Kris Yuet Wan Lok

Effect of a hospital policy of not accepting free infant formula on in-hospital formula supplementation rates and breast-feeding duration

OBJECTIVE To investigate the effect of public hospitals in Hong Kong not accepting free infant formula from manufacturers on in-hospital formula supplementation rates and breast-feeding duration. DESIGN Prospective cohort study. SETTING In-patient postnatal units of four public hospitals in Hong Kong. SUBJECTS Two cohorts of breast-feeding mother-infant pairs (n 2560). Cohort 1 (n 1320) was recruited before implementation of the policy to stop accepting free infant formula and cohort 2 (n 1240) was recruited after policy implementation. Participants were followed prospectively for 12 months or until they stopped breast-feeding. RESULTS The mean number of formula supplements given to infants in the first 24 h was 2·70 (sd 3·11) in cohort 1 and 1·17 (sd 1·94) in cohort 2 (P<0·001). The proportion of infants who were exclusively breast-fed during the hospital stay increased from 17·7 % in cohort 1 to 41·3 % in cohort 2 (P<0·001) and the risk of breast-feeding cessation was significantly lower in cohort 2 (hazard ratio=0·81; 95 % CI 0·73, 0·90). Participants who non-exclusively breast-fed during the hospital stay had a significantly higher risk of stopping any or exclusive breast-feeding. Higher levels of formula supplementation also increased the risk of breast-feeding cessation in a dose-response pattern. CONCLUSIONS After implementation of a hospital policy to pay market price for infant formula, rates of in-hospital formula supplementation were reduced and the rates of in-hospital exclusive breast-feeding and breast-feeding duration increased.

Interventions to increase the uptake of seasonal influenza vaccination among pregnant women: A systematic review

BACKGROUND Pregnant women and their infants under 6 months of age infected with influenza have a high risk of serious morbidity and mortality. Influenza vaccine during pregnancy offers 3-for-1 benefits to pregnant women, fetuses and newborn infants. Current vaccination uptake rates during pregnancy, however, are often lower than other high-risk groups and the general population. METHODS We systematically reviewed evidence on the effectiveness of interventions to improve influenza vaccination coverage in pregnant women. Risk differences (RDs) were calculated from the included studies. RESULTS Eleven studies were included in the review, of which four were randomized controlled trials (RCTs). Three cohort studies assessed provider-focused interventions while four RCTs and one cohort study evaluated pregnant women-focused interventions. Two cohort studies and a prospective intervention study assessed the effectiveness of bundled interventions. No study solely assessed the effectiveness of interventions to enhance access to influenza vaccination. One moderate quality RCT showed that an influenza pamphlet, with or without a verbalized benefit statement, improved the vaccination rate (RD=0.26; RD=0.39). The other reviewed RCTs showed discordant results, with RDs ranging from -0.15 to 0.03. Although all observational studies significantly improved vaccination rates (RDs ranged from 0.03 to 0.44), the quality of the evidence varied. CONCLUSIONS There is a lack of effective interventions to increase the influenza vaccination rate in pregnant women. Based on the existing research, we recommend that clinicians provide influenza pamphlets to pregnant women with a verbalized statement about the benefits of influenza vaccine to newborns. Further high-quality RCTs are needed to develop successful maternal influenza vaccination programs. Increased clarity in reporting the content of interventions would help to improve the comparability and generalizability of the published studies.

Group versus Individual Professional Antenatal Breastfeeding Education for Extending Breastfeeding Duration and Exclusivity A Systematic Review

Although breastfeeding initiation rates have increased substantially in many developed countries over the past several decades, breastfeeding duration and exclusivity remain suboptimal. In the antenatal period, both group and individual education interventions have been implemented to improve breastfeeding. The purpose of this review was to compare the effectiveness of group and individual antenatal professional education on breastfeeding exclusivity and duration. A systematic search of the literature was conducted using Medline (1946-June 2014), PubMed (1883-June 2014), the Cumulative Index to Nursing and Allied Health Literature (1947-June 2014), EMBASE (1947-June 2014), British Nursing Index (1994-June 2014), Google Scholar, and the Cochrane Library. Included studies were limited to health care professional-conducted education delivered to pregnant women only. Only studies reporting breastfeeding duration or exclusivity were included. Nineteen studies were included, of which 13 evaluated antenatal group education, 5 evaluated individual antenatal education, and 1 evaluated both a group and an individual antenatal education. When compared with standard care, 4 out of 12 studies supported the effectiveness of antenatal group education on breastfeeding duration or exclusivity, whereas 4 out of 6 studies supported the effectiveness of antenatal individual education. Two studies compared antenatal group education with peer-led education and neither study showed a significant difference in breastfeeding outcomes. The methodological heterogeneity and the small number of high quality studies limited our ability to draw firm conclusions about the effectiveness of either mode of antenatal education.

