Women's views and experiences of breastfeeding during the coronavirus disease 2019 pandemic: A systematic review of qualitative evidence.

The coronavirus disease 2019 pandemic affected breastfeeding women in various ways. Understanding their experiences during the pandemic is crucial for informing actionable recommendations, evidence-based strategies and future policies to support breastfeeding during global pandemics. This review aimed to synthesise qualitative evidence on women's breastfeeding perceptions, experiences and support needs during the pandemic. The Joanna Briggs Institute's (JBI) guidelines on systematic reviews of qualitative evidence were followed. MEDLINE, Embase, CINAHL and Web of Science Core Collection databases were searched. Methodological quality of included papers was assessed using JBI's checklist for qualitative research. The synthesised findings were generated using JBI's meta-aggregation approach. The JBI ConQual process was used to rank each synthesised finding. Fifty-two papers were included. The synthesised findings included: (1) women's awareness and commitment to breastfeeding during the pandemic, (2) the multifaceted breastfeeding experiences of women during the pandemic, (3) breastfeeding practices and challenges for working women, (4) professional support during the pandemic: navigating breastfeeding in an evolving health care context and (5) family and peer support groups during the challenging times of the pandemic. Breastfeeding women require clear information, accessible in-person lactation support, family emotional support, food security and protection of psychological well-being. The review reported diverse breastfeeding experiences, from social support challenges to positive aspects like remote work. Breastfeeding support and lactation consultants should be considered as essential services in future pandemics. Food security is crucial for breastfeeding households. Lactation services could prioritise face-to-face consultations for physical challenges and providing online informational support. Future research could explore innovative breastfeeding education strategies.

Infant Suck Strength Exam: Introduction of an Accessible Clinical Technique for Measuring Infant Suck at the Breast.

One of the core skills required in lactation support is understanding and correcting ineffective or painful breastfeeding. The behavior being corrected, however, occurs inside the infant's mouth, making it difficult to see and assess. When providing care in the field, we use standardized tools and digital suck exams. In research, instruments have been developed to measure infant suck strength with a pacifier, bottle, or at the breast using ultrasound. The aim of this article is to introduce a simple manual clinical technique to identify areas of weakness in an infant's suck and describe one treatment option that can be used to reduce weakness in the identified area. During the Infant Suck Strength Exam, the lactation support provider places a finger on the breast 2 to 4 cm from the edge of the infant's mouth at the upper and lower lip and then at both corners of the mouth, testing the strength of the suck in each of these four areas. To address any specific areas of weakness, the nursing parent can be taught to apply light skin traction back toward the chest wall at the affected area. This engages the suckling reflex and amplifies the strength of the infant's suck in that particular area. The traction applied should not indent the breast but rather just pull back on the skin. It should be applied with enough strength to challenge the infant without pulling the breast out. This is a teaching tool, and is typically only needed for a few weeks before the infant improves their nursing habits.

From Breastfeeding to Support in Mothers' Feeding Choices: A Key Role in the Prevention of Postpartum Depression?

The postpartum period represents a critical phase of profound transition for women. This timeframe encompasses the physical recuperation associated with childbirth, the intricate psychosocial adjustments inherent in assuming the role of motherhood and also important alterations in steroid and peptide hormones. Hence, as women navigate the reconfiguration of relationships and strive to address the diverse needs of their infants and family members, they concurrently grapple with dramatic transformations which are characteristic of the postpartum phase. In fact, relevant prevalence ranges are reported for maternity blues, a mild condition characterized by self-limited and transient depressive symptoms, but also a well-established risk factor for more serious postpartum mood disorders, such as depression (PPD), with an incidence of 10-15%. Unlike in the US, at the European level, there are no concrete recommendations for the routine integration of the assessment of the mother's emotional state by healthcare professionals, with a considerable risk of underdiagnosing or undertreating these conditions. In this regard, there is a growing body of scientific evidence on the important role of breastfeeding in reducing the risk of PPD and also of the importance of mothers' compliance with this practice. Indeed, sucking the baby regulates the circadian rhythm of the HPA axis and, together with the action of prolactin, the stress response is decreased. In addition, other positive consequences of breastfeeding, which are inversely correlated with the onset of PPD, include the regulation of sleep and waking patterns for mother and baby, the improvement of the mother's self-efficacy and her emotional involvement. It should also be considered that the request for support for breastfeeding can often conceal a request for support for motherhood itself and for the mother's emotional well-being. It therefore emerges that the personnel involved in primary pediatric care to provide adequate support in the transition to motherhood must support mothers in their breastfeeding choices, whether breastfeeding or formula feeding, so that each choice is made conscientiously and serenely. Therefore, neonatal feeding assumes a decisive role, since if, on the one hand, it regulates specific neurohormonal pathways that are protective for maternal emotional well-being (breastfeeding), on the other hand, support in mothers' breastfeeding choices, even in the case of formula feeding, means validating their being mothers in the absence of judgement and counteracting any feelings of inadequacy, conditions that are inversely correlated to DPP.

