Establishing Breastfeeding with the Late Preterm Infant in the NICU

Mother's Own Milk Provision During the First 12 Weeks of Life by Gestational Age

Importance

Although mother's own milk (MOM) is associated with reduced risk of neonatal complications of prematurity and improved neurodevelopmental outcomes, to our knowledge, there have been no large US studies reporting rates of MOM feeding initiation and sustained MOM feedings by gestational age (GA).

Objective

To compare rates of MOM feeding initiation and continuation at 12 weeks for infants by GA.

Design, Setting, and Participants

This retrospective cross-sectional study used state-level surveillance data for maternal characteristics and behaviors before and after pregnancy. Participants were women who gave birth from January 1 through December 31, 2021, in 36 US jurisdictions (33 states, the District of Columbia, New York City, and Puerto Rico) and completed the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire. Data were analyzed from July 2023 to April 2024.

Exposure

Infant GA, including early preterm (EPT; ≤27 weeks' gestation), moderately preterm (MPT; 28-33 weeks' gestation), late preterm (LPT; 34-36 weeks' gestation), and early term to postterm (≥37 weeks' gestation).

Main Outcomes and Measures

MOM feeding initiation and continuation at 12 weeks after delivery. Weighted multivariable binary logistic regression models were used to test the association between MOM feeding initiation and continued provision at 12 weeks after delivery by infant GA.

Results

Among 29 098 births, there were 0.4% EPT, 1.8% MPT, 6.7% LPT, and 91.1% early-term to postterm infants. Unadjusted MOM feeding initiation was highest for EPT infants (89.7% [95% CI, 85.0%-94.7%]) and lowest for LPT infants (81.8% [95% CI, 79.5%-84.1%]). For infants that initially received MOM, 71.6% (95% CI, 70.7%-72.6%) of early-term to postterm infants still received MOM at 12 weeks followed by 63.1% (95% CI, 52.9%-73.2%) of EPT infants, 61.2% (95% CI, 58.0%-64.3%) of LPT infants, and 58.6% (95% CI, 53.4%-63.8%) of MPT infants. After adjusting for maternal characteristics, LPT infants were 4.4 (95% CI, -6.7 to -2.1) percentage points less likely to initiate MOM feedings and those who received any MOM were 6.7 (95% CI, -9.9 to -3.5) percentage points less likely to receive MOM at 12 weeks compared with early-term to postterm infants. There were no differences in adjusted initiation or continuation rates among EPT (3.1 [95% CI, -1.4 to 7.5] percentage points for initiation and -0.0 [95% CI, -8.6 to 8.6] percentage points for continuation) or MPT (2.4 [95% CI, -0.5 to 5.3] percentage points for initiation and -3.3 [95% CI, -8.0 to 1.5] percentage points for continuation) infants compared with early-term to postterm infants.

Conclusions and Relevance

This cross-sectional study found that MOM feeding initiation and continuation rates at 12 weeks after birth for LPT infants were substantially lower than rates for infants with other GAs. Research is needed to pinpoint barriers to MOM feeding initiation and continuation in this vulnerable population of infants.

An Examination of the Benefits of Lactation Consultant Services in NICUs for Mothers and Their Newborn: A Systematic Review

Background: It is well accepted that lactation consultant (LC) services can enhance the breastfeeding success in mother-infant dyads. However, despite such advantages, not all neonatal intensive care units (NICUs) offer LC services. The objective of this systematic review was to assess the available evidence on the effect of LC service on breastfeeding outcomes for mothers whose infants are in the NICU. Methods: The PRISMA Extension for Systematic Reviews were used to conduct this systematic review. The following databases: Embase, Medline, CINAHL, and Cochrane library were searched. An initial 464 studies were obtained. Duplicates and studies that did not fit the inclusion criteria were removed, leaving 30 full-text articles to review. Nineteen were further excluded after full-text review. A total of 11 studies were included. Due to the heterogeneity of the included studies, a meta-analysis could not be performed, instead a qualitative numerical summary was conducted. Results: Overall, 10/11 (90%) of studies observed a 6-31% increase in the number of infants who received mother's own milk, and 11-27% in the number of infants who received direct breastfeeds associated with the implementation of LC services in the NICU. The two most common types of LC services studied included: i) multidisciplinary lactation support-described as a team-based approach that includes at least one LC and ii) designation of LC formal role in the NICU. Conclusions: This review highlights that having LC services in the NICU is vital for meeting the unique needs and enhancing breastfeeding outcomes for mothers whose infants are in the NICU.

