Abstracts from The Academy of Breastfeeding Medicine 16th Annual International Meeting Miami,Florida November 3–6,2011

1. Hindmilk Feedings Improve Weight Gain for Low Birth Weight Infants

Background: The use of hindmilk rich completely expressed human milk increases the endogenous lipid content of human milk. This can improve the rate of weight gain of newborns and serve as a low-cost “fortifier” in resource-limited settings.

Objective: To study the effect of completely expressed hindmilk rich feeds vs. composite milk feedings in increasing the weight gain of preterm newborns.

Methods: Newborn infants between 28 to 32 weeks of gestational age with no significant medical issues except prematurity on expressed breastmilk feeds were randomized to hindmilk and composite milk feeding over a two week period. Rates of gain for weight, head circumference and length were compared between the two groups. Fat content of milk samples was analyzed using the crematocrit technique.

Results: Small-for-gestational age infants in the hindmilk group had a mean rate of weight gain of 15.62 ± 2.51 g/kg/d while their control group gained weight at the rate of 5.44 ± 1.99 g/kg/d. For appropriate-for-gestational age infants weight gain rates for the study and control group were 18.80 ± 3.20 and 8.02 ± 2.68 g/kg/d respectively. Similar rates for LGA infants were 21.56 ± 3.00 and 9.98 ± 2.98 g/kg/d. There were no significant differences in the rates of increase in length and head circumference between the two groups. Lipid content of hindmilk was 1.4 times that of composite milk.

Conclusions: Hindmilk feeds improve weight gain rates of preterm infants and can be a strategy to reduce length of stay in-hospital and improve newborn outcomes.

Funding Sources: Institute of Child Health Post-graduate Education Fund.

2. Exclusively Human DIET (EHD) for Infants <1250 grams to Prevent Nectrotizing Enterocolitis (NEC)

Background: NEC remains a common disease of infants weighing <1250 grams at birth. Preferential maternal milk feeds is a successful strategy to prevent NEC. However, maternal milk alone does not achieve optimal growth for these infants. A standard feeding guideline for infants <1250 grams implemented 2 years prior to the EHD did not yield any change in NEC. Currently, a human-derived liquid human milk fortifier (HHMF) is available, making EHD a possibility.

Objective: To confirm that EHD is effective for prevention of NEC in high risk infants.

Methods: Prospective cohort. Power of 80% with a 50% NEC reduction requires 244 patients. EHD differs from historical cohort in the fortification of breastmilk with HHMF (Prolacta ™) vs. standard HMF. EHD ended at 33-34 weeks gestation and >1500 grams. Data collected from 7/2010 - 3/2011. Statistical analysis was by Chi-Square.

Results: After 9 months, we have experience with 84 patients (34% of total). Total NEC rates declined to 4.8% from 16% (p=0.026, NNT=9). Surgical NEC rates have declined to 2.4% from 10% (p=0.35 NNT=13).

Conclusions: For infants <1250gm, EHD is an effective intervention, and may significantly reduce both total and surgical NEC.

Funding Sources: None.

6. Supporting Mother-Infant Bonding Increases the Duration of Breastfeeding in Mothers with Newborns in the Neonatal Intensive Care Unit

Background: Smoking mothers are more than twice as likely to quit breastfeeding by ten weeks postpartum. Approximately 40% of women who smoke tobacco quit smoking during pregnancy, yet up to 85% relapse after delivery. Those who resume smoking often do so by eight weeks postpartum. The hospitalization of a newborn, while stressful, is an opportunity to emphasize the importance of breastfeeding and creating a smoke-free environment for babies. Supporting maternal-infant bonding may reduce maternal stress and motivate mothers to continue breastfeeding and remain smoke free.

Objective: To prolong breastfeeding duration during the first eight weeks postpartum and reduce postpartum smoking relapse in mothers who quit smoking just prior to or during pregnancy and have newborns admitted to the NICU.

Methods: This study was an IRB approved prospective randomized clinical trial. After informed consent, mothers of newborns admitted to the NICU were randomized to a control or intervention group. Both groups received routine breastfeeding support and weekly encouragement to remain smoke free. Mothers in the intervention group were also given enhanced support for maternal-infant bonding including information about newborn behaviors and encouraged to hold their babies skin-to-skin.

Results: More mothers were breastfeeding (86 vs. 21%, p<0.001) and smoke free (81 vs. 46%, p<0.001) in the intervention than in the control group at eight weeks postpartum.

Conclusions: Interventions to support mother-infant bonding during a newborn's hospitalization in the NICU are associated with prolonged duration of breastfeeding and reduced rates of smoking relapse during the first eight weeks postpartum.

Funding Sources: AAP Richmond Center, Flight Attendant Medical Research Institute and The March of Dimes (Inland Empire, CA) and Masimo, Corp.

Background: There is controversy about the mode of feeding babies with congenital heart disease (CHD) complicated by heart failure (HF).

Aim: To examine the effect of skin-to-skin care (SSC) during breastfeeding and artificial feeding on the vital signs of babies with CHD admitted to hospital with HF.

Subjects included 55 infants under one year with CHD and HF divided according to their mode of feeding into 19 exclusively breastfed, 21 formula fed and 15 controls. Their oxygen saturations (PO₂) and heart rate (HR) were monitored before and during a session of feeding, and after a period of SSC. The anxiety state of the mother was measured before and after SSC.

Results: Babies who were breastfeeding exhibited significantly higher levels of PO₂ at start of the feed than the formula fed ones and it continued to rise decreasing at about 8 minutes then rising again at the end of the feed. The PO₂ of formula fed did not rise during a feed and fell at 6 minutes. PO₂ and HR patterns improved with SSC in both groups but PO₂ remained statistically significantly higher in the breastfed. The anxiety state of mothers was high in both groups but severer grades were common among the formula fed.

Conclusion: Contrary to previous belief, formula feeding is not safer than breastfeeding. It is more stressful for babies with CHD and HF. SSC appears effective in stabilizing disturbed heamodynamics in these babies and is recommended as a means for improving their outcome irrespective of maternal anxiety.

Funding Sources: Self funded by the candidate student for fulfillment of the requirements of Master degree in Pediatrics.