Investigating factors influencing decision-making around use of breastmilk substitutes by health care professionals: a qualitative study.

BACKGROUND: Breastfeeding is recognized as the gold standard of infant feeding and nutrition. The World Health Organization recommends exclusive breastfeeding (EBF) of infants for the first 6 months of life. A variety of factors may impact breastfeeding practices in-hospital which may continue after hospital discharge, such as the use of breastmilk substitutes (BMS). The Baby-Friendly Initiative (BFI), which aims to promote and support breastfeeding practices, established a target rate of 75% for EBF from birth to hospital discharge. Currently, this target is not being met at The Ottawa Hospital (TOH), indicating there is room for improvement in EBF rates. The purpose of this study is to explore health care professionals (HCP) decision-making around use of BMS and identify factors that drive the use of BMS with and without medical indications. METHODS: In this qualitative study, semi-structured interviews were conducted with HCPs within TOH from January to June 2022. All participants had experience in maternity or postpartum care and were probed on factors influencing use of BMS at this institution. Interview transcripts were coded using an inductive approach. RESULTS: A total of 18 HCPs were interviewed including physicians, midwives, lactation consultants, and registered nurses. Multilevel barriers influencing the use of BMS were categorized into patient, HCP, and institution-level factors. Subthemes that emerged ranged from parental preferences, training differences amongst HCPs, to budget and staffing issues. Over half of HCPs were prepared to answer questions on EBF and were familiar with the BFI. Although most were supportive of this institution receiving BFI designation, a few providers raised concerns of its impact on parents who would like to supplement. CONCLUSIONS: Several modifiable factors influencing decision-making for use of BMS were identified. These findings will be used to inform unit leads, help identify effective strategies to address modifiable barriers, and develop tailored breastfeeding supports to improve EBF rates.

Establishing Methods to Assess Baby-Friendly Hospital Initiative Compliance Using the Global Standards and Women's Self-Reported Experiences.

The World Health Organization recommends assessing compliance with key clinical practices of the Baby-Friendly Hospital Initiative (BFHI; Steps 3-9) using birthing women's self-reports. Globally, compliance is mainly assessed using health staff reports, and the use of women's self-reports in selected countries has deviated from the Global Standards for the BFHI. Therefore, we aimed to provide insight into the appropriate method of incorporating women's self-reports in assessing compliance with Steps 3-9 of the BFHI. We developed questions and coding algorithms for assessing compliance with Steps 3-9 based on Global Standards for BFHI compliance, and implemented them via a cross-sectional survey of 302 women who gave birth to a live baby in Sri Lankan hospitals. Compliance with specific practices within each of Steps 3-9 and overall compliance with each step were described as percentages. Compliance with specific practices and each BFHI Step ranged from 15.9%-100% and 7.0%-100%, respectively. Our findings particularly emphasize the potentially enhanced usefulness and robustness of assessing all specific practices within BFHI key clinical steps and not focusing only on one practice within a step, to derive more useful health service guidance globally for capturing BFHI compliance and its impact on breastfeeding outcomes. This method could be translated across multiple settings globally. It would enable more specific identification of care advancements required by health services to improve the effectiveness of breastfeeding support and address the prevailing undervaluing and under-use of women's experiential data to evaluate and guide health service improvement.

