Integrative Review of Interventions to Promote Breastfeeding in the Late Preterm Infant

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.

Early Bloomers: A Nursing-Driven Program to Support Human Milk Feeding Among Late Preterm Infants in the Mother-Baby Unit

Late preterm infants have lower breastfeeding rates than term infants, yet few published interventions or guidelines exist to guide hospitals in managing them in the non-intensive nursery setting. Here we describe the development and implementation of an interdisciplinary, hospital-based, breastfeeding support program among late preterm infants not requiring intensive care. The Early Bloomer Program includes an order set applied at birth, immediate lactation consultation, availability of donor milk, parent education on late preterm infants, hand expression teaching and kit including spoon and video link, and daily interdisciplinary team huddles. The program was developed with staff input using Diffusion of Innovation Theory, and implemented first among early adopters before expanding to all postpartum nurses. Nursing staff received education on late preterm infant physiology and feeding, and trainings on the Early Bloomers program through various learning modalities during the year leading up to implementation. To further understand the strengths and weakness of the program, we surveyed nurses (n = 43). Nurses reported that they were more attentive to the needs of late preterm infants, more confident in their care, and more aware of possible complications and feeding needs. Areas noted in need of improvement included lack of overnight lactation consults and little involvement of labor and delivery staff in the program. The Early Bloomers program increased confidence in care and was well received by nurses. Well-designed clinical studies are needed to identify effective breastfeeding support practices for late preterm infants.

Maternal Reasons for Early Termination of Exclusive Breastfeeding in Premature Infants: A Prospective Study

PURPOSE

Maternal concerns for health and growth in prematurely born infants affect the breastfeeding duration.

METHOD

This prospective observational study evaluated whether maternal concerns regarding insufficient milk supply were supported by inadequate nutrients in human milk or low infant growth. The study followed mothers of 211 premature born infants for 6 months after delivery.

RESULTS

Of the 211 infants, 156 were not exclusively breastfed for the recommended 6 months after delivery. For 79 of these 156 infants, termination was due to maternal concerns regarding insufficient milk supply. There was no difference in human milk nutrients or infant growth when comparing infants who were exclusively breastfed with those who were not.

CONCLUSION

Maternal concern regarding insufficient milk supply was the primary explanation for termination of exclusive breastfeeding after premature delivery. Concerns regarding insufficient milk supply were not found associated with inadequate nutrients in the human milk, nor with low infant growth.

IMPLICATIONS

Breastfeeding support should remain in focus in this population.

A quality improvement project to increase breast milk feeding of hospitalized late preterm infants in China

BACKGROUND

The breastfeeding rates of late preterm infants are lower than both term and extremely preterm infants. To explore the interventions of increasing full breast milk feeding rate of hospitalized late preterm infants on the 7th day after birth (D7) and evaluate the effect of these quality improvement (QI) interventions.

METHODS

The full breast milk feeding (amount of enteral breast milk reached 120ml/kg/d on D7) rate of hospitalized late preterm infants during May 2017 and November 2017 was set as the baseline before intervention, and the specific aim of promoting breast milk feeding was put forward. The Pareto Chart was used to analyze the factors that affect breast milk feeding process, as well as the discussion of multidisciplinary experts. Key drivers were constructed, including informational materials and education about breast milk feeding, consultations and support on optimal breast milk initiation, initiating breast milk expression within one hour after birth, accurate measurement and recording of expressed breast milk, stimulating continuous and effective lactation, proper breast pump selection in and out of hospital and sending and preserving of expressed milk to NICU. Control chart was used to monitor the monthly change of full breast milk feeding rate until the aim was achieved and sustained.

RESULTS

The baseline of full breast milk feeding rate of late preterm infants was 10%, and the aim of QI was to increase the rate to 60% within a two-year period. Control chart dynamically showed the full breast milk feeding rate increased to 80% with the implementation of the interventions, achieved and made the aim of QI sustained.

CONCLUSION

QI interventions including breast milk feeding education, early postpartum breast milk pumping, kangaroo care to stimulate breast milk secretion, and convenient way of transporting breast milk to NICU, could significantly improve the full breast milk feeding rate of hospitalized late preterm infants.

