The Gap Between Breast and Bottle, What Are the Disparities in a Large Community Hospital in Southern West Virginia?

Background: Exclusive breastfeeding is recognized as the ideal feeding method for infants. Newborns receiving formula in-hospital are at higher risk for early breastfeeding cessation. Among infants born in 2017, CDC Breastfeeding Report Card, 2020, reported the rate of breastfed infants receiving formula before two days of age as 15% in West Virginia (WV). We aimed to determine factors associated with in-hospital formula supplementation of breastfed newborns at a large community hospital in Southern WV. We hypothesized that disparities exist in supporting women to exclusively breastfeed.

Methods: We retrospectively reviewed 500 randomly selected charts of infants born 09/01/2019-09/1/2020. Full-term infants with a recorded maternal decision to exclusively breastfeed were included. Exclusion criteria were prematurity, NICU admission, maternal diabetes, and infant hypoglycemia. Factors associated with formula supplementation were compared between mothers exclusively breastfeeding and those who were not at the time of discharge.

Results: Of the reviewed charts, 70% of birth mothers desired to exclusively breastfeed. 211 infants met all inclusion criteria. 70% were delivered via vaginal delivery; 52% were induced. Of the included newborns, 41% were supplemented with formula. 32% of mothers met with lactation consultants prior to formula supplementation. Top reasons for formula supplementation were mother request (45%) and newborn difficulty latching (22%). Median time of first supplementation was 20.0 hours (range:0.5-54). 12% of the supplementation occurred within 6 hours and 96.5% within 2 days of age. Rates of formula supplementation did not increase during the nurses’ night shift or at nurses’ shift change. Exclusive breastfeeding at discharge was associated with higher education level (p=0.002), tobacco abstinence (p=0.03), prior births (p=0.04), and increased maternal age (p=0.02); with every 1 year increase in maternal age, there was 7% decrease in supplementation. No statistically significant associations were present between exclusive breastfeeding at discharge meeting with a hospital lactation consultant, maternal race, marital status, induction need, or neonatal characteristics (p>0.05). When controlling for confounders of maternal age, marital status, tobacco use, and lactation consultation, Cesarean delivery (odd ratio: 2.0,1.03-4.2, 95% confidence interval), primiparity (2.6, 1.4-4.8), and not completing high school (12.5, 1.6-96.5) predicted formula supplementation. Exclusive breastfeeding discharge rates remained relatively steady over the 12 month study period, including during the COVID-19 pandemic.

Conclusion: At our center, formula supplementation rate of 41% in the first two days of age appears higher than the state’s rate using the CDC report card. Mother request and newborn difficulty latching are the top reasons for formula supplementation. Median age of supplementation was 20 hours. Lactation consultations were not universal and disparities existed for breastfeeding mothers supplementing with formula. Addressing maternal disparities is essential to enhance newborn health equity. Our study’s findings will be used to develop prenatal and postnatal interventions to maximize hospital breastfeeding support and minimize formula supplementation.