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Background: The World Health Organization recommends that infants should be exclusively breastfed for the first 6 months of life and that breastfeeding should continue for 2 years and beyond. Most women initiate breastfeeding, but many do not continue for the recommended duration. While midwife-led continuity of antenatal care is linked to improved mother and infant outcomes, the influence on breastfeeding duration has not been previously reviewed., Research Aim: To critically analyze the literature that compared midwife-led continuity of antenatal care with other models of care where researchers have measured breastfeeding duration beyond postpartum hospital discharge., Methods: A systematic literature review with critical analysis was used to answer the research aim. We systematically searched and screened five databases for quantitative studies where researchers had reported breastfeeding duration beyond postpartum hospital discharge after midwife-led continuity of antenatal care, compared with another model of antenatal care. Methodological quality was assessed using tools from the Cochrane Collaboration (RoB2 and ROBINS-I). In total, nine studies met the inclusion criteria., Results: Clear conclusions about the association between midwife-led continuity of antenatal care and breastfeeding duration were not found. The risk of bias within non-randomized studies ranged from serious to critical, and a judgement of "some concerns" of risk of bias in the one randomized study., Conclusion: To date, the question of whether midwife-led continuity of antenatal care improves breastfeeding duration has not been established. There has been a lack of consistency in definitions of breastfeeding and descriptions of models of care, which has weakened the evidence-based of literature reviewed.Our review protocol was registered with PROSPERO; although due to COVID-19, this registration was not checked for eligibility by the PROSPERO team (CRD42020151276). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151276.

Background: Peer support may help mothers to feel satisfied with their breastfeeding and to continue breastfeeding. However, previous researchers have not examined the influence of peer support on the three breastfeeding-satisfaction domains., Research Aim: We aimed to examine the influence of telephone-based peer support on the following three domains of breastfeeding satisfaction among Japanese mothers: maternal satisfaction, perceived benefit to the infant, and lifestyle compatibility with breastfeeding., Methods: Breastfeeding mothers were recruited at four maternity hospitals in Japan to participate in a randomized controlled trial. Data were collected 1 month and 4 months postpartum. Among all of the participants ( N = 114), those in the intervention group ( n = 60) received telephone-based peer support until 4 months postpartum, and participants in the control group ( n = 54) received conventional support. Breastfeeding satisfaction was measured using the short version of the revised Japanese Maternal Breastfeeding Evaluation Scale. Generalized estimating equations and effect size analyses were used to examine the influence of the intervention., Results: On the subscale measuring lifestyle compatibility, participants with peer support had a higher score than those without peer support: regression coefficient 1.54 (95% confidence interval [0.03, 3.04]). The effect size was 0.40 standard deviations among participants with low and mid-level scores at baseline., Conclusion: Although peer support did not change maternal satisfaction or perceived benefit to the infant, it did increase lifestyle compatibility with breastfeeding among these Japanese mothers. This is evidence in favor of increasing the use of peer support.

Background: Prenatal care providers play a central role in breastfeeding outcomes. A survey on obstetricians' support of breastfeeding was conducted in 1993 in Monroe County, NY. Since the landscape of prenatal care and breastfeeding support has changed significantly in the past 2 decades, we repeated and extended this survey in 2015., Research Aim: To determine changes in breastfeeding support by prenatal care providers over a 20 year period., Methods: We sent a 46-item on-line or paper questionnaire to all categories of prenatal care providers identified by an online search. A breastfeeding support score was created based on the prior survey, with a maximum score of 3. One point was awarded for: (1) personally discussing breastfeeding; (2) generally suggesting breastfeeding; and (3) commonly receiving questions from patients. Data were analyzed using Chi-square., Results: We had 164 participants (response rate 80%). More current participants, compared to 1993, reported discussing (97% vs. 86%, p < .001) and recommending (93% vs. 80%, p = .001) breastfeeding. Only 10% of 2015 participants gave infant formula samples, compared with 34% in 1993 ( p < .0001). Improvement in the support score was seen, with 98% of current participants having high scores compared to 87% in 1993 ( p < .001). Similar numbers reported receiving breastfeeding education, though more reported that the education was inadequate (54% vs. 19%, p < .0001)., Conclusion: Breastfeeding support improved significantly over time, even though breastfeeding education has not improved in quality or quantity. Improving education of prenatal care providers may help future providers be more prepared to support breastfeeding.

While conducting my dissertation research on the professionalization of breastfeeding support, I identified key "founders" of lactation consulting. I focused on the people involved in the formation of the International Board Certified Lactation Consultant, as certified by the International Board of Lactation Consultant Examiners and represented by the International Lactation Consultant Association. Jan Riordan was at the top of my list. As the editor and co-author of the first text on breastfeeding and human lactation for non-physicians, Dr. Riordan shaped the professional body of knowledge for International Board Certified Lactation Consultants and others providing clinical breastfeeding support. She was a La Leche League leader and founding member of the Kansas La Leche League International Chapter, served on the first International Board of Lactation Consultant Examiners Board of Directors, and served on the first editorial review board of the Journal of Human Lactation. She was a professor of nursing at Wichita State University for 23 years. I met her at an International Lactation Consultant Association conference in San Antonio, Texas in 2010, just after she had retired from Wichita State, and I interviewed her by phone on August 10, 2010. This is from a taped interview. (AE = Aimee Eden's initials; JR = Jan Riordan's initials). The University of South Florida IRB approved the full study.

