Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters Elisabet Mattsson, RNM, PhD (Pediatric nurse/Midwife)a,b,n, Eva-Lotta Funkquist, RNM, PhD (Midwife)b, Maria Wickström, RNM, MScN (Midwife)c, Kerstin H. Nyqvist, RN, MScN, PhD (Associate Professor emerita)b, Helena Volgsten, RNM, PhD (Midwife)b a
Department of Public Health and Caring Sciences, Uppsala University, Sweden Department of Women's and Children's Health, Uppsala University, Sweden c Children's Hospital, Uppsala University Hospital, Sweden b
art ic l e i nf o
a b s t r a c t
Article history: Received 18 July 2014 Received in revised form 26 November 2014 Accepted 22 December 2014
Objectives: to compare the influence of supplementary artificial milk feeds on breast feeding and certain clinical parameters among healthy late preterm infants given regular supplementary artificial milk feeds versus being exclusively breast fed from birth. Design: a comparative study using quantitative methods. Data were collected via a parental diary and medical records. Methods: parents of 77 late preterm infants (34 5/7–36 6/7 weeks), whose mothers intended to breast feed, completed a diary during the infants' hospital stay. Findings: infants who received regular supplementary artificial milk feeds experienced a longer delay before initiation of breast feeding, were breast fed less frequently and had longer hospital stays than infants exclusively breast fed from birth. Exclusively breast-fed infants had a greater weight loss than infants with regular artificial milk supplementation. A majority of the mothers (65%) with an infant prescribed artificial milk never expressed their milk and among the mothers who used a breast-pump, milk expression commenced late (10–84 hours after birth). At discharge, all infants were breast fed to some extent, 43% were exclusively breast fed. Key conclusions: clinical practice and routines influence the initiation of breast feeding among late preterm infants and may act as barriers to the mothers' establishment of exclusive breast feeding. & 2015 Published by Elsevier Ltd.
Keywords: Premature neonates Breast feeding Breast milk supplementation
Introduction Infants born between 34 0/7 and 36 6/7 weeks of gestational age (GA) should preferably be referred to as ‘late preterm,’ rather than as ‘near term,’ to better convey their vulnerability and need for closer monitoring and follow up (Raju et al., 2006). Late preterm infants (LPIs) are at an increased risk for bradycardia, feeding difficulties, hypoglycaemia, jaundice, respiratory distress, sepsis, temperature instability, and hospital readmission (Engle et al., 2007; Celik et al., 2013). Despite the risks associated with prematurity, these infants are often managed in postnatal units instead of special units with qualified health-care professionals assigned to LPI care during the immediate postpartum recovery n Corresponding author at: Department of Public Health and Caring Sciences, Psychosocial Oncology and Supportive Care, Box 564, Uppsala University, S-751 22 Uppsala, Sweden. E-mail address: [email protected] (E. Mattsson).
period following birth (Engle et al., 2007; Phillips et al., 2013). A lower breast-feeding prevalence has been reported for LPIs in comparison with term infants (Demirci et al., 2013) and preterm infants born at less than 34 weeks of GA (Jang et al., 2012). Preterm infants have problems in co-ordinating respiration with sucking and swallowing when they are bottle fed (Gewolb and Vice, 2006). This is the reason for assessing preterm infants' readiness for introduction of oral feeding (Fujinaga et al., 2013). In contrast, the capacity for nutritive sucking at the mother's breast has been observed in preterm and very preterm infants of 28 weeks gestation (Nyqvist et al., 1999). However, there are wide individual variations in nutritive sucking competence that are unrelated to GA at birth or birth weight (Nyqvist et al., 2001). The Academy of Breastfeeding Medicine recommends LPI be breast fed as much as possible and argues the World Health Organization (WHO) Baby Friendly Hospital Initiative with Ten Steps to Successful Breastfeeding (BFHI) also applies to these infants (Academy of Breastfeeding, 2011). An expert group from the Nordic countries
http://dx.doi.org/10.1016/j.midw.2014.12.004 0266-6138/& 2015 Published by Elsevier Ltd.
Please cite this article as: Mattsson, E., et al., Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2014.12.004i
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and Quebec, Canada, has commenced the process of adapting the BFHI program to the special needs of preterm, low-birthweight, and sick infants and their mothers (Nyqvist et al., 2013). Kangaroo mother care is an important factor to consider when planning the care of LPIs and their mothers. It has been concluded that skin-to-skin care between low-birthweight/preterm infants and their mothers maintains infant body temperature, enhances long-term cognitive development, and facilitates breast feeding and breast milk production (Britton et al., 2007; Nyqvist et al., 2010; Feldman et al., 2014). In addition, skin-to-skin care increases maternal attachment behaviour in the postpartum period and reduces maternal anxiety (Feldman et al., 2014). The prerequisites for successful breast feeding are optimised when LPIs commence nursing within one hour after birth (Santos et al., 2008), have free access to the breast and, are breast fed at least 8–12 times per day (Britton et al., 2007). However, unless a feeding regimen adapted to the infants' current nutritive sucking capacity is applied (Nyqvist et al., 1999), their immature physiology may decrease feeding efficiency and increase the length of each feed (Santos et al., 2008); thus increasing the risk of malnutrition (Walker, 2008) and negatively affecting breastfeeding duration (Donath and Amir, 2008). Among breast-fed infants, LPIs are more likely to require hospital-related care and readmission to hospital than term infants do. However, a comparison of readmission rates between LPIs and term infants who were not breast fed found no difference (Tomashek et al., 2006). This highlights the need for guidelines to promote, support, and sustain breast feeding with particular attention to late preterm infants' special vulnerabilities. The objective of this study was to compare the influence of supplementary artificial milk feeds on breast feeding and certain clinical parameters among healthy LPIs given regular supplementary artificial milk feeds with LPIs exclusively breast fed from birth. More specifically, were there any differences between the groups with regard to – The mothers' patterns of breast feeding and milk expression, and use of nipple shield? – The infants' age at the first breast feeding occasion? – The infants' weight loss and age at commencement of weight gain after birth? – Incidence of hypoglycaemia and neonatal jaundice requiring phototherapy? – Duration of hospital stay? – Exclusive breast feeding at discharge? – Readmission to hospital after discharge?
