Article: Mukhopadhyay S, et al. “Effect of early-onset sepsis evaluations on in-hospital breastfeeding practices among asymptomatic term neonates.” Hosp Pediatr. 2015 Apr;5(4):203-10. doi: 10.1542/hpeds.2014-0126.
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Why this article: For newborns, I feel the area of suspected neonatal sepsis and chorioamnionitis is full of variations in practice. From variations in what obstetricians label as “chorio” to how long we keep infants in the special care nursery (SCN) while on antibiotics, the literature doesn’t have a lot of definitive information to offer. There are many times in the newborn/NICU setting where breastfeeding takes a backseat to other interventions. This is one of the first studies that looks at the link between early-onset sepsis evaluation and delays in breastfeeding.
Methods: The study was a secondary observational analysis of data from a previous study looking at epidural analgesia at Brigham and Women’s and Massachusetts General Hospitals. The study group included 820 first-time mothers who intended on breastfeeding after birth. The goal was to look at rates of breastfeeding initiation within the first 2 hours of birth and the use of supplementation in the first 24 hours after birth. Infants were all well-appearing and full term. Infant’s excluded from the study were those with any issues of hypoglycemia or an NPO order. Of the 692 dyads enrolled, 101 infants were separated from their mothers for early-onset sepsis (EOS) evaluation. Criteria for EOS were based on the GBS prevention guidelines from the CDC (including maternal fever >100.4, inadequate GBS treatment, membrane rupture >18 hrs), as well as OB diagnosis of chorioamnionitis. Infants were assessed to be well appearing and had blood cultures and labs drawn, and antibiotics started if necessary. All infants were returned to mom’s room after initial workup initiated, and received antibiotics in the postpartum room if required.
Results: Of the 101 babies evaluated who were separated from their mother for EOS evaluation after birth, 47% of them had delayed onset of breastfeeding (classified as first feed >2 hrs after birth). Only 13% of infants who were not separated had delays in breastfeeding. The group looked at multiple other variables related to EOS, such as degree of maternal temperature, membrane rupture time etc, and no factors related to the clinical picture itself seemed linked to delayed onset of breastfeeding. The main factor related to delayed onset of breastfeeding was the amount of time child was separated from mother within the first 2 hours after birth. Formula supplementation in the first 24 hrs was also significantly associated with separation for EOS evaluation, with 19% of infants separated ultimately receiving supplementation compared to 10% of infants who were not separated.
Conclusion: The authors concluded that separation of infants from their mothers in the first 2 hours after birth for EOS evaluation caused delays in breastfeeding and increased the likelihood of receiving formula supplementation. They discussed limitations to the length of the supplementation data being only 24 hrs after birth, as many of the babies in this study were discharged between 24-48 hrs. They did point out, however, other studies which have shown that breastfeeding within 1 hour of birth and avoiding supplementation were strong predictive factors for exclusive breastfeeding at 6 weeks for infants. They also discussed the challenge with generalizing this data to other populations, as each hospital may have their own protocols and criteria for which babies require EOS evaluations.
Discussion: I felt this study examined some fairly interesting questions. In terms of methods I was a little leery about subjective declaration of “chorio” by OB’s, as there seems to be wide variations in practice (at least at our hospitals). In the end the authors concluded that it wasn’t the EOS evaluation itself that seemed to matter with breastfeeding and supplementation, but rather the act of being separated from mom in general. This made sense to me, and also gave me caution in thinking of all the disruptive activities that take place in the first two hours of birth that might also disrupt breastfeeding (from newborn meds and obtaining measurements to the throng of excited relatives rushing in to visit). I was also interested in how the group kept well-appearing infants in the postpartum room with mom after labs were drawn and IV’s were placed. In our group’s practice I feel even healthy appearing infants may stay in the NICU for 12-24 hours of “observation” while on antibiotics. If this study showed the potential disruptive power of a 1-2 hr separation from mom, it makes me fear what the effects of longer disruptions would be. It would also be interesting to see other data on breastfeeding longer than 24 hrs (i.e do babies that received supplementation in the hospital related to EOS evaluations go on to successfully breastfeed after discharge?) Obviously metrics and predictive tools for neonatal sepsis could be the topic of a whole other journal club. Hopefully this article will remind us to not let breastfeeding be pushed to the back burner!