Preterm Infant Feeding: A Mechanistic Comparison between a Vacuum Triggered Novel Teat and Breastfeeding

A Ducted, Biomimetic Nipple Improves Aspects of Infant Feeding Physiology and Performance in an Animal Model

Breastfeeding is widely regarded as the optimal form of feeding infants, as it provides both nutritional and physiological benefits. For example, breastfed infants generate greater intraoral suction and have higher amplitude muscle activities compared to bottle-fed infants, with downstream implications for motor function, development, and health. One mechanism that might explain these physiological differences is the structure of the nipple an infant is feeding on. Breasts in most mammals are ducted soft-tissue structures that require suction to be generated for milk to be released, whereas bottle nipples are hollow and allow milk to be acquired by compression of the nipple. We used a validated animal model (pigs) to test how being raised on a novel ducted nipple impacted feeding physiology and performance compared to infants raised on a standard (cisternic) nipple. At the end of infancy, we fed both groups with both nipple types and used high-speed videofluoroscopy synchronized with intraoral pressure measurements to evaluate feeding function. Nipple type did not have a profound impact on sucking or swallowing rates. However, when feeding on a ducted nipple, infant pigs raised on a ducted nipple generated more suction, consumed milk at a faster rate, swallowed larger boluses of milk, and had decreased likelihood of penetration and aspiration than those raised on a cisternic nipple. These data replicate those found when comparing breast- and bottle-fed infants, suggesting that a ducted, biomimetic nipple may provide bottle-fed infants with the physiologic benefits of breastfeeding.

Spatial variations and determinants of bottle feeding among children aged 0-23 months in Ethiopia in 2019: A spatial and multi-level analysis

BACKGROUND

Bottle feeding should be avoided since it interferes with optimal breastfeeding and it causes diarrheal-related morbidity and mortality. Despite the WHO's recommendation that children to avoid bottle feeding, it is still widely practiced in developing countries including our country, Ethiopia. Therefore, this study aimed to assess the spatial variations, and determinants of bottle feeding among children aged 0-23 months using the recent demographic and health survey data for Ethiopia.

METHODS

A secondary data analysis was conducted using the 2019 Ethiopian mini demographic and health survey data. The total weighted sample of 2067 children aged 0-23 months was included in this study. Spatial analysis was done to identify the hotspot areas of bottle feeding among children in Ethiopia. Multivariable multilevel logistic regression was used to identify predictors of bottle feeding. The spatial analysis was done using ArcGIS 10.7 and Sat Scan 9.6 software.

RESULT

The prevalence of bottle feeding among children aged 0-23 months was 21.52% with 95% CI(19.80%, 23.34%). Age of the child from 6-11 months, and 12-23 months age, having secondary and above education [AOR = 2.09; 95%CI; 1.31, 3.32], being from middle and rich household [AOR = 2.14; 95%CI; 1.37, 3.34] and [AOR = 2.30; 95%CI; 1.46, 3.63], and twin birth [AOR = 8.06; 95%CI; 2.87, 22.58] were significant predictors of bottle feeding. Hotspot areas of bottle feeding were observed in Addis Ababa, Dire Dawa, Harari, and Afar regions of Ethiopia.

CONCLUSION

Bottle feeding practice was found to be spatially clustered in Ethiopia. Education, wealth index, parity, and child's age were significant predictors of bottle feeding. Hotspot areas of bottle feeding were observed in Addis Ababa, Dire Dawa, Harari, and Afar regions. Special attention should be directed towards mothers residing in hotspot areas, educated mothers, mothers of multiple births, and mothers from rich households through community education programs focused on child feeding practices to reduce the practice of bottle-feeding in Ethiopia.

Analysis of the duration of exclusive breastfeeding in premature infants and its influencing factors

PURPOSE

The purpose of this study was to investigate the duration of breastfeeding among preterm infants within the first 12 months after birth and analyzed factors influencing the duration of exclusive breastfeeding.

