Infants admitted to neonatal units--interventions to improve breastfeeding outcomes: a systematic review 1990-2007

Role of the neonatal registered dietitian nutritionist in Canada: A description of staffing and a comparison to practices in the United States

BACKGROUND

Neonatal registered dietitian nutritionists (RDNs) are critical members of the neonatal intensive care unit (NICU) team. Ideal RDN staffing levels are unknown. Current staffing levels of neonatal RDNs in Canadian NICUs have not been recently reported. The objective of this study was to describe neonatal RDN staffing and responsibilities in Canada and contrast these findings with those of neonatal RDNs in the United States.

METHODS

An online cross-sectional neonatal RDN survey was performed in the Fall of 2021 to collect hospital-level and individual-RDN-level data. Descriptive statistics were performed to summarize Canadian neonatal RDN staffing levels and responsibilities and compared with US findings.

RESULTS

Canadian RDNs reported a median staffing ratio of 25.3 NICU beds per RDN full-time equivalent, with neonatal RDNs reporting a desired 31% increase in staffing. The majority of Canadian NICUs (n = 20/24) reported having a dedicated space to prepare infant feeds away from bedside. Canadian neonatal RDNs reported wanting to expand their responsibilities in research, administration, and education. Canadian neonatal RDNs reported a higher rate of order writing privileges as compared with that of US neonatal RDNs.

CONCLUSION

Canadian neonatal RDNs reported a desired increase in their staffing levels. Neonatal RDNs have the potential to expand their professional role but require additional staffing, dedicated time, and compensation to support this. Further research determining the optimal neonatal RDN staffing ratio to maximize patient outcomes is required.

Does regular antenatal exercise promote exclusive breastfeeding during the first 3 months of life? Secondary analyses of a randomized controlled trial

INTRODUCTION

Exclusive breastfeeding (EBF) and antenatal exercise are independently associated with positive short- and long-term health effects for women and their children. The aims of the study were to investigate whether antenatal exercise promotes EBF three months postpartum and further to explore factors associated with EBF at three months postpartum.

METHODS

This study was a follow-up of a Norwegian two-center randomized controlled trial to assess the effect of an antenatal exercise protocol. The recruited pregnant women were randomized to either a 12-week standardized antenatal exercise program with one weekly group training led by a physiotherapist and two weekly home training sessions or standard antenatal care. Women reported breastfeeding status in a questionnaire at three months postpartum.

RESULTS

Of the 726 women, 88% were EBF at three months postpartum. There was no significant difference in EBF rates between the intervention group (87%) and the control group (89%). EBF was positively associated with maternal education (AOR=3.4; 95% CI: 1.7-6.7) and EBF at discharge from the hospital (AOR=22.2; 95% CI: 10-49). Admission to neonatal intensive care unit was identified as a significant barrier to EBF (AOR=0.2; 95% CI: 0.1-0.4). Significantly more women in the non-EBF group had sought professional help compared to women in the EBF group (p≤0.001).

CONCLUSIONS

Regular physical exercise during pregnancy did not influence the exclusive breastfeeding rates at three months postpartum. Considering the health effects of exclusive breastfeeding and antenatal physical exercise, studies with follow-up periods beyond three months postpartum are warranted.

Innovations in Breastfeeding Support

Despite the numerous benefits that breastfeeding confers to those who breastfeed and their infants, the United States' exclusive breastfeeding rates and any breastfeeding rates at 12 months remain low and inequitable. This public health crisis has been prioritized in the US Healthy People 2030 goals. Current evidence-based practices to support lactation have afforded limited progress, thus, achieving national breastfeeding goals requires innovative ideas in thinking, technology, and care. This article highlights potential innovative strategies in the field of lactation to improve outcomes and work toward achieving health equity, while underscoring the critical role that perinatal caregivers play in lactation support.