Background: Despite a documented underutilization of healthcare by the LGBTQIA+ community due to fear of mistreatment, reproduction incurs a likely dependence on the medical system. Within breastfeeding medicine, the language used for breastfeeding or chestfeeding has broadened and there is an emphasis on inclusion of all types of gender identities; however, that care can be heavily biased toward the inclusion of all breasts/chests in infant feeding., Research Aim: The purpose of this case study was to examine the impact of queer identity on the gestational and postpartum experience of a bisexual woman married to, and parenting with, a transgender man. It draws into perspective the need to practice in accordance with patients' self-described gender and parenting roles., Results: The parenting roles of this couple were the same as any married, straight, cisgender couple, yet the family identified as queer. The mother in this case experienced low milk production, but the father had had chest reconstructive surgery and started hormones so that they could enter parenthood as the family they had envisioned for themselves. At no point was there any consideration that the father induce milk production for his baby or that chest reconstructive surgery had been mistimed. Their pregnancy support team was supportive of their gender identities and parenting roles, yet they still found themselves orienting and educating the healthcare team throughout their pregnancy and postpartum experience., Conclusions: Caring for the LGBTQIA+ community requires us to recognize our assumptions and act in affirming ways for all parents, regardless of their family constellation.

Introduction: This case of a mother and her two children, born 20 years apart, highlights how Biological Nurturing (BN) supported a woman in meeting her personal breastfeeding goals. We know lack of breastfeeding support contributes to early weaning. Applying the principles of BN (unrestricted and laid-back breastfeeding) enabled this mother to return to breastfeeding without supplements., Main Issue: After giving birth to her first son prematurely in 1997, the dyad was separated, and formula introduced. These interventions, combined with inadequate breastfeeding support, resulted in low milk supply and unplanned weaning by week six. In 2017, a full term sibling baby girl was born, with breastfeeding again beginning with concerns of low milk supply., Management: Consultation with an International Board Certified Lactation Consultant successfully addressed common breastfeeding problems, including vasospasm and insufficient milk supply. Continuous emotional support helped this mother overcome perceived insufficient milk supply. Introducing BN led to breastfeeding without supplementation, by enabling the dyad to experience enjoyment, comfort and feeding autonomy., Conclusion: While the repeated experience of insufficient milk supply two decades apart constituted a psychological barrier to exclusive breastfeeding, BN enabled reaching this mother's breastfeeding goals. BN appears to be a powerful tool for both breastfeeding initiation and overcoming breastfeeding difficulties, potentially setting new best practice standards.

Background: Metformin improves insulin action, but feasibility in treating low milk supply is unknown., Research Aim: To determine the feasibility of a metformin- versus-placebo definitive randomized clinical trial in women with low milk production and signs of insulin resistance., Methods: Pilot trial criteria included: Mother 1-8 weeks postpartum (ideally 1-2 weeks), low milk production, and ≥1 insulin resistance sign; and singleton, healthy, term infant. Eligible mothers were randomly assigned 2:1 (metformin:placebo) and instructed in frequent milk removal for 28 days with option to stop at 14 days., Results: From 02/2015 through 06/2016, we screened 114 women, completed baseline assessments on 46, and trialed 15 (median, 36 days postpartum). Comparing metformin-assigned ( n = 10) to placebo ( n = 5), 70% versus 80% continued to day 28; peak median change in milk output was +8 versus -58 mL/24 hr ( p = .31) and 80% peaked at Day 14 for both groups; 0% versus 20% desired to continue assigned drug after study completion; 44% versus 0% reported nausea/vomiting. Post-hoc, median peak change in milk output was +22 (metformin completers, n = 8) versus -58 mL/24 hr (placebo + non-completers, n = 7, p = .07). At baseline assessment, median milk production was significantly lower in those with ( n = 31), versus those without ( n = 15) signs of insulin resistance ( p = .002)., Conclusions: Although results trend toward hypothesized direction, trial feasibility concerns include late enrollment and only 20% of metformin-assigned participants sustaining improved milk output to Day 28, with none perceiving metformin worthwhile. Better tools are needed to identify and treat metabolically-driven low milk production. Registered at ClinicalTrials.gov (NCT02179788) on 02/JUL/2014.

Background: Establishing breastfeeding in the first days of an infant's life is important for longer term success in breastfeeding. In 2009, New York State (NYS) was the second state to require maternity care facilities to collect infant feeding information and to publicly disseminate hospital-specific infant feeding statistics. Public reporting of these statistics as performance measures is a strategy to prompt hospitals to improve breastfeeding support., Objective: This qualitative study sought to explore how maternity care administrators and clinical staff responded to the mandate for publicly reported performance measures and whether they used this information to improve maternity care practices., Methods: This study used a stratified random sample of NYS hospitals with maternity care units. Participants were recruited by email and telephone calls. A total of 25 hospitals participated in the study, and 37 hospital administrators and staff completed in-depth interviews by telephone. The interviews were analyzed using an explanatory framework in NVivo 8., Results: Publicly reported hospital-specific breastfeeding measures increased attention to breastfeeding performance. Hospital administrators and staff reported comparing their relative rankings to other hospitals in the state. Some hospitals used publicly reported breastfeeding measures to monitor performance, whereas others were prompted to generate additional measures for more frequent monitoring. Hospitals with relatively low breastfeeding statistics took certain actions to improve their maternity care practices to support breastfeeding. Limitations of the usefulness of publicly reported measures were reported by interview participants., Conclusion: Publicly reported, hospital-specific breastfeeding measures may prompt hospitals to monitor and improve maternity care practices related to supporting breastfeeding.

Background: Breastfeeding is the gold standard nutrition for infants, and more than three-fourths of US mother-infant couplets initiate breastfeeding at birth. However, breastfeeding rates plummet after hospital discharge, when mother-infant couplets enter primary care. This quality improvement project examined the effect of a primary care intervention on breastfeeding rates from the newborn visit through the 4-month visit., Objective: The overall aim of this evidence-based quality improvement project was to increase breastfeeding rates by refining the care provided to a diverse patient population with historically low breastfeeding rates., Methods: Two independent groups of mother-infant couplets, a pre-implementation (N = 43) and a post-implementation (N = 45), were longitudinally evaluated on breastfeeding rates at the newborn, 1-month, 2-month, and 4-month well-child visits for exclusive, partial, and any breastfeeding rates. Relationships for the 2 groups were compared using 2-sample t tests, chi-square, and Fisher exact tests., Results: Post-implementation rates for any breastfeeding progressively increased at each timepoint. Exclusive breastfeeding increased 40.98% at the 1-month visit, 27.4% at the 2-month visit, and 139% at the 4-month visit., Conclusion: The implementation of an evidence-based breastfeeding-friendly office protocol in a rural low breastfeeding rate primary care setting was associated with increased breastfeeding rates.

