 35, 74.5%) and included infants who were at risk of growth failure at birth (preterm infants/small for gestational age) and newborns with early growth faltering. Interventions included formula fortification or supplementation (n = 31, 66%), enteral feeds (n = 8, 17%), cup feeding (n = 2, 4.2%), and other (n = 6, 12.8%). Outcomes included anthropometric change (n = 40, 85.1%), reported feeding practices (n = 16, 34%), morbidity (n = 11, 23.4%), and mortality (n = 5, 10.6%). Of 31 studies that assessed formula fortification or supplementation, 30 reported anthropometric changes (n = 17 no effect, n = 9 positive, n = 4 mixed), seven morbidity (n = 3 no effect, n = 2 positive, n = 2 negative), five feeding (n = 2 positive, n = 2 no effect, n = 1 negative), and four mortality (n = 3 no effect, n = 1 negative). Of eight studies that assessed enteral feed interventions, seven reported anthropometric changes (n = 4 positive, n = 3 no effect), five feeding practices (n = 2 positive, n = 2 no effect, n = 1 negative), four morbidity (n = 4 no effect), and one reported mortality (n = 1 no effect). Overall, interventions with positive effects on feeding practices were cup feeding compared to bottle-feeding among preterm; nasogastric tube feed compared to bottle-feeding among low birth weight preterm; and early progressive feeding compared to delayed feeding among extremely low birth weight preterm. Bovine/cow milk feeding and high volume feeding interventions had an unfavourable effect, while electric breast pump and Galactagogue had a mixed effect. Regarding anthropometric outcomes, overall, macronutrient fortified formula, cream supplementation, and fortified human milk formula had a positive effect (weight gain) on preterm infants. Interventions comparing human breastmilk/donor milk with formula had mixed effects. Overall, only human milk compared to formula intervention had a positive effect on morbidity among preterm infants, while none of the interventions had any positive effect on mortality. Bovine/cow milk supplementation had unfavourable effects on both morbidity and mortality. (4) Conclusion: Future research should prioritise low- and middle-income countries, include infants presenting with growth failure in the post-neonatal period and record effects on morbidity and mortality outcomes.

Evidence-Based Updates on the First Week of Exclusive Breastfeeding Among Infants ≥35 Weeks

The nutritional and immunologic properties of human milk, along with clear evidence of dose-dependent optimal health outcomes for both mothers and infants, provide a compelling rationale to support exclusive breastfeeding. US women increasingly intend to breastfeed exclusively for 6 months. Because establishing lactation can be challenging, exclusivity is often compromised in hopes of preventing feeding-related neonatal complications, potentially affecting the continuation and duration of breastfeeding. Risk factors for impaired lactogenesis are identifiable and common. Clinicians must be able to recognize normative patterns of exclusive breastfeeding in the first week while proactively identifying potential challenges. In this review, we provide new evidence from the past 10 years on the following topics relevant to exclusive breastfeeding: milk production and transfer, neonatal weight and output assessment, management of glucose and bilirubin, immune development and the microbiome, supplementation, and health system factors. We focus on the early days of exclusive breastfeeding in healthy newborns ≥35 weeks' gestation managed in the routine postpartum unit. With this evidence-based clinical review, we provide detailed guidance in identifying medical indications for early supplementation and can inform best practices for both birthing facilities and providers.

Typologies of postnatal support and breastfeeding at two months in the UK: Research participant commentary

Emmott et al. (2020) presented in this journal an analysis of different types of postnatal support that mothers in the UK experience and their relationship to breastfeeding status at two months. This paper is a commentary by two participants in the study. It draws on the research literature alongside recent lived experiences of breastfeeding and formula feeding in the UK to question and expand on Emmott et al.'s analysis. It highlights how a decision to stop breastfeeding in the current UK context may lead to experiencing a lack of support from healthcare professionals. We argue that a family-centred approach to infant feeding should acknowledge the benefits and costs of all infant feeding methods and enable all families to be fully informed and supported in feeding their babies.

Improved breastfeeding duration with Baby Friendly Hospital Initiative implementation in a diverse and underserved population

BACKGROUND

Few studies have evaluated the impact of Baby Friendly Hospital Initiative (BFHI) implementation on underserved populations in the United States. We undertook this study in New Mexico, a large southwestern state with a diverse population and limited health care access.

METHODS

A quasi-experimental, retrospective cohort design was used to compare short-term breastfeeding duration between a pre-BFHI and a post-BFHI cohort. Among the post-BFHI cohort, logistic regression models were fitted to predict short-term breastfeeding duration from both individual and cumulative exposure to inpatient maternity care practices (Steps 4 to 9).

RESULTS

Implementation of the BFHI and cumulative exposure to the Ten Steps increased short-term duration of any breastfeeding and exclusive breastfeeding at 2-6 weeks postpartum. Exposure to all six of the inpatient Ten Steps increased the odds of any breastfeeding by 34 times and exclusive breastfeeding by 24 times. Exposure to Step 9 ("Give no pacifiers or artificial nipples") uniquely increased the likelihood of any breastfeeding at 2-6 weeks postpartum by 5.7 times, whereas Step 6 ("Give infants no food or drink other than breastmilk") increased the rate of exclusive breastfeeding by 4.4 times at 2-6 weeks postpartum.

