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Evidence-Based Paper

Mario Agundez, Samantha Gold, Caetlin Cornwell, Lauren Young, Jacqueline Robles

College of Nursing, University of Arizona

NURS 379 Scholarly Inquiry for Evidence-Based Practice

Dr. Lorre Laws

December, 4, 2022
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Breastfeeding versus Formula Feeding and its Effect on Low Birth Weight Babies

Infant nutrition is a complex topic that plays a vital role in the growth of infants and

warrants exploration to inform with an evidence-based nursing practice. Integrative nursing

principles (INP) provide the perspective of using the whole person, such as social, cultural, and

spiritual factors (Koithan, 2018). There are six principles of integrative nursing: (1) whole

systems are inseparable from the environment, (2) humans have the innate capacity for health

and well-being, (3) nature has healing and restorative properties, (4) person-centered and

relationship-based, (5) informed by evidence, (6) health and the well-being of caregivers

(Koithan, 2018). Infant nutrition is an important factor for healthy birth weights and connects to

INPs one and four given that some mothers are not living in environments where the importance

of breastfeeding is discussed, and according to Koithan, person-centered care is cultivated by

seeking solutions that honor their beliefs and values, which plays a role in how infants are fed

(2018).

The topic of feeding methods and birthweight is crucial due to their long-lasting effects

on the child. The World Health Organization suggests only breastfeeding an infant for the first

six months to achieve optimal growth, development, and health (2022). Unfortunately, this topic

lacks education, and many infants are not breastfed for the recommended time frame (World

Health Organization, 2022). Due to the gap in research and knowledge among new mothers, this

group wanted to research further the specific effects of feeding methods on an infant’s birth

weight. Given our clinical observations of breastfeeding impact, how nutrition affects weight,

and the evidence surrounding this topic, we will examine whether babies with low birth weight

who have been formula fed are at an increased risk of weight disparities compared to breastfed

babies.
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Background and Purpose

The main ways that infants are nourished include breastfeeding and formula feeding. It is

challenging to decide which way to feed an infant, provided the many options available, but they

all can lead to the normal development of infant growth (Karmaus et al., 2017). When formula

feeding an infant, it is known that they gain more weight due to higher protein balances—in

contrast, breastfeeding a newborn, protein content decreases while fat and carbohydrate contents

remain stable (Caroli et al., 2021). Since the proteins in a mother's breast milk decrease over

time, the infant does not gain the extra weight. To this day, mothers are recommended as the

primary source for breastfeeding their infants for optimal growth and development. Infants who

are breastfed are known to experience more benefits than a child who is formula fed.

Observational studies showed that children who were breastfed were at lower risks of

hypertension and cardiovascular disease and showed that the children had higher IQs than infants

who were not breastfed (Westerfield et al., 2018).

Low birth weight in infants is a common concern worldwide. Any infant can be at risk

due to the external elements that contribute to low birth weight and differs because of

demographic factors, such as disparity that is dependent on their race. Regarding mothers that

breastfeed, statistics show that African American women are less likely to breastfeed (Devane-

Johnson et al., 2022). Many minor differences in lactation, infant latching, demographic

information, and more can have an effect when it comes to low birth weight. To inform

evidence-based nursing practice, exploring how to support infant nutrition and healthy birth

weight is imperative. The paper's purpose is to critically appraise four articles to examine the

utility of breastfeeding as it relates to who has a higher risk of developing weight inequalities in

formula-fed or breastfed infants.

PICO Question

A PICO question is a formatted technique that guides the user toward forming a clinical

question that is ultimately unbiased and seamlessly effortless to research (Gallagher, 2019).

Through this technique, the researcher eases the research process by using the key terms in the

PICO question to conduct their search effectively. The “P” refers to the population. The “I”

represents the variable of interest. “C” is for the form of comparison used. Lastly, the “O” stands

for the outcome. The etiological PICO question guiding this paper is: are babies with low birth

weight formula fed at increased risk of weight disparities compared to breastfed babies?

