Parents' views on factors that help or hinder breast milk supply in neonatal care units: systematic review

East Meets West: Effect of Acupuncture on Lactation and Maternal Quality of Life

Objective: To evaluate the impact of acupuncture as part of a traditional Chinese medicine (TCM) treatment plan on lactation and maternal well-being in pump-dependent mothers of hospitalized neonates during the first 30 days after delivery. Study Design: This single-center study was conducted in a level IV regional neonatal intensive care unit with access to integrative health services. Sixty-six mothers were prospectively enrolled in two nonparallel groups: (1) Standard lactation support and (2) standard lactation support augmented with acupuncture. Daily pump volumes were documented. Participants completed a quality-of-life (QOL) survey at baseline and neonatal day of life 30. A linear model was constructed, adjusting for increased milk production over time. Results: Acupuncture was associated with increased milk production at all time points: Day 10 (p = 0.0002), day 14 (p < 0.0001), day 21 (p < 0.0001), and day 30 (p < 0.0001). Acupuncture was associated with an increase in three of five QOL components: psychological/child's health (p = 0.0006), family/friend relationship (p = 0.0006), and health/functioning (p = 0.02). Conclusion: Mothers receiving acupuncture reported enhanced milk supply and improved QOL. The limited sample size restricts the broad applicability of the results; nonetheless, this study paves the way for further research on the advantages of merging Eastern and Western treatments to enhance human lactation.

Predictors of Human Milk Feeding and Direct Breastfeeding for Infants with Single Ventricle Congenital Heart Disease: Machine Learning Analysis of the National Pediatric Cardiology Quality Improvement Collaborative Registry

OBJECTIVE

To identify factors that support or limit human milk (HM) feeding and direct breastfeeding (BF) for infants with single ventricle congenital heart disease at neonatal stage 1 palliation (S1P) discharge and at stage 2 palliation (S2P) (∼4-6 months old).

STUDY DESIGN

Analysis of the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry (2016-2021; 67 sites). Primary outcomes were any HM, exclusive HM, and any direct BF at S1P discharge and at S2P. The main analysis involved multiple phases of elastic net logistic regression on imputed data to identify important predictors.

RESULTS

For 1944 infants, the strongest predictor domain areas included preoperative feeding, demographics/social determinants of health, feeding route, clinical course, and site. Significant findings included: preoperative BF was associated with any HM at S1P discharge (OR = 2.02, 95% CI = 1.74-3.44) and any BF at S2P (OR = 2.29, 95% CI = 1.38-3.80); private/self-insurance was associated with any HM at S1P discharge (OR = 1.91, 95% CI = 1.58-2.47); and Black/African-American infants had lower odds of any HM at S1P discharge (OR = 0.54, 95% CI = 0.38-0.65) and at S2P (0.57, 0.30-0.86). Adjusted odds of HM/BF practices varied among NPC-QIC sites.

CONCLUSIONS

Preoperative feeding practices predict later HM and BF for infants with single ventricle congenital heart disease; therefore, family-centered interventions focused on HM/BF during the S1P preoperative time are needed. These interventions should include evidence-based strategies to address implicit bias and seek to minimize disparities related to social determinants of health. Future research is needed to identify supportive practices common to high-performing NPC-QIC sites.

Knowledge Gaps and Current Evidence Regarding Breastfeeding Issues in Mothers with Chronic Diseases

The prevalence of chronic maternal disease is rising in the last decades in the developed world. Recent evidence indicated that the incidence of chronic maternal disease ranges from 10 to 30% of pregnancies worldwide. Several epidemiological studies in mothers with chronic diseases have mainly focused on the risk for adverse obstetric outcomes. Evidence from these studies supports a correlation between maternal chronic conditions and adverse perinatal outcomes, including increased risk for preeclampsia, cesarean section, preterm birth, and admission in the Neonatal Intensive Care Unit (NICU). However, there is a knowledge gap pertaining to the management of these women during lactation. This review aimed at summarizing the available research literature regarding breastfeeding in mothers with chronic diseases. Adjusted and evidence-based support may be required to promote breastfeeding in women with chronic diseases; however, our comprehension of breastfeeding in this subpopulation is still unclear. The literature related to breastfeeding extends in various scientific areas and multidisciplinary effort is necessary to compile an overview of current evidence and knowledge regarding breastfeeding issues in mothers with chronic diseases.

Comparison of bacterial profiles in human milk from mothers of term and preterm infants

BACKGROUND

Reducing the disposal of donated human milk (HM) is important for efficient management of human milk banks (HMBs). The presence of bacteria growth is the main factor that contributes to the disposal of donated HM. The bacterial profile in HM is suspected to differ between term and preterm mothers, with HM from preterm mothers containing more bacteria. Thus, elucidation of the causes of bacterial growth in preterm and term HM may help to reduce the disposal of donated preterm HM. This study compared the bacterial profiles of HM between mothers of term infants and mothers of preterm infants.

METHODS

This pilot study was conducted in the first Japanese HMB, which was initiated in 2017. This study analyzed 214 human milk samples (term: 75, preterm: 139) donated by 47 registered donors (term: 31, preterm: 16) from January to November 2021. Bacterial culture results in term and preterm HM were retrospectively reviewed in May 2022. Differences in total bacterial count and bacterial species count per batch were analyzed using the Mann-Whitney U test. Bacterial loads were analyzed using the Chi-square test or Fisher's exact test.

RESULTS

The disposal rate did not significantly differ between term and preterm groups (p = 0.77), but the total amount of disposal was greater in the preterm group (p < 0.01). Coagulase-negative Staphylococci, Staphylococcus aureus, and Pseudomonas fluorescens were frequently found in both types of HM. Serratia liquefaciens (p < 0.001) and two other bacteria were present in term HM; a total of five types of bacteria, including Enterococcus faecalis and Enterobacter aerogenes (p < 0.001) were present in preterm HM. The median (interquartile range) total bacterial counts were 3,930 (435-23,365) colony-forming units (CFU)/mL for term HM and 26,700 (4,050-334,650) CFU/mL for preterm HM (p < 0.001).

CONCLUSIONS

This study revealed that HM from preterm mothers had a higher total bacterial count and different types of bacteria than HM from term mothers. Additionally, preterm infants can receive nosocomial-infection-causing bacteria in the NICU through their mother's milk. Enhanced hygiene instructions for preterm mothers may reduce the disposal of valuable preterm human milk, along with the risk of HM pathogen transmission to infants in NICUs.

