2021 platform presentations

Thursday, November 4, 3:15 - 4:15 pm

Skin to Skin Contact and Mother's Own Milk Consumption in Preterm Infant-Mother Dyads
Felicia Daniels, MD, Thao (Tina) Ho, DO, Adetola Louis-Jacques, MD, and Ambuj Kumar
Category: Research
Background: Mother’s own milk (MOM) has been shown to improve neurodevelopmental outcomes and reduce risks of co-morbidities. Human milk diet, preferably MOM over donor milk (DM), is recommended for preterm infants. Preterm mother’s milk contains more protein, fat, free amino acids and sodium when compared to DM, which is often pooled term milk. DM also has lower protective immunological components due to pasteurization. Skin to skin contact (SSC) has beneficial effects including decreased infant pain scores with procedures, decreased maternal stress response, and improved infant mother bonding. Although the literature suggests that SSC can increase MOM production, few studies have investigated the direct correlation between SSC and MOM consumption.
Materials/Methods: This was a prospective observational study for preterm infants born <34 weeks gestational age admitted to a level III NICU between 11/2019-12/2020. SSC documentation was reviewed retrospectively for feasibility in the electronic medical record (EMR). Infant-mother dyads were given a binder to document pumped breastmilk volumes and SSC sessions which was compared to EMR documentation. Pumped breastmilk volumes, enteral feedings, and SSC duration and frequency were collected daily over the first 28 days of life along with discharge feeding plans. Demographic, perinatal, and detail feeding data were also collected from EMR. Spearman correlation and Mann-Whitney U test were performed.
Results: We collected preliminary data on 29 infant-mother dyads with birth gestational age of 30 ± 3.2 weeks, birth weight of 1406 ± 524 grams, and maternal age of 31.5 ± 6.4 years. There was a correlation between daily SSC duration and pumped MOM (rho=0.198, p=0.020). The mean daily volume of ingested MOM was higher on the days SSC was performed than when SSC was not performed (160 [IQR=79-224] vs 125 [IQR=5-216] ml, p=0.001). Infants who went home with exclusive MOM diet had significantly more SSC time during the hospital stay than infants who went home with formula or mixed diet (732 [IQR=393-985] vs 465 [IQR=30-600] minutes, p=0.019).
Conclusions: SSC was associated with higher MOM production and consumption in the hospital and after discharge. Improving SSC practice can increase the preterm infant health benefits from MOM.

Effects of Maternal COVID-19 Vaccination on Breastfed Children
April Castillo, MD and Erin Lavin, M.Ed.
Category: Research
Background
: Although there is no clinical data on the use of COVID-19 mRNA vaccines in lactation, the United States Food and Drug Administration (FDA) Emergency Use Authorization (EUA) for the Moderna and Pfizer-BioNTech mRNA COVID-19 vaccines left open the possibility of administering the vaccine to lactating individuals. While most major medical societies have issued statements in support of vaccination of lactating women, they are based on theoretical risk, or lack thereof. The Academy of Breastfeeding Medicine stated “there is little biological plausibility that the vaccine will cause harm, and antibodies to SARS-CoV-2 in milk may protect the breastfeeding child” (ABM 2020). Of note, the Centers for Disease Control and Prevention (CDC) did not establish a registry for lactating mothers who receive the vaccine as of the writing of this IRB proposal, nor did they inquire about lactation on their V-safe after vaccination health checker. This presents a large gap in the data that urgently needs to be filled.
