To protect mothers as well as their newborn infants during the COVID-19 pandemic, hospitals imposed strict visitation limits on postpartum units. Little is known about whether the presence of visitors helps or hinders early breastfeeding success, so this born-of-necessity "experiment" might shed some light on this question.
Medscape spoke with lactation consultants Dominique Gallo, IBCLC, RLC, and Jackee Haak, IBCLC, RLC, to find out what they have observed through their ongoing work in support of lactation during the pandemic.
Before the pandemic, what was visitation like in the maternity/postpartum unit, and how did it change with the lockdown?
Gallo: At both of the hospitals where I do lactation consultation, visitation was unrestricted before the pandemic, with no limits on the number of visitors. They could come any time of day or night, and even stay all night if they chose to.
Now, due to the pandemic, mothers are permitted to have only a single visitor (father, partner, support person), and it must be the same person throughout her hospital stay, from labor through post partum. Even the doulas have to leave as soon as the baby is born.
What have you observed about the effect of visitors on breastfeeding?
Haak: Babies tend to feed poorly when visitors are around, especially with first-time moms. The babies are overstimulated from being passed around for hours from person to person, and the mothers don't get any rest when they are entertaining visitors all day. Mom is exhausted, and then she hits a wall at night, just when her baby starts to cluster feed (a period when newborns demand feedings more frequently, usually in the evening).
Gallo: As a lactation consultant, having a parade of visitors in the room makes it very hard to work with the mothers who are learning how to breastfeed or whose babies aren't latching on. Parents dislike asking their visitors to leave so we can work with the mom. It happens all the time. They feel that it's unfair to ask grandparents who traveled a long way to see the new baby to leave the room, even temporarily.
What do you do in that situation?
Gallo: I have to help mom with breastfeeding underneath a blanket, which is really awkward and uncomfortable. I need to be able to see what mom and baby are doing, but it's hard with all three of us under the blanket.
Haak: Some parents will ask me to leave and come back later, and then we miss the opportunity to take advantage of the baby's hunger cues, when it's much easier to get the baby to latch on. I often have to be the "bad guy" and ask the visitors to step out. But even then, the mothers feel a lot of pressure to finish feeding the baby when visitors are waiting outside the door to come back in the room. It's not conducive to a good experience.
The pandemic has created a situation in which new parents are mostly on their own during those few days spent in the hospital. Has the lack of visitors had any effect on breastfeeding success?
Gallo: Moms are getting more comfortable with breastfeeding during the daytime, so there is less breakdown in breastfeeding at night. They are resting more between feedings instead of entertaining visitors. Since they aren't so tired, they are trying harder at night and not giving up as quickly and asking for a bottle of formula.
Haak: I no longer have to leave the room and return after the visitors are gone. Now I can start right away and take advantage of baby's hunger cues. And without visitors all the time, I feel that the babies are eating more frequently, which is what they should be doing to establish mom's milk supply.
But also, I've noticed that the fathers or partners are more attentive. Both are more engaged in the consultation when there are no visitors in the room or waiting outside the door. Instead of mom struggling on her own, her partner is learning too, and is more helpful. So when they go home, they are more of a team, and they are both part of the breastfeeding plan. That's a huge change from before.
You mentioned formula — have you noticed any change in the amount of supplementation given to breastfeeding newborns?
Gallo: I don't think our supplementation rates have changed, but I've noticed that parents are trying to breastfeed longer before they ask for supplementation. Instead of the nurse coming in and saying, "The baby is fussy-do, you want to try some formula?," and mom agreeing right away, now mom might say, "No, I want to try one more time before we do that."
Haak: When the parents are more rested, they are doing the finger feeding themselves at night, if the baby won't latch on, rather than sending the baby to the nursery. They are giving less formula. So the next day when I come in to help, it's easier for me to help them get back on track, vs after the baby has been fed large amounts of formula all night in the nursery.
How do your colleagues and the rest of the staff feel about the lack of visitors?
