Direct Feeding at the Breast Is Associated with Breast Milk Feeding Duration among Preterm Infants

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.

Clinical assessment of breastfeeding in preterm infants

Breastmilk confers empirical benefits for preterm infants, however direct breastfeeding rates in this population remain low. For preterm infants, it may be useful to assess the volume of breastmilk transferred from mother to baby when breastfeeding, particularly during transition to oral feeding when breastfeeding attrition is high. Establishing breastfeeding in preterm infants is complex and without knowledge of milk intake during breastfeeds there is risk of inaccurate feed supplementation with subsequent effects on growth and nutrition. Here we review the evidence for clinical assessments of breastfeeding in preterm infants including test weighing, use of isotope labelled water and clinical observation tools designed to estimate adequacy of breastfeeds. Test weighing is a validated measurement, however requires rigorous protocols and further investigation in small infants. Use of isotope labelled water is a validated technique but, due to sampling requirements, reflects intake over days and weeks instead of individual feeds. Clinical observation tools assessed in preterm infants, have not been shown to reflect volumes of breastmilk intake. While current methods have limitations, the goal is to identify measurement tools to be used as temporary aids to facilitate transition to direct breastfeeding while minimising risk of inaccurate supplementation.

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.

Exploring factors influencing the uptake of kangaroo mother care: key informant interviews with parents

BACKGROUND

The updated World Health Organization (WHO) guideline recommends immediate kangaroo mother care (KMC) for all infants, particularly those born preterm. However, its uptake and sustainability have been unsatisfactory. Therefore, we aimed to gain deeper insight into factors influencing the uptake of KMC practice in our setting, and thereby identify possible solutions for the development of relevant interventions to improve its adoption and make KMC a routine practice for all infants.

METHODS

Using the Triandis model of social behaviour as our framework, we conducted key informant interviews with parents and healthcare providers. Trained interviewers conducted interviews with nine parents, recruited via purposive sampling. These parents were parents of preterm infants who had been introduced to KMC. Data was transcribed and analysed based on Triandis' Theory of Interpersonal Behaviour. This paper only reports the results of the parent interviews.

RESULTS

Major findings were how positive feelings like warmth and contentment, the sense of parenthood with KMC, the benefits of KMC for their infant and parents being enablers for KMC uptake. Conversely, the lack of KMC awareness, the initial negative feelings such as fear, uncertainty and embarrassment, the prioritization of time for milk expression, overcrowding in the ward, lack of space and privacy, limited visiting hours, lack of support and poor communication resulting in misapprehension about KMC were major barriers.

CONCLUSION

A deeper understanding of the factors influencing the uptake of KMC using the Triandis behavioural model provided a way forward to help improve its uptake and sustainability in our settings.

TRIAL REGISTRATION

This study was registered with the National Medical Research Registry (NMRR-17-2984-39191).

Wayfinding through the "ocean of the great unknown": how lactating parents establish a direct breastfeeding relationship with an infant with critical CHD

INTRODUCTION

Lactating parents of infants hospitalised for critical congenital heart disease (CHD) face significant barriers to direct breastfeeding. While experiences of directly breastfeeding other hospitalised neonates have been described, studies including infants with critical CHD are scarce. There is no evidence-based standard of direct breastfeeding care for these infants, and substantial practice variation exists.

AIM

To explain how direct breastfeeding is established with an infant hospitalised for critical CHD, from lactating parents' perspectives.

MATERIALS & METHODS

This study is a qualitative grounded dimensional analysis of interviews with 30 lactating parents of infants with critical CHD who directly breastfed within 3 years. Infants received care from 26 United States cardiac centres; 57% had single ventricle physiology. Analysis included open, axial, and selective coding; memoing; member checking; and explanatory matrices.

RESULTS

Findings were represented by a conceptual model, "Wayfinding through the 'ocean of the great unknown'." The core process of Wayfinding involved a nonlinear trajectory requiring immense persistence in navigating obstacles, occurring in a context of life-and-death consequences for the infant. Wayfinding was characterised by three subprocesses: navigating the relationship with the healthcare team; protecting the direct breastfeeding relationship; and doing the long, hard work. Primary influencing conditions included relentless concern about weight gain, the infant's clinical course, and the parent's previous direct breastfeeding experience.