stayed with their infants in hospital until their babies were discharged, and the majority of fathers/partners stayed together with the mother and the new-born baby in family rooms during the period of postnatal care. Siblings had free visiting hours but were not allowed to stay overnight. The midwifery care was provided by a midwife working with an assistant nurse and neonatologists directed the infants' medical care plan. Mothers intending to breast feed were offered individualised support to facilitate the establishment of lactation and exclusive breast feeding as soon as possible. To enable a first breast feed as soon as possible after birth all infants were placed skin-to-skin on their mother immediately after birth. In the wards, skin-to-skin contact between the infant and the mother/father was recommended. Feeding policy The postnatal feeding policy prescribed artificial milk supplementation for LPIs fully artificial milk fed according to the following schedule: postnatal day 0: a total daily volume of 70–80 ml/kg a day; day 1: 80–90 ml; day 2: 90–100 ml; and, day 3: 100–110 ml and so on up to 160–170 ml/kg a day. There was a milk bank at the study hospital, but donor breast milk was reserved for infants at the NICU and not available for infants at the postnatal wards because of a limited supply. The artificial milk supplementation of LPIs born at a GA o36 0/7 weeks commenced within one to two hours after birth, whereas supplementation with artificial milk to infants born Z36 0/7 was based on assessment of the infant's competence to suck and signs of hypoglycaemia. The artificial milk feeds were initially given every two/three hours and then gradually reduced until breast feeding was established. Blood glucose levels were monitored every two hours, from approximately three hours of age, during the first 24 hours after birth. The total daily volume of artificial milk supplementation was reduced individually, based on the infant's progress in milk intake, assessed by observations of active suckling behaviour, audible swallowing, and signs of fresh milk in the infant's mouth, ability to maintain blood glucose levels, and by daily assessment of the infant's weight. The wards had no written guidelines regarding routinely prescribed artificial milk supplementation following weight loss. Test-weighing before and after breast feeding was used when mothers wanted. Infants were fed by cup, if breast feeding, to comply with the International Code of Marketing of Breast Milk Substitutes in order to reduce incorrect latching, superficial suckling at the breast (Geddes et al., 2013) and transition difficulties from bottle to breast (Naylor, 2001). Sample
Methods Study design The study was prospective, with a quantitative and comparative design. Study setting The study was performed at Uppsala University Hospital, Sweden, in which approximately 4200 infants are born each year. The hospital has two postnatal wards, where all mothers and fathers/partners are offered rooming in during their infants' entire hospital stay, and a neonatal intensive care unit (NICU). At the time of the study, healthy LPIs born at a GA of Z 35 0/7 weeks were routinely cared for at the postnatal wards. There was no separate transitional care area for LPIs at the wards. The mothers
The study consists of a consecutive sample of LPIs cared for in family rooms. Inclusion criteria were mothers to LPIs who intended to breast feed, whereas twins and infants whose mother chose not to breast feed were excluded. An overview of the potential participants and study participants included is presented in Fig. 1. During the data collection period, between 15 November 2010 and 30 November 2011, 77 (71%) mothers completed the study. Fifty infants were born at a GA between 36 0/7 and 36 6/7 weeks and 26 infants were born between 35 0/7 and 35 6/7 weeks. One infant was born at 34 5/7 weeks. Data collection Data were collected via a parental diary. The diary consisted of one chart for each day with a time-line (hours and minutes) and columns with fixed options regarding breast feeding, supplementary feeds,
Please cite this article as: Mattsson, E., et al., Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2014.12.004i
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Potential participants November 15, 2010 – November 30, 2011 N=206
Missed due to administrative problems N=6
Excluded
Agreed to participate
N=96
N=86
Referred to NICU NICU n=56 Twins n=36 Not breastfed n=4
N=5
Did not complete data collection N=4 Study participants N=77
Fig. 1. A flow diagram of the potential and included study participants.
the timing and duration of skin-to-skin care, mothers' use of an electrical breast-pump and nipple shield and provision of supplementary feeds by bottle or cup. Parents recorded the duration of each breast-feeding session, supplementary feeds and skin-to-skin care by drawing a line marking the hours and minutes for each variable (Blomqvist et al., 2011). In addition, the mothers' use of a breast-pump and nipple shield and the method used for giving supplementary feeds (bottle or cup) were marked on each occasion. The data for gestational age (according to ultrasound screening), birth weight, weight loss and gain during hospital stay, blood glucose levels, breast feeding at discharge, neonatal jaundice requiring phototherapy, length of hospital stay and readmission were retrieved from the infant's medical record. The World Health Organization (WHO) definition of exclusive breast feeding was used, but with a certain modification. The definition stipulates that exclusive breast feeding means that the infant receives only breast milk, and no other liquids or solids are given – not even water – with the exception of oral rehydration solutions, or drops/syrups of vitamins, minerals, or medicines. In this study, infants (n¼5) that received one or two artificial milk feeds were categorised as exclusively breast fed due to their limited exposure to another feeding method: three infants received one (n¼2) or two (n¼1) artificial milk feed/s when their mother was cared for at a postoperative unit following caesarean section (n¼3), whereas no reason for supplementation was documented for two infants who received one artificial milk feed. Hypoglycaemia was also defined according to WHO guidelines, i.e., a blood glucose concentration less than 2.6 mmol/L or 46.8 mg/dl (WHO, 1997). Jaundice was defined as clinically relevant if serum bilirubin concentrations were sufficiently high to require phototherapy, according to the 2004 criteria of the American Academy of Pediatrics (2004). Maternal data were retrieved from the mothers' medical records. Ethical approval to conduct the study was obtained from the Regional Ethical Review Board in Uppsala, Sweden. Written and oral information about the study was given to mothers/parents by the authors EM, ELF, MW and HV during the first day after birth. Potential participants were informed that participation in the study was entirely voluntary and, whether they chose to participate or not all the services received at the wards were continued and nothing was changed. If the mother/ parents was/were reluctant to participate, additional reflection
was offered without the researcher present and decline/consent was thereafter given to the responsible midwife at the ward. Mothers/parents who agreed to participate and completed a written informed consent form started to complete the diary, one chart/day, during the infant's whole hospital stay. Data from birth to the initiation of study participation was entered retrospectively. The authors visited the mother/couple every day to answer questions regarding the diary. When the family was discharged from the hospital, the diary was returned in a special study mailbox at the postnatal units. The authors EM and MW retrieved the study variables from the infants' and mothers' medical records.
Data analysis Data were compared between infants who were given supplementary artificial milk feeds on a regular basis, 8–12 times/day (n ¼54), and infants who were exclusively breast fed (n¼ 23) from birth to postnatal day 1, respectively. Five infants who received one or two artificial milk feeds during the entire hospital stay were included in the latter group. The Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL) was used for the statistical analyses. Sample characteristics are presented by descriptive statistics. χ2 tests and independent t-tests were used to assess differences between groups. A p-value of o0.05 was considered as significant.
