Lack of knowledge persists about early breastfeeding competence in preterm infants

Breastfeeding and human milk in the NICU: From birth to discharge

It is well recognized that human milk is the optimal nutritive source for all infants, including those requiring intensive care. This statement reviews evidence supporting the importance of breastfeeding and human milk for infants, and why breastfeeding practices should be prioritized in the neonatal intensive care unit (NICU). It also reviews how to optimally feed infants based on their stability and maturity, and how to support mothers to establish and maintain milk production when their infants are unable to feed at the breast.

Breastfeeding Outcomes and Associated Risks in HIV-Infected and HIV-Exposed Infants: A Systematic Review

Purpose: To critically appraise recent literature regarding breastfeeding outcomes and associated risks in HIV-infected (HI) and HIV-exposed (HE) infants, using the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement guidelines. Materials and Methods: Five electronic databases were systematically searched to obtain English publications from the last 10 years (2010-2020), pertaining to breastfeeding outcomes and associated risks of HI and HE infants and children. Gray literature sources were also included. Data were extracted according to various data items and were synthesized using thematic synthesis. Results: Of the initial 7,151 sources identified, 42 articles were eligible for final inclusion. The final selection included 19 cohort studies and 2 expert committee reports, classified as gray literature. The remaining 21 studies comprised case-control, cross-sectional, and randomized controlled trial studies. The following themes were identified: breastfeeding outcomes in HI and HE infants, risks for suboptimal breastfeeding, HI and HE infant growth and developmental outcomes, and barriers and facilitators to feeding decisions. Most studies highlighted HE infants' growth and developmental outcomes and did not directly interrogate breastfeeding outcomes. The most prevalent risks for suboptimal breastfeeding were maternal factors affecting decision making for breastfeeding. Conclusions: This systematic review adds to the evidence of breastfeeding in HIV-affected mother-infant dyads. Findings reiterated that exclusive breastfeeding has a positive outcome on growth and development of all infants irrespective of HIV status. The review highlighted a dearth of research on breastfeeding outcomes of HI and HE infants. Large-scale prospective comparative studies should profile breastfeeding and developmental outcomes of infants with HIV infection or exposure and antiretroviral treatment exposure to enable early identification and intervention for this vulnerable population in low-income settings.

Effects of relaxation therapy on maternal psychological state, infant growth and gut microbiome: protocol for a randomised controlled trial investigating mother-infant signalling during lactation following late preterm and early term delivery

Background

Breastfeeding is of great importance for infant health both short and long term, especially for those born preterm. Apart from the socio-economic and cultural factors which may influence a mother's decision on breastfeeding, lactation performance is also influenced by maternal physiological and psychological condition, as well as infant behavioural factors. The aim of this project is to investigate physiological, psychological and anthropological aspects of 'signalling' between mother and infant during lactation in a stressful situation, following late preterm delivery, using an experimental approach.

Method

A single blind parallel randomised controlled trial will be conducted in Chinese primiparous mothers who deliver a infant (34 0/7-37 6/7) weeks and plan to exclusively breastfeed. Mothers will be recruited from four local community clinics attached to Beijing Children Hospital. Two home visits will be arranged at one week and eight weeks postpartum. Participants will be randomly assigned to either intervention arm or control (no intervention) before the first home visit. Mothers from the intervention group will be asked to listen to an audio recording with relaxation meditation daily during breastfeeding. Maternal stress and anxiety will be measured at one week and eight week postpartum using Chinese version of Cohen's Perceived Stress Scale (PSS) and Beck Anxiety Inventory (BAI). Infant weight and length gain (as SD scores) from one to eight week will be measured using anthropometry. Milk volume will be measured using 48-h test-weighing method. Breast milk samples and mother and infant's stool samples will be collected to measure macronutrient and microbiome content. Anthropometric measurements (weight, length and head circumference) will be performed during all home visits.

Discussion

Primary outcomes of this study will be the effect of the intervention on maternal psychological state, and infant growth. Other outcomes will include the effect of the intervention on milk production, infant behaviours, and the microbiome composition in breastmilk and maternal and infant's gut. Results of this study will provide greater understanding about maternal-infant factors which influence the success of breastfeeding, and which may then be useful targets for future interventions.

Trial registration

ClinicalTrials.gov identifier: NCT03674632. Registered 14 September 2018.