CONCLUSIONS

For parents, engaging in the Wayfinding process to establish direct breastfeeding was feasible and meaningful - though challenging. The conceptual model of Wayfinding explains how direct breastfeeding can be established and provides a framework for research and practice.

Improving Early Colostrum Administration to Very Low Birth Weight Infants in a Level 3 Neonatal Intensive Care Unit: A Quality Improvement Initiative

OBJECTIVE

To improve our human milk practices by increasing early and sustained use of colostrum as oral immune therapy (OIT) in very low birthweight (VLBW) infants admitted at a level 3 neonatal intensive care unit.

STUDY DESIGN

Using the Institute for Healthcare Improvement's Model for Improvement, several interventions aimed at increasing early OIT administration were implemented. Four key drivers included: optimizing evidence-based OIT guidelines, personnel alignment and engagement, optimal electronic health record use for ordering practices, and timely lactation consultant involvement. The primary outcome measure was early OIT administration, whereas secondary outcome measures examined all OIT administration and human milk at discharge. Process measures included the percentage of staff members who were compliant with OIT protocol.

RESULTS

Early OIT administration increased from a baseline mean of 6% to 55% in the 12-month study period. Percentage of total (early and late) OIT administration to VLBW infants increased from a baseline of 21% to 85%. Average human milk at discharge for VLBW infants remained at 44%, without significant improvement.

CONCLUSIONS

A multidisciplinary quality improvement initiative led to significant improvement in OIT administration to infants at a level 3 neonatal intensive care unit.

Nutrition Management of High-Risk Neonates After Discharge

Nutrition management of the high-risk infant after hospital discharge is complicated by the infant's dysfunctional or immature oral feeding skills, nutritional deficits, and the family's feeding plan. Although evidence is limited, available studies point to developing an individualized nutritional plan, which accounts for these factors; protects and prioritizes the family's plan for breastfeeding; and promotes an acceptable growth pattern. Further research is needed to identify the type and duration of posthospital discharge nutrition to optimize high-risk infant neurodevelopment and body composition. Attention to infant growth, lactation support, and safe feed preparation practices are critical in the transition to home.

Neurodevelopmental Outcomes Among Infants Born Preterm Fed With Mother's Own Milk: A Comparison of Singletons and Twins

OBJECTIVE

To examine associations between early exposure to mother's own milk (MOM) and neurodevelopmental outcomes among preterm infants, and to compare these associations between singletons and twins.

STUDY DESIGN

Retrospective cohort study that included low-risk infants born at <32 weeks gestational age. Nutrition was documented over a 3-day period at mean ages of 14 and 28 days of life; an average of the 3 days was calculated. The Griffiths Mental Development Scales (GMDS) were administered at 12 months corrected age.

RESULTS

Preterm infants (n = 131) with median gestational age of 30.6 weeks were included; 56 (42.7%) were singletons. On days 14 and 28 of life, 80.9% and 77.1% were exposed to MOM, respectively. Exposure rate was comparable, but MOM intake (mL/kg/day) was higher among singletons than among twins (P < .05). At both time points, MOM-exposed infants scored higher on personal-social, hearing-language, and total GMDS assessments than nonexposed infants. These differences were significant for the entire cohort and for twins (P < .05). MOM intake correlated with total GMDS score for both singletons and twins. Any exposure to MOM was associated with additional 6-7 points on total GMDS score or 2-3 additional points for every 50 mL/kg/day of MOM.

CONCLUSIONS

The study supports the positive association between early MOM exposure among low-risk preterm infants and neurodevelopmental outcomes at 12 months corrected age. The differential effects of MOM exposure on singletons vs twins need further exploration.

