When is it safe to initiate breastfeeding for preterm infants?

Practices supporting cue-based breastfeeding of preterm infants in neonatal intensive care units across Europe

BACKGROUND

Emerging knowledge about supportive neurodevelopmental neonatal care shows the need for an individual approach to establish breastfeeding. However, evidence on how cue-based breastfeeding is supported in neonatal intensive care units (NICUs) is scarce. Therefore, the aim was to describe supporting practices for cue-based breastfeeding.

METHOD

Through Delphi rounds, a questionnaire was developed comprising questions on the usage and occurrence of supportive practices for cue-based breastfeeding. A multinational online survey was distributed September to October in 2023 to NICUs in Europe using snowball sampling. Practices such as the practice of skin-to-skin contact (SSC), restrictions for breastfeeding, providing information to parents, observing and responding to infants' cues were explored.

RESULTS

The survey was completed by 105 neonatal units across 15 European countries. Less than half (46%) of the NICUs had no restrictions upon placing the infant in SSC with the parents. Approximately half (49%) of the NICUs stated that infants had SSC within the first hour after birth. Many units (68%) had some restriction for breastfeeding. One week after birth, 48% of the NICUs encouraged breastfeeding for infants at 33 postmenstrual age whenever the infant showed cues, regardless of scheduled tube feeding time. This percentage increased to 59% at 33-35 gestational age. Less than half of the units (47%) stated that they had the necessary tools/instruments to support the transition from tube feeding to breastfeeding. There were variations in how milk intake was assessed, such as weighing before and after breastfeeding or estimating milk intake by time spent sucking. Infants in 50% of the units had to be fed exclusively orally before discharge. Many units (65%) provided specific support to or enabled discharge before the infant was exclusively orally fed.

CONCLUSION

European NICUs employ supportive practices, SSC, early initiation of breastfeeding, and provide information to parents. Staff plays a significant role in fostering cue-based feeding in preterm infant-mother dyads. There still exist restrictions for SSC and breastfeeding. To understand the impact of different strategies and practices, there is need for evaluations by parents and testing of the implementation of cue-based feeding practices in neonatal care.

Breastfeeding Self-Efficacy, a Predictor of Early Cessation of Exclusive Breastfeeding Among Mothers Giving Birth Preterm

The aim was to describe the prevalence of exclusive breastfeeding among mothers of premature infants and investigate the extent to which breastfeeding self-efficacy is associated with early cessation of exclusive breastfeeding. The study population consisted of 136 mother-infant dyads with information on the outcome of exclusive breastfeeding and exposure of self-efficacy, recruited between September 2016 and February 2018. Data were collected via questionnaires with follow-up at 6 months. The statistical analysis included descriptive analysis with survival curves and logistic regression analysis. At 2 months, 101 (74%) premature infants were exclusively breastfed; at 4 and 6 months, 82 (60%) and 41 (30%), respectively. Higher levels of self-efficacy were significantly associated with breastfeeding exclusively for 2 months ( P = .03). In multivariate analysis, mothers who had a low level of early self-efficacy toward breastfeeding had 2½ times higher odds of breastfeeding cessation before 2 months (odds ratio = 2.63, 95% confidence interval: 1.16-5.96). The risk did not change when adjusted for potential confounders. Breastfeeding self-efficacy is an early predictor of exclusive breastfeeding for 2 months of the premature infant. Health professionals should use self-efficacy as a prognostic factor to identify mothers at risk of early cessation of breastfeeding and support those with low self-efficacy to increase duration of exclusive breastfeeding.

Development of a Protocol for the Direct Breastfeeding of Premature Infants in Neonatal Intensive Care Units

PURPOSE

This study aimed to develop a direct breastfeeding protocol for premature infants admitted to neonatal intensive care units (NICUs) and investigate its efficacy.

BACKGROUND

Direct breastfeeding increases the amount and duration of breastfeeding. However, NICUs have low direct feeding rates owing to medical staff anxiety, lack of knowledge and experience, and fear of overwork. Accordingly, this study developed a protocol for direct breastfeeding in the NICU and evaluated its effect.

METHODS

The protocol was developed through a literature review, expert validation, and preliminary investigation. Its application effects were identified using a nonexperimental, evidence-based research design targeting premature infants, their mothers, and NICU nurses.

