Academy of Breastfeeding Medicine. ABM clinical protocol #10: breastfeeding the late preterm infant (34(0/7) to 36(6/7) weeks gestation) (first revision June 2011)

The metabolome of human milk is altered differentially by Holder pasteurization and high hydrostatic pressure processing

The milk metabolome is composed of hundreds of molecules that can impact infant development. In preterm infants, sterilized donor milk (DM) is frequently used for their feeding. We aimed to identify differences in the metabolome of DM after two types of milk sterilization: the Holder pasteurization (HoP) and a high hydrostatic pressure (HP) processing. DM samples were sterilized by HoP (62.5°C for 30 min) or processed by HP (350 MPa at 38°C). 595 milk metabolites were analyzed using an untargeted metabolomic analysis. Both treatments differentially altered several classes of compounds. The major changes noted included decreased levels of free fatty acids, phospholipid metabolites, and sphingomyelins. Decreases were more strongly noted in HP samples rather than in HoP ones. Both HoP and HP treatments increased the levels of ceramides and nucleotide compounds. The sterilization of human milk altered its metabolome especially for lipids.

Breastfeeding in Neonates Admitted to an NICU: 18-Month Follow-Up

Introduction: The admission of neonates to Neonatal Intensive Care Units (NICUs) has been identified as a primary inhibiting factor in the establishment of breastfeeding. The aims of this study were to (1) estimate the prevalence and duration of breastfeeding in infants/toddlers who had been admitted to an NICU in Greece and (2) to investigate factors, associated with the NICU stay, which affected the establishment and maintenance of breastfeeding in infants/toddlers previously admitted to the NICU. Materials and methods: Data for this cohort study were retrieved from interviews with mothers of infants/toddlers who had been admitted to our NICU as neonates during the period of 2017−2019. Interviews were conducted based on a questionnaire regarding the child’s nutrition from birth to the day of the interview, including previous maternal experience with breastfeeding. Information related to the prenatal period, gestation age, delivery mode, duration of NICU stay, and neonatal feeding strategies during their hospital stay were recorded. Results: The response rate to the telephone interviews was 57%, resulting in 279 mother−infant pairs being included in this study. The results showed that 78.1% of children received maternal milk during their first days of life. Of all infants, 58.1% were exclusively breastfed during their first month, with a gradual decrease to 36.9% and 19.4% by the end of the third and sixth months of life, respectively. The prevalence of breastfed children reached 14.7% and 7.5% at the ages of twelve and eighteen months, respectively. In the multivariate analysis, prematurity emerged as an independent prognostic factor for the duration of exclusive and any breastfeeding (aHR 1.64, 95% CI: 1.03−2.62; and 1.69, 95% CI: 1.05−2.72, respectively; p < 0.05). Additionally, the nationality of the mother, NICU breastfeeding experience, the administration of maternal milk during neonatal hospital stay, and previous breastfeeding experience of the mother were independent prognostic factors for the duration of breastfeeding. Conclusions: Although breastfeeding is a top priority in our NICU, the exclusive-breastfeeding rates at 6 months were quite low for the hospitalized neonates, not reaching World Health Organization (WHO) recommendations. Mothers/families of hospitalized neonates should receive integrated psychological and practical breastfeeding support and guidance.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The management of late preterm infants: effects of rooming-in assistance versus direct admission to neonatal care units

Late preterm infants (LPIs) represent a significant percentage of all neonates (6-8%), but there are limited published data on their postnatal management. Our aim was to compare the frequency of neonatal intensive care unit (NICU) admission and the breastfeeding rate of LPIs born at 35⁺⁰-36⁺⁶ weeks of gestation who were cared for by initial rooming in strategy rather than directly admitted to the special care unit (SCU) and, eventually, to the NICU. We carried out a retrospective study in the perinatal centers of Careggi University Hospital (CUH) and San Giovanni di Dio Hospital in Florence, Italy, where the first and second strategies were applied, respectively. Main outcomes were LPIs admission rate at SCU/NICU and breastfeeding rate at discharge. We studied 190 LPIs born at SGDH and 240 born at CUH. The admission rate in SCU (81 vs. 43%; P < 0.001) and NICU (20 vs. 10%; P = 0.008) was higher in SGDH than in CUH, as was the exclusive breastfeeding rate (36 vs. 22%; P < 0.001). However, infants who were assisted in rooming-in at CUH and infants with similar clinical characteristics at SGDH had similar mixed (60 vs. 69%) and exclusive (35 vs. 31%) breastfeeding rates.  Conclusion: Postnatal assistance of LPIs in rooming-in, eventually followed by admission in SCU/NICU based on their clinical conditions, allowed to safely halve their hospitalization. The assistance of infants in rooming-in did not negatively affect their breastfeeding rate. These results support the possibility of assisting LPIs in rooming-in. What is Known: • Late preterm infants represent a significant percentage of all neonates. • Early rooming-in and breastfeeding is recommended for late preterm infants. What is New: • Postnatal assistance of late preterm infants in rooming-in, followed when necessary by admission in neonatal units based on clinical conditions, allowed to safely avoid about half the number of hospitalizations in comparison with direct admission in neonatal units. • This strategy did not affect breastfeeding rate. Infants who were admitted to SCU/NICU after initial rooming-in had worst breastfeeding rate.

Effects of a breastfeeding coaching program on growth and neonatal jaundice in late preterm infants in South Korea

PURPOSE

This study examined the effects of a breastfeeding coaching program for mothers on growth and neonatal jaundice in late preterm infants (LPIs).