Support Networks for Exclusive Breastfeeding (SNEB). A conceptual approach and characterization in Mexico.

BACKGROUND: This study focuses on the conceptualization and graphical characterization of Exclusive Breastfeeding Support Networks (EBSN) in Mexico. METHODS: Through a sample design stratified by federal entity with state significance at 95%, a questionnaire was administered online via Microsoft Forms to a representative sample of 2989 women whose primiparity occurred in Mexico. The questionnaire primarily focused on sociodemographic data of the mothers and the structure of their EBSNs during primiparity. RESULTS: In this work, EBSNs are defined as networks mainly composed of women, whose function is to share knowledge and experiences about breastfeeding, as well as to provide emotional and physical support to breastfeeding mothers, contributing to strengthening the emotional and caregiving bonds between mothers and their newborns. CONCLUSIONS: Sankey diagrams were employed for the characterization of EBSNs, revealing that the mother of the primipara is generally the main node, resulting in a network with greater flow and reach. Conversely, when the first node is not related to the primipara, the networks tend to be smaller and with less flow.

INTRODUCCIÓN: Este estudio se centra en la conceptualización y la caracterización gráfica de las Redes de Apoyo a la Lactancia Materna Exclusiva (RALME) en México. MÉTODOS: Mediante un diseño muestral estratificado por entidad federativa con significancia estatal al 95%, se aplicó un cuestionario en línea, a través de Microsoft Forms, a una muestra representativa de 2989 mujeres cuya primiparidad fue en México. El cuestionario se enfocó principalmente en datos sociodemográficos de las madres y en la estructura de sus RALME durante la primiparidad. RESULTADOS: En este trabajo se definen las RALME como redes compuestas mayormente por mujeres, cuya función es compartir conocimientos y experiencias sobre la lactancia, así como ofrecer apoyo emocional y físico a madres lactantes, contribuyendo a fortalecer los lazos afectivos y de cuidado entre las madres y sus recién nacidos. CONCLUSIONES: Para la caracterización de las RALME se utilizó el diagrama de Sankey, revelando que la madre de la primípara es generalmente el nodo principal, lo que resulta en una red con mayor flujo y alcance. Por el contrario, cuando el primer nodo no tiene parentesco con la primípara, las redes tienden a ser más reducidas y con menor flujo.

The Rights of Physicians and Future Physicians Who Are Lactating, Breastfeeding, or Chestfeeding: An American Medical Women's Association Position Article.

Breastfeeding is a fundamental and biologically normal function with well-established benefits for both lactating parents and infants. Despite these benefits, physicians, particularly those in training, often face significant obstacles when attempting to meet their breastfeeding and pumping goals. In response to these challenges, the American Medical Women's Association (AMWA) and a diverse group of health care professionals have come together to advocate for comprehensive lactation support policies in medical learning environments and workplaces. This position article highlights the ethical necessity of comprehensive lactation support in medical educational and workplace settings, emphasizing the importance of not only providing physical accommodations but also fostering a cultural shift, educational initiatives, and policy reforms to empower lactating parents. It offers an examination of the difficulties encountered by lactating parents within medical environments and proposes guidelines for the formulation and enhancement of supportive policies. The position article envisions a future where medical professionals can thrive in both their careers and parenthood through collaborative efforts and a commitment to the key elements of Effective Lactation Support Programs in medical workplaces based on the following: (1) well-equipped lactation facilities, (2) customized work schedules, (3) mentorship and support networks, (4) lactation support in clinical settings, and (5) research and advocacy.

Effectiveness of a Postpartum Breastfeeding Support Group Intervention in Promoting Exclusive Breastfeeding and Perceived Self-Efficacy: A Multicentre Randomized Clinical Trial.

