Assessing Clinical Recommendations for Interruption or Cessation of Breastfeeding
Sara Oberhelman1, Jacqueline Zayas1
1Mayo Clinic, Rochester, Minnesota, USA
Category: Clinical Practice/Lactation Management
Background: Breastfeeding has clearly been identified as the ideal form of infant nutrition with a plethora of health benefits for the mother and child as well as societal advantages. While the World Health Organization, American Academy of Family Physicians and American Academy of Pediatrics all recommend that infants exclusively breastfeed for at least 6 months, less than 30% of mother‐infant dyads meet this objective. Studies have shown that 60% of breastfeeding mothers do not meet their personal breastfeeding duration goals with one of the most common reasons identified for premature cessation being concerns regarding maternal medical conditions or need to take medication. To the best of our knowledge, there have been no studies performed identifying the frequency in which health care professional recommend either temporary interruption of breastfeeding or premature cessation of breastfeeding due to concerns regarding maternal testing, procedures or medication use.
Objective(s): Identify the most common indications for which clinicians recommend interruption or cessation of breastfeeding. Determine how frequently a clinician's recommendation for interruption or cessation of breastfeeding impacted a mother's ability to reach her breastfeeding goals. Compare the most common indications that clinicians document their recommendation for interruption or cessation of breastfeeding compared to patient's perception of recommendations for interruption or cessation of breastfeeding.
Materials/Methods: Initially, we performed a retrospective cohort chart review utilizing Advanced Cohort Explorer, a Mayo Clinic repository that allows for text‐based queries of EHRs, to identify charts related to breastfeeding interruption or cessation. Inclusion criteria for this study included female patients between the ages of 18–55 from between January 1, 2015 and April 30, 2018 with terms related to breastfeeding interruption or cessation within the EHR: An extensive list of search terms were used to identify records including, but not limited to, “pump and dump”, “discard breastmilk”, and “stop breastfeeding”. Data from this portion of our study is complete. Work in progress: We are now in the process of surveying patients who gave birth at Mayo Clinic from January 1, 2014‐April 1, 2018. Invitation to participate in this survey will be sent by email. The survey will ask these patients whether they had a procedure, had an imaging study or were prescribed a medication while they were lactating; if a clinician made a recommendation to continue, interrupt or cease breastfeeding due to this procedure/study/medication; if they met their lactation goals and what impacted meeting/not meeting said goals. We plan to have this data for presentation at the meeting.
Results: Initial results: 785 recommendations met our inclusion criteria. Providers reassured patients that breastfeeding interruption was not indicated in 129 records (16.4%). Providers recommended an alternative therapy or delay in therapy to preserve breastfeeding in 155 records (19.7%). In 488 records (62.2%), breastfeeding interruption or cessation was recommended. Indications for breastfeeding interruption included medications (63%), procedures (16%), and imaging studies (12%). The most common medications were antibiotics and pain medications; the most common procedures required general anesthesia; and the most common imaging study was MRI with contrast. Patient survey results: work in progress, we plan to have this data for presentation at the meeting.
Conclusions: We identified the most frequent indications for which recommend breastfeeding interruption or cessation using Mayo Clinic EHRs as medications, procedures, and imaging studies. Many of the instances where clinicians recommended that a mother “pump and dump” are known to be safe during lactation. We are currently evaluating the patient perspective via the survey study and will have additional conclusions for the meeting. We hope to use this data to create quality improvement projects to help clinicians provide accurate counseling and help mothers meet their breastfeeding goals.
Study on the effect of combined treatment of abscess puncture on milk volume
Haifeng Gao1
1Haidian Maternal and Child Health Hospital, Beijing, China
Category: Clinical Practice/Lactation Management
Background: The world health organization recommends breastfeeding for two years, however, some nursing mothers still have to give up breastfeeding because of a mammary abscess, in part because of reduced milk production. treatment methods from the traditional incision and drainage to minimally invasive puncture, and vacuum breast biopsy system interventional therapy, etc., the cure rate is improved, while the recurrence rate is lower, fewer complications. Debord et al.studied that 87.8% of patients with mammary abscess could continue breastfeeding on the healthy side, and 48.5% could continue breastfeeding on the affected side. This study analyzed the specific changes in the milk volume of the healthy side and the affected side before and after the comprehensive treatment of mammary abscess puncture, so as to provide a reference for doctors to make comprehensive treatment plans and enhance the confidence of nursing mothers to continue breastfeeding.
Objective(s): To summarize the changes of patients' milk volume before and after comprehensive treatment of abscess puncture. To explore the effect of comprehensive treatment of mammary abscess puncture on milk volume.
Materials/Methods: Prospective selected breast abscess patients in lactation from Beijing haidian district maternal and child health care hospital in March 2017 to November 2018, The 24‐hour milk secretion of both sides was summarized before and after breast abscess puncture combined with increased frequency and degree of emptying, SPSS24.0 statistical software was used to analyze the changes in the milk volume of the healthy side and the affected side using paired t test. P < 0.05 was considered statistically significant.
Results: A total of 50 patients were enrolled. The comparison of bilateral milk volume before treatment t = 3.016, P = 0.004, and the comparison of bilateral milk volume after treatment t = 4.336, P = 0.000, the differences were statistically significant. The total amount of milk in the healthy side, affected side and bilateral sides before treatment was 254.18 ± 175.38ml, 159.76 ± 144.02ml, 423.74 ± 228.90ml, after the treatment respectively was354.86 ± 211.94ml (t = ‐4.789, P = 0.000), 210.12 ± 174.64ml (t = ‐2.555, P = 0.014), 543.78 ± 305.90ml (t = ‐3.288, P = 0.002), the difference was statistically significant.
Conclusions: The total amount of milk on the affected side of mammary abscess in lactation is less than the total amount of milk on the healthy side. the treatment of abscess puncture combined with increasing frequency of milk and milk emptying can promote increased milk production on both sides, it can help the mother realize the desire of breastfeeding.
Report on a Series of Cases of Granulomatous Mastitis in Multiparae during Pregnancy and Lactation
Yajun Gao1
1Haidian Maternal and Child Health Hospital, Beijing, China
Category: Clinical Practice/Lactation Management
Background: The incidence of granulomatous mastitis (GLM) in multiparae has continued to increase, which seriously affect the quality of life and breastfeeding of pregnant women after delivery. Treatment of GLM during pregnancy and breastfeeding is rarely reported. Therefore, the purpose of this study was to explore treatment safety and prognosis of GLM during pregnancy and lactation.
Objective(s): To explore the breastfeeding safety of mothers with granulomatous mastitis during pregnancy. To investigate the relationship between the healing time of granulomatous mastitis during pregnancy and whether it is breastfeeding
Materials/Methods: A retrospective analysis was performed on 10 cases of GLM treated at the Haidian Maternal and Child Health Hospital, Breast department, Beijing and three cases of GLM treated in the Weihai Municipal Hospital, Breast department Weihai, Shandong, CN, from February 2017 to May 2018. The recovery time, success rate of lactation, safety, and feasibility of treatment in these cases were discussed.
Results: Among the 13 patients, conservative symptomatic treatment was adopted during pregnancy and lactation: anti‐infective therapy consisting of oral cephalosporin antibiotic for patients with or without fever and with inflammatory breast swelling and pain; ultrasound‐guided puncture and drainage of pus or incision and drainage after abscess formation. Observation continued during the sinus tract phase. Postpartum breastfeeding was encouraged, especially on the affected side. The healing time of postpartum granuloma ranged from 2 to 18 months. In this study, the median healing time was 20 months and the average healing time was 30.4 months in five healthy breast lactation cases. In eight cases of bilateral breast lactation, the median healing time was 30 months and the average healing time was 26.5 months. One patient with GLM was able to breastfeed for 2 months, two patients were able to breastfeed for 3–6 months, and 10 cases were able to breastfeed for >6 months. Univariate analysis: due to the small sample size, whether the affected breast was breast‐fed after delivery had no effect on the postpartum wound healing time, P = 0.817. The wounds of 13 patients healed well after lactation, and none of them recurred since the last follow‐up visit.
Conclusions: Conservative symptomatic treatment for GLM of multiparous women during pregnancy and lactation and encouraging breastfeeding after delivery have no effect on infant health and on the recovery time of patients with GLM.
Low Breast Milk Production Associated with Brexipiprazole (Rexulti)
Shruti Berlin1, Karen Bodnar1
1Inova Children's Hospital, Falls Church, Virginia, USA
Category: Clinical Practice/Lactation Management
Background: 35 year old, G4P013, and her 23 day old son present to breastfeeding medicine clinic due to decreased breast milk production. Baby was born at 40 weeks 5 days gestation via emergency c/s after difficult labor. At 5 hours of life, baby was intubated due to desaturations and seizure activity, transported to outside NICU and placed on a therapeutic hypothermia protocol for 90 hours. Baby was diagnosed with hypoxic ischemic encephalopathy. Mother began pumping following delivery. While baby was in the NICU for 18 days, his mother pumped for 20 minutes 10 times/day and by 1 week of life, was able to pump about 4 oz/day. By the clinic visit, she was pumping for 20 minutes 8 times/day and producing 1 oz/day. She had successfully breastfed her 2 older daughters for 2 years each and had experience pumping. Prior to pregnancy, she was treated with Rexulti for a history of bipolar 2 disorder. She stopped Rexulti in the first trimester and restarted 2mg daily during the third trimester due to increasing depressive symptoms. While baby was in the NICU, her supply of Rexulti was low and she took her pill every other day. Once back home, she was able to resume taking it daily.
Objective(s): This case is the first report suggesting Rexulti may suppress breast milk production in lactating women. New mothers who fail to achieve expected milk volumes after delivery should be promptly identified and referred for evaluation.
Materials/Methods: N/A
Results: Even though this mother‐infant dyad had many risk factors for breastfeeding difficulties (a difficult labor, stress, early separation and ongoing pump dependence) her ample production with previous children and adequate early breast emptying indicated another possible cause of her low milk production. Rexulti is similar to another atypical antipsychotic, Abilify, that is known to interfere with prolactin and milk production. After weighing the risks and benefits to the dyad, mother decided to stop her Rexulti and use a short course of metoclopramide to increase her prolactin. On follow up, she reported within 10 days of stopping Rexulti, her milk supply increased and she was able to breastfeed almost exclusively with adequate infant weight gain and her prolactin level increased to 97, normal for lactation
Conclusions: This case is the first report suggesting Rexulti may suppress breast milk production in lactating women. Furthermore, there was a restoration of milk production after discontinuing the drug. More research is required to investigate the relationship between Rexulti and milk production to provide information for healthcare providers and nursing mothers during informed consent discussions and in evaluating mothers with insufficient milk production who are being treated for mood disorders.
Perioperative management of a lactating cancer patient undergoing surgical placement and removal of an iodine‐125 brachytherapy plaque for uveal melanoma
Elizabeth Rieth1, Kara Barnett1, Jennifer Simon1
1Memorial Sloan Kettering Cancer Center, New York, New York, USA
Category: Clinical Practice/Lactation Management
Background: Melanoma is the most commonly diagnosed malignancy during pregnancy. In addition, the overall incidences of both breastfeeding and melanoma are increasing. As a result, anesthesiologists are more likely to encounter lactating women requiring melanoma treatment. Plaque brachytherapy is a common form of treatment for uveal melanoma. Prior reports have described management of uveal melanoma during pregnancy. This is the first known case report of an anesthesiologist‐led multidisciplinary team dedicated to perioperative management of a lactating patient undergoing plaque brachytherapy.
Objective(s): Understand the utility of a perioperative multidisciplinary team to coordinate care of complex patients, such as lactating cancer patients. Describe perioperative medication safety in lactation, including the use of plaque brachytherapy. Describe strategies for maintaining perioperative lactation in situations requiring temporary breastfeeding interruption.
Materials/Methods: N/A
Results: This 42‐year old woman presented for treatment of uveal melanoma. She was breastfeeding an 11‐month old infant. She underwent general anesthesia for placement of an iodine‐125 plaque on postoperative day (POD) 0, with subsequent removal on POD 3. Between POD 0 and 3, she was placed on radioactive isolation, during which time she intermittently expressed breast milk with a breast pump and stored the milk. Through consultation with the department of medical physics, it was determined that the plaque was a sealed source, so radiation would not be present in her breast milk. She was counseled that commonly used perioperative medications are typically compatible with lactation, but that she could not be in close proximity to her infant for the duration of brachytherapy (1).
Conclusions: Anesthesiologists are often called upon by patients and surgeons to review the safety of perioperative medications in lactation. Recent models of perioperative care, such as the Perioperative Surgical Home (2), highlight robust involvement of anesthesiologists in the perioperative journey of the surgical patient. Because of the patient's lactation status, complexity of perioperative medications, and use of radiotherapy in this case, an anesthesiologist‐led multidisciplinary team was formed to coordinate complex patient‐centered perioperative care. To our knowledge, this is the first report that describes how perioperative lactation may be safely maintained during plaque brachytherapy treatment. References: 1. Hale TW. Medications & Mothers' Milk 2019. 2. ASA Perioperative Surgical Home. https://www.asahq.org/psh. Accessed 3/31/2020.
Insufficient glandular tissue: lactation failure?
Mariana Colmenares1
1Acclam, Mexico City, Mexico
Category: Clinical Practice/Lactation Management
Background: Breastfeeding is the normative way to feed babies al over the world. We have access to tons of scientific evidence that supports it. Advocates of breastfeeding such as health care professionals that protect, promotes and support the breast/chest feeding dyad can struggle sometimes with women or babies who cannot breastfeed as the World Health Organization suggests. Mothers with low milk supply are often supported by family, friends and health care with well meaning advices and remedies to help them do their best. Women who have insufficient glandular tissue (IGT) struggle with their milk supply, despite good breastfeeding management. Is common to see families with this issue in the second or third lactation failure without really understanding what might be going wrong. This babies can have dehydration in the neonatal period, hypernatremia or even death without anybody that could help with a correct diagnosis or help with achievable goals that can benefit both, mother and baby. It is of great importance to help with accurate diagnosis that can benefit also psychologically and choose continue breastfeeding with breast/ chest supplementation.
Objective(s): Learn the theoretical framework that can give us useful information for a timely and appropriate diagnosis of Insufficient Glandular Tissue. Encourage and support the best way possible for the dyad to achieve a healthful breastfeeding experience. Learn about useful tools that can help achieve the personal goals.
Materials/Methods: Review from the literature
Results: Clinical. Experience and review from the literature.
Conclusions:
Increasing Lactation Clinic Patients Per Hour: A Quality Improvement Project
Jennifer Somers1, Jamie Ellis1
1Greater Lawrence Family Health Center, Lawrence, Massachusetts, USA
Category: Clinical Practice/Lactation Management
Background: Greater Lawrence Family Health Center serves a underserved, primarily Latinx, community north of Boston. Our goal is to improve access to outpatient lactation support, provide early interventions to assist with breastfeeding, and offering a high quality teaching clinic for Family Medicine residents.
Objective(s): Improve Lactation Clinic Volume. Improve Clinical Lactation Teaching for Residents. Provide greater access to outpatient lactation services for an underserved community.
Materials/Methods: Our aim was to improve lactation clinic attendance by better meeting the needs of our community. We chose to change multiple factors that improved our clinic volume and show rate. Our first intervention switched the clinic time from mornings to afternoons began July of 2019. We had gathered feedback from our patients that arriving in the morning was much harder for them. Our second intervention was to encourage the hospital discharge planners to automatically offer a lactation clinic appointment to all women discharging from the hospital this was fully operational October of 2019. In order to evaluate the effectiveness of our interventions we manually counted the number of patients seen in our weekly Lactation clinics over the course of a year, from March 2019 to March 2020. We then modeled the clinic numbers using a simple line graph, plotting individual clinic sessions. In order to evaluate effectiveness of our interventions and get a sense of overall numbers rather than individual sessions, the average number of patients seen during each period was evaluated with period one being prior to intervention (March 2019 through July 2019), period 2 being PDSA cycle 1 (July 2019 through October 2019) and period 3 being PDSA cycle 2 (October 2019 through March 2020). The time of evaluation for PDSA cycle 2 was lengthened to minimize the effect of the more erratic nature of clinic sessions over the winter holidays due to sessions occurring less frequently.
Results: In PDSA cycle 1 our volume went from an average of 2 patients to 7.5 per clinic. The number of patients per hour went from <1 to 2.5. In PDSA cycle 2 we then went to an average of 9 patients per clinic, 3 patients per hour. We were able to quadruple our volume in 9 months by intentionally changing the timing of the clinic and how we referred patients into the clinic.
Conclusions: Best practices for lactation clinics have been based primarily on the presence of access to lactation consultants and/or other outpatient non‐physician support providers. There is very little data about providing high quality breastfeeding medicine outpatient clinics. In our quality improvement project, we found that by offering a lactation clinic in the afternoon increased our volume. Offering a lactation follow‐up appointment in a local primary care clinic for all post‐partum patients, significantly increased the patients per hour in our lactation clinic. Having an increased volume and a more robust clinic provided greater learning opportunities for our residents as well as access to outpatient lactation support for the community we serve.
Characteristics of neonatal patients who received combined in‐home medical care and lactation support in 2019
Jessica Madden1
1Rainbow Babies and Children's Hospital, Willowick, Ohio, USA
Category: Clinical Practice/Lactation Management
Background: As a neonatologist, I have a wealth of experience tending to the medical needs of newborn babies and the psychosocial needs of their mothers. I opened an independent pediatric and lactation home‐visiting practice in Cleveland, Ohio in 2018. The main goal of starting my practice, Primrose Newborn Care, was to improve “fourth trimester” support for new moms. I presented an overview of the steps involved in starting Primrose, along with pilot data, at the Academy of Breastfeeding Medicine conference in 2019.
Objective(s): To present a detailed overview of my first full year in practice as a home‐visiting neonatologist and lactation specialist. To describe characteristics of newborns seen during in‐home visits in 2019. To discuss barriers to this current model of care and explore areas for expansion of services offered.
Materials/Methods: Each in‐home visit was 60 minutes long and included a review of pregnancy and delivery, a newborn physical exam, measurement and plotting of growth parameters, transcutaneous bilirubin check, discussion of feeding and sleeping, screening for postpartum depression, and referrals to community resources. Additional services I began to offer in 2019 included virtual (video) visits, telephone visits, and text message and email consultations.
Results: From January 1, 2019 through December 31, 2019 I worked with 36 mother‐infant dyads. Of my 36 patients, 56% were female and 44% were male. 78% of my patients were full‐term and 22% were preterm (born at less than 37 weeks gestation). The majority were singletons (88%). The most common maternal concerns I encountered were related to breastfeeding (52.8%), prematurity (19.4%), infections (16.7%), gastroesophageal reflux (16.7%), postpartum depression (16.7%), bronchiolitis (13.9%), formula‐feeding (13.9%), sleeping patterns (13.9%), and suspected milk‐protein allergies (8.3%). Other diagnoses I encountered included laryngomalacia, ankyloglossia, blocked tear ducts, eczema, failure to thrive, hyperbilirubinemia (both indirect and direct), a history of hypoxic‐ischemic encephalopathy, delayed developmental milestones, respiratory distress, teething, thrush, and diaper candidiasis. 15 of my 36 patients were seen for in‐home visits. The average number of home visits per patient were 2, with a range from 1–7 total visits per patient. Of the additional 21 patients, 10 were evaluated via telemedicine (video visits), and the remaining 11 babies were evaluated by phone. Parents' preferred method of continuing contact with me after our initial encounter was via text message, followed by phone, and then email. 100% percent of my parental encounters were with my patients' mothers, however I met almost every father in the in‐home setting. I had an additional 6 phone encounters in which I needed to refer patients directly to local emergency rooms. One was for a possible head injury after an accidental fall and five were for respiratory distress secondary to bronchiolitis.
Conclusions: Barriers to continuing my newborn practice include difficulty negotiating reimbursement from local insurers and Medicaid, the cost of malpractice insurance, time dedicated to travel, and my lack of IBCLC certification. Ideas for expansion and growth include being able to offer virtual visits (telemedicine) for those who live within my state but outside of my geographic area, obtaining certification to become an IBCLC (in process), offering rentals and drop‐offs of breastfeeding and baby supplies, being able to provide in‐home phototherapy, and working with local milk banks to be able to distribute donor breast milk for supplementation. In summary, physician in‐home newborn visits are an innovative way to support breastfeeding, newborn care, and the physical, mental, and emotional transition to motherhood in geographic locations that currently lack adequate postpartum supports for new moms and babies.
Venlafaxine for functional breast and nipple pain in a breastfeeding woman: Case report
Sarah Calhoun1
1University of Missouri, Colombia, Missouri, USA
Category: Clinical Practice/Lactation Management
Background: Persistent breast and nipple pain while breastfeeding may lead to early weaning and is associated with postpartum depression. Known treatments for functional breast pain include nonsteroidal anti‐inflammatory medications, propranolol, and selective serotonin reuptake inhibitors.
Objective(s): To present a case report of a breastfeeding mother who had resolution of functional breast pain and postpartum depression with venlafaxine. To consider venlafaxine as a treatment for functional breast pain during breastfeeding.
Materials/Methods: Not applicable, case report.
Results: A 28‐year‐old breastfeeding mother developed persistent breast and nipple pain despite evaluation and treatment for known causes of pain. Her pain was determined to be functional in nature and improved with the use of propranolol and escitalopram. Her pain score decreased from an 8 to a 6 on a numeric pain rating scale of 0 through 10. As is common in women with breast and nipple pain, she developed postpartum depression. Her symptoms had not resolved with the maximum dosage of escitalopram so venlafaxine was initiated for better control of postpartum depression. Not only did postpartum depression symptoms improve, but the breast and nipple pain resolved. She ultimately tapered off propranolol and escitalopram with continued improvement in pain with only venlafaxine.
Conclusions: Venlafaxine has known benefits for the treatment of neuropathic pain. Venlafaxine may be considered as a treatment option for functional breast and nipple pain in lactating women with postpartum depression.
Utilization of a New Breastfeeding Medicine Consult Service
Holly Cummings1, Anna Graseck1, Kirstin Leitner1
1University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
Category: Clinical Practice/Lactation Management
Background: At our quaternary‐care, academic medical center, breastfeeding initiation rates were 83% in FY18. However, breastfeeding continuation remains low. Only 33.7% of US women are still breastfeeding at 12 months.1 This is mirrored at our institution, where within one practice at our center, 6‐month continuation rates are 30%. The reasons for early discontinuation are multiple, but one study showed that 60% of women stopped breastfeeding sooner than they desired. Thirteen percent of women cited their own medical illness or use of medication as a reason they stopped breastfeeding.2 Residents in obstetrics and gynecology (OB/Gyn) have formal learning objectives related to lactation knowledge identified by the Council on Resident Education in Obstetrics and Gynecology (CREOG).3 A breastfeeding medicine inpatient consult service was created at our hospital after performing a needs assessment and obtaining stakeholder feedback4 and debuted in September 2019.
Objective(s): Our objective was to develop an inpatient breastfeeding medicine consult service, staffed by OB/Gyn physicians with a particular interest and knowledge base in lactation. The consult service goals are:‐ to provide evidence‐based guidance to breastfeeding women who are admitted to the hospital beyond routine postpartum hospitalization. This typically will be for patients admitted to services other than obstetrics, such as general surgery or medicine. To educate these patients and their physicians on safety of imaging, medications, and maternal illness while lactating. to collaborate with lactation consultants (LCs) who will facilitate a plan for maintaining lactation while hospitalized. To educate OB/@Gyn resident physicians on formal residency learning objectives regarding breastfeeding
Materials/Methods: The inpatient breastfeeding medicine consult service was created after soliciting feedback from key stakeholders, including the department chair, hospital LCs, residency program director, and attending physicians. A consult order was created for the electronic medical record (EMR) system. A resident curriculum was developed to support education on the service. The service debuted in September 2019. All consults were tracked. As word of the service spread, additional opportunities for patient management were identified by the LCs in the intensive care nursery, facilitating further collaboration for the care of lactating patients.