METHODS

This was a quasi-experimental study (non-randomized intervention) with a time-series design. The study was conducted among 40 LPIs who were admitted to the neonatal intensive care unit of a university hospital in Daegu, South Korea. In the order of admission, the first 21 infants were assigned to the experimental group, and 19 were assigned to the control group. The intervention program consisted of home- based and web-based practical breastfeeding support education for mothers across a total of 5 sessions. Infant growth was measured using body weight, length, and head circumference, and neonatal jaundice was assessed using transcutaneous bilirubin levels.

RESULTS

The likelihood of breastfeeding for infants in the experimental group at 4 weeks after discharge was the same as on the day of discharge, whereas it steadily decreased in the control group. There were significant differences in head circumference between the groups. However, weight, length, and transcutaneous bilirubin levels did not show a significant group-time interaction.

CONCLUSION

A formal breastfeeding coaching program should be considered in clinical settings and at home within the first few weeks postpartum.

Strategies to Eliminate Mother-to-Child Transmission of HIV in Addis Ababa, Ethiopia (Qualitative Study)

OBJECTIVE

Globally, nearly 38 million people are living with HIV, and 1.8 million are children. Each day approximately 5600 people acquire HIV. Since the emerging of HIV, 78 million people have been infected and close to 39 million have died. In developing countries, from all new HIV infections, half are because of mother-to-child transmission (MTCT). The aim of this study is to evaluate the effect of option B+ prevention of mother-to-child HIV transmission (PMTCT) and to develop strategies that contribute to eliminate MTCT in Addis Ababa, Ethiopia.

METHODS

The study was conducted in three hospitals of Addis Ababa, Ethiopia, with a qualitative approach. Sixteen (16) in-depth interviews of HIV-positive mothers who had PMTCT follow-up and six focus group discussions with health professionals who work at a PMTCT unit were conducted. To analyse the data ATLAS.ti version 7 was used.

RESULTS

According to the findings of this study mother-to-child HIV transmission was associated with lack of HIV-discordant couples counselling guideline, lack of HIV disclosure strategy and counselling guidelines, unavailability of special PMTCT counselling guideline for HIV-positive commercial sex worker mothers and lack of HIV-free human breast milk (banked human breast milk) for PMTCT. Based on the study findings, a strategy that contributes to eliminate MTCT was developed.

CONCLUSION

Based on the research finding, the following four strategies were developed. Strategy 1: establish and use banked human breast milk for elimination of MTCT; Strategy 2: incorporate obligatory policy for discordant couple testing, counselling and disclosure with option B+ PMTCT; Strategy 3: develop disclosure policy and counselling guideline for PMTCT; and Strategy 4: formulate special PMTCT guideline for HIV-positive commercial sex worker mothers.

Hidden Communities of Practice in Social Media Groups: Mixed Methods Study

BACKGROUND

Although most US mothers initiate breastfeeding, suboptimal breastfeeding rates still exist. Although breastfeeding is a complex process, social support has been linked with increases in positive breastfeeding outcomes. Recent technological advances, including the development of social networking sites, provide mothers with convenient access to a unique array of audiences from which to seek advice about parenting, including breastfeeding. However, little is known about how the use of the sites-specifically groups centered around breastfeeding-influences breastfeeding knowledge, attitudes, or behaviors.

OBJECTIVE

This mixed methods study aimed to explore utilization of an existing probreastfeeding Facebook group and how utilization influences breastfeeding-related knowledge, attitudes, and behaviors.

METHODS

Participants were recruited online through Facebook wall posts from within the existing group. Mothers aged between 18 and 50 years who were pregnant and intended to breastfeed, were currently breastfeeding, or had recently weaned their infant in the past 3 years were eligible to participate. Participants engaged in online focus group discussions (n=21) and individual interviews (n=12). Inductive content analysis of qualitative data led to the conceptualization and contextualization of a breastfeeding community of practice (COP). Using qualitative results, a quantitative survey was then developed to assess the prevalence of qualities of a COP as well as how COP usage influenced breastfeeding-related attitudes and knowledge. A total of 314 mothers completed the online survey.

RESULTS

Qualitative findings showed an overall sense of community, with subthemes of group trust, interaction, and the promotion of breastfeeding. A majority (287/314, 91.5%) of mothers initiated breastfeeding, with 69.0% (216/314) of mothers reporting exclusive breastfeeding their infant at 6 months. Approximately 98.5% (309/314) of mothers reported that the Facebook group captured and stored knowledge; therefore, information could be easily accessed and applied. In addition, 96.2% (302/317) of mothers reported that the Facebook group motivated them to share breastfeeding-related knowledge.

CONCLUSIONS

The results suggest that this existing probreastfeeding Facebook group exhibits characteristics of an online COP, which was organically formed. Utilization of the Facebook group, in the context of an online COP, could be beneficial in impacting breastfeeding-related knowledge, attitudes, and behaviors. However, further examination and exploration of breastfeeding COPs, including using this type of model as a method of lactation support or as a telemedicine framework, is a clear need.

Effects of an Infant Care Education Program for Mothers of Late-preterm Infants on Parenting Confidence, Breastfeeding Rates, and Infants' Growth and Readmission Rates

Purpose

The purpose of this study was to evaluate the effects of an education program for mothers of late-preterm infants on parenting confidence, breastfeeding rate, and infants’ growth and readmission rate.

Methods

The participants were 53 mothers of late-preterm infants (26 in the experimental group and 27 in the control group). The experimental group was administered the late-preterm care education program while the control group received standard care. The program consisted of two sessions during hospitalization after birth, one session at the time of discharge, and telephone and social networking service consultations at weekly intervals for the month following discharge. The collected data were analyzed using the t-test, χ² test, and repeated-measures analysis of variance.