There are numerous recognized benefits of breastfeeding; however, sociocultural, individual, and environmental factors influence its initiation and continuation, sometimes leading to breastfeeding rates that are lower than recommended by international guidelines. The aim of this study was to evaluate the effectiveness of a group intervention led by midwives supporting breastfeeding during the postpartum period in promoting exclusive breastfeeding, as well as to assess the impact of this intervention on perceived self-efficacy. This was a non-blind, multicentric, cluster-randomized controlled trial. Recruitment started October 2021, concluding May 2023. A total of 382 women from Andalusia (Spain) participated in the study. The results showed that at 4 months postpartum there was a higher prevalence of breastfeeding in the intervention group compared to formula feeding (p = 0.01), as well as a higher prevalence of exclusive breastfeeding (p = 0.03), and also at 6 months (p = 0.01). Perceived self-efficacy was similar in both groups for the first two months after delivery, which then remained stable until 4 months and decreased slightly at 6 months in both groups (p = 0.99). The intervention improved the average scores of perceived self-efficacy and indirectly caused higher rates of exclusive breastfeeding (p = 0.005). In conclusion, the midwife-led group intervention supporting breastfeeding proved to be effective at maintaining exclusive breastfeeding at 6 months postpartum and also at increasing perceived self-efficacy.

Health professional competency building for the Baby-Friendly Hospital Initiative in Malawi.

Health professional competency building is one of nine national responsibilities (to achieve universal coverage and sustainability) described in the 2018 World Health Organization (WHO)/United Nations Children's Fund (UNICEF) implementation guidance for the Baby-Friendly Hospital Initiative (BFHI). With stagnating rates of exclusive breastfeeding worldwide, skilled breastfeeding support as a standard of newborn care is critical to the establishment of lactation and exclusive breastfeeding. Few studies exist on how low-income countries are integrating BFHI into their standards of care. This qualitative case study describes Malawi's experience. We interviewed 48 key informants and conducted a desk review of the literature on BFHI programming, national plans, policies and other related documents. We explored the findings using the seven key domains and 16 competencies to implement the Ten Steps to successful breastfeeding from the WHO and UNICEF Competency Verification Toolkit. The study found that although the focus of the guidance is on preservice training, continuing education and in-service training remain important. To achieve universal coverage for health professional competency, Malawi uses preservice, in-service and refresher training. However, their main limitations to aligning with the new guidance are a lack of preservice BFHI- and breastfeeding-specific curricula, experienced lecturers and sufficient time to dedicate to practical skill development. Conducted during the coronavirus disease 2019 pandemic, this study confirmed disruptions to BFHI training and service delivery, while also documenting Malawi's resilient attempts to mitigate impacts on breastfeeding support through mentoring and coaching. Opportunities exist for strengthening and scaling up, including engaging preservice training institutions and standardizing mentoring, coaching and competency verification.

Dysphoric milk ejection reflex among Japanese mothers: a self-administered survey.

BACKGROUND: The dysphoric milk ejection reflex (D-MER) is a reflex that causes temporary discomfort during milk ejection. D-MER develops due to the effects of hormones involved in lactation, and it has been reported that it is a physiological symptom different from postpartum depression, but the actual situation is unknown in Japan. METHODS: This study was conducted using a self-administered, anonymous survey of mothers of children who had undergone health checkups at three years of age at five health centers in Kagoshima city and aimed to clarify the reality and perceptions of mothers regarding D-MER. The survey period was from May to September, 2022. The questionnaires were distributed to 389 mothers, and 216 (55.5% recovery rate) responses were received, of which 202 (valid response rate 93.5%) were included in the analysis. RESULTS: Regarding the experience of D-MER, 202 mothers in the study population had given birth to a total of 403 children and experienced D-MER when breastfeeding 62 children (15.4%). Of the 202 mothers included in the analysis, 47 (23.3%) answered that they had experienced D-MER with at least one child while breastfeeding. Sixty-six mothers (32.7%) knew about D-MER. Compared to those who had not experienced D-MER, those who had experienced D-MER had significantly higher scores on the items related to having had trouble breastfeeding (odds ratio (OR]: 3.78; 95% confidence interval (CI]: 1.57, 9.09) and knowing about D-MER (OR 2.41; 95% CI 1.20, 4.84). Regarding symptoms, irritability (n = 24, 51.1%), anxiety (n = 22, 46.8%), and sadness (n = 18, 38.3%) ranked high. Coping strategies included distraction, focusing on the child, and, in some cases, cessation of breastfeeding. Thirty mothers (63.8%) answered that they did not consult anyone, citing reasons such as a belief that no one would be likely to understand their symptoms, and that they could not sufficiently explain their symptoms. CONCLUSION: The low level of awareness of D-MER suggests that it is necessary to inform and educate mothers and the public about the physiological symptoms of D-MER. Moreover, it is necessary to listen to the feelings of mothers with D-MER and support them in coping with their symptoms.

