Response to Editor

Response to Editor:

On my read I noted many sentences that did not quite literally mean what you were intending them to mean. For instance in the 2 nd paragraph of the Introduction the placement of "31% to 47%" at the end of the sentence suggests that the LC presence increased from 31 to 47%, not the proportion of infants receiving HM which was intended.

The sentence in the 2nd paragraph of the Introduction has been changed to read:

“Gonzalez et al. (2003) reported a significant increase in the proportion of babies receiving human milk from 31% to 47% (p=0.002) while they were in the NICU following the implementation of a comprehensive International Board Certified Lactation Consultant (IBCLC) service, including a telephone helpline and LC presence.”

I suggest you enlist the aid of an experienced scientific writer to help your revision.

The aid of an experienced editor was enlisted to help with this revision.

Second, the Reference listings do not adhere to the requirements of the publisher (too few authors before et al). See our Instructions to Authors on the website.

The Reference listings were changed to adhere to the requirements of the publisher.

Response to Reviewer # 1

On page 8, the authors note some demographic differences re: birthweight, gestational age, length of stay, etc. Was the population during time frame T2 a "sicker" population? Although the difference in IVH rates did not reach statistical significance, the T2 rate was considerably higher. Any thoughts concerning this?

Although T2 and T3 were “sicker” populations as compared to T1, this was controlled for in our multivariate analysis, see Methods, Statistical Analysis, 1st paragraph; and Results, 3rd paragraph. As the reviewer noted T2 and T3 had significantly lower gestational age, lower birth weight, longer length of stay, and greater number of multiples. In addition, there were trends that were not statistically significant in higher rates of IVH and number of days on oxygen in T2 and T3. We have added additional discussion of the differences in populations by time period to the Results, 1st paragraph and the Discussion, 1st paragraph, 2nd sentence.

Results, 1st paragraph

“Compared with T2 and T3, infants from T1 were healthier; they had significantly higher birth weight (T1=2639 g + 902 g vs. T2=2281 g + 1060 g and T3=2284 g + 943 g, p = 0.003); and greater gestational age (36 + 4 weeks vs. 34 + 5 weeks and 34 + 4 weeks, p = 0.004). Similarly, significant differences by time were found for length of stay, which was greatest for T2, and the highest percentage of gravida > 1 occurred during T3. Furthermore, for birth order, T1 had the highest percentage of singletons, while T3 had the highest percentage of twins and triplets.”

Discussion, 1st paragraph, 2nd sentence

“The T2 and T3 populations were sicker as compared to T1; they had significantly lower gestational age, lower birth weight, longer length of stay, and greater number of multiples. The multivariate analysis, controlling for differences in study population by time periods, demonstrated the impact of the LC was greatest during Time 3 (T3).”

I would be curious as to the authors' thinking as to why the rates of breast feeding were high to start with in the inborn population, prior to lacatation consultation availability.

Initial higher rates of breastfeeding within the inborn population could be due to additional support in the peripartum period at the RegionalPerinatalCenter. Further prospective studies will examine this. We feel that the rates of inborns receiving any human milk have been maximized.

The following sentence was added to Discussion, 1st paragraph, 8th sentence.

“We feel that the rates of IB infants receiving any human milk in our study population had already been maximized, and thus the addition of an IBCLC had little impact on the IB subgroup.”

Although not the focus of the paper, was the inborn population demographics different for outborns vs. inborns re: socioeconomic status, amount of education achieved, etc. Was there something inherent in the inborn population such that lactation consultation did not increase breast feeding rates in this group of mothers?

The reviewer is correct; this was not the focus of our paper. However, we took this into account in the multivariate analysis by controlling for gravida, birth order, race, vaginal delivery, and type of insurance; none of which altered the results. We feel that the rates of inborn infants receiving any human milk were maximized. This study was a retrospective medical record chart review; maternal educational levels were not recorded in the medical record. (Discussion, 3rd paragraph, 3rd sentence)

An additional sentence was added in the Results, 3rd paragraph, 5th sentence.

“Other models controlling for gravida, birth order, race, vaginal delivery, and type of insurance, significant factors from the bivarate analysis, did not alter the results.”

Response to Reviewer # 2

As you did not look at the percentage of enteral intake that was human mi k, only whether an infant received ANY human milk during hospital discharge, your paper needs to be edited to reflect this. The abstract needs to read (Objective, Results, and Conclusions) "...neonates receiving any human milk.....".