Results: In the first seven months, consults were requested eight times from non‐OB/Gyn hospital services. The reason for consult included safety of medication use in lactation; questions regarding perioperative management of lactation; breastmilk expression logistics; and clogged duct. The consult requests came from a variety of other departments, including neurosurgery (6 patients), plastic surgery (1 patient), colo‐rectal surgery (1 patient), and internal medicine (1 patient). Within the first month of the service, LCs in the neonatal intensive care unit reached out to the physician consultants to discuss management of maternal patients with low milk supply. This developed into a regular collaboration, with management of 10 intensive care nursery dyads, and the identification of a possible medication‐related case reportable event. One lactation “tipsheets” was created by the residents during their postpartum rotation. Anecdotally, residents have been noticed to discuss lactation, including challenges and medical implications, during team signouts more frequently than in prior years. Opportunities for improvement of the consult service were identified, including specifying when separate LC involvement was recommended to address issues of storing expressed breastmilk, infant latch, or assistance with milk expression in the postoperative phase of care.
Conclusions: The breastfeeding medicine consult service has been utilized by non‐OB/Gyn departments, demonstrating the efficacy and need for such a service. Resident CREOG education goals are being addressed, supporting education efforts during service. A previously unidentified opportunity for collaboration between breastfeeding medicine physicians and LCs in the intensive care nursey was identified, thereby increasing the numbers of breastfeeding dyads being served. Future goals for the service include increasing awareness of the service among other hospital departments; further facilitating inpatient to outpatient transition of breastfeeding patients from the intensive care nursery to the OB/Gyn office; and increasing resident completion of the educational goals of the service. References:1. Centers for Disease Control National Immunization Survey. “Breastfeeding Among U.S. Children Born 2002–2014”. https://www.cdc.gov/breastfeeding/data/nis_data/results.html Accessed July 18 2018. 2. Odom EC et al. “Reasons for earlier than desired cessation of breastfeeding.” Pediatrics. 2013 Mar;131(3):e726–32. 3. Council on Resident Education in Obstetrics and Gynecology (CREOG). “Educational Objectives: Core Curriculum in Obstetrics and Gynecology.” 11th edition, 2016.4. Graseck, A; Cummings, H; Leitner, K: Development of a Breastfeeding Medicine Consult Service. Academy of Breastfeeding Medicine Annual Meeting, San Francisco, CA November 2018 Notes: Poster presentation November 2018.
Experiences of breastfeeding and milk expression in a Latinx community in rural Iowa
Amelia Underwood1, Stephanie Radke1, David Bedell1
1University of Iowa, Iowa City, Iowa, USA
Category: Clinical Practice/Lactation Management
Background: Latina mothers have a rate of initiation of breastfeeding above the national average but levels of exclusive breastfeeding at 4 months as low as 22% 1. In previous studies, Latina mothers have cited multiple reasons for non‐exclusive breastfeeding, including concerns about supply, lack of support from medical professionals, influence by family and friends, and concerns about returning to work or school2. The concern about being successful in breastfeeding following return to work or school exists despite mothers' stated willingness to express milk at work2. Although these concerns about supply and returning to work are given as reasons for non‐exclusive breastfeeding or cessation of breastfeeding, little work has been done to identify specific barriers to breastfeeding or the expression of breast milk in working mothers, and no studies have looked at the perception and practice of expressing breast milk among a Latinx population. References 1. Bartick M, Reyes C. Las Dos Cosas: An Analysis of Attitudes of Latina Women on Non‐Exclusive Breastfeeding. Breastfeed Med. 2011;7(1):19–24. doi:10.1089/bfm.2011.00392. Linares AM, Rayens MK, Dozier A, Wiggins A, Dignan MB. Factors influencing exclusive breastfeeding at 4 months postpartum in a sample of urban Hispanic mothers in kentucky. J Hum Lact. 2015;31(2):307–314. doi:10.1177/0890334414565711
Objective(s): To gain an understanding of the experiences of breastfeeding and milk expression among Latina mothers in rural Iowa. To identify potential barriers‐ economic, social, employment‐related and educational‐ to expressing milk and feeding of expressed milk in a rural Iowan Latinx population.
Materials/Methods: The setting for this study was a family practice clinic in rural Iowa which is associated with a large academic hospital. The inclusion criteria for this study were women who self‐identified as Latina or Hispanic, who spoke English or Spanish, who had given birth in the past three years and who had ever breastfed. Eligible participants were identified using the electronic medical record patient schedule of the clinic and approached by one of the authors. Thirteen eligible women were interviewed in their preferred language. We specifically investigated knowledge, expectations, experience, facilitators and barriers to breastfeeding and milk expression. Interviews were transcribed in their original language and analyzed separately for principal themes by two bilingual researchers.
Results: This group was diverse in age, education level, number of children, and experience with breastfeeding and the expression of breast milk. There was great variability in the exposure to and experience with pumping milk, with some women who exclusively pumped and those who had minimal exposure to the concept of pumping breast milk. We found that many women in this study had unrealistic expectations of the experience of breastfeeding or misunderstandings about lactation. For example, some women found themselves unprepared for the initial normal discomfort of direct breastfeeding, leading them to believe there was a physical problem with themselves or their infant. Others expected their milk to come in sooner and interpreted the scant amount of early colostrum as inadequate milk production, often leading to supplementation. Many of these same women expressed that they would have liked more education or resources from their healthcare providers in preparation for breastfeeding or pumping, and increased in‐person lactation support during their post‐partum hospital stay, offered in their primary language.
Conclusions: The breastfeeding experiences of Hispanic and Latina women in rural Iowa are diverse and no single educational strategy will be appropriate for every mother. Wide variation in knowledge of the expression of breast milk suggests that this topic is not being routinely or comprehensively covered in the prenatal breastfeeding education offered at this particular clinic. More work needs to be done to determine what constitutes adequate prenatal education on milk expression in this population and the larger population of rural Iowa. In order to support women in meeting their breastfeeding goals, healthcare providers must help manage expectations surrounding the normal physiologic process of lactation and provide education on the options for successful breastfeeding including the role of milk expression. Additionally, it is important that this information be provided early enough in the prenatal period to allow for individual preparation, such as the acquisition of equipment to express breastmilk. Finally, it is important to offer services to women in their preferred language whenever possible, particularly skill‐based patient education such as lactation support.
Associations between maternal medical history and symptoms of dysphoric milk ejection reflex
Anitha Muddana1, Alison Stuebe1, Noemi Salinas1
1University of North Carolina, Chapel Hill, North Carolina, USA
Category: Clinical Practice/Lactation Management
Background: Dysphoric Milk Ejection Reflex (DMER) is a complication of breastfeeding characterized by transient negative emotions associated with milk let down. Although D‐MER has been described in case reports, little is known about the underlying pathophysiology.
Objective(s): To understand Dysphoric Milk Ejection Reflex (DMER) frequency and associations. To improve research and care provided for breastfeeding dyads.
Materials/Methods: We analyzed associations between DMER symptoms and patient history as reported on intake forms for the Breastfeeding Medicine Consult Clinic at the University of North Carolina Women's Hospital. The clinic is a regional referral center staffed by a breastfeeding medicine physician and an international board‐certified lactation consultant. Patients presenting for evaluation complete a standardized intake form. To assess DMER, patients are asked, “Some mothers experience negative emotions such as anxiety, unpleasantness or dread during milk let down. Have you experienced this?” Patients who respond “yes” are further asked to what extent they experience specific sensations during milk let down using a five‐point Likert scale from “Not at all” to “extremely.” Likert square responses were summed to create a composite DMER score. Women who reported pain with breastfeeding also completed the Catastrophizing subscale of the Coping Strategies Questionnaire. For women with more than one visit to the clinic, data from the first visit was used. We used Fisher's Exact tests to evaluate associations between reporting any DMER symptoms and presenting complaint, pregnancy complications, and maternal medical history. Among women with pain, we further quantified correlations between DMER symptoms and catastrophizing.
Results: Among 302 patients presenting for breastfeeding medicine care, 271 responded to the question about DMER symptoms, and 42 (15.5%) reported DMER. We found no association between DMER and presenting complaint or pregnancy complications. Women with DMER symptoms were more likely to report a history of panic attacks (28.6 vs. 12.2%, OR 2.87, 95% CI 1.23–6.25) and depression (35.7 vs. 22.3%, OR 1.94, 95% CI 0.96–3.92), although confidence intervals for depression were wide. Among the 28 women with DMER symptoms and breastfeeding‐associated pain, catastrophizing scores were correlated with DMER symptom scores (Pearson r = 0.44, p = 0.02).
Conclusions: We found associations between DMER symptoms and self‐reported history of both panic attacks and depression. Our findings should be interpreted with caution given that we sampled women presenting to a referral clinic; associations may differ in the general population. More research is needed to understand the pathophysiology of DMER and to develop evidence‐based treatment approaches.
The Role of Lip Tie Release in Infants with Breastfeeding Challenges Associated with a Tight Maxillary Frenulum
1Georgetown University School of Medicine, Washington, DC, USA
Category: Clinical Practice/Lactation Management
Background: Despite extensive literature supporting the numerous health benefits associated with breastfeeding to both mother and infant, many mothers discontinue breastfeeding before the recommended 6‐months. While the clinical indications of lingual frenotomies has recently been called into question, there is little known about the impact the presence of a maxillary frenulum can have on breastfeeding.
Objective(s): To characterize breastfeeding habits of infants who undergo a lingual frenotomy but not a maxillary frenotomy. To determine if the presence of a maxillary frenulum negatively impacts overall duration of time mothers breastfeed.
Materials/Methods: A retrospective chart review of infants who presented for tongue‐tie consultation between January 2014‐December 2018 was conducted. Parents of infants who were diagnosed with both maxillary and lingual frenulum, but underwent only a release of the lingual frenulum, were emailed an anonymous survey. The survey contained questions inquiring about symptoms the mother‐infant dyad experienced while breastfeeding, overall duration of breastfeeding, and what factors, if any, led the mother to cease breastfeeding.
Results: A minimum of 1‐year between date of initial visit and follow up in the online survey was required to assess the impact on breastfeeding including infant weight‐gain trends and overall duration of time the mother spent breastfeeding. Results from the anonymous online survey showed that the presence of a maxillary frenulum had minimal impact on the infant's ability to nurse once the lingual frenulum was released.
Conclusions: Since the early 18th century, lingual frenotomies have been conducted to improve tongue mobility which is believed to ease breastfeeding difficulties. Similar to the negative impact a lingual frenulum can have on breastfeeding, the presence of a maxillary frenulum has been speculated to also contribute to difficulties breastfeeding. However, without conclusive evidence supporting these speculations, clinicians will continue to remain divided over the necessity of maxillary frenotomies and the role it may play in breastfeeding.
Feeding Outcomes in Infants with Tongue Tie Who Did Not Undergo Lingual Frenotomy: Implications on Breastfeeding
1 Georgetown University School of Medicine, Washington, DC, USA
Category: Clinical Practice/Lactation Management
Background: Despite studies citing both short‐ and long‐term benefits from breastfeeding, many infants are not breastfed for the minimum, recommended 6‐months. Multi‐factorial reasons including pain, frustration, as well as external pressure to return to work are all thought to play a role. While frenotomies have been conducted since the 18th century, recent literature has called into question the clinical benefits of frenotomies.
Objective(s): To characterize the duration of time that infants with a tight lingual frenulum are breastfed. To present factors that led mothers to cease breastfeeding.
Materials/Methods: A retrospective chart review of infants who presented for tongue‐tie consultation between January 2015 –December 2018 was conducted. Parents of infants who ultimately did not have surgical action at the time of visit were emailed an online survey inquiring about symptoms the mother‐infant dyad might have experienced while breastfeeding, overall duration the infant was breastfed, and what factors led the mother to cease breastfeeding.
Results: A minimum of 1‐year between date of initial visit and follow up in the online survey was required to assess long‐term consequences including infant weight‐gain trends and overall time the mother spent breastfeeding. Results from the anonymous survey indicated that infants who did not undergo a frenotomy struggled with weight gain and the mothers of these infants experienced more discomfort and frustration while trying to breastfeed; both of which contributed to early termination of breastfeeding.
Conclusions: While recent literature has stated that frenotomies have little added clinical benefit to patients, our study demonstrates the impact not undergoing a frenotomy can have on both mother and infant. With the renewed interest in breastfeeding and a lack of clear clinical guidelines, the long‐term benefits of breastfeeding should be taken into consideration when an infant presents with a lingual frenulum.
Transforming Growth Factor Beta‐1 in Human Breast Milk and Its Correlation with Infants' Parameters
Jehan Alsharnoubi1
1Cairo University, Giza, Egypt
Category: Human Milk Composition
Background: Breastfeeding provides optimal nutrition and health protection for the infant; it contains many anti‐inflammatory factors, including transforming growth factor beta‐1 (TGF‐b1)
Objective(s): To measure the level of TGF‐b1 in human milk. To find its correlation with some infant anthropometric characteristics.
Materials/Methods: A milk sample was collected from 84 mothers and the level of TGF‐b1 was measured using enzyme‐linked immunosorbent assay.
Results: TGF‐b1 was significantly higher in vegetarian mothers compared with non‐vegetarian mothers( p = 0.044). Additionally, the mean value of breast milk TGF‐b1 was significantly higher in mothers using contraceptive pills compared with those who do not ( p = 0.021). Also, the mean value of TGF‐b1 was significantly higher in infants 3–6 months than those <3 months ( p = 0.010); also there was a significant difference regarding infants' weight and length with average weight and length ( p = 0.042) and ( p = 0.009), respectively.
Conclusions: TGF‐b1 in human milk may play a role in infants' growth and development; mothers' diet is known to influence TGF‐b1 level and its relation to infants' age and weight. Contraceptive method could have an influence on TGF‐b1 levels during breastfeeding.
Methods Matter: A Comparison of Macronutrient‐Based Methods for Deriving Energy Values in Human Milk
Erin Hamilton Spence1, Maryanne Perrin2, Mandy Belfort3, Margaret Parker4, Lars Bode5
1Mother's Milk Bank of North Texas, Pediatric Medical Group, Cook Children's Hospital, Ft. Worth, Texas, USA
2University of North Carolina Greensboro, Greensboro, North Carolina, USA
3Brigham Women's Hospital and Harvard Med, Boston, Massachusetts, USA
4Boston Medical Center: Boston University, Boston, Massachusetts, USA
5University of California, San Diego, San Diego, California, USA
Category: Human Milk Composition
Background: Energy values for human milk are increasingly available through labeled human milk products, and the use of infrared point‐of‐care analyzers. There are currently no agreed upon reference methods for reporting calories in human milk.
Objective(s): To compare published methods for calculating calories in human milk using a common set of human milk samples. To determine if important differences in these methods may have research and clinical implications.
Materials/Methods: Ten human milk samples were measured for macronutrients using laboratory methods. Calorie were calculated using 2 different sets of macronutrient values: gross nutrients (GROSS) which included crude protein, total fat, and total carbohydrates; and digestible nutrients (DIGESTIBLE) which included true protein, total fat, and lactose. Four calorie conversion factors were used: Atwater general (ATW‐GEN); Atwater milk specific (ATW‐MILK), human milk specific (HUM‐MILK), and combustible conversions (COMBUST). Differences in calories derived from GROSS and DIGESTIBLE macronutrients were assessed using ANOVA analysis. Macronutrients were also measured in all samples using an FDA approved mid‐infrared human milk analyzer that reports calorie values.
Results: GROSS macronutrients with COMBUST conversion factors produced the highest calorie values whereas DIGESTIBLE macronutrients with HUM‐MILK conversion factors produced the lowest calorie values. The mean difference between these values was 3.1 kcal/ounce (19.2%). There was a significant difference (P < 0.0001) in derived calorie values based on calorie conversion methods that used GROSS versus DIGESTIBLE macronutrients. Calorie values reported by the mid‐infrared analyzer were similar to those derived using GROSS macronutrients with COMBUST conversion factors.
Conclusions: Calorie differences of 3 kcal/ounce (20%) is clinically important when determining feeding therapies for the preterm infant. There is a need for standard methods of reporting calories in human milk to support clinical practices and research.
Tandem Breastfeeding and its Impact on Human Milk Macronutrients Content – A Prospective Study
Background: Tandem Breastfeeding is defined as two or more offsprings of different ages who breastfeed at the same time. Based on the feedback from social forums, tandem breastfeeding in Israel is on the rise. There is a paucity of publications on breastfeeding during pregnancy and tandem breastfeeding.
Objective(s): We aimed to evaluate the impact of tandem breastfeeding on the macronutrient content of human milk (HM).
Materials/Methods: Milk samples from 18 Tandem‐Breastfeeding mothers were compared to milk samples from 31 Non‐Tandem‐Breastfeeding mothers. Samples were collected during the last month of pregnancy (Pregnancy milk), within the 72 hours (Colostrum) and 14 to 60 days after delivery (Mature milk). Macronutrients content was measured using mid‐infrared spectroscopy.
Results: In Tandem‐Breastfeeding (TBF) mothers, fat content in pregnancy milk was lower than in mature milk (2.5 ± 1.4 vs 4.2 ± 1.2, p = 0.0096). Pregnancy milk protein content was higher than in colostrum and mature milk (4.3 ± 1.7 vs 2.6 ± 1 and vs 1.4 ± 0.3, p = 0.00236 and 0.00044, respectively). Inversely, carbohydrate content was lower than in colostrum and mature milk (6.4 ± 1.4 vs 7.1 ± 1 and vs 8.1 ± 0.2, p = 0.0198 and 0.0012, respectively). In addition, energy content of pregnancy milk was similar to the one found in colostrum but lower than the one observed in mature milk (63.4 ± 11.4 vs 71.9 ± 10, p = 0.04338). When compared to Non‐Tandem‐Breastfeeding (NTBF) mothers, fat and energy content in pregnancy milk was lower than in mature milk (2.5 ± 1.4 vs 4.8 ± 1.9 and 63.4 ± 11.4 vs 76.9 ± 14.8, p = 0.00012 and p = 0.00132, respectively), and protein content was higher than in colostrum and mature milk (4.3 ± 1.7 vs 3.2 ± 2.4 and vs 1.5 ± 0.4, p = 0.0244 and p < 0.00001, respectively). Carbohydrate content was higher in pregnancy milk than in colostrum of NTBF mothers (6.4 ± 1.4 vs 5.1 ± 1.6, p = 0.011). In TBF mothers, carbohydrate content in colostrum and mature milk was higher than the ones of NTBF mothers (7.1 ± 1 vs 5.1 ± 1.6 and 8.1 ± 0.2 vs 6.2 ± 1.5, p < 0.00001, for both).
Conclusions: HM during pregnancy has different macronutrient content than HM produced after delivery. However, colostrum and mature milk of TBF mothers are similar to HM produced by NTBF mothers, to the exception of carbohydrate content.
A mixed‐method evaluation of the views of medical teachers on the applicability of infant and young child feeding chapter in Saudi Medical colleges
Fouzia Alhreashy1, Hanan Mohammad Fouad Alkadri2, Abdulelah Mobierek3, Albert Scherber4
1Ministry of Health, Chicago, Illinois, USA
2King Saud in Abdulziz for Health Science, Riyadh, Saudi Arabia
3King Saud University, Riyadh, Saudi Arabia
4Maastricht University, Maastricht, Netherlands
Category: Medical Education
Background: Lack of sufficient preparation of physicians for the provision of breastfeeding support and counselling has been well‐documented. The development of training in breastfeeding medicine for medical students is currently ongoing worldwide. This study was conducted to gain insights into a potential framework for a breastfeeding education curriculum.
Objective(s): The general opinion on breastfeeding medicine education in medical colleges. The opinion on contents of the chapter under investigation. The opinion on cultural points regarding Saudi Arabia and breastfeeding education in medical colleges.
Materials/Methods: A mixed‐method design was used to evaluate the opinions of medical teachers regarding current lactation education and the applicability of the World Health Organization (infant and young child feeding: model chapter for textbooks for medical students and allied health professionals in medical colleges in Riyadh, Saudi Arabia. Twelve teachers from three medical schools were invited to participate in three rounds of the research. The first round was carried out through an interview using open‐ended questions under three headings: 1) the general opinion on breastfeeding medicine education in medical colleges, 2) the opinion on contents of the chapter under investigation, and 3) the opinion on cultural points regarding Saudi Arabia and breastfeeding education in medical colleges. This was followed by a thematic analysis. Self ‐administered, close ended questionnaire was created in the second round based on the results of the first round. The third round addressed areas of disagreement in opinions. To assess the degree of agreement objectively, rounds 2 and 3 were analyzed according to the 5‐point likert scale, with responses merged to a 3‐point Likert scale where appropriate. A consensus was reached when greater than 70% agreement achieved.
Results: All participants agreed that breastfeeding education is suboptimal. Although they considered the world health organization resource on infant and young child chapter a suitable reference for the curriculum, they agreed that modifications to suit the Saudi Arabian context are necessary. The medical teachers suggested a unique curriculum for medical students, which is similar for both genders. However, disagreement existed regarding the provision of extra clinical training to female students.
Conclusions: Breastfeeding medicine education in medical colleges should be developed using resources that are rich in content, are physician‐specific and take into consideration the culture.
Breastfeeding Education: An approach to educating first year medical students
Camron Johnson‐Privitera1, Jennifer Cleveland1
1Virginia Tech School of Medicine, Roanoke, Virginia, USA
Category: Medical Education
Background: The long‐term health impacts of breastfeeding has been well established globally, yet, its emphasis within medical school curriculum is limited. Medical school students can benefit from increased content exposure on breastfeeding to provide solid foundational knowledge and increased comfortability when discussing with future patients.
Objective(s): Assess the breastfeeding knowledge and perceptions of first year medical students. Provide foundational pathophysiology of breastfeeding and long‐term outcomes associated.
Materials/Methods: Using a pre and post‐questionnaire design, we invited 42 first year medical students (M1) to explore the basics of breastfeeding to evaluate mastery of content and perception of a novel educational session. Prior to the session, students reviewed session objectives along with two brief articles addressing the physiology of lactation and prolactin. During class, students completed the pre‐exercise questionnaire, participated in a 40‐ minute educational session on the physiology, pathophysiology and importance of breastfeeding, followed by the post‐exercise questionnaire.
Results: 100% of students present participated in the study. Students' knowledge scores on breastfeeding when evaluated on post questionnaires showed a statistically significant increase compared to the pre‐questionnaires (n = 15, p = 0.007). There was no change in students' perceived level of importance of breastfeeding on long term outcomes. However, 100% of students increased their confidence in comfort level discussing breastfeeding with families after the activity.
Conclusions: The long‐term benefits of breastfeeding to mothers and children has long been established. Yet despite the accepted implications to population health, the education curriculum for medical students and residents has been lacking in its presentation. Our results indicate that the inclusion of breastfeeding education in the first year is an effective way to convey pathophysiology and long‐term benefits. This education builds confidence in future physicians ability to discuss long term implications of human milk nutrition. Incorporation of a small exposure, such as this, provides an opportunity for programs to address this critical gap in curriculum.
