Barriers to Providing Mother's Own Milk to Extremely Preterm Infants in the NICU

An innovative low-cost breast pump-hire program to enhance breastfeeding rates in a neonatal intensive care unit

AIM

To evaluate the outcomes of a low-cost hospital-grade breast pump hire program for women experiencing financial hardship with infants in neonatal intensive care.

DESIGN

A multi-method evaluation including data audits and surveys.

METHODS

Twenty-four electric breast pumps were purchased and rented to mothers at a cost of $1/day. To be eligible, mothers needed to have given birth to an infant <32 weeks and/or <1500 g and self-identified as experiencing financial hardship. Data were collected by (1) a retrospective audit to evaluate infant feeding and clinical outcomes at hospital discharge; (2) prospective telephone surveys to evaluate women's satisfaction with the program; and (3) analysis of the breast pump register to determine any loss or damages.

RESULTS

Twenty-four mothers of 26 infants participated in the program. More than half of the infants were exclusively breastmilk fed at hospital discharge, and more than three-quarters were fed a combination of breastmilk and formula. Women who intended to formula feed were supported to provide breastmilk to their infants in the first few weeks of life. Most participants were highly satisfied with the program. Women reported that accessibility to a hospital-grade breast pump improved their ability to provide expressed breastmilk to their infants. Most participants were 'extremely satisfied' with the performance of the breast pump. One-quarter of the women reported that they would have exclusively formula-fed if they did not have access to the breast pump hire program. The audit of the equipment register showed no reported technical issues, loss or damages.

CONCLUSION

The findings suggested that the low-cost breast pump hire program supported equitable care, increasing women's ability to provide expressed breastmilk for their infants.

IMPACT

Providing access to low-cost hospital-grade breast pumps to mothers of vulnerable infants is likely to prevent poor infant clinical outcomes and improve women's care satisfaction.

PUBLIC OR PATIENT CONTRIBUTION

Nil.

Barriers and Facilitators in Lactation Support for the Preterm Mother-Infant Dyad: An Integrated Approach

Breastfeeding offers significant health benefits for both mothers and infants, particularly preterm infants, where it serves as a therapeutic strategy to reduce mortality and morbidities. However, breastfeeding practices are threatened globally by societal norms and systemic barriers at both micro and macro levels. This paper explores the complex interplay of these barriers and facilitators, focusing on the Neonatal Intensive Care Unit (NICU) setting. Preterm infants face specific feeding challenges due to immature physiological functions, yet evidence supports that strategies like cue-based feeding and individualized care can enhance feeding success and health outcomes. For mothers, initiating and maintaining lactation after preterm birth is critical but challenging, with early lactation support and achieving sufficient milk volume being key predictors of success. Partner support significantly influences lactation outcomes, although more inclusive research is needed for diverse family structures. In the NICU, a multidisciplinary approach to lactation care is vital, emphasizing the need for experienced staff and family-centered practices. NICU design, policies promoting parental presence, and adherence to Baby-friendly Hospital Initiative guidelines further support breastfeeding. This paper aims to provide directives for local breastfeeding policies through an integrated approach, considering societal attitudes and healthcare practices. The findings advocate for improved lactation support in NICUs, inclusive language and policies, and further research into diverse familial and gender roles in breastfeeding.

Exclusive Human Milk Diets and the Reduction of Necrotizing Enterocolitis

BACKGROUND

Necrotizing enterocolitis (NEC) is common in preterm infants, especially infants less than 32 weeks gestation. Mortality from NEC is 7% and occurs in 1 out of 1000 preterm infants. Studies have shown the efficacy of an exclusive milk from mother diet in decreasing rates of NEC and associated mortality.

PURPOSE

To evaluate the effectiveness of an existing exclusive human milk diet (EHMD) protocol on the incidence of NEC in extremely premature infants. EHMD, for the purposes of this project is defined as breast milk of mother, with or without human milk-based fortifier.