Findings Maternal and infant characteristics The mothers' median (range) age was 31 (19–40) years and 42 (54%) had prior deliveries. Thirteen mothers (17%) gave birth by caesarean section. The infants' median GA was 36 2/7 and ranged between 34 5/7 and 36 6/7 weeks, and the median birth weight was 2890 g (2270–3760). Eleven infants (14%) had a birth weight below 2500 g; however, none of them were small for gestational age. No infant had an Apgar score below 7 points at 5 minutes after birth.
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The infants' age at the first breast-feeding occasion and breastfeeding frequency
The infants' duration of hospital stay, and rate of exclusive and partial breast feeding at discharge
Infants who were given artificial milk on a regular basis had their first experience of breast feeding later than infants who were exclusively breast fed, Table 1. They were also breast fed less frequently on days 1 and 2.
Exclusively breast-fed infants had a shorter duration of hospital stay (Table 3). All infants were breast fed at discharge, but 87% of infants exclusively breast fed from birth continued after discharge, compared to 24% who were given artificial milk regularly from birth. There was no difference between these groups in rates of readmission to hospital.
The mothers' patterns of milk expression and use of nipple shield More than half (65%) of the 54 mothers with an infant that was prescribed artificial milk on a regular basis never used a breastpump (Table 1). Among the mothers who used a breast pump (n ¼19, 35%), it took between 10 and 84 hours, with a mean duration of 41.6 hours, before they started to express their milk. There was no difference in proportion of the use of a nipple shield between mothers with an infant that was prescribed artificial milk on a regular basis and mothers with an infant that was exclusively breast fed.
The infants' weight pattern, rate of hypoglycaemia and hyperbilirubinemia The infants with exclusive breast feeding lost more weight than infants receiving supplementary feeds did, but there were no differences between the groups in incidence of hypoglycaemia or hyperbilirubinemia requiring phototherapy treatment (Table 2). Table 1 Breast and artificial milk feeding patterns and nipple shield use in late preterm infants. Groups
Total sample (n¼ 77)
Artificial milk supplementation (n ¼54)
Exclusive breastfeeding (n¼ 23)
Time to first breastfeeding, hours: Mean 7 SD (range) Breastfeeding frequency, day 1: Mean 7 SD (range) Breastfeeding frequency, day 2: Mean 7 SD (range) Breastfeeding frequency, day 3: Mean 7 SD (range) Use of nipple shield: Yes, n (%)
4.6 7 7.2
6.1 78.3
1.6 7 2.7nn
(0.1–28) 9.0 7 3.6
(0.1–28) 7.9 7 3.5
(0.1–12) 11.3 72.7nn
(0–18) 9.7 7 3.6
(0–14) 8.9 7 3.6
(8–18) 12.0 7 2.9nn
(0–18) 9.2 7 3.5
(0–16) 8.7 7 3.2
(8–18) 11.5 74.6
(0–21) 19 (25)
(0–14) 16 (30)
(7–21) 3 (13)
Discussion All study infants were breast fed at discharge, 43% of them exclusively. Partial instead of exclusive breast feeding was associated with regular artificial milk supplementation from birth. Over half (65%) of the mothers with an infant prescribed artificial milk on a regular basis never expressed their milk using an electric breast-pump or delayed their initiation of milk expression to more than three days after birth. Seventy per cent (n ¼54) of the infants in this study were given regular artificial milk supplementation from birth. In the light of this, it is important to consider how clinical practice influenced the initiation of breast feeding. Half of the infants (n ¼27) in the artificial milk group were born o36 0/7 weeks and were given regular artificial milk routinely according to local guidelines. The other half (n ¼ 27) were given artificial milk on a regular basis based on assessments of the infant's competence to suck and signs of hypoglycaemia. However, no differences were found regarding incidence of hypoglycaemia between infants with regular artificial milk supplementation and infants who were exclusively breast fed from birth. Consequently, no firm conclusion can be drawn regarding which children were in need of regular artificial milk Table 3 Exclusive breastfeeding and artificial milk feeding correlations to hospital stay and readmission in late preterm infants. Groups
Total sample (n¼ 77)
Artificial milk supplementation (n¼ 54)
Exclusive breastfeeding (n ¼23)
Duration of hospital stay: Mean 7 SD (range) Readmission: Yes, n (%) Breast feeding at discharge: Exclusive: n (%) Partial: n (%)
4.2 71.8
4.7 7 1.5
(1–9)
(2–9)
(1–9)
4 (5)
2 (4)
2 (9)
33 (43) 44 (57)
13 (24) 41 (76)
20 (87)† 3 (13)
nn
3.3 71.9
nn nn
†
p o0.01.
p o 0.01. p o 0.001.
Table 2 Exclusive breastfeeding and artificial milk feeding correlations to weight, hypoglycemia, hyperbilirubinemia in late preterm infants. Groups
Total weight loss, %: Mean 7 SD (range) Age at commencement of weight gain after birth, days: Mean 7 SD (range) Hypoglycemia: Yes, n (%) Hyperbilirubinemia: Yes, n (%) n
Total sample (n ¼77)
Artificial milk supplementation (n ¼54)
Exclusive breastfeeding (n¼ 23)
5.5 7 2.2 (2–11) 3.8 7 1.1 (2–7) 17 (22) 18 (23)
5.17 2.0 (1–9) 3.9 7 1.3 (2–7) 14 (26) 12 (22)
6.3 72.4n (2–11) 3.6 7 0.9 (3–6) 3 (13) 6 (26)
po 0.05.
