A review of the literature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants

Predictors of Breastfeeding among Patients Admitted with Preterm Prelabor Rupture of Membranes

OBJECTIVE

 We sought to describe rates of breastmilk feeding (BF) at hospital discharge and 6 weeks postpartum and to identify risk factors for noninitiation or cessation among pregnancies complicated by preterm prelabor rupture of membranes (PPROM).

STUDY DESIGN

 Retrospective cohort study of pregnant persons with PPROM admitted to a single tertiary center (2013-2019). Patients with deliveries complicated by intrauterine or neonatal demise or with incomplete BF data were excluded. Demographic, antepartum, and delivery characteristics were evaluated. Primary analysis identified rate of BF initiation at maternal discharge and factors associated with noninitiation. Secondary analysis evaluated BF continuation and factors associated with cessation at 6 weeks postpartum. Bivariate statistics were used to compare characteristics and logistic regression was used to estimate adjusted odds ratios (aOR).

RESULTS

 Of 397 patients with PPROM, 342(86%) initiated BF prior to discharge. Those reporting tobacco use in pregnancy were less likely to initiate BF (aOR: 0.32; 95% confidence interval [CI]: 0.16, 0.64). In contrast, private insurance (aOR: 2.53; 95% CI: 1.19, 5.37) and pregnancy latency ≥ 14 days (aOR: 3.02; 95% CI: 1.09, 8.38) were associated with BF initiation at hospital discharge. Of the 293 patients with postpartum follow-up, only 214 (73%) had BF continuation at 6 weeks postpartum. Maternal age <20 years (aOR: 0.07; 95% CI: 0.01, 0.68) and multiparity (aOR: 0.54; 95% CI: 0.29, 0.99) were associated with BF cessation. Patients with private insurance were observed to have increased odds of BF continuation (aOR: 2.10; 95% CI: 1.07, 4.12).

CONCLUSION

 Among patients with PPROM, tobacco use may be associated with noninitiation of BF prior to discharge, whereas age < 20 years and multiparity were associated with cessation by 6 weeks postpartum. Longer pregnancy latency ≥ 14 days was associated with BF initiation prior to discharge. Private insurance was associated with increased rates of BF initiation and continuation postpartum. BF education and support should be offered to all patients admitted for PPROM.

KEY POINTS

· Tobacco use may be associated with BF noninitiation.. · Young age and multiparity are linked with BF cessation.. · Private insurance resulted in BF initiation and continuation..

Predictors of Breastfeeding among Women Admitted with Severe Preeclampsia Before 34 Weeks

OBJECTIVE

 Patients with severe preeclampsia (sPREX) face barriers to successful breastfeeding (BF), including an increased risk of maternal and newborn complications, prematurity, and low birth weight. Patients with early-onset sPREX (before 34 weeks' gestation) may be at even greater risk, yet there are little data available on factors associated with BF challenges in this population. We describe rates of BF initiation at hospital discharge and BF continuation at postpartum (PP) visit and identify factors associated with BF noninitiation and BF cessation among patients admitted with early-onset sPREX.

STUDY DESIGN

 Retrospective cohort study of women with sPREX admitted at less than 34 weeks' gestation to a single tertiary center (2013-2019). Demographic, antepartum, and delivery characteristics were evaluated. Factors associated with BF noninitiation at maternal discharge and with BF cessation at routine PP were assessed. Patients with intrauterine or neonatal demise and those missing BF data were excluded. Bivariate statistics were used to compare characteristics and Poisson regression was used to estimate relative risks (RR).

RESULTS

 Of 255 patients with early-onset sPREX, 228 (89.4%) had BF initiation at maternal hospital discharge. Initiation of BF occurred less frequently among patients with tobacco use in pregnancy (7.5 vs. 37.0%, χ2 p < 0.001, RR: 0.69 [95% confidence interval, CI: 0.52-0.92]). At 6 weeks' PP, 159 of 199 (79.9%) patients had BF continuation. Maternal age under 20 years (1.9 vs. 17.5%, χ2 p = 0.01, RR: 0.36 [95% CI: 0.14-0.91]) and experiencing maternal morbidity (25.2 vs. 45.0%, χ2 p = 0.01, RR: 0.80 [95% CI: 0.66-0.96]) were associated with BF cessation at the PP visit.

CONCLUSION

 Among patients with early sPREX, tobacco use in pregnancy was associated with noninitiation of BF at discharge, whereas young maternal age and maternal morbidity were associated with cessation of BF by routine PP visit. Further research is needed on how to support BF in this population, especially among patients with these associated factors.

KEY POINTS

· Tobacco use was associated with BF noninitiation in patients with early preeclampsia.. · Maternal age < 20 and maternal morbidity were associated with BF cessation by PP visit.. · BF support for patients with risk factors is important for BF success PP..

East Meets West: Effect of Acupuncture on Lactation and Maternal Quality of Life

Objective: To evaluate the impact of acupuncture as part of a traditional Chinese medicine (TCM) treatment plan on lactation and maternal well-being in pump-dependent mothers of hospitalized neonates during the first 30 days after delivery. Study Design: This single-center study was conducted in a level IV regional neonatal intensive care unit with access to integrative health services. Sixty-six mothers were prospectively enrolled in two nonparallel groups: (1) Standard lactation support and (2) standard lactation support augmented with acupuncture. Daily pump volumes were documented. Participants completed a quality-of-life (QOL) survey at baseline and neonatal day of life 30. A linear model was constructed, adjusting for increased milk production over time. Results: Acupuncture was associated with increased milk production at all time points: Day 10 (p = 0.0002), day 14 (p < 0.0001), day 21 (p < 0.0001), and day 30 (p < 0.0001). Acupuncture was associated with an increase in three of five QOL components: psychological/child's health (p = 0.0006), family/friend relationship (p = 0.0006), and health/functioning (p = 0.02). Conclusion: Mothers receiving acupuncture reported enhanced milk supply and improved QOL. The limited sample size restricts the broad applicability of the results; nonetheless, this study paves the way for further research on the advantages of merging Eastern and Western treatments to enhance human lactation.

Skin-to-skin contact for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

BACKGROUND

Skin-to-skin contact between mother and infant after birth is recommended to promote breastfeeding and maternal-infant bonding. However, its impact on the incidence of neonatal hypoglycaemia is unknown. We conducted a systematic review and meta-analysis to assess this.

METHODS

Published randomised control trials (RCTs), quasi-RCTs, non-randomised studies of interventions, cohort, or case-control studies with an intervention of skin-to-skin care compared to other treatment were included without language or date restrictions. The primary outcome was neonatal hypoglycaemia (study-defined). We searched 4 databases and 4 trial registries from inception to May 12th, 2023. Quality of studies was assessed using Cochrane Risk of Bias 1 or Effective Public Health Practice Project Quality Assessment tools. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Results were synthesised using RevMan 5.4.1 or STATA and analysed using random-effects meta-analyses where possible, otherwise with direction of findings tables. This review was registered prospectively on PROSPERO (CRD42022328322).

RESULTS

This review included 84,900 participants in 108 studies, comprising 65 RCTs, 16 quasi-RCTs, seven non-randomised studies of intervention, eight prospective cohort studies, nine retrospective cohort studies and three case-control studies. Evidence suggests skin-to-skin contact may result in a large reduction in the incidence of neonatal hypoglycaemia (7 RCTs/quasi-RCTs, 922 infants, RR 0.29 (0.13, 0.66), p < 0.0001, I2 = 47%). Skin-to-skin contact may reduce the incidence of admission to special care or neonatal intensive care nurseries for hypoglycaemia (1 observational study, 816 infants, OR 0.50 (0.25-1.00), p = 0.050), but the evidence is very uncertain. Skin-to-skin contact may reduce duration of initial hospital stay after birth (31 RCTs, 3437 infants, MD -2.37 (-3.66, -1.08) days, p = 0.0003, I2 = 90%, p for Egger's test = 0.02), and increase exclusive breastmilk feeding from birth to discharge (1 observational study, 1250 infants, RR 4.30 (3.19, 5.81), p < 0.0001), but the evidence is very uncertain.

