Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Chrystal Armstead

Dr. Christine Turner

NUR 4122: Nursing Research

Bon Secours Memorial College of Nursing

November 18, 2018

I pledge…
Integrative Literature Review 2

Abstract

Purpose: The purpose of this integrative review is to determine whether there is a relationship

between neonatal exposure to intrapartum medications, such as oxytocin and fentanyl, and the

success of breastfeeding.

Introduction/Background: The American Academy of Pediatrics recommends exclusively

breastfeeding infants for the first six months of life. There are many women who receive

intrapartum medications, but there is very little research that examines the effect that these

medications can have on the success of breastfeeding.

Methods: For this integrative review, the research was collected from online databases. The

articles are quantitative studies that were chosen based on distinct criteria. The information

gathered was then used to determine the effects of neonates’ exposure to intrapartum

medications on breastfeeding success.

Results and Findings: Four of the five articles compiled for this integrative review support the

idea that neonates’ exposure to intrapartum medications can interfere with breastfeeding success,

but there was one article that did not support the idea. There are maternal and neonatal factors

that can influence these results.

Limitations: A major limitation of this review is the researcher’s inexperience and lack of

knowledge in conducting an integrative review. Other limitations include the specificity of the

criteria used to choose the articles and the various limitations of the research articles.

Implications and Recommendations: Healthcare professionals should use this information to

inform expecting mothers who plan to breastfeed. It is recommended that additional research is

conducted to further support this correlation since the current research on this topic is

inconclusive.
Integrative Literature Review 3

Integrative Literature Review

The purpose of this integrated review is to identify the relationship between neonatal

exposure to intrapartum medications and the success of breastfeeding. Many women receive

medications during labor for various reasons, including induction and pain management, but

there is limited research on how these medications can affect infant prefeeding cues and

breastfeeding success (Bell, White-Traut, & Rankin, 2013). The need for this information comes

from the American Academy of Pediatrics’ recommendation that infants should breastfeed

exclusively for the first six months of life (Lind, Perrine, & Li, 2014).

There are many factors that can influence the success of breastfeeding, including the

maternal desire for breastfeeding and maternal support from her social network. The use of

epidural anesthesia, which is very common during labor, may also interfere with breastfeeding

(Dozier et al., 2013). Along with the initiation of breastfeeding, there is also some research

available that suggests the correlation between high cumulative doses of fentanyl and early

termination of breastfeeding (Lee et al., 2017). The aim of this literature review is to analyze and

discuss published data related to the PICOT question formulated by the researcher. The question

asks, in newborns, what is the effect of the exposure to intrapartum medications, such as

oxytocin and fentanyl, on the success of breastfeeding compared to those who do not receive

intrapartum medications?

Design and Methods

This integrative review focuses on five different research articles. The method employed

by the researcher began with an inceptive search using Academic Search Complete, EBSCO’s

Nursing Reference Center Plus, and EBSCO CINAHL Complete databases. The search words

were intrapartum medications, synthetic oxytocin, fentanyl, breastfeeding success, breastfeeding

Integrative Literature Review 4

outcomes, and labor drugs. The results yielded over 100 articles, which were then filtered by

year, language, peer-review, range of publication dates, and relevance to the PICOT question.

The articles were limited to five years, which were published between 2013 and 2018, and only

included those that were peer-reviewed and written in the English language. There were many

articles eliminated during this process due to these requirements. The article also had to have

full-text availability in order to be chosen for this integrated review.

After the results were further narrowed down, the articles were then chosen based on the

inclusion criteria and the article’s relevance to the researcher’s PICOT question. The inclusion

criteria selected by the researcher was as follows: neonate population, breastfeeding mothers, and

use of medications during labor. Additionally, the researcher restricted the chosen articles to

those who had authors with relevant and qualified credentials, including Registered Nurse (RN),

Master of Science in Nursing (MSN), Doctor of Nursing Practice (DNP), Doctor of Philosophy

(PhD), and Doctor of Medicine (MD). Articles that failed to meet the inclusion criteria were

excluded from the integrative review. The screening produced five quantitative articles (Bell et

al., 2013; Brimdyr et al., 2015; Dozier et al., 2013; Lee et al., 2017; Lind et al., 2014), which

allowed the researcher to analyze quantified findings.

