“Topping Up”: In-Hospital Supplementation

in a Population Intending to Exclusively Breastfeed

Julie Temple Newhook, PhD CIHR-RPP Post-Doctoral Fellow

School of Pharmacy/Faculty of Medicine

Leigh Anne Newhook, MD, FRCPC Associate Professor of Pediatrics

William K. Midodzi, PhD

Assistant Professor of Clinical Epidemiology

Janet Murphy Goodridge, RN, MN, IBCLC Provincial Breastfeeding Consultant

Lorraine Burrage

Provincial Perinatal Program

Laurie Twells, PhD Associate Professor of Pharmacy/Medicine

PUBLIC HEALTH 2015 Vancouver, BC May 27th, 2015

Breastfeeding

Breastfeeding is a public health concern. But it is not just about nutrition.

It is also a social, cultural, and deeply personal experience.

Breastfeeding is a relationship.

The FiNaL Study

The Feeding Infants in Newfoundland & Labrador (FiNaL) Study

Primary objective: to examine infant and young child feeding practices in NL

Longitudinal, prospective birth cohort

3rd trimester of pregnancy (phase I) , 1-3 months (phase 2), 6-12 months postpartum (phase 3).

Re-contacted when their child is 12 months and 4 years of age (phase 4) to examine other health outcomes, including health services usage.

Inclusion Criteria

Recruitment was carried out at clinics, prenatal classes and through social media, and in response to posters.

Questionnaires were completed either in paper form, by telephone, or on-line.

Post-natal: full-term, healthy singleton infants. Pre-term infants, multiples, or infants with major congenital disorders or inability to feed orally were excluded. English-speaking, living in NL

3rd trimester of pregnancy Aged 19 years or older

Photography by Malin Enström

What does the FiNaL study measure?

Prenatal Socio-demographic variables

Attitudes to infant feeding, measured by the Iowa Infant Feeding Attitude Scale (IIFAS). (repeated in Postnatal)

Self-efficacy.

Perinatal

Hospital experience, including adherence to Baby-Friendly Initiative policies.

Post-natal (1-3 mos) (6-12 mos) Infant feeding practices.

Formal and informal supports Health services use, health and well-

being of infant and mother/ parent

Why the focus on Exclusive Breastfeeding?

Exclusive breastfeeding for the first 6 months of life is associated with optimal health outcomes for both infant and mother/birthing parent.1,2,3

Even the introduction of plain water can increase health risks.4

Two-thirds of participants want to exclusively breastfeed their infants for 6 months.

Yet Newfoundland and Labrador has the lowest EBF duration rates in the country: 5.8%-17.1% of infants EBFed for 6 months5,6

How can we better support mothers/birthing parents* who want to exclusively breastfeed?

Population Intending to Exclusively Breastfeed

14%

4%

17% 65%

82%

Intention in Pregnancy, n=1131

Intend to Formula Feed,n=162Have not Decided, n=41

Intend to Mixed Feed,n=193Intend to ExclusivelyBreastfeed, n=735

Who Intends to Exclusively Breastfeed?

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Income >$80,000

Post-SecondaryCompleted

Age >25 years Breastfed as anInfant

48.6%

69.6% 79.7%

32.3%

54.8%

75.0% 83.4%

39.0%

Survey Population Intending to EBF

“Topping Up”

A recent chart review of the primary healthcare centre in NL indicated that just 26% of all healthy newborns were fed exclusively breastmilk in hospital.7

Primary objective of this study:

to investigate the determinants of in-hospital introduction of non-breastmilk fluids (formula, water, sugar water) to healthy full-

term infants whose mother/birthing parent had intended to EBF for 6 months

Descriptive Analysis

Prenatal Variables n % Total 346 100 Age (years) 19-25 26-34 >=35

41

242 63

11.8 69.9 18.2

Highest level of education No post-secondary completed Post-secondary degree or diploma Post-graduate degree

56

208 82

16.2 60.1 23.7

Marital status Married/common-law Single/separated/divorced

325 21

93.9 6.1

Smoking status Currently non-smoking

336

97.1

Participant was breastfed as an infant Yes No

146 200

42.2 57.8

Parity Primiparous Multiparous

202 144

58.4 41.6

Previously breastfed a child Yes No

137 209

39.6 60.4

Total score on IOWA infant feeding attitude scale

M=70.75, SD=7.14

Descriptive Analysis

Post-natal Variables n % Hospital/Health Region St. John’s a Other Eastern Central Western Labrador Grenfell

222 18 31 64 11

64.2 5.2 9.0

18.5 3.2

Delivery Vaginal Elective caesarean Emergency caesarean

248 48 50

71.7 13.9 14.5

Satisfaction with birth experience Neutral/Satisfied Unsatisfied

308 38

89.0 11.0

Infant health problems at birth Yes No

42

304

12.1 87.9

n % Any skin-to-skin contact after birth Yes No

256 90

74.0 26.0

Rooming-in Yes No

290 56

83.8 16.2

First impression of breastfeeding Excellent/Good Some problems/Many problems

222 124

64.2 35.8

Breastfeeding support or advice from health care professional Yes No

294 52

85.0 15.0

Breastfeeding parent’s length of stay in hospital (days)

M = 2.51 days,

SD 1.16

Results: Multi-Variate Logistic Regression Modelling

Three determinants of introduction of NBF:

1. not being breastfed as an infant (OR 2.03, 95% CI, 1.13-3.67)

2. negative first impression of breastfeeding (OR 3.02, 95% CI, 1.72-5.31)

3. length of breastfeeding parent’s hospital stay in days (OR 1.30, 95% CI, 1.00-1.69), while controlling for mode of delivery

Overall, 23.7% of healthy full-term singleton infants whose mother/birthing parent intended to EBF were introduced to non-breastmilk fluids in hospital.