METHODS

A single-center retrospective quasi-experimental study. The sample included 201 infants born less than 32 weeks gestation, weighing less than 1250 grams, small for gestational age (SGA) and with low Apgar scores. Outcomes measured included incidences of NEC, mortality, and co-morbidities in infants pre- and postinitiation of an EHMD protocol.

RESULTS

Just 4.8% of the EHMD group had a NEC diagnosis compared to 10.5% of the bovine-based (BOV) group. There was a 1% mortality rate of the EHMD group as compared to 6% in the BOV group. The EHMD group had a statistically significant greater weight gain during hospitalization as compared to infants fed BOV ( P = < .05).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Neonatal intensive care units should consider EHMDs for use in this infant population. Future research is needed to support dissemination of the use of EHMD as standard of practice.

Mothers' experiences of privacy in neonatal intensive care units: A qualitative study

BACKGROUND

Examining the privacy experiences of mothers in neonatal intensive care units (NICUs) can play a crucial role in bolstering patient privacy safeguards and elevating the overall quality of health care. However, our understanding of mothers' experiences regarding privacy issues they may face after their infants' hospitalization in the NICU is limited.

AIM

This study aimed to investigate the experiences of mothers concerning privacy within NICUs to contribute valuable insights for improving infant care and privacy protection.

DESIGN

A qualitative content analysis using a conventional approach was conducted. A total of 18 participants, with diverse sociodemographic backgrounds, were interviewed using open-ended questions. Qualitative content analysis was undertaken for data analysis.

SETTING

The study was conducted in the NICU of an urban teaching hospital in Iran.

RESULTS

The study identified four main themes: 'understanding of privacy', 'fluctuating respect for privacy', 'efforts to maintain privacy' and 'privacy barriers'. Participants viewed privacy as multidimensional, influenced by cultural and religious factors. Respect for privacy varied, with instances of both adherence and violation. Mothers employed strategies to preserve privacy, emphasizing the importance of their infants' privacy. Privacy barriers included hospital attire, the physical space of the NICU, inhomogeneous human resources and insufficient supervision and training.

CONCLUSION

This study, the first of its kind in the NICU context, provides valuable insights into maternal experiences of privacy. Integrating these insights into practice and future research can contribute to creating more empathetic and privacy-respecting NICU environments.

RELEVANCE TO CLINICAL PRACTICE

Health care providers can use these findings to enhance support for mothers, potentially reshaping physical spaces and communication practices within NICUs.

Mothers' experiences of breast milk expression during separation from their hospitalized infants: a systematic review of qualitative evidence

BACKGROUND

Mother-infant separation, which is occurring with an increasing incidence, is a barrier to direct breastfeeding. Owing to the importance of breast milk to hospitalized infants, mothers are actively encouraged to express milk during their infants' neonatal intensive care unit (NICU) stay. However, mothers are often faced with a number of challenges in this process. There is a need to understand such mothers' real-life experiences of breast milk expression to develop supportive strategies to reduce the burden on mothers and increase breastfeeding rates.

METHODS

A comprehensive search of 12 databases was conducted for relevant studies published from database construction to December 2022. All qualitative and mixed-method studies published in English and Chinese that reported on mothers' experiences of human milk expression during separation from their hospitalized infants were included. Two reviewers independently conducted screening, data extraction, and quality appraisal, with disagreements resolved by a third reviewer. The process of searching followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. The JBI Qualitative Assessment and Review Instrument was used to assess study quality and the credibility of study findings. Meta-aggregation was performed to integrate the results.

RESULTS

This systematic review aggregated mothers' experiences of milk expression during separation from their hospitalized infants. Database search yielded 600 records, of which 19 full-text documents were screened. Finally, 13 studies of good quality were included with data from 332 mothers across seven countries. A total of 61 primary findings with illustrations were extracted from the 13 eligible studies, the findings were generalized into 16 categories, and further were concluded as four synthesized findings: purpose and motivation, physical and emotional experiences, barrier factors, and coping styles.