Findings and Results

The findings and results of all but one of the articles identify an inverse relationship

between a neonate’s intrapartum medication exposure and success of breastfeeding (Bell et al.,

2013; Brimdyr et al., 2015; Dozier et al., 2013; Lind et al., 2014). There was one article that did

not recognize a negative correlation between the two variables (Lee et al., 2017). A summary of

the five research articles is located in the Appendix. The results of the literature review are
Integrative Literature Review 5

presented below and are organized according to the following themes identified by the

researcher: maternal factors and neonatal factors.

Maternal Factors

There was a consensus amongst three studies that there are maternal factors that can

affect the success of breastfeeding after being exposed to intrapartum medications, such as

oxytocin and fentanyl (Dozier et al., 2013; Lee et al., 2017; Lind et al., 2014). In a study

conducted by Lind et al. (2014), the authors sought to figure out whether the use of labor pain

medications can be associated with delayed onset of lactation for the postpartum mother. This

study was conducted using an observational design. The authors analyzed the data from a

longitudinal study entitled Infant Feeding Practices Study II (IFPS II), which was conducted by

the United States Food and Drug Administration in collaboration with the Centers for Disease

Control and Prevention. The study captures data from women from the last trimester of their

pregnancy through the entire first postpartum year. The sample consisted of 2,586 women who

breastfed at least once.

Lind et al. (2014) mentioned that the data from the IFPS II study was collected using an

initial prenatal questionnaire, a short telephone interview close to the due date, a neonatal

questionnaire when the infant was around one month old, and a monthly questionnaire through

12 months of age. The data was analyzed using bivariate analyses, but only consisted of the

information from the prenatal and neonatal questionnaires. The authors also used multivariable

logistic regression analyses to assess the relationship between the use of labor medications and

the delayed onset of lactation. The findings of this study showed that women who had received

labor medications had higher odds of experience delayed onset of lactation compared to those

women who did not receive medications.

Integrative Literature Review 6

In a study conducted by Dozier et al. (2013), the authors wanted to examine the

correlation between epidural anesthesia use and overall breastfeeding cessation within 30 days

postpartum. The authors drew subjects from a local prospective study and a local retrospective

study, which both incorporated cohort designs. The prospective study evaluated in-hospital

breastfeeding support and the retrospective study evaluated perinatal breastfeeding support. The

sample was constricted to 727 healthy mothers from the two cohorts combined who had initiated

breastfeeding at least once and delivered at one of three hospitals in Rochester, New York. The

participants of the prospective and retrospective studies completed interviewer-administered

surveys upon hospital enrollment. The participants of the retrospective study also provided

consent to access their prenatal records. The data was analyzed using bivariate analyses and Chi-

square tests. The authors also used the Kaplan-Meier method with corresponding log-rank test

and a modified Cox Proportional Hazard model for analyses. The findings of the study revealed

that the mothers who had received epidural anesthesia and IV oxytocin were more likely to

report breastfeeding issues and cessation at one month postpartum than those mothers who had

not received intrapartum medications.

Although the aforementioned studies found that intrapartum medications can negatively

affect the success of breastfeeding, Lee et al. (2017) conducted a study testing the hypothesis that

breastfeeding success is adversely influenced by high cumulative doses of fentanyl administered

during the intrapartum period. The authors orchestrated a randomized, double-blind control trial

that consisted of a convenience sample of 345 women who gave birth at Prentice Women’s

Hospital in Chicago, Illinois. The study participants were screened using an assessment of the

woman’s prior breastfeeding history, plans for intrapartum medication use and breastfeeding

with the current newborn, using the Breastfeeding Motivational Measurement Scale. The data
Integrative Literature Review 7

collection method used by the authors was researcher-conducted interviews shortly after the

delivery and other pertinent records obtained via the electronic medical record.

The data was analyzed by Lee et al. (2017) using chi-square tests to compare the women

who continued breastfeeding throughout six weeks postpartum. The authors also used the

Pearson-Koppler method to calculate the differences and confidence interval and the data were

compared using the Krukal-Wallis H test. The statistical tests were two-tailed and a P-value of

less than 0.05 was required to reject the null hypothesis. Of the 345 women enrolled in the study,

only 305 women actually completed all of the data for the analysis. The findings of the study

showed that there was no difference in the rate of breastfeeding between six weeks and three

months postpartum. The authors also found that labor epidural solutions containing fentanyl do

not appear to negatively influence breastfeeding success rates at six weeks postpartum.