Background: Kangaroo mother care (KMC) has been accepted as a safe and effective method in caring for low birth weight infants (LBWI). However, the adoption of this method by many countries of the Eastern Mediterranean region (EMR) is still low.

Objective: To identify the barriers to the implementation of KMC in neonatal intensive care units (NICUs) in two countries in the EMR; one with low affluence: Egypt, and one with high affluence: Kingdom of Saudi Arabia (KSA).

Methods: This is a cross-sectional study including 90 major hospitals with NICUs, 60 in Egypt and 30 in KSA. The knowledge, attitude and practice (KAP) toward KMC of 560 NICU staff and hospital administrators was assessed through quantitative and qualitative methods of analysis.

Results: Overall acceptance rate was high at 79%. It was higher among doctors and nurses (80% and 86% respectively) as compared to only 63% for hospital administrative staff. Barriers and suggested solutions focused on space and awareness about the value and safety of KMC in Egypt and on cultural issues and training in KSA.

Conclusions: Resistance to implementation of KMC continues to prevail in over-medicalized health care systems. This originates mainly from the administrative staff irrespective of the degree of affluence in a country. Producing training and advocacy material targeting the latter staff is recommended. A training module for administrators based on current evidence, cost effectiveness, compliance with quality in health care and patient satisfaction may prove useful for this region.

Funding Sources: Self funded by the candidate student (Dr. Nesreen) for fulfillment of the requirements of Master degree in Pediatrics.

3. Breastfeeding Knowledge, Attitude and Practices Among Service Patients Who Delivered at University of Perpetual Help Dalta Medical Center

Background: Little information is available with regards to breastfeeding mothers especially once they are discharged from the hospital. To improve rates of breastfeeding, information on beliefs and practices that influence this outcome is needed.

Objective: To determine the breastfeeding knowledge, attitude and practices of low income mothers who delivered at Perpetual Hospital.

Methods: This is a cross sectional-analytical study using a semi-structured interview. Mothers who completed the prenatal, Iowa Infant Feeding Assessment Scale (IIFAS) and postpartum questionnaires were included in this study. Responses from IIFAS were graded using a five-point Likert rating system. Univariate analysis using crude odds ratio was utilized to determine the association of demographic and breastfeeding knowledge, attitudes and practices. Non-parametric Kruskal WallisANOVAand median test were utilized to compare the ranked mean responses across three or more categories. All tests of significance were performed at .05 alpha level of significance using MEDCALC as biostatistical software.

Results: The IIFAS was able to distinguish three breastfeeding intentions (breastfeeding, formula and mixed feeding) and eventual outcome. The breastfeeding initiation in our study was very high (100%) however only 51% were exclusively breastfeeding at 1–2 weeks. Social support was significantly associated with breastfeeding continuation postpartum. The intention to breastfeed, early initiation ( μ 1 hour) and high IIFAS scores were significantly associated with the actual practice.

Conclusions: This study provides evidence for the reliability of IIFAS. It identified mothers who have higher tendency to breastfeed. This survey tool could prove useful in targeting mothers and provide intervention prior to delivery.

4. The Impact of Baby-Friendly Hospital Designations, Employment Status, Parity, and Other Social-Ecological Factors on Lactation Duration in Upstate New York

Background: The purpose of this study, that analyzed the existing Feeding Your Infant (FYI) dataset, was to examine the impact of Baby-Friendly (BF) Hospital designation, employment, parity, and other social-ecological factors on lactation status at three months postpartum in upstate New York.

Objective: The dataset was analyzed using an adapted version of the Bronfenbrenner Social-Ecological Systems Framework.

Methods: A convenience sample of 842 breastfeeding mothers was surveyed at baseline between two sites - one a BF designated hospital, and one a community-based hospital with a mature breastfeeding program. T-tests, Chi square,multiple correspondence analyses, and multiple logistic regression analyses were performed

Results: Of the 515 mothers who returned the three month survey, 409 (79.4%) were still breastfeeding. Maternal age of 31 to 35 years, women with 16 or more years of education, and married women, were statistically more likely to be breastfeeding. Mothers who expected a maternity leave > 3 months, who had a prior live birth, and who associated breastfeeding with “convenience” were more likely to be breastfeeding. Mother's race, parity status, perception of having a “sleepy baby,” experience with engorgement and/or sore/bleeding nipples, and a mother's delivery site, were not statistically significant. Predictors of breastfeeding status were insufficient milk, perception of “too much time,” and mothers' educational level.

Conclusion: In light of “The 2011 U.S. Surgeon General's Call to Action to Support Breastfeeding,” and the growing interest in The Ten Steps to Successful Breastfeeding and the WHO/UNICEF BF Hospital Initiative, these findings have important implications for education, practice, policy, and future research.

Funding Sources: None.

7. Sustainability of Exclusive Breastfeeding for 6 Months and Infant Health Outcomes in Baby-Friendly Hospitals

Background: Exclusive Breastfeeding (EBF) for 6 months is challenging in Thailand. The strengthening of the Baby-Friendly Hospital Initiative (BFHI) could be a key strategy to overcome the factors affecting the EBF rate.

Objective: To determine the associated factors of EBF practices and related infant health outcomes in Thailand Baby-Friendly Hospitals.

Methods: A Cohort Study of 3,964 mother-infant dyad discharged from 11 BFHI hospitals was conducted during April 2009 to February 2011.The perinatal data, infant feeding practices, maternal knowledge, attitude and practices and infant health status from birth to 24 months were analyzed.

Results: The mean EBF rate was 46.7%. The 7/11 hospitals achieved the higher EBF rate than the national targeted rate of 30%, one of those achieved the highest rate of 70.5%. Maternal occupation, income, comprehensive breastfeeding knowledge and skill and continuous support after discharging from hospitals were the most common outcome determinants. The upper respiratory tract infection and the diarrhea rate was high during 9–24 months among the group of infants who were both breastfed and formula-fed during the first 6 months of life. The rate of diarrhea was significantly reduced at 24 month old infants by the increased duration of EBF during the first 6 months of life.