Haak: The nursing staff want to know if they have to let the visitors back! They are asking whether it's possible to continue limiting postpartum visitation, or at least having defined visiting hours.
Allowing 24-hour unlimited visitation can be detrimental, even if mom isn't breastfeeding. The baby and the parents don't get enough rest, and new moms in particular don't have enough time to learn basic baby care skills before going home.
Gallo: We can do our jobs better when we aren't contending with visitors. It's very frustrating, but the nurses can't do proper fundal checks with 20 people in the room. It's hard to do all your nursing care under a blanket because mom doesn't want to kick the family or visitors out of the room.
Do you think hospitals should reevaluate their postpartum visitation policies? What would you like to see?
Haak: After the pandemic is over, we'd like to implement "snuggle and snooze," which means no visitors for a few hours each day, for example, from 1:00 to 3:00 or 2:00 to 4:00 PM. Restricting visitors any further will be a very hard sell because of patient satisfaction scores, which will be negatively impacted
Gallo: It would be nice to have defined visiting hours, but there will be resistance even to that. In our prenatal breastfeeding classes, we tell parents that they will get more rest, be less stressed, and will have more successful breastfeeding without visitors present all the time. We encourage them to limit their visitors. Some listen, some don't.
What about after the family goes home? Do they continue to be semi-isolated, and how does this affect breastfeeding?
Gallo: The discharge instructions are that they should have few to no visitors at the house. We talk about the baby's immune system and the fact that visitors can be asymptomatic yet can infect mom or baby. Whether they comply or not, we don't know, but that is our recommendation.
We don't know how a lack of visitors at home in those first few weeks affects breastfeeding. Some moms who are more sensitive to hormonal changes and more anxious need more support — they want their own mothers there to help with the baby at night. Other moms are getting a lot more sleep without having visitors in the home.
Haak: We aren't getting as many frantic, panicked phone calls because mothers didn't get things figured out in the hospital. And we've had fewer calls asking about milk supply. Many of the mothers in this area doubt that their bodies can make enough milk for the baby. But now they are staying home more, without the pressure to do everything they were doing before. They are responding more to baby's hunger cues and just feeding on demand. They aren't trying to feed on a schedule.
Are women who shelter at home breastfeeding longer?
Haak: We don't know yet. Our breastfeeding initiation rates have always been high — around 82% — but our continuation rates have not been as good. It will be interesting to see going forward if our continuation rates at 3 months and 6 months have improved during the pandemic.
Gallo: We need to gather these data, because it will help the case for longer maternity leaves if moms are breastfeeding longer because they are staying home.
Having identified a potential link between the absence of visitors and more successful breastfeeding, where do we go from here?
Haak: It's still up in the air. We recently had several pregnant women transfer their care from a different local hospital to us at the end of their pregnancy because our visitor policies were less strict. This illustrates that even though we may realize that not having constant visitors is helpful for new mothers, limiting visitors is a source of patient dissatisfaction. I'm hoping the fact that people are taking a look at how visitors affect breastfeeding will eventually lead to a culture shift.
Dominique Gallo, IBCLC, RLC, is a lactation consultant and director at large for the United States Lactation Consultants Association. Dominique also sits on the board for the International Board Certified Lactation Consultants. She is also a professional doula and childbirth educator. Dominque is director at large for the United States Lactation Consultant Association (USLCA) and is part of the Roanoke Doula Collective. She volunteers with organizations that work with Black mothers to help close the disparity gap with birth and breastfeeding.
Jackee Haak, MPH, RN, IBCLC , is treasurer of the USLCA and RN manager for lactation services at Sanford Hospital in Sious Falls, South Dakota. She is also the president-elect for the North Dakota Breastfeeding Coalition. The course of her career as a lactation consultant, mother, nurse, and soldier not only has honed her leadership skills but also has unearthed a passion for lactation care, policy, research, and advocacy.
Medscape Pediatrics © 2020
Cite this: Could the Pandemic Be a Boon to Breastfeeding? - Medscape - Jul 15, 2020.