Background: The Baby-Friendly Hospital Initiative (BFHI) has a positive effect on breastfeeding in maternity wards; however, few studies have examined to what degree it affects care in neonatal intensive care units (NICUs). Recently, the BFHI has been adapted to the NICUs (Neo-BFHI)., Objective: This study aimed to compare breastfeeding support in Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited (group 1) with NICUs in hospitals that have not yet begun this initiative (group 2)., Methods: A validated questionnaire on breastfeeding support was distributed to level II and III NICUs in Spanish public hospitals. A univariate analysis and an analysis adjusted for the number of beds in NICUs were conducted. The results of the analysis of 36 breastfeeding support measures are presented in accordance with the Ten Steps to Successful Breastfeeding adapted to NICUs., Results: Of the 141 participating NICUs, 129 (91%) responded to the questionnaire: 38 NICUs from group 1 and 91 NICUs from group 2. Group 1 had implemented a higher number of breastfeeding support measures than group 2. There were significant differences in 18 measures related to steps 2, 4, 5, 7, and 8 of the Neo-BFHI. In addition, a comparison of NICUs in hospitals with full accreditation (7 of 129) with those in group 2 revealed significant differences in 7 measures pertaining to steps 2, 5, 8, and 9., Conclusion: The Spanish NICUs in hospitals with BFHI accreditation or in the process of being accredited have better implementation of practices to promote and support breastfeeding.

Background: Breastfeeding initiation rates vary considerably across racial and ethnic groups, maternal age, and education level, yet there are limited data concerning the influence of geography on community rates of breastfeeding initiation., Objective: This study aimed to describe how community rates of breastfeeding initiation vary in geographic space, highlighting "hot spots" and "cool spots" of initiation and exploring the potential connections between race, socioeconomic status, and urbanization levels on these patterns., Methods: Birth certificate data from the Kentucky Department of Health for 2004-2010 were combined with county-level geographic base files, Census 2010 demographic and socioeconomic data, and Rural-Urban Continuum Codes to conduct a spatial statistical analysis of community rates of breastfeeding initiation., Results: Between 2004 and 2010, the average rate of breastfeeding initiation for Kentucky increased from 43.84% to 49.22%. Simultaneously, the number of counties identified as breastfeeding initiation hot spots also increased, displaying a systematic geographic pattern in doing so. Cool spots of breastfeeding initiation persisted in rural, Appalachian Kentucky. Spatial regression results suggested that unemployment, income, race, education, location, and the availability of International Board Certified Lactation Consultants are connected to breastfeeding initiation., Conclusion: Not only do spatial analytics facilitate the identification of breastfeeding initiation hot spots and cool spots, but they can be used to better understand the landscape of breastfeeding initiation and help target breastfeeding education and/or support efforts.

The Baby-Friendly Hospital Initiative (BFHI) was launched in Croatia in 1993. By 1998, 15 of 34 maternity facilities were designated "Baby-Friendly." Introduction of hospital bags, violating the International Code of the Marketing of Breastmilk Substitutes, led to a standstill in the BFHI. The aim of this article is to describe the successful reintroduction of the BFHI in Croatia between 2007 and 2015. After hospital bags were abolished in 2007, UNICEF Croatia undertook an assessment of BFHI implementation. All maternity facilities were invited by UNICEF and the Ministry of Health to join the renewed BFHI. UNICEF materials were translated and training for trainers, assessors, coordinators, and hospital staff held. By June 2015, 30 of 32 (94%) maternity facilities, providing care to 89% of newborns, were Baby-Friendly. Nine maternity hospitals have been renovated and 2 new hospitals have been built. Exclusive breastfeeding rates have risen 16% at 0 to 2 months (from 51% in 2007 to 67% in 2014) and 14% at 3 to 5 months (from 32% in 2007 to 46% in 2014). Fourteen "Breastfeeding-Friendly" primary care practices have been designated, 166 breastfeeding support groups are in operation, criteria for Mother-Friendly care are being piloted in 2 maternity facilities, and "Ten Steps in the Neonatal Intensive Care Unit" are being introduced. The BFHI provides an excellent opportunity for revitalizing breastfeeding protection, promotion, and support in all settings. Recognition and support of the BFHI by the Croatian government was crucial for implementing the BFHI, whereas the marketing practices of the breast milk substitutes industry are an ongoing challenge., (© The Author(s) 2016.)

The Baby-Friendly Hospital Initiative (BFHI) increases exclusive breastfeeding. Breastfeeding protects against obesity and diabetes, conditions to which American Indians and Alaska Natives are particularly prone. As part of the First Lady'sLet's Move! in Indian Countryinitiative, the US Department of Health and Human Services' Indian Health Service (IHS) began implementing the BFHI in 2011. The IHS administers 13 US birthing hospitals. There are 5 tribally administered hospitals in the lower 48 states that receive IHS funding, and the IHS encouraged them to seek Baby-Friendly designation also. In the 13 federally administered hospitals, the IHS implemented a Baby-Friendly infant feeding policy, extensive clinician training, and Baby-Friendly compatible medical records. All hospitals also became compliant with the World Health Organization's International Code of Marketing of Breast-Milk Substitutes. Strategies and solutions were shared systemwide via webinars and conference calls. Quality improvement methods, technical assistance, and site visits assisted with the implementation process. Between 2011 and December 2014, 100% (13 of 13) of IHS federally administered hospitals gained Baby-Friendly designation. The first Baby-Friendly hospitals in Arizona, New Mexico, North Dakota, Oklahoma, and South Dakota were all IHS sites; 6% of all US Baby-Friendly hospitals are currently IHS hospitals. One tribal site has also been Baby-Friendly designated and 3 of the 5 remaining tribally administered hospitals in the lower 48 states are pursuing Baby-Friendly status. Baby-Friendly Hospital Initiative implementation systemwide is possible in a US government agency serving a high-risk, underprivileged population. Other systems looking to implement the BFHI can learn from the IHS model., (© International Lactation Consultant Association 2015.)

