Targeted program for provision of mother's own milk to very low birth weight infants

Practices supporting cue-based breastfeeding of preterm infants in neonatal intensive care units across Europe

BACKGROUND

Emerging knowledge about supportive neurodevelopmental neonatal care shows the need for an individual approach to establish breastfeeding. However, evidence on how cue-based breastfeeding is supported in neonatal intensive care units (NICUs) is scarce. Therefore, the aim was to describe supporting practices for cue-based breastfeeding.

METHOD

Through Delphi rounds, a questionnaire was developed comprising questions on the usage and occurrence of supportive practices for cue-based breastfeeding. A multinational online survey was distributed September to October in 2023 to NICUs in Europe using snowball sampling. Practices such as the practice of skin-to-skin contact (SSC), restrictions for breastfeeding, providing information to parents, observing and responding to infants' cues were explored.

RESULTS

The survey was completed by 105 neonatal units across 15 European countries. Less than half (46%) of the NICUs had no restrictions upon placing the infant in SSC with the parents. Approximately half (49%) of the NICUs stated that infants had SSC within the first hour after birth. Many units (68%) had some restriction for breastfeeding. One week after birth, 48% of the NICUs encouraged breastfeeding for infants at 33 postmenstrual age whenever the infant showed cues, regardless of scheduled tube feeding time. This percentage increased to 59% at 33-35 gestational age. Less than half of the units (47%) stated that they had the necessary tools/instruments to support the transition from tube feeding to breastfeeding. There were variations in how milk intake was assessed, such as weighing before and after breastfeeding or estimating milk intake by time spent sucking. Infants in 50% of the units had to be fed exclusively orally before discharge. Many units (65%) provided specific support to or enabled discharge before the infant was exclusively orally fed.

CONCLUSION

European NICUs employ supportive practices, SSC, early initiation of breastfeeding, and provide information to parents. Staff plays a significant role in fostering cue-based feeding in preterm infant-mother dyads. There still exist restrictions for SSC and breastfeeding. To understand the impact of different strategies and practices, there is need for evaluations by parents and testing of the implementation of cue-based feeding practices in neonatal care.

Lactation-focused audio relaxation versus standard care for mothers of very preterm infants (the EXPRESS randomised clinical trial)

BACKGROUND

Mothers of very premature newborns often have low milk supply. Systematic review has shown increased milk quantity with relaxation interventions. We hypothesised that a self-directed audio relaxation and lactation-specific visualisation would increase milk quantity after a very premature birth.

METHODS

Unmasked, randomised, controlled trial, recruiting 132 participants in four United Kingdom neonatal units. Eligible women had given birth to one or two infants between 23+0 and 31+6 weeks of gestation. The intervention was a 12-min voice recording including breathing exercises, muscle relaxation and lactation-specific visualisation. Primary outcome was the highest 24-h breastmilk weight expressed on any of day 4, day 14 or day 21 after birth.

RESULTS

Mean birth gestation was 27.8 weeks (SD 2.4), with 26% of participants giving birth under 26 weeks (34/132). Adjusted mean difference in primary outcome was 73.9 g (95% CI -61.7 to 209.5, p = 0.28). Spielberger State-Trait Anxiety Index adjusted mean difference was -1.9 (-8.2 to 4.3, p = 0.54). The majority of relaxation group participants felt the intervention was relaxing (32/42, 76%).

CONCLUSIONS

There was no beneficial effect of this relaxation intervention on milk quantity. Mothers of very premature infants may value relaxation interventions but they are unlikely to have a large effect on milk quantity.

IMPACT

This randomised trial did not show a beneficial effect of a self-directed audio relaxation and visualisation on mothers' own milk quantity expressed after very preterm birth. Mothers of very and extremely preterm infants may value relaxation interventions, but they are unlikely to have a large effect on milk quantity. Prior systematic review of mixed populations has shown an increase in mothers' own milk quantity with relaxation interventions. Combining this study with existing meta-analysis could result in a new hypothesis that the lower the gestation at birth, the smaller the impact of relaxation on milk quantity.