Knowledge of healthcare providers regarding breastfeeding preterm infants in mainland China

Background

Support from healthcare professionals has been identified as an important variable affecting successful breastfeeding in preterm infants. This study aimed to explore the knowledge of healthcare providers regarding breastfeeding preterm infants in mainland China.

Methods

An online cross-sectional survey of healthcare providers from 9 tertiary level neonatal intensive care units across 4 districts in mainland China was conducted from May–November, 2017. A total of 187 healthcare providers responded to the survey. Data included demographic information and current and desired knowledge about breastfeeding preterm infants. Breastfeeding knowledge was evaluated using a researcher-developed questionnaire with six domains based on breastfeeding preterm infant guidelines.

Results

The average percent of correctly answered questions was 53.73%. The domain with the highest mean percent was ‘indications and methods of breastfeeding’ (64.41%). The lowest scoring domain was ‘characteristics of premature human milk’ (38.83%). Knowledge score was related to the following factors: age, profession, professional title, education background and offspring amount by univariate analysis (p < 0.05). Multiple linear regression analysis found that healthcare provider breastfeeding knowledge was associated with profession (physician or nurse), professional title, sex and total offspring. In terms of training needs, 86.7% of healthcare providers reported insufficient knowledge about breastfeeding in the preterm infant population; 82.2% wanted more knowledge about indications and contraindications related to breastfeeding premature infant; and 71.7% considered expert lectures as the most effective way of acquiring additional breastfeeding knowledge.

Conclusion

The knowledge about breastfeeding in the preterm infant population among NICU healthcare professionals in mainland China was limited. More targeted training is needed to improve NICU healthcare provider knowledge regarding breastfeeding preterm infants.

Review concludes that specific recommendations are needed to harmonise the provision of fresh mother's milk to their preterm infants

AIM

There are no specific recommendations for using a mother's fresh milk for her preterm infant. We reviewed the available evidence on its collection, storage and administration.

METHODS

The working group of the French Neonatal Society on fresh human milk use in preterm infants searched the MEDLINE database and Cochrane Library up to June 2017 for papers published in English or French. They specifically analysed 282 papers providing information on prospective, retrospective and clinical studies and examined guidelines from various countries.

RESULTS

The review concluded that fresh mother's own milk should be favoured in accordance with the latest recommendations. However, it must be carried out under stringent conditions so that the expected benefits are not offset by risks related to different practices. The working group has summarised the best conditions for feeding preterm infants with human milk, balancing high nutritional and immunological quality with adequate virological and bacteriological safety. Professionals must provide parents with the necessary conditions to establish breastfeeding, together with specific and strong support.

CONCLUSION

Based on their review, the working group has made specific recommendations for using fresh mother's own milk under careful conditions, so that the expected benefits are not offset by risks related to practices.

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.

Implementation of Feeding Guidelines Hastens the Time to Initiation of Enteral Feeds and Improves Growth Velocity in Very Low Birth-Weight Infants

BACKGROUND

Growth and nutrition are critical in neonatal care. Whether feeding guidelines improve growth and nutrition and reduce morbidity is unknown.

PURPOSE

Feeding guidelines for very low birth-weight (VLBW) infants were implemented in our neonatal intensive care unit (NICU) to start and achieve full enteral feeds sooner, and increase weight gain over the first month.

METHODS

Feeding guidelines for VLBW infants were implemented in January 2014, stratified by birth weight (<750, 750-1000, and 1000-1500 g). After trophic feedings, enteral feedings were advanced by 20 to 30 mL/kg/d.Data were analyzed for 2 years prior (baseline) and 6 months after (guideline) guidelines were implemented and included days to initiation of enteral feeds, days on total parenteral nutrition (TPN), and weight gain over the first month. Potential concomitant factors that could affect feeding tolerance were examined including indomethacin or dopamine treatment, delivery room cardiopulmonary resuscitation, and growth restriction.

RESULTS

A total of 95 infants with a birth weight of less than 1500 g were included (59 baseline and 36 guideline). Days to start enteral feeds decreased by 47% (P < .01) and days on TPN decreased by 25% (16 days vs 11 days; P < .01). Weight gain over the first month of life increased by 15% (p < .05). Dopamine and indomethacin use decreased during the study period, and small for gestational age infants were overrepresented in the guideline group.

IMPLICATIONS FOR PRACTICE/RESEARCH

Establishment of feeding guidelines for VLBW infants in our NICU reduced the days to start feeds and days on TPN while increasing weight gain over the first month. Improving growth and nutrition and reducing need for TPN in this vulnerable population may ultimately prevent infection and improve neurodevelopmental outcomes.