“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.

Defining postnatal growth failure among preterm infants in Indonesia

Background

Postnatal growth failure (PGF) frequently occurred among preterm infants with malnutrition. The decline in a weight-for-age z-score of ≥1.2 has been proposed to define PGF. It was unknown whether this indicator would be useful among Indonesian preterm infants.

Methods

Infants of &lt;37 weeks of gestational age born between 2020 and 2021, both stable and unstable, were recruited for a prospective cohort study during hospitalization in the level III neonatal intensive care unit at the Cipto Mangunkusumo General Hospital, Jakarta, Indonesia. The prevalence of PGF as defined by a weight-for-age z-score of &lt;−1.28 (&lt;10th percentile) at discharge, a weight-for-age z-score of &lt;−1.5 (&lt;7th percentile) at discharge, or a decline in a weight-for-age z-score of ≥1.2 from birth till discharge was compared. The association between those PGF indicators with the preterm subcategory and weight gain was assessed. The association between the decline in a weight-for-age z-score of ≥1.2 with the duration to achieve full oral feeding and the time spent for total parenteral nutrition was analyzed.

Results

Data were collected from 650 preterm infants who survived and were discharged from the hospital. The weight-for-age z-score of &lt;−1.28 or &lt;−1.5 was found in 307 (47.2%) and 270 (41.5%) subjects with PGF, respectively. However, both indicators did not identify any issue of weight gain among subjects with PGF, questioning their reliability in identifying malnourished preterm infants. By contrast, the decline in a weight-for-age z-score of ≥1.2 was found in 51 (7.8%) subjects with PGF, in which this indicator revealed that subjects with PGF had an issue of weight gain. Next, a history of invasive ventilation was identified as a risk factor for preterm infants to contract PGF. Finally, the decline in a weight-for-age z-score of ≥1.2 confirmed that preterm infants with PGF took a longer time to be fully orally fed and a longer duration for total parenteral nutrition than the ones without PGF.

Conclusion

The decline in a weight-for-age z-score of ≥1.2 was useful to identify preterm infants with PGF within our cohort. This could reassure pediatricians in Indonesia to use this new indicator.

The effect of Pimpinella Anisum herbal tea on human milk volume and weight gain in the preterm infant: a randomized controlled clinical trial

BACKGROUND AND AIMS

Human milk supports pre-term infants to thrive. Yet human milk production can be inhibited when infants are born prematurely. Pimpinella Anisum has been evidenced to increase milk production and infant weight gain in previous animal studies. The present study aimed to determine the effect of Pimpinella Anisum herbal tea on human milk volume and preterm infant weight in human populations for the first time.

METHODS

Human milk supports pre-term infants to thrive. Yet human milk production can be inhibited when infants are born prematurely. Pimpinella Anisum has been evidenced to increase milk production and infant weight gain in previous animal studies. The present study aimed to determine the effect of Pimpinella Anisum herbal tea on human milk volume and preterm infant weight in human populations for the first time.

RESULTS

There was a statistically significant difference in terms of milk volume in the first, third, fourth, fifth, sixth and seventh days between the three groups of intervention, placebo, and control (p < 0.05). On the first day, the mean volume of pumped milk in the intervention group was significantly higher than the control group (p = 0.008). On the second day, there was no statistically significant difference between groups. On the third, fourth, fifth, sixth and seventh days, the mean volume of pumped milk in the intervention group was significantly higher than the placebo and control groups (p < 0.05). There was no statistically significant difference in terms of preterm infant weight on days 0, 3 and 7 between the three groups.

CONCLUSION

The use of Pimpinella Anisum or 'Anise' tea can increase the volume of human milk and since no specific side effects have been reported in its use, it may be incorporated easily, cheaply, and effectively in practice where appropriate to the benefit of preterm infant nutrition worldwide.

The Impact of Human Milk on Outcomes for Infants with Congenital Heart Disease: A Systematic Review

Background: Infants with congenital heart disease (CHD) are at risk for feeding-related morbidity and mortality, with growth failure and oral feeding problems associated with poor outcomes. The benefits of human milk (HM) for preterm infants have been well documented, but evidence on HM for infants with CHD has recently begun to emerge. Objectives: Our primary aim was to examine the impact of HM feeding on outcomes for infants with CHD. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. The quality of each study was assessed using the Joanna Briggs Critical Appraisal Tools. A total of 16 studies were included. Results: There was evidence that an exclusive HM diet reduces the risk of necrotizing enterocolitis (NEC) for infants with CHD. Evidence with a higher risk for bias indicated that a well-managed HM diet may be associated with improved growth, shorter length of stay, and improved postoperative feeding and nutritional outcomes. Chylothorax outcomes were similar between modified HM and medium-chain triglyceride formula. The studies had significant limitations related to power, lack of control for covariates, and inconsistent delineation of feeding groups. Conclusions: Based on the reduced risk for NEC and given the conclusive benefits in other vulnerable populations, we recommend that clinicians and institutions prioritize programs to support HM feeding for infants with CHD. Large high-quality studies are needed to validate these results. Future work should clarify best practices in managing an HM diet to support optimal growth and development for these infants.

Family-centred care change during COVID-19

BACKGROUND

Family-centred care (FCC) is an approach to promote family and health care provider partnership. This has been incorporated into neonatal intensive care units (NICUs) worldwide. However, FCC in low resource health settings, such as Thailand, is challenging and further impacted by coronavirus disease 2019 (COVID-19).

AIMS

To evaluate FCC innovations to improve respect, collaboration and support in a Thai NICU.

STUDY DESIGN

A quasi-experimental study was conducted in an NICU in southern Thailand. Pre-implementation was prior to COVID-19, and parental and staff perceptions of FCC were measured via Perceptions of Family Centred Care-Parent (PFCC-P) and -Staff (PFCC-S) survey. The FCC innovations were developed by stakeholders based on the COVID-19 restrictions, pre-survey results, parents' and clinicians' interviews and integrative review, then implemented via a flowchart. Post-implementation evaluation was via repeated surveys. Comparisons were made pre-and post-implementation, with Mann-Whitney U-test statistics for parents and Wilcoxon's Rank Sum for staff.

