Breastfeeding Support Intervention in Jaundiced Infants
Breastfeeding Support Intervention in Jaundiced Infants
Breastfeeding decreases the risk of many infantile infectious diseases and certain types of
 cancers in women. It strengthens the bond between mothers and babies and decreases the health
 care cost to society by making children healthier. Although it is controversial,
 breastfeeding has been reported to increase the risk of jaundice in the neonatal period.
 There is some evidence that mothers of hospitalized jaundiced infants discontinue
 breastfeeding early, as they feel responsible for the baby's condition.

 The main objective of this study is to determine the effect of a breastfeeding intervention
 on breastfeeding duration in jaundiced infants. All eligible infants will be randomized to
 one of two groups (an intervention or a control group). Mothers of infants in the
 intervention group will meet with a lactation consultant during their hospital stay, and
 three times post hospital discharge. Lactation consultants are individuals who have received
 certification in breastfeeding support from an international board, ensuring safe and
 effective practice. Mothers of infants in the control group will receive the current standard
 of care, which is typically support from the nursing staff, who are often not trained in
 lactation support. Information will be collected on length of time that infants are fed only
 breast milk, future visits to health care providers, mothers' need for breastfeeding support
 post hospital discharge, mothers' perception of their physicians' attitudes towards
 breastfeeding, and mothers' experiences at the hospital, as well as feedback on the
 intervention. Phone follow-up will occur one week post hospital discharge, and when the child
 is 2, 3, 4 and 6 months old.

 The results of this study will clarify the importance of offering sound breastfeeding advice
 to mothers of young infants hospitalized with jaundice and help determine whether there is a
 need for trained lactation specialists in children's hospitals. It will allow us to examine
 whether such an intervention can have a quantifiable impact on children's health in their
 first 6 months of life, as measured by physician encounters and hospitalizations. It will
 also allow collection of information on advice and support given to breastfeeding women by
 primary care physicians, potentially identifying needs for more rigorous breastfeeding
 training during medical training.
1.1 Overview This study will assess the effectiveness of a breastfeeding support intervention
 for infants admitted to the hospital with jaundice. It will evaluate the effect of this
 intervention on duration of breastfeeding and health care utilization.

 1.2 Study Objectives: Primary: To determine the effect of a breastfeeding support
 intervention on breastfeeding duration in breastfeeding infants admitted to the hospital with
 jaundice.

 Secondary:

 -  To determine the rate of breastfeeding failure, defined as breastfeeding cessation
 before the infant turns 6 months, in mothers of jaundiced infants randomized to the
 control group, as compared to the rate of breastfeeding failure in the general
 population.

 -  To compare subsequent healthcare utilization between groups during their first six
 months of life, as determined by the number of re-hospitalizations for jaundice,
 hospitalizations for non-jaundice related causes, as well as physician encounters.

 -  To determine the number of mothers seeking breastfeeding help once discharged from the
 hospital and compare it between both groups.

 -  To determine the kind and perceived effectiveness of breastfeeding support and advice
 given by the infant's primary physician throughout the child's first six months of life.

 2.1 Summary: Breastfeeding confers many advantages to infants, mothers, families, and society
 in general. There is strong evidence that human milk feeding decreases the incidence of many
 infectious diseases and enhances the immunologic status of the newborn. It has been
 associated with enhanced performance on neurocognitive development tests, and has also been
 shown to provide important health benefits to the mother, including a decrease in risk of
 breast and ovarian cancers. It should be strongly encouraged for the first six months of
 life, and then continued for up to 2 years and beyond, as recommended in the World Health
 Organization's Innocent Declaration.

 Neonatal jaundice is the most common problem in full-term infants during the immediate
 post-natal period. There is controversy as to whether breastfeeding increases the incidence
 of jaundice in the first days of life. In a study conducted in Italy, neonatal jaundice was
 not associated with breastfeeding per se, but rather with increased weight loss after birth
 subsequent to fasting, which can be seen with inadequate lactation.

 When an infant is hospitalized, previously established patterns of breastfeeding are
 difficult to maintain. There is evidence to suggest that mothers of young infants admitted to
 hospital with hyperbilirubinemia commonly experience guilt as they feel breastfeeding caused
 the jaundice. Many of these women struggle with feelings of failure or inadequacy. A study
 recently conducted by the principal investigator of this current study (CP) suggested that
 infants admitted to the hospital with hyperbilirubinemia may have a higher rate of
 breastfeeding discontinuation than babies in the general population.