Maternal Milk and Relationships to Early Neurobehavioral Outcome in Preterm Infants

The purpose of this study was to (1) define medical and sociodemographic factors related to maternal milk feedings and (2) explore relationships between maternal milk feeding and early neurobehavioral outcome. Ninety-two preterm infants born ≤ 32 weeks gestation had maternal milk feeding and breastfeeding tracked in this retrospective analysis. At 34 to 41 weeks postmenstrual age (PMA), neurobehavior was assessed with the NICU Network Neurobehavioral Scale. Maternal milk feeding was often delayed by the use of total parenteral nutrition, administered for a median of 11 (7-26) days, impacting the timing of gastric feeding initiation. Seventy-nine (86%) infants received some maternal milk during neonatal intensive care unit (NICU) hospitalization. Twenty-one (27%) infants continued to receive maternal milk at 34 to 41 weeks PMA, with 10 (48%) of those receiving maternal milk exclusively. Among mothers who initiated maternal milk feeds, 20 (25%) put their infants directly at the breast at least once during hospitalization. Mothers who were younger (P = .02), non-Caucasian (P < .001), or on public insurance (P < .001) were less likely to provide exclusive maternal milk feedings by 34 to 41 weeks PMA. Infants who received maternal milk at 34 to 41 weeks PMA demonstrated better orientation (P = .03), indicating they had better visual and auditory attention to people and objects in the environment. Our findings demonstrate a relationship between maternal milk feedings and better neurobehavior, which is evident before the infant is discharged home from the NICU.

The impact of neonatal unit policies on breast milk feeding at discharge of moderate preterm infants: The EPIPAGE-2 cohort study

Facilitating factors and barriers to breast milk feeding (BMF) for preterm infants have been mainly studied in very preterm populations, but little is known about moderate preterm infants. We aimed to analyze hospital unit characteristics and BMF policies associated with BMF at discharge for infants born at 32 to 34 weeks' gestation. EPIPAGE-2, a French national cohort of preterm births, included 883 infants born at 32 to 34 weeks' gestation. We investigated kangaroo care in the first 24 hr, early involvement of parents in feeding support, volume of the unit, BMF information given to mothers hospitalized for threatened preterm delivery, protocols for BMF, presence of a professional trained in human lactation, unit training in neurodevelopmental care, and regional BMF initiation rates in the general population. Multilevel logistic regression analysis was used to investigate associations between unit policies and BMF at discharge, adjusted for individual characteristics and estimating odds ratios (ORs) and 95% confidence intervals (CIs). Overall, 59% (490/828) of infants received BMF at discharge (27% to 87% between units). Rates of BMF at discharge were higher with kangaroo care (adjusted OR 2.03 [95% CI 1.01, 4.10]), early involvement of parents in feeding support (1.94 [1.23, 3.04]), unit training in a neurodevelopmental care programme (2.57 [1.18, 5.60]), and in regions with a high level of BMF initiation in the general population (1.85 [1.05, 3.28]). Creating synergies by interventions at the unit and population level may reduce the variability in BMF rates at discharge for moderate preterm infants.

Formula versus maternal breast milk for feeding preterm or low birth weight infants

BACKGROUND

Artificial formula can be manipulated to contain higher amounts of macro-nutrients than maternal breast milk but breast milk confers important immuno-nutritional advantages for preterm or low birth weight (LBW) infants.

OBJECTIVES

To determine the effect of feeding preterm or LBW infants with formula compared with maternal breast milk on growth and developmental outcomes.

SEARCH METHODS

We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 9), and Ovid MEDLINE, Ovid Embase, Ovid Maternity & Infant Care Database, and CINAHL to October 2018. We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm or low birth weight infants with formula versus maternal breast milk.

DATA COLLECTION AND ANALYSIS

Two review authors planned independently to assess trial eligibility and risk of bias, and extract data. We planned to analyse treatment effects as described in the individual trials and report risk ratios and risk differences for dichotomous data, and mean differences for continuous data, with 95% confidence intervals. We planned to use a fixed-effect model in meta-analyses and to explore potential causes of heterogeneity in subgroup analyses. We planned to use the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We did not identify any eligible trials.