Conclusions: The strengthening of the BFHI especially the 10^th step was the recommended strategy for the sustainability of EBF. The infant infection, especially diarrhea, was prevented by EBF for 6 months.

Funding Sources: Thai Health Foundation.

8. A Quality Improvement Project Focused on Promoting a Baby-Friendly Environment at an Academic Medical Center

Background: Exclusive breastfeeding is an important metric in hospital quality measures. The 10 steps of the Baby-Friendly Hospital Initiative are known to be predictive of immediate and long term breastfeeding success.

Objective: To describe progress towards a “Baby-Friendly Hospital” in an Academic Medical Center.

Methods: A multidisciplinary task force, BFIT (Breastfeeding Improvement Task Force), was assembled with the short term goal of improving exclusive breastfeeding rates at hospital discharge. BFIT chose three of ten Baby-Friendly Steps – breastfeeding within the first hour, exclusive breastfeeding, and having a written breastfeeding policy. Much improvement was made over the first year. Increased transitioning (from 87% to 97%), allowed improvement in “breastfeeding in the first hour”. Exclusive breastfeeding was encouraged through educating health care providers and parents. A written breastfeeding and supplementation policy was written and implemented. An electronic medical record was incorporated that allowed accurate tracking of many breastfeeding metrics.

Results: Over a 12 month period, implementation of 3 of the 10 Baby-Friendly Hospital steps occurred. The EMR enabled accurate tracking of any breastfeeding, exclusive breastfeeding and percentage of babies who successfully transitioned. Monthly reports are part of the Hospital Scorecards. Exclusive breastfeeding rates went from 30% to 42% over a one year period. Any breastfeeding increased from 74–85%.

Conclusions: The organization of a multidisciplinary task force is effective in moving towards “Baby-Friendly” in Medical Centers. Having an accurate way to track breastfeeding data will allow hospitals moving toward “Baby-Friendly Status” to document improvement over time.

Funding Sources: None.

9. Use of an Eletronic Medical Record (EMR) for Breastfeeding Statistics

Background: Breastfeeding statistics are an important metric in hospital quality measures. Current national breastfeeding reported data is predominately based on parental or nursing report and is inaccurate.

Objective: To describe an EMR allowing accurate breastfeeding tracking in an academic medical center.

Methods: In October 2009, an EMR was created for newborn and maternal care at the University of Kentucky. Many important breastfeeding metrics were added over the next 16 months to allow collection of comprehensive and accurate breastfeeding data. Examples of reportable data include timing of all feedings, whether the baby transitioned and if not, why, and cc's of formula supplementation. Percentage of women who do any breastfeeding and exclusive breastfeeding is reported. Exclusivity is measured by breast milk-fed term infants as a proportion of all term infants. Our EMR excludes babies with contraindications to breastfeeding. Exclusivity by ethnicity, age and type of insurance is tracked and reported. To improve physician compliance, many of the fields are mandatory.

Results: As a result of a nursery EMR, accurate monthly breastfeeding metrics are collected and reported. This data can be used to direct changes in patient care that can result in improved breastfeeding practices.

Conclusions: National breastfeeding data currently is collected by parent or nursing report. Using an EMR to ensure accurate reporting is the first step in monitoring and improving breastfeeding rates. Data can document success or failure of small cycles of change in breastfeeding management. Ideally a standardized EMR across institutions would allow true measurements of change across institutions.

Funding Sources: None.

10. Breastfeeding Knowledge, Attitude and Practices of Nurses in Department of Obstetrics and Gynecology – Philippine General Hospital

Background: Nurses play a pivotal role in collaborating and implementing the Baby-Friendly Hospital Initiative policy. Despite the vital role of nurses in promotion and support of breastfeeding, there are few studies regarding the knowledge and activities in breastfeeding promotion.

Objective: To evaluate the knowledge, attitude and practices of nurses employed in Department of Obstetrics and Gynecology - Philippine General Hospital.

Methods: This descriptive study had for subjects 62 nurses. The questionnaire included 20 questions on attitudes to and knowledge of breastfeeding, and five multiple-choice questions on breastfeeding management.

Results: The participants have a positive attitude towards breastfeeding. 93.5% of subjects knew that breastmilk is enough to satisfy babies for six months. 82.3% of them recognized the benefit of breastfeeding on mother's health. The common reason for terminating exclusive breastfeeding is resumption of work after a maternity leave. The subjects have inadequate understanding in recognizing symptoms and managing the common breastfeeding problems. A few of the nurses who have attended the lactation management training still have inadequate understanding on the facts on breastmilk and management of breastfeeding problems.

Conclusions: The nurses of the Department of Obstetrics and Gynecology-Philippine General Hospital understand and accept that breastfeeding is an important aspect of primary care. Additional training programs are required to increase optimal breastfeeding knowledge and improve practice.

Funding Sources: None.

11. Barriers to Breastfeeding in Women of Lower Socioeconomic Status

Background: When encouraging mothers to breastfeed, it is critical to understand how socioeconomic status can impact a woman's breastfeeding experience. When healthcare providers do not understand the impact of socioeconomic status on breastfeeding, segments of our population are excluded and barriers are not broken, but cemented.

Objective: The purpose of this study is to compare the impact of socioeconomic status on mothers' breastfeeding experience.

Methods: Surveys were offered to mothers at a clinic serving low-income patients. The data from 77 completed surveys were analyzed using EpiInfo version 3.5.1 and then were compared to prior survey results from more affluent mothers in the same geographic area.

Results: Of those surveyed, 50% planned to breastfeed for 12 months and only 1.8% met this goal (versus 50% of the more affluent planning this goal, and 50% falling short), 38.9% reported their physician frequently encouraged them to breastfeed (versus 28.2% of the more affluent), and 32.4% reported that breastfeeding was not common among family and friends (versus 10% of the more affluent).

Conclusions: Socioeconomic status clearly is an important factor contributing to mothers not meeting their own goals for breastfeeding duration. But regardless of socioeconomic status, breastfeeding mothers need more support from their physicians to attain breastfeeding success.

Funding Sources: None.