The Interaction of Early Exclusive Mother's Milk Feeding and Ethnic Background with Ultimate Feeding Outcomes After Very Preterm Birth

Background: Mothers of very preterm infants (born under 32 weeks' gestation) have specific lactation challenges. There is little literature related to the influences on exclusive maternal milk provision. Method: An observational cohort using prospectively entered clinical data in a single tertiary neonatal unit in the United Kingdom over a 2-year period 2019-2021. There were 112 infants born under 32 weeks' gestation who fulfilled inclusion criteria. Results: Average gestation was 27.9 ± 2.6 weeks at birth and 37.3 ± 3.3 at discharge. On day 4 after birth, 29% (31/107) received exclusive maternal milk. At discharge, 54% (60/112) received exclusive maternal milk. Exclusive maternal milk at day 4 was associated with exclusive maternal milk at discharge (adjusted relative risk 2.3, 95% confidence interval 1.5-3.6, p < 0.001). Mothers from "white other," Asian, and mixed/multiple ethnic backgrounds were more likely than white British mothers to give exclusive maternal milk at discharge. This association emerged only after adjustment for exclusive maternal milk at day 4 after birth. Conclusions: The association of minority ethnic background with feeding outcomes that has previously been noted in the United Kingdom general population was also found in this very preterm cohort. The relationship was strengthened after adjustment for exclusive maternal milk at day 4. This may suggest that establishing early milk supply is a universal barrier to later exclusive maternal milk in this population and that once milk supply is established, standard social and cultural experiences come to bear on infant feeding decisions.

Neonatal Intensive Care Unit Interventions to Improve Breastfeeding Rates at Discharge Among Preterm and Low Birth Weight Infants: A Systematic Review and Meta-Analysis

Background: While breast milk is widely accepted as the best source of nutrients for almost all newborns, breastfeeding can be especially challenging for preterm and low birth weight (LBW) infants. With increased risk of admission to neonatal intensive care units (NICUs) and separation from parents, this population experiences significant barriers to successful breastfeeding. Thus, it is crucial to identify interventions that can optimize breastfeeding for preterm and LBW infants that is continued from birth and admission, through to hospital discharge and beyond. Objectives: To identify and analyze evidence-based interventions that promote any and exclusive breastfeeding among preterm and LBW neonates at discharge and/or postdischarge from hospital. Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist. Searches were performed in the following databases: MEDLINE Ovid, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health (CINAHL). Results: From the 42 studies included, 6 groups of intervention types were identified: educational and breastfeeding support programs, early discharge, oral stimulation, artificial teats and cups, kangaroo mother care (KMC), and supportive policies within NICUs. All groupings of interventions were associated with significantly increased rates of any breastfeeding at discharge. All types of interventions except artificial teats/cups and oral stimulation showed statistically significant increases in exclusive breastfeeding at discharge. KMC demonstrated the highest increased odds of breastfeeding at discharge among preterm and LBW infants. Conclusions: A variety of effective interventions exist to promote breastfeeding among hospitalized preterm and LBW infants. Hospital settings hold unique opportunities for successful breastfeeding promotion. PROSPERO registration: CRD42021252610.

A report on parent involvement in planning a randomised controlled trial in neonatology and lactation – insights for current and future research

Background

Patient and Public Involvement (PPI) is a rich and valuable part of the process of planning, designing, carrying out and disseminating research. It is important to communicate PPI findings in detail so that the contributions of those involved are fully utilised and disseminated. The extended and iterative PPI process used within a neonatal randomised controlled trial related to the expression of breastmilk after very preterm birth is reported here.

Methods

Seven iterative stages of PPI were used. Stage 1 was informal PPI using historical interaction with parents and publicly available resources. Stage 2 was an online questionnaire open to parents of premature babies and advertised via a charity collaborator. Stage 3 was partnership with a charity collaborator. Stage 4 was a set of online panels focusing on study design and documents. Stage 5 was an interactive exercise to modify the trial intervention. Stage 6 is the presence of PPI contributors on the trial steering committee. Stage 7 is a dissemination panel. At each stage attention was paid to the diversity of participants involved, with strategies to increase the involvement of parents from under-reached groups.

Results

Six hundred and seventy-five participants responded at Stage 2, six parents were involved at Stage 4 and 12 parents at Stage 5. PPI contributed to the choice of study question, outcomes and produced a set of questions for future research. PPI impacted on the study design, with specific emphasis on reducing participant distress related to lactation, and reducing the burden of being involved in research at a time of significant stress.

