Benefits and challenges of transitioning preterm infants to at-breast feedings

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.

Predictors of Direct Breastfeeding in Preterm Infants

Objective: Rates of mother's own milk (MOM) provision in the neonatal intensive care unit (NICU) vary widely, despite acceptance as the gold standard for nutrition in preterm infants. Direct breastfeeding (DBF) supports long-term provision of MOM, but factors that support DBF in preterm infants are unknown. The purpose of this study was to identify factors that predict DBF at oral feeding initiation and at NICU discharge. Methods: This was a retrospective cohort study of preterm infants born at ≤ 32 weeks who were receiving MOM at 32 weeks corrected gestational age (cohort 1) and at discharge to home (cohort 2). The primary outcomes were rates of DBF at oral feeding initiation (cohort 1) and at hospital discharge (cohort 2). We examined bivariate associations between infant characteristics, maternal sociodemographic factors, and hospital practices (e.g., lactation visit timing and frequency) with DBF outcomes and then built logistic regression models to determine the adjusted odds ratio and 95% confidence interval ([adjusted odds ratio [aOR] [95%CI]) for independent predictors of the DBF outcomes. Results: Sixty-four percent of eligible infants initiated DBF, and 51% were DBF at discharge. Sociodemographic, NICU, and lactation support factors were associated with both outcomes. Post hoc analysis showed that similar factors also influenced lactation support provision. Conclusions: Lactation support, NICU and sociodemographic variables influence DBF initiation and DBF at discharge. Interventions that optimize efficient use of available lactation support, address bias, and provide ample opportunity for DBF practice could improve rates.

Motivators and barriers to the acceptability of a human milk bank among Malaysians

The World Health Organisation (WHO) recommends that all babies be exclusively breastfed, stating that donor milk is the next best alternative in the absence of the mother's own milk. Milk sharing takes many forms, namely wet nursing, co-feeding, cross-feeding, and a human milk bank (HMB). However, the establishment of a human milk bank is still not widely accepted and is a debatable topic because of religious concerns in Malaysia. The aim of this study is to determine the facilitators and barriers among Malaysians towards the acceptance of an HMB. A cross-sectional study with 367 participants was conducted; the participants answered an online-validated, self-administered questionnaire. Data on sociodemographic, knowledge on breastfeeding benefits, knowledge and attitude on HMB-specific issues were analysed in terms of frequency before proceeded with multiple logistic regression. The majority of the respondents were Muslim (73.3%), had completed their tertiary education (82.8%), and were employed (70.8%). Only 55.9% of respondents had heard of HMB, stating the internet as their main source of information, but many respondents were agreeable to its establishment (67.8%). Most respondents had a good score on knowledge of breastfeeding benefits and on HMB-specific issues (70% and 54.2%, respectively), while 63.8% had a positive attitude towards HMB. In the multivariate analysis, mothers with a good score on general knowledge of breastfeeding (AOR: 1.715; 95% CI 1.047-2.808) were more likely to accept the establishment of HMB, while being a Muslim was negatively associated with its establishment (AOR = 0.113, 95% CI 0.050-0.253). The study found a high prevalence of mothers who were willing to accept the establishment of HMB. By educating mothers on the benefits of breastfeeding, as well as addressing their religious concerns, the establishment of a religiously abiding HMB in Malaysia may be accepted without compromising their beliefs or the health benefit of donor milk.

Knowledge and Attitude of Parents of Preterm Babies and Health-Care Providers Related to Human Milk Banking in a Tertiary-Care Hospital

The aim of the study was to assess the knowledge and attitude of parents of preterm babies and health-care providers related to human milk and human milk banking in a tertiary-care hospital in North India. A descriptive study was conducted on 280 samples (200 parents and 80 health-care providers) of neonatal units of a tertiary-care hospital in North India. Self-developed 25-item knowledge-related questionnaire and 15-item attitude scale was used for health-care providers. Whereas ten-item knowledge-related interview schedule and five-item open-ended attitude assessment tools were used for parents. The content validity index was more than 0.72 for all the tools. Among health-care providers, majority (93.3%) of doctors and nursing officers (80%) were aware of human milk banking, but they demonstrated lack of knowledge about the processing and safety of such milk. Majority of mothers (89.3%) and fathers (90%) reported that they don't have problem in accepting the breast milk from other mothers if provided by human milk bank, while others had certain concerns related to infection and religious/cultural beliefs. There is a need to spread public awareness about human milk and human milk banking to foster its acceptance. The health-care providers also need regular update to ensure adequate knowledge and acceptability.

