An Integrative Review of Factors that Influence Breastfeeding Duration for Premature Infants after NICU Hospitalization

Breastfeeding Practice Before Bottle-Feeding: An Initiative to Increase the Rate of Breastfeeding for Preterm Infants at the Time of Neonatal Intensive Care Unit Discharge

Preterm babies who received 72 hours of breastfeeding practice before introducing a bottle had significantly higher rates of breastfeeding at the time of neonatal intensive care unit (NICU) discharge than did babies who were introduced to bottle-feeding with or before breastfeeding during the first 72 hours of oral feeding or babies who were primarily bottle-fed. There were no statistical differences in corrected gestational age (CGA) at birth, first oral feeding, or full oral feeds, in days from first to full oral feeds, or in CGA or days of life at NICU discharge.

Predictors of Breastfeeding among Women Admitted with Severe Preeclampsia Before 34 Weeks

OBJECTIVE

 Patients with severe preeclampsia (sPREX) face barriers to successful breastfeeding (BF), including an increased risk of maternal and newborn complications, prematurity, and low birth weight. Patients with early-onset sPREX (before 34 weeks' gestation) may be at even greater risk, yet there are little data available on factors associated with BF challenges in this population. We describe rates of BF initiation at hospital discharge and BF continuation at postpartum (PP) visit and identify factors associated with BF noninitiation and BF cessation among patients admitted with early-onset sPREX.

STUDY DESIGN

 Retrospective cohort study of women with sPREX admitted at less than 34 weeks' gestation to a single tertiary center (2013-2019). Demographic, antepartum, and delivery characteristics were evaluated. Factors associated with BF noninitiation at maternal discharge and with BF cessation at routine PP were assessed. Patients with intrauterine or neonatal demise and those missing BF data were excluded. Bivariate statistics were used to compare characteristics and Poisson regression was used to estimate relative risks (RR).

RESULTS

 Of 255 patients with early-onset sPREX, 228 (89.4%) had BF initiation at maternal hospital discharge. Initiation of BF occurred less frequently among patients with tobacco use in pregnancy (7.5 vs. 37.0%, χ2 p < 0.001, RR: 0.69 [95% confidence interval, CI: 0.52-0.92]). At 6 weeks' PP, 159 of 199 (79.9%) patients had BF continuation. Maternal age under 20 years (1.9 vs. 17.5%, χ2 p = 0.01, RR: 0.36 [95% CI: 0.14-0.91]) and experiencing maternal morbidity (25.2 vs. 45.0%, χ2 p = 0.01, RR: 0.80 [95% CI: 0.66-0.96]) were associated with BF cessation at the PP visit.

CONCLUSION

 Among patients with early sPREX, tobacco use in pregnancy was associated with noninitiation of BF at discharge, whereas young maternal age and maternal morbidity were associated with cessation of BF by routine PP visit. Further research is needed on how to support BF in this population, especially among patients with these associated factors.

KEY POINTS

· Tobacco use was associated with BF noninitiation in patients with early preeclampsia.. · Maternal age < 20 and maternal morbidity were associated with BF cessation by PP visit.. · BF support for patients with risk factors is important for BF success PP..

Pressure to provide milk among mothers of very low birth weight infants: an explorative study

BACKGROUND

Pump-dependent mothers of very low birth weight (VLBW, < 1500g) infants experience specific challenges achieving sufficient milk supply in the neonatal intensive care unit (NICU) and are therefore less frequently able to achieve (exclusive) breast milk feeding. Stress due to the limitations on participating in the infant's care may contribute to this problem. Some explorative studies suggest that pressure to provide milk may be an additional stressor in mothers. However, the type of pressure to provide milk perceived by mothers of VLBW infants has rarely been examined.

METHODS

A retrospective and anonymous questionnaire was conducted with mothers of VLBW infants aged 6 to 24 months at the time of data collection. Quantitative data and written comments were used to examine the mothers' perceptions. Descriptive and bivariate tests (Spearman´s rho, Pearson's chi2) were performed to show correlations between pressure to provide breast milk, parental stress (PSS:NICU: role alteration subscale), milk volume, and maternal factors. Pressure to provide milk was measured through two self-developed single items to differentiate between internal and external pressures.

RESULTS

Data of n = 533 mothers of VLBW infants was analysed. More than 70% of the mothers agreed that they pressured themselves to provide milk for their infant. In contrast, 34% of the mothers agreed that they felt pressure from outside to provide milk. Higher milk volume 14 days post-partum was significantly correlated with higher internal (Spearman´s rho = 0.2017, p = 0.000) and higher external pressure to provide milk (Spearman´s rho = 0.2991; p = 0.000). Higher PSS:NICU parental role alteration scores were significantly correlated with more internal (Spearman´s rho = -0.2865, p = 0.000) and more external pressure to provide milk (Spearman´s rho = -0.1478; p = 0.002). Milk volume 14 days post-partum and the PSS:NICU were not significantly correlated (Spearman´s rho = -0.0190; p = 0.701). Qualitative analyses highlighted these results and enhanced the bidirectional relationships between maternal pressure to provide milk and milk volume.

CONCLUSIONS

Especially internal pressure to provide milk is perceived by many mothers, being mutually dependent on milk supply and parental stress. Pressure to provide milk may be an important factor to decrease maternal stress in the NICU and, therefore, lead to more positive pumping and breastfeeding experiences. More research and validated instruments are needed to adequately measure pressure to provide milk with its different psychological, social, and environmental dimensions.

“Breastfeeding at Night Is Awesome” Mothers’ Intentions of Continuation of Breastfeeding Extreme and Very Preterm Babies upon Discharge from a Kangaroo Mother Care Unit of a Tertiary Hospital in South Africa

Kangaroo mother care (KMC) is effective in increasing mothers’ initiation and maintenance of breastfeeding (BF) for extreme and very preterm (VLBW) infants. Although South Africa has implemented KMC for more than two decades, little is known about mothers’ perspectives on KMC. The purpose of this study was to describe the BF intentions and practices of mothers of VLBW infants at home following discharge and assess the role long stay in KMC has on their decision to BF beyond discharge. This qualitative study was conducted at the KMC unit of a tertiary hospital in Pretoria, South Africa. Focus group interviews were conducted with 38 mothers of VLBW infants who had transitioned from neonatal intensive care (NICU) to KMC. We analysed transcripts following the five steps for qualitative thematic data analysis. Mothers were knowledgeable of the importance and value of BF preterm infants and conceded that breast milk has advantages over formula. Mothers had positive feelings toward BF their preterm infants. The stay in KMC increased the direct BF of their preterm infants, mothers’ BF efficacy, and had a positive influence on mothers’ intentions to continue BF following discharge and to exclusively breastfeed for six months. Their BF intentions, efficacy, and practices were influenced by the skilful BF counselling, training, and support they received from the nursing staff. High intention to BF among these mothers is suggestive of their knowledge and confidence in BF for their VLBW infants. It is important that nursing staff in NICU and KMC appreciate the significant role they play in mothers’ readiness and confidence to breastfeed beyond discharge.