Conclusions

PPI had a far-reaching influence on this neonatal randomised controlled trial during the planning and design phase, which reinforces the importance of PPI at the earliest stages of the research cycle. The online questionnaire format elicited an unexpectedly deep and broad pool of transferable insights, which will have an impact on future research focus and design in the area of lactation and prematurity. Approaches to increasing PPI involvement from under-reached populations are important and can be successful despite resource constraints.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-022-00509-1.

Comparing the effect of a lactation-specific relaxation and visualisation intervention versus standard care on lactation and mental health outcomes in mothers of very premature infants (the EXPRESS trial): study protocol for a multi-centre, unmasked, randomised, parallel-group trial

Background

Premature birth is the leading cause of neonatal death and can cause major morbidity. Maximising the amount of maternal breastmilk given to very premature infants is important to improve outcomes, but this can be challenging for parents. Parents of infants receiving neonatal care also have high rates of anxiety and distress. There is growing evidence for the impact of maternal relaxation interventions on lactation, as well as mental health. The trial will assess whether a brief self-directed relaxation and visualisation intervention, recommended for use several times a day during expression of milk, improves lactation and mental health outcomes for mothers of very premature infants.

Methods

Multi-centre, randomised, controlled, unmasked, parallel-group trial with planned 132 participants who have experienced premature birth between 23 weeks and 31 weeks and 6 days of gestation and plan to express milk for at least 14 days. The primary outcome is the highest 24-h expressed milk yield recorded on any of day 4, day 14 or day 21 after birth. Secondary outcomes include exclusive breastmilk feeding at 36 weeks post-menstrual age and at 4 months after the estimated date of delivery, Spielberger State Trait Anxiety Index at day 21 and Post-traumatic stress Check List (for DSM 5) at day 21.

Discussion

Breastmilk feeding for premature infants is an important research priority, but there are few randomised controlled trials assessing interventions to help parents reach lactation goals in this challenging context. This trial will assess whether a no cost, easily scalable relaxation tool has a role in this setting. Given the lack of harm and potential for immediate dissemination, even a small benefit could have an important global impact.

Trial registration

ISRCTN16356650. Date assigned: 19/04/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06570-9.

Quality improvement initiative to improve mother's own milk usage till hospital discharge in very low birth weight infants from a tertiary care NICU

IMPORTANCE

Mother's own milk (MOM) for premature infants is a complete nutrition. It is an ideal issue for a quality improvement (QI) initiative.

OBJECTIVE

To increase the proportionate usage of MOM as enteral feeds.

METHODS

A QI study conducted in Tertiary care NICU involving all eligible very low birth weight (VLBW) infants and mother dyads. The proportionate usages of MOM as enteral feeds were the main outcomes.

EXPOSURE

Education, milk expression, and mother-infant interaction formed the key drivers.

RESULTS

We studied 282 mother infant dyads during the QI period. The proportionate usage of MOM as the enteral feed increased from 55% (±34) at baseline to 80% (±27) during the intervention and to 88% (±16) in sustenance phase.

CONCLUSIONS

A QI initiative resulted in 60% relative improvement in proportionate usage of MOM as enteral feeds in VLBW infants during hospital stay.

A Quality Improvement Initiative to Increase Mother's Own Milk Use in a Chinese Neonatal Intensive Care Unit