Investigating short-stay admission to a neonatal intensive care unit as a risk factor for reduced breast feeding at discharge in infants ≥36 weeks' gestation: a retrospective cohort study

OBJECTIVE

This study aims to determine the effect of infant-mother separation following a short-stay (≤72 hours) admission to a Level 5 neonatal unit versus no admission on infant-feeding outcomes at hospital discharge.

DESIGN

Retrospective cohort study.

SETTING

An Australian Level 5 neonatal unit within a tertiary referral hospital.

PARTICIPANTS

Mothers and their infants born between 1 January 2018 and 31 December 2020 had a short-stay admission to the neonatal unit or no admission. All participants met admission criteria to the postnatal ward and were discharged home at ≤72 hours (n=12 540). Postnatal ward admission criteria included ≥36 weeks' gestation and birth weight ≥2.2 kg.

MAIN OUTCOME MEASURES

Infant feeding at discharge from hospital. Multivariate logistic regression analysis was conducted, adjusting for confounders associated with known breastfeeding issues. These included age, ethnicity, parity, obesity, socioeconomic score, hypertensive disorders of pregnancy, diabetes, infant gestation and birthweight centile, caesarean section birth, postpartum haemorrhage and skin-to-skin contact.

RESULTS

Of the 12 540 live births meeting inclusion criteria, 1000 (8%) infants were admitted to the neonatal unit. The primary reasons for admission were suspicion of sepsis (24%), maternal diabetes (19%) and jaundice (16%). We found a reduction in full breast feeding at hospital discharge in cases of a short admission to the neonatal unit compared with no admission (aOR 0.40; 95% CI 0.34 to 0.47; p<0.001). We identified that women of different ethnicities had differing levels of risk for formula supplementation at hospital discharge. The ethnic grouping least likely to be fully breast feeding at discharge was Southeast Asian women (aOR 0.47; 95% CI 0.39 to 0.57; p<0.001).

CONCLUSIONS

Identifying mother-infant dyads at risk of non-exclusive breast feeding at hospital discharge will help target resources for practice improvement.

Exclusive breastfeeding of full-term infants during the first 6 months after discharge from a neonatal unit in China: A cross-sectional study

OBJECTIVES

To elucidate breastfeeding patterns, the reasons for stopping exclusive breastfeeding, and the sociodemographic characteristics associated with exclusive breastfeeding of full-term infants during the 6 months after discharge from a neonatal unit in China.

METHODS

This cross-sectional study included mothers of full-term infants who were discharged from the 40-bed neonatal unit (level IIA) of a tertiary hospital in Hunan province, China between August 2019 and September 2020. Information on breastfeeding patterns was collected through telephone interviews with the mothers 6 months after their infants had been discharged from the neonatal unit. Binary logistic regression was used to determine the factors associated with exclusive breastfeeding.

RESULTS

This study included 489 mother-infant dyads. At 6 months after discharge, 51.5% of mothers were exclusively breastfeeding, 29.0% of mothers were partially breastfeeding, and 19.4% of mothers were not breastfeeding. The most common reason for stopping breastfeeding was "poor milk supply" (81.2%). Factors associated with exclusive breastfeeding included multiparity, exclusive breastfeeding before the hospitalization, providing breast milk to the hospitalized infant, and a high level of maternal education.

CONCLUSIONS

In the Chinese culture, mothers who experienced multiparity and higher-level education were more likely to breastfeed their infants to 6 months after discharge from the neonatal unit. In addition, infants who were exclusively breastfed before and during hospitalization were also more likely to be exclusively breastfed after discharge. The results will help inform future research aimed at identifying interventions to reduce early breastfeeding cessation.

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.

Passive and active immunity in infants born to mothers with SARS-CoV-2 infection during pregnancy: prospective cohort study

OBJECTIVE

To investigate maternal immunoglobulins' (IgM, IgG) response to SARS-CoV-2 infection during pregnancy and IgG transplacental transfer, to characterise neonatal antibody response to SARS-CoV-2 infection, and to longitudinally follow actively and passively acquired antibodies in infants.

DESIGN

A prospective observational study.