Background: Hospital breastfeeding support practices can affect breastfeeding outcomes. Learning collaboratives are an increasingly common strategy to improve practices in health care and have been applied to breastfeeding in many cases., Objectives: The aims of this study of the Evidence-Based Hospital Breastfeeding Support Learning Collaborative (EBBS LC) were to describe the perceptions of participants regarding the process and effectiveness of the EBBS LC, describe perceived barriers and facilitators to implementing the Ten Steps to Successful Breastfeeding, and identify additional actions and resources needed in future learning collaboratives., Methods: Qualitative, semistructured telephone interviews were conducted with 13 key staff who represented 16 of the 18 participating hospitals., Results: The learning collaborative was perceived positively by participants, meeting the expectations of 9 and exceeding the expectations of 4 persons interviewed. The most beneficial aspect of the program was its collaborative nature, and the most difficult aspect was the time required to participate as well as technological difficulties. The key barriers were staff time, staff changes, cost, and the difficulty of changing the existing practices of hospitals and communities. The key facilitating factors were supportive management, participation in multiple breastfeeding quality improvement projects, collecting data on breastfeeding outcomes, tangible resources regarding the Ten Steps, and positive community response. Participants in the EBBS LC stated that they would like to see the Washington State Department of Health create a resource-rich, centralized source of information for participants., Conclusion: This learning collaborative approach was valued by participants. Future efforts can be guided by these evaluation findings., (© The Author(s) 2015.)

Background: The Baby-Friendly Hospital Initiative requires hospitals to pay market price for infant formula. No studies have specifically examined the effect of hospitals paying for infant formula on breastfeeding mothers' exposure to Baby-Friendly steps., Objectives: To investigate the effect of hospitals implementing a policy of paying for infant formula on new mothers' exposure to Baby-Friendly steps and examine the effect of exposure to Baby-Friendly steps on breastfeeding rates., Methods: We used a repeated prospective cohort study design. We recruited 2 cohorts of breastfeeding mother-infant pairs (n = 2470) in the immediate postnatal period from 4 Hong Kong public hospitals and followed them by telephone up to 12 months postpartum. We assessed participants' exposure to 6 Baby-Friendly steps by extracting data from the medical record and by maternal self-report., Results: After hospitals began paying for infant formula, new mothers were more likely to experience 4 out of 6 Baby-Friendly steps. Breastfeeding initiation within the first hour increased from 28.7% to 45%, and in-hospital exclusive breastfeeding rates increased from 17.9% to 41.4%. The proportion of mothers who experienced all 6 Baby-Friendly steps increased from 4.8% to 20.5%. The risk of weaning was progressively higher among participants experiencing fewer Baby-Friendly steps. Each additional step experienced by new mothers decreased the risk of breastfeeding cessation by 8% (hazard ratio = 0.92; 95% CI, 0.89-0.95)., Conclusion: After implementing a policy of paying for infant formula, breastfeeding mothers were exposed to more Baby-Friendly steps, and exposure to more steps was significantly associated with a lower risk of breastfeeding cessation., (© The Author(s) 2015.)

Breastfeeding is recommended for women with opioid use disorder who are treated with methadone or buprenorphine. Infants with neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure have unique challenges related to breastfeeding but also have significant benefits including improved NAS symptoms with a decreased need for pharmacotherapy. Poor understanding of substance use disorder and treatment, lack of evidence-based recommendations, and vague guidelines from national academies create controversy about breastfeeding eligibility for these women. Defining breastfeeding guidelines is often difficult, particularly in large institutions with multiple providers caring for the mother-infant dyad. Based on the available evidence and review of our institutional data, we revised our breastfeeding guidelines for mothers with opioid use disorder. The aims of our new guidelines are (a) to safely promote breastfeeding in all mothers with opioid use disorder who are in recovery, (b) to improve NAS outcomes through use of breastfeeding as a key nonpharmacologic treatment modality, and (c) to improve staff communication and consistency on the subject of breastfeeding in this patient population., (© The Author(s) 2015.)

Well Babies at Walgreens is a unique community-based corporate partnership program that offers breastfeeding support by a lactation professional in a private room at the pharmacy. Walgreens is a community pharmacy chain with more than 8000 locations in the United States, Puerto Rico, and the US Virgin Islands. The primary goal of Well Babies is to support breastfeeding women using a model that is expandable to other Walgreens pharmacy sites. The Well Babies program offers drop-in services, with a professional consultation by a lactation consultant and baby weight check, if desired. Well Babies creators are developing a business plan for Walgreens and a toolkit that would help other stores implement the program. An additional goal is to improve continuity of care for breastfeeding by engaging pharmacists as vital members of the health care team. Offering breastfeeding support at a pharmacy improves access and encourages support persons to attend while simultaneously allowing the family to complete other errands. This initiative included education for pharmacists to improve the recommendations they make for breastfeeding mothers and to improve awareness among pharmacists of the benefits associated with breastfeeding and the need to preserve the breastfeeding relationship. The first drop-in location opened in April 2012. Grant funding from the US Centers for Disease Control and Prevention, awarded to the Indiana State Department of Health, made it possible to open a second drop-in location in June 2013. Future plans include developing an employee lactation program and expanding Well Babies at Walgreens at other store locations., (© The Author(s) 2015.)

The Michigan Department of Community Health (MDCH) funded 9 local breastfeeding coalitions to implement breastfeeding support groups and to develop breastfeeding resources for mothers and health professionals. The authors conducted qualitative analyses of reports, success stories, and MDCH grantees' interview responses (via follow-up call with 3 coalitions) to assess key barriers, facilitators, and lessons learned for coalitions implementing breastfeeding support groups. Coalitions noted implementation barriers related to their organizational structure and to recruiting mothers and finding meeting locations. Facilitators to implementing breastfeeding support groups included referrals, expertise, resources, and incentives. The following themes emerged from the reports analysis regarding how to implement breastfeeding support groups: "meet moms where they are," build community partnerships, and leverage in-kind and financial resources to sustain breastfeeding support groups., (© International Lactation Consultant Association 2015.)