DESIGN AND METHODS

In this retrospective study, premature infants who were hospitalized in the Neonatal Intensive Care Unit (NICU) premature delivery area of a third-class maternal and child health hospital in Changsha City, Hunan Province, China from October 2020 to January 2021 were selected as the participants for this study. Relevant data of these infants during their hospitalization was obtained from the hospital information system, while the rate of exclusive breastfeeding among preterm infants at a corrected age of 12 months was tracked through telephone follow-up. Univariate analysis of the effects of breastfeeding duration in preterm infants was conducted based on Mann-Whitney U test and Kruskal-Wallis H test. Multiple linear regression was then applied to determine the factors influencing the duration of exclusive breastfeeding in preterm infants.

RESULTS

The median and interquartile range of breastfeeding duration for preterm infants in this study was 4.00 (1.00, 6.00) months. Multiple linear regression analysis showed that the duration of exclusive breastfeeding was affected by several factors including how much other family members support breastfeeding, whether the mother returns to work after maternal leave, and whether the infant is a twin (P < 0.05).

CONCLUSION

The duration of exclusive breastfeeding among preterm infants needs to be improved by strengthening health education regarding the benefits of breastfeeding for preterm infants. Medical staff should provide guidance, encourage continuous nursing after discharge, and work with the community to implement targeted intervention measures with the goal of increasing the duration of exclusive breastfeeding among premature infants.

IMPLICATIONS TO PRACTICE

Because breastfeeding is vitally important for premature infants, we should encourage longer breastfeeding duration for premature infants by increasing family support, removing barriers to workplace breastfeeding, enhancing people's confidence in breastfeeding and providing support to mothers with twins. Hopefully, these measure can promote breastfeeding for premature infants.

Using the theory of planned behavior model to predict factors influencing breastfeeding behavior among preterm mothers at week 6 postpartum: the mediating effect of breastfeeding intention

Background

Exclusive breastfeeding (EBF) in the first 6 weeks postpartum is key to continued breastfeeding. This study aimed to explore the role of EBF-related predictors (particularly breastfeeding intention) in breastfeeding behavior among preterm mothers at week 6 postpartum based on the theory of planned behavior (TPB).

Methods

A total of 352 mothers of preterm infants were recruited, 340 of whom participated in this study. Prior to discharge, participants completed the Chinese versions of the modified Breastfeeding Attrition Predictive Tool, the Breastfeeding Knowledge Questionnaire (BKQ), the Infant Feeding Intention, and the Edinburgh Postnatal Depression Scale. Responses to the items of the Breastfeeding Behavioral Questionnaire (BBQ) were also collected by telephone at week 6 postpartum. The final analyses included 321 participants who completed the full two-wave data collection.

Results

The fitness indices of the modified TPB model were acceptable. Breastfeeding knowledge and EBF before discharge positively impacted breastfeeding intention, whereas depression had a negative impact. Before discharge, breastfeeding intention fully mediated the impacts of breastfeeding attitude, social and professional support, knowledge, depression, and EBF on breastfeeding behavior and partially mediated the influence of perceived breastfeeding control on breastfeeding behavior.

Conclusion

These findings indicate that TPB accurately predicts breastfeeding behavior among preterm mothers at week 6 postpartum, and breastfeeding intention is key to the above-mentioned EBF-related factors and breastfeeding behavior. The findings underline the need for further longitudinal studies and corresponding interventions for preterm mothers with a high risk of EBF attrition.

Breastfeeding needs of mothers of preterm infants in China: a qualitative study informed by the behaviour change wheel

BACKGROUND

Although breastfeeding is strongly recommended, the breastfeeding rate of preterm infants in China remains significantly low. In addition to the global structural challenges to breastfeeding and the physiological immaturity of preterm infants, Chinese mothers of preterm infants face unique challenges of maternal-infant separation after birth. Moreover, little is known about Chinese mothers' specific needs in coping with the difficulties posed by these challenges. This study utilized the Behaviour Change Wheel to investigate the breastfeeding needs of Chinese preterm mothers that may facilitate its practice in the future.

METHOD

A qualitative descriptive design was implemented in Wuhan in 2022. Based on purposeful sampling, 13 preterm mothers were recruited from a NICU in a Grade III Class A hospital in Wuhan, China. Face-to-face semi-structured interviews were conducted to collect data using the interview guide developed by the Theoretical Domains Framework. Theoretical Thematic Analysis was used to review the data in 6 steps to identify themes.