Very-low-birth-weight infant short-term post-discharge outcomes: A retrospective study of specialized compared to standard care

OBJECTIVE

Ongoing health care challenges, low breast milk intake, and the need for rehospitalization are common during the first year of life after hospital discharge for very low birth weight (VLBW) infants. This retrospective cohort study examined breast milk intake, growth, emergency department (ED) visits, and non-surgical rehospitalizations for VLBW infants who received specialized post-discharge follow-up in western Canada, compared to VLBW infants who received standard follow-up in central Canada.

DESIGN

Data were collected from two neonatal follow-up programs for VLBW babies (n = 150 specialized-care; n = 205 standard-care). Logistic regression was used to examine odds of breast milk intake and generalized estimating equations were used for odds of growth, ED visits and non-surgical rehospitalization by site.

RESULTS

Specialized-care was associated with enhanced breast milk intake duration; the odds of receiving breastmilk at 4 months in the specialized-care cohort was 6 times that in the standard-care cohort. The specialized-care cohort had significantly more ED visits and rehospitalizations. However, for infants with oxygen use beyond 36 weeks compared to those with no oxygen use, the standard-care cohort had over 7 times the odds of rehospitalization where as the specialized-care cohort with no increased odds of rehospitalization.

CONCLUSION

Specialized neonatal nursing follow-up was associated with continued breastmilk intake beyond discharge. Infants in the specialized-care cohort used the ED and were hospitalized more often than the standard-care cohort with the exception of infants with long term oxygen needs.

Breastfeeding and human milk bank in a neonatal intensive care unit: impact of the COVID-19 pandemic in an Italian cohort of very low birth weight infants

BACKGROUND

Parental stress in neonatal intensive care units (NICU) is well known, as is the stress induced by the COVID-19 pandemic. This combination might increase stress to the extent of affecting the availability of maternal expressed milk and the success of establishing breastfeeding. This is particularly relevant in very preterm infants.

METHODS

We conducted a single-centre retrospective analysis in two cohorts of very low birth weight infants born in a hospital in Italy. Babies born before the pandemic (September 2017 - December 2019) (n = 101) and during the pandemic (March 2020 - December 2021) (n = 67) were included in the analysis. We compared the rate of babies fed with maternal milk (both expressed and / or donated) at the achievement of full enteral feeding and the rate of those exclusively breastfed at discharge in the two groups. Then, we analysed the impact of donated human milk availability on infant formula use. We also compared mother's need for psychological support during NICU stay and the duration of psychological follow-up after discharge.

RESULTS

In our NICU the availability of expressed maternal milk significantly decreased during the COVID-19 pandemic (86.1% before the pandemic vs 44.8% during the pandemic, p < 0.001) at the time of full enteral feeding achievement. Thanks to the availability of donated human milk, the rate of formula-fed babies remained almost unchanged (13.9% vs 14.9%). At discharge, the rate of breastfeeding was similar (73.3% vs 72.7%). The maternal need for psychological support was significantly higher during the pandemic (33% vs 64%, p < 0.001), as well as the duration of follow-up > 6 months (1% vs 15%, p < 0.001). No differences in the main clinical outcomes were found.

CONCLUSION

Pandemic-induced stress had a significant impact on the availability of expressed maternal milk in NICU. However, the presence of human donated milk was fundamental in preventing increased use of infant formula during NICU stays. This underlines how strategies to implement the widespread establishment of donor milk banks on a national level are warranted. Further research is desirable to optimise the use of donated human milk banks during emergency situations.

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.

Human Milk Sodium and Potassium as Markers of Mastitis in Mothers of Preterm Infants

Introduction: This prospective longitudinal study examined changes in milk sodium concentration (Na) and sodium:potassium ratio (Na:K), microbiological culture, milk production, and breast health in relation to mastitis after preterm birth. Methods: We studied women who gave birth at 29-34 weeks of gestation in a tertiary obstetric hospital in Perth, Western Australia. Milk samples, 24-hour milk production, and breast health data were collected every second day to day 10 postpartum, then every third day until infant discharge from the neonatal unit. Milk Na and K were measured at point of care (POC) using handheld ion selective meters, and Na:K calculated. Cultures were performed on postnatal days 8, 13, and every 6 days thereafter. For episodes of mastitis, milk was cultured at onset, and Na and Na:K measured daily until resolution. Women were followed up at 4 and 8 weeks postpartum. Results: In a sample of 44 women, 4 mastitis cases were detected in 3 women during their infants' neonatal stay; all had elevated milk Na and Na:K that resolved within 48 hours; 2/4 experienced reduced milk production and 1/4 had heavy growth of Staphylococcus epidermidis. A further 2 mastitis cases were reported in 39 women followed up to 8 weeks postpartum. Four women had elevated milk Na and Na:K without clinical signs of mastitis; three also had reduced milk production. Conclusions: POC testing of milk Na and/or Na:K may offer a useful indicator of breast health. Mastitis may cause an acute reduction in milk production regardless of the presence of culture-positive infection.

Longitudinal Follow-up of Preterm Breastfeeding to 12 Weeks Corrected Gestational Age

BACKGROUND

Preterm infants have shorter breastfeeding duration than that of term infants. Details of postdischarge feeding methods and difficulties are needed to inform the care of preterm breastfeeding dyads.

PURPOSE

To describe postdischarge breastfeeding characteristics of mother-preterm infant dyads up to 12 weeks corrected gestational age (CGA).

METHODS

A prospective observational study of preterm dyads (birth 24-33 weeks' gestation) that fed their mother's own milk (MOM) at discharge from a neonatal unit in Perth, Western Australia. Feeding method and frequency, breastfeeding duration, difficulties, and nipple shield use were recorded at 2, 6, and 12 weeks CGA.

