Weighing worth against uncertain work: the interplay of exhaustion, ambiguity, hope and disappointment in mothers breastfeeding late preterm infants

Wayfinding through the "ocean of the great unknown": how lactating parents establish a direct breastfeeding relationship with an infant with critical CHD

INTRODUCTION

Lactating parents of infants hospitalised for critical congenital heart disease (CHD) face significant barriers to direct breastfeeding. While experiences of directly breastfeeding other hospitalised neonates have been described, studies including infants with critical CHD are scarce. There is no evidence-based standard of direct breastfeeding care for these infants, and substantial practice variation exists.

AIM

To explain how direct breastfeeding is established with an infant hospitalised for critical CHD, from lactating parents' perspectives.

MATERIALS & METHODS

This study is a qualitative grounded dimensional analysis of interviews with 30 lactating parents of infants with critical CHD who directly breastfed within 3 years. Infants received care from 26 United States cardiac centres; 57% had single ventricle physiology. Analysis included open, axial, and selective coding; memoing; member checking; and explanatory matrices.

RESULTS

Findings were represented by a conceptual model, "Wayfinding through the 'ocean of the great unknown'." The core process of Wayfinding involved a nonlinear trajectory requiring immense persistence in navigating obstacles, occurring in a context of life-and-death consequences for the infant. Wayfinding was characterised by three subprocesses: navigating the relationship with the healthcare team; protecting the direct breastfeeding relationship; and doing the long, hard work. Primary influencing conditions included relentless concern about weight gain, the infant's clinical course, and the parent's previous direct breastfeeding experience.

CONCLUSIONS

For parents, engaging in the Wayfinding process to establish direct breastfeeding was feasible and meaningful - though challenging. The conceptual model of Wayfinding explains how direct breastfeeding can be established and provides a framework for research and practice.

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

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

Breastfeeding initiation, duration, and experiences of mothers of late preterm twins: a mixed-methods study

Background

Twins and late preterm (LPT) infants are at an increased risk of being breastfed to a lesser extent than term singletons. This study aimed to describe the initiation and duration of any and exclusive breastfeeding at the breast for mothers of LPT twins and term twins during the first 4 months and to explore the breastfeeding experiences of mothers of LPT twins.

Methods

A sequential two-sample quantitative–qualitative explanatory mixed-methods design was used. The quantitative data were derived from a longitudinal cohort study in which 22 mothers of LPT twins and 41 mothers of term twins answered questionnaires at one and four months after birth (2015–2017). The qualitative data were obtained from semi-structured interviews with 14 mothers of LPT twins (2020–2021), based on results from the quantitative study and literature. Analysis included descriptive statistics of quantitative data and deductive content analysis of the qualitative data, followed by condensation and synthesis.

Results

All mothers of LPT twins (100%) and most mothers of term twins (96%) initiated breastfeeding. There was no difference in any breastfeeding during the first week at home (98% versus 95%) and at 1 month (88% versus 85%). However, at 4 months, the difference was significant (44% versus 75%). The qualitative data highlighted that mothers of LPT twins experienced breastfeeding as complex and strenuous. Key factors influencing mothers’ experiences and decisions were their infants’ immature breastfeeding behaviors requiring them to express breast milk alongside breastfeeding, the burden of following task-oriented feeding regimes, and the lack of guidance from healthcare professionals. As a result, mothers started to question the worth of their breastfeeding efforts, leading to changes in breastfeeding management with diverse results. Support from fathers and grandparents positively influenced sustained breastfeeding.

Conclusions

Mothers of LPT twins want to breastfeed, but they face many challenges in breastfeeding during the first month, leading to more LPT twins’ mothers than term twins’ mothers ceasing breastfeeding during the following months. To promote and safeguard breastfeeding in this vulnerable group, care must be differentiated from routine term infant services, and healthcare professionals need to receive proper education and training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00507-3.

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.

Intergenerational Transmissible Meanings in Breastfeeding in Spain: A Phenomenological Study

BACKGROUND

The process of breastfeeding is linked to intergenerational influences based on attitudes and messages of grandmothers about their own experience, and this can reinforce or interfere with the experiences of future mothers in breastfeeding. The aim of this study was to explore the meanings transmissible to the next generation of nursing mothers, based on the experiences of grandmothers.

METHODS

We report the findings of an interpretive phenomenological qualitative research based on the philosophy of Martin Heidegger. In-depth interviews were conducted in Madrid with 17 participants who breastfed before the age of 35 and more than 8 years ago (to ensure the settlement of transmissible meanings in remote memory). Data were analyzed by interpretive phenomenological analysis (IPA).

