key: cord-0818697-cklyzg4h
authors: Gomez, Jessica; Wardell, Diane; Cron, Stanley; Hurst, Nancy
title: Relationship Between Maternal COVID-19 Infection and In-hospital Exclusive Breastfeeding for Term Newborns
date: 2022-05-20
journal: J Obstet Gynecol Neonatal Nurs
DOI: 10.1016/j.jogn.2022.05.002
sha: f1cd16ea69b4b282d32a62c772d98bf66fb10d4c
doc_id: 818697
cord_uid: cklyzg4h

Objective To evaluate the relationship between maternal COVID-19 infection and the odds of in-hospital exclusive breastfeeding for term newborns. Design Retrospective descriptive quantitative. Setting A large, urban hospital with more than 6,000 births annually. Sample Term newborns born between March 1, 2020, and March 31, 2021 (N = 6151). Methods: We retrospectively extracted data from electronic health records to evaluate the relationship of maternal COVID-19 infection with the odds of in-hospital exclusive breastfeeding using univariate analysis and logistic regression models. The covariates included insurance type, race/ethnicity, glucose gel administration, length of stay, newborn gestational age, newborn birth weight, and maternal COVID-19 infection. Results Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding (p = .138) after adjusting for covariates in the logistic regression model. However, when newborns who received pasteurized donor human milk supplementation were excluded from the logistic regression model, maternal COVID-19 infection significantly decreased the odds of in-hospital exclusive breastfeeding (p = .043). Conclusion Maternal COVID-19 infection was not significantly related to the odds of in-hospital exclusive breastfeeding when newborns received donor human milk supplementation. Access to donor human milk for supplementation for term newborns may protect the odds of in-hospital exclusive breastfeeding.

2. The use of pasteurized donor human milk for supplementation may protect the odds of in-28 hospital exclusive breastfeeding despite maternal 3. Improving access to pasteurized donor human milk for supplementation of term 30 newborns may help to maintain in-hospital exclusive breastfeeding when mother-31 newborn separation is necessary. Many of the supportive breastfeeding practices recommended by the Baby-Friendly 47 and long term (Sriraman, 2017; Yu et al., 2019) . Indeed, exclusive breastfeeding in the hospital 74 after birth is a significant predictor of continued breastfeeding (Vehling et al., 2018) . Therefore, 75 hospital practices designed to support exclusive breastfeeding are critical. 76 The effect of changing practices regarding mother-newborn separation and visitor 77 restrictions in hospitals after birth could reasonably alter a woman's plans for breastfeeding.

Because separation may require supplementing expressed mother's milk with DHM or formula, 79 we hypothesized that in-hospital exclusive breastfeeding rates would decline in the presence of 80 maternal COVID-19 infection. Therefore, the objective of our study was to evaluate the 81 relationship between maternal COVID-19 infection and the odds of in-hospital exclusive 82 breastfeeding for term newborns born between March 2020 and March 2021.

Design 85 We used a retrospective descriptive quantitative design to determine the breastfeeding The University of Texas Health Science Center at Houston granted human subjects approval.

Both institutional review boards waived the requirement of informed consent.

We conducted our study at a large academic women's and children's hospital in southeast 92 Texas with more than 6,000 births per year. The facility was initially designated Baby Friendly 93 in 2016 and completed the re-designation survey in January 2022. Clinical staff members are 94 trained on the practices required to achieve the BFHI 10 steps for successful breastfeeding.