Establishment of oral microbiome in very low birth weight infants during the first weeks of life and the impact of oral diet implementation

Very low birth weight (VLBW) infants, mostly preterm, have many barriers to feeding directly from the mother's breast, and need to be fed alternatively. Feeding is a major influencer in oral microbial colonization, and this colonization in early life is crucial for the promotion of human health. Therefore, this research aimed to observe the establishment of oral microbiome in VLBW infants during their first month of life through hospitalization, and to verify the impact caused by the implementation of oral diet on the colonization of these newborns. We included 23 newborns followed during hospitalization and analyzed saliva samples collected weekly, using 16S rRNA gene sequencing. We observed a significant decrease in richness and diversity and an increase in dominance over time (q-value < 0.05). The oral microbiome is highly dynamic during the first weeks of life, and beta diversity suggests a microbial succession in early life. The introduction of oral diet does not change the community structure, but affects the abundance, especially of Streptococcus. Our results indicate that although time is related to significant changes in the oral microbial profile, oral feeding benefits genera that will remain colonizers throughout the host's life.

Trace elements status in human breast milk of mothers from Île-de-France region

Breastfeeding is the main source of nutrition during first months of life. Its composition varies according to parameters like mother's diet and health, living area, number of pregnancies and lactation duration… Trace-elements concentration in breastmilk is then an important parameter that can affect infant's health, growth or immune system and organ functions. Few data are available on this topic, and results are often very variable. The aim of this work is to determine reference values of Copper (Cu), Zinc (Zn), Selenium (Se), Cobalt (Co), Iron (Fe) and Iodine (I) in human breastmilk according to lactation duration and to study influencing parameters on its elementary composition. Regional Human Milk Bank of Necker Enfants Malades Hospital provided samples that came from breastfeeding woman involved in voluntary milk donation and epidemiologic data. Two hundred thirty-two breastmilk were analysed. After nitric acid mineralization of milk samples, Cu, Zn, Se, Co and I were determined by Inductively Coupled Plasma Mass Spectrometry (ICP-MS) in a standard mode. Fe was measured by Inductively Coupled Plasma Optical Emission Spectroscopy (ICP-OES). Both assays were validated in terms of sensitivity, repeatability and accuracy.Studied breast milks came from mothers with an average age of 32 years and donation time ranged from one day after childbirth to 974 days (> 2.5 years); mean lactation duration is 59 days (> 8 weeks) while median duration is 29 days (around 4 weeks). In all studied samples, mean results and reference values are for Cu: 6.02 (1.71-13.23), Zn: 43.86 (7.3-107.0), Se: 0.12 (0.07-0.24), I: 0.29 (0.07-1.01) and Fe: 4.72 (1.25-11.49) µmol/L and for Co: 12.28 (5.27-25.82) nmol/L. Important number of studied milks allowed their distribution into seven classes of lactation durations. Samples were divided into four successive classes of fifteen days after childbirth, two other classes corresponding to the 3rd and 4th months and a last class for milks sampled after 4 months of lactation. Results were analysed in each class allowing study of evolution during lactation. That was particularly interesting for Zn, that presented an important variability in the total population (4-132 µmol/L) explained by variation along lactation evolution decreasing from 48 to 17 µmol/L in first and last duration classes respectively. In addition, Cu and Fe concentrations were also significantly correlated with lactation duration while Se and I were in a lesser extent (p = 0.002). In this study, we present reference values for studied trace elements at different lactation stages, allowing a fine interpretation of future breast milk samples results according to their sampling time. By continuing this study, we plan to increase number of samples in some of the classes and to study the influence of premature birth or twin pregnancy on breast milk elementary composition.