RESULTS

Data were obtained for 49 mothers (singleton infant n = 39, twins n = 10). At 12 weeks CGA, 59% fed any MOM with 47% exclusively fed MOM and 31% fully breastfed. Nipple shield use reduced from 42% at 2 weeks CGA to 11% at 12 weeks CGA. Compared with mothers who exclusively fed MOM at discharge (n = 41) those who fed both MOM and infant formula (n = 8) were more likely to wean before 12 weeks CGA ( P < .001). Weaning occurred before 2 weeks CGA in 12/19 (63%), with low milk supply the most frequently cited reason.

IMPLICATIONS FOR PRACTICE

Most mothers with a full milk supply at discharge successfully transition to predominant breastfeeding. Frequent milk removal needs to be prioritized throughout the preterm infant's hospital stay.

IMPLICATIONS FOR RESEARCH

Examination of facilitators and barriers to early and continued frequent milk removal across the postpartum period is required to identify strategies to optimize lactation after preterm birth.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.

Analysis of the Influence of Pre-Pregnancy BMI and Weight Gain during Pregnancy on the Weight of Healthy Children during the First 2 Years of Life: A Prospective Study

Background: Increased pre-pregnancy maternal BMI (pBMI) and gestational weight gain (GWG) have been found to increase infants’ birthweight and result in the programming of child weight and impact its later weight gain. Aim: To assess the impact of pBMI and GWG on the weight of children from birth to 2 years of age and over the duration of breastfeeding. Methods: Single Centre observational prospective longitudinal cohort study. Data were collected from medical records, and medical history. The analysis of multiple linear and mixed models was involved. Findings: 20% of females were overweight, while 13% were obese before the pregnancy. An overall model, including gender and smoking, indicated a significant impact of pBMI category on a child’s birth mass (p = 0.01). The GWG category affected a child’s birth weight (p = 0.018, Effect size 0.41). pBMI did not affect the breastfeeding duration. Conclusion: pBMI and GWG correlate with birth weight and weight in neonatal period, however they become insignificant in later childhood. Weight assessment methods among children aged up to two years of age require standardization. Maternal weight before the pregnancy nor the weight gain during the pregnancy do not influence the length of breastfeeding. The biggest limitation was the small sample size and the failure to account for weight gain per trimester of pregnancy. Further research on a larger population should be continued.

Relationship Between the Rates of Breast Milk Production of Preterm Mothers in the First Week Post-Delivery and Continuation of Breastfeeding Through Discharge

Background

Mothers of preterm infants born between 26- and 35-weeks’ gestation often report challenges with maintaining a pumping schedule and experience perceptions of low milk supply, both of which may contribute to early termination of breastfeeding within the first few weeks.

Purpose

The purpose of this study was to assess the relationship between the amount of expressed milk volumes in the first 2 weeks after delivery and infant’s continuing to receive mother’s milk at hospital discharge. These results were part of a larger study that examined multiple maternal variables that may impact the amount of milk volumes and continuation of breastfeeding in the preterm infant admitted to the NICU.

Methods

Mothers of infants (N = 37) in the NICU were recruited for this correlational, longitudinal study. Data was collected at 24–48 hours post-delivery, at 2 weeks, at 4 weeks from mothers participating in the study and from infant chart reviews.

Results/Outcomes

Mothers who reported higher expressed milk volumes at 3 days post-delivery had consistently higher volumes of expressed breast milk and a higher percentage of continued breastfeeding at hospital discharge. There was no statistically significant relationship between breastfeeding self-efficacy scores, socio-demographic variables, or pumping frequency and the percentage of infants receiving breast milk at hospital discharge. Overall, 76.4% of the infants enrolled in the study were receiving 100% of their intake with fortified mother’s milk at hospital discharge.

Discussion/Implications for Practice

The use of a breast pump log in the first 2 weeks to monitor milk volumes may assist in predicting mothers who are at risk of lower milk supply and early discontinuation of breastfeeding.

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.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Evaluation of Methods of Breast or Bottle Feeding on Length of Hospitalization of Preterm Infants

Background: Direct breastfeeding is the optimal method of nourishing preterm infants. Preconceived notions exist among health practitioners that establishment of direct breastfeeding lengthens hospitalization. Thus far, the aforementioned association remains unknown. Research Aim: The objective of this study was to assess the impact of direct breastfeeding establishment on length of hospital stay in preterm infants. Methods: A retrospective chart review on a sample of 101 mother-infant dyads was conducted in the neonatal intensive care unit at Kingston Health Sciences Center (KHSC) in Ontario, Canada. The sample consisted of three groups: (1) modified direct breastfeeding group, defined as infants receiving ≥50% direct breastfeeds during hospitalization, (2) partial breastfeeding group, defined as infants receiving <50% breastfeeds during hospitalization, and (3) bottle feeding group, defined as infants only receiving bottle feeds during hospitalization. A multiple linear regression model was performed to assess the relationship between length of hospitalization and method of oral feeds (modified direct breastfeeds vs. partial breastfeeds vs. bottle feeds) while controlling for infant (gestational age [GA], birth weight, 5 minutes Apgar score, ventilator support) and maternal (age, first-time mother, mental health conditions) factors. Results: GA was inversely associated with length of hospitalization. The number of days on ventilator support was positively associated with length of hospitalization. Method of oral feed, birth weight, 5 minutes Apgar score, maternal age, first-time mother status, and maternal mental health conditions were not associated with duration of hospitalization. Conclusions: Direct breastfeeding establishment does not lengthen hospitalization in preterm infants. This finding may aid health practitioners in increasing direct breastfeeding success in this population.

The effect of risk at birth on breastfeeding duration and exclusivity: A cohort study at a Brazilian referral center for high-risk neonates and infants

Background and aim

Both breastfeeding and the use of human milk are strategies that provide better conformation to health throughout an individual’s life and bring countless short- and long- term benefits, which are well established in the scientific literature. For at-risk newborns (NBs), these strategies are crucial interventions to enable neonatal survival with better quality of life due to the distinctive and complex composition of human milk, which serves as personalized food-medicine-protection. However, there is limited knowledge about breastfeeding practices in high-risk NBs. The aim was to estimate the duration of EBF and to investigate the effect of risk at birth on EBF discontinuity in the first six months of life’.

Methods

This cohort study included 1,003 NBs from a high-risk referral center, followed up from birth to the sixth month of life, between 2017 and 2018. Correspondence and cluster analysis was used to identify neonatal risk clusters as the main exposure. The object of interest was the time until EBF discontinuity. The Kaplan-Meier methods and the Cox proportional hazards model were used to estimate the hazard ratio and 95% confidence intervals.