CONCLUSION

These findings demonstrate that the Baby Friendly Hospital Initiative can have a positive impact on breastfeeding among underserved populations.

Neonatal intensive care unit admissions before and after the adoption of the baby friendly hospital initiative

Background: The Baby Friendly Hospital initiative (BFHI) is a global initiative of the World Health Organization developed in 1991 to promote and support successful breastfeeding. It has led to increased rates of exclusive breastfeeding. Exclusive breastfeeding may increase risk for hypoglycemia, hyperbilirubinemia, and dehydration requiring higher level of neonatal care.Objective: To determine if there was a change in admissions to the Neonatal Intensive Care Unit (NICU) from the newborn nursery after the adoption of BFHI in a large urban hospital.Methods: This is a retrospective analysis of all neonates admitted to the NICU from the newborn nursery between January 2007 and December 2016 at Thomas Jefferson University Hospital, in Philadelphia, PA, USA. Demographics, clinical characteristics and primary diagnosis for admission were compared between those admitted before (January 2007 to December 2011) and after (January 2012 to December 2016) the initiation of BFHI.Results: A total of 20,124 infants were born and 3,684 infants (18.3%) were admitted to NICU. 570 infants (2.8% of live birth) were admitted to the NICU from the newborn nursery, 282 (49.5%) were born before and 288 (50.5%) born after BFHI. There was no significant difference in the number of infants admitted from the newborn nursery either as a percentage of total deliveries (2.8 versus 2.9%, p = .6) or percentage of total NICU admissions (15.5 versus 15.5%, p = 1.0) before and after the BFHI. Additionally, there was no difference in number of infants admitted with a diagnosis of possible sepsis, hypoglycemia, neonatal abstinence syndrome (NAS) and hyperbilirubinemia between the two groups. However, significantly more infants admitted with hypoglycemia required IV fluids for hypoglycemia after the initiation of BFHI (8 out of 27 versus 21 out of 28, p .001). The age of admission was higher and the duration of NICU stay was shorter in infants admitted after the initiation of the BFHI.Conclusions: The BFHI has not led to a significant change in the number of infants admitted to NICU from the newborn nursery or reasons for their admissions. However, since its adoption, there has been an increase in the use of IV fluids for treatment of hypoglycemia. These findings suggest a role for additional treatments other than formula to prevent IV fluid use, such as glucose gel. Change in NICU guidelines for the management of possible sepsis and NAS may have impacted the duration of hospitalization in infants born after BFHI.

Breastfeeding Difficulties and Risk for Early Breastfeeding Cessation

Although breast milk is the normative feeding for infants, breastfeeding rates are lower than recommended. We investigated breastfeeding difficulties experienced by mothers in the first months after delivery and their association with early breastfeeding discontinuation. We conducted a prospective observational study. Mothers breastfeeding singleton healthy term newborns at hospital discharge were enrolled and, at three months post-delivery, were administered a questionnaire on their breastfeeding experience. Association among neonatal/maternal characteristics, breastfeeding difficulties and support after hospital discharge, and type of feeding at three months was assessed using multivariate binary logistic regression analysis. We enrolled 792 mothers, 552 completed the study. Around 70.3% of mothers experienced breastfeeding difficulties, reporting cracked nipples, perception of insufficient amount of milk, pain, and fatigue. Difficulties occurred mostly within the first month. Half of mothers with breastfeeding issues felt well-supported by health professionals. Maternal perception of not having a sufficient amount of milk, infant's failure to thrive, mastitis, and the return to work were associated with a higher risk of non-exclusive breastfeeding at three months whereas vaginal delivery and breastfeeding support after hospital discharge were associated with a decreased risk. These results underline the importance of continued, tailored professional breastfeeding support.

Effect of Early Limited Formula on Breastfeeding Duration in the First Year of Life: A Randomized Clinical Trial

IMPORTANCE

Breastfeeding through 6 and 12 months are 2 goals of the Centers for Disease Control and Prevention Healthy People 2020 initiative, but the 6-month goal is met for only 52% of US infants and the 12-month goal for 30% of US infants.

OBJECTIVE

To determine whether structured, short-term formula supplementation for at-risk neonates affects the proportion still breastfeeding at 6 and 12 months.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial conducted at 2 US academic medical centers enrolled 164 exclusively breastfeeding mother-infant dyads of mothers who were not yet producing copious milk and infants who were 24 to 72 hours old with newborn weight loss at or above the 75th percentile for age. Participants were enrolled from January 2015 through September 2016.

INTERVENTIONS

Early Limited Formula (ELF), a structured formula supplementation protocol (10 mL formula fed after each breastfeeding until mothers produced copious milk), compared with control dyads, who continued exclusive breastfeeding and received a safety teaching intervention.

MAIN OUTCOMES AND MEASURES

The study's primary outcome was any breastfeeding at 6 months. Secondary outcomes included age at breastfeeding cessation and any breastfeeding at 12 months. All outcomes were assessed by maternal phone survey.