SETTING

Public healthcare system in Santa Clara County (California, USA).

PARTICIPANTS

Women with symptomatic or asymptomatic SARS-CoV-2 infection during pregnancy and their infants were enrolled between 15 April 2020 and 31 March 2021.

OUTCOMES

SARS-CoV-2 serology analyses in the cord and maternal blood at delivery and longitudinally in infant blood between birth and 28 weeks of life.

RESULTS

Of 145 mothers who tested positive for SARS-CoV-2 during pregnancy, 86 had symptomatic infections: 78 with mild-moderate symptoms, and 8 with severe-critical symptoms. The seropositivity rates of the mothers at delivery was 65% (95% CI 0.56% to 0.73%) and the cord blood was 58% (95% CI 0.49% to 0.66%). IgG levels significantly correlated between the maternal and cord blood (Rs=0.93, p<0.0001). IgG transplacental transfer ratio was significantly higher when the first maternal positive PCR was 60-180 days before delivery compared with <60 days (1.2 vs 0.6, p<0.0001). Infant IgG seroreversion rates over follow-up periods of 1-4, 5-12, and 13-28 weeks were 8% (4 of 48), 12% (3 of 25), and 38% (5 of 13), respectively. The IgG seropositivity in the infants was positively related to IgG levels in the cord blood and persisted up to 6 months of age. Two newborns showed seroconversion at 2 weeks of age with high levels of IgM and IgG, including one premature infant with confirmed intrapartum infection.

CONCLUSIONS

Maternal SARS-CoV-2 IgG is efficiently transferred across the placenta when infections occur more than 2 months before delivery. Maternally derived passive immunity may persist in infants up to 6 months of life. Neonates are capable of mounting a strong antibody response to perinatal SARS-CoV-2 infection.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.

Passive and active immunity in infants born to mothers with SARS-CoV-2 infection during pregnancy: Prospective cohort study

OBJECTIVE

To investigate maternal immunoglobulins' (IgM, IgG) response to SARS-CoV-2 infection during pregnancy and IgG transplacental transfer, to characterize neonatal antibody response to SARS-CoV-2 infection, and to longitudinally follow actively- and passively-acquired SARS-CoV-2 antibodies in infants.

DESIGN

A prospective observational study.

SETTING

A public healthcare system in Santa Clara County (CA, USA).

PARTICIPANTS

Women with SARS-CoV-2 infection during pregnancy and their infants were enrolled between April 15, 2020 and March 31, 2021.

OUTCOMES

SARS-CoV-2 serology analyses in the cord and maternal blood at delivery and longitudinally in infant blood between birth and 28 weeks of life.

RESULTS

Of 145 mothers who tested positive for SARS-CoV-2 during pregnancy, 86 had symptomatic infections: 78 with mild-moderate symptoms, and eight with severe-critical symptoms. Of the 147 newborns, two infants showed seroconversion at two weeks of age with high levels of IgM and IgG, including one premature infant with confirmed intrapartum infection. The seropositivity rates of the mothers at delivery was 65% (95% CI 0.56-0.73) and the cord blood was 58% (95% CI 0.49-0.66). IgG levels significantly correlated between the maternal and cord blood (Rs= 0.93, p< 0.0001). IgG transplacental transfer ratio was significantly higher when the first maternal positive PCR was 60-180 days before delivery compared to <60 days (1.2 vs. 0.6, p=<0.0001). Infant IgG negative conversion rate over follow-up periods of 1-4, 5-12, and 13-28 weeks were 8% (4/48), 12% (3/25), and 38% (5/13), respectively. The IgG seropositivity in the infants was positively related to IgG levels in the cord blood and persisted up to six months of age.

CONCLUSIONS

Maternal SARS-CoV-2 IgG is efficiently transferred across the placenta when infections occur more than two months before delivery. Maternally-derived passive immunity may protect infants up to six months of life. Neonates mount a strong antibody response to perinatal SARS-CoV-2 infection.