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supplementation from birth. It could be speculated that in settings where artificial milk feeding is the norm, it may be easier for health professionals to start with artificial milk rather than support breast feeding. In addition, glucose screening among LPIs born Z35 GA should be performed only on at-risk infants and those with clinical signs compatible with hypoglycaemia in order to promote the mother–infant relationship and successful breastfeeding patterns (Wight et al., 2014). Fifty-seven per cent of the mothers did not succeed in attaining exclusive breast feeding at discharge. One possible explanation, also highlighted in the literature (Academy of Breastfeeding, 2009), can be that the volume of supplementary feeds exceeded the volume the infants would have received at the breast. This in turn may delay the infant's display of feeding cues and, consequently, delay the mother's milk production (Callen and Pinelli, 2005; Morton et al., 2009). Several factors complicate the breast-feeding process among LPIs. For the mother, these barriers include delayed lactation (Callen and Pinelli, 2005) and lower milk volumes (Morton et al., 2009). Mothers of LPIs are often recommended to use a breastpump between feeds to meet the challenge of increasing their milk production (Academy of Breastfeeding, 2011) and the mothers' initial pumping technique is significant for increasing their milk production (Celik et al., 2013). Evidence supports encouragement of mothers to commence milk expression early after birth, i.e., within 6–12 hours post partum, and to continue with a frequency of 6–11 times a day until breast feeding is established and the infant can be supported exclusively with breast feeding (Martens and Romphf, 2007; Academy of Breastfeeding, 2011; Geddes et al., 2013). In contrast with these recommendations, a majority of the study mothers (65%) never expressed their milk, and among the mothers who used a pump, milk expression commenced late (10–84 hours after birth). This may partly explain why majority of the mothers were discharged with partial instead of exclusive breast feeding. In short, without frequent milk expression, maternal milk supply may be inadequate and the transition to exclusive feeding at-breast may fail among LPIs receiving artificial milk on a regular basis. Our results agree with earlier findings suggesting that breast feeding could be associated with a higher weight loss than reported for artificial milk fed infants (Martens and Romphf, 2007). However, in a situation when weight is routinely monitored and breast feeding is assessed and supported, and careful supplementation is prescribed to promptly treat excess weight loss, breast feeding may not be a risk factor for weight loss (Davanzo et al., 2013). In clinical practice, uncertainty concerning acceptable levels of weight loss in late preterm neonates may promote the use of artificial milk and thus hinder the establishment of breast feeding. Therefore, additional studies regarding the definitions of both an average normal weight loss and an upper limit of safe weight loss among breast-fed LPIs are warranted. It could be assumed that the length of hospital stay was too short to provide the mothers in this study with sufficient opportunities to establish exclusive breast feeding before discharge. This assumption was supported by a Swedish study, which reported exclusive breast feeding among over 80% of preterm infants born at a GA ranging between 28 and 35 weeks with a median duration of stay of 18 days (Funkquist et al., 2010). The difference between these outcomes could be attributed to differences in support of the establishment of successful breast feeding offered to the mother– infant dyads. This highlights a need for reorganising in hospital lactation, breast-feeding counselling and support, feeding and nutrition guidelines plus the necessity of continued postdischarge breast-feeding support to mothers with LPIs. No difference was found regarding the requirement of phototherapy treatment between infants with regular artificial milk
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supplementation and infants who were exclusively breast fed from birth. The result might be explained by the higher breast-feeding frequency in the exclusive breast-fed group, which decreased the incidence of severe hyperbilirubinemia (Gartner et al., 2005). However, inadequate breast feeding resulting in dehydration and/or poor caloric intake can contribute to the development of hyperbilirubinemia (Lavanya et al., 2012). Consequently, close follow-up and lactation support and counselling are essential for providing breast-fed preterm infants with safe care. The response rate in the study was adequate, 71%. Nine participants did not complete the data collection, five of them because their infants were referred to the NICU. Only four maternal diaries were not completed at the postnatal units, indicating the participants found the documentation easy to use and not time-consuming. These findings were in agreement with a study (Blomqvist et al., 2011) that reported parents' ability to document variables related to skin-to-skin care of their infants in a complete and reliable manner. It could be speculated that mothers who did not participate had infants with more morbidities than the participants had: if this was the case, the initiation and extent of breast feeding could have been lower. Even so, all infants were discharged with breast feeding, exclusive or partial. A limitation of the present study was that the data on breastfeeding frequency were based only on the mothers' self-reports. As immature oral movements when breast-feeding LPIs may be mistaken for nutritive feedings (Santos et al., 2008; Walker, 2008), self-reports in combination with breast-feeding observation would have strengthened the reliability of these findings. Another potential limitation was that five infants in the breastfeeding group received one or two artificial milk feeds during the hospital stay; however, all five were exclusively breast fed at discharge. Although even one-two artificial milk feeds constitute partial feeding by the WHO, we chose to include infants with this limited extent of artificial milk intake in the exclusively breast-fed group as their predominant mode of feeding was breast feeding, and our focus was not infant nutrition, but the infants' and mothers' experience of another oral feeding method. In addition, the diary lacked certain variables of importance for the initiation of breast feeding, for example, the infant's use of a pacifier, data regarding the mother's use of manual expression in addition to using a breast-pump and socio-economic variables. However, despite a relatively small sample, significant differences of clinical importance emerged.
Conclusion Clinical practice and routines influence the initiation of breast feeding among late preterm infants and may act as barriers to the mothers' establishment of exclusive breast feeding. Individualised care and follow-up by health professionals with adequate education and practical skills in supporting this vulnerable group are essential components in postnatal and post-discharge care for enabling these mothers to attain and maintain successful lactation and breast feeding.
Conflict of interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no financial support for the research, authorship, and/or publication of this article.
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Jang, G.J., Lee, S.L., Kim, H.M., 2012. Breast feeding rates and factors influencing breast feeding practice in late preterm infants: comparison with preterm born at less than 34 weeks of gestational age. J. Korean Acad. Nurs. 42, 181–189. Lavanya, K.R., Jaiswal, A., Reddy, P., Murki, S., 2012. Predictors of significant jaundice in late preterm infants. Indian Pediatr. 49, 717–720. Martens, P.J., Romphf, L., 2007. Factors associated with newborn in-hospital weight loss: comparisons by feeding method, demographics, and birthing procedures. J. Hum. Lact. 23, 233–241 (quiz 42–45). Morton, J., Hall, J.Y., Wong, R.J., Thairu, L., Benitz, W.E., Rhine, W.D., 2009. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. J. Perinatol. 29, 757–764. Naylor, A.J., 2001. Baby-Friendly Hospital Initiative. Protecting, promoting, and supporting breastfeeding in the twenty-first century. Pediatr. Clin. North Am. 48, 475–483. Nyqvist, K.H., Anderson, G.C., Bergman, N., et al., 2010. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatr. 99, 820–826. Nyqvist, K.H., Farnstrand, C., Eeg-Olofsson, K.E., Ewald, U., 2001. Early oral behaviour in preterm infants during breastfeeding: an electromyographic study. Acta Paediatr. 90, 658–663. Nyqvist, K.H., Haggkvist, A.P., Hansen, M.N., et al., 2013. Expansion of the babyfriendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations. J. Hum. Lact. 29, 300–309. Nyqvist, K.H., Sjoden, P.O., Ewald, U., 1999. The development of preterm infants' breastfeeding behavior. Early Hum. Dev. 55, 247–264. Phillips, R.M., Goldstein, M., Hougland, K., et al., 2013. Multidisciplinary guidelines for the care of late preterm infants. J. Perinatol. 33, 5–22. Raju, T.N., Higgins, R.D., Stark, A.R., Leveno, K.J., 2006. Optimizing care and outcome for late-preterm (near-term) infants: a summary of the workshop sponsored by the National Institute of Child Health and Human Development. Pediatrics 118, 1207–1214. Santos, I.S., Matijasevich, A., Silveira, M.F., et al., 2008. Associated factors and consequences of late preterm births: results from the 2004 Pelotas birth cohort. Paediatr. Perinat. Epidemiol. 22, 350–359. Tomashek, K.M., Shapiro-Mendoza, C.K., Weiss, J., et al., 2006. Early discharge among late preterm and term newborns and risk of neonatal morbidity. Semin. Perinatol. 30, 61–68. Walker, M., 2008. Breastfeeding the late preterm infant. J. Obstet. Gynecol. Neonatal Nurs. 37, 692–701. WHO, 1997. Hypoglycaemia of the Newborn: Review of the Literature in Hypoglycaemia. World Health Organization, Geneva 〈http://whqlibdoc.who.int/hq/ 1997/WHO_CHD_97.1.pdf〉 (retrieved 14 October 2014). Wight, N., Marinelli, K.A., Academy of Breastfeeding, M., 2014. ABM clinical protocol #1: guidelines for blood glucose monitoring and treatment of hypoglycemia in term and late-preterm neonates, revised 2014. Breastfeed. Med. 9, 173–179.
