Impact of COVID-19 Pandemic in Breastfeeding Consultations on LactApp, an m-Health Solution for Breastfeeding Support

Table 1 shows the main results of the Interrupted time series model for total queries and active users. As shown, time significantly increased both queries consulted in LactApp (6,919 queries per month, p < 0.001) and active users (785.3 users per month, p < 0.001). COVID-19 outbreak and the beginning of confinement in Europe significantly increased active users by 12,092 users (p < 0.001). After the pandemic outbreak, time significantly increased in queries consulted by 10,899 queries per month (p = 0.003). Thus, after the COVID-19 pandemic, queries positively increased by 3,980 each month.

As previously reported,¹⁵ the most consulted queries in LactApp are related to breastfeeding technique (12.6%), infant sleep and breastfeeding (8.9%), growth spurts (5.5%), introducing solid foods (5%), and breastfeeding stages (4.9%).

Monthly queries per user significantly increased during the COVID-19 pandemic (pre-pandemic = mean 19.25, pandemic = mean 23.11, p = 0.02), as shown in Table 1.

The breastfeeding topics that significantly increased after COVID-19 outbreak are those related to growth spurts (mean increase of 107%, p < 0.001), breastfeeding stages (mean increase of 76.8%, p = 0.01), breastfeeding technique (mean increase of 56%, p = 0.003), breast pain and mastitis (mean increase of 43.3%, p < 0.001), mother’s disease and breastfeeding (mean increase of 38.5%, p = 0.05), problems with infants not gaining weight correctly (mean increase of 31.2%, p = 0.04), hypogalactia and sensation of insufficient milk production (mean increase of 26.4%, p < 0.001), increased milk demand (mean increase of 21%, p < 0.001), and relactation (significant mean increase of relactation personalized plan by 15.3%, p < 0.001) (Table 2).

However, monthly queries per user that did not significantly change between the pre-pandemic and pandemic period were related to tandem breastfeeding (p = 0.29), breastfeeding twins (p = 0.73) or breastfeeding older infants (p = 0.98), breastmilk pumping (p = 0.3), and breastmilk donation (p = 0.8), infant care (p = 0.31) and infant sleep (p = 0.5), menstruation and fertility (p = 0.1), pregnancy (p = 0.78), returning to work (p = 0.7), mother’s health (p = 0.9), feelings (p = 0.67), and weaning (p = 0.62) (Table 1).

Queries about COVID-19 have been highly visited during the pandemic (mean 11,304 queries per month from March 2020 to March 2021) and were in the top 20 most consulted queries in 2020, and the sixth most consulted in the first quarter of 2021. The most answered question about COVID-19 was about the compatibility of the vaccine with breastfeeding.

One of LactApp’s core functionalities is its automated breastfeeding symptom checker. However, it is also possible to consult breastfeeding questions through an in-app live chat function, answered by breastfeeding experts within the LactApp team. Live chat consultations increased by 28.5% during the outbreak of COVID-19. Further, thanks to LactApp experts’ efforts to classify those queries into the different topics covered (which is required for training AI), they were able to assess the impact of such an increase on each of the different topics.

Therefore, we can see how LactApp’s live chat received significantly more consultations about mastitis and breast pain (mean increase of 105.7%, p = 0.01) and how to latch on to the breast correctly (mean increase of 88.4, p = 0.04) (Table 3). Other topics such as breastfeeding basics, infant not gaining weight correctly, introducing solid foods, and growth spurts increased by more than 50% during the pandemic; however, that increase was not statistically conclusive due to high dispersion of the weekly consultations in the live chat.

Discussion

The COVID-19 pandemic has unquestionably changed our daily life in every aspect. The general restriction measures the affected women’s well-being during pregnancy, birth, and the postnatal care period.⁵ In-person support from a lactation specialist became restricted and, consequently, mothers experienced increased levels of stress and isolation.¹²

Recent studies have reported that exclusive breastfeeding rates might have decreased during the COVID-19 pandemic and lockdown in the United Kingdom, Italy, the United States, and Canada.^{7–9,13,14,18,19} The reasons for breastfeeding cessation were shorter hospital stays at birth, deficient professional support throughout the first days of life, worries about the safety of breastfeeding, and symptomatology of COVID-19.

Due to the lack of in-person professional support from pediatricians, midwives, lactation experts, and lactation support groups, mothers sought breastfeeding support in technological tools such as telehealth services (either phone-only or videoconferencing), chats and texting support via WhatsApp or HouseParty App, online support groups, web pages,^8,20,21 and breastfeeding apps²² such as LactApp. The Interrupted time series model showed that LactApp active users increased largely during the COVID-19 outbreak and confinement and queries consulted in LactApp also significantly increased monthly after the pandemic outbreak.

Our main results are in concordance with an online survey of the Australian Breastfeeding Association reporting that mothers’ main concerns during the pandemic were related to insufficient milk or weight gain, painful breasts, relactation, and reducing supplemental infant formula milk. And these concerns were aggravated by the lack of health care access due to fear and unavailability.¹²

Our results are also in agreement with those of Brown and Shenker,¹⁴ which reported that the most common reasons for women to stop breastfeeding during the pandemic were insufficient professional support and technical issues such as difficulties with latch, perception of insufficient milk, breast pain, and exhaustion.¹⁴ All these topics were highly consulted in LactApp and significantly more visited during the pandemic compared with the pre-pandemic period.