Background: The Massachusetts Department of Public Health's (MDPH) Mass in Motion Program (MiM) facilitates the adoption of community-level strategies that promote healthy weight in 52 municipalities. MiM provided the platform for enhancing postdischarge continuity of care for breastfeeding., Objective: This study aimed to improve the continuity of breastfeeding care and support for mothers by enhancing postdischarge care infrastructure and supportive contacts for women and families., Methods: The MDPH awarded catalyst grants to community-based organizations (CBOs) that facilitated the formation of teams for improving breastfeeding support. The effort focused on populations that often experience disparities in breastfeeding outcomes such as minority women and women receiving Medicaid. The Added Value Model of Community Coalitions was used to qualitatively assess effect across multiple levels of the socioecological model of influence., Results: Six communities were awarded grants to enhance or convene Breastfeeding Continuity-of-Care Teams consisting of at least 3 CBOs, including 1 maternity hospital, the local Special Supplemental Nutrition Program for Women, Infants, and Children, and the local MiM representative. Teams implemented customized plans with performance indicators to create and strengthen infrastructure for supportive contacts with breastfeeding mothers. The project included Baby Café pilots in 3 additional MiM communities. Across all grantee communities, there was an average total increase of 491 contacts with mothers per month, an improvement of 8.5% over baseline. The project created 153 added value outcomes of community collaboration at 5 levels in the socioecological framework., Conclusion: The project demonstrated how cross-sector, coordinated efforts focused on vulnerable populations can leverage local strengths to establish/enhance breastfeeding support services customized to local needs., (© The Author(s) 2015.)

Background: Implementing evidence-based practices and policies for breastfeeding support in community clinics is a promising, but challenging, approach to reducing disparities in breastfeeding rates., Objective: This study aimed to apply a policy process research framework to increase knowledge of factors that facilitate adoption and implementation of breastfeeding policy changes., Methods: In 2013, Washington State piloted a process to encourage 8 clinics to adopt and implement steps to become breastfeeding friendly. Evaluation data were collected through interviews, project reports, training evaluations, and pre- and post-self-assessments of achievement of the steps., Results: In 6 months, clinics increased the breastfeeding-friendly steps that they were implementing from a median (interquartile range) of 1.5 (0-3) to 6 (5-7). Improvements were most likely in the steps that required the fewest resources and administrative changes. Barriers to implementation included misperceptions about breastfeeding and breastfeeding support; lack of administrative "buy-in"; need for organizational changes to accommodate actions like monitoring breastfeeding rates and allowing providers training time; and the social-political climate of the clinic. Several factors, including actions taken by public health practitioners, enhanced the change process. These included fostering supportive relationships, targeting technical assistance, and providing resources for planning and training., Conclusion: This pilot project demonstrates that it is possible to make changes in breastfeeding support practices and policies in community clinics. Recommendations to enhance future work include framing and marketing breastfeeding support in ways that resonate with clinic decision makers and enhancing training, resources, and advocacy to build capacity for internal and external systems changes to support breastfeeding best practices., (© The Author(s) 2015.)

The Tele-Lactation Pilot Project (TLPP), 1 of 13 community-based breastfeeding projects implemented in Indiana in 2013 using Centers for Disease Control and Prevention grant funds, explored the feasibility of using videoconferencing technology to provide breastfeeding education and support to low-income women by a centrally located International Board Certified Lactation Consultant (IBCLC). The IBCLC was housed at the Breastfeeding Center at the hospital where the women would deliver; the women receiving the education and support were located at an inner-city community health center (CHC) where they received their primary care. The videoconferencing sessions were juxtaposed with the women's regularly scheduled prenatal and postnatal visits at the CHC. After delivery, the lactation consultant visited the mother and infant in person at the hospital to offer additional support. Overall, 35 mothers were served by the TLPP during the 9-month project period. A total of 134 visits (30-45 minutes each) were conducted (3.8 sessions per woman). At the conclusion of the project, interviews with key participants indicated that the tele-lactation videoconferencing sessions were easy to implement, allowed the IBCLC to reach a wider client base, and allowed the women to receive expert support that they might not have otherwise received. Comments indicated that, in addition to providing education and increasing the women's confidence, the tele-lactation sessions appeared to have decreased the mothers' anxiety about the birthing process and the hospital experience. The TLPP demonstrated that incorporating videoconferencing technology into routine care can help foster collaboration among health care providers and provide mothers with continuous, easily accessible breastfeeding education and support., (© The Author(s) 2015.)

Background: Breastfeeding initiation in Washington State (Northwest United States) is high, yet rates plummet by 3 months postpartum. In the United States, national quality improvement (QI) efforts to improve breastfeeding outcomes have largely focused on hospital maternity care practices through implementation of the Ten Steps to Successful Breastfeeding. This framework has not extended similarly to primary care clinics, a key site for supporting continued breastfeeding following hospital discharge. This article details a pilot effort with community clinics to implement 10 evidence-based steps to support breastfeeding in the clinic setting and to evaluate the process and outcomes., Objective: A public-private-academic partnership developed and piloted a 10-step clinic breastfeeding support strategy and focused resources, training, and technical assistance on primary care clinics to help facilitate best-practice policy and environmental changes to improve clinic breastfeeding support., Methods: Eight health centers, serving predominantly Latino and Native American communities, worked to systematically implement 10 evidence-based steps developed for the community primary care setting. An evidence table, self-assessment with scoring criteria, tool kit, and provider reference documents were developed to guide clinics., Results: At baseline, clinics had 2 steps, on average, already in practice (range, 1-4 steps); by final assessment, an average of 7 steps was implemented (range, 5-9 steps). Within 6 months from pre-intervention to post, clinics fully operationalized between 2 and 7 steps., Conclusion: Catalyzing clinic QI efforts through an evidence-based 10-step model is an effective way to optimize primary care breastfeeding support and to strengthen the continuum of care for breastfeeding mothers and babies following hospital discharge., (© The Author(s) 2015.)