Effectiveness of Workshop for Teaching Breastfeeding Promotion and Management to Medical Students
Miena Hall1, Maureen Gecht‐Silver2
1AMITA Adventist Hinsdale Hospital, Hinsdale, Illinois, USA
2University of Illinois at Chicago, Chicago, Illinois, USA
Category: Medical Education
Background: Breastfeeding education for physicians is extraordinarily varied across the United States despite the relatively standardized process of medical school coursework and residency curriculum. Although lactation is listed as testable content for board examinations, ACGME only requires residents involved in direct neonatal care to learn about breastfeeding. Given that most physicians have the potential to care for patient who is breastfeeding or lactating, it is imperative that all medical students and residents have a basic understanding of the physiology of lactation, the contraindications to its use, and the safety of medications during its course.
Objective(s): To determine if a three‐hour workshop covering breastfeeding promotion and management is effective at increasing the breastfeeding knowledge of medical students on their family medicine clerkship. To evaluate the effect that past exposure to breastfeeding has on medical students' knowledge changes following the educational intervention. To assess changes to medical students' confidence levels in addressing and managing common breastfeeding concerns following the educational intervention.
Materials/Methods: The study was a randomized controlled trial in which 46 medical students during their third‐year family medicine clerkship were assigned to either the educational intervention or control groups. All subjects took the pretest at the beginning of the clerkship, participated in either the three‐hour breastfeeding workshop or received an email outlining the topics to be covered, and were administered the posttest at the end of their rotation. The pretest and posttest were validated assessment tools taken from the AAP Breastfeeding Residency Curriculum.
Results: Breastfeeding knowledge increased significantly following the workshop. Clinical exposure to breastfeeding dyads during clerkship rotations was similar between groups and provided baseline knowledge. Increased student age and personal breastfeeding exposure was correlated with higher pretest scores. Participation in the workshop significantly increased students' confidence in addressing breastfeeding questions and management. Students felt that breastfeeding training in medical school would strongly influence how they care for mothers and babies in the future.
Conclusions: In our study, we showed that small‐group, active learning sessions on breastfeeding were well received by medical students. Our curriculum, based on resident‐level content and assessment tools, was appropriate to educate third‐year medical students, allowed students to recognize that training in breastfeeding was clinically important, and increased their interest in the subject. We showed that a workshop during a third‐year Family Medicine clerkship was effective at increasing medical students' knowledge and confidence about breastfeeding.
Implementation and Evaluation of a Breastfeeding Medicine Curriculum in Undergraduate Medical Education
1MedStar Georgetown University Hospital, Washington, DC, USA
Category: Medical Education
Background: Breastfeeding improves lifelong health outcomes for both the mother and the infant. The American Academy of Pediatrics recommends exclusive breastfeeding in the first 6 months of life. However, breastfeeding rates in the U.S. are sub‐optimal and disparities are stark. Physician breastfeeding education has been shown to improve breastfeeding outcomes. Breastfeeding education in undergraduate and graduate medical education is recommended so that physicians can adequately support breastfeeding initiation and maintenance. Education on breastfeeding is however not a core element of most medical school curricula. Challenges to integration into existing curriculum include time, faculty expertise, and multi‐specialty support.
Objective(s): To design and integrate a breastfeeding medicine curriculum into undergraduate medical education. To evaluate a breastfeeding medicine curriculum.
Materials/Methods: Faculty in the Division of Community Pediatrics in collaboration with the Pediatric Clerkship Director developed and implemented a new medical student curriculum on breastfeeding medicine using the Wellstart International Lactation Management Self‐Study Level 1 Modules and supplemental video and reading materials. The materials are designed to be completed in one half day. The curriculum was integrated as a requirement into the third year Pediatric Clerkship and fourth year Community Pediatrics elective. It was evaluated using the Wellstart assessment tool for knowledge and additional questions assessed acceptability and potential for impact on practice.
Results: 196 students completed the curriculum as part of their required pediatric clerkship and 9 as part of an elective in academic year 2018–2019. Participants of this study were largely third year medical students (85.5%). Of the 134 students who took the pre‐test, 89.6% reported less than 2 hours of prior breastfeeding medicine education. 76 students took both the pre and post‐tests. Mean total scores increased from 19.0 (67.9%) to 24.16 (86.3%) out of 28.0 (p < 0.001) as well as in each knowledge category (Anatomy & Physiology, Clinical Assessment & Anticipatory Guidance, Public Health & Policy and Diagnosis, Management & Pathophysiology) (p < 0.001). Of the 80 students who took the post test, 95% thought the content was at the appropriate learning level, 91% said they are at least sometimes likely to use what they learned, and 56% said it will at least moderately change the way they practice medicine.
Conclusions: Development and integration of a focused breastfeeding medicine curriculum into clinical rotations in undergraduate medical education is feasible and effective. This study demonstrates significant improvement in knowledge, curriculum acceptance and intention to change clinical practice after completing the curriculum. This model is easily replicable in other medical school settings and can have an important impact on maternal and infant health.
Efficacy of a Pediatric Resident Developed Educational Module in Increasing Resident Knowledge of Donor Milk
Xiang Ng1, Parvathy Krishnan1, Jorge Revelo Escobar1, Kevin Heringman1, Lawrence Noble2, Anita Noble3
1Elmhurst Hospital Center, Queens, New York, USA
2Icahn School of Medicine at Mount Sinai, New York City, New York, USA
3Hadassah-Hebrew University, Jerusalem, Israel
Category: Medical Education
Background: The AAP recommends the use of pasteurized donor human milk (DHM) for preterm infants with very low birth weight (VLBW) infants (< 1500 g) when own mother's milk is inadequate or unavailable. Pasteurized donor milk, when provided as a sole diet or in conjunction with mother's own milk for preterm infants, is protective against necrotizing enterocolitis (NEC). Knowledge of donor milk is vitally important for pediatric residents who manage the care of VLBW infants in the NICU.
Objective(s): The purpose of this study was to develop and evaluate an educational module for pediatric residents to improve knowledge of donor human milk for preterm infants.
Materials/Methods: This was an educational intervention study that included the development of a module regarding the knowledge and use of donor human milk for VLBW infants. Developed by pediatric residents for use by pediatric residents and medical students, the module underwent expert validity by neonatologists specializing in human milk. A convenience sample of 20 pediatric residents and medical students completed the modular study during a designated lecture period. All participants were invited to complete a pre & post‐tests. Data was collected and analyzed by t‐test with SPSS 25.
Results: Participants scores increased from a mean pretest score of 19.8 + 1.6 to posttest score 23.5 + 1.5 (P = 0.000). The percentage of correct answers was 48.2 + 10.5% prior to the module and improved to 73.4 + 9.0% post‐survey (P = 0.000). Pediatric residents' mean confidence level was 3.4 + 0.7 prior and increased to 4.4 + 0.9 after completing the module (P = 0.002). Resident knowledge significantly improved in multiple subject areas, including eligibility criteria for donor milk, process to eliminate non‐infectious contaminant of DHM, process of pasteurization and benefits of DHM.
Conclusions: Participants scores increased from a mean pretest score of 19.8 + 1.6 to posttest score 23.5 + 1.5 (P = 0.000). The percentage of correct answers was 48.2 + 10.5% prior to the module and improved to 73.4 + 9.0% post‐survey (P = 0.000). Pediatric residents' mean confidence level was 3.4 + 0.7 prior and increased to 4.4 + 0.9 after completing the module (P = 0.002). Resident knowledge significantly improved in multiple subject areas, including eligibility criteria for donor milk, process to eliminate non‐infectious contaminant of DHM, process of pasteurization and benefits of DHM.
Preventing Dental Caries in Breastfeeding Toddlers: 2020 Updates
Gina Weissman1
1Laniado Hospital, Netanya, Israel
Category: Medical Education
Background: Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants. Exclusive breastfeeding for 6 months is the optimal way of feeding infants. Thereafter infants should receive complementary foods with continued breastfeeding up to 2 years of age or beyond. Breast milk promotes sensory and cognitive development, and protects the infant against infectious and chronic diseases. The increasing awareness to the benefits of breastfeeding has led an incremental rise in toddler breastfeeding. Common recommendations to toddlers who are diagnosed with Early Childhood Caries (ECC) are dental treatment under general anesthesia and weaning from the breast. Dental caries is a chronic disease that relates to the modern lifestyle. It is affected by nutrition habits, oral hygiene and oral bacteria composition. Prolonged acidity in oral cavity increases the risk of developing tooth decay. Being an experienced Lactation Consultant and a DMD, Dr Weissman presents a unique perspective of treating and preventing dental caries in breastfeeding toddlers.
Objective(s): To review current studies in breastfeeding‐dental caries correlation. To assess risk factors for dental caries. To review alternatives for conventional dental treatment and present a conservative protocol for treating ECC.
Materials/Methods: Literature regarding breastfeeding and dental caries will be reviewed, as well as alternatives for conventional dental treatment. A variety of Case Studies will be presented including clinical photos.
Results: Clinical research demonstrates a protective effect of breastmilk on dental caries development up to 12 months in comparison with other feeding methods. Breast milk contains immunomodulators and microbiome which are necessary for flora's equilibrium. As for the age range of 13–23 months, no significant correlation was observed between breastfeeding and dental caries. Clinical research did show increased dental caries rate for children above 24 months. However, most studies did not refer to oral hygiene, fluoride exposure and complementary foods.
Conclusions: When assessing dental caries risk, one needs to consider the effect of pre‐natal and post‐natal complications and the dental and systemic condition of both mother and baby. These have been proven to have an effect on enamel structure and resiliency and the levels of cariogenic bacteria. When treating ECC a conservative approach should be considered. Dental treatment usually includes inhaled sedation, deep sedation or general anesthesia. Conservative methods arenon‐restorative dental treatment and frequent follow‐ups that include use of topical fluorides, nutrition and OH modification. Only in cases of severe ECC one should consider avoiding ad‐libitum night breastfeeding.
International Lactation training trip in China
Jie Chang1
1Stanford Children's Hospital, Palo Alto, California, USA
Category: Medical Education
Background: China, a country with the largest population in the world, reported having only 568 International Board Certified Lactation Consultants (IBCLC's) in 2018, (1) and an exclusive breastfeeding rate for infants under six‐month‐old, of 29.2%,2 which is lower than the world's average rate of 43%. (2) Inadequate number of IBCLC leads to a delivery of inaccurate information and low exclusive breastfeeding rates. (3)
Objective(s): To promote professional lactation service in China by providing a comprehensive education for Chinese health providers. Effective professional lactation training for Chinese health providers.
Materials/Methods: Lucile Packard Children's Hospital Stanford developed and delivered a three day course on Lactation. The content was based on “Core Curriculum for Lactation Consultant Practice”. A post questionnaire survey was conducted. (4)
Results: A total of 191 trainees from 22 local hospitals and institutes attended the training, including physicians (65), nurses (125) and a hospital administrator. Post questionnaire surveys (86) were completed. The program was rated excellent for courses' organization (87%, 75/86), the presenters' knowledge (82.5%, 71/86), relevant and helpful teaching material (80%, 69/86). The three favorite topics were lactation pharmacology, building an effective breastfeeding service, managing breast and nipple problems. The suggestions for course improvement were to increase the interaction between instructor and trainees and provide more opportunities for hands on clinical practice.
Conclusions: Evidence based and clinical practical lactation knowledge, techniques, principle, and protocol, all of which are needed to inform and support Chinese health providers.
Non‐maternal Nursing in the Muslim Community: A Health Perspective Review
Fouzia Alhreashy1
1Ministry of Health, Chicago, Illinois, USA
Category: Other
Background: Non‐maternal nursing is a valuable option for healthy infant nutrition. It is currently practiced as direct wet nursing and feeding of expressed milk from a wet nurse, and the applicability of both varies across cultures. Review of the relevant literature revealed an understanding of the characteristics, benefits, and challenges in the practice of wet nursing across different cultures. There is a paucity of literature on direct wet nursing in medicine. On the other hand, there is a considerable amount of discussion on the indirect method (donor human milk feeding) in the context of milk banks and feeding premature infants or sharing in the community. The ideal characteristics of a wet nurse and/or a human milk donor are addressed. The challenges that face non‐maternal nursing include health, economic, cultural, and other challenges – the majority of which can be overcome at the individual or community level. Finally, in the context of Muslim communities, milk kinship should not be considered an obstacle to non‐maternal nursing; indeed, it should be addressed as a fortunate feature that can expand human relations between the wet nurses and the receiving families. The findings of this review indicate the need for evidence‐based guidelines for non‐maternal nursing across various social context and clinical scenarios. Moreover, it is important to utilize modern technology in donor human milk feeding in specific situations to ensure that the benefits of human milk are extended to infants of all cultures.
Objective(s): This review seeks to answer a series of questions: 1. What is the current practice of wet nursing in the Muslim world? 2. Is direct wet nursing preferable to the use of human milk expressed by a wet nurse? 3. What are the ideal characteristics of a wet nurse? 4. What are the health indications for non‐maternal nursing? 5. What are the challenges to wet nursing practice in the Muslim community?
Materials/Methods: Review
Results: Review Paper
Conclusions: The options for non‐maternal nursing vary in quality, feasibility, customs, and cost across communities; this is in addition to the physiological variabilities of lactation. Direct wet nursing is a valuable resource that should be encouraged with appropriate support from the medical community. Islam supports breastfeeding from mothers as well as from wet nurses. However, the parents must know the identity of the human milk donors as a mark of respect for the kinship created between the wet nurse and the infant according to Islamic law. Thus, there is a need for multidisciplinary, evidence‐based guidelines for non‐maternal nursing of healthy and sick infants that are in keeping with cultural norms.
A Graves' Matter: Poor Weight Gain in a Breastfed Infant
Janean Wedeking1, Dillon Savard1
1Offutt Air Force Base, Sarpy County, Nebraska, USA
Category: Other
Background: Poor weight gain, or failure to thrive (FTT), has myriad possible etiologies and is relatively common in primary care practice. Also known, through large population studies, that it is estimated the incidence rate of maternal hyperthyroidism is 65 per 100,000 mothers per year with the highest rate during the 7 to 9 months postpartum. It is also estimated that 40–45% of all new Graves' disease in parous women happens in the postpartum timeframe. Presented, is a case report of a breastfed infant with FTT in the setting of unknown, uncontrolled maternal Graves' disease. A normal breastfed infant began to have slowed growth at four months of age. The social situation was optimal and laboratory work‐up was normal. The mother's only medication was etonogestrel‐releasing contraceptive implant. The mother engaged in breast massage and supplemented with expressed breast milk. Full fats were also added to the infant's solid diet, yielding no improvement in growth. Unknown to the infant's physician, from 4 to 11 months postpartum the mother lost 30 pounds, had palpitations, and exophthalmos. She began methimazole for Graves' disease and, once optimized, the infant's weight rapidly normalized.
Objective(s): Thoroughly assess the details of the case report of a breastfed infant with FTT in the setting of unknown, uncontrolled maternal Graves' disease, and attempt to identify an underlying cause. Review literature to understand the underlying pathophysiology of maternal hyperthyroidism and how it may lead to changes in breastfeeding and possibly infant FTT. Determine what implications this case has for primary care practice and providing care for mothers and infants.
Materials/Methods: N/A
Results: Data is lacking regarding Graves' disease's effects on lactation and breastfed infants. In rats, induced maternal hyperthyroidism is associated with milk stasis and lower weight gain in rat pups. In the infant reported here, decreased growth was likely related to uncontrolled maternal Graves' disease, given that growth dramatically responded to maternal treatment. However the underlying pathophysiology of this is in humans is not clearly known.
Conclusions: Primary care providers routinely encounter infant FTT. This case illustrates the importance for clinicians to include a broad range of maternal health causes in their differential for FTT in breastfed infants, including hyperthyroidism. Currently the American Thyroid Association does not recommend treatment of Graves' disease on the basis of improving lactation alone. However, this case demonstrates that treating maternal Graves' disease may improve lactation for breastfed infants. Also demonstrated in this case is the importance of inclusive infant and maternal pre/postnatal care. Employing this model of care may have facilitated earlier identification and treatment of this infant's FTT and maternal Graves' disease.
Idiopathic Granulomatous Mastitis Diagnosed During Pregnancy Associated with Successful Breastfeeding Experience
Adeola Awomolo1, Adetola Louis‐Jacques2, Susan Crowe3
1University of Arizona, Tucson, Arizona, USA
2University of South Florida, Tampa, Florida, USA
3Stanford University, Stanford, California, USA
Category: Other
Background: Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast condition with unclear etiology. It occurs primarily in women of childbearing age and can mimic two common breast conditions, breast abscess and breast malignancy. Most common symptoms include unilateral breast tenderness, breast mass, erythema, nipple retraction, and axillary adenopathy. The diagnosis of IGM can be challenging and is often delayed. Due to a lack of consensus on treatment, choice, and duration of treatment add another layer of complexity to IGM management. There is also limited guidance on IGM and breastfeeding management.
Objective(s): Describe a rare diagnosis that should be considered with atypical presentation of mastitis. Describe co‐management of IGM associated with successful breastfeeding experience.
Materials/Methods: Case Report
Results: Case Description: A 30‐ year‐old gravida 3 para 1 with a history of intrauterine fetal demise and eczema presented to her prenatal visit at 33 weeks' gestation with left breast pain and galactorrhea. Physical examination revealed erythema and induration, and dicloxacillin was initiated for presumed mastitis. Within a day of starting dicloxacillin, she developed joint pain and erythematous plaques and was switched to clindamycin. Due to persistent symptoms despite treatment, breast surgery was consulted. Ultrasound revealed dilated fluid‐filled ducts and hypervascularity of overlying skin. Fine‐needle aspiration showed acute inflammation with no growth on culture. Ultrasound‐guided breast core biopsy revealed chronic granulomatous inflammation, neutrophilic and eosinophilic inflammation, and a diagnosis of IGM was made. Simultaneously, the joint pain and erythematous plaques worsened. Dermatology diagnosed concurrent erythema nodosum. Rheumatology recommended prednisone, the erythema nodosum and polyarthritis responded well to prednisone, but the breast condition remained severe. She was noted to have drainage from multiple sites on the left breast and methotrexate was recommended postpartum. She had vaginal birth at 39 weeks and due to multiple draining fistulas on her left breast, she was started on Bactrim for bacterial mastitis prophylaxis. She initiated breastfeeding with her right breast. The left breast was hand expressed for comfort. She declined methotrexate because she desired to breastfeed, and azathioprine was initiated. She was co‐managed by a breastfeeding medicine specialist and rheumatology. Eight weeks postpartum, the patient was breastfeeding exclusively. There was some induration and multiple residual draining fistulas on her left breast. At 3 months postpartum, her breast exam was improved with minimal residual induration but persistent draining fistulas. She chose to discontinue azathioprine. At seven months postpartum, her breast exam was normal except for a 2cm firm area. The patient reported breastfeeding exclusively for 6 months, and breastfeeding continued throughout the first year.
Conclusions: IGM is a challenging diagnosis that should be considered in cases of sterile breast abscesses. Management is complex and regardless of therapeutic intervention reported duration to resolution ranges from 6 to 12 months. This case illustrates how a multidisciplinary approach in the management of idiopathic granulomatous mastitis during pregnancy and postpartum can facilitate a successful breastfeeding experience.
Lactation in the Workplace: A Pediatric Employee Survey
Tavor Allali1, Cristina Senger1, Wayne Franklin1
1Loyola University Medical Center, Maywood, Illinois, USA
Category: Other
Background: Numerous benefits of breastfeeding exist, including lower incidence of diabetes, asthma, and eczema for infants and decreased risk of postpartum bleeding and depression for mothers. Employers of breastfeeding mothers have improved employee productivity, morale, company image, and employee retention. The AAP recommends exclusive breastfeeding until six months of age; however, in the US, only 25% of mothers report meeting that goal. Studies investigating the relationship between breastfeeding and employment found that working mothers are more likely to stop breastfeeding in the first month of return to work compared to their non‐working counterparts. Barriers to pumping at work include an unsupportive environment, and lack of privacy, time or access to a lactation room. The latter two are positively correlated with continuation of breastfeeding in working mothers.
Objective(s): Determine the current lactation preferences and practices of women within the pediatrics department at Loyola University Medical Center (LUMC). Identify strengths and weaknesses of the current staff lactation room at LUMC. Propose an intervention to improve workplace lactation in the pediatrics department at LUMC.
Materials/Methods: A survey was sent to 265 women in the pediatric department at Loyola Medical Center in Illinois. Questions were aimed at identifying current pumping practices, locations, and attitudes within the workplace.
Results: A total of 127 participants (48%) responded. Participants included nurses (52%), residents (17%), attending physicians (11%), and other clinical or administrative staff. About 70% of participants work in the hospital, 13% in administration or the outpatient center, and 16% are residents, who rotate through multiple locations. Of the participants, 47% reported no lactation room in their department and 52% didn't know the location of it or that one existed. 47% of participants had pumped at work, and of those, 60% exclusively used a room other than the existing lactation room. The majority of participants stored their breast milk in the employee refrigerator (35%) or a personal cooler (29%). Women (49%) reported they wouldn't use the existing room, citing its lack of cleanliness, inconvenient location, and limited space as major reasons. Despite these shortcomings, 80% of women felt their workplace was supportive and only 30% were dissatisfied with available resources.
Conclusions: Our proposal is to renovate and update the existing lactation room in our facility to provide a cleaner and more inviting space and encourage long term continuation of breastfeeding. To increase awareness of the existing room, we created a website on the employee intranet portal that includes information about the room and an official employee breastfeeding policy. Our proposal also includes plans to convert several more conveniently located rooms into employee‐only lactation rooms. Breastfeeding is beneficial for infants, mothers, employers, and society. One role of pediatricians is to promote and support breastfeeding in clinics, communities, and society. Studies indicate that personal success with breastfeeding is positively associated with breastfeeding advocacy amongst physicians. As the specialty with the highest percentage of women physicians, pediatrics should be at the forefront of lactation support in the workplace. This includes providing a clean, quiet, relaxing, and private environment for women to pump. Surveying healthcare workers is crucial in gaining knowledge about their attitudes towards employer resources and support of lactation. An intervention that improves the current conditions will not only lead to improved employee morale, but also enhanced breastfeeding promotion to benefit our patients.
Sharing the Science of Lactation and Mothers' Own Milk with NICU Families and Staff
Paula Meier1, Aloka Patel1, Judy Janes1
1Rush University Medical Center, Chicago, Illinois, USA
Category: Other
Background: The evidence for the use of mothers' own milk (MOM) for premature and other infants hospitalized in the newborn intensive care unit (NICU) is substantial, and includes a dose‐dependent reduction in the risk of potentially preventable morbidities that are serious and costly. Similarly, there is considerable evidence about initiating and maintaining lactation in breast pump dependent mothers of NICU infants. However, there is a significant gap between this evidence and its routine implementation into best NICU practices.
Objective(s): To share a recently completed demonstration project, Translating Research to Practice: Evidence Based Toolkit to Optimize Mothers' Own Milk Feeding in the NICU, that standardizes messaging and practices for NICU families and staff. Describe NICU implementation strategies for project materials.
Materials/Methods: This project prepared 25 one‐page parent education sheets and 20 short segment video clips that share the latest science about lactation and MOM with NICU families and staff. The content was developed with a specific focus on questions and concerns commonly experienced by NICU families and staff. A core tenet of the project was depicting otherwise complicated scientific mechanisms in words or visuals that were understandable and actionable by users, including the enteromammary pathway, barrier protection with MOM oligosaccharides, and neuroprotection of developing brain white matter.