RESULTS

A total of 185 (85 pre; 100 post) parents and 20 (pre and post; paired group) health care professionals participated. Because of COVID-19, many planned interventions were unfeasible, however, other innovations achieved (e.g., structured telephone updates, information booklet revision). There was an increase in parents' perception of respect ([median] 2.50-3.50), collaboration (2.33-3.33) and support (2.60-3.60) domains and overall (2.50-3.43; p < .001; 95% CI: 2.93-3.11). Interdisciplinary professionals' perception of FCC did not significantly change pre-and post-implementation/COVID-19 pandemic for respect (3.00-2.92), collaboration (3.22-3.33), support (3.20-3.20) and overall (3.15-3.20; 95% CI: 3.10-3.25).

CONCLUSION

Despite the challenges of COVID-19 restricting NICU access, the provision of FCC was maintained and even improved.

RELEVANCE TO CLINICAL PRACTICE

Further research is necessary to develop FCC practice innovations associated with communication, across diverse health care systems and resources.

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.

Exclusive breastfeeding of full-term infants during the first 6 months after discharge from a neonatal unit in China: A cross-sectional study

OBJECTIVES

To elucidate breastfeeding patterns, the reasons for stopping exclusive breastfeeding, and the sociodemographic characteristics associated with exclusive breastfeeding of full-term infants during the 6 months after discharge from a neonatal unit in China.

METHODS

This cross-sectional study included mothers of full-term infants who were discharged from the 40-bed neonatal unit (level IIA) of a tertiary hospital in Hunan province, China between August 2019 and September 2020. Information on breastfeeding patterns was collected through telephone interviews with the mothers 6 months after their infants had been discharged from the neonatal unit. Binary logistic regression was used to determine the factors associated with exclusive breastfeeding.

RESULTS

This study included 489 mother-infant dyads. At 6 months after discharge, 51.5% of mothers were exclusively breastfeeding, 29.0% of mothers were partially breastfeeding, and 19.4% of mothers were not breastfeeding. The most common reason for stopping breastfeeding was "poor milk supply" (81.2%). Factors associated with exclusive breastfeeding included multiparity, exclusive breastfeeding before the hospitalization, providing breast milk to the hospitalized infant, and a high level of maternal education.

CONCLUSIONS

In the Chinese culture, mothers who experienced multiparity and higher-level education were more likely to breastfeed their infants to 6 months after discharge from the neonatal unit. In addition, infants who were exclusively breastfed before and during hospitalization were also more likely to be exclusively breastfed after discharge. The results will help inform future research aimed at identifying interventions to reduce early breastfeeding cessation.

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.

Fathers' experiences of feeding their extremely preterm infants in family-centred neonatal intensive care: a qualitative study

BACKGROUND

Extremely preterm infants need advanced intensive care for survival and are usually not discharged before they reach the time of expected birth. In a family-centred neonatal intensive care unit both parents are involved at all levels of care including the feeding process. However, studies focusing on fathers in this situation are scarce. The purpose of this study was to explore the experiences of feeding extremely preterm infants in a neonatal intensive care unit from fathers' perspectives.

METHODS

The study adopts a qualitative inductive method, reported according to the COREQ checklist. Seven fathers of extremely preterm infants (gestational age 24-27 weeks) in neonatal intensive care in Sweden were interviewed by telephone after discharge in 2013-2014. The interviews were analysed using a qualitative content analysis and confirmed by triangulation in 2021.

RESULTS

Six sub-categories and two generic categories formed the main category: "a team striving towards the same goal". The fathers were equally involved and engaged members of the feeding team all hours of the day. The fathers shared responsibility and practical duties with the mothers, and they provided as much support to the mothers as they could. However, the fathers found it difficult to support and encourage the mothers to breastfeed and express breastmilk when the breastmilk production was low. The fathers experienced a loss when breastfeeding was not successful.

CONCLUSIONS

The findings indicate that fathers want to be involved with infant care, including night-time feeds, and long and demanding feeding processes. Fathers and staff need to collaborate to provide the best support to mothers during the feeding process. This study may inspire hospital staff to acknowledge and support fathers to become more involved in the oral feeding process when an infant is born extremely preterm.

Feeding infants with complex congenital heart disease: a modified Delphi survey to examine potential research and practice gaps

OBJECTIVE

To determine clinical consensus and non-consensus in regard to evidence-based statements about feeding infants with complex CHD, with a focus on human milk. Areas of non-consensus may indicate discrepancies between research findings and practice, with consequent variation in feeding management.

MATERIALS AND METHODS

A modified Delphi survey validated key feeding topics (round 1), and determined consensus on evidence-based statements (rounds 2 and 3). Patients (n=25) were an interdisciplinary group of clinical experts from across the United States of America. Descriptive analysis used SPSS Statistics (Version 26.0). Thematic analysis of qualitative data provided context for quantitative data.

RESULTS

Round 1 generated 5 key topics (human milk, developing oral feeding skills, clinical feeding practice, growth failure, and parental concern about feeding) and 206 evidence-based statements. The final results included 110 (53.4%) statements of consensus and 96 (46.6%) statements of non-consensus. The 10 statements of greatest consensus strongly supported human milk as the preferred nutrition for infants with complex CHD. Areas of non-consensus included the adequacy of human milk to support growth, need for fortification, safety, and feasibility of direct breastfeeding, issues related to tube feeding, and prevention and treatment of growth failure.

CONCLUSIONS

The results demonstrate clinical consensus about the importance of human milk, but reveal a need for best practices in managing a human milk diet for infants with complex CHD. Areas of non-consensus may lead to clinical practice variation. A sensitive approach to these topics is needed to support family caregivers in navigating feeding concerns.

Strategies to increase the use of mother's own milk for infants at risk of necrotizing enterocolitis

High-dose mother's own milk (MOM) feedings during the first 14 days post birth reduce the risk of necrotizing enterocolitis in very low birthweight (VLBW; <1500 g birthweight). However, high-dose MOM feedings are only possible if mothers provide sufficient quantities of MOM in a timely manner, and data indicate that the lack of MOM during the early post-birth period is a global problem. This paper reviews the modifiable and unmodifiable barriers to accessing adequate quantities of MOM during the early post-birth period and proposes evidence-based strategies to increase and improve the use of MOM during the neonatal intensive care unit (NICU) hospitalization with an emphasis on the critical first 2 weeks post birth.