Background: Few studies have analyzed patient education materials provided at discharge. To the best of our knowledge, there are no comprehensive studies analyzing and reporting the content of breastfeeding discharge packets within the United States., Objective: This study analyzed the extent to which patient education materials provided at discharge from maternity facilities in Massachusetts cover topics that support successful breastfeeding., Methods: We collected discharge packets from all 48 maternity hospitals/birth centers. Topics for analysis were based on recommendations associated with the Baby-Friendly Hospital Initiative and content identified for discharge packets generally. Materials were reviewed independently and scored according to 39 criteria that we assembled from various sources for optimal breastfeeding information at discharge. Bivariate and multivariate analyses were used to explore if any hospital characteristics predicted presence of breastfeeding education topics in written information provided at discharge., Results: An average of 25.4 of 39 criteria (65.2%, ranging from 30.7%-97.4%) were included in packets submitted by all 48 facilities. Exploratory multivariate analyses did not show relationships of hospital characteristics to contents of packets. Each facility received a 2-page report noting strengths, suggestions for improvement, and individual scores on all 39 criteria., Conclusion: Discharge packet contents varied widely; whereas some institutions' information met and/or exceeded recommended content, others were limited and/or missing information. These analyses provide a thorough review of discharge packet content for all facilities in Massachusetts; however, further study is needed to identify the implications of such variation for breastfeeding outcomes., (© The Author(s) 2015.)

Background: Primary care providers play an important role in encouraging and counseling pregnant and postpartum women to successfully breastfeed., Objective: One objective of this 1-year grant was to establish the Breastfeeding Friendly Practice Designation criteria and process to identify and designate at least 5 primary care practices as New York State Breastfeeding Friendly Practices in a high-need, racially/ethnically diverse, urban county in New York with very low prevalence of breastfeeding initiation, exclusivity, and duration., Methods: A partnership between the New York State Department of Health and the P(2) Collaborative of Western New York and United Way of Buffalo & Erie County's Healthy Start Healthy Future for All Coalition facilitated the development of the New York State Ten Steps to a Breastfeeding Friendly Practice, accompanying implementation guide, designation criteria, and model office policies. Practice staff and providers received on-site training and materials and participated in a virtual learning network to share their experiences, celebrate successes, and overcome challenges in implementing system changes. Practice staff completed a self-assessment survey at baseline and after implementation of the Ten Steps and submitted their written office breastfeeding policy for review., Results: Fourteen practices met the criteria for designation and were recognized by the New York State Health Commissioner., Conclusion: The number of practices designated as Breastfeeding Friendly far exceeded the grant objective. Future efforts are directed at expanding this initiative statewide and determining the impact of the designation on breastfeeding outcomes., (© The Author(s) 2015.)

In 2012, the Centers for Disease Control and Prevention awarded the Indiana State Department of Health funding for breastfeeding activities. The grant, issued in part in response to the 2011 Surgeon General's Call to Action to Support Breastfeeding, focused on providing funding and technical support to small community-based organizations to address challenges encountered by breastfeeding mothers. Indiana used the funds to develop the Community Breastfeeding Support Initiative (CBSI). The goal was to provide funding and technical support to small community-based organizations to carry out self-selected projects in their communities. The 13 CBSI programs served 1345 individual clients (n = 3664 visits) during the 9-month period. This article provides valuable information about collaboration at the state level and the supporting infrastructure in place to carry out this project. Our findings about the number of clients served, number of visits, community-specific programs and activities, and lessons learned can be used by other organizations as they plan breastfeeding support programs for their community., (© The Author(s) 2015.)

Background: Community-based organizations (CBOs) have an important role to play in promoting breastfeeding continuation among mothers. The Centers for Disease Control and Prevention's Nutrition, Physical Activity, and Obesity Program's Cooperative Agreement Breastfeeding Supplement funded 6 state health departments to support CBOs to implement community-based breastfeeding support activities., Objectives: Study objectives were to (1) describe the reach of the Cooperative Agreement, (2) describe breastfeeding support strategies implemented by state health departments and CBOs, and (3) understand the barriers and facilitators to implementing community-based breastfeeding support strategies., Methods: Qualitative and quantitative data were abstracted from state health departments' final evaluation reports. Qualitative data were analyzed for common themes using deductive and inductive approaches., Results: Within the 6 states funded by the Cooperative Agreement, 66 primary CBOs implemented breastfeeding support strategies and reported 59 256 contacts with mothers. Support strategies included incorporating lactation services into community-based programs, training staff, providing walk-in locations for lactation support, connecting breastfeeding mothers to resources, and providing services that reflect community-specific culture. Community partnerships, network building, stakeholders' commitment, and programmatic and policy environments were key facilitators of program success., Conclusion: Key lessons learned include the importance of time in creating lasting organizational change, use of data for program improvement, choosing the right partners, taking a collective approach, and leveraging resources., (© International Lactation Consultant Association 2015.)

In 2012, the Indiana Black Breastfeeding Coalition (IBBC) used grant funds to increase participation in the Bosom Buddy Project, an original breastfeeding support group that pairs breastfeeding mothers with trained mentors. Resources for local organizations that support breastfeeding are extremely limited, making it difficult to expand programs and services. This article describes a variety of strategies used by the IBBC to expand programs and services. These activities provide a template for other community-based organizations that wish to provide culturally sensitive breastfeeding support in their community., (© The Author(s) 2015.)