Patterns of Breastfeeding and Human Milk Feeding in Infants with Single-Ventricle Congenital Heart Disease: A Population Study of the National Pediatric Cardiology Quality Improvement Collaborative Registry

Introduction: Infants with single-ventricle (SV) congenital heart disease (CHD) undergo staged surgical and/or catheter-based palliation and commonly experience feeding challenges and poor growth. Little is known about human milk (HM) feeding or direct breastfeeding (BF) in this population. Aim: To determine (1) HM and BF prevalence for infants with SV CHD, and (2) whether BF at neonatal stage 1 palliation (S1P) discharge is associated with any HM at stage 2 palliation (S2P; ∼4-6 months old). Materials and Methods: Analysis of the National Pediatric Cardiology Quality Improvement Collaborative registry (2016-2021) using (1) descriptive statistics for prevalence, and (2) logistic regression adjusted for multiple variables (e.g., prematurity, insurance, length of stay) to examine early BF/later HM feeding. Results: Participants included 2,491 infants from 68 sites. HM prevalence ranged from 49.3% any/41.5% exclusive before S1P to 37.1% any/7.0% exclusive at S2P. Direct BF ranged from 16.1% any/7.9% exclusive before S1P to 9.2% any/3.2% exclusive at S2P discharge. Prevalence varied among sites; for example, 0-100% any HM before S1P. Infants BF at S1P discharge had greater odds of any HM (odds ratio = 4.11, 95% confidence interval [CI] = 2.79-6.07, p < 0.001) and exclusive HM (1.85, 95% CI 1.03-3.30, p = 0.039) at S2P. Conclusions: The prevalence of HM and BF for infants with SV CHD was low and declined over time. Direct BF at S1P discharge was associated with increased odds of any HM at S2P. Wide variation suggests that site-specific practices impact feeding outcomes. HM and BF prevalence are suboptimal in this population, and identification of supportive institutional practices is needed.

Longitudinal Follow-up of Preterm Breastfeeding to 12 Weeks Corrected Gestational Age

BACKGROUND

Preterm infants have shorter breastfeeding duration than that of term infants. Details of postdischarge feeding methods and difficulties are needed to inform the care of preterm breastfeeding dyads.

PURPOSE

To describe postdischarge breastfeeding characteristics of mother-preterm infant dyads up to 12 weeks corrected gestational age (CGA).

METHODS

A prospective observational study of preterm dyads (birth 24-33 weeks' gestation) that fed their mother's own milk (MOM) at discharge from a neonatal unit in Perth, Western Australia. Feeding method and frequency, breastfeeding duration, difficulties, and nipple shield use were recorded at 2, 6, and 12 weeks CGA.

RESULTS

Data were obtained for 49 mothers (singleton infant n = 39, twins n = 10). At 12 weeks CGA, 59% fed any MOM with 47% exclusively fed MOM and 31% fully breastfed. Nipple shield use reduced from 42% at 2 weeks CGA to 11% at 12 weeks CGA. Compared with mothers who exclusively fed MOM at discharge (n = 41) those who fed both MOM and infant formula (n = 8) were more likely to wean before 12 weeks CGA ( P < .001). Weaning occurred before 2 weeks CGA in 12/19 (63%), with low milk supply the most frequently cited reason.

IMPLICATIONS FOR PRACTICE

Most mothers with a full milk supply at discharge successfully transition to predominant breastfeeding. Frequent milk removal needs to be prioritized throughout the preterm infant's hospital stay.

IMPLICATIONS FOR RESEARCH

Examination of facilitators and barriers to early and continued frequent milk removal across the postpartum period is required to identify strategies to optimize lactation after preterm birth.

Early Enteral Feeding of the Preterm Infant-Delay until Own Mother's Breastmilk Becomes Available? (Israel, 2012-2017)

AIM

To consider the question of whether to initiate trophic feeds with formula in the absence of own mother's breastmilk or to wait for breastmilk to be available.

METHODS

A retrospective study of infants born prior to 32 weeks of gestation during the period 2012-2017 at a single tertiary center in Tel Aviv, Israel. Three TF groups were defined: exclusive breastmilk, mixed, and exclusive formula. Univariate and multivariate analyses were conducted. Logistic regression was used, and adjusted odds ratio and 95% interval were reported.