CONCLUSION

Skin-to-skin contact may lead to a large reduction in the incidence of neonatal hypoglycaemia. This, along with other established benefits, supports the practice of skin-to-skin contact for all infants and especially those at risk of hypoglycaemia.

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.

Smartphone-Based Video Antenatal Preterm Birth Education: The Preemie Prep for Parents Randomized Clinical Trial

Importance

Preterm birth is a leading cause of infant mortality and child morbidity. Preterm birth is not always unexpected, yet standard prenatal care does not offer anticipatory education to parents at risk of delivering preterm, which leaves parents unprepared to make health care choices during the pregnancy that can improve survival and decrease morbidity in case of preterm birth.

Objective

To evaluate the effect of the Preemie Prep for Parents (P3) program on maternal knowledge of preterm birth, preparation for decision-making, and anxiety.

Design, Setting, and Participants

Recruitment for this randomized clinical trial conducted at a US academic medical center took place from February 3, 2020, to April 12, 2021. A total of 120 pregnant persons with a risk factor for preterm birth were enrolled between 16 and 21 weeks' gestational age and followed up through pregnancy completion.

Intervention

Starting at 18 weeks' gestational age, P3 program participants received links delivered via text message to 51 gestational age-specific short animated videos. Control participants received links to patient education webpages from the American College of Obstetricians and Gynecologists.

Main Outcomes and Measures

At 25 weeks' gestation, scores on the Parent Prematurity Knowledge Questionnaire (scored as percent correct), Preparation for Decision Making Scale (scored 0-100), and Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety computerized adaptive test. Analysis was based on an intention to treat.

Results

A total of 120 pregnant participants (mean [SD] age, 32.5 [4.9] years) were included in the study; 60 participants were randomized to each group. Participants in the P3 group scored higher than those in the control group on knowledge of long-term outcomes at 25 weeks (88.5% vs 73.2%; estimated difference, 15.3 percentage points; 95% CI, 8.3-22.5 percentage points; P < .001). Participants in the P3 group reported being significantly more prepared than did participants in the control group for neonatal resuscitation decision-making at 25 weeks (Preparation for Decision Making Scale score, 76.0 vs 52.3; difference, 23.7; 95% CI, 14.1-33.2). There was no difference between the P3 group and the control group in anxiety at 25 weeks (mean [SE] PROMIS Anxiety scores, 53.8 [1.1] vs 54.0 [1.1]; difference, -0.1; 95% CI, -3.2 to 2.9).

Conclusions and Relevance

In this randomized clinical trial, pregnant persons randomly assigned to the P3 program had more knowledge of core competencies and were more prepared to make decisions that affect maternal and infant health, without experiencing worse anxiety. Mobile antenatal preterm birth education may provide a unique benefit to parents with preterm birth risk factors.

Trial Registration

ClinicalTrials.gov Identifier: NCT04093492.

Human Milk Fatty Acid Composition and Its Effect on Preterm Infants' Growth Velocity

This study aimed to analyze the fatty acid content in human milk and to find its relationship with the growth velocity of preterm infants. Mature milk samples from 15 mothers of preterm infants were collected from three different hospitals, followed by lipid extraction, fatty acid methylation, and finally gas chromatography analysis to determine the fatty acids composition. The average total lipid content was 3.61 ± 1.57 g/100 mL with the following classes of fatty acids: saturated fatty acids 43.54 ± 11.16%, unsaturated fatty acids 52.22 ± 10.89%, in which monounsaturated fatty acids were 36.52 ± 13.90%, and polyunsaturated fatty acids were 15.70 ± 7.10%. Polyunsaturated fatty acid sub-class n-6 was 15.23 ± 8.23% and n-3 was 0.46 ± 0.18%. Oleic acid, palmitic acid, and linoleic acid were the most abundant fatty acids. The n-6/n-3 ratio was 32.83:1. EPA and DHA fatty acids were not detected. As gestational age and birth weight increase, C20:2n6 content increases. The growth velocity increases with the decrement in C16 and increment in C20:2n6. The lipid profile of preterm human milk was found to be low in some essential fatty acids, which may affect the quality of preterm infants' nutrition.

Predictive factors of exclusive breastfeeding attrition at Week 6 post-partum among mothers of preterm infants based on the theory of planned behaviour

Breastfeeding plays an important role in the growth and development of preterm infants, and exclusive breastfeeding (EBF) in the first 6 weeks post-partum is the key to continuous breastfeeding. This study was designed to explore the influencing factors that contribute to breastfeeding attrition among mothers of preterm infants at Week 6 post-partum based on the theory of planned behaviour (TPB). We herein adopted a prospective observational study design in which 97 mothers who exclusively breastfed at Week 6 post-partum at a tertiary specialised hospital in Shanghai from June 2021 to February 2022 were taken as the EBF group, and 179 mothers without EBF were assigned to the EBF attrition group. Through an extensive literature review and expert consultation, we determined the possible factors influencing EBF attrition, analysed those factors that showed statistical significance in our univariate analysis by applying binary logistic regression, and constructed a nomogram model for predicting EBF attrition. The results revealed that negative breastfeeding sentiment (odds ratio [OR] = 1.006; 95% confidence interval [CI], 1.000-1.011) generated a greater risk of breastfeeding attrition. However, positive breastfeeding sentiment (OR = 0.991; 95% CI, 0.983-0.999), social and professional support (OR = 0.993; 95% CI, 0.987-0.999), breastfeeding control (OR = 0.945; 95% CI, 0.896-0.996), knowledge (OR = 0.893; 95% CI, 0.799-0.998), and intention to EBF at Week 6 post-partum (OR = 0.522; 95% CI, 0.276-0.988) were the protective factors and facilitated the development of our nomogram model. The Hosmer-Lemeshow goodness-of-fit test generated a χ² value of 11.344 (p = 0.183) and an area under the curve of 0.822 (95% CI, 0.771-0.873). The C-index was 0.800 in the internal bootstrap validation, indicating that the nomogram model possessed favourable predictive accuracy and discrimination.

The effect of Pimpinella Anisum herbal tea on human milk volume and weight gain in the preterm infant: a randomized controlled clinical trial

BACKGROUND AND AIMS

Human milk supports pre-term infants to thrive. Yet human milk production can be inhibited when infants are born prematurely. Pimpinella Anisum has been evidenced to increase milk production and infant weight gain in previous animal studies. The present study aimed to determine the effect of Pimpinella Anisum herbal tea on human milk volume and preterm infant weight in human populations for the first time.

METHODS

Human milk supports pre-term infants to thrive. Yet human milk production can be inhibited when infants are born prematurely. Pimpinella Anisum has been evidenced to increase milk production and infant weight gain in previous animal studies. The present study aimed to determine the effect of Pimpinella Anisum herbal tea on human milk volume and preterm infant weight in human populations for the first time.

RESULTS

There was a statistically significant difference in terms of milk volume in the first, third, fourth, fifth, sixth and seventh days between the three groups of intervention, placebo, and control (p < 0.05). On the first day, the mean volume of pumped milk in the intervention group was significantly higher than the control group (p = 0.008). On the second day, there was no statistically significant difference between groups. On the third, fourth, fifth, sixth and seventh days, the mean volume of pumped milk in the intervention group was significantly higher than the placebo and control groups (p < 0.05). There was no statistically significant difference in terms of preterm infant weight on days 0, 3 and 7 between the three groups.

CONCLUSION

The use of Pimpinella Anisum or 'Anise' tea can increase the volume of human milk and since no specific side effects have been reported in its use, it may be incorporated easily, cheaply, and effectively in practice where appropriate to the benefit of preterm infant nutrition worldwide.

Perinatal Factors Associated With Breastfeeding Trends After Preterm Birth <29 Weeks Gestation: Can We Predict Early Discontinuation?

