Outcomes and factors associated with breastfeeding for <8 weeks among preterm infants: findings from 6 states and NYC, 2004-2007

Breastfeeding Barriers for Preterm Infants in Neonatal Intensive Care Unit Environments: A Systematic Assessment and Meta-Analysis

Background: Breast milk is vital for the growth and development of preterm infants. However, in Neonatal Intensive Care Units (NICUs), mothers often encounter significant challenges in breastfeeding. Objective: This study aims to systematically evaluate the barriers to breastfeeding in NICUs, thereby providing evidence-based support for clinical practices. Methods: A comprehensive search was conducted in the Cochrane Library, PubMed, Web of Science, Embase, and Scopus databases, up to September 2023. Meta-analysis was performed using Stata 15.0, applying fixed or random effects models to calculate odds ratios (OR) and their 95% confidence intervals (CI). Study quality was assessed using the Newcastle-Ottawa Scale for cases and cohorts and the Agency for Healthcare Research and Quality standards for cross-sectional studies. Heterogeneity was evaluated using Cochran's chi-squared test (Cochran's Q) and I2 statistics, and publication bias was assessed through funnel plots and symmetry tests. Results: A total of 32 studies were included, encompassing 96,053 preterm infants. The main barriers to breastfeeding in preterm infants included: low gestational age (OR = 1.36, 95% CI: 1.06-1.75), lower maternal education (OR = 1.64, 95% CI: 1.39-1.93), insufficient breast milk (OR = 2.09, 95% CI: 1.39-1.93), multiple births (OR = 1.615, 95% CI: 1.18-2.210), smoking (OR = 2.906, 95% CI: 2.239-3.771), and single motherhood (OR = 1.439, 95% CI: 1.251-1.654). Conclusion: This study underscores the need for individualized breastfeeding support strategies in NICUs, taking into account the diverse backgrounds of mothers. Future research should focus on unraveling the underlying mechanisms affecting breastfeeding in preterm infants, with the goal of enhancing breastfeeding rates and improving developmental outcomes.

Predictors of Breastfeeding among Patients Admitted with Preterm Prelabor Rupture of Membranes

OBJECTIVE

 We sought to describe rates of breastmilk feeding (BF) at hospital discharge and 6 weeks postpartum and to identify risk factors for noninitiation or cessation among pregnancies complicated by preterm prelabor rupture of membranes (PPROM).

STUDY DESIGN

 Retrospective cohort study of pregnant persons with PPROM admitted to a single tertiary center (2013-2019). Patients with deliveries complicated by intrauterine or neonatal demise or with incomplete BF data were excluded. Demographic, antepartum, and delivery characteristics were evaluated. Primary analysis identified rate of BF initiation at maternal discharge and factors associated with noninitiation. Secondary analysis evaluated BF continuation and factors associated with cessation at 6 weeks postpartum. Bivariate statistics were used to compare characteristics and logistic regression was used to estimate adjusted odds ratios (aOR).

RESULTS

 Of 397 patients with PPROM, 342(86%) initiated BF prior to discharge. Those reporting tobacco use in pregnancy were less likely to initiate BF (aOR: 0.32; 95% confidence interval [CI]: 0.16, 0.64). In contrast, private insurance (aOR: 2.53; 95% CI: 1.19, 5.37) and pregnancy latency ≥ 14 days (aOR: 3.02; 95% CI: 1.09, 8.38) were associated with BF initiation at hospital discharge. Of the 293 patients with postpartum follow-up, only 214 (73%) had BF continuation at 6 weeks postpartum. Maternal age <20 years (aOR: 0.07; 95% CI: 0.01, 0.68) and multiparity (aOR: 0.54; 95% CI: 0.29, 0.99) were associated with BF cessation. Patients with private insurance were observed to have increased odds of BF continuation (aOR: 2.10; 95% CI: 1.07, 4.12).

CONCLUSION

 Among patients with PPROM, tobacco use may be associated with noninitiation of BF prior to discharge, whereas age < 20 years and multiparity were associated with cessation by 6 weeks postpartum. Longer pregnancy latency ≥ 14 days was associated with BF initiation prior to discharge. Private insurance was associated with increased rates of BF initiation and continuation postpartum. BF education and support should be offered to all patients admitted for PPROM.

KEY POINTS

· Tobacco use may be associated with BF noninitiation.. · Young age and multiparity are linked with BF cessation.. · Private insurance resulted in BF initiation and continuation..