Results: Included among the one‐page education sheets are: Why does my milk matter for my premature baby? What is colostrum and why is it important for my NICU baby? How does my milk help my baby's brain grow and develop? Are my medications safe while I am providing milk for my NICU baby? Benefits to mothers who provide milk for their NICU babies. Kangaroo care for mothers and NICU babies. Mouth care with mother's milk for your NICU baby. Fresh, refrigerated, frozen and pasteurized milk for NICU babies. Mastitis in the NICU. Marijuana and providing milk for a NICU baby. Among the video footage are very short (30 seconds) and longer (9 minutes) segments for use with families and staff. Examples include: Skin‐to‐skin holding in the NICU (for NICU staff; demonstrates transfer of intubated, critically ill infant into skin‐to‐skin position). Skin‐to‐skin holding in the NICU (for NICU families, demonstrating transfer, and addressing common questions such as “Is my baby really ready to be held skin‐to‐skin?”). Mouth care with MOM. Making individualized decisions about medications in MOM. Effective, efficient and comfortable breast pump use in the NICU. Positioning premature babies for feedings at the breast. Performing test weights to measure milk intake during breastfeeding. Preparing to breastfeed after NICU discharge: What to expect in the first month at home.
Conclusions: For families, these materials provide evidence‐based information about NICU‐specific lactation and MOM concerns. For NICU staff, these materials standardize practice and messaging, and provide a valuable addition to current quality improvement initiatives that seek to improve outcomes for lactation and MOM in the NICU.
The value of breastfeeding and the costs of artificial feeding to society: An analysis of the methods and comparison of results
Melissa Bartick1, Briana Jegier2, Julie Smith3
1Mt. Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
2D'Youville College, Buffalo, New York, USA
3Research School of Population Health, Australia National University, Canberra, Australia
Category: Quality Improvement Advocacy
Background: Economic analyses of breastfeeding are diverse in focus ‐ yielding vastly different estimates and using very different methods to assess costs.
Objective(s): To compare and contrast the different cost estimates for the costs of artificial feeding, as these estimates can differ widely. To review the different methodologies for the estimates, which thus largely explained the wide variability in cost estimates. To explain to policy‐makers and advocates the differences in the types of estimates, so in order to better guide decision‐making.
Materials/Methods: We reviewed peer‐reviewed and major grey literature between 1995–2020 using keywords on the cost of suboptimal breastfeeding or artificial feeding. Articles were excluded if they did not have monetary values assigned or evaluated breastfeeding programs or donor milk only.
Results: We identified 2 types of costs and several methodologies, arising from different perspectives on costs. Costs consisted of a) resource costs and b) longer‐term societal costs. Resource costs included direct and indirect medical costs and lost wages, which can be calculated by several methods. Longer term societal costs are human capital costs measured by lost productivity, and included the costs of premature death and of cognitive losses. The bulk of economic costs come from societal costs and can vary widely depending on method of calculation. Although direct medical treatment costs can vary widely in their precision depending on method of calculation, this variation has little effect on overall estimates when compared to the much larger cognitive or death costs.
Conclusions: When evaluating economic analyses of breastfeeding, it is important for readers to be familiar with key economic concepts, methodologies, and the distribution of resource and societal costs. Readers also must be cautious that direct medical costs should not be summed with costs for lost productivity. Governments may be more concerned about societal and resource costs, whereas businesses and insurers may be more concerned about resource costs.
Improving Postpartum Breast Pumping in Mothers of Babies in the NICU
Karampreet Kaur1, Lisa Zuckerwise1, Stephanie Attarian2, Mary Dye2
1Vanderbilt University Medical Center, Nashville, Tennessee, USA
2The Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
Category: Quality Improvement Advocacy
Background: Human milk provides ideal nutrition for premature infants in the Neonatal Intensive Care Unit (NICU). Human milk's unique properties protect these vulnerable patients from morbidities such as late onset sepsis, central catheter associated blood stream infections (CLABSI), necrotizing enterocolitis (NEC), feeding intolerance, and retinopathy of prematurity (ROP). Stage II lactogenesis marks the start of abundant human milk production in the postpartum period. Delayed lactogenesis II leads to decreased total milk volume and lactation time, especially in mothers of infants admitted to the NICU. Initiation of milk expression within one hour following delivery increases milk volume and decreases time to lactogenesis II in mothers of very low birth weight infants. Despite these known benefits, only ∼57% of NICU mothers delivering at Vanderbilt University Medical Center initiate breast‐pumping within 6 hours of delivery.
Objective(s): Determine our current performance with postpartum pumping. Decrease the median time to first breast pump in NICU mothers by 50%.
Materials/Methods: The baseline time to first breast pump was calculated for mothers who delivered between 10/01/2019 and 10/31/2019 and were seen for consultation in our Fetal Center by a single Maternal Fetal Medicine (MFM) provider (LCZ). For patients who delivered vaginally, we determined the time from delivery to first breast pump using time stamps in the electronic medical record (EMR). For patients who delivered via Cesarean delivery, we calculated time interval from exiting the operating room to first breast pump. Intervention 1 was conducted from 11/5/19 ‐12/17/19 in The Fetal Center at Vanderbilt during a single MFM physician's clinic (LCZ). During this intervention, patients were identified in their 3rd trimester and counseled on the importance of early breast pumping using a brief educational narrative about the benefits of short interval to first pump. Intervention 2 was conducted from 12/20/19 ‐ 12/27/19 on the inpatient antepartum service. During bedside rounds with nursing staff present, the same physician counseled women likely to deliver neonates requiring NICU care about the importance of short interval to first breast pump after delivery. Time to first breast pump was similarly calculated for intervention patients via time stamps in the EMR.
Results: Nine patients seen by our MFM physician were delivered during the baseline data collection period. Among this group, the median [interquartile range, IQR] baseline time in hours from delivery to first breast pump was 8.38 [7.55–10.22]. Ten of 15 patients who received Intervention 1 commenced breast pumping after delivery. The median time in hours to first breast pump in this group was 4.63 [2.52–5.67]. Five patients who received Intervention 2 commenced breast pumping after delivery. The median time to first breast pump was 9.92 [6.28–11.12] hours. Two mothers who received the inpatient intervention took >17 hours to initiate pumping. One did not receive her breast pump supplies in a timely manner and the other's child was unstable and NPO, which may have contributed to delays in pumping. The overall combined intervention median was 4.92 [2.88–8.12] hours. This represented a 41% decrease from the baseline time to first breast pump among patients with neonates admitted to the NICU who received directed counseling in either the outpatient or inpatient setting.
Conclusions: Overall, our educational interventions reduced median time to first breast pump amongst mothers whose babies went to the NICU, and this was especially true of our outpatient counseling intervention. Next, we plan to recruit more MFM attendings to implement the outpatient counseling on breast pumping, create a flier to supplement patient education, and modify the surgical 'time out' protocols for deliveries of neonates at risk for NICU care to include intraoperative retrieval of a breast pump for the mother's postpartum recovery room.
Increasing the Use of Donor Expressed Breast milk in the NICU
Lakshmy Vaidyanathan1
1UT Dell Medical School, Austin, Texas, USA
Category: Quality Improvement Advocacy
Background: Breastmilk has numerous health benefits for newborn infants, including many that formula does not provide. Donor expressed breastmilk (DEBM) is available for infants in the neonatal intensive care unit (NICU) but is often underutilized in lieu of formula.
Objective(s): The purpose of this project was to determine the barriers to DEBM usage in the NICU, assess the understanding and educational awareness about DEBM amongst nursing staff and families, and create an intervention to increase the use of DEBM in the NICU. Conduct short bedside educational sessions to NICU nurses with the goal of increasing their educational awareness about DEBM.
Materials/Methods: A pre‐education survey was created for families whose infants were receiving DEBM and for NICU nurses which included questions about education regarding DEBM and possible barriers to usage. Nine families and thirty‐six nursing staff members completed these surveys. After analyzing the survey results, determined that the families had a good level of understanding of DEBM and did not need further education; however there were several areas we identified for potential improvement on the nursing staff surveys. We created a 20‐minute educational presentation about the benefits and processing of DEBM using educational materials provided by Mother's Milk Bank in Austin, along with articles from Pediatrics, the Journal of Perinatology, and Pediatric Research. Twenty nurses attended one of three educational sessions, which were given during two day shifts and one night shift. Following the educational sessions another survey with similar questions was distributed to assess what was learned and what changes, if any, the nurses anticipated making to their practice.
Results: Seventeen out of twenty nurses completed the post‐education survey. 100% of nurses found the presentation useful and relevant to their clinical practice. 82% reported they would discuss the benefits of exclusive breastmilk feeding with families who indicate their feeding plan is breastmilk and formula. 100% (pre‐survey 94%) would discuss DEBM as a choice for feeding when a mother has not pumped sufficient milk. 94% (pre‐survey 69%) would offer DEBM to all families who require supplementation in addition to the mother's breastmilk. 94% (pre‐survey 67%) would discuss DEBM as a choice for supplementation with the physician team when only formula is ordered. 88% (pre‐survey 61%) would offer DEBM before formula for supplementing a >/ = 33 week old infant. 82% (pre‐survey 47%) would discuss DEBM with a family if a physician has not ordered it. 82% reported learning something from the presentation. 35% would make changes to their existing practice.
Conclusions: A short educational presentation can increase education about and intent to offer DEBM in the NICU.
Initiation, Duration of Breastfeeding and Specification Factors that Influence it
Background: Exclusive breastfeeding is difficult to achieve.
Objective(s): The purpose of this retrospective study was to record the frequency of breastfeeding for the first 6 months of life. The secondary purpose of this retrospective study was to record factors that contribute to the establishment and continuation of breastfeeding.
Materials/Methods: We performed a retrospective study using a telephone questionnaire to all mothers who gave birth at the obstetrics clinic of General Hospital of Trikala from January 2015 to December 2016.
Results: Data were collected from 268 mothers. About 84,87% begun to nurse after birth, 37,64% of mothers continued with exclusive or partial breastfeeding up to 6 months, while 33,58% continued with exclusive breastfeeding up to the sixth postpartum month. Mothers who adopted lactation exclusively rather partial breastfeeding declared very well informed about the process, especially from the obstetric and medical staff of the hospital (p < 0.001). Home help did seem to play a role in the choice of exclusive comparing with partial breastfeeding (p = 0,016).
Conclusions: It appears that on the part of mothers there is strong interest in the initiation and establishment of breastfeeding. Almost all of the mothers who breastfeed up to sixth postpartum months continue with exclusive breastfeeding. The overall breastfeeding rates decline. The approach of obstetric and pediatric care is not enough and the health care system should focus on the support of breastfeeding at the community too, apart from the hospital services, for better breastfeeding rates to be achieved.
Donor Breast Milk versus Formula for Treatment of Hypoglycemia in a Newborn Nursery
Allison Heizelman1, Ellen Bryant1, Nicole Baumann‐Blackmore1, Michael Lasarev1, Elizabeth Goetz1
1University of Wisconsin, Madison, Wisconsin, USA
Category: Quality Improvement Advocacy
Background: Oral dextrose gel with feed supplementation is shown to treat neonatal hypoglycemia, avoiding intensive care admission for intravenous fluids. It remains unclear whether donor breast milk (DBM) or formula (FM) is a superior supplementation choice.
Objective(s): Investigate the impact of feed type on hypoglycemia. Determine whether our hypoglycemia protocol should be revised to include supplementation type.
Materials/Methods: Analysis of newborns with hypoglycemia in a community‐based hospital center from Jan to Oct 2019 was performed through chart review. Patients received oral dextrose gel with self‐selected feeding supplementation (DBM, FM, DBM+FM) per hospital protocol. General characteristics and potential confounding factors were assessed. Main outcomes included ICU admission, total gel doses required and ability to resolve hypoglycemia with one gel dose. Feeding intention was a secondary outcome. Statistical analyses included binomial regressions, Kaplan‐Meier estimation, log‐rank test and Cox proportional hazards regression.
Results: 393 newborns were analyzed: 28% (n = 110) DBM, 63% (n = 248) FM and 9% (n = 35) DBM+FM, 3 excluded for inadequate documentation or refusal of supplementation. Sex, mode of delivery and Apgar scores were comparable between groups. Infant size showed imbalance among groups, shown in Table 1. Feeding type at discharge and presence of low body temperature at time of hypoglycemia (p = 0.33) did not statistically differ among groups. Percent of infants requiring ICU care differed among the three groups (p < 0.001). No difference existed when comparing DBM and FM, with overall ICU admission rate of 8.4% (95% CI: 5.9–11.8%) when one feed type used. DBM+FM was associated with a 3.41 (95% CI: 1.82–6.38; p < 0.001) fold increase in ICU admission rate relative to other groups (28.6% vs 8.4%). Hypoglycemia resolution with only one dose did not differ between DBM and FM individually. DBM+FM had a 77% lower chance of resolution with an average of 2.80 (95% CI: 1.83–4.28; p < 0.001) additional gels required. DBM+FM also had earlier onset of hypoglycemia after birth (median 2 hrs; 95% CI: 1.5–3hrs), followed by DBM (median 4 hrs; 95% CI: 2–5hrs), than FM (median 4 hrs; 95% CI: 4–5hrs). Table 1. Description of Demographic Characteristics Full cohort(n = 393)Donor Breast Milk(n = 110)Formula(n = 248)Donor Breast Milk + Formula(n = 35)Sex (%)FemaleMale177 (45%)216 (55%)48 (43.6%)62 (56.4%)116 (46.8%)132 (53.2%)13 (37.1%)22 (62.9%)Gestational age weeks range median (IQR)30.0 − 41.738.2(36.9, 39.3)35.1 − 41.438.8(37.1, 39.4)30.0 − 41.738.0(36.9, 39.2)35.0 − 41.137.5(36.5, 39.0)Birth Weight grams range median(IQR)2020 − 56203179(2698, 3794)2190 − 56203371(2807, 4012)2020 − 49003083(2650, 3671)2250 − 51103232(2657, 3979)Size for Age n (%)SGAAGALGA53 (13.5%)247 (63.0%)92 (23.5%)17 (15.6%)57 (52.3%)35 (32.1%)34 (13.7%)166 (66.9%)48 (19.4%)2 (5.7%)24 (68.6%)9 (25.7%)Route of Delivery (%)Vaginal Cesarean section222 (56.5%)171 (43.5%)63 (57.3%)47 (42.7%)136 (54.8%)112 (45.2%)23 (65.7%)12 (34.3%)Apgar Scores median (IQR)1 minute5 minute Score improvement8 (7, 9)9 (9, 9)1 (0, 1)8 (8, 9)9 (9, 9)1 (0, 1)8 (7, 9)9 (9, 9)1 (0, 1)8 (7, 9)9 (9, 9)1 (0, 2)Low Temp (<36.5°C)with Hypoglycemia n (%)85 (21.6%)22 (20.0%)52 (21.0%)11 (31.4%)IQR = Interquartile RangeTable 2. Comparing Outcomes of Interest Between Donor Breast Milk and Formula Donor Breast Milk(n = 110)Formula(n = 248)P‐value (RR, CI)ICU admission for treatment of hypoglycemia n (%)9 (8.2 %)21 (8.5 %)0.93 (1.03, 0.50–2.19)Hypoglycemia resolved with first treatment*n (%)54 (49.1 %)144 (58.1 %)0.13 (1.18, 0.95–1.47)Number of additional treatments* required mean (95% CI)0.92 (0.72–1.18)0.79(0.66–0.94)0.33(0.86, 0.64–1.17)*Treatment includes oral dextrose gel + feed supplementation RR = Relative Risk CI = Confidence Interval
Conclusions: We found no difference in ICU admission rate between DBM and FM, supporting either option to treat hypoglycemia with oral dextrose gel. DBM+FM had quicker onset hypoglycemia and worse outcomes across all categories; this small group may be intrinsically different, requiring further investigation. Feeding type at discharge was equivalent between all groups, suggesting formula supplementation did not dissuade caregivers from breast milk feeding.
Utilization of Team‐based Lactation Consultant/Primary Care Provider Breastfeeding Support in a Socioeconomically Diverse Practice
Rachel Witt1, Lauren Lasko1, Thanvi Vatti1, Ann Witt1
1Breastfeeding Medicine of Northeast Ohio, South Euclid, Ohio, USA
Category: Quality Improvement Advocacy
Background: A team based, integrated lactation consultant (LC) and primary care provider (PCP) program improves breastfeeding rates in some outpatient settings, but limited studies have assessed efficacy in socioeconomically disadvantaged communities.
Objective(s): Following implementation of team‐based LC/PCP breastfeeding care at a federally qualified health center (FQHC) in 2018, quality improvement efforts were undertaken to assess utilization of services. Preliminarily analyze breastfeeding rates and patient satisfaction.
Materials/Methods: One year after implementation of routine team‐based LC/PCP breastfeeding program at the FQHC, a survey of patient experience was conducted (N = 20). Additionally, a retrospective chart review examined consecutive newborns in the 6 months of 2017 before (N = 89) implementation and in the full year of 2019 after (N = 250) implementation. Primary variables reviewed included LC visit utilization and feeding status at the newborn, 2, 4, and 6 month well visits (WCC). Chi‐square analysis compared pre and post implementation feeding rates at all time points and included a sub analysis of patients who initiated breastfeeding (BF).
Results: After LC/PCP implementation, a LC saw 72% of infants initiating breastfeeding (n = 204) at some point with 55% of families receiving the care at their first PCP visit. Mean LC visit per BF patient was 1.13(SD +1.2). There was no significant difference in practice wide BF rates before and after implementation. However, among patients who initiated BF in 2019, those who received a LC/PCP visit were significantly more likely to be breastfeeding at 2 weeks (94% vs 80%, p = 0.004) and 4 months (68% vs 47%, p = 0.014) than those BF patients who did not receive a LC/PCP visit. Patient survey reported the LC visit to be “much better than expected,” (85%) and said “helpful information and advice” (85%) was given. The three most commonly helpful aspects of the visit were “latch instruction” (60%), “breastfeeding questions answered” (80%) and “learning about massage and hand expression” (50%).
Conclusions: Team‐based LC/PCP care is feasible at a FQHC and facilitated 75% of BF patients receiving lactation support at the primary care office. Patients were satisfied with the care and found it helpful. A larger sample size maybe needed to identify practice‐wide improvement in BF rates; however, among families who initiated breastfeeding, receiving LC/PCP care was associated with increased breastfeeding duration at two weeks and four months. These findings are consistent with past research indicating team‐based care helps address breastfeeding problems and barriers in health care services among patients initiating breastfeeding.
Addressing Community Gaps in Breastfeeding Support: From Hospital to First Visit
Julie Ware1, Jennifer McAllister1, Clara Chlon1, Erica Walters1, Robin Steffen1, Rebecca Haehnle1, Laura Ward1, Suzanne Crable2
1Cincinnati Children's Hospital, Cincinnati, Ohio, USA
2TriHealth, Cincinnati, Ohio, USA
Category: Quality Improvement Advocacy
Background: Although there is an increasing trend for more mothers to initiate breastfeeding in the US, there is a rapid decline after initiation, and racial disparities persist. A multidisciplinary team comprised of pediatricians, neonatologists, prenatal lactation support, primary care lactation experts, and members of the community partnered to address the cessation of breastfeeding before the first “Newborn” visit at our institution's busy primary care safety net clinics, using Quality Improvement methodology.
Objective(s): Explain QI tools including ‘Aim Statement,’ ‘Key Driver Diaghram,’ ‘PDSA cycle,’ ‘Pareto Chart.’ Describe how a multidisciplinary team can help to address ‘the gaps’ of breastfeeding care from hospital to first visit. Delineate interventions to “close the gap” in breastfeeding support initiated through a Quality Improvement Collaborative.
Materials/Methods: The aim of this project was to increase the number of babies still receiving some of their mother's milk at the first visit by 5%. Key Drivers affecting early cessation were identified and interventions developed to affect change through PDSA (Plan‐Do‐Study‐Act) cycles. Mothers identified as no longer breastfeeding at the first visit were interviewed to learn the reasons for cessation to help the team plan interventions.
Results: Baseline breastfeeding continuation at the newborn visit was 88% from all area birth hospitals. Variation between birth hospitals ranged from 82–92% still breastfeeding at the first visit. Mothers identified the following reasons for their discontinuation including: concerns about “not enough milk”, difficult latch, baby not satisfied, stress, work, and mother's habits not safe for the baby. Early interventions included the addition of lactation support to the Primary Care Clinics. Systematic procedures were developed, launched, and implemented to improve identification of feeding type at discharge and are now spread to all area birth hospitals for more accurate classification of feeding. Community support resource guides were developed and shared with birth hospitals and the community. A one page infographic is in development to share guidance on the most common concerns of mothers during the early days.
Conclusions: A quality improvement collaborative has successfully engaged partners from across institutions and disciplines to work on improving breastfeeding continuation at the first visit with QI methodology.
Breastfeeding Practice Before Bottle Feeding Increases Breastfeeding Rates for Preterm Infants at Time of NICU Discharge
Raylene Phillips1, Dawn Van Natta1, Jenny Chu1, Allison Best1, Pamela Bratton1, Tonya Oswalt1, Dianne Wooldridge1, Elba Fayard1
1Loma Linda University Children's Hospital, Loma Linda, California, USA
Category: Quality Improvement Advocacy
Background: In our NICU, efforts over several years have resulted in improved rates of breast milk feeds for preterm infants at time of NICU discharge, but rates of actual breastfeeding have remained low.
Objective(s): To increase the rate of preterm infants who were breastfeeding at the time of NICU discharge. To evaluate the effects of breastfeeding before bottle feeding on time to full oral feeding and corrected gestational gestational age at NICU discharge.
Materials/Methods: We created a Preterm Breastfeeding Pathway (PBP) algorithm for infants who were cleared for oral feeding and whose mothers desired to breastfeed. If mothers could be present for at least 3 feedings a day, we deferred introduction of bottle feeding for 72 hours and gave full gavage feedings during cue‐based breastfeeding practice. After 72 hours of breastfeeding practice, babies continued to practice breastfeeding with full gavage support when mother was present and practice bottle feeding with gavage support when mother was absent. After 35 weeks corrected gestational age (CGA), breastfeeding intake was estimated by pre/post weights or time/quality of feeding and gavage volume was adjusted until baby was weaned off gavage feeds. In addition to breast milk feeding and breastfeeding at NICU discharge, we documented birth gestational age and weight, gender, CGA at time of first oral feed and full oral feeds, days from first to full oral feeds, as well as days of life and CGA at NICU discharge.
Results: Seventy‐five preterm infants (birth GA <33 weeks) who had met criteria for the PBP were discharged from our 84‐bed Level 4B NICU between April and December 2019. By chart review, we compared babies who received 72 hours of breastfeeding practice before introducing a bottle (Group 1, n = 27) with babies who were introduced to bottle feeding with or before breastfeeding (Group 2, n = 15) and babies who were primarily bottle fed (Group 3, n = 33). We found that babies in Group 1 had significantly higher rates than those in Groups 2 or 3 for breastfeeding (88.9%, 66.7%, 3% respectively, p < 0.001) and breast milk feeding (100%, 86.7%, 39.4% respectively, p < 0.001) at time of NICU discharge. A slight difference in gestational age at birth among groups was found, but there were no statistical differences in CGA at first oral feed or full oral feeds, days from first to full oral feeds, CGA or days of life at NICU discharge.
Conclusions: Introducing breastfeeding practice before bottle feeding may contribute to increased rates of breastfeeding by supporting mothers who are already highly motivated to breastfeed. Preterm infants may learn to breastfeed easier if allowed to practice breastfeeding before bottles are introduced. Preterm babies and their mothers can be supported in direct breastfeeding without increasing time to full oral feeds or length of NICU stay.