Effectiveness of Interventions to Manage Difficulties with Breastfeeding for Mothers of Infants under Six Months with Growth Faltering: A Systematic Review Update

(1) Background: The current evidence on management of infants under six months (u6m) with growth faltering is limited and of low quality. This review aimed at updating an existing review to inform the WHO guideline update on prevention and management of growth faltering in infants u6m. The objective is to synthesise evidence on interventions to manage breastfeeding difficulties in mothers or caregivers of infants u6m with growth faltering to improve breastfeeding practices and breastmilk intake. (2) Methods: We searched PubMed, CINAHL, and Cochrane Library from December 2018 to December 2021 for experimental studies. Using RoB 2.0 and ROBINS-I tools, we assessed study quality and results were synthesised narratively. Using the GRADE approach, we assessed the quality of evidence for four outcome domains-breastfeeding (critical), anthropometric (important), mortality (important), and morbidity (important). (3) Results: We identified seven studies, conducted among neonates (mainly preterm, n = 14 to 607), and assessed the following interventions: (a) non-nutritive sucking (NNS) on breast (n = 2) and (b) alternative supplemental feeding techniques (n = 5, cup feeding, spoon feeding, supplemental feeding tube device, and syringe feeding), and reported breastfeeding and anthropometric outcomes. None of the studies reported mortality and morbidity outcomes. The reported breastfeeding outcomes included LATCH (Latch, Audible swallowing, Type of nipple, Comfort, Hold) total score, PIBBS (Preterm Infants Breastfeeding Behaviour Scale) total score, EBF (exclusive breastfeeding) at various time points and time to transition to full breastfeeding, and reported anthropometric outcomes included weight gain and weight at different time points. Studies had 'serious' indirectness and 'serious' to 'very serious' risks of bias. From the limited studies we found, NNS on breast compared to NNS on finger may have some benefits on PIBBS total score; NNS on breast compared to NNS on pacifier may have some benefits on EBF at discharge; and cup feeding compared to bottle feeding may have some benefits on EBF at discharge, at three months and at six months. (4) Conclusions: Evidence on the effectiveness of interventions to manage breastfeeding difficulties in mothers or caregivers of infants u6m with growth faltering to improve breastfeeding practices and increase breastmilk intake is 'limited' and of 'low' to 'very low' quality. As the majority of the infants in the included studies were neonates, no new recommendations can be made for infants from one to six months due to lack of evidence in this population. We need more studies targeting infants from one to six months of age. The review was registered with PROSPERO (CRD42022309001).

How to Provide Breast Milk for the Preterm Infant and Avoid Symptomatic Cytomegalovirus Infection with Possible Long-Term Sequelae

Cytomegalovirus (CMV) is able to replicate in the breast milk of lactating mothers and thus the offspring might be affected by mild to severe symptoms of postnatal CMV disease in case of prematurity; not in term infants. Sepsis-like syndrome affects only very low birth infants; and few cases have been reported. The neurodevelopmental long-term outcome of those preterm infants revealed possible subtle deficiencies, but no major neurodevelopmental impairment. Neurodevelopmental sequelae are still in discussion and seem somewhat overestimated after careful evaluation of the published evidence. The main focus of postnatal CMV disease lies upon the extremely low birth weight of infants. Elimination of CMV is provided by short-term heating methods like the most widely used Holder pasteurization. Freezing and thawing methods leave a risk for CMV acquisition. The benefits of untreated breast milk have to be considered to outweigh the possible sequelae of postnatal CMV infection in the most vulnerable preterm infants.

Supporting Direct Breastfeeding in a Tracheostomy-Dependent Neonate: A Case Report

Objectives:

There are numerous well-described benefits to breastfeeding to both infant and mother. Even in healthy children with an uncomplicated perinatal course, there may be significant struggles maintaining a breastfeeding relationship. Infants with a complicated clinical course have been shown to benefit even more from the provision of breastmilk, however they are seldom encouraged to feed directly at the breast. There are no reports of successful direct breastfeeding in an infant with a tracheostomy.

Methods and Results:

We present the case of a breastfeeding dyad including a trach-dependent infant with congenital idiopathic bilateral vocal fold immobility who successfully initiated and maintained an inclusive breastfeeding relationship.

Conclusion:

This case illustrates that successful direct breastfeeding can be achieved in an infant with a tracheostomy. If a patient is felt to be capable of oral feeding via bottle, there is no reason that there should not be a trial of direct feeding at the breast, for the benefit of both members of the breastfeeding dyad.