Delayed Initiation of Breastfeeding and Role of Mode and Place of Childbirth: Evidence from Health Surveys in 58 Low- and Middle- Income Countries (2012-2017)

Background: Timely initiation of breastfeeding is the first step towards achieving recommended breastfeeding behaviours. Delayed breastfeeding initiation harms neonatal health and survival, including infection associated neonatal mortality. Eighty percent of neonatal deaths occur in the low-and middle-income countries (LMICs), where delayed breastfeeding initiation is the highest. Place and mode of childbirth are important factors determining the time of initiation of breastfeeding. In this study, we report the prevalence of delayed breastfeeding initiation from 58 LMICs and investigate the relationship between place and mode of childbirth and delayed breastfeeding initiation in each country. Methods: We analysed data from the most recent Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) collected between 2012 and 2017 and reported by 2019. The study sample comprised all women who had a live birth in the 24 months preceding the survey. ‘Delayed’ initiation of breastfeeding was defined using WHO recommendations as starting breastfeeding after one hour of birth. We coded the stratifying variable for the place and mode of childbirth as “vaginal birth at a facility (VBF)”, “caesarean section birth (CSB) “, and “vaginal birth at home (VBH)”. We used respondent-level sampling weights to account for individual surveys and de-normalised the standard survey weights to ensure the appropriate contribution of data from each country. We report the prevalence and population attributable fractions with robust standard errors. The population attributable risk identifies the proportion of delayed initiation that we could avert among VBH and CSB if everyone had the same risk of delaying breastfeeding as in VBF. Results: The overall prevalence of delayed initiation of breastfeeding was 53.8% (95% CI 53.3, 54.3), ranging from 15.0% (95% CI 13.8, 16.2) in Burundi to 83.4% (95% CI 80.6, 86.0) in Guinea. The prevalence of delayed initiation of breastfeeding was consistently high among women who experienced caesarean section births; however, there was no direct association with each country’s national caesarean section rates. The prevalence of delayed initiation among women who experienced VBF was high in Sub-Saharan Africa and South Asia, even though the CSB rates were low. In some countries, women who give birth vaginally in health facilities were more likely to delay breastfeeding initiation than women who did not. In many places, women who give birth by caesarean section were less likely to delay breastfeeding initiation. Population attributable risk percent for VBH ranged from −28.5% in Ukraine to 22.9% in Moldova, and for CSB, from 10.3% in Guinea to 54.8% in Burundi. On average, across all 58 countries, 24.4% of delayed initiation could be prevented if all women had the same risk of delaying breastfeeding initiation as in VBF. Discussion: In general, women who give birth in a health facility were less likely to experience delayed initiation of breastfeeding. Programs could avert much of the delayed breastfeeding initiation in LMICs if the prevalence of delayed initiation amongst women who experience CSB were the same as amongst women who experience VBF. Crucial reforms of health facilities are required to ensure early breastfeeding practices and to create pro-breastfeeding supportive environments as recommended in intervention packages like the Baby-friendly hospital initiative and Early essential newborn care. The findings from this study will guide program managers to identify countries at varying levels of preparedness to establish and maintain a breastfeeding-friendly environment at health facilities. Thus, governments should prioritise intervention strategies to improve coverage and settings surrounding early initiation of breastfeeding while considering the complex role of place and mode of childbirth.

The Interaction of Donor Human Milk Availability and Race/Ethnicity on Provision of Mother's Own Milk for Very Low Birth Weight Infants

Objective: To compare (1) differences in mother's own milk (MOM) provision and enteral feeding outcomes, (2) differences in preterm formula and donor human milk (DHM) uses as bridges to exclusive MOM feedings at discharge, and (3) MOM and enteral feeding outcomes for racial/ethnic subgroups before and after the implementation of a hospital DHM feeding program. Methods: Retrospective data from 313 very low birth weight (VLBW; birth weight <1,500 g) infants born between January 2011 to December 2012 (pre-DHM, n = 157) and April 2013 to March 2015 (DHM, n = 156) were analyzed. Results: For this predominantly low-income and minority VLBW infant cohort, the percent of enteral fed hospitalization days was higher in the DHM group (pre-DHM 94% [88, 97] versus DHM 98% [95, 99], p < 0.001). Although MOM remained the predominant first enteral feeding type, significantly fewer DHM infants received MOM (pre-DHM 89% versus DHM 75%, p = 0.001). During days of life 1-14, a lower percentage of DHM infants received 100% MOM (pre-DHM 68% versus DHM 55%, p = 0.02). For the entire cohort, the risk for MOM discontinuation was significantly associated with maternal young age, multiparity, non-Hispanic Black race/ethnicity, and low income. Implementation of a DHM program did not predict duration of MOM feedings. However, non-Hispanic White infants had a longer duration of MOM feedings with DHM availability. Conclusions: Our findings highlight the importance of using precise dose and exposure period methodology to determine the impact of DHM on MOM provision. In addition, DHM availability may be associated with varying effects on MOM provision among racial/ethnic groups.

