Determinants of Early Infant Feeding Practices in US Hospitals Open Access
High Bookhart, Larelle (Fall 2021)
Abstract
Exclusive breastfeeding (EBF) is the optimal feeding method for most infants for the first 6 months of life and is recommended globally. Despite global recommendations, approximately a fifth of US breastfed newborns are supplemented with infant formula within the first few days of life. This dissertation aimed to examine the relationship between sociodemographic factors, medical factors, breastfeeding intentions, and health care system breastfeeding support with in-hospital EBF among healthy, term newborns.
We examined the most common reasons reported by hospital staff for in-hospital infant formula supplementation of healthy, term, breastfed infants in hospitals using national data from the 2018 Maternity Practices in Infant Nutrition and Care survey (mPINC) (n=2,045 hospitals). These reasons included medical indications (70.0%); maternal request/preference/feelings about breastfeeding such as frustration or lack of confidence (55.9%); lactation management-related issues (51.3%); physical but non-medically indicated reasons (36.7%); social influences (18.8%); perceived cultural/societal/demographic factors (8.2%); and medical staff/institutional practices (4.7%).
Next, we examined the national maternity hospital implementation of the 2018 updated Ten Steps to Successful Breastfeeding and the association with in-hospital EBF prevalence using data from the mPINC survey. Steps with low implementation were rooming-in (18.9%), hospital policies (23.4%), and limited supplementation (28.2%). Limited supplementation was associated with the greatest difference in EBF prevalence [β= 17.2: 95% CI: 15.4, 19.1]. Other significant steps were prenatal breastfeeding education (β= 8.0; 95% CI: 4.0, 12.0), responsive feeding (β= 7.0; 95% CI: 4.1, 9.8), care right after birth (skin-to-skin) (β = 6.7; 95% CI: 5.0, 8.5), and rooming-in (β= 3.3; 95% CI: 1.1, 5.5). We also found a dose response relationship between the number of steps implemented and in-hospital EBF prevalence.
Third, we examined US in-hospital EBF prevalence and associations with Baby-Friendly designation and hospital neighborhood sociodemographic factors using data from the mPINC survey and the American Community Survey. Baby-Friendly designation was associated with 9.1 percentage points higher in-hospital %EBF prevalence compared to non-designated hospitals (95% CI: 7.0, 11.2]. Hospitals located in neighborhoods with a high percentage of Black residents and high percentage of poverty were associated with lower EBF prevalence (β= -3.3; 95% CI: -5.1, -1.4 and β= -3.8; 95% CI: -5.7, -1.8, respectively). Baby-friendly designation was associated with a 4.0 percentage point reduction in the EBF prevalence disparity due to poverty.
Lastly, we examined in-hospital EBF and the association with sociodemographic factors, medical factors, breastfeeding intentions, and breastfeeding support using medical record data (n=8,901 mother-infant dyads) from Grady Memorial Hospital. Black mothers had the lowest prevalence of EBF (27.2%) compared to all other races and ethnicities (Hispanic=31.9%; other=32.3%; Asian=33.2%; and White=48.4%). Factors with the largest associations with in-hospital EBF were maternal age [prevalence ratio (PR): 95% CI; 1.9: 1.4, 2.5 for ≥35 years compared to ≤17 years), breastfeeding intentions (PR: 95% CI; 0.2: 0.1, 0.2 for intending to formula feed only compared to intending to EBF), and neonatal hypoglycemia (PR: 95% CI; 0.5: 0.4, 0.6). Mother-infant dyads that received a lactation consult were more likely to EBF compared to those who did not (PR: 95% CI; 1.2: 1.2, 1.3).
Our findings signal the need to increase in-hospital breastfeeding support including the Ten Steps to Successful Breastfeeding, particularly limited formula supplementation; Baby-Friendly designation; and lactation support from trained professionals to improve in-hospital EBF. Ongoing, national surveillance of in-hospital EBF, including stratification by sociodemographic factors is needed to guide future intervention efforts.
Table of Contents
Chapter 1: Introduction. 1
1.1 Objective & Specific Aims. 4
Chapter 2: Literature Review.. 12
2.1 Physiology of Lactation. 18
2.2 Formula Supplementation. 21
2.2.1 Formula supplementation and breastfeeding duration. 21
2.2.2 Formula supplementation- Possible medical indications compared to non-medical factors. 21
2.2.3 Reasons for formula supplementation. 24
2.3 Sociodemographic Factors (Race/Ethnicity, Education, Income, Maternal Age) 26
2.4 Medical Factors. 32
2.4.1 Diabetes. 32
2.4.2 Hypertension. 34
2.4.3 Body Mass Index. 35
2.4.4 Cesarean delivery. 37
2.4.5 Neonatal hypoglycemia. 38
2.4.6 Neonatal jaundice. 40
2.4.7 Birth weight and gestational age. 41
2.5 Breastfeeding Intentions. 44
2.6 Health Care System Breastfeeding Support Factors. 46
2.6.1 Ten Steps to Successful Breastfeeding. 47
2.6.2 Baby-Friendly Designation. 49
2.7 Existing data sources. 51
2.7 Summary and Research Gaps. 54
Chapter 3: A nation-wide study on the common reasons for infant formula supplementation among healthy, term, breastfed infants in US hospitals. 77
Abstract 79
1. Introduction. 81
2. Methods. 82
3. Results. 84
4. Discussion. 88
5. Conclusion. 94
Chapter 4: A dose-response relationship found between the Ten Steps to Successful Breastfeeding indicators and in-hospital exclusive breastfeeding in US hospitals. 106
Abstract 109
1. Introduction. 110
2. Materials and Methods. 111
3. Results. 113
4. Discussion. 115
5. Conclusion. 119
Chapter 5: Associations between sociodemographic factors and Baby-Friendly hospital designation with in-hospital exclusive breastfeeding prevalence in the US. 130
Abstract 133
1. Introduction. 135
2. Methods. 136
3. Results. 140
4. Discussion. 142
5. Conclusion. 146
Chapter 6: Factors associated with in-hospital exclusive breastfeeding among a diverse patient population 160
Abstract 161
1. Introduction. 163
2. Methods. 165
3. Results. 168
4. Discussion. 169
5. Conclusion. 173
Chapter 7: Discussion. 186
7.1 Main Findings. 187
7.2 Strengths and Limitations. 191
7.2.1 Strengths. 191
7.2.2 Limitations. 193
7.3 Public Health Implications. 197
7.3.1 Aim 1: Reasons for formula supplementation. 197
7.3.2 Aim 2: Ten Steps to Successful Breastfeeding. 201
7.3.3 Aim 3: Baby-Friendly designation & neighborhood sociodemographic factors. 206
7.3.4 Aim 4: Factors associated with in-hospital EBF at Grady Memorial Hospital 210
Chapter 8: Conclusion. 229
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