OBJECTIVE

To determine the rates and perinatal factors associated with initiation and early discontinuation of breastfeeding among very preterm neonates.

METHODS

This was a retrospective cohort study of very preterm infants (<29 weeks gestation) admitted to 2 regional Level III neonatal intensive care units (NICUs) from January 1, 2015, to December 31, 2019. A national neonatal database was used to evaluate initiation and continuation rates of breastfeeding and associated perinatal factors. Stored nutrition profiles and delivery record books were used to determine feeding volumes associated with continuation of breastfeeding to hospital discharge for a subgroup of infants at a single site. Descriptive and inferential statistics were used to present the results between groups, and logistic regression modeling was used to calculate crude and adjusted odds ratios (OR) and 95% CI.

RESULTS

Of 391 eligible neonates, 84% initiated breastfeeding but only 38% continued to discharge. Interestingly, frequency of breastfeeding initiation (P < 0.001) and continuation (P < 0.001) declined over the study period. After adjustment for confounders, younger maternal age, earlier gestational age, cigarette smoking, and multiparity were significantly associated with early discontinuation of breastfeeding prior to hospital discharge. Early discontinuation of breastfeeding was also related to lower volumes of breastmilk by day 7 of life (P = 0.004).

CONCLUSION

Very preterm neonates are at high risk for non-initiation and early discontinuation of breastfeeding. The early postnatal period represents a critical time to establish breastmilk volumes, and the identification of key perinatal risk factors allows for early and targeted breastfeeding support.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

FINDINGS

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

IMPLICATIONS FOR PRACTICE

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

IMPLICATIONS FOR RESEARCH

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

The Rates of Breastfeeding in Baby-Friendly Hospitals in Greece: A Nationwide Survey

BACKGROUND

Exclusive breastfeeding (EBF) remains the cornerstone of infant nutrition for the first six months of life, presenting multiple short and long term benefits. The purpose of this study is the demonstration of EBF rates of infants born in baby-friendly hospitals (BFH) and the factors that positively influence EBF.

METHODS

The study was conducted in all four of the BFH that exist in Greece, between 2020 and 2022. The study sample consisted of 1200 mothers, taken from the 7101 that delivered at those hospitals during the time of the study. A questionnaire was used that included questions to evaluate the infant's nutrition after birth, after exiting the maternity hospital and during the 2nd, 4th and 6th month of age. The WHO guidelines on EBF and breastfeeding (BF), as well as the "Infant and Young Child Feeding" indicators, were used.

RESULTS

The EBF rate within 1 h after birth was 71.3%, which gradually declined to 21.2% in the 6th month. The respective rate of BF was 94.5% and declined to 66.1%. The logistic regression revealed that attending antenatal breastfeeding courses, vaginal delivery, full-term pregnancies and the mothers' advanced education level constitute independent positive prognostic factors for increased EBF rates.

CONCLUSION

The results of the first national study on BFH are presented. Despite the improvement of EBF rates in Greece, compared to the latest available data from 2018, reinforcement of EBF promotion measures is required in order to approach the WHO's targets by 2025.

Factors Associated with Breastfeeding Initiation and Duration in Greece: Data from the Hellenic National Nutrition and Health Survey

Despite its well-documented benefits, breastfeeding rates and duration worldwide do not meet the recommended goals set by the World Health Organization. Data on infant feeding, socio-demographic, lifestyle and perinatal factors were used from 490 mothers (and 958 children), participants at the Hellenic National Nutrition and Health Survey between 2013−2015. Clustered multiple logistic regression and multilevel mixed-model regression analyses were performed to identify factors associated with breastfeeding initiation and duration, respectively. Maternal lower education [Odds Ratio (OR): 2.29, 95% Confidence intervals (95% CI): 1.30−4.04; p = 0.004], smoking during pregnancy (OR: 3.08, 95% CI: 1.64−5.77; p < 0.001), caesarean section (OR = 3.26, 95% CI: 1.83−5.83; p < 0.001), prematurity (OR = 2.74, 95% CI: 1.40−5.37; p = 0.003) and higher birth order (OR = 1.30, 95% CI: 1.04−1.62; p = 0.020) were associated with increased odds of not initiating breastfeeding. Living in rural areas [beta coefficient b = −27.93, p = 0.043], smoking during pregnancy (b = −64.47, p < 0.001), caesarean section (b = −28.76, p = 0.046) and prematurity (b = −46.67, p = 0.048) were significantly associated with shorter breastfeeding duration. Children born chronologically closer to the survey were more likely to breastfeed and for longer periods. Educational promotion and enhancement of breastfeeding awareness that account for maternal exposures are required. Prevention of prematurity and avoidance of unnecessary caesarean section is crucial, while additional breastfeeding support is needed when preterm birth occurs, or caesarean section cannot be avoided.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.

The Effects of Breastfeeding on Maternal Mental Health: A Systematic Review

Background: Breastfeeding has many positive effects on the health of infants and mothers, however, the effect of breastfeeding on maternal mental health is largely unknown. The goal of this systematic review was to (1) synthesize the existing literature on the effects of breastfeeding on maternal mental health, and (2) inform breastfeeding recommendations. Materials and Methods: A literature search was conducted in electronic databases using search terms related to breastfeeding (e.g., breastfeeding, infant feeding practices) and mental health conditions (e.g., mental illness, anxiety, depression), resulting in 1,110 records. After reviewing article titles and abstracts, 339 articles were advanced to full-text review. Fifty-five articles were included in the final analysis. Results: Thirty-six studies reported significant relationships between breastfeeding and maternal mental health outcomes, namely symptoms of postpartum depression and anxiety: 29 found that breastfeeding is associated with fewer mental health symptoms, one found it was associated with more, and six reported a mixed association between breastfeeding and mental health. Five studies found that breastfeeding challenges were associated with a higher risk of negative mental health symptoms. Conclusions: Overall, breastfeeding was associated with improved maternal mental health outcomes. However, with challenges or a discordance between breastfeeding expectations and actual experience, breastfeeding was associated with negative mental health outcomes. Breastfeeding recommendations should be individualized to take this into account. Further research, specifically examining the breastfeeding experiences of women who experienced mental health conditions, is warranted to help clinicians better personalize breastfeeding and mental health counseling.

Maternal Milk Provision in the Neonatal Intensive Care Unit and Mother–Infant Emotional Connection for Preterm Infants

Maternal milk (MM) intake during neonatal intensive care unit (NICU) hospitalization is associated with improved neurodevelopment in preterm infants. Underlying mechanisms may include stronger mother–infant emotional connection. This paper examines associations between MM provision in the NICU with maternal connection to her infant using three factors validated in our sample: maternal sensitivity, emotional concern, and positive interaction/engagement. We studied 70 mothers of infants born <1500 g and/or <32 weeks’ gestation. Associations between MM provision and mother–infant connection were modeled using median regression adjusted for clustering. Mothers who provided exclusive MM (i.e., 100% MM, no other milk) reported higher levels of maternal sensitivity by a median score of 2 units (β = 2.00, 95% CI: 0.76, 3.24, p = 0.002) than the mixed group (i.e., MM < 100% days, other milk ≥1 days), as well as greater emotional concern (β = 3.00, 95% CI: −0.002, 6.00, p = 0.05). Among mothers of very preterm infants, greater milk provision was associated with greater maternal sensitivity, but also with greater emotional concern about meeting the infant’s needs. These findings highlight the importance of supporting MM provision and early infant care as an integrated part of lactation support. The findings may also provide insight into links between MM provision in the NICU and infant neurodevelopment.

Cohort profile: Japanese human milk study, a prospective birth cohort: baseline data for lactating women, infants and human milk macronutrients

PURPOSE

The Japanese Human Milk Study, a longitudinal prospective cohort study, was set up to clarify how maternal health, nutritional status, lifestyle and sociodemographic and economic factors affect breastfeeding practices and human milk composition. This would eventually determine factors affecting the growth and development of infants and children.