RESULTS

Eighty-two newborns were randomized to ELF and 82 to the control group. Mean (SD) maternal age was 31.4 (5.9) years, and 114 (69.5%) self-identified as non-Hispanic white; 20 (12.2%), Hispanic; 17 (10.4%), Asian; 5 (3.0%), non-Hispanic black; and 7 (4.3%), other. Compared with controls, mothers randomized to ELF were less likely to be married (n = 53 [64.6%] vs n = 66 [80.5%]; P = .03) and had shorter mean (SD) intended duration of breastfeeding (8.6 [3.4] vs 9.9 [4.4] months; P = .049). Median (interquartile range) duration of breastfeeding in the cohort was 9 (6-12) months. At 6 months, 47 (65%) infants randomized to ELF were breastfeeding, compared with 60 (77%) of the control infants (absolute difference, -12%; 95% CI, -26% to 3%; P = .12). At 12 months, 21 of the 71 ELF infants available for analysis (29.6%) were breastfeeding, compared with 37 of the available 77 (48.1%) control infants (risk difference, -18%; 95% CI, -34% to -3%). Marital status and intended breastfeeding duration were both associated with breastfeeding duration; models adjusting for these found a hazard ratio for time-to-event of breastfeeding cessation through 12 months of 0.74 (95% CI, 0.48-1.14) for ELF infants compared with infants in the control group.

CONCLUSIONS AND RELEVANCE

In this cohort with high breastfeeding prevalence, ELF was not associated with any improvement in breastfeeding duration. Future research should examine the effect of ELF in populations at higher risk of early cessation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02313181.

Effect of Donor Milk Supplementation on Breastfeeding Outcomes in Term Newborns: A Randomized Controlled Trial

BACKGROUND

Pasteurized donor human milk (DHM) use for healthy newborns is increasing; however, no studies have explored its effect on breastfeeding outcomes.

PATIENTS AND METHODS

We enrolled 60 healthy, term breastfeeding newborns with ≥4.5% weight loss in the first 36 hours in a randomized controlled trial. Thirty newborns were randomly assigned to early limited-volume DHM supplementation and 30 newborns to exclusive breastfeeding. Mothers were surveyed at 1 week and 1, 2, and 3 months regarding the mode of infant feeding. Comparing infants randomized to DHM supplementation with those exclusively breastfeeding, there was no significant difference in the proportion using formula at 1 week (21% vs 7%, P = .15), nor in the proportion of any breastfeeding (79% vs 90%, P = .30) or breastfeeding without formula at 3 months (62% vs 77%, P = .27). Conclusion For newborns with ≥4.5% weight loss in the first 36 hours, early limited-volume supplementation with DHM is unlikely to have a significant favorable impact on breastfeeding outcomes.

Exclusive breastfeeding in hospital predicts longer breastfeeding duration in Canada: Implications for health equity

BACKGROUND

Breastfeeding has many established health benefits for women and children. We examined the association between maternal education, newborn feeding in hospital, and long-term breastfeeding duration.

METHODS

We studied 3195 Canadian mother-infant dyads in the CHILD pregnancy cohort. Newborn feeding was documented from hospital records. Caregivers reported sociodemographic factors and infant feeding at 3, 6, 12, 18, and 24 months.

RESULTS

Overall, 97% of newborns initiated breastfeeding and 74% were exclusively breastfed in hospital. Exclusively breastfed newborns were ultimately breastfed longer compared with those who received formula supplementation during their hospital stay (median 11.0 vs 7.0 months, P < .001). After controlling for maternal age, ethnicity, birth mode, and gestational age, exclusively breastfed newborns had a 21% reduced risk of breastfeeding cessation (HR = 0.79, 0.71-0.87). This effect was strongest among women without a postsecondary education (HR = 0.65, 0.53-0.79).

DISCUSSION

Exclusive breastfeeding in hospital is associated with longer breastfeeding duration, particularly among women of lower socioeconomic status. Initiatives that support exclusive breastfeeding of newborns in hospital could improve long-term breastfeeding rates and help reduce health inequities arising in early life.

Determinants of breastfeeding discontinuation in an Italian cohort of mother-infant dyads in the first six months of life: a randomized controlled trial

BACKGROUND

Among breastfeeding determinants, the marketing of breast milk substitutes might contribute to suboptimal breastfeeding rates. The aim of this study was to investigate the effect of receiving information on breast milk substitutes on breastfeeding rates.

METHODS

We conducted a randomized, single-blind, controlled trial from 2012 to 2014 in a northern Italian maternity ward. We enrolled 802 Caucasian mothers who gave birth to healthy, full-term singletons with a birth weight > 2500 g and who were exclusively breastfeeding from delivery to discharge. Mothers who gave birth to infants with congenital diseases, chromosomal abnormalities, perinatal infections and/or cardio-respiratory instability and/or mothers being affected by endocrine and/or metabolic and/or gastrointestinal and/or renal diseases were excluded. Mothers were randomized to either receive (group A, n = 405) or not (group B, n = 397) written information on a breast milk substitute at discharge. Breastfeeding was promoted and supported in all mother-infant pairs equally. The mode of feeding for up to 6 months after delivery was determined by phone interview. To detect a 10% difference between groups in the discontinuation rate of exclusive breastfeeding at three months of age at 5% significance and 80% power, a total of 356 mother-infant pairs per group were needed.