Breastfeeding preterm born infant: Chance and challenge

Background and Objectives

For preterm infants, breastmilk plays an important role in their development, but mothers encounter a number of barriers to breastfeeding. The aim of this study was to investigate breastfeeding prevalence in preterm infants and to examine factors that may face mothers when starting to feed at-breast and their impact on the result.

Methods

Women (N = 79) with preterm infants (N = 84) were interviewed within the follow-up program in Latvia during a six-month period in 2018 using the original study protocol.

Results

61.9% infants were breastfed and 38.1% were not. The median infant birth weight in breastfed group was 1730 g, the median duration of tube feeding 21 days. The median age when started to feed at-breast 33 days. Later only 40.4% infants were still feeding at-breast. A relationship was found between breastfeeding and the mother's confidence during pregnancy that she would breastfeed (P < .05). 98% mothers who began to feed at-breast, during pregnancy were confident that they would breastfeed. 54.2% women who started to breastfeed as success mentioned medical staff training, 29.2% family support.The median birth weight in the non-breastfed group was 1494 g, the median duration of tube feeding 21 days. 50% women who did not begin to breastfeed had not received enough information about breastfeeding; 17.2% during pregnancy were not confident that they would breastfeed. 38.7% women stated infants' inability to suckle as failure, 22.6% thought they had no milk. Mothers under 32 years were more likely not to breastfeed their infant (OR = 0.8, 95% CI 0.33-1.96).

Conclusion

Most mothers began to breastfeed immediately, less than half continued later. Women did not receive enough family support. Young maternal age was associated with decrease in breastfeeding. Mothers with higher education were more likely to breastfeed. Being born extremely preterm and very preterm were associated with the least chance of being breastfed.

Mechanisms of support for exclusive breastmilk expressers in the community: a scoping review

BACKGROUND

The World Health Organization recommends that infants be exclusively breastfed until the age of six months. Breastfeeding is generally understood to mean the provision of human breastmilk to the infant by direct feeding at the breast, and interventions aimed at supporting exclusive breastfeeding are therefore targeted at this activity. However, breastfeeding is actually an umbrella term covering the provision of breastmilk to an infant by any means. Our population of interest is mothers who exclusively feed their infants indirectly using expressed breastmilk. Some research suggests that any expressing, and exclusively expressing in particular, can be a risk factor for early cessation of exclusive breastmilk provision, so we were interested to identify whether any specific support existed for exclusively expressing mothers outside of the context of premature infants and the Neonatal Intensive Care Unit setting.

METHODS

A scoping review following the Joanna Briggs Institute approach was used to explore the phenomenon of formal and informal supports in the community for exclusively expressing mothers. Searches were run across academic databases and of government websites and infant feeding support organisations. Finally, an informal internet search was run using a simple search string.

RESULTS

On analysis of results, there were no studies or articles that met the search criteria. An informal internet search linked us directly with websites and blogs that could be considered a form of support intervention. These informal results suggest that support material or programs could possibly exist in other modalities but we cannot find them in the context of this type of scoping review.

CONCLUSIONS

The results of the search corroborated what we had suspected - that exclusively expressing mothers are not specifically supported by usual channels for new parents and that it is also difficult to find acknowledgement that exclusive expression exists. The absence of results demonstrates the relevance of this study: exclusively expressing mothers are an under-served population. If we wish to strive towards achievement of World Health Organization breastfeeding goals, exclusively expressing mothers require targeted support to assist in their infant feeding experience, and there is little formal evidence of it currently being provided.

Do workplace policies influence a woman's decision to breastfeed?

This literature review addresses workplace breastfeeding policies in the United States. Breastfeeding yields many important benefits to both mother and infants, yet workplace barriers contribute to low rates of breastfeeding. NPs often serve as the initial point of education for new mothers and may impact decisions to breastfeed.

