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Breastfeeding disruption during hospitalization for

bronchiolitis in children, pilot study

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2017-000158

Article Type: Original article

Date Submitted by the Author: 13-Jun-2017

Complete List of Authors: heilbronner, claire; Assistance Publique - Hopitaux de Paris, Roy, Emeline; Assistance Publique - Hopitaux de Paris Hadchouel, Alice; Assistance Publique - Hopitaux de Paris Jebali, Sabrine; Assistance Publique - Hopitaux de Paris Smii, Siwar; Assistance Publique - Hopitaux de Paris Masson, Alexandra; Assistance Publique - Hopitaux de Paris

Renolleau, Sylvain ; Assistance Publique - Hopitaux de Paris Rigourd, Virginie; Assistance Publique - Hopitaux de Paris

Keywords: General Paediatrics, Nursing Care, Nutrition, Respiratory

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Breastfeeding disruption during hospitalization for bronchiolitis in children, pilot study

Claire Heilbronner 1, Emeline Roy

2, Alice Hadchouel

3, Sabrine Jebali

4, Siwar Smii

4,

Alexandra Masson1, Sylvain Renolleau

1, Virginie Rigourd

4

Affiliations: 1 Pediatric Intensive Care Unit, AP-HP, Necker Hospital for Sick Children, Paris, France 2 Pediatric Department, AP-HP, Necker Hospital for Sick Children, Paris, France 3 Pediatric Pulmonology Department, AP-HP, Necker Hospital for Sick Children, Paris, France 4 Region Ile de France Human milk bank, AP-HP, Necker Hospital for Sick Children, Paris, France

Address correspondence to:

Dr Claire Heilbronner Pediatric Intensive Care Unit AP-HP, Hôpital Necker Enfants Malades, 149 rue de Sèvres, Paris, 75015 France e-mail: [email protected] Tel: +33.1.71.19.64.61; Fax: Tel: +33.1.44.49.42.17

Abbreviations: PICU: Pediatric intensive Care Unit

Word count: 2481 Key words: Bronchiolitis, breastfeeding, unwanted weaning

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ABSTRACT

Background

Being hospitalized for an acute bronchiolitis might be a situation at risk of unwanted weaning

off breastfeeding for several reasons (respiratory distress, use of enteral or parenteral feeding,

mothers’ tiredness, etc..) yet it has never been really evaluated and quantified.

Methods

We conducted a pilot study to evaluate breastfeeding disruption during hospitalization for

bronchiolitis and try to identify its determining factors.

This is a prospective study during one epidemic season of bronchiolitis in a tertiary care

hospital. All patients aged 6 months or younger hospitalized with acute bronchiolitis and

receiving at least partial breastfeeding were eligible for the study. Patients discharged at home

whose parents accepted to be contacted by phone were included.

Results

Eighty four patients were included in the study. Length of hospital stay was 3 days (1; 34) and

27 patients (32%) spent some time in PICU.

Forty three mothers (51%) stated that their breastfeeding had been modified by the

hospitalization (17 stopped, 12 switched to partial breastfeeding and 14 reduced without

stopping). Mothers stated that the causes of breastfeeding disturbance were lack of support

and advices (63%), followed by severity of child’s respiratory disease (32%), logistic hospital

difficulties (30%) and personal organization issues (9.3%). Lengh of stay, need for ventilatory

support or nutritional support was not statistically different between groups.

Conclusion

Bronchiolitis is a high risk event for breastfeeding disruption.

Correct advices and support could be a determining factor and further studies should focus on

preventive interventions

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What is already known on this topic Breastfeeding might be perturbed during hospitalization for bronchiolitis. This issue has not been quantified and no data can support any intervention. What this study adds There is a high rate of breastfeeding disruption during hospitalization for bronchiolitis. Respiratory severity of the bronchiolitis is not determining, supporting mother is. This study gives clues for some possible therapeutic interventions in the future.

INTRODUCTION

Breastfeeding is a well-documented protective factor against respiratory diseases in

children.[1–3]. Exclusive breastfeeding should therefore be promoted and international

guidelines recommend to maintain it at least until the age of 6 months [4, 5].

Breastfeeding though is not always easy [6] . A recent survey estimated that 75% of infants

were breastfed in maternity wards in France (including partial breastfeeding) but only 40% of

children were still partially breastfed after 3 months [7, 8].

Children’s health might influence breastfeeding continuation (quality of suctioning, short

breathing in respiratory or cardiologic diseases, mother/ child separation, mother’s fatigue,

formula introduction).Given the fact that most children are healthy, it is likely that the impact

of childs’ disease on breastfeeding might not be perceivable in big cohorts who focus more on

social or economic factors.

In France, each year, about 500000 toddlers are affected with acute bronchiolitis [9]. Among

children consulting at the emergency room, about 50% of children under 6 months (and 62%

under 3 months) require hospitalization [10] and 10 to 15% spend some time in PICU for

respiratory support [11].


off breastfeeding for several reasons:

-dyspnea, suctioning difficulties or even swallowing difficulties can occur

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-enteral or parenteral feeding can be necessary, sometimes with formula milk

-mothers might not always be able to stay with their child continuously in hospital (either

because of hospital accommodation or because of family situation, working issues…)

-mothers might get stressed and tired, sleep badly, eat or drink less than usual or irregularly

-breast milk expression might not always be easy in hospital by lack of material or caregiving

attention

-caregivers might have different attitudes and contradictory advices towards breastfeeding

Only Lapillone and al. mention breastfeeding disturbance among the potential impacts of an

hospitalization for bronchiolitis [12, 13]. No study has been published to specifically measure

breastfeeding disruption during hospitalization for bronchiolitis although the high number of

patients concerned makes it a potentially important health issue.

With no study available, no intervention can be proposed in national or international

guidelines on bronchiolitis.

We conducted a pilot study to try to measure the risk of breastfeeding being impaired during a

hospitalization for bronchiolitis in children previously breastfed and to try to identify

children, mother or hospital factors that might participate in poor breastfeeding outcome.

MATERIAL AND METHODS

The Bronchilact study is a single centre prospective observational study conducted from

October 1st 2015 to February 15th 2016 at Necker-Enfants Malades Hospital in Paris (tertiary

care) in all wards attending to patients with acute bronchiolitis (pediatric ward, pediatric

pulmonology ward and PICU (pediatric intensive care unit)).

Bronchiolitis was defined on the basis of history and physical examination as rhinorrhoea,

cough, tachypnea, wheezing, increased respiratory effort expressed by grunting, nasal flaring,

and intercostal and/or subcostal retractions [14]. Apneic bronchiolitis in neonates were also

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included. Hospital admission was decided by emergency ward’s attending physicians. PICU

admission was decided according to intensivist’s assessment.

Were eligible for the study

-all infants under 6month on admission

-with acute bronchiolitis and no other serious condition

-breastfed (at least partially) on admission

-discharged at home

We included all patients whose parents spoke French and accepted to be contacted by phone

to answer a standardized survey.

We did not include parents that could not be reached on their phone. Patients could not be

included twice in the event of recurrent bronchiolitis during the study period.

The primary outcome was unwanted weaning from breastfeeding, either total or partial

attributed to hospitalization for bronchiolitis.

The secondary aim of the study was to identify patients or conditions of hospital stay at risk

of breastfeeding’s disruption.

Standard care was given accordingly to both French and US latest guidelines [9, 14] .

Data collection included : growth evaluation (birth weight, growth, weight on admission and

at discharge), social background, tobacco exposure, length of stay (LOS), ICU requirements,

length of oxygen or ventilatory support requirement, enteral or parenteral nutritional support,

room accommodation during hospitalization, breastfeeding help and material (breast pump,

freezer) available during hospital stay, total or partial weaning from breastfeeding at discharge

or in the fortnight following discharge, mother’s opinion on the cause of the weaning,

mother’s opinion and satisfaction about breastfeeding support during hospitalization,

patient/nurse ratio, breastfeeding experts among caregivers.