RESULTS

The exclusive breastfeeding prevalence was 91% and 92% at 7 days, 79% and 70% at 1 month, 75% and 66% at 2 months, 72% and 62% at 3 months, and 3% and 2% at 6 months in groups A and B, respectively. The relative risk (95% confidence interval) of exclusive breastfeeding (group A vs B) at 7 days and at 1, 2, 3 and 6 months was as follows: 0.99 (0.95-1.03), 1.12 (1.03-1.21), 1.13 (1.03-1.24), 1.15 (1.04-1.27), and 1.49 (0.62-3.61). Nutritional, lifestyle and lactational factors were the primary contributing determinants to early breastfeeding discontinuation.

CONCLUSIONS

The present findings indicate that receiving written information on breast milk substitutes at hospital discharge, provided that breastfeeding support and education are offered, does not negatively affect breastfeeding rates.

TRIAL REGISTRATION

NCT03208114. Registered 5 July 2017.

Is Exclusive Breastfeeding Dangerous?

Social media has been alight with descriptions of exclusive breastfeeding being dangerous, resulting in significant and severe negative outcomes in infants whose mothers wished to breastfeed. This backlash has been led by a campaign that uses inflammatory anecdotes and misleading and inaccurate interpretation of research to bolster its assault on breastfeeding. However, poor breastfeeding outcomes can and do happen. The narratives identify areas where clinicians can improve their delivery of care. A closer look at risk factors and interventions may help reduce the risk of poor outcomes and increase the likelihood of mothers meeting their breastfeeding goals.

The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature

There is no doubt regarding the multiple benefits of breastfeeding for infants and society in general. Therefore, the World Health Organization (WHO) in a conjoint effort with United Nations International Children's Emergency Fund (UNICEF) developed the "Ten Steps to Successful Breastfeeding" in 1992, which became the backbone of the Baby Friendly Hospital Initiative (BFHI). Following this development, many hospitals and countries intensified their position towards creating a "breastfeeding oriented" practice. Over the past two decades, the interest increased in the BFHI and the Ten Steps. However, alongside the implementation of the initiative, extensive research continues to evaluate the benefits and dangers of the suggested practices. Hence, it is our intention to make a critical evaluation of the current BFHI and the Ten Steps recommendations in consideration of the importance of providing an evidence-based breastfeeding supported environment for our mothers and infants.

The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial

OBJECTIVE

To determine whether using 10 mL formula after each breastfeeding before copious maternal milk production affects breastfeeding duration, readmission, and intestinal microbiota through 1 month of age.

STUDY DESIGN

In this randomized controlled trial, we enrolled 164 exclusively breastfeeding newborns, 24-72 hours old, whose weight loss was ≥75th percentile for age, and whose mothers had not yet begun mature milk production. Enrolled newborns were assigned randomly to either supplement breastfeeding with early limited formula (ELF), 10 mL of formula after each breastfeeding stopped at the onset of copious maternal milk production (intervention), or to continue exclusive breastfeeding (control). Outcomes assessed through 1 month included breastfeeding duration, readmission, and intestinal microbiota.

RESULTS

At 1 week of age, 95.8% of infants receiving ELF and 93.5% of control infants were still breastfeeding (P > .5); readmission occurred for 4 (4.8%) control infants and none of the infants receiving ELF (P = .06). At 1 month of age, 86.5% of infants receiving ELF and 89.7% of control infants were still breastfeeding (P > .5); 54.6% of infants receiving ELF and 65.8% of controls were breastfeeding without formula (P = .18). ELF did not lead to decreased abundance of Lactobacillus or Bifidobacterium and was not associated with expansion of Clostridium.

CONCLUSION

In this population of healthy newborns with weight loss ≥75th percentile, ELF did not interfere with breastfeeding at 1 month, breastfeeding without formula at 1 month, or intestinal microbiota. ELF may be an important therapeutic option for newborns with the potential to reduce readmission rates.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02313181.

Efficacy of Subthreshold Newborn Phototherapy During the Birth Hospitalization in Preventing Readmission for Phototherapy

IMPORTANCE

Treatment of jaundiced newborns with subthreshold phototherapy (phototherapy given to newborns with bilirubin levels below those recommended in American Academy of Pediatrics [AAP] guidelines) is common. However, the use of subthreshold phototherapy may have risks and increase costs, and, to date, it has not been systematically studied in newborns.

OBJECTIVES

To estimate the efficacy of subthreshold phototherapy for newborns with total serum bilirubin (TSB) levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold during the birth hospitalization in preventing readmissions for phototherapy, and to identify predictors of readmission for phototherapy.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 25 895 newborns born at 35 or more weeks' gestation, born in 1 of 16 Kaiser Permanente Northern California hospitals from January 1, 2010, through December 31, 2014, with at least 1 TSB level from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold and not exceeding the threshold during the birth hospitalization. Data were analyzed from November 1, 2015, to November 28, 2017.

EXPOSURE

Subthreshold phototherapy during the birth hospitalization.

MAIN OUTCOMES AND MEASURES

Readmission for phototherapy.

