Use of A Supplemental Feeding Tube Device And.7
Use of A Supplemental Feeding Tube Device And.7
Use of A Supplemental Feeding Tube Device And.7
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USE OF A SUPPLEMENTAL
FEEDING TUBE DEVICE AND
BREASTFEEDING AT 4 WEEKS
Frances Penny, PhD, MSN, MPH, RN, IBCLC, Elizabeth A. Brownell, PhD, MA, Michelle Judge, PhD, Mary Marshall-
Crim, MSN, FNP-BC, IBCLC, Diana Cartagena, PhD, RN, CPNP, and Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
man Services (2021) outlined breastfeeding goals within hospitalization in the United States found a shorter
the Healthy People 2030 Objectives. U.S. Department of breastfeeding duration for those fully separated during
Health and Human Services, Office of Disease Prevention birth hospitalization compared to those that were not
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/20/2023
and Health Promotion. (n.d.). One goal outlined in the separated (Rostomian et al., 2022). During separation
objectives was for 42.4% of mothers to be exclusive mothers must use alternative feeding methods, such as
breastfeeding for the first 6 months of life. The current syringe feeding, cup feeding, and feeding using a sup-
6-month exclusive breastfeeding rate is only 25.6%. There plemental feeding tube device (SFTD). These can be
is a concerning downward trend in breastfeeding rates in used to provide breastmilk or formula if breastmilk is
the United Stated. In 2017 according unavailable.
to the Centers for Disease Control Given that bedside nurses rou-
and Prevention (CDC) Report Card tinely provide breastfeeding educa-
(CDC, 2022), the percentage of ba- tion to mothers (Simpson et al.,
bies “ever breastfed” was at 84% 2020), it is imperative that postpar-
and breastfed at 6 months was
The initial months of tum and pediatric nurses be knowl-
58.3%. In 2019, the percentage of the COVID-19 pandemic edgeable and educated on normal
babies “ever breastfed” was 83.2%, breastfeeding behavior. Their
breastfeeding at 6 months was 55.8%
created situations where knowledge should extend to being
(CDC, 2022). Although these de- the mother sometimes well versed in strategies for trouble-
creased rates may seem insignificant, needed to be separated shooting and providing appropriate
it is extremely important that these evidence-based interventions to
downward trends do not continue from her infant. sustain lactation. This would in-
(CDC, 2022). clude the use of supplementation
In 1991, the WHO and the United devices. During the COVID-19
Nations Children’s Fund (UNICEF) pandemic, some hospitals reduced
launched the Baby Friendly Initiative in-person lactation support with
as a global effort for recognition to hospitals and birthing 20% of hospitals reporting reluctance in encouraging
centers that provide lactation support at the highest level. direct breastfeeding (Perrine et al., 2020). When there
Currently, over 604 US hospitals are designated as Baby- is a reduction in lactation support, bedside nurses must
Friendly (Baby-Friendly USA, 2023); approximately one provide lactation assistance and education. Lactation
in four babies are born in a Baby Friendly Hospital (CDC, problems have been attributed to lack of knowledge
2022). Baby Friendly implementation includes integra- and inappropriate and conflicting guidance (Spatz et
tion of the 10 Steps of Successful Breastfeeding. Program- al., 2015). Many hospitals have policies on supplemen-
matic success includes increases in breastfeeding rates, tation, yet implementation of these policies varies (Pen-
exclusivity, and duration (Munn et al., 2016). Per Step 9, ny et al., 2019).