RESULTS

Univariate analysis demonstrated that infants in the exclusive breastmilk group were born earlier, had lower birth weights and lower Apgar scores, were given lower volumes of TF, and were more likely to have a longer hospital stay. Poor composite outcome was more common among the exclusive breastmilk group. Multivariate regression analysis revealed no differences in incidence of early neonatal morbidities between the groups, except for longer duration of parenteral nutrition in the exclusive breastmilk group.

CONCLUSION

In our cohort, exclusive formula TF was not associated with increased risk of any of the studied morbidities. Clinicians should consider this finding in deciding between early TF or fasting while waiting for own mother's breastmilk.

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.

Pilot Study of Sham Feeding in Postoperative Neonates

OBJECTIVE

Sham feeding may enhance development of oral skills in neonates after bowel surgery and decrease stress levels in mothers. In this pilot study, we test the feasibility of sham feeding, identify safety hazards, and assess maternal satisfaction.

STUDY DESIGN

A convenience sample of 15 postoperative neonates was enrolled. Sham feeding with unfortified human milk was offered following a strict advancement protocol beginning with 5 mL once daily and increasing up to 30 mL, three times daily. Continuous gastric suction was used during sham feeding. Each mother completed a satisfaction survey. Sham-fed gastroschisis patients were compared with a historic cohort.

RESULTS

All 15 patients were able to sham feed. A total of 312 sham feeds were offered with a median of 23 sham events per patient. Four minor complications occurred during sham feeding. No differences were noted between 11 sham-fed gastroschisis patients and 81 historic controls. The mothers reported a decrease in stress after sham feeding using a 5-point score (3.8 ± 1.4 vs. 1.5 ± 0.7, p < 0.005) and 100% satisfaction with sham feeding.

CONCLUSION

Sham feeding is feasible for neonates after bowel surgery and is highly rated by mothers.

KEY POINTS

· Sham-feeding human milk to neonates after bowel surgery is feasible and safe.. · A novel postoperative sham feeding protocol is described.. · Mothers of sham-fed infants report it reduces stress compared with not feeding..

A prospective cohort study on lactation status and breastfeeding challenges in mothers giving birth to preterm infants

Background

Mothers of preterm infants face many challenges in breastfeeding, especially regarding lactation. This study aimed to investigate the lactation status and challenges in breastfeeding faced by preterm infants’ mothers.

Methods

We approached 124 mothers who gave birth to preterm infants between 26 May and 31 October 2018 in a tertiary hospital in China. Lactation status and challenges in breastfeeding on day 7 postpartum, at discharge of infants, 2 weeks post-discharge, and 3 months of corrected age were collected using questionnaires. The area under the receiver operating characteristic (ROC) curve for expressed milk volume on day 7 postpartum for predicting expressed milk volume ≥ 300 mL/d at discharge was calculated. Logistic regression analyses were performed to identify factors associated with delayed lactogenesis II onset and continuation of breastfeeding at 3 months of corrected age.

Results

Seventy mothers were enrolled, and 51.4% had delayed lactogenesis II. Multivariate logistic regression analysis revealed that older maternal age (aOR = 1.19; 95% CI: 1.01, 1.40) and first live birth (aOR = 4.81; 95% CI 1.43, 16.18) were significant independent predictors of delayed lactogenesis II. Mothers with delayed lactogenesis II had significantly lower expressed milk volume (day 7 postpartum: 160.0 mL vs. 300.0 mL, U = 328.50, p = 0.001; at discharge: 425.0 mL vs. 612.5 mL, U = 372.00, p = 0.005), with a lower proportion of exclusive breastfeeding in their infants (at discharge: 33.3% vs. 69.8%, χ² = 12.39, df = 1, p < 0.001; 3 months of corrected age: 17.8% vs. 52.8%, χ² = 11.03, df = 1, p = 0.001). The ROC showed that expressed milk volume > 190 mL/d on day 7 postpartum significantly predicted expressed milk volume ≥ 300 mL/d at discharge. Insufficient human milk was the main reason for breastfeeding discontinuation at 3 months of corrected age. Twins were less likely to continue breastfeeding at 3 months of corrected age (aOR = 0.27; 95% CI 0.09, 0.86). In singleton infants, mother’s own milk ≥50% of total milk uptake at 2 weeks post-discharge (aOR = 32.66; 95% CI 3.00, 355.25) was an independent predictor of continuous breastfeeding at 3 months of corrected age. Feeding complications in infants, poor breastfeeding technique, and low milk output are the main challenges in breastfeeding.