Feeding Practices of Preterm Low Birthweight Infants Up to 6 Months: A Comparison Between Kangaroo and Conventional Care

OBJECTIVE

The objective of this study is to compare feeding practices of low birthweight (LBW) infants, according to type of care received during and after hospital discharge: Kangaroo Care (KC) and Conventional Care (CC).

METHODS

Prospective cohort study was conducted at a university hospital (Brazil) between 2019 and 2021. The sample consisted of 65 LBW infants (weight ≤ 1800 g)-46 in KC and 19 in CC. KC includes breastfeeding (BF) guidance and support to parents at hospital and after discharge. Data collection was performed at hospital discharge, and at the 4th and 6th month of corrected gestational age (CGA). Consumption of 27 foods was analyzed in the last 2 periods of the follow-up and expressed in relative frequency. Three indicators were analyzed: exclusive breastfeeding (EBF), mixed BF, and introduction of liquid and solid foods.

RESULTS

Groups had similar health characteristics, except for the weight at hospital discharge and the Score for Neonatal Acute Physiology - Perinatal (SNAPPE II) score that were lower in KC group. We found higher frequency of EBF among KC at hospital discharge (CC = 5.3% vs KC = 47.8%; P = 0.001). The higher frequency of mixed BF was observed in KC at 4 months of CGA (CC = 5.6% vs KC = 35.0%; P = 0.023), and at 6 months of CGA (CC = 0.0% vs KC = 24.4%; P = 0.048). Consumption of solid foods (4th month of CGA = 25.9%, 6th month of CGA = 91.2%) and liquids (4th month of CGA = 77.6%, 6th month of CGA = 89.5%) were similar between groups.

CONCLUSIONS

In KC, SNAPPE II scores were lower and frequency of EBF was higher at hospital discharge and frequency of mixed BF was higher over 6 months. Early supply of infant formula, liquid and solid foods were similar in both groups.

Feeding Difficulties in Late Preterm Infants and Their Impact on Maternal Mental Health and the Mother-Infant Relationship: A Literature Review

Late preterm infants constitute the largest subset of premature infants and are more likely to experience feeding issues leading to delayed oral feeding independence and low breastfeeding rates. Considering the increased parental concern about their infants' nutrition and growth, we performed a literature review to provide an update on the feeding challenges faced by late preterm infants and the impact of these issues on maternal mental health and the mother-infant relationship. Based on our findings, late preterm infants have a high prevalence of feeding difficulties which need to be addressed by targeted support interventions to promote breastfeeding success and the establishment of a harmonious dyadic interaction between the mother and her infant, all of which contribute to the prevention of altered feeding behavior later in life. There is still a need for additional research to develop a standardized and shared strategy that can be proven to be effective. Should this be accomplished, it will be possible to offer appropriate support for mothers, encourage the oral skills and maturation of late preterm infants, and improve the relationship quality within the dyad.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Neonatal Intensive Care Unit Interventions to Improve Breastfeeding Rates at Discharge Among Preterm and Low Birth Weight Infants: A Systematic Review and Meta-Analysis

Background: While breast milk is widely accepted as the best source of nutrients for almost all newborns, breastfeeding can be especially challenging for preterm and low birth weight (LBW) infants. With increased risk of admission to neonatal intensive care units (NICUs) and separation from parents, this population experiences significant barriers to successful breastfeeding. Thus, it is crucial to identify interventions that can optimize breastfeeding for preterm and LBW infants that is continued from birth and admission, through to hospital discharge and beyond. Objectives: To identify and analyze evidence-based interventions that promote any and exclusive breastfeeding among preterm and LBW neonates at discharge and/or postdischarge from hospital. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Searches were performed in the following databases: MEDLINE Ovid, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health (CINAHL). Results: From the 42 studies included, 6 groups of intervention types were identified: educational and breastfeeding support programs, early discharge, oral stimulation, artificial teats and cups, kangaroo mother care (KMC), and supportive policies within NICUs. All groupings of interventions were associated with significantly increased rates of any breastfeeding at discharge. All types of interventions except artificial teats/cups and oral stimulation showed statistically significant increases in exclusive breastfeeding at discharge. KMC demonstrated the highest increased odds of breastfeeding at discharge among preterm and LBW infants. Conclusions: A variety of effective interventions exist to promote breastfeeding among hospitalized preterm and LBW infants. Hospital settings hold unique opportunities for successful breastfeeding promotion. PROSPERO registration: CRD42021252610.