CONCLUSION

Mothers were driven by extrinsic motivation in their decision to express breast milk. They experienced physical exhaustion and many negative emotional feelings while expressing. This process was affected by numerous barriers. Social support was essential to the initiation and maintenance of milk expression. Medical staff and families should pay more attention to the mental health of mothers with infants in the NICU. Future research should incorporate strategies to cope with emotional responses and offer practical strategies for managing milk expression.

SYSTEMATIC REVIEW REGISTRATION

[ www.crd.york.ac.uk ], identifier [PROSPERO 2022 CRD42022383080].

A Mobile App to Promote Breastfeeding Self-Efficacy in Preterm Infants' Mothers: Development and Validation

Improving breastfeeding rates is a global goal. To achieve it, actions targeting modifiable factors that influence the breastfeeding experience, such as maternal self-efficacy, could be a promising path, especially with preterm infants' mothers. Considering the current ubiquitous technology, we developed a mobile application for mothers of preterm infants to constitute a breastfeeding information and support platform. The study was developed in three phases: a survey to determine characteristics and preferences of preterm infants' mothers; the app development by an interdisciplinary team, following the principles of Disciplined Agile Delivery; and the face and content validation by 10 professionals. The app contains 80 screens and 11 strategies to address prematurity, lactation, breastfeeding, peer support, maternal emotions, resilience, and motivation. Nurses can apply their expertise by designing mHealth-based interventions, employing scientific evidence, and considering the interests and preferences of the target population. Future studies will assess the user experience, the effect on breastfeeding self-efficacy, and breastfeeding rates, and develop a culturally adapted English version of the app for women in Canada.

Breastfeeding Characteristics and Duration of Feeding Human Milk in Infants With Congenital Heart Disease

BACKGROUND

Although infants with congenital heart disease (CHD) are able to breastfeed successfully, the factors that affect feeding human milk across the first year are not well established.

PURPOSE

The objective of this study was to examine breastfeeding characteristics and their relationships to the exclusivity and duration of feeding human milk among infants with CHD.

METHODS

Breastfeeding characteristics data from a cohort of 75 infants with CHD enrolled in a study that examined relationships among milk type and infant growth in the first year of life were analyzed.

RESULTS

Infants whose mothers reported not having enough milk were exclusively fed human milk for a shorter duration than those who did not have this challenge ( P = .04); however, the duration of feeding any human milk did not differ ( P = .18). Average daily volume expressed at 1 month was positively related to the duration of exclusive human milk (β = .07, P = .04) and any human milk (β = .07, P = .04) feeding.

CONCLUSIONS

Future efforts to support feeding human milk in infants with CHD should emphasize practices that support maximal human milk production.

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.

Factors Which May Contribute to the Success or Failure of the Use of Mother's Own Milk in a Level IV Neonatal Intensive Care Unit

BACKGROUND

Benefits of mother's own milk (MOM) for infants in neonatal intensive care units (NICUs) are well known. Many mothers provide for their infant's feedings during their entire hospitalization while others are unable. Knowledge is limited about which infant and maternal factors may contribute most to cessation of MOM feedings.

PURPOSE

Study aims were to (1) identify which maternal and infant risk factors or combination of factors are associated with cessation of provision of MOM during hospitalization, (2) develop a lactation risk tool to identify neonatal intensive care unit infants at higher risk of not receiving MOM during hospitalization, and (3) identify when infants stop receiving MOM during hospitalization.

METHODS

A data set of 797 infants admitted into a level IV neonatal intensive care unit before 7 days of age, whose mothers chose to provide MOM, was created from analysis of data from the Children's Hospital Neonatal Database. Maternal and infant factors of 701 dyads who received MOM at discharge were compared with 87 dyads who discontinued use of MOM by discharge using χ 2 , t tests, and Wilcoxon rank tests. Logistic regression was used to build a risk-scoring model.