Breastfeeding Initiation and Exclusive Breastfeeding Rates during the Delivery Hospitalization are lower in Spanish‐Speaking Vs English‐Speaking Women in a Large Medical System in the Midwest United States
Clara Chlon1, Laura Ward1, Scott Wexelblatt1, Larry Mayborg2
1Cincinnati Children's Hospital, Cincinnati, Ohio, USA
2TriHealth Baldwin, Cincinnati, Ohio, USA
Category: Quality Improvement Advocacy
Background: Breast milk has been shown to provide the optimal nutrition for newborn infants, and exclusive breast milk feedings for the first six months of a newborn infant's life is the recommendation of many health organizations, including the American Academy of Pediatrics (AAP) and World Health Organization (WHO). Exclusive breastfeeding (EBF) in the delivery hospitalization is associated with increased breastfeeding rates within the first year of life. For this reason, we are interested in monitoring demographic and ethnic differences within our patient population as they relate to breastfeeding rates and success.
Objective(s): Determine if there are differences in the rates of breastfeeding initiation between Spanish‐speaking and English‐speaking mothers. Determine if there are differences in the rates of EBF success within the newborn hospital stay according to mothers' primary language.
Materials/Methods: We extracted EPIC data from a large hospital system in Cincinnati, Ohio throughout 16 months based on chart documentation. This was achieved both manually and via Tableau Data Analytics Software, and allowed us to report breastfeeding initiation and percent success in meeting the goal of EBF within the newborn stay, Perinatal Core Measure 5 (PC‐05).
Results: We analyzed data from the period between 1/1/2019 and 4/28/2020, during which 83% of English speaking mothers ever initiated breastfeeding, and 85% of all Spanish‐speaking mothers ever initiated breastfeeding. For primarily English‐speaking mothers whose expressed intent was to exclusively breastfeed, EBF rates were 54.9% (n = 6,062). Primarily Spanish‐speaking mothers whose expressed intent was to exclusively breastfeed had an EBF rate of 33.33% (n = 105), P < 0.00001. Feeding preference aside, EBF rates were, 43.99% (n = 8,613) in the primarily English‐speaking dyads, vs. 20.41% in the primarily Spanish‐speaking dyads (n = 245), P < 0.00001.
Conclusions: Within a large health system in Cincinnati, OH, we have found that mothers who identify Spanish as their primary language have a much lower incidence of exclusive breastfeeding, regardless of their initial feeding goals. We hope that exploring reasons for these disparities, as well as the implementation of educational tools before, during, and after the delivery hospitalization will allow us to improve the breastfeeding rates in this vulnerable population.
Exclusive Breastfeeding Rates Increase Following Implementation of Strict Visitor Restrictions during COVID‐19 Pandemic in a Large Medical System in the Midwest United States
Clara Chlon1, Laura Ward1, Scott Wexelblatt1, Larry Mayborg2
1Cincinnati Children's Hospital, Cincinnati, Ohio, USA
2TriHealth Baldwin, Cincinnati, Ohio, USA
Category: Quality Improvement Advocacy
Background: Exclusive breastfeeding (EBF) during the newborn hospitalization helps predict overall breastfeeding success. In the first few days after birth, breastfeeding dyads need time, rest, and support to succeed in the crucial first days of breastfeeding. In the birth hospital, there are often many barriers to ensuring that mothers and babies can have the best start possible. These include family members and other visitors to the postpartum room. Beginning 3/16/20, such visitors were limited to one per dyad due to Covid‐19 precautions at a large hospital system based in Cincinnati, OH. We explored the potential link between this restriction and breastfeeding success.
Objective(s): Compare exclusive breastfeeding rates before and after the onset of visitor restrictions at a large delivery hospital system in the Midwest United States. Explore how the current climate of Covid‐19 is affecting the rates of exclusive breastfeeding (Perinatal Core Measure 5) at our medical center.
Materials/Methods: We extracted data from EPIC data from a large medical center based in Cincinnati, Ohio throughout 16 months based on chart documentation. This was achieved via Tableau Data Analytics Software, and allowed us to visualize percent success in meeting the goal of EBF within the newborn hospital stay, a.k.a Perinatal Core Measure 5 (PC‐05).
Results: We analyzed data between the dates of 1/1/2019 and 4/28/2020. Over those dates, we found that pre‐visitor restrictions (before 3/16/2020), 44% (n = 8779) of mothers were successful in exclusively breastfeeding during the delivery hospitalization in our large delivery center, vs. 47% (n = 826) after the restrictions, with a P‐value of 0.056.
Conclusions: Within a large health system based in Cincinnati, OH, we have found that mothers had greater success with exclusive breast milk feeding (PC‐05) during the newborn hospital stay following the implementation of strict visitor restrictions in the setting of the COVID‐19 pandemic. We feel that the reasons for this are worth exploring further and are likely multifactorial. Limiting the number of postpartum visitors leaves mothers with much more time to rest, latch their infants, and receive valuable support from lactation consultants and other support staff at the hospital. In the current climate, mothers also may be more inclined to consider breastfeeding to allow their newborns to benefit from the myriad benefits of human milk during this time of uncertainty. Through the use of our software interface, we will be able to track the rates in the months to come and continue to explore if this hypothesis persists.
Induced Lactation for Adoptive Breastfeeding Dyads
Dyah Febriyanti1, Asti Praborini2
1Kemang Medical Hospital, South Jakarta City, Jakarta, Indonesia
2Permata Depok Hospital, Depok, Indonesia
Category: Research
Background: Breastfeeding has many benefits for both mother and baby, but not all mothers can have their own babies. Here we used an induced lactation protocol to breastfeed adopted babies.
Objective(s): Describe applicative induced lactation protocol for adoptive breastfeeding dyads. Describe the length of breastfeeding periods of induced lactation protocol for adoptive breastfeeding dyads.
Materials/Methods: We implement and describe an induced lactation protocol for adoptive breastfeeding dyads at Kemang Medical Care (KMC) Women and Children Hospital and Permata Depok Hospital, Greater Jakarta, Indonesia. Participants included 32 of 48 breastfeeding dyads or subjects undergoing induced lactation protocols and fulfilling the inclusion criteria. The induced lactation protocol included the Praborini Method (hospitalization for nipple confusion) to promote latching, pharmacologically induced lactation, and at‐breast supplementation.
Results: Nineteen babies (59.4%) were aged <1 month and nine (28.1%) were aged 1–3 months at protocol initiation. Almost all (31 babies, 96.8%) were adopted after birth. At first examination, 20 babies (62.5%) could not latch, but all dyads could breastfeed after hospitalization for <1–2 days. Breast milk was induced after one cycle of Yasmin in 24 cases (75%). All mothers took domperidone and no side‐effects were reported. Average breastfeeding duration was 8.5 months, with weaning at 2–25 months of age, with working mothers weaning at ≤4 months. At‐breast supplementation was used until weaning.
Conclusions: Adopted babies can achieve long‐term breastfeeding through this multimodal protocol. Further prospective studies are warranted.
Differences in the Early Breastfeeding Experience in Women With and Without Obesity
Ashley Schulz1, Laura Ward2, Laurie Rivers1
1University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
2Cincinnati Children's Hospital, Cincinnati, Ohio, USA
Category: Research
Background: Due to numerous benefits for mother and baby, six months of exclusive breastfeeding is recommended. Obesity is associated with lower rates of exclusive breastfeeding, including during the maternity stay. However, the specific drivers of this disparity are not fully understood.
Objective(s): To determine the differences in the birth, early postpartum, and breastfeeding experiences between obese and non‐obese women. To determine if there are differences in exposure to Baby Friendly practices between obese and non‐obese women.
Materials/Methods: A single face‐to‐face structured interview was conducted with mothers who initiated breastfeeding of their singleton, term infant. Interviews typically occurred on weekdays during a six week period during the summer of 2019 based on the availability of the primary investigator. Exclusion criteria included maternal transfer to the ICU or newborn transfer out of the mother‐baby unit, death, adoption, or entrance into foster care. Data collected included: maternally reported demographics, obstetric characteristics, infant feeding attitudes and intentions, and breastfeeding practices, problems, and concern, including the seven Baby Friendly patient care practices. Mothers were categorized as obese based on early postpartum BMI> = 30.0kg/m2. Chi squared analysis and t‐tests were used to identify statistically significant differences between mothers with and without obesity (p < 0.05).
Results: Of the 79 mothers approached, 10 declined and 69 were interviewed, of which 40.6% were obese and 43.0% were primiparous. Mothers with obesity were significantly more likely to deliver at a lower gestational age, experience hypertension during pregnancy, deliver by cesarean section and report a history of breastfeeding problems. Additionally, mothers with obesity had significantly fewer breastfeeding episodes in the 24 hours prior to the interview and had longer delays before first holding their babies after delivery. There was no significant difference between obese and non‐obese mothers regarding any of the seven Baby Friendly patient care practices; however, the Baby Friendly steps least adhered to were mothers staying with their newborn 24 hours per day, breastfeeding based upon infant cues, exclusive breastfeeding unless medically indicated, and the avoidance of artificial nipples.
Conclusions: The observed differences in the early postpartum experience in mothers with obesity, coupled with a higher prevalence of previous breastfeeding problems, may contribute to shorter duration of exclusive breastfeeding in mothers with obesity. Although obese women were more likely to deliver by cesarean section, delivery mode did not explain their lower frequency of breastfeeding. We did not observe a difference in Baby Friendly patient care between obese and non‐obese women, suggesting that mothers with obesity may require additional tailored breastfeeding support.
Perinatal psychiatric symptoms and the continuum of breastfeeding in African American women
Swati Jain Goel1, Sindile Dlamini1, Thomas Mellman1, Inez Reeves1
1Howard University College of Medicine, Washington, DC, USA
Category: Research
Background: Breastfeeding has well‐established public health benefits; nevertheless, reduced rates for breastfeeding remains an important health disparity in African American communities. The burden of mental health disorders unique to African American mothers has not been fully elucidated and perinatal psychiatric disorders likely constitute important barriers to achieving the established goals for initiation, duration, continuation of breastfeeding. Of all the perinatal psychiatric disorders, depression has been the best studied but there is limited literature that addresses screening of women for a wider spectrum of perinatal psychiatric diagnoses. This study examines the relationship between perinatal psychiatric disorders on African American women's plan, initiation and continuation of breastfeeding.
Objective(s): To expand perinatal psychiatric health screening by utilizing the 'What's my M‐3 (My Mood Monitor)' ‐ a validated 27‐question checklist for mental health screening in primary care settings. The M‐3 screens for: major depressive disorder (MDD), bipolar disorder, anxiety disorder, post‐traumatic stress disorder (PTSD), suicidal ideation and measures of functional impairment. To determine the relationship between screening positive for perinatal psychiatric disorders and its impact on (i) planning to breastfeed, (ii) initiation of breastfeeding and (iii) continuation of breastfeeding.
Materials/Methods: One hundred English speaking minority pregnant women ≥18 years old were recruited from our academic health center in Washington D.C. and surveyed using the “What's my M‐3” psychiatric screening tool and breastfeeding questionnaires in the second trimester of pregnancy (plan to breastfeed), 2–3 days post‐delivery (initiation of breastfeeding) and in the postpartum period (continuation of breastfeeding). Data was analyzed to establish the relationship of breastfeeding to any positive M‐3 screen (for major depressive disorder, bipolar, anxiety and post‐traumatic stress syndrome) at corresponding time points.
Results: Plan to breastfeed and initiation of breastfeeding immediately postpartum was not different between women who screened positively for perinatal psychiatric disorders as compared to healthy women. However screening positive for perinatal psychiatric disorder(s) was associated with lower rates of breastfeeding continuation (Chi‐square = 7.32, p = 0.01). Among the disorder categories, anxiety was significantly associated with discontinuation of breastfeeding (Chi‐square = 7.17, p < 0.008).
Conclusions: Women should be screened for the full spectrum of perinatal psychiatric disorders and provided with interventions designed to assist with treatment and support of the mother‐infant breastfeeding dyad. Special attention should be paid to different ethnic groups with a focus on identifying and managing maternal anxiety to support optimal breastfeeding practices.
The Effect of Intrapartum Complications on Breastfeeding Success
Background: Breastfeeding is the normative feeding modality for human infants. The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) both recommend exclusive breastfeeding for the first six months of life with ongoing breastfeeding with addition of complementary foods through the first year of life. Breastfeeding confers numerous health benefits for both mother and baby, as well as societal and ecological benefits. Women who achieve optimal breastfeeding duration experience a 28% reduced rate of developing cardiovascular disease, as well as a 4% decrease in the risk of breast cancer per year of breastfeeding [4]. Infants also greatly benefit from breastfeeding including overall reduction of infectious morbidity in the first year of life, reduced risk for Sudden Infant Death Syndrome, the promotion of brain development, as well as lower risk of developing other condition such as childhood leukemia and asthma, in addition to decreased obesity and Type II Diabetes Mellitus later in life. Breastfeeding is also shown to promote bonding and attachment between mother‐baby couplets, decrease risk for child abuse, and improve a mother's confidence in her caregiving abilities. The benefits of breastfeeding for mother and baby appear to be well understood by expectant women in the United States as over 80% of women initiate breastfeeding following the birth of their baby. However, many women fail to achieve their breastfeeding goals. The CDC reported that in 2016 83.8% of women‐initiated breastfeeding, however by 6 months only 57.3% continued to breastfeed in any capacity. These numbers are slightly better for Iowa at 84.5% and 62.0%, respectively, but still indicate that over a quarter of women are not able to maintain breastfeeding. A study found that over 60% of mothers desired to exclusively breastfeed, with 85% of this population intending to breastfeed for more than 3 months and another 58% planned to continue well after 5 months. Out of those women who had breastfeeding as part of their plan, only 32.4% of the group were able to achieve their goal. In addition to lost health benefits, inability to achieve a breastfeeding goal is shown to be independently associated with postpartum depression. There are many systemic challenges faced by women in the United States who desire to breastfeed, however there are also physiologic challenges that could be recognized and addressed early in the breastfeeding journey. One study looked at 1532 mother‐infant dyads and the impact of postpartum anemia had on success with the initiation of breastfeeding. It found that women with postpartum anemia (hemoglobin levels of <11) were significantly less likely to be successful with breastfeeding. Women who experience preeclampsia are also found to cease breastfeeding at an earlier stage than women without preeclampsia. This may be due to delayed onset of lactogenesis in women with preeclampsia, thought to be due to edema within the breast, but also may be further exacerbated by stressful delivery, unit policies resulting in separation from her newborn, and early perceptions of ineffective feeding. Successful breastfeeding requires optimal physiologic functioning and psychologic well‐being. Literature on the impact of common intrapartum complications and their effect of successful breastfeeding is sorely lacking. This study will attempt to quantify the impact of various conditions on breastfeeding success.
Objective(s): To determine the effect that experience of various intrapartum complications (such as hemorrhage, preeclampsia with severe features, ICU admission, uterine rupture, prolonged labor, uterine infection) had on breastfeeding success among women who expressed prior intention to breastfeed. To examine interactions between complications when multiple complications are experienced by one woman. To examine for any protective effects, such as inpatient and outpatient lactation support or prior breastfeeding experience, that mitigated the harm of experience of intrapartum complications.
Materials/Methods: The study will involve a retrospective cohort analysis of women with expressed intention to breastfeed who delivered at the University of Iowa Hospitals and Clinics (UIHC) and also brought their child to UIHC for well‐child care in the first year of life. We plan to examine the delivery records of a cohort of women who meet our inclusion criteria and delivered at UIHC between January 1, 2016 and December 31, 2019. The study will utilize the Mother‐Baby DataMart [IRB #201902830] for automated data abstraction with additional manual data abstraction of infant feeding patterns as these data points are not all documented in objective fields. To minimize confounding factors, the criteria for these mother‐baby couplets will be inclusive of full‐term, singleton deliveries where the baby was admitted to the Normal Newborn Nursery. Breastfeeding intention and actual feeding method will be assessed at multiple time points: admission to Labor & Delivery, at hospital discharge, and at the 2‐week and 2‐month well child visits. Couplets with incomplete records will be excluded. Our primary interest is in first‐time mothers to eliminate the confounding factor of prior breastfeeding experience on our outcome. However, we are also interested in determining any protective effect that prior experience may carry and to this end we plan additional analyses of women who delivered more than one baby in our study period and experienced an intrapartum complication. Data abstraction will be into a secure REDCaps database. Statistical analyses with multinomial regression is planned.
Results: Pending at time of submission
Conclusions: Our hypothesis is that a range of common intrapartum complications will be found to have a deleterious effect on breastfeeding success. We anticipate, if this is confirmed, that this study will provide the groundwork for future prospective studies examining measures that can mitigate this impact and improve breastfeeding rates among women who experience complications during the labor and delivery course.
A Qualitative Analysis of Providing Low‐Income, First‐Time Mothers with a Manual Breast Pump
Adrienne Hoyt‐Austin1, Jessica Cheng1, Hana Moua1, Caroline Chantry1, Daniel Tancredi1, Laura Kair1
1UC Davis Medical Center, Sacramento, California, USA
Category: Research
Background: Low‐income first‐time mothers are known to have suboptimal breastfeeding outcomes. One potential barrier is access to a breast pump after birth.
Objective(s): To investigate attitudes and opinions regarding the breastfeeding experience and use of manual pump in low income primiparous women.
Materials/Methods: Data collection for this qualitative study followed a clinical trial (clinicaltrials.gov NCT03192241) where low‐income (eligible for the US Special Supplemental Nutrition Program for Women, Infants and Children (WIC)) participants were randomized at discharge from newborn hospitalization to receive a manual breast pump versus control intervention of a children's book. 60 participants enrolled in the study, of which half received a breast pump. Three months following the intervention, participants completed an interview regarding breastfeeding experience. 31 women (52%) responded to the thirteen open‐ended questions which were then transcribed, coded, and grouped into themes.
Results: Four themes regarding the breastfeeding experience, need for additional support, pumping experience, and reasons to stop breastfeeding were identified. Themes and example quotations are noted below. In general, breastfeeding was described as stressful, but participants also found it to be an amazing experience. A need for increased support in the immediate postpartum day and ongoing medically accurate outpatient support was reported. Manual pumps were well‐received and noted as a convenient, but time‐consuming, method to store milk. Those who stopped breastfeeding reported a cyclical decrease in milk supply with introduction of formula and/or desiring to prepare the infant for extended separation from the mother. Themes and Selected Quotations1. Breastfeeding experience: “…rewarding at first, we have grown so close. My son knows me and feels safe.” (participant 8) “I had to give up on it because it was adding to my anxiety a lot” (participant 12) “…very time consuming and sacrificial, but great bonding experience. If I'm not breastfeeding, then I was pumping, and it took too much time” (participant 34)2. Need for support: “I wish that I was still able to breastfeed and that as soon as I was to feed my baby when she was born someone would have been there to help. The hospital just left me on my own for the first few feeds resulting in lots of pain and discouragement” (participant 14) “When I was having a hard time getting baby to latch the doctor said to supplement…I wish I went to a lactation consultant instead” (participant 35)3. Pumping experience “I have my manual pump if I only want to take the pressure off, but not pump a full session. It is extremely helpful.” (participant 51)“yes, it [manual pump] was helpful so I didn't have to get up every night to feed, so that dad can help…” (participant 34) “it [manual pump] was faster than setting up the electric one…” (participant 25) 4. Reasons for stopping breastfeeding “I wasn't sure if baby was getting enough breast milk, so I supplemented with formula… I lost the breast milk supply because I didn't maintain pumping…” (participant 13)“I was starting school and work and wanted to make sure he was used to the formula if he needed it.” (participant 18)
Conclusions: While receipt of a manual breast pump did not improve breastfeeding outcomes, women in our study universally felt that provision of a manual pump at discharge should be standard of care. In addition, women endorsed a need for earlier and ongoing lactation support following discharge after birth hospitalization to help with latch, supply, and infant weight loss.
Breastfeeding continuation rates following gestational diabetes
1Women & Infants Hospital, Providence, Rhode Island, USA
Category: Research
Background: Breastfeeding is known to have a positive impact on both maternal and neonatal health. It has been demonstrated that mothers with gestational diabetes mellitus (GDM) have lower breastfeeding rates compared to mothers without diabetes but it is less clear how breastfeeding success compares between mothers who have diet controlled (A1) GDM compared to those who require medication for glucose control (A2).
Objective(s): Compare breastfeeding initiation rates between mothers with A1 and A2 GDM. Compare exclusive breastfeeding continuation rates between mothers with A1 and A2 GDM.
Materials/Methods: This is a secondary analysis of a prospective cohort study of 600 women with GDM funded by the American Diabetes Association. Eligible women were diagnosed with GDM by either a 1‐hour glucose challenge test value >200 mg/dl or by the Carpenter‐Coustan criteria using the 3‐hour 100 gram glucose tolerance test and enrolled during their delivery hospitalization. Baseline demographic, antepartum and detailed neonatal information were recorded in addition to mode of infant feeding at hospital discharge and 3 months postpartum. Breastfeeding was classified as any or exclusive breastfeeding. Women with A1 GDM were compared to women with A2 GDM using Fischer's exact test.
Results: Of the 600 women consented to participate 301 had A1 and 299 had A2 GDM. Mothers with A1 and A2 GDM had similar rates of any breastfeeding at hospital discharge (242 (80.4%) vs 228 (76.4%); p = 0.24); however, exclusive breastfeeding rates at hospital discharge were lower in A2 GDM mothers compared to A1 GDM (28.9% vs. 38.2%; p = 0.02). Similar findings were noted at three months; no difference in any breastfeeding (84.3% vs 87.5%; p = 0.28), but a difference in exclusive breastfeeding (13.9% vs 26.6%; p = <0.001). Among women who were exclusively breastfeeding at hospital discharge, exclusive breastfeeding continuation at 3 months postpartum was decreased in women with A2 compared to A1 GDM (53.3% vs 74.8%; p = 0.004).
Conclusions: Mothers with A2 GDM had decreased rates of both initiating and continuing exclusive breastfeeding postpartum compared to mothers with A1 GDM. Further investigation is needed to determine additional barriers that mothers with A2 GDM may face when attempting to exclusively breastfeed.
Contraceptive Choices and Fertility Intention among Women on Exclusive Breastfeeding in South West Nigeria
Kolade Afolayan Afolabi1, Adebukunola Olajumoke2
1Obafemi Awolowo University, Ife, Nigeria
2O.A.U. Teaching Hospitals, Ife, Nigeria
Category: Research
Background: Exclusive breastfeeding has been recognized to offer significant contraceptive protection due to associated Lactational Amenorrhea. Several women of reproductive age would have preferred to postpone or even stop further childbearing but eventually ended with unplanned pregnancies thereby contributing to high incidence of unplanned births and associated sequalae in developing countries including Nigeria where low contraceptive uptake has been reported. The increasingly high incidence of unplanned births could be attributed to widespread non‐use or in‐effective contraceptive use among these category of women despite widespread awareness. Previous research findings on reasons for low contraceptive use in Nigeria identified women's low perception on risk of pregnancy, women's perceived lack of need for contraception, opposition to contraceptive use base on cultural or religious reasons among others. There is however a dearth of information on the interplay between contraceptive choices and fertility preference among women practicing exclusive breastfeeding in this region; hence this study.
Objective(s): This study explored perception of women on exclusive breastfeeding about contraceptive choices and fertility intention; assessed the pattern of contraceptive uptake post‐partum; and identified factors associated with contraceptive choices among these women.