Materials/Methods: This is an observational cohort study of women physicians who provided breastmilk for one or more children at the time novel Covid-19mRNA vaccines began to be distributed in the United States. Subjects self-selected into cohort arms based on whether they received no vaccine (control), the Pfizer-BioNTech vaccine (Pfizer) or the Moderna vaccine (Moderna). Neither study participants nor the research team were blinded to vaccine allocation. Self-report outcome surveys which inquired about potential effects of vaccination on breastfed children were administered to individual participants 3 days after receipt of their first and second dose vaccinations. Two-month follow up surveys were also administered. . Subjects in the control arm completed surveys timed to that of their Pfizer counterparts. Exploratory factor analysis, Pearson chi square, and independent variable Kruskal-Wallis analyses were run to evaluate whether adverse effect outcomes differed amongst the three arms. Adverse effects assessed include irritability, fevers, rash, allergic reaction, lymphadenopathy (LAD), change in sleep, neurologic changes, behavioral changes, change in appetite, vomiting, diarrhea, and constipation. Significant results and pertinent negatives are reported.
Results: After the first dose, no adverse effects in breastfed children were found to be significantly different between the arms (N=1188: Control N=75, Pfizer N=795, Moderna N=318) after testing irritability, fevers, rash, allergic reaction, LAD, vomiting, diarrhea, or changes in sleep, behavior, or neurologic function. No significant differences between groups were noted in the number of children who needed medication for symptoms (p=0.447) or who needed to see a doctor (p=0.542). However, one child in the Pfizer group was taken to the ED for a brief resolved unexplained event (BRUE); it is unknown if this was related to the vaccine. This single hospitalization was not statistically significant (p=0.781).
After the second dose, some mild side effects were noted to be significant between the groups (N=759, Control N=55, Pfizer N=490, Moderna N=214). There were statistically significant increases in irritability (p=0.017), fever (p=0.026), and increased appetite (p=0.018) in the Pfizer group compared to the control. None of these differences were significant in the Moderna group compared to controls. Notably, a non-parametric Friedman test of differences revealed that fevers in children were directly correlated to fevers in mothers (p<0.001). None of the adverse events were found to be correlated to age of child. Additionally, no significant differences between groups were noted in the number of children who needed medication for symptoms (p=0.709) or who needed to see a doctor (p=0.701). No children were hospitalized.
At the time of this writing, some subjects were eligible for the two month follow-up survey (N=367, Control N=4, Pfizer N=273, Moderna N=110). Notably, all children about whom the two month follow-up survey had been completed had full resolution of all symptoms in less than two weeks, with the exception of increased appetite.
Conclusions: The decision whether to receive an mRNA vaccine for COVID-19 while breastfeeding is complicated by lack of information regarding adverse effects. This longitudinal survey study shows that after first dose maternal mRNA vaccination, adverse events were not observed in larger proportion among children of vaccinated mothers compared to children of unvaccinated controls. After the second dose, children of mothers who received the Pfizer-BioNTech vaccine had elevated proportions of irritability, fever, and increased appetite compared to children of mothers who were not vaccinated. Moreover, maternal vaccination was not correlated with breastfed children needing symptomatic treatment with medication nor medical attention from a doctor or emergency department.
Further research and larger populations are needed to confirm the safety of breastfeeding after mRNA covid vaccination. However, the data obtained in this study shows few statistically significant adverse effects in breastfed children of mothers receiving the Pfizer-BioNTech vaccine, and no significant effects in the breastfed children of mothers receiving the Moderna vaccine compared to the breastfed children of mothers who did not receive a vaccine. For subjects who have reached the two month follow-up, there has been full resolution of symptoms in under two weeks.

Implicit Association Test of Infant Feeding Among Healthcare Professionals
Beatrice Bichara, MS BSc, Sarah Brennan, MD, Katherine Murray, MB BCh U Dubl MICGO MScMedEd PGDip, Emily Stoll, BSc, Hannah Scott, Ian Stewart, and Amy Brown, PhD
Category: Research
Background: The purpose of our project was to develop the Infant Feeding Implicit Association Tool (IAT), which aims to measure implicit biases towards infant feeding among healthcare professionals. Implicit biases are measured according to IAT response times and self-report questionnaire. In response to Ireland’s poor breastfeeding rates, this project seeks to address the role of implicit bias in the therapeutic doctor-patient relationship as a possible target to optimize patient informed decision-making regarding breastfeeding.