Results

Parenting confidence and the breastfeeding rate were significantly higher in the experimental group than in the control group. However, there was no significant difference in the late-preterm infants’ growth and readmission rates between the experimental and control groups.

Conclusion

A care education program for mothers of late-preterm infants can be a useful nursing intervention in clinical practice.

Feeding the Late and Moderately Preterm Infant: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

Nutritional guidelines and requirements for late or moderately preterm (LMPT) infants are notably absent, although they represent the largest population of preterm infants. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (CoN) performed a review of the literature with the aim to provide guidance on how to feed infants born LMPT, and identify gaps in the literature and research priorities.Only limited data from controlled trials are available. Late preterm infants have unique, often unrecognized, vulnerabilities that predispose them to high rates of nutritionally related morbidity and hospital readmissions. They frequently have feeding difficulties that delay hospital discharge, and poorer rates of breastfeeding initiation and duration compared with term infants. This review also identified that moderately preterm infants frequently exhibit postnatal growth restriction.The ESPGHAN CoN strongly endorses breast milk as the preferred method of feeding LMPT infants and also emphasizes that mothers of LMPT infants should receive qualified, extended lactation support, and frequent follow-up. Individualized feeding plans should be promoted. Hospital discharge should be delayed until LMPT infants have a safe discharge plan that takes into account local situation and resources.In the LMPT population, the need for active nutritional support increases with lower gestational ages. There may be a role for enhanced nutritional support including the use of human milk fortifier, enriched formula, parenteral nutrition, and/or additional supplements, depending on factors, such as gestational age, birth weight, and significant comorbidities. Further research is needed to assess the benefits (improved nutrient intakes) versus risks (interruption of breast-feeding) of providing nutrient-enrichment to the LMPT infant.

Going home with baby: innovative and comprehensive support for new mothers

Shorter length of stay for postpartum mothers and their newborns necessitates careful community follow-up after hospital discharge. The vast amount of information given during the initial postpartum period can be overwhelming. New parents often need considerable support to understand the nuances of newborn care including newborn feeding. Primary health care and community services need to ensure there is a seamless continuum of care to support, empower, and educate new mothers and their families to prevent unnecessary hospital readmission and other negative health outcomes. The Healthy & Home postpartum community nursing program provides clinical communication and supports to bridge the gap between acute hospital and community follow-up care through home visits, a primary health care clinic, a breastfeeding center, a breastfeeding café, a postpartum anxiety and depression support group, bereavement support, and involvement in a Baby-Friendly Initiative™ coalition. Nurses working in the program have the acute care skills and resources to complete required health care assessments and screening tests. They are also international board-certified lactation consultants able to provide expert breastfeeding and lactation care. This paper describes how the Healthy & Home program has evolved over the past 25 years and offers suggestions to other organizations wanting to develop a postpartum program to meet the physical and mental health needs of postpartum families to promote maternal and infant wellbeing.

Evaluation of an intervention supporting breastfeeding among late-preterm infants during in-hospital stay

BACKGROUND

Late-preterm infants show lower breastfeeding rates when compared with term infants. Current practice is to keep them in low-risk wards where clinical guidelines to support breastfeeding are well established for term infants but can be insufficient for late-preterm.

OBJECTIVE

The aim of this study was to evaluate an intervention supporting breastfeeding among late-preterm infants in a maternity service in the Basque Country, Spain.

METHODS

The intervention was designed to promote parents' education and involvement, provide a multidisciplinary approach and decision-making, and avoid separation of the mother-infant dyad. A quasi-experimental study was conducted with a control (n=212) and an intervention group (n=161). Data was collected from clinical records from November 2012 to January 2015. Feeding rate at discharge, breast-pump use, incidence of morbidities, infant weight loss and hospital stay length were compared between the two groups.

RESULTS

Infants in the control group were 50.7% exclusive breastfeeding, 37.8% breastfeeding, and, 11.5% formula feeding at discharge, whereas in the intervention group, frequencies were 68.4%, 25.9%, and 5.7%, respectively (p=0.002). Mothers in the intervention group were 2.66 times more likely to use the breast-pump after almost all or all feeds and 2.09 times more likely to exclusively breastfeed at discharge. There were no significant differences in morbidities and infant weight loss between groups. Hospital stay was longer for infants who required phototherapy in the intervention group (p=0.009).

CONCLUSION

The intervention resulted in a higher breastfeeding rate at discharge. Interventions aimed to provide specific support among late-pretem infants in maternity services are effective.

The effect of a care program and social support on anxiety level in mothers of late preterm infants in Sistan and Baluchestan, Iran

Late and moderate preterm (LAMP) neonates are at risk of developing severe complications that can lead to anxiety in mothers. The aim of this study was to determine the effectiveness of a care program on the anxiety level of mothers with LAMP babies and to determine the effectiveness of the care program on the level of anxiety of new mothers in the presence of social support. This quasi-experimental study was conducted on 80 mothers whose late preterm infants were admitted to neonatal intensive care unit at Ali-ibn Abi Talib Hospital, Zahedan. Data were gathered between July 10 and October 13, 2016. The intervention group received the care program. Anxiety and social support were evaluated using the State-Trait Anxiety Inventory and Multidimensional Scale of Perceived Social Support (MSPSS), respectively. After receiving the intervention, the mean MSPSS was higher for the mothers in the intervention group (p = .0025). Additionally, they experienced less state anxiety 72 hours after discharge and 1 month after delivery (p < .0025). Regression analysis showed that mothers with higher social support were 39 percent more likely to be in the "no to moderate STAI" (<51) group. Perceived social support can mediate the effect of care programs on diminishing anxiety.

