548459
research-article2014
JHLXXX10.1177/0890334414548459Journal of Human LactationTender et al
Original Research
Educating Pediatric Residents about Breastfeeding: Evaluation of 3 Time-Efficient Teaching Strategies
Journal of Human Lactation 2014, Vol. 30(4) 458–465 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334414548459 jhl.sagepub.com
Jennifer A.F. Tender, MD, IBCLC1, Sandra Cuzzi, MD2, Terry Kind, MD, MPH1, Samuel J. Simmens, PhD3, Benjamin Blatt, MD4, and Larrie Greenberg, MD4 Abstract Background: Previously reported breastfeeding curricula for residents have combined different teaching methods, have focused on knowledge and attitudes, and have been time-intensive. Objective: This study aimed to evaluate 3 time-efficient breastfeeding curricula for effectiveness in regard to pediatric residents’ knowledge, confidence, and skills in managing a simulated breastfeeding scenario. Methods: First-year pediatric residents during their 4-week community hospital newborn nursery rotation were consecutively assigned to 1 of 3 groups. Group 1 shadowed an International Board Certified Lactation Consultant (IBCLC) for 1 hour; group 2 watched a 25-minute case-based breastfeeding DVD; and group 3 observed a 3-hour prenatal parent breastfeeding class (CLS). Residents were assessed by (1) a pretest and posttest evaluating their breastfeeding knowledge and confidence, and (2) a clinical skills scenario managing a breastfeeding standardized patient (SP). Results: Thirty-nine pediatric residents participated in the study (11 in IBCLC, 16 DVD, 12 CLS) over a 1-year period. All groups significantly improved their knowledge scores and confidence in managing breastfeeding problems, with the IBCLC group showing more improvement in knowledge than the other groups (P = .02) and a higher rating of their teaching method (P = .01). All groups performed well on the SP clinical skills scenario, with no significant difference between groups. Conclusion: All 3 teaching methods were time-efficient and produced important gains in knowledge and confidence, with residents in the IBCLC group demonstrating greatest improvement in knowledge and a higher rating of their teaching method. Our study provides support for 3 methods of teaching residents breastfeeding management and demonstrates that IBCLCs are well-received as interprofessional educators. Keywords breastfeeding, education, pediatric residents, standardized patients
Well Established
1
Time-intensive breastfeeding curricula that combine different teaching methods improve residents’ knowledge and attitudes and their patients’ breastfeeding rates.
Newly Expressed Shadowing an IBCLC for 1 hour, attending a 3-hour class, or watching an interactive, case-based DVD are each time-efficient, effective, and promising options for improving pediatric residents’ general breastfeeding knowledge and increasing their confidence in managing common breastfeeding concerns during a clinical well baby nursery rotation.
Background Breastfeeding is recommended by the American Academy of Pediatrics (AAP) for the first year of life, and as long
Division of General and Community Pediatrics, Children’s National Medical Center and George Washington University School of Medicine and Health Sciences, Washington, DC, USA 2 Children’s National Medical Center and Holy Cross Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA 3 Department of Epidemiology and Biostatistics, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA 4 The Clinical Learning and Simulation Skills Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA Date submitted: January 24, 2014; Date accepted: July 25, 2014. Corresponding Author: Jennifer A.F. Tender, MD, IBCLC, Division of General and Community Pediatrics, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, USA. Email: [email protected]
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Tender et al thereafter as mutually desired by mother and infant, for numerous medical, neurodevelopmental, and economic reasons.1-7 Clinician support is crucial in helping families meet their breastfeeding goals; mothers are less likely to discontinue breastfeeding early if they receive encouragement from their clinicians.8,9 It is unfortunate that many pediatricians never receive the practical training needed to help the breastfeeding dyad,10-12 with pediatric residents receiving an average of only 3 hours of breastfeeding education annually.13 Several studies have evaluated the effectiveness of breastfeeding curricula to improve residents’ clinical skills. These curricula included didactic lectures, breastfeeding Objective Structured Clinical Examinations (OSCEs), observation of International Board Certified Lactation Consultants (IBCLCs), faculty observation of residents’ interactions with breastfeeding mothers, and use of the AAP Breastfeeding Residency Curriculum.14-18 The evaluation of the AAP curriculum consisted of a self-study module, didactic lectures, a skills workshop, and assisting 3 new mothers to breastfeed with 1 of these encounters being observed by a faculty member. Residents in the 13 pediatric programs enrolled in the curriculum had improved knowledge and confidence regarding breastfeeding management, and infants in their programs were more likely to exclusively breastfeed at 6 months than controls.17 All of these studies have demonstrated effectiveness in teaching residents about breastfeeding, but their curricula combined multiple teaching strategies and have ranged from 1 to 4 days, a significant time commitment in the context of restricted duty hours. Residency programs may not have the time or resources to implement these curricula. We therefore wanted to separately study 3 time-efficient teaching methods—observation of an IBCLC, observation of a prenatal parent breastfeeding class (CLS), and watching a case-based DVD. We chose these methods because we use them in our residency program and others have studied them as part of a breastfeeding curriculum, but they have not been evaluated individually. One study of pediatric residents who observed lactation clinics, lactation rounds, and La Leche groups showed that residents had improved attitudes about breastfeeding compared to controls, whereas another study of family practice residents who participated in a breastfeeding workshop consisting of lectures and interactions with IBCLCs and standardized patients (SPs) showed that residents had better clinical skills as assessed by OSCE and felt more confident in managing problems than controls.14,16 No studies have evaluated in isolation how having a pediatric resident observe an IBCLC with patients affects the resident’s breastfeeding management skills. Likewise, although prenatal breastfeeding education improves breastfeeding rates,19 evaluating the effect of having residents observe a prenatal breastfeeding class has not been assessed. Finally, online learning has been used to improve residents’ knowledge and ability to correctly answer parents’ questions,20 but
self-directed learning using a DVD to improve breastfeeding clinical skills has not been studied.
Objective We evaluated 3 brief (ie, ≤ 3 hours) curricula for effectiveness in improving residents’ breastfeeding knowledge, confidence, and skills in counseling breastfeeding mothers. We wanted to determine if it is possible to deliver an effective breastfeeding curriculum to residents in a time-efficient manner, making it more feasible to be used by residency programs.
Methods Study Participants From July 2011 to June 2012, all first-year residents from a large pediatric residency program were invited to participate during their 4-week well baby nursery (WBN) rotation at an affiliated community hospital that is not designated as BabyFriendly. The study was a quasi-experimental design where residents were assigned to 1 of 3 study groups based on rotation rather than individually randomized. Residents signed a written informed consent and were assigned as follows: residents in rotation 1 (July) were assigned to group 1, residents in rotation 2 (August) to group 2, residents in rotation 3 (September) to group 3, and residents in rotation 4 (October) to group 1 again, and so forth throughout the year. Group 1 shadowed an IBCLC for a 1-hour session counseling postpartum breastfeeding mothers about common breastfeeding challenges such as pain related to improper positioning and latch and signs of adequate milk intake. Group 2 watched a 25-minute interactive DVD that was created by 2 of the authors and included prenatal counseling about breastfeeding and the management of 3 breastfeeding cases: maternal pain during breastfeeding, maternal concern about milk supply, and a jaundiced, dehydrated infant. The DVD demonstrated proper positioning, latch, and assessment of milk transfer and supply. It also contained stop-start points to frame questions for residents to enable them to translate knowledge from the DVD into a plan for each patient.21 Group 3 observed a regularly scheduled 3-hour breastfeeding class (CLS) given to expectant parents by an IBCLC that included discussions about breastfeeding benefits, positioning, latch, and common challenges. The parents in the class used a breastfeeding doll to learn about positioning. Children’s National Medical Center’s institutional review board approved the study.