FINDINGS

Two thematic categories were identified: "Breastfeeding: life experiences" and "Breastfeeding: body and mind process", which show that mothers want to convey the need for a balance that allows maintaining the role of women outside of stereotypes but that is also compatible with the rhythm of life, giving new meanings to attachment, weaning, and modesty.

CONCLUSIONS

Meanings that future grandmothers wish to transmit to the next generation of nursing mothers are related to the search for a satisfactory experience for the mother, who must make an adjustment in her life, freeing herself of inflexible messages about attachment and the maternal role.

PRACTICAL IMPLICATIONS

Strategies to promote breastfeeding and care for nursing mothers can improve the impact of trying to understand the meanings that are transmitted by the grandmothers in the family environment.

Breastfeeding progression in late preterm infants from birth to one month

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

"Something is wrong with your milk": Qualitative study of maternal dietary restriction and beliefs about infant colic

OBJECTIVE

To investigate new mothers' perceptions about the role of maternal diet in infant fuss-cry behaviour, and to explore patterns of food restriction in breastfeeding women.

DESIGN

Qualitative study.

SETTING

Calgary, Alta.

PARTICIPANTS

Twenty-one mothers of healthy singleton infants aged 6 months and younger.

METHODS

Focus groups and one-on-one interviews with a semistructured interview guide, followed by content analysis.

MAIN FINDINGS

Most respondents believed that infant cry-fuss behaviour was related to abdominal pain linked to feeding and had eliminated items from their diet in an attempt to change infant behaviour. Typical targets of elimination were caffeine, cruciferous vegetables (eg, broccoli and cabbage), garlic and onions, spicy foods, gluten, and beans. Women commonly viewed elimination diets as an extension of neutral or benign choices made during pregnancy, even when it led to extreme diet restrictions. Participants reported feeling appraised by society for their infant-feeding choices, and often harshly judged. Many women reported feeling confused by conflicting sources of reliable information on breastfeeding and preferred advice from trusted friends and family to that from health care providers or the Internet.

CONCLUSION

The breastfeeding women in this study believed that maternal diet influenced infant cry-fuss behaviour, in spite of scientific evidence demonstrating the contrary. An understandable desire for a calm baby, as well as to be favourably judged by friends and family, can drive breastfeeding women to restrict their diet, often to the point of hardship.

Do a Few Weeks Matter? Late Preterm Infants and Breastfeeding Issues

The late preterm infant population is increasing globally. Many studies show that late preterm infants are at risk of experiencing challenges common to premature babies, with breastfeeding issues being one of the most common. In this study, we investigated factors and variables that could interfere with breastfeeding initiation and duration in this population. We conducted a prospective observational study, in which we administered questionnaires on breastfeeding variables and habits to mothers of late preterm infants who were delivered in the well-baby nursery of our hospital and followed up for three months after delivery. We enrolled 149 mothers and 189 neonates, including 40 pairs of twins. Our findings showed that late preterm infants had a low rate of breastfeeding initiation and early breastfeeding discontinuation at 15, 40 and 90 days of life. The mothers with higher educational levels and previous positive breastfeeding experience had a longer breastfeeding duration. The negative factors for breastfeeding were the following: Advanced maternal age, Italian ethnicity, the feeling of reduced milk supply and having twins. This study underlines the importance of considering these variables in the promotion and protection of breastfeeding in this vulnerable population, thus offering mothers tailored support.

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.

Education for WIC Peer Counselors About Breastfeeding the Late Preterm Infant

Mothers of late preterm infants need ongoing support because they often find establishing breastfeeding (BF) to be complex and difficult. Special Supplemental Nutrition Program for Women, Infants and Children peer counselors provide BF information and emotional support to new mothers in many communities. However, their current training does not include education about BF for the late preterm infant. The purpose of this report is to present important information about BF and the late preterm infant that can enhance peer counselors' ability to offer appropriate support. The effect of this education on outcomes such as BF rates, maternal self-efficacy, infant hospital readmissions, and peer counselors' self-efficacy needs to be investigated.

Breastfeeding Characteristics of Late-Preterm Infants in a Kangaroo Mother Care Unit

OBJECTIVE

To describe the breastfeeding characteristics of late-preterm infants (LPIs) in a kangaroo mother care (KMC) unit.

MATERIALS AND METHODS

In a 20-bed KMC unit, the breastfeeding of 73 purposively-selected LPIs' (mean gestational age: 34.8 weeks) was observed once-off, using the Preterm Infant Breastfeeding Behavior Scale. Participants' mean age was 9.5 days, mean number of days in the unit was 3.1 days, and mean number of days breastfeeding was 7.5 on observation.