12. Health Professionals' Attitudes, Knowledge and Experience Regarding Wet Nursing and Human Milk Sharing

Background: Many families who are unable to provide breastmilk for their babies look for and accept breastmilk from other lactating women. There is no research evaluating the attitudes of health professionals regarding milk sharing and wet nursing.

Objective: This survey evaluates the knowledge, experience and attitudes of wet nursing and milk sharing among health professionals who are experienced in the field of breastfeeding.

Methods: The survey was sent via email to health professionals who participated in listserves regarding breastfeeding. Survey questions asked for demographic and medical specialty information, and assessed the health professionals' knowledge, experience and attitudes regarding wet-nursing and milk sharing.

Results: 410 respondents finished the survey; 30% physicians, 16% nurses, 26% lactation consultants, 7% La Leche League leaders, 5% midwifes, and 16% other. Ninety percent of all respondents agreed that women should share unpasteurized milk or wet nurse a term healthy infant. 75% of all respondents agreed that the donors should be screened like blood donors, and 25% agreed that the donors don't need such screening. The respondents' 2 highest ranked issues in ensuring safety of shared unpasteurized milk were 1)Donors are screened via interview and blood work in the same way that blood donors are screened and 2) Instructions are given to donors on safe expression and milk storage/handling techniques.

Conclusions: Health professionals who are knowledgeable about breastfeeding overwhelmingly support wet nursing and sharing of unpasteurized human milk. Donors should be screened and should be instructed on safe milk handling and storage techniques.

Funding Sources: None.

13. Systemic Interaction in Families Engaging in Physiological Breastfeeding Patterns: the Contribution of Family Interchanges Associated with Breastfeeding to Parental Sensitivity and Children's Social Emotional Development

Background: Author's previous study on breastfeeding dyads demonstrates that nursing facilitates the development of intricate interactions, contributing to sensitive mothering styles and healthy psychological growth. Systems theory indicates that interchanges in dyads affect the family and vice versa.

Objective: To broaden earlier research and investigate the reverberating impact of nursing on the family system.

Methods: Observations, interviews, audio and videotape of families actively involved in physiological breastfeeding in natural settings over time and interviews with carefully selected key informants were organized into case studies and categories and analyzed.

Results: Families engaging in physiological breastfeeding patterns display unique behaviors and interactions associated with evolving and reverberating themes related to breastfeeding. Themes facilitate interaction based on infant and child cues. Parents' attuned responses to cues for nursing and proximity evolve into an overall sensitive parenting and family style extending beyond nursing and early childhood. The circulation of themes associated with the development of sensitivity through nursing is influenced by complementary parenting task allocation, open communication and tutoring. Unresolved couple discord and closed communication interfere with these processes and is expressed through distancing, the use of artificial pacifiers, and naming nursing as feeding.

Conclusions: The study concludes that interaction in the nursing sub-system affects and is influenced by overall systemic interchanges, and facilitates the development of parental and family sensitivity extending beyond nursing. The conclusions have important implications for child outcome, including for children in families with multiple risk factors, due to the importance of parental sensitivity for healthy socio-emotional development.

Funding Sources: None.

The author has published the findings in a book and receives intermittent royalties.

Epstein-Gilboa, K. (2009). Interaction and relationships in breastfeeding families: Implications for Practice.

Amarillo TX: Hale Publishing.

14. Using Language Implying that Nursing is a Normal Developmental Task

Background: Wiessinger's (1996) original work demonstrates the negative implications of using artificial feeding as the term of reference versus the facilitative factors of referring to nursing as normal for breastfeeding behaviors.

Objective: To investigate and enhance language associated with breastfeeding in clinical discourse and education.

Methods: Data were collected from the abstract author's study on breastfeeding families, observations of interaction, assessment of narrative, language and images in the media, and lay and professional literature. Analysis was facilitated by the application of psychological concepts.

Results: Clinical discourse and educational material is abundant with examples of language interfering with maintenance of physiological breastfeeding patterns. Examples include referring to breastfeeding as superlative and beneficial, naming nursing as food and a feeding choice, discussing breastfeeding frequency and amount, using patriarchal and hierarchal terms including management and compliance, negating the encompassing nature of nursing, and commending breastfeeding initiation while implying that nursing beyond infancy and associated proximity behaviors are abnormal. Personal experience and the false believe in one's ability to induce guilt impair optimal language use and clinical interaction.

Conclusions: Enhanced language use in clinical practice requires an acknowledgement of bias and the capacity to use concepts implying that physiologically based nursing patterns are the norm. Guiding principles include framing nursing as an encompassing and normal developmental task associated with infancy and early childhood that includes proximity behaviors. Discourse is enhanced and the obligation to facilitate informed decision making is fulfilled when practitioners inform clients about the risks of veering from normal nursing patterns.

Funding Sources: None.

15. The Effect of Birth Weight on Exclusive Breastfeeding Through 3 Months

Background: Exclusive breastfeeding through 3 months is a Healthy People 2020 goal, yet most U.S. infants who initiate breastfeeding receive formula before 3 months.

Objective: To examine the effect of birth weight on exclusive breastfeeding at 3 months.

Methods: We analyzed data from a randomized trial of probiotics for healthy infants to determine the effect of birth weight and other predictors available at birth on any breastfeeding and exclusive breastfeeding through 3 months. We used backward stepwise logistic regression to examine the effect of maternal age, education, feeding plan, delivery method and parity and infant birth weight and gestational age on the outcomes of any and exclusive breastfeeding through 3 months.

Results: Among 162 infants, we found that birth weight was strongly associated with exclusive breastfeeding through 3 months (OR 5.85 (2.18, 15.7) per kg birth weight), adjusting for maternal education and feeding plan. However, birth weight was not associated with any breastfeeding at 3 months when adjusting for the same predictors. The area under the receiver-operator curve was 0.82 for the exclusive-breastfeeding model and 0.87 for the any breastfeeding model; no other predictors reached significance when added to either model.

Conclusions: Smaller newborns were much more likely to receive formula before 3 months in this study population. It is possible that some mothers of smaller babies mistakenly believe that formula is needed to promote growth. Educating mothers of smaller babies about normal newborn weight patterns might reduce unnecessary formula use.

