Running head: SPECIALIZED BREASTFEEDING EDUCATION

Specialized Breastfeeding Education vs. Standard Education Claire Hobelmann University of South Florida

Specialized Breastfeeding Education Abstract Clinical problem: Breastfeeding is the most natural, cost effective, and safest form of feeding a new baby. Formula feeding, however, is still regularly practiced in the hospital setting. Breastfeeding transfers antibodies from the mother to the baby, which strengthens the babys immune system and decreases the chance that they will develop an infection or illness, therefore decreasing the likelihood of a hospital readmission and increased costs. Objective: To discover if the evidence-based practice interventions researched and published can increase the rate of breastfeeding in new mothers and decrease the rate of formula feeding. Data sources: Three randomized control trials from CINAHL Plus. The keywords used to find sources included breastfeeding vs. formula feeding, breastfeeding education, and infant formula. A clinical guideline was obtained from the Academy of Breastfeeding Medicine (ABM) referring to the promotion of breastfeeding in the prenatal setting. Results: The clinical guideline from ABM recommended incorporating breastfeeding promotion, education, and support throughout prenatal care, among other interventions. The research completed by Ciftci and colleagues (2012), McQueen and colleagues (2011), and Thakur and colleagues (2012) concluded that specialized education increased the rate of mothers breastfeeding and reduced the percentage of respiratory illness, etc. Conclusion: After synthesis of the included studies, it has been shown that support and focused one-on-one education for new mothers can significantly increase the rate of breastfeeding in the hospital setting and further into the home setting. Research is still needed on the use of specialized education in the NICU setting and on mothers of babies who have been readmitted to the hospital after birth with an illness secondary to formula feeding.

Specialized Breastfeeding Education Specialized Breastfeeding Education vs. Standard Education Breast feeding offers a wealth of positive effects for both mother and baby; but formula feeding, which carries a higher risk of the baby developing an illness, is still being practiced regularly in the clinical setting. The World Health Organizations (WHO) recommends that babies are breastfeed from birth to at least six months of age, and subsequently introduced to solid and semi-solid foods with the supplementation of breast milk up to two years of age (Demirtas, 2012). Research has shown that breastfeeding offers a lesser chance of the baby developing a gastrointestinal or respiratory illness, type I and II diabetes, otitis media, and childhood leukemia, among other diseases. Furthermore, breastfeeding provides numerous benefits to the mother including a reduced incidence of breast cancer, ovarian cancer and postpartum depression (Demirtas, 2012). There are many reasons why mothers choose not to breastfeed their baby. Some of these reasons include convenience, embarrassment at feeding in public, personal health concerns, fear of pain, early return to work, and previous experience (Atchan, Foureur, & Davis, 2011, p. 9). A number of myths also propel the negative stigma of breastfeeding. One of the biggest reasons women dont breastfeed is a lack of knowledge and support. To delve a little deeper into this topic, a PICOT question was created. In new mothers, how does specialized breastfeeding education, as compared to standard education, affect the rate of exclusive breastfeeding for the first six months of the babys life? Literature Search The literature search for this paper was conducted via the Welch Medical Library. The main database used was CINAHL Plus. Key terms included breastfeeding vs. formula feeding, breastfeeding education, and infant formula.

Specialized Breastfeeding Education Literature Review For the literature review, three randomized controlled trials and one clinical guideline were acquired regarding specialized education for new mothers and its effect on adherence to breastfeeding for at least six months. This information is organized into a table at the end of this paper. The clinical guideline was obtained from the Academy of Breastfeeding Medicine (ABM) and refers to promoting breastfeeding to expectant mothers. The guideline recommends many interventions, such as integrate breastfeeding promotion, education, and support throughout prenatal care, consider the culture of individual women, families, and communities, and assure the mother has adequate support and access to information on how to get breastfeeding help (Wood, Hineman, & Meyers, 2010, p.1). One specific strategy the guideline suggests is using the Best Start 3-Step Counseling plan, which includes promoting open discussion about breastfeeding, supporting the mothers feelings, and providing focused education (Wood et al., 2010). The purpose of Ciftci et al.s randomized control trial was to determine how training of working mothers reduced anxiety level and affected breastfeeding habits. There were 62 mothers who were randomly placed in either the control (n=30) or experimental (n=32) group. Participants in the experimental group were given one-on-one training concerning the benefits of breastfeeding for both mother and baby, and how to express and store breast milk. They were also given materials with this information. Both groups were interviewed and received five home visits. The results of the study showed that the training received by the experimental group reduced their anxiety level and made them more likely to breastfeed. The anxiety score for the experimental group was lower than that of the control group after the study (31.93 vs. 36.46, p<0.01). Additionally, the more that mothers breastfed, the more their anxiety level went down.