Materials/Methods: An evidence-based and validated tool to measure implicit bias was developed. A literature review on breast and bottle feeding was conducted and terminology was selected for descriptions of biases towards each infant feeding method. An illustrator was commissioned to create image stimuli with minimal confounding bias. We consulted an IAT expert, behavioral psychologist, and international experts on breastfeeding medicine throughout the development of our tool. Our tool was piloted for feedback at the Academy of Breastfeeding Conference in 2019 and changes were implemented. The tool measures implicit bias to different infant feeding methods by recording response times to a series of comparative tests, using either terminology or images as stimuli. Completion of the test results in a score that represents a participant’s average response time to stimuli that are either consistent or inconsistent with the presumed bias. Explicit biases, attitudes and knowledge of breastfeeding were also assessed through the validated Iowa Infant Feeding Attitudes Scale (IIFAS)).
Results: We have successfully developed a validated tool to measure implicit infant feeding bias. Furthermore, this tool will allow us to compare results between different populations among healthcare providers. Piloting of the tool and data collection has begun.
Conclusions: Now that we have developed this tool, we will apply it to future research in hopes of optimizing breastfeeding rates, through education of healthcare professionals and increased awareness of implicit biases in medical practice.

The Effect of IV Fluid during Labour on Neonatal Weight Loss
Shereen Abd Elghani Soliman, IBCLC
Category: Research
Background: A weight loss of 10% or greater is generally cause for concern and merits further medical evaluation. Infants are given breast milk substitutes in the hospital shortly following birth for various reasons, including significant dehydration, hypoglycemia, maternal illness, medications that are contraindicated in breastfeeding, congenital deformation of the infant, delayed lactogenesis, hyperbilirubinemia, or if they have lost greater than approximately 7 to 10 percent of their body weight since birth .
Evidence as to the factors that contribute to excess weight loss in newborn infants is a multifaceted phenomenon. Fluid overload is one
clinical factor that not only affects the mother, but the newborn infant as well. A newborn may appear bloated when the mother receives
excess intravenous fluid, the proposed contributor to newborn weight loss. Interest in the association between intrapartum intravenous
fluid administration and newborn weight loss has given rise to several studies. Factors associated with newborn weight loss and concluded that epidural use was a contributor. Other factors included the infant’s sex, length of hospital stay, and initial birth weight. Epidural use may play a role in delayed infant suckling, which could explain the weight loss. Moreover, intravenous preloading has become routine in administering regional analgesia in order to counter maternal hypotension. The intravenous fluids used during labor may be associated with neonatal weight loss. These results support the opinion that a greater weight loss may be the result of the mother receiving intrapartum intravenous therapy. There has been a moderate amount of research that specifically examines the influence of intravenous therapy during labour and newborn weight loss and therefore forms the primary objective of this study
Materials/Methods: This study incorporated a cross sectional design in which 200 mother/baby charts were initially examined for consideration.
Exclusion criteria included multiple births, delivery complications in the mother or the infant, intravenous insertion in the infant, admission to neonatal intensive care, nasogastic feeds, malformations in the infant such as cleft lip or palate, or prematurity of less than 36 weeks. Infant birth weight was measured at birth and every 24 hours thereafter until discharge.
Results: Independent t-test analysis indicated significantly less intravenous infusion volume in the mothers of newborns with <7% weight loss (p<0.01). While a trend was observed, no significant difference was found in the duration of intravenous therapy between newborn weight loss groups (p=0.06). The initial birth weight was comparable in both newborn groups (p>0.05). However, absolute and relative weight losses were significantly different between the two groups (p<0.01). The duration of labour and gravida were not significantly different between newborn weight loss groups. The objective of this study was to determine if intravenous therapy before and during labour increased the risk of newborn weight loss. Binary logistic regression analysis indicated that increased intrapartum intravenous therapy significantly (p<0.013) increased the risk of newborn infant relative weight loss of ≥ 7%. Intrapartum intravenous therapy was found to explain 11% of newborn weight loss variance.