Facilitators and Barriers of Wet Nursing from Antiquity to the Present: A Narrative Review with Implications for Emergencies.

Background: If maternal breastfeeding is not possible, wet nursing allows infants to receive the nutrition and protection against disease that breastfeeding provides. Such protection may be particularly valuable in emergencies. However, while wet nursing is recommended in the Operational Guidance on Infant and Young Child Feeding in Emergencies it is underutilized. This narrative review aimed to develop an understanding of wet nursing practice across time and location, and why wet nursing is currently so little supported to inform interventions to support wet nursing in emergencies. Method: Medline and Embase were searched for "wet nursing," "cross-nursing," "shared breastfeeding," and "non-maternal nursing". Included articles were inductively analyzed to identify positive and negative factors associated with previous wet nursing practice. Results: This review included 74 records. Our analysis of the wet nursing literature includes historical and contemporary themes with milk kinship and wet nursing as risky being shared themes across time periods. Our analysis revealed that it is how wet nursing is undertaken that influences whether it benefits women, children, and societies or not. Facilitators and barriers to wet nursing in emergencies related to infant mortality rates, cultural and individual support for wet nursing, availability of wet nurses, and resources to support wet nursing. Conclusion: Understanding the conditions under which wet nursing has positive outcomes and what can be done to facilitate beneficial wet nursing practices will assist in enabling wet nursing to be more commonly implemented in emergencies.

Multicomponent perinatal breastfeeding support in women with BMI >25: The Latch On multi-centre randomised trial.

OBJECTIVE: To investigate the effectiveness of a multicomponent breastfeeding support intervention on breastfeeding prevalence at 3 months among women with a body mass index (BMI) >25 kg/m2. DESIGN: Multicentre multicomponent randomised controlled trial. SETTING: Four maternity centres in Ireland. POPULATION: A total of 225 primiparous women and their nominated support partners. Participants were aged 18 years and over, with BMI ≥25 kg/m2, carrying a singleton pregnancy and without contraindication for breastfeeding. METHODS: The intervention included an antenatal group breastfeeding education session for participants and their support partners, followed by a planned postnatal breastfeeding assessment and telephone support for up to 6 weeks by a lactation consultant. MAIN OUTCOME MEASURES: Any breastfeeding at 3 months postpartum. RESULTS: Any breastfeeding prevalence was 68.7% (n = 68) in the intervention group and 62.1% (n = 59) in the control group at 3 months postpartum (odds ratio 1.33, 95% confidence interval 0.72-2.46, p = 0.36). Any and exclusive breastfeeding rates did not significantly differ at any other time point. More women in the control group accessed support from private lactation consultants (intervention 23.5% [n = 12], control 45.3% [n = 24], p = 0.02). CONCLUSIONS: The control group had higher than expected breastfeeding rates, and the study found no evidence of effect on the primary outcome. Providing comprehensive education and support for women intending to breastfeed remains of paramount importance.

'Breastfeeding exclusivity, difficulties, and support in the first days after hospital discharge: A correlational study'.