Outcome Measures Assessment of residents’ knowledge and confidence. We assessed residents’ knowledge of breastfeeding clinical practice using a 23-question multiple-choice test given at the start
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and end (after the intervention) of the WBN rotation. Confidence level for addressing parents’ questions about breastfeeding and managing common breastfeeding problems, also determined pre-intervention and post-intervention, was assessed by resident self-rating on a 5-point scale (1 = not at all confident, 3 = neutral, 5 = very confident). Questions were all taken from the validated AAP Breastfeeding Residency Curriculum.22
the faculty evaluator for all residents. She observed their performance either in person or by video recording and completed the scoring sheet. The residents received individual verbal feedback from both the faculty evaluator and the SP. The residents then provided verbal feedback to the faculty evaluator about the quality and educational value of the experience. The total feedback time per resident lasted approximately 10 minutes.
Assessment of clinical skills. We assessed residents’ clinical management skills by a 1-station OSCE during the last week of the WBN rotation that consisted of a mother-infant breastfeeding dyad scenario. We used the same SP for all encounters; she was trained for 4 hours to accurately portray her role as a breastfeeding mother. In lieu of a live newborn, we used a breastfeeding doll to ensure consistency and to eliminate infection risk to a real child. The SP wore cloth breasts under her shirt to simulate a lactating mother. The SP scenario involved a mother presenting with her 5-day-old, mildly jaundiced infant for a routine well child visit. The mother complained of pain with nursing and expressed concern about having an inadequate milk supply. The 15-minute videotaped encounter required the resident to obtain a focused history, and if, after 5 minutes, the resident did not ask to observe the mother breastfeed, the SP covertly activated a recording of a crying infant and stated, “I think my baby is hungry.” If the resident still did not ask to observe the mother breastfeed, the SP asked permission to feed her infant. The SP positioned the infant doll in an awkward cradle hold with the infant doll’s body facing outward and then showed the resident a short video clip of an infant with a shallow inadequate latch to simulate the infant doll’s latch. We developed a clinical scoring form to assess the residents’ performance based on the AAP Breastfeeding Residency Curriculum OSCE Case Study Performance Assessment.23 The clinical scoring form was reviewed by 4 pediatricians and 3 IBCLCs to ensure face validity and that it included evaluation items specific to the case. The clinical scoring form (Figure 1) contained 22 items divided into the following 5 sections: interpersonal skills, maternal history taking, assessment of milk supply, clinical assessment, and counseling skills. The section on interpersonal skills used questions from the Structured Clinical Observation form.24,25 The residents’ interpersonal skills, maternal history taking, and milk supply assessment were scored using dichotomous variables (yes/no). Clinical assessment (eg, assisting with infant positioning) was scored using dichotomous variables (yes/no) as well as measures of promptness of residents’ actions. Counseling skills were also scored using dichotomous variables (yes/no) based on residents’ discussion of the signs of adequate milk intake, proper positioning/ latch, and providing a follow-up plan. For consistency, the principal investigator (JAFT), a pediatrician and IBCLC who is not a staff member of the community hospital, served as
Rating of teaching method. As part of the posttest, the residents rated their overall experience with breastfeeding education in the WBN rotation on a 5-point scale (1 = least helpful to 5 = most helpful). They rated their specific assigned teaching methodology using the same scale on how well it prepared them to manage the breastfeeding dyad. They could also write in additional comments about their experience with their specific teaching method.
Statistical Methods All analyses were conducted using SAS 9.3.26 Baseline differences among groups were tested by Fisher exact test. Analysis of covariance was used to test for overall posttest differences among the 3 study groups, controlling for pretest levels of the variable as well as any variable showing statistically significant group differences at baseline. We compared the 3 groups using the Nelson-Hsu procedure,26(p470) which involves comparing each group’s posttest mean to the overall mean after controlling for covariates. Pre–post changes were tested by paired t test. Differences among groups on clinical rating checklist items were tested by Pearson chi-square or Fisher exact test. Standardized effect size was calculated as the difference between pre and post scores divided by the overall standard deviation of scores.
Results All 40 of the potential first-year pediatric resident participants initially agreed to participate in the study. One resident requested that none of her data be included in the analysis, leaving 39 participants. We have incomplete data on 2 residents who were included in the analysis—1 who did not take part in the intervention (parenting class was cancelled) and 1 who did not complete the SP evaluation because of scheduling conflicts. These residents’ results were included in the analysis under the intent-to-treat principle. Eleven residents were assigned to shadow the IBCLC, 16 to watch the DVD, and 12 to observe the CLS. Data from these participants were included in all analyses unless noted. The residents’ demographics are shown in Table 1. Prior to the intervention, the majority of residents had observed a mother breastfeeding in a clinical setting (79%) or discussed feeding options with a family (67%).
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Tender et al Figure 1. Standardized Patient Scoring Form for Breastfeeding Management Skills. Y
N
N/A
DATA GATHERING Interpersonal Skills
Introduces self
Addresses parent/patient by name after initial introductions
Actively listens using nonverbal techniques (e.g. eye contact, nodding)
Asks about concerns
Asks about mother’s breastfeeding goals (e.g. breastfeeding duration, exclusive/ partial)
Maternal History
Asks about prior breasts surgery
Asks if breasts enlarged during pregnancy
Asks mother to clarify when the pain occurs during breastfeeding (i.e. latch on or throughout the feeding)
Assessment of Milk Supply
Asks about number of feeds/24 hours
Asks about length of feeds
Asks if breasts feel less full after feeds
Asks about wet diapers
Asks about bowel movements
Asks if any formula/water given
PHYSICAL EXAMINATION/CLINICAL ASSESSMENT
Asks to observe mother breastfeeding
When? [ ] prior to 5 minute warning
Comments about/assists with infant positioning
When? [ ] prior to 5 minute warning [ ] when baby starts crying
[ ] after mom starts breastfeeding [ ] when mom asks for help
Comments about/assists with infant latch-on
When? [ ] prior to 5 minute warning [ ] when baby starts crying
Comments about infant suck/swallow
When? [ ] prior to 5 minute warning [ ] when baby starts crying
[ ] after mom starts breastfeeding [ ] when mom asks for help
SPECIFIC BREASTFEEDING INFORMATION GIVING
Discusses signs of adequate milk intake
Discusses/demonstrates proper positioning
Discusses/demonstrates proper latch-on
Provides follow up visit/plan
[ ] when baby starts crying
[ ] after mom starts breastfeeding [ ] when mom asks for help
[ ] after mom starts breastfeeding [ ] when mom asks for help
Abbreviations: N, no; N/A, no opportunity to observe or not applicable to this encounter; Y, yes.
Yet, only 44% had previously counseled a breastfeeding mother about lactation problems and 24% had taught a new mother breastfeeding techniques (Table 1). The only statistically significant difference among groups on
baseline variables was for counseling a breastfeeding mother about lactation problems, where the IBCLC group had the highest experience (73%) and the DVD group had the lowest (25%, P = .05).