mothers should be advised about use and risks of feeding If breastfeeding difficulties are experienced, and moth-
bottles, teats, and pacifiers (WHO, 2022). Supportive ini- ers still desire their infant to receive human milk, moth-
tiatives led to the use of alternative feeding devices as a ers may turn to the use of alternative feeding methods
means of decreasing use of bottles and artificial nipples. such as cup feeding, finger feeding, and use of a lactation
Evidence demonstrates that breastfeeding or receipt of aid or SFTD (Penny et al., 2018). The SFTD is a con-
mother’s own milk has potential to positively affect in- tainer with a tube that attaches to the nipple. The con-
fant developmental outcomes as well as other overall tainer may hold formula or pumped human milk. Brand
health indices (Sorce et al., 2020). According to the As- names of SFTD include Supplemental Nursing System by
sociation of Women’s Health, Obstetric and Neonatal Medela (2023) (Figure 1) and the Nursing Training Sys-
Nurses (2021, p. e1) “breastfeeding and the provision of tem by Lact-Aid (2023). Though multiple studies evalu-
expressed human milk are critical components to ensure ated the use of cups as an alternative feeding method, few
the health and well-being of newborns, young children, studies explore use of the SFTD (Penny et al., 2018).
and childbearing women.” The American Academy of Only one published descriptive study was found examin-
Pediatrics (Meek et al., 2022, p. 1) “recommends exclu- ing use of SFTDs as the primary research question for
sive breastfeeding for approximately 6 months after term infants (Borucki, 2005). This qualitative study re-
birth” and “supports continued breastfeeding, along sults showed that mothers had both positive and negative
with appropriate complementary foods introduced at experiences with the use of an SFTD (Borucki, 2005). In
about 6 months, as long as mutually desired by mother a randomized control study conducted in Turkey with 46
and child for 2 years or beyond.” preterm infants, there was no difference in timing of
The COVID-19 pandemic introduced new breast- transitioning to breastfeeding for preterm infants fed us-
⋅
feeding challenges (Spatz, 2021). A study in the United ing the SFTD versus bottle-fed infants (I ncekar et al.,
breastfeeding mothers as an alternative feeding method already chosen to use the SFTD for supplementation.
through exploration of associations between STFD use Those mothers were recruited for the study, and all agreed
and continued breastfeeding (feeding directly at the to participate. It is important to note, that the study par-
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breast) at 4 weeks of infant’s age. Four weeks was cho- ticipants were mothers who were self-selecting the SFTD
sen because a high percentage of infants are still receiv- because of breastfeeding difficulty. All participants identi-
ing some breastmilk at this point (CDC, 2022). In 2019, fied themselves as mothers and discussed and answered
approximately 78% of infants were still receiving questions related to breastfeeding. Thus, we acknowledge
breastmilk at 1 month in the United States (CDC, 2022). that these participants were highly motivated to continue
to work toward successful breastfeeding. Inclusion criteria
Methods were 18 years or older, English-speaking mothers with
Design term infants. Mothers of infants born <37 weeks gestation
This is a descriptive exploratory design with quantitative or with any major health problems that would inhibit
analysis augmented by open-ended qualitative question- breastfeeding were excluded. Data collection occurred be-
naire data. Institutional review board approval was ob- tween March 2016 and February 2017.
tained at the hospital and university.
Measurement
Setting and Sample LATCH Assessment Tool
New mothers were recruited by convenience sampling Use of this assessment tool is standard practice in the
from the postpartum unit in a medium-sized hospital in study setting and performed at least once per shift by the
nurse or lactation consultant. The assessor assigns a score
of 0, 1, or 2 to five different components of breastfeeding
TABLE 1. RELATIONSHIP OF MOTHERS' (latch [L]; audible swallowing [A]; nipple type [T]; moth-
DEMOGRAPHIC CHARACTERISTICS TO er’s comfort level [C]; and amount of help mother needs
BREASTFEEDING AT 4 WEEKS to hold baby to the breast [H]). Scores range between 0
and 10, with higher scores representing increased breast-
Category n (%) P feeding success (Jensen et al., 1994; Shah et al., 2021).
Age in Years .748
<25 2 (5) Data Collection
26–28 9 (22.5)
Once participants provided informed consent, they com-
pleted a demographic data form. Variables collected in-
29–31 15 (37.5) cluded age, race, parity, breastfeeding experience, and type
32–34 7 (17.5) of birth. The PI who is a certified lactation consultant,
35–38 5 (12.5) scored the LATCH during a feeding session prior to hospi-
tal discharge and maintained score reliability at greater
39–40 2 (5)
than 95% with the nurses throughout study completion.