Please cite this article as: Mattsson, E., et al., Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2014.12.004i
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Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters Elisabet Mattsson, RNM, PhD (Pediatric nurse/Midwife)a,b,n, Eva-Lotta Funkquist, RNM, PhD (Midwife)b, Maria Wickström, RNM, MScN (Midwife)c, Kerstin H. Nyqvist, RN, MScN, PhD (Associate Professor emerita)b, Helena Volgsten, RNM, PhD (Midwife)b a
Department of Public Health and Caring Sciences, Uppsala University, Sweden Department of Women's and Children's Health, Uppsala University, Sweden c Children's Hospital, Uppsala University Hospital, Sweden b
art ic l e i nf o
a b s t r a c t
Article history: Received 18 July 2014 Received in revised form 26 November 2014 Accepted 22 December 2014
Objectives: to compare the influence of supplementary artificial milk feeds on breast feeding and certain clinical parameters among healthy late preterm infants given regular supplementary artificial milk feeds versus being exclusively breast fed from birth. Design: a comparative study using quantitative methods. Data were collected via a parental diary and medical records. Methods: parents of 77 late preterm infants (34 5/7–36 6/7 weeks), whose mothers intended to breast feed, completed a diary during the infants' hospital stay. Findings: infants who received regular supplementary artificial milk feeds experienced a longer delay before initiation of breast feeding, were breast fed less frequently and had longer hospital stays than infants exclusively breast fed from birth. Exclusively breast-fed infants had a greater weight loss than infants with regular artificial milk supplementation. A majority of the mothers (65%) with an infant prescribed artificial milk never expressed their milk and among the mothers who used a breast-pump, milk expression commenced late (10–84 hours after birth). At discharge, all infants were breast fed to some extent, 43% were exclusively breast fed. Key conclusions: clinical practice and routines influence the initiation of breast feeding among late preterm infants and may act as barriers to the mothers' establishment of exclusive breast feeding. & 2015 Published by Elsevier Ltd.
Keywords: Premature neonates Breast feeding Breast milk supplementation
Introduction Infants born between 34 0/7 and 36 6/7 weeks of gestational age (GA) should preferably be referred to as ‘late preterm,’ rather than as ‘near term,’ to better convey their vulnerability and need for closer monitoring and follow up (Raju et al., 2006). Late preterm infants (LPIs) are at an increased risk for bradycardia, feeding difficulties, hypoglycaemia, jaundice, respiratory distress, sepsis, temperature instability, and hospital readmission (Engle et al., 2007; Celik et al., 2013). Despite the risks associated with prematurity, these infants are often managed in postnatal units instead of special units with qualified health-care professionals assigned to LPI care during the immediate postpartum recovery n Corresponding author at: Department of Public Health and Caring Sciences, Psychosocial Oncology and Supportive Care, Box 564, Uppsala University, S-751 22 Uppsala, Sweden. E-mail address: [email protected] (E. Mattsson).
period following birth (Engle et al., 2007; Phillips et al., 2013). A lower breast-feeding prevalence has been reported for LPIs in comparison with term infants (Demirci et al., 2013) and preterm infants born at less than 34 weeks of GA (Jang et al., 2012). Preterm infants have problems in co-ordinating respiration with sucking and swallowing when they are bottle fed (Gewolb and Vice, 2006). This is the reason for assessing preterm infants' readiness for introduction of oral feeding (Fujinaga et al., 2013). In contrast, the capacity for nutritive sucking at the mother's breast has been observed in preterm and very preterm infants of 28 weeks gestation (Nyqvist et al., 1999). However, there are wide individual variations in nutritive sucking competence that are unrelated to GA at birth or birth weight (Nyqvist et al., 2001). The Academy of Breastfeeding Medicine recommends LPI be breast fed as much as possible and argues the World Health Organization (WHO) Baby Friendly Hospital Initiative with Ten Steps to Successful Breastfeeding (BFHI) also applies to these infants (Academy of Breastfeeding, 2011). An expert group from the Nordic countries
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Please cite this article as: Mattsson, E., et al., Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2014.12.004i
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and Quebec, Canada, has commenced the process of adapting the BFHI program to the special needs of preterm, low-birthweight, and sick infants and their mothers (Nyqvist et al., 2013). Kangaroo mother care is an important factor to consider when planning the care of LPIs and their mothers. It has been concluded that skin-to-skin care between low-birthweight/preterm infants and their mothers maintains infant body temperature, enhances long-term cognitive development, and facilitates breast feeding and breast milk production (Britton et al., 2007; Nyqvist et al., 2010; Feldman et al., 2014). In addition, skin-to-skin care increases maternal attachment behaviour in the postpartum period and reduces maternal anxiety (Feldman et al., 2014). The prerequisites for successful breast feeding are optimised when LPIs commence nursing within one hour after birth (Santos et al., 2008), have free access to the breast and, are breast fed at least 8–12 times per day (Britton et al., 2007). However, unless a feeding regimen adapted to the infants' current nutritive sucking capacity is applied (Nyqvist et al., 1999), their immature physiology may decrease feeding efficiency and increase the length of each feed (Santos et al., 2008); thus increasing the risk of malnutrition (Walker, 2008) and negatively affecting breastfeeding duration (Donath and Amir, 2008). Among breast-fed infants, LPIs are more likely to require hospital-related care and readmission to hospital than term infants do. However, a comparison of readmission rates between LPIs and term infants who were not breast fed found no difference (Tomashek et al., 2006). This highlights the need for guidelines to promote, support, and sustain breast feeding with particular attention to late preterm infants' special vulnerabilities. The objective of this study was to compare the influence of supplementary artificial milk feeds on breast feeding and certain clinical parameters among healthy LPIs given regular supplementary artificial milk feeds with LPIs exclusively breast fed from birth. More specifically, were there any differences between the groups with regard to – The mothers' patterns of breast feeding and milk expression, and use of nipple shield? – The infants' age at the first breast feeding occasion? – The infants' weight loss and age at commencement of weight gain after birth? – Incidence of hypoglycaemia and neonatal jaundice requiring phototherapy? – Duration of hospital stay? – Exclusive breast feeding at discharge? – Readmission to hospital after discharge?