PARTICIPANTS

A total of 1210 Japanese lactating women who satisfied the inclusion criteria, were invited across the country at various participating sites, between 2014 and 2019. Finally a total of 1122 women were enrolled in this study.

FINDINGS TO DATE

Among 1122 eligible participants, mean age at delivery was 31.2 (SD 4.4) years and mean prepregnancy BMI was 20.8 (SD 2.7). Among these women, 35% were previously nulliparous and 77.7% had college, university or higher education. The mean gestational period was 39.0 (SD 1.3) weeks. Caesarean section was reported among 11.9%; mean infant birth weight was 3082 (SD 360) g. Of the infants, 53.7% were male. Overall, our participants appeared to be healthier than the general population in Japan. Analyses of the 1079 eligible human milk samples obtained at the first and second months postpartum showed the following composition: carbohydrate, 8.13 (SD 0.32) g/100 mL; fat, 3.77 (SD 1.29) g/100 mL; and crude protein, 1.20 (SD 0.23) g/100 mL. We also analysed osteopontin, fatty acid, vitamin D and phospholipid levels in limited subcohorts of the samples.

FUTURE PLANS

Follow-up surveys will be conducted to obtain milk samples every 2 months for 12 months and to investigate mother and child health until the children reach 5 years of age. These will be completed in 2024. We plan to longitudinally analyse the composition of macronutrients and various bioactive factors in human milk and investigate the lifestyle and environmental factors that influence breastfeeding practices, maternal and child health, and child development.

TRIAL REGISTRATION NUMBER

UMIN000015494; pre-results.

A Statewide Evaluation of the Breastfeeding Resource Nurse Model

OBJECTIVE

To evaluate a statewide initiative to increase the provisioning of human milk in NICUs.

DESIGN

A survey of nurses before participation in an educational session, immediately after education, and again 9 months later.

SETTING

Nurses from 22 hospitals throughout Florida.

PARTICIPANTS

We surveyed 121 participants, including some nurses who had prior breastfeeding education or certification as well as those without specialized breastfeeding training.

INTERVENTION

An educational project called the Breastfeeding Resource Nurse Master program was intended to educate NICU nurses to implement the "Ten Steps to Promote and Protect Human Milk and Breastfeeding in Vulnerable Infants."

MEASUREMENT

A quantitative needs assessment survey was administered to participants to determine current hospital practices, policies, and perceived areas for improvement. Pre- and immediate posttraining surveys assessed NICU nurses' knowledge, attitudes, and beliefs about human milk feeding of critical care infants and their self-efficacy for implementing the program in their respective NICUs. A follow-up, open-ended survey was administered at 9 months to yield information on program implementation.

RESULTS

NICU breastfeeding practices varied widely at baseline. Nurses' scores for knowledge, beliefs, and behavioral intentions improved postsession, but the implementation of practice changes related to the Ten Steps for Vulnerable Infants proved difficult. Nurses identified insufficient time and resources as barriers to educating others and changing practice.

CONCLUSIONS

Policies and regulations that make hospitals accountable for increasing human milk provision to vulnerable infants may be necessary to ensure that hospitals devote adequate resources to implementing practice changes in this area.

Breastfeeding and Risk of Late-Onset Group B Streptococcal Disease

BACKGROUND

Group B Streptococcus (GBS) is a major contributor to neonatal sepsis worldwide. Late-onset group B Streptococcus disease (LOGBS) and its risk factors remain poorly understood. The isolation of GBS from breast milk has been described in cases of LOGBS. This potential association has raised concerns for mothers and clinicians regarding the safety of ongoing breastfeeding. In this study, we aimed to investigate whether exposure to breast milk is associated with increased risk of LOGBS.

METHODS

A case-control study of LOGBS was conducted across 4 hospital networks in Victoria, Australia, including the 2 major tertiary pediatric centers in the state, to evaluate 11 years of data (2007-2017). Cases were captured initially from microbiology databases and recaptured with International Classification of Diseases discharge coding. Each case patient was matched with 4 controls to assess feeding status. Patients were matched for chronological age, gestation, discharge status, recruitment site, and calendar year.

RESULTS

We identified 92 cases of LOGBS: 73 cases on initial capture and 76 cases on the recapture analysis. Case patients were matched with 368 controls: 4 controls to each patient. Seventy-two patients were exposed to breast milk at the time of LOGBS (78.3%), compared with 274 controls (74.5%; odds ratio 1.2 [95% confidence interval 0.7-2.3]).

CONCLUSIONS

Breastfeeding was not associated with increased risk of LOGBS. Breast milk should not be tested for GBS during a first episode of LOGBS.

Privacy, Early Colostrum, and Gestational Age are Associated with Exclusive Breastfeeding in Preterm and Sick Term Infants

Our study was designed to assess the rates of exclusive breastfeeding (defined as direct breastfeeding) and the use of mother's own milk (MOM) in preterm infants and sick term infants at discharge and to identify potential influencing factors such as gestational age, early colostrum, and privacy. The study was conducted at a German level III neonatal department. All preterm and sick term infants admitted to the neonatal intensive care unit, the pediatric intensive care unit, the intermediate care unit, and the low care ward were included in the study. Infants were recruited between March and October 2015 (phase 1) and April to July 2016 (phase 2). Due to an emergency evacuation, privacy was limited during the first phase. Breastfeeding and the use of MOM were assessed daily using a self-designed score. In total, 482 infants of 452 mothers were included. More than 90% initiated breastfeeding and one-third were exclusively breastfed at discharge. Extremely immature infants and late preterm infants were less likely to be exclusively breastfed at discharge. Privacy (p<0.001) and early colostrum (p=0.002) significantly increased exclusive breastfeeding. Conclusion Extremely immature and late preterm infants were least likely to be exclusively breastfed at discharge and need special support. Interventions such as privacy and early colostrum should be promoted to increase breastfeeding.

Nonnutritive Sucking Before Oral Feeding of Preterm Infants in Turkey: A Randomized Controlled Study

BACKGROUND

The use of a pacifier is recommended to support sucking reflex during transition from gavage feeding to oral feeding and ensure readiness for feeding.

PURPOSE

A randomized controlled experimental design was used to determine the effect of a pacifier given before feeding on physiological characteristics and feeding performance in preterm infants initially fed orally.

DESIGN AND METHODS

The data were obtained from preterm infants (N = 72) born before 31st gestational week, who were admitted to Newborn Intensive Care Unit of a training and research hospital affiliated with Ministry of Health between January 2017-July 2018 and met the case selection criteria. Heart rates, oxygen saturation levels and feeding performances of preterm infants in both groups before, during, and after feeding were compared.

RESULTS

Heart rates of preterm infants in the experimental group were statistically significantly lower (Experimental: 139.64 ± 10.16; Control: 149.31 ± 8.40; p < 0.01) and their oxygen saturation levels were higher (Experimental: 97.22 ± 2.22; Control: 96.33 ± 1.93; p < 0.05). Feeding efficiency rates (Experimental: 1.94 ± 1.19; Control: 0.69 ± 0.34; p < 0.01) and the percentage of food intake (Experimental: 89.5 ± 23.93; Control: 70.86 ± 27.41; p < 0.01) of newborns in the experimental group were statistically significantly higher and their feeding duration was shorter (Experimental: 10.58 ± 8.29; Control: 16.14 ± 8.31; p < 0.01).

CONCLUSIONS

It was determined that a pacifier given before feeding is effective on regulating physiological parameters and supporting feeding performance in preterm infants.

PRACTICE IMPLICATIONS

The use of a pacifier in the first transition to oral feeding in preterm infants supports their sucking reflex, calms them down, and ensures the readiness for feeding.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prevalence of prelacteal feeding and associated risk factors in Indonesia: Evidence from the 2017 Indonesia Demographic Health Survey

Background

Prelacteal feeding (PLF) is a recognised challenge to optimal breastfeeding but remains common in Indonesia. Meanwhile, PLF-related epidemiological research is limited, particularly in this setting. This study examines the prevalence and determinants of overall PLF as well as common PLF types (formula, other milk, and honey) in Indonesia.