RESULTS

Among 25 895 newborns with qualifying TSB levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold, 4956 (19.1%) received subthreshold phototherapy and 241 of these (4.9%) were readmitted for phototherapy compared with 2690 of 20 939 untreated newborns (12.8%) (unadjusted odds ratio [OR], 0.35; 95% CI, 0.30-0.40). In a logistic regression model, adjustment for confounding variables, including gestational age, race/ethnicity, formula feedings per day, and the difference between the TSB level and the phototherapy threshold, strengthened the association (OR, 0.28; 95% CI, 0.19-0.40). Estimated numbers needed to treat ranged from 60.8 in the lowest quintile of predicted risk to 6.3 in the highest quintile. Newborns who received formula feedings had lower adjusted odds of readmission for phototherapy compared with exclusively breastfed newborns (OR, 0.58; 95% CI, 0.47-0.72 for >0 to <2 formula feedings per day; OR, 0.24; 95% CI, 0.21-0.27 for ≥6 formula feedings per day). Subthreshold phototherapy was associated with a 22-hour longer length of stay (95% CI, 16-28 hours).

CONCLUSIONS AND RELEVANCE

Subthreshold phototherapy during the birth hospitalization is effective in preventing readmissions for phototherapy; however, for each readmission prevented, many newborns require phototherapy who would otherwise not need it.

Human Donor Milk or Formula: A Qualitative Study of Maternal Perspectives on Supplementation

BACKGROUND

Breastfeeding is fundamental to maternal and child health and is the most cost-effective intervention to reduce child mortality. Pasteurized human donor milk (HDM) is increasingly provided for term newborns requiring temporary supplementation. Few studies examine maternal perspectives on supplementation of term newborns.

MATERIALS AND METHODS

We conducted semistructured in-person interviews with mothers of term newborns (n = 24) during postpartum hospitalization. Mothers were asked whether they had chosen or would choose to supplement with HDM versus infant formula, if medically indicated, and why. Data were gathered to saturation and analyzed inductively by consensus. Emerging semantic themes were compared between mothers who chose or would choose HDM and those who chose or would choose infant formula.

RESULTS

Most mothers had concerns about HDM, including uncertainty regarding screening and substances passed through HDM. Experiences with prior children influenced decision-making. Mothers who chose or would choose HDM (56%, n = 14) praised it as "natural," and some felt suspicious of infant formula as "synthetic." Mothers who chose or would choose infant formula (44%, n = 10) did not know enough about HDM to choose it, and many viewed infant formula as a short-term solution to supply concerns. Mothers unanimously mistrusted online milk purchasing sources, although the majority felt positively about using a friend or family member's milk.

CONCLUSIONS

Counseling regarding term newborn supplementation should focus on HDM education, specifically on areas of greatest concern and uncertainty such as donor selection, screening, transmission of substances, and mother's milk supply. Research is needed to assess the long-term impact of attitudes and choices on breastfeeding.

Prevalence and Trends in Donor Milk Use in the Well-Baby Nursery: A Survey of Northeast United States Birth Hospitals

BACKGROUND AND OBJECTIVES

Pasteurized donor human milk ("donor milk") is an alternative to formula for supplementation of breastfed infants. We conducted a survey to determine (1) prevalence, trends, and hospital-level correlates of donor milk use for healthy newborns in the northeast United States and (2) clinician knowledge and opinions regarding this practice.

METHODS

We conducted parallel surveys of clinicians (88% nurse and/or lactation consultant) at (1) all birth hospitals in Massachusetts (MA) and (2) all birth hospitals served by a northeast United States milk bank. We asked about hospital use of donor milk for newborns ≥35 weeks' gestation and receiving Level I care in well nursery, hospital-related factors we hypothesized would be associated with this practice, and clinician knowledge and opinions about donor milk use.

RESULTS

35/46 (76%) of MA birth hospitals and 51/69 (74%) of hospitals served by the milk bank responded; 71 unique hospitals were included. Twenty-nine percent of MA birth hospitals and 43% of hospitals served by the milk bank reported using donor milk for healthy newborns. Hospitals that used donor milk for healthy newborns had higher exclusive breastfeeding at hospital discharge than hospitals that did not (77% versus 56%, p = 0.02). Eighty-three percent of respondents agreed or strongly agreed that using donor milk is an effective way to increase the hospital's exclusive breastfeeding rate.

CONCLUSIONS

Many northeast United States birth hospitals currently use donor milk for healthy newborns. This practice is associated with higher exclusive breastfeeding at hospital discharge. Relationships with breastfeeding after discharge and related outcomes are unknown.

What Happens to Blood Glucose Concentrations After Oral Treatment for Neonatal Hypoglycemia?

OBJECTIVE

To determine the change in blood glucose concentration after oral treatment of infants with hypoglycemia in the first 48 hours after birth.

STUDY DESIGN

We analyzed data from 227 infants with hypoglycemia (blood glucose <46.8 mg/dL, 2.6 mmol/L) born at a tertiary hospital who experienced 295 episodes of hypoglycemia. Blood glucose concentrations were measured (glucose oxidase) within 90 minutes after randomization to dextrose or placebo gel plus feeding with formula, expressed breast milk, or breast feeding.