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Table 1. Sample Characteristics by Study Group. Study Group Characteristic
Class (n = 12)
Female 67% Born outside US 25% Is a parent 0% Race (checked all that apply) White 58% Black/African American 8% Asian 33% Previous learning about breastfeeding (checked all that apply) No prior training 33% Continuity or noon lectures 58% Reading on my own 17% Observing a lactation consultant 8% Observing an attending or nurse assist a 17% breastfeeding mother Previous clinical experience with breastfeeding Observed a patient breastfeeding in hospital or 58% office Counseled about infant feeding choices 58% Taught a new mother breastfeeding techniques 17% 42% Counseled about breastfeeding problemsd Breastfed own child 0%
a
b
c
DVD (n = 16)
IBCLC (n = 11)
Total (n = 39)
81% 19% 6%
82% 0% 0%
77% 15% 3%
56% 25% 12%
91% 0% 9%
69% 13% 18%
31% 31% 38% 12% 6%
18% 55% 36% 0% 18%
28% 46% 31% 8% 13%
88%
91%
79%
75% 13% 25% 6%
64% 45% 73% 0%
67% 24% 44% 3%
Abbreviation: IBCLC, International Board Certified Lactation Consultant. a Class group observed a 3-hour prenatal parent breastfeeding class. b DVD group watched a 25-minute case-based breastfeeding DVD. c IBCLC group shadowed an IBCLC for 1 hour. d There was a statistically significant difference among study groups (P = .05), Fisher exact test.
Table 2. Pre–Post Knowledge and Confidence regarding Breastfeeding Skills by Study Group. Measure Breastfeeding general knowledge test (11 items)c Formula supplementation knowledge (6 items)c Confidence (3 items)e
Groupa Class DVD IBCLCd Class DVD IBCLC Class DVD IBCLC
Pre Mean (SD)
Post Mean (SD)
Post–Pre Mean Change (Standardized Effect Size)
P Valueb
66.9 (11.8) 59.6 (18.2) 66.1 (13.5) 56.7 (22.6) 62.3 (16.4) 61.2 (19.8) 2.0 (0.9) 2.2 (0.8) 2.2 (0.8)
81.1 (12.5) 74.8 (13.9) 89.2 (8.9) 79.2 (17.6) 72.9 (14.8) 84.8 (20.3) 3.7 (1.0) 3.8 (0.6) 3.9 (0.6)
14.2 (0.85) 15.2 (0.90) 23.1 (1.38) 22.5 (1.11) 10.6 (0.52) 23.6 (1.16) 1.7 (1.48) 1.6 (1.39) 1.7 (1.48)
.0007 .004 < .0001 .01 .11 .006 .0001 < .0001 .0002
Abbreviations: IBCLC, International Board Certified Lactation Consultant; SD, standard deviation. a Class group observed a 3-hour prenatal parent breastfeeding class (n = 12). DVD group watched a 25-minute case-based breastfeeding DVD (n = 16). IBCLC group shadowed an IBCLC for 1 hour (n = 11). b P values in this column refer to tests of pre–post change. c Both knowledge scores were calculated as the percentage of test items answered correctly. d IBCLC mean at posttest, after adjusting for pretest knowledge and prior experience counseling about breastfeeding problems, was significantly higher than the overall mean (P = .02). e Confidence scores were calculated as the mean of items, where each item was scored 1 = not at all confident, 3 = neutral, and 5 = very confident.
Table 2 shows that all 3 groups showed a statistically significant improvement in their mean general knowledge score after the intervention. These improvements were large, based
on the standardized effect sizes, where by convention a standardized effect of 0.50 is usually considered medium in magnitude and 0.80 is large.27 Residents in the IBCLC group had
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Tender et al Table 3. Standardized Patient Clinical Skills Rating by Study Group. Class (n = 12)a
DVD (n = 16)b
IBCLC (n = 11)c
P Value
2.4 (1.4)
2.9 (1.3)
2.6 (1.0)
.49
64
75
91
.32
73 91 91 91
69 81 94 75
73 73 100 60
.97 .55 .62 .26
Number of questions asked to assess milk supply, mean (SD) Commented or assisted with infant latch-on prior to 5-minute warning, % Discussed signs of adequate milk intake, % Discussed/demonstrated proper positioning, % Discussed/demonstrated proper latch-on, % Provided follow-up plan, %
Abbreviations: IBCLC, International Board Certified Lactation Consultant; SD, standard deviation. a Class group observed a 3-hour prenatal parent breastfeeding class. b DVD group watched a 25-minute case-based breastfeeding DVD. c IBCLC group shadowed an IBCLC for 1 hour.
Table 4. Perceived Helpfulness of Breastfeeding Education by Intervention Group. Perceived Helpfulness
Class (n = 11)a
Overall breastfeeding education in WBN rotation % with 4 or 5 on 1-5 scaled Specific intervention teaching method % with 4 or 5 on 1-5 scale
DVD (n = 16)b
IBCLC (n = 11)c
P Value
91
56
73
.36
—e
56
91
.01
Abbreviations: IBCLC, International Board Certified Lactation Consultant; SD, standard deviation; WBN, well baby nursery. a Class group observed a 3-hour prenatal parent breastfeeding class. b DVD group watched a 25-minute case-based breastfeeding DVD. c IBCLC group shadowed an IBCLC for 1 hour. d Rated on a 5-point scale (1 = not at all helpful to 5 = very helpful). e Data not obtained due to an omission on the posttest form.
an adjusted mean (controlling for pretest score) at posttest that was significantly higher than the overall mean (P = .02), indicating that this group improved more than the others in general knowledge. Residents in the IBCLC and CLS groups improved significantly in their knowledge about when it is appropriate to supplement a breastfed infant with formula; improvement for residents in the DVD group did not reach statistical significance. Resident confidence managing common breastfeeding problems and answering parents’ questions about breastfeeding also improved significantly for all 3 groups (Table 2). The standardized effect sizes were all large in magnitude. Between-group differences were not statistically significant (P = .70) There was no statistically significant difference between the 3 groups in their clinical management of the breastfeeding SP or with regard to the number of questions asked to assess milk supply, discussion of adequate milk intake, or commenting/assisting with infant latch (Table 3). Residents who observed an IBCLC or the CLS rated their overall breastfeeding education in the WBN rotation very highly (91% and 73% giving a rating of helpful or very helpful, respectively) and this was less true for residents who watched the DVD (56%). Similarly, 91% of residents who observed an IBCLC rated their teaching experience as
helpful or very helpful in preparing them to manage the breastfeeding dyad compared to 56% of residents who watched the DVD (P = .01). Residents in the CLS did not score their experience due to an omission on the posttest form (Table 4).
Discussion Shadowing an IBCLC for 1 hour, attending a 3-hour class, or watching an interactive, case-based DVD are time-efficient, effective options for improving pediatric residents’ general breastfeeding knowledge and increasing their confidence in managing common breastfeeding concerns. In particular, this is the first study to assess the role of the IBCLC as an interprofessional educator for pediatric residents. Although previous studies have demonstrated improvement in pediatric residents’ breastfeeding knowledge and management skills using combined teaching methods that require a substantial amount of time, this study demonstrates similar results for some common and brief teaching methods used individually. All 3 groups had statistically significant improvement in their general breastfeeding knowledge, with the residents in the IBCLC group showing significantly higher improvement than residents in the other groups. Only residents in the
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IBCLC and CLS groups improved their knowledge about appropriate formula supplementation. It is essential that residents know the medical indications for formula supplementation to avoid formula being given unnecessarily to newborns and to comply with the Joint Commission’s perinatal care core measure on exclusive breast milk feeding. All 3 groups also had statistically significant improvement in their breastfeeding management confidence with no significant difference between the groups. A larger trial would be needed to determine superiority for any of the methods. Using SPs, we also assessed the effect of the interventions on residents’ performance. This higher level of evaluation examines whether learners can translate their knowledge into skills.28 Residents’ clinical performance skills in the SP breastfeeding scenario proved to be similar among the 3 groups. Residents in each group performed well on the OSCE (Table 3) with the majority assisting with infant position and latch, a critical intervention when breastfeeding is not going well. We used SPs only as an evaluative tool for the study, a step that could be eliminated for programs seeking to adapt all or some of our teaching methods. A number of residents commented that the SP was a valuable teaching asset due to her direct feedback and demonstration of correct position and latch, which concurs with Haughwout’s14 finding that her “OSCE evaluation process [was] enthusiastically received.” However, this study was not designed to assess the effect of the SP on breastfeeding knowledge and, therefore, we do not know if this SP effect was real or simply a perception. The 25-minute DVD was the most time-efficient method, compared to the 1-hour IBCLC observation and the 3-hour CLS. Although trainees who watched the DVD would have liked more hands-on participation, this method enabled residents to achieve a level of knowledge and skills about breastfeeding similar to the other interventions. An additional advantage is that residents were able to view the DVD in a self-directed manner, minimizing scheduling difficulties. This result could be compared to the users’ appreciation of the flexibility of an online breastfeeding course that similarly improved participants’ knowledge.29 The DVD was the most consistent and controlled teaching method of the 3. All the CLS classes followed the same outline and were also highly consistent but would have dealt with additional subjects variably in response to parents’ questions. Although the IBCLC tried to show all residents how to position infants and assess latch, the IBCLC experience was the least consistent from session to session and was dependent on the type of problems that residents encountered during the session. Nonetheless, the residents in the IBCLC group rated their teaching method higher (P = .01) and gave it more positive comments than residents in the DVD group, attesting to residents’ enthusiasm for the IBCLC as an interprofessional educator. Challenges of the IBCLC shadowing experience included aligning resident and IBCLC schedules and balancing clinical and teaching time demands.
