Direct-Breastfeeding Premature Infants in the Neonatal Intensive Care Unit

Factors Associated with Mother's Own Milk Feeding and Direct Breastfeeding at Discharge in Preterm Infants with Feeding Difficulties: Clinical and Research Implications

Background: Prematurity presents numerous barriers to mother's own milk (MOM) feeding and direct breastfeeding (DBF). Aim: This study aimed to determine factors associated with MOM feeding and DBF at discharge from the neonatal intensive care unit (NICU) in preterm-born infants presenting with feeding difficulties. Methods: A retrospective study of data from 237 preterm-born infants referred for evaluation of feeding difficulties and discharged home on full oral feeds was examined. Maternal and infant characteristics and oral feeding milestones were examined for their association with MOM intake and DBF at discharge using bivariate and multivariate regression analyses. Results: MOM feeding at discharge occurred in 35.4% (n = 84) infants. The odds of any MOM feeding at discharge were higher with higher maternal age, absence of maternal substance use, and fewer days between full per oral (PO) and discharge (all, p < 0.05). Among the 84 MOM-fed infants, 4.76% (n = 4) were exclusively breastfed, whereas 39.3% (n = 33) were partially DBF at discharge. The DBF infants had higher birthweight, no incidence of being small for gestational age, lower incidence of respiratory support at birth and intraventricular hemorrhage, lower postmenstrual age (PMA) at full PO, shorter duration from first PO to full PO, and lower PMA at discharge (all, p < 0.05). Conclusion: We found reduced use of MOM and DBF among preterm-born infants with feeding difficulties at NICU discharge. Clinical management and research advocacy must focus on targeted interventions in this setting by recognizing significant modifiable factors applicable to prepregnancy, pregnancy, NICU, and postdischarge care.

An Examination of the Benefits of Lactation Consultant Services in NICUs for Mothers and Their Newborn: A Systematic Review

Background: It is well accepted that lactation consultant (LC) services can enhance the breastfeeding success in mother-infant dyads. However, despite such advantages, not all neonatal intensive care units (NICUs) offer LC services. The objective of this systematic review was to assess the available evidence on the effect of LC service on breastfeeding outcomes for mothers whose infants are in the NICU. Methods: The PRISMA Extension for Systematic Reviews were used to conduct this systematic review. The following databases: Embase, Medline, CINAHL, and Cochrane library were searched. An initial 464 studies were obtained. Duplicates and studies that did not fit the inclusion criteria were removed, leaving 30 full-text articles to review. Nineteen were further excluded after full-text review. A total of 11 studies were included. Due to the heterogeneity of the included studies, a meta-analysis could not be performed, instead a qualitative numerical summary was conducted. Results: Overall, 10/11 (90%) of studies observed a 6-31% increase in the number of infants who received mother's own milk, and 11-27% in the number of infants who received direct breastfeeds associated with the implementation of LC services in the NICU. The two most common types of LC services studied included: i) multidisciplinary lactation support-described as a team-based approach that includes at least one LC and ii) designation of LC formal role in the NICU. Conclusions: This review highlights that having LC services in the NICU is vital for meeting the unique needs and enhancing breastfeeding outcomes for mothers whose infants are in the NICU.

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

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

Development of a Protocol for the Direct Breastfeeding of Premature Infants in Neonatal Intensive Care Units

PURPOSE

This study aimed to develop a direct breastfeeding protocol for premature infants admitted to neonatal intensive care units (NICUs) and investigate its efficacy.

BACKGROUND

Direct breastfeeding increases the amount and duration of breastfeeding. However, NICUs have low direct feeding rates owing to medical staff anxiety, lack of knowledge and experience, and fear of overwork. Accordingly, this study developed a protocol for direct breastfeeding in the NICU and evaluated its effect.

METHODS

The protocol was developed through a literature review, expert validation, and preliminary investigation. Its application effects were identified using a nonexperimental, evidence-based research design targeting premature infants, their mothers, and NICU nurses.

RESULTS

The protocol comprised 5 areas and 23 items. Application of the protocol resulted in continuous weight gain of the infants and increased self-efficacy in the mothers' direct breastfeeding ( t = 3.219, P = .004). Significant increases were noted in NICU nurses' direct breastfeeding activities ( t = 3.93, P < .001), breastfeeding rates in the NICU ( P = .037), and direct breastfeeding rates ( P = .007).