AUTHORS' CONCLUSIONS

There are no trials of formula versus maternal breast milk for feeding preterm or low birth weight infants. Such trials are unlikely to be conducted because of the difficulty of allocating an alternative form of nutrition to an infant whose mother wishes to feed with her own breast milk. Maternal breast milk remains the default choice of enteral nutrition because observational studies, and meta-analyses of trials comparing feeding with formula versus donor breast milk, suggest that feeding with breast milk has major immuno-nutritional advantages for preterm or low birth weight infants.

Predictors of breastfeeding non-initiation in the NICU

This study compared predictors of breastfeeding non-initiation between infants who were and were not admitted to the NICU so that interventions can target high-risk mothers whose infants desperately need breastmilk. This was a population-based retrospective cohort study of singleton Ohio live births using birth certificates, 2006-2015. In babies who were and were not admitted to the NICU, a multivariable logistic regression model assessed the association between breastfeeding non-initiation and predictors relating to the mother, neonate, and labour and delivery events while adjusting for covariables. Of 1,463,506 births, 76,855 infants were admitted to the NICU (5.8% of study population), and breastfeeding was not initiated in 39.4% of them, compared with 31.5% of infants in the newborn nursery, p < 0.001. Apart from abnormal newborn conditions, smoking during pregnancy was the most significant risk factor for not breastfeeding in the NICU (RR 1.91 [95% CI 1.82-2.02]) and newborn nursery (RR 2.10 [95% CI 2.08-2.13]), followed by socioeconomic factors and multiparity. Limited prenatal visits (≤5) were a significantly higher risk factor in the NICU (RR 1.41 [95% CI 1.34-1.49]) than in the newborn nursery (RR 1.24 [95% CI 1.22-1.26]). Intentional home birth and use of infertility treatment were associated with breastfeeding initiation. The rate of breastfeeding initiation is lower in infants admitted to the NICU than those who are not, especially among mothers with limited prenatal care. Interventions should target mothers who smoke because they are least likely to breastfeed, and their babies, who are prone to serious health conditions, could especially benefit from breastmilk.

Prenatal developmental toxicity evaluation of Verbena officinalis during gestation period in female Sprague-Dawley rats

Verbena officinalis is widely used by women for maintaining general health and treating various gynaecological disorders during pregnancy. A case report has indicated that the consumption of V. officinalis induced an abortifacient effect. Hence, this study aimed to investigate the prenatal developmental toxicity of this plant according to OECD guideline (no. 414). A total of 50 pregnant female rats (dams) were distributed into five groups (n = 10); 500 mg/kg 1000 mg/2000 mg/kg and 3000 mg/kg of V. offcinalis extracts and the fifth group served as a normal control. All dams received their respective oral single daily treatment from the 6th to the 20th day of gestation. Maternal clinical toxicity signs, body weight and weight gain were recorded. Caesarean sections were performed on day 21 to evaluate embryo-foetal developmental toxicity. For dams, ovaries were harvested and weighed. The number of corpora lutea, implantation sites, and resorptions were recorded. No mortality was observed in dams, but their body weight gain was significantly reduced particularly in dams treated with 2000 and 3000 mg/kg V. officinalis. Asymmetrical distribution of implantation sites and embryos were observed. Embryo-fetotoxicity retardation was observed as evident by the decrease in foetal weight, head cranium, tail length, and higher incidence in the pre-and post-implantation loss. Some foetal skeleton abnormalities such as incomplete ossification of skull, sternebrae, and metatarsal bones were observed in foetuses of the 2000 and 3000 mg/kg V. officinalis-treated dams. LC/MS analysis identified the major constituents including geniposidic acid, tuberonic acid glucoside, luteolin 7, 3'-digalacturonide, iridotrial and apigenin. The glycosylated flavonoids such as apigenin and luteolin could be responsible for the reported prenatal developmental toxicity. In conclusion, the use of V. officinalis during pregnancy is not safe indicating evidence-based toxic effects on the reproductive performance of dams and dose-dependent risk potentials to the foetuses.