Materials/Methods: Study was a cross‐sectional study, employed sequential explanatory mixed method design using quantitative and qualitative data collection methods. Quantitative data were collected from 396 exclusive breastfeeding women selected through multi‐stage sampling technique. Semi structured questionnaire was used to collect quantitative data while Focus Group Discussion guide was used to conduct qualitative study. Quantitative data was analyzed using IBM SPSS software version 22 with level of significance taken at P < 0.05. Qualitative responses were analyzed and findings presented thematically.
Results: Result showed that majority of the women on exclusive breastfeeding retorted their intention to delay their next pregnancies. The women also opined that active contraception may be optional in the first six months post‐partum in view of anticipated protection offered by exclusive breastfeeding. Significant proportion of the women (69.7%) relied on Lactational amenorrhea for contraception, 20.3% used barrier method, 4.7% used intrauterine contraceptive device, 2.3% hormonal method of contraception, 0.5% used traditional methods of contraception, 1.7% calendar method and 0.8% had bilateral tubal ligation. Fifty six percent of the women solely made their contraceptive choices, 25.0% jointly made their choice with their spouse or partner, 7.8% of the women attributed their choice to previous convenience of the method, 1.4% of the women were influenced by their friends while 9.8% gave cultural and religious reasons. Women's marital status (p = 0.004, OR = 10.67, CI = 2.09–54.64), highest level of education (p = 0.04, OR = 13.8. CI = 2.33–81.38), parity (p = 0.03, OR = 0.42, CI = 0.19–0.93) and age (p = 0.01, OR = 0.25, CI = 0.10–0.66) were main predators of contraceptive use among this category of women.
Conclusions: Significant proportion of women on exclusive breastfeeding in South‐West Nigeria relied on Lactational Amenorrhea for contraception. A high level of autonomy and informed decision making about contraceptive choices and fertility intention were observed among this category of women.
Role of nutritional support and breastfeeding in neonatal intensive care units (NICUs), as indicated by decreased morbidity, mortality, and length of stay
Shereen Abd elghani1
1Faculty of Medicine, Cairo University, Giza, Egypt
Category: Research
Background: Breastfeeding has crucial role in lessening morbidity, mortality, and length of hospital stay in neonatal intensive care units (NICUs).
Objective(s): To assess the benefits of nutritional support and breastfeeding in full term infants in NICU to lessen morbidity. To assess the benefits of nutritional support and breastfeeding in full term infants in NICU to lessen mortality. To assess the benefits of nutritional support and breastfeeding in full term infants in NICU to shorten length of hospital stay.
Materials/Methods: This is a systematic review performed according to PRISMA guidelines for reporting on systematic reviews. Medline, Pubmed, Web of Science Citation Index and Cochrane Central Register of Controlled Trials Registry, were searched electronically in January 2019, using key words “Nutritional support”, “breastfeeding” and “NICU”. The inclusion criteria were studies written in English which evaluated benefits of nutritional support and breastfeeding in full term infants in NICU and their impacts on the outcomes, as indicated by decreased morbidity, mortality, and length of stay.
Results: Breastfeeding and STS lessen morbidity; indicated by increased weight gain, decreased the incidence of NEC, increased immunity reflected by decreased the nosocomial infection and neonatal septicemia, lessens mortality, and the length of stay in the NICU
Conclusions: Breastfeeding and STS lessen morbidity, mortality, and the length of stay in the NICU.
Use of Nipple Ointments and Outcomes for Managing Breastfeeding Pain
Shereen Abd elghani1
1Faculty of Medicine, Cairo University, Giza, Egypt
Category: Research
Background: Exclusive breast milk feeding for the first six months of life is recommended by multiple public health and medical organizations. Nipple pain is commonly cited as a reason woman discontinue breastfeeding. Multiple ointments are commercially marketed to soothe nipple pain, yet studies are lacking on the use of nipple ointments and adverse effects encountered.
Objective(s): 1) Identify ointments used and perceived effectiveness to soothe nipple pain and/or skin damage during breastfeeding. 2) Differentiate maternal and infant side effects that occurred with use of nipple ointments.
Materials/Methods: This is a quantitative descriptive study, women at least 18 years of age residing in the United States who breastfed at least one child within the previous 5 years were eligible to participate in the study. Data were collected using an online survey developed by the research team. Qualtrics survey software was used to design, send, and analyze data. A message including the link to the online survey was posted on breastfeeding and women's health social media sites. No incentives were provided to complete the survey. Data were analyzed using descriptive and chi‐square statistics.
Results: Over a 4‐week period, 1,866 women completed the survey. The majority of participants were white (65%), 25–34 years old (57%), and currently breastfeeding (68%). Of the total number of children reported, 92% were born full‐term. Nipple pain was the most commonly reported problem during breastfeeding with 88% women using a nipple ointment. Lanolin (71%) and coconut oil (35%) were the most frequently used ointments for cracked nipples and pain. Both ointments were reported to be effective. Skin irritation was the most common maternal side effect for both lanolin (2%) and coconut oil (<1%). Rash (1%) and refusing to nurse (1%) were common infant side effects reported by women using lanolin with only 1 report of infant rash when using coconut oil. Being a first‐time mother was significantly associated with use of any nipple ointment during breastfeeding (?2 = 15.32, p < .001).
Conclusions: Breastfeeding women routinely use nipple ointments for managing nipple pain. Both lanolin and coconut oil were reported to be effective in treating cracked nipples and pain. No significant maternal or infant side effects were reported.
The association between breastfeeding and abnormal glucose metabolism at 1 year postpartum following gestational diabetes
1Brown/Women and Infants Hospital, Providence, Rhode Island, USA
Category: Research
Background: Previous studies have suggested that increased length and intensity of breastfeeding in women with gestational diabetes (GDM) are associated with decreased risk of developing diabetes within two years of delivery.
Objective(s): We sought to investigate whether breastfeeding was associated with lower rates of abnormal glucose metabolism at 1 year postpartum in women with GDM.
Materials/Methods: Prospective cohort study which enrolled postpartum women who delivered at a single tertiary care hospital from Jan 2017 ‐ June 2018. Participants were eligible if they had GDM, spoke English or Spanish, and were >18 years of age. Consented women were surveyed immediately postpartum and at 3 months postpartum about infant feeding. They also underwent glucose tolerance testing at 4–12 weeks and had a glycosylated hemoglobin (HgbA1c) obtained at 1 year postpartum. Breastfeeding status was classified as never breastfed, any breastfeeding, or exclusive breastfeeding. Rates of abnormal glucose metabolism at 1 year postpartum (HgbA1c >5.7%) were compared between women with any or exclusive breastfeeding at 3 months postpartum compared to those who never breastfed.
Results: Women who were exclusively breastfeeding at 3 months postpartum (44/186, 24%) were more likely to be parous, college educated, thin, and had private insurance. When rates of abnormal glucose metabolism at one year postpartum were compared by breastfeeding status (HgbA1c >5.7%: 36% for no breastfeeding, 34% for any breastfeeding, p = 0.81, and 27% for exclusive breastfeeding, p = 0.57), no difference was found, even after adjusting for differences between the never breastfed and exclusively breastfed groups.
Conclusions: Women who report breastfeeding their infants at 3 months postpartum have similar rates of impaired glucose metabolism at 1 year postpartum as women who did not breastfeed at all.
Testosterone Impacts on Milk and Infant in a Lactating Transgender Individual, A Case Report
Sara Oberhelman1, Alice Chang1, Andrew Braith1, Natalie Erbs1, Aida Lteif1, Cesar Gonzalez1, Ravinder Singh1
1Mayo Clinic, Rochester, Minnesota, USA
Category: Research
Background: Pregnancy and lactation are becoming more common among transgender men. There is limited data to support the safety or danger of testosterone use during lactation, making it difficult for clinicians to make evidence‐based recommendations. There is a descriptive paper with mention of a case‐report for an individual who restarted testosterone therapy when his infant was 21 months old. The individual self‐reported that over 15 months of continued lactation, blood testosterone levels in his child remained normal and milk supply did not subjectively decrease. (MacDonald T, Noel‐Weiss J, West D et al. Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy and Childbirth. 16:106.) A study of cis‐gender lactating women who administered testosterone therapy vial vaginal cream, sublingual drops or subcutaneous pellet implant did not show measureable excretion of testosterone into breast milk and showed low levels of testosterone in infant blood samples with no adverse events for the seven months of the study. (Glaser RL, Newman M, Parsons M et al. Safety of maternal testosterone therapy during breast feeding. Int J Pharm Compd. 2009;13(4):314‐7.). The World Health Organization recommends avoiding breastfeeding with testosterone use (Anon: Breastfeeding and Maternal Medication. World Health Organization, Geneva, Switzerland, 2002.). Infant Risk categorizes testosterone as “L4 – limited data – possibly hazardous.” Micromedex states “infant risk has been demonstrated” but does not cite any literature.
Objective(s): Identify the concentration of testosterone in human milk samples before and after subcutaneous testosterone supplementation has been initiated. Evaluate for the presence of testosterone in the serum of an infant receiving human milk from a lactating parent who has initiated testosterone therapy.
Materials/Methods: This patient self‐identified as wishing to initiate testosterone therapy while continuing to lactate. After discussing the current limited data and potential risks, he wished to proceed. We recommended safety monitoring by checking his and his son's serum testosterone values and his son's growth and development periodically. We also offered measuring milk values via a study as this is not a routine lab available for clinician ordering. Evaluating milk specimens was approved by our IRB. The patient self‐expressed milk on the same day as their blood draws. He provided the milk specimens to the study team for analysis. Blood specimens were collected and evaluated for parent total testosterone, parent bioavailable testosterone and infant total testosterone. Milk samples were evaluated by mass spectroscopy using the routine testosterone acquisition method. Each sample along with routine testosterone standards and quality control and an internal standard were all run twice. Routine control and internal standards showed good accuracy and precision; the two sample values were all within 1 ng/dL of each other. Samples were collected at baseline, 4 days after initiation of testosterone (which is when peak is expected after subcutaneous administration), 14 days after initiation of testosterone and 28 days after initiation of testosterone. Samples will continue to be obtained as long as the patient continues to lactate.
Results: The patient initiated gender‐affirming testosterone therapy by subcutaneous administration of 50 mcg testosterone cypionate weekly when his infant was 13 months and 3 weeks old and continuing to receive human milk directly ad lib. At baseline, parent serum total testosterone was 14 ng/dL, parent serum bioavailable testosterone was 1.5 ng/dL, milk total testosterone (average of 2 runs) was 0.462 ng/dL and infant serum total testosterone was <7 ng/dL (lowest reported value for pediatric patients at our institution). Four days after initiating testosterone therapy, parent serum total testosterone was 171 ng/dL, parent serum bioavailable testosterone was 29 ng/dL, milk total testosterone was 8.395 ng/dL and infant serum total testosterone was <7 ng/dL. Fourteen days after initiating testosterone therapy, parent serum total testosterone was 300 ng/dL, parent serum bioavailable testosterone was 66 ng/dL, milk total testosterone was 20.85 ng/dL and infant serum total testosterone was <7 ng/dL. Twenty eight days after initiating testosterone therapy, parent serum total testosterone was 340 ng/dL, parent serum bioavailable testosterone was 85 ng/dL, milk total testosterone was 12.36 ng/dL and infant serum total testosterone was <7 ng/dL. Testosterone measurements will continue as long as the patient continues to lactate. Nine months' worth of data will be available at the time of the conference.
Conclusions: This single patient case report showed that over the first month of gender‐affirming subcutaneous testosterone therapy in a transgender man lactating for his 13 month old child, testosterone did cross into the milk but was not measureable in infant serum. Interestingly, while the milk values increased over the first two weeks, the 28 day milk value decreased despite the parent serum value continuing to increase. The infant's serum testosterone values remained undetectable throughout this study period, likely secondary to the poor oral bio‐availability of testosterone. By the time of the conference, we will have an additional 8 months' worth of data to present which will help demonstrate whether the milk testosterone values change or stabilize over time. While this study has many limitations (single patient report, initiation of testosterone was not until infant was 13 months old, unmeasured quantity of milk the child receives each day), it will certainly help clinicians and patients interested in simultaneous lactation and gender‐affirming therapy make decisions.
Impact of Lactation Consultation on Breastfeeding Rates in Women with Gestational Diabetes
1Women and Infants Hospital, Providence, Rhode Island, USA
Category: Research
Background: In patients with gestational diabetes (GDM), breastfeeding decreases the lifetime risk of type II diabetes by as much as 50%. Patients with GDM face many barriers to breastfeeding success. Lactation consultations may help to address these barriers. We sought to determine if lactation consultation during postpartum hospitalization was associated with any or exclusive breastfeeding success in women with GDM.
Objective(s): To determine if women with GDM who receive lactation consults were more likely to report any breastfeeding attempts or exclusive breastfeeding at hospital discharge compared to women who did not receive lactation consultation. To determine if women with GDM who receive lactation consults were more likely to report any breastfeeding attempts or exclusive breastfeeding at 3 months and one year compared to women who did not receive lactation consultation.
Materials/Methods: Six hundred patients diagnosed with GDM by either the Carpenter‐Coustan criteria or a 1‐hour glucose challenge result over 200mg/dl were prospectively enrolled. Patients completed surveys during delivery hospitalization and at three month follow‐up visits including questions about infant feeding. For this secondary analysis, data regarding lactation consultations were retrospectively extracted from the electronic medical record. Demographics and self‐reported breastfeeding rates were compared between women with GDM who did and did not receive lactation consultations during their postpartum hospitalization.
Results: Complete data were available for 575 pregnancies. Inpatient lactation consultations were completed for 444 (77%). Women who received lactation consults were more likely to report any breastfeeding attempts post‐partum (82.2% vs 69.5%, p = 0.002) or exclusive breastfeeding at hospital discharge (37.7% vs 21.4%, p = 0.001) compared to women who did not receive lactation consultation. Similarly, at three months postpartum, women who had lactation consultations were more likely to have continued any breastfeeding (87.8% vs 78.2%, p = 0.01) or exclusive breastfeeding (22.5 vs 13.5%, p = 0.03).
Conclusions: Inpatient lactation consultations during the immediate postpartum period are associated with improved rates of breastfeeding in women with GDM. Future work should focus on specific educational interventions to further improve breastfeeding rates.
Impact of exclusive breastfeeding on maternal body composition at 6 months postpartum
Nicole Marshall1, Katherine Au1, Kent Thornburg1, Jonathan Purnell1
1Oregon Health & Science University, Portland, Oregon, USA
Category: Research
Background: Exclusive breastfeeding (EBF) is often recommended to help facilitate restoration of pre‐pregnancy weight. However, few studies have examined the impact of EBF compared to non‐EBF on postpartum maternal weight retention or fat mass.
Objective(s): 1) Determine body composition in early pregnancy (pre‐pregnancy BMI, fat mass, body fat percent (%body fat)) and changes in body composition across pregnancy (gestational weight gain, change in fat mass, change in percent body fat) according to later EBF status. 2) Determine postpartum body composition changes (weight loss, return to pre‐pregnancy weight, change in fat mass, change in body fat percent) during the first 6 months postpartum based on EBF status.
Materials/Methods: This was a cross‐sectional study of 57 healthy mother‐baby pairs over a range of maternal pre‐pregnancy BMI enrolled at Oregon Health & Science University from October 2015 to January 2018. Women were either early enrollers (12–16 weeks gestation, n = 32) or late enrollers (>37 weeks gestation, n = 25). Weight and fat mass via air displacement plethysmography were assessed at enrollment, 37 weeks gestation, and 6 months postpartum. Modified Infant Feeding Practices II surveys were completed at 6 weeks and 6 months postpartum. Descriptive statistics were used to characterize the demographic profile of the cross‐sectional sample. Unadjusted associations between EBF and maternal body composition were analyzed.
Results: Pre‐pregnancy BMI's and demographics were similar in women who did and did not breastfeed exclusively at 6 months postpartum. However, compared to non‐EBF mothers, %body fat (and fat mass) in EBF mothers was lower in early pregnancy. This lower %body fat remained lower in the EBF mothers in later pregnancy and out to 6 months postpartum such that the change in %body fat from early pregnancy to 6 months postpartum declined in EBF mothers and increased in non‐EBF mothers (‐2.0% vs. 1.3%, p‐value 0.035). EBF and non‐EBF mothers otherwise showed no differences in gestational weight gain, postpartum weight loss, or return to pre‐pregnancy weight.
Conclusions: Our data do not support recommending EBF as a means of facilitating postpartum weight loss or restoration of pre‐pregnancy weight. Instead, we find that despite similarities in pre‐pregnancy BMI, GWG, and 6 month BMI, the body composition in women who successfully EBF differs from non‐EBF women. Lower %body fat and fat mass are already evident by early pregnancy and women who EBF experienced a greater reduction in %body fat 6 months postpartum than non‐EBF mothers. This finding suggests that, even in early pregnancy, EBF mothers may be more efficient at mobilizing fat stores and retaining lean mass than non‐EBF mothers. This might be missed when only weight and BMI measurements are utilized.
Mother's Milk Messaging™ (MMM): Mixed Methods Evaluation of Bilingual App and Texting Program to Support Breastfeeding (BF)
Maya Bunik1, Andrea Jimenez‐Zambrano1, Brenda Beaty1, Xuhong Zhang2, Susan Moore2, Sheana Bull2, Jenn Leiferman2
1University of Colorado, Aurora, Colorado, USA
2Colorado School of Public Health, Aurora, Colorado, USA
Category: Research
Background: Breastfeeding (BF) provides optimal health benefits for mothers and their infants. Most new mothers experience BF challenges but evidence‐based support online and through mobile apps is limited. We developed and evaluated an app (MMM) in English and Spanish to help mothers from late third trimester through 2 months postpartum meet their BF goals.
Objective(s): To describe engagement with the app. To determine if using the app improved aspects of breastfeeding and breastfeeding rates.
Materials/Methods: We recruited online a national sample of primiparous, singleton mothers with uncomplicated pregnancy, interested in BF, through ads and listservs. We randomized the mothers to one of three arms: 1) BF text messages plus app access; 2) BF text messages, app access, and physician‐moderated private Facebook (FB) group; and 3) Attention control group who received injury prevention texts not related to BF. We determined engagement through analysis of app usage metrics. We conducted and content coded using Atlas Ti 60 qualitative interviews with participants to learn more about app usage and BF experience. Attitude, confidence, social support and BF outcomes were determined from comparing baseline and 3‐month post‐intervention responses to a survey with validated questions. We combined 2 intervention arms because of minimal FB activity and similar outcomes.
Results: Total participants included n = 311 with the Intervention n = 201 and Control n = 110. Demographics are shown in Table 1. Greater than 80% registered the app, 40% interacted with the app on some level with greater app use after baby's birth. Mothers reported positively to receiving text messages and to reliability of information. Discontinuation of app use was common among mothers reporting early problems and no problems with BF. Women in the intervention arm reported significantly higher confidence and social support compared to the control group.
Conclusions: Highly motivated, white married women were the highest utilizers of the new MMM app despite a national online recruitment mode and the bilingual and culturally enhanced option. Mothers perceived MMM as useful and reported increased confidence and supports with breastfeeding.
Mother's Milk Messaging™ (MMM): Mothers Favor Daily Texting and Reliability of App Content in Qualitative Evaluation
Maya Bunik1, Andrea Jimenez‐Zambrano1, Sheana Bull2, Jenn Leiferman2
1University of Colorado, Aurora, Colorado, USA
2Colorado School of Public Health, Aurora, Colorado, USA
Category: Research
Background: Although the benefits and advantages of breastfeeding (BF) are known, disparities exist in BF practices from different ethnic/racial groups. We developed and evaluated an app (MMM) in English and Spanish to help mothers from late trimester through 2 months postpartum meet their BF goals. MMM includes theoretical‐based text messaging with social support features, videos and evidence‐based written content to encourage BF exclusivity and duration among first time mothers.
Objective(s): To understand the perspectives of first‐time mothers using an evidence‐based BF app. To obtain qualitative information to understand RCT outcomes as well as inform future engagement and dissemination of the app.
Materials/Methods: We conducted 60 telephone interviews with a subgroup from a total of 311 participants completing a randomized controlled trial of the breastfeeding app. We aimed questions at obtaining reactions to the app content, understanding engagement and how the app influenced their BF experience. We also explored other sources of support (providers, family, friends) on BF for these mothers. We content coded the transcripts of focused interviews and analyzed for thematic domains using Atlas Ti and then performed comparisons for concurrence and differences. Three of the four domains ‘Use of app’, ‘BF experience/journey’ and 'Timing of app content' are presented here.
Results: Demographics included mothers with mean age 29 years, 23% Hispanic, 80% White, 68% married and 90% with some post high school education. These subgroup mothers were similar to the larger trial population. Participants who accessed and engaged with the app had positive attitudes towards the usefulness of the app during their BF journey. Most participants preferred receiving the app's BF text messages as well as the texts with bidirectional quizzes. Mothers also appreciated the reliability of the information on the app. Engagement of the app varied by each individual's BF experiences. We learned that discontinuation of app use was common among mothers reporting early problems and also no problems with BF. Most mothers engaged in the app once the baby was born.
Conclusions: Perceptions of MMM text messages, content and structure were positive. Mothers struggling with breastfeeding early on may need focused direction toward in person lactation support. This qualitative information provides perspectives for the RCT outcomes as well as assists in improving future engagement and dissemination of MMM.
Is the Newborn Weight Loss Tool Clinically Useful for Predicting Excess Newborn Weight loss at Day 4 of Life?
Anna Smith1, Laura Ward2, Jane Heinig3, Kathryn Dewey3, Laurie Nommsen‐Rivers1
1University of Cincinnati, Cincinnati, Ohio, USA
2Cincinnati Children's Hospital, Cincinnati, Ohio, USA
3University of California Davis, Davis, California, USA
Category: Research
Background: Breast milk provides powerful benefits for infants. However, some newborns experience excess weight loss while breastfeeding is being established.
Objective(s): Evaluate the validity of the Newborn Weight Loss Tool (NEWT) in early identification of exclusively breastfed newborns who will eventually lose >10% of birthweight once discharged to home.
Materials/Methods: We conducted a secondary analysis of prospective data from mother‐infant dyads screened during the birth hospitalization for inclusion in the Davis, CA site of the WHO Growth Reference Study. Infant feeding and weight data were collected from birth through day of life (DoL) 4 and beyond. For our analysis, we excluded records where: newborn received >60 mL formula prior to the DoL4 home visit, relevant data were missing, or NEWT exclusion criteria were met (newborn admission to Level II or Level III care, birthweight <2000 g or >5000 g, or biologically implausible weight value recorded). We examined the sensitivity and specificity of in‐hospital newborn NEWT status in predicting newborn weight loss >10% by DoL4. We defined NEWT test‐positive status as in‐hospital newborn weight falling at or below the NEWT trajectory intersecting with eventual 10% weight loss. We defined cases as having actual weight loss >10% between birth and the DoL4 home visit.
Results: Of 280 records in the original dataset, 60 were excluded (27 did not meet NEWT inclusion criteria, 15 were missing DoL4 data, and 18 newborns received >60 mL formula). Among n = 220 eligible records, in‐hospital newborn weight was recorded at 17+/‐8 h, and DoL4 weight was recorded at 84+/‐8 h. NEWT correctly identified 6 of 28 cases of excess newborn weight loss (21% sensitivity [95% CI: 8–34%]), and 158 of 192 non‐cases (82% specificity [95% CI: 75–89%]). NEWT test‐positive status was significantly associated with the following DoL4 outcomes (P < 0.05): greater newborn weight loss, maternal perception of less breastfeeding support, and less frequent infant feeding interest. In post hoc analysis, formula use exclusions did not explain the low sensitivity, as only 3 of those 18 newborns were NEWT test‐positive.