Neonatal Factors

Along with maternal factors, the remaining two studies in this literature review agreed

that there are definitely some neonatal factors that can influence breastfeeding success (Bell et

al., 2013; Brimdyr et al., 2015). There are the factors that are not controlled by the mother’s milk

supply and motivation to continue breastfeeding. For the purpose of this literature review,

neonatal factors relate to the newborn’s ability to suckle and demonstrate prefeeding cues. In a

cohort study conducted by Bell et al. (2013), the authors sought to explore whether exposure to

synthetic oxytocin is associated with an infant’s level of prefeeding after birth. The authors

utilized a prefeeding organization chart that came from the findings in their literature to analyze

the study’s data. The authors also included the Neonatal Behavioral Assessment Scale as being

equivalent to their prefeeding organization chart.

Integrative Literature Review 8

The sample group for the Bell et al. (2013) study was a convenience sample of 47 healthy

full-term infants (36 exposed to intrapartum synthetic oxytocin and 11 unexposed to intrapartum

synthetic oxytocin) in an inner-city community hospital in Chicago, Illinois. The authors

collected the data by videotaping the infants for 45 to 50 minutes after birth to examine the

frequency of eight prefeeding cues, which were analyzed using a prefeeding organization chart.

The authors performed a bivariate analysis using sample t-tests and chi-square tests to compare

the characteristics of exposed versus unexposed infants. The findings of this study showed that

fewer prefeeding cues were seen in the infants with exposure to synthetic oxytocin than those

who were not exposed. The authors also found that forty-four percent of exposed infants showed

a low level of prefeeding organization compared to the unexposed infants. Additionally, the

exposed infants were eleven and a half times more likely to demonstrate low-to-medium versus

high levels of prefeeding organization compared to the unexposed infants. Although the authors

realized the correlation between infant exposure to intrapartum synthetic oxytocin and

prefeeding cues, they also identified the need for further research to be conducted.

Brimdyr et al. (2015) also led a study that examined the normal neonatal behavior of

suckling within the first hour after birth in relation to commonly used intrapartum medications,

such as fentanyl and synthetic oxytocin. The framework used for this study was Widstrom’s nine

stages of newborn behavior and the authors analyzed whether or not the newborns achieved

those stages within the first hour after birth. Using a prospective comparative design, the authors

collected data from 63 low-risk mother-infant dyads at Loma Linda Medical Center in Loma

Linda, California. The mothers self-selected to have intrapartum medications or not during their

vaginal deliveries. The data was collected using video recordings of the mother-infant dyads
Integrative Literature Review 9

while skin-to-skin for the first hour after delivery. The researchers of the study recorded from

behind the mother’s head, capturing all of the neonate’s activities.

The data for the Brimdyr et al. (2015) study was analyzed using the Adapted Kaplan-

Meier curve, ANOVA comparisons, t-tests, binary logistic regression, and binary logistic

multiple regression. The findings of this study were significant and showed that there was an

inverse dose-dependent relationship between achieving suckling in the initial hour after birth and

the amounts of exposure to fentanyl. The researchers of the study also found that with increased

dose amounts of fentanyl and synthetic oxytocin, there was a decreased likelihood of the

newborn achieving the suckling prefeeding cue within the first hour after birth. The authors

identified a need for women to be aware of this information when they are thinking about

breastfeeding but also want to have intrapartum medications.

Discussions and Implications

The articles selected for review indicate an inverse relationship between neonatal

exposure to intrapartum medications and the success of breastfeeding. Two of the articles

touched on maternal issues that can affect the neonate’s ability to breastfeed after exposure to

intrapartum medications, such as delayed onset of lactation and overall difficulty with sustaining

breastfeeding (Dozier et al., 2013; Lind et al., 2014). Two of the remaining articles focused on

issues with the infant that can affect breastfeeding, such as decreased prefeeding cues and

decreased suckling patterns (Bell et al., 2013; Brimdyr et al., 2015). These four articles are

important to the PICOT question because they all bring something different to the table.

Although the PICOT question focuses on neonatal exposure to intrapartum medications, the

mothers still need to be considered because the medications directly affect them. The current

research on this topic is still young and there are so many factors that can contribute to
Integrative Literature Review 10

breastfeeding being unsuccessful. Neonates undergo a great amount of stress during the labor

process, so many of them may experience some hypoxia from the strength of the contractions

(Bell et al., 2013). This hypoxia and stress can also affect success of breastfeeding, and this

information should be considered when recognizing the correlation in the PICOT question.