There were limitations of our study. First, since we had a small sample size, we did not include a fourth group as a control. This is a major limitation as it is not known if residents’ breastfeeding skills would have improved by completing the newborn nursery rotation alone even without a specific breastfeeding education component. Ideally, this study should be followed up with a multiprogram randomized trial to address these limitations. Second, although we demonstrated statistically significant increases in knowledge and confidence within all 3 of our intervention groups, we could have improved the strength of the study by comparing their effectiveness to the validated AAP Breastfeeding Residency Curriculum. We did not make this comparison because the AAP curriculum was published after we created our study design and completed the DVD; it also would have diminished the power of our study. Third, our study was a quasi-experimental, pretest– posttest design without a control group, with assignment by rotation rather than by an individual randomization. Fourth, our sample size was small, constrained by the number of first-year residents rotating in the community hospital during that academic year. There were also imbalances among the 3 groups that could not be controlled because of the sample size. Finally, the rating of the parenting class was inadvertently omitted; the results obtained may have provided a more complete evaluation of this teaching method.
Conclusion Our study provides support for 3 brief methods to teach residents breastfeeding management in a time-efficient manner feasible within the constraints of limited duty hours. Taking into account the consistency of the DVD and residents’ enthusiasm for the hands-on experience with the IBCLC, we propose a combined curriculum using the breastfeeding DVD for a self-directed overview of infant latch and positioning followed by an IBCLC-guided clinical experience. This multimodal approach would still take significantly less time than previously reported breastfeeding curricula. In addition, it would offer residents complementary educational methods that address different learning styles and mutually reinforce management techniques. Acknowledgments The authors thank the Association of Pediatric Program Directors for funding this project, Erin Steenson for her realistic portrayal as a standardized patient, Janet Montrie, RN, IBCLC, for her dedication in educating residents and students, Pat Cavey for her outstanding administrative assistance, and Rachel Y. Moon, MD, for her insightful review.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Tender et al Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Association of Pediatric Program Directors.
References 1. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2011. 2. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics. 2004;113(5):e435-e439. 3. Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. Breastfeed Med. 2009;4(1):S17-S30. 4. Kramer MS, Fombonne E, Igumnov S, et al. Promotion of Breastfeeding Intervention Trial (PROBIT) Study Group. Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: evidence from a large, randomized trial. Pediatrics. 2008;121(3):e435-e440. 5. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048-e1056. 6. Bartick M. Breastfeeding and the U.S. economy. Breastfeed Med. 2011;6(5):313-318. 7. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):827-841. 8. Taveras EM, Li R, Grummer-Strawn L, et al. Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics. 2004;113(4):e283-e290. 9. Taveras EM, Capra AM, Braveman P, et al. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics. 2003;112(1, pt 1):108-115. 10. Freed GL, Clark SJ, Lohr JA, Sorenson JR. Pediatrician involvement in breast-feeding promotion: a national study of residents and practitioners. Pediatrics. 1995;96(3, pt 1):490-494. 11. Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians’ practice and attitudes regarding breastfeeding promotion. Pediatrics. 1999;103(3):E35. 12. Feldman-Winter LB, Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians and the promotion and support of breastfeeding. Arch Pediatr Adolesc Med. 2008;162(12):1142-1149. 13. Osband YB, Altman RL, Patrick PA, Edwards KS. Breastfeeding education and support services offered to pediatric residents in the US. Acad Pediatr. 2011;11(1):75-79.
14. Haughwout JC, Eglash AR, Plane MB, Mundt MP, Fleming MF. Improving residents’ breastfeeding assessment skills: a problem-based workshop. Fam Pract. 2000;17(6):541-546. 15. Hillenbrand KM, Larsen PG. Effect of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians. Pediatrics. 2002;110(5):e59. 16. Bunik M, Gao D, Moore L. An investigation of a field trip model as a method for teaching breastfeeding to pediatric residents. J Hum Lact. 2006;22(2):195-202. 17. Feldman-Winter L, Barone L, Milcarek B, et al. Residency curriculum improves breastfeeding care. Pediatrics. 2010;126(2):289-297. 18. Holmes AV, McLeod AY, Thesing C, Kramer S, Howard CR. Physician breastfeeding education leads to practice changes and improved clinical outcomes. Breastfeed Med. 2012;7(6):403408. 19. Lumbiganon P, Martis R, Laopaiboon M, Festin MR, Ho JJ, Hakimi M. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database Syst Rev. 2012;9:CD006425. 20. Lasarte Velillas JJ, Hernández-Aguilar MT, Pallás Alonso CR, et al. A breastfeeding e-learning project based on a web forum. Breastfeed Med. 2007;2(4):219-228. 21. Tender JAF, Hughes V, Greenberg L. Breastfeeding for Medical Providers: Translating Knowledge into Practice [DVD]. Washington, DC: GW University; 2010. 22. American Academy of Pediatrics. Welcome to the breastfeeding residency curriculum. http://www2.aap.org/breastfeeding/ curriculum/. Accessed October 21, 2012. 23. American Academy of Pediatrics. Curriculum tools. http:// www2.aap.org/breastfeeding/curriculum/tools.html. Accessed October 21, 2012. 24. Hamburger EK, Cuzzi S, Coddington DA, et al. Observation of resident clinical skills: outcomes of a program of direct observation in the continuity clinic setting. Acad Pediatr. 2011;11(5):394-402. 25. Lane JL, Gottlieb RP. Structured clinical observations: a method to teach clinical skills with limited time and financial resources. Pediatrics. 2000;105(4, pt 2):973-977. 26. SAS Institute Inc. SAS/STAT® 9.3 User’s Guide. Cary, NC: SAS Institute Inc; 2011. 27. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988:25-26. 28. Miller GE. The assessment of clinical skills/competence/performance. Academic Med. 1990;65(9 suppl):S63-S67. 29. Lewin LO, O’Connor ME. “BreastfeedingBasics”: web based education that meets current knowledge competencies. J Hum Lact. 2012;28(3):407-413.