CONCLUSIONS

Results underscore the value of an evidence-based protocol for improving breastfeeding rates in premature infants. This study highlights the need for continuous nursing education on protocol applications and human resource support.

Human Milk Feeding Is Associated with Decreased Incidence of Moderate-Severe Bronchopulmonary Dysplasia in Extremely Preterm Infants

BACKGROUND

An increased rate of bronchopulmonary dysplasia (BPD) is reported in extremely preterm infants. A potential role of human milk feeding in protecting against this condition has been suggested.

METHODS

A retrospective descriptive study was conducted based on data about morbidity in the population of infants born between 22+0 and 26+6 weeks of gestation, included in the Spanish network SEN1500 during the period 2004-2019 and discharged alive. The primary outcome was moderate-severe BPD. Associated conditions were studied, including human milk feeding at discharge. The temporal trends of BPD and human milk feeding rates at discharge were also studied.

RESULTS

In the study population of 4341 infants, the rate of moderate-severe BPD was 43.7% and it increased to >50% in the last three years. The factors significantly associated with a higher risk of moderate-severe BPD were birth weight, male sex, high-frequency oscillatory ventilation, duration of invasive mechanical ventilation, inhaled nitric oxide, patent ductus arteriosus, and late-onset sepsis. Exclusive human milk feeding and any amount of human milk at discharge were associated with a lower incidence of moderate-severe BPD (OR 0.752, 95% CI 0.629-0.901 and OR 0.714, 95% CI 0.602-0.847, respectively). During the study period, the proportion of infants with moderate-severe BPD fed any amount of human milk at discharge increased more than twofold. And the proportion of infants with moderate-severe BPD who were exclusively fed human milk at discharge increased at the same rate.

CONCLUSIONS

Our work shows an inverse relationship between human milk feeding at discharge from the neonatal unit and the occurrence of BPD.

Impact of the Covid-19 Pandemic on Breastfeeding Establishment in Preterm Infants: An Exploratory Study

Purpose: To evaluate breastfeeding outcomes in preterm infants born during the Covid-19 pandemic. Design: An observational cohort study of 33 infants born ≤34 weeks' gestation was conducted. Sample: The study sample consisted of 33 infants divided into 2 groups: infants born during the Covid-19 pandemic (Covid group, n = 11) and those born prior to the pandemic (pre-Covid group, n = 22). Main Outcome Variable: Breastfeeding at hospital discharge. Results: Fewer infants in the Covid group received breastfeeds at full oral feed (p = .015) and none breastfeeding at hospital discharge (p = .001). In addition, fewer infants in the Covid group received non nutritive sucking (p = .612) and more infants in the Covid group required milk supplementation (p = .032). Study results suggest that breastfeeding establishment at hospital discharge in preterm infants is significantly impacted by the Covid-19 pandemic. There is a critical need, in low-risk disease transmission areas, to enhance parental access and to increase in-hospital lactation supports to help safeguard breastfeeding outcomes in preterm infants.

From Expressing Human Milk to Breastfeeding-An Essential Element in the Journey to Motherhood of Mothers of Prematurely Born Infants

BACKGROUND

Lactation and breastfeeding present an extraordinary challenge for mothers of prematurely born infants.

PURPOSE

To explore the significance of and the circumstances that affect lactation for mothers of premature infants.

METHODS

A qualitative exploratory study based on single, in-depth, semistructured interviews with 16 purposefully sampled mothers of premature infants admitted to the neonatal intensive care unit (NICU). Data were analyzed using content analysis. The study was reported according to Standards for Reporting Qualitative Research.

FINDINGS

The overall theme was "From expressing human milk to breastfeeding-an essential element in the journey to motherhood." The theme emerged from 3 categories: the birth preparation time has been interrupted; expressing human milk is essential for lactation; and the motherhood journey encompasses breastfeeding. The analysis also revealed that the categories were impacted by initiating, performing, and maintaining lactation and further influenced by inhibitors and promoters.