Background: To evaluate the efficacy of a multidisciplinary quality improvement intervention to promote mother's own milk feeding and reduce necrotizing enterocolitis (NEC) in very low-birth-weight infants. Materials and Methods: We conducted a pre (January 2014 to March 2015)-post (April 2015 to June 2016), nonrandomized, interventional cohort study of infants born at <1,500 g birth weight and admitted to the Fudan University Children's Hospital level III neonatal intensive care unit in Shanghai. The intervention included establishing a breast milk promotion team and breast milk pumping room, educating staff and parents, and distributing teaching materials. The primary outcome was breast milk feeding rate. Secondary outcomes included incidences of NEC, NEC needing surgery, mortality, and time to full enteral feeds. Results: A total of 488 infants (210 baseline, 278 intervention) <1,500 g were enrolled. The intervention group had significantly increased feeding rates for any mother's milk (34.76% vs. 80.58%; p < 0.01) and high-volume mother's milk (≥50% of feeds; 22.86% vs. 61.15%; p < 0.01), and decreased incidence of NEC needing surgery (7.62% vs. 3.24%; adjusted odds ratio [OR] 0.32, 95% confidence interval [CI] 0.14-0.76). There were no significant differences in rates of mortality (0.5% vs. 1.49%; adjusted OR 2.10, 95% CI 0.22-19.6), NEC (10.00% vs. 7.55%; adjusted OR 0.59, 95% CI 0.31-1.14), and time to full enteral feeds (20.18 ± 1.67 days vs. 24.15 ± 1.65 days; adjusted OR = 1.09, 95% CI 0.99-1.21). Conclusions: Our quality improvement initiative increased the consumption of mother's own milk and reduced the severity of NEC in very low-birth-weight infants.

A plausible pathway of imprinted behaviors: Skin-to-skin actions of the newborn immediately after birth follow the order of fetal development and intrauterine training of movements

We hypothesize that the competence of a newborn in the first hours after birth is the direct result of behavior training that begins during the first 12 weeks of fetal life. Correlation of Widström's 9 Instinctive Stages (behaviors of the full-term newborn during the first hours after birth) with the developmental movements during fetal life demonstrate that the fetus is invested in learning specific tasks, in a specific order, that are evolutionarily necessary for survival during the first hour and beyond.

Factors associated with infants receiving their mother's own breast milk on discharge from hospital in a unit where pasteurised donor human milk is available

AIM

To determine the proportion of very preterm infants who were exclusively fed breast milk at the time of discharge home, before and after the availability of pasteurised donor human milk (PDHM).

METHODS

This was an observational retrospective cohort study with historical comparison, comparing two cohorts (<32 weeks gestational age or very low birthweight) before and after the availability of donor human milk. The main explanatory variable was the PDHM cohort: pre-PDHM or post-PDHM. The primary dichotomous outcome variable was defined as whether the baby was being fed with breast milk only at the time of discharge home, compared with those fed with artificial formula alone or mixed feeding (artificial formula and breast milk).

RESULTS

There were 1088 babies in the pre-PDHM cohort and 330 in the post-PDHM cohort (total n = 1418). Following the introduction of PDHM, 56% (185/330) were exclusively fed breast milk at the time of hospital discharge and 57% (620/1088) in the pre-PDHM cohort. The availability of PDHM is not a significant predictor of feeding outcome upon discharge (P = 0.45) when adjusted for maternal age, log-transformed post-natal age at discharge home and any congenital abnormality.

CONCLUSIONS

The availability of donor human milk in our unit is not associated with a decrease in the number of very preterm infants receiving mother's own breast milk at time of discharge home. Other factors that positively impact the successful establishment of breastfeeding in preterm babies were older maternal age, the absence of any congenital abnormality and a shorter duration of hospital stay.

Breastfeeding Trends Among Very Low Birth Weight, Low Birth Weight, and Normal Birth Weight Infants

OBJECTIVE

To examine the change in breastfeeding behaviors over time, among low birth weight (LBW), very low birth weight (VLBW), and normal birth weight (NBW) infants using nationally representative US data.

STUDY DESIGN

Univariate statistics and bivariate logistic models were examined using the Early Child Longitudinal Study-Birth Cohort (2001) and National Study of Children's Health (2007 and 2011/2012).

RESULTS

Breastfeeding behaviors improved for infants of all birth weights from 2007 to 2011/2012. In 2011/2012, a higher percentage of VLBW infants were ever breastfed compared with LBW and NBW infants. In 2011/2012, LBW infants had a 28% lower odds (95% CI, 0.57-0.92) of ever breastfeeding and a 52% lower odds (95% CI, 0.38-0.61) of breastfeeding for ≥6 months compared with NBW infants. Among black infants, a larger percentage of VLBW infants were breastfed for ≥6 months (26.2%) compared with LBW infants (14.9%).