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.

Changes in the prevalence of breast feeding in preterm infants discharged from neonatal units: a register study over 10 years

OBJECTIVE

There are indications that the prevalence of exclusively breastfed preterm infants is decreasing in Sweden. The objective was to investigate trends in exclusive breast feeding at discharge from Swedish neonatal units and associated factors in preterm infants.

DESIGN, SETTING AND PARTICIPANTS

This is a register study with data from the Swedish Neonatal Quality Register. Data from 29 445 preterm infants (gestational age (GA) <37 weeks) who were born during the period 2004-2013 were retrieved. Data included maternal, perinatal and neonatal characteristics. Data were analysed for the whole population as well as for 3 GA groups.

RESULTS

From 2004 to 2013, the prevalence of exclusive breast feeding decreased, in extremely preterm (GA 22-27 weeks) from 55% to 16%, in very preterm (GA 28-31 weeks) from 41% to 34% and in moderately preterm infants (GA 32-36 weeks) from 64% to 49%. The decline was statistically significant (p<0.001) in all 3 GA groups. This decline remained significant when adjustments were made for factors negatively associated with exclusive breast feeding and which became more prevalent during the study period, that is, small for GA (all groups) and maternal mental illness (very preterm and moderately preterm infants).

CONCLUSIONS

In the past 10 years, Sweden has experienced a lower rate of exclusive breast feeding in preterm infants, especially in extremely preterm infants. The factors analysed in this study explain only a small proportion of this decline. The decline in exclusive breast feeding at discharge from neonatal units raises concern and present challenges to the units to support and promote breast feeding.

Predictors of impaired breastfeeding initiation and maintenance in a diverse sample: what is important?

PURPOSE

This study aimed to investigate socio-demographic, medical and psychological factors that have an impact on breastfeeding.

METHODS

Questionnaires were administered to 330 women prenatally (TI third trimester) and postpartum (TII 3-4 days, TIII 4 months). Medical data were collected from the hospital records. Self-reported data on initiation and maintenance of breastfeeding was collected simultaneously. Primary endpoint was breastfeeding initiation and maintenance. Data analyses were performed using Spearman's ρ correlations between breastfeeding and other study variables and generalized multiple ordinal logistic regression analysis.

RESULTS

Neonatal admission to the NICU, high BMI, cesarean section, difficulties with breastfeeding initiation and high maternal state anxiety were the strongest predictors of impaired breastfeeding initiation, explaining together 50 % of variance. After 4 months, the strongest predictors of impaired maintenance of breastfeeding were maternal smoking, a high BMI and a history of postpartum anxiety disorder, explaining 30 % of variance.

CONCLUSIONS

Successful initiation and maintenance of breast feeding is a multifactorial process. Our results underline the need of interdisciplinary approaches to optimise breastfeeding outcomes by demonstrating the equality of medical and psychological variables. Whereas practices on maternity wards are crucial for optimal initiation, continuous lifestyle modifying and supporting approaches are essential for breastfeeding maintenance. Healthcare providers can also significantly influence breastfeeding initiation and maintenance by counselling on the importance of maternal BMI.

Approaches to supporting lactation and breastfeeding for very preterm infants in the NICU: a qualitative study in three European regions

OBJECTIVES

To explore differences in approaches to supporting lactation and breastfeeding for very preterm infants in neonatal intensive care units (NICU) in 3 European regions.

DESIGN

Qualitative cross-sectional study carried out by means of face-to-face semistructured interviews. Verbatim transcripts were coded using a theoretical framework derived from the literature and supplemented by data-driven concepts and codes.