Funding Sources: NIH/NHLBI ROI HL080074 (Cabana and McKean) and NICHD K23 HD059818-01 (Flaherman).

17. Latch Now: Mobilizing a Community Through Collaboration, Coalition Building, and Education

Background: Exclusive breastfeeding rates at birth are low in Los Angeles County (33%) and very low in the community served by Children's Hospital Los Angeles (CHLA) and Hollywood Presbyterian Medical Center (HPMC) (∼13%).

Objective: To increase exclusive breastfeeding rates in the community served by CHLA, HPMC, and affiliate clinics, and impact approximately 10,000 infants a year.

Methods: LATCH NOW (Lactation, Advocacy, and Teaching at CHLA, HPMC, and Network of WICs) is as an ongoing evidence-based project. Informal key stakeholder interviews were used to identify inpatient and outpatient barriers to breastfeeding. A multi-institution, collaborative coalition addresses these barriers. Consultation is provided to HPMC toward achieving Baby-Friendly designation. Tailored breastfeeding curricula for nurses and staff were modeled after the Baby-Friendly Hospital Initiative. Reimbursable breastfeeding classes for community parents were modeled after the California Perinatal Services Program.

Results: In two years LATCH NOW has collaborated with numerous stakeholders and decision-makers; moved CHLA and HPMC toward Baby-Friendly practice, including increased awareness and lactation staffing; and designed free and reimbursable curricula for hospitals and families, respectively. Institutional buy-in is very high. Policy and practice have measurably improved. Partners now include the LA County Department of Public Health and hospitals throughout LA. A county-wide provider educational campaign is being planned.

Conclusions: LATCH NOW has transformed breastfeeding culture at influential institutions in the community through collaboration. Improvements in exclusive breastfeeding rates are highly anticipated. To the authors' knowledge, this is a unique initiative that comprehensively and simultaneously addresses many barriers to breastfeeding.

Funding Sources: First 5 Los Angeles Baby-Friendly Hospital Project grant (March, 2010), American Academy of Pediatrics Community Access To Child Health grant (October, 2010), American Academy of Pediatrics California Chapter 2 Resident Research Award (June, 2011), Children's Hospital Los Angeles Gary F. Krieger, M.D. Pediatric Advocacy Award (June, 2011).

18. Adaptive Breastfeeding – Defining the Mission

Background: There is very little data on adoptive breastfeeding (ABF), especially in special needs' and/or older infants' adoptions. “ABF” and similar terms fail to identify parental designation (adoptive, foster, or kinship), dyad's primary goals (nutrition and/or attachment), and child's condition (developmental, emotional, sensory and/or physical).

Objective: To review the available information, define the ABF process, and determine the feasibility of further investigations.

Methods: Medical literature was accessed by using the database searches with key words 'adoption', 'breastfeeding', 'lactation'. Data from the general Internet searches as well as archives of adoption-related and breastfeeding-related discussion groups was collected and evaluated.

Results: Studies were limited to case reports with mostly either single or few dyads of newborn or young infant adoption. Failure to initiate or sustain ABF (partial or exclusive) was frequently attributed to intrinsic maternal factors (higher education, lack of motivation, etc) only. Breastfeeding-related Internet sources had similar attitudes. Adoption-related groups were more open about failures and complications and usually had reservations towards ABF. Very few authors were objectively addressing unusual demands of special needs children, international adoptions, and/or older adoptions.

Conclusions: ABF is a desirable and realistically achievable goal. ABF should be viewed as a continuum of attachment and development promoting interventions ranging from encouraging holding and skin-to skin contact to the pinnacle of partial or exclusive breastfeeding. We suggest the term “adaptive nursing” to define the very special needs of that very unique dyad. Further research is essential and requires cooperation of adoption and breastfeeding specialists.

Funding Sources: None.

20. In-Hospital Weight Loss in Breastfeeding Newborns During Initial Post-Delivery Period

Background: Breastfeeding's many benefits may be lost with poor initial breastfeeding competence and loss to follow-up post-discharge. Weight loss may be an early predictor. We determined that early (in hospital) intervention would be beneficial for this population and needed to identify contributors in order to intervene.

Objective: To describe factors influencing weight loss in healthy, term, breastfeeding newborns.

Methods: This descriptive correlation study, using data from 200 retrospectively charts audits of mother-infant dyads who delivered in early 2009. Descriptive statistics describe infant (sex, gestational age, number of breast feeding attempts) and maternal characteristics (gravity, parity, and type of delivery, epidural use, hospital length of stay, lactation consultation or depression). Hierarchical multiple regression techniques determined contribution of infant and maternal characteristics to percent of weight loss.

Results: Babies born by cesarean lost more weight than those delivered vaginally (6.7% versus 4.2%). There was no difference in weight loss by gender, epidural use, or prenatal maternal depression.

Conclusions: Cesarean Delivery is now a priority for lactation consultation at this institution. It was noted that newborns and mothers were separated from time of delivery to recovery completion, losing the critical period for skin to skin (STS) benefits and initial breastfeeding opportunity afforded to vaginal delivery mother-newborn dyads. Early intervention of skin to skin and low early intervention protocols were instituted to motivate greater efforts during the critical periods and solidify breastfeeding competence/confidence prior to discharge. Test of change shows 94% lactation consultation and 90% of all (77.3% CD) deliveries placed STS and breastfed within 30 min of delivery.

Funding Sources: Beta Psi Chapter of Sigma Theta Tau clinical Scholarship/Research Grant.

22. Improved Growth is Possible in Very Low Birth Weight Infants (VLBWI) Receiving Exclusively Human Milk (HM) or HM/PRETERM Formula (F) Combination Feeds

Background: Improved VLBWI growth is associated with improved neurodevelopment. Protein intake is an important factor for growth, and HM has low protein density. HM supplementation products exist but may remain inadequate and therefore some institutions promote PF over HM to optimize growth. In 2009, one institution developed quality improvement initiative (QII) to improve VLBWI growth while promoting HM as optimal VLBWI intake.

Objective: Determine QII effect on VLBWI growth/body composition (BC) while not promoting PF over HM.