Conclusion

Interventions to improve early postpartum lactation and breastfeeding techniques may increase breastfeeding adoption in mothers of preterm infants.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00447-4.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Feeding Twins with Human Milk and Factors Associated with Its Duration: A Qualitative and Quantitative Study in Southern Italy

BACKGROUND

Over the past year, there has been a rise in twin births. The current scientific consensus recommended breast-feed milk for all newborns for at least 6 months. They stated that it is possible to meet the nutritional needs of two or more newborns with only one mother's milk. More information would be desirable about the factors that influence or lead to the initiation and interruption of breastfeeding. The quality of the evidence available from multiple studies has been inconclusive and therefore led to controversial interpretations and practices.

AIMS

The first aim of this study was to analyze the extent of the feeding of multiples with breast milk in the experience of our clinical unit in terms of incidence and duration. The second objective was to evaluate the correlation between maternal, perinatal and neonatal variables with breast milk feeding rates and duration.

METHODS

The study was conducted between 2015 and 2020, in a NICU in Southern Italy (San Giovanni Rotondo, Foggia). Sixty-one women who have given birth to multiples were enrolled into the study. Newborn data were retrospectively collected by informatic database and breastfeeding information were collected by a questionnaire.

RESULTS

In our centre, the percentage of twins out of the total number of births over the years has almost doubled from 1.28% in 2015 to 2.48% in 2020 and the 88% of twins are premature. 18.1% received breast milk for more than 6 months and 6.3% received it for more than 12 months. Infants of lower gestational age and weight, born to multiparous, more mature and medium-high schooling mothers received breast milk for a longer period. 35% of women explained that the interruption of breastfeeding was due to the insufficient milk production and 41% to the stress and difficulties in managing the twins. Qualitative analysis of maternal narrative revealed, for many of them, the awareness of the importance of breastfeeding and the efforts made to try to give breast milk, but also fears about the quantity of milk and satiety of their children.

CONCLUSIONS

It is important to identify the factors both favoring and obstructing maternal milk feeding of multiples and it would be desirable the activation of a network of training and support for mothers after discharge, with particular regard to the categories found to be less inclined.

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.

Breastfeeding initiation among women with preeclampsia with and without severe features

BACKGROUND

Timely delivery and magnesium sulfate (MgSO4) are mainstay in the treatment of preeclampsia with severe features (PWSF). Premature delivery, severity of illness and mother-infant separation may increase the risk for breastfeeding (BF) initiation failure.

OBJECTIVE

To compare BF initiation among women with late-onset PWSF treated with MgSO4 to women with late-onset preeclampsia without severe features (WOSF) who did not receive MgSO4.

METHODS

Retrospective study of 158 women with PWSF and 104 with WOSF who delivered at ≥34 weeks. Intention to BF, formula feed (FF) or partially BF was declared prenatally. At discharge, exclusive BF included direct BF or direct BF with expressed breast milk (EBM).

RESULTS

PWSF and WOSF groups were similar in age, race, and obstetric history. PWSF and WSOF differed in primiparity (65 & 51%), late preterm births (73 vs 15%), admission to NICU (44 &17%) and mother (5 & 4d) and infant (6 & 3d) hospital stay. Both groups were similar in intention to BF (80 & 84%), to FF (16 & 13%) and to partially BF (5 & 5%). At discharge, exclusive BF (37 & 39%), partial BF (33 & 31%) and FF (30 & 30%) were similar. Exclusive BF in the PWSF group was 43% direct BF, 28% direct BF and EBM and 29% EBM alone whereas in the WOSF group exclusive BF was 93% direct BF and 7% direct BF and EBM.