Maternal chronic disease and breastfeeding outcomes: a Canadian population-based study

Background: The prevalence of chronic disease in pregnant women has consistently risen over the past two decades. Substantial evidence demonstrates that maternal chronic disease is associated with adverse medical outcomes like preterm birth, but less research has characterized postpartum outcomes such as infant feeding practices. It is recommended that infants be exclusively breastfed from birth to 6 months given the numerous health benefits it provides.Objective: To determine the association between maternal chronic disease and breastfeeding outcomes.Methods: We analyzed cross-sectional self-report data from the 2015/2016 Canadian Community Health Survey, restricted to women who gave birth within 2 years of data collection (n = 2100, rounded). The exposure was professionally diagnosed chronic physical disease (e.g. diabetes, arthritis, heart disease). The outcomes were breastfeeding non-initiation and early cessation of breastfeeding before 6 months. Multivariable logistic regression modeling was used to estimate adjusted odds ratios (AOR) with 95% confidence intervals (CIs). Estimates were bootstrapped and weighted to represent the national population.Results: Overall, 11.9% (95% CI 9.8-14.1) of women reported chronic disease, and were more likely to be single, be Canadian born, have low education, and be overweight/obese than women without chronic disease. The mean maternal age was approximately 30 years in both groups. Women with chronic disease had similar odds of breastfeeding non-initiation (AOR 0.96, 95% CI 0.54-1.71) and early cessation of any breastfeeding (AOR 1.40, 95% CI 0.82-2.40), but over twice the odds of early cessation of exclusive breastfeeding (AOR 2.48, 95% CI 1.49-4.12) compared to unaffected women.Conclusion: Mothers with chronic disease initiate and continue some form of breastfeeding to six months as often as their unaffected peers. However, they have substantially higher odds of ceasing exclusive breastfeeding before the recommended 6 months. Findings suggest a need to investigate the reasons for this disparity to ensure that appropriate breastfeeding support is available for women with chronic disease and their children.

Factors Associated With Breastfeeding Among Women With Gestational Diabetes

BACKGROUND

Breastfeeding offers benefits to mother and child but is frequently not practiced among women whose pregnancy is complicated by gestational diabetes mellitus. Factors associated with not initiating or not maintaining breastfeeding among these women have been little investigated.

RESEARCH AIMS

(1) To evaluate the frequency of breastfeeding for 30 days among women with a recent pregnancy complicated by gestational diabetes and (2) to determine factors associated with not initiating or not maintaining breastfeeding.

METHODS

Between January 2014 and July 2017 we enrolled women with gestational diabetes at high-risk prenatal services in three Brazilian cities. We collected baseline sociodemographic and health data and followed up with participants by telephone. Using Kaplan-Meier curves, we calculated the proportions of participants not initiating breastfeeding or not maintaining it for at least 30 days. We used Poisson regression with robust variance to identify factors related to this outcome.

RESULTS

Of the 2328 participants with complete information, 2236 (96.1%) initiated breastfeeding, and 2166 (93.1%) maintained breastfeeding for 30 days. Not having breastfed the previous infant (relative risk [RR] = 5.02, 95% CI [3.39, 7.45]), smoking during pregnancy (RR = 2.37, 95% CI [1.48, 3.80]), infant with health problems (RR = 2.25, 95% CI [1.27, 3.99]), early preterm birth (RR = 2.49, 95% CI [1.07, 5.77]), and not intending to breastfeed (RR = 3.73, 95% CI [1.89, 7.33]) were related to not maintaining breastfeeding for at least 30 days.

CONCLUSIONS

Breastfeeding initiation was nearly universal among participants, and most maintained breastfeeding for 30 days. Factors relating to not breastfeeding at 30 days were easily identifiable.

Comparison of family centered care with family integrated care and mobile technology (mFICare) on preterm infant and family outcomes: a multi-site quasi-experimental clinical trial protocol

Background

Family Centered Care (FCC) has been widely adopted as the framework for caring for infants in the Neonatal Intensive Care Unit (NICU) but it is not uniformly defined or practiced, making it difficult to determine impact. Previous studies have shown that implementing the Family Integrated Care (FICare) intervention program for preterm infants in the NICU setting leads to significant improvements in infant and family outcomes. Further research is warranted to determine feasibility, acceptability and differential impact of FICare in the US context. The addition of a mobile application (app) may be effective in providing supplemental support for parent participation in the FICare program and provide detailed data on program component uptake and outcomes.

Methods

This exploratory multi-site quasi-experimental study will compare usual FCC with mobile enhanced FICare (mFICare) on growth and clinical outcomes of preterm infants born at or before 33 weeks gestational age, as well as the stress, competence and self-efficacy of their parents. The feasibility and acceptability of using mobile technology to gather data about parent involvement in the care of preterm infants receiving FCC or mFICare as well as of the mFICare intervention will be evaluated (Aim 1). The effect sizes for infant growth (primary outcome) and for secondary infant and parent outcomes at NICU discharge and three months after discharge will be estimated (Aim 2).

Discussion

This study will provide new data about the implementation of FICare in the US context within various hospital settings and identify important barriers, facilitators and key processes that may contribute to the effectiveness of FICare. It will also offer insights to clinicians on the feasibility of a new mobile application to support parent-focused research and promote integration of parents into the NICU care team in US hospital settings.

Trial registration

ClinicalTrials.gov, ID NCT03418870. Retrospectively registered on December 18, 2017.

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.

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.

Caregiving can be costly: A qualitative study of barriers and facilitators to conducting kangaroo mother care in a US tertiary hospital neonatal intensive care unit

BACKGROUND

Preterm birth is a leading cause of morbidity and mortality in children under five and often requires a newborn to have an extended stay in a neonatal intensive care unit (NICU). Maternal engagement, such as visiting the NICU to provide kangaroo mother care (KMC), can improve outcomes for preterm infants but requires significant investment of time and resources. This study sought to understand barriers and facilitators to provision of KMC in the NICU.

METHODS

We conducted semi-structured in-depth interviews with mothers of preterm infants (N = 20) at a large academic medical center in Massachusetts. A series of open-ended interview questions were designed to elicit all aspects of mothers' experiences and to understand how these experiences influence provision of KMC. All interviews were recorded and transcribed verbatim. We conducted an inductive thematic analysis to identify themes in the data with a focus on the barriers and facilitators of KMC provision in the NICU.

RESULTS

Findings show that engaging in KMC is heavily influenced by the mental, emotional, and physical effects of preterm birth on the birth mother, such as stress around preterm birth and difficulty recovering from birth. These challenges are compounded by structural barriers such as costly accommodations, unreliable transportation, lack of child care, and inadequate maternity leave policies that limit the frequency and duration of KMC and parental ability to provide care.