RESULTS

The probability of cessation of MOM increased significantly with the number of maternal-infant risk factors. A Risk Calculator was developed to identify dyads at higher risk for cessation of MOM by discharge.

IMPLICATIONS FOR PRACTICE

Identifying mothers at risk for cessation of MOM can enable the healthcare team to provide optimal lactation management and outcomes.

IMPLICATIONS FOR RESEARCH

Although the Risk Calculator has potential to identify dyads at risk of early MOM cessation, further research is needed to validate these results.

First Feed Type Is Associated With Birth/Lactating Parent's Own Milk Use During NICU Stay Among Infants Who Require Surgery

BACKGROUND

Early exclusive birth/lactating parent's own milk (B/LPOM) feeds have been associated with longer duration of B/LPOM use for infant feedings in healthy term and hospitalized preterm infants. This relationship has not been explored in infants undergoing neonatal surgery (surgical infants).

PURPOSE

To evaluate the relationship between early exclusive B/LPOM feeds and cumulative B/LPOM patterns during surgical infants' neonatal intensive care unit (NICU) hospitalization.

METHODS

A secondary cross-sectional analysis was performed using the electronic health record data of surgical infants admitted to a level IV NICU between January 2014 and March 2015. Multiple linear regression and Fisher's exact test were used to examine the associations between first NICU feed type and total percentage of diet composed of B/LPOM during NICU stay and continuation of any or exclusive B/LPOM feedings at NICU discharge, respectively.

RESULTS

The analysis included 59 infants who required surgery for gastrointestinal, cardiac, or multisystem defects or pregnancy-related complications. Receipt of B/LPOM as the first NICU feed was associated with higher percentage of B/LPOM feeds ( P < .001) throughout NICU stay, as well as continuation of any or exclusive B/LPOM feedings at NICU discharge ( P = .03).

IMPLICATIONS FOR PRACTICE

Early exclusive B/LPOM feeds may be an important predictor for continuation of any B/LPOM use throughout the NICU stay and at NICU discharge. Continued efforts to identify and address gaps in prenatal and postpartum lactation support for parents of surgical infants are needed.

IMPLICATIONS FOR RESEARCH

Powered studies are needed to corroborate these findings and to explore the potential impact of other factors on duration and exclusivity of B/LPOM use.

VIDEO ABSTRACT AVAILABLE AT

https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx .

Antenatal breastfeeding promotion amongst pregnancies at high-risk for newborn admission to the NICU: A cross-sectional study

Objectives

To determine the prevalence and factors associated with antenatal promotion of breastfeeding in high-risk pregnancies.

Study design

This was a cross-sectional study of trends in breastfeeding promotion during antenatal consultation of pregnancies at high-risk for newborn admission to the neonatal intensive care unit (NICU) between January 2017 and December 2020. Eligible high-risk pregnant patients undergoing antenatal consultation in a tertiary-level fetal assessment unit were identified using an electronic clinic repository. Consult letters and fetal assessment reports were reviewed to determine baseline demographics, pregnancy history, fetal findings, and communication about breastfeeding. Descriptive and inferential statistics were used to present findings and compare outcomes between groups.

Results

316 pregnancies were included for final analysis. The mean maternal age was 28.7 years (SD 6.2) and 65 % were multiparas. Median gestational age at time of antenatal consult was 32 weeks [IQR 29–34]. The main indication for consultation was fetal anomalies (72.8%), namely cardiac defects (21.2 %). There was a significant improvement in prevalence of antenatal discussions about breastfeeding over the study period, from 48.8 % early in the study period compared to 73.7 % in the past year (p = 0.036). However, amongst consults where breastfeeding was discussed, almost one-quarter (23.8 %) of patients indicated that they were not planning on breastfeeding postnatally.