CONCLUSION

BF initiation rates for women with PWSF and WOSF were similar. EBM alone or with direct BF enabled infants in the PWSF group to exclusively BF at discharge.

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.

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.

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.

Breastfeeding progression in late preterm infants from birth to one month

This study aimed to describe and compare breastfeeding progression, infants' feeding behaviours, maternal feeding difficulties, and mothers' usage of breastfeeding interventions for singleton late preterm (LPT) and term infants. A further aim was to identify associated factors for exclusive breastfeeding at breast at 1 month in LPT infants. This was a cohort study where mothers of LPT infants from a neonatal unit (n = 60), LPT infants from a maternity unit (n = 62), and term infants from a maternity unit (n = 269) answered a questionnaire approximately 1 month after delivery. Findings showed no significant differences in exclusive breastfeeding at breasts between LPT infants admitted to the neonatal unit compared with the maternity unit, during the first week at home (38% vs. 48%), or at 1 month of age (52% vs. 50%). Term infants were more likely to be exclusively breastfed at the breast (86% and 74%, p < 0.05) compared with LPT infants. Multiple regression analysis showed that usage of a nipple shield, not feeding breast milk exclusively during the first week at home, or feeding less than 10 times per day at 1 month were statistically significant for not exclusively breastfeed at the breast. A protective factor was the mothers' experience of having an abundance of milk during the first week at home. In conclusion, LPT infants are less likely to be exclusively breastfed at the breast than term infants, highlighting the need for further research to guide interventions aimed at optimising exclusive breastfeeding rates.

Breastfeeding Disparities between Multiples and Singletons by NICU Discharge

Multiple pregnancy increases the risk of a range of adverse perinatal outcomes, including breastfeeding failure. However, studies on predictive factors of breastfeeding duration in preterm twin infants have a conflicting result. The purpose of this observational study was to compare feeding practices, at hospital discharge, of twin and singleton very low birth weight infants. The study is part of a prospective survey of a national Spanish cohort of very low birth weight infants (SEN1500) that includes 62 neonatal units. The study population comprised all infants registered in the network from 2002 to 2013. They were grouped into singletons and multiples. The explanatory variables were first analyzed using univariate models; subsequently, significant variables were analyzed simultaneously in a multiple stepwise backward model. During the twelve-year period, 32,770 very low birth weight infants were included in the database, of which 26.957 were discharged alive and included in this analysis. Nine thousand seven hundred and fifty-eight neonates were multiples, and 17,199 were singletons. At discharge, 31% of singleton infants were being exclusively breastfed, 43% were bottle-fed, and 26% were fed a combination of both. In comparison, at discharge, only 24% of multiple infants were exclusively breastfed, 43% were bottle-fed, and 33% were fed a combination of both (p < 0.001). On multivariable analysis, twin pregnancy had a statistically significant, but small effect, on cessation of breastfeeding before discharge (OR 1.10; 95% CI: 1.02, 1.19). Risks of early in-hospital breastfeeding cessation were also independently associated with multiple mother-infant stress factors, such as sepsis, intraventricular hemorrhage, retinopathy, necrotizing enterocolitis, intubation, and use of inotropes. Instead, antibiotic treatment at delivery, In vitro fertilization and prenatal steroids were associated with a decreased risk for shorter in-hospital breastfeeding duration. Multiple pregnancy, even in the absence of pathological conditions associated to very low birth weight twin infants, may be an impeding factor for in-hospital breastfeeding.

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.

Breastfeeding outcomes in European NICUs: impact of parental visiting policies

OBJECTIVE

The documented benefits of maternal milk for very preterm infants have raised interest in hospital policies that promote breastfeeding. We investigated the hypothesis that more liberal parental policies are associated with increased breastfeeding at discharge from the neonatal unit.

DESIGN

Prospective area-based cohort study.

SETTING

Neonatal intensive care units (NICUs) in 19 regions of 11 European countries.

PATIENTS

All very preterm infants discharged alive in participating regions in 2011-2012 after spending >70% of their hospital stay in the same NICU (n=4407).