Methods

Data from 6127 mothers whose last child was ≤23-month-old were drawn from the 2017 Indonesia Demographic and Health Survey. Multivariable modified Poisson regression was used to measure the prevalence ratio (PR) for selected PLF risk factors. PLF was defined as anything to drink other than breast milk within three days after birth, before breastmilk flows. Additional analyses were performed on mothers who gave formula, other milk, and honey.

Results

About 45% babies in Indonesia received PLF with formula being the most frequent (25%), followed by other milk (14%), plain water (5%), and honey (3%). Factors associated with higher prevalence of any PLF were higher wealth quintiles in rural area (PR 1.07; 95% CI 1.03–1.11 per increase in quintile), baby perceived to be small at birth (PR 1.23; 95% CI 1.12–1.35), caesarean deliveries at either public (PR 1.27; 95% CI 1.13–1.44) or private facilities (PR 1.15; 95% CI 1.01–1.31), and not having immediate skin-to-skin contact after birth (PR 1.32; 95% CI 1.23–1.42). PLF was less prevalent among mothers who gave birth to second/subsequent child (PR 0.82; 95% CI 0.76–0.88) and who had an antenatal card (PR 0.89; 95% CI 0.80–0.99). These patterns did not apply uniformly across all PLF types. For example, honey was more common among home births than deliveries at health facilities, but formula and other milk were more common among caesarean deliveries.

Conclusions

Mapping risk factors for PLF, especially by types, could help to design more targeted interventions to reduce PLF and improve breastfeeding practices in Indonesia.

Effects of in-hospital breast feeding on brain function development in preterm infants in China: study protocol for a prospective longitudinal cohort study

INTRODUCTION

Due to immature brain development, preterm infants are more likely to develop neurological developmental defects compared with full-term infants. Most preterm infants without neurodevelopmental damage can eventually reach the same scholastic level as their same-age peers; however, some show persistent impairment. Breast feeding (BF), which is an important public health measure, is of great significance for preterm infants. Various active substances in breast milk promote the development of the brain and central nervous system in premature infants. We present a protocol for a prospective longitudinal cohort study to explore the effect of in-hospital BF on brain development in preterm infants and possible influencing factors.

METHODS AND ANALYSIS

This study will enrol 247 Chinese preterm infants (gestational age: 30-34 weeks) delivered in Women's Hospital School of Medicine, Zhejiang University, and transferred to the neonatal intensive care unit. Demographic, clinical and in-hospital BF data will be collected through electronic medical records. Moreover, follow-up data will be obtained by telephone, interview or online. Measurements will be obtained using the Breastfeeding Self-Efficacy Scale-Short Form, neuroimaging with functional near-infrared spectroscopy, extrauterine growth restriction and the Ages and Stages Questionnaire. Follow-up will be performed at 3, 6 and 12 months after birth.

ETHICS AND DISSEMINATION

This study has been approved by the Women's Hospital School of Medicine Zhejiang University Medical Ethics Committee (2019-058). The study results are expected to be published in peer-reviewed journals and reported at relevant national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR1900027648; Pre-results.

Quality of complementary feeding and its effect on nutritional status in preterm infants: a cross-sectional study

BACKGROUND

The first 2 years of life represent a critical phase for growth and development, with the quality of the diet at this stage having repercussions throughout adulthood. The present study aimed to develop an Index for Measuring the Quality of Complementary Feeding (IMQCF) for infants, as well as to evaluate diet quality and its effects on the nutritional status of preterm infants.

METHODS

This cross-sectional study was conducted at a Brazilian University Hospital. The data were extracted by care protocol of outpatient preterm infants at 2 years of corrected age (CA). Dietary data were collected from 24-h recalls. The diet quality was assessed by the IMQCF composed of nine items based on a Brazilian Food Guide for children aged <2 years. Response options were scored 0-100, with scores closer to 100 representing a better quality diet. Association with growth indicators (Z-scores for weight- and length-for-age (WAZ and LAZ) were evaluated via tests of mean difference and multiple linear regression.

RESULTS

The median complementary feeding (CF) score was 72.2 (61.1-77.8) A shorter breastfeeding duration or infant formula use and the early introduction of wheat-based foods, ultra-processed foods and cow's milk in the preterm's diet were the main factors interfering in the adequacy of diet. There was an association between the quality of the diet score and WAZ (0.44; 95% confidence interval = 0.03-0.85; P = 0.03).

CONCLUSIONS

The introduction of poor quality food in the first 2 years of life interfered with the CF quality of preterm infants and can affect nutritional status at 2 years of CA, possibly in the long term.

ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

Prevalence of Exclusive Breast Milk Feeding at Discharge and Associated Factors Among Preterm Neonates Admitted to a Neonatal Intensive Care Unit in Public Hospitals, Addis Ababa, Ethiopia: A Cross-Sectional Study

Background

Studies show that rates of breast milk feeding are much lower among preterm infants than term infants, and breast milk feeding at discharge varies widely between countries. However, research examining factors associated with exclusive breast milk feeding at discharge among preterm neonates in Ethiopia is limited. The study aimed to assess the prevalence of exclusive breast milk feeding at discharge and associated factors among preterm neonates at the neonatal intensive care unit (NICU) in public hospitals, Addis Ababa, Ethiopia.

Methods

This facility-based cross-sectional study was conducted from February to March 2017 among preterm infants discharged from the NICU of public hospitals. Data were collected using pretested structured questionnaires. Purposive sampling technique was used. Factors associated with exclusive breast milk-fed infants at discharge among preterm neonates were determined using bivariate and multivariate logistic regression models. Statistically significant associations were declared at P<0.05.

Results

The study assessed 263 mother-preterm dyads. The findings from this study revealed that 71.9% of exclusive breast milk-fed infants at discharge at NICU of the selected Public hospitals in Addis Ababa. Factors associated with exclusive breast milk-fed infants at discharge included duration of hospital stay for 7-14 days (AOR 0.19, 95% CI 0.049-0.808) and more than 14 days (AOR 0.20, 95% CI 0.046,0.891), Initiation of breast milk expression later than 48 hrs postpartum (AOR 0.10, 95% CI 0.032-0.365) and receiving hospital support (AOR 39.00, 95% CI 11.676-130.290).

Conclusion

In this study, nearly ¾ of the NICU premature population exclusively breast milk fed at discharge, which designates to establish exclusive breastfeeding in the majority of preterm infants in this cohort. Thus, support for exclusive breast milk fed should be at the forefront of maternity practice in hospital and mothers of preterm infants to be guided to initiation of early breast milk expression as soon after delivery as possible and frequent expression thereafter.

The Rates of Any Breastfeeding at the Time of Postpartum Hospital Discharge for Early Term (370-386 Weeks) Versus Full Term (390-416 Weeks) Infants

OBJECTIVE

This study sought to compare the rates of any breastfeeding between early term (37⁰-38⁶ weeks) and full term (39⁰-41⁶ weeks) infants at the time of postpartum hospital discharge.

METHODS

A retrospective cohort study of women with live, singleton pregnancies who were delivered in St. John's, Newfoundland and Labrador, between April 2001 and March 2018 was completed. The primary outcome was any breastfeeding at the time of postpartum hospital discharge. Secondary analyses included a comparison of breastfeeding by week of gestational age at term and by maternal and neonatal demographics and outcomes of pregnancy. Univariate and multiple logistic regression analyses were performed.

RESULTS

A total of 34 511 women were included. Early term infants were less likely to be breastfed than were full-term infants (67.9 vs. 70.4%) (adjusted odds ratio [aOR] 0.91; 95% confidence interval [CI] 0.86-0.97). Multiple logistic regression analysis also showed a significant effect of maternal age (aOR 1.07; 95% CI 1.05-1.09), partner status (aOR 1.56; 95% CI 1.20-2.03), smoking (aOR 0.32; 95% CI 0.26-0.41), prenatal education (aOR 2.43; 95% CI 1.99-2.97), pre-pregnancy body mass index (kg/m²) (aOR 0.97; 95% CI 0.96-0.98), and cesarean section (aOR 0.72; 95% CI 0.60-0.88). When compared by week of gestational age at term, the likelihood of breastfeeding significantly increased with each successive week (aOR 1.08; 95% CI 1.007-1.16).