Conclusion

There has been a significant improvement in promoting breastfeeding antenatally amongst high-risk pregnancies. However, no follow-up or supports were offered to one-quarter of patients who indicated no intention of breastfeeding or using donor milk postnatally. Ongoing work is required to further advance breastfeeding promotion antenatally, increase parental supports and education, and optimize breastfeeding rates postnatally for improving outcomes of this high-risk group.

•

While there has been a significant improvement in antenatal breastfeeding promotion amongst high-risk pregnancies, it is still missing in almost one-quarter of patients.

•

There are no obvious demographic or clinical differences between high-risk patients that received antenatal breastfeeding promotion versus those that did not, suggesting that a more standardized approach to antenatal discussions about infant feeding could improve breastfeeding success in the NICU.

•

Ongoing work is required to further improve breastfeeding promotion antenatally along with additional postnatal supports to enhance breastfeeding success.

Increasing early exposure to mother's own milk in premature newborns

OBJECTIVE

Increase the proportion of ≤33 weeks newborns exposed to mother's own milk (MOM) oral care by 12 h of age by 20% over 2 years to support a healthier microbiome.

STUDY DESIGN

We implemented interventions to support early expression of colostrum and reliable delivery of resultant MOM to premature newborns. Statistical process control charts were used to track progress and provide feedback to staff. Proportions of newborns exposed to MOM by 12 h were compared relative to baseline.

RESULTS

There were 46, 66, and 46 newborns in the baseline, implementation, and sustainability periods, respectively. The primary outcome improved from 48% to 61% in the implementation period (relative change 1.27, 95% CI 0.89, 1.81, p = 0.2), to 69% in sustainability period (relative to baseline 1.45, 95% CI 1.02, 2.08, p = 0.03).

CONCLUSION

An interdisciplinary team-based, multicycle, quality improvement intervention resulted in increased rates of early exposure to MOM.

Behavioral and emotional outcomes at preschool age in children born very preterm: The role of breast milk feeding practices

BACKGROUND

Breast milk feeding (BMF) improved neurodevelopment in children born very preterm (VPT, <32 weeks of gestation), but knowledge about its effect on other mental health outcomes remains limited.

OBJECTIVE

To estimate the association of BMF practices with behavioral and emotional problems at preschool age in children born VPT.

METHODS

We studied 263 children born VPT during 2011-12 and enrolled in the Portuguese EPICE cohort. At the age of 3, information on BMF initiation and duration was collected and behavioral and emotional problems were assessed using the parents' completed Child Behavior Checklist 1.5-5 years (CBCL/1½-5). Children were categorized for all CBCL/1½-5 sub-scales and for Diagnostic and Statistical Manual of Mental Disorders (DSM5)-oriented scales. Risk ratios were estimated to assess the association of BMF with subclinical/clinical problems, fitting a Poisson regression.

RESULTS

Behavioral or emotional subclinical/clinical problems were found in almost 20% of children (11.8% in the clinical range). BMF was consistently associated with lower adverse behavioral and emotional outcomes, particularly risks of externalizing problems, somatic complaints, aggressive behavior, as well as autism spectrum and attention deficit/hyperactivity symptoms, although the magnitude of the unadjusted risks was attenuated by adjustment for relevant confounders and wider confidence intervals included the null.

CONCLUSION

Lower exposure to BMF seemed to increase the risk of adverse behavioral and emotional outcomes at preschool age in children born VPT. These results raise questions about explanatory pathways and strengthen evidence underpinning BMF promotion for VPT children.

Experience using donor human milk: A single-center cohort study in Japan

BACKGROUND

Donor human milk (DHM) became available in Japan when the first human milk bank was established in 2017. This study investigated the effects of DHM on enteral nutrition (EN) in very low birth weight (VLBW) infants in the single center in Japan.