Statistical analysis:

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Data are expressed as median values (with minimum and maximum value) for continuous

variables, and number and/or frequency (%) for binary or categorical data.

For qualitative variables we used Student test

For comparison of non-parametric means, Wilcoxon’s test was used if necessary for

quantitative criteria while χ2 and Fisher’s exact test was used to compare qualitative criteria.

P values < 0.05 were considered statistically significant.

Analyses were performed with Biostat TGV software ®.

The study was approved by the ethical board (CER_SFP 2015_009_2). Legal guardians

received written information about the study either given hand to hand during their hospital

stay or sent by mail if they could not be seen during hospital stay.

RESULTS

During the study period 332 patients under 6 months were hospitalized at our hospital for 345

episodes of bronchiolitis. Among these, only 144 patients were breastfed, totally (N=107,

74%) or partially (N=37, 26%). Four were not included because they did not speak any

French and 56 did not answer their phone despite several calls at different times of the day, 84

patients (58% of breastfed patients) could to be included in the study. The median delay for

phone contact was 3 months (0.5; 6).

Among eligible patients, no significant difference could be observed concerning LOS, need

for PICU, respiratory support, nutritional support between included (n=84) and non-included

patients (n=60).

Bronchiolitis description (n=84)

Median LOS for all breastfed patients was 3 days (1; 34), 27 patients (32%) patients spent

some time in PICU (median length in PICU: 3 days (1; 26). One patient (1%) needed invasive

ventilation for 10 days, 18 (21%) received either NIV or high flow oxygen for 3 days (1; 9),

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34 patients (40%) received standard oxygen for 3 days (1; 7), and 34 patients (40%) received

no respiratory support during hospitalization. No patient died of bronchiolitis during the study

period. Regarding feeding difficulties, 45 (53%) patients received nutritional support, either

by enteral feeding (n=38, 45%) or parenteral nutrition (n=5, 6%) or both (n=2, 2%).

Socioeconomic background (n=84)

Most breastfeeding mothers (96%) did not smoke and lived as a couple (98%). Concerning

occupation, 2% of mothers were working at the time of hospitalization, 52% were on

maternity break, 18% were on a parental education break and 28% were housewives.

Breastfeeding during hospitalization (n=84)

Sixty five patients (77%) were exclusively breastfed before, the others received both breast

milk and formula milk. Forty-three mothers (51%) stated that their breastfeeding had been

modified by the hospitalization of their child, either moderately (N=19, 23%) or totally (N=

17, 20.5%).

Among those 43 mothers

-17 (group 1) stopped breastfeeding

-12 (group 2) switched from total breastfeeding to partial breastfeeding

-14 (group 3) reduced breastfeeding without stopping or switching.

Remaining mothers (41/84, 49%) stated to have kept breastfeeding as before or that their

breastfeeding modification was not because of the hospitalization but was a personal choice

or a planned weaning (group 4).

Daily growth rate before hospitalization and type of breastfeeding before hospitalisation (as

described in table 1) did not significantly differ between groups 1+2+3 and 4.

No statistically significant difference either was observed between patients of groups 1+2+3

and group 4 regarding medical severity of the bronchiolitis evaluated by LOS, oxygen

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requirement or need for respiratory support, enteral or parenteral feeding during

hospitalization, growth evaluation on admission, PICU admission (table 1).

When asked about the causes of their breastfeeding difficulties, mothers of group 1, 2 or 3

answered

-63%: lack of support and advices

-32%: severity of child’s respiratory disease

-30%: logistics issues (difficulties to draw breast milk, availability of breast pumps, room

accommodation and bedding for mothers, introduction of formula milk or baby bottle)

-9.3%: personal and family organisation issues due to hospitalization (sitting the siblings, long

journey home).

All children were in single rooms and all mothers could sleep in the same room as their child.

Patient/nurse ratio was 3/1 in ICU and 6 or 7/1 in paediatric ward and pulmonology ward.

Each ward had several breastfeeding experts among doctors or nurses.

Data about prior experience with breastfeeding was available for 63 breastfeeding mothers.

Mothers in the study had a median number of children of 2 (1; 5) and had an experience of

cumulated breastfeeding for their children of 8 month (0.9; 36). No difference was observed

between groups 1+2+3 and 4 regarding cumulated length of previous breastfeeding for the

elder children.

DISCUSSION

We observed in our study a high rate of breastfeeding on admission compared to

epidemiologic surveys [7, 8] but also a very high rate of breastfeeding disturbance during

hospitalization for bronchiolitis as previously suggested in a large multicentre study [12, 13].

The hospitalization of infants for bronchiolitis in our survey generated undesired weaning

from breastfeeding, a transition to mixed breastfeeding or even partial changes that may affect

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the nutritional balance suitable for infants and alter their protection against further respiratory

events [3, 21] .

Our study is subject to possible biases, the most important is that it is single centred

Several local particularities could have influenced the results in our hospital:

-It is possible that a high number of nurses could help to better support breastfeeding mothers

since it is a time-consuming activity, probably even more in an epidemic period with high

workload. The nurse to patient ratio seemed correct in our wards but we could not find much

data about optimal ratio in the literature.

-It is possible that breastfeeding knowledge or involvement is not optimal among our

caregivers despite the fact that all the nurses in our hospital are specifically trained for

paediatrics. Hence the results in our study gives a baseline information about what happens

for breastfeeding during bronchiolitis with no or minimal support from caregivers.

-Room accommodation could be considered non optimal in our hospital but we believe that it

would be similar or possibly even worse in some other settings since our hospital is a

referring and teaching hospital with most paediatric wards hosted in a new building

inaugurated in 2013, and with all patients being bedded in single rooms with possible sleeping

accommodation for parents.

Another possible bias is the long time period between hospitalization and survey that could

have altered the quality of answers from the mothers, but Lapillonne et al. in their study

concluded that interrogation as far as 6 months after hospitalization can be considered as

relevant to evaluate burden of hospitalization [12]. Moreover, this delay has helped not to

include transitory modifications after hospitalization and to only collect data on persistent

alterations of breastfeeding.

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The last potential bias is that a significant amount of patients could not be reached on the

phone. If we consider that all eligible mothers that we could not include in this survey

continued their breastfeeding with no disturbance (which is unlikely), we still have 30%

(43/144) of mothers whose breastfeeding was either stopped or altered.

Despite these considerations, Bronchilact is the first study to really highlight the effect of

hospitalization for acute bronchiolitis for children under 6 months on breastfeeding, and to

question the various factors involved.

Exclusive breastfeeding was not a protective factor in our study and we even observed a non

significant tendency to the opposite (and a tendency for children with altered breastfeeding to

be younger). It is possible that very young infants about 10-15 days old are more frequently

exclusively breastfed but are also those whose breastfeeding is the more fragile and we should

probably be more supportive for the mothers of those very young infants.

We expected to find severity of respiratory disease as the first risk factor (on medical charts or

mother’s survey) for breastfeeding discontinuation but only 32% of mothers pointed out the

severity of disease as one of the causes for unwanted weaning. It is possible that the delay

between discharge and phone call could have altered mothers perception of respiratory

diseases’ severity but objective evaluation of respiratory distress on medical charts (LOS,

PICU requirements, respiratory and nutritional support) was also not significantly different

between groups.

It is possible that most severe patients with long PICU stay and invasive ventilation should be

more impacted but our population was not powerfull enough to evaluate this since intubation

rate for bronchiolitis has dramatically fallen in the last few years with NIV development. It is

important to notice that breastfeeding disturbance observed in our patients occurred despite a

short LOS (median 3 days) and despite a good outcome of this acute but rather benign

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respiratory disease. It is possible that caregivers underestimate the possible impact of such a

short stay on breastfeeding, and that they might think that breastfeeding will necessarily go

back to normal after discharge but our study highlights a different outcome.