SETTING

4 purposively selected NICUs in each of 3 European regions in 2010 (Ile-de-France in France, Lazio in Italy, and the former Trent region in the UK).

PARTICIPANTS

NICU staff members (n=22).

RESULTS

Policies and practices for managing mother's own milk for very preterm babies differed between regions, and were much more complex in Ile-de-France than in the Trent or Lazio regions. Staff approaches to mothers to initiate lactation differed by region, with an emphasis on the nutritional and immunological value of human milk in the Trent region and on the 'normalising' effect of breastfeeding on the mother-child relationship in Lazio. French and English staff expressed conflicting opinions about the use of bottles, which was routine in Italy. Italian informants stressed the importance of early maternal milk expression and feeding, but also mentioned discharging infants home before feeding at the breast was established. In Ile-de-France and Trent, successful feeding from the breast was achieved before discharge, although this was seen as a factor that could prolong hospitalisation and discourage continued breastfeeding for some women.

CONCLUSIONS

Targeted health promotion policies in the NICU are necessary to increase the number of infants receiving their mother's milk and to support mothers with transfer of the infant to the breast. Integrating knowledge about the different approaches to lactation and breastfeeding in European NICUs could improve the relevance of recommendations in multiple cultural settings.

Validity and reliability of breastfeeding advice and coping with breastfeeding instruments

PURPOSE

To pilot two instruments: Breastfeeding Advice and Coping with Breastfeeding in NICU settings.

DESIGN

Psychometric testing of the Breastfeeding Advice and Coping with Breastfeeding instruments.

SAMPLE

Mothers (N = 47) with singleton or twin preterm (≤36 + 6 gestation weeks) infant(s) (N = 55) at discharge collected from seven NICUs in Finland.

MAIN OUTCOME VARIABLES

The validity and reliability of two instruments: Breastfeeding Advice measuring the quality of breastfeeding counseling and Coping with Breastfeeding measuring the mothers' experienced ability to cope with breastfeeding issues.

RESULTS

Infants' mean gestation age was 32.5 weeks at birth. The items of the instruments were supported by previous studies, demonstrating content validity. There was a significant correlation (r = .72, p < .001) between Breastfeeding Advice and Coping with Breastfeeding, indicating constructor validity. Evidence for predictive validity was not found. Good reliability for internal consistency of the Breastfeeding Advice (Cronbach's α = .86) and Coping with Breastfeeding (Cronbach's α = .85) was found.

Barriers and facilitators to implementing the Baby-Friendly hospital initiative in neonatal intensive care units

OBJECTIVE

To explore manager, educator, and clinical leader perceptions of barriers and facilitators to implementing Baby-Friendly practice in the neonatal intensive care unit (NICU).

DESIGN

Qualitative, descriptive design.

SETTING

Two university-affiliated level-III NICUs in Canada.

PARTICIPANTS

A purposive sample of 10 medical and nursing managers, nurse educators, lactation consultants, and neonatal nurse practitioners.

METHODS

In-depth, semistructured interviews transcribed and analyzed using qualitative content analysis.

RESULTS

Participants valued breastfeeding and family-centered care yet identified numerous contextual barriers to Baby-Friendly care including infant health status, parent/infant separation, staff workloads and work patterns, gaps in staff knowledge and skills, and lack of continuity of breastfeeding support. Facilitators included breastfeeding education, breastfeeding champions, and interprofessional collaboration.

CONCLUSION

Despite identifying numerous barriers, participants recognized the potential value of expanding the Baby-Friendly Hospital Initiative (BFHI) to the NICU setting. Recommendations include promoting BFHI as a facilitator of family-centered care, interdisciplinary staff education, increasing access to lactation consultants, and establishing a group of NICU champions dedicated to BFHI implementation.

