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Running head: SYNTHESIS PAPER

Synthesis of Breastfeeding Rates and Lactation Consults


Samantha Visser
University of South Florida

SYNTHESIS PAPER

Abstract
This paper explores randomized controlled trials and clinical guidelines of breastfeeding rates
and related interventions to help increase said rates. The selection of this research is based on a
previously developed PICOT question. The concentration is to determine what the relationship is
between pre or postnatal lactation consults and breastfeeding rates over 12 months. This paper
examines the consistency of the research and the presence of any gaps. Clinical
recommendations were determined from the research, and changes at the clinical setting will be
made if the new results differed from the clinical guidelines already in place. All three
randomized controlled trials concluded that the inclusion of a lactation consult increases the rates
of breastfeeding in hospitalized postpartum mothers. This new finding should be implemented
into the clinical practice of the hospitals that do not already mandate a lactation consult.

SYNTHESIS PAPER
Synthesis of Breastfeeding Rates and Lactation Consults
Breastfeeding is the most natural and beneficial method of feeding an infant, yet rates are
still significantly lower than desired by obstetricians and pediatricians. Of the babies that were
born in 2013, 77% were breastfed. However of the 77% that were initially breastfed, only 49%
were breastfeeding at six months and an even lower 27% of babies were breastfed at 12 months
(Centers for Disease Control and Prevention [CDC], 2013). Babies who are breastfed receive
antibodies from their mothers that can defend against a long list of illnesses. Infants who are fed
with formula are at an increased risk for many diseases that breast fed babies are not. Formulafed babies are at a higher risk of developing the following: necrotizing entercolitis, asthma, lower
respiratory infections, obesity, and type 2 diabetes (Office of Womens Health, 2011).
Increasing the rates of breast feeding will decrease the cost of infants readmitted for
health related reasons that could be caused from lack of breast feeding and natural antibodies. A
PICOT question was developed in order to guide existing research and make a change in current
practice to better the health and bond of new mothers and their infants. In hospitalized
postpartum mothers, does a consult with the lactation nurse postpartum, compared to no consult
with the lactation nurse, increase the rates of breastfeeding at six months after delivery?
Literature Search
To find the research articles relevant to the topic of breastfeeding, the database CINAHL
was referenced. The key words breastfeeding, breastfeeding, lactation, lactation consult, and
lactation nurse helped to narrow the search.
Literature Review
In a study by Bonuck et al. (2014), the purpose was to determine the effectiveness of preand postnatal interventions to increase breastfeeding. The study was completed as two separately

SYNTHESIS PAPER
funded trials, Best Infant Nutrition for Good Outcomes (BINGO) arm and Provider Approaches
to Improved Rates of Infant Nutrition and Growth Study (PAIRINGS) arm. There was a total of
666 participants in the BINGO trial. Mothers were randomly assigned to one of three different
groups; either the electronically prompted (EP) only group (n= 207), the lactation consult (LC)
only group (n= 70), or the EP and LC group (n=218). A total of 275 participants were from the
PAIRINGS arm and mothers were randomly assigned to one of two groups; either the usual care
group (n=123) or the EP and LC group (n=122) (Bonuck et al., 2014). The EP groups had
electronic prompts that appeared in the medical records for the 5 prenatal visits. Each prompt had
two or three open ended questions that portrayed breastfeeding as the norm. The LC group
included two 30-minute sessions, a hospital visit, and regular phone calls through 3 months
postpartum. Follow up telephone interviews were done with both locations at 1, 3, and 6 months
postpartum.
The results of the BINGO arm was the intensity of breastfeeding was higher in the EP
and LC group and the LC only group, refer to the Table 1 (Bonuck et al., 2014). As for the
PAIRINGS arm, the intervention group rates greatly exceeded the usual care group (Bonuck et
al., 2014). Overall it was found that LC integrated into routine care alone or in combination with
EP increased the intensity of breastfeeding at 3 months postpartum, refer to Table 1. The
strengths of this study include: (1) The trial was randomized, (2) The mothers were blind to
which group they were placed, (3) There was a large sample size, (4) The interventions were
clearly defined in the study.
A randomized controlled trial conducted by Bonuck, Trombley, Freeman, and McKee
(2005) to determine whether an individualized, prenatal and postnatal, lactation consultant
intervention resulted in increased cumulative intensity of breastfeeding up to 52 weeks