Exploring Social Media Group Use Among Breastfeeding Mothers: Qualitative Analysis

BACKGROUND

Breastfeeding is well known as the optimal source of nutrition for the first year of life. However, suboptimal exclusively breastfeeding rates in the United States are still prevalent. Given the extent of social media use and the accessibility of this type of peer-to-peer support, the role of social networking sites in enabling and supporting breastfeeding mothers needs to be further explored.

OBJECTIVE

This study aimed to leverage mothers' attitudes and behaviors of social media usage to understand effects on breastfeeding outcomes.

METHODS

Participants were recruited from 1 probreastfeeding social media group with over 6300 members throughout the United States. Online focus group discussions were conducted with 21 women; interviews were conducted with 12 mothers. Qualitative data were aggregated for thematic analysis.

RESULTS

Participants indicated that the social media group formed a community of support for breastfeeding, with normalizing breastfeeding, empowerment for breastfeeding, resource for breastfeeding, and shared experiences in breastfeeding as additional themes.

CONCLUSIONS

According to participants, social media groups can positively influence breastfeeding-related attitudes, knowledge, and behaviors as well as lead to longer duration of breastfeeding. The results of this study should be taken into account when designing interventions for breastfeeding mothers.

Microbial Community Dynamics in Mother's Milk and Infant's Mouth and Gut in Moderately Preterm Infants

Mother's own milk represents the optimal source for preterm infant nutrition, as it promotes immune defenses and gastrointestinal function, protects against necrotizing enterocolitis, improves long-term clinical outcome and is hypothesized to drive gut microbiota assembly. Preterm infants at birth usually do not receive their mother's milk directly from the breast, because active suckling and coordination between suckling, swallowing and breathing do not develop until 32-34 weeks gestational age, but actual breastfeeding is usually possible as they grow older. Here, we enrolled moderately preterm infants (gestational age 32-34 weeks) to longitudinally characterize mothers' milk and infants' gut and oral microbiomes, up to more than 200 days after birth, through 16S rRNA sequencing. This peculiar population offers the chance to disentangle the differential contribution of human milk feeding per se vs. actual breastfeeding in the development of infant microbiomes, that have both been acknowledged as crucial contributors to short and long-term infant health status. In this cohort, the milk microbiome composition seemed to change following the infant's latching to the mother's breast, shifting toward a more diverse microbial community dominated by typical oral microbes, i.e., Streptococcus and Rothia. Even if all infants in the present study were fed human milk, features typical of healthy, full term, exclusively breastfed infants, i.e., high percentages of Bifidobacterium and low abundances of Pseudomonas in fecal and oral samples, respectively, were detected in samples taken after actual breastfeeding started. These findings underline the importance of encouraging not only human milk feeding, but also an early start of actual breastfeeding in preterm infants, since the infant's latching to the mother's breast might constitute an independent factor helping the health-promoting assembly of the infant gut microbiome.

Education for WIC Peer Counselors About Breastfeeding the Late Preterm Infant

Mothers of late preterm infants need ongoing support because they often find establishing breastfeeding (BF) to be complex and difficult. Special Supplemental Nutrition Program for Women, Infants and Children peer counselors provide BF information and emotional support to new mothers in many communities. However, their current training does not include education about BF for the late preterm infant. The purpose of this report is to present important information about BF and the late preterm infant that can enhance peer counselors' ability to offer appropriate support. The effect of this education on outcomes such as BF rates, maternal self-efficacy, infant hospital readmissions, and peer counselors' self-efficacy needs to be investigated.

Breastfeeding Characteristics of Late-Preterm Infants in a Kangaroo Mother Care Unit

OBJECTIVE

To describe the breastfeeding characteristics of late-preterm infants (LPIs) in a kangaroo mother care (KMC) unit.

MATERIALS AND METHODS

In a 20-bed KMC unit, the breastfeeding of 73 purposively-selected LPIs' (mean gestational age: 34.8 weeks) was observed once-off, using the Preterm Infant Breastfeeding Behavior Scale. Participants' mean age was 9.5 days, mean number of days in the unit was 3.1 days, and mean number of days breastfeeding was 7.5 on observation.

RESULTS

Only 13.7% of participants were directly breastfeeding without supplementary naso- or orogastric feeding/cup-feeding and 86.3% received supplementary cup-feeding of expressed breast milk. Most participants did not exhibit obvious rooting (83.5%) and although most latched-on (97.3%), those who did, latched shallowly (93%). The mean longest sucking burst was 18.8 (standard deviation: 10.5) and approximately half the participants swallowed repeatedly (53.4%). The mean breastfeeding session duration was 17.8 minutes, but most participants breastfed for less than 10 minutes (76.7%). No statistically significant differences in breastfeeding characteristics were detected between participants of different chronological ages. A general trend toward more mature behaviors in participants' breastfeeding for more days was present for many breastfeeding characteristics. More infants exhibited the most mature behavior for each breastfeeding characteristic when the environment was quiet, rather than noisy and disturbing, except for depth of latching (quiet: 0%, disturbance: 15.2%).

CONCLUSION

LPIs in this sample presented with subtle breastfeeding difficulties, highlighting their need for breastfeeding support. Further research is required to examine the effect of KMC on breastfeeding in LPIs.