OBJECTIVE: Global breastfeeding rates are not optimal, and the early postpartum period represents a critical time for breastfeeding initiation. The Baby-Friendly Hospital Initiative endeavours to provide mothers with evidence-based breastfeeding support in birth hospitals. This study examined factors associated with breastfeeding exclusivity and breastfeeding difficulties in the first days after being discharged from Baby-Friendly designated hospital. The adequacy of breastfeeding support and maternal preferences for optimal support were also reported. STUDY DESIGN: A non-experimental correlational study was conducted between May 2021 and October 2022. A total of n = 80 breastfeeding mothers completed a semi-structured questionnaire within two weeks of discharge from Baby-Friendly hospital in Finland. The questionnaire included demographic and obstetric background information and six questions on breastfeeding exclusivity, breastfeeding difficulties, and breastfeeding support. Descriptive statistical analysis and multivariate binary logistic regression analysis were performed. RESULTS: The mean age of the mothers was 30.6 years (SD 5.4), and half of the mothers were primiparas (49 %). Most mothers gave birth vaginally (85 %) to a full-term infant (84 %). Most (85 %) had made some prenatal plans for breastfeeding, and the median planned duration of breastfeeding was 12 months. Half of the infants (53 %) received supplemental milk while in the hospital. Most mothers (81 %) were exclusively breastfeeding after hospital discharge. Mothers whose infants received supplemental milk in the hospital had an increased odds of non-exclusive breastfeeding (aOR 16.5 [CI 95 % 1.7-156.7], p 0.015). Approximately one-third of the mothers (39 %) experienced breastfeeding difficulties. Primiparous mothers had increased odds of experiencing breastfeeding difficulties (aOR 3.41 [CI 95 % 1.2-9.8], p 0.023). Mothers who received adequate postnatal breastfeeding support in birth hospital had decreased odds of experiencing breastfeeding difficulties (aOR 0.16 [CI 95 % 0.03-0.8], p 0.026). Mothers were mainly satisfied with breastfeeding support, although timelier access to support was preferred after hospital discharge. CONCLUSION: Adequate in-hospital postnatal breastfeeding support, including avoidance of non-medical supplementation, contributes to successful breastfeeding after hospital discharge in terms of more exclusive breastfeeding and fewer breastfeeding difficulties. Primiparous mothers need emphasized support to mitigate breastfeeding difficulties. Timelier access to breastfeeding support after discharge is needed.

Breastfeeding support among re-hospitalized young children: a survey from Italy.

BACKGROUND: In 2021, the Task Force on Breastfeeding of the Italian Ministry of Health released a document calling for the provision of breastfeeding support in case of re-hospitalization of the child after birth. Since type and quality of breastfeeding support during re-hospitalization in Italian Pediatric Units (PUs) is largely unknown, the Breastfeeding Section of the Italian Society of Pediatrics (TASIP) conducted an ad hoc national survey. METHODS: In March 2023, a specifically designed electronic questionnaire was sent to the Directors of 328 PUs, who were requested to fill it online. RESULTS: Data from 161 PUs were received, with a response rate of 48.7%. Our results highlighted that 18.6% of units do not provide training on breastfeeding for healthcare professionals and 46% of PUs lack of an ad hoc policy on breastfeeding support in case of re-hospitalization of the child. Although 88.2% of PUs provide breast pumps to the mothers of the re-hospitalized young children, 34.8% lack of a protocol on the storage of expressed breast milk. CONCLUSIONS: Breastfeeding support for the mothers of hospitalized breastfed young children appears to be suboptimal in Italian PUs. Interventions aimed to structure and improve the quality of breastfeeding support for the mother-child dyad are needed, particularly developing protocols and providing a training on breastfeeding to the majority of healthcare professionals.

Breastfeeding experience of postnatal mothers separated from preterm infants after discharge: a phenomenology qualitative approach.

BACKGROUND: Breastfeeding practices are influenced by the maternal-infant bond relationship. Mothers of preterm infants in the puerperium face many challenges and support is needed to maintain breastfeeding after hospital discharge. This study explored the breastfeeding experiences among mothers of preterm infants and challenges that influenced their breastfeeding practices. METHODS: A qualitative phenomenological approach was used involving the mothers of preterm infants during the puerperium in Shanghai who fulfilled the inclusion criteria and consented to participate in the study. The mothers were recruited using purposive sampling. Eighteen participants were interviewed using semi-structured in-depth interviews. All interviews were recorded in digital audio, transcribed verbatim, and analyzed using thematic analysis. FINDINGS: The breastfeeding experience among mothers of preterm infants included four themes: breastfeeding motivation, breastfeeding challenges, breastfeeding support and education, and response to parental stress. Breastfeeding challenges included perceived insufficient milk, bottle preference, and maternal-infant separation. Two sub-themes of breastfeeding support included breastfeeding knowledge and approach. CONCLUSION: To overcome breastfeeding challenges and improve the breastfeeding rate of preterm infants after discharge, medical professionals must develop individualized breastfeeding plans based on a comprehensive assessment of the needs of mothers who delivered a preterm infant.