Methods: VLBWI born pre-QII (9/2007–10/2009) and post-QII (12/2009–3/2011) were consented for BC measurement by air displacement plethysmography (ADP) (COSMED USA, Inc.) at term age (TA). QII included goal >3.5 g/kg/day protein intake and daily discussion of nutrition/growth. BC and growth parameters were followed from birth to TA. Growth parameter percentiles per Fenton. Growth rates from birth to TA. Comparisons by t-test and regression. Significance p<0.05.

Results: 116 infants (65 pre-QII/51 post-QII; 64% black; 40% male). All received HM instead of PF until 32 weeks post-menstrual age (PMA). 55% received predominately HM past 32 weeks PMA. Mean birth weight, birth PMA, PMA at ADP were 1050g, 29 weeks, 36 weeks pre-QII and 1125g, 29 weeks, 40 weeks post-QII. Controlling for PMA, length gain rate (0.97 cm/week pre- and post-QII) and % fat (13% vs. 17%, respectively) at TA were not significantly different. Weight gain rate significantly improved post-QII (19.9 vs. 25.7 g/day, respectively). Fenton weight percentile significantly improved when controlling for PMA (6% tile vs. 23.9% tile, respectively).

Conclusions: Preterm infant growth was significantly improved while maintaining and promoting HM feeds.

Funding Sources: COSMED USA, Inc (formerly Life Measurements, Inc) and the MUSC Division of Neonatology.

Background: In 2008, the DC Breastfeeding Coalition (DCBFC) evaluated Washington, DC birthing facilities for their support of breastfeeding. We hypothesized that collaboration between hospitals could improve breastfeeding support city-wide.

Objectives:

1) Determine if representatives from DC hospitals would collaborate to improve breastfeeding-related maternity care services.

Methods: The PLQCC was established by the DCBFC in October 2010 and meets quarterly. The initial PLQCC meeting was attended by representatives from every facility in the District (7 general hospitals, 1 children's hospital and one free-standing birthing facility). We reviewed The Joint Commission's Perinatal Care Core Measure Set, specifically focusing on the exclusive breastfeeding measure. Subsequent meetings have included thorough discussions of practical implementation of each of the Ten Steps to Successful Breastfeeding.

Results: Of the 28 respondents to the online evaluation surveys, 90% indicated that the information shared during the meetings was helpful in improving their breastfeeding support services and 100% indicated that they would continue to attend future meetings. Participants' interest for future topics include: (1) ideas to optimize mother-baby nursing care that promotes breastfeeding, (2) identifying post-discharge breastfeeding support services (3) assistance with improving workplace support and (4) collaborating with research.

Conclusions: The PLQCC has been a well-accepted model for collaboration between hospitals to enhance breastfeeding support in the District.

Funding Sources: Center for Perinatal Advocacy at Providence Hospital.

26. State-Wide Support for Physician-Mothers Who are Breastfeeding

Background: Despite the significant health and financial benefits of breastfeeding, there is a substantial gap between professional recommendations and personal practices among physician-mothers in the United States.

Objective: To understand the typical barriers to breastfeeding for physician-mothers in Rhode Island and systematically coordinate ongoing efforts to overcome these common obstacles.

Methods: This project was comprised of a comprehensive literature review of the barriers and support for physician-mothers at the federal and local levels in conjunction with a formal, regional needs assessment of physician-mothers.

Results: Historically, physicians-mothers lack time and space to express milk in a private, convenient, and healthy manner. In addition to federal legislation to promote breastfeeding, two well-established Rhode Island resources actively advocating on behalf of physician-mothers are: 1) MomDocFamily (MDF), a RI-based multi-specialty group of physicians and medical students who are mothers and 2) the Rhode Island Breastfeeding Coalition (RIBC), made up of community organizations that aim to support local businesses in the breastfeeding promotion by distributing the Department of Health and Human Services' Business Case for Breastfeeding Toolkit and through mini-grants for employers to start or enhance their lactation programs. MDF and RIBC have collaborated on two mini-grants, are working with the state's only medical school and two university-affiliated hospitals to establish four new lactation rooms, and have compiled and distributed a list of existing lactation accommodations for medical students and physicians in Rhode Island hospitals.

Conclusions: Systematic collaborative advocacy efforts in support of breastfeeding among physician-mothers in Rhode Island can serve as a national model.

Funding Sources: None.

27. Does Health Care Provider Support for Breastfeeding Make a Difference in Selecting an Infant Feeding Method?

Background: Rates of breastfeeding among African-Americans have long been found to be lower than those for Whites/Latinas. Although low socioeconomic status among African-Americans has often been cited as a factor, other factors may play a role, including that of the health care provider (HCP).

Objective: To examine the role that the HCP may play by expressing strong support for breastfeeding and how that support might influence the selection of infant feeding method (IFM) among college-educated African-American women, a subgroup not often studied in this area.

Methods: 85 African-American women were recruited through the alumni association of Spelman College and through local chapters of Delta Sigma Theta sorority. They were asked to complete a survey questionnaire through Survey Monkey regarding their infant-feeding choices.

Results: More than ½ of the women reported that their HCP expressed strong support for breastfeeding. These providers were also more likely to discuss the benefits and disadvantages of each method (88.1% vs. 39.5%) and to have the discussion early in pregnancy (25.0% vs. 12.1%). Women whose providers expressed strong support were more likely to initiate breastfeeding (72.1% vs. 57.1%) and to not discontinue breastfeeding until at least month 4 or later (80.6% vs. 43.8%). These women were also less likely to see breastfeeding complications as a barrier (37.5% vs. 65.2%) or to report that medical issues (e.g., C-section, maternal/infant complications) played an important role in their selection of an IFM.

Conclusions: The findings of this study support the importance of HCPs expressing strong support for breastfeeding in contributing to improving rates of breastfeeding among African-American women.

Funding Sources: None.

29. Barriers to Breastfeeding in Brooklyn

Background: Breastfeeding has extensive benefits for mothers, babies, and society. We suspected that rates of both initiation and duration of breastfeeding at The Brooklyn Hospital Center (TBHC) are far below national standards.

Objective: 1: Assess breastfeeding initiation, exclusive breastfeeding, and duration of breastfeeding. 2: Define barriers to breastfeeding.