MAIN OUTCOME MEASURES

We assessed four feeding outcomes at hospital discharge: any and exclusive maternal milk feeding, independent of feeding method; any and exclusive direct breastfeeding, defined as sucking at the breast. We computed a neonatal unit Parental Presence Score (PPS) based on policies regarding parental visiting in the intensive care area (range 1-10, with higher values indicating more liberal policies), and we used multivariable multilevel modified Poisson regression analysis to assess the relation between unit PPS and outcomes.

RESULTS

Policies regarding visiting hours, duration of visits and possibility for parents to stay during medical rounds and spend the night in unit differed within and across countries. After adjustment for potential confounders, infants cared for in units with liberal parental policies (PPS≥7) were about twofold significantly more likely to be discharged with exclusive maternal milk feeding and exclusive direct breastfeeding.

CONCLUSION

Unit policies promoting parental presence and involvement in care may increase the likelihood of successful breastfeeding at discharge for very preterm infants.

Profile of at-risk newborns attended by nurses in outpatient follow-up clinic: a retrospective cohort study

OBJECTIVE

to analyze the cohort profile of at-risk newborns attended by nurses in a multidisciplinary follow-up clinic, with emphasis on the type of feeding and weight gain, after hospital discharge.

METHOD

retrospective cohort, whose population is composed of at-risk newborns attended in a 4-year period. Data came from medical records and attendance report, later exported to R Program. The outcome variables were number of the nursing consultation, type of feeding, daily weight gain and main guidelines. We used descriptive statistics, frequency distribution and applied Mann-Whitney, Chi-Square, Spearman correlation, Variance and Tukey analysis, with p <0.05 being significant.

RESULTS

a total of 882 consultations with 629 infants and families were analyzed. The frequencies of exclusive breastfeeding and weight gain increased as the consultations progressed. The infants who needed more consultations and with lower weight gain were those with lower gestational age (p = 0.001) and birth weight (p = 0.000), longer length of hospital stay (p <0.005), and diagnoses related to extreme prematurity (p <0.05), among others.

CONCLUSION

nurses verified the importance of outpatient follow-up of at-risk newborns, especially in promoting breastfeeding and healthy growth.

Breastfeeding woman or lactating object? A critical philosophical discussion on the influence of Cartesian dualism on breastfeeding in the neonatal intensive care unit

AIM

This discursive paper aims to bring to the foreground the ongoing influence of Cartesian dualism and other important contextual complexities on breastfeeding in the neonatal intensive care unit (NICU).

BACKGROUND

Breastfeeding is widely supported as the optimal form of nutrition for the first 6 months of life and beyond. Amidst a myriad of contextual factors, current breastfeeding rates are below globally targeted goals. For premature and/or critically ill infants, the importance of receiving breast milk is often encouraged based on its immunological and nutritive benefits as opposed to the entirety of the breastfeeding interaction, underscoring the influence of dualism in the NICU.

DESIGN

The impact of Cartesian dualism and other sociocultural underpinnings of breastfeeding focused within the NICU environment are illustrated through a critical, philosophical discussion.

METHODS

Relevant historical context is provided followed by an overview of the realities of contemporary breastfeeding. These are presented as a frame of reference for the NICU breastfeeding experiences currently encountered by many mothers of preterm and critically ill neonates, further illustrated using a clinical exemplar as well as the author's own observations from neonatal nursing practice.

RELEVANCE TO CLINICAL PRACTICE

Shifting away from a dualistic approach requires rethinking breastfeeding support interactions between NICU nurses and mothers. To address the disembodied and often mechanistic approach to care inherent in the dominant Western medical model, a relational approach to breastfeeding support in the NICU is suggested and discussed.

CONCLUSION

Future research from a more critical lens is needed to examine the complex dynamics involved when nurses and mothers are negotiating decisions and processes related to infant feeding. In focusing on the relational dimensions of the breastfeeding experience, nurses can resist the dualistic influence and dominant discourses impacting infant feeding and motherhood in the 21st century.