Barriers and Facilitators to Breastfeeding in Moderate and Late Preterm Infants: A Systematic Review

Rationale: Most of the preterm infants are born between 32 and 36 weeks of gestation (moderate to late preterm infants [MLPIs]). This comes with significant short- and long-term risks. Breastfeeding reduces many of these risks, but breastfeeding rates in MLPIs are lower than those in full-term infants. We performed a systematic review of studies identifying factors associated with successful breastfeeding in MLPIs and interventions to improve breastfeeding. Methods: Systematic search performed using PubMed April 24, 2020. In total, 11 articles describing barriers to breastfeeding in MLPIs and 6 articles about interventions to improve breastfeeding were included. Interventions were categorized according to different outcomes: breastfeeding initiation, continuation for 5 days to 6 weeks, and continuation ≥3 months. Because of heterogeneity in study characteristics, no meta-analysis was performed. Results: Breastfeeding rates were lower in those with lower socioeconomic status and single-parent households. Providing parents with more information and direct health care support significantly improved breastfeeding initiation. Cup feeding instead of bottle feeding had inconsistent effects on breastfeeding initiation and continuation. Continuous skin-to-skin contact did not affect breastfeeding initiation or continuation. Discussion: Risk groups for lower breastfeeding rates of MLPIs include mothers with lower socioeconomic status and single mothers. Interventions that may improve breastfeeding include cup feeding and providing parents with more information and health care support. Key limitations of included studies are lack of adequate adjustment for confounders and lack of blinding. However, this is the first systematic review identifying both risk groups and interventions to improve breastfeeding in MLPIs.

Duration of breastmilk feeding of NICU graduates who live with individuals who smoke

BACKGROUND

Breast milk has many benefits for infants, but initiating breastfeeding/pumping can be difficult for mothers of preterm infants, especially those who smoke (or live with individuals who smoke). The primary aim of this study was to identify risks for breastfeeding/pumping cessation with neonatal intensive care unit (NICU) infants' mothers who smoke or live with individuals who smoke, using a novel survival-analytic approach.

METHODS/DESIGN

Mothers (N = 360) were recruited for a secondhand smoke prevention intervention during infants' NICU hospitalizations and followed for ~6 months after infant discharge. Data were obtained from medical records and participant self-report/interviews.

RESULTS

The sample was predominantly ethnic/racial minorities; mean age was 26.8 (SD = 5.9) years. One-fifth never initiated breastfeeding/pumping (n = 67; 18.9%) and mean time-to-breastfeeding cessation was 48.1 days (SD = 57.2; median = 30.4 [interquartile range: 6.0-60.9]). Education, length of stay, employment, race/ethnicity, number of household members who smoke, and readiness-to-protect infants from tobacco smoke were significantly associated with breastfeeding cessation. Further, infants fed breast milk for ≥4 months had 42.7% more well-child visits (p < 0.001) and 50.0% fewer respiratory-related clinic visits (p < 0.05).

CONCLUSIONS

One-quarter of infants admitted to NICUs will be discharged to households where individuals who smoke live; we demonstrated that smoking-related factors were associated with mothers' breastfeeding practices. Infants who received breast milk longer had fewer respiratory-related visits.

IMPACT

One-quarter of NICU infants will be discharged to households where smokers live. Initiating/sustaining breastfeeding can be difficult for mothers of preterm NICU infants, especially mothers who smoke or live with others who smoke. Education, employment, race/ethnicity, length of stay, household member smoking, and readiness-to-protect infants from tobacco smoke were significantly associated with time-to-breastfeeding cessation. Infants fed breast milk for ≥4 months had 42.7% more well-child visits and 50.0% fewer respiratory-related clinic visits, compared to infants fed breast milk <4 months. Data support intervention refinements for mothers from smoking households and making NICU-based healthcare workers aware of risk factors for early breastfeeding cessation.

Breastfeeding Plan of Care for the Late Preterm Infant From Birth Through Discharge

The focus of this clinical practice case is on the initiation of successful breastfeeding in the late preterm infant. The exploration of a case of a late preterm infant born at 360/7 weeks' gestation, delivered via cesarean section, at risk for breastfeeding challenges. Common difficulties encountered in the late preterm, defined as 340/7 to 366/7 weeks' gestation, include delayed lactogenesis, decreased milk transfer, and ineffective suck and swallow. This may lead to hospital readmission due to inadequate weight gain, dehydration, and/or hyperbilirubinemia. These difficulties often result in premature breastfeeding cessation. A management strategy incorporating an individualized mother's breastfeeding plan of care across 2 care continuums is a unique feature in this case presentation. Assessment of the mother-infant dyad provides the foundation to develop clinical strategies to initiate prompt individualized lactation support for the late preterm infant. Interventions focus on establishing maternal milk supply, facilitating milk transfer, and providing breast milk to the newborn. This case illustrates how developing an individualized in-hospital breastfeeding plan for the late preterm infant, followed by comprehensive primary care follow-up at discharge, can reduce the risk factors that lead to readmission in the late preterm birth and promote breastfeeding success.