Relationship between the Infant Feeding Preferences of Chinese Mothers’ Immediate Social Network and Early Breastfeeding Cessation

Background: The relationship between support from members of a mother’s social network and breastfeeding continuation is receiving increased attention. Objectives: The objectives of this study were to describe the infant feeding preferences of Chinese mothers’ immediate social network and to examine the association between these preferences and early breastfeeding cessation. Methods: In total, 1172 mother-infant pairs were recruited from 4 public hospitals in Hong Kong and followed prospectively for 12 months or until breastfeeding stopped. Results: Over 40% of participants’ partners preferred breastfeeding and half had no infant feeding preference. Only about 20% of participants’ mothers or mothers-in-law preferred breastfeeding, and less than 10% reported that all of the 3 significant family members (partner, mother, and mother-in-law) preferred breastfeeding. The partner’s preference for infant formula or mixed feeding (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.43-4.71) or having no preference (OR, 1.64; 95% CI, 1.16-2.30) was strongly associated with higher odds of stopping breastfeeding before 1 month. For every additional family member who preferred breastfeeding, the odds of stopping breastfeeding was reduced by almost 20% (OR, 0.81; 95% CI, 0.68-0.97). However, living with a parent-in-law (OR, 1.45; 95% CI, 1.02-2.07) was also a predictor of early breastfeeding cessation. Knowing someone who had breastfed for ≥ 1 month (OR, 0.64; 95% CI, 0.42-0.97) or having been breastfed as a child (OR, 0.67; 95% CI, 0.45-0.98) significantly lowered the odds of early breastfeeding cessation. Conclusions: The infant feeding preferences of mothers’ immediate social network are significantly associated with breastfeeding continuation. Prenatal breastfeeding education programs should involve significant family members to promote breastfeeding.

Increase in Weight in Low Birth Weight and Very Low Birth Weight Infants Fed Fortified Breast Milk versus Formula Milk: A Retrospective Cohort Study

There has been a dramatic rise in preterm births in developed countries owing to changes in clinical practices and greater use of assisted reproductive techniques. However, few studies have examined the growth and outcomes of preterm infants according to the type of feeding (with fortified breast milk or formula). The purpose of this study was to examine the effect of breast milk feedings and formula on the growth and short-term outcomes of preterm infants in Hong Kong. In a single-center retrospective cohort study, we included 642 preterm infants at gestational age <37 weeks with birth weights <2200 g. According to World Health Organization criteria, 466 were classified as low birth weight (LBW) infants (≥1500 g and <2200 g) and 176 were classified as very low birth weight (VLBW) infants (<1500 g). The mothers of approximately 80% of VLBW infants and 60% LBW infants initiated breast milk feeding. When compared with no breast milk intake, LBW infants that received breast milk were significantly more likely to have growth z-scores closer to the median of the reference population on admission and experienced slower weight gain from birth to discharge. When breast milk was categorized by percent of total enteral intake, significant differences were seen among LBW infants, with lower percentages of small-for-gestational-age (SGA) status at discharge with increased proportions of breast milk intake. Our results suggest that LBW infants fed breast milk had better growth z-scores and lower SGA status at discharge compared with those predominately fed preterm formula.

Brief education to promote maternal influenza vaccine uptake: A randomized controlled trial