RESULTS

Five major themes emerged: (1) capability: ability to interpret infants' cues and identify problems, and need for breastfeeding knowledge and skills training; (2) physical opportunity: cleanliness and quietness in household environment, private lactation spaces and breastfeeding tools in workplaces and hospitals; (3) social opportunity: family support, peer support, and authoritative support from healthcare providers; (4) reflective motivation: information on health impacts of breastfeeding; (5) automatic motivation: maternal-infant bonding, free of aversive stimulus.

CONCLUSION

Preterm mothers' needs to enable breastfeeding were diverse, including increasing their capability, physical and social opportunities, and reflective and automatic motivation. People, resources and environments associated with these needs should be engaged together to stablish a conducive structural environment for breastfeeding. The policy change for "zero separation" and implementation of kangaroo care should also be implemented in Chinese neonatal intensive care units. Future studies are needed to design effective interventions according to mothers' specific needs.

Magnitude of bottle-feeding practice and associated factors among mothers of 0-24 months' children in Asella town, Oromia region, Ethiopia

BACKGROUND

Since bottle feeding has an impact on the effectiveness of breastfeeding and appropriate supplemental feeding, the World health organization recommends being avoided for infant and early child feeding. Thus, this study aimed to assess the level of the bottle-feeding practice and its associated factors among mothers of 0-24 month's children in Asella town, Oromia region, Ethiopia.

METHODS

Community-based cross-sectional study design was conducted from March 8-April 8, 2022, among a sample of 692 mothers of children aged 0-24 months. A multi-stage sampling technique was used to select the study subjects. Data were collected using a pretested and structured questionnaire by face-to-face interview technique questionnaire. The outcome variable bottle-feeding practice (BFP) was assessed using WHO and UNICEF UK healthy baby initiative BF assessment tools. Binary logistic regression analysis was used to identify the association between explanatory and outcome variables. Adjusted Odds ratio (AOR) with a 95% confidence interval was used to measure the strength of the association and a p-value < 0.05 was used to declare statistical significance.

RESULTS

A total of 692 mothers with mean age and standard deviation (SD) of 31.86 (± 4.87) participated in the study. The prevalence of bottle-feeding practice was 246(35.5% with 95% CI: (31.8, 39.5). Mothers who were government-employed (AOR: 1.64, 95% CI: 1.02, 2.64), mothers who delivered at home (AOR: 3.74, 95% CI: 2.58-5.42), mothers who did not attend postnatal care (AOR: 3.76, 95% CI: 2.60,5.44) and mother who had negative attitude (AOR: 1.94, 95%CI: 1.34,2.8) were significantly associated with bottle feeding practices.

CONCLUSION

The BFP were higher in the study area when compared with national reports of practices. The occupational status of the mothers, place of delivery, attending postnatal care, and attitude of the mothers were factors that increased bottle-feeding practice in the study area. Strengthening dietary behavioral modification for mothers who have children 0-24 months of the child to practice appropriate feeding is recommended.

Non-Pharmacological and Non-Surgical Feeding Interventions for Hospitalized Infants with Pediatric Feeding Disorder: A Scoping Review

Infants born prematurely or with complex medical conditions often require treatment to facilitate safe and efficient feeding. Practice is based on evidence, so frontline clinicians look to the literature to make informed clinical decisions. The aim of this scoping review was to map and describe the literature base for infant feeding and swallowing interventions and to identify areas for further research. Four electronic databases were searched from the sources' inceptions through April 2020 using a search strategy designed by a health sciences research librarian. Thirteen grey literature sources were searched and forward and backward citation chasing was performed. Inclusion criteria were English-language studies reporting non-pharmacological and non-surgical interventions for hospitalized infants. Exclusion criteria included interventions exclusively for infants with cleft lip or palate or for infants being fed exclusively though enteral feeding. Data were extracted using a form created a priori and data were reported descriptively. We reviewed 6654 abstracts: 725 were chosen for full-text review and 136 met inclusion. Most studies explored interventions for infants born prematurely (n = 128). Studies were stratified by intervention domain: bridging (n = 91) and feeding/swallowing (n = 45); intervention approach: direct (n = 72), indirect (n = 31), or combination (n = 33); and outcome: feeding performance (n = 125), physiologic stability (n = 40), and swallowing physiology (n = 12). The body of research in infant feeding has grown; however, a need remains for research focused on populations of infants with various medical complexities and for frequently used interventions that lack supporting evidence.

