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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

Abstract use of supplemental feeding tube devices, breastfeeding issues,


Background: Mothers having difficulty breastfeeding their infants and continued breastfeeding relationships. We examined the
may use alternative supportive feeding methods. Although a relationship between LATCH scores at 2 to 3 days of life. Results:
supplemental feeding tube device is commonly used, efficacy for Breastfeeding mothers who chose to supplement with bottle-feeding
supporting sustained breastfeeding remains unknown. Purpose: instead of use of a supplemental feeding tube device were 30% less
To describe supplemental feeding tube device use by breastfeed- likely to continue breastfeeding at a medium/high/exclusive level.
ing mothers as an alternative feeding method through exploration Conclusion: Use of the supplemental feeding tube device may help
of associations between supplemental feeding tube device use avoid the potentially detrimental effect of bottle-feeding on continued
and continued breastfeeding at 4 weeks of infant’s age. Method: breastfeeding.
Forty mothers participated. They were interviewed during the birth
hospitalization and at 4 weeks postpartum. Questions addressed Key words: Baby-friendly hospital initiative; Bottle-feeding; Breast
feeding; Breastfeeding exclusive; Exclusive breastfeeding; Human
Figure 1. Supplemental Nursing System by Medela milk; Lactation.

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06 MCN1123_Feeding_00001_Deepak.indd 334 06/10/23 4:55 AM


Background Kingdom found during the early pandemic 27% of
Human milk has been identified as the optimal nutrition mothers struggled with breastfeeding (Brown & Shen-
for all newborns (World Health Organization [WHO], ker, 2021). A study of mothers who were positive for
2022). The United States Department of Health and Hu- COVID-19 at birth and separated from infants during
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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
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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.,

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06 MCN1123_Feeding_00001_Deepak.indd 335 06/10/23 4:55 AM


2021). Although SFTDs are commonly used, there are New England. As a Baby Friendly hospital, lactation con-
limited data on the breastfeeding efficacy or benefits to sultants (IBCLCs) and nurses on the postpartum unit often
the mother or the infant (Penny et al., 2018). recommended use of SFTDs for supplementation. Nurses
The purpose of our study is to describe SFTD use by notified the principal investigator (PI) when a mother had
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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

336 volume 48 | number 6 November/December 2023

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06 MCN1123_Feeding_00001_Deepak.indd 336 06/10/23 4:55 AM


Logistic Regression was used FIGURE 2. UNADJUSTED RELATIONSHIP BETWEEN BOTTLE USE PER DAY
for analysis for comparisons
of variables and breastfeeding
AND SUPPLEMENTAL FEEDING TUBE DEVICE (SFTD) USE PER DAY
rates. Breastfeeding groups
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were separated at the middle 8.0 R2 Linear = 0.142


point with approximately
half in the medium/high/ex-
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clusive rate and half in the


low/none rate. Responses to
open-ended questions were Bottle Use Times per Day
examined through content 6.0
analysis. Data were catego-
rized using open coding and
categories were developed to
describe a common phenom-
enon (Polit & Beck, 2021).
Dendrograms were created to
4.0
organize the data into themes.

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

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06 MCN1123_Feeding_00001_Deepak.indd 337 06/10/23 4:55 AM


LATCH Scores SFTD with difficulty and navigating use of SFTD well
LATCH score was grouped into low (0–5), medium (6– (with two subthemes agency toward breastfeeding and
8), and high (9–10). LATCH scores were not significantly emotional support). One mother stated Nothing was
associated with breastfeeding outcomes (P = .495, P = .7, coming out, so my baby needed milk, this tube made
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and P = .6). my baby breastfeed and he wasn’t starving. Another


mother responded that I finally felt that I could see my
Responses to Open-Ended Questions baby getting something to eat and was learning to
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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

FIGURE 3. DENDROGRAM: THEMES IDENTIFIED FROM RESPONSES TO QUALITATIVE QUESTIONS

• 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

Navigating Use of Supplemental Feeding


Agency Toward Breastfeeding
Tube Device Well

• I stopped using (the SFTD) because I felt overwhelmed.


• It was helpful in the hospital but much too complicated
at home.
• Liked using it in the hospital but too messy at home
with the tape etc.
• I had no help at home, so it was difficult.
• Breastfeeding was not working for me, and the
supplemental nursing system (supplemental feeding
tube device) did not help.
• This is a two-man job. I needed my husband to set me
up every time. When the tube slipped out of the baby’s
mouth, I needed help getting it back in help set me up
every time. When the tube slipped out of the baby’s
mouth, I needed help getting it back in.