Along with the four articles that agree on the inverse relationship between neonates’

exposure to intrapartum medications and success of breastfeeding, there was also one article that

did not have the same viewpoint as the previous four articles (Lee et al., 2017). This information

is very important to the PICOT question because the researcher realizes that there must be

further research conducted on this topic. Health care providers should alert expecting mothers of

this strong correlation, especially those mothers who have plans to breastfeed their newborn

immediately after birth and for the following weeks. These mothers should be aware of this

research, but they should also know that the correlation has yet to be confirmed. For further

research, the implementation of larger sample sizes and a standardized protocol will eradicate

any irrelevant variables that may affect the results and outcomes of the study.

Limitations

The researcher of this literature review encountered many limitations. One of the biggest

limitations of this integrative review is the researcher’s lack of knowledge and inexperience with

conducting research of this caliber. The researcher only has few qualifications for producing a

reliable discussion of the topic being studied due to the fact that the author is a nursing student,

not a registered nurse. Also, the researcher was limited to five articles for this review and the

articles had to be published within the past five years. Another limitation would be that this

review was written as a class assignment, so this is not an exhaustive review.

Integrative Literature Review 11

Some of the major study limitations would be the authors’ failure to conduct power

analyses to determine whether the sample size was adequate. A few of the studies used

convenience sampling, which could introduce bias, so this can also be considered a limitation.

The type of study designs could be considered limitations as well because the authors did not

conduct power analyses to determine how to conduct their specific studies. The authors of the

articles mentioned additional limitations, which hinders the reliability of each article. All of this

information should be taken into account for further research on this topic.

Conclusions

Most of the evidence compiled for this integrative review supports the idea that neonatal

exposure to intrapartum medications, such as oxytocin and fentanyl, can interfere with the

success of breastfeeding (Bell et al., 2013; Brimdyr et al., 2015; Dozier et al., 2013; Lind et al.,

2014). There was one article that did not support the idea due to the results of their research

study (Lee et al., 2017). The themes of this integrative review are the maternal factors and

neonatal factors that can affect breastfeeding outcomes in neonates who have been exposed to

intrapartum medications. The maternal factors that can affect breastfeeding are the delayed onset

of lactation and early breastfeeding cessation after being exposed to intrapartum medications

(Dozier et al., 2013; Lind et al., 2014). Lee et al. (2017) conducted a study that revealed no

difference in breastfeeding success between the women who received intrapartum medications

and those who did not receive any medications. The neonatal factors that can affect breastfeeding

after exposure to intrapartum medications include decreased prefeeding cues and suckling

patterns (Bell et al., 2013; Brimdyr et al., 2015).

In further research, power analyses should be conducted to determine what sample size is

considered adequate for a study on this topic. Healthcare professionals should take this
Integrative Literature Review 12

information and apply it to their practice because expecting mothers should be aware that the

medications given during labor may have an effect on their success of breastfeeding. In relation

to the PICOT question being addressed in this integrative review, “In newborns, what is the

effect of the exposure to intrapartum medications, such as oxytocin and fentanyl, on the success

of breastfeeding compared to those who do not receive intrapartum medications?”, the literature

reflects a strong inverse relationship between neonates’ exposure to intrapartum medications and

breastfeeding success.
Integrative Literature Review 13

References

Bell, A. F., White-Traut, R., & Rankin, K. (2013). Fetal exposure to synthetic oxytocin and the

relationship with prefeeding cues within one hour postbirth. Early Human Development,

89(3), 137-143. doi:10.1016/j.earlhumdev.2012.09.017

Brimdyr, K., Cadwell, K., Widström, A., Svensson, K., Neumann, M., Hart, E. A., . . . Phillips,

R. (2015). The association between common labor drugs and suckling when skin-to-skin

during the first hour after birth. Birth, 42(4), 319-328. doi:10.1111/birt.12186

Dozier, A. M., Howard, C. R., Brownell, E. A., Wissler, R. N., Glantz, J. C., Ternullo, S. R., . . .