[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.

Longer duration of kangaroo care improves neurobehavioral performance and feeding in preterm infants: a randomized controlled trial

AIM

To investigate the effect of kangaroo care (KC) and its duration on neurobehavioral performance, stress response, breastfeeding success, and vital signs in premature infants.

METHODS

One hundred and twenty premature infants were randomized to receive either KC for 60 min daily, KC for 120 min daily or conventional care (controls) for at least 7 days. Salivary cortisol was measured before and after the first KC session and then after 7 days. Temperature, respiration rate, heart rate, and oxygen saturation were recorded, before and after KC. Neonates were evaluated by the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS).

RESULTS

Both KC groups demonstrated higher scores for attention, arousal, regulation, nonoptimal reflexes, and quality of movements and lower scores for handling, excitability, and lethargy, compared to controls (p < 0.05). Both KC groups had higher infant breastfeeding assessment tool score and reached full enteral feeds faster than controls (p < 0.05). After the first KC session, improvement in O₂ saturation and temperature was observed in KC 120-min group compared with the KC 60-min group (p < 0.05). Salivary cortisol decreased in both KC groups compared with controls after 7 days (p < 0.05).

CONCLUSION

Preterm neonates who receive KC for long durations reach full enteral feeds faster, have better breastfeeding success, neurobehavioral performance, thermal control, and tissue oxygenation.

Effects of a Breastfeeding Support Program on the Prevalence of Exclusive Breastfeeding and Growth in Late Preterm Infants

Purpose

The purpose of this study was to investigate the effects of a breastfeeding support program (BSP) on the prevalence of exclusive breastfeeding and growth in late-preterm infants.

Methods

A quasi-experimental study was conducted. The participants were 40 late preterm infants (LPIs), of whom 20 were assigned to the experimental group and 20 to the control group. For the mothers in the experimental group, a BSP was provided prior to the LPIs’ discharge and reinforced once a week for 4 weeks. Information on the feeding type was collected by observation and the LPIs’ body weight was measured.

Results

There were significant differences in feeding type by group and time. Exclusive breastfeeding was 5.18 times more common in the experimental group than in the control group (odds ratio=5.18, 95% confidence interval=1.11~16.70). However, weekly weight gain did not show a significant relationship with group and time (F=0.40, p=.712).

Conclusion

The BSP was helpful for increasing the rate of exclusive breastfeeding in LPIs. Furthermore, the LPIs in the experimental group, which had a higher likelihood of being exclusively breastfed, showed an equivalent amount of weight gain as the LPIs in the control group, in which infants were more likely to be formula-fed.

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.

Late Preterm Infants: Morbidities, Mortality, and Management Recommendations

Infants born between 34 weeks 0 days and 36 weeks 6 days of gestation are termed late preterm. This group accounts for the majority of premature births in the United States, with rates increasing in each of the last 3 years. This increase is significant given their large number: nearly 280,000 in 2016 alone. Late preterm infants place a significant burden on the health care and education systems because of their increased risk of morbidities and mortality compared with more mature infants. This increased risk persists past the newborn period, leading to the need for continued health monitoring throughout life.

Factors Affecting Breastfeeding Outcomes at Six Months in Preterm Infants

BACKGROUND:

Preterm mother-infant dyads often face many obstacles to breastfeeding. Preterm infants are at highest risk for low rates of exclusive breastfeeding.

RESEARCH AIM:

To determine the prevalence of breastfeeding at 6 months among preterm infants and to identify factors that influenced mothers' breastfeeding practices.

METHODS:

A longitudinal observational study was conducted in a metropolitan hospital in Beijing, China. Mothers ( N = 270) and their preterm infants ( N = 280) were included in the study. Characteristics of preterm mothers and their perceptions of breastfeeding self-efficacy, knowledge, social support, and postpartum depression symptoms were measured at the discharge of neonatal intensive care. Breastfeeding data were collected by phone interview at 6 months corrected age.