Exclusive Breastfeeding Rates and Associated Factors in 13 "Economic Community of West African States" (ECOWAS) Countries

Exclusive breastfeeding (EBF) has important protective effects on child survival and also increases the growth and development of infants. This paper examined EBF rates and associated factors in 13 “Economic Community of West African States” (ECOWAS) countries. A weighted sample of 19,735 infants from the recent Demographic and Health Survey dataset in ECOWAS countries for the period of 2010–2018 was used. Survey logistic regression analyses that adjusted for clustering and sampling weights were used to determine the factors associated with EBF. In ECOWAS countries, EBF rates for infants 6 months or younger ranged from 13.0% in Côte d’Ivoire to 58.0% in Togo. EBF decreased significantly by 33% as the infant age (in months) increased. Multivariate analyses revealed that mothers with at least primary education, older mothers (35–49 years), and those who lived in rural areas were significantly more likely to engage in EBF. Mothers who made four or more antenatal visits (ANC) were significantly more likely to exclusively breastfeed their babies compared to those who had no ANC visits. Our study shows that EBF rates are still suboptimal in most ECOWAS countries. EBF policy interventions in ECOWAS countries should target mothers with no schooling and those who do not attend ANC. Higher rates of EBF are likely to decrease the burden of infant morbidity and mortality in ECOWAS countries due to non-exposure to contaminated water or other liquids.

Factors Associated with the Early Initiation of Breastfeeding in Economic Community of West African States (ECOWAS)

The early initiation of breastfeeding (EIBF) within one hour after birth enhanced mother–newborn bonding and protection against infectious diseases. This paper aimed to examine factors associated with EIBF in 13 Economic Community of West African States (ECOWAS). A weighted sample of 76,934 children aged 0–23 months from the recent Demographic and Health Survey dataset in the ECOWAS for the period 2010 to 2018 was pooled. Survey logistic regression analyses, adjusting for country-specific cluster and population-level weights, were used to determine the factors associated with EIBF. The overall combined rate of EIBF in ECOWAS was 43%. After adjusting for potential confounding factors, EIBF was significantly lower in Burkina Faso, Cote d’Ivoire, Guinea, Niger, Nigeria, and Senegal. Mothers who perceived their babies to be average and large at birth were significantly more likely to initiate breastfeeding within one hour of birth than those mothers who perceived their babies to be small at birth. Mothers who had a caesarean delivery (AOR = 0.28, 95%CI = 0.22–0.36), who did not attend antenatal visits (ANC) during pregnancy, and delivered by non-health professionals were more likely to delay initiation of breastfeeding beyond one hour after birth. Male children and mothers from poorer households were more likely to delay introduction of breastfeeding. Infant and young child feeding nutrition programs aimed at improving EIBF in ECOWAS need to target mothers who underutilize healthcare services, especially mothers from lower socioeconomic groups.

Considerations for Preterm Human Milk Feedings When Caring for Mothers Who Are Overweight or Obese

BACKGROUND

Mother's milk is the recommended source of nutrition for all newborns. Preterm infants may be further compromised by maternal factors that impede successful lactation and alter milk composition.

PURPOSE

To review and summarize the state of the science regarding implications of maternal overweight and obesity on successful lactation and associated alterations in preterm mother's milk composition.

METHODS/SEARCH STRATEGY

PubMed, EMBASE, and Web of Science searches were performed using relevant key words to identify references addressing maternal overweight or obesity, prematurity, human milk, and lactation.

FINDINGS/RESULTS

In the United States, more than half of women enter pregnancy with an overweight or obese body mass index. These women have increased risk of adverse pregnancy outcomes and obstetric complications that can undermine successful initiation and continuation of lactation, including preterm birth. Maternal overweight and obesity are also associated with alterations in mother's milk composition.

IMPLICATIONS FOR PRACTICE

Mother-preterm infant dyads affected by maternal overweight and obesity are at risk for barriers to initiation and continuation of lactation. Support for early initiation of milk expression is needed. Continued support, especially during the first weeks of lactation, can facilitate sustained milk production.