Lawrence, R. A. (2013). Labor epidural anesthesia, obstetric factors and breastfeeding

cessation. Maternal and Child Health Journal, 17(4), 689-698. doi:10.1007/s10995-012-

1045-4

Lee, A. I., Mccarthy, R. J., Toledo, P., Jones, M. J., White, N., & Wong, C. A. (2017). Epidural

labor analgesia - fentanyl dose and breastfeeding success. Anesthesiology,127(4), 614-

624. doi:10.1097/ALN.0000000000001793

Lind, J. N., Perrine, C. G., & Li, R. (2014). Relationship between use of labor pain medications

and delayed onset of lactation. Journal of Human Lactation, 30(2), 167-173.

doi:10.1177/0890334413520189
 Integrative Literature Review 14

APPENDIX

APA Citation for Bell, A. F., White-Traut, R., & Rankin, K. (2013). Fetal exposure to synthetic oxytocin and the relationship with
Article prefeeding cues within one hour postbirth. Early Human Development, 89(3), 137-143.
doi:10.1016/j.earlhumdev.2012.09.017
Author(s) -  Aleeca F. Bell (a), Rosemary White-Traut (a), Kristin Rankin (b)
Qualifications  a. Department of Women, Children, and Family Health Science, University of Illinois at Chicago
 b. Division of Epidemiology and Biostatistics, University of Illinois at Chicago
Background/Problem  Prefeeding cues communicate feeding readiness and the ability for a newborn to self-comfort. Intrapartum
Statement synthetic oxytocin is used very frequently, but there is not enough research on the potential effects on infant
neurobehavioral cues. This study aims to explore whether exposure to synthetic oxytocin is associated with
infant’s level of prefeeding after birth.

Conceptual/theoretical  The authors did not mention the use of a theoretical or conceptual framework.
Framework

Design/Method  Convenience/cohort design

 The researchers used a prefeeding organization chart that came from findings in their literature. The prefeeding
cues include mouthing, rooting, tonguing, suckling, hand swipes at mouth, brief hand to mouth, sustained hand
to mouth, and sucking on hand.
 The researchers also included the Neonatal Behavioral Assessment Scale (NBAS) as being equivalent to their
prefeeding organizational chart.
Sample/  A convenience sample of 47 healthy full-term infants (36 exposed and 11 unexposed to intrapartum synthetic
Setting/Ethical oxytocin) in an inner-city community hospital in the United States.
Considerations  The women gave consent for their newborns to be recorded on video and the study was approved by the ethical
review boards of the participating hospital and the University of Illinois at Chicago.

Major Variables  The relationship among maternal epidural analgesia, newborn nutritive sucking patterns, maternal/fetal
Studied (and their cortisol levels, and newborn behavioral state organization.
definition), if
appropriate
 Integrative Literature Review 15

Measurement  Videotaping of infants 45-50 minutes after birth used to examine the frequency of eight prefeeding cues, which
Tool/Data Collection were analyzed by prefeeding organization.
Method

Data Analysis  The researchers used PASW Statistics 17, Release Version 17.0. Bivariate analysis was performed using two
sample t-tests and chi-square tests to compare the characteristics of exposed versus unexposed infants.

Findings/Discussion  Fewer prefeeding cues were seen in infants with exposure to synthetic oxytocin than those who were not
exposed to it.
 Forty-four percent of exposed infants showed a low level of prefeeding organization.
 Exposed infants were 11.5 times more likely to demonstrate low-to-medium versus high levels of prefeeding
organization compared to unexposed infants.

Appraisal/Worth to  There may be correlation between exposure to intrapartum synthetic oxytocin and prefeeding cues. More
practice research would have to be conducted.

APA Citation for Brimdyr, K., Cadwell, K., Widström, A., Svensson, K., Neumann, M., Hart, E. A., . . . Phillips, R. (2015). The
Article association between common labor drugs and suckling when skin-to-skin during the first hour after
birth. Birth, 42(4), 319-328. doi:10.1111/birt.12186
Author(s) -  Kajsa Brimdyr, PhD, CLC, Karin Cadwell, PhD, RN, FAAN, ANLC, IBCLC, Ann-Marie Widstrom, PhD,
Qualifications RN, MTD, Kristin Svensson, PhD, RNM, Monica Neumann, MD, Elaine A. Hart, MD, FACOG, Sarah
Harrington, MD, and Raylene Phillips, MD, FAAP, FABM, IBCLC
Background/Problem  Intrapartum drugs, like synthetic oxytocin and fentanyl, can have a negative impact on breastfeeding
Statement outcomes. Suckling in the first hour after birth is correlated with increasing desirable breastfeeding outcomes.
Conceptual/theoretical  The researchers analyzed whether or not the infants achieved Widstrom’s nine stages of newborn behavior
Framework during the first hour after birth.