We apologize for the confusion; the Abstract (Objective, Results and Conclusion) has been changed to read “neonates receiving any human milk…..”. Additionally the entire paper was edited to reflect “infants receiving any human milk during hospitalization and at hospital discharge”.

I would strike the 2nd sentence in your conclusion - too broad a statement for what you showed.

2nd sentence in Abstract conclusion was deleted.

First paragraph under results: it appears the presence of an LC significantly lengthened the hospital stay! - you might want to comment (ie also EGA 34 vs. 36 weeks).

The T2 and T3 populations were sicker as compared to T1; they had significantly lower gestational age, lower birth weight, longer length of stay, and greater number of multiples.

The following was changed in the Results, 1st paragraph.

Results paragraph 2: You cannot say "Human milk consumption" only : The percentage of infants receiving any human milk......

Results paragraph 2 was changed to: “the percentage of infants receiving any human milk….”

Same error in results paragraph 3: human milk intake may not of increased (ie. more babies but receiving less milk each), but you can say: number or percentage of human infants receiving any human milk....

Results paragraph 3 was changed to: “the multivariate analysis showed percentage of infants receiving any human milk increased over time for infants…….”

Same error in Discussion - cannot say human milk consumption - can only say infants receiving any human milk.

Discussion 1st sentence was changed to: “We found that the addition of a dedicated IBCLC in the RNICU increased the rates over time of infants receiving any human milk in the hospital as well as any human milk at time of discharge”

Also - your results do not support the findings that "face-to-face support" increased infants getting human milk. The only effect was on outborn infants - presumably NOT face-to-face for several days! You really don't know whether it was the LC teaching the nurses, direct LC support for mothers, or something else that made the difference.

The following sentence was deleted. “These results also support the findings that extra face-to-face support by a dedicated lactation consultant has a beneficial effect on provision of human milk”.

Discussion paragraph 2: The 2nd sentence is very confusing and should read: The AAP (2005 ref) and WHO (ref) have recommended exclusive breastfeeding for the first 6 months of life in healthy term infants. The US DHHS has added exclusive breastfeeding to its Healthy People 2010 goals (need to give web address).

Discussion paragraph 2, 2nd sentence was changed to read as recommended by reviewer 2.

“The AAP and WHO have recommended exclusive breastfeeding for the first 6 months of life in healthy term infants (1,17). The US DHHS has added exclusive breastfeeding to its Healthy People 2010 goals (18).”

Web address for Healthy People 2010 goals for exclusive breastfeeding has been added to reference listing. “ “

The AAP reference is cited incorrectly. It is:
AmericanAcademy of Pediatrics, Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics Feb 2005; 115(2):496-506
WHO ref: World Health Organization/UNICEF. Global Strategy for Infant and Young Child Feeding, World Health Organization, Geneva, 2003, pg 7-8 (also in several other earlier references - give web address as well)

Appropriate citation for AAP reference has been added to the reference listing:

“AmericanAcademy of Pediatrics, Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics 2005; 115: 496-506.”

Appropriate citation for WHO reference has been added to the reference listing:

“World Health Organization/UNICEF. Global Strategy for Infant and Young Child Feeding, World Health Organization, Geneva, 2003, pg 7-8”

Web address for WHO has been added to reference listing:

“

Discussion paragraph 3 (limitations): maternal educational levels were not recorded. (strike not obtainable - they are obtainable).

In Discussion paragraph 3, deleted “not obtainable”.

Information on prior maternal breastfeeding experience is crucial to supporting mothers in the NICU - I can't believe it is not a part of your LCs intake evaluation!

Information on prior maternal breastfeeding experience was part of lactation consultant verbal intake evaluation, however, this information was not recorded.

Figure 2: p < 0.05 comparing what T to what T?

This is a test in the slope of the proportions over time. The significance means that the slope is not zero. The following sentence was added to the Methods, Statistical Analysis paragraph.

“This is a test to determine whether there is a non-zero slope in the proportions over time.”

The following sentence was added to Title and legends to figures, for Figures 2 and 3.

“Significance means that the slope of the proportions of infants receiving any HM is not zero.”

Figure 3: same question

See answer above.

Also title of both figures should read "trends over time for any human milk (HM)...... "

Titled in both figures was changed to read:

“Trends in proportions over time for any human milk (HM)…….”