METHODS

Seventy-six VLBW infants hospitalized between April 2017 and March 2020 at Showa University Hospital were included in the study. We retrospectively evaluated age (hours) at which EN was initiated and age (days) until complete feeding (EN > 100 mL/kg/day) was achieved. We compared the DHM and non-DHM groups, or the early human milk (EHM) and non-EHM groups. The EHM group was defined as those in which EN was initiated with the mother's own milk or DHM within 12 h of birth.

RESULTS

In 30 extremely low birth weight (ELBW) infants, EN was initiated at significantly earlier postnatal hours in the DHM group compared to those in the non-DHM group. Complete feeding was achieved at significantly earlier ages in the EHM group after adjusting for gastrointestinal complications and gestational age. Additionally, the changes in body weight z-scores from birth to term-equivalent age were significantly greater in the EHM group after adjusting for exclusive breastfeeding and small for gestational age, compared to the non-EHM group. Statistical significance was not noted in 46 subjects (birth weight, 1000-1500 g).

CONCLUSION

The use of DHM may contribute to earlier initiation and achievement of EN, resulting in greater early postnatal growth in ELBW infants in Japan.

Using a WeChat mini-program-based lactation consultant intervention to increase the consumption of mother's own milk by preterm infants in the neonatal intensive care unit: a study protocol for a cluster randomized controlled trial

BACKGROUND

The benefits of mother's own milk (MOM) for preterm infants have been widely recognized. Many studies have shown that the rate of breastfeeding of premature infants remains very low. Although many studies use measures to promote breastfeeding, few high-quality cluster randomized controlled studies have evaluated the effectiveness of these measures. WeChat is an instant messaging software for smart terminals, and WeChat mini-programs have been widely used to promote health and self-management in China. Based on this background, we designed a randomized controlled study based on WeChat mini-programs to promote MOM feeding of premature infants in the neonatal intensive care unit (NICU).

METHODS/DESIGN

This study will evaluate the effectiveness of WeChat mini-programs to increase the consumption of MOM feeding in twelve NICUs in Jiangsu Province, namely, six "intervention" NICUs and six "control" NICUs. The study process is as follows: (1) design and preparation, (2) NICU recruitment and training, (3) interpretation and analysis of baseline data, (4) quality control implementation process, and (5) data analysis feedback and publication of study reports. The primary outcome is the proportion of MOM feeding of premature infants during NICU hospitalization. The secondary outcomes are as follows: (1) time to initiation of MOM feeding (hours) and proportion of first-time MOM feeding (%), (2) duration of parenteral nutrition (days), (3) time to total gastrointestinal feeding (days), (4) hospitalization time and hospitalization cost, and (5) incidence of complications (necrotizing enterocolitis, bronchopulmonary dysplasia, feeding intolerance, late-onset sepsis, retinopathy of prematurity).

DISCUSSION

This study is the first cluster randomized controlled trial on the intervention of using a WeChat mini-program-based lactation consultant for premature infants in the NICU in China. We hope this study can improve the consumption of MOM by NICU premature infants during hospitalization through the intervention of WeChat mini-programs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04383379. Registered on May 5, 2020.

Human milk microbes: Strategies to improve delivery to the infant

Mother's own milk provides personalized nutrition and immune protection to the developing infant. The presence of healthy microbes plays an important role in the infant's gut by programming the microbiota and excluding potential pathogens. This review describes the important components in mother's own milk that contribute to its superiority for infant nutrition and suggest potential strategies to replicate these factors in alternative feedings when sufficient milk is unavailable. Current strategies to supplement, substitute and replicate mother's own milk including microbial restoration, use of unpasteurized donor human milk, probiotics and fortification are discussed. Critical work remains to be done in understanding the human milk microbiome and metabolome and in improving lactation support for mothers of preterm infants. Increasing delivery of mother's own milk and milk components to infants would likely positively impact infant mortality and health worldwide.