A Community Partnership to Support Breastfeeding Mothers of Late Preterm Infants

Mothers of late preterm infants need timely breastfeeding support after hospital discharge. Breastfeeding peer counselors with the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) can provide this support, but communication with hospitals is needed to facilitate early contact with women. We aimed to develop and implement a sustainable organizational process that would expedite support by providing WIC peer counselors access to mothers of late preterm infants before hospital discharge. Key strategies included creating a workable process; addressing barriers and stakeholder concerns; planning a pilot program to test the process; and inviting the WIC breastfeeding peer counselors to tour the hospital, meet nursing staff, and practice scripting their initial encounter with mothers. The organizational pathway currently is being implemented throughout the health system.

Integrative Review of Interventions to Promote Breastfeeding in the Late Preterm Infant

OBJECTIVE

To define the different breastfeeding interventions that promote breastfeeding exclusivity and duration in the late preterm infant and to synthesize findings from the published empirical literature on late preterm infant breastfeeding interventions.

DATA SOURCES

The databases CINAHL, Scopus, and PubMed were searched for primary research articles on breastfeeding interventions for late preterm infants. Inclusion criteria included original research studies in which authors examined a breastfeeding intervention or second-line strategy in a sample inclusive of but not necessarily limited to the gestational age range of 34 to 3667 weeks gestation, written in English, and published between 2005 and 2015.

STUDY SELECTION

Thirteen articles were identified, including five randomized controlled trials, three quasi-experimental studies, four descriptive studies, and one case study.

DATA EXTRACTION

Whittemore and Knafl's methodology guided this integrative review. Data extraction and organization occurred under the following headings: author and year, study design, level of evidence, purpose, sample, setting, results, limitations, recommendations, and intervention.

DATA SYNTHESIS

Studies on breastfeeding interventions were synthesized under four concepts within the Late Preterm Conceptual Framework: Physiologic Functional Status, Care Practices, Family Role, and Care Environment.

CONCLUSION

Most breastfeeding interventions within this integrative review had positive effects on exclusivity and duration of breastfeeding in the late preterm infant. However, second-line strategies had equivocal effects on exclusivity but had positive effects on duration. The positive effects of breastfeeding interventions on breastfeeding exclusivity and duration are highlighted in our results, and we point to the need for a focus on breastfeeding after the transition home for late preterm infants.

A qualitative study: Mothers of late preterm infants relate their experiences of community-based care

Purpose

In Alberta, the high occurrence of late preterm infants and early hospital discharge of mother-infant dyads has implications for postpartum care in the community. Shortened hospital stay and complexities surrounding the care of biologically and developmentally immature late preterm infants heighten anxiety and fears. Our descriptive phenomenological study explores mothers’ experience of caring for their late preterm infants in the community.

Methods

Eleven mothers were interviewed using a semi-structured interview guide. Interview transcripts were analysed using an interpretive thematic approach.

Findings

The mothers’ hospital experience informed their perspective that being a late preterm infant was not a “big deal,” and they tended to treat their infant as normal. “Feeding was really problem,” especially the variability in feeding effectiveness, which was not anticipated. Failing to recognize late preterm infants’ feeding distress exemplified lack of knowledge of feeding cues and tendencies to either rationalize or minimize feeding concerns. Public health nurses represent a source of informational support for managing neonatal morbidities associated with being late preterm; however, maternal experiences with public health nurses varied. Some nurses used a directive style that overwhelmed certain mothers. Seeing multiple public health nurses and care providers was not always effective, given inconsistent and contradictory guidance to care. These new and changing situations increased maternal anxiety and stress and influenced maternal confidence in care. Fathers, family, and friends were important sources of emotional support.

Conclusion

After discharge, mothers report their lack of preparation to meet the special needs of their late preterm infants. Current approaches to community-based care can threaten maternal confidence in care. New models and pathways of care for late preterm infants and their families need to be responsive to the spectrum of feeding issues encountered, limit duplication of services, and ensure consistent and effective care that parents will accept.

The Relationship Between Infant Feeding Outcomes and Maternal Emotional Well-being Among Mothers of Late Preterm and Term Infants: A Secondary, Exploratory Analysis

BACKGROUND

Late preterm birth is associated with lower rates of breastfeeding and earlier breastfeeding cessation than term birth.

PURPOSE

The objectives of this secondary analysis were to compare the incidence of exclusive breastfeeding after late preterm and term childbirth and to examine the association between infant feeding outcomes and maternal emotional well-being.

METHODS

Participants were 105 mother-infant dyads (54 late preterm and 51 term) at a southeastern US medical center. Face-to-face data collection and telephone follow-up occurred during 2009-2012.

RESULTS

Late preterm mothers were less likely to exclusively provide their milk than were term mothers during hospitalization. Feeding at 1 month did not differ between late preterm and term infants. Among late preterm mothers, (1) formula supplementation during hospitalization was associated with greater severity of anxiety than among those exclusively providing formula and (2) exclusive provision of human milk at 1 month was associated with less severe depressive symptoms than among those supplementing or exclusively formula feeding. Among term mothers, feeding outcome was not related to emotional well-being measures at either time point.

IMPLICATIONS FOR PRACTICE

Mothers of late preterm infants may particularly benefit from anticipatory guidance and early mental health screening, with integrated, multidisciplinary lactation teams to support these interrelated healthcare needs.

IMPLICATIONS FOR RESEARCH

Prospective research is critical to document women's intentions for infant feeding and how experiences with childbirth and the early postpartum period impact achievement of their breastfeeding goals.