CONCLUSIONS

A complex array of mental, emotional, physical, and structural factors determine a mother's ability to visit the NICU and provide kangaroo mother care. Providing social supports, such as improved maternity leave policies and reliable hospital access through child care, accommodation, and transportation services, may address the structural barriers that inhibit KMC, reduce burdensome costs, and improve the health of mothers and their preterm infants.

Integrative Review of Parents' Perspectives of the Nursing Role in Neonatal Family-Centered Care

OBJECTIVES

To identify the perceptions of mothers and fathers of newborns admitted to NICUs regarding the role of neonatal nurses in the provision of family-centered care and how neonatal nurses were able to interpret and meet parents' needs.

DATA SOURCES

We conducted literature searches in the CINAHL, MEDLINE, Embase, PsycINFO, Dissertations and Theses Global, and Maternity and Infant Care databases.

STUDY SELECTION

Articles on qualitative and quantitative studies were selected if they were published in English from 2009 to 2018; they were set in countries with similar health care resources in Australasia, Canada, Europe, Scandinavia, the United Kingdom, and the United States; and the data were collected from parents. We identified 31 studies for analysis.

DATA EXTRACTION

We used the thematic analysis method of Braun and Clarke to extract data elements that were grouped and coded into themes and subthemes.

DATA SYNTHESIS

Through ongoing iterative analysis, we generated six themes from the 18 subthemes that in combination presented the experiences of parents in the context of family-centered care provided by neonatal nurses: Process of Becoming a Parent, Neonatal NursesSupportingParents, Infant Safety, Communication, Barriers to Parenting, and Parenting Inhibited by Neonatal Nurses.

CONCLUSION

The six themes reflected the contribution made by neonatal nurses to family-centered care in the NICU. The parents' perspectives of nurses were mostly positive, but some negative aspects attributed to nurses identified in earlier studies persisted.

A Typology of Breastfeeding Mothers of Preterm Infants: A Qualitative Analysis

BACKGROUND

Breastfeeding is an important element of motherhood with a preterm infant, but the role of maternal emotions in relation to breastfeeding is vague.

PURPOSE

To describe maternal emotions regarding and insights into breastfeeding during the first year after a preterm birth.

METHODS

In total, 80 mothers of preterm infants (<35 gestational weeks) participated in this secondary analysis of a larger study. The data were collected with an open question at discharge and 3, 6, and 12 months after the expected birth date and analyzed using thematic analysis.

FINDINGS

A typology of breastfeeding mothers of preterm infants was created. The group of survivors wished to be breastfeeding mothers, but after some unexpected difficulties, they had to give up their dream. The disappointment alleviated with time, but some of the mothers still harbored self-accusations after a year. The highfliers were mothers who succeeded in breastfeeding because of their own persistence. They described breastfeeding as enjoyable for both the mother and the infant. The pragmatist mothers breastfed because it was the general norm and a practical way to feed the infant; breastfeeding caused neither passion nor discomfort. The group of bottle-feeding-oriented mothers expressed that breastfeeding did not interest them at any point.

IMPLICATIONS FOR PRACTICE

Being aware of the typology could help nurses and midwives carefully observe mothers' individual counselling needs. Mothers' wishes and decisions regarding breastfeeding need to be respected and supported without any judgment.

IMPLICATIONS FOR RESEARCH

The possibilities to tailor breastfeeding interventions based on the typology should be investigated.

Growth and breastfeeding of preterm infants receiving neonatal tele-homecare compared to hospital-based care

OBJECTIVE

Neonatal tele-homecare implies that parents of clinically stable preterm infants can manage tube feeding and establishment of oral feeding in the home. Support is provided from the neonatal intensive care unit (NICU) through a telehealth service. The aim of this study was to compare growth and breastfeeding rates amongst infants being managed in the NICU (conventional care) and by neonatal tele-homecare.

METHODS

A total of 96 preterm infants with tube feeding requirements participated in the observational study of neonatal tele-homecare. Retrospective data in 278 preterm infants receiving standard care in the same neonatal intensive care unit prior to implementation of neonatal tele-homecare were used for comparison. Rates of breastfeeding and growth were monitored during neonatal tele-homecare. Infant weights were converted to standard deviation weight-for-age z-scores based on a reference.

RESULTS

There was no significant difference in rates of exclusive breastfeeding between the neonatal tele-homecare infants and the controls. Among the very preterm singleton infants more neonatal tele-homecare infants were exclusively breastfed at discharge compared to the controls (p = 0.04). There was no significant difference in median weight for age z-scores at discharge.

CONCLUSION

This study demonstrates that neonatal tele-homecare may be an appropriate model of care for the management of preterm infants outside of the hospital environment; with the added benefit of higher rates of breastfeeding at time of discharge for very preterm infants.

Maternal views on facilitators of and barriers to breastfeeding preterm infants

Background

The supply of breast milk to preterm infants tends to occur at a lower rate than that recorded among term infants. We aimed to investigate the facilitators of and barriers to breastfeeding during hospital stay according to the experiences of mothers that gave birth to premature infants requiring admission to neonatal intensive care unit.

Methods

A cross-sectional questionnaire survey was conducted. Mothers who had delivered a newborn with a gestational age ≤33 weeks requiring intensive care, entered the study. Basic subjects’ characteristics and infant feeding practices were also recorded.

Results

A total of 64 mothers were enrolled, leading to a total of 81 infants. At discharge, any breastfeeding was recorded in 66% of infants, with 27% of those infants being exclusively breastfed. Any infant was exclusively fed directly at the breast. Most mothers experienced adequate support during their infant’s hospitalization and reported satisfaction with breastfeeding. Almost all mothers felt that feeding their infant human milk was beneficial for the infant’s health. Thirty percent of the mothers reported that they had experienced some obstacles to breastfeeding. Specifically, infants born to mothers who experienced difficulties in pumping breast milk (OR = 4.6; CI 1.5–13.9) or in providing an adequate amount of milk to the infant (OR = 3.57; CI 1.1–11.5) were at higher risk of being fed with formula at discharge.

Conclusions

On the basis of the present results, health care professionals should target their efforts to optimize breastfeeding support for mothers of premature infants admitted to level III care, especially by improving breast milk production and endorsing direct breastfeeding.

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.