Nurses conduct a literary review to obtain a comprehensive view of previous research

topics that have been previously critically evaluated, classified, and compared with already

existing publications on said topics (Sonoma State, 2022). We searched PubMed and Google

Scholar databases, applied publications made within the last five years, publications in English,

and publications that offered full free text filters, and used these key terms: low birth weight,

formula-fed, weight disparities, and breastfed babies.

Critical Appraisal of the Articles

According to Giddens (2021), the goal of a critical appraisal of any type of research

evidence is to systematically and thoughtfully judge whether the research evidence is credible,

clinically significant, and applicable. The appraised articles below provide insight into factors

related to whether or not babies with low birth weight who have been formula fed are at an

increased risk of weight disparities compared to breastfed babies within their first year of life.

Article One

The investigators (Tahir et al., 2021) conducted a secondary analysis study to investigate

the relationship between the mode of feeding and infant anthropometric and body composition
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variables at six months. A purposive sample of 259 mother-infant dyads provided data via

various anthropometric and body composition measurements. Data were analyzed using various

general linear and median regression models, unpaired t-tests, and chi-square tests. The results of

this study included length and weight being unrelated to the mode of infant feeding. However,

the fat-free body mass was significantly lower, and the body fat percentage was significantly

more significant in breastfed infants at six months. The strengths of this study were that the

sample was a large, well-defined group of mother and infant pairs which allowed for specificity.

The limitations of this study were that the sample was purposive and there was an opportunity

for bias. This study is relevant to the PICO question because the overall results indicate no

difference in weight and length from an infant’s feeding mode from one month to six months.

However, breastfeeding infants tend to have a more significant body fat percentage.

Article Two

The investigators (Natalia et al., 2021) conducted a randomized controlled trial study to

examine the effect of the “SATUPAS” program on breast milk production, frequency of breast

milk expression, and partial breastfeeding. The low-birth-weight (LBW) infants were divided

into an intervention group, and the control group provided data via observation of the two groups

over four days, with measurement data recorded daily in an observation checklist. Data was

analyzed using homogeneity and subsequent bivariate analysis. This study's results suggest that

nurses in perinatology introduce SATUPAS to mothers of LBW infants at high risk of

breastfeeding cessation after hospitalization. The strengths of this study include the ability to

reduce bias and provide randomization of patients and have the only difference be the exposure

to treatment. The limitations of this study were the inability to control certain confounding
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variables. This study is relevant to the PICO question because it highlights the importance of

breastfeeding for LBW.

Article Three

The investigators (DiTomasso & Cloud, 2019) conducted a systematic review to examine

neonatal weight changes in the early weeks of life among full-term, breastfed newborns. The

investigators conducted a literature search to locate quantitative studies that met the inclusion

criteria. These studies provided data that was extracted by the Evidence-Based Practice

Synthesis and Recommendations Tool and analyzed by consensus discussions. The results

included that two days after birth, weight loss was 6% to 7% of birth weight, and day 3 weight

loss was 7% to 8%. At 14 days, most newborns regain their birth weight. The strength of this

study was that it has a specific research question which allows for certain information to be used

and looked for. The limitation of this study was that it included only studies published in English

for the past 5 years. This study is relevant to the PICO question because it highlights weight

disparities among breastfed or non-breastfed infants.

Article Four

The investigators (Parker et al., 2019) conducted a cohort study to examine if the

provision of human milk among very-low-birth-weight infants has changed in the U.S. during

the past decade and how human milk varies by U.S. census region and maternal race/ethnicity. A

secondary analysis method was used to collect 347,248 LBW hospitalized neonates. Data were

analyzed using a risk-adjusted Poisson regression mode, crude and risk-adjusted prevalence, and

the coefficient of variability for the crude prevalences between states for race/ethnicity. This

study's results include that breastmilk use in the neonatal intensive unit in babies with a very low

birth weight has increased over the past decades in 4 U.S. regions and 5 races/ethnicities. The
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strengths of this study were that it contained a considerable sample size that examined a national

population. The limitations of this study were that measurement of human milk right before

discharge does not talk about the amount of milk used before and after discharge due to it only

looking at a short amount of time. This study is relevant to the PICO question because it looks at

why some mothers prefer to breastfeed after birth due to birth weight based on different

races/ethnicities.