ABM Clinical Protocol #16: Breastfeeding the Hypotonic Infant, Revision 2016

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Breastfeeding: What are the Barriers? Why Women Struggle to Achieve Their Goals

Despite recognized health benefits for both mothers and infants, significant disparities still exist in the rates of breastfeeding in the United States. Major organizations representing the health of women and children (including the Centers for Disease Control and Prevention [CDC], American Academy of Pediatrics [AAP], American Congress of Obstetrics and Gynecology [ACOG], American Academy of Family Physicians [AAFP], United Nations International Children's Emergency Fund (UNICEF), the World Health Organization [WHO], and the United States Public Health Service [PHS]) recommend exclusive breastfeeding, but statistics show that although many women initiate breastfeeding, few meet the recommended goals for duration and exclusivity. This article reviews the evidence related to barriers (prenatal, medical, societal, hospital, and sociocultural) that many mothers face, and explore the known barriers and the impact they have on a woman's ability to breastfeed her infant. Strategies will be discussed to address (and potentially overcome) some of the most common barriers women face along with a list of resources that can be useful in this effort. Gaps in care and areas that need further research will be noted. This article is targeted toward physicians and other healthcare providers who work with women and who can assist with and advocate for the removal of barriers and thereby improve the health of women and children by increasing the rates of breastfeeding initiation, duration, and exclusivity in the United States.

Failure to initiate breastfeeding among high risk obstetrical patients who intended to breastfeed

BACKGROUND

In the US, at the time of discharge from the hospital, 79% of women had initiated breastfeeding. Intention to breastfeed is a strong predictor of breastfeeding initiation; however, we reported initiation failure in 45% of women with pregestational diabetes who intended to breastfeed. Information regarding intention and initiation among women with other high risk obstetrical conditions (HROB) remains scarce.

OBJECTIVE

To ascertain demographic and clinical factors associated with breastfeeding initiation failure among women with HROB conditions who intended to breastfeed.

METHODS

The study population is comprised of 89 women with diabetes (DM), 57 who were receiving treatment for substance abuse (SA), 51 women diagnosed with miscellaneous (MISC) conditions and 32 with history of preterm labor/delivery (PTL/D). Intention to exclusively breastfeed or in combination with formula (breastfed/FF) was ascertained prenatally. Breastfeeding was considered initiated if at discharge ≥50% of their infant feedings were maternal milk. Statistics include chi-square, Wilcoxon's and logistic regression (p < 0.05).

RESULTS

Of all women, 59% initiated any breastfeeding. Intention to breastfeed/FF, lack of mother-infant contact during the first hour following birth and limited lactation consultation were predictive of initiation failure. The odds of initiation failure were 2.3 times higher among women who wished to breastfeed/FF as compared to those who wished to exclusively breastfeed. Women from the SA group had lower rates of initiation failure than the other three HROB groups.

CONCLUSION

Intention to breastfeed among women with diverse HROB conditions is similar to that of the general population; however, initiation rates are disappointingly low. Intention to exclusively breastfeed results in fewer initiation failures. Prenatal intention to combine breast and formula feeding characterize women who may benefit from specific educational programs.

Strategies to Support Sustained Breastfeeding of Late Preterm Multiple Birth Infants

Strategies to support sustained breastfeeding in late preterm multiple birth infants include developing a family-centered feeding plan in collaboration with the medical team, assessing and supporting breastfeeding sessions, promoting lactogenesis with pumping or manual expression, and activating a support system for families.

Macro preemies: no thresholds for risks or concerns

PURPOSE OF REVIEW

To provide an overview of the literature regarding medical and developmental risks for moderate to late preterm infants (32-36 weeks gestation), with particular attention to the pediatrician's role in care during both inpatient and outpatient periods.

RECENT FINDINGS

Although the risks of medical issues and developmental delays decrease with increasing gestational age, research suggests that infants born after 32 weeks' gestation often exhibit significant morbidities associated with prematurity. These infants, often referred to as 'macro preemies', have been found to be at a greater risk for medical complications secondary to immature organ systems including impairments in temperature regulation, respiratory functioning, feeding coordination, bilirubin excretion, glucose control, and infection susceptibility. Recent studies of macro preemies also suggest a higher incidence of significant deficits noted in gross and fine motor skills, speech and communication, and learning and behavior compared to their full-term counterparts. Without careful attention from birth, macro preemie infants could be susceptible to both medical issues and developmental delays.

SUMMARY

Physicians should be aware of the research regarding increased medical and developmental risks for all infants born before term in order to provide their patients with comprehensive medical and neurodevelopmental follow-up care.

The experience of breastfeeding the late preterm infant: a qualitative study

BACKGROUND

Breastfeeding confers several health advantages to both infants and mothers. For reasons that are multifactorial, infants born even a few weeks prematurely are less likely to initiate breastfeeding, and those who breastfeed do so for a shorter duration than term infants.

MATERIALS AND METHODS

Qualitative analysis of structured telephone interviews was used to examine the breastfeeding experience of mothers of late preterm infants.

RESULTS

Our study found that, among mothers of late preterm infants, breastfeeding is both a positive bonding experience and a challenging experience, fraught with physical and medical struggles and feelings of guilt and failure. When looking back at the breastfeeding experience, many mothers recount negative experiences of milk supply concerns and breast pumping and report aspiring to be able to feed at breast more and pump less with their next child.

CONCLUSIONS

Mothers of late preterm infants reported that breastfeeding was a bonding experience for themselves and their infants, and many plan to do it again if they have future children. However, these mothers also reported that their breastfeeding experience included challenges with latching and milk supply, inadequate lactation support from providers after hospital discharge, and feelings of failure. Interventions with the potential to improve the breastfeeding experience of mothers of late preterm infants include (1) nipple shields and other devices to assist with latching, (2) hand expression or supplementation with small volumes of donor milk or formula to help limit the burden of pumping, (3) provider education to improve lactation support after hospital discharge, and (4) peer support groups.