Paid Family Leave to Enhance the Health Outcomes of Preterm Infants

Prematurity is the largest contributor to perinatal morbidity and mortality. Preterm infants and their families are a significant vulnerable population burdened with limited resources, numerous health risks, and poor health outcomes. The social determinants of health greatly shape the economic and psychosocial resources that families possess to promote optimal outcomes for their preterm infants. The purposes of this article are to analyze the resource availability, relative risks, and health outcomes of preterm infants and their families and to discuss why universal paid family leave could be one potential public policy that would promote optimal outcomes for this infant population. First, we discuss the history of family leave in the United States and draw comparisons with other countries around the world. We use the vulnerable populations conceptual model as a framework to discuss why universal paid family leave is needed and to review how disparities in resource availability are driving the health status of preterm infants. We conclude with implications for research, nursing practice, and public policy. Although health care providers, policy makers, and other key stakeholders have paid considerable attention to and allocated resources for preventing and treating prematurity, this attention is geared toward individual-based health strategies for promoting preconception health, preventing a preterm birth, and improving individual infant outcomes. Our view is that public policies addressing the social determinants of health (e.g., universal paid family leave) would have a much greater impact on the health outcomes of preterm infants and their families than current strategies.

Dietary Protein Intake, Breast Feeding and Growth in Human Milk Fed Preterm Infants

Protein intakes of preterm infants are frequently below recommendations, but few studies report accurate intakes due to the difficulty of analysing human milk clinically. This observational analysis from a randomised trial of infants born <31 weeks’ gestation, investigating two levels of protein fortification, reports protein intakes compared with requirements and determines the association of direct breastfeeding on growth. Ninety-two infants (median gestational age 28 weeks, Interquartile range (IQR) 26–29; mean birth weight 1040 g, SD 300 g) were studied. Infants born weighing <1000 g were underfed protein compared with recommendations (median (IQR) intake of 3.0 (2.0–3.7) g/kg/day in week 2 versus recommendation of 4–4.5 g/kg/day), while those born weighing ≥1000 g met recommended protein intakes after the first week of life (median (IQR) intake of 3.7 (3.0–4.0) g/kg/day in week 2 versus recommendation of 3.5–4.5 g/kg/day). A moderate, negative correlation between the mean number of breast feeds and change in rate of weight gain (r = −0.37, p = 0.001) was found. Protein intakes of infants <1000 g did not meet recommendations and all infants were underfed protein and energy in the first week of life. Current protein fortification is inadequate for infants born <1000 g. Exploratory analysis showed faltering rate weight gain associated with increasing number of breast feeds and these results warrant confirmation.

Mother's breast milk supplemented with donor milk reduces hospital and health service usage costs in low-birthweight infants

OBJECTIVE

to compare hospital and health service usage costs of feeding low-birthweight (LBW) infants predominantly with their mother's milk, supplemented with donor milk, with donor milk and preterm formula.

DESIGN

prospective matching study.

SETTING

tertiary public perinatal centre, neonatal intensive care unit (NICU) and donor human milk bank.

PARTICIPANTS

100LBW infants (Group I) fed predominantly with their mother's milk from the first hour of life, supplemented (mainly for the first week of life) with donor milk, were matched on a 1:1 basis with 100LBW infants (Group II) who were fed with donor milk for the first 3 weeks of life followed by preterm formula until hospital discharge. Individualised targeted fortification of human milk was implemented in both study groups.

FINDINGS

the costs of hospitalisation, doctor visits and prescription drugs for viral infections until 8 months of age were calculated for each infant. Infants fed predominantly with their mother's milk had significantly shorter hospital stays and lower hospitalisation costs. In Group I infants, the duration of enteral gavage feeding was shorter, resulting in significantly lower costs. Up to 8 months of age, Group I infants experienced fewer episodes of viral infections, and the cost of each doctor visit and drug prescription was lower for these infants.

CONCLUSIONS

feeding LBW infants predominantly with their mother's milk reduces hospital and health service usage costs.

IMPLICATIONS FOR PRACTICE

feeding LBW infants predominantly with their mother's milk, supplemented with donor milk, followed by exclusive breast feeding seems to result in potential savings in hospital and health service usage costs.

Novel feeding system to promote establishment of breastfeeds after preterm birth: a randomized controlled trial

OBJECTIVE

We aimed to determine if a novel feeding system where milk only flowed when the preterm infant created a vacuum would influence time to full oral feeds, the length of stay (LOS) in hospital and breastfeeding at discharge.

