Avoidance of bottles during the establishment of breast feeds in preterm infants

The Effect of Supplemental Feeding Tube Device on Time to Transition to Exclusive Breastfeeding and Discharge: A Randomized Controlled Trial with Preterm Infants

Aim: This study investigated the effect of supplemental feeding tube device (SFTD) method on time to transition to exclusive breastfeeding and discharge time in preterm infants. Methods: This randomized controlled trial was conducted in the neonatal intensive care unit of a public hospital in Turkey (Clinical Trial Number: NCT05815706). The sample consisted of 65 preterm infants randomized into a control (n = 32) and an experimental (n = 33) group. The experimental group participants were SFTD-fed until they switched to exclusive breastfeeding. The control group participants were fed according to the routine procedure. Data were collected using a questionnaire, a Preterm Infant Monitoring Form, and the LATCH Breastfeeding Assessment Tool. The data were analyzed using numbers, percentage distributions, means, standard deviations, Pearson's chi-square test, and independent samples t-test. The study was approved by an Ethics Committee. Permission was obtained from the hospital. Informed consent was obtained from all parents. Results: The experimental group (123.64 ± 63.25 hours) demonstrated an earlier transition to exclusive breastfeeding compared with the control group (187.50 ± 95.30 hours) (p < 0.05). The experimental group (361.45 ± 110.46 hours) had significantly shorter hospital stays than the control group (479.25 ± 163.17 hours). The experimental group (35.33 ± 1.14 weeks) had a significantly younger gestational age at discharge than the control group (35.97 ± 1.03 weeks). Conclusion: The SFTD is an alternate supportive feeding method that helps preterm infants switch to exclusive breastfeeding sooner, have shorter hospital stays, and have a younger gestational age at discharge than their bottle-fed counterparts.

Avoidance of bottles during the establishment of breastfeeds in preterm infants

BACKGROUND

Preterm infants often start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women with preterm infants may not always be in hospital to breastfeed their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breastfeeds is detrimental to breastfeeding success is a topic of ongoing debate.

OBJECTIVES

To identify the effects of avoidance of bottle feeds during establishment of breastfeeding on the likelihood of successful breastfeeding, and to assess the safety of alternatives to bottle feeds.

SEARCH METHODS

A new search strategy was developed for this update. Searches were conducted without date or language limits in September 2021 in: MEDLINE, CENTRAL, and CINAHL.  We also searched the ISRCTN trial registry and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.  SELECTION CRITERIA: We included RCTs and quasi-RCTs comparing avoidance of bottles with use of bottles for preterm infants where their mothers planned to breastfeed.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. We used the GRADE approach to assess the certainty of evidence. Outcomes included full breastfeeding and any breastfeeding on discharge home and at three and six months after discharge, as well as length of hospital stay and episodes of infant infection. We synthesised data using risk ratios (RR), risk differences (RD) and mean differences (MD), with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included seven trials with 1152 preterm infants in this updated review. There are three studies awaiting classification. Five included studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breastfeeds were needed. We included the novel teat study in this review as the teat was designed to closely mimic the sucking action of breastfeeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff or parents (or both); the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Avoiding bottles may increase the extent of full breastfeeding on discharge home (RR 1.47, 95% CI 1.19 to 1.80; 6 studies, 1074 infants; low-certainty evidence), and probably increases any breastfeeding (full and partial combined) on discharge (RR 1.11, 95% CI 1.06 to 1.16; studies, 1138 infants; moderate-certainty evidence). Avoiding bottles probably increases the occurrence of full breastfeeding three months after discharge (RR 1.56, 95% CI 1.37 to 1.78; 4 studies, 986 infants; moderate-certainty evidence), and may also increase full breastfeeding six months after discharge (RR 1.64, 95% CI 1.14 to 2.36; 3 studies, 887 infants; low-certainty evidence). Avoiding bottles may increase the occurrence of any breastfeeding (full and partial combined) three months after discharge (RR 1.31, 95% CI 1.01 to 1.71; 5 studies, 1063 infants; low-certainty evidence), and six months after discharge (RR 1.25, 95% CI 1.10 to 1.41; 3 studies, 886 infants; low-certainty evidence). The effects on breastfeeding outcomes were evident at all time points for the tube alone strategy and for all except any breastfeeding three months after discharge for cup feeding, but were not present for the novel teat. There were no other benefits or harms including for length of hospital stay (MD 2.25 days, 95% CI -3.36 to 7.86; 4 studies, 1004 infants; low-certainty evidence) or episodes of infection per infant (RR 0.70, 95% CI 0.35 to 1.42; 3 studies, 500 infants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Avoiding the use of bottles when preterm infants need supplementary feeds probably increases the extent of any breastfeeding at discharge, and may improve any and full breastfeeding (exclusive) up to six months postdischarge. Most of the evidence demonstrating benefit was for cup feeding. Only one study used a tube feeding strategy. We are uncertain whether a tube alone approach to supplementing breastfeeds improves breastfeeding outcomes; further studies of high certainty are needed to determine this.