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research-article2014
JHLXXX10.1177/0890334414548459Journal of Human LactationTender et al
Original Research
Educating Pediatric Residents about Breastfeeding: Evaluation of 3 Time-Efficient Teaching Strategies
Journal of Human Lactation 2014, Vol. 30(4) 458–465 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334414548459 jhl.sagepub.com
Jennifer A.F. Tender, MD, IBCLC1, Sandra Cuzzi, MD2, Terry Kind, MD, MPH1, Samuel J. Simmens, PhD3, Benjamin Blatt, MD4, and Larrie Greenberg, MD4 Abstract Background: Previously reported breastfeeding curricula for residents have combined different teaching methods, have focused on knowledge and attitudes, and have been time-intensive. Objective: This study aimed to evaluate 3 time-efficient breastfeeding curricula for effectiveness in regard to pediatric residents’ knowledge, confidence, and skills in managing a simulated breastfeeding scenario. Methods: First-year pediatric residents during their 4-week community hospital newborn nursery rotation were consecutively assigned to 1 of 3 groups. Group 1 shadowed an International Board Certified Lactation Consultant (IBCLC) for 1 hour; group 2 watched a 25-minute case-based breastfeeding DVD; and group 3 observed a 3-hour prenatal parent breastfeeding class (CLS). Residents were assessed by (1) a pretest and posttest evaluating their breastfeeding knowledge and confidence, and (2) a clinical skills scenario managing a breastfeeding standardized patient (SP). Results: Thirty-nine pediatric residents participated in the study (11 in IBCLC, 16 DVD, 12 CLS) over a 1-year period. All groups significantly improved their knowledge scores and confidence in managing breastfeeding problems, with the IBCLC group showing more improvement in knowledge than the other groups (P = .02) and a higher rating of their teaching method (P = .01). All groups performed well on the SP clinical skills scenario, with no significant difference between groups. Conclusion: All 3 teaching methods were time-efficient and produced important gains in knowledge and confidence, with residents in the IBCLC group demonstrating greatest improvement in knowledge and a higher rating of their teaching method. Our study provides support for 3 methods of teaching residents breastfeeding management and demonstrates that IBCLCs are well-received as interprofessional educators. Keywords breastfeeding, education, pediatric residents, standardized patients
Well Established
1
Time-intensive breastfeeding curricula that combine different teaching methods improve residents’ knowledge and attitudes and their patients’ breastfeeding rates.
Newly Expressed Shadowing an IBCLC for 1 hour, attending a 3-hour class, or watching an interactive, case-based DVD are each time-efficient, effective, and promising options for improving pediatric residents’ general breastfeeding knowledge and increasing their confidence in managing common breastfeeding concerns during a clinical well baby nursery rotation.
Background Breastfeeding is recommended by the American Academy of Pediatrics (AAP) for the first year of life, and as long
Division of General and Community Pediatrics, Children’s National Medical Center and George Washington University School of Medicine and Health Sciences, Washington, DC, USA 2 Children’s National Medical Center and Holy Cross Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA 3 Department of Epidemiology and Biostatistics, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA 4 The Clinical Learning and Simulation Skills Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA Date submitted: January 24, 2014; Date accepted: July 25, 2014. Corresponding Author: Jennifer A.F. Tender, MD, IBCLC, Division of General and Community Pediatrics, Children’s National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, USA. Email: [email protected]
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Tender et al thereafter as mutually desired by mother and infant, for numerous medical, neurodevelopmental, and economic reasons.1-7 Clinician support is crucial in helping families meet their breastfeeding goals; mothers are less likely to discontinue breastfeeding early if they receive encouragement from their clinicians.8,9 It is unfortunate that many pediatricians never receive the practical training needed to help the breastfeeding dyad,10-12 with pediatric residents receiving an average of only 3 hours of breastfeeding education annually.13 Several studies have evaluated the effectiveness of breastfeeding curricula to improve residents’ clinical skills. These curricula included didactic lectures, breastfeeding Objective Structured Clinical Examinations (OSCEs), observation of International Board Certified Lactation Consultants (IBCLCs), faculty observation of residents’ interactions with breastfeeding mothers, and use of the AAP Breastfeeding Residency Curriculum.14-18 The evaluation of the AAP curriculum consisted of a self-study module, didactic lectures, a skills workshop, and assisting 3 new mothers to breastfeed with 1 of these encounters being observed by a faculty member. Residents in the 13 pediatric programs enrolled in the curriculum had improved knowledge and confidence regarding breastfeeding management, and infants in their programs were more likely to exclusively breastfeed at 6 months than controls.17 All of these studies have demonstrated effectiveness in teaching residents about breastfeeding, but their curricula combined multiple teaching strategies and have ranged from 1 to 4 days, a significant time commitment in the context of restricted duty hours. Residency programs may not have the time or resources to implement these curricula. We therefore wanted to separately study 3 time-efficient teaching methods—observation of an IBCLC, observation of a prenatal parent breastfeeding class (CLS), and watching a case-based DVD. We chose these methods because we use them in our residency program and others have studied them as part of a breastfeeding curriculum, but they have not been evaluated individually. One study of pediatric residents who observed lactation clinics, lactation rounds, and La Leche groups showed that residents had improved attitudes about breastfeeding compared to controls, whereas another study of family practice residents who participated in a breastfeeding workshop consisting of lectures and interactions with IBCLCs and standardized patients (SPs) showed that residents had better clinical skills as assessed by OSCE and felt more confident in managing problems than controls.14,16 No studies have evaluated in isolation how having a pediatric resident observe an IBCLC with patients affects the resident’s breastfeeding management skills. Likewise, although prenatal breastfeeding education improves breastfeeding rates,19 evaluating the effect of having residents observe a prenatal breastfeeding class has not been assessed. Finally, online learning has been used to improve residents’ knowledge and ability to correctly answer parents’ questions,20 but
self-directed learning using a DVD to improve breastfeeding clinical skills has not been studied.
Objective We evaluated 3 brief (ie, ≤ 3 hours) curricula for effectiveness in improving residents’ breastfeeding knowledge, confidence, and skills in counseling breastfeeding mothers. We wanted to determine if it is possible to deliver an effective breastfeeding curriculum to residents in a time-efficient manner, making it more feasible to be used by residency programs.
Methods Study Participants From July 2011 to June 2012, all first-year residents from a large pediatric residency program were invited to participate during their 4-week well baby nursery (WBN) rotation at an affiliated community hospital that is not designated as BabyFriendly. The study was a quasi-experimental design where residents were assigned to 1 of 3 study groups based on rotation rather than individually randomized. Residents signed a written informed consent and were assigned as follows: residents in rotation 1 (July) were assigned to group 1, residents in rotation 2 (August) to group 2, residents in rotation 3 (September) to group 3, and residents in rotation 4 (October) to group 1 again, and so forth throughout the year. Group 1 shadowed an IBCLC for a 1-hour session counseling postpartum breastfeeding mothers about common breastfeeding challenges such as pain related to improper positioning and latch and signs of adequate milk intake. Group 2 watched a 25-minute interactive DVD that was created by 2 of the authors and included prenatal counseling about breastfeeding and the management of 3 breastfeeding cases: maternal pain during breastfeeding, maternal concern about milk supply, and a jaundiced, dehydrated infant. The DVD demonstrated proper positioning, latch, and assessment of milk transfer and supply. It also contained stop-start points to frame questions for residents to enable them to translate knowledge from the DVD into a plan for each patient.21 Group 3 observed a regularly scheduled 3-hour breastfeeding class (CLS) given to expectant parents by an IBCLC that included discussions about breastfeeding benefits, positioning, latch, and common challenges. The parents in the class used a breastfeeding doll to learn about positioning. Children’s National Medical Center’s institutional review board approved the study.