Factors associated with post NICU discharge exclusive breastfeeding rate and duration amongst first time mothers of preterm infants in Shanghai: a longitudinal cohort study

BACKGROUND

Breastfeeding is crucial for the preterm infants. Breast milk is not only food but also medicine. Few studies have focused on the longitudinal effects of exclusive breastfeeding outcome of preterm infants separated from their mothers after discharge, especially in Shanghai. We aimed to examine the exclusive breastfeeding rate and duration amongst first time mothers of preterm infants after discharge and its determinants.

METHODS

Analyses were based on 500 preterm infants separated from their mothers in a tertiary maternity and infant-specialized hospital in Shanghai from September 2018 to September 2019.The Socio-demographic characteristics, breastfeeding knowledge questionnaire, breastfeeding self-efficacy short form scale, Edinburgh postpartum depression scale and breastfeeding family support scale were used for the investigation and the exclusive breastfeeding rate of premature infants was followed up on 1 month, 3 months and 6 months after discharge. The changing trend of breastfeeding knowledge, breastfeeding self-efficacy, postpartum depression and family support were measured by ANOVA at different stages. Using the chi-square test and multiple logistic regression, factors impacting the breastfeeding rate of preterm infants at three time intervals after discharge were investigated. The Kaplan Meier survival curve and cox regression model were used to analyze the determinants of exclusive breastfeeding duration of premature infants after discharge.

RESULTS

Exclusive breastfeeding rates were 19.0, 17.2 and 10.4% at 1 month, 3 months and 6 months after discharge of preterm infants, respectively. The average length of exclusive breastfeeding duration was(3.69 ± 1.80)months. Finally, type of delivery (adjusted odds ratio [AOR] 1.564; 95% confidence interval [CI] 0.513,3.116), gestational age(AOR 0.612, 95% CI 0.236, 3.418), maternal family support (AOR 6.125,95% CI 6.359, 98.452) were discovered to be independent predictors on the exclusive breastfeeding rate at 6 months after preterm infants were discharged. Through the cox regression model, we found that a maternal planned pregnancy (HR 0.681, 95%CI 0.531,0.873), delivering breast milk during hospitalization (HR 0.797, 95%CI 0.412,2.288), NICU feeding mode during hospitalization (HR 1.221, 95%CI 0.128,1.381) and family support (HR 0.561, 95%CI 0.004,2.428) were significantly associated with the exclusive breastfeeding duration after discharge.

CONCLUSIONS

The exclusive breastfeeding outcome of premature infants was affected by many factors, so we should focus on the three levels of individual, family, society and design targeted intervention measures to increase the exclusive breastfeeding rate and prolong exclusive breastfeeding duration.

Variability in Swallowing Biomechanics in Infants with Feeding Difficulties: A Videofluoroscopic Analysis

Clinicians performing feeding evaluations in infants often report swallow variability or inconsistency as concerning. However, little is known about whether this represents pathological incoordination or normal physiologic variance in a developing child. Our retrospective study explored quantitative videofluoroscopic measures in 50 bottle-fed infants (0-9 months) referred with feeding concerns. Our research questions were as follows: Is it possible to assess swallow to swallow variability in an infant with feeding concerns, is there variability in pharyngeal timing and displacement in infants referred for videofluoroscopy, and is variability associated with aspiration risk? Measures were taken from a mid-feed, 20-s loop recorded at 30 frames per second. Each swallow within the 20-s loop (n = 349 swallows) was analysed using quantitative digital measures of timing, displacement and coordination (Swallowtail™). Two blinded raters measured all swallows with strong inter-rater reliability (ICC .78). Swallow frequency, suck-swallow ratio, residue and aspiration were also rated. Variability in timing and displacement was identified across all infants but did not correlate with aspiration (p > .05). Sixteen infants (32%) aspirated. Across the cohort, swallow frequency varied from 1 to 15 within the 20-s loops; suck-swallow ratios varied from 1:1 to 6:1. Within-infant variability in suck-swallow ratios was associated with higher penetration-aspiration scores (p < .001). In conclusion, pharyngeal timing and displacement variability is present in infants referred with feeding difficulties but does not correlate with aspiration. Suck-swallow ratio variability, however, is an important risk factor for aspiration that can be observed at bedside without radiation. These objective measures provide insight into infant swallowing biomechanics and deserve further exploration for their clinical applicability.