[Breastfeeding practices in neonatal wards in Spain. Neo-BFHI international survey]

INTRODUCTION

In 2017, a worldwide survey was conducted on compliance with the practices promoted by Neo-BFHI (Baby-friendly Hospital Initiative expansion to neonatal wards).

OBJECTIVE

Present the results of the Spanish wards that participated in the global survey and compare them with those obtained internationally.

MATERIAL AND METHODS

Cross-sectional study through a survey on compliance with the Neo-BFHI ("Three basic principles", "Ten steps adapted to neonatal wards" and "the compliance with the International Code of Marketing of Breast-milk Substitutes" and subsequent relevant World Health Assembly resolutions). Compliance was calculated as the mean in each indicator and a final mean score for each neonatal unit. For the partial and final scores for each country and at the international level, the median was used. All score ranged between 0 and 100.

RESULTS

The response rate in Spain was 90%. The range of the national mean for neonatal wards were from 37 to 99, with no differences in the final score according to the level of care. The global score for Spain (72) is below the international median (77) and this also occurs in 8 of 14 items. The neonatal wards from BFHI designated hospitals, obtained a significantly higher mean global score, and in 9 of 14 items than the non-accredited ones.

CONCLUSIONS

Both international and national results indicate an improvement in breastfeeding practices in neonatal units. The benefits of the BFHI accreditation of maternity reach neonatal wards. Spain has several key points below the international score.

Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review

(1) Introduction: Current evidence on managing infants under six months with growth failure or other nutrition-related risk is sparse and low quality. This review aims to inform research priorities to fill this evidence gap, focusing on breastfeeding practices. (2) Methods: We searched PubMed, CINAHL Plus, and Cochrane Library for studies on feeding interventions that aim to restore or improve the volume or quality of breastmilk and breastfeeding when breastfeeding practices are sub-optimal or prematurely stopped. We included studies from both low- and middle-income countries and high-income countries. (3) Results: Forty-seven studies met the inclusion criteria. Most were from high-income countries (n = 35, 74.5%) and included infants who were at risk of growth failure at birth (preterm infants/small for gestational age) and newborns with early growth faltering. Interventions included formula fortification or supplementation (n = 31, 66%), enteral feeds (n = 8, 17%), cup feeding (n = 2, 4.2%), and other (n = 6, 12.8%). Outcomes included anthropometric change (n = 40, 85.1%), reported feeding practices (n = 16, 34%), morbidity (n = 11, 23.4%), and mortality (n = 5, 10.6%). Of 31 studies that assessed formula fortification or supplementation, 30 reported anthropometric changes (n = 17 no effect, n = 9 positive, n = 4 mixed), seven morbidity (n = 3 no effect, n = 2 positive, n = 2 negative), five feeding (n = 2 positive, n = 2 no effect, n = 1 negative), and four mortality (n = 3 no effect, n = 1 negative). Of eight studies that assessed enteral feed interventions, seven reported anthropometric changes (n = 4 positive, n = 3 no effect), five feeding practices (n = 2 positive, n = 2 no effect, n = 1 negative), four morbidity (n = 4 no effect), and one reported mortality (n = 1 no effect). Overall, interventions with positive effects on feeding practices were cup feeding compared to bottle-feeding among preterm; nasogastric tube feed compared to bottle-feeding among low birth weight preterm; and early progressive feeding compared to delayed feeding among extremely low birth weight preterm. Bovine/cow milk feeding and high volume feeding interventions had an unfavourable effect, while electric breast pump and Galactagogue had a mixed effect. Regarding anthropometric outcomes, overall, macronutrient fortified formula, cream supplementation, and fortified human milk formula had a positive effect (weight gain) on preterm infants. Interventions comparing human breastmilk/donor milk with formula had mixed effects. Overall, only human milk compared to formula intervention had a positive effect on morbidity among preterm infants, while none of the interventions had any positive effect on mortality. Bovine/cow milk supplementation had unfavourable effects on both morbidity and mortality. (4) Conclusion: Future research should prioritise low- and middle-income countries, include infants presenting with growth failure in the post-neonatal period and record effects on morbidity and mortality outcomes.