CONCLUSION

Early term delivery is an independent risk factor for not breastfeeding at the time of postpartum hospital discharge. It is important to target and support these women to increase breastfeeding rates. Additionally, these findings further validate recommendations to avoid non-medically indicated early term deliveries because of the increased risks of adverse outcomes.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

FINDINGS

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

IMPLICATION FOR PRACTICE

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

IMPLICATION FOR RESEARCH

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

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

BACKGROUND

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

PURPOSE

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

SEARCH STRATEGY

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

FINDINGS

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

IMPLICATIONS FOR PRACTICE

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

IMPLICATIONS FOR RESEARCH

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

The impact of neonatal unit policies on breast milk feeding at discharge of moderate preterm infants: The EPIPAGE-2 cohort study

Facilitating factors and barriers to breast milk feeding (BMF) for preterm infants have been mainly studied in very preterm populations, but little is known about moderate preterm infants. We aimed to analyze hospital unit characteristics and BMF policies associated with BMF at discharge for infants born at 32 to 34 weeks' gestation. EPIPAGE-2, a French national cohort of preterm births, included 883 infants born at 32 to 34 weeks' gestation. We investigated kangaroo care in the first 24 hr, early involvement of parents in feeding support, volume of the unit, BMF information given to mothers hospitalized for threatened preterm delivery, protocols for BMF, presence of a professional trained in human lactation, unit training in neurodevelopmental care, and regional BMF initiation rates in the general population. Multilevel logistic regression analysis was used to investigate associations between unit policies and BMF at discharge, adjusted for individual characteristics and estimating odds ratios (ORs) and 95% confidence intervals (CIs). Overall, 59% (490/828) of infants received BMF at discharge (27% to 87% between units). Rates of BMF at discharge were higher with kangaroo care (adjusted OR 2.03 [95% CI 1.01, 4.10]), early involvement of parents in feeding support (1.94 [1.23, 3.04]), unit training in a neurodevelopmental care programme (2.57 [1.18, 5.60]), and in regions with a high level of BMF initiation in the general population (1.85 [1.05, 3.28]). Creating synergies by interventions at the unit and population level may reduce the variability in BMF rates at discharge for moderate preterm infants.

Predictors of breastfeeding non-initiation in the NICU

This study compared predictors of breastfeeding non-initiation between infants who were and were not admitted to the NICU so that interventions can target high-risk mothers whose infants desperately need breastmilk. This was a population-based retrospective cohort study of singleton Ohio live births using birth certificates, 2006-2015. In babies who were and were not admitted to the NICU, a multivariable logistic regression model assessed the association between breastfeeding non-initiation and predictors relating to the mother, neonate, and labour and delivery events while adjusting for covariables. Of 1,463,506 births, 76,855 infants were admitted to the NICU (5.8% of study population), and breastfeeding was not initiated in 39.4% of them, compared with 31.5% of infants in the newborn nursery, p < 0.001. Apart from abnormal newborn conditions, smoking during pregnancy was the most significant risk factor for not breastfeeding in the NICU (RR 1.91 [95% CI 1.82-2.02]) and newborn nursery (RR 2.10 [95% CI 2.08-2.13]), followed by socioeconomic factors and multiparity. Limited prenatal visits (≤5) were a significantly higher risk factor in the NICU (RR 1.41 [95% CI 1.34-1.49]) than in the newborn nursery (RR 1.24 [95% CI 1.22-1.26]). Intentional home birth and use of infertility treatment were associated with breastfeeding initiation. The rate of breastfeeding initiation is lower in infants admitted to the NICU than those who are not, especially among mothers with limited prenatal care. Interventions should target mothers who smoke because they are least likely to breastfeed, and their babies, who are prone to serious health conditions, could especially benefit from breastmilk.

Role of days postdelivery on breast milk production: a secondary analysis from the EMPOWER trial

Background

With an increasing demand for mother's own milk to be viewed as a primary source of nutritional support in the care of very small and preterm infants, mothers of preterm infants may be at risk of expressing suboptimal amounts of milk. The use of a galactogogue is often considered when these mothers are still having challenges in breast milk production.

Methods

For this analysis, the study participants were the 90 mothers who participated in the EMPOWER trial and, at the time of randomization, were stratified by days post-delivery, 8-14 days and 15-21 days. The primary outcome measure was the proportion of mothers in each of the days post-delivery groups who achieved a 50% increase in breast milk volume on day 14 of the study treatment period.

Results

There was no significant difference in the proportion of mothers in the 8-14 days group (75.0%) who achieved a 50% increase in breast milk volume on day 14 of the study treatment period.compared to those in the 15-21 days group (60.9%), OR 1.93 (95% CI 0.78, 4.76; p = 0.15). Because comorbidities and exposure to antenatal corticosteroids between the groups of mothers were viewed as potential confounders, a logistic regression was performed after controlling for these two variables with the adjusted OR being 1.84 (0.73, 4.64; p = 0.19).

Conclusions

This secondary analysis was able to demonstrate that mothers of very preterm infants, < 30 weeks gestation at birth, were able to respond to the study treatment in a similar fashion regardless of timing of entry and exposure to domperidone. In the presence of a suboptimal breast milk production by the end of the first week postpartum, below 250 ml/kg/d based on infant birth weight, a 14 day treatment of domperidone could be considered to augment breast milk production.

Trial registration

EMPOWER has been registered at http://www.clinicaltrials.gov (identifier NCT01512225) on January 10, 2012.

A Pilot Study of Mothers' Breastfeeding Experiences in Infants With Cleft Lip and/or Palate

BACKGROUND

Despite the recognized importance of human milk (HM) use, breastfeeding is often discouraged for infants with cleft lip and/or palate because of their anatomical abnormalities. Poor weight gain may require formula for calorie supplementation. Stresses associated with caring for infants with cleft lip/palate may decrease rates of HM provision to these infants.

PURPOSE

This study investigates the experiences of mothers of infants with cleft lip/palate (CL/P) to determine choices and factors associated with providing HM to their infants.

METHODS

A retrospective telephone survey was administered to a cohort of mothers of infants with CL/P.

RESULTS

Fifty mothers agreed to participate in the survey. Most (78%) initiated use of HM for a median duration of 4 months, 32% provided HM for 6 months or more, and 79% exclusively expressed their HM. Poor supply was the most frequent challenge to providing HM and led to cessation in 46% of the mothers. Formula was used to supplement for poor supply or poor infant weight gain in 90% of the mothers. The best predictors of a mother's use of HM were child not in day care, genetic diagnosis, and gestational age at birth. Only 36% of mothers reported individual encouragement to provide HM, and 18% reported they were specifically discouraged from providing HM for their infants.

IMPLICATIONS FOR PRACTICE

Although initiation rates were high, there are opportunities to improve support for mothers to increase duration of HM provision in children with CL/P.

IMPLICATIONS FOR RESEARCH

This study establishes a baseline for future prospective studies looking at the impact of active encouragement and provision of lactation support within the cleft team setting.

Nonnutritive Sucking at the Mother's Breast Facilitates Oral Feeding Skills in Premature Infants: A Pilot Study

BACKGROUND

Premature infants have difficulties in transitioning from gavage to breastfeeding. Targeted interventions to support breastfeeding in premature infants in the neonatal intensive care unit are scarce.

PURPOSE

This pilot study evaluates the effectiveness of nonnutritive sucking at the mother's breast in premature infants to facilitate breastfeeding performance and exclusive breastfeeding.