Specialized Breastfeeding Education Strengths of the study include: subjects were selected based on the non-probability random sampling method, reasons were given as to why participants did not complete the study, and subjects in each of the groups were similar in regards to demographic and baseline clinical variables. The major weakness of this study is that the providers were not blind to the study group. This study is included because it examines how mothers can be more relaxed and confident in regards to breastfeeding. It is relevant because it shows that one-on-one education encouraged the mothers to breastfeed. The objective of McQueen et al.s randomized control trial was to test a new breastfeeding self-efficacy intervention. One hundred and fifty subjects were randomly distributed to the control and experimental groups using sealed, opaque envelopes. Those in the control group (n=81) received standard in-hospital and community care. Those in the experimental group (n=69) received three individualized self-efficacy enhancing meetings with the researcher. Results showed that the intervention was beneficial to the mothers. At 4 and 8 weeks postpartum, mothers from the experimental group had higher rates of breastfeeding selfefficacy, duration, and exclusivity. At 4 weeks 85.9% of mothers in the experimental group were still breastfeeding compared to 74.4% in the control group. Likewise, at 8 weeks, 70.5% of the mothers in the experimental group were still breastfeeding as opposed to 65.6% in the control group. The difference between both groups, however, was not statistically significant. Strengths of the study include: the research assistant who collected data at 4 and 8 weeks was blinded to group allocation, follow-up assessments were conducted long enough to fully study the effects of the intervention, and the control group was appropriate. One weakness was the large gap in group allocation; this could have been fixed with block randomization. This RCT is included because first time mothers are a distinct subgroup of all mothers and their willingness to

Specialized Breastfeeding Education breastfeed could be different than that of mothers who already have children. It is relevant because it studies first time mothers and how specialized education affected their likelihood to breastfeed. The goal of Thakur et al.s study was to measure the influence of nutrition education with emphasis on exclusive breastfeeding on the growth of low birth weight babies. One hundred and eighty-four mothers were randomly distributed to either the control (n=92) or intervention group (n=92) by random table. Those in the experimental group received nutrition education twice weekly for two months, while those in the control group did not receive any education. The height and weight of all babies was assessed every two weeks as well. The results showed that the babies in the experimental group suffered less from respiratory illness (39% vs. 66%). Moreover, the number of exclusively breastfeeding mothers was higher in the intervention group (59.8% vs. 37.2%). Thus, nutrition education proved to be quite effective in this study and could be used to prevent malnutrition and mortality in low birth weight infants. A weakness of the study was that providers were not blind to the study group. Some strengths of the study include: reasons were given as to why participants could not complete the study, subjects were analyzed in the group to which they were assigned, and the instruments used to measure the outcomes were valid and reliable. This study is included because low birth weight infants should especially be breastfed in the first few months of life because they are at a higher risk of getting an infection. It is relevant because the mothers in the experimental group received focused education which resulted in higher rates of breastfeeding. Synthesis The existing research validates that specialized and supportive education can influence mothers to initiate breastfeeding and continue with it for at least six months, which produces

Specialized Breastfeeding Education numerous beneficial outcomes for both mother and baby. Thakur and colleagues (2012) found that the rate of breastfeeding in mothers who received focused education twice a week for two months was 62% higher than those who didnt receive education. Moreover, the babies who were breastfeed were 41% less likely to suffer from a respiratory illness. In McQueen et al.s (2011) study, a higher number of women were breastfeeding at four weeks (85.9% vs. 74.4%) and eight weeks postpartum (70.5 vs. 65.6) after receiving three self-efficacy enhancing meetings. Likewise, in Ciftci et al.s (2012) randomized control trial, 81.8% of mothers who were specially educated were exclusively breastfeeding at three months whereas only 40% of mothers who did not receive education were still exclusively breastfeeding. Thus, the evidence shows that thorough one-on-one specialized education and support of new mothers is an effective intervention that encourages them to initiate breastfeeding. This reduces the likelihood that the babies will come back to the hospital with a respiratory or gastrointestinal illness, therefore lowering hospital costs. While these studies have shown that specialized education can encourage mothers to breastfeed their babies, there are still gaps in the research. In McQueen et al.s (2011) study, the participants reported that they would have liked to been able to call the researcher with questions when they needed to. This added support could have urged the mothers to breastfeed for a longer period of time. In all three of the reports, babies in the NICU were not included. Having a more diverse group of participants and situations could have shown what barriers to breastfeeding were present. Clinical Recommendations Multiple studies have proved that specialized education increases the percentage of women breastfeeding their babies, which reduces the incidence of newborn infections and

Specialized Breastfeeding Education illnesses. At All Childrens Hospital, a group of nurses called the BEST Team (Breastfeeding, Enrichment, Support, & Teaching) exists to educate mothers in the NICU. While this team does a great job supporting the mothers in the NICU, they dont work with any of the mothers on other floors in the hospital. In order to best employ the current evidence-based practice and guidelines, All Childrens and other hospitals nationwide should train their staff to educate any and all mothers of an infant six months of age or younger on the numerous benefits of breastfeeding and how to breastfeed successfully. With successful breastfeeding, mothers will be less likely to develop post-partum depression and babies will be less likely to develop an infection, thus leading to fewer hospital readmissions and lowering hospital costs.