Pharmacists as an underutilized resource for improving community-level support of breastfeeding

With their highly visible roles in the community, frequent interactions with soon-to-be and new parents, and knowledge of medication safety, pharmacists can be a key component in breastfeeding promotion and support. A review of the literature showed that pharmacists have poor knowledge but positive attitudes toward breastfeeding and that pharmacy practices are variable and mostly guided by personal experience. A review of 58 health professional organizations' English-language infant feeding/breastfeeding policy statements showed that no US pharmacists' association has a position statement, as exists for professional pharmacist organizations in Canada and Australia. We explored pharmacists' interactions with mothers before and after birth and possible opportunities to expand pharmacists' roles in the promotion and support of breastfeeding. Barriers to meeting unmet needs of breastfeeding mothers were identified in order to plan strategies for implementing programs to address these barriers. Through input obtained from pharmacy and breastfeeding experts and from information available in the published literature, good matches between unmet needs and capabilities were identified in (a) provision of health promotion resources and public awareness campaigns, (b) assistance with purchase of breastfeeding products and pumps, and (c) provision of information, support, and referral related to commonly encountered difficulties as well as medication use during lactation. Absence of adequate breastfeeding knowledge was identified as a crucial barrier. Leveraging pharmacists to address unmet preventive health needs is especially important as we strive to align resources to support healthy behaviors in our current health care delivery environment.

Preterm birth: Strategies for establishing adequate milk production and successful lactation

Whilst human milk has not evolved to meet the unique requirements of the preterm infant there are unquestionable benefits to be gained via breast milk in terms of the development and health of the infant. Many mothers of preterm infants struggle to achieve a full milk production for many reasons the mechanisms of which are still unclear. Strategies to enhance milk volume include early, frequent simultaneous expression of milk combined with breast massage and a reduction of stress. However, these are not always successful, therefore a greater understanding of lactation physiology is required to devise more effective interventions to increase milk supply. The difficulty these infants experience transitioning to oral feeding and ultimately full breastfeeding further complicates lactation. In order to improve the health of these already compromised infants it is critical that more research be directed to this area so that they reap all the benefits that can be gained from breastfeeding.

Early conditions in the breastfeeding of premature newborn infants

PURPOSE

To describe the breastfeeding initial conditions for premature infants.

METHODS

The sample consisted on 26 mother/baby dyads. The babies had an average of 36.1 weeks corrected gestational age and were hospitalized in a Neonatal Intensive Care Unit in Southern Brazil. Data was collected from medical records, and the observation of the dyads was conducted during feeding, using the Observation and Evaluation of the Breastfeeding Protocol. Favorable and unfavorable behaviors were registered regarding position, responses, suction, affection and anatomy of the breast. After the observation, a questionnaire was applied to the mothers.

RESULTS

The best results refer to the position of mother/child and affection and the poorer ones to the infant responses. Statistically significant correlations by the Spearman Correlations Coefficient were observed between some items of the protocol and other study variables.

CONCLUSION

Most premature infants from this sample presented a satisfactory initiation on analyzed aspects referring to breastfeeding. Still, we emphasize the need of practices for breastfeeding effectiveness and its encouragement in this population.

Expansion of the ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations for three guiding principles

The World Health Organization/United Nations Children's Fund Baby-Friendly Hospital Initiative: Revised, Updated, and Expanded for Integrated Care (2009) identifies the need for expanding the guidelines originally developed for maternity units to include neonatal intensive care. For this purpose, an expert group from the Nordic countries and Quebec, Canada, prepared a draft proposal, which was discussed at an international workshop in Uppsala, Sweden, in September 2011. The expert group suggests the addition of 3 "Guiding Principles" to the Ten Steps to support this vulnerable population of mothers and infants: 1. The staff attitude to the mother must focus on the individual mother and her situation. 2. The facility must provide family-centered care, supported by the environment. 3. The health care system must ensure continuity of care, that is, continuity of pre-, peri-, and postnatal care and post-discharge care. The goal of the expert group is to create a final document, the Baby Friendly Hospital Initiative for Neonatal Units, including standards and criteria for each of the 3 Guiding Principles, Ten Steps, and the Code; to develop tools for self-appraisal and monitoring compliance with the guidelines; and for external assessment to decide whether neonatal intensive/intermediate care units meet the conditions required to be designated as Baby-Friendly. The documents will be finalized after consultation with the World Health Organization/United Nations Children's Fund, and the goal is to offer these documents to international health care, professional, and other nongovernmental organizations involved in lactation and breastfeeding support for mothers of infants who require special neonatal care.