RESULTS:

At discharge, mothers of very preterm infants perceived a lower level of breastfeeding self-efficacy (measured with the Breastfeeding Self-Efficacy Scale-Short Form) and had a higher level of depression symptoms (measured with the Edinburgh Postnatal Depression Scale [EPDS]) than mothers of moderate and late preterm infants ( p < .05-.01). Nearly half of all mothers had an elevated EPDS score, considered to be symptomatic of postpartum depression. At 6 months, only 22.5% of all infants were exclusively breastfeeding. Factors associated with exclusive breastfeeding, including younger maternal age, previous breastfeeding experience, shorter mother-infant separation time during intensive care, older infant gestational age, and a higher level of breastfeeding self-efficacy, significantly predicted exclusive breastfeeding practice ( p < .05-.001).

CONCLUSION:

The prevalence of breastfeeding at 6 months for preterm infants in this sample was low. Strategies to improve breastfeeding duration for preterm infants are needed, including support and education of mothers while in the hospital.

The influence of time of birth and seasonal variations on weight loss in breastfeeding neonates

BACKGROUND

Breastfeeding (BF) neonates generally lose weight after birth. Neonatal factors like gestational age, birth weight and mode of delivery can affect the neonatal weight loss after birth. Similarly, maternal age, parity and illness may contribute to newborn weight loss. However, influence of the time of birth and season on changes in weight is not well elucidated.

OBJECTIVE

The aim of this study is to determine the effect of birth time and the seasonal variations on weight loss in BF newborns.

METHODS

In this retrospective study of a prospectively maintained database of two sets of groups, from January 2013 to October 2016, were evaluated- Birth time group and Seasonal group; Birth time of the groups was: night time 7pm to 7am and day time 7am to 7pm; and the seasonal variations groups studies were summer, fall, winter and spring. Weight loss of >5%, 7%, and 10% at <24 hours (h), 48 h and 72 h of birth, respectively, were considered as a significant weight loss. Preterm, exclusively formula fed and neonates admitted to NICU were excluded.

RESULTS

A total of 2044 newborns were analyzed. In the birth time group, babies born during the night time had significantly lost >5% of birth weight at <24 h (p < 0.01) and >7% birth weight at <48 h of life (p < 0.02). Weight loss >10% at <72 h was similar in both birth time cohorts. C-section, prolonged rupture of membrane, and maternal pre-delivery hospital stay for >12 h were significant contributing factors. Whereas, seasonal variations were not associated with weight loss in neonates.

CONCLUSION

BF babies born at night time lose significantly more weight during the first two days of life and seasonal association was not found to affect weight loss in the neonates.

Outcomes of infants born near term: not quite ready for the "big wide world"?

Until recently, there has been a strongly held belief on the part of neonatal and pediatric clinicians that outcomes for infants born close to term are not different from those of babies born at full term. In the last decade, however, this assumption has been challenged by reports suggesting that this is not correct, and highlighting differences in morbidity and mortality both in the short and long term. This has led to development of new terminology to more accurately reflect the impact of immaturity associated with birth at 32-33 weeks (moderately preterm) and 34-36 weeks (late preterm) of gestation. These babies account for around 5-7% of all births and more than 75% of the preterm births in developed countries, so this new recognition of the associated increase in adverse outcomes may have a substantial impact on health care services. This review article will discuss the changing perceptions and concepts of gestational age in the preterm population, and explore the recent and emerging evidence around neonatal, early childhood, school-age, adolescent and adult outcomes for babies who are born moderately preterm and late preterm. It highlights important neonatal and childhood morbidities and will summarize associated health care, developmental and educational problems of affected children. The implications for the provision of ongoing primary and secondary health care, educational and social support to this large and heterogeneous group of individuals will be discussed.

Outcomes Associated With Type of Milk Supplementation Among Late Preterm Infants

OBJECTIVE

To assess whether type of milk supplementation provided to breastfeeding late preterm infants was associated with hospital length of stay (LOS) or breastfeeding status at discharge.

DESIGN

Retrospective chart review.

SETTING

Tertiary care teaching hospital in the southern United States.

PARTICIPANTS

Late preterm infants 35 0/7 to 36 6/7 weeks gestational age (N = 183) admitted to the mother-baby unit between November 1, 2014, and October 31, 2016.