Self-Identified Race .528 Study participants were contacted by the PI at 4 weeks
White 21 (52.5) by phone. During this phone call, participants were asked
Latino 10 (25) how often they used the SFTD, how many times a day,
and for how many days. Answers were recorded by the
Black 3 (7.5)
interviewer on a data sheet. Participants were asked five
Asian/East Indian 6 (15) open-ended questions on their perception of use of the
Parity .250 SFTD and related benefits and challenges and one ques-
1 25 (62.5) tion about their current breastfeeding practice using stan-
dard definitions (Labbok & Krasovec, 1990).
2 9 (22.5)
3 5 (12.5) Data Analysis
6 1 (2.5) Demographic data were reported using means, stan-
Type of Birth .726 dard deviations, ranges, and percentages. A Chi-square
test of independence was performed to examine asso-
Cesarean 21 (47.5)
ciations between demographic data and continued
Vaginal 19 (52.5) breastfeeding at 4 weeks. Mothers were given a choice
Breastfeeding Experience .501 of categories of breastfeeding. The category of none/
Yes 11 (27.5) low breastfeeding mothers was defined as none to less
than 20% feedings as breastfeeding. Medium/high/
No 29 (72.5)
exclusive was defined as greater than 20%. Binary
Results y=4.95–0.46*x
Forty-three mothers consented
to participate, and 40 mothers 2.0
completed both data collection
points.
Demographic Data
The age range of participants
was 25–40 with a mean age 0.0
of 30.9 years (SD = 3.8). De-
mographic data including 0.0 2.0 4.0 6.0 8.0 10.0
birth mode and parity were Supplemental Feeding Tube Device Use Times per Day
not associated with amount
of breastfeeding or contin-
ued breastfeeding at 4 weeks (Table 1). sive rate at 4 weeks. As bottle-feeding use per day in-
creased, odds of breastfeeding, at 4 weeks, at a
Breastfeeding Outcomes medium/high/exclusive rate decreased (OR = .67, CI
The retention rate at the 4-week data point was 93%. .510–.898; P = .007. Pearson’s correlation coefficient
There was no significant difference between those with or revealed a significant inverse correlation between bot-
without breastfeeding experience in breastfeeding at 4 tle usage and SFTD use (r = -.377, P = .018) (Figure 2).
weeks (OR = 1.7; CI .147–2.55; P = .50). The adjusted model containing both predictors was
significant (X2 = 9.40, P = .009), and indicates that the
Use of SFTD and model was able to distinguish between none/low and
Breastfeeding medium/high/exclusive breast feeders. Increased use of
Only 1 mother was exclusively breastfeeding (2.5%) at bottles resulted in a decrease in overall breastfeeding
4 weeks and 27 (67.5%) of mothers in the study con- at 4 weeks. Bottle use per day was significantly associ-
tinued to breastfeed some of infant feedings at 4 weeks. ated with SFTD uses per day (OR = 0.67; CI 0.491–
The greater the number of bottle-feedings provided per 0.906; P = .01) (Table 2). SFTD use per day was sig-
day over the course of 4 weeks, the less likely partici- nificantly inversely associated with one bottle use per
pants would be breastfeeding at a medium/high/exclu- day (F = 6.142, P = .018).