Lack of support from caregivers was the first factor pointed out by mothers after discharge. It

is possible that this lack of support might be less important in other hospitals, especially in

countries where breastfeeding is better supported. Yet, although relying mostly on mothers

recall and perception, this information is still very important as it is a modifiable factor for

further practice. If other studies confirm the results of our survey, it could lead to

recommendations of therapeutic interventions to prevent unwanted weaning during

bronchiolitis, especially in younger infants for witch breastfeeding is still precarious.

Our data encourages us to endorse preventive measures in all wards hosting patients with

bronchiolitis (even if children stay in hospital for a very short length of time) especially to

support mothers during hospitalization.

We only studied bronchiolitis in hospital but it is possible that children who do not require

hospitalization might also have altered breastfeeding; this should be evaluated in another

prospective study involving outpatient’s caregivers.

CONCLUSION

Breastfeeding is a key part of the 1000 days period for proper development of the child. It will

also participate in the prevention of relapse of other respiratory infections and re

hospitalization

With no intervention, bronchiolitis in a breastfed infant is a high risk event with about half of

mothers of hospitalized children either stopping or diminishing their breastfeeding during

hospitalization.

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These results should encourage caregivers to evaluate breastfeeding’s alterations in their own

patients and to take in consideration that these alterations may not be transitory.

Correct advice and support at this critical time could be a determining factor of

breastfeeding’s continuation and further studies should focus on interventions to prevent

unwanted weaning.

S.Jebali and S. Smii both received a grand from the Regional Agency for Health (ARS IDF)

but have no other conflict of interest to disclose

The other authors have indicated they have no financial relationships relevant to this article to

disclose.

No external funding was received for this study

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Pédiatrie. 2013;20:S29-S48. doi:10.1016/S0929-693X(13)72251-6.

Table 1 : Baseline and evolution comparison between groups Modified breastfeeding

(group 1,2 and 3) Non modified breastfeeding

(group 4) p

Birth weight (g)*

3330 (1010 ; 4160) 3180 (1050 ; 4695) NS

Gestationnal age (GW)*

38 (26 ; 39) 37 (25 ; 40) NS

Mean growth before hospitalisation (g/d)*

26 (-10 ; 112) 30 (0 ; 213) NS

Exclusive breastfeeding before hospitalisation**

35 (81%) 30 (73%) NS

Age on admission (d)*

34 (3 ; 166) 50 (16 ; 159) NS, p=0.06

Length of stay (d)*

3 (1 ; 34) 3 (1 ; 14) NS

Length of ICU (d)*

3 (1 ; 26) 4 (1 ; 14) NS

Length of ventilation (d)*

3 (1 ; 9) 3 (1 ; 6) NS

Length of oxygen requirement (d)*

3 (1 ; 7) 3 (1 ; 5) NS

Enteral or parenteral nutrition**

25 (58%) 19 (46%) NS

Length of nutritionnal support (d)*

2 (1 ;6) 2 (1 ; 13 NS

* Median (minimum, maximum)** n (%) NS: non-significant, g : gram, GW : gestational weeks, d : day, ICU: intensive care unit

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bronchiolitis in children, pilot study


Manuscript ID bmjpo-2017-000158.R1


Date Submitted by the Author: 21-Jun-2017

Complete List of Authors: Heilbronner, Claire; Assistance Publique - Hopitaux de Paris, Roy, Emeline; Assistance Publique - Hopitaux de Paris Hadchouel, Alice; Assistance Publique - Hopitaux de Paris Jebali, Sabrine; Assistance Publique - Hopitaux de Paris Smii, Siwar; Assistance Publique - Hopitaux de Paris Masson, Alexandra; Assistance Publique - Hopitaux de Paris






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Breastfeeding disruption during hospitalization for bronchiolitis in children, pilot study


2, Alice Hadchouel

3, Sabrine Jebali

4, Siwar Smii

4,


1, Virginie Rigourd

4




Abbreviations:

PICU: Pediatric intensive Care Unit

Word count: 2481

Key words: Bronchiolitis, breastfeeding, unwanted weaning

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ABSTRACT

Background




Methods

We conducted a pilot study to evaluate breastfeeding disruption during hospitalization for

bronchiolitis and try to identify its determining factors.

This is a prospective study during one epidemic season of bronchiolitis in a tertiary care



whose parents accepted to be contacted by phone were included.

Results


27 patients (32%) spent some time in PICU.

Forty three mothers (51%) stated that their breastfeeding had been modified by the

hospitalization (17 stopped, 12 switched to partial breastfeeding and 14 reduced without

stopping). Mothers stated that the causes of breastfeeding disturbance were lack of support

and advices (63%), followed by severity of child’s respiratory disease (32%), logistic hospital

difficulties (30%) and personal organization issues (9.3%). Lengh of stay, need for ventilatory

support or nutritional support was not statistically different between groups.

Conclusion

Bronchiolitis is a high risk event for breastfeeding disruption.


preventive interventions

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What is already known on this topic Breastfeeding might be perturbed during hospitalization for bronchiolitis. This issue has not been quantified and no data can support any intervention. What this study adds There is a high rate of breastfeeding disruption during hospitalization for bronchiolitis. Respiratory severity of the bronchiolitis is not determining, supporting mother is. This study gives clues for some possible therapeutic interventions in the future.

INTRODUCTION


children.[1–3] Exclusive breastfeeding should therefore be promoted and international

guidelines recommend to maintain it at least until the age of 6 months.[1,2]

Breastfeeding though is not always easy.[3] A recent survey estimated that 75% of infants


children were still partially breastfed after 3 months.[4,5]

Children’s health might influence breastfeeding continuation (quality of suctioning, short


formula introduction). Given the fact that most children are healthy, it is likely that the impact

of childs’ disease on breastfeeding might not be perceivable in big cohorts who focus more on

social or economic factors.

In France, each year, about 500000 toddlers are affected with acute bronchiolitis.[6] Among


under 3 months) require hospitalization[7] and 10 to 15% spend some time in PICU for

respiratory support.[8]



-dyspnea, suctioning difficulties or even swallowing difficulties can occur

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attention

-caregivers might have different attitudes and contradictory advices towards breastfeeding


hospitalization for bronchiolitis.[9,10] No study has been published to specifically measure


patients concerned makes it a potentially important health issue.



We conducted a pilot study to try to measure the risk of breastfeeding being impaired during a

hospitalization for bronchiolitis in children previously breastfed and to try to identify

children, mother or hospital factors that might participate in poor breastfeeding outcome.


This study is a single centre prospective observational study conducted from October 1st 2015

to February 15th 2016 at Necker-Enfants Malades Hospital in Paris (tertiary care) in all wards

attending to patients with acute bronchiolitis (pediatric ward, pediatric pulmonology ward and

PICU (pediatric intensive care unit)).



and intercostal and/or subcostal retractions.[11] Apneic bronchiolitis in neonates were also

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admission was decided according to intensivist’s assessment.





-discharged at home

We included all patients whose parents spoke French and accepted to be contacted by phone

to answer a standardized survey.



The primary outcome was unwanted weaning from breastfeeding, either total or partial

attributed to hospitalization for bronchiolitis.

The secondary aim of the study was to identify patients or conditions of hospital stay at risk

of breastfeeding’s disruption.

Standard care was given accordingly to both French and US latest guidelines.[6,11]

Data collection included : growth evaluation (birth weight, growth, weight on admission and

at discharge), social background, tobacco exposure, length of stay (LOS), ICU requirements,

length of oxygen or ventilatory support requirement, enteral or parenteral nutritional support,

room accommodation during hospitalization, breastfeeding help and material (breast pump,

freezer) available during hospital stay, total or partial weaning from breastfeeding at discharge

or in the fortnight following discharge, mother’s opinion on the cause of the weaning,

mother’s opinion and satisfaction about breastfeeding support during hospitalization,

patient/nurse ratio, breastfeeding experts among caregivers.


