Background
The World Health Organization (WHO), the American Academy of Pediatrics (AAP), and many other professional organizations endorse feeding exclusive human milk for the first 6 months of life with continued breastfeeding for 2 years or more (Meek et al., 2022; WHO, 2022). Although breastfeeding initiation rates have steadily increased in the United States, exclusivity and duration rates remain suboptimal (CDC, 2021a). The COVID-19 pandemic has had a negative impact on birth and breastfeeding practices in the United States and globally (Spatz et al., 2021; Spatz & Froh, 2021). In June 2022, the AAP reaffirmed the importance of breastfeeding, with a recommendation to continue breastfeeding through age 2 years and beyond, to align with WHO and other health expert recommendations (Meek et al., 2022; WHO, 2022). In their report, AAP highlights the critical role of the pediatrician to support breastfeeding and calls on pediatricians to work collaboratively with members of the health care team to provide evidence-based breastfeeding support (Meek et al., 2022).
The AAP published The Breastfeeding-Friendly Pediatric Office Practice in 2017. This clinical report outlines evidence-based practices that support breastfeeding in the outpatient setting, stating, "Because of the importance of breastfeeding to maternal and infant health outcomes, all pediatric care providers should aim to improve breastfeeding rates in their practices" (Meek et al., 2017, p. e3). A summary of these practices is listed in Table 1. The Academy of Breastfeeding Medicine (ABM) also has a clinical protocol, Breastfeeding-Friendly Physician's Office, most recently updated in 2021, which outlines evidence-based practices that support breastfeeding in the outpatient setting (Vanguri et al., 2021). Both resources provide expert guidance on implementation of breastfeeding-friendly practices in the ambulatory setting; however, little has been published on the implementation and effectiveness of these recommendations.
Corriveau et al. (2013) demonstrated that implementation of an office-based breastfeeding protocol increased breastfeeding rates in the primary care setting. They found that use of the ABM clinical protocol The Breastfeeding-Friendly Physician's Office increased rates of exclusive breastfeeding at the 2-, 4-, and 6-month infant visits. Creating a supportive environment for breastfeeding mothers with access to well-trained clinicians resulted in improved rates of breastfeeding, providing more infants with the health benefits of human milk for a longer period than without the use of this protocol (Corriveau et al., 2013).
Both AAP and ABM clinical reports emphasize caregiver education as a cornerstone to providing evidence-based care to breastfeeding dyads. The Baby-Friendly Hospital Initiative for inpatient providers has specific recommendations for education; however, there are no standards for outpatient clinicians (Ware & Piovanetti, 2020). Our Ambulatory Breastfeeding Consortium (ABC) provides a forum for ongoing education on a variety of topics related to breastfeeding and human lactation. The ABC serves to increase awareness of resources to allow nurses and other clinicians to improve their knowledge base and to acquire skills to support breastfeeding in their practices. We describe the creation and implementation of a network-wide consortium for discussion, education, and awareness on lactation and use of human milk with a goal to improve health care provider knowledge and ability to provide informed care to lactating families.
Creating the Ambulatory Breastfeeding Consortium
Setting and Participants
Children's Hospital of Philadelphia (CHOP) has an extensive primary care network including 31 sites across Pennsylvania and New Jersey. In 2019, our group established the ABC to increase consistency of breastfeeding care and interventions across the network. Nurses, physicians, and advanced practice providers in the ambulatory setting should be positioned to provide care and support to breastfeeding families. Many clinicians may not have had breastfeeding-specific education and therefore often refer families outside of the CHOP network.
Breastfeeding support in primary care had been identified by CHOP as an area for improvement with a goal to align with the AAP recommendations for a breastfeeding-friendly practice. The ABC was originally proposed as a monthly virtual meeting to reach more sites across the network, with a goal to share education and resources about breastfeeding support specific to the primary care setting. Once established, information about the meetings was shared with nursing leaders, and all primary care clinical and nonclinical employees were invited by email to join each month.
The ABC was started in September of 2019 before the COVID-19 pandemic. The pandemic has increased importance of this group, as more families are being discharged earlier from birthing hospitals, many without any breastfeeding or latch assessment and with little evaluation, education, or interventions offered related to breastfeeding (Spatz et al., 2021; Spatz & Froh, 2021). Consequently, the burden has substantially increased on pediatric primary care clinicians to help families effectively establish their breastfeeding relationships (Spatz et al., 2021).
The goals of the ABC are to improve infant and child health outcomes by advocating for human milk as the optimal source of nutrition during the first year of life and beyond through interprofessional education, awareness, discussion, and outreach. We aim to support primary care clinicians to develop the knowledge and skills that can empower families to meet their personal breastfeeding goals, with equity of support, education, resources, and access to care across all care network sites.
The authors, the leadership of the ABC, represent an interdisciplinary team that is reflective of the target audience. The leadership team includes a nurse scientist who is an internationally recognized expert in the field of breastfeeding and lactation, a physician who is certified as an Internationally Board-Certified Lactation Consultant (IBCLC), two pediatric nurse practitioners, one of whom is certified as an IBCLC, and an ambulatory care registered nurse certified as an IBCLC. Members of the leadership team volunteer their time planning, organizing, and participating in the meetings. The intended and typical audience for each meeting includes nurses and other clinical providers from 31 primary care sites who provide direct patient care. This includes nurses, advanced practice providers, resident physicians in training, physicians, and other multidisciplinary clinical providers.