IMPLICATIONS FOR RESEARCH

Considerable knowledge gaps remain in this area of human milk science. Future research is needed to facilitate more comprehensive understanding of differences in milk composition associated with maternal overweight and obesity and their impact on clinical outcomes in the preterm infant.

Barriers and Facilitators of Breastfeeding Reported by Postpartum Women in Methadone Maintenance Therapy

INTRODUCTION

This study utilized a cross-sectional qualitative and quantitative interview-based survey to capture the infant feeding practices and barriers to exclusive breastfeeding for women in methadone maintenance therapy. Participants were recruited from an opioid dependence treatment center in an urban setting in the Southeastern United States.

MATERIALS AND METHODS

A convenience sample of women in treatment (n = 30) were interviewed using an adapted instrument designed to capture decisions and intentions to formula feed or breastfeed; support from friends and family; hospital experience; support from healthcare personnel; and maternal knowledge of breastfeeding while taking methadone.

RESULTS

The majority of women in the sample initiated breastfeeding, but only 10% continued for >1 month. Challenges related to infant hospital stay posed a significant barrier. Two-thirds of infants remained hospitalized after the mother was discharged. Out of the 24 women who initiated breastfeeding, 11 reported that they discontinued because of issues related to infant's neonatal intensive care unit (NICU) stay. Eleven women reported that their healthcare providers did not discuss breastfeeding with them. Women who were encouraged to breastfeed by healthcare staff were more likely to breastfeed for longer durations.

CONCLUSIONS

Women in treatment for opioid dependence both desire and attempt to establish breastfeeding, but encounter significant challenges, including long NICU stays and lack of support and education, that compromise their success. These findings should inform the development of future programs or interventions geared toward increasing breastfeeding initiation, support, and duration among women who give birth to babies while in treatment for opioid addiction.

Environmental Scan of Breastfeeding Resources in Canadian NICUs

We conducted an environmental scan using a mixed methods approach to determine the types and frequencies of breastfeeding resources available to mothers of infants in Canadian NICUs. Through interviews with key informants from 29 Level 3 NICUs, we identified six categories of resources: breastfeeding-friendly layout, breastfeeding support personnel, breastfeeding education for mothers, breast pump-related resources, coordination of postdischarge breastfeeding support, and breastfeeding-related policies. Findings from this national study indicate that a wide range of breastfeeding resources were reportedly available in Canadian Level 3 NICUs. NICU professionals are encouraged to connect with other units across Canada to facilitate the exchange of breastfeeding resources and best practices.

Prenatal Exposure to Stressful Life Events and Infant Breastfeeding

BACKGROUND

Of the various barriers to breastfeeding, limited information is available on the relationship between prenatal stress and breastfeeding. This study investigates the association between prenatal stressful life event (SLE) exposure and breastfeeding initiation postpartum.

MATERIALS AND METHODS

Using Rhode Island Pregnancy Risk Assessment Monitoring System data from 2012 to 2014, SLE was defined as self-report of prenatal exposure to 14 predefined life events such as job loss or illness. Exposure to SLE was categorized by number and type of events. Multivariable logistic regression was performed to assess the relationship between SLE and breastfeeding initiation. Results accounted for complex survey design and were adjusted for maternal and infant characteristics (age, race, ethnicity, insurance, delivery type, parity, gestational age, birth weight for gestational age, and neonatal intensive care unit admission).

RESULTS

Among 3,353 respondents, 86% reported breastfeeding initiation, 74% reported exposure to ≥1 SLE, and 17% reported exposure to ≥4 SLE. Decreased odds of breastfeeding initiation were associated with prenatal exposure to ≥4 SLE (adjusted odds ratio [aOR] 0.67; 95% confidence interval [CI]: 0.48-0.95), emotional stressors (aOR 0.77; 95% CI: 0.61-0.98), and traumatic stressors (aOR 0.68; 95% CI: 0.50-0.91).

CONCLUSION

This study underscores the impact of exposure to prenatal SLE on breastfeeding initiation among postpartum women. Findings may assist providers in identifying at-risk women for anticipatory guidance to improve breastfeeding rates.

Evidence-Based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review

Best practices translating the evidence for high-dose human milk (HM) feeding for preterm infants during neonatal intensive care unit (NICU) hospitalization have been described, but their implementation has been compromised. Although the rates of any HM feeding have increased over the last decade, efforts to help mothers maintain HM provision through to NICU discharge have remained problematic. Special emphasis should be placed on prioritizing the early lactation period of coming to volume so that mothers have sufficient HM volume to achieve their personal HM feeding goals. Donor HM does not provide the same risk reduction as own mother's HM.