The Type of Feeding at Discharge of Very Preterm Infants: Neonatal Intensive Care Units Policies and Practices Make a Difference

Objective: To assess the influence of neonatal intensive care units (NICUs) on feeding practices at discharge of Portuguese very preterm infants. Materials and Methods: We analyzed data from 580 very preterm infants (<32 gestational weeks) discharged home from NICUs of two Portuguese regions and enrolled during 2011-2012 in Effective Perinatal Intensive Care in Europe population-based cohort. Maternal and infant characteristics were abstracted from medical records, and heads of NICUs provided the units characteristics. Feeding at discharge was classified as exclusive formula, exclusive breast milk or mixed, and differences among NICUs were obtained by comparison with pooled geometric mean odds of all NICUs, using multinomial logistic regression. Median odds ratios (MOR) were calculated to quantify variability among NICUs using multilevel logistic regression. Results: At discharge, 25.2% very preterm infants were exclusively on breast milk, 34.1% exclusively on formula, and 40.7% had mixed feeding, with a wide variation among NICUs. Exclusive breast milk increased in NICUs that had higher numbers of admissions, provided parents eating facilities, and by having designated members to support mothers who were breastfeeding. The individual NICU odds of mixed versus exclusive formula feeding ranged from 0.36 to 2.07 and for exclusive breast milk versus exclusive formula ranged from 0.16 and 5.11. Adjusting for individual and unit characteristics, heterogeneity across NICUs remained evident, being the MOR 1.33 for mixed feeding and 1.35 for exclusive breast milk. Conclusions: NICUs influence feeding practices independently of individual characteristics, highlighting the importance of institution-based interventions to promote breast milk.

Roles and Experiences of Parents in Necrotizing Enterocolitis: An International Survey of Parental Perspectives of Communication in the NICU

BACKGROUND

Although partnering with parents is important to improving neonatal outcomes, no studies have investigated what parents are taught, remember, or experience when their child is afflicted with necrotizing enterocolitis (NEC).

PURPOSE

To characterize parental perceptions of communication and support they were given about NEC.

METHODS

An online survey was developed, reviewed for face validity, and then administered to parents whose child had experienced NEC. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using a qualitative descriptive approach.

FINDINGS

Parents (N = 110) wanted to know the risk factors and warning signs for NEC and wanted to be told as soon as their child was admitted to the neonatal intensive care unit (NICU). Information provided before diagnosis was felt to be poor by the majority of families, with only 32% feeling satisfied or very satisfied. No parent wrote that they were "scared" by information provided to them about NEC; in fact, parents were dissatisfied when they received "sugar-coated" information. Engaged parents were significantly more satisfied than those who were not informed, had their concerns and suggestions dismissed, or who had to advocate for their baby against clinician opposition (eg, activating the chain of command).

IMPLICATIONS FOR PRACTICE

Areas for quality improvement include better communication and collaboration with parents through early engagement in NEC prevention using modalities beyond verbal instruction.

IMPLICATIONS FOR RESEARCH

More research is needed on how best to engage parents, especially to engage in prevention, and how doing so affects satisfaction and outcomes.

Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort

Breast milk feeding (BMF) is associated with lower neonatal morbidity in the very preterm infant (<32 weeks gestation) and breastfeeding is beneficial for maternal health. Previous studies show large variations in BMF after very preterm birth and recognize the need for targeted breastfeeding support in the neonatal intensive care units (NICU). In a European collaboration project about evidence-based practices after very preterm birth, we examined the association between maternal, obstetric, and infant clinical factors; neonatal and maternal care unit policies; and BMF at discharge from the NICU. In multivariable analyses, covariates associated with feeding at discharge were first investigated as predictors of any BMF and in further analysis as predictors of exclusive or partial BMF. Overall, 58% (3,826/6,592) of the infants received any BMF at discharge, but there were large variations between regions (range 36-80%). Primiparity, administration of antenatal corticosteroids, first enteral feed <24 hr after birth, and mother's own milk at first enteral feed were predictors positively associated with any BMF at discharge. Vaginal delivery, singleton birth, and receiving mother's own milk at first enteral feed were associated with exclusive BMF at discharge. Units with a Baby Friendly Hospital accreditation improved any BMF at discharge; units with protocols for BMF and units using donor milk had higher rates of exclusive BMF at discharge. This study suggests that there is a high potential for improving BMF through policies and support in the NICU.

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.

Breastfeeding education and support for women with twins or higher order multiples

BACKGROUND

There are rising rates of multiple births worldwide with associated higher rates of complications and more hospital care, often due to prematurity. While there is strong evidence about the risks of not breastfeeding, rates of breastfeeding in women who have given birth to more than one infant are lower than with singleton births. Breastfeeding more than one infant can be more challenging because of difficulties associated with the birth or prematurity. The extra demands on the mother of frequent suckling, coordinating the needs of more than one infant or admission to the neonatal intensive care unit can lead to delayed initiation or early cessation. Additional options such as breast milk expression, the use of donor milk or different methods of supplementary feeding may be considered. Support and education about breastfeeding has been found to improve the duration of any breastfeeding for healthy term infants and their mothers, however evidence is lacking about interventions that are effective to support women with twins or higher order multiples.

OBJECTIVES

To assess effectiveness of breastfeeding education and support for women with twins or higher order multiples.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), ClinicalTrials.gov (30 June 2016), the WHO International Clinical Trials Registry Platform (ICTRP) (1 July 2016), the excluded studies list from the equivalent Cochrane review of singletons, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing extra education or support for women with twins or higher order multiples were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We planned to assess the quality of evidence using the GRADE approach, but were unable to analyse any data.

MAIN RESULTS

We found 10 trials (23 reports) of education and support for breastfeeding that included women with twins or higher order multiples. The quality of evidence was mixed, and the risk of bias was mostly high or unclear. It is difficult to blind women or staff to group allocation for this intervention, so in all studies there was high risk of performance and high or unclear risk of detection bias. Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial); of these, data were available from two studies for 42 women with twins or higher order multiples. None of the interventions were specifically designed for women with more than one infant, and the outcomes for multiples were not reported separately for each infant. Due to the scarcity of evidence and the format in which data were reported, a narrative description of the data is presented, no analyses are presented in this review, and we were unable to GRADE the evidence.The two trials with data for women with multiple births compared home nurse visits versus usual care (15 women), and telephone peer counselling versus usual care (27 women). The number of women who initiated breastfeeding was reported (all 15 women in one study, 25 out of 27 women in one study). Stopping any breastfeeding before four to six weeks postpartum, stopping exclusive breastfeeding before four to six weeks postpartum, stopping any breastfeeding before six months postpartum andstopping exclusive breastfeeding before six months postpartum were not explicitly reported, and there were insufficient data to draw any meaningful conclusions from survival data. Stopping breast milk expression before four to six weeks postpartum, andstopping breast milk expression before six months postpartum were not reported. Measures ofmaternal satisfaction were reported in one study of 15 women, but there were insufficient data to draw any conclusions; no other secondary outcomes were reported for women with multiple births in either study. No adverse events were reported.