RESULTS

The overall mean increase in blood glucose concentration was 11.7 mg/dL (95% CI 10.4-12.8). The increase was greater after buccal dextrose gel than after placebo gel (+3.0 mg/dL; 95% CI 0.7-5.3; P = .01) and greater after infant formula than after other feedings (+3.8 mg/dL; 95% CI 0.8-6.7; P = .01). The increase in blood glucose concentration was not affected by breast feeding (+2.0 mg/dL; 95% CI -0.3 to 44.2; P = .09) or expressed breast milk (-1.4 mg/dL; 95% CI -3.7 to 0.9; P = .25). However, breast feeding was associated with reduced requirement for repeat gel treatment (OR = 0.52; 95% CI 0.28-0.94; P = .03).

CONCLUSIONS

Treatment of infants with hypoglycemia with dextrose gel or formula is associated with increased blood glucose concentration and breast feeding with reduced need for further treatment. Dextrose gel and breast feeding should be considered for first-line oral treatment of infants with hypoglycemia.

Breast-Feeding Friendly, but Not Formula Averse

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

Donor Milk Utilization for Healthy Infants: Experience at a Single Academic Center

BACKGROUND

Banked donor milk (BDM) has historically been used as an alternative to formula for preterm infants. Recently, BDM has been endorsed by two national organizations for use in healthy infants. We sought to quantify utilization trends and characteristics of mothers and their healthy newborns who received BDM during their postpartum stay between 2013 and 2016 at a single academic medical center.

MATERIALS AND METHODS

In this observational study, we used a clinical log to identify all infants who received BDM in the well-baby nursery between July 2013 and June 2016. From this log, we abstracted data on the numbers of babies who received BDM, the quantity of BDM provided, and indications for usage. We also collected clinical data from the medical records of a subset of corresponding mothers and infants.

RESULTS

BDM utilization increased over time in healthy infants, with 0.04% of infants before July 2014 receiving BDM compared with 4.7% in July 2015 to June 2016. During the same periods, the number of bottles provided per infant also increased, from 0.6 bottles per infant to 4.6 bottles per infant. The most common indications for providing BDM were parent/caregiver request (19%) and excessive weight loss/dehydration (17%).

CONCLUSION

At our center, the use of BDM for healthy infants increased substantially over the study period. More research is urgently needed to understand the repercussions of this practice on resource utilization as well as short- and long-term breastfeeding and health outcomes.

Weight gain in the first week of life predicts overweight at 2 years: A prospective cohort study

In formula-fed infants, rapid weight gain during the first week of life is associated with later obesity. To examine the association between weight gain during the first week and overweight at age 2 among infants with various feeding practices and the relationship between exclusive breastfeeding in early infancy and overweight, we enrolled a prospective cohort of healthy mother-infant dyads and followed them for 2 years. We enrolled 450 mother/infant pairs and obtained information on 306 infants at year 2. Weight change during the first week of life and detailed feeding information were collected during the first month of life. Anthropometric measures were collected at 2 years. Overweight was defined as body mass index (BMI) ≥85th percentile for age. At 2 years, 81% had normal weights and 19% were overweight. Maternal pre-pregnancy BMI; infant birth weight; maternal education; and Women, Infants, and Children status were associated with the risk of overweight at age 2. Children who gained more than 100 g during the first week were 2.3 times as likely after adjustment (p = .02) to be overweight at age 2 compared to infants who lost weight. There was no association between feeding type and BMI, but feeding type was significantly associated with change in weight at week 1 and anthropometric measurements at age 2. Infant weight gain in the first week of life is related to overweight at age 2, and exclusively breastfed infants are least likely to gain ≥100 g.

In-Hospital Breastfeeding Experiences Among Women with Gestational Diabetes

BACKGROUND

In-hospital experiences among women with gestational diabetes mellitus (GDM) could impact breastfeeding success. We sought (1) to determine changes in the prevalence of hospital breastfeeding experiences between 2004-2008 and 2009-2011 among women with GDM and women without diabetes; (2) to determine whether GDM is associated with higher occurrence of experiencing Baby-Friendly hospital practices because of their known higher rates of breastfeeding difficulties.

MATERIALS AND METHODS

Data from the 2004 to 2011 Pregnancy Risk Assessment Monitoring System, a survey of women with a recent live birth from 16 states and New York City, were used based on inclusion of an optional survey question about hospital breastfeeding experiences. We examined the association of in-hospital experiences with GDM within each survey phase using chi-square tests. Weighted multivariable logistic regression was used to determine the association between GDM and hospital breastfeeding experiences.

RESULTS

Among 157,187 (8.8% GDM), there were crude differences by GDM status for at least 60% of hospital experiences despite increases in positive hospital experiences between time periods. Women with GDM were less likely to report breastfeeding in the first hour (adjusted odds ratio: 0.83, confidence interval [95% CI] 0.73-0.94), feeding only breast milk in the hospital (0.73, 0.65-0.82), and feeding on demand (0.86, 0.74-0.99) compared with women without diabetes. Women with GDM were significantly more likely to report receiving a pump (1.28, 1.07-1.53) and a formula gift pack (1.17, 1.03-1.34) compared with women without diabetes.

CONCLUSIONS

Although women with GDM experienced improvements in-hospital breastfeeding experiences over time, disparities in breastfeeding practices remained for five in-patient (hospital) practices that included four negative practices (breastfeeding in the first hour, feeding only breast milk in the hospital, told to feed per mother's preference, receiving a formula gift pack) and one positive practice (receiving a pump).