Conclusions: There is a significant relationship between the volume of intravenous therapy infused, and weight loss in a newborn. The utility of this finding is significant in that the infusion of intravenous therapy at the time of delivery is a controllable action. Therefore, policies should be reviewed regarding the use of intravenous therapy,taking into account the issues of the  potential significant impacts for the mother, the newborn, and the hospital.

Saturday, November 6, 10 - 11 am

Telemedicine for Breastfeeding Support in the NICU during the COVID-19 Pandemic and Beyond
Maria Obaid, MD, Sarriyah Hanif, BS, Jai Ahluwalia, Regina Eichenberger, PA-C MPH IBCLC, Patricia Krumholtz-Belkin, RN MSN PNP IBCLC, Annamma John, RNC MSN IBCLC, Tina Roeder, and Boriana Parvez
Category: Research
Background: Telemedicine has emerged as an essential medical tool during the COVID19 pandemic, affording uninterrupted services while ensuring the safety of both patients and providers. Its effectiveness in breastfeeding support especially for NICU mothers has not been studied. Lactation support plays an essential role in empowering mothers to successfully breastfeed. Mothers face tremendous barriers for initiation and sustaining breastfeeding in the NICU and post discharge. The pandemic has further exacerbated many of these obstacles. Our lactation service transitioned to telemedicine on March 18, 2020. We utilized all approved platforms to provide ongoing support to mother in the comfort of their own homes, while facilitating access to continued care with flexibility.
Materials/Methods: This is a case control study of mothers whose infants were admitted to our NICU from 1/1/2020 to 6/30/2020. Mothers in the Pre-Telemedicine (Pre-TM) group (1/1/2020-3/17/2020) received in-house lactation support while visiting their babies; mothers in the Telemedicine (TM) group (3/18/2020-6/30/2020) received telemedicine consults. Maternal and infant demographics, type of feeds in the first 24 hours and at discharge were analyzed. Follow-up survey will assess ongoing breastfeeding rates, including current type of feed, maternal preference of type of consult and satisfaction with each different type of consultations.
Results: There were 130 mothers in the Pre-TM and 161 in TM periods with 303 infants who survived to discharge (136 in Pre-TM and 167 in TM). There were 6 sets of twins in each cohort. We found no significant difference in maternal and infant demographics in the two groups. More infants in the TM group received their mothers' own milk (MOM) in the first 24 hours of life (39% vs 26%, p < 0.03); with infants not eligible for donor milk (DM) experiencing the greatest benefit (17% vs 7%, p <0.01). Exclusive breastfeeding at discharge increased during TM although not reaching statistical significance (18% vs 11%, p=0.1). During TM, mothers who were not successful in providing MOM in the first 24 hours of life, experienced the greatest improvement in exclusive breastfeeding at discharge (13% vs 3%, p <0.03).
Conclusions: During the TM period, more mothers were able to provide their own milk in the first 24 hour of life and the overall rates of exclusive breastfeeding were sustained. In our experience, telemedicine lactation support was easy to implement and proved to be an invaluable alternative to in-person consultations. Telemedicine should be incorporated to optimize breastfeeding support for all mothers even after the pandemic.

Multidisciplinary Newborn Well and Lactation Clinic: A Novel Approach to Improving Family Medicine Resident Lactation Education
Kara Garcia, MD IBCLC and Amy Jimenez, BS IBCLC
Category: Medical Education
Background: While the medical literature repeatedly identifies the importance of lactation instruction in educating Family Medicine residents, its provision are lacking in the United States . Given the nature of Family Medicine’s patient population and its specialty goals, this deficiency is ripe for improvement. Excellent care of the breastfeeding dyad has a long lasting health effects on both the mother and infant . While the need for lactation education of Family Medicine residents has been recognized, best practices for educational approaches have not been thoroughly explored. To address this gap, Eglin Family Medicine Residency Clinic (FMRC) developed a newborn well visit clinic pairing an IBCLC with an upper level year resident.