Design/Method  Prospective comparative design

 Integrative Literature Review 16

Sample/  63 low-risk mothers at Loma Linda University Medical Center (LLUMC) in Loma Linda, California self-
Setting/Ethical selected to have intrapartum analgesia or anesthesia or not (during vaginal deliveries). The study consisted of
Considerations 63 mother-infant dyads.
 The study was approved by the Institutional Review Board of LLUMC.
 Informed consent obtained from clinically uncomplicated primipara and multipara mothers over the course of
four weeks in 2013; one week each in May, July, August, and December. The informed consent materials
were available in English and Spanish, and a translator was available for Spanish-speakers.
Major Variables  The researchers examined the relationship between the recorded administered amounts of synthetic oxytocin
Studied (and their and fentanyl (via epidural), duration of the epidural, the birthweight, five-minute Apgar scores, and whether
definition), if or not the baby suckled in the first hour.
appropriate

Measurement  Video recording of the mother-infant dyads were taken for the first hour after delivery.
Tool/Data Collection  The researchers were recording from behind the mother’s head and the video captured the neonatal activities.
Method

Data Analysis  The researchers used SPSS Version 20 for the Adapted Kaplan-Meier, ANOVA, t-tests, Binary Logistic
Regression, and Binary Logistic Multiple Regression.

Findings/Discussion  Out of the 63 women, there was an inverse dose-dependent relationship between achieving suckling in the
first hour after birth and the amounts of exposure to fentanyl.
 The researchers found that with increased dose amounts of fentanyl and synthetic oxytocin, there was a
decreased likelihood of the newborn achieving suckling in the first hour.

Appraisal/Worth to  This may be something to include in labor teaching because some women may opt to not have the epidural or
practice induction if they are keen on breastfeeding immediately after birth.

APA Citation for Dozier, A. M., Howard, C. R., Brownell, E. A., Wissler, R. N., Glantz, J. C., Ternullo, S. R., . . . Lawrence, R. A.
Article (2013). Labor epidural anesthesia, obstetric factors and breastfeeding cessation. Maternal and Child Health
Journal, 17(4), 689-698. doi:10.1007/s10995-012-1045-4
 Integrative Literature Review 17

Author(s) -  Ann M. Dozier: Department of Community and Preventative Medicine, University of Rochester, NY
Qualifications  Cynthia R. Howard: Department of Pediatrics and Community and Preventative Medicine, University of
Rochester, NY
 Elizabeth A. Brownell: Department of Neonatology, Connecticut Children’s Medical Center, Hartford, CT
 Richard N. Wissler: Department of Anesthesiology and Obstetrics and Gynecology, University of Rochester,
NY
 J. Christopher Glantz: Department of Obstetrics and Gynecology, University of Rochester, NY
 Sharon R. Ternullo: College of Pharmacy, St. John Fisher, Pittsford, NY
 Kelly N. Thevenet-Morrison: Department of Community and Preventative Medicine, University of
Rochester, NY
 Cynthia K. Childs: Department of Psychology, University of Rochester, NY
 Ruth A. Lawrence: Department of Pediatrics and Obstetrics and Gynecology, University of Rochester, NY
Background/Problem  The use of epidural anesthesia during labor is common and it may interfere with breastfeeding.
Statement  The American Academy of Pediatrics recommends exclusive breastfeeding for 6 months.
 Many studies have found that epidurals are negatively associated with breastfeeding behaviors.
 The purpose of this study was to analyze the correlation between epidural anesthesia use and overall
breastfeeding cessation within thirty days postpartum.

Conceptual/theoretical  The authors did not mention the use of a theoretical or conceptual framework.
Framework

Design/Method  The authors drew subjects from two local cohort studies, one prospective and one retrospective.
If appropriate,  The prospective descriptive study evaluated in-hospital breastfeeding support and the retrospective descriptive
Philosophical study evaluated perinatal breastfeeding support.
Underpinnings

Sample/  The prospective study enrolled 842 breastfeeding mothers from two community hospitals.
Setting/Ethical  The retrospective study enrolled 419 mothers at area WIC clinics who delivered at one of three hospitals.
Considerations  The analyses were constricted to 727 healthy mothers from the two cohorts combined with healthy term
vaginal deliveries and who had initiated breastfeeding at least once.
 The three hospitals were a community hospital (Level I Nursery), the prenatal center (NICU) in the same
health system, and another community hospital with a Level II nursery and Baby Friendly hospital.
 Integrative Literature Review 18

 Both studies received approval from the Institutional Review Board at the University of Rochester.
 The participants provided written consent to release the data from the maternal and infant records and birth
certificate.
Major Variables  Epidural anesthesia and IV oxytocin interaction
Studied (and their  Breastfeeding cessation
definition), if  Baby-Friendly Hospital versus non-Baby-Friendly Hospital
appropriate

Measurement  The participants completed an interviewer-administered survey at hospital enrollment.