stayed with their infants in hospital until their babies were discharged, and the majority of fathers/partners stayed together with the mother and the new-born baby in family rooms during the period of postnatal care. Siblings had free visiting hours but were not allowed to stay overnight. The midwifery care was provided by a midwife working with an assistant nurse and neonatologists directed the infants' medical care plan. Mothers intending to breast feed were offered individualised support to facilitate the establishment of lactation and exclusive breast feeding as soon as possible. To enable a first breast feed as soon as possible after birth all infants were placed skin-to-skin on their mother immediately after birth. In the wards, skin-to-skin contact between the infant and the mother/father was recommended. Feeding policy The postnatal feeding policy prescribed artificial milk supplementation for LPIs fully artificial milk fed according to the following schedule: postnatal day 0: a total daily volume of 70–80 ml/kg a day; day 1: 80–90 ml; day 2: 90–100 ml; and, day 3: 100–110 ml and so on up to 160–170 ml/kg a day. There was a milk bank at the study hospital, but donor breast milk was reserved for infants at the NICU and not available for infants at the postnatal wards because of a limited supply. The artificial milk supplementation of LPIs born at a GA o36 0/7 weeks commenced within one to two hours after birth, whereas supplementation with artificial milk to infants born Z36 0/7 was based on assessment of the infant's competence to suck and signs of hypoglycaemia. The artificial milk feeds were initially given every two/three hours and then gradually reduced until breast feeding was established. Blood glucose levels were monitored every two hours, from approximately three hours of age, during the first 24 hours after birth. The total daily volume of artificial milk supplementation was reduced individually, based on the infant's progress in milk intake, assessed by observations of active suckling behaviour, audible swallowing, and signs of fresh milk in the infant's mouth, ability to maintain blood glucose levels, and by daily assessment of the infant's weight. The wards had no written guidelines regarding routinely prescribed artificial milk supplementation following weight loss. Test-weighing before and after breast feeding was used when mothers wanted. Infants were fed by cup, if breast feeding, to comply with the International Code of Marketing of Breast Milk Substitutes in order to reduce incorrect latching, superficial suckling at the breast (Geddes et al., 2013) and transition difficulties from bottle to breast (Naylor, 2001). Sample
Methods Study design The study was prospective, with a quantitative and comparative design. Study setting The study was performed at Uppsala University Hospital, Sweden, in which approximately 4200 infants are born each year. The hospital has two postnatal wards, where all mothers and fathers/partners are offered rooming in during their infants' entire hospital stay, and a neonatal intensive care unit (NICU). At the time of the study, healthy LPIs born at a GA of Z 35 0/7 weeks were routinely cared for at the postnatal wards. There was no separate transitional care area for LPIs at the wards. The mothers
The study consists of a consecutive sample of LPIs cared for in family rooms. Inclusion criteria were mothers to LPIs who intended to breast feed, whereas twins and infants whose mother chose not to breast feed were excluded. An overview of the potential participants and study participants included is presented in Fig. 1. During the data collection period, between 15 November 2010 and 30 November 2011, 77 (71%) mothers completed the study. Fifty infants were born at a GA between 36 0/7 and 36 6/7 weeks and 26 infants were born between 35 0/7 and 35 6/7 weeks. One infant was born at 34 5/7 weeks. Data collection Data were collected via a parental diary. The diary consisted of one chart for each day with a time-line (hours and minutes) and columns with fixed options regarding breast feeding, supplementary feeds,
Please cite this article as: Mattsson, E., et al., Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2014.12.004i
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Potential participants November 15, 2010 – November 30, 2011 N=206
Missed due to administrative problems N=6
Excluded
Agreed to participate
N=96
N=86
Referred to NICU NICU n=56 Twins n=36 Not breastfed n=4
N=5
Did not complete data collection N=4 Study participants N=77
Fig. 1. A flow diagram of the potential and included study participants.
the timing and duration of skin-to-skin care, mothers' use of an electrical breast-pump and nipple shield and provision of supplementary feeds by bottle or cup. Parents recorded the duration of each breast-feeding session, supplementary feeds and skin-to-skin care by drawing a line marking the hours and minutes for each variable (Blomqvist et al., 2011). In addition, the mothers' use of a breast-pump and nipple shield and the method used for giving supplementary feeds (bottle or cup) were marked on each occasion. The data for gestational age (according to ultrasound screening), birth weight, weight loss and gain during hospital stay, blood glucose levels, breast feeding at discharge, neonatal jaundice requiring phototherapy, length of hospital stay and readmission were retrieved from the infant's medical record. The World Health Organization (WHO) definition of exclusive breast feeding was used, but with a certain modification. The definition stipulates that exclusive breast feeding means that the infant receives only breast milk, and no other liquids or solids are given – not even water – with the exception of oral rehydration solutions, or drops/syrups of vitamins, minerals, or medicines. In this study, infants (n¼5) that received one or two artificial milk feeds were categorised as exclusively breast fed due to their limited exposure to another feeding method: three infants received one (n¼2) or two (n¼1) artificial milk feed/s when their mother was cared for at a postoperative unit following caesarean section (n¼3), whereas no reason for supplementation was documented for two infants who received one artificial milk feed. Hypoglycaemia was also defined according to WHO guidelines, i.e., a blood glucose concentration less than 2.6 mmol/L or 46.8 mg/dl (WHO, 1997). Jaundice was defined as clinically relevant if serum bilirubin concentrations were sufficiently high to require phototherapy, according to the 2004 criteria of the American Academy of Pediatrics (2004). Maternal data were retrieved from the mothers' medical records. Ethical approval to conduct the study was obtained from the Regional Ethical Review Board in Uppsala, Sweden. Written and oral information about the study was given to mothers/parents by the authors EM, ELF, MW and HV during the first day after birth. Potential participants were informed that participation in the study was entirely voluntary and, whether they chose to participate or not all the services received at the wards were continued and nothing was changed. If the mother/ parents was/were reluctant to participate, additional reflection
was offered without the researcher present and decline/consent was thereafter given to the responsible midwife at the ward. Mothers/parents who agreed to participate and completed a written informed consent form started to complete the diary, one chart/day, during the infant's whole hospital stay. Data from birth to the initiation of study participation was entered retrospectively. The authors visited the mother/couple every day to answer questions regarding the diary. When the family was discharged from the hospital, the diary was returned in a special study mailbox at the postnatal units. The authors EM and MW retrieved the study variables from the infants' and mothers' medical records.