BACKGROUND Although pregnant women are the highest priority group for seasonal influenza vaccination, maternal influenza vaccination rates remain suboptimal. The purpose of this study was to evaluate the effect of a brief education intervention on maternal influenza vaccine uptake. METHODS During the 2013-14 and 2014-15 influenza seasons, we recruited 321 pregnant women from the antenatal clinics of 4 out of 8 public hospitals in Hong Kong with obstetric services. Hospitals were geographically dispersed and provided services to pregnant women with variable socioeconomic backgrounds. Participants were randomized to receive either standard antenatal care or brief one-to-one education. Participants received telephone follow-up at 2 weeks postpartum. The primary study outcome was self-reported receipt of influenza vaccination during pregnancy. The secondary outcomes were the proportion of participants who initiated discussion about influenza vaccination with a health care professional and the proportion of participants who attempted to get vaccinated. RESULTS Compared with participants who received standard care, the vaccination rate was higher among participants who received brief education (21.1% vs. 10%; p=0.006). More participants in the education group initiated discussion about influenza vaccination with their HCP (19.9% vs. 13.1%; p=0.10), but the difference was not statistically significant. Of participants who did not receive the influenza vaccine (n=271), 45 attempted to get vaccinated. A significantly higher proportion of participants who attempted to get vaccinated were in the intervention group (82.2% vs. 17.8%; p<0.001). If participants who had attempted vaccination had received the vaccine, vaccination rates would have been substantially higher (44.1% vs. 15%; p<0.001). Twenty-six participants were advised against influenza vaccination by a healthcare professional, including general practitioners, obstetricians, and nurses. CONCLUSION Although brief education was effective in improving vaccination uptake among pregnant women, overall vaccination rates remain suboptimal. Multicomponent approaches, including positive vaccination recommendations by healthcare professionals, are needed to promote maternal influenza vaccination. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov (NCT01772901).

Effect on Baby-Friendly Hospital Steps When Hospitals Implement a Policy to Pay for Infant Formula

Background: The Baby-Friendly Hospital Initiative requires hospitals to pay market price for infant formula. No studies have specifically examined the effect of hospitals paying for infant formula on breastfeeding mothers’ exposure to Baby-Friendly steps. Objectives: To investigate the effect of hospitals implementing a policy of paying for infant formula on new mothers’ exposure to Baby-Friendly steps and examine the effect of exposure to Baby-Friendly steps on breastfeeding rates. Methods: We used a repeated prospective cohort study design. We recruited 2 cohorts of breastfeeding mother–infant pairs (n = 2470) in the immediate postnatal period from 4 Hong Kong public hospitals and followed them by telephone up to 12 months postpartum. We assessed participants’ exposure to 6 Baby-Friendly steps by extracting data from the medical record and by maternal self-report. Results: After hospitals began paying for infant formula, new mothers were more likely to experience 4 out of 6 Baby-Friendly steps. Breastfeeding initiation within the first hour increased from 28.7% to 45%, and in-hospital exclusive breastfeeding rates increased from 17.9% to 41.4%. The proportion of mothers who experienced all 6 Baby-Friendly steps increased from 4.8% to 20.5%. The risk of weaning was progressively higher among participants experiencing fewer Baby-Friendly steps. Each additional step experienced by new mothers decreased the risk of breastfeeding cessation by 8% (hazard ratio = 0.92; 95% CI, 0.89-0.95). Conclusion: After implementing a policy of paying for infant formula, breastfeeding mothers were exposed to more Baby-Friendly steps, and exposure to more steps was significantly associated with a lower risk of breastfeeding cessation.

Breastfeeding Duration And The Theory Of Planned Behavior And Breastfeeding Self-efficacy Framework: A Systematic Review Of Observational Studies.

Introduction Numerous studies have shown that the constructs of the Theory of Reasoned Action (TRA), Theory of Planned Behavior (TPB) and Breastfeeding Self-Efficacy (BSE) Framework can effectively identify relationships between maternal psychosocial factors and breastfeeding initiation. However, the ability of these theories to predict breastfeeding duration has not been adequately analyzed. The aim of the review was to examine the utility of the constructs of TRA/TPB and BSE to predict breastfeeding duration. Methods We conducted a literature search using Pubmed (1980-May 2015), Medline (1966-May 2015), CINAHL (1980-May 2015), EMBASE (1980-May 2015) and PsycINFO (1980-May 2015). We selected studies that were observational studies without randomization or blinding, using TRA, TPB or BSE as the framework for analysis. Only studies reporting on breastfeeding duration were included. Results Thirty studies were selected, which include four using TRA, 10 using TPB, 15 using BSE and one using a combination of TPB and BSE. Maternal intention and breastfeeding self-efficacy were found to be important predictors of breastfeeding duration. Inconsistent findings were found in assessing the relationship between maternal attitudes, subjective norms, perceived behavior control and breastfeeding duration. Discussion The inadequacy of these constructs in explaining breastfeeding duration indicates a need to further explore the role of maternal self-determination in breastfeeding behavior.