Tool/Data Collection  For the retrospective study, the participants also provided consent to access their prenatal and WIC records.
Method  Trained research staff abstracted all of the data and an obstetric anesthesiologist verified epidural anesthesia
use.

Data Analysis  Bivariate analyses were used, along with Chi-square tests.
 The researchers used the Kaplan-Meier method and corresponding log-rank test.
 A modified Cox Proportional Hazard model was used as well.

Findings/Discussion  Mothers who received epidural anesthesia were more likely to have lower confidence in their ability to
breastfeed.
 The Kaplan-Meier curve showed a relationship between epidural anesthesia use and breastfeeding cessation
within one month.
 IV oxytocin was found to protect against early breastfeeding cessation in the baby-friendly hospital, but not in
the non-baby-friendly hospital.
 Regardless of hospital, mothers with epidural anesthesia were significantly more likely to cease breastfeeding
within one month. The risk factors included maternal education, income, and planned breastfeeding goal.
 They also found that combined epidural anesthesia and IV oxytocin negatively affects breastfeeding.

Appraisal/Worth to  Although there is still plenty of research to be conducted on this topic, health care professionals should be
practice more aware of the potential effects of epidural anesthesia and IV oxytocin on breastfeeding, as this
information could sway how mothers choose their delivery method.
 Integrative Literature Review 19

APA Citation for Lee, A. I., Mccarthy, R. J., Toledo, P., Jones, M. J., White, N., & Wong, C. A. (2017). Epidural labor analgesia -
Article fentanyl dose and breastfeeding success. Anesthesiology,127(4), 614-624.
doi:10.1097/ALN.0000000000001793
Author(s) - Amy I. Lee, M.D., Robert J. McCarthy, Pharm.D., Paloma Toledo, M.D., M.P.H., Mary Jane Jones,
Qualifications R.N., Nancy White, R.N., I.B.C.L.C., Cynthia A. Wong, M.D.
Background/Problem  Women who receive high cumulative doses of epidural fentanyl are more likely to terminate breastfeeding
Statement earlier than those women who do not receive high doses of epidural fentanyl.
 When women terminate breastfeeding early, the newborn is no longer receiving the vital nutrients and
antibiotics that come from the mother’s breast milk.
 The researchers tested the hypothesis that breastfeeding success is adversely influenced by high cumulative
doses of fentanyl.

Conceptual/theoretical  The authors did not mention the use of a theoretical or conceptual framework.
Framework

Design/Method  A randomized, double-blind control trial.

Sample/ Setting/Ethical  A convenience sample of 345 women who gave birth at Prentice Women’s Hospital in Chicago, Illinois.
Considerations  The researchers received approval for the study by the Institutional Review Board of Northwestern University
in Chicago, Illinois.
 The study was conducted on English-speaking parous women at greater than 38 weeks of gestation who
successfully breastfed a prior infant for at least 6 weeks. These women also had to agree to breastfeed for 3
months postpartum and they had to have a plan to use analgesia during labor.
 The women were screened using an assessment of the woman’s prior breastfeeding history, plans for labor
pain medication and breastfeeding with the current newborn, and using the Breastfeeding Motivational
Measurement Scale.
Major Variables  The different dosage levels of fentanyl plus bupivacaine were major variables in this study.
Studied (and their  1. Bupivacaine 1 mg/ml + fentanyl 0 ug/ml
definition), if  2. Bupivacaine 0.8 mg/ml + fentanyl 1 ug/ml
appropriate  3. Bupivacaine 0.625 mg/ml + fentanyl 2 ug/ml
 Integrative Literature Review 20

Measurement  The participants were interviewed shortly after the delivery and other records were obtained via the electronic
Tool/Data Collection medical record.
Method  Breastfeeding was assessed by a lactation consultant certified by the International Board of Lactation
Consultant Examiners in Fairfax, Virginia. It was also assessed using the LATCH assessment tool
.
Data Analysis  The researchers used chi-square tests to compare the women who continued breastfeeding throughout the 6
weeks.
 They also used the Pearson-Koppler method to calculate the differences and confidence interval.
 The data were compared using the Krukal-Wallis H test.
 The statistical tests were two-tailed and a P-value less than 0.05 was required to reject the null hypothesis.
 The analysis was performed using RStudio version 1.0.136 and R version 3.3.3. The sample size analysis was
performed using PASS 2005.