RESULTS

The protocol comprised 5 areas and 23 items. Application of the protocol resulted in continuous weight gain of the infants and increased self-efficacy in the mothers' direct breastfeeding ( t = 3.219, P = .004). Significant increases were noted in NICU nurses' direct breastfeeding activities ( t = 3.93, P < .001), breastfeeding rates in the NICU ( P = .037), and direct breastfeeding rates ( P = .007).

CONCLUSIONS

Results underscore the value of an evidence-based protocol for improving breastfeeding rates in premature infants. This study highlights the need for continuous nursing education on protocol applications and human resource support.

Breastfeeding and human milk in the NICU: From birth to discharge

It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.

Effectiveness of technology-based interventions compared with other non-pharmacological interventions for relieving procedural pain in hospitalized neonates: a systematic review

OBJECTIVE

The objective of this review was to evaluate the effectiveness of technology-based interventions for relieving procedural pain among hospitalized neonates compared with other non-pharmacological interventions.

INTRODUCTION

Neonates who require hospital care often experience acute pain during medical procedures. The current best practice for relieving pain in neonates is the use of non-pharmacological interventions, such as oral solutions or intervention-based human touch. Technological solutions (eg, games, eHealth applications, mechanical vibrators) have become more commonplace in pediatric pain management over recent years; however, there is a sizeable knowledge gap around how effective technology-based interventions are for relieving pain in neonates.

INCLUSION CRITERIA

This review considered experimental trials that include technology-based, non-pharmacological interventions for relieving procedural pain among hospitalized neonates. The primary outcomes of interest include pain response to a procedure measured by a pain assessment scale validated for neonates, behavioral indicators, and changes in physiological indicators.

METHODS

The search strategy aimed to identify both published and unpublished studies. MEDLINE (PubMed), CINAHL (EBSCOhost), Scopus, Cochrane Central Register of Controlled Trials, MedNar, and EBSCO Open Dissertations databases were searched for studies published in English, Finnish, or Swedish. Critical appraisal and data extraction were conducted by 2 independent researchers who adhered to JBI methodology. Meta-analysis could not be performed due to considerable heterogeneity in the studies; as a result, the findings are presented narratively.

RESULTS

A total of 10 randomized controlled trials involving 618 children were included in the review. The staff members delivering the interventions and the outcome assessors were not blinded in all of the studies, which introduced a potential risk of bias. The presented technology-based interventions were diverse, including laser acupuncture, noninvasive electrical stimulation of acupuncture points, robot platform, vibratory stimulation, recorded maternal voice, and recorded intrauterine voice. In the studies, pain was measured using validated pain scales, behavioral indicators, and physiological variables. In the studies in which pain was assessed with a validated pain measure (N=8), technology-based pain relief was significantly more effective than the comparator in 2 studies, whereas no statistically significant differences were observed in 4 studies and the technology-based intervention was less effective than the comparator in 2 studies.

CONCLUSIONS

The effectiveness of technology-based interventions in relieving neonatal pain, either as a standalone method or in combination with another non-pharmacological method, was mixed. Further research is needed to provide reliable evidence on which technology-based, non-pharmacological pain relief intervention is most effective for hospitalized neonates.

SUPPLEMENTAL DIGITAL CONTENT

A Finnish-language version of the abstract of this review is available as supplemental digital content [ http://links.lww.com/SRX/A19 ].

REVIEW REGISTRATION

PROSPERO CRD42021254218.

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.

Strategies to Improve Mother's Own Milk Expression in Black and Hispanic Mothers of Premature Infants

BACKGROUND

Mother's own milk (MOM) is the gold standard of nutrition for premature infants. Yet, Hispanic and Black preterm infants are less likely than their White counterparts to receive MOM feedings. Evidence is lacking concerning potential modifiable factors and evidence-based strategies that predict provision of MOM among minority mothers of premature infants.

PURPOSE

A review of the literature was conducted to answer the clinical question: "What evidence-based strategies encourage and improve mother's own milk expression in Black and Hispanic mothers of premature infants?"