METHODS

The study design constituted a single-blinded randomized control trial, with 9 participants randomly allocated into experimental (n = 4) and control (n = 5) groups. The intervention, nonnutritive sucking at the mother's breast thrice a day for 5 minutes, till nutritive breastfeeding was started, was done in addition to standard care, which was nonnutritive sucking on a finger during gavage feeds. The control group received only standard care. Nonnutritive sucking was assessed using "Stages of Nonnutritive Sucking Scale," and breastfeeding performance was assessed using the "Preterm Infant Breastfeeding Behavior Scale" by a blinded assessor unaware of the infants' allocation.

RESULTS

Five infants in the control arm and 4 in the intervention arm completed the study. The infants in the intervention group showed faster transition to mature stages of nonnutritive sucking (P = .05) and had longer sucking bursts during breastfeeding (P = .06) than those in the control group. There was no difference in the rates of exclusive breastfeeding at 6 months in the intervention and control groups.

IMPLICATIONS FOR PRACTICE

Early initiation of nonnutritive sucking at the mother's breast in very preterm infants is a safe and effective intervention to facilitate maturation of oral feeding and breastfeeding behavior.

IMPLICATIONS FOR RESEARCH

Nonnutritive sucking at the mother's breast can be explored as an intervention, with a larger sample, to facilitate exclusive breastfeeding and to establish intervention fidelity.

Do a Few Weeks Matter? Late Preterm Infants and Breastfeeding Issues

The late preterm infant population is increasing globally. Many studies show that late preterm infants are at risk of experiencing challenges common to premature babies, with breastfeeding issues being one of the most common. In this study, we investigated factors and variables that could interfere with breastfeeding initiation and duration in this population. We conducted a prospective observational study, in which we administered questionnaires on breastfeeding variables and habits to mothers of late preterm infants who were delivered in the well-baby nursery of our hospital and followed up for three months after delivery. We enrolled 149 mothers and 189 neonates, including 40 pairs of twins. Our findings showed that late preterm infants had a low rate of breastfeeding initiation and early breastfeeding discontinuation at 15, 40 and 90 days of life. The mothers with higher educational levels and previous positive breastfeeding experience had a longer breastfeeding duration. The negative factors for breastfeeding were the following: Advanced maternal age, Italian ethnicity, the feeling of reduced milk supply and having twins. This study underlines the importance of considering these variables in the promotion and protection of breastfeeding in this vulnerable population, thus offering mothers tailored support.

Impact of Donor Milk on Short- and Long-Term Growth of Very Low Birth Weight Infants

Mother’s own milk (MOM) reduces the risk of morbidities in very low birth weight (VLBW) infants. When MOM is unavailable, donor breastmilk (DM) is used, with unclear impact on short- and long-term growth. This retrospective analysis compared anthropometric data at six time points from birth to 20–24 months corrected age in VLBW infants who received MOM supplements of preterm formula (n = 160) versus fortified DM (n = 161) during neonatal intensive care unit (NICU) hospitalization. The cohort was 46% female; mean birth weight and gestational age (GA) were 998 g and 27.3 weeks. Multilevel linear growth models assessed changes in growth z-scores short-term (to NICU discharge) and long-term (post-discharge), controlling for amount of DM or formula received in first 28 days of life, NICU length of stay (LOS), birth GA, and sex. Z-scores for weight and length decreased during hospitalization but increased for all parameters including head circumference post-discharge. Short-term growth was positively associated with LOS and birth GA. A higher preterm formula proportion, but not DM proportion, was associated with slower rates of decline in short-term growth trajectories, but feeding type was unrelated to long-term growth. In conclusion, controlling for total human milk fed, DM did not affect short- or long-term growth.

Improving Access to Lactation Consultation and Early Breast Milk Use in an Outborn NICU

Introduction

Increasing the use of breast milk in critically ill neonates is an important priority to improve neonatal care. Lactation consultants (LCs) educate mothers about evidence-based benefits of breast milk and provide technical support. LC support can lead to increased breastfeeding initiation. The project aim was to improve access to lactation services for mothers of patients admitted at <48 hours after birth to an exclusively outborn level III/IV neonatal intensive care unit (NICU).

Methods

The interventions included (1) implementation of an automatic electronic admission order for a lactation consult, (2) initiation of a daily lactation team notification, (3) assignment of a consistent NICU LC, and (4) targeted education. The percent of mothers who received lactation consults, the time to the first consultation, and the percent of patients receiving breast milk at 7 days of age were measured over 32 months and analyzed using statistical process control charts.

Results

The lactation consultation rate increased significantly from 74% to 88% with a shift in the mean by statistical process control chart analysis that was sustained over time. Concurrently, the time to first lactation consultation significantly decreased from hospital days 5 to 3.3, and variation decreased. Rates of breast milk use at 7 days of age also significantly increased from 75.6% to 89.6%.

Conclusions

Targeted quality improvement interventions led to an increased rate of lactation consultations, decreased time to first lactation consult, and increased rate of breast milk use at 7 days of age. These interventions could feasibly be implemented in similar referral NICU settings.

Association of Exclusive Breastfeeding with Risk of Obesity in Childhood and Early Adulthood

OBJECTIVE

To explore the effects of exclusive breastfeeding and its duration on the development of childhood and early adulthood obesity.

MATERIALS AND METHODS

A random sample of 5,125 dyad children and their mothers was extracted from a national database. With the use of a standardized questionnaire, telephone interviews were carried out for the collection of maternal lifestyle factors (e.g., breastfeeding). The body mass index was determined based on International Obesity Task Force criteria. Body weight and height of the offspring at the age of 8 was calculated from measurements derived from the national database, while the corresponding body measurements at early adulthood were self-reported.

RESULTS

Mothers who had breastfed or exclusively breastfed ≥6 months were 22.4% and 15.2%, respectively. Exclusive breastfeeding ≥6 months (versus never) was associated with a lower risk of overweight in childhood (8 years old; odds ratio [OR] = 0.89; 95% confidence interval [95% CI], 0.82-0.96) and adolescence/adulthood (15-25 years old; OR = 0.83; 95% CI, 0.68-0.97). Also, exclusive breastfeeding ≥6 months (versus never) was associated with a decreased risk of childhood and adolescence obesity by 30% (95% CI, 0.54-0.91) and 38% (95% CI, 0.40-0.83), respectively.

CONCLUSIONS

Exclusive breastfeeding had a favorable influence on offspring's overweight and obesity not only in childhood but also in adolescence/adulthood.

Pregnancy gestation at delivery and breast milk production: a secondary analysis from the EMPOWER trial

Background

Preterm birth alters the normal sequence of lactogenesis. Lactogenesis I may not yet have started when mothers of very preterm infants (≤ 29 weeks gestation) have given birth. Preterm infants are too small or too ill to initiate suckling in the immediate postpartum period thus altering the normal cascade of event for lactogenesis II. With an increasing demand for mother’s own milk as a primary source of nutritional support in the care of very small and preterm infants, mothers of these infants are often at risk of expressing inadequate amounts of milk. The use of galactogogues is often considered when mothers of preterm infants are still having challenges in breast milk production. What is not clear in the literature is the role that pregnancy gestation at birth plays in successful response to galactogogues. Our objective for this study was to evaluate the role of pregnancy gestation at birth on a mother’s response to the treatment interventions in the EMPOWER trial.

Methods

For this analysis, the study participants are the 90 mothers who participated in the EMPOWER trial and were in the stratified in two gestational age groups, 23^0/7–26^6/7 weeks and 27^0/7–29^6/7 weeks at the time of randomization. The primary outcome measures were the proportion of mothers in each of the gestational age groupings who achieved a 50% increase in breast milk volume on day 14 and day 28 of the study treatment period.

Results

On day 14 of the study treatment, there was no significant difference in the proportion of mothers in the 23–26 weeks gestation group (72.9%) compared to those in the 27–29 weeks gestation group (64.2%), OR 1.51 (95% CI 0.60, 3.78; p = 0.38). Similarly, there was no difference in the proportion of mothers between the two gestational age groupings on day 28 of the study treatment, 70.3% compared to 62.3%, OR 1.43 (95% CI 0.58, 3.51; p = 0.43).