STUDY DESIGN

This was a randomized controlled trial in the tertiary neonatal intensive care unit at King Edward Memorial Hospital, Perth, Australia. Eligibility criteria were: preterm infants of gestational age 25 to 34 weeks receiving >75% human milk by gastric tube. Infants were randomly assigned to being fed with a novel teat (NT) or conventional teat (CT). Intention to treat analysis was performed.

RESULT

Time to full suck feeds was not different between groups. LOS was shorter (mean: 2.5 days; P=0.026) and less formula was fed at discharge in the NT group (P=0.036).

CONCLUSION

Use of a NT that releases milk when the infant applies vacuum while establishing breastfeeding reduces duration of hospitalization of preterm infants.

LATCH scores and milk intake in preterm and term infants: a prospective comparative study

OBJECTIVES

We aimed to detect the breastmilk intake in preterm and term infants and to determine if the LATCH scoring system (latch; audible swallowing; type of nipple; comfort [breast/nipple]; hold [positioning]) could be helpful to denote that infants have taken enough breastmilk according to their postnatal age and weight.

MATERIALS AND METHODS

Sixty-six breastfeeding sessions were monitored and scored simultaneously by using the LATCH scoring system. The weight of the 66 infants (33 preterm, 33 term) was measured before and after a breastfeeding session, and thereby milk intake by breastfeeding was determined. The expected amount of milk volume that infants should receive for each feeding session was calculated according to the postnatal age and weight. The breastmilk intake by breastfeeding was compared with LATCH scores and the expected milk volume for each feeding.

RESULTS

We observed that 25 term infants (75.8%) took 100% of the expected milk volume for each feeding session, compared with two preterm infants (2.1%) (p=0.009). The median LATCH scores were 7.0 (minimum-maximum=5-9) in preterm babies and 9 (minimum-maximum=7-10) in term babies (p<0.0001). Term babies could consume 95.4% of the expected milk volume for each feeding session, whereas this ratio was only 45% in preterm babies. In each group, babies receiving a score of ≥7 took at least 50% of the expected milk volume for each feeding session. In each group, higher LATCH scores were associated with higher median intake, but the minimum and maximum intake for each LATCH score revealed marked variability.

CONCLUSIONS

High LATCH scores (7-10) may be helpful to determine that infants take at least 50% of the expected breastmilk volume for each feeding in both preterm and term infants. However, LATCH scores cannot substitute for test weights in premature infants because of variability in minimum and maximum milk intake per LATCH score.

A case study of a late preterm infant's transition to full at-breast feedings at 4 months of age

Breast milk intake is recommended for late preterm infants. Many mothers provide expressed breast milk during hospitalization and anticipate transitioning their late preterm infant to full feedings at-breast after discharge. However, some infants take months to transition to full feedings at-breast. This article describes the case of a mother and her 35-week infant who transitioned to full feeding at-breast at 4 months after discharge. The clinical strategies to maintain maternal milk supply, use of hospital-grade scale, and importance of professional and community lactation support are discussed.

Maternal and breast pump factors associated with breast pump problems and injuries

BACKGROUND

Benefits of using a breast pump are well documented, but pump-related problems and injuries and the associated risk factors have not been reported.

OBJECTIVES

This study aimed to describe breast pump-related problems and injuries and identify factors associated with these problems and injuries.

METHODS

Data were from the Infant Feeding Practices Study II; mothers were recruited from a nationally distributed consumer opinion panel. Mothers were asked about breast pump use, problems, and injuries at infant ages 2, 5, and 7 months. Survival analysis was used to identify factors associated with pump-related problems and injuries.

RESULTS

The sample included 1844 mothers. About 62% and 15% of mothers reported pump-related problems and injuries, respectively. The most commonly reported problem was that the pump did not extract enough milk and the most commonly reported injury was sore nipples. Using a battery-operated pump and intending to breastfeed less than 12 months were associated with higher risks of pump-related problems and injury. Learning from a friend to use the pump was associated with lower risk of pump-related problems, and using a manual pump and renting a pump were associated with a higher risk of problems.

CONCLUSION

Our results suggest that problems and injuries associated with breast pump use can happen to mothers of all socioeconomic characteristics. Breastfeeding mothers may reduce their risks of problems and injury by not using battery-operated pumps and may reduce breast pump problems by not using manual pumps and by learning breast pump skills from a person rather than following written or video instructions.