METHODS/SEARCH STRATEGY

Multiple databases including PubMed, Cochrane, and CINAHL were searched for articles published in the past 10 years (2010 through May 2020), reporting original research and available in English. Initial search yielded zero articles specifically addressing the impact of lactation interventions on MOM provision in minority mothers. Additional studies were included and reviewed if addressed breastfeeding facilitators and barriers (n = 3) and neonatal intensive care unit breastfeeding support practices (n = 7).

FINDINGS/RESULTS

Current strategies used to encourage and improve MOM expression in minority mothers are based on or extrapolated from successful strategies developed and tested in predominantly White mothers. However, limited evidence suggests that variation in neonatal intensive care unit breastfeeding support practices may explain (in part) variation in disparities and supports further research in this area.

IMPLICATIONS FOR PRACTICE

Neonatal intensive care unit staff should consider implementing scaled up or bundled strategies showing promise in improving MOM milk expression among minorities while taking into consideration the cultural and racial norms influencing breastfeeding decisions and practice.

IMPLICATIONS FOR RESEARCH

Experimental studies are needed to evaluate the effectiveness of targeted and culturally sensitive lactation support interventions in Hispanic and Black mothers.

Positive breastfeeding experiences and facilitators in mothers of preterm and low birthweight infants: a meta-ethnographic review

Background

Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences. We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.

Methods

A systematic review using meta-ethnographic methods was conducted. Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking. The analysis involved a reciprocal level of translation and a line of argument synthesis.

Results

Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers. A positive breastfeeding experience was identified as being ‘attuned’. Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding. ‘Trusting the body and what it can do’, concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed. ‘Being emotionally present – in the here and now’ described the importance of feeling relaxed and reassured. ‘Experiencing mutual positive responses’, illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant’s cues, responds to these signals and receives a positive response from the infant. The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues.

Conclusions

This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding. Improvements in units’ design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial. The mother’s physical and emotional states and the infant’s behavioural responses and physiological signals should guide the process towards positive breastfeeding practices.

[Effect of Direct Breastfeeding Program for Premature Infants in Neonatal Intensive Care Unit]

PURPOSE

This study aimed to identify the effects of a direct breastfeeding program for premature infants in neonatal intensive care units (NICUs).

METHODS

This quasi-experimental study was conducted during August 2016 to April 2017. Sixty mothers of premature infants were assigned to the experimental (n = 31) or control groups (n = 29). The program was comprised of breastfeeding education and direct breastfeeding support. The experimental and control groups were provided with education and counseling on breastfeeding at the time of admission and discharge. In the experimental group, the mothers initiated oral feeding with direct breastfeeding and engaged in breastfeeding at least seven times during the NICU stay. The collected data were analyzed by the χ²-test and repeated measures ANOVA using an SPSS program.

RESULTS

The experimental group showed a higher direct breastfeeding practice rate (χ² = 19.29, p < .001), breastfeeding continuation rate (χ² = 3.76, p < .001), and self-efficacy (F = 25.37, p < .001) than the control group except for maternal attachment.

CONCLUSION

The direct breastfeeding program in the NICU has significant effects on the practice and continuation rate of breastfeeding and breastfeeding self-efficacy. Therefore, this program can be applied in the NICU settings where direct breastfeeding is limited.

Intermittent kangaroo mother care and the practice of breastfeeding late preterm infants: results from four hospitals in different provinces of China

BACKGROUND

China has an extremely low exclusive breastfeeding rate. Kangaroo mother care (KMC) has been shown to increase the exclusive breastfeeding rate among infants born extremely or very preterm. However, there is limited evidence surrounding intermittent KMC and exclusive breastfeeding in late preterm infants. In our study we investigated the association between the provision of intermittent KMC and breastfeeding practice for late preterm infants in four hospitals in different provinces of China.

METHODS

Intermittent KMC was recommended to the mothers of all preterm infants admitted to the postnatal wards of participating hospitals between March 2018 and March 2019. Those who agreed to practice KMC were enrolled in the "KMC group", those who did not were enrolled in the "No KMC group". Basic maternal socio-demographic information was collected, feeding practice; outcome and method, were recorded daily whilst in hospital. A follow-up survey of feeding practice was conducted 42 days after discharge. Calculations for feeding practice were performed separately for both groups. Logistics regression was used to analyze the association between KMC and feeding outcome and method, adjusting for socio-demographic covariates.