Outcome Measures Assessment of residents’ knowledge and confidence. We assessed residents’ knowledge of breastfeeding clinical practice using a 23-question multiple-choice test given at the start
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and end (after the intervention) of the WBN rotation. Confidence level for addressing parents’ questions about breastfeeding and managing common breastfeeding problems, also determined pre-intervention and post-intervention, was assessed by resident self-rating on a 5-point scale (1 = not at all confident, 3 = neutral, 5 = very confident). Questions were all taken from the validated AAP Breastfeeding Residency Curriculum.22
the faculty evaluator for all residents. She observed their performance either in person or by video recording and completed the scoring sheet. The residents received individual verbal feedback from both the faculty evaluator and the SP. The residents then provided verbal feedback to the faculty evaluator about the quality and educational value of the experience. The total feedback time per resident lasted approximately 10 minutes.
Assessment of clinical skills. We assessed residents’ clinical management skills by a 1-station OSCE during the last week of the WBN rotation that consisted of a mother-infant breastfeeding dyad scenario. We used the same SP for all encounters; she was trained for 4 hours to accurately portray her role as a breastfeeding mother. In lieu of a live newborn, we used a breastfeeding doll to ensure consistency and to eliminate infection risk to a real child. The SP wore cloth breasts under her shirt to simulate a lactating mother. The SP scenario involved a mother presenting with her 5-day-old, mildly jaundiced infant for a routine well child visit. The mother complained of pain with nursing and expressed concern about having an inadequate milk supply. The 15-minute videotaped encounter required the resident to obtain a focused history, and if, after 5 minutes, the resident did not ask to observe the mother breastfeed, the SP covertly activated a recording of a crying infant and stated, “I think my baby is hungry.” If the resident still did not ask to observe the mother breastfeed, the SP asked permission to feed her infant. The SP positioned the infant doll in an awkward cradle hold with the infant doll’s body facing outward and then showed the resident a short video clip of an infant with a shallow inadequate latch to simulate the infant doll’s latch. We developed a clinical scoring form to assess the residents’ performance based on the AAP Breastfeeding Residency Curriculum OSCE Case Study Performance Assessment.23 The clinical scoring form was reviewed by 4 pediatricians and 3 IBCLCs to ensure face validity and that it included evaluation items specific to the case. The clinical scoring form (Figure 1) contained 22 items divided into the following 5 sections: interpersonal skills, maternal history taking, assessment of milk supply, clinical assessment, and counseling skills. The section on interpersonal skills used questions from the Structured Clinical Observation form.24,25 The residents’ interpersonal skills, maternal history taking, and milk supply assessment were scored using dichotomous variables (yes/no). Clinical assessment (eg, assisting with infant positioning) was scored using dichotomous variables (yes/no) as well as measures of promptness of residents’ actions. Counseling skills were also scored using dichotomous variables (yes/no) based on residents’ discussion of the signs of adequate milk intake, proper positioning/ latch, and providing a follow-up plan. For consistency, the principal investigator (JAFT), a pediatrician and IBCLC who is not a staff member of the community hospital, served as
Rating of teaching method. As part of the posttest, the residents rated their overall experience with breastfeeding education in the WBN rotation on a 5-point scale (1 = least helpful to 5 = most helpful). They rated their specific assigned teaching methodology using the same scale on how well it prepared them to manage the breastfeeding dyad. They could also write in additional comments about their experience with their specific teaching method.
Statistical Methods All analyses were conducted using SAS 9.3.26 Baseline differences among groups were tested by Fisher exact test. Analysis of covariance was used to test for overall posttest differences among the 3 study groups, controlling for pretest levels of the variable as well as any variable showing statistically significant group differences at baseline. We compared the 3 groups using the Nelson-Hsu procedure,26(p470) which involves comparing each group’s posttest mean to the overall mean after controlling for covariates. Pre–post changes were tested by paired t test. Differences among groups on clinical rating checklist items were tested by Pearson chi-square or Fisher exact test. Standardized effect size was calculated as the difference between pre and post scores divided by the overall standard deviation of scores.
Results All 40 of the potential first-year pediatric resident participants initially agreed to participate in the study. One resident requested that none of her data be included in the analysis, leaving 39 participants. We have incomplete data on 2 residents who were included in the analysis—1 who did not take part in the intervention (parenting class was cancelled) and 1 who did not complete the SP evaluation because of scheduling conflicts. These residents’ results were included in the analysis under the intent-to-treat principle. Eleven residents were assigned to shadow the IBCLC, 16 to watch the DVD, and 12 to observe the CLS. Data from these participants were included in all analyses unless noted. The residents’ demographics are shown in Table 1. Prior to the intervention, the majority of residents had observed a mother breastfeeding in a clinical setting (79%) or discussed feeding options with a family (67%).
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Tender et al Figure 1. Standardized Patient Scoring Form for Breastfeeding Management Skills. Y
N
N/A
DATA GATHERING Interpersonal Skills
Introduces self
Addresses parent/patient by name after initial introductions
Actively listens using nonverbal techniques (e.g. eye contact, nodding)
Asks about concerns
Asks about mother’s breastfeeding goals (e.g. breastfeeding duration, exclusive/ partial)
Maternal History
Asks about prior breasts surgery
Asks if breasts enlarged during pregnancy
Asks mother to clarify when the pain occurs during breastfeeding (i.e. latch on or throughout the feeding)
Assessment of Milk Supply
Asks about number of feeds/24 hours
Asks about length of feeds
Asks if breasts feel less full after feeds
Asks about wet diapers
Asks about bowel movements
Asks if any formula/water given
PHYSICAL EXAMINATION/CLINICAL ASSESSMENT
Asks to observe mother breastfeeding
When? [ ] prior to 5 minute warning
Comments about/assists with infant positioning
When? [ ] prior to 5 minute warning [ ] when baby starts crying
[ ] after mom starts breastfeeding [ ] when mom asks for help
Comments about/assists with infant latch-on
When? [ ] prior to 5 minute warning [ ] when baby starts crying
Comments about infant suck/swallow
When? [ ] prior to 5 minute warning [ ] when baby starts crying
[ ] after mom starts breastfeeding [ ] when mom asks for help
SPECIFIC BREASTFEEDING INFORMATION GIVING
Discusses signs of adequate milk intake
Discusses/demonstrates proper positioning
Discusses/demonstrates proper latch-on
Provides follow up visit/plan
[ ] when baby starts crying
[ ] after mom starts breastfeeding [ ] when mom asks for help
[ ] after mom starts breastfeeding [ ] when mom asks for help
Abbreviations: N, no; N/A, no opportunity to observe or not applicable to this encounter; Y, yes.
Yet, only 44% had previously counseled a breastfeeding mother about lactation problems and 24% had taught a new mother breastfeeding techniques (Table 1). The only statistically significant difference among groups on
baseline variables was for counseling a breastfeeding mother about lactation problems, where the IBCLC group had the highest experience (73%) and the DVD group had the lowest (25%, P = .05).
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Table 1. Sample Characteristics by Study Group. Study Group Characteristic
Class (n = 12)
Female 67% Born outside US 25% Is a parent 0% Race (checked all that apply) White 58% Black/African American 8% Asian 33% Previous learning about breastfeeding (checked all that apply) No prior training 33% Continuity or noon lectures 58% Reading on my own 17% Observing a lactation consultant 8% Observing an attending or nurse assist a 17% breastfeeding mother Previous clinical experience with breastfeeding Observed a patient breastfeeding in hospital or 58% office Counseled about infant feeding choices 58% Taught a new mother breastfeeding techniques 17% 42% Counseled about breastfeeding problemsd Breastfed own child 0%
a
b
c
DVD (n = 16)
IBCLC (n = 11)
Total (n = 39)
81% 19% 6%
82% 0% 0%
77% 15% 3%
56% 25% 12%
91% 0% 9%
69% 13% 18%
31% 31% 38% 12% 6%
18% 55% 36% 0% 18%
28% 46% 31% 8% 13%
88%
91%
79%
75% 13% 25% 6%
64% 45% 73% 0%
67% 24% 44% 3%
Abbreviation: IBCLC, International Board Certified Lactation Consultant. a Class group observed a 3-hour prenatal parent breastfeeding class. b DVD group watched a 25-minute case-based breastfeeding DVD. c IBCLC group shadowed an IBCLC for 1 hour. d There was a statistically significant difference among study groups (P = .05), Fisher exact test.