Efficacy of a breastfeeding support education program for nurses and midwives: a randomized controlled trial

BACKGROUND

Nutritional support influences the growth and development of late preterm infants (LPIs) and their long-term health status. However, healthy LPIs have a shorter hospital stay and may not receive adequate care after discharge. In this study, we developed and evaluated the effectiveness of an educational program for nurses and midwives to enable them to support breastfeeding of healthy LPIs.

METHODS

A randomized controlled trial was conducted in Japan from July 2018 to April 2019. The participant pool consisted of nurses and midwives working at midwiferies and obstetric centers in Tokyo, Japan. A total of 395 candidates were recruited for participation across 79 facilities. The final participants were assigned to two groups: the breastfeeding support for LPIs program (BSLPI group; n = 36) or the non-technical skills program (NTS group; n = 33). The measures included the Self-Efficacy of Breastfeeding Support scale (SBS), the Social Skills in Nursing Interactions with Mothers (SS) scale, and the Knowledge and Skills Necessary for Breastfeeding Support for LPIs test (K-S). Scores for each measure were collected before, after, and one-month after the intervention. Repeated-measures ANOVA was used to identify differences (main effects) according to program (BSLPI and NTS) and time (before, immediately after, and one month after intervention).

RESULTS

All 69 participants attended the program. Main effects of the program were observed only for K-S scores (F[1,58] = 78.57, p = 0.01). No significant differences were found for SBS (F[1,58] = 0.63, p = 0.43) or SS scores (F[1,58] = 1.51, p = 0.23).

CONCLUSIONS

Participation in the BSLPI was related to improved breastfeeding support knowledge and skills but was not related to improvements in nurses' self-efficacy or social skills.

TRIAL REGISTRATION

Registered 12 December 2018, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000040145 (UMIN: UMIN000035227).

From Expressing Human Milk to Breastfeeding-An Essential Element in the Journey to Motherhood of Mothers of Prematurely Born Infants

BACKGROUND

Lactation and breastfeeding present an extraordinary challenge for mothers of prematurely born infants.

PURPOSE

To explore the significance of and the circumstances that affect lactation for mothers of premature infants.

METHODS

A qualitative exploratory study based on single, in-depth, semistructured interviews with 16 purposefully sampled mothers of premature infants admitted to the neonatal intensive care unit (NICU). Data were analyzed using content analysis. The study was reported according to Standards for Reporting Qualitative Research.

FINDINGS

The overall theme was "From expressing human milk to breastfeeding-an essential element in the journey to motherhood." The theme emerged from 3 categories: the birth preparation time has been interrupted; expressing human milk is essential for lactation; and the motherhood journey encompasses breastfeeding. The analysis also revealed that the categories were impacted by initiating, performing, and maintaining lactation and further influenced by inhibitors and promoters.

IMPLICATIONS FOR PRACTICE

The promoters for performing milk expression and breastfeeding should be stimulated and the inhibitors should be eliminated. The achievement of "zero separation" and mother-infant couplet care in the NICU would be beneficial. In order for mothers to maintain successful lactation, it is essential that they receive supportive around-the-clock access to health professionals with expertise in lactation and breastfeeding until exclusive breastfeeding is well established.

IMPLICATIONS FOR RESEARCH

The study highlights the need to investigate mother-infant as one entity rather than separately as mother and infant.

A Breastfeeding Relaxation Intervention Promotes Growth in Late Preterm and Early Term Infants: Results from a Randomized Controlled Trial

Breastfeeding involves signaling between mother and offspring through biological (breast milk) and behavioral pathways. This study tested this by examining the effects of a relaxation intervention in an understudied infant population. Breastfeeding mothers of late preterm (34^0/7-36^6/7 weeks) and early term (37^0/7-38^6/7 weeks) infants were randomized to the relaxation group (RG, n = 35), where they were asked to listen to a meditation recording while breastfeeding from 3 weeks post-delivery, or the control group (CG, n = 37) where no intervention was given. Primary outcomes-maternal stress and infant weight-were assessed at 2-3 (baseline) and 6-8 weeks post-delivery. Secondary outcomes included infant length, infant behavior, maternal verbal memory, salivary cortisol, and breast milk composition. Infants in the RG had significantly higher change in weight-for-age Z-score compared to those in CG (effect size: 0.4; 95% CI: 0.09, 0.71; p = 0.01), and shorter crying duration [RG: 5.0 min, 0.0-120.0 vs. CG: 30.0 min, 0.0-142.0; p = 0.03]. RG mothers had greater reduction in cortisol (effect size: -0.08 ug/dL, 95% CI -0.15, -0.01; p = 0.03) and better maternal verbal learning score (effect size: 1.1 words, 95% CI 0.04, 2.1; p = 0.04) than CG mothers, but did not differ in stress scores. A simple relaxation intervention during breastfeeding could be beneficial in promoting growth of late preterm and early term infants. Further investigation of other potential biological and behavioral mediators is warranted.