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variables, and number and/or frequency (%) for binary or categorical data.

For qualitative variables we used Student test

For comparison of non-parametric means, Wilcoxon’s test was used if necessary for

quantitative criteria while χ2 and Fisher’s exact test was used to compare qualitative criteria.

P values < 0.05 were considered statistically significant.


The study was approved by the ethical board (CER_SFP 2015_009_2). Legal guardians

received written information about the study either given hand to hand during their hospital

stay or sent by mail if they could not be seen during hospital stay.

RESULTS


episodes of bronchiolitis (see figure 1). Among these, only 144 patients were breastfed, totally

(N=107, 74%) or partially (N=37, 26%). Four were not included because they did not speak

any French and 56 did not answer their phone despite several calls at different times of the

day, 84 patients (58% of breastfed patients) could to be included in the study. The median

delay for phone contact was 3 months (0.5; 6).



patients (n=60).


Median LOS for all breastfed patients was 3 days (1; 34), 27 patients (32%) patients spent

some time in PICU (median length in PICU: 3 days (1; 26). One patient (1%) needed invasive

ventilation for 10 days, 18 (21%) received either NIV or high flow oxygen for 3 days (1; 9),

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34 patients (40%) received standard oxygen for 3 days (1; 7), and 34 patients (40%) received

no respiratory support during hospitalization. No patient died of bronchiolitis during the study

period. Regarding feeding difficulties, 45 (53%) patients received nutritional support, either

by enteral feeding (n=38, 45%) or parenteral nutrition (n=5, 6%) or both (n=2, 2%).


Most breastfeeding mothers (96%) did not smoke and lived as a couple (98%). Concerning

occupation, 2% of mothers were working at the time of hospitalization, 52% were on

maternity break, 18% were on a parental education break and 28% were housewives.


Sixty five patients (77%) were exclusively breastfed before, the others received both breast

milk and formula milk. Forty-three mothers (51%) stated that their breastfeeding had been

modified by the hospitalization of their child, either moderately (N=19, 23%) or totally (N=

17, 20.5%).


-17 (group 1) stopped breastfeeding

-12 (group 2) switched from total breastfeeding to partial breastfeeding

-14 (group 3) reduced breastfeeding without stopping or switching.

Remaining mothers (41/84, 49%) stated to have kept breastfeeding as before or that their


or a planned weaning (group 4).


described in table 1) did not significantly differ between groups 1+2+3 and 4.

No statistically significant difference either was observed between patients of groups 1+2+3

and group 4 regarding medical severity of the bronchiolitis evaluated by LOS, oxygen

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requirement or need for respiratory support, enteral or parenteral feeding during

hospitalization, growth evaluation on admission, PICU admission (table 1).

When asked about the causes of their breastfeeding difficulties, mothers of group 1, 2 or 3

answered

-63%: lack of support and advices

-32%: severity of child’s respiratory disease

-30%: logistics issues (difficulties to draw breast milk, availability of breast pumps, room


-9.3%: personal and family organisation issues due to hospitalization (sitting the siblings, long

journey home).







between groups 1+2+3 and 4 regarding cumulated length of previous breastfeeding for the

elder children.

DISCUSSION


epidemiologic surveys.[4,5] but also a very high rate of breastfeeding disturbance during

hospitalization for bronchiolitis as previously suggested in a large multicentre study.[9,10]



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events.[12,13]



















relevant to evaluate burden of hospitalization.[9] Moreover, this delay has helped not to



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continued their breastfeeding with no disturbance (which is unlikely), we still have 30%

(43/144) of mothers whose breastfeeding was either stopped or altered.

Despite these considerations, this is the first study to really highlight the effect of



Exclusive breastfeeding was not a protective factor in our study and we even observed a non-





We expected to find severity of respiratory disease as the first risk factor (on medical charts or



between discharge and phone call could have altered mothers perception of respiratory

diseases’ severity but objective evaluation of respiratory distress on medical charts (LOS,

PICU requirements, respiratory and nutritional support) was also not significantly different

between groups.

It is possible that most severe patients with long PICU stay and invasive ventilation should be

more impacted but our population was not powerfull enough to evaluate this since intubation

rate for bronchiolitis has dramatically fallen in the last few years with NIV development. It is

important to notice that breastfeeding disturbance observed in our patients occurred despite a

short LOS (median 3 days) and despite a good outcome of this acute but rather benign

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respiratory disease. It is possible that caregivers underestimate the possible impact of such a

short stay on breastfeeding, and that they might think that breastfeeding will necessarily go

back to normal after discharge but our study highlights a different outcome.














CONCLUSION

Breastfeeding is a key part of the 1000 days period for proper development of the child. It will

also participate in the prevention of relapse of other respiratory infections and re

hospitalization

With no intervention, bronchiolitis in a breastfed infant is a high risk event with about half of

mothers of hospitalized children either stopping or diminishing their breastfeeding during

hospitalization.

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unwanted weaning.




disclose.

No external funding was received for this study

REFERENCES

1 Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. In: The Cochrane

Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester, UK: : John Wiley & Sons, Ltd 2002. http://doi.wiley.com/10.1002/14651858.CD003517 (accessed 27 Sep 2016).

2 World Health Organization. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. 2009. http://www.ncbi.nlm.nih.gov/books/NBK148965/ (accessed 27 Sep 2016).

3 Cattaneo A, Yngve A, Koletzko B, et al. Protection, promotion and support of breast-feeding in Europe: current situation. Public Health Nutr 2005;8:39–46.

4 Salanave B, de Launay C, Bouder-Berquier J, et al. Durée de l’allaitement maternel en France (Épifane 2012-2013). Bull Epidémiol Hebd 2014;2014:450–7.

5 Kersuzan C, Gojard S, Tichit C, et al. Prévalence de l’allaitement à la maternité selon les caractéristiques des parents et les conditions de l’accouchement. Résultats de l’enquête elfe maternité, France métropolitaine, 2011. Bull Epidémiol Hebd 2014;2014:440–9.

6 [Consensus conference on the management of infant bronchiolitis. Paris, France, 21 September 2000. Proceedings]. Arch Pédiatrie Organe Off Sociéte Fr Pédiatrie 2001;8 Suppl 1:1s–196s.

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7 Che D, Caillère N, Josseran L. [Surveillance and epidemiology of infant bronchiolitis in France]. Arch Pédiatrie Organe Off Sociéte Fr Pédiatrie 2008;15:327–8. doi:10.1016/j.arcped.2007.11.014

8 Fortin N, Gras-Le Guen C, Picherot G, et al. aractéristiques des épidémies de bronchiolite dans l’agglomération nantaise, 2007-2012: apport de différentes sources de données. Bull Epidémiol Hebd 2014;2014:58–64.