SYNTHESIS PAPER
postpartum. Baseline interviews covered demographic data and breastfeeding experience,
intention, and knowledge. There was a total of 304 participants who were randomized into two
different groups, the intervention (n=188) or the control (n=159). The intervention involved two
prenatal meetings, postpartum hospital visit, and/or home visits and telephone calls. The control
group received standard care. Cumulative intensities were drawn at 13 and 52 weeks from
interviews conducted at 1,2,3,4,6,8,10, and 12 months postpartum through the mothers self
report of weekly breast feedings on a 7 level scale (Bonuck et al., 2005).
The results were that the intervention group was more likely to breastfeed through week
20 (month 5), 53.0% in the intervention group versus 39.3% in the control group. The control
groups had lower breastfeeding intensities at 13 weeks and at 52 weeks, refer to Table 1. It was
found that there were no significant differences between the two groups for exclusive
breastfeeding. This indicates that other areas like breastfeeding knowledge were increased
(Bonuck et al., 2005). The strengths for this study include: (1) The trial was randomized, (2) The
reasons were listed for why some participants did not complete the study, (3) There was a large
sample size. There was one weakness, the study was not done as a blind study. However, it did
not cause a problem nor did it alter the validity of the study. It did not make a difference if the
researchers and lactation specialists knew which group was which. The same care was given
whether these individuals knew the groups or not.
In the study conducted by Mattar et al. (2007), the purpose was to address the impact of
simple antenatal educational interventions on breastfeeding practice. There was a total of 401
mothers recruited from clinics in Singapore who participated in the study (Mattar et al., 2007).
Randomization was conducted by a computer-generated list that was used to distribute the
women into the three different groups, A, B and C. Group A (n=123) received an information

SYNTHESIS PAPER
booklet with techniques and benefits of breast feeding, a 16 minute video with demonstrations,
and a 15 minute session with a lactation counselor. Group B (n=132) received only the same
booklet and video, but no counseling session. Group C (n=146) was the control, which did not
receive any additional education. Investigators found that Group A was the most successful with
breastfeeding at 3 months due to the lactation counseling, and at 6 months, refer to Table 1
(Mattar et al., 2007). The results also concluded that printed and audiovisual materials were not
enough and that nurses should make an effort to make face-to-face contact with the mothers. The
strengths of the trial include: (1) The trial was randomized, (2) The women and the second
researcher were blind to the intervention groups, (3) The questionnaires to report data were
assessed for reliability and validity, (4) The participants were demographically similar.
Synthesis
After reviewing all of the articles pertaining to the topic of breastfeeding and the
incorporation of a lactation consult either pre or postnatal, the research seems to be consistent in
increasing the rates of breastfeeding of hospitalized postpartum mothers. All three trials
concluded that the intervention of a lactation consult pre or postnatal resulted in higher rates of
breastfeeding over other interventions (Bonuck et al., 2014; Bonuck et al., 2005; Mattar et al.,
2007). Although all the trials found that the teaching increased the initial rates of breastfeeding,
the three trials also found no difference in the length that the mothers breastfed with any of the
interventions.
The clinical guidelines by the International Lactation Consultant Association (ILCA)
state the standard expectations for every mother and infant after birth. This document is how
mothers are measured as meeting the recommended newborn care or not. ILCAs expected
outcome for the breastfeeding infant is to breastfeed eight times a day for the first 24 hours and

SYNTHESIS PAPER
also be exclusively breastfed for the first six months of life (ILCA, 2005). This is where the only
gaps in the research were found. In the trial by Bonuck, Trombley, Freeman, and McKee (2005)
the results indicated that exclusive breastfeeding peaked at only week 2 and decreased at week 6.
The trial conducted by Mattar et al. (2007) concluded that breastfeeding increased up to the third
month after delivery. The third and last trial by Bonuck et al (2014) found that both arms of the
study had consistent breastfeeding rates until month three, and then began to decrease to the sixth
month. Although the clinical guidelines are from 2005, the research is still valid. The research
trials show that rates in the early months postpartum can be increased, so the gap in the research
is how to improve the breastfeeding rates up to the sixth month, as ILCA recommends.
Clinical Recommendations
The clinical recommendation that would increase the rates of breastfeeding in
hospitalized postpartum mothers is the incorporation of a lactation consult into the protocol of
child birthing, both vaginal and cesarean section deliveries. The research indicates that the rates
of breastfeeding significantly increase with the inclusion of a lactation consult either pre and/or
postnatal as an intervention. In order for the mother and infant to have the best results with
breastfeeding, at least one consult with the lactation nurse within the first six hours of delivery in
order to help with early breastfeeding attempts should be mandatory.