Results: Participants’ Perspectives on Reasons for Supplementation in Hospital

0 20 40 60 80 100

Fussiness or other non-medical reason,…

"I don't know, nurse advised it." 14.6%

Low blood glucose, 12.2%

Signs of inadequate intake, 9.8%

Other medical reasons, 3.7%

%

Qualitative Results

“Initially I was thrilled at her AMAZING latch. During the first night, she was on my breast literally continuously and I questioned myself and the nursing staff if this was normal, and I was told it wasn't and suggested I give her sugar water. …I questioned whether I was providing enough colostrum.”

Qualitative Results

“Baby was very tired due to jaundice, and would not stay at the breast. Also, I received conflicting information regarding breastfeeding techniques from various nurses (need nipple shield; do not need one) and this made it a very confusing and overwhelming process for me.”

What do these results tell us?

Post-birth can be a difficult and vulnerable period for new mothers/parents8,9

Dominant theme: Participants expressed a need to be “mothered” and cared for themselves as they recovered from birth and learned to breastfeed and care for their infants.

Inconsistent information from health care providers is experienced as confusing and overwhelming and undermines self-efficacy.10

Dominant theme: participants expressed the need to understand normal newborn nursing behaviour.

Normal Newborn Nursing Behaviour: What do new moms/parents want to know?

What is normal? Newborn fussiness, nursing for comfort, very frequent feedings, losing weight in the first week of life, particularly if they received IV fluids.

Learning to latch can take time and patience, and it is normal for baby to take a few days to learn to latch well.

Colostrum is milk! Newborn stomachs are tiny and colostrum is everything they need.

Infants crave skin-to-skin contact, and bundling or swaddling baby can interfere with learning to nurse.

If baby can latch, milk supply will build to meet demand. There are very few physiological reasons for insufficient milk.

Why is the Hospital Experience so Important?

“I feel that if I had better help in the beginning at the hospital I would not have experienced the problems I've faced since. …At the hospital I begged for help. …She never latched properly in the beginning. She didn't get any milk. I had sore cracked nipples by the time I was discharged and she wasn't gaining weight. I started pumping. But she still wouldn't latch.

After infections and two terrible bouts of mastitis, sore painful nipples and many tears I just had to throw in the towel. It broke my heart because I really wanted to breastfeed.”

How can we better support NL mothers/birthing parents

who want to exclusively breastfeed?

Photography by Laura Vokey

Implications for Practice: Hospital

Implementation of Baby-Friendly policies (The 10 Steps, including uninterrupted skin-to-skin, 24-hour rooming in, avoid artificial nipples, no supplementation unless medically indicated, baby-led cue-based feeding).11

Reduce the Rush: Create a comfortable, relaxed atmosphere for learning to breastfeed.

Education about normal newborn nursing behaviours.

Chart audits.

Peer breastfeeding support in hospital.

Acknowledgements

Thank you to all of the 1200+ participants in the FiNaL study, the members of the Breastfeeding Research Group at Memorial.

Funding for this research was provided by the Canadian Institutes of Health Research and the Research Development Corporation of NL.

Thank you to the peer support volunteers at the Breastfeeding Support in NL Facebook group who generously shared their beautiful breastfeeding pictures for this presentation.

References

1. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev 2012;8:CD003517.

2. World Health Organization. Exclusive breastfeeding. http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/. Accessed December 8, 2014.

3. UNICEF. Breastfeeding. http://www.unicef.org/nutrition/index_24824.html. Revised August 4, 2014. Accessed December 8, 2014.

4. Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Stud Fam Plann. 1990;21,4:226-230.

5. Chalmers B, Levitt C, Heaman M, O’Brien B, Suave R, Kaczorowski J. Breastfeeding rates and hospital breastfeeding practices in Canada: A national survey. Birth 2009;36,2,122-132.

6. Statistics Canada. Breastfeeding practices by province and territory (Percent). Canadian Community Health Survey. http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health92b-eng.htm. Published November 25, 2013. Accessed December 16, 2014.

References

7 Kidd M, Aubrey-Bassler K. Breastfeeding and hospital infant feeding practices in Newfoundland, 20 years on: more work to do. Canadian Journal of Public Health 2012;103,4,e320.

8 Burns E, Schmied V, Sheehan A, Fenwick J. A meta-ethnographic synthesis of women’s experiences of breastfeeding. Maternal and Child Nutrition 2010;6,201-219.

9 Redshaw M, Henderson J. Learning the hard way: Expectations and experiences of infant feeding support. Birth 2009;39,1,21-29.

10 De Jager E, Skouteris H, Broadbent J, Amir L, Mellor K. Psychosocial correlates of exclusive breastfeeding: A systematic review. Midwifery 2010;29,506-518.

11 Pound CM, Unger, SL. The Baby-Friendly Initiative: Protecting, promoting and supporting breastfeeding. Paediatr Child Health 2012;17,6,317-321.

12 Montalto, sA et al. Incorrect advice: the most significant negative determinant of breastfeeding in Malta. Midwifery 2010;26,e6-e13.