A qualitative study on the breastfeeding experience of mothers of preterm infants in the first 12 months after birth

Background

Being a mother of a preterm infant (< 37 gestational weeks) puts the mother in a vulnerable and fragile situation wherein breastfeeding is an important part of becoming a mother and bonding with the infant. Nevertheless, the breastfeeding experience of mothers during the first year after a preterm birth has not been well studied. To develop professional caring and supporting relationships, it is important to address this knowledge gap. The aim of this study was to describe the breastfeeding experience of mothers of preterm infants from birth up until 12 months after birth.

Methods

The data in this qualitative study are derived from a multicentre randomized controlled trial where 270 mothers of preterm infants provided 496 written comments through questionnaires containing open-ended questions. The questionnaires were sent to the mother three times during the first 12 months after birth. A thematic network analysis based on hermeneutical philosophy was used to analyse and interpret the resulting data to describe the mothers’ experiences of breastfeeding.

Results

Three organizing themes, namely, “navigating smoothly,” “navigating with a struggle” and “navigating in ambiguity” were revealed in the mothers’ narratives regarding their breastfeeding experiences during the first 12 months after birth. These organizing themes were further interpreted as one global theme that was deemed “A journey to finding one’s unique way in breastfeeding.”

Conclusion

Mothers of preterm infants are in an exposed and vulnerable situation when initiating breastfeeding during the first year. This situation leads to a unique journey wherein each mother navigates through breastfeeding depending on her individual situation. An awareness of the diversity of breastfeeding experiences may contribute to the provision of professional caring and supportive relationships.

Trial registration

www.clinicaltrial.gov NCT01806480 registered 7 March 2013.

Effect of vacuum-release teat versus standard teat use on feeding milestones and breastfeeding outcomes in very preterm infants: A randomized controlled trial

Background

Breast milk is important to infant health, yet shorter breastfeeding duration is reported for preterm infants. Both breast and bottle feeds are given in the neonatal unit, with full oral feeding often the last milestone to be achieved prior to discharge home. Unlike standard bottle teats, a vacuum release teat requires the application of negative intra-oral pressure to release milk, and so may facilitate breastfeeding in preterm infants. The objective of this study was to determine the effect of vacuum release teat use on timing of achievement of the first full oral feed and on first completion of 24 h full oral feeds. Feeding method at discharge home, 2 weeks, 6 weeks and 12 weeks corrected gestational age were also examined.

Methods

A randomized controlled trial was completed with mothers of preterm infants born 24–33 weeks gestation in the neonatal unit of a tertiary women’s hospital. Infants were randomized to one of two parallel groups using a vacuum release teat or standard teat for oral feeds when the mother was not available to breastfeed. Test weights were completed for all oral feeds. It was not possible to blind participants, care givers and outcome assessors to group assignment due to the nature of the study.

Results

The groups did not differ with regard to timing of achievement of first full oral feed or 24 h of full oral feeds. Significantly more infants in the vacuum release teat group were exclusively fed breast milk at discharge from hospital and breastfed at 3 months corrected gestational age.

Conclusions

Use of a vacuum release teat when the mother is not available to breastfeed may promote preterm breastfeeding skills, resulting in higher rates of exclusivity and longer breastfeeding duration.

Trial registration

The trial is registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000245594.

Turkish Neonatal Society guideline on enteral feeding of the preterm infant

Early initiation of enteral feeding with the own mother's milk and prevention of postnatal growth failure is the target of nutrition in preterm infants. Together with total parenteral nutrition, mouth care and minimal enteral nutrition is started with colostrum in the very early hours of life in small preterm infants. Expressed mother's milk is given via a gastric tube and gradually increased in accordance with the gestational age/birth weight and the risk factors. For infants born heavier than 1 000 grams, the aim is to reach total enteral feeding at the end of first week, and at the end of the second week for infants weighing less than 1000 grams. Supporting mothers in milk expression and kangaroo mother care, promoting non-nutritive feeding, appropriate fortification of mother' milk, and initiating and advancing breastfeeding as soon as the infant is ready are all crucial. Donor mother milk, and as a second choice, preterm formula is advised if the mother's milk is not available. Individualized post-discharge nutrition decisions can be taken in accordance with the actual growth at the time of discharge. The goal is optimal neurodevelopmental achievement together with the prevention of long-term metabolic problems. Late preterm infants, which constitute the majority of preterm infants, also need close nutritional attention and follow-up.