TABLE 2. SUPPLEMENTAL FEEDING TUBE DEVICE AND BOTTLE USE AND RELATIONSHIP TO
CONTINUED BREASTFEEDING
Supplemental Method OR (95% CI) P (Binary logistic)
Supplemental feeding tube device use per day 1.0 (.967–1.00) .68
Bottle use per day .67 (.510–.898) .007*
Bottle use + supplemental feeding tube device use per day .67 (.491–.906) .01*
*
Significant
At the 4-week phone call each mother was asked five nurse.
open-ended questions related to SFTD use (benefits or In a response that illustrates the subtheme emotional
detriments, challenges, feelings related to SFTD use). support, one mother stated I finally felt I was helping
Both positive (supporting SFTD use) and negative themes him (my baby). These statements illustrate that the SFTD
(problems using SFTD) were identified and are displayed allowed the infant to breastfeed and helped their baby
in the dendrogram (Figure 3). learn to breastfeed and provided emotional support for
There were two main subthemes related to the main the mother, thus navigating the use of SFTD well. The
theme journey through breastfeeding: navigating use of second theme navigating the SFTD with difficulty was
• I felt pushed to breastfeed, so this gave me the option, • After instruction in the hospital, I was worried I
like I had a say in this. had to supplement, it was so helpful to continue
• I felt that I could choose not to use bottle and still breastfeeding.
benefit, my baby just loves the breast! • At home it was very helpful because I was worried,
• I liked having him on the breast. I did not have enough milk.
• It gave my baby control when eating. • Nothing was coming out so my baby needed milk, this
• My baby lost too much weight and needed formula. tube made my baby breastfeed and he wasn’t starving.
This let him get it while on my breast. • Because I could see it, and he could get a latch I knew
• The device was very helpful, my baby learned to latch he was getting something to eat.
by himself. • The stimulation at the breast helped my milk come in
and helped mentally and to bond.
• It helped be eventually get a better latch.
Emotional Support
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Michelle Judge is an Associate Professor, University of of hospital practices supportive of breastfeeding in the context of
Connecticut, School of Nursing, Storrs, CT. Dr. Judge COVID-19 - United States, July 15-August 20, 2020. Morbidity and
Mortality Weekly Report, 69(47), 1767–1770. https://doi.org/10.15585/
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Mary Marshall-Crim is the Lactation Director, Hart- Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and as-
ford Hospital, Hartford, CT. The author can be reached sessing evidence for nursing practice (11th ed.). Wolters Kluwer.
Riordan, J., Bibb, D., Miller, M., & Rawlins, T. (2001). Predicting breastfeed-
at Mary.Marshall-Crim@hhchealth.org ing duration using the LATCH breastfeeding assessment tool. Journal
Diana Cartagena is an Assistant Professor, Old Do- of Human Lactation : Official Journal of International Lactation Con-
sultant Association, 17(1), 20-23. doi: 10.1177/089033440101700105
minion University, Virginia Beach, VA. Dr. Cartagena Rostomian, L., Angelidou, A., Sullivan, K., Melvin, P. R., Shui, J. E., Tele-
can be reached at dcartage@odu.edu fus Goldfarb, I., Bartolome, R., Chaudhary, N., Singh, R., Vaidya, R.,
Jacqueline M. McGrath is the Thelma and Joe Crow Steele, T., Yanni, D., Patrizi, S., Culic, I., Parker, M. G., & Belfort, M. B.
(2022). The effects of COVID-19 hospital practices on breastfeeding
Endowed Professor, Vice Dean for Faculty Excellence, initiation and duration postdischarge. Breastfeeding Medicine,
School of Nursing, University of Texas Health San Anto- 17(9), 736–744. https://doi.org/10.1089/bfm.2022.0039
nio, San Antonio, TX. Dr. McGrath can be reached at Shah, M. H., Roshan, R., Parikh, T., Sathe, S., Vaidya, U., & Pandit, A.
(2021). LATCH score at discharge: A predictor of weight gain and
mcgrathj@uthscsa.edu exclusive breastfeeding at 6 weeks in term healthy babies. Journal
The authors declare no conflicts of interest. of Pediatric Gastroenterology and Nutrition, 72(2), e48–e52. https://
doi.org/10.1097/MPG.0000000000002927
Simpson, K. R., Lyndon, A., Spetz, J., Gay, C. L., & Landstrom, G. L.
DOI:10.1097/NMC.0000000000000962 (2020). Missed nursing care during labor and birth and exclusive
breast milk feeding during hospitalization for childbirth. MCN. The
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