25 Years of Research in Human Lactation: From Discovery to Translation

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.

Sucking versus swallowing coordination, integration, and performance in preterm and term infants

Mammalian infants must be able to integrate the acquisition, transport, and swallowing of food to effectively feed. Understanding how these processes are coordinated is critical, as they have differences in neural control and sensitivity to perturbation. Despite this, most studies of infant feeding focus on isolated processes, resulting in a limited understanding of the role of sensorimotor integration in the different processes involved in infant feeding. This is especially problematic in the context of preterm infants, as they are considered to have pathophysiological brain development and often experience feeding difficulties. Here, we use an animal model to study how the different properties of food acquisition, transport, and swallowing differ between term and preterm infants longitudinally through infancy to understand which processes are sensitive to variation in the bolus being swallowed. We found that term infants are better able to acquire milk than preterm infants, and that properties of acquisition are strongly correlated with the size of the bolus being swallowed. In contrast, behaviors occurring during the pharyngeal swallow, such as hyoid and soft palate movements, show little to no correlation with bolus size. These results highlight the pathophysiological nature of the preterm brain and also demonstrate that behaviors occurring during oral transport are much more likely to respond to sensory intervention than those occurring during the "pharyngeal phase."NEW & NOTEWORTHY Physiological maturation of infant feeding is clinically and developmentally significant, but seldom examined as an integrated function. Using longitudinal high-speed videofluoroscopic data, we found that properties of sucking, such as the length of the suck, are more sensitive to swallow physiology than those associated with the pharyngeal swallow itself, such as hyoid excursion. Prematurity impacted the function and maturation of the feeding system, resulting in a physiology that fundamentally differs from term infants by weaning.

No long-term effect of oral stimulation on the intra-oral vacuum in healthy premature infants

AIM

Exclusive breastfeeding is recommended for the first 6 months of life, but the breastfeeding rate in premature infants is low. We examined the effect of oral stimulation on infant's strength of suction and the relation between this intra-oral vacuum and breastfeeding duration.

METHOD

Between 2016 and 2018, 211 infants in a Danish neonatal unit were randomised 1:1 and of these 108 to oral stimulation intervention and 103 to control. Suction was measured as peak vacuum at enrolment and a corrected age of 6 weeks. Breastfeeding duration was registered.

RESULTS

Vacuum increased from enrolment to a corrected age of 6 weeks in all infants, and no effect of oral stimulation intervention was demonstrated P = .08. Infants born ≤32 gestational weeks had lower vacuum compared with infants born after, 350 vs 398 mbar P < .001. For infants born after 32 gestational weeks, the odds ratio for exclusive breastfeeding at 6 months was 1.99 per 100 mbar increase in vacuum P = .01.

CONCLUSION

In our study, infant's intra-oral vacuum increased with age and was not affected by the oral stimulation intervention. For infants born after 32 gestational weeks, the exclusive breastfeeding rate was positively associated with a strong vacuum.

Influence of NICU Nurse Education on Intention to Support Lactation Using Tailored Techniques: A Pilot Study

BACKGROUND

Preterm infants' outcomes improve when fed their mothers' milk. Low percentages of neonatal intensive care unit (NICU) nurses support mothers facing barriers to establishing and sustaining adequate milk supplies. Nurses' motivations and attitudes are instrumental, but understudied, factors in their intention to promote maternal lactation.