Breastfeeding and risk for ceasing in mothers of preterm infants-Long-term follow-up

Breastfeeding is challenging for mothers of preterm infants. The aim of this paper is to describe risk factors for ceasing breastfeeding and methods of feeding until 12 months postnatal age in mothers who breastfed their preterm infants at discharge from neonatal intensive care units (NICUs). The data come from a randomised controlled trial, which evaluated the effectiveness on exclusive breastfeeding at 8 weeks of proactive telephone support compared with reactive support offered to mothers of preterm infants following discharge from NICU. Six NICUs across Sweden randomised a total of 493 mothers. We used regression and survival analyses to assess the risk factors for ceasing breastfeeding and the long‐term outcomes of the intervention. The results showed that 305 (64%) of the infants were breastfed at 6 months and 49 (21%) at 12 months. Partial breastfeeding at discharge, low maternal educational level, and longer length of stay in the NICU increased the risk for ceasing breastfeeding during the first 12 months. Furthermore, the Kaplan–Meier analysis showed that the proportion of mothers who ceased breastfeeding did not differ between the intervention (n = 231) and controls (n = 262) during the first 12 months (log‐rank test p = .68). No difference was found between groups on method of feeding. More than 85% of the infants were fed directly at the breast. These findings provide important insights for health professionals who are supporting mothers of preterm infants to breastfeed long term. Registered in http://www.clinicaltrials.gov (NCT01806480).

Pacifier use in newborns: related to socioeconomic status but not to early feeding performance

AIM

Mothers are often advised not to use pacifiers until breastfeeding has been well-established. This study determined the infant and social factors that were related to pacifier use during the first few days of life and whether it led to alterations in feeding performance.

METHODS

We enroled 51 full-term infants and their mothers at Barnes-Jewish Hospital in urban St. Louis, USA, in 2015. Before they were discharged the mothers completed a questionnaire, and infant feeding was assessed using a standardised assessment.

RESULTS

There were 24 (47%) infants who used a pacifier during the first few days of life and seven (29%) of these were exclusively breastfed. Pacifier use was less common among mothers who exclusively breastfed (p = 0.04). Pacifier use was more common among mothers whose income was less than 25 000 US dollars (p = 0.02), who were single (p = 0.002) and who did not have a college education (p = 0.03). No associations between pacifier use and feeding performance were observed.

CONCLUSION

While lower socioeconomic status was related to pacifier use, feeding performance in the first few days of life was no different between those infants who did and did not use pacifiers after a full-term birth.

Oral feeding practices and discharge timing for moderately preterm infants

BACKGROUND

Oral feeding skills of moderately preterm infants are not mature at birth.

AIMS

To establish the relationship between postmenstrual age at introduction of first oral feeding and attainment of full oral feeding and hospital discharge for moderately preterm infants.

STUDY DESIGN

Multicenter retrospective analysis of a prospective cohort of moderately preterm infants admitted to a Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network hospital.

SUBJECTS

6146 infants born at 29-33 weeks' gestation from January 2012 to November 2013.

OUTCOME MEASURES

Postmenstrual age at full oral feeding and at hospital discharge.

RESULTS

The median postmenstrual age at first oral feeding was 33.9 weeks (interquartile range 33.1-34.3). For each week earlier at first oral feeding, full oral feeding occurred 4.5 days earlier (p < 0.0001) and hospital stay was shortened by 3.4 days (p < 0.0001). Higher birth weight (p < 0.0001) and black maternal race (p = 0.0001) were associated with younger postmenstrual age at full oral feeding and at discharge.

CONCLUSION

Moderately preterm infants with earlier introduction of oral feeding achieved earlier full oral feeding and hospital discharge.

Breast-Feeding Friendly, but Not Formula Averse

Breast-feeding is the optimal source of newborn nutrition in term infants and is associated with multiple short- and long-term health benefits. Establishment of breast-feeding may be difficult in a small subset of mothers, which can lead to adverse consequences in the newborn. Some of the consequences of suboptimal nutritional provision to the newborn, such as severe hyperbilirubinemia and breast-feeding-associated hypernatremic dehydration, can have devastating and long-lasting sequelae. Timely identification of mothers and newborns at risk for developing these complications is necessary to avoid significant morbidity and mortality. In these cases, the judicious use of formula supplementation may be considered. However, more studies are necessary to develop comprehensive formula supplementation criteria and guidelines for pediatric medical providers. [Pediatr Ann. 2017;46(11):e402-e408.].