9 Lapillonne A, Regnault A, Gournay V, et al. Development of a questionnaire to assess the impact on parents of their infant’s bronchiolitis hospitalization. BMC Health Serv Res 2013;13:272. doi:10.1186/1472-6963-13-272

10 Lapillonne A, Regnault A, Gournay V, et al. Impact on parents of bronchiolitis hospitalization of full-term, preterm and congenital heart disease infants. BMC Pediatr 2012;12:171. doi:10.1186/1471-2431-12-171

11 Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. PEDIATRICS 2014;134:e1474–502. doi:10.1542/peds.2014-2742

12 Turck D, Vidailhet M, Bocquet A, et al. Allaitement maternel : les bénéfices pour la santé de l’enfant et de sa mère. Arch Pédiatrie 2013;20:S29–48. doi:10.1016/S0929-693X(13)72251-6

13 Ajetunmobi OM, Whyte B, Chalmers J, et al. Breastfeeding is Associated with Reduced Childhood Hospitalization: Evidence from a Scottish Birth Cohort (1997-2009). J Pediatr 2015;166:620–625.e4. doi:10.1016/j.jpeds.2014.11.013


(group 1,2 and 3) Non modified breastfeeding

(group 4) p

Birth weight (g)*

3330 (1010 ; 4160) 3180 (1050 ; 4695) NS


38 (26 ; 39) 37 (25 ; 40) NS


26 (-10 ; 112) 30 (0 ; 213) NS


35 (81%) 30 (73%) NS


34 (3 ; 166) 50 (16 ; 159) NS, p=0.06

Length of stay (d)*

3 (1 ; 34) 3 (1 ; 14) NS

Length of ICU (d)*

3 (1 ; 26) 4 (1 ; 14) NS


3 (1 ; 9) 3 (1 ; 6) NS


3 (1 ; 7) 3 (1 ; 5) NS


25 (58%) 19 (46%) NS


2 (1 ;6) 2 (1 ; 13 NS

* Median (minimum, maximum)** n (%)

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NS: non-significant, g : gram, GW : gestational weeks, d : day, ICU: intensive care unit

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Name of the patient……………………………………. Date of the call : …./…./……….

What was your occupation before pregnancy?

Including (name of the patient), how many children do you have? N=

How many children did you breastfeed before (name of the patient) ? N=

How long did you breastfeed the elders ? Cumulated length (month)=....

Do you live as a couple with the father? Yes No

Do you smoke ? Yes No

When did you go back to work/ when will you go back to work? Date …./…./……….

no going back to work scheduled

If you did not get back to work yet, what type of break are you on? Maternity break Unemployment

Parental education break Home mum

other ..............................

Before the bronchiolitis started, did you? totally breastfeed partially breastfeed

Would you describe your breastfeeding as easy ? From 1(not at all) to 5 (totally) =……

Before the hospitalization, had you ever used a breast pump ? Yes No

Did (name of the patient) have a single room in hospital ? Yes No only in some wards

Was there a bed available for you in (name of the patient)’s room? Yes No only in some wards

If there was no bed, was there an armchair or any other sleeping

accommodation?

Yes No only in some wards

Was there an armchair for breastfeeding in the room? Yes No only in some wards

Was there a written document about breastfeeding available for you during

hospitalization ?


Was there a breast pump available for you during hospitalization ? Yes No only in some wards

Did you feel supported with your breastfeeding during hospitalization ? From 1(not at all) to 5 (totally) =……

Did you have difficulties in breastfeeding during hospitalization ? From 1(not at all) to 5 (totally) =……

Do you feel hospitalization might have interfered with your breastfeeding ? From 1(not at all) to 5 (totally) =……

How was your breastfeeding just after hospitalization? Exclusive / partial / stopped

For mothers who stopped during hospitalization :

Was it your intention to stop your breastfeeding at that moment?

From 1(not at all) to 5 (totally) =……

Was your breastfeeding modified by hospitalization ? Yes No

If so, what was modified ?

Length ? exclusivness ?

other...................................................

What do you feel were the reasons for this modification ? (multiple answers

possible)

-severity of the bronchiolitis ?

-lack of support?

-personal organisation issues?

-logistic issues (breast pump, bedding, etc...)

in hospital ward?

Other?..............................................................

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bronchiolitis in children, preliminary study




Date Submitted by the Author: 23-Aug-2017







jpaedsopen.bmj.com

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Breastfeeding disruption during hospitalization for bronchiolitis in children,

preliminary study


2, Alice Hadchouel

3, Sabrine Jebali

4, Siwar Smii

4,


1, Virginie Rigourd

4




Abbreviations:


Word count: 2542


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ABSTRACT

Background




Methods

We conducted this preliminary study to evaluate breastfeeding disruption during

hospitalization for bronchiolitis and try to identify its determining factors for future

interventions.

This is across sectional study during one epidemic season of bronchiolitis in a tertiary care



whose parents accepted to be contacted for a phone survey were included.

Results


27 patients spent some time in PICU.

Forty three mothers stated that their breastfeeding had been modified by the hospitalization

(17 stopped, 12 switched to partial breastfeeding and 14 reduced without stopping). Mothers

stated that the causes of breastfeeding disturbance were lack of support and advices (n=27)

followed by child’s respiratory disease (n=14), logistic hospital difficulties (n=13) and

personal organization issues (n=4). Lengh of stay, need for ventilatory support or nutritional

support was not statistically different between groups.

Conclusion

Bronchiolitis is a hazardous situation for breastfeeding.

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preventive interventions.

What is already known on this topic Breastfeeding may be affected during hospitalization for bronchiolitis. This issue has not been quantified and no data can support any intervention. What this study adds There is a high rate of breastfeeding disruption during hospitalization for bronchiolitis. Lack of support for breastfeeding was a major problem.

INTRODUCTION







Children’s health might influence breastfeeding continuation (quality of sucking, short


formula introduction).

In France, each year, about 500000 toddlers are affected with acute bronchiolitis.[6] Among






-dyspnea, sucking difficulties or even swallowing difficulties can occur

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attention

-caregivers might have different attitudes towards breastfeeding and may give contradictory

advices. Only Lapillone and al. mention breastfeeding disturbance among the potential

impacts of an hospitalization for bronchiolitis.[9,10] No study has been published to

specifically measure breastfeeding disruption during hospitalization for bronchiolitis although

the high number of patients concerned makes it a potentially important health issue.



We conducted this preliminary study to try to measure the chance of breastfeeding being

impaired during a hospitalization for bronchiolitis in children previously breastfed and to try

to identify children, mother or hospital factors that might be associated with poor

breastfeeding outcome for future intervention.


This study is a single centre prospective observational study conducted from October 1st 2015

to February 15th 2016 at Necker-Enfants Malades Hospital in Paris (tertiary care) in all wards

attending to patients with acute bronchiolitis (pediatric ward, pediatric pulmonology ward and

pediatric intensive care unit (PICU)).



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admission was decided according to intensivist’s assessment. Standard care was given

accordingly to both French and US latest guidelines.[6,11]

Study design:





-discharged at home

All parents signed a consent form on admission allowing extraction of data from medical

charts. The parents were also informed about this study during hospitalization if possible (pre-

inclusion) or received information either by mail or by e-mail when reached on the phone for

the survey itself.

We included all patients whose parents spoke French, had been informed about the study and

accepted to answer a standardized survey on the phone after discharge.



We made the hypothesis that bronchiolitis would be associated with alterations of

breastfeeding and that severity of bronchiolitis would be associated with unwanted weaning.

We also aimed at identifying patients or hospital conditions at risk of breastfeeding disruption

and that might be targeted in future interventions.

Data collection included

-data collected from the caregivers (both paramedical and medical staff): patient/nurse ratio,

existence of breastfeeding experts among caregivers

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-data extracted from the charts: growth evaluation (birth weight, growth, weight on admission

and at discharge), length of stay (LOS), PICU requirements, length of oxygen or ventilatory

support requirement, enteral or parenteral nutritional support, room accommodation during

hospitalization

-answers from the survey (see supplementary file) concerning past and present occupation and

familial situation (basic social background) that could be relevant to explain weaning from

breastfeeding, tobacco exposure, breastfeeding help and material (breast pump, freezer)

available during hospital stay

-answers from the survey (see supplementary file) concerning total or partial weaning from

breastfeeding at discharge or in the fortnight following discharge, mother’s opinion on the

cause of the weaning (severity of the bronchiolitis, lack of support, personal organisation

issues and/or logistic issues in hospital ward), mother’s opinion and satisfaction about

breastfeeding support during hospitalization.