RESULTS

Among the 844 mothers participating in the study, 627 (74.3%) chose to perform KMC. More of the mothers who provided KMC were exclusively breast milk feeding their infants in the 24 h before hospital discharge (54.6%) and at follow-up (57.3%), compared to mothers who did not provide KMC (34.6% at discharge and 33.2% at follow-up,). Mothers in the KMC group were more likely to be breastfeeding (method) than mothers in the No KMC group (65.3% vs. 52.1% at discharge, and 83.1% vs. 67.3% at follow up). Logistic regression indicated that compared with the No KMC group, mothers who provided KMC were twice as likely to be exclusively breast milk feeding their infants at discharge (OR = 2.15 (95% CI 1.53, 3.02)), use breastfeeding method at discharge as opposed to other means such as bottle or cup feeding (OR = 1.61 (95% CI 1.15, 2.25)), be exclusive breast milk feeding at follow-up (OR = 2.55 (95% CI 1.81, 3.61)), and use breastfeeding method at follow-up (OR = 2.09 (95% CI 1.44, 3.02)).

CONCLUSIONS

Intermittent KMC was associated with a nearly doubled increase in exclusive breast milk feeding (outcome) and breastfeeding (method) at both discharge and 42 days after discharge for late preterm infants. This is especially important in China where exclusive breastfeeding rates are low, intermittent KMC provides a feasible means to increase the likelihood of these vulnerable infants receiving the benefits of exclusive breastmilk.

Does breastfeeding self-efficacy theory apply to mothers of moderate and late preterm infants? A qualitative exploration

BACKGROUND

Breastmilk feeding reduces morbidities and improves outcomes related to prematurity. However, breastmilk feeding rates in preterm infants are substantially lower than those in term infants. Breastfeeding self-efficacy theory is a social change theory, which is predictive of exclusive breastmilk feeding at 2 months postpartum in mothers of full-term infants. However, this theory has not been well explored in mothers of moderate and late preterm infants.

AIMS AND OBJECTIVES

To explore maternal experiences with feeding moderate (32^0/7 - 33^6/7  weeks' gestational age) and late preterm infants (34^0/7 - 36^6/7  weeks' GA) in neonatal intensive care units and assess applicability of breastfeeding self-efficacy theory.

METHODS

We conducted a qualitative descriptive exploration of maternal experiences with infant feeding in neonatal intensive care units. Using purposive, maximum variation sampling, we selected mothers of preterm infants born at 32^0/7 - 34^6/7  weeks, who experienced high mean differences in their BSE scores between admission and discharge. Fourteen mothers participated in semi-structured telephone interviews. Data were examined using thematic analysis. To explore and describe breastfeeding self-efficacy within the context of neonatal intensive care units, we super-imposed the four sources of information from breastfeeding self-efficacy theory onto the defined themes.

RESULTS

Three main themes emerged: (a) institutional influences, (b) relationship with the pump and (c) establishing breastfeeding, with an emphasis on the importance of direct breastfeeding at discharge. Overlaying the four sources of information from breastfeeding self-efficacy highlighted the presence of three sources of information: verbal persuasion, performance accomplishment and physiologic/affective responses. Vicarious experience was not identified in maternal experiences with infant feeding.

CONCLUSION

Our findings indicate that breastfeeding self-efficacy is an applicable theory for mothers of preterm infants.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers need to be aware of the influence that institutional culture and policies may have on maternal breastfeeding self-efficacy and breastfeeding outcomes.

What Is the Impact of NICU-Dedicated Lactation Consultants? An Evidence-Based Practice Brief

BACKGROUND

Benefits of exclusive human milk diets for preterm and low birth-weight infants are well established. Despite known benefits, supporting mothers in the provision of mother's own milk for high-risk infants is challenging. Lactation support in the neonatal intensive care unit (NICU) is highly variable. Lactations consultants (LCs) are often shared between postpartum units and the NICU, potentially increasing LC workload with less time spent with high-risk mothers. Furthermore, less than half of NICUs in the United States staff an international board-certified lactation consultant. Limited understanding exists regarding impacts of NICU-specific lactation support on breastfeeding outcomes.