Thus, LactApp could have been a potent tool to support breastfeeding when women had no support from health services. Moreover, since LactApp has been able to detect an increased need for support on this critical topic without asking breastfeeding mothers directly, LactApp might also be a powerful tool to identify the trends, difficulties, and critical issues of breastfeeding in an automatized manner.

Our results reveal a clear change in breastfeeding consultations due to the COVID-19 pandemic. Our lactation experts who are daily in contact with breastfeeding mothers through the live chat function also detected a significant change in breastfeeding consultations. These data are not shown in the present work; however, this knowledge has helped to interpret the main results of this article.

Monthly queries per user about breastfeeding technique significantly increase by 56% during the pandemic period compared with during the pre-pandemic period. The most consulted queries about this topic during the COVID-19 pandemic were about latching, breastfeeding on demand, breastfeeding positions, and milk supply. Accordingly, another issue that significantly increased during the pandemic was queries related to infants not gaining weight correctly, and monthly queries per user about those topics increased by 31%.

Based on the information we obtained from breastfeeding women on the live chat, we believe that this fact could be attributed to the lack of breastfeeding support during the pandemic since mothers did not have professional guidance on a proper latch, optimal milk transfer, and breastfeeding on demand, which could have led to a deficient breastfeeding technique and poor milk transfer to the child. As a result, monthly queries about user perception of insufficient milk supply also significantly increased by 26%.

These results are also in concordance with Brown and Shenker’s study, which reported that women either expressed milk or gave formula as a supplement during the pandemic due to the lack of support, which led to pain or poor latch.¹⁴ We also believe that queries related to hypogalactia increased due to the perception of women not having enough milk supply, since they did not receive adequate in-person support to correct latching issues, positioning, or even evaluate potential oral complications of the infant such as ankyloglossia. However, further studies are needed to confirm this hypothesis.

Another feature that increased highly in consultations is the personalized relactation plan in the app. Relactation is the process by which a mother reestablishes breastfeeding after reducing milk production or having interrupted it for some time. Based on what breastfeeding women reported to us, mothers needed to search for information about relactation since breastfeeding was not successfully established in the crucial first days because most families were sent home shortly after birth without any further information or guidance.

Another reason to search for information about relactation could be that infected mothers with COVID-19 were separated from their children either at birth or in older infants. Also, front-line midwives, nurses, and physicians might have also been discouraging mothers to breastfeed during the first COVID-19 outbreak, leading to an interruption of breastfeeding.

Monthly consultations per user about mastitis and breast pain also significantly increased by 43% in the self-administered questionnaire and by 105.7% in the live chat. As reported by breastfeeding women in the live chat, this could be due to the fact that most of the face-to-face appointments were canceled, many health care staff were unavailable because of the pandemic, and women were afraid to go to a medical center. This situation led women to seek information about mastitis symptomatology, management, and treatment in LactApp.

Accordingly, queries about nipple damage care and breast lumps also significantly increased during the pandemic by 36% and 37%, respectively. These types of consultations are often dealt with in health care centers since they cause acute pain and other possible symptoms such as fever. However, as medical centers were unavailable, these consultations might have been transferred to LactApp.

The main limitations of the present study are that LactApp is available worldwide; however, most of the users are from Spain (80%), followed by Mexico (4.3%), Argentina (2.3%), Chile (2.1%), the United States (2.1%), Colombia (1.4%), Germany (0.7%), Peru (0.7%), the United Kingdom (0.7%), and Uruguay (0.5%). Thus, the results of the present study might be biased by the Spanish COVID-19 restriction measures and lockdown as well as Spanish culture, social habits, and the health care system.

Moreover, user profile data and their children’s data entry are optional and are not verified; thus, the models may include some uncontrolled bias. Another limitation that we detected is that final answers are given according to the user’s and their registered child’s data, for example, mother’s status (pregnant or not pregnant). If the user does not update her status in her user profile, personalized answers given by the decision tree algorithm might not have been corrected. Since we only registered the final answer but not the whole path, some of the results might also have bias.

In conclusion, COVID-19 restrictions negatively impacted breastfeeding support and mothers’ breastfeeding experiences. Critical issues in breastfeeding establishment such as inadequate latching, perception of insufficient milk supply, breast pain, and poor infant weight gain worsened during the COVID-19 pandemic due to lack of in-person professional guidance.

These issues were highly consulted and significantly increased in the app during the pandemic. We believe that LactApp was a useful tool for breastfeeding support when women could not find appropriate support elsewhere. LactApp might be a powerful tool to identify critical issues of breastfeeding and trends in an automatized manner. However, this must be studied in detail in future approaches.

Authors’ Contributions

P.Q.-R., D.M.-T., L.A.-C., and A.P.-A. were responsible for concept and design, methodology, and interpretation of data. P.Q.-R. and I.G.-S. extracted the data and performed the analysis. P.Q.-R. drafted the article and created tables and figures. All authors revised and approved the final version of the article. All authors meet the criteria detailed in Author Instructions.

Disclosure Statement

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A.P.-A. created and designed the software. L.A.-C. serves as a consultant at LactApp. Nevertheless, none of these potential conflicts affected the study design, the collection, analysis and interpretation of data, or the writing of the article produced by P.Q.-R., D.M.-T., and I.G.-S.

Funding Information

This research received no external funding.