What works to protect, promote and support breastfeeding on a large scale: A review of reviews

Globally women continue to face substantial barriers to breastfeeding. The 2016 Lancet Breastfeeding Series identified key barriers and reviewed effective interventions that address them. The present study updates the evidence base since 2016 using a review of reviews approach. Searches were implemented using the Epistomenikos database. One hundred and fifteen reviews of interventions were identified and assessed for quality and risk of bias. Over half of reviews (53%) were high- or moderate quality, with the remaining low or critically low quality due to weaknesses in assessment of bias. A large portion of studies addressed high-income and upper-middle income settings, (41%), and a majority (63%) addressed health systems, followed by community and family settings (39%). Findings from reviews continue to strengthen the evidence base for effective interventions that improve breastfeeding outcomes across all levels of the social-ecological model, including supportive workplace policies; implementation of the Baby-Friendly Hospital Initiative, skin to skin care, kangaroo mother care, and cup feeding in health settings; and the importance of continuity of care and support in community and family settings, via home visits delivered by CHWs, supported by fathers', grandmothers' and community involvement. Studies disproportionately focus on health systems in high income and upper-middle income settings. There is insufficient attention to policy and structural interventions, the workplace and there is a need for rigorous assessment of multilevel interventions. Evidence from the past 5 years demonstrates the need to build on well-established knowledge to scale up breastfeeding protection, promotion and support programmes.

Promotion of early and exclusive breastfeeding in neonatal care units in rural Rwanda: a pre- and post-intervention study

Background

Early initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes. However, only 42% of newborns worldwide are breastfed within the first hour of life. Small and sick newborns are at greater risk of not receiving breastmilk and often require additional support for feeding. This study compares breastfeeding practices in Rwandan neonatal care units (NCUs) before and after the implementation of a package of interventions aimed to improve breastfeeding.

Methods

This pre-post intervention study was conducted at two district hospital NCUs in rural Rwanda from October–December 2017 (pre-intervention) and September 2018–March 2019 (post-intervention). Only newborns admitted before their second day of life (DOL) were included. Data were extracted from patient charts for clinical and demographic characteristics, feeding, and patient outcomes. Exclusive breastfeeding at discharge was based on last recorded infant feeding on the day of discharge. Logistic regression analysis was used to evaluate factors associated with exclusive breastfeeding at discharge.

Results

Pre-intervention, 255 newborns were admitted in the NCUs and 793 were admitted in post-intervention. Exclusive breastfeeding on the day of birth (DOL0) increased from 5.4% (12/255) to 35.9% (249/793). At discharge, exclusive breastfeeding increased from 69.6% (149/214) to 87.0% (618/710). The mortality rate decreased from 16.1% (41/255) to 10.5% (83/793). Factors associated with greater odds of exclusive breastfeeding at discharge included admission during the post-intervention period (aOR 4.91; 95% CI 1.99, 12.11), and admission for infection (aOR 2.99; 95% CI 1.13, 7.93). Home deliveries (aOR 0.15; 95% CI 0.05, 0.47), preterm delivery (aOR 0.36; 95% CI 0.15, 0.87) and delayed first breastmilk feed (aOR 0.04 for DOL3 vs. DOL0; 95% CI 0.01, 0.35) reduced odds of exclusive breastfeeding at discharge.

Conclusions

Expansion and adoption of evidenced-based guidelines, using innovative approaches, aimed at the unique needs of small and sick newborns may help to improve earlier initiation of breastfeeding, decrease mortality, and improve exclusive breastfeeding on discharge from hospital among small and sick newborns. These interventions should be replicated in similar settings to determine their effectiveness.