New Validated Tool to Diagnose Breastfeeding Dysfunction.

BACKGROUND: Breastfeeding behaviors and experiences exist on a continuum. What differentiates normal from dysfunctional is defined by frequency and severity. No current validated tool addresses the subjective experience of dyads with a predictive score that can be followed over time. RESEARCH AIM: To create and validate a self-report tool to assess breastfeeding and evaluate its ability to predict risk of breastfeeding dysfunction. METHODS: This study used a cross-sectional design to determine the validity of a novel instrument to assess breastfeeding dysfunction. We gave the initial questionnaire to 2085 breastfeeding dyads. We assessed content validity by comparison with other tools. We used exploratory factor analysis with varimax rotation for concept identification and Cronbach's alpha for internal consistency. We employed logistic regression to assess the tool's ability to differentiate between normal breastfeeding and breastfeeding dysfunction. RESULTS: Factor analysis mapped 17 questions to four concepts to create a score (FLIP; flow, latch, injury [to the nipple], and post-feed behavior). Internal consistency and reliability of the scores in these concepts were acceptable (Cronbach's alpha ≥ 0.087 for all measures). A logistic regression model that controlled for infant age, with a breastfeeding dysfunction risk classification threshold of 60%, yielded a correct classification of 88.7%, with 93.1% sensitivity, 64.6% specificity, and a 6.5% false positive rate. CONCLUSIONS: The FLIP score was determined to be a valid and reliable instrument for quantifying the severity of breastfeeding dysfunction in children under 1 year old. Further studies will assess its usefulness in the management of breastfeeding dysfunction.

Community Pharmacists' Current Practice and Educational Needs in Breastfeeding Support in Jordan: A Cross-Sectional Study.

BACKGROUND: Improving breastfeeding practices is a worldwide priority. Pharmacists have the opportunity to actively promote breastfeeding and educate parents as well as the general public about its benefits. RESEARCH AIMS: The aims of this study are to investigate Jordanian pharmacists' present breastfeeding support practices and perceptions regarding their need for education and training in breastfeeding support. METHODS: To examine sociodemographic characteristics of community pharmacists in Jordan and their current breastfeeding support practices and educational needs, a descriptive cross-sectional online (self-report) survey was conducted. Through social media, pharmacists working in community pharmacies in Jordan were recruited between August 2021 and February 2022. The level of breastfeeding support participants had been provided with was measured using eight items in a 5-point Likert scale ranging from 5 (Always) to 1 (Never). Each participant self-reported the frequency of advice/information given to breastfeeding women in each of these areas. Univariate and multivariable linear regression models were used to identify factors associated with the level of breastfeeding support. RESULTS: Participants (N = 381) reported a high level of breastfeeding support, but expressed a need for training and education for further improvement. The breastfeeding support score of female participants was found to be 0.12 higher than that of males (Beta = 0.12, p = .02), 0.16 higher in married participants compared to non-married participants (Beta = 0.16, p = .03), and 0.10 higher in participants working in rural areas compared to those working in urban areas (Beta = 0.10, p = .04). CONCLUSION: While community pharmacists generally report a high level of breastfeeding support, our findings revealed demographic differences. Attention to specific areas of need might enhance what pharmacists could offer; however, additional research would be required to guide the specific educational content.

Early Bloomers: A Nursing-Driven Program to Support Human Milk Feeding Among Late Preterm Infants in the Mother-Baby Unit.