PURPOSE

The purpose of this evidence-based practice brief is to synthesize the literature on the impact of NICU-specific lactation support, LCs who work exclusively in the NICU, and provide guidance about how NICU staffing with LCs solely focused on supporting mothers of high-risk infants impacts breastfeeding outcomes for low birth-weight infants.

SEARCH STRATEGY

CINAHL PLUS, PubMed, Cochrane Library, and OVID databases were searched using key words and restricted to English language.

FINDINGS

During hospitalization, NICUs staffed with dedicated board-certified LCs have increased potential to yield improved breastfeeding rates through hospital discharge, increased proportion of infants who receive mother's own milk, and increased duration of breastfeeding or human milk expression through hospital discharge.

IMPLICATIONS FOR PRACTICE

Human milk nutrition is related to improved outcomes for high-risk infants. Neonatal intensive care unit-specific lactation support can potentially optimize maternal breastfeeding practices and improve outcomes for high-risk infants.

IMPLICATIONS FOR RESEARCH

There is a need for further studies pertaining to NICU-specific lactation consultants and influences on breastfeeding outcomes.

Assessing the Breastfeeding Dyad: A Guide for Speech-Language Pathologists

Purpose

More than 80% of U.S. mothers initiate breastfeeding; for many of them, direct breastfeeding is an important goal. Speech-language pathologists (SLPs) who assess infants with feeding concerns, however, are generally much more familiar with assessing bottle-feeding. The purpose of this tutorial is to assist SLPs in building on their existing assessment skills in order to provide effective, evidence-based options for mothers who wish to breastfeed their infants.

Conclusion

SLPs can assist families in meeting their breastfeeding goals through effective assessment of breastfeeding dyads.

Nonnutritive Sucking at the Mother's Breast Facilitates Oral Feeding Skills in Premature Infants: A Pilot Study

BACKGROUND

Premature infants have difficulties in transitioning from gavage to breastfeeding. Targeted interventions to support breastfeeding in premature infants in the neonatal intensive care unit are scarce.

PURPOSE

This pilot study evaluates the effectiveness of nonnutritive sucking at the mother's breast in premature infants to facilitate breastfeeding performance and exclusive breastfeeding.

METHODS

The study design constituted a single-blinded randomized control trial, with 9 participants randomly allocated into experimental (n = 4) and control (n = 5) groups. The intervention, nonnutritive sucking at the mother's breast thrice a day for 5 minutes, till nutritive breastfeeding was started, was done in addition to standard care, which was nonnutritive sucking on a finger during gavage feeds. The control group received only standard care. Nonnutritive sucking was assessed using "Stages of Nonnutritive Sucking Scale," and breastfeeding performance was assessed using the "Preterm Infant Breastfeeding Behavior Scale" by a blinded assessor unaware of the infants' allocation.

RESULTS

Five infants in the control arm and 4 in the intervention arm completed the study. The infants in the intervention group showed faster transition to mature stages of nonnutritive sucking (P = .05) and had longer sucking bursts during breastfeeding (P = .06) than those in the control group. There was no difference in the rates of exclusive breastfeeding at 6 months in the intervention and control groups.

IMPLICATIONS FOR PRACTICE

Early initiation of nonnutritive sucking at the mother's breast in very preterm infants is a safe and effective intervention to facilitate maturation of oral feeding and breastfeeding behavior.

IMPLICATIONS FOR RESEARCH

Nonnutritive sucking at the mother's breast can be explored as an intervention, with a larger sample, to facilitate exclusive breastfeeding and to establish intervention fidelity.

Implementation of Pre-/Post-Weights to Enhance Direct Breastfeeding in the NICU

Introduction

Mother's own milk (MOM) is recommended as the optimal nutrition for preterm infants. Direct breastfeeding (DBF) is correlated with a longer duration of receiving MOM during hospitalization. Infants' transition to DBF may be enhanced when accurate pre-/post-weights are incorporated into nursing practice. An evidence-based practice change was introduced to promote use and increase consistency in methodology of pre-/post-weights after DBF in the neonatal intensive care unit (NICU), with the ultimate goal of increasing DBF at hospital discharge.