CONCLUSIONS

Breastfeeding rates for VLBW and NBW infants have improved over time. Both VLBW and NBW infants are close to meeting the Healthy People 2020 ever breastfeeding goal of 81.9%. LBW infants are farther from this goal than VLBW infants. The results suggest a need for policies that encourage breastfeeding specifically among LBW infants.

Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort

Breast milk feeding (BMF) is associated with lower neonatal morbidity in the very preterm infant (<32 weeks gestation) and breastfeeding is beneficial for maternal health. Previous studies show large variations in BMF after very preterm birth and recognize the need for targeted breastfeeding support in the neonatal intensive care units (NICU). In a European collaboration project about evidence-based practices after very preterm birth, we examined the association between maternal, obstetric, and infant clinical factors; neonatal and maternal care unit policies; and BMF at discharge from the NICU. In multivariable analyses, covariates associated with feeding at discharge were first investigated as predictors of any BMF and in further analysis as predictors of exclusive or partial BMF. Overall, 58% (3,826/6,592) of the infants received any BMF at discharge, but there were large variations between regions (range 36-80%). Primiparity, administration of antenatal corticosteroids, first enteral feed <24 hr after birth, and mother's own milk at first enteral feed were predictors positively associated with any BMF at discharge. Vaginal delivery, singleton birth, and receiving mother's own milk at first enteral feed were associated with exclusive BMF at discharge. Units with a Baby Friendly Hospital accreditation improved any BMF at discharge; units with protocols for BMF and units using donor milk had higher rates of exclusive BMF at discharge. This study suggests that there is a high potential for improving BMF through policies and support in the NICU.

[Effect of breastfeeding quality improvement on breastfeeding rate in very low birth weight and extremely low birth weight infants]

OBJECTIVE

To study the effect of breastfeeding quality improvement on the breastfeeding rate in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants in the neonatal intensive care unit (NICU).

METHODS

A retrospective analysis was performed for the clinical data of VLBW and ELBW infants who were admitted from July 2014 to July 2015 (pre-improvement group) and those who were admitted from August 2015 to June 2016 after the implementation of breastfeeding quality improvement measures (post-improvement group). The parameters including condition of breastfeeding (breastfeeding rate, breastfeeding amount, and breastfeeding time), duration of parenteral nutrition, time to enteral feeding, and incidence of feeding intolerance were compared between the two groups.

RESULTS

The implementation of breastfeeding quality improvement measures significantly increased breastfeeding rate and amount, significantly shortened time to addition of human milk fortifier, duration of parenteral nutrition, and time to enteral feeding, and significantly decreased the incidence of feeding intolerance.

CONCLUSIONS

Breastfeeding quality improvement measures can increase breastfeeding rate in the NICU and decrease gastrointestinal complications in preterm infants.

Home care practices for preterm and term infants after hospital discharge in Massachusetts, 2007 to 2010

OBJECTIVE

The objective of this study was to compare the prevalence of home care practices in very to moderately preterm (VPT), late preterm (LPT) and term infants born in Massachusetts.

STUDY DESIGN

Using 2007 to 2010 Massachusetts Pregnancy Risk Assessment Monitoring System data, births were categorized by gestational age (VPT: 23 to 33 weeks; LPT: 34 to 36 weeks; term: 37 to 42 weeks). Home care practices included breastfeeding initiation and continuation, and infant sleep practices (supine sleep position, sleeping in a crib, cosleeping in an adult bed). We developed multivariate models to examine the association of infant sleep practices and breastfeeding with preterm status, controlling for maternal sociodemographic characteristics.

RESULTS

Supine sleep position was more prevalent among term infants compared with VPT and LPT infants (77.1%, 71.5%, 64.4%; P=0.02). In the adjusted model, LPT infants were less likely to be placed in supine sleep position compared with term infants (adjusted prevalence ratio=0.86; 95% confidence interval: 0.75 to 0.97). Breastfeeding initiation and continuation did not differ among preterm and term groups. Nearly 16% of VPT and 18% of LPT and term infants were not sleeping in cribs and 14% of LPT and term infants were cosleeping on an adult bed.

CONCLUSION

Compared with term infants, LPT infants were less likely to be placed in supine sleep position after hospital discharge. A significant percent of preterm and term infants were cosleeping on an adult bed. Hospitals may consider improving their safe sleep education, particularly to mothers of LPT infants.