Effects of a breastfeeding coaching program on growth and neonatal jaundice in late preterm infants in South Korea

PURPOSE

This study examined the effects of a breastfeeding coaching program for mothers on growth and neonatal jaundice in late preterm infants (LPIs).

METHODS

This was a quasi-experimental study (non-randomized intervention) with a time-series design. The study was conducted among 40 LPIs who were admitted to the neonatal intensive care unit of a university hospital in Daegu, South Korea. In the order of admission, the first 21 infants were assigned to the experimental group, and 19 were assigned to the control group. The intervention program consisted of home- based and web-based practical breastfeeding support education for mothers across a total of 5 sessions. Infant growth was measured using body weight, length, and head circumference, and neonatal jaundice was assessed using transcutaneous bilirubin levels.

RESULTS

The likelihood of breastfeeding for infants in the experimental group at 4 weeks after discharge was the same as on the day of discharge, whereas it steadily decreased in the control group. There were significant differences in head circumference between the groups. However, weight, length, and transcutaneous bilirubin levels did not show a significant group-time interaction.

CONCLUSION

A formal breastfeeding coaching program should be considered in clinical settings and at home within the first few weeks postpartum.

Barriers and Facilitators to Breastfeeding in Moderate and Late Preterm Infants: A Systematic Review

Rationale: Most of the preterm infants are born between 32 and 36 weeks of gestation (moderate to late preterm infants [MLPIs]). This comes with significant short- and long-term risks. Breastfeeding reduces many of these risks, but breastfeeding rates in MLPIs are lower than those in full-term infants. We performed a systematic review of studies identifying factors associated with successful breastfeeding in MLPIs and interventions to improve breastfeeding. Methods: Systematic search performed using PubMed April 24, 2020. In total, 11 articles describing barriers to breastfeeding in MLPIs and 6 articles about interventions to improve breastfeeding were included. Interventions were categorized according to different outcomes: breastfeeding initiation, continuation for 5 days to 6 weeks, and continuation ≥3 months. Because of heterogeneity in study characteristics, no meta-analysis was performed. Results: Breastfeeding rates were lower in those with lower socioeconomic status and single-parent households. Providing parents with more information and direct health care support significantly improved breastfeeding initiation. Cup feeding instead of bottle feeding had inconsistent effects on breastfeeding initiation and continuation. Continuous skin-to-skin contact did not affect breastfeeding initiation or continuation. Discussion: Risk groups for lower breastfeeding rates of MLPIs include mothers with lower socioeconomic status and single mothers. Interventions that may improve breastfeeding include cup feeding and providing parents with more information and health care support. Key limitations of included studies are lack of adequate adjustment for confounders and lack of blinding. However, this is the first systematic review identifying both risk groups and interventions to improve breastfeeding in MLPIs.

Maternal production of milk for infants in the neonatal intensive care unit

Mother's own milk (MOM) feeding is a cost-effective strategy to reduce risks of comorbidities associated with prematurity and improve long-term health of infants hospitalized in the Neonatal Intensive Care Unit (NICU). Significant racial and socioeconomic disparities exist in MOM provision in the NICU, highlighting the importance of developing strategies to reduce these disparities. Mothers of infants in the NICU experience many health concerns which may negatively impact lactation physiology. Objective measures of lactation physiology are limited but may assist in identifying mothers at particular risk. Several strategies to assist mothers of hospitalized infants are essential, including maternal education, qualified lactation professionals, early and frequent milk expression with a hospital-grade double electric breast pump, and providing support for transitioning to direct breastfeeding prior to discharge from the NICU.

Developing the Preterm Breastfeeding Attitudes Instrument: A tool for describing attitudes to breastfeeding among health care professionals in neonatal intensive care

OBJECTIVE

The aim of this study was to develop an instrument that measures health care professionals' (HCPs) attitudes to breastfeeding and skin-to-skin contact in relation to the Baby-Friendly Hospital Initiative for neonatal intensive care.

DESIGN

The study was part of a larger project aiming to revive the Ten Steps to Successful Breastfeeding for both full-term and preterm infants. The study had a pre-test/post-test design using online questionnaires distributed by email before and after a training programme.