Community-based lactation support groups help improve breastfeeding duration by offering practical peer and professional help and counseling through the sharing of information and experiences in a relaxed setting. The objective of this project, funded by the Centers for Disease Control and Prevention, was to establish at least 5 Baby Cafés in organizations that reach low-income women living in a high-need, racially/ethnically diverse, urban county with 1 of the lowest rates of breastfeeding initiation, exclusivity, and duration in New York. The New York State Department of Health partnered with the P(2) Collaborative of Western New York and United Way of Buffalo & Erie County's Healthy Start Healthy Future for All Coalition to facilitate the recruitment of 11 community-based agencies in Erie County, New York, to provide and/or enhance breastfeeding support. Six organizations were funded to establish licensed Baby Cafés, which provided skilled, free-of-charge, drop-in lactation support and counseling to mothers at easily accessible locations. The organizations provided staff training and staffing at the Baby Cafés, established coordinated hours of operation between all locations, and jointly marketed their services. Collectively, the 6 Baby Cafés provided 11 drop-in sessions per week. During the 7-month start-up time, mothers/babies made 276 visits and they averaged 75 visits per month, representing at least 150 clients. After the funding ended, 5 organizations continued to support and staff the Baby Cafés whereas 1 organization added another Baby Café. Future evaluation is needed to determine their effect on breastfeeding exclusivity and duration., (© The Author(s) 2015.)

Bloomington Area Birth Services (BABS), centered in Bloomington, Indiana, is a community-based program that provides comprehensive education and support for new breastfeeding mothers, infants, family members, and the community by working together with local hospitals, midwives, obstetricians, pediatric offices, and social service agencies to create a seamless continuity of care for families. To help with continuity of care in the community, BABS established a volunteer doula program (birth and postpartum), allowing BABS to combine the services of a community lactation center with birth and postpartum doulas. This article describes the volunteer doula program and highlights one client's story in an effort to encourage and motivate other communities to focus their limited dollars on the development of a volunteer doula program., (© The Author(s) 2015.)

Background: Breastfeeding rates are lower among infants living in rural areas of the United States, yet there are limited data on whether hospital breastfeeding support differs between rural and urban areas., Objective: This study aimed to describe whether maternity care practices supportive of breastfeeding vary by level of urbanization., Methods: We linked data from the 2007, 2009, and 2011 Maternity Practices in Infant Nutrition and Care (mPINC) surveys with Rural-Urban Continuum Codes to categorize hospital counties as metropolitan urbanized, nonmetropolitan urbanized, less urbanized, and thinly populated., Results: From 2007 to 2011, the average hospital mPINC score, a composite quality score ranging from 0 to 100, increased from 64 to 71 in metropolitan urbanized counties and from 54 to 65 in thinly populated areas. Scores were lowest in thinly populated counties in 2007 and 2009 and in less urbanized counties in 2011. Examination of 2011 mPINC scores by 7 domains of care revealed that hospitals in less urbanized counties had lower scores than those in metropolitan urbanized counties for feeding of breastfed infants, breastfeeding assistance, staff training, and structural and organizational aspects of care delivery; for 3 of these practices, scores were 10 or more points lower-breastfeeding assistance, structural and organizational aspects of care, and staff training. In contrast, hospitals in thinly populated areas had higher scores than in metropolitan areas for mother-infant contact and facility discharge care; differences were less than 10 points., Conclusion: Interventions that specifically target rural hospitals may reduce the gap in access to hospital maternity care practices supportive of breastfeeding by population density., (© The Author(s) 2015.)

Background: Increasing the number of infants who are breastfed has become a worldwide health priority because of the extensively documented health and economic benefits of breastfeeding for mothers and their children. It is unfortunate that adolescents initiate and continue breastfeeding at rates lower than adult women. Health care providers can improve these breastfeeding rates through the social support they offer adolescent mothers as they initiate breastfeeding., Objective: The purpose of this study was to explore the needs of adolescents for social support from nurses when initiating breastfeeding., Methods: Secondary qualitative content analysis of 90 adolescents' responses to 2 open-ended questions was conducted using social support theory as a framework. The 2 researchers independently categorized each response as informational, instrumental, emotional, and/or appraisal social support., Results: Adolescent mothers wanted nurses to take the time to explain breastfeeding, answer their questions, and provide consistent information that supported their informational needs. Emotional needs were met as the nurse provided for the adolescents' privacy, treated them with respect, and stayed calm. Nurses met adolescents' appraisal support needs through praise and encouragement. Participants valued instrumental support that included being given opportunities to work out breastfeeding under a nurse's guidance., Conclusion: Adolescents needed a combination of informational, instrumental, emotional, and appraisal support. Adolescent mothers appreciate and value nurses who take the time to dialogue with them about breastfeeding.

Background: A substantial proportion of US maternity care facilities engage in practices that are not evidence-based and that interfere with breastfeeding. The CDC Survey of Maternity Practices in Infant Nutrition and Care (mPINC) showed significant variation in maternity practices among US states., Objective: The purpose of this article is to use benchmarking techniques to identify states within relevant peer groups that were top performers on mPINC survey indicators related to breastfeeding support., Methods: We used 11 indicators of breastfeeding-related maternity care from the 2011 mPINC survey and benchmarking techniques to organize and compare hospital-based maternity practices across the 50 states and Washington, DC. We created peer categories for benchmarking first by region (grouping states by West, Midwest, South, and Northeast) and then by size (grouping states by the number of maternity facilities and dividing each region into approximately equal halves based on the number of facilities)., Results: Thirty-four states had scores high enough to serve as benchmarks, and 32 states had scores low enough to reflect the lowest score gap from the benchmark on at least 1 indicator. No state served as the benchmark on more than 5 indicators and no state was furthest from the benchmark on more than 7 indicators. The small peer group benchmarks in the South, West, and Midwest were better than the large peer group benchmarks on 91%, 82%, and 36% of the indicators, respectively. In the West large, the Midwest large, the Midwest small, and the South large peer groups, 4-6 benchmarks showed that less than 50% of hospitals have ideal practice in all states., Conclusion: The evaluation presents benchmarks for peer group state comparisons that provide potential and feasible targets for improvement.