IMPLICATIONS FOR PRACTICE

The promoters for performing milk expression and breastfeeding should be stimulated and the inhibitors should be eliminated. The achievement of "zero separation" and mother-infant couplet care in the NICU would be beneficial. In order for mothers to maintain successful lactation, it is essential that they receive supportive around-the-clock access to health professionals with expertise in lactation and breastfeeding until exclusive breastfeeding is well established.

IMPLICATIONS FOR RESEARCH

The study highlights the need to investigate mother-infant as one entity rather than separately as mother and infant.

Breastfeeding rates at discharge for very low birthweight neonates and their determinants: An observational study from a tertiary care neonatal intensive care unit in India

BACKGROUND

Mother's milk is the best milk for neonates. Preterm very low birthweight (VLBW) neonates face many challenges leading to low rates of breastfeeding at discharge.

AIMS

(i) To determine the proportion of <32 weeks preterm VLBW neonates who are exclusively breastfed (EB) at discharge and (ii) determinants of exclusive breastfeeding (EBF) at discharge.

METHODS

An observational study was conducted for a duration of 1 year, from May 2019 to April 2020 in a tertiary care neonatal intensive care unit (NICU) in North India. Consecutive <32 weeks preterm VLBW neonates admitted within 72 h of birth and on full enteral feeds (FEF) within 10 days of birth were included in this study and followed up till discharge.

RESULTS

Forty-four of 97 (45.4%) preterm VLBW neonates were exclusively breastfed and 31/97 (32%) received more than 80% mother's own milk (MOM) at discharge. Male sex (P = 0.03), those whose first feed had any amount of MOM (P = 0.038) or exclusive MOM in their first feed or when initiated on first FEF (P = 0.002), and neonates with longer duration of hospital stay (P = 0.035) had an increased chance of being exclusively breastfed at discharge.

CONCLUSION

Preterm VLBW neonates who receive any amount of MOM in their first feed or first FEF, male infants and those who stay longer in hospital are more likely to be exclusively breastfed at discharge.

Encourage, Assess, Transition (EAT): A Quality Improvement Project Implementing a Direct Breastfeeding Protocol for Preterm Hospitalized Infants

BACKGROUND

The opportunity to establish a direct breastfeeding (DBF) relationship with a preterm infant, if desired by the mother or lactating parent, is a known driver of positive healthcare experiences. Preterm birth is an independent risk factor for early human milk (HM) cessation, and DBF at the first oral meal promotes continued DBF during hospitalization and HM duration beyond discharge. While the Spatz 10-step model for protecting and promoting HM and breastfeeding in vulnerable infants provides best practices, lack of standardized implementation results in missed opportunities to meet parents' DBF goals.

PURPOSE

To standardize clinical practices to increase DBF at the first oral meal, total DBF meals during hospitalization, and use of test weighing to measure milk transfer for preterm infants.

METHODS

Quality improvement methods were used to develop and implement Encourage, Assess, Transition (EAT): a DBF protocol for infants less than 37 weeks gestation at birth, in a level II neonatal intensive care unit.

RESULTS

Thirty-eight (45%) infants from 27.7 to 36.7 weeks of gestation initiated the protocol. The proportion of infants' DBF at first oral meal increased from 22% to 54%; mean DBF meals during hospitalization increased from 13.3 to 20.3; and use of test weighing increased by 166%.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Standardizing DBF practices with the EAT protocol increased DBF during hospitalization-a known driver of patient experience-and HM duration beyond discharge, in hospitalized preterm infants. Researchers should validate the reported benefits of EAT (increased DBF during hospitalization, use of test weighing, and improved patient experience), methods to promote passive dissemination of evidence, and sustain change.Video abstract available at: https://journals.na.lww.com/advancesinneonatalcare/pages/videogallery.aspx?autoPlay=false&videoId=61.

Lactation Outcomes After Participation in a Tailored Prenatal Nutrition Consultation Among Women With Infants With Congenital Anomalies

OBJECTIVE

To describe lactation outcomes among of a cohort of mother-infant dyads in which the women had an individualized prenatal nutrition consultation intervention.

DESIGN

Descriptive cohort study.

SETTING

A free-standing children's hospital with a center for fetal diagnosis and treatment and a specialized maternity unit.

PARTICIPANTS

A total of 160 women who had prenatal nutrition consultations in 2014 to 2017 and gave birth to infants with known congenital anomalies and required intensive care after birth.