A Test of Kangaroo Care on Preterm Infant Breastfeeding

OBJECTIVE

To test the effects of kangaroo care (KC) on breastfeeding outcomes in preterm infants compared with two control groups and to explore whether maternal-infant characteristics and the mother's choice to use KC were related to breastfeeding measures.

DESIGN

Secondary analysis of a multisite, stratified, randomized three-arm trial. The treatment groups used KC, auditory-tactile-visual-vestibular (ATVV) intervention, or received preterm infant care information.

SETTING

Neonatal intensive care units from 4 hospitals in the United States from 2006 to 2011.

PARTICIPANTS

Racially diverse mothers (N = 231) and their preterm infants born weighing less than 1,750 g.

METHODS

Mothers and their infants were enrolled once the infants were no longer critically ill, weighed at least 1,000 g, and could be safely held outside the incubator by parents. Participants were instructed by study nurses; those allocated to the KC or ATVV groups were asked to engage in these interactions with their infants for a minimum of 3 times a week in the hospital and at home until their infants reached age 2 months adjusted for prematurity.

RESULTS

Feeding at the breast during hospitalization, the duration of postdischarge breastfeeding, and breastfeeding exclusivity after hospital discharge did not differ statistically among the treatment groups. Regardless of group assignment, married, older, and more educated women were more likely to feed at the breast during hospitalization. Mothers who practiced KC, regardless of randomly allocated group, were more likely to provide their milk than those who did not practice KC. Breastfeeding duration was greatest among more educated women.

CONCLUSION

As implemented in this study, assignment to the KC group did not appear to influence the measured breastfeeding outcomes.

Trends in breastfeeding initiation in the NICU by gestational age in Ohio, 2006-2012

BACKGROUND

While breastfeeding in the United States is on the rise, trends among infants admitted to the Neonatal Intensive Care Unit (NICU) are less known. The objective of this study was to examine trends in breastfeeding initiation among NICU-admitted infants in Ohio from 2006 to 2012 and to determine differences in breastfeeding initiation trends by gestational age.

METHODS

Using Ohio Vital Statistics birth certificate data, the Cochran-Armitage test for trend was used to determine significant trends in breastfeeding by gestational age. Logistic regression was used to examine the association between breastfeeding initiation and gestational age by year.

RESULTS

From 2006 to 2012, 48,758 infants born in Ohio were admitted to the NICU, representing 5.6 percent of all newborns. Breastfeeding among NICU-admitted infants increased from 53.3 percent in 2006 to 63.8 percent in 2012 (p < 0.01). Increasing, significant trends in breastfeeding were also observed within each gestational age category over the 7 years. In 2011 and 2012, preterm infants were significantly more likely than term infants to be fed breastmilk in the NICU.

DISCUSSION

The gap between breastfeeding initiation among NICU-admitted and non-admitted infants appears to be narrowing, particularly for the most extreme gestational ages. While these increasing trends in breastfeeding among the most premature infants are encouraging, nearly 40 percent of mothers of term infants admitted to the NICU, the largest proportion of the NICU population, are still not initiating breastfeeding. More education and support specific to mothers of infants admitted to the NICU is needed.

Factors associated with exclusive breastfeeding in Timor-Leste: findings from Demographic and Health Survey 2009-2010

Exclusive breastfeeding is known to have nutritional and health benefits. This study investigated factors associated with exclusive breastfeeding among infants aged five months or less in Timor-Leste. The latest data from the national Demographic and Health Survey 2009–2010 were analyzed by binary logistic regression. Of the 975 infants included in the study, overall 49% (95% confidence interval 45.4% to 52.7%) were exclusively breastfed. The exclusive breastfeeding prevalence declined with increasing infant age, from 68.0% at less than one month to 24.9% at five months. Increasing infant age, mothers with a paid occupation, who perceived their newborn as non-average size, and residence in the capital city Dili, were associated with a lower likelihood of exclusive breastfeeding. On the other hand, women who could decide health-related matters tended to breastfeed exclusively, which was not the case for others whose decisions were made by someone else. The results suggested the need of breastfeeding promotion programs to improve the exclusive breastfeeding rate. Antenatal counseling, peer support network, and home visits by health workers could be feasible options to promote exclusive breastfeeding given that the majority of births occur at home.