Early Provision of Mother's Own Milk and Other Predictors of Successful Breast Milk Feeding after Very Preterm Birth: A Regional Observational Study

BACKGROUND

Breast milk is associated with a lower risk of neonatal morbidity in very preterm infants. Despite the benefits, the duration of breastfeeding is shorter in very preterm infants than in term infants.

OBJECTIVE

This study aimed to investigate how early provision of mother's own milk (MOM) and maternal and infant characteristics are related to breast milk feeding (BMF) between 36 and 40 weeks postmenstrual age (PMA) after very preterm birth.

METHODS

A regional observational study of 138 singleton infants born at < 32 weeks of gestation in Stockholm, Sweden, was conducted. Data were derived from medical charts to investigate the association between early provision of MOM; maternal and infant characteristics; and exclusive, partial, or no BMF at 36 weeks PMA. Moreover, changes in BMF between 36 and 40 weeks PMA were studied.

RESULTS

Most infants (80%) received MOM at 36 weeks PMA (55% exclusively, 25% partial). High provision of MOM at postnatal day 7 was associated with exclusive BMF at 36 weeks PMA, odds ratio (OR) 1.18 per 10 mL/kg MOM (95% confidence interval [CI], 1.06-1.32). Mothers born in non-Nordic countries provided MOM exclusively less often, adjusted OR 0.27 (95% CI, 0.10-0.69), compared to Nordic mothers. Between 36 and 40 weeks PMA, BMF decreased overall. This change was not associated with investigated predictors.

CONCLUSION

It is possible to achieve high rates of BMF in very preterm infants. High intake of MOM early in the postnatal period is strongly related to exclusive BMF at 36 weeks PMA.

From tube to breast: the bridging role of semi-demand breastfeeding

Determination of the optimal timing of breastfeeding initiation for preterm infants is still a challenge for health professionals. Often unjustified delays and restrictions of breastfeeding occur due to non-evidence-based current opinions about preterm infants' feeding capacity. Semi-demand feeding has been proposed for preterm infants during the transition from scheduled to full demand feeding, to promote the establishment of self-regulated oral feeding. Although semi-demand feeding has been shown to be safe and effective in reducing time to reaching oral feeding, the implementation of this feeding pattern for preterm infants in the neonatal intensive care unit (NICU) is still limited. We developed a protocol for the application of semi-demand feeding in preterm infants based on the existing knowledge of preterm infant neurodevelopment and NICU organization and staff experience. The protocol's aim is to attain successful transition from tube feeding to breastfeeding. In this article, we describe the protocol used in the neonatal unit of the Maternal and Child Health Institute of Trieste, a third level care center in northeastern Italy.

Effect of cup feeding and bottle feeding on breastfeeding in late preterm infants: a randomized controlled study

BACKGROUND

Cup feeding has been used as an alternative feeding method for preterm infants.

OBJECTIVE

The purpose of this study was to determine the effect of bottle and cup feeding on exclusive breastfeeding rates at hospital discharge and 3 and 6 months post-discharge in late preterm infants.

METHODS

Included in the study were preterm infants of 32 to 35 weeks' gestation fed only by intermittent gastric tube at the time of recruitment; 522 infants were randomly assigned to 2 groups: the cup-fed group (n = 254) and bottle-fed group (n = 268). Main outcomes were prevalence of exclusive breastfeeding at discharge and 3 and 6 months after discharge, and length of hospital stay.

RESULTS

Infants randomized to cup versus bottle feeding were more likely to be exclusively breastfed at discharge home (relative risk [RR], 1.58; 95% confidence interval [CI], 1.36-1.83), 3 months after discharge (RR, 1.64; 95% CI, 1.42-1.89), and 6 months after discharge (RR, 1.36; 95% CI, 1.14-1.63). There was no significant difference between groups for length of hospital stay. The mean hospital stay was 25.96 ± 2.20 days in the bottle-fed group and 25.68 ± 2.22 days in the cup-fed group. There was no significant difference between groups for time spent feeding, feeding problems, or weight gain in hospital.

CONCLUSION

Cup feeding significantly increased the likelihood of late preterm infants being exclusively breastfed at discharge and 3 and 6 months after discharge, and cup feeding did not increase the length of hospital stay. Overall, we recommend cup feeding as a transitional method prior to breastfeeding for late preterm infants during hospitalization.