Results

The prevalence and median duration of EBF decreased proportionally in the three groups. The multiple model revealed a gradient in EBF discontinuity, which was 40% higher in risk group 1 and 111% higher in risk group 2 compared to healthy full-term NBs. Additionally, EBF during hospitalization predicted a longer median duration of this practice for high-risk NBs.

Conclusion

This study confirms a high proportion of high-risk NBs who have EBF discontinued before six months of life. The risk of EBF discontinuity is higher in risk groups, with a gradual effect even when adjusted by several factors. Effective interventions are needed to promote, protect, and support breastfeeding in different profiles of risk-at-birth groups.

Disparities in Breastfeeding Duration of New York City Latinx Mothers by Birth Region

Background: Disparities in breastfeeding patterns by race and ethnicity in the United States have been documented, and Latinx ethnicity is often associated with higher rates of breastfeeding initiation and longer breastfeeding duration compared to other U.S. racial and ethnic groups. Despite marked differences in infant feeding practices in Latinx countries of origin, U.S. breastfeeding data are routinely presented with Latinx as a single category. Objective: To analyze breastfeeding duration of New York City Latinx mothers by birth region. Methods: Using data from the 2016 New York City Work and Family Leave Survey (WAFLS) surveying residents who gave birth in 2014, we conducted a survival analysis of breastfeeding duration in a sample of Latinx-identifying mothers (n = 271), who reported having ever breastfed their child. Kaplan-Meier survival curves for time to breastfeeding cessation were created for four birth regions (United States, Caribbean, Mexico/Central America, and South America) and compared using the log-rank test. Adjusted hazard ratios (AHRs) were calculated using Cox regression. Results: Survival curves and median breastfeeding duration were significantly different between the four regions. AHR models found that non-Caribbean birthplace was significantly associated with a lower risk of early breastfeeding cessation. Being partnered at the time of childbirth and neonate hospitalization of 6 days or longer was associated with a greater risk of earlier breastfeeding cessation. Conclusion: The significant differences reinforce the need to separate breastfeeding findings by birth region in the Latinx population. Within-group differences are lost in combined analyses and reinforce conclusions that Latinx mothers have optimal breastfeeding behaviors.

Enhancing breastfeeding establishment in preterm infants: A randomized clinical trial of two non-nutritive sucking approaches

BACKGROUND

Preterm infants and their mothers face many barriers to the establishment of exclusive breastfeeding in the neonatal intensive care unit.

OBJECTIVE

The objective of this study was to assess and compare the effect of maternally administered non-nutritive sucking (NNS) on an emptied breast versus a pacifier on exclusive breastfeeding establishment at hospital discharge.

STUDY DESIGN

A block randomized study design was performed.

TRIAL REGISTRATION NUMBER

NCT03434743.

METHODS

A total of 33 preterm infants born less than or equal to 34 weeks gestation participated in the study. The NNS on an emptied breast or pacifier interventions were administered by mothers, once a day for 15 min. Outcomes included: exclusive breastfeeding acquisition, described as infants who received greater than or equal to 50% of direct breastfeeds at hospital discharge; time to achieve independent oral feeding, defined as the number of days to transition from complete tube feeds to full oral feeds (full breast, partial breast/bottle, or full bottle); length of hospitalization, described as the number of days from admission to hospital discharge.

RESULTS

A significantly greater number of infants in the NNS emptied breast group acquired exclusive breastfeeds at hospital discharge as compared with those in the NNS pacifier group (63% vs. 24%, p = 0.037). There was no difference between groups in time to achieve independent oral feeds (14.4 ± 8.0 vs. 14.4 ± 6.4 days, p = 0.683) and length of hospital stay (48.7 ± 33.7 vs. 53.1 ± 30.6 days, p = 0.595).

CONCLUSION

Provision of NNS on an emptied breast is a safe and low-cost infant and mother targeted intervention which can increase exclusive breastfeeding rates and its well-recognized advantages in a highly vulnerable population.

Association of Cesarean Delivery with Childhood Hospitalization for Infections Before 13 Years of Age

OBJECTIVES

To determine the association between cesarean delivery and childhood infections up to 13 years of age.

STUDY DESIGN

We conducted a longitudinal cohort study of 731 803 children born between 2006 and 2016 at all hospitals in the province of Quebec, Canada. We followed children born by cesarean, operative vaginal, and nonoperative vaginal delivery up to 13 years of age. Outcomes included hospitalization for otitis media, respiratory, infectious enteritis, and other infections. We estimated hazard ratios with 95% CIs for the association between mode of delivery and childhood infections, adjusted for patient characteristics.

RESULTS

At age 3-4 years, cesarean delivery was associated with a 1.07-fold greater risk of otitis media (95% CI, 1.03-1.11), a 1.15-fold greater risk of respiratory infection (95% CI, 1.09-1.22), and a 1.13-fold greater risk of infectious enteritis (95% CI, 1.03-1.25) compared with nonoperative vaginal delivery. However, operative vaginal delivery was associated with these same outcomes. Both cesarean and operative vaginal delivery were more strongly associated with infection hospitalization before age 1 year, but associations disappeared after 5 years.

CONCLUSIONS

Cesarean delivery is associated with infection hospitalization before but not after age 5 years. However, associations were also present for operative vaginal delivery, which suggests that mechanisms other than exposure to maternal vaginal flora explain the relationship.

Multifactorial influence on duration of exclusive breastfeeding; a Danish cohort study

The multifactorial aspects of breastfeeding require measures at many levels to identify mothers in need of breastfeeding support from healthcare professionals. Our objective was to examine the relative importance of sociodemographic, pre/perinatal-, infant-, psychosocial-, and interaction-related factors affecting duration of exclusive breastfeeding. We used self-reported data from a community-based trial including 1265 women (response rate 49%) giving birth from January 2017 to February 2018. Data on outcome, duration of exclusive breastfeeding, were collected three and nine months postpartum; data on the study variables concerning known risk factors for breastfeeding cessation were collected two weeks postpartum. Crude and multiple Cox proportional hazards models were used for statistical analyses with additional analyses for time varying effects. Factors with an independent prognostic influence on duration of exclusive breastfeeding in fully adjusted models included early skin-to-skin contact (HR = 1.18 CI:1.04–1.33), intention to breastfeed (HR = 0.77 CI: 0.73–0.80), positive outcome evaluation, meaning the value mothers attributed to breastfeeding (HR = 1.33 CI: 1.08–1.63), higher level of self-efficacy (HR = 1.46 CI: 1.24–1.72), and maternal sense of security in relation to breastfeeding (HR = 1.31 CI: 1.14–1.50). Higher maternal BMI, lower self-efficacy, shorter breastfeeding duration of previous child, and hospitalization during birth were time dependent by affecting the exclusive breastfeeding duration primarily in the first months following birth. The results suggest that target groups in special need of early breastfeeding support are defined by being hospitalized, obese, having low self-efficacy or short previous breastfeeding experience. The extensive influence of psychosocial factors emphasizes the importance of including both practical facilitating guidance and positive verbal encouragement to ensure effective breastfeeding support.