Table 2. Pre–Post Knowledge and Confidence regarding Breastfeeding Skills by Study Group. Measure Breastfeeding general knowledge test (11 items)c Formula supplementation knowledge (6 items)c Confidence (3 items)e
Groupa Class DVD IBCLCd Class DVD IBCLC Class DVD IBCLC
Pre Mean (SD)
Post Mean (SD)
Post–Pre Mean Change (Standardized Effect Size)
P Valueb
66.9 (11.8) 59.6 (18.2) 66.1 (13.5) 56.7 (22.6) 62.3 (16.4) 61.2 (19.8) 2.0 (0.9) 2.2 (0.8) 2.2 (0.8)
81.1 (12.5) 74.8 (13.9) 89.2 (8.9) 79.2 (17.6) 72.9 (14.8) 84.8 (20.3) 3.7 (1.0) 3.8 (0.6) 3.9 (0.6)
14.2 (0.85) 15.2 (0.90) 23.1 (1.38) 22.5 (1.11) 10.6 (0.52) 23.6 (1.16) 1.7 (1.48) 1.6 (1.39) 1.7 (1.48)
.0007 .004 < .0001 .01 .11 .006 .0001 < .0001 .0002
Abbreviations: IBCLC, International Board Certified Lactation Consultant; SD, standard deviation. a Class group observed a 3-hour prenatal parent breastfeeding class (n = 12). DVD group watched a 25-minute case-based breastfeeding DVD (n = 16). IBCLC group shadowed an IBCLC for 1 hour (n = 11). b P values in this column refer to tests of pre–post change. c Both knowledge scores were calculated as the percentage of test items answered correctly. d IBCLC mean at posttest, after adjusting for pretest knowledge and prior experience counseling about breastfeeding problems, was significantly higher than the overall mean (P = .02). e Confidence scores were calculated as the mean of items, where each item was scored 1 = not at all confident, 3 = neutral, and 5 = very confident.
Table 2 shows that all 3 groups showed a statistically significant improvement in their mean general knowledge score after the intervention. These improvements were large, based
on the standardized effect sizes, where by convention a standardized effect of 0.50 is usually considered medium in magnitude and 0.80 is large.27 Residents in the IBCLC group had
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Tender et al Table 3. Standardized Patient Clinical Skills Rating by Study Group. Class (n = 12)a
DVD (n = 16)b
IBCLC (n = 11)c
P Value
2.4 (1.4)
2.9 (1.3)
2.6 (1.0)
.49
64
75
91
.32
73 91 91 91
69 81 94 75
73 73 100 60
.97 .55 .62 .26
Number of questions asked to assess milk supply, mean (SD) Commented or assisted with infant latch-on prior to 5-minute warning, % Discussed signs of adequate milk intake, % Discussed/demonstrated proper positioning, % Discussed/demonstrated proper latch-on, % Provided follow-up plan, %
Abbreviations: IBCLC, International Board Certified Lactation Consultant; SD, standard deviation. a Class group observed a 3-hour prenatal parent breastfeeding class. b DVD group watched a 25-minute case-based breastfeeding DVD. c IBCLC group shadowed an IBCLC for 1 hour.
Table 4. Perceived Helpfulness of Breastfeeding Education by Intervention Group. Perceived Helpfulness
Class (n = 11)a
Overall breastfeeding education in WBN rotation % with 4 or 5 on 1-5 scaled Specific intervention teaching method % with 4 or 5 on 1-5 scale
DVD (n = 16)b
IBCLC (n = 11)c
P Value
91
56
73
.36
—e
56
91
.01
Abbreviations: IBCLC, International Board Certified Lactation Consultant; SD, standard deviation; WBN, well baby nursery. a Class group observed a 3-hour prenatal parent breastfeeding class. b DVD group watched a 25-minute case-based breastfeeding DVD. c IBCLC group shadowed an IBCLC for 1 hour. d Rated on a 5-point scale (1 = not at all helpful to 5 = very helpful). e Data not obtained due to an omission on the posttest form.
an adjusted mean (controlling for pretest score) at posttest that was significantly higher than the overall mean (P = .02), indicating that this group improved more than the others in general knowledge. Residents in the IBCLC and CLS groups improved significantly in their knowledge about when it is appropriate to supplement a breastfed infant with formula; improvement for residents in the DVD group did not reach statistical significance. Resident confidence managing common breastfeeding problems and answering parents’ questions about breastfeeding also improved significantly for all 3 groups (Table 2). The standardized effect sizes were all large in magnitude. Between-group differences were not statistically significant (P = .70) There was no statistically significant difference between the 3 groups in their clinical management of the breastfeeding SP or with regard to the number of questions asked to assess milk supply, discussion of adequate milk intake, or commenting/assisting with infant latch (Table 3). Residents who observed an IBCLC or the CLS rated their overall breastfeeding education in the WBN rotation very highly (91% and 73% giving a rating of helpful or very helpful, respectively) and this was less true for residents who watched the DVD (56%). Similarly, 91% of residents who observed an IBCLC rated their teaching experience as
helpful or very helpful in preparing them to manage the breastfeeding dyad compared to 56% of residents who watched the DVD (P = .01). Residents in the CLS did not score their experience due to an omission on the posttest form (Table 4).
Discussion Shadowing an IBCLC for 1 hour, attending a 3-hour class, or watching an interactive, case-based DVD are time-efficient, effective options for improving pediatric residents’ general breastfeeding knowledge and increasing their confidence in managing common breastfeeding concerns. In particular, this is the first study to assess the role of the IBCLC as an interprofessional educator for pediatric residents. Although previous studies have demonstrated improvement in pediatric residents’ breastfeeding knowledge and management skills using combined teaching methods that require a substantial amount of time, this study demonstrates similar results for some common and brief teaching methods used individually. All 3 groups had statistically significant improvement in their general breastfeeding knowledge, with the residents in the IBCLC group showing significantly higher improvement than residents in the other groups. Only residents in the
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IBCLC and CLS groups improved their knowledge about appropriate formula supplementation. It is essential that residents know the medical indications for formula supplementation to avoid formula being given unnecessarily to newborns and to comply with the Joint Commission’s perinatal care core measure on exclusive breast milk feeding. All 3 groups also had statistically significant improvement in their breastfeeding management confidence with no significant difference between the groups. A larger trial would be needed to determine superiority for any of the methods. Using SPs, we also assessed the effect of the interventions on residents’ performance. This higher level of evaluation examines whether learners can translate their knowledge into skills.28 Residents’ clinical performance skills in the SP breastfeeding scenario proved to be similar among the 3 groups. Residents in each group performed well on the OSCE (Table 3) with the majority assisting with infant position and latch, a critical intervention when breastfeeding is not going well. We used SPs only as an evaluative tool for the study, a step that could be eliminated for programs seeking to adapt all or some of our teaching methods. A number of residents commented that the SP was a valuable teaching asset due to her direct feedback and demonstration of correct position and latch, which concurs with Haughwout’s14 finding that her “OSCE evaluation process [was] enthusiastically received.” However, this study was not designed to assess the effect of the SP on breastfeeding knowledge and, therefore, we do not know if this SP effect was real or simply a perception. The 25-minute DVD was the most time-efficient method, compared to the 1-hour IBCLC observation and the 3-hour CLS. Although trainees who watched the DVD would have liked more hands-on participation, this method enabled residents to achieve a level of knowledge and skills about breastfeeding similar to the other interventions. An additional advantage is that residents were able to view the DVD in a self-directed manner, minimizing scheduling difficulties. This result could be compared to the users’ appreciation of the flexibility of an online breastfeeding course that similarly improved participants’ knowledge.29 The DVD was the most consistent and controlled teaching method of the 3. All the CLS classes followed the same outline and were also highly consistent but would have dealt with additional subjects variably in response to parents’ questions. Although the IBCLC tried to show all residents how to position infants and assess latch, the IBCLC experience was the least consistent from session to session and was dependent on the type of problems that residents encountered during the session. Nonetheless, the residents in the IBCLC group rated their teaching method higher (P = .01) and gave it more positive comments than residents in the DVD group, attesting to residents’ enthusiasm for the IBCLC as an interprofessional educator. Challenges of the IBCLC shadowing experience included aligning resident and IBCLC schedules and balancing clinical and teaching time demands.