Materials/Methods: Eglin Military Treatment Facility is a community hospital based in semirural northwest Florida. It serves a population of approximately 52K patients compromised of active duty military and veteran families through both inpatient and outpatient medicine. The Family Medicine Residency is a fully accredited 3 year 12-12-12 program with a focus on obstetric skills. Upon graduation, Eglin Family Medicine Residency graduates care for military families assigned through the United States and world. 750 babies are born per year at this military hospital with almost all of them delivered by a supervised resident family medicine physician. Eglin AFB employs one IBCLC assigned to the inpatient unit who also responded to outpatient consult requests as needed. Additionally, FMRC has a Pediatrician/IBCLC on faculty.
Historically, while FMRC consistently exceed ACGME requirements for obstetrical deliveries, residents struggled to see the required number of pediatric patients. Additionally, infants of military and veteran families born at Eglin AFB hospital and civilian hospitals were seen for their routine hospital follow up at a wide variety of clinics ranging from civilian Family Health clinics to pediatric clinics to the Family Medicine residency clinic. Thus, breastfeeding dyads received varying degrees of lactation support and follow up appointments were difficult to arrange.
Into this situation, the Family Medicine Residency partnered with the IBCLC and developed a newborn clinic focused on consistent quality. The FMRC newborn clinic sees all infants born both at Eglin AFB and at civilian locations that are eligible for care within the military system. The clinic consists of either a PGY-2 or PGY-3 FM resident, IBCLC, and a staff family medicine or pediatrician faculty for supervision. Weight, bilirubin, and feeding evaluation are performed on each infant. Moms are evaluated for post-partum hypertension, wound care checks, and postpartum depression. Families receive anticipatory guidance, feeding guidance, and address common lactation concerns for the early postpartum visits.
Results: The multidisciplinary well infant clinic began in Jan 2021. It is conducted Monday through Friday in the afternoons, averaging 6 dyads per day. The multidisciplinary nature of the clinic enables dyads to receive high quality, consistent and greater lactation support. Within the military community, most mothers are geographically separated from their support systems. The default booking of newborns with FMRC’s newborn clinic has enabled the FM residents to substantially and consistently increase their number of pediatric visits. Preliminary forecasts demonstrate that this will greatly reduce the risk of missing the pediatric visit graduation requirement. Equally important, this clinic provides a venue to organically incorporate lactation education into resident training. Dyads are evaluated in tandem with both resident and IBCLC present for the entire visit.
Conclusions: The multidisciplinary clinic is in the beginning stages since its creation this year. So far feedback has been positive. Increasing resident education in lactation can have far reaching effects on increasing breastfeeding friendly culture in primary care GME practices. Capturing all newborn care within a health system in one clinic has led to improved consistency and safety for patients by decreasing dyads who ‘fall through the cracks’ when scheduling. Moreover, it provides a powerful venue to potentially improve quality through educating large numbers of residents. As the largest AF family medicine residency, this effect of this clinic is multiplied by our residents’ future work all over the US and world. This in turn has the potential to change AF medicine culture to become more breastfeeding friendly. Future research will focus on this newborn clinic’s effect on breastfeeding rates as well as resident graduate confidence in giving breastfeeding advice prior to and after the implementation.

Racial Disparities in Sudden Unexpected Infant Death in the United States: The Role of Breastfeeding
Melissa Bartick, MD, Alexis Barr, PhD, Lori Feldman-Winter, MD MPH and Henning Tiemeier, MD MA PhD
Category: Research
Background: The United States has one of the highest rates of Sudden Unexpected Infant Death (SUID) worldwide. Not breastfeeding is a known risk factor. SUID disproportionately affects non-Hispanic Blacks (NHB) and American Indian/Alaskan Natives (AI/AN), and these groups have lower rates of breastfeeding and higher preterm birth than other demographic groups. We sought to determine how much the risk of not-breastfeeding explains the disparities in SUID rates across demographic groups.