Methods

The practice change was introduced through an educational program, a video demonstrating pre-/post-DBF weighing techniques, and a return-demonstration. A 10-item pre-/posttest was used to evaluate nurses' knowledge gained by an educational intervention that included seven knowledge questions, three attitude questions, and three demographic descriptors.

Results

Nurses' knowledge gained following the educational intervention was statistically significant (p < .001) using a paired t-test.

Conclusions

The use of pre-/post-DBF weights as an accurate assessment of MOM transfer can promote DBF during hospitalization through education of NICU nurses. Understanding nursing characteristics and attitudes can aid in promotion of DBF in the NICU by bedside nurses.

Breastfeeding self-efficacy and breastmilk feeding for moderate and late preterm infants in the Family Integrated Care trial: a mixed methods protocol

BACKGROUND

Breastmilk is the ideal nutrition for preterm infants. Yet, breastmilk feeding rates among preterm infants are substantially lower than those of full-term infants. Barriers incurred through hospital care practices as well as the physical environment of the neonatal intensive care unit (NICU) can result in physical and emotional separation of infants from their parents, posing a substantial risk to establishing and maintaining breastfeeding. Additionally, current practitioner-focused care provision in the NICU can result in decreased breastfeeding self-efficacy (BSE), which is predictive of breastfeeding rates in mothers of preterm infants at 6 weeks postpartum.

METHODS

Family Integrated Care (FICare) integrates and supports parents to actively participate in the care of their infant while in the NICU. Nested within the broader FICare trial, we will conduct an explanatory sequential mixed methods study to investigate if FICare improves maternal BSE and rates of breastmilk feeding in moderate and late preterm infants at discharge from the NICU. In phase 1, we will calculate the mean difference between admission and discharge BSE scores for the intervention group. Mothers who score in the top and bottom 20th percentile of change scores will be invited to participate in a semi-structured telephone interview exploring maternal experiences with infant feeding in the NICU. We will conduct inductive thematic analysis to identify and describe the facilitators and barriers of FICare on maternal feeding experiences. Once data saturation is achieved and themes have been established, phase 2 will revisit the quantitative data to determine whether FICare was impactful on BSE and breastmilk feeding rates. Findings from the qualitative and quantitative phases will be integrated to determine how infant feeding experiences on FICare units work to improve or detract from maternal BSE and rates of breastmilk feeding.

DISCUSSION

FICare may help to improve maternal BSE and rates of breastmilk feeding in moderate and late preterm infants. Improved breastmilk feeding outcomes can have a substantial impact on overall infant health, developmental outcomes, and maternal-infant bonding and will help to improve long-term health outcomes for moderate and late preterm infants.

TRIAL REGISTRATION

(NCT02879799). Registered May 27, 2016 protocol version June 9, 2016 Version 2.

Supports and Barriers to the Provision of Human Milk by Mothers of African American Preterm Infants

BACKGROUND

Mother's own milk (MOM) provides significant health benefits to very low birth-weight infants (VLBW, ≤1500 g). However, 60% of African American (AA) women initiate lactation, and less than 35% provide MOM 6 months following the birth of their infant. Previous research focuses on term infants and is not specific to AA mothers of VLBW infants.

PURPOSE

To qualitatively describe supports and barriers experienced by AA mothers while providing MOM for their VLBW infants.

METHODS

In this qualitative, descriptive study, we conducted semistructured interviews with AA mothers who provided MOM for their VLBW infant. Interviews were transcribed and manually coded concurrently with enrollment until theoretical saturation was achieved. Infant charts were reviewed for demographics, and triangulation with notes from the medical record by bedside nurse lactation consultants and other providers was performed to increase validity. Member checks were completed to ensure true meaning of responses.

RESULTS

Theoretical saturation was achieved after 9 interviews. Themes perceived to support provision of MOM included (1) Being a Mother; (2) Neonatal intensive care unit environment; (3) Community support; and (4) Useful resources. Themes that emerged as barriers to the provision of MOM were: (1) Maternal illness; (2) Milk expression; (3) Challenging home environment; and (4) Emotional distress.

IMPLICATIONS FOR PRACTICE

African American mothers report supports similar to published data but faced challenges not previously reported. These factors warrant attention by professionals who support lactation in this population.