AUTHORS' CONCLUSIONS

We found no evidence from randomised controlled trials about the effectiveness of breastfeeding education and support for women with twins or higher order multiples, or the most effective way to provide education and support . There was no evidence about the best way to deliver the intervention, the timing of care, or the best person to deliver the care. There is a need for well-designed, adequately powered studies of interventions designed for women with twins or higher order multiples to find out what types of education and support are effective in helping these mothers to breastfeed their babies.

"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.

Factors Influencing Parent Reports of Facilitators and Barriers to Human Milk Supply in Neonatal Intensive Care Units

BACKGROUND

Successful human milk supply in neonatal intensive care units (NICUs) requires the development of family-centered services.

OBJECTIVE

This study aimed to assess parent perceptions of factors that help or hinder providing human milk to very preterm infants (VPI) in the NICU according to sociodemographic, reproductive, and obstetric characteristics.

METHODS

This cross-sectional quantitative study included 120 mothers and 91 fathers of VPI hospitalized in a level 3 NICU located in the Northern Health Region of Portugal (July 2013-June 2014). Interviewers administered structured questionnaires regarding parent characteristics and the provision and perception of factors that help or hinder human milk supply in the NICU, 15 to 22 days after birth.

RESULTS

The main facilitators of human milk supply were its contribution to infant growth and well-being (51.4%) and parents' knowledge of breastfeeding benefits (27.6%). The main barriers were worries related to inadequate milk supply (35.7%), difficulties with expressing breast milk (24.8%), and physical separation from infants (24.3%). Fathers referred less frequently to the contribution of human milk to infant growth and well-being (odds ratio [OR] = 0.57; 95% confidence interval [CI], 0.32-1.00) but more frequently to knowledge of breastfeeding benefits as facilitators (OR = 2.31; 95% CI, 1.23-4.32). Participants with > 12 years of education (OR = 1.91; 95% CI, 1.05-3.47) and those with an extremely low birth weight infant (OR = 1.90; 95% CI, 1.02-3.54) highlighted worries related to inadequate milk supply. Fathers (OR = 2.16; 95% CI, 1.11-4.19) and participants with ≤ 12 years of education (OR = 0.25; 95% CI, 0.11-0.57) more frequently reported difficulties with expressing as the main barrier.

CONCLUSION

The parent's gender and education and the infant's birth weight are crucial considerations for establishing optimal practices for supporting breastfeeding.

Telemedicine in Neonatal Home Care: Identifying Parental Needs Through Participatory Design

Background

For the majority of preterm infants, the last weeks of hospital admission mainly concerns tube feeding and establishment of breastfeeding. Neonatal home care (NH) was developed to allow infants to remain at home for tube feeding and establishment of breastfeeding with regular home visits from neonatal nurses. For hospitals covering large regions, home visits may be challenging, time consuming, and expensive and alternative approaches must be explored.

Objective

To identify parental needs when wanting to provide neonatal home care supported by telemedicine.

Methods

The study used participatory design and qualitative methods. Data were collected from observational studies, individual interviews, and focus group interviews. Two neonatal units participated. One unit was experienced in providing neonatal home care with home visits, and the other planned to offer neonatal home care with telemedicine support. A total of 9 parents with preterm infants assigned to a neonatal home care program and 10 parents with preterm infants admitted to a neonatal unit participated in individual interviews and focus group interviews, respectively.

Results

Three overall themes were identified: being a family, parent self-efficacy, and nurse-provided security. Parents expressed desire for the following: (1) a telemedicine device to serve as a “bell cord” to the neonatal unit, giving 24-hour access to nurses, (2) video-conferencing to provide security at home, (3) timely written email communication with the neonatal unit, and (4) an online knowledge base on preterm infant care, breastfeeding, and nutrition.

Conclusions

Our findings highlight the importance of neonatal home care. NH provides parents with a feeling of being a family, supports their self-efficacy, and gives them a feeling of security when combined with nursing guidance. Parents did not request hands-on support for infant care, but instead expressed a need for communication and guidance, which could be met using telemedicine.

Father's role in supporting breastfeeding of preterm infants in the neonatal intensive care unit: a qualitative study

OBJECTIVE

To analyse the social beliefs, representations and experiences of fathers of preterm newborns (NBs) regarding breastfeeding.

DESIGN

A qualitative interview study with analysis of transcripts using the Alceste software.

SETTING

A tertiary university hospital neonatal intensive care unit (NICU) in France.

PARTICIPANTS

20 fathers of preterm NBs hospitalised in an NICU.

RESULTS

The software classified 72% of the corpus into six lexical classes. Two main networks of classes emerged from the analysis: one for lactation, consisted of 'breastfeeding' and 'expression of milk' classes, and one for 'care'. The analysis demonstrated that fathers were sensitive to arguments related to the health benefits of human milk. Fathers mentioned that breastfeeding preterm NBs was constraining and tiring for their partners (multiple daily sessions of milk expression with breast pumps, time constraints and need for supplements to tube-feeding…). They also mentioned how they could genuinely help their partners during breastfeeding.

CONCLUSIONS

The results of this qualitative study provide insight into how fathers can be supportive of breastfeeding when experiencing a preterm birth. Targeted information and practical advice provided by caregivers on the first days of life can help fathers to get involved in the breastfeeding process.

Breast-feeding perceptions, beliefs and experiences of Marshallese migrants: an exploratory study

OBJECTIVE

To determine perceptions, beliefs and experiences affecting breast-feeding in Marshallese mothers residing in Northwest Arkansas, USA.

DESIGN

A qualitative, exploratory study using a brief survey and focus groups. Marshallese women, 18 years or older who had a child under 7 years of age, were included in the study.

SETTING

Community-based organization in Northwest Arkansas.