There were limitations of our study. First, since we had a small sample size, we did not include a fourth group as a control. This is a major limitation as it is not known if residents’ breastfeeding skills would have improved by completing the newborn nursery rotation alone even without a specific breastfeeding education component. Ideally, this study should be followed up with a multiprogram randomized trial to address these limitations. Second, although we demonstrated statistically significant increases in knowledge and confidence within all 3 of our intervention groups, we could have improved the strength of the study by comparing their effectiveness to the validated AAP Breastfeeding Residency Curriculum. We did not make this comparison because the AAP curriculum was published after we created our study design and completed the DVD; it also would have diminished the power of our study. Third, our study was a quasi-experimental, pretest– posttest design without a control group, with assignment by rotation rather than by an individual randomization. Fourth, our sample size was small, constrained by the number of first-year residents rotating in the community hospital during that academic year. There were also imbalances among the 3 groups that could not be controlled because of the sample size. Finally, the rating of the parenting class was inadvertently omitted; the results obtained may have provided a more complete evaluation of this teaching method.
Conclusion Our study provides support for 3 brief methods to teach residents breastfeeding management in a time-efficient manner feasible within the constraints of limited duty hours. Taking into account the consistency of the DVD and residents’ enthusiasm for the hands-on experience with the IBCLC, we propose a combined curriculum using the breastfeeding DVD for a self-directed overview of infant latch and positioning followed by an IBCLC-guided clinical experience. This multimodal approach would still take significantly less time than previously reported breastfeeding curricula. In addition, it would offer residents complementary educational methods that address different learning styles and mutually reinforce management techniques. Acknowledgments The authors thank the Association of Pediatric Program Directors for funding this project, Erin Steenson for her realistic portrayal as a standardized patient, Janet Montrie, RN, IBCLC, for her dedication in educating residents and students, Pat Cavey for her outstanding administrative assistance, and Rachel Y. Moon, MD, for her insightful review.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Tender et al Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Association of Pediatric Program Directors.
References 1. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Dept of Health and Human Services, Office of the Surgeon General; 2011. 2. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatrics. 2004;113(5):e435-e439. 3. Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary of the Agency for Healthcare Research and Quality’s evidence report on breastfeeding in developed countries. Breastfeed Med. 2009;4(1):S17-S30. 4. Kramer MS, Fombonne E, Igumnov S, et al. Promotion of Breastfeeding Intervention Trial (PROBIT) Study Group. Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: evidence from a large, randomized trial. Pediatrics. 2008;121(3):e435-e440. 5. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048-e1056. 6. Bartick M. Breastfeeding and the U.S. economy. Breastfeed Med. 2011;6(5):313-318. 7. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):827-841. 8. Taveras EM, Li R, Grummer-Strawn L, et al. Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics. 2004;113(4):e283-e290. 9. Taveras EM, Capra AM, Braveman P, et al. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics. 2003;112(1, pt 1):108-115. 10. Freed GL, Clark SJ, Lohr JA, Sorenson JR. Pediatrician involvement in breast-feeding promotion: a national study of residents and practitioners. Pediatrics. 1995;96(3, pt 1):490-494. 11. Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians’ practice and attitudes regarding breastfeeding promotion. Pediatrics. 1999;103(3):E35. 12. Feldman-Winter LB, Schanler RJ, O’Connor KG, Lawrence RA. Pediatricians and the promotion and support of breastfeeding. Arch Pediatr Adolesc Med. 2008;162(12):1142-1149. 13. Osband YB, Altman RL, Patrick PA, Edwards KS. Breastfeeding education and support services offered to pediatric residents in the US. Acad Pediatr. 2011;11(1):75-79.
14. Haughwout JC, Eglash AR, Plane MB, Mundt MP, Fleming MF. Improving residents’ breastfeeding assessment skills: a problem-based workshop. Fam Pract. 2000;17(6):541-546. 15. Hillenbrand KM, Larsen PG. Effect of an educational intervention about breastfeeding on the knowledge, confidence, and behaviors of pediatric resident physicians. Pediatrics. 2002;110(5):e59. 16. Bunik M, Gao D, Moore L. An investigation of a field trip model as a method for teaching breastfeeding to pediatric residents. J Hum Lact. 2006;22(2):195-202. 17. Feldman-Winter L, Barone L, Milcarek B, et al. Residency curriculum improves breastfeeding care. Pediatrics. 2010;126(2):289-297. 18. Holmes AV, McLeod AY, Thesing C, Kramer S, Howard CR. Physician breastfeeding education leads to practice changes and improved clinical outcomes. Breastfeed Med. 2012;7(6):403408. 19. Lumbiganon P, Martis R, Laopaiboon M, Festin MR, Ho JJ, Hakimi M. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database Syst Rev. 2012;9:CD006425. 20. Lasarte Velillas JJ, Hernández-Aguilar MT, Pallás Alonso CR, et al. A breastfeeding e-learning project based on a web forum. Breastfeed Med. 2007;2(4):219-228. 21. Tender JAF, Hughes V, Greenberg L. Breastfeeding for Medical Providers: Translating Knowledge into Practice [DVD]. Washington, DC: GW University; 2010. 22. American Academy of Pediatrics. Welcome to the breastfeeding residency curriculum. http://www2.aap.org/breastfeeding/ curriculum/. Accessed October 21, 2012. 23. American Academy of Pediatrics. Curriculum tools. http:// www2.aap.org/breastfeeding/curriculum/tools.html. Accessed October 21, 2012. 24. Hamburger EK, Cuzzi S, Coddington DA, et al. Observation of resident clinical skills: outcomes of a program of direct observation in the continuity clinic setting. Acad Pediatr. 2011;11(5):394-402. 25. Lane JL, Gottlieb RP. Structured clinical observations: a method to teach clinical skills with limited time and financial resources. Pediatrics. 2000;105(4, pt 2):973-977. 26. SAS Institute Inc. SAS/STAT® 9.3 User’s Guide. Cary, NC: SAS Institute Inc; 2011. 27. Cohen J. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988:25-26. 28. Miller GE. The assessment of clinical skills/competence/performance. Academic Med. 1990;65(9 suppl):S63-S67. 29. Lewin LO, O’Connor ME. “BreastfeedingBasics”: web based education that meets current knowledge competencies. J Hum Lact. 2012;28(3):407-413.
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