 Previous studies have shown that breastfeeding support offered to various groups of
 mother-infant pairs significantly increased rates of breastfeeding at 2 to 6 months of age.

 Given the clear health, social and economic advantages that breastfeeding confers to mothers,
 infants, and society in general, there is a need to assess the effectiveness of a
 breastfeeding support intervention for infants admitted to the hospital with jaundice.

 2.2 Benefits of breastfeeding Breastfeeding is preferred for all infants, and exclusive
 breastfeeding of infants is recommended for the first 6 months after birth. Research has
 shown that human milk feeding decreases the incidence of multiple illnesses including
 bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, otitis media, and
 urinary tract infections. A recent study conducted in Spain showed that exclusive
 breastfeeding lowered the risk of hospitalization as a result of infectious diseases during
 the first year of life. In that study, each additional month of exclusive breastfeeding would
 have avoided 30% of hospital admissions. A meta-analysis of 33 studies examining healthy
 infants in developed nations showed similar results, with formula-fed infants experiencing a
 tripling in severe respiratory illnesses compared with those who were exclusively breastfed
 for 4 months. Based on these results, breastfeeding promotion can lead to important
 economical gains from a societal perspective.

 According to the most recent Ottawa Public Health Survey, breastfeeding rates in the general
 population are as follows: 91% of women initiate breastfeeding, with 56% practicing exclusive
 breastfeeding (no fluids other than breast milk). At 3 months, 71% of women continue to
 breastfeed, with 50% doing exclusive breastfeeding. This number drops to 60% for any
 breastfeeding at 6 months, with 39% of women exclusively breastfeeding.

 2.3 Breastfeeding in hospitalized children Published reports have shown that previously
 established patterns of breastfeeding are hard to maintain once an infant is hospitalized.
 Moreover, as mentioned, evidence suggests that mothers of infants admitted to the hospital
 with jaundice experience guilt, as well feelings of failure and inadequacy as they often feel
 responsible for the child's admission to hospital. Maternal confidence has been shown to be a
 strong predictor of breastfeeding duration, with lack of confidence in breastfeeding skills
 leading to a higher likelihood of weaning in the first six weeks post-partum. There is only
 one study in the literature examining the rates of breastfeeding in the jaundiced population,
 which was done by the PI of this current study. Surveys were sent to all mothers of eligible
 infants admitted with jaundice to the Children's Hospital of Eastern Ontario (CHEO) over a
 2.5 year period. One hundred and twenty-eight (64%) out of the 200 eligible mothers returned
 a completed survey. Of those, 92% had a post-secondary education. Information was collected,
 retrospectively, on length of breastfeeding after discharge from the hospital. Length of
 breastfeeding for hospitalized infants was compared to that of the Ottawa population, as
 reported by the City of Ottawa Public Health survey in 2005. Although numbers were the same
 between the jaundiced group and the City of Ottawa group, it is likely that the high
 education level of the study participants falsely elevated the rate of breastfeeding in the
 jaundiced infants. As mentioned, 92% of study participants had completed a post-secondary
 education, as compared to 53% of women involved in the population-based survey. Given that
 previous reports have shown that women with lower levels of education are more likely to
 discontinue breastfeeding early, it is reasonable to postulate that for comparable levels of
 education, mothers of infants admitted to the hospital with jaundice discontinue
 breastfeeding earlier than women in the general population.

 2.4 Breastfeeding support interventions There are very few studies quantifying the effects of
 breastfeeding promotion interventions. A recent Cochrane review found that both professional
 and lay support were effective in prolonging breastfeeding. More specifically, this review
 found that professional support had more of an impact than lay support on both partial and
 exclusive breastfeeding and lay support affected exclusive breastfeeding. A review of four
 randomized controlled trials combining breastfeeding support with educational programs in
 developed countries found that combined education and support strategies increased short-term
 breastfeeding rates by 36%. Short-term breastfeeding in these studies was described as
 anywhere between 2 to 6 months. The education interventions were primarily conducted by
 lactation specialists or nurses as antepartum sessions, while the support interventions
 varied between telephone or in-person conversations, hospital or home visits by lactation
 consultants, nurses or peer counselors, and combined prearranged appointments and unscheduled
 visits or telephone calls for problems. Breastfeeding education and support had the biggest
 effect on initiation and maintenance of breastfeeding. Many of the studies however lacked
 scientific rigor. Most studies did not make a difference between exclusive and partial
 breastfeeding. Details regarding description and length of interventions as well as training
 of the individual delivering the educational session were often lacking.