METHODS

We surveyed women regarding their lactation outcomes after the Breastfeeding Report Card metrics of the Centers for Disease Control and Prevention and obtained permission to abstract demographic and clinical information from the setting's electronic health record. We analyzed data with standard descriptive statistics.

RESULTS

Among the cohort, 86.9% (n = 139) of participants intended to provide human milk or combination feeding in the prenatal period. A total of 128 (92.1%) infants were first exposed to human milk enterally. At the time of discharge, 92.1% (n = 128) of the infants received human milk. The breastfeeding outcomes of the cohort significantly surpassed national data: initiation (98.1% vs. 84.1% national), breastfeeding at 3 months (89.4%), exclusive breastfeeding at 3 months (60% vs. 46.9% national), breastfeeding at 6 months (76.9% vs. 58.3% national), exclusive breastfeeding at 6 months (45% vs. 25.6% national), breastfeeding at 12 months (50.6% vs. 35.3% national), and breastfeeding beyond 12 months (34.4%).

CONCLUSIONS

Lactation outcomes among women who had prenatal nutrition consultations far surpassed national data, and this intervention has implications for family-centered prenatal care, informed decision making, and improved breastfeeding outcomes in the hospital setting and postdischarge.

Predictors of the Provision of Mother's Milk Feedings in Newborns Admitted to the Neonatal Intensive Care Unit

Background: Breast milk reduces morbidity and mortality in infants admitted to neonatal intensive care unit (NICU). Objectives: We determined predictors of procuring mother's own milk (MOM) among NICU-admitted newborn-mother dyads: (1) initiation of any milk expression; (2) initiation of milk expression within 6 hours of birth; (3) MOM as the first enteral feeding; (4) colostrum for oral care within 36 hours of birth if not yet orally fed; and (5) provision of MOM at 21 days of life or discharge, whichever occurred first. Methods: We performed a retrospective chart review of NICU-admitted newborn-mother dyads at an urban medical center from June 1, 2018-May 31, 2019. We excluded infants not directly admitted to the NICU, those never enterally fed, multiple gestations if not the first to be discharged, and infants discharged to a nonbiological caregiver. We used chi-square analysis to examine unadjusted associations between independent variables and MOM outcomes and then used logistic regression to determine the adjusted odds ratio and 95% confidence interval (AOR [95% CI]) for predictors of MOM outcomes. Results: There were 341 mother-infant dyads who met inclusion criteria and 71% of these mothers initiated milk expression. Smoking, multiparity, gestational diabetes, and Hepatitis C lowered the odds for at least one MOM outcome; whereas mothers who delivered at 28-32 weeks versus ≥33 weeks, and infants with birthweight <1,500 g versus 1,500-2,500 g had higher odds for at least one MOM outcome. Conclusion: Maternal/infant dyad characteristics may predict some, but not all NICU breastfeeding outcomes. This suggests that hospital practices may influence these outcomes and can inform future interventions.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

A block randomized study design was performed.

TRIAL REGISTRATION NUMBER

NCT03434743.

METHODS

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

RESULTS

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

CONCLUSION

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

[Effect of Direct Breastfeeding Program for Premature Infants in Neonatal Intensive Care Unit]

PURPOSE

This study aimed to identify the effects of a direct breastfeeding program for premature infants in neonatal intensive care units (NICUs).

METHODS

This quasi-experimental study was conducted during August 2016 to April 2017. Sixty mothers of premature infants were assigned to the experimental (n = 31) or control groups (n = 29). The program was comprised of breastfeeding education and direct breastfeeding support. The experimental and control groups were provided with education and counseling on breastfeeding at the time of admission and discharge. In the experimental group, the mothers initiated oral feeding with direct breastfeeding and engaged in breastfeeding at least seven times during the NICU stay. The collected data were analyzed by the χ²-test and repeated measures ANOVA using an SPSS program.

RESULTS

The experimental group showed a higher direct breastfeeding practice rate (χ² = 19.29, p < .001), breastfeeding continuation rate (χ² = 3.76, p < .001), and self-efficacy (F = 25.37, p < .001) than the control group except for maternal attachment.