Association between Maternal Pre-pregnancy Body Mass Index and Breastfeeding Duration in Taiwan: A Population-Based Cohort Study

An association between high pre-pregnancy body mass index (BMI) and early breastfeeding cessation has been previously observed, but studies examining the effect of underweight are still scant and remain inconclusive. This study analyzed data from a nationally representative cohort of 18,312 women (mean age 28.3 years; underweight 20.1%; overweight 8.2%; obesity 1.9%) who delivered singleton live births in 2005 in Taiwan. Comprehensive face-to-face interviews and surveys were completed at 6 and 18 months postpartum. BMI status and breastfeeding duration were calculated from the self-reported data in the questionnaires. In the adjusted ordinal logistic regression model, maternal obesity and underweight had a higher odds of shorter breastfeeding duration compared with normal-weight women. The risk of breastfeeding cessation was significantly higher in underweight women than in normal-weight women after adjustments in the logistic regression model (2 m: aOR = 1.11, 95% CI = 1.03–1.2; 4 m: aOR = 1.32, 95% CI = 1.21–1.43; 6 m: aOR = 1.3, 95% CI = 1.18–1.42). Our findings indicated that maternal underweight and obesity are associated with earlier breastfeeding cessation in Taiwan. Optimizing maternal BMI during the pre-conception period is essential, and future interventions to promote and support breastfeeding in underweight mothers are necessary to improve maternal and child health.

Cessation of breastfeeding in mothers of preterm infants-A mixed method study

INTRODUCTION

Many women cease breastfeeding earlier than desired. This study examined the cessation of breastfeeding among mothers of preterm infants. Thus, the aim was to describe the cessation of breastfeeding in mothers of preterm infants up to 12 months after birth.

METHOD

This mixed methods study used a convergent design with both qualitative data, consisting of written comments, and quantitative data, on breastfeeding status and breastfeeding satisfaction. The data were collected from questionnaires sent to the mothers at three points during the first year after birth. In total, 270 mothers of preterm infants who breastfed at the time of discharge from the neonatal unit provided data for the study. The quantitative and qualitative data were analysed separately with statistical tests and hermeneutical analysis, respectively and then together according to the convergent mixed methods design.

RESULTS

Four themes of the meanings of the cessation of breastfeeding were identified in the qualitative analysis: "Desire to regain the mother's and the infant's well-being", "The mothers interpretation that the infants actively ceased breastfeeding", "The mother's body and/or the infants' signals showing the way" and "The mother's own will and perceived external obstacles". Mothers who did not breastfeed as long as they wanted were more likely to report less satisfaction with breastfeeding, a shorter breastfeeding period, and less activity when ceasing breastfeeding. In comparison, mothers who breastfed as long as they wanted were more satisfied with breastfeeding, breastfed for a longer period of time and were more active in decision making in breastfeeding cessation.

CONCLUSION

Maternal passivity or activity influenced the cessation of breastfeeding in mothers of preterm infants who breastfed at the time of discharge from the neonatal unit. Passive behaviour related to breastfeeding may result in early cessation of breastfeeding, and low breastfeeding satisfaction while active behaviour may increase breastfeeding length and satisfaction.

Breastfeeding experiences and perspectives on support among Chinese mothers separated from their hospitalized preterm infants: a qualitative study

Background

Chinese mothers of preterm infants often face obstacles to breastfeeding and commonly experience prolonged maternal-infant separation when their high-risk infants are hospitalized in a Neonatal Intensive Care Unit (NICU). This separation hinders mother-infant attachment and the establishment of breastfeeding. Currently, little is known about Chinese mothers’ experiences breastfeeding their preterm infants, or their support needs. The aim of this study was to develop an understanding of mothers’ experiences breastfeeding a hospitalized preterm infant and the support needed to establish a milk supply during the period separation from their infants.

Methods

A qualitative descriptive study was conducted in Beijing in 2017. A total of 11 Chinese mothers were individually interviewed while separated from their infants. The interviews were audio-recorded and transcribed verbatim. A thematic analysis involving a seven-step protocol identified key themes.

Results

Mothers of preterm infants reported physically and mentally challenging breastfeeding experiences during the period they were separated from their babies. They viewed expressing breast milk as integral to their maternal role, even though some found expressing breastmilk exhausting. With little professional support available, the mothers depended upon nonprofessionals to establish breastfeeding.

Conclusions

The study identified the difficulties mothers experienced establishing a milk supply while separated from their preterm infants, and the importance of access to health professional support.

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

BACKGROUND

Mothers' own milk (MOM) has more than nutritional benefits for extremely preterm infants (<28 weeks). However, mothers encounter barriers that make it difficult to provide their own milk to their extremely preterm infants.

PURPOSE

The aim of this study was to describe and understand the experiences of mothers of extremely preterm infants regarding barriers to providing their own milk during infant hospital stay in the neonatal intensive care unit (NICU).

METHODS

This study followed a qualitative, interpretative design using Gadamer's hermeneutic approach and included 15 in-depth semistructured interviews. The data were analyzed using a modified form of the steps described by Fleming.

RESULTS

Fifteen mothers of extremely preterm infants participated in the study. The following themes were extracted from the data analysis: (1) "unexpected and unusual lactation," including the subthemes "the extremely preterm birth and the decision to provide MOM," "the battle to produce milk," and "my job was to make milk"; and (2) "providing MOM to a tiny infant in an unknown technological environment," with the subthemes "the limitations of providing MOM in the NICU" and "the difficulties of having an extremely preterm infant."

IMPLICATIONS FOR PRACTICE

To provide MOM to an extremely preterm infant, there is a need for informational and practical counseling by neonatal nurses educated in breastfeeding according to mothers' requirements and emotional needs.