 A recent randomized controlled trial evaluating the effectiveness of a breastfeeding
 promotion intervention in the Republic of Belarus19 found an absolute increase of almost 37%
 in the prevalence of exclusive breastfeeding at 3 months in the intervention group. The chief
 obstetrician from each intervention maternity hospital, and the chief pediatrician from each
 intervention polyclinic, received the same 18-hour courses emphasizing methods to maintain
 lactation, promote exclusive and prolonged breastfeeding, and resolve common problems. All
 midwives, nurses and physicians providing care to study mothers and infants, as well as all
 pediatricians and nurses working in the polyclinics were trained over a period of 12 to 16
 months. Such a program offered the advantage of providing reliable and consistent support,
 with the goal of being widely available. This study was published after the Cochrane review
 and thus is not included in the review.

 Although no study published to date has determined which aspect of a breastfeeding support
 intervention yields positive results, it is likely to result from a combination of factors.
 Breastfeeding support results in increased confidence, and maternal confidence is known to be
 a strong predictor of breastfeeding outcome, with lack of confidence in breastfeeding skills
 leading to a higher likelihood of weaning in the first six weeks post-partum.

 2.5 Availability of breastfeeding support In the recent CHEO study, 57% of the participating
 mothers needed to seek breastfeeding support after discharge from the hospital, suggesting
 they did not receive adequate help while hospitalized. Half of these women received help from
 private lactation consultants. These lactation consultants have variable training and may or
 may not hold recognized certifications or credentials. Their fees also vary from 10$ to 90$
 an hour, and therefore may not be a suitable alternative for families with financial
 difficulties. This indicates the need for a standardized breastfeeding support intervention
 that will be accessible to all.

 2.6 Breastfeeding and health care professionals Many studies have shown that physicians and
 physicians in training lack the necessary skills to offer proper guidance to lactating
 mothers. Freed et al surveyed pediatric residents and practitioners about breastfeeding
 knowledge and found that both groups had considerable knowledge deficits, and were
 ill-prepared for counseling mothers with lactation difficulties. Many residents surveyed in a
 study performed by Hillenbrand et al believed that early supplementation was not a cause of
 breast-feeding failure, although previous studies have clearly demonstrated this
 relationship. In the Ottawa study, only 3.9% of women reported receiving breastfeeding help
 from the treating physician while admitted to the hospital, suggesting the possibility that
 physicians do not have adequate knowledge to assess proper breastfeeding methods and counsel
 appropriately.

 In summary, there is a need for this comprehensive study examining the impact of a
 breastfeeding support intervention for mothers of infants admitted to the hospital with
 jaundice. This study will clarify the rates of early breastfeeding discontinuation in the
 jaundiced population and help determine whether physicians in the Ottawa population have
 knowledge deficits when it comes to breastfeeding, as there may be a role for incorporating
 teaching of breastfeeding skills to physicians and physicians in training.
Inclusion Criteria:

 -  Mothers of infants admitted during the study period with hyperbilirubinemia,
 breastfeeding at the time of admission (any amount of breastfeeding)

 -  Mothers of infants < 1 month of age at the time of admission

 Exclusion Criteria:

 -  Mothers of infants admitted with hyperbilirubinemia who are exclusively formula-fed

 -  Mothers of infants with hyperbilirubinemia of the predominantly conjugated type as
 this is a different disease, not associated with breastfeeding difficulties

 -  Mothers of infants with anatomical abnormalities, such as cleft lip or palate, as this
 would interfere with breastfeeding and require more intensive intervention.

 -  Mothers of neurologically impaired infants as breastfeeding may be more difficult in
 this population

 -  Mother of infants who were admitted to the Neonatal Intensive Care Unit (NICU) after
 birth and never went home as they are likely to have other comorbidities affecting
 feeding.

 -  Mothers of infants feeding via naso-gastric, naso-jejunal, or gastric tube

 -  Mothers of infants > 1 month of age

 -  Mothers who have had breast surgery in the past

 -  Foster mothers or adoptive mothers

 -  Mothers who do not understand English or French

 -  Mothers of infants that are the result of multiple birth (eg twins)