RESULTS

Only 13.7% of participants were directly breastfeeding without supplementary naso- or orogastric feeding/cup-feeding and 86.3% received supplementary cup-feeding of expressed breast milk. Most participants did not exhibit obvious rooting (83.5%) and although most latched-on (97.3%), those who did, latched shallowly (93%). The mean longest sucking burst was 18.8 (standard deviation: 10.5) and approximately half the participants swallowed repeatedly (53.4%). The mean breastfeeding session duration was 17.8 minutes, but most participants breastfed for less than 10 minutes (76.7%). No statistically significant differences in breastfeeding characteristics were detected between participants of different chronological ages. A general trend toward more mature behaviors in participants' breastfeeding for more days was present for many breastfeeding characteristics. More infants exhibited the most mature behavior for each breastfeeding characteristic when the environment was quiet, rather than noisy and disturbing, except for depth of latching (quiet: 0%, disturbance: 15.2%).

CONCLUSION

LPIs in this sample presented with subtle breastfeeding difficulties, highlighting their need for breastfeeding support. Further research is required to examine the effect of KMC on breastfeeding in LPIs.

Breastfeeding the late preterm infant: experiences of mothers and perceptions of public health nurses

BACKGROUND

The promotion and maintenance of breastfeeding with late preterm infants (LPIs) remain under examined topics of study. This dearth of research knowledge, especially for this population at-risk for various health complications, requires scientific investigation. In this study, we explore the experiences of mothers and the perceptions of public health nurses (PHNs) about breastfeeding late preterm infants in Calgary, Alberta, Canada.

METHODS

We used an exploratory mixed methods design with a convenience sample of 122 mothers to gather quantitative data about breastfeeding. We collected qualitative data by means of individual face-to-face interviews with 11 mothers and 10 public health nurses. Data were collected from April 2013 to June 2014. We then employed an interpretive thematic analysis to identify central themes and relationships across narratives.

RESULTS

We collected 74 complete data sets about breastfeeding. During the first 6-8 weeks postpartum, 61 mothers breastfed their infants. Of these, 51 partially breastfed and 10 exclusively breastfed. For qualitative purposes, the researchers interviewed 11 mothers with late preterm babies and three themes emerged: significant difficulty with breastfeeding, failing to recognize the infant's feeding distress and disorganized behavior, and the parental stress caused by the multiple feeding issues. The public health nurses' comments reinforced and expanded on what the mothers reported. The themes for the nurses included: challenges with initiating breastfeeding, challenges during breastfeeding, and the need for stimulation during breastfeeding.

CONCLUSION

Mothers face challenges when breastfeeding their late preterm infants and public health nurses can guide them through this experience. Families with a late preterm infant need to be informed about the challenges associated with breastfeeding a late preterm infant. It is necessary for all health care professionals to receive proper training on safe and effective breastfeeding of late preterm infants. It is essential for public health nurses to communicate effectively with families of late preterm infants to provide anticipatory guidance about potential challenges and strategies to resolve any breastfeeding problems.

A qualitative study: Mothers of late preterm infants relate their experiences of community-based care

Purpose

In Alberta, the high occurrence of late preterm infants and early hospital discharge of mother-infant dyads has implications for postpartum care in the community. Shortened hospital stay and complexities surrounding the care of biologically and developmentally immature late preterm infants heighten anxiety and fears. Our descriptive phenomenological study explores mothers’ experience of caring for their late preterm infants in the community.

Methods

Eleven mothers were interviewed using a semi-structured interview guide. Interview transcripts were analysed using an interpretive thematic approach.

Findings

The mothers’ hospital experience informed their perspective that being a late preterm infant was not a “big deal,” and they tended to treat their infant as normal. “Feeding was really problem,” especially the variability in feeding effectiveness, which was not anticipated. Failing to recognize late preterm infants’ feeding distress exemplified lack of knowledge of feeding cues and tendencies to either rationalize or minimize feeding concerns. Public health nurses represent a source of informational support for managing neonatal morbidities associated with being late preterm; however, maternal experiences with public health nurses varied. Some nurses used a directive style that overwhelmed certain mothers. Seeing multiple public health nurses and care providers was not always effective, given inconsistent and contradictory guidance to care. These new and changing situations increased maternal anxiety and stress and influenced maternal confidence in care. Fathers, family, and friends were important sources of emotional support.

Conclusion

After discharge, mothers report their lack of preparation to meet the special needs of their late preterm infants. Current approaches to community-based care can threaten maternal confidence in care. New models and pathways of care for late preterm infants and their families need to be responsive to the spectrum of feeding issues encountered, limit duplication of services, and ensure consistent and effective care that parents will accept.