CONCLUSION

The direct breastfeeding program in the NICU has significant effects on the practice and continuation rate of breastfeeding and breastfeeding self-efficacy. Therefore, this program can be applied in the NICU settings where direct breastfeeding is limited.

Maternal production of milk for infants in the neonatal intensive care unit

Mother's own milk (MOM) feeding is a cost-effective strategy to reduce risks of comorbidities associated with prematurity and improve long-term health of infants hospitalized in the Neonatal Intensive Care Unit (NICU). Significant racial and socioeconomic disparities exist in MOM provision in the NICU, highlighting the importance of developing strategies to reduce these disparities. Mothers of infants in the NICU experience many health concerns which may negatively impact lactation physiology. Objective measures of lactation physiology are limited but may assist in identifying mothers at particular risk. Several strategies to assist mothers of hospitalized infants are essential, including maternal education, qualified lactation professionals, early and frequent milk expression with a hospital-grade double electric breast pump, and providing support for transitioning to direct breastfeeding prior to discharge from the NICU.

Use of the Theory of Planned Behavior Framework to Understand Breastfeeding Decision-Making Among Mothers of Preterm Infants

Background: Mothers of preterm infants face significant challenges to breastfeeding. The theory of planned behavior (TPB) is a well-known framework comprising three domains (attitudes, perceived control, and social norms), which has been used to conceptualize the array of factors that influence health-related behaviors and develop interventions to promote behaviors. Aim: We used the TPB framework to determine the array of factors that contribute to breastfeeding among mothers of preterm infants. Materials and Methods: Using qualitative research methods, we conducted in-depth, semistructured interviews with mothers regarding their experiences feeding their preterm infants according to TPB domains. We developed themes based on an iterative process of review of transcripts and conducted interviews until thematic saturation was reached. Results: We interviewed 23 mothers in 3 states 2 to 6 months after hospital discharge; 22 mothers initiated milk production and 6 were breastfeeding at the time of the interview. Factors that were positive and negative toward breastfeeding were present for all three TPB domains. Regarding attitudes, mothers felt that breastfeeding was a way to bond, that breast milk was healthy and protective, and that breast milk alone was insufficient for a growing preterm infant. Regarding perceived control, mothers felt empowered to breastfeed due to encouragement from hospital staff, friends, and family, and had difficulty overcoming their infant's immature oral feeding skills, competing responsibilities, and perceived infant preference for bottle feeding. Regarding social norms, mothers reported support for and against breastfeeding among hospital and Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) providers, family, friends, and the media. Conclusion: Interventional studies geared toward breastfeeding promotion among mothers of preterm infants may focus on addressing barriers to direct breastfeeding during the neonatal intensive care unit and early post-discharge time periods.

Does breastfeeding self-efficacy theory apply to mothers of moderate and late preterm infants? A qualitative exploration

BACKGROUND

Breastmilk feeding reduces morbidities and improves outcomes related to prematurity. However, breastmilk feeding rates in preterm infants are substantially lower than those in term infants. Breastfeeding self-efficacy theory is a social change theory, which is predictive of exclusive breastmilk feeding at 2 months postpartum in mothers of full-term infants. However, this theory has not been well explored in mothers of moderate and late preterm infants.

AIMS AND OBJECTIVES

To explore maternal experiences with feeding moderate (32^0/7 - 33^6/7  weeks' gestational age) and late preterm infants (34^0/7 - 36^6/7  weeks' GA) in neonatal intensive care units and assess applicability of breastfeeding self-efficacy theory.

METHODS

We conducted a qualitative descriptive exploration of maternal experiences with infant feeding in neonatal intensive care units. Using purposive, maximum variation sampling, we selected mothers of preterm infants born at 32^0/7 - 34^6/7  weeks, who experienced high mean differences in their BSE scores between admission and discharge. Fourteen mothers participated in semi-structured telephone interviews. Data were examined using thematic analysis. To explore and describe breastfeeding self-efficacy within the context of neonatal intensive care units, we super-imposed the four sources of information from breastfeeding self-efficacy theory onto the defined themes.

RESULTS

Three main themes emerged: (a) institutional influences, (b) relationship with the pump and (c) establishing breastfeeding, with an emphasis on the importance of direct breastfeeding at discharge. Overlaying the four sources of information from breastfeeding self-efficacy highlighted the presence of three sources of information: verbal persuasion, performance accomplishment and physiologic/affective responses. Vicarious experience was not identified in maternal experiences with infant feeding.

