Study in Pediatrics: Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals

The journal Pediatrics has released an article entitled, “Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals.” The authors found that approximately half of breastfed infants in their cohort received formula in the first 2 days. Furthermore, there was a higher likelihood of supplementation with increasing level of perinatal care at the delivery hospitals. These findings persisted after adjusting for variables known to impact breastfeeding outcomes. There was significant interhospital variation in the rate of formula supplementation, ranging from rare (2.8%) to nearly universal (98.4%). This variance was widest in level 3 facilities (that are capable of providing complex care to high-risk women and their newborns) and narrowed with lower levels of care.

OBJECTIVES: We examined the variation between 126 New York hospitals in formula supplementation among breastfed infants after adjusting for socioeconomic, maternal, and infant factors and stratifying by level of perinatal care.

METHODS: We used 2014 birth certificate data for 160 911 breastfed infants to calculate hospital-specific formula supplementation percentages by using multivariable hierarchical logistic regression models.

RESULTS: Formula supplementation percentages varied widely among hospitals, from 2.3% to 98.3%, and was lower among level 1 hospitals (18.2%) than higher-level hospitals (50.6%–57.0%). Significant disparities in supplementation were noted for race and ethnicity (adjusted odds ratios [aORs] were 1.54–2.05 for African Americans, 1.85–2.74 for Asian Americans, and 1.25–2.16 for Hispanics, compared with whites), maternal education (aORs were 2.01–2.95 for ≤12th grade, 1.74–1.85 for high school or general education development, and 1.18–1.28 for some college or a college degree, compared with a Master’s degree), and insurance coverage (aOR was 1.27–1.60 for Medicaid insurance versus other). Formula supplementation was higher among mothers who smoked, had a cesarean delivery, or diabetes. At all 4 levels of perinatal care, there were exemplar hospitals that met the HealthyPeople 2020 supplementation goal of ≤14.2%. After adjusting for individual risk factors, the hospital-specific, risk-adjusted supplemental formula percentages still revealed a wide variation.

CONCLUSIONS: A better understanding of the exemplar hospitals could inform future efforts to improve maternity care practices and breastfeeding support to reduce unnecessary formula supplementation, reduce disparities, increase exclusive breastfeeding and breastfeeding duration, and improve maternal and child health outcomes.

Article Commentary: Laura P. Ward, MD, IBCLC: Widespread Hospital Variation in Supplementation of Breastfed Newborns