ABC meetings are 1 hour in length and held virtually during the lunch hour of most of the offices. When eligible, continuing education credits are offered. CHOP is an approved provider for nursing continuing professional development by the Pennsylvania State Nurses Association, so credit is offered through our nursing professional development department. Currently, credit is only offered for attending live meetings; however, these sessions are recorded and accessible through CHOP's internal intranet for later viewing for those who cannot attend.
Content Covered by the Ambulatory Breastfeeding Consortium
The monthly meetings cover a variety of breastfeeding-related subjects, and guest speakers are often invited to share their expertise on topics related to breastfeeding and human milk. See Table 2 for a list of recent meeting topics. Managing specific breastfeeding challenges has been a common theme for many meetings. Spatz and Conover (2021) described a case of managing growth failure while maintaining exclusive breastfeeding for the first year of life, and this case was presented to the ABC while care was ongoing for this patient. A case describing glandular hypoplasia as a factor influencing low milk supply was also presented to the ABC and later published as anticipatory guidance for clinicians (Spatz & Miller, 2021). The typical format is an educational presentation followed by discussion and questions from participants. Presenters are unpaid, and volunteer or are requested by our leadership team based on the topic of interest. Information sharing and highlighting common examples of barriers to breastfeeding has created connections and learning experiences for participants across our large primary care network. Currently, the focus is on educating health care providers. Our goal is that this improved breastfeeding knowledge will in turn affect families and improve individualized care given by those who participate in our meetings. ABC meetings provide resources and valuable information related to the presented topic for health care providers to share with families.
ABC meetings feature many expert speakers from within our organization and beyond. The presentation Tongue Tie and Breastfeeding, given by a CHOP otolaryngologist, had high attendance, and covered current practices and opinions by a physician in the field along with practical advice on when to refer and to whom. Other noteworthy topics including Feeding the Late Preterm Infant, Same Sex Mothers, and Breastfeeding and Contraception offer primary care clinicians an opportunity to explore important, yet less commonly discussed issues that can affect breastfeeding families. Due to diversity of patient populations across our network sites, this valuable approach broadens the knowledge of health care providers in the primary care setting.
Impact of COVID-19 Pandemic
In Spring 2020, the COVID-19 pandemic provided an opportunity for the ABC to increase engagement and participation. Early in the pandemic, little was known about the risk COVID-19 positive mothers posed to their infants, and if breastfeeding was a safe practice. On April 23, 2020, AAP published initial guidance on the management of infants born to COVID-19 positive mothers and recommended temporary separation of birth parent and infant (AAP, 2020, 2022). This guidance contrasted with published recommendations from WHO (2020) that supported direct breastfeeding, and with guidance from the Centers for Disease Control and Prevention (CDC, 2020, 2021b), which emphasized shared decision-making between the birth parent and clinical team.
In April 2020, the ABC held our regular monthly meeting on this topic, with record attendance of 43 participants. Discussion focused on current guidance as many pediatric providers were confused about conflicting information from health organizations. As the pandemic surged in our region, the ABC served as a hub for the latest guidelines and information, and as an area for discussion and questions related to breastfeeding in the setting of COVID-19. During the following months, members of the leadership disseminated updated CDC guidelines and information about COVID-19 as it pertains to breastfeeding and use of human milk. These updates were given during meetings, and on a few occasions sent via email.
Due to the pandemic, many mothers were receiving no lactation care in the birth hospital. Once discharged, there were few, if any options to visit with a lactation specialist. The role of lactation support and assessment fell heavily to primary care providers, so disseminating the most accurate and up-to-date information on breastfeeding and COVID-19 became especially important.
The AAP recommendations on management of infants born to COVID-19 positive mothers changed as new evidence emerged. Data from the National Registry for Surveillance and Epidemiology of Perinatal COVID-19 infection indicated that the risk of infection to the baby was low (AAP, 2022). This evolving guidance continued to be a topic of interest for ambulatory practices and generated engagement in our monthly meetings as we provided brief updates from AAP and other major health organizations on this topic at each meeting. Many ambulatory practices noticed a significant decrease in breastfeeding rates due to the pandemic, which led to further engagement in our consortium. This decrease in breastfeeding rates is concerning from a public health perspective. The COVID-19 pandemic has also contributed to widespread formula shortages making it even more critical for families to have access to breastfeeding support (Abrams, 2022).
Quality Improvement Data Collection Development
Several of the offices in the Primary Care Network implemented formal quality improvement projects focused on data capture, monitoring of breastfeeding data, and improvement efforts as recommended by AAP and ABM. This process has led to a tracking model for observation of breastfeeding rates and the work has served as a topic of several meetings. Successful development of a data analytics tool tracking breastfeeding rates has engaged other offices across the network to model and expand this work. The ABC has served as a forum for other primary care sites to receive support from practices who have undergone formal data capture and monitoring. Currently, a process is in development to collect and track breastfeeding data across all primary care sites. Creating consistency in documentation of feeding and data capture has proved challenging across all sites; however, this group has laid the groundwork for accurate data collection of infant feeding status. Collection and monitoring of accurate breastfeeding data is key to ensure that practices are supporting families in meeting their breastfeeding goals.