IMPLICATIONS FOR RESEARCH

Future research may analyze the parents' and neonatal nurses' experience about facilitators to improve MOM provision and the influence of women's sociodemographic characteristics in providing MOM to the extremely preterm infants.

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.

Mitigating Infant Medical Trauma in the NICU: Skin-to-Skin Contact as a Trauma-Informed, Age-Appropriate Best Practice

Infant medical trauma in the NICU is associated with serious and lasting consequences. Skin-to-skin contact (SSC) of infants with their parents is a nursing intervention that provides significant benefits and can mitigate the negative consequences of the infant's traumatic experiences in the NICU. The purpose of this article is to explain how SSC aligns with the concept of trauma-informed age-appropriate care (TIAAC) in the NICU. The evidence supporting SSC will be reviewed and discussed using TIAAC as a framework. SSC is an effective and evidence-based care strategy that reduces the infant's traumatic NICU experiences by improving parental proximity, attachment, and lactation; decreasing stress and pain; improving physiologic stability; supporting sleep; and enhancing neurologic outcomes.

Profile of at-risk newborns attended by nurses in outpatient follow-up clinic: a retrospective cohort study

OBJECTIVE

to analyze the cohort profile of at-risk newborns attended by nurses in a multidisciplinary follow-up clinic, with emphasis on the type of feeding and weight gain, after hospital discharge.

METHOD

retrospective cohort, whose population is composed of at-risk newborns attended in a 4-year period. Data came from medical records and attendance report, later exported to R Program. The outcome variables were number of the nursing consultation, type of feeding, daily weight gain and main guidelines. We used descriptive statistics, frequency distribution and applied Mann-Whitney, Chi-Square, Spearman correlation, Variance and Tukey analysis, with p <0.05 being significant.

RESULTS

a total of 882 consultations with 629 infants and families were analyzed. The frequencies of exclusive breastfeeding and weight gain increased as the consultations progressed. The infants who needed more consultations and with lower weight gain were those with lower gestational age (p = 0.001) and birth weight (p = 0.000), longer length of hospital stay (p <0.005), and diagnoses related to extreme prematurity (p <0.05), among others.

CONCLUSION

nurses verified the importance of outpatient follow-up of at-risk newborns, especially in promoting breastfeeding and healthy growth.

Breastfeeding woman or lactating object? A critical philosophical discussion on the influence of Cartesian dualism on breastfeeding in the neonatal intensive care unit

AIM

This discursive paper aims to bring to the foreground the ongoing influence of Cartesian dualism and other important contextual complexities on breastfeeding in the neonatal intensive care unit (NICU).

BACKGROUND

Breastfeeding is widely supported as the optimal form of nutrition for the first 6 months of life and beyond. Amidst a myriad of contextual factors, current breastfeeding rates are below globally targeted goals. For premature and/or critically ill infants, the importance of receiving breast milk is often encouraged based on its immunological and nutritive benefits as opposed to the entirety of the breastfeeding interaction, underscoring the influence of dualism in the NICU.

DESIGN

The impact of Cartesian dualism and other sociocultural underpinnings of breastfeeding focused within the NICU environment are illustrated through a critical, philosophical discussion.

METHODS

Relevant historical context is provided followed by an overview of the realities of contemporary breastfeeding. These are presented as a frame of reference for the NICU breastfeeding experiences currently encountered by many mothers of preterm and critically ill neonates, further illustrated using a clinical exemplar as well as the author's own observations from neonatal nursing practice.

RELEVANCE TO CLINICAL PRACTICE

Shifting away from a dualistic approach requires rethinking breastfeeding support interactions between NICU nurses and mothers. To address the disembodied and often mechanistic approach to care inherent in the dominant Western medical model, a relational approach to breastfeeding support in the NICU is suggested and discussed.

CONCLUSION

Future research from a more critical lens is needed to examine the complex dynamics involved when nurses and mothers are negotiating decisions and processes related to infant feeding. In focusing on the relational dimensions of the breastfeeding experience, nurses can resist the dualistic influence and dominant discourses impacting infant feeding and motherhood in the 21st century.

Oral Sensorimotor Intervention Enhances Breastfeeding Establishment in Preterm Infants

OBJECTIVE

To assess the efficacy of an oral sensorimotor intervention on breastfeeding establishment and maintenance in preterm infants.

STUDY DESIGN

Thirty-one preterm infants born ≤34 weeks gestation were randomized into an experimental or control group. The experimental group received a 15-minute program consisting of stroking the peri-oral structures for the first 5 minutes, tongue exercises for the next 5 minutes, followed by non-nutritive sucking for the final 5 minutes. The control group received a sham intervention for the same duration. The interventions were administered once daily for 10 days. The outcomes included: time to attainment of full oral feeding, breastfeeding acquisition (i.e., ≥50% of direct breastfeeding at hospital discharge), breastfeeding skill assessment using the Preterm Infant Breastfeeding Behavior Scale (PIBBS), length of hospitalization, and breastfeeding maintenance at 3 and 6 months posthospitalization.

RESULTS

Full oral feeding was attained earlier in the experimental group compared with the control (10.7 ± 2.1 vs. 19.3 ± 3.6 days, p < 0.01). This was associated with a greater number of infants in the intervention group acquiring breastfeeding at hospital discharge compared with the controls (n = 11 vs. 5, p = 0.049). There was no statistical difference in PIBBS score, length of hospitalization, and breastfeeding rates at 3 and 6 months posthospitalization between the two groups (all tests, p > 0.32).

CONCLUSIONS

An oral sensorimotor intervention accelerated the achievement of full oral feeding and enhanced direct breastfeeding rates at hospital discharge only. Provision of an oral sensorimotor intervention is a safe and low-cost intervention that may increase breastfeeding rates in a highly vulnerable population.