METHODS

The exposure of interest was type of milk supplementation, for example, expressed human milk, pasteurized donor human milk, and formula. Outcomes measured were LOS and breastfeeding status at discharge. Generalized Poisson regression models were used to compare LOS by type of milk supplementation. Modified Poisson regression models were used to estimate risk ratios and 95% confidence intervals for associations with breastfeeding status at discharge.

RESULTS

The LOS for breastfed infants supplemented with expressed human milk and/or pasteurized donor human milk did not differ significantly from exclusively breastfed infants who received no supplement. Exclusively formula-fed infants had longer LOS of 3.2 days compared with 2.6 days for exclusively breastfed infants (p = .001). Breastfed infants who received any formula supplementation were 16% less likely to continue breastfeeding until day of discharge compared with breastfed infants who received human milk supplementation (risk ratio = .84, 95% confidence interval [.77, .92]).

CONCLUSION

The high prevalence of supplementation among breastfeeding late preterm infants underscores the potential effect of type of milk supplementation on LOS and breastfeeding outcomes. Our findings suggest that human milk supplementation discourages transition to formula feeding before hospital discharge without increasing LOS.

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.

Utilization of the Premature Birth Knowledge Scale to Assess Pediatric Provider Knowledge of Neurodevelopmental Outcomes

INTRODUCTION

Prematurity affects a significant portion (10-12%) of children in the Unites States, with potential for physical, psychological, neurodevelopmental, and behavioral impairments continuing long past the neonatal period. The specific aim of this research was to evaluate pediatric primary and specialty care providers' knowledge and understanding of neurodevelopmental outcomes of children born prematurely.

METHODS

Pediatric nurse practitioner (PNP) members of the National Association of Pediatric Nurse Practitioners participated in an online survey using the 33-item Premature Birth Knowledge Scale (PB-KS) to assess their knowledge of current neurodevelopmental outcomes of children born prematurely.

RESULTS

Neither years of practice as a registered nurse nor as a PNP predicted performance on the PB-KS. The mean score on the PB-KS in the PNP sample was 17.8 (possible score = 0-33), with a mean accuracy of 53.9%. Higher scores on the PB-KS were correlated with higher perceived level of preparation to care for children born prematurely.

DISCUSSION

To our knowledge, this is the first study to use the PB-KS with pediatric primary and specialty providers. PNPs are uniquely situated to educate and support families facing the long-term consequences of premature birth; to do so they must maintain accurate understanding of current outcomes.

Breastfeeding the late preterm infant: experiences of mothers and perceptions of public health nurses

BACKGROUND

The promotion and maintenance of breastfeeding with late preterm infants (LPIs) remain under examined topics of study. This dearth of research knowledge, especially for this population at-risk for various health complications, requires scientific investigation. In this study, we explore the experiences of mothers and the perceptions of public health nurses (PHNs) about breastfeeding late preterm infants in Calgary, Alberta, Canada.

METHODS

We used an exploratory mixed methods design with a convenience sample of 122 mothers to gather quantitative data about breastfeeding. We collected qualitative data by means of individual face-to-face interviews with 11 mothers and 10 public health nurses. Data were collected from April 2013 to June 2014. We then employed an interpretive thematic analysis to identify central themes and relationships across narratives.

RESULTS

We collected 74 complete data sets about breastfeeding. During the first 6-8 weeks postpartum, 61 mothers breastfed their infants. Of these, 51 partially breastfed and 10 exclusively breastfed. For qualitative purposes, the researchers interviewed 11 mothers with late preterm babies and three themes emerged: significant difficulty with breastfeeding, failing to recognize the infant's feeding distress and disorganized behavior, and the parental stress caused by the multiple feeding issues. The public health nurses' comments reinforced and expanded on what the mothers reported. The themes for the nurses included: challenges with initiating breastfeeding, challenges during breastfeeding, and the need for stimulation during breastfeeding.

CONCLUSION

Mothers face challenges when breastfeeding their late preterm infants and public health nurses can guide them through this experience. Families with a late preterm infant need to be informed about the challenges associated with breastfeeding a late preterm infant. It is necessary for all health care professionals to receive proper training on safe and effective breastfeeding of late preterm infants. It is essential for public health nurses to communicate effectively with families of late preterm infants to provide anticipatory guidance about potential challenges and strategies to resolve any breastfeeding problems.