Background: In 2009, the Centers for Disease Control and Prevention implemented the Maternity Practices in Infant Nutrition and Care (mPINC) survey in all US birth facilities to assess breastfeeding-related maternity practices. Maternity practices and hospital policies are known to influence breastfeeding, and Alabama breastfeeding rates are very low., Objective: Our objective was to assess whether staff training and structural-organizational aspects of care, such as policies, were associated with infants' breastfeeding behaviors 24 to 48 hours postpartum., Methods: We linked 2009 mPINC data from 48 Alabama hospitals with birth certificate and newborn screening databases. We used data collected 24 to 48 hours postpartum to classify 41 536 healthy, term, singleton infants as breastfed (any breast milk) or completely formula fed and examined associations with hospitals' mPINC scores in comparison with the state mean. We conducted multilevel analyses to assess infants' likelihood of being breastfed if their birth hospital scores were lower versus at least equal to the Alabama mean, accounting for hospital clustering, demographics, payment method, and prenatal care., Results: The odds of breastfeeding were greater in hospitals with a higher-than-state-mean score on the following: new employees' breastfeeding education, nurses' receipt of breastfeeding education in the past year, prenatal breastfeeding classes offered, having a lactation coordinator, and having a written breastfeeding policy. The number of recommended elements included in hospitals' written breastfeeding policies was positively associated with newborn breastfeeding rates., Conclusion: Educating hospital staff to improve breastfeeding-related knowledge, attitudes, and skills; implementing a written hospital breastfeeding policy; and ensuring continuity of prenatal and postnatal breastfeeding education and support may improve newborn breastfeeding rates.

Background: Breastfeeding assessment in the hospital to determine adequacy of feeds remains controversial. Swallow evaluation is integral to current assessment tools, but the literature is not clear about whether the number of swallows is an accurate indicator of breast milk intake in early postpartum., Objectives: To determine the reliability and validity of swallows as a measure of breast milk intake in the first days of a newborn's life., Methods: Thirty mother-baby dyads were observed at one breastfeeding; pre- and postfeed weights were done, bedside audible swallows were counted, and feeds were videotaped for independent rating. Milk intake was determined from weight change, adjusted for insensible water loss., Results: Number of swallows was significantly and positively correlated with breast milk intake (r = .71). Number of swallows alone, however, accounted for only 50.8% (R (2) = .508) of the variation in milk intake. Infant age was the best predictor of milk intake (β(age) = .56 vs β(No. swallows) = .36), accounting for 68% of the variation in milk intake when combined with swallows. The majority of infants took in 10 g or less of breast milk (77%); length of feeds was variable. In-room (at bedside) lactation consultant (LC) and video rater LC swallow counts were significantly and positively correlated (r = .93; P < .01). However, the 2 lactation consultant swallow numbers include clinically important discrepancies in a Bland-Altman analysis., Conclusions: Number of swallows was not supported as a reliable or valid indicator of milk intake and adequacy of a feed in the first few days of life.

While substantial evidence exists identifying risks factors associated with premature weaning from breastfeeding, there are no previously published definitions of patient acuity in the lactation field. This article defines evidence-based levels of lactation acuity based on maternal and infant characteristics. Patient acuity, matching severity of illness to intensity of care required, is an important determinant of patient safety and outcomes. It is often used as part of a patient classification system to determine staffing needs and acceptable workloads in health care settings. As acuity increases, more resources, including more skilled clinicians, are needed to provide optimal care. Developing an evidence-based definition of lactation acuity can help to standardize terminology, more effectively distribute health care staff resources, encourage research to verify the validity and reliability of lactation acuity, and potentially improve breastfeeding initiation and duration rates.

The authors' objective was to determine whether cumulative weekly breastfeeding duration by 13 weeks was associated with infant otitis media, respiratory and gastrointestinal illness, and total illness visits up to 12 months. The authors performed a secondary analysis of data from a randomized clinical trial of low-income, primarily Hispanic and Black women enrolled from 2 medical center affiliated clinics. "Breastfeeding sensitive" (BFS) outpatient and emergency room (ER) visit data for the above illnesses were obtained for 255 mother/infant dyads. Outcome measures were unadjusted and adjusted rates of outpatient and ER visits with sick and BFS diagnoses. The authors found no significant associations between breastfeeding intensity and infant visits for otitis media, respiratory and gastrointestinal illness, or total illness visits. In this low-income, multiethnic sample, breastfeeding intensity was not associated with infant health service use, in contrast to other evidence-based reports. Low exclusive breastfeeding rates and lack of coverage for health visits may be reasons for this finding.

The Ontario Mother and Infant Study II examined changes in postpartum health outcomes, including breastfeeding initiation and discontinuation, for mothers and their infants and compared these results to data collected prior to the initiation of the Universal Hospital Stay and Postpartum Home Visiting Program policy change in 1998. Data were collected using cross-sectional surveys before discharge and at 4 weeks postdischarge. Ninety percent of the women surveyed at 4 weeks postpartum initiated breastfeeding. Of these, 84% were still breastfeeding at 4 weeks postpartum. None of the 3 major program components-extended length of stay, a postpartum phone call from a public health worker, or a postpartum in-home visit-were associated with breastfeeding continuation to 4 weeks. Discontinuation before 4 weeks postdischarge was associated with maternal attitudes toward breastfeeding, formula feeding or supplementation in hospital, infant readmission, and use of walk-in clinics for infant care.

Dehydration and poor weight gain in breastfed infants are common but potentially preventable problems. Serious consequences are severe hypernatremic dehydration, severe weight loss, and severe hyperbilirubinemia with possible irreversible damage to the baby's brain or other vital organs. The dangers of dehydration have been emphasized by recent media reports of severe cases. These reports have resulted in increased, but often inappropriate, intervention in breastfeeding. On the basis of our experience at the Hospital for Sick Children, and the Doctors Hospital (Toronto), we have developed a decision tree and management protocol to assess breastfeeding, intervene effectively, and prevent such problems. If all breastfeeding mothers and babies are evaluated by qualified staff before discharge using this tool, it is expected that the serious consequences associated with babies leaving hospital appearing to be breastfeeding, but in fact not breastfeeding at all, will be prevented. Application of this approach, however, will require considerable upgrading of nurses' and physicians' skills and knowledge with regard to breastfeeding. A case report is presented.