PURPOSE

Using the Theory of Reasoned Action, this study explored (1) NICU nurses' attitudes, social pressures, feelings of preparedness, perceptions of comfort, and intention to support lactation; and (2) magnitude of relationships among these concepts before and after undertaking an educational module.

METHODS

A descriptive pre-/postintervention design included a sample of 24 NICU nurses who completed a module, including general lactation and hands-on expressing information. The Nursing Support for Breastfeeding Questionnaire was administered before and after completing the module.

RESULTS

Attitudes, social norms, perception of preparedness, and intention were moderate to high before and after completion of the module. Perception of comfort was moderate. When comparing pre- and postintervention, effect sizes for intention and perception of comfort were moderate. Magnitude of the relationship between attitudes and intention was strong before intervention and moderate after intervention. Subjective norms demonstrated stronger relationships with attitudes and intention after intervention. Preparedness and comfort had stronger relationships with attitudes than with intention both before and after intervention.

IMPLICATIONS FOR PRACTICE

Nurses' attitudes, perception of preparedness, and comfort are modifiable considerations in developing strategies to support evidence-based lactation techniques.

IMPLICATIONS FOR RESEARCH

Additional studies are needed with fully powered and stronger designs to validate findings to guide interventions for nurse support for NICU mothers to optimize lactation.

Iron delivery from liquid-core hydrogels within a therapeutic nipple shield

To aid oral therapeutic administration to infants, a novel delivery technology, referred to as a Therapeutic Nipple Shield (TNS), was previously developed. It consists of a silicone nipple shield device and a dosage form containing a therapeutic (or Active Pharmaceutical Ingredient (API)) to enable delivery during breastfeeding. A range of dosage forms were investigated in past literature, but sufficient API release into human milk had not been achieved. The presented work illustrates the delivery of iron sulphate pentahydrate from liquid-core sodium alginate hydrogels, inserted into a commercially available ultra-thin silicone nipple shield into human milk during in-vitro breastfeeding simulation. Release of iron was quantified employing absorbance measurements of a salicylic assay. An absolute recovery of 44.35 ± 5.43% of loaded iron(III)sulphate pentahydrate was obtained after 10.58 ± 0.09 g of human milk had passed through the nipple shield. This finding is superior to previous investigations involving the delivery of zinc from rapidly disintegrating tablets and non-woven fibres within a TNS. Due to their superior delivery properties, ease of fabrication and cost-efficiency, liquid-core sodium alginate hydrogels consequently represent a promising dosage form for use as part of the TNS. Further improvements can be made to enhance handling stability and shelf-life characteristics.

Effect of vacuum-release teat versus standard teat use on feeding milestones and breastfeeding outcomes in very preterm infants: A randomized controlled trial

Background

Breast milk is important to infant health, yet shorter breastfeeding duration is reported for preterm infants. Both breast and bottle feeds are given in the neonatal unit, with full oral feeding often the last milestone to be achieved prior to discharge home. Unlike standard bottle teats, a vacuum release teat requires the application of negative intra-oral pressure to release milk, and so may facilitate breastfeeding in preterm infants. The objective of this study was to determine the effect of vacuum release teat use on timing of achievement of the first full oral feed and on first completion of 24 h full oral feeds. Feeding method at discharge home, 2 weeks, 6 weeks and 12 weeks corrected gestational age were also examined.

Methods

A randomized controlled trial was completed with mothers of preterm infants born 24–33 weeks gestation in the neonatal unit of a tertiary women’s hospital. Infants were randomized to one of two parallel groups using a vacuum release teat or standard teat for oral feeds when the mother was not available to breastfeed. Test weights were completed for all oral feeds. It was not possible to blind participants, care givers and outcome assessors to group assignment due to the nature of the study.

Results

The groups did not differ with regard to timing of achievement of first full oral feed or 24 h of full oral feeds. Significantly more infants in the vacuum release teat group were exclusively fed breast milk at discharge from hospital and breastfed at 3 months corrected gestational age.

Conclusions

Use of a vacuum release teat when the mother is not available to breastfeed may promote preterm breastfeeding skills, resulting in higher rates of exclusivity and longer breastfeeding duration.

Trial registration

The trial is registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000245594.