Factors influencing breastfeeding duration: a survey in a Turkish population

Breastfeeding provides perfect nutrition for infants and is a source of many health benefits for both mother and baby. To obtain the maximum beneficial effects of breast milk, it is necessary to prolong the breastfeeding duration. In this study, we investigated the factors influencing the duration of breastfeeding. We conducted a 32-question survey of mothers with children aged 2-4 years, who presented to our medical school's pediatric outpatient clinics. The questionnaire solicited information on demographics and breastfeeding attitudes. We found correlations between total duration of breastfeeding and the time the mother and baby spent together (sharing a room to sleep at night) and the father's engagement in breastfeeding. Breastfeeding duration inversely correlated with maternal employment. Total duration of breastfeeding did not correlate with breastfeeding education by health personnel, the mother's education level, the gender of the child, regular prenatal care visits, the use of a pacifier, the interval between birth and the onset of breastfeeding, gestational age, method of delivery, or the birth weight of the infant.

CONCLUSION

Our findings suggest several strategies to increase the duration of breastfeeding, including educating fathers along with mothers, supporting a shared bedroom until the child is 2 years of age, and promoting measures that allow mothers to be with their children during working hours.

The extent that noncompliance with the ten steps to successful breastfeeding influences breastfeeding duration

BACKGROUND, OBJECTIVES: The Ten Steps to Successful Breastfeeding are not, as yet, the norm in the United States. This study examined how noncompliance with each of the Steps, and combinations of 2 Steps, influence duration of breastfeeding at the breast.

METHODS

Data were from the national Infant Feeding Practices Study II. The outcome was duration of any breastfeeding at the breast. Propensity scores modeled the probability of exposure to lacking 1 or more of the Ten Steps. Inverse probability weights controlled for confounding. Survival analyses estimated the relationship between the lack of a Step and breastfeeding duration.

RESULTS

Lack of Step 6 (No human milk substitutes) was associated with shorter breastfeeding duration, compared with being exposed to Step 6 (10.5-wk decrease). Lack of both Steps 4 (Breastfeed within 1 hour after birth) and 9 (Pacifiers), together, was related to the greatest decrease in breastfeeding duration (11.8-wk decrease). The findings supported a dose-response relationship: being exposed to 6 Steps was related to the longest median duration (48.8 wk), followed by 4 or 5 Steps (39.8 wk), followed by 2 or 3 Steps (36.4 wk).

CONCLUSIONS

Prevalent US maternity care practices do not, as yet, include all of the Ten Steps. This lack of care may be associated with poor establishment of the physiological feedback systems that support sustained breastfeeding. Breastfeeding at the breast is compromised when specific combinations of Steps are lacking. Efforts to increase implementation of specific Steps and combinations of Steps may be associated with increased duration of breastfeeding.

Developing maternal self-efficacy for feeding preterm babies in the neonatal unit

Developing maternal self-efficacy offsets negative psychological consequences of premature birth, improving maternal well-being. We investigated women's experiences in a neonatal unit (NNU) in Scotland in semistructured interviews with 19 primiparous mothers of preterm babies. We explored their experience of preterm birth and development of self-efficacy in infant feeding behaviors, identifying emergent and a priori themes. Women reported experiencing loss and biographical disruption in relation to mothering, loss of autonomy, and searching for normality after premature birth. Providing breast milk symbolized embodied contact with their baby and increased maternal confidence. They developed motivation, knowledge, and perseverance and perceived success from positive feedback, primarily from their baby and health professionals' support and encouragement. Women actively constructed opportunities to develop ownership, control, and confidence in relation to interactions with their baby. We linked sources of self-efficacy with potential behavior change techniques to be used in practice to improve maternal confidence in the NNU.