Conclusion

This secondary analysis was able to demonstrate that mothers of very preterm infants, < 30 weeks gestation at birth, were able to respond to the study treatment in a similar fashion regardless of gestation at birth. If non-pharmacologic approaches are unsuccessful, then a 14–day treatment of domperidone may be considered to enhance breast milk production, even in the lowest gestational ages at delivery.

Trial registration

EMPOWER has been registered at www.clinicaltrials.gov (identifier NCT 01512225) on January 10, 2012.

Maternal views on facilitators of and barriers to breastfeeding preterm infants

Background

The supply of breast milk to preterm infants tends to occur at a lower rate than that recorded among term infants. We aimed to investigate the facilitators of and barriers to breastfeeding during hospital stay according to the experiences of mothers that gave birth to premature infants requiring admission to neonatal intensive care unit.

Methods

A cross-sectional questionnaire survey was conducted. Mothers who had delivered a newborn with a gestational age ≤33 weeks requiring intensive care, entered the study. Basic subjects’ characteristics and infant feeding practices were also recorded.

Results

A total of 64 mothers were enrolled, leading to a total of 81 infants. At discharge, any breastfeeding was recorded in 66% of infants, with 27% of those infants being exclusively breastfed. Any infant was exclusively fed directly at the breast. Most mothers experienced adequate support during their infant’s hospitalization and reported satisfaction with breastfeeding. Almost all mothers felt that feeding their infant human milk was beneficial for the infant’s health. Thirty percent of the mothers reported that they had experienced some obstacles to breastfeeding. Specifically, infants born to mothers who experienced difficulties in pumping breast milk (OR = 4.6; CI 1.5–13.9) or in providing an adequate amount of milk to the infant (OR = 3.57; CI 1.1–11.5) were at higher risk of being fed with formula at discharge.

Conclusions

On the basis of the present results, health care professionals should target their efforts to optimize breastfeeding support for mothers of premature infants admitted to level III care, especially by improving breast milk production and endorsing direct breastfeeding.

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.

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.

Breastfeeding self-efficacy and breastmilk feeding for moderate and late preterm infants in the Family Integrated Care trial: a mixed methods protocol

BACKGROUND

Breastmilk is the ideal nutrition for preterm infants. Yet, breastmilk feeding rates among preterm infants are substantially lower than those of full-term infants. Barriers incurred through hospital care practices as well as the physical environment of the neonatal intensive care unit (NICU) can result in physical and emotional separation of infants from their parents, posing a substantial risk to establishing and maintaining breastfeeding. Additionally, current practitioner-focused care provision in the NICU can result in decreased breastfeeding self-efficacy (BSE), which is predictive of breastfeeding rates in mothers of preterm infants at 6 weeks postpartum.

METHODS

Family Integrated Care (FICare) integrates and supports parents to actively participate in the care of their infant while in the NICU. Nested within the broader FICare trial, we will conduct an explanatory sequential mixed methods study to investigate if FICare improves maternal BSE and rates of breastmilk feeding in moderate and late preterm infants at discharge from the NICU. In phase 1, we will calculate the mean difference between admission and discharge BSE scores for the intervention group. Mothers who score in the top and bottom 20th percentile of change scores will be invited to participate in a semi-structured telephone interview exploring maternal experiences with infant feeding in the NICU. We will conduct inductive thematic analysis to identify and describe the facilitators and barriers of FICare on maternal feeding experiences. Once data saturation is achieved and themes have been established, phase 2 will revisit the quantitative data to determine whether FICare was impactful on BSE and breastmilk feeding rates. Findings from the qualitative and quantitative phases will be integrated to determine how infant feeding experiences on FICare units work to improve or detract from maternal BSE and rates of breastmilk feeding.

DISCUSSION

FICare may help to improve maternal BSE and rates of breastmilk feeding in moderate and late preterm infants. Improved breastmilk feeding outcomes can have a substantial impact on overall infant health, developmental outcomes, and maternal-infant bonding and will help to improve long-term health outcomes for moderate and late preterm infants.

TRIAL REGISTRATION

(NCT02879799). Registered May 27, 2016 protocol version June 9, 2016 Version 2.

Supporting Mothers of Very Preterm Infants and Breast Milk Production: A Review of the Role of Galactogogues

Human milk, either mother’s own milk or donor human milk, is recommended as the primary source of nutrition for very preterm infants. Initiatives should be in place in neonatal units to provide support to the mother as she strives to initiate and maintain a supply of breast milk for her infant. The use of galactogogues are considered when these initiatives alone may not be successful in supporting mothers in this endeavor. Although there are non-pharmacologic compounds, this review will focus on the pharmacologic galactogogues currently available and the literature related to their use in mothers of very preterm infants.

Effects of two different feeding positions on physiological characteristics and feeding performance of preterm infants: A randomized controlled trial

PURPOSE

The aim of this randomized controlled study was to determine the effect of semielevated side-lying (ESL) and semielevated supine (ESU) positions, which are used to bottle-feed preterm infants, on their physiological characteristics and feeding performance.

DESIGN AND METHODS

The sample consisted of preterm infants who were born in the 31st gestational week and below, and met the inclusion criteria. A randomization was provided in the sample group with a total of 80 infants including 38 infants in the ESL (experimental) group and 42 infants in the ESU (control) group. Both groups were compared in terms of their SpO2 values, heart rates, and feeding performances before, during, and after the feeding. The data were obtained by using a form for infant descriptive characteristics, feeding follow-up form, a Masimo Radical-7 pulse oximeter device, and a video camera.

RESULTS

It was determined that the infants in the ESL group had statistically significantly higher SpO2 values (ESL: 96.77 ± 2.51; ESU: 93.48 ± 5.63) and lower heart rates (ESL: 155.87 ± 11.18; ESU: 164.35 ± 6.00) during the feeding compared to the infants in the ESU group (p < .05). Besides, oxygen saturation levels of the infants in the ESU group decreased more (p < .01) and their heart rates increased more (p < .05) during the feeding than those obtained before the feeding compared to the infants in the ESL group.

PRACTICE IMPLICATIONS

The ESL position has a more positive effect on oxygen saturation and heart rate of infants and it is more effective in providing a physiological stabilization during the feeding, compared to the ESU position. According to these results, the ESL position can be recommended for preterm feeding.

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

The goal for preterm infants is to achieve full oral feeds quickly and ultimately progress to full breastfeeding. Supplementary oral feeds are often given when the mother is not available to breastfeed. Bottles typically deliver milk in a different fashion compared to breastfeeding, which is thought to hamper transition to full breastfeeding. The aim of this study was to compare the sucking dynamics of preterm infants fed at the breast to feeding with an experimental novel teat (NT) designed to release milk only upon the application of vacuum. Simultaneous ultrasound imaging of the infant oral cavity and measurement of intra-oral vacuum was performed during a breastfeed and a feed with the NT. Test weighs were used to measure milk intake. Linear mixed effects models were performed to investigate differences by feed type, and simultaneous linear regression was performed to investigate individual patterns. Tongue movement was not different between breastfeeding and the NT. Intra-oral vacuums (median (interquartile range: IQR)) were significantly lower with the NT (Baseline vacuum: -5.8 mmHg (-11.0, 0.1); Peak: 40.0 mmHg (-54.6, -27.1)) compared to breastfeeding (Baseline: -31.1 mmHg (-60.0, -12.7); Peak: -106.2 mmHg (-153.0, -65.5)). Milk intake was significantly higher with the NT (33 mL (22.5, 42.5)) compared to the breastfeed (12 mL (3, 15.5)). The novel teat encouraged a similar tongue action to breastfeeding, and infants transferred a greater volume of milk with the novel teat. Intra-oral vacuums were lower in strength with the novel teat compared to the breast. Use of the novel teat for the training of sucking dynamics in preterm infants has the potential to improve breastfeeding success and requires further investigation.