Methods: We surveyed 95 healthy mothers of healthy newborns at TBHC within 48 hours of birth. Data collected included mother's age, race, education, WIC eligibility, father's involvement, breastfeeding education, and age of newborn at initiation of breastfeeding. Follow up phone surveys were done at 1, 3, and 6 months.

Results: Eighty-six percent of mothers received breastfeeding education. Breastfeeding was initiated by 81% (9% exclusively). At 1, 3, and 6 months, 67, 40, and 19%, respectively, were breastfeeding (follow up for 63/95 mothers). One baby continued breastfeeding exclusively at 1 and 3 months. Reasons for not breastfeeding were: baby not latching, mother on medication, returning to work/school. Fifty percent did not give a reason.

Conclusions: We were pleased with our breastfeeding initiation rate, but found exclusive breastfeeding and continuation rates low. Our study population was primarily low-income non-Hispanic black, known to have the lowest breastfeeding rates. We hypothesize that insufficient breastfeeding education during prenatal visits, rapid separation of mother and baby in the delivery room, infrequent rooming-in, and inadequate breast feeding support explain our results. In further study, we plan to focus QI and research efforts to address these factors and are committed to improving breastfeeding rates at TBHC.

Funding Sources: None.

31. Breastfeeding Habits of Orthodox Jewish Women in Norfolk, Virginia

Abstract Withdrawn

32. Profile of a Group of Mothers Attending a Breastfeeding Clinic

Background: Many women experience breastfeeding problems in a non-supportive setting. Breastfeeding clinics can have an important role in helping these women to overcome breastfeeding difficulties.

Objective: The purpose of this study was to describe the variables associated with breastfeeding problems in a group of Puerto Rican mothers who attend a breastfeeding clinic.

Methods: An exploratory, cross-sectional design was used. 141 medical records were examined to gather data related to maternal, perinatal, feeding practices, family and nutritional history. Data analysis was done by descriptive and inferential statistics, and cross tables.

Results: The median time of gestation was 38 weeks (SD=3.27). 28.9% of the participants reported having had medical problems during their pregnancy and 23.0% at the time of the labor. 66.7% used anesthesia during labor [45.5%-spinal and 9.8% epidural]. 51.5% delivered by C-section. At the time of evaluation 35.5% of the participants were breastfeeding. 25.9% had started to breastfeed immediately after birth; median time for breastfeeding initiation was 7.5 hours [SD=249.4]. 86% of the participants reported having been separated from their babies for over 2 hours, and 45.1% breastfed less than 8 times during their first 24 hours in the hospital. Participants reported the following problems: difficulty to latch to the breast [45.5%], sleepy baby [45.0%], pain in the nipples [40.5%], insufficient milk production [24.2%], preference for one particular breast [26.7%], and other problems [15.4%]. It was observed that those having C-sections had shorter mean breastfeeding time than those having vaginal births [106 vs. 221 days respectively; p>0.05].

Conclusions: Hospital practices appear to hinder successful breastfeeding in the studied group.

Funding Sources: None.

35. Use of Lamotrigine During Breastfeeding–Descriptive Analysis of Our Population and Report of Five Cases of Premature Neonates

Background: High plasma lamotrigine levels can be measured in breastfed infants whose mothers take lamotrigine. There is no data on the use of lamotrigine when breastfeeding a premature neonate. Since lamotrigine is eliminated by glucuronidation, an immature metabolic pathway in neonates, an accumulation of the medication is anticipated in premature neonates.

Objective: Report lamotrigine blood levels in premature neonates and evaluate side effects.

Methods: This is a descriptive study on the use of lamotrigine during breastfeeding. All women on lamotrigine that delivered a live newborn in a five year period at CHU Ste-Justine were included. Data were collected in medical files.

Results: There were twenty term newborns and five preterm newborns in our population. Fifty percent of the term newborns and all the premature babies were breastfed. Plasma levels were monitored in three of the premature newborns. Lamotrigine was not detectable in the infant of a mother on a daily dosage of 200 mg for epilepsy and no adverse effects were noted. Lamotrigine was within therapeutic range in the premature twins of a mother on polytherapy for bipolar disorder including lamotrigine 200 mg daily. With the exception of transient elevation of liver enzymes, no side effects were reported. No levels were drawn in the two other premature infants but no adverse effects were seen.

Conclusions: Breastfeeding is possible when taking lamotrigine, with a follow-up of side effects and plasma levels if necessary. When breastfeeding an early preterm neonate, lamotrigine plasma levels should always be measured in the baby.

Funding Sources: None.

Background: The risk of anemia among exclusively breastfed infants varies widely in the literature, both positively and negatively.

Objective: To compare the incidence of anemia between infants who were exclusively breastfed (EBF) for 6 months and those who were not.

Methods: A cross-sectional survey by face to face interview with care-givers was conducted for the prevalence of anemia, looking at hematocrit and other red cell indices among 6-month-old infants visiting the well-child clinic at two Bangkok hospitals.

Results: 63 infants were included: 24 (38%) EBF; and 39 (62%) non-EBF. Mean hematocrits in the EBF and non-EBF groups were 34.5+1.7 and 35.1+2.3% respectively. The prevalence of anemia in the EBF group was 4.2%, and in the non-EBF group, 12.8%. Although the findings were not statistically significant, the red blood cell indices for the one anemic infant in EBF group were not compatible with a diagnosis of iron deficiency, whereas 4 of the 5 anemic infants in the non-EBF group had indices compatible with iron deficiency. Growth parameters were comparable between the two groups.

Conclusions: This study did not show statistical differences between the hematocrits or other red blood cell indices of EBF and non-EBF infants, but the prevalence of anemia was higher among those who were not exclusively breastfed for 6 months. No iron deficiency anemia was identified in the EBF group, whereas indices suggesting iron deficiency were seen in over 10% of those not EBF. Our study supports the advocacy of exclusive breastfeeding for six months.

Funding support: QSNICH research fund.