Low breastfeeding continuation to 6 months for very preterm infants: A European multiregional cohort study

Breastfeeding confers multiple benefits for the health and development of very preterm infants, but there is scarce information on the duration of breastfeeding after discharge from the neonatal intensive care unit (NICU). We used data from the Effective Perinatal Intensive Care in Europe population-based cohort of births below 32 weeks of gestation in 11 European countries in 2011-2012 to investigate breastfeeding continuation until 6 months. Clinical and sociodemographic characteristics were collected from obstetric and neonatal medical records as well as parental questionnaires at 2 years of corrected age. Among 3,217 ever-breastfed infants, 34% were breastfeeding at 6 months of age (range across countries from 25% to 56%); younger and less educated mothers were more likely to stop before 6 months (adjusted relative risk [aRR] <25 years: 0.68, 95% CI [0.53, 0.88], vs. 25-34 years; lower secondary: 0.58, 95% CI [0.45, 0.76] vs. postgraduate education). Multiple birth, bronchopulmonary dysplasia (BPD), and several neonatal transfers reduced the probability of continuation but not low gestational age, fetal growth restriction, congenital anomalies, or severe neonatal morbidities. Among infants breastfeeding at discharge, mixed versus exclusive breast milk feeding at discharge was associated with stopping before 6 months: aRR = 0.60, 95% CI [0.48, 0.74]. Low breastfeeding continuation rates in this high-risk population call for more support to breastfeeding mothers during and after the neonatal hospitalization, especially for families with low socio-economic status, multiples, and infants with BPD. Promotion of exclusive breastfeeding in the NICU may constitute a lever for improving breastfeeding continuation after discharge.

Determinants of Successful Direct Breastfeeding at Hospital Discharge in High-Risk Premature Infants

BACKGROUND

Despite a mother's intention to breastfeed, there are many barriers to feeding preterm infants that decrease breastfeeding rates.

OBJECTIVE

The objective of this research was to determine factors associated with successful direct breastfeeding (DBF) of the preterm infant at hospital discharge.

MATERIALS AND METHODS

A retrospective chart review of 69 preterm (<34 weeks' gestational age) infants in the neonatal intensive care unit, whose mothers intended to breastfeed, was conducted. Infant-, mother-, and feeding-related factors were examined by chi-square or t test for their relationship with breastfeeding success, and by multiple logistic regression to identify predictive factors.

RESULTS

Successful DBF at discharge occurred in 64%. Mothers of infants who were breastfed were older (p < 0.0001); had less psychiatric illness (p = 0.03); and were less likely to smoke (p < 0.0001) and use recreational drugs (p = 0.04). The infants had higher birth weights (p = 0.03) and lower incidence of bronchopulmonary dysplasia (p = 0.04). A higher proportion of infants received DBF at their first oral feed (p < 0.001), and were discharged earlier (p = 0.03). Reduced milk supply was cited for breastfeeding failure in 36%. Older maternal age (odds ratio [OR] = 1.24, 95% confidence interval [CI] 1.02-1.51) and DBF at the first oral feed (OR = 7.72, 95% CI 1.37-43.6) were associated with successful DBF at discharge.

CONCLUSION

Maternal age and method of first oral feed are critical predictors of breastfeeding success in preterm infants. Mothers should be encouraged to breastfeed at the infant's first oral attempt and strategic breastfeeding support should be provided before initiation of oral feeding.

Human milk peptides differentiate between the preterm and term infant and across varying lactational stages

Variations in endogenous peptide profiles, functionality, and the enzymes responsible for the formation of these peptides in human milk are understudied. Additionally, there is a lack of knowledge regarding peptides in donor human milk, which is used to feed preterm infants when mother's own milk is not (sufficiently) available. To assess this, 29 human milk samples from the Dutch Human Milk Bank were analyzed as three groups, preterm late lactation stage (LS) (n = 12), term early (n = 8) and term late LS (n = 9). Gestational age (GA) groups were defined as preterm (24-36 weeks) and term (≥37 weeks). LS was determined as days postpartum as early (16-36 days) or late (55-88 days). Peptides, analyzed by LC-MS/MS, and parent proteins (proteins from matched peptide sequences) were identified and quantified, after which peptide functionality and the enzymes responsible for protein cleavage were determined. A total of 16 different parent proteins were identified from human milk, with no differences by GA or LS. We identified 1104 endogenous peptides, of which, the majority were from the parent proteins β-casein, polymeric immunoglobulin receptor, α_s1-casein, osteopontin, and κ-casein. The absolute number of peptides differed by GA and LS with 30 and 41 differing sequences respectively (p < 0.05) Odds likelihood tests determined that 32 peptides had a predicted bioactive functionality, with no significant differences between groups. Enzyme prediction analysis showed that plasmin/trypsin enzymes most likely cleaved the identified human milk peptides. These results explain some of the variation in endogenous peptides in human milk, leading to future targets that may be studied for functionality.

Environmental Scan of Breastfeeding Resources in Canadian NICUs

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

Expressing Human Milk in the NICU: Coping Mechanisms and Challenges Shape the Complex Experience of Closeness and Separation

BACKGROUND

Human milk has multiple benefits for human health; however, rates of infants receiving human milk at discharge in Canadian neonatal intensive care units (NICUs) are far below recommendations of the Baby Friendly Hospital Initiative supported by the Canadian Pediatric Association. Mothers of infants requiring NICU care usually need to express their milk, especially mothers of premature infants, since for some time their infant is unable to feed directly at the breast. Expressing human milk for an extended period can be challenging for mothers.

PURPOSE

To document maternal experiences expressing human milk for their infant in the NICU as a closeness or separation experience, and to discover what factors gave rise to these perceptions.

METHODS

In this descriptive qualitative cross-sectional study, 15 mothers whose infants were hospitalized in a level III NICU and who were expressing human milk audio recorded their thoughts and feelings with a smartphone application for 48 hours while they were expressing milk. A thematic content analysis was used to analyze data.

FINDINGS

Expressing human milk for their hospitalized infant was a difficult experience for all mothers, and most described both closeness and separation feelings while expressing milk. Their feelings fluctuated depending on their coping mechanisms, perceived challenges, as well as their location and environment. Mothers were all pursuing their goal of continued milk expression with various levels of motivation.

IMPLICATIONS FOR PRACTICE

NICUs should adopt a family-centered approach to care whereby mothers' care needs related to milk expression are addressed. Nurses can ask open-ended questions to explore how mothers are coping, and they can assist mothers to find effective coping strategies to minimize the challenges related to milk expression to promote mother-infant closeness.

IMPLICATIONS FOR RESEARCH

The impact of environment and location on mothers with hospitalized infants should be explored, as unit designs could be altered to foster closeness.

Predictors of Breastfeeding Initiation and Maintenance in an Integrated Healthcare Setting

BACKGROUND

The American Academy of Pediatrics recommends exclusive breastfeeding to age 6 months. Although breastfeeding rates in the United States have been increasing over time, further improvements are needed to meet Healthy People 2020 targets. Research aim: This study examined predictors of breastfeeding initiation and maintenance among a population of insured pregnant women.