Effectiveness of the Ambulatory Breastfeeding Consortium Approach
The ABC has been effective in engaging health care providers who work in our pediatric primary care network. We have had consistent meeting attendance since the ABC was established in 2019. Monthly attendance of meetings ranges from 11 to 43 participants. Participation in the ABC has prompted attendees to arrange for continuing education at their individual network sites and has allowed for opportunities for networking and collaboration between offices.
The virtual format allows for inclusion across CHOP's 31 care network sites. As virtual meetings have become more common, this remains an accessible and convenient way for members to attend and watch recordings of previous sessions. This format has fostered greater dissemination of information, allowing the ABC to become the authority on breastfeeding for the network. During meetings, participants often comment with appreciation for interesting and varied topics, and discussion centers on improved care practices in the ambulatory setting. The ABC is a valued resource as evidenced by consistent participation in meetings and robust discussion.
Evaluations are collected anonymously by electronic survey after each meeting and feedback is given by participants. Presenters have received overwhelmingly positive feedback and have been described as knowledgeable and informative. Overall, participants state they feel they are receiving valuable information that they can incorporate into the care they give to patients and families. When asked "What changes will you make in your role as a result of this activity" one reviewer stated, I will change the way we assess the effectiveness of breastfeeding and how to make breastfeeding sessions more successful. When asked about the strengths of one presentation that included a useful smartphrase, which is a documentation tool, a participant states The presenters were clear, and information is relevant to the care I provide. There was a fantastic smartphrase for breastfeeding assessment that I have incorporated into my care. Some responses to the question "When will you incorporate what you learned" include immediately, right away, and one reviewer states I have already started. These evaluations reinforce the value and utility of the information presented by the ABC.
Replicating the Ambulatory Breastfeeding Consortium
Other primary care practices should prioritize education related to breastfeeding and use of human milk to ensure families are supported by knowledgeable providers. Pediatric primary care practice sites can consider identifying a small leadership team to organize a regular meeting to discuss breastfeeding-related issues. Time commitment from our team averages about 2 to 3 hours per month in planning and attending the meetings and is the main resource necessary for the leadership members. The virtual platform allows for inclusion across a large care network, and participants can be included from home or in the clinical setting. We recommend using a virtual meeting format to allow for inclusion of all primary care team members and ability to revisit meetings if unable to attend live. The virtual format also allows for a low-risk setting considering the persisting COVID-19 pandemic. Meeting topics should be relevant to the population served and can be based on the interest of those who attend. In our experience, the most well-received topics include featured guest speakers and lactation experts, local lactation and breastfeeding resources, and lactation-specific case presentations.
Discussion
We believe that other pediatric primary care centers could replicate our efforts to improve their breastfeeding practices. Given there is a critical window to effectively establish milk supply (Medina Poeliniz et al., 2020; Spatz, 2020), the first newborn visit in primary care is an essential intervention timepoint to ensure that the lactating parent can come to volume. Following the initial newborn visit, infants may have between two and four additional primary care visits during their first month of life. These visits are critical touchpoints for lactation interventions and support that could improve breastfeeding exclusivity and duration in the long term. Lactation support has become an even more essential component of primary care since the beginning of the COVID-19 pandemic, which has magnified the need for primary care providers to be educated on current guidelines as well as make up for the lack of support offered in birthing hospitals. The more knowledgeable primary care clinicians are concerning human milk and lactation, the more effectively they can support breastfeeding families. Their efforts in turn, will hopefully increase breastfeeding exclusivity and duration rates and enhance overall infant health.
Conclusions
To improve the landscape of breastfeeding in the United States, all health professionals must commit to providing evidence-based lactation interventions, care, and support. Primary care clinicians who can provide lactation care are crucial to ensure that all families can meet their personal breastfeeding goals. The ABC serves as a replicable model for primary care sites to improve their knowledge and help better support families through education, shared experience, and awareness across multiple network sites.
CLINICAL IMPLICATIONS
* Nurses and clinical care providers in the pediatric primary care setting should seek education on lactation to provide well-informed care to breastfeeding families.
* Nurses should be able to assess breastfeeding at each primary care visit, recognize normal patterns associated with breastfeeding, and identify barriers that can compromise exclusive breastfeeding and milk supply.
* Consider developing a regular consortium to collaborate and share knowledge, experience, and awareness of issues related to breastfeeding to improve their proficiency in caring for breastfeeding families.
* Consider a virtual forum for regularly scheduled consortium to promote inclusion of clinical and nonclinical primary care team members, and the ability to revisit meeting topics as desired.
* By increasing their knowledge of breastfeeding and lactation-related issues, nurses and primary care providers will be able to better care for patients from infancy through toddlerhood, or until the breastfeeding relationship is complete.
References