CONCLUSION

Our findings indicate that breastfeeding self-efficacy is an applicable theory for mothers of preterm infants.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers need to be aware of the influence that institutional culture and policies may have on maternal breastfeeding self-efficacy and breastfeeding outcomes.

Management of Oral Feeding Challenges in Neonatal Intensive Care Units (NICUs): A National Survey in China

Objectives: To investigate the current practices of oral feeding difficulties facing high-risk infants in Chinese NICUs. Methods: A questionnaire to survey infant oral feeding practices was distributed to 100 level II and III Chinese neonatal intensive care units (NICUs). Results: Responses were obtained from 88 NICUs. No Units had any structured guidelines regarding the management of infant oral feeding as they transitioned from tube to independent oral feeding. In 54 (61.4%) NICUs, nurses and physicians made shared decisions on when oral feeding were to be initiated. Fifty-four (61.4%) and 22 (25.0%) NICUs used postmenstrual age (PMA) or weight at PMA as a criterion for initiating oral feedings, respectively. The top three criteria to determine introduction of oral feeding were severity of disease, presence of sucking reflex, and trial feeding success. Adverse events were used by 78 Units as indices of oral feeding difficulty. Twenty (22.7%) and 25 (28.4%) Units had access to occupational therapists or nurses who provided oral motor interventions during feeding, i.e., oral support (chin and cheek support, aid to deglutition), non-nutritive sucking with pacifier, and oral stimulation. Conclusions: The management of oral feeding issues in NICUs vary widely in China in relation to the assessment of readiness to oral feeding, daily oral feeding practices and interventions used by staff. It is proposed that an educational program focused on the physiology of infant oral feeding, available evidence-based tools and interventions would assist NICU caregivers develop structured guidelines to improve infants' safe and efficient attainment of independent oral feeding.

Neonatal Intensive Care Unit-Specific Lactation Support and Mother's Own Breast Milk Availability for Very Low Birth-Weight Infants

BACKGROUND

Mother's own milk (MOM) is the preferred nutrition for premature infants, particularly for the very low birth-weight (VLBW) cohort. Benefits are well documented; yet, numerous barriers exist for provision of MOM in the neonatal intensive care unit (NICU). Lactation consultants (LCs) can optimize breastfeeding support for NICU mothers; however, understanding of the impact of NICU-dedicated LCs is limited.

PURPOSE

Evaluate the effectiveness of NICU-dedicated LCs in improving breastfeeding outcomes and MOM provision in VLBW infants.

METHODS

A retrospective chart review of 167 VLBW infants comparing breastfeeding outcomes between 2 NICUs, one with NICU-dedicated LCs (hospital A; n = 48) and one without (hospital B; n = 119). Primary outcome measures included feeding percentages of MOM received by infants at 3 intervals, throughout hospitalization, and number of direct breastfeeding events. Secondary outcome measures included number of days to first enteral feed, days to reach full feeds, days of nil per os, days on total parenteral nutrition, and length of stay.

FINDINGS

Neonatal intensive care unit-specific lactation support increased the number of direct breastfeeding events on day of discharge (P = .048). No statistical significance was found at each of the 3 time intervals, or throughout hospitalization (week 1: P = .18; midpoint: P = .40; discharge: P = .16; total hospitalization: P = .19). No statistical significance was demonstrated in secondary outcome measures (days to first enteral feed: P = .22; days to full feeds: P = .25; nil per os days: P = .27; total parenteral nutrition days: P = .34; length of stay: P = .01). Length of stay not found to be significant after correcting for confounding variables.

IMPLICATION FOR PRACTICE

Increased direct breastfeeding events on day of discharge with exposure to NICU-dedicated LCs in the VLBW population.

IMPLICATION FOR RESEARCH

Prospective studies regarding NICU-specific lactation support with larger samples are warranted.

A qualitative cross-cultural analysis of NICU care culture and infant feeding in Finland and the U.S

BACKGROUND

The benefits of family-centered care for the health and well-being of preterm infants and their families include increased parent-infant closeness, improved lactation, and positive mental health outcomes; however, it is known that the extent to which family-centered care is adopted varies by unit. This study aimed to understand how differences in neonatal care culture in two units in Finland and the U.S. were translated to parents' infant feeding experiences in the hope of improving relationally focused feeding practices in both locations.