Summary

A key theme that emerged from the critical analysis is that the larger fat content in breast

milk supports increased body fat percentage in low birth weight infants. Tahir et al. (2021)

presents findings that infants have a greater body fat percentage after drinking breast milk rather

than formula fed, and the weight and length overall have no relevance. DiTomasso & Cloud

(2019) and Natalia et al. (2021) support the same theme, but in regards to most breastfed infants

losing about 10 percent more of their birth weight compared to formula-fed infants and regaining

the weight in about 10 days, likely due to the idea that infants benefit more from breast milk due

to the significant source of nutrition in fat content. Another theme that connects to the theme

prior, based on what Parker et al. (2019) mentioned with mothers making a preference for breast

milk after birth, especially for low birth weight infants, based on different races and ethnicities.

Asian mothers have the highest prevalence of low-term birth weight, and the use of breastmilk in

the neonatal intensive unit in all US regions has increased.

The critical analysis, overall, directly supports the PICO question as a whole to examine

whether babies with low birth weight that are formula fed are at an increased risk of weight

disparities compared to breastfed babies. Tahir et al. (2021) and Natalia et al. (2021) directly

support the question, by presenting how breast milk has a greater effect on increased body fat
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percentage than formula-fed infants and correlating an improvement of low birth weight in

breastfed infants after education was provided to the mothers. Parker et al. (2019) is directly

relevant, and partially supports the PICO question because there has been an increase in the

choice made by mothers to breastfeed neonates in the neonatal intensive care unit amongst five

races and ethnicities across the 4 regions of the United States, especially with low birth weight

infants. This is also likely from education of the benefits of breastfeeding to the mothers.

DiTomasso & Cloud (2019) is indirect, but still supports the PICO question by providing

evidence to show that infants may lose more than 10 percent of their mean birth weight when

breastfed. However, they regain the weight in about 10 days. This shows that the nutrients from

breast milk nourishes infants by regaining the lost weight. The PICO question is directly

supported by highlighting the choices made by the mothers after education and in the NICU, and

the improvement of weight in low birth weight infants due to the nutrients found in the breast

milk.

Implications for Nursing Education, Research, and Practice

The findings of the critical appraisal provide evidence of why breastmilk is the preferred

type of feeding for low birth weight infants. Breast milk leads to better health outcomes like

lower incidences of necrotizing enterocolitis, late-onset sepsis, chronic lung disease, retinopathy

of prematurity, and neurodevelopmental impairment (Parker et al., 2021). Nursing education and

clinical practice need to reflect the large amount of evidence surrounding the benefits of

breastfeeding low birth weight infants.

Nursing Education

Nurses may feel uncomfortable initiating breastfeeding education because nursing

students do not always acquire enough knowledge to effectively promote breastfeeding for low
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birth-weight infants (Yang et al., 2018). In order to address this knowledge deficit, a nursing

curriculum should be developed to teach nursing students how to initiate breastfeeding if the

infant has a low birth weight. Nurse educators should include into the curriculum curriculum

about alternatives to breastfeeding like donor milk and fortified formulas because these

alternatives are easy to implement for mothers with low birth weight babies who are either

unable to breastfeed or choose not to breastfeed.

Nursing Research

Further research is needed to explore the effectiveness of donor breast milk versus breast

milk from the mom because donor breast milk is used without having evidence of the short-term

and long-term effects on the growth of low birth weight infants (Hoban et al., 2019).

Additionally, research needs to explore the impact of fortification of human milk with infant

formula for low birth weight babies because its benefits and safety do not have enough high-

quality evidence (Kumar et al., 2021).

Nursing Practice

Incorporating predominantly breastfeeding low birth weight babies can reduce the risks

of necrotizing enterocolitis and sepsis and improve neurodevelopment (Soldateli et al., 2020).

Nurses should learn how to initiate breastfeeding. If the mother decides it is something they do

not want to do, encourage milk donors who have been screened or learn about different formulas

beneficial for low birth weight babies. If hesitating about breastfeeding, find ways to reassure the

mother, such as increasing breast milk and fortifying breast milk with formula.

