Academy of Breastfeeding Medicine Clinical Protocol #2: Guidelines for Birth Hospitalization Discharge of Breastfeeding Dyads, Revised 2022.

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. The Academy of Breastfeeding Medicine recognizes that not all lactating individuals identify as women. Using gender-inclusive language, however, is not possible in all languages and all countries and for all readers. The position of the Academy of Breastfeeding Medicine (https://doi.org/10.1089/bfm.2021.29188.abm) is to interpret clinical protocols within the framework of inclusivity of all breastfeeding, chestfeeding, and human milk-feeding individuals.

Ethical and Public Health Implications of Targeted Screening for Congenital Cytomegalovirus.

Congenital cytomegalovirus (cCMV) is the most common congenital infection and is associated with sensorineural hearing loss, developmental delays, and visual impairment. The clinical presentation of cCMV is variable, and the majority (80%-90%) of newborns will never manifest any clinical symptoms. Given the clinical heterogeneity of cCMV infection, it is challenging to identify which newborns may benefit from testing. Recently, certain states have implemented a targeted screening program in which newborns who fail the newborn hearing screen are tested for cCMV. Clinicians and legislative bodies have been propelled into debates about the ethical and moral permissibility of a targeted cCMV screening approach. Those who oppose this screening approach describe undue burden on patients, families, and the health care system because the majority of newborns who fail the newborn hearing screen and have cCMV will not go on to have any sequelae related to cCMV, including hearing loss. However, those who support this screening approach cite the importance of early detection and ongoing surveillance for hearing loss and developmental delays in this high-risk group of newborns. This debate will be considered by experts in the field.

Clinical and Sociodemographic Factors Associated With Human Donor Milk Supplementation in Term Newborns.

OBJECTIVES: To identify differences between healthy term newborns supplemented with human donor milk (HDM) and those supplemented with infant formula. We hypothesized that sociodemographic and clinical distinctions exist between newborns receiving different milk types. METHODS: This retrospective study included term newborns admitted to the postpartum unit between March 2017 and April 2019 with ≥1 supplemental feeding with HDM or formula for indications other than hypoglycemia. Maternal and newborn data were abstracted from the electronic medical record. RESULTS: Five hundred eighty-four dyads met inclusion criteria. More newborns received supplementation with formula than with HDM (57.7% vs 42.3%; P < .001). Infants undergoing phototherapy who required supplementation were more likely to receive HDM (P < .001). Newborns born to white and non-Hispanic mothers were more likely to receive HDM than those born to African American (adjusted odds ratio [aOR] 5.6; P = .007), Hispanic (aOR 3.0; P = .001), or Asian American mothers (aOR 2.7; P = .007). Newborns born to primiparous women (aOR 1.6; P = .03), those born to women with private insurance (aOR 3.7; P < .001), and those born via cesarean delivery (aOR 2.0; P < .001) were more likely to receive HDM. HDM use was more likely in primary English- or Spanish-speaking households (aOR 8.5; P = .009). Newborns receiving their first supplemental feeding during the day (aOR 1.9; P = .001) were more likely to be supplemented with HDM. CONCLUSIONS: There are clinical and sociodemographic differences between healthy term newborns supplemented with HDM and formula. These findings reveal that there are disparities in current supplementation practices for healthy newborns.

Pacifier Use and Breastfeeding: A Qualitative Study of Postpartum Mothers.

Objective: Due to the inconclusive evidence supporting the traditional recommendation to avoid early pacifier use among breastfeeding newborns, this study aims to understand what information mothers are receiving from hospital based care providers and their perspectives about pacifier use in the newborn period. Methods: Interviews with mothers of healthy, term newborns during the postpartum hospitalization were conducted in this qualitative study. Results: Qualitative data analysis yielded several major themes that included the following: (1) pacifiers are beneficial for the maternal/infant experience, (2) concerns that pacifiers may interfere with breastfeeding, and (3) concerns about long-term use (including reliance and effect on teeth). Conclusion: Given the maternal perception of benefit and the paucity of high-quality evidence showing harm, further research on the effects of early pacifier use is needed.

Exposure to Hospital Breastfeeding Support by Maternal Race and Ethnicity: A Pilot Study.