Association Between In-Hospital Pacifier Use and Breastfeeding Continuation and Exclusivity: Neonatal Intensive Care Unit Admission as a Possible Effect Modifier

BACKGROUND

Breastfeeding dyads frequently use pacifiers during the birth hospitalization, but the relationships between this exposure and breastfeeding continuation and exclusivity remain unclear.

MATERIALS AND METHODS

In this secondary analysis of cross-sectional survey data from the CDC Pregnancy Risk Assessment Monitoring System (PRAMS) from 10 U.S. states (AK, AR, CO, ME, MN, NJ, NY, OR, TX, and VT) from 2009 to 2011, we assessed to what extent pacifier use during the birth hospitalization is independently associated with any and exclusive breastfeeding ≥10 weeks.

RESULTS

A total of 37,628 mothers who were chosen by random birth certificate sampling completed surveys at ∼4 months postpartum. Adjusting for multiple pro-breastfeeding hospital practices and maternal and infant demographic characteristics, pacifier exposure during the birth hospitalization was independently associated with decreased odds of breastfeeding ≥10 weeks (adjusted odds ratio [aOR]) 0.71, 95% confidence interval [CI] 0.63-0.80, p < 0.0001) and exclusive breastfeeding ≥10 weeks (aOR 0.70, 95% CI 0.63-0.79, p < 0.0001) among infants admitted to the well-baby nursery, but not among those admitted to the neonatal intensive care unit (NICU).

CONCLUSIONS

In this population study of mothers from 10 U.S. states, pacifier use during the birth hospitalization was associated with decreased odds of breastfeeding and exclusive breastfeeding ≥10 weeks among well-newborn, but not NICU-admitted infants. Pacifier use may be a marker rather than a cause of breastfeeding difficulties, but prospective, randomized studies are needed to help clarify this. Future studies exploring pacifier exposure and breastfeeding outcomes should account for NICU admission as an effect modifier.

Hospital Supplementation Differentially Impacts the Association Between Breastfeeding Intention and Duration Among Women With and Without Gestational Diabetes Mellitus History

BACKGROUND

Little is known about how in-hospital supplementation with water, infant formula, or sugar water affects the relationship between breastfeeding intentions and duration, and whether this differs by gestational diabetes mellitus (GDM) history. Our study objectives were to assess the associations between GDM and exclusive breastfeeding intentions, hospital supplementation, and breastfeeding duration, including whether hospital supplementation mediates the association between exclusive breastfeeding intentions and breastfeeding duration.

STUDY DESIGN AND METHODS

Using data from the Infant Feeding Practices Study II (2005-2007), we included women with GDM (n = 160) and women without GDM or prepregnancy diabetes (no diabetes mellitus [NDM]) (n = 2,139). We used multivariable logistic and linear regressions to determine the associations between GDM history and exclusive breastfeeding intentions, and between breastfeeding intentions, hospital supplementation, and breastfeeding duration, by GDM. We used mediation analysis to assess whether hospital supplementation mediated the association between exclusive breastfeeding intention and breastfeeding duration, also by GDM. All analyses were adjusted for prepregnancy body mass index.

RESULTS

GDM was associated with lower odds of intending to exclusively breastfeed (adjusted odds ratio [AOR] 0.71; 95% confidence interval [CI, 0.51-0.99]). GDM and NDM women who did not intend to exclusively breastfeed had similarly increased odds of hospital supplementation (GDM: AOR 3.52; 95% CI [1.44-8.57], NDM: AOR 3.66; 95% CI [2.93-4.56]). Breastfeeding duration was similar by exclusive breastfeeding intentions and by hospital supplementation, regardless of GDM. Hospital supplementation partially mediated the association between breastfeeding intentions and duration in NDM women, but it did not mediate the association in women with GDM.

CONCLUSIONS

Breastfeeding intentions, rather than hospital supplementation, are particularly important for women with GDM to optimize breastfeeding outcomes.

Early Lactation and Infant Feeding Practices Differ by Maternal Gestational Diabetes History

BACKGROUND

Detailed data on lactation practices by gestational diabetes mellitus (GDM) history are lacking, precluding potential explanations and targets for interventions to improve lactation intensity and duration and, ultimately, long-term maternal and child health.

OBJECTIVE

This study aimed to examine breastfeeding practices through 12 months postpartum by GDM history.

METHODS

Women who delivered a singleton, liveborn infant at The Ohio State University Wexner Medical Center (Columbus, OH), in 2011 completed a postal questionnaire to assess lactation and infant feeding practices and difficulties. Bivariate and multivariate associations between GDM history and lactation and infant feeding practices were examined.

RESULTS

The sample included 432 women (62% response rate), including 7.9% who had GDM during the index pregnancy. Women with GDM initiated breastfeeding (at-the-breast or pumping) as often as women without any diabetes but were more likely to report introduction of formula within the first 2 days of life (79.4% vs 53.8%, P < .01; adjusted odds ratio: 3.48; 95% confidence interval, 1.47-8.26). Women with GDM initiated pumping 4 days earlier than women without diabetes ( P < .05), which was confirmed in adjusted analyses. There was no difference in the proportion of women reporting breastfeeding difficulty (odds ratio: 2.08; 95% confidence interval, 0.78-5.52). However, there was a trend toward women with GDM reporting more formula feeding and less at-the-breast feeding as strategies to address difficulty compared with women without diabetes.