SYNTHESIS PAPER
References
Bonuck, K., Stuebe, A., Barnett, J., Labbok, M. H., Fletcher, J., & Bernstein, P. S. (2014). Effect
of primary care intervention on breastfeeding duration and intensity. American Journal
Of Public Health, 104(S1), S119-27. doi:10.2105/AJPH.2013.301360
Bonuck, K., Trombley, M., Freeman, K., & McKee, D. (2005). Randomized, controlled trial of a
prenatal and postnatal lactation consultant intervention on duration and intensity of
breastfeeding up to 12 months. Pediatrics, 116(6), 1413-1426.
Centers for Disease Control and Prevention. (2013, July). Breastfeeding report card. Retrieved
from http://www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportcard.pdf
International Lactation Consultant Association. (2005). Clinical guidelines for the establishment
of exclusive breastfeeding. Washington, D.C.: US Department of Health and Human
Services.
Mattar, C., Chong, Y., Chan, Y., Chew, A., Tan, P., Chan, Y., & Rauff, M. (2007). Simple
antenatal preparation to improve breastfeeding practice: A randomized controlled
trial. Obstetrics & Gynecology,109(1), 73-80.
Office of Womens Health. (2011, August 4). Why breastfeeding is so important. Retrieved from
http://www.womenshealth.gov/breastfeeding/why-breastfeeding-is-important/

SYNTHESIS PAPER
Table 1
Literature Review
Reference

Aims

Bonuck, K., Stuebe, A.,


Barnett, J., Labbok, M.
H., Fletcher, J., &
Bernstein, P. S. (2014).
Effect of primary care
intervention on
breastfeeding duration
and intensity. American
Journal Of Public
Health, 104(S1), S11927.
doi:10.2105/AJPH.2013.
301360

To determine the
effectiveness of
primary carebased, and preand postnatal
interventions to
increase
breastfeeding.

Bonuck, K., Trombley,


M., Freeman, K., &
McKee, D. (2005).
Randomized, controlled
trial of a prenatal and
postnatal lactation
consultant intervention
on duration and intensity
of breastfeeding up to 12
months.
Pediatrics, 116(6), 14131426.

To determine
whether an
individualized,
pre and
postnatal,
lactation
consultant
intervention
resulted in
increased
cumulative
intensity of
breastfeeding up
to 52 weeks.

Design and
Measures
Two separately
funded singleblind
randomized
controlled trials,
PAIRIINGS and
BINGO

Randomized,
non-blinded,
controlled trial
of recruited
women from
prenatal care.
The
breastfeeding
intensities were
self-reported by
the mothers at
both 13 and 52
weeks of the
trail.

Sample
666 mothers in
the BINGO
trial were
given 1 of 3
interventions:
207 were
electronically
prompted only,
70 had
lactation
consult only,
218 got a
combination.
275 mothers in
the PAIRINGS
trial got 1 of 2
interventions:
123 got the
usual care, 122
got
electronically
prompted and
lactation
consult.
304 mothers
were selected
and randomly
put into either
the control
group (n=159)
or the
intervention
group (n=188).

Outcomes /
statistics
In the BINGO
trial the intensity
of breastfeeding
was higher in the
combination
group (P<.001,
OR: 2.7, 95%, CI:
1.08-6.84) and the
lactation consult
only group
(P<.001, OR:
3.22, 95%, CI:
1.14-9.09).
In the PAIRINGS
trial the
intervention
group rates of
breast feeding
greatly exceeded
over the usual
care group
(P<.001, OR:
2.86, 95%, CI:
1.21-6.76).
The intervention
group was more
likely to
breastfeed
through week 20.
The control group
had lower
intensities of
breastfeeding for
both at 13 weeks
(P<.028,
OR:1.90, 95%,
CI: 1.13-3.20)
and at 52 weeks
(OR: 2.50, 95%
CI: 1.48-4.21).

SYNTHESIS PAPER
Mattar, C., Chong, Y.,
Chan, Y., Chew, A., Tan,
P., Chan, Y., & Rauff, M.
(2007). Simple antenatal
preparation to improve
breastfeeding practice: A
randomized controlled
trial. Obstetrics &
Gynecology,109(1), 7380.

To address the
impact of simple
antenatal
education
interventions on
breastfeeding
practice.

Randomized
control trial, the
data was
collected
through reliable
questionnaires
filled out by the
mothers.

The 401
mothers were
put into 1 of 3
groups by a
computerized
randomizer:
123 received
reading
material, a
video and a
consult with a
lactation
counselor; 132
received the
reading
material and
the video; 146
were the
control.

The group A were


twice as likely to
practice exclusive
or predominant
breastfeeding
(P<.047) and
were most
successful at 3
months (OR 2.6,
95%, CI 1.2-5.4)
and at 6 months
(OR 2.4 95% CI
1.0-5.7). For
every 6 women
that were given
antenatal
preparation, 1
woman would
practice exclusive
breastfeeding for
3 months.