Navigating Use of Supplemental Feeding Tube


Journey through Breastfeeding Difficulty
Device with Difficulty

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06 MCN1123_Feeding_00001_Deepak.indd 338 06/10/23 4:55 AM


identified in responses of some mothers. When mothers
discussed the negative aspects of the SFTD, the common
theme was that it required a lot of help. One mother said Breastfeeding mothers who chose to
my baby lost too much weight and needed formula. This supplement with bottle-feeding instead
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let him get it while on my breast. Some mothers noted


that this is a two-man job. I needed my husband to help
of use of a supplemental feeding tube
set me up every time. When the tube slipped out of the device were 30% less likely to continue to
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baby’s mouth, I needed help getting it back in. And this


is a two-person job. It was impossible to do it alone, es-
breastfeed at a medium/high/exclusive level.
pecially while he was crying.

Discussion instruction was needed from a professional for success-


Our study contributes to the limited data on use of a ful use.
supplemental feeding device in relationship to contin-
ued breastfeeding. The SFTD is commonly used by lac- Limitations
tation consultants and nurses to help mothers who want The small sample size of 40 participants is a study limita-
to continue breastfeeding but are having difficulty either tion. As such, a full model multivariate analysis could
with transition breastfeeding or breastfeeding continua- not be performed. Breastfeeding, bottle use, and SFTD
tion (Penny et al., 2018). The SFTD is one of the more use were based on maternal recall at the 4-week phone
preferred methods of supplementation by IBCLCs in the call. Collecting data on reasons for supplementation and
United States (Penny et al., 2019) yet this device is rec- breastfeeding intent may have been helpful to under-
ommended and used without any quantitative evidence stand other potential variables that may have affected
for increasing continued breastfeeding. breastfeeding cessation. It is important to note that par-
We examined whether LATCH scores during hospital- ticipants were mothers who had already chosen to
ization were related to breastfeeding outcomes with SFTD breastfeed and to use a STFD and thus, were highly mo-
use and no associations were found, consistent with tivated. We acknowledge that this motivation could have
Riordan et al. (2001). Only one mother was exclusively skewed results.
breastfeeding at 4 weeks and about two-thirds of mothers
in the study continued to breastfeed some of infant feed- Conclusion
ings at 4 weeks. Both numbers are lower than reported This study provides important information on the use of
averages in the United States at 1 month (CDC, 2022). an SFTD as a supplemental feeding method for breastfeed-
The large discrepancy with the exclusive rates between ing infants. The COVID-19 pandemic created situations
this study and national rates may have been due to the where the mother needed to be separated from her infant
uniqueness of this population. These were mothers who and cannot always be planned for in advance (Spatz,
needed or wanted to supplement their infants, which puts 2021). Mothers should be offered supplementation meth-
mothers at a higher risk of early weaning. There is no way ods that best preserve a close feeding relationship with
to know if these mothers would have weaned sooner had their infant. The SFTD is a method that could minimize
they not used the SFTD. exposure to bottle-feeding, at least in the first few days or
When outcomes of using the SFTD were examined, we weeks to help avoid the potentially detrimental effect of
found that the SFTD does not have a significant impact, use of bottles on continued lactation and breastfeeding.
either negatively or positively, on breastfeeding at 4 Postpartum nurses, as the first line of breastfeeding assis-
weeks. However, bottle use had a detrimental effect on tance, can provide the necessary support and education
breastfeeding outcomes. This result is consistent with for breastfeeding mothers who may need to supplement
previous research (Chantry et al., 2014). For every bottle the infant feedings. Further research with a larger sample
used, the chance of breastfeeding at the medium/high/ex- size and a more diverse population could help to provide
clusive rate at 4 weeks was reduced by 30%. Meaning, as further evidence for this supplemental method. Bedside
bottle use increased, SFTD use decreased, therefore nurses should be using evidence-based practice to best
breastfeeding did as well. promote lactation practices and provide mothers the sup-
Conversely, our findings indicate that the less bottles port they need for continued lactation and breastfeeding
are used, the more chance of breastfeeding at a higher even when supplementation occurs. ✜
level at 4 weeks of infant age. For every SFTD use, bottle
use decreased. If bottle supplemental feedings are re- Frances Penny is an Associate Professor, Southern
placed by use of an SFTD, breastfeeding chances at the Connecticut State University, School of Nursing, New
medium/high/exclusive rates may be increased. This is Haven, CT. Dr. Penny can be reached at pennyf1@
an important finding for lactation consultants, nurses, southernct.edu
and providers. Qualitative results revealed themes that Elizabeth A. Brownell is an Associate Professor,
demonstrated that the SFTD has value with helping to University of Texas Health Science Center, San Anto-
maintain continued breastfeeding; however, in some in- nio, TX. Dr. Brownell can be reached at brownelle@
stances, there may be a learning curve and assistance, or uthscsa.edu

November/December 2023 MCN 339

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06 MCN1123_Feeding_00001_Deepak.indd 339 06/10/23 4:55 AM


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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-
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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.
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breast milk feeding during hospitalization for childbirth. MCN. The
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