Conclusion

After further research, it can be determined that the modality of nutrition, such as

breastfeeding or formula, impacts weight disparities based on research on this topic. Therefore,
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using breastmilk with infants reaped significantly greater developmental benefits than formula

infants. INP one describes how environmental factors impact care. This is relevant because

factors such as education level and exposure to the importance of breastfeeding can determine

whether or not a mother chooses to breastfeed. Through our critical appraisals, we concluded that

babies breastfed experienced significantly lower risks of low birth weight with an increased

reduction of future adverse effects, which answers the PICO question posed by our team. A

critical factor in an infant's development is nutrition. Mothers educated about the importance of

breastfeeding are probably more likely to reach the recommendation of six months, which can

impact birth weight. Overall, patients who have just given birth should have an in-depth

education on how breastfeeding can affect the birth weight and development of their newborn.
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References

Caroli, M., Vania, A., Tomaselli, M., Scotese, I., Tezza, G., Verga, M., Di Mauro, G., Antignani,

A., Miniello, A., & Bergamini, M. (2021). Breastfed and formula-fed infants: Need of a

different complementary feeding model? Nutrients, 13(11), 3756.

https://doi.org/10.3390/nu13113756

Devane-Johnson, S., Williams, R., & Woods Giscombe, C. (2022). Historical research:

The history of African American breastfeeding in the United States. Journal of Human

Lactation, 38(4), 723–731. https://doi.org/10.1177/08903344221118542

DiTomasso, D., & Cloud, M. (2019). Systematic review of expected weight changes after

birth for full-term, breastfed newborns. Journal of Obstetric, Gynecologic & Neonatal

Nursing, 48(6), 593–603. https://doi.org/10.1016/j.jogn.2019.09.004

Gallagher Ford, L., & Melnyk, B. M. (2019). The underappreciated and misunderstood

PICOT question: A critical step in the EBP Process. Worldviews on Evidence-Based

Nursing, 16(6), 422–423. https://doi.org/10.1016/j.nepr.2021.103194

Giddens, J. (2021). Concepts for nursing practice (3rd ed.). Elsevier, Inc.

https://bookshelf.vitalsource.com/reader/books/9781284129120/epubcfi/

6/40[%3Bvnd.vst.idref%3DChapter13]!/4/2[ch13]/6[d6e5625]/2[ch13sc1]/8

Hoban, R., Schoeny, M. E., Esquerra-Zwiers, A., Kaenkumchorn, T. K., Casini, G.,

Tobin, G., Siegel, A. H., Patra, K., Hamilton, M., Wicks, J., Meier, P., & Patel, A. L.

(2019). Impact of donor milk on short-and long-term growth of very low birth weight

infants. Nutrients, 11(2), Article 241. https://doi.org/10.3390/nu11020241

Karmaus, W., Soto-Ramírez, N., & Zhang, H. (2017). Infant feeding pattern in the first six

months of age in usa: A follow-up study. International Breastfeeding Journal, 12(1).

https://doi.org/10.1186/s13006-017-0139-4

Koithan, M (2018). Concepts and principles of integrative nursing. In M. J. Kreitzer, M.

Koithan & A. Weil (Eds.), Integrative nursing (2nd ed., pp. 3-19). Oxford University

Press. https://doi.org/10.1093/med/9780190851040.001.0001

Kumar, M., Upadhyay, J., & Basu, S. (2021). Fortification of human milk with infant

formula for very low birth weight preterm infants: A systematic review. Indian

Pediatrics, 58(3), 253–258. https://doi.org/10.1007/s13312-021-2166-x

Parker, M. G., Greenberg, L. T., Edwards, E. M., Ehret, D., Belfort, M. B., & Horbar, J.

D. (2019). National trends in the provision of human milk at hospital discharge among

very low-birth-weight infants. JAMA Pediatrics, 173(10), 961–968.

https://doi.org/10.1001/jamapediatrics.2019.2645

Parker, M. G., Stellwagen, L. M., Noble, L., Kim, J. H., Poindexter, B. B., Puopolo, K.

M. (2021). Promoting human milk and breastfeeding for the very low birth weight infant.

Pediatrics, 148(5), Article e2021054272. https://doi.org/10.1542/peds.2021-054272

Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and

healthcare: A guide to best practice (4th ed.). Wolters Kluwer Lippincott Williams &

Wilkins.