Mother⁻Infant Physical Contact Predicts Responsive Feeding among U.S. Breastfeeding Mothers

Responsive feeding—initiating feeding in response to early hunger cues—supports the physiology of lactation and the development of infant feeding abilities, yet there is a dearth of research examining what predicts responsive feeding. In non-Western proximal care cultures, there is an association between responsive feeding and mother–infant physical contact, but this has not been investigated within Western populations. In two studies, we tested whether mother–infant physical contact predicted feeding in response to early hunger cues versus feeding on a schedule or after signs of distress among U.S. breastfeeding mothers. With an online questionnaire in Study 1 (n = 626), physical contact with infants (via co-sleeping and babywearing) predicted increased likelihood of self-reported responsive feeding. Mothers who reported responsive feeding were more likely to exclusively breastfeed for the first six months, breastfeed more frequently throughout the day, and had a longer planned breastfeeding duration than mothers who reported feeding on a schedule or after signs of infant distress. In Study 2 (n = 96), a three-day feeding log showed that mother–infant physical contact predicted feeding in response to early hunger cues but mother–infant proximity (without physical contact) did not. In sum, our results demonstrate that physical contact with infants may shape breastfeeding behavior among U.S. mothers, highlighting a connection between social interaction and infant nutrition that warrants further investigation.

Low breastfeeding continuation to 6 months for very preterm infants: A European multiregional cohort study

Breastfeeding confers multiple benefits for the health and development of very preterm infants, but there is scarce information on the duration of breastfeeding after discharge from the neonatal intensive care unit (NICU). We used data from the Effective Perinatal Intensive Care in Europe population-based cohort of births below 32 weeks of gestation in 11 European countries in 2011-2012 to investigate breastfeeding continuation until 6 months. Clinical and sociodemographic characteristics were collected from obstetric and neonatal medical records as well as parental questionnaires at 2 years of corrected age. Among 3,217 ever-breastfed infants, 34% were breastfeeding at 6 months of age (range across countries from 25% to 56%); younger and less educated mothers were more likely to stop before 6 months (adjusted relative risk [aRR] <25 years: 0.68, 95% CI [0.53, 0.88], vs. 25-34 years; lower secondary: 0.58, 95% CI [0.45, 0.76] vs. postgraduate education). Multiple birth, bronchopulmonary dysplasia (BPD), and several neonatal transfers reduced the probability of continuation but not low gestational age, fetal growth restriction, congenital anomalies, or severe neonatal morbidities. Among infants breastfeeding at discharge, mixed versus exclusive breast milk feeding at discharge was associated with stopping before 6 months: aRR = 0.60, 95% CI [0.48, 0.74]. Low breastfeeding continuation rates in this high-risk population call for more support to breastfeeding mothers during and after the neonatal hospitalization, especially for families with low socio-economic status, multiples, and infants with BPD. Promotion of exclusive breastfeeding in the NICU may constitute a lever for improving breastfeeding continuation after discharge.

Winging it: maternal perspectives and experiences of breastfeeding newborns with complex congenital surgical anomalies

OBJECTIVE

To describe the experience of breastfeeding (inclusive of breast milk expression/pumping, provision of breast milk via devices, and at-breastfeeding) among mothers of newborns with complex congenital surgical anomalies and the contexts under which pro-breastfeeding behaviors and attitudes are facilitated or compromised.

STUDY DESIGN

We used qualitative description to analyze 23 interviews conducted with 15 mothers of newborns undergoing surgery for gastrointestinal, cardiac, or neural tube defects.

RESULTS

Breastfeeding experiences were characterized by naivety regarding the importance and rationale for exclusive breast milk feedings and best practices to facilitate milk supply maintenance and transition to at-breast feeds. Maternal breastfeeding views and behaviors were impacted by indeterminate prenatal plans to breastfeed/provide breast milk, limited prior breastfeeding exposure and knowledge, and gaps in postnatal lactation support.

CONCLUSION

Future research should investigate methods to improve exclusive breast milk feeding and facilitate transitions to at-breast feeds among mothers of newborns with surgical congenital anomalies, with consideration of identified barriers.