Conclusions: The Newborn Weight Loss Tool, when applied to a single in‐hospital newborn weight at about DoL1, demonstrated poor sensitivity in identifying exclusively breastfeeding newborns who develop excessive weight loss; however, NEWT test‐positive status was associated with less favorable breastfeeding outcomes at DoL4. Further research is needed to determine the clinical usefulness of NEWT when used later in the birth hospitalization.
Predictors of the Provision of Mother's Milk Feedings in Newborns Admitted to the NICU
Lisa Marie Piwoszkin1, Megan Corley2, Karthikeyan Meganathan2, Vivek Narendran1, Laurie Rivers2, Laura Ward1
1Cincinnati Children's Hospital, Cincinnati, Ohio, USA
2University of Cincinnati, Cincinnati, Ohio, USA
Category: Research
Background: Breast milk has been shown to improve morbidity and mortality in NICU‐admitted infants. Most infants admitted to the NICU are reliant on expressed mother's own milk (MOM) and vulnerable to decreased maternal milk availability and sustainability. We sought to determine predictors of the provision of MOM in infants admitted to the NICU.
Objective(s): Determine predictors of initiation of milk expression among mothers of NICU‐admitted infants (MOM‐initiation). Determine predictors of NICU‐admitted infants receiving MOM as their first enteral feeding (MOM‐First). Determine predictors of the provision of MOM at 21 days of life or discharge (MOM‐21/DC), whichever occurred first.
Materials/Methods: We performed a retrospective chart review of inborn NICU admissions at UCMC from June 1, 2018‐May 31, 2019 and examined a comprehensive set of socio‐demographic, maternal, infant, and hospital variables to determine potential predictors of MOM‐Initiation, MOM‐First, and MOM‐21/DC. We excluded infants not directly admitted to the NICU, those never enterally fed, multiple gestation if not the first to be discharged, and infants discharged to a non‐biological caregiver. We used chi‐square analysis to examine unadjusted associations between independent variables and MOM outcomes and then used logistic regression to determine the adjusted odds ratio and 95% Confidence Interval (AOR [95%CI]) for predictors of MOM outcomes.
Results: There were 341 mother‐infant dyads who met inclusion criteria and 71% of these mothers initiated milk expression. Adjusted odds of MOM‐Initiation were significantly lower for mothers who smoked (0.16 [95% CI 0.07–0.39]), were multiparous, (0.55 [0.31–0.95]), or with shorter antepartum stays (0.41 [0.22–0.76]); and significantly higher for mothers who delivered at 28–32 weeks versus > = 33 weeks (2.35 [1.14–4.84]). Adjusted odds of MOM‐First were significantly lower for infants of mothers with gestational diabetes (0.30 [0.15–0.64]). Adjusted odds of MOM‐21/DC were significantly lower for infants of mothers with Hepatitis C (0.28 [0.10–0.75]) and significantly higher for infants with birthweight <1500 grams versus 1500–2500 grams (7.92 [1.70–36.87]).
Conclusions: In the context of a NICU setting, we identified characteristics of mothers and infants at risk for poor breastfeeding outcomes that can inform future interventions. While many NICUs have policies to ensure strong counseling regarding the benefits of MOM for very low birthweight infants, our analysis suggests that lactation support should also be prioritized for more mature infants in the NICU. Furthermore, mothers with gestational diabetes or Hepatitis C could benefit from targeted support ensuring best lactation practices should their infants require NICU admission.
Hand Expression Simulation: A Staff Education Intervention to Improve the Provision of Maternal Breast Milk for Infants Admitted to the NICU
Lisa Marie Piwoszkin1, Karthikeyan Meganathan2, Divya Denduluri2, Vivek Narendran1, Laurie Rivers2, Laura Ward1
1Cincinnati Children's Hospital, Cincinnati, Ohio, USA
2University of Cincinnati, Cincinnati, Ohio, USA
Category: Research
Background: Maternal breast milk (MOM) improves several outcomes related to infant morbidity and mortality. Many infants admitted to the Neonatal Intensive Care Unit (NICU) are reliant on pumped MOM and vulnerable to decreased milk availability and sustainability. Early initiation of hand expression is shown to increase immediate and long‐term milk supply. An assessment of lactation support knowledge gaps among NICU, labor and delivery (L&D), and postpartum (PP) nurses at the University of Cincinnati Medical Center (UCMC) revealed low confidence in instructing mothers how to perform hand expression.
Objective(s): Evaluate the effect of a targeted hand expression simulation curriculum for NICU, L&D, and PP nurses on confidence in instructing mothers to perform hand expression. Evaluate the effect of a targeted hand expression simulation curriculum on MOM outcomes in the NICU.
Materials/Methods: We implemented a hand expression workshop for nurses using a hands‐on simulator model. We compared pre and post‐training self‐assessment surveys with the Wilcoxon signed‐rank test. We used interrupted time series analysis to compare the trends for initiation of MOM expression (MOM‐initiation), first MOM expression within 6 hours postpartum (MOM‐hour), infants receiving MOM as their first enteral feeding (MOM‐first), non‐orally feeding infants receiving colostrum for oral care within 36 hours of life (COC36), and proportion of infants receiving any MOM at 21 days of life or discharge (MOM‐DC/21). We excluded outborn infants, those not directly admitted to the NICU, never enterally fed, discharged to non‐biological caregiver(s), and multiple gestations if not the first to be discharged.
Results: 105 nurses (50.5% NICU, 25.7% L&D, and 23.8% PP) were included in the analysis. There was significant improvement in confidence ratings for teaching hand expression following training, p < 0.0001. For MOM outcomes, 341 (pre n = 182, inter+post n = 159) dyads met initial inclusion criteria. Although there wasn't a significant change in pre‐ versus post‐intervention linear trends for any outcome over time, there was a significant increase in the average prevalence of MOM‐initiation (17.3% increase, p = 0.03) and MOM‐first (41.8% increase, p = 0.02) following the intervention.
Conclusions: Simulated hand expression training for nurses is a useful educational approach. There was a significant increase in initiation of milk expression and in infants receiving MOM as their first feed. Targeted training may improve hand expression skills and outcomes related to breastfeeding support in the NICU. Additional research is needed to target other MOM outcomes.
Effects of a Donor Human Milk Program on Maternal Breast Milk Rates
Smrithy Jacob1, Philip Roth1, Amanda Rahman1, Jonathan Blau1
1Staten Island University Hospital, Staten Island, New York, USA
Category: Research
Background: Human milk is the optimal source of nutrition for premature neonates and is associated with significantly decreased rates of late‐onset sepsis (LOS) and necrotizing enterocolitis (NEC). In 2017, the AAP recommended the use of donor human milk (DHM) for the very low birth weight (VLBW, ≤1500 grams) population. As more neonatal intensive care units begin utilizing DHM, it is unclear if this new practice has an effect on maternal pumping and exclusive maternal breast milk (EBM) rates in the neonatal intensive care unit (NICU).
Objective(s): To compare the rates of maternal breast feeding/EBM feeding among VLBW infants before and after the implementation of a DHM program in the Level 3 NICU at Staten Island University Hospital in 01/2017. To compare the rates of NEC pre‐ and post‐ implementation of the DHM Program in these patients.
Materials/Methods: A retrospective chart review was conducted for newborns with a gestational age ≤32 weeks and/or birth weight ≤1500 grams admitted to the NICU. The pre‐intervention cohort (N = 80) was admitted from 03/2014 – 12/2016 and the post‐intervention cohort (N = 79) from 07/2017 – 06/2019. A six month “wash‐out” period occurred after the program began in 01/2017 to allow for adequate staff education and culture change after the implementation of the new program. Chart review examined the type of enteral feeding the infant received on DOL 7, 28 and day of discharge. Feeds were recorded as EBM, DHM or formula. Proportions of the types of enteral feeds were also noted.
Results: The demographics of the pre‐ and post‐intervention cohorts were similar. In the pre‐intervention group (n = 80), there was a high use of EBM on day of life (DOL) 7 (78%), and remained high on DOL 28 (70%). This was in comparison to formula. There was a lower use of maternal breast milk in the post‐intervention group (58% on DOL 7 and 28), suggesting that mothers who initially committing to providing breast milk continued to do so but that many mothers were also relying on DHM. At time of discharge, only 28% of mothers pre‐intervention were providing exclusive breast milk, while 45% were in the post‐intervention group. We found a trend in the increased rates of NEC from pre‐ to post‐intervention (4% to 9%). Of note, during the post‐intervtuion group, there was a cluster of NEC in a few month period significantly outside normal rates. This appears to have skewed the post‐intervention data, as there have been no NEC incidents reported since this cluster.
Conclusions: After the initiation of a DHM program, we found that the use of exclusive human milk increased (with the access to DHM) but that the rates of exclusive EBM declined on DOL 7 and DOL 28 compared to when DHM was not an option. This may be due to decreased maternal pressure, knowing that DHM is available to the infant if EBM is not available. There is concern however, that this could also be due to a subconscious drop in emphasis on the importance of breast milk or education on the ICU team. Further investigation of potential causes is ongoing, and emphasis of maternal education, ensuring access to lactation and early access to a breast pump. We were reassured that there was an increase in EBM usage at time of discharge, suggesting that the use of the DHM program has helped parents to understand the importance of breast milk for the preterm infant.
Impact of a novel smartphone app on low‐income, first‐time mothers' breastfeeding rates: a randomized controlled trial
Adam Lewkowitz1, Julia Lopez2, Ebony Carter2, Hillary Duckham2, Tianta' Strickland2, George Macones3, Alison Cahill3
1Women and Infants Hospital, Providence, Rhode Island, USA
2Washington University in St. Louis, St. Louis, Missouri, USA
3University of Texas at Austin, Austin, Texas, USA
Category: Research
Background: Low‐income women are less likely to exclusively breastfeed on postpartum day two compared to high‐income women, but focus groups of low‐income women have suggested that on‐demand videos on breastfeeding and infant behavior would support exclusive breastfeeding beyond postpartum day two. Smartphone applications (apps) provide on‐demand video.
Objective(s): To determine whether a novel app—BreastFeeding Friend (BFF)—increases the rate of exclusive breastfeeding on postpartum day two for low‐income first‐time mothers. To determine whether BFF increases the rate of exclusive or non‐exclusive breastfeeding up to six months postpartum among low‐income first‐time mothers. To determine what low‐income first‐time mothers reported providing the most breastfeeding support at various postpartum intervals.
Materials/Methods: This double‐blinded randomized trial recruited low‐income first‐time mothers at 36 weeks gestation. Consenting women received a complimentary Android smartphone and internet service before 1:1 randomization to BFF or a control app. BFF was created by a multidisciplinary team of perinatologists, neonatologists, lactation consultants, and a middle‐school teacher and was refined by end‐user focus groups. BFF contained on‐demand education and videos on breastfeeding and newborn behavior, tailored to a 5th‐grade reading level. The control app contained digital breastfeeding handouts. The primary outcome was exclusive breastfeeding on postpartum day two; secondary outcomes were breastfeeding rates until 6 months postpartum and patient‐reported best breastfeeding resource. Primary statistical analyses compared outcomes between study groups via intention‐to‐treat; pre‐specified secondary analyses did so per‐protocol. 170 women (85 per arm) were needed to detect whether BFF increased exclusive breastfeeding at postpartum day two from 34% (known baseline) to 56%. The study was registered on clinicaltrials.gov (NCT03167073).
Results: 253 women were approached; 170 women enrolled. Most participants were Black, and more than half reported annual household incomes <$25,000. Exclusive breastfeeding rates on postpartum day two were low and similar among BFF and control app users (n = 30 (36.6%) vs n = 30 (35.7%); relative risk (RR) 1.02 (95% Confidence Interval (CI) .068 – 1.53)). Breastfeeding rates until six months postpartum were also similar between study groups: the rate of exclusive breastfeeding was 8.3% (n = 5) and 10.4%) (n = 7) in the BFF and control app group, respectively (RR 0.8 (95% CI 0.27 – 2.38)). At six weeks postpartum, the majority of BFF users (n = 34 (52.3%)) rated their app as providing the best breastfeeding support. Excluding women who did not utilize their study app (BFF n = 18 (21.4%); control app n = 9 (10.6%)) did not affect outcomes.
Conclusions: Neither app improved breastfeeding rates among low‐income first‐time mothers above the known baseline rates, despite user perception that BFF was the best breastfeeding resource at six weeks postpartum. By demonstrating the feasibility of app‐based interventions within a particularly high‐needs population, our research supports efforts in obstetrics to examining whether mobile health improves peripartum health outcomes.
Does increased use of breastfeeding smartphone applications improve breastfeeding rates among low‐income women?
Laurie Griffin1, Julia López2, George Macones2, Alison Cahill2, Adam Lewkowitz1
1Women and Infants Hospital/Brown University, Providence, Rhode Island, USA
2Washington University in St. Louis, St. Louis, Missouri, USA
Category: Research
Background: Low‐income women are less likely to breastfeed compared to high‐income women. Complex and simple technology‐based interventions have both shown promise in decreasing postpartum health disparities. We aimed to determine whether increased use of breastfeeding smartphone applications (apps) impacts breastfeeding rates for low‐income women.
Objective(s): To determine if breastfeeding initiation differed between the highest and lowest quartiles of breastfeeding app users. To determine if use of the breastfeeding app improved exclusive and sustained breastfeeding until 6 months postpartum between the highest and lowest quartiles of breastfeeding app users.
Materials/Methods: This is a planned secondary analysis of an RCT including nulliparous, low‐income English‐speaking women at 36 weeks. In the parent trial, consenting women were randomized to one of two apps: a skeleton app containing digital breastfeeding handouts and BreastFeeding Friend(BFF), an app designed to provide postpartum support via on‐demand educational and video content. A secure website tracked app usage. For this study, women were stratified into usage quartiles by app. The highest quartile of BFF and skeleton app users were combined into one group. The lowest quartile of each app's users were combined into another group. Outcomes were compared between the highest and lowest quartiles of breastfeeding app users.
Results: Among 169 women in the parent study, usage was similar in both apps (median 15 uses (Interquartile Range (IQR) 15 – 50 for BFF vs 19 uses (IQR 9 – 30) for skeleton app; p = 0.1). This study included 44 women and 41 women in the highest and lowest app‐usage quartiles, respectively. Breastfeeding initiation did not differ with app usage (84.1% (n = 37) in highest quartile vs 78.2% (n = 32) for lowest quartile; p = 0.5). Rates of sustained and exclusive breastfeeding from two days postpartum until six months postpartum were similar in the two groups.
Conclusions: Increased usage of breastfeeding smartphone applications did not improve breastfeeding rates among low‐income women. In this high‐needs population, complex postpartum environmental factors may decrease the effectiveness of technology‐based interventions attempting to increase breastfeeding equity.
Four Years after Donor Milk Implementation in Our Mother‐Baby Unit: How Are We Doing?
Rana Alissa1, Patty Williams1, Erika Baker1, Anuta Ciurte1, Carmen Smotherman1
1University of Florida Jacksonville, Jacksonville, Florida, USA
Category: Research
Background: The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for the first 6 months of life minimum. Many studies showed that in‐hospital exclusive breastfeeding after birth is the key for a successful 6 months and beyond duration of exclusive breastfeeding. Neonatal hypoglycemia, physiologic neonatal jaundice, physiologic delay in colostrum production, weight loss, and maternal exhaustion are some of the causes that necessitate formula supplementation; which interrupts the numerous benefits of exclusive breastfeeding and fall against WHO and AAP recommendation. Replacing formula with donor milk offers a bridge to balance the neonatal need for feeding supplementation without interrupting exclusive breastfeeding.
Objective(s): Study the effect of donor milk's supplementation on the rates of exclusive breastfeeding at the time of discharge from the Mother‐Baby Unit. Compare the exclusive breastfeeding rate at the time of discharge from the Mother‐ Baby unit before and after donor milk implementation.
Materials/Methods: This project was conducted at the University of Florida in Jacksonville, and it was approved by the Institutional Review Board. Donor milk was implemented in our Mother‐Baby unit in October 2015. We collected the exclusive breastfeeding rates at the time of discharge from the hospital four years before and four years after donor milk implementation. The monthly breastfeeding rates were used to calculate the average rate of breastfeeding and its 95% confidence interval (CI) for each time period. The averages breastfeeding rate between the before‐ and after‐implementation were compared using the Wilcoxon rank sum test.
Results: On average, the breastfeeding rate was higher post‐implementation (average 45.9%, 95%CI 44.3%, 47.6%) compared to pre‐implementation (average 25.0%, 95%CI 23.5%, 26.49%, p < .0001).
Conclusions: The donor milk increased exclusive breastfeeding rates during the four years after its implementation.
Preliminary results from a survey of the pharmacologic, herbal, and nutritional galactagogue prescribing practices of physicians in the United States and Canada
Anna Sadovnikova1, Jane Sommers2, Sara Oberhelman3
1University of California, Davis, Davis, California, USA
2Dalhousie University, Nova Scotia, Canada
3Mayo Clinic, Rochester, Minnesota, USA
Category: Research
Background: One of the most common reasons for premature cessation of breastfeeding is insufficient milk production. Healthcare providers and mothers often turn to medications, foods, vitamins, and herbs to increase milk production; however, there is limited evidence regarding the efficacy and safety of any potential galactagogue. The United States (US) Food and Drug Administration (FDA) has issued a black box warning regarding the pharmacologic galactagogue, domperidone. To build the evidence‐base for the utilization of galactagogues, it is important to characterize and compare the current state of galactagogue knowledge, beliefs, and prescribing practices of physicians in the US and Canada.
Objective(s): 1) Characterize the current state of pharmacologic, herbal, and nutritional galactagogue knowledge, beliefs, and prescribing practices of physicians in the US and Canada. 2) Compare the galactagogue knowledge, beliefs, and prescribing practices between physicians in the US and Canada. 3) Describe the association between a physicians' breastfeeding experience and their likelihood to discuss, recommend, or prescribe various potential galactagogues.
Materials/Methods: The Mayo Clinic Institutional Review Board approved the study design and instrument (RedCap). Study participants were physicians recruited from the Dr. MILK (Doctor Mothers Interested in Lactation Knowledge) Facebook group. The survey consisted of 5 sections with questions about demographic information and prior breastfeeding experience and practice patterns related to potential galactagogues: pharmacologic agents, herbal supplements, vitamins and minerals, and foods. Participants were asked to report on whether and why they had ever discussed, recommended, or prescribed various galactagogues, how certain conditions (eg. poor access, lack of research) may limit their practice, and which conditions (eg. more education, quality control) would encourage them to incorporate galactagogues into their clinical practice. The association (odds ratio, OR) between a study participant's geographic location (Canada or US) and their likelihood to discuss, recommend, or prescribe a galactagogue was determined using Fisher's Exact Test, with ‘never’ as the reference group.
Results: A total of 314 study participants completed the pharmacologic galactagogue section, with 263 physicians from the US and 43 from Canada. Physicians in the US were more likely to discuss (OR 7.45, P = .002) and prescribe (OR 6.8, P = .03) metoclopramide. Canadian physicians were more likely to discuss (OR 9.6, P < .0001), recommend (OR 28.3, P < .0001), and prescribe (OR 67.8, P < .0001) domperidone. Canadian physicians were also more likely to prescribe levothyroxine (OR 5.5, P = .003) and metformin (OR 4, P = .01) to increase milk supply.
Conclusions: Given the US FDA's ban on the use of domperidone for increasing milk production, it is not surprising that physicians in the US are more likely to utilize metoclopramide while Canadian physicians prescribe domperidone. Next steps in data analysis are to define the association between a study participant's geographic location or breastfeeding experience and their likelihood to discuss, recommend, or prescribe various galactagogues.
Qualitative study exploring the LGBTQI parental experience with infant nutrition in the setting of current breastfeeding guidelines
Jason Jackson1, Lissette Moreno1, Rita Dadiz1
1University of Rochester, Rochester, Minnesota, USA
Category: Research
Background: Nationally, 4.5% of the population identifies as Lesbian, Gay, Bisexual, Transgender, Queer or Intersex (LGBTQI), with 29% raising children. However, healthcare providers are ill‐equipped to adequately support LGBTQI parents on infant nutrition and alternative feeding methods. Currently available research remains very limited from both the healthcare provider and parental perspective.
Objective(s): To explore resources sought after and provided to LGBTQI parents regarding feeding options and alternative feeding methods during the prenatal, perinatal and early postpartum periods. To identify challenges, both universal and unique, that LGBTQI parents face in attempts to successfully meet their infant feeding goals. To identify areas in which healthcare providers have the opportunity to more fully support LGBTQI parents in their infant nutrition decision making.
Materials/Methods: We conducted a qualitative study of semi‐structured interviews of LGBTQI parents with a <1‐year‐old infant. Using convenience sampling, we recruited parents in‐person, via Facebook and from a Clinical and Translation Science Institute research database. Interview questions were iteratively revised, focusing on parental support, resources, decisions and overall experience around infant nutrition during the prenatal to neonatal period. We interviewed parents primarily via Zoom videoconferencing, though face‐to‐face interviews were offered when available based on the family's location. Interviews were audio recorded, de‐identified, and transcribed verbatim. We inductively analyzed transcripts using grounded theory, applying immersion and crystallization cycles to identify and verify emergent themes. During this process, they developed visual aids to conceptualize the relationship between themes and subthemes. To support the trustworthiness of data analysis, a third party reviewed the codes for >75% of the transcripts and participated in group discussions regarding emerging themes and subthemes. The investigators maintained an audit trail of the coding process. Interviews continued until thematic saturation was met, which was determined by agreement between co‐investigators.
Results: We conducted 12 interviews with families, with a mixture of parental dyads together and only one parent, for a total of 17 participants. Of the individuals interviewed, all were married and Caucasian and non‐Hispanic. The majority of the participants were cis‐gender females (80%) and identified as homosexual (70%) which is typical of prior studies involving LGBTQI parents. Uniquely we also had 10% of male respondents and 10% gender non‐binary/gender‐queer participants. No infant was hospitalized for more than a week. Respondents resided in New York, Connecticut, Vermont, North Carolina, Maine, and Washington State. Preliminary results revealed the following themes:‐ Sources of nutrition support: Parents shifted their primary sources of information from the internet prenatally to counseling by nurses after delivery. Counseling did not include LGBTQI‐specific information. ‐ Traditional versus alternative feeding methods: Limited information about alternative feeding methods such as induced lactation and simulated nursing systems was available. Parents generally believed their options consisted of breastfeeding by the gestational parent or formula feeding. ‐ Unexpected challenges; universal versus unique: Limited support left many parents feeling unprepared for unexpected challenges when breastfeeding at home. ‐ Inclusion of the non‐gestational parent: Level of involvement of the non‐gestational parent in the perinatal period to a greater extent than during the early prenatal period had a greater influence on the non‐gestational parent's feeling of inclusion and ability to bond with the infant. ‐ Implicit biases: Perceptions of normative feeding plans and the environment in which families live influenced parental attitudes and decisions. ‐ Need for open communication: A common thread throughout all themes was that much of the work self‐guided research being done by the parents was not being shared with the health care team and the health care providers in general did not ask questions regarding parental feeding wishes. This is a primary area of focus where future opportunities to improve could be explored in the support of LGBTQI parents.
Conclusions: LGBTQI parents faced challenges obtaining infant nutrition options and support. Opportunities exist for healthcare providers to increase their knowledge of feeding options and challenges faced by LGBTQI parents to better help them. These opportunities, though diverse among the LGBTQI community, share a commonality in the reliance on open and bias‐free communication between the parents and all members of the health care team.