When the mothers did not have sufficient time to answer all the questions on the phone, the

questions about occupation, familial situation and tobacco exposure were skipped from the

survey.

The study was approved by the ethical board of the French Pediatric Society (CER_SFP

2015_009_2).



variables, and number for binary or categorical data.

For qualitative (categorical) variables we used Student test. For comparison of non-parametric

means, Wilcoxon’s test was used if necessary for quantitative (numerical) criteria while χ2

and Fisher’s exact test was used to compare qualitative criteria. P values < 0.05 were

considered statistically significant.

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RESULTS


episodes of bronchiolitis (see figure 1). Among these, only 144 patients were breastfed, totally

(n=107) or partially (n=37). Four were not included because they did not speak any French

and 56 did not answer their phone despite several calls at different times of the day, 84

patients could be included in the study. The median delay for phone contact was 3 months

(0.5; 6).



patients (n=60).


Median LOS for all breastfed patients was 3 days (1; 34), 27 patients spent some time in

PICU (median length in PICU: 3 days (1; 26)). One patient needed invasive ventilation for 10

days, 18 received either Non Invasive Ventilation (NIV) or high flow oxygen for 3 days (1;

9), 34 patients received standard oxygen for 3 days (1; 7), and 34 patients received no

respiratory support during hospitalization. No patient died of bronchiolitis during the study

period. Regarding feeding difficulties, 45 patients received nutritional support, either by

enteral feeding (n=38) or parenteral nutrition (n=5) or both (n=2).


Answers about socio-economical background were available for 54/84 patients. Most

breastfeeding mothers (n=52) did not smoke and lived as a couple (n=53). Concerning

occupation, 1 mother was working at the time of hospitalization, 28 were on maternity break,

10 were on a parental education break and 15 were housewives.

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Sixty five patients were exclusively breastfed before, the others received both breast milk and

formula milk. Forty-three mothers stated that their breastfeeding had been modified by the

hospitalization of their child, either moderately (n=19) or totally (n= 17).


-17 stopped breastfeeding

-12 switched from total breastfeeding to partial breastfeeding

-14 reduced breastfeeding without stopping or switching.

Remaining mothers (41/84) stated to have kept breastfeeding as before or that their


or a planned weaning.


described in table 1) did not significantly differ between the mothers who reduced or stopped

breastfeeding compared to those who continued to breastfeed normally.

No statistically significant difference either was observed regarding medical severity of the

bronchiolitis evaluated by LOS, oxygen requirement or need for respiratory support, enteral

or parenteral feeding during hospitalization, growth evaluation on admission, PICU admission

(table 1).

When asked about the causes of their breastfeeding difficulties, mothers who reduced

breastfeeding answered

-n=27: lack of support and advices

-n=14: severity of child’s respiratory disease

-n=13: logistics issues (difficulties to draw breast milk, availability of breast pumps, room


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-n=4: personal and family organisation issues due to hospitalization (sitting the siblings, long

journey home).







regarding cumulated length of previous breastfeeding for the elder children.

DISCUSSION


epidemiologic surveys[4,5] but also a very high rate of breastfeeding disturbance during

hospitalization for bronchiolitis as previously suggested in a large multicentre study.[9,10]




events.[12,13]







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relevant to evaluate burden of hospitalization.[9] Moreover, this delay has helped not to





continued their breastfeeding with no disturbance (which is unlikely), we still have 43/144

mothers whose breastfeeding was either stopped or altered.

Despite these considerations, this is the first study to really highlight the effect of



Exclusive breastfeeding was not a protective factor in our study and we even observed a non-


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We expected to find severity of respiratory disease as the first factor (on medical charts or



between discharge and phone call could have altered mother’s perception of the respiratory

distress of their child and its impact on breastfeeding. It is also possible that some guilty

feelings about weaning from breastfeeding might have influenced the mother’s answers

towards answers a little less incriminating for them (like child’s respiratory condition and lack

of support), but objective evaluation of respiratory distress on medical charts (LOS, PICU

requirements, respiratory and nutritional support) was also not significantly different between

groups. It is possible that most severe patients with long PICU stay and invasive ventilation

should be more impacted but our population was not powerfull enough to evaluate this since

intubation rate for bronchiolitis has dramatically fallen in the last few years with NIV

development. It is important to notice that breastfeeding disturbance observed in our patients

occurred despite a short LOS (median 3 days) and despite a good outcome of this acute but

rather benign respiratory disease. It is possible that caregivers underestimate the possible

impact of such a short stay on breastfeeding, and that they might think that breastfeeding will

necessarily go back to normal after discharge but our study highlights a different outcome.






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CONCLUSION

With no intervention, bronchiolitis in a breastfed infant is a hazardous situation for

breastfeeding with about half of mothers of hospitalized children either stopping or

diminishing their breastfeeding during hospitalization.





unwanted weaning.




disclose.

This research received no specific grant from any funding agency in the public, commercial or

not-for-profit sectors

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Authors contribution

Dr Heilbronner conceptualized and designed the study, drafted the initial manuscript,

analysed the data, reviewed and revised the manuscript and approved the final manuscript as

submitted.

Dr Roy, Dr Hadchouel, Dr Masson and Dr Renolleau participated in patient’s selection and

data collection, reviewed and revised the manuscript, and approved the final manuscript as

submitted

Ms Smii and Ms Jebali managed patient’s selection and interrogation, critically reviewed the

manuscript, and approved the final manuscript as submitted.

Dr Rigourd helped conceptualize and design the study, coordinated and supervised data

collection, reviewed and revised the manuscript, and approved the final manuscript as

submitted

REFERENCES




3 Cattaneo A, Yngve A, Koletzko B, et al. Protection, promotion and support of breast-feeding in Europe: current situation. Public Health Nutr 2005;8:39–46.

4 Salanave B, de Launay C, Bouder-Berquier J, et al. Durée de l’allaitement maternel en France (Épifane 2012-2013). Bull Epidémiol Hebd 2014;2014:450–7.

5 Kersuzan C, Gojard S, Tichit C, et al. Prévalence de l’allaitement à la maternité selon les caractéristiques des parents et les conditions de l’accouchement. Résultats de l’enquête elfe maternité, France métropolitaine, 2011. Bull Epidémiol Hebd 2014;2014:440–9.

6 [Consensus conference on the management of infant bronchiolitis. Paris, France, 21 September 2000. Proceedings]. Arch Pédiatrie Organe Off Sociéte Fr Pédiatrie 2001;8 Suppl 1:1s–196s.

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7 Che D, Caillère N, Josseran L. [Surveillance and epidemiology of infant bronchiolitis in France]. Arch Pédiatrie Organe Off Sociéte Fr Pédiatrie 2008;15:327–8. doi:10.1016/j.arcped.2007.11.014

8 Fortin N, Gras-Le Guen C, Picherot G, et al. aractéristiques des épidémies de bronchiolite dans l’agglomération nantaise, 2007-2012: apport de différentes sources de données. Bull Epidémiol Hebd 2014;2014:58–64.







(n=43) Non modified breastfeeding

(n=41) p

Birth weight (g)*

3330 (1010 ; 4160) 3180 (1050 ; 4695) NS


38 (26 ; 39) 37 (25 ; 40) NS


26 (-10 ; 112) 30 (0 ; 213) NS


35 30 NS


34 (3 ; 166) 50 (16 ; 159) NS, p=0.06

Length of stay (d)*

3 (1 ; 34) 3 (1 ; 14) NS

Length of PICU (d)*

3 (1 ; 26) 4 (1 ; 14) NS


3 (1 ; 9) 3 (1 ; 6) NS


3 (1 ; 7) 3 (1 ; 5) NS


25 19 NS


2 (1 ;6) 2 (1 ; 13 NS

* Median (minimum, maximum)** n

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NS: non-significant, g : gram, GW : gestational weeks, d : day, PICU: pediatric intensive care unit

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other ..............................







accommodation?




hospitalization ?













other...................................................


possible)


-lack of support?



in hospital ward?