SETTING AND PARTICIPANTS

A total of 70 specialist registered nurses, registered nurses, assistant nurses and physicians working at a Swedish neonatal intensive care unit answered 55 breastfeeding attitudes questions online before the training. The Preterm Breastfeeding Attitudes Instrument (PreBAI) consists of twelve of these 55 items/questions, selected using exploratory factor analysis.

MEASUREMENTS AND FINDINGS

Higher scores indicated more positive attitudes and the median total PreBAI score was 42 points (out of 48), on both the pre- and the post-test questionnaires, showing no significant difference. In the pre-test questionnaire, the majority of HCPs (84%) stated that they needed further breastfeeding training. They also stated that they perceived breastfeeding as very important, scoring a median of 10 (range 5-10) points on a 10-point scale. Three separate underlying dimensions were identified in the questionnaire, indicating different attitudes: Facilitating (five items), Regulating (four items), and Breastfeeding- and skin-to-skin contact-friendly (three items). A positive correlation was found between how many years the HCPs had worked in neonatal care, and their PreBAI score (r_s = 0.383, p = 0.001). Those who had previously received extra breastfeeding education scored higher on the instrument.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Neonatal intensive care units need to increase their efforts to support breastfeeding. An important factor for mothers when establishing breastfeeding is support from well-trained professionals with a positive attitude to breastfeeding. The PreBAI could be a useful tool for identifying attitudes among HCPs before and after attending a breastfeeding training programme.

Breastfeeding trends, influences, and perceptions among Italian women: a qualitative study

Purpose: Breastfeeding behaviours are routinely assessed in worldwide capacities, and the World Health Organization (WHO) European Region has the lowest rates of exclusive breastfeeding. Rates in Italy are not well documented but suggest breastfeeding rates are rising since the early 2000s. Professional recommendations suggest exclusive breastfeeding should persist until the infant is at least six to twelve months of age. However, barriers to adhering to this recommendation exist, often resulting in a lack of initiation or premature cessation of breastfeeding behaviours. This study explored women's perceptions, attitudes, and experiences with breastfeeding living in Florence, Italy. Methods: Participants were 44 reproductive-aged (M = 31.7 ± 6.14; Range = 19 to 45 years) women currently utilizing the Italian healthcare system. All participants completed an in-depth, individual interview between June and August 2017 on topics related to reproductive health, including breastfeeding. Results: Resulting themes relate to breastfeeding trends and influences, the role of identity and empowered choice, as well as perspectives on public breastfeeding. Conclusions: Findings provide practical recommendations for future exploration and social marketing campaign application related to breastfeeding decision-making empowerment. Results can also be used for between-country comparison of breastfeeding behaviours and attitudes.

Influence of a Breastfeeding Coaching Program on the Breastfeeding Rates and Neonatal Morbidity in Late Preterm Infants

PURPOSE

This study aimed to determine the influence of a breastfeeding coaching program (BCP) for mothers of late preterm infants (LPIs) on the breastfeeding rate and neonatal morbidity within 1 month after discharge.

METHODS

This was a non-randomized quasi-experimental study with a time series design. The participants were 40 LPIs and their mothers who were hospitalized in a neonatal intensive care unit at a university hospital. Nineteen LPIs were assigned to the control group, and 21 to the experimental group. The mothers of the LPIs in the experimental group received the BCP once on the discharge day and then once a week for 1 month. Neonatal morbidity was defined as an outpatient department or emergency room visit due to an LPI's health problem.

RESULTS

The breastfeeding rate in the experimental group was significantly higher than in the control group at the fourth week after discharge (x 2=7.17, p=.028). Five and two LPIs in the control group and the experimental group, respectively, visited a hospital due to neonatal jaundice. Neonatal morbidity was not significantly different between the two groups (x 2=1.95, p=.164).

CONCLUSION

The BCP was useful for improving the breastfeeding rates of LPIs and may have potential to reduce neonatal morbidity.