Natalia, R., Rustina, Y., & Efendi, D. (2022). Combining breastfeeding education and

support to improve breastmilk production, frequency of breastmilk expression, and partial

breastfeeding in low-birth-weight infants. Journal of Neonatal Nursing, 28(5). 356-360.

https://doi.org/10.1016/j.jnn.2021.08.015
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Soldateli, B., Parker, M., Melvin, P., Gupta, M., & Belfort, M. (2020). Human milk

feeding and physical growth in very low-birth-weight infants: A multicenter study.

Journal of Perinatology, 40(8), 1246–1252. https://doi.org/10.1038/s41372-020-0705-2

Sonoma State University Library. (2022). Literature reviews. Sonoma State University.

https://libguides.sonoma.edu/c.php?g=202651&p=1355172

Tahir, M. J., Ejima, K., Li, P., Demerath, E. W., Allison, D. B., & Fields, D. A. (2021).

Associations of breastfeeding or formula feeding with infant anthropometry and body

composition at 6 months. Maternal and Child Nutrition, 17(2), Article e13105.

https://doi.org/10.1111/mcn.13105

Westerfield, K., Koenig, K., & Oh, R. (2018). Breastfeeding: Common questions and

answers. American Family Physician, 98(6), 368–373.

https://www.aafp.org/pubs/afp/issues/2018/0915/p368.html

World Health Organization. (2022). Breastfeeding.

https://www.who.int/health-topics/breastfeeding#tab=tab_1

Yang, S.-F., Salamonson, Y., Burns, E., & Schmied, V. (2018). Breastfeeding knowledge

and attitudes of health professional students: A systematic review. International

Breastfeeding Journal, 13, Article 8. https://doi.org/10.1186/s13006-018-0153-1

Table of Evidence

Table 1

Summary of Evidence

Author(s) & Date Study Purpose Design, Sample, Results relevant to Level of Evidence
Setting PICO Question (Melnyk & Fineout-
Overholt, 2019)

(Tahir et al., 2021) To investigate the Design: secondary The mode of feeding Level IV
associations of the mode analysis was unrelated to weight
of feeding with infant and length at 6 months.
anthropometric and Sample: 259 mother-
body composition infant dyads Fat-free mass was lower
variables at 6 months of at 6 months and body fat
age. Setting: University of percent was greater at 6
Oklahoma Health and months in breastfed
Sciences Center infants than in formula-
fed infants.

(Natalia et al., 2022) Examines the effect of Design: randomized Suggested that nurses in Level II
the “SATUPAS” controlled study perinatology introduce
program on breastmilk SATUPAS to mothers
production, frequency Sample: 82 mothers and of LBW infants who are
of breastmilk their low-birth-weight at high risk of
expression, and partial (LBW) infant breastfeeding cessation
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breastfeeding after hospitalization.

(DiTomasso et. al., To summarize the Design: Systemic By 2 days after birth, Level V
2019) findings of recent Review (Preferred mean weight loss among
studies on neonatal Reporting Items for neonates was 6% to 7%
weight changes that Systematic Reviews and of birth weight, and by
occur in the early weeks Meta-Analyses) Day 3, mean weight loss
of life among full-term, was usually 7% to 8%.
breastfed newborns Sample: 11 quantitative
studies Rates of exclusive
breastfeeding decreased
Setting: Top country when newborns lost
was the United States, in greater amounts of
California and weight.
Northeastern parts.

(Parker et al., 2019) To describe US trends in Design: Cohort study Prevalence of the use of Level IV
the provision of human human milk after
milk at hospital Sample: 346,248 discharge among very
discharge for VLBW infants, born at 23 to 29 low birth weight infants
infants during the past weeks’ gestation or with has increased in the past
decade according to a birth weight of 401 to decade.
census region and 1500 g.
maternal race/ethnicity, Due to national public
quantify associations of Setting: 802 US health campaigns geared
census region and hospitals in the Vermont toward healthy infants
maternal race/ethnicity. Oxford Network and the benefits of
breastfeeding increased
awareness of the impact
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that breast milk could