Breastfeeding attitudes and practice amongst mothers with neonates with congenital heart disease
1Columbia University Medical Center, New York City, New York, USA
Category: Research
Background: The health advantages of breastfeeding in the general population are well‐documented. Breastfeeding may play an important role in infants with congenital heart disease (CHD). To our knowledge, attitudes regarding breastfeeding in mothers with infants with CHD (CHD mothers) have not been previously assessed. A better understanding of breastfeeding determinants may improve nutritional practices for infants with CHD.
Objective(s): We aimed to assess attitudes towards breastfeeding in CHD mothers using the Iowa Infant Feeding Attitude Scale (IIFAS). We sought to identify modifiable barriers to breastmilk consumption in infants with CHD.
Materials/Methods: This is a prospective observational pilot study. English‐speaking mothers of well‐babies and CHD infants were enrolled. IIFAS was used to assess maternal attitudes toward infant feeding and the Edinburgh Postnatal Depression Scale was used to assess for postnatal depression. We collected demographic data, information about mothers' prior feeding experiences and ideal feeding plans, and CHD medical data. Mothers completed surveys and questionnaires after birth and at 3 months.
Results: We enrolled 59 well‐baby and 25 CHD mother‐infant dyads. Follow‐up data were available on 33 dyads from the well‐baby and 24 from the CHD group; 6 patients from the CHD group remained hospitalized at follow‐up. Compared to the well‐baby group (63.7 ± 7.3), the CHD mothers scored higher on the attitude survey at birth (67.3 ± 6.6) (p = 0.04). At follow‐up, 22/33 (67%) well babies and 17/24 (71%) CHD babies were consuming breastmilk (p = 0.12). Of the CHD babies discharged by the time of follow‐up, there was a non‐significant difference noted in hospital length of stay (days) between those consuming only formula (n = 5) (median 13, IQR 13–19) compared to any amount of breastmilk (n = 13) (median 33, IQR 15–52) (p = 0.17). Of the CHD babies who were consuming only formula vs any breastmilk at follow‐up, the mothers' Iowa Infant Feeding Attitude Scores were significantly different at birth (60.85 ± 5.64 vs 70 ± 5.02; p = 0.0007) and at follow‐up (57.5 ± 4.37 vs 67.75 ± 5.66; p = 0.0013).
Conclusions: CHD mothers scored higher on the breastfeeding attitude survey than the nursery mothers. Mothers of CHD infants may be more interested in breastfeeding their babies compared to mothers of children without CHD. Most CHD mothers had prior breastfeeding experience and were perhaps more motivated to continue providing a diet consisting of any amount of breastmilk for their infants. Interestingly, within the CHD group, we noted significantly lower breastfeeding attitude scores in mothers that provided an only‐formula diet compared to mothers that provided a diet containing some amount of breastmilk. The IIFAS breast feeding attitude score may be helpful for identifying mothers who may need interventions to increase breastmilk consumption in their CHD infant. Future research should devise interventions to support mothers who want to breastfeed their infants with CHD.
Lack of Permanence in Measures of Secretory Activation in Breast Pump Dependent Mothers of Premature Infants in the First 14 Days Postpartum
1Rush University Medical Center, Chicago, Illinois, USA
Category: Research
Background: Breast pump‐dependent mothers who give birth to premature infants cared for in the newborn intensive care unit (NICU) experience delayed or impaired secretory activation (SA) and achievement of coming to volume (pumping ≥500 mL daily by postpartum day 14). Little is known about the relationship among pumping behaviors, pumped milk volume and the permanence of SA as measured by milk Na: K ratios (Na: K ratio <1.0).
Objective(s): To describe the lack of permanence in initial achievement of SA and subsequent re‐achievement of SA in 3 breast pump dependent mothers of premature infants during the first 14 days postpartum, using precise measures of pumping behaviors, pumped milk volume, and milk Na: K ratio.
Materials/Methods: This ongoing prospective observational study measures pumping behaviors (daily pumping frequency and total minutes pumped), pumped milk volume (nearest 0.1 mL) and daily maternal milk Na and K concentrations (LAQUA Twin Sodium and Potassium Meters; Horiba, Ltd, Kyoto, Japan) during the first 14 days postpartum in breast pump‐dependent mothers of premature infants (<33 weeks gestation). Pumping behaviors and pumped milk volume were measured electronically using an adapted Symphony Breast Pump (Medela, AG, Switzerland) with implanted microchip technology to capture these measures. Of an anticipated sample of 30 mothers, 10 mothers have completed all study requirements. Of these 10 mothers, the data for 3 mothers revealed achievement and re‐achievement of SA over the first 14 days postpartum. These data were graphed over the 14‐day study period to examine the relationships among the variables of interest.
Results: Of the 10 subjects (50% Black, 40 % White, 10% other), the mean maternal age and infant gestational age were 30 ± 5.7 years and 29.8 ± 2.3 weeks, respectively, and maternal pre‐pregnancy BMI was 32.8 ± 7. Nine of the ten mothers achieved SA, all between days 3 and 6. However, data from 3 of these 9 mothers revealed that 2 achieved SA on postpartum day 4, and 1 on postpartum day 6. For the 3 mothers, achievement of SA was not permanent (Na: K ratio ≥1) over the 14 days. In each case, the reversal preceded a brief interval (1–2 days) of decreased daily pumping frequency and total minutes pumped, but without an abrupt decrease in pumped milk volume. Each mother attributed the brief interruption in pumping to common clinical scenarios for this population: a lengthy doctor's visit for pregnancy complications that resulted in 2 missed pumping sessions; a single day caring for children in the home when pumping frequency decreased from 5 to 1; and the decision to stop pumping entirely after having pumped >1300 mL only 5 days earlier. In each instance a NICU nurse intervened, the mothers' improved pumping behaviors and Na: K ratios returned to <1.0 within 1 day of the nurse's intervention.
Conclusions: For the first time we report the lack of permanence in achievement and reversal of SA during the first 14 days postpartum in 3 breast pump‐dependent mothers of premature infants. Once achieving SA, brief interruptions in pumping behaviors resulted in a reversal of SA, which was re‐achieved within one day following timely, targeted interventions. These data contribute critical information to the importance of establishing lactation in the first 14 days postpartum in this vulnerable population and highlight the potential utility of using Na: K ratios as point‐of‐care intervention in the clinical setting.
Perceptions of Lactation‐Related Discrimination Experienced by Physician Mother Trainees
1Stanford Children's Health, Stanford, California, USA
Category: Research
Background: There is growing recognition in the medical literature of female physicians as a particularly at‐risk breastfeeding group. Due to a variety of unique barriers in the workplace, physician mothers are less likely to meet their desired breastfeeding goals, despite federal, state, and local policies that may exist to protect them. In addition, aggregate survey data suggests that instances of maternal bias and discrimination in the workplace are high, often directly related to pregnancy, maternity leave, and breastfeeding practices. Female physician trainees have reported even more pronounced barriers than their faculty counterparts. Our study aims to complement existing quantitative data by describing the lived experience of trainees who are pumping/breastfeeding at work.
Objective(s): Explore the experience of female trainees as they navigate lactation at work while fulfilling clinical duties, and better understand workplace culture as it relates to lactation. Describe perceptions of lactation‐related bias or discrimination witnessed or experienced. Summarize barriers and strategies for improving the institutional environment surrounding lactation.
Materials/Methods: This is an IRB‐approved, exploratory study using qualitative methods with a phenomenological framework. Data will be analyzed through the lens of Cruess et al.'s conceptual model of professional identity formation in medicine, with particular focus on factors that impact socialization in the workplace. We are conducting semi‐structured focus groups of physician mother trainees (residents and fellows) across disciplines within the Stanford housestaff community between January and May 2020. To meet inclusion criteria, participants must self‐report breastfeeding (includes pumping) at some time during their current residency or fellowship training. Questions were developed using extensive literature review and consensus of experts in both medical education and lactation to appropriately address study objectives. Sessions are audio recorded and transcribed verbatim. Two authors will independently code transcripts, with validation by a third author for consensus of thematic analysis and by member checking for accuracy.
Results: To date, no prior studies have explored the collective experience of breastfeeding trainees across disciplines at Stanford. We anticipate that female resident and fellow trainees will describe their personal experiences navigating lactation and work, including any instances of maternal bias and discrimination they have encountered. Three focus groups have been conducted thus far, with a fourth in progress. Data analysis is expected to be completed by the end of June 2020. We hope our study will highlight opportunities to promote workplace culture change and help inform ways institutions can enhance their support of physician mothers.
Conclusions: This study remains in‐progress. Based on results, we will summarize the collective lived experience of physician trainee mothers and use their voice to directly identify opportunities to better support breastfeeding women in medicine moving forward.
Comparison of growth and morbidities in extremely low gestational age infants fed sterilized shelf‐stable versus Holder pasteurized donor human milk
Sarah Jordan‐Crowe1, Melindy Dorcin2, Cheryl Thompson2, Deanne Wilson‐Costello1, Jessica Madden1
1Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
2Case Western Reserve University, Cleveland, Ohio, USA
Category: Research
Background: Preterm infants are known to be at increased risk of poor growth and other morbidities, including sepsis and retinopathy of prematurity (ROP), which is partly mitigated with human milk. The protective role of human milk is especially important in the smallest neonates who are at highest risk. However, it is unknown whether these benefits extend to donor human milk (DM), especially when processed using retort methods (involving a higher temperature and pressure to make the product shelf‐stable). Retort sterilization (used in commercially available DM products) has been shown to significantly reduce levels of protein, human milk oligosaccharides, antimicrobial proteins, and antibodies compared to milk which has been processed using the Holder pasteurization method (utilized by the Human Milk Banking Association of North America). To date, there is not any published data comparing neonatal outcomes of patients fed Holder pasteurized DM versus DM sterilized via retort methods.
Objective(s): Compare growth in infants less than 27 weeks gestational age (GA) fed sterilized vs pasteurized donor milk products. Compare sepsis and development of severe ROP in infants less than 27 weeks GA fed sterilized vs pasteurized donor milk products.
Materials/Methods: We performed a retrospective cohort study of all infants less than 27 weeks GA admitted to our urban Level 4 NICU (Cleveland, OH) from January 2014 – December 2018 who were being fed DM at 28 days of life. There was an institutional change in DM in June 2016 (from pasteurized to sterilized). Infants were grouped according to the type of DM they received. Those with congenital malformations were excluded. Severe ROP defined as ROP requiring anti‐VEGF treatment or laser surgery. Sepsis defined in accordance with the neonatal Vermont‐Oxford Network (VON). Statistical significance assessed using a t‐test or Fisher exact test.
Results: There were 51 infants who met inclusion criteria and 2 were excluded due to congenital anomalies. Of the remaining 49 infants, 31 were fed sterilized DM and 18 were fed pasteurized DM. The infants had a mean GA of 25.1 weeks and birthweight of 790g (neither of which differed significantly between the two groups). Infants in both groups had the same rate of daily weight gain (22.9g for both, p = 0.98). The infants fed sterilized DM had a significantly decreased rate of weekly head growth (70mm) compared to those who received Holder pasteurized DM (77mm, p = 0.03). There was also a trend (although statistically insignificant) toward increased rates of both sepsis (10% vs 0%, p = 0.29) and severe ROP (17% vs 11%, p = 0.7) in the retort sterilized group compared to pasteurized.
Conclusions: The decreased head growth in neonates who received sterilized shelf‐stable DM rather than pasteurized DM is clinically significant. It may have implications for worsened neurodevelopmental outcomes given the known association between the two. The trend toward increasing rates of sepsis and severe ROP in infants fed sterilized DM is also concerning. It suggests the need for studies with increased sample sizes for additional power to detect statistical differences.
US women's awareness that breastfeeding reduces breast cancer risk
Adrienne Hoyt‐Austin1, Laura Kair1, Melanie Dove1, Renata RA. Abrahao1, E. Bimla Schwarz1
1UC Davis Medical Center, Sacramento, California, USA
Category: Research
Background: It is widely accepted in the medical community that mothers who breastfeed their infants are less likely to develop breast cancer. However, it is not known if US women have awareness that breastfeeding is a modifiable protective factor in the prevention of breast cancer.
Objective(s): To estimate the prevalence of US women's awareness that breastfeeding protects against the development of breast cancer. To estimate differences in awareness that breastfeeding protects against the development of breast cancer among women with and without a personal history of breast cancer.
Materials/Methods: We conducted a population based cross‐sectional study using a weighted sample of 5554 female participants of the National Survey for Family Growth aged 15–49, years 2015–2017. Multivariable logistic regression was used to examine associations between age, parity, breastfeeding history, race, ethnicity, US birth, education, income, prior mammogram, family history of breast cancer, personal history of breast cancer, and tobacco and alcohol use and women's awareness of this modifiable risk factor.
Results: Only 38.5% of US women were aware that breastfeeding reduces risk of breast cancer. In women without a history of breast cancer (N = 5519), nulliparous women (29% vs 46%, aOR = 0.52, 95% CI = 0.37–0.71), parous women who never breastfed (29% vs 55.1%, aOR = 0.43, CI = 0.31–0.58), those with a high school education or less (34% vs 46%, aOR = 0.64, 95% CI = 0.53–0.77), and US born Hispanic women (33% versus 39%, aOR = 0.68, 95% CI = 0.52 – 0.89) were less likely to be aware that breastfeeding reduces risk of breast cancer. Black (46% vs 39%, aOR 2.72, 95% CI = 1.28 – 5.77), and Hispanic (55% vs 39%, aOR 1.88, 95% CI = 1.39–2.54) women born outside of the US were more likely to have awareness of the protective effect of breastfeeding. In women with history of breast cancer who had not breastfed, none (0 or 6 participants) were aware that breastfeeding reduces risk. Awareness of this modifiable risk factor did not vary by family history of breast cancer, prior receipt of mammogram, alcohol use, or smoking status.
Conclusions: Almost two‐thirds of US women remain unaware that breastfeeding reduces risk for breast cancer. When providing preconception counseling and lactation support, it is of vital importance that clinicians mention to women the dose‐dependent breast cancer risk reduction that breastfeeding provides.
Parental Perceptions and Patterns of Cannabis Use During Pregnancy and Breastfeeding at a Canadian Tertiary Obstetrics Centre
Anne Drover1, Sarah Manning1
1Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
Category: Research
Background: On October 17th, 2018, recreational cannabis use became legalized in Canada. Tetrahydrocannabinol (THC) is the main psychoactive compound in cannabis. It has the ability to cross the placenta and enter fetal tissues during pregnancy and accumulate in breast milk postpartum. There is limited research on the long‐term effects of cannabis use, particularly on the developing brain. Canadian guidelines recommend that women who are thinking about becoming pregnant, pregnant, or breastfeeding should abstain from using cannabis.
Objective(s): The objective of this study was to investigate parental perceptions of cannabis use during the pre‐ and post‐natal periods. The objective of this study was to investigate parental patterns of cannabis use during the pre‐ and post‐natal periods.
Materials/Methods: Participants were recruited from the women's health unit at a tertiary care centre; 103 patients or partners of patients who were currently pregnant or less than 6 months post‐partum were enrolled in the study. Participants consented to complete an anonymous, online questionnaire including previously validated demographic questions and newly developed questions on cannabis use during pregnancy and breastfeeding. Descriptive statistics and chi‐square tests were used for data analysis.
Results: Overall, 5.0% of pregnant women and 6.3% of breastfeeding women used cannabis daily or weekly. Cannabis use during pregnancy was found to be significantly associated with lower level of education (p < 0.0001), cannabis use prior to pregnancy (p < 0.05), and smoking or vaping tobacco during pregnancy (p < 0.001; p < 0.0001). Among all participants, 22.3% and 30.0% believed there was no harm or were unsure of the harm associated with cannabis use during pregnancy and breastfeeding, respectively. All of the women who used cannabis during pregnancy or breastfeeding indicated that knowledge of the possible effects on the fetus or child would decrease their cannabis use. The majority of participants reported obtaining their information on cannabis use during breastfeeding from the internet (51.5%); while only 12.9% reported receiving information from a family doctor, 7.9% from an OBGYN, and 3.0% from a pediatrician. Legalization of cannabis had no reported effect on cannabis use during pregnancy and breastfeeding for the majority of participants.
Conclusions: It is clear that parents lack information about the safety of cannabis use during pregnancy and breastfeeding. Perinatal counselling should put an emphasis on educating parents on the risks associated with cannabis use during fetal development. In addition, given the overwhelming benefits of breastfeeding, harm reduction approaches to cannabis use while breastfeeding should be investigated.
Short‐Term Neonatal Outcomes of Colocating and Breastfeeding Infants of Mothers Who Tested Positive for SARS‐COV‐2
Parvathy Krishnan1, Lawrence Noble1, Uday Patil1
1Icahn School of Medicine at Mount Sinai, New York City, New York, USA
Category: Research
Background: There is a paucity of data on the neonatal outcomes of maternal SARS‐COV2 infection which has emerged as a pandemic spreading rapidly across the world. Further, conflicts in current guidelines exist on whether to routinely separate infants from infected mothers in the hospital, to utilize shared decision‐making to regulate care or to encourage exclusive breastfeeding and standard feeding guidelines for these infants. At our hospital in New York City which has been the epicenter of the infection in the US, shared decision‐making between the mother and clinical team was utilized. Mothers who elected to room‐in were encouraged to initiate skin‐to‐skin care and follow routine breast‐feeding practices while following strict hand washing and use of masks. Infected mothers who were restricted from NICU and mothers of isolated infants were encouraged to provide pumped breastmilk. We aimed to elucidate the outcomes of the infants born to mothers with COVID‐19 infection following these practices.
Objective(s): To assess the outcomes of the infants born to mothers with COVID‐19 infection. To assess the rates of direct breast feeding in the infants born to mothers with COVID‐19 infection.
Materials/Methods: We identified all neonates born to mothers who were tested positive for SARS‐CoV‐2 from March 19 to April 22, 2020 at Elmhurst Hospital Center. All infants were tested by nasopharyngeal PCR swabs. Data regarding demographic, epidemiologic, clinical features, breastfeeding practices and short‐term outcomes including outpatient follow up through tele‐medicine or in‐person visits were obtained by retrospective chart review of medical records.
Results: Among 118 mothers tested during the study period, 45 (38%) of mothers tested positive of which 18(40%) was asymptomatic. All the infants were screened for SARS‐CoV‐2 and none were positive. 3 infants initially tested positive for SARS‐CoV‐2 on a screen at <24 hours of age, but tested negative on 2 repeated screens and were considered false positives. All the infants were asymptomatic for COVID‐19 in the hospital. Demographic characteristics are described in Table 1. 33 babies were roomed with the mother while 7 required NICU admission. 5 newborns were isolated from the mother at birth due to maternal request. 31 infants were breastfed directly, 9 received expressed breastmilk and 5 did not receive any breastmilk. 41 babies were discharged to the same household as mother, one is still in the hospital and 3 were discharged to a different household (Table 2). During follow up, there was a 93% adherence to the initial in‐person newborn visit while there was a 100 % compliance to the tele‐medicine visit around 14 days. All infants were asymptomatic at follow up visits and none had COVID‐19 related emergency department visits or subsequent hospital admissions.
Conclusions: We report no short term adverse neonatal outcomes to skin‐to‐skin care, rooming‐in or breastfeeding in infants of SARS‐CoV‐2 positive mothers in our population. Although this data is preliminary, it could help decide best practices for these infants.
Helping Early Bloomers: Evaluation of a late preterm breastfeeding support program
Katherine Standish1, Ginny Combs2, Lisa Zani2, Cheryl Slater2, Barbara Philipp1
1Boston University, Boston, Massachusetts, USA
2Boston Medical Center, Boston, Massachusetts, USA
Category: Research
Background: Late preterm infants (LPI) have lower breastfeeding rates than term infants, yet few studies have evaluated LPI breastfeeding interventions. In April 2019, Boston Medical Center, a Baby‐Friendly designated hospital since 1999, implemented the Early Bloomer Program, an interdisciplinary, hospital‐based breastfeeding support program among LPI not requiring intensive care.
Objective(s): Measure differences in feeding outcomes among LPI who did and did not receive the Early Bloomer Program. Measure differences in neonatal outcomes among LPI who did and did not receive the Early Bloomer Program.
Materials/Methods: The Early Bloomer Program includes an order set applied at birth, immediate lactation consult, availability of donor milk, hand expression teaching and kit including spoon and video link, and daily interdisciplinary team huddles. We collected data from medical records of singleton infants born at 36.0–36.6 weeks gestational age in the 24 months before and 12 months after program implementation. Exclusion criteria included NICU admission, maternal HIV or active substance use contraindicating breastfeeding, or significant social issues including state custody of infant. We performed chi square and t‐tests to assess for significant differences between groups.
Results: Among eligible infants born in the study period, 89 received the Early Bloomer Program order set (EBP) and 112 did not (non‐EBP). There were no significant differences in mean birth weight, gestational age, Apgar scores, delivery mode, or race/ethnicity. Maternal age was higher in the EBP group (mean 32.3 ± 6.3 vs 30.5 ± 6.0, p = 0.04). EBP and non‐EBP infants had similar rates of receiving any breastmilk (89.9% vs 90.2% p = 0.9454). EBP infants were significantly more likely to receive donor milk (23.6% vs 12.5%, p = 0.0394) and showed a trend toward fewer one‐year readmissions (11.2% vs 20.5%, p = 0.0771).
Conclusions: Late preterm infants receiving the Early Bloomer Program were more likely to receive donor milk and had fewer one‐year readmission rates. Future studies and interventions are needed to further tailor breastfeeding support to late preterm infants and their mothers.
Breastfeeding Counseling based on Formative Research at Primary Care Health Services in Mexico
Diana Bueno1, Uriel Romero1
1Universidad Autonoma de Baja California, Baja California, Mexico
Category: Research
Background: Breastfeeding rates in Mexico are one of the lowest of Latin America with 14.4% of exclusive breastfeeding under six months. There are even lower rates in the North of Mexico (10.6%). Evidence shows that an effective way to improve breastfeeding practices is by using culturally appropriate counseling based on formative research.
Objective(s): The objective of this study was to evaluate the effect of counseling at improving exclusive breastfeeding (EBF) in primary care health services in Tijuana, México. The objective of this study was to evaluate the effect of counseling at improving exclusive breastfeeding (EBF) in primary care health services in Tijuana, México.
Materials/Methods: This study is a randomized, controlled trial pilot, where a convenience sampling of mothers received breastfeeding counseling at an immunization service within a Primary Care Health Center. Mothers of infants under 4 months were randomized to a 1) Control Group, receiving counseling about immunizations as well as routine infant feeding information, and 2) Intervention Group, receiving breastfeeding counseling based on previous formative research conducted in this region (3). We evaluated changes in breastfeeding attitudes, self‐efficacy and EBF at 2 months post‐intervention.
Results: Eighty mothers were included in the study (40 in each group). The mean age was 26.4 years for mothers and 1.4 months for infants. Main breastfeeding obstacles reported were breastfeeding in public (23%), pain (19%), insufficient milk (15%) and returning to work (8%). We observed a significant improvement in breastfeeding attitudes (P = 0.0001), self‐efficacy (P = 0.018) and EBF (P = 0.001). There was a 30% increase in EBF in the intervention group and 15% decrease in the control group, at 2 months post‐intervention.
Conclusions: This pilot intervention based on formative research in this population was successful to improve breastfeeding attitudes, self‐efficacy and practices. We are planning the expansion of this project to 10 health care centers. Breastfeeding counseling integrated to the immunization program can be a sustainable way to increase breastfeeding in this population,