METHODS

Participants were 1,149 pregnant women enrolled in the Pregnancy and Influenza Project in two Kaiser Permanente regions in 2010-2011. Data were collected through interviews at enrollment and 1 month and 6 months postpartum and through participants' electronic medical records.

RESULTS

Nearly all (99%) women reported initiating breastfeeding. Rates of exclusive breastfeeding were 70% and 54% at 1 month and 6 months, respectively; an additional 22% and 23% of women reported supplementing breastfeeding with formula. Of the women who supplemented, the mean ( SD) infant age at formula introduction was 53 (62) days. Of those who had stopped breastfeeding, the mean ( SD) infant age at cessation was 85 (59) days. Higher maternal education level, better maternal self-rated health, prenatal folic acid use, absence of chronic medical conditions, and infant full-term birth were significantly associated with breastfeeding maintenance.

CONCLUSION

Although rates of breastfeeding in this population were higher than national rates, a significant number of women stopped breastfeeding or introduced formula earlier than recommended. Two to 3 months postpartum may be a critical period warranting additional encouragement or intervention by healthcare providers. Mothers' education attainment, maternal health factors, and gestational age at delivery may predict likelihood of breastfeeding maintenance.

Using quality improvement to increase human milk use for preterm infants

This review will provide an overview of quality improvement methods that have been used to improve human milk use (mother's own milk and donor milk) for very low-birth-weight infants in the hospital setting in the last decade. We will review the following: (1) evidence-based practices known to increase mother's own milk for very low-birth-weight infants; (2) individual hospitals with exemplary lactation programs and past and current US-based statewide quality improvement collaboratives focused on increasing mother's own milk; and (3) existing quality metrics for human milk and gaps in metrics. Finally, we will provide practical examples of key driver diagrams and change concepts that may be used to inform quality improvement for mother's own milk for very low-birth-weight infants.

"I Had One Job and That Was To Make Milk"

BACKGROUND

For very-low-birth-weight (VLBW) infants, breastfeeding may no longer be an immediate option. Mothers often turn to mechanically expressing their milk with a breast pump to provide their infants human milk. Research aim: This study aimed to describe mothers' experiences expressing milk for their VLBW infants in a level 3 neonatal intensive care unit.

METHODS

Qualitative, phenomenological methods were used to better understand the milk expression experiences of 17 mothers of VLBW infants. In-depth interviews were audio-recorded and transcribed verbatim. Transcripts were analyzed using Colaizzi's seven-step protocol, and themes were identified to illustrate the lived experience of the mothers.

RESULTS

Five global themes emerged from interviews with mothers. However, this article focuses on one global theme, "I had one job and that was to make milk," and the supporting subthemes: (1) "I was heartbroken," (2) "Pumping is a full-time thing," and (3) "I literally sacrificed nights."

CONCLUSION

This study provides insight into the complex experience that mothers in the southeastern United States undergo when expressing milk for their VLBW infants.

Barriers to Human Milk Feeding at Discharge of Very-Low-Birth-Weight Infants: Maternal Goal Setting as a Key Social Factor

BACKGROUND

While black mothers initiate human milk (HM) provision at lower rates than non-black mothers in the United States, some neonatal intensive care units (NICUs) report similar initiation rates regardless of race/ethnicity for mothers of very-low-birth-weight (VLBW) infants. However, racial disparity frequently becomes evident in the proportion of black infants who continue to receive HM feedings at NICU discharge. Since social factors have been associated with differences in HM provision for term infants, we sought to identify differences in social factors associated with HM feeding at discharge based on race/ethnicity.

MATERIALS AND METHODS

A prospective cohort study of racially diverse mothers of VLBW infants measured social factors including maternal education, breastfeeding support, return to work/school, HM feeding goal, previous breastfeeding, or formula experience. Multivariate logistic regression modeling was applied to social factors to predict HM feeding at discharge. Additional regression models were created for racial/ethnic subgroups to identify differences.

RESULTS

For all 362 mothers, WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) eligibility and maternal goal near time of discharge of providing any HM negatively and positively predicted HM feeding at discharge, respectively. Perceived breastfeeding support from the infant's maternal grandmother negatively predicted HM feeding at discharge for black mothers.

CONCLUSIONS

Future interventions to increase duration of HM provision in VLBW infants should focus on the establishment and maintenance of maternal HM feeding goals. Further studies of the familial support system of black mothers are warranted to determine multigenerational impact and potential interventions.

Understanding kangaroo care and its benefits to preterm infants

The holding of an infant with ventral skin-to-skin contact typically in an upright position with the swaddled infant on the chest of the parent, is commonly referred to as kangaroo care (KC), due to its simulation of marsupial care. It is recommended that KC, as a feasible, natural, and cost-effective intervention, should be standard of care in the delivery of quality health care for all infants, regardless of geographic location or economic status. Numerous benefits of its use have been reported related to mortality, physiological (thermoregulation, cardiorespiratory stability), behavioral (sleep, breastfeeding duration, and degree of exclusivity) domains, as an effective therapy to relieve procedural pain, and improved neurodevelopment. Yet despite these recommendations and a lack of negative research findings, adoption of KC as a routine clinical practice remains variable and underutilized. Furthermore, uncertainty remains as to whether continuous KC should be recommended in all settings or if there is a critical period of initiation, dose, or duration that is optimal. This review synthesizes current knowledge about the benefits of KC for infants born preterm, highlighting differences and similarities across low and higher resource countries and in a non-pain and pain context. Additionally, implementation considerations and unanswered questions for future research are addressed.

Breastfed or bottle-fed: who goes home sooner?

A literature search was conducted to answer the clinical question, "Do premature infants who breastfeed have different oral feeding outcomes compared with those who receive bottles?" The CINAHL, PubMed, and PsycInfo databases were queried for articles published in the past 10 years that reported original research available in English. Two studies specifically addressed a comparison between infants who received exclusive direct breastfeeding, mixed direct breast and bottle, and/or exclusive bottle-feeding. Additional studies were included that addressed oral feeding outcomes specific to either direct breastfeeding (n = 2) or those that grouped bottle and breastfeeding together (n = 3). The findings from these studies indicate that the statement that bottle-feeding leads to sooner discharge is not based in evidence. Although more data are needed to fully understand the differences between direct breastfeeding and bottle-feeding, neonatal intensive care unit staff should be aware of the message they send to breastfeeding families when they encourage the use of bottles over direct breastfeeding.