Specialized Breastfeeding Education References Atchan, M., Foureur, M., & Davis, D. (2011). The decision not to initiate breastfeeding women's reasons, attitudes and influencing factors -- a review of the literature. Breastfeeding Review, 19(2), 9-17. Ciftci, E. K., & Arikan, D. (2012). The effect of training administered to working mothers on maternal anxiety levels and breastfeeding habits. Journal of Clinical Nursing, 15(16), 2170-2178. doi: 10.1111/j.1365-2702.2011.03957.x Demirtas, B. (2012). Strategies to support breastfeeding: a review. International Nursing Review, 59(1), 474-481. doi: 10.1111/j.1466-7657.2012.01017.x McQueen, K. A., Dennis, C. L., Stremler, R., & Norman, C. D. (2011). A pilot randomized control trial of a breastfeeding self-efficacy intervention with primiparous mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(1), 35-46. doi: 10.1111/j.1552-6909.2010.01210.x Thakur, S. K., Roy, S. K., Paul, K., Khanam, M., Khatun, W., & Sarker, D. (2012). Effect of nutrition education on exclusive breastfeeding for nutritional outcome of low birth weight babies. European Journal of Clinical Nutrition, 66(1), 376-381. doi: 10.1038/ejcn.2011. 182 Wood, J., Hineman, E., & Meyers, D. (2010). Breastfeeding promotion in the prenatal setting. Retrieved from http://www.guideline.gov/content.aspx?id=15182&search=breast+ feeding#Section424

Specialized Breastfeeding Education Table 1 Literature Review Reference Design and Measures Ciftci, E. K., & To determine Participants in Arikan, D. (2012). how training of the experimental The effect of working mothers group were training reduced anxiety given one-onadministered to level and one training working mothers affected concerning the on maternal anxiety breastfeeding benefits of levels and habits. breastfeeding for breastfeeding both mother and habits. Journal of baby, and how Clinical Nursing, to express and 15(16), 2170-2178. store breast doi:10.1111/j.1365milk. They were 2702.2011.03957.x also given materials with this information. Both groups were interviewed and received five home visits. McQueen, K. A., Dennis, C. L., Stremler, R., & Norman, C. D. (2011). A pilot randomized control trial of a breast feeding selfefficacy intervention with primiparous mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40(1), 35-46. doi: 10.1111/j.15526909.2010.01210.x To test a new breastfeeding self-efficacy intervention Mothers in the control group received standard inhospital and community care. Mothers in the intervention group received three one-on-one sessions with an experienced RN. These sessions included assessment, strategies to increase selfefficacy of Aims Sample There were 62 mothers who were randomly placed in either the control (n=30) or experimental (n=32) group. Outcomes / statistics The anxiety score for the experimental group was lower than that of the control group after the study (31.93 vs. 36.46, p<0.01). 81.8% of mothers who were specially educated were exclusively breastfeeding at three months whereas only 40% of mothers who did not receive education were still exclusively breastfeeding. At 4 weeks 85.9% of mothers in the experimental group were still breastfeeding compared to 74.4% in the control group. Likewise, at 8 weeks, 70.5% of the mothers in the experimental group were still breastfeeding as opposed to 65.6% in the control group.

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150 subjects were randomly distributed to the control and experimental groups using sealed, opaque envelopes. Those in the control group (n=81) received standard inhospital and community care. Those in the experimental group (n=69) received three

Specialized Breastfeeding Education breastfeeding, and evaluation. individualized self-efficacy enhancing meetings with the researcher. 184 mothers were randomly distributed to either the control (n=92) or intervention group (n=92) by random table.

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Thakur, S. K., Roy, S. K., Paul, K., Khanam, M., Khatun, W., & Sarker, D. (2012). Effect of nutrition education on exclusive breastfeeding for nutritional outcome of low birth weight babies. European Journal of Clinical Nutrition, 66(1), 376-381. doi: 10.1038/ejcn.2011. 182

To measure the influence of nutrition education with emphasis on exclusive breastfeeding on the growth of low birth weight babies.

Those in the experimental group received nutrition education twice weekly for two months, while those in the control group did not receive any education. The height and weight of all babies was assessed every two weeks as well.

The babies in the experimental group suffered less from respiratory illness (39% vs. 66%). The number of exclusively breastfeeding mothers was higher in the intervention group (59.8% vs. 37%).