Breastfeeding progression in late preterm infants from birth to one month

This study aimed to describe and compare breastfeeding progression, infants' feeding behaviours, maternal feeding difficulties, and mothers' usage of breastfeeding interventions for singleton late preterm (LPT) and term infants. A further aim was to identify associated factors for exclusive breastfeeding at breast at 1 month in LPT infants. This was a cohort study where mothers of LPT infants from a neonatal unit (n = 60), LPT infants from a maternity unit (n = 62), and term infants from a maternity unit (n = 269) answered a questionnaire approximately 1 month after delivery. Findings showed no significant differences in exclusive breastfeeding at breasts between LPT infants admitted to the neonatal unit compared with the maternity unit, during the first week at home (38% vs. 48%), or at 1 month of age (52% vs. 50%). Term infants were more likely to be exclusively breastfed at the breast (86% and 74%, p < 0.05) compared with LPT infants. Multiple regression analysis showed that usage of a nipple shield, not feeding breast milk exclusively during the first week at home, or feeding less than 10 times per day at 1 month were statistically significant for not exclusively breastfeed at the breast. A protective factor was the mothers' experience of having an abundance of milk during the first week at home. In conclusion, LPT infants are less likely to be exclusively breastfed at the breast than term infants, highlighting the need for further research to guide interventions aimed at optimising exclusive breastfeeding rates.

Feeding the Late and Moderately Preterm Infant: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

Nutritional guidelines and requirements for late or moderately preterm (LMPT) infants are notably absent, although they represent the largest population of preterm infants. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (CoN) performed a review of the literature with the aim to provide guidance on how to feed infants born LMPT, and identify gaps in the literature and research priorities.Only limited data from controlled trials are available. Late preterm infants have unique, often unrecognized, vulnerabilities that predispose them to high rates of nutritionally related morbidity and hospital readmissions. They frequently have feeding difficulties that delay hospital discharge, and poorer rates of breastfeeding initiation and duration compared with term infants. This review also identified that moderately preterm infants frequently exhibit postnatal growth restriction.The ESPGHAN CoN strongly endorses breast milk as the preferred method of feeding LMPT infants and also emphasizes that mothers of LMPT infants should receive qualified, extended lactation support, and frequent follow-up. Individualized feeding plans should be promoted. Hospital discharge should be delayed until LMPT infants have a safe discharge plan that takes into account local situation and resources.In the LMPT population, the need for active nutritional support increases with lower gestational ages. There may be a role for enhanced nutritional support including the use of human milk fortifier, enriched formula, parenteral nutrition, and/or additional supplements, depending on factors, such as gestational age, birth weight, and significant comorbidities. Further research is needed to assess the benefits (improved nutrient intakes) versus risks (interruption of breast-feeding) of providing nutrient-enrichment to the LMPT infant.

Weight-Related Concerns as Barriers to Exclusive Breastfeeding at 6 Months

BACKGROUND

Human milk is considered the gold standard for infant nutrition, but more data are needed that examine the constellation of weight-related concerns as barriers to exclusive breastfeeding.

RESEARCH AIMS

The aim of this study was to examine how mothers' concerns regarding their own and their infants' weight, as well as disordered eating behaviors, were associated with breastfeeding self-efficacy and exclusive breastfeeding at 6 months.

METHODS

A prospective, quantitative, and self-report online survey design was used. Participants included 206 women (88.30% White, 59.20% with graduate degrees), with a mean age of 33.04 years ( SD = 4.31 years) and a mean prepregnancy body mass index (BMI) of 24.80 kg/m² ( SD = 5.50 kg/m²), who had given birth within the past 6 months.

RESULTS

Participants who reported not exclusively breastfeeding at 6 months had significantly higher prepregnancy BMI ( p < .001), higher body dissatisfaction ( p = .003), more disordered eating ( p = .036), higher child weight concerns ( p < .001), and lower breastfeeding self-efficacy ( p < .001). Mediation modeling revealed a direct negative relationship between prepregnancy BMI and exclusive breastfeeding at 6 months ( p < .001). Indirect negative relationships between prepregnancy BMI and exclusive breastfeeding at six months via (a) body dissatisfaction, (b) disordered eating, and (c) child weight concern, as well as breastfeeding self-efficacy (entered as concurrent mediators), were all significant.

CONCLUSIONS

Mothers' weight, body image and eating concerns, concern regarding their children's weight, and breastfeeding self-efficacy may constitute critical barriers to exclusive breastfeeding at 6 months. Interventions to improve breastfeeding duration and confidence should target maternal body image and eating concerns.

Evaluation of an intervention supporting breastfeeding among late-preterm infants during in-hospital stay

BACKGROUND

Late-preterm infants show lower breastfeeding rates when compared with term infants. Current practice is to keep them in low-risk wards where clinical guidelines to support breastfeeding are well established for term infants but can be insufficient for late-preterm.