RESULTS

The majority of mothers viewed breast milk as superior to formula, but had concerns about adequate milk supply and the nutritional value of their milk. The primary barriers to exclusive breast-feeding in the USA included public shaming (both verbal and non-verbal), perceived milk production and quality, and maternal employment. These barriers are not reported in the Marshall Islands and are encountered only after moving to the USA. Breast-feeding mothers rely heavily on familial support, especially the eldest female, who may not reside in the USA. The influence of institutions, including the Special Supplemental Nutrition Program for Women, Infants, and Children, is strong and may negatively affect breast-feeding.

CONCLUSIONS

Despite the belief that breast milk is the healthiest option, breast-feeding among Marshallese mothers is challenged by numerous barriers they encounter as they assimilate to US cultural norms. The barriers and challenges, along with the strong desire to assimilate to US culture, impact Marshallese mothers' perceptions, beliefs and experiences with breast-feeding.

Making meaning of pumping for mothers of infants with congenital diaphragmatic hernia

OBJECTIVE

To describe the process of initiation and maintenance of milk supply and potential transition to direct breastfeeding among mother/infant dyads with infants with congenital diaphragmatic hernia (CDH).

SETTING

A Level-III neonatal intensive care unit.

PARTICIPANTS

Eleven mother/infant dyads with infants with CDH.

METHODS

Prospective, longitudinal qualitative descriptive design. Semistructured interviews were conducted over the course of the NICU stay. Conventional content analysis was used.

RESULTS

Human milk oral care emerged from the interview data as a strong facilitating factor to encouraging mothers to continue pumping during hospitalization. Four main themes emerged regarding the importance and value of human milk oral care for the mothers in relation to pumping and maintenance of milk supply: (a) It motivates me; (b) I'm a part of my baby getting better; (c) We do it together, and (d) We're getting somewhere.

CONCLUSIONS

The findings of this study reflect the importance and value of human milk oral care as a driving factor to motivate mothers to maintain milk supply during the critical time when the infant with CDH is not able to take in enteral nutrition and throughout the hospital stay.

Trends in breastfeeding initiation in the NICU by gestational age in Ohio, 2006-2012

BACKGROUND

While breastfeeding in the United States is on the rise, trends among infants admitted to the Neonatal Intensive Care Unit (NICU) are less known. The objective of this study was to examine trends in breastfeeding initiation among NICU-admitted infants in Ohio from 2006 to 2012 and to determine differences in breastfeeding initiation trends by gestational age.

METHODS

Using Ohio Vital Statistics birth certificate data, the Cochran-Armitage test for trend was used to determine significant trends in breastfeeding by gestational age. Logistic regression was used to examine the association between breastfeeding initiation and gestational age by year.

RESULTS

From 2006 to 2012, 48,758 infants born in Ohio were admitted to the NICU, representing 5.6 percent of all newborns. Breastfeeding among NICU-admitted infants increased from 53.3 percent in 2006 to 63.8 percent in 2012 (p < 0.01). Increasing, significant trends in breastfeeding were also observed within each gestational age category over the 7 years. In 2011 and 2012, preterm infants were significantly more likely than term infants to be fed breastmilk in the NICU.

DISCUSSION

The gap between breastfeeding initiation among NICU-admitted and non-admitted infants appears to be narrowing, particularly for the most extreme gestational ages. While these increasing trends in breastfeeding among the most premature infants are encouraging, nearly 40 percent of mothers of term infants admitted to the NICU, the largest proportion of the NICU population, are still not initiating breastfeeding. More education and support specific to mothers of infants admitted to the NICU is needed.

Furthering our understanding of the needs of mothers who are pumping breast milk for infants in the NICU: an integrative review

The purpose of this integrative review was to uncover information regarding emotional and other types of support required by mothers providing breast milk for infants in the neonatal intensive care unit (NICU). These high-risk infants are often unable to directly breastfeed and, thus, mothers need to pump their breast milk for weeks to months, which can be both a pleasing experience that increases satisfaction and infant involvement, while at the same time being an uncomfortable and tiring endeavor. Understanding this notion is important because pumping at least 8 times each day is central to increasing or maintaining breast milk production. Articles were gathered using PubMed and CINAHL databases. Forty-four sources were chosen for inclusion in this review. Search terms included "breastfeeding," "pumping," "neonatal intensive care unit," "emotional support," and "breast milk." We identified that the emotional and practical support for NICU mothers is different from those of other breastfeeding mothers, especially around the development of early bonding behaviors. These mothers require significant ongoing emotional support from healthcare professionals and their partners and peers. Healthcare providers need to monitor breast milk production and provide educated encouragement that anticipates breastfeeding challenges, especially when the mother is pumping for an extended period of time while their infant is maturing in the NICU. Effective providers' support may be best provided by selectively bundling interventions to support pumping initiation and transition to direct breastfeeding.

Parenting roles and knowledge in neonatal intensive care units: protocol of a mixed methods study

INTRODUCTION

There is a strong focus on the translation of scientific knowledge into evidence-based practice when dealing with very preterm births. The aim is to standardise and rationalise healthcare. The incorporation of parents' perspectives with respect to the organisation of care and technical interventions in neonatal intensive care units (NICUs) is needed. This study aims to analyse the repertoire of meanings, knowledge and emotions actualised by the parents of very preterm infants hospitalised in NICUs in the decision process regarding parental care, treatment options and uses of information sources.

METHODS AND ANALYSIS

This is a mixed-methods, observational study. The methodological strategy will rely on: (1) Ethnographic observation, carried out in a level III NICU located in the North of Portugal, during 6 months; (2) NICU-based surveys of mothers and fathers of very preterm infants born between July 2013 and June 2014 and admitted at the seven public level III NICUs of the Northern Health Region of Portugal; (3) Single and couple semistructured interviews to a subsample of mothers and fathers of very preterm infants, 4 months after birth. Inferential statistics will be used to analyse the quantitative data and content analysis, with an iterative and reflexive process and will be implemented to assess qualitative data.

ETHICS AND DISSEMINATION

The study protocol was approved by the National Data Protection Commission and the Ethics Committee of all the hospitals involved. The current project will contribute to develop resources for enriched good medical practices in the context of neonatal services through integrating insights from social sciences, public health, epidemiology and ethics. The expected dissemination actions are effective tools in designing strategies that aim to develop family-centred care and to improve medical practices in the context of neonatal services.