Data analysis Data were compared between infants who were given supplementary artificial milk feeds on a regular basis, 8–12 times/day (n ¼54), and infants who were exclusively breast fed (n¼ 23) from birth to postnatal day 1, respectively. Five infants who received one or two artificial milk feeds during the entire hospital stay were included in the latter group. The Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL) was used for the statistical analyses. Sample characteristics are presented by descriptive statistics. χ2 tests and independent t-tests were used to assess differences between groups. A p-value of o0.05 was considered as significant.
Findings Maternal and infant characteristics The mothers' median (range) age was 31 (19–40) years and 42 (54%) had prior deliveries. Thirteen mothers (17%) gave birth by caesarean section. The infants' median GA was 36 2/7 and ranged between 34 5/7 and 36 6/7 weeks, and the median birth weight was 2890 g (2270–3760). Eleven infants (14%) had a birth weight below 2500 g; however, none of them were small for gestational age. No infant had an Apgar score below 7 points at 5 minutes after birth.
Please cite this article as: Mattsson, E., et al., Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2014.12.004i
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The infants' age at the first breast-feeding occasion and breastfeeding frequency
The infants' duration of hospital stay, and rate of exclusive and partial breast feeding at discharge
Infants who were given artificial milk on a regular basis had their first experience of breast feeding later than infants who were exclusively breast fed, Table 1. They were also breast fed less frequently on days 1 and 2.
Exclusively breast-fed infants had a shorter duration of hospital stay (Table 3). All infants were breast fed at discharge, but 87% of infants exclusively breast fed from birth continued after discharge, compared to 24% who were given artificial milk regularly from birth. There was no difference between these groups in rates of readmission to hospital.
The mothers' patterns of milk expression and use of nipple shield More than half (65%) of the 54 mothers with an infant that was prescribed artificial milk on a regular basis never used a breastpump (Table 1). Among the mothers who used a breast pump (n ¼19, 35%), it took between 10 and 84 hours, with a mean duration of 41.6 hours, before they started to express their milk. There was no difference in proportion of the use of a nipple shield between mothers with an infant that was prescribed artificial milk on a regular basis and mothers with an infant that was exclusively breast fed.
The infants' weight pattern, rate of hypoglycaemia and hyperbilirubinemia The infants with exclusive breast feeding lost more weight than infants receiving supplementary feeds did, but there were no differences between the groups in incidence of hypoglycaemia or hyperbilirubinemia requiring phototherapy treatment (Table 2). Table 1 Breast and artificial milk feeding patterns and nipple shield use in late preterm infants. Groups
Total sample (n¼ 77)
Artificial milk supplementation (n ¼54)
Exclusive breastfeeding (n¼ 23)
Time to first breastfeeding, hours: Mean 7 SD (range) Breastfeeding frequency, day 1: Mean 7 SD (range) Breastfeeding frequency, day 2: Mean 7 SD (range) Breastfeeding frequency, day 3: Mean 7 SD (range) Use of nipple shield: Yes, n (%)
4.6 7 7.2
6.1 78.3
1.6 7 2.7nn
(0.1–28) 9.0 7 3.6
(0.1–28) 7.9 7 3.5
(0.1–12) 11.3 72.7nn
(0–18) 9.7 7 3.6
(0–14) 8.9 7 3.6
(8–18) 12.0 7 2.9nn
(0–18) 9.2 7 3.5
(0–16) 8.7 7 3.2
(8–18) 11.5 74.6
(0–21) 19 (25)
(0–14) 16 (30)
(7–21) 3 (13)
Discussion All study infants were breast fed at discharge, 43% of them exclusively. Partial instead of exclusive breast feeding was associated with regular artificial milk supplementation from birth. Over half (65%) of the mothers with an infant prescribed artificial milk on a regular basis never expressed their milk using an electric breast-pump or delayed their initiation of milk expression to more than three days after birth. Seventy per cent (n ¼54) of the infants in this study were given regular artificial milk supplementation from birth. In the light of this, it is important to consider how clinical practice influenced the initiation of breast feeding. Half of the infants (n ¼27) in the artificial milk group were born o36 0/7 weeks and were given regular artificial milk routinely according to local guidelines. The other half (n ¼ 27) were given artificial milk on a regular basis based on assessments of the infant's competence to suck and signs of hypoglycaemia. However, no differences were found regarding incidence of hypoglycaemia between infants with regular artificial milk supplementation and infants who were exclusively breast fed from birth. Consequently, no firm conclusion can be drawn regarding which children were in need of regular artificial milk Table 3 Exclusive breastfeeding and artificial milk feeding correlations to hospital stay and readmission in late preterm infants. Groups
Total sample (n¼ 77)
Artificial milk supplementation (n¼ 54)
Exclusive breastfeeding (n ¼23)
Duration of hospital stay: Mean 7 SD (range) Readmission: Yes, n (%) Breast feeding at discharge: Exclusive: n (%) Partial: n (%)
4.2 71.8
4.7 7 1.5
(1–9)
(2–9)
(1–9)
4 (5)
2 (4)
2 (9)
33 (43) 44 (57)
13 (24) 41 (76)
20 (87)† 3 (13)
nn
3.3 71.9
nn nn
†
p o0.01.
p o 0.01. p o 0.001.