Materials/Methods: Using 13,640,174 US birth certificates and 12,842 linked SUID death certificates from 2014-2017, we performed multivariable logistic regression across demographic strata to analyze the risk of SUID by not-breastfeeding. In one model, we adjusted for 12 covariates including maternal age, smoking, marital status, education, preterm birth (<37 weeks), and insurance status. We calculated adjusted AdjRD for not-breastfeeding on SUID. A second model also included an interaction term for not-breastfeeding and preterm birth. We performed a mediation analysis with race as the exposure and not-breastfeeding as the mediator.
Results: Not-breastfeeding was a strong risk factor for SUID (aOR 1.63 (1.56, 1.70), although less prominent for groups with more prevalent SUID rates, NHB and AI/AN. The strongest association between not-breastfeeding and SUID was for Hispanics and Asians, in whom SUID is rare. Adjusted risk difference (AdjRD) was largest for NHB and Hispanics. Preterm birth and not-breastfeeding synergistically increased risk in all groups, but less in NHB. Mediation analysis showed not-breastfeeding mediated the effect of race on SUID ranging from 12.4% (NHB) to 19.9% (Hispanics).
Conclusions: Neither higher prevalence of not-breastfeeding nor preterm birth in NHB and AI/AN fully explains the higher SUID risk in these demographic groups. Multiple competing risks likely explain the lower effect of not-breastfeeding on SUID in NHB and AI/AN than in Asians or Hispanics, suggesting that structural determinants must be addressed to reduce racial disparities in SUID.

Reasons Associated with Cannabis Use Frequency among Breastfeeding Women: Results from an Online Survey
Teresa Baker, MD, Christine Garner, PhD RD, Kathleen Kendall-Tackett, PhD IBCLC FAPA, Christina Young, MD, and Thomas Hale, PhD PRh
Category: Research
Background: Cannabis has been increasingly reported among breastfeeding mothers. However, little is known about reasons for cannabis use in this population. The aim of this study was to understand factors associated with frequency of cannabis use.
Materials/Methods: An anonymous online survey was conducted among breastfeeding mothers who used cannabis. Reasons for and frequency of cannabis use were ascertained. Respondents were grouped by frequency of cannabis use: less-than-daily (n=686), low-daily (1-3 times/d; n=423), high-daily (≥4 times/d; n=218). Chi-square and ANOVA were used to test differences between groups. Ordinal logistic regression examined factors associated with the frequency of cannabis use.
Results: Half of the total sample reported using cannabis to “get high.” This reason was reported more among the most frequent users (p<0.001). Health reasons, however, were reported by 89% of the total sample. In fact, 2, 3, or 4 health-related reasons were reported by 19%, 26%, and 19%, respectively. The top 5 reasons reported were anxiety (87%), depression (70%), gastrointestinal symptoms (54%), chronic pain (46%), and posttraumatic stress disorder (34%). For each of these reasons, significant differences (p<0.001) were observed by cannabis use frequency with lower reports in the less-than-daily group, and higher reports in the high-daily group. Regression analysis revealed that the number of health reasons reported was the strongest predictor of cannabis use frequency. Compared to reporting no health reasons for cannabis use, the adjusted odds ratios of increasing cannabis use were 2.7, 5.6 and 13.1 for reporting 1-2, 3-4, and ≥5 health reasons, respectively.
Conclusions: Healthcare professionals need to understand the reasons that breastfeeding mothers use cannabis. Identifying women who report multiple co-morbidities or diagnoses may facilitate targeted conversations about mothers’ options for treatment to better address their needs and potential risks of cannabis exposure through breast milk.