INTRODUCTION: The Ten Steps to Successful Breastfeeding are evidence-based practices used to improve breastfeeding outcomes, and most are to be implemented shortly after birth. Although breastfeeding is increasing in the United States, racial disparities persist. Available national samples used to examine trends in maternity care rely on maternal recall, which may be subject to error and bias. Thus, we conducted a pilot study to determine the feasibility of a large-scale study conducted during the birth hospitalization to explore patterns in practices supporting breastfeeding across maternal racial and ethnic groups. METHODS: A convenience sample of 37 women with healthy, term singletons who intended to breastfeed were recruited from 2 academic medical centers (one in the Midwest and the other in the Pacific Northeast) and surveyed during their birth hospitalizations between July and November 2016. Women were asked whether they received the 7 steps that are recommended to be implemented shortly after birth (eg, encourage breastfeeding on demand). We generated descriptive statistics and conducted independent chi-square tests to determine associations between self-reported exposure to these 7 practices and race and ethnicity. RESULTS: In this sample, 23 women (62.2%) were non-Hispanic white, 5 (13.5%) were non-Hispanic black, and 6 (16.2%) were Hispanic. Approximately 26 (70.3%) reported experiencing at least 6 of the 7 practices. Non-Hispanic white women were significantly more likely to room-in with their newborns, were less likely to receive formula, and were less likely to receive pacifiers than women of other races and ethnicities (P < .05). Furthermore, differences in exposure to practices by maternal race/ethnicity appeared more pronounced at one center than the other. DISCUSSION: Preliminary findings suggest that some practices used to improve breastfeeding may be provided inconsistently across maternal racial and ethnic groups. Additional investigation is needed to further explore these patterns and to identify reasons for any inconsistencies in order to reduce health disparities in the United States.

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

BACKGROUND: Breastfeeding is fundamental to maternal and child health and is the most cost-effective intervention to reduce child mortality. Pasteurized human donor milk (HDM) is increasingly provided for term newborns requiring temporary supplementation. Few studies examine maternal perspectives on supplementation of term newborns. MATERIALS AND METHODS: We conducted semistructured in-person interviews with mothers of term newborns (n = 24) during postpartum hospitalization. Mothers were asked whether they had chosen or would choose to supplement with HDM versus infant formula, if medically indicated, and why. Data were gathered to saturation and analyzed inductively by consensus. Emerging semantic themes were compared between mothers who chose or would choose HDM and those who chose or would choose infant formula. RESULTS: Most mothers had concerns about HDM, including uncertainty regarding screening and substances passed through HDM. Experiences with prior children influenced decision-making. Mothers who chose or would choose HDM (56%, n = 14) praised it as "natural," and some felt suspicious of infant formula as "synthetic." Mothers who chose or would choose infant formula (44%, n = 10) did not know enough about HDM to choose it, and many viewed infant formula as a short-term solution to supply concerns. Mothers unanimously mistrusted online milk purchasing sources, although the majority felt positively about using a friend or family member's milk. CONCLUSIONS: Counseling regarding term newborn supplementation should focus on HDM education, specifically on areas of greatest concern and uncertainty such as donor selection, screening, transmission of substances, and mother's milk supply. Research is needed to assess the long-term impact of attitudes and choices on breastfeeding.

Are abusive fractures in young children becoming less common? Changes over 24 years.

OBJECTIVE: To determine whether the proportion of fractures rated as abusive in children <36 months of age evaluated at a regional pediatric hospital increased over a 24-year period from 1979 to 2002. Fractures were chosen as an example of serious injuries in young children. METHODS: Medical records were abstracted for all children <36 months of age who were seen at a single pediatric hospital with a fracture during three time periods: 1979-1983, 1991-1994, and 1999-2002. After reviewing the abstracted and radiographic information, two clinicians (one an expert on child abuse) and two pediatric radiologists each rated the likelihood of abuse using explicit criteria and a seven-point scale from definite abuse to definite unintentional injury. Ratings were done independently; when disagreements occurred, the case was discussed, and a joint rating was agreed upon, if possible. The proportions of cases rated as abuse were compared over the three time periods, and logistic regression was used to calculate adjusted odds ratios (OR). RESULTS: In the early, middle, and late samples, there were 200, 240, and 232 children, respectively, with fractures. The proportion of cases rated as abuse decreased from 22.5% in the early period to 10.0% in the middle period and was 10.8% in the late period (p<.001). When comparing the odds of abuse in the middle and late groups to the odds of abuse in the early group (controlling for age, gender, ethnicity, type of medical insurance, and site of pediatric care), the adjusted ORs were .31 (95% CI=.15, .62) for the middle group and .45 (95% CI=.23, .86) for the late group. Thus, the odds of a given case being rated as abuse decreased by over 50% from the early period to the middle and late time periods. No statistically significant difference was found when comparing the odds of abuse for the middle group to those of the late group, OR: 1.46 (95% CI=.69, 3.08). CONCLUSIONS: The proportion of abusive fractures in young children decreased substantially from 1979-1983 to 1991-1994 and 1999-2002 at a major pediatric hospital. We speculate that this decrease may reflect early recognition of less serious forms of maltreatment and the availability of services to high-risk families.