A New Bottle Design Decreases Hypoxemic Episodes during Feeding in Preterm Infants

Oxygen saturation is lower during bottle feeding than during breastfeeding in preterm infants. Our objective was to compare two different bottle systems in healthy preterm infants before discharge in terms of SpO(2) and oral feeding efficiency (rate of milk intake). Infants without supplement oxygen needs were evaluated twice on the same day during two consecutive feeds, by the same nurse. Infants served as their own controls for comparison of two systems of bottles, the order of which was randomized. The new bottle's nipple design mimics mom's breast in shape and feel, and the bottle vents to air when the child sucks on the nipple. The other system was the hospital's standard plastic bottle with silicone nipple. The rate of milk intake was calculated as the total volume transferred minus volume lost divided by time of feeding, mL/min. Thirty-four infants (BW: 1, 163 ± 479.1 g) were studied at 35.4 ± 1.3 weeks after-conception. SpO(2) was significantly higher in infants fed with the new bottle design. Milk intake rate was significantly higher with the new bottle than with the standard bottle design. The new bottle design improves oral feeding performance in preterm infants near to discharge when compared to that of a standard bottle.

Mode of anaesthetic for category 1 caesarean sections and neonatal outcomes

BACKGROUND

Birth by emergency caesarean section (CS) is common and often considered urgent (category 1). In the UK, over half of all category 1 CS are performed under general anaesthesia (GA). In this setting, little is known about the effect of the mode of anaesthesia on the neonate.

METHODS

A retrospective cohort study was performed using routinely collected de-identified data from Mater Health Services, Brisbane, Australia. The data set included 533 term babies born by category 1 CS for presumed fetal compromise between 2008 and 2011. Bivariate and multivariate analyses were undertaken.

RESULTS

The outcomes of 81 babies born by GA CS were compared with 452 by CS under regional anaesthesia (RA). Compared with a category 1 CS under RA, the decision-to-delivery interval for a GA CS was almost eight minutes faster (24.7 vs 32.6 minutes; P < 0.001). When adjusted for confounders, babies born by category 1 GA CS were significantly more likely to have an Apgar score < 7 at five minutes (aOR 6.89; 95%CI 1.79-26.55; P = 0.005), to require Neopuff or bag/mask ventilation for > 60 seconds (aOR 2.34; 95%CI 1.13-4.84; P = 0.022) and to be admitted to a neonatal intensive care nursery (aOR 2.24; 95%CI 1.16-4.31; P = 0.016).

CONCLUSIONS

General anaesthesia was associated with short-term neonatal morbidity of term babies born by category 1 CS for presumed fetal compromise, despite enabling a more rapid delivery of the baby. These data should help inform the discussion between anaesthetist and obstetrician, in balancing the risks and benefits of the mode of anaesthesia.

Infant feeding in the neonatal unit

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

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

This review aimed to identify interventions to promote breastfeeding or breast milk feeding for infants admitted to the neonatal unit. The medical electronic databases were searched for papers listed between 1990 and June 2005 which had breastfeeding or breast milk as an outcome and which targeted infants who had been admitted to a neonatal unit, thus including the infant and/or their parents and/or neonatal unit staff. Only papers culturally relevant to the UK were included resulting in studies from the USA, Canada, Europe, Australia and New Zealand. This search was updated in December 2007 to include publications up to this date. We assessed 86 papers in full, of which 27 ultimately fulfilled the inclusion criteria. The studies employed a range of methods and targeted different aspects of breastfeeding in the neonatal unit. Variations in study type and outcomes meant that there was no clear message of what works best but skin-to-skin contact and additional postnatal support seemed to offer greater advantage for the infant in terms of breastfeeding outcome. Galactogogues for mothers who are unable to meet their infants' needs may also help to increase milk supply. Evidence of an effect from other practices, such as cup-feeding on breastfeeding was limited; mainly because of a lack of research but also because few studies followed up the population beyond discharge from the unit. Further research is required to explore the barriers to breastfeeding in this vulnerable population and to identify appropriate interventions to improve breastfeeding outcomes.

A double-edged sword: lactation consultants' perceptions of the impact of breast pumps on the practice of breastfeeding

This qualitative descriptive study examined the beliefs and experiences of 12 lactation consultants regarding the impact of breast pumps on breastfeeding practices. Interview topics on breast pumps included types and patterns of use, mothers' experiences, and advantages and risks. The lactation consultants reported an increase in the use of breast pumps due to improved marketing, a change in society's view of pumps as a necessity rather than a luxury, and the impact of birthing technology. Reasons given for this increased use were mothers' need to have greater control over the breastfeeding process and to quantify the amount of breastmilk. Concerns were expressed regarding an overdependency on breastfeeding technology by some lactation consultants and mothers.