The Development and Implementation of a Prenatal Education Program for Expectant Parents of Multiples

Preparing expectant parents of multiples required a unique prenatal education program. A thorough explanation of the course layout, curriculum, and content the faculty developed for this unique 9-hour program is presented. The unique implications for parenting multiples was highlighted throughout the program, which included expectations for late pregnancy, preparation for labor and birth, assuring infant safety, learning how to provide infant care, identifying sources of support, breastfeeding information and support, potential for neonatal intensive care, postpartum depression, and providing a multiple parent's personal perspective. All classes were interactive and used active learner-based teaching strategies.

Weighing worth against uncertain work: the interplay of exhaustion, ambiguity, hope and disappointment in mothers breastfeeding late preterm infants

Poor breastfeeding outcomes among late preterm infants (LPIs) have been attributed to inadequate breast milk transfer stemming from physiological immaturities. However, breastfeeding is more than a biological phenomenon, and it is unclear how mothers of LPIs manage other factors that may also impact the breastfeeding course. Using grounded theory methods and incorporating serial post-partum interviews with several novel data collection techniques, we examined breastfeeding establishment over a 6-8-week-period among 10 late preterm mother-infant dyads recruited from a maternity hospital in Pittsburgh, Pennsylvania, USA. We found that breastfeeding in the LPI population was a fluctuating, cascade-like progression of trial and error, influenced by a host of contextual factors and events and culminating with breastfeeding continuation (with or without future caveats for duration or exclusivity of breastfeeding) or cessation. The trajectory was explained by the basic psychosocial process Weighing Worth against Uncertain Work, which encompassed the tension among breastfeeding motivation, the intensity of breastfeeding work and the ambiguity surrounding infant behaviour and feeding cues. Several sub-processes were also identified: Playing the Game, Letting Him Be the Judge vs. Accommodating Both of Us and Questioning Worth vs. Holding out Hope. If valid, our theoretical model indicates a need for earlier, more extensive and more qualified breastfeeding support for mothers of LPIs that emphasizes the connection between prematurity and observed feeding behaviours.

Short-term respiratory outcomes in late preterm infants

Objective

To evaluate short-term respiratory outcomes in late preterm infants (LPI) compared with those of term infants (TI).

Methods

A retrospective study conducted in a single third level Italian centre (2005–2009) to analyse the incidence and risk factors of composite respiratory morbidity (CRM), the need for adjunctive therapies (surfactant therapy, inhaled nitric oxide, pleural drainage), the highest level of respiratory support (mechanical ventilation – MV, nasal continuous positive airway pressure – N-CPAP, nasal oxygen) and the duration of pressure support (hours in N-CPAP and/or MV).

Results

During the study period 14,515 infants were delivered. There were 856 (5.9%) LPI and 12,948 (89.2%) TI. CRM affected 105 LPI (12.4%), and 121 TI (0.9%), with an overall rate of 1.6%. Eighty-four LPI (9.8%) and 73 TI (0.56%) received respiratory support, of which 13 LPI (1.5%) and 16 TI (0.12%) were ventilated. The adjusted OR for developing CRM significantly increased from 3.3 (95% CI 2.0-5.5) at 37 weeks to 40.8 (95% CI 19.7-84.9%) at 34 weeks. The adjusted OR for the need of MV significantly increased from 3.4 (95% CI 1.2-10) at 37 weeks to 34.4 (95% CI 6.7-180.6%) at 34 weeks. Median duration of pressure support was significantly higher at 37 weeks (66.6 h vs 40.5 h). Twin pregnancies were related to a higher risk of CRM (OR 4.3, 95% CI 2.6-7.3), but not independent of gestational age (GA). Cesarean section (CS) was associated with higher risk of CRM independently of GA, but the OR was lower in CS with labour (2.2, 95% CI 1.4-3.4 vs 3.0, 95% CI 2.1-4.2).

Conclusions

In this single third level care study late preterm births, pulmonary diseases and supportive respiratory interventions were lower than previously documented. LPI are at a higher risk of developing pulmonary disease than TI. Infants born from elective cesarean sections, late preterm twins in particular and 37 weekers too might benefit from preventive intervention.

Early feeding and neonatal hypoglycemia in infants of diabetic mothers

Objectives:

To examine the effects of early formula feeding or breast-feeding on hypoglycemia in infants born to 303 A1-A2 and 88 Class B-RF diabetics.

Methods:

Infants with hypoglycemia (blood glucose < 40 mg/dL) were breast-fed or formula-fed, and those with recurrences were given intravenous dextrose.

Results:

Of 293 infants admitted to the well-baby nursery, 87 (30%) had hypoglycemia, corrected by early feeding in 75 (86%), while 12 (14%) required intravenous dextrose. In all, 98 infants were admitted to the newborn intensive care unit for respiratory distress (40%), prematurity (33%) or prevention of hypoglycemia (27%). Although all newborn intensive care unit patients received intravenous dextrose, 22 (22%) had hypoglycemia. Of 109 hypoglycemia episodes, 89 (82%) were single low occurrences. At discharge, 56% of well-baby nursery and 43% of newborn intensive care unit infants initiated breast-feeding.

Conclusions:

Hypoglycemia among infants of diabetic mothers can be corrected by early breast-feeding or formula feeding.