Other?..............................................................

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bronchiolitis in children, telephone survey




Date Submitted by the Author: 07-Sep-2017







jpaedsopen.bmj.com

/bm


eptember 2017. D

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Breastfeeding disruption during hospitalization for bronchiolitis in children, telephone

survey


2, AliceHadchouel

3, Sabrine Jebali

4, Siwar Smii

4,


1, VirginieRigourd

4

Affiliations: 1 Pediatric Intensive Care Unit, AP-HP, Necker Hospital-Sick Children, Paris, France 2 Pediatric Department, AP-HP, Necker Hospital -Sick Children, Paris, France 3 Pediatric Pulmonology Department, AP-HP, Necker Hospital -Sick Children, Paris, France 4 Region Ile de France Human milk bank, AP-HP, Necker Hospital -Sick Children, Paris, France



Abbreviations:


Word count:2421


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ABSTRACT

Background

Hospitalization for an acute bronchiolitis might lead to unwanted weaning off breastfeeding

for several reasons (respiratory distress, use of enteral or parenteral feeding, mothers’

tiredness, etc..) yet it has never been really evaluated nor quantified.

Methods

We conducted this telephone survey to evaluate breastfeeding disruption during

hospitalization for bronchiolitis and try to identify its determining factors for future

interventions.

This cross sectional study extends over one epidemic season of bronchiolitis in a tertiary care


receiving at least partial breastfeeding were eligible for the study (n=144). Patients discharged

home whose parents accepted to be contacted for a phone survey were included. Parents were

contacted 3 month (range 0.5-6) after discharge.

Results

Eighty four patients were included in the study. Median length of hospital stay was 3 days (1;

34) and 27 patients spent some time in PICU.

Forty three mothers stated that hospitalization modified their breastfeeding (17 stopped, 12

switched to partial breastfeeding and 14 reduced without stopping). Mothers stated that the

causes of breastfeeding disturbance were lack of support and advices (n=27) followed by

child’s respiratory disease (n=14), logistic hospital difficulties (n=13) and personal

organization issues (n=4).

Conclusion

Admission to hospital with bronchiolitis may adversely affect breastfeeding.

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preventive interventions.

What is already known on this topic Breastfeeding may be affected during hospitalization for bronchiolitis. This issue has not been quantified and no data can support any intervention. What this study adds There is a high rate of breastfeeding disruption during hospitalization for bronchiolitis. Lack of support for breastfeeding was a major problem.

INTRODUCTION







Children’s health might influence breastfeeding continuation (quality of sucking, short


formula introduction).

In France, about 500000 infants are affected with acute bronchiolitis each year.[6] Among




Hospitalization for an acute bronchiolitis might lead to unwanted weaning off breastfeeding

for several reasons:

-dyspnea, sucking difficulties or even swallowing difficulties can occur

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-mothers might not always be able to stay continuously with their child in hospital (either




attention

-caregivers might have different attitudes towards breastfeeding and may give contradictory

advices.


hospitalization for bronchiolitis.[9,10] No study has been published to specifically measure


patients affected makes it a potentially important health issue.



We conducted this preliminary study to try to measure the chance of breastfeeding being

impaired during a hospitalization for bronchiolitis in children previously breastfed and to try

to identify children, mother or hospital factors that might be associated with poor

breastfeeding outcome for future intervention.

Our hospital participates in many actions to promote breastfeeding but it hasn’t the “Baby

Friendly Initiative” accreditation.


This study is a single centre telephone survey conducted from October 1st 2015 to February

15th 2016 at Necker-Enfants Malades Hospital in Paris (tertiary care) in all wards attending to

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patients with acute bronchiolitis (pediatric ward,pediatric pulmonology ward and pediatric

intensive care unit (PICU)).





admission was decided according to intensivist’s assessment. Standard care was given

accordingly to both French and US latest guidelines.[6,11]

Study design:





-discharged home

All parents signed a consent form on admission allowing extraction of data from medical

charts. Parents were also informed about this study during hospitalization if possible (pre-

inclusion) or received information either by mail or by e-mail when reached on the phone for

the survey itself.

We included all patients whose parents spoke French, had been informed about the study and

accepted to answer a standardized survey on the phone after discharge. Parents were

contacted 3 month (range 0.5-6) after discharge.



We made the hypothesis that bronchiolitis would be associated with alterations of

breastfeeding and that severity of bronchiolitis would be associated with unwanted weaning.

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We also aimed at identifying patients or hospital conditions at risk of breastfeeding disruption

and that might be targeted in future interventions.

Data collection included

-data collected from the caregivers (both paramedical and medical staff): patient/nurse ratio,

existence of breastfeeding experts among caregivers

-data extracted from the charts: growth evaluation (birth weight, growth, weight on admission

and at discharge), length of stay, PICU requirements, length of oxygen or ventilatory support

requirement, enteral or parenteral nutritional support, room accommodation during

hospitalization

-answers from the survey (see supplementary file) concerning past and present occupation and

family situation (basic social background) that could be relevant to explain weaning off

breastfeeding, tobacco exposure, breastfeeding help and material (breast pump, freezer)

available during hospital stay

-answers from the survey (see supplementary file) concerning total or partial weaning off

breastfeeding at discharge or in the fortnight following discharge, mother’s opinion on the

cause of the weaning (severity of the bronchiolitis, lack of support, personal organization

issues and/or logistic issues in hospital ward), mother’s opinion and satisfaction about

breastfeeding support during hospitalization.

When the mothers did not have sufficient time to answer all the questions on the phone, the

questions about occupation, familial situation and tobacco exposure were skipped from the

survey.

The study was approved by the ethical board of the French Pediatric Society (CER_SFP

2015_009_2).


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Data are expressed as median values (with minimum and maximum values) for continuous

variables, and number for binary or categorical data.

Student test was used for qualitative (categorical) variables. For comparison of non-

parametric means, Wilcoxon’s test was used if necessary for quantitative (numerical) criteria

while χ2 and Fisher’s exact test was used to compare qualitative criteria. P values < 0.05 were

considered statistically significant.


RESULTS


episodes of bronchiolitis (see figure 1). Among these, 144 patients were breastfed, totally

(n=107) or partially (n=37). Four were not included because they did not speak any French

and 56 did not answer their phone despite several calls at different times of the day, 84

patients could be included in the study. The median delay for phone contact was 3 months

(0.5;6).

Among eligible patients, no significant difference could be observed regarding length of stay,

need for PICU, respiratory support, nutritional support between included (n=84) and non-

included patients (n=60).


Median length of stay for all breastfed patients was 3 days(1; 34), 27 patients spent some time

in PICU (median length in PICU: 3 days (1;26)). One patient needed invasive ventilation for

10 days, 18 received either Non Invasive Ventilation (NIV) or high flow oxygen for 3 days

(1; 9), 34 patients received standard oxygen for 3 days (1;7), and 34 patients received no

respiratory support during hospitalization. No patient died of bronchiolitis during the study

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period. Regarding feeding difficulties, 45 patients received nutritional support, either by

enteral feeding (n=38) or parenteral nutrition (n=5) or both (n=2).


Answers about socio-economical background were available for 54/84 patients. Most

breastfeeding mothers (n=52) did not smoke and lived as a couple (n=53). Concerning

occupation, 1 mother was working at the time of hospitalization, 28 were on maternity leave,

10 were on a parental education leave and 15 were housewives.


Sixty five patients were exclusively breastfed before, the others received both breast milk and

formula milk. Forty-three mothers stated that their breastfeeding had been modified by the

hospitalization of their child, either moderately (n=19) or totally (n= 17).