Augmenting the support provided by nursing staff is a robust lactation and human milk lab department that offers lactation consultation from a nurse who is a board-certified lactation 97 consultant and with peer breastfeeding counselors (24/7 coverage) for higher acuity couplets in 98 the mother-baby units, including mothers of newborns admitted to critical care units (e.g., 99 neonatal and cardiovascular). The department also offers an outpatient breastfeeding clinic for 100 in-person and e-health lactation consultation following hospital discharge. Milk lab services 101 include technical support related to the storage, preparation, fortification, and delivery of 102 mothers' own milk and DHM. Post-birth clinical practice includes skin-to-skin contact between 103 the newborn and mother immediately after birth unless a maternal or postnatal medical reason 104 delays this practice. Skin-to-skin contact continues for at least 1 hour or until breastfeeding is 105 initiated. If any reason necessitates mother-newborn separation, mothers are supported to express 106 milk for their newborns. When supplementation is medically indicated for breastfed newborns in 107 the mother-baby unit, mothers are given the option to use DHM rather than formula if their own 108 expressed milk is not available. Donor human milk is provided at no cost to patients. We included newborns born between March 1, 2020, and March 31, 2021 who were 122 discharged from the mother-baby unit before 5 days after birth. Newborns were excluded if they 123 were born at less than 37 completed weeks gestation, had a birth weight of 2.0 kilograms or less, 124 were admitted to the NICU, or did not have a documented weight and gestational age (GA). We 

Of the 6,542 newborns born during the study's year, 6,151 met the inclusion criteria. We 129 excluded 373 with a GAs less than 37 weeks, 17 with length of stays (LOS) of 5 days or longer, 130 and one who did not have a documented GA and birth weight. We included twin newborns if 131 they met the inclusion criteria. Forty sets of twins were included, and the feeding status of each 132 twin was considered individually.

We extracted newborn feeding status from the electronic health record based on the 135 milk/feed type recorded by nursing staff: breastfed, expressed mother's milk, colostrum, DHM, 136 or formula. Exclusive breastfeeding was the dependent variable that we defined as receipt of 137 only human milk, which included direct breastfeeding, expressed mother's milk, and DHM with We also included the following as variables: maternal COVID-19 status, newborn GA, weight at 142 birth, newborn feeding during the hospital stay, receipt of glucose gel, LOS, race/ethnicity, and 143 insurance type (i.e., self-pay, private, or Medicaid). Social determinants such as race/ethnicity 144 and insurance type may be associated with breastfeeding rates (CDC, 2019) and so we included 145 them as variables. We used insurance type was used as a marker of socioeconomic status, as 146 described by Snyder and Chang (2020). To evaluate potential covariates, we completed unadjusted univariate analyses for all 153 variables to test for associations with exclusive breastfeeding. We used chi-square tests for 154 categorical variables (maternal COVID-19 status, glucose gel administration, insurance type, and 155 race/ethnicity) and t tests for independent samples for continuous variables (GA, birth weight, 156 and LOS). We used JMP (version 16.0.0, 2021) for data analysis. 157 We included all variables that had significant univariate relationships with exclusive 158 breastfeeding as covariates in the logistic regression models with exclusive breastfeeding as the 159 dependent variable. The covariates included in each model were insurance type, race/ethnicity, 160 glucose gel administration, LOS, newborn GA, newborn birth weight, and maternal COVID-19 161 status. Because the use of DHM in healthy term newborns is not common practice, we also used 162 a logistic regression model that excluded the newborns who received DHM (n = 476) from the 163 exclusive breastfeeding group (Belfort et al., 2018; Sen et al., 2018) . We also added an interaction term in the logistic regression model to evaluate the interaction between 165 race/ethnicity and insurance status.

Demographics 168 Overall, the sample was racially and ethnically diverse: 29.9% White Non-Hispanic, 169 42.2% Hispanic, 19.8% African American, and 7.3% Asian (see Table 1 ). Most mothers (52.4%) 170 had private insurance, 45.4% had Medicaid, and 2.1% were self-paying. Additionally, 371 (6%) 171 of mothers tested positive for COVID-19 and had a mean LOS of 2.06 days (SD = 0.6).

Newborn feeding status was documented as exclusive breastfeeding in 54% of dyads. Of 

We estimated a second logistic regression model for exclusive breastfeeding, not 200 including those receiving DHM and adjusted for insurance type, race/ethnicity, glucose gel 201 administration, LOS, newborn GA, newborn birth weight, and maternal COVID-19 status (see 202   Table 4 ). The overall model explained a small but significant amount of variance in exclusive Note. OR = odds ratio; CI = confidence interval. 

AAP issues guidance on infants born to mothers with 299 suspected or confirmed COVID-19

American Academy of Pediatrics. (2020b) . Rooming-in, with precautions, now OK