METHODS

This qualitative, cross-sectional study utilized narrative methodologies to understand the lived experiences of 15 families hospitalized in a tertiary neonatal intensive care unit in Finland (n = 8) and the U. S (n = 7).

RESULTS

A global theme of lactation as a means or an end showed that lactation and infant feeding were framed differently in each location. The three supporting themes that explain families' perceptions of their transition to parenthood, support as a family unit, and experience with lactation include: universal early postnatal challenges; culture and space-dependent nursing support; and controlled or empowering breastfeeding experiences.

CONCLUSIONS

Care culture plays a large role in framing all infant caring activities, including lactation and infant feeding. This study found that in the unit in Finland, breastfeeding was one method to achieve closeness with an infant, while in the unit in the U.S., pumping was only an end to promote infant nutritional health. Therefore, breastfeeding coupled with closeness was found to be supportive of a salutogenic, or health-promoting, care approach for the whole family.

What Is the Impact of NICU-Dedicated Lactation Consultants? An Evidence-Based Practice Brief

BACKGROUND

Benefits of exclusive human milk diets for preterm and low birth-weight infants are well established. Despite known benefits, supporting mothers in the provision of mother's own milk for high-risk infants is challenging. Lactation support in the neonatal intensive care unit (NICU) is highly variable. Lactations consultants (LCs) are often shared between postpartum units and the NICU, potentially increasing LC workload with less time spent with high-risk mothers. Furthermore, less than half of NICUs in the United States staff an international board-certified lactation consultant. Limited understanding exists regarding impacts of NICU-specific lactation support on breastfeeding outcomes.

PURPOSE

The purpose of this evidence-based practice brief is to synthesize the literature on the impact of NICU-specific lactation support, LCs who work exclusively in the NICU, and provide guidance about how NICU staffing with LCs solely focused on supporting mothers of high-risk infants impacts breastfeeding outcomes for low birth-weight infants.

SEARCH STRATEGY

CINAHL PLUS, PubMed, Cochrane Library, and OVID databases were searched using key words and restricted to English language.

FINDINGS

During hospitalization, NICUs staffed with dedicated board-certified LCs have increased potential to yield improved breastfeeding rates through hospital discharge, increased proportion of infants who receive mother's own milk, and increased duration of breastfeeding or human milk expression through hospital discharge.

IMPLICATIONS FOR PRACTICE

Human milk nutrition is related to improved outcomes for high-risk infants. Neonatal intensive care unit-specific lactation support can potentially optimize maternal breastfeeding practices and improve outcomes for high-risk infants.

IMPLICATIONS FOR RESEARCH

There is a need for further studies pertaining to NICU-specific lactation consultants and influences on breastfeeding outcomes.

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.

Implementation of Pre-/Post-Weights to Enhance Direct Breastfeeding in the NICU

Introduction

Mother's own milk (MOM) is recommended as the optimal nutrition for preterm infants. Direct breastfeeding (DBF) is correlated with a longer duration of receiving MOM during hospitalization. Infants' transition to DBF may be enhanced when accurate pre-/post-weights are incorporated into nursing practice. An evidence-based practice change was introduced to promote use and increase consistency in methodology of pre-/post-weights after DBF in the neonatal intensive care unit (NICU), with the ultimate goal of increasing DBF at hospital discharge.

Methods

The practice change was introduced through an educational program, a video demonstrating pre-/post-DBF weighing techniques, and a return-demonstration. A 10-item pre-/posttest was used to evaluate nurses' knowledge gained by an educational intervention that included seven knowledge questions, three attitude questions, and three demographic descriptors.

Results

Nurses' knowledge gained following the educational intervention was statistically significant (p < .001) using a paired t-test.

Conclusions

The use of pre-/post-DBF weights as an accurate assessment of MOM transfer can promote DBF during hospitalization through education of NICU nurses. Understanding nursing characteristics and attitudes can aid in promotion of DBF in the NICU by bedside nurses.

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.