38. Physician-LED Model for Post-Discharge Breastfeeding Clinic Contributes to Success

Background: Breastfeeding rates at most urban Midwestern hospitals fall short of WHO 2010 goals, with the rate at St. John Hospital and Medical Center being less than 60% at initiation, 15% at 6 months, and <10% at one year despite a robust inpatient lactation support service. The early discontinuation rate has been attributed to delay in management of problems which arise after hospital discharge.

Objective: Our objective was to identify attributes of post-discharge services that make them approachable and desirable to the breastfeeding mother.

Methods: Data were collected by chart review and telephone survey. Study group consisted of 186 couplets seen at the physician-led outpatient breastfeeding clinic for any difficulty experienced. Control group consisted of mothers who were breastfeeding at discharge who did not access the clinic.

Results: In the study group, 43% reported their decision to utilize the breastfeeding clinic was influenced by physician presence and 50%, by insurance billing policies. 90% of those in study group reported they breastfed longer because of the clinic, and 97.5% reported it contributed to their meeting their breastfeeding goal. Mothers in the control group who had discontinued breastfeeding at the time of survey reported that utilization of the clinic could have contributed to prolonged breastfeeding (p=0.043).

Conclusion: Women who utilize a physician-led accessible breastfeeding clinic were able to prolong their breastfeeding experience and meet or exceed their breastfeeding goals. Physician involvement and insurance coverage were the most positive attributes of the clinic.

Funding Sources: None.

39. Autism and Oxytocin System Dysfunction—The Influence of Exclusive Breastfeeding on the Incidence of Autism

Background: There is significant evidence that autistic disorders are the result of the interaction of the autism genes and the infant's social environment. Animal research and neuro-imaging studies have demonstrated that exclusive breastfeeding and bonding increase the production of oxytocin and its receptors in the brain. Oxytocinergic neurons may have the physiological capability to alter gene expression and therefore prevent autism.

Objective: To investigate the association between feeding methods, exclusive breastfeeding, breast-milk or formula feeding on the prevalence of autism diagnosis. We postulate that exclusive breastfeeding and bonding will reduce the prevalence of autism.

Methods: A random, confidential and anonymous parent's survey was conducted from our pediatric practice to ascertain the association of a parent's reported autism diagnosis with the duration and exclusivity of breastfeeding, breast milk or formula feeding.

Results: One hundred and forty five parents responded to the survey. Sixty children had autism diagnosis. Twelve of the sixty children were formula-fed. Twenty six were exclusively breast-fed from less than two months to greater than two years and had autism diagnosis. Twenty two were fed breast-milk, via a bottle, from less than two months to greater than two years. The survey results indicate that exclusive breastfeeding longer than nine months was associated with significant reduction in autism diagnosis (odds ratio 9.56 and confidence interval 2.42, 37.7).

Conclusions: This study demonstrates an association between exclusive breastfeeding and decline in autism diagnosis. The results validate the hypothesis that oxytocin has a major and central role on the brain plasticity and prevention of autism.

Funding Sources: None.

40. Breastfeeding Education of the Medical Students of the First Moscow State Medical University

Abstract Withdrawn

45. Support Program Increases Exclusive Breastfeeding Rate in Hospital Personnel at Queen Sirikit National Institute of Child Health (QSNICH)

Background: Queen Sirikit National Institute of Child Health (QSNICH) is the tertiary care hospital for Thailand's children. Almost all personnel (95 %) are women. Before 2006 there was no system to support exclusive breastfeeding (ECBF) for hospital personnel.

Objective: To implement and monitor an exclusive breastfeeding support program for the hospital personnel v.

Methods: Lactation clinic leads the program by: inviting pregnant mothers to join a mother support group at least once before and after delivery, visiting within 3 days after delivery, breastfeeding gift set given by administrative team, convenient channel to access lactation clinic either by call or drop in. Day care support and two 30 minute breaks to breastfeed were allowed. Questionnaire on breastfeeding duration and the infant health situation at 4 and 6 months were included.

Results: From 2006–2010, 69 mothers participated in this program. The remainder of the mothers did not participate because their children were cared for by out of town relatives once they returned to work. For 2006 to 2010 the exclusive breastfeeding rate at six months was 52% (12/23 births), 53% (8/22), 63% (14/22), 66% (10/15) and 69% (11/16) respectively. Factors associated with breastfeeding at 6 months include attendance at breastfeeding support group before delivery, lactation clinic team support during delivery and postpartum period and also the adequate milk production at discharge from the hospital.

Conclusions: A program to support exclusive breastfeeding for hospital personnel increases the rate of breastfeeding at 6 months.

46. Are Health Professionals Treating Breastfeeding the Same as Other Health Issues? — A Review of Policy Statements and Position Papers of Professional Health Organizations

Abstract Withdrawn

Background: The Tennessee Initiative for Perinatal Quality Care (TIPQC) is a statewide quality improvement collaborative that elected to develop a project to address Tennessee's low breastfeeding rates.

Objective: The project aim is to improve the health of infants and mothers in Tennessee by systematically promoting breastfeeding at prenatal care visits.

Methods: A toolkit of evidence-based practices was developed by an interdisciplinary project development team after review of published tools from the AAP, ACOG, ABM, and elsewhere. Inclusion of a practice was based on evidence of effectiveness and consensus/approval by the team and pilot centers. The project pilot was launched in four TN practices in spring 2011.

Results: Participating practices will first establish a primary improvement team of relevant stakeholders. The toolkit includes a menu of “potentially better practices” (PBPs) that may be implemented individually, or as a bundle. Success of this project relies on use of rapid Plan-Do-Study-Act (PDSA) cycles. Web-based data-entry through REDCap will allow practices to access on-demand run-charts for their project data and comparisons to project-wide aggregate data. The fractions of mothers exclusively feeding breastmilk, feeding both breastmilk and formula, and feeding exclusively formula at the first post-partum visit at 4–8 weeks post-delivery will be determined. Local audits will be used to evaluate reliability of implementation of potentially better practices.

Conclusions: This project may serve as a model for how quality improvement methodologies may be combined with use of distance-learning and web-based data entry and reporting to facilitate implementation of potentially better practices to increase breastfeeding rates.

Funding Sources: Funded under an agreement with the state of Tennessee.