Management of breastfeeding during and after the maternity hospitalization for late preterm infants

Among infants born moderately and late preterm or early term, the greatest challenge for breastfeeding management is the late preterm infant (LPI) who is cared for with the mother in the maternity setting. Breastfeeding failure among LPIs and their mothers is high. Evidence-based strategies are needed to protect infant hydration and growth, and the maternal milk supply, until complete feeding at breast can be established. This article reviews the evidence for lactation and breastfeeding risks in LPIs and their mothers, and describes strategies for managing these immaturity-related feeding problems. Application to moderately and early preterm infants is made throughout.

Moderately preterm, late preterm and early term infants: research needs

In spite of increased appreciation that all preterm infants and early term infants are at higher risk for mortality and morbidities compared with their term counterparts, there are many knowledge gaps affecting optimal clinical care for this vulnerable population. This article presents a research agenda focusing on the systems biology, epidemiology, and clinical and translational sciences on this topic.

Nutritional recommendations for the late-preterm infant and the preterm infant after hospital discharge

Early nutritional support of preterm infants is critical to life-long health and well being. Numerous studies have demonstrated that preterm infants are at increased risk of mortality and morbidity, including disturbances in brain development. To date, much attention has focused on enhancing the nutritional support of very low and extremely low birth weight infants to improve survival and quality of life. In most countries, preterm infants are sent home before their expected date of term birth for economic or other reasons. It is debatable whether these newborns require special nutritional regimens or discharge formulas. Furthermore, guidelines that specify how to feed very preterm infants after hospital discharge are scarce and conflicting. On the other hand, the late-preterm infant presents a challenge to health care providers immediately after birth when decisions must be made about how and where to care for these newborns. Considering these infants as well babies may place them at a disadvantage. Late-preterm infants have unique and often-unrecognized medical vulnerabilities and nutritional needs that predispose them to greater rates of morbidity and hospital readmissions. Poor or inadequate feeding during hospitalization may be one of the main reasons why late-preterm infants have difficulty gaining weight right after birth. Providing optimal nutritional support to late premature infants may improve survival and quality of life as it does for very preterm infants. In this work, we present a review of the literature and provide separate recommendations for the care and feeding of late-preterm infants and very preterm infants after discharge. We identify gaps in current knowledge as well as priorities for future research.

Establishing successful breastfeeding in the newborn period

The first days after delivery of a newborn infant are critical for breastfeeding establishment. Successful initiation and continuation-especially of exclusive breastfeeding-have become public health priorities, but it is fraught with many individual- and systems-level barriers. In this article, we review how hospital newborn services can be constructed or restructured to support the breastfeeding mother-infant dyad so that they can achieve high levels of breastfeeding success. Important positive and negative factors from the prenatal period, and the preparation for hospital discharge are also discussed.

Overcoming clinical barriers to exclusive breastfeeding

Although a large majority of US mothers now begin breastfeeding, exclusive breastfeeding rates fall far below national health objectives, with vulnerable populations being least likely to breastfeed exclusively. This article explores common personal and societal barriers to exclusive breastfeeding and offers evidence-based strategies to support mothers to breastfeed exclusively, such as ensuring prenatal education, supportive maternity practices, timely follow-up, and management of lactation challenges. The article also addresses common reasons nursing mothers discontinue exclusive breastfeeding, including the perception of insufficient milk, misinterpretation of infant crying, returning to work or school, early introduction of solid foods, and lack of support.

A review of postpartum depression, preterm birth, and culture

Postpartum depression (PPD) varies worldwide and is considered a serious issue because of its devastating effects on mothers, families, and infants or children. Preterm birth may be a risk factor for PPD. In 2005, the global incidence of preterm birth was estimated to be 9.6%, and of these births, 85% occurred in Africa and Asia. Among Asian countries, Pakistan has a preterm birth rate of 15.7% and the highest prevalence rate of PPD (63.3%). A literature review was therefore undertaken to better understand the potential contribution of preterm birth to PPD and to identify gaps in the scientific literature. Limited studies compare prevalence rates of PPD in mothers of full-term infants and mothers of preterm infants. Furthermore, meta-analyses examining predictors of PPD have not included preterm birth as a variable. The interrelationship between preterm birth and PPD may be explained by early parental stress and mother-infant interaction among mothers of preterm infants. Culture plays an important role in shaping communication between mothers and their infants and defines social support rituals that may or may not mediate PPD. More research is needed to provide evidence for practice.

Implementing the use of donor milk in the hospital setting: implications for nurses

Breast milk is the ideal choice for neonates, particularly for the more vulnerable neonates in the neonatal intensive care unit (NICU). When milk from the mother is not available, pasteurized donor milk is an important option, because it maintains many of its health benefits after pasteurization. Yet there are barriers to implementing the use of donor milk at a hospital. This article discusses the implementation of a donor program for pasteurized donor breast milk in the NICUs of three hospitals.

Developmental physiology of late and moderate prematurity

This is a brief review of the developmental physiology of selected organ and functional systems in moderate and late preterm infants. This outline provides a discussion of the physiological underpinnings for some of the clinical conditions seen in this group of infants, including hypothermia, hypoglycemia, respiratory distress syndrome, transient tachypnea, severe respiratory failure, apnea, feeding difficulties, jaundice, and increased susceptibility to infections.

Transitions in the early-life of late preterm infants: vulnerabilities and implications for postpartum care

The focus of this article is on the transition of late preterm infants from hospital to home. The current state of literature related to mortality, morbidities, emergency department visits, and rehospitalization underscores the vulnerability of late preterm infants following discharge from hospital. Universal provision of postpartum care to late preterm infants is viewed as an environmental support intended to facilitate transition of these vulnerable infants from hospital to home. Gaps in provision of postpartum care of late preterm infants are situated within the discussion of guidelines and models of postpartum care (home vs clinic) of late preterm infants.