Parents' Experience of Having an Infant in the Neonatal Intensive Care Unit: A Qualitative Study

INTRODUCTION

Admission to the neonatal intensive care unit (NICU) is usually unexpected and can be stressful to the parents causing strenuous psychosocial effects. Parents of these infants are subject to suffering stress, depression, and feelings of powerlessness. This study aimed at describing parents' experience of having their infant in the neonatal intensive care unit.

METHOD

 A qualitative descriptive design was used. Parents (six couples and four mothers) of infants hospitalized for at least ten days regardless of gestational age, gender, or medical diagnosis were selected from a teaching hospital in Amman, Jordan. Semi-structured interviews were conducted between June 2019 and November 2019.

RESULTS

 Thematic analysis of the data revealed four emerging themes: (1) Living the ambiguities of the admission to the NICU, (2) Living the burdens of their infants' hospitalization, (3) Coping with the stresses of a hospitalized infant, and (4) Reflecting on interactions with healthcare staff and the environment.

DISCUSSION AND CONCLUSION

 The study findings demonstrated parents' worries and needs and highlighted the use of spirituality/religiosity as a coping mechanism. The findings will guide healthcare providers and policymakers to develop caring strategies that enhance care delivered to parents of infants in intensive care units.

Mapping the Field in Stress, Anxiety, and Postpartum Depression in Mothers of Preterm Infants in Neonatal Intensive Care

Objective: The main aim of this study was to describe and conduct a bibliometric analysis of the state of research on stress, anxiety, and postpartum depression in mothers of preterm infants in the Neonatal Intensive Care Unit. Background: Women affected by premature births are particularly exposed to mental health difficulties in the postpartum period. The desire to comprehend and the growing interest in research on stress, anxiety, and postpartum depression in mothers of preterm infants in neonatal intensive care have led to a substantial rise in the number of documents in this field over the last years. Thus, it makes it vital to regularly review the state of knowledge on this phenomenon in order to identify progress and constraints, to stimulate reflection, and to encourage progress in future research. Method: This study examined 366 articles published in the Scopus database (1976–2020). Keyword analysis was also used to identify hot research trends to be developed in future studies. This study complies with the PRISMA-Scr guidelines for quality improvement research in the EQUATOR network. Results: Our results reveal that research in this field is in a period of high production and allows this flourishing body of work to be organized into different periods, highlighting the most important themes. In such a way, our research enriches the lively field by presenting a comprehensive understanding of the field. Discussion: The key contribution of this study is the development of a conceptual map of research on stress, anxiety, and postpartum depression in mothers of preterm infants in neonatal intensive care units.

Tube Feeding Practices and Transition to Breastfeeding Experiences of Mothers of Preterm Infants at a Kangaroo Mother Care Unit of a Tertiary Hospital in South Africa

To receive human milk, most preterm infants initially receive the mothers’ expressed milk through a nasogastric tube. However, breast milk feeding the preterm infant and making the transition to direct breast-feeding come with significant challenges. The study explored and described the experiences of mothers of preterm infants regarding initiation and expressing breast milk, tube feeding practices, and transition to breastfeeding during the infants’ stay in a kangaroo care unit (KMC) of an academic hospital in South Africa. Using a qualitative design, focus group interviews were conducted with 38 mothers of preterm infants after discharge from the neonatal intensive care unit (NICU). We analyzed transcripts following the 5 steps for qualitative thematic data analysis. Tube feeding and breastfeeding preterm infants was challenging and exhausting for the mothers. Many described their experiences of initiating expression and sustaining milk supply as negative. They had constant concerns about their ability to produce adequate milk volumes to feed their infants. They had immense dislike of expressing, which they described as physically exhausting, stressful, and painful. Those who had initiated breastfeeding were highly motivated to breastfeed their preterm infants. They described breastfeeding as a positive bonding experience that they derived pleasure from. The mothers’ dislike of expressing was overshadowed by their emotional obligation toward their preterm infants. Although the KMC unit promotes breastfeeding, mothers encountered problems and struggled to initiate expression and sustain milk production. Mothers of extreme and very preterm infants need support to continue with milk expression during the long NICU and KMC stay.