OBJECTIVE

The aim of this study was to evaluate an intervention supporting breastfeeding among late-preterm infants in a maternity service in the Basque Country, Spain.

METHODS

The intervention was designed to promote parents' education and involvement, provide a multidisciplinary approach and decision-making, and avoid separation of the mother-infant dyad. A quasi-experimental study was conducted with a control (n=212) and an intervention group (n=161). Data was collected from clinical records from November 2012 to January 2015. Feeding rate at discharge, breast-pump use, incidence of morbidities, infant weight loss and hospital stay length were compared between the two groups.

RESULTS

Infants in the control group were 50.7% exclusive breastfeeding, 37.8% breastfeeding, and, 11.5% formula feeding at discharge, whereas in the intervention group, frequencies were 68.4%, 25.9%, and 5.7%, respectively (p=0.002). Mothers in the intervention group were 2.66 times more likely to use the breast-pump after almost all or all feeds and 2.09 times more likely to exclusively breastfeed at discharge. There were no significant differences in morbidities and infant weight loss between groups. Hospital stay was longer for infants who required phototherapy in the intervention group (p=0.009).

CONCLUSION

The intervention resulted in a higher breastfeeding rate at discharge. Interventions aimed to provide specific support among late-pretem infants in maternity services are effective.

Outcomes Associated With Type of Milk Supplementation Among Late Preterm Infants

OBJECTIVE

To assess whether type of milk supplementation provided to breastfeeding late preterm infants was associated with hospital length of stay (LOS) or breastfeeding status at discharge.

DESIGN

Retrospective chart review.

SETTING

Tertiary care teaching hospital in the southern United States.

PARTICIPANTS

Late preterm infants 35 0/7 to 36 6/7 weeks gestational age (N = 183) admitted to the mother-baby unit between November 1, 2014, and October 31, 2016.

METHODS

The exposure of interest was type of milk supplementation, for example, expressed human milk, pasteurized donor human milk, and formula. Outcomes measured were LOS and breastfeeding status at discharge. Generalized Poisson regression models were used to compare LOS by type of milk supplementation. Modified Poisson regression models were used to estimate risk ratios and 95% confidence intervals for associations with breastfeeding status at discharge.

RESULTS

The LOS for breastfed infants supplemented with expressed human milk and/or pasteurized donor human milk did not differ significantly from exclusively breastfed infants who received no supplement. Exclusively formula-fed infants had longer LOS of 3.2 days compared with 2.6 days for exclusively breastfed infants (p = .001). Breastfed infants who received any formula supplementation were 16% less likely to continue breastfeeding until day of discharge compared with breastfed infants who received human milk supplementation (risk ratio = .84, 95% confidence interval [.77, .92]).

CONCLUSION

The high prevalence of supplementation among breastfeeding late preterm infants underscores the potential effect of type of milk supplementation on LOS and breastfeeding outcomes. Our findings suggest that human milk supplementation discourages transition to formula feeding before hospital discharge without increasing LOS.

Prospective questionnaire study showed that higher self-efficacy predicted longer exclusive breastfeeding by the mothers of late preterm infants

AIM

An important variable that influences breastfeeding outcomes is how confident a woman feels about her ability to breastfeed successfully at an early stage. We investigated breastfeeding self-efficacy in the mothers of late preterm infants.

METHODS

This was a prospective, comparative study that focused on mothers who had delivered babies at 34 + 0 to 36 + 6 weeks and were recruited in 2012-2015 from a neonatal intensive care unit and a postnatal ward at a Swedish university hospital. The Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) was used to psychometrically assess the mothers at 40 weeks of postmenstrual age (n = 148) and at three months of corrected age (n = 114).

RESULTS

The BSES-SF scores were higher in the 87% of mothers that exclusively breastfed when their babies reached 40 weeks (57.1 out of 70) than those who did not (41.4, p < 0.001), indicating better self-efficacy. The figures remained higher in the 68% of exclusive breastfeeding mothers at three months of corrected age (60.9 versus 51.7).

CONCLUSION

Self-efficacy was an important predictor of the length of breastfeeding in mothers of late preterm infants, and the BSES-SF can be used to detect low self-efficacy that could lead to early breastfeeding cessation.