Principles for maintaining or increasing breast milk production

Breastfeeding rates in many developed countries remain low, and maternal perception of insufficient milk production is a major contributing factor. Mothers with a perception of insufficient milk should be advised that normal breastfeeding frequencies, suckling times, and amounts are very variable. If objective assessment confirms insufficient milk production, mothers should ensure optimal milk removal frequency and thorough breast drainage. In addition, galactogogues can be prescribed. Understanding physiological principles underlying milk production will help clinicians reassure and assist mothers.

Infant feeding in the neonatal unit

Infants admitted to a neonatal unit (NNU) are frequently unable to feed by breast or bottle because of ill health or prematurity. These infants require nutritional support until they can start oral feeding. Breastfeeding is advocated for these infants, and mothers are frequently encouraged to express breast milk to be fed via the enteral tube. However, by discharge, breastfeeding rates tend to be low. Oral feeding requires careful management, and although practices may vary because of clinical need, some may be informed by unit norms. There is limited evidence for effective breastfeeding support in this environment and little exploration of the effect of routine feeding decisions. This study aimed to explore feeding decisions and considered how these might affect outcomes. The staff in the two large urban NNUs who participated in the feeding decisions were interviewed and the data were analysed using a theoretical framework. Feeding decisions were made mainly by the unit staff, with limited parental involvement. Subsequent management varied, with differences being related to staff experience and beliefs, unit norms, parent's expectations and physical constraints within the unit. The staff were overtly supportive of breastfeeding, but the need to monitor and quantify milk intake may undermine breastfeeding. Furthermore, feeding breastfed infants during the mothers' absence was controversial and provoked debate. There is a need for clear guidelines and increased parental involvement in feeding decisions. Routine practices within the system may discourage mothers from initiating and persisting with breastfeeding. A change in unit culture is required to fully support the parent's feeding choices.

Análise da produção científica acerca da atenção ao recém-nascido de baixo peso em UTI

O objetivo deste estudo foi analisar a natureza e tendência dos artigos na temática saúde do recém nascido de baixo peso. Trata-se de uma revisão integrativa desenvolvida em agosto de 2009, a partir dos descritores: "recém-nascido de baixo peso" or "recém-nascido de muito baixo peso" and "unidades de terapia intensiva neonatal", no recorte temporal 1990-2008. A amostra de 608 resumos foi submetida à análise de conteúdo temática. Nos resultados, os estudos de natureza clínico-epidemiológica contemplam os fatores de risco do baixo peso e morbimortalidade neonatal e os de tendência assistencial contribuem com as rotinas e cuidados prestados. Evidenciam-se os avanços na atenção a saúde do recém-nascido, a complexidade clínica e as implicações para sua assistência. Destaca-se a lacuna de pesquisas que aponte a subjetividade, o apoio e a inclusão das famílias nos cuidados e no enfrentamento dessa situação.

Induced lactation and exclusive breast milk feeding of adopted premature twins

The authors report the first published case of premature twins whose adoptive mother induced lactation. Both infants are receiving exclusively human milk (adoptive mother's milk) at 2 months of age. This remarkable achievement reflects careful planning by the adoptive mother beginning in the prenatal period, her active role during the infants' hospital stay, and support from health care personnel and family members. Health care professionals are encouraged to support any adoptive mother who expresses interest in breastfeeding her infant(s).