Table 2 Exclusive breastfeeding and artificial milk feeding correlations to weight, hypoglycemia, hyperbilirubinemia in late preterm infants. Groups
Total weight loss, %: Mean 7 SD (range) Age at commencement of weight gain after birth, days: Mean 7 SD (range) Hypoglycemia: Yes, n (%) Hyperbilirubinemia: Yes, n (%) n
Total sample (n ¼77)
Artificial milk supplementation (n ¼54)
Exclusive breastfeeding (n¼ 23)
5.5 7 2.2 (2–11) 3.8 7 1.1 (2–7) 17 (22) 18 (23)
5.17 2.0 (1–9) 3.9 7 1.3 (2–7) 14 (26) 12 (22)
6.3 72.4n (2–11) 3.6 7 0.9 (3–6) 3 (13) 6 (26)
po 0.05.
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supplementation from birth. It could be speculated that in settings where artificial milk feeding is the norm, it may be easier for health professionals to start with artificial milk rather than support breast feeding. In addition, glucose screening among LPIs born Z35 GA should be performed only on at-risk infants and those with clinical signs compatible with hypoglycaemia in order to promote the mother–infant relationship and successful breastfeeding patterns (Wight et al., 2014). Fifty-seven per cent of the mothers did not succeed in attaining exclusive breast feeding at discharge. One possible explanation, also highlighted in the literature (Academy of Breastfeeding, 2009), can be that the volume of supplementary feeds exceeded the volume the infants would have received at the breast. This in turn may delay the infant's display of feeding cues and, consequently, delay the mother's milk production (Callen and Pinelli, 2005; Morton et al., 2009). Several factors complicate the breast-feeding process among LPIs. For the mother, these barriers include delayed lactation (Callen and Pinelli, 2005) and lower milk volumes (Morton et al., 2009). Mothers of LPIs are often recommended to use a breastpump between feeds to meet the challenge of increasing their milk production (Academy of Breastfeeding, 2011) and the mothers' initial pumping technique is significant for increasing their milk production (Celik et al., 2013). Evidence supports encouragement of mothers to commence milk expression early after birth, i.e., within 6–12 hours post partum, and to continue with a frequency of 6–11 times a day until breast feeding is established and the infant can be supported exclusively with breast feeding (Martens and Romphf, 2007; Academy of Breastfeeding, 2011; Geddes et al., 2013). In contrast with these recommendations, a majority of the study mothers (65%) never expressed their milk, and among the mothers who used a pump, milk expression commenced late (10–84 hours after birth). This may partly explain why majority of the mothers were discharged with partial instead of exclusive breast feeding. In short, without frequent milk expression, maternal milk supply may be inadequate and the transition to exclusive feeding at-breast may fail among LPIs receiving artificial milk on a regular basis. Our results agree with earlier findings suggesting that breast feeding could be associated with a higher weight loss than reported for artificial milk fed infants (Martens and Romphf, 2007). However, in a situation when weight is routinely monitored and breast feeding is assessed and supported, and careful supplementation is prescribed to promptly treat excess weight loss, breast feeding may not be a risk factor for weight loss (Davanzo et al., 2013). In clinical practice, uncertainty concerning acceptable levels of weight loss in late preterm neonates may promote the use of artificial milk and thus hinder the establishment of breast feeding. Therefore, additional studies regarding the definitions of both an average normal weight loss and an upper limit of safe weight loss among breast-fed LPIs are warranted. It could be assumed that the length of hospital stay was too short to provide the mothers in this study with sufficient opportunities to establish exclusive breast feeding before discharge. This assumption was supported by a Swedish study, which reported exclusive breast feeding among over 80% of preterm infants born at a GA ranging between 28 and 35 weeks with a median duration of stay of 18 days (Funkquist et al., 2010). The difference between these outcomes could be attributed to differences in support of the establishment of successful breast feeding offered to the mother– infant dyads. This highlights a need for reorganising in hospital lactation, breast-feeding counselling and support, feeding and nutrition guidelines plus the necessity of continued postdischarge breast-feeding support to mothers with LPIs. No difference was found regarding the requirement of phototherapy treatment between infants with regular artificial milk
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supplementation and infants who were exclusively breast fed from birth. The result might be explained by the higher breast-feeding frequency in the exclusive breast-fed group, which decreased the incidence of severe hyperbilirubinemia (Gartner et al., 2005). However, inadequate breast feeding resulting in dehydration and/or poor caloric intake can contribute to the development of hyperbilirubinemia (Lavanya et al., 2012). Consequently, close follow-up and lactation support and counselling are essential for providing breast-fed preterm infants with safe care. The response rate in the study was adequate, 71%. Nine participants did not complete the data collection, five of them because their infants were referred to the NICU. Only four maternal diaries were not completed at the postnatal units, indicating the participants found the documentation easy to use and not time-consuming. These findings were in agreement with a study (Blomqvist et al., 2011) that reported parents' ability to document variables related to skin-to-skin care of their infants in a complete and reliable manner. It could be speculated that mothers who did not participate had infants with more morbidities than the participants had: if this was the case, the initiation and extent of breast feeding could have been lower. Even so, all infants were discharged with breast feeding, exclusive or partial. A limitation of the present study was that the data on breastfeeding frequency were based only on the mothers' self-reports. As immature oral movements when breast-feeding LPIs may be mistaken for nutritive feedings (Santos et al., 2008; Walker, 2008), self-reports in combination with breast-feeding observation would have strengthened the reliability of these findings. Another potential limitation was that five infants in the breastfeeding group received one or two artificial milk feeds during the hospital stay; however, all five were exclusively breast fed at discharge. Although even one-two artificial milk feeds constitute partial feeding by the WHO, we chose to include infants with this limited extent of artificial milk intake in the exclusively breast-fed group as their predominant mode of feeding was breast feeding, and our focus was not infant nutrition, but the infants' and mothers' experience of another oral feeding method. In addition, the diary lacked certain variables of importance for the initiation of breast feeding, for example, the infant's use of a pacifier, data regarding the mother's use of manual expression in addition to using a breast-pump and socio-economic variables. However, despite a relatively small sample, significant differences of clinical importance emerged.
Conclusion Clinical practice and routines influence the initiation of breast feeding among late preterm infants and may act as barriers to the mothers' establishment of exclusive breast feeding. Individualised care and follow-up by health professionals with adequate education and practical skills in supporting this vulnerable group are essential components in postnatal and post-discharge care for enabling these mothers to attain and maintain successful lactation and breast feeding.
Conflict of interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no financial support for the research, authorship, and/or publication of this article.
Please cite this article as: Mattsson, E., et al., Healthy late preterm infants and supplementary artificial milk feeds: Effects on breast feeding and associated clinical parameters. Midwifery (2015), http://dx.doi.org/10.1016/j.midw.2014.12.004i
E. Mattsson et al. / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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