Breastfeeding Evaluation Indicators System is a Promising Evaluation Tool for Preterm Infants in Neonatal Intensive Care Units (NICU)

Background

Breast feeding can enhance preterm infants’ neurodevelopmental outcome, regulate immune function development. This study aims to develop breastfeeding evaluation indicators system in neonatal intensive care units (NICU) and to provide theoretical basis for all-round evaluation of breast feeding quality for hospitalized preterm infants.

Material/Methods

This study was performed based on Avedis Donabedian’s theory of medical care quality. Preterm infant breast feeding evaluation indicators system frame was initially formed by using literature review, clinical on-spot observation and expert consultation methods. By using specialists meeting method and Delphi method, evaluation indicators system for preterm infants breastfeeding was verified and established. Breastfeeding evaluation indicators system were performed in NICU of hospitals in Binzhou and Shanghai. Feasibility and usability of indicators system were examined.

Results

Breastfeeding evaluation indicators system for preterm infants comprise 3 levels, including level 1 (3 indicators), level 2 (7 indicators), and level 3 (18 indicators). Recognition rates of importance for level 2 and 3 range from 94.4% to 100.0% and 80.6% to 100.0%, respectively. Mean of Likert rating for level 2 and 3 range from 3.31 to 3.89 and 3.03 to 3.97, which are all higher than the average value of 2.50. Kendall’s coefficient and its significance test showed that consistency of experts’ opinion for indicators’ importance is high (P<0.001). This strategy of combining qualitative and quantitative methods could be used in overall evaluation of the breastfeeding quality in NICUs.

Conclusions

Indicators system is feasible and is a promising evaluation tool for continuously improving breastfeeding quality for preterm infants in NICUs.

Breastfeeding Continuation Among Late Preterm Infants: Barriers, Facilitators, and Any Association With NICU Admission?

BACKGROUND AND OBJECTIVES

Late preterm birth (at 34-36 6/7 weeks' gestation) is a risk factor for early breastfeeding cessation. The objective of this study was to determine barriers to and facilitators of breastfeeding continuation among late preterm infants (LPI) and to compare the barriers faced by LPI admitted to the well nursery versus the NICU.

METHODS

The SAS Complex Survey was used to perform multivariable logistic regression analysis by using data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System. Data from 3 states (Illinois, Maine, and Vermont) for the years 2004 to 2008 were used.

RESULTS

A total of 2530 mothers of LPI were surveyed. Odds of breastfeeding initiation were similar among LPI admitted to the NICU versus the well nursery (adjusted odds ratio, 1.24 [95% confidence interval, 0.88-1.73]; P = .209). Odds of breastfeeding for ≥ 10 weeks were no different between LPI admitted to the NICU versus those admitted to the well-nursery (adjusted odds ratio, 1.02 [95% confidence interval, 0.73-1.43]; P = .904). Factors associated with increased odds of breastfeeding for ≥ 10 weeks among LPI were higher maternal education, mother being married, and normal maternal BMI. Regardless of NICU admission, the top reasons cited by mothers of LPI for early breastfeeding discontinuation were perceived inadequate milk supply and nursing difficulties.

CONCLUSIONS

Among LPIs, NICU admission was not associated with early breastfeeding cessation. Mothers of LPIs with lower odds of sustaining breastfeeding for at least 10 weeks were single mothers, those with a high school education only, and those who were obese. Breastfeeding support should be enhanced for LPIs and should address perceived maternal milk supply concerns and nursing difficulties.

The experience of breastfeeding the late preterm infant: a qualitative study

BACKGROUND

Breastfeeding confers several health advantages to both infants and mothers. For reasons that are multifactorial, infants born even a few weeks prematurely are less likely to initiate breastfeeding, and those who breastfeed do so for a shorter duration than term infants.

MATERIALS AND METHODS

Qualitative analysis of structured telephone interviews was used to examine the breastfeeding experience of mothers of late preterm infants.

RESULTS

Our study found that, among mothers of late preterm infants, breastfeeding is both a positive bonding experience and a challenging experience, fraught with physical and medical struggles and feelings of guilt and failure. When looking back at the breastfeeding experience, many mothers recount negative experiences of milk supply concerns and breast pumping and report aspiring to be able to feed at breast more and pump less with their next child.

CONCLUSIONS

Mothers of late preterm infants reported that breastfeeding was a bonding experience for themselves and their infants, and many plan to do it again if they have future children. However, these mothers also reported that their breastfeeding experience included challenges with latching and milk supply, inadequate lactation support from providers after hospital discharge, and feelings of failure. Interventions with the potential to improve the breastfeeding experience of mothers of late preterm infants include (1) nipple shields and other devices to assist with latching, (2) hand expression or supplementation with small volumes of donor milk or formula to help limit the burden of pumping, (3) provider education to improve lactation support after hospital discharge, and (4) peer support groups.