Breastfeeding for the Re-Hospitalized Infant

The benefits of breastfeeding for infant and maternal long-term health have been well described.1 Despite the strong evidence in support of breastfeeding, the rate of exclusive breastfeeding at 6 months in the United States is less than 25%, with the majority of women unable to meet their breastfeeding goals.2 Multiple barriers exist that prevent women from continuing to provide breast milk for their infants. These include the belief that formula is an equivalent alternative, pain, perceived low milk supply, lack of support, and absence of paid parental leave.3 For some families, hospitalization of the child directly causes or contributes to the early termination of breastfeeding.4–6Numerous barriers exist to continuing breastfeeding during pediatric inpatient admissions. The child may be prevented from eating for medical reasons, be temporarily unable to feed at the breast directly, or have decreased interest in feeding due to illness. On the parental side, hospitalization is likely to induce stress, prevent adequate sleep, impair privacy, and negatively impact eating and hydration patterns, all of which can diminish milk supply. In addition, the lactating mother may be unable to stay at the bedside because of personal obligations or lack of accommodations at the hospital.4,7 Hospitals may further unintentionally interfere with breastfeeding efforts by lacking formal policies addressing the re-hospitalized breastfeeding child, including breast milk storage, provision of electric pumps, and lactation support.8 Unsupportive hospital cultures and failure to prioritize breastfeeding during hospitalization makes it more challenging for lactation champions to advocate for and provide support to families.7 Moreover, individual medical providers may inadvertently discourage breastfeeding by providing formula, recommending prolonged fasting periods before procedures, not discussing the importance of continued breast milk expression, or providing conflicting information.4,7 Combined, these difficulties may decrease milk supply, exacerbate preexisting insecurities, and create trauma, further reducing breastfeeding.9,10Studies documenting the effects of re-hospitalization on breastfeeding rates are limited. We performed searches in PubMed, Embase, and Google Scholar for relevant English-language articles. We further used the “similar articles” (PubMed) and “similar records” (Embase) tools and reviewed each publication’s list of citations. Only 2 were identified in our literature search. In one study of 30 lactating women in the United Kingdom, mothers highlighted the desire to continue breastfeeding their sick child while in the hospital. Mothers also reported receiving inappropriate pump supplies and inaccurate information from hospital staff and sensing that breastfeeding was inconvenient for their child’s medical providers.9 In a second study, conducted in France, a telephone survey was administered following inpatient admission for acute bronchiolitis. Hospitalization negatively impacted breastfeeding in over one-half of the 84 families (n = 43; 51%), with 17 (20%) stopping breastfeeding completely and 12 (14%) changing from exclusive to partial breastfeeding. Younger infants were more likely to have negative breastfeeding outcomes. There were no statistical differences based on length of stay, disease severity, or provision of enteral or parenteral nutrition compared to those who reported no consequences of the hospitalization on breastfeeding. Lack of support from hospital staff was cited as the most important contributor to adverse breastfeeding effects.4The role of pediatric providers to encourage breastfeeding in the immediate newborn period is outlined in the Baby Friendly Hospital initiative, developed jointly by the World Health Organization and UNICEF. Most recently updated in 2018, the Baby Friendly Hospital Initiative provides 10 steps that can be implemented to promote breastfeeding before discharge following delivery.11 In addition, the US Preventive Services Task Force supports office-based breastfeeding, indicating the important role that outpatient pediatric primary care providers play in encouraging breastfeeding mothers.1,3,12 However, no analogous recommendations have been widely adopted for inpatient providers caring for breastfed children during pediatric hospitalizations. In addition, while there is clear evidence of the beneficial role of outpatient breastfeeding support,12 less is known about the specific interventions that may prevent interruption to breastfeeding during hospitalization.In a follow-up from the French hospital discussed above,4 study investigators implemented a set of interventions to mitigate the adverse effects of bronchiolitis hospitalization on breastfeeding rates. The interventions consisted of a 1-hour course for hospital staff on how to support breastfeeding, increasing the quality and quantity of equipment, and educational materials for mothers on how to maintain breastfeeding while in the hospital. Following these interventions, 10 of 50 (20%) of mothers reported a negative impact on breastfeeding, with only 4 (8%) stopping completely.13 Other studies highlight the importance of consultation with lactation professionals,14 that providing food to lactating parents would help assist breastfeeding efforts,9 and the benefits of peer support groups, although most studies took place in a neonatal intensive care unit or in low resource settings.15,16 The cumulative results of the limited research indicates that encouragement from medical staff and supportive hospital policies may help prevent early breastfeeding cessation due to hospital admission.Very few published resources are available to hospitals creating breastfeeding policies for readmitted children. The American Academy of Pediatrics (AAP) policy statement on human milk, published in 2022, does not address the care of the re-hospitalized infant, and the topic is only briefly mentioned in the AAP Breastfeeding Handbook for Physicians.1,17 Although the Academy of Breastfeeding Medicine’s (ABM) Clinical Protocol number 35 addresses breastfeeding during hospitalization, the majority of its recommendations focus on maternal rather than infant hospitalization.10Here, we identify several key areas along with potential steps for hospitals that admit children under 2 years of age to consider (Table 1). These target areas were developed by addressing barriers identified in the literature cited above, adapting recommendations from the ABM Clinical Protocol to infant hospitalization, using guidance from the AAP Breastfeeding Handbook, and drawing from our own experiences as pediatricians. The first target area addresses the hospital environment to ensure that the institution as a whole and each individual medical staff member supports breastfeeding. The second area focuses on eliminating barriers facing families who wish to continue to breastfeed during an inpatient admission. Target area 3 presents suggestions to minimize the negative effect of medical care and the hospital environment on breastfeeding. Finally, the paucity of research in this important area is impeding development of clear evidence-based guidelines for hospitals. In our final target area, we make a call to action to further study the impact of hospitalization on breastfeeding rates as well as on the effectiveness of implemented interventions. In the future, we envision the creation of formalized recommendations by a collaborative group of national leaders in this area but currently lack sufficient evidence to develop generalizable steps for implementation.Inpatient admission of a child is a challenging time for families. Although only a small portion of children will require a hospital stay in the first year of life, an admission can be a potentially catastrophic disruptor of the breastfeeding relationship, particularly for children with complex medical needs who may have multiple and/or prolonged hospitalization(s). All hospitals that care for young children should evaluate their internal policies and procedures to ensure an environment that bolsters rather than hinders breastfeeding during hospitalization. Pediatricians and other pediatric medical providers can work within their institution to develop relevant policies, advocate for individual patients, and teach trainees the importance of maintaining breastfeeding during hospital admissions. Lastly, professional organizations such as the ABM and AAP should aim to include infant hospitalizations in future policy statements. More research is needed to support continued refinement of evidence-driven interventions that minimize negative effects of hospital admissions on the breastfeeding relationship.