Agreement between self-/home-measured and assessor-measured waist circumference at three sites in adolescents/children

The objective of this study was to assess the validity of the self-/home-measured waist circumference (WC) method in children/adolescents at three sites: at the level of the umbilicus, immediately above the iliac crest, and at the midpoint of the lower margin of the last palpable rib and top of the iliac crest. A cross-sectional study of 3360 Hong Kong Chinese children/adolescents was conducted, with 2980 (88.7%) participants included in the final analysis. The WC of children aged 6 to 9 was measured at the three sites by their parent/guardian at home followed by measurement by trained assessors at school within one week. Children/adolescents between the ages of 10 and 17 self-measured their WC at the three sites during school hours, followed by measurements by the trained assessors. Bland-Altman limits of agreement (LOA) analysis was performed to evaluate between-measurement agreement. The difference between assessor- and self-/home-measured WC was defined as ≤ ±2.5 cm for the upper and lower LOA at all three sites as an a priori criterion based on the assessor-measured inter-rater results. The results showed that most measurements (about 96%) at each site was within 95% of the LOA. Of the three measurement sites, the smallest LOA interval width was found at the umbilicus site, with an upper LOA of 5.08 and 7.13 and lower LOA of -2.61 and -3.43 in boys and girls, respectively. In conclusion, the range of LOA was relatively large, exceeding the acceptable limits of the predefined a priori criterion of upper and lower LOA, and thus suggesting disagreement between the two measurement methods. The use of WC as a measure of abdominal obesity in clinical practice/epidemiological studies should be restricted to measurement by trained health professionals/research staff.

Household Smoking And Breastfeeding Duration Among Hong Kong Chinese Women: A Prospective Cohort Study

Abstract Background Maternal smoking or the inhalation of ambient cigarette smoke remains an important public health problem that affects child health with potential lifelong consequences. Hong Kong is one of the most densely populated cities in the world, and living with extended family members is common. Many pregnant women are exposed to secondhand smoke from household and family members. Thus, the aim of this study was to examine the effect of maternal, paternal, and other household smokers on the duration of breastfeeding in Hong Kong. Methods This analysis was based on a prospective cohort study. From Oct 11, 2011, to May 31, 2012, mother–infant pairs were recruited during the postnatal hospital admission from four geographically distributed public hospitals in Hong Kong. Participants were Cantonese-speaking Hong Kong residents who gave birth to a full-term, singleton infant, who intended to breastfeed, and had no serious medical or obstetric complications. Exclusion criteria were admission to the special care nursery for more than 48 h after birth or admission to the neonatal intensive care unit. Data were collected directly from participants during postnatal hospitalisation and after discharge through telephone follow-up. In-hospital data collection included basic demographic details, maternal and infant data, and in-hospital feeding data. Follow-up data included infant feeding status at 1, 2, 3, 6, 9, and 12 months post partum or until breastfeeding was stopped. Participants were asked whether they smoked during pregnancy, whether their partner or husband smoked, and whether any other family members living in the same household smoked. Smoking was then categorised as total number of smokers living in the same household (zero, one, or two or more). The primary outcome was the duration of any and exclusive breastfeeding up to 12 months post partum. The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster and from all study hospitals. Informed written consent was obtained from each participant. Findings We recruited a total of 1277 mother–infant pairs admitted to the obstetric units of four public hospitals in Hong Kong and followed them up by telephone up to 12 months post partum. After further exclusion of 37 (3%) participants with no further contact after hospitalisation, 1240 mother–infant pairs were successfully followed up. Of the mothers, 806 (65%) reported no smokers in the household, 337 (27%) reported one smoker in the household, and 95 (8%) reported two or more smokers in the household. We noted a pattern of increasing number of smokers living in the household associated with progressively shorter duration of any and exclusive breastfeeding. However, the effect of number of smokers living in the household on the overall duration of exclusive breastfeeding was not statistically significant. A Kaplan-Meier survival curve showed that the number of smokers living in the household was associated with progressively shorter duration of any breastfeeding. When compared with mothers who reported no smokers in the family, those exposed to two or more family members that smoked were almost 40% more likely to stop any breastfeeding (adjusted hazard ratio 1·37, 95% CI 1·06–1·76) within 12 months. Interpretation We found that mothers exposed to a greater number of smokers in the household had a significantly higher risk of breastfeeding cessation. Practitioners can assess the smoking patterns of pregnant women and their family members and provide smoking cessation education and support to this high-risk group. Future research is needed to identify the physiological factors associated with smoking on breastfeeding practices. Funding Health and Medical Research Fund; Food and Health Bureau of the Hong Kong Government.