CONCLUSION

Additional research is needed to understand why women with GDM engage in different early lactation and infant feeding practices, and how best to promote and sustain breastfeeding among these women.

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.

BReastfeeding Attitude and Volume Optimization (BRAVO) trial: study protocol for a randomized controlled trial

BACKGROUND

A growing body of evidence shows the short-term benefits of breastfeeding, which include protection against infections, allergies, and lung diseases. However, evidence on the long-term benefits of breastfeeding is scarce and often conflicting. The BReastfeeding Attitude and Volume Optimization (BRAVO) trial is designed to study the effect of breastfeeding on early signs of later chronic diseases, particularly cardiovascular, respiratory, and metabolic risks later in life. In addition, the effectiveness of breastfeeding empowerment in promoting breastfeeding will also be evaluated.

METHODS/DESIGN

This study is an ongoing randomized trial in Jakarta, Indonesia, that began in July 2012. Pregnant women are being screened for their breastfeeding plan in the third trimester, and those with low intention to breastfeed are randomly allocated to either receiving an add-on breastfeeding-optimization program or usual care. Primary outcomes include breastfeeding rate, lung function, and blood pressure during the first year of life and vascular/cardiac characteristics, which will be measured at the age of 4 to 5 years. Child growth and infection/illness episodes are measured, whereas cognitive testing is planned for the children at 5 years of age.

DISCUSSION

To date, 784 women (80 %) have been randomized of the 1,000 planned, with satisfactory completeness of the 1-year follow up (90.1 %). Included mothers are of lower socioeconomic status and more often have blue-collar jobs, similar to what was observed in the pilot study.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01566812 . Registered on 27 March 2012.

Intraoral Vacuum of Breast-Feeding Newborns Within the First 24 Hr

Objectives:

To explore whether newborns born via Cesarean section have a weaker intraoral vacuum compared with those born vaginally and to determine whether a weaker intraoral vacuum is related to a delayed onset of lactation.

Methods:

For this prospective cohort study, 71 mother–infant dyads were enrolled and divided into birthing groups, vaginal or Cesarean. The newborn intraoral vacuum was measured via a tube placed alongside the nipple and connected to a pressure sensor during a breast-feeding session within the first 24 hr after birth. Onset of lactation was confirmed by maternal perception of breast fullness. The intraoral vacuum and its relationship with the onset of lactation were analyzed. Results: After adjustment for confounding factors, the peak intraoral vacuum was −19.50 kPa in the vaginal group, which was significantly stronger than the −13.78 kPa in the Cesarean group ( p = .005). Additionally, the baseline intraoral vacuum in the vaginal group (−2.35 kPa) was significantly stronger than that in the Cesarean group (−1.18 kPa; p = .022). Strength of the newborn intraoral vacuum was associated with the time of onset of maternal lactation.

Conclusion:

Cesarean section may weaken newborns’ intraoral vacuum within the first 24 hr after birth. Stronger intraoral vacuum was related to earlier onset of lactation. Early intervention aimed at the weaker intraoral vacuum should be provided to promote the onset of lactation.

Limited Amount of Formula May Facilitate Breastfeeding: Randomized, Controlled Trial to Compare Standard Clinical Practice versus Limited Supplemental Feeding

OBJECTIVES

Breastfeeding is known to reduce infant morbidity and improve well-being. Nevertheless, breastfeeding rates remain low despite public health efforts. Our study aims to investigate the effect of controlled limited formula usage during birth hospitalisation on breastfeeding, using the primary hypothesis that early limited formula feeds in infants with early weight loss will not adversely affect the rate of exclusive or any breastfeeding as measured at discharge, 3 and 6 months of age.

MATERIAL AND METHODS

We randomly assigned 104 healthy term infants, 24 to 48 hours old, with ≥ 5% loss of birth weight to controlled limited formula (CLF) intervention (10 ml formula by syringe after each breastfeeding, discontinued at onset of lactation) or control group (standard approach, SA). Groups were compared for demographic data and breastfeeding rates at discharge, 3 months and 6 months of age (p-values adjusted for multiple testing).

RESULTS

Fifty newborns were analysed in CLF and 50 in SA group. There were no differences in demographic data or clinical characteristics between groups. We found no evidence of difference between treatment groups in the rates of exclusive as well as any breastfeeding at discharge (p-value 0.2 and >0.99 respectively), 3 months (p-value 0.12 and 0.10) and 6 months of infants' age (p-value 0.45 and 0.34 respectively). The percentage weight loss during hospitalisation was significantly higher in the SA group (7.3% in CLF group, 8.4% in SA group, p = 0.002).

CONCLUSION

The study shows that controlled limited formula use does not have an adverse effect on rates of breastfeeding in the short and long term. Larger studies are needed to confirm a possible potential in controlled limited formula use to support establishing breastfeeding and to help to improve the rates of breastfeeding overall.

TRIAL REGISTRATION

ISRCTN registry ISRCTN61915183.