Findings/Discussion  Of the 345 women enrolled in the study, only 305 had completed data for analysis.
 There was no difference in the rate of breastfeeding between 6-weeks and 3 months. The frequency of
breastfeeding at 6 weeks was 97, 98, and 94%, respectively according to the variables mentioned in the
“Major Variables Studied” section.
 The researchers found that labor epidural solutions containing fentanyl do not appear to influence
breastfeeding rates at 6 weeks postpartum.

Appraisal/Worth to  There is a lot of research available that shows fentanyl having an effect on breastfeeding, so this study is
practice definitely an outlier. Although further research would need to be conducted, health care professionals can use
this information to guide their practice and inform the mothers under their care.

APA Citation for Lind, J. N., Perrine, C. G., & Li, R. (2014). Relationship between use of labor pain medications and delayed
Article onset of lactation. Journal of Human Lactation, 30(2), 167-173. doi:10.1177/0890334413520189
Author(s) -  Jennifer N. Lind, PharmD, MPH (1,2,3), Cria G. Perrine, PhD (2,3), and Ruowei Li, MD, PhD (2)
Qualifications  1. Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for
Disease Control and Prevention, Atlanta, GA, USA
 Integrative Literature Review 21

 2. Division of Nutrition, Physical Activity, and Obesity, Centers for Disease Control and Prevention, Atlanta,
GA, USA
 3. United States Public Health Service Commissioned Corps, Atlanta, GA, USA
Background/Problem  The American Academy of Pediatrics recommends exclusively breastfeeding for the first 6 months of life.
Statement  The authors mention that 83% of mothers in the United States receive labor medications, but there is little
research available that examines how the use of these medications affect the onset of lactation.
 The purpose of the study is to figure out whether the use of labor pain management medications can be
associated with delayed onset of lactation.
Conceptual/theoretical  The authors did not mention the use of a theoretical or conceptual framework.
Framework

Design/Method  The authors used an observational design for this research study.
If appropriate,  The authors analyzed data from the 2005-2007 Infant Feeding Practices Study II (IFPS II), which was a
Philosophical longitudinal study that captured data of women from late pregnancy through the entire first year after birth.
Underpinnings

Sample/ Setting/Ethical  The IFPS II was conducted by the US FDA in collaboration with the CDC.
Considerations  The eligible women were 18 years of age or older who gave birth to a single infant with a gestational age of
more than 35 weeks and a birth weight of more at least 5 pounds.
 The sample consisted of 2,586 women who initiated breastfeeding.
 The questionnaires and procedures were approved by the FDA’s institutional review board and the US Office
of Management and Budget.
Major Variables  Mothers having their milk coming in more than three days after delivery were classified as having delayed
Studied (and their onset of lactation.
definition), if  Mothers with their milk coming in by postpartum day three or less were classified as not having delayed onset
appropriate of lactation.
 The authors classified the use of pain medications into four groups (no medication, spinal/epidural only,
spinal/epidural plus another pain medication, and other labor pain medication use only [not spinal/epidural]).
 The methods of delivery were grouped as vaginal, planned cesarean, and emergency cesarean.
 The combination of pain medication use and method of delivery was broken down into eight groups: vaginal
with no meds, vaginal with spinal/epidural only, vaginal with spinal/epidural and another medication, vaginal
with other labor meds only, planned cesarean with spinal/epidural only, planned cesarean with spinal/epidural
 Integrative Literature Review 22

plus another med, emergency cesarean with spinal/epidural only, and emergency cesarean with spinal/epidural
plus another medication.
Measurement  The data was collected using a prenatal questionnaire, a short telephone interview near the infant’s birth, a
Tool/Data Collection neonatal questionnaire sent when the infant was around one month old, and monthly questionnaires through
Method 12 months of age.

Data Analysis  SAS 9.3 was used for the analyses. Bivariate analyses were also used.
 The analysis only uses data from the prenatal and neonatal questionnaires.
 The authors used multivariable logistic regression analyses to assess the relationship between mothers’ use of
labor medications and delayed onset of lactation.

Findings/Discussion  23.4% of the women in the sample experienced delayed onset of lactation.
 Compared with women who delivered vaginally and received no labor pain medication, women who received
labor pain medications had higher odds of experiencing delayed onset of lactation.
 Mothers who received labor medications were more likely to report delayed onset of lactation, regardless of
delivery method.

Appraisal/Worth to  This information could help inform health care providers regarding clinical decisions for labor and delivery.
practice