IMPLICATIONS FOR RESEARCH

Future research will address perceived barriers to improve provision of MOM and the quality of the lactation journey of AA mothers of preterm infants.

Administration of Fortifier by Finger Feeder During Breastfeeding in Preterm Infants

OBJECTIVE

To evaluate the acceptance, adherence, and feasibility of fortifier administration by finger feeder during breastfeeding and to determine weight, length, and head circumference gains after discharge for preterm infants.

DESIGN

Observational pilot study.

SETTING

A Level III NICU and its outpatient clinic in Vienna, Austria.

PARTICIPANTS

Infants born at younger than 34 weeks gestation were included.

METHODS

Mothers were screened in a tertiary NICU and trained by certified lactation consultants to administer fortifier with a finger feeder during breastfeeding. Data on finger feeder use at home were collected by self-reported feeding diaries and questionnaires.

RESULTS

In total, data from 24 mother-infant dyads were analyzed. The acceptance rate was 67%. In 41.7%, more than 50% of meals were fortified. Mothers did not report problems in preparation, but 33% of the infants stopped latching on or drooled milk during finger feeder use.

CONCLUSION

Use of a finger feeder to administer fortifier to preterm infants enabled mothers to exclusively breastfeed their infants and meet their nutritional needs. The development of further methods to augment preterm infant nutrition that do not interfere with breastfeeding is of great interest.

Implementation of Feeding Guidelines Hastens the Time to Initiation of Enteral Feeds and Improves Growth Velocity in Very Low Birth-Weight Infants

BACKGROUND

Growth and nutrition are critical in neonatal care. Whether feeding guidelines improve growth and nutrition and reduce morbidity is unknown.

PURPOSE

Feeding guidelines for very low birth-weight (VLBW) infants were implemented in our neonatal intensive care unit (NICU) to start and achieve full enteral feeds sooner, and increase weight gain over the first month.

METHODS

Feeding guidelines for VLBW infants were implemented in January 2014, stratified by birth weight (<750, 750-1000, and 1000-1500 g). After trophic feedings, enteral feedings were advanced by 20 to 30 mL/kg/d.Data were analyzed for 2 years prior (baseline) and 6 months after (guideline) guidelines were implemented and included days to initiation of enteral feeds, days on total parenteral nutrition (TPN), and weight gain over the first month. Potential concomitant factors that could affect feeding tolerance were examined including indomethacin or dopamine treatment, delivery room cardiopulmonary resuscitation, and growth restriction.

RESULTS

A total of 95 infants with a birth weight of less than 1500 g were included (59 baseline and 36 guideline). Days to start enteral feeds decreased by 47% (P < .01) and days on TPN decreased by 25% (16 days vs 11 days; P < .01). Weight gain over the first month of life increased by 15% (p < .05). Dopamine and indomethacin use decreased during the study period, and small for gestational age infants were overrepresented in the guideline group.

IMPLICATIONS FOR PRACTICE/RESEARCH

Establishment of feeding guidelines for VLBW infants in our NICU reduced the days to start feeds and days on TPN while increasing weight gain over the first month. Improving growth and nutrition and reducing need for TPN in this vulnerable population may ultimately prevent infection and improve neurodevelopmental outcomes.

Eating in "SINC": Safe Individualized Nipple-Feeding Competence, a Quality Improvement Project to Explore Infant-Driven Oral Feeding for Very Premature Infants Requiring Noninvasive Respiratory Support

Oral feeding is a developmental task for all premature infants. often, independent nipple feeding is the last barrier to discharge home from the NICU. A relationship exists between consistent, infant-driven feeding management practices and improved feeding performance. Conversely, a random approach to feeding may contribute to poor short-term and long-term clinical outcomes. We report a quality improvement project that was undertaken across five NICUs in an urban setting. our aim was to safely initiate and advance nipple feeding for very preterm neonates (born at <32 weeks gestation) who had a respiratory morbidity requiring nasal continuous positive airway pressure therapy. A novel algorithm entitled "eating in SINC: Safe individualized nipple-Feeding Competence" was developed. Safe individualized nipple-feeding competence involves the baby, the parents, and the health care team by using infant-driven strategies, common language, and developmentally appropriate goals while supporting fragile neonates to be skilled feeders.