-17stopped breastfeeding

-12 switched from total breastfeeding to partial breastfeeding

-14 reduced breastfeeding without stopping or switching.

Remaining mothers (41/84) stated that they kept breastfeeding as before, or that their

breastfeeding modification was not due to hospitalization but was a personal choice or a

planned weaning.


described in table 1) did not significantly differ between mothers who reduced or stopped

breastfeeding and those who continued to breastfeed normally.

The patients whose breastfeeding was affected had a tendency to be younger (p=0.06).

No statistically significant difference was observed regarding medical severity of the

bronchiolitis evaluated by length of stay, oxygen requirement or need for respiratory support,

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enteral or parenteral feeding during hospitalization, growth evaluation on admission, PICU

admission (table 1).

When asked about the causes of their breastfeeding difficulties, mothers who reduced

breastfeeding mentioned

-n=27: lack of support and advices

-n=14:severity of child’s respiratory disease

-n=13: logistics issues (difficulties to draw breast milk, availability of breast pumps, room


-n=4: personal and family organization issues due to hospitalization (sitting the siblings, long

journey home).


Patient/nurse ratio was 3/1 in ICU and6 or 7/1 in paediatric ward and pulmonology ward.



Mothers in the study had a median number of children of 2 (1;5) and had an experience of


between groups regarding cumulated length of previous breastfeeding for the elder children.

DISCUSSION

Our study showed a high rate of breastfeeding on admission compared to epidemiologic

surveys[4,5] but also a very high rate of breastfeeding disturbance during hospitalization for

bronchiolitis as previously suggested in a large multicentre study.[9,10] Hospitalization of

infants for bronchiolitis in our survey lead to undesired weaning off breastfeeding, transition

to mixed breastfeeding or even partial changes that may affect the nutritional balance suitable

for infants and alter their protection against further respiratory events.[12,13]

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-Increasing the number of nurses might help to better support breastfeeding mothers since it is

a time-consuming activity, probably even more in an epidemic period with high workload.

The nurse to patient ratio seemed correct in our wards but we could not find much data about

optimal ratio in the literature.



paediatrics. Hence the results in our study give baseline information about what happens to

breastfeeding during bronchiolitis with no or minimal support from caregivers.






The long time period between hospitalization and survey is another possible bias for it could

have altered the quality of answers from the mothers, but Lapillonne et al. concluded in their

study that interrogation as far as 6 months after hospitalization can be considered as relevant

to evaluate burden of hospitalization.[9] Moreover, this delay has helped not to include

transitory modifications after hospitalization and to only collect data on persistent alterations

of breastfeeding.



continued their breastfeeding with no disturbance (which is unlikely), we still have 43/144

mothers whose breastfeeding was either stopped or altered.

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Exclusive breastfeeding was not a protective factor in our study and we even noticed a non-



exclusively breastfed but are also those whose breastfeeding is the more fragile. We should


We expected to find severity of respiratory disease as the first factor for breastfeeding

discontinuation but only 32% of mothers pointed out the severity of disease as one of the

causes for unwanted weaning. It is possible that the delay between discharge and phone call

could have altered mother’s perception, or that some guilty feelings about weaning off

breastfeeding might have influenced the answers, but objective evaluation of respiratory

distress on medical charts (length of stay, PICU requirements, respiratory and nutritional

support) did not differ between groups. It is possible that most severe patients with long PICU

stay and invasive ventilation should be more impacted but our study was not powerful enough

to evaluate this. It is important to notice that breastfeeding disturbance observed in our

patients occurred despite a short length of stay (median 3 days) and despite a good outcome of

this acute but rather benign respiratory disease. Caregivers might be underestimating the

possible impact of such a short stay on breastfeeding and think that it will go back to normal

after discharge but this is not what we observed in our patients.




recall and perception, this information is still very important as it is modifiable for further

practice. If other studies confirm the results of our survey, it could lead to recommendations

of therapeutic interventions to prevent unwanted weaning during bronchiolitis, especially in

younger infants for which breastfeeding is still precarious.

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bronchiolitis (even if children stay in hospital for a very short length of time)especially to



hospitalization might also suffer from altered breastfeeding; this should be evaluated in

another prospective study involving outpatient’s caregivers.

CONCLUSION

With no intervention, bronchiolitis in a breastfed infant is a hazardous situation for

breastfeeding with about half of mothers of hospitalized children either stopping or

diminishing their breastfeeding during hospitalization.





unwanted weaning.

Acknowledgments: The authors thank for her English editing Mrs Guillemette Roy, UGET

Translations, Paris, France

S.Jebali and S. Smii both received a grant from the Regional Agency for Health (ARS IDF)

but have no other conflict of interest to disclose.


disclose.

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This research received no specific grant from any funding agency in the public, commercial or

not-for-profit sectors.

Authors contribution

Dr Heilbronner conceptualized and designed the study, drafted the initial manuscript,

analysed the data, reviewed and revised the manuscript and approved the final manuscript as

submitted.

Dr Roy, Dr Hadchouel, Dr Masson and Dr Renolleau participated in patients’ selection and

data collection, reviewed and revised the manuscript, and approved the final manuscript as

submitted.

Ms Smii and Ms Jebali managed patient’s selection and interrogation, critically reviewed the

manuscript, and approved the final manuscript as submitted.

Dr Rigourd helped conceptualize and design the study, coordinated and supervised data

collection, reviewed and revised the manuscript, and approved the final manuscript as

submitted.

REFERENCES




3 Cattaneo A, Yngve A, Koletzko B, et al. Protection, promotion and support of breast-feeding in Europe: current situation. Public HealthNutr 2005;8:39–46.

4 Salanave B, de Launay C, Bouder-Berquier J, et al. Durée de l’allaitement maternel en France (Épifane 2012-2013). Bull EpidémiolHebd 2014;2014:450–7.

5 Kersuzan C, Gojard S, Tichit C, et al.Prévalence de l’allaitement à la maternité selon les caractéristiques des parents et les conditions de l’accouchement. Résultats de l’enquête elfe maternité, France métropolitaine, 2011. Bull EpidémiolHebd 2014;2014:440–9.

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6 [Consensus conference on the management of infant bronchiolitis. Paris, France, 21 September 2000. Proceedings]. Arch PédiatrieOrgane Off Sociéte Fr Pédiatrie 2001;8 Suppl 1:1s–196s.

7 Che D, Caillère N, Josseran L. [Surveillance and epidemiology of infant bronchiolitis in France]. Arch PédiatrieOrgane Off Sociéte Fr Pédiatrie 2008;15:327–8. doi:10.1016/j.arcped.2007.11.014

8 Fortin N, Gras-Le Guen C, Picherot G, et al.aractéristiques des épidémies de bronchiolite dans l’agglomération nantaise, 2007-2012: apport de différentes sources de données. Bull EpidémiolHebd 2014;2014:58–64.







(n=43) Non modified breastfeeding

(n=41) Birth weight (g)*

3330 (1010 ; 4160) 3180 (1050 ; 4695)


38 (26 ; 39) 37 (25 ; 40)


26 (-10 ; 112) 30 (0 ; 213)


35 30


34 (3 ; 166) 50 (16 ; 159)

Length of stay (d)*

3 (1 ; 34) 3 (1 ; 14)

Length of PICU (d)*

3 (1 ; 26) 4 (1 ; 14)


3 (1 ; 9) 3 (1 ; 6)


3 (1 ; 7) 3 (1 ; 5)

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2 (1 ;6) 2 (1 ; 13

* Median (minimum, maximum)** n NS: non-significant, g : gram, GW : gestational weeks, d : day, PICU:pediatric intensive care unit

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other ..............................







accommodation?




hospitalization ?













other...................................................


possible)


-lack of support?



in hospital ward?

Other?..............................................................

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bmj paediatrics open is committed to open peer review. as ...€¦ · bronchiolitis and try to...

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