Late preterm infants have lower breastfeeding rates than term infants, yet few published interventions or guidelines exist to guide hospitals in managing them in the non-intensive nursery setting. Here we describe the development and implementation of an interdisciplinary, hospital-based, breastfeeding support program among late preterm infants not requiring intensive care. The Early Bloomer Program includes an order set applied at birth, immediate lactation consultation, availability of donor milk, parent education on late preterm infants, hand expression teaching and kit including spoon and video link, and daily interdisciplinary team huddles. The program was developed with staff input using Diffusion of Innovation Theory, and implemented first among early adopters before expanding to all postpartum nurses. Nursing staff received education on late preterm infant physiology and feeding, and trainings on the Early Bloomers program through various learning modalities during the year leading up to implementation. To further understand the strengths and weakness of the program, we surveyed nurses (n = 43). Nurses reported that they were more attentive to the needs of late preterm infants, more confident in their care, and more aware of possible complications and feeding needs. Areas noted in need of improvement included lack of overnight lactation consults and little involvement of labor and delivery staff in the program. The Early Bloomers program increased confidence in care and was well received by nurses. Well-designed clinical studies are needed to identify effective breastfeeding support practices for late preterm infants.

Does planning to mixed feed undermine breastfeeding?

Continued breastfeeding is important for infants' health, but it is unclear whether mixed feeding increases the risk of breastfeeding cessation. We aimed to explore associations of mixed feeding and lactation problems with early cessation of breastfeeding. We analysed data from mothers who completed the Scottish National Maternal and Infant Feeding Survey and had previously breastfed their infants. At age 8-12 weeks, mothers (N = 1974) reported their feeding history and intentions, lactation problems and reasons for giving formula milk. The main outcome measure was cessation of breastfeeding before 6-8 weeks and time to cessation. By 6 weeks, 65% had mixed fed at some point, 32% had ceased breastfeeding, 22% were currently mixed feeding and 46% were exclusively breastfeeding. Lactation problems before 2 weeks were common (65%), and strongly associated with stopping breastfeeding (relative risk [RR]: 3.23, 95% confidence interval [CI]: 2.0-5.3) and with mixed feeding (RR: 3.14, 95% CI: 2.5-4.0). However, even after adjustment for breastfeeding problems mothers who planned to mixed feed (RR: 3.39, 95% CI: 2.4-4.9) and those who introduced formula for practicalities (RR: 3.21, 95% CI: 2.3-4.4) were more likely to stop breastfeeding. These variables also predicted later lactation insufficiency (planned mixed feeding RR: 1.39, 95% CI: 1.0-2.0; formula for practicalities RR: 1.76, 95% CI: 1.3-2.3). Mothers who received specialist lactation support were less likely to cease breastfeeding (RR: 0.63, 95% CI: 0.5-0.9) but nonspecialist input was unrelated to risk of cessation (RR: 1.06, 95% CI: 0.2-4.9). In conclusion, choosing to mix feed an infant is strongly associated with stopping breastfeeding, even in the absence of lactation problems.

Development of the generic Community Infant and Young Child Feeding Counselling Package.

Infant and young child feeding (IYCF) promotion is a key component in the set of high impact interventions to improve nutrition. The literature provides evidence of the positive impact of IYCF promotion through various platforms, including communities. In 2009, UNICEF and WHO agreed that a global, "generic" IYCF package of resources and tools to plan, implement, and monitor community-based IYCF programmes and to build skills of community-based workers was needed. In 2010, the UNICEF Community Infant and Young Child Feeding Counselling Package was finalized and field tested under a strategic collaboration between UNICEF New York and Nutrition Policy and Practice and the Center for Human Services/University Research Company. The Package includes 11 tools to guide adaptation of the materials, the design, planning, and implementation of IYCF programmes and the training, monitoring, supervision, and mentoring of community workers, using an interactive and experiential adult learning approach. The Package was rolled out from 2011 onwards and by 2017 was implemented in 87 countries. In 2013, UNICEF and the United States Agency for International Development-funded Strengthening Partnerships, Results, and Innovations in Nutrition Globally project started planning the evaluation, and a study site was selected in Nigeria to assess the efficacy and effectiveness of the Package on IYCF practices, knowledge, and worker skills. This article describes the need for and development of the Package, its content and approach to skills building, as well as its current implementation. Finally, it makes the case for the evaluation of the Package, which is covered in the other papers in the Supplement in relation to the Nigeria evaluation.