Factors Affecting Breastfeeding Outcomes at Six Months in Preterm Infants

BACKGROUND:

Preterm mother-infant dyads often face many obstacles to breastfeeding. Preterm infants are at highest risk for low rates of exclusive breastfeeding.

RESEARCH AIM:

To determine the prevalence of breastfeeding at 6 months among preterm infants and to identify factors that influenced mothers' breastfeeding practices.

METHODS:

A longitudinal observational study was conducted in a metropolitan hospital in Beijing, China. Mothers ( N = 270) and their preterm infants ( N = 280) were included in the study. Characteristics of preterm mothers and their perceptions of breastfeeding self-efficacy, knowledge, social support, and postpartum depression symptoms were measured at the discharge of neonatal intensive care. Breastfeeding data were collected by phone interview at 6 months corrected age.

RESULTS:

At discharge, mothers of very preterm infants perceived a lower level of breastfeeding self-efficacy (measured with the Breastfeeding Self-Efficacy Scale-Short Form) and had a higher level of depression symptoms (measured with the Edinburgh Postnatal Depression Scale [EPDS]) than mothers of moderate and late preterm infants ( p < .05-.01). Nearly half of all mothers had an elevated EPDS score, considered to be symptomatic of postpartum depression. At 6 months, only 22.5% of all infants were exclusively breastfeeding. Factors associated with exclusive breastfeeding, including younger maternal age, previous breastfeeding experience, shorter mother-infant separation time during intensive care, older infant gestational age, and a higher level of breastfeeding self-efficacy, significantly predicted exclusive breastfeeding practice ( p < .05-.001).

CONCLUSION:

The prevalence of breastfeeding at 6 months for preterm infants in this sample was low. Strategies to improve breastfeeding duration for preterm infants are needed, including support and education of mothers while in the hospital.

Determinants of Exclusive Breastfeeding in a Sample of Egyptian Infants

BACKGROUND

Breastfeeding is an optimum, healthy, and economical mode of feeding an infant. However, many preventable obstacles hinder exclusive breastfeeding in the first six months of life.

AIM

We aimed to assess the social-, maternal- and infant-related factors disturbing exclusive breastfeeding in the first six months of life.

METHODS

It is a retrospective study included 827 dyads of mothers and infants older than 6 months (411 exclusively breastfed, 311 artificially-fed and 105 mixed feds). Mothers were interviewed to obtain sociodemographic information, maternal medical history and perinatal history and a detailed history of infant feeding.

RSULTS

Many factors were found to support the decision for artificial feeding rather than exclusive breastfeeding, including maternal age < 25 years (OR = 2.252), child birth order > 3rd (OR = 2.436), being a primi-para (OR = 1.878), single marital status (OR = 2.762), preterm infant (OR = 3.287) and complicated labor (OR = 1.841). Factors in favor of mixed feeding included cesarean section (OR = 2.004) and admission to the Neonatal Intensive Care Unit (OR = 1.925).

CONCLUSIONS

Although it isn't a community-based study and its results can't be generalised, plans to improve health and development of children are preferable to include the following: health education and awareness programs about the importance of exclusive breastfeeding should be directed for young and first-time mothers. Improved antenatal care to reduce perinatal and neonatal problems; and training, monitoring, and supervising community health care workers to recognise labour complications and provide support and knowledge to lactating mothers.

Oral Sensorimotor Intervention Enhances Breastfeeding Establishment in Preterm Infants

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

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.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Effect of co-morbidities on the development of oral feeding ability in pre-term infants: a retrospective study

Pre-term infants frequently experience difficulties in attaining independent oral feeding, thus delaying the achievement of an adequate nutritional status and hospital discharge. The aim of this retrospective, single-centre, observational study was to investigate the effect of co-morbidities on the timing of the achievement of full oral feeding in pre-term infants. The neonatal and feeding data of 84 infants born at a gestational age of <32 weeks were collected, and the effect of co-morbidities on the achievement of feeding independence was evaluated using multiple linear regression analysis. The mean postmenstrual age at the time of the achievement of full oral feeding was 36.7 ± 3.68 weeks (range 33–53) weeks. The multiple linear regression analysis showed that a low birth weight, the occurrence of bronchopulmonary dysplasia, and the need for gastrointestinal surgical procedures were independently associated with a higher postmenstrual age at achievement of full oral feedings.