Baby-Friendly Hospital Initiative for Neonatal Wards: impact on breastfeeding practices among preterm infants

OBJECTIVE

to assess breastfeeding support practices for preterm infants at two Baby-Friendly hospitals in southeastern Brazil, comparing the effect of implementing the guidelines for Baby-Friendly Hospital Initiative for Neonatal wards.

METHODS

a quasi-experimental study, pre- and post-intervention with control. Implementation of this initiative in the intervention hospital using Knowledge Translation. Data collection on compliance with the adapted Ten Steps, Three Guiding Principles and the Code before and after the intervention was carried out via interviews with mothers of preterm babies and professionals, unit observation and documentary analysis in the intervention and control hospitals. Intra-intergroup comparison was performed.

RESULTS

increases in global compliance with the Three Principles, Ten Steps, the Code, partial compliance with each Principle and in most Steps was greater in the intervention hospital. Conclusion: this initiative improved practices related to breastfeeding in the intervention hospital, demonstrating the potential to improve care and breastfeeding in neonatal wards.

Factors associated with postpartum women's knowledge, attitude and practice regarding human milk banks and milk donation: A cross-sectional survey

BACKGROUND

Breast milk is the optimal method of human nutrition, and donor human milk is often needed to reduce the incidence of necrotizing enterocolitis and septicemia in preterm infants and improve their survival rate. Donor human milk is recommended as the first alternative when mothers' milk is not available. The establishment of human milk banks is of great significance to promote the breastfeeding of preterm infants. However, there are insufficient studies on human milk banks and milk donation in China.

OBJECTIVES

(1) To investigate postpartum women's knowledge, attitude and practice regarding human milk banks and milk donation and to analyze the influencing factors. (2) To explore reasons why postpartum women reject milk donation and donor milk.

DESIGN AND SETTINGS

A cross-sectional survey was conducted from February 2019 to July 2019 at two hospitals in Wuhan, a large city in central China.

PARTICIPANTS

Mothers who returned to hospital for postpartum follow-up within six months participated in this survey (N = 1078).

METHODS

Questionnaires were used to obtain sociodemographic data and to determine participants' knowledge, attitude and practice regarding human milk banks and milk donation.

FINDINGS

Of the respondents, 216 (20%) had prior knowledge of human milk banks and milk donation. For the sub-domain of knowledge, the item with the highest correct response rate was the benefit of breast milk, and the item with the lowest correct rate was the acceptance of donor human milk. For the sub-domain of attitude, 811(75.3%) of participants held a supportive attitude for the establishment of human milk banks, and 877(81.3%) were supportive of donating breast milk while 412 (38.3%) were supportive of accepting donor human milk. For the sub-domain of practice, the practice of milk donation was not optimistic as participants lacked interest in donating breast milk and spreading knowledge of breast milk banks, and only 28.3% of participants indicated that they would donate breast milk continuously. Participants' age, educational background, weight of the newborn and having prior knowledge of human milk banks were factors that could positively predict their knowledge, attitude and practice associated with human milk banks and milk donation; medication usage during pregnancy or lactation was a factor negatively predicting their knowledge about human milk banks and milk donation.

CONCLUSION

This study reveals that a majority of postpartum women are supportive of human milk banks and more willing to donate breast milk than receive donor milk. Lack of knowledge about human milk banks and safety concerns are the main factors hindering postpartum women from donating or accepting donor milk. Findings suggest that it is important to enhance public awareness regarding human milk banks as potential resources for life-saving therapy for preterm infants.This information should be disseminated during the early stage of the establishment of human milk banks. Moreover, health education of pregnant women should include the importance of human milk as well as the alternative and safety of donor